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Senate File 154 - IntroducedA Bill ForAn Act 1relating to reimbursement of hospitals for days awaiting
2placement through private insurance and the Medicaid
3program.
4BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
1 Section 1. NEW SECTION. 514C.2A Days awaiting placement
2in a hospital — reimbursement.
31. For the purposes of this section:
4a. “Days awaiting placement” means the days during which
5a covered individual no longer meets acute care criteria for
6stay in a hospital, has been verified to require placement in a
7lower-level facility which may not be immediately located, and
8is awaiting placement at the lower-level facility.
9b. “Lower-level facility” means a facility that is able
10to provide adequate, available, and accessible services and
11supports, including but not limited to mental health services
12and supports, to meet the covered individual’s needs as
13specified in the covered individual’s discharge plan.
142. Notwithstanding the uniformity of treatment requirements
15of section 514C.6, a policy, contract, or plan providing
16for third-party payment or prepayment of health or medical
17expenses that provides hospital benefits shall not deny
18reimbursement for the continuation of all higher-level
19services, including but not limited to inpatient care, provided
20to a covered individual during a days awaiting placement
21period. Reimbursement shall be provided to a hospital for each
22day a covered individual remains in the care of the hospital
23while awaiting placement in a lower-level facility.
243. For a hospital to receive days awaiting placement
25reimbursement under this section, all of the following criteria
26must be met:
27a. The covered individual has a diagnosed condition that
28required an acute inpatient level of care.
29b. The covered individual no longer meets continued
30stay criteria for the acute inpatient level of care and
31requires placement in a lower-level facility, but barriers to
32implementation of the discharge plan exist that are beyond the
33control of the hospital.
34c. The carrier as defined in section 513B.2 has authorized
35placement in the lower-level facility sought under the
-1-1discharge plan.
2d. The hospital is making every reasonable effort to
3continue to actively work to identify resources to implement
4the discharge plan in a timely manner and documents the
5reasonable efforts taken.
64. This section applies to the following classes of
7third-party payment provider policies, contracts, or plans
8delivered, issued for delivery, continued, or renewed in this
9state on or after January 1, 2022:
10a. Individual or group accident and sickness insurance
11providing coverage on an expense-incurred basis.
12b. An individual or group hospital or medical service
13contract issued pursuant to chapter 509, 514, or 514A.
14c. An individual or group health maintenance organization
15contract regulated under chapter 514B.
16d. A plan established pursuant to chapter 509A for public
17employees.
185. This section shall not apply to accident-only, specified
19disease, short-term hospital or medical, hospital confinement
20indemnity, credit, dental, vision, Medicare supplement,
21long-term care, basic hospital and medical-surgical expense
22coverage as defined by the commissioner of insurance,
23disability income insurance coverage, coverage issued as a
24supplement to liability insurance, workers’ compensation or
25similar insurance, or automobile medical payment insurance.
266. This section shall not apply to the medical assistance
27program pursuant to chapter 249A, including to a managed care
28organization acting pursuant to a contract with the department
29of human services to provide coverage to medical assistance
30program members, or to the hawk-i program pursuant to chapter
31514I.
327. The commissioner of insurance may adopt rules pursuant to
33chapter 17A as necessary to administer this section.
34 Sec. 2. DAYS AWAITING PLACEMENT — MEDICAID REIMBURSEMENT.
351. Under both fee-for-service and managed care
-2-1administration of the Medicaid program, a hospital shall not
2be denied reimbursement based on failure to meet medical
3necessity for the continuation of all higher-level services,
4including but not limited to inpatient care, provided to a
5Medicaid-eligible member during a days awaiting placement
6period. Reimbursement shall be provided to a hospital for
7each day a Medicaid-eligible member remains in the care of the
8hospital while awaiting placement in a lower-level facility.
92. For a hospital to receive days awaiting placement
10reimbursement under this section, all of the following criteria
11must be met:
12a. The Medicaid-eligible member has a diagnosed condition
13that required an acute inpatient level of care.
14b. The Medicaid-eligible member no longer meets continued
15stay criteria for the acute inpatient level of care and
16requires placement in a lower-level facility, but barriers to
17implementation of the discharge plan exist that are beyond the
18control of the hospital.
19c. The department of human services or managed care
20organization has authorized placement in the lower-level
21facility sought under the discharge plan.
