HF 2635

House
File
2635
-
Enrolled
House
File
2635
AN
ACT
RELATING
TO
HEALTH
CARRIERS
STANDARDS
OF
CONDUCT;
UTILIZATION
REVIEW
ORGANIZATIONS,
ARTIFICIAL
INTELLIGENCE,
AUDITS,
AND
PRIOR
AUTHORIZATIONS;
CERTIFICATE
OF
NEED
PROCESSES;
AND
INCLUDING
APPLICABILITY
PROVISIONS.
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
DIVISION
I
HEALTH
INSURANCE
TRADE
PRACTICES
Section
1.
Section
514F.8,
subsection
1,
Code
2026,
is
amended
by
adding
the
following
new
paragraph:
NEW
PARAGRAPH
.
0b.
“Downgrade”
means
a
decision
by
a
utilization
review
organization
to
change
an
expedited
or
urgent
request
for
prior
authorization
to
a
standard
determination,
or
otherwise
modify
a
health
care
service
that
is
the
subject
of
a
request
for
prior
authorization
to
a
lower-level
health
care
service.
House
File
2635,
p.
2
Sec.
2.
Section
514F.8,
Code
2026,
is
amended
by
adding
the
following
new
subsection:
NEW
SUBSECTION
.
2A.
A
utilization
review
organization
may
use
an
artificial
intelligence-based
algorithm
or
system
to
provide
an
initial
review
of
a
request
for
prior
authorization,
except
that,
for
a
prior
authorization
request
for
a
health
care
service
based
on
medical
necessity,
a
utilization
review
organization
shall
not
use
an
artificial
intelligence-based
algorithm
or
system
as
the
sole
basis
for
the
utilization
review
organization’s
decision
to
deny,
delay,
or
downgrade
the
prior
authorization
request.
Sec.
3.
NEW
SECTION
.
514F.8C
Utilization
review
organizations
——
audits.
1.
As
used
in
this
section,
unless
the
context
otherwise
requires:
a.
“Audit”
means
a
review,
investigation,
or
request
for
additional
documentation
by
a
utilization
review
organization
before
or
after
issuing
payment
on
a
claim
to
a
health
care
provider.
b.
“Commissioner”
means
the
commissioner
of
insurance.
c.
“Health
care
provider”
means
the
same
as
defined
in
section
514F.8.
d.
“Health
carrier”
means
the
same
as
defined
in
section
514F.8.
e.
“Utilization
review
organization”
means
the
same
as
defined
in
section
514F.8.
2.
a.
A
utilization
review
organization
that
conducts
an
audit
shall
notify
the
health
care
provider
that
submitted
the
claim
of
the
initiation
of
the
audit
no
later
than
fifteen
calendar
days
after
the
date
the
utilization
review
organization
selects
the
claim
for
audit.
b.
A
utilization
review
organization
shall
complete
an
audit
of
a
claim
and
issue
a
determination
on
the
claim
to
the
health
care
provider
that
submitted
the
claim
no
later
than
forty-five
calendar
days
after
the
date
that
the
utilization
review
organization
receives
all
requested
documentation
regarding
the
claim
from
the
health
care
provider.
c.
A
health
care
provider
that
submitted
a
claim
that
is
the
subject
of
an
audit
by
a
utilization
review
organization
House
File
2635,
p.
3
that
receives
an
adverse
determination
regarding
the
claim
may
appeal
the
adverse
determination
no
later
than
thirty
calendar
days
after
the
date
the
health
care
provider
receives
the
audit
determination.
d.
A
utilization
review
organization
shall
consider
an
appeal
under
paragraph
“c”
and
issue
a
final
determination
on
the
claim
that
is
the
subject
of
the
appeal
no
later
than
thirty
calendar
days
after
the
date
the
utilization
review
organization
receives
notice
of
the
appeal.
e.
If,
after
a
hearing,
the
commissioner
finds
that
a
utilization
review
organization
has
violated
this
subsection,
the
claim
shall
be
approved
by
the
utilization
review
organization
and
promptly
paid,
including
interest
at
the
rate
of
ten
percent
per
annum.
3.
A
health
care
provider
may
opt-in
to
receive
electronic
delivery
of
notices
and
audit
determinations
from
a
utilization
review
organization.
A
utilization
review
organization
may
determine
the
method
by
which
a
health
care
provider
may
opt-in.
4.
a.
This
section
applies
to
the
following
classes
of
third-party
payment
provider
contracts,
policies,
or
plans
delivered,
issued
for
delivery,
continued,
or
renewed
in
this
state
on
or
after
January
1,
2027:
(1)
Individual
or
group
accident
and
sickness
insurance
providing
coverage
on
an
expense-incurred
basis.
(2)
An
individual
or
group
hospital
or
medical
service
contract
issued
pursuant
to
chapter
509,
514,
or
514A.
(3)
An
individual
or
group
health
maintenance
organization
contract
regulated
under
chapter
514B.
(4)
A
plan
established
for
public
employees
pursuant
to
chapter
509A.
b.
This
section
shall
not
apply
to
accident-only,
specified
disease,
short-term
hospital
or
medical,
hospital
confinement
indemnity,
credit,
dental,
vision,
Medicare
supplement,
long-term
care,
basic
hospital
and
medical-surgical
expense
coverage
as
defined
by
the
commissioner
of
insurance,
disability
income
insurance
coverage,
coverage
issued
as
a
supplement
to
liability
insurance,
workers’
compensation
or
similar
insurance,
or
automobile
medical
payment
insurance.
House
File
2635,
p.
4
5.
