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H0776......................................................by STATE AFFAIRS
MEDICAID SIMPLIFICATION ACT - Adds to existing law relating to the Medicaid
Simplification Act 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 designate categories of eligible participants;
and to specify the services for which payment may be made.
03/07 House intro - 1st rdg - to printing
03/08 Rpt prt - to Health/Wel
03/09 Rpt out - rec d/p - to 2nd rdg
03/10 2nd rdg - to 3rd rdg
03/14 3rd rdg - PASSED - 56-11-3
AYES -- Anderson, Andrus, Barraclough, Bastian, Bedke, Bell, Bilbao,
Block, Boe, Bolz, Bradford, Cannon, Chadderdon, Clark, Collins, Deal,
Denney, Edmunson, Ellsworth, Eskridge, Field(18), Field(23), Garrett,
Harwood, Henbest, Henderson, Jaquet, Kemp, Lake, Martinez, Mathews,
Miller, Mitchell, Moyle, Nonini, Pasley-Stuart, Pence, Raybould,
Ring, Ringo, Roberts, Rusche, Rydalch, Sayler, Schaefer, Shepherd(2),
Shirley, Skippen, Smith(30), Smith(24), Smylie, Snodgrass, Stevenson,
Trail, Wills, Mr. Speaker
NAYS -- Barrett, Bayer, Hart, LeFavour, Loertscher, McGeachin,
McKague, Nielsen, Sali, Shepherd(8), Wood
Absent and excused -- Black, Brackett, Crow
Floor Sponsor - Block
Title apvd - to Senate
03/14 Senate intro - 1st rdg - to Health/Wel
03/21 Rpt out - rec d/p - to 2nd rdg
03/22 2nd rdg - to 3rd rdg
03/23 3rd rdg - PASSED - 33-0-2
AYES -- Andreason, Broadsword, Bunderson, Burkett(Clark), Burtenshaw,
Cameron, Coiner, Compton, Corder, Darrington, Davis, Fulcher, Geddes,
Goedde, Hill, Jorgenson, Kelly, Keough, Langhorst, Little, Lodge,
Malepeai, Marley, McGee, McKenzie, Pearce, Richardson, Schroeder,
Stegner, Stennett, Sweet, Werk, Williams
NAYS -- None
Absent and excused -- Brandt, Gannon
Floor Sponsors - Compton, Broadsword & Darrington
Title apvd - to House
03/24 To enrol
03/27 Rpt enrol - Sp signed
03/28 Pres signed
03/29 To Governor
03/31 Governor signed
Session Law Chapter 278
Effective: 07/01/06
]]]] LEGISLATURE OF THE STATE OF IDAHO ]]]]
Fifty-eighth Legislature Second Regular Session - 2006
IN THE HOUSE OF REPRESENTATIVES
HOUSE BILL NO. 776
BY STATE AFFAIRS 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 PAYMENTS FOR MEDICALLY NEC-
9 ESSARY SERVICES FURNISHED BY PROVIDERS TO DESIGNATED CATEGORIES OF ELIGI-
10 BLE PARTICIPANTS AND TO SPECIFY THE SERVICES FOR WHICH PAYMENTS MAY BE
11 MADE.
12 Be It Enacted by the Legislature of the State of Idaho:
13 SECTION 1. That Chapter 2, Title 56, Idaho Code, be, and the same is
14 hereby amended by the addition thereto of NEW SECTIONS, to be known and desig-
15 nated as Sections 56-250, 56-251, 56-252, 56-253, 56-254 and 56-255, Idaho
16 Code, and to read as follows:
17 56-250. SHORT TITLE. This act shall be known and may be cited as the
18 "Idaho Medicaid Simplification Act."
