Senate File 296 - Introduced SENATE FILE 296 BY COMMITTEE ON HUMAN RESOURCES (SUCCESSOR TO SF 71) A BILL FOR An Act relating to integrated care models for the delivery 1 of health care, including but not limited to required 2 utilization of a medical home by individuals currently and 3 newly eligible for coverage under the Medicaid program and 4 including effective date provisions. 5 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 6 TLSB 1441SV (2) 85 pf/rj

S.F. 296 Section 1. Section 135.157, subsections 4 and 6, Code 2013, 1 are amended to read as follows: 2 4. “Medical home” means a team approach to providing health 3 care that originates in a primary care setting; fosters a 4 partnership among the patient, the personal provider, and 5 other health care professionals, and where appropriate, the 6 patient’s family; utilizes the partnership to access and 7 integrate all medical and nonmedical health-related services 8 across all elements of the health care system and the patient’s 9 community as needed by the patient and the patient’s family 10 to achieve maximum health potential; maintains a centralized, 11 comprehensive record of all health-related services to 12 promote continuity of care; and has all of the characteristics 13 specified in section 135.158 . 14 6. “Personal provider” means the patient’s first point of 15 contact in the health care system with a primary care provider 16 who identifies the patient’s health health-related needs and, 17 working with a team of health care professionals and providers 18 of medical and nonmedical health-related services , provides 19 for and coordinates appropriate care to address the health 20 health-related needs identified. 21 Sec. 2. Section 135.158, subsection 2, paragraphs b, c, and 22 d, Code 2013, are amended to read as follows: 23 b. A provider-directed team-based medical practice. The 24 personal provider leads a team of individuals at the practice 25 level who collectively take responsibility for the ongoing 26 health care health-related needs of patients. 27 c. Whole person orientation. The personal provider is 28 responsible for providing for all of a patient’s health care 29 health-related needs or taking responsibility for appropriately 30 arranging health care for health-related services provided 31 by other qualified health care professionals and providers 32 of medical and nonmedical health-related services . This 33 responsibility includes health health-related care at all 34 stages of life including provision of preventive care, 35 -1- LSB 1441SV (2) 85 pf/rj 1/ 14

S.F. 296 acute care, chronic care, preventive services long-term 1 care, transitional care between providers and settings , and 2 end-of-life care. This responsibility includes whole-person 3 care consisting of physical health care including but not 4 limited to oral, vision, and other specialty care, pharmacy 5 management, and behavioral health care. 6 d. Coordination and integration of care. Care is 7 coordinated and integrated across all elements of the 8 complex health care system and the patient’s community. Care 9 coordination and integration provides linkages to community 10 and social supports to address social determinants of health, 11 to engage and support patients in managing their own health, 12 and to track the progress of these community and social 13 supports in providing whole-person care. Care is facilitated 14 by registries, information technology, health information 15 exchanges, and other means to assure that patients receive the 16 indicated care when and where they need and want the care in a 17 culturally and linguistically appropriate manner. 18 Sec. 3. Section 135.159, subsections 1, 9, and 11, Code 19 2013, are amended to read as follows: 20 1. The department shall administer the medical home system. 21 The department shall collaborate with the department of human 22 services in administering medical homes under the medical 23 assistance program. The department shall adopt rules pursuant 24 to chapter 17A necessary to administer the medical home system , 25 and shall collaborate with the department of human services in 26 adopting rules for medical homes under the medical assistance 27 program . 28 9. The department shall coordinate the requirements and 29 activities of the medical home system with the requirements 30 and activities of the dental home for children as described 31 in section 249J.14 , and shall recommend financial incentives 32 for dentists and nondental providers to promote oral health 33 care coordination through preventive dental intervention, early 34 identification of oral disease risk, health care coordination 35 -2- LSB 1441SV (2) 85 pf/rj 2/ 14