The
commissioner
may
adopt
rules
pursuant
to
chapter
17A
to
administer
and
enforce
this
section.
6.
a.
This
section
shall
apply
to
an
audit
initiated
on
or
after
January
1,
2027.
b.
This
section
shall
not
apply
to
a
claim
that
is
under
active
fraud
investigation
by
a
state
or
federal
authority.
Sec.
4.
NEW
SECTION
.
514F.8D
Health
carriers
——
standards
of
conduct.
1.
As
used
in
this
section,
unless
the
context
otherwise
requires:
a.
“Health
care
provider”
means
the
same
as
defined
in
section
514J.102.
b.
“Health
carrier”
means
the
same
as
defined
in
section
514F.8.
2.
A
health
carrier
shall
not
impose
on
a
health
care
provider,
directly
or
indirectly,
any
financial
penalty,
reimbursement
reduction,
or
administrative
fee,
or
terminate
a
health
care
provider’s
participation
in
the
health
carrier’s
network,
based
on
the
health
care
provider’s
referral
to,
or
affiliation
with,
an
out-of-network
health
care
provider.
3.
A
health
carrier
shall
not
interfere
with,
or
participate
in
any
capacity
in,
a
health
care
provider’s
decisions
regarding
staffing
and
referrals,
except
as
otherwise
provided
by
law.
4.
A
health
carrier
shall
not
offer,
attempt
to
enforce,
or
enforce
an
agreement,
or
an
amendment
to
an
agreement,
with
a
health
care
provider
without
providing
an
opportunity
for
negotiation.
5.
The
commissioner
may
adopt
rules
pursuant
to
chapter
17A
to
administer
and
enforce
this
section.
DIVISION
II
PRIOR
AUTHORIZATIONS
Sec.
5.
Section
514F.8,
Code
2026,
is
amended
by
adding
the
following
new
subsection:
NEW
SUBSECTION
.
6A.
a.
A
health
care
provider
shall
submit
all
requests
for
prior
authorization
to
a
health
carrier
electronically
using
a
standards-based
application
programming
interface,
or
another
form
of
electronic
submission,
supported
by
the
health
carrier
that
is
compliant
with
federal
House
File
2635,
p.
5
interoperability
regulations.
b.
This
subsection
applies
to
a
request
for
prior
authorization
made
on
or
after
July
1,
2027.
Sec.
6.
NEW
SECTION
.
514F.8A
Prior
authorizations
——
peer
review.
1.
For
purposes
of
this
section,
unless
the
context
otherwise
requires:
a.
“Clinical
peer”
means
a
health
care
professional
that
meets
all
of
the
following
requirements:
(1)
The
health
care
professional
practices
in
the
same
or
similar
specialty
as
the
health
care
provider
that
requested
a
prior
authorization.
(2)
The
health
care
professional
has
experience
managing
the
specific
medical
condition
or
administering
the
health
care
service
that
is
the
subject
of
the
prior
authorization
request.
(3)
The
health
care
professional
is
employed
by
or
contracted
with
the
utilization
review
organization
or
health
carrier
to
which
a
health
care
provider
submitted
a
request
for
prior
authorization.
b.
“Covered
person”
means
the
same
as
defined
in
section
514F.8.
c.
“Downgrade”
means
a
decision
by
a
utilization
review
organization
to
change
an
expedited
or
urgent
request
for
prior
authorization
to
a
standard
determination,
or
otherwise
modify
a
health
care
service
that
is
the
subject
of
a
request
for
prior
authorization
to
a
lower-level
health
care
service.
d.
“Health
care
professional”
means
the
same
as
defined
in
section
514J.102.
e.
“Health
care
provider”
means
the
same
as
defined
in
section
514F.8.
f.
“Health
care
services”
means
the
same
as
defined
in
section
514F.8.
g.
“Health
carrier”
means
the
same
as
defined
in
section
514F.8.
h.
“Physician”
means
a
doctor
of
medicine
and
surgery,
or
a
doctor
of
osteopathic
medicine
and
surgery,
licensed
under
chapter
148.
i.
“Prior
authorization”
means
the
same
as
defined
in
section
514F.8.
House
File
2635,
p.
6
j.
“Qualified
reviewer”
means
a
physician
that
meets
all
of
the
following
requirements:
(1)
The
physician
practices
in
the
same
or
a
similar
specialty
as
the
health
care
provider
that
requested
a
prior
authorization.
(2)
The
physician
has
the
training
and
expertise
to
treat
the
specific
medical
condition
that
is
the
subject
of
a
request
for
prior
authorization,
including
sufficient
knowledge
to
determine
whether
the
health
care
service
that
is
the
subject
of
the
request
is
medically
necessary
or
clinically
appropriate.
(3)
The
physician
is
employed
by
or
contracted
with
the
utilization
review
organization
to
which
a
health
care
provider
submitted
a
request
for
prior
authorization.
k.
“Utilization
review
organization”
means
the
same
as
defined
in
section
514F.8.
2.
A
utilization
review
organization
shall
not
deny
or
downgrade
a
request
for
prior
authorization
unless
all
of
the
following
requirements
are
met:
a.
The
decision
to
deny
or
downgrade
the
request
is
made
by
either
of
the
following:
(1)
A
qualified
reviewer,
if
the
health
care
provider
requesting
prior
authorization
is
a
physician.
(2)
A
clinical
peer,
if
the
health
care
provider
requesting
prior
authorization
is
not
a
physician.
b.
