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House File 96 - IntroducedA Bill ForAn Act 1establishing the healthy Iowa program and including
2effective date provisions.
3BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
1 Section 1. NEW SECTION. 135E.1 Findings and intent of the
2general assembly.
31. The general assembly finds that all residents of the
4state have the right to health care.
52. It is the intent of the general assembly:
6a. To provide comprehensive universal single-payer health
7care coverage and a health care cost control system for the
8benefit of all residents of Iowa.
9b. To establish the healthy Iowa program to provide
10comprehensive, universal health coverage for every Iowa
11resident funded by broad-based sources of revenue.
12c. That the state obtain waivers and other approvals
13relating to the Medicaid program, the healthy and well kids
14in Iowa program, Medicare, the federal Patient Protection and
15Affordable Care Act, and any other federally regulated programs
16related to the provision of health care so that any federal
17funds and other subsidies that would otherwise be available to
18the state, Iowa residents, and Iowa health care providers, is
19instead paid by the federal government to the state of Iowa and
20deposited in the healthy Iowa trust fund.
21d. That the state incorporates health care coverage of
22Iowa residents who are employed in other jurisdictions into
23the waivers and other approvals involving federally regulated
24programs related to the provision of health care.
25e. That any funds obtained under waivers and other approvals
26involving federally regulated programs related to the provision
27of health care be used for health coverage that provides health
28benefits equal to or exceeding the health benefits provided
29under those programs, as well as other program modifications,
30including elimination of cost sharing and insurance premiums.
31f. That the healthy Iowa program replaces the Medicaid
32program, the healthy and well kids in Iowa program, Medicare,
33coverage provided through the federal Patient Protection and
34Affordable Care Act, and any other federally regulated programs
35relating to the provision of health care, and that those
-1-1programs are merged into the healthy Iowa program, which will
2operate as a true single-payer program.
3g. That, even if all necessary waivers and approvals are not
4obtained, the state maximize the approvals received and pool
5multiple sources of funding to the greatest extent possible,
6to make the provision of health care coverage and health care
7under the healthy Iowa program as seamless as possible.
8h. To extend the current benefits and current health care
9coverage provided under the healthy and well kids in Iowa
10program to all Iowa residents.
11i. That the healthy Iowa program addresses the high cost
12of prescription drugs to ensure that prescription drugs are
13affordable for patients.
14j. That neither health information technology nor clinical
15practice guidelines limit the effective exercise of the
16professional judgment of health care providers.
17k. That health care providers be authorized to override
18health information technology or clinical practice guidelines
19if it is consistent with the treating health care provider’s
20determination of medical necessity and if, in the professional
21judgment of the health care provider, it is in the best
22interest of the patient and consistent with the patient’s
23wishes.
24l. To develop a revenue plan for the healthy Iowa program,
25in consultation with appropriate stakeholders, taking into
26consideration anticipated federal revenue available for the
27program.
28m. To require that all federal revenue received for the
29healthy Iowa program be deposited in an account within the
30healthy Iowa trust fund to be known as the healthy Iowa trust
31fund account.
32 Sec. 2. NEW SECTION. 135E.2 Definitions.
33As used in this chapter, unless the context otherwise
34requires:
351. “Affiliation” means any of the following:
-2- 1a. A financial interest.
2b. A position of governance, including membership on a board
3of directors, regardless of compensation.
4c. A relationship through which compensation is received.
5d. A relationship for the provision of services as a
6regulated lobbyist.
72. “Affordable Care Act” means the federal Patient
8Protection and Affordable Care Act (Pub.L. No.111-148), as
9amended by the federal Health Care and Education Reconciliation
10Act of 2010 (Pub.L. No.111-152), and any amendments to, or
11regulations or guidance issued under, those Acts.
123. “Allied health practitioner” means a group of health
13professionals who apply their expertise to prevent disease
14transmission; diagnose, treat, and rehabilitate people of all
15ages and in all specialties; and, with a range of technical and
16support staff, deliver direct patient care, rehabilitation,
17treatment, diagnosis, and health improvement interventions to
18restore and maintain optimal physical, sensory, psychological,
19cognitive, and social functions. “Allied health practitioner”
20includes but is not limited to audiologists, physical
21therapists, occupational therapists, social workers, and
22radiographers.
234. “Board” means the healthy Iowa board which adopts rules
24and establishes policy for and directs the agency regarding the
25healthy Iowa program.
265. “Care coordination” means services provided by a care
27coordinator under the healthy Iowa program.
286. “Care coordinator” means an individual or entity approved
29by the healthy Iowa board to provide care coordination.
307. “Carrier” means carrier as defined in section 513B.2.
318. “Director” means the director of the healthy Iowa
32program.
339. “Essential community provider” means a person or entity
34acting as a safety net clinic, safety net health care provider,
35or rural hospital.
-3- 110. “Federally matched public health program” means the
2Medicaid program or the healthy and well kids in Iowa program
3established in section 514I.3.
411. “Fund” means the healthy Iowa trust fund.
512. “Health care provider” means any of the following:
6a. A person who is licensed, certified, registered, or
7authorized to practice a health care profession in the state
8pursuant to chapter 147A, 148, 148A, 148B, 148C, 148E, 148F,
9148G, 149, 151, 152, 152A, 152B, 153, 154, 154A, 154B, 154C,
10154D, 154F, 155, or 155A, who practices the profession in which
11they are licensed, certified, registered, or authorized, and
12who provides a health care service in this state.
13b. A health care entity licensed under title IV that employs
14or utilizes the health care services of a person described
15in paragraph “a”, including but not limited to a hospital
16licensed pursuant to chapter 135B, a health care facility
17licensed pursuant to chapter 135C, a subacute mental health
18care facility licensed pursuant to chapter 135G, a psychiatric
19medical institution for children licensed pursuant to chapter
20135H, a hospice program licensed pursuant to chapter 135J, an
21entity providing emergency medical services pursuant to chapter
22147A, and a pharmacy licensed pursuant to chapter 155A.
2313. “Health care service” means any health care service,
24including care coordination that is included as a benefit under
25the healthy Iowa program.
2614. “Health maintenance organization” means a health
27maintenance organization as defined in section 514B.1.
2815. “Healthy Iowa agency” means the healthy Iowa agency
29created in this chapter as an independent agency to provide
30comprehensive, universal single-payer health care coverage
31and a health care cost control system for the benefit of all
32residents of Iowa, and to implement the healthy Iowa program.
3316. “Healthy Iowa program” means the healthy Iowa program
34created in this chapter to provide comprehensive, universal
35single-payer health care coverage.
-4- 117. “Implementation period” means the period during which
2the healthy Iowa program is subject to special eligibility and
3financing provisions until the healthy Iowa program is fully
4implemented.
518. “Long-term care” means long-term care, treatment,
6maintenance, or services as defined by the healthy Iowa board.
719. “Medicaid” means the Medicaid program established under
8chapter 249A.
920. “Medicare” means the program established pursuant to
10Tit.XVIII of the federal Social Security Act, 42 U.S.C.§1395
11et seq.
1221. “Member” means an individual who is enrolled in the
13healthy Iowa program.
1422. “Out-of-state health care service” means a health
15care service provided in person under any of the following
16circumstances:
17a. It is medically necessary that the health care service be
18provided while the member is physically outside of this state
19for a period of time not exceed ninety days.
20b. It is clinically appropriate and necessary that the
21health care service is provided outside this state because the
22health care service can only be provided by a particular health
23care provider physically located outside of this state.
2423. “Participating health care provider” means an individual
25or entity that is a health care provider qualified pursuant to
26section 135E.15 that provides health care services to members
27under the healthy Iowa program.
2824. “Prescription drugs” means a controlled substance
29requiring a prescription as defined in section 124.101,
30subsection 5.
3125. “Resident” means an individual, without regard to that
32individual’s immigration status, whose primary place of abode
33is in this state and who meets the Iowa residence requirements
34adopted by the healthy Iowa board.
35 Sec. 3. NEW SECTION. 135E.3 Healthy Iowa agency and program
-5-1— created.
21. A healthy Iowa agency is created as an independent
3agency which shall be responsible for the planning,
4development, implementation, and regulation of the provision of
5comprehensive, universal single-payer health care coverage in
6this state under the healthy Iowa program and of a health care
7cost control system for the benefit of all residents.
82. The purposes of the healthy Iowa agency include all of
9the following:
10a. To create the healthy Iowa program.
11b. To provide comprehensive, universal single-payer health
12care services for all residents.
13c. To provide a health care cost control system for the
14benefit of all residents.
15d. To provide choice of and access to health care
16coordinators and health care providers for all residents.
17e. To provide broad-based public financing of health care
18services for all residents.
19f. To establish mechanisms for participating health care
20providers to collectively negotiate with the healthy Iowa
21program regarding any matter relating to the administration
22of the healthy Iowa program, including but not limited to
23rates of payment for health care services, rates of payment
24for prescription drugs and nonprescription drugs, and payment
25methodologies.
26g. To ensure transparency and accountability of the healthy
27Iowa program to the public.
28h. To provide for the collection of data to promote
29transparency, assess adherence to patient care standards
30established under this chapter, compare patient outcomes, and
31review utilization of health care services reimbursed through
32the healthy Iowa program.
333. This chapter and any rule or policy adopted under this
34chapter shall not be construed, is not intended as, and shall
35not imply, a change or impact in any way on the authority of any
-6-1of the following:
2a. The authority of a licensing board or other agencies of
3this state otherwise has relative to the provision of health
4care services or health care providers under law.
5b. The authority the healthy Iowa program, the healthy Iowa
6board, a licensing board, the department of public health, or
7the department of inspections and appeals has to establish or
8revise licensure standards for health care providers.
9c. The authority the healthy Iowa program has to carry out
10any function not authorized by waivers.
11d. The authority an employer has to create an employment
12benefit or to require, prohibit, or limit the provision of any
13employment benefit.
144. This chapter shall not be construed to allow the healthy
15Iowa program, other agencies of this state, local agencies,
16or public employees, acting under color of law, to provide or
17disclose to anyone, including but not limited to the federal
18government, any personally identifiable information obtained
19by the healthy Iowa program, including but not limited to a
20person’s religious beliefs, practices, or affiliation, national
21origin, ethnicity, or immigration status, for law enforcement
22or immigration purposes.
235. This chapter shall not be construed to allow law
24enforcement agencies to use healthy Iowa program moneys,
25facilities, property, equipment, or personnel to investigate,
26enforce, or assist in the investigation or enforcement of any
27criminal, civil, or administrative violation or warrant for a
28violation of any requirement that individuals register with the
29federal government or any federal agency based on religion,
30national origin, ethnicity, or immigration status.
31 Sec. 4. NEW SECTION. 135E.4 Healthy Iowa board — created.
321. A healthy Iowa board is created consisting of the
33following voting members:
34a. Four public members appointed by the governor, subject
35to confirmation by the senate.
-7- 1b. Two public members appointed by the senate majority
2leader subject to section 2.32A.
3c. Two public members appointed by the speaker of the house
4of representatives subject to section 2.32A.
52. The director of human services or the director’s designee
6shall serve as an ex officio member of the board.
73. The voting members shall serve four-year staggered
8terms. A vacancy shall be filled for the unexpired portion of
9the term and in the same manner as the original appointment.
10Any member may be reappointed for an additional term.
114. Members of the board shall not receive compensation as a
12member of the board but are entitled to receive reimbursement
13of actual expenses incurred in the discharge of their duties.
14Public members of the board are also eligible to receive
15compensation as provided in section 7E.6.
165. In making appointments under this section, an appointing
17authority shall do all of the following:
18a. Assure that the appointee has demonstrated and
19acknowledged expertise in health care.
20b. Consider the expertise of the other members of the
21board and attempt to make appointments so that the board’s
22composition reflects a diversity of expertise in various
23aspects of health care services.
24c. Consider the cultural, ethnic, and geographical diversity
25of this state so that the board’s composition reflects the
26communities of this state.
27d. Assure that the board’s composition is comprised of all
28of the following:
29(1) At least one representative of a labor organization
30representing registered nurses.
31(2) At least one representative of the general public.
32(3) At least one representative of a labor organization not
33representing registered nurses.
34(4) At least one representative of the health care provider
35community.
-8- 16. The board shall determine the time, location, and
2frequency of the board’s meetings. Five members of the board
3constitute a quorum and the affirmative vote of a majority of
4the voting members is necessary for any substantive action to
5be taken by the board.
67. The members of the board shall elect a chairperson on an
7annual basis from among the membership of the board.
88. A member of the board may be removed for incompetence,
9misconduct, or failure to perform the duties of the position.
109. The board shall approve all contracts entered into
11pursuant to this chapter. All contracts entered into pursuant
12to this chapter shall be made available to the public.
1310. The board may receive and accept grants, loans, or
14advances of moneys from any person and may receive and accept
15from any source contributions of moneys, property, labor, or
16any other thing of value, to be held, used, and applied for the
17purposes of the healthy Iowa program.
1811. A member of the board shall do all of the following:
19a. Meet the requirements of this chapter and all applicable
20state and federal laws and regulations.
21b. Serve the public interest of the individuals, employers,
22and taxpayers seeking health care coverage through the healthy
23Iowa healthy Iowa program.
24c. Ensure the sound operation and fiscal solvency of the
25healthy Iowa program.
2612. A member of the board, within the two-year period
27immediately preceding the member’s appointment, while serving
28on the board, and for two years immediately after the end
29of the member’s term, and staff of the board, shall not be
30employed or have been employed in any capacity by, a consultant
31to a member of the board of, have an affiliation with, receive
32compensation from, or otherwise be a representative of any of
33the following:
34a. A health care provider, unless the member or staff
35practices a health care profession as an employee of another
-9-1health care provider.
2b. A pharmaceutical company.
3c. A medical equipment company.
4d. An insurance company.
5e. A carrier, an insurance producer, a third-party
6administrator, a managed care organization, or any other person
7contracting directly with the healthy Iowa program.
8f. A member, a board member, or an employee of a trade
9association of health care facilities, health clinics, health
10care providers, carriers, insurance producers, third-party
11administrators, managed care organizations, or any association
12of entities in a position to contract directly with the
13healthy Iowa program, unless the member or employee receives no
14compensation for rendering services as a health care provider
15and does not have an ownership interest in a health care
16practice.
1713. A member of the board shall perform the member’s duties
18in good faith, in the manner the member reasonably believes
19to be in the best interest of the healthy Iowa program, and
20without intentional or reckless disregard of the care an
21ordinarily prudent person in a like position would use under
22similar circumstances. A member of the board who performs the
23member’s duties in accordance with the standards specified in
24this subsection shall not be liable personally for actions
25taken as a member when performed in good faith, without intent
26to defraud, and in connection with the administration of this
27chapter or actions or conduct related to this chapter.
2814. A member of the board shall be subject to chapter 68B.
29In addition to the disclosures required pursuant to chapter
3068B, a member of the board shall disclose to the board and
31to the public any relationship that the member has with a
32health care provider, pharmaceutical company, medical equipment
33company, insurance company, carrier, insurance producer,
34third-party administrator, managed care organization, or other
35entity in an industry involved in matters likely to come before
-10-1the board.
215. On all matters that come before the board, a member
3shall do all of the following:
4a. Adhere strictly to the conflict of interest provisions
5of section 68B.2A.
6b. Provide full disclosure to the board and the public on
7any matter that gives rise to a potential conflict of interest
8and the manner in which the member will comply with public
9disclosure required by chapter 68B and rules adopted pursuant
10to chapter 68B to avoid any conflict of interest or appearance
11of a conflict of interest.
1216. A member of the board shall not have an interest, direct
13or indirect, in a contract for the purchase of goods, including
14materials and profits, or for the performance of services for
15the healthy Iowa program. A contract entered into in violation
16of this section is voidable.
17 Sec. 5. NEW SECTION. 135E.5 Director — appointment.
181. a. The board shall appoint a director of the healthy
19Iowa program.
20b. The director shall serve at the pleasure of the board.
21c. The board shall determine the appropriate compensation
22for the director.
232. Under the direction of and with the approval of the
24board, the director shall administer this chapter. The
25director shall do all of the following:
26a. Act as the chief administrative officer of the healthy
27Iowa program, including the healthy Iowa trust fund.
28b. Direct, organize, administer, and manage the internal
29operations of the healthy Iowa program and the board, and
30establish guidelines and procedures to promote the orderly and
31efficient administration of the healthy Iowa agency.
32c. Perform all duties necessary to comply with and carry out
33the provisions of this chapter, other state law, and federal
34law.
35d. Recommend to the board proposed rules necessary to
-11-1administer the healthy Iowa program.
2e. Prepare a budget for the healthy Iowa program and prepare
3reports as required by law.
4f. Present the healthy Iowa agency’s proposed budget to the
5board prior to December 31 of each year.
6g. Appoint the administrators within the healthy Iowa
7program.
8h. Provide for the receipt and disbursement of federal
9moneys allocated to the state and its political subdivisions
10for health care services and coverage purposes.
11i. Include in the healthy Iowa program’s annual budget all
12estimated federal funds to be received or allocated to the
13healthy Iowa program.
14j. Employ, or designate another to employ, personnel
15as necessary to carry out the duties and responsibilities
16prescribed under this chapter consistent with the merit system
17provisions of chapter 8A, subchapter IV.
18k. As necessary, retain as independent contractors
19attorneys, financial consultants, and any other professionals
20or consultants necessary to carry out the planning,
21development, and operations of the healthy Iowa program and the
22provisions of this chapter.
233. The director or the director’s designee shall
24give preference in hiring under this section to all
25individuals displaced or unemployed as a direct result of the
26implementation of the healthy Iowa program.
27 Sec. 6. NEW SECTION. 135E.6 Board and director — duties
28— powers.
291. Subject to any limitations under this chapter or other
30applicable law, the enumeration of specific powers in this
31chapter is not intended to restrict the board’s power to take
32any lawful action that the board determines is necessary
33or convenient to carry out the functions authorized by the
34Affordable Care Act and consistent with the purposes of the
35healthy Iowa program.
-12- 12. The board shall do all of the following:
2a. Adopt rules pursuant to chapter 17A to implement and
3administer this chapter.
4b. Consult with and solicit input from the healthy Iowa
5advisory committee and any other person as the board determines
6appropriate.
7c. Promote the public understanding and awareness of
8available benefits and options through the healthy Iowa
9program.
10d. Avoid jeopardizing federal financial participation in the
11programs that are incorporated into the healthy Iowa program.
12e. Ensure that there is adequate funding to meet the health
13care service needs of residents and to compensate health care
14providers that participate in the healthy Iowa program.
15f. Evaluate requests for capital expenses required to meet
16the health care service needs of residents.
17g. Approve the benefits provided by the healthy Iowa
18program.
19h. Evaluate the performance of the healthy Iowa program.
20i. Evaluate and make recommendations to the general assembly
21on any legislation related to the healthy Iowa program.
22j. Guarantee that mechanisms for public feedback are
23accessible and nondiscriminatory.
24k. Develop a plan to coordinate the activities of the
25healthy Iowa program with the activities of the department of
26public health’s bureau of health planning and the department
27of human services’ mental health planning and advisory council
28to ensure appropriate planning for the effective delivery and
29equitable distribution of health care services throughout the
30state.
31l. Provide grants from moneys in the healthy Iowa trust
32fund or moneys otherwise appropriated for this purpose to the
33health planning programs established by the bureau of health
34planning of the department of public health or the mental
35health planning and advisory council of the department of human
-13-1services to support the operation of those health planning
2programs.
3m. Allocate moneys from the healthy Iowa trust fund
4or moneys otherwise appropriated for this purpose to the
5department of human services or the department of education
6workforce training and economic development fund to be used for
7all of the following purposes:
8(1) A program for retraining and assisting job transition
9for individuals employed or previously employed in the fields
10of health insurance, health care service plans, and other
11third-party payments for health care services.
