S.F. 558 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 health and human services shall adopt rules 6 pursuant to chapter 17A to ensure that services are provided 7 under the Medicaid program to members of the long-term 8 services and supports population in a conflict-free manner. 9 Specifically, case management services shall be provided by 10 independent providers and supports intensity scale assessments 11 shall be performed by independent assessors. 12 DIVISION II 13 LONG-TERM SERVICES AND SUPPORTS POPULATION MEMBERS —— OPTION 14 FOR FEE-FOR-SERVICE PROGRAM ADMINISTRATION 15 Sec. 2. LONG-TERM SERVICES AND SUPPORTS POPULATION MEMBERS 16 —— OPTION FOR FEE-FOR-SERVICE PROGRAM ADMINISTRATION. The 17 department of health and human services shall require each 18 Medicaid managed care organization with whom the department 19 executes a contract to administer the Iowa high-quality 20 health care initiative as established by the department, 21 to provide the option to Medicaid long-term services and 22 supports population members to enroll in or transition to 23 fee-for-service Medicaid program administration rather than 24 managed care administration. The department shall amend any 25 contract, request any Medicaid state plan amendment, and adopt 26 rules pursuant to chapter 17A, as necessary, to administer this 27 section. The rules shall include the process for transitioning 28 a current Medicaid long-term services and supports population 29 member to fee-for-service program administration. 30 DIVISION III 31 LONG-TERM SERVICES AND SUPPORTS POPULATION MEMBERS —— POLICY 32 FOR DENIAL OF CARE 33 Sec. 3. LONG-TERM SERVICES AND SUPPORTS POPULATION MEMBERS 34 —— POLICY FOR DENIAL OF CARE. The department of health 35 -1- LSB 1662XS (5) 91 lh/ko 1/ 12

S.F. 558 and human services shall require each Medicaid managed care 1 organization with whom the department executes a contract 2 under the Medicaid program to maintain an authorized member’s 3 Medicaid long-term services and supports unless the member’s 4 health care provider determines a change in the long-term 5 services and supports is medically necessary. The inability of 6 a member who is authorized for long-term services and supports 7 to utilize all approved service hours, including respite care, 8 shall not result in a reduction in authorized services unless 9 there is medical evidence that the services are medically 10 unnecessary for the member. 11 DIVISION IV 12 MEDICAID WORKFORCE PROGRAM 13 Sec. 4. WORKFORCE RECRUITMENT, RETENTION, AND TRAINING 14 PROGRAMS. The department of health and human services shall 15 contractually require any managed care organization with whom 16 the department executes a contract under the Medicaid program 17 to collaborate with the department and stakeholders to develop 18 and administer a workforce recruitment, retention, and training 19 program to provide adequate access to appropriate services, 20 including but not limited to services to older Iowans. 21 The department shall ensure that any program developed is 22 administered in a coordinated and collaborative manner across 23 all contracting managed care organizations and shall require 24 the managed care organizations to submit quarterly progress and 25 outcomes reports to the department. 26 DIVISION V 27 PROVIDER APPEALS PROCESS —— EXTERNAL REVIEW 28 Sec. 5. MEDICAID MANAGED CARE ORGANIZATION APPEALS PROCESS 29 —— EXTERNAL REVIEW —— PENALTY. 30 1. a. A Medicaid managed care organization under contract 31 with the department of health and human services shall include 32 in any written response to a Medicaid provider under contract 33 with the managed care organization that reflects a final 34 adverse determination of the managed care organization’s 35 -2- LSB 1662XS (5) 91 lh/ko 2/ 12

S.F. 558 internal appeal process relative to an appeal filed by the 1 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 -3- LSB 1662XS (5) 91 lh/ko 3/ 12

S.F. 558 (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 health and human services of 11 the Medicaid provider’s 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 of health and human services 23 all documentation submitted by the Medicaid provider in the 24 course of the managed care organization’s internal appeal 25 process. 26 (2) Provide the managed care organization’s designated 27 contact information, including name, mailing address, phone 28 number, fax number, and email address. 29 b. If a managed care organization fails to satisfy the 30 requirements of this subsection, the Medicaid provider shall 31 automatically prevail in the review. 32 5. A request for an external independent third-party review 33 shall automatically extend the deadline to file an appeal for a 34 contested case hearing under chapter 17A, pending the outcome 35 -4- LSB 1662XS (5) 91 lh/ko 4/ 12

