S.F. 61 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 35 -1- LSB 1099XS (5) 89 pf/rh 1/ 10

S.F. 61 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. 35 -2- LSB 1099XS (5) 89 pf/rh 2/ 10

S.F. 61 (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 35 -3- LSB 1099XS (5) 89 pf/rh 3/ 10

S.F. 61 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. 35 -4- LSB 1099XS (5) 89 pf/rh 4/ 10

S.F. 61 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 35 -5- LSB 1099XS (5) 89 pf/rh 5/ 10

S.F. 61 independent third-party reviewer within forty-five calendar 1 days of entry of the final order. 2 DIVISION IV 3 MEMBER DISENROLLMENT FOR GOOD CAUSE 4 Sec. 4. MEMBER DISENROLLMENT FOR GOOD CAUSE. The department 5 of human services shall adopt rules pursuant to chapter 17A 6 and shall contractually require all Medicaid managed care 7 organizations to issue a decision in response to a member’s 8 request for disenrollment for good cause within ten days 9 of the date the member submits the request to the Medicaid 10 managed care organization utilizing the Medicaid managed care 11 organization’s grievance process. 12 DIVISION V 13 UNIFORM, SINGLE CREDENTIALING 14 Sec. 5. MEDICAID PROGRAM —— USE OF UNIFORM AUTHORIZATION 15 CRITERIA AND SINGLE CREDENTIALING VERIFICATION 16 ORGANIZATION. The department of human services shall 17 develop uniform authorization criteria for, and shall 18 utilize a request for proposals process to procure, a single 19 credentialing verification organization to be utilized by 20 the state in credentialing and recredentialing providers for 21 both the Medicaid managed care and fee-for-service payment and 22 delivery systems. The department shall contractually require 23 all Medicaid managed care organizations to apply the uniform 24 authorization criteria and to accept verified information from 25 the single credentialing verification organization procured by 26 the state, and shall contractually prohibit Medicaid managed 27 care organizations from requiring additional credentialing 28 information from a provider in order to participate in the 29 Medicaid managed care organization’s provider network. 30 DIVISION VI 31 MEDICAID MANAGED CARE OMBUDSMAN PROGRAM —— APPROPRIATION 32 Sec. 6. OFFICE OF LONG-TERM CARE OMBUDSMAN —— MEDICAID 33 MANAGED CARE OMBUDSMAN. 34 1. There is appropriated from the general fund of the 35 -6- LSB 1099XS (5) 89 pf/rh 6/ 10

S.F. 61 state to the office of long-term care ombudsman for the fiscal 1 year beginning July 1, 2021, and ending June 30, 2022, in 2 addition to any other funds appropriated from the general 3 fund of the state to, and in addition to any other full-time 4 equivalent positions authorized for, the office of long-term 5 care ombudsman for the same purpose, the following amount, or 6 so much thereof as is necessary, to be used for the purposes 7 designated: 8 For the purposes of the Medicaid managed care ombudsman 9 program including for salaries, support, administration, 10 maintenance, and miscellaneous purposes, and for not more than 11 the following full-time equivalent positions: 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 300,000 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FTEs 2.50 14 2. The funding appropriated and the full-time equivalent 15 positions authorized under this section are in addition to any 16 other funds appropriated from the general fund of the state and 17 actually expended, and any other full-time equivalent positions 18 authorized and actually filled as of July 1, 2021, for the 19 Medicaid managed care ombudsman program. 20 3. Any funds appropriated to and any full-time equivalent 21 positions authorized for the office of long-term care ombudsman 22 for the Medicaid managed care ombudsman program for the fiscal 23 year beginning July 1, 2021, and ending June 30, 2022, shall 24 be used exclusively for the Medicaid managed care ombudsman 25 program. 26 4. The additional full-time equivalent positions authorized 27 in this section for the Medicaid managed care ombudsman program 28 shall be filled no later than September 1, 2021. 29 5. The office of long-term care ombudsman shall include 30 in the Medicaid managed care ombudsman program report, on a 31 quarterly basis, the disposition of resources for the Medicaid 32 managed care ombudsman program including actual expenditures 33 and a full-time equivalent positions summary for the prior 34 quarter. 35 -7- LSB 1099XS (5) 89 pf/rh 7/ 10

