§ 249N.6 — Iowa health and wellness plan provider network

Iowa § 249N.6

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

Text

1. TheIowahealthandwellnessplanprovidernetworkshallincludeallprovidersenrolled
in the medical assistance program and all participating accountable care organizations.
Reimbursement under this chapter shall only be made to such Iowa health and wellness
plan providers for covered benefits.
2. a. Upon enrollment, a member shall choose a primary medical provider and, to the
extent feasible, shall also choose a medical home within the Iowa health and wellness plan
provider network.
b. If the member does not choose a primary medical provider or a medical home, the
department shall assign the member to a primary medical provider or a medical home
in accordance with the Medicaid managed health care, mandatory enrollment provisions
specified in rules adopted by the department pursuant to chapter 249A and in accordance
with quality data available to the department.
c. The department shall develop a mechanism for primary medical providers, medical
homes, and participating accountable care organizations to jointly facilitate member care
coordination. The Iowa health and wellness plan shall provide for reimbursement of care
coordination services provided under the plan.
3. a. The department shall provide procedures for accountable care organizations that
emerge through local markets to participate in the Iowa health and wellness plan provider
network. Such accountable care organizations shall incorporate the medical home as a
foundation and shall emphasize whole-person orientation and coordination and integration
of both clinical services and nonclinical community and social supports that address social
determinants of health. A participating accountable care organization shall enter into a
contract with the department to ensure the coordination and management of the health of
attributed members, to produce quality health care outcomes, and to control overall cost.
b. The department shall establish by rule in accordance with chapter 17A the
qualifications, contracting processes, and contract terms for a participating accountable care
organization. The rules shall also establish a methodology for attribution of a member to a
participating accountable care organization.
c. A participating accountable care organization contract shall establish accountability
based on quality performance and total cost-of-care metrics for the attributed population. In
developing quality performance standards, the department shall consider those utilized by
state accountable care organization models including but not limited to the quality index
score and the Medicare shared savings program quality reporting metrics. The payment
models shall include but are not limited to risk sharing, including both shared savings and
shared costs, between the state and the participating accountable care organization, and
bonus payments for improved quality. The contract terms shall require that a participating
accountable care organization is subject to shared savings beginning with the initial year
of the contract, must have quality metrics in place within three years of the initial year of
the contract, and must participate in risk sharing within five years of the initial year of the
contract.
4. To the greatest extent possible, members shall have a choice of providers within
the Iowa health and wellness plan provider network to facilitate access to locally-based
health care providers and services. However, member choice may be limited by the results
of attribution under this section and by the participating accountable care organization,
with prior approval of the department, if the member’s health condition would benefit
from limiting the member’s choice of an Iowa health and wellness plan provider to ensure
coordination of services, or due to overutilization of covered benefits. The participating
accountable care organization shall provide thirty days’ notice to the member prior to
limitation of such choice.
5. a. An Iowa health and wellness plan provider shall be reimbursed for covered benefits
§249N.6, IOWA HEALTH AND WELLNESS PLAN 6
under the Iowa health and wellness plan utilizing the same reimbursement methodology as
that applicable to individuals eligible for medical assistance under section 249A.3, subsection
1.
b. Notwithstanding paragraph “a”, a participating accountable care organization under
contract with the department shall be reimbursed utilizing a value-based reimbursement
methodology.
6. a. Iowa health and wellness plan providers shall exchange member health information
as provided by rule to facilitate coordination and management of members’ health, quality
health care outcomes, and containment of and reduction in costs.
b. The department shall provide the health care claims data of attributed members to a
member’s participating accountable care organization on a timeframe established by rule of
the department.