Bill Text: IA SF2213 | 2015-2016 | 86th General Assembly | Amended
Bill Title: A bill for an act relating to Medicaid program improvement, and including effective date and retroactive applicability provisions. (Formerly SF 2107.)
Spectrum: Committee Bill
Status: (Engrossed - Dead) 2016-03-17 - Fiscal note. HCS. [SF2213 Detail]
Download: Iowa-2015-SF2213-Amended.html
Senate File 2213 - Reprinted SENATE FILE BY COMMITTEE ON HUMAN RESOURCES (SUCCESSOR TO SF 2107) (As Amended and Passed by the Senate March 2, 2016) 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: SF 2213 (3) 86 pf/nh/jh 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 HEALTH POLICY OVERSIGHT COMMITTEE 4 6 Sec. 2. Section 2.45, subsection 6, Code 2016, is amended 4 7 to read as follows: 4 8 6. The legislative health policy oversight committee, which 4 9 shall be composed of ten members of the general assembly, 4 10 consisting of five members from each house, to be appointed 4 11 by the legislative council. The legislative health policy 4 12 oversight committee shallreceive updates and review data, 4 13 public input and concerns, and make recommendations for 4 14 improvements to and changes in law or rule regarding Medicaid 4 15 managed caremeet at least four times annually to evaluate 4 16 state health policy and provide continuing oversight for 4 17 publicly funded programs, including but not limited to all 4 18 facets of the Medicaid and hawk=i programs to, at a minimum, 4 19 ensure effective and efficient administration of these 4 20 programs, address stakeholder concerns, monitor program costs 4 21 and expenditures, and make recommendations relative to the 4 22 programs. 4 23 Sec. 3. HEALTH POLICY OVERSIGHT COMMITTEE ==== SUBJECT 4 24 MATTER REVIEW FOR 2016 LEGISLATIVE INTERIM. During the 2016 4 25 legislative interim, the health policy oversight committee 4 26 created in section 2.45 shall, as part of the committee's 4 27 evaluation of state health policy and review of all facets 4 28 of the Medicaid and hawk=i programs, review and make 4 29 recommendations regarding, at a minimum, all of the following: 4 30 1. The resources and duties of the office of long=term 4 31 care ombudsman relating to the provision of assistance to and 4 32 advocacy for Medicaid recipients to determine the designation 4 33 of duties and level of resources necessary to appropriately 4 34 address the needs of such individuals. The committee shall 4 35 consider the health consumer ombudsman alliance report 5 1 submitted to the general assembly in December 2015, as well as 5 2 input from the office of long=term care ombudsman and other 5 3 entities in making recommendations. 5 4 2. The health benefits and health benefit utilization 5 5 management criteria for the Medicaid and hawk=i programs to 5 6 determine the sufficiency and appropriateness of the benefits 5 7 offered and the utilization of these benefits. 5 8 3. Prior authorization requirements relative to benefits 5 9 provided under the Medicaid and hawk=i programs, including but 5 10 not limited to pharmacy benefits. 5 11 4. Consistency and uniformity in processes, procedures, 5 12 forms, and other activities across all Medicaid and hawk=i 5 13 program participating insurers and managed care organizations, 5 14 including but not limited to cost and quality reporting, 5 15 credentialing, billing, prior authorization, and critical 5 16 incident reporting. 5 17 5. Provider network adequacy including the use of 5 18 out=of=network and out=of=state providers. 5 19 6. The role and interplay of other advisory and oversight 5 20 entities, including but not limited to the medical assistance 5 21 advisory council and the hawk=i board. 5 22 REVIEW OF PROGRAM INTEGRITY DUTIES 5 23 Sec. 4. REVIEW OF PROGRAM INTEGRITY DUTIES ==== WORKGROUP ==== 5 24 REPORT. 5 25 1. The director of human services shall convene a 5 26 workgroup comprised of members including the commissioner 5 27 of insurance, the auditor of state, the Medicaid director 5 28 and bureau chiefs of the managed care organization oversight 5 29 and supports bureau, the Iowa Medicaid enterprise support 5 30 bureau, and the medical and long=term services and supports 5 31 bureau, and a representative of the program integrity unit, 5 32 or their designees; and representatives of other appropriate 5 33 state agencies or other entities including but not limited to 5 34 the office of the attorney general, the office of long=term 5 35 care ombudsman, and the Medicaid fraud control unit of the 6 1 investigations division of the department of inspections and 6 2 appeals. The workgroup shall do all of the following: 6 3 a. Review the duties of each entity with responsibilities 6 4 relative to Medicaid program integrity and managed care 6 5 organizations; review state and federal laws, regulations, 6 6 requirements, guidance, and policies relating to Medicaid 6 7 program integrity and managed care organizations; and review 6 8 the laws of other states relating to Medicaid program integrity 6 9 and managed care organizations. The workgroup shall determine 6 10 areas of duplication, fragmentation, and gaps; shall identify 6 11 possible integration, collaboration and coordination of duties; 6 12 and shall determine whether existing general state Medicaid 6 13 program and fee=for=service policies, laws, and rules are 6 14 sufficient, or if changes or more specific policies, laws, and 6 15 rules are required to provide for comprehensive and effective 6 16 administration and oversight of the Medicaid program including 6 17 under the fee=for=service and managed care methodologies. 6 18 b. Review historical uses of the Medicaid fraud fund created 6 19 in section 249A.50 and make recommendations for future uses 6 20 of the moneys in the fund and any changes in law necessary to 6 21 adequately address program integrity. 6 22 c. Review medical loss ratio provisions relative to 6 23 Medicaid managed care contracts and make recommendations 6 24 regarding, at a minimum, requirements for the necessary 6 25 collection, maintenance, retention, reporting, and sharing of 6 26 data and information by Medicaid managed care organizations 6 27 for effective determination of compliance, and to identify 6 28 the costs and activities that should be included in the 6 29 calculation of administrative costs, medical costs or benefit 6 30 expenses, health quality improvement costs, and other costs and 6 31 activities incidental to the determination of a medical loss 6 32 ratio. 6 33 d. Review the capacity of state agencies, including the need 6 34 for specialized training and expertise, to address Medicaid 6 35 and managed care organization program integrity and provide 7 1 recommendations for the provision of necessary resources and 7 2 infrastructure, including annual budget projections. 7 3 e. Review the incentives and penalties applicable to 7 4 violations of program integrity requirements to determine their 7 5 adequacy in combating waste, fraud, abuse, and other violations 7 6 that divert limited resources that would otherwise be expended 7 7 to safeguard the health and welfare of Medicaid recipients, 7 8 and make recommendations for necessary adjustments to improve 7 9 compliance. 7 10 f. Make recommendations regarding the quarterly and annual 7 11 auditing of financial reports required to be performed for 7 12 each Medicaid managed care organization to ensure that the 7 13 activities audited provide sufficient information to the 7 14 division of insurance of the department of commerce and the 7 15 department of human services to ensure program integrity. The 7 16 recommendations shall also address the need for additional 7 17 audits or other reviews of managed care organizations. 7 18 g. Review and make recommendations to prohibit 7 19 cost=shifting between state and local and public and private 7 20 funding sources for services and supports provided to Medicaid 7 21 recipients whether directly or indirectly through the Medicaid 7 22 program. 7 23 2. The department of human services shall submit a report 7 24 of the workgroup to the governor, the health policy oversight 7 25 committee created in section 2.45, and the general assembly 7 26 initially, on or before November 15, 2016, and on or before 7 27 November 15, on an annual basis thereafter, to provide findings 7 28 and recommendations for a coordinated approach to comprehensive 7 29 and effective administration and oversight of the Medicaid 7 30 program including under the fee=for=service and managed care 7 31 methodologies. 7 32 MEDICAID REINVESTMENT FUND 7 33 Sec. 5. NEW SECTION. 249A.4C Medicaid reinvestment fund. 7 34 1. A Medicaid reinvestment fund is created in the state 7 35 treasury under the authority of the department. The department 8 1 of human services shall collect an initial contribution of five 8 2 million dollars from each of the managed care organizations 8 3 contracting with the state during the fiscal year beginning 8 4 July 1, 2015, for an aggregate amount of fifteen million 8 5 dollars, and shall deposit such amount in the fund to be 8 6 used for Medicaid ombudsman activities through the office 8 7 of long=term care ombudsman. Additionally, moneys from 8 8 savings realized from the movement of Medicaid recipients from 8 9 institutional settings to home and community=based services, 8 10 the portion of the capitation rate withheld from and not 8 11 returned to Medicaid managed care organizations at the end 8 12 of each fiscal year, any recouped excess of capitation rates 8 13 paid to Medicaid managed care organizations, any overpayments 8 14 recovered under Medicaid managed care contracts, and any 8 15 other savings realized from Medicaid managed care or from 8 16 Medicaid program cost=containment efforts, with the exception 8 17 of the total amount attributable to the projected savings from 8 18 Medicaid managed care based on the initial capitation rates 8 19 established for the fiscal year beginning July 1, 2015, shall 8 20 be credited to the Medicaid reinvestment fund. 8 21 2. Notwithstanding section 8.33, moneys credited to 8 22 the fund from any other account or fund shall not revert to 8 23 the other account or fund. Moneys in the fund shall only 8 24 be used as provided in appropriations from the fund for 8 25 the Medicaid program and for health system transformation 8 26 and integration, including but not limited to providing 8 27 the necessary infrastructure and resources to protect the 8 28 interests of Medicaid recipients, maintaining adequate provider 8 29 participation, and ensuring program integrity. Such uses may 8 30 include but are not limited to: 8 31 a. Ensuring appropriate reimbursement of Medicaid 8 32 providers to maintain the type and number of appropriately 8 33 trained providers necessary to address the needs of Medicaid 8 34 recipients. 