Bill Text: IA SF154 | 2021-2022 | 89th General Assembly | Introduced


Bill Title: A bill for an act relating to reimbursement of hospitals for days awaiting placement through private insurance and the Medicaid program.

Spectrum: Partisan Bill (Democrat 9-0)

Status: (Introduced) 2021-01-27 - Subcommittee: Costello, Edler, and Mathis. S.J. 173. [SF154 Detail]

Download: Iowa-2021-SF154-Introduced.html
Senate File 154 - Introduced SENATE FILE 154 BY MATHIS , RAGAN , KINNEY , J. SMITH , CELSI , GIDDENS , TRONE GARRIOTT , BOULTON , and QUIRMBACH A BILL FOR An Act relating to reimbursement of hospitals for days awaiting 1 placement through private insurance and the Medicaid 2 program. 3 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 4 TLSB 1100XS (3) 89 pf/rh
S.F. 154 Section 1. NEW SECTION . 514C.2A Days awaiting placement 1 in a hospital —— reimbursement. 2 1. For the purposes of this section: 3 a. “Days awaiting placement” means the days during which 4 a covered individual no longer meets acute care criteria for 5 stay in a hospital, has been verified to require placement in a 6 lower-level facility which may not be immediately located, and 7 is awaiting placement at the lower-level facility. 8 b. “Lower-level facility” means a facility that is able 9 to provide adequate, available, and accessible services and 10 supports, including but not limited to mental health services 11 and supports, to meet the covered individual’s needs as 12 specified in the covered individual’s discharge plan. 13 2. Notwithstanding the uniformity of treatment requirements 14 of section 514C.6, a policy, contract, or plan providing 15 for third-party payment or prepayment of health or medical 16 expenses that provides hospital benefits shall not deny 17 reimbursement for the continuation of all higher-level 18 services, including but not limited to inpatient care, provided 19 to a covered individual during a days awaiting placement 20 period. Reimbursement shall be provided to a hospital for each 21 day a covered individual remains in the care of the hospital 22 while awaiting placement in a lower-level facility. 23 3. For a hospital to receive days awaiting placement 24 reimbursement under this section, all of the following criteria 25 must be met: 26 a. The covered individual has a diagnosed condition that 27 required an acute inpatient level of care. 28 b. The covered individual no longer meets continued 29 stay criteria for the acute inpatient level of care and 30 requires placement in a lower-level facility, but barriers to 31 implementation of the discharge plan exist that are beyond the 32 control of the hospital. 33 c. The carrier as defined in section 513B.2 has authorized 34 placement in the lower-level facility sought under the 35 -1- LSB 1100XS (3) 89 pf/rh 1/ 5
S.F. 154 discharge plan. 1 d. The hospital is making every reasonable effort to 2 continue to actively work to identify resources to implement 3 the discharge plan in a timely manner and documents the 4 reasonable efforts taken. 5 4. This section applies to the following classes of 6 third-party payment provider policies, contracts, or plans 7 delivered, issued for delivery, continued, or renewed in this 8 state on or after January 1, 2022: 9 a. Individual or group accident and sickness insurance 10 providing coverage on an expense-incurred basis. 11 b. An individual or group hospital or medical service 12 contract issued pursuant to chapter 509, 514, or 514A. 13 c. An individual or group health maintenance organization 14 contract regulated under chapter 514B. 15 d. A plan established pursuant to chapter 509A for public 16 employees. 17 5. This section shall not apply to accident-only, specified 18 disease, short-term hospital or medical, hospital confinement 19 indemnity, credit, dental, vision, Medicare supplement, 20 long-term care, basic hospital and medical-surgical expense 21 coverage as defined by the commissioner of insurance, 22 disability income insurance coverage, coverage issued as a 23 supplement to liability insurance, workers’ compensation or 24 similar insurance, or automobile medical payment insurance. 25 6. This section shall not apply to the medical assistance 26 program pursuant to chapter 249A, including to a managed care 27 organization acting pursuant to a contract with the department 28 of human services to provide coverage to medical assistance 29 program members, or to the hawk-i program pursuant to chapter 30 514I. 31 7. The commissioner of insurance may adopt rules pursuant to 32 chapter 17A as necessary to administer this section. 33 Sec. 2. DAYS AWAITING PLACEMENT —— MEDICAID REIMBURSEMENT. 34 1. Under both fee-for-service and managed care 35 -2- LSB 1100XS (3) 89 pf/rh 2/ 5
