Bill Text: IA SF2107 | 2015-2016 | 86th General Assembly | Introduced
Bill Title: A bill for an act relating to Medicaid program improvement, and including effective date and retroactive applicability provisions. (See SF 2213.)
Spectrum: Partisan Bill (Democrat 3-0)
Status: (Introduced - Dead) 2016-02-15 - Returned to committee. [SF2107 Detail]
Download: Iowa-2015-SF2107-Introduced.html
Senate File 2107 - Introduced SENATE FILE BY RAGAN, MATHIS, and BOLKCOM A BILL FOR 1 An Act relating to Medicaid program improvement, and including 2 effective date and retroactive applicability provisions. 3 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: TLSB 5711XS (27) 86 pf/nh PAG LIN 1 1 Section 1. LEGISLATIVE FINDINGS == GOALS AND INTENT. 1 2 1. The general assembly finds all of the following: 1 3 a. In the majority of states, Medicaid managed care has 1 4 been introduced on an incremental basis, beginning with the 1 5 enrollment of low=income children and parents and proceeding 1 6 in stages to include nonelderly persons with disabilities and 1 7 older individuals. Iowa, unlike the majority of states, is 1 8 implementing Medicaid managed care hastily and simultaneously 1 9 across a broad and diverse population that includes individuals 1 10 with complex health care and long=term services and supports 1 11 needs, making these individuals especially vulnerable to 1 12 receiving inappropriate, inadequate, or substandard services 1 13 and supports. 1 14 b. The success or failure of Medicaid managed care in Iowa 1 15 depends on proper strategic planning and strong oversight, and 1 16 the incorporation of the core values, principles, and goals 1 17 of the strategic plan into Medicaid managed care contractual 1 18 obligations. While Medicaid managed care techniques may create 1 19 pathways and offer opportunities toward quality improvement and 1 20 predictability in costs, if cost savings and administrative 1 21 efficiencies are the primary goals, Medicaid managed care may 1 22 instead erect new barriers and limit the care and support 1 23 options available, especially to high=need, vulnerable Medicaid 1 24 recipients. A well=designed strategic plan and effective 1 25 oversight ensure that cost savings, improved health outcomes, 1 26 and efficiencies are not achieved at the expense of diminished 1 27 program integrity, a reduction in the quality or availability 1 28 of services, or adverse consequences to the health and 1 29 well=being of Medicaid recipients. 1 30 c. Strategic planning should include all of the following: 1 31 (1) Guidance in establishing and maintaining a robust 1 32 and appropriate workforce and a provider network capable of 1 33 addressing all of the diverse, distinct, and wide=ranging 1 34 treatment and support needs of Medicaid recipients. 1 35 (2) Developing a sound methodology for establishing and 2 1 adjusting capitation rates to account for all essential costs 2 2 involved in treating and supporting the entire spectrum of 2 3 needs across recipient populations. 2 4 (3) Addressing the sufficiency of information and data 2 5 resources to enable review of factors such as utilization, 2 6 service trends, system performance, and outcomes. 2 7 (4) Building effective working relationships and developing 2 8 strategies to support community=level integration that provides 2 9 cross=system coordination and synchronization among the various 2 10 service sectors, providers, agencies, and organizations to 2 11 further holistic well=being and population health goals. 2 12 d. While the contracts entered into between the state 2 13 and managed care organizations function as a mechanism for 2 14 enforcing requirements established by the federal and state 2 15 governments and allow states to shift the financial risk 2 16 associated with caring for Medicaid recipients to these 2 17 contractors, the state ultimately retains responsibility for 2 18 the Medicaid program and the oversight of the performance of 2 19 the program's contractors. Administration of the Medicaid 2 20 program benefits by managed care organizations should not be 2 21 viewed by state policymakers and state agencies as a means of 2 22 divesting themselves of their constitutional and statutory 2 23 responsibilities to ensure that recipients of publicly funded 2 24 services and supports, as well as taxpayers in general, are 2 25 effectively served. 2 26 e. Overseeing the performance of Medicaid managed care 2 27 contractors requires a different set of skills than those 2 28 required for administering a fee=for=service program. In the 2 29 absence of the in=house capacity of the department of human 2 30 services to perform tasks specific to Medicaid managed care 2 31 oversight, the state essentially cedes its responsibilities 2 32 to private contractors and relinquishes its accountability 2 33 to the public. In order to meet these responsibilities, 2 34 state policymakers must ensure that the state, including the 2 35 department of human services as the state Medicaid agency, has 3 1 the authority and resources, including the adequate number of 3 2 qualified personnel and the necessary tools, to carry out these 3 3 responsibilities, provide effective administration, and ensure 3 4 accountability and compliance. 3 5 f. State policymakers must also ensure that Medicaid 3 6 managed care contracts contain, at a minimum, clear, 3 7 unambiguous performance standards, operating guidelines, 3 8 data collection, maintenance, retention, and reporting 3 9 requirements, and outcomes expectations so that contractors 3 10 and subcontractors are held accountable to clear contract 3 11 specifications. 3 12 g. As with all system and program redesign efforts 3 13 undertaken in the state to date, the assumption of the 3 14 administration of Medicaid program benefits by managed care 3 15 organizations must involve ongoing stakeholder input and 3 16 earn the trust and support of these stakeholders. Medicaid 3 17 recipients, providers, advocates, and other stakeholders have 3 18 intimate knowledge of the people and processes involved in 3 19 ensuring the health and safety of Medicaid recipients, and are 3 20 able to offer valuable insight into the barriers likely to be 3 21 encountered as well as propose solutions for overcoming these 3 22 obstacles. Local communities and providers of services and 3 23 supports have firsthand experience working with the Medicaid 3 24 recipients they serve and are able to identify factors that 3 25 must be considered to make a system successful. Agencies and 3 26 organizations that have specific expertise and experience with 3 27 the services and supports needs of Medicaid recipients and 3 28 their families are uniquely placed to provide needed assistance 3 29 in developing the measures for and in evaluating the quality 3 30 of the program. 3 31 2. It is the intent of the general assembly that the 3 32 Medicaid program be implemented and administered, including 3 33 through Medicaid managed care policies and contract provisions, 3 34 in a manner that safeguards the interests of Medicaid 3 35 recipients, encourages the participation of Medicaid providers, 4 1 and protects the interests of all taxpayers, while attaining 4 2 the goals of Medicaid modernization to improve quality and 4 3 access, promote accountability for outcomes, and create a more 4 4 predictable and sustainable Medicaid budget. 4 5 REVIEW OF PROGRAM INTEGRITY DUTIES 4 6 Sec. 2. REVIEW OF PROGRAM INTEGRITY DUTIES == WORKGROUP == 4 7 REPORT. 