Senate File 452 - Reprinted
SENATE FILE
BY COMMITTEE ON HUMAN
RESOURCES
(SUCCESSOR TO SSB
1253)
(As Amended and Passed by the Senate March 18, 2015)
A BILL FOR
1 An Act relating to Medicaid program transformation and
2 oversight.
3 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
SF 452 (5) 86
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PAG LIN
1 1 Section 1. NEW SECTION. 249A.9 Medicaid transformation and
1 2 oversight commission == findings, goals, and intent.
1 3 1. The general assembly finds that state Medicaid program
1 4 initiatives have consistently advanced the goals of a health
1 5 care delivery system that improves population health, enhances
1 6 the experiences and outcomes of patients, reduces the costs of
1 7 care, and integrates and coordinates services and supports to
1 8 address social determinants of health. Existing initiatives,
1 9 including the healthiest state initiative, the balancing
1 10 incentive program, the Iowa health and wellness plan created
1 11 pursuant to chapter 249N, and the state innovation models
1 12 initiative, all reflect these consistent goals. Each of
1 13 these programs and initiatives has been formulated to realign
1 14 the health care delivery system to provide whole=person,
1 15 patient=centered and family=centered care while moving toward a
1 16 value and risk=based model of reimbursement.
1 17 2. Legislative involvement and oversight is essential to
1 18 ensure stakeholder input, consumer protection, and quality
1 19 assurance in the transformation of the Medicaid program. A
1 20 transition to a managed care system, especially one that
1 21 affects vulnerable populations so diverse in medical and
1 22 functional needs and that involves such a wide spectrum of
1 23 providers and state agencies, requires intentional planning
1 24 and attention. The state must also provide for appropriate
1 25 and adequate infrastructure, resources, and funding to ensure
1 26 accountability to and compliance with state policy, rules, and
1 27 contract requirements.
1 28 3. Given the challenges presented, a Medicaid
1 29 transformation and oversight commission is created to provide
1 30 a formal venue for guidance and oversight of and stakeholder
1 31 engagement in, the design, development, and implementation of
1 32 Medicaid program transformation.
1 33 4. a. The commission shall include all of the following
1 34 members:
1 35 (1) The co=chairpersons and ranking members of the
2 1 legislative joint appropriations subcommittee on health
2 2 and human services, or members of the joint appropriations
2 3 subcommittee designated by the respective co=chairpersons or
2 4 ranking members.
2 5 (2) The chairpersons and ranking members of the
2 6 human resources committees of the senate and house of
2 7 representatives, or members of the respective committees
2 8 designated by the respective chairpersons or ranking members.
2 9 (3) The chairpersons and ranking members of the
2 10 appropriations committees of the senate and house of
2 11 representatives, or members of the respective committees
2 12 designated by the respective chairpersons or ranking members.
2 13 b. The members of the commission shall receive a per diem as
2 14 provided in section 2.10.
2 15 c. The commission shall meet at least quarterly, but may
2 16 meet as often as necessary. The commission may use sources of
2 17 information deemed appropriate, and the department of human
2 18 services and other agencies of state government shall provide
2 19 information to the commission as requested. The legislative
2 20 services agency shall provide staff support to the commission.
2 21 d. The commission shall select co=chairpersons, one
2 22 representing the senate and one representing the house of
2 23 representatives, annually, from its membership. A majority of
2 24 the members of the commission shall constitute a quorum.
2 25 e. The commission may contract for the services of persons
2 26 who are qualified by education, expertise, or experience to
2 27 advise, consult with, or otherwise assist the commission in the
2 28 performance of its duties. The commission may specifically
2 29 enlist the assistance of entities such as the university of
2 30 Iowa public policy center to provide ongoing evaluation of the
2 31 Medicaid program and to make evidence=based recommendations to
2 32 improve the program.
2 33 5. The commission shall do all of the following:
2 34 a. Provide overall long=term and real=time guidance for the
2 35 Medicaid program including but not limited to:
3 1 (1) Developing a strategic plan to provide a predictable
3 2 guide for transformation prior to any transition. The
3 3 strategic plan shall address health care delivery and payment
3 4 reforms that reflect a holistic, integrated, patient=centered
3 5 and family=centered, primary care=focused, value=based model
3 6 and extend beyond a medical model to address the social
3 7 determinants of health.
