CHAPTER 13
PROGRAM EVALUATION
Preamble
The purpose of this chapter is to define the methods and procedures used by the department to provide a systematic method for measuring the validity of the eligibility determinations in the aid to dependent children (ADC), food stamp, and Medicaid programs; to provide a basis for establishing state agency liability for errors that exceed the national standard and state agency eligibility for enhanced funding; and to provide program information which can be used by the department in determining a corrective action plan to ensure the rules and regulations are implemented in accordance with the ADC, food stamp and Medicaid rules.
441—13.1(234,239B,249A) Definitions.
“Active case” means a case that was receiving assistance for the month of review.
“Case record” means the record used to establish a client’s eligibility.
“Client” means a current or former applicant or recipient of aid to dependent children, food stamps, or Medicaid.
“Collateral contact” means a source of information which can be used to verify the client’s circumstances.
“Department” means the Iowa department of human services.
“Field investigation” means a contact involving the public or other agencies to obtain information about the client’s circumstances for the appropriate month of review.
“Local agency” means the local or district office of the department.
“Month of review” means the specific calendar or fiscal month for which the assistance under review is received.
“Negative case” means a case that was terminated or denied assistance for the month of review.
“Public assistance programs” means those programs involving federal funds, i.e., aid to dependent children, food stamps, Medicaid.
“Random sample” means a systematic (or every nth unit) sample drawn monthly for which each item in the universe has an equal probability of being selected. Sample size is determined by federal guidelines.
“State policies” means the rules and regulations used by the local agency to administer the aid to dependent children, food stamp, and Medicaid programs.
This rule is intended to implement Iowa Code sections 234.12, 239B.4, and 249A.4.
441—13.2(234,239B,249A) Review of public assistance records by the department.
	13.2(1) Authorized representatives of the department shall have the right to review case records to determine the following:
	a. 	If the client has provided complete, correct and accurate information to the local agency to be used in the determination of the assistance benefits.
	b. 	If the local agency has correctly administered the state policies in determination of assistance for the public assistance programs.
	c. 	Whether overpayments or underpayments have been made correctly to the public assistance client during the month of review.
	d. 	If there is indication of fraudulent practice or abuse of the public assistance programs by either the client or local agency.
	13.2(2) All pertinent case records within the department may be used by the reviewer to assist in substantiating an accurate reflection as to the correctness of the assistance paid to the client.
This rule is intended to implement Iowa Code sections 234.12, 239B.4 and 249A.4.
441—13.3(234,239B,249A) Who shall be reviewed. Any active or negative public assistance case may be reviewed at any time at the discretion of the department based upon a random sample to:
	13.3(1) Ensure federal and state requirements for quality control are met.
	13.3(2) Detect error prone case issues to assist in corrective action.
	13.3(3) Maintain public assistance program integrity.
This rule is intended to implement Iowa Code sections 234.12, 239B.4, and 249A.4.
441—13.4(234,239B,249A) Notification of review. On positive case actions, clients shall be notified, either orally or in writing, that their case has been selected for review. The client will be contacted in a negative case only if a discrepancy exists which cannot be resolved from the case record.
This rule is intended to implement Iowa Code sections 234.12, 239B.4, and 249A.4.
441—13.5(234,239B,249A) Review procedure. The department will select the appropriate method of conducting the review. Review procedures may include, but are not limited to, the following:
	13.5(1) A random sampling of active and negative case actions shall be used to determine the case records to be studied.
	13.5(2) The case record shall be analyzed for discrepancies, correct application of policies and procedures and shall be used as the basis for a field investigation.
	13.5(3) Client interviews shall be required as follows:
	a. 	Personal interviews are required on all active aid to dependent children and food stamp reviews. Form 470-1065, Appointment Confirmation, may be sent to the client requesting written confirmation of the appointment time.
	b. 	In lieu of the personal interview, Medicaid clients or their representatives are required to provide all information requested on Form 470-1633, Medicaid Questionnaire.
	c. 	Client contacts are only required in negative case reviews when there is a discrepancy which cannot be resolved from the case record.
	13.5(4) Collateral contacts are required whenever the client is unable to furnish information needed or the reviewer needs additional information to establish the correctness of eligibility and payment. The following forms shall be used to contact the collateral source in order to verify information specified below. The collateral contact shall complete the requested information and return the form to the reviewer.
	a. 	The client shall not be required to give written permission of the following collateral contacts:
	(1)	Absent Parent Questionnaire, Form 470-0457, sent to the absent parent in order to determine whether or not the absent parent had provided any income to or had any resources for the client or children which would have affected the review month.
