Senate File 296 - Reprinted SENATE FILE 296 BY COMMITTEE ON HUMAN RESOURCES (SUCCESSOR TO SF 71) (As Amended and Passed by the Senate March 26, 2013 ) A BILL FOR An Act relating to integrated care models for the delivery 1 of health care, including but not limited to required 2 utilization of a medical home by individuals currently and 3 newly eligible for coverage under the Medicaid program and 4 including effective date provisions. 5 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 6 SF 296 (3) 85 pf/rj/jh
S.F. 296 Section 1. Section 135.157, subsections 4 and 6, Code 2013, 1 are amended to read as follows: 2 4. “Medical home” means a team approach to providing health 3 care that originates in a primary care setting; fosters a 4 partnership among the patient, the personal provider, and 5 other health care professionals, and where appropriate, the 6 patient’s family; utilizes the partnership to access and 7 integrate all medical and nonmedical health-related services 8 across all elements of the health care system and the patient’s 9 community as needed by the patient and the patient’s family 10 to achieve maximum health potential; maintains a centralized, 11 comprehensive record of all health-related services to 12 promote continuity of care; and has all of the characteristics 13 specified in section 135.158 . 14 6. “Personal provider” means the patient’s first point of 15 contact in the health care system with a primary care provider 16 who identifies the patient’s health health-related needs and, 17 working with a team of health care professionals and providers 18 of medical and nonmedical health-related services , provides 19 for and coordinates appropriate care to address the health 20 health-related needs identified. 21 Sec. 2. Section 135.158, subsection 2, paragraphs b, c, and 22 d, Code 2013, are amended to read as follows: 23 b. A provider-directed team-based medical practice. The 24 personal provider leads a team of individuals at the practice 25 level who collectively take responsibility for the ongoing 26 health care health-related needs of patients. 27 c. Whole person orientation. The personal provider is 28 responsible for providing for all of a patient’s health care 29 health-related needs or taking responsibility for appropriately 30 arranging health care for health-related services provided 31 by other qualified health care professionals and providers 32 of medical and nonmedical health-related services . This 33 responsibility includes health health-related care at all 34 stages of life including provision of preventive care, 35 -1- SF 296 (3) 85 pf/rj/jh 1/ 14
S.F. 296 acute care, chronic care, preventive services long-term 1 care, transitional care between providers and settings , and 2 end-of-life care. This responsibility includes whole-person 3 care consisting of physical health care including but not 4 limited to oral, vision, and other specialty care, pharmacy 5 management, and behavioral health care. 6 d. Coordination and integration of care. Care is 7 coordinated and integrated across all elements of the 8 complex health care system and the patient’s community. Care 9 coordination and integration provides linkages to community 10 and social supports to address social determinants of health, 11 to engage and support patients in managing their own health, 12 and to track the progress of these community and social 13 supports in providing whole-person care. Care is facilitated 14 by registries, information technology, health information 15 exchanges, and other means to assure that patients receive the 16 indicated care when and where they need and want the care in a 17 culturally and linguistically appropriate manner. 18 Sec. 3. Section 135.159, subsections 1, 9, and 11, Code 19 2013, are amended to read as follows: 20 1. The department shall administer the medical home system. 21 The department shall collaborate with the department of human 22 services in administering medical homes under the medical 23 assistance program. The department shall adopt rules pursuant 24 to chapter 17A necessary to administer the medical home system , 25 and shall collaborate with the department of human services in 26 adopting rules for medical homes under the medical assistance 27 program . 28 9. The department shall coordinate the requirements and 29 activities of the medical home system with the requirements 30 and activities of the dental home for children as described 31 in section 249J.14 , and shall recommend financial incentives 32 for dentists and nondental providers to promote oral health 33 care coordination through preventive dental intervention, early 34 identification of oral disease risk, health care coordination 35 -2- SF 296 (3) 85 pf/rj/jh 2/ 14
