Bill aimed at improving subacute mental health care accessibility moves forward

A bill seeking to make subacute mental health care more accessible in Iowa moved forward Tuesday while some health coverage providers said the bill could limit necessary reviews of patients receiving this care.

House File 2220, approved unanimously by the subcommittee, addresses treatment for people who are not at a high enough risk to need emergency hospitalization, but need more intense, in-person support than is available through outpatient treatment programs. It makes several changes to time limits in current law for receiving subacute mental health care.

The bill would eliminate the requirement for subacute mental health care to be limited to a period of 10 days unless a longer period is approved by the Iowa Department of Health and Human Services. It also bans preauthorization requirements for being admitted to a subacute mental health care facility for the first 15 days of treatment, in addition to stating Managed Care Organizations (MCOs) can only review the "medical necessity" of a resident's treatment in such a program once per month after the initial and 45-day review.

It also prohibits MCOs from requiring residents' discharge until such a move has been approved by the mental health professional supervising the resident's treatment plan, requiring that they ensure the patient will be able to move outside the facility with enough support to avoid risking harm to themselves or others. Facilities are required to develop written treatment care plans for residents within a day of their admission.

Many of these changes proposed were brought up during the January Subacute Mental Health Care Services Interim Study Committee meeting, when lawmakers heard from Iowa departments of Health and Human Services and Inspections, Appeals, and Licensing officials and impacted family members. During that meeting, speakers said the lack of subacute mental health care available in the state was not entirely because of a lack of resources, but caused in part due to time limitations in current code that made it difficult for patients to access insurance coverage and health providers to make these services economically viable to provide.

But some advocates for MCOs pushed back against the changes, saying that some of the proposals would not make this care more accessible. Lynh Patterson, representing the MCO Wellpoint Iowa, specifically said the health insurance company was concerned with the changes to "prior authorization" included in the bill. She said the changes regarding preauthorization were not brought up as recommendations by the interim committee, and asked for a "continued conversation" on the best ways to improve the system.

"When we look at our data, we don't see that prior authorization has been the barrier to subacute services. Currently, we looked at the amount of requests that we received for prior authorization for 2025, we approved 100% of them — all of them. We also currently allow five days without prior authorization, and then, as required by code, 10 days of concurrence days after that. We would be happy to be part of the solution. … I'm not saying things can't be improved, but we would like to have a discussion, since we weren't aware that this was an issue."

Rep. Rob Johnson, D-Des Moines, asked for clarification on issues with authorization and the timelines set out in the bill. Patterson said the measure as written would provide "almost too much time" without oversight and review, without checking that this care is still actively addressing the patients' mental health needs.

"The average length of stay for our members is … about eight days," Patterson said. "So 45 (days) is extremely long to go without a type of review to make sure that they couldn't be in a better place where they are getting help."

Mary Neubauer, a former Iowa Lottery spokesperson, was one of the people who spoke to the interim study committee about the need to expand subacute services in Iowa. She told the panel about her family's experience attempting to find this type of mental health care for their son, Sergei, who died by suicide in 2017. After her son, who struggled with mental health problems due an abusive childhood in Russia before adoption, was hospitalized for the second time for inpatient psychiatric care, she and her husband searched for a subacute mental health program to help provide Sergei support.

Neubauer said her family found care for their son in a subacute mental health program in Arizona, and he later received "step-down care" in California. After he returned to Iowa, he appeared to be in a better mental state, but went on to commit suicide. Neubauer said having more options to access this care within the state would make a significant difference to families dealing with similar situations.

"There will rightfully be a discussion about the cost of providing this care, but I can tell you that we as a state already are paying those costs at the very highest levels possible," Neubauer told the subcommittee. "That comes through folks in crisis, routinely having to spend days in emergency rooms awaiting treatment, often with law enforcement personnel required to remain with them. It comes through folks in need of treatment, repeatedly having involvement with law enforcement, the courts and the correction system, and as in our case, it comes through the ultimate loss of a loved one's life."

The measure heads to the House Health and Human Services Committee for further consideration.

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