4 8 1. The director of human services shall convene a 4 9 workgroup comprised of members including the commissioner 4 10 of insurance, the auditor of state, the Medicaid director 4 11 and bureau chiefs of the managed care organization oversight 4 12 and supports bureau, the Iowa Medicaid enterprise support 4 13 bureau, and the medical and long=term services and supports 4 14 bureau, and a representative of the program integrity unit, 4 15 or their designees; and representatives of other appropriate 4 16 state agencies or other entities including but not limited to 4 17 the office of the attorney general, the office of long=term 4 18 care ombudsman, and the Medicaid fraud control unit of the 4 19 investigations division of the department of inspections and 4 20 appeals. The workgroup shall do all of the following: 4 21 a. Review the duties of each entity with responsibilities 4 22 relative to Medicaid program integrity and managed care 4 23 organizations; review state and federal laws, regulations, 4 24 requirements, guidance, and policies relating to Medicaid 4 25 program integrity and managed care organizations; and review 4 26 the laws of other states relating to Medicaid program integrity 4 27 and managed care organizations. The workgroup shall determine 4 28 areas of duplication, fragmentation, and gaps; shall identify 4 29 possible integration, collaboration and coordination of duties; 4 30 and shall determine whether existing general state Medicaid 4 31 program and fee=for=service policies, laws, and rules are 4 32 sufficient, or if changes or more specific policies, laws, and 4 33 rules are required to provide for comprehensive and effective 4 34 administration and oversight of the Medicaid program. 4 35 b. Review historical uses of the Medicaid fraud fund created 5 1 in section 249A.50 and make recommendations for future uses 5 2 of the moneys in the fund and any changes in law necessary to 5 3 adequately address program integrity. 5 4 c. Review medical loss ratio provisions relative to 5 5 Medicaid managed care contracts and make recommendations 5 6 regarding, at a minimum, requirements for the necessary 5 7 collection, maintenance, retention, reporting, and sharing of 5 8 data and information by Medicaid managed care organizations 5 9 for effective determination of compliance, and to identify 5 10 the costs and activities that should be included in the 5 11 calculation of administrative costs, medical costs or benefit 5 12 expenses, health quality improvement costs, and other costs and 5 13 activities incidental to the determination of a medical loss 5 14 ratio. 5 15 d. Review the capacity of state agencies, including the need 5 16 for specialized training and expertise, to address Medicaid 5 17 and managed care organization program integrity and provide 5 18 recommendations for the provision of necessary resources and 5 19 infrastructure, including annual budget projections. 5 20 e. Review the incentives and penalties applicable to 5 21 violations of program integrity requirements to determine their 5 22 adequacy in combating waste, fraud, abuse, and other violations 5 23 that divert limited resources that would otherwise be expended 5 24 to safeguard the health and welfare of Medicaid recipients, 5 25 and make recommendations for necessary adjustments to improve 5 26 compliance. 5 27 f. Make recommendations regarding the quarterly and annual 5 28 auditing of financial reports required to be performed for 5 29 each Medicaid managed care organization to ensure that the 5 30 activities audited provide sufficient information to the 5 31 division of insurance of the department of commerce and the 5 32 department of human services to ensure program integrity. The 5 33 recommendations shall also address the need for additional 5 34 audits or other reviews of managed care organizations. 5 35 2. The department of human services shall submit a report 6 1 of the workgroup to the governor and the general assembly 6 2 on or before November 15, 2016, to provide findings and 6 3 recommendations for a coordinated approach to comprehensive and 6 4 effective administration and oversight of the Medicaid program. 6 5 MEDICAID REINVESTMENT FUND 6 6 Sec. 3. NEW SECTION. 249A.4C Medicaid reinvestment fund. 6 7 1. A Medicaid reinvestment fund is created in the state 6 8 treasury under the authority of the department. Moneys from 6 9 savings realized from the movement of Medicaid recipients from 6 10 institutional settings to home and community=based services, 6 11 the portion of the capitation rate withheld from and not 6 12 returned to Medicaid managed care organizations at the end 6 13 of each fiscal year, any recouped excess of capitation rates 6 14 paid to Medicaid managed care organizations, any overpayments 6 15 recovered under Medicaid managed care contracts, and any other 6 16 savings realized from Medicaid managed care or from Medicaid 6 17 program cost=containment efforts, shall be credited to the 6 18 Medicaid reinvestment fund. 6 19 2. Notwithstanding section 8.33, moneys credited to 6 20 the fund from any other account or fund shall not revert to 6 21 the other account or fund. Moneys in the fund shall only 6 22 be used as provided in appropriations from the fund for 6 23 the Medicaid program and for health system transformation 6 24 and integration, including but not limited to providing 6 25 the necessary infrastructure and resources to protect the 6 26 interests of Medicaid recipients, maintaining adequate provider 6 27 participation, and ensuring program integrity. Such uses may 6 28 include but are not limited to: 6 29 a. Ensuring appropriate reimbursement of Medicaid 6 30 providers to maintain the type and number of appropriately 6 31 trained providers necessary to address the needs of Medicaid 6 32 recipients. 6 33 b. Providing home and community=based services as necessary 6 34 to rebalance the long=term services and supports infrastructure 6 35 and to reduce Medicaid home and community=based services waiver 7 1 waiting lists. 7 2 c. Ensuring that a fully functioning independent long=term 7 3 services and supports ombudsman program is available to provide 7 4 advocacy services and assistance to Medicaid recipients. 7 5 d. Ensuring adequate and appropriate capacity of the 7 6 department of human services as the single state agency 7 7 designated to administer and supervise the administration of 7 8 the Medicaid program, to ensure compliance with state and 7 9 federal law and program integrity requirements. 7 10 e. Addressing workforce issues to ensure a competent, 7 11 diverse, and sustainable health care workforce and to 7 12 improve access to health care in underserved areas and among 7 13 underserved populations, recognizing long=term services and 7 14 supports as an essential component of the health care system. 7 15 f. Supporting innovation, longer=term community 7 16 investments, and the activities of local public health 7 17 agencies, aging and disability resource centers and service 7 18 agencies, mental health and disability services regions, social 7 19 services, and child welfare entities and other providers of 7 20 and advocates for services and supports to encourage health 7 21 system transformation and integration through a broad range of 7 22 prevention strategies and population=based approaches to meet 7 23 the holistic needs of the population as a whole. 7 24 3. The department shall establish a mechanism to measure and 7 25 certify the amount of savings resulting from Medicaid managed 7 26 care and Medicaid program cost=containment activities and shall 7 27 ensure that such realized savings are credited to the fund and 7 28 used as provided in appropriations from the fund. 7 29 LONG=TERM SERVICES AND SUPPORTS OMBUDSMAN 7 30 Sec. 4. Section 231.44, subsection 1, Code 2016, is amended 7 31 by adding the following new paragraphs: 7 32 NEW PARAGRAPH. d. Accessing the results of a review 7 33 of a level of care or a needs=based eligibility assessment 7 34 or reassessment by a managed care organization in which 7 35 the managed care organization recommends denial or limited 8 1 authorization of a service, including the type or level 8 2 of service, the reduction, suspension, or termination of a 8 3 previously authorized service, or a change in level of care, 8 4 upon the request of the individual receiving long=term services 8 5 and supports. 