Senate
File
2213
-
Reprinted
SENATE
FILE
2213
BY
COMMITTEE
ON
HUMAN
RESOURCES
(SUCCESSOR
TO
SF
2107)
(As
Amended
and
Passed
by
the
Senate
March
2,
2016
)
A
BILL
FOR
An
Act
relating
to
Medicaid
program
improvement,
and
including
1
effective
date
and
retroactive
applicability
provisions.
2
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
3
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2213
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2213
Section
1.
LEGISLATIVE
FINDINGS
——
GOALS
AND
INTENT.
1
1.
The
general
assembly
finds
all
of
the
following:
2
a.
In
the
majority
of
states,
Medicaid
managed
care
has
3
been
introduced
on
an
incremental
basis,
beginning
with
the
4
enrollment
of
low-income
children
and
parents
and
proceeding
5
in
stages
to
include
nonelderly
persons
with
disabilities
and
6
older
individuals.
Iowa,
unlike
the
majority
of
states,
is
7
implementing
Medicaid
managed
care
hastily
and
simultaneously
8
across
a
broad
and
diverse
population
that
includes
individuals
9
with
complex
health
care
and
long-term
services
and
supports
10
needs,
making
these
individuals
especially
vulnerable
to
11
receiving
inappropriate,
inadequate,
or
substandard
services
12
and
supports.
13
b.
The
success
or
failure
of
Medicaid
managed
care
in
Iowa
14
depends
on
proper
strategic
planning
and
strong
oversight,
and
15
the
incorporation
of
the
core
values,
principles,
and
goals
16
of
the
strategic
plan
into
Medicaid
managed
care
contractual
17
obligations.
While
Medicaid
managed
care
techniques
may
create
18
pathways
and
offer
opportunities
toward
quality
improvement
and
19
predictability
in
costs,
if
cost
savings
and
administrative
20
efficiencies
are
the
primary
goals,
Medicaid
managed
care
may
21
instead
erect
new
barriers
and
limit
the
care
and
support
22
options
available,
especially
to
high-need,
vulnerable
Medicaid
23
recipients.
A
well-designed
strategic
plan
and
effective
24
oversight
ensure
that
cost
savings,
improved
health
outcomes,
25
and
efficiencies
are
not
achieved
at
the
expense
of
diminished
26
program
integrity,
a
reduction
in
the
quality
or
availability
27
of
services,
or
adverse
consequences
to
the
health
and
28
well-being
of
Medicaid
recipients.
29
c.
Strategic
planning
should
include
all
of
the
following:
30
(1)
Guidance
in
establishing
and
maintaining
a
robust
31
and
appropriate
workforce
and
a
provider
network
capable
of
32
addressing
all
of
the
diverse,
distinct,
and
wide-ranging
33
treatment
and
support
needs
of
Medicaid
recipients.
34
(2)
Developing
a
sound
methodology
for
establishing
and
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adjusting
capitation
rates
to
account
for
all
essential
costs
1
involved
in
treating
and
supporting
the
entire
spectrum
of
2
needs
across
recipient
populations.
3
(3)
Addressing
the
sufficiency
of
information
and
data
4
resources
to
enable
review
of
factors
such
as
utilization,
5
service
trends,
system
performance,
and
outcomes.
6
(4)
Building
effective
working
relationships
and
developing
7
strategies
to
support
community-level
integration
that
provides
8
cross-system
coordination
and
synchronization
among
the
various
9
service
sectors,
providers,
agencies,
and
organizations
to
10
further
holistic
well-being
and
population
health
goals.
11
d.
While
the
contracts
entered
into
between
the
state
12
and
managed
care
organizations
function
as
a
mechanism
for
13
enforcing
requirements
established
by
the
federal
and
state
14
governments
and
allow
states
to
shift
the
financial
risk
15
associated
with
caring
for
Medicaid
recipients
to
these
16
contractors,
the
state
ultimately
retains
responsibility
for
17
the
Medicaid
program
and
the
oversight
of
the
performance
of
18
the
program’s
contractors.
Administration
of
the
Medicaid
19
program
benefits
by
managed
care
organizations
should
not
be
20
viewed
by
state
policymakers
and
state
agencies
as
a
means
of
21
divesting
themselves
of
their
constitutional
and
statutory
22
responsibilities
to
ensure
that
recipients
of
publicly
funded
23
services
and
supports,
as
well
as
taxpayers
in
general,
are
24
effectively
served.
25
e.
Overseeing
the
performance
of
Medicaid
managed
care
26
contractors
requires
a
different
set
of
skills
than
those
27
required
for
administering
a
fee-for-service
program.
In
the
28
absence
of
the
in-house
capacity
of
the
department
of
human
29
services
to
perform
tasks
specific
to
Medicaid
managed
care
30
oversight,
the
state
essentially
cedes
its
responsibilities
31
to
private
contractors
and
relinquishes
its
accountability
32
to
the
public.
In
order
to
meet
these
responsibilities,
33
state
policymakers
must
ensure
that
the
state,
including
the
34
department
of
human
services
as
the
state
Medicaid
agency,
has
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the
authority
and
resources,
including
the
adequate
number
of
1
qualified
personnel
and
the
necessary
tools,
to
carry
out
these
2
responsibilities,
provide
effective
administration,
and
ensure
3
accountability
and
compliance.
4
f.
State
policymakers
must
also
ensure
that
Medicaid
5
managed
care
contracts
contain,
at
a
minimum,
clear,
6
unambiguous
performance
standards,
operating
guidelines,
7
data
collection,
maintenance,
retention,
and
reporting
8
requirements,
and
outcomes
expectations
so
that
contractors
9
and
subcontractors
are
held
accountable
to
clear
contract
10
specifications.
11
g.
As
with
all
system
and
program
redesign
efforts
12
undertaken
in
the
state
to
date,
the
assumption
of
the
13
administration
of
Medicaid
program
benefits
by
managed
care
14
organizations
must
involve
ongoing
stakeholder
input
and
15
earn
the
trust
and
support
of
these
stakeholders.
Medicaid
16
recipients,
providers,
advocates,
and
other
stakeholders
have
17
intimate
knowledge
of
the
people
and
processes
involved
in
18
ensuring
the
health
and
safety
of
Medicaid
recipients,
and
are
19
able
to
offer
valuable
insight
into
the
barriers
likely
to
be
20
encountered
as
well
as
propose
solutions
for
overcoming
these
21
obstacles.
Local
communities
and
providers
of
services
and
22
supports
have
firsthand
experience
working
with
the
Medicaid
23
recipients
they
serve
and
are
able
to
identify
factors
that
24
must
be
considered
to
make
a
system
successful.
Agencies
and
25
organizations
that
have
specific
expertise
and
experience
with
26
the
services
and
supports
needs
of
Medicaid
recipients
and
27
their
families
are
uniquely
placed
to
provide
needed
assistance
28
in
developing
the
measures
for
and
in
evaluating
the
quality
29
of
the
program.
30
2.
It
is
the
intent
of
the
general
assembly
that
the
31
Medicaid
program
be
implemented
and
administered,
including
32
through
Medicaid
managed
care
policies
and
contract
provisions,
33
in
a
manner
that
safeguards
the
interests
of
Medicaid
34
recipients,
encourages
the
participation
of
Medicaid
providers,
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and
protects
the
interests
of
all
taxpayers,
while
attaining
1
the
goals
of
Medicaid
modernization
to
improve
quality
and
2
access,
promote
accountability
for
outcomes,
and
create
a
more
3
predictable
and
sustainable
Medicaid
budget.
4
HEALTH
POLICY
OVERSIGHT
COMMITTEE
5
Sec.
2.
Section
2.45,
subsection
6,
Code
2016,
is
amended
6
to
read
as
follows:
7
6.
The
legislative
health
policy
oversight
committee,
which
8
shall
be
composed
of
ten
members
of
the
general
assembly,
9
consisting
of
five
members
from
each
house,
to
be
appointed
10
by
the
legislative
council.
The
legislative
health
policy
11
oversight
committee
shall
receive
updates
and
review
data,
12
public
input
and
concerns,
and
make
recommendations
for
13
improvements
to
and
changes
in
law
or
rule
regarding
Medicaid
14
managed
care
meet
at
least
four
times
annually
to
evaluate
15
state
health
policy
and
provide
continuing
oversight
for
16
publicly
funded
programs,
including
but
not
limited
to
all
17
facets
of
the
Medicaid
and
hawk-i
programs
to,
at
a
minimum,
18
ensure
effective
and
efficient
administration
of
these
19
programs,
address
stakeholder
concerns,
monitor
program
costs
20
and
expenditures,
and
make
recommendations
relative
to
the
21
programs
.
22
Sec.
3.
HEALTH
POLICY
OVERSIGHT
COMMITTEE
——
SUBJECT
23
MATTER
REVIEW
FOR
2016
LEGISLATIVE
INTERIM.
During
the
2016
24
legislative
interim,
the
health
policy
oversight
committee
25
created
in
section
2.45
shall,
as
part
of
the
committee’s
26
evaluation
of
state
health
policy
and
review
of
all
facets
27
of
the
Medicaid
and
hawk-i
programs,
review
and
make
28
recommendations
regarding,
at
a
minimum,
all
of
the
following:
29
1.
The
resources
and
duties
of
the
office
of
long-term
30
care
ombudsman
relating
to
the
provision
of
assistance
to
and
31
advocacy
for
Medicaid
recipients
to
determine
the
designation
32
of
duties
and
level
of
resources
necessary
to
appropriately
33
address
the
needs
of
such
individuals.
The
committee
shall
34
consider
the
health
consumer
ombudsman
alliance
report
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submitted
to
the
general
assembly
in
December
2015,
as
well
as
1
input
from
the
office
of
long-term
care
ombudsman
and
other
2
entities
in
making
recommendations.
3
2.
The
health
benefits
and
health
benefit
utilization
4
management
criteria
for
the
Medicaid
and
hawk-i
programs
to
5
determine
the
sufficiency
and
appropriateness
of
the
benefits
6
offered
and
the
utilization
of
these
benefits.
7
3.
Prior
authorization
requirements
relative
to
benefits
8
provided
under
the
Medicaid
and
hawk-i
programs,
including
but
9
not
limited
to
pharmacy
benefits.
10
4.
Consistency
and
uniformity
in
processes,
procedures,
11
forms,
and
other
activities
across
all
Medicaid
and
hawk-i
12
program
participating
insurers
and
managed
care
organizations,
13
including
but
not
limited
to
cost
and
quality
reporting,
14
credentialing,
billing,
prior
authorization,
and
critical
15
incident
reporting.
16
5.
Provider
network
adequacy
including
the
use
of
17
out-of-network
and
out-of-state
providers.
18
6.
The
role
and
interplay
of
other
advisory
and
oversight
19
entities,
including
but
not
limited
to
the
medical
assistance
20
advisory
council
and
the
hawk-i
board.
21
REVIEW
OF
PROGRAM
INTEGRITY
DUTIES
22
Sec.
4.
REVIEW
OF
PROGRAM
INTEGRITY
DUTIES
——
WORKGROUP
——
23
REPORT.
24
1.
