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 1 appropriation, and providing penalties. 2 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 3 TLSB 5052XS (8) 90 pf/ko
S.F. 2083 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 health and human services shall adopt rules 6 pursuant to chapter 17A to ensure that services are provided 7 under the Medicaid program to members of the long-term 8 services and supports population in a conflict-free manner. 9 Specifically, case management services shall be provided by 10 independent providers and supports intensity scale assessments 11 shall be performed by independent assessors. 12 DIVISION II 13 LONG-TERM SERVICES AND SUPPORTS POPULATION MEMBERS OPTION 14 FOR FEE-FOR-SERVICE PROGRAM ADMINISTRATION 15 Sec. 2. LONG-TERM SERVICES AND SUPPORTS POPULATION MEMBERS 16 OPTION FOR FEE-FOR-SERVICE PROGRAM ADMINISTRATION. The 17 department of health and human services shall require each 18 Medicaid managed care organization with whom the department 19 executes a contract to administer the Iowa high quality 20 health care initiative as established by the department, 21 to provide the option to Medicaid long-term services and 22 supports population members to enroll in or transition to 23 fee-for-service Medicaid program administration rather than 24 managed care administration. The department shall amend any 25 contract, request any Medicaid state plan amendment, and adopt 26 rules pursuant to chapter 17A, as necessary, to administer this 27 section. The rules shall include the process for transitioning 28 a current Medicaid long-term services and supports population 29 member to fee-for-service program administration. 30 DIVISION III 31 MEDICAID WORKFORCE PROGRAM 32 Sec. 3. WORKFORCE RECRUITMENT, RETENTION, AND TRAINING 33 PROGRAMS. The department of health and human services shall 34 contractually require any managed care organization with whom 35 -1- LSB 5052XS (8) 90 pf/ko 1/ 11
S.F. 2083 the department executes a contract under the Medicaid program 1 to collaborate with the department and stakeholders to develop 2 and administer a workforce recruitment, retention, and training 3 program to provide adequate access to appropriate services, 4 including but not limited to services to older Iowans. 5 The department shall ensure that any program developed is 6 administered in a coordinated and collaborative manner across 7 all contracting managed care organizations and shall require 8 the managed care organizations to submit quarterly progress and 9 outcomes reports to the department. 10 DIVISION IV 11 PROVIDER APPEALS PROCESS EXTERNAL REVIEW 12 Sec. 4. MEDICAID MANAGED CARE ORGANIZATION APPEALS PROCESS 13 EXTERNAL REVIEW PENALTY. 14 1. a. A Medicaid managed care organization under contract 15 with the department of health and human services shall include 16 in any written response to a Medicaid provider under contract 17 with the managed care organization that reflects a final 18 adverse determination of the managed care organizations 19 internal appeal process relative to an appeal filed by the 20 Medicaid provider, all of the following: 21 (1) A statement that the Medicaid providers internal 22 appeal rights within the managed care organization have been 23 exhausted. 24 (2) A statement that the Medicaid provider is entitled to 25 an external independent third-party review pursuant to this 26 section. 27 (3) The requirements for requesting an external independent 28 third-party review. 29 b. If a managed care organizations written response does 30 not comply with the requirements of paragraph a, the managed 31 care organization shall pay to the affected Medicaid provider a 32 penalty not to exceed one thousand dollars. 33 2. a. A Medicaid provider who has been denied the provision 34 of a service to a Medicaid member or a claim for reimbursement 35 -2- LSB 5052XS (8) 90 pf/ko 2/ 11
S.F. 2083 for a service rendered to a Medicaid member, and who has 1 exhausted the internal appeal process of a managed care 2 organization, shall be entitled to an external independent 3 third-party review of the managed care organizations final 4 adverse determination. 5 b. To request an external independent third-party review of 6 a final adverse determination by a managed care organization, 7 an aggrieved Medicaid provider shall submit a written request 8 for such review to the managed care organization within sixty 9 calendar days of receiving the final adverse determination. 10 c. A Medicaid providers request for an external 11 independent third-party review shall include all of the 12 following: 13 (1) Identification of each specific issue and dispute 14 directly related to the final adverse determination issued by 15 the managed care organization. 16 (2) A statement of the basis upon which the Medicaid 17 provider believes the managed care organizations determination 18 to be erroneous. 19 (3) The Medicaid providers designated contact information, 20 including name, mailing address, phone number, fax number, and 21 email address. 22 3. a. Within five business days of receiving a Medicaid 23 providers request for an external independent third-party 24 review pursuant to this subsection, the managed care 25 organization shall do all of the following: 26 (1) Confirm to the Medicaid providers designated contact, 27 in writing, that the managed care organization has received the 28 request for review. 29 (2) Notify the department of health and human services of 30 the Medicaid providers request for review. 31 (3) Notify the affected Medicaid member of the Medicaid 32 providers request for review, if the review is related to the 33 denial of a service. 34 b. If the managed care organization fails to satisfy the 35 -3- LSB 5052XS (8) 90 pf/ko 3/ 11