3 8 (2) Reviewing, recommending, and approving the design,
3 9 development, and implementation of all initiatives under the
3 10 Medicaid program, and making additional recommendations for
3 11 Medicaid program reform.
3 12 (3) Monitoring progress in obtaining federal approval of
3 13 proposals such as those relating to benefit design, service
3 14 delivery, payment reform, and quality and cost containment
3 15 measures.
3 16 (4) Reviewing other states' models of health care delivery
3 17 and payment reform and specifically those related to Medicaid
3 18 managed care to determine best practices and inform future
3 19 state Medicaid program initiatives.
3 20 (5) Ensuring that at each stage of transformation, existing
3 21 models, provider networks, reimbursement methodologies,
3 22 and performance and quality metrics are integrated into the
3 23 subsequent stage to provide consistency and reliability.
3 24 (6) Ensuring that the state has a clearly articulated
3 25 vision for the Medicaid program, which is reflected in contract
3 26 expectations, oversight, incentives, and penalties under the
3 27 program.
3 28 (7) Assessing state agencies including those involved
3 29 in the Medicaid program, child welfare, aging and disability
3 30 services, and public health to articulate clear roles and
3 31 responsibilities and to promote state program interoperability.
3 32 (a) The commission shall review and make recommendations
3 33 regarding potential integration of various service delivery
3 34 systems including public health, aging and disability services
3 35 agencies, and mental health and disability services regions to
4 1 more efficiently and effectively address consumer needs.
4 2 (b) The commission shall ensure that state agencies provide
4 3 leadership and have the appropriate organizational structures,
4 4 adequate resources and funding, and qualified staff with
4 5 specialized skills, training, and expertise to provide the
4 6 level of expertise and scrutiny required to administer and
4 7 oversee the various transformation initiatives, including those
4 8 related to Medicaid managed care.
4 9 (8) Ensuring that state Medicaid managed care initiatives
4 10 comply with the guidance to states using 1115 demonstrations
4 11 or 1915(b) waivers for managed long=term services and supports
4 12 programs published by the centers for Medicare and Medicaid
4 13 services of the United States department of health and human
4 14 services on May 20, 2013, including those relating to adequate
4 15 planning, stakeholder engagement, enhanced provision of home
4 16 and community=based services, alignment of structures and
4 17 goals, support for beneficiaries, a person=centered process, a
4 18 comprehensive, integrated service package, qualified providers,
4 19 consumer protections, and quality.
4 20 (9) Reviewing the performance under and outcomes of
4 21 contracts including but not limited to those between the
4 22 state and the Iowa Medicaid enterprise and managed care
4 23 organizations, to determine compliance.
4 24 (10) Ensuring that the various Medicaid populations are
4 25 managed at all times within funding limitations and contract
4 26 terms. The commission shall also monitor service delivery
4 27 and utilization to ensure the responsibility for provision of
4 28 services to Medicaid consumers is not shifted to non=Medicaid
4 29 covered services solely to attain savings, and that such
4 30 responsibility is not shifted to mental health and disability
4 31 services regions, local public health agencies, aging and
4 32 disability resource centers, or other entities unless agreement
4 33 to provide, and provision for adequate compensation for, such
4 34 services is agreed to in advance.
4 35 b. Address provider access and workforce adequacy issues.
5 1 (1) As the state moves toward integration of long=term
5 2 services and supports into Medicaid managed care, the
5 3 commission shall provide for a comprehensive review of
5 4 long=term services and supports and make recommendations to
5 5 create a sustainable, person=centered approach that increases
5 6 health and life outcomes, supports maximum independence,
5 7 addresses medical and social needs in a coordinated, integrated
5 8 manner, and provides for sufficient resources including a
5 9 stable, well=qualified workforce.
5 10 (a) The commission shall provide a forum for open and
5 11 constructive dialogue among stakeholders representing
5 12 individuals involved in the delivery and financing of long=term
5 13 services and supports, address the cost and financing of
5 14 long=term services and supports, the coordination of services
5 15 among providers, and the availability of and access to a
5 16 well=qualified workforce, and consider methods to educate
5 17 consumers and enhance engagement of consumers in the broader
5 18 conversation regarding long=term services and supports.
