ARC 4762C
HUMAN SERVICES DEPARTMENT[441]
Notice of Intended Action
Proposing rule making related to children’s behavioral health services
and providing an opportunity for public comment
The Human Services Department hereby proposes to amend Chapter 25, “Disability Services Management,” Iowa Administrative Code.
Legal Authority for Rule Making
This rule making is proposed under the authority provided in Iowa Code chapter 331.
State or Federal Law Implemented
This rule making implements, in whole or in part, 2019 Iowa Acts, chapter 61.
Purpose and Summary
These proposed amendments to Chapter 25 provide the framework for a children’s behavioral health system requiring certain children’s behavioral health core services for children with a serious emotional disturbance. The amendments provide guidance to mental health and disability services (MHDS) regions in developing the new children’s behavioral health core services and include new definitions, provider standards, access standards, and implementation dates.  The amendments also make changes in MHDS regional governance structure and reporting requirements and establish eligibility standards for children’s behavioral health services.  
Fiscal Impact
These changes are expected to increase costs for both the Medicaid program and MHDS regions. There will be additional Medicaid costs to fund increased access to Medicaid-funded services, such as crisis services. Many MHDS regions fund some services for children, such as crisis services, but they do not fund all of the core services nor does every region fund children’s services or have access to crisis services for children.
Jobs Impact
These amendments are not likely to have any significant impact on private-sector jobs and employment opportunities in Iowa. To the extent there is any impact, it would be the creation of a demand for more mental health professionals and direct support staff.
Waivers
Any person who believes that the application of the discretionary provisions of this rule making would result in hardship or injustice to that person may petition the Department for a waiver of the discretionary provisions, if any, pursuant to rule 441—1.8(17A,217).
Public Comment
Any interested person may submit written comments concerning this proposed rule making. Written comments in response to this rule making must be received by the Department no later than 4:30 p.m. on December 10, 2019. Comments should be directed to:

Nancy Freudenberg
Iowa Department of Human Services
Hoover State Office Building, Fifth Floor
1305 East Walnut Street
Des Moines, Iowa 50319-0114
Email: appeals@dhs.state.ia.us	
Public Hearing
No public hearing is scheduled at this time. As provided in Iowa Code section 17A.4(1)“b,” an oral presentation regarding this rule making may be demanded by 25 interested persons, a governmental subdivision, the Administrative Rules Review Committee, an agency, or an association having 25 or more members.
Review by Administrative Rules Review Committee
The Administrative Rules Review Committee, a bipartisan legislative committee which oversees rule making by executive branch agencies, may, on its own motion or on written request by any individual or group, review this rule making 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 rule-making actions are proposed:
	Item 1. Amend 441—Chapter 25, preamble, as follows:
This chapter provides for definitions of regional core services; access standards; implementation dates; practice standards; reporting of regional expenditures; development and submission of regional management plans; data collection; applications for funding as they relate to regional service systems for individuals adults with mental illness, intellectual disabilities, developmental disabilities, or brain injury ; and submission of data for Medicaid offset calculations and children with a serious emotional disturbance.
	Item 2. Adopt the following new definitions of “Behavioral health inpatient treatment,” “Behavioral health outpatient therapy,” “Child,” “Children’s behavioral health services,” “Children’s behavioral health system,” “Early identification,” “Early intervention,” “Education services,” “Mental health inpatient treatment,” “Prevention,” “Serious emotional disturbance” and “State board” in rule 441—25.1(331):
“Behavioral health inpatient treatment” or “mental health inpatient treatment” means inpatient psychiatric services to treat an acute psychiatric condition provided in a licensed hospital with a psychiatric unit or a licensed freestanding psychiatric hospital.
“Behavioral health outpatient therapy” means the same as “outpatient services” described in Iowa Code section 230A.106(2)“a.”
“Child” or “children” means a person or persons under 18 years of age.
“Children’s behavioral health services” means behavioral health services for children who have a diagnosis of serious emotional disturbance.
“Children’s behavioral health system” or “children’s system” means the behavioral health system for children implemented pursuant to Iowa Code chapter 225C.
“Early identification” means the process of detecting developmental delays or untreated conditions that may indicate the need for further evaluation.
