CHAPTER 78
AMOUNT, DURATION AND SCOPE OF
MEDICAL AND REMEDIAL SERVICES
[Prior to 7/1/83, Social Services[770] Ch 78]
[Prior to 2/11/87, Human Services[498]]
441—78.1(249A) Physicians’ services. Payment will be approved for all medically necessary services and supplies provided by the physician including services rendered in the physician’s office or clinic, the home, in a hospital, nursing home or elsewhere.
Payment shall be made for all services rendered by a doctor of medicine or osteopathy within the scope of this practice and the limitations of state law subject to the following limitations and exclusions:
	78.1(1) Payment will not be made for:
	a. 	Drugs dispensed by a physician or other legally qualified practitioner (dentist, podiatrist, therapeutically certified optometrist, physician assistant, or advanced registered nurse practitioner) unless it is established that there is no licensed retail pharmacy in the community in which the legally qualified practitioner’s office is maintained. Payment will not be made for biological supplies and drugs provided free of charge to practitioners by the state department of public health. Rate of payment shall be established as in subrule 78.2(2), but no professional fee shall be paid.
	b. 	Routine physical examinations. Rescinded IAB 8/1/07, effective 8/1/07.
	c. 	Treatment of certain foot conditions as specified in 78.5(2)“a,” “b,” and “c.”
	d. 	Acupuncture treatments.
	e. 	Rescinded 9/6/78.
	f. 	Unproven or experimental medical and surgical procedures. The criteria in effect in the Medicare program shall be utilized in determining when a given procedure is unproven or experimental in nature.
	g. 	Charges for surgical procedures on the “Outpatient/Same Day Surgery List” produced by the Iowa Foundation for Medical Care or associated inpatient care charges when the procedure is performed in a hospital on an inpatient basis unless the physician has secured approval from the hospital’s utilization review department prior to the patient’s admittance to the hospital. Approval shall be granted only when inpatient care is deemed to be medically necessary based on the condition of the patient or when the surgical procedure is not performed as a routine, primary, independent procedure. The “Outpatient/Same Day Surgery List” shall be published by the department in the provider manuals for hospitals and physicians. The “Outpatient/Same Day Surgery List” shall be developed by the Iowa Foundation for Medical Care, and shall include procedures which can safely and effectively be performed in a doctor’s office or on an outpatient basis in a hospital. The Iowa Foundation for Medical Care may add, delete, or modify entries on the “Outpatient/Same Day Surgery List.”
	78.1(2) Drugs and supplies may be covered when prescribed by a legally qualified practitioner as provided in this rule.
	a. 	Drugs are covered as provided by rule 441—78.2(249A).
	b. 	Medical supplies are payable when ordered by a legally qualified practitioner for a specific rather than incidental use, subject to the conditions specified in rule 441—78.10(249A). When a member is receiving care in a nursing facility or residential care facility, payment will be approved only for the following supplies when prescribed by a legally qualified practitioner:
	(1)	Colostomy and ileostomy appliances.
	(2)	Colostomy and ileostomy care dressings, liquid adhesive and adhesive tape.
	(3)	Disposable irrigation trays or sets.
	(4)	Disposable catheterization trays or sets.
	(5)	Indwelling Foley catheter.
	(6)	Disposable saline enemas.
	(7)	Diabetic supplies including needles and syringes, blood glucose test strips, and diabetic urine test supplies.
	c. 	Prescription records are required for all drugs as specified in Iowa Code sections 124.308, 155A.27 and 155A.29. For the purposes of the medical assistance program, prescriptions for medical supplies are required and shall be subject to the same provisions.
	d. 	Rescinded IAB 1/30/08, effective 4/1/08.
	e. 	All physicians who administer vaccines which are available through the Vaccines for Children program to Medicaid members shall enroll in the Vaccines for Children program. Vaccines available through the Vaccines for Children program shall be obtained from the department of public health for Medicaid members. Physicians shall, however, receive reimbursement for the administration of these vaccines to Medicaid members.
	f. 	Nonprescription drugs. Rescinded IAB 1/30/08, effective 4/1/08.
	78.1(3) Payment will be approved for injections provided they are reasonable, necessary, and related to the diagnosis and treatment of an illness or injury. When billing for an injection, the legally qualified practitioner must specify the brand name of the drug and the manufacturer, the strength of the drug, the amount administered, and the charge of each injection. When the strength and dosage of the drug is not included, payment will be made based on the customary dosage. The following exclusions are applicable.
	a. 	Payment will not be approved for injections when they are considered by standards of medical practice not to be specific or effective treatment for the particular condition for which they are administered.
	b. 	Payment will not be approved for an injection when administered for a reason other than the treatment of a particular condition, illness, or injury. When injecting an amphetamine or legend vitamin, prior approval must be obtained as specified in 78.1(2)“a”(3).
	c. 	Payment will not be approved when injection is not an indicated method of administration according to accepted standards of medical practice.
	d. 	Allergenic extract materials provided the patient for self-administration shall not exceed a 90-day supply.
	e. 	Payment will not be approved when an injection is determined to fall outside of what is medically reasonable or necessary based on basic standards of medical practice for the required level of care for a particular condition.
	f. 	Payment will not be approved for vaccines which are available through the Vaccines for Children program. In lieu of payment, vaccines available through the Vaccines for Children program shall be accessed from the department of public health.
	g. 	Payment will not be approved for injections of “covered Part D drugs” as defined by 42 U.S.C. Section 1395w-102(e)(1)-(2) for any “Part D eligible individual” as defined in 42 U.S.C. Section 1395w-101(a)(3)(A), including an individual who is not enrolled in a Part D plan.
	78.1(4) For the purposes of this program, cosmetic, reconstructive, or plastic surgery is surgery which can be expected primarily to improve physical appearance or which is performed primarily for psychological purposes or which restores form but which does not correct or materially improve the bodily functions. When a surgical procedure primarily restores bodily function, whether or not there is also a concomitant improvement in physical appearance, the surgical procedure does not fall within the provisions set forth in this subrule. Surgeries for the purpose of sex reassignment are not considered as restoring bodily function and are excluded from coverage.
	a. 	Coverage under the program is generally not available for cosmetic, reconstructive, or plastic surgery. However, under certain limited circumstances payment for otherwise covered services and supplies may be provided in connection with cosmetic, reconstructive, or plastic surgery as follows:
	(1)	Correction of a congenital anomaly; or
	(2)	Restoration of body form following an accidental injury; or
	(3)	Revision of disfiguring and extensive scars resulting from neoplastic surgery.
	(4)	Generally, coverage is limited to those cosmetic, reconstructive, or plastic surgery procedures performed no later than 12 months subsequent to the related accidental injury or surgical trauma. However, special consideration for exception will be given to cases involving children who may require a growth period.
	b. 	Cosmetic, reconstructive, or plastic surgery performed in connection with certain conditions is specifically excluded. These conditions are:
	(1)	Dental congenital anomalies, such as absent tooth buds, malocclusion, and similar conditions.
	(2)	Procedures related to transsexualism, hermaphroditism, gender identity disorders, or body dysmorphic disorders.
	(3)	Cosmetic, reconstructive, or plastic surgery procedures performed primarily for psychological reasons or as a result of the aging process.
	(4)	Breast augmentation mammoplasty, surgical insertion of prosthetic testicles, penile implant procedures, and surgeries for the purpose of sex reassignment.
	c. 	When it is determined that a cosmetic, reconstructive, or plastic surgery procedure does not qualify for coverage under the program, all related services and supplies, including any institutional costs, are also excluded.
	d. 	Following is a partial list of cosmetic, reconstructive, or plastic surgery procedures which are not covered under the program. This list is for example purposes only and is not considered all inclusive.
	(1)	Any procedure performed for personal reasons, to improve the appearance of an obvious feature or part of the body which would be considered by an average observer to be normal and acceptable for the patient’s age or ethnic or racial background.
	(2)	Cosmetic, reconstructive, or plastic surgical procedures which are justified primarily on the basis of a psychological or psychiatric need.
	(3)	Augmentation mammoplasties.
	(4)	Face lifts and other procedures related to the aging process.
	(5)	Reduction mammoplasties, unless there is medical documentation of intractable pain not amenable to other forms of treatment as the result of increasingly large pendulous breasts.
	(6)	Panniculectomy and body sculpture procedures.
	(7)	Repair of sagging eyelids, unless there is demonstrated and medically documented significant impairment of vision.
	(8)	Rhinoplasties, unless there is evidence of accidental injury occurring within the past six months which resulted in significant obstruction of breathing.
	(9)	Chemical peeling for facial wrinkles.
	(10)	Dermabrasion of the face.
	(11)	Revision of scars resulting from surgery or a disease process, except disfiguring and extensive scars resulting from neoplastic surgery.
	(12)	Removal of tattoos.
	(13)	Hair transplants.
	(14)	Electrolysis.
	(15)	Sex reassignment.
	(16)	Penile implant procedures.
	(17)	Insertion of prosthetic testicles.
	e. 	Coverage is available for otherwise covered services and supplies required in the treatment of complications resulting from a noncovered incident or treatment, but only when the subsequent complications represent a separate medical condition such as systemic infection, cardiac arrest, acute drug reaction, or similar conditions. Coverage shall not be extended for any subsequent care or procedure related to the complication that is essentially similar to the initial noncovered care. An example of a complication similar to the initial period of care would be repair of facial scarring resulting from dermabrasion for acne.
	78.1(5) The legally qualified practitioner’s prescription for medical equipment, appliances, or prosthetic devices shall include the patient’s diagnosis and prognosis, the reason the item is required, and an estimate in months of the duration of the need. Payment will be made in accordance with rule 78.10(249A).
	78.1(6) Payment will be approved for the examination to establish the need for orthopedic shoes in accordance with rule 78.15(249A).
	78.1(7) No payment shall be made for the services of a private duty nurse.
	78.1(8) Payment for mileage shall be the same as that in effect in part B of Medicare.
	78.1(9) Payment will be approved for visits to patients in nursing facilities subject to the following conditions:
	a. 	Payment will be approved for only one visit to the same patient in a calendar month. Payment for further visits will be made only when the need for the visits is adequately documented by the physician.
	b. 	When only one patient is seen in a single visit the allowance shall be based on a follow-up home visit. When more than one patient is seen in a single visit, payment shall be based on a follow-up office visit. In the absence of information on the claim, the carrier will assume that more than one patient was seen, and payment approved on that basis.
	c. 	Payment will be approved for mileage in connection with nursing home visits when:
	(1)	It is necessary for the physician to travel outside the home community, and
	(2)	There are not physicians in the community in which the nursing home is located.
	d. 	Payment will be approved for tasks related to a resident receiving nursing facility care which are performed by a physician’s employee who is a nurse practitioner, clinical nurse specialist, or physician assistant as specified in subrule 81.13(13)“e.” On-site supervision of the physician is not required for these services.
	78.1(10) Payment will be approved in independent laboratory when it has been certified as eligible to participate in Medicare.
	78.1(11) Rescinded, effective 8/1/87.
	78.1(12) Payment will be made on the same basis as in Medicare for services associated with treatment of chronic renal disease including physician’s services, hospital care, renal transplantation, and hemodialysis, whether performed on an inpatient or outpatient basis. Payment will be made for deductibles and coinsurance for those persons eligible for Medicare.
	78.1(13) Payment will be made to the physician for services rendered by auxiliary personnel employed by the physician and working under the direct personal supervision of the physician, when such services are performed incident to the physician’s professional service.
	a. 	Auxiliary personnel are nurses, physician’s assistants, psychologists, social workers, audiologists, occupational therapists and physical therapists.
	b. 	An auxiliary person is considered to be an employee of the physician if the physician:
	(1)	Is able to control the manner in which the work is performed, i.e., is able to control when, where and how the work is done. This control need not be actually exercised by the physician.
	(2)	Sets work standards.
	(3)	Establishes job description.
	(4)	Withholds taxes from the wages of the auxiliary personnel.
	c. 	Direct personal supervision in the office setting means the physician must be present in the same office suite, not necessarily the same room, and be available to provide immediate assistance and direction.
Direct personal supervision outside the office setting, such as the member’s home, hospital, emergency room, or nursing facility, means the physician must be present in the same room as the auxiliary person.
Advanced registered nurse practitioners certified under board of nursing rules 655—Chapter 7 performing services within their scope of practice are exempt from the direct personal supervision requirement for the purpose of reimbursement to the employing physicians. In these exempted circumstances, the employing physicians must still provide general supervision and be available to provide immediate needed assistance by telephone. Advanced registered nurse practitioners who prescribe drugs and medical devices are subject to the guidelines in effect for physicians as specified in rule 441—78.1(249A).
A physician assistant licensed under board of physician assistants’ professional licensure rules in 645—Chapter 325 is exempt from the direct personal supervision requirement but the physician must still provide general supervision and be available to provide immediate needed assistance by telephone. Physician assistants who prescribe drugs and medical devices are subject to the guidelines in effect for physicians as specified in rule 441—78.1(249A).
	d. 	Services incident to the professional services of the physician means the service provided by the auxiliary person must be related to the physician’s professional service to the member. If the physician has not or will not perform a personal professional service to the member, the clinical records must document that the physician assigned treatment of the member to the auxiliary person.
	78.1(14) Payment will be made for persons aged 20 and under for nutritional counseling provided by a licensed dietitian employed by or under contract with a physician for a nutritional problem or condition of a degree of severity that nutritional counseling beyond that normally expected as part of the standard medical management is warranted. For persons eligible for the WIC program, a WIC referral is required. Medical necessity for nutritional counseling services exceeding those available through WIC shall be documented.
	78.1(15) The certification of inpatient hospital care shall be the same as that in effect in part A of Medicare. The hospital admittance record is sufficient for the original certification.
	78.1(16) No payment will be made for sterilization of an individual under the age of 21 or who is mentally incompetent or institutionalized. Payment will be made for sterilization performed on an individual who is aged 21 or older at the time the informed consent is obtained and who is mentally competent and not institutionalized when all the conditions in this subrule are met.
	a. 	The following definitions are pertinent to this subrule:
	(1)	Sterilization means any medical procedure, treatment, or operation performed for the purpose of rendering an individual permanently incapable of reproducing and which is not a necessary part of the treatment of an existing illness or medically indicated as an accompaniment of an operation on the genital urinary tract. Mental illness or retardation is not considered an illness or injury.
	(2)	Hysterectomy means a medical procedure or operation to remove the uterus.
	(3)	Mentally incompetent individual means a person who has been declared mentally incompetent by a federal, state or local court of jurisdiction for any purpose, unless the individual has been declared competent for purposes which include the ability to consent to sterilization.
	(4)	Institutionalized individual means an individual who is involuntarily confined or detained, under a civil or criminal statute, in a correctional or rehabilitative facility, including a mental hospital or other facility for the care and treatment of mental illness, or an individual who is confined under a voluntary commitment in a mental hospital or other facility for the care and treatment of mental illness.
	b. 	The sterilization shall be performed as the result of a voluntary request for the services made by the person on whom the sterilization is performed.
	c. 	The person shall be advised prior to the receipt of consent that no benefits provided under the medical assistance program or other programs administered by the department may be withdrawn or withheld by reason of a decision not to be sterilized.
	d. 	The person shall be informed that the consent can be withheld or withdrawn any time prior to the sterilization without prejudicing future care and without loss of other project or program benefits.
	e. 	The person shall be given a complete explanation of the sterilization. The explanation shall include:
	(1)	A description of available alternative methods and the effect and impact of the proposed sterilization including the fact that it must be considered to be an irreversible procedure.
	(2)	A thorough description of the specific sterilization procedure to be performed and benefits expected.
	(3)	A description of the attendant discomforts and risks including the type and possible effects of any anesthetic to be used.
	(4)	An offer to answer any inquiries the person to be sterilized may have concerning the procedure to be performed. The individual shall be provided a copy of the informed consent form in addition to the oral presentation.
	f. 	At least 30 days and not more than 180 days shall have elapsed following the signing of the informed consent except in the case of premature delivery or emergency abdominal surgery which occurs not less than 72 hours after the informed consent was signed. The informed consent shall have been signed at least 30 days prior to the expected delivery date for premature deliveries. Consent shall be obtained on Form 470-0835 or 470-0835(S), Consent Form, and shall be attached to the claim for payment.
	g. 	The information in paragraphs “b” through “f” shall be effectively presented to a blind, deaf, or otherwise handicapped individual and an interpreter shall be provided when the individual to be sterilized does not understand the language used on the consent form or used by the person obtaining consent. The individual to be sterilized may have a witness of the individual’s choice present when consent is obtained.
	h. 	Form 470-0835 or 470-0835(S), Consent Form, shall be signed by the individual to be sterilized, the interpreter, when one was necessary, the physician, and the person who provided the required information.
	i. 	Informed consent shall not be obtained while the individual to be sterilized is:
	(1)	In labor or childbirth, or
	(2)	Seeking to obtain or obtaining an abortion, or
	(3)	Under the influence of alcohol or other substance that affects the individual’s state of awareness.
	j. 	Payment will be made for a medically necessary hysterectomy only when it is performed for a purpose other than sterilization and only when one or more of the following conditions is met:
	(1)	The individual or representative has signed an acknowledgment that she has been informed orally and in writing from the person authorized to perform the hysterectomy that the hysterectomy will make the individual permanently incapable of reproducing, or
	(2)	The individual was already sterile before the hysterectomy, the physician has certified in writing that the individual was already sterile at the time of the hysterectomy and has stated the cause of the sterility, or
	(3)	The hysterectomy was performed as a result of a life-threatening emergency situation in which the physician determined that prior acknowledgment was not possible and the physician includes a description of the nature of the emergency.
	78.1(17) Abortions. Payment for an abortion or related service is made when Form 470-0836 is completed for the applicable circumstances and is attached to each claim for services. Payment for an abortion is made under one of the following circumstances:
	a. 	The physician certifies that the pregnant woman’s life would be endangered if the fetus were carried to term.
	b. 	The physician certifies that the fetus is physically deformed, mentally deficient or afflicted with a congenital illness and the physician states the medical indication for determining the fetal condition.
	c. 	The pregnancy was the result of rape reported to a law enforcement agency or public or private health agency which may include a family physician within 45 days of the date of occurrence of the incident. The report shall include the name, address, and signature of the person making the report. Form 470-0836 shall be signed by the person receiving the report of the rape.
	d. 	The pregnancy was the result of incest reported to a law enforcement agency or public or private health agency including a family physician no later than 150 days after the date of occurrence. The report shall include the name, address, and signature of the person making the report. Form 470-0836 shall be signed by the person receiving the report of incest.
	78.1(18) Payment and procedure for obtaining eyeglasses, contact lenses, and visual aids, shall be the same as described in 441—78.6(249A). (Cross-reference 78.28(3))
	78.1(19) Preprocedure review by the Iowa Foundation for Medical Care (IFMC) will be required if payment under Medicaid is to be made for certain frequently performed surgical procedures which have a wide variation in the relative frequency the procedures are performed. Preprocedure surgical review applies to surgeries performed in hospitals (outpatient and inpatient) and ambulatory surgical centers. Approval by the IFMC will be granted only if the procedures are determined to be necessary based on the condition of the patient and the published criteria established by the IFMC and the department. If not so approved by the IFMC, payment will not be made under the program to the physician or to the facility in which the surgery is performed. The criteria are available from IFMC, 6000 Westown Parkway, Suite 350E, West Des Moines, Iowa 50265-7771, or in local hospital utilization review offices.
The “Preprocedure Surgical Review List” shall be published by the department in the provider manuals for physicians, hospitals, and ambulatory surgical centers. The “Preprocedure Surgical Review List” shall be developed by the department with advice and consultation from the IFMC and appropriate professional organizations and will list the procedures for which prior review is required and the steps that must be followed in requesting such review. The department shall update the “Preprocedure Surgical Review List” annually. (Cross-reference 78.28(1)“e.”)
	78.1(20) Transplants.
	a. 	Payment will be made only for the following organ and tissue transplant services:
	(1)	Kidney, cornea, skin, and bone transplants.
	(2)	Allogeneic bone marrow transplants for the treatment of aplastic anemia, severe combined immunodeficiency disease, Wiskott-Aldrich syndrome, or the following types of leukemia: acute myelocytic leukemia in relapse or remission, chronic myelogenous leukemia, and acute lemphocytic leukemia in remission.
	(3)	Autologous bone marrow transplants for treatment of the following conditions: acute leukemia in remission with a high probability of relapse when there is no matched donor; resistant non-Hodgkin’s lymphomas; lymphomas presenting poor prognostic features; recurrent or refractory neuroblastoma; or advanced Hodgkin’s disease when conventional therapy has failed and there is no matched donor.
	(4)	Liver transplants for persons with extrahepatic biliary artesia or any other form of end-stage liver disease, except that coverage is not provided for persons with a malignancy extending beyond the margins of the liver.
Liver transplants require preprocedure review by the Iowa Foundation for Medical Care. (Cross-reference 78.1(19) and 78.28(1)“f.”)
Covered liver transplants are payable only when performed in a facility that meets the requirements of 78.3(10).
	(5)	Heart transplants. Artificial hearts and ventricular assist devices, either as a permanent replacement for a human heart or as a temporary life-support system until a human heart becomes available for transplants, are not covered. Heart-lung transplants are covered where bilateral or unilateral lung transplantation with repair of a congenital cardiac defect is contraindicated.
Heart transplants and heart-lung transplants described above require preprocedure review by the Iowa Foundation for Medical Care. (Cross-reference 78.1(19) and 78.28(1)“f.”) Covered heart transplants are payable only when performed in a facility that meets the requirements of 78.3(10).
	(6)	Lung transplants. Lung transplants for persons having end-stage pulmonary disease. Lung transplants require preprocedure review by the Iowa Foundation for Medical Care. (Cross-reference 78.1(19) and 78.28(1)“f.”) Covered transplants are payable only when performed in a facility that meets the requirements of 78.3(10). Heart-lung transplants are covered consistent with criteria in subparagraph (5) above.
	(7)	Pancreas transplants for persons with type I diabetes mellitus, as follows:
	1.	Simultaneous pancreas-kidney transplants and pancreas after kidney transplants are covered.
	2.	Pancreas transplants alone are covered for persons exhibiting any of the following:
	●	A history of frequent, acute, and severe metabolic complications (e.g., hypoglycemia, hyperglycemia, or ketoacidosis) requiring medical attention.
	●	Clinical problems with exogenous insulin therapy that are so severe as to be incapacitating.
	●	Consistent failure of insulin-based management to prevent acute complications.
The pancreas transplants listed under this subparagraph require preprocedure review by the Iowa Foundation for Medical Care. (Cross-reference 78.1(19) and 78.28(1)“f.”)
Covered transplants are payable only when performed in a facility that meets the requirements of 78.3(10).
Transplantation of islet cells or partial pancreatic tissue is not covered.
	b. 	Donor expenses incurred directly in connection with a covered transplant are payable. Expenses incurred for complications that arise with respect to the donor are covered only if they are directly and immediately attributed to surgery. Expenses of searching for a donor are not covered.
	c. 	All transplants must be medically necessary and meet other general requirements of this chapter for physician and hospital services.
	d. 	Payment will not be made for any transplant not specifically listed in paragraph “a.”
	78.1(21) Utilization review. Utilization review shall be conducted of Medicaid members who access more than 24 outpatient visits in any 12-month period from physicians, advanced registered nurse practitioners, federally qualified health centers, other clinics, and emergency rooms. For the purposes of utilization review, the term “physician” does not include a psychiatrist. Refer to rule 441—76.9(249A) for further information concerning the member lock-in program.
	78.1(22) Risk assessment. Risk assessment, using Form 470-2942, Medicaid Prenatal Risk Assessment, shall be completed at the initial visit during a Medicaid member’s pregnancy.
	a. 	If the risk assessment reflects a low-risk pregnancy, the assessment shall be completed again at approximately the twenty-eighth week of pregnancy.
	b. 	If the risk assessment reflects a high-risk pregnancy, referral shall be made for enhanced services. Enhanced services include health education, social services, nutrition education, and a postpartum home visit. Additional reimbursement shall be provided for obstetrical services related to a high-risk pregnancy. (See description of enhanced services at subrule 78.25(3).)
	78.1(23) EPSDT care coordination. Rescinded IAB 12/3/08, effective 2/1/09.
	78.1(24) Topical fluoride varnish. Payment shall be made for application of an FDA-approved topical fluoride varnish, as defined by the Current Dental Terminology, Third Edition (CDT-3), for the purpose of preventing the worsening of early childhood caries in children aged 0 to 36 months of age, when rendered by physicians acting within the scope of their practice, licensure, and other applicable state law, subject to the following provisions and limitations:
	a. 	Application of topical fluoride varnish must be provided in conjunction with an early and periodic screening, diagnosis, and treatment (EPSDT) examination which includes a limited oral screening.
	b. 	Separate payment shall be available only for application of topical fluoride varnish, which shall be at the same rate of reimbursement paid to dentists for providing this service. Separate payment for the limited oral screening shall not be available, as this service is already part of and paid under the EPSDT screening examination.
	c. 	Parents, legal guardians, or other authorized caregivers of children receiving application of topical fluoride varnish as part of an EPSDT screening examination shall be informed by the physician or auxiliary staff employed by and under the physician’s supervision that this application is not a substitute for comprehensive dental care.
	d. 	Physicians rendering the services under this subrule shall make every reasonable effort to refer or facilitate referral of these children for comprehensive dental care rendered by a dental professional.
This rule is intended to implement Iowa Code section 249A.4.
441—78.2(249A) Prescribed outpatient drugs. Payment will be made for “covered outpatient drugs” as defined in 42 U.S.C. Section 1396r-8(k)(2)-(4) subject to the conditions and limitations specified in this rule.
	78.2(1) Qualified prescriber. All drugs are covered only if prescribed by a legally qualified practitioner (physician, dentist, podiatrist, therapeutically certified optometrist, physician assistant, or advanced registered nurse practitioner).
	78.2(2) Prescription required. As a condition of payment for all drugs, including “nonprescription” or “over-the-counter” drugs that may otherwise be dispensed without a prescription, a prescription shall be transmitted as specified in Iowa Code sections 124.308 and 155A.27, subject to the provisions of Iowa Code section 155A.29 regarding refills. All prescriptions shall be available for audit by the department.
	78.2(3) Qualified source. All drugs are covered only if marketed by manufacturers that have signed a Medicaid rebate agreement with the Secretary of Health and Human Services in accordance with Public Law 101-508 (Omnibus Budget Reconciliation Act of 1990).
	78.2(4) Prescription drugs. Drugs that may be dispensed only upon a prescription are covered subject to the following limitations.
	a. 	Prior authorization is required as specified in the preferred drug list published by the department pursuant to Iowa Code section 249A.20A. For drugs requiring prior authorization, reimbursement will be made for a 72-hour supply dispensed in an emergency when a prior authorization request cannot be submitted.
	b. 	Payment is not made for:
	(1)	Drugs whose prescribed use is not for a medically accepted indication as defined by Section 1927(k)(6) of the Social Security Act.
	(2)	Drugs used to cause anorexia, weight gain, or weight loss, except for lipase inhibitor drugs prescribed for weight loss with prior authorization as provided in paragraph “a.”
	(3)	Drugs used for cosmetic purposes or hair growth.
	(4)	Drugs used to promote smoking cessation, except for varenicline with prior authorization as provided in paragraph “a” above and generic, sustained-release bupropion products that are indicated for smoking cessation by the U.S. Food and Drug Administration.
	(5)	Otherwise covered outpatient drugs if the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or the manufacturer’s designee.
	(6)	Drugs described in Section 107(c)(3) of the Drug Amendments of 1962 and identical, similar, or related drugs (within the meaning of Section 310.6(b)(1) of Title 21 of the Code of Federal Regulations (drugs identified through the Drug Efficacy Study Implementation (DESI) review)).
	(7)	“Covered Part D drugs” as defined by 42 U.S.C. Section 1395w-102(e)(1)-(2) for any “Part D eligible individual” as defined by 42 U.S.C. Section 1395w-101(a)(3)(A), including a member who is not enrolled in a Medicare Part D plan.
	(8)	Drugs prescribed for fertility purposes, except when prescribed for a medically accepted indication other than infertility, as defined in subparagraph (1).
	(9)	Drugs used for the treatment of sexual or erectile dysfunction, except when used to treat a condition other than sexual or erectile dysfunction for which the drug has been approved by the U.S. Food and Drug Administration.
	(10)	Prescription drugs for which the prescription was executed in written (and nonelectronic) form unless the prescription was executed on a tamper-resistant pad, as required by Section 1903(i)(23) of the Social Security Act (42 U.S.C. Section 1396b(i)(23)).
	78.2(5) Nonprescription drugs. The following drugs that may otherwise be dispensed without a prescription are covered subject to the prior authorization requirements stated below and as specified in the preferred drug list published by the department pursuant to Iowa Code section 249A.20A:
Acetaminophen tablets 325 mg, 500 mg
Acetaminophen elixir 160 mg/5 ml
Acetaminophen solution 100 mg/ml
Acetaminophen suppositories 120 mg
Artificial tears ophthalmic solution
Artificial tears ophthalmic ointment
Aspirin tablets 325 mg, 650 mg, 81 mg (chewable)
Aspirin tablets, enteric coated 325 mg, 650 mg, 81 mg
Aspirin tablets, buffered 325 mg
Bacitracin ointment 500 units/gm
Benzoyl peroxide 5%, gel, lotion
Benzoyl peroxide 10%, gel, lotion
Calcium carbonate chewable tablets 1250 mg (500 mg elemental calcium)
Calcium carbonate suspension 1250 mg/5 ml
Calcium carbonate tablets 600 mg
Calcium carbonate-vitamin D tablets 500 mg-200 units
Calcium carbonate-vitamin D tablets 600 mg-200 units
Calcium citrate tablets 950 mg (200 mg elemental calcium)
Calcium gluconate tablets 650 mg
Calcium lactate tablets 650 mg
Cetirizine hydrochloride liquid 1 mg/ml
Cetirizine hydrochloride tablets 5 mg
Cetirizine hydrochloride tablets 10 mg
Chlorpheniramine maleate tablets 4 mg
Clotrimazole vaginal cream 1%
Diphenhydramine hydrochloride capsules 25 mg
Diphenhydramine hydrochloride elixir, liquid, and syrup 12.5 mg/5 ml
Epinephrine racemic solution 2.25%
Ferrous sulfate tablets 325 mg
Ferrous sulfate elixir 220 mg/5 ml
Ferrous sulfate drops 75 mg/0.6 ml
Ferrous gluconate tablets 325 mg
Ferrous fumarate tablets 325 mg
Guaifenesin 100 mg/5 ml with dextromethorphan 10 mg/5 ml liquid
Ibuprofen suspension 100 mg/5 ml
Ibuprofen tablets 200 mg
Insulin
Lactic acid (ammonium lactate) lotion 12%
Loperamide hydrochloride liquid 1 mg/5 ml
Loperamide hydrochloride tablets 2 mg
Loratadine syrup 5 mg/5 ml
Loratadine tablets 10 mg
Magnesium hydroxide suspension 400 mg/5 ml
Magnesium oxide capsule 140 mg (85 mg elemental magnesium)
Magnesium oxide tablets 400 mg
Meclizine hydrochloride tablets 12.5 mg, 25 mg oral and chewable
Miconazole nitrate cream 2% topical and vaginal
Miconazole nitrate vaginal suppositories, 100 mg
Multiple vitamin and mineral products with prior authorization
Neomycin-bacitracin-polymyxin ointment
Niacin (nicotinic acid) tablets 50 mg, 100 mg, 250 mg, 500 mg
Nicotine gum 2 mg, 4 mg
Nicotine patch 7 mg/day, 14 mg/day and 21 mg/day
Pediatric oral electrolyte solutions
Permethrin liquid 1%
Pseudoephedrine hydrochloride tablets 30 mg, 60 mg
Pseudoephedrine hydrochloride liquid 30 mg/5 ml
Pseudoephedrine/dextromethorphan 15 mg/7.5 mg/5 mL liquid
Pseudoephedrine/dextromethorphan 20 mg/10 mg/5 mL liquid
Pseudoephedrine/dextromethorphan 30 mg/15 mg/5 mL liquid
Pseudoephedrine/dextromethorphan 20 mg/10 mg/5 mL elixir
Pseudoephedrine/dextromethorphan 15 mg/7.5 mg/5 mL syrup
Pseudoephedrine/dextromethorphan 30 mg/15 mg/5 mL syrup
Pseudoephedrine/dextromethorphan 7.5 mg/2.5 mg/0.8 mL solution
Pyrethrins-piperonyl butoxide liquid 0.33-4%
Pyrethrins-piperonyl butoxide shampoo 0.3-3%
Pyrethrins-piperonyl butoxide shampoo 0.33-4%
Salicylic acid liquid 17%
Senna tablets 187 mg
Sennosides-docusate sodium tablets 8.6 mg-50 mg
Sennosides syrup 8.8 mg/5 ml
Sennosides tablets 8.6 mg
Sodium bicarbonate tablets 325 mg
Sodium bicarbonate tablets 650 mg
Sodium chloride hypertonic ophthalmic ointment 5%
Sodium chloride hypertonic ophthalmic solution 5%
Tolnaftate 1% cream, solution, powder
Other nonprescription drugs listed as preferred in the preferred drug list published by the department pursuant to Iowa Code section 249A.20A.
	78.2(6) Quantity prescribed and dispensed.
	a. 	When it is not therapeutically contraindicated, the legally qualified practitioner shall prescribe a quantity of prescription medication sufficient for up to a 31-day supply. Oral contraceptives may be prescribed in 90-day quantities.
	b. 	Oral solid forms of covered nonprescription items shall be prescribed and dispensed in a minimum quantity of 100 units per prescription or the currently available consumer package size except when dispensed via a unit-dose system.
	78.2(7) Lowest cost item. The pharmacist shall dispense the lowest cost item in stock that meets the requirements of the practitioner as shown on the prescription.
	78.2(8) Consultation. In accordance with Public Law 101-508 (Omnibus Budget Reconciliation Act of 1990), a pharmacist shall offer to discuss information regarding the use of the medication with each Medicaid member or the caregiver of a member presenting a prescription. The consultation is not required if the person refuses the consultation. Standards for the content of the consultation shall be found in rules of the Iowa board of pharmacy.
This rule is intended to implement Iowa Code section 249A.4.
[ARC 8097B, IAB 9/9/09, effective 11/1/09]
441—78.3(249A) Inpatient hospital services. Payment for inpatient hospital admission is approved when it meets the criteria for inpatient hospital care as determined by the Iowa Foundation for Medical Care (IFMC). All cases are subject to random retrospective review and may be subject to a more intensive retrospective review if abuse is suspected. In addition, transfers, outliers, and readmissions within 31 days are subject to random review. Readmissions to the same facility due to premature discharge shall not be paid a new DRG. Selected admissions and procedures are subject to a 100 percent review before the services are rendered. Medicaid payment for inpatient hospital admissions and continued stays are approved when the admissions and continued stays are determined to meet the criteria for inpatient hospital care. (Cross-reference 78.28(5)) The criteria are available from IFMC, 6000 Westown Parkway, Suite 350E, West Des Moines, Iowa 50265-7771, or in local hospital utilization review offices. No payment will be made for waiver days.
See rule 441—78.31(249A) for policies regarding payment of hospital outpatient services.
If the recipient is eligible for inpatient or outpatient hospital care through the Medicare program, payment will be made for deductibles and coinsurance as set out in 441—subrule 79.1(22).
The DRG payment calculations include any special services required by the hospital, including a private room.
	78.3(1) Payment for Medicaid-certified physical rehabilitation units will be approved for the day of admission but not the day of discharge or death.
	78.3(2) No payment will be approved for private duty nursing.
	78.3(3) Certification of inpatient hospital care shall be the same as that in effect in part A of Medicare. The hospital admittance records are sufficient for the original certification.
	78.3(4) Services provided for intestinal or gastric bypass surgery for treatment of obesity requires prior approval, which must be obtained by the attending physician before surgery is performed.
	78.3(5) Payment will be approved for drugs provided inpatients subject to the same provisions specified in 78.2(1) and 78.2(4)“b”(1) to (10) except for 78.2(4)“b”(7). The basis of payment for drugs administered to inpatients is through the DRG reimbursement.
	a. 	Payment will be approved for drugs and supplies provided outpatients subject to the same provisions specified in 78.2(1) through 78.2(4) except for 78.2(4)“b”(7). The basis of payment for drugs provided outpatients is through a combination of Medicaid-determined fee schedules and ambulatory payment classification, pursuant to 441—subrule 79.1(16).
	b. 	Hospitals that wish to administer vaccines which are available through the Vaccines for Children program to Medicaid members shall enroll in the Vaccines for Children program. In lieu of payment, vaccines available through the Vaccines for Children program shall be accessed from the department of public health for Medicaid members.
	78.3(6) Payment for nursing care provided by a hospital shall be made to those hospitals which have been certified by the department of inspections and appeals as meeting the standards for a nursing facility.
	78.3(7) Payment for inpatient hospital tests for purposes of diagnosis and treatment shall be made only when the tests are specifically ordered for the diagnosis and treatment of a particular patient’s condition by the attending physician or other licensed practitioner acting within the scope of practice as defined by law, who is responsible for that patient’s diagnosis or treatment.
	78.3(8) Rescinded IAB 2/6/91, effective 4/1/91.
	78.3(9) Payment will be made for sterilizations in accordance with 78.1(16).
	78.3(10) Payment will be approved for organ and tissue transplant services, as specified in subrule 78.1(20). Kidney, cornea, skin, bone, allogeneic bone marrow, autologous bone marrow, heart, liver, and lung transplants are covered as specified in subrule 78.1(20). Lung transplants are payable at Medicare-designated lung transplant centers only. Heart and liver transplants are payable when performed at facilities that meet the following criteria:
	a. 	Recipient selection and education.
	(1)	Selection. The transplant center must have written criteria based on medical need for transplantation for final facility selection of recipients. These criteria should include an equitable, consistent and practical protocol for selection of recipients. The criteria must be at least as strict as those specified by Medicare.
	(2)	Education. The transplant center will provide a written plan for recipient education. It shall include educational plans for recipient, family and significant others during all phases of the program. These phases shall include:
Intake.
Preparation and waiting period.
Preadmission.
Hospitalization.
Discharge planning.
Follow-up.
	b. 	Staffing and resource commitment.
	(1)	Transplant surgeon. The transplant center must have on staff a qualified transplant surgeon.
The surgeon must have received at least one year of training at a transplant center approved by the American Society of Transplant Surgeons under the direction of an experienced transplant surgeon and must have had at least two years of experience in all facets of transplant surgery specific to the surgeon’s specialty. This experience must include management of recipients’ presurgical and postsurgical care and actual experience as a member of a transplant team at the institution. The transplant surgeon will have an understanding of the principles of and demonstrated expertise in the use of immunosuppressive therapy.
The transplant surgeon will be certified by the American Board of Thoracic Surgery or equivalent for heart transplants and the American Board of Surgery or equivalent for liver transplants.
The transplant surgeon will be the defined leader of a stable, established transplant team that has a strong commitment to the transplant program.
	(2)	Transplant team. The transplant team will be clearly defined with leadership and corresponding responsibilities of all team members identified.
The team should consist of:
A surgeon director.
A board-certified internist or pediatrician with training and expertise in organ transplantation medicine and clinical use of immunosuppressive regimens.
The transplant center will assume responsibility for initial training and continuing education of the transplant team and ancillary personnel. The center will maintain records that demonstrate competency in achieving, maintaining and improving skills in the distinct areas of expertise of each of the team members.
	(3)	Physicians. The transplant center will have on staff or available for consultation physicians with the following areas of expertise:
Anesthesiology.
Cardiology.
Dialysis.
Gastroenterology.
Hepatology.
Immunology.
Infectious diseases.
Nephrology.
Neurology.
Pathology.
Pediatrics.
Psychiatry.
Pulmonary medicine.
Radiology.
Rehabilitation medicine.
Liaison with the recipient’s permanent physician is established for the purpose of providing continuity and management of the recipient’s long-term care.
	(4)	Support personnel and resources. The center must have a commitment of sufficient resources and planning for implementation and operation of the transplant program. Indicators of the commitment will include the following:
Persons with expertise in the following areas available at the transplant center:
Anesthesiology.
Blood bank services.
Cardiology.
Cardiovascular surgery.
Dialysis.
Dietary services.
Gastroenterology.
Infection control.
Laboratory services (pathology, microbiology, immunology, tissue typing, and monitoring of immunosuppressive drugs).
Legal counsel familiar with transplantation laws and regulations.
Nursing service department with staff available who have expertise in the care of transplant recipients, especially in managing immunosuppressed patients and hemodynamic support.
Respiratory therapy.
Pharmaceutical services.
Physical therapy.
Psychiatry.
