LEGISLATURE OF THE STATE OF IDAHO
Sixty-fifth Legislature
First Regular Session - 2019
IN THE SENATE
SENATE BILL NO. 1204, As Amended, As Amended in the House
BY STATE AFFAIRS COMMITTEE

18

AN ACT
RELATING TO MEDICAID; AMENDING SECTION 56-253, IDAHO CODE, TO PROVIDE THAT
A HEALTH RISK ASSESSMENT SHALL INCLUDE QUESTIONS RELATING TO SUBSTANCE
USE DISORDERS, TO PROVIDE THAT THE DIRECTOR OF THE DEPARTMENT OF HEALTH
AND WELFARE SHALL CONDUCT CERTAIN RESEARCH AND SEEK CERTAIN WAIVERS,
AND TO MAKE A TECHNICAL CORRECTION; AMENDING SECTION 56-267, IDAHO
CODE, TO PROVIDE THAT ELIGIBILITY FOR MEDICAID SHALL NOT BE DELAYED
FOR WAIVER CONSIDERATION, NEGOTIATION, OR APPROVAL, TO PROVIDE THAT
A WAIVER SHALL NOT BE IMPLEMENTED IF IT WOULD RESULT IN A REDUCTION IN
FEDERAL FINANCIAL PARTICIPATION FOR CERTAIN PERSONS, TO PROVIDE THAT
THE LEGISLATURE SHALL DECLARE THE SECTION TO BE NULL, VOID, AND OF NO
FORCE AND EFFECT UNDER CERTAIN CIRCUMSTANCES, TO PROVIDE FOR CERTAIN
REVIEWS AND RECOMMENDATIONS, TO PROVIDE THAT PERSONS PARTICIPATING IN
MEDICAID PURSUANT TO THE SECTION BE PLACED IN MANAGED CARE TO THE EXTENT
POSSIBLE, AND TO MAKE TECHNICAL CORRECTIONS; AMENDING SECTION 56-263,
IDAHO CODE, TO PROVIDE THAT THE DEPARTMENT SHALL SEEK CERTAIN APPROVAL
OR A WAIVER AND TO PROVIDE APPLICABILITY; PROVIDING FOR THE APPOINTMENT
OF A TASK FORCE; PROVIDING SEVERABILITY; AND DECLARING AN EMERGENCY.

19

Be It Enacted by the Legislature of the State of Idaho:

20

SECTION 1. That Section 56-253, Idaho Code, be, and the same is hereby
amended to read as follows:

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41

56-253. POWERS AND DUTIES OF THE DIRECTOR. (1) The director is hereby
encouraged and empowered to obtain federal approval in order that Idaho design and implement changes to its medicaid program that advance the quality of services to participants while allowing access to needed services and
containing excessive costs. The design of Idaho's medicaid program shall
incorporate the concepts expressed in section 56-251, Idaho Code.
(2) The director may create health-need categories other than those
stated in section 56-251(2)(a), Idaho Code, subject to legislative approval, and may develop a medicaid benchmark plan for each category.
(3) Each benchmark plan shall include explicit policy goals for the
covered population identified in the plan, as well as specific benefit packages, delivery system components and performance measures in accordance
with section 67-1904, Idaho Code.
(4) The director shall establish a mechanism to ensure placement of
participants into the appropriate benchmark plan as allowed under section
6044 of the deficit reduction act of 2005. This mechanism shall include,
but not be limited to, a health risk assessment. This assessment shall comply with federal requirements for early and periodic screening, diagnosis
and treatment (EPSDT) services for children, in accordance with section
1905(a)(4)(B) of the social security act. The health risk assessment shall

