Bill Text: IA HF2244 | 2017-2018 | 87th General Assembly | Introduced
Bill Title: A bill for an act relating to the Medicaid program, including long-term services and supports, integrated health homes, capitation and reimbursement rates, and oversight, and including effective date provisions.
Spectrum: Partisan Bill (Democrat 19-0)
Status: (Introduced - Dead) 2018-02-05 - Introduced, referred to Human Resources. H.J. 208. [HF2244 Detail]
Download: Iowa-2017-HF2244-Introduced.html
House File 2244 - Introduced HOUSE FILE BY HEDDENS, HUNTER, KRESSIG, STAED, P. MILLER, GASKILL, STECKMAN, WINCKLER, McCONKEY, BEARINGER, KEARNS, BRECKENRIDGE, HALL, PRICHARD, COHOON, ISENHART, OLDSON, KURTH, OURTH, and T. TAYLOR A BILL FOR 1 An Act relating to the Medicaid program, including long=term 2 services and supports, integrated health homes, capitation 3 and reimbursement rates, and oversight, and including 4 effective date provisions. 5 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: TLSB 5730YH (7) 87 pf/rh PAG LIN 1 1 Section 1. TERMINATION OF MEDICAID MANAGED CARE CONTRACTS 1 2 RELATIVE TO LONG=TERM SERVICES AND SUPPORTS POPULATION == 1 3 TRANSITION TO FEE=FOR=SERVICE. The department of human 1 4 services shall, upon the effective date of this Act, provide 1 5 written notice in accordance with the termination provisions 1 6 of the contract, to each managed care organization with whom 1 7 the department executed a contract to administer the Iowa 1 8 high quality health care initiative as established by the 1 9 department, to terminate such contracts as applicable to 1 10 the Medicaid long=term services and supports population, 1 11 following a sixty=day transition period. The department shall 1 12 transfer the long=term services and supports population to 1 13 fee=for=service program administration. The transition shall 1 14 be based on a transition plan developed by the department and 1 15 submitted to the council on human services and the medical 1 16 assistance advisory council for review. 1 17 Sec. 2. INTEGRATED HEALTH HOME FOR PERSONS WITH SERIOUS AND 1 18 PERSISTENT MENTAL ILLNESS (SPMI INTEGRATED HEALTH HOME). The 1 19 department of human services shall adopt rules pursuant to 1 20 chapter 17A and shall amend existing Medicaid managed care 1 21 contracts to carve out SPMI integrated health homes services 1 22 as specified in the Medicaid state plan amendment, IA=16=013, 1 23 from Medicaid managed care contracts and instead provide SPMI 1 24 integrated health home services through the fee=for=service 1 25 payment and delivery system. 1 26 Sec. 3. RECALCULATION OF CERTAIN CAPITATION RATES UNDER 1 27 MEDICAID MANAGED CARE. For the fiscal year beginning July 1 28 1, 2018, the department of human services shall utilize 1 29 Medicaid program claims paid data for the period beginning 1 30 April 1, 2015, and ending March 31, 2016, as base data to 1 31 develop and certify capitation rates for providers of home and 1 32 community=based intellectual disability waiver services under 1 33 Medicaid managed care. 1 34 Sec. 4. MEDICAID MANAGED CARE OVERSIGHT. The department of 1 35 human services shall amend the Medicaid managed care contracts 2 1 and adopt rules pursuant to chapter 17A to provide that 2 2 beginning July 1, 2018, all of the following shall apply: 2 3 1. MEMBER STATUS CHANGES. 2 4 a. A Medicaid managed care organization shall provide prior 2 5 notice, in writing, to a member and to any affected provider, 2 6 of any change in the status of the member at least thirty 2 7 days prior to the effective date of the change in status. If 2 8 notification is not received by the provider and the member 2 9 continues to receive services from the provider, the Medicaid 2 10 managed care organization shall reimburse the provider for 2 11 services rendered. 2 12 b. If a member transfers from one managed care organization 2 13 to another, the managed care organization from which the 2 14 member is transferring shall forward the member's records to 2 15 the managed care organization assuming the member's coverage 2 16 at least thirty days prior to the managed care organization 2 17 assuming such coverage. 2 18 c. If a provider provides services to a member for which the 2 19 member is eligible while awaiting any necessary authorization, 2 20 and the authorization is subsequently approved, the provider 2 21 shall be reimbursed at the contracted rate for any services 2 22 provided prior to receipt of the authorization. 2 23 2. DATA. Managed care organizations shall report to the 2 24 department of human services not only the percentage of medical 2 25 and pharmacy clean claims paid or denied within a certain 2 26 time frame, but shall also report all of the following on a 2 27 quarterly basis: 2 28 a. The total number of original medical and pharmacy claims 2 29 submitted to the managed care organization. 