S.F. 296 and data tracking, treatment, chronic care management, 1 education and training, parental guidance, and oral health 2 promotions for children. Additionally, the department shall 3 establish requirements for the medical home system to provide 4 linkages to accessible dental homes for adults and older 5 individuals. 6 11. Implementation phases . 7 a. Initial implementation shall require participation 8 in the medical home system of children The department shall 9 collaborate with the department of human services to make 10 medical homes accessible to the greatest extent possible to all 11 of the following no later than January 1, 2015: 12 (1) Children who are recipients of full benefits under the 13 medical assistance program. The department shall work with 14 the department of human services and shall recommend to the 15 general assembly a reimbursement methodology to compensate 16 providers participating under the medical assistance program 17 for participation in the medical home system. 18 b. The department shall work with the department of human 19 services to expand the medical home system to adults 20 (2) Adults who are recipients of full benefits under the 21 medical assistance program and the expansion population under 22 the IowaCare program. The department shall work with including 23 those adults who are recipients of medical assistance under 24 section 249A.3, subsection 1, paragraph “v” . 25 (3) Medicare and dually eligible Medicare and medical 26 assistance program recipients, to the extent approved by the 27 centers for Medicare and Medicaid services of the United States 28 department of health and human services to allow Medicare 29 recipients to utilize the medical home system . 30 c. b. The department shall work with the department of 31 administrative services to allow state employees to utilize the 32 medical home system. 33 d. c. The department shall work with insurers and 34 self-insured companies, if requested, to make the medical 35 -3- SF 296 (3) 85 pf/rj/jh 3/ 14
S.F. 296 home system available to individuals with private health care 1 coverage. 2 d. The department shall assist the department of human 3 services in developing a reimbursement methodology to 4 compensate providers participating under the medical assistance 5 program as a medical home. 6 e. Any integrated care model implemented on or after July 1, 7 2013, that delivers health care to medical assistance program 8 recipients shall incorporate medical homes as its foundation. 9 The medical home shall act as the catalyst in any such 10 integrated care model to ensure compliance with the purposes, 11 characteristics, and implementation plan requirements specified 12 in sections 135.158 and 135.159, including an emphasis on whole 13 person orientation and coordination and integration of both 14 clinical services and nonclinical community and social supports 15 that address social determinants of health. 16 Sec. 4. Section 249A.3, subsection 1, Code 2013, is amended 17 by adding the following new paragraphs: 18 NEW PARAGRAPH . v. Beginning January 1, 2014, in 19 accordance with section 1902(a)(10)(A)(i)(VIII) of the 20 federal Social Security Act, as codified in 42 U.S.C. § 21 1396a(a)(10)(A)(i)(VIII), is an individual who is nineteen 22 years of age or older and under sixty-five years of age; is 23 not pregnant; is not entitled to or enrolled for Medicare 24 benefits under part A, or enrolled for Medicare benefits under 25 part B, of Tit. XVIII of the federal Social Security Act; is 26 not otherwise described in section 1902(a)(10)(A)(i) of the 27 federal Social Security Act; is not exempt pursuant to section 28 1902(k)(3), as codified in 42 U.S.C. § 1396a(k)(3), and whose 29 income as determined under 1902(e)(14) of the federal Social 30 Security Act, as codified in 42 U.S.C. § 1396a(e)(14), does 31 not exceed one hundred thirty-three percent of the poverty 32 line as defined in section 2110(c)(5) of the federal Social 33 Security Act, as codified in 42 U.S.C. § 1397jj(c)(5), for the 34 applicable family size. Notwithstanding any provision to the 35 -4- SF 296 (3) 85 pf/rj/jh 4/ 14