8 35 b. Providing home and community=based services as necessary 9 1 to rebalance the long=term services and supports infrastructure 9 2 and to reduce Medicaid home and community=based services waiver 9 3 waiting lists. 9 4 c. Ensuring that a fully functioning independent Medicaid 9 5 ombudsman program through the office of long=term care 9 6 ombudsman is available to provide advocacy services and 9 7 assistance to eligible and potentially eligible Medicaid 9 8 recipients. 9 9 d. Ensuring adequate and appropriate capacity of the 9 10 department of human services as the single state agency 9 11 designated to administer and supervise the administration of 9 12 the Medicaid program, to ensure compliance with state and 9 13 federal law and program integrity requirements. 9 14 e. Addressing workforce issues to ensure a competent, 9 15 diverse, and sustainable health care workforce and to 9 16 improve access to health care in underserved areas and among 9 17 underserved populations, recognizing long=term services and 9 18 supports as an essential component of the health care system. 9 19 f. Supporting innovation, longer=term community 9 20 investments, and the activities of local public health 9 21 agencies, aging and disability resource centers and service 9 22 agencies, mental health and disability services regions, social 9 23 services, and child welfare entities and other providers of 9 24 and advocates for services and supports to encourage health 9 25 system transformation and integration through a broad range of 9 26 prevention strategies and population=based approaches to meet 9 27 the holistic needs of the population as a whole. 9 28 3. The department shall establish a mechanism to measure and 9 29 certify the amount of savings resulting from Medicaid managed 9 30 care and Medicaid program cost=containment activities and shall 9 31 ensure that such realized savings are credited to the fund and 9 32 used as provided in appropriations from the fund. 9 33 MEDICAID OMBUDSMAN 9 34 Sec. 6. Section 231.44, Code 2016, is amended to read as 9 35 follows: 10 1 231.44 Utilization of resources ==== assistance and advocacy 10 2 related to long=term services and supports under the Medicaid 10 3 program. 10 4 1. The office of long=term care ombudsmanmayshall 10 5 utilize its available resources to provide assistance and 10 6 advocacy services to eligible recipients of long=term services 10 7 and supports, or individuals seeking long=term services and 10 8 supports, and the families or legal representatives of such 10 9eligible recipients, of long=term services and supports 10 10 provided throughindividuals under the Medicaid program. Such 10 11 assistance and advocacy shall include but is not limited to all 10 12 of the following: 10 13 a. Assistingrecipientssuch individuals in understanding 10 14 the services, coverage, and access provisions and their rights 10 15 under Medicaid managed care. 10 16 b. Developing procedures for the tracking and reporting 10 17 of the outcomes of individual requests for assistance, the 10 18 obtaining of necessary services and supports, and other 10 19 aspects of the services provided toeligible recipientssuch 10 20 individuals. 10 21 c. Providing advice and assistance relating to the 10 22 preparation and filing of complaints, grievances, and appeals 10 23 of complaints or grievances, including through processes 10 24 available under managed care plans and the state appeals 10 25 process, relating to long=term services and supports under the 10 26 Medicaid program. 10 27 d. Accessing the results of a review of a level of care 10 28 assessment or reassessment by a managed care organization 10 29 in which the managed care organization recommends denial or 10 30 limited authorization of a service, including the type or level 10 31 of service, the reduction, suspension, or termination of a 10 32 previously authorized service, or a change in level of care, 10 33 upon the request of an affected individual. 10 34 e. Receiving notices of disenrollment or notices that would 10 35 result in a change in level of care for affected individuals, 11 1 including involuntary and voluntary discharges or transfers, 11 2 from the department of human services or a managed care 11 3 organization. 11 4 2. A representative of the office of long=term care 11 5 ombudsman providing assistance and advocacy services authorized 11 6 under this section for an individual, shall be provided 11 7 access to the individual, and shall be provided access to 11 8 the individual's medical and social records as authorized by 11 9 the individual or the individual's legal representative, as 11 10 necessary to carry out the duties specified in this section. 11 11 3. A representative of the office of long=term care 11 12 ombudsman providing assistance and advocacy services authorized 11 13 under this section for an individual, shall be provided access 11 14 to administrative records related to the provision of the 11 15 long=term services and supports to the individual, as necessary 11 16 to carry out the duties specified in this section. 11 17 4. The office of long=term care ombudsman and 11 18 representatives of the office, when providing assistance and 11 19 advocacy services under this section, shall be considered a 11 20 health oversight agency as defined in 45 C.F.R. {164.501 for 11 21 the purposes of health oversight activities as described in 11 22 45 C.F.R. {164.512(d) including access to the health records 11 23 and other appropriate information of an individual, including 11 24 from the department of human services or the applicable 11 25 Medicaid managed care organization, as necessary to fulfill the 11 26 duties specified under this section. The department of human 11 27 services, in collaboration with the office of long=term care 11 28 ombudsman, shall adopt rules to ensure compliance by affected 11 29 entities with this subsection and to ensure recognition of the 11 30 office of long=term care ombudsman as a duly authorized and 11 31 identified agent or representative of the state. 11 32 5. The department of human services and Medicaid managed 11 33 care organizations shall inform eligible and potentially 11 34 eligible Medicaid recipients of the advocacy services and 11 35 assistance available through the office of long=term care 12 1 ombudsman and shall provide contact and other information 12 2 regarding the advocacy services and assistance to eligible and 12 3 potentially eligible Medicaid recipients as directed by the 12 4 office of long=term care ombudsman. 12 5 6. When providing assistance and advocacy services under 12 6 this section, the office of long=term care ombudsman shall act 12 7 as an independent agency, and the office of long=term care 12 8 ombudsman and representatives of the office shall be free of 12 9 any undue influence that restrains the ability of the office 12 10 or the office's representatives from providing such services 12 11 and assistance. 12 12 7. The office of long=term care ombudsman shall, in addition 12 13 to other duties prescribed and at a minimum, do all of the 12 14 following in the furtherance of the provision of advocacy 12 15 services and assistance under this section: 12 16 a. Represent the interests of eligible and potentially 12 17 eligible Medicaid recipients before governmental agencies. 12 18 b. Analyze, comment on, and monitor the development and 12 19 implementation of federal, state, and local laws, regulations, 12 20 and other governmental policies and actions, and recommend 12 21 any changes in such laws, regulations, policies, and actions 12 22 as determined appropriate by the office of long=term care 12 23 ombudsman. 12 24 c. To maintain transparency and accountability for 12 25 activities performed under this section, including for the 12 26 purposes of claiming federal financial participation for 12 27 activities that are performed to assist with administration of 12 28 the Medicaid program: 12 29 (1) Have complete and direct responsibility for the 12 30 administration, operation, funding, fiscal management, and 12 31 budget related to such activities, and directly employ, 12 32 oversee, and supervise all paid and volunteer staff associated 12 33 with these activities. 12 34 (2) Establish separation=of=duties requirements, provide 12 35 limited access to work space and work product for only 13 1 necessary staff, and limit access to documents and information 13 2 as necessary to maintain the confidentiality of the protected 13 3 health information of individuals served under this section. 13 4 (3) Collect and submit, annually, to the governor, the 13 5 health policy oversight committee created in section 2.45, and 13 6 the general assembly, all of the following with regard to those 13 7 seeking advocacy services or assistance under this section: 13 8 (a) The number of contacts by contact type and geographic 13 9 location. 13 10 (b) The type of assistance requested including the name of 13 11 the managed care organization involved, if applicable. 13 12 (c) The time frame between the time of the initial contact 13 13 and when an initial response was provided. 