The
director
of
human
services
shall
convene
a
25
workgroup
comprised
of
members
including
the
commissioner
26
of
insurance,
the
auditor
of
state,
the
Medicaid
director
27
and
bureau
chiefs
of
the
managed
care
organization
oversight
28
and
supports
bureau,
the
Iowa
Medicaid
enterprise
support
29
bureau,
and
the
medical
and
long-term
services
and
supports
30
bureau,
and
a
representative
of
the
program
integrity
unit,
31
or
their
designees;
and
representatives
of
other
appropriate
32
state
agencies
or
other
entities
including
but
not
limited
to
33
the
office
of
the
attorney
general,
the
office
of
long-term
34
care
ombudsman,
and
the
Medicaid
fraud
control
unit
of
the
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investigations
division
of
the
department
of
inspections
and
1
appeals.
The
workgroup
shall
do
all
of
the
following:
2
a.
Review
the
duties
of
each
entity
with
responsibilities
3
relative
to
Medicaid
program
integrity
and
managed
care
4
organizations;
review
state
and
federal
laws,
regulations,
5
requirements,
guidance,
and
policies
relating
to
Medicaid
6
program
integrity
and
managed
care
organizations;
and
review
7
the
laws
of
other
states
relating
to
Medicaid
program
integrity
8
and
managed
care
organizations.
The
workgroup
shall
determine
9
areas
of
duplication,
fragmentation,
and
gaps;
shall
identify
10
possible
integration,
collaboration
and
coordination
of
duties;
11
and
shall
determine
whether
existing
general
state
Medicaid
12
program
and
fee-for-service
policies,
laws,
and
rules
are
13
sufficient,
or
if
changes
or
more
specific
policies,
laws,
and
14
rules
are
required
to
provide
for
comprehensive
and
effective
15
administration
and
oversight
of
the
Medicaid
program
including
16
under
the
fee-for-service
and
managed
care
methodologies.
17
b.
Review
historical
uses
of
the
Medicaid
fraud
fund
created
18
in
section
249A.50
and
make
recommendations
for
future
uses
19
of
the
moneys
in
the
fund
and
any
changes
in
law
necessary
to
20
adequately
address
program
integrity.
21
c.
Review
medical
loss
ratio
provisions
relative
to
22
Medicaid
managed
care
contracts
and
make
recommendations
23
regarding,
at
a
minimum,
requirements
for
the
necessary
24
collection,
maintenance,
retention,
reporting,
and
sharing
of
25
data
and
information
by
Medicaid
managed
care
organizations
26
for
effective
determination
of
compliance,
and
to
identify
27
the
costs
and
activities
that
should
be
included
in
the
28
calculation
of
administrative
costs,
medical
costs
or
benefit
29
expenses,
health
quality
improvement
costs,
and
other
costs
and
30
activities
incidental
to
the
determination
of
a
medical
loss
31
ratio.
32
d.
Review
the
capacity
of
state
agencies,
including
the
need
33
for
specialized
training
and
expertise,
to
address
Medicaid
34
and
managed
care
organization
program
integrity
and
provide
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recommendations
for
the
provision
of
necessary
resources
and
1
infrastructure,
including
annual
budget
projections.
2
e.
Review
the
incentives
and
penalties
applicable
to
3
violations
of
program
integrity
requirements
to
determine
their
4
adequacy
in
combating
waste,
fraud,
abuse,
and
other
violations
5
that
divert
limited
resources
that
would
otherwise
be
expended
6
to
safeguard
the
health
and
welfare
of
Medicaid
recipients,
7
and
make
recommendations
for
necessary
adjustments
to
improve
8
compliance.
9
f.
Make
recommendations
regarding
the
quarterly
and
annual
10
auditing
of
financial
reports
required
to
be
performed
for
11
each
Medicaid
managed
care
organization
to
ensure
that
the
12
activities
audited
provide
sufficient
information
to
the
13
division
of
insurance
of
the
department
of
commerce
and
the
14
department
of
human
services
to
ensure
program
integrity.
The
15
recommendations
shall
also
address
the
need
for
additional
16
audits
or
other
reviews
of
managed
care
organizations.
17
g.
Review
and
make
recommendations
to
prohibit
18
cost-shifting
between
state
and
local
and
public
and
private
19
funding
sources
for
services
and
supports
provided
to
Medicaid
20
recipients
whether
directly
or
indirectly
through
the
Medicaid
21
program.
22
2.
The
department
of
human
services
shall
submit
a
report
23
of
the
workgroup
to
the
governor,
the
health
policy
oversight
24
committee
created
in
section
2.45,
and
the
general
assembly
25
initially,
on
or
before
November
15,
2016,
and
on
or
before
26
November
15,
on
an
annual
basis
thereafter,
to
provide
findings
27
and
recommendations
for
a
coordinated
approach
to
comprehensive
28
and
effective
administration
and
oversight
of
the
Medicaid
29
program
including
under
the
fee-for-service
and
managed
care
30
methodologies.
31
MEDICAID
REINVESTMENT
FUND
32
Sec.
5.
NEW
SECTION
.
249A.4C
Medicaid
reinvestment
fund.
33
1.
A
Medicaid
reinvestment
fund
is
created
in
the
state
34
treasury
under
the
authority
of
the
department.
The
department
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2213
of
human
services
shall
collect
an
initial
contribution
of
five
1
million
dollars
from
each
of
the
managed
care
organizations
2
contracting
with
the
state
during
the
fiscal
year
beginning
3
July
1,
2015,
for
an
aggregate
amount
of
fifteen
million
4
dollars,
and
shall
deposit
such
amount
in
the
fund
to
be
5
used
for
Medicaid
ombudsman
activities
through
the
office
6
of
long-term
care
ombudsman.
Additionally,
moneys
from
7
savings
realized
from
the
movement
of
Medicaid
recipients
from
8
institutional
settings
to
home
and
community-based
services,
9
the
portion
of
the
capitation
rate
withheld
from
and
not
10
returned
to
Medicaid
managed
care
organizations
at
the
end
11
of
each
fiscal
year,
any
recouped
excess
of
capitation
rates
12
paid
to
Medicaid
managed
care
organizations,
any
overpayments
13
recovered
under
Medicaid
managed
care
contracts,
and
any
14
other
savings
realized
from
Medicaid
managed
care
or
from
15
Medicaid
program
cost-containment
efforts,
with
the
exception
16
of
the
total
amount
attributable
to
the
projected
savings
from
17
Medicaid
managed
care
based
on
the
initial
capitation
rates
18
established
for
the
fiscal
year
beginning
July
1,
2015,
shall
19
be
credited
to
the
Medicaid
reinvestment
fund.
20
2.
Notwithstanding
section
8.33,
moneys
credited
to
21
the
fund
from
any
other
account
or
fund
shall
not
revert
to
22
the
other
account
or
fund.
Moneys
in
the
fund
shall
only
23
be
used
as
provided
in
appropriations
from
the
fund
for
24
the
Medicaid
program
and
for
health
system
transformation
25
and
integration,
including
but
not
limited
to
providing
26
the
necessary
infrastructure
and
resources
to
protect
the
27
interests
of
Medicaid
recipients,
maintaining
adequate
provider
28
participation,
and
ensuring
program
integrity.
Such
uses
may
29
include
but
are
not
limited
to:
30
a.
Ensuring
appropriate
reimbursement
of
Medicaid
31
providers
to
maintain
the
type
and
number
of
appropriately
32
trained
providers
necessary
to
address
the
needs
of
Medicaid
33
recipients.
34
b.
Providing
home
and
community-based
services
as
necessary
35
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to
rebalance
the
long-term
services
and
supports
infrastructure
1
and
to
reduce
Medicaid
home
and
community-based
services
waiver
2
waiting
lists.
3
c.
Ensuring
that
a
fully
functioning
independent
Medicaid
4
ombudsman
program
through
the
office
of
long-term
care
5
ombudsman
is
available
to
provide
advocacy
services
and
6
assistance
to
eligible
and
potentially
eligible
Medicaid
7
recipients.
8
d.
Ensuring
adequate
and
appropriate
capacity
of
the
9
department
of
human
services
as
the
single
state
agency
10
designated
to
administer
and
supervise
the
administration
of
11
the
Medicaid
program,
to
ensure
compliance
with
state
and
12
federal
law
and
program
integrity
requirements.
13
e.
Addressing
workforce
issues
to
ensure
a
competent,
14
diverse,
and
sustainable
health
care
workforce
and
to
15
improve
access
to
health
care
in
underserved
areas
and
among
16
underserved
populations,
recognizing
long-term
services
and
17
supports
as
an
essential
component
of
the
health
care
system.
18
f.
Supporting
innovation,
longer-term
community
19
investments,
and
the
activities
of
local
public
health
20
agencies,
aging
and
disability
resource
centers
and
service
21
agencies,
mental
health
and
disability
services
regions,
social
22
services,
and
child
welfare
entities
and
other
providers
of
23
and
advocates
for
services
and
supports
to
encourage
health
24
system
transformation
and
integration
through
a
broad
range
of
25
prevention
strategies
and
population-based
approaches
to
meet
26
the
holistic
needs
of
the
population
as
a
whole.
27
3.
The
department
shall
establish
a
mechanism
to
measure
and
28
certify
the
amount
of
savings
resulting
from
Medicaid
managed
29
care
and
Medicaid
program
cost-containment
activities
and
shall
30
ensure
that
such
realized
savings
are
credited
to
the
fund
and
31
used
as
provided
in
appropriations
from
the
fund.
32
MEDICAID
OMBUDSMAN
33
Sec.
6.
Section
231.44,
Code
2016,
is
amended
to
read
as
34
follows:
35
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231.44
Utilization
of
resources
——
assistance
and
advocacy
1
related
to
long-term
services
and
supports
under
the
Medicaid
2
program.
3
1.
The
office
of
long-term
care
ombudsman
may
shall
4
utilize
its
available
resources
to
provide
assistance
and
5
advocacy
services
to
eligible
recipients
of
long-term
services
6
and
supports
,
or
individuals
seeking
long-term
services
and
7
supports,
and
the
families
or
legal
representatives
of
such
8
eligible
recipients,
of
long-term
services
and
supports
9
provided
through
individuals
under
the
Medicaid
program.
Such
10
assistance
and
advocacy
shall
include
but
is
not
limited
to
all
11
of
the
following:
12
a.
Assisting
recipients
such
individuals
in
understanding
13
the
services,
coverage,
and
access
provisions
and
their
rights
14
under
Medicaid
managed
care.
15
b.
Developing
procedures
for
the
tracking
and
reporting
16
of
the
outcomes
of
individual
requests
for
assistance,
the
17
obtaining
of
necessary
services
and
supports,
and
other
18
aspects
of
the
services
provided
to
eligible
recipients
such
19
individuals
.
20
c.
Providing
advice
and
assistance
relating
to
the
21
preparation
and
filing
of
complaints,
grievances,
and
appeals
22
of
complaints
or
grievances,
including
through
processes
23
available
under
managed
care
plans
and
the
state
appeals
24
process,
relating
to
long-term
services
and
supports
under
the
25
Medicaid
program.
26
d.
Accessing
the
results
of
a
review
of
a
level
of
care
27
assessment
or
reassessment
by
a
managed
care
organization
28
in
which
the
managed
care
organization
recommends
denial
or
29
limited
authorization
of
a
service,
including
the
type
or
level
30
of
service,
the
reduction,
suspension,
or
termination
of
a
31
previously
authorized
service,
or
a
change
in
level
of
care,
32
upon
the
request
of
an
affected
individual.
33
e.
Receiving
notices
of
disenrollment
or
notices
that
would
34
result
in
a
change
in
level
of
care
for
affected
individuals,
35
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including
involuntary
and
voluntary
discharges
or
transfers,
1
from
the
department
of
human
services
or
a
managed
care
2
organization.