 2

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50

include questions related to substance use disorders to allow referral to
treatment for such disorders by the department.
(5) The director may require, subject to federal approval, participants to designate a medical home. Applicants for medical assistance shall
receive information about primary care case management, and, if required to
so designate, shall select a primary care provider as part of the eligibility
determination process.
(6) The director may, subject to federal approval, enter into contracts
for medical and other services when such contracts are beneficial to participant health outcomes as well as economically prudent for the medicaid program.
(7) The director may obtain agreements from medicare, school districts
and other entities to provide medical care if it is practical and cost-effective.
(8) The director shall research options and apply for federal waivers
to enable cost-efficient use of medicaid funds to pay for substance abuse
and/or mental health services in institutions for mental disease.
(9) The director shall, in cooperation with the director of the department of insurance, seek waivers from the federal government to provide that
persons eligible for medicaid pursuant to section 56-267, Idaho Code, who
have a modified adjusted gross income at or above one hundred percent (100%)
of the federal poverty level shall receive the advance premium tax credit to
purchase a qualified health plan through the Idaho health insurance exchange
established by chapter 61, title 41, Idaho Code, instead of enrolling in medicaid, except as provided in paragraph (a) of this subsection.
(a) A person described in this subsection may choose to enroll in medicaid instead of receiving the advance premium tax credit to purchase a
qualified health plan.
(b) If the waivers described in this subsection are not approved before
January 1, 2020, then the persons described in this subsection shall be
enrolled in medicaid.
(10) The director shall seek a waiver from the federal government consistent with the provisions of this subsection.
(a) A person participating in medicaid pursuant to section 56-267,
Idaho Code, must be:
(i)
Working at least twenty (20) hours per week, averaged
monthly, or earning wages equal to or greater than the federal minimum wage for twenty (20) hours of work per week;
(ii) Participating in and complying with the requirements of a
work training program at least twenty (20) hours per week, as determined by the department;
(iii) Volunteering at least twenty (20) hours per week, as determined by the department;
(iv) Enrolled at least half-time in postsecondary education or
another recognized education program, as determined by the department, and remaining enrolled and attending classes during
normal class cycles;
(v) Meeting any combination of working, volunteering, and participating in a work program for a total of at least twenty (20)
hours per week, as determined by the department; or

 3

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50

(vi) Subject to and complying with the requirements of the work
program for temporary assistance for needy families (TANF) or participating and complying with the requirements of a workfare program in the supplemental nutrition assistance program (SNAP).
(b) A person is exempt from the provisions of paragraph (a) of this subsection if the person is:
(i) Under the age of nineteen (19) years;
(ii) Over the age of fifty-nine (59) years;
(iii) Physically or intellectually unable to work;
(iv) Pregnant;
(v) A parent or caretaker who is the primary caregiver of a dependent child under the age of eighteen (18) years, as determined by
the department;
(vi) A parent or caretaker personally providing care for a person with serious medical conditions or with a disability, as determined by the department;
(vii) Applying for or receiving unemployment compensation and
complying with work requirements that are part of the federal-state unemployment insurance program;
(viii) Applying for social security disability benefits, until
such time eligibility is determined;
(ix) Participating in a drug addiction or alcohol treatment and
rehabilitation program, as determined by the department; or
(x) An American Indian or Alaska native who is eligible for services through the Indian health service or through a tribal health
program pursuant to the Indian self-determination and education
assistance act and the Indian health care improvement act.
(c) The department shall verify a medicaid participant's compliance
with paragraph (a) of this subsection every six (6) months and shall
promulgate rules based on federal final waiver approval relating to
the requirements of this subsection. A person who fails to comply with
paragraph (a) of this subsection shall:
(i) Be ineligible for medicaid but may reapply for medicaid two
(2) months after such determination is made or earlier if in compliance; or
(ii) If the provisions of subparagraph (i) of this paragraph are
not federally approved or are found unlawful by a court of competent jurisdiction, be subject to the maximum allowable copayments
on covered Idaho medicaid services for a period of six (6) months
or until the person complies with paragraph (a) of this subsection, whichever is earlier.
(d) It is the intent of the legislature, in enacting the requirements of
this subsection, to enable coverage of medicaid participants while also
promoting the participants' health and financial independence.
(e) The department shall implement the waiver described in this subsection as soon as possible once federal approval has been obtained.
(11) The director is given authority to promulgate rules consistent
with this act.
SECTION 2. That Section 56-267, Idaho Code, be, and the same is hereby
amended to read as follows:

 4

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48

56-267. MEDICAID ELIGIBILITY EXPANSION. (1) Notwithstanding any provision of law or federal waiver to the contrary, the state shall amend its
state plan to expand Mmedicaid eligibility to include those persons under
sixty-five (65) years of age whose modified adjusted gross income is one hundred thirty-three percent (133%) of the federal poverty level or below and
who are not otherwise eligible for any other coverage under the state plan,
in accordance with sections 1902(a)(10)(A)(i)(VIII) and 1902(e)(14) of the
Ssocial Ssecurity Aact.
(2) No later than ninety (90) days after approval of this act, the
department shall submit any necessary state plan amendments to the United
States Ddepartment of Hhealth and Hhuman Sservices, Ccenters for Mmedicare
and Mmedicaid Sservices to implement the provisions of this section. The
department is required and authorized to take all actions necessary to implement the provisions of this section as soon as practicable.
(3) Eligibility for medicaid as described in this section shall not be
delayed if the centers for medicare and medicaid services fail to approve any
waivers of the state plan for which the department applies, nor shall such
eligibility be delayed while the department is considering or negotiating
any waivers to the state plan. The department shall not implement any waiver
that would result in a reduction in federal financial participation for persons identified in subsection (1) of this section below the ninety percent
(90%) commitment described in section 1905(y) of the social security act.
(4) If section 1905(y) of the social security act is held unlawful or
unconstitutional by the United States supreme court, then the legislature
shall declare this section to be null, void, and of no force and effect.
(5) If federal financial participation for persons identified in subsection (1) of this section is reduced below the ninety percent (90%) commitment described in section 1905(y) of the social security act, then the senate
and house of representatives health and welfare committees shall, as soon as
practicable, review the effects of such reduction and make a recommendation
to the legislature as to whether medicaid eligibility expansion should remain in effect. The review and recommendation described in this subsection
shall be conducted by the date of adjournment of the regular legislative session following the date of reduction in federal financial participation.
(6) The department:
(a) Shall place all persons participating in medicaid pursuant to
this section in a care management program authorized under section
56-265(5), Idaho Code, or in another managed care program to improve the
quality of their care, to the extent possible; and
(b) Is authorized to seek any federal approval necessary to implement
the provisions of this subsection.
(7) No later than January 31 in the 2023 legislative session, the senate and house of representatives health and welfare committees shall review
all fiscal, health, and other impacts of medicaid eligibility expansion pursuant to this section and shall make a recommendation to the legislature as
to whether such expansion should remain in effect.
SECTION 3. That Section 56-263, Idaho Code, be, and the same is hereby
amended to read as follows:

 5

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50

56-263. MEDICAID MANAGED CARE PLAN. (1) The department shall present
to the legislature on the first day of the second session of the sixty-first
Idaho legislature a plan for medicaid managed care with focus on high-cost
populations including, but not limited to:
(a) Dual eligibles; and
(b) High-risk pregnancies.
(2) The medicaid managed care plan shall include, but not be limited to,
the following elements:
(a) Improved coordination of care through primary care medical homes.
(b) Approaches that improve coordination and provide case management
for high-risk, high-cost disabled adults and children that reduce costs
and improve health outcomes, including mandatory enrollment in special
needs plans, and that consider other managed care approaches.
(c) Managed care contracts to pay for behavioral health benefits as described in executive order number 2011-01 and in any implementing legislation. At a minimum, the system should include independent, standardized, statewide assessment and evidence-based benefits provided by
businesses that meet national accreditation standards.
(d) The elimination of duplicative practices that result in unnecessary utilization and costs.
(e) Contracts based on gain sharing, risk-sharing or a capitated basis.
(f) Medical home development with focus on populations with chronic
disease using a tiered case management fee.
(3) The department shall seek federal approval or a waiver to require
that a medicaid participant who has a medical home as required in section
56-255(5)(b), Idaho Code, and who seeks family planning services or supplies
from a provider outside the participant's medical home, must have a referral
to such outside provider. The provisions of this subsection shall apply to
medicaid participants upon such approval or the granting of such a waiver.
SECTION 4. TASK FORCE. (1) The 2019 Legislative Council shall appoint a
bipartisan task force to undertake and complete a study of the impact of Medicaid eligibility expansion on the financial obligation of counties and the
state to provide indigent medical assistance. The Legislative Council shall
determine the number of legislators and membership from each house appointed
to the task force and shall authorize the task force to receive input, advice, and assistance from interested and affected parties who are not members of the Legislature. Nonlegislative members of the task force shall be
appointed by the cochairs of the task force who are appointed by the Legislative Council and shall include, but are not limited to, a person representing the Department of Health and Welfare, a person representing the Idaho
Association of Counties, and a person representing the health care professions. Nonlegislative members of the task force shall not be reimbursed from
legislative funds for per diem, mileage, or other expenses. The task force
shall evaluate the effectiveness of Medicaid eligibility expansion and its
impact on the financial obligation of the counties and the state in providing
indigent assistance including, but not limited to:
(a) The county indigent program and how to leverage savings, if any, resulting from Medicaid eligibility expansion;
(b) The catastrophic health care cost program and how to leverage savings, if any, resulting from Medicaid eligibility expansion;

 6

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

(c) The impact of Medicaid eligibility expansion on the obligation of
counties to provide assistance for involuntary mental health commitments pursuant to chapter 3, title 66, Idaho Code; and
(d) The county charity levy and how to use the levy to pay for the
remaining county nonmedical indigent obligations including, but not
limited to, public defense, indigent burials, jail medical, and other
criminal justice and mental health-related services.
(2) Upon concluding its study, the task force shall report its findings
and recommendations to the Legislature and the Governor.
SECTION 5. SEVERABILITY. The provisions of this act are hereby declared
to be severable and if any provision of this act or the application of such
provision to any person or circumstance is declared invalid for any reason,
such declaration shall not affect the validity of the remaining portions of
this act.
SECTION 6. An emergency existing therefor, which emergency is hereby
declared to exist, this act shall be in full force and effect on and after its
passage and approval.