13 14 (d) The amount of time from the initial contact to 13 15 resolution of the problem or concern. 13 16 (e) The actions taken in response to the request for 13 17 advocacy or assistance. 13 18 (f) The outcomes of requests to address problems or 13 19 concerns. 13 204.8. For the purposes of this section: 13 21 a. "Institutional setting" includes a long=term care 13 22 facility, an elder group home, or an assisted living program. 13 23 b. "Long=term services and supports" means the broad range of 13 24 health, health=related, and personal care assistance services 13 25 and supports, provided in both institutional settings and home 13 26 and community=based settings, necessary for older individuals 13 27 and persons with disabilities who experience limitations in 13 28 their capacity for self=care due to a physical, cognitive, or 13 29 mental disability or condition. 13 30 Sec. 7. NEW SECTION. 231.44A Willful interference with 13 31 duties related to long=term services and supports ==== penalty. 13 32 Willful interference with a representative of the office of 13 33 long=term care ombudsman in the performance of official duties 13 34 in accordance with section 231.44 is a violation of section 13 35 231.44, subject to a penalty prescribed by rule. The office 14 1 of long=term care ombudsman shall adopt rules specifying the 14 2 amount of a penalty imposed, consistent with the penalties 14 3 imposed under section 231.42, subsection 8, and specifying 14 4 procedures for notice and appeal of penalties imposed. Any 14 5 moneys collected pursuant to this section shall be deposited in 14 6 the Medicaid reinvestment fund created in section 249A.4C. 14 7 MEDICAL ASSISTANCE ADVISORY COUNCIL 14 8 Sec. 8. Section 249A.4B, Code 2016, is amended to read as 14 9 follows: 14 10 249A.4B Medical assistance advisory council. 14 11 1. A medical assistance advisory council is created to 14 12 comply with 42 C.F.R. {431.12 based on section 1902(a)(4) of 14 13 the federal Social Security Act and to advise the director 14 14 about health and medical care services under themedical 14 15 assistanceMedicaid program, participate in Medicaid policy 14 16 development and program administration, and provide guidance 14 17 on key issues related to the Medicaid program, whether 14 18 administered under a fee=for=service, managed care, or other 14 19 methodology, including but not limited to access to care, 14 20 quality of care, and service delivery. 14 21 a. The council shall have the opportunity for participation 14 22 in policy development and program administration, including 14 23 furthering the participation of recipients of the program, and 14 24 without limiting this general authority shall specifically do 14 25 all of the following: 14 26 (1) Formulate, review, evaluate, and recommend policies, 14 27 rules, agency initiatives, and legislation pertaining to the 14 28 Medicaid program. The council shall have the opportunity 14 29 to comment on proposed rules prior to commencement of the 14 30 rulemaking process and on waivers and state plan amendment 14 31 applications. 14 32 (2) Prior to the annual budget development process, engage 14 33 in setting priorities, including consideration of the scope 14 34 and utilization management criteria for benefits, beneficiary 14 35 eligibility, provider and services reimbursement rates, and 15 1 other budgetary issues. 15 2 (3) Provide oversight for and review of the administration 15 3 of the Medicaid program. 15 4 (4) Ensure that the membership of the council effectively 15 5 represents all relevant and concerned viewpoints, particularly 15 6 those of consumers, providers, and the general public; create 15 7 public understanding; and ensure that the services provided 15 8 under the Medicaid program meet the needs of the people served. 15 9 b. The council shall meetno more thanat least quarterly, 15 10 and prior to the next subsequent meeting of the executive 15 11 committee.The director of public healthThe public member 15 12 acting as a co=chairperson of the executive committee and 15 13 the professional or business entity member acting as a 15 14 co=chairperson of the executive committee, shall serve as 15 15chairpersonco=chairpersons of the council. 15 16 2. The council shall include all of the following voting 15 17 members: 15 18 a. The president, or the president's representative, of each 15 19 of the following professional or business entities, or a member 15 20 of each of the following professional or business entities, 15 21 selected by the entity: 15 22 (1) The Iowa medical society. 15 23 (2) The Iowa osteopathic medical association. 15 24 (3) The Iowa academy of family physicians. 15 25 (4) The Iowa chapter of the American academy of pediatrics. 15 26 (5) The Iowa physical therapy association. 15 27 (6) The Iowa dental association. 15 28 (7) The Iowa nurses association. 15 29 (8) The Iowa pharmacy association. 15 30 (9) The Iowa podiatric medical society. 15 31 (10) The Iowa optometric association. 15 32 (11) The Iowa association of community providers. 15 33 (12) The Iowa psychological association. 15 34 (13) The Iowa psychiatric society. 15 35 (14) The Iowa chapter of the national association of social 16 1 workers. 16 2 (15) The coalition for family and children's services in 16 3 Iowa. 16 4 (16) The Iowa hospital association. 16 5 (17) The Iowa association of rural health clinics. 16 6 (18) The Iowa primary care association. 16 7 (19) Free clinics of Iowa. 16 8 (20) The opticians' association of Iowa, inc. 16 9 (21) The Iowa association of hearing health professionals. 16 10 (22) The Iowa speech and hearing association. 16 11 (23) The Iowa health care association. 16 12 (24) The Iowa association of area agencies on aging. 16 13 (25) AARP. 16 14 (26) The Iowa caregivers association. 16 15 (27) The Iowa coalition of home and community=based 16 16 services for seniors. 16 17 (28) The Iowa adult day services association. 16 18 (29) Leading age Iowa. 16 19 (30) The Iowa association for home care. 16 20 (31) The Iowa council of health care centers. 16 21 (32) The Iowa physician assistant society. 16 22 (33) The Iowa association of nurse practitioners. 16 23 (34) The Iowa nurse practitioner society. 16 24 (35) The Iowa occupational therapy association. 16 25 (36) The ARC of Iowa, formerly known as the association for 16 26 retarded citizens of Iowa. 16 27 (37) The national alliancefor the mentally illon mental 16 28 illness of Iowa. 16 29 (38) The Iowa state association of counties. 16 30 (39) The Iowa developmental disabilities council. 16 31 (40) The Iowa chiropractic society. 16 32 (41) The Iowa academy of nutrition and dietetics. 16 33 (42) The Iowa behavioral health association. 16 34 (43) The midwest association for medical equipment services 16 35 or an affiliated Iowa organization. 17 1 (44) The Iowa public health association. 17 2 (45) The epilepsy foundation. 17 3 b. Public representatives which may include members of 17 4 consumer groups, including recipients of medical assistance or 17 5 their families, consumer organizations, and others, which shall 17 6 be appointed by the governor in equalinnumber to the number 17 7 of representatives of the professional and business entities 17 8 specifically represented under paragraph "a",appointed by the 17 9 governorfor staggered terms of two years each, none of whom 17 10 shall be members of, or practitioners of, or have a pecuniary 17 11 interest in any of the professional or business entities 17 12 specifically represented under paragraph "a", and a majority 17 13 of whom shall be current or former recipients of medical 17 14 assistance or members of the families of current or former 17 15 recipients. 17 16 3. The council shall include all of the following nonvoting 17 17 members: 17 18c.a. The director of public health, or the director's 17 19 designee. 17 20d.b. The director of the department on aging, or the 17 21 director's designee. 17 22 c. The state long=term care ombudsman, or the ombudsman's 17 23 designee. 17 24 d. The ombudsman appointed pursuant to section 2C.3, or the 17 25 ombudsman's designee. 17 26 e. The dean of Des Moines university ==== osteopathic medical 17 27 center, or the dean's designee. 17 28 f. The dean of the university of Iowa college of medicine, 17 29 or the dean's designee. 17 30 g. The following members of the general assembly, each for a 17 31 term of two years as provided in section 69.16B: 17 32 (1) Two members of the house of representatives, one 17 33 appointed by the speaker of the house of representatives 17 34 and one appointed by the minority leader of the house of 17 35 representatives from their respective parties. 18 1 (2) Two members of the senate, one appointed by the 18 2 president of the senate after consultation with the majority 18 3 leader of the senate and one appointed by the minority leader 18 4 of the senate. 18 53.4. a. An executive committee of the council is created 18 6 and shall consist of the following members of the council: 18 7 (1) As voting members: 18 8 (a) Five of the professional or business entity members 18 9 designated pursuant to subsection 2, paragraph "a", and 18 10 selected by the members specified under that paragraph. 18 11(2)(b) Five of the public members appointed pursuant 18 12 to subsection 2, paragraph "b", and selected by the members 18 13 specified under that paragraph. Of the five public members, at 18 14 least one member shall be a recipient of medical assistance. 18 15(3)(2) As nonvoting members: 18 16 (a) The director of public health, or the director's 18 17 designee. 18 18 (b) The director of the department on aging, or the 18 19 director's designee. 18 20 (c) The state long=term care ombudsman, or the ombudsman's 18 21 designee. 18 22 (d) The ombudsman appointed pursuant to section 2C.3, or the 18 23 ombudsman's designee. 18 24 b. The executive committee shall meet on a monthly basis. 