ARC 7885C
HUMAN SERVICES DEPARTMENT[441]
Notice of Intended Action
Proposing rulemaking related to disability services management
and providing an opportunity for public comment
The Department of Health and Human Services (HHS) hereby proposes to amend Chapter 25, “Disability Services Management,” Iowa Administrative Code.
Legal Authority for Rulemaking
This rulemaking is proposed under the authority provided in Iowa Code sections 225C.55 and 225C.69.
State or Federal Law Implemented
This rulemaking implements, in whole or in part, 2023 Iowa Acts, House File 471.
Purpose and Summary
The proposed amendments are designed to provide oversight and establish standards for the regional mental health and disability services system. Chapter 25 needs to be updated to reflect changes made in 2023 Iowa Acts, House File 471, which changed the governance structure for Mental Health and Disability Services (MHDS) regions. Other amendments are designed to clarify a new core (required) service of competency restoration, specifically, that “community” means “outpatient” so it is clear for the courts, attorneys, practitioners, and the public.
A Regulatory Analysis, including the proposed chapter text, was published on January 10, 2024. A public hearing was held on January 31, 2024. HHS received no public comments. The Administrative Rules Coordinator provided preclearance for publication of this Notice of Intended Action on February 5, 2024.
Fiscal Impact
This rulemaking has no fiscal impact to the State of Iowa.
Jobs Impact
After analysis and review of this rulemaking, no impact on jobs has been found.
Waivers
Any person who believes that the application of the discretionary provisions of this rulemaking would result in hardship or injustice to that person may petition HHS for a waiver of the discretionary provisions, if any, pursuant to 441—Chapter 6.
Public Comment
Any interested person may submit written or oral comments concerning this proposed rulemaking. Written or oral comments in response to this rulemaking must be received by HHS no later than 4:30 p.m. on May 24, 2024. Comments should be directed to:

Joe Campos
Lucas State Office Building
321 East 12th Street
Des Moines, Iowa 50319
Phone: 515.304.0963
Email: compliancerules@hhs.iowa.gov	
Public Hearing
Public hearings at which persons may present their views orally or in writing will be held as follows:

May 22, 2024
11:30 a.m. to 12 noon	Microsoft Teams meeting ID: 218 701 087 784
Passcode: nnfJbK	
May 24, 2024
11:30 a.m. to 12 noon	Microsoft Teams meeting ID: 262 230 051 90
Passcode: FFUvAN	
Persons who wish to make oral comments at a public hearing may be asked to state their names for the record and to confine their remarks to the subject of this proposed rulemaking.
Any persons who intend to attend a public hearing and have special requirements, such as those related to hearing or mobility impairments, should contact HHS and advise of specific needs.
Review by Administrative Rules Review Committee
The Administrative Rules Review Committee, a bipartisan legislative committee which oversees rulemaking by executive branch agencies, may, on its own motion or on written request by any individual or group, review this rulemaking at its regular monthly meeting or at a special meeting. The Committee’s meetings are open to the public, and interested persons may be heard as provided in Iowa Code section 17A.8(6).
The following rulemaking action is proposed:
	Item 1. Amend rule 441—25.1(331), parenthetical implementation statute, as follows:
441—25.1(331 225C) Definitions.
	Item 2. Amend rule 441—25.1(331), definitions of “Region” and “Severe and persistent mental illness,” as follows:
“Region” means a mental health and disability service region that operates as the “‘regional administrator’ or ‘regional administrative entity’” as defined in rule 441—25.11(331) 441—25.11(225C).
“Severe and persistent mental illness” or “SPMI” means a documented primary mental health disorder diagnosed by a mental health professional that causes symptoms and impairments in basic mental and behavioral processes that produce distress and major functional disability in adult role functioning inclusive of social, personal, family, educational or vocational roles. The individual has a degree of impairment arising from a psychiatric disorder such that: (1) the individual does not have the resources or skills necessary to maintain function in the home or community environment without assistance or support; (2) the individual’s judgment, impulse control, or cognitive perceptual abilities are compromised; (3) the individual exhibits significant impairment in social, interpersonal, or familial functioning; and (4) the individual has a documented mental health diagnosis. For this purpose, a “mental health diagnosis” means a disorder, dysfunction, or dysphoria diagnosed pursuant to the current version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association (published 2013, with all changes and updates approved by the American Psychiatric Association through September 2023 incorporated herein), excluding neurodevelopmental disorders, substance use disorders, personality disorders, medication-induced movement disorders and other adverse effects of medication, and other conditions that may be a focus of clinical attention as defined in the current version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association (published 2013, with all changes and updates approved by the American Psychiatric Association through September 2023 incorporated herein).