S.F. 296 contrary, individuals eligible for medical assistance under 1 this paragraph shall receive coverage for benefits pursuant 2 to 42 U.S.C. § 1396u-7(b)(1)(D) which are at a minimum those 3 included in the medical assistance state plan benefit package 4 for individuals otherwise eligible under this subsection 1, and 5 adjusted as necessary to provide the essential health benefits 6 as required pursuant to section 1302 of the federal Patient 7 Protection and Affordable Care Act, Pub. L. No. 111-148, and 8 as approved by the United States secretary of health and human 9 services. If the methodology for calculating the federal 10 medical assistance percentage for newly eligible individuals 11 under this paragraph, as provided in 42 U.S.C. § 1396d(y), 12 is modified through federal law or regulation before January 13 1, 2020, in a manner that reduces the percentage of federal 14 assistance to the state, the department of human services shall 15 implement an alternative plan as specified in the medical 16 assistance state plan for coverage of the affected population. 17 NEW PARAGRAPH . w. Beginning January 1, 2014, is an 18 individual who meets all of the following requirements: 19 (1) Is under twenty-six years of age. 20 (2) Was in foster care under the responsibility of the state 21 on the date of attaining eighteen years of age or such higher 22 age to which foster care is provided. 23 (3) Was enrolled in the medical assistance program under 24 this chapter while in such foster care. 25 Sec. 5. Section 249A.3, subsection 2, paragraph a, 26 subparagraph (9), Code 2013, is amended by striking the 27 subparagraph. 28 Sec. 6. Section 249J.26, subsection 2, Code 2013, is amended 29 to read as follows: 30 2. This chapter is repealed October December 31, 2013. 31 Sec. 7. Section 249J.26, Code 2013, is amended by adding the 32 following new subsection: 33 NEW SUBSECTION . 3. The department shall prepare a plan for 34 the transition of expansion population members to other health 35 -5- SF 296 (3) 85 pf/rj/jh 5/ 14
S.F. 296 care coverage options beginning January 1, 2014. The options 1 shall include the option of coverage through the medical 2 assistance program as provided in section 249A.3, subsection 1, 3 paragraph “v” , relating to coverage for adults who are nineteen 4 years of age or older and under sixty-five years of age, and 5 the option of coverage through the health benefits exchange 6 established pursuant to the federal Patient Protection and 7 Affordable Care Act, Pub. L. No. 111-148, as amended by the 8 federal Health Care and Education Reconciliation Act of 2010, 9 Pub. L. No. 111-152. To the greatest extent possible, the plan 10 shall maintain and incorporate utilization of the existing 11 medical home and service delivery structure as developed 12 under this chapter, including the utilization of federally 13 qualified health centers, public hospitals, and other safety 14 net providers, in providing access to care. The department 15 shall submit the plan to the governor and the general assembly 16 no later than September 1, 2013. 17 Sec. 8. ADVISORY COUNCIL FOR STATE INNOVATION MODEL 18 INITIATIVE. 19 1. No later than thirty days after the effective date of 20 this Act, the legislative council shall establish a legislative 21 advisory council to guide the development of the design 22 model and implementation plan for the state innovation model 23 grant awarded by the Centers for Medicare and Medicaid of 24 the United States department of health and human services. 25 The legislative advisory council shall consist of members 26 of the general assembly, members of the governor’s advisory 27 committee who developed the grant proposal, and representatives 28 of consumers and health care providers, appointed by the 29 legislative council as necessary to ensure that the process is 30 comprehensive and provides ample opportunity for the variety of 31 stakeholders to participate in the process. 32 2. The legislative advisory council shall provide oversight 33 throughout the process, shall receive periodic progress reports 34 from the department of human services, and shall approve any 35 -6- SF 296 (3) 85 pf/rj/jh 6/ 14
S.F. 296 integrated care model and implementation strategies for the 1 medical assistance program presented by the department of human 2 services, and shall prepare proposed legislation to implement 3 the model and the strategies prior to its submission to the 4 general assembly for approval during the 2014 session of the 5 general assembly. 