Senate
File
2066
-
Introduced
SENATE
FILE
2066
BY
RAGAN
and
MATHIS
A
BILL
FOR
An
Act
relating
to
Medicaid
program
improvements.
1
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
2
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DIVISION
I
1
MEDICAID
LONG-TERM
SERVICES
AND
SUPPORTS
POPULATION
MEMBERS
——
2
PROVISION
OF
CONFLICT-FREE
SERVICES
3
Section
1.
MEDICAID
LONG-TERM
SERVICES
AND
SUPPORTS
4
POPULATION
MEMBERS
——
PROVISION
OF
CONFLICT-FREE
SERVICES.
The
5
department
of
human
services
shall
adopt
rules
pursuant
to
6
chapter
17A
to
ensure
that
services
are
provided
under
the
7
Medicaid
program
to
members
of
the
long-term
services
and
8
supports
population
in
a
conflict-free
manner.
Specifically,
9
case
management
services
shall
be
provided
by
independent
10
providers
and
supports
intensity
scale
assessments
shall
be
11
performed
by
independent
assessors.
12
DIVISION
II
13
MEDICAID
WORKFORCE
PROGRAM
14
Sec.
2.
WORKFORCE
RECRUITMENT,
RETENTION,
AND
TRAINING
15
PROGRAMS.
The
department
of
human
services
shall
contractually
16
require
any
managed
care
organization
with
whom
the
department
17
contracts
under
the
Medicaid
program
to
collaborate
with
18
the
department
and
stakeholders
to
develop
and
administer
a
19
workforce
recruitment,
retention,
and
training
program
to
20
provide
adequate
access
to
appropriate
services,
including
21
but
not
limited
to
services
to
older
Iowans.
The
department
22
shall
ensure
that
any
program
developed
is
administered
in
a
23
coordinated
and
collaborative
manner
across
all
contracting
24
managed
care
organizations
and
shall
require
the
managed
care
25
organizations
to
submit
quarterly
progress
and
outcomes
reports
26
to
the
department.
27
DIVISION
III
28
PROVIDER
APPEALS
PROCESS
——
EXTERNAL
REVIEW
29
Sec.
3.
MEDICAID
MANAGED
CARE
ORGANIZATION
APPEALS
PROCESS
30
——
EXTERNAL
REVIEW.
31
1.
a.
A
Medicaid
managed
care
organization
under
contract
32
with
the
state
shall
include
in
any
written
response
to
33
a
Medicaid
provider
under
contract
with
the
managed
care
34
organization
that
reflects
a
final
adverse
determination
of
the
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managed
care
organization’s
internal
appeal
process
relative
to
1
an
appeal
filed
by
the
Medicaid
provider,
all
of
the
following:
2
(1)
A
statement
that
the
Medicaid
provider’s
internal
3
appeal
rights
within
the
managed
care
organization
have
been
4
exhausted.
5
(2)
A
statement
that
the
Medicaid
provider
is
entitled
to
6
an
external
independent
third-party
review
pursuant
to
this
7
section.
8
(3)
The
requirements
for
requesting
an
external
independent
9
third-party
review.
10
b.
If
a
managed
care
organization’s
written
response
does
11
not
comply
with
the
requirements
of
paragraph
“a”,
the
managed
12
care
organization
shall
pay
to
the
affected
Medicaid
provider
a
13
penalty
not
to
exceed
one
thousand
dollars.
14
2.
a.
A
Medicaid
provider
who
has
been
denied
the
provision
15
of
a
service
to
a
Medicaid
member
or
a
claim
for
reimbursement
16
for
a
service
rendered
to
a
Medicaid
member,
and
who
has
17
exhausted
the
internal
appeal
process
of
a
managed
care
18
organization,
shall
be
entitled
to
an
external
independent
19
third-party
review
of
the
managed
care
organization’s
final
20
adverse
determination.
21
b.
To
request
an
external
independent
third-party
review
of
22
a
final
adverse
determination
by
a
managed
care
organization,
23
an
aggrieved
Medicaid
provider
shall
submit
a
written
request
24
for
such
review
to
the
managed
care
organization
within
sixty
25
calendar
days
of
receiving
the
final
adverse
determination.
26
c.
A
Medicaid
provider’s
request
for
an
external
27
independent
third-party
review
shall
include
all
of
the
28
following:
29
(1)
Identification
of
each
specific
issue
and
dispute
30
directly
related
to
the
final
adverse
determination
issued
by
31
the
managed
care
organization.
32
(2)
A
statement
of
the
basis
upon
which
the
Medicaid
33
provider
believes
the
managed
care
organization’s
determination
34
to
be
erroneous.
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(3)
The
Medicaid
provider’s
designated
contact
information,
1
including
name,
mailing
address,
phone
number,
fax
number,
and
2
email
address.
3
3.
a.