S.F. 558 of the external independent third-party review, until thirty 1 calendar days following receipt of the review decision by the 2 Medicaid provider. 3 6. Upon receiving notification of a request for an external 4 independent third-party review, the department of health and 5 human services shall do all of the following: 6 a. Assign the review to an external independent third-party 7 reviewer. 8 b. Notify the managed care organization of the identity of 9 the external independent third-party reviewer. 10 c. Notify the Medicaid provider’s designated contact of the 11 identity of the external independent third-party reviewer. 12 7. The department of health and human services shall deny a 13 request for an external independent third-party review if the 14 requesting Medicaid provider fails to exhaust the managed care 15 organization’s internal appeal process or fails to submit a 16 timely request for an external independent third-party review 17 pursuant to this section. 18 8. a. Multiple appeals through the external independent 19 third-party review process regarding the same Medicaid member, 20 a common question of fact, or the interpretation of common 21 applicable regulations or reimbursement requirements may 22 be combined and determined in one action upon request of a 23 party in accordance with rules and regulations adopted by the 24 department of health and human services. 25 b. The Medicaid provider that initiated a request for 26 an external independent third-party review, or one or more 27 other Medicaid providers, may add claims to such an existing 28 external independent third-party review request following the 29 exhaustion of any applicable managed care organization internal 30 appeal process, if the claims involve a common question of 31 fact or interpretation of common applicable regulations or 32 reimbursement requirements. 33 9. Documentation reviewed by the external independent 34 third-party reviewer shall be limited to documentation 35 -5- LSB 1662XS (5) 91 lh/ko 5/ 12

S.F. 558 submitted pursuant to subsection 4. 1 10. An external independent third-party reviewer shall do 2 all of the following: 3 a. Conduct an external independent third-party review 4 of any claim submitted to the reviewer pursuant to this 5 subsection. 6 b. Within thirty calendar days from receiving the request 7 for an external independent third-party review from the 8 department of health and human services and the documentation 9 submitted pursuant to subsection 4, issue the reviewer’s final 10 decision to the Medicaid provider’s designated contact, the 11 managed care organization’s designated contact, the department 12 of health and human services, and the affected Medicaid member 13 if the decision involves a denial of service. The reviewer may 14 extend the time to issue a final decision by up to fourteen 15 calendar days upon agreement of all parties to the review. 16 11. The department of health and human services shall 17 enter into a contract with an external independent review 18 organization that does not have a conflict of interest with the 19 department of health and human services or any managed care 20 organization to conduct the external independent third-party 21 reviews under this section. 22 a. A party, including the affected Medicaid member or 23 Medicaid provider, may appeal a final decision of the external 24 independent third-party reviewer in a contested case proceeding 25 in accordance with chapter 17A within thirty calendar days from 26 receiving the final decision. A final decision in a contested 27 case proceeding is subject to judicial review. 28 b. The final decision of an external independent 29 third-party reviewer conducted pursuant to this section shall 30 also direct the nonprevailing party to pay an amount equal to 31 the costs of the review to the external independent third-party 32 reviewer. Any payment ordered pursuant to this subsection 33 shall be stayed pending any appeal of the review. If the 34 final outcome of any appeal is to reverse the decision of the 35 -6- LSB 1662XS (5) 91 lh/ko 6/ 12

S.F. 558 external independent third-party reviewer, the nonprevailing 1 party on appeal shall pay the costs of the review to the 2 external independent third-party reviewer within forty-five 3 calendar days of entry of the final order. 4 DIVISION VI 5 MEMBER DISENROLLMENT FOR GOOD CAUSE 6 Sec. 6. MEMBER DISENROLLMENT FOR GOOD CAUSE. The department 7 of health and human services shall contractually require all 8 Medicaid managed care organizations to issue a decision in 9 response to a member’s request for disenrollment for good cause 10 within ten days of the date the member submits the request to 11 the Medicaid managed care organization utilizing the Medicaid 12 managed care organization’s grievance process. The department 13 shall adopt rules pursuant to chapter 17A to administer this 14 division. 15 DIVISION VII 16 UNIFORM, SINGLE CREDENTIALING 17 Sec. 7. MEDICAID PROGRAM —— USE OF UNIFORM AUTHORIZATION 18 CRITERIA AND SINGLE CREDENTIALING VERIFICATION 19 ORGANIZATION. The department of health and human services 20 shall develop uniform authorization criteria for, and 21 shall utilize a request for proposals process to procure, 22 a single credentialing verification organization to be 23 utilized in credentialing and recredentialing providers for 24 both the Medicaid managed care and fee-for-service payment 25 and delivery systems. The department or health and human 26 services shall contractually require all Medicaid managed care 27 organizations to apply the uniform authorization criteria and 28 to accept verified information from the single credentialing 29 verification organization procured by the department, and shall 30 contractually prohibit Medicaid managed care organizations 31 from requiring additional credentialing information from a 32 provider in order to participate in the Medicaid managed care 33 organization’s provider network. 34 DIVISION VIII 35 -7- LSB 1662XS (5) 91 lh/ko 7/ 12