	Item 3. Adopt the following new definition of “Outpatient competency restoration” in rule 441—25.1(331):
“Outpatient competency restoration” means a community-based service to restore competency for individuals found by a court not to pose a danger to the public but to be incompetent to stand trial. The service includes components such as psychiatric prescribing and medication management, mental health and substance use disorder treatment services, competency education, and service coordination.
	Item 4. Amend rule 441—25.2(331) as follows:
441—25.2(331 225C) Core service domains.
	25.2(1) The region shall ensure that core service domains are available in regions as determined in Iowa Code sections 331.397 and 331.397A 225C.65 and 225C.66.
	25.2(2)  No change.
	25.2(3) The region shall ensure that the following services are available for adults in the region:
	a.  to r.  No change.
	s. 	Outpatient competency restoration.
	s.  t.	Peer support.
	t.  u.	Personal emergency response system.
	u.  v.	Prevocational services.
	v.  w.	Respite.
	w.  x.	Subacute mental health services.
	x.  y.	Supported employment.
	y.  z.	Supportive community living.
	z.  aa.	Twenty-four-hour access to crisis response.
	aa.  bb.	Twenty-three-hour crisis observation and holding.
Regions may fund or provide other services in addition to the required core services consistent with requirements set forth in subrules 25.2(5) and 25.2(6).
	25.2(4) The region shall ensure that the following services are available for children in the region:
	a.  to j.  No change.
	k. 	Outpatient competency restoration.
	k.  l.	Prevention.
	25.2(5) and 25.2(6) No change.
	Item 5. Amend rule 441—25.4(331) as follows:
441—25.4(331 225C) Access standards. Regions shall meet the following access standards:
	25.4(1) to 25.4(12) No change.
	Item 6. Amend rule 441—25.5(331) as follows:
441—25.5(331 225C) Practices. A region shall ensure that access is available to providers of core services that demonstrate the following competencies:
	25.5(1) to 25.5(3) No change.
	Item 7. Amend rule 441—25.6(331) as follows:
441—25.6(331 225C) Intensive mental health services. The purpose of intensive mental health services is to provide a continuum of services and supports to adults with complex mental health and multi-occurring conditions who need a high level of intensive and specialized support to attain stability in health, housing, and employment and to work toward recovery.
	25.6(1) to 25.6(7) No change.
	25.6(8) Intensive residential services. The purpose of intensive residential services is to serve adults with the most intensive severe and persistent mental illness conditions who have functional impairments and may also have multi-occurring conditions. Intensive residential services provide intensive 24-hour supervision, behavioral health services, and other supportive services in a community-based residential setting.
	a.  and b.  No change.
	c. 	Eligibility criteria for admission to intensive residential services. To be eligible to receive intensive residential services, an individual shall meet all of the following criteria:
	(1)	No change.
	(2)	The individual has had a standardized functional assessment and screening for multi-occurring conditions completed 30 days or less prior to application for intensive residential services, and the functional assessment and screening demonstrates that the individual:
	1.	Has a diagnosis that meets the criteria of severe and persistent mental illness as defined in rule 441—25.1(331) 441—25.1(225C);
	2. to 6. No change.
	Item 8. Amend rule 441—25.7(331) as follows:
441—25.7(331 225C) Non-core services. When a mental health and disability services region chooses to make the following non-core services available, the region shall ensure that such services meet the requirements of this rule.
	25.7(1) and 25.7(2) No change.
	Item 9. Amend 441—Chapter 25, Division I implementation sentence, as follows:
These rules are intended to implement Iowa Code chapter 331 225C.
	Item 10. Amend 441—Chapter 25, Division II preamble, as follows:
These rules define the standards for a regional service system. The mental health and disability services and children’s behavioral health services shall be delivered in accordance with a regional service system management plan approved by the region’s governing board and implemented by the regional administrator (Iowa Code section 331.393 225C.60). It is the intent of the Iowa general assembly that the adult residents of this state should have access to needed mental health and disability services and that Iowa children should have access to needed behavioral health services regardless of the location of their residence.
