249J.24A - NONPARTICIPATING PROVIDER REIMBURSEMENT FOR COVERED SERVICES -- REIMBURSEMENT FUND.
249J.24A NONPARTICIPATING PROVIDER REIMBURSEMENT FOR
COVERED SERVICES -- REIMBURSEMENT FUND.
1. A nonparticipating provider may be reimbursed for covered
expansion population services provided to an expansion population
member by a nonparticipating provider if the nonparticipating
provider contacts the appropriate participating provider prior to
providing covered services to verify consensus regarding one of the
following courses of action:
a. If the nonparticipating provider and the participating
provider agree that the medical status of the expansion population
member indicates it is medically possible to postpone provision of
services, the nonparticipating provider shall direct the expansion
population member to the appropriate participating provider for
services.
b. If the nonparticipating provider and the participating
provider agree that the medical status of the expansion population
member indicates it is not medically possible to postpone provision
of services, the nonparticipating provider shall provide medically
necessary services.
c. If the nonparticipating provider and the participating
provider agree that transfer of the expansion population member is
not possible due to lack of available inpatient capacity, the
nonparticipating provider shall provide medically necessary services.
d. If the medical status of the expansion population member
indicates a medical emergency and the nonparticipating provider is
not able to contact the appropriate participating provider prior to
providing medically necessary services, the nonparticipating provider
shall document the medical emergency and inform the appropriate
participating provider immediately after the member has been
stabilized of any covered services provided.
2. a. If the nonparticipating provider meets the requirements
specified in subsection 1, the nonparticipating provider shall be
reimbursed for covered expansion population services provided to the
expansion population member through the nonparticipating provider
reimbursement fund in accordance with rules adopted by the department
of human services. However, any funds received from participating
providers, appropriated to participating providers, or deposited in
the IowaCare account pursuant to section 249J.24, shall not be
transferred or appropriated to the nonparticipating provider
reimbursement fund or otherwise used to reimburse nonparticipating
providers.
b. Reimbursement of nonparticipating providers under this
section shall be based on the reimbursement rates and policies
applicable to the nonparticipating provider under the full benefit
medical assistance program, subject to the availability of funds in
the nonparticipating provider reimbursement fund and subject to the
appropriation of moneys in the fund to the department.
c. The department shall reimburse the nonparticipating
provider only if the recipient of the services is an expansion
population member with active eligibility status at the time the
services are provided.
3. a. A nonparticipating provider reimbursement fund is
created in the state treasury under the authority of the department.
Moneys designated for deposit in the fund that are received from
sources including but not limited to appropriations from the general
fund of the state, grants, and contributions, shall be deposited in
the fund. However, any funds received from participating providers,
appropriated to participating providers, or deposited in the IowaCare
account pursuant to section 249J.24 shall not be transferred or
appropriated to the nonparticipating provider reimbursement fund or
otherwise used to reimburse nonparticipating providers.
b. Moneys in the fund shall be separate from the general fund
of the state and shall not be considered part of the general fund of
the state. The moneys deposited in the fund are not subject to
section 8.33 and shall not be transferred, used, obligated,
appropriated, or otherwise encumbered, except to provide for the
purposes specified in this section. Notwithstanding section 12C.7,
subsection 2, interest or earnings on moneys deposited in the fund
shall be credited to the fund.
c. Moneys deposited in the fund shall be used only to
reimburse nonparticipating providers who provide covered services to
expansion population members if no other third party is liable for
reimbursement and as specified in subsection 1.
d. The department shall attempt to maximize receipt of
federal matching funds under the medical assistance program for
covered services provided under this section if such attempt does not
directly or indirectly limit the federal funds available to
participating providers.
4. For the purposes of this section, "nonparticipating
provider" means a hospital licensed pursuant to chapter 135B that
is not a member of the expansion population provider network as
specified in section 249J.7. Section History: Recent Form
2009 Acts, ch 182, §127 Footnotes
Beginning July 1, 2010, medical assistance program waivers
relating to continuation of IowaCare program to include provisions
relating to reimbursement of nonparticipating providers; 2009 Acts,
ch 182, §128