S.F. 296 and data tracking, treatment, chronic care management, 1 education and training, parental guidance, and oral health 2 promotions for children. Additionally, the department shall 3 establish requirements for the medical home system to provide 4 linkages to accessible dental homes for adults and older 5 individuals. 6 11. Implementation phases . 7 a. Initial implementation shall require participation 8 in the medical home system of children The department shall 9 collaborate with the department of human services to make 10 medical homes accessible to the greatest extent possible to all 11 of the following no later than January 1, 2015: 12 (1) Children who are recipients of full benefits under the 13 medical assistance program. The department shall work with 14 the department of human services and shall recommend to the 15 general assembly a reimbursement methodology to compensate 16 providers participating under the medical assistance program 17 for participation in the medical home system. 18 b. The department shall work with the department of human 19 services to expand the medical home system to adults 20 (2) Adults who are recipients of full benefits under the 21 medical assistance program and the expansion population under 22 the IowaCare program. The department shall work with including 23 those adults who are recipients of medical assistance under 24 section 249A.3, subsection 1, paragraph “v” . 25 (3) Medicare and dually eligible Medicare and medical 26 assistance program recipients, to the extent approved by the 27 centers for Medicare and Medicaid services of the United States 28 department of health and human services to allow Medicare 29 recipients to utilize the medical home system . 30 c. b. The department shall work with the department of 31 administrative services to allow state employees to utilize the 32 medical home system. 33 d. c. The department shall work with insurers and 34 self-insured companies, if requested, to make the medical 35 -3- LSB 1441SV (2) 85 pf/rj 3/ 14

S.F. 296 home system available to individuals with private health care 1 coverage. 2 d. The department shall assist the department of human 3 services in developing a reimbursement methodology to 4 compensate providers participating under the medical assistance 5 program as a medical home. 6 e. Any integrated care model implemented on or after July 1, 7 2013, that delivers health care to medical assistance program 8 recipients shall incorporate medical homes as its foundation. 9 The medical home shall act as the catalyst in any such 10 integrated care model to ensure compliance with the purposes, 11 characteristics, and implementation plan requirements specified 12 in sections 135.158 and 135.159, including an emphasis on whole 13 person orientation and coordination and integration of both 14 clinical services and nonclinical community and social supports 15 that address social determinants of health. 16 Sec. 4. Section 249A.3, subsection 1, Code 2013, is amended 17 by adding the following new paragraphs: 18 NEW PARAGRAPH . v. Beginning January 1, 2014, in 19 accordance with section 1902(a)(10)(A)(i)(VIII) of the 20 federal Social Security Act, as codified in 42 U.S.C. § 21 1396a(a)(10)(A)(i)(VIII), is an individual who is nineteen 22 years of age or older and under sixty-five years of age; is 23 not pregnant; is not entitled to or enrolled for Medicare 24 benefits under part A, or enrolled for Medicare benefits under 25 part B, of Tit. XVIII of the federal Social Security Act; is 26 not otherwise described in section 1902(a)(10)(A)(i) of the 27 federal Social Security Act; is not exempt pursuant to section 28 1902(k)(3), as codified in 42 U.S.C. § 1396a(k)(3), and whose 29 income as determined under 1902(e)(14) of the federal Social 30 Security Act, as codified in 42 U.S.C. § 1396a(e)(14), does 31 not exceed one hundred thirty-three percent of the poverty 32 line as defined in section 2110(c)(5) of the federal Social 33 Security Act, as codified in 42 U.S.C. § 1397jj(c)(5), for the 34 applicable family size. Notwithstanding any provision to the 35 -4- LSB 1441SV (2) 85 pf/rj 4/ 14

