Relating to processes and assistance under the Medicaid program

The division specifies the minimum areas of assistance and advocacy to be provided, directs the ombudsman to adopt administrative rules for administration of the division, and directs the ombudsman to publish special reports and investigative reports as deemed necessary, and to include findings and recommendations related to the Medicaid program assistance and advocacy provided under the division in the ombudsman’s annual report. The division also repeals the section of the Code that directs the office of long-term care ombudsman to provide assistance and advocacy services to members of the Medicaid long-term services and supports population since under the division, the ombudsman will provide assistance and advocacy for both Medicaid managed care and fee-for-service payment and delivery systems and for all populations including the long-term services and supports population. The division also requires the ombudsman and DHS to collaborate to develop a cost allocation plan, consistent with federal requirements, requesting Medicaid administrative funding to provide for the claiming of federal financial participation, by January 1, 2020, for ombudsman activities that are performed to assist with administration of the Medicaid program. Division III of the bill requires DHS to contractually require a Medicaid managed care organization (MCO) to utilize an external review process in accordance with administrative rules adopted by DHS, to provide for a review by an independent third-party reviewer of a Medicaid provider’s claims denied by an MCO and following a final adverse determination of the MCO’s internal appeal process. The bill specifies what the external review process, at a minimum, shall provide for, and directs DHS to enter into a contract with a review organization that does not have a conflict of interest with DHS or any MCO to conduct the independent third-party reviews under the bill.