Psycho-social.
The center will have active cardiovascular, medical, and surgical programs with the ability and willingness to perform diagnostic and evaluative procedures appropriate to transplants on an emergency and ongoing basis.
The center will have designated an adequate number of intensive care and general service beds to support the transplant center.
	(5)	Laboratory. Each transplant center must have direct local 24-hour per day access to histocompatibility testing facilities. These facilities must meet the Standards for Histocompatibility Testing set forth by the Committee on Quality Assurance and Standards of the American Society for Histocompatibility and Immunogenetics (ASHI). As specified by ASHI, the director of the facility shall hold a doctoral degree in biological science, or be a physician, and subsequent to graduation shall have had four years’ experience in immunology, two of which were devoted to formal training in human histocompatibility testing, documented to be professionally competent by external measures such as national proficiency testing, participation in national or international workshops or publications in peer-reviewed journals. The laboratory must successfully participate in a regional or national testing program.
	c. 	Experience and survival rates.
	(1)	Experience. Centers will be given a minimum volume requirement of 12 heart or 12 liver transplants that should be met within one year. Due to special considerations such as patient case mix or donor availability, an additional one year conditional approval may be given if the minimum volume is not met the first year.
For approval of an extrarenal organ transplant program it is highly desirable that the institution: 1. has available a complete team of surgeons, physicians, and other specialists with specific experience in transplantation of that organ, or 2. has an established approved renal transplant program at that institution and personnel with expertise in the extrarenal organ system itself.
	(2)	Survival rates. The transplant center will achieve a record of acceptable performance consistent with the performance and outcomes at other successful designated transplant centers. The center will collect and maintain recipient and graft survival and complication rates. A level of satisfactory success and safety will be demonstrated with bases for substantial probability of continued performance at an acceptable level.
To encourage a high level of performance, transplant programs must achieve and maintain a minimum one-year patient survival rate of 70 percent for heart transplants and 50 percent for liver transplants.
	d. 	Organ procurement. The transplant center will participate in a nationwide organ procurement and typing network.
Detailed plans must exist for organ procurement yielding viable transplantable organs in reasonable numbers, meeting established legal and ethical criteria.
The transplant center must be a member of the National Organ Procurement and Transplant Network.
	e. 	Maintenance of data, research, review and evaluation.
	(1)	Maintenance of data. The transplant center will collect and maintain data on the following:
Risk and benefit.
Morbidity and mortality.
Long-term survival.
Quality of life.
Recipient demographic information.
These data should be maintained in the computer at the transplant center monthly.
The transplant center will submit the above data to the United Network of Organ Sharing yearly.
	(2)	Research. The transplant center will have a plan for and a commitment to research.
Ongoing research regarding the transplanted organs is required.
The transplant center will have a program in graduate medical education or have a formal agreement with a teaching institution for affiliation with a graduate medical education program.
	(3)	Review and evaluation. The transplant center will have a plan for ongoing evaluation of the transplantation program.
The transplant center will have a detailed plan for review and evaluation of recipient selection, preoperative, operative, postoperative and long-term management of the recipient.
The transplant center will conduct concurrent ongoing studies to ensure high quality services are provided in the transplantation program.
The transplant center will provide information to members of the transplant team and ancillary staff regarding the findings of the quality assurance studies. This information will be utilized to provide education geared toward interventions to improve staff performance and reduce complications occurring in the transplant process.
The transplant center will maintain records of all quality assurance and peer review activities concerning the transplantation program to document identification of problems or potential problems, intervention, education and follow-up.
	f. 	Application procedure. A Medicare-designated heart, liver, or lung transplant facility needs only to submit evidence of this designation to the Iowa Medicaid enterprise provider services unit. The application procedure for other heart and liver facilities is as follows:
	(1)	An original and two copies of the application must be submitted on 8½ by 11 inch paper, signed by a person authorized to do so. The facility must be a participating hospital under Medicaid and must specify its provider number, and the name and telephone number of a contact person should there be questions regarding the application.
	(2)	Information and data must be clearly stated, well organized and appropriately indexed to aid in its review against the criteria specified in this rule. Each page must be numbered.
	(3)	To the extent possible, the application should be organized into five sections corresponding to each of the five major criteria and addressing, in order, each of the subcriteria identified.
	(4)	The application should be mailed to the Iowa Medicaid enterprise provider services unit.
	g. 	Review and approval of facilities. An organized review committee will be established to evaluate performance and survival statistics and make recommendations regarding approval as a designated transplant center based on acceptable performance standards established by the review organization and approved by the Medicaid agency.
There will be established protocol for the systematic evaluation of patient outcome including survival statistics.
Once a facility applies for approval and is approved as a heart or liver transplant facility for Medicaid purposes, it is obliged to report immediately to the department any events or changes which would affect its approved status. Specifically, a facility must report any significant decrease in its experience level or survival rates, the transplantation of patients who do not meet its patient selection criteria, the loss of key members of the transplant team, or any other major changes that could affect the performance of heart or liver transplants at the facility. Changes from the terms of approval may lead to withdrawal of approval for Medicaid coverage of heart or liver transplants performed at the facility.
	78.3(11) Payment will be approved for inpatient hospital care rendered a patient in connection with dental treatment only when the mental, physical, or emotional condition of the patient prevents the dentist from providing this necessary care in the office.
	78.3(12) Payment will be approved for an assessment fee as specified in 441—paragraphs 79.1(16)“a” and “r” to determine if a medical emergency exists.
Medical emergency is defined as a sudden or unforeseen occurrence or combination of circumstances presenting a substantial risk to an individual’s health unless immediate medical treatment is given.
The determination of whether a medical emergency exists will be based on the patient’s medical condition including presenting symptoms and medical history prior to treatment or evaluation.
	78.3(13) Payment for patients in acute hospital beds who are determined by IFMC to require the skilled nursing care level of care shall be made at an amount equal to the sum of the direct care rate component limit for Medicare-certified hospital-based nursing facilities pursuant to 441—subparagraph 81.6(16)“f”(3) plus the non-direct care rate component limit for Medicare-certified hospital-based nursing facilities pursuant to 441—subparagraph 81.6(16)“f”(3), with the rate component limits being revised July 1, 2001, and every second year thereafter. This rate is effective (a) as of the date of notice by IFMC that the lower level of care is required or (b) for the days IFMC determines in an outlier review that the lower level of care was required.
	78.3(14) Payment for patients in acute hospital beds who are determined by IFMC to require nursing facility level of care shall be made at an amount equal to the sum of the direct care rate component limit for Medicaid nursing facilities pursuant to 441—subparagraph 81.6(16)“f”(1) plus the non-direct care rate component limit for Medicaid nursing facilities pursuant to 441—subparagraph 81.6(16)“f”(1), with the rate component limits being revised July 1, 2001, and every second year thereafter. This rate is effective (a) as of the date of notice by IFMC that the lower level of care is required or (b) for the days IFMC determines in an outlier review that the lower level of care was required.
	78.3(15) Payment for inpatient hospital charges associated with surgical procedures on the “Outpatient/Same Day Surgery List” produced by the Iowa Foundation for Medical Care shall be made only when attending physician has secured approval from the hospital’s utilization review department prior to admittance to the hospital. Approval shall be granted when inpatient care is deemed to be medically necessary based on the condition of the patient or when the surgical procedure is not performed as a routine, primary, independent procedure. The “Outpatient/Same Day Surgery List” shall be published by the department in the provider manuals for hospitals and physicians. The “Outpatient/Same Day Surgery List” shall be developed by the Iowa Foundation for Medical Care, and shall include procedures which can safely and effectively be performed in a doctor’s office or on an outpatient basis in a hospital. The Iowa Foundation for Medical Care may add, delete or modify entries on the “Outpatient/Same Day Surgery List.”
	78.3(16) Payment will be made for medically necessary skilled nursing care when provided by a hospital participating in the swing-bed program certified by the department of inspections and appeals and approved by the U.S. Department of Health and Human Services. Payment shall be at an amount equal to the sum of the direct care rate component limit for Medicare-certified hospital-based nursing facilities pursuant to 441—subparagraph 81.6(16)“f”(3) and the non-direct care rate component limit for Medicare-certified hospital-based nursing facilities pursuant to 441—subparagraph 81.6(16)“f”(3), with the rate component limits being revised July 1, 2001, and every second year thereafter.
	78.3(17) Rescinded IAB 8/9/89, effective 10/1/89.
	78.3(18) Preprocedure review by the IFMC is required if hospitals are to be reimbursed for certain frequently performed surgical procedures as set forth under subrule 78.1(19). Criteria are available from IFMC, 6000 Westown Parkway, Suite 350E, West Des Moines, Iowa 50265-7771, or in local hospital utilization review offices. (Cross-reference 78.28(5))
	78.3(19) Rescinded IAB 10/8/97, effective 12/1/97.
This rule is intended to implement Iowa Code section 249A.4.
441—78.4(249A) Dentists. Payment will be made for medical and surgical services furnished by a dentist to the extent these services may be performed under state law either by doctors of medicine, osteopathy, dental surgery or dental medicine and would be covered if furnished by doctors of medicine or osteopathy. Payment will also be made for the following dental procedures subject to the exclusions for services to adults 21 years of age and older set forth in subrule 78.4(14):
	78.4(1) Preventive services. Payment shall be made for the following preventive services:
	a. 	Oral prophylaxis, including necessary scaling and polishing, is payable only once in a six-month period except for persons who, because of physical or mental disability, need more frequent care. Documentation supporting the need for oral prophylaxis performed more than once in a six-month period must be maintained.
	b. 	Topical application of fluoride is payable once in a six-month period except for people who need more frequent applications because of physical or mental disability. (This does not include the use of fluoride prophylaxis paste as fluoride treatment.)
	c. 	Pit and fissure sealants are payable for placement on deciduous and permanent posterior teeth only. Reimbursement for sealants is restricted to work performed on members through 18 years of age and on members who have a physical or mental disability that impairs their ability to maintain adequate oral hygiene. Replacement sealants are covered when medically necessary, as documented in the patient record.
	78.4(2) Diagnostic services. Payment shall be made for the following diagnostic services:
	a. 	A comprehensive oral evaluation is payable once per patient per dentist in a three-year period when the patient has not seen that dentist during the three-year period.
	b. 	A periodic oral examination is payable once in a six-month period.
	c. 	A complete mouth radiograph survey consisting of a minimum of 14 periapical films and bite-wing films is a payable service once in a five-year period, except when medically necessary to evaluate development, and to detect anomalies, injuries and diseases. Complete mouth radiograph surveys are not payable under the age of six. A panographic-type radiography with bitewings is considered the same as a complete mouth radiograph survey.
	d. 	Supplemental bitewing films are payable only once in a 12-month period.
	e. 	Single periapical films are payable when necessary.
	f. 	Intraoral radiograph, occlusal.
	g. 	Extraoral radiograph.
	h. 	Posterior-anterior and lateral skull and facial bone radiograph, survey film.
	i. 	Temporomandibular joint radiograph.
	j. 	Cephalometric film.
	k. 	Diagnostic casts are payable only for orthodontic cases or when requested by the Iowa Medicaid enterprise medical services unit’s dental consultant.
	78.4(3) Restorative services. Payment shall be made for the following restorative services:
	a. 	Treatment of dental caries is payable in those areas which require immediate attention. Restoration of incipient or nonactive carious lesions are not payable. Carious activity may be considered incipient when there is no penetration of the dento-enamel junction as demonstrated in diagnostic radiographs.
	b. 	Amalgam alloy and composite resin-type filling materials are reimbursable only once for the same restoration in a two-year period.
	c. 	Rescinded IAB 5/1/02, effective 7/1/02.
	d. 	Two laboratory-fabricated crowns using nonprecious materials, other than stainless steel, are payable per member in a 12-month period. Additional laboratory-fabricated crowns using nonprecious materials, other than stainless steel, are payable when prior authorization has been obtained. Noble metals are payable for crowns when members are allergic to all other restorative materials. Stainless steel crowns are payable when a more conservative procedure would not be serviceable. (Cross-reference 78.28(2)“e”)
	e. 	Cast post and core, steel post and composite or amalgam in addition to a crown is payable when a tooth is functional and the integrity of the tooth would be jeopardized by no post support.
	f. 	Payment as indicated will be made for the following restorative procedures:
	(1)	Amalgam or acrylic buildups are considered part of the preparation for the completed restoration.
	(2)	One, two, or more restorations on one surface of a tooth shall be paid as a one-surface restoration, i.e., mesial occlusal pit and distal occlusal pit of a maxillary molar or mesial and distal occlusal pits of a lower bicuspid.
	(3)	Occlusal lingual groove of a maxillary molar that extends from the distal occlusal pit and down the distolingual groove will be paid as a two-surface restoration. This restoration and a mesial occlusal pit restoration on the same tooth will be paid as one, two-surface restoration.
	(4)	Rescinded IAB 5/1/02, effective 7/1/02.
	(5)	A two-surface anterior composite restoration will be payable as a one-surface restoration if it involved the lingual surface.
	(6)	Tooth preparation, temporary restorations, cement bases, pulp capping, impressions, local anesthesia and inhaled anesthesia are included in the restorative fee and may not be billed separately.
	(7)	Pin retention will be paid on a per-tooth basis and in addition to the final restoration.
	(8)	More than four surfaces on an amalgam restoration will be reimbursed as a “four-surface” amalgam.
	(9)	An amalgam restoration is not payable following a sedative filling in the same tooth unless the sedative filling was placed more than 30 days previously.
	78.4(4) Periodontal services. Payment may be made for the following periodontal services:
	a. 	Full-mouth debridement to enable comprehensive periodontal evaluation and diagnosis is payable once every 24 months. This procedure is not payable on the same date of service when other prophylasix or periodontal services are performed.
	b. 	Periodontal scaling and root planing is payable when prior approval has been received. A request for approval must be accompanied by a plan for treatment, a completed copy of a periodontal probe chart that exhibits pocket depths, history and radiograph(s). Payment for periodontal scaling and root planing will be approved when interproximal and subgingival calculus is evident in X-rays or when justified and documented that curettage, scaling or root planing is required in addition to routine prophylaxis. (Cross-reference 78.28(2)“a”(1))
	c. 	Periodontal surgical procedures which include gingivoplasty, osseous surgery, and osseous allograft are payable services when prior approval has been received. A request for approval must be accompanied by a plan for treatment, a completed copy of a periodontal probe chart that exhibits pocket depths, history and radiograph(s). Payment for these surgical procedures will be approved after periodontal scaling and root planing has been provided, a reevaluation examination has been completed, and the patient has demonstrated reasonable oral hygiene, unless the patient is unable to demonstrate reasonable oral hygiene because of physical or mental disability or in cases which demonstrate gingival hyperplasia resulting from drug therapy. (Cross-reference 78.28(2)“a”(2))
	d. 	Pedicle soft tissue graft and free soft tissue graft are payable services with prior approval based on a written narrative describing medical necessity. (Cross-reference 78.28(2)“a”(3))
	e. 	Periodontal maintenance therapy which includes oral prophylaxis, measurement of pocket depths and limited root planing and scaling is a payable service when prior approval has been received. A request for approval must be accompanied by a periodontal treatment plan, a completed copy of a periodontal probe chart which exhibits pocket depths, periodontal history and radiograph(s). Payment for periodontal maintenance therapy may be approved after periodontal scaling and root planing or periodontal surgical procedures have been provided. Periodontal maintenance therapy may be approved once per three-month interval for moderate to advanced cases if the condition would deteriorate without treatment. (Cross-reference 78.28(2)“a”(4))
	f. 	Payment as indicated will be made for the following periodontal services:
	(1)	Periodontal scaling and root planing, gingivoplasty, osseous surgery will be paid per quadrant.
	(2)	Gingivoplasty will be paid per tooth.
	(3)	Osseous allograft will be paid as a single site if one site is involved, or if more than one site is involved, payment will be made for multiple sites.
	78.4(5) Endodontic services. Payment shall be made for the following endodontic services:
	a. 	Root canal treatments on permanent anterior and posterior teeth when extensive posttreatment restorative procedures are not necessary and when missing teeth do not jeopardize the integrity or function of the dental arches.
	b. 	Vital pulpotomies. Cement bases, pulp capping, and insulating liners are considered part of the restoration and may not be billed separately.
	c. 	Surgical endodontic treatment is payable when prior approval has been received. Payment for an apicoectomy, performed as a separate surgical procedure; an apicoectomy, performed in conjunction with endodontic procedure; an apical curettage; a root resection; or excision of hyperplastic tissue will be approved when nonsurgical treatment has been attempted and a reasonable time has elapsed after which failure has been demonstrated. Surgical endodontic procedures may be indicated when:
	(1)	Conventional root canal treatment cannot be successfully completed because canals cannot be negotiated, debrided or obturated due to calcifications, blockages, broken instruments, severe curvatures, and dilacerated roots.
	(2)	Correction of problems resulting from conventional treatment including gross underfilling, perforations, and canal blockages with restorative materials. (Cross-reference 78.28(2)“d”)
	d. 	Endodontic retreatment when prior authorization has been received. Authorization for retreatment of a tooth with previous endodontic treatment shall be granted when the conventional treatment has been completed, a reasonable time has elapsed, and failure has been demonstrated with a radiograph and narrative history.
	78.4(6) Oral surgery—medically necessary. Payment shall be made for medically necessary oral surgery services furnished by dentists to the extent that these services may be performed under state law either by doctors of medicine, osteopathy, dental surgery or dental medicine and would be covered if furnished by doctors of medicine or osteopathy, as defined in rule 441—78.1(249A). These services will be reimbursed in a manner consistent with the physician’s reimbursement policy. The following surgical procedures are also payable when performed by a dentist:
	a. 	Extractions, both surgical and nonsurgical.
	b. 	Impaction (soft tissue impaction, upper or lower) that requires an incision of overlying soft tissue and the removal of the tooth.
	c. 	Impaction (partial bony impaction, upper or lower) that requires incision of overlying soft tissue, elevation of a flap, removal of bone and removal of the tooth.
	d. 	Impaction (complete bony impaction, upper or lower) that requires incision of overlying soft tissue, elevation of a flap, removal of bone and section of the tooth for removal.
	e. 	Root recovery (surgical removal of residual root).
	f. 	Oral antral fistula closure (or antral root recovery).
	g. 	Surgical exposure of impacted or unerupted tooth for orthodontic reasons, including ligation when indicated.
	h. 	Surgical exposure of impacted or unerupted tooth to aid eruption.
	i. 	General anesthesia, intravenous sedation, and non-intravenous conscious sedation are payable services when the extensiveness of the procedure indicates it or there is a concomitant disease or impairment which warrants its use.
	j. 	Routine postoperative care is considered part of the fee for surgical procedures and may not be billed separately.
	k. 	Payment may be made for postoperative care where need is shown to be beyond normal follow-up care or for postoperative care where the original service was performed by another dentist.
	78.4(7) Prosthetic services. Payment may be made for the following prosthetic services:
	a. 	An immediate denture and a first-time complete denture including six months’ postdelivery care. An immediate denture and a first-time complete denture are payable when the denture is provided to establish masticatory function. An immediate denture or a first-time complete denture is payable only once following the removal of teeth it replaces. A complete denture is payable only once in a five-year period except when the denture is broken beyond repair, lost or stolen, or no longer fits due to growth or changes in jaw structure and is required to prevent significant dental problems. Replacement of complete dentures due to resorption in less than a five-year period is not payable.
	b. 	A removable partial denture replacing anterior teeth, including six months’ postdelivery care. A removable partial denture replacing anterior teeth is payable only once in a five-year period unless the removable partial denture is broken beyond repair, lost or stolen, or no longer fits due to growth or changes in jaw structure and is required to prevent significant dental problems. Replacement of a removable partial denture replacing anterior teeth due to resorption in less than a five-year period is not payable.
	c. 	A removable partial denture replacing posterior teeth including six months’ postdelivery care when prior approval has been received. A removable partial denture replacing posterior teeth shall be approved when the member has fewer than eight posterior teeth in occlusion or the member has a full denture in one arch, and a partial denture replacing posterior teeth is required in the opposing arch to balance occlusion. When one removable partial denture brings eight posterior teeth in occlusion, no additional removable partial denture will be approved. A removable partial denture replacing posterior teeth is payable only once in a five-year period unless the removable partial denture is broken beyond repair, lost or stolen, or no longer fits due to growth or changes in jaw structure and is required to prevent significant dental problems. Replacement of a removable partial denture replacing posterior teeth due to resorption in less than a five-year period is not payable. (Cross-reference 78.28(2)“c”(1))
	d. 	A fixed partial denture (including an acid etch fixed partial denture) replacing anterior teeth when prior approval has been received. A fixed partial denture (including an acid etch fixed partial denture) replacing anterior teeth shall be approved for members whose medical condition precludes the use of a removable partial denture. High noble or noble metals shall be approved only when the member is allergic to all other restorative materials. A fixed partial denture replacing anterior teeth is payable only once in a five-year period unless the fixed partial denture is broken beyond repair. (Cross-reference 78.28(2)“c”(2))
	e. 	A fixed partial denture (including an acid etch fixed partial denture) replacing posterior teeth when prior approval has been received. A fixed partial denture (including an acid etch fixed partial denture) replacing posterior teeth shall be approved for the member whose medical condition precludes the use of a removable partial denture and who has fewer than eight posterior teeth in occlusion or if the member has a full denture in one arch and a partial denture replacing posterior teeth is required in the opposing arch to balance occlusion. When one fixed partial denture brings eight posterior teeth in occlusion, no additional fixed partial denture will be approved. High noble or noble metals will be approved only when the member is allergic to all other restorative materials. A fixed partial denture replacing posterior teeth is payable only once in a five-year period unless the fixed partial denture is broken beyond repair. (Cross-reference 78.28(2)“c”(3))
	f. 	Obturator for surgically excised palatal tissue or deficient velopharyngeal function of cleft palate patients.
	g. 	Chairside relines are payable only once per prosthesis every 12 months.
	h. 	Laboratory processed relines are payable only once per prosthesis every 12 months.
	i. 	Tissue conditioning is a payable service twice per prosthesis in a 12-month period.
	j. 	Two repairs per prosthesis in a 12-month period are payable.
	k. 	Adjustments to a complete or removable partial denture are payable when medically necessary after six months’ postdelivery care. An adjustment consists of removal of acrylic material or adjustment of teeth to eliminate a sore area or to make the denture fit better. Warming dentures and massaging them for better fit or placing them in a sonic device does not constitute an adjustment.
	l. 	Dental implants and related services when prior authorization has been received. Prior authorization shall be granted when the member is missing significant oral structures due to cancer, traumatic injuries, or developmental defects such as cleft palate and cannot use a conventional denture.
	78.4(8) Orthodontic procedures. Payment may be made for the following orthodontic procedures:
	a. 	When prior approval has been given for orthodontic services to treat the most handicapping malocclusions in a manner consistent with “Handicapping Malocclusion Assessment to Establish Treatment Priority,” by J.A. Salzmann, D.D.S., American Journal of Orthodontics, October 1968.
A handicapping malocclusion is a condition that constitutes a hazard to the maintenance of oral health and interferes with the well-being of the patient by causing impaired mastication, dysfunction of the temporomandibular articulation, susceptibility to periodontal disease, susceptibility to dental caries, and impaired speech due to malpositions of the teeth. Treatment of handicapping malocclusions will be approved only for the severe and the most handicapping. Assessment of the most handicapping malocclusion is determined by the magnitude of the following variables: degree of malalignment, missing teeth, angle classification, overjet and overbite, openbite, and crossbite.
A request to perform an orthodontic procedure must be accompanied by an interpreted cephalometric radiograph and study models trimmed so that the models simulate centric occlusion of the patient. A written plan of treatment must accompany the diagnostic aids. Posttreatment records must be furnished upon request of the Iowa Medicaid enterprise.
Approval may be made for eight units of a three-month active treatment period. Additional units may be approved by the Iowa Medicaid enterprise’s orthodontic consultant if found to be medically necessary. (Cross-reference 78.28(2)“d”)
	b. 	Space management services shall be payable when there is too little dental ridge to accommodate either the number or the size of teeth and if not corrected significant dental disease will result.
	c. 	Tooth guidance for a limited number of teeth or interceptive orthodontics is a payable service when extensive treatment is not required. Pretreatment records are not required.
	78.4(9) Treatment in a hospital. Payment will be approved for dental treatment rendered a hospitalized patient only when the mental, physical, or emotional condition of the patient prevents the dentist from providing necessary care in the office.
	78.4(10) Treatment in a nursing facility. Payment will be approved for dental treatment provided in a nursing facility. When more than one patient is examined during the same nursing home visit, payment will be made by the Medicaid program for only one visit to the nursing home.
	78.4(11) Office visit. Payment will be approved for an office visit for care of injuries or abnormal conditions of the teeth or supporting structure when treatment procedures or exams are not billed for that visit.
	78.4(12) Office calls after hours. Payment will be approved for office calls after office hours in emergency situations. The office call will be paid in addition to treatment procedures.
	78.4(13) Drugs. Payment will be made for drugs dispensed by a dentist only if there is no licensed retail pharmacy in the community where the dentist’s office is located. If eligible to dispense drugs, the dentist should request a copy of the Prescribed Drugs Manual from the Iowa Medicaid enterprise provider services unit. Payment will not be made for writing prescriptions.
	78.4(14) Services to members 21 years of age or older. Orthodontic procedures are not covered for members 21 years of age or older.
This rule is intended to implement Iowa Code section 249A.4.
441—78.5(249A) Podiatrists. Payment will be approved only for certain podiatric services.
	78.5(1) Payment will be approved for the following orthotic appliances and treatment of nail pathologies:
	a. 	Durable plantar foot orthotic.
	b. 	Plaster impressions for foot orthotic.
	c. 	Molded digital orthotic.
	d. 	Shoe padding when appliances are not practical.
	e. 	Custom molded space shoes for rheumatoid arthritis, congenital defects and deformities, neurotropic, diabetic and ischemic intractable ulcerations and deformities due to injuries.
	f. 	Rams horn (hypertrophic) nails.
	g. 	Onychomycosis (mycotic) nails.
	78.5(2) Payment will be made for the same scope of podiatric services available through Part B of Title XVIII (Medicare) except as listed below:
	a. 	Treatment of flatfoot. The term “flatfoot” is defined as a condition in which one or more arches have flattened out.
	b. 	Treatment of subluxations of the foot are defined as partial dislocations or displacements of joint surfaces, tendons, ligaments, or muscles of the foot. Surgical or nonsurgical treatments undertaken for the sole purpose of correcting a subluxated structure in the foot as an isolated entity are not covered.
Reasonable and necessary diagnosis of symptomatic conditions that result from or are associated with partial displacement of foot structures is a covered service. Surgical correction in the subluxated foot structure that is an integral part of the treatment of a foot injury or is undertaken to improve the function of the foot or to alleviate an induced or associated symptomatic condition is a covered service.
	c. 	Routine foot care. Routine foot care includes the cutting or removal of corns or callouses, the trimming of nails and other hygienic and preventive maintenance care in the realm of self-care such as cleaning and soaking the feet, the use of skin creams to maintain skin tone of both ambulatory and bedfast patients and any services performed in the absence of localized illness, injury, or symptoms involving the foot.
	d. 	Orthopedic shoes. Payment will not be made for orthopedic shoes or for any device to be worn in or attached to orthopedic shoes or other types of shoes when provided by the podiatrist. Payment will be made to the podiatrist for the examination including tests to establish the need for orthopedic shoes.
	78.5(3) Prescriptions are required for drugs and supplies as specified in rule 78.1(2)“c.” Payment shall be made for drugs dispensed by a podiatrist only if there is no licensed retail pharmacy in the community where the podiatrist’s office is located. If eligible to dispense drugs, the podiatrist should request a copy of the Prescribed Drugs Manual from the Iowa Medicaid enterprise provider services unit. Payment will not be made for writing prescriptions.
This rule is intended to implement Iowa Code section 249A.4.
441—78.6(249A) Optometrists. Payment will be approved for medically necessary services and supplies provided by the optometrist within the scope of practice of optometry and the limitations of state law, subject to the following limitations and exclusions. Covered optometric services include a professional component and materials.
	78.6(1) Payable professional services are:
	a. 	Eye examinations. The coverage of eye examinations depends on the purpose of the examination. Services are covered if the examination is the result of a complaint or symptom of an eye disease or injury. Routine eye examinations are covered once in a 12-month period. These services are rendered in the optometrist’s office or clinic, the home, a nursing facility, or other appropriate setting. Payment for mileage shall be subject to the same approval and payment criteria as those in effect for Medicare Part B. The following levels of service are recognized for optometric examinations:
	(1)	Intermediate examination. A level of optometric or ophthalmological services pertaining to medical examination and evaluation, with initiation or continuation of a diagnostic and treatment program.
	(2)	Comprehensive examination. A level of optometric or ophthalmological services pertaining to medical examination and evaluation, with initiation or continuation of a diagnostic and treatment program, and a general evaluation of the complete visual system.
	b. 	Medical services. Payment will be approved for medically necessary services and supplies within the scope of practice of the optometrist, including services rendered in the optometrist’s office or clinic, the home, a nursing facility, or other appropriate setting. Payment for mileage shall be subject to the same approval and payment criteria as those in effect for Medicare Part B.
	c. 	Auxiliary procedures. The following auxiliary procedures and special tests are payable when performed by an optometrist. Auxiliary procedures and special tests are reimbursed as a separate procedure only when warranted by case history or diagnosis.
	(1)	Serial tonometry. Single tonometry is part of the intermediate and comprehensive exams and is not payable as a separate procedure as is serial tonometry.
	(2)	Gonioscopy.
	(3)	Extended ophthalmoscopy. Routine ophthalmoscopy is part of the intermediate and comprehensive examination and is not payable as a separate procedure. Generally, extended ophthalmoscopy is considered to be part of the comprehensive examination and, if performed in conjunction with that level of service, is not payable as a separate procedure.
	(4)	Visual fields. Gross visual field testing is part of general optometric services and is not reported separately.
	(5)	External photography.
	(6)	Fundus photography.
	(7)	Retinal integrity evaluation.
	d. 	Single vision and multifocal lens service, verification and subsequent service. When lenses are necessary, the following enumerated professional and technical optometric services are to be provided:
	(1)	When lenses are necessary, the following enumerated professional and technical optometric services are to be provided:
	1.	Ordering of corrective lenses.
	2.	Verification of lenses after fabrication.
	3.	Adjustment and alignment of completed lens order.
	(2)	New lenses are subject to the following limitations:
	1.	Up to three times for children up to one year of age.
	2.	Up to four times per year for children one through three years of age.
	3.	Once every 12 months for children four through seven years of age.
	4.	Once every 24 months after eight years of age when there is a change in the prescription.
	(3)	Protective lenses are allowed for:
	1.	Children through seven years of age.
	2.	Members with vision in only one eye.
	3.	Members with a diagnosis-related illness or disability where regular lenses would pose a safety risk.
	e. 	Rescinded IAB 4/3/02, effective 6/1/02.
	f. 	Frame service.
	(1)	When a new frame is necessary, the following enumerated professional and technical optometric services are to be provided:
	1.	Selection and styling.
	2.	Sizing and measurements.
	3.	Fitting and adjustment.
	4.	Readjustment and servicing.
	(2)	New frames are subject to the following limitations:
	1.	One frame every six months is allowed for children through three years of age.
	2.	One frame every 12 months is allowed for children four through six years of age.
	3.	When there is a prescribed lens change and the new lenses cannot be accommodated by the current frame.
	(3)	Safety frames are allowed for:
	1.	Children through seven years of age.
	2.	Members with a diagnosis-related disability or illness where regular frames would pose a safety risk.
	g. 	Rescinded IAB 4/3/02, effective 6/1/02.
	h. 	Repairs or replacement of frames, lenses or component parts. Payment shall be made for service in addition to materials. The service fee shall not exceed the dispensing fee for a replacement frame. Payment shall be made for replacement of glasses when the original glasses have been lost or damaged beyond repair. Replacement of lost or damaged glasses is limited to once every 12 months for adults aged 21 and over, except for people with a mental or physical disability.
	i. 	Fitting of contact lenses when required following cataract surgery, documented keratoconus, aphakia, or for treatment of acute or chronic eye disease. Up to eight pairs of contact lenses are allowed for children up to one year of age with aphakia. Up to four pairs of contact lenses per year are allowed for children one to three years of age with aphakia.
	78.6(2) Ophthalmic materials. Ophthalmic materials which are provided in connection with any of the foregoing professional optometric services shall provide adequate vision as determined by the optometrist and meet the following standards:
	a. 	Corrected curve lenses, unless clinically contraindicated, manufactured by reputable American manufacturers.
	b. 	Standard plastic, plastic and metal combination, or metal frames manufactured by reputable American manufacturers, if available.
	c. 	Prescription standards according to the American National Standards Institute (ANSI) standards and tolerance.
	78.6(3) Reimbursement. The reimbursement for allowed ophthalmic material is subject to a fee schedule established by the department or to actual laboratory cost as evidenced by an attached invoice.
	a. 	Materials payable by fee schedule are:
	(1)	Lenses, single vision and multifocal.
	(2)	Frames.
	(3)	Case for glasses.
	b. 	Materials payable at actual laboratory cost as evidenced by an attached invoice are:
	(1)	Contact lenses.
	(2)	Schroeder shield.
	(3)	Ptosis crutch.
	(4)	Protective lenses and safety frames.
	(5)	Subnormal visual aids.
	78.6(4) Prior authorization. Prior authorization is required for the following:
	a. 	A second lens correction within a 24-month period for members eight years of age and older. Approval shall be given when the member’s vision has at least a five-tenths diopter of change in sphere or cylinder or ten-degree change in axis in either eye.
	b. 	Visual therapy may be authorized when warranted by case history or diagnosis for a period of time not greater than 90 days. Should continued therapy be warranted, the prior approval process shall be reaccomplished, accompanied by a report showing satisfactory progress. Approved diagnoses are convergence insufficiency and amblyopia. Visual therapy is not covered when provided by opticians.
	c. 	Subnormal visual aids where near visual acuity is better than 20/100 at 16 inches, 2M print. Prior authorization is not required if near visual acuity as described above is less than 20/100. Subnormal visual aids include, but are not limited to, hand magnifiers, loupes, telescopic spectacles, or reverse Galilean telescope systems. Payment shall be actual laboratory cost as evidenced by an attached invoice.
(Cross-reference 78.28(3))
	78.6(5) Noncovered services. Noncovered services include, but are not limited to, the following services:
	a. 	Glasses with cosmetic gradient tint lenses or other eyewear for cosmetic purposes.
	b. 	Glasses for protective purposes including glasses for eye safety, sunglasses, or glasses with photogray lenses. An exception to this is in 78.6(3)“b”(4).
	c. 	A second pair of glasses or spare glasses.
	d. 	Cosmetic surgery and experimental medical and surgical procedures.
	e. 	Contact lenses if vision is correctable with noncontact lenses except as found at paragraph 78.6(1)“i.”
	78.6(6) Therapeutically certified optometrists. Therapeutically certified optometrists may provide services and employ pharmaceutical agents in accordance with Iowa Code chapter 154 regulating the practice of optometry. A therapeutically certified optometrist is an optometrist who is licensed to practice optometry in this state and who is certified by the board of optometry to employ the agents and perform the procedures provided by the Iowa Code.
This rule is intended to implement Iowa Code section 249A.4.
[ARC 7548B, IAB 2/11/09, effective 4/1/09]
441—78.7(249A) Opticians. Payment will be approved only for certain services and supplies provided by opticians when prescribed by a physician (MD or DO) or an optometrist. Payment and procedure for obtaining services and supplies shall be the same as described in rule 441—78.6(249A). (Cross-reference 78.28(3))
	78.7(1) to 78.7(3) Rescinded IAB 4/3/02, effective 6/1/02.
This rule is intended to implement Iowa Code section 249A.4.
441—78.8(249A) Chiropractors. Payment will be made for the same chiropractic procedures payable under Title XVIII of the Social Security Act (Medicare).
	78.8(1) Covered services. Chiropractic manipulative therapy (CMT) eligible for reimbursement is specifically limited by Medicaid to the manual manipulation (i.e., by use of the hands) of the spine for the purpose of correcting a subluxation demonstrated by X-ray. Subluxation means an incomplete dislocation, off-centering, misalignment, fixation, or abnormal spacing of the vertebrae.
	78.8(2) Indications and limitations of coverage.
	a. 	The subluxation must have resulted in a neuromusculoskeletal condition set forth in the table below for which CMT is appropriate treatment. The symptoms must be directly related to the subluxation that has been diagnosed. The mere statement or diagnosis of “pain” is not sufficient to support the medical necessity of CMT. CMT must have a direct therapeutic relationship to the patient’s condition. No other diagnostic or therapeutic service furnished by a chiropractor is covered under the Medicaid program.

ICD-9	CATEGORY I	ICD-9	CATEGORY II	ICD-9	CATEGORY III	
307.81	Tension headache	353.0	Brachial plexus lesions	721.7	Traumatic spondylopathy	
721.0	Cervical spondylosis
without myelopathy	353.1	Lumbosacral plexus lesions	722.0	Displacement of cervical intervertebral disc without myelopathy	
721.2	Thoracic spondylosis
without myelopathy	353.2	Cervical root lesions, NEC	722.10	Displacement of lumbar
intervertebral disc without myelopathy	
721.3	Lumbosacral spondylosis without myelopathy	353.3	Thoracic root lesions, NEC	722.11	Displacement of thoracic intervertebral disc without myelopathy	
723.1	Cervicalgia	353.4	Lumbosacral root lesions, NEC	722.4	Degeneration of cervical intervertebral disc	
724.1	Pain in thoracic spine	353.8	Other nerve root and
plexus disorders	722.51	Degeneration of thoracic
or thoracolumbar intervertebral disc	
724.2	Lumbago	719.48	Pain in joint (other specified sites, must specify site)	722.52	Degeneration of lumbar
or lumbosacral intervertebral disc	
724.5	Backache, unspecified	720.1	Spinal enthesopathy	722.81	Post laminectomy syndrome, cervical region	
784.0	Headache	722.91	Calcification of intervertebral cartilage or disc, cervical region	722.82	Post laminectomy syndrome, thoracic region	
 	 	722.92	Calcification of intervertebral cartilage or disc, thoracic region	722.83	Post laminectomy syndrome, lumbar region	
 	 	722.93	Calcification of intervertebral cartilage or disc, lumbar region	724.3	Sciatica	
 	 	723.0	Spinal stenosis in cervical region	 	 	
 	 	723.2	Cervicocranial syndrome	 	 	
 	 	723.3	Cervicobrachial syndrome	 	 	
 	 	723.4	Brachial neuritis or radiculitis, NOC	 	 	
 	 	723.5	Torticollis, unspecified	 	 	
 	 	724.01	Spinal stenosis, thoracic region	 	 	
 	 	724.02	Spinal stenosis, lumbar region	 	 	
 	 	724.4	Thoracic or lumbosacral neuritis or radiculitis	 	 	
 	 	724.6	Disorders of sacrum, ankylosis	 	 	
 	 	724.79	Disorders of coccyx, coccygodynia	 	 	
 	 	724.8	Other symptoms referable to back, facet syndrome	 	 	
 	 	729.1	Myalgia and myositis, unspecified	 	 	
 	 	729.4	Fascitis, unspecified	 	 	
 	 	738.40	Acquired spondylolisthesis	 	 	
 	 	756.12	Spondylolisthesis	 	 	
 	 	846.0	Sprains and strains of sacroiliac region, lumbosacral (joint; ligament)	 	 	
 	 	846.1	Sprains and strains of sacroiliac region, sacroiliac ligament	 	 	
 	 	846.2	Sprains and strains of sacroiliac region, sacrospinatus (ligament)	 	 	
 	 	846.3	Sprains and strains of sacroiliac region, sacrotuberous (ligament)	 	 	
 	 	846.8	Sprains and strains of sacroiliac region, other specified sites of sacroiliac region	 	 	
 	 	847.0	Sprains and strains, neck	 	 	
 	 	847.1	Sprains and strains, thoracic	 	 	
 	 	847.2	Sprains and strains, lumbar	 	 	
 	 	847.3	Sprains and strains, sacrum	 	 	
 	 	847.4	Sprains and strains, coccyx	 	 	
	b. 	The neuromusculoskeletal conditions listed in the table in paragraph “a” generally require short-, moderate-, or long-term CMT. A diagnosis or combination of diagnoses within Category I generally requires short-term CMT of 12 per 12-month period. A diagnosis or combination of diagnoses within Category II generally requires moderate-term CMT of 18 per 12-month period. A diagnosis or combination of diagnoses within Category III generally requires long-term CMT of 24 per 12-month period. For diagnostic combinations between categories, 28 CMTs are generally required per 12-month period. If the CMT utilization guidelines are exceeded, documentation supporting the medical necessity of additional CMT must be submitted with the Medicaid claim form or the claim will be denied for failure to provide information.
	c. 	CMT is not a covered benefit when:
	(1)	The maximum therapeutic benefit has been achieved for a given condition.