S.F. 296 contrary, individuals eligible for medical assistance under 1 this paragraph shall receive coverage for benefits pursuant 2 to 42 U.S.C. § 1396u-7(b)(1)(D) which are at a minimum those 3 included in the medical assistance state plan benefit package 4 for individuals otherwise eligible under this subsection 1, and 5 adjusted as necessary to provide the essential health benefits 6 as required pursuant to section 1302 of the federal Patient 7 Protection and Affordable Care Act, Pub. L. No. 111-148, and 8 as approved by the United States secretary of health and human 9 services. 10 NEW PARAGRAPH . w. Beginning January 1, 2014, is an 11 individual who meets all of the following requirements: 12 (1) Is under twenty-six years of age. 13 (2) Was in foster care under the responsibility of the state 14 on the date of attaining eighteen years of age or such higher 15 age to which foster care is provided. 16 (3) Was enrolled in the medical assistance program under 17 this chapter while in such foster care. 18 Sec. 5. Section 249A.3, subsection 2, paragraph a, 19 subparagraph (9), Code 2013, is amended by striking the 20 subparagraph. 21 Sec. 6. Section 249J.26, subsection 2, Code 2013, is amended 22 to read as follows: 23 2. This chapter is repealed October December 31, 2013. 24 Sec. 7. Section 249J.26, Code 2013, is amended by adding the 25 following new subsection: 26 NEW SUBSECTION . 3. The department shall prepare a plan for 27 the transition of expansion population members to other health 28 care coverage options beginning January 1, 2014. The options 29 shall include the option of coverage through the medical 30 assistance program as provided in section 249A.3, subsection 1, 31 paragraph “v” , relating to coverage for adults who are nineteen 32 years of age or older and under sixty-five years of age, and 33 the option of coverage through the health benefits exchange 34 established pursuant to the federal Patient Protection and 35 -5- LSB 1441SV (2) 85 pf/rj 5/ 14

S.F. 296 Affordable Care Act, Pub. L. No. 111-148, as amended by the 1 federal Health Care and Education Reconciliation Act of 2010, 2 Pub. L. No. 111-152. To the greatest extent possible, the plan 3 shall maintain and incorporate utilization of the existing 4 medical home and service delivery structure as developed 5 under this chapter, including the utilization of federally 6 qualified health centers, public hospitals, and other safety 7 net providers, in providing access to care. The department 8 shall submit the plan to the governor and the general assembly 9 no later than September 1, 2013. 10 Sec. 8. ADVISORY COUNCIL FOR STATE INNOVATION MODEL 11 INITIATIVE. 12 1. No later than thirty days after the effective date of 13 this Act, the legislative council shall establish a legislative 14 advisory council to guide the development of the design 15 model and implementation plan for the state innovation model 16 grant awarded by the Centers for Medicare and Medicaid of 17 the United States department of health and human services. 18 The legislative advisory council shall consist of members 19 of the general assembly, members of the governor’s advisory 20 committee who developed the grant proposal, and representatives 21 of consumers and health care providers, appointed by the 22 legislative council as necessary to ensure that the process is 23 comprehensive and provides ample opportunity for the variety of 24 stakeholders to participate in the process. 25 2. The legislative advisory council shall provide oversight 26 throughout the process, shall receive periodic progress reports 27 from the department of human services, and shall approve any 28 integrated care model and implementation strategies for the 29 medical assistance program presented by the department of human 30 services, and shall prepare proposed legislation to implement 31 the model and the strategies prior to its submission to the 32 general assembly for approval during the 2014 session of the 33 general assembly. 34 3. The department of human services shall develop the 35 -6- LSB 1441SV (2) 85 pf/rj 6/ 14

S.F. 296 integrated care model based on the goals and strategies 1 included in the state innovation model grant application to 2 improve patient outcomes and satisfaction, while lowering 3 costs, as follows: 4 a. Goals: 5 (1) Ensure the coordination of health care delivery for 6 medical assistance program recipients to address the entire 7 spectrum of an individual’s physical, behavioral, and mental 8 health needs by targeting at a minimum population health, 9 prevention, health promotion, chronic disease management, 10 disability, and long-term care. 11 (2) Emphasize whole person orientation and coordination and 12 integration of both clinical and nonclinical care and supports, 13 to provide individuals with the necessary tools to address 14 determinants of health and to empower individuals to be full 15 participants in their own health. The health care delivery 16 model shall focus on addressing population health through 17 primary and team-based care that incorporates the attributes of 18 a medical home as specified in chapter 135, division XXII. 19 (3) Ensure accessibility of medical assistance program 20 recipients to an adequate and qualified workforce by most 21 efficiently utilizing the skills of the available workforce. 22 (4) Incorporate appropriate incentives that focus on 23 quality outcomes and patient satisfaction, to move from 24 volume-based to value-based purchasing. 25 (5) Provide for alignment of payment methods and quality 26 across health care payers to ensure a unified set of outcomes 27 and to recognize, through reimbursement, all participants in 28 the integrated system of care. 29 b. Strategies and model designs: 30 (1) A strategy to implement a multipayer integrated 31 care model methodology across primary health care payers 32 in the state, by aligning performance measures, utilizing 33 a shared savings or other accountable payment methodology, 34 and integrating an information technology platform to 35 -7- LSB 1441SV (2) 85 pf/rj 7/ 14

