Iowa-2019-SF2177-Introduced

S.F. 2177 DIVISION I 1 MEDICAID LONG-TERM SERVICES AND SUPPORTS POPULATION MEMBERS —— 2 PROVISION OF CONFLICT-FREE SERVICES 3 Section 1. MEDICAID LONG-TERM SERVICES AND SUPPORTS 4 POPULATION MEMBERS —— PROVISION OF CONFLICT-FREE SERVICES. The 5 department of human services shall adopt rules pursuant to 6 chapter 17A to ensure that services are provided under the 7 Medicaid program to members of the long-term services and 8 supports population in a conflict-free manner. Specifically, 9 case management services shall be provided by independent 10 providers and supports intensity scale assessments shall be 11 performed by independent assessors. 12 DIVISION II 13 MEDICAID WORKFORCE PROGRAM 14 Sec. 2. WORKFORCE RECRUITMENT, RETENTION, AND TRAINING 15 PROGRAMS. The department of human services shall contractually 16 require any managed care organization with whom the department 17 contracts under the Medicaid program to collaborate with 18 the department and stakeholders to develop and administer a 19 workforce recruitment, retention, and training program to 20 provide adequate access to appropriate services, including 21 but not limited to services to older Iowans. The department 22 shall ensure that any program developed is administered in a 23 coordinated and collaborative manner across all contracting 24 managed care organizations and shall require the managed care 25 organizations to submit quarterly progress and outcomes reports 26 to the department. 27 DIVISION III 28 PROVIDER APPEALS PROCESS —— EXTERNAL REVIEW 29 Sec. 3. MEDICAID MANAGED CARE ORGANIZATION APPEALS PROCESS 30 —— EXTERNAL REVIEW. 31 1. a. A Medicaid managed care organization under contract 32 with the state shall include in any written response to 33 a Medicaid provider under contract with the managed care 34 organization that reflects a final adverse determination of the 35 -1- LSB 6020XS (8) 88 pf/rh 1/ 10

S.F. 2177 managed care organization’s internal appeal process relative to 1 an appeal filed by the Medicaid provider, all of the following: 2 (1) A statement that the Medicaid provider’s internal 3 appeal rights within the managed care organization have been 4 exhausted. 5 (2) A statement that the Medicaid provider is entitled to 6 an external independent third-party review pursuant to this 7 section. 8 (3) The requirements for requesting an external independent 9 third-party review. 10 b. If a managed care organization’s written response does 11 not comply with the requirements of paragraph “a”, the managed 12 care organization shall pay to the affected Medicaid provider a 13 penalty not to exceed one thousand dollars. 14 2. a. A Medicaid provider who has been denied the provision 15 of a service to a Medicaid member or a claim for reimbursement 16 for a service rendered to a Medicaid member, and who has 17 exhausted the internal appeals process of a managed care 18 organization, shall be entitled to an external independent 19 third-party review of the managed care organization’s final 20 adverse determination. 21 b. To request an external independent third-party review of 22 a final adverse determination by a managed care organization, 23 an aggrieved Medicaid provider shall submit a written request 24 for such review to the managed care organization within sixty 25 calendar days of receiving the final adverse determination. 26 c. A Medicaid provider’s request for such review shall 27 include all of the following: 28 (1) Identification of each specific issue and dispute 29 directly related to the final adverse determination issued by 30 the managed care organization. 31 (2) A statement of the basis upon which the Medicaid 32 provider believes the managed care organization’s determination 33 to be erroneous. 34 (3) The Medicaid provider’s designated contact information, 35 -2- LSB 6020XS (8) 88 pf/rh 2/ 10