19 56-251. LEGISLATIVE INTENT. (1) The legislature finds that the current
20 federal medicaid law and regulations have not kept pace with modern health
21 care management practices, create obstacles to quality care and impose unnec-
22 essary costs on the delivery of effective and efficient health care. The leg-
23 islature believes that the state of Idaho must strive to balance efforts to
24 contain medicaid costs, improve program quality and improve access to ser-
25 vices. The legislature further believes that the state of Idaho could achieve
26 improved health outcomes for medicaid participants by simplifying eligibility
27 and developing health benefits for medicaid participants according to their
28 health needs, including appropriate preventive and wellness services.
29 (2) The legislature supports development, at a minimum, of the following
30 health-need categories:
31 (a) Low-Income Children and Working-Age Adults. The broad policy goal for
32 the medicaid program for low-income children and working-age adults is to
33 achieve and maintain wellness by emphasizing prevention and by proactively
34 managing health. Additional specific goals are:
35 (i) To emphasize preventive care and wellness;
36 (ii) To increase participant ability to make good health choices;
37 and
38 (iii) To strengthen the employer-based health insurance system.
39 (b) Persons with Disabilities or Special Health Needs. The broad policy
40 goal for the medicaid program for persons with disabilities or special
41 health needs is to finance and deliver cost-effective individualized care.
42 Additional specific goals are:
2
1 (i) To emphasize preventive care and wellness;
2 (ii) To empower individuals with disabilities to manage their own
3 lives;
4 (iii) To provide opportunities for employment for persons with dis-
5 abilities; and
6 (iv) To provide and to promote family-centered, community-based,
7 coordinated care for children with special health care needs.
8 (c) Elders. The broad policy goal for the medicaid program for elders is
9 to finance and deliver cost-effective individualized care which is inte-
10 grated, to the greatest extent possible, with medicare coverage. Addi-
11 tional specific goals are:
12 (i) To emphasize preventive care and wellness;
13 (ii) To improve coordination between medicaid and medicare coverage;
14 (iii) To increase nonpublic financing options for long-term care; and
15 (iv) To ensure participants' dignity and quality of life.
16 (3) To the extent practicable, the department shall achieve savings and
17 efficiencies through use of modern care management practices, in areas such as
18 network management, cost-sharing, benefit design and premium assistance.
19 (4) The department's duty to implement these changes in accordance with
20 the intent of the legislature is contingent upon federal approval.
21 56-252. DEFINITIONS. As used in sections 56-250 through 56-255, Idaho
22 Code:
23 (1) "Benefit design" means selection of services, providers and benefi-
24 ciary cost-sharing to create the scope of coverage for participants.
25 (2) "Community supports" means services that promote the ability of per-
26 sons with disabilities to be self-sufficient and live independently in their
27 own communities.
28 (3) "Cost-sharing" means participant payment for a portion of medicaid
29 service costs such as deductibles, coinsurance or copayment amounts.
30 (4) "Department" means the department of health and welfare.
31 (5) "Director" means the director of the department of health and wel-
32 fare.
33 (6) "Health risk assessment" means a process of assessing the health sta-
34 tus and health needs of participants.
35 (7) "Medicaid" means Idaho's medical assistance program.
36 (8) "Medical assistance" means payments for part or all of the cost of
37 services funded by titles XIX or XXI of the federal social security act as
38 amended, as may be designated by department rule.
39 (9) "Medical home" means a primary care case manager designated by the
40 participant or the department to coordinate the participant's care.
41 (10) "Network management" means establishment and management of contracts
42 between the department and limited groups of providers or suppliers of medical
43 and other services to participants.
44 (11) "Participant" means a person eligible for and enrolled in the Idaho
45 medical assistance program.
46 (12) "Premium assistance" means use of medicaid funds to pay part or all
47 of the costs of enrolling eligible individuals into private insurance cover-
48 age.
49 (13) "Primary care case manager" means a primary care physician who con-
50 tracts with medicaid to coordinate the care of certain participants.
51 (14) "Provider" means any individual, partnership, association, corpora-
52 tion or organization, public or private, which provides residential or
53 assisted living services, certified family home services, nursing facility
54 services or services offered pursuant to medical assistance.