S.F. 2083 requirements of this subsection, the Medicaid provider shall 1 automatically prevail in the review. 2 4. a. Within fifteen calendar days of receiving a Medicaid 3 providers request for an external independent third-party 4 review, the managed care organization shall do all of the 5 following: 6 (1) Submit to the department of health and human services 7 all documentation submitted by the Medicaid provider in the 8 course of the managed care organizations internal appeal 9 process. 10 (2) Provide the managed care organizations designated 11 contact information, including name, mailing address, phone 12 number, fax number, and email address. 13 b. If a managed care organization fails to satisfy the 14 requirements of this subsection, the Medicaid provider shall 15 automatically prevail in the review. 16 5. A request for an external independent third-party review 17 shall automatically extend the deadline to file an appeal for a 18 contested case hearing under chapter 17A, pending the outcome 19 of the external independent third-party review, until thirty 20 calendar days following receipt of the review decision by the 21 Medicaid provider. 22 6. Upon receiving notification of a request for an external 23 independent third-party review, the department of health and 24 human services shall do all of the following: 25 a. Assign the review to an external independent third-party 26 reviewer. 27 b. Notify the managed care organization of the identity of 28 the external independent third-party reviewer. 29 c. Notify the Medicaid providers designated contact of the 30 identity of the external independent third-party reviewer. 31 7. The department of health and human services shall deny a 32 request for an external independent third-party review if the 33 requesting Medicaid provider fails to exhaust the managed care 34 organizations internal appeal process or fails to submit a 35 -4- LSB 5052XS (8) 90 pf/ko 4/ 11
S.F. 2083 timely request for an external independent third-party review 1 pursuant to this section. 2 8. a. Multiple appeals through the external independent 3 third-party review process regarding the same Medicaid member, 4 a common question of fact, or the interpretation of common 5 applicable regulations or reimbursement requirements may 6 be combined and determined in one action upon request of a 7 party in accordance with rules and regulations adopted by the 8 department of health and human services. 9 b. The Medicaid provider that initiated a request for 10 an external independent third-party review, or one or more 11 other Medicaid providers, may add claims to such an existing 12 external independent third-party review request following the 13 exhaustion of any applicable managed care organization internal 14 appeal process, if the claims involve a common question of 15 fact or interpretation of common applicable regulations or 16 reimbursement requirements. 17 9. Documentation reviewed by the external independent 18 third-party reviewer shall be limited to documentation 19 submitted pursuant to subsection 4. 20 10. An external independent third-party reviewer shall do 21 all of the following: 22 a. Conduct an external independent third-party review 23 of any claim submitted to the reviewer pursuant to this 24 subsection. 25 b. Within thirty calendar days from receiving the request 26 for an external independent third-party review from the 27 department of health and human services and the documentation 28 submitted pursuant to subsection 4, issue the reviewers final 29 decision to the Medicaid providers designated contact, the 30 managed care organizations designated contact, the department 31 of health and human services, and the affected Medicaid member 32 if the decision involves a denial of service. The reviewer may 33 extend the time to issue a final decision by up to fourteen 34 calendar days upon agreement of all parties to the review. 35 -5- LSB 5052XS (8) 90 pf/ko 5/ 11
S.F. 2083 11. The department of health and human services shall 1 enter into a contract with an external independent review 2 organization that does not have a conflict of interest with the 3 department of health and human services or any managed care 4 organization to conduct the external independent third-party 5 reviews under this section. 6 a. A party, including the affected Medicaid member or 7 Medicaid provider, may appeal a final decision of the external 8 independent third-party reviewer in a contested case proceeding 9 in accordance with chapter 17A within thirty calendar days from 10 receiving the final decision. A final decision in a contested 11 case proceeding is subject to judicial review. 