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House
File
2053
-
Introduced
HOUSE
FILE
2053
BY
COLLINS
A
BILL
FOR
An
Act
relating
to
the
standardization
of
claim
submission
and
1
reimbursement
processes
of
managed
care
organizations.
2
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
3
TLSB
5071YH
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H.F.
2053
Section
1.
Section
249A.2,
Code
2026,
is
amended
by
adding
1
the
following
new
subsections:
2
NEW
SUBSECTION
.
5A.
“Managed
care
contract”
means
a
3
contract
between
the
department
and
a
managed
care
organization
4
that
obligates
the
managed
care
organization
to
administer
the
5
medical
assistance
program
under
this
chapter.
6
NEW
SUBSECTION
.
5B.
“Managed
care
organization”
means
a
7
“health
maintenance
organization”
,
as
that
term
is
defined
in
8
section
514B.1,
acting
pursuant
to
a
managed
care
contract.
9
Sec.
2.
Section
249A.4,
subsection
9,
Code
2026,
is
amended
10
to
read
as
follows:
11
9.
a.
Adopt
rules
pursuant
to
chapter
17A
in
determining
12
the
method
to
establish
a
standardized
claim
submission
and
13
reimbursement
process
and
the
level
of
reimbursement
for
all
14
medical
and
health
services
to
be
provided
under
the
medical
15
assistance
program,
after
considering
benefits
received
by
or
16
services
rendered
to
a
recipient
by
a
provider
on
or
after
July
17
1,
2027.
In
establishing
such
rules,
the
department
shall
18
consider
all
of
the
following:
19
a.
(1)
The
promotion
of
efficient
and
cost-effective
20
delivery
of
medical
and
health
services.
21
b.
(2)
Compliance
with
federal
law
and
regulations.
22
c.
(3)
The
level
of
state
and
federal
appropriations
for
23
medical
assistance.
24
d.
(4)
Reimbursement
at
a
level
as
near
as
possible
to
25
After
weighing
the
considerations
in
subparagraphs
(1),
(2),
26
and
(3),
the
actual
costs
and
charges
after
priority
is
given
27
to
the
considerations
in
paragraphs
“a”
,
“b”
,
and
“c”
incurred
28
by
a
provider
for
any
benefits
received
by
or
services
rendered
29
to
a
recipient
.
30
b.
The
department
shall
amend
all
existing
managed
care
31
contracts,
pursuant
to
the
terms
of
each
contract,
to
provide
32
for
adherence
to
the
standardized
claim
submission
and
33
reimbursement
process
established
under
this
subsection.
All
34
managed
care
contracts
entered
into,
extended,
or
renewed
35
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2
H.F.
2053
by
the
department
on
or
after
July
1,
2027,
must
provide
1
for
adherence
to
the
standardized
claim
submission
and
2
reimbursement
process
established
under
this
subsection.
3
c.
For
purposes
of
this
subsection,
“claim”
means
a
formal
4
request
by
a
provider
for
reimbursement
for
benefits
received
5
by
a
recipient
or
services
rendered
to
a
recipient.
6
EXPLANATION
7
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
8
the
explanation’s
substance
by
the
members
of
the
general
assembly.
9
This
bill
relates
to
claim
submission
and
reimbursement
10
processes
followed
by
managed
care
organizations
(MCOs)
11
administering
the
medical
assistance
program
(program).
12
The
bill
defines
“managed
care
contract”
and
“managed
care
13
organization”.
14
Under
current
law,
the
department
of
health
and
human
15
services
(HHS)
is
directed
to
adopt
rules
determining
the
16
method
and
level
of
reimbursement
for
all
medical
and
health
17
services
provided
under
the
program.
The
bill
directs
the
18
director
of
HHS
to
also
adopt
rules
establishing
a
standardized
19
submission
and
reimbursement
process
(process)
for
claims
for
20
all
benefits
received
by
or
services
rendered
to
a
recipient
by
21
a
provider
on
or
after
July
1,
2027.
22
The
bill
requires
HHS
to
amend
all
managed
care
contracts,
23
pursuant
to
the
terms
of
each
contract,
to
provide
that
MCOs
24
adhere
to
the
process.
The
bill
further
requires
that
all
25
managed
care
contracts
entered
into,
extended,
or
renewed
by
26
HHS
on
or
after
July
1,
2027,
provide
that
MCOs
adhere
to
the
27
process.
28
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