	(2)	There is not a reasonable expectation that the continuation of CMT would result in improvement of the patient’s condition.
	(3)	The CMT seeks to prevent disease, promote health and prolong and enhance the quality of life.
	78.8(3) Documenting X-ray. An X-ray must document the primary regions of subluxation being treated by CMT.
	a. 	The documenting X-ray must be taken at a time reasonably proximate to the initiation of CMT. An X-ray is considered to be reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of CMT. X-rays need not be repeated unless there is a new condition and no payment shall be made for subsequent X-rays, absent a new condition, consistent with paragraph “c” of this subrule. No X-ray is required for pregnant women and for children aged 18 and under.
	b. 	The X-ray films shall be labeled with the patient’s name and date the X-rays were taken and shall be marked right or left. The X-ray shall be made available to the department or its duly authorized representative when requested. A written and dated X-ray report, including interpretation and diagnosis, shall be present in the patient’s clinical record.
	c. 	Chiropractors shall be reimbursed for documenting X-rays at the physician fee schedule rate. Payable X-rays shall be limited to those Current Procedural Terminology (CPT) procedure codes that are appropriate to determine the presence of a subluxation of the spine. Criteria used to determine payable X-ray CPT codes may include, but are not limited to, the X-ray CPT codes for which major commercial payors reimburse chiropractors. The Iowa Medicaid enterprise shall publish in the Chiropractic Services Provider Manual the current list of payable X-ray CPT codes. Consistent with CPT, chiropractors may bill the professional, technical, or professional and technical components for X-rays, as appropriate. Payment for documenting X-rays shall be further limited to one per condition, consistent with the provisions of paragraph “a” of this subrule. A claim for a documenting X-ray related to the onset of a new condition is only payable if the X-ray is reasonably proximate to the initiation of CMT for the new condition, as defined in paragraph “a” of this subrule. A chiropractor is also authorized to order a documenting X-ray whether or not the chiropractor owns or possesses X-ray equipment in the chiropractor’s office. Any X-rays so ordered shall be payable to the X-ray provider, consistent with the provisions in this paragraph.
This rule is intended to implement Iowa Code section 249A.4.
441—78.9(249A) Home health agencies. Payment shall be approved for medically necessary home health agency services prescribed by a physician in a plan of home health care provided by a Medicare-certified home health agency.
The number of hours of home health agency services shall be reasonable and appropriate to meet an established medical need of the member that cannot be met by a family member, significant other, friend, or neighbor. Services must be medically necessary in the individual case and be related to a diagnosed medical impairment or disability.
The member need not be homebound to be eligible for home health agency services; however, the services provided by a home health agency shall only be covered when provided in the member’s residence with the following exception. Private duty nursing and personal care services for persons aged 20 and under as described at 78.9(10)“a” may be provided in settings other than the member’s residence when medically necessary.
Medicaid members of home health agency services need not first require skilled nursing care to be entitled to home health aide services.
Further limitations related to specific components of home health agency services are noted in subrules 78.9(3) to 78.9(10).
Payment shall be made on an encounter basis. An encounter is defined as separately identifiable hours in which home health agency staff provide continuous service to a member.
Payment for supplies shall be approved when the supplies are incidental to the patient’s care, e.g., syringes for injections, and do not exceed $15 per month. Dressings, durable medical equipment, and other supplies shall be obtained from a durable medical equipment dealer or pharmacy. Payment of supplies may be made to home health agencies when a durable medical equipment dealer or pharmacy is not available in the member’s community.
Payment may be made for restorative and maintenance home health agency services.
Payment may be made for teaching, training, and counseling in the provision of health care services.
Treatment plans for these services shall additionally reflect: to whom the services are to be provided (patient, family member, etc.); prior teaching training, or counseling provided; medical necessity for the rendered service; identification of specific services and goals; date of onset of the teaching, training, or counseling; frequency of services; progress of member in response to treatment; and estimated length of time these services will be needed.
The following are not covered: services provided in the home health agency office, homemaker services, well child care and supervision, and medical equipment rental or purchase.
Services shall be authorized by a physician, evidenced by the physician’s signature and date on a plan of treatment.
	78.9(1) Treatment plan. A plan of treatment shall be completed prior to the start of care and at a minimum reviewed every 62 days thereafter. The plan of care shall support the medical necessity and intensity of services to be provided by reflecting the following information:
	a. 	Place of service.
	b. 	Type of service to be rendered and the treatment modalities being used.
	c. 	Frequency of the services.
	d. 	Assistance devices to be used.
	e. 	Date home health services were initiated.
	f. 	Progress of member in response to treatment.
	g. 	Medical supplies to be furnished.
	h. 	Member’s medical condition as reflected by the following information, if applicable:
	(1)	Dates of prior hospitalization.
	(2)	Dates of prior surgery.
	(3)	Date last seen by a physician.
	(4)	Diagnoses and dates of onset of diagnoses for which treatment is being rendered.
	(5)	Prognosis.
	(6)	Functional limitations.
	(7)	Vital signs reading.
	(8)	Date of last episode of instability.
	(9)	Date of last episode of acute recurrence of illness or symptoms.
	(10)	Medications.
	i. 	Discipline of the person providing the service.
	j. 	Certification period (no more than 62 days).
	k. 	Estimated date of discharge from the hospital or home health agency services, if applicable.
	l. 	Physician’s signature and date. The date of the signature shall be within the certification period.
	78.9(2) Supervisory visits. Payment shall be made for supervisory visits two times a month when a registered nurse acting in a supervisory capacity provides supervisory visits of services provided by a home health aide under a home health agency plan of treatment or when services are provided by an in-home health care provider under the department’s in-home health-related care program as set forth in 441—Chapter 177.
	78.9(3) Skilled nursing services. Skilled nursing services are services that when performed by a home health agency require a licensed registered nurse or licensed practical nurse to perform. Situations when a service can be safely performed by the member or other nonskilled person who has received the proper training or instruction or when there is no one else to perform the service are not considered a “skilled nursing service.” Skilled nursing services shall be available only on an intermittent basis. Intermittent services for skilled nursing services shall be defined as a medically predictable recurring need requiring a skilled nursing service at least once every 60 days, not to exceed five days per week (except as provided below), with an attempt to have a predictable end. Daily visits (six or seven days per week) that are reasonable and necessary and show an attempt to have a predictable end shall be covered for up to three weeks. Coverage of additional daily visits beyond the initial anticipated time frame may be appropriate for a short period of time, based on the medical necessity of service. Medical documentation shall be submitted justifying the need for continued visits, including the physician’s estimate of the length of time that additional visits will be necessary. Daily skilled nursing visits or multiple daily visits for wound care or insulin injections shall be covered when ordered by a physician and included in the plan of care. Other daily skilled nursing visits which are ordered for an indefinite period of time and designated as daily skilled nursing care do not meet the intermittent definition and shall be denied.
Skilled nursing services shall be evaluated based on the complexity of the service and the condition of the patient.
Private duty nursing for persons aged 21 and over is not a covered service. See subrule 78.9(10) for guidelines for private duty nursing for persons aged 20 or under.
	78.9(4) Physical therapy services. Payment shall be made for physical therapy services when the services relate directly to an active written treatment plan, follow a treatment plan established by the physician after any needed consultation with the qualified physical therapist, are reasonable and necessary to the treatment of the patient’s illness or injury, and meet the guidelines defined for restorative, maintenance, or trial therapy as set forth in subrule 78.19(1), paragraphs “a” and “b.”
For physical therapy services, the treatment plan shall additionally reflect goals, modalities of treatment, date of onset of conditions being treated, restorative potential, and progress notes.
	78.9(5) Occupational therapy services. Payment shall be made for occupational therapy services when the services relate directly to an active written treatment plan, follow a treatment plan established by the physician, are reasonable and necessary to the treatment of the patient’s illness or injury, and meet the guidelines defined for restorative, maintenance, or trial therapy as set forth in subrule 78.19(1), paragraphs “a” and “c.”
For occupational therapy services, the treatment plan shall additionally reflect goals, modalities of treatment, date of onset of conditions being treated, restorative potential, and progress notes.
	78.9(6) Speech therapy services. Payment shall be made for speech therapy services when the services relate directly to an active written treatment plan, follow a treatment plan established by the physician, are reasonable and necessary to the treatment of the patient’s illness or injury, and meet the guidelines defined for restorative, maintenance, or trial therapy as set forth in subrule 78.19(1), paragraphs “a” and “d.”
For speech therapy services, the treatment plan shall additionally reflect goals, modalities of treatment, date of onset of conditions being treated, restorative potential, and progress notes.
	78.9(7) Home health aide services. Payment shall be made for unskilled services provided by a home health aide if the following conditions are met:
	a. 	The service as well as the frequency and duration are stated in a written plan of treatment established by a physician. The home health agency is encouraged to collaborate with the member, or in the case of a child with the child’s caregiver, in the development and implementation of the plan of treatment.
	b. 	The member requires personal care services as determined by a registered nurse or other appropriate therapist. The services shall be given under the supervision of a registered nurse, physical, speech, or occupational therapist and the registered nurse or therapist shall assign the aide who will provide the care.
	c. 	Services shall be provided on an intermittent basis. “Intermittent basis” for home health agency services is defined as services that are usually two to three times a week for two to three hours at a time. Services provided for four to seven days per week, not to exceed 28 hours per week, when ordered by a physician and included in a plan of care shall be allowed as intermittent services. Increased services provided when medically necessary due to unusual circumstances on a short-term basis of two to three weeks may also be allowed as intermittent services when the home health agency documents the need for the excessive time required for home health aide services.
Home health aide daily care may be provided for persons employed or attending school whose disabling conditions require the persons to be assisted with morning and evening activities of daily living in order to support their independent living.
Personal care services include the activities of daily living, e.g., helping the member to bathe, get in and out of bed, care for hair and teeth, exercise, and take medications specifically ordered by the physician, but ordinarily self-administered, and retraining the member in necessary self-help skills.
Certain household services may be performed by the aide in order to prevent or postpone the member’s institutionalization when the primary need of the member for home health aide services furnished is for personal care. If household services are incidental and do not substantially increase the time spent by the aide in the home, the entire visit is considered a covered service. Domestic or housekeeping services which are not related to patient care are not a covered service if personal care is not rendered during the visit.
For home health aide services, the treatment plan shall additionally reflect the number of hours per visit and the living arrangement of the member, e.g., lives alone or with family.
	78.9(8) Medical social services.
	a. 	Payment shall be made for medical social work services when all of the following conditions are met and the problems are not responding to medical treatment and there does not appear to be a medical reason for the lack of response. The services:
	(1)	Are reasonable and necessary to the treatment of a member’s illness or injury.
	(2)	Contribute meaningfully to the treatment of the member’s condition.
	(3)	Are under the direction of a physician.
	(4)	Are provided by or under the supervision of a qualified medical or psychiatric social worker.
	(5)	Address social problems that are impeding the member’s recovery.
	b. 	Medical social services directed toward minimizing the problems an illness may create for the member and family, e.g., encouraging them to air their concerns and providing them with reassurance, are not considered reasonable and necessary to the treatment of the patient’s illness or injury.
	78.9(9) Home health agency care for maternity patients and children. The intent of home health agency services for maternity patients and children shall be to provide services when the members are unable to receive the care outside of their home and require home health care due to a high-risk factor. Routine prenatal, postpartum, or child health care is a covered service in a physician’s office or clinic and, therefore, is not covered by Medicaid when provided by a home health agency.
	a. 	Treatment plans for maternity patients and children shall identify:
	(1)	The potential risk factors,
	(2)	The medical factor or symptom which verifies the child is at risk,
	(3)	The reason the member is unable to obtain care outside of the home,
	(4)	The medically related task of the home health agency,
	(5)	The member’s diagnosis,
	(6)	Specific services and goals, and
	(7)	The medical necessity for the services to be rendered. A single high-risk factor does not provide sufficient documentation of the need for services.
	b. 	The following list of potential high-risk factors may indicate a need for home health services to prenatal maternity patients:
	(1)	Aged 16 or under.
	(2)	First pregnancy for a woman aged 35 or over.
	(3)	Previous history of prenatal complications such as fetal death, eclampsia, C-section delivery, psychosis, or diabetes.
	(4)	Current prenatal problems such as hypertensive disorders of pregnancy, diabetes, cardiac disease, sickle cell anemia, low hemoglobin, mental illness, or drug or alcohol abuse.
	(5)	Sociocultural or ethnic problems such as language barriers, lack of family support, insufficient dietary practices, history of child abuse or neglect, or single mother.
	(6)	Preexisting disabilities such as sensory deficits, or mental or physical disabilities.
	(7)	Second pregnancy in 12 months.
	(8)	Death of a close family member or significant other within the previous year.
	c. 	The following list of potential high-risk factors may indicate a need for home health services to postpartum maternity patients:
	(1)	Aged 16 or under.
	(2)	First pregnancy for a woman aged 35 or over.
	(3)	Major postpartum complications such as severe hemorrhage, eclampsia, or C-section delivery.
	(4)	Preexisting mental or physical disabilities such as deaf, blind, hemaplegic, activity-limiting disease, sickle cell anemia, uncontrolled hypertension, uncontrolled diabetes, mental illness, or mental retardation.
	(5)	Drug or alcohol abuse.
	(6)	Symptoms of postpartum psychosis.
	(7)	Special sociocultural or ethnic problems such as lack of job, family problems, single mother, lack of support system, or history of child abuse or neglect.
	(8)	Demonstrated disturbance in maternal and infant bonding.
	(9)	Discharge or release from hospital against medical advice before 36 hours postpartum.
	(10)	Insufficient antepartum care by history.
	(11)	Multiple births.
	(12)	Nonhospital delivery.
	d. 	The following list of potential high-risk factors may indicate a need for home health services to infants:
	(1)	Birth weight of five pounds or under or over ten pounds.
	(2)	History of severe respiratory distress.
	(3)	Major congenital anomalies such as neonatal complications which necessitate planning for long-term follow-up such as postsurgical care, poor prognosis, home stimulation activities, or periodic development evaluation.
	(4)	Disabling birth injuries.
	(5)	Extended hospitalization and separation from other family members.
	(6)	Genetic disorders, such as Down’s syndrome, and phenylketonuria or other metabolic conditions that may lead to mental retardation.
	(7)	Noted parental rejection or indifference toward baby such as never visiting or calling the hospital about the baby’s condition during the infant’s extended stay.
	(8)	Family sociocultural or ethnic problems such as low education level or lack of knowledge of child care.
	(9)	Discharge or release against medical advice before 36 hours of age.
	(10)	Nutrition or feeding problems.
	e. 	The following list of potential high-risk factors may indicate a need for home health services to preschool or school-age children:
	(1)	Child or sibling victim of child abuse or neglect.
	(2)	Mental retardation or other physical disabilities necessitating long-term follow-up or major readjustments in family lifestyle.
	(3)	Failure to complete the basic series of immunizations by 18 months, or boosters by 6 years.
	(4)	Chronic illness such as asthma, cardiac, respiratory or renal disease, diabetes, cystic fibrosis, or muscular dystrophy.
	(5)	Malignancies such as leukemia or carcinoma.
	(6)	Severe injuries necessitating treatment or rehabilitation.
	(7)	Disruption in family or peer relationships.
	(8)	Suspected developmental delay.
	(9)	Nutritional deficiencies.
	78.9(10) Private duty nursing or personal care services for persons aged 20 and under. Payment for private duty nursing or personal care services for persons aged 20 and under shall be approved if determined to be medically necessary. Payment shall be made on an hourly unit of service.
	a. 	Definitions.
	(1)	Private duty nursing services are those services which are provided by a registered nurse or a licensed practical nurse under the direction of the member’s physician to a member in the member’s place of residence or outside the member’s residence, when normal life activities take the member outside the place of residence. Place of residence does not include nursing facilities, intermediate care facilities for the mentally retarded, or hospitals.
Services shall be provided according to a written plan of care authorized by a licensed physician. The home health agency is encouraged to collaborate with the member, or in the case of a child with the child’s caregiver, in the development and implementation of the plan of treatment. These services shall exceed intermittent guidelines as defined in subrule 78.9(3). Private duty nursing and personal care services shall be inclusive of all home health agency services personally provided to the member. Enhanced payment under the interim fee schedule shall be made available for services to children who are technology dependent, i.e., ventilator dependent or whose medical condition is so unstable as to otherwise require intensive care in a hospital.
Private duty nursing or personal care services do not include:
	1.	Respite care, which is a temporary intermission or period of rest for the caregiver.
	2.	Nurse supervision services including chart review, case discussion or scheduling by a registered nurse.
	3.	Services provided to other persons in the member’s household.
	4.	Services requiring prior authorization that are provided without regard to the prior authorization process.
	5.	Transportation services.
	6.	Homework assistance.
	(2)	Personal care services are those services provided by a home health aide or certified nurse’s aide and which are delegated and supervised by a registered nurse under the direction of the member’s physician to a member in the member’s place of residence or outside the member’s residence, when normal life activities take the member outside the place of residence. Place of residence does not include nursing facilities, intermediate care facilities for the mentally retarded, or hospitals. Payment for personal care services for persons aged 20 and under that exceed intermittent guidelines may be approved if determined to be medically necessary as defined in subrule 78.9(7). These services shall be in accordance with the member’s plan of care and authorized by a physician. The home health agency is encouraged to collaborate with the member, or in the case of a child with the child’s caregiver, in the development and implementation of the plan of treatment.
Medical necessity means the service is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions that endanger life, cause pain, result in illness or infirmity, threaten to cause or aggravate a disability or chronic illness, and no other equally effective course of treatment is available or suitable for the member requesting a service.
	b. 	Requirements.
	(1)	Private duty nursing or personal care services shall be ordered in writing by a physician as evidenced by the physician’s signature on the plan of care.
	(2)	Private duty nursing or personal care services shall be authorized by the department or the department’s designated review agent prior to payment.
	(3)	Prior authorization shall be requested at the time of initial submission of the plan of care or at any time the plan of care is substantially amended and shall be renewed with the department or the department’s designated review agent. Initial request for and request for renewal of prior authorization shall be submitted to the department’s designated review agent. The provider of the service is responsible for requesting prior authorization and for obtaining renewal of prior authorization.
The request for prior authorization shall include a nursing assessment, the plan of care, and supporting documentation. The request for prior authorization shall include all items previously identified as required treatment plan information and shall further include: any planned surgical interventions and projected time frame; information regarding caregiver’s desire to become involved in the member’s care, to adhere to program objectives, to work toward treatment plan goals, and to work toward maximum independence; and identify the types and service delivery levels of all other services to the member whether or not the services are reimbursable by Medicaid. Providers shall indicate the expected number of private duty nursing RN hours, private duty nursing LPN hours, or home health aide hours per day, the number of days per week, and the number of weeks or months of service per discipline. If the member is currently hospitalized, the projected date of discharge shall be included.
Prior authorization approvals shall not be granted for treatment plans that exceed 16 hours of home health agency services per day. (Cross-reference 78.28(9))
	78.9(11) Vaccines. Home health agencies which wish to administer vaccines which are available through the Vaccines for Children program to Medicaid members shall enroll in the Vaccines for Children program. In lieu of payment, vaccines available through the Vaccines for Children program shall be accessed from the department of public health for Medicaid members. Home health agencies may provide Vaccines for Children clinics and be reimbursed for vaccine administration to provide Vaccines for Children program vaccines to Medicaid children in other than the home setting.
This rule is intended to implement Iowa Code section 249A.4.
[ARC 7548B, IAB 2/11/09, effective 4/1/09]
441—78.10(249A) Durable medical equipment (DME), prosthetic devices and medical supplies.
	78.10(1) General payment requirements. Payment will be made for items of DME, prosthetic devices and medical supplies, subject to the following general requirements and the requirements of subrule 78.10(2), 78.10(3), or 78.10(4), as applicable:
	a. 	DME, prosthetic devices, and medical supplies must be required by the member because of the member’s medical condition.
	b. 	The item shall be necessary and reasonable either for the treatment of an illness or injury, or to improve the functioning of a malformed body part. Determination will be made by the Iowa Medicaid enterprise medical services unit.
	(1)	An item is necessary when it can be expected to make a meaningful contribution to the treatment of a specific illness or injury or to the improvement in function of a malformed body part.
	(2)	Although an item may be necessary, it must also be a reasonable expenditure for the Medicaid program. The following considerations enter into the determination of reasonableness: Whether the expense of the item to the program would be clearly disproportionate to the therapeutic benefits which could ordinarily be derived from use of the item; whether the item would be substantially more costly than a medically appropriate and realistically feasible alternative pattern of care; and whether the item serves essentially the same purpose as an item already available to the beneficiary.
	c. 	A physician’s (doctor of medicine, osteopathy, or podiatry), physician assistant’s, or advanced registered nurse practitioner’s prescription is required to establish medical necessity. The prescription shall state the diagnosis, prognosis, and length of time the item is to be required.
For items requiring prior approval, a request shall include a physician’s, physician assistant’s, or advanced registered nurse practitioner’s written order or prescription and sufficient medical documentation to permit an independent conclusion that the requirements for the equipment or device are met and the item is medically necessary and reasonable. A request for prior approval is made on Form 470-0829, Request for Prior Authorization. See rule 441—78.28(249A) for prior approval requirements.
	d. 	Nonmedical items will not be covered. These include but are not limited to:
	(1)	Physical fitness equipment, e.g., an exercycle, weights.
	(2)	First-aid or precautionary-type equipment, e.g., preset portable oxygen units.
	(3)	Self-help devices, e.g., safety grab bars, raised toilet seats.
	(4)	Training equipment, e.g., speech teaching machines, braille training texts.
	(5)	Equipment used for environmental control or to enhance the environmental setting, e.g., room heaters, air conditioners, humidifiers, dehumidifiers, and electric air cleaners.
	(6)	Equipment which basically serves comfort or convenience functions, or is primarily for the convenience of a person caring for the patient, e.g., elevators, stairway elevators and posture chairs.
	e. 	The amount payable is based on the least expensive item which meets the patient’s medical needs. Payment will not be approved for duplicate items.
	f. 	Consideration will be given to rental or purchase based on the price of the item and the length of time it would be required. The decision on rental or purchase shall be made by the Iowa Medicaid enterprise, and be based on the most reasonable method to provide the equipment.
	(1)	The provider shall monitor rental payments up to 100 percent of the purchase price. At the point that total rent paid equals 100 percent of the purchase allowance, the member will be considered to own the item and no further rental payments will be made to the provider.
	(2)	Payment may be made for the purchase of an item even though rental payments may have been made for prior months. The rental of the equipment may be necessary for a period of time to establish that it will meet the identified need before the purchase of the equipment. When a decision is made to purchase after renting an item, all of the rental payments will be applied to the purchase allowance.
	(3)	Exception:  Ventilators will be maintained on a rental basis for the duration of use.
	g. 	Payment may be made for necessary repair, maintenance, and supplies for member-owned equipment. No payment may be made for repairs, maintenance, or supplies when the member is renting the item.
	h. 	Replacement of member-owned equipment is covered in cases of loss or irreparable damage or when required because of a change in the member’s condition.
	i. 	No allowance will be made for delivery, freight, postage, or other provider operating expenses for DME, prosthetic devices or medical supplies.
	78.10(2) Durable medical equipment. DME is equipment which can withstand repeated use, is primarily and customarily used to serve a medical purpose, is generally not useful to a person in the absence of an illness or injury, and is appropriate for use in the home.
	a. 	Durable medical equipment will not be provided in a hospital, nursing facility, or intermediate care facility for the mentally retarded except when a Medicaid-eligible resident of a nursing facility medically needs oxygen for 12 or more hours per day for at least 30 days or more. Medicaid will provide payment to medical equipment and supply dealers to provide oxygen services in a nursing facility when all of the following requirements and conditions have been met:
	(1)	A physician’s, physician assistant’s, or advanced registered nurse practitioner’s prescription documents that a resident of a nursing facility requires oxygen for 12 hours or more per day and the provider and physician, physician assistant, or advanced registered nurse practitioner jointly submit Certificate of Medical Necessity, Form CMS-484, from Medicare or a reasonable facsimile to the Iowa Medicaid enterprise with the monthly billing. The documentation submitted must contain the following:
	1.	The number of hours oxygen is required per day;
	2.	The diagnosis of the disease requiring continuous oxygen, prognosis, and length of time the oxygen will be needed;
	3.	The oxygen flow rate and concentration; the type of system ordered, i.e., cylinder gas, liquid gas, or concentrator;
	4.	A specific estimate of the frequency and duration of use; and
	5.	The initial reading on the time meter clock on each concentrator, where applicable.
Oxygen prescribed “PRN” or “as necessary” is not allowed.
	(2)	The maximum Medicaid payment shall be based on the least costly method of oxygen delivery.
	(3)	Medicaid payment shall be made for the rental of equipment only. All accessories and disposable supplies related to the oxygen delivery system, servicing and repairing of equipment are included in the Medicaid payment.
	(4)	Oxygen logs must be maintained by the provider. When random postpayment review of these logs indicates less than an average of 12 hours per day of oxygen was provided over a 30-day period, recoupment of the overpayment may occur.
	(5)	Payment will be made for only one mode of oxygen even if the physician’s, physician assistant’s, or advanced registered nurse practitioner’s prescription allows for multiple modes of delivery.
	(6)	Payment will not be made for oxygen that is not documented according to department of inspections and appeals 481—subrule 58.21(8).
	b. 	Only the following types of durable medical equipment can be covered through the Medicaid program:
Alternating pressure pump.
Automated medication dispenser. See 78.10(2)“d” for prior authorization requirements.
Bedpan.
Blood glucose monitors, subject to the limitation in 78.10(2)“e.”
Blood pressure cuffs.
Cane.
Cardiorespiratory monitor (rental and supplies).
Commode.
Commode pail.
Crutches.
Decubitus equipment.
Dialysis equipment.
Diaphragm (contraceptive device).
Enclosed bed. See 78.10(2)“d” for prior authorization requirements.
Enuresis alarm system (bed-wetting alarm device) for members five years of age or older.
Hospital bed.
Hospital bed accessories.
Inhalation equipment.
Insulin infusion pump. See 78.10(2)“d” for prior authorization requirements.
Lymphedema pump.
Neuromuscular stimulator.
Oximeter.
Oxygen, subject to the limitations in 78.10(2)“a” and 78.10(2)“c.”
Patient lift (Hoyer).
Phototherapy bilirubin light.
Pressure unit.
Protective helmet.
Respirator.
Resuscitator bags and pressure gauge.
Seat lift chair.
Suction machine.
Traction equipment.
Urinal (portable).
Vaporizer.
Ventilator.
Vest airway clearance system. See 78.10(2)“d” for prior authorization requirements.
Walker.
Wheelchair—standard and adaptive.
Whirlpool bath.
	c. 	Coverage of home oxygen equipment and oxygen will be considered reasonable and necessary only for members with significant hypoxemia, as shown by medical documentation. The physician’s, physician assistant’s, or advanced registered nurse practitioner’s prescription shall document that other forms of treatment have been tried and have not been successful, and that oxygen therapy is required.
	(1)	To identify the medical necessity for oxygen therapy, the supplier and a physician, physician assistant, or advanced registered nurse practitioner shall jointly submit Medicare Form B-7401, Physician’s Certification for Durable Medical Equipment, or a reasonable facsimile. The following information is required:
	1.	A diagnosis of the disease requiring home use of oxygen;
	2.	The oxygen flow rate and concentration;
	3.	The type of system ordered, i.e., cylinder gas, liquid gas, or concentrator;
	4.	A specific estimate of the frequency and duration of use; and
	5.	The initial reading on the time meter clock on each concentrator, where applicable.
Oxygen prescribed “PRN” or “as necessary” is not allowed.
	(2)	If the patient’s condition or need for oxygen services changes, the attending physician, physician assistant, or advanced registered nurse practitioner must adjust the documentation accordingly.
	(3)	A second oxygen system is not covered by Medicaid when used as a backup for oxygen concentrators or as a standby in case of emergency. Members may be provided with a portable oxygen system to complement a stationary oxygen system, or to be used by itself, with documentation from the physician (doctor of medicine or osteopathy), physician assistant, or advanced registered nurse practitioner of the medical necessity for portable oxygen for specific activities.
	(4)	Payment for concentrators shall be made only on a rental basis.
	(5)	All accessories, disposable supplies, servicing, and repairing of concentrators are included in the monthly Medicaid payment for concentrators.
	d. 	Prior authorization is required for the following medical equipment and supplies (Cross-reference 78.28(1)):
	(1)	Enclosed beds. Payment for an enclosed bed will be approved when prescribed for a patient who meets all of the following conditions:
	1.	The patient has a diagnosis-related cognitive or communication impairment that results in risk to safety.
	2.	The patient’s mobility puts the patient at risk for injury.
	3.	The patient has suffered injuries when getting out of bed.
	4.	The patient has had a successful trial with an enclosed bed.
	(2)	External insulin infusion pumps. Payment will be approved according to Medicare coverage criteria.
	(3)	Vest airway clearance systems. Payment will be approved for a vest airway clearance system when prescribed by a pulmonologist for a patient with a diagnosis of a lung disorder if all of the following conditions are met:
	1.	Pulmonary function tests for the 12 months before the initiation of the vest demonstrate an overall significant decrease of lung function.
	2.	The patient resides in an independent living situation or has a medical condition that precludes the caregiver from administering traditional chest physiotherapy.
	3.	Treatment by flutter device failed or is contraindicated.
	4.	Treatment by intrapulmonary percussive ventilation failed or is contraindicated.
	5.	All other less costly alternatives have been tried.
	(4)	Automated medication dispenser. Payment will be approved for an automated medication dispenser when prescribed for a member who meets all of the following conditions:
	1.	The member has a diagnosis indicative of cognitive impairment or age-related factors that affect the member’s ability to remember to take medications.
	2.	The member is on two or more medications prescribed to be administered more than one time a day.
	3.	The availability of a caregiver to administer the medications or perform setup is limited or nonexistent.
	4.	Less costly alternatives, such as medisets or telephone reminders, have failed.
	(5)	Blood glucose monitors and diabetic test strips produced by a manufacturer that does not have a current agreement to provide a rebate to the department for monitors or test strips provided through the Medicaid program. Prior approval shall be granted when the member’s medical condition necessitates use of a blood glucose monitor or diabetic test strips produced by a manufacturer that does not have a current rebate agreement with the department.
	e. 	Blood glucose monitors are covered through the Medicaid program only if:
	(1)	The monitor is produced by a manufacturer that has a current agreement to provide a rebate to the department for monitors provided through the Medicaid program; or
	(2)	Prior authorization based on medical necessity is received pursuant to rule 441—79.8(249A) for a monitor produced by a manufacturer that does not have a current rebate agreement with the department.
	78.10(3) Prosthetic devices. Prosthetic devices mean replacement, corrective, or supportive devices prescribed by a physician (doctor of medicine, osteopathy or podiatry), physician assistant, or advanced registered nurse practitioner within the scope of practice as defined by state law to artificially replace a missing portion of the body, prevent or correct a physical deformity or malfunction, or support a weak or deformed portion of the body. This does not require a determination that there is no possibility that the patient’s condition may improve sometime in the future.
	a. 	Prosthetic devices are not covered when dispensed to a patient prior to the time the patient undergoes a procedure which will make necessary the use of the device.
	b. 	Only the following types of prosthetic devices shall be covered through the Medicaid program:
Artificial eyes.
Artificial limbs.
Augmentative communications systems provided for members unable to communicate their basic needs through oral speech or manual sign language. Payment will be made for the most cost-effective item that meets basic communication needs commensurate with the member’s cognitive and language abilities. See 78.10(3)“c” for prior approval requirements.
Enteral delivery supplies and products. See 78.10(3)“c” for prior approval requirements.
Hearing aids. See rule 441—78.14(249A).
Oral nutritional products. See 78.10(3)“c” for prior approval requirements.
Orthotic devices. See 78.10(3)“d” for limitations on coverage of cranial orthotic devices.
Ostomy appliances.
Parenteral delivery supplies and products. Daily parenteral nutrition therapy is considered necessary and reasonable for a member with severe pathology of the alimentary tract that does not allow absorption of sufficient nutrients to maintain weight and strength commensurate with the member’s general condition.
Prosthetic shoes. See rule 441—78.15(249A).
Tracheotomy tubes.
Vibrotactile aids. Vibrotactile aids are payable only once in a four-year period unless the original aid is broken beyond repair or lost. (Cross-reference 78.28(8))
	c. 	Prior approval is required for the following prosthetic devices:
	(1)	Augmentative communication systems. Form 470-2145, Augmentative Communication System Selection, completed by a speech pathologist and a physician’s, physician assistant’s, or advanced registered nurse practitioner’s prescription for a particular device shall be submitted to the Iowa Medicaid enterprise medical services unit to request prior approval. Information requested on the prior approval form includes a medical history, diagnosis, and prognosis completed by a physician, physician assistant, or advanced registered nurse practitioner. In addition, a speech or language pathologist needs to describe current functional abilities in the following areas: communication skills, motor status, sensory status, cognitive status, social and emotional status, and language status. Also needed from the speech or language pathologist is information on educational ability and needs, vocational potential, anticipated duration of need, prognosis regarding oral communication skills, prognosis with a particular device, and recommendations. The department’s consultants with expertise in speech pathology will evaluate the prior approval requests and make recommendations to the department. (Cross-reference 78.28(1)“c”)
	(2)	Enteral products and enteral delivery pumps and supplies. Daily enteral nutrition therapy shall be approved as medically necessary only for a member who either has a metabolic or digestive disorder that prevents the member from obtaining the necessary nutritional value from usual foods in any form and cannot be managed by avoidance of certain food products or has a severe pathology of the body that does not allow ingestion or absorption of sufficient nutrients from regular food to maintain weight and strength commensurate with the member’s general condition.
A request for prior approval shall include a physician’s, physician assistant’s, or advanced registered nurse practitioner’s written order or prescription and documentation to establish the medical necessity for enteral products and enteral delivery pumps and supplies pursuant to the above standards. The documentation shall include:
	1.	A statement of the member’s total medical condition that includes a description of the member’s metabolic or digestive disorder or pathology.
	2.	Documentation of the medical necessity for commercially prepared products. The information submitted must identify other methods attempted to support the member’s nutritional status and indicate that the member’s nutritional needs were not or could not be met by regular food in pureed form.
	3.	Documentation of the medical necessity for an enteral pump, if the request includes an enteral pump. The information submitted must identify the medical reasons for not using a gravity feeding set.
Examples of conditions that will not justify approval of enteral nutrition therapy are: weight-loss diets, wired-shut jaws, diabetic diets, milk or food allergies (unless the member is under five years of age and coverage through the Women, Infant and Children’s program is not available), and the use of enteral products for convenience reasons when regular food in pureed form would meet the medical need of the member.
Basis of payment for nutritional therapy supplies shall be the least expensive method of delivery that is reasonable and medically necessary based on the documentation submitted.
	(3)	Oral nutritional products. Payment for oral nutritional products shall be approved as medically necessary only when the member is not able to ingest or absorb sufficient nutrients from regular food due to a metabolic, digestive, or psychological disorder or pathology, to the extent that supplementation is necessary to provide 51 percent or more of the daily caloric intake, or when the use of oral nutritional products is otherwise determined medically necessary in accordance with evidence-based guidelines for treatment of the member’s condition.
A request for prior approval shall include a physician’s, physician assistant’s, or advanced registered nurse practitioner’s written order or prescription and documentation to establish the medical necessity for oral supplementation pursuant to these standards. The documentation shall include:
	1.	A statement of the member’s total medical condition that includes a description of the member’s metabolic, digestive, or psychological disorder or pathology.
	2.	Documentation of the medical necessity for commercially prepared products. The information submitted must identify other methods attempted to support the member’s nutritional status and indicate that the member’s nutritional needs were not or could not be met by regular food in pureed form.
	3.	Documentation to support the fact that regular foods will not provide sufficient nutritional value to the member.
Examples of conditions that will not justify approval of oral supplementation are: weight-loss diets, wired-shut jaws, diabetic diets, milk or food allergies (unless the member is under five years of age and coverage through the Women, Infant and Children’s program is not available), supplementation to boost calorie or protein intake by less than 51 percent of the daily intake, and the absence of severe pathology of the body or psychological pathology or disorder.
	d. 	Cranial orthotic device. Payment shall be approved for cranial orthotic devices when the device is medically necessary for the postsurgical treatment of synostotic plagiocephaly. Payment shall also be approved when there is photographic evidence supporting moderate to severe nonsynostotic positional plagiocephaly and either:
	(1)	The member is between 3 and 5 months of age and has failed to respond to a two-month trial of repositioning therapy; or
	(2)	The member is between 6 and 18 months of age and there is documentation of either of the following conditions:
	1.	Cephalic index at least two standard deviations above the mean for the member’s gender and age; or
	2.	Asymmetry of 12 millimeters or more in the cranial vault, skull base, or orbitotragial depth.
	78.10(4) Medical supplies. Medical supplies are nondurable items consumed in the process of giving medical care, for example, nebulizers, gauze, bandages, sterile pads, adhesive tape, and sterile absorbent cotton. Medical supplies are payable for a specific medicinal purpose. This does not include food or drugs. Medical supplies are not to be dispensed at any one time for quantities exceeding a three-month supply. After the initial dispensing of medical supplies, the provider must document a refill request from the Medicaid member or the member’s caregiver for each refill.
	a. 	Only the following types of medical supplies and supplies necessary for the effective use of a payable item can be purchased through the medical assistance program:
Catheter (indwelling Foley).
Colostomy and ileostomy appliances.
Colostomy and ileostomy care dressings, liquid adhesive, and adhesive tape.
Diabetic blood glucose test strips, subject to the limitation in 78.10(4)“c.”
Diabetic supplies, other than blood glucose test strips (needles, syringes, and diabetic urine test supplies).
Dialysis supplies.
Diapers (for members aged four and above).
Disposable catheterization trays or sets (sterile).
Disposable irrigation trays or sets (sterile).
Disposable saline enemas (e.g., sodium phosphate type).
Disposable underpads.
Dressings.
Elastic antiembolism support stocking.
Enema.
Hearing aid batteries.
Respirator supplies.
Surgical supplies.
Urinary collection supplies.
	b. 	Only the following types of medical supplies will be approved for payment for members receiving care in a nursing facility or an intermediate care facility for the mentally retarded when prescribed by the physician, physician assistant, or advanced registered nurse practitioner:
Catheter (indwelling Foley).
Colostomy and ileostomy appliances.
Colostomy and ileostomy care dressings, liquid adhesive and adhesive tape.
Diabetic supplies (needles and syringes, blood glucose test strips and diabetic urine test supplies).
Disposable catheterization trays or sets (sterile).
Disposable irrigation trays or sets (sterile).
Disposable saline enemas (e.g., sodium phosphate type).
	c. 	Diabetic blood glucose test strips are covered through the Medicaid program only if:
	(1)	The strips are produced by a manufacturer that has a current agreement to provide a rebate to the department for test strips provided through the Medicaid program, or
	(2)	Prior authorization is received pursuant to rule 441—79.8(249A) for test strips produced by a manufacturer that does not have a current rebate agreement with the department, based on medical necessity.
This rule is intended to implement Iowa Code sections 249A.3, 249A.4 and 249A.12.
[ARC 7548B, IAB 2/11/09, effective 4/1/09; ARC 8344B, IAB 12/2/09, effective 12/1/09; ARC 8643B, IAB 4/7/10, effective 3/11/10]
441—78.11(249A) Ambulance service. Payment will be approved for ambulance service if it is required by the recipient’s condition and the recipient is transported to the nearest hospital with appropriate facilities or to one in the same locality, from one hospital to another, to the patient’s home or to a nursing facility. Payment for ambulance service to the nearest hospital for outpatient service will be approved only for emergency treatment. Ambulance service must be medically necessary and not merely for the convenience of the patient.
	78.11(1) Partial payment may be made when an individual is transported beyond the destinations specified, and is limited to the amount that would have been paid had the individual been transported to the nearest institution with appropriate facilities. When transportation is to the patient’s home, partial payment is limited to the amount that would have been paid from the nearest institution with appropriate facilities. When a recipient who is a resident of a nursing care facility is hospitalized and later discharged from the hospital, payment will be made for the trip to the nursing care facility where the recipient resides even though it may not in fact be the nearest nursing care facility.
	78.11(2) The Iowa Medicaid enterprise medical services unit shall determine that the ambulance transportation was medically necessary and that the condition of the patient precluded any other method of transportation. Payment can be made without the physician’s confirmation when:
	a. 	The individual is admitted as a hospital inpatient or in an emergency situation.
	b. 	Previous information on file relating to the patient’s condition clearly indicates ambulance service was necessary.