S.F. 2177 including name, mailing address, phone number, fax number, and 1 email address. 2 3. a. Within five business days of receiving a Medicaid 3 provider’s request for review pursuant to this subsection, the 4 managed care organization shall do all of the following: 5 (1) Confirm to the Medicaid provider’s designated contact, 6 in writing, that the managed care organization has received the 7 request for review. 8 (2) Notify the department of the Medicaid provider’s 9 request for review. 10 (3) Notify the affected Medicaid member of the Medicaid 11 provider’s request for review, if the review is related to the 12 denial of a service. 13 b. If the managed care organization fails to satisfy the 14 requirements of this subsection 3, the Medicaid provider shall 15 automatically prevail in the review. 16 4. a. Within fifteen calendar days of receiving a Medicaid 17 provider’s request for external independent third-party review, 18 the managed care organization shall do all of the following: 19 (1) Submit to the department all documentation submitted 20 by the Medicaid provider in the course of the managed care 21 organization’s internal appeal process. 22 (2) Provide the managed care organization’s designated 23 contact information, including name, mailing address, phone 24 number, fax number, and email address. 25 b. If a managed care organization fails to satisfy the 26 requirements of this subsection 4, the Medicaid provider shall 27 automatically prevail in the review. 28 5. An external independent third-party review shall 29 automatically extend the deadline to file an appeal for a 30 contested case hearing under chapter 17A, pending the outcome 31 of the external independent third-party review, until thirty 32 calendar days following receipt of the review decision by the 33 Medicaid provider. 34 6. Upon receiving notification of a request for external 35 -3- LSB 6020XS (8) 88 pf/rh 3/ 10

S.F. 2177 independent third-party review, the department shall do all of 1 the following: 2 a. Assign the review to an external independent third-party 3 reviewer. 4 b. Notify the managed care organization of the identity of 5 the external independent third-party reviewer. 6 c. Notify the Medicaid provider’s designated contact of the 7 identity of the external independent third-party reviewer. 8 7. The department shall deny a request for an external 9 independent third-party review if the requesting Medicaid 10 provider fails to exhaust the managed care organization’s 11 internal appeals process or fails to submit a timely request 12 for an external independent third-party review pursuant to this 13 subsection. 14 8. a. Multiple appeals through the external independent 15 third-party review process regarding the same Medicaid 16 member, a common question of fact, or interpretation of common 17 applicable regulations or reimbursement requirements may 18 be combined and determined in one action upon request of a 19 party in accordance with rules and regulations adopted by the 20 department. 21 b. The Medicaid provider that initiated a request for 22 an external independent third-party review, or one or more 23 other Medicaid providers, may add claims to such an existing 24 external independent third-party review following exhaustion 25 of any applicable managed care organization internal appeals 26 process, if the claims involve a common question of fact 27 or interpretation of common applicable regulations or 28 reimbursement requirements. 29 9. Documentation reviewed by the external independent 30 third-party reviewer shall be limited to documentation 31 submitted pursuant to subsection 4. 32 10. An external independent third-party reviewer shall do 33 all of the following: 34 a. Conduct an external independent third-party review 35 -4- LSB 6020XS (8) 88 pf/rh 4/ 10

S.F. 2177 of any claim submitted to the reviewer pursuant to this 1 subsection. 2 b. Within thirty calendar days from receiving the request 3 for review from the department and the documentation submitted 4 pursuant to subsection 4, issue the reviewer’s final decision 5 to the Medicaid provider’s designated contact, the managed 6 care organization’s designated contact, the department, and 7 the affected Medicaid member if the decision involves a denial 8 of service. The reviewer may extend the time to issue a final 9 decision by fourteen calendar days upon agreement of all 10 parties to the review. 11 11. The department shall enter into a contract with 12 an independent review organization that does not have a 13 conflict of interest with the department or any managed care 14 organization to conduct the independent third-party reviews 15 under this section. 16 a. A party, including the affected Medicaid member or 17 Medicaid provider, may appeal a final decision of the external 18 independent third-party reviewer in a contested case proceeding 19 in accordance with chapter 17A within thirty calendar days from 20 receiving the final decision. A final decision in a contested 21 case proceeding is subject to judicial review. 22 b. The final decision of any external independent 23 third-party review conducted pursuant to this subsection shall 24 also direct the nonprevailing party to pay an amount equal to 25 the costs of the review to the external independent third-party 26 reviewer. Any payment ordered pursuant to this subsection 27 shall be stayed pending any appeal of the review. If the 28 final outcome of any appeal is to reverse the decision of the 29 external independent third-party review, the nonprevailing 30 party shall pay the costs of the review to the external 31 independent third-party reviewer within forty-five calendar 32 days of entry of the final order. 33 DIVISION IV 34 MEMBER DISENROLLMENT FOR GOOD CAUSE 35 -5- LSB 6020XS (8) 88 pf/rh 5/ 10