12 b. The final decision of an external independent 13 third-party reviewer conducted pursuant to this section shall 14 also direct the nonprevailing party to pay an amount equal to 15 the costs of the review to the external independent third-party 16 reviewer. Any payment ordered pursuant to this subsection 17 shall be stayed pending any appeal of the review. If the 18 final outcome of any appeal is to reverse the decision of the 19 external independent third-party reviewer, the nonprevailing 20 party on appeal shall pay the costs of the review to the 21 external independent third-party reviewer within forty-five 22 calendar days of entry of the final order. 23 DIVISION V 24 MEMBER DISENROLLMENT FOR GOOD CAUSE 25 Sec. 5. MEMBER DISENROLLMENT FOR GOOD CAUSE. The department 26 of health and human services shall contractually require all 27 Medicaid managed care organizations to issue a decision in 28 response to a members request for disenrollment for good cause 29 within ten days of the date the member submits the request to 30 the Medicaid managed care organization utilizing the Medicaid 31 managed care organizations grievance process. The department 32 shall adopt rules pursuant to chapter 17A to administer this 33 division. 34 DIVISION VI 35 -6- LSB 5052XS (8) 90 pf/ko 6/ 11
S.F. 2083 UNIFORM, SINGLE CREDENTIALING 1 Sec. 6. MEDICAID PROGRAM USE OF UNIFORM AUTHORIZATION 2 CRITERIA AND SINGLE CREDENTIALING VERIFICATION 3 ORGANIZATION. The department of health and human services 4 shall develop uniform authorization criteria for, and 5 shall utilize a request for proposals process to procure, 6 a single credentialing verification organization to be 7 utilized in credentialing and recredentialing providers for 8 both the Medicaid managed care and fee-for-service payment 9 and delivery systems. The department or health and human 10 services shall contractually require all Medicaid managed care 11 organizations to apply the uniform authorization criteria and 12 to accept verified information from the single credentialing 13 verification organization procured by the department, and shall 14 contractually prohibit Medicaid managed care organizations 15 from requiring additional credentialing information from a 16 provider in order to participate in the Medicaid managed care 17 organizations provider network. 18 DIVISION VII 19 MEDICAID MANAGED CARE OMBUDSMAN PROGRAM APPROPRIATION 20 Sec. 7. OFFICE OF LONG-TERM CARE OMBUDSMAN MEDICAID 21 MANAGED CARE OMBUDSMAN. 22 1. There is appropriated from the general fund of the 23 state to the department of health and human services office of 24 long-term care ombudsman for the fiscal year beginning July 25 1, 2024, and ending June 30, 2025, in addition to any other 26 funds appropriated from the general fund of the state to, 27 and in addition to any other full-time equivalent positions 28 authorized for, the office of long-term care ombudsman for the 29 same purpose, the following amount, or so much thereof as is 30 necessary, to be used for the purposes designated: 31 For the purposes of the Medicaid managed care ombudsman 32 program including for salaries, support, administration, 33 maintenance, and miscellaneous purposes, and for not more than 34 the following full-time equivalent positions: 35 -7- LSB 5052XS (8) 90 pf/ko 7/ 11
S.F. 2083 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 300,000 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FTEs 2.50 2 2. The funding appropriated and the full-time equivalent 3 positions authorized under this section are in addition to any 4 other funds appropriated from the general fund of the state and 5 actually expended, and any other full-time equivalent positions 6 authorized and actually filled as of July 1, 2024, for the 7 Medicaid managed care ombudsman program. 8 3. Any funds appropriated to and any full-time equivalent 9 positions authorized for the office of long-term care ombudsman 10 for the Medicaid managed care ombudsman program for the fiscal 11 year beginning July 1, 2024, and ending June 30, 2025, shall 12 be used exclusively for the Medicaid managed care ombudsman 13 program. 14 4. The additional full-time equivalent positions authorized 15 in this section for the Medicaid managed care ombudsman program 16 shall be filled no later than September 1, 2024. 17 5. The office of long-term care ombudsman shall include 18 in the Medicaid managed care ombudsman program report, on a 19 quarterly basis, the disposition of resources for the Medicaid 20 managed care ombudsman program including actual expenditures 21 and a full-time equivalent positions summary for the prior 22 quarter. 23 DIVISION VIII 24 HEALTH POLICY OVERSIGHT COMMITTEE MEETINGS 25 Sec. 8. Section 2.45, subsection 5, Code 2024, is amended 26 to read as follows: 27 5. The legislative health policy oversight committee, 28 which shall be composed of ten members of the general 29 assembly, consisting of five members from each house, to 30 be appointed by the legislative council. The legislative 31 health policy oversight committee may shall meet at least two 32 times, annually , during the legislative interim to provide 33 continuing oversight for Medicaid managed care, and to ensure 34 effective and efficient administration of the program, address 35 -8- LSB 5052XS (8) 90 pf/ko 8/ 11