S.F. 296 support the integrated care model. The strategy shall 1 ensure statewide adoption of integrated care for the medical 2 assistance population; explore the role of managed care 3 plans and expansion of managed care in the medical assistance 4 program as part of the integrated care model; address the 5 special circumstances of areas of the state that are rural, 6 underserved, or have higher rates of health disparities; and 7 seek the participation of the Medicare population in the 8 integrated care model. 9 (2) A strategy to incorporate long-term care and behavioral 10 health services for the medical assistance population into the 11 integrated care model, through integration of community health 12 and community prevention activities. 13 (3) A strategy to address population health and health 14 promotion, by investing in approaches to influence modifiable 15 determinants of health such as access to health care, healthy 16 behaviors, socioeconomic factors, and the physical environment 17 that collectively impact the health of the community. The 18 strategy shall address the underlying, pervasive, and 19 multifaceted socioeconomic impediments that medical assistance 20 recipients face in being full participants in their own health. 21 (4) A multiphase strategy to implement a statewide 22 integrated care model to maximize access to health care for 23 medical assistance program recipients in all areas of the 24 state. The strategy shall incorporate flexible integrated 25 care model options and accountable payment methodologies 26 for participation by various types of providers including 27 individual providers, safety net providers, and nonprofit 28 and public providers that have long experience in caring for 29 vulnerable populations, into the integrated system. 30 (5) Implement a stakeholder process. In addition to the 31 oversight and input provided by the legislative advisory 32 council, the department shall hold public local listening 33 sessions throughout the state, collaborate with consumer groups 34 and provider groups, and partner with other state agencies such 35 -8- LSB 1441SV (2) 85 pf/rj 8/ 14

S.F. 296 as the department on aging and the department of public health 1 to elicit input and feedback on the model design. 2 (6) Develop a multipayer approach including the medical 3 assistance and children’s health insurance programs, private 4 payers, and Medicare. 5 (7) Oversee the administration of the model design project. 6 (8) Engage providers beyond the large integrated health 7 systems to maximize access to all levels of care within an 8 integrated model program by medical assistance recipients. 9 4. The department shall submit proposed legislation 10 specifying the model design and implementation plan to the 11 advisory council no later than December 15, 2013. 12 Sec. 9. LEGISLATIVE COMMISSION ON INTEGRATED CARE MODELS. 13 1. a. A legislative commission on integrated care models 14 is created for the 2013 Legislative Interim. The legislative 15 services agency shall provide staffing assistance to the 16 commission. 17 b. The commission shall include 10 members of the general 18 assembly, three appointed by the majority leader of the senate, 19 two appointed by the minority leader of the senate, three 20 appointed by the speaker of the house of representatives, 21 and two appointed by the minority leader of the house of 22 representatives. 23 c. The commission shall include members of the public 24 appointed by the legislative council who represent consumers, 25 health care providers, hospitals and health systems, and other 26 entities with interest or expertise related to integrated care 27 models. 28 d. The commission shall include as ex officio members, the 29 director of human services, the commissioner of insurance, the 30 director of public health, and the attorney general, or the 31 individual’s designee. 32 2. The chairpersons of the commission shall be those members 33 of the general assembly so appointed by the majority leader of 34 the senate and the speaker of the house of representatives. 35 -9- LSB 1441SV (2) 85 pf/rj 9/ 14

S.F. 296 Legislative members of the commission are eligible for per diem 1 and reimbursement of actual expenses as provided in section 2 2.10. Consumers appointed to the commission, are entitled 3 to receive a per diem as specified in section 7E.6 for each 4 day spent in performance of duties as members, and shall be 5 reimbursed for all actual and necessary expenses incurred in 6 the performance of duties as members of the commission. 7 3. The commission shall do all of the following: 8 a. Review and make recommendations relating to the 9 formation and operation of integrated care models in the 10 state. The models shall include any care delivery model that 11 integrates providers and incorporates a financial incentive 12 to improve patient health outcomes, improve care, and reduce 13 costs. Integrated care models include but are not limited 14 to patient-centered medical homes, health homes, accountable 15 care organizations (ACOs), ACO-like models, community and 16 regional care networks, and other integrated and accountable 17 care delivery models that utilize value-based financing 18 methodologies and emphasize person-centered, coordinated, and 19 comprehensive care. 20 b. Review integrated care models created in other states 21 that integrate both clinical services and nonclinical community 22 and social supports utilizing patient-centered medical homes 23 and community care teams as basic components to determine the 24 feasibility of adapting any of these models as a statewide 25 system in Iowa. These models may include but are not limited 26 to the ACO demonstration program based on the Camden Coalition 27 of Healthcare Providers in Camden, New Jersey; the Medical 28 Home Network in Chicago, Illinois; the Health Commons model in 29 New Mexico; the Accountable Care Collaborative in Colorado; 30 Community Care of North Carolina, in North Carolina; the 31 Blueprint for Health and the Community Health Teams in Vermont; 32 and the Coordinated Care Organizations in Oregon. 33 c. Recommend the best means of providing care through 34 integrated delivery models throughout the state including to 35 -10- LSB 1441SV (2) 85 pf/rj 10/ 14

S.F. 296 vulnerable populations and how best to incorporate safety net 1 providers, including but not limited to federally qualified 2 health centers, rural health clinics, community mental health 3 centers, public hospitals, and other nonprofit and public 4 providers that have long experience in caring for vulnerable 5 populations, into the integrated system. 6 d. Review the progress of the development of medical 7 homes as specified in chapter 135, division XXII in the 8 state and make recommendations for development of a statewide 9 infrastructure of actual and virtual medical homes to act as 10 the foundation for integrated care models. 11 e. Review opportunities under the federal Patient 12 Protection and Affordable Care Act (Affordable Care Act), 13 Pub. L. No. 11-148, as amended, for the development of 14 integrated care models including the Medicare Shared Savings 15 Program for accountable care organizations, community-based 16 collaborative care networks that include safety net providers, 17 and consumer-operated and oriented plans. The legislative 18 commission shall also review existing and proposed integrated 19 care models in the state including commercial models and those 20 developed or proposed under the Affordable Care Act including 21 the Medicare Shared Savings Program and the Pioneer ACO to 22 determine the opportunities for expansion or replication. 23 f. Address the issues relative to integrated care models 24 including those relating to consumer protection including 25 those that relate to confidentiality, quality assurance, 26 grievance procedures, and appeals of patient care decisions; 27 payment methodologies, multipayer alignment, coordination 28 of funding streams, and financing methods that support full 29 integration of clinical and nonclinical services and providers; 30 organizational, management, and governing structures; 31 access, quality, outcomes, utilization, and other appropriate 32 performance standards; patient attribution or assignment 33 models; health information exchange, data reporting, and 34 infrastructure standards; and regulatory issues including 35 -11- LSB 1441SV (2) 85 pf/rj 11/ 14

S.F. 296 clinical integration limitations, physician self-referral, 1 anti-kickback provisions, gain-sharing, beneficiary 2 inducements, antitrust issues, tax exemption issues, and 3 application of insurance regulations. 4 4. The legislative commission may request from any state 5 agency or official information and assistance as needed to 6 perform the review and make recommendations. 7 5. The legislative commission shall submit a final report 8 summarizing the legislative commission’s review and making 9 recommendations to the governor and the general assembly by 10 December 15, 2013. 11 Sec. 10. MEDICAID STATE PLAN. 12 1. The department of human services shall amend the medical 13 assistance state plan to reflect the provisions relating to the 14 provision of a medical home to medical assistance recipients 15 as provided in this Act. 16 2. The department of human services shall amend the medical 17 assistance state plan to provide for coverage of adults up to 18 133 percent of the federal poverty level as provided in this 19 Act beginning January 1, 2014. 20 3. The department of human services shall amend the medical 21 assistance state plan to provide that the benchmark benefit 22 plan provided to the newly covered adults under the medical 23 assistance program is the option provided pursuant to 42 U.S.C. 24 § 1396u-7(b)(1)(D) which is at a minimum the coverage included 25 in the medical assistance state plan benefit package for 26 individuals otherwise eligible under section 249A.3, subsection 27 1, and adjusted as necessary to provide the essential health 28 benefits as required pursuant to section 1302 of the federal 29 Patient Protection and Affordable Care Act, Pub. L. No. 30 111-148, and as approved by the United States secretary of 31 health and human services. 32 Sec. 11. ADOPTION OF RULES. The department of human 33 services shall adopt emergency rules pursuant to section 17A.4, 34 subsection 3, and section 17A.5, subsection 2, paragraph “b”, 35 -12- LSB 1441SV (2) 85 pf/rj 12/ 14

S.F. 296 as necessary to implement the provisions of this Act, and 1 the rules shall be effective immediately upon filing unless 2 a later date is specified in the rules. Any rules adopted 3 in accordance with this section shall also be published as a 4 notice of intended action as provided in section 17A.4. 5 Sec. 12. EFFECTIVE UPON ENACTMENT. This Act, being deemed 6 of immediate importance, takes effect upon enactment. 7 EXPLANATION 8 This bill relates to integrated health care delivery. 9 The bill amends provisions relating to medical homes to 10 require a team-based, multidisciplinary approach to health 11 care delivery. The bill requires the department of human 12 services (DHS) to collaborate with the department of public 13 health (DPH) in administering medical homes under the Medicaid 14 program. The bill amends provisions relating to implementation 15 of medical homes in the state by requiring that medical homes 16 be accessible to the greatest extent possible by January 1, 17 2015, to all children and adults who are recipients of full 18 benefits under the medical assistance program, including the 19 newly eligible adults up to 133 percent of the federal poverty 20 level (FPL), and individuals who are dually eligible for both 21 the Medicaid and Medicare programs to the extent approved by 22 the centers for Medicare and Medicaid services of the United 23 States department of health and human services (CMS). 24 The bill provides for Medicaid program eligibility for 25 certain adults with incomes at or below 133 percent of the 26 FPL as provided under the federal Affordable Care Act (ACA). 27 Additionally, the bill provides that the benefit package for 28 these newly eligible adults is to be the medical assistance 29 state plan benefit package offered in the state as adjusted to 30 provide the essential health benefits required under the ACA, 31 and as approved by the United States secretary of health and 32 human services. 33 The bill also provides, as required under the ACA, that 34 individuals who were in foster care and enrolled in the medical 35 -13- LSB 1441SV (2) 85 pf/rj 13/ 14

S.F. 296 assistance program while they were in foster care, are eligible 1 for medical assistance up to 26 years of age. 2 The bill provides for the repeal of Code chapter 249J 3 (IowaCare) on December 31, 2013, rather than October 31, 2013, 4 and directs DHS to develop a plan for transition of IowaCare 5 members to other health coverage options. 6 The bill directs the legislative council to establish a 7 legislative advisory council to guide the development of the 8 design model and implementation plan for the state innovation 9 model grant awarded to DHS by the Centers for Medicare and 10 Medicaid Services of the United States department of health and 11 human services to develop an integrated care model including 12 the Medicaid population. The advisory council is to provide 13 oversight throughout the process, receive periodic progress 14 reports, approve any integrated care model and implementation 15 strategies, and prepare proposed legislation to implement 16 the model and strategies prior to submission of the proposed 17 legislation to the general assembly in 2014. 18 The bill also establishes a legislative commission for the 19 2013 interim to review and make recommendations regarding 20 provision of care through integrated delivery models in the 21 state. The legislative commission is directed to submit a 22 final report to the governor and the general assembly by 23 December 15, 2013. 24 The bill directs DHS to amend the Medicaid state plan to 25 reflect the provisions in the bill relating to medical homes, 26 the coverage of adults up to 133 percent of the FPL, and 27 the coverage to be available to the new adults group under 28 Medicaid. 29 The bill directs DHS to adopt emergency rules as necessary 30 to implement the bill. 31 The bill takes effect upon enactment. 32 -14- LSB 1441SV (2) 85 pf/rj 14/ 14