§ 514I.5 — Medical assistance advisory council — duties

Iowa § 514I.5

• Jurisdiction: Iowa
• Title XIII: COMMERCE
• Ch. 514I: HEALTHY AND WELL KIDS IN IOWA PROGRAM

Text

1. Themedicalassistanceadvisorycouncilshallestablishpolicyfor,directthedepartment
on, and adopt rules for the Hawki program.
2. The advisory council shall approve any contract entered into pursuant to this chapter.
All contracts entered into pursuant to this chapter shall be made available to the public.
3. The medical assistance advisory council shall do all of the following:
a. Define, in consultation with the department, the regions of the state for which plans
are offered in a manner as to ensure access to services for all children participating in the
program.
b. Approve the benefit package design, review the benefit package design on a periodic
basis, and make necessary changes in the benefit design to reflect the results of the periodic
reviews.
c. Develop, with the assistance of the department, an outreach plan, and provide for
periodic assessment of the effectiveness of the outreach plan. The plan shall provide
outreach to families of children likely to be eligible for assistance under the program, to
inform them of the availability of and to assist the families in enrolling children in the
program. The outreach efforts may include, but are not limited to, solicitation of cooperation
from programs, agencies, and other persons who are likely to have contact with eligible
children, including but not limited to those associated with the educational system, and the
development of community plans for outreach and marketing. Other state agencies shall
assist the department in data collection related to outreach efforts to potentially eligible
children and their families.
d. In consultation with the clinical advisory committee, assess the initial health status
of children participating in the program, establish a baseline for comparison purposes,
and develop appropriate indicators to measure the subsequent health status of children
participating in the program.
e. Review, in consultation with the department, and take necessary steps to improve
interaction between the program and other public and private programs which provide
services to the population of eligible children.
f. By January 1, annually, prepare, with the assistance of the department, and submit a
report to the governor, the general assembly, and the council on health and human services,
concerning the advisory council’s activities, findings, and recommendations.
g. Solicit input from the public regarding the program and related issues and services.
h. Establish and consult with a clinical advisory committee to make recommendations to
the board regarding the clinical aspects of the Hawki program.
i. Prescribe the elements to be included in a health improvement program plan required
to be developed by a participating insurer. The elements shall include but are not limited to
health maintenance and prevention and health risk assessment.
j. Make recommendations to the general assembly by January 1 annually concerning
the provision of health insurance coverage to children with special health care needs. The
recommendations shall address, but are not limited to, all of the following:
(1) The definition of the target population of children with special health care needs for
the purposes of determining eligibility under the program.
(2) Eligibility options for and assessment of children with special health care needs for
eligibility.
(3) Benefit options for children with special health care needs.
(4) Options for enrollment of children with special health care needs in and disenrollment
of children with special health care needs from qualified child health plans utilizing a
capitated fee form of payment.
(5) The appropriateness and quality of care for children with special health care needs.
(6) The coordination of health services provided for children with special health care
needs under the program with services provided by other publicly funded programs.
k. Develop options and recommendations to allow children eligible for the Hawki
program to participate in qualified employer-sponsored health plans through a premium
assistance program. The options and recommendations shall ensure reasonable alignment
between the benefits and costs of the Hawki program and the employer-sponsored health
5 HEALTHY AND WELL KIDS IN IOWA PROGRAM, §514I.5
plans consistent with federal law. In addition, the advisory council shall implement
the premium assistance program options described under the federal Children’s Health
Insurance Program Reauthorization Act of 2009, Pub. L. No. 111-3, for the Hawki program.
4. The medical assistance advisory council, in consultation with the department, shall
adopt rules which address, but are not limited to addressing, all of the following:
a. Implementation and administration of the program.
b. Qualifying standards for selecting participating insurers for the program.
c. The benefits to be included in a qualified child health plan which are those included in
a benchmark or benchmark equivalent plan and which comply with Tit. XXI of the federal
Social Security Act. Benefits covered shall include but are not limited to all of the following:
(1) Inpatient hospital services including medical, surgical, intensive care unit, mental
health, and substance use disorder services.
(2) Nursing care services including skilled nursing facility services.
(3) Outpatient hospital services including emergency room, surgery, lab, and x-ray
services and other services.
(4) Physician services, including surgical and medical, and including office visits,
newborn care, well-baby and well-child care, immunizations, urgent care, specialist care,
allergy testing and treatment, mental health visits, and substance use disorder visits.
(5) Ambulance services.
(6) Physical therapy.
(7) Speech therapy.
(8) Durable medical equipment.
(9) Home health care.
(10) Hospice services.
(11) Prescription drugs.
(12) Dental services including preventive services.
(13) Medically necessary hearing services.
(14) Vision services including corrective lenses.
(15) Translation and interpreter services as specified pursuant to the federal Children’s
Health Insurance Program Reauthorization Act of 2009, Pub. L. No. 111-3.
(16) Chiropractic services.
(17) Occupational therapy.
d. Presumptive eligibility criteria for the program. Presumptive eligibility shall be
provided for eligible children.
e. The amount of any cost sharing under the program which shall be assessed based on
family income and which complies with federal law.
f. The reasons for disenrollment including, but not limited to, nonpayment of premiums,
eligibility for medical assistance or other insurance coverage, admission to a public
institution, relocation from the area, and change in income.
g. Conflict of interest provisions applicable to participating insurers and between
members of the advisory council and participating insurers.
h. Penalties for breach of contract or other violations of requirements or provisions under
the program.
i. Amechanismforparticipatinginsurerstoreportanyrebatesreceivedtothedepartment.
j. The data to be maintained by the department including data to be collected for the
purposes of quality assurance reports.
k. The use of provider guidelines in assessing the well-being of children, which may
include the use of the bright futures for infants, children, and adolescents program as
developed by the federal maternal and child health bureau and the American academy of
pediatrics guidelines for well-child care.
5. a. The medical assistance advisory council may provide approval to the director to
contract with participating insurers to provide dental-only services. In determining whether
to provide such approval to the director, the advisory council shall take into consideration the
impact on the overall program of single source contracting for dental services.
b. The medical assistance advisory council may provide approval to the director to
contract with participating insurers to provide the supplemental dental-only coverage to
§514I.5, HEALTHY AND WELL KIDS IN IOWA PROGRAM 6
otherwise eligible children who have private health care coverage as specified in the federal
Children’s Health Insurance Program Reauthorization Act of 2009, Pub. L. No. 111-3.
6. The medical assistance advisory council shall monitor the capacity of Medicaid
managed care organizations acting pursuant to a contract with the department to administer
the Hawki program to specifically and appropriately address the unique needs of children
and children’s health delivery.