The
utilization
review
organization
provides
the
health
care
provider
that
requested
the
prior
authorization
all
of
the
following:
(1)
A
written
statement
that
cites
the
specific
reasons
for
the
denial
or
downgrade,
including
any
coverage
criteria
or
limits,
or
clinical
criteria,
that
the
utilization
review
organization
considered
or
that
was
the
basis
for
the
denial
or
downgrade.
The
written
statement
must
be
signed
by
either
of
the
following:
(a)
The
qualified
reviewer
that
made
the
denial
or
downgrade
determination
if
the
health
care
provider
that
requested
prior
authorization
is
a
physician.
(b)
The
clinical
peer
that
made
the
denial
or
downgrade
determination
if
the
health
care
provider
that
requested
prior
House
File
2635,
p.
7
authorization
is
not
a
physician.
(2)
A
written
explanation
of
the
utilization
review
organization’s
appeals
process.
The
utilization
review
organization
shall
also
provide
the
written
explanation
to
the
covered
person
for
whom
prior
authorization
was
requested.
(3)
A
written
attestation
that
is
either
of
the
following:
(a)
If
the
health
care
provider
that
requested
prior
authorization
is
a
physician,
a
written
attestation
that
the
qualified
reviewer
who
made
the
denial
or
downgrade
determination
practices
in
the
same
or
a
similar
specialty
as
the
health
care
provider,
and
has
the
requisite
training
and
expertise
to
treat
the
medical
condition
that
is
the
subject
of
the
request
for
prior
authorization,
including
sufficient
knowledge
to
determine
whether
the
health
care
service
is
medically
necessary
or
clinically
appropriate.
The
attestation
shall
include
the
qualified
reviewer’s
board
certifications,
specialty
expertise,
and
educational
background,
excluding
any
personal
identifiable
information.
(b)
If
the
health
care
provider
that
requested
prior
authorization
is
not
a
physician,
a
written
attestation
that
the
clinical
peer
who
made
the
denial
or
downgrade
determination
practices
in
the
same
or
a
similar
specialty
as
the
health
care
provider,
and
the
clinical
peer
has
experience
managing
the
specific
medical
condition
or
administering
the
health
care
service
that
is
the
subject
of
the
request
for
prior
authorization.
The
attestation
shall
include
the
clinical
peer’s
board
certifications,
specialty
expertise,
and
educational
background,
excluding
any
personal
identifiable
information.
3.
At
the
request
of
the
requesting
health
care
provider,
a
utilization
review
organization
that
denies
a
request
for
prior
authorization
shall,
no
later
than
seven
business
days
after
the
date
that
the
utilization
review
organization
notifies
the
requesting
health
care
provider
of
the
denial,
conduct
a
consultation
either
in
person
or
remotely,
as
follows:
a.
Between
the
health
care
provider
and
a
qualified
reviewer
if
the
health
care
provider
requesting
prior
authorization
is
a
physician.
b.
Between
the
health
care
provider
and
a
clinical
peer
if
House
File
2635,
p.
8
the
health
care
provider
requesting
prior
authorization
is
not
a
physician.
4.
a.
If
a
utilization
review
organization’s
decision
to
deny
or
downgrade
a
request
for
prior
authorization
is
appealed
by
the
requesting
health
care
provider
or
covered
person,
the
appeal
shall
be
conducted
by
either
of
the
following:
(1)
A
qualified
reviewer
if
the
health
care
provider
requesting
prior
authorization
is
a
physician.
(2)
A
clinical
peer
if
the
health
care
provider
requesting
prior
authorization
is
not
a
physician.
b.
A
qualified
reviewer
or
clinical
peer
involved
in
the
initial
denial
or
downgrade
determination
of
a
request
for
prior
authorization
that
is
the
subject
of
an
appeal
shall
not
conduct
the
appeal.
c.
When
conducting
an
appeal
of
a
request
for
prior
authorization,
the
qualified
reviewer
or
clinical
peer
shall
consider
the
known
clinical
aspects
of
the
health
care
services
under
review,
including
but
not
limited
to
medical
records
relevant
to
the
covered
person’s
medical
condition
who
is
the
subject
of
the
health
care
services
for
which
prior
authorization
is
requested,
and
any
relevant
medical
literature
submitted
by
the
health
care
provider
as
part
of
the
appeal.
5.
This
section
applies
to
requests
for
prior
authorization
made
on
or
after
January
1,
2027.
6.
a.
This
section
applies
to
the
following
classes
of
third-party
payment
provider
contracts,
policies,
or
plans
delivered,
issued
for
delivery,
continued,
or
renewed
in
this
state
on
or
after
January
1,
2027:
(1)
Individual
or
group
accident
and
sickness
insurance
providing
coverage
on
an
expense-incurred
basis.
(2)
An
individual
or
group
hospital
or
medical
service
contract
issued
pursuant
to
chapter
509,
514,
or
514A.
(3)
An
individual
or
group
health
maintenance
organization
contract
regulated
under
chapter
514B.
(4)
A
plan
established
for
public
employees
pursuant
to
chapter
509A.
b.
This
section
shall
not
apply
to
accident-only,
specified
disease,
short-term
hospital
or
medical,
hospital
confinement
indemnity,
credit,
dental,
vision,
Medicare
supplement,
House
File
2635,
p.
9
long-term
care,
basic
hospital
and
medical-surgical
expense
coverage
as
defined
by
the
commissioner
of
insurance,
disability
income
insurance
coverage,
coverage
issued
as
a
supplement
to
liability
insurance,
workers’
compensation
or
similar
insurance,
or
automobile
medical
payment
insurance.
7.
The
commissioner
of
insurance
may
adopt
rules
pursuant
to
chapter
17A
to
administer
this
section.
Sec.
7.
NEW
SECTION
.