8 6 NEW PARAGRAPH. e. Receiving and reviewing for Medicaid 8 7 recipients who receive long=term services and supports notices 8 8 of disenrollment from a managed care organization or notices 8 9 that would result in a change in such recipient's level of care 8 10 setting, including involuntary and voluntary discharges or 8 11 transfers of a recipient. 8 12 Sec. 5. Section 231.44, Code 2016, is amended by adding the 8 13 following new subsections: 8 14 NEW SUBSECTION. 3A. The office of long=term care ombudsman 8 15 and representatives of the office, when providing assistance 8 16 and advocacy services authorized under this section, shall be 8 17 considered a health oversight agency as defined in 45 C.F.R. 8 18 {164.501 for the purposes of health oversight activities 8 19 as described in 45 C.F.R. {164.512(d) including access to 8 20 Medicaid recipients' health records and other appropriate 8 21 information, including from the department of human services 8 22 or the applicable Medicaid managed care organization, as 8 23 necessary to fulfill the duties specified under this section. 8 24 The department of human services, in collaboration with the 8 25 office of long=term care ombudsman, shall adopt rules to ensure 8 26 compliance by affected entities with this subsection and to 8 27 ensure recognition of the office of long=term care ombudsman 8 28 as a duly authorized and identified agent or representative of 8 29 the state. 8 30 NEW SUBSECTION. 3B. The department of human services and 8 31 Medicaid managed care organizations shall inform Medicaid 8 32 recipients of the advocacy services and assistance available 8 33 through the office of long=term care ombudsman and shall 8 34 provide contact and other information regarding the advocacy 8 35 services and assistance to Medicaid recipients as directed by 9 1 the office of long=term care ombudsman. 9 2 NEW SUBSECTION. 3C. The office of long=term care ombudsman 9 3 shall act as an independent agency in providing advocacy 9 4 services and assistance under this section. The office of 9 5 long=term care ombudsman shall, in addition to other duties 9 6 prescribed and, at a minimum, do all of the following in 9 7 the furtherance of the provision of advocacy services and 9 8 assistance under this section: 9 9 a. Represent the interests of Medicaid program recipients 9 10 before governmental agencies and seek administrative, legal, 9 11 and other remedies for the recipient. 9 12 b. Analyze, comment on, and monitor the development and 9 13 implementation of federal, state, and local laws, regulations, 9 14 and other governmental policies and actions, and recommend 9 15 any changes in such laws, policies, and actions as determined 9 16 appropriate by the office of long=term care ombudsman. 9 17 Sec. 6. NEW SECTION. 231.44A Willful interference with 9 18 duties related to long=term services and supports == penalty. 9 19 Willful interference with a representative of the office of 9 20 long=term care ombudsman in the performance of official duties 9 21 in accordance with section 231.44 is a violation of section 9 22 231.44, subject to a penalty prescribed by rule. The office 9 23 of long=term care ombudsman shall adopt rules specifying the 9 24 amount of a penalty imposed, consistent with the penalties 9 25 imposed under section 231.42, subsection 8, and specifying 9 26 procedures for notice and appeal of penalties imposed. Any 9 27 moneys collected pursuant to this section shall be deposited in 9 28 the Medicaid reinvestment fund created in section 249A.4C. 9 29 MEDICAL ASSISTANCE ADVISORY COUNCIL 9 30 Sec. 7. Section 249A.4B, subsection 1, Code 2016, is amended 9 31 to read as follows: 9 32 1. A medical assistance advisory council is created to 9 33 comply with 42 C.F.R. {431.12 based on section 1902(a)(4) of 9 34 the federal Social Security Act and to advise the director 9 35 about health and medical care services under the medical 10 1 assistance program. The council shall meetno more thanat 10 2 least quarterly. The director of public health shall serve as 10 3 chairperson of the council. 10 4 Sec. 8. Section 249A.4B, subsection 2, paragraph b, Code 10 5 2016, is amended to read as follows: 10 6 b. Public representatives which may include members of 10 7 consumer groups, including recipients of medical assistance or 10 8 their families, consumer organizations, and others, which shall 10 9 be appointed by the governor in equalinnumber to the number 10 10 of representatives of the professional and business entities 10 11 specifically represented under paragraph "a",appointed by the 10 12 governorfor staggered terms of two years each, none of whom 10 13 shall be members of, or practitioners of, or have a pecuniary 10 14 interest in any of the professional or business entities 10 15 specifically represented under paragraph "a", and a majority 10 16 of whom shall be current or former recipients of medical 10 17 assistance or members of the families of current or former 10 18 recipients. 10 19 Sec. 9. Section 249A.4B, subsection 2, Code 2016, is amended 10 20 by adding the following new paragraph: 10 21 NEW PARAGRAPH. 0g. The state long=term care ombudsman or 10 22 the ombudsman's designee. 10 23 Sec. 10. Section 249A.4B, subsection 3, paragraph a, Code 10 24 2016, is amended by adding the following new subparagraph: 10 25 NEW SUBPARAGRAPH. (4) The state long=term care ombudsman or 10 26 the ombudsman's designee. 10 27 Sec. 11. Section 249A.4B, subsection 3, paragraph c, Code 10 28 2016, is amended to read as follows: 10 29 c. Based upon the deliberations of the council,andthe 10 30 executive committee, and the subcommittees, the executive 10 31 committee and the subcommittees, respectively, shall make 10 32 recommendations to the director regarding the budget, policy, 10 33 and administration of the medical assistance program. 10 34 Sec. 12. Section 249A.4B, Code 2016, is amended by adding 10 35 the following new subsections: 11 1 NEW SUBSECTION. 3A. a. The council shall create 11 2 the following subcommittees, and may create additional 11 3 subcommittees as necessary to address medical assistance 11 4 program policies, administration, budget, and other factors and 11 5 issues: 11 6 (1) The stakeholder safeguards subcommittee, for which 11 7 the co=chairpersons shall be a member of the council who is a 11 8 current recipient or family member of a recipient of medical 11 9 assistance or who represents a consumer advocacy entity, and a 11 10 member of the council who represents a professional or business 11 11 entity, both selected by the executive committee. The mission 11 12 of the stakeholder safeguards subcommittee is to provide for 11 13 ongoing stakeholder engagement and feedback on issues affecting 11 14 Medicaid recipients, providers, and other stakeholders. 11 15 (2) The long=term services and supports subcommittee 11 16 which shall be chaired by the state long=term care ombudsman, 11 17 or the ombudsman's designee. The mission of the long=term 11 18 services and supports subcommittee is to be a resource for 11 19 the council and advise the department on policy development 11 20 and program administration relating to Medicaid long=term 11 21 services and support including but not limited to developing 11 22 outcomes and performance measures for Medicaid managed care 11 23 for the long=term services and supports population; addressing 11 24 issues related to home and community=based services waivers and 11 25 waiting lists; and reviewing the system of long=term services 11 26 and supports to ensure provision of home and community=based 11 27 services and the rebalancing of the health care infrastructure 11 28 in accordance with state and federal law including but not 11 29 limited to the principles established in Olmstead v. L.C., 527 11 30 U.S. 581 (1999) and the federal Americans with Disabilities Act 11 31 and in a manner that reflects a sustainable, person=centered 11 32 approach to improve health and life outcomes, supports 11 33 maximum independence, addresses medical and social needs in a 11 34 coordinated, integrated manner, and provides for sufficient 11 35 resources including a stable, well=qualified workforce. 