249J.6 - EXPANSION POPULATION BENEFITS.
249J.6 EXPANSION POPULATION BENEFITS.
1. Beginning July 1, 2005, the expansion population shall be
eligible for all of the following expansion population services:
a. Inpatient hospital procedures described in the diagnostic
related group codes or other applicable inpatient hospital
reimbursement methods designated by the department.
b. Outpatient hospital services described in the ambulatory
patient groupings or non-inpatient services designated by the
department.
c. Physician and advanced registered nurse practitioner
services described in the current procedural terminology codes
specified by the department.
d. Dental services described in the dental codes specified by
the department.
e. Limited pharmacy benefits provided by an expansion
population provider network hospital pharmacy and solely related to
an appropriately billed expansion population service.
f. Transportation to and from an expansion population
provider network provider only if the provider offers such
transportation services or the transportation is provided by a
volunteer.
2. a. Each expansion population member who enrolls or
reenrolls in the expansion population on or after January 31, 2007,
shall participate, in conjunction with receiving a single
comprehensive medical examination and completing a personal health
improvement plan, in a health risk assessment coordinated by a health
consortium representing providers, consumers, and medical education
institutions. The criteria for the health risk assessment, the
comprehensive medical examination, and the personal health
improvement plan shall be developed and applied in a manner that
takes into consideration cultural variations that may exist within
the expansion population. The health risk assessment shall utilize a
gender-specific approach. In developing the queries unique to women,
a clinical advisory team shall be utilized that includes women's
health professionals including but not limited to those with
specialties in obstetrics and gynecology, endocrinology, mental
health, behavioral health, oncology, cardiology, and rheumatology.
b. The health risk assessment shall be a web-based electronic
system capable of capturing and integrating basic data to provide an
individualized personal health improvement plan for each expansion
population member. The health risk assessment shall provide a
preliminary diagnosis of current and prospective health conditions
and recommendations for improving health conditions with an
individualized wellness program. The health risk assessment shall be
made available to the expansion population member and the provider
specified in paragraph "c" who performs the comprehensive medical
examination and provides the individualized personal health
improvement plan.
c. The single comprehensive medical examination and personal
health improvement plan may be provided by an expansion population
provider network physician, advanced registered nurse practitioner,
or physician assistant or any other physician, advanced registered
nurse practitioner, or physician assistant, available to any full
benefit recipient including but not limited to such providers
available through a free clinic or rural health clinic under a
contract with the department to provide these services, through
federally qualified health centers that employ a physician, or
through any other nonprofit agency qualified or deemed to be
qualified by the department to perform these services.
d. Following completion of an initial health risk assessment,
comprehensive medical examination, and personal health improvement
plan, an expansion population member may complete subsequent
assessments, examinations, or plans with the recommendation and
approval of a provider specified in paragraph "c".
e. Refusal of an expansion population member to participate
in a health risk assessment, comprehensive medical examination, or
personal health improvement plan shall not be a basis for
ineligibility for or disenrollment from the expansion population.
3. Beginning no later than July 1, 2006, expansion population
members shall be provided all of the following:
a. Access to a pharmacy assistance clearinghouse program to
match expansion population members with free or discounted
prescription drug programs provided by the pharmaceutical industry.
b. Access to a medical information hotline, accessible
twenty-four hours per day, seven days per week, to assist expansion
population members in making appropriate choices about the use of
emergency room and other health care services.
4. Membership in the expansion population shall not preclude an
expansion population member from eligibility for services not covered
under the expansion population for which the expansion population
member is otherwise entitled under state or federal law.
5. Members of the expansion population shall not be considered
full benefit dually eligible Medicare Part D beneficiaries for the
purposes of calculating the state's payment under Medicare Part D,
until such time as the expansion population is eligible for all of
the same benefits as full benefit recipients under the medical
assistance program. Section History: Recent Form
2005 Acts, ch 167, §6, 66; 2006 Acts, ch 1184, §113, 114, 128
Referred to in § 249J.9, 249J.23 Footnotes
2006 amendments to subsection 2 are retroactively applicable to
March 1, 2006; 2006 Acts, ch 1184, §128