12(2) A program for retraining and assisting job transition
13for those individuals employed or previously employed in
14fields providing services to health care providers to address
15the needs of third-party payers for health care services,
16whose jobs may be or have been ended as a result of the
17implementation of the healthy Iowa program.
18n. Organize, administer, and market the healthy Iowa program
19and program services as a single-payer program under the name
20“Healthy Iowa” or any other name as the board determines.
21o. Sue, be sued, plead, and be impleaded.
22p. Apply for, accept, and expend federal, state, or private
23moneys or contracts for the implementation of the healthy Iowa
24program or other state or federal health care programs for
25residents.
26q. Maintain an office at a place designated by the board.
27r. Create subcommittees from among its members.
28s. Establish divisions and subdivisions within the healthy
29Iowa program.
30t. Make agreements with a grantor or payor of moneys,
31property, or services, including agreements to perform any
32study, plan, demonstration, or project.
33u. Enter into any agreements, contracts, or memoranda
34of understanding and execute the instruments necessary or
35convenient to manage its own affairs and carry out the purposes
-14-1of this chapter, including but not limited to contracts with
2health care providers and care coordinators.
3v. Share information with relevant state entities,
4consistent with the confidentiality provisions in this chapter,
5necessary for the administration of the healthy Iowa program.
6w. Subject to the limitations of this chapter, exercise any
7other power that is reasonably necessary or convenient to carry
8out the purposes of this chapter.
9x. Adopt rules pursuant to chapter 17A regarding residency
10requirements under the healthy Iowa program. In adopting
11such rules, the board shall be guided by the principles and
12requirements set forth in the Medicaid program without regard
13to immigration status.
14y. Contract with not-for-profit organizations to provide any
15of the following:
16(1) Assistance to consumers in the selection of a care
17coordinator, enrollment, obtaining of health care services,
18disenrollment, and other matters relating to the healthy Iowa
19program.
20(2) Assistance to health care providers providing, seeking,
21or considering whether to provide health care services under
22the healthy Iowa program.
23z. Delegate to the director any of its duties under this
24section subject to all of the following:
25(1) The board shall ensure that any entity under a contract
26or other agreement with the healthy Iowa program complies with
27the provisions of this chapter when performing services on
28behalf of the healthy Iowa program.
29(2) The operations of the healthy Iowa program are subject
30to the provisions of this chapter whether the operations are
31performed directly by the healthy Iowa program or through an
32entity under a contract or other agreement with the healthy
33Iowa program.
34 Sec. 7. NEW SECTION. 135E.7 Healthy Iowa program —
35implementation — coordination with other health care coverage.
-15- 11. The board shall determine the date of implementation of
2the healthy Iowa program when individuals may begin enrolling
3in the healthy Iowa program and the date the implementation
4period ends.
52. An insurer, carrier, or health maintenance organization
6shall not offer benefits or cover any services for which
7coverage is offered to individuals under the healthy Iowa
8program.
93. An insurer, carrier, or health maintenance organization
10that is issued a certificate of authority by the commissioner
11of insurance may offer only the following:
12a. Benefits that do not duplicate the health care services
13covered by the healthy Iowa program.
14b. Benefits available to individuals and their families who
15are employed or self-employed in this state but who are not
16residents.
17c. Benefits available during the implementation period
18to individuals who enroll or may enroll in the healthy Iowa
19program.
204. This chapter shall not prohibit a resident who is
21employed outside this state from choosing to receive health
22insurance benefits through the resident’s employer and from
23opting out of participation in the healthy Iowa program.
245. After the end of the implementation period, board members
25shall enroll as members of the healthy Iowa program.
266. a. No later than July 1, 2021, the board shall develop
27a proposal, consistent with the principles of this chapter,
28for provision by the healthy Iowa program of long-term care
29coverage, including the development of a proposal, consistent
30with the principles of this chapter, for its funding.
31b. In developing the proposal required in paragraph “a”,
32the board shall consult with a special advisory committee,
33appointed by the chairperson of the board, that includes
34representatives of consumers and potential consumers of
35long-term care, providers of long-term care, members of
-16-1organized labor, and other interested parties.
27. The board shall develop proposals for all of the
3following:
4a. Accommodating employer retiree health benefits for people
5who have been members of the healthy Iowa program but live as
6retirees outside this state.
7b. Accommodating employer retiree health benefits for people
8who earned or accrued those benefits while residing in this
9state prior to the implementation of the healthy Iowa program
10and who live as retirees outside this state.
11c. For healthy Iowa program coverage of health care services
12covered under the state workers’ compensation law, including
13whether and how to continue funding for those health care
14services under the workers’ compensation law and whether and
15how to incorporate an element of experience rating.
16 Sec. 8. NEW SECTION. 135E.8 Data collection.
171. The board shall require and enforce the collection
18and availability of all of the following data to promote
19transparency, assess adherence to patient care standards,
20compare patient outcomes, and review utilization of health care
21services paid for by the healthy Iowa program:
22a. Inpatient discharge data, including acuity and risk of
23mortality.
24b. Emergency department, ambulatory surgery, and other
25outpatient department data, including charge data, length of
26stay, and patients’ unit of observation.
27c. Hospital annual financial data, including all of the
28following:
29(1) Community benefits by hospital in dollar value.
30(2) Number of employees and classification by hospital
31unit.
32(3) Number of hours worked by hospital unit.
33(4) Employee wage information by job title and hospital
34unit.
35(5) Number of registered nurses per staffed bed by hospital
-17-1unit.
2(6) Type and value of health information technology.
3(7) Annual spending on health information technology,
4including purchases, upgrades, and maintenance.
5d. Physician services and office visits, including charge
6data.
7e. Prescription drug cost and charge data for prescription
8drugs prescribed and dispensed through hospitals or a
9physician’s office.
102. Data collected under subsection 1 shall be reported
11to the healthy Iowa program and to the public health data
12management program of the department of public health.
133. The board shall make all disclosed data collected under
14subsection 1 publicly available and searchable through an
15internet site and through the department of public health’s
16public health data management program.
174. The board shall, directly and through grants to
18not-for-profit entities, conduct programs using data collected
19through the healthy Iowa program to promote and protect public,
20environmental, and occupational health, including cooperation
21with other data collection and research programs of the
22department of public health consistent with this chapter and
23otherwise applicable law.
245. Prior to the end of the healthy Iowa program
25implementation period, the board shall provide for the
26collection and availability of all of the following data on the
27number of patients served by hospitals and the dollar value of
28the care provided, at cost, for all of the following categories
29of data items:
30a. Patients receiving charity care.
31b. Contractual adjustments of county and indigent programs,
32including traditional and managed care.
33c. Bad debt.
346. The healthy Iowa program, any state or local agency,
35or any public employee acting under color of law shall not
-18-1provide or disclose to anyone, including but not limited to the
2federal government, any personally identifiable information
3obtained under this section, including but not limited to a
4person’s religious beliefs, practices, or affiliation, national
5origin, ethnicity, or immigration status for law enforcement
6or immigration purposes.
7 Sec. 9. NEW SECTION. 135E.9 Healthy Iowa advisory committee
8— established.
91. A healthy Iowa advisory committee for the healthy Iowa
10program is established.
112. The healthy Iowa advisory committee shall consist of all
12of the following voting members:
13a. (1) Four physicians who are board certified in the
14individual’s specialty, at least one of whom shall be a
15psychiatrist.
16(2) The physician members shall include all of the
17following:
18(a) One physician appointed by the senate majority leader.
19(b) One physician appointed by the governor.
20(c) Two physicians appointed by the speaker of the house of
21representatives who are primary care providers.
22b. Two registered nurses appointed by the senate majority
23leader.
24c. One licensed allied health practitioner appointed by the
25speaker of the house of representatives.
26d. One mental health care provider appointed by the senate
27majority leader.
28e. One dentist appointed by the governor.
29f. One representative of private hospitals appointed by the
30governor.
31g. One representative of public hospitals appointed by the
32governor.
33h. (1) Four consumers of health care services.
34(2) The consumer members shall include all of the following,
35one of whom shall be a person with a disability:
-19- 1(a) Two consumers appointed by the governor.
2(b) One consumer appointed by the senate majority leader who
3is a healthy Iowa program member and who is sixty-five years of
4age or older.
5(c) One consumer appointed by the speaker of the house of
6representatives.
7i. One representative of organized labor appointed by the
8speaker of the house of representatives.
9j. One representative of community providers appointed by
10the senate majority leader.
11k. One member of organized labor appointed by the senate
12majority leader.
13l. One representative of a business that employs less than
14twenty-five people, appointed by the governor.
15m. One representative of a business that employs more than
16two hundred fifty people, appointed by the speaker of the house
17of representatives.
18n. One pharmacist appointed by the speaker of the house of
19representatives.
203. Appointed members, except for consumer members, shall
21have worked in the field they represent for a period of at
22least two years prior to being appointed.
234. Members shall serve four-year staggered terms. A vacancy
24shall be filled for the unexpired portion of the term and in
25the same manner as the original appointment. Any member may
26be reappointed for an additional term, but shall not serve for
27more than two consecutive full terms.
285. Members shall not receive compensation as a member
29but are entitled to receive reimbursement of actual expenses
30incurred in the discharge of their duties. Public members are
31also eligible to receive compensation as provided in section
327E.6.
336. In making appointments of members under this section, the
34appointing authority shall make good-faith efforts to ensure
35that their appointments, as a whole, reflect, to the greatest
-20-1extent feasible, the social and geographic diversity of this
2state.
37. The healthy Iowa advisory committee shall advise the
4board on all matters of policy related to the healthy Iowa
5program.
68. a. The healthy Iowa advisory committee shall meet at
7least six times per year in a place convenient to the public
8in accordance with chapter 21 and records of the healthy
9Iowa advisory committee shall be subject to the open records
10requirements of chapter 22.
11b. Eleven members of the healthy Iowa advisory committee
12constitute a quorum and the affirmative vote of at least twelve
13voting members is necessary for any substantive action to be
14taken.
159. The healthy Iowa advisory committee shall elect a
16chairperson from among its membership who shall serve two years
17and who may be reelected as chairperson for an additional two
18years.
1910. Members shall not use for personal benefit any
20information that is filed with, or obtained by, the healthy
21Iowa advisory committee and that is not generally available to
22the public.
2311. A member shall perform the member’s duties in good
24faith, in the manner the member reasonably believes to be in
25the best interest of the healthy Iowa program, and without
26intentional or reckless disregard of the care an ordinarily
27prudent person in a like position would use under similar
28circumstances. A member who performs the member’s duties in
29accordance with this subsection shall not be liable personally
30for actions taken as a member when done in good faith, without
31intent to defraud, and in connection with the administration of
32this chapter or actions or conduct related to this chapter.
3312. A member shall be subject to the provisions of chapter
3468B. In addition to the disclosures required pursuant to
35chapter 68B, a member shall disclose to the healthy Iowa
-21-1advisory committee and to the public any relationship
2that the member has with a health care provider, health
3clinic, pharmaceutical company, medical equipment company,
4insurance company, carrier, insurance producer, third-party
5administrator, managed care organization, or other entity in an
6industry involved in matters likely to come before the healthy
7Iowa advisory committee.
813. On all matters that come before the healthy Iowa
9advisory committee, members shall do all of the following:
10a. Adhere strictly to the conflict of interest provisions
11of section 68B.2A.
12b. Provide full disclosure to the healthy Iowa advisory
13committee and the public on any matter that gives rise to a
14potential conflict of interest and the manner in which the
15member will comply with public disclosure required by chapter
1668B and rules adopted pursuant to chapter 68B to avoid any
17conflict of interest or appearance of a conflict of interest.
1814. A member shall not have an interest, direct or indirect,
19in a contract for the purchase of goods, including materials
20and profits, and the performance of services for the healthy
21Iowa program or the healthy Iowa advisory committee. A
22contract entered into in violation of this section is void.
2315. A member may be removed for incompetence, misconduct, or
24failure to perform the duties of the position.
25 Sec. 10. NEW SECTION. 135E.10 Eligibility and enrollment
26— generally.
271. Each resident is eligible and entitled to enroll as a
28member in and receive benefits for health care services covered
29by the healthy Iowa program.
302. A member shall not pay any fee, payment, or other charge
31for enrolling in or being a member.
323. A participating health care provider or participating
33care coordinator shall not do any of the following:
34a. Require members to pay any premium, copayment,
35coinsurance, deductible, or any other form of cost sharing for
-22-1any covered health care services.
2b. Use preexisting medical conditions to determine the
3eligibility of a member to receive benefits for health care
4services covered by the program.
5c. Refuse to provide health care services to a member
6on the basis of age, citizenship, claims experience, color,
7creed, familial status, gender identity, genetic information,
8geography, health status, immigration status, marital status,
9medical condition, medical history, mental disability, military
10or veteran status, national origin, physical disability,
11primary language, race, receipt of health care, religion, sex,
12sexual orientation, or source of income.
13d. A college, university, or other institution of higher
14education in this state may purchase coverage under the healthy
15Iowa program for a student, or a student’s dependent, who is
16not a resident.
17 Sec. 11. NEW SECTION. 135E.11 Eligibility and enrollment —
18cross border employees.
191. If a resident is employed outside this state by an
20employer that is subject to the laws of this state, the
21employer and resident shall pay any payroll premium adopted
22under this chapter as if the employment were in this state.
232. If a resident is employed outside this state by an
24employer that is not subject to the laws of this state,
25either the employer and resident may comply with any payroll
26premium adopted under this chapter as if the employee were
27employed in this state, or the resident shall pay the payroll
28premium adopted under this chapter as if the resident were
29self-employed in this state.
303. Any payroll premium adopted under this chapter applies
31to all of the following:
32a. A resident of another state employed in this state.
33b. A resident of another state self-employed in this state.
344. a. A resident who is employed outside this state
35may choose to receive health insurance benefits through the
-23-1resident’s employer and opt out of participation in the healthy
2Iowa program.
3b. The board shall develop and implement rules establishing
4procedures for state residents employed outside this state to
5opt out of participation in the healthy Iowa program.
65. If any provision of this section or application of the
7provision to any person or circumstance is held to violate the
8federal Employee Retirement Income Security Act of 1974 in any
9court of competent jurisdiction, the provision or application
10found invalid shall be null and void and the invalidity shall
11not affect other provisions or any other application of this
12chapter that can be given effect without the invalid provision
13or application.
14 Sec. 12. NEW SECTION. 135E.12 Health benefit credit.
151. a. If an individual who is a resident of another state
16is employed in this state, the individual and the individual’s
17employer may be eligible for a credit against any payroll
18premium payment requirement adopted under this chapter that the
19individual or the individual’s employer would otherwise pay
20relative to that individual.
21b. The credit available under this subsection shall be for
22the amount spent on health benefits for the individual that
23would otherwise be covered by the healthy Iowa program if that
24individual were a member of the healthy Iowa program.
25c. The credit available under this subsection shall be
26distributed between the individual and employer in the same
27proportion as the actual spending by each for the health
28benefits.
29d. An employer and employee may apply their respective
30portion of the credit available under this subsection to their
31respective portion of any payroll premium payment requirement
32adopted under this chapter.
332. a. If an individual who is a resident of another state
34is self-employed in this state, the individual is eligible
35for a credit against any payroll premium payment requirement
-24-1adopted under this chapter that the individual would otherwise
2pay.
3b. Credit taken under this subsection shall be in the
4amount that the individual spends on health benefits that
5would otherwise be covered by the healthy Iowa program if the
6individual were a member of the healthy Iowa program.
73. a. The credit available for non-employment-based
8spending by an individual under subsection 2 is limited to
9spending for health benefits.
10b. An individual shall not be eligible for credit under
11subsection 2 for out-of-pocket health care services spending.
124. Credit under this section is available regardless of
13the cost or comprehensiveness of the health benefits, and
14regardless of the form of the health benefits.
155. a. An employer or individual is eligible for credit
16under this section only against payroll premiums payment
17requirement adopted under this chapter.
18b. An employer or individual shall not apply any health
19benefits spending in excess of the payroll premium payment
20requirement to other tax liability.
216. If any provision of this section or application of the
22provision to any person or circumstance is held to violate
23the federal Employee Retirement Income Security Act of 1974
24in any court of competent jurisdiction, the provision or the
25application found invalid shall be null and void and the
26invalidity shall not affect other provisions or any other
27application of this chapter that can be given effect without
28the invalid provision or application.
29 Sec. 13. NEW SECTION. 135E.13 Covered benefits.
301. a. All members are eligible to receive covered health
31care services benefits under the program.
32b. Covered health care services benefits under the program
33include all medical care that is medically necessary as
34determined by the member’s treating physician in accordance
35with the program standards established in section 135E.19 and
-25-1by the board.
2c. A member’s treating physician shall be a person
3licensed to engage in the practice of medicine and surgery or
4osteopathic medicine and surgery pursuant to chapter 148.
52. Covered health care services benefits for members
6include but are not limited to all of the following:
7a. Licensed inpatient and licensed outpatient medical and
8health care facility services.
9b. Inpatient and outpatient health care services.
10c. Diagnostic imaging, laboratory services, and other
11diagnostic and evaluative services.
12d. Medical equipment, appliances, and assistive technology,
13including prosthetics, eyeglasses, and hearing aids and
14the repair, technical support, and customization needed for
15individual use.
16e. Inpatient and outpatient rehabilitative care.
17f. Emergency care services.
18g. Emergency transportation.
19h. Necessary transportation for health care services for
20persons with disabilities or who may qualify as low-income.
21i. Child and adult immunizations and preventive care.
22j. Health and wellness education.
23k. Hospice care.
24l. Care in a skilled nursing facility.
25m. Home health care, including home health care provided in
26an assisted living facility.
27n. Mental health services.
28o. Substance abuse treatment.
29p. Dental care.
30q. Vision care.
31r. Prescription drugs.
32s. Pediatric care.
33t. Prenatal and postnatal care.
34u. Podiatric care.
35v. Chiropractic care.
-26- 1w. Acupuncture.
2x. Therapies that are shown by the United States national
3institutes of health, national center for complementary and
4integrative health to be safe and effective.
5y. Blood and blood products.
6z. Dialysis.
7aa. Adult day care.
8ab. Rehabilitative and habilitative services.
9ac. Ancillary health care or social services previously
10covered by integrated health homes as determined under Iowa
11Medicaid enterprise administrative rules and as designated
12under 42 U.S.C.§1396w-4.
13ad. Case management and care coordination.
14ae. Language interpretation and translation for health care
15services, including sign language and braille or other services
16needed for individuals with communication barriers.
17af. Health care and long-term supportive services covered
18under Medicaid or the healthy and well kids in Iowa program on
19June 30, 2017.
20ag. All of the following health care services required
21to be covered under any of the following provisions, without
22regard to whether the member would otherwise be eligible for or
23covered by the program or source referred to:
24(1) The healthy and well kids in Iowa program pursuant to
25chapter 514I.
26(2) The Medicaid program.
27(3) Medicare.
28(4) A health maintenance organization as defined in section
29514B.1.
30(5) A managed health care program as defined by rule of
31the department of human services, including health maintenance
32organizations, prepaid health plans, the Medicaid patient
33access to service system, Iowa plan for behavioral health,
34programs of all-inclusive care for the elderly, Iowa health
35link, and the Iowa health and wellness plan.
-27- 1ah. Any additional health care services authorized by the
2board.
3ai. All essential health benefits mandated by the Affordable
4Care Act as of January 1, 2017.
5 Sec. 14. NEW SECTION. 135E.14 Covered benefits —
6additions.
