2018 Final Legislative Report
With a number of pen strokes this past Friday, June 1st, the Governor officially brought the 2018 session of the 87th Iowa General Assembly to a close. After the Legislature's closedown, the Governor has 30 days to take action on any bills sent to her at the end of session. Last Friday, she completed that by taking action on the last 12 bills remaining from the session, signing eight, vetoing one, and using a line-item veto on three.

  • The Governor vetoed SF 2316, which was amended prior to legislative passage to allow self-employed persons with no employees to qualify for small group health insurance coverage. In her veto message, Gov. Reynolds was concerned that this would further destabilize Iowa’s health insurance market, and the changes would be contrary to federal law.

  • The Standings Budget (HF 2502) included language that would have required newly formed Multiple Employer Welfare Arrangements (MEWA) be formed as a 501(c)(9). These new structures would allow employer groups and associations to band together (as allowed in SF 2349) to offer small group health plans to their members/employees. The Governor vetoed that language, saying the state should not dictate business structure of a private entity. This does not affect the ability to develop MEWAs, and in fact gives more flexibility to how they are formed.

  • Iowa is currently taking part in a Public Safety Assessment (PSA) pilot program that provides judges with an objective, data-driven approach that they can use in pretrial proceedings while still exercising their discretion. Legislators ended this pilot immediately in the Justice Systems Budget (HF 2492). Governor Reynolds line-item vetoed this immediate shutdown, opting instead to wrap up the pilot at the end of the year. She left the door open to restart a 2.0 version of the pilot should the evaluation show promising results.

  • The Governor line-item vetoed a single new appropriation from the Health/Human Services Budget (SF 2418), which required the University of Iowa to give an out-of-state durable medical equipment provider space at their hospital to renovate and resell used equipment. The Governor said the state should not favor one provider over another, and instead encouraged a formal bidding process, giving in-state and out-of-state providers the same opportunity.

With these limited vetoes behind us, the things we were watching are now law. Here’s a quick rundown:

  • Marital and family therapists, mental health counselors, social workers, and psychologists were given permission to form an LLC or PC, effective April 2, 2018 (SF 2300)

  • Two new professionals got licensure this year - Behavior Analysts/Assistant Behavior Analysts will be licensed by the Board of Behavioral Health (SF 192) and Genetic Counselors by the Board of Medicine (SF 2228).

  • All state-regulated health insurance plans will now be required to provide the same coverage for covered health care services whether the health care services are provided in person or delivered by telehealth, including behavioral health services. This will go into affect with each plan as they are renewed, beginning July 1, 2018. Medicaid and the state employee plan already have this requirement. (HF 2305)

  • All state-regulated health insurance plans and Medicaid must now allow supervising mental health professionals to bill for services provided by temporarily/provisionally licensed professionals. This applies to psychologists, marriage and family therapists, social workers, and mental health counselors working under the supervision of a fully licensed, and fully credentialed/enrolled professional.  This is effective June 1, 2018, but you each insurer will have their own process or guidance for implementing. Psychologists already received approval to do this for Medicaid, thanks to your awesome State Advocacy Chair Dr. Paul Ascheman. (SF 2418).

  • School employees that have contact with kids will be required to have one hour of suicide awareness and prevention training annually, which is to include a focus on identifying ACEs and addressing toxic stress response. (SF 2113)

  • Farm Bureau will be allowed to offer its health insurance plan on the individual market, without being on the Health Insurance Exchange (which allows their plan to be non ACA compliant), and employer groups will be allowed to form associations in order to offer health plans to members, employees, former employees, family members, and other beneficiaries of the employer members of the association. (SF 2349)

  • The Psychological Internship Program will again be level-funded at $48,069. What a bargain! Might be time to ask for more money since this program always gets good reviews. Not all of these workforce-directed programs is so highly regarded - this year the UI mental health workforce initiative was shut down, allowing $52,828 to be redirected. Some of that went to the new $250,000 initiative by DMU/NAMI to train primary care docs in identifying and treating patients with mental illness. That initiative is the first year of a three-year phase in that will eventually train all physicians coming out of DMU as well as provide CEUs. (SF 2418)

  • The Youth Suicide and Anti-Bullying Initiative (YourLifeIowa) has its $50,000 funding restored for next year, but the big winner in the Department of Public Health budget this year appears to be childhood obesity, which got a whopping $300,000 increase! That brings total to $494,993, and certainly puts a spotlight on this issue.. (SF 2418)

  • There were several changes to sex offender and child abuse laws this year. If this is an area of interest, I’d suggest perusing SF 2418 & HF 2502 (which are in our bill tracker here). DHS is tasked with taking another look at long-term care residential placement options for people needing that level of care, but are either on the sex offender registry or sexually aggressive. They’ll pull together other agencies and stakeholders to do this, and will look specifically at vacant state-owned property as one option (like Clarinda, Mt. Pleasant).
Big Picture Budget
The Legislature passed and the Governor approved a $7.5 billion budget for the state's fiscal year that starts on July 1, 2018 (FY 2019). This is an increase of $225.9 million. Here's how the budget breaks down:

  • Added back the $23.3 million deappropriation made in March.