5 19 (b) The commission shall recommend ways to eliminate Iowa's
5 20 institutional bias and come into full compliance with the
5 21 Olmstead decision.
5 22 (2) The commission shall review current and projected
5 23 overall health care workforce availability to determine
5 24 the most efficient utilization of the roles, functions,
5 25 responsibilities, activities, and decision=making capacity
5 26 of health care professionals and make recommendations for
5 27 improvement. The commission shall encourage the use of
5 28 alternative modes of health care delivery, as appropriate.
5 29 (3) The commission shall ensure the linguistic and cultural
5 30 competency of providers and other program facilitators.
5 31 c. Provide for consumer engagement, address consumer
5 32 choice and satisfaction, and provide for consumer appeal and
5 33 grievance procedures. The commission shall provide for input
5 34 from the medical assistance advisory council created in section
5 35 249A.4B, the mental health and disabilities services commission
6 1 created in section 225C.5, the commission on aging created
6 2 in section 231.11, the medical home system advisory council
6 3 created in section 135.159, the bureau of substance abuse of
6 4 the department of public health, and other appropriate entities
6 5 to provide advice to the commission.
6 6 d. Review and make recommendations regarding reimbursement
6 7 and rate setting to ensure adequate compensation for all
6 8 providers of services and supports to the Medicaid population,
6 9 an adequate provider network, and timely access to services for
6 10 consumers.
6 11 e. Define the desired outcomes and the metrics by which
6 12 improvement is determined. The commission shall provide for
6 13 consistency and uniformity of metrics and required outcomes
6 14 across payors and providers to the greatest extent possible.
6 15 f. Ensure that care coordination and case management are
6 16 provided in a patient=centered and family=centered manner that
6 17 requires a knowledge of community supports, a reasonable ratio
6 18 of care coordinators to consumers, standards for frequency
6 19 of contact with the consumer, and specific and adequate
6 20 reimbursement.
6 21 g. Address health information technology and data collection
6 22 and sharing.
6 23 6. The commission shall submit a report of its findings and
6 24 recommendations to the governor and the general assembly by
6 25 December 15, annually.
6 26 Sec. 2. TRANSITION TO MEDICAID MANAGED CARE ==
6 27 DIRECTIVES. In order to ensure a seamless transition of
6 28 Medicaid consumers to Medicaid managed care, all of the
6 29 following circumstances shall be considered and all of the
6 30 following conditions shall be met in any design, development,
6 31 or implementation of Medicaid managed care on or after March
6 32 1, 2015:
6 33 1. The state shall engage in a thoughtful and deliberative
6 34 planning process that permits sufficient time to outline a
6 35 clear vision for the program, solicit and consider stakeholder
7 1 input, educate program consumers, assess readiness, and
7 2 develop safeguards and oversight mechanisms to ensure a
7 3 smooth transition to and effective ongoing implementation of
7 4 Medicaid managed care. The movement to Medicaid managed care
7 5 shall retain an emphasis on choice, consumer=driven care and
7 6 services, a community=based infrastructure, and promotion of
7 7 community=based alternatives. The state shall demonstrate
7 8 that systems and processes are in place between state agencies
7 9 to support the populations enrolled in Medicaid managed care
7 10 such as elders, persons with physical, intellectual, and
7 11 developmental disabilities, persons with chronic diseases, and
7 12 persons with mental health or substance abuse issues.
7 13 2. a. Prior to the transition to Medicaid managed care
7 14 of any population, and especially to ensure that high=risk
7 15 populations are provided continuity of care and do not
7 16 experience gaps in coverage or access to care issues, the state
7 17 shall perform a readiness assessment to ensure that managed
7 18 care organizations are in compliance with network adequacy
7 19 requirements, that necessary consumer and provider outreach and
7 20 education have been conducted, and that programmatic gaps have
7 21 been identified prior to the system becoming operational.