	78.11(3) When a patient is transferred from one nursing home to another because of the closing of a facility or from a nursing home to a custodial home because the recipient no longer requires nursing care, the conditions of medical necessity and the distance requirements shall not be applicable. Approval for transfer shall be made by the local office of the department of human services prior to the transfer. When such a transfer is made, the following rate schedule shall apply:
One patient - normal allowance
Two patients - 3/4 normal allowance per patient
Three patients - 2/3 normal allowance per patient
Four patients - 5/8 normal allowance per patient
	78.11(4) Transportation of hospital inpatients. When an ambulance service provides transport of a hospital inpatient to a provider and returns the recipient to the same hospital (the recipient continuing to be an inpatient of the hospital), the ambulance service shall bill the hospital for reimbursement as the hospital’s DRG reimbursement system includes all costs associated with providing inpatient services as stated in 79.1(5)“j.”
	78.11(5) In the event that more than one ambulance service is called to provide ground ambulance transport, payment shall be made only to one ambulance company. When a paramedic from one ambulance service joins a ground ambulance company already in transport, coverage is not available for the services and supplies provided by the paramedic.
This rule is intended to implement Iowa Code section 249A.4.
441—78.12(249A) Remedial services. Payment will be made for remedial services not otherwise covered under this chapter that are designed to minimize or, if possible, eliminate the symptoms or causes of a psychological disorder, subject to the limitations in this rule.
	78.12(1) Covered services. Medicaid covers the following remedial services:
	a. 	Community psychiatric supportive treatment, which offers intensive interventions to modify psychological, behavioral, emotional, cognitive, and social factors affecting a member’s functioning when less intensive remedial services do not meet the member’s needs.
	(1)	Interventions must focus on the member’s remedial needs to minimize or eliminate psychological barriers to a member’s ability to effectively manage symptoms associated with a psychological disorder in an age-appropriate manner.
	(2)	Interventions may assist the member in skills such as conflict resolution, problem solving, social skills, interpersonal relationship skills, and communication.
	(3)	Community psychiatric supportive treatment is covered only for Medicaid members who are aged 20 or under.
	(4)	Community psychiatric supportive treatment is not intended for members in congregate care.
	(5)	Community psychiatric supportive treatment is not intended to be provided in a group.
	b. 	Crisis intervention to de-escalate situations in which a risk to self, others, or property exists.
	(1)	Services shall assist a member to regain self-control and reestablish effective management of behavioral symptoms associated with a psychological disorder in an age-appropriate manner.
	(2)	Crisis intervention is covered only for Medicaid members who are aged 20 or under and shall be provided as outlined in a written treatment plan.
	c. 	Health or behavior intervention, used to modify the psychological, behavioral, emotional, cognitive, and social factors affecting a member’s functioning.
	(1)	Interventions may address the following skills for effective functioning with family, peers, and community: conflict resolution skills, problem-solving skills, social skills, interpersonal relationship skills, and communication skills.
	(2)	The purpose of intervention shall be to minimize or eliminate psychological barriers to the member’s ability to effectively manage symptoms associated with a psychological disorder in an age-appropriate manner.
	(3)	Health or behavior intervention is covered only for Medicaid members aged 20 or under.
	d. 	Rehabilitation program, which consists of interventions to enhance a member’s independent living, social, and communication skills; to minimize or eliminate psychological barriers to a member’s ability to effectively manage symptoms associated with a psychological disorder; and to maximize the member’s ability to live and participate in the community.
	(1)	Interventions may address the following skills for effective functioning with family, peers, and community: communication skills, conflict resolution skills, problem-solving skills, social skills, interpersonal relationship skills, and employment-related skills.
	(2)	Rehabilitation program services are covered only for Medicaid members who are aged 18 or over.
	e. 	Skills training and development, which consists of interventions to enhance independent living, social, and communication skills; to minimize or eliminate psychological barriers to a member’s ability to effectively manage symptoms associated with a psychological disorder; and to maximize a member’s ability to live and participate in the community.
	(1)	Interventions may include the following skills for effective functioning with family, peers, and community: communication skills, conflict resolution skills, problem-solving skills, social skills, interpersonal relationship skills, and employment-related skills.
	(2)	Skills training and development services are covered only for Medicaid members aged 18 or over.
	78.12(2) Excluded services. Services that are habilitative in nature are not covered as remedial services. For purposes of this subrule, “habilitative services” means services that are designed to assist individuals in acquiring skills that they never had, as well as associated training to acquire self-help, socialization, and adaptive skills necessary to reside successfully in a home or community setting.
	78.12(3) Coverage requirements. Medicaid covers remedial services only when the following conditions are met:
	a. 	A licensed practitioner of the healing arts acting within the practitioner’s scope of practice under state law has diagnosed the member with a psychological disorder. For example, licensed practitioners of the healing arts include physicians (M.D. or D.O.), advanced registered nurse practitioners (ARNP), psychologists (Ph.D. or Psy.D.), independent social workers (LISW), marital and family therapists (LMFT), and mental health counselors (LMHC). For purposes of this rule, the licensed practitioner of the healing arts must be:
	(1)	Enrolled in the Iowa Plan pursuant to 441—Chapter 88, Division IV; and
	(2)	Qualified to provide clinical assessment services under the Iowa Plan pursuant to 441—Chapter 88, Division IV (Current Procedural Terminology code 90801).
	b. 	The licensed practitioner of the healing arts has recommended the remedial services as part of a plan of treatment designed to treat the member’s psychological disorder. Diagnosis and treatment plan development provided in connection with this rule for members enrolled in the Iowa Plan are covered services under the Iowa Plan pursuant to 441— Chapter 88, Division IV.
	c. 	For a member under the age of 21, the licensed practitioner of the healing arts:
	(1)	Has, in cooperation with the managed care contractor, selected a standardized assessment instrument appropriate for baseline measurement of the member’s current skill level in managing mental health needs;
	(2)	Has completed an initial formal assessment of the member using the instrument selected; and
	(3)	Completes a formal assessment using the same instrument every six months thereafter if continued services are ordered.
	d. 	The remedial services provider has prepared a written remedial services implementation plan that has been approved by:
	(1)	The member or the member’s parent or guardian; and
	(2)	The medical services unit of the Iowa Medicaid enterprise.
	78.12(4) Approval of plan. The remedial services provider shall submit the treatment plan, the results of the formal assessment, and the remedial services implementation plan to the Iowa Medicaid enterprise (IME) medical services unit for approval before providing the services.
	a. 	Initial plan. The IME medical services unit shall approve the provider’s initial remedial services implementation plan if:
	(1)	The plan conforms to the medical necessity requirements in subrule 78.12(3);
	(2)	The plan is consistent with the written diagnosis and treatment recommendations made by the licensed practitioner of the healing arts;
	(3)	The plan is sufficient in amount, duration, and scope to reasonably achieve its purpose;
	(4)	The provider can demonstrate that the provider possesses the skills and resources necessary to implement the plan, as required in rule 441—77.12(249A);
	(5)	The plan does not exceed six months’ duration; and
	(6)	The plan requires that written progress notes be submitted no less often than every six weeks to the IME medical services unit.
	b. 	Subsequent plans. The IME medical services unit may approve a subsequent remedial services implementation plan according to the conditions in paragraph “a” if the services are recommended by a licensed practitioner of the healing arts who has:
	(1)	Reexamined the member;
	(2)	Reviewed the original diagnosis and treatment plan;
	(3)	Evaluated the member’s progress, including a formal assessment as required by 78.12(3)“c”(3); and
	(4)	Submitted the results of the formal assessment with the recommendation for continued services.
	c. 	Quality review. The IME medical services unit will establish a quality review process. Reviews will evaluate:
	(1)	The time elapsed from referral to remedial plan development;
	(2)	The continuity of treatment;
	(3)	The affiliation of the licensed practitioner of the healing arts with the remedial services provider;
	(4)	Gaps in service;
	(5)	The results achieved; and
	(6)	Member satisfaction.
	78.12(5) Medical necessity. Nothing in this rule shall be deemed to exempt coverage of remedial services from the requirement that services be medically necessary. “Medically necessary” means that the service is:
	a. 	Consistent with the diagnosis and treatment of the member’s condition;
	b. 	Required to meet the medical needs of the member and is needed for reasons other than the convenience of the member or the member’s caregiver;
	c. 	The least costly type of service that can reasonably meet the medical needs of the member; and
	d. 	In accordance with the standards of good medical practice. The standards of good practice for each field of medical and remedial care covered by the Iowa Medicaid program are those standards of good practice identified by:
	(1)	Knowledgeable Iowa clinicians practicing or teaching in the field; and
	(2)	The professional literature regarding best practices in the field.
This rule is intended to implement Iowa Code section 249A.4.
[ARC 8504B, IAB 2/10/10, effective 3/22/10]
441—78.13(249A) Transportation to receive medical care. Payment will be approved for transportation to receive services covered under the program, including transportation to obtain prescribed drugs, when all of the following conditions are met.
	78.13(1) Transportation costs are reimbursable only when:
	a. 	The source of the care is located outside the city limits of the community in which the member resides; or
	b. 	The member resides in a rural area and must travel to a city to receive necessary care.
	78.13(2) Transportation costs are reimbursable only when:
	a. 	The type of care is not available in the community in which the member resides; or
	b. 	The member has been referred by the attending physician to a specialist in another community.
	78.13(3) Transportation costs are reimbursable only when there is no resource available to the member through which necessary transportation might be secured free of charge. Exception: Costs of transportation to obtain prescribed drugs may be reimbursed irrespective of whether free delivery is offered when the prescription drug is needed immediately.
	78.13(4) Transportation is reimbursable only to the nearest institution or practitioner having appropriate facilities for the care of the member.
	78.13(5) Transportation may be of any type and may be provided from any source.
	a. 	When transportation is by car, the maximum payment that may be made will be the actual charge made by the provider for transportation to and from the source of medical care, but not in excess of 30 cents per mile.
	b. 	When public transportation is utilized, the basis of payment will be the actual charge made by the provider of transportation, not to exceed $1.40 per mile.
	c. 	In all cases where public transportation is reasonably available to or from the source of care and the member’s condition does not preclude its use, public transportation must be utilized. When the member’s condition precludes the use of public transportation, a statement to the effect shall be included in the case record.
	78.13(6) In the case of a child too young to travel alone, or an adult or child who because of physical or mental incapacity is unable to travel alone, payment subject to the above conditions shall be made for the transportation costs of an escort. The worker is responsible for making a decision concerning the necessity of an escort and recording the basis for the decision in the case record.
	78.13(7) When meals and lodging or other travel expenses are required in connection with transportation, payment will be subject to the same conditions as for a state employee and the maximum amount payable shall not exceed the maximum payable to a state employee for the same expenses in connection with official travel within the state of Iowa.
	78.13(8) When the services of an escort are required subject to the conditions in subrule 78.13(6), payment may be made for the escort’s meals and lodging, when required, on the same basis as for the member.
	78.13(9) Payment will not be made in advance to a member or a provider of medical transportation.
	78.13(10) Payment for transportation to receive medical care is made to the member with the following exceptions:
	a. 	Payment may be made to the agency that provided transportation if the agency is certified by the department of transportation and requests direct payment. Reimbursement for transportation shall be based on a fee schedule by mile or by trip.
	b. 	In cases where the local office has established that the member has persistently failed to reimburse a provider of medical transportation, payment may be made directly to the provider.
	c. 	In all situations where one of the department’s volunteers is the provider of transportation.
	78.13(11) Form 470-0386, Medical Transportation Claim, shall be completed by the member and the medical provider and submitted to the local office for each trip for which payment is requested. All trips to the same provider in a calendar month may, at the member’s option, be submitted on the same form.
	78.13(12) No claim shall be paid if presented after the lapse of 365 days from its accrual unless it is to correct payment on a claim originally submitted within the required period.
This rule is intended to implement Iowa Code section 249A.4.
[ARC 8344B, IAB 12/2/09, effective 12/1/09; ARC 8643B, IAB 4/7/10, effective 3/11/10]
441—78.14(249A) Hearing aids. Payment shall be approved for a hearing aid and examinations subject to the following conditions:
	78.14(1) Physician examination. The member shall have an examination by a physician to determine that the member has no condition which would contraindicate the use of a hearing aid. This report shall be documented in the patient record. The requirement for a physician evaluation shall be waived for members 18 years of age or older when the member has signed an informed consent statement acknowledging that the member:
	a. 	Has been advised that it may be in the member’s best health interest to receive a medical evaluation from a licensed physician before purchase of a hearing aid.
	b. 	Does not wish to receive a medical evaluation prior to purchase of a hearing aid.
	78.14(2) Audiological testings. A physician or an audiologist shall perform audiological testing as a part of making a determination that a member could benefit from the use of a hearing aid. The department shall cover vestibular testing performed by an audiologist only when prescribed by a physician.
	78.14(3) Hearing aid evaluation. A physician or an audiologist shall perform a hearing aid evaluation to establish if a member could benefit from a hearing aid. When a hearing aid is recommended for a member, the physician or audiologist recommending the hearing aid shall see the member at least one time within 30 days after purchase of the hearing aid to determine that the aid is adequate.
	78.14(4) Hearing aid selection. A physician or audiologist may recommend a specific brand or model appropriate to the member’s condition. When a physician or an audiologist makes a general hearing aid recommendation, a hearing aid dispenser may perform the tests to determine the specific brand or model appropriate to the member’s condition.
	78.14(5) Travel. When a member is unable to travel to the physician or audiologist because of health reasons, the department shall make payment for travel to the member’s place of residence or other suitable location. The department shall make payment to physicians as specified in 78.1(8) and payment to audiologists at the same rate it reimburses state employees for travel.
	78.14(6) Purchase of hearing aid. The department shall pay for the type of hearing aid recommended when purchased from an eligible licensed hearing aid dispenser pursuant to rule 441—77.13(249A). The department shall pay for binaural amplification when:
	a. 	A child needs the aid for speech development,
	b. 	The aid is needed for educational or vocational purposes,
	c. 	The aid is for a blind member,
	d. 	The member’s hearing loss has caused marked restriction of daily activities and constriction of interests resulting in seriously impaired ability to relate to other people, or
	e. 	Lack of binaural amplification poses a hazard to a member’s safety.
	78.14(7) Payment for hearing aids.
	a. 	Payment for hearing aids shall be acquisition cost plus a dispensing fee covering the fitting and service for six months. The department shall make payment for routine service after the first six months. Dispensing fees and payment for routine service shall not exceed the fee schedule appropriate to the place of service. Shipping and handling charges are not allowed.
	b. 	Payment for ear mold and batteries shall be at the current audiologist’s fee schedule.
	c. 	Payment for repairs shall be made to the dealer for repairs made by the dealer. Payment for in-house repairs shall be made at the current fee schedule. Payment shall also be made to the dealer for repairs when the hearing aid is repaired by the manufacturer or manufacturer’s depot. Payment for out-of-house repairs shall be at the amount shown on the manufacturer’s invoice. payment shall be allowed for a service or handling charge when it is necessary for repairs to be performed by the manufacturer or manufacturer’s depot and this charge is made to the general public.
	d. 	Prior approval. When prior approval is required, Form 470-4767, Examiner Report of Need for a Hearing Aid, shall be submitted along with the forms required by 441—paragraph 79.8(1)“a.”
	(1)	Payment for the replacement of a hearing aid less than four years old shall require prior approval except when the member is under 21 years of age. The department shall approve payment when the original hearing aid is lost or broken beyond repair or there is a significant change in the member’s hearing that would require a different hearing aid. (Cross-reference 78.28(4)“a”)
	(2)	Payment for a hearing aid costing more than $650 shall require prior approval. The department shall approve payment for either of the following purposes (Cross-reference 78.28(4)“b”):
	1.	Educational purposes when the member is participating in primary or secondary education or in a postsecondary academic program leading to a degree and an in-office comparison of an analog aid and a digital aid matched (+/− 5dB) for gain and output shows a significant improvement in either speech recognition in quiet or speech recognition in noise or an in-office comparison of two aids, one of which is single channel, shows significantly improved audibility.
	2.	Vocational purposes when documentation submitted indicates the necessity, such as varying amounts of background noise in the work environment and a need to converse in order to do the job, and an in-office comparison of an analog aid and a digital aid matched (+/- 5dB) for gain and output shows a significant improvement in either speech recognition in quiet or speech recognition in noise or an in-office comparison of two aids, one of which is single channel, shows significantly improved audibility.
This rule is intended to implement Iowa Code section 249A.4.
[ARC 8008B, IAB 7/29/09, effective 8/1/09]
441—78.15(249A) Orthopedic shoes. Payment shall be approved only for depth or custom-molded orthopedic shoes, inserts, and modifications, subject to the following definitions and conditions.
	78.15(1) Definitions.
“Custom-molded shoe” means a shoe that:
	1.	Has been constructed over a cast or model of the recipient’s foot;
	2.	Is made of leather or another suitable material of equal quality;
	3.	Has inserts that can be removed, altered, or replaced according to the recipient’s conditions and needs; and
	4.	Has some form of closure.
“Depth shoe” means a shoe that:
	1.	Has a full length, heel-to-toe filler that when removed provides a minimum of 3/16 inch of additional depth used to accommodate custom-molded or customized inserts;
	2.	Is made from leather or another suitable material of equal quality;
	3.	Has some form of closure; and
	4.	Is available in full and half sizes with a minimum of three widths, so that the sole is graded to the size and width of the upper portions of the shoe according to the American Standard last sizing schedule or its equivalent.
“Insert” means a foot mold or orthosis constructed of more than one layer of a material that:
	1.	Is soft enough and firm enough to take and hold an impression during use, and
	2.	Is molded to the recipient’s foot or is made over a model of the foot.
	78.15(2) Prescription. The recipient shall present to the provider a written prescription by a physician, a podiatrist, a physician assistant, or an advanced registered nurse practitioner that includes all of the following:
	1.	The date.
	2.	The patient’s diagnosis.
	3.	The reason orthopedic shoes are needed.
	4.	The probable duration of need.
	5.	A specific description of any required modification of the shoes.
	78.15(3) Diagnosis. The recipient shall have a diagnosis of an orthopedic, neuromuscular, vascular, or insensate foot condition, supported by applicable codes from the current version of the International Classification of Diseases (ICD). A diagnosis of flat feet is not covered.
	a. 	A recipient with diabetes must meet the Medicare criteria for therapeutic depth and custom-molded shoes.
	b. 	Custom-molded shoes are covered only when the recipient has a foot deformity and the provider has documentation of all of the following:
	(1)	The reasons the recipient cannot be fitted with a depth shoe.
	(2)	Pain.
	(3)	Tissue breakdown or a high probability of tissue breakdown.
	(4)	Any limitation on walking.
	78.15(4) Frequency. Only two pairs of orthopedic shoes are allowed per recipient in a 12-month period unless documentation of change in size or evidence of excessive wear is submitted. EXCEPTION: School-aged children under the age of 21 may obtain athletic shoes in addition to the two pairs of shoes in a 12-month period.
This rule is intended to implement Iowa Code section 249A.4.
441—78.16(249A) Community mental health centers. Payment will be approved for all reasonable and necessary services provided by a psychiatrist on the staff of a community mental health center. Payment will be approved for services provided by a clinical psychologist, social worker or psychiatric nurse on the staff of the center, subject to the following conditions:
	78.16(1) Payment to a community mental health center will be approved for reasonable and necessary services provided to members by a psychiatrist, psychologist, social worker or psychiatric nurse on the staff of the center under the following conditions:
	a. 	Services must be rendered under the supervision of a board-eligible or board-certified psychiatrist. All services must be performed under the supervision of a board-eligible or board-certified psychiatrist subject to the conditions set forth in 78.16(1)“b” with the following exceptions:
	(1)	Services by staff psychiatrists, or
	(2)	Services rendered by psychologists meeting the requirements of the National Register of Health Service Providers in Psychology, or
	(3)	Services provided by a staff member listed in this subrule performing the preliminary diagnostic evaluation of a member for voluntary admission to one of the state mental health institutes.
	b. 	Supervisory process.
	(1)	Each patient shall have an initial evaluation completed which shall include at least one personal evaluation interview with a mental health professional, as defined under Iowa Code section 228.1. If the evaluation interview results indicate a need for an interview with a board-eligible or board-certified psychiatrist, then such referral shall be made. This must be accomplished before submission of the first claim for services rendered to that patient.
	(2)	Ongoing review and assessment of patients’ treatment needs, treatment plans, and the appropriateness of services rendered shall be assured through the peer review process in effect for community mental health centers, as directed by 2002 Iowa Acts, chapter 1120, section 13.
	(3) and (4)	Rescinded IAB 2/5/03, effective 2/1/03.
	78.16(2) The treatment plans for and services rendered to patients of the center shall be evaluated and revised as necessary and appropriate, consistent with the standards of the peer review process described in subparagraph 78.16(1)“b”(1).
	78.16(3) The peer review process and related activities, as described under subparagraph 78.16(1)“b”(1), are not payable as separate services under the Medicaid program. The center shall maintain the results of and information related to the peer review process, and these records shall be subject to audit by the department of human services or department designees, as necessary and appropriate.
	78.16(4) Clinical records of medical assistance patients shall be available to the carrier on request. All these records shall be held confidential.
	78.16(5) At the time of application for participation in the program the center will be provided with a form on which to list its professional staff. The center shall report acquisitions or losses of professional staff to the carrier within ten days.
	78.16(6) Payment to a community mental health center will be approved for day treatment services for persons aged 21 or over if the center is certified by the department for day treatment services, the services are provided on the premises of the community mental health center or satellite office of the community mental health center, and the services meet the standards outlined herein.
	a. 	Community mental health centers providing day treatment services for persons aged 21 or over shall have available a written narrative providing the following day treatment information:
	(1)	Documented need for day treatment services for persons aged 21 and over in the area served by the program, including studies, needs assessments, and consultations with other health care professionals.
	(2)	Goals and objectives of the day treatment program for persons aged 21 and over that meet the day treatment program guidelines noted in 78.16(6)“b.”
	(3)	Organization and staffing including how the day treatment program for persons aged 21 and over fits with the rest of the community mental health center, the number of staff, staff credentials, and the staff’s relationship to the program, e.g., employee, contractual, or consultant.
	(4)	Policies and procedures for the program including admission criteria, patient assessment, treatment plan, discharge plan, postdischarge services, and the scope of services provided.
	(5)	Any accreditations or other types of approvals from national or state organizations.
	(6)	The physical facility and any equipment to be utilized.
	b. 	Day treatment services for persons aged 21 and over shall be structured, long-term services designed to assist in restoring, maintaining or increasing levels of functioning, minimizing regression, and preventing hospitalization.
	(1)	Service components include training in independent functioning skills necessary for self-care, emotional stability and psychosocial interactions and training in medication management.
	(2)	Services are structured with an emphasis on program variation according to individual need.
	(3)	Services are provided for a period of three to five hours per day, three or four times per week.
	c. 	Payment will be approved for day treatment services provided by or under the general supervision of a mental health professional as defined in rule 441—33.1(225C,230A). When services are provided by an employee or consultant of the community mental health center who is not a mental health professional, the employee or consultant shall be supervised by a mental health professional who gives professional direction and active guidance to the employee or consultant and who retains responsibility for consumer care. The supervision shall be timely, regular, and documented. The employee or consultant shall meet the following minimum requirements:
	(1)	Have a bachelor’s degree in a human services related field from an accredited college or university; or
	(2)	Have an Iowa license to practice as a registered nurse with two years of experience in the delivery of nursing or human services.
	d. 	Persons aged 18 through 20 with chronic mental illness as defined by rule 441—24.1(225C) can receive day treatment services under this subrule or subrule 78.16(7).
	78.16(7) Payment to a community mental health center will be approved for day treatment services for persons aged 20 or under if the center is certified by the department for day treatment services and the services are provided on the premises of the community mental health center or satellite office of the community mental health center. Exception: Field trips away from the premises are a covered service when the trip is therapeutic and integrated into the day treatment program’s description and milieu plan.
Day treatment coverage will be limited to a maximum of 15 hours per week. Day treatment services for persons aged 20 or under shall be outpatient services provided to persons who are not inpatients in a medical institution or residents of a group care facility licensed under 441—Chapter 114.
	a. 	Program documentation. Community mental health centers providing day treatment services for persons aged 20 or under shall have available a written narrative which provides the following day treatment program information:
	(1)	Documented need for day treatment services for persons aged 20 or under in the area served by the program, including studies, needs assessments, and consultations with other health care professionals.
	(2)	Goals and objectives of the day treatment program for persons aged 20 or under that meet the guidelines noted in paragraphs “c” to “h” below.
	(3)	Organization and staffing including how the day treatment program for persons aged 20 or under fits with the rest of the community mental health center, the number of staff, staff credentials, and the staff’s relationship to the program, e.g., employee, contractual, or consultant.
	(4)	Policies and procedures for the program including admission criteria, patient assessment, treatment plan, discharge plan, postdischarge services, and the scope of services provided.
	(5)	Any accreditations or other types of approvals from national or state organizations.
	(6)	The physical facility and any equipment to be utilized.
	b. 	Program standards. Medicaid day treatment program services for persons aged 20 and under shall meet the following standards:
	(1)	Staffing shall:
	1.	Be sufficient to deliver program services and provide stable, consistent, and cohesive milieu with a staff-to-patient ratio of no less than one staff for each eight participants. Clinical, professional, and paraprofessional staff may be counted in determining the staff-to-patient ratio. Professional or clinical staff are those staff who are either mental health professionals as defined in rule 441—33.1(225C,230A) or persons employed for the purpose of providing offered services under the supervision of a mental health professional. All other staff (administrative, adjunctive, support, nonclinical, clerical, and consulting staff or professional clinical staff) when engaged in administrative or clerical activities shall not be counted in determining the staff-to-patient ratio or in defining program staffing patterns. Educational staff may be counted in the staff-to-patient ratio.
	2.	Reflect how program continuity will be provided.
	3.	Reflect an interdisciplinary team of professionals and paraprofessionals.
	4.	Include a designated director who is a mental health professional as defined in rule 441—33.1(225C,230A). The director shall be responsible for direct supervision of the individual treatment plans for participants and the ongoing assessment of program effectiveness.
	5.	Be provided by or under the general supervision of a mental health professional as defined in rule 441—33.1(225C,230A). When services are provided by an employee or consultant of the community mental health center who is not a mental health professional, the employee or consultant shall be supervised by a mental health professional who gives direct professional direction and active guidance to the employee or consultant and who retains responsibility for consumer care. The supervision shall be timely, regular and documented. The employee or consultant shall have a bachelor’s degree in a human services related field from an accredited college or university or have an Iowa license to practice as a registered nurse with two years of experience in the delivery of nursing or human services. Exception: Other certified or licensed staff, such as certified addiction counselors or certified occupational and recreational therapy assistants, are eligible to provide direct services under the general supervision of a mental health professional, but they shall not be included in the staff-to-patient ratio.
	(2)	There shall be written policies and procedures addressing the following: admission criteria; patient assessment; patient evaluation; treatment plan; discharge plan; community linkage with other psychiatric, mental health, and human service providers; a process to review the quality of care being provided with a quarterly review of the effectiveness of the clinical program; postdischarge services; and the scope of services provided.
	(3)	The program shall have hours of operation available for a minimum of three consecutive hours per day, three days or evenings per week.
	(4)	The length of stay in a day treatment program for persons aged 20 or under shall not exceed 180 treatment days per episode of care, unless the rationale for a longer stay is documented in the patient’s case record and treatment plan every 30 calendar days after the first 180 treatment days.
	(5)	Programming shall meet the individual needs of the patient. A description of services provided for patients shall be documented along with a schedule of when service activities are available including the days and hours of program availability.
	(6)	There shall be a written plan for accessing emergency services 24 hours a day, seven days a week.
	(7)	The program shall maintain a community liaison with other psychiatric, mental health, and human service providers. Formal relationships shall exist with hospitals providing inpatient programs to facilitate referral, communication, and discharge planning. Relationships shall also exist with appropriate school districts and educational cooperatives. Relationships with other entities such as physicians, hospitals, private practitioners, halfway houses, the department, juvenile justice system, community support groups, and child advocacy groups are encouraged. The provider’s program description will describe how community links will be established and maintained.
	(8)	Psychotherapeutic treatment services and psychosocial rehabilitation services shall be available. A description of the services shall accompany the application for certification.
	(9)	The program shall maintain a distinct clinical record for each patient admitted. Documentation, at a minimum, shall include: the specific services rendered, the date and actual time services were rendered, who rendered the services, the setting in which the services were rendered, the amount of time it took to deliver the services, the relationship of the services to the treatment regimen described in the plan of care, and updates describing the patient’s progress.
	c. 	Program services. Day treatment services for persons aged 20 or under shall be a time-limited, goal-oriented active treatment program that offers therapeutically intensive, coordinated, structured clinical services within a stable therapeutic milieu. Time-limited means that the patient is not expected to need services indefinitely or lifelong, and that the primary goal of the program is to improve the behavioral functioning or emotional adjustment of the patient in order that the service is no longer necessary. Day treatment services shall be provided within the least restrictive therapeutically appropriate context and shall be community-based and family focused. The overall expected outcome is clinically adaptive behavior on the part of the patient and the family.
At a minimum, day treatment services will be expected to improve the patient’s condition, restore the condition to the level of functioning prior to onset of illness, control symptoms, or establish and maintain a functional level to avoid further deterioration or hospitalization. Services are expected to be age-appropriate forms of psychosocial rehabilitation activities, psychotherapeutic services, social skills training, or training in basic care activities to establish, retain or encourage age-appropriate or developmentally appropriate psychosocial, educational, and emotional adjustment.
Day treatment programs shall use an integrated, comprehensive and complementary schedule of therapeutic activities and shall have the capacity to treat a wide array of clinical conditions.
The following services shall be available as components of the day treatment program. These services are not separately billable to Medicaid, as day treatment reimbursement includes reimbursement for all day treatment components.
	(1)	Psychotherapeutic treatment services (examples would include individual, group, and family therapy).
	(2)	Psychosocial rehabilitation services. Active treatment examples include, but are not limited to, individual and group therapy, medication evaluation and management, expressive therapies, and theme groups such as communication skills, assertiveness training, other forms of community skills training, stress management, chemical dependency counseling, education, and prevention, symptom recognition and reduction, problem solving, relaxation techniques, and victimization (sexual, emotional, or physical abuse issues).
Other program components may be provided, such as personal hygiene, recreation, community awareness, arts and crafts, and social activities designed to improve interpersonal skills and family mental health. Although these other services may be provided, they are not the primary focus of treatment.
	(3)	Evaluation services to determine need for day treatment prior to program admission. For persons for whom clarification is needed to determine whether day treatment is an appropriate therapy approach, or for persons who do not clearly meet admission criteria, an evaluation service may be performed. Evaluation services shall be individual and family evaluation activities made available to courts, schools, other agencies, and individuals upon request, who assess, plan, and link individuals with appropriate services. This service must be completed by a mental health professional. An evaluation from another source performed within the previous 12 months or sooner if there has not been a change may be substituted. Medicaid will not make separate payment for these services under the day treatment program.
	(4)	Assessment services. All day treatment patients will receive a formal, comprehensive biopsychosocial assessment of day treatment needs including, if applicable, a diagnostic impression based on the current Diagnostic and Statistical Manual of Mental Disorders. An assessment from another source performed within the previous 12 months may be used if the symptomatology is the same as 12 months ago. If not, parts of the assessment which reflect current functioning may be used as an update. Using the assessment, a comprehensive summation will be produced, including the findings of all assessments performed. The summary will be used in forming a treatment plan including treatment goals. Indicators for discharge planning, including recommended follow-up goals and provision for future services, should also be considered, and consistently monitored.
	(5)	The day treatment program may include an educational component as an additional service. The patient’s educational needs shall be served without conflict from the day treatment program. Hours in which the patient is involved in the educational component of the day treatment program are not included in the day treatment hours billable to Medicaid.
	d. 	Admission criteria. Admission criteria for day treatment services for persons aged 20 or under shall reflect the following clinical indicators:
	(1)	The patient is at risk for exclusion from normative community activities or residence.
	(2)	The patient exhibits psychiatric symptoms, disturbances of conduct, decompensating conditions affecting mental health, severe developmental delays, psychological symptoms, or chemical dependency issues sufficiently severe to bring about significant or profound impairment in day-to-day educational, social, vocational, or interpersonal functioning.
	(3)	Documentation is provided that the traditional outpatient setting has been considered and has been determined not to be appropriate.
	(4)	The patient’s principal caretaker (family, guardian, foster family or custodian) must be able and willing to provide the support and monitoring of the patient, to enable adequate control of the patient’s behavior, and must be involved in the patient’s treatment. Persons aged 20 or under who have reached the age of majority, either by age or emancipation, are exempt from family therapy involvement.
	(5)	The patient has the capacity to benefit from the interventions provided.
	e. 	Individual treatment plan. Each patient receiving day treatment services shall have a treatment plan prepared. A preliminary treatment plan should be formulated within 3 days of participation after admission, and replaced within 30 calendar days by a comprehensive, formalized plan utilizing the comprehensive assessment. This individual treatment plan should reflect the patient’s strengths and weaknesses and identify areas of therapeutic focus. The treatment goals which are general statements of consumer outcomes shall be related to identified strengths, weaknesses, and clinical needs with time-limited, measurable objectives. Objectives shall be related to the goal and have specific anticipated outcomes. Methods that will be used to pursue the objectives shall be stated. The plan should be reviewed and revised as needed, but shall be reviewed at least every 30 calendar days. The treatment plan shall be developed or approved by a board-eligible or board-certified psychiatrist, a staff psychiatrist, physician, or a psychologist registered either on the “National Register of Health Service Providers in Psychology” or the “Iowa Register of Health Service Providers for Psychology.” Approval will be evidenced by a signature of the physician or health service provider.
	f. 	Discharge criteria. Discharge criteria for the day treatment program for persons aged 20 or under shall incorporate at least the following indicators:
	(1)	In the case of patient improvement:
	1.	The patient’s clinical condition has improved as shown by symptom relief, behavioral control, or indication of mastery of skills at the patient’s developmental level. Reduced interference with and increased responsibility with social, vocational, interpersonal, or educational goals occurs sufficient to warrant a treatment program of less supervision, support, and therapeutic intervention.
	2.	Treatment goals in the individualized treatment plan have been achieved.
	3.	An aftercare plan has been developed that is appropriate to the patient’s needs and agreed to by the patient and family, custodian, or guardian.
	(2)	If the patient does not improve:
	1.	The patient’s clinical condition has deteriorated to the extent that the safety and security of inpatient or residential care is necessary.
	2.	Patient, family, or custodian noncompliance with treatment or with program rules exists.
	g. 	Coordination of services. Programming services shall be provided in accordance with the individual treatment plan developed by appropriate day treatment staff, in collaboration with the patient and appropriate caretaker figure (parent, guardian, or principal caretaker), and under the supervision of the program director, coordinator, or supervisor.
The program for each patient will be coordinated by primary care staff of the community mental health center. A coordinated, consistent array of scheduled therapeutic services and activities shall comprise the day treatment program. These may include counseling or psychotherapy, theme groups, social skills development, behavior management, and other adjunctive therapies. At least 50 percent of scheduled therapeutic program hours exclusive of educational hours for each patient shall consist of active treatment that specifically addresses the targeted problems of the population served. Active treatment shall be defined as treatment in which the program staff assume significant responsibility and often intervene.
Family, guardian, or principal caretaker shall be involved with the program through family therapy sessions or scheduled family components of the program. They will be encouraged to adopt an active role in treatment. Medicaid will not make separate payment for family therapy services. Persons aged 20 or under who have reached the age of majority, either by age or emancipation, are exempt from family therapy involvement.
Therapeutic activities will be scheduled according to the needs of the patients, both individually and as a group.
Scheduled therapeutic activities, which may include other program components as described above, shall be provided at least 3 hours per week up to a maximum of 15 hours per week.
	h. 	Stable milieu. The program shall formally seek to provide a stable, consistent, and cohesive therapeutic milieu. In part this will be encouraged by scheduling attendance such that a stable core of patients exists as much as possible. The milieu will consider the developmental and social stage of the participants such that no patient will be significantly involved with other patients who are likely to contribute to retardation or deterioration of the patient’s social and emotional functioning. To help establish a sense of program identity, the array of therapeutic interventions shall be specifically identified as the day treatment program. Program planning meetings shall be held at least quarterly to evaluate the effectiveness of the clinical program. In the program description, the provider shall state how milieu stability will be provided.
	i. 	Chronic mental illness. Persons aged 18 through 20 with chronic mental illness as defined by rule 441—24.1(225C) can receive day treatment services under this subrule or subrule 78.16(6).
This rule is intended to implement Iowa Code section 249A.4.
441—78.17(249A) Physical therapists. Payment will be approved for the same services payable under Title XVIII of the Social Security Act (Medicare).
This rule is intended to implement Iowa Code section 249A.4.
441—78.18(249A) Screening centers. Payment will be approved for health screening as defined in 441—subrule 84.1(1) for Medicaid members under 21 years of age.
	78.18(1) Vaccines available through the Vaccines for Children program under Section 1928 of the Social Security Act are not covered as screening center services. Screening centers that wish to administer those vaccines to Medicaid members shall enroll in the Vaccines for Children program and obtain the vaccines from the department of public health. Screening centers shall receive reimbursement for the administration of vaccines to Medicaid members.
	78.18(2) Payment will be approved for necessary laboratory service related to an element of screening when performed by the screening center and billed as a separate item.
	78.18(3) Periodicity schedules for health, hearing, vision, and dental screenings.
	a. 	Payment will be approved for health, vision, and hearing screenings as follows:
	(1)	Six screenings in the first year of life.
	(2)	Four screenings between the ages of 1 and 2.
	(3)	One screening a year at ages 3, 4, 5, and 6.
	(4)	One screening a year at ages 8, 10, 12, 14, 16, 18, and 20.
	b. 	Payment for dental screenings will be approved in conjunction with the health screenings up to age 12 months. Screenings will be approved at ages 12 months and 24 months and thereafter at six-month intervals up to age 21.
	c. 	Interperiodic screenings will be approved as medically necessary.
	78.18(4) When it is established by the periodicity schedule in 78.18(3) that an individual is in need of screening the individual will receive a notice that screening is due.
	78.18(5) When an individual is screened, a member of the screening center shall complete a medical history. The medical history shall become part of the individual’s medical record.
	78.18(6) Rescinded IAB 12/3/08, effective 2/1/09.
	78.18(7) Payment will be made for persons aged 20 and under for nutritional counseling provided by a licensed dietitian employed by or under contract with a screening center for a nutritional problem or condition of a degree of severity that nutritional counseling beyond that normally expected as part of the standard medical management is warranted. For persons eligible for the WIC program, a WIC referral is required. Medical necessity for nutritional counseling services exceeding those available through WIC shall be documented.
	78.18(8) Payment shall be made for dental services provided by a dental hygienist employed by or under contract with a screening center.
This rule is intended to implement Iowa Code section 249A.4.
441—78.19(249A) Rehabilitation agencies.
	78.19(1) Coverage of services.
	a. 	General provisions regarding coverage of services.
	(1)	Services are provided in the recipient’s home or in a care facility (other than a hospital) by a speech therapist, physical therapist, or occupational therapist employed by or contracted by the agency. Services provided a recipient residing in a nursing facility or residential care facility are payable when a statement is submitted signed by the facility that the facility does not have these services available. The statement need only be submitted at the start of care unless the situation changes. Payment will not be made to a rehabilitation agency for therapy provided to a recipient residing in an intermediate care facility for the mentally retarded since these facilities are responsible for providing or paying for services required by recipients.
	(2)	All services must be determined to be medically necessary, reasonable, and meet a significant need of the recipient that cannot be met by a family member, friend, medical staff personnel, or other caregiver; must meet accepted standards of medical practice; and must be a specific and effective treatment for a patient’s medical or disabling condition.
	(3)	In order for a service to be payable, a licensed therapist must complete a plan of treatment every 30 days and indicate the type of service required. The plan of treatment must contain the information noted in subrule 78.19(2).
	(4)	There is no specific limitation on the number of visits for which payment through the program will be made so long as that amount of service is medically necessary in the individual case, is related to a diagnosed medical impairment or disabling condition, and meets the current standards of practice in each related field. Documentation must be submitted with each claim to support the need for the number of services being provided.
	(5)	Payments will be made both for restorative service and also for maintenance types of service. Essentially, maintenance services means services to a patient whose condition is stabilized and who requires observation by a therapist of conditions defined by the physician as indicating a possible deterioration of health status. This would include persons with long-term illnesses or a disabling condition whose status is stable rather than posthospital. Refer to 78.19(1)“b”(7) and (8) for guidelines under restorative and maintenance therapy.