  • Paid back the remaining $113.1 million that was borrowed from the Cash Reserve Fund in 2017. With this payment, Republicans say they have fully reimbursed the fund for money borrowed to balance the budget in the past two years, and the fund will be at its statutory max.

  • Increased funding for specific programs, services, and government functions by $89.5 million (1.2% increase). Of that, $55.1 million went to Medicaid.

As you can see, most of your tax dollars go to Medicaid, human services, schools, and prisons.
MCO Oversight Finalized
During the 2018 session, the House of Representatives passed two bills to address billing errors, poor communications, and expectations when dealing with Medicaid members. The votes were unanimous (97-0 & 95-0), but the Senate did not bring them up for a vote. Ultimately, MCO oversight was added to the Health/Human Services Budget ( SF 2418 ).

The biggest criticism we’ve heard about these requirements is that many are already in the MCO contracts. It is important to note that this is now the law; contacts can be changed by DHS and the Governor, but the law can only be changed by legislators, during a legislative session.  So legislators believe there is more “teeth” in these requirements now, and that its passage has put the MCOs (and Medicaid) on notice.

With the signing of the HHS Budget, Medicaid MCOs are now required by law to do the following:

  • Pay claims accurately, use the right rates, and give reasons for any full or partial denials. They are to do this in a way that is consistent with national industry best practices. 

  • Correct any errors they find in their systems “within a reasonable timeframe" and reprocess claims affected by the error within 30 days of the correction. DHS will determine what a "reasonable timeframe" is for corrections. 

  • Give 60-day written notice to affected individuals when there is a program or procedural change. That would include the persons getting the service as well as the providers of the service. However, DHS will develop a list of changes that require 60-day notice by July 1, 2018, so not all changes will be subject to this new law. Changes that may be included in this notificiation period include billing and collection procedures, provider network provisions, member/provider services, and prior authorization requirements. Watch for updates on this after July 1.
  • Approve and pay for at least three days of court-ordered substance use disorder treatment or mental health services before requiring prior authorization or medical necessity standards be met. This makes sure hospitals can stabilize a person in crisis without fear that the MCOs will deny coverage or delay approval.

  • Use a standard Medicaid provider enrollment form and a uniform credentialing process developed by DHS.

  • Recognize both PAs and ARNPs as “primary care providers” when they make assignments for population health management (like in an ACO arrangement). Currently both MCOs do this, but AmeriHealth did not. This will ensure that Centene/TotalCare Iowa does as well.

In order to ensure better member services and make sure MCOs are complying with their contracts and the new laws, DHS is now required to do the following :

  • Convene a Health Home Work Group with integrated health home providers, chronic condition health home providers, and MCOs to review health homes, look at what is required in the state plan amendment, discuss the rationale for any proposed changes, develop a consistent delivery model that clearly defines outcomes and data reporting requirements, and implement a communications plan that keeps stakeholders informed on the operation and administration of the programs. A report on the group's work is due December 1, 2018, including recommendations and actions taken.
  • Review the effectiveness of MCO prior authorizations. The Medicaid director has publicly said services that are nearly always approved should not be subject to prior authorization. Why go to the extra work to get a service authorized if it is approved 99% of the time?

  • Hire a dedicated provider relations staff to help providers to resolve billing conflicts with MCOs (including claims denials, technical omissions, incomplete information). These staff will watch for trends, and report them to DHS for further review.
  • Maintain and update Medicaid member eligibility files in a timely manner. MCOs have said some of the errors stem from bad information in DHS eligibility files; legislators hope this will lead to fewer errors and service denials.
  • Hire an independent external quality review consultant to randomly sample decreased level of care determinations to make sure the MCOs are providing appropriate medically necessary services and are following national industry best practices in their decision-making. The consultant is to report on findings, with a plan of corrective action, by December 15, 2018.  

  • Annually review all appeals dismissed, withdrawn, or overturned to watch for any negative patterns or trends.  Members whose appeals are subject to this review will have their services continued while the new assessments are being done, up to 90 days. DHS is to report these findings twice a year (biannually).

  • Contract with an independent review organization to perform small claim (less than $2,500) audits denied or paid to long term care services and supports providers during the first quarter of calendar year 2018 (with report and findings by February 1, 2019).

