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H0662.................................................by HEALTH AND WELFARE
MEDICAID SIMPLIFICATION ACT - Adds to existing law relating to Medicaid to
provide a short title; to state legislative intent; to provide definitions;
to provide powers and duties of the director of the Department of Health
and Welfare; to provide for medical assistance payments by the Department
of Health and Welfare to or on behalf of designated categories of eligible
persons; to permit the Department of Health and Welfare to make payment for
medically necessary services furnished by providers to designated
categories of eligible participants; and to specify the service for which
payment may be made.
02/13 House intro - 1st rdg - to printing
02/14 Rpt prt - to Health/Wel
]]]] LEGISLATURE OF THE STATE OF IDAHO ]]]]
Fifty-eighth Legislature Second Regular Session - 2006
IN THE HOUSE OF REPRESENTATIVES
HOUSE BILL NO. 662
BY HEALTH AND WELFARE COMMITTEE
1 AN ACT
2 RELATING TO MEDICAID; AMENDING CHAPTER 2, TITLE 56, IDAHO CODE, BY THE ADDI-
3 TION OF NEW SECTIONS 56-250, 56-251, 56-252, 56-253, 56-254 AND 56-255,
4 IDAHO CODE, TO PROVIDE A SHORT TITLE, TO STATE LEGISLATIVE INTENT, TO PRO-
5 VIDE DEFINITIONS, TO PROVIDE POWERS AND DUTIES OF THE DIRECTOR OF THE
6 DEPARTMENT OF HEALTH AND WELFARE, TO PROVIDE FOR MEDICAL ASSISTANCE PAY-
7 MENTS BY THE DEPARTMENT TO OR ON BEHALF OF DESIGNATED CATEGORIES OF ELIGI-
8 BLE PERSONS, TO PERMIT THE DEPARTMENT TO MAKE PAYMENT FOR MEDICALLY NECES-
9 SARY SERVICES FURNISHED BY PROVIDERS TO DESIGNATED CATEGORIES OF ELIGIBLE
10 PARTICIPANTS AND TO SPECIFY THE SERVICES FOR WHICH PAYMENT MAY BE MADE;
11 REPEALING SECTION 56-209d, IDAHO CODE, RELATING TO THE MEDICAL ASSISTANCE
12 PROGRAM, SERVICES TO BE PROVIDED AND EXPERIMENTAL SERVICES OR PROCEDURES
13 EXCLUDED; AND AMENDING SECTION 31-873, IDAHO CODE, TO PROVIDE A CORRECT
14 CODE REFERENCE.
15 Be It Enacted by the Legislature of the State of Idaho:
16 SECTION 1. That Chapter 2, Title 56, Idaho Code, be, and the same is
17 hereby amended by the addition thereto of NEW SECTIONS, to be known and desig-
18 nated as Sections 56-250, 56-251, 56-252, 56-253, 56-254 and 56-255, Idaho
19 Code, and to read as follows:
20 56-250. SHORT TITLE. This act shall be known and may be cited as the
21 "Idaho Medicaid Simplification Act."
22 56-251. LEGISLATIVE INTENT. (1) The legislature finds that the current
23 federal medicaid law and regulations have not kept pace with modern health
24 care management practices, create obstacles to quality care and impose unnec-
25 essary costs on the delivery of effective and efficient health care. The leg-
26 islature believes that the state of Idaho must strive to balance efforts to
27 contain medicaid costs, improve program quality and improve access to ser-
28 vices. The legislature further believes that the state of Idaho could achieve
29 improved health outcomes for medicaid participants by simplifying eligibility
30 and developing health benefits for medicaid participants according to their
31 health needs, including appropriate preventive and wellness services.
32 (2) The legislature supports development, at a minimum, of the following
33 health-need categories:
34 (a) Low-Income Children and Working-Age Adults. The broad policy goal for
35 the medicaid program for low-income children and working-age adults is to
36 achieve and maintain wellness by emphasizing prevention and by proactively
37 managing health. Additional specific goals are:
38 (i) To emphasize preventive care and wellness;
39 (ii) To increase participant ability to make good health choices;
40 and
41 (iii) To strengthen the employer-based health insurance system.