514F.8B
Prior
authorizations
——
exemptions.
1.
For
purposes
of
this
section:
a.
“Covered
person”
means
the
same
as
defined
in
section
514F.8.
b.
“Emergency
medical
condition”
means
the
same
as
defined
in
42
C.F.R.
§438.114.
c.
“Health
benefit
plan”
means
the
same
as
defined
in
section
514J.102.
d.
“Health
care
professional”
means
the
same
as
defined
in
section
514J.102.
e.
“Health
carrier”
means
the
same
as
defined
in
section
514F.8.
f.
“Prior
authorization”
means
the
same
as
defined
in
section
514F.8.
g.
“Utilization
review”
means
the
same
as
defined
in
section
514F.4,
subsection
3.
2.
A
health
carrier
shall
not
require
prior
authorization
for,
or
impose
additional
utilization
review
requirements
on,
a
covered
person
for
any
of
the
following:
a.
A
cancer-related
screening
if
the
cancer-related
screening
is
recommended
by
the
covered
person’s
health
care
professional
based
on
the
most
recently
updated
national
comprehensive
cancer
network
clinical
practice
guidelines
in
oncology
which
are
designated
as
category
2A
or
lower.
b.
Diagnosis
and
treatment
of
an
emergency
medical
condition
that
develops
or
becomes
evident
in
a
covered
person
while
the
covered
person
is
receiving
inpatient
care
that
meets
inpatient
care
standards,
if
the
emergency
medical
condition
is
reasonably
determined
by
a
health
care
professional
to
be
a
life-threatening
condition
unless
the
covered
person
receives
immediate
assessment
and
treatment.
House
File
2635,
p.
10
3.
This
section
applies
to
all
of
the
following:
a.
Health
benefit
plans
delivered,
issued
for
delivery,
continued,
or
renewed
in
this
state
on
or
after
January
1,
2027.
b.
Requests
for
prior
authorization
for
a
cancer-related
screening,
if
the
screening
is
recommended
by
the
covered
person’s
health
care
professional
based
on
the
most
recently
updated
national
comprehensive
cancer
network
clinical
practice
guidelines
in
oncology
designated
as
category
2A
or
lower,
and
is
made
on
or
after
January
1,
2027.
c.
Requests
for
prior
authorization
for
the
diagnosis
and
treatment
of
an
emergency
medical
condition
that
develops
or
becomes
evident
in
a
covered
person
while
the
covered
person
is
receiving
inpatient
care
that
meets
inpatient
care
standards,
if
the
emergency
medical
condition
is
reasonably
determined
by
a
health
care
professional
to
be
a
life-threatening
condition
unless
the
covered
person
receives
immediate
assessment
and
treatment
if
the
request
is
made
on
or
after
January
1,
2027.
4.
a.
This
section
applies
to
the
following
classes
of
third-party
payment
provider
contracts,
policies,
or
plans
delivered,
issued
for
delivery,
continued,
or
renewed
in
this
state
on
or
after
January
1,
2027:
(1)
Individual
or
group
accident
and
sickness
insurance
providing
coverage
on
an
expense-incurred
basis.
(2)
An
individual
or
group
hospital
or
medical
service
contract
issued
pursuant
to
chapter
509,
514,
or
514A.
(3)
An
individual
or
group
health
maintenance
organization
contract
regulated
under
chapter
514B.
(4)
A
plan
established
for
public
employees
pursuant
to
chapter
509A.
b.
This
section
shall
not
apply
to
accident-only,
specified
disease,
short-term
hospital
or
medical,
hospital
confinement
indemnity,
credit,
dental,
vision,
Medicare
supplement,
long-term
care,
basic
hospital
and
medical-surgical
expense
coverage
as
defined
by
the
commissioner
of
insurance,
disability
income
insurance
coverage,
coverage
issued
as
a
supplement
to
liability
insurance,
workers’
compensation
or
similar
insurance,
or
automobile
medical
payment
insurance.
5.
The
commissioner
of
insurance
may
adopt
rules
pursuant
to
House
File
2635,
p.
11
chapter
17A
to
administer
this
section.
Sec.
8.
NEW
SECTION
.
514F.8E
Enforcement.
The
remedy
for
noncompliance
with
section
514F.8,
514F.8A,
514F.8B,
514F.8C,
or
514F.8D
shall
be
those
remedies
authorized
by
chapters
505
and
507B
pursuant
to
the
procedures
set
forth
in
sections
507B.6,
507B.7,
and
507B.8.
Upon
a
finding
of
a
pattern
or
practice
of
noncompliance
with
sections
514F.8,
514F.8A,
514F.8B,
514F.8C,
or
514F.8D,
the
commissioner
of
insurance
may
also
suspend
a
utilization
review
organization’s
authority
to
conduct
utilization
review.
DIVISION
III
PRIOR
AUTHORIZATIONS
——
MEDICAL
ASSISTANCE
PROGRAM
Sec.
9.
NEW
SECTION
.
249A.5
Prior
authorization
——
exemptions.
1.
For
purposes
of
this
section,
unless
the
context
otherwise
requires:
a.
“Emergency
medical
condition”
means
the
same
as
defined
in
42
C.F.R.
§438.114.
b.
“Managed
care
organization”
means
an
entity
acting
pursuant
to
a
contract
with
the
department
to
administer
the
medical
assistance
program.
c.
“Prior
authorization”
means
any
process
used
by
the
department
or
a
managed
care
organization
to
determine
if,
before
a
health
care
service
is
furnished
to
a
recipient,
the
service
is
covered
or
medically
necessary.
d.