The focus of most of these changes is on internal processes and administration which legislators feel is the main reason for system problems. It does not address payments to providers, which many think is the real reason for service disruptions and denials. Again, we'll be watching this closely and will report back as these groups meet and as these changes are implemented.
MH/DS Region Changes
Since many of you work hand-in-hand with your MH/DS regions, we wanted to give you a quick review of the changes made this year in the regional MH/DS system. Some of these changes were in Complex Needs legislation ( HF 2456 ), others were made in the HHS Budget ( SF 2418 ) and Standings ( HF 2502 ).

MH/DS Region Services:

  • All of the existing crisis services provided by MH/DS regions are moved to the list of "core services." Mobile response, 23-hour crisis observation and holding, crisis residential services, subacute and crisis stabilization community-based services are no longer considered optional services. The existing subacute bed cap is removed, so regions are free to develop these beds based on the needs of their community. Justice system services (jail diversion, crisis intervention training, civil commitment prescreening) and advancements in evidence-based treatment (positive behavior support, peer self-help drop-in centers) are still considered "additional core” services and are still optional.  

  • Regions are expected to build out three new core services and work together to ensure that they are available throughout the state. These include:
  • Access Centers to provide short-term care for those in crisis, and provide resources needed to get Iowans back home to their families (at least six statewide).

  • Assertive Community Treatment (ACT) teams to provide individualized treatment and support to individuals with mental illness in their homes, 365 days a year (at least 22 teams statewide).

  • Intensive Residential Service Homes will provide individuals with severe and persistent mental illness with the chance to live in smaller community-based settings close to home, while receiving the 24-hour intensive services needed to address their individual needs. There are up to 120 beds available statewide (to be scattered, with facilities preferably serving no more than four individuals at each site, although each site may serve up to 16 individuals).

  • It is important to note that Medicaid is now expected to pay for these new core services if the person is enrolled in or eligible for Medicaid.  Regions will continue to pay for others who are not eligible for Medicaid (to the extent funding is available). Regions do not yet have a good idea how much it will cost to provide these services, so they cannot say if their current funding is sufficient.  The cost to Medicaid increases substantially next year – legislators will need to find another $5-6 million to cover the expected costs once the services are operational. 
  • Regions are no longer required to fund a 24-hour crisis hotline service. A single statewide 24-hour crisis hotline will replace the ones managed by each individual MH/DS region, but it will continue to connect people to the local resources they need.

MH/DS Regional Funding: 

  • The Legislative Council has been asked to appoint an interim committee to look at the funding of these regional services, including the new services added this year.  In every redesign, funding has always been the one thing that never quite gets addressed. If approved, this interim committee will look at levies, budgets, per capita expenditure targets, and fund balances, and make recommendations in time for action in the 2019 session. (FYI...legislative leaders that sit on the Legislative Council do not have to approve every request for an interim study)  

  • Regions are still required to spend down excess fund balances before July 1, 2021.  After that time, county levies within the region will be lowered.

  • The Polk County MH/DS Region is allowed to use other funds to pay for regional services if the MH/DS levy is not sufficient.  Polk County already gets $6.3 million in funds/in-kind services from its county hospital (Broadlawns) to cover some of its shortfall, but estimates they are still about $1-2 million short.  They will have to report back on the funds used by September 1, 2019.
  • DHS will review reimbursement rates for ACT teams over the interim and make recommendations by 12/15/18. 

Formation of New MH/DS Regions:

  • New single county regions are no longer allowed. This will not impact the existing single-county region (Polk), but will stop other counties from trying to form their own region.  Similarly, DHS will no longer be able to waive the three-county minimum requirement (so no two-county regions either).

  • New regions must include bordering counties only.  DHS will no longer be able to waive the requirement that counties in a region be contiguous.  

  • DHS is allowed to approve the formation of a new region with counties wanting to leave the 22-county County Social Services Region. New regions must now meet the following new minimum requirements before being approved by DHS: population must be at least 100,000, must include a city with a population of more than 24,000, must be able to meet all core service requirements by February 1, 2019 and be in full operation by July 1, 2019.  DHS is directed to work with any counties having difficulty joining a new region and allows DHS to assign a county to a region if they have not joined one by February 1, 2019. The new requirements apply to new regions only; existing regions are not affected.

  • New regions are allowed to reset their per capita expenditure targets (the amount of money the county can levy per resident), but they cannot go over the statewide cap.  Expenditure targets cannot be increased after July 1, 2020.  

The MH/DS Commission and DHS have already started to write the rules on these new laws, so they can be noticed as prescribed in August. Administrative rules are important here, because they will more fully define these services, set service provider standards, establish reimbursement rates (always key to making services available), access standards, implementation dates, and possibly even location of the services. While DHS has been asked to get rules noticed in August, it will still need to go through the normal rules process that includes many opportunities for input, including public hearings, public comment period, required responses to comments, and a review by a legislative panel (called the Administrative Rules Review Committee). During that final legislative review, stakeholders are also able to provide comment, and legislators can stop rules if they feel public comments have not been adequately addressed. So lots of opportunity for input; we'll make sure you know about these as this gets started!