	(6)	Restorative or maintenance therapy sessions must meet the following criteria:
	1.	There must be face-to-face patient contact interaction.
	2.	Services must be provided primarily on an individual basis. Group therapy is covered, but total units of service in a month shall not exceed total units of individual therapy. Family members receiving therapy may be included as part of a group.
	3.	Treatment sessions may be no less than 15 minutes of service and no more than 60 minutes of service per date unless more than 60 minutes of service is required for a treatment session due to the patient’s specific condition. If more than 60 minutes of service is required for a treatment session, additional documentation of the specific condition and the need for the longer treatment session shall be submitted with the claim. A unit of treatment shall be considered to be 15 minutes in length.
	4.	Progress must be documented in measurable statistics in the progress notes in order for services to be reimbursed. Refer to 78.19(1)“b”(7) and (8) for guidelines under restorative and maintenance therapy.
	(7)	Payment will be made for an appropriate period of diagnostic therapy or trial therapy (up to two months) to determine a patient’s rehabilitation potential and establish appropriate short-term and long-term goals. Documentation must be submitted with each plan to support the need for diagnostic or trial therapy. Refer to 78.19(1)“b”(16) for guidelines under diagnostic or trial therapy.
	b. 	Physical therapy services.
	(1)	To be covered under rehabilitation agency services, physical therapy services must relate directly and specifically to an active written treatment plan, follow a treatment plan established by the licensed therapist after consultation with the physician, be reasonable and necessary to the treatment of the person’s illness, injury, or disabling condition, be specific and effective treatment for the patient’s medical or disabling condition, and be of such a level of complexity and sophistication, or the condition of the patient must be such that the services required can be safely and effectively performed only by a qualified physical therapist or under the supervision of the therapist.
	(2)	A qualified physical therapist assistant may provide any restorative services performed by a licensed physical therapist under supervision of the therapist as set forth in the department of public health, professional licensure division, 645—subrule 200.20(7).
	(3)	The initial physical therapy evaluation must be provided by a licensed physical therapist.
	(4)	There must be an expectation that there will be a significant, practical improvement in the patient’s condition in a reasonable amount of time based on the patient’s restorative potential assessed by the physician.
	(5)	It must be demonstrated there is a need to establish a safe and effective maintenance program related to a specific disease state, illness, injury, or disabling condition.
	(6)	The amount, frequency, and duration of the services must be reasonable.
	(7)	Restorative therapy must be reasonable and necessary to the treatment of the patient’s injury or disabling condition. The expected restorative potential must be practical and in relation to the extent and duration of the treatment. There must be an expectation that the patient’s medical or disabling condition will show functional improvement in a reasonable period of time. Functional improvement means that demonstrable measurable increases have occurred in the patient’s level of independence outside the therapeutic environment.
	(8)	Generally, maintenance therapy means services to a patient whose condition is stabilized and who requires observation by a therapist of conditions defined by the physician as indicating a possible deterioration of health status. This includes persons with long-term illnesses or disabling conditions whose status is stable rather than posthospital. Maintenance therapy is also appropriate for individuals whose condition is such that a professionally established program of activities, exercises, or stimulation is medically necessary to prevent deterioration or maintain present functioning levels.
Where a maintenance program is appropriate, the initial evaluation and the instruction of the patient, family members, home health aides, facility personnel, or other caregivers to carry out the program are considered a covered physical therapy service. Payment shall be made for a maximum of three visits to establish a maintenance program and instruct the caregivers. Payment for supervisory visits to monitor the program is limited to two per month for a maximum period of 12 months. The plan of treatment must specify the anticipated monitoring activity of the supervisor.
Beyond evaluation, instruction, and monitoring, maintenance therapy is not reimbursable.
After 12 months of maintenance therapy, a reevaluation is a covered service, if medically necessary. A reevaluation will be considered medically necessary only if there is a significant change in residential or employment situation or the patient exhibits an increase or decrease in functional ability or motivation, clearing of confusion, or the remission of some other medical condition which previously contraindicated restorative therapy. A statement by the interdisciplinary team of a person with developmental disabilities recommending a reevaluation and stating the basis for medical necessity will be considered as supporting the necessity of a reevaluation and may expedite approval.
(Restorative and maintenance therapy definitions also apply to speech and occupational therapy.)
When a patient is under a restorative physical therapy program, the patient’s condition is regularly reevaluated and the program adjusted by the physical therapist. It is expected that prior to discharge, a maintenance program has been designed by the physical therapist. Consequently, where a maintenance program is not established until after the restorative program has been completed, it would not be considered reasonable and necessary to the treatment of the patient’s condition and would be excluded from coverage.
	(9)	Hot packs, hydrocollator, infrared treatments, paraffin baths, and whirlpool baths do not ordinarily require the skills of a qualified physical therapist. These are covered when the patient’s condition is complicated by other conditions such as a circulatory deficiency or open wounds or if the service is an integral part of a skilled physical therapy procedure.
	(10)	Gait training and gait evaluation and training constitute a covered service if the patient’s ability to walk has been impaired by a neurological, muscular or skeletal condition or illness. The gait training must be expected to significantly improve the patient’s ability to walk or level of independence.
Repetitious exercise to increase endurance of weak or unstable patients can be safely provided by supportive personnel, e.g., aides, nursing personnel. Therefore, it is not a covered physical therapy service.
	(11)	Ultrasound, shortwave, and microwave diathermy treatments are considered covered services.
	(12)	Range of motion tests must be performed by a qualified physical therapist. Range of motion exercises require the skills of a qualified physical therapist only when they are part of the active treatment of a specific disease or disabling condition which has resulted in a loss or restriction of mobility.
Documentation must reflect the degree of motion lost, the normal range of motion, and the degree to be restored.
Range of motion to unaffected joints only does not constitute a covered physical therapy service.
	(13)	Reconditioning programs after surgery or prolonged hospitalization are not covered as physical therapy.
	(14)	Therapeutic exercises would constitute a physical therapy service due either to the type of exercise employed or to the condition of the patient.
	(15)	Use of isokinetic or isotonic type equipment in physical therapy is covered when normal range of motion of a joint is affected due to bone, joint, ligament or tendon injury or postsurgical trauma. Billing can only be made for the time actually spent by the therapist in instructing the patient and assessing the patient’s progress.
	(16)	When recipients do not meet restorative or maintenance therapy criteria, diagnostic or trial therapy may be utilized. When the initial evaluation is not sufficient to determine whether there are rehabilitative goals that should be addressed, diagnostic or trial therapy to establish goals shall be considered appropriate. Diagnostic or trial therapy may be appropriate for recipients who need evaluation in multiple environments in order to adequately determine their rehabilitative potential. Diagnostic or trial therapy consideration may be appropriate when there is a need to assess the patient’s response to treatment in the recipient’s environment.
When during diagnostic or trial therapy a recipient has been sufficiently evaluated to determine potential for restorative or maintenance therapy, or lack of therapy potential, diagnostic or trial therapy ends. When as a result of diagnostic or trial therapy, restorative or maintenance therapy is found appropriate, claims shall be submitted noting restorative or maintenance therapy (instead of diagnostic or trial therapy).
At the end of diagnostic or trial therapy, the rehabilitation provider shall recommend continuance of services under restorative therapy, recommend continuance of services under maintenance therapy, or recommend discontinuance of services. Continuance of services under restorative or maintenance therapy will be reviewed based on the criteria in place for restorative or maintenance therapy.
Trial therapy shall not be granted more often than once per year for the same issue. If the recipient has a previous history of rehabilitative services, trial therapy for the same type of services generally would be payable only when a significant change has occurred since the last therapy. Requests for subsequent diagnostic or trial therapy for the same issue would require documentation reflecting a significant change. See number 4 below for guidelines under a significant change. Further diagnostic or trial therapy for the same issue would not be considered appropriate when progress was not achieved, unless the reasons which blocked change previously are listed and the reasons the new diagnostic or trial therapy would not have these blocks are provided.
The number of diagnostic or trial therapy hours authorized in the initial treatment period shall not exceed 12 hours per month. Documentation of the medical necessity and the plan for services under diagnostic trial therapy are required as they will be reviewed in the determination of the medical necessity of the number of hours of service provided.
Diagnostic or trial therapy standards also apply to speech and occupational therapy.
The following criteria additionally must be met:
	1.	There must be face-to-face interaction with a licensed therapist. (An aide’s services will not be payable.)
	2.	Services must be provided on an individual basis. (Group diagnostic or trial therapy will not be payable.)
	3.	Documentation of the diagnostic therapy or trial therapy must reflect the provider’s plan for therapy and the recipient’s response.
	4.	If the recipient has a previous history of rehabilitative services, trial therapy for the same type of services generally would be payable only when a significant change has occurred since the last therapy. A significant change would be considered as having occurred when any of the following exist: new onset, new problem, new need, new growth issue, a change in vocational or residential setting that requires a reevaluation of potential, or surgical intervention that may have caused new rehabilitative potentials.
	5.	For persons who received previous rehabilitative treatment, consideration of trial therapy generally should occur only if the person has incorporated any regimen recommended during prior treatment into the person’s daily life to the extent of the person’s abilities.
	6.	Documentation should include any previous attempts to resolve problems using nontherapy personnel (i.e., residential group home staff, family members, etc.) and whether follow-up programs from previous therapy have been carried out.
	7.	Referrals from residential, vocational or other rehabilitation personnel that do not meet present evaluation, restorative or maintenance criteria shall be considered for trial therapy. Documentation of the proposed service, the medical necessity and the current medical or disabling condition, including any secondary rehabilitative diagnosis, will need to be submitted with the claim.
	8.	Claims for diagnostic or trial therapy shall reflect the progress being made toward the initial diagnostic or trial therapy plan.
	c. 	Occupational therapy services.
	(1)	To be covered under rehabilitation agency services, occupational therapy services must be included in a plan of treatment, improve or restore practical functions which have been impaired by illness, injury, or disabling condition, or enhance the person’s ability to perform those tasks required for independent functioning, be prescribed by a physician under a plan of treatment, be performed by a qualified licensed occupational therapist or a qualified licensed occupational therapist assistant under the general supervision of a qualified licensed occupational therapist as set forth in the department of public health, professional licensure division, rule 645—201.9(148B), and be reasonable and necessary for the treatment of the person’s illness, injury, or disabling condition.
	(2)	Restorative therapy is covered when an expectation exists that the therapy will result in a significant practical improvement in the person’s condition.
However, in these cases where there is a valid expectation of improvement met at the time the occupational therapy program is instituted, but the expectation goal is not realized, services would only be covered up to the time one would reasonably conclude the patient would not improve.
The guidelines under restorative therapy, maintenance therapy, and diagnostic or trial therapy for physical therapy in 78.19(1)“b”(7), (8), and (16) apply to occupational therapy.
	(3)	Maintenance therapy, or any activity or exercise program required to maintain a function at the restored level, is not a covered service. However, designing a maintenance program in accordance with the requirements of 78.19(1)“b”(8) and monitoring the progress would be covered.
	(4)	The selection and teaching of tasks designed to restore physical function are covered.
	(5)	Planning and implementing therapeutic tasks, such as activities to restore sensory-integrative functions are covered. Other examples include providing motor and tactile activities to increase input and improve responses for a stroke patient.
	(6)	The teaching of activities of daily living and energy conservation to improve the level of independence of a patient which require the skill of a licensed therapist and meet the definition of restorative therapy is covered.
	(7)	The designing, fabricating, and fitting of orthotic and self-help devices are considered covered services if they relate to the patient’s condition and require occupational therapy. A maximum of 13 visits is reimbursable.
	(8)	Vocational and prevocational assessment and training are not payable by Medicaid. These include services which are related solely to specific employment opportunities, work skills, or work settings.
	d. 	Speech therapy services.
	(1)	To be covered by Medicaid as rehabilitation agency services, speech therapy services must be included in a plan of treatment established by the licensed, skilled therapist after consultation with the physician, relate to a specific medical diagnosis which will significantly improve a patient’s practical, functional level in a reasonable and predictable time period, and require the skilled services of a speech therapist. Services provided by a speech aide are not reimbursable.
	(2)	Speech therapy activities which are considered covered services include: restorative therapy services to restore functions affected by illness, injury, or disabling condition resulting in a communication impairment or to develop functions where deficiencies currently exist. Communication impairments fall into the general categories of disorders of voice, fluency, articulation, language, and swallowing disorders resulting from any condition other than mental impairment. Treatment of these conditions is payable if restorative criteria are met.
	(3)	Aural rehabilitation, the instruction given by a qualified speech pathologist in speech reading or lip reading to patients who have suffered a hearing loss (input impairment), constitutes a covered service if reasonable and necessary to the patient’s illness or injury. Group treatment is not covered. Audiological services related to the use of a hearing aid are not reimbursable.
	(4)	Teaching a patient to use sign language and to use an augmentative communication device is reimbursable. The patient must show significant progress outside the therapy sessions in order for these services to be reimbursable.
	(5)	Where a maintenance program is appropriate, the initial evaluation, the instruction of the patient and caregivers to carry out the program, and supervisory visits to monitor progress are covered services. Beyond evaluation, instruction, and monitoring, maintenance therapy is not reimbursable. However, designing a maintenance program in accordance with the requirements of maintenance therapy and monitoring the progress are covered.
	(6)	The guidelines and limits on restorative therapy, maintenance therapy, and diagnostic or trial therapy for physical therapy in 78.19(1)“b”(7), (8), and (16) apply to speech therapy. If the only goal of prior rehabilitative speech therapy was to learn the prerequisite speech components, then number “5” under 78.19(1)“b”(16) will not apply to trial therapy.
	78.19(2) General guidelines for plans of treatment.
	a. 	The minimum information to be included on medical information forms and treatment plans includes:
	(1)	The patient’s current medical condition and functional abilities, including any disabling condition.
	(2)	The physician’s signature and date (within the certification period).
	(3)	Certification period.
	(4)	Patient’s progress in measurable statistics. (Refer to 78.19(1)“b”(16).)
	(5)	The place services are rendered.
	(6)	Dates of prior hospitalization (if applicable or known).
	(7)	Dates of prior surgery (if applicable or known).
	(8)	The date the patient was last seen by the physician (if available).
	(9)	A diagnosis relevant to the medical necessity for treatment.
	(10)	Dates of onset of any diagnoses for which treatment is being rendered (if applicable).
	(11)	A brief summary of the initial evaluation or baseline.
	(12)	The patient’s prognosis.
	(13)	The services to be rendered.
	(14)	The frequency of the services and discipline of the person providing the service.
	(15)	The anticipated duration of the services and the estimated date of discharge (if applicable).
	(16)	Assistive devices to be used.
	(17)	Functional limitations.
	(18)	The patient’s rehabilitative potential and the extent to which the patient has been able to apply the skills learned in the rehabilitation setting to everyday living outside the therapy sessions.
	(19)	The date of the last episode of instability or the date of the last episode of acute recurrence of illness or symptoms (if applicable).
	(20)	Quantitative, measurable, short-term and long-term functional goals.
	(21)	The period of time of a session.
	(22)	Prior treatment (history related to current diagnosis) if available or known.
	b. 	The information to be included when developing plans for teaching, training, and counseling include:
	(1)	To whom the services were provided (patient, family member, etc.).
	(2)	Prior teaching, training, or counseling provided.
	(3)	The medical necessity of the rendered services.
	(4)	The identification of specific services and goals.
	(5)	The date of the start of the services.
	(6)	The frequency of the services.
	(7)	Progress in response to the services.
	(8)	The estimated length of time the services are needed.
This rule is intended to implement Iowa Code section 249A.4.
441—78.20(249A) Independent laboratories. Payment will be made for medically necessary laboratory services provided by laboratories that are independent of attending and consulting physicians’ offices, hospitals, and critical access hospitals and that are certified to participate in the Medicare program.
This rule is intended to implement Iowa Code section 249A.4.
441—78.21(249A) Rural health clinics. Payment will be made to rural health clinics for the same services payable under the Medicare program (Title XVIII of the Social Security Act). Payment will be made for sterilization in accordance with 78.1(16).
	78.21(1) Utilization review. Utilization review shall be conducted of Medicaid members who access more than 24 outpatient visits in any 12-month period from physicians, advanced registered nurse practitioners, federally qualified health centers, other clinics, and emergency rooms. Refer to rule 441—76.9(249A) for further information concerning the member lock-in program.
	78.21(2) Risk assessment. Risk assessment, using Form 470-2942, Medicaid Prenatal Risk Assessment, shall be completed at the initial visit during a Medicaid member’s pregnancy.
	a. 	If the risk assessment reflects a low-risk pregnancy, the assessment shall be completed again at approximately the twenty-eighth week of pregnancy.
	b. 	If the risk assessment reflects a high-risk pregnancy, referral shall be made for enhanced services. (See description of enhanced services at subrule 78.25(3).)
	78.21(3) Vaccines. Vaccines available through the Vaccines for Children program under Section 1928 of the Social Security Act are not covered as rural health center services. Rural health clinics that wish to administer those vaccines to Medicaid members shall enroll in the Vaccines for Children program and obtain the vaccines from the department of public health. However, the administration of vaccines is a covered service.
This rule is intended to implement Iowa Code section 249A.4.
441—78.22(249A) Family planning clinics. Payments will be made on a fee schedule basis for services provided by family planning clinics.
	78.22(1) Payment will be made for sterilization in accordance with 78.1(16).
	78.22(2) Vaccines available through the Vaccines for Children program under Section 1928 of the Social Security Act are not covered as family planning clinic services. Family planning clinics that wish to administer those vaccines for Medicaid members who receive services at the clinic shall enroll in the Vaccines for Children program and obtain the vaccines from the department of public health. Family planning clinics shall receive reimbursement for the administration of vaccines to Medicaid members.
This rule is intended to implement Iowa Code section 249A.4.
441—78.23(249A) Other clinic services. Payment will be made on a fee schedule basis to facilities not part of a hospital, funded publicly or by private contributions, which provide medically necessary treatment by or under the direct supervision of a physician or dentist to outpatients.
	78.23(1) Sterilization. Payment will be made for sterilization in accordance with 78.1(16).
	78.23(2) Utilization review. Utilization review shall be conducted of Medicaid members who access more than 24 outpatient visits in any 12-month period from physicians, advanced registered nurse practitioners, federally qualified health centers, other clinics, and emergency rooms. Refer to rule 441—76.9(249A) for further information concerning the member lock-in program.
	78.23(3) Risk assessment. Risk assessment, using Form 470-2942, Medicaid Prenatal Risk Assessment, shall be completed at the initial visit during a Medicaid member’s pregnancy.
	a. 	If the risk assessment reflects a low-risk pregnancy, the assessment shall be completed again at approximately the twenty-eighth week of pregnancy.
	b. 	If the risk assessment reflects a high-risk pregnancy, referral shall be made for enhanced services. (See description of enhanced services at subrule 78.25(3).)
	78.23(4) Vaccines. Vaccines available through the Vaccines for Children program under Section 1928 of the Social Security Act are not covered as clinic services. Clinics that wish to administer those vaccines to Medicaid members shall enroll in the Vaccines for Children program and obtain the vaccines from the department of public health. Clinics shall receive reimbursement for the administration of vaccines to Medicaid members.
This rule is intended to implement Iowa Code section 249A.4.
441—78.24(249A) Psychologists. Payment will be approved for services authorized by state law when they are provided by the psychologist in the psychologist’s office, a hospital, nursing facility, or residential care facility.
	78.24(1) Payment for covered services provided by the psychologist shall be made on a fee for service basis.
	a. 	Payment shall be made only for time spent in face-to-face consultation with the client.
	b. 	Time spent with clients shall be rounded to the quarter hour.
	78.24(2) Payment will be approved for the following psychological procedures:
	a. 	Individual outpatient psychotherapy or other psychological procedures not to exceed one hour per week or 40 hours in any 12-month period, or
	b. 	Couple, marital, family, or group outpatient therapy not to exceed one and one-half hours per week or 60 hours in any 12-month period, or
	c. 	A combination of individual and group therapy not to exceed the cost of 40 individual therapy hours in any 12-month period.
	d. 	Psychological examinations and testing for purposes of evaluation, placement, psychotherapy, or assessment of therapeutic progress, not to exceed eight hours in any 12-month period.
	e. 	Mileage at the same rate as in 78.1(8) when the following conditions are met:
	(1)	It is necessary for the psychologist to travel outside of the home community, and
	(2)	There is no qualified mental health professional more immediately available in the community, and
	(3)	The member has a medical condition which prohibits travel.
	f. 	Covered procedures necessary to maintain continuity of psychological treatment during periods of hospitalization or convalescence for physical illness.
	g. 	Procedures provided within a licensed hospital, residential treatment facility, day hospital, or nursing home as part of an approved treatment plan and a psychologist is not employed by the facility.
	78.24(3) Payment will not be approved for the following services:
	a. 	Psychological examinations performed without relationship to evaluations or psychotherapy for a specific condition, symptom, or complaint.
	b. 	Psychological examinations covered under Part B of Medicare, except for the Part B Medicare deductible and coinsurance.
	c. 	Psychological examinations employing unusual or experimental instrumentation.
	d. 	Individual and group psychotherapy without specification of condition, symptom, or complaint.
	e. 	Sensitivity training, marriage enrichment, assertiveness training, growth groups or marathons, or psychotherapy for nonspecific conditions of distress such as job dissatisfaction or general unhappiness.
	78.24(4) Rescinded IAB 10/12/94, effective 12/1/94.
	78.24(5) The following services shall require review by a consultant to the department.
	a. 	Protracted therapy beyond 16 visits. These cases shall be reviewed following the sixteenth therapy session and periodically thereafter.
	b. 	Any service which does not appear necessary or appears to fall outside the scope of what is professionally appropriate or necessary for a particular condition.
This rule is intended to implement Iowa Code sections 249A.4 and 249A.15.
441—78.25(249A) Maternal health centers. Payment will be made for prenatal and postpartum medical care, health education, and transportation to receive prenatal and postpartum services. Payment will be made for enhanced perinatal services for persons determined high risk. These services include additional health education services, nutrition counseling, social services, and one postpartum home visit. Maternal health centers shall provide trimester and postpartum reports to the referring physician. Risk assessment using Form 470-2942, Medicaid Prenatal Risk Assessment, shall be completed at the initial visit during a Medicaid member’s pregnancy. If the risk assessment reflects a low-risk pregnancy, the assessment shall be completed again at approximately the twenty-eighth week of pregnancy. If the risk assessment reflects a high-risk pregnancy, referral shall be made for enhanced services. (See description of enhanced services at subrule 78.25(3).)
Vaccines available through the Vaccines for Children program under Section 1928 of the Social Security Act are not covered as maternal health center services. Maternal health centers that wish to administer those vaccines to Medicaid members shall enroll in the Vaccines for Children program and obtain the vaccines from the department of public health. Maternal health centers shall receive reimbursement for the administration of vaccines to Medicaid members.
	78.25(1) Provider qualifications.
	a. 	Prenatal and postpartum medical services shall be provided by a physician, a physician assistant, or a nurse practitioner employed by or on contract with the center. Medical services performed by maternal health centers shall be performed under the supervision of a physician. Nurse practitioners and physician assistants performing under the supervision of a physician must do so within the scope of practice of that profession, as defined by Iowa Code chapters 152 and 148C, respectively.
	b. 	Rescinded IAB 12/3/08, effective 2/1/09.
	c. 	Education services and postpartum home visits shall be provided by a registered nurse.
	d. 	Nutrition services shall be provided by a licensed dietitian.
	e. 	Psychosocial services shall be provided by a person with at least a bachelor’s degree in social work, counseling, sociology, psychology, family and community services, health or human development, health education, or individual and family studies.
	78.25(2) Services covered for all pregnant women. Services provided may include:
	a. 	Prenatal and postpartum medical care.
	b. 	Health education, which shall include:
	(1)	Importance of continued prenatal care.
	(2)	Normal changes of pregnancy including both maternal changes and fetal changes.
	(3)	Self-care during pregnancy.
	(4)	Comfort measures during pregnancy.
	(5)	Danger signs during pregnancy.
	(6)	Labor and delivery including the normal process of labor, signs of labor, coping skills, danger signs, and management of labor.
	(7)	Preparation for baby including feeding, equipment, and clothing.
	(8)	Education on the use of over-the-counter drugs.
	(9)	Education about HIV protection.
	c. 	Home visit.
	d. 	Transportation to receive prenatal and postpartum services that is not payable under rule 441—78.11(249A) or 441—78.13(249A).
	e. 	Dental hygiene services within the scope of practice as defined by the dental board at 650—paragraph 10.5(3)“b.”
	78.25(3) Enhanced services covered for women with high-risk pregnancies. Enhanced perinatal services may be provided to a patient who has been determined to have a high-risk pregnancy as documented by Form 470-2942, Medicaid Prenatal Risk Assessment. An appropriately trained physician or advanced registered nurse practitioner must be involved in staffing the patients receiving enhanced services.
Enhanced services are as follows:
	a. 	Rescinded IAB 12/3/08, effective 2/1/09.
	b. 	Education, which shall include as appropriate education about the following:
	(1)	High-risk medical conditions.
	(2)	High-risk sexual behavior.
	(3)	Smoking cessation.
	(4)	Alcohol usage education.
	(5)	Drug usage education.
	(6)	Environmental and occupational hazards.
	c. 	Nutrition assessment and counseling, which shall include:
	(1)	Initial assessment of nutritional risk based on height, current and prepregnancy weight status, laboratory data, clinical data, and self-reported dietary information.
	(2)	Ongoing nutritional assessment.
	(3)	Development of an individualized nutritional care plan.
	(4)	Referral to food assistance programs if indicated.
	(5)	Nutritional intervention.
	d. 	Psychosocial assessment and counseling, which shall include:
	(1)	A psychosocial assessment including: needs assessment, profile of client demographic factors, mental and physical health history and concerns, adjustment to pregnancy and future parenting, and environmental needs.
	(2)	A profile of the client’s family composition, patterns of functioning and support systems.
	(3)	An assessment-based plan of care, risk tracking, counseling and anticipatory guidance as appropriate, and referral and follow-up services.
	e. 	A postpartum home visit within two weeks of the child’s discharge from the hospital, which shall include:
	(1)	Assessment of mother’s health status.
	(2)	Physical and emotional changes postpartum.
	(3)	Family planning.
	(4)	Parenting skills.
	(5)	Assessment of infant health.
	(6)	Infant care.
	(7)	Grief support for unhealthy outcome.
	(8)	Parenting of a preterm infant.
	(9)	Identification of and referral to community resources as needed.
This rule is intended to implement Iowa Code section 249A.4.
441—78.26(249A) Ambulatory surgical center services. Ambulatory surgical center services are those services furnished by an ambulatory surgical center in connection with a covered surgical procedure or a covered dental procedure. Covered procedures are listed in the fee schedule published on the department’s Web site.
	78.26(1) Covered surgical procedures shall be those medically necessary procedures that are eligible for payment as physicians’ services, under the circumstances specified in rule 441—78.1(249A) and performed on a Medicaid member, that can safely be performed in an outpatient setting as determined by the department upon advice from the Iowa Medicaid enterprise medical services unit.
	78.26(2) Covered dental procedures are those medically necessary procedures that are eligible for payment as dentists’ services, under the circumstances specified in rule 441—78.4(249A) and performed on a Medicaid member, that can safely be performed in an outpatient setting for Medicaid members whose mental, physical, or emotional condition necessitates deep sedation or general anesthesia.
	78.26(3) The covered services provided by the ambulatory surgical center in connection with a Medicaid-covered surgical or dental procedure shall be those nonsurgical and nondental services that:
	a. 	Are medically necessary in connection with a Medicaid-covered surgical or dental procedure;
	b. 	Are eligible for payment as physicians’ services under the circumstances specified in rule 441—78.1(249A) or as dentists’ services under the circumstances specified in rule 441—78.4(249A); and
	c. 	Can safely and economically be performed in an outpatient setting, as determined by the department upon advice from the Iowa Medicaid enterprise medical services unit.
	78.26(4) Limits on covered services.
	a. 	Abortion procedures are covered only when criteria in subrule 78.1(17) are met.
	b. 	Sterilization procedures are covered only when criteria in subrule 78.1(16) are met.
	c. 	Preprocedure review by the Iowa Foundation for Medical Care (IFMC) is required if ambulatory surgical centers are to be reimbursed for certain frequently performed surgical procedures as set forth under subrule 78.1(19). Criteria are available from IFMC, 1776 West Lakes Parkway, West Des Moines, Iowa 50266-8239, or in local hospital utilization review offices. (Cross-reference 78.28(6))
This rule is intended to implement Iowa Code section 249A.4.
[ARC 8205B, IAB 10/7/09, effective 11/11/09]
441—78.27(249A) Home- and community-based habilitation services.
	78.27(1) Definitions.
“Adult” means a person who is 18 years of age or older.
“Assessment” means the review of the current functioning of the member using the service in regard to the member’s situation, needs, strengths, abilities, desires, and goals.
“Case management” means case management services accredited under 441—Chapter 24 and provided according to 441—Chapter 90.
“Comprehensive service plan” means an individualized, goal-oriented plan of services written in language understandable by the member using the service and developed collaboratively by the member and the case manager.
“Department” means the Iowa department of human services.
“Emergency” means a situation for which no approved individual program plan exists that, if not addressed, may result in injury or harm to the member or to other persons or in significant amounts of property damage.
“HCBS” means home- and community-based services.
“Interdisciplinary team” means a group of persons with varied professional backgrounds who meet with the member to develop a comprehensive service plan to address the member’s need for services.
“ISIS” means the department’s individualized services information system.
“Member” means a person who has been determined to be eligible for Medicaid under 441—Chapter 75.
“Program” means a set of related resources and services directed to the accomplishment of a fixed set of goals for qualifying members.
	78.27(2) Member eligibility. To be eligible to receive home- and community-based habilitation services, a member shall meet the following criteria:
	a. 	Risk factors. The member has at least one of the following risk factors:
	(1)	The member has undergone or is currently undergoing psychiatric treatment more intensive than outpatient care (e.g., emergency services, alternative home care, partial hospitalization, or inpatient hospitalization) more than once in the member’s life; or
	(2)	The member has a history of psychiatric illness resulting in at least one episode of continuous, professional supportive care other than hospitalization.
	b. 	Need for assistance. The member has a need for assistance demonstrated by meeting at least two of the following criteria on a continuing or intermittent basis for at least two years:
	(1)	The member is unemployed, is employed in a sheltered setting, or has markedly limited skills and a poor work history.
	(2)	The member requires financial assistance for out-of-hospital maintenance and is unable to procure this assistance without help.
	(3)	The member shows severe inability to establish or maintain a personal social support system.
	(4)	The member requires help in basic living skills such as self-care, money management, housekeeping, cooking, and medication management.
	(5)	The member exhibits inappropriate social behavior that results in a demand for intervention.
	c. 	Income. The countable income used in determining the member’s Medicaid eligibility does not exceed 150 percent of the federal poverty level.
	d. 	Needs assessment. The member’s case manager has completed an assessment of the member’s need for service, and, based on that assessment, the Iowa Medicaid enterprise medical services unit has determined that the member is in need of home- and community-based habilitation services. A member who is not eligible for Medicaid case management services under 441—Chapter 90 shall receive case management as a home- and community-based habilitation service. The designated case manager shall:
	(1)	Complete a needs-based evaluation that meets the standards for assessment established in 441—subrule 90.5(1) before services begin and annually thereafter.
	(2)	Use the evaluation results to develop a comprehensive service plan as specified in subrule 78.27(4).
	e. 	Plan for service. The department has approved the member’s plan for home- and community-based habilitation services. A service plan that has been validated through ISIS shall be considered approved by the department. Home- and community-based habilitation services provided before department approval of a member’s eligibility for the program cannot be reimbursed.
	(1)	The member’s comprehensive service plan shall be completed annually according to the requirements of subrule 78.27(4). A service plan may change at any time due to a significant change in the member’s needs.
	(2)	The member’s habilitation services shall not exceed the maximum number of units established for each service in 441—subrule 79.1(2).
	(3)	The cost of the habilitation services shall not exceed unit expense maximums established in 441—subrule 79.1(2).
	78.27(3) Application for services. The case manager shall apply for services on behalf of a member by entering a program request for habilitation services in ISIS.
	a. 	Assignment of payment slot. The number of persons who may be approved for home- and community-based habilitation services is subject to a yearly total to be served. The total is set by the department based on available funds and is contained in the Medicaid state plan approved by the federal Centers for Medicare and Medicaid Services. The limit is maintained through the awarding of payment slots to members applying for services.
	(1)	The case manager shall contact the Iowa Medicaid enterprise through ISIS to determine if a payment slot is available for each member applying for home- and community-based habilitation services.
	(2)	When a payment slot is assigned, the case manager shall give written notice to the member.
	(3)	The department shall hold the assigned payment slot for the member as long as reasonable efforts are being made to arrange services and the member has not been determined to be ineligible for the program. If services have not been initiated and reasonable efforts are no longer being made to arrange services, the slot shall revert for use by the next applicant on the waiting list, if applicable. The member must reapply for a new slot.
	b. 	Waiting list for payment slots. When the number of applications exceeds the number of members specified in the state plan and there are no available payment slots to be assigned, the member’s application for habilitation services shall be denied. The department shall issue a notice of decision stating that the member’s name will be maintained on a waiting list.
	(1)	The Iowa Medicaid enterprise shall enter the member on a waiting list based on the date and time when the member’s request for habilitation services was entered into ISIS. In the event that more than one application is received at the same time, members shall be entered on the waiting list on the basis of the month of birth, January being month one and the lowest number.
	(2)	When a payment slot becomes available, the Iowa Medicaid enterprise shall notify the member’s case manager, based on the member’s order on the waiting list. The case manager shall give written notice to the member within five working days.
	(3)	The department shall hold the payment slot for 20 calendar days to allow the case manager to reapply for habilitation services by entering a program request through ISIS. If a request for habilitation services has not been entered within 20 calendar days, the slot shall revert for use by the next member on the waiting list, if applicable. The member assigned the slot must reapply for a new slot.
	(4)	The case manager shall notify the Iowa Medicaid enterprise within five working days of the withdrawal of an application.
	c. 	Notice of decision. The department shall issue a notice of decision to the applicant when financial eligibility, determination of needs-based eligibility, and approval of the service plan have been completed.
	78.27(4) Comprehensive service plan. Individualized, planned, and appropriate services shall be guided by a member-specific comprehensive service plan developed with the member in collaboration with an interdisciplinary team, as appropriate. Medically necessary services shall be planned for and provided at the locations where the member lives, learns, works, and socializes.
	a. 	Development. A comprehensive service plan shall be developed for each member receiving home- and community-based habilitation services based on the member’s current assessment and shall be reviewed on an annual basis.
	(1)	The case manager shall establish an interdisciplinary team for the member. The team shall include the case manager and the member and, if applicable, the member’s legal representative, the member’s family, the member’s service providers, and others directly involved.
	(2)	With the interdisciplinary team, the case manager shall identify the member’s services based on the member’s needs, the availability of services, and the member’s choice of services and providers.
	(3)	The comprehensive service plan development shall be completed at the member’s home or at another location chosen by the member.
	(4)	The interdisciplinary team meeting shall be conducted before the current comprehensive service plan expires.
	(5)	The comprehensive service plan shall reflect desired individual outcomes.
	(6)	Services defined in the comprehensive service plan shall be appropriate to the severity of the member’s problems and to the member’s specific needs or disabilities.
	(7)	Activities identified in the comprehensive service plan shall encourage the ability and right of the member to make choices, to experience a sense of achievement, and to modify or continue participation in the treatment process.
	(8)	For members receiving home-based habilitation in a licensed residential care facility of 16 or fewer beds, the service plan shall address the member’s opportunities for independence and community integration.
	b. 	Service goals and activities. The comprehensive service plan shall:
	(1)	Identify observable or measurable individual goals.
	(2)	Identify interventions and supports needed to meet those goals with incremental action steps, as appropriate.
	(3)	Identify the staff persons, businesses, or organizations responsible for carrying out the interventions or supports.
	(4)	List all Medicaid and non-Medicaid services received by the member and identify:
	1.	The name of the provider responsible for delivering the service;
	2.	The funding source for the service; and
	3.	The number of units of service to be received by the member.
	(5)	Identify for a member receiving home-based habilitation:
	1.	The member’s living environment at the time of enrollment;
	2.	The number of hours per day of on-site staff supervision needed by the member; and
	3.	The number of other members who will live with the member in the living unit.
	(6)	Include a separate, individualized, anticipated discharge plan that is specific to each service the member receives.
	c. 	Rights restrictions. Any rights restrictions must be implemented in accordance with 441—subrule 77.25(4). The comprehensive service plan shall include documentation of:
	(1)	Any restrictions on the member’s rights, including maintenance of personal funds and self-administration of medications;
	(2)	The need for the restriction; and
	(3)	Either a plan to restore those rights or written documentation that a plan is not necessary or appropriate.
	d. 	Emergency plan. The comprehensive service plan shall include a plan for emergencies and identification of the supports available to the member in an emergency. Emergency plans shall be developed as follows:
	(1)	The member’s interdisciplinary team shall identify in the comprehensive service plan any health and safety issues applicable to the individual member based on information gathered before the team meeting, including a risk assessment.
	(2)	The interdisciplinary team shall identify an emergency backup support and crisis response system to address problems or issues arising when support services are interrupted or delayed or the member’s needs change.
	(3)	Providers of applicable services shall provide for emergency backup staff.
	e. 	Plan approval. Services shall be entered into ISIS based on the comprehensive service plan. A service plan that has been validated and authorized through ISIS shall be considered approved by the department. Services must be authorized in ISIS as specified in paragraph 78.27(2)“e.”
	78.27(5) Requirements for services. Home- and community-based habilitation services shall be provided in accordance with the following requirements:
	a. 	The services shall be based on the member’s needs as identified in the member’s comprehensive service plan.
	b. 	The services shall be delivered in the least restrictive environment appropriate to the needs of the member.
	c. 	The services shall include the applicable and necessary instruction, supervision, assistance, and support required by the member to achieve the member’s life goals.
	d. 	Service components that are the same or similar shall not be provided simultaneously.
	e. 	Service costs are not reimbursable while the member is in a medical institution, including but not limited to a hospital or nursing facility.
	f. 	Reimbursement is not available for room and board.
	g. 	Services shall be billed in whole units.
	h. 	Services shall be documented. Each unit billed must have corresponding financial and medical records as set forth in rule 441—79.3(249A).
	78.27(6) Case management. Case management assists members in gaining access to needed medical, social, educational, housing, transportation, vocational, and other appropriate services in order to ensure the health, safety, and welfare of the member.
	a. 	Scope. Case management services shall be provided as set forth in rules 441—90.5(249A) and 441—90.8(249A).
	b. 	Exclusion. Payment shall not be made for case management provided to a member who is eligible for case management services under 441—Chapter 90.
	78.27(7) Home-based habilitation. “Home-based habilitation” means individually tailored supports that assist with the acquisition, retention, or improvement of skills related to living in the community.
	a. 	Scope. Home-based habilitation services are individualized supportive services provided in the member’s home and community that assist the member to reside in the most integrated setting appropriate to the member’s needs. Services are intended to provide for the daily living needs of the member and shall be available as needed during any 24-hour period. The specific support needs for each member shall be determined necessary by the interdisciplinary team and shall be identified in the member’s comprehensive service plan. Covered supports include:
	(1)	Adaptive skill development;
	(2)	Assistance with activities of daily living;
	(3)	Community inclusion;
	(4)	Transportation;
	(5)	Adult educational supports;
	(6)	Social and leisure skill development;
	(7)	Personal care; and
	(8)	Protective oversight and supervision.
	b. 	Exclusions. Home-based habilitation payment shall not be made for the following:
	(1)	Room and board and maintenance costs, including the cost of rent or mortgage, utilities, telephone, food, household supplies, and building maintenance, upkeep, or improvement.
	(2)	Service activities associated with vocational services, day care, medical services, or case management.
	(3)	Transportation to and from a day program.
	(4)	Services provided to a member who lives in a licensed residential care facility of more than 16 persons.
	(5)	Services provided to a member who lives in a facility that provides the same service as part of an inclusive or “bundled” service rate, such as a nursing facility or an intermediate care facility for persons with mental retardation.
	(6)	Personal care and protective oversight and supervision may be a component part of home-based habilitation services but may not comprise the entirety of the service.