“Utilization
review”
means
a
set
of
formal
techniques
used
to
monitor
or
evaluate
the
medical
necessity,
appropriateness,
or
efficiency
of
a
health
care
service.
2.
The
department,
or
a
managed
care
organization,
shall
not
require
prior
authorization
for,
or
impose
additional
utilization
review
requirements
on,
a
recipient
for
any
of
the
following:
a.
A
cancer-related
screening
recommended
for
the
recipient
by
the
recipient’s
provider
in
accordance
with
the
most
recently
updated
national
comprehensive
cancer
network
clinical
practice
guidelines
in
oncology
which
are
designated
as
category
2A
or
lower.
b.
The
diagnosis
and
treatment
of
an
emergency
medical
condition
that
develops
or
becomes
evident
in
a
recipient
House
File
2635,
p.
12
while
the
recipient
is
receiving
inpatient
care
that
meets
inpatient
care
standards,
if
the
emergency
medical
condition
is
reasonably
determined
by
a
provider
to
present
a
life-threatening
risk
unless
the
recipient
receives
immediate
assessment
and
treatment.
3.
This
section
applies
to
all
of
the
following:
a.
All
contracts
between
the
department
and
a
managed
care
organization
that
are
delivered,
issued
for
delivery,
continued,
extended,
or
renewed
on
or
after
January
1,
2027.
b.
All
requests
for
prior
authorization
made
on
or
after
January
1,
2027.
4.
The
department
may
adopt
rules
pursuant
to
chapter
17A
to
administer
this
section.
Sec.
10.
NEW
SECTION
.
249A.6
Prior
authorization
——
requests.
1.
A
health
care
provider
submitting
a
request
for
prior
authorization
to
a
managed
care
organization
shall
submit
the
request
electronically
using
a
standards-based
application
programming
interface,
or
another
form
of
electronic
submission,
supported
by
the
managed
care
organization,
that
is
compliant
with
federal
interoperability
regulations.
2.
This
section
applies
to
a
request
for
prior
authorization
made
on
or
after
July
1,
2027.
Sec.
11.
NEW
SECTION
.
514I.13
Prior
authorizations
——
exemptions.
1.
For
purposes
of
this
section:
a.
“Emergency
medical
condition”
means
the
same
as
defined
in
42
C.F.R.
§438.114.
b.
“Health
care
professional”
means
a
person
licensed
or
certified
under
the
laws
of
this
state
to
provide
health
care
services
to
an
eligible
child.
c.
“Managed
care
organization”
means
an
entity
acting
pursuant
to
a
contract
with
the
department
to
administer
the
Hawki
program.
d.
“Prior
authorization”
means
any
process
used
by
the
department
or
a
managed
care
organization
to
determine
if,
before
a
health
care
service
is
furnished
to
an
eligible
child,
the
service
is
covered
or
medically
necessary.
e.
“Utilization
review”
means
a
set
of
formal
techniques
House
File
2635,
p.
13
used
to
monitor
or
evaluate
the
medical
necessity,
appropriateness,
or
efficiency
of
a
health
care
service.
2.
The
department,
or
a
managed
care
organization,
shall
not
require
prior
authorization
for,
or
impose
additional
utilization
review
requirements
on,
an
eligible
child
for
any
of
the
following:
a.
A
cancer-related
screening
recommended
for
the
eligible
child
by
the
eligible
child’s
health
care
professional
in
accordance
with
the
most
recently
updated
national
comprehensive
cancer
network
clinical
practice
guidelines
in
oncology
which
are
designated
as
category
2A
or
lower.
b.
The
diagnosis
and
treatment
of
an
emergency
medical
condition
that
develops
or
becomes
evident
in
an
eligible
child
while
the
eligible
child
is
receiving
inpatient
care
that
meets
inpatient
care
standards,
if
the
emergency
medical
condition
is
reasonably
determined
by
a
health
care
professional
to
present
a
life-threatening
risk
unless
the
eligible
child
receives
immediate
assessment
and
treatment.
3.
This
section
applies
to
all
of
the
following:
a.
All
contracts
between
the
department
and
a
managed
care
organization
that
are
delivered,
issued
for
delivery,
continued,
extended,
or
renewed
on
or
after
January
1,
2027.
b.
All
requests
for
prior
authorizations
made
on
or
after
January
1,
2027.
4.
The
department
may
adopt
rules
pursuant
to
chapter
17A
to
administer
this
section.
DIVISION
IV
CERTIFICATES
OF
NEED
Sec.
12.
Section
135.61,
subsection
1,
paragraphs
d
and
f,
Code
2026,
are
amended
by
striking
the
paragraphs.
Sec.
13.
Section
135.61,
subsection
12,
paragraph
e,
Code
2026,
is
amended
by
striking
the
paragraph.
Sec.
14.
Section
135.61,
subsection
16,
Code
2026,
is
amended
to
read
as
follows:
16.
“New
institutional
health
service”
or
“changed
institutional
health
service”
means
any
of
the
following:
a.
(1)
The
construction,
development
,
or
other
establishment
of
a
new
institutional
health
facility
regardless
of
ownership
if
completing
the
construction,
development,
or
House
File
2635,
p.
14
other
establishment
requires
more
than
the
following
amount:
(a)
Beginning
on
or
after
January
1,
2027,
and
before
December
31,
2031,
four
million
dollars
.
(b)
Beginning
on
or
after
January
1,
2032,
and
before
December
31,
2036,
four
million
five
hundred
thousand
dollars.
(c)
Beginning
on
or
after
January
1,
2037,
five
million
dollars.