	Item 11. Amend rule 441—25.11(331) as follows:
441—25.11(331 225C) Definitions.
“Access point” means a provider, public or private institution, advocacy organization, legal representative, or educational institution with staff trained to complete applications and guide individuals with a disability to needed services.
“Assessment and evaluation” means the same as defined in rule 441—25.1(331) 441—25.1(225C).
“Assistive technology account” means funds in contracts, savings, trust or other financial accounts, financial instruments, or other arrangements with a definite cash value that are set aside and designated for the purchase, lease, or acquisition of assistive technology, assistive technology services, or assistive technology devices. Assistive technology accounts must be held separately from other accounts. Funds must be used to purchase, lease, or otherwise acquire assistive technology services or devices for a working individual with a disability. Any withdrawal from an assistive technology account other than for the designated purpose becomes a countable resource.
“Authorized representative” means a person designated by the individual or by Iowa law to act on the individual’s behalf in specified affairs to the extent prescribed by law.
“Cash flow” means the same as “ending fund balance.”
“Chief executive officer” means the person chosen and supervised by the governing board who serves as the single point of accountability for the mental health and disability services region and whose responsibilities include, but are not limited to, planning, budgeting, monitoring county and regional expenditures, and ensuring the delivery of quality services that achieve expected outcomes for the individuals served.
“Choice” means the individual or authorized representative chooses the services, supports, and goods needed to best meet the individual’s goals and accepts the responsibility and consequences of those choices.
“Clear lines of accountability” means the structure of the governing board’s organization makes it evident that the ultimate responsibility for the administration of the non-Medicaid-funded mental health and disability services lies with the governing board and that the governing board directly and solely supervises the organization’s chief executive officer.
“Community” means an integrated setting of an individual’s choice.
“Conflict-free case management” means there is no real or seeming incompatibility between the case manager’s other interests and the case manager’s duties to the individual served and includes case management separate from direct service provision; eligibility determination for services; establishment of funding levels for the individual’s services; and requirements that prohibit the case manager from performing evaluations, assessments, and plans of care if the case manager is related by blood or marriage to the individual or any of the individual’s paid caregivers or persons financially responsible for the individual or empowered to make financial or health-related decisions on behalf of the individual.
“Coordinator of children’s behavioral health services” means a member of the regional administrative entity staff who meets the requirements described in Iowa Code section 331.390(3)“b” 225C.57(3)“b” and is responsible for coordinating behavioral health services for children.
“Coordinator of mental health and disability services” means a member of the regional administrative entity staff who meets the requirements described in Iowa Code section 331.390(3)“b” 225C.57(3)“b” and is responsible for coordinating mental health and disability services for adults.
“Countable household income” means earned and unearned income of the family of a child according to the modified adjusted gross income methodology.
“Countable resource” means real or personal property that has a cash value that is available to the owner upon disposition and is capable of being liquidated.
“Countable value” means the equity value of a resource, which is the current fair market value minus any legal debt on the item.
“County of residence” means the same as defined in Iowa Code section 331.394 225C.61.
“Department” means the department of health and human services.
“Director” means the director of health and human services.
“Disability services” means the same as defined in Iowa Code section 225C.2.
“Emergency services” means the same as defined in 441—subrule 24.4(15).
“Empowerment” means that the service system ensures the rights, dignity, and ability of individuals and their families to exercise choices, take risks, provide input, and accept responsibility.
“Encumbered” or “encumbrances”  means regional commitments related to obligations or contracts as defined in subrule 25.13(6).
“Ending balance limitation” means the percentage limit allowable by state law that a region’s ending fund balance can exceed actual expenditures for the previous fiscal year.
“Ending balance threshold” means the same as defined in Iowa Code section 225C.7A.
“Ending fund balance” means the amount of residual funds remaining in a region’s combined account at the conclusion of a fiscal year after the region has met the financial obligations for implementation of its regional service system management plan.
“Exempt resource” means a resource that is disregarded in the determination of eligibility for public funding assistance and in the calculation of client participation amounts.