12 1 (3) The transparency, data, and program evaluation 12 2 subcommittee which shall be chaired by the director of the 12 3 university of Iowa public policy center, or the director's 12 4 designee. The mission of the transparency, data, and program 12 5 evaluation subcommittee is to ensure Medicaid program 12 6 transparency; ensure the collection, maintenance, retention, 12 7 reporting, and analysis of sufficient and meaningful data 12 8 to inform policy development and program effectiveness; 12 9 support development and administration of a consumer=friendly 12 10 dashboard; and promote the ongoing evaluation of Medicaid 12 11 recipient and provider satisfaction with the Medicaid program. 12 12 (4) The program integrity subcommittee which shall be 12 13 chaired by the Medicaid director, or the director's designee. 12 14 The mission of the program integrity subcommittee is to ensure 12 15 that a comprehensive system including specific policies, laws, 12 16 and rules and adequate resources and measures are in place to 12 17 effectively administer the program and to maintain compliance 12 18 with federal and state program integrity requirements. 12 19 b. The chairperson of the council shall appoint members to 12 20 each subcommittee from the general membership of the council. 12 21 Consideration in appointing subcommittee members shall include 12 22 the individual's knowledge about, and interest or expertise in, 12 23 matters that come before the subcommittee. 12 24 c. Subcommittees shall meet at the call of the chairperson 12 25 of the subcommittee or at the request of a majority of the 12 26 members of the subcommittee. 12 27 NEW SUBSECTION. 7. The council, executive committee, and 12 28 subcommittees shall jointly submit a report to the governor and 12 29 the general assembly by January 1, annually, summarizing the 12 30 outcomes and findings of their respective deliberations and any 12 31 recommendations including but not limited to those for changes 12 32 in law or policy. 12 33 NEW SUBSECTION. 8. The council, executive committee, 12 34 and subcommittees may enlist the services of persons who are 12 35 qualified by education, expertise, or experience to advise, 13 1 consult with, or otherwise assist the council, executive 13 2 committee, or subcommittees in the performance of their 13 3 duties. The council, executive committee, or subcommittees 13 4 may specifically enlist the assistance of entities such as the 13 5 university of Iowa public policy center to provide ongoing 13 6 evaluation of the Medicaid program and to make evidence=based 13 7 recommendations to improve the program. The council, executive 13 8 committee, and subcommittees shall enlist input from the 13 9 patient=centered health advisory council created in section 13 10 135.159, the mental health and disabilities services commission 13 11 created in section 225C.5, the commission on aging created in 13 12 section 231.11, the bureau of substance abuse of the department 13 13 of public health, and other appropriate state and local 13 14 entities to provide advice to the council, executive committee, 13 15 and subcommittees. 13 16 Sec. 13. Section 249A.4B, subsections 4, 5, and 6, Code 13 17 2016, are amended to read as follows: 13 18 4. For each council meeting, other than those held during 13 19 the time the general assembly is in session, each legislative 13 20 member of the council shall be reimbursed for actual travel 13 21 and other necessary expenses and shall receive a per diem as 13 22 specified in section 7E.6 for each day in attendance, as shall 13 23 the members of the council,orthe executive committee, or 13 24 a subcommittee who are recipients or the family members of 13 25 recipients of medical assistance, regardless of whether the 13 26 general assembly is in session. 13 27 5. The department shall provide staff support and 13 28 independent technical assistance to the council,andthe 13 29 executive committee, and the subcommittees. 13 30 6. The director shall consider the recommendations 13 31 offered by the council,andthe executive committee, and 13 32 the subcommittees in the director's preparation of medical 13 33 assistance budget recommendations to the council on human 13 34 services pursuant to section 217.3 and in implementation of 13 35 medical assistance program policies. 14 1 HEALTH RESOURCES AND INFRASTRUCTURE 14 2 Sec. 14. PATIENT=CENTERED HEALTH ADVISORY COUNCIL == 14 3 ASSESSMENT OF HEALTH RESOURCES AND INFRASTRUCTURE. 14 4 1. The patient=centered health advisory council created 14 5 in section 135.159 shall assess the capacity of the health 14 6 care infrastructure and resources in the state and recommend 14 7 more appropriate alignment with broad systems changes, the 14 8 increasing array of care delivery models such as the expansion 14 9 of Medicaid managed care, accountable care organizations, and 14 10 public health modernization, and a more integrated, holistic, 14 11 prevention=based and population=based approach to health and 14 12 health care. The assessment shall also address the sufficiency 14 13 and proficiency of the existing health=related workforce and 14 14 the potential of braiding and blending funding streams to 14 15 support the holistic needs of the population. 14 16 2. Initially, the council shall do all of the following: 14 17 a. Assess the potential for integration and coordination 14 18 of various service delivery sectors including public health, 14 19 aging and disability services agencies, mental health and 14 20 disability services regions, social services, child welfare, 14 21 and other such sectors and shall make recommendations for 14 22 such integration and coordination to more efficiently and 14 23 effectively address consumer needs. 14 24 b. Assess funding streams, including Medicaid funding, 14 25 and make recommendations to blend or braid funding to support 14 26 prevention and population health strategies in addressing the 14 27 holistic well=being of consumers. 14 28 c. Assess current and projected health workforce 14 29 availability to determine the most efficient application 14 30 and utilization of the roles, functions, responsibilities, 14 31 activities, and decision=making capacity of health care 14 32 professionals and other allied and support personnel, and make 14 33 recommendations for improvement and alternative modes of health 14 34 care delivery. 14 35 3. The council shall submit a report of its findings and 15 1 recommendations regarding the initial assessments specified 15 2 in subsection 2 to the governor and the general assembly by 15 3 January 1, 2017. The council shall submit subsequent reports 15 4 relating to additional assessments of and recommendations 15 5 relating to the health care infrastructure and resources on or 15 6 before January 1, annually, thereafter. 15 7 MEDICAID PROGRAM POLICY IMPROVEMENT 15 8 Sec. 15. DIRECTIVES FOR MEDICAID PROGRAM POLICY 15 9 IMPROVEMENTS. In order to safeguard the interests of Medicaid 15 10 recipients, encourage the participation of Medicaid providers, 15 11 and protect the interests of all taxpayers, the department of 15 12 human services shall comply with or ensure that the specified 15 13 entity complies with all of the following and shall amend 15 14 Medicaid managed care contract provisions as necessary to 15 15 reflect all of the following: 15 16 1. CONSUMER PROTECTIONS. 