(2)
If
the
new
institutional
health
facility
involves
the
use
of
a
leased
building,
the
market
value
of
the
leased
building
shall
be
used
when
calculating
the
value
of
completing
construction,
development,
or
other
establishment
under
subparagraph
(1).
b.
Relocation
of
an
institutional
health
facility.
c.
Any
A
capital
expenditure,
lease,
or
donation
by
or
on
behalf
of
an
institutional
health
facility
in
excess
of
one
million
five
hundred
thousand
dollars
the
following
amount
within
a
consecutive
twelve-month
period
:
(1)
Beginning
on
or
after
January
1,
2027,
and
before
December
31,
2031,
four
million
dollars.
(2)
Beginning
on
or
after
January
1,
2032,
and
before
December
31,
2036,
four
million
five
hundred
thousand
dollars.
(3)
Beginning
on
or
after
January
1,
2037,
five
million
dollars
.
d.
A
permanent
change
in
the
bed
capacity,
as
determined
by
the
department,
of
an
institutional
health
facility.
For
purposes
of
this
paragraph,
a
change
is
permanent
if
it
is
intended
to
be
effective
for
one
year
or
more.
e.
Any
expenditure
in
excess
of
five
hundred
thousand
dollars
by
or
on
behalf
of
an
institutional
health
facility
for
health
services
which
are
or
will
be
offered
in
or
through
an
institutional
health
facility
at
a
specific
time
but
which
were
not
offered
on
a
regular
basis
in
or
through
that
institutional
health
facility
within
the
twelve-month
period
prior
to
that
time.
f.
The
deletion
of
one
or
more
health
services,
previously
offered
on
a
regular
basis
by
an
institutional
health
facility
or
health
maintenance
organization
or
the
relocation
of
one
or
more
health
services
from
one
physical
facility
to
another.
g.
Any
acquisition
by
or
on
behalf
of
a
health
care
provider
House
File
2635,
p.
15
or
a
group
of
health
care
providers
of
any
piece
of
replacement
equipment
with
a
value
in
excess
of
one
million
five
hundred
thousand
dollars,
whether
acquired
by
purchase,
lease,
or
donation.
h.
e.
(1)
Any
acquisition
by
or
on
behalf
of
a
health
care
provider
or
group
of
health
care
providers
of
any
piece
of
equipment
with
a
value
in
excess
of
one
million
five
hundred
thousand
dollars
,
whether
acquired
by
purchase,
lease,
or
donation,
which
results
in
the
offering
or
development
of
a
health
service
not
previously
provided
that
has
a
value
in
excess
of
the
following
amount:
(a)
Beginning
on
or
after
January
1,
2027,
and
before
December
31,
2031,
four
million
dollars
.
(b)
Beginning
on
or
after
January
1,
2032,
and
before
December
31,
2036,
four
million
five
hundred
thousand
dollars.
(c)
Beginning
on
or
after
January
1,
2037,
five
million
dollars.
(2)
A
mobile
health
service
provided
on
a
contract
basis
is
not
considered
to
have
been
previously
provided
by
a
health
care
provider
or
group
of
health
care
providers.
i.
Any
acquisition
by
or
on
behalf
of
an
institutional
health
facility
or
a
health
maintenance
organization
of
any
piece
of
replacement
equipment
with
a
value
in
excess
of
one
million
five
hundred
thousand
dollars,
whether
acquired
by
purchase,
lease,
or
donation.
j.
f.
(1)
Any
acquisition
by
or
on
behalf
of
an
institutional
health
facility
or
health
maintenance
organization
of
any
piece
of
equipment
with
a
value
in
excess
of
one
million
five
hundred
thousand
dollars
,
whether
acquired
by
purchase,
lease,
or
donation,
which
results
in
the
offering
or
development
of
a
health
service
not
previously
provided
that
has
a
value
in
excess
of
the
following
amount:
(a)
Beginning
on
or
after
January
1,
2027,
and
before
December
31,
2031,
four
million
dollars
.
(b)
Beginning
on
or
after
January
1,
2032,
and
before
December
31,
2036,
four
million
five
hundred
thousand
dollars.
(c)
Beginning
on
or
after
January
1,
2037,
five
million
dollars.
(2)
A
mobile
health
service
provided
on
a
contract
basis
House
File
2635,
p.
16
is
not
considered
to
have
been
previously
provided
by
an
institutional
health
facility.
k.
Any
air
transportation
service
for
transportation
of
patients
or
medical
personnel
offered
through
an
institutional
health
facility
at
a
specific
time
but
which
was
not
offered
on
a
regular
basis
in
or
through
that
institutional
health
facility
within
the
twelve-month
period
prior
to
the
specific
time.
l.
g.
Any
A
mobile
health
service
with
a
value
in
excess
of
one
four
million
five
hundred
thousand
dollars.
m.
Any
of
the
following:
(1)
Cardiac
catheterization
service.
(2)
Open
heart
surgical
service.
(3)
Organ
transplantation
service.
(4)
Radiation
therapy
service
applying
ionizing
radiation
for
the
treatment
of
malignant
disease
using
megavoltage
external
beam
equipment.
Sec.
15.
Section
135.62,
subsection
1,
Code
2026,
is
amended
to
read
as
follows:
1.
a.
A
new
institutional
health
service
or
changed
institutional
health
service
shall
not
be
offered
or
developed
in
this
state
without
prior
application
to
the
department
for
,
and
receipt
of
,
a
certificate
of
need,
pursuant
to
this
subchapter
.
b.
The
application
shall
be
made
upon
on
forms
furnished
or
prescribed
by
the
department
and
shall
contain
such
information
as
required
by
the
department
may
require
under
this
subchapter
by
rule
adopted
pursuant
to
chapter
17A
.
c.
