2020 Legislative Priorities

We work at the state and federal levels of government on legislative priorities to ensure that public policy decisions improve the lives of Iowans in need of care from nursing facilities, assisted living programs and home health agencies.

Skilled Nursing Facilities
  • Nursing Facility Reimbursement – The Iowa Legislature is tasked with appropriating funding to ensure Medicaid rates are adjusted as costs rise over time. However, in the past, the system has not been adequately funded, creating a significant shortfall in the rates nursing facility providers are receiving from Medicaid. In 2019, the Iowa Legislature included $23.4 million in its Health and Human Services budget, which included approximately $15 million in new appropriations and $8.4 million in Quality Assurance Assessment Fee (QAAF) provider return. Nursing facilities faced a $54.9 million shortfall at the time of the appropriation, leaving $31.5 million remaining to be addressed during the 2020 legislative session. Until nursing facility Medicaid is funded to provide cost coverage, nursing facility providers will continue to face challenges delivering health care to vulnerable Iowans. POSITION: IHCA is asking the Iowa Legislature to appropriate $31.5 million — the remainder of the state share of the 2019 nursing facility Medicaid funding shortfall.
  • Nursing Facility Renovation Funding – The General Assembly has historically appropriated Rebuilding Iowa Infrastructure Fund funding for renovation of older nursing facilities and those caring for high numbers of Iowans on Medicaid. These facilities typically have limited access to capital. Renovation of aging facilities is vital to meeting evolving regulatory and quality improvement requirements. Since its inception, this funding has helped leverage over $100 million in capital investment in many rural and high-Medicaid Iowa nursing homes. POSITION: In order to help rural and high-Medicaid nursing homes remain compliant with state and federal regulations and continue providing quality care, IHCA requests an $800,000 appropriation from the Rebuilding Iowa Infrastructure Fund.
  • Hospice Room and Board Pass-Through – Last session Governor Reynolds signed House File 518, which directs the Department of Human Services (DHS) to take appropriate actions to allow for payment of nursing facility room and board expenses for dual-eligible and Medicaid-only recipients who have elected their hospice benefit to be paid directly from managed care organizations and fee-for-service payors. Eliminating the hospice room and board pass-through reduces administrative burden by removing the middleman and allowing providers to view client participation changes for residents on hospice. POSITION: IHCA continues to monitor progress of the removal of this pass-through and is working with DHS to design and submit these changes in a timely and approvable manner.
  • Certificate of Need – Iowa’s Health Facilities Council, the five-panel council that votes to approve or deny applications for expansion or new institutional health care facilities, has historically prevented over-construction of expensive health care facilities (hospitals and nursing facilities) by applying an objective test to each application it reviews. This has helped keep health care cost increases in check by reducing duplication in services across the state. However, each year the legislature is presented with proposals that would weaken Iowa’s current Certificate of Need system. Weakening the requirements for a Certificate of Need, especially the project cost threshold, would allow new classes of providers to “cherry-pick” patients/residents from higher reimbursement categories, and would tilt the playing field against providers required to seek Certificate of Need approval. POSITION: IHCA opposes any legislative measures that would weaken or eliminate the Certificate of Need process for nursing facilities.
Assisted Living Programs
  • Home and Community-Based Services Elderly Waiver Rate Cap – Assisted living programs operate under the Home- and Community-Based Services (HCBS) Elderly Waiver Cap of approximately $44 per day for care, medicine, meals and assistance with daily activities such as bathing and dressing. The last rate increase for HCBS occurred in 2016, with a 1% increase in service rates. The Iowa Center for Assisted Living (ICAL) proposes that the Iowa Legislature direct the Department of Human Services to eliminate the monthly budget maximum or cap for individuals eligible for the Medicaid HCBS Elderly Waiver and allocate funding to increase the HCBS elderly services rate floor. POSITION: ICAL supports the elimination of the HCBS elderly waiver rate cap and an allocation of $2.03 million in state funding to increase the HCBS elderly waiver services rate floor.
  • Assisted Living Social Model Foundation – As elderly Iowans begin transitioning to home and care models like assisted living and/or nursing facility care, it is important that their care is provided in settings that prioritize social well-being, quality care and high patient satisfaction. ICAL advocates for allowing tenants to make their own choices of how to live and supports any state initiative that carries forward and enhances this practice. POSITION: ICAL advocates for the continued support of the assisted living program social model foundation.