15 17 a. In accordance with 42 C.F.R. {438.420, a Medicaid managed 15 18 care organization shall continue a recipient's benefits during 15 19 an appeal process. If, as allowed when final resolution of 15 20 an appeal is adverse to the Medicaid recipient, the Medicaid 15 21 managed care organization chooses to recover the costs of the 15 22 services furnished to the recipient while an appeal is pending, 15 23 the Medicaid managed care organization shall provide adequate 15 24 prior notice of potential recovery of costs to the recipient at 15 25 the time the appeal is filed, and any costs recovered shall be 15 26 remitted to the department of human services and deposited in 15 27 the Medicaid reinvestment fund created in section 249A.4C. 15 28 b. Ensure that each Medicaid managed care organization 15 29 provides, at a minimum, all the benefits and services deemed 15 30 medically necessary that were covered, including to the 15 31 extent and in the same manner and subject to the same prior 15 32 authorization criteria, by the state program directly under 15 33 fee for service prior to January 1, 2016. Benefits covered 15 34 through Medicaid managed care shall comply with the specific 15 35 requirements in state law applicable to the respective Medicaid 16 1 recipient population under fee for service. 16 2 c. Enhance monitoring of the reduction in or suspension 16 3 or termination of services provided to Medicaid recipients, 16 4 including reductions in the provision of home and 16 5 community=based services waiver services or increases in home 16 6 and community=based services waiver waiting lists. Medicaid 16 7 managed care organizations shall provide data to the department 16 8 as necessary for the department to compile periodic reports on 16 9 the numbers of individuals transferred from state institutions 16 10 and long=term care facilities to home and community=based 16 11 services, and the associated savings. Any savings resulting 16 12 from the transfers as certified by the department shall be 16 13 deposited in the Medicaid reinvestment fund created in section 16 14 249A.4C. 16 15 d. (1) Require each Medicaid managed care organization to 16 16 adhere to reasonableness and service authorization standards 16 17 that are appropriate for and do not disadvantage those 16 18 individuals who have ongoing chronic conditions or who require 16 19 long=term services and supports. Services and supports for 16 20 individuals with ongoing chronic conditions or who require 16 21 long=term services and supports shall be authorized in a manner 16 22 that reflects the recipient's continuing need for such services 16 23 and supports, and limits shall be consistent with a recipient's 16 24 current needs assessment and person=centered service plan. 16 25 (2) In addition to other provisions relating to 16 26 community=based case management continuity of care 16 27 requirements, Medicaid managed care contractors shall provide 16 28 the option to the case manager of a Medicaid recipient who 16 29 retained the case manager during the six months of transition 16 30 to Medicaid managed care, if the recipient chooses to continue 16 31 to retain that case manager beyond the six=month transition 16 32 period and if the case manager is not otherwise a participating 16 33 provider of the recipient's managed care organization provider 16 34 network, to enter into a single case agreement to continue to 16 35 provide case management services to the Medicaid recipient. 17 1 e. Ensure that Medicaid recipients are provided care 17 2 coordination and case management by appropriately trained 17 3 professionals in a conflict=free manner. Care coordination and 17 4 case management shall be provided in a patient=centered and 17 5 family=centered manner that requires a knowledge of community 17 6 supports, a reasonable ratio of care coordinators and case 17 7 managers to Medicaid recipients, standards for frequency of 17 8 contact with the Medicaid recipient, and specific and adequate 17 9 reimbursement. 17 10 f. A Medicaid managed care contract shall include a 17 11 provision for continuity and coordination of care for a 17 12 consumer transitioning to Medicaid managed care, including 17 13 maintaining existing provider=recipient relationships and 17 14 honoring the amount, duration, and scope of a recipient's 17 15 authorized services based on the recipient's medical history 17 16 and needs. In the initial transition to Medicaid managed care, 17 17 to ensure the least amount of disruption, Medicaid managed 17 18 care organizations shall provide, at a minimum, a one=year 17 19 transition of care period for all provider types, regardless 17 20 of network status with an individual Medicaid managed care 17 21 organization. 17 22 g. Ensure that a Medicaid managed care organization does 17 23 not arbitrarily deny coverage for medically necessary services 17 24 based solely on financial reasons. 17 25 h. Ensure that dental coverage, if not integrated into 17 26 an overall Medicaid managed care contract, is part of the 17 27 overall holistic, integrated coverage for physical, behavioral, 17 28 and long=term services and supports provided to a Medicaid 17 29 recipient. 17 30 i. Require each Medicaid managed care organization to 17 31 collect, maintain, retain, and share data as necessary to 17 32 inform monitoring activities including but not limited to 17 33 verifying the offering and actual utilization of services and 17 34 supports and value=added services, an individual recipient's 17 35 encounters and the costs associated with each encounter, and 18 1 requests and associated approvals or denials of services. 18 2 Verification of actual receipt of services and supports and 18 3 value=added services shall, at a minimum, consist of comparing 18 4 receipt of service against both what was authorized in the 18 5 recipient's benefit or service plan and what was actually 18 6 reimbursed. Value=added services shall not be reportable as 18 7 allowable medical or administrative costs or factored into rate 18 8 setting, and the costs of value=added services shall not be 18 9 passed on to recipients or providers. 18 10 j. Provide periodic reports to the governor and the general 18 11 assembly regarding changes in quality of care and health 18 12 outcomes for Medicaid recipients under managed care compared to 18 13 quality of care and health outcomes of the same populations of 18 14 Medicaid recipients prior to January 1, 2016. 18 15 k. Require each Medicaid managed care organization to 18 16 maintain records of complaints, grievances, and appeals, and 18 17 report the number and types of complaints, grievances, and 18 18 appeals filed, the resolution of each, and a description of 18 19 any patterns or trends identified to the department of human 18 20 services and the health policy oversight committee created 18 21 in section 2.45, on a monthly basis. The department shall 18 22 review and compile the data on a quarterly basis and make the 18 23 compilations available to the public. Following review of 18 24 reports submitted by the department, a Medicaid managed care 18 25 organization shall take any corrective action required by the 18 26 department and shall be subject to any applicable penalties. 18 27 l. Require Medicaid managed care organizations to survey 18 28 Medicaid recipients, to collect satisfaction data using a 18 29 uniform instrument, and to provide a detailed analysis of 18 30 recipient satisfaction as well as various metrics regarding the 18 31 volume of and timelines in responding to recipient complaints 18 32 and grievances as directed by the department of human services. 18 33 2. CHILDREN. 18 34 a. The hawk=i board created under section 514I.5 shall 18 35 provide recommendations to the director of human services 19 1 relating to the application of Medicaid managed care to the 19 2 child population. At a minimum, the board shall: 19 3 (1) Require that all Medicaid managed care organization 19 4 contracts specifically and appropriately address the unique 19 5 needs of children and children's health care delivery. 19 6 (a) Medicaid managed care organizations shall maintain 19 7 child health panels that include representatives of child 19 8 health, welfare, policy, and advocacy organizations in the 19 9 state that address child health and child well=being. 