ARC 4896C
HUMAN SERVICES DEPARTMENT[441]
Adopted and Filed
Rule making related to children’s behavioral health services
The Human Services Department hereby amends Chapter 25, “Disability Services Management,” Iowa Administrative Code.
Legal Authority for Rule Making
This rule making is adopted 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, House File 690.
Purpose and Summary
These 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.
Public Comment and Changes to Rule Making
Notice of Intended Action for this rule making was published in the Iowa Administrative Bulletin on November 20, 2019, as ARC 4762C.
The Department received 22 comments from five respondents on the proposed amendments. The comments and corresponding responses from the Department are divided into four topic areas as follows:
A. Definitions.
B. General.
C. Governing boards and advisory councils.
D. Cost-sharing and resources.
 
A. Definitions.
1. One respondent commented that the rules should include a definition for “medical necessity.”
Department response: No change was made in response to the comment. There is no need to define the term “medical necessity” because it is not used in Chapter 25.
2. One respondent commented that the rules should include a definition for “psychiatric medical institution for children” (PMIC).
Department response: No change was made in response to the comment. The term “psychiatric medical institution for children” is defined in Iowa Code chapter 135H and is not used in Chapter 25. A PMIC is not among the core service domains that the Legislature identified for the Department to define in rule.
3. One respondent commented that the definition for “early identification” should be changed to include “mental illness” along with “developmental delays” and “untreated conditions.”
Department response:  The Department agrees and has added “mental illness” to the conditions listed in the definition of “early identification.”
4. One respondent commented that all noncore domains and services for children should be included, along with a definition for each of them.
Department response: No change was made in response to the comment. The legislation creating the children’s behavioral health system specifically directed the Department to “define the services included in the core domains listed.” Noncore service domains were not listed; therefore, the Department does not have the authority to define them in these rules.
5. One respondent commented that “supplemental services” should be defined.
Department response: No change was made in response to the comment. The legislation creating the children’s behavioral health system specifically directed the Department to “define the services included in the core domains listed.” Supplemental services were not listed as a core domain, and the term “supplemental services” is not used in Chapter 25; therefore, the Department does not have the authority to define the term in these rules.
6. One respondent commented that the term “serious emotional disturbance” (SED) is not clearly defined and that the definition is inconsistent with other definitions of “SED” and should be changed to be the same across all funding sources in the state. The respondent suggested that if a more detailed definition of “SED” is not included in the rule that there should be a reference to the Medicaid state plan amendment that includes that detail.
Department response: No change was made in response to the comment. “Serious emotional disturbance” is defined by reference to the existing definition in Iowa Code section 225C.2, which definition is the same standard used for the children’s mental health waiver. Any further inclusionary or exclusionary criteria would be based on an individual clinical determination by a qualified mental health professional.
B. General.
7. One respondent commented that subrule 25.3(1) should be changed to add the words “for adults” after “core services.”
Department response: No change was made in response to the comment. Subrule 25.3(1) was not included in the noticed changes proposed for Chapter 25 and therefore is not open for revision at this time.
8. One respondent commented that subrule 25.3(2) should be changed to add the words “for adults” after “core services.”
Department response: No change was made in response to the comment. Subrule 25.3(2) was not included in the noticed changes proposed for Chapter 25 and therefore is not open for revision at this time.
9. One respondent commented that access centers are supposed to be for both adults and children, so language throughout the access center requirements should continue to refer to “individuals” rather than being changed to refer to “adults.”
Department response: No change was made in response to the comment. Access centers were created as a part of intensive mental health services for the purpose of serving adults and are required to provide an array of services for adults. Some of the services offered by access centers may also be accessed by individuals under the age of 18, but the centers are not designed as a children’s service. The word “individual” was used in the definition of “access center” to indicate that while regions are required to fund services for children, access centers are allowed to serve individuals under the age of 18 when appropriate and if funding is available.
