Iowa Code 249N.6 – Iowa health and wellness plan provider network
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1. The Iowa health and wellness plan provider network shall include all providers enrolled 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.
Terms Used In Iowa Code 249N.6
- 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. See Iowa Code 249N.2
- Contract: A legal written agreement that becomes binding when signed.
- Covered benefits: means covered benefits as specified in section 249N. See Iowa Code 249N.2
- Department: means the department of health and human services. See Iowa Code 249L.2
- Department: means the department of health and human services. See Iowa Code 249N.2
- Iowa health and wellness plan provider: means any provider enrolled in the medical assistance program or any participating accountable care organization. See Iowa Code 249N.2
- Iowa health and wellness plan provider network: means the health care delivery network approved by the department for Iowa health and wellness plan members. See Iowa Code 249N.2
- Medicaid: means the program paying all or part of the costs of care and services provided to an individual pursuant to chapter 249A and Tit. See Iowa Code 249N.2
- 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 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. See Iowa Code 249N.2
- Member: means an eligible individual who is enrolled in the Iowa health and wellness plan. See Iowa Code 249N.2
- Participating accountable care organization: means an accountable care organization approved by the department to participate in the Iowa health and wellness plan provider network. See Iowa Code 249N.2
- plan: means the Iowa health and wellness plan established under this chapter. See Iowa Code 249N.2
- 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. See Iowa Code 249N.2
- Rule: includes "regulation". See Iowa Code 4.1
- state: when applied to the different parts of the United States, includes the District of Columbia and the territories, and the words "United States" may include the said district and territories. See Iowa Code 4.1
- 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. See Iowa Code 249N.2
- year: means twelve consecutive months. See Iowa Code 4.1
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 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.