	78.27(8) Day habilitation. “Day habilitation” means assistance with acquisition, retention, or improvement of self-help, socialization, and adaptive skills.
	a. 	Scope. Day habilitation activities and environments are designed to foster the acquisition of skills, appropriate behavior, greater independence, and personal choice. Services focus on enabling the member to attain or maintain the member’s maximum functional level and shall be coordinated with any physical, occupational, or speech therapies in the comprehensive service plan. Services may serve to reinforce skills or lessons taught in other settings. Services must enhance or support the member’s:
	(1)	Intellectual functioning;
	(2)	Physical and emotional health and development;
	(3)	Language and communication development;
	(4)	Cognitive functioning;
	(5)	Socialization and community integration;
	(6)	Functional skill development;
	(7)	Behavior management;
	(8)	Responsibility and self-direction;
	(9)	Daily living activities;
	(10)	Self-advocacy skills; or
	(11)	Mobility.
	b. 	Setting. Day habilitation shall take place in a nonresidential setting separate from the member’s residence. Services shall not be provided in the member’s home. When the member lives in a residential care facility of more than 16 beds, day habilitation services provided in the facility are not considered to be provided in the member’s home if the services are provided in an area apart from the member’s sleeping accommodations.
	c. 	Duration. Day habilitation services shall be furnished for four or more hours per day on a regularly scheduled basis for one or more days per week or as specified in the member’s comprehensive service plan. Meals provided as part of day habilitation shall not constitute a full nutritional regimen (three meals per day).
	d. 	Exclusions. Day habilitation payment shall not be made for the following:
	(1)	Vocational or prevocational services.
	(2)	Services that duplicate or replace education or related services defined in Public Law 94-142, the Education of the Handicapped Act.
	(3)	Compensation to members for participating in day habilitation services.
	78.27(9) Prevocational habilitation. “Prevocational habilitation” means services that prepare a member for paid or unpaid employment.
	a. 	Scope. Prevocational habilitation services include teaching concepts such as compliance, attendance, task completion, problem solving, and safety. Services are not oriented to a specific job task, but instead are aimed at a generalized result. Services shall be reflected in the member’s comprehensive service plan and shall be directed to habilitative objectives rather than to explicit employment objectives.
	b. 	Setting. Prevocational habilitation services may be provided in a variety of community-based settings based on the individual need of the member. Meals provided as part of these services shall not constitute a full nutritional regimen (three meals per day).
	c. 	Exclusions. Prevocational habilitation payment shall not be made for the following:
	(1)	Services that are available under a program funded under Section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.). Documentation that funding is not available for the service under these programs shall be maintained in the file of each member receiving prevocational habilitation services.
	(2)	Services that duplicate or replace education or related services defined in Public Law 94-142, the Education of the Handicapped Act.
	(3)	Compensation to members for participating in prevocational services.
	78.27(10) Supported employment habilitation. “Supported employment habilitation” means services associated with maintaining competitive paid employment.
	a. 	Scope. Supported employment habilitation services are intensive, ongoing supports that enable members to perform in a regular work setting. Services are provided to members who need support because of their disabilities and who are unlikely to obtain competitive employment at or above the minimum wage absent the provision of supports. Covered services include:
	(1)	Activities to obtain a job. Covered services directed to obtaining a job must be provided to or on behalf of a member for whom competitive employment is reasonably expected within less than one year. Services must be focused on job placement, not on teaching generalized employment skills or habilitative goals. Three conditions must be met before services are provided. First, the member and the interdisciplinary team described in subrule 78.27(4) must complete the form that Iowa vocational rehabilitation services uses to identify the supported employment services appropriate to meet a person’s employment needs. Second, the member’s interdisciplinary team must determine that the identified services are necessary. Third, the Iowa Medicaid enterprise medical services unit must approve the services. Available components of activities to obtain a job are as follows:
	1.	Job development services. Job development services are directed toward obtaining competitive employment. A unit of service is a job placement that the member holds for 30 consecutive calendar days or more. Payment is available once the service is authorized in the member’s service plan. A member may receive two units of job development services during a 12-month period. The activities provided to the member may include job procurement training, including grooming and hygiene, application, résumé development, interviewing skills, follow-up letters, and job search activities; job retention training, including promptness, coworker relations, transportation skills, disability-related supports, job benefits, and an understanding of employee rights and self-advocacy; and customized job development services specific to the member.
	2.	Employer development services. The focus of employer development services is to support employers in hiring and retaining members in their workforce and to communicate expectations of the employers to the interdisciplinary team described in subrule 78.27(4). Employer development services may be provided only to members who are reasonably expected to work for no more than 10 hours per week. A unit of service is one job placement that the member holds for 30 consecutive calendar days or more. Payment for this service may be made only after the member holds the job for 30 days. A member may receive two units of employer development services during a 12-month period if the member is competitively employed for 30 or more consecutive calendar days and the other conditions for service approval are met. The services provided may include: developing relationships with employers and providing leads for individual members when appropriate; job analysis for a specific job; development of a customized training plan identifying job-specific skill requirements, employer expectations, teaching strategies, time frames, and responsibilities; identifying and arranging reasonable accommodations with the employer; providing disability awareness and training to the employer when it is deemed necessary; and providing technical assistance to the employer regarding the training progress as identified on the member’s customized training plan.
	3.	Enhanced job search activities. Enhanced job search activities are associated with obtaining initial employment after job development services have been provided to the member for a minimum of 30 days or with assisting the member in changing jobs due to layoff, termination, or personal choice. The interdisciplinary team must review and update the Iowa vocational rehabilitation services supported employment readiness analysis form to determine if this service remains appropriate for the member’s employment goals. A unit of service is an hour. A maximum of 26 units may be provided in a 12-month period. The services provided may include: job opening identification with the member; assistance with applying for a job, including completion of applications or interviews; and work site assessment and job accommodation evaluation.
	(2)	Supports to maintain employment, including the following services provided to or on behalf of the member:
	1.	Individual work-related behavioral management.
	2.	Job coaching.
	3.	On-the-job or work-related crisis intervention.
	4.	Assistance in the use of skills related to sustaining competitive paid employment, including assistance with communication skills, problem solving, and safety.
	5.	Assistance with time management.
	6.	Assistance with appropriate grooming.
	7.	Employment-related supportive contacts.
	8.	On-site vocational assessment after employment.
	9.	Employer consultation.
	b. 	Setting. Supported employment may be conducted in a variety of settings, particularly work sites where persons without disabilities are employed.
	(1)	The majority of coworkers at any employment site with more than two employees where members seek, obtain, or maintain employment must be persons without disabilities.
	(2)	In the performance of job duties at any site where members seek, obtain, or maintain employment, the member must have daily contact with other employees or members of the general public who do not have disabilities, unless the absence of daily contact with other employees or the general public is typical for the job as performed by persons without disabilities.
	(3)	When services for maintaining employment are provided to members in a teamwork or “enclave” setting, the team shall include no more than eight people with disabilities.
	c. 	Service requirements. The following requirements shall apply to all supported employment services:
	(1)	All supported employment services shall provide individualized and ongoing support contacts at intervals necessary to promote successful job retention.
	(2)	The provider shall provide employment-related adaptations required to assist the member in the performance of the member’s job functions as part of the service.
	(3)	Community transportation options (such as carpools, coworkers, self or public transportation, families, volunteers) shall be attempted before the service provider provides transportation. When no other resources are available, employment-related transportation between work and home and to or from activities related to employment may be provided as part of the service.
	(4)	Members may access both services to maintain employment and services to obtain a job for the purpose of job advancement or job change. A member may receive a maximum of three job placements in a 12-month period and a maximum of 40 units per week of services to maintain employment.
	d. 	Exclusions. Supported employment habilitation payment shall not be made for the following:
	(1)	Services that are available under a program funded under Section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.). Documentation that funding is not available under these programs shall be maintained in the file of each member receiving supported employment services.
	(2)	Incentive payments made to an employer to encourage or subsidize the employer’s participation in a supported employment program.
	(3)	Subsidies or payments that are passed through to users of supported employment programs.
	(4)	Training that is not directly related to a member’s supported employment program.
	(5)	Services involved in placing or maintaining members in day activity programs, work activity programs, or sheltered workshop programs.
	(6)	Supports for volunteer work or unpaid internships.
	(7)	Tuition for education or vocational training.
	(8)	Individual advocacy that is not member-specific.
	78.27(11) Adverse service actions.
	a. 	Denial. Services shall be denied when the department determines that:
	(1)	A payment slot is not available to the member pursuant to paragraph 78.27(3)“a.”
	(2)	The member is not eligible for or in need of home- and community-based habilitation services.
	(3)	The service is not identified in the member’s comprehensive service plan.
	(4)	Needed services are not available or received from qualifying providers, or no qualifying providers are available.
	(5)	The member’s service needs exceed the unit or reimbursement maximums for a service as set forth in 441—subrule 79.1(2).
	(6)	Completion or receipt of required documents for the program has not occurred.
	b. 	Reduction. A particular home- and community-based habilitation service may be reduced when the department determines that continued provision of service at its current level is not necessary.
	c. 	Termination. A particular home- and community-based habilitation service may be terminated when the department determines that:
	(1)	The member’s income exceeds the allowable limit, or the member no longer meets other eligibility criteria for the program established by the department.
	(2)	The service is not identified in the member’s comprehensive service plan.
	(3)	Needed services are not available or received from qualifying providers, or no qualifying providers are available.
	(4)	The member’s service needs are not being met by the services provided.
	(5)	The member has received care in a medical institution for 30 consecutive days in any one stay. When a member has been an inpatient in a medical institution for 30 consecutive days, the department will issue a notice of decision to inform the member of the service termination. If the member returns home before the effective date of the notice of decision and the member’s condition has not substantially changed, the decision shall be rescinded, and eligibility for home- and community-based habilitation services shall continue.
	(6)	The member’s service needs exceed the unit or reimbursement maximums for a service as established by the department.
	(7)	Duplication of services provided during the same period has occurred.
	(8)	The member or the member’s legal representative, through the interdisciplinary process, requests termination of the service.
	(9)	Completion or receipt of required documents for the program has not occurred, or the member refuses to allow documentation of eligibility as to need and income.
	d. 	Appeal rights. The department shall give notice of any adverse action and the right to appeal in accordance with 441—Chapter 7. The member is entitled to have a review of the determination of needs-based eligibility by the Iowa Medicaid enterprise medical services unit by sending a letter requesting a review to the medical services unit. If dissatisfied with that decision, the member may file an appeal with the department.
	78.27(12) County reimbursement. The county board of supervisors of the member’s county of legal settlement shall reimburse the department for all of the nonfederal share of the cost of home- and community-based habilitation services provided to an adult member with a chronic mental illness as defined in 441—Chapter 90. The department shall notify the county’s central point of coordination administrator through ISIS of the approval of the member’s service plan.
This rule is intended to implement Iowa Code section 249A.4.
[ARC 7957B, IAB 7/15/09, effective 7/1/09 (See Delay note at end of chapter)]
441—78.28(249A) List of medical services and equipment requiring prior approval, preprocedure review or preadmission review.
	78.28(1) Services, procedures, and medications prescribed by a physician (M.D. or D.O.) which are subject to prior approval or preprocedure review are as follows or as specified in the preferred drug list published by the department pursuant to Iowa Code Supplement section 249A.20A:
	a. 	Drugs require prior authorization as specified in the preferred drug list published by the department pursuant to Iowa Code section 249A.20A. For drugs requiring prior authorization, reimbursement will be made for a 72-hour supply dispensed in an emergency when a prior authorization request cannot be submitted.
	b. 	Automated medication dispenser. (Cross-reference 78.10(2)“b”) Payment will be approved for an automated medication dispenser when prescribed for a member who meets all of the following conditions:
	(1)	The member has a diagnosis indicative of cognitive impairment or age-related factors that affect the member’s ability to remember to take medications.
	(2)	The member is on two or more medications prescribed to be administered more than one time a day.
	(3)	The availability of a caregiver to administer the medications or perform setup is limited or nonexistent.
	(4)	Less costly alternatives, such as medisets or telephone reminders, have failed.
	c. 	Enteral products and enteral delivery pumps and supplies require prior approval. Daily enteral nutrition therapy shall be approved as medically necessary only for a member who either has a metabolic or digestive disorder that prevents the member from obtaining the necessary nutritional value from usual foods in any form and cannot be managed by avoidance of certain food products or has a severe pathology of the body that does not allow ingestion or absorption of sufficient nutrients from regular food to maintain weight and strength commensurate with the member’s general condition. (Cross-reference 78.10(3)“c”(2))
	(1)	A request for prior approval shall include a physician’s, physician assistant’s, or advanced registered nurse practitioner’s written order or prescription and documentation to establish the medical necessity for enteral products and enteral delivery pumps and supplies pursuant to the above standards. The documentation shall include:
	1.	A statement of the member’s total medical condition that includes a description of the member’s metabolic or digestive disorder or pathology.
	2.	Documentation of the medical necessity for commercially prepared products. The information submitted must identify other methods attempted to support the member’s nutritional status and indicate that the member’s nutritional needs were not or could not be met by regular food in pureed form.
	3.	Documentation of the medical necessity for an enteral pump, if the request includes an enteral pump. The information submitted must identify the medical reasons for not using a gravity feeding set.
	(2)	Examples of conditions that will not justify approval of enteral nutrition therapy are: weight-loss diets, wired-shut jaws, diabetic diets, milk or food allergies (unless the member is under five years of age and coverage through the Women, Infant and Children’s program is not available), and the use of enteral products for convenience reasons when regular food in pureed form would meet the medical need of the member.
	(3)	Basis of payment for nutritional therapy supplies shall be the least expensive method of delivery that is reasonable and medically necessary based on the documentation submitted.
	d. 	Rescinded IAB 5/11/05, effective 5/1/05.
	e. 	Augmentative communication systems, which are provided to persons unable to communicate their basic needs through oral speech or manual sign language, require prior approval. Form 470-2145, Augmentative Communication System Selection, completed by a speech pathologist and a physician’s prescription for a particular device shall be submitted to request prior approval. (Cross-reference 78.10(3)“c”(1))
	(1)	Information requested on the prior authorization form includes a medical history, diagnosis, and prognosis completed by a physician. In addition, a speech or language pathologist needs to describe current functional abilities in the following areas: communication skills, motor status, sensory status, cognitive status, social and emotional status, and language status.
	(2)	Also needed from the speech or language pathologist is information on educational ability and needs, vocational potential, anticipated duration of need, prognosis regarding oral communication skills, prognosis with a particular device, and recommendations.
	(3)	The department’s consultants with an expertise in speech pathology will evaluate the prior approval requests and make recommendations to the department.
	f. 	Preprocedure review by the Iowa Foundation for Medical Care (IFMC) will be required if payment under Medicaid is to be made for certain frequently performed surgical procedures which have a wide variation in the relative frequency the procedures are performed. Preprocedure surgical review applies to surgeries performed in hospitals (outpatient and inpatient) and ambulatory surgical centers. Approval by IFMC will be granted only if the procedures are determined to be necessary based on the condition of the patient and on the published criteria established by the department and the IFMC. If not so approved by the IFMC, payment will not be made under the program to the physician or to the facility in which the surgery is performed. The criteria are available from IFMC, 3737 Woodland Avenue, Suite 500, West Des Moines, Iowa 50265, or in local hospital utilization review offices.
The “Preprocedure Surgical Review List” shall be published by the department in the provider manuals for physicians, hospitals, and ambulatory surgical centers. (Cross-reference 78.1(19))
	g. 	Prior authorization is required for enclosed beds. (Cross-reference 78.10(2)“c”) The department shall approve payment for an enclosed bed when prescribed for a patient who meets all of the following conditions:
	(1)	The patient has a diagnosis-related cognitive or communication impairment that results in risk to safety.
	(2)	The patient’s mobility puts the patient at risk for injury.
	(3)	The patient has suffered injuries when getting out of bed.
	(4)	The patient has had a successful trial with an enclosed bed.
	h. 	Prior authorization is required for external insulin infusion pumps and is granted according to Medicare coverage criteria. (Cross-reference 78.10(2)“c”)
	i. 	Prior authorization is required for oral nutritional products. (Cross-reference 78.10(2)“c”) The department shall approve payment for oral nutritional products when the member is not able to ingest or absorb sufficient nutrients from regular food due to a metabolic, digestive, or psychological disorder or pathology to the extent that supplementation is necessary to provide 51 percent or more of the daily caloric intake, or when the use of oral nutritional products is otherwise determined medically necessary in accordance with evidence-based guidelines for treatment of the member’s condition.
	(1)	A request for prior approval shall include a written order or prescription from a physician, physician assistant, or advanced registered nurse practitioner and documentation to establish the medical necessity for oral nutritional products pursuant to these standards. The documentation shall include:
	1.	A statement of the member’s total medical condition that includes a description of the member’s metabolic, digestive, or psychological disorder or pathology.
	2.	Documentation of the medical necessity for commercially prepared products. The information submitted must identify other methods attempted to support the member’s nutritional status and indicate that the member’s nutritional needs were not or could not be met by regular food in pureed form.
	3.	Documentation to support the fact that regular foods will not provide sufficient nutritional value to the member, if the request includes oral supplementation of a regular diet.
	(2)	Examples of conditions that will not justify approval of oral nutritional products are: weight-loss diets, wired-shut jaws, diabetic diets, and milk or food allergies (unless the member is under five years of age and coverage through the Special Supplemental Nutrition Program for Women, Infants, and Children is not available).
	j. 	Prior authorization is required for vest airway clearance systems. (Cross-reference 78.10(2)“c”) The department shall approve payment for a vest airway clearance system when prescribed by a pulmonologist for a patient with a medical diagnosis related to a lung disorder if all of the following conditions are met:
	(1)	Pulmonary function tests for the 12 months before initiation of the vest demonstrate an overall significant decrease of lung function.
	(2)	The patient resides in an independent living situation or has a medical condition that precludes the caregiver from administering traditional chest physiotherapy.
	(3)	Treatment by flutter device failed or is contraindicated.
	(4)	Treatment by intrapulmonary percussive ventilation failed or is contraindicated.
	(5)	All other less costly alternatives have been tried.
	k. 	Prior authorization is required for blood glucose monitors and diabetic test strips produced by a manufacturer that does not have a current agreement to provide a rebate to the department for monitors or test strips provided through the Medicaid program. The department shall approve payment when a blood glucose monitor or diabetic test strips produced by a manufacturer that does not have a current rebate agreement with the department are medically necessary.
	78.28(2) Dental services. Dental services which require prior approval are as follows:
	a. 	The following periodontal services:
	(1)	Payment for periodontal scaling and root planing will be approved when interproximal and subgingival calculus is evident in X-rays or when justified and documented that curettage, scaling or root planing is required in addition to routine prophylaxis. (Cross-reference 78.4(4)“b”)
	(2)	Payment for pedicle soft tissue graft and free soft tissue graft will be approved when the written narrative describes medical necessity. Payment for other periodontal surgical procedures will be approved after periodontal scaling and root planing has been provided, a reevaluation examination has been completed, and the patient has demonstrated reasonable oral hygiene, unless the patient is unable to demonstrate reasonable oral hygiene because of physical or mental disability or in cases which demonstrate gingival hyperplasia resulting from drug therapy. (Cross-reference 78.4(4)“c”)
	(3)	Payment for pedicle soft tissue graft and free soft tissue graft will be approved when the written narrative describes medical necessity. (Cross-reference 78.4(4)“d”)
	(4)	Payment for periodontal maintenance therapy may be approved after periodontal scaling and root planing or periodontal surgical procedures have been provided. Periodontal maintenance therapy may be approved once per three-month interval for moderate to advanced cases if the condition would deteriorate without treatment. (Cross-reference 78.4(4)“e”)
	b. 	Surgical endodontic treatment which includes an apicoectomy, performed as a separate surgical procedure; an apicoectomy, performed in conjunction with endodontic procedure; an apical curettage; a root resection; or excision of hyperplastic tissue will be approved when nonsurgical treatment has been attempted and a reasonable time has elapsed after which failure has been demonstrated. Surgical endodontic procedures may be indicated when:
	(1)	Conventional root canal treatment cannot be successfully completed because canals cannot be negotiated, debrided or obturated due to calcifications, blockages, broken instruments, severe curvatures, and dilacerated roots.
	(2)	Correction of problems resulting from conventional treatment including gross underfilling, perforations, and canal blockages with restorative materials. (Cross-reference 78.4(5)“c”)
	c. 	The following prosthetic services:
	(1)	A removable partial denture replacing posterior teeth will be approved when the member has fewer than eight posterior teeth in occlusion or the member has a full denture in one arch, and a partial denture replacing posterior teeth is required in the opposing arch to balance occlusion. When one removable partial denture brings eight posterior teeth in occlusion, no additional removable partial denture will be approved. A removable partial denture replacing posterior teeth is payable only once in a five-year period unless the removable partial denture is broken beyond repair, lost or stolen, or no longer fits due to growth or changes in jaw structure, and is required to prevent significant dental problems. Replacement of a removable partial denture replacing posterior teeth due to resorption in less than a five-year period is not payable. (Cross-reference 78.4(7)“c”)
	(2)	A fixed partial denture (including an acid etch fixed partial denture) replacing anterior teeth will be approved for members whose medical condition precludes the use of a removable partial denture. High noble or noble metals will be approved only when the member is allergic to all other restorative materials. A fixed partial denture replacing anterior teeth is payable only once in a five-year period unless the fixed partial denture is broken beyond repair. (Cross-reference 78.4(7)“d”)
	(3)	A fixed partial denture (including an acid etch fixed partial denture) replacing posterior teeth will be approved for members whose medical condition precludes the use of a removable partial denture and who have fewer than eight posterior teeth in occlusion or if the member has a full denture in one arch and a partial denture replacing posterior teeth is required in the opposing arch to balance occlusion. When one fixed partial denture brings eight posterior teeth in occlusion, no additional fixed partial denture will be approved. High noble or noble metals will be approved only when the member is allergic to all other restorative materials. A fixed partial denture replacing posterior teeth is payable only once in a five-year period unless the fixed partial denture is broken beyond repair. (Cross-reference 78.4(7)“e”)
	(4)	Dental implants and related services will be authorized when the member is missing significant oral structures due to cancer, traumatic injuries, or developmental defects such as cleft palate and cannot use a conventional denture.
	d. 	Orthodontic services will be approved when it is determined that a patient has the most handicapping malocclusion. This determination is made in a manner consistent with the “Handicapping Malocclusion Assessment to Establish Treatment Priority,” by J. A. Salzmann, D.D.S., American Journal of Orthodontics, October 1968.
	(1)	A handicapping malocclusion is a condition that constitutes a hazard to the maintenance of oral health and interferes with the well-being of the patient by causing impaired mastication, dysfunction of the temporomandibular articulation, susceptibility to periodontal disease, susceptibility to dental caries, and impaired speech due to malpositions of the teeth. Treatment of handicapping malocclusions will be approved only for the severe and the most handicapping. Assessment of the most handicapping malocclusion is determined by the magnitude of the following variables:
	1.	Degree of malalignment;
	2.	Missing teeth;
	3.	Angle classification;
	4.	Overjet and overbite;
	5.	Openbite; and
	6.	Crossbite.
	(2)	A request to perform an orthodontic procedure must be accompanied by an interpreted cephalometric radiograph and study models trimmed so that the models simulate centric occlusion of the patient. A written plan of treatment must accompany the diagnostic aids. Posttreatment records must be furnished upon request of the Iowa Medicaid enterprise medical services unit.
	(3)	Approval may be made for eight units of a three-month active treatment period. Additional units may be approved by the department’s orthodontic consultant if the additional units are found to be medically necessary. (Cross-reference 78.4(8)“a”)
	e. 	More than two laboratory-fabricated crowns will be approved in a 12-month period for anterior teeth that cannot be restored with a composite or amalgam restoration and for posterior teeth that cannot be restored with a composite or amalgam restoration or stainless steel crown. (Cross-reference 78.4(3)“d”)
	f. 	Endodontic retreatment of a tooth will be authorized when the conventional treatment has been completed, a reasonable time has elapsed, and failure has been demonstrated with a radiograph and narrative history.
	78.28(3) Optometric services and ophthalmic materials which must be submitted for prior approval are as follows:
	a. 	A second lens correction within a 24-month period for members eight years of age and older. Payment shall be made when the member’s vision has at least a five-tenths diopter of change in sphere or cylinder or ten-degree change in axis in either eye.
	b. 	Visual therapy may be authorized when warranted by case history or diagnosis for a period of time not greater than 90 days. Should continued therapy be warranted, the prior approval process should be reaccomplished, accompanied by a report showing satisfactory progress. Approved diagnoses are convergence insufficiency and amblyopia. Visual therapy is not covered when provided by opticians.
	c. 	Subnormal visual aids where near visual acuity is better than 20/100 at 16 inches, 2M print. Prior authorization is not required if near visual acuity as described above is less than 20/100. Subnormal aids include, but are not limited to, hand magnifiers, loupes, telescopic spectacles or reverse Galilean telescope systems.
For all of the above, the optometrist shall furnish sufficient information to clearly establish that these procedures are necessary in terms of the visual condition of the patient. (Cross-references 78.6(4), 441—78.7(249A), and 78.1(18))
	78.28(4) Hearing aids that must be submitted for prior approval are:
	a. 	Replacement of a hearing aid less than four years old (except when the member is under 21 years of age). The department shall approve payment when the original hearing aid is lost or broken beyond repair or there is a significant change in the person’s hearing that would require a different hearing aid. (Cross-reference 78.14(7)“d”(1))
	b. 	A hearing aid costing more than $650. The department shall approve payment for either of the following purposes (Cross-reference 78.14(7)“d”(2)):
	(1)	Educational purposes when the member is participating in primary or secondary education or in a postsecondary academic program leading to a degree and an in-office comparison of an analog aid and a digital aid matched (+/- 5dB) for gain and output shows a significant improvement in either speech recognition in quiet or speech recognition in noise or an in-office comparison of two aids, one of which is single channel, shows significantly improved audibility.
	(2)	Vocational purposes when documentation submitted indicates the necessity, such as varying amounts of background noise in the work environment and a need to converse in order to do the job and an in-office comparison of an analog aid and a digital aid matched (+/- 5dB) for gain and output shows a significant improvement in either speech recognition in quiet or speech recognition in noise or an in-office comparison of two aids, one of which is single channel, shows significantly improved audibility.
	78.28(5) Hospital services which must be subject to prior approval, preprocedure review or preadmission review are:
	a. 	Any medical or surgical procedure requiring prior approval as set forth in Chapter 78 is subject to the conditions for payment set forth although a request form does not need to be submitted by the hospital as long as the approval is obtained by the physician. (Cross-reference 441—78.1(249A))
	b. 	All inpatient hospital admissions are subject to preadmission review. Payment for inpatient hospital admissions is approved when it meets the criteria for inpatient hospital care as determined by the IFMC or its delegated hospitals. Criteria are available from IFMC, 6000 Westown Parkway, Suite 350E, West Des Moines, Iowa 50265-7771, or in local hospital utilization review offices. (Cross-reference 441—78.3(249A))
	c. 	Preprocedure review by the IFMC is required if hospitals are to be reimbursed for the inpatient and outpatient surgical procedures set forth in subrule 78.1(19). Approval by the IFMC will be granted only if the procedures are determined to be necessary based on the condition of the patient and the criteria established by the department and IFMC. The criteria are available from IFMC, 6000 Westown Parkway, Suite 350E, West Des Moines, Iowa 50265-7771, or in local hospital utilization review offices.
	78.28(6) Ambulatory surgical centers are subject to prior approval and preprocedure review as follows:
	a. 	Any medical or surgical procedure requiring prior approval as set forth in Chapter 78 is subject to the conditions for payment set forth although a request form does not need to be submitted by the ambulatory surgical center as long as the prior approval is obtained by the physician.
	b. 	Preprocedure review by the IFMC is required if ambulatory surgical centers are to be reimbursed for surgical procedures as set forth in subrule 78.1(19). Approval by the IFMC will be granted only if the procedures are determined to be necessary based on the condition of the patient and criteria established by the IFMC and the department. The criteria are available from IFMC, 6000 Westown Parkway, Suite 350E, West Des Moines, Iowa 50265-7771, or in local hospital utilization review offices.
	78.28(7) Rescinded IAB 6/4/08, effective 5/15/08.
	78.28(8) Rescinded IAB 1/3/96, effective 3/1/96.
	78.28(9) Private duty nursing or personal care services provided by a home health agency provider for persons aged 20 or under require prior approval and shall be approved if determined to be medically necessary. Payment shall be made on an hourly unit of service.
	a. 	Definitions.
	(1)	Private duty nursing services are those services which are provided by a registered nurse or a licensed practical nurse under the direction of the member’s physician to a member in the member’s place of residence or outside the member’s residence, when normal life activities take the member outside the place of residence. Place of residence does not include nursing facilities, intermediate care facilities for the mentally retarded, or hospitals.
Services shall be provided according to a written plan of care authorized by a licensed physician. The home health agency is encouraged to collaborate with the member, or in the case of a child with the child’s caregiver, in the development and implementation of the plan of treatment. These services shall exceed intermittent guidelines as defined in subrule 78.9(3). Private duty nursing and personal care services shall be inclusive of all home health agency services personally provided to the member.
Private duty nursing services do not include:
	1.	Respite care, which is a temporary intermission or period of rest for the caregiver.
	2.	Nurse supervision services including chart review, case discussion or scheduling by a registered nurse.
	3.	Services provided to other persons in the member’s household.
	4.	Services requiring prior authorization that are provided without regard to the prior authorization process.
	(2)	Personal care services are those services provided by a home health aide or certified nurse’s aide and which are delegated and supervised by a registered nurse under the direction of the member’s physician to a member in the member’s place of residence or outside the member’s residence, when normal life activities take the member outside the place of residence. Place of residence does not include nursing facilities, intermediate care facilities for the mentally retarded, or hospitals. Payment for personal care services for persons aged 20 and under that exceed intermittent guidelines may be approved if determined to be medically necessary as defined in subrule 78.9(7). These services shall be in accordance with the member’s plan of care and authorized by a physician. The home health agency is encouraged to collaborate with the member, or in the case of a child with the child’s caregiver, in the development and implementation of the plan of treatment.
Medical necessity means the service is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions that endanger life, cause pain, result in illness or infirmity, threaten to cause or aggravate a disability or chronic illness, and no other equally effective course of treatment is available or suitable for the member requesting a service.
	b. 	Requirements.
	(1)	Private duty nursing or personal care services shall be ordered in writing by a physician as evidenced by the physician’s signature on the plan of care.
	(2)	Private duty nursing or personal care services shall be authorized by the department or the department’s designated review agent prior to payment.
	(3)	Prior authorization shall be requested at the time of initial submission of the plan of care or at any time the plan of care is substantially amended and shall be renewed with the department or the department’s designated review agent. Initial request for and request for renewal of prior authorization shall be submitted to the department’s designated review agent. The provider of the service is responsible for requesting prior authorization and for obtaining renewal of prior authorization.
The request for prior authorization shall include a nursing assessment, the plan of care, and supporting documentation. The request for prior authorization shall include all items previously identified as required treatment plan information and shall further include: any planned surgical interventions and projected time frame; information regarding caregiver’s desire to become involved in the member’s care, to adhere to program objectives, to work toward treatment plan goals, and to work toward maximum independence; and identify the types and service delivery levels of all other services to the member whether or not the services are reimbursable by Medicaid. Providers shall indicate the expected number of private duty nursing RN hours, private duty nursing LPN hours, or home health aide hours per day, the number of days per week, and the number of weeks or months of service per discipline. If the member is currently hospitalized, the projected date of discharge shall be included.
Prior authorization approvals shall not be granted for treatment plans that exceed 16 hours of home health agency services per day. (Cross-reference 78.9(10))
	78.28(10) Replacement of vibrotactile aids less than four years old shall be approved when the original aid is broken beyond repair or lost. (Cross-reference 78.10(3)“b”)
This rule is intended to implement Iowa Code section 249A.4.
[ARC 7548B, IAB 2/11/09, effective 4/1/09]
441—78.29(249A) Behavioral health services. Payment shall be made for medically necessary behavioral health services provided by a participating marital and family therapist, independent social worker, or master social worker within the practitioner’s scope of practice pursuant to state law and subject to the limitations and exclusions set forth in this rule.
	78.29(1) Limitations.
	a. 	An assessment and a treatment plan are required.
	b. 	Services provided by a licensed master social worker must be provided under the supervision of an independent social worker qualified to participate in the Medicaid program.
	78.29(2) Exclusions. Payment will not be approved for the following services:
	a. 	Services provided in a medical institution.
	b. 	Services performed without relationship to a specific condition, risk factor, symptom, or complaint.
	c. 	Services provided for nonspecific conditions of distress such as job dissatisfaction or general unhappiness.
	d. 	Sensitivity training, marriage enrichment, assertiveness training, and growth groups or marathons.
	78.29(3) Payment.
	a. 	Payment shall be made only for time spent in face-to-face consultation with the member.
	b. 	A unit of service is 15 minutes. Time spent with members shall be rounded to the quarter hour, where applicable.
This rule is intended to implement Iowa Code section 249A.4.
441—78.30(249A) Birth centers. Payment will be made for prenatal, delivery, and postnatal services.
	78.30(1) Risk assessment. Risk assessment, using Form 470-2942, Medicaid Prenatal Risk Assessment, shall be completed at the initial visit during a Medicaid member’s pregnancy.
	a. 	If the risk assessment reflects a low-risk pregnancy, the assessment shall be completed again at approximately the twenty-eighth week of pregnancy.
	b. 	If the risk assessment reflects a high-risk pregnancy, referral shall be made for enhanced services. (See description of enhanced services at subrule 78.25(3).)
	78.30(2) Vaccines. Vaccines available through the Vaccines for Children program under Section 1928 of the Social Security Act are not covered as birth center services. Birth centers that wish to administer those vaccines to Medicaid members shall enroll in the Vaccines for Children program and obtain the vaccines from the department of public health. Birth centers shall receive reimbursement for the administration of vaccines to Medicaid members.
This rule is intended to implement Iowa Code section 249A.4.
441—78.31(249A) Hospital outpatient services.
	78.31(1) Covered hospital outpatient services. Payment will be approved only for the following outpatient hospital services and medical services when provided on the licensed premises of the hospital or pursuant to subrule 78.31(5). Hospitals with alternate sites approved by the department of inspections and appeals are acceptable sites. All outpatient services listed in paragraphs “g” to “m” are subject to a random sample retrospective review for medical necessity by the Iowa Foundation for Medical Care. All services may also be subject to a more intensive retrospective review if abuse is suspected. Services in paragraphs “a” to “f” shall be provided in hospitals on an outpatient basis and are subject to no further limitations except medical necessity of the service.
Services listed in paragraphs “g” to “m” shall be provided by hospitals on an outpatient basis and must be certified by the department before payment may be made. Other limitations apply to these services.
	a. 	Emergency service.
	b. 	Outpatient surgery.
	c. 	Laboratory, X-ray and other diagnostic services.
	d. 	General or family medicine.
	e. 	Follow-up or after-care specialty clinics.
	f. 	Physical medicine and rehabilitation.
	g. 	Alcoholism and substance abuse.
	h. 	Eating disorders.
	i. 	Cardiac rehabilitation.
	j. 	Mental health.
	k. 	Pain management.
	l. 	Diabetic education.
	m. 	Pulmonary rehabilitation.
	n. 	Nutritional counseling for persons aged 20 and under.
	78.31(2) Requirements for all outpatient services.
	a. 	Need for service. It must be clearly established that the service meets a documented need in the area served by the hospital. There must be documentation of studies completed, consultations with other health care facilities and health care professionals in the area, community leaders, and organizations to determine the need for the service and to tailor the service to meet that particular need.
	b. 	Professional direction. All outpatient services must be provided by or at the direction and under the supervision of a medical doctor or osteopathic physician except for mental health services which may be provided by or at the direction and under the supervision of a medical doctor, osteopathic physician, or certified health service provider in psychology.
	c. 	Goals and objectives. The goals and objectives of the program must be clearly stated. Paragraphs “d” and “f” and the organization and administration of the program must clearly contribute to the fulfillment of the stated goals and objectives.
	d. 	Treatment modalities used. The service must employ multiple treatment modalities and professional disciplines. The modalities and disciplines employed must be clearly related to the condition or disease being treated.
	e. 	Criteria for selection and continuing treatment of patients. The condition or disease which is proposed to be treated must be clearly stated. Any indications for treatment or contraindications for treatment must be set forth together with criteria for determining the continued medical necessity of treatment.
	f. 	Length of program. There must be established parameters that limit the program either in terms of its overall length or in terms of number of visits, etc.
	g. 	Monitoring of services. The services provided by the program must be monitored and evaluated to determine the degree to which patients are receiving accurate assessments and effective treatment.
The monitoring of the services must be an ongoing plan and systematic process to identify problems in patient care or opportunities to improve patient care.
The monitoring and evaluation of the services are based on the use of clinical indicators that reflect those components of patient care important to quality.
	h. 	Hospital outpatient programs that wish to administer vaccines which are available through the Vaccines for Children program to Medicaid members shall enroll in the Vaccines for Children program. In lieu of payment, vaccines available through the Vaccines for Children program shall be accessed from the department of public health for Medicaid members. Hospital outpatient programs receive payment via the APC reimbursement for the administration of vaccines to Medicaid members.
	78.31(3) Application for certification. Hospital outpatient programs listed in subrule 78.31(1), paragraphs “g” to “m,” must submit an application to the Iowa Medicaid enterprise provider services unit for certification before payment will be made. The provider services unit will review the application against the requirements for the specific type of outpatient service and notify the provider whether certification has been approved.
Applications will consist of a narrative providing the following information:
	a. 	Documented need for the program including studies, needs assessments, and consultations with other health care professionals.
	b. 	Goals and objectives of the program.
	c. 	Organization and staffing including how the program fits with the rest of the hospital, the number of staff, staff credentials, and the staff’s relationship to the program, e.g., hospital employee, contractual consultant.
	d. 	Policies and procedures including admission criteria, patient assessment, treatment plan, discharge plan and postdischarge services, and the scope of services provided, including treatment modalities.
	e. 	Any accreditations or other types of approvals from national or state organizations.
	f. 	The physical facility and any equipment to be utilized, and whether the facility is part of the hospital license.
	78.31(4) Requirements for specific types of service.
	a. 	Alcoholism and substance abuse.
	(1)	Approval by joint commission or substance abuse commission. In addition to certification by the department, alcoholism and substance abuse programs must also be approved by either the joint commission on the accreditation of hospitals or the Iowa substance abuse commission.
	(2)	General characteristics. The services must be designed to identify and respond to the biological, psychological and social antecedents, influences and consequences associated with the recipient’s dependence.
These needed services must be provided either directly by the facility or through referral, consultation or contractual arrangements or agreements.
Special treatment needs of recipients by reason of age, gender, sexual orientation, or ethnic origin are evaluated and services for children and adolescents (as well as adults, if applicable) address the special needs of these age groups, including but not limited to, learning problems in education, family involvement, developmental status, nutrition, and recreational and leisure activities.
	(3)	Diagnostic and treatment staff. Each person who provides diagnostic or treatment services shall be determined to be competent to provide the services by reason of education, training, and experience.
Professional disciplines which must be represented on the diagnostic and treatment staff, either through employment by the facility (full-time or part-time), contract or referral, are a physician (M.D. or D.O.), a licensed psychologist and a substance abuse counselor certified by the Iowa board of substance abuse certification. Psychiatric consultation must be available and the number of staff should be appropriate to the patient load of the facility.
	(4)	Initial assessment. A comprehensive assessment of the biological, psychological, social, and spiritual orientation of the patient must be conducted which shall include:
A history of the use of alcohol and other drugs including age of onset, duration, patterns, and consequences of use; use of alcohol and drugs by family members and types of and responses to previous treatment.
A comprehensive medical history and physical examination including the history of physical problems associated with dependence.
Appropriate laboratory screening tests based on findings of the history and physical examination and tests for communicable diseases when indicated.
Any history of physical abuse.
A systematic mental status examination with special emphasis on immediate recall and recent and remote memory.
A determination of current and past psychiatric and psychological abnormality.
A determination of any degree of danger to self or others.
The family’s history of alcoholism and other drug dependencies.
The patient’s educational level, vocational status, and job performance history.
The patient’s social support networks, including family and peer relationships.
The patient’s perception of the patient’s strengths, problem areas, and dependencies.
The patient’s leisure, recreational, or vocational interests and hobbies.
The patient’s ability to participate with peers and in programs and social activities.
Interview of family members and significant others as available with the patient’s written or verbal permission.
Legal problems, if applicable.
	(5)	Admission criteria. Both of the first two criteria and one additional criterion from the following list must be present for a patient to be accepted for treatment.
Alcohol or drugs taken in greater amounts over a longer period than the person intended.
Two or more unsuccessful efforts to cut down or control use of alcohol or drugs.
Continued alcohol or drug use despite knowledge of having a persistent or recurrent family, social, occupational, psychological, or physical problem that is caused or exacerbated by the use of alcohol or drugs.