S.F. 558 MEDICAID MANAGED CARE OMBUDSMAN PROGRAM —— APPROPRIATION 1 Sec. 8. OFFICE OF LONG-TERM CARE OMBUDSMAN —— MEDICAID 2 MANAGED CARE OMBUDSMAN. 3 1. There is appropriated from the general fund of the 4 state to the department of health and human services office of 5 long-term care ombudsman for the fiscal year beginning July 6 1, 2025, and ending June 30, 2026, in addition to any other 7 funds appropriated from the general fund of the state to, 8 and in addition to any other full-time equivalent positions 9 authorized for, the office of long-term care ombudsman for the 10 same purpose, the following amount, or so much thereof as is 11 necessary, to be used for the purposes designated: 12 For the purposes of the Medicaid managed care ombudsman 13 program including for salaries, support, administration, 14 maintenance, and miscellaneous purposes, and for not more than 15 the following full-time equivalent positions: 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 300,000 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FTEs 2.50 18 2. The funding appropriated and the full-time equivalent 19 positions authorized under this section are in addition to any 20 other funds appropriated from the general fund of the state and 21 actually expended, and any other full-time equivalent positions 22 authorized and actually filled as of July 1, 2025, for the 23 Medicaid managed care ombudsman program. 24 3. Any funds appropriated to and any full-time equivalent 25 positions authorized for the office of long-term care ombudsman 26 for the Medicaid managed care ombudsman program for the fiscal 27 year beginning July 1, 2025, and ending June 30, 2026, shall 28 be used exclusively for the Medicaid managed care ombudsman 29 program. 30 4. The additional full-time equivalent positions authorized 31 in this section for the Medicaid managed care ombudsman program 32 shall be filled no later than September 1, 2025. 33 5. The office of long-term care ombudsman shall include 34 in the Medicaid managed care ombudsman program report, on a 35 -8- LSB 1662XS (5) 91 lh/ko 8/ 12

S.F. 558 quarterly basis, the disposition of resources for the Medicaid 1 managed care ombudsman program including actual expenditures 2 and a full-time equivalent positions summary for the prior 3 quarter. 4 DIVISION IX 5 HEALTH POLICY OVERSIGHT COMMITTEE MEETINGS 6 Sec. 9. Section 2.45, subsection 5, Code 2025, is amended 7 to read as follows: 8 5. The legislative health policy oversight committee, 9 which shall be composed of ten members of the general 10 assembly, consisting of five members from each house, to 11 be appointed by the legislative council. The legislative 12 health policy oversight committee may shall meet at least two 13 times, annually , during the legislative interim to provide 14 continuing oversight for Medicaid managed care, and to ensure 15 effective and efficient administration of the program, address 16 stakeholder concerns, monitor program costs and expenditures, 17 and make recommendations. 18 DIVISION X 19 MANAGED CARE ORGANIZATIONS —— ANNUAL REPORT ON PROFIT 20 Sec. 10. MANAGED CARE ORGANIZATIONS —— REPORT ON 21 PROFIT. The department of health and human services shall 22 require each Medicaid managed care organization with whom the 23 department executes a contract under the Medicaid program 24 to annually submit a report by March 1 to the department 25 detailing the profit the managed care organization received 26 from administering Medicaid care during the immediately 27 preceding calendar year, and the methodology used to calculate 28 the profit. The department may select an independent auditor 29 to verify each managed care organization’s profit report. The 30 department shall make each managed care organization’s report 31 publicly available on the department’s internet site. 32 EXPLANATION 33 The inclusion of this explanation does not constitute agreement with 34 the explanation’s substance by the members of the general assembly. 35 -9- LSB 1662XS (5) 91 lh/ko 9/ 12