6 3. The department of human services shall develop the 7 integrated care model based on the goals and strategies 8 included in the state innovation model grant application to 9 improve patient outcomes and satisfaction, while lowering 10 costs, as follows: 11 a. Goals: 12 (1) Ensure the coordination of health care delivery for 13 medical assistance program recipients to address the entire 14 spectrum of an individual’s physical, behavioral, and mental 15 health needs by targeting at a minimum population health, 16 prevention, health promotion, chronic disease management, 17 disability, and long-term care. 18 (2) Emphasize whole person orientation and coordination and 19 integration of both clinical and nonclinical care and supports, 20 to provide individuals with the necessary tools to address 21 determinants of health and to empower individuals to be full 22 participants in their own health. The health care delivery 23 model shall focus on addressing population health through 24 primary and team-based care that incorporates the attributes of 25 a medical home as specified in chapter 135, division XXII. 26 (3) Ensure accessibility of medical assistance program 27 recipients to an adequate and qualified workforce by most 28 efficiently utilizing the skills of the available workforce. 29 (4) Incorporate appropriate incentives that focus on 30 quality outcomes and patient satisfaction, to move from 31 volume-based to value-based purchasing. 32 (5) Provide for alignment of payment methods and quality 33 across health care payers to ensure a unified set of outcomes 34 and to recognize, through reimbursement, all participants in 35 -7- SF 296 (3) 85 pf/rj/jh 7/ 14
S.F. 296 the integrated system of care. 1 b. Strategies and model designs: 2 (1) A strategy to implement a multipayer integrated 3 care model methodology across primary health care payers 4 in the state, by aligning performance measures, utilizing 5 a shared savings or other accountable payment methodology, 6 and integrating an information technology platform to 7 support the integrated care model. The strategy shall 8 ensure statewide adoption of integrated care for the medical 9 assistance population; explore the role of managed care 10 plans and expansion of managed care in the medical assistance 11 program as part of the integrated care model; address the 12 special circumstances of areas of the state that are rural, 13 underserved, or have higher rates of health disparities; and 14 seek the participation of the Medicare population in the 15 integrated care model. 16 (2) A strategy to incorporate long-term care and behavioral 17 health services for the medical assistance population into the 18 integrated care model, through integration of community health 19 and community prevention activities. 20 (3) A strategy to address population health and health 21 promotion, by investing in approaches to influence modifiable 22 determinants of health such as access to health care, healthy 23 behaviors, socioeconomic factors, and the physical environment 24 that collectively impact the health of the community. The 25 strategy shall address the underlying, pervasive, and 26 multifaceted socioeconomic impediments that medical assistance 27 recipients face in being full participants in their own health. 28 (4) A multiphase strategy to implement a statewide 29 integrated care model to maximize access to health care for 30 medical assistance program recipients in all areas of the 31 state. The strategy shall incorporate flexible integrated 32 care model options and accountable payment methodologies 33 for participation by various types of providers including 34 individual providers, safety net providers, and nonprofit 35 -8- SF 296 (3) 85 pf/rj/jh 8/ 14
S.F. 296 and public providers that have long experience in caring for 1 vulnerable populations, into the integrated system. 2 (5) Implement a stakeholder process. In addition to the 3 oversight and input provided by the legislative advisory 4 council, the department shall hold public local listening 5 sessions throughout the state, collaborate with consumer groups 6 and provider groups, and partner with other state agencies such 7 as the department on aging and the department of public health 8 to elicit input and feedback on the model design. 9 (6) Develop a multipayer approach including the medical 10 assistance and children’s health insurance programs, private 11 payers, and Medicare. 12 (7) Oversee the administration of the model design project. 13 (8) Engage providers beyond the large integrated health 14 systems to maximize access to all levels of care within an 15 integrated model program by medical assistance recipients. 16 4. The department shall submit proposed legislation 17 specifying the model design and implementation plan to the 18 advisory council no later than December 15, 2013. 19 Sec. 9. LEGISLATIVE COMMISSION ON INTEGRATED CARE MODELS. 20 1. a. A legislative commission on integrated care models 21 is created for the 2013 Legislative Interim. The legislative 22 services agency shall provide staffing assistance to the 23 commission. 24 b. The commission shall include 10 members of the general 25 assembly, three appointed by the majority leader of the senate, 26 two appointed by the minority leader of the senate, three 27 appointed by the speaker of the house of representatives, 28 and two appointed by the minority leader of the house of 29 representatives. 30 c. The commission shall include members of the public 31 appointed by the legislative council who represent consumers, 32 health care providers, hospitals and health systems, and other 33 entities with interest or expertise related to integrated care 34 models. 35 -9- SF 296 (3) 85 pf/rj/jh 9/ 14
