Bill Text: IA HF2264 | 2017-2018 | 87th General Assembly | Introduced
Bill Title: A bill for an act relating to Medicaid managed care oversight including issues related to network adequacy, home and community-based services waiver services, member eligibility, and appeals processes.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2018-02-06 - Introduced, referred to Human Resources. H.J. 214. [HF2264 Detail]
Download: Iowa-2017-HF2264-Introduced.html
House File 2264 - Introduced HOUSE FILE BY HEATON A BILL FOR 1 An Act relating to Medicaid managed care oversight including 2 issues related to network adequacy, home and community=based 3 services waiver services, member eligibility, and appeals 4 processes. 5 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: TLSB 5854YH (4) 87 pf/rh PAG LIN 1 1 Section 1. MEDICAID MANAGED CARE OVERSIGHT. 1 2 1. Because access to services is of critical importance 1 3 to the vulnerable Medicaid populations receiving long=term 1 4 services and supports, the network of long=term services and 1 5 supports providers under contract with each managed care 1 6 organization on January 1, 2018, shall be deemed necessary 1 7 to meet the requirement for network adequacy. Any willing 1 8 provider under contract on that date shall remain a network 1 9 provider as long as the network provider complies with Medicaid 1 10 state plan requirements for that provider. The rates in effect 1 11 for each such provider on January 1, 2018, shall serve as the 1 12 rate floor for such provider through June 30, 2019, unless the 1 13 rate floors are otherwise amended or scheduled to be amended 1 14 by law. The department of human services shall adopt rules 1 15 pursuant to chapter 17A and shall amend all Medicaid managed 1 16 care contracts as necessary to administer this subsection. 1 17 2. The department of human services shall adopt rules 1 18 pursuant to chapter 17A and shall amend all Medicaid managed 1 19 care contracts as necessary to provide for a process, 1 20 under both the Medicaid fee=for=service and managed care 1 21 reimbursement and services delivery methodologies, for 1 22 reconsideration of a Medicaid member's supports intensity scale 1 23 (SIS) assessment score if a member, a member's authorized 1 24 representative, or a provider acting on behalf of the member 1 25 disputes the accuracy or adequacy of the assessment score. 1 26 The reconsideration process shall provide for an expedited 1 27 first=level review by the applicable Medicaid managed care 1 28 organization, followed by an appeals process in accordance 1 29 with contested case proceedings pursuant to chapter 17A if the 1 30 member, the member's authorized representative, or a provider 1 31 acting on behalf of the member is dissatisfied with the notice 1 32 of decision resulting from the managed care organization's 1 33 review. The rules adopted and the amendment to any Medicaid 1 34 managed care contract shall require that the expedited 1 35 first=level review be completed and the notice of decision 2 1 be issued by the managed care organization within 30 days of 2 2 receipt by the managed care organization of the request for 2 3 reconsideration. 2 4 3. The department of human services and all Medicaid managed 2 5 care organizations under contract with the state shall maintain 2 6 and update member eligibility files in a timely manner. 2 7 Medicaid providers who, in good faith, provide services to 2 8 members in accordance with service plans and reimbursement 2 9 agreements, shall not be denied payment for services rendered. 2 10 Additionally, under such circumstances, payments shall not be 2 11 recouped by the department or a managed care organization if, 2 12 subsequent to the provision of such services, the managed care 2 13 organization or the department determines that the member was 2 14 not eligible for such services and if the provider of services 2 15 is able to demonstrate, based on the information available to 2 16 the provider, that the services were authorized at the time 2 17 the services were rendered. The department of human services 2 18 shall adopt rules pursuant to chapter 17A and shall amend all 2 19 Medicaid managed care contracts to administer this subsection. 2 20 4. The department of human services shall adopt rules 2 21 pursuant to chapter 17A and shall amend all Medicaid managed 2 22 care contracts to provide that if a Medicaid member prevails in 2 23 a first=level review by the Medicaid managed care organization 2 24 or on appeal in an action regarding provision of services, the 2 25 services subject to the review or appeal shall be extended for 2 26 not less than six months following the date of the decision. 2 27 However, services shall not be extended if there is a change in 2 28 the member's condition that warrants a change in services as 2 29 determined by the member's interdisciplinary team, there is a 2 30 change in the member's eligibility status as determined by the 2 31 department, or the member voluntarily withdraws from services. 2 32 EXPLANATION 2 33 The inclusion of this explanation does not constitute agreement with 2 34 the explanation's substance by the members of the general assembly. 2 35 This bill relates to Medicaid managed care oversight. 3 1 With regard to network adequacy, the bill requires that the 3 2 network of long=term services and supports providers under 3 3 contract with each managed care organization (MCO) on January 3 4 1, 2018, shall be deemed necessary to meet the requirement 3 5 for network adequacy, and any willing provider under contract 3 6 on that date shall remain a network provider as long as the 3 7 network provider remains in compliance with Medicaid state plan 3 8 requirements for that provider. Additionally, the rates in 3 9 effect for each such provider on January 1, 2018, shall serve 3 10 as the rate floor for such provider through June 30, 2019, 3 11 unless the rate floors are amended or scheduled to be amended 3 12 by law. 3 13 With regard to supports intensity scale (SIS) assessments, 3 14 the bill requires provision of a process, under both Medicaid 3 15 fee=for=service and managed care for reconsideration of 3 16 a Medicaid member's SIS assessment score if a member, a 3 17 member's authorized representative, or a provider acting on 3 18 behalf of the member disputes the accuracy or adequacy of the 3 19 assessment score. The reconsideration process must provide 3 20 for an expedited first=level review by the applicable MCO 3 21 followed by an appeals process in accordance with contested 3 22 case proceedings if the member, the member's authorized 3 23 representative, or a provider acting on behalf of the member 3 24 is dissatisfied with the notice of decision resulting from 3 25 the MCO's review. The expedited first=level review must be 3 26 completed and the notice of decision must be issued by the MCO 3 27 within 30 days of receipt of the request for reconsideration. 3 28 With regard to Medicaid member eligibility, the bill 3 29 requires the department of human services (DHS) and all MCOs 3 30 under contract with the state to maintain and update member 3 31 eligibility files in a timely manner. Medicaid providers 3 32 who, in good faith, provide services to members in accordance 3 33 with service plans and reimbursement agreements shall not be 3 34 denied payment for services rendered. Additionally, under 3 35 such circumstances, DHS and the MCOs are prohibited from not 4 1 paying or recouping payments to such providers if, subsequent 4 2 to the provision of services, DHS or an MCO determines that the 4 3 member was not eligible for such services and if the provider 4 4 is able to demonstrate, based on the information available to 4 5 the provider, that the services were authorized at the time the 4 6 services were rendered. 4 7 With regard to member appeals regarding the provision of 4 8 services, the bill also requires that if a Medicaid member 4 9 prevails in a first=level review by the MCO or on appeal, the 4 10 services subject to the review or appeal must be extended for 4 11 not less than six months following the date of the decision. 4 12 However, the services are not required to be extended if there 4 13 is a change in the member's condition that warrants a change 4 14 in services as determined by the member's interdisciplinary 4 15 team, there is a change in the member's eligibility status as 4 16 determined by DHS, or the member voluntarily withdraws from 4 17 services. 4 18 With regard to each requirement or provision under the 4 19 bill, DHS is required to adopt administrative rules and amend 4 20 Medicaid managed care contracts to administer the requirement 4 21 or provision. 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