Bill Text: IA SF2083 | 2023-2024 | 90th General Assembly | Introduced

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Bill Title: A bill for an act relating to Medicaid program improvements, making an appropriation, and providing penalties.

Spectrum: Partisan Bill (Democrat 16-0)

Status: (Introduced - Dead) 2024-01-24 - Subcommittee: Edler, Costello, and Jochum. S.J. 146. [SF2083 Detail]

Download: Iowa-2023-SF2083-Introduced.html

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Senate File 2083 - Introduced
SENATE FILE 2083
BY JOCHUM , PETERSEN , TRONE
GARRIOTT , DONAHUE , WAHLS ,
DOTZLER , T. TAYLOR , WEINER ,
WINCKLER , GIDDENS , CELSI ,
BISIGNANO , BOULTON , KNOX ,
BENNETT , and QUIRMBACH
A BILL FOR
An Act relating to Medicaid program improvements, making an
appropriation, and providing penalties.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
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DIVISION I
MEDICAID LONG-TERM SERVICES AND SUPPORTS POPULATION MEMBERS ——
PROVISION OF CONFLICT-FREE SERVICES
Section 1. MEDICAID LONG-TERM SERVICES AND SUPPORTS
POPULATION MEMBERS —— PROVISION OF CONFLICT-FREE SERVICES. The
department of health and human services shall adopt rules
pursuant to chapter 17A to ensure that services are provided
under the Medicaid program to members of the long-term
services and supports population in a conflict-free manner.
Specifically, case management services shall be provided by
independent providers and supports intensity scale assessments
shall be performed by independent assessors.
DIVISION II
LONG-TERM SERVICES AND SUPPORTS POPULATION MEMBERS —— OPTION
FOR FEE-FOR-SERVICE PROGRAM ADMINISTRATION
Sec. 2. LONG-TERM SERVICES AND SUPPORTS POPULATION MEMBERS
—— OPTION FOR FEE-FOR-SERVICE PROGRAM ADMINISTRATION. The
department of health and human services shall require each
Medicaid managed care organization with whom the department
executes a contract to administer the Iowa high quality
health care initiative as established by the department,
to provide the option to Medicaid long-term services and
supports population members to enroll in or transition to
fee-for-service Medicaid program administration rather than
managed care administration. The department shall amend any
contract, request any Medicaid state plan amendment, and adopt
rules pursuant to chapter 17A, as necessary, to administer this
section. The rules shall include the process for transitioning
a current Medicaid long-term services and supports population
member to fee-for-service program administration.
DIVISION III
MEDICAID WORKFORCE PROGRAM
Sec. 3. WORKFORCE RECRUITMENT, RETENTION, AND TRAINING
PROGRAMS. The department of health and human services shall
contractually require any managed care organization with whom
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the department executes a contract under the Medicaid program
to collaborate with the department and stakeholders to develop
and administer a workforce recruitment, retention, and training
program to provide adequate access to appropriate services,
including but not limited to services to older Iowans.
The department shall ensure that any program developed is
administered in a coordinated and collaborative manner across
all contracting managed care organizations and shall require
the managed care organizations to submit quarterly progress and
outcomes reports to the department.
DIVISION IV
PROVIDER APPEALS PROCESS —— EXTERNAL REVIEW
Sec. 4. MEDICAID MANAGED CARE ORGANIZATION APPEALS PROCESS
—— EXTERNAL REVIEW —— PENALTY.
1. a. A Medicaid managed care organization under contract
with the department of health and human services shall include
in any written response to a Medicaid provider under contract
with the managed care organization that reflects a final
adverse determination of the managed care organization’s
internal appeal process relative to an appeal filed by the
Medicaid provider, all of the following:
(1) A statement that the Medicaid provider’s internal
appeal rights within the managed care organization have been
exhausted.
(2) A statement that the Medicaid provider is entitled to
an external independent third-party review pursuant to this
section.
(3) The requirements for requesting an external independent
third-party review.
b. If a managed care organization’s written response does
not comply with the requirements of paragraph “a”, the managed
care organization shall pay to the affected Medicaid provider a
penalty not to exceed one thousand dollars.