71. The board, on a regular basis, shall evaluate whether
8covered benefits under the healthy Iowa program should be
9improved or adjusted to promote the health of beneficiaries,
10account for changes in medical practice or new information from
11medical research, or respond to other relevant developments in
12health science. In carrying out this duty, the board shall
13consult with the persons described in subsection 2 on all of
14the following:
15a. Identifying specific complementary and integrative
16medicine practices that, on the basis of research findings or
17promising clinical interventions, are appropriate to include as
18benefits under the healthy Iowa program package.
19b. Identifying barriers to the effective provision and
20integration of such practices into the delivery of health care,
21and identifying mechanisms for overcoming such barriers.
222. The board shall consult with all of the following when
23carrying out the requirements of subsection 1:
24a. Institutions of higher education, private research
25institutes, and individual researchers with extensive
26experience in complementary and alternative medicine and the
27integration of such practices into the delivery of health care.
28b. Nationally recognized providers of complementary and
29integrative medicine.
30c. Such other officials, entities, and individuals with
31expertise in complementary and integrative medicine as the
32board determines appropriate.
333. a. Health care providers and members may petition the
34board to improve or adjust covered benefits under the healthy
35Iowa program.
-28- 1b. The board shall develop and adopt rules pursuant to
2chapter 17A establishing procedures for members to petition the
3board to improve or adjust covered benefits under the healthy
4Iowa program.
5 Sec. 15. NEW SECTION. 135E.15 Delivery of care —
6participating health care providers.
71. Any health care provider is qualified to participate in
8the healthy Iowa program if the health care provider meets all
9of the following criteria:
10a. The health care provider is licensed to practice in this
11state and is otherwise in good standing.
12b. The health care provider’s services are performed while
13physically present in this state.
14c. The health care provider agrees to accept program rates
15as payment in full for all covered health care services.
162. The board shall establish and maintain procedures and
17standards for recognizing health care providers located outside
18this state for purposes of providing coverage under the program
19for members who require out-of-state health care services while
20the member is physically outside this state for a period of
21time not to exceed ninety days.
223. Any health care provider qualified to participate under
23this section may provide covered health care services under the
24healthy Iowa program as long as the health care provider is
25legally authorized to perform the health care service for the
26individual and under the circumstances involved.
274. A member may choose to receive health care services
28under the healthy Iowa program from any participating provider,
29consistent with all of the following:
30a. Provisions of this section.
31b. The willingness or availability of the health care
32provider.
33c. Provisions of this chapter prohibiting discrimination
34against members.
35d. The appropriate clinically relevant circumstances and
-29-1standards.
25. The board may establish and maintain procedures for
3member enrollment and disenrollment with participating health
4care providers that are health maintenance organizations, group
5medical practices, or essential community providers that offer
6comprehensive services.
76. a. Participating health care providers shall not use
8health information technology or clinical practice guidelines
9that limit the effective exercise of the professional judgment
10of a physician or registered nurse.
11b. A physician or registered nurse may override health
12information technology and clinical practice guidelines if all
13of the following criteria are met:
14(1) It is consistent with the treating physician’s or
15registered nurse’s determination of medical necessity.
16(2) In the professional judgment of the treating physician
17or registered nurse, it is in the best interest of the patient
18and consistent with the patient’s wishes.
197. The board shall establish and maintain procedures and
20standards for recognizing health care providers located outside
21this state for purposes of providing coverage under the healthy
22Iowa program for health care services provided outside this
23state under the healthy Iowa program.
24 Sec. 16. NEW SECTION. 135E.16 Delivery of care — care
25coordination.
261. Care coordinators shall provide care coordination,
27including administrative tracking and medical recordkeeping
28services, to members.
292. a. Care coordinators may employ or utilize the services
30of other individuals or entities to assist in providing care
31coordination for a member, consistent with rules adopted by the
32board and consistent with the statutory requirements for care
33coordinator licensure.
34b. Care coordinators shall give preference, when employing
35or utilizing the services of other individuals, to those
-30-1individuals who have transitioned out of employment due to
2displacement resulting from implementation of the healthy Iowa
3program.
43. Care coordinators shall comply with all federal and
5state privacy laws, including but not limited to the federal
6Health Insurance Portability and Accountability Act of
71996, Pub.L. No.104-191, 42 U.S.C.§1320d et seq.and its
8implementing regulations, and the disclosure of mental health
9and psychological information requirements of chapter 228.
104. A referral from a care coordinator is not required for a
11member to receive health care services from any participating
12health care provider.
135. A care coordinator may be an individual or entity
14approved by the board that is any of the following:
15a. A health care provider that is any of the following:
16(1) The member’s primary care provider.
17(2) The member’s provider of primary gynecological care.
18(3) At the option of a member who has a chronic condition
19that requires specialty care, a specialist health care provider
20who regularly and continually provides treatment to the member
21for that condition.
22b. An entity licensed as any of the following:
23(1) A hospital licensed pursuant to chapter 135B.
24(2) A limited service organization established under the
25requirements of section 514B.33.
26(3) An outpatient surgical facility, as defined in section
27135.61, certified as an ambulatory surgical center under the
28federal Medicare program or under the Medicaid program.
29(4) An organized outpatient health facility as defined in
30section 135.61.
31(5) A licensed subacute care facility for persons with
32serious and persistent mental illness as defined in section
33135G.1.
34(6) A licensed psychiatric medical institution for children
35as defined in section 135H.1.
-31- 1(7) A entity certified by the department of human services
2to provide home and community-based services, including
3habilitation services, the program of all-inclusive care for
4the elderly, home health services, private duty nursing and
5personal care programs, or targeted case management.
6(8) A medical care ambulance service or nontransport
7service that has received authorization from the department
8pursuant to section 147A.5.
9(9) A health maintenance organization as defined in section
10514B.1.
11(10) A licensed nursing facility as defined in section
12135C.1.
13(11) A licensed nursing home as defined in section 155.1.
14(12) A licensed residential care facility as defined in
15section 135C.1.
16(13) A licensed intermediate care facility for persons with
17an intellectual disability as defined in section 135C.1.
18(14) A licensed intermediate care facility for persons with
19mental illness as defined in section 135C.1.
20(15) A licensed health care facility that provides adult day
21services as defined in section 135C.1.
22(16) A licensed health care facility that provides
23rehabilitative services as defined in section 135C.1.
24(17) A facility that provides hospice care under a licensed
25hospice program as defined in section 135J.1.
26(18) A licensed boarding home as defined in section 135O.1.
27(19) A certified assisted living program as defined in
28section 231C.2.
29(20) A designated community mental health center as defined
30in section 230A.102.
31(21) A certified elder group home as defined in section
32231B.1.
33c. (1) A Taft-Hartley health and welfare fund, with respect
34to its members and their family members.
35(2) This provision does not preclude a Taft-Hartley health
-32-1and welfare fund from becoming a care coordinator under
2paragraph “d”.
3d. Any not-for-profit or governmental entity approved by the
4healthy Iowa board.
56. a. (1) A healthy Iowa program member shall enroll with
6a healthy Iowa care coordinator prior to receiving health care
7services.
8(2) A member shall enroll with a care coordinator within
9sixty days of enrollment in the healthy Iowa program.
10(3) The healthy Iowa program shall only reimburse a health
11care provider for services if the member is enrolled with a
12care coordinator at the time the health care services are
13provided.
14b. If a member receives health care services before choosing
15a care coordinator, the healthy Iowa program shall assist the
16member, when appropriate, in choosing a care coordinator.
17c. A member shall remain enrolled with a care coordinator
18until the member becomes enrolled with a different care
19coordinator or ceases to be a member.
20d. A member may change the member’s care coordinator based
21on rules applicable to selecting a primary medical provider
22or a medical home under the Iowa health and wellness program
23pursuant to chapter 249N.
247. This section shall not be interpreted to authorize
25any individual to engage in any act in violation of the
26individual’s professional licensure under title IV.
278. An individual or entity shall not act as a care
28coordinator unless the health care services included in care
29coordination are within the individual’s professional scope of
30practice or within the entity’s legal authority.
319. a. The board shall adopt rules pursuant to chapter
3217A regarding and including but not limited to all of the
33following:
34(1) Procedures and standards for an individual or entity
35to be approved as a care coordinator under the healthy Iowa
-33-1program.
2(2) Procedures and standards relating to the limitation,
3suspension, or revocation of an individual’s approval as a care
4coordinator based on a determination that the individual or
5entity is incompetent to be a care coordinator.
6(3) Procedures and standards relating to the limitation,
7suspension, or revocation of the approval of an individual’s
8or entity’s approval as a care coordinator based on an
9exhibited course of conduct that is inconsistent with healthy
10Iowa program standards and regulations or that exhibits an
11unwillingness to meet those standards and regulations.
12(4) Procedures and standards relating to the limitation,
13suspension, or revocation of approval of an individual or
14entity as a care coordinator based on a determination that the
15individual or entity is a potential threat to the public health
16or safety.
17b. The rules adopted by the board under this subsection
18shall be consistent with professional practice, licensure
19standards, and regulations established pursuant to title IV,
20title VI, and title XIII, as applicable.
21c. In developing and implementing rules or standards for
22the approval of care coordinators for individuals receiving
23chronic mental health care services, the board shall consult
24with the division of mental health and disability services of
25the department of human services.
2610. To maintain approval under the program, a care
27coordinator shall do all of the following:
28a. Renew the person’s status as a care coordinator every
29three years pursuant to rules adopted by the board.
30b. Provide the healthy Iowa program any data required by the
31department of human services or the department of public health
32and as required by the board that would enable the board to
33evaluate the impact of care coordinators on quality, outcomes,
34and cost of health care.
3511. This chapter shall not be construed to alter the
-34-1professional practice of health care providers or their
2licensure standards established pursuant to title IV.
312. a. Care coordinators shall not use health information
4technology or clinical practice guidelines that limit the
5effective exercise of the professional judgment of physicians
6and registered nurses.
7b. Physicians and registered nurses may override health
8information technology and clinical practice guidelines if all
9of the following criteria are met:
10(1) It is consistent with the treating physician’s
11determination of medical necessity.
12(2) In the professional judgment of the treating physician
13or registered nurse, it is in the best interest of the patient
14and consistent with the patient’s wishes.
15 Sec. 17. NEW SECTION. 135E.17 Rates and payment
16methodologies.
171. a. The board shall adopt rules pursuant to chapter 17A
18regarding contracting and establishing payment methodologies
19for covered health care services and care coordination provided
20to members under the healthy Iowa program by participating
21providers and care coordinators.
22b. The board may adopt a variety of payment methodologies,
23including those established on a demonstration basis.
24c. All payment rates under the healthy Iowa program shall be
25reasonable and reasonably related to the cost of efficiently
26providing the health care service and ensuring an adequate and
27accessible supply of health care services.
282. a. Health care services provided to members under the
29healthy Iowa program, with the exception of care coordination,
30shall be paid for on a fee-for-service basis unless and until
31the board establishes another payment methodology.
32b. A rebuttable presumption exists that the Medicare rate of
33reimbursement constitutes a reasonable fee-for-service payment
34rate.
353. Notwithstanding subsection 2, health maintenance
-35-1organizations, essential community providers, and group
2medical practices that provide comprehensive, coordinated
3services shall be reimbursed on the basis of a capitated system
4operating budget or a noncapitated system operating budget.
54. a. Payment for health care services established under
6this chapter shall be considered payment in full.
7b. A participating health care provider shall not charge any
8rate in excess of the payment established under this chapter
9for any health care service provided to a member and shall not
10solicit or accept payment from any member or third party for
11any health care service, except as provided under federal law.
12c. This section does not preclude the healthy Iowa program
13from acting as a primary or secondary payer in conjunction with
14another third-party payer when permitted by federal law.
155. a. The board may adopt rules pursuant to chapter
1617A to provide payment methodologies for the payment of
17capital-related expenses for specifically identified capital
18expenditures incurred by not-for-profit or governmental
19entities that are health care entities licensed under title IV,
20including but not limited to hospitals, health care facilities,
21subacute mental health care facilities, psychiatric medical
22institutions for children, entities providing licensed hospice
23programs, and entities providing emergency medical care.
24b. Any capital-related expense generated by a capital
25expenditure that requires prior approval by the board shall not
26be paid unless such prior approval has been received.
27c. Approval of a capital expenditure shall be based on
28achievement of the program standards described in section
29135E.19.
306. Payment methodologies and rates shall include a distinct
31component of reimbursement for direct and indirect graduate
32medical education.
337. a. The board shall adopt rules pursuant to chapter
3417A regarding payment methodologies and procedures to pay for
35health care services provided to a member while the member is
-36-1located outside this state for a period of time not to exceed
2ninety days except as provided in paragraph “b”.
3b. (1) The board may adopt rules pursuant to chapter 17A
4regarding payment methodologies and procedures to pay for
5health care services provided to a member while the member is
6outside this state for a period of time not to exceed ninety
7days if it is medically necessary as determined by the member’s
8treating physician in accordance with the program standards
9established in section 135E.19 and by the board.
10(2) A member’s treating physician is a person licensed to
11engage in the practice of medicine and surgery or osteopathic
12medicine and surgery pursuant to chapter 148.
13 Sec. 18. NEW SECTION. 135E.18 Rate negotiations.
141. The healthy Iowa program shall engage in good-faith
15negotiations with health care provider representatives under
16chapter 135F to develop all of the following:
17a. Rates of payment for health care services.
18b. Rates of payment for prescription and nonprescription
19drugs.
20c. Payment methodologies.
212. Rate negotiations shall be conducted annually through a
22single entity on behalf of the entire program for prescription
23and nonprescription drugs.
243. a. The board shall establish a prescription drug
25formulary system, which shall discourage the use of
26ineffective, dangerous, or excessively costly medications when
27better alternatives are available.
28b. The formulary established under this subsection shall
29promote the use of generic medications to the greatest extent
30possible.
31c. Clinicians and patients may petition the board to add
32new pharmaceuticals or to remove ineffective or dangerous
33medications from the formulary.
34d. The board shall adopt rules pursuant to chapter 17A
35regarding the use of off-formulary medications which allow for
-37-1patient access but do not compromise the formulary.
2 Sec. 19. NEW SECTION. 135E.19 Program standards.
31. The healthy Iowa program shall establish a single
4standard of safe, therapeutic health care services for all
5residents.
62. The board shall adopt rules pursuant to chapter 17A to
7establish requirements and standards for the program and for
8care coordinators and health care providers, consistent with
9this chapter and consistent with the applicable professional
10practice and licensure standards for health care providers,
11health care facilities, and health care professionals
12established in title IV, title VI, and title XIII, as
13applicable. The rules adopted under this subsection shall
14address all of the following:
15a. Requirements and standards for the scope, quality, and
16accessibility of health care services.
17b. Requirements and standards for interactions between
18health care providers and members.
19c. Requirements and standards for interactions between care
20coordinators and health care providers, including credentialing
21and participation in health care organization networks, and
22terms, methods, and rates of payment.
233. The board shall adopt rules pursuant to chapter 17A to
24establish requirements and standards to promote all of the
25following:
26a. Simplification, transparency, uniformity, and fairness in
27health care provider credentialing and participation in health
28care organization networks, referrals, payment procedures and
29rates, claims processing, and approval of health care services,
30as applicable.
31b. In-person primary and preventive care, care coordination,
32efficient and effective health care services, quality
33assurance, and promotion of public, environmental, and
34occupational health.
35c. Elimination of health care disparities, including
-38-1geographic disparities, racial disparities, income-based
2disparities, gender-based disparities, sex-based disparities,
3and other disparities.
4d. Nondiscrimination with respect to members and health
5care providers on the basis of age, citizenship, claims
6experience, color, creed, familial status, gender identity,
7genetic information, geography, health status, immigration
8status, marital status, medical condition, medical history,
9mental disability, military or veteran status, national origin,
10physical disability, primary language, race, receipt of health
11care, religion, sex, sexual orientation, or source of income.
12e. Provision of health care services under the healthy
13Iowa program that is appropriate to the patient’s clinically
14relevant circumstances.
15f. Accessibility of care coordination and health care
16services, including accessibility for people with disabilities
17and people with limited ability to speak or understand English.
18g. Providing care coordination and health care services in
19a culturally competent manner.
204. The board shall adopt rules pursuant to chapter 17A to
21establish requirements and standards, to the extent authorized
22by federal law, for replacing and merging with the healthy
23Iowa program any health care services and ancillary services
24currently provided by other programs, including but not limited
25to Medicare, the Affordable Care Act, and federally matched
26public health programs.
275. a. Any participating health care provider or care
28coordinator that is organized as a for-profit entity shall meet
29the same requirements and standards as entities organized as
30not-for-profit entities.
31b. Payments under the program to for-profit entities shall
32not be calculated to accommodate the generation of profit,
33excess revenue, revenue for dividends, or other return on
34investment or the payment of taxes that would not be paid by a
35not-for-profit entity.
-39- 16. a. A participating health care provider shall do all of
2the following:
3(1) Furnish information as required by the department of
4public health, including the public health data management
5program.
6(2) Permit examination of information by the healthy Iowa
7program as may be reasonably required for purposes of reviewing
8accessibility and utilization of health care services, quality
9assurance, cost containment, the making of payments, and
10statistical or other studies of the operation of the healthy
11Iowa program or for protection and promotion of public,
12environmental, and occupational health.
13b. The board shall use data collected under this subsection
14to ensure that clinical practices meet the utilization,
15quality, and access standards of the healthy Iowa program.
167. In developing requirements and standards and making
17other policy determinations under this chapter, the board
18shall consult with representatives of members, health care
19providers, care coordinators, health care organizations, labor
20organizations representing health care provider employees, and
21other interested parties.
22 Sec. 20. NEW SECTION. 135E.20 Advocacy for necessary health
23care.
241. As part of a health care provider’s duty to exercise
25a professional standard of care when evaluating a patient’s
26medical condition, a participating health care provider under
27the healthy Iowa program shall do all of the following:
28a. Advocate for medically necessary health care services for
29the provider’s patients.
30b. Act in the exclusive interest of patients.
312. Consistent with subsection 1 and with professional
32standards of care under title IV, a patient’s treating
33physician or health care provider is responsible for the
34determination of the health care services medically necessary
35for the patient.
-40- 13. Consistent with subsection 1 and with professional
2standards of care under title IV, title VI, and title XIII,
3care coordinators and health care providers shall use
4reasonable care and diligence in safeguarding their patients
5and shall not impair any health care provider’s duty to
6advocate for medically appropriate health care services for
7patients.
84. Consistent with subsection 1 and with professional
9standards of care under title IV, title VI, and title XIII, any
10pecuniary interest or relationship of a physician or health
11care provider, including any interest or relationship disclosed
12or reported under this section, that impairs the physician’s or
13health care provider’s ability to provide medically necessary
14health care services to a patient violates the physician’s or
15health care provider’s duty to advocate for medically necessary
16health care services for patients.
175. A health care provider violates the duty to provide
18medically necessary care services under this section if the
19health care provider accepts any bonus, incentive payment, or
20compensation based on any of the following:
21a. A patient’s utilization of health care services.
22b. The financial results of any other health care provider
23or care coordinator with which the health care provider or
24care coordinator has a pecuniary interest or contractual
25relationship, including employment or other compensation-based
26relationship.
27c. The financial results of any health maintenance
28organization, essential community providers, or group medical
29practices that receives capitated payments from the healthy
30Iowa program.
316. To evaluate and review compliance by participating
32health care providers and care coordinators under the healthy
33Iowa program, participating health care providers and care
34coordinators shall report, at least annually, to the department
35of public health’s public health data management program all
-41-1of the following:
2a. Any beneficial interest in or compensation arrangement
3with an entity to which the participating health care provider
4referred a patient.