S.F. 296 d. The commission shall include as ex officio members, the 1 director of human services, the commissioner of insurance, the 2 director of public health, and the attorney general, or the 3 individual’s designee. 4 2. The chairpersons of the commission shall be those members 5 of the general assembly so appointed by the majority leader of 6 the senate and the speaker of the house of representatives. 7 Legislative members of the commission are eligible for per diem 8 and reimbursement of actual expenses as provided in section 9 2.10. Consumers appointed to the commission, are entitled 10 to receive a per diem as specified in section 7E.6 for each 11 day spent in performance of duties as members, and shall be 12 reimbursed for all actual and necessary expenses incurred in 13 the performance of duties as members of the commission. 14 3. The commission shall do all of the following: 15 a. Review and make recommendations relating to the 16 formation and operation of integrated care models in the 17 state. The models shall include any care delivery model that 18 integrates providers and incorporates a financial incentive 19 to improve patient health outcomes, improve care, and reduce 20 costs. Integrated care models include but are not limited 21 to patient-centered medical homes, health homes, accountable 22 care organizations (ACOs), ACO-like models, community and 23 regional care networks, and other integrated and accountable 24 care delivery models that utilize value-based financing 25 methodologies and emphasize person-centered, coordinated, and 26 comprehensive care. 27 b. Review integrated care models created in other states 28 that integrate both clinical services and nonclinical community 29 and social supports utilizing patient-centered medical homes 30 and community care teams as basic components to determine the 31 feasibility of adapting any of these models as a statewide 32 system in Iowa. These models may include but are not limited 33 to the ACO demonstration program based on the Camden Coalition 34 of Healthcare Providers in Camden, New Jersey; the Medical 35 -10- SF 296 (3) 85 pf/rj/jh 10/ 14
S.F. 296 Home Network in Chicago, Illinois; the Health Commons model in 1 New Mexico; the Accountable Care Collaborative in Colorado; 2 Community Care of North Carolina, in North Carolina; the 3 Blueprint for Health and the Community Health Teams in Vermont; 4 and the Coordinated Care Organizations in Oregon. 5 c. Recommend the best means of providing care through 6 integrated delivery models throughout the state including to 7 vulnerable populations and how best to incorporate safety net 8 providers, including but not limited to federally qualified 9 health centers, rural health clinics, community mental health 10 centers, public hospitals, and other nonprofit and public 11 providers that have long experience in caring for vulnerable 12 populations, into the integrated system. 13 d. Review the progress of the development of medical 14 homes as specified in chapter 135, division XXII in the 15 state and make recommendations for development of a statewide 16 infrastructure of actual and virtual medical homes to act as 17 the foundation for integrated care models. 18 e. Review opportunities under the federal Patient 19 Protection and Affordable Care Act (Affordable Care Act), 20 Pub. L. No. 11-148, as amended, for the development of 21 integrated care models including the Medicare Shared Savings 22 Program for accountable care organizations, community-based 23 collaborative care networks that include safety net providers, 24 and consumer-operated and oriented plans. The legislative 25 commission shall also review existing and proposed integrated 26 care models in the state including commercial models and those 27 developed or proposed under the Affordable Care Act including 28 the Medicare Shared Savings Program and the Pioneer ACO to 29 determine the opportunities for expansion or replication. 30 f. Address the issues relative to integrated care models 31 including those relating to consumer protection including 32 those that relate to confidentiality, quality assurance, 33 grievance procedures, and appeals of patient care decisions; 34 payment methodologies, multipayer alignment, coordination 35 -11- SF 296 (3) 85 pf/rj/jh 11/ 14