3
2.
A
representative
of
the
office
of
long-term
care
4
ombudsman
providing
assistance
and
advocacy
services
authorized
5
under
this
section
for
an
individual,
shall
be
provided
6
access
to
the
individual,
and
shall
be
provided
access
to
7
the
individual’s
medical
and
social
records
as
authorized
by
8
the
individual
or
the
individual’s
legal
representative,
as
9
necessary
to
carry
out
the
duties
specified
in
this
section
.
10
3.
A
representative
of
the
office
of
long-term
care
11
ombudsman
providing
assistance
and
advocacy
services
authorized
12
under
this
section
for
an
individual,
shall
be
provided
access
13
to
administrative
records
related
to
the
provision
of
the
14
long-term
services
and
supports
to
the
individual,
as
necessary
15
to
carry
out
the
duties
specified
in
this
section
.
16
4.
The
office
of
long-term
care
ombudsman
and
17
representatives
of
the
office,
when
providing
assistance
and
18
advocacy
services
under
this
section,
shall
be
considered
a
19
health
oversight
agency
as
defined
in
45
C.F.R.
§164.501
for
20
the
purposes
of
health
oversight
activities
as
described
in
21
45
C.F.R.
§164.512(d)
including
access
to
the
health
records
22
and
other
appropriate
information
of
an
individual,
including
23
from
the
department
of
human
services
or
the
applicable
24
Medicaid
managed
care
organization,
as
necessary
to
fulfill
the
25
duties
specified
under
this
section.
The
department
of
human
26
services,
in
collaboration
with
the
office
of
long-term
care
27
ombudsman,
shall
adopt
rules
to
ensure
compliance
by
affected
28
entities
with
this
subsection
and
to
ensure
recognition
of
the
29
office
of
long-term
care
ombudsman
as
a
duly
authorized
and
30
identified
agent
or
representative
of
the
state.
31
5.
The
department
of
human
services
and
Medicaid
managed
32
care
organizations
shall
inform
eligible
and
potentially
33
eligible
Medicaid
recipients
of
the
advocacy
services
and
34
assistance
available
through
the
office
of
long-term
care
35
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ombudsman
and
shall
provide
contact
and
other
information
1
regarding
the
advocacy
services
and
assistance
to
eligible
and
2
potentially
eligible
Medicaid
recipients
as
directed
by
the
3
office
of
long-term
care
ombudsman.
4
6.
When
providing
assistance
and
advocacy
services
under
5
this
section,
the
office
of
long-term
care
ombudsman
shall
act
6
as
an
independent
agency,
and
the
office
of
long-term
care
7
ombudsman
and
representatives
of
the
office
shall
be
free
of
8
any
undue
influence
that
restrains
the
ability
of
the
office
9
or
the
office’s
representatives
from
providing
such
services
10
and
assistance.
11
7.
The
office
of
long-term
care
ombudsman
shall,
in
addition
12
to
other
duties
prescribed
and
at
a
minimum,
do
all
of
the
13
following
in
the
furtherance
of
the
provision
of
advocacy
14
services
and
assistance
under
this
section:
15
a.
Represent
the
interests
of
eligible
and
potentially
16
eligible
Medicaid
recipients
before
governmental
agencies.
17
b.
Analyze,
comment
on,
and
monitor
the
development
and
18
implementation
of
federal,
state,
and
local
laws,
regulations,
19
and
other
governmental
policies
and
actions,
and
recommend
20
any
changes
in
such
laws,
regulations,
policies,
and
actions
21
as
determined
appropriate
by
the
office
of
long-term
care
22
ombudsman.
23
c.
To
maintain
transparency
and
accountability
for
24
activities
performed
under
this
section,
including
for
the
25
purposes
of
claiming
federal
financial
participation
for
26
activities
that
are
performed
to
assist
with
administration
of
27
the
Medicaid
program:
28
(1)
Have
complete
and
direct
responsibility
for
the
29
administration,
operation,
funding,
fiscal
management,
and
30
budget
related
to
such
activities,
and
directly
employ,
31
oversee,
and
supervise
all
paid
and
volunteer
staff
associated
32
with
these
activities.
33
(2)
Establish
separation-of-duties
requirements,
provide
34
limited
access
to
work
space
and
work
product
for
only
35
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necessary
staff,
and
limit
access
to
documents
and
information
1
as
necessary
to
maintain
the
confidentiality
of
the
protected
2
health
information
of
individuals
served
under
this
section.
3
(3)
Collect
and
submit,
annually,
to
the
governor,
the
4
health
policy
oversight
committee
created
in
section
2.45,
and
5
the
general
assembly,
all
of
the
following
with
regard
to
those
6
seeking
advocacy
services
or
assistance
under
this
section:
7
(a)
The
number
of
contacts
by
contact
type
and
geographic
8
location.
9
(b)
The
type
of
assistance
requested
including
the
name
of
10
the
managed
care
organization
involved,
if
applicable.
11
(c)
The
time
frame
between
the
time
of
the
initial
contact
12
and
when
an
initial
response
was
provided.
13
(d)
The
amount
of
time
from
the
initial
contact
to
14
resolution
of
the
problem
or
concern.
15
(e)
The
actions
taken
in
response
to
the
request
for
16
advocacy
or
assistance.
17
(f)
The
outcomes
of
requests
to
address
problems
or
18
concerns.
19
4.
8.
For
the
purposes
of
this
section
:
20
a.
“Institutional
setting”
includes
a
long-term
care
21
facility,
an
elder
group
home,
or
an
assisted
living
program.
22
b.
“Long-term
services
and
supports”
means
the
broad
range
of
23
health,
health-related,
and
personal
care
assistance
services
24
and
supports,
provided
in
both
institutional
settings
and
home
25
and
community-based
settings,
necessary
for
older
individuals
26
and
persons
with
disabilities
who
experience
limitations
in
27
their
capacity
for
self-care
due
to
a
physical,
cognitive,
or
28
mental
disability
or
condition.
29
Sec.
7.
NEW
SECTION
.
231.44A
Willful
interference
with
30
duties
related
to
long-term
services
and
supports
——
penalty.
31
Willful
interference
with
a
representative
of
the
office
of
32
long-term
care
ombudsman
in
the
performance
of
official
duties
33
in
accordance
with
section
231.44
is
a
violation
of
section
34
231.44,
subject
to
a
penalty
prescribed
by
rule.
The
office
35
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of
long-term
care
ombudsman
shall
adopt
rules
specifying
the
1
amount
of
a
penalty
imposed,
consistent
with
the
penalties
2
imposed
under
section
231.42,
subsection
8,
and
specifying
3
procedures
for
notice
and
appeal
of
penalties
imposed.
Any
4
moneys
collected
pursuant
to
this
section
shall
be
deposited
in
5
the
Medicaid
reinvestment
fund
created
in
section
249A.4C.
6
MEDICAL
ASSISTANCE
ADVISORY
COUNCIL
7
Sec.
8.
Section
249A.4B,
Code
2016,
is
amended
to
read
as
8
follows:
9
249A.4B
Medical
assistance
advisory
council.
10
1.
A
medical
assistance
advisory
council
is
created
to
11
comply
with
42
C.F.R.
§431.12
based
on
section
1902(a)(4)
of
12
the
federal
Social
Security
Act
and
to
advise
the
director
13
about
health
and
medical
care
services
under
the
medical
14
assistance
Medicaid
program
,
participate
in
Medicaid
policy
15
development
and
program
administration,
and
provide
guidance
16
on
key
issues
related
to
the
Medicaid
program,
whether
17
administered
under
a
fee-for-service,
managed
care,
or
other
18
methodology,
including
but
not
limited
to
access
to
care,
19
quality
of
care,
and
service
delivery
.
20
a.
The
council
shall
have
the
opportunity
for
participation
21
in
policy
development
and
program
administration,
including
22
furthering
the
participation
of
recipients
of
the
program,
and
23
without
limiting
this
general
authority
shall
specifically
do
24
all
of
the
following:
25
(1)
Formulate,
review,
evaluate,
and
recommend
policies,
26
rules,
agency
initiatives,
and
legislation
pertaining
to
the
27
Medicaid
program.
The
council
shall
have
the
opportunity
28
to
comment
on
proposed
rules
prior
to
commencement
of
the
29
rulemaking
process
and
on
waivers
and
state
plan
amendment
30
applications.
31
(2)
Prior
to
the
annual
budget
development
process,
engage
32
in
setting
priorities,
including
consideration
of
the
scope
33
and
utilization
management
criteria
for
benefits,
beneficiary
34
eligibility,
provider
and
services
reimbursement
rates,
and
35
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other
budgetary
issues.
1
(3)
Provide
oversight
for
and
review
of
the
administration
2
of
the
Medicaid
program.
3
(4)
Ensure
that
the
membership
of
the
council
effectively
4
represents
all
relevant
and
concerned
viewpoints,
particularly
5
those
of
consumers,
providers,
and
the
general
public;
create
6
public
understanding;
and
ensure
that
the
services
provided
7
under
the
Medicaid
program
meet
the
needs
of
the
people
served.
8
b.
The
council
shall
meet
no
more
than
at
least
quarterly
,
9
and
prior
to
the
next
subsequent
meeting
of
the
executive
10
committee
.
The
director
of
public
health
The
public
member
11
acting
as
a
co-chairperson
of
the
executive
committee
and
12
the
professional
or
business
entity
member
acting
as
a
13
co-chairperson
of
the
executive
committee,
shall
serve
as
14
chairperson
co-chairpersons
of
the
council.
15
2.
The
council
shall
include
all
of
the
following
voting
16
members:
17
a.
The
president,
or
the
president’s
representative,
of
each
18
of
the
following
professional
or
business
entities,
or
a
member
19
of
each
of
the
following
professional
or
business
entities,
20
selected
by
the
entity:
21
(1)
The
Iowa
medical
society.
22
(2)
The
Iowa
osteopathic
medical
association.
23
(3)
The
Iowa
academy
of
family
physicians.
24
(4)
The
Iowa
chapter
of
the
American
academy
of
pediatrics.
25
(5)
The
Iowa
physical
therapy
association.
26
(6)
The
Iowa
dental
association.
27
(7)
The
Iowa
nurses
association.
28
(8)
The
Iowa
pharmacy
association.
29
(9)
The
Iowa
podiatric
medical
society.
30
(10)
The
Iowa
optometric
association.
31
(11)
The
Iowa
association
of
community
providers.
32
(12)
The
Iowa
psychological
association.
33
(13)
The
Iowa
psychiatric
society.
34
(14)
The
Iowa
chapter
of
the
national
association
of
social
35
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workers.
1
(15)
The
coalition
for
family
and
children’s
services
in
2
Iowa.
3
(16)
The
Iowa
hospital
association.
4
(17)
The
Iowa
association
of
rural
health
clinics.
5
(18)
The
Iowa
primary
care
association.
6
(19)
Free
clinics
of
Iowa.
7
(20)
The
opticians’
association
of
Iowa,
inc.
8
(21)
The
Iowa
association
of
hearing
health
professionals.
9
(22)
The
Iowa
speech
and
hearing
association.
10
(23)
The
Iowa
health
care
association.
11
(24)
The
Iowa
association
of
area
agencies
on
aging.
12
(25)
AARP.
13
(26)
The
Iowa
caregivers
association.
14
(27)
The
Iowa
coalition
of
home
and
community-based
15
services
for
seniors.
16
(28)
The
Iowa
adult
day
services
association.