Marked tolerance: the need for markedly increased amounts of alcohol or drugs (i.e., at least a 50 percent increase) in order to achieve intoxication or desired effect or markedly diminished effect with continued use of same amount.
Characteristic withdrawal symptoms.
Alcohol or drugs taken often to relieve or avoid withdrawal symptoms.
	(6)	Plan of treatment. For each patient there is a written comprehensive and individualized description of treatment to be undertaken. The treatment plan is based on the problems and needs identified in the assessment and specifies the regular times at which the plan will be reassessed.
The patient’s perception of needs and, when appropriate and available, the family’s perception of the patient’s needs shall be documented.
The patient’s participation in the development of the treatment plan is sought and documented.
Each patient is reassessed to determine current clinical problems, needs, and responses to treatment. Changes in treatment are documented.
	(7)	Discharge plan. For each patient before discharge, a plan for discharge is designed to provide appropriate continuity of care which meets the following requirements:
The plan for continuing care must describe and facilitate the transfer of the patient and the responsibility for the patient’s continuing care to another phase or modality of the program, other programs, agencies, persons or to the patient and the patient’s personal support system.
The plan is in accordance with the patient’s reassessed needs at the time of transfer.
The plan is developed in collaboration with the patient and, as appropriate and available, with the patient’s written verbal permission with family members.
The plan is implemented in a manner acceptable to the patient and the need for confidentiality.
Implementation of the plan includes timely and direct communication with and transfer of information to the other programs, agencies, or persons who will be providing continuing care.
	(8)	Restrictions and limitations on payment. Medicaid will reimburse for a maximum of 28 treatment days. Payment beyond 28 days is made when documentation indicates that the patient has not reached an exit level.
If an individual has completed all or part of the basic 28-day program, a repeat of the program will be reimbursed with justification. The program will include an aftercare component meeting weekly for at least one year without charge.
	b. 	Eating disorders.
	(1)	General characteristics. Eating disorders are characterized by gross disturbances in eating behavior. Eating disorders include anorexia nervosa, bulimia, or bulimarexia. Compulsive overeaters are not acceptable for this program.
	(2)	Diagnostic and treatment staff. Each person who provides diagnostic or treatment services shall be determined to be competent to provide the services by reason of education, training, and experience.
Professional disciplines which must be represented on the diagnostic and treatment staff, either through employment by a facility (full-time or part-time), contract or referral, are a physician (M.D. or D.O.), a licensed psychologist, a counselor with a master’s or bachelor’s degree and experience, a dietitian with a bachelor’s degree and registered dietitian’s certificate, and a licensed occupational therapist. The number of staff should be appropriate to the patient load of the facility.
	(3)	Initial assessment. A comprehensive assessment of the biological, psychological, social, and family orientation of the patient must be conducted. The assessment must include a weight history and a history of the patient’s eating and dieting behavior, including binge eating, onset, patterns, and consequences. The assessment shall include the following:
A family history as well as self-assessment regarding chronic dieting, obesity, anorexia, bulimia, drug abuse, alcohol problems, depression, hospitalization for psychiatric reasons, and threatened or attempted suicide.
A history of purging behavior including frequency and history of vomiting, use of laxatives, history and frequency of use of diuretics, history and frequency of use of diet pills, ipecac, or any other weight control measures, and frequency of eating normal meals without vomiting.
A history of exercise behavior, including type, frequency, and duration.
A complete history of current alcohol and other drug use.
Any suicidal thoughts or attempts.
Sexual history, including sexual preference and activity. Sexual interest currently as compared to prior to the eating disorder is needed.
History of experiencing physical or sexual (incest or rape) abuse.
History of other counseling experiences.
Appropriate psychological assessment, including psychological orientation to the above questions.
A medical history, including a physical examination, covering the information listed in subparagraph (4) below.
Appropriate laboratory screening tests based on findings of the history and physical examination and tests for communicable diseases when indicated.
The patient’s social support networks, including family and peer relationships.
The patient’s educational level, vocational status, and job or school performance history, as appropriate.
The patient’s leisure, recreational, or vocational interests and hobbies.
The patient’s ability to participate with peers and programs and social activities.
Interview of family members and significant others as available with the patient’s written or verbal permission as appropriate.
Legal problems, if applicable.
	(4)	Admission criteria. In order to be accepted for treatment, the patient shall meet the diagnostic criteria for anorexia nervosa or bulimia as established by the DSM III R (Diagnostic and Statistical Manual, Third Edition, Revised).
In addition to the diagnostic criteria, the need for treatment will be determined by a demonstrable loss of control of eating behaviors and the failure of the patient in recent attempts at voluntary self-control of the problem. Demonstrable impairment, dysfunction, disruption or harm of physical health, emotional health (e.g., significant depression withdrawal, isolation, suicidal ideas), vocational or educational functioning, or interpersonal functioning (e.g., loss of relationships, legal difficulties) shall have occurred.
The need for treatment may be further substantiated by substance abuse, out-of-control spending, incidence of stealing to support habit, or compulsive gambling.
The symptoms shall have been present for at least six months and three of the following criteria must be present:
Medical criteria including endocrine and metabolic factors (e.g., amenorrhea, menstrual irregularities, decreased reflexes, cold intolerance, hypercarotenemia, parotid gland enlargement, lower respiration rate, hair loss, abnormal cholesterol or triglyceride levels).
Other cardiovascular factors including hypotension, hypertension, arrhythmia, ipecac poisoning, fainting, or bradycardia.
Renal considerations including diuretic abuse, dehydration, elevated BUN, renal calculi, edema, or hypokalemia.
Gastrointestinal factors including sore throats, mallery-weiss tears, decreased gastric emptying, constipation, abnormal liver enzymes, rectal bleeding, laxative abuse, or esophagitis.
Hematologic considerations including anemia, leukopenia, or thrombocytopenia.
Ear, nose, and throat factors including headaches or dizziness.
Skin considerations including lanugo or dry skin.
Aspiration pneumonia, a pulmonary factor.
The presence of severe symptoms and complications as evaluated and documented by the medical director may require a period of hospitalization to establish physical or emotional stability.
	(5)	Plan of treatment. For each patient there is a written comprehensive and individualized description of treatment to be undertaken. The treatment plan is based on problems and needs identified in the assessment and specifies the regular times at which the plan will be reassessed.
The patient’s perceptions of needs and, when appropriate and available, the family’s perceptions of the patient’s needs shall be documented.
The patient’s participation in the development of the treatment plans is sought and documented.
Each patient is reassessed to determine current clinical problems, needs, and responses to treatment. Changes in treatment are documented.
	(6)	Discharge plan. Plans for discharge shall meet the requirements for discharge plans for alcohol and substance abuse patients in subrule 78.31(3), paragraph “a,” subparagraph (6).
	(7)	Restriction and limitations on payment. Medicaid will pay for a maximum of 30 days of a structured outpatient treatment program. Payment beyond 30 days is made when documentation indicates that the patient has not reached an exit level.
Eating disorder programs will include an aftercare component meeting weekly for at least one year without charge.
Family counseling groups held in conjunction with the eating disorders program will be part of the overall treatment charge.
	c. 	Cardiac rehabilitation.
	(1)	General characteristics. Cardiac rehabilitation programs shall provide a supportive educational environment in which to facilitate behavior change with respect to the accepted cardiac risk factors, initiate prescribed exercise as a mode of facilitating the return of the patient to everyday activities by improving cardiovascular functional capacity and work performance, and promote a long-term commitment to lifestyle changes that could positively affect the course of the cardiovascular disease process.
	(2)	Treatment staff. Professional disciplines who must be represented on the treatment staff, either by employment by the facility (full-time or part-time), contract or referral, are as follows:
At least one physician responsible for responding to emergencies must be physically present in the hospital when patients are receiving cardiac rehabilitation services. The physician must be trained and certified at least to the level of basic life support.
A medical consultant shall oversee the policies and procedures of the outpatient cardiac rehabilitation area. The director shall meet with the cardiac rehabilitation staff on a regular basis to review exercise prescriptions and any concerns of the team.
A cardiac rehabilitation nurse shall carry out the exercise prescription after assessment of the patient. The nurse shall be able to interpret cardiac disrhythmia and be able to initiate emergency action if necessary. The nurse shall assess and implement a plan of care for cardiac risk factor modification. The nurse shall have at least one year of experience in a coronary care unit.
A physical therapist shall offer expertise in unusual exercise prescriptions where a patient has an unusual exercise problem.
A dietitian shall assess the dietary needs of persons and appropriately instruct them on their prescribed diets.
A social worker shall provide counseling as appropriate and facilitate a spouse support group. A licensed occupational therapist shall be available as necessary.
	(3)	Admission criteria. Candidates for the program must be referred by the attending physician. The following conditions are eligible for the program:
Postmyocardial infarction (within three months postdischarge).
Postcardiac surgery (within three months postdischarge).
Poststreptokinase.
Postpercutaneous transluminal angioplasty (within three months postdischarge).
Patient with severe angina being treated medically because of client or doctor preference or inoperable cardiac disease.
	(4)	Physical environment and equipment. A cardiac rehabilitation unit must be an autonomous physical unit specifically equipped with the necessary telemetry monitoring equipment, exercise equipment, and appropriate equipment and supplies for cardiopulmonary resuscitation (CPR). The exercise equipment must have the capacity to measure the intensity, speed, and length of the exercises. The equipment must be periodically inspected and maintained in accordance with the hospital’s preventive maintenance program.
	(5)	Medical records. Medical records for each cardiac rehabilitation patient shall consist of at least the following:
Referral form.
Physician’s orders.
Laboratory reports.
Electrocardiogram reports.
History and physical examination.
Angiogram report, if applicable.
Operative report, if applicable.
Preadmission interview.
Exercise prescription.
Rehabilitation plan, including participant’s goals.
Documentation for exercise sessions and progress notes.
Nurse’s progress reports.
Discharge instructions.
	(6)	Discharge plan. The patient will be discharged from the program when the physician, staff, and patient agree that the work level is functional for them and little benefit could be derived from further continuation of the program, disrhythmia disturbances are resolved, and appropriate cardiovascular response to exercise is accomplished.
	(7)	Monitoring of services. The program should be monitored by the hospital on a periodic basis using measuring criteria for evaluating cardiac rehabilitation services provided.
	(8)	Restrictions and limitations. Payment will be made for a maximum of three visits per week for a period of 12 weeks. Payment beyond 12 weeks is made when documentation indicates that the patient has not reached an exit level.
	d. 	Mental health.
	(1)	General characteristics. To be covered, mental health services must be prescribed by a physician or certified health service provider in psychology, provided under an individualized treatment plan and reasonable and necessary for the diagnosis or treatment of the patient’s condition. This means the services must be for the purpose of diagnostic study or the services must reasonably be expected to improve the patient’s condition.
	(2)	Individualized treatment plan. The individualized written plan of treatment shall be established by a physician or certified health service provider in psychology after any needed consultation with appropriate staff members. The plan must state the type, amount, frequency and duration of the services to be furnished and indicate the diagnoses and anticipated goals. (A plan is not required if only a few brief services will be furnished.)
	(3)	Supervision and evaluation. Services must be supervised and periodically evaluated by a physician, certified health service provider in psychology, or both within the scopes of their respective practices if clinically indicated to determine the extent to which treatment goals are being realized. The evaluation must be based on periodic consultation and conference with therapists and staff. The physician or certified health service provider in psychology must also provide supervision and direction to any therapist involved in the patient’s treatment and see the patient periodically to evaluate the course of treatment and to determine the extent to which treatment goals are being realized and whether changes in direction or services are required.
	(4)	Reasonable expectation of improvement. Services must be for the purpose of diagnostic study or reasonably be expected to improve the patient’s condition. The treatment must at a minimum be designed to reduce or control the patient’s psychiatric or psychological symptoms so as to prevent relapse or hospitalization and improve or maintain the patient’s level of functioning.
It is not necessary that a course of therapy have as its goal restoration of the patient to the level of functioning exhibited prior to the onset of the illness although this may be appropriate for some patients. For many other patients, particularly those with long-term chronic conditions, control of symptoms and maintenance of a functional level to avoid further deterioration or hospitalization is an acceptable expectation of improvement. “Improvement” in this context is measured by comparing the effect of continuing versus discontinuing treatment. Where there is a reasonable expectation that if treatment services were withdrawn, the patient’s condition would deteriorate, relapse further, or require hospitalization, this criterion would be met.
	(5)	Diagnostic and treatment staff. Each person who provides diagnostic or treatment services shall be determined to be competent to provide the services by reason of education, training, and experience. The number of the above staff employed by the facility must be appropriate to the facility’s patient load. The staff may be employees of the hospital, on contract, or the service may be provided through referral.
The diagnostic and treatment staff shall consist of a physician, a psychologist, social workers or counselors meeting the requirements for “mental health professionals” as set forth in rule 441—33.1(225C,230A).
	(6)	Initial assessment. A comprehensive assessment of the biological, psychological, social, and spiritual orientation of the patient must be conducted, which shall include:
A history of the mental health problem, including age of onset, duration, patterns of symptoms, consequences of symptoms, and responses to previous treatment.
A comprehensive clinical history, including the history of physical problems associated with the mental health problem. Appropriate referral for physical examination for determination of any communicable diseases.
Any history of physical abuse.
A systematic mental health examination, with special emphasis on any change in cognitive, social or emotional functioning.
A determination of current and past psychiatric and psychological abnormality.
A determination of any degree of danger to self or others.
The family’s history of mental health problems.
The patient’s educational level, vocational status, and job performance history.
The patient’s social support network, including family and peer relationship.
The patient’s perception of the patient’s strengths, problem areas, and dependencies.
The patient’s leisure, recreational or vocational interests and hobbies.
The patient’s ability to participate with peers in programs and social activities.
Interview of family members and significant others, as available, with the patient’s written or verbal permission.
Legal problems if applicable.
	(7)	Covered services. Services covered for the treatment of psychiatric conditions are:
	1.	Individual and group therapy with physicians, psychologists, social workers, counselors, or psychiatric nurses.
	2.	Occupational therapy services if the services require the skills of a qualified occupational therapist and must be performed by or under the supervision of a licensed occupational therapist or by an occupational therapy assistant.
	3.	Drugs and biologicals furnished to outpatients for therapeutic purposes only if they are of the type which cannot be self-administered and are not “covered Part D drugs” as defined by 42 U.S.C. Section 1395w-102(e)(1)-(2) for a “Part D eligible individual” as defined in 42 U.S.C. Section 1395w-101(a)(3)(A), including an individual who is not enrolled in a Part D plan.
	4.	Activity therapies which are individualized and essential for the treatment of the patient’s condition. The treatment plan must clearly justify the need for each particular therapy utilized and explain how it fits into the patient’s treatment.
	5.	Family counseling services are covered only if the primary purpose of the counseling is the treatment of the patient’s condition.
	6.	Partial hospitalization and day treatment services to reduce or control a person’s psychiatric or psychological symptoms so as to prevent relapse or hospitalization, improve or maintain the person’s level of functioning and minimize regression. These services include all psychiatric services needed by the patient during the day.
Partial hospitalization services means an active treatment program that provides intensive and structured support that assists persons during periods of acute psychiatric or psychological distress or during transition periods, generally following acute inpatient hospitalization episodes.
Service components may include individual and group therapy, reality orientation, stress management and medication management.
Services are provided for a period for four to eight hours per day.
Day treatment services means structured, long-term services designed to assist in restoring, maintaining or increasing levels of functioning, minimizing regression and preventing hospitalization.
Service components include training in independent functioning skills necessary for self-care, emotional stability and psychosocial interactions, and training in medication management.
Services are structured with an emphasis on program variation according to individual need.
Services are provided for a period of three to five hours per day, three or four times per week.
7. Partial hospitalization and day treatment for persons aged 20 or under. Payment to a hospital will be approved for day treatment services for persons aged 20 or under if the hospital is certified by the department for hospital outpatient mental health services. All conditions for the day treatment program for persons aged 20 or under as outlined in subrule 78.16(7) for community mental health centers shall apply to hospitals. All conditions of the day treatment program for persons aged 20 or under as outlined in subrule 78.16(7) for community mental health centers shall be applicable for the partial hospitalization program for persons aged 20 or under with the exception that the maximum hours shall be 25 hours per week.
	(8)	Restrictions and limitations on coverage. The following are generally not covered except as indicated:
Activity therapies, group activities, or other services and programs which are primarily recreational or diversional in nature. Outpatient psychiatric day treatment programs that consist entirely of activity therapies are not covered.
Geriatric day-care programs, which provide social and recreational activities to older persons who need some supervision during the day while other family members are away from home. These programs are not covered because they are not considered reasonable and necessary for a diagnosed psychiatric disorder.
Vocational training. While occupational therapy may include vocational and prevocational assessment of training, when the services are related solely to specific employment opportunities, work skills, or work setting, they are not covered.
	(9)	Frequency and duration of services. There are no specific limits on the length of time that services may be covered. There are many factors that affect the outcome of treatment. Among them are the nature of the illness, prior history, the goals of treatment, and the patient’s response. As long as the evidence shows that the patient continues to show improvement in accordance with the individualized treatment plan and the frequency of services is within acceptable norms of medical practice, coverage will be continued.
	(10)	Documentation requirements. The provider shall develop and maintain sufficient written documentation to support each medical or remedial therapy, service, activity, or session for which billing is made. All outpatient mental health services shall include:
	1.	The specific services rendered.
	2.	The date and actual time the services were rendered.
	3.	Who rendered the services.
	4.	The setting in which the services were rendered.
	5.	The amount of time it took to deliver the services.
	6.	The relationship of the services to the treatment regimen described in the plan of care.
	7.	Updates describing the patient’s progress.
For services that are not specifically included in the patient’s treatment plan, a detailed explanation of how the services being billed relate to the treatment regimen and objectives contained in the patient’s plan of care and the reason for the departure from the plan shall be given.
	e. 	Pain management.
	(1)	Approval by commission on accreditation of rehabilitation facilities. In addition to certification by the department, pain management programs must also be approved by the commission on accreditation of rehabilitation facilities (CARF).
	(2)	General characteristics. A chronic pain management program shall provide coordinated, goal-oriented, interdisciplinary team services to reduce pain, improve quality of life, and decrease dependence on the health care system for persons with pain which interferes with physical, psychosocial, and vocational functioning.
	(3)	Treatment staff. Each person who provides treatment services shall be determined to be competent to provide the services by reason of education, training, and experience. Professional disciplines which must be represented on the treatment staff, either through employment by the facility (full-time or part-time), contract or referral, are a physician (M.D. or D.O.), a registered nurse, a licensed physical therapist and a licensed clinical psychologist or psychiatrist. The number of staff should be appropriate to the patient load of the facility.
	(4)	Admission criteria. Candidates for the program shall meet the following guidelines:
The person must have had adequate medical evaluation and treatment in the months preceding admission to the program including an orthopedic or neurological consultation if the problem is back pain or a neurological evaluation if the underlying problem is headaches.
The person must be free of any underlying psychosis or severe neurosis.
The person cannot be toxic on any addictive drugs.
The person must be capable of self-care; including being able to get to meals and to perform activities of daily living.
	(5)	Plan of treatment. For each patient there is a written comprehensive and individualized description of treatment to be undertaken. The treatment plan is based on the problems and needs identified in the assessment and specifies the times at which the plan will be reassessed.
The patient’s perception of needs and, when appropriate and available, the family’s perception of the patient’s needs shall be documented.
The patient’s participation in the development of the treatment plan is sought and documented.
Each patient is reassessed to determine current clinical problems, needs, and responses to treatment. Changes in treatment are documented.
	(6)	Discharge plan. For each patient before discharge, a plan for discharge is designed to provide appropriate continuity of care which meets the following requirements:
The plan for continuing care must describe and facilitate the transfer of the patient and the responsibility for the patient’s continuing care to another phase or modality of the program, other programs, agencies, persons or to the patient and the patient’s personal support system.
The plan is in accordance with the patient’s reassessed needs at the time of transfer.
The plan is developed in collaboration with the patient and, as appropriate and available, with the patient’s written verbal permission with the family members.
The plan is implemented in a manner acceptable to the patient and the need for confidentiality.
Implementation of the plan includes timely and direct communication with and transfer of information to the other programs, agencies, or persons who will be providing continuing care.
	(7)	Restrictions and limitations on payment. Medicaid will pay for a maximum of three weeks of a structured outpatient treatment program. When documentation indicates that the patient has not reached an exit level, coverage may be extended an extra week.
A repeat of the entire program for any patient will be covered only if a different disease process is causing the pain or a significant change in life situation can be demonstrated.
	f. 	Diabetic education.
	(1)	Certification by department of public health. In addition to certification by the department for Medicaid, diabetic education programs must also be certified by the department of public health. (See department of public health rules 641—Chapter 9.)
	(2)	General characteristics. An outpatient diabetes self-management education program shall provide instruction which will enable people with diabetes and their families to understand the diabetes disease process and the daily management of diabetes. People with diabetes must learn to balance their special diet and exercise requirements with drug therapy (insulin or oral agents). They must learn self-care techniques such as monitoring their own blood glucose. And often, they must learn to self-treat insulin reactions, protect feet that are numb and have seriously compromised circulation, and accommodate their regimen to changes in blood glucose because of stress or infections.
	(3)	Program staff. Each person who provides services shall be determined to be competent to provide the services by reason of education, training and experience. Professional disciplines which must be represented on the staff, either through employment by the facility (full-time or part-time), contract or referral, are a physician (M.D. or D.O.), a registered nurse, a registered dietitian and a licensed pharmacist. The number of staff should be appropriate to the patient load of the facility.
	(4)	Admission criteria. Candidates for the program shall meet the following guidelines:
The person must have Type I or Type II diabetes.
The person must be referred by the attending physician.
The person shall demonstrate an ability to follow through with self-management.
	(5)	Health assessment. An individualized and documented assessment of needs shall be developed with the patient’s participation. Follow-up assessments, planning and identification of problems shall be provided.
	(6)	Restrictions and limitations on payment. Medicaid will pay for a diabetic self-management education program. Diabetic education programs will include follow-up assessments at 3 and 12 months without charge. A complete diabetic education program is payable once in the lifetime of a recipient.
	g. 	Pulmonary rehabilitation.
	(1)	General characteristics. Pulmonary rehabilitation is an individually tailored, multidisciplinary program through which accurate diagnosis, therapy, emotional support, and education stabilizes or reverses both the physio- and psychopathology of pulmonary diseases and attempts to return the patient to the highest possible functional capacity allowed by the pulmonary handicap and overall life situation.
	(2)	Diagnostic and treatment staff. Each person who provides diagnostic or treatment services shall be determined to be competent to provide the services by reason of education, training, and experience.
Professional disciplines which must be represented by the diagnostic and treatment staff, either through employment by the facility (full-time or part-time), contract, or referral, are a physician (doctor of medicine or osteopathy), a respiratory therapist, a licensed physical therapist, and a registered nurse.
	(3)	Initial assessment. A comprehensive assessment must occur initially, including:
A diagnostic workup which entails proper identification of the patient’s specific respiratory ailment, appropriate pulmonary function studies, a chest radiograph, an electrocardiogram and, when indicated, arterial blood gas measurements at rest and during exercise, sputum analysis and blood theophylline measurements.
Behavioral considerations include emotional screening assessments and treatment or counseling when required, estimating the patient’s learning skills and adjusting the program to the patient’s ability, assessing family and social support, potential employment skills, employment opportunities, and community resources.
	(4)	Admission criteria. Criteria include a patient’s being diagnosed and symptomatic of chronic obstructive pulmonary disease (COPD), having cardiac stability, social, family, and financial resources, ability to tolerate periods of sitting time; and being a nonsmoker for six months, or if a smoker, willingness to quit and a physician’s order to participate anyway.
Factors which would make a person ineligible include acute or chronic illness that may interfere with rehabilitation, any illness or disease state that affects comprehension or retention of information, a strong history of medical noncompliance, unstable cardiac or cardiovascular problems, and orthopedic difficulties that would prohibit exercise.
	(5)	Plan of treatment. Individualized long- and short-term goals will be developed for each patient. The treatment goals will be based on the problems and needs identified in the assessment and specify the regular times at which the plan will be reassessed.
The patients and their families need to help determine and fully understand the goals, so that they realistically approach the treatment phase.
Patients are reassessed to determine current clinical problems, needs, and responses to treatment. Changes in treatment are documented.
Components of pulmonary rehabilitation to be included are physical therapy and relaxation techniques, exercise conditioning or physical conditioning for those with exercise limitations, respiratory therapy, education, an emphasis on the importance of smoking cessation, and nutritional information.
	(6)	Discharge plan. Ongoing care will generally be the responsibility of the primary care physician. Periodic reassessment will be conducted to evaluate progress and allow for educational reinforcement.
	(7)	Restrictions and limitations on payment. Medicaid will pay for a maximum of 25 treatment days. Payment beyond 25 days is made when documentation indicates that the patient has not reached an exit level.
	h. 	Nutritional counseling. Payment will be made for persons aged 20 and under for nutritional counseling provided by a licensed dietitian employed by or under contract with a hospital for a nutritional problem or condition of a degree of severity that nutritional counseling beyond that normally expected as part of the standard medical management is warranted. For persons eligible for the WIC program, a WIC referral is required. Medical necessity for nutritional counseling services exceeding those available through WIC shall be documented.
	78.31(5) Services rendered by advanced registered nurse practitioners certified in family, pediatric, or psychiatric mental health specialties and employed by a hospital. Rescinded IAB 10/15/03, effective 12/1/03.
This rule is intended to implement Iowa Code section 249A.4.
441—78.32(249A) Area education agencies. Payment will be made for physical therapy, occupational therapy, psychological evaluations and counseling, psychotherapy, speech-language therapy, and audiological, nursing, and vision services provided by an area education agency (AEA). Services shall be provided directly by the AEA or through contractual arrangement with the AEA.
This rule is intended to implement Iowa Code section 249A.4.
441—78.33(249A) Case management services. Payment on a monthly payment per enrollee basis will be approved for the case management functions required in 441—Chapter 90.
	78.33(1) Payment will be approved for MR/CMI/DD case management services pursuant to 441—Chapter 90 to:
	a. 	Recipients 18 years of age or over with a primary diagnosis of mental retardation, developmental disabilities, or chronic mental illness as defined in rule 441—90.1(249A).
	b. 	Rescinded IAB 1/8/03, effective 1/1/03.
	c. 	Recipients under 18 years of age receiving HCBS MR waiver or HCBS children’s mental health waiver services.
	78.33(2) Payment for services pursuant to 441—Chapter 90 to recipients under age 18 who have a primary diagnosis of mental retardation or developmental disabilities as defined in rule 441—90.1(249A) and are residing in a child welfare decategorization county shall be made when the following conditions are met:
	a. 	The child welfare decategorization county has entered into an agreement with the department certifying that the state match for case management is available within funds allocated for the purpose of decategorization.
	b. 	The child welfare decategorization county has executed an agreement to remit the nonfederal share of the cost of case management services to the enhanced mental health, mental retardation and developmental disabilities services fund administered by the department.
	c. 	The child welfare decategorization county has certified that the funds remitted for the nonfederal share of the cost of case management services are not federal funds.
	78.33(3) Rescinded IAB 10/12/05, effective 10/1/05.
This rule is intended to implement Iowa Code section 249A.4.
441—78.34(249A) HCBS ill and handicapped waiver services. Payment will be approved for the following services to clients eligible for HCBS ill and handicapped waiver services as established in 441—Chapter 83. Services must be billed in whole units.
	78.34(1) Homemaker services. Homemaker services are those services provided when the client lives alone or when the person who usually performs these functions for the client needs assistance with performing the functions. A unit of service is one hour. Components of the service are directly related to the care of the client and include:
	a. 	Essential shopping: shopping for basic need items such as food, clothing or personal care items, or drugs.
	b. 	Limited housecleaning: maintenance cleaning such as vacuuming, dusting, scrubbing floors, defrosting refrigerators, cleaning stoves, cleaning medical equipment, washing and mending clothes, washing personal items used by the client, and dishes.
	c. 	Rescinded IAB 9/30/92, effective 12/1/92.
	d. 	Meal preparation planning and preparing balanced meals.
	78.34(2) Home health services. Home health services are personal or direct care services provided to the client which are not payable under Medicaid as set forth in rule 441—78.9(249A). A unit of service is a visit.
	a. 	Components of the service include, but are not limited to:
	(1)	Observation and reporting of physical or emotional needs.
	(2)	Helping a client with bath, shampoo, or oral hygiene.
	(3)	Helping a client with toileting.
	(4)	Helping a client in and out of bed and with ambulation.
	(5)	Helping a client reestablish activities of daily living.
	(6)	Assisting with oral medications ordered by the physician which are ordinarily self-administered.
	(7)	Performing incidental household services which are essential to the client’s health care at home and are necessary to prevent or postpone institutionalization in order to complete a full unit of service.
	(8)	Accompaniment to medical services or transport to and from school.
	b. 	In some cases, a nurse may provide home health services if the health of the client is such that the agency is unable to place an aide in that situation due to limitations by state law or in the event that the agency’s Medicare certification requirements prohibit the aide from providing the service. It is not permitted for the convenience of the provider.
	c. 	Skilled nursing care is not covered.
	78.34(3) Adult day care services. Adult day care services provide an organized program of supportive care in a group environment to persons who need a degree of supervision and assistance on a regular or intermittent basis in a day care center. A unit of service is a half day (1 to 4 hours), a full day (4 to 8 hours), or an extended day (8 to 12 hours). Components of the service are as set forth in rule 441—171.6(234) or the department of elder affairs rule 321—24.7(231).
	78.34(4) Nursing care services. Nursing care services are services which are included in the plan of treatment approved by the physician and which are provided by licensed nurses to consumers in the home and community. The services shall be reasonable and necessary to the treatment of an illness or injury and include all nursing tasks recognized by the Iowa board of nursing. A unit of service is a visit.
	78.34(5) Respite care services. Respite care services are services provided to the consumer that give temporary relief to the usual caregiver and provide all the necessary care that the usual caregiver would provide during that time period. The purpose of respite care is to enable the consumer to remain in the consumer’s current living situation.
	a. 	Services provided outside the consumer’s home shall not be reimbursable if the living unit where respite is provided is reserved for another person on a temporary leave of absence.
	b. 	Staff-to-consumer ratios shall be appropriate to the individual needs of the consumer as determined by the consumer’s interdisciplinary team.
	c. 	A unit of service is one hour.
	d. 	Respite care is not to be provided to persons during the hours in which the usual caregiver is employed except when the consumer is attending a camp. Respite cannot be provided to a consumer whose usual caregiver is a consumer-directed attendant care provider for the consumer.
	e. 	The interdisciplinary team shall determine if the consumer will receive basic individual respite, specialized respite, or group respite as defined in rule 441—83.1(249A).
	f. 	A maximum of 14 consecutive days of 24-hour respite care may be reimbursed.
	g. 	Respite services provided for a period exceeding 24 consecutive hours to three or more individuals who require nursing care because of a mental or physical condition must be provided by a health care facility licensed as described in Iowa Code chapter 135C.
	78.34(6) Counseling services. Counseling services are face-to-face mental health services provided to the client and caregiver by a mental health professional as defined in rule 441—24.61(225C,230A) to facilitate home management of the client and prevent institutionalization. Counseling services are nonpsychiatric services necessary for the management of depression, assistance with the grief process, alleviation of psychosocial isolation and support in coping with a disability or illness, including terminal illness. Counseling services may be provided both for the purpose of training the client’s family or other caregiver to provide care, and for the purpose of helping the client and those caring for the client to adjust to the client’s disability or terminal condition. Counseling services may be provided to the client’s caregiver only when included in the case plan for the client.
Payment will be made for individual and group counseling. A unit of individual counseling for the waiver client or the waiver client and the client’s caregiver is 15 minutes. A unit of group counseling is one hour. Payment for group counseling is based on the group rate divided by six, or, if the number of persons who comprise the group exceeds six, the actual number of persons who comprise the group.
	78.34(7) Consumer-directed attendant care service. Consumer-directed attendant care services are service activities performed by a person to help a consumer with self-care tasks which the consumer would typically do independently if the consumer were otherwise able.
	a. 	The service activities may include helping the consumer with any of the following nonskilled service activities:
	(1)	Dressing.
	(2)	Bath, shampoo, hygiene, and grooming.
	(3)	Access to and from bed or a wheelchair, transferring, ambulation, and mobility in general. It is recommended that the provider receive certification of training and return demonstration for transferring. Certification for this is available through the area community colleges.
	(4)	Toilet assistance, including bowel, bladder, and catheter assistance. It is recommended that the provider receive certification of training and return demonstration for catheter assistance. Certification for this is available through the area community colleges.
	(5)	Meal preparation, cooking, eating and feeding but not the cost of meals themselves.
	(6)	Housekeeping services which are essential to the consumer’s health care at home.
	(7)	Medications ordinarily self-administered including those ordered by a physician or other qualified health care provider. It is recommended the provider successfully complete a medication aide course administered by an area community college.
	(8)	Wound care.
	(9)	Assistance needed to go to or return from a place of employment and assistance with job-related tasks while the consumer is on the job site. The cost of transportation for the consumer and assistance with understanding or performing the essential job functions are not included in consumer-directed attendant care services.
	(10)	Cognitive assistance with tasks such as handling money and scheduling.
	(11)	Fostering communication through interpreting and reading services as well as assistive devices for communication.
	(12)	Assisting or accompanying a consumer in using transportation essential to the health and welfare of the consumer. The cost of the transportation is not included.
	b. 	The service activities may include helping the consumer with any of the following skilled services under the supervision of a licensed nurse or licensed therapist working under the direction of a physician. The licensed nurse or therapist shall retain accountability for actions that are delegated. The licensed nurse or therapist shall ensure appropriate assessment, planning, implementation, and evaluation. The licensed nurse or therapist shall make on-site supervisory visits every two weeks with the provider present. The cost of the supervision provided by the licensed nurse or therapist shall be paid from private insurance and other third-party payment sources, Medicare, the regular Medicaid program, or the early periodic screening diagnosis and treatment program before accessing the HCBS waiver.
	(1)	Tube feedings of consumers unable to eat solid foods.
	(2)	Intravenous therapy administered by a registered nurse.
	(3)	Parenteral injections required more than once a week.
	(4)	Catheterizations, continuing care of indwelling catheters with supervision of irrigations, and changing of Foley catheters when required.
	(5)	Respiratory care including inhalation therapy and tracheotomy care or tracheotomy care and ventilator.
	(6)	Care of decubiti and other ulcerated areas, noting and reporting to the nurse or therapist.
	(7)	Rehabilitation services including, but not limited to, bowel and bladder training, range of motion exercises, ambulation training, restorative nursing services, reteaching the activities of daily living, respiratory care and breathing programs, reality orientation, reminiscing therapy, remotivation, and behavior modification.
	(8)	Colostomy care.
	(9)	Care of medical conditions out of control which includes brittle diabetes and comfort care of terminal conditions.
	(10)	Postsurgical nursing care.
	(11)	Monitoring medications requiring close supervision because of fluctuating physical or psychological conditions, e.g., antihypertensives, digitalis preparations, mood-altering or psychotropic drugs, or narcotics.
	(12)	Preparing and monitoring response to therapeutic diets.
	(13)	Recording and reporting of changes in vital signs to the nurse or therapist.
	c. 	A unit of service is 1 hour, or one 8- to 24-hour day provided by an individual or an agency. Each service shall be billed in whole units.
	d. 	The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care shall be responsible for selecting the person or agency who will provide the components of the attendant care services to be provided.
	e. 	The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care shall determine the components of the attendant care services to be provided with the person who is providing the services to the consumer.
	f. 	The service activities may not include parenting or child care for or on behalf of the consumer.
	g. 	The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care and the provider shall complete and sign Form 470-3372, HCBS Consumer-Directed Attendant Care Agreement. A copy of the completed agreement shall be attached to the service plan, which is signed by the service worker prior to the initiation of services, and kept in the consumer’s and department’s records.
	h. 	If the consumer has a guardian or attorney in fact under a durable power of attorney for health care, the care plan shall address how consumer-directed attendant care services will be monitored to ensure the consumer’s needs are being adequately met. If the guardian or attorney in fact is the service provider, the service plan shall address how the service worker or case manager shall oversee service provision.
	i. 	If the consumer has a guardian or attorney in fact under a durable power of attorney for health care, the guardian or attorney in fact shall sign the claim form in place of the consumer, indicating that the service has been provided as presented on the claim.
	j. 	The frequency or intensity of services shall be indicated in the service plan.
	k. 	Consumer-directed attendant care services may not be simultaneously reimbursed with any other HCBS waiver services.
	l. 	Consumer-directed attendant care services may be provided to a recipient of in-home health-related care services, but not at the same time.
	m. 	Services may be provided in the absence of a parent or guardian if the parent or guardian has given advanced direction for the service provision.
	78.34(8) Interim medical monitoring and treatment services. Interim medical monitoring and treatment services are monitoring and treatment of a medical nature requiring specially trained caregivers beyond what is normally available in a day care setting. The services must be needed to allow the consumer’s usual caregivers to be employed or, for a limited period of time, for academic or vocational training of a usual caregiver; due to the hospitalization, treatment for physical or mental illness, or death of a usual caregiver; or during a search for employment by a usual caregiver.
	a. 	Service requirements. Interim medical monitoring and treatment services shall:
	(1)	Provide experiences for each consumer’s social, emotional, intellectual, and physical development;
	(2)	Include comprehensive developmental care and any special services for a consumer with special needs; and
	(3)	Include medical assessment, medical monitoring, and medical intervention as needed on a regular or emergency basis.
	b. 	Interim medical monitoring and treatment services may include supervision to and from school.
	c. 	Limitations.
	(1)	A maximum of 12 one-hour units of service is available per day.
	(2)	Covered services do not include a complete nutritional regimen.
	(3)	Interim medical monitoring and treatment services may not duplicate any regular Medicaid or waiver services provided under the state plan.
	(4)	Interim medical monitoring and treatment services may be provided only in the consumer’s home, in a registered group child care home, in a registered family child care home, in a licensed child care center, or during transportation to and from school.
	(5)	The staff-to-consumer ratio shall not be less than one to six.
	d. 	A unit of service is one hour.
	78.34(9) Home and vehicle modifications. Covered home and vehicle modifications are those physical modifications to the consumer’s home or vehicle listed below that directly address the consumer’s medical or remedial need. Covered modifications must be necessary to provide for the health, welfare, or safety of the consumer and enable the consumer to function with greater independence in the home or vehicle.
	a. 	Modifications that are necessary or desirable without regard to the consumer’s medical or remedial need and that would be expected to increase the fair market value of the home or vehicle, such as furnaces, fencing, roof repair, or adding square footage to the residence, are excluded except as specifically included below. Repairs are also excluded.
	b. 	Only the following modifications are covered:
	(1)	Kitchen counters, sink space, cabinets, special adaptations to refrigerators, stoves, and ovens.
	(2)	Bathtubs and toilets to accommodate transfer, special handles and hoses for shower heads, water faucet controls, and accessible showers and sink areas.
	(3)	Grab bars and handrails.
	(4)	Turnaround space adaptations.
	(5)	Ramps, lifts, and door, hall and window widening.
	(6)	Fire safety alarm equipment specific for disability.
	(7)	Voice-activated, sound-activated, light-activated, motion-activated, and electronic devices directly related to the consumer’s disability.
	(8)	Vehicle lifts, driver-specific adaptations, remote-start systems, including such modifications already installed in a vehicle.
	(9)	Keyless entry systems.
	(10)	Automatic opening device for home or vehicle door.
	(11)	Special door and window locks.
	(12)	Specialized doorknobs and handles.
	(13)	Plexiglas replacement for glass windows.
	(14)	Modification of existing stairs to widen, lower, raise or enclose open stairs.
	(15)	Motion detectors.
	(16)	Low-pile carpeting or slip-resistant flooring.
	(17)	Telecommunications device for the deaf.
	(18)	Exterior hard-surface pathways.
	(19)	New door opening.
	(20)	Pocket doors.
	(21)	Installation or relocation of controls, outlets, switches.
	(22)	Air conditioning and air filtering if medically necessary.
	(23)	Heightening of existing garage door opening to accommodate modified van.
	(24)	Bath chairs.
	c. 	A unit of service is the completion of needed modifications or adaptations.
	d. 	All modifications and adaptations shall be provided in accordance with applicable federal, state, and local building and vehicle codes.
	e. 	Services shall be performed following department approval of a binding contract between the enrolled home and vehicle modification provider and the consumer.
	f. 	The contract shall include, at a minimum, the work to be performed, cost, time frame for work completion, and assurance of liability and workers’ compensation coverage.
	g. 	Service payment shall be made to the enrolled home and vehicle modification provider. If applicable, payment will be forwarded to the subcontracting agency by the enrolled home and vehicle modification provider following completion of the approved modifications. Payment of up to $6,060 per year may be made to certified providers upon satisfactory completion of the service. The service worker shall encumber up to $505 per month within the monthly dollar cap allowed for the consumer until the amount of the modification is reached within the 12-month period.
	h. 	Services shall be included in the consumer’s service plan and shall exceed the Medicaid state plan services.