22d. The hospital is making every reasonable effort to
23continue to actively work to identify resources to implement
24the discharge plan in a timely manner and documents the
25reasonable efforts taken. However, if the Medicaid-eligible
26member is covered through a managed care organization, the
27managed care organization, rather than the hospital, shall
28be responsible for identifying and obtaining the lower-level
29facility placement.
303. For the purposes of this section:
31a. “Days awaiting placement” means the days during which a
32Medicaid-eligible member no longer meets acute care criteria
33for stay in a hospital, has been verified to require placement
34in a lower-level facility which may not be immediately located,
35and is awaiting placement at the lower-level facility.
-3- 1b. “Lower-level facility” means a facility that is able
2to provide adequate, available, and accessible services and
3supports, including but not limited to mental health services
4and supports, to meet the Medicaid-eligible member’s needs as
5specified in the member’s discharge plan.
64. The department of human services shall adopt rules
7pursuant to chapter 17A to administer this section.
8EXPLANATION
9The inclusion of this explanation does not constitute agreement with
10the explanation’s substance by the members of the general assembly.
11This bill relates to reimbursement for services provided by
12a hospital during a days awaiting placement period.
13The bill provides that under private insurance and
14fee-for-service and managed care administration of Medicaid, a
15hospital shall not be denied reimbursement for the continuation
16of all higher-level services, including but not limited
17to inpatient care, provided to a covered individual or
18Medicaid-eligible member, respectively, during a days awaiting
19placement period. Reimbursement shall be provided to a
20hospital for each day a covered individual or Medicaid-eligible
21member remains in the care of the hospital while awaiting
22placement in a lower-level facility.
23The bill defines ”days awaiting placement” as the days
24during which a covered individual or Medicaid-eligible member
25no longer meets acute care criteria for stay in a hospital, has
26been verified to require placement in a lower-level facility
27which may not be immediately located, and is awaiting placement
28at the lower-level facility. “Lower-level facility” is defined
29as a facility that is able to provide adequate, available, and
30accessible services and supports, including but not limited
31to mental health services and supports, to meet a covered
32individual’s or Medicaid-eligible member’s needs as specified
33in the covered individual’s or Medicaid-eligible member’s
34discharge plan.
35The bill provides the criteria that must be met by a hospital
-4-1to receive reimbursement and requires the department of human
2services and the commissioner or insurance, respectively, to
3adopt administrative rules to administer the bill.
-5-pf/rh
2placement through private insurance and the Medicaid
3program.
4BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
1 Section 1. NEW SECTION. 514C.2A Days awaiting placement
2in a hospital — reimbursement.
31. For the purposes of this section:
4a. “Days awaiting placement” means the days during which
5a covered individual no longer meets acute care criteria for
6stay in a hospital, has been verified to require placement in a
7lower-level facility which may not be immediately located, and
8is awaiting placement at the lower-level facility.
9b. “Lower-level facility” means a facility that is able
10to provide adequate, available, and accessible services and
11supports, including but not limited to mental health services
12and supports, to meet the covered individual’s needs as
13specified in the covered individual’s discharge plan.
142. Notwithstanding the uniformity of treatment requirements
15of section 514C.6, a policy, contract, or plan providing
16for third-party payment or prepayment of health or medical
17expenses that provides hospital benefits shall not deny
18reimbursement for the continuation of all higher-level
19services, including but not limited to inpatient care, provided
20to a covered individual during a days awaiting placement
21period. Reimbursement shall be provided to a hospital for each
22day a covered individual remains in the care of the hospital
23while awaiting placement in a lower-level facility.
243. For a hospital to receive days awaiting placement
25reimbursement under this section, all of the following criteria
26must be met:
27a. The covered individual has a diagnosed condition that
28required an acute inpatient level of care.
29b. The covered individual no longer meets continued
30stay criteria for the acute inpatient level of care and
31requires placement in a lower-level facility, but barriers to
32implementation of the discharge plan exist that are beyond the
33control of the hospital.
34c. The carrier as defined in section 513B.2 has authorized
35placement in the lower-level facility sought under the
-1-1discharge plan.
2d. The hospital is making every reasonable effort to
3continue to actively work to identify resources to implement
4the discharge plan in a timely manner and documents the
5reasonable efforts taken.
64. This section applies to the following classes of
7third-party payment provider policies, contracts, or plans
8delivered, issued for delivery, continued, or renewed in this
9state on or after January 1, 2022:
10a. Individual or group accident and sickness insurance
11providing coverage on an expense-incurred basis.
12b. An individual or group hospital or medical service
13contract issued pursuant to chapter 509, 514, or 514A.
