§ 249N.2 — Definitions

Iowa § 249N.2

• Jurisdiction: Iowa
• Title VI: HUMAN SERVICES
• Ch. 249N: IOWA HEALTH AND WELLNESS PLAN

Text

As used in this chapter, unless the context otherwise requires:
1. “Accountable care organization” means a risk-bearing, integrated health care
organization characterized by a payment and care delivery model that ties provider
reimbursement to quality metrics and reductions in the total cost of care for an attributed
population of patients.
2. “Affordable Care Act” means the federal Patient Protection and Affordable Care Act,
Pub. L. No. 111-148, as amended by the federal Health Care and Education Reconciliation
Act of 2010, Pub. L. No. 111-152.
3. “Covered benefits” means covered benefits as specified in section 249N.5.
4. “Department” means the department of health and human services.
5. “Director” means the director of health and human services.
6. “Eligible individual” means an individual eligible for medical assistance pursuant to
section 249A.3, subsection 1, paragraph “v”.
7. “Essential health benefits” means essential health benefits as defined in section 1302
of the Affordable Care Act, that include at least the general categories and the items and
services covered within the categories of ambulatory patient services; emergency services;
hospitalization; maternity and newborn care; mental health and substance use disorder
services, including behavioral health treatment; prescription drugs; rehabilitative and
habilitative services and devices; laboratory services; preventive and wellness services and
chronic disease management; and pediatric services, including oral and vision care.
8. “Federal approval” means approval by the centers for Medicare and Medicaid services
of the United States department of health and human services.
9. “Federal poverty level” means the most recently revised poverty income guidelines
published by the United States department of health and human services.
10. “Household income” means household income as determined using the modified
adjusted gross income methodology pursuant to section 2002 of the Affordable Care Act.
11. “Iowa health and wellness plan” or “plan” means the Iowa health and wellness plan
established under this chapter.
12. “Iowa health and wellness plan provider” means any provider enrolled in the medical
assistance program or any participating accountable care organization.
13. “Iowa health and wellness plan provider network” means the health care delivery
network approved by the department for Iowa health and wellness plan members.
14. “Medicalassistanceprogram”,“Medicaidprogram”,or“Medicaid”meanstheprogram
paying all or part of the costs of care and services provided to an individual pursuant to
chapter 249A and Tit. XIX of the federal Social Security Act.
15. “Medical home” means a team approach to providing health care that originates
in a primary care setting; fosters a partnership among the patient, the personal provider,
and other health care professionals, and where appropriate, the patient’s family; utilizes
the partnership to access and integrate all medical and nonmedical health-related services
across all elements of the health care system and the patient’s community as needed by
§249N.2, IOWA HEALTH AND WELLNESS PLAN 2
the patient and the patient’s family to achieve maximum health potential; maintains a
centralized, comprehensive record of all health-related services to promote continuity of
care; and has all of the following characteristics:
a. A personal provider.
b. A provider-directed team-based medical practice.
c. Whole-person orientation.
d. Coordination and integration of care.
e. Quality and safety.
f. Enhanced access to health care.
g. A payment system that appropriately recognizes the added value provided to patients
who have a patient-centered medical home.
16. “Member”meansaneligibleindividualwhoisenrolledintheIowahealthandwellness
plan.
17. “Participating accountable care organization” means an accountable care
organization approved by the department to participate in the Iowa health and wellness plan
provider network.
18. “Personal provider” means the patient’s first point of contact in the health care
system with a primary care provider who identifies the patient’s health-related needs and,
working with a team of health care professionals and providers of medical and nonmedical
health-related services, provides for and coordinates appropriate care to address the
health-related needs identified.
19. “Preventive care services” means care that is provided to an individual to promote
health, prevent disease, or diagnose disease.
20. “Primary care provider” includes but is not limited to any of the following licensed or
certified health care professionals who provide primary care:
a. A physician who is a family or general practitioner, a pediatrician, an internist, an
obstetrician, or a gynecologist.
b. An advanced registered nurse practitioner.
c. A physician assistant.
d. A chiropractor.
21. “Primary medical provider” means the personal provider trained to provide first
contact and continuous and comprehensive care to a member, chosen by a member or to
whom a member is assigned under the Iowa health and wellness plan.
22. “Value-based reimbursement” means a payment methodology that links provider
reimbursement to improved performance by health care providers by holding health care
providers accountable for both the cost and quality of care provided.