(1)
The
application
shall
be
accompanied
by
a
fee
equivalent
to
three-tenths
of
one
percent
of
the
anticipated
cost
of
the
project
with
a
minimum
fee
of
six
hundred
dollars
and
a
maximum
fee
of
twenty-one
thousand
dollars.
The
fee
shall
be
remitted
by
the
department
to
the
treasurer
of
state
,
who
shall
place
it
for
deposit
in
the
general
fund
of
the
state.
An
applicant
for
a
new
institutional
health
service
or
a
changed
institutional
health
service
offered
or
developed
by
an
intermediate
care
facility
for
persons
with
an
intellectual
disability
or
an
intermediate
care
facility
for
persons
with
mental
illness,
as
each
of
those
terms
are
defined
in
section
House
File
2635,
p.
17
135C.1,
shall
not
be
required
to
pay
the
application
fee.
(2)
If
an
application
is
voluntarily
withdrawn
within
thirty
calendar
days
after
submission,
seventy-five
percent
of
the
application
fee
shall
be
refunded
;
if
the
application
is
voluntarily
withdrawn
more
than
thirty
but
within
sixty
days
after
submission,
fifty
percent
of
the
application
fee
shall
be
refunded;
if
the
application
is
withdrawn
voluntarily
more
than
sixty
days
after
submission,
twenty-five
percent
of
the
application
fee
shall
be
refunded
.
Notwithstanding
the
required
payment
of
an
application
fee
under
this
subsection
,
an
applicant
for
a
new
institutional
health
service
or
a
changed
institutional
health
service
offered
or
developed
by
an
intermediate
care
facility
for
persons
with
an
intellectual
disability
or
an
intermediate
care
facility
for
persons
with
mental
illness
as
defined
pursuant
to
section
135C.1
is
exempt
from
payment
of
the
application
fee.
Sec.
16.
Section
135.62,
subsection
2,
paragraphs
a
and
e,
Code
2026,
are
amended
to
read
as
follows:
a.
Private
offices
and
private
clinics
of
an
individual
physician,
dentist,
or
other
practitioner
or
group
of
health
care
providers,
except
as
provided
by
section
135.61,
subsection
16
,
paragraphs
“g”
,
“h”
,
and
“m”
paragraph
“e”
,
and
section
135.61,
subsections
2
and
18
.
e.
A
health
maintenance
organization
or
combination
of
health
maintenance
organizations
or
an
institutional
health
facility
controlled
directly
or
indirectly
by
a
health
maintenance
organization
or
combination
of
health
maintenance
organizations,
except
when
the
health
maintenance
organization
or
combination
of
health
maintenance
organizations
does
any
of
the
following:
(1)
Constructs,
develops,
renovates,
relocates,
or
otherwise
establishes
an
institutional
health
facility.
(2)
Acquires
major
medical
equipment
as
provided
by
section
135.61,
subsection
16,
paragraphs
“i”
and
“j”
paragraph
“f”
.
Sec.
17.
Section
135.62,
subsection
2,
paragraph
h,
subparagraph
(2),
Code
2026,
is
amended
to
read
as
follows:
(2)
If
these
conditions
are
not
met,
the
institutional
health
facility
or
health
maintenance
organization
is
subject
to
review
as
a
“new
institutional
health
service”
or
“changed
House
File
2635,
p.
18
institutional
health
service”
under
section
135.61,
subsection
16
,
paragraph
“f”
,
and
is
subject
to
sanctions
under
section
135.72
.
Sec.
18.
Section
135.62,
subsection
2,
Code
2026,
is
amended
by
adding
the
following
new
paragraphs:
NEW
PARAGRAPH
.
r.
An
organized
outpatient
health
facility
that
provides
behavioral
health
services
as
defined
by
the
department
by
rule,
including
but
not
limited
to
substitution-based
treatment
centers
for
opiate
addiction.
NEW
PARAGRAPH
.
s.
Open
heart
surgical
services.
NEW
PARAGRAPH
.
t.
Organ
transplantation
services.
NEW
PARAGRAPH
.
u.
Radiation
therapy
services.
NEW
PARAGRAPH
.
v.
Cardiac
catheterization
services.
Sec.
19.
Section
135.63,
subsection
2,
paragraph
b,
Code
2026,
is
amended
by
striking
the
paragraph.
Sec.
20.
Section
135.65,
subsections
1
and
2,
Code
2026,
are
amended
to
read
as
follows:
1.
a.
Within
fifteen
business
days
after
receipt
of
the
date
the
department
receives
an
application
for
a
certificate
of
need,
the
department
shall
examine
the
application
for
form
and
completeness
and
accept
or
reject
it.
An
application
shall
be
rejected
only
if
it
fails
to
provide
all
information
required
by
the
department
pursuant
to
section
135.62,
subsection
1
.
The
department
shall
promptly
return
to
the
applicant
any
a
rejected
application
,
to
the
applicant
with
an
explanation
of
the
reasons
for
its
rejection.
b.
Within
thirty
calendar
days
of
the
date
the
department
sends
a
rejected
application
to
an
applicant,
the
applicant
may
revise
and
resubmit
the
application
once
for
review
without
submitting
another
application
fee
under
section
135.62.
2.
Upon
acceptance
of
an
application
for
a
certificate
of
need,
the
department
shall
promptly
undertake
to
notify
all
affected
persons
in
writing
through
electronic
means
that
formal
review
of
the
application
has
been
initiated.