“Early intervention” means services designed to address the social, emotional, and developmental needs of children at their earliest stages to decrease long-term effects and provide support in meeting developmental milestones.
“Education services” means activities that increase awareness and understanding of the causes and nature of conditions or factors which affect an individual’s development and functioning.
“Mental health inpatient treatment” or “behavioral health inpatient treatment” means inpatient psychiatric services to treat an acute psychiatric condition that are provided in a licensed hospital with a psychiatric unit or a licensed freestanding psychiatric hospital.
“Prevention” means efforts to increase awareness and understanding of the causes and nature of conditions or situations which affect an individual’s functioning in society. Prevention activities are designed to convey information about the cause of conditions, situations, or problems that interfere with an individual’s functioning or ways in which that information can be used to prevent their occurrence or reduce their effect and may include, but are not limited to, training events, webinars, presentations, and public meetings.
“Serious emotional disturbance” means the same as defined in Iowa Code section 225C.2.
“State board” means the children’s behavioral health system state board created in Iowa Code section 225C.51.
	Item 3. Amend subrule 25.2(1) as follows:
	25.2(1) The region shall ensure that core service domains are available in regions as determined in Iowa Code section sections 331.397and 331.397A.
	Item 4. Amend subrule 25.2(3) as follows:
	25.2(3) The region shall ensure that the following services are available for adults in the region:
	a.  to aa.  No change.
Regions may fund or provide other services in addition to the required core services consistent with requirements set forth in subrules 25.2(4) and25.2(5)and 25.2(6).
	Item 5. Renumber subrules 25.2(4) and 25.2(5) as 25.2(5) and 25.2( 6).
	Item 6. Adopt the following new subrule 25.2(4):
	25.2(4) The region shall ensure that the following services are available for children in the region:
	a. 	Assessment and evaluation relating to eligibility for services.
	b. 	Behavioral health inpatient treatment.
	c. 	Behavioral health outpatient therapy.
	d. 	Crisis stabilization community-based services.
	e. 	Crisis stabilization residential services.
	f. 	Early identification.
	g. 	Early intervention.
	h. 	Education services.
	i. 	Medication prescribing and management.
	j. 	Mobile response.
	k. 	Prevention.
	Item 7. Adopt the following new subrule 25.3(3):
	25.3(3) Regions shall implement the following children’s behavioral health core services on or before July 1, 2020, and meet applicable access standards on or before July 1, 2021:
	a. 	Assessment and evaluation relating to eligibility for services.
	b. 	Behavioral health outpatient therapy.
	c. 	Education services.
	d. 	Medication prescribing and management.
	e. 	Prevention.
	Item 8. Adopt the following new subrule 25.3(4):
	25.3(4) Regions shall implement the following children’s behavioral health core services on or before July 1, 2021, and meet applicable access standards on or before July 1, 2021:
	a. 	Behavioral health inpatient treatment.
	b. 	Crisis stabilization community-based services.
	c. 	Crisis stabilization residential services.
	d. 	Early identification.
	e. 	Early intervention.
	f. 	Mobile response.
	Item 9. Amend subrule 25.4(1) as follows:
	25.4(1) A sufficient provider network which shall include:
	a. 	A community mental health center or federally qualified health center that provides psychiatric and outpatient mental health services to individuals in the region.
	b. 	A hospital with an inpatient psychiatric unit or state mental health institute located in or within reasonably close proximity that has the capacity to provide inpatient services to the applicant.
	Item 10. Amend subrule 25.4(2) as follows:
	25.4(2) Crisis services shall be available 24 hours per day, 7 days per week, 365 days per year for individuals experiencing mental health and disability-related emergencies. A region may make arrangements with one or more other regions to meet the required access standards.
	a.  to d.  No change.
	e. 	Twenty-three-hour observation and holding. An individual adult who has been determined to need 23-hour observation and holding shall receive 23-hour observation and holding within 120 minutes of referral. The service shall be located within 120 miles from the residence of the individual.
	Item 11. Amend subrule 25.4(4) as follows:
	25.4(4) Subacute facility-based mental health services. An individual adult shall receive subacute facility-based mental health services within 24 hours of referral. The service shall be located within 120 miles of the residence of the individual.