S.F. 2083 stakeholder concerns, monitor program costs and expenditures, 1 and make recommendations. 2 EXPLANATION 3 The inclusion of this explanation does not constitute agreement with 4 the explanations substance by the members of the general assembly. 5 This bill relates to the Medicaid program. 6 Division I of the bill requires the department of health 7 and human services (HHS) to adopt administrative rules to 8 ensure that services are provided to the Medicaid long-term 9 services and supports population in a conflict-free manner. 10 Specifically, the bill requires that case management services 11 shall be provided by independent providers and that the 12 supports intensity scale assessments are performed by 13 independent assessors. 14 Division II of the bill directs HHS to require each Medicaid 15 managed care organization (MCO) with whom HHS executes 16 a contract, to provide the option to Medicaid long-term 17 services and supports population members to enroll in or 18 transition to fee-for-service Medicaid program administration 19 rather than managed care administration. The department 20 shall amend any contract, request any Medicaid state plan 21 amendment, and adopt administrative rules, as necessary, 22 to administer this provision. The rules shall include the 23 process for transitioning a current Medicaid long-term services 24 and supports population member to fee-for-service program 25 administration. 26 Division III of the bill requires HHS to contractually 27 require any Medicaid MCO to collaborate with HHS and 28 stakeholders to develop and administer a workforce recruitment, 29 retention, and training program to provide adequate access to 30 appropriate services, including but not limited to services 31 to older Iowans. The department shall ensure that any such 32 program developed is administered in a coordinated and 33 collaborative manner across all contracting MCOs and shall 34 require the MCOs to submit quarterly progress and outcomes 35 -9- LSB 5052XS (8) 90 pf/ko 9/ 11
S.F. 2083 reports to HHS. 1 Division IV of the bill establishes an external independent 2 third-party review process for Medicaid providers for the 3 review of final adverse determinations of the MCOs internal 4 appeals processes. The division provides that a final 5 decision of an external independent third-party reviewer may 6 be reviewed in a contested case proceeding pursuant to Code 7 chapter 17A, and ultimately is subject to judicial review. The 8 bill provides a civil penalty for an MCO that does not comply 9 with the written response requirements relating to an adverse 10 determination. 11 Division V of the bill relates to member disenrollment 12 for good cause during the 12 months of closed enrollment 13 between open enrollment periods. The bill requires HHS to 14 contractually require all Medicaid MCOs to issue a decision 15 in response to a members request for disenrollment for good 16 cause within 10 days of the date the member submits the request 17 to the MCO utilizing the MCOs grievance process and to adopt 18 administrative rules to administer the division. 19 Division VI of the bill requires the HHS to develop 20 uniform authorization criteria for, and to utilize a request 21 for proposals process to procure, a single credentialing 22 verification organization to be utilized in credentialing 23 and recredentialing providers for the Medicaid managed care 24 and fee-for-service payment and delivery systems. The bill 25 requires HHS to contractually require all Medicaid MCOs to 26 apply the uniform authorization criteria, to accept verified 27 information from the single credentialing verification 28 organization procured by HHS, and to contractually prohibit the 29 MCOs from requiring additional credentialing information from a 30 provider in order to participate in the Medicaid MCOs provider 31 network. 32 Division VII of the bill relates to the office of long-term 33 care ombudsman (OLTCO) and the Medicaid managed care ombudsman 34 program (MCOP). 35 -10- LSB 5052XS (8) 90 pf/ko 10/ 11
S.F. 2083 For fiscal year 2024-2025, the bill appropriates $300,000 1 from the general fund of the state, in addition to any other 2 funds appropriated from the general fund of the state to, 3 and authorizes 2.50 FTEs in addition to any other full-time 4 equivalent (FTE) positions authorized for, HHS for the OLTCO 5 for the purposes of the MCOP. The funding appropriated and the 6 FTE positions authorized under the bill are in addition to any 7 other funds appropriated from the general fund of the state and 8 actually expended, and any other FTE positions authorized and 9 actually filled as of July 1, 2024, for the MCOP. 10 The bill requires that any funds appropriated to and any 11 full-time equivalent positions authorized for the OLTCO for the 12 MCOP for fiscal year 2024-2025 shall be used exclusively for 13 the MCOP. The additional FTE positions authorized in the bill 14 for the MCOP shall be filled no later than September 1, 2024. 15 The bill requires the OLTCO to include in the MCOP report, on 16 a quarterly basis, the disposition of resources for the MCOP 17 including expenditures and an FTE positions summary for the 18 prior quarter. 19 Division VIII amends the provision regarding the meetings of 20 the health policy oversight committee (HPOC) of the legislative 21 council. Current law provides that HPOC may meet annually. 22 The bill provides that HPOC shall meet, and further requires 23 that HPOC meet at least two times, annually, during the 24 legislative interim. The bill reflects the law related to the 25 meeting of HPOC in effect prior to that law being amended in 26 2023. 27 -11- LSB 5052XS (8) 90 pf/ko 11/ 11