42 (b) Persons with Disabilities or Special Health Needs. The broad policy
2
1 goal for the medicaid program for persons with disabilities or special
2 health needs is to finance and deliver cost-effective individualized
3 care. Additional specific goals are:
4 (i) To emphasize preventive care and wellness;
5 (ii) To empower individuals with disabilities to manage their own
6 lives;
7 (iii) To provide opportunities for employment for persons with dis-
8 abilities; and
9 (iv) To provide and to promote family-centered, community-based,
10 coordinated care for children with special health care needs.
11 (c) Elders. The broad policy goal for the medicaid program for elders is
12 to finance and deliver cost-effective individualized care which is inte-
13 grated, to the greatest extent possible, with medicare coverage. Addi-
14 tional specific goals are:
15 (i) To emphasize preventive care and wellness;
16 (ii) To improve coordination between medicaid and medicare coverage;
17 (iii) To increase nonpublic financing options for long-term care; and
18 (iv) To ensure participants' dignity and quality of life.
19 (3) To the extent practical, the department shall achieve savings and
20 efficiencies through use of modern care management practices, in areas such as
21 network management, cost-sharing, benefit design and premium assistance.
22 (4) The department's duty to implement these changes in accordance with
23 the intent of the legislature is contingent upon federal approval.
24 56-252. DEFINITIONS. As used in sections 56-250 through 56-255, Idaho
25 Code:
26 (1) "Benefit design" means selection of services, providers and benefi-
27 ciary cost-sharing to create the scope of coverage for participants.
28 (2) "Community supports" means services that promote the ability of per-
29 sons with disabilities to be self-sufficient and live independently in their
30 own communities.
31 (3) "Cost-sharing" means participant payment for a portion of medicaid
32 service costs such as deductibles, coinsurance or copayment amounts.
33 (4) "Department" means the department of health and welfare.
34 (5) "Director" means the director of the department of health and wel-
35 fare.
36 (6) "Health risk assessment" means a process of assessing the health sta-
37 tus and health needs of participants.
38 (7) "Medicaid" means Idaho's medical assistance program.
39 (8) "Medical assistance" means payments for part or all of the cost of
40 services funded by titles XIX or XXI of the federal social security act as
41 amended, as may be designated by department rule.
42 (9) "Medical home" means a primary care case manager designated by the
43 participant or the department to coordinate the participant's care.
44 (10) "Network management" means establishment and management of contracts
45 between the department and limited groups of providers or suppliers of medical
46 and other services to participants.
47 (11) "Participant" means a person eligible for and enrolled in the Idaho
48 medical assistance program.
49 (12) "Premium assistance" means use of medicaid funds to pay part or all
50 of the costs of enrolling eligible individuals into private insurance cover-
51 age.
52 (13) "Primary care case manager" means a primary care physician who con-
53 tracts with medicaid to coordinate the care of certain participants.
54 (14) "Provider" means any individual, partnership, association, corpora-
3
1 tion or organization, public or private, which provides residential or
2 assisted living services, certified family home services, nursing facility
3 services or services offered pursuant to medical assistance.
4 (15) "Self-determination" means medicaid services that allow persons with
5 disabilities to exercise choice and control over the services and supports
6 they receive.
7 (16) "State plan" means the contract between the state and federal govern-
8 ment under 42 U.S.C. section 1396a(a).
9 56-253. POWERS AND DUTIES OF THE DIRECTOR. (1) The director is hereby
10 encouraged and empowered to obtain federal approval in order that Idaho design
11 and implement changes to its medicaid program that advance the quality of ser-
12 vices to participants while allowing access to needed services and containing
13 excessive costs. The design of Idaho's medicaid program shall incorporate the
14 concepts expressed in section 56-251, Idaho Code.
15 (2) The director may create health-need categories other than those
16 stated in section 56-251(2)(a), Idaho Code, subject to legislative approval,
17 and may develop a medicaid state plan for each category.
18 (3) Each state plan shall include explicit policy goals for the covered
19 population identified in the plan, as well as specific benefit packages,
20 delivery system components and performance measures in accordance with section
21 67-1904, Idaho Code.