	Item 12. Amend subrule 25.4(5) as follows:
	25.4(5) Support for community living for adults. The first appointment shall occur within four weeks of the individual’s request of support for community living.
	Item 13. Amend subrule 25.4(6) as follows:
	25.4(6) Support for employment for adults. The initial referral shall take place within 60 days of the individual’s request of support for employment.
	Item 14. Amend subrule 25.4(7) as follows:
	25.4(7) Recovery services for adults. An individual receiving recovery services shall not have to travel more than 30 miles if residing in an urban area or 45 miles if residing in a rural area to receive services.
	Item 15. Amend subrule 25.4(8) as follows:
	25.4(8) Service coordination.
	a. 	An individual adult receiving service coordination shall not have to travel more than 30 miles if residing in an urban area or 45 miles if residing in a rural area to receive services.
	b. 	An individual adult shall receive service coordination within ten days of the initial request for such service or being discharged from an inpatient facility.
	Item 16. Amend subrule 25.4(9), introductory paragraph, as follows:
	25.4(9) The region shall make the following intensive mental health services available for adults. A region may make arrangements with one or more other regions to meet the required access standards.
	Item 17. Adopt the following new subrule 25.4(11):
	25.4(11) The region shall make the following efforts and activities related to children’s behavioral health available to the residents of the region:
	a. 	Prevention. Prevention activities shall be carried out at least four times a year.
	b. 	Education services. Education activities shall be carried out at least four times a year.
	Item 18. Adopt the following new subrule 25.4(12):
	25.4(12) The region shall ensure that the following behavioral health services are available to children in the region:
	a. 	Early identification. A child shall receive early identification services within four weeks of the time the request for such services is made.
	b. 	Early intervention. A child shall receive early intervention services within four weeks of the time the request for such services is made.
	Item 19. Amend rule 441—25.6(331), introductory paragraph, as follows:
441—25.6(331) Intensive mental health services. The purpose of intensive mental health services is to provide a continuum of services and supports to individuals 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.
	Item 20. Amend subrule 25.6(1) as follows:
	25.6(1) Access centers. The purpose of an access center is to serve individuals adults experiencing a mental health or substance use crisis who are not in need of an inpatient psychiatric level of care and who do not have alternative, safe, effective services immediately available.
	a.  and b.  No change.
	c. 	Eligibility for access center services. To be eligible to receive access center services, an individual shall meet all of the following criteria:
	(1)	The individual is an adult in need of screening, assessment, services or treatment related to a mental health or substance use crisis.
	(2) to (4) No change.
	d. 	No change.
	Item 21. Amend subrule 25.6(2), introductory paragraph, as follows:
	25.6(2) Assertive community treatment (ACT) services. The purpose of assertive community treatment is to serve individuals adults with the most severe and persistent mental illness conditions and functional impairments. ACT services provide a set of comprehensive, integrated, intensive outpatient services delivered by a multidisciplinary team under the supervision of a psychiatrist, an advanced registered nurse practitioner, or a physician assistant under the supervision of a psychiatrist. An ACT program shall designate an individual a staff member to be responsible for administration of the program and with the authority to sign documents and receive payments on behalf of the program.
	Item 22. Amend subrule 25.6(4) as follows:
	25.6(4) 23-hour observation and holding. The purpose of 23-hour observation and holding is to provide up to 23 hours of care for adults in a safe and secure, medically staffed treatment environment. Twenty-three-hour observation and holding shall be provided as described in rule 441—24.37(225C).
	Item 23. Amend subrule 25.6(7), introductory paragraph, as follows:
	25.6(7) Subacute mental health services. The purpose of subacute mental health services is to provide a comprehensive set of wraparound services to individuals adults who have had or are at imminent risk of having acute or crisis mental health symptoms.
	Item 24. Amend subrule 25.6(8), introductory paragraph, as follows:
	25.6(8) Intensive residential services. The purpose of intensive residential services is to serve individuals 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.
	Item 25. Amend 441—Chapter 25, implementation sentence, Division I, as follows:
These rules are intended to implement Iowa Code chapter 331 and 2018 Iowa Acts, House File 2456.