7 22 b. A managed care contract shall include a provision
7 23 for continuity and coordination of care for a consumer
7 24 transitioning to managed care, including maintaining existing
7 25 provider=consumer relationships and honoring the amount and
7 26 duration of an individual's authorized services under an
7 27 existing service plan, based on individual assessment and
7 28 needs. In the initial transition of a consumer to Medicaid
7 29 managed care, to ensure the least amount of disruption, managed
7 30 care organizations shall provide, at a minimum, a one=year
7 31 transition of care period for all provider types, regardless of
7 32 network status with an individual managed care organization.
7 33 c. The state shall ensure that if an individual is
7 34 auto=enrolled in a Medicaid managed care plan, there are
7 35 sufficient staff and safeguards available to ensure continuity
8 1 of care for the consumer through the consumer's existing
8 2 provider.
8 3 d. The state shall administratively credential existing
8 4 Medicaid providers, rather than requiring such providers to
8 5 complete a new credentialing process, to ensure a seamless
8 6 transition to the new managed care system and to ensure rapid
8 7 development of managed care provider networks.
8 8 e. The state shall retain external managed care experts to
8 9 guide patient transition, system implementation, and oversight
8 10 until the department of human services is able to develop the
8 11 internal staff capacity to confidently operate independently.
8 12 Such external experts shall be selected through a request for
8 13 proposals process and the state shall ensure that such experts
8 14 are not affiliated with any of the managed care organizations
8 15 selected in order to provide unbiased and appropriate guidance.
8 16 3. a. The state shall establish a specific, enforceable
8 17 process to ensure managed care organizations grievance and
8 18 appeals procedures are fully accessible to patients regardless
8 19 of physical, intellectual, behavioral, or sensory barriers.
8 20 b. Managed care contracts shall include consumer
8 21 protections including a statement of consumer rights and
8 22 responsibilities, a critical incident management system with
8 23 safeguards to prevent abuse, neglect, and exploitation, and
8 24 fair hearing protections including the continuation of services
8 25 during an appeal.
8 26 c. Managed care organization contracts shall include
8 27 provider appeals and grievance procedures that in part allow a
8 28 provider to file a grievance independently but on behalf of a
8 29 member and to appeal claims denials which, if determined to be
8 30 based on claims for medically necessary services whether or not
8 31 denied on an administrative basis, shall receive appropriate
8 32 payment.
8 33 4. a. The state shall utilize public forums, public input
8 34 surveys, stakeholder workgroup sessions, and other effective
8 35 formal channels for stakeholder engagement in the design,
9 1 development, and implementation of Medicaid managed care. The
9 2 state shall utilize the medical assistance advisory council
9 3 established pursuant to section 249A.4B to provide a forum
9 4 for oversight of managed care organizations and to advise the
9 5 department regarding systemic issues identified by the council.
9 6 b. Managed care organizations shall maintain stakeholder
9 7 panels comprised of an equal number of consumers and providers
9 8 in place at least thirty days prior to the transition to
9 9 managed care. Managed care organizations shall provide for
9 10 separate provider=specific panels to address detailed payment
9 11 and claims issues and grievance and appeals processes.
9 12 5. a. The state shall ensure that a managed care
9 13 organization develops and maintains a network of qualified
9 14 providers who meet state licensing, credentialing, and
9 15 certification requirements, as applicable, which network shall
9 16 be sufficient to provide adequate access to all services
9 17 covered and for all populations served under the managed
9 18 care contract. The state shall ensure that managed care
9 19 organizations incorporate existing and traditional providers,
9 20 including but not limited to those that comprise the Iowa
9 21 collaborative safety net provider network created in section
9 22 135.153.
9 23 b. Managed care contracts shall specify provider network
9 24 composition and access requirements including continuity of
9 25 care provisions and rules for when and how consumers may
9 26 access out=of=network providers. Managed care plans shall
9 27 provide reports of compliance with state network composition
9 28 and access standards and the state shall include financial
9 29 incentives and disincentives as management tools to support
9 30 state expectations.
9 31 c. The state shall review managed care organization
9 32 credentialing processes to provide consistency across such
9 33 organizations and to simplify and streamline the credentialing
9 34 process.
