House File 2009 - Introduced HOUSE FILE 2009 BY BRECKENRIDGE A BILL FOR An Act relating to reimbursement for services provided in an 1 emergency department to Medicaid members. 2 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 3 TLSB 5035YH (5) 88 pf/rh

H.F. 2009 Section 1. MEDICAID —— REIMBURSEMENT FOR EMERGENCY 1 DEPARTMENT SERVICES. 2 1. Reimbursement provided under both Medicaid 3 fee-for-service and managed care administration for services 4 delivered in an emergency department shall comply with all of 5 the following: 6 a. Reimbursement shall be based on the services provided as 7 indicated by the patient’s presenting symptoms and not solely 8 on the patient’s eventual or final diagnosis. 9 b. Reimbursement shall reflect the prudent layperson 10 standard relative to the definition of an emergency medical 11 condition pursuant to 24 C.F.R. §2590.715-2719A(b)(4)(i). 12 c. Reimbursement shall not be denied, including 13 retroactively denied, restricted, or down-coded based on a 14 policy of selective emergency services coverage. For the 15 purposes of this subsection, “policy of selective emergency 16 services coverage” means any practice making reimbursement for 17 emergency services dependent upon a determination of whether 18 an injury, symptom, complaint, or other presenting condition 19 strictly constitutes an emergency medical condition. 20 2. The department of human services shall adopt rules 21 pursuant to chapter 17A to administer this section. Any 22 contract the department enters into with a managed care 23 organization shall require the managed care organization to 24 comply with this section and the rules adopted under this 25 section. 26 EXPLANATION 27 The inclusion of this explanation does not constitute agreement with 28 the explanation’s substance by the members of the general assembly. 29 This bill relates to reimbursement of services delivered 30 in an emergency department under the Medicaid program. The 31 bill requires that reimbursement provided under both Medicaid 32 fee-for-service and managed care administration for services 33 delivered in an emergency department shall comply with all of 34 the following: 35 -1- LSB 5035YH (5) 88 pf/rh 1/ 2

H.F. 2009 1. Be based on the services provided as indicated by the 1 patient’s presenting symptoms and not on the patient’s eventual 2 or final diagnosis. 3 2. Reflect the prudent layperson standard relative to the 4 definition of an emergency medical condition under federal 5 law which provides that an emergency medical condition means 6 a medical condition manifesting itself by acute symptoms of 7 sufficient severity (including severe pain) so that a prudent 8 layperson, who possesses an average knowledge of health and 9 medicine, could reasonably expect the absence of immediate 10 medical attention to result in placing the health of an 11 individual (or, with respect to a pregnant woman, the health 12 of the woman or her unborn child) in serious jeopardy; serious 13 impairment to bodily functions; or serious dysfunction of any 14 bodily organ or part. 15 3. Shall not be denied including retroactively denied, 16 restricted, reduced, or down-coded based on a “policy of 17 selective emergency services coverage” which means any practice 18 of making reimbursement for emergency services dependent upon 19 a determination of whether an injury, symptom, complaint, or 20 other presenting condition strictly constitutes an emergency 21 medical condition. 22 The bill requires the department of human services to 23 adopt administrative rules and provides that any contract the 24 department enters into with a managed care organization shall 25 require the managed care organization to comply with the bill 26 and the rules adopted under the bill. 27 -2- LSB 5035YH (5) 88 pf/rh 2/ 2