	Item 26. 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 provided by counties operating as a region 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). Iowa counties are encouraged to enter into a regional system when the regional approach is likely to increase the availability of services to residents of the state who need the services. 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 27. Rescind the definitions of “Applicant” and “Coordinator of mental health and disability services” in rule 441—25.11(331).
	Item 28. Adopt the following new definitions of “Coordinator of children’s behavioral health services,” “Coordinator of mental health and disability services,” “Countable household income,” “Federal poverty level,” and “Modified adjusted gross income” in rule 441—25.11(331):
“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” 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” 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.
“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.
“Modified adjusted gross income” means the methodology prescribed in 42 U.S.C. Section 1396a(e)(14) and 42 CFR 435.603.
	Item 29. Amend subrule 25.12(1) as follows:
	25.12(1) Governing board. The governing board shall comply with the provisions of Iowa Code section 331.390, Iowa Code chapter 69 and other applicable laws relating to boards and commissions, including but not limited to the following requirements:
	a. 	The governing board shall comply with the membership requirements as outlined in Iowa Code section 331.390 and follow the requirements in Iowa Code chapter 69 and other applicable laws relating to boards and commissions. include the following voting members:
	(1)	At least one board of supervisors member from each county comprising the region or their designees.
	(2)	One adult person who utilizes mental health and disability services or is an actively involved relative of an adult who utilizes such services, designated by the regional adult mental health and disability services advisory committee.
	(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.
	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.  c.	A The governing board shall create a regional adult mental health and disability services advisory committee shall be created and, which shall designate members to the governing board as defined in Iowa Code section 331.390(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).
	c.  e.	The governing board shall appoint and evaluate the performance of the chief executive officer of the regional administrative entity who will serve as the single point of accountability for the region.
	Item 30. Amend subrule 25.12(2) as follows:
	25.12(2) Regional administrator. The formation of the regional administrator shall be as defined in Iowa Code sections 331.388 and 331.390.
	a.  to d.  No change.
	e. 	The regional administrative entity staff shall include one or more coordinators of mental health and disability services.
	f. 	The regional administrative entity staff shall include one or more coordinators of children’s behavioral health services.
	Item 31. Amend subrule 25.13(1), introductory paragraph, as follows:
	25.13(1) Funding. Non-Medicaid Funding for non-Medicaid mental health and disability services funding and children’s behavioral health services is under the control of the governing board and shall:
	Item 32. Amend paragraph 25.14(1)“i” as follows:
	i. 	Provision for formation and assigned responsibilities for one or more regional advisory committees for adult mental health and disability services consisting of:
	(1)	Individuals who utilize services or the actively involved relatives of such individuals.
	(2)	Service providers of adult mental health and disability services.
	(3)	Governing board members.
	(4)	Other interests identified in the agreement.
	Item 33. Adopt the following new paragraph 25.14(1)“j”:
	j. 	Provision for formation and assigned responsibilities for one or more regional advisory committees for children’s behavioral health services consisting of:
	(1)	A parent of a child who utilizes services or an actively involved relative of such child.
	(2)	A member of the education system.
	(3)	An early childhood advocate.
	(4)	A child welfare advocate.
	(5)	A children’s behavioral health service provider.
	(6)	A member of the juvenile court.
	(7)	A pediatrician.
	(8)	A child care provider.
	(9)	A local law enforcement representative.
	(10)	A regional governing board member.
	Item 34. Amend paragraph 25.14(2)“c” as follows:
	c. 	A general list of the functions and responsibilities of the regional administrative entity’s chief executive officer and other staff including but not limited to coordinators of mental health and disability services and coordinators of children’s behavioral health services.
	Item 35. Rescind subrule 25.15(2) and adopt the following new subrule in lieu thereof:
	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. 	The individual is a child under 18 years of age.
	b. 	The child’s custodial parent is a resident of the state of Iowa, and the child is physically present in the state.
	c. 	The child’s family meets the financial eligibility requirements in rule 441—25.16(331).
	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.”
	Item 36. Amend rule 441—25.16(331), introductory paragraph, as follows:
441—25.16(331) 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 section sections 331.395and 331.396A.
