Iowa Admin. Code r. 441-73.2

Current through Regsiter Vol. 46, No. 26, June 12, 2024

Rule 441-73.2 - Contracts with a managed care plan (MCP)

(1) The department may enter into a contract with an MCP licensed under the provisions of insurance division rules set forth in 191-Chapter 40 for the scope of services as described in rule 441-73.6 (249A).

(2) The department shall determine that the MCP meets the following requirements:

a. The MCP shall make available the services it provides to enrollees as established in the contract.

b. The MCP shall provide satisfaction to the department against the risk of insolvency and ensure that neither Medicaid members nor the state shall be responsible for the MCP's debts if the MCP becomes insolvent. The MCP shall comply with insurance division provisions set forth in rule 191-40.12 (514B) regarding net worth and rule 191-40.14 (514B) containing reporting requirements.

c. The MCP shall attain and maintain accreditation by the National Committee for Quality Assurance (NCQA) or URAC (formerly known as the Utilization Review Accreditation Commission).

(3) If not already accredited, the MCP must demonstrate it has initiated the accreditation process as of the contract effective date and must achieve accreditation at the earliest date allowed by NCQA or URAC. Prior to the contract effective date, the MCP must be licensed and in good standing in the state of Iowa as a health maintenance organization in accordance with insurance division rules set forth in 191-Chapter 40.

(4) The contract shall meet the following minimum requirements. The contract shall:

a. Be in writing.

b. Specify the duration of the contract period.

c. List the services that must be covered.

d. Describe service access and provide access information.

e. List conditions for nonrenewal, termination, suspension, and modification.

f. Specify the method and rate of reimbursement.

g. Provide for disclosure of ownership and subcontracted relationships.

h. Specify that all subcontracts shall be in writing, shall comply with the provisions of the contract between the department and the MCP, and shall include any general requirements of the contract that are appropriate to the service or activity covered by the subcontract.

i. Specify appeal and grievance rights.

j. Specify all operational and service delivery expectations.

k. Specify reporting requirements.

l. Specify requirements for utilization management and quality improvement.

m. Specify requirements for program integrity.

n. Specify termination requirements and assessment of penalties.

o. Require the MCP and the fee-for-service Medicaid program to utilize a uniform prior authorization process.

The process will include forms, information requirements, and time frames.

Iowa Admin. Code r. 441-73.2

Adopted by IAB January 6, 2016/Volume XXXVIII, Number 14, effective 1/1/2016

Amended by IAB January 1, 2020/Volume XLII, Number 14, effective 6/29/2020

Amended by IAB April 5, 2023/Volume XLV, Number 20, effective 6/1/2023