2019 Legislative Update | Issue #3 | March 9, 2019
Legislative Deadline Narrows Focus
It was a wild ride this week as legislators went into overdrive to pump bills out of committee before the first legislative deadline hit on Friday, March 8. Only bills that made it out of committee survived this funnel week – any other bills are dead for the year.  These deadlines do not apply to bills that spend money, deal with taxes, or come out of the Government Oversight Committee.

Your online, real-time Bill Tracker is updated now, but remember that the vast majority of bills you are watching will likely change numbers after committee passage. Some things that survived:

  • Takes the first steps in creating a children’s behavioral health system that parallels the adult system managed by regions (HSB 206 & SF 479), and allowing regions to keep a bit more money in reserve while they build out both the adult complex needs service system and the children’s behavioral health system (HF548). More on this follows.

  • Requires anyone calling themselves "music therapists" to hold a board-certified credentials or be on the national registry, but does not create state licensure or require third-party payor reimbursement (HF 419).

  • Convenes another work group to address the ongoing challenges of the psychiatric patient placement clearinghouse and inpatient psychiatric bed tracking system, this time including a review of tele-psychiatry services (HF 624).

  • Allows DHS to release confidential information to a multidisciplinary team if the team’s sole focus is identifying services for children who are victims of, and children at risk of becoming victims of, human trafficking (HF 642).

  • Fixes recent bad case law in appellate courts by stating that expert testimony in child abuse, child sexual abuse, and child endangerment cases is permitted (SF 329, HSB 19)

  • Requires Medication Assisted Treatment (MAT) be available without prior authorization in both the Medicaid managed care and fee-for-service systems. At least one prior authorization free option must be made available for methadone, buprenorphine, naloxone, buprenorphine and naloxone combination (Suboxone), and naltrexone (HF 623 & SSB 1231).

  • Requires Medicaid coverage for tobacco cessation without prior authorization for members that reach out to an MCO tobacco cessation program or through Quitline Iowa - but they can require prior authorization for minors and those that have twice-failed in a consecutive 18-month period (SF 490).

  • Expands use of cannabidiol (CBD oil) for additional conditions (including PTSD), allows ARNPs and PAs to authorize use, increases THC levels dispensed over a six-month period, and authorizes home delivery in some instances (SF 501, HSB 244).

  • Authorizes the IDPH to set up syringe exchange pilot programs in five jurisdictions around the state, and legalizes possession and distribution of syringes for participants in the pilot programs (SF 500).

  • Prohibits a state licensing board from suspending or revoking a practitioner's license solely because they defaulted or are delinquent on student loans (HF 660).

  • Opens up the Health Care Loan Repayment Program to mental health professionals, but does not add additional funding to build out the program (SF 167).

  • Directs an interim committee to review the income cliff effect in public assistance programs and examine ways to phase out programs to encourage career advancement (HF 597).

  • Requires quarterly real-time monitoring and quarterly eligibility verification for public assistance programs (FIP, Medicaid, SNAP), with individuals found ineligible given only 30 days to provide proof of continued eligibility. Fortunately, the fiscal note on this estimates the state share of the cost to be $15.9 million in FY20 and $24.4 million in FY21, making passage highly unlikely (SF 334).

  • Requires the Medicaid expansion population (Iowa Health & Wellness Plan members) to participate in community engagement activities (work, volunteer) to remain eligible; more on this later (SF 538).

  • Takes the schools out of the equation for school-based health screening, instead making the parent and provider responsible for submitting necessary vision, dental, and blood lead test screenings to the Iowa Department of Public Health. Interestingly, part of the Governor's children's mental health initiative includes school-based mental health screenings for students; seems this bill goes in the opposite direction (SF 438).

You can see all of the bills that didn't make the cut here. Of note, the bill that would have included occupational therapists in the codified list of "mental health professionals" failed to make the cut, but you can bet they'll be back. OTs say they should be recognized as a mental health professional, but their bill placed them with professionals who can diagnose (something not in their scope of practice). Two OTs at the subcommittee said that diagnosis is in the future for them; others admitted that they are not trained for diagnosing, but they do "identify." They'll be back in 2020.

Community Engagement Alive, Evolving
As noted above, the Iowa Senate has kept a bill requiring those enrolled in the Iowa Health & Wellness Plan to participate in some type of community engagement for at least 20 hours per week. The bill that survived ( SF 538) was drafted by the Senate Labor Committee, but Senators that sit on the Senate Human Resources Committee had a different approach ( SF 434) that did not survive the deadline.