“Federal poverty level” means the most recently revised annual poverty income guidelines published in the Federal Register by the United States Department of Health and Human Services.
“Homeless person” means the same as defined in Iowa Code section 48A.2.
“Household” means, for an individual who is 18 years of age or over, the individual, the individual’s spouse or domestic partner, and any children, stepchildren, or wards under the age of 18 who reside with the individual. For an individual under the age of 18, “household” means the individual, the individual’s parents (or parent and domestic partner), stepparents or guardians, and any children, stepchildren, or wards under the age of 18 of the individual’s parents (or parent and domestic partner), stepparents, or guardians who reside with the individual.
“Income” means all gross income received by the individual’s household, including but not limited to wages, income from self-employment, retirement benefits, disability benefits, dividends, annuities, public assistance, unemployment compensation, alimony, child support, investment income, rental income, and income from trust funds.
“Individual” means any person seeking or receiving services in a regional service system.
“Individualized services” means services and supports that are tailored to meet the personalized needs of the individual.
“Judicial system” means the same as described in Iowa Code section 602.1102.
“Law enforcement” or “law enforcement representative” means the same as “law enforcement officer” as defined in Iowa Code section 80B.3(3), or state and local correctional officers, and community-based corrections personnel.
“Liquid assets” means assets that can be converted to cash in 20 days. Liquid assets include but are not limited to cash on hand, checking accounts, savings accounts, stocks, bonds, cash value of life insurance, individual retirement accounts, certificates of deposit, and other investments.
“Managed care” means a system that provides the coordinated delivery of services and supports that are necessary and appropriate, delivered in the least restrictive settings and in the least intrusive manner. Managed care seeks to balance three factors: achieving high-quality outcomes for participants, coordinating access, and containing costs.
“Managed system” means a system that integrates planning, administration, financing, and service delivery. The system consists of the financing or governing organization, the entity responsible for care management, and the network of service providers.
“Management organization” means an organization contracted to manage part or all of the service system for a region.
“Medical savings account” means an account that is exempt from federal income taxation pursuant to Section 223 of the U.S. Internal Revenue Code (26 U.S.C. §223) (January 5, 2023) as supported by documentation provided by the bank or other financial institution. Any withdrawal from a medical savings account other than for the designated purpose becomes a countable resource.
“Mental health professional” means the same as defined in Iowa Code section 228.1(7).
“Modified adjusted gross income” means the methodology prescribed in 42 U.S.C. Section 1396a(e)(14) and 42 CFR 435.603 (October 1, 2022).
“Non-liquid assets” means assets that cannot be converted to cash in 20 days. Non-liquid assets include, but are not limited to, real estate, motor vehicles, motor vessels, livestock, tools, machinery, and personal property.
“Population” means the same as defined in Iowa Code section 331.388 225C.55.
“Provider” means an individual, firm, corporation, association, or institution which is providing or has been approved to provide medical assistance, is accredited under 441—Chapter 24, holds a professional license to provide the service, is accredited by a national insurance panel, or holds other national accreditation or certification.
“Region incentive fund” means the same as defined in Iowa Code section 225C.7A.
“Regional administrator” or “regional administrative entity” means the administrative office or organization formed by agreement of the counties participating in a mental health and disability services region to function on behalf of those counties.
“Regional service growth factor” means the same as defined in Iowa Code section 225C.7A.
“Regional service fund” means the mental health and disability regional service fund created in Iowa Code section 225C.7A.
“Regional service system management plan” means the regional service system plan developed pursuant to Iowa Code section 331.393 225C.60 for the funding and administration of non-Medicaid-funded mental health and disability services and includes an annual service and budget plan, a policies and procedures manual, and an annual report and how the region will coordinate with the department in the provision of mental health and disability services funded under the medical assistance program.
“Resources” means all liquid and non-liquid assets that are owned in part or in whole by the individual household, that could be converted to cash to use for support and maintenance, and that the individual household is not legally restricted from using for support and maintenance.
“Retirement account” means any retirement or pension fund or account listed in Iowa Code section 627.6(8)“f.”
“Retirement account in the accumulation stage” means a retirement account into which a deposit was made in the previous tax year. Any withdrawal from a retirement account becomes a countable resource.