	78.34(10) Personal emergency response system. A personal emergency response system is an electronic device that transmits a signal to a central monitoring station to summon assistance in the event of an emergency when the consumer is alone.
	a. 	The required components of the system are:
	(1)	An in-home medical communications transmitter and receiver.
	(2)	A remote, portable activator.
	(3)	A central monitoring station with backup systems staffed by trained attendants at all times.
	(4)	Current data files at the central monitoring station containing response protocols and personal, medical, and emergency information for each consumer.
	b. 	The service shall be identified in the consumer’s service plan.
	c. 	A unit of service is a one-time installation fee or one month of service.
	d. 	Maximum units per state fiscal year shall be the initial installation and 12 months of service.
	78.34(11) Home-delivered meals. Home-delivered meals means meals prepared elsewhere and delivered to a waiver recipient at the recipient’s residence. Each meal shall ensure the recipient receives a minimum of one-third of the daily recommended dietary allowance as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences. The meal may also be a liquid supplement that meets the minimum one-third standard. When a restaurant provides the home-delivered meal, the recipient is required to have a nutritional consultation. The nutritional consultation includes contact with the restaurant to explain the dietary needs of the client and what constitutes the minimum one-third daily dietary allowance.
A maximum of 14 meals is allowed per week. A unit of service is a meal.
	78.34(12) Nutritional counseling. Nutritional counseling services may be provided for a nutritional problem or condition of such a degree of severity that nutritional counseling beyond that normally expected as part of the standard medical management is warranted. A unit of service is 15 minutes.
	78.34(13) Consumer choices option. The consumer choices option provides a consumer with a flexible monthly individual budget that is based on the consumer’s service needs. With the individual budget, the consumer shall have the authority to purchase goods and services and may choose to employ providers of services and supports. Components of this service are set forth below.
	a. 	Agreement. As a condition of participating in the consumer choices option, a consumer shall sign Form 470-4289, HCBS Consumer Choices Informed Consent and Risk Agreement, to document that the consumer has been informed of the responsibilities and risks of electing the consumer choices option.
	b. 	Individual budget amount. A monthly individual budget amount shall be set for each consumer. The consumer’s department service worker or case manager shall determine the amount of each consumer’s individual budget, based on the services and supports authorized in the consumer’s service plan. The consumer shall be informed of the individual budget amount during the development of the service plan.
	(1)	Services that may be included in determining the individual budget amount for a consumer in the HCBS ill and handicapped waiver are:
	1.	Consumer-directed attendant care (unskilled).
	2.	Home and vehicle modification.
	3.	Home-delivered meals.
	4.	Homemaker service.
	5.	Basic individual respite care.
	(2)	The department shall determine an average unit cost for each service selected under subparagraph (1) based on actual unit costs from the previous fiscal year plus a cost-of-living adjustment.
	(3)	In aggregate, costs for individual budget services shall not exceed the current costs of waiver program services. In order to maintain cost neutrality, the department shall apply a utilization adjustment factor to the amount of service authorized in the consumer’s service plan before calculating the value of that service to be included in the individual budget amount.
	(4)	The department shall compute the utilization adjustment factor for each service by dividing the net costs of all claims paid for the service by the total of the authorized costs for that service, using at least 12 consecutive months of aggregate service data. The utilization adjustment factor shall be no lower than 60 percent. The department shall analyze and adjust the utilization adjustment factor at least annually in order to maintain cost neutrality.
	(5)	Anticipated costs for home and vehicle modification are not subject to the average cost in subparagraph (2) or the utilization adjustment factor in subparagraph (3). Costs for home and vehicle modification may be released in a one-time payment.
	(6)	The individual budget amount may be changed only at the first of the month and shall remain fixed for the entire month.
	c. 	Required service components. To participate in the consumer choices option, a consumer must hire an independent support broker and must work with a financial management service that is enrolled as a Medicaid HCBS ill and handicapped waiver services provider.
	(1)	Before hiring the individual support broker, the consumer shall receive the results of the background check conducted pursuant to 441—subrule 77.30(14).
	(2)	If the consumer chooses to hire a person who has a criminal record or founded abuse report, the consumer assumes the risk for this action and shall acknowledge this information on Form 470-4289, HCBS Consumer Choices Informed Consent and Risk Agreement.
	d. 	Optional service components. A consumer who elects the consumer choices option may purchase the following services and supports, which shall be provided in the consumer’s home or at an integrated community setting:
	(1)	Self-directed personal care services. Self-directed personal care services are services or goods that provide a range of assistance in activities of daily living and incidental activities of daily living that help the consumer remain in the home and community.
	(2)	Self-directed community supports and employment. Self-directed community supports and employment are services that support the consumer in developing and maintaining independence and community integration.
	(3)	Individual-directed goods and services. Individual-directed goods and services are services, equipment, or supplies not otherwise provided through the Medicaid program that address a need identified in the consumer’s service plan. The item or service shall decrease the consumer’s need for other Medicaid services, promote the consumer’s inclusion in the community, or increase the consumer’s safety in the community.
	e. 	Development of the individual budget. The individual support broker shall assist the consumer in developing and implementing the consumer’s individual budget. The individual budget shall include:
	(1)	The costs of the financial management service.
	(2)	The costs of the independent support broker. The independent support broker may be compensated for up to 6 hours of service for assisting with the implementation of the initial individual budget. After the initial implementation, the independent support broker shall not be paid for more than 20 hours of service during a 12-month period without prior approval by the department.
	(3)	The costs of any services and supports chosen by the consumer as described in paragraph “d.”
	f. 	Budget authority. The consumer shall have authority over the individual budget authorized by the department to perform the following tasks:
	(1)	Contract with entities to provide services and supports as described in this subrule.
	(2)	Determine the amount to be paid for services with the exception of the independent support broker and the financial management service. Reimbursement rates for the independent support broker and the financial management service are subject to the limits in 441—subrule 79.1(2).
	(3)	Schedule the provision of services.
	(4)	Authorize payment for waiver goods and services identified in the individual budget. Consumers shall not use the individual budget to purchase room and board, sheltered workshop services, child care, or personal entertainment items.
	(5)	Reallocate funds among services included in the budget.
	g. 	Delegation of budget authority. The consumer may delegate responsibility for the individual budget to a representative in addition to the independent support broker.
	(1)	The representative must be at least 18 years old.
	(2)	The representative shall not be a current provider of service to the consumer.
	(3)	The consumer shall sign a consent form that designates who the consumer has chosen as a representative and what responsibilities the representative shall have.
	(4)	The representative shall not be paid for this service.
	h. 	Employer authority. The consumer shall have the authority to be the common-law employer of employees providing services and support under the consumer choices option. A common-law employer has the right to direct and control the performance of the services. The consumer may perform the following functions:
	(1)	Recruit employees.
	(2)	Select employees from a worker registry.
	(3)	Verify employee qualifications.
	(4)	Specify additional employee qualifications.
	(5)	Determine employee duties.
	(6)	Determine employee wages and benefits.
	(7)	Schedule employees.
	(8)	Train and supervise employees.
	i. 	Employment agreement. Any person employed by the consumer to provide services under the consumer choices option shall sign an employment agreement with the consumer that outlines the employee’s and consumer’s responsibilities.
	j. 	Responsibilities of the independent support broker. The independent support broker shall perform the following services:
	(1)	Assist the consumer with developing the consumer’s initial and subsequent individual budgets and with making any changes to the individual budget.
	(2)	Have monthly contact with the consumer for the first four months of implementation of the initial individual budget and have quarterly contact thereafter.
	(3)	Complete the required employment packet with the financial management service.
	(4)	Assist with interviewing potential employees and entities providing services and supports if requested by the consumer.
	(5)	Assist the consumer with determining whether a potential employee meets the qualifications necessary to perform the job.
	(6)	Assist the consumer with obtaining a signed consent from a potential employee to conduct background checks if requested by the consumer.
	(7)	Assist the consumer with negotiating with entities providing services and supports if requested by the consumer.
	(8)	Assist the consumer with contracts and payment methods for services and supports if requested by the consumer.
	(9)	Assist the consumer with developing an emergency backup plan. The emergency backup plan shall also address any health and safety concerns.
	(10)	Review expenditure reports from the financial management service to ensure that services and supports in the individual budget are being provided.
	(11)	Document in writing on the independent support broker timecard every contact the broker has with the consumer. Contact documentation shall include information on the extent to which the consumer’s individual budget has addressed the consumer’s needs and the satisfaction of the consumer.
	k. 	Responsibilities of the financial management service. The financial management service shall perform all of the following services:
	(1)	Receive Medicaid funds in an electronic transfer.
	(2)	Process and pay invoices for approved goods and services included in the individual budget.
	(3)	Enter the individual budget into the Web-based tracking system chosen by the department and enter expenditures as they are paid.
	(4)	Provide real-time individual budget account balances for the consumer, the independent support broker, and the department, available at a minimum during normal business hours (9 a.m. to 5 p.m., Monday through Friday).
	(5)	Conduct criminal background checks on potential employees, if requested.
	(6)	Verify for the consumer an employee’s citizenship or alien status.
	(7)	Assist the consumer with fiscal and payroll-related responsibilities. Key employer-related tasks include:
	1.	Verifying that hourly wages comply with federal and state labor rules.
	2.	Collecting and processing timecards.
	3.	Withholding, filing, and paying federal, state and local income taxes, Medicare and Social Security (FICA) taxes, and federal (FUTA) and state (SUTA) unemployment and disability insurance taxes, as applicable.
	4.	Computing and processing other withholdings, as applicable.
	5.	Processing all judgments, garnishments, tax levies, or other withholding on an employee’s pay as may be required by federal, state, or local laws.
	6.	Preparing and issuing employee payroll checks.
	7.	Preparing and disbursing IRS Forms W-2 and W-3 annually.
	8.	Processing federal advance earned income tax credit for eligible employees.
	9.	Refunding over-collected FICA, when appropriate.
	10.	Refunding over-collected FUTA, when appropriate.
	(8)	Purchase from the individual budget workers’ compensation or other forms of insurance, as applicable or if requested by the consumer.
	(9)	Assist the consumer in completing required federal, state, and local tax and insurance forms.
	(10)	Establish and manage documents and files for the consumer and the consumer’s employees.
	(11)	Monitor timecards, receipts, and invoices to ensure that they are consistent with the individual budget. Keep records of all timecards and invoices for each consumer for a total of five years.
	(12)	Provide monthly and quarterly status reports for the department, the independent support broker, and the consumer that include a summary of expenditures paid and amount of budget unused.
	(13)	Establish an accessible customer service system and a method of communication for the consumer and the individual support broker that includes alternative communication formats.
	(14)	Establish a customer services complaint reporting system.
	(15)	Develop a policy and procedures manual that is current with state and federal regulations and update as necessary.
	(16)	Develop a business continuity plan in the case of emergencies and natural disasters.
	(17)	Provide to the department an annual independent audit of the financial management service.
	(18)	Assist in implementing the state’s quality management strategy related to the financial management service.
This rule is intended to implement Iowa Code section 249A.4.
441—78.35(249A) Occupational therapist services. Payment will be approved for the same services provided by an occupational therapist that are payable under Title XVIII of the Social Security Act (Medicare).
This rule is intended to implement Iowa Code section 249A.4.
441—78.36(249A) Hospice services.
	78.36(1) General characteristics. A hospice is a public agency or private organization or a subdivision of either that is primarily engaged in providing care to terminally ill individuals. A hospice provides palliative and supportive services to meet the physical, psychosocial, social and spiritual needs of a terminally ill individual and the individual’s family or other persons caring for the individual regardless of where the individual resides. Hospice services are those services to control pain and provide support to individuals to continue life with as little disruption as possible.
	a. 	Covered services. Covered services shall include, in accordance with Medicare guidelines, the following:
	(1)	Nursing care.
	(2)	Medical social services.
	(3)	Physician services.
	(4)	Counseling services provided to the terminally ill individual and the individual’s family members or other persons caring for the individual at the individual’s place of residence, including bereavement, dietary, and spiritual counseling.
	(5)	Short-term inpatient care provided in a participating hospice inpatient unit or a participating hospital or nursing facility that additionally meets the special hospice standards regarding staffing and patient areas for pain control, symptom management and respite purposes.
	(6)	Medical appliances and supplies, including drugs and biologicals, as needed for the palliation and management of the individual’s terminal illness and related conditions, except for “covered Part D drugs” as defined by 42 U.S.C. Section 1395w-102(e)(1)-(2) for a “Part D eligible individual” as defined in 42 U.S.C. Section 1395w-101(a)(3)(A), including an individual who is not enrolled in a Part D plan.
	(7)	Homemaker and home health aide services.
	(8)	Physical therapy, occupational therapy and speech-language pathology unless this provision has been waived under the Medicare program for a specific provider.
	(9)	Other items or services specified in the resident’s plan that would otherwise be paid under the Medicaid program.
Nursing care, medical social services, and counseling are core hospice services and must routinely be provided directly by hospice employees. The hospice may contract with other providers to provide the remaining services. Bereavement counseling, consisting of counseling services provided after the individual’s death to the individual’s family or other persons caring for the individual, is a required hospice service but is not reimbursable.
	b. 	Noncovered services.
	(1)	Covered services not related to the terminal illness. In accordance with Medicare guidelines, all medical services related to the terminal illness are the responsibility of the hospice. Services unrelated to the terminal illness are to be billed separately by the respective provider.
	(2)	Administrative duties performed by the medical director, any hospice-employed physician, or any consulting physician are included in the normal hospice rates. Patient care provided by the medical director, hospice-employed physician, attending physician, or consulting physician is separately reimbursable. Payment to the attending or consulting physician includes other partners in practice.
	(3)	Hospice care provided by a hospice other than the hospice designated by the individual unless provided under arrangements made by the designated hospice.
	(4)	AZT (Retrovir) and other curative antiviral drugs targeted at the human immunodeficiency virus for the treatment of AIDS.
	78.36(2) Categories of care. Hospice care entails the following four categories of daily care. Guidelines for core and other services must be adhered to for all categories of care.
	a. 	Routine home care is care provided in the place of residence that is not continuous.
	b. 	Continuous home care is provided only during a period of crisis when an individual requires continuous care which is primarily nursing care to achieve palliation or management of acute medical symptoms. Nursing care must be provided by either a registered nurse or a licensed practical nurse and a nurse must be providing care for more than half of the period of care. A minimum of eight hours of care per day must be provided during a 24-hour day to qualify as continuous care. Homemaker and aide services may also be provided to supplement the nursing care.
	c. 	Inpatient respite care is provided to the individual only when necessary to relieve the family members or other persons caring for the individual at home. Respite care may be provided only on an occasional basis and may not be reimbursed for more than five consecutive days at a time. Respite care may not be provided when the individual is a resident of a nursing facility.
	d. 	General inpatient care is provided in periods of acute medical crisis when the individual is hospitalized or in a participating hospice inpatient unit or nursing facility for pain control or acute or chronic symptom management.
	78.36(3) Residence in a nursing facility. For purposes of the Medicaid hospice benefit, a nursing facility can be considered the residence of a beneficiary. When the person does reside in a nursing facility, the requirement that the care of a resident of a nursing facility must be provided under the immediate direction of either the facility or the resident’s personal physician does not apply if all of the following conditions are met:
	a. 	The resident is terminally ill.
	b. 	The resident has elected to receive hospice services under the Medicaid program from a Medicaid-enrolled hospice program.
	c. 	The nursing facility and the Medicaid-enrolled hospice program have entered into a written agreement under which the hospice program takes full responsibility for the professional management of the resident’s hospice care and the facility agrees to provide room and board to the resident.
	78.36(4) Approval for hospice benefits. Payment will be approved for hospice services to individuals who are certified as terminally ill, that is, the individuals have a medical prognosis that their life expectancy is six months or less if the illness runs its normal course, and who elect hospice care rather than active treatment for the illness.
	a. 	Physician certification process. The hospice must obtain certification that an individual is terminally ill in accordance with the following procedures:
	(1)	The hospice may obtain verbal orders to initiate hospice service from the medical director of the hospice or the physician member of the hospice interdisciplinary group and by the individual’s attending physician (if the individual has an attending physician). The verbal order shall be noted in the patient’s record. The verbal order must be given within two days of the start of care and be followed up in writing no later than eight calendar days after hospice care is initiated. The certification must include the statement that the individual’s medical prognosis is that the individual’s life expectancy is six months or less if the illness runs its normal course.
	(2)	When verbal orders are not secured, the hospice must obtain, no later than two calendar days after hospice care is initiated, written certification signed by the medical director of the hospice or the physician member of the hospice interdisciplinary group and by the individual’s attending physician (if the individual has an attending physician). The certification must include the statement that the individual’s medical prognosis is that the individual’s life expectancy is six months or less, if the illness runs its normal course.
	(3)	Hospice care benefit periods consist of up to two periods of 90 days each and an unlimited number of subsequent 60-day periods as elected by the individual. The medical director or a physician must recertify at the beginning of each benefit period that the individual is terminally ill.
	b. 	Election procedures. Individuals who are dually eligible for Medicare and Medicaid must receive hospice coverage under Medicare.
	(1)	Election statement. An individual, or individual’s representative, elects to receive the hospice benefit by filing an election statement, Form 470-2618, Election of Medicaid Hospice Benefit, with a particular hospice. The hospice may provide the individual with another election form to use provided the form includes the following information:
	1.	Identification of the hospice that will provide the care.
	2.	Acknowledgment that the recipient has been given a full understanding of hospice care.
	3.	Acknowledgment that the recipient waives the right to regular Medicaid benefits, except for payment to the regular physician and treatment for medical conditions unrelated to the terminal illness.
	4.	Acknowledgment that recipients are not responsible for copayment or other deductibles.
	5.	The recipient’s Medicaid number.
	6.	The effective date of election.
	7.	The recipient’s signature.
	(2)	Change of designation. An individual may change the designation of the particular hospice from which the individual elects to receive hospice care one time only.
	(3)	Effective date. An individual may designate an effective date for the hospice benefit that begins with the first day of the hospice care or any subsequent day of hospice care, but an individual may not designate an effective date that is earlier than the date that the election is made.
	(4)	Duration of election. The election to receive hospice care will be considered to continue until one of the following occurs:
	1.	The individual dies.
	2.	The individual or the individual’s representative revokes the election.
	3.	The individual’s situation changes so that the individual no longer qualifies for the hospice benefit.
	4.	The hospice elects to terminate the recipient’s enrollment in accordance with the hospice’s established discharge policy.
	(5)	Revocation. Form 470-2619, Revocation of Medicaid Hospice Benefit, is completed when an individual or the individual’s representative revokes the hospice benefit allowed under Medicaid. When an individual revokes the election of Medicaid coverage of hospice care, the individual resumes Medicaid coverage of the benefits waived when hospice care was elected.
This rule is intended to implement Iowa Code section 249A.4.
441—78.37(249A) HCBS elderly waiver services. Payment will be approved for the following services to consumers eligible for the HCBS elderly waiver services as established in 441—Chapter 83. The consumer shall have a billable waiver service each calendar quarter. Services must be billed in whole units.
	78.37(1) Adult day care services. Adult day care services provide an organized program of supportive care in a group environment to persons who need a degree of supervision and assistance on a regular or intermittent basis in a day care center. A unit of service is a half day (1 to 4 hours), a full day (4 to 8 hours), or an extended day (8 to 12 hours). Components of the service are set forth in rule 441—171.6(234) or as indicated in the Iowa department of elder affairs Annual Service and Fiscal Reporting Manual.
	78.37(2) Emergency response system. The emergency response system allows a person experiencing a medical emergency at home to activate electronic components that transmit a coded signal via digital equipment over telephone lines to a central monitoring station. The necessary components of a system are:
	a. 	An in-home medical communications transceiver.
	b. 	A remote, portable activator.
	c. 	A central monitoring station with backup systems staffed by trained attendants 24 hours per day, seven days per week.
	d. 	Current data files at the central monitoring station containing preestablished response protocols and personal, medical, and emergency information for each client.
	78.37(3) Home health aide services. Home health aide services are personal or direct care services provided to the client which are not payable under Medicaid as set forth in rule 441—78.9(249A). A unit of service is a visit. Components of the service include:
	a. 	Observation and reporting of physical or emotional needs.
	b. 	Helping a client with bath, shampoo, or oral hygiene.
	c. 	Helping a client with toileting.
	d. 	Helping a client in and out of bed and with ambulation.
	e. 	Helping a client reestablish activities of daily living.
	f. 	Assisting with oral medications ordinarily self-administered and ordered by a physician.
	g. 	Performing incidental household services which are essential to the client’s health care at home and are necessary to prevent or postpone institutionalization in order to complete a full unit of service.
	78.37(4) Homemaker services. Homemaker services are those services provided when the client lives alone or when the person who usually performs these functions for the client is incapacitated or occupied providing direct care to the client. A unit of service is one hour. Components of the service include:
	a. 	Essential shopping: shopping for basic need items such as food, clothing or personal care items, or drugs.
	b. 	Limited housecleaning: maintenance cleaning such as vacuuming, dusting, scrubbing floors, defrosting refrigerators, cleaning stoves, and washing and mending clothes.
	c. 	Accompaniment to medical or psychiatric services.
	d. 	Meal preparation: planning and preparing balanced meals.
	e. 	Bathing and dressing for self-directing recipients.
	78.37(5) Nursing care services. Nursing care services are services provided by licensed agency nurses to clients in the home which are ordered by and included in the plan of treatment established by the physician. The services are reasonable and necessary to the treatment of an illness or injury and include: observation; evaluation; teaching; training; supervision; therapeutic exercise; bowel and bladder care; administration of medications; intravenous, hypodermoclysis, and enteral feedings; skin care; preparation of clinical and progress notes; coordination of services and informing the physician and other personnel of changes in the patient’s condition and needs.
A unit of service is one visit. Nursing care service can pay for a maximum of eight nursing visits per month for intermediate level of care persons. There is no limit on the maximum visits for skilled level of care persons.
	78.37(6) Respite care services. Respite care services are services provided to the consumer that give temporary relief to the usual caregiver and provide all the necessary care that the usual caregiver would provide during that time period. The purpose of respite care is to enable the consumer to remain in the consumer’s current living situation.
	a. 	Services provided outside the consumer’s home shall not be reimbursable if the living unit where respite is provided is reserved for another person on a temporary leave of absence.
	b. 	Staff-to-consumer ratios shall be appropriate to the individual needs of the consumer as determined by the consumer’s interdisciplinary team.
	c. 	A unit of service is one hour.
	d. 	The interdisciplinary team shall determine if the consumer will receive basic individual respite, specialized respite or group respite as defined in rule 441—83.21(249A).
	e. 	When respite care is provided, the provision of, or payment for, other duplicative services under the waiver is precluded.
	f. 	A maximum of 14 consecutive days of 24-hour respite care may be reimbursed.
	g. 	Respite services provided for a period exceeding 24 consecutive hours to three or more individuals who require nursing care because of a mental or physical condition must be provided by a health care facility licensed as described in Iowa Code chapter 135C.
	h. 	Respite care is not to be provided to persons during the hours in which the usual caregiver is employed except when the consumer is attending a camp. Respite cannot be provided to a consumer whose usual caregiver is a consumer-directed attendant care provider for the consumer.
	78.37(7) Chore services. Chore services include the following services: window and door maintenance, such as hanging screen windows and doors, replacing windowpanes, and washing windows; minor repairs to walls, floors, stairs, railings and handles; heavy cleaning which includes cleaning attics or basements to remove fire hazards, moving heavy furniture, extensive wall washing, floor care or painting and trash removal; and yard work such as mowing lawns, raking leaves and shoveling walks. A unit of service is one-half hour.
	78.37(8) Home-delivered meals. Home-delivered meals means meals prepared elsewhere and delivered to a waiver recipient at the recipient’s residence. Each meal shall ensure the recipient receives a minimum of one-third of the daily recommended dietary allowance as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences. The meal may also be a liquid supplement which meets the minimum one-third standard. When a restaurant provides the home-delivered meal, the recipient is required to have a nutritional consultation. The nutritional consultation includes contact with the restaurant to explain the dietary needs of the client and explain what constitutes the minimum one-third daily dietary allowance.
A maximum of 14 meals is allowed per week. A unit of service is a meal.
	78.37(9) Home and vehicle modification. Covered home and vehicle modifications are those physical modifications to the consumer’s home or vehicle listed below that directly address the consumer’s medical or remedial need. Covered modifications must be necessary to provide for the health, welfare, or safety of the consumer and enable the consumer to function with greater independence in the home or vehicle.
	a. 	Modifications that are necessary or desirable without regard to the consumer’s medical or remedial need and that would be expected to increase the fair market value of the home or vehicle, such as furnaces, fencing, roof repair, or adding square footage to the residence, are excluded except as specifically included below. Repairs are also excluded.
	b. 	Only the following modifications are covered:
	(1)	Kitchen counters, sink space, cabinets, special adaptations to refrigerators, stoves, and ovens.
	(2)	Bathtubs and toilets to accommodate transfer, special handles and hoses for shower heads, water faucet controls, and accessible showers and sink areas.
	(3)	Grab bars and handrails.
	(4)	Turnaround space adaptations.
	(5)	Ramps, lifts, and door, hall and window widening.
	(6)	Fire safety alarm equipment specific for disability.
	(7)	Voice-activated, sound-activated, light-activated, motion-activated, and electronic devices directly related to the consumer’s disability.
	(8)	Vehicle lifts, driver-specific adaptations, remote-start systems, including such modifications already installed in a vehicle.
	(9)	Keyless entry systems.
	(10)	Automatic opening device for home or vehicle door.
	(11)	Special door and window locks.
	(12)	Specialized doorknobs and handles.
	(13)	Plexiglas replacement for glass windows.
	(14)	Modification of existing stairs to widen, lower, raise or enclose open stairs.
	(15)	Motion detectors.
	(16)	Low-pile carpeting or slip-resistant flooring.
	(17)	Telecommunications device for the deaf.
	(18)	Exterior hard-surface pathways.
	(19)	New door opening.
	(20)	Pocket doors.
	(21)	Installation or relocation of controls, outlets, switches.
	(22)	Air conditioning and air filtering if medically necessary.
	(23)	Heightening of existing garage door opening to accommodate modified van.
	(24)	Bath chairs.
	c. 	A unit of service is the completion of needed modifications or adaptations.
	d. 	All modifications and adaptations shall be provided in accordance with applicable federal, state, and local building and vehicle codes.
	e. 	Services shall be performed following department approval of a binding contract between the enrolled home and vehicle modification provider and the consumer.
	f. 	The contract shall include, at a minimum, the work to be performed, cost, time frame for work completion, and assurance of liability and workers’ compensation coverage.
	g. 	Service payment shall be made to the enrolled home and vehicle modification provider. If applicable, payment will be forwarded to the subcontracting agency by the enrolled home and vehicle modification provider following completion of the approved modifications.
	h. 	Services shall be included in the consumer’s service plan and shall exceed the Medicaid state plan services.
	78.37(10) Mental health outreach. Mental health outreach services are services provided in a recipient’s home to identify, evaluate, and provide treatment and psychosocial support. The services can only be provided on the basis of a referral from the consumer’s interdisciplinary team established pursuant to 441—subrule 83.22(2). A unit of service is 15 minutes.
	78.37(11) Transportation. Transportation services may be provided for recipients to conduct business errands, essential shopping, to receive medical services not reimbursed through medical transportation, and to reduce social isolation. A unit of service is per mile, per trip, or rate established by area agency on aging.
	78.37(12) Nutritional counseling. Nutritional counseling services may be provided for a nutritional problem or condition of such a degree of severity that nutritional counseling beyond that normally expected as part of the standard medical management is warranted. A unit of service is 15 minutes.
	78.37(13) Assistive devices. Assistive devices means practical equipment products to assist persons with activities of daily living and instrumental activities of daily living to allow the person more independence. They include, but are not limited to: long-reach brush, extra long shoehorn, nonslip grippers to pick up and reach items, dressing aids, shampoo rinse tray and inflatable shampoo tray, double-handled cup and sipper lid. A unit is an item.
	78.37(14) Senior companion. Senior companion services are nonmedical care supervision, oversight, and respite. Companions may assist with such tasks as meal preparation, laundry, shopping and light housekeeping tasks. This service cannot provide hands-on nursing or medical care. A unit of service is one hour.
	78.37(15) Consumer-directed attendant care service. Consumer-directed attendant care services are service activities performed by a person to help a consumer with self-care tasks which the consumer would typically do independently if the consumer were otherwise able.
	a. 	The service activities may include helping the consumer with any of the following nonskilled service activities:
	(1)	Dressing.
	(2)	Bath, shampoo, hygiene, and grooming.
	(3)	Access to and from bed or a wheelchair, transferring, ambulation, and mobility in general. It is recommended that the provider receive certification of training and return demonstration for transferring. Certification for this is available through the area community colleges.
	(4)	Toilet assistance, including bowel, bladder, and catheter assistance. It is recommended that the provider receive certification of training and return demonstration for catheter assistance. Certification for this is available through the area community colleges.
	(5)	Meal preparation, cooking, eating and feeding but not the cost of meals themselves.
	(6)	Housekeeping services which are essential to the consumer’s health care at home.
	(7)	Medications ordinarily self-administered including those ordered by a physician or other qualified health care provider. It is recommended the provider successfully complete a medication aide course administered by an area community college.
	(8)	Wound care.
	(9)	Assistance needed to go to or return from a place of employment and assistance with job-related tasks while the consumer is on the job site. The cost of transportation for the consumer and assistance with understanding or performing the essential job functions are not included in consumer-directed attendant care services.
	(10)	Cognitive assistance with tasks such as handling money and scheduling.
	(11)	Fostering communication through interpreting and reading services as well as assistive devices for communication.
	(12)	Assisting or accompanying a consumer in using transportation essential to the health and welfare of the consumer. The cost of the transportation is not included.
	b. 	The service activities may include helping the consumer with any of the following skilled services under the supervision of a licensed nurse or licensed therapist working under the direction of a physician. The licensed nurse or therapist shall retain accountability for actions that are delegated. The licensed nurse or therapist shall ensure appropriate assessment, planning, implementation, and evaluation. The licensed nurse or therapist shall make on-site supervisory visits every two weeks with the provider present. The cost of the supervision provided by the licensed nurse or therapist shall be paid from private insurance and other third-party payment sources, Medicare, the regular Medicaid program, or the early periodic screening diagnosis and treatment program before accessing the HCBS waiver.
	(1)	Tube feedings of consumers unable to eat solid foods.
	(2)	Intravenous therapy administered by a registered nurse.
	(3)	Parenteral injections required more than once a week.
	(4)	Catheterizations, continuing care of indwelling catheters with supervision of irrigations, and changing of Foley catheters when required.
	(5)	Respiratory care including inhalation therapy and tracheotomy care or tracheotomy care and ventilator.
	(6)	Care of decubiti and other ulcerated areas, noting and reporting to the nurse or therapist.
	(7)	Rehabilitation services including, but not limited to, bowel and bladder training, range of motion exercises, ambulation training, restorative nursing services, reteaching the activities of daily living, respiratory care and breathing programs, reality orientation, reminiscing therapy, remotivation, and behavior modification.
	(8)	Colostomy care.
	(9)	Care of medical conditions out of control which includes brittle diabetes and comfort care of terminal conditions.
	(10)	Postsurgical nursing care.
	(11)	Monitoring medications requiring close supervision because of fluctuating physical or psychological conditions, e.g., antihypertensives, digitalis preparations, mood-altering or psychotropic drugs, or narcotics.
	(12)	Preparing and monitoring response to therapeutic diets.
	(13)	Recording and reporting of changes in vital signs to the nurse or therapist.
	c. 	A unit of service provided by an individual or an agency, other than an assisted living program, is 1 hour, or one 8- to 24-hour day. When provided by an assisted living program, a unit of service is one calendar month. If services are provided by an assisted living program for less than one full calendar month, the monthly reimbursement rate shall be prorated based on the number of days service is provided. Except for services provided by an assisted living program, each service shall be billed in whole units.
	d. 	The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care shall be responsible for selecting the person or agency who will provide the components of the attendant care services to be provided.
	e. 	The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care shall determine the components of the attendant care services to be provided with the person who is providing the services to the consumer.
	f. 	The service activities may not include parenting or child care for or on behalf of the consumer.
	g. 	The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care and the provider shall complete and sign Form 470-3372, HCBS Consumer-Directed Attendant Care Agreement. A copy of the completed agreement shall be attached to the service plan, which is signed by the service worker prior to the initiation of services, and kept in the consumer’s and department’s records.
	h. 	If the consumer has a guardian or attorney in fact under a durable power of attorney for health care, the care plan shall address how consumer-directed attendant care services will be monitored to ensure the consumer’s needs are being adequately met. If the guardian or attorney in fact is the service provider, the service plan shall address how the service worker or case manager shall oversee service provision.
	i. 	If the consumer has a guardian or attorney in fact under a durable power of attorney for health care, the guardian or attorney in fact shall sign the claim form in place of the consumer, indicating that the service has been provided as presented on the claim.
	j. 	The frequency or intensity of services shall be indicated in the service plan.
	k. 	Consumer-directed attendant care services may not be simultaneously reimbursed with any other HCBS waiver services.
	l. 	Consumer-directed attendant care services may be provided to a recipient of in-home health-related care services, but not at the same time.
	m. 	Services may be provided in the absence of a parent or guardian if the parent or guardian has given advanced direction for the service provision.
	78.37(16) Consumer choices option. The consumer choices option provides a consumer with a flexible monthly individual budget that is based on the consumer’s service needs. With the individual budget, the consumer shall have the authority to purchase goods and services and may choose to employ providers of services and supports. Components of this service are set forth below.
	a. 	Agreement. As a condition of participating in the consumer choices option, a consumer shall sign Form 470-4289, HCBS Consumer Choices Informed Consent and Risk Agreement, to document that the consumer has been informed of the responsibilities and risks of electing the consumer choices option.
	b. 	Individual budget amount. A monthly individual budget amount shall be set for each consumer. The consumer’s department service worker or Medicaid targeted case manager shall determine the amount of each consumer’s individual budget, based on the services and supports authorized in the consumer’s service plan. The consumer shall be informed of the individual budget amount during the development of the service plan.
	(1)	Services that may be included in determining the individual budget amount for a consumer in the HCBS elderly waiver are:
	1.	Assistive devices.
	2.	Chore service.
	3.	Consumer-directed attendant care (unskilled).
	4.	Home and vehicle modification.
	5.	Home-delivered meals.
	6.	Homemaker service.
	7.	Basic individual respite care.
	8.	Senior companion.
	9.	Transportation.
	(2)	The department shall determine an average unit cost for each service listed in subparagraph (1) based on actual unit costs from the previous fiscal year plus a cost-of-living adjustment.
	(3)	In aggregate, costs for individual budget services shall not exceed the current costs of waiver program services. In order to maintain cost neutrality, the department shall apply a utilization adjustment factor to the amount of service authorized in the consumer’s service plan before calculating the value of that service to be included in the individual budget amount.
	(4)	The department shall compute the utilization adjustment factor for each service by dividing the net costs of all claims paid for the service by the total of the authorized costs for that service, using at least 12 consecutive months of aggregate service data. The utilization adjustment factor shall be no lower than 60 percent. The department shall analyze and adjust the utilization adjustment factor at least annually in order to maintain cost neutrality.
	(5)	Anticipated costs for home and vehicle modification are not subject to the average cost in subparagraph (2) or the utilization adjustment factor in subparagraph (3). Costs for home and vehicle modification may be released in a one-time payment.
	(6)	The individual budget amount may be changed only at the first of the month and shall remain fixed for the entire month.
	c. 	Required service components. To participate in the consumer choices option, a consumer must hire an independent support broker and must work with a financial management service that is enrolled as a Medicaid HCBS elderly waiver services provider.
	(1)	Before hiring the individual support broker, the consumer shall receive the results of the background check conducted pursuant to 441—subrule 77.30(14).
	(2)	If the consumer chooses to hire a person who has a criminal record or founded abuse report, the consumer assumes the risk for this action and shall acknowledge this information on Form 470-4289, HCBS Consumer Choices Informed Consent and Risk Agreement.
	d. 	Optional service components. A consumer who elects the consumer choices option may purchase the following services and supports, which shall be provided in the consumer’s home or at an integrated community setting:
	(1)	Self-directed personal care services. Self-directed personal care services are services or goods that provide a range of assistance in activities of daily living and incidental activities of daily living that help the consumer remain in the home and community.
	(2)	Self-directed community supports and employment. Self-directed community supports and employment are services that support the consumer in developing and maintaining independence and community integration.
	(3)	Individual-directed goods and services. Individual-directed goods and services are services, equipment, or supplies not otherwise provided through the Medicaid program that address a need identified in the consumer’s service plan. The item or service shall decrease the consumer’s need for other Medicaid services, promote the consumer’s inclusion in the community, or increase the consumer’s safety in the community.
	e. 	Development of the individual budget. The individual support broker shall assist the consumer in developing and implementing the consumer’s individual budget. The individual budget shall include:
	(1)	The costs of the financial management service.
	(2)	The costs of the independent support broker. The independent support broker may be compensated for up to 6 hours of service for assisting with the implementation of the initial individual budget. After the initial implementation, the independent support broker shall not be paid for more than 20 hours of service during a 12-month period without prior approval by the department.
	(3)	The costs of any services and supports chosen by the consumer as described in paragraph “d.”
	f. 	Budget authority. The consumer shall have authority over the individual budget authorized by the department to perform the following tasks:
	(1)	Contract with entities to provide services and supports as described in this subrule.
	(2)	Determine the amount to be paid for services with the exception of the independent support broker and the financial management service. Reimbursement rates for the independent support broker and the financial management service are subject to the limits in 441—subrule 79.1(2).
	(3)	Schedule the provision of services.
	(4)	Authorize payment for waiver goods and services identified in the individual budget. Consumers shall not use the individual budget to purchase room and board, sheltered workshop services, child care, or personal entertainment items.
	(5)	Reallocate funds among services included in the budget.
	g. 	Delegation of budget authority. The consumer may delegate responsibility for the individual budget to a representative in addition to the independent support broker.
	(1)	The representative must be at least 18 years old.
	(2)	The representative shall not be a current provider of service to the consumer.
	(3)	The consumer shall sign a consent form that designates who the consumer has chosen as a representative and what responsibilities the representative shall have.
	(4)	The representative shall not be paid for this service.
	h. 	Employer authority. The consumer shall have the authority to be the common-law employer of employees providing services and support under the consumer choices option. A common-law employer has the right to direct and control the performance of the services. The consumer may perform the following functions:
	(1)	Recruit employees.
	(2)	Select employees from a worker registry.
	(3)	Verify employee qualifications.
	(4)	Specify additional employee qualifications.
	(5)	Determine employee duties.
	(6)	Determine employee wages and benefits.
	(7)	Schedule employees.
	(8)	Train and supervise employees.
	i. 	Employment agreement. Any person employed by the consumer to provide services under the consumer choices option shall sign an employment agreement with the consumer that outlines the employee’s and consumer’s responsibilities.
	j. 	Responsibilities of the independent support broker. The independent support broker shall perform the services specified in 78.34(13)“j.”
	k. 	Responsibilities of the financial management service. The financial management service shall perform all of the services specified in 78.34(13)“k.”
	78.37(17) Case management services. Case management services are services that assist Medicaid members who reside in a community setting or are transitioning to a community setting in gaining access to needed medical, social, educational, housing, transportation, vocational, and other appropriate services in order to ensure the health, safety, and welfare of the member. Case management is provided at the direction of the member and the interdisciplinary team established pursuant to 441—subrule 83.22(2).
	a. 	Case management services shall be provided as set forth in rules 441—90.5(249A) and 441—90.8(249A).
	b. 	Case management shall not include the provision of direct services by the case managers.
	c. 	Payment for case management shall not be made until the consumer is enrolled in the waiver. Payment shall be made only for case management services performed on behalf of the consumer during a month when the consumer is enrolled.
This rule is intended to implement Iowa Code section 249A.4.
[ARC 7957B, IAB 7/15/09, effective 7/1/09]
441—78.38(249A) HCBS AIDS/HIV waiver services. Payment will be approved for the following services to clients eligible for the HCBS AIDS/HIV waiver services as established in 441—Chapter 83. Services must be billed in whole units.
	78.38(1) Counseling services. Counseling services are face-to-face mental health services provided to the client and caregiver by a mental health professional as defined in rule 441—24.61(225C