	(2)	Grandparent Questionnaire, Form 470-1643, sent to the child(ren)’s grandparents to determine whether or not the grandparents had provided any income or had any resources for the client or child(ren) which would have affected the review month.
	(3)	Motor Vehicle Information Request, Form 470-1634, used to determine whether or not the client had any registered vehicles.
	(4)	Property Verification Request, Form 470-1641, used to determine whether or not the client had any recorded property.
	(5)	Application for Confidential Verification of Vital Statistics, Form 470-0474, used to verify birth, death, and marital status when the event took place in Iowa.
	(6)	Address Information Request, Form 470-0176, used to contact the post office to determine a person’s mailing address.
	(7)	Facility Questionnaire, Form 470-0100, used in Medicaid cases to determine information concerning a client’s stay in a facility.
	(8)	Parent Questionnaire for Foster Children, Form 470-2014, used to contact the natural parents of the foster care child to determine the resources and income of the child.
	(9)	Foster Parent Questionnaire, Form 470-2013, used to contact the foster parents of the foster child to determine any resources and income of the child.
	(10)	Child Support Verification Request, Form 470-2009, used to contact the clerk of court or the friend of court in order to determine if child support or alimony was paid.
	b. 	The client shall be required to sign the following specified release of information forms whenever necessary to verify information essential to the determination of eligibility and payment:
	(1)	Household Member Questionnaire, Form 470-1630, used to obtain information concerning a client’s household composition.
	(2)	Landlord Questionnaire, Form 470-1632, used to contact the client’s landlord.
	(3)	Financial Institution Questionnaire, Form 470-1631, used to verify information from a financial institution.
	(4)	Request for School Verification, Form 470-1638, used to verify information in the child(ren)’s school records.
	(5)	Earned Income Verification, Form 470-1639, used to verify information concerning a client’s employment.
	(6)	Verification of Educational Financial Aid, Form 470-1640, used to verify information from an institution of higher learning.
	(7)	Authorization for Release of Information, Form 470-0461, used whenever it is necessary to verify information which is not covered by a specific release in order to establish the correctness of eligibility and payment.
	c. 	Should the client refuse to authorize the department to contact an informant to verify information that is necessary for the completion of the review, collateral contacts shall still be made through use of the general release statement contained in the:
	(1)	Health and Financial Support Application, Form 470-0462 or 470-0466 (Spanish);
	(2)	Health Services Application, Form 470-2927 or 470-2927(S);
	(3)	Public Assistance Eligibility Report, Form 470-0454, 470-0455, or 470-3719(S);
	(4)	Application for Food Assistance, Form 470-0306 or 470-0307 (Spanish);
	(5)	Review/Recertification Eligibility Document, Form 470-2881, 470-2881(M), 470-4083 (Spanish), or 470-4083(M);
	(6)	Food Assistance Interim Report, Form 470-4026, 470-4026(M), or 470-4026(S).
	13.5(5) On aid to dependent children and Medicaid reviews, the quality control reviewer shall seek to identify potential third-party payment resources for health services in noncasualty situations, and to identify accidents that occurred prior to or during the review month.
This rule is intended to implement Iowa Code sections 234.12, 239B.4 and 249A.4.
441—13.6(234,239B,249A) Failure to cooperate. Client cooperation with quality control is a program eligibility requirement as set forth in 441—subrule 40.7(4), paragraph “d,” and rules 441—65.3(234) and 441—76.8(249A). When quality control determines that the client has refused to cooperate with the review process, the client is no longer eligible for the program benefits and will not be eligible for the program benefits until the client has cooperated.
This rule is intended to implement Iowa Code sections 234.12, 239B.4 and 249A.4.
441—13.7(234,239B,249A) Report of findings. The quality control review findings are utilized by the department in the following ways:
	13.7(1) The local agency will use the findings in taking the appropriate case actions where an overpayment or underpayment has been found in a client’s case record.
	13.7(2) The department will use the overall findings to identify error prone program issues to be used in planning their corrective action plan.
	13.7(3) The department will use the findings of the overall sample period to determine the error rate used to establish state agency liability or enhanced funding.
This rule is intended to implement Iowa Code sections 234.12, 239B.4 and 249A.4.
441—13.8(234,239B,249A) Federal rereview. A sample of the cases selected by the department for review will also be reviewed by the applicable federal agency to determine the correctness of the department’s review of the case.
[Filed 3/26/87, Notice 1/28/87—published 4/22/87, effective 6/1/87]
[Filed emergency 10/10/03—published 10/29/03, effective 11/1/03]
[Filed emergency 11/16/05—published 12/7/05, effective 12/1/05]