Updates to Medicaid

The bill exempts an assisted living residence with fewer than 19 beds that has not undergone new construction or major renovations and that complies with the standards for assisted living residences from complying with facility guidelines adopted by the state board of health from complying with the facility guideline institute guidelines. The bill requires the department of health care policy and financing (state department) to follow the standards set by the federal centers for medicare and medicaid when updating rules.

The department of health care policy and financing (state department) state department must establish a process for reviewing and updating the general billing manual on an annual basis and ensure that the general billing manual includes all necessary CPT codes or links to the state department's list of CPT codes.

Beginning January 1, 2026, for claims that must be reprocessed as a result of updating the provider rates, the bill requires a managed care organization to issue payment to a contracted provider within one year after the provider rate is updated. The state department must notify the managed care organizations of changes to the provider rates within 60 days of changing the provider rates.

The bill requires the state department to include in each new contract with, or renewal of a contract with, a managed care entity (MCE) a provision requiring the MCE to submit to the state department, on an annual basis, the amount the MCE is paid and the MCE's medical loss ratio. The state department is required to publish this information , as well as historical medical loss ratio data for each MCE, and audit findings regarding an MCE's most recently completed medical loss ratio audit on the state department's website on an annual basis.

The bill prohibits the state department from imposing signature requirements on a physician or practitioner certifying a medicaid member's (member) plan of care that involves physical therapy, or occupational therapy, or speech therapy.

The bill prevents a member receiving home- and community-based services from losing the services the member currently receives if the member's disability and need for services have not changed in the preceding 3 years requires that for members receiving home- and community-based services, if a service the member receives is discontinued or no longer a covered service, the state department must confirm the timeline for the continuity of treatment with the federal centers for medicare and medicaid during the transition period of the benefit or service being discontinued and must communicate that timeline to the member impacted by the benefit or service being discontinued. The bill makes updates to the system of care for children and youth.

(Note: Italicized words indicate new material added to the original summary; dashes through words indicate deletions from the original summary.)

(Note: This summary applies to the reengrossed version of this bill as introduced in the second house.)