Within
five
business
days
of
receiving
a
Medicaid
4
provider’s
request
for
an
external
independent
third-party
5
review
pursuant
to
this
subsection,
the
managed
care
6
organization
shall
do
all
of
the
following:
7
(1)
Confirm
to
the
Medicaid
provider’s
designated
contact,
8
in
writing,
that
the
managed
care
organization
has
received
the
9
request
for
review.
10
(2)
Notify
the
department
of
the
Medicaid
provider’s
11
request
for
review.
12
(3)
Notify
the
affected
Medicaid
member
of
the
Medicaid
13
provider’s
request
for
review,
if
the
review
is
related
to
the
14
denial
of
a
service.
15
b.
If
the
managed
care
organization
fails
to
satisfy
the
16
requirements
of
this
subsection,
the
Medicaid
provider
shall
17
automatically
prevail
in
the
review.
18
4.
a.
Within
fifteen
calendar
days
of
receiving
a
Medicaid
19
provider’s
request
for
an
external
independent
third-party
20
review,
the
managed
care
organization
shall
do
all
of
the
21
following:
22
(1)
Submit
to
the
department
all
documentation
submitted
23
by
the
Medicaid
provider
in
the
course
of
the
managed
care
24
organization’s
internal
appeal
process.
25
(2)
Provide
the
managed
care
organization’s
designated
26
contact
information,
including
name,
mailing
address,
phone
27
number,
fax
number,
and
email
address.
28
b.
If
a
managed
care
organization
fails
to
satisfy
the
29
requirements
of
this
subsection,
the
Medicaid
provider
shall
30
automatically
prevail
in
the
review.
31
5.
A
request
for
an
external
independent
third-party
review
32
shall
automatically
extend
the
deadline
to
file
an
appeal
for
a
33
contested
case
hearing
under
chapter
17A,
pending
the
outcome
34
of
the
external
independent
third-party
review,
until
thirty
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calendar
days
following
receipt
of
the
review
decision
by
the
1
Medicaid
provider.
2
6.
Upon
receiving
notification
of
a
request
for
an
external
3
independent
third-party
review,
the
department
shall
do
all
of
4
the
following:
5
a.
Assign
the
review
to
an
external
independent
third-party
6
reviewer.
7
b.
Notify
the
managed
care
organization
of
the
identity
of
8
the
external
independent
third-party
reviewer.
9
c.
Notify
the
Medicaid
provider’s
designated
contact
of
the
10
identity
of
the
external
independent
third-party
reviewer.
11
7.
The
department
shall
deny
a
request
for
an
external
12
independent
third-party
review
if
the
requesting
Medicaid
13
provider
fails
to
exhaust
the
managed
care
organization’s
14
internal
appeal
process
or
fails
to
submit
a
timely
request
for
15
an
external
independent
third-party
review
pursuant
to
this
16
section.
17
8.
a.
Multiple
appeals
through
the
external
independent
18
third-party
review
process
regarding
the
same
Medicaid
member,
19
a
common
question
of
fact,
or
the
interpretation
of
common
20
applicable
regulations
or
reimbursement
requirements
may
21
be
combined
and
determined
in
one
action
upon
request
of
a
22
party
in
accordance
with
rules
and
regulations
adopted
by
the
23
department.
24
b.
The
Medicaid
provider
that
initiated
a
request
for
25
an
external
independent
third-party
review,
or
one
or
more
26
other
Medicaid
providers,
may
add
claims
to
such
an
existing
27
external
independent
third-party
review
request
following
the
28
exhaustion
of
any
applicable
managed
care
organization
internal
29
appeal
process,
if
the
claims
involve
a
common
question
of
30
fact
or
interpretation
of
common
applicable
regulations
or
31
reimbursement
requirements.
32
9.
Documentation
reviewed
by
the
external
independent
33
third-party
reviewer
shall
be
limited
to
documentation
34
submitted
pursuant
to
subsection
4.
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10.
An
external
independent
third-party
reviewer
shall
do
1
all
of
the
following:
2
a.
Conduct
an
external
independent
third-party
review
3
of
any
claim
submitted
to
the
reviewer
pursuant
to
this
4
subsection.
5
b.
Within
thirty
calendar
days
from
receiving
the
6
request
for
an
external
independent
third-party
review
from
7
the
department
and
the
documentation
submitted
pursuant
to
8
subsection
4,
issue
the
reviewer’s
final
decision
to
the
9
Medicaid
provider’s
designated
contact,
the
managed
care
10
organization’s
designated
contact,
the
department,
and
the
11
affected
Medicaid
member
if
the
decision
involves
a
denial
of
12
service.
The
reviewer
may
extend
the
time
to
issue
a
final
13
decision
by
up
to
fourteen
calendar
days
upon
agreement
of
all
14
parties
to
the
review.
15
11.
The
department
shall
enter
into
a
contract
with
an
16
external
independent
review
organization
that
does
not
have
a
17
conflict
of
interest
with
the
department
or
any
managed
care
18
organization
to
conduct
the
external
independent
third-party
19
reviews
under
this
section.
20
a.