2 30 b. The total number of original medical and pharmacy claims 2 31 deemed rejected and the reason for rejection. 2 32 c. The total number of original medical and pharmacy claims 2 33 deemed suspended, the reason for suspension, and the number of 2 34 days from suspension to submission for processing. 2 35 d. The total number of original medical and pharmacy 3 1 claims initially deemed either rejected or suspended that are 3 2 subsequently deemed clean claims and paid, and the average 3 3 number of days from initial submission to payment of the clean 3 4 claim. 3 5 e. The total number of medical and pharmacy claims that 3 6 are outstanding for thirty, sixty, ninety, one hundred eighty, 3 7 or more than one hundred eighty days, and the total amount 3 8 attributable to these outstanding claims if paid as submitted. 3 9 f. The total amount requested as payment for all original 3 10 medical or pharmacy claims versus the total amount actually 3 11 paid as clean claims and the total amount of payment denied. 3 12 g. The total number of original medical and pharmacy claims 3 13 received, the number of such claims for which one hundred 3 14 percent of the requested amount was paid, the number of such 3 15 claims for which less than one hundred percent of the requested 3 16 amount was paid and the percentage actually paid, and the total 3 17 dollar amount of payments denied. 3 18 3. REIMBURSEMENT. For the fiscal year beginning July 1, 3 19 2018, Medicaid providers or services shall be reimbursed as 3 20 follows: 3 21 a. For fee=for=service claims, reimbursement shall be 3 22 calculated based on the methodology in effect on June 30, 2018, 3 23 for the respective provider or service. 3 24 b. For claims subject to a managed care contract: 3 25 (1) Reimbursement shall be based on the methodology 3 26 established by the managed care contract. However, any 3 27 reimbursement established under such contract shall not be 3 28 lower than the rate floor established by the department of 3 29 human services as the managed care organization provider or 3 30 service reimbursement rate floor for the respective provider or 3 31 service in effect on June 30, 2018. 3 32 (2) For any provider or service to which a reimbursement 3 33 increase is applicable for the fiscal year under state law, 3 34 upon the effective date of the reimbursement increase, the 3 35 department of human services shall modify the rate floor in 4 1 effect on June 30, 2018, to reflect the increase specified. 4 2 Any reimbursement established under the managed care contract 4 3 shall not be lower than the rate floor as modified by the 4 4 department of human services to reflect the provider rate 4 5 increase specified. 4 6 (3) Any reimbursement established between the managed 4 7 care organization and the provider shall be in effect for at 4 8 least twelve months from the date established, unless the 4 9 reimbursement is increased. A reimbursement rate that is 4 10 negotiated and established above the rate floor shall not be 4 11 decreased from that amount for at least twelve months from the 4 12 date established. 4 13 4. PRIOR AUTHORIZATION. 4 14 a. Any change by a Medicaid managed care organization in a 4 15 requirement for prior authorization for a prescription drug or 4 16 service shall be preceded by the provision of sixty days' prior 4 17 written notice published on the managed care organization's 4 18 internet site and provided in writing to all affected members 4 19 and providers before the effective date of the change. 4 20 b. Each managed care organization shall post to the managed 4 21 care organization's internet site prior authorization data 4 22 including but not limited to statistics on approvals and 4 23 denials of prior authorization requests by physician specialty, 4 24 medication, test, procedure, or service, the indication 4 25 offered, and if denied, the reason for denial. 4 26 Sec. 5. MEDICAID STATE PLAN OR WAIVER AMENDMENTS. The 4 27 department of human services shall seek any Medicaid state plan 4 28 or waiver amendments necessary to administer this Act. 4 29 Sec. 6. EFFECTIVE DATE. This Act, being deemed of immediate 4 30 importance, takes effect upon enactment. 4 31 EXPLANATION 4 32 The inclusion of this explanation does not constitute agreement with 4 33 the explanation's substance by the members of the general assembly. 4 34 This bill directs the department of human services (DHS) 4 35 to provide written notice in accordance with the termination 5 1 provisions of the contract, to each managed care organization 5 2 (MCO) with whom DHS executed a contract to administer the Iowa 5 3 high quality health care initiative as established by the 5 4 department, to terminate such contracts as applicable to the 5 5 long=term services and supports population, following a 60=day 5 6 transition period. DHS is directed to transfer the long=term 5 7 services and supports population to fee=for=service program 5 8 administration. The transition is to be based on a transition 5 9 plan developed by the department and submitted to the council 5 10 on human services and the medical assistance advisory council 5 11 for review. 