2. a. A Medicaid provider who has been denied the provision
of a service to a Medicaid member or a claim for reimbursement
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for a service rendered to a Medicaid member, and who has
exhausted the internal appeal process of a managed care
organization, shall be entitled to an external independent
third-party review of the managed care organization’s final
adverse determination.
b. To request an external independent third-party review of
a final adverse determination by a managed care organization,
an aggrieved Medicaid provider shall submit a written request
for such review to the managed care organization within sixty
calendar days of receiving the final adverse determination.
c. A Medicaid provider’s request for an external
independent third-party review shall include all of the
following:
(1) Identification of each specific issue and dispute
directly related to the final adverse determination issued by
the managed care organization.
(2) A statement of the basis upon which the Medicaid
provider believes the managed care organization’s determination
to be erroneous.
(3) The Medicaid provider’s designated contact information,
including name, mailing address, phone number, fax number, and
email address.
3. a. Within five business days of receiving a Medicaid
provider’s request for an external independent third-party
review pursuant to this subsection, the managed care
organization shall do all of the following:
(1) Confirm to the Medicaid provider’s designated contact,
in writing, that the managed care organization has received the
request for review.
(2) Notify the department of health and human services of
the Medicaid provider’s request for review.
(3) Notify the affected Medicaid member of the Medicaid
provider’s request for review, if the review is related to the
denial of a service.
b. If the managed care organization fails to satisfy the
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requirements of this subsection, the Medicaid provider shall
automatically prevail in the review.
4. a. Within fifteen calendar days of receiving a Medicaid
provider’s request for an external independent third-party
review, the managed care organization shall do all of the
following:
(1) Submit to the department of health and human services
all documentation submitted by the Medicaid provider in the
course of the managed care organization’s internal appeal
process.
(2) Provide the managed care organization’s designated
contact information, including name, mailing address, phone
number, fax number, and email address.
b. If a managed care organization fails to satisfy the
requirements of this subsection, the Medicaid provider shall
automatically prevail in the review.
5. A request for an external independent third-party review
shall automatically extend the deadline to file an appeal for a
contested case hearing under chapter 17A, pending the outcome
of the external independent third-party review, until thirty
calendar days following receipt of the review decision by the
Medicaid provider.
6. Upon receiving notification of a request for an external
independent third-party review, the department of health and
human services shall do all of the following:
a. Assign the review to an external independent third-party
reviewer.
b. Notify the managed care organization of the identity of
the external independent third-party reviewer.
c. Notify the Medicaid provider’s designated contact of the
identity of the external independent third-party reviewer.
7. The department of health and human services shall deny a
request for an external independent third-party review if the
requesting Medicaid provider fails to exhaust the managed care
organization’s internal appeal process or fails to submit a
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timely request for an external independent third-party review
pursuant to this section.
8. a. Multiple appeals through the external independent
third-party review process regarding the same Medicaid member,
a common question of fact, or the interpretation of common
applicable regulations or reimbursement requirements may
be combined and determined in one action upon request of a
party in accordance with rules and regulations adopted by the
department of health and human services.
b. The Medicaid provider that initiated a request for
an external independent third-party review, or one or more
other Medicaid providers, may add claims to such an existing
external independent third-party review request following the
exhaustion of any applicable managed care organization internal
appeal process, if the claims involve a common question of
fact or interpretation of common applicable regulations or
reimbursement requirements.
9. Documentation reviewed by the external independent
third-party reviewer shall be limited to documentation
submitted pursuant to subsection 4.
10. An external independent third-party reviewer shall do
all of the following:
a. Conduct an external independent third-party review
of any claim submitted to the reviewer pursuant to this
subsection.
b. Within thirty calendar days from receiving the request
for an external independent third-party review from the
department of health and human services and the documentation
submitted pursuant to subsection 4, issue the reviewer’s final
decision to the Medicaid provider’s designated contact, the
managed care organization’s designated contact, the department
of health and human services, and the affected Medicaid member
if the decision involves a denial of service. The reviewer may
extend the time to issue a final decision by up to fourteen
calendar days upon agreement of all parties to the review.