“Service system” refers to the mental health and disability services and supports administered by the regional administrative entity and paid from the regional services fund.
“State case status” means the standing of an individual who has no county of residence.
“State commission” means the same as defined in Iowa Code section 225C.5.
“System of care” means the coordination of a system of services and supports to individuals and their families that ensures they optimally live, work, and recreate in integrated communities of their choice.
“System principles” means practices that include individual choice, community and empowerment.
	Item 12. Amend rule 441—25.12(331) as follows:
441—25.12(331 225C) Regional governance structure. The counties comprising a mental health and disability services region shall enter into an agreement to form a regional administrator under the control of a governing board to function on behalf of those counties as defined in Iowa Code chapter 28E and sections 331.388, 331.390, 331.392 and 331.399 225C.55, 225C.57, 225C.59 and 225C.68.
	25.12(1) Governing board. The governing board shall comply with the provisions of Iowa Code section 331.390 225C.57, Iowa Code chapter 69 and other applicable laws relating to boards and commissions, including but not limited to the following:
	a. 	The governing board shall include the following voting members:
	(1)	At least one board Board of supervisors member from each county members’ counties comprising the region or their designees. Members representing boards of supervisors shall not exceed 49 percent of the total membership of the governing board.
	(2)	No change.
	(3)	Members designated by the regional children’s behavioral health services advisory committee as follows:
	1.	One member representing the education system in the region.
	2.	One member who is a parent of a child who utilizes children’s behavioral health services or is an actively involved relative of a child who utilizes such services.
	(3)	One member representing the education system in the region.
	(4)	One member who is a parent of a child who utilizes children’s behavioral health services or is an actively involved relative of a child who utilizes such services.
	(5)	One member representing an adult service provider in the region, designated by the regional adult mental health and disability services advisory committee.
	(6)	One member representing a children’s behavioral health service provider in the region, designated by the regional children’s behavioral health services advisory committee.
	(7)	One member representing law enforcement in the region.
	(8)	One member representing the judicial system in the region.
	b. 	The governing board shall include the following nonvoting members in an ex officio capacity:
	(1)	One member representing an adult service provider in the region, designated by the regional adult mental health and disability services advisory committee.
	(2)	One member representing a children’s behavioral health service provider in the region, designated by the regional children’s behavioral health services advisory committee.
	b. 	Each member of the governing board shall have one vote.
	c. 	The governing board shall create a regional adult mental health and disability services advisory committee, which shall designate members to the governing board as defined in Iowa Code section 331.390(2) 225C.57(2).
	d. 	The governing board shall create a regional children’s behavioral health services advisory committee, which shall designate members to the governing board as defined in Iowa Code section 331.390(2) 225C.57(2).
	e. 	No change.
	25.12(2) Regional administrator. The formation of the regional administrator shall be as defined in Iowa Code sections 331.388, 331.390, and 331.399 225C.55, 225C.57, and 225C.68.
	a.  to f.  No change.
	25.12(3) Regional service system management. The region may either directly implement a system of service management and contract with service providers, or contract with a private entity to manage the regional service system, provided all requirements of Iowa Code section 331.393 225C.60 are met by the private entity.
	Item 13. Amend rule 441—25.13(331) as follows:
441—25.13(331 225C) Regional finances.
	25.13(1)  No change.
	25.13(2) Funding. Funding for non-Medicaid mental health and disability services and children’s behavioral health services is under the control of the governing board and shall:
	a.  to c.  No change.
	d. 	Be maintained in a county mental health and disability services fund for the deposit of regional service payments for those counties exempted under Iowa Code section 331.389 225C.56. Expenditures to be made from the county mental health and disability services fund will not be made from any other fund of the county. The exempted county mental health and disability services fund is considered to be the same as a region combined account and is subject to the same requirements as a region combined account.
	25.13(3) Accounting system and financial reporting. The accounting system and financial reporting to the department shall conform to Iowa Code section 331.391 225C.58 and include all non-Medicaid mental health and disability expenditures. Information shall be separated and identified in a uniform chart of accounts, including but not limited to the following: expenses for administration; purchase of services; and enterprise costs for which the region is a service provider or is directly billing and collecting payments.
	25.13(4) to 25.13(7) No change.