5 12 The bill requires DHS to adopt rules pursuant to Code chapter 5 13 17A and to amend existing Medicaid managed care contracts to 5 14 carve out SPMI integrated health homes services as specified 5 15 in the Medicaid state plan amendment, IA=16=013, from Medicaid 5 16 managed care contracts and instead provide SPMI integrated 5 17 health home services through the fee=for=service payment and 5 18 delivery system. 5 19 The bill requires DHS to use Medicaid program claims paid 5 20 data for the period beginning April 1, 2015, and ending March 5 21 31, 2016, as base data to develop and certify capitation 5 22 rates for providers of home and community=based intellectual 5 23 disability waiver services under Medicaid managed care for the 5 24 fiscal year beginning July 1, 2018. 5 25 The bill provides for Medicaid managed care oversight. The 5 26 bill requires DHS to amend the Medicaid managed care contracts 5 27 and adopt rules pursuant to Code chapter 17A to provide for a 5 28 number of changes, beginning July 1, 2018. 5 29 The bill requires MCOs to provide prior written notice to a 5 30 member and to any affected provider of any change in the status 5 31 of the member that affects such provider at least 30 days prior 5 32 to the effective date of the change in status. If notification 5 33 is not received by the provider and the member continues to 5 34 receive services from the provider, the MCO shall reimburse the 5 35 provider for services rendered. If a member transfers from one 6 1 MCO to another, the MCO from which the member is transferring 6 2 shall forward the member's records to the MCO assuming the 6 3 member's coverage at least 30 days prior to the MCO assuming 6 4 such coverage. Additionally, if a provider provides services 6 5 to a member for which the member is eligible while the provider 6 6 is awaiting any necessary authorization to provide the service, 6 7 and the authorization is subsequently approved, the provider 6 8 shall be reimbursed at the contracted rate for any services 6 9 provided prior to receipt of the authorization. 6 10 With regard to data, the bill requires that MCOs, in addition 6 11 to reporting to DHS the percentage of medical and pharmacy 6 12 clean claims paid or denied within a certain time frame, to 6 13 also report additional data regarding claims as specified in 6 14 the bill on a quarterly basis. 6 15 With regard to reimbursement, the bill requires 6 16 reimbursement beginning July 1, 2018, for Medicaid providers 6 17 and services, to be calculated based on the methodology 6 18 in effect on June 30, 2018, for the respective provider or 6 19 service for fee=for=service claims and for claims subject to 6 20 a managed care contract, reimbursement shall be based on the 6 21 methodology established by the managed care contract. However, 6 22 any reimbursement established under such contract shall not be 6 23 lower than the rate floor established by DHS as a rate floor 6 24 for the respective provider or service in effect on June 30, 6 25 2018. Additionally, for any provider or service to which a 6 26 reimbursement increase is applicable for the fiscal year under 6 27 state law beginning July 1, 2018, upon the effective date of 6 28 the reimbursement increase, DHS shall modify the rate floor in 6 29 effect on June 30, 2018, to reflect the increase specified and 6 30 any reimbursement established under the managed care contract 6 31 shall not be lower than the rate floor as modified. Any 6 32 reimbursement established between the managed care organization 6 33 and the provider shall be in effect for at least 12 months from 6 34 the date established, unless the reimbursement is increased. A 6 35 reimbursement rate negotiated and established above the rate 7 1 floor shall not be decreased from that negotiated amount for at 7 2 least a 12=month period. 7 3 With regard to prior authorization, the bill requires that 7 4 any change by an MCO in a requirement for prior authorization 7 5 for a prescription drug or service shall be preceded by 60 7 6 days' prior written notice published on the MCO's internet site 7 7 and provided in writing to all affected members and providers 7 8 before the effective date of the change. The bill requires 7 9 an MCO to place certain prior authorization data on the MCO's 7 10 internet site. 7 11 The bill requires DHS to seek any Medicaid state plan or 7 12 waiver amendments necessary to administer the bill. 7 13 The bill takes effect upon enactment. LSB 5730YH (7) 87 pf/rh