Senate Republicans plan to amend SF 538, using language from SF 434. it's not clear yet if the House has any plans to take up this issue, and this is something that may end up in the budget bill as floor debate might take some time. Here's a quick review of the differences:
This issue was considered stalled earlier several weeks ago, when legislators were told over 70% of Iowans receiving IHWP-funded services were employed. DHS recently provided lawmakers with data showing that only 76,000 of the 172,827 IHWP participants reported earnings - only 45%. With 61,000 Iowans potentially not engaged in one of the identified "community engagement" options, Senators decided to take another look at it. You can see DHS' calculations here.
Work Continues on Governor's Signature Program
One of Governor Kim Reynolds’ first acts as Governor last year was the appointment of a work group to examine Iowa’s children’s behavioral health system and make recommendations that would guarantee all Iowa children had access to a full array of quality, evidence-based behavioral health services.  This was seen as the follow-up to last year’s “Complex Needs” legislation, which mental health and disability services (MH/DS) regions are implementing now for adults with multi-occurring conditions.

The children’s work group met over the last year and came up with a set of recommendations.  Senate File 479 and  House Study Bill 206 , both of which survived the first legislative deadline, implement most of those recommendations. Here is a quick review of the bills:

  • Each MH/DS region is required to plan for and ensure access to core children’s behavioral health services within their area.  Each region must designate at least one children’s behavioral health coordinator. They would continue to have at least one staff person designated as an adult mental health and disability services coordinator.  The region must have their initial plan for services completed by April 1, 2020.

  • Children living in families with incomes up to 500% of the federal poverty level would be eligible for these regional services, and the region will use a sliding fee scale for children in families between 150-500% of the federal poverty level.

  • Regions are to make sure the following comprehensive facility and community-based crisis services are available to any eligible child, regardless of diagnosis:
  • Mobile response
  • Crisis stabilization community-based services
  • Crisis stabilization residential services
  • Behavioral health inpatient treatment

  • Regions are to make sure the following core services are available to eligible children with a diagnosed serious emotional disturbance:
  • Prevention, early identification, early intervention, education
  • Assessment and evaluation to determine eligibility for services
  • Medication prescribing and management
  • Behavioral health outpatient therapy

  • If additional resources are identified, regions are to make sure the following additional core services are available to eligible children with a diagnosed serious emotional disturbance: 
  • Behavioral health school-based therapy
  • Support for community living (family & peer support, therapeutic foster care, respite care)
  • Transition services to bridge to adult system (day habilitation, job development, supported employment prevocational service, educational services, care coordination, health homes)

  • Regions are required to pay for core services to children with diagnosed serious emotional disorders who are not eligible for Medicaid and do not have other insurance coverage, but only if funding is available.  No additional funding sources have been identified, and funding for services is not addressed in this bill (or any other bill filed to date).

  • Medicaid (and managed care organizations) would be required to pay for the services that are provided to their members, “to the extent funding is available.”  If these are to be funded, the Health and Human Services Budget would need to include additional funding for the Medicaid share of these services.

  • The Children’s Behavioral Health System Board is also formalized in these bills. The Board will continue to provide guidance and support the ongoing development of the system, and representatives from state agencies, courts, MH/DS Commission, Early Childhood Iowa, providers, schools and AEA, parents, advocates, regional MH/DS administrators, sheriffs, pediatricians, and hospitals.

  • Regional MH/DS governing boards are also reconfigured.  Currently only elected officials are allowed to vote on these boards.  The changes would add a parent, AEA, and children’s service provider to the board, and allow the AEA, parent, and the existing adult consumer member to vote.  The bill splits the current advisory committee into an adult services advisory committee, and a children’s service advisory committee.

Advocates and organizations voiced support during subcommittee meetings, but also expressed concern about funding (or lack thereof). As you will recall, legislators have not yet addressed predictable and sustainable funding for the enhanced MH/DS adult services system that was just expanded to address the service needs of Iowans with complex needs. 

Regions are asking that the property tax caps be lifted so they can fully fund their services and equalize levies throughout the region.  Some advocates are asking for the state to buy out the system using money generated from a one-cent sales tax increase (about $300 million would be available after the constitutionally protected increase for water quality).

To date no one has proposed a fix for the adult service system funding. The Governor’s budget only includes funding to partially address the children’s mental health services waiver waiting list; it does not include funding for these additional services at the regional level or in Medicaid.