	Item 14. Amend rule 441—25.14(331) as follows:
441—25.14(331 225C) Regional governance agreement. The expectations for regional governance agreements entered into by the counties comprising a mental health and disability services region are defined in Iowa Code sections 28E.1, 331.388, 331.390 and 331.392 225C.55, 225C.57, and 225C.59.
	25.14(1) Organizational provisions. The organizational provisions of the regional governance agreement shall include the following:
	a.  to e.  No change.
	f. 	Provisions for joining a region. Additional counties may join the region. The agreement shall not prohibit a county from being assigned by the department to a region according to Iowa Code section 331.389(4)“c.” 225C.56(4)“c.”
	g.  to k.  No change.
	25.14(2) Administrative provisions. The administrative provisions of the regional governance agreement shall include all of the following:
	a. 	Identification of whether the region will either directly implement a system of service management or contract with a private entity to manage the regional service system as defined in Iowa Code section 331.393(7) 225C.60(7).
	b.  to d.  No change.
	25.14(3)  No change.
	Item 15. Amend rule 441—25.15(331) as follows:
441—25.15(331 225C) Eligibility, diagnosis, and functional assessment criteria.
	25.15(1) Eligibility for mental health services. An individual must comply with all of the following requirements to be eligible for mental health services under the regional service system:
	a. 	The individual complies with the financial eligibility requirements in rule 441—25.16(331) 441—25.16(225C).
	b.  and c.  No change.
	d. 	The individual has had at any time during the preceding 12-month period a mental health, behavioral, or emotional disorder or, in the opinion of a mental health professional, may now have such a diagnosable disorder. The diagnosis shall be made in accordance with the criteria provided in the most recent Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association (published 2013, with all changes and updates approved by the American Psychiatric Association through September 2023 incorporated herein) and shall not include the manual’s “V” codes identifying conditions other than a disease or injury. The diagnosis shall also not include substance-related disorders, dementia, antisocial personality, or developmental disabilities, unless co-occurring with another diagnosable mental illness.
	e. 	The results of a standardized functional assessment support the need for mental health services of the type and frequency identified in the individual’s case plan. The standardized functional assessment methodology shall be designated for mental health services by the director of human services in consultation with the state commission. A functional assessment must be completed within 90 days of application for services.
	25.15(2) Eligibility for children’s behavioral health services. An individual must comply with all of the following requirements to be eligible for children’s behavioral health services under the regional service system:
	a.  and b.  No change.
	c. 	The child’s family meets the financial eligibility requirements in rule 441—25.16(331) 441—25.16(225C).
	d. 	The child has been diagnosed with a serious emotional disturbance. A serious emotional disturbance diagnosis is not required to access comprehensive facility and community-based crisis services according to Iowa Code section 331.397A(4)“b.” 225C.66(4)“b.”
	25.15(3) Eligibility for intellectual disability services. An individual must comply with all of the following requirements to be eligible for intellectual disability services under the regional service system:
	a. 	The individual complies with the financial eligibility requirements in rule 441—25.16(331) 441—25.16(225C).
	b.  to d.  No change.
	e. 	The results of a standardized functional assessment support the need for intellectual disability services of the type and frequency identified in the individual’s case plan. The standardized functional assessment methodology shall be designated for intellectual services by the director of human services in consultation with the state commission. A functional assessment must be completed within 90 days of application for services.
	25.15(4)  No change.
	25.15(5) Eligibility for brain injury services. An individual must comply with all of the following requirements to be eligible for brain injury services under the regional service system, if such services were provided to the same class of individuals by a county in the region prior to regional formation.
	a. 	The individual complies with the financial eligibility requirements in rule 441—25.16(331) 441—25.16(225C).
	b.  to d.  No change.
	e. 	The results of a standardized functional assessment support the need for brain injury services of the type and frequency identified in the individual’s case plan. The standardized functional assessment methodology used is the methodology approved for brain injury services by the director of human services in consultation with the state commission. A functional assessment must be completed within 90 days of application for services.
	25.15(6)  No change.
	25.15(7) Eligibility for developmental disability services.
	a. 	Until funding is designated for other service populations, eligibility for the core service domains shall be as identified in Iowa Code section 331.397(2)“b.” 225C.65(2)“b.”
	b. 	No change.
	c. 	The individual complies with the financial eligibility requirements in rule 441—25.16(331) 441—25.16(225C).
	d.  to f.  No change.