Complex Needs - Commitments
Much of what was in the Complex Needs bill ( HF 2456 ) is referenced in the previous article, but there were a few other important changes to highlight:

  • Makes changes to free up hospital beds quicker by allowing a hospital to immediately release a person under a 125 (substance use) or 229 (mental health) commitment order when they no longer meet the criteria. They would only need to notify the courts in order to do so; they do not need to wait for approval. Hospitals would still need to notify law enforcement of the release, and now must also notify the region’s transportation providers (including those under contract), and requires all contracted transportation providers use secure vehicles and have staff with mental health training.

  • Hospitalization hearings can now be held via videoconference to help make sure all parties are available without delay.

  • Changes are made to allow mental health professionals to disclose mental health information to an expanded list of law enforcement officers (DNR officers, county attorneys, probation/parole officers, jailers). Disclosure continues to be permitted only if consistent with professional ethics, and the person is an imminent threat to self or others, and has ability to carry out that threat. Liability protections were added for those that disclose (or do not disclose consistent with law). 

  • The definition of Serious Mental Illness (SMI) is changed to include those with a history of non-compliance in taking medications or treatment plans, resulting in hospitalizations. It also adds oral medication to the list of options for treatment during hospitalizations (currently only allows injectables).  

  • DHS’s psychiatric bed tracking system will now include both adult and child co-occuring subacute beds.

There is still work to be done. Here are a few things the bill directs be done over the interim:

  • MH/DS regions and Medicaid MCOs are required to pay for these services, yet funding for both is strapped. Medicaid will need to find another $5-6 million next year to cover the need, and regions do not yet know how much is needed. Because these services will be available only as funding allows, fixing the funding is an important next step. House File 2456 calls for an interim committee this summer to review funding for these and other services delivered through the MH/DS regions, and determine funding needed to make sure they are available statewide. Action will be needed on this when the Legislature returns in 2019.

  • DHS is directed to pull together stakeholders to review the role of tertiary care psychiatric hospitals in the array of mental health services and make further recommendations if necessary. The workgroup will include the Department of Inspections and Appeals, representative members of the Iowa Hospital Association, managed care organizations, the National Alliance on Mental Illness, the mental health institutes, and other interested stakeholders. A report is to be completed by November 30, 2018.

  • DHS is also directed to bring stakeholders together to review the mental health and substance use disorder commitment processes and make recommendations for improvements in the process. The workgroup will include the Department of Public Health, representative members of the judicial branch, the Iowa Hospital Association, the Iowa Medical Society, the National Alliance on Mental Illness, the Iowa State Sheriffs’ and Deputies’ Association, Iowa Behavioral Health Association, and other interested stakeholders. This report is due on December 31, 2018.

  • The MHDS Commission will be setting rules for civil commitment prescreening assessments to be done in each MH/DS region. Rules will address prescreening by MH professional within 4 hours of emergency detention; coordination of services (inpatient, outpatient, subacute, detox, and community-based); ongoing consultations by MH professional while person is in ER; and filing of appropriation documentation/reports.

  • DHS is instructed to review reimbursement rates for ACT teams, and recommend any changes by 12/15/18. 

 Here are a few other resources you might find helpful: 
  • Read the Governor's comments from the bill signing here.
  • Review House File 2456 here.
  • Read more detail on House File 2456 here.
  • Read the Complex Needs Report here.
  • See who was on the Complex Needs Work Group here.
  • Read the recommendations of the Children's Mental Health & Well-Being Work Group here.
  • See who is on the Children's Mental Health & Well-Being Work Group here.
  • Read Governor’s Executive Order #2
Stats from 2018 Session
To paraphrase School House Rock, it’s a long, long way to becoming a law. This year, seven out of every eight bills introduced died somewhere along the line. 

1,423 bills were introduced this year.
176 bills were passed by the Legislature.
175 were signed into law.

Check out the final summaries & status of the bills tracked for IPA here .
The default page shows you only the bills that passed and were sent to the Governor.
To see bills that didn’t make it, switch the dropdown list to “inactive."
You can export either list to an excel sheet for your own use/tracking.

You can see the entire list of bills passed by the Legislature here .
You can read the non-partisan staff mark-ups of all the budget bills here (pick those marked “Final")

Your Bill Tracker
Click above to see status of important bills, or create your own report with our custom download.
Town Hall Meetings & Public Forums
Find a local event with your state or federal elected officials here. Three weeks are shown at a time on this website.