Relating to Medicaid program improvements, making an appropriation, and providing penalties

This bill relates to the Medicaid program. Division I of the bill requires the department of health and human services (HHS) to adopt administrative rules to ensure that services are provided to the Medicaid long-term services and supports (LTSS) 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 directs HHS to require each Medicaid managed care organization (MCO) with whom HHS executes a contract, to provide the option to LTSS population members to enroll in or transition to fee-for-service Medicaid program administration rather than managed care administration. The department shall amend any contract, request any Medicaid state plan amendment, and adopt administrative rules, as necessary, to administer this provision. The rules shall include the process for transitioning a current LTSS population member to fee-for-service program administration. Division III of the bill directs HHS to require each MCO with whom HHS executes a contract to maintain an authorized member’s LTSS unless the member’s health care provider determines a change in the LTSS is medically necessary for the member. The inability of a member who is authorized for LTSS to utilize all approved service hours, including respite care, shall not result in a reduction in authorized services unless there is medical evidence that the services are medically unnecessary for the member. Division IV of the bill requires HHS to contractually require any Medicaid MCO to collaborate with HHS 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 HHS. Division V of the bill establishes an external independent third-party review process for Medicaid providers for the review of final adverse determinations of the MCOs’ internal appeals processes. The division provides that a final decision of an external independent third-party reviewer may be reviewed in a contested case proceeding pursuant to Code chapter 17A, and ultimately is subject to judicial review. The bill provides a civil penalty for an MCO that does not comply with the written response requirements relating to an adverse determination. Division VI of the bill relates to member disenrollment for good cause during the 12 months of closed enrollment between open enrollment periods. The bill requires HHS to 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 and to adopt administrative rules to administer the division. Division VII of the bill requires the HHS to develop 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 HHS to contractually require all Medicaid MCOs to apply the uniform authorization criteria, to accept verified information from the single credentialing verification organization procured by HHS, and to contractually prohibit the MCOs from requiring additional credentialing information from a provider in order to participate in the Medicaid MCO’s provider network. Division VIII of the bill relates to the office of long-term care ombudsman (OLTCO) and the Medicaid managed care ombudsman program (MCOP).50 FTEs in addition to any other full-time equivalent (FTE) positions authorized for, HHS 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, 2025, for the MCOP. The bill requires that any funds appropriated to and any full-time equivalent positions authorized for the OLTCO for the MCOP for fiscal year 2025-2026 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, 2025. The bill requires the OLTCO to include in the MCOP report, on a quarterly basis, the disposition of resources for the MCOP including expenditures and an FTE positions summary for the prior quarter. Division IX amends the provision regarding the meetings of the health policy oversight committee (HPOC) of the legislative council. Current law provides that HPOC may meet annually. The bill provides that HPOC shall meet, and further requires that HPOC meet at least two times, annually, during the legislative interim. Division X of the bill directs HHS to require each MCO with whom HHS executes a contract to annually submit a report by March 1 to HHS detailing the profit the MCO received from administering Medicaid care during the immediately preceding calendar year, and the methodology the MCO used to calculate the profit. HHS may select an independent auditor to verify each MCO’s report. HHS shall make each MCO’s report publicly available on HHS’s internet site.