9 35 d. The state shall ensure that management of care for the
10 1 population served is consumer=driven, patient=focused and
10 2 family=focused, and provider=led.
10 3 e. The state shall monitor and enforce access standards
10 4 to ensure that consumers are able to access appropriate care
10 5 as close to their own homes as possible. The state shall
10 6 review, at least quarterly, network adequacy compliance and
10 7 require the dissemination of easily accessible and updated
10 8 provider directories to ensure consumers have the most accurate
10 9 information possible regarding the number, location, type, and
10 10 current capacity of providers contracted with the individual
10 11 managed care organization. The state shall ensure that
10 12 noncompliance results in swift corrective action.
10 13 f. The state shall require managed care plans to remove
10 14 administrative barriers to, provide reimbursement for,
10 15 and utilize emerging technologies such as e=health, mobile
10 16 technologies, and telehealth in health care delivery in a
10 17 medically appropriate manner in order to expand access to
10 18 services and extend the reach of approved provider networks
10 19 into rural and underserved areas of the state. Reimbursement
10 20 for telehealth shall be at the same rate as in=person services.
10 21 Reimbursable activities shall include store and forward
10 22 consultation, direct=to=consumer virtual care, telehealth
10 23 visits, home=based monitoring, and telehealth monitoring in
10 24 long=term care facilities.
10 25 g. The state shall require managed care organizations to
10 26 implement tools and strategies that support community=level
10 27 system integration between acute care, long=term services and
10 28 supports, and community=level agencies and organizations to
10 29 further population health goals.
10 30 6. a. (1) The state shall require managed care
10 31 organizations to align economic incentives, delivery system
10 32 reform, and performance and outcome metrics with those of the
10 33 state innovation models initiative and Medicaid accountable
10 34 care organizations.
10 35 (2) The state shall develop a common, uniform set of
11 1 process, quality, and consumer satisfaction measures across
11 2 all Medicaid payors and providers that align with those
11 3 developed through the state innovation models initiative and
11 4 shall ensure that such measures are expanded and adjusted to
11 5 address additional populations and to meet population health
11 6 objectives. Measures considered may include but are not
11 7 limited to those related to consumer education, transition
11 8 to and ongoing implementation of managed care, monitoring
11 9 and oversight, consumer input and rights, network adequacy
11 10 and access to care including services that address social
11 11 determinants of health, the provision of preventive services
11 12 and supports as well as those that address chronic conditions,
11 13 continuity of care, long=term services and supports, provider
11 14 standards, and evaluation and quality measures.
11 15 (3) Any quality data collected regarding provider
11 16 performance shall be shared with providers for review and input
11 17 prior to dissemination to consumers.
11 18 b. Managed care contracts shall include long=term
11 19 performance goals that reward success in achieving population
11 20 health goals such as improved community health metrics.
11 21 c. The state shall require consistency and uniformity
11 22 of processes and forms across all managed care organizations
11 23 including but not limited to the use of uniform cost and
11 24 quality reporting and uniform prior authorization procedures.
11 25 7. The state shall require the provision of independent
11 26 choice counseling, education, functional assessment, and
11 27 enrollment and disenrollment from a managed care plan by
11 28 an entity free of conflicts. The state shall ensure an
11 29 independent advocate is available to assist consumers in
11 30 navigating the Medicaid managed care landscape, understanding
11 31 their rights, responsibilities, choices, and opportunities,
11 32 and helping to resolve any problems that arise between the
11 33 consumer and the managed care organization. Unless such an
11 34 entity declines, as applicable to the population of consumers,
11 35 the aging and disability resource centers and the long=term
12 1 care ombudsman shall provide such independent, conflict=free
12 2 services in an accessible, ongoing, and consumer=friendly
12 3 manner, and shall be provided adequate resources and
12 4 reimbursement for provision of such services.
12 5 7A. a. Managed care organization contracts shall
12 6 specifically and appropriately address the unique needs of
12 7 children and children's health care delivery.
12 8 b. Managed care organizations shall maintain child health
12 9 panels that include representatives of child health, welfare,
12 10 policy, and advocacy organizations in the state that address
12 11 child health and child well=being.