S.F. 61 EXPLANATION 1 The inclusion of this explanation does not constitute agreement with 2 the explanation’s substance by the members of the general assembly. 3 This bill relates to the Medicaid program. 4 Division I of the bill requires the department of human 5 services (DHS) to adopt administrative rules to ensure that 6 services are provided to the Medicaid long-term services and 7 supports population in a conflict-free manner. Specifically, 8 the bill requires that case management services shall be 9 provided by independent providers and that the supports 10 intensity scale assessments are performed by independent 11 assessors. 12 Division II of the bill requires DHS to contractually 13 require any Medicaid managed care organization (MCO) to 14 collaborate with the department and stakeholders to develop and 15 administer a workforce recruitment, retention, and training 16 program to provide adequate access to appropriate services, 17 including but not limited to services to older Iowans. The 18 department shall ensure that any such program developed is 19 administered in a coordinated and collaborative manner across 20 all contracting MCOs and shall require the MCOs to submit 21 quarterly progress and outcomes reports to the department. 22 Division III of the bill establishes an external independent 23 third-party review process for Medicaid providers for the 24 review of final adverse determinations of the MCOs’ internal 25 appeal processes. The division provides that a final decision 26 of an external independent third-party reviewer may be reviewed 27 in a contested case proceeding pursuant to Code chapter 17A, 28 and ultimately is subject to judicial review. 29 Division IV of the bill relates to member disenrollment for 30 good cause during the 12 months of closed enrollment between 31 open enrollment periods. Currently, a member may request 32 disenrollment for good cause initially through their MCO’s 33 grievance process, which may take up to 30 to 45 days to 34 process. The bill requires DHS to adopt administrative rules 35 -8- LSB 1099XS (5) 89 pf/rh 8/ 10

S.F. 61 and contractually require all Medicaid MCOs to issue a decision 1 in response to a member’s request for disenrollment for good 2 cause within 10 days of the date the member submits the request 3 to the MCO utilizing the MCO’s grievance process. 4 Division V of the bill requires the DHS to develop 5 uniform authorization criteria for, and to utilize a request 6 for proposals process to procure, a single credentialing 7 verification organization to be utilized in credentialing 8 and recredentialing providers for the Medicaid managed care 9 and fee-for-service payment and delivery systems. The bill 10 requires DHS to contractually require all Medicaid managed 11 care organizations (MCOs) to apply the uniform authorization 12 criteria and to accept verified information from the single 13 credentialing verification organization procured by the 14 state, and to contractually prohibit the MCOs from requiring 15 additional credentialing information from a provider in order 16 to participate in the Medicaid managed care organization’s 17 provider network. 18 Division VI of the bill relates to the office of long-term 19 care ombudsman (OLTCO) and the Medicaid managed care ombudsman 20 program (MCOP). 21 For fiscal year 2021-2022, the bill appropriates $300,000 22 from the general fund of the state, in addition to any other 23 funds appropriated from the general fund of the state to, 24 and authorizes 2.50 FTEs in addition to any other full-time 25 equivalent (FTE) positions authorized for, the OLTCO for the 26 purposes of the MCOP. The funding appropriated and the FTE 27 positions authorized under the bill are in addition to any 28 other funds appropriated from the general fund of the state and 29 actually expended, and any other FTE positions authorized and 30 actually filled as of July 1, 2021, for the MCOP. 31 The bill requires that any funds appropriated to and any 32 full-time equivalent positions authorized for the OLTCO for the 33 MCOP for fiscal year 2021-2022 shall be used exclusively for 34 the MCOP. The additional FTE positions authorized in the bill 35 -9- LSB 1099XS (5) 89 pf/rh 9/ 10