3
1 (15) "Self-determination" means medicaid services that allow persons with
2 disabilities to exercise choice and control over the services and supports
3 they receive.
4 (16) "State plan" means the contract between the state and federal govern-
5 ment under 42 U.S.C. section 1396a(a).
6 56-253. POWERS AND DUTIES OF THE DIRECTOR. (1) The director is hereby
7 encouraged and empowered to obtain federal approval in order that Idaho design
8 and implement changes to its medicaid program that advance the quality of ser-
9 vices to participants while allowing access to needed services and containing
10 excessive costs. The design of Idaho's medicaid program shall incorporate the
11 concepts expressed in section 56-251, Idaho Code.
12 (2) The director may create health-need categories other than those
13 stated in section 56-251(2)(a), Idaho Code, subject to legislative approval,
14 and may develop a medicaid state plan for each category.
15 (3) Each state plan shall include explicit policy goals for the covered
16 population identified in the plan, as well as specific benefit packages,
17 delivery system components and performance measures in accordance with section
18 67-1904, Idaho Code.
19 (4) The director shall establish a mechanism to ensure placement of par-
20 ticipants into the appropriate state plan. This mechanism shall include, but
21 not be limited to, a health risk assessment. This assessment shall comply with
22 federal requirements for early and periodic screening, diagnosis and treatment
23 (EPSDT) services for children, in accordance with section 1905(a)(4)(B) of the
24 social security act.
25 (5) The director may require, subject to federal approval, participants
26 to designate a medical home. Applicants for medical assistance shall receive
27 information about primary care case management, and, if required to so desig-
28 nate, shall select a primary care provider as part of the eligibility determi-
29 nation process.
30 (6) The director may, subject to federal approval, enter into contracts
31 for medical and other services when such contracts are beneficial to partici-
32 pant health outcomes as well as economically prudent for the medicaid program.
33 (7) The director may obtain agreements from medicare, school districts
34 and other entities to provide medical care if it is practical and cost-effec-
35 tive.
36 (8) The director is given authority to promulgate rules consistent with
37 this act.
38 56-254. ELIGIBILITY FOR MEDICAL ASSISTANCE. The department shall make
39 payments for medical assistance to, or on behalf of, the following persons
40 eligible for medical assistance.
41 (1) The state plan for low-income children and working-age adults
42 includes the following persons:
43 (a) Children in families whose family income does not exceed one hundred
44 eighty-five percent (185%) of the federal poverty guideline and who meet
45 age-related and other eligibility standards in accordance with department
46 rule;
47 (b) Pregnant women of any age whose family income does not exceed one
48 hundred thirty-three percent (133%) of the federal poverty guideline and
49 who meet other eligibility standards in accordance with department rule,
50 or who meet the presumptive eligibility guidelines in accordance with sec-
51 tion 1920 of the social security act;
52 (c) Infants born to medicaid-eligible pregnant women. Medicaid eligibil-
53 ity must be offered throughout the first year of life so long as the
4
1 infant remains in the mother's household and she remains eligible, or
2 would be eligible if she were still pregnant;
3 (d) Adults in families with dependent children as described in section
4 1931 of the social security act, who meet the requirements in the state's
5 assistance to families with dependent children (AFDC) plan in effect on
6 July 16, 1996;
7 (e) Families who are provided six (6) to twelve (12) months of medicaid
8 coverage following loss of eligibility under section 1931 of the social
9 security act due to earnings, or four (4) months of medicaid coverage fol-
10 lowing loss of eligibility under section 1931 of the social security act
11 due to an increase in child or spousal support;
12 (f) Employees of small businesses who meet the definition of "eligible
13 adult" as described in section 56-238, Idaho Code, whose eligibility is
14 limited to the medical assistance program described in section 56-241,
15 Idaho Code; and
16 (g) All other mandatory groups as defined in title XIX of the social
17 security act, if not listed separately in subsection (2) or (3) of this
18 section.