S.F. 154 administration of the Medicaid program, a hospital shall not 1 be denied reimbursement based on failure to meet medical 2 necessity for the continuation of all higher-level services, 3 including but not limited to inpatient care, provided to a 4 Medicaid-eligible member during a days awaiting placement 5 period. Reimbursement shall be provided to a hospital for 6 each day a Medicaid-eligible member remains in the care of the 7 hospital while awaiting placement in a lower-level facility. 8 2. For a hospital to receive days awaiting placement 9 reimbursement under this section, all of the following criteria 10 must be met: 11 a. The Medicaid-eligible member has a diagnosed condition 12 that required an acute inpatient level of care. 13 b. The Medicaid-eligible member no longer meets continued 14 stay criteria for the acute inpatient level of care and 15 requires placement in a lower-level facility, but barriers to 16 implementation of the discharge plan exist that are beyond the 17 control of the hospital. 18 c. The department of human services or managed care 19 organization has authorized placement in the lower-level 20 facility sought under the discharge plan. 21 d. The hospital is making every reasonable effort to 22 continue to actively work to identify resources to implement 23 the discharge plan in a timely manner and documents the 24 reasonable efforts taken. However, if the Medicaid-eligible 25 member is covered through a managed care organization, the 26 managed care organization, rather than the hospital, shall 27 be responsible for identifying and obtaining the lower-level 28 facility placement. 29 3. For the purposes of this section: 30 a. “Days awaiting placement” means the days during which a 31 Medicaid-eligible member no longer meets acute care criteria 32 for stay in a hospital, has been verified to require placement 33 in a lower-level facility which may not be immediately located, 34 and is awaiting placement at the lower-level facility. 35 -3- LSB 1100XS (3) 89 pf/rh 3/ 5
S.F. 154 b. “Lower-level facility” means a facility that is able 1 to provide adequate, available, and accessible services and 2 supports, including but not limited to mental health services 3 and supports, to meet the Medicaid-eligible member’s needs as 4 specified in the member’s discharge plan. 5 4. The department of human services shall adopt rules 6 pursuant to chapter 17A to administer this section. 7 EXPLANATION 8 The inclusion of this explanation does not constitute agreement with 9 the explanation’s substance by the members of the general assembly. 10 This bill relates to reimbursement for services provided by 11 a hospital during a days awaiting placement period. 12 The bill provides that under private insurance and 13 fee-for-service and managed care administration of Medicaid, a 14 hospital shall not be denied reimbursement for the continuation 15 of all higher-level services, including but not limited 16 to inpatient care, provided to a covered individual or 17 Medicaid-eligible member, respectively, during a days awaiting 18 placement period. Reimbursement shall be provided to a 19 hospital for each day a covered individual or Medicaid-eligible 20 member remains in the care of the hospital while awaiting 21 placement in a lower-level facility. 22 The bill defines ”days awaiting placement” as the days 23 during which a covered individual or Medicaid-eligible member 24 no longer meets acute care criteria for stay in a hospital, has 25 been verified to require placement in a lower-level facility 26 which may not be immediately located, and is awaiting placement 27 at the lower-level facility. “Lower-level facility” is defined 28 as a facility that is able to provide adequate, available, and 29 accessible services and supports, including but not limited 30 to mental health services and supports, to meet a covered 31 individual’s or Medicaid-eligible member’s needs as specified 32 in the covered individual’s or Medicaid-eligible member’s 33 discharge plan. 34 The bill provides the criteria that must be met by a hospital 35 -4- LSB 1100XS (3) 89 pf/rh 4/ 5
S.F. 154 to receive reimbursement and requires the department of human 1 services and the commissioner or insurance, respectively, to 2 adopt administrative rules to administer the bill. 3 -5- LSB 1100XS (3) 89 pf/rh 5/ 5
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