	Item 37. Rescind subrule 25.16(1) and adopt the following new subrule in lieu thereof:
	25.16(1) Income requirements.
	a. 	Income requirements for adult mental health and disability services shall be as follows:
	(1)	The person must have an income equal to or less than 150 percent of the federal poverty level.
	(2)	A person who is eligible for federally funded services and other support must apply for such services and support.
	b. 	Income requirements for children’s behavioral health services shall be as follows:
	(1)	The child’s family has countable household income equal to or less than 500 percent of the federal poverty level. Countable household income and family size shall be determined using the modified adjusted gross income methodology.
	(2)	An eligible child whose family’s countable household income is at least 150 percent and not more than 500 percent of the federal poverty level shall be subject to a cost share as described in subrule 25.16(3).
	(3)	Verification of income. Income shall be verified using the best information available.
	1.	Pay stubs, tip records and employers’ statements are acceptable forms of verification of earned income.
	2.	Self-employment income can be verified through business records from the previous year if they are representative of anticipated earnings. If business records from the previous year are not representative of anticipated earnings, an average of the business records from the previous two or three years may be used if that average is representative of anticipated earnings.
	(4)	Changes in income. Financial eligibility shall be reviewed on an annual basis and may be reviewed more often in response to increases or decreases in income.
	(5)	A child who is eligible for federally funded services and other support must apply for such services and support.
	Item 38. Amend subrule 25.16(2), introductory paragraph, as follows:
	25.16(2) Resource requirements. There are no resource limits for the family of a child seeking children’s behavioral health services. An individual adult seeking mental health and disability services must have resources that are equal to or less than $2,000 in countable value for a single-person household or $3,000 in countable value for a multiperson household or follow the most recent federal supplemental security income guidelines.
	Item 39. Rescind subrule 25.16(3) and adopt the following new subrule in lieu thereof:
	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.
	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 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. 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%	
	Item 40. Amend subrule 25.16(4), introductory paragraph, as follows:
	25.16(4) Copayment Cost-share standards required by any federal, state, regional, or municipal program. Any copayments cost sharing or other client participation required by any federal, state, regional or municipal program in which the individual participates shall be required by the regional administrative entity. Such copayments include cost sharing includes, but are is not limited to:
	Item 41. Amend subrule 25.18(1) as follows:
	25.18(1) The annual service and budget plan is due on April 1 prior to the July 1 implementation of the annual plan and shall be approved by the region’s governing board prior to submittal to the department. The initial plan is due on April 1, 2014.
	Item 42. Amend subrule 25.18(2) as follows:
	25.18(2) The annual service and budget plan shall include but not be limited to the following:
	a. 	The locations of the Access points. A list of the local access points for mental health and disability services . This shall include and children’s behavioral health services, including the name names of the access points including and the physical locations and contact information.
	b. 	Targeted Service coordination and targeted case management. The A list of the service coordination and targeted case management agencies for utilized in the region, whether funded by the region, the medical assistance program, or third-party payers, including the physical location and contact information for those agencies, shall be included.
	c. 	Crisis planning. A list of accredited crisis services available in the region for crisis prevention, response and resolution, including contact information for the agencies responsible, shall be included.
	d. 	Intensive mental health services. Identification of the intensive mental health services designated by the region according to rule 441—25.6(331), including the provider name, contact information, and location of each of the following, shall be included:
	(1)	Access center(s).
	(2)	ACT services.
	(3)	Intensive residential services.
	(4)	Subacute mental health services.
	e. 	Children’s behavioral health services. Identification of children’s behavioral health services as described in subrule 25.2(4), including eligibility requirements or reference to where eligibility requirements can be found in the policies and procedures manual.
	e.  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 shall be included.
	(1)	The scope shall include the regional core services as defined identified in rule 441—25.1(331) 441—25.2(331).