19 (2) The state plan for persons with disabilities or special health needs
20 includes the following persons:
21 (a) Persons under age sixty-five (65) years eligible in accordance with
22 title XVI of the social security act, as well as persons eligible for aid
23 to the aged, blind and disabled (AABD) under titles I, X and XIV of the
24 social security act;
25 (b) Persons under age sixty-five (65) years who are in need of the ser-
26 vices of a licensed nursing facility, a licensed intermediate care facil-
27 ity for the developmentally disabled, a state mental hospital, or home-
28 based and community-based care, whose income does not exceed three hundred
29 percent (300%) of the social security income (SSI) standard and who meet
30 the asset standards and other eligibility standards in accordance with
31 federal law and regulation, Idaho law and department rule;
32 (c) Certain disabled children described in 42 CFR 435.225 who meet
33 resource limits for aid to the aged, blind and disabled (AABD) and income
34 limits for social security income (SSI) and other eligibility standards in
35 accordance with department rules;
36 (d) Persons under age sixty-five (65) years who are eligible for services
37 under both titles XVIII and XIX of the social security act;
38 (e) Children who are eligible under title IV-E of the social security act
39 for subsidized board payments, foster care or adoption subsidies, and
40 children for whom the state has assumed temporary or permanent responsi-
41 bility and who do not qualify for title IV-E assistance but are in foster
42 care, shelter or emergency shelter care, or subsidized adoption, and who
43 meet eligibility standards in accordance with department rule;
44 (f) Eligible women under age sixty-five (65) years with incomes at or
45 below two hundred percent (200%) of the federal poverty level, for cancer
46 treatment pursuant to the federal breast and cervical cancer prevention
47 and treatment act of 2000;
48 (g) Low-income children and working-age adults under age sixty-five (65)
49 years who qualify under subsection (1) of this section and who require the
50 services for persons with disabilities or special health needs listed in
51 subsection 56-255(3), Idaho Code; and
52 (h) Persons over age sixty-five (65) years who choose to enroll in this
53 state plan.
54 (3) The state plan for elders includes the following persons:
55 (a) Persons aged sixty-five (65) years or older eligible in accordance
5
1 with title XVI of the social security act, as well as persons eligible for
2 aid to the aged, blind and disabled (AABD) under titles I, X and XIV of
3 the social security act;
4 (b) Persons aged sixty-five (65) years or older who are in need of the
5 services of a licensed nursing facility, a licensed intermediate care
6 facility for the developmentally disabled, a state mental hospital, or
7 home-based and community-based care, whose income does not exceed three
8 hundred percent (300%) of the social security income (SSI) standard and
9 who meet the assets standards and other eligibility standards in accor-
10 dance with federal and state law and department rule;
11 (c) Persons aged sixty-five (65) years or older who are eligible for ser-
12 vices under both titles XVIII and XIX of the social security act who have
13 enrolled in the medicare program; and
14 (d) Persons under age sixty-five (65) years who are eligible for services
15 under both titles XVIII and XIX of the social security act and who elect
16 to enroll in this state plan.
17 56-255. MEDICAL ASSISTANCE PROGRAM -- SERVICES TO BE PROVIDED. (1) The
18 department may make payments for the following services furnished by providers
19 to participants who are determined to be eligible on the dates on which the
20 services were provided. Any service under this section shall be reimbursed
21 only when medically necessary and in accordance with federal law and regula-
22 tion, Idaho law and department rule. Notwithstanding any other provision of
23 this chapter, medical assistance includes the following benefits specific to
24 the eligibility categories established in section 56-254(1), (2) and (3),
25 Idaho Code, as well as a list of benefits to which all Idaho medicaid partici-
26 pants are entitled, defined in subsection (5) of this section.