S.F. 558 This bill relates to the Medicaid program. 1 Division I of the bill requires the department of health 2 and human services (HHS) to adopt administrative rules to 3 ensure that services are provided to the Medicaid long-term 4 services and supports (LTSS) population in a conflict-free 5 manner. Specifically, the bill requires that case management 6 services shall be provided by independent providers and that 7 the supports intensity scale assessments are performed by 8 independent assessors. 9 Division II of the bill directs HHS to require each Medicaid 10 managed care organization (MCO) with whom HHS executes a 11 contract, to provide the option to LTSS population members to 12 enroll in or transition to fee-for-service Medicaid program 13 administration rather than managed care administration. The 14 department shall amend any contract, request any Medicaid state 15 plan amendment, and adopt administrative rules, as necessary, 16 to administer this provision. The rules shall include the 17 process for transitioning a current LTSS population member to 18 fee-for-service program administration. 19 Division III of the bill directs HHS to require each MCO with 20 whom HHS executes a contract to maintain an authorized member’s 21 LTSS unless the member’s health care provider determines a 22 change in the LTSS is medically necessary for the member. The 23 inability of a member who is authorized for LTSS to utilize 24 all approved service hours, including respite care, shall not 25 result in a reduction in authorized services unless there is 26 medical evidence that the services are medically unnecessary 27 for the member. 28 Division IV of the bill requires HHS to contractually 29 require any Medicaid MCO to collaborate with HHS and 30 stakeholders to develop and administer a workforce recruitment, 31 retention, and training program to provide adequate access to 32 appropriate services, including but not limited to services 33 to older Iowans. The department shall ensure that any such 34 program developed is administered in a coordinated and 35 -10- LSB 1662XS (5) 91 lh/ko 10/ 12

S.F. 558 collaborative manner across all contracting MCOs and shall 1 require the MCOs to submit quarterly progress and outcomes 2 reports to HHS. 3 Division V of the bill establishes an external independent 4 third-party review process for Medicaid providers for the 5 review of final adverse determinations of the MCOs’ internal 6 appeals processes. The division provides that a final 7 decision of an external independent third-party reviewer may 8 be reviewed in a contested case proceeding pursuant to Code 9 chapter 17A, and ultimately is subject to judicial review. The 10 bill provides a civil penalty for an MCO that does not comply 11 with the written response requirements relating to an adverse 12 determination. 13 Division VI of the bill relates to member disenrollment 14 for good cause during the 12 months of closed enrollment 15 between open enrollment periods. The bill requires HHS to 16 contractually require all Medicaid MCOs to issue a decision 17 in response to a member’s request for disenrollment for good 18 cause within 10 days of the date the member submits the request 19 to the MCO utilizing the MCO’s grievance process and to adopt 20 administrative rules to administer the division. 21 Division VII of the bill requires the HHS to develop 22 uniform authorization criteria for, and to utilize a request 23 for proposals process to procure, a single credentialing 24 verification organization to be utilized in credentialing 25 and recredentialing providers for the Medicaid managed care 26 and fee-for-service payment and delivery systems. The bill 27 requires HHS to contractually require all Medicaid MCOs to 28 apply the uniform authorization criteria, to accept verified 29 information from the single credentialing verification 30 organization procured by HHS, and to contractually prohibit the 31 MCOs from requiring additional credentialing information from a 32 provider in order to participate in the Medicaid MCO’s provider 33 network. 34 Division VIII of the bill relates to the office of long-term 35 -11- LSB 1662XS (5) 91 lh/ko 11/ 12

S.F. 558 care ombudsman (OLTCO) and the Medicaid managed care ombudsman 1 program (MCOP). 2 For fiscal year 2025-2026, the bill appropriates $300,000 3 from the general fund of the state, in addition to any other 4 funds appropriated from the general fund of the state to, 5 and authorizes 2.50 FTEs in addition to any other full-time 6 equivalent (FTE) positions authorized for, HHS for the OLTCO 7 for the purposes of the MCOP. The funding appropriated and the 8 FTE positions authorized under the bill are in addition to any 9 other funds appropriated from the general fund of the state and 10 actually expended, and any other FTE positions authorized and 11 actually filled as of July 1, 2025, for the MCOP. 12 The bill requires that any funds appropriated to and any 13 full-time equivalent positions authorized for the OLTCO for the 14 MCOP for fiscal year 2025-2026 shall be used exclusively for 15 the MCOP. The additional FTE positions authorized in the bill 16 for the MCOP shall be filled no later than September 1, 2025. 17 The bill requires the OLTCO to include in the MCOP report, on 18 a quarterly basis, the disposition of resources for the MCOP 19 including expenditures and an FTE positions summary for the 20 prior quarter. 21 Division IX amends the provision regarding the meetings of 22 the health policy oversight committee (HPOC) of the legislative 23 council. Current law provides that HPOC may meet annually. 24 The bill provides that HPOC shall meet, and further requires 25 that HPOC meet at least two times, annually, during the 26 legislative interim. 27 Division X of the bill directs HHS to require each MCO with 28 whom HHS executes a contract to annually submit a report by 29 March 1 to HHS detailing the profit the MCO received from 30 administering Medicaid care during the immediately preceding 31 calendar year, and the methodology the MCO used to calculate 32 the profit. HHS may select an independent auditor to verify 33 each MCO’s report. HHS shall make each MCO’s report publicly 34 available on HHS’s internet site. 35 -12- LSB 1662XS (5) 91 lh/ko 12/ 12