It is important to remember, regardless of where you land on how services should be funded, access to services can only be guaranteed if there is a way to pay for it.  As US Senator Bernie Sanders of Vermont said, “ `Has access to’ does not mean that they are guaranteed health care. I have access to buying a $10 million home. I don’t have the money to do that.” 
Medicaid Managed Care Bills Die
This year legislators from both House and Senate, Republican and Democrat, introduced bills to address problems with Iowa’s now three-year-old Medicaid managed care system. None of these bills survived the first deadline, but that doesn’t mean the debate is over.  

Legislators like to deal with Medicaid and managed care issues in the Health and Human Services Budget, since these issues usually come with a price tag.  Here is a cumulative list of the ideas legislators put forward so far this year:

  • End managed care for everyone or only persons receiving long term supports and services, returning to fee-for-service system.

  • End managed care for everyone and move to an administrative services contract (this managed care hybrid is similar to what the state had with Magellan prior to managed care and was proposed by the Iowa Hospital Association as their “better way” – basically the state hires a single company to administer the fee-for-service system).

  • Require an independent external review process for appealing decisions on claims and services.

  • Demand true conflict-free case management, separate from the MCO.

  • Ban MCOs from asking for payment back or denying payment for services that were provided according to a service plan or contract.

  • Make MCOs pay a provider 12% interest on claims that were not paid on time, inaccurately denied, not paid according to the contract, or not settled in a timely manner. MCOs would pay a provider 20% interest if they deny coverage and it is overturned on an appeal.

  • Require independent, conflict-free administration of the uniform Supports Intensity Scale (SIS) assessment given to individuals who have an intellectual disability or developmental disability.

  • Report on long term supports and services provided to individuals with disabilities to make sure people are receiving necessary services and supports.

  • Develop a single, uniform credentialing process for Medicaid providers, using the same criteria for both fee-for-service and managed care.

  • Eliminate prior authorization for some services or require a uniform prior authorization process for both fee-for-service and managed care.

  • Streamline all administrative processes and procedures, so they are the same for all managed care organizations and the state’s fee-for-service system.

  • Direct MCOs to work with state agencies and provider groups to help recruit, retain, and train the direct care and health care workforce.

  • Require MCOs honor requests to switch MCOs for good cause within 10 days (currently it may take up to 45 days for this to be done).

  • Add staff to the Ombudsman Office to investigate complaints made by any Medicaid member, whether receiving long term supports and services, whether in managed care or fee-for-service.

While none of these survived the deadline, they could still be included in the budget (but you can expect no major overhauls - just picking around the edges).

Around the Rotunda
Fun Fact. As of close of business Friday, the Legislature has now seen a total of 1,786 bills introduced (832 in the Senate and 954 in the House). We're only halfway through the 110-day session.

Publicly Funded Lobbyists. When debating a bill that would ban taxpayer dollars from being used to hire lobbyists, Sen. Tony Bisignano got heated, telling supporters of the bill that county and city lobbyists hold legislators in check, saying "This isn't a country club. They're protecting taxpayers from you Senators." This will be a lively floor debate.

Death Penalty. The Senate advanced a limited (rape, kidnap, and murder of child) death penalty bill. Two Republicans joined Democrats in voting against this in committee (Sen. Zach Nunn & Sen. Amy Sinclair). The bill's sponsor said Iowa's current life in prison laws "creates a perverse incentive to kill a child once you've raped and kidnapped them." Sen. Kevin Kinney, who was the law enforcement officer who found Jetseta Gage, gave an impassioned plea against the bill,

"I have wrestled with this for years...I have seen young victims who were murdered...I have worked those investigations...I have put people in prison for life for those crimes...I can see and I can feel that young person who was been carried out of a trailer or a ditch...I know what it's like. I have looked at (Jetseta Gage's killer)...I've gone to Ft. Madison and I've gone to his cell. He is living a deplorable life. If we kill him, that would be a gift to him. I want him to sit in there and rot for the rest of his life...it is more painful for him to sit in his cell and think about what he did."

What's Next. The Iowa legislative session has now come to its halfway point.  With only eight weeks to go, legislators will turn their attention to floor debate.  They will spend most of their time over the next 2-3 weeks debating the bills that have come out of committee, getting ready for the second legislative deadline on April 5.  At this time, bills need to pass the House or Senate, and then come out of committee on the other side.

In addition, legislators will look at new revenue estimates that come out on March 15. This will tell them if the state’s economy is doing well, and if there is enough money to go around without budget cuts.  Soon after that we should see joint targets and budget bills emerging. Not many things are certain in Legislative Land, but we do know that leaders plan to get done as close to on time as possible (May 3 is the last day legislators get their per diem checks). Buckle up, things are just getting interesting.
 
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