S.F. 2177 Sec. 4. MEMBER DISENROLLMENT FOR GOOD CAUSE. The department 1 of human services shall adopt rules pursuant to chapter 17A 2 and shall contractually require all Medicaid managed care 3 organizations to issue a decision in response to a member’s 4 request for disenrollment for good cause within ten days 5 of the date the member submits the request to the Medicaid 6 managed care organization utilizing the Medicaid managed care 7 organization’s grievance process. 8 DIVISION V 9 UNIFORM, SINGLE CREDENTIALING 10 Sec. 5. MEDICAID PROGRAM —— USE OF UNIFORM AUTHORIZATION 11 CRITERIA AND SINGLE CREDENTIALING VERIFICATION 12 ORGANIZATION. The department of human services shall 13 develop uniform authorization criteria for, and shall 14 utilize a request for proposals process to procure a single 15 credentialing verification organization to be utilized by 16 the state in credentialing and recredentialing providers for 17 both the Medicaid managed care and fee-for-service payment and 18 delivery systems. The department shall contractually require 19 all Medicaid managed care organizations to apply the uniform 20 authorization criteria and to accept verified information from 21 the single credentialing verification organization procured by 22 the state, and shall contractually prohibit Medicaid managed 23 care organizations from requiring additional credentialing 24 information from a provider in order to participate in the 25 Medicaid managed care organization’s provider network. 26 DIVISION VI 27 MEDICAID MANAGED CARE OMBUDSMAN PROGRAM —— APPROPRIATION 28 Sec. 6. OFFICE OF LONG-TERM CARE OMBUDSMAN —— MEDICAID 29 MANAGED CARE OMBUDSMAN. 30 1. There is appropriated from the general fund of the 31 state to the office of long-term care ombudsman for the fiscal 32 year beginning July 1, 2020, and ending June 30, 2021, in 33 addition to any other funds appropriated from the general 34 fund of the state to, and in addition to any other full-time 35 -6- LSB 6020XS (8) 88 pf/rh 6/ 10

S.F. 2177 equivalent positions authorized for, the office of long-term 1 care ombudsman for the same purpose, the following amount, or 2 so much thereof as is necessary, to be used for the purposes 3 designated: 4 For the purposes of the Medicaid managed care ombudsman 5 program including for salaries, support, administration, 6 maintenance, and miscellaneous purposes, and for not more than 7 the following full-time equivalent positions: 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 300,000 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FTEs 2.50 10 2. The funding appropriated and the full-time equivalent 11 positions authorized under this section are in addition to any 12 other funds appropriated from the general fund of the state and 13 actually expended, and any other full-time equivalent positions 14 authorized and actually filled as of July 1, 2020, for the 15 Medicaid managed care ombudsman program. 16 3. Any funds appropriated to and any full-time equivalent 17 positions authorized for the office of long-term care ombudsman 18 for the Medicaid managed care ombudsman program for the fiscal 19 year beginning July 1, 2020, and ending June 30, 2021, shall 20 be used exclusively for the Medicaid managed care ombudsman 21 program. 22 4. The additional full-time equivalent positions authorized 23 in this section for the Medicaid managed care ombudsman program 24 shall be filled no later than September 1, 2020. 25 5. The office of long-term care ombudsman shall include 26 in the Medicaid managed care ombudsman program report, on a 27 quarterly basis, the disposition of resources for the Medicaid 28 managed care ombudsman program including actual expenditures 29 and a full-time equivalent positions summary for the prior 30 quarter. 31 EXPLANATION 32 The inclusion of this explanation does not constitute agreement with 33 the explanation’s substance by the members of the general assembly. 34 This bill relates to the Medicaid program. 35 -7- LSB 6020XS (8) 88 pf/rh 7/ 10