22 (4) The director shall establish a mechanism to ensure placement of par-
23 ticipants into the appropriate state plan. This mechanism shall include, but
24 not be limited to, a health risk assessment. This assessment shall comply with
25 federal requirements for early and periodic screening, diagnosis and treatment
26 (EPSDT) services for children, in accordance with section 1905(a)(4)(B) of the
27 social security act.
28 (5) The director may require, subject to federal approval, participants
29 to designate a medical home. Applicants for medical assistance shall receive
30 information about primary care case management, and, if required to so desig-
31 nate, shall select a primary care provider as part of the eligibility determi-
32 nation process.
33 (6) The director may, subject to federal approval, enter into contracts
34 for medical and other services when such contracts are beneficial to partici-
35 pant health outcomes as well as economically prudent for the medicaid program.
36 (7) The director may obtain agreements from medicare, school districts
37 and other entities to provide medical care if it is practical and cost-effec-
38 tive.
39 (8) The director is given authority to promulgate rules consistent with
40 this act.
41 56-254. ELIGIBILITY FOR MEDICAL ASSISTANCE. The department shall make
42 payments for medical assistance to, or on behalf of, the following persons
43 eligible for medical assistance.
44 (1) The state plan for low-income children and working-age adults
45 includes the following persons:
46 (a) Children in families whose family income does not exceed one hundred
47 eighty-five percent (185%) of the federal poverty guideline and who meet
48 age-related and other eligibility standards in accordance with department
49 rule;
50 (b) Pregnant women of any age whose family income does not exceed one
51 hundred thirty-three percent (133%) of the federal poverty guideline and
52 who meet other eligibility standards in accordance with department rule,
53 or who meet the presumptive eligibility guidelines in accordance with sec-
4
1 tion 1920 of the social security act;
2 (c) Infants born to medicaid-eligible pregnant women. Medicaid eligibil-
3 ity must be offered throughout the first year of life so long as the
4 infant remains in the mother's household and she remains eligible, or
5 would be eligible if she were still pregnant;
6 (d) Adults in families with dependent children as described in section
7 1931 of the social security act, who meet the requirements in the state's
8 assistance to families with dependent children (AFDC) plan in effect on
9 July 16, 1996;
10 (e) Families who are provided six (6) to twelve (12) months of medicaid
11 coverage following loss of eligibility under section 1931 of the social
12 security act due to earnings, or four (4) months of medicaid coverage fol-
13 lowing loss of eligibility under section 1931 of the social security act
14 due to an increase in child or spousal support;
15 (f) Employees of small businesses who meet the definition of "eligible
16 adult" as described in section 56-238, Idaho Code, whose eligibility is
17 limited to the medical assistance program described in section 56-241,
18 Idaho Code; and
19 (g) All other mandatory groups as defined in title XIX of the social
20 security act, if not listed separately in subsection (2) or (3) of this
21 section.
22 (2) The state plan for persons with disabilities or special health needs
23 includes the following persons:
24 (a) Persons under age sixty-five (65) years eligible in accordance with
25 title XVI of the social security act, as well as persons eligible for aid
26 to the aged, blind and disabled (AABD) under titles I, X and XIV of the
27 social security act;
28 (b) Persons under age sixty-five (65) years who are in need of the ser-
29 vices of a licensed nursing facility, a licensed intermediate care facil-
30 ity for the developmentally disabled, a state mental hospital, or home-
31 based and community-based care, whose income does not exceed three hundred
32 percent (300%) of the social security income (SSI) standard and who meet
33 the asset standards and other eligibility standards in accordance with
34 federal law and regulation, Idaho law and department rule;
35 (c) Certain disabled children described in 42 CFR 435.225 who meet
36 resource limits for aid to the aged, blind and disabled (AABD) and income
37 limits for social security income (SSI) and other eligibility standards in
38 accordance with department rules;
39 (d) Persons under age sixty-five (65) years who are eligible for services
40 under both titles XVIII and XIX of the social security act;
41 (e) Children who are eligible under title IV-E of the social security act
42 for subsidized board payments, foster care or adoption subsidies, and
43 children for whom the state has assumed temporary or permanent responsi-
44 bility and who do not qualify for title IV-E assistance but are in foster
45 care, shelter or emergency shelter care, or subsidized adoption, and who
46 meet eligibility standards in accordance with department rule;
47 (f) Eligible women under age sixty-five (65) years with incomes at or
48 below two hundred percent (200%) of the federal poverty level, for cancer
49 treatment pursuant to the federal breast and cervical cancer prevention
50 and treatment act of 2000;
51 (g) Low-income children and working-age adults under age sixty-five (65)
52 years who qualify under subsection (1) of this section and who require the
53 services for persons with disabilities or special health needs listed in
54 subsection 56-255(3), Idaho Code; and
55 (h) Persons over age sixty-five (65) years who choose to enroll in this
5
1 state plan.