12 12 c. Managed care organization contracts that apply
12 13 to children's health care delivery shall address early
12 14 intervention and prevention strategies, the provision of a
12 15 child health delivery infrastructure for children with special
12 16 health care needs, utilization of current standards and
12 17 guidelines for children's health care and pediatric=specific
12 18 screening and assessment tools, the inclusion of pediatric
12 19 specialty providers in the provider network, and the
12 20 utilization of health homes for children and youth with special
12 21 health care needs including intensive care coordination and
12 22 family support and access to a professional family=to=family
12 23 support system.
12 24 d. Managed care organization contracts that apply
12 25 to children's health care delivery shall utilize
12 26 pediatric=specific quality measures, which shall align
12 27 with existing pediatric=specific measures as determined in
12 28 consultation with the child health panel.
12 29 e. Managed care contracts shall provide special incentives
12 30 for innovative and evidence=based preventive, behavioral, and
12 31 developmental health care and mental health care for children's
12 32 programs that improve the life course trajectory of those
12 33 children.
12 34 8. The state shall require the use of uniform, standardized,
12 35 person=centered, and state=approved instruments to assess
13 1 a consumer's physical, psychosocial, and functional needs,
13 2 including current health status and treatment needs; social,
13 3 employment, and transportation needs and preferences;
13 4 personal goals; consumer and caregiver preferences for
13 5 care; back=up plans for situations in which caregivers are
13 6 unavailable; and informal networks. The state shall approve a
13 7 pediatric=specific assessment tool and quality measures. The
13 8 information collected from these assessments shall be used to
13 9 identify health risks and social determinants of health that
13 10 impact health outcomes. Plans and providers shall use this
13 11 data in care coordination and interventions to improve patient
13 12 outcomes and to drive program designs that improve the health
13 13 of the population. Managed care organizations shall share
13 14 aggregate assessment data for consumers with providers on a
13 15 routine basis.
13 16 9. The state shall establish guidelines for care
13 17 coordination across managed care organizations to ease
13 18 administrative burdens on providers and help streamline
13 19 access to care. Coordinated care shall utilize the team=based
13 20 care model by connecting a Medicaid consumer to a single
13 21 primary care provider. The state shall require managed care
13 22 organizations to coordinate data sharing and analytics across
13 23 providers to facilitate care coordination. A managed care plan
13 24 shall provide for identification of the care coordination needs
13 25 of a consumer including those related to social determinants of
13 26 health, ensure that appropriate care coordination services are
13 27 provided, and provide evidence on an ongoing basis to the state
13 28 that both have occurred.
13 29 10. The state shall review and integrate the activities of
13 30 state agencies, including those agencies with public health,
13 31 child welfare, aging and disabilities, and ombudsman functions
13 32 to ensure there is no wrong door for consumers to access the
13 33 medical and social services and supports necessary for improved
13 34 outcomes. Managed care organizations shall provide or ensure
13 35 that consumers are connected with or referred to providers
14 1 and services to meet social determinants of health, even if
14 2 provision of services is outside their provider network.
14 3 Managed care contracts shall encourage partnerships between
14 4 managed care organizations and local public health agencies,
14 5 aging and disability resource centers, child welfare agencies,
14 6 mental health and disability services regions, and others to
14 7 address the holistic needs of the consumer and shall provide
14 8 for adequate reimbursement for such services.
14 9 11. a. Managed care plans shall include policies, plans,
14 10 and procedures to prepare consumers for transitions between
14 11 care settings to improve the quality of care for all consumers,
14 12 reduce avoidable rehospitalizations, and allow individuals to
14 13 live and receive services in the setting of their choice.
14 14 b. The state shall require managed care organizations
14 15 to have in place nursing facility diversion programs. The
14 16 state shall provide for the use of incentives in managed care
14 17 contracts for transition of consumers from a nursing facility
14 18 to home and community=based services.
14 19 12. The state shall ensure a sufficient and sustainable
14 20 state infrastructure for monitoring managed care organizations.