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11. The department of health and human services shall
enter into a contract with an external independent review
organization that does not have a conflict of interest with the
department of health and human services or any managed care
organization to conduct the external independent third-party
reviews under this section.
a. A party, including the affected Medicaid member or
Medicaid provider, may appeal a final decision of the external
independent third-party reviewer in a contested case proceeding
in accordance with chapter 17A within thirty calendar days from
receiving the final decision. A final decision in a contested
case proceeding is subject to judicial review.
b. The final decision of an external independent
third-party reviewer conducted pursuant to this section shall
also direct the nonprevailing party to pay an amount equal to
the costs of the review to the external independent third-party
reviewer. Any payment ordered pursuant to this subsection
shall be stayed pending any appeal of the review. If the
final outcome of any appeal is to reverse the decision of the
external independent third-party reviewer, the nonprevailing
party on appeal shall pay the costs of the review to the
external independent third-party reviewer within forty-five
calendar days of entry of the final order.
DIVISION V
MEMBER DISENROLLMENT FOR GOOD CAUSE
Sec. 5. MEMBER DISENROLLMENT FOR GOOD CAUSE. The department
of health and human services shall contractually require all
Medicaid managed care organizations to issue a decision in
response to a member’s request for disenrollment for good cause
within ten days of the date the member submits the request to
the Medicaid managed care organization utilizing the Medicaid
managed care organization’s grievance process. The department
shall adopt rules pursuant to chapter 17A to administer this
division.
DIVISION VI
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UNIFORM, SINGLE CREDENTIALING
Sec. 6. MEDICAID PROGRAM —— USE OF UNIFORM AUTHORIZATION
CRITERIA AND SINGLE CREDENTIALING VERIFICATION
ORGANIZATION. The department of health and human services
shall develop uniform authorization criteria for, and
shall utilize a request for proposals process to procure,
a single credentialing verification organization to be
utilized in credentialing and recredentialing providers for
both the Medicaid managed care and fee-for-service payment
and delivery systems. The department or health and human
services shall contractually require all Medicaid managed care
organizations to apply the uniform authorization criteria and
to accept verified information from the single credentialing
verification organization procured by the department, and shall
contractually prohibit Medicaid managed care organizations
from requiring additional credentialing information from a
provider in order to participate in the Medicaid managed care
organization’s provider network.
DIVISION VII
MEDICAID MANAGED CARE OMBUDSMAN PROGRAM —— APPROPRIATION
Sec. 7. OFFICE OF LONG-TERM CARE OMBUDSMAN —— MEDICAID
MANAGED CARE OMBUDSMAN.
1. There is appropriated from the general fund of the
state to the department of health and human services office of
long-term care ombudsman for the fiscal year beginning July
1, 2024, and ending June 30, 2025, in addition to any other
funds appropriated from the general fund of the state to,
and in addition to any other full-time equivalent positions
authorized for, the office of long-term care ombudsman for the
same purpose, the following amount, or so much thereof as is
necessary, to be used for the purposes designated:
For the purposes of the Medicaid managed care ombudsman
program including for salaries, support, administration,
maintenance, and miscellaneous purposes, and for not more than
the following full-time equivalent positions:
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 300,000
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FTEs 2.50
2. The funding appropriated and the full-time equivalent
positions authorized under this section are in addition to any
other funds appropriated from the general fund of the state and
actually expended, and any other full-time equivalent positions
authorized and actually filled as of July 1, 2024, for the
Medicaid managed care ombudsman program.
3. Any funds appropriated to and any full-time equivalent
positions authorized for the office of long-term care ombudsman
for the Medicaid managed care ombudsman program for the fiscal
year beginning July 1, 2024, and ending June 30, 2025, shall
be used exclusively for the Medicaid managed care ombudsman
program.
4. The additional full-time equivalent positions authorized
in this section for the Medicaid managed care ombudsman program
shall be filled no later than September 1, 2024.
5. The office of long-term care ombudsman shall include
in the Medicaid managed care ombudsman program report, on a
quarterly basis, the disposition of resources for the Medicaid
managed care ombudsman program including actual expenditures
and a full-time equivalent positions summary for the prior
quarter.
DIVISION VIII
HEALTH POLICY OVERSIGHT COMMITTEE MEETINGS
Sec. 8. Section 2.45, subsection 5, Code 2024, is amended
to read as follows:
5. The legislative health policy oversight committee,
which shall be composed of ten members of the general
assembly, consisting of five members from each house, to
be appointed by the legislative council. The legislative
health policy oversight committee may shall meet at least two
times, annually , during the legislative interim to provide
continuing oversight for Medicaid managed care, and to ensure
effective and efficient administration of the program, address
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stakeholder concerns, monitor program costs and expenditures,
and make recommendations.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
This bill relates to the Medicaid program.