S.F. 296 of funding streams, and financing methods that support full 1 integration of clinical and nonclinical services and providers; 2 organizational, management, and governing structures; 3 access, quality, outcomes, utilization, and other appropriate 4 performance standards; patient attribution or assignment 5 models; health information exchange, data reporting, and 6 infrastructure standards; and regulatory issues including 7 clinical integration limitations, physician self-referral, 8 anti-kickback provisions, gain-sharing, beneficiary 9 inducements, antitrust issues, tax exemption issues, and 10 application of insurance regulations. 11 4. The legislative commission may request from any state 12 agency or official information and assistance as needed to 13 perform the review and make recommendations. 14 5. The legislative commission shall submit a final report 15 summarizing the legislative commission’s review and making 16 recommendations to the governor and the general assembly by 17 December 15, 2013. 18 Sec. 10. MEDICAID STATE PLAN. 19 1. The department of human services shall amend the medical 20 assistance state plan to reflect the provisions relating to the 21 provision of a medical home to medical assistance recipients 22 as provided in this Act. 23 2. The department of human services shall amend the medical 24 assistance state plan to provide for coverage of adults up to 25 133 percent of the federal poverty level as provided pursuant 26 to section 249A.3, subsection 1, paragraph “v”, as enacted in 27 this Act, beginning January 1, 2014. The state plan amendment 28 shall include a provision specifying that if the methodology 29 for calculating the federal medical assistance percentage for 30 newly eligible individuals under section 249A.3, subsection 1, 31 paragraph “v”, as provided in 42 U.S.C. § 1396d(y), is modified 32 through federal law or regulation before January 1, 2020, in 33 a manner that reduces the percentage of federal assistance to 34 the state, the department of human services shall implement 35 -12- SF 296 (3) 85 pf/rj/jh 12/ 14
S.F. 296 an alternative plan for coverage of the affected population, 1 to the extent necessary, so that state expenditures remain 2 budget neutral under the modified federal medical assistance 3 percentage relative to the percentage specified for the same 4 fiscal year under section 42 U.S.C. § 1396d(y). The state plan 5 amendment shall provide that implementation by the department 6 of human services of any alternative plan for coverage of 7 the affected population is subject to prior approval of the 8 implementation by statute. 9 3. The department of human services shall amend the medical 10 assistance state plan to provide that the benchmark benefit 11 plan provided to the newly covered adults under the medical 12 assistance program is the option provided pursuant to 42 U.S.C. 13 § 1396u-7(b)(1)(D) which is at a minimum the coverage included 14 in the medical assistance state plan benefit package for 15 individuals otherwise eligible under section 249A.3, subsection 16 1, and adjusted as necessary to provide the essential health 17 benefits as required pursuant to section 1302 of the federal 18 Patient Protection and Affordable Care Act, Pub. L. No. 19 111-148, and as approved by the United States secretary of 20 health and human services. 21 Sec. 11. ADOPTION OF RULES. The department of human 22 services shall adopt emergency rules pursuant to section 17A.4, 23 subsection 3, and section 17A.5, subsection 2, paragraph “b”, 24 as necessary to implement the provisions of this Act, and 25 the rules shall be effective immediately upon filing unless 26 a later date is specified in the rules. Any rules adopted 27 in accordance with this section shall also be published as a 28 notice of intended action as provided in section 17A.4. 29 Sec. 12. EFFECTIVE DATE. The following provision or 30 provisions of this Act take effect December 31, 2013: 31 1. The section of this Act amending section 249A.3, 32 subsection 2, paragraph “a”, subparagraph (9). 33 Sec. 13. EFFECTIVE UPON ENACTMENT. With the exception of 34 the section of this Act amending section 249A.3, subsection 35 -13- SF 296 (3) 85 pf/rj/jh 13/ 14
S.F. 296 2, paragraph “a”, subparagraph (9), this Act, being deemed of 1 immediate importance, takes effect upon enactment. 2 -14- SF 296 (3) 85 pf/rj/jh 14/ 14