27 (2) Specific health benefits and limitations for low-income children and
28 working-age adults include:
29 (a) All services described in subsection (5) of this section;
30 (b) Early and periodic screening, diagnosis and treatment services for
31 individuals under age twenty-one (21) years, and treatment of conditions
32 found; and
33 (c) Cost-sharing required of participants. Participants in the low-income
34 children and working-age adult group are subject to the following premium
35 payments, as stated in department rules:
36 (i) Participants with family incomes equal to or less than one hun-
37 dred thirty-three percent (133%) of the federal poverty guideline are
38 not required to pay premiums; and
39 (ii) Participants with family incomes above one hundred thirty-three
40 percent (133%) of the federal poverty guideline will be required to
41 pay premiums in accordance with department rule.
42 (3) Specific health benefits for persons with disabilities or special
43 health needs include:
44 (a) All services described in subsection (5) of this section;
45 (b) Early and periodic screening, diagnosis and treatment services for
46 individuals under age twenty-one (21) years, and treatment of conditions
47 found;
48 (c) Case management services as defined in accordance with subsection
49 1905(a)(19) or section 1915(g) of the social security act; and
50 (d) Mental health services, including:
51 (i) Inpatient psychiatric facility services whether in a hospital,
52 or for persons under age twenty-two (22) years in a freestanding psy-
53 chiatric facility, as permitted by federal law, in excess of those
54 limits in department rules on inpatient psychiatric facility services
6
1 provided under subsection (5) of this section;
2 (ii) Outpatient mental health services in excess of those limits in
3 department rules on outpatient mental health services provided under
4 subsection (5) of this section; and
5 (iii) Psychosocial rehabilitation for reduction of mental disability
6 for children under the age of eighteen (18) years with a serious emo-
7 tional disturbance (SED) and for severely and persistently mentally
8 ill adults, aged eighteen (18) years or older, with severe and per-
9 sistent mental illness;
10 (e) Long-term care services, including:
11 (i) Nursing facility services, other than services in an institu-
12 tion for mental diseases, subject to participant cost-sharing;
13 (ii) Home-based and community-based services, subject to federal
14 approval, provided to individuals who require nursing facility level
15 of care who, without home-based and community-based services, would
16 require institutionalization. These services will include community
17 supports, including an option for self-determination, which will
18 enable individuals to have greater freedom to manage their own care;
19 and
20 (iii) Personal care services in a participant's home, prescribed in
21 accordance with a plan of treatment and provided by a qualified per-
22 son under supervision of a registered nurse;
23 (f) Services for persons with developmental disabilities, including:
24 (i) Intermediate care facility services, other than such services
25 in an institution for mental diseases, for persons determined in
26 accordance with section 1902(a)(31) of the social security act to be
27 in need of such care, including such services in a public institu-
28 tion, or distinct part thereof, for the mentally retarded or persons
29 with related conditions;
30 (ii) Home-based and community-based services, subject to federal
31 approval, provided to individuals who require an intermediate care
32 facility for the mentally retarded (ICF/MR) level of care who, with-
33 out home-based and community-based services, would require institu-
34 tionalization. These services will include community supports,
35 including an option for self-determination, which will enable indi-
36 viduals to have greater freedom to manage their own care; and
37 (iii) Developmental services. The department shall pay for rehabili-
38 tative services, including medical or remedial services provided by a
39 facility that has entered into a provider agreement with the depart-
40 ment and is certified as a developmental disabilities agency by the
41 department;
42 (g) Home health services, including:
43 (i) Intermittent or part-time nursing services provided by a home
44 health agency or by a registered nurse when no home health agency
45 exists in the area;
46 (ii) Home health aide services provided by a home health agency; and
47 (iii) Physical therapy, occupational therapy or speech pathology and
48 audiology services provided by a home health agency or medical reha-
49 bilitation facility;
50 (h) Hospice care in accordance with section 1905(o) of the social secu-
51 rity act;
52 (i) Specialized medical equipment and supplies; and
53 (j) Medicare cost-sharing, including:
54 (i) Medicare cost-sharing for qualified medicare beneficiaries
55 described in section 1905(p) of the social security act;
7
1 (ii) Medicare part A premiums for qualified disabled and working
2 individuals described in section 1902(a)(10)(E)(ii) of the social
3 security act;
4 (iii) Medicare part B premiums for specified low-income medicare ben-
5 eficiaries described in section 1902(a)(10)(E)(iii) of the social
6 security act; and
7 (iv) Medicare part B premiums for qualifying individuals described
8 in section 1902(a)(10)(E)(iv) and subject to section 1933 of the
9 social security act.
