Idaho H 201: MEDICAID – Amends existing law to provide minimum risk-sharing levels for value care organizations.

Bill Text

LEGISLATURE OF THE STATE OF IDAHO
Sixty-eighth Legislature First Regular Session - 2025
IN THE HOUSE OF REPRESENTATIVES
HOUSE BILL NO. 201
BY HEALTH AND WELFARE COMMITTEE
AN ACT1
RELATING TO MEDICAID; AMENDING SECTION 56-265, IDAHO CODE, TO SPECIFY CER-2
TAIN REQUIREMENTS FOR VALUE CARE ORGANIZATIONS AND TO MAKE A TECHNICAL3
CORRECTION; AND DECLARING AN EMERGENCY AND PROVIDING AN EFFECTIVE DATE.4
Be It Enacted by the Legislature of the State of Idaho:5
SECTION 1. That Section 56-265, Idaho Code, be, and the same is hereby6
amended to read as follows:7
56-265. PROVIDER PAYMENT. (1) Where there is an equivalent, the pay-8
ment to medicaid providers:9
(a) May be up to but shall not exceed one hundred percent (100%) of the10
current medicare rate for primary care procedure codes as defined by the11
centers for medicare and medicaid services; and12
(b) Shall be ninety percent (90%) of the current medicare rate for all13
other procedure codes.14
(2) Where there is no medicare equivalent, the payment rate to medicaid15
providers shall be prescribed by rule.16
(3) Notwithstanding any other provision of this chapter, if the17
services are provided by a private, freestanding mental health hospital18
facility that is an institution for mental disease as defined in 42 U.S.C.19
1396d(i), the department shall reimburse for inpatient services at a rate20
not to exceed ninety-one percent (91%) of the current medicare rate within21
federally allowed reimbursement under the medicaid program. The reimburse-22
ment provided for in this subsection shall be effective until July 1, 2021.23
(4) The department shall, through the annual budget process, include24
a line-item request for adjustments to provider rates. All changes to25
provider payment rates shall be subject to approval of the legislature by26
appropriation.27
(5) Notwithstanding any other provision of this chapter, the depart-28
ment may enter into agreements with providers to pay for services based on29
their value in terms of measurable health care quality and positive impacts30
to participant health.31
(a) Any such agreement shall be designed to be cost-neutral or cost-32
saving compared to other payment methodologies.33
(b) The department is authorized to pursue waiver agreements with the34
federal government as needed to support value-based payment arrange-35
ments, up to and including fully capitated provider-based managed care.36
(c) Agreements between the department and value care organizations37
shall require value care organizations to select a minimum risk sharing38
level of:39
(i) Forty percent (40%) for the performance year commencing July40
1, 2026;41

2
(ii) Fifty percent (50%) for the performance year commencing July1
1, 2027;2
(iii) Sixty percent (60%)for the performance year commencing July3
1, 2028; and4
(iv) Seventy percent (70%) for the performance year commencing5
July 1, 2029, and all subsequent performance years.6
(6) Medicaid reimbursement for critical access, out-of-state, and7
state-owned hospitals shall be as follows:8
(a) In-state, critical access hospitals as designated according to 429
U.S.C. 1395i-4(c)(2)(B) shall be reimbursed at one hundred one percent10
(101%) of cost;11
(b) Out-of-state hospitals shall be reimbursed at eighty-seven percent12
(87%) of cost;13
(c) State-owned hospitals shall be reimbursed at one hundred percent14
(100%) of cost; and15
(d) Out-of-state hospital institutions for mental disease as defined16
in 42 U.S.C. 1396d(i) shall be reimbursed at a per diem equivalent to17
ninety-five percent (95%) of cost.18
(7) The department shall equitably reduce net reimbursements for all19
hospital services, including in-state institutions for mental disease but20
excluding all hospitals and institutions described in subsection (6) of21
this section, by amounts targeted to reduce general fund needs for hospital22
payments by three million one hundred thousand dollars ($3,100,000) in state23
fiscal year 2020 and eight million seven hundred twenty thousand dollars24
($8,720,000) in state fiscal year 2021.25
(8) The department shall work with all Idaho hospitals, including in-26
stitutions for mental disease as defined in 42 U.S.C. 1396d(i), to establish27
value-based payment methods for inpatient and outpatient hospital services28
to replace existing cost-based reimbursement methods for in-state hospi-29
tals, other than those hospitals and institutions described in subsection30
(6) of this section, effective July 1, 2021. Budgets for hospital payments31
shall be subject to prospective legislative approval.32
(9) The department shall work with Idaho hospitals to establish a33
quality payment program for inpatient and outpatient adjustment payments34
described in section 56-1406, Idaho Code. Inpatient and outpatient adjust-35
ment payments shall be subject to increase or reduction based on hospital36
service quality measures established by the department in consultation with37
Idaho hospitals.38
SECTION 2. An emergency existing t