Notification
to
those
affected
persons
who
are
consumers
or
third-party
payers
or
other
payers
for
health
services
may
be
provided
by
electronic
distribution
of
the
pertinent
information
to
the
news
media
.
Sec.
21.
Section
135.65,
subsection
3,
paragraph
b,
Code
House
File
2635,
p.
19
2026,
is
amended
to
read
as
follows:
b.
A
period
for
the
submission
of
written
public
hearing
comments
from
affected
persons
on
the
application,
to
be
held
scheduled
prior
to
completion
of
the
evaluation
required
by
paragraph
“a”
.
Sec.
22.
Section
135.65,
subsection
4,
Code
2026,
is
amended
by
striking
the
subsection.
Sec.
23.
Section
135.66,
subsection
1,
Code
2026,
is
amended
to
read
as
follows:
1.
The
department
may
waive
the
letter
of
intent
procedures
prescribed
by
section
135.64
and
substitute
conduct
a
summary
review
procedure,
which
shall
be
established
by
rules
of
adopted
by
the
department,
when
it
the
department
accepts
an
application
for
a
certificate
of
need
for
a
project
which
that
meets
any
of
the
following
criteria
in
paragraphs
“a”
through
“e”
:
a.
A
project
which
is
limited
to
repair
or
replacement
of
a
facility
or
equipment
damaged
or
destroyed
by
a
disaster,
and
which
will
not
expand
the
facility
nor
increase
the
services
provided
beyond
the
level
existing
prior
to
the
disaster.
b.
A
project
necessary
to
enable
the
facility
or
service
to
achieve
or
maintain
compliance
with
federal,
state,
or
other
appropriate
licensing,
certification,
or
safety
requirements.
c.
A
project
which
will
not
change
the
existing
bed
capacity
of
the
applicant’s
facility
or
service,
as
determined
by
the
department,
by
more
than
ten
percent
or
ten
beds,
whichever
is
less,
over
a
two-year
period.
d.
A
project
the
total
cost
of
which
will
not
exceed
one
hundred
fifty
thousand
dollars.
e.
d.
Any
other
project
for
which
the
applicant
proposes
and
the
department
agrees
to
summary
review.
Sec.
24.
Section
135.70,
subsection
2,
Code
2026,
is
amended
to
read
as
follows:
2.
Upon
expiration
of
a
certificate
of
need,
and
prior
to
extension
of
the
certificate
of
need,
any
affected
person
shall
have
the
right
to
submit
to
the
department
information
which
may
be
relevant
to
the
question
of
granting
an
extension.
The
department
may
call
a
public
hearing
for
this
purpose.
Sec.
25.
Section
135.71,
subsection
4,
Code
2026,
is
amended
House
File
2635,
p.
20
to
read
as
follows:
4.
Criteria
for
determining
when
it
is
not
feasible
to
complete
formal
review
of
an
application
for
a
certificate
of
need
within
the
time
limits
limit
specified
in
section
135.68
.
The
rules
adopted
under
this
subsection
shall
include
criteria
for
determining
whether
an
application
proposes
introduction
of
technologically
innovative
equipment,
and
if
so,
procedures
to
be
followed
in
reviewing
the
application.
However,
a
rule
adopted
under
this
subsection
shall
not
permit
a
deferral
of
more
than
sixty
thirty
calendar
days
beyond
the
time
when
a
decision
is
required
under
section
135.68
,
unless
both
the
applicant
and
the
department
agree
to
a
longer
deferment.
Sec.
26.
Section
135P.1,
subsection
3,
Code
2026,
is
amended
to
read
as
follows:
3.
“Health
facility”
means
an
any
of
the
following:
a.
An
institutional
health
facility
as
defined
in
section
135.61
,
a
.
b.
A
birth
center
as
defined
in
section
135.131
,
a
.
c.
A
hospice
licensed
under
chapter
135J
,
a
.
d.
A
home
health
agency
as
defined
in
section
144D.1
,
an
.
e.
An
assisted
living
program
certified
under
chapter
231C
,
a
.
f.
A
clinic
,
a
.
g.
A
community
health
center
,
or
the
.
h.
The
university
of
Iowa
hospitals
and
clinics
,
and
includes
any
.
i.
A
corporation,
professional
corporation,
partnership,
limited
liability
company,
limited
liability
partnership,
or
other
entity
comprised
of
such
health
facilities.
Sec.
27.
Section
135P.1,
Code
2026,
is
amended
by
adding
the
following
new
subsection:
NEW
SUBSECTION
.
3A.
“Institutional
health
facility”
means
any
of
the
following
without
regard
to
whether
the
facility
is
publicly
or
privately
owned,
organized
for
profit,
or
is
part
of
or
sponsored
by
a
health
maintenance
organization:
a.
A
hospital
as
defined
in
section
135B.1.
b.
A
health
care
facility
as
defined
in
section
135C.1.
c.
An
organized
outpatient
health
facility
as
defined
in
section
135.61.
House
File
2635,
p.
21
d.
An
ambulatory
surgical
center
as
defined
in
section
135.61.
e.
A
community
mental
health
center
as
defined
in
section
225A.1.
Sec.
28.
REPEAL.
Section
135.64,
Code
2026,
is
repealed.
______________________________
PAT
GRASSLEY
Speaker
of
the
House
______________________________
AMY
SINCLAIR
President
of
the
Senate
I
hereby
certify
that
this
bill
originated
in
the
House
and
is
known
as
House
File
2635,
Ninety-first
General
Assembly.
______________________________
MEGHAN
NELSON
Chief
Clerk
of
the
House
Approved
_______________,
2026
______________________________
KIM
REYNOLDS
Governor