19 10 (b) Medicaid managed care contracts that apply to 19 11 children's health care delivery shall address early 19 12 intervention and prevention strategies, the provision of 19 13 a child health care delivery infrastructure for children 19 14 with special health care needs, utilization of current 19 15 standards and guidelines for children's health care and 19 16 pediatric=specific screening and assessment tools, the 19 17 inclusion of pediatric specialty providers in the provider 19 18 network, and the utilization of health homes for children and 19 19 youth with special health care needs including intensive care 19 20 coordination and family support and access to a professional 19 21 family=to=family support system. Such contracts shall utilize 19 22 pediatric=specific quality measures and assessment tools 19 23 which shall align with existing pediatric=specific measures 19 24 as determined in consultation with the child health panel and 19 25 approved by the hawk=i board. 19 26 (c) Medicaid managed care contracts shall provide special 19 27 incentives for innovative and evidence=based preventive, 19 28 behavioral, and developmental health care and mental health 19 29 care for children's programs that improve the life course 19 30 trajectory of those children. 19 31 (d) The information collected from the pediatric=specific 19 32 assessments shall be used to identify health risks and social 19 33 determinants of health that impact health outcomes. Medicaid 19 34 managed care organizations and providers shall use this data in 19 35 care coordination and interventions to improve patient outcomes 20 1 and to drive program designs that improve the health of the 20 2 population. Medicaid managed care organizations shall share 20 3 aggregate assessment data with providers on a routine basis. 20 4 (2) Review benefit plans and utilization review provisions 20 5 and ensure that benefits provided to children under Medicaid 20 6 managed care, at a minimum, reflect those required by state law 20 7 as specified in section 514I.5 and are provided as medically 20 8 necessary relative to the child population served and based on 20 9 the needs of the program recipient and the program recipient's 20 10 medical history. 20 11 b. In order to monitor the quality of and access to health 20 12 care for children receiving coverage under the Medicaid 20 13 program, each Medicaid managed care organization shall 20 14 uniformly report, in a template format designated by the 20 15 department of human services, the number of claims submitted by 20 16 providers and the percentage of claims approved by the Medicaid 20 17 managed care organization for the early and periodic screening, 20 18 diagnostic, and treatment (EPSDT) benefit based on the Iowa 20 19 EPSDT care for kids health maintenance recommendations, 20 20 including but not limited to physical exams, immunizations, the 20 21 seven categories of developmental and behavioral screenings, 20 22 vision and hearing screenings, and lead testing. 20 23 3. PROVIDER PARTICIPATION ENHANCEMENT. 20 24 a. Ensure that savings achieved through Medicaid managed 20 25 care does not come at the expense of further reductions in 20 26 provider rates. The department shall ensure that Medicaid 20 27 managed care organizations use reasonable reimbursement 20 28 standards for all provider types and compensate providers for 20 29 covered services at not less than the minimum reimbursement 20 30 established by state law applicable to fee for service for a 20 31 respective provider, service, or product for a fiscal year 20 32 and as determined in conjunction with actuarially sound rate 20 33 setting procedures. Such reimbursement shall extend for the 20 34 entire duration of a managed care contract. 20 35 b. To enhance continuity of care in the provision of 21 1 pharmacy services, Medicaid managed care organizations shall 21 2 utilize the same preferred drug list, recommended drug list, 21 3 prior authorization criteria, and other utilization management 21 4 strategies that apply to the state program directly under fee 21 5 for service and shall apply other provisions of applicable 21 6 state law including those relating to chemically unique mental 21 7 health prescription drugs. Reimbursement rates established 21 8 under Medicaid managed care contracts for ingredient cost 21 9 reimbursement and dispensing fees shall be subject to and shall 21 10 reflect provisions of state and federal law, including the 21 11 minimum reimbursements established in state law for fee for 21 12 service for a fiscal year. 21 13 c. Address rate setting and reimbursement of the entire 21 14 scope of services provided under the Medicaid program to 21 15 ensure the adequacy of the provider network and to ensure 21 16 that providers that contribute to the holistic health of the 21 17 Medicaid recipient, whether inside or outside of the provider 21 18 network, are compensated for their services. 21 19 d. Managed care contractors shall submit financial 21 20 documentation to the department of human services demonstrating 21 21 payment of claims and expenses by provider type. 21 22 e. Participating Medicaid providers under a managed care 21 23 contract shall be allowed to submit claims for up to 365 days 21 24 following discharge of a Medicaid recipient from a hospital or 21 25 following the date of service. 21 26 f. (1) A managed care contract entered into on or after 21 27 July 1, 2015, shall, at a minimum, reflect all of the following 21 28 provisions and requirements, and shall extend the following 21 29 payment rates based on the specified payment floor, as 21 30 applicable to the provider type: 21 31 (a) In calculating the rates for prospective payment system 21 32 hospitals, the following base rates shall be used: 21 33 (i) The inpatient diagnostic related group base rates and 21 34 certified unit per diem in effect on October 1, 2015. 21 35 (ii) The outpatient ambulatory payment classification base 22 1 rates in effect on July 1, 2015. 22 2 (iii) The inpatient psychiatric certified unit per diem in 22 3 effect on October 1, 2015. 22 4 (iv) The inpatient physical rehabilitation certified unit 22 5 per diem in effect on October 1, 2015. 22 6 (b) In calculating the critical access hospital payment 22 7 rates, the following base rates shall be used: 22 8 (i) The inpatient diagnostic related group base rates in 22 9 effect on July 1, 2015. 22 10 (ii) The outpatient cost=to=charge ratio in effect on July 22 11 1, 2015. 22 12 (iii) The swing bed per diem in effect on July 1, 2015. 22 13 (c) Critical access hospitals shall receive cost=based 22 14 reimbursement for one hundred percent of the reasonable costs 22 15 for the provision of services to Medicaid recipients. 22 16 (d) Critical access hospitals shall submit annual cost 22 17 reports and managed care contractors shall submit annual 22 18 payment reports to the department of human services. The 22 19 department shall reconcile the critical access hospital's 22 20 reported costs with the managed care contractor's reported 22 21 payments. The department shall require the managed care 22 22 contractor to retroactively reimburse a critical access 22 23 hospital for underpayments. 22 24 (2) For managed care contract periods subsequent to the 22 25 initial contract period, base rates for prospective payment 22 26 system hospitals and critical access hospitals shall be 22 27 calculated using the base rate for the prior contract period 22 28 plus 3 percent. Prospective payment system hospital and 22 29 critical access hospital base rates shall at no time be less 22 30 than the previous contract period's base rates. 22 31 (3) A managed care contract shall require out=of=network 22 32 prospective payment system hospital and critical access 22 33 hospital payment rates to meet or exceed ninety=nine percent of 22 34 the rates specified for the respective in=network hospitals in 22 35 accordance with this paragraph "f". 