14c. An individual or group health maintenance organization
15contract regulated under chapter 514B.
16d. A plan established pursuant to chapter 509A for public
17employees.
185. This section shall not apply to accident-only, specified
19disease, short-term hospital or medical, hospital confinement
20indemnity, credit, dental, vision, Medicare supplement,
21long-term care, basic hospital and medical-surgical expense
22coverage as defined by the commissioner of insurance,
23disability income insurance coverage, coverage issued as a
24supplement to liability insurance, workers’ compensation or
25similar insurance, or automobile medical payment insurance.
266. This section shall not apply to the medical assistance
27program pursuant to chapter 249A, including to a managed care
28organization acting pursuant to a contract with the department
29of human services to provide coverage to medical assistance
30program members, or to the hawk-i program pursuant to chapter
31514I.
327. The commissioner of insurance may adopt rules pursuant to
33chapter 17A as necessary to administer this section.
34 Sec. 2. DAYS AWAITING PLACEMENT — MEDICAID REIMBURSEMENT.
351. Under both fee-for-service and managed care
-2-1administration of the Medicaid program, a hospital shall not
2be denied reimbursement based on failure to meet medical
3necessity for the continuation of all higher-level services,
4including but not limited to inpatient care, provided to a
5Medicaid-eligible member during a days awaiting placement
6period. Reimbursement shall be provided to a hospital for
7each day a Medicaid-eligible member remains in the care of the
8hospital while awaiting placement in a lower-level facility.
92. For a hospital to receive days awaiting placement
10reimbursement under this section, all of the following criteria
11must be met:
12a. The Medicaid-eligible member has a diagnosed condition
13that required an acute inpatient level of care.
14b. The Medicaid-eligible member no longer meets continued
15stay criteria for the acute inpatient level of care and
16requires placement in a lower-level facility, but barriers to
17implementation of the discharge plan exist that are beyond the
18control of the hospital.
19c. The department of human services or managed care
20organization has authorized placement in the lower-level
21facility sought under the discharge plan.
22d. The hospital is making every reasonable effort to
23continue to actively work to identify resources to implement
24the discharge plan in a timely manner and documents the
25reasonable efforts taken. However, if the Medicaid-eligible
26member is covered through a managed care organization, the
27managed care organization, rather than the hospital, shall
28be responsible for identifying and obtaining the lower-level
29facility placement.
303. For the purposes of this section:
31a. “Days awaiting placement” means the days during which a
32Medicaid-eligible member no longer meets acute care criteria
33for stay in a hospital, has been verified to require placement
34in a lower-level facility which may not be immediately located,
35and is awaiting placement at the lower-level facility.
-3- 1b. “Lower-level facility” means a facility that is able
2to provide adequate, available, and accessible services and
3supports, including but not limited to mental health services
4and supports, to meet the Medicaid-eligible member’s needs as
5specified in the member’s discharge plan.
64. The department of human services shall adopt rules
7pursuant to chapter 17A to administer this section.
8EXPLANATION
9The inclusion of this explanation does not constitute agreement with
10the explanation’s substance by the members of the general assembly.
11This bill relates to reimbursement for services provided by
12a hospital during a days awaiting placement period.
13The bill provides that under private insurance and
14fee-for-service and managed care administration of Medicaid, a
15hospital shall not be denied reimbursement for the continuation
16of all higher-level services, including but not limited
17to inpatient care, provided to a covered individual or
18Medicaid-eligible member, respectively, during a days awaiting
19placement period. Reimbursement shall be provided to a
20hospital for each day a covered individual or Medicaid-eligible
21member remains in the care of the hospital while awaiting
22placement in a lower-level facility.
23The bill defines ”days awaiting placement” as the days
24during which a covered individual or Medicaid-eligible member
25no longer meets acute care criteria for stay in a hospital, has
26been verified to require placement in a lower-level facility
27which may not be immediately located, and is awaiting placement
28at the lower-level facility. “Lower-level facility” is defined
29as a facility that is able to provide adequate, available, and
30accessible services and supports, including but not limited
31to mental health services and supports, to meet a covered
32individual’s or Medicaid-eligible member’s needs as specified
33in the covered individual’s or Medicaid-eligible member’s
34discharge plan.
35The bill provides the criteria that must be met by a hospital
-4-1to receive reimbursement and requires the department of human
2services and the commissioner or insurance, respectively, to
3adopt administrative rules to administer the bill.
-5-pf/rh