10. One respondent commented that rule 441—25.7(331) only addresses the noncore services of prescreening assessment and transportation and should include all noncore service domains for adults, including a definition for each of them.
Department response: No change was made in response to the comment. 2018 Iowa Acts, House File 2456, mandated the addition of transportation and prescreening assessment standards to Chapter 25. The legislation did not direct or authorize the addition of other noncore services to these rules. Rule 441—25.7(331) was not included in the noticed changes proposed for Chapter 25 and therefore is not open for revision at this time. The legislation creating the children’s behavioral health system specifically directed the Department to “define the services included in the core domains listed.” Noncore service domains were not listed, so the Department does not have the authority to define them in these rules.
11. One respondent commented that it appears prevention, screening and early intervention services will not be paid for unless the child has a qualifying diagnosis of SED. The respondent would like clarification that prevention, screening and early intervention services are available to any child who needs them and do not require an SED diagnosis at the time of service.
Department response: No change was made in response to the comment. The definitions of and access standards for “prevention” and “education services” specify that such services are intended to increase awareness and understanding, and as described, the reasonable interpretation is that they are applicable to information and activities available to residents of the region without respect to a diagnosis. The definitions of and access standards for “early identification” and “early intervention” indicate that they involve “detecting” untreated conditions that may indicate the need for further evaluation and addressing the needs of children at the earliest stages. These definitions would be meaningless if they did not apply to children who have not yet been diagnosed.
12. One respondent commented that the access standard for early identification services is four weeks and expressed concern that services should be provided more promptly.
Department response: No change was made in response to the comment. The access standards are designed to provide achievable parameters on the reasonable time to ensure services are available. MHDS regions have to work within the capacity of qualified providers and are expected to strive to make all services available as promptly as possible.
13. One respondent commented that the rule should reference the use of telehealth services, such as telepsychiatry, and the use of advanced practice registered nurses who are certified in psychiatric and mental health care to provide services in areas with provider shortages.
Department response: No change was made in response to the comment. These suggestions are beyond the scope of these amendments as authorized by 2019 Iowa Acts, House File 690.
C. Governing boards and advisory councils.
14. One respondent commented that the voting members of the regional governing boards should include one member representing the behavioral health system in the region who is not a provider.
Department response: No change was made in response to the comment. 2019 Iowa Acts, House File 690, specified the voting membership of the regional governing boards, and the Department does not have the authority to change the requirements, which have been codified in Iowa Code section 331.390.
15. One respondent commented that subparagraph 25.14(1)“j”(7), which requires a pediatrician to sit on the regional advisory committees for children’s behavioral health services, should be broadened to include mid-level providers such as advanced registered nurse practitioners (ARNPs), doctors of nursing practice (DNPs), certified pediatric nurse practitioners (CPNPs), certified physician assistants (PA-Cs), or similar professionals because there are limited numbers of pediatricians available, particularly in rural Iowa.
Department response: No change was made in response to the comment. The requirement for a pediatrician to serve as a member of a regional advisory committee for children’s behavioral health services was established in Iowa Code by 2019 Iowa Acts, House File 690; therefore, the Department does not have the authority to make alterations.
16. One respondent commented that the subrule 25.12(1) provision requiring that a governing board member representing the education system in the region be designated as a voting member should be removed because: (1) the education system should not be viewed differently from providers of adult and children’s services which are designated as nonvoting members, and (2) since education systems receive tax dollars, there could be a conflict of interest.
Department response: No change was made in response to the comment. The requirement for a voting regional governing board member representing the education system in the region was included in 2019 Iowa Acts, House File 690, and has been codified in Iowa Code chapter 225; therefore, the Department does not have the authority to make alterations.
17. One respondent commented that the makeup of the regional advisory committees for children’s behavioral health services is too prescriptive and should have broader requirements similar to those of the adult system advisory committees. The respondent specifically suggested:
• The requirement for a pediatrician should be removed or at least broadened to allow a nurse practitioner, psychologist, or therapist.