Division I of the bill requires the department of health
and human services (HHS) to adopt administrative rules to
ensure that services are provided to the Medicaid long-term
services and supports population in a conflict-free manner.
Specifically, the bill requires that case management services
shall be provided by independent providers and that the
supports intensity scale assessments are performed by
independent assessors.
Division II of the bill directs HHS to require each Medicaid
managed care organization (MCO) with whom HHS executes
a contract, to provide the option to Medicaid long-term
services and supports population members to enroll in or
transition to fee-for-service Medicaid program administration
rather than managed care administration. The department
shall amend any contract, request any Medicaid state plan
amendment, and adopt administrative rules, as necessary,
to administer this provision. The rules shall include the
process for transitioning a current Medicaid long-term services
and supports population member to fee-for-service program
administration.
Division III of the bill requires HHS to contractually
require any Medicaid MCO to collaborate with HHS and
stakeholders to develop and administer a workforce recruitment,
retention, and training program to provide adequate access to
appropriate services, including but not limited to services
to older Iowans. The department shall ensure that any such
program developed is administered in a coordinated and
collaborative manner across all contracting MCOs and shall
require the MCOs to submit quarterly progress and outcomes
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reports to HHS.
Division IV of the bill establishes an external independent
third-party review process for Medicaid providers for the
review of final adverse determinations of the MCOs’ internal
appeals processes. The division provides that a final
decision of an external independent third-party reviewer may
be reviewed in a contested case proceeding pursuant to Code
chapter 17A, and ultimately is subject to judicial review. The
bill provides a civil penalty for an MCO that does not comply
with the written response requirements relating to an adverse
determination.
Division V of the bill relates to member disenrollment
for good cause during the 12 months of closed enrollment
between open enrollment periods. The bill requires HHS to
contractually require all Medicaid MCOs to issue a decision
in response to a member’s request for disenrollment for good
cause within 10 days of the date the member submits the request
to the MCO utilizing the MCO’s grievance process and to adopt
administrative rules to administer the division.
Division VI of the bill requires the HHS to develop
uniform authorization criteria for, and to utilize a request
for proposals process to procure, a single credentialing
verification organization to be utilized in credentialing
and recredentialing providers for the Medicaid managed care
and fee-for-service payment and delivery systems. The bill
requires HHS to contractually require all Medicaid MCOs to
apply the uniform authorization criteria, to accept verified
information from the single credentialing verification
organization procured by HHS, and to contractually prohibit the
MCOs from requiring additional credentialing information from a
provider in order to participate in the Medicaid MCO’s provider
network.
Division VII of the bill relates to the office of long-term
care ombudsman (OLTCO) and the Medicaid managed care ombudsman
program (MCOP).
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For fiscal year 2024-2025, the bill appropriates $300,000
from the general fund of the state, in addition to any other
funds appropriated from the general fund of the state to,
and authorizes 2.50 FTEs in addition to any other full-time
equivalent (FTE) positions authorized for, HHS for the OLTCO
for the purposes of the MCOP. The funding appropriated and the
FTE positions authorized under the bill are in addition to any
other funds appropriated from the general fund of the state and
actually expended, and any other FTE positions authorized and
actually filled as of July 1, 2024, for the MCOP.
The bill requires that any funds appropriated to and any
full-time equivalent positions authorized for the OLTCO for the
MCOP for fiscal year 2024-2025 shall be used exclusively for
the MCOP. The additional FTE positions authorized in the bill
for the MCOP shall be filled no later than September 1, 2024.
The bill requires the OLTCO to include in the MCOP report, on
a quarterly basis, the disposition of resources for the MCOP
including expenditures and an FTE positions summary for the
prior quarter.
Division VIII amends the provision regarding the meetings of
the health policy oversight committee (HPOC) of the legislative
council. Current law provides that HPOC may meet annually.
The bill provides that HPOC shall meet, and further requires
that HPOC meet at least two times, annually, during the
legislative interim. The bill reflects the law related to the
meeting of HPOC in effect prior to that law being amended in
2023.
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