S.F. 2177 Division I of the bill requires the department of human 1 services (DHS) to adopt administrative rules to ensure that 2 services are provided to the Medicaid long-term services and 3 supports population in a conflict-free manner. Specifically, 4 the bill requires that case management services shall be 5 provided by independent providers and that the supports 6 intensity scale assessments are performed by independent 7 assessors. 8 Division II of the bill requires DHS to contractually 9 require any Medicaid managed care organization (MCO) to 10 collaborate with the department and stakeholders to develop and 11 administer a workforce recruitment, retention, and training 12 program to provide adequate access to appropriate services, 13 including but not limited to services to older Iowans. The 14 department shall ensure that any such program developed is 15 administered in a coordinated and collaborative manner across 16 all contracting MCOs and shall require the MCOs to submit 17 quarterly progress and outcomes reports to the department. 18 Division III of the bill establishes an external review 19 process for Medicaid providers for the review of final adverse 20 determinations of the MCOs’ internal appeal processes. The 21 division provides that a final decision of an external reviewer 22 may be reviewed in a contested case proceeding pursuant to Code 23 chapter 17A, and ultimately is subject to judicial review. 24 Division IV of the bill relates to member disenrollment for 25 good cause during the 12 months of closed enrollment between 26 open enrollment periods. Currently, a member may request 27 disenrollment for good cause initially through their MCO’s 28 grievance process, which may take up to 30 to 45 days to 29 process. The bill requires DHS to adopt administrative rules 30 and contractually require all Medicaid MCOs to issue a decision 31 in response to a member’s request for disenrollment for good 32 cause within 10 days of the date the member submits the request 33 to the MCO utilizing the MCO’s grievance process. 34 Division V of the bill requires the DHS to develop 35 -8- LSB 6020XS (8) 88 pf/rh 8/ 10

S.F. 2177 uniform authorization criteria for, and to utilize a request 1 for proposals process to procure a single credentialing 2 verification organization to be utilized in credentialing 3 and recredentialing providers for the Medicaid managed care 4 and fee-for-service payment and delivery systems. The bill 5 requires DHS to contractually require all Medicaid managed 6 care organizations (MCOs) to apply the uniform authorization 7 criteria and to accept verified information from the single 8 credentialing verification organization procured by the 9 state, and to contractually prohibit the MCOs from requiring 10 additional credentialing information from a provider in order 11 to participate in the Medicaid managed care organization’s 12 provider network. 13 Division VI of the bill relates to the office of long-term 14 care ombudsman (OLTCO) and the Medicaid managed care ombudsman 15 program (MCOP). 16 For fiscal year 2020-2021, the bill appropriates $300,000 17 from the general fund of the state, in addition to any other 18 funds appropriated from the general fund of the state to, 19 and authorizes 2.50 FTEs in addition to any other full-time 20 equivalent (FTE) positions authorized for, the OLTCO for the 21 purposes of the MCOP. The funding appropriated and the FTE 22 positions authorized under the bill are in addition to any 23 other funds appropriated from the general fund of the state 24 and actually expended, and any other FTE positions authorized 25 and actually filled as of July 1, 2020, for the MCOP. For 26 fiscal year 2019-2020, the expenditures budgeted for MCOP were 27 $171,536 and the FTE positions filled totaled 1.50. 28 The bill requires that any funds appropriated to and any 29 full-time equivalent positions authorized for the OLTCO for the 30 MCOP for fiscal year 2020-2021 shall be used exclusively for 31 the MCOP. The additional FTE positions authorized in the bill 32 for the MCOP shall be filled no later than September 1, 2020. 33 The bill requires the OLTCO to include in the MCOP report, on 34 a quarterly basis, the disposition of resources for the MCOP 35 -9- LSB 6020XS (8) 88 pf/rh 9/ 10