5b. Any membership, proprietary interest, or co-ownership in
6any form in or with a clinical or bioanalytical laboratory.
7c. Any payments to a clinical or bioanalytical laboratory
8for a test or test series for a patient.
9d. Any profit-sharing arrangement with a clinical or
10bioanalytical laboratory.
11e. Any contracts or subcontracts entered into that contain
12incentive plans, involve general payments such as capitation
13payments or shared risk agreements, and are not tied to
14specific medical decisions involving specific members or groups
15of members with similar medical conditions. Such contracts
16and subcontracts include those entered into with a health
17maintenance organization or group practice.
18f. Any bonus, incentive agreements, or compensation
19arrangements with any other participating health care provider,
20care coordinator, health maintenance organization, or group
21medical practice under the healthy Iowa program.
22g. Any offer, delivery, receipt, or acceptance of rebates,
23refunds, commission, preference, patronage dividend, discount,
24or other consideration for a referral made when treating a
25member of a health maintenance organization, to another health
26care provider in the same group practice as the referring
27health care provider, or made for in-office ancillary services
28or tests that are furnished by the referring health care
29provider, a person in the same group practice as the referring
30health care provider, or an individual employed or supervised
31by the referring health care provider.
32h. Any other referral or relationship that the board finds
33necessary to disclose to meet the purposes of this section.
347. The board may adopt rules pursuant to chapter 17A as
35necessary to implement and enforce this section and may adopt
-42-1such rules to expand reporting requirements under this section.
2 Sec. 21. NEW SECTION. 135E.21 Federal waivers.
31. The board shall seek all federal waivers and other
4federal approvals and arrangements and submit federal state
5plan amendments as necessary to operate the healthy Iowa
6program consistent with this chapter.
72. a. The board and, as appropriate, the director of human
8services, shall apply to the United States secretary of health
9and human services or other appropriate federal official for
10all waivers of requirements, and make other arrangements under
11Medicare, any federally matched public health program, the
12Affordable Care Act, and any other federal programs pertaining
13to the provision of health care that provide federal funds for
14payment for health care services that are necessary to:
15(1) Enable all members to receive all benefits through the
16healthy Iowa program.
17(2) Enable the state to implement this chapter.
18(3) Allow the state to receive and deposit all federal
19payments under those programs, including funds that may
20be provided in lieu of premium tax credits, cost-sharing
21subsidies, and small business tax credits, in the state
22treasury to the credit of the healthy Iowa trust fund.
23(4) Use moneys deposited in the healthy Iowa trust fund
24for the healthy Iowa program and other provisions under this
25chapter.
26b. To the greatest extent possible, the board shall
27negotiate arrangements with the federal government to ensure
28that federal payments are paid to the healthy Iowa program in
29place of federal funding of, or tax benefits for, federally
30matched public health programs or federal health programs.
31c. (1) The board may require members or applicants to
32provide information necessary for the healthy Iowa program to
33comply with any waiver or arrangement under this chapter.
34(2) Information provided by members to the board for the
35purposes of this paragraph shall not be used for any other
-43-1purpose.
2d. The board may take any additional actions necessary to
3effectively implement the healthy Iowa program to the maximum
4extent possible as a single-payer program consistent with this
5chapter.
63. a. The board may take actions consistent with this
7chapter to enable the healthy Iowa program to administer
8Medicare in this state.
9b. The healthy Iowa program shall do all of the following:
10(1) Be a provider of Medicare part B supplemental insurance
11coverage.
12(2) Provide premium assistance drug coverage under Medicare
13part D for eligible members of the healthy Iowa program.
144. The board may waive or modify the applicability of any
15provisions of this section relating to any federally matched
16public health program or Medicare, as necessary, to do any of
17the following:
18a. Implement any waiver arrangement under this section.
19b. Maximize the federal benefits to the healthy Iowa program
20under this section.
215. a. The board may apply for coverage for, and enroll,
22any eligible member under any federally matched public health
23program or Medicare.
24b. Enrollment in a federally matched public health program
25or Medicare shall not cause any member to lose any health care
26services provided by the healthy Iowa program or diminish any
27right the member would otherwise have.
286. The board shall take necessary action to incorporate
29health care coverage of residents who are employed in another
30state into waivers and other approvals applied for or obtained
31under this section.
327. a. The board shall take necessary action to reduce or
33eliminate a member’s coinsurance, cost-sharing, or premium
34obligations or to increase the likelihood of an individual’s
35eligibility for any federal financial support related to
-44-1Medicare or the Affordable Care Act.
2b. The board may act under paragraph “a” only upon a
3finding approved by the board that the action does all of the
4following:
5(1) Helps to increase the number of members who are eligible
6for and enrolled in federally matched public health programs,
7or for any program to reduce or eliminate an individual’s
8coinsurance, cost-sharing, or premium obligations or increase
9an individual’s eligibility for any federal financial support
10related to Medicare or the Affordable Care Act.
11(2) Does not diminish any individual’s access to any health
12care service or right the individual would otherwise have.
13(3) Is in the interest of the healthy Iowa program.
14(4) Does not require or has received any necessary federal
15waivers or approvals to ensure federal financial participation.
16c. Action that the board may take under paragraph “a” may
17include any of the following:
18(1) An increase to the income eligibility level related to
19Medicare or the Affordable Care Act.
20(2) An increase to resource retention or an elimination of
21the resource test for eligibility related to Medicare or the
22Affordable Care Act.
23(3) Simplification of any procedural or documentation
24requirement for enrollment related to Medicare or the
25Affordable Care Act.
26(4) An increase in the benefits for any federally matched
27public health program and for any program in order to reduce or
28eliminate an individual’s coinsurance, cost-sharing, or premium
29obligations or increase an individual’s eligibility for any
30federal financial support related to Medicare or the Affordable
31Care Act.
32d. Board actions under this subsection shall not apply to
33eligibility for payment for long-term care.
348. To enable the board to apply for coverage for, and
35enroll, any eligible member under any federally matched public
-45-1health program or Medicare, the board may require that all
2members or applicants provide the information necessary to
3enable the board to determine whether the applicant is eligible
4for a federally matched public health program or for Medicare,
5or any program or benefit under Medicare.
69. As a condition of continued eligibility for health
7care services under the healthy Iowa program, a member who is
8eligible for benefits under Medicare shall enroll in Medicare,
9including parts A, B, and D.
1010. a. The healthy Iowa program shall provide premium
11assistance for all members enrolling in a Medicare part D plan.
12b. Premium assistance required under paragraph “a” is
13limited to the low-income benchmark premium amount established
14by the centers for Medicare and Medicaid services of the United
15States department of health and human services and any other
16amount the federal agency establishes under its de minimis
17premium policy, except that those payments made on behalf of
18members enrolled in a Medicare advantage plan may exceed the
19low-income benchmark premium amount if determined to be cost
20effective to the healthy Iowa program.
2111. a. If the board has reasonable grounds to believe that
22a member may be eligible for an income-related subsidy under
23§1860D-14 of Tit.XVIII of the federal Social Security Act, 42
24U.S.C.§1395w-114, the member shall be required to provide and
25authorize the healthy Iowa program to obtain any information or
26documentation required to establish the member’s eligibility
27for that subsidy.
28b. The board shall attempt to obtain as much of the
29information and documentation required by paragraph “a” as
30possible.
3112. a. The healthy Iowa program shall make a reasonable
32effort to notify members of their obligations under this
33section.
34b. After a reasonable effort has been made to contact the
35member, the member shall be notified in writing that the member
-46-1has sixty days to provide the required information.
2c. If the required information is not provided within the
3sixty-day period, the member’s coverage under the healthy Iowa
4program may be terminated.
5d. Information provided by members to the board for the
6purposes of this section shall not be used for any other
7purpose.
813. The board shall assume responsibility for all benefits
9and health care services paid for by the federal government
10with those funds.
11 Sec. 22. NEW SECTION. 135E.22 Healthy Iowa trust fund —
12special fund created.
131. A special fund is created in the state treasury, separate
14and apart from all other public moneys or funds of this state,
15to be known as the healthy Iowa trust fund. The fund shall
16consist of all of the following:
17a. All moneys appropriated by the state to the fund.
18b. All moneys received from the federal government, as
19the result of any waiver of requirements granted or other
20arrangements agreed to by the federal government for health
21care programs.
22c. All moneys transferred to the fund attributable to state
23and federal financial participation in Medicaid, the healthy
24and well kids in Iowa program, and Medicare.
25d. All receipts and revenue after January 1, 2019, as a
26result of the collection of taxes or other moneys, as provided
27by law, shall also be deposited in the healthy Iowa trust fund.
28e. All federal and state moneys received for purposes of the
29provision of services authorized under Tit.XX of the federal
30Social Security Act, 42 U.S.C.§1397 et seq., but are provided
31under the healthy Iowa program.
32f. All moneys received from other federal programs that
33provide moneys for the payment of health care services that are
34provided under this chapter.
35g. All moneys paid by the state that are equivalent to those
-47-1amounts that are paid on behalf of residents under Medicare,
2any federally matched public health program, or the Affordable
3Care Act for health benefits that are equivalent to health
4benefits covered under the healthy Iowa program.
52. All moneys in the fund shall be deposited, administered,
6and disbursed, in the same manner and under the same conditions
7and requirements as is provided by law for special funds in
8the state treasury. The moneys credited to the fund are not
9subject to section 8.33 and shall not be transferred, used,
10obligated, appropriated, or otherwise encumbered except as
11provided in this section. Moneys deposited into the fund are
12appropriated and made available to the healthy Iowa program to
13be used only for the following purposes established by this
14chapter:
15a. To implement the purposes of the healthy Iowa program.
16b. To be used by the healthy Iowa program for the payment of
17claims or reimbursement of member benefits.
18c. To be used by the healthy Iowa program for the payment,
19in accordance with any agreement with the federal government,
20of amounts required to obtain federal waivers and such other
21purposes under the healthy Iowa program as may be authorized
22by law.
233. The treasurer of state is the custodian and trustee of
24the fund and shall administer the fund in accordance with the
25purposes of the healthy Iowa program. It is the duty of the
26treasurer of state to do all of the following:
27a. To hold the trust funds.
28b. To disburse the trust funds upon warrants drawn by the
29director of the healthy Iowa program.
304. The healthy Iowa program shall administer the healthy
31Iowa trust fund and shall also administer all other provisions
32of this section.
335. All moneys in the fund, except moneys received
34pursuant to federal waivers entered into pursuant to section
35135E.21, which are received from the federal government
-48-1shall be expended solely for the purposes and in the amounts
2found necessary by the board for the proper and efficient
3administration of this chapter and any federal waivers or
4agreements.
56. Moneys deposited in the fund shall not be loaned to, or
6borrowed by, any other special fund or the general fund of the
7state, or a county general fund or any other county fund.
87. The board shall establish and maintain a reserve fund in
9the healthy Iowa trust fund.
108. The board or staff of the board shall not utilize any
11moneys intended for the administrative and operational expenses
12of the board for staff retreats, promotional giveaways,
13excessive executive compensation, or promotion of federal or
14state legislative or regulatory modifications.
159. a. A healthy Iowa federal funds account is created
16within the fund.
17b. All federal moneys received shall be placed into the
18healthy Iowa federal funds account.
19 Sec. 23. NEW SECTION. 135E.23 Severability.
20If any provision of this chapter or its application to any
21person or circumstance is held invalid, the invalidity does
22not affect other provisions or application of this chapter
23which can be given effect without the invalid provision or
24application, and to this end the provisions of this chapter are
25severable.
26 Sec. 24. NEW SECTION. 135E.24 Relation to other laws.
27This chapter does not preempt or prevail over and is
28not meant to be construed to preempt or prevail over any
29ordinances, resolutions, or other actions of a local government
30or rules or actions of a state agency that are consistent with
31this chapter or that provide more protections and benefits to
32residents of this state than this chapter or are more stringent
33than this chapter.
34 Sec. 25. NEW SECTION. 135F.1 Definitions.
35As used in this chapter, unless the context otherwise
-49-1requires:
21. a. “Health care provider” means a person who meets all
3of the following criteria:
4(1) Is licensed, certified, registered, or authorized to
5practice a health care profession in the state pursuant to
6chapter 147A, 148, 148A, 148B, 148C, 148E, 148F, 148G, 149,
7151, 152, 152A, 152B, 152C, 153, 154, 154A, 154B, 154C, 154D,
8154F, 155, or 155A.
9(2) Is an approved health care provider under the healthy
10Iowa program created in chapter 135E.
11(3) Is an individual who does any of the following:
12(a) Practices the profession in which that person is
13licensed, certified, registered, or authorized to practice
14in the state as a health care provider or as an independent
15contractor.
16(b) Is an owner, officer, shareholder, or proprietor of a
17health care provider.
18(c) Is an entity that employs or utilizes health care
19providers to provide health care services under the healthy
20Iowa program.
21b. “Health care provider” does not include an individual who
22practices as an employee of another health care provider.
232. “Health care provider representative” means a third party
24that is authorized by a health care provider to negotiate
25on behalf of the health care provider with the healthy Iowa
26program over terms and conditions of participation affecting
27those health care providers.
28 Sec. 26. NEW SECTION. 135F.2 Collective negotiation
29authorized.
301. Health care providers may meet and communicate for the
31purpose of collectively negotiating with the healthy Iowa
32program on any matter relating to the healthy Iowa program
33including but not limited to rates of payment for health care
34services, rates of payment for prescription and nonprescription
35drugs, and payment methodologies.
-50- 12. This chapter shall not be construed, is not intended to
2be construed, and shall not imply any of the following:
3a. To allow or authorize an alteration of the terms of the
4internal and external review procedures set forth in law.
5b. To allow a strike by health care providers related to the
6collective negotiations under the healthy Iowa program.
7c. To allow or authorize terms or conditions of
8participation that would impede the ability of the healthy
9Iowa program to obtain or retain accreditation by the national
10committee for quality assurance or a similar body, or to comply
11with applicable state or federal law.
12 Sec. 27. NEW SECTION. 135F.3 Collective negotiation —
13requirements.
141. A health care provider representative is the only party
15authorized to negotiate with the healthy Iowa program on behalf
16of the health care providers as a group.
172. A health care provider shall be bound by the terms
18and conditions negotiated by the health care provider
19representative.
203. Health care providers have the right during collective
21negotiations under this chapter to communicate with other
22health care providers regarding the terms and conditions of
23participation to be negotiated with the healthy Iowa program
24and to communicate with health care provider representatives.
254. The healthy Iowa program may communicate or negotiate
26with the health care provider representative, and may offer
27and provide different terms and conditions of participation to
28individual competing health care providers.
295. This section shall not be construed, is not intended to
30be construed to, and shall not imply any of the following:
31a. An effect on or limitation to the right of a health care
32provider or group of health care providers to collectively
33petition a governmental entity for a change in a law, rule, or
34regulation.
35b. An effect on or limitation to collective bargaining
-51-1on the part of a health care provider with the health care
2provider’s employer or any other lawful collective bargaining.
36. Before engaging in collective negotiations with the
4healthy Iowa program on behalf of health care providers, a
5health care provider representative shall file with the board,
6in the manner prescribed by the board, all of the following
7information:
8a. The name of the representative.
9b. The representative’s plan of operation.
10c. The representative’s procedures to ensure compliance with
11this chapter.
127. a. A person who acts as the representative of
13negotiating parties under this chapter shall pay a fee to the
14board to act as a representative.
15b. The board shall set fees in amounts deemed reasonable
16and necessary to cover the costs incurred by the board in
17administering this chapter.
18 Sec. 28. NEW SECTION. 135F.4 Health care providers —
19prohibited collective action.
201. This chapter shall not authorize competing health care
21providers to act in concert in response to discussions or
22negotiations of a health care provider representative with the
23healthy Iowa program, except as authorized by other law.
242. A health care provider representative shall not
25negotiate any agreement that excludes, limits the participation
26or reimbursement of, or otherwise limits the scope of health
27care services to be provided by any health care provider or
28group of health care providers with respect to the performance
29of health care services that are within the health care
30provider’s scope of practice, license, registration, or
31certification.
32 Sec. 29. NEW SECTION. 135F.5 Severability.
33If any provision of this chapter or its application to any
34person or circumstance is held invalid, the invalidity does
35not affect other provisions or application of this chapter
-52-1which can be given effect without the invalid provision or
2application, and to this end the provisions of this chapter are
3severable.
4 Sec. 30. NEW SECTION. 135F.6 Relation to other laws.
5This chapter does not preempt or prevail over and is
6not meant to be construed to preempt or prevail over any
7ordinances, resolutions, or other actions of a local government
8or rules or actions of a state agency that are consistent with
9this chapter or that provide more protections and benefits to
10Iowa residents than this chapter or are more stringent than
11this chapter.
12 Sec. 31. EFFECTIVE DATE. This Act, being deemed of
13immediate importance, takes effect upon enactment.
14 Sec. 32. CONTINGENT IMPLEMENTATION. Implementation of this
15Act is contingent upon sufficient revenue in the healthy Iowa
16trust fund to bear the costs of implementing the healthy Iowa
17program, as determined by the director of human services. The
18director of human services shall notify the secretary of the
19senate, the chief clerk of the house of representatives, and
20the Iowa Code editor, in writing when the healthy Iowa trust
21fund has sufficient revenue to bear the costs of implementing
22this Act. The department of human services shall publish a
23copy of the notice on its internet site.
24EXPLANATION
25The inclusion of this explanation does not constitute agreement with
26the explanation’s substance by the members of the general assembly.
27This bill creates new Code chapter 135E, establishing the
28healthy Iowa program, which provides comprehensive, universal
29single-payer health care coverage and a health care cost
30control system for all residents of Iowa. The bill provides
31that all residents of the state are eligible to be members of
32the healthy Iowa program and are eligible to receive health
33care services benefits under the program. The bill requires
34that the healthy Iowa program provide all members of the
35program with certain health care services, and incorporate the
-53-1health care benefits and standards of other existing federal
2and state programs. The bill prohibits health care providers
3participating in the healthy Iowa program from refusing to
4provide services to a member on the basis of certain protected
5categories. The bill establishes the healthy Iowa board and
6public advisory committee.
7The bill provides that health care coverage under the
8healthy Iowa program shall not be subject to coinsurance,
9deductibles, or copayments. The bill prohibits certain
10insurers, nonprofit health service plans, and health
11maintenance organizations from offering benefits that duplicate
12the services covered by the program. The bill prohibits health
13insurers from offering health benefits covering any health care
14service for which coverage is offered to individuals under
15the healthy Iowa program, except as otherwise provided, and
16prohibits a participating health care provider from imposing
17charges directly on healthy Iowa members.
18The bill provides for approval of participating health
19care providers and care coordinators under the program and
20provides for enrollment of residents in the program. The bill
21also provides that healthy Iowa program members may choose a
22participating health care provider and requires that members
23select a care coordinator.
24The bill specifies healthy Iowa program standards and
25payment for health care services and care coordination, and
26requires that the program provide reimbursements to certain
27members. The bill establishes a health benefit credit for
28certain employers and residents.
29The bill establishes the healthy Iowa trust fund as a special
30fund for the purpose of implementing the program and its
31purposes. The bill requires the board and the department of
32human services to apply to the federal government for waivers
33and other approvals relating to federally regulated health care
34programs.
35The bill also creates new Code chapter 135F providing for
-54-1collective negotiations between health care providers and
2the healthy Iowa program. The bill authorizes health care
3providers to collectively negotiate with the program for
4rates of payment for health care services, rates of payment
5for prescription and nonprescription drugs, and payment
6methodologies using a third-party representative.
7The bill takes effect upon enactment but implementation of
8the bill is contingent upon sufficient revenue in the healthy
9Iowa trust fund to bear the costs of implementing the healthy
10Iowa program as determined by the director of human services.