10 (4) Specific health benefits for elders include:
11 (a) All services described in subsection (5) of this section, other than
12 if provided under the federal medicare program;
13 (b) All services described in subsection (3) of this section, other than
14 if provided under the federal medicare program; and
15 (c) Other services that supplement medicare coverage.
16 (5) Benefits for all medicaid participants, unless specifically limited
17 in subsection (2), (3) or (4) of this section include the following:
18 (a) Health care coverage including, but not limited to, basic inpatient
19 and outpatient medical services, and including:
20 (i) Physicians' services, whether furnished in the office, the
21 patient's home, a hospital, a nursing facility or elsewhere;
22 (ii) Services provided by a physician or other licensed practitio-
23 ner to prevent disease, disability and other health conditions or
24 their progressions, to prolong life, or to promote physical or mental
25 health; and
26 (iii) Hospital care, including:
27 1. Inpatient hospital services other than those services pro-
28 vided in an institution for mental diseases;
29 2. Outpatient hospital services; and
30 3. Emergency hospital services;
31 (iv) Laboratory and x-ray services;
32 (v) Prescribed drugs;
33 (vi) Family planning services and supplies for individuals of
34 child-bearing age;
35 (vii) Certified pediatric or family nurse practitioners' services;
36 (viii) Emergency medical transportation;
37 (ix) Mental health services, including:
38 1. Outpatient mental health services that are appropriate,
39 within limits stated in department rules; and
40 2. Inpatient psychiatric facility services within limits stated
41 in department rules;
42 (x) Medical supplies, equipment, and appliances suitable for use
43 in the home; and
44 (xi) Physical therapy and related services;
45 (b) Primary care case management;
46 (c) Dental services, and medical and surgical services furnished by a
47 dentist in accordance with section 1905(a)(5)(B) of the social security
48 act;
49 (d) Medical care and any other type of remedial care recognized under
50 Idaho law, furnished by licensed practitioners within the scope of their
51 practice as defined by Idaho law, including:
52 (i) Podiatrists' services;
53 (ii) Optometrists' services;
54 (iii) Chiropractors' services; and
55 (iv) Other practitioners' services, in accordance with department
8
1 rules;
2 (e) Services for individuals with speech, hearing and language disorders,
3 provided by or under the supervision of a speech pathologist or audiolo-
4 gist;
5 (f) Eyeglasses prescribed by a physician skilled in diseases of the eye
6 or by an optometrist;
7 (g) Services provided by essential providers, including:
8 (i) Rural health clinic services and other ambulatory services fur-
9 nished by a rural health clinic in accordance with section
10 1905(l)(1) of the social security act;
11 (ii) Federally qualified health center (FQHC) services and other
12 ambulatory services that are covered under the plan and furnished by
13 an FQHC in accordance with section 1905(l)(2) of the social security
14 act;
15 (iii) Indian health services; and
16 (iv) District health departments;
17 (h) Any other medical care and any other type of remedial care recognized
18 under state law, specified by the secretary of the federal department of
19 health and human services;
20 (i) Nonemergency medical transportation; and
21 (j) Physician, hospital or other services deemed experimental are
22 excluded from coverage. The director may allow coverage of procedures or
23 services deemed investigational if the procedures or services are as
24 cost-effective as traditional, standard treatments.
STATEMENT OF PURPOSE
RS 16219
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 IMPACT
There is no impact to the general fund.
Contact
Name: Representative Sharon Block
Senator Richard L. "Dick" Compton
Phone: (208) 332-1000
STATEMENT OF PURPOSE/FISCAL NOTE H 776