  • Certificate of Need – ICAL supports continuation of free market opportunities allowing assisted living program construction unfettered by additional state oversight and opposes the establishment of a Certificate of Need process for assisted living development. Unlike nursing facilities, assisted living communities in Iowa are predominately private market-driven. Ninety percent of assisted living residents are private pay, meaning they are unsupported by state and federal waiver programs. Since the assisted living sector exists today as a primarily free market part of the health care continuum, ICAL opposes the establishment of a Certificate of Need process for assisted living development. POSITION: ICAL opposes the establishment of a Certificate of Need process for assisted living development.
Home Health Agencies
  • State Funding for Home Health – Home care utilization in Iowa continues to climb. The Iowa Center for Home Care (ICHC) is requesting a $3.1 million appropriation from the Iowa Legislature to increase Medicaid funding for low-income elderly and disabled Iowans receiving care in their own home. The appropriation would produce cost coverage for Iowa home health agency providers through the low utilization payment adjustment (LUPA) rate system. Home health agency providers are currently reimbursed at 85% of the LUPA rate. This funding request is vital to ensuring that home care providers are able to continue to serve Iowa Medicaid patients and ensuring Iowa has a robust health care continuum. Additionally, home health care providers offer the most affordable service in Iowa’s Medicaid care continuum. POSITION: ICHC is asking the Iowa Legislature to appropriate $2.97 million to Medicaid funding for low-income elderly and disabled Iowans receiving care in their home.
All Providers
  • Criminal Background Checks – Currently long-term care providers and many other providers are required to utilize the Department of Public Safety’s background check system for current and prospective employees. The Department of Public Safety’s system only provides a background check for Iowa offenses and is inexpedient—requiring providers to wait to hire prospective new employees. IHCA, ICAL and ICHC support modernizing the system to ensure a more thorough, national background check for every applicant and a real-time system that operates 365 days a year, 7 days a week and 24 hours a day. POSITION: IHCA, ICAL and ICHC support modernizing Iowa’s background check system to ensure a more thorough, national background check for every applicant.
  • Tort Reform – In 2017, the Iowa Legislature passed Senate File 465 related to medical malpractice claims. In an effort to contain health care costs, the bill established $250,000 “soft” caps for non-economic damages, while still allowing plaintiffs to recover punitive and economic damages. These caps, however, are subject to exceptions for particular injuries, scheduled increases and inflation adjustments, and therefore claims still often result in exorbitant malpractice judgments against facilities. Such outcomes promote a negative litigious environment and make it difficult for providers to maintain operations. POSITION: IHCA, ICAL and ICHC supports hard caps that are not subject to exceptions and do not adjust over time on non-economic damages in medical malpractice claims.
  • Medicaid Managed Care – Access to the Managed Care Organization (MCO) network and timely and accurate payment of Medicaid claims by the MCOs is essential to providing long-term care services to Iowans who depend upon the Medicaid system. IHCA supports: 1) Any Willing Provider: IHCA supports ensuring that any provider who is an enrolled Iowa Medicaid provider is allowed to be a network provider with all of the MCOs with which the provider chooses to contract/credential. 2) Prompt and Accurate Claims Payment: IHCA supports adjusting claims payment timeline requirements to ensure providers are paid promptly by the MCOs. 3) Managed Care Reporting Oversight: IHCA supports ensuring claims payment accuracy by requiring quarterly MCO reporting of claims denial trends for long-term care providers to the Department of Human Services. POSITION: IHCA, ICAL and ICHC support allowing Medicaid-enrolled providers to be a network provider with the MCOs they choose and MCO accountability requirements that support prompt and accurate claims payment.
  • Workforce – The need for long-term care professionals has never been greater, as Iowa’s population continues to age and the need for care grows. Workforce is a critical component to providing long-term care to Iowans. The quality of care provided is intrinsically linked to the quality of the profession’s workforce. At the same time, there has never been a more challenging time for recruiting and retaining a skilled workforce. Unemployment rates in Iowa have remained consistently low and are among the lowest in the country, making it difficult to fill open positions. Providers are continually burdened by an inadequate pool of trained health care providers to meet the demands of the patients they serve every day. POSITION: IHCA, ICAL and ICHC support public policies that support workforce development and retention to Iowa’s health care field.
  • Medical Cannabis – Throughout the 2019 legislative session, IHCA, ICAL and ICHC worked to educate legislative and regulatory entities on the impact of the medical cannabidiol program on Iowa’s long-term care providers. The issue of medical cannabidiol is expected to resurface in future legislative sessions. As the medical cannabidiol program evolves, IHCA, ICAL and ICHC will continue to work with legislative and regulatory entities to ensure clear, expedient guidance is available to long-term care providers. POSITION: IHCA, ICAL and ICHC advocate for clear and expedited guidance to be available to long-term care providers to comply with Iowa’s medical cannabidiol program.