-55-pf/rh
2effective date provisions.
3BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
1 Section 1. NEW SECTION. 135E.1 Findings and intent of the
2general assembly.
31. The general assembly finds that all residents of the
4state have the right to health care.
52. It is the intent of the general assembly:
6a. To provide comprehensive universal single-payer health
7care coverage and a health care cost control system for the
8benefit of all residents of Iowa.
9b. To establish the healthy Iowa program to provide
10comprehensive, universal health coverage for every Iowa
11resident funded by broad-based sources of revenue.
12c. That the state obtain waivers and other approvals
13relating to the Medicaid program, the healthy and well kids
14in Iowa program, Medicare, the federal Patient Protection and
15Affordable Care Act, and any other federally regulated programs
16related to the provision of health care so that any federal
17funds and other subsidies that would otherwise be available to
18the state, Iowa residents, and Iowa health care providers, is
19instead paid by the federal government to the state of Iowa and
20deposited in the healthy Iowa trust fund.
21d. That the state incorporates health care coverage of
22Iowa residents who are employed in other jurisdictions into
23the waivers and other approvals involving federally regulated
24programs related to the provision of health care.
25e. That any funds obtained under waivers and other approvals
26involving federally regulated programs related to the provision
27of health care be used for health coverage that provides health
28benefits equal to or exceeding the health benefits provided
29under those programs, as well as other program modifications,
30including elimination of cost sharing and insurance premiums.
31f. That the healthy Iowa program replaces the Medicaid
32program, the healthy and well kids in Iowa program, Medicare,
33coverage provided through the federal Patient Protection and
34Affordable Care Act, and any other federally regulated programs
35relating to the provision of health care, and that those
-1-1programs are merged into the healthy Iowa program, which will
2operate as a true single-payer program.
3g. That, even if all necessary waivers and approvals are not
4obtained, the state maximize the approvals received and pool
5multiple sources of funding to the greatest extent possible,
6to make the provision of health care coverage and health care
7under the healthy Iowa program as seamless as possible.
8h. To extend the current benefits and current health care
9coverage provided under the healthy and well kids in Iowa
10program to all Iowa residents.
11i. That the healthy Iowa program addresses the high cost
12of prescription drugs to ensure that prescription drugs are
13affordable for patients.
14j. That neither health information technology nor clinical
15practice guidelines limit the effective exercise of the
16professional judgment of health care providers.
17k. That health care providers be authorized to override
18health information technology or clinical practice guidelines
19if it is consistent with the treating health care provider’s
20determination of medical necessity and if, in the professional
21judgment of the health care provider, it is in the best
22interest of the patient and consistent with the patient’s
23wishes.
24l. To develop a revenue plan for the healthy Iowa program,
25in consultation with appropriate stakeholders, taking into
26consideration anticipated federal revenue available for the
27program.
28m. To require that all federal revenue received for the
29healthy Iowa program be deposited in an account within the
30healthy Iowa trust fund to be known as the healthy Iowa trust
31fund account.
32 Sec. 2. NEW SECTION. 135E.2 Definitions.
33As used in this chapter, unless the context otherwise
34requires:
351. “Affiliation” means any of the following:
-2- 1a. A financial interest.
2b. A position of governance, including membership on a board
3of directors, regardless of compensation.
4c. A relationship through which compensation is received.
5d. A relationship for the provision of services as a
6regulated lobbyist.
72. “Affordable Care Act” means the federal Patient
8Protection and Affordable Care Act (Pub.L. No.111-148), as
9amended by the federal Health Care and Education Reconciliation
10Act of 2010 (Pub.L. No.111-152), and any amendments to, or
11regulations or guidance issued under, those Acts.
123. “Allied health practitioner” means a group of health
13professionals who apply their expertise to prevent disease
14transmission; diagnose, treat, and rehabilitate people of all
15ages and in all specialties; and, with a range of technical and
16support staff, deliver direct patient care, rehabilitation,
17treatment, diagnosis, and health improvement interventions to
18restore and maintain optimal physical, sensory, psychological,
19cognitive, and social functions. “Allied health practitioner”
20includes but is not limited to audiologists, physical
21therapists, occupational therapists, social workers, and
22radiographers.
234. “Board” means the healthy Iowa board which adopts rules
24and establishes policy for and directs the agency regarding the
25healthy Iowa program.
265. “Care coordination” means services provided by a care
27coordinator under the healthy Iowa program.
286. “Care coordinator” means an individual or entity approved
29by the healthy Iowa board to provide care coordination.
307. “Carrier” means carrier as defined in section 513B.2.
318. “Director” means the director of the healthy Iowa
32program.
339. “Essential community provider” means a person or entity
34acting as a safety net clinic, safety net health care provider,
35or rural hospital.
-3- 110. “Federally matched public health program” means the
2Medicaid program or the healthy and well kids in Iowa program
3established in section 514I.3.
411. “Fund” means the healthy Iowa trust fund.
512. “Health care provider” means any of the following:
6a. A person who is licensed, certified, registered, or
7authorized to practice a health care profession in the state
8pursuant to chapter 147A, 148, 148A, 148B, 148C, 148E, 148F,
9148G, 149, 151, 152, 152A, 152B, 153, 154, 154A, 154B, 154C,
10154D, 154F, 155, or 155A, who practices the profession in which
11they are licensed, certified, registered, or authorized, and
12who provides a health care service in this state.
13b. A health care entity licensed under title IV that employs
14or utilizes the health care services of a person described
15in paragraph “a”, including but not limited to a hospital
16licensed pursuant to chapter 135B, a health care facility
17licensed pursuant to chapter 135C, a subacute mental health
18care facility licensed pursuant to chapter 135G, a psychiatric
19medical institution for children licensed pursuant to chapter
20135H, a hospice program licensed pursuant to chapter 135J, an
21entity providing emergency medical services pursuant to chapter
22147A, and a pharmacy licensed pursuant to chapter 155A.
2313. “Health care service” means any health care service,
24including care coordination that is included as a benefit under
25the healthy Iowa program.
2614. “Health maintenance organization” means a health
27maintenance organization as defined in section 514B.1.
2815. “Healthy Iowa agency” means the healthy Iowa agency
29created in this chapter as an independent agency to provide
30comprehensive, universal single-payer health care coverage
31and a health care cost control system for the benefit of all
32residents of Iowa, and to implement the healthy Iowa program.
3316. “Healthy Iowa program” means the healthy Iowa program
34created in this chapter to provide comprehensive, universal
35single-payer health care coverage.
-4- 117. “Implementation period” means the period during which
2the healthy Iowa program is subject to special eligibility and
3financing provisions until the healthy Iowa program is fully
4implemented.
518. “Long-term care” means long-term care, treatment,
6maintenance, or services as defined by the healthy Iowa board.
719. “Medicaid” means the Medicaid program established under
8chapter 249A.
920. “Medicare” means the program established pursuant to
10Tit.XVIII of the federal Social Security Act, 42 U.S.C.§1395
11et seq.
1221. “Member” means an individual who is enrolled in the
13healthy Iowa program.
1422. “Out-of-state health care service” means a health
15care service provided in person under any of the following
16circumstances:
17a. It is medically necessary that the health care service be
18provided while the member is physically outside of this state
19for a period of time not exceed ninety days.
20b. It is clinically appropriate and necessary that the
21health care service is provided outside this state because the
22health care service can only be provided by a particular health
23care provider physically located outside of this state.
2423. “Participating health care provider” means an individual
25or entity that is a health care provider qualified pursuant to
26section 135E.15 that provides health care services to members
27under the healthy Iowa program.
2824. “Prescription drugs” means a controlled substance
29requiring a prescription as defined in section 124.101,
30subsection 5.
3125. “Resident” means an individual, without regard to that
32individual’s immigration status, whose primary place of abode
33is in this state and who meets the Iowa residence requirements
34adopted by the healthy Iowa board.
35 Sec. 3. NEW SECTION. 135E.3 Healthy Iowa agency and program
-5-1— created.
21. A healthy Iowa agency is created as an independent
3agency which shall be responsible for the planning,
4development, implementation, and regulation of the provision of
5comprehensive, universal single-payer health care coverage in
6this state under the healthy Iowa program and of a health care
7cost control system for the benefit of all residents.
82. The purposes of the healthy Iowa agency include all of
9the following:
10a. To create the healthy Iowa program.
11b. To provide comprehensive, universal single-payer health
12care services for all residents.
13c. To provide a health care cost control system for the
14benefit of all residents.
15d. To provide choice of and access to health care
16coordinators and health care providers for all residents.
17e. To provide broad-based public financing of health care
18services for all residents.
19f. To establish mechanisms for participating health care
20providers to collectively negotiate with the healthy Iowa
21program regarding any matter relating to the administration
22of the healthy Iowa program, including but not limited to
23rates of payment for health care services, rates of payment
24for prescription drugs and nonprescription drugs, and payment
25methodologies.
26g. To ensure transparency and accountability of the healthy
27Iowa program to the public.
28h. To provide for the collection of data to promote
29transparency, assess adherence to patient care standards
30established under this chapter, compare patient outcomes, and
31review utilization of health care services reimbursed through
32the healthy Iowa program.
333. This chapter and any rule or policy adopted under this
34chapter shall not be construed, is not intended as, and shall
35not imply, a change or impact in any way on the authority of any
-6-1of the following:
2a. The authority of a licensing board or other agencies of
3this state otherwise has relative to the provision of health
4care services or health care providers under law.
5b. The authority the healthy Iowa program, the healthy Iowa
6board, a licensing board, the department of public health, or
7the department of inspections and appeals has to establish or
8revise licensure standards for health care providers.
9c. The authority the healthy Iowa program has to carry out
10any function not authorized by waivers.
11d. The authority an employer has to create an employment
12benefit or to require, prohibit, or limit the provision of any
13employment benefit.
144. This chapter shall not be construed to allow the healthy
15Iowa program, other agencies of this state, local agencies,
16or public employees, acting under color of law, to provide or
17disclose to anyone, including but not limited to the federal
18government, any personally identifiable information obtained
19by the healthy Iowa program, including but not limited to a
20person’s religious beliefs, practices, or affiliation, national
21origin, ethnicity, or immigration status, for law enforcement
22or immigration purposes.
235. This chapter shall not be construed to allow law
24enforcement agencies to use healthy Iowa program moneys,
25facilities, property, equipment, or personnel to investigate,
26enforce, or assist in the investigation or enforcement of any
27criminal, civil, or administrative violation or warrant for a
28violation of any requirement that individuals register with the
29federal government or any federal agency based on religion,
30national origin, ethnicity, or immigration status.
31 Sec. 4. NEW SECTION. 135E.4 Healthy Iowa board — created.
321. A healthy Iowa board is created consisting of the
33following voting members:
34a. Four public members appointed by the governor, subject
35to confirmation by the senate.
-7- 1b. Two public members appointed by the senate majority
2leader subject to section 2.32A.
3c. Two public members appointed by the speaker of the house
4of representatives subject to section 2.32A.
52. The director of human services or the director’s designee
6shall serve as an ex officio member of the board.
73. The voting members shall serve four-year staggered
8terms. A vacancy shall be filled for the unexpired portion of
9the term and in the same manner as the original appointment.
10Any member may be reappointed for an additional term.
114. Members of the board shall not receive compensation as a
12member of the board but are entitled to receive reimbursement
13of actual expenses incurred in the discharge of their duties.
14Public members of the board are also eligible to receive
15compensation as provided in section 7E.6.
165. In making appointments under this section, an appointing
17authority shall do all of the following:
18a. Assure that the appointee has demonstrated and
19acknowledged expertise in health care.
20b. Consider the expertise of the other members of the
21board and attempt to make appointments so that the board’s
22composition reflects a diversity of expertise in various
23aspects of health care services.
24c. Consider the cultural, ethnic, and geographical diversity
25of this state so that the board’s composition reflects the
26communities of this state.
27d. Assure that the board’s composition is comprised of all
28of the following:
29(1) At least one representative of a labor organization
30representing registered nurses.
31(2) At least one representative of the general public.
32(3) At least one representative of a labor organization not
33representing registered nurses.
34(4) At least one representative of the health care provider
35community.
-8- 16. The board shall determine the time, location, and
2frequency of the board’s meetings. Five members of the board
3constitute a quorum and the affirmative vote of a majority of
4the voting members is necessary for any substantive action to
5be taken by the board.
67. The members of the board shall elect a chairperson on an
7annual basis from among the membership of the board.
88. A member of the board may be removed for incompetence,
9misconduct, or failure to perform the duties of the position.
109. The board shall approve all contracts entered into
11pursuant to this chapter. All contracts entered into pursuant
12to this chapter shall be made available to the public.
1310. The board may receive and accept grants, loans, or
14advances of moneys from any person and may receive and accept
15from any source contributions of moneys, property, labor, or
16any other thing of value, to be held, used, and applied for the
17purposes of the healthy Iowa program.
1811. A member of the board shall do all of the following:
19a. Meet the requirements of this chapter and all applicable
20state and federal laws and regulations.
21b. Serve the public interest of the individuals, employers,
22and taxpayers seeking health care coverage through the healthy
23Iowa healthy Iowa program.
24c. Ensure the sound operation and fiscal solvency of the
25healthy Iowa program.
2612. A member of the board, within the two-year period
27immediately preceding the member’s appointment, while serving
28on the board, and for two years immediately after the end
29of the member’s term, and staff of the board, shall not be
30employed or have been employed in any capacity by, a consultant
31to a member of the board of, have an affiliation with, receive
32compensation from, or otherwise be a representative of any of
33the following:
34a. A health care provider, unless the member or staff
35practices a health care profession as an employee of another
-9-1health care provider.
2b. A pharmaceutical company.
3c. A medical equipment company.
4d. An insurance company.
5e. A carrier, an insurance producer, a third-party
6administrator, a managed care organization, or any other person
7contracting directly with the healthy Iowa program.
8f. A member, a board member, or an employee of a trade
9association of health care facilities, health clinics, health
10care providers, carriers, insurance producers, third-party
11administrators, managed care organizations, or any association
12of entities in a position to contract directly with the
13healthy Iowa program, unless the member or employee receives no
14compensation for rendering services as a health care provider
15and does not have an ownership interest in a health care
16practice.
1713. A member of the board shall perform the member’s duties
18in good faith, in the manner the member reasonably believes
19to be in the best interest of the healthy Iowa program, and
20without intentional or reckless disregard of the care an
21ordinarily prudent person in a like position would use under
22similar circumstances. A member of the board who performs the
23member’s duties in accordance with the standards specified in
24this subsection shall not be liable personally for actions
25taken as a member when performed in good faith, without intent
26to defraud, and in connection with the administration of this
27chapter or actions or conduct related to this chapter.
2814. A member of the board shall be subject to chapter 68B.
29In addition to the disclosures required pursuant to chapter
3068B, a member of the board shall disclose to the board and
31to the public any relationship that the member has with a
32health care provider, pharmaceutical company, medical equipment
33company, insurance company, carrier, insurance producer,
34third-party administrator, managed care organization, or other
35entity in an industry involved in matters likely to come before
-10-1the board.
215. On all matters that come before the board, a member
3shall do all of the following:
4a. Adhere strictly to the conflict of interest provisions
5of section 68B.2A.
6b. Provide full disclosure to the board and the public on
7any matter that gives rise to a potential conflict of interest
8and the manner in which the member will comply with public
9disclosure required by chapter 68B and rules adopted pursuant
10to chapter 68B to avoid any conflict of interest or appearance
11of a conflict of interest.
1216. A member of the board shall not have an interest, direct
13or indirect, in a contract for the purchase of goods, including
14materials and profits, or for the performance of services for
15the healthy Iowa program. A contract entered into in violation
16of this section is voidable.
17 Sec. 5. NEW SECTION. 135E.5 Director — appointment.
181. a. The board shall appoint a director of the healthy
19Iowa program.
20b. The director shall serve at the pleasure of the board.
21c. The board shall determine the appropriate compensation
22for the director.
232. Under the direction of and with the approval of the
24board, the director shall administer this chapter. The
25director shall do all of the following:
26a. Act as the chief administrative officer of the healthy
27Iowa program, including the healthy Iowa trust fund.
28b. Direct, organize, administer, and manage the internal
29operations of the healthy Iowa program and the board, and
30establish guidelines and procedures to promote the orderly and
31efficient administration of the healthy Iowa agency.
32c. Perform all duties necessary to comply with and carry out
33the provisions of this chapter, other state law, and federal
34law.
35d. Recommend to the board proposed rules necessary to
-11-1administer the healthy Iowa program.
2e. Prepare a budget for the healthy Iowa program and prepare
3reports as required by law.
4f. Present the healthy Iowa agency’s proposed budget to the
5board prior to December 31 of each year.
6g. Appoint the administrators within the healthy Iowa
7program.
8h. Provide for the receipt and disbursement of federal
9moneys allocated to the state and its political subdivisions
10for health care services and coverage purposes.
11i. Include in the healthy Iowa program’s annual budget all
12estimated federal funds to be received or allocated to the
13healthy Iowa program.
14j. Employ, or designate another to employ, personnel
15as necessary to carry out the duties and responsibilities
16prescribed under this chapter consistent with the merit system
17provisions of chapter 8A, subchapter IV.
18k. As necessary, retain as independent contractors
19attorneys, financial consultants, and any other professionals
20or consultants necessary to carry out the planning,
21development, and operations of the healthy Iowa program and the
22provisions of this chapter.
233. The director or the director’s designee shall
24give preference in hiring under this section to all
25individuals displaced or unemployed as a direct result of the
26implementation of the healthy Iowa program.
27 Sec. 6. NEW SECTION. 135E.6 Board and director — duties
28— powers.
291. Subject to any limitations under this chapter or other
30applicable law, the enumeration of specific powers in this
31chapter is not intended to restrict the board’s power to take
32any lawful action that the board determines is necessary
33or convenient to carry out the functions authorized by the
34Affordable Care Act and consistent with the purposes of the
35healthy Iowa program.
-12- 12. The board shall do all of the following:
2a. Adopt rules pursuant to chapter 17A to implement and
3administer this chapter.
4b. Consult with and solicit input from the healthy Iowa
5advisory committee and any other person as the board determines
6appropriate.
7c. Promote the public understanding and awareness of
8available benefits and options through the healthy Iowa
9program.
10d. Avoid jeopardizing federal financial participation in the
11programs that are incorporated into the healthy Iowa program.
12e. Ensure that there is adequate funding to meet the health
13care service needs of residents and to compensate health care
14providers that participate in the healthy Iowa program.
15f. Evaluate requests for capital expenses required to meet
16the health care service needs of residents.
17g. Approve the benefits provided by the healthy Iowa
18program.
19h. Evaluate the performance of the healthy Iowa program.
20i. Evaluate and make recommendations to the general assembly
21on any legislation related to the healthy Iowa program.
22j. Guarantee that mechanisms for public feedback are
23accessible and nondiscriminatory.
24k. Develop a plan to coordinate the activities of the
25healthy Iowa program with the activities of the department of
26public health’s bureau of health planning and the department
27of human services’ mental health planning and advisory council
28to ensure appropriate planning for the effective delivery and
29equitable distribution of health care services throughout the
30state.
31l. Provide grants from moneys in the healthy Iowa trust
32fund or moneys otherwise appropriated for this purpose to the
33health planning programs established by the bureau of health
34planning of the department of public health or the mental
35health planning and advisory council of the department of human
-13-1services to support the operation of those health planning
2programs.
3m. Allocate moneys from the healthy Iowa trust fund
4or moneys otherwise appropriated for this purpose to the
5department of human services or the department of education
6workforce training and economic development fund to be used for
7all of the following purposes:
8(1) A program for retraining and assisting job transition
9for individuals employed or previously employed in the fields
10of health insurance, health care service plans, and other
11third-party payments for health care services.