	Item 16. Amend rule 441—25.16(331) as follows:
441—25.16(331 225C) Financial eligibility requirements. The regional service system management plan shall identify basic financial eligibility standards for mental health and disability services as defined in Iowa Code sections 331.395 and 331.396A 225C.62 and 225C.64.
	25.16(1) and 25.16(2) No change.
	25.16(3) Cost-share standards. A regional administrative entity must comply with cost-share standards as defined in Iowa Code sections 331.395 and 331.396A 225C.62 and 225C.64.
	a. 	Cost sharing is allowed for adults with income above 150 percent of the federal poverty level as defined by the most recently revised poverty guidelines published by the United States Department of Health and Human Services.
Cost-share amounts for regionally funded adult mental health and disability services in this rule are related to core services as defined in Iowa Code section 331.397 225C.65 and must be identified in the enrollment and eligibility section of the region’s policy and procedures approved by the department.
	b. 	Cost-share amounts for children’s behavioral health services are applicable to core services as defined in Iowa Code section 331.397A 225C.66. The family of a child receiving regional funding for behavioral health services shall be responsible for a cost-share amount based on the family’s household income as follows:

Family Income as a % of FPL	Cost Share % Paid by Family	
0 to 150%	0%	
151 to 200%	10%	
201 to 250%	15%	
251 to 300%	20%	
301 to 350%	35%	
351 to 400%	50%	
401 to 450%	65%	
451 to 500%	80%	
Over 500%	100%	
	25.16(4)  No change.
	Item 17. Amend rule 441—25.17(331) as follows:
441—25.17(331 225C) Exempted counties. If a county has been exempted pursuant to Iowa Code section 331.389 225C.56 from the requirement to enter into a regional service system, the county and the county’s board of supervisors shall fulfill all the requirements of this chapter for a regional service system management plan.
	Item 18. Amend rule 441—25.18(331) as follows:
441—25.18(331 225C) Annual service and budget plan. The annual service and budget plan shall describe the services to be provided and the cost of those services for the ensuing year.
	25.18(1)  No change.
	25.18(2) The annual service and budget plan shall include but not be limited to the following:
	a.  to c.  No change.
	d. 	Intensive mental health services. Identification of the intensive mental health services designated by the region according to rule 441—25.6(331) 441—25.6(225C), including the provider name, contact information, and location of each of the following:
	(1) to (4) No change.
	e. 	No change.
	f. 	Scope of services. A description of the scope of services to be provided, a projection of need for the service, and the funding necessary to meet the need.
	(1)	The scope shall include the regional core services as identified in rule 441—25.2(331) 441—25.2(225C).
	(2)	No change.
	g.  to i.  No change.
	Item 19. Amend rule 441—25.19(331) as follows:
441—25.19(331 225C) Annual service and budget plan approval. The annual service and budget plan shall be submitted each year by April 1. The director shall review all regional annual service and budget plans submitted by the dates specified. If the director finds the regional annual service and budget plan in compliance with these rules and state and federal laws, the director may approve the plan. A plan approved by the director for a fiscal year beginning July 1 shall remain in effect until June 30, subject to amendment.
	25.19(1) to 25.19(5) No change.
	Item 20. Amend rule 441—25.20(331) as follows:
441—25.20(331 225C) Annual report. The annual report shall describe the services provided, the cost of those services, the number of individuals served, and the outcomes achieved for the previous fiscal year. The annual report is due on December 1 following a completed fiscal year of implementing the annual service and budget plan. The annual report shall include but not be limited to:
	1. to 9. No change.	
	Item 21. Amend rule 441—25.21(331) as follows:
441—25.21(331 225C) Policies and procedures manual for the regional service system. The policies and procedures manual shall describe the policies and process developed to direct the management and administration of the regional service system.
	25.21(1) Content. The manual shall include but not be limited to:
	a.  and b.  No change.
	c. 	Eligibility. The process utilized to determine eligibility shall be included in the manual and shall include but not be limited to:
	(1)	No change.
	(2)	Financial eligibility and copayment criteria, which shall meet the requirements of rule 441—25.16(331) 441—25.16(225C).