2 (3) The state plan for elders includes the following persons:
3 (a) Persons aged sixty-five (65) years or older eligible in accordance
4 with title XVI of the social security act, as well as persons eligible for
5 aid to the aged, blind and disabled (AABD) under titles I, X and XIV of
6 the social security act;
7 (b) Persons aged sixty-five (65) years or older who are in need of the
8 services of a licensed nursing facility, a licensed intermediate care
9 facility for the developmentally disabled, a state mental hospital, or
10 home-based and community-based care, whose income does not exceed three
11 hundred percent (300%) of the social security income (SSI) standard and
12 who meet the assets standards and other eligibility standards in accor-
13 dance with federal and state law and department rule;
14 (c) Persons aged sixty-five (65) years or older who are eligible for ser-
15 vices under both titles XVIII and XIX of the social security act who have
16 enrolled in the medicare program; and
17 (d) Persons under age sixty-five (65) years who are eligible for services
18 under both titles XVIII and XIX of the social security act and who elect
19 to enroll in this state plan.
20 56-255. MEDICAL ASSISTANCE PROGRAM -- SERVICES TO BE PROVIDED. (1) The
21 department may make payments for the following services furnished by providers
22 to participants who are determined to be eligible on the dates on which the
23 services were provided. Any service under this section shall be reimbursed
24 only when medically necessary and in accordance with federal law and regula-
25 tion, Idaho law and department rule. Nothing in this section shall be con-
26 strued to prevent or limit the department from adjusting fees, reimbursement
27 rates, lengths of stay, number of visits, number of services or any other
28 adjustments necessary to comply with the availability of moneys and any limi-
29 tations or directions set forth in department rules. Notwithstanding any other
30 provision of this chapter, medical assistance includes the following benefits
31 specific to the eligibility categories established in section 56-254(1), (2)
32 and (3), Idaho Code, as well as a list of benefits to which all Idaho medicaid
33 participants are entitled, defined in subsection (5) of this section.
34 (2) Specific health benefits and limitations for low-income children and
35 working-age adults include:
36 (a) All services described in subsection (5) of this section;
37 (b) Early and periodic screening, diagnosis and treatment services for
38 individuals under age twenty-one (21) years, and treatment of conditions
39 found; and
40 (c) Cost-sharing required of participants. Participants in the low-income
41 children and working-age adult group are subject to the following premium
42 payments, as stated in department rules:
43 (i) Participants with family incomes equal to or less than one hun-
44 dred thirty-three percent (133%) of the federal poverty guideline are
45 not required to pay premiums; and
46 (ii) Participants with family incomes above one hundred thirty-three
47 percent (133%) of the federal poverty guideline will be required to
48 pay premiums in accordance with department rule.