12(2) A program for retraining and assisting job transition
13for those individuals employed or previously employed in
14fields providing services to health care providers to address
15the needs of third-party payers for health care services,
16whose jobs may be or have been ended as a result of the
17implementation of the healthy Iowa program.
18n. Organize, administer, and market the healthy Iowa program
19and program services as a single-payer program under the name
20“Healthy Iowa” or any other name as the board determines.
21o. Sue, be sued, plead, and be impleaded.
22p. Apply for, accept, and expend federal, state, or private
23moneys or contracts for the implementation of the healthy Iowa
24program or other state or federal health care programs for
25residents.
26q. Maintain an office at a place designated by the board.
27r. Create subcommittees from among its members.
28s. Establish divisions and subdivisions within the healthy
29Iowa program.
30t. Make agreements with a grantor or payor of moneys,
31property, or services, including agreements to perform any
32study, plan, demonstration, or project.
33u. Enter into any agreements, contracts, or memoranda
34of understanding and execute the instruments necessary or
35convenient to manage its own affairs and carry out the purposes
-14-1of this chapter, including but not limited to contracts with
2health care providers and care coordinators.
3v. Share information with relevant state entities,
4consistent with the confidentiality provisions in this chapter,
5necessary for the administration of the healthy Iowa program.
6w. Subject to the limitations of this chapter, exercise any
7other power that is reasonably necessary or convenient to carry
8out the purposes of this chapter.
9x. Adopt rules pursuant to chapter 17A regarding residency
10requirements under the healthy Iowa program. In adopting
11such rules, the board shall be guided by the principles and
12requirements set forth in the Medicaid program without regard
13to immigration status.
14y. Contract with not-for-profit organizations to provide any
15of the following:
16(1) Assistance to consumers in the selection of a care
17coordinator, enrollment, obtaining of health care services,
18disenrollment, and other matters relating to the healthy Iowa
19program.
20(2) Assistance to health care providers providing, seeking,
21or considering whether to provide health care services under
22the healthy Iowa program.
23z. Delegate to the director any of its duties under this
24section subject to all of the following:
25(1) The board shall ensure that any entity under a contract
26or other agreement with the healthy Iowa program complies with
27the provisions of this chapter when performing services on
28behalf of the healthy Iowa program.
29(2) The operations of the healthy Iowa program are subject
30to the provisions of this chapter whether the operations are
31performed directly by the healthy Iowa program or through an
32entity under a contract or other agreement with the healthy
33Iowa program.
34 Sec. 7. NEW SECTION. 135E.7 Healthy Iowa program —
35implementation — coordination with other health care coverage.
-15- 11. The board shall determine the date of implementation of
2the healthy Iowa program when individuals may begin enrolling
3in the healthy Iowa program and the date the implementation
4period ends.
52. An insurer, carrier, or health maintenance organization
6shall not offer benefits or cover any services for which
7coverage is offered to individuals under the healthy Iowa
8program.
93. An insurer, carrier, or health maintenance organization
10that is issued a certificate of authority by the commissioner
11of insurance may offer only the following:
12a. Benefits that do not duplicate the health care services
13covered by the healthy Iowa program.
14b. Benefits available to individuals and their families who
15are employed or self-employed in this state but who are not
16residents.
17c. Benefits available during the implementation period
18to individuals who enroll or may enroll in the healthy Iowa
19program.
204. This chapter shall not prohibit a resident who is
21employed outside this state from choosing to receive health
22insurance benefits through the resident’s employer and from
23opting out of participation in the healthy Iowa program.
245. After the end of the implementation period, board members
25shall enroll as members of the healthy Iowa program.
266. a. No later than July 1, 2021, the board shall develop
27a proposal, consistent with the principles of this chapter,
28for provision by the healthy Iowa program of long-term care
29coverage, including the development of a proposal, consistent
30with the principles of this chapter, for its funding.
31b. In developing the proposal required in paragraph “a”,
32the board shall consult with a special advisory committee,
33appointed by the chairperson of the board, that includes
34representatives of consumers and potential consumers of
35long-term care, providers of long-term care, members of
-16-1organized labor, and other interested parties.
27. The board shall develop proposals for all of the
3following:
4a. Accommodating employer retiree health benefits for people
5who have been members of the healthy Iowa program but live as
6retirees outside this state.
7b. Accommodating employer retiree health benefits for people
8who earned or accrued those benefits while residing in this
9state prior to the implementation of the healthy Iowa program
10and who live as retirees outside this state.
11c. For healthy Iowa program coverage of health care services
12covered under the state workers’ compensation law, including
13whether and how to continue funding for those health care
14services under the workers’ compensation law and whether and
15how to incorporate an element of experience rating.
16 Sec. 8. NEW SECTION. 135E.8 Data collection.
171. The board shall require and enforce the collection
18and availability of all of the following data to promote
19transparency, assess adherence to patient care standards,
20compare patient outcomes, and review utilization of health care
21services paid for by the healthy Iowa program:
22a. Inpatient discharge data, including acuity and risk of
23mortality.
24b. Emergency department, ambulatory surgery, and other
25outpatient department data, including charge data, length of
26stay, and patients’ unit of observation.
27c. Hospital annual financial data, including all of the
28following:
29(1) Community benefits by hospital in dollar value.
30(2) Number of employees and classification by hospital
31unit.
32(3) Number of hours worked by hospital unit.
33(4) Employee wage information by job title and hospital
34unit.
35(5) Number of registered nurses per staffed bed by hospital
-17-1unit.
2(6) Type and value of health information technology.
3(7) Annual spending on health information technology,
4including purchases, upgrades, and maintenance.
5d. Physician services and office visits, including charge
6data.
7e. Prescription drug cost and charge data for prescription
8drugs prescribed and dispensed through hospitals or a
9physician’s office.
102. Data collected under subsection 1 shall be reported
11to the healthy Iowa program and to the public health data
12management program of the department of public health.
133. The board shall make all disclosed data collected under
14subsection 1 publicly available and searchable through an
15internet site and through the department of public health’s
16public health data management program.
174. The board shall, directly and through grants to
18not-for-profit entities, conduct programs using data collected
19through the healthy Iowa program to promote and protect public,
20environmental, and occupational health, including cooperation
21with other data collection and research programs of the
22department of public health consistent with this chapter and
23otherwise applicable law.
245. Prior to the end of the healthy Iowa program
25implementation period, the board shall provide for the
26collection and availability of all of the following data on the
27number of patients served by hospitals and the dollar value of
28the care provided, at cost, for all of the following categories
29of data items:
30a. Patients receiving charity care.
31b. Contractual adjustments of county and indigent programs,
32including traditional and managed care.
33c. Bad debt.
346. The healthy Iowa program, any state or local agency,
35or any public employee acting under color of law shall not
-18-1provide or disclose to anyone, including but not limited to the
2federal government, any personally identifiable information
3obtained under this section, including but not limited to a
4person’s religious beliefs, practices, or affiliation, national
5origin, ethnicity, or immigration status for law enforcement
6or immigration purposes.
7 Sec. 9. NEW SECTION. 135E.9 Healthy Iowa advisory committee
8— established.
91. A healthy Iowa advisory committee for the healthy Iowa
10program is established.
112. The healthy Iowa advisory committee shall consist of all
12of the following voting members:
13a. (1) Four physicians who are board certified in the
14individual’s specialty, at least one of whom shall be a
15psychiatrist.
16(2) The physician members shall include all of the
17following:
18(a) One physician appointed by the senate majority leader.
19(b) One physician appointed by the governor.
20(c) Two physicians appointed by the speaker of the house of
21representatives who are primary care providers.
22b. Two registered nurses appointed by the senate majority
23leader.
24c. One licensed allied health practitioner appointed by the
25speaker of the house of representatives.
26d. One mental health care provider appointed by the senate
27majority leader.
28e. One dentist appointed by the governor.
29f. One representative of private hospitals appointed by the
30governor.
31g. One representative of public hospitals appointed by the
32governor.
33h. (1) Four consumers of health care services.
34(2) The consumer members shall include all of the following,
35one of whom shall be a person with a disability:
-19- 1(a) Two consumers appointed by the governor.
2(b) One consumer appointed by the senate majority leader who
3is a healthy Iowa program member and who is sixty-five years of
4age or older.
5(c) One consumer appointed by the speaker of the house of
6representatives.
7i. One representative of organized labor appointed by the
8speaker of the house of representatives.
9j. One representative of community providers appointed by
10the senate majority leader.
11k. One member of organized labor appointed by the senate
12majority leader.
13l. One representative of a business that employs less than
14twenty-five people, appointed by the governor.
15m. One representative of a business that employs more than
16two hundred fifty people, appointed by the speaker of the house
17of representatives.
18n. One pharmacist appointed by the speaker of the house of
19representatives.
203. Appointed members, except for consumer members, shall
21have worked in the field they represent for a period of at
22least two years prior to being appointed.
234. Members shall serve four-year staggered terms. A vacancy
24shall be filled for the unexpired portion of the term and in
25the same manner as the original appointment. Any member may
26be reappointed for an additional term, but shall not serve for
27more than two consecutive full terms.
285. Members shall not receive compensation as a member
29but are entitled to receive reimbursement of actual expenses
30incurred in the discharge of their duties. Public members are
31also eligible to receive compensation as provided in section
327E.6.
336. In making appointments of members under this section, the
34appointing authority shall make good-faith efforts to ensure
35that their appointments, as a whole, reflect, to the greatest
-20-1extent feasible, the social and geographic diversity of this
2state.
37. The healthy Iowa advisory committee shall advise the
4board on all matters of policy related to the healthy Iowa
5program.
68. a. The healthy Iowa advisory committee shall meet at
7least six times per year in a place convenient to the public
8in accordance with chapter 21 and records of the healthy
9Iowa advisory committee shall be subject to the open records
10requirements of chapter 22.
11b. Eleven members of the healthy Iowa advisory committee
12constitute a quorum and the affirmative vote of at least twelve
13voting members is necessary for any substantive action to be
14taken.
159. The healthy Iowa advisory committee shall elect a
16chairperson from among its membership who shall serve two years
17and who may be reelected as chairperson for an additional two
18years.
1910. Members shall not use for personal benefit any
20information that is filed with, or obtained by, the healthy
21Iowa advisory committee and that is not generally available to
22the public.
2311. A member shall perform the member’s duties in good
24faith, in the manner the member reasonably believes to be in
25the best interest of the healthy Iowa program, and without
26intentional or reckless disregard of the care an ordinarily
27prudent person in a like position would use under similar
28circumstances. A member who performs the member’s duties in
29accordance with this subsection shall not be liable personally
30for actions taken as a member when done in good faith, without
31intent to defraud, and in connection with the administration of
32this chapter or actions or conduct related to this chapter.
3312. A member shall be subject to the provisions of chapter
3468B. In addition to the disclosures required pursuant to
35chapter 68B, a member shall disclose to the healthy Iowa
-21-1advisory committee and to the public any relationship
2that the member has with a health care provider, health
3clinic, pharmaceutical company, medical equipment company,
4insurance company, carrier, insurance producer, third-party
5administrator, managed care organization, or other entity in an
6industry involved in matters likely to come before the healthy
7Iowa advisory committee.
813. On all matters that come before the healthy Iowa
9advisory committee, members shall do all of the following:
10a. Adhere strictly to the conflict of interest provisions
11of section 68B.2A.
12b. Provide full disclosure to the healthy Iowa advisory
13committee and the public on any matter that gives rise to a
14potential conflict of interest and the manner in which the
15member will comply with public disclosure required by chapter
1668B and rules adopted pursuant to chapter 68B to avoid any
17conflict of interest or appearance of a conflict of interest.
1814. A member shall not have an interest, direct or indirect,
19in a contract for the purchase of goods, including materials
20and profits, and the performance of services for the healthy
21Iowa program or the healthy Iowa advisory committee. A
22contract entered into in violation of this section is void.
2315. A member may be removed for incompetence, misconduct, or
24failure to perform the duties of the position.
25 Sec. 10. NEW SECTION. 135E.10 Eligibility and enrollment
26— generally.
271. Each resident is eligible and entitled to enroll as a
28member in and receive benefits for health care services covered
29by the healthy Iowa program.
302. A member shall not pay any fee, payment, or other charge
31for enrolling in or being a member.
323. A participating health care provider or participating
33care coordinator shall not do any of the following:
34a. Require members to pay any premium, copayment,
35coinsurance, deductible, or any other form of cost sharing for
-22-1any covered health care services.
2b. Use preexisting medical conditions to determine the
3eligibility of a member to receive benefits for health care
4services covered by the program.
5c. Refuse to provide health care services to a member
6on the basis of age, citizenship, claims experience, color,
7creed, familial status, gender identity, genetic information,
8geography, health status, immigration status, marital status,
9medical condition, medical history, mental disability, military
10or veteran status, national origin, physical disability,
11primary language, race, receipt of health care, religion, sex,
12sexual orientation, or source of income.
13d. A college, university, or other institution of higher
14education in this state may purchase coverage under the healthy
15Iowa program for a student, or a student’s dependent, who is
16not a resident.
17 Sec. 11. NEW SECTION. 135E.11 Eligibility and enrollment —
18cross border employees.
191. If a resident is employed outside this state by an
20employer that is subject to the laws of this state, the
21employer and resident shall pay any payroll premium adopted
22under this chapter as if the employment were in this state.
232. If a resident is employed outside this state by an
24employer that is not subject to the laws of this state,
25either the employer and resident may comply with any payroll
26premium adopted under this chapter as if the employee were
27employed in this state, or the resident shall pay the payroll
28premium adopted under this chapter as if the resident were
29self-employed in this state.
303. Any payroll premium adopted under this chapter applies
31to all of the following:
32a. A resident of another state employed in this state.
33b. A resident of another state self-employed in this state.
344. a. A resident who is employed outside this state
35may choose to receive health insurance benefits through the
-23-1resident’s employer and opt out of participation in the healthy
2Iowa program.
3b. The board shall develop and implement rules establishing
4procedures for state residents employed outside this state to
5opt out of participation in the healthy Iowa program.
65. If any provision of this section or application of the
7provision to any person or circumstance is held to violate the
8federal Employee Retirement Income Security Act of 1974 in any
9court of competent jurisdiction, the provision or application
10found invalid shall be null and void and the invalidity shall
11not affect other provisions or any other application of this
12chapter that can be given effect without the invalid provision
13or application.
14 Sec. 12. NEW SECTION. 135E.12 Health benefit credit.
151. a. If an individual who is a resident of another state
16is employed in this state, the individual and the individual’s
17employer may be eligible for a credit against any payroll
18premium payment requirement adopted under this chapter that the
19individual or the individual’s employer would otherwise pay
20relative to that individual.
21b. The credit available under this subsection shall be for
22the amount spent on health benefits for the individual that
23would otherwise be covered by the healthy Iowa program if that
24individual were a member of the healthy Iowa program.
25c. The credit available under this subsection shall be
26distributed between the individual and employer in the same
27proportion as the actual spending by each for the health
28benefits.
29d. An employer and employee may apply their respective
30portion of the credit available under this subsection to their
31respective portion of any payroll premium payment requirement
32adopted under this chapter.
332. a. If an individual who is a resident of another state
34is self-employed in this state, the individual is eligible
35for a credit against any payroll premium payment requirement
-24-1adopted under this chapter that the individual would otherwise
2pay.
3b. Credit taken under this subsection shall be in the
4amount that the individual spends on health benefits that
5would otherwise be covered by the healthy Iowa program if the
6individual were a member of the healthy Iowa program.
73. a. The credit available for non-employment-based
8spending by an individual under subsection 2 is limited to
9spending for health benefits.
10b. An individual shall not be eligible for credit under
11subsection 2 for out-of-pocket health care services spending.
124. Credit under this section is available regardless of
13the cost or comprehensiveness of the health benefits, and
14regardless of the form of the health benefits.
155. a. An employer or individual is eligible for credit
16under this section only against payroll premiums payment
17requirement adopted under this chapter.
18b. An employer or individual shall not apply any health
19benefits spending in excess of the payroll premium payment
20requirement to other tax liability.
216. If any provision of this section or application of the
22provision to any person or circumstance is held to violate
23the federal Employee Retirement Income Security Act of 1974
24in any court of competent jurisdiction, the provision or the
25application found invalid shall be null and void and the
26invalidity shall not affect other provisions or any other
27application of this chapter that can be given effect without
28the invalid provision or application.
29 Sec. 13. NEW SECTION. 135E.13 Covered benefits.
301. a. All members are eligible to receive covered health
31care services benefits under the program.
32b. Covered health care services benefits under the program
33include all medical care that is medically necessary as
34determined by the member’s treating physician in accordance
35with the program standards established in section 135E.19 and
-25-1by the board.
2c. A member’s treating physician shall be a person
3licensed to engage in the practice of medicine and surgery or
4osteopathic medicine and surgery pursuant to chapter 148.
52. Covered health care services benefits for members
6include but are not limited to all of the following:
7a. Licensed inpatient and licensed outpatient medical and
8health care facility services.
9b. Inpatient and outpatient health care services.
10c. Diagnostic imaging, laboratory services, and other
11diagnostic and evaluative services.
12d. Medical equipment, appliances, and assistive technology,
13including prosthetics, eyeglasses, and hearing aids and
14the repair, technical support, and customization needed for
15individual use.
16e. Inpatient and outpatient rehabilitative care.
17f. Emergency care services.
18g. Emergency transportation.
19h. Necessary transportation for health care services for
20persons with disabilities or who may qualify as low-income.
21i. Child and adult immunizations and preventive care.
22j. Health and wellness education.
23k. Hospice care.
24l. Care in a skilled nursing facility.
25m. Home health care, including home health care provided in
26an assisted living facility.
27n. Mental health services.
28o. Substance abuse treatment.
29p. Dental care.
30q. Vision care.
31r. Prescription drugs.
32s. Pediatric care.
33t. Prenatal and postnatal care.
34u. Podiatric care.
35v. Chiropractic care.
-26- 1w. Acupuncture.
2x. Therapies that are shown by the United States national
3institutes of health, national center for complementary and
4integrative health to be safe and effective.
5y. Blood and blood products.
6z. Dialysis.
7aa. Adult day care.
8ab. Rehabilitative and habilitative services.
9ac. Ancillary health care or social services previously
10covered by integrated health homes as determined under Iowa
11Medicaid enterprise administrative rules and as designated
12under 42 U.S.C.§1396w-4.
13ad. Case management and care coordination.
14ae. Language interpretation and translation for health care
15services, including sign language and braille or other services
16needed for individuals with communication barriers.
17af. Health care and long-term supportive services covered
18under Medicaid or the healthy and well kids in Iowa program on
19June 30, 2017.
20ag. All of the following health care services required
21to be covered under any of the following provisions, without
22regard to whether the member would otherwise be eligible for or
23covered by the program or source referred to:
24(1) The healthy and well kids in Iowa program pursuant to
25chapter 514I.
26(2) The Medicaid program.
27(3) Medicare.
28(4) A health maintenance organization as defined in section
29514B.1.
30(5) A managed health care program as defined by rule of
31the department of human services, including health maintenance
32organizations, prepaid health plans, the Medicaid patient
33access to service system, Iowa plan for behavioral health,
34programs of all-inclusive care for the elderly, Iowa health
35link, and the Iowa health and wellness plan.
-27- 1ah. Any additional health care services authorized by the
2board.
3ai. All essential health benefits mandated by the Affordable
4Care Act as of January 1, 2017.
5 Sec. 14. NEW SECTION. 135E.14 Covered benefits —
6additions.