	(2)	The scope shall also include services in addition to the required core services.
	f.  g.	Budget and financing provisions for the next year. The provisions shall address how county, regional, state and other funding sources will be used to meet the service needs within the region.
	g.  h.	Financial forecasting measures. The plan shall describe A description of the financial forecasting measures used in the identification of service need and funding necessary for services and a financial statement of actual revenues and actual expenses by chart of account codes, including levies by county.
	h.  i.	The provider Provider reimbursement provisions. The plan shall describe A description of the types of provider reimbursement methods that will be used, including fee for service, compensating providers compensation for a “system of care” approach, and for use of nontraditional providers. A region also shall provide information on funding approaches that identify and incorporate all services and sources of funding used by the individuals receiving services, including the medical assistance program.
	Item 43. Amend rule 441—25.20(331) as follows:
441—25.20(331) 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 initial report is due on December 1, 2015. The annual report shall include but not be limited to:
	1.	Services actually provided.
	2.	The status of service development.
	2. 3.	Actual numbers of individuals children and adults served.
	3. 4.	Documentation that each regionally designated access center has met the service standards in subrule 25.6(1).
	4. 5.	Documentation that each regionally designated ACT team has been evaluated for program fidelity, including a peer review as required by subrule 25.6(2), and documentation of each team’s most recent fidelity score.
	5. 6.	Documentation that each regionally designated subacute service has met the service standards in subrule 25.6(7).
	6. 7.	Documentation that each regionally designated intensive residential service home or intensive residential service has met the service standards in subrule 25.6(8).
	7. 8.	Moneys expended. Financial statement of actual revenues and actual expenditures by chart of account codes, including levies by county.
	8. 9.	Outcomes achieved.
	Item 44. Amend subrule 25.21(1) as follows:
	25.21(1) Content. The manual shall include but not be limited to:
	a. 	No change.
	b. 	Enrollment. The application and enrollment process that is readily accessible to applicants individuals and their families or authorized representatives shall be included. This procedure shall identify regional access points and where applicants individuals can apply for services and how and when the applications will reach the regional administrative entity’s designated staff for processing.
	c. 	Eligibility. The process utilized to determine eligibility shall be included in the manual and shall include but not be limited to:
	(1) to (3) No change.
	(4)	The process for development of a written notice of decision. The time frame for sending a written notice of decision to the individual and guardian (if applicable) and the service providers identified in the notice shall be included. The notice of decision shall:
	1. and 2. No change.	
	3.	Outline the applicant’s individual’s right to appeal.
	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”:
	1.	Performance and outcome measures relating to the health, safety, school attendance and performance, work performance, and community residency of the individuals receiving the services.
	2. and 3. No change.	
	h.  to r.  No change.
	Item 45. Rescind 441—Chapter 25, Division IV, heading and preamble.
	Item 46. Rescind rules 441—25.51(77GA,HF2545) to 441—25.55(77GA,HF2545).
	Item 47. Rescind 441—Chapter 25, Division IV, implementation sentence.
	Item 48. Rescind 441—Chapter 25, Division V, heading and preamble.
	Item 49. Rescind rules 441—25.61(426B) to 441—25.66(426B).
	Item 50. Rescind 441—Chapter 25, Division V, implementation sentence.
	Item 51. Rescind 441—Chapter 25, Division VI, heading and preamble.
	Item 52. Rescind rules 441—25.71(78GA,ch1221) to 441—25.77(78GA,ch1221).
	Item 53. Rescind 441—Chapter 25, Division VI, implementation sentence.
	Item 54. Rescind 441—Chapter 25, Division IX, heading and preamble.
	Item 55. Rescind rules 441—25.95(426B) and 441—25.96(426B).
	Item 56. Rescind 441—Chapter 25, Division IX, implementation sentence.
	Item 57. Renumber 441—Chapter 25, Division X, heading and preamble, as 441—Chapter 25, Division IV, heading and preamble.
	Item 58. Renumber rules 441—25.101(229) to 441—25.107(229) as 441—25.51(229) to 441—25.57(229).
	Item 59. Amend renumbered paragraph 25.52(2)“b” as follows:
	b. 	A person employed as an advocate on or before July 1, 2015, who does not meet the requirements of subparagraph 25.102(2)“a”(1) or (2) 25.52(2)“a”(1) or (2) shall be considered to meet those requirements so long as the person is continuously appointed as an advocate in the employing county.