17
(29)
Leading
age
Iowa.
18
(30)
The
Iowa
association
for
home
care.
19
(31)
The
Iowa
council
of
health
care
centers.
20
(32)
The
Iowa
physician
assistant
society.
21
(33)
The
Iowa
association
of
nurse
practitioners.
22
(34)
The
Iowa
nurse
practitioner
society.
23
(35)
The
Iowa
occupational
therapy
association.
24
(36)
The
ARC
of
Iowa,
formerly
known
as
the
association
for
25
retarded
citizens
of
Iowa.
26
(37)
The
national
alliance
for
the
mentally
ill
on
mental
27
illness
of
Iowa.
28
(38)
The
Iowa
state
association
of
counties.
29
(39)
The
Iowa
developmental
disabilities
council.
30
(40)
The
Iowa
chiropractic
society.
31
(41)
The
Iowa
academy
of
nutrition
and
dietetics.
32
(42)
The
Iowa
behavioral
health
association.
33
(43)
The
midwest
association
for
medical
equipment
services
34
or
an
affiliated
Iowa
organization.
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(44)
The
Iowa
public
health
association.
1
(45)
The
epilepsy
foundation.
2
b.
Public
representatives
which
may
include
members
of
3
consumer
groups,
including
recipients
of
medical
assistance
or
4
their
families,
consumer
organizations,
and
others,
which
shall
5
be
appointed
by
the
governor
in
equal
in
number
to
the
number
6
of
representatives
of
the
professional
and
business
entities
7
specifically
represented
under
paragraph
“a”
,
appointed
by
the
8
governor
for
staggered
terms
of
two
years
each,
none
of
whom
9
shall
be
members
of,
or
practitioners
of,
or
have
a
pecuniary
10
interest
in
any
of
the
professional
or
business
entities
11
specifically
represented
under
paragraph
“a”
,
and
a
majority
12
of
whom
shall
be
current
or
former
recipients
of
medical
13
assistance
or
members
of
the
families
of
current
or
former
14
recipients.
15
3.
The
council
shall
include
all
of
the
following
nonvoting
16
members:
17
c.
a.
The
director
of
public
health,
or
the
director’s
18
designee.
19
d.
b.
The
director
of
the
department
on
aging,
or
the
20
director’s
designee.
21
c.
The
state
long-term
care
ombudsman,
or
the
ombudsman’s
22
designee.
23
d.
The
ombudsman
appointed
pursuant
to
section
2C.3,
or
the
24
ombudsman’s
designee.
25
e.
The
dean
of
Des
Moines
university
——
osteopathic
medical
26
center,
or
the
dean’s
designee.
27
f.
The
dean
of
the
university
of
Iowa
college
of
medicine,
28
or
the
dean’s
designee.
29
g.
The
following
members
of
the
general
assembly,
each
for
a
30
term
of
two
years
as
provided
in
section
69.16B
:
31
(1)
Two
members
of
the
house
of
representatives,
one
32
appointed
by
the
speaker
of
the
house
of
representatives
33
and
one
appointed
by
the
minority
leader
of
the
house
of
34
representatives
from
their
respective
parties.
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(2)
Two
members
of
the
senate,
one
appointed
by
the
1
president
of
the
senate
after
consultation
with
the
majority
2
leader
of
the
senate
and
one
appointed
by
the
minority
leader
3
of
the
senate.
4
3.
4.
a.
An
executive
committee
of
the
council
is
created
5
and
shall
consist
of
the
following
members
of
the
council:
6
(1)
As
voting
members:
7
(a)
Five
of
the
professional
or
business
entity
members
8
designated
pursuant
to
subsection
2
,
paragraph
“a”
,
and
9
selected
by
the
members
specified
under
that
paragraph.
10
(2)
(b)
Five
of
the
public
members
appointed
pursuant
11
to
subsection
2
,
paragraph
“b”
,
and
selected
by
the
members
12
specified
under
that
paragraph.
Of
the
five
public
members,
at
13
least
one
member
shall
be
a
recipient
of
medical
assistance.
14
(3)
(2)
As
nonvoting
members:
15
(a)
The
director
of
public
health,
or
the
director’s
16
designee.
17
(b)
The
director
of
the
department
on
aging,
or
the
18
director’s
designee.
19
(c)
The
state
long-term
care
ombudsman,
or
the
ombudsman’s
20
designee.
21
(d)
The
ombudsman
appointed
pursuant
to
section
2C.3,
or
the
22
ombudsman’s
designee.
23
b.
The
executive
committee
shall
meet
on
a
monthly
basis.
24
The
director
of
public
health
A
public
member
of
the
executive
25
committee
selected
by
the
public
members
appointed
pursuant
to
26
subsection
2,
paragraph
“b”
,
and
a
professional
or
business
27
entity
member
of
the
executive
committee
selected
by
the
28
professional
or
business
entity
members
appointed
pursuant
29
to
subsection
2,
paragraph
“a”
,
shall
serve
as
chairperson
30
co-chairpersons
of
the
executive
committee.
31
c.
Based
upon
the
deliberations
of
the
council
,
and
the
32
executive
committee,
and
the
subcommittees,
the
executive
33
committee
,
the
council,
and
the
subcommittees,
respectively,
34
shall
make
recommendations
to
the
director
,
to
the
health
35
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policy
oversight
committee
created
in
section
2.45,
to
the
1
general
assembly’s
joint
appropriations
subcommittee
on
health
2
and
human
services,
and
to
the
general
assembly’s
standing
3
committees
on
human
resources
regarding
the
budget,
policy,
and
4
administration
of
the
medical
assistance
program.
5
5.
a.
The
council
shall
create
the
following
subcommittees,
6
and
may
create
additional
subcommittees
as
necessary
to
address
7
Medicaid
program
policies,
administration,
budget,
and
other
8
factors
and
issues:
9
(1)
A
stakeholder
safeguards
subcommittee,
for
which
10
the
co-chairpersons
shall
be
a
public
member
of
the
council
11
appointed
pursuant
to
subsection
2,
paragraph
“b”
,
and
selected
12
by
the
public
members
of
the
council,
and
a
representative
13
of
a
professional
or
business
entity
appointed
pursuant
to
14
subsection
2,
paragraph
“a”
,
and
selected
by
the
professional
or
15
business
entity
representatives
of
the
council.
The
mission
16
of
the
stakeholder
safeguards
subcommittee
is
to
provide
for
17
ongoing
stakeholder
engagement
and
feedback
on
issues
affecting
18
Medicaid
recipients,
providers,
and
other
stakeholders,
19
including
but
not
limited
to
benefits
such
as
transportation,
20
benefit
utilization
management,
the
inclusion
of
out-of-state
21
and
out-of-network
providers
and
the
use
of
single-case
22
agreements,
and
reimbursement
of
providers
and
services.
23
(2)
The
long-term
services
and
supports
subcommittee
24
which
shall
be
chaired
by
the
state
long-term
care
ombudsman,
25
or
the
ombudsman’s
designee.
The
mission
of
the
long-term
26
services
and
supports
subcommittee
is
to
be
a
resource
and
to
27
provide
advice
on
policy
development
and
program
administration
28
relating
to
Medicaid
long-term
services
and
supports
including
29
but
not
limited
to
developing
outcomes
and
performance
30
measures
for
Medicaid
managed
care
for
the
long-term
services
31
and
supports
population;
addressing
issues
related
to
home
32
and
community-based
services
waivers
and
waiting
lists;
and
33
reviewing
the
system
of
long-term
services
and
supports
to
34
ensure
provision
of
home
and
community-based
services
and
the
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rebalancing
of
the
health
care
infrastructure
in
accordance
1
with
state
and
federal
law
including
but
not
limited
to
the
2
principles
established
in
Olmstead
v.
L.C.,
527
U.S.
581
3
(1999)
and
the
federal
Americans
with
Disabilities
Act
and
4
in
a
manner
that
reflects
a
sustainable,
person-centered
5
approach
to
improve
health
and
life
outcomes,
supports
6
maximum
independence,
addresses
medical
and
social
needs
in
a
7
coordinated,
integrated
manner,
and
provides
for
sufficient
8
resources
including
a
stable,
well-qualified
workforce.
The
9
subcommittee
shall
also
address
and
make
recommendations
10
regarding
the
need
for
an
ombudsman
function
for
eligible
and
11
potentially
eligible
Medicaid
recipients
beyond
the
long-term
12
services
and
supports
population.
13
(3)
The
transparency,
data,
and
program
evaluation
14
subcommittee
which
shall
be
chaired
by
the
director
of
the
15
university
of
Iowa
public
policy
center,
or
the
director’s
16
designee.
The
mission
of
the
transparency,
data,
and
program
17
evaluation
subcommittee
is
to
ensure
Medicaid
program
18
transparency;
ensure
the
collection,
maintenance,
retention,
19
reporting,
and
analysis
of
sufficient
and
meaningful
data
to
20
provide
transparency
and
inform
policy
development
and
program
21
effectiveness;
support
development
and
administration
of
a
22
consumer-friendly
dashboard;
and
promote
the
ongoing
evaluation
23
of
Medicaid
stakeholder
satisfaction
with
the
Medicaid
program.
24
(4)
The
program
integrity
subcommittee
which
shall
be
25
chaired
by
the
Medicaid
director,
or
the
director’s
designee.
26
The
mission
of
the
program
integrity
subcommittee
is
to
ensure
27
that
a
comprehensive
system
including
specific
policies,
laws,
28
and
rules
and
adequate
resources
and
measures
are
in
place
to
29
effectively
administer
the
program
and
to
maintain
compliance
30
with
federal
and
state
program
integrity
requirements.
31
(5)
A
health
workforce
subcommittee,
co-chaired
by
the
32
bureau
chief
of
the
bureau
of
oral
and
health
delivery
systems
33
of
the
department
of
public
health,
or
the
bureau
chief’s
34
designee,
and
the
director
of
the
national
alliance
on
mental
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illness
of
Iowa,
or
the
director’s
designee.
The
mission
of
1
the
health
workforce
subcommittee
is
to
assess
the
sufficiency
2
and
proficiency
of
the
current
and
projected
health
workforce;
3
identify
barriers
to
and
gaps
in
health
workforce
development
4
initiatives
and
health
workforce
data
to
provide
foundational,
5
evidence-based
information
to
inform
policymaking
and
resource
6
allocation;
evaluate
the
most
efficient
application
and
7
utilization
of
roles,
functions,
responsibilities,
activities,
8
and
decision-making
capacity
of
health
care
professionals
and
9
other
allied
and
support
personnel;
and
make
recommendations
10
for
improvement
in,
and
alternative
modes
of,
health
care
11
delivery
in
order
to
provide
a
competent,
diverse,
and
12
sustainable
health
workforce
in
the
state.
The
subcommittee
13
shall
work
in
collaboration
with
the
office
of
statewide
14
clinical
education
programs
of
the
university
of
Iowa
Carver
15
college
of
medicine,
Des
Moines
university,
Iowa
workforce
16
development,
and
other
entities
with
interest
or
expertise
in
17
the
health
workforce
in
carrying
out
the
subcommittee’s
duties
18
and
developing
recommendations.
19
b.
The
co-chairpersons
of
the
council
shall
appoint
20
members
to
each
subcommittee
from
the
general
membership
of
21
the
council.
Consideration
in
appointing
subcommittee
members
22
shall
include
the
individual’s
knowledge
about,
and
interest
or
23
expertise
in,
matters
that
come
before
the
subcommittee.
24
c.
Subcommittees
shall
meet
at
the
call
of
the
25
co-chairpersons
or
chairperson
of
the
subcommittee,
or
at
the
26
request
of
a
majority
of
the
members
of
the
subcommittee.
27
4.
6.
For
each
council
meeting,
executive
committee
28
meeting,
or
subcommittee
meeting,
a
quorum
shall
consist
of
29
fifty
percent
of
the
membership
qualified
to
vote.
Where
a
30
quorum
is
present,
a
position
is
carried
by
a
majority
of
the
31
members
qualified
to
vote.
32
7.
For
each
council
meeting,
other
than
those
held
during
33
the
time
the
general
assembly
is
in
session,
each
legislative
34
member
of
the
council
shall
be
reimbursed
for
actual
travel
35
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and
other
necessary
expenses
and
shall
receive
a
per
diem
1
as
specified
in
section
7E.6
for
each
day
in
attendance,
as
2
shall
the
members
of
the
council
,
or
the
executive
committee
,
3
or
a
subcommittee,
for
each
day
in
attendance
at
a
council,
4
executive
committee,
or
subcommittee
meeting,
who
are
5
recipients
or
the
family
members
of
recipients
of
medical
6
assistance,
regardless
of
whether
the
general
assembly
is
in
7
session.
8
5.
8.
The
department
shall
provide
staff
support
and
9
independent
technical
assistance
to
the
council
,
and
the
10
executive
committee
,
and
the
subcommittees
.
11
6.
9.
The
director
shall
consider
comply
with
the
12
requirements
of
this
section
regarding
the
duties
of
the
13
council,
and
the
deliberations
and
recommendations
offered
14
by
of
the
council
,
and
the
executive
committee
,
and
the
15
subcommittees
shall
be
reflected
in
the
director’s
preparation
16
of
medical
assistance
budget
recommendations
to
the
council
on
17
human
services
pursuant
to
section
217.3
,
and
in
implementation
18
of
medical
assistance
program
policies
,
and
in
administration
19
of
the
Medicaid
program
.
20
10.
The
council,
executive
committee,
and
subcommittees
21
shall
jointly
submit
quarterly
reports
to
the
health
policy
22
oversight
committee
created
in
section
2.45
and
shall
jointly
23
submit
a
report
to
the
governor
and
the
general
assembly
24
initially
by
January
1,
2017,
and
annually,
therefore,
25
summarizing
the
outcomes
and
findings
of
their
respective
26
deliberations
and
any
recommendations
including
but
not
limited
27
to
those
for
changes
in
law
or
policy.
28
11.
The
council,
executive
committee,
and
subcommittees
29
may
enlist
the
services
of
persons
who
are
qualified
by
30
education,
expertise,
or
experience
to
advise,
consult
with,
31
or
otherwise
assist
the
council,
executive
committee,
or
32
subcommittees
in
the
performance
of
their
duties.
The
council,
33
executive
committee,
or
subcommittees
may
specifically
enlist
34
the
assistance
of
entities
such
as
the
university
of
Iowa
35
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2213
public
policy
center
to
provide
ongoing
evaluation
of
the
1
Medicaid
program
and
to
make
evidence-based
recommendations
to
2
improve
the
program.
The
council,
executive
committee,
and
3
subcommittees
shall
enlist
input
from
the
patient-centered
4
health
advisory
council
created
in
section
135.159,
the
mental
5
health
and
disabilities
services
commission
created
in
section
6
225C.5,
the
commission
on
aging
created
in
section
231.11,
7
the
bureau
of
substance
abuse
of
the
department
of
public
8
health,
the
Iowa
developmental
disabilities
council,
and
other
9
appropriate
state
and
local
entities
to
provide
advice
to
the
10
council,
executive
committee,
and
subcommittees.
11
12.
The
department,
in
accordance
with
42
C.F.R.
§431.12,
12
shall
seek
federal
financial
participation
for
the
activities
13
of
the
council,
the
executive
committee,
and
the
subcommittees.
14
PATIENT-CENTERED
HEALTH
RESOURCES
AND
INFRASTRUCTURE
15
Sec.
9.
Section
135.159,
subsection
2,
Code
2016,
is
amended
16
to
read
as
follows:
17
2.
a.
The
department
shall
establish
a
patient-centered
18
health
advisory
council
which
shall
include
but
is
not
limited
19
to
all
of
the
following
members,
selected
by
their
respective
20
organizations,
and
any
other
members
the
department
determines
21
necessary
to
assist
in
the
department’s
duties
at
various
22
stages
of
development
of
the
medical
home
system
and
in
the
23
transformation
to
a
patient-centered
infrastructure
that
24
integrates
and
coordinates
services
and
supports
to
address
25
social
determinants
of
health
and
meet
population
health
goals
:
26
(1)
The
director
of
human
services,
or
the
director’s
27
designee.
28
(2)
The
commissioner
of
insurance,
or
the
commissioner’s
29
designee.
30
(3)
A
representative
of
the
federation
of
Iowa
insurers.
31
(4)
A
representative
of
the
Iowa
dental
association.
32
(5)
A
representative
of
the
Iowa
nurses
association.
33
(6)
A
physician
and
an
osteopathic
physician
licensed
34
pursuant
to
chapter
148
who
are
family
physicians
and
members
35
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of
the
Iowa
academy
of
family
physicians.
1
(7)
A
health
care
consumer.
2
(8)
A
representative
of
the
Iowa
collaborative
safety
net
3
provider
network
established
pursuant
to
section
135.153
.
4
(9)
A
representative
of
the
Iowa
developmental
disabilities
5
council.
6
(10)
A
representative
of
the
Iowa
chapter
of
the
American
7
academy
of
pediatrics.
8
(11)
A
representative
of
the
child
and
family
policy
center.
9
(12)
A
representative
of
the
Iowa
pharmacy
association.
10
(13)
A
representative
of
the
Iowa
chiropractic
society.
11
(14)
A
representative
of
the
university
of
Iowa
college
of
12
public
health.
13
(15)
A
representative
of
the
Iowa
public
health
14
association.
15
(16)
A
representative
of
the
area
agencies
on
aging.
16
(17)
A
representative
of
the
mental
health
and
disability
17
services
regions.
18
(18)
A
representative
of
early
childhood
Iowa.
19
b.
Public
members
of
the
patient-centered
health
advisory
20
council
shall
receive
reimbursement
for
actual
expenses
21
incurred
while
serving
in
their
official
capacity
only
if
they
22
are
not
eligible
for
reimbursement
by
the
organization
that
23
they
represent.
24
c.
(1)
Beginning
July
1,
2016,
the
patient-centered
health
25
advisory
council
shall
do
all
of
the
following:
26
(a)
Review
and
make
recommendations
to
the
department
and
27
to
the
general
assembly
regarding
the
building
of
effective
28
working
relationships
and
strategies
to
support
state-level
29
and
community-level
integration,
to
provide
cross-system
30
coordination
and
synchronization,
and
to
more
appropriately
31
align
health
delivery
models
and
service
sectors,
including
but
32
not
limited
to
public
health,
aging
and
disability
services
33
agencies,
mental
health
and
disability
services
regions,
34
social
services,
child
welfare,
and
other
providers,
agencies,
35
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organizations,
and
sectors
to
address
social
determinants
of
1
health,
holistic
well-being,
and
population
health
goals.
Such
2
review
and
recommendations
shall
include
a
review
of
funding
3
streams
and
recommendations
for
blending
and
braiding
funding
4
to
support
these
efforts.
5
(b)
Assist
in
efforts
to
evaluate
the
health
workforce
to
6
inform
policymaking
and
resource
allocation.
7
(2)
The
patient-centered
health
advisory
council
shall
8
submit
a
report
to
the
department,
the
health
policy
oversight
9
committee
created
in
section
2.45,
and
the
general
assembly,
10
initially,
on
or
before
December
15,
2016,
and
on
or
before
11
December
15,
annually,
thereafter,
including
any
findings
or
12
recommendations
resulting
from
the
council’s
deliberations.
13
HAWK-I
PROGRAM
14
Sec.
10.
Section
514I.5,
subsection
8,
paragraph
d,
Code
15
2016,
is
amended
by
adding
the
following
new
subparagraph:
16
NEW
SUBPARAGRAPH
.
(17)
Occupational
therapy.
17
Sec.
11.
Section
514I.5,
subsection
8,
Code
2016,
is
amended
18
by
adding
the
following
new
paragraph:
19
NEW
PARAGRAPH
.
m.
The
definition
of
medically
necessary
20
and
the
utilization
management
criteria
under
the
hawk-i
21
program
in
order
to
ensure
that
benefits
are
uniformly
and
22
consistently
provided
across
all
participating
insurers
in
23
the
type
and
manner
that
reflects
and
appropriately
meets
24
the
needs,
including
but
not
limited
to
the
habilitative
and
25
rehabilitative
needs,
of
the
child
population
including
those
26
children
with
special
health
care
needs.
27
MEDICAID
PROGRAM
POLICY
IMPROVEMENT
28
Sec.
12.
DIRECTIVES
FOR
MEDICAID
PROGRAM
POLICY
29
IMPROVEMENTS.
In
order
to
safeguard
the
interests
of
Medicaid
30
recipients,
encourage
the
participation
of
Medicaid
providers,
31
and
protect
the
interests
of
all
taxpayers,
the
department
of
32
human
services
shall
comply
with
or
ensure
that
the
specified
33
entity
complies
with
all
of
the
following
and
shall
amend
34
Medicaid
managed
care
contract
provisions
as
necessary
to
35
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2213
reflect
all
of
the
following:
1
1.
CONSUMER
PROTECTIONS.
2
a.
In
accordance
with
42
C.F.R.
§438.420,
a
Medicaid
managed
3
care
organization
shall
continue
a
recipient’s
benefits
during
4
an
appeal
process.
If,
as
allowed
when
final
resolution
of
5
an
appeal
is
adverse
to
the
Medicaid
recipient,
the
Medicaid
6
managed
care
organization
chooses
to
recover
the
costs
of
the
7
services
furnished
to
the
recipient
while
an
appeal
is
pending,
8
the
Medicaid
managed
care
organization
shall
provide
adequate
9
prior
notice
of
potential
recovery
of
costs
to
the
recipient
at
10
the
time
the
appeal
is
filed,
and
any
costs
recovered
shall
be
11
remitted
to
the
department
of
human
services
and
deposited
in
12
the
Medicaid
reinvestment
fund
created
in
section
249A.4C.
13
b.
Ensure
that
each
Medicaid
managed
care
organization
14
provides,
at
a
minimum,
all
the
benefits
and
services
deemed
15
medically
necessary
that
were
covered,
including
to
the
16
extent
and
in
the
same
manner
and
subject
to
the
same
prior
17
authorization
criteria,
by
the
state
program
directly
under
18
fee
for
service
prior
to
January
1,
2016.
Benefits
covered
19
through
Medicaid
managed
care
shall
comply
with
the
specific
20
requirements
in
state
law
applicable
to
the
respective
Medicaid
21
recipient
population
under
fee
for
service.
22
c.
Enhance
monitoring
of
the
reduction
in
or
suspension
23
or
termination
of
services
provided
to
Medicaid
recipients,
24
including
reductions
in
the
provision
of
home
and
25
community-based
services
waiver
services
or
increases
in
home
26
and
community-based
services
waiver
waiting
lists.
Medicaid
27
managed
care
organizations
shall
provide
data
to
the
department
28
as
necessary
for
the
department
to
compile
periodic
reports
on
29
the
numbers
of
individuals
transferred
from
state
institutions
30
and
long-term
care
facilities
to
home
and
community-based
31
services,
and
the
associated
savings.
Any
savings
resulting
32
from
the
transfers
as
certified
by
the
department
shall
be
33
deposited
in
the
Medicaid
reinvestment
fund
created
in
section
34
249A.4C.
35
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d.
(1)
Require
each
Medicaid
managed
care
organization
to
1
adhere
to
reasonableness
and
service
authorization
standards
2
that
are
appropriate
for
and
do
not
disadvantage
those
3
individuals
who
have
ongoing
chronic
conditions
or
who
require
4
long-term
services
and
supports.
Services
and
supports
for
5
individuals
with
ongoing
chronic
conditions
or
who
require
6
long-term
services
and
supports
shall
be
authorized
in
a
manner
7
that
reflects
the
recipient’s
continuing
need
for
such
services
8
and
supports,
and
limits
shall
be
consistent
with
a
recipient’s
9
current
needs
assessment
and
person-centered
service
plan.
10
(2)
In
addition
to
other
provisions
relating
to
11
community-based
case
management
continuity
of
care
12
requirements,
Medicaid
managed
care
contractors
shall
provide
13
the
option
to
the
case
manager
of
a
Medicaid
recipient
who
14
retained
the
case
manager
during
the
six
months
of
transition
15
to
Medicaid
managed
care,
if
the
recipient
chooses
to
continue
16
to
retain
that
case
manager
beyond
the
six-month
transition
17
period
and
if
the
case
manager
is
not
otherwise
a
participating
18
provider
of
the
recipient’s
managed
care
organization
provider
19
network,
to
enter
into
a
single
case
agreement
to
continue
to
20
provide
case
management
services
to
the
Medicaid
recipient.
21
e.
Ensure
that
Medicaid
recipients
are
provided
care
22
coordination
and
case
management
by
appropriately
trained
23
professionals
in
a
conflict-free
manner.
Care
coordination
and
24
case
management
shall
be
provided
in
a
patient-centered
and
25
family-centered
manner
that
requires
a
knowledge
of
community
26
supports,
a
reasonable
ratio
of
care
coordinators
and
case
27
managers
to
Medicaid
recipients,
standards
for
frequency
of
28
contact
with
the
Medicaid
recipient,
and
specific
and
adequate
29
reimbursement.
30
f.
A
Medicaid
managed
care
contract
shall
include
a
31
provision
for
continuity
and
coordination
of
care
for
a
32
consumer
transitioning
to
Medicaid
managed
care,
including
33
maintaining
existing
provider-recipient
relationships
and
34
honoring
the
amount,
duration,
and
scope
of
a
recipient’s
35
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authorized
services
based
on
the
recipient’s
medical
history
1
and
needs.
In
the
initial
transition
to
Medicaid
managed
care,
2
to
ensure
the
least
amount
of
disruption,
Medicaid
managed
3
care
organizations
shall
provide,
at
a
minimum,
a
one-year
4
transition
of
care
period
for
all
provider
types,
regardless
5
of
network
status
with
an
individual
Medicaid
managed
care
6
organization.
7
g.
Ensure
that
a
Medicaid
managed
care
organization
does
8
not
arbitrarily
deny
coverage
for
medically
necessary
services
9
based
solely
on
financial
reasons
and
does
not
shift
the
10
responsibility
for
provision
of
services
or
payment
of
costs
of
11
services
to
another
entity
to
avoid
costs
or
attain
savings.
12
h.
Ensure
that
dental
coverage,
if
not
integrated
into
13
an
overall
Medicaid
managed
care
contract,
is
part
of
the
14
overall
holistic,
integrated
coverage
for
physical,
behavioral,
15
and
long-term
services
and
supports
provided
to
a
Medicaid
16
recipient.
17
i.
Require
each
Medicaid
managed
care
organization
to
18
verify
the
offering
and
actual
utilization
of
services
and
19
supports
and
value-added
services,
an
individual
recipient’s
20
encounters
and
the
costs
associated
with
each
encounter,
and
21
requests
and
associated
approvals
or
denials
of
services.
22
Verification
of
actual
receipt
of
services
and
supports
and
23
value-added
services
shall,
at
a
minimum,
consist
of
comparing
24
receipt
of
service
against
both
what
was
authorized
in
the
25
recipient’s
benefit
or
service
plan
and
what
was
actually
26
reimbursed.
Value-added
services
shall
not
be
reportable
as
27
allowable
medical
or
administrative
costs
or
factored
into
rate
28
setting,
and
the
costs
of
value-added
services
shall
not
be
29
passed
on
to
recipients
or
providers.
30
j.
Provide
periodic
reports
to
the
governor
and
the
general
31
assembly
regarding
changes
in
quality
of
care
and
health
32
outcomes
for
Medicaid
recipients
under
managed
care
compared
to
33
quality
of
care
and
health
outcomes
of
the
same
populations
of
34
Medicaid
recipients
prior
to
January
1,
2016.
35
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2213
k.
Require
each
Medicaid
managed
care
organization
to
1
maintain
records
of
complaints,
grievances,
and
appeals,
and
2
report
the
number
and
types
of
complaints,
grievances,
and
3
appeals
filed,
the
resolution
of
each,
and
a
description
of
4
any
patterns
or
trends
identified
to
the
department
of
human
5
services
and
the
health
policy
oversight
committee
created
6
in
section
2.45,
on
a
monthly
basis.
The
department
shall
7
review
and
compile
the
data
on
a
quarterly
basis
and
make
the
8
compilations
available
to
the
public.
Following
review
of
9
reports
submitted
by
the
department,
a
Medicaid
managed
care
10
organization
shall
take
any
corrective
action
required
by
the
11
department
and
shall
be
subject
to
any
applicable
penalties.
12
l.
Require
Medicaid
managed
care
organizations
to
survey
13
Medicaid
recipients,
to
collect
satisfaction
data
using
a
14
uniform
instrument,
and
to
provide
a
detailed
analysis
of
15
recipient
satisfaction
as
well
as
various
metrics
regarding
the
16
volume
of
and
timelines
in
responding
to
recipient
complaints
17
and
grievances
as
directed
by
the
department
of
human
services.
18
m.
Require
managed
care
organizations
to
allow
a
recipient
19
to
request
that
the
managed
care
organization
enter
into
20
a
single
case
agreement
with
a
recipient’s
out-of-network
21
provider,
including
a
provider
outside
of
the
state,
to
provide
22
for
continuity
of
care
when
the
recipient
has
an
existing
23
relationship
with
the
provider
to
provide
a
covered
benefit,
or
24
to
ensure
adequate
or
timely
access
to
a
provider
of
a
covered
25
benefit
when
the
managed
care
organization
provider
network
26
cannot
ensure
such
adequate
or
timely
access.
27
2.
CHILDREN.
28
a.
(1)
The
hawk-i
board
shall
retain
all
authority
29
specified
under
chapter
514I
relative
to
the
children
eligible
30
under
section
514I.8
to
participate
in
the
hawk-i
program,
31
including
but
not
limited
to
approving
any
contract
entered
32
into
pursuant
to
chapter
514I;
approving
the
benefit
package
33
design,
reviewing
the
benefit
package
design,
and
making
34
necessary
changes
to
reflect
the
results
of
the
reviews;
and
35
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adopting
rules
for
the
hawk-i
program
including
those
related
1
to
qualifying
standards
for
selecting
participating
insurers
2
for
the
program
and
the
benefits
to
be
included
in
a
health
3
plan.
4
(2)
The
hawk-i
board
shall
review
benefit
plans
and
5
utilization
review
provisions
and
ensure
that
benefits
provided
6
to
children
under
the
hawk-i
program,
at
a
minimum,
reflect
7
those
required
by
state
law
as
specified
in
section
514I.5,
8
include
both
habilitative
and
rehabilitative
services,
and
9
are
provided
as
medically
necessary
relative
to
the
child
10
population
served
and
based
on
the
needs
of
the
program
11
recipient
and
the
program
recipient’s
medical
history.
12
(3)
The
hawk-i
board
shall
work
with
the
department
of
human
13
services
to
coordinate
coverage
and
care
for
the
population
14
of
children
in
the
state
eligible
for
either
Medicaid
or
15
hawk-i
coverage
so
that,
to
the
greatest
extent
possible,
16
the
two
programs
provide
for
continuity
of
care
as
children
17
transition
between
the
two
programs
or
to
private
health
care
18
coverage.
To
this
end,
all
contracts
with
participating
19
insurers
providing
coverage
under
the
hawk-i
program
and
with
20
all
managed
care
organizations
providing
coverage
for
children
21
eligible
for
Medicaid
shall
do
all
of
the
following:
22
(a)
Specifically
and
appropriately
address
the
unique
needs
23
of
children
and
children’s
health
delivery.
24
(b)
Provide
for
the
maintaining
of
child
health
panels
that
25
include
representatives
of
child
health,
welfare,
policy,
and
26
advocacy
organizations
in
the
state
that
address
child
health
27
and
child
well-being.
28
(c)
Address
early
intervention
and
prevention
strategies,
29
the
provision
of
a
child
health
care
delivery
infrastructure
30
for
children
with
special
health
care
needs,
utilization
of
31
current
standards
and
guidelines
for
children’s
health
care
32
and
pediatric-specific
screening
and
assessment
tools,
the
33
inclusion
of
pediatric
specialty
providers
in
the
provider
34
network,
and
the
utilization
of
health
homes
for
children
and
35
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2213
youth
with
special
health
care
needs
including
intensive
care
1
coordination
and
family
support
and
access
to
a
professional
2
family-to-family
support
system.
Such
contracts
shall
utilize
3
pediatric-specific
quality
measures
and
assessment
tools
4
which
shall
align
with
existing
pediatric-specific
measures
5
as
determined
in
consultation
with
the
child
health
panel
and
6
approved
by
the
hawk-i
board.
7
(d)
Provide
special
incentives
for
innovative
and
8
evidence-based
preventive,
behavioral,
and
developmental
9
health
care
and
mental
health
care
for
children’s
programs
that
10
improve
the
life
course
trajectory
of
these
children.
11
(e)
Provide
that
information
collected
from
the
12
pediatric-specific
assessments
be
used
to
identify
health
risks
13
and
social
determinants
of
health
that
impact
health
outcomes.
14
Such
data
shall
be
used
in
care
coordination
and
interventions
15
to
improve
patient
outcomes
and
to
drive
program
designs
that
16
improve
the
health
of
the
population.
Aggregate
assessment
17
data
shall
be
shared
with
affected
providers
on
a
routine
18
basis.
19
b.
In
order
to
monitor
the
quality
of
and
access
to
health
20
care
for
children
receiving
coverage
under
the
Medicaid
21
program,
each
Medicaid
managed
care
organization
shall
22
uniformly
report,
in
a
template
format
designated
by
the
23
department
of
human
services,
the
number
of
claims
submitted
by
24
providers
and
the
percentage
of
claims
approved
by
the
Medicaid
25
managed
care
organization
for
the
early
and
periodic
screening,
26
diagnostic,
and
treatment
(EPSDT)
benefit
based
on
the
Iowa
27
EPSDT
care
for
kids
health
maintenance
recommendations,
28
including
but
not
limited
to
physical
exams,
immunizations,
the
29
seven
categories
of
developmental
and
behavioral
screenings,
30
vision
and
hearing
screenings,
and
lead
testing.
31
3.
PROVIDER
PARTICIPATION
ENHANCEMENT.
32
a.
Ensure
that
savings
achieved
through
Medicaid
managed
33
care
does
not
come
at
the
expense
of
further
reductions
in
34
provider
rates.
The
department
shall
ensure
that
Medicaid
35
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2213
managed
care
organizations
use
reasonable
reimbursement
1
standards
for
all
provider
types
and
compensate
providers
for
2
covered
services
at
not
less
than
the
minimum
reimbursement
3
established
by
state
law
applicable
to
fee
for
service
for
a
4
respective
provider,
service,
or
product
for
a
fiscal
year
5
and
as
determined
in
conjunction
with
actuarially
sound
rate
6
setting
procedures.
Such
reimbursement
shall
extend
for
the
7
entire
duration
of
a
managed
care
contract.
8
b.
To
enhance
continuity
of
care
in
the
provision
of
9
pharmacy
services,
Medicaid
managed
care
organizations
shall
10
utilize
the
same
preferred
drug
list,
recommended
drug
list,
11
prior
authorization
criteria,
and
other
utilization
management
12
strategies
that
apply
to
the
state
program
directly
under
fee
13
for
service
and
shall
apply
other
provisions
of
applicable
14
state
law
including
those
relating
to
chemically
unique
mental
15
health
prescription
drugs.
Reimbursement
rates
established
16
under
Medicaid
managed
care
contracts
for
ingredient
cost
17
reimbursement
and
dispensing
fees
shall
be
subject
to
and
shall
18
reflect
provisions
of
state
and
federal
law,
including
the
19
minimum
reimbursements
established
in
state
law
for
fee
for
20
service
for
a
fiscal
year.
21
c.
Address
rate
setting
and
reimbursement
of
the
entire
22
scope
of
services
provided
under
the
Medicaid
program
to
23
ensure
the
adequacy
of
the
provider
network
and
to
ensure
24
that
providers
that
contribute
to
the
holistic
health
of
the
25
Medicaid
recipient,
whether
inside
or
outside
of
the
provider
26
network,
are
compensated
for
their
services.
27
d.
Managed
care
contractors
shall
submit
financial
28
documentation
to
the
department
of
human
services
demonstrating
29
payment
of
claims
and
expenses
by
provider
type.
30
e.
Participating
Medicaid
providers
under
a
managed
care
31
contract
shall
be
allowed
to
submit
claims
for
up
to
365
days
32
following
discharge
of
a
Medicaid
recipient
from
a
hospital
or
33
following
the
date
of
service.
34
f.
(1)
A
managed
care
contract
entered
into
on
or
after
35
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2213
July
1,
2015,
shall,
at
a
minimum,
reflect
all
of
the
following
1
provisions
and
requirements,
and
shall
extend
the
following
2
payment
rates
based
on
the
specified
payment
floor,
as
3
applicable
to
the
provider
type:
4
(a)
In
calculating
the
rates
for
prospective
payment
system
5
hospitals,
the
following
base
rates
shall
be
used:
6
(i)
The
inpatient
diagnostic
related
group
base
rates
and
7
certified
unit
per
diem
in
effect
on
October
1,
2015.
8
(ii)
The
outpatient
ambulatory
payment
classification
base
9
rates
in
effect
on
July
1,
2015.
10
(iii)
The
inpatient
psychiatric
certified
unit
per
diem
in
11
effect
on
October
1,
2015.
12
(iv)
The
inpatient
physical
rehabilitation
certified
unit
13
per
diem
in
effect
on
October
1,
2015.
14
(b)
In
calculating
the
critical
access
hospital
payment
15
rates,
the
following
base
rates
shall
be
used:
16
(i)
The
inpatient
diagnostic
related
group
base
rates
in
17
effect
on
July
1,
2015.
18
(ii)
The
outpatient
cost-to-charge
ratio
in
effect
on
July
19
1,
2015.
20
(iii)
The
swing
bed
per
diem
in
effect
on
July
1,
2015.
21
(c)
Critical
access
hospitals
shall
receive
cost-based
22
reimbursement
for
one
hundred
percent
of
the
reasonable
costs
23
for
the
provision
of
services
to
Medicaid
recipients.
24
(d)
Critical
access
hospitals
shall
submit
annual
cost
25
reports
and
managed
care
contractors
shall
submit
annual
26
payment
reports
to
the
department
of
human
services.
The
27
department
shall
reconcile
the
critical
access
hospital’s
28
reported
costs
with
the
managed
care
contractor’s
reported
29
payments.
The
department
shall
require
the
managed
care
30
contractor
to
retroactively
reimburse
a
critical
access
31
hospital
for
underpayments.
32
(e)
Community
mental
health
centers
shall
receive
one
33
hundred
percent
of
the
reasonable
costs
for
the
provision
of
34
services
to
Medicaid
recipients.
35
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(f)
Federally
qualified
health
centers
shall
receive
1
cost-based
reimbursement
for
one
hundred
percent
of
the
2
reasonable
costs
for
the
provision
of
services
to
Medicaid
3
recipients.
4
(g)
The
reimbursement
rates
for
substance-related
disorder
5
treatment
programs
licensed
under
section
125.13,
shall
be
no
6
lower
than
the
rates
in
effect
for
the
fiscal
year
beginning
7
July
1,
2015.
8
(2)
For
managed
care
contract
periods
subsequent
to
the
9
initial
contract
period,
base
rates
for
prospective
payment
10
system
hospitals
and
critical
access
hospitals
shall
be
11
calculated
using
the
base
rate
for
the
prior
contract
period
12
plus
3
percent.
Prospective
payment
system
hospital
and
13
critical
access
hospital
base
rates
shall
at
no
time
be
less
14
than
the
previous
contract
period’s
base
rates.
15
(3)
A
managed
care
contract
shall
require
out-of-network
16
prospective
payment
system
hospital
and
critical
access
17
hospital
payment
rates
to
meet
or
exceed
ninety-nine
percent
of
18
the
rates
specified
for
the
respective
in-network
hospitals
in
19
accordance
with
this
paragraph
“f”.
20
g.
If
the
department
of
human
services
collects
ownership
21
and
control
information
from
Medicaid
providers
pursuant
to
42
22
C.F.R.
§455.104,
a
managed
care
organization
under
contract
23
with
the
state
shall
not
also
require
submission
of
this
24
information
from
approved
enrolled
Medicaid
providers.
25
h.
(1)
Ensure
that
a
Medicaid
managed
care
organization
26
develops
and
maintains
a
provider
network
of
qualified
27
providers
who
meet
state
licensing,
credentialing,
and
28
certification
requirements,
as
applicable,
which
network
shall
29
be
sufficient
to
provide
adequate
access
to
all
services
30
covered
and
for
all
populations
served
under
the
managed
31
care
contract.
Medicaid
managed
care
organizations
shall
32
incorporate
existing
and
traditional
providers,
including
33
but
not
limited
to
those
providers
that
comprise
the
Iowa
34
collaborative
safety
net
provider
network
created
in
section
35
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135.153,
into
their
provider
networks.
1
(2)
Ensure
that
respective
Medicaid
populations
are
2
managed
at
all
times
within
funding
limitations
and
contract
3
terms.
The
department
shall
also
monitor
service
delivery
4
and
utilization
to
ensure
the
responsibility
for
provision
5
of
services
to
Medicaid
recipients
is
not
shifted
to
6
non-Medicaid
covered
services
to
attain
savings,
and
that
such
7
responsibility
is
not
shifted
to
mental
health
and
disability
8
services
regions,
local
public
health
agencies,
aging
and
9
disability
resource
centers,
or
other
entities
unless
agreement
10
to
provide,
and
provision
for
adequate
compensation
for,
such
11
services
is
agreed
to
between
the
affected
entities
in
advance.
12
i.
Medicaid
managed
care
organizations
shall
provide
an
13
enrolled
Medicaid
provider
approved
by
the
department
of
14
human
services
the
opportunity
to
be
a
participating
network
15
provider.
16
j.
Medicaid
managed
care
organizations
shall
include
17
provider
appeals
and
grievance
procedures
that
in
part
allow
18
a
provider
to
file
a
grievance
independently
but
on
behalf
19
of
a
Medicaid
recipient
and
to
appeal
claims
denials
which,
20
if
determined
to
be
based
on
claims
for
medically
necessary
21
services
whether
or
not
denied
on
an
administrative
basis,
22
shall
receive
appropriate
payment.
23
k.
(1)
Medicaid
managed
care
organizations
shall
include
24
as
primary
care
providers
any
provider
designated
by
the
state
25
as
a
primary
care
provider,
subject
to
a
provider’s
respective
26
state
certification
standards,
including
but
not
limited
to
all
27
of
the
following:
28
(a)
A
physician
who
is
a
family
or
general
practitioner,
a
29
pediatrician,
an
internist,
an
obstetrician,
or
a
gynecologist.
30
(b)
An
advanced
registered
nurse
practitioner.
31
(c)
A
physician
assistant.
32
(d)
A
chiropractor
licensed
pursuant
to
chapter
151.
33
(2)
A
Medicaid
managed
care
organization
shall
not
impose
34
more
restrictive,
additional,
or
different
scope
of
practice
35
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2213
requirements
or
standards
of
practice
on
a
primary
care
1
provider
than
those
prescribed
by
state
law
as
a
prerequisite
2
for
participation
in
the
managed
care
organization’s
provider
3
network.
4
4.
CAPITATION
RATES
AND
MEDICAL
LOSS
RATIO.
5
a.
Capitation
rates
shall
be
developed
based
on
all
6
reasonable,
appropriate,
and
attainable
costs.
Costs
that
are
7
not
reasonable,
appropriate,
or
attainable,
including
but
not
8
limited
to
improper
payment
recoveries,
shall
not
be
included
9
in
the
development
of
capitated
rates.
10
b.
Capitation
rates
for
Medicaid
recipients
falling
within
11
different
rate
cells
shall
not
be
expected
to
cross-subsidize
12
one
another
and
the
data
used
to
set
capitation
rates
shall
13
be
relevant
and
timely
and
tied
to
the
appropriate
Medicaid
14
population.
15
c.
Any
increase
in
capitation
rates
for
managed
care
16
contractors
is
subject
to
prior
statutory
approval
and
shall
17
not
exceed
three
percent
over
the
existing
capitation
rate
18
in
any
one-year
period
or
five
percent
over
the
existing
19
capitation
rate
in
any
two-year
period.
20
d.
In
addition
to
withholding
two
percent
of
a
managed
21
care
organization’s
annual
capitation
payment
as
a
22
pay-for-performance
enforcement
mechanism,
the
department
of
23
human
services
shall
also
withhold
an
additional
two
percent
of
24
a
managed
care
organization’s
annual
capitation
payment
until
25
the
department
is
able
to
ensure
that
the
respective
managed
26
care
organization
has
complied
with
all
requirements
relating
27
to
data,
information,
transparency,
evaluation,
and
oversight
28
specified
by
law,
rule,
contract,
or
other
basis.
29
e.
The
department
of
human
services
shall
collect
an
initial
30
contribution
of
five
million
dollars
from
each
of
the
managed
31
care
organizations
contracting
with
the
state
during
the
fiscal
32
year
beginning
July
1,
2015,
for
an
aggregate
amount
of
fifteen
33
million
dollars,
and
shall
deposit
such
amount
in
the
Medicaid
34
reinvestment
fund,
as
provided
in
section
249A.4C,
as
enacted
35
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86
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42
S.F.
2213
in
this
Act,
to
be
used
for
Medicaid
ombudsman
activities
1
through
the
office
of
long-term
care
ombudsman.
2
f.
A
managed
care
contract
shall
impose
a
minimum
Medicaid
3
loss
ratio
of
at
least
eighty-eight
percent.
In
calculating
4
the
medical
loss
ratio,
medical
costs
or
benefit
expenses
shall
5
include
only
those
costs
directly
related
to
patient
medical
6
care
and
not
ancillary
expenses,
including
but
not
limited
to
7
any
of
the
following:
8
(1)
Program
integrity
activities.
9
(2)
Utilization
review
activities.
10
(3)
Fraud
prevention
activities
beyond
the
scope
of
those
11
activities
necessary
to
recover
incurred
claims.
12
(4)
Provider
network
development,
education,
or
management
13
activities.
14
(5)
Provider
credentialing
activities.
15
(6)
Marketing
expenses.
16
(7)
Administrative
costs
associated
with
recipient
17
incentives.
18
(8)
Clinical
data
collection
activities.
19
(9)
Claims
adjudication
expenses.
20
(10)
Customer
service
or
health
care
professional
hotline
21
services
addressing
nonclinical
recipient
questions.
22
(11)
Value-added
or
cost-containment
services,
wellness
23
programs,
disease
management,
and
case
management
or
care
24
coordination
programs.
25
(12)
Health
quality
improvement
activities
unless
26
specifically
approved
as
a
medical
cost
by
state
law.
Costs
of
27
health
quality
improvement
activities
included
in
determining
28
the
medical
loss
ratio
shall
be
only
those
activities
that
are
29
independent
improvements
measurable
in
individual
patients.
30
(13)
Insurer
claims
review
activities.
31
(14)
Information
technology
costs
unless
they
directly
32
and
credibly
improve
the
quality
of
health
care
and
do
not
33
duplicate,
conflict
with,
or
fail
to
be
compatible
with
similar
34
health
information
technology
efforts
of
providers.
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(15)
Legal
department
costs
including
information
1
technology
costs,
expenses
incurred
for
review
and
denial
of
2
claims,
legal
costs
related
to
defending
claims,
settlements
3
for
wrongly
denied
claims,
and
costs
related
to
administrative
4
claims
handling
including
salaries
of
administrative
personnel
5
and
legal
costs.
6
(16)
Taxes
unrelated
to
premiums
or
the
provision
of
medical
7
care.
Only
state
and
federal
taxes
and
licensing
or
regulatory
8
fees
relevant
to
actual
premiums
collected,
not
including
such
9
taxes
and
fees
as
property
taxes,
taxes
on
investment
income,
10
taxes
on
investment
property,
and
capital
gains
taxes,
may
be
11
included
in
determining
the
medical
loss
ratio.
12
g.
(1)
Provide
enhanced
guidance
and
criteria
for
defining
13
medical
and
administrative
costs,
recoveries,
and
rebates
14
including
pharmacy
rebates,
and
the
recording,
reporting,
and
15
recoupment
of
such
costs,
recoveries,
and
rebates
realized.
16
(2)
Medicaid
managed
care
organizations
shall
offset
17
recoveries,
rebates,
and
refunds
against
medical
costs,
include
18
only
allowable
administrative
expenses
in
the
determination
of
19
administrative
costs,
report
costs
related
to
subcontractors
20
properly,
and
have
complete
systems
checks
and
review
processes
21
to
identify
overpayment
possibilities.
22
(3)
Medicaid
managed
care
contractors
shall
submit
publicly
23
available,
comprehensive
financial
statements
to
the
department
24
of
human
services
to
verify
that
the
minimum
medical
loss
ratio
25
is
being
met
and
shall
be
subject
to
periodic
audits.
26
5.
DATA
AND
INFORMATION,
EVALUATION,
AND
OVERSIGHT.
27
a.
Develop
and
administer
a
clear,
detailed
policy
28
regarding
the
collection,
storage,
integration,
analysis,
29
maintenance,
retention,
reporting,
sharing,
and
submission
30
of
data
and
information
from
the
Medicaid
managed
care
31
organizations
and
shall
require
each
Medicaid
managed
care
32
organization
to
have
in
place
a
data
and
information
system
to
33
ensure
that
accurate
and
meaningful
data
is
available.
At
a
34
minimum,
the
data
shall
allow
the
department
to
effectively
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measure
and
monitor
Medicaid
managed
care
organization
1
performance,
quality,
outcomes
including
recipient
health
2
outcomes,
service
utilization,
finances,
program
integrity,
3
the
appropriateness
of
payments,
and
overall
compliance
with
4
contract
requirements;
perform
risk
adjustments
and
determine
5
actuarially
sound
capitation
rates
and
appropriate
provider
6
reimbursements;
verify
that
the
minimum
medical
loss
ratio
is
7
being
met;
ensure
recipient
access
to
and
use
of
services;
8
create
quality
measures;
and
provide
for
program
transparency.
9
b.
Medicaid
managed
care
organizations
shall
directly
10
capture
and
retain
and
shall
report
actual
and
detailed
11
medical
claims
costs
and
administrative
cost
data
to
the
12
department
as
specified
by
the
department.
Medicaid
managed
13
care
organizations
shall
allow
the
department
to
thoroughly
and
14
accurately
monitor
the
medical
claims
costs
and
administrative
15
costs
data
Medicaid
managed
care
organizations
report
to
the
16
department.
17
c.
Any
audit
of
Medicaid
managed
care
contracts
shall
ensure
18
compliance
including
with
respect
to
appropriate
medical
costs,
19
allowable
administrative
costs,
the
medical
loss
ratio,
cost
20
recoveries,
rebates,
overpayments,
and
with
specific
contract
21
performance
requirements.
22
d.
The
external
quality
review
organization
contracting
23
with
the
department
shall
review
the
Medicaid
managed
care
24
program
to
determine
if
the
state
has
sufficient
infrastructure
25
and
controls
in
place
to
effectively
oversee
the
Medicaid
26
managed
care
organizations
and
the
Medicaid
program
in
order
27
to
ensure,
at
a
minimum,
compliance
with
Medicaid
managed
28
care
organization
contracts
and
to
prevent
fraud,
abuse,
and
29
overpayments.
The
results
of
any
external
quality
review
30
organization
review
shall
be
submitted
to
the
governor,
the
31
general
assembly,
and
the
health
policy
oversight
committee
32
created
in
section
2.45.
33
e.
Publish
benchmark
indicators
based
on
Medicaid
program
34
outcomes
from
the
fiscal
year
beginning
July
1,
2015,
to
35
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be
used
to
compare
outcomes
of
the
Medicaid
program
as
1
administered
by
the
state
program
prior
to
July
1,
2015,
to
2
those
outcomes
of
the
program
under
Medicaid
managed
care.
The
3
outcomes
shall
include
a
comparison
of
actual
costs
of
the
4
program
as
administered
prior
to
and
after
implementation
of
5
Medicaid
managed
care.
The
data
shall
also
include
specific
6
detail
regarding
the
actual
expenses
incurred
by
each
managed
7
care
organization
by
specific
provider
line
of
service.
8
f.
Review
and
approve
or
deny
approval
of
contract
9
amendments
on
an
ongoing
basis
to
provide
for
continuous
10
improvement
in
Medicaid
managed
care
and
to
incorporate
any
11
changes
based
on
changes
in
law
or
policy.
12
g.
(1)
Require
managed
care
contractors
to
track
and
report
13
on
a
monthly
basis
to
the
department
of
human
services,
at
a
14
minimum,
all
of
the
following:
15
(a)
The
number
and
details
relating
to
prior
authorization
16
requests
and
denials.
17
(b)
The
ten
most
common
reasons
for
claims
denials.
18
Information
reported
by
a
managed
care
contractor
relative
19
to
claims
shall
also
include
the
number
of
claims
denied,
20
appealed,
and
overturned
based
on
provider
type
and
service
21
type.
22
(c)
Utilization
of
health
care
services
by
diagnostic
23
related
group
and
ambulatory
payment
classification
as
well
as
24
total
claims
volume.
25
(2)
The
department
shall
ensure
the
validity
of
all
26
information
submitted
by
a
Medicaid
managed
care
organization
27
and
shall
make
the
monthly
reports
available
to
the
public.
28
h.
Medicaid
managed
care
organizations
shall
maintain
29
stakeholder
panels
comprised
of
an
equal
number
of
Medicaid
30
recipients
and
providers.
Medicaid
managed
care
organizations
31
shall
provide
for
separate
provider-specific
panels
to
address
32
detailed
payment,
claims,
process,
and
other
issues
as
well
as
33
grievance
and
appeals
processes.
34
i.
Medicaid
managed
care
contracts
shall
align
economic
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incentives,
delivery
system
reforms,
and
performance
and
1
outcome
metrics
with
those
of
the
state
innovation
models
2
initiatives
and
Medicaid
accountable
care
organizations.
3
The
department
of
human
services
shall
develop
and
utilize
4
a
common,
uniform
set
of
process,
quality,
and
consumer
5
satisfaction
measures
across
all
Medicaid
payors
and
providers
6
that
align
with
those
developed
through
the
state
innovation
7
models
initiative
and
shall
ensure
that
such
measures
are
8
expanded
and
adjusted
to
address
additional
populations
and
9
to
meet
population
health
objectives.
Medicaid
managed
care
10
contracts
shall
include
long-term
performance
and
outcomes
11
goals
that
reward
success
in
achieving
population
health
goals
12
such
as
improved
community
health
metrics.
13
j.
(1)
Require
consistency
and
uniformity
of
processes,
14
procedures,
and
forms
across
all
Medicaid
managed
care
15
organizations
to
reduce
the
administrative
burden
to
providers
16
and
consumers
and
to
increase
efficiencies
in
the
program.
17
Such
requirements
shall
apply
to
but
are
not
limited
to
18
areas
of
uniform
cost
and
quality
reporting,
uniform
prior
19
authorization
requirements
and
procedures,
uniform
utilization
20
management
criteria,
centralized,
uniform,
and
seamless
21
credentialing
requirements
and
procedures,
and
uniform
critical
22
incident
reporting.
23
(2)
The
department
of
human
services
shall
establish
a
24
comprehensive
provider
credentialing
process
to
be
recognized
25
and
utilized
by
all
Medicaid
managed
care
organization
26
contractors.
The
process
shall
meet
the
national
committee
for
27
quality
assurance
and
other
appropriate
standards.
The
process
28
shall
ensure
that
credentialing
is
completed
in
a
timely
manner
29
without
disruption
to
provider
billing
processes.
30
k.
Medicaid
managed
care
organizations
and
any
entity
with
31
which
a
managed
care
organization
contracts
for
the
performance
32
of
services
shall
disclose
at
no
cost
to
the
department
all
33
discounts,
incentives,
rebates,
fees,
free
goods,
bundling
34
arrangements,
and
other
agreements
affecting
the
net
cost
of
35
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goods
or
services
provided
under
a
managed
care
contract.
1
Sec.
13.
RETROACTIVE
APPLICABILITY.
The
section
of
this
Act
2
relating
to
directives
for
Medicaid
program
policy
improvements
3
applies
retroactively
to
July
1,
2015.
4
Sec.
14.
EFFECTIVE
UPON
ENACTMENT.
This
Act,
being
deemed
5
of
immediate
importance,
takes
effect
upon
enactment.
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