71. The board, on a regular basis, shall evaluate whether
8covered benefits under the healthy Iowa program should be
9improved or adjusted to promote the health of beneficiaries,
10account for changes in medical practice or new information from
11medical research, or respond to other relevant developments in
12health science. In carrying out this duty, the board shall
13consult with the persons described in subsection 2 on all of
14the following:
15a. Identifying specific complementary and integrative
16medicine practices that, on the basis of research findings or
17promising clinical interventions, are appropriate to include as
18benefits under the healthy Iowa program package.
19b. Identifying barriers to the effective provision and
20integration of such practices into the delivery of health care,
21and identifying mechanisms for overcoming such barriers.
222. The board shall consult with all of the following when
23carrying out the requirements of subsection 1:
24a. Institutions of higher education, private research
25institutes, and individual researchers with extensive
26experience in complementary and alternative medicine and the
27integration of such practices into the delivery of health care.
28b. Nationally recognized providers of complementary and
29integrative medicine.
30c. Such other officials, entities, and individuals with
31expertise in complementary and integrative medicine as the
32board determines appropriate.
333. a. Health care providers and members may petition the
34board to improve or adjust covered benefits under the healthy
35Iowa program.
-28- 1b. The board shall develop and adopt rules pursuant to
2chapter 17A establishing procedures for members to petition the
3board to improve or adjust covered benefits under the healthy
4Iowa program.
5 Sec. 15. NEW SECTION. 135E.15 Delivery of care —
6participating health care providers.
71. Any health care provider is qualified to participate in
8the healthy Iowa program if the health care provider meets all
9of the following criteria:
10a. The health care provider is licensed to practice in this
11state and is otherwise in good standing.
12b. The health care provider’s services are performed while
13physically present in this state.
14c. The health care provider agrees to accept program rates
15as payment in full for all covered health care services.
162. The board shall establish and maintain procedures and
17standards for recognizing health care providers located outside
18this state for purposes of providing coverage under the program
19for members who require out-of-state health care services while
20the member is physically outside this state for a period of
21time not to exceed ninety days.
223. Any health care provider qualified to participate under
23this section may provide covered health care services under the
24healthy Iowa program as long as the health care provider is
25legally authorized to perform the health care service for the
26individual and under the circumstances involved.
274. A member may choose to receive health care services
28under the healthy Iowa program from any participating provider,
29consistent with all of the following:
30a. Provisions of this section.
31b. The willingness or availability of the health care
32provider.
33c. Provisions of this chapter prohibiting discrimination
34against members.
35d. The appropriate clinically relevant circumstances and
-29-1standards.
25. The board may establish and maintain procedures for
3member enrollment and disenrollment with participating health
4care providers that are health maintenance organizations, group
5medical practices, or essential community providers that offer
6comprehensive services.
76. a. Participating health care providers shall not use
8health information technology or clinical practice guidelines
9that limit the effective exercise of the professional judgment
10of a physician or registered nurse.
11b. A physician or registered nurse may override health
12information technology and clinical practice guidelines if all
13of the following criteria are met:
14(1) It is consistent with the treating physician’s or
15registered nurse’s determination of medical necessity.
16(2) In the professional judgment of the treating physician
17or registered nurse, it is in the best interest of the patient
18and consistent with the patient’s wishes.
197. The board shall establish and maintain procedures and
20standards for recognizing health care providers located outside
21this state for purposes of providing coverage under the healthy
22Iowa program for health care services provided outside this
23state under the healthy Iowa program.
24 Sec. 16. NEW SECTION. 135E.16 Delivery of care — care
25coordination.
261. Care coordinators shall provide care coordination,
27including administrative tracking and medical recordkeeping
28services, to members.
292. a. Care coordinators may employ or utilize the services
30of other individuals or entities to assist in providing care
31coordination for a member, consistent with rules adopted by the
32board and consistent with the statutory requirements for care
33coordinator licensure.
34b. Care coordinators shall give preference, when employing
35or utilizing the services of other individuals, to those
-30-1individuals who have transitioned out of employment due to
2displacement resulting from implementation of the healthy Iowa
3program.
43. Care coordinators shall comply with all federal and
5state privacy laws, including but not limited to the federal
6Health Insurance Portability and Accountability Act of
71996, Pub.L. No.104-191, 42 U.S.C.§1320d et seq.and its
8implementing regulations, and the disclosure of mental health
9and psychological information requirements of chapter 228.
104. A referral from a care coordinator is not required for a
11member to receive health care services from any participating
12health care provider.
135. A care coordinator may be an individual or entity
14approved by the board that is any of the following:
15a. A health care provider that is any of the following:
16(1) The member’s primary care provider.
17(2) The member’s provider of primary gynecological care.
18(3) At the option of a member who has a chronic condition
19that requires specialty care, a specialist health care provider
20who regularly and continually provides treatment to the member
21for that condition.
22b. An entity licensed as any of the following:
23(1) A hospital licensed pursuant to chapter 135B.
24(2) A limited service organization established under the
25requirements of section 514B.33.
26(3) An outpatient surgical facility, as defined in section
27135.61, certified as an ambulatory surgical center under the
28federal Medicare program or under the Medicaid program.
29(4) An organized outpatient health facility as defined in
30section 135.61.
31(5) A licensed subacute care facility for persons with
32serious and persistent mental illness as defined in section
33135G.1.
34(6) A licensed psychiatric medical institution for children
35as defined in section 135H.1.
-31- 1(7) A entity certified by the department of human services
2to provide home and community-based services, including
3habilitation services, the program of all-inclusive care for
4the elderly, home health services, private duty nursing and
5personal care programs, or targeted case management.
6(8) A medical care ambulance service or nontransport
7service that has received authorization from the department
8pursuant to section 147A.5.
9(9) A health maintenance organization as defined in section
10514B.1.
11(10) A licensed nursing facility as defined in section
12135C.1.
13(11) A licensed nursing home as defined in section 155.1.
14(12) A licensed residential care facility as defined in
15section 135C.1.
16(13) A licensed intermediate care facility for persons with
17an intellectual disability as defined in section 135C.1.
18(14) A licensed intermediate care facility for persons with
19mental illness as defined in section 135C.1.
20(15) A licensed health care facility that provides adult day
21services as defined in section 135C.1.
22(16) A licensed health care facility that provides
23rehabilitative services as defined in section 135C.1.
24(17) A facility that provides hospice care under a licensed
25hospice program as defined in section 135J.1.
26(18) A licensed boarding home as defined in section 135O.1.
27(19) A certified assisted living program as defined in
28section 231C.2.
29(20) A designated community mental health center as defined
30in section 230A.102.
31(21) A certified elder group home as defined in section
32231B.1.
33c. (1) A Taft-Hartley health and welfare fund, with respect
34to its members and their family members.
35(2) This provision does not preclude a Taft-Hartley health
-32-1and welfare fund from becoming a care coordinator under
2paragraph “d”.
3d. Any not-for-profit or governmental entity approved by the
4healthy Iowa board.
56. a. (1) A healthy Iowa program member shall enroll with
6a healthy Iowa care coordinator prior to receiving health care
7services.
8(2) A member shall enroll with a care coordinator within
9sixty days of enrollment in the healthy Iowa program.
10(3) The healthy Iowa program shall only reimburse a health
11care provider for services if the member is enrolled with a
12care coordinator at the time the health care services are
13provided.
14b. If a member receives health care services before choosing
15a care coordinator, the healthy Iowa program shall assist the
16member, when appropriate, in choosing a care coordinator.
17c. A member shall remain enrolled with a care coordinator
18until the member becomes enrolled with a different care
19coordinator or ceases to be a member.
20d. A member may change the member’s care coordinator based
21on rules applicable to selecting a primary medical provider
22or a medical home under the Iowa health and wellness program
23pursuant to chapter 249N.
247. This section shall not be interpreted to authorize
25any individual to engage in any act in violation of the
26individual’s professional licensure under title IV.
278. An individual or entity shall not act as a care
28coordinator unless the health care services included in care
29coordination are within the individual’s professional scope of
30practice or within the entity’s legal authority.
319. a. The board shall adopt rules pursuant to chapter
3217A regarding and including but not limited to all of the
33following:
34(1) Procedures and standards for an individual or entity
35to be approved as a care coordinator under the healthy Iowa
-33-1program.
2(2) Procedures and standards relating to the limitation,
3suspension, or revocation of an individual’s approval as a care
4coordinator based on a determination that the individual or
5entity is incompetent to be a care coordinator.
6(3) Procedures and standards relating to the limitation,
7suspension, or revocation of the approval of an individual’s
8or entity’s approval as a care coordinator based on an
9exhibited course of conduct that is inconsistent with healthy
10Iowa program standards and regulations or that exhibits an
11unwillingness to meet those standards and regulations.
12(4) Procedures and standards relating to the limitation,
13suspension, or revocation of approval of an individual or
14entity as a care coordinator based on a determination that the
15individual or entity is a potential threat to the public health
16or safety.
17b. The rules adopted by the board under this subsection
18shall be consistent with professional practice, licensure
19standards, and regulations established pursuant to title IV,
20title VI, and title XIII, as applicable.
21c. In developing and implementing rules or standards for
22the approval of care coordinators for individuals receiving
23chronic mental health care services, the board shall consult
24with the division of mental health and disability services of
25the department of human services.
2610. To maintain approval under the program, a care
27coordinator shall do all of the following:
28a. Renew the person’s status as a care coordinator every
29three years pursuant to rules adopted by the board.
30b. Provide the healthy Iowa program any data required by the
31department of human services or the department of public health
32and as required by the board that would enable the board to
33evaluate the impact of care coordinators on quality, outcomes,
34and cost of health care.
3511. This chapter shall not be construed to alter the
-34-1professional practice of health care providers or their
2licensure standards established pursuant to title IV.
312. a. Care coordinators shall not use health information
4technology or clinical practice guidelines that limit the
5effective exercise of the professional judgment of physicians
6and registered nurses.
7b. Physicians and registered nurses may override health
8information technology and clinical practice guidelines if all
9of the following criteria are met:
10(1) It is consistent with the treating physician’s
11determination of medical necessity.
12(2) In the professional judgment of the treating physician
13or registered nurse, it is in the best interest of the patient
14and consistent with the patient’s wishes.
15 Sec. 17. NEW SECTION. 135E.17 Rates and payment
16methodologies.
171. a. The board shall adopt rules pursuant to chapter 17A
18regarding contracting and establishing payment methodologies
19for covered health care services and care coordination provided
20to members under the healthy Iowa program by participating
21providers and care coordinators.
22b. The board may adopt a variety of payment methodologies,
23including those established on a demonstration basis.
24c. All payment rates under the healthy Iowa program shall be
25reasonable and reasonably related to the cost of efficiently
26providing the health care service and ensuring an adequate and
27accessible supply of health care services.
282. a. Health care services provided to members under the
29healthy Iowa program, with the exception of care coordination,
30shall be paid for on a fee-for-service basis unless and until
31the board establishes another payment methodology.
32b. A rebuttable presumption exists that the Medicare rate of
33reimbursement constitutes a reasonable fee-for-service payment
34rate.
353. Notwithstanding subsection 2, health maintenance
-35-1organizations, essential community providers, and group
2medical practices that provide comprehensive, coordinated
3services shall be reimbursed on the basis of a capitated system
4operating budget or a noncapitated system operating budget.
54. a. Payment for health care services established under
6this chapter shall be considered payment in full.
7b. A participating health care provider shall not charge any
8rate in excess of the payment established under this chapter
9for any health care service provided to a member and shall not
10solicit or accept payment from any member or third party for
11any health care service, except as provided under federal law.
12c. This section does not preclude the healthy Iowa program
13from acting as a primary or secondary payer in conjunction with
14another third-party payer when permitted by federal law.
155. a. The board may adopt rules pursuant to chapter
1617A to provide payment methodologies for the payment of
17capital-related expenses for specifically identified capital
18expenditures incurred by not-for-profit or governmental
19entities that are health care entities licensed under title IV,
20including but not limited to hospitals, health care facilities,
21subacute mental health care facilities, psychiatric medical
22institutions for children, entities providing licensed hospice
23programs, and entities providing emergency medical care.
24b. Any capital-related expense generated by a capital
25expenditure that requires prior approval by the board shall not
26be paid unless such prior approval has been received.
27c. Approval of a capital expenditure shall be based on
28achievement of the program standards described in section
29135E.19.
306. Payment methodologies and rates shall include a distinct
31component of reimbursement for direct and indirect graduate
32medical education.
337. a. The board shall adopt rules pursuant to chapter
3417A regarding payment methodologies and procedures to pay for
35health care services provided to a member while the member is
-36-1located outside this state for a period of time not to exceed
2ninety days except as provided in paragraph “b”.
3b. (1) The board may adopt rules pursuant to chapter 17A
4regarding payment methodologies and procedures to pay for
5health care services provided to a member while the member is
6outside this state for a period of time not to exceed ninety
7days if it is medically necessary as determined by the member’s
8treating physician in accordance with the program standards
9established in section 135E.19 and by the board.
10(2) A member’s treating physician is a person licensed to
11engage in the practice of medicine and surgery or osteopathic
12medicine and surgery pursuant to chapter 148.
13 Sec. 18. NEW SECTION. 135E.18 Rate negotiations.
141. The healthy Iowa program shall engage in good-faith
15negotiations with health care provider representatives under
16chapter 135F to develop all of the following:
17a. Rates of payment for health care services.
18b. Rates of payment for prescription and nonprescription
19drugs.
20c. Payment methodologies.
212. Rate negotiations shall be conducted annually through a
22single entity on behalf of the entire program for prescription
23and nonprescription drugs.
243. a. The board shall establish a prescription drug
25formulary system, which shall discourage the use of
26ineffective, dangerous, or excessively costly medications when
27better alternatives are available.
28b. The formulary established under this subsection shall
29promote the use of generic medications to the greatest extent
30possible.
31c. Clinicians and patients may petition the board to add
32new pharmaceuticals or to remove ineffective or dangerous
33medications from the formulary.
34d. The board shall adopt rules pursuant to chapter 17A
35regarding the use of off-formulary medications which allow for
-37-1patient access but do not compromise the formulary.
2 Sec. 19. NEW SECTION. 135E.19 Program standards.
31. The healthy Iowa program shall establish a single
4standard of safe, therapeutic health care services for all
5residents.
62. The board shall adopt rules pursuant to chapter 17A to
7establish requirements and standards for the program and for
8care coordinators and health care providers, consistent with
9this chapter and consistent with the applicable professional
10practice and licensure standards for health care providers,
11health care facilities, and health care professionals
12established in title IV, title VI, and title XIII, as
13applicable. The rules adopted under this subsection shall
14address all of the following:
15a. Requirements and standards for the scope, quality, and
16accessibility of health care services.
17b. Requirements and standards for interactions between
18health care providers and members.
19c. Requirements and standards for interactions between care
20coordinators and health care providers, including credentialing
21and participation in health care organization networks, and
22terms, methods, and rates of payment.
233. The board shall adopt rules pursuant to chapter 17A to
24establish requirements and standards to promote all of the
25following:
26a. Simplification, transparency, uniformity, and fairness in
27health care provider credentialing and participation in health
28care organization networks, referrals, payment procedures and
29rates, claims processing, and approval of health care services,
30as applicable.
31b. In-person primary and preventive care, care coordination,
32efficient and effective health care services, quality
33assurance, and promotion of public, environmental, and
34occupational health.
35c. Elimination of health care disparities, including
-38-1geographic disparities, racial disparities, income-based
2disparities, gender-based disparities, sex-based disparities,
3and other disparities.
4d. Nondiscrimination with respect to members and health
5care providers on the basis of age, citizenship, claims
6experience, color, creed, familial status, gender identity,
7genetic information, geography, health status, immigration
8status, marital status, medical condition, medical history,
9mental disability, military or veteran status, national origin,
10physical disability, primary language, race, receipt of health
11care, religion, sex, sexual orientation, or source of income.
12e. Provision of health care services under the healthy
13Iowa program that is appropriate to the patient’s clinically
14relevant circumstances.
15f. Accessibility of care coordination and health care
16services, including accessibility for people with disabilities
17and people with limited ability to speak or understand English.
18g. Providing care coordination and health care services in
19a culturally competent manner.
204. The board shall adopt rules pursuant to chapter 17A to
21establish requirements and standards, to the extent authorized
22by federal law, for replacing and merging with the healthy
23Iowa program any health care services and ancillary services
24currently provided by other programs, including but not limited
25to Medicare, the Affordable Care Act, and federally matched
26public health programs.
275. a. Any participating health care provider or care
28coordinator that is organized as a for-profit entity shall meet
29the same requirements and standards as entities organized as
30not-for-profit entities.
31b. Payments under the program to for-profit entities shall
32not be calculated to accommodate the generation of profit,
33excess revenue, revenue for dividends, or other return on
34investment or the payment of taxes that would not be paid by a
35not-for-profit entity.
-39- 16. a. A participating health care provider shall do all of
2the following:
3(1) Furnish information as required by the department of
4public health, including the public health data management
5program.
6(2) Permit examination of information by the healthy Iowa
7program as may be reasonably required for purposes of reviewing
8accessibility and utilization of health care services, quality
9assurance, cost containment, the making of payments, and
10statistical or other studies of the operation of the healthy
11Iowa program or for protection and promotion of public,
12environmental, and occupational health.
13b. The board shall use data collected under this subsection
14to ensure that clinical practices meet the utilization,
15quality, and access standards of the healthy Iowa program.
167. In developing requirements and standards and making
17other policy determinations under this chapter, the board
18shall consult with representatives of members, health care
19providers, care coordinators, health care organizations, labor
20organizations representing health care provider employees, and
21other interested parties.
22 Sec. 20. NEW SECTION. 135E.20 Advocacy for necessary health
23care.
241. As part of a health care provider’s duty to exercise
25a professional standard of care when evaluating a patient’s
26medical condition, a participating health care provider under
27the healthy Iowa program shall do all of the following:
28a. Advocate for medically necessary health care services for
29the provider’s patients.
30b. Act in the exclusive interest of patients.
312. Consistent with subsection 1 and with professional
32standards of care under title IV, a patient’s treating
33physician or health care provider is responsible for the
34determination of the health care services medically necessary
35for the patient.
-40- 13. Consistent with subsection 1 and with professional
2standards of care under title IV, title VI, and title XIII,
3care coordinators and health care providers shall use
4reasonable care and diligence in safeguarding their patients
5and shall not impair any health care provider’s duty to
6advocate for medically appropriate health care services for
7patients.
84. Consistent with subsection 1 and with professional
9standards of care under title IV, title VI, and title XIII, any
10pecuniary interest or relationship of a physician or health
11care provider, including any interest or relationship disclosed
12or reported under this section, that impairs the physician’s or
13health care provider’s ability to provide medically necessary
14health care services to a patient violates the physician’s or
15health care provider’s duty to advocate for medically necessary
16health care services for patients.
175. A health care provider violates the duty to provide
18medically necessary care services under this section if the
19health care provider accepts any bonus, incentive payment, or
20compensation based on any of the following:
21a. A patient’s utilization of health care services.
22b. The financial results of any other health care provider
23or care coordinator with which the health care provider or
24care coordinator has a pecuniary interest or contractual
25relationship, including employment or other compensation-based
26relationship.
27c. The financial results of any health maintenance
28organization, essential community providers, or group medical
29practices that receives capitated payments from the healthy
30Iowa program.
316. To evaluate and review compliance by participating
32health care providers and care coordinators under the healthy
33Iowa program, participating health care providers and care
34coordinators shall report, at least annually, to the department
35of public health’s public health data management program all
-41-1of the following:
2a. Any beneficial interest in or compensation arrangement
3with an entity to which the participating health care provider
4referred a patient.
5b. Any membership, proprietary interest, or co-ownership in
6any form in or with a clinical or bioanalytical laboratory.