23 1 g. If the department of human services collects ownership 23 2 and control information from Medicaid providers pursuant to 42 23 3 C.F.R. {455.104, a managed care organization under contract 23 4 with the state shall not also require submission of this 23 5 information from approved enrolled Medicaid providers. 23 6 h. (1) Ensure that a Medicaid managed care organization 23 7 develops and maintains a provider network of qualified 23 8 providers who meet state licensing, credentialing, and 23 9 certification requirements, as applicable, which network shall 23 10 be sufficient to provide adequate access to all services 23 11 covered and for all populations served under the managed 23 12 care contract. Medicaid managed care organizations shall 23 13 incorporate existing and traditional providers, including 23 14 but not limited to those providers that comprise the Iowa 23 15 collaborative safety net provider network created in section 23 16 135.153, into their provider networks. 23 17 (2) Ensure that respective Medicaid populations are 23 18 managed at all times within funding limitations and contract 23 19 terms. The department shall also monitor service delivery 23 20 and utilization to ensure the responsibility for provision 23 21 of services to Medicaid recipients is not shifted to 23 22 non=Medicaid covered services to attain savings, and that such 23 23 responsibility is not shifted to mental health and disability 23 24 services regions, local public health agencies, aging and 23 25 disability resource centers, or other entities unless agreement 23 26 to provide, and provision for adequate compensation for, such 23 27 services is agreed to between the affected entities in advance. 23 28 i. Medicaid managed care organizations shall provide an 23 29 enrolled Medicaid provider approved by the department of 23 30 human services the opportunity to be a participating network 23 31 provider. 23 32 j. Medicaid managed care organizations shall include 23 33 provider appeals and grievance procedures that in part allow 23 34 a provider to file a grievance independently but on behalf 23 35 of a Medicaid recipient and to appeal claims denials which, 24 1 if determined to be based on claims for medically necessary 24 2 services whether or not denied on an administrative basis, 24 3 shall receive appropriate payment. 24 4 4. CAPITATION RATES AND MEDICAL LOSS RATIO. 24 5 a. Capitation rates shall be developed based on all 24 6 reasonable, appropriate, and attainable costs. Costs that are 24 7 not reasonable, appropriate, or attainable, including but not 24 8 limited to improper payment recoveries, shall not be included 24 9 in the development of capitated rates. 24 10 b. Capitation rates for Medicaid recipients falling within 24 11 different rate cells shall not be expected to cross=subsidize 24 12 one another and the data used to set capitation rates shall 24 13 be relevant and timely and tied to the appropriate Medicaid 24 14 population. 24 15 c. Any increase in capitation rates for managed care 24 16 contractors is subject to prior statutory approval and shall 24 17 not exceed three percent over the existing capitation rate 24 18 in any one=year period or five percent over the existing 24 19 capitation rate in any two=year period. 24 20 d. A managed care contract shall impose a minimum Medicaid 24 21 loss ratio of at least eighty=eight percent. In calculating 24 22 the medical loss ratio, medical costs or benefit expenses shall 24 23 include only those costs directly related to patient medical 24 24 care and not ancillary expenses, including but not limited to 24 25 any of the following: 24 26 (1) Program integrity activities. 24 27 (2) Utilization review activities. 24 28 (3) Fraud prevention activities beyond the scope of those 24 29 activities necessary to recover incurred claims. 24 30 (4) Provider network development, education, or management 24 31 activities. 24 32 (5) Provider credentialing activities. 24 33 (6) Marketing expenses. 24 34 (7) Administrative costs associated with recipient 24 35 incentives. 25 1 (8) Clinical data collection activities. 25 2 (9) Claims adjudication expenses. 25 3 (10) Customer service or health care professional hotline 25 4 services addressing nonclinical recipient questions. 25 5 (11) Value=added or cost=containment services, wellness 25 6 programs, disease management, and case management or care 25 7 coordination programs. 25 8 (12) Health quality improvement activities unless 25 9 specifically approved as a medical cost by state law. Costs of 25 10 health quality improvement activities included in determining 25 11 the medical loss ratio shall be only those activities that are 25 12 independent improvements measurable in individual patients. 25 13 (13) Insurer claims review activities. 25 14 (14) Information technology costs unless they directly 25 15 and credibly improve the quality of health care and do not 25 16 duplicate, conflict with, or fail to be compatible with similar 25 17 health information technology efforts of providers. 25 18 (15) Legal department costs including information 25 19 technology costs, expenses incurred for review and denial of 25 20 claims, legal costs related to defending claims, settlements 25 21 for wrongly denied claims, and costs related to administrative 25 22 claims handling including salaries of administrative personnel 25 23 and legal costs. 25 24 (16) Taxes unrelated to premiums or the provision of medical 25 25 care. Only state and federal taxes and licensing or regulatory 25 26 fees relevant to actual premiums collected, not including such 25 27 taxes and fees as property taxes, taxes on investment income, 25 28 taxes on investment property, and capital gains taxes, may be 25 29 included in determining the medical loss ratio. 25 30 e. (1) Provide enhanced guidance and criteria for defining 25 31 medical and administrative costs, recoveries, and rebates 25 32 including pharmacy rebates, and the recording, reporting, and 25 33 recoupment of such costs, recoveries, and rebates realized. 25 34 (2) Medicaid managed care organizations shall offset 25 35 recoveries, rebates, and refunds against medical costs, include 26 1 only allowable administrative expenses in the determination of 26 2 administrative costs, report costs related to subcontractors 26 3 properly, and have complete systems checks and review processes 26 4 to identify overpayment possibilities. 26 5 (3) Medicaid managed care contractors shall submit 26 6 publically available, comprehensive financial statements to 26 7 verify that the minimum medical loss ratio is being met and 26 8 shall be subject to periodic audits. 26 9 5. DATA AND INFORMATION, EVALUATION, AND OVERSIGHT. 26 10 a. Develop and administer a clear, detailed policy 26 11 regarding the collection, storage, integration, analysis, 26 12 maintenance, retention, reporting, sharing, and submission 26 13 of data and information from the Medicaid managed care 26 14 organizations and shall require each Medicaid managed care 26 15 organization to have in place a data and information system to 26 16 ensure that accurate and meaningful data is available. At a 26 17 minimum, the data shall allow the department to effectively 26 18 measure and monitor Medicaid managed care organization 26 19 performance, quality, outcomes including recipient health 26 20 outcomes, service utilization, finances, program integrity, 26 21 the appropriateness of payments, and overall compliance with 26 22 contract requirements; perform risk adjustments and determine 26 23 actuarially sound capitation rates and appropriate provider 26 24 reimbursements; verify that the minimum medical loss ratio is 26 25 being met; ensure recipient access to and use of services; 26 26 create quality measures; and provide for program transparency. 26 27 b. Medicaid managed care organizations shall directly 26 28 capture and retain and shall report actual and detailed 26 29 medical claims costs and administrative cost data to the 26 30 department as specified by the department. Medicaid managed 26 31 care organizations shall allow the department to thoroughly and 26 32 accurately monitor the medical claims costs and administrative 26 33 costs data Medicaid managed care organizations report to the 26 34 department. 