249J.24A - NONPARTICIPATING PROVIDER REIMBURSEMENT FOR COVERED SERVICES -- REIMBURSEMENT FUND. - Iowa Statutes

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