49 (3) Specific health benefits for persons with disabilities or special
50 health needs include:
51 (a) All services described in subsection (5) of this section;
52 (b) Early and periodic screening, diagnosis and treatment services for
53 individuals under age twenty-one (21) years, and treatment of conditions
54 found;
6
1 (c) Case management services as defined in accordance with subsection
2 1905(a)(19) or section 1915(g) of the social security act; and
3 (d) Mental health services, including:
4 (i) Inpatient psychiatric facility services whether in a hospital,
5 or for persons under age twenty-two (22) years in a freestanding psy-
6 chiatric facility, as permitted by federal law, in excess of those
7 limits in department rules on inpatient psychiatric facility services
8 provided under subsection (5) of this section;
9 (ii) Outpatient mental health services in excess of those limits in
10 department rules on outpatient mental health services provided under
11 subsection (5) of this section; and
12 (iii) Psychosocial rehabilitation for reduction of mental disability
13 for children under the age of eighteen (18) years with a serious emo-
14 tional disturbance (SED) and for severely and persistently mentally
15 ill adults, aged eighteen (18) years or older, with severe and per-
16 sistent mental illness;
17 (e) Long-term care services, including:
18 (i) Nursing facility services, other than services in an institution
19 for mental diseases, subject to participant cost-sharing;
20 (ii) Home-based and community-based services, subject to federal
21 approval, provided to individuals who require nursing facility level
22 of care who, without home-based and community-based services, would
23 require institutionalization. These services will include community
24 supports, including an option for self-determination, which will
25 enable individuals to have greater freedom to manage their own care;
26 and
27 (iii) Personal care services in a participant's home, prescribed in
28 accordance with a plan of treatment and provided by a qualified per-
29 son under supervision of a registered nurse;
30 (f) Services for persons with developmental disabilities, including:
31 (i) Intermediate care facility services, other than such services
32 in an institution for mental diseases, for persons determined in
33 accordance with section 1902(a)(31) of the social security act to be
34 in need of such care, including such services in a public institu-
35 tion, or distinct part thereof, for the mentally retarded or persons
36 with related conditions;
37 (ii) Home-based and community-based services, subject to federal
38 approval, provided to individuals who require intermediate care
39 facility for the mentally retarded (ICF/MR) level of care who, with-
40 out home-based and community-based services, would require institu-
41 tionalization. These services will include community supports,
42 including an option for self-determination, which will enable indi-
43 viduals to have greater freedom to manage their own care; and
44 (iii) Developmental services. The department shall pay for rehabili-
45 tative services, including medical or remedial services provided by a
46 facility that has entered into a provider agreement with the depart-
47 ment and is certified as a developmental disabilities agency by the
48 department;
49 (g) Home health services, including:
50 (i) Intermittent or part-time nursing services provided by a home
51 health agency or by a registered nurse when no home health agency
52 exists in the area;
53 (ii) Home health aide services provided by a home health agency; and
54 (iii) Physical therapy, occupational therapy or speech pathology and
55 audiology services provided by a home health agency or medical reha-
7
1 bilitation facility;
2 (h) Hospice care in accordance with section 1905(o) of the social secu-
3 rity act;
4 (i) Specialized medical equipment and supplies; and
5 (j) Medicare cost-sharing, including:
6 (i) Medicare cost-sharing for qualified medicare beneficiaries
7 described in section 1905(p) of the social security act;
8 (ii) Medicare part A premiums for qualified disabled and working
9 individuals described in section 1902(a)(10)(E)(ii) of the social
10 security act;
11 (iii) Medicare part B premiums for specified low-income medicare ben-
12 eficiaries described in section 1902(a)(10)(E)(iii) of the social
13 security act; and
14 (iv) Medicare part B premiums for qualifying individuals described
15 in section 1902(a)(10)(E)(iv) and subject to section 1933 of the
16 social security act.
17 (4) Specific health benefits for elders include:
18 (a) All services described in subsection (5) of this section, other than
19 if provided under the federal medicare program;
20 (b) All services described in subsection (3) of this section, other than
21 if provided under the federal medicare program; and
22 (c) Other services that supplement medicare coverage.