26 35 c. Conduct regular audits of Medicaid managed care 27 1 contracts according to a routine, ongoing schedule to ensure 27 2 compliance including with respect to appropriate medical costs, 27 3 allowable administrative costs, the medical loss ratio, cost 27 4 recoveries, rebates, overpayments, and compliance with specific 27 5 contract performance requirements. 27 6 d. Following completion of the initial year of 27 7 implementation of Medicaid managed care, the department shall 27 8 hire an independent performance auditor to perform an audit of 27 9 the Medicaid managed care program and participating Medicaid 27 10 managed care organizations to determine if the state has 27 11 sufficient infrastructure and controls in place to effectively 27 12 oversee the Medicaid managed care organizations and the 27 13 Medicaid program to ensure, at a minimum, compliance with 27 14 Medicaid managed care organization contracts and to prevent 27 15 fraud, abuse, and overpayments. The results of the audit shall 27 16 be submitted to the governor, the general assembly, and the 27 17 health policy oversight committee created in section 2.45. 27 18 e. Publish benchmark indicators based on Medicaid program 27 19 outcomes from the fiscal year beginning July 1, 2015, to 27 20 be used to compare outcomes of the Medicaid program as 27 21 administered by the state program prior to July 1, 2015, to 27 22 those outcomes of the program under Medicaid managed care. The 27 23 outcomes shall include a comparison of actual costs of the 27 24 program as administered prior to and after implementation of 27 25 Medicaid managed care. 27 26 f. Review and approve or deny approval of contract 27 27 amendments on an ongoing basis to provide for continuous 27 28 improvement in Medicaid managed care and to incorporate any 27 29 changes based on changes in law or policy. 27 30 g. (1) Require managed care contractors to track and report 27 31 on a monthly basis to the department of human services, all of 27 32 the following: 27 33 (a) The number and details relating to prior authorization 27 34 requests and denials. 27 35 (b) The ten most common reasons for claims denials. 28 1 Information reported by a managed care contractor relative 28 2 to claims shall also include the number of claims denied, 28 3 appealed, and overturned based on provider type and service 28 4 type. 28 5 (c) Utilization of health care services by diagnostic 28 6 related group and ambulatory payment classification as well as 28 7 total claims volume. 28 8 (2) The department shall make the monthly reports available 28 9 to the public. 28 10 h. Medicaid managed care organizations shall maintain 28 11 stakeholder panels comprised of an equal number of Medicaid 28 12 recipients and providers. Medicaid managed care organizations 28 13 shall provide for separate provider=specific panels to address 28 14 detailed payment, claims, process, and other issues as well as 28 15 grievance and appeals processes. 28 16 i. Medicaid managed care contracts shall align economic 28 17 incentives, delivery system reforms, and performance and 28 18 outcome metrics with those of the state innovation models 28 19 initiatives and Medicaid accountable care organizations. 28 20 The department of human services shall develop and utilize 28 21 a common, uniform set of process, quality, and consumer 28 22 satisfaction measures across all Medicaid payors and providers 28 23 that align with those developed through the state innovation 28 24 models initiative and shall ensure that such measures are 28 25 expanded and adjusted to address additional populations and 28 26 to meet population health objectives. Medicaid managed care 28 27 contracts shall include long=term performance and outcomes 28 28 goals that reward success in achieving population health goals 28 29 such as improved community health metrics. 28 30 j. Require consistency and uniformity of processes, 28 31 procedures, and forms across all Medicaid managed care 28 32 organizations to reduce the administrative burden to providers 28 33 and consumers and to increase efficiencies in the program. 28 34 Such requirements shall apply to but are not limited to 28 35 areas of uniform cost and quality reporting, uniform prior 29 1 authorization requirements and procedures, centralized, 29 2 uniform, and seamless credentialing requirements and 29 3 procedures, and uniform critical incident reporting. 29 4 k. Medicaid managed care organizations and any entity with 29 5 which a managed care organization contracts for the performance 29 6 of services shall disclose at no cost to the department all 29 7 discounts, incentives, rebates, fees, free goods, bundling 29 8 arrangements, and other agreements affecting the net cost of 29 9 goods or services provided under a managed care contract. 29 10 Sec. 16. RETROACTIVE APPLICABILITY. The section of this Act 29 11 relating to directives for Medicaid program policy improvements 29 12 applies retroactively to July 1, 2015. 29 13 Sec. 17. EFFECTIVE UPON ENACTMENT. This Act, being deemed 29 14 of immediate importance, takes effect upon enactment. 29 15 EXPLANATION 29 16 The inclusion of this explanation does not constitute agreement with 29 17 the explanation's substance by the members of the general assembly. 29 18 This bill relates to Medicaid program improvement. 29 19 The bill provides legislative findings, goals, and the 29 20 intent for the program. 29 21 The bill provides for a review of program integrity 29 22 activities by a workgroup, required to make recommendations 29 23 to the governor and general assembly by November 15, 2016, to 29 24 provide findings and recommendations for a coordinated approach 29 25 to provide for comprehensive and effective administration of 29 26 program integrity activities to support such a system. 29 27 The bill creates a Medicaid reinvestment fund for the 29 28 deposit of savings related to and realized from Medicaid 29 29 managed care. Moneys in the fund are subject to appropriation 29 30 by the general assembly for the Medicaid program. 29 31 The bill provides additional duties for and authority to 29 32 the office of long=term care ombudsman relating to providing 29 33 advocacy services and assistance for Medicaid recipients who 29 34 receive long=term services and supports. 29 35 The bill clarifies the membership of the medical assistance 30 1 advisory council and the executive committee, provides for 30 2 the creation of subcommittees of the council relating to 30 3 stakeholder safeguards; long=term services and supports; 30 4 transparency, data, and program evaluation; and program 30 5 integrity. 30 6 The bill directs the patient=centered health advisory 30 7 council to assess the health resources and infrastructure 30 8 of the state to recommend more appropriate alignment with 30 9 changes in health care delivery and the integrated, holistic, 30 10 population health=based approach to health and health care. 30 11 The bill directs the council to perform an initial review and 30 12 submit a report by January 1, 2017, to the governor and the 30 13 general assembly, and to submit subsequent reports on January 30 14 1, annually, thereafter. 30 15 The bill directs the department of human services and other 30 16 appropriate entities to undertake specific tasks relating to 30 17 Medicaid program policy improvement in the areas of consumer 30 18 protections, children, provider participation enhancement, 30 19 capitation rates and medical loss ratio, and data and 30 20 information, evaluation, and oversight. 30 21 The section of the bill relating to directives for Medicaid 30 22 program policy improvements is retroactively applicable to July 30 23 1, 2015. 30 24 The bill takes effect upon enactment. LSB 5711XS (27) 86 pf/nh