7c. Any payments to a clinical or bioanalytical laboratory
8for a test or test series for a patient.
9d. Any profit-sharing arrangement with a clinical or
10bioanalytical laboratory.
11e. Any contracts or subcontracts entered into that contain
12incentive plans, involve general payments such as capitation
13payments or shared risk agreements, and are not tied to
14specific medical decisions involving specific members or groups
15of members with similar medical conditions. Such contracts
16and subcontracts include those entered into with a health
17maintenance organization or group practice.
18f. Any bonus, incentive agreements, or compensation
19arrangements with any other participating health care provider,
20care coordinator, health maintenance organization, or group
21medical practice under the healthy Iowa program.
22g. Any offer, delivery, receipt, or acceptance of rebates,
23refunds, commission, preference, patronage dividend, discount,
24or other consideration for a referral made when treating a
25member of a health maintenance organization, to another health
26care provider in the same group practice as the referring
27health care provider, or made for in-office ancillary services
28or tests that are furnished by the referring health care
29provider, a person in the same group practice as the referring
30health care provider, or an individual employed or supervised
31by the referring health care provider.
32h. Any other referral or relationship that the board finds
33necessary to disclose to meet the purposes of this section.
347. The board may adopt rules pursuant to chapter 17A as
35necessary to implement and enforce this section and may adopt
-42-1such rules to expand reporting requirements under this section.
2 Sec. 21. NEW SECTION. 135E.21 Federal waivers.
31. The board shall seek all federal waivers and other
4federal approvals and arrangements and submit federal state
5plan amendments as necessary to operate the healthy Iowa
6program consistent with this chapter.
72. a. The board and, as appropriate, the director of human
8services, shall apply to the United States secretary of health
9and human services or other appropriate federal official for
10all waivers of requirements, and make other arrangements under
11Medicare, any federally matched public health program, the
12Affordable Care Act, and any other federal programs pertaining
13to the provision of health care that provide federal funds for
14payment for health care services that are necessary to:
15(1) Enable all members to receive all benefits through the
16healthy Iowa program.
17(2) Enable the state to implement this chapter.
18(3) Allow the state to receive and deposit all federal
19payments under those programs, including funds that may
20be provided in lieu of premium tax credits, cost-sharing
21subsidies, and small business tax credits, in the state
22treasury to the credit of the healthy Iowa trust fund.
23(4) Use moneys deposited in the healthy Iowa trust fund
24for the healthy Iowa program and other provisions under this
25chapter.
26b. To the greatest extent possible, the board shall
27negotiate arrangements with the federal government to ensure
28that federal payments are paid to the healthy Iowa program in
29place of federal funding of, or tax benefits for, federally
30matched public health programs or federal health programs.
31c. (1) The board may require members or applicants to
32provide information necessary for the healthy Iowa program to
33comply with any waiver or arrangement under this chapter.
34(2) Information provided by members to the board for the
35purposes of this paragraph shall not be used for any other
-43-1purpose.
2d. The board may take any additional actions necessary to
3effectively implement the healthy Iowa program to the maximum
4extent possible as a single-payer program consistent with this
5chapter.
63. a. The board may take actions consistent with this
7chapter to enable the healthy Iowa program to administer
8Medicare in this state.
9b. The healthy Iowa program shall do all of the following:
10(1) Be a provider of Medicare part B supplemental insurance
11coverage.
12(2) Provide premium assistance drug coverage under Medicare
13part D for eligible members of the healthy Iowa program.
144. The board may waive or modify the applicability of any
15provisions of this section relating to any federally matched
16public health program or Medicare, as necessary, to do any of
17the following:
18a. Implement any waiver arrangement under this section.
19b. Maximize the federal benefits to the healthy Iowa program
20under this section.
215. a. The board may apply for coverage for, and enroll,
22any eligible member under any federally matched public health
23program or Medicare.
24b. Enrollment in a federally matched public health program
25or Medicare shall not cause any member to lose any health care
26services provided by the healthy Iowa program or diminish any
27right the member would otherwise have.
286. The board shall take necessary action to incorporate
29health care coverage of residents who are employed in another
30state into waivers and other approvals applied for or obtained
31under this section.
327. a. The board shall take necessary action to reduce or
33eliminate a member’s coinsurance, cost-sharing, or premium
34obligations or to increase the likelihood of an individual’s
35eligibility for any federal financial support related to
-44-1Medicare or the Affordable Care Act.
2b. The board may act under paragraph “a” only upon a
3finding approved by the board that the action does all of the
4following:
5(1) Helps to increase the number of members who are eligible
6for and enrolled in federally matched public health programs,
7or for any program to reduce or eliminate an individual’s
8coinsurance, cost-sharing, or premium obligations or increase
9an individual’s eligibility for any federal financial support
10related to Medicare or the Affordable Care Act.
11(2) Does not diminish any individual’s access to any health
12care service or right the individual would otherwise have.
13(3) Is in the interest of the healthy Iowa program.
14(4) Does not require or has received any necessary federal
15waivers or approvals to ensure federal financial participation.
16c. Action that the board may take under paragraph “a” may
17include any of the following:
18(1) An increase to the income eligibility level related to
19Medicare or the Affordable Care Act.
20(2) An increase to resource retention or an elimination of
21the resource test for eligibility related to Medicare or the
22Affordable Care Act.
23(3) Simplification of any procedural or documentation
24requirement for enrollment related to Medicare or the
25Affordable Care Act.
26(4) An increase in the benefits for any federally matched
27public health program and for any program in order to reduce or
28eliminate an individual’s coinsurance, cost-sharing, or premium
29obligations or increase an individual’s eligibility for any
30federal financial support related to Medicare or the Affordable
31Care Act.
32d. Board actions under this subsection shall not apply to
33eligibility for payment for long-term care.
348. To enable the board to apply for coverage for, and
35enroll, any eligible member under any federally matched public
-45-1health program or Medicare, the board may require that all
2members or applicants provide the information necessary to
3enable the board to determine whether the applicant is eligible
4for a federally matched public health program or for Medicare,
5or any program or benefit under Medicare.
69. As a condition of continued eligibility for health
7care services under the healthy Iowa program, a member who is
8eligible for benefits under Medicare shall enroll in Medicare,
9including parts A, B, and D.
1010. a. The healthy Iowa program shall provide premium
11assistance for all members enrolling in a Medicare part D plan.
12b. Premium assistance required under paragraph “a” is
13limited to the low-income benchmark premium amount established
14by the centers for Medicare and Medicaid services of the United
15States department of health and human services and any other
16amount the federal agency establishes under its de minimis
17premium policy, except that those payments made on behalf of
18members enrolled in a Medicare advantage plan may exceed the
19low-income benchmark premium amount if determined to be cost
20effective to the healthy Iowa program.
2111. a. If the board has reasonable grounds to believe that
22a member may be eligible for an income-related subsidy under
23§1860D-14 of Tit.XVIII of the federal Social Security Act, 42
24U.S.C.§1395w-114, the member shall be required to provide and
25authorize the healthy Iowa program to obtain any information or
26documentation required to establish the member’s eligibility
27for that subsidy.
28b. The board shall attempt to obtain as much of the
29information and documentation required by paragraph “a” as
30possible.
3112. a. The healthy Iowa program shall make a reasonable
32effort to notify members of their obligations under this
33section.
34b. After a reasonable effort has been made to contact the
35member, the member shall be notified in writing that the member
-46-1has sixty days to provide the required information.
2c. If the required information is not provided within the
3sixty-day period, the member’s coverage under the healthy Iowa
4program may be terminated.
5d. Information provided by members to the board for the
6purposes of this section shall not be used for any other
7purpose.
813. The board shall assume responsibility for all benefits
9and health care services paid for by the federal government
10with those funds.
11 Sec. 22. NEW SECTION. 135E.22 Healthy Iowa trust fund —
12special fund created.
131. A special fund is created in the state treasury, separate
14and apart from all other public moneys or funds of this state,
15to be known as the healthy Iowa trust fund. The fund shall
16consist of all of the following:
17a. All moneys appropriated by the state to the fund.
18b. All moneys received from the federal government, as
19the result of any waiver of requirements granted or other
20arrangements agreed to by the federal government for health
21care programs.
22c. All moneys transferred to the fund attributable to state
23and federal financial participation in Medicaid, the healthy
24and well kids in Iowa program, and Medicare.
25d. All receipts and revenue after January 1, 2019, as a
26result of the collection of taxes or other moneys, as provided
27by law, shall also be deposited in the healthy Iowa trust fund.
28e. All federal and state moneys received for purposes of the
29provision of services authorized under Tit.XX of the federal
30Social Security Act, 42 U.S.C.§1397 et seq., but are provided
31under the healthy Iowa program.
32f. All moneys received from other federal programs that
33provide moneys for the payment of health care services that are
34provided under this chapter.
35g. All moneys paid by the state that are equivalent to those
-47-1amounts that are paid on behalf of residents under Medicare,
2any federally matched public health program, or the Affordable
3Care Act for health benefits that are equivalent to health
4benefits covered under the healthy Iowa program.
52. All moneys in the fund shall be deposited, administered,
6and disbursed, in the same manner and under the same conditions
7and requirements as is provided by law for special funds in
8the state treasury. The moneys credited to the fund are not
9subject to section 8.33 and shall not be transferred, used,
10obligated, appropriated, or otherwise encumbered except as
11provided in this section. Moneys deposited into the fund are
12appropriated and made available to the healthy Iowa program to
13be used only for the following purposes established by this
14chapter:
15a. To implement the purposes of the healthy Iowa program.
16b. To be used by the healthy Iowa program for the payment of
17claims or reimbursement of member benefits.
18c. To be used by the healthy Iowa program for the payment,
19in accordance with any agreement with the federal government,
20of amounts required to obtain federal waivers and such other
21purposes under the healthy Iowa program as may be authorized
22by law.
233. The treasurer of state is the custodian and trustee of
24the fund and shall administer the fund in accordance with the
25purposes of the healthy Iowa program. It is the duty of the
26treasurer of state to do all of the following:
27a. To hold the trust funds.
28b. To disburse the trust funds upon warrants drawn by the
29director of the healthy Iowa program.
304. The healthy Iowa program shall administer the healthy
31Iowa trust fund and shall also administer all other provisions
32of this section.
335. All moneys in the fund, except moneys received
34pursuant to federal waivers entered into pursuant to section
35135E.21, which are received from the federal government
-48-1shall be expended solely for the purposes and in the amounts
2found necessary by the board for the proper and efficient
3administration of this chapter and any federal waivers or
4agreements.
56. Moneys deposited in the fund shall not be loaned to, or
6borrowed by, any other special fund or the general fund of the
7state, or a county general fund or any other county fund.
87. The board shall establish and maintain a reserve fund in
9the healthy Iowa trust fund.
108. The board or staff of the board shall not utilize any
11moneys intended for the administrative and operational expenses
12of the board for staff retreats, promotional giveaways,
13excessive executive compensation, or promotion of federal or
14state legislative or regulatory modifications.
159. a. A healthy Iowa federal funds account is created
16within the fund.
17b. All federal moneys received shall be placed into the
18healthy Iowa federal funds account.
19 Sec. 23. NEW SECTION. 135E.23 Severability.
20If any provision of this chapter or its application to any
21person or circumstance is held invalid, the invalidity does
22not affect other provisions or application of this chapter
23which can be given effect without the invalid provision or
24application, and to this end the provisions of this chapter are
25severable.
26 Sec. 24. NEW SECTION. 135E.24 Relation to other laws.
27This chapter does not preempt or prevail over and is
28not meant to be construed to preempt or prevail over any
29ordinances, resolutions, or other actions of a local government
30or rules or actions of a state agency that are consistent with
31this chapter or that provide more protections and benefits to
32residents of this state than this chapter or are more stringent
33than this chapter.
34 Sec. 25. NEW SECTION. 135F.1 Definitions.
35As used in this chapter, unless the context otherwise
-49-1requires:
21. a. “Health care provider” means a person who meets all
3of the following criteria:
4(1) Is licensed, certified, registered, or authorized to
5practice a health care profession in the state pursuant to
6chapter 147A, 148, 148A, 148B, 148C, 148E, 148F, 148G, 149,
7151, 152, 152A, 152B, 152C, 153, 154, 154A, 154B, 154C, 154D,
8154F, 155, or 155A.
9(2) Is an approved health care provider under the healthy
10Iowa program created in chapter 135E.
11(3) Is an individual who does any of the following:
12(a) Practices the profession in which that person is
13licensed, certified, registered, or authorized to practice
14in the state as a health care provider or as an independent
15contractor.
16(b) Is an owner, officer, shareholder, or proprietor of a
17health care provider.
18(c) Is an entity that employs or utilizes health care
19providers to provide health care services under the healthy
20Iowa program.
21b. “Health care provider” does not include an individual who
22practices as an employee of another health care provider.
232. “Health care provider representative” means a third party
24that is authorized by a health care provider to negotiate
25on behalf of the health care provider with the healthy Iowa
26program over terms and conditions of participation affecting
27those health care providers.
28 Sec. 26. NEW SECTION. 135F.2 Collective negotiation
29authorized.
301. Health care providers may meet and communicate for the
31purpose of collectively negotiating with the healthy Iowa
32program on any matter relating to the healthy Iowa program
33including but not limited to rates of payment for health care
34services, rates of payment for prescription and nonprescription
35drugs, and payment methodologies.
-50- 12. This chapter shall not be construed, is not intended to
2be construed, and shall not imply any of the following:
3a. To allow or authorize an alteration of the terms of the
4internal and external review procedures set forth in law.
5b. To allow a strike by health care providers related to the
6collective negotiations under the healthy Iowa program.
7c. To allow or authorize terms or conditions of
8participation that would impede the ability of the healthy
9Iowa program to obtain or retain accreditation by the national
10committee for quality assurance or a similar body, or to comply
11with applicable state or federal law.
12 Sec. 27. NEW SECTION. 135F.3 Collective negotiation —
13requirements.
141. A health care provider representative is the only party
15authorized to negotiate with the healthy Iowa program on behalf
16of the health care providers as a group.
172. A health care provider shall be bound by the terms
18and conditions negotiated by the health care provider
19representative.
203. Health care providers have the right during collective
21negotiations under this chapter to communicate with other
22health care providers regarding the terms and conditions of
23participation to be negotiated with the healthy Iowa program
24and to communicate with health care provider representatives.
254. The healthy Iowa program may communicate or negotiate
26with the health care provider representative, and may offer
27and provide different terms and conditions of participation to
28individual competing health care providers.
295. This section shall not be construed, is not intended to
30be construed to, and shall not imply any of the following:
31a. An effect on or limitation to the right of a health care
32provider or group of health care providers to collectively
33petition a governmental entity for a change in a law, rule, or
34regulation.
35b. An effect on or limitation to collective bargaining
-51-1on the part of a health care provider with the health care
2provider’s employer or any other lawful collective bargaining.
36. Before engaging in collective negotiations with the
4healthy Iowa program on behalf of health care providers, a
5health care provider representative shall file with the board,
6in the manner prescribed by the board, all of the following
7information:
8a. The name of the representative.
9b. The representative’s plan of operation.
10c. The representative’s procedures to ensure compliance with
11this chapter.
127. a. A person who acts as the representative of
13negotiating parties under this chapter shall pay a fee to the
14board to act as a representative.
15b. The board shall set fees in amounts deemed reasonable
16and necessary to cover the costs incurred by the board in
17administering this chapter.
18 Sec. 28. NEW SECTION. 135F.4 Health care providers —
19prohibited collective action.
201. This chapter shall not authorize competing health care
21providers to act in concert in response to discussions or
22negotiations of a health care provider representative with the
23healthy Iowa program, except as authorized by other law.
242. A health care provider representative shall not
25negotiate any agreement that excludes, limits the participation
26or reimbursement of, or otherwise limits the scope of health
27care services to be provided by any health care provider or
28group of health care providers with respect to the performance
29of health care services that are within the health care
30provider’s scope of practice, license, registration, or
31certification.
32 Sec. 29. NEW SECTION. 135F.5 Severability.
33If any provision of this chapter or its application to any
34person or circumstance is held invalid, the invalidity does
35not affect other provisions or application of this chapter
-52-1which can be given effect without the invalid provision or
2application, and to this end the provisions of this chapter are
3severable.
4 Sec. 30. NEW SECTION. 135F.6 Relation to other laws.
5This chapter does not preempt or prevail over and is
6not meant to be construed to preempt or prevail over any
7ordinances, resolutions, or other actions of a local government
8or rules or actions of a state agency that are consistent with
9this chapter or that provide more protections and benefits to
10Iowa residents than this chapter or are more stringent than
11this chapter.
12 Sec. 31. EFFECTIVE DATE. This Act, being deemed of
13immediate importance, takes effect upon enactment.
14 Sec. 32. CONTINGENT IMPLEMENTATION. Implementation of this
15Act is contingent upon sufficient revenue in the healthy Iowa
16trust fund to bear the costs of implementing the healthy Iowa
17program, as determined by the director of human services. The
18director of human services shall notify the secretary of the
19senate, the chief clerk of the house of representatives, and
20the Iowa Code editor, in writing when the healthy Iowa trust
21fund has sufficient revenue to bear the costs of implementing
22this Act. The department of human services shall publish a
23copy of the notice on its internet site.
24EXPLANATION
25The inclusion of this explanation does not constitute agreement with
26the explanation’s substance by the members of the general assembly.
27This bill creates new Code chapter 135E, establishing the
28healthy Iowa program, which provides comprehensive, universal
29single-payer health care coverage and a health care cost
30control system for all residents of Iowa. The bill provides
31that all residents of the state are eligible to be members of
32the healthy Iowa program and are eligible to receive health
33care services benefits under the program. The bill requires
34that the healthy Iowa program provide all members of the
35program with certain health care services, and incorporate the
-53-1health care benefits and standards of other existing federal
2and state programs. The bill prohibits health care providers
3participating in the healthy Iowa program from refusing to
4provide services to a member on the basis of certain protected
5categories. The bill establishes the healthy Iowa board and
6public advisory committee.
7The bill provides that health care coverage under the
8healthy Iowa program shall not be subject to coinsurance,
9deductibles, or copayments. The bill prohibits certain
10insurers, nonprofit health service plans, and health
11maintenance organizations from offering benefits that duplicate
12the services covered by the program. The bill prohibits health
13insurers from offering health benefits covering any health care
14service for which coverage is offered to individuals under
15the healthy Iowa program, except as otherwise provided, and
16prohibits a participating health care provider from imposing
17charges directly on healthy Iowa members.
18The bill provides for approval of participating health
19care providers and care coordinators under the program and
20provides for enrollment of residents in the program. The bill
21also provides that healthy Iowa program members may choose a
22participating health care provider and requires that members
23select a care coordinator.
24The bill specifies healthy Iowa program standards and
25payment for health care services and care coordination, and
26requires that the program provide reimbursements to certain
27members. The bill establishes a health benefit credit for
28certain employers and residents.
29The bill establishes the healthy Iowa trust fund as a special
30fund for the purpose of implementing the program and its
31purposes. The bill requires the board and the department of
32human services to apply to the federal government for waivers
33and other approvals relating to federally regulated health care
34programs.
35The bill also creates new Code chapter 135F providing for
-54-1collective negotiations between health care providers and
2the healthy Iowa program. The bill authorizes health care
3providers to collectively negotiate with the program for
4rates of payment for health care services, rates of payment
5for prescription and nonprescription drugs, and payment
6methodologies using a third-party representative.
7The bill takes effect upon enactment but implementation of
8the bill is contingent upon sufficient revenue in the healthy
9Iowa trust fund to bear the costs of implementing the healthy
10Iowa program as determined by the director of human services.
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