GOP: House Republican Medicaid Oversight Plan

April 7, 2016

Consumer Protection  |  Outcome Achievement  |  Program Integrity

Medicaid Modernization has full-time, comprehensive oversight in place, and this bill adds additional consumer protections and accountability measures to ensure patients are receiving the high quality health care that the state provides.

The House GOP Plan:

  • Requires an unprecedented amount of data and reporting from CMS, DHS, and MCOs to be filed with the legislature.
  • Provides a level of transparency for the public that the Medicaid program has never seen.
  • Focuses on patient health outcomes, contract management, and financial sustainability.
  • Requires specific reporting on the most vulnerable Iowans (special needs, behavioral, and elderly).
  • Protects against abuse, fraud, and waste within the Medicaid program.

This bill ensures that consumers are protected, patient health and financial outcomes are monitored and transparent, and the integrity of our health care system remains.

The House GOP Plan builds upon the oversight of last session, with the creation of the Health Policy Oversight Committee, without fragmenting the system with further bureaucracy.  This committee is equipped with the experience and knowledge in health care policy to provide expertise about the Medicaid program.

Consumer Protection > Are safeguards in place to protect consumers?

Medicaid patients must be able to have access to protections and advocates when needed to ensure that they are receiving the high-quality healthcare that they expect.

The legislature will receive reports on:

  • Adequate amount of doctors to provide continuity of care.
  • Grievances and appeals and how timely appeals are resolved.
  • Call center performance for both DHS and MCOs (timeliness and quality).
  • Timeliness and process of prior authorization for services approval, denial, and modifications.
  • Detailed reporting on the most vulnerable Medicaid patients (special needs, behavioral, and elderly).

Health Outcome Achievement > Are health care outcomes improving?

A focus on wellness initiatives, preventative care, and care coordination will improve Medicaid patient outcomes in a way that the old system never did.

The legislature will receive reports on:

  • Annual health care effectiveness data.
  • Quality measures, but not limited to: behavioral health, children, prenatal and birth, chronic conditions, and adult preventative care.
  • Utilization of hospital admissions and potential preventative admissions, readmissions, outpatient visits, ER visits, and preventative ER visits.
  • Medical Loss Ratio (amount spent on medical care versus administrative), program cost savings, and per member payments.

Program Integrity > Are measures in place to prevent fraud, waste and abuse?

Federal, state, and contractual safeguards are in place for Medicaid Modernization to prevent, detect, and eliminate fraud, waste, and abuse.

The legislature will receive reports on:

  • Level of fraud, waste, and abuse.
  • MCO adherence to program integrity plan.
  • MCO adherence to insurance licensure, certifications, accreditation, and financial accounting.

House GOP Medicaid Oversight


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