	(3) and (4) No change.
	d.  to f.  No change.
	g. 	Targeted case management.
	(1) and (2) No change.
	(3)	Targeted case management and service coordination services. Targeted case management and service coordination services utilized in a regional service system shall include but are not limited to the following as defined in Iowa Code section 331.393(4)“g” 225C.60(4)“g”:
	1. to 3. No change.	
	h.  to o.  No change.
	p. 	Service system management. The policies and procedures manual shall identify whether the region will be directly implementing a system of service management or will contract with a private entity to manage the regional service system. If the region contracts with a private entity, the region will ensure that all requirements of Iowa Code section 331.393 225C.60 and these administrative rules are fulfilled.
	q.  and r.  No change.
	25.21(2) and 25.21(3) No change.
	25.21(4) Reconsideration. Regions dissatisfied with the director’s decision on a manual or an amendment may file a letter with the director requesting reconsideration. The letter of reconsideration must be received within 30 working days of the date of the notice of decision and shall include a request for the director to review the decision and the reasons for dissatisfaction. Within 30 working days of the receipt of the letter requesting reconsideration, the director will review both the reconsideration request and evidence provided. The director shall issue a final decision in writing.
These rules are intended to implement Iowa Code sections 331.388 to 331.398 225C.55 to 225C.67.
	Item 22. Amend Free-form subrule 25.22(2) as follows:
	25.22(2) Applicant conditions. To receive funding, a region must submit to the department sufficient data to demonstrate that the region has met the standards in the region’s performance-based contract outlined in rule 441—25.23(331) 441—25.23(225C). Additionally, the region must meet the following conditions:
	a. 	The region must be in compliance with the regional service system management plan as defined in Iowa Code section 331.393 225C.60.
	b.  and c.  No change.
	Item 23. Amend rule 441—25.23(331) as follows:
441—25.23(331 225C) Performance-based contract. The mental health and disability services region shall enter into a performance-based contract with the department to administer the service system in accordance with Iowa Code section 225C.7A. The performance-based contract shall include but not be limited to the following requirements:
	25.23(1) The department will approve, deny, or revise each region’s annual service and budget plan in accordance with rule 441—25.19(331) 441—25.19(225C).
	25.23(2) The region will provide access to all core services under Iowa Code sections 331.397 225C.65 and 331.397A 225C.66 and in accordance with this chapter.
	25.23(3) to 25.23(5) No change.
	25.23(6) The department will take steps to address a region’s noncompliance with the contract in accordance with Iowa Code section 331.389 225C.56.
This rule is intended to implement Iowa Code section 225C.7A.
	Item 24. Amend rule 441—25.41(331) as follows:
441—25.41(331 225C) Minimum data set. Each region shall maintain data on all clients served.
	25.41(1)  No change.
	25.41(2) Data required. The data to be submitted are as follows:
	a.  to e.  No change.
	f. 	Regions must submit their data for each fiscal year by December 1 of the following fiscal year.
	(1) and (2) No change.
	(3)	If the region remains noncompliant after the 30-day time period, the department may take action as allowable under the performance-based contracts established pursuant to rule 441—25.23(331) 441—25.23(225C).
This rule is intended to implement Iowa Code chapter 331, subchapter III, parts 1 and 2 225C, subchapter V.
	Item 25. Amend rule 441—25.51(229), definitions of “County of residence,” “County where the individual is located” and “Mental health and disability services region,” as follows:
“County of residence” means the same as defined in Iowa Code section 331.394 225C.61.
“County where the individual is located” means the individual’s county of residence as defined in Iowa Code section 331.394 225C.61, or if the individual has been ordered to receive treatment services under an Iowa Code chapter 229 commitment and is placed in a residential or other treatment facility.
“Mental health and disability services region” means the same as defined in Iowa Code section 331.389 225C.56.
	Item 26. Amend subrule 25.56(2) as follows:
	25.56(2) As defined in rule 441—25.41(331) 441—25.41(225C), the data to be submitted are as follows:
	a. 	No change.
	b. 	Demographic information, including the individual’s date of birth, sex, ethnicity, education, and diagnosis made in accordance with the criteria provided in the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association (APA) (published 2013, with all changes and updates approved by the American Psychiatric Association through September 2023 incorporated herein).
	c. 	No change.