18 25The director of public healthA public member of the executive 18 26 committee selected by the public members appointed pursuant to 18 27 subsection 2, paragraph "b", and a professional or business 18 28 entity member of the executive committee selected by the 18 29 professional or business entity members appointed pursuant 18 30 to subsection 2, paragraph "a", shall serve aschairperson 18 31co=chairpersons of the executive committee. 18 32 c. Based upon the deliberations of the council,andthe 18 33 executive committee, and the subcommittees, the executive 18 34 committee, the council, and the subcommittees, respectively, 18 35 shall make recommendations to the director, to the health 19 1 policy oversight committee created in section 2.45, to the 19 2 general assembly's joint appropriations subcommittee on health 19 3 and human services, and to the general assembly's standing 19 4 committees on human resources regarding the budget, policy, and 19 5 administration of the medical assistance program. 19 6 5. a. The council shall create the following subcommittees, 19 7 and may create additional subcommittees as necessary to address 19 8 Medicaid program policies, administration, budget, and other 19 9 factors and issues: 19 10 (1) A stakeholder safeguards subcommittee, for which 19 11 the co=chairpersons shall be a public member of the council 19 12 appointed pursuant to subsection 2, paragraph "b", and selected 19 13 by the public members of the council, and a representative 19 14 of a professional or business entity appointed pursuant to 19 15 subsection 2, paragraph "a", and selected by the professional or 19 16 business entity representatives of the council. The mission 19 17 of the stakeholder safeguards subcommittee is to provide for 19 18 ongoing stakeholder engagement and feedback on issues affecting 19 19 Medicaid recipients, providers, and other stakeholders, 19 20 including but not limited to benefits such as transportation, 19 21 benefit utilization management, the inclusion of out=of=state 19 22 and out=of=network providers and the use of single=case 19 23 agreements, and reimbursement of providers and services. 19 24 (2) The long=term services and supports subcommittee 19 25 which shall be chaired by the state long=term care ombudsman, 19 26 or the ombudsman's designee. The mission of the long=term 19 27 services and supports subcommittee is to be a resource and to 19 28 provide advice on policy development and program administration 19 29 relating to Medicaid long=term services and supports including 19 30 but not limited to developing outcomes and performance 19 31 measures for Medicaid managed care for the long=term services 19 32 and supports population; addressing issues related to home 19 33 and community=based services waivers and waiting lists; and 19 34 reviewing the system of long=term services and supports to 19 35 ensure provision of home and community=based services and the 20 1 rebalancing of the health care infrastructure in accordance 20 2 with state and federal law including but not limited to the 20 3 principles established in Olmstead v. L.C., 527 U.S. 581 20 4 (1999) and the federal Americans with Disabilities Act and 20 5 in a manner that reflects a sustainable, person=centered 20 6 approach to improve health and life outcomes, supports 20 7 maximum independence, addresses medical and social needs in a 20 8 coordinated, integrated manner, and provides for sufficient 20 9 resources including a stable, well=qualified workforce. The 20 10 subcommittee shall also address and make recommendations 20 11 regarding the need for an ombudsman function for eligible and 20 12 potentially eligible Medicaid recipients beyond the long=term 20 13 services and supports population. 20 14 (3) The transparency, data, and program evaluation 20 15 subcommittee which shall be chaired by the director of the 20 16 university of Iowa public policy center, or the director's 20 17 designee. The mission of the transparency, data, and program 20 18 evaluation subcommittee is to ensure Medicaid program 20 19 transparency; ensure the collection, maintenance, retention, 20 20 reporting, and analysis of sufficient and meaningful data to 20 21 provide transparency and inform policy development and program 20 22 effectiveness; support development and administration of a 20 23 consumer=friendly dashboard; and promote the ongoing evaluation 20 24 of Medicaid stakeholder satisfaction with the Medicaid program. 20 25 (4) The program integrity subcommittee which shall be 20 26 chaired by the Medicaid director, or the director's designee. 20 27 The mission of the program integrity subcommittee is to ensure 20 28 that a comprehensive system including specific policies, laws, 20 29 and rules and adequate resources and measures are in place to 20 30 effectively administer the program and to maintain compliance 20 31 with federal and state program integrity requirements. 20 32 (5) A health workforce subcommittee, co=chaired by the 20 33 bureau chief of the bureau of oral and health delivery systems 20 34 of the department of public health, or the bureau chief's 20 35 designee, and the director of the national alliance on mental 21 1 illness of Iowa, or the director's designee. The mission of 21 2 the health workforce subcommittee is to assess the sufficiency 21 3 and proficiency of the current and projected health workforce; 21 4 identify barriers to and gaps in health workforce development 21 5 initiatives and health workforce data to provide foundational, 21 6 evidence=based information to inform policymaking and resource 21 7 allocation; evaluate the most efficient application and 21 8 utilization of roles, functions, responsibilities, activities, 21 9 and decision=making capacity of health care professionals and 21 10 other allied and support personnel; and make recommendations 21 11 for improvement in, and alternative modes of, health care 21 12 delivery in order to provide a competent, diverse, and 21 13 sustainable health workforce in the state. The subcommittee 21 14 shall work in collaboration with the office of statewide 21 15 clinical education programs of the university of Iowa Carver 21 16 college of medicine, Des Moines university, Iowa workforce 21 17 development, and other entities with interest or expertise in 21 18 the health workforce in carrying out the subcommittee's duties 21 19 and developing recommendations. 21 20 b. The co=chairpersons of the council shall appoint 21 21 members to each subcommittee from the general membership of 21 22 the council. Consideration in appointing subcommittee members 21 23 shall include the individual's knowledge about, and interest or 21 24 expertise in, matters that come before the subcommittee. 21 25 c. Subcommittees shall meet at the call of the 21 26 co=chairpersons or chairperson of the subcommittee, or at the 21 27 request of a majority of the members of the subcommittee. 21 284.6. For each council meeting, executive committee 21 29 meeting, or subcommittee meeting, a quorum shall consist of 21 30 fifty percent of the membership qualified to vote. Where a 21 31 quorum is present, a position is carried by a majority of the 21 32 members qualified to vote. 21 33 7. For each council meeting, other than those held during 21 34 the time the general assembly is in session, each legislative 21 35 member of the council shall be reimbursed for actual travel 22 1 and other necessary expenses and shall receive a per diem 22 2 as specified in section 7E.6 for each day in attendance, as 22 3 shall the members of the council,orthe executive committee, 22 4 or a subcommittee, for each day in attendance at a council, 22 5 executive committee, or subcommittee meeting, who are 22 6 recipients or the family members of recipients of medical 22 7 assistance, regardless of whether the general assembly is in 22 8 session. 22 95.8. The department shall provide staff support and 22 10 independent technical assistance to the council,andthe 22 11 executive committee, and the subcommittees. 22 126.9. The director shallconsidercomply with the 22 13 requirements of this section regarding the duties of the 22 14 council, and the deliberations and recommendationsoffered 22 15 byof the council,andthe executive committee, and the 22 16 subcommittees shall be reflected in the director's preparation 22 17 of medical assistance budget recommendations to the council on 22 18 human services pursuant to section 217.3,andin implementation 22 19 of medical assistance program policies, and in administration 22 20 of the Medicaid program. 22 21 10. The council, executive committee, and subcommittees 22 22 shall jointly submit quarterly reports to the health policy 22 23 oversight committee created in section 2.45 and shall jointly 22 24 submit a report to the governor and the general assembly 22 25 initially by January 1, 2017, and annually, therefore, 22 26 summarizing the outcomes and findings of their respective 22 27 deliberations and any recommendations including but not limited 22 28 to those for changes in law or policy. 22 29 11. The council, executive committee, and subcommittees 22 30 may enlist the services of persons who are qualified by 22 31 education, expertise, or experience to advise, consult with, 22 32 or otherwise assist the council, executive committee, or 22 33 subcommittees in the performance of their duties. The council, 22 34 executive committee, or subcommittees may specifically enlist 22 35 the assistance of entities such as the university of Iowa 23 1 public policy center to provide ongoing evaluation of the 23 2 Medicaid program and to make evidence=based recommendations to 23 3 improve the program. The council, executive committee, and 23 4 subcommittees shall enlist input from the patient=centered 23 5 health advisory council created in section 135.159, the mental 23 6 health and disabilities services commission created in section 23 7 225C.5, the commission on aging created in section 231.11, 23 8 the bureau of substance abuse of the department of public 23 9 health, the Iowa developmental disabilities council, and other 23 10 appropriate state and local entities to provide advice to the 23 11 council, executive committee, and subcommittees. 23 12 12. The department, in accordance with 42 C.F.R. {431.12, 23 13 shall seek federal financial participation for the activities 23 14 of the council, the executive committee, and the subcommittees. 23 15 PATIENT=CENTERED HEALTH RESOURCES AND INFRASTRUCTURE 23 16 Sec. 9. Section 135.159, subsection 2, Code 2016, is amended 23 17 to read as follows: 23 18 2. a. The department shall establish a patient=centered 23 19 health advisory council which shall include but is not limited 23 20 to all of the following members, selected by their respective 23 21 organizations, and any other members the department determines 23 22 necessary to assist in thedepartment's duties at various 23 23 stages ofdevelopment of the medical home system and in the 23 24 transformation to a patient=centered infrastructure that 23 25 integrates and coordinates services and supports to address 23 26 social determinants of health and meet population health goals: 23 27 (1) The director of human services, or the director's 23 28 designee. 23 29 (2) The commissioner of insurance, or the commissioner's 23 30 designee. 23 31 (3) A representative of the federation of Iowa insurers. 23 32 (4) A representative of the Iowa dental association. 23 33 (5) A representative of the Iowa nurses association. 23 34 (6) A physician and an osteopathic physician licensed 23 35 pursuant to chapter 148 who are family physicians and members 24 1 of the Iowa academy of family physicians. 24 2 (7) A health care consumer. 24 3 (8) A representative of the Iowa collaborative safety net 24 4 provider network established pursuant to section 135.153. 24 5 (9) A representative of the Iowa developmental disabilities 24 6 council. 24 7 (10) A representative of the Iowa chapter of the American 24 8 academy of pediatrics. 24 9 (11) A representative of the child and family policy center. 24 10 (12) A representative of the Iowa pharmacy association. 24 11 (13) A representative of the Iowa chiropractic society. 24 12 (14) A representative of the university of Iowa college of 24 13 public health. 24 14 (15) A representative of the Iowa public health 24 15 association. 24 16 (16) A representative of the area agencies on aging. 24 17 (17) A representative of the mental health and disability 24 18 services regions. 24 19 (18) A representative of early childhood Iowa. 24 20 b. Public members of the patient=centered health advisory 24 21 council shall receive reimbursement for actual expenses 24 22 incurred while serving in their official capacity only if they 24 23 are not eligible for reimbursement by the organization that 24 24 they represent. 24 25 c. (1) Beginning July 1, 2016, the patient=centered health 24 26 advisory council shall do all of the following: 24 27 (a) Review and make recommendations to the department and 24 28 to the general assembly regarding the building of effective 24 29 working relationships and strategies to support state=level 24 30 and community=level integration, to provide cross=system 24 31 coordination and synchronization, and to more appropriately 24 32 align health delivery models and service sectors, including but 24 33 not limited to public health, aging and disability services 24 34 agencies, mental health and disability services regions, 24 35 social services, child welfare, and other providers, agencies, 25 1 organizations, and sectors to address social determinants of 25 2 health, holistic well=being, and population health goals. Such 25 3 review and recommendations shall include a review of funding 25 4 streams and recommendations for blending and braiding funding 25 5 to support these efforts. 25 6 (b) Assist in efforts to evaluate the health workforce to 25 7 inform policymaking and resource allocation. 25 8 (2) The patient=centered health advisory council shall 25 9 submit a report to the department, the health policy oversight 25 10 committee created in section 2.45, and the general assembly, 25 11 initially, on or before December 15, 2016, and on or before 25 12 December 15, annually, thereafter, including any findings or 25 13 recommendations resulting from the council's deliberations. 25 14 HAWK=I PROGRAM 25 15 Sec. 10. Section 514I.5, subsection 8, paragraph d, Code 25 16 2016, is amended by adding the following new subparagraph: 25 17 NEW SUBPARAGRAPH. (17) Occupational therapy. 25 18 Sec. 11. Section 514I.5, subsection 8, Code 2016, is amended 25 19 by adding the following new paragraph: 25 20 NEW PARAGRAPH. m. The definition of medically necessary 25 21 and the utilization management criteria under the hawk=i 25 22 program in order to ensure that benefits are uniformly and 25 23 consistently provided across all participating insurers in 25 24 the type and manner that reflects and appropriately meets 25 25 the needs, including but not limited to the habilitative and 25 26 rehabilitative needs, of the child population including those 25 27 children with special health care needs. 25 28 MEDICAID PROGRAM POLICY IMPROVEMENT 25 29 Sec. 12. DIRECTIVES FOR MEDICAID PROGRAM POLICY 25 30 IMPROVEMENTS. In order to safeguard the interests of Medicaid 25 31 recipients, encourage the participation of Medicaid providers, 25 32 and protect the interests of all taxpayers, the department of 25 33 human services shall comply with or ensure that the specified 25 34 entity complies with all of the following and shall amend 25 35 Medicaid managed care contract provisions as necessary to 26 1 reflect all of the following: 26 2 1. CONSUMER PROTECTIONS. 26 3 a. In accordance with 42 C.F.R. {438.420, a Medicaid managed 26 4 care organization shall continue a recipient's benefits during 26 5 an appeal process. If, as allowed when final resolution of 26 6 an appeal is adverse to the Medicaid recipient, the Medicaid 26 7 managed care organization chooses to recover the costs of the 26 8 services furnished to the recipient while an appeal is pending, 26 9 the Medicaid managed care organization shall provide adequate 26 10 prior notice of potential recovery of costs to the recipient at 26 11 the time the appeal is filed, and any costs recovered shall be 26 12 remitted to the department of human services and deposited in 26 13 the Medicaid reinvestment fund created in section 249A.4C. 26 14 b. Ensure that each Medicaid managed care organization 26 15 provides, at a minimum, all the benefits and services deemed 26 16 medically necessary that were covered, including to the 26 17 extent and in the same manner and subject to the same prior 26 18 authorization criteria, by the state program directly under 26 19 fee for service prior to January 1, 2016. Benefits covered 26 20 through Medicaid managed care shall comply with the specific 26 21 requirements in state law applicable to the respective Medicaid 26 22 recipient population under fee for service. 26 23 c. Enhance monitoring of the reduction in or suspension 26 24 or termination of services provided to Medicaid recipients, 26 25 including reductions in the provision of home and 26 26 community=based services waiver services or increases in home 26 27 and community=based services waiver waiting lists. Medicaid 26 28 managed care organizations shall provide data to the department 26 29 as necessary for the department to compile periodic reports on 26 30 the numbers of individuals transferred from state institutions 26 31 and long=term care facilities to home and community=based 26 32 services, and the associated savings. Any savings resulting 26 33 from the transfers as certified by the department shall be 26 34 deposited in the Medicaid reinvestment fund created in section 26 35 249A.4C. 27 1 d. (1) Require each Medicaid managed care organization to 27 2 adhere to reasonableness and service authorization standards 27 3 that are appropriate for and do not disadvantage those 27 4 individuals who have ongoing chronic conditions or who require 27 5 long=term services and supports. Services and supports for 27 6 individuals with ongoing chronic conditions or who require 27 7 long=term services and supports shall be authorized in a manner 27 8 that reflects the recipient's continuing need for such services 27 9 and supports, and limits shall be consistent with a recipient's 27 10 current needs assessment and person=centered service plan. 27 11 (2) In addition to other provisions relating to 27 12 community=based case management continuity of care 27 13 requirements, Medicaid managed care contractors shall provide 27 14 the option to the case manager of a Medicaid recipient who 27 15 retained the case manager during the six months of transition 27 16 to Medicaid managed care, if the recipient chooses to continue 27 17 to retain that case manager beyond the six=month transition 27 18 period and if the case manager is not otherwise a participating 27 19 provider of the recipient's managed care organization provider 27 20 network, to enter into a single case agreement to continue to 27 21 provide case management services to the Medicaid recipient. 27 22 e. Ensure that Medicaid recipients are provided care 27 23 coordination and case management by appropriately trained 27 24 professionals in a conflict=free manner. Care coordination and 27 25 case management shall be provided in a patient=centered and 27 26 family=centered manner that requires a knowledge of community 27 27 supports, a reasonable ratio of care coordinators and case 27 28 managers to Medicaid recipients, standards for frequency of 27 29 contact with the Medicaid recipient, and specific and adequate 27 30 reimbursement. 27 31 f. A Medicaid managed care contract shall include a 27 32 provision for continuity and coordination of care for a 27 33 consumer transitioning to Medicaid managed care, including 27 34 maintaining existing provider=recipient relationships and 27 35 honoring the amount, duration, and scope of a recipient's 28 1 authorized services based on the recipient's medical history 28 2 and needs. In the initial transition to Medicaid managed care, 28 3 to ensure the least amount of disruption, Medicaid managed 28 4 care organizations shall provide, at a minimum, a one=year 28 5 transition of care period for all provider types, regardless 28 6 of network status with an individual Medicaid managed care 28 7 organization. 28 8 g. Ensure that a Medicaid managed care organization does 28 9 not arbitrarily deny coverage for medically necessary services 28 10 based solely on financial reasons and does not shift the 28 11 responsibility for provision of services or payment of costs of 28 12 services to another entity to avoid costs or attain savings. 28 13 h. Ensure that dental coverage, if not integrated into 28 14 an overall Medicaid managed care contract, is part of the 28 15 overall holistic, integrated coverage for physical, behavioral, 28 16 and long=term services and supports provided to a Medicaid 28 17 recipient. 28 18 i. Require each Medicaid managed care organization to 28 19 verify the offering and actual utilization of services and 28 20 supports and value=added services, an individual recipient's 28 21 encounters and the costs associated with each encounter, and 28 22 requests and associated approvals or denials of services. 28 23 Verification of actual receipt of services and supports and 28 24 value=added services shall, at a minimum, consist of comparing 28 25 receipt of service against both what was authorized in the 28 26 recipient's benefit or service plan and what was actually 28 27 reimbursed. Value=added services shall not be reportable as 28 28 allowable medical or administrative costs or factored into rate 28 29 setting, and the costs of value=added services shall not be 28 30 passed on to recipients or providers. 28 31 j. Provide periodic reports to the governor and the general 28 32 assembly regarding changes in quality of care and health 28 33 outcomes for Medicaid recipients under managed care compared to 28 34 quality of care and health outcomes of the same populations of 28 35 Medicaid recipients prior to January 1, 2016. 29 1 k. Require each Medicaid managed care organization to 29 2 maintain records of complaints, grievances, and appeals, and 29 3 report the number and types of complaints, grievances, and 29 4 appeals filed, the resolution of each, and a description of 29 5 any patterns or trends identified to the department of human 29 6 services and the health policy oversight committee created 29 7 in section 2.45, on a monthly basis. The department shall 29 8 review and compile the data on a quarterly basis and make the 29 9 compilations available to the public. Following review of 29 10 reports submitted by the department, a Medicaid managed care 29 11 organization shall take any corrective action required by the 29 12 department and shall be subject to any applicable penalties. 29 13 l. Require Medicaid managed care organizations to survey 29 14 Medicaid recipients, to collect satisfaction data using a 29 15 uniform instrument, and to provide a detailed analysis of 29 16 recipient satisfaction as well as various metrics regarding the 29 17 volume of and timelines in responding to recipient complaints 29 18 and grievances as directed by the department of human services. 29 19 m. Require managed care organizations to allow a recipient 29 20 to request that the managed care organization enter into 29 21 a single case agreement with a recipient's out=of=network 29 22 provider, including a provider outside of the state, to provide 29 23 for continuity of care when the recipient has an existing 29 24 relationship with the provider to provide a covered benefit, or 29 25 to ensure adequate or timely access to a provider of a covered 29 26 benefit when the managed care organization provider network 29 27 cannot ensure such adequate or timely access. 29 28 2. CHILDREN. 29 29 a. (1) The hawk=i board shall retain all authority 29 30 specified under chapter 514I relative to the children eligible 29 31 under section 514I.8 to participate in the hawk=i program, 29 32 including but not limited to approving any contract entered 29 33 into pursuant to chapter 514I; approving the benefit package 29 34 design, reviewing the benefit package design, and making 29 35 necessary changes to reflect the results of the reviews; and 30 1 adopting rules for the hawk=i program including those related 30 2 to qualifying standards for selecting participating insurers 30 3 for the program and the benefits to be included in a health 30 4 plan. 30 5 (2) The hawk=i board shall review benefit plans and 30 6 utilization review provisions and ensure that benefits provided 30 7 to children under the hawk=i program, at a minimum, reflect 30 8 those required by state law as specified in section 514I.5, 30 9 include both habilitative and rehabilitative services, and 30 10 are provided as medically necessary relative to the child 30 11 population served and based on the needs of the program 30 12 recipient and the program recipient's medical history. 30 13 (3) The hawk=i board shall work with the department of human 30 14 services to coordinate coverage and care for the population 30 15 of children in the state eligible for either Medicaid or 30 16 hawk=i coverage so that, to the greatest extent possible, 30 17 the two programs provide for continuity of care as children 30 18 transition between the two programs or to private health care 30 19 coverage. To this end, all contracts with participating 30 20 insurers providing coverage under the hawk=i program and with 30 21 all managed care organizations providing coverage for children 30 22 eligible for Medicaid shall do all of the following: 30 23 (a) Specifically and appropriately address the unique needs 30 24 of children and children's health delivery. 30 25 (b) Provide for the maintaining of child health panels that 30 26 include representatives of child health, welfare, policy, and 30 27 advocacy organizations in the state that address child health 30 28 and child well=being. 30 29 (c) Address early intervention and prevention strategies, 30 30 the provision of a child health care delivery infrastructure 30 31 for children with special health care needs, utilization of 30 32 current standards and guidelines for children's health care 30 33 and pediatric=specific screening and assessment tools, the 30 34 inclusion of pediatric specialty providers in the provider 30 35 network, and the utilization of health homes for children and 31 1 youth with special health care needs including intensive care 31 2 coordination and family support and access to a professional 31 3 family=to=family support system. Such contracts shall utilize 31 4 pediatric=specific quality measures and assessment tools 31 5 which shall align with existing pediatric=specific measures 31 6 as determined in consultation with the child health panel and 31 7 approved by the hawk=i board. 31 8 (d) Provide special incentives for innovative and 31 9 evidence=based preventive, behavioral, and developmental 31 10 health care and mental health care for children's programs that 31 11 improve the life course trajectory of these children. 31 12 (e) Provide that information collected from the 31 13 pediatric=specific assessments be used to identify health risks 31 14 and social determinants of health that impact health outcomes. 31 15 Such data shall be used in care coordination and interventions 31 16 to improve patient outcomes and to drive program designs that 31 17 improve the health of the population. Aggregate assessment 31 18 data shall be shared with affected providers on a routine 31 19 basis. 31 20 b. In order to monitor the quality of and access to health 31 21 care for children receiving coverage under the Medicaid 31 22 program, each Medicaid managed care organization shall 31 23 uniformly report, in a template format designated by the 31 24 department of human services, the number of claims submitted by 31 25 providers and the percentage of claims approved by the Medicaid 31 26 managed care organization for the early and periodic screening, 31 27 diagnostic, and treatment (EPSDT) benefit based on the Iowa 31 28 EPSDT care for kids health maintenance recommendations, 31 29 including but not limited to physical exams, immunizations, the 31 30 seven categories of developmental and behavioral screenings, 31 31 vision and hearing screenings, and lead testing. 31 32 3. PROVIDER PARTICIPATION ENHANCEMENT. 31 33 a. Ensure that savings achieved through Medicaid managed 31 34 care does not come at the expense of further reductions in 31 35 provider rates. The department shall ensure that Medicaid 32 1 managed care organizations use reasonable reimbursement 32 2 standards for all provider types and compensate providers for 32 3 covered services at not less than the minimum reimbursement 32 4 established by state law applicable to fee for service for a 32 5 respective provider, service, or product for a fiscal year 32 6 and as determined in conjunction with actuarially sound rate 32 7 setting procedures. Such reimbursement shall extend for the 32 8 entire duration of a managed care contract. 32 9 b. To enhance continuity of care in the provision of 32 10 pharmacy services, Medicaid managed care organizations shall 32 11 utilize the same preferred drug list, recommended drug list, 32 12 prior authorization criteria, and other utilization management 32 13 strategies that apply to the state program directly under fee 32 14 for service and shall apply other provisions of applicable 32 15 state law including those relating to chemically unique mental 32 16 health prescription drugs. Reimbursement rates established 32 17 under Medicaid managed care contracts for ingredient cost 32 18 reimbursement and dispensing fees shall be subject to and shall 32 19 reflect provisions of state and federal law, including the 32 20 minimum reimbursements established in state law for fee for 32 21 service for a fiscal year. 32 22 c. Address rate setting and reimbursement of the entire 32 23 scope of services provided under the Medicaid program to 32 24 ensure the adequacy of the provider network and to ensure 32 25 that providers that contribute to the holistic health of the 32 26 Medicaid recipient, whether inside or outside of the provider 32 27 network, are compensated for their services. 32 28 d. Managed care contractors shall submit financial 32 29 documentation to the department of human services demonstrating 32 30 payment of claims and expenses by provider type. 32 31 e. Participating Medicaid providers under a managed care 32 32 contract shall be allowed to submit claims for up to 365 days 32 33 following discharge of a Medicaid recipient from a hospital or 32 34 following the date of service. 32 35 f. (1) A managed care contract entered into on or after 33 1 July 1, 2015, shall, at a minimum, reflect all of the following 33 2 provisions and requirements, and shall extend the following 33 3 payment rates based on the specified payment floor, as 33 4 applicable to the provider type: 33 5 (a) In calculating the rates for prospective payment system 33 6 hospitals, the following base rates shall be used: 33 7 (i) The inpatient diagnostic related group base rates and 33 8 certified unit per diem in effect on October 1, 2015. 33 9 (ii) The outpatient ambulatory payment classification base 33 10 rates in effect on July 1, 2015. 33 11 (iii) The inpatient psychiatric certified unit per diem in 33 12 effect on October 1, 2015. 33 13 (iv) The inpatient physical rehabilitation certified unit 33 14 per diem in effect on October 1, 2015. 33 15 (b) In calculating the critical access hospital payment 33 16 rates, the following base rates shall be used: 33 17 (i) The inpatient diagnostic related group base rates in 33 18 effect on July 1, 2015. 33 19 (ii) The outpatient cost=to=charge ratio in effect on July 33 20 1, 2015. 33 21 (iii) The swing bed per diem in effect on July 1, 2015. 33 22 (c) Critical access hospitals shall receive cost=based 33 23 reimbursement for one hundred percent of the reasonable costs 33 24 for the provision of services to Medicaid recipients. 33 25 (d) Critical access hospitals shall submit annual cost 33 26 reports and managed care contractors shall submit annual 33 27 payment reports to the department of human services. The 33 28 department shall reconcile the critical access hospital's 33 29 reported costs with the managed care contractor's reported 33 30 payments. The department shall require the managed care 33 31 contractor to retroactively reimburse a critical access 33 32 hospital for underpayments. 33 33 (e) Community mental health centers shall receive one 33 34 hundred percent of the reasonable costs for the provision of 33 35 services to Medicaid recipients. 34 1 (f) Federally qualified health centers shall receive 34 2 cost=based reimbursement for one hundred percent of the 34 3 reasonable costs for the provision of services to Medicaid 34 4 recipients. 34 5 (g) The reimbursement rates for substance=related disorder 34 6 treatment programs licensed under section 125.13, shall be no 34 7 lower than the rates in effect for the fiscal year beginning 34 8 July 1, 2015. 34 9 (2) For managed care contract periods subsequent to the 34 10 initial contract period, base rates for prospective payment 34 11 system hospitals and critical access hospitals shall be 34 12 calculated using the base rate for the prior contract period 34 13 plus 3 percent. Prospective payment system hospital and 34 14 critical access hospital base rates shall at no time be less 34 15 than the previous contract period's base rates. 34 16 (3) A managed care contract shall require out=of=network 34 17 prospective payment system hospital and critical access 34 18 hospital payment rates to meet or exceed ninety=nine percent of 34 19 the rates specified for the respective in=network hospitals in 34 20 accordance with this paragraph "f". 34 21 g. If the department of human services collects ownership 34 22 and control information from Medicaid providers pursuant to 42 34 23 C.F.R. {455.104, a managed care organization under contract 34 24 with the state shall not also require submission of this 34 25 information from approved enrolled Medicaid providers. 34 26 h. (1) Ensure that a Medicaid managed care organization 34 27 develops and maintains a provider network of qualified 34 28 providers who meet state licensing, credentialing, and 34 29 certification requirements, as applicable, which network shall 34 30 be sufficient to provide adequate access to all services 34 31 covered and for all populations served under the managed 34 32 care contract. Medicaid managed care organizations shall 34 33 incorporate existing and traditional providers, including 34 34 but not limited to those providers that comprise the Iowa 34 35 collaborative safety net provider network created in section 35 1 135.153, into their provider networks. 35 2 (2) Ensure that respective Medicaid populations are 35 3 managed at all times within funding limitations and contract 35 4 terms. The department shall also monitor service delivery 35 5 and utilization to ensure the responsibility for provision 35 6 of services to Medicaid recipients is not shifted to 35 7 non=Medicaid covered services to attain savings, and that such 35 8 responsibility is not shifted to mental health and disability 35 9 services regions, local public health agencies, aging and 35 10 disability resource centers, or other entities unless agreement 35 11 to provide, and provision for adequate compensation for, such 35 12 services is agreed to between the affected entities in advance. 35 13 i. Medicaid managed care organizations shall provide an 35 14 enrolled Medicaid provider approved by the department of 35 15 human services the opportunity to be a participating network 35 16 provider. 35 17 j. Medicaid managed care organizations shall include 35 18 provider appeals and grievance procedures that in part allow 35 19 a provider to file a grievance independently but on behalf 35 20 of a Medicaid recipient and to appeal claims denials which, 35 21 if determined to be based on claims for medically necessary 35 22 services whether or not denied on an administrative basis, 35 23 shall receive appropriate payment. 35 24 k. (1) Medicaid managed care organizations shall include 35 25 as primary care providers any provider designated by the state 35 26 as a primary care provider, subject to a provider's respective 35 27 state certification standards, including but not limited to all 35 28 of the following: 35 29 (a) A physician who is a family or general practitioner, a 35 30 pediatrician, an internist, an obstetrician, or a gynecologist. 35 31 (b) An advanced registered nurse practitioner. 35 32 (c) A physician assistant. 35 33 (d) A chiropractor licensed pursuant to chapter 151. 35 34 (2) A Medicaid managed care organization shall not impose 35 35 more restrictive, additional, or different scope of practice 36 1 requirements or standards of practice on a primary care 36 2 provider than those prescribed by state law as a prerequisite 36 3 for participation in the managed care organization's provider 36 4 network. 36 5 4. CAPITATION RATES AND MEDICAL LOSS RATIO. 36 6 a. Capitation rates shall be developed based on all 36 7 reasonable, appropriate, and attainable costs. Costs that are 36 8 not reasonable, appropriate, or attainable, including but not 36 9 limited to improper payment recoveries, shall not be included 36 10 in the development of capitated rates. 36 11 b. Capitation rates for Medicaid recipients falling within 36 12 different rate cells shall not be expected to cross=subsidize 36 13 one another and the data used to set capitation rates shall 36 14 be relevant and timely and tied to the appropriate Medicaid 36 15 population. 36 16 c. Any increase in capitation rates for managed care 36 17 contractors is subject to prior statutory approval and shall 36 18 not exceed three percent over the existing capitation rate 36 19 in any one=year period or five percent over the existing 36 20 capitation rate in any two=year period. 36 21 d. In addition to withholding two percent of a managed 36 22 care organization's annual capitation payment as a 36 23 pay=for=performance enforcement mechanism, the department of 36 24 human services shall also withhold an additional two percent of 36 25 a managed care organization's annual capitation payment until 36 26 the department is able to ensure that the respective managed 36 27 care organization has complied with all requirements relating 36 28 to data, information, transparency, evaluation, and oversight 36 29 specified by law, rule, contract, or other basis. 36 30 e. The department of human services shall collect an initial 36 31 contribution of five million dollars from each of the managed 36 32 care organizations contracting with the state during the fiscal 36 33 year beginning July 1, 2015, for an aggregate amount of fifteen 36 34 million dollars, and shall deposit such amount in the Medicaid 36 35 reinvestment fund, as provided in section 249A.4C, as enacted 37 1 in this Act, to be used for Medicaid ombudsman activities 37 2 through the office of long=term care ombudsman. 37 3 f. A managed care contract shall impose a minimum Medicaid 37 4 loss ratio of at least eighty=eight percent. In calculating 37 5 the medical loss ratio, medical costs or benefit expenses shall 37 6 include only those costs directly related to patient medical 37 7 care and not ancillary expenses, including but not limited to 37 8 any of the following: 37 9 (1) Program integrity activities. 37 10 (2) Utilization review activities. 37 11 (3) Fraud prevention activities beyond the scope of those 37 12 activities necessary to recover incurred claims. 37 13 (4) Provider network development, education, or management 37 14 activities. 37 15 (5) Provider credentialing activities. 37 16 (6) Marketing expenses. 37 17 (7) Administrative costs associated with recipient 37 18 incentives. 37 19 (8) Clinical data collection activities. 37 20 (9) Claims adjudication expenses. 37 21 (10) Customer service or health care professional hotline 37 22 services addressing nonclinical recipient questions. 37 23 (11) Value=added or cost=containment services, wellness 37 24 programs, disease management, and case management or care 37 25 coordination programs. 37 26 (12) Health quality improvement activities unless 37 27 specifically approved as a medical cost by state law. Costs of 37 28 health quality improvement activities included in determining 37 29 the medical loss ratio shall be only those activities that are 37 30 independent improvements measurable in individual patients. 37 31 (13) Insurer claims review activities. 37 32 (14) Information technology costs unless they directly 37 33 and credibly improve the quality of health care and do not 37 34 duplicate, conflict with, or fail to be compatible with similar 37 35 health information technology efforts of providers. 38 1 (15) Legal department costs including information 38 2 technology costs, expenses incurred for review and denial of 38 3 claims, legal costs related to defending claims, settlements 38 4 for wrongly denied claims, and costs related to administrative 38 5 claims handling including salaries of administrative personnel 38 6 and legal costs. 38 7 (16) Taxes unrelated to premiums or the provision of medical 38 8 care. Only state and federal taxes and licensing or regulatory 38 9 fees relevant to actual premiums collected, not including such 38 10 taxes and fees as property taxes, taxes on investment income, 38 11 taxes on investment property, and capital gains taxes, may be 38 12 included in determining the medical loss ratio. 38 13 g. (1) Provide enhanced guidance and criteria for defining 38 14 medical and administrative costs, recoveries, and rebates 38 15 including pharmacy rebates, and the recording, reporting, and 38 16 recoupment of such costs, recoveries, and rebates realized. 38 17 (2) Medicaid managed care organizations shall offset 38 18 recoveries, rebates, and refunds against medical costs, include 38 19 only allowable administrative expenses in the determination of 38 20 administrative costs, report costs related to subcontractors 38 21 properly, and have complete systems checks and review processes 38 22 to identify overpayment possibilities. 38 23 (3) Medicaid managed care contractors shall submit publicly 38 24 available, comprehensive financial statements to the department 38 25 of human services to verify that the minimum medical loss ratio 38 26 is being met and shall be subject to periodic audits. 38 27 5. DATA AND INFORMATION, EVALUATION, AND OVERSIGHT. 38 28 a. Develop and administer a clear, detailed policy 38 29 regarding the collection, storage, integration, analysis, 38 30 maintenance, retention, reporting, sharing, and submission 38 31 of data and information from the Medicaid managed care 38 32 organizations and shall require each Medicaid managed care 38 33 organization to have in place a data and information system to 38 34 ensure that accurate and meaningful data is available. At a 38 35 minimum, the data shall allow the department to effectively 39 1 measure and monitor Medicaid managed care organization 39 2 performance, quality, outcomes including recipient health 39 3 outcomes, service utilization, finances, program integrity, 39 4 the appropriateness of payments, and overall compliance with 39 5 contract requirements; perform risk adjustments and determine 39 6 actuarially sound capitation rates and appropriate provider 39 7 reimbursements; verify that the minimum medical loss ratio is 39 8 being met; ensure recipient access to and use of services; 39 9 create quality measures; and provide for program transparency. 39 10 b. Medicaid managed care organizations shall directly 39 11 capture and retain and shall report actual and detailed 39 12 medical claims costs and administrative cost data to the 39 13 department as specified by the department. Medicaid managed 39 14 care organizations shall allow the department to thoroughly and 39 15 accurately monitor the medical claims costs and administrative 39 16 costs data Medicaid managed care organizations report to the 39 17 department. 39 18 c. Any audit of Medicaid managed care contracts shall ensure 39 19 compliance including with respect to appropriate medical costs, 39 20 allowable administrative costs, the medical loss ratio, cost 39 21 recoveries, rebates, overpayments, and with specific contract 39 22 performance requirements. 39 23 d. The external quality review organization contracting 39 24 with the department shall review the Medicaid managed care 39 25 program to determine if the state has sufficient infrastructure 39 26 and controls in place to effectively oversee the Medicaid 39 27 managed care organizations and the Medicaid program in order 39 28 to ensure, at a minimum, compliance with Medicaid managed 39 29 care organization contracts and to prevent fraud, abuse, and 39 30 overpayments. The results of any external quality review 39 31 organization review shall be submitted to the governor, the 39 32 general assembly, and the health policy oversight committee 39 33 created in section 2.45. 39 34 e. Publish benchmark indicators based on Medicaid program 39 35 outcomes from the fiscal year beginning July 1, 2015, to 40 1 be used to compare outcomes of the Medicaid program as 40 2 administered by the state program prior to July 1, 2015, to 40 3 those outcomes of the program under Medicaid managed care. The 40 4 outcomes shall include a comparison of actual costs of the 40 5 program as administered prior to and after implementation of 40 6 Medicaid managed care. The data shall also include specific 40 7 detail regarding the actual expenses incurred by each managed 40 8 care organization by specific provider line of service. 40 9 f. Review and approve or deny approval of contract 40 10 amendments on an ongoing basis to provide for continuous 40 11 improvement in Medicaid managed care and to incorporate any 40 12 changes based on changes in law or policy. 40 13 g. (1) Require managed care contractors to track and report 40 14 on a monthly basis to the department of human services, at a 40 15 minimum, all of the following: 40 16 (a) The number and details relating to prior authorization 40 17 requests and denials. 40 18 (b) The ten most common reasons for claims denials. 40 19 Information reported by a managed care contractor relative 40 20 to claims shall also include the number of claims denied, 40 21 appealed, and overturned based on provider type and service 40 22 type. 40 23 (c) Utilization of health care services by diagnostic 40 24 related group and ambulatory payment classification as well as 40 25 total claims volume. 40 26 (2) The department shall ensure the validity of all 40 27 information submitted by a Medicaid managed care organization 40 28 and shall make the monthly reports available to the public. 40 29 h. Medicaid managed care organizations shall maintain 40 30 stakeholder panels comprised of an equal number of Medicaid 40 31 recipients and providers. Medicaid managed care organizations 40 32 shall provide for separate provider=specific panels to address 40 33 detailed payment, claims, process, and other issues as well as 40 34 grievance and appeals processes. 40 35 i. Medicaid managed care contracts shall align economic 41 1 incentives, delivery system reforms, and performance and 41 2 outcome metrics with those of the state innovation models 41 3 initiatives and Medicaid accountable care organizations. 41 4 The department of human services shall develop and utilize 41 5 a common, uniform set of process, quality, and consumer 41 6 satisfaction measures across all Medicaid payors and providers 41 7 that align with those developed through the state innovation 41 8 models initiative and shall ensure that such measures are 41 9 expanded and adjusted to address additional populations and 41 10 to meet population health objectives. Medicaid managed care 41 11 contracts shall include long=term performance and outcomes 41 12 goals that reward success in achieving population health goals 41 13 such as improved community health metrics. 41 14 j. (1) Require consistency and uniformity of processes, 41 15 procedures, and forms across all Medicaid managed care 41 16 organizations to reduce the administrative burden to providers 41 17 and consumers and to increase efficiencies in the program. 41 18 Such requirements shall apply to but are not limited to 41 19 areas of uniform cost and quality reporting, uniform prior 41 20 authorization requirements and procedures, uniform utilization 41 21 management criteria, centralized, uniform, and seamless 41 22 credentialing requirements and procedures, and uniform critical 41 23 incident reporting. 41 24 (2) The department of human services shall establish a 41 25 comprehensive provider credentialing process to be recognized 41 26 and utilized by all Medicaid managed care organization 41 27 contractors. The process shall meet the national committee for 41 28 quality assurance and other appropriate standards. The process 41 29 shall ensure that credentialing is completed in a timely manner 41 30 without disruption to provider billing processes. 41 31 k. Medicaid managed care organizations and any entity with 41 32 which a managed care organization contracts for the performance 41 33 of services shall disclose at no cost to the department all 41 34 discounts, incentives, rebates, fees, free goods, bundling 41 35 arrangements, and other agreements affecting the net cost of 42 1 goods or services provided under a managed care contract. 42 2 Sec. 13. RETROACTIVE APPLICABILITY. The section of this Act 42 3 relating to directives for Medicaid program policy improvements 42 4 applies retroactively to July 1, 2015. 42 5 Sec. 14. EFFECTIVE UPON ENACTMENT. This Act, being deemed 42 6 of immediate importance, takes effect upon enactment. SF 2213 (3) 86 pf/nh/jh
