HF 2053 (LSB 5071YH (4) 91)

HOUSE FILE 2053

BY  COLLINS

A BILL FOR

An Act relating to the standardization of claim submission and reimbursement processes of managed care organizations.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  Section 249A.2, Code 2026, is amended by adding the following new subsections:
   NEW SUBSECTION.  5A.  “Managed care contract” means a contract between the department and a managed care organization that obligates the managed care organization to administer the medical assistance program under this chapter.
   NEW SUBSECTION.  5B.  “Managed care organization” means a “health maintenance organization”, as that term is defined in section 514B.1, acting pursuant to a managed care contract.
    Sec. 2.  Section 249A.4, subsection 9, Code 2026, is amended to read as follows:
   9.  a.  Adopt rules pursuant to chapter 17A in determining the method to establish a standardized claim submission and reimbursement process and the level of reimbursement for all medical and health services to be provided under the medical assistance program, after considering benefits received by or services rendered to a recipient by a provider on or after July 1, 2027. In establishing such rules, the department shall consider all of the following:
   a.  (1)  The promotion of efficient and cost-effective delivery of medical and health services.
   b.  (2)  Compliance with federal law and regulations.
   c.  (3)  The level of state and federal appropriations for medical assistance.
   d.  (4)  Reimbursement at a level as near as possible to After weighing the considerations in subparagraphs (1), (2), and (3), the actual costs and charges after priority is given to the considerations in paragraphs “a”, “b”, and “c” incurred by a provider for any benefits received by or services rendered to a recipient.
   b.  The department shall amend all existing managed care contracts, pursuant to the terms of each contract, to provide for adherence to the standardized claim submission and reimbursement process established under this subsection. All managed care contracts entered into, extended, or renewed by the department on or after July 1, 2027, must provide for adherence to the standardized claim submission and reimbursement process established under this subsection.
   c.  For purposes of this subsection, “claim” means a formal request by a provider for reimbursement for benefits received by a recipient or services rendered to a recipient.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
   This bill relates to claim submission and reimbursement processes followed by managed care organizations (MCOs) administering the medical assistance program (program). The bill defines “managed care contract” and “managed care organization”.
   Under current law, the department of health and human services (HHS) is directed to adopt rules determining the method and level of reimbursement for all medical and health services provided under the program. The bill directs the director of HHS to also adopt rules establishing a standardized submission and reimbursement process (process) for claims for all benefits received by or services rendered to a recipient by a provider on or after July 1, 2027.
   The bill requires HHS to amend all managed care contracts, pursuant to the terms of each contract, to provide that MCOs adhere to the process. The bill further requires that all managed care contracts entered into, extended, or renewed by HHS on or after July 1, 2027, provide that MCOs adhere to the process.