14 21 There shall be sufficient resources for the state to evaluate
14 22 contractually required quality reports and financial reports,
14 23 evaluate the impact or effectiveness of incentive programs,
14 24 conduct quality=focused audits, provide quality=related
14 25 technical assistance, validate that managed care organization
14 26 corrective actions have been implemented, analyze quality
14 27 findings and develop reports to assess quality trends and
14 28 to identify areas for improvement, develop, implement, and
14 29 evaluate performance improvement projects, solicit and analyze
14 30 consumer feedback, and investigate and follow up on critical
14 31 incident events.
14 32 13. a. Managed care contracts shall require that a portion
14 33 of the savings achieved by a managed care organization be
14 34 reinvested in innovations and longer=term community investments
14 35 to address population health, infrastructure, the healthcare
15 1 workforce, and improved service delivery and capacity.
15 2 b. A managed care contract shall impose a medical loss ratio
15 3 of at least eighty=five percent and shall include well=defined
15 4 criteria of what qualifies as a medical expense, and reporting
15 5 requirements and recoupment provisions to ensure compliance.
15 6 14. a. The state shall ensure that savings achieved
15 7 through Medicaid managed care do not come at the expense
15 8 of further reduction in already inadequate provider rates.
15 9 The state shall ensure that managed care organizations use
15 10 reasonable reimbursement standards for all provider types and
15 11 compensate providers for covered services at not less than
15 12 current Medicaid fee=for=service levels, as determined in
15 13 conjunction with actuarially sound rate setting procedures.
15 14 Such reimbursement shall extend for the entire duration of a
15 15 managed care organization's contract.
15 16 b. The state shall address rate setting and reimbursement
15 17 of the entire scope of services provided under the Medicaid
15 18 program to ensure the adequacy of the provider network and to
15 19 ensure that providers that contribute to the holistic health
15 20 of the consumer, whether inside or outside of the provider
15 21 network, are compensated for their services.
15 22 c. The state shall ensure that managed care organizations do
15 23 not arbitrarily deny coverage for medically necessary services
15 24 solely based on financial reasons.
15 25 15. a. In order to provide adequate access to care for
15 26 vulnerable Iowans, managed care organizations shall extend
15 27 nonemergency transportation services to all consumers.
15 28 b. The state shall ensure that dental coverage, if not
15 29 integrated into an overall managed care contract, is provided
15 30 and is part of the overall integrated coverage for physical,
15 31 behavioral, and long=term services and supports provided to a
15 32 Medicaid consumer.
15 33 c. The state shall ensure that the existing formulary for
15 34 pharmacy benefits under the Medicaid state plan is honored and
15 35 continued.
16 1 d. Managed care plans shall ensure consumers receive
16 2 services and supports in the amount, duration, scope, and
16 3 manner as identified through the applicable person=centered
16 4 assessment and service planning process.
16 5 e. The state shall ensure that for those populations
16 6 for whom Medicaid home and community=based services waiver
16 7 services have been historically provided, managed care
16 8 organizations address with specific plans the expansion,
16 9 support, reinvestment of savings in, and adequate reimbursement
16 10 of community=based services and supports.
16 11 16. a. The state shall utilize the application of
16 12 liquidated damages in contracts to be paid from moneys other
16 13 than those paid by the state to hold managed care organizations
16 14 accountable regarding such provisions as timely claims
16 15 processing and claims payment accuracy, compliance with
16 16 licensure and background check requirements, timely provision
16 17 of an approved service, continuation of benefits pending
16 18 appeal, timely development of a plan of care, initiation
16 19 of long=term services and supports, and completion of care
16 20 coordination contacts.
16 21 b. The state shall review and approve or deny approval
16 22 for contract amendments on an ongoing basis to provide for
16 23 continuous improvement in Medicaid managed care.
16 24 c. Medicaid managed care organization contracts shall
16 25 include sanctions for failure to comply with the terms of
16 26 a contract, including failure relating to performance or
16 27 deliverables including meeting of performance and outcomes
16 28 measures. Such sanctions may include but are not limited to
16 29 assessment of a penalty or assessment of liquidated damages or
16 30 other monetary remedies.
16 31 Sec. 3. EFFECTIVE UPON ENACTMENT. This Act, being deemed of
16 32 immediate importance, takes effect upon enactment.
SF 452 (5) 86
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