A
party,
including
the
affected
Medicaid
member
or
21
Medicaid
provider,
may
appeal
a
final
decision
of
the
external
22
independent
third-party
reviewer
in
a
contested
case
proceeding
23
in
accordance
with
chapter
17A
within
thirty
calendar
days
from
24
receiving
the
final
decision.
A
final
decision
in
a
contested
25
case
proceeding
is
subject
to
judicial
review.
26
b.
The
final
decision
of
an
external
independent
27
third-party
reviewer
conducted
pursuant
to
this
section
shall
28
also
direct
the
nonprevailing
party
to
pay
an
amount
equal
to
29
the
costs
of
the
review
to
the
external
independent
third-party
30
reviewer.
Any
payment
ordered
pursuant
to
this
subsection
31
shall
be
stayed
pending
any
appeal
of
the
review.
If
the
32
final
outcome
of
any
appeal
is
to
reverse
the
decision
of
the
33
external
independent
third-party
reviewer,
the
nonprevailing
34
party
shall
pay
the
costs
of
the
review
to
the
external
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independent
third-party
reviewer
within
forty-five
calendar
1
days
of
entry
of
the
final
order.
2
DIVISION
IV
3
UNIFORM,
SINGLE
CREDENTIALING
4
Sec.
4.
MEDICAID
PROGRAM
——
USE
OF
UNIFORM
AUTHORIZATION
5
CRITERIA
AND
SINGLE
CREDENTIALING
VERIFICATION
6
ORGANIZATION.
The
department
of
human
services
shall
7
develop
uniform
authorization
criteria
for,
and
shall
8
utilize
a
request
for
proposals
process
to
procure,
a
single
9
credentialing
verification
organization
to
be
utilized
by
10
the
state
in
credentialing
and
recredentialing
providers
for
11
both
the
Medicaid
managed
care
and
fee-for-service
payment
and
12
delivery
systems.
The
department
shall
contractually
require
13
all
Medicaid
managed
care
organizations
to
apply
the
uniform
14
authorization
criteria
and
to
accept
verified
information
from
15
the
single
credentialing
verification
organization
procured
by
16
the
state,
and
shall
contractually
prohibit
Medicaid
managed
17
care
organizations
from
requiring
additional
credentialing
18
information
from
a
provider
in
order
to
participate
in
the
19
Medicaid
managed
care
organization’s
provider
network.
20
EXPLANATION
21
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
22
the
explanation’s
substance
by
the
members
of
the
general
assembly.
23
This
bill
relates
to
Medicaid
program
improvements.
24
Division
I
of
the
bill
requires
the
department
of
human
25
services
(DHS)
to
adopt
administrative
rules
to
ensure
that
26
services
are
provided
to
the
Medicaid
long-term
services
and
27
supports
population
in
a
conflict-free
manner.
Specifically,
28
the
bill
requires
that
case
management
services
shall
be
29
provided
by
independent
providers
and
that
the
supports
30
intensity
scale
assessments
are
performed
by
independent
31
assessors.
32
Division
II
of
the
bill
requires
DHS
to
contractually
33
require
any
Medicaid
managed
care
organization
(MCO)
to
34
collaborate
with
DHS
and
stakeholders
to
develop
and
administer
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a
workforce
recruitment,
retention,
and
training
program
to
1
provide
adequate
access
to
appropriate
services,
including
but
2
not
limited
to
services
to
older
Iowans.
DHS
shall
ensure
that
3
any
such
program
developed
is
administered
in
a
coordinated
4
and
collaborative
manner
across
all
contracting
MCOs
and
shall
5
require
the
MCOs
to
submit
quarterly
progress
and
outcomes
6
reports
to
DHS.
7
Division
III
of
the
bill
establishes
an
external
independent
8
third-party
review
process
for
Medicaid
providers
for
the
9
review
of
final
adverse
determinations
of
the
MCOs’
internal
10
appeal
processes.
The
bill
provides
that
a
final
decision
of
11
an
external
independent
third-party
reviewer
may
be
reviewed
in
12
a
contested
case
proceeding
pursuant
to
Code
chapter
17A,
and
13
ultimately
is
subject
to
judicial
review.
14
Division
IV
of
the
bill
requires
DHS
to
develop
uniform
15
authorization
criteria
for,
and
to
utilize
a
request
16
for
proposals
process
to
procure,
a
single
credentialing
17
verification
organization
to
be
utilized
in
credentialing
18
and
recredentialing
providers
for
the
Medicaid
managed
care
19
and
fee-for-service
payment
and
delivery
systems.
The
bill
20
requires
DHS
to
contractually
require
all
MCOs
to
apply
21
the
uniform
authorization
criteria
and
to
accept
verified
22
information
from
the
single
credentialing
verification
23
organization
procured
by
the
state,
and
to
contractually
24
prohibit
MCOs
from
requiring
additional
credentialing
25
information
from
a
provider
in
order
to
participate
in
the
26
Medicaid
managed
care
organization’s
provider
network.
27
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