23 (5) Benefits for all medicaid participants, unless specifically limited
24 in subsection (2), (3) or (4) of this section include the following:
25 (a) Health care coverage including, but not limited to, basic inpatient
26 and outpatient medical services, and including:
27 (i) Physicians' services, whether furnished in the office, the
28 patient's home, a hospital, a nursing facility or elsewhere;
29 (ii) Services provided by a physician or other licensed practitio-
30 ner to prevent disease, disability and other health conditions or
31 their progressions, to prolong life, or to promote physical or mental
32 health; and
33 (iii) Hospital care, including:
34 1. Inpatient hospital services other than those services pro-
35 vided in an institution for mental diseases;
36 2. Outpatient hospital services; and
37 3. Emergency hospital services;
38 (iv) Laboratory and x-ray services;
39 (v) Prescribed drugs;
40 (vi) Family planning services and supplies for individuals of
41 child-bearing age;
42 (vii) Certified pediatric or family nurse practitioners' services;
43 (viii) Emergency medical transportation;
44 (ix) Mental health services, including:
45 1. Outpatient mental health services that are appropriate,
46 within limits stated in department rules; and
47 2. Inpatient psychiatric facility services within limits stated
48 in department rules;
49 (x) Medical supplies, equipment, and appliances suitable for use
50 in the home; and
51 (xi) Physical therapy and related services;
52 (b) Primary care case management;
53 (c) Dental services, and medical and surgical services furnished by a
54 dentist in accordance with section 1905(a)(5)(B) of the social security
55 act;
8
1 (d) Medical care and any other type of remedial care recognized under
2 Idaho law, furnished by licensed practitioners within the scope of their
3 practice as defined by Idaho law, including:
4 (i) Podiatrists' services;
5 (ii) Optometrists' services;
6 (iii) Chiropractors' services; and
7 (iv) Other practitioners' services, in accordance with department
8 rules;
9 (e) Services for individuals with speech, hearing and language disorders,
10 provided by or under the supervision of a speech pathologist or audiolo-
11 gist;
12 (f) Eyeglasses prescribed by a physician skilled in diseases of the eye
13 or by an optometrist;
14 (g) Services provided by essential providers, including:
15 (i) Rural health clinic services and other ambulatory services fur-
16 nished by a rural health clinic in accordance with section 1905(l)(1)
17 of the social security act;
18 (ii) Federally qualified health center (FQHC) services and other
19 ambulatory services that are covered under the plan and furnished by
20 an FQHC in accordance with section 1905(l)(2) of the social security
21 act;
22 (iii) Indian health services; and
23 (iv) District health departments;
24 (h) Any other medical care and any other type of remedial care recognized
25 under state law, specified by the secretary of the federal department of
26 health and human services;
27 (i) Nonemergency medical transportation; and
28 (j) Physician, hospital or other services deemed experimental are
29 excluded from coverage. The director may allow coverage of procedures or
30 services deemed investigational if the procedures or services are as
31 cost-effective as traditional, standard treatments.
32 SECTION 2. That Section 56-209d, Idaho Code, be, and the same is hereby
33 repealed.
34 SECTION 3. That Section 31-873, Idaho Code, be, and the same is hereby
35 amended to read as follows:
36 31-873. REIMBURSEMENT FOR CERTAIN MEDICAL ASSISTANCE PAYMENTS. (1) For
37 the purpose of assisting counties with their medical indigency claims, state
38 participation in the federal medical assistance (medicaid) program under title
39 XIX of the social security act, as amended, shall be expanded to match federal
40 funds for coverage of services as defined by section 56-209d chapter 2, title
41 56, Idaho Code.
42 (2) Boards of county commissioners shall safeguard all provided informa-
43 tion as provided for in section 1902(a)(7) of the social security act, 42 CFR
44 431.300 through 431.307 and sections 56-221 and 56-222, Idaho Code.
STATEMENT OF PURPOSE
RS 15988
This bill authorizes the Director of the Idaho Department of
Health and Welfare to restructure the Idaho Medicaid program in
order to achieve improved health outcomes for Medicaid
participants and slow the rate of growth in Medicaid costs. The
bill simplifies current eligibility categories by establishing
three new population groups, based on participants' health needs.
The bill authorizes the Director to develop a State Plan for
Medical Assistance for each of the three groups. The bill further
describes the benefits for each of the three groups, in addition
to a global benefit list for all Idaho Medicaid participants.
FISCAL NOTE
There is no fiscal impact to the general fund.
Contact
Name: Representative Sharon Block
Phone: 332-1000
Senator Dick Compton
David Rogers, Department of Health and Welfare
364-1804
STATEMENT OF PURPOSE/FISCAL NOTE H 662