Federal Priorities
  • National Practitioner Data Bank – The National Practitioner Data Bank (NPDB) (45 CFR § 60.1) is a repository of reports containing information on medical malpractice payments and certain adverse actions related to health care practitioners, providers and suppliers. It is a workforce tool intended to prevent practitioners from moving between states without disclosure of previous damaging performance. Currently, our providers do not have authorization under federal regulations to access the NPDB. POSITION: IHCA seeks authorization as an eligible entity to access all reports and queries of the NPDB to assist in promoting quality health care and deterring fraud and abuse within our health care delivery system.
  • JOBS Act of 2019 – The JOBS Act of 2019 (S. 839) proposes making federal financial aid available to individuals seeking skills training (not just those seeking college degrees) by expanding Pell grants for short-term training programs that lead to higher-paying, in-demand jobs. POSITION: IHCA supports extending federal financial aid to short-term education and high-quality training programs.
  • Nursing Home Workforce Quality Act – The Nursing Home Workforce Quality Act (H.R. 1265) would eliminate the mandatory Certified Nurse Assistant (CNA) training lockout for skilled nursing facilities, and instead allow the Secretary of the Department of Health and Human Services to impose a lockout based on a substandard quality of care. POSITION: IHCA supports the Nursing Home Workforce Quality Act (H.R. 1265).
  • Workforce for an Expanding Economy Act – The Workforce for an Expanding Economy Act (H.R. 1740) provides critical access to new workers and creates a commonsense visa system, capped at 85,000 positions annually, that would allow the government to ensure workers and employers are utilizing the system as it was intended. POSITION: IHCA supports immigration reform that will fill critical jobs if a U.S. employer is offering a job that American citizens are not available to take.
  • Dream Act – Workforce recruitment and retention are among the most pressing challenges confronting long-term care providers today. The Dream Act (H.R. 6) provides permanent legal protections and a path to citizenship for undocumented immigrants brought to the United States as children (“Dreamers”). This legislation offers protection for Temporary Protected Status (TPS) recipients from deportation, as recently TPS was terminated for individuals from several important countries that have typically contributed to the U.S. workforce. POSITION: IHCA supports the Dream Act (H.R. 6).
  • Nursing Facility Relief for Requirements of Participation – In 2019 the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that changes the current Requirements of Participation (RoP) (CMS 3347-P) and delays implementation of some elements of Phase 3 by a year. The intention of this rule is to ease some of the pressures of the RoP and reduce excessively burdensome and overly prescriptive regulations. IHCA supports the proposed rule, which will bring the regulatory relief needed to allow for more time and greater focus on providing high-quality care to Iowa’s nursing facility residents. POSITION: IHCA supports the proposed rule with changes to RoP, which brings regulatory relief needed to allow more time for providing high-quality care to Iowa’s nursing facility residents.
  • Home Health Payment Innovation Act – In 2020 CMS plans to implement a new payment model for home health services: The Patient-Driven Groupings Model (PDGM). In doing so, Medicare will apply “behavioral adjustments” to account for anticipated changes in provider behavior. These adjustments would mean a 4.36% base rate reduction that would start before any actual behavioral changes occur, translating to a $3.8 million reduction in home health payments to Iowa home health providers in 2020 alone. The Home Health Payment Innovation Act (S. 433 & H.R. 2573) would prohibit pre-change rate reductions based on untested assumptions, and require behavioral adjustments based on real, actual changes in provider behavior that reflect provider behavioral changes in response to the new payment model rather than changes in the patient population. POSITION: ICHC strongly supports the Home Health Payment Innovation Act (S. 433 & H.R. 2573), which would prohibit pre-change rate reductions based on untested assumptions.
  • Veterans Administration Managed Care (Optum) – The ICHC has significant concerns regarding the roll-out of the new managed care system for Veterans Administration (VA) home care patients. Several changes have already been imposed, including a contract transition to TriWest, and most recently a switch to new third-party payor, Optum. The roll-out to Optum for Iowa VA patients began October 8, 2019. Providers have received little information to date and lack answers regarding the impact of this change on their contracting and billing. POSITION: ICHC will continue to seek answers from the VA to ensure clear guidance is available to home care patients and providers throughout this transition.
  • Home Health Care Planning Improvement Act – Medicare law requires that a physician certify a patient’s eligibility for coverage of home health services. However, much of the primary care provided today comes from highly skilled non-physician practitioners. In order to comply with the current Medicare certification requirements, these professionals are forced to “hand-off” their patients to a physician who has not previously cared for them. POSITION: ICHC supports the Home Health Care Planning Improvement Act (S. 296 & H.R. 2150), which would allow non-physician providers to certify a patient’s eligibility for the Medicare Home Health Benefit.

2019 Legislative Session Report