• The requirement for a child care provider should be removed.
• The requirement for a local law enforcement representative should be allowed to be filled by one person for both the adult and child advisory committees.
Department response: No change was made in response to the comment. The requirements for a pediatrician and a child care provider to be members of the regional advisory committees for children’s behavioral health services are specified in 2019 Iowa Acts, House File 690, now codified in Iowa Code chapter 331; therefore, the Department does not have the authority to make alterations. There is nothing in these rules that prohibits one individual who meets the membership criteria for a seat on the adult advisory committee and a seat on the child advisory committee from serving in both roles.
18. One respondent commented that it would be more reasonable to require one advisory committee for both adult services and children’s services instead of two separate committees, as all the services should be seen as part of one single system.
Department response: No change was made in response to the comment. The requirement for separate advisory committees for adult services and children’s services with specific membership criteria was included in 2019 Iowa Acts, House File 690, now codified in Iowa Code chapter 331; therefore, the Department does not have the authority to make alterations.
19. One respondent commented that the composition of the regional advisory committees for children’s behavioral health services should include a school nurse in addition to the education representative.
Department response: No change was made in response to the comment. The requirements for members of the regional advisory committees for children’s behavioral health services are specified in House File 690, now codified in Iowa Code chapter 331; therefore, the Department does not have the authority to make alterations.
D. Cost-sharing and resource limits.
20. One respondent indicated support for the cost-sharing chart for children’s services and commented that there should also be a consistent cost-sharing fee scale across the state for adults.
Department response: No change was made in response to the comment. 2019 Iowa Acts, House File 690, specifically required that family income eligibility limits for children’s behavioral health services be “subject to a copayment, a single statewide sliding fee scale, or other cost-sharing requirements approved by the department.” There is no similar requirement in Iowa Code for adult services; therefore, the MHDS regions retain flexibility in how income standards are applied, and the Department does not have the authority to impose a statewide standard.
21. One respondent commented that there should be a standard resource limit for the family of a child seeking children’s behavioral health services and that having resource limits for adult services and no resource limits for children’s services does not seem reasonable or fair.
Department response: No change was made in response to the comment. Prior to this rule-making action, Chapter 25 included a resource limit for adults seeking mental health and disability services. Eligibility for new children’s behavioral health services was established by 2019 Iowa Acts, House File 690. The legislation specified an income limitation of 500 percent of the federal poverty level, subject to a copayment, a single statewide sliding fee scale, or other cost-sharing requirement approved by the Department. Since the Legislature chose not to include a resource limit for children’s services, the Department does not have the authority to establish one in rule.
22. One respondent expressed support for the sliding fee scale for children’s behavioral health services, but expressed concern about how quickly the percentage of the family cost-share amount increases, and suggested gathering data to determine if services are declined by families due to the inability to pay the cost-share amount.
Department response: No change was made in response to the comment. The cost-share percentages were established to balance keeping services affordable for families with the ability of regional funding to meet the needs of residents requesting services. MHDS regions are not required to gather data relating to the ability of families to pay the cost-share amounts, but the regions may do so if they choose.
Summary of changes: The definition of “early identification” has been changed to add the words “mental illness” in the phrase “the process of detecting developmental delays, mental illness, or untreated conditions that may indicate the need for further evaluation.” In addition, a rescinded definition in Item 27 was corrected to read “Coordinator of disability services.”
Adoption of Rule Making
This rule making was adopted by the Mental Health and Disability Services Commission on January 16, 2020.
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 to create 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).
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).
Effective Date
This rule making will become effective on March 18, 2020.
The following rule-making actions are adopted:
	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, mental illness, 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 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.
[Filed 1/23/20, effective 3/18/20]
[Published 2/12/20]
Editor’s Note: For replacement pages for IAC, see IAC Supplement 2/12/20.