Bill Text: IA SF2177 | 2019-2020 | 88th General Assembly | Introduced

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Bill Title: A bill for an act relating to Medicaid program improvements, providing an appropriation, and including effective date provisions.

Spectrum: Partisan Bill (Democrat 2-0)

Status: (Introduced - Dead) 2020-02-10 - Subcommittee: Costello, Breitbach, and Mathis. S.J. 261. [SF2177 Detail]

Download: Iowa-2019-SF2177-Introduced.html

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Senate File 2177 - Introduced
SENATE FILE 2177
BY MATHIS and RAGAN
A BILL FOR
An Act relating to Medicaid program improvements, providing an
appropriation, and including effective date provisions.
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 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
MEDICAID WORKFORCE PROGRAM
Sec. 2. WORKFORCE RECRUITMENT, RETENTION, AND TRAINING
PROGRAMS. The department of human services shall contractually
require any managed care organization with whom the department
contracts 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 III
PROVIDER APPEALS PROCESS —— EXTERNAL REVIEW
Sec. 3. MEDICAID MANAGED CARE ORGANIZATION APPEALS PROCESS
—— EXTERNAL REVIEW.
1. a. A Medicaid managed care organization under contract
with the state 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
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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
for a service rendered to a Medicaid member, and who has
exhausted the internal appeals 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 such 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,
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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 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 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
requirements of this subsection 3, the Medicaid provider shall
automatically prevail in the review.
4. a. Within fifteen calendar days of receiving a Medicaid
provider’s request for external independent third-party review,
the managed care organization shall do all of the following:
(1) Submit to the department 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 4, the Medicaid provider shall
automatically prevail in the review.
5. 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 external
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independent third-party review, the department 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 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 appeals process or fails to submit a timely request
for an external independent third-party review pursuant to this
subsection.
8. a. Multiple appeals through the external independent
third-party review process regarding the same Medicaid
member, a common question of fact, or 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.
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 following exhaustion
of any applicable managed care organization internal appeals
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
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of any claim submitted to the reviewer pursuant to this
subsection.
b. Within thirty calendar days from receiving the request
for review from the department 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, 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 fourteen calendar days upon agreement of all
parties to the review.
11. The department shall enter into a contract with
an independent review organization that does not have a
conflict of interest with the department or any managed care
organization to conduct the 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 any external independent
third-party review conducted pursuant to this subsection 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 review, the nonprevailing
party 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 IV
MEMBER DISENROLLMENT FOR GOOD CAUSE
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Sec. 4. MEMBER DISENROLLMENT FOR GOOD CAUSE. The department
of human services shall adopt rules pursuant to chapter 17A
and 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.
DIVISION V
UNIFORM, SINGLE CREDENTIALING
Sec. 5. MEDICAID PROGRAM —— USE OF UNIFORM AUTHORIZATION
CRITERIA AND SINGLE CREDENTIALING VERIFICATION
ORGANIZATION. The department of 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 by
the state in credentialing and recredentialing providers for
both the Medicaid managed care and fee-for-service payment and
delivery systems. The department 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 state, 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 VI
MEDICAID MANAGED CARE OMBUDSMAN PROGRAM —— APPROPRIATION
Sec. 6. OFFICE OF LONG-TERM CARE OMBUDSMAN —— MEDICAID
MANAGED CARE OMBUDSMAN.
1. There is appropriated from the general fund of the
state to the office of long-term care ombudsman for the fiscal
year beginning July 1, 2020, and ending June 30, 2021, in
addition to any other funds appropriated from the general
fund of the state to, and in addition to any other full-time
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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:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 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, 2020, 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, 2020, and ending June 30, 2021, 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, 2020.
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.
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.
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Division I of the bill requires the department of human
services (DHS) 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 requires DHS to contractually
require any Medicaid managed care organization (MCO) 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 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 reports to the department.
Division III of the bill establishes an external review
process for Medicaid providers for the review of final adverse
determinations of the MCOs’ internal appeal processes. The
division provides that a final decision of an external reviewer
may be reviewed in a contested case proceeding pursuant to Code
chapter 17A, and ultimately is subject to judicial review.
Division IV of the bill relates to member disenrollment for
good cause during the 12 months of closed enrollment between
open enrollment periods. Currently, a member may request
disenrollment for good cause initially through their MCO’s
grievance process, which may take up to 30 to 45 days to
process. The bill requires DHS to adopt administrative rules
and 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.
Division V of the bill requires the DHS to develop
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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 DHS to contractually require all Medicaid managed
care organizations (MCOs) to apply the uniform authorization
criteria and to accept verified information from the single
credentialing verification organization procured by the
state, and to contractually prohibit the MCOs from requiring
additional credentialing information from a provider in order
to participate in the Medicaid managed care organization’s
provider network.
Division VI of the bill relates to the office of long-term
care ombudsman (OLTCO) and the Medicaid managed care ombudsman
program (MCOP).
For fiscal year 2020-2021, 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, 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, 2020, for the MCOP. For
fiscal year 2019-2020, the expenditures budgeted for MCOP were
$171,536 and the FTE positions filled totaled 1.50.
The bill requires that any funds appropriated to and any
full-time equivalent positions authorized for the OLTCO for the
MCOP for fiscal year 2020-2021 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, 2020.
The bill requires the OLTCO to include in the MCOP report, on
a quarterly basis, the disposition of resources for the MCOP
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including expenditures and a full-time equivalent positions
summary for the prior quarter.
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