Section 441.88.2. Participation.

         88.2(1) Contracts with PHPs. The department shall enter into contracts for the scope of services specified in 441—Chapter 78, or a part thereof, with a PHP which has verified to the department that the criteria set forth in the Social Security Act have been met. This verification shall be reviewed by Centers for Medicare and Medicaid Services (CMS) staff to ensure that the status of PHP is rightfully conferred. The department may also include the scope of services described in 441—Chapter 74, known as the Iowa Health and Wellness Plan, or part thereof, in contracts with PHPs.

            a.               The department shall also determine that the PHP meets the following additional requirements:

             (1)             The PHP shall make the services it provides to enrolled recipients at least as accessible (in terms of timeliness, duration, and scope) to them as those services are accessible to recipients in the enrollment area who are not enrolled.

             (2)             The PHP shall provide satisfaction to the department that insolvency is not likely to occur and that enrolled Medicaid recipients shall not be responsible for its debts if the PHP should become insolvent.

            b.               The contract shall meet the following minimum requirements. The contract shall:

             (1)             Be in writing.

             (2)             Be renewable by mutual consent for a period of up to three years.

             (3)             List the services covered.

             (4)             Describe information access and disclosure.

             (5)             List conditions for nonrenewal, termination, suspension, and modification.

             (6)             Specify the method and rate of reimbursement.

             (7)             Provide for disclosure of ownership and subcontractor relationship.

             (8)             Be made with the licensee by the department.

            c.               Any protests to the award of contracts shall be in writing and submitted to the director of the department. Prior to termination or suspension of a contract, the department shall send a notice to cure to the PHP, specifying the number of days the PHP has to correct the problems. Failure to correct the problems in the time given shall then result in termination or suspension. The PHP may appeal the decision of the department in writing to the director of the department or to the federal Department of Health and Human Services, Centers for Medicare and Medicaid Services, if the appeal documents state violations of federal law or regulation.

         88.2(2) Method of selection of PHP. In counties served by a single prospective PHP, the department shall attempt to negotiate directly with the PHP. In counties where two or more prospective PHPs exist, the department shall initiate communication and attempt to negotiate as many contracts as are administratively feasible.

         88.2(3) Termination of contract. Either party may, by mutual consent, terminate a contract. Either party may give 60 days written notice to the other party. The effective date of termination must be the first day of a month. The department may terminate or suspend a contract if the contract is determined by the department to be inconsistent with the overall goals and objectives of the Medicaid program. The determination shall be based upon, but not limited to, the following:

            a.               The PHP’s delivery system does not ensure enrolled recipients adequate access to medical services.

            b.               The PHP’s delivery system does not ensure the availability of all services covered under the contract.

            c.               There are not proper assurances of solvency on the part of the PHP.

            d.               There is not substantial compliance with all provisions of the contract.

            e.               The PHP has discriminated against persons eligible to be covered under the contract on the basis of age, race, sex, religion, national origin, creed, color, physical or mental disability, political belief, health status, or the need for health services.

         88.2(4) Recipients eligible to enroll. Any Medicaid-eligible recipient is eligible to enroll in a contracting PHP except for the following:

            a.               Recipients who are medically needy as defined at 441—subrule 75.1(35).

            b.               Recipients over the age of 65 and under the age of 21 in psychiatric institutions as defined at 441—Chapter 85.

            c.               Recipients who are supplemental security income-related case members.

            d.               Rescinded IAB 10/3/01, effective 12/1/01.

            e.               Recipients whose eligibility is in the process of automatic redetermination as defined at rule 441—76.11(249A).

            f.                Recipients who are foster care and subsidized adoption-related case members.

            g.               Recipients who are Medicare beneficiaries.

            h.               Recipients who are pregnant women and who are deemed to be presumptively eligible as defined at 441—subrule 75.1(30).

            i.                Recipients who are Native American Indians or Alaskan natives.

            j.                Recipients who are receiving services from a Title V provider.

[ARC 1135C, IAB 10/30/13, effective 10/2/13; ARC 2358C, IAB 1/6/16, effective 1/1/16]