Bill Text: IA SF420 | 2019-2020 | 88th General Assembly | Introduced
Bill Title: A bill for an act relating to processes and assistance under the Medicaid program.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2020-01-16 - Subcommittee reassigned: Johnson, Ragan, and Segebart. S.J. 108. [SF420 Detail]
Download: Iowa-2019-SF420-Introduced.html
Senate
File
420
-
Introduced
SENATE
FILE
420
BY
R.
SMITH
A
BILL
FOR
An
Act
relating
to
processes
and
assistance
under
the
Medicaid
1
program.
2
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
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DIVISION
I
1
MEDICAID
PRIOR
AUTHORIZATION
2
Section
1.
MEDICAID
——
PRIOR
AUTHORIZATION
UNIFORM
3
PROCESS.
The
department
of
human
services
shall
adopt
rules
4
pursuant
to
chapter
17A
to
require,
and
shall
contractually
5
require,
that
both
managed
care
and
fee-for-service
payment
6
and
delivery
systems
utilize
a
uniform
process,
including
but
7
not
limited
to
uniform
forms,
information
requirements,
and
8
time
frames,
to
request
prior
authorization
under
the
Medicaid
9
program.
10
DIVISION
II
11
MEDICAID
PROGRAM
OMBUDSMAN
12
Sec.
2.
NEW
SECTION
.
2C.6A
Assistant
for
Medicaid
program.
13
1.
The
ombudsman
shall
appoint
an
assistant
who
shall
be
14
primarily
responsible
for
investigating
complaints
relating
to
15
the
Medicaid
program,
including
both
Medicaid
fee-for-service
16
and
managed
care
payment
and
delivery
systems,
and
all
Medicaid
17
populations
including
the
long-term
services
and
supports
18
population.
19
2.
The
ombudsman
shall
provide
assistance
and
advocacy
20
services
to
Medicaid
recipients
and
the
families
or
legal
21
representatives
of
Medicaid
recipients.
Such
assistance
22
and
advocacy
shall
include
but
is
not
limited
to
all
of
the
23
following:
24
a.
Assisting
recipients
in
understanding
the
services,
25
coverage,
and
access
provisions
and
their
rights
under
the
26
Medicaid
program.
27
b.
Developing
procedures
for
the
tracking
and
reporting
28
of
the
outcomes
of
individual
requests
for
assistance,
the
29
procedures
available
for
obtaining
services,
and
other
aspects
30
of
the
services
provided
to
Medicaid
recipients.
31
c.
Providing
advice
and
assistance
relating
to
the
32
preparation
and
filing
of
complaints,
grievances,
and
appeals
33
of
complaints
or
grievances,
including
through
processes
34
available
under
managed
care
plans
and
the
state
appeals
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process
under
the
Medicaid
program.
1
3.
The
ombudsman
shall
adopt
rules
to
administer
this
2
section.
3
4.
The
ombudsman
shall
publish
special
reports
and
4
investigative
reports
as
deemed
necessary
and
shall
include
5
findings
and
recommendations
related
to
the
assistance
and
6
advocacy
provided
under
this
section
in
the
ombudsman’s
annual
7
report.
8
5.
The
ombudsman
and
the
department
of
human
services
9
shall
collaborate
to
develop
a
cost
allocation
plan
requesting
10
Medicaid
administrative
funding
to
provide
for
the
claiming
of
11
federal
financial
participation
for
ombudsman
activities
that
12
are
performed
to
assist
with
the
administration
of
the
Medicaid
13
program.
The
cost
allocation
plan
shall
document
the
costs
14
that
directly
benefit
the
Medicaid
program
and
are
consistent
15
with
federal
requirements.
The
cost
allocation
plan
shall
be
16
developed
in
a
timely
manner
to
allow
for
such
claiming
to
17
begin
by
January
1,
2020.
18
Sec.
3.
REPEAL.
Section
231.44,
Code
2019,
is
repealed.
19
DIVISION
III
20
MEDICAID
MANAGED
CARE
——
EXTERNAL
REVIEW
OF
PROVIDER-DENIED
21
CLAIMS
22
Sec.
4.
MEDICAID
MANAGED
CARE
——
EXTERNAL
REVIEW
OF
23
PROVIDER-DENIED
CLAIMS.
24
1.
The
department
of
human
services
shall
contractually
25
require
a
Medicaid
managed
care
organization
to
utilize
an
26
external
review
process
in
accordance
with
rules
adopted
by
27
the
department
pursuant
to
chapter
17A.
The
external
review
28
process
shall
provide
for
review
by
an
independent
third
party
29
of
a
Medicaid
provider’s
claims
denied
by
the
Medicaid
managed
30
care
organization
and
following
a
final
adverse
determination
31
of
the
managed
care
organization’s
internal
appeal
process.
32
2.
The
external
review
process
shall
provide
for
all
of
the
33
following:
34
a.
A
request
for
an
external
review
shall
automatically
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extend
the
deadline
to
file
an
appeal
for
a
contested
case
1
hearing
under
chapter
17A,
pending
the
outcome
of
the
external
2
review,
until
thirty
calendar
days
following
receipt
of
the
3
final
decision
by
the
Medicaid
provider.
4
b.
Upon
receipt
of
a
request
from
a
Medicaid
provider
for
5
external
review,
the
department
shall
assign
the
review
to
6
an
external
independent
third-party
reviewer,
and
notify
the
7
applicable
Medicaid
managed
care
organization
and
the
Medicaid
8
provider
of
the
identity
of
the
external
reviewer.
9
c.
Within
fifteen
calendar
days
of
notification
of
a
10
Medicaid
provider’s
request
for
external
review,
the
managed
11
care
organization
shall
submit
to
the
external
reviewer
all
12
documentation
submitted
by
the
Medicaid
provider
in
the
course
13
of
the
internal
appeal
process.
14
d.
Within
thirty
calendar
days
of
receiving
all
15
documentation
from
the
applicable
Medicaid
managed
care
16
organization
submitted
by
the
Medicaid
provider
in
the
course
17
of
the
internal
appeal
process,
the
external
reviewer
shall
18
issue
a
final
decision
to
the
Medicaid
provider,
the
applicable
19
Medicaid
managed
care
organization,
and
the
department.
The
20
reviewer
may
extend
the
time
to
issue
a
final
decision
by
21
fourteen
calendar
days
upon
agreement
of
all
parties
to
the
22
review.
23
e.
A
party
may
appeal
a
final
decision
of
the
external
24
reviewer
in
a
contested
case
proceeding
in
accordance
with
25
chapter
17A
within
thirty
calendar
days
from
receipt
of
the
26
final
decision
by
the
Medicaid
provider.
A
final
decision
in
a
27
contested
case
proceeding
is
subject
to
judicial
review.
28
3.
The
department
shall
enter
into
a
contract
with
a
review
29
organization
that
does
not
have
a
conflict
of
interest
with
30
the
department
or
any
managed
care
organization
to
conduct
the
31
independent
third-party
reviews
under
this
section.
32
EXPLANATION
33
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
34
the
explanation’s
substance
by
the
members
of
the
general
assembly.
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Division
I
of
this
bill
requires
the
department
of
human
1
services
(DHS)
to
adopt
administrative
rules
to
require,
2
and
to
contractually
require,
that
both
managed
care
and
3
fee-for-service
payment
and
delivery
systems
utilize
a
4
uniform
process,
including
but
not
limited
to
uniform
forms,
5
information
requirements,
and
time
frames,
to
request
prior
6
authorization
under
the
Medicaid
program.
7
Division
II
of
the
bill
directs
the
ombudsman
to
appoint
an
8
assistant
who
shall
be
primarily
responsible
for
investigating
9
complaints
relating
to
the
Medicaid
program,
including
both
10
the
Medicaid
managed
care
and
fee-for-service
payment
and
11
delivery
systems,
and
all
Medicaid
populations
including
the
12
long-term
services
and
supports
population.
The
division
13
specifies
the
minimum
areas
of
assistance
and
advocacy
to
be
14
provided,
directs
the
ombudsman
to
adopt
administrative
rules
15
for
administration
of
the
division,
and
directs
the
ombudsman
16
to
publish
special
reports
and
investigative
reports
as
deemed
17
necessary,
and
to
include
findings
and
recommendations
related
18
to
the
Medicaid
program
assistance
and
advocacy
provided
under
19
the
division
in
the
ombudsman’s
annual
report.
20
The
division
also
repeals
the
section
of
the
Code
that
21
directs
the
office
of
long-term
care
ombudsman
to
provide
22
assistance
and
advocacy
services
to
members
of
the
Medicaid
23
long-term
services
and
supports
population
since
under
the
24
division,
the
ombudsman
will
provide
assistance
and
advocacy
25
for
both
Medicaid
managed
care
and
fee-for-service
payment
26
and
delivery
systems
and
for
all
populations
including
the
27
long-term
services
and
supports
population.
28
The
division
also
requires
the
ombudsman
and
DHS
to
29
collaborate
to
develop
a
cost
allocation
plan,
consistent
30
with
federal
requirements,
requesting
Medicaid
administrative
31
funding
to
provide
for
the
claiming
of
federal
financial
32
participation,
by
January
1,
2020,
for
ombudsman
activities
33
that
are
performed
to
assist
with
administration
of
the
34
Medicaid
program.
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Division
III
of
the
bill
requires
DHS
to
contractually
1
require
a
Medicaid
managed
care
organization
(MCO)
to
utilize
2
an
external
review
process
in
accordance
with
administrative
3
rules
adopted
by
DHS,
to
provide
for
a
review
by
an
independent
4
third-party
reviewer
of
a
Medicaid
provider’s
claims
denied
by
5
an
MCO
and
following
a
final
adverse
determination
of
the
MCO’s
6
internal
appeal
process.
The
bill
specifies
what
the
external
7
review
process,
at
a
minimum,
shall
provide
for,
and
directs
8
DHS
to
enter
into
a
contract
with
a
review
organization
that
9
does
not
have
a
conflict
of
interest
with
DHS
or
any
MCO
to
10
conduct
the
independent
third-party
reviews
under
the
bill.
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