House File 2399 - Reprinted HOUSE FILE 2399 BY COMMITTEE ON COMMERCE (SUCCESSOR TO HSB 650) (As Amended and Passed by the House February 24, 2022 ) A BILL FOR An Act relating to reimbursement for health care services 1 provided after receipt of a prior authorization, and 2 including applicability provisions. 3 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 4 HF 2399 (3) 89 ko/rn/md

H.F. 2399 Section 1. NEW SECTION . 514F.8 Prior authorizations —— 1 reimbursement. 2 1. For purposes of this section: 3 a. “Covered person” means a policyholder, subscriber, 4 enrollee, or other individual participating in a health benefit 5 plan. 6 b. “Facility” means the same as defined in section 514J.102. 7 c. “Health benefit plan” means the same as defined in 8 section 514J.102. 9 d. “Health care professional” means the same as defined in 10 section 514J.102. 11 e. “Health care provider” means a health care professional 12 or a facility. 13 f. “Health care services” means services provided by a 14 health care provider for the diagnosis, prevention, treatment, 15 cure, or relief of a health condition, illness, injury, or 16 disease. “Health care services” includes the provision of 17 durable medical equipment. “Health care services” does not 18 include prescription drugs or dental care services as that term 19 is defined in section 514J.102. 20 g. “Health carrier” means an entity subject to the 21 insurance laws and regulations of this state, or subject 22 to the jurisdiction of the commissioner, including an 23 insurance company offering sickness and accident plans, a 24 health maintenance organization, a nonprofit health service 25 corporation, a plan established pursuant to chapter 509A 26 for public employees, or any other entity providing a plan 27 of health insurance, health care benefits, or health care 28 services. “Health carrier ” does not include the department 29 of human services, or a managed care organization acting 30 pursuant to a contract with the department of human services to 31 administer the medical assistance program under chapter 249A 32 or the healthy and well kids in Iowa (hawk-i) program under 33 chapter 514I. 34 h. “Prior authorization” means a determination by a 35 -1- HF 2399 (3) 89 ko/rn/md 1/ 4

H.F. 2399 utilization review organization that a specific health care 1 service proposed by a health care provider for a covered person 2 is medically necessary or medically appropriate, and the 3 determination is made prior to the provision of the health care 4 service to the covered person, and, if applicable, includes a 5 utilization review organization’s requirement that a covered 6 person or a health care provider notify the utilization review 7 organization prior to receiving or providing a specific health 8 care service. 9 i. “Utilization review” means the same as defined in section 10 514F.4, subsection 3. 11 j. “Utilization review organization” means an entity that 12 performs utilization review, including a health carrier that 13 meets the requirements established for accreditation set by the 14 utilization review accreditation commission or the national 15 committee on quality assurance and that performs utilization 16 review for the health carrier’s health benefit plans. 17 2. a. A utilization review organization shall not revoke, 18 or impose a limitation, condition, or restriction on, a prior 19 authorization after the date on which a health care provider 20 provides a health care service to a covered person per the 21 prior authorization. 22 b. A health carrier shall reimburse a health care provider 23 at the contracted reimbursement rate for a health care service 24 provided by the health care provider to a covered person per 25 a prior authorization. 26 c. Paragraphs “a” and “b” shall not apply in any of the 27 following circumstances: 28 (1) The health care provider or the covered person committed 29 fraud, waste, or abuse. 30 (2) The health care provider or the covered person provided 31 inaccurate information that the utilization review organization 32 relied on for the utilization review organization’s prior 33 authorization determination. 34 (3) On the date that the health care service was provided by 35 -2- HF 2399 (3) 89 ko/rn/md 2/ 4

H.F. 2399 the health care provider to the covered person per the prior 1 authorization, the health care service was no longer a benefit 2 covered by the covered person’s health benefit plan. 3 (4) On the date that the health care service was provided 4 by the health care provider to the covered person per the 5 prior authorization, the health care provider was no longer 6 contracted with the health carrier that provides the covered 7 person’s health benefit plan. 8 (5) The health care provider failed to meet the health 9 carrier’s requirements related to timely filing of claims for 10 submission of a claim for the health care service provided by 11 the health care provider to the covered person per the prior 12 authorization. 13 (6) Due to coordination of benefits, the health carrier 14 does not have liability for a claim for the health care service 15 provided by the health care provider to the covered person per 16 a prior authorization. 17 (7) On the date that the health care service was provided 18 by the health care provider to the covered person per the 19 prior authorization, the covered person was no longer a 20 participant in the health benefit plan in which the covered 21 person participated on the date that the prior authorization 22 was received by the health care provider. 23 3. A prior authorization for a specific health care service 24 for a covered person shall be valid for the specific health 25 care service for not less than ninety days from the date 26 that the covered person’s health care provider receives the 27 prior authorization from a utilization review organization, 28 provided that during the ninety days the covered person remains 29 a participant in the same health benefit plan in which the 30 covered person participated on the date the prior authorization 31 was received by the health care provider. 32 4. The commissioner may adopt rules pursuant to chapter 17A 33 as necessary to administer this chapter. 34 Sec. 2. APPLICABILITY. This Act applies January 1, 2023, to 35 -3- HF 2399 (3) 89 ko/rn/md 3/ 4

H.F. 2399 health benefit plans that are delivered, issued for delivery, 1 continued, or renewed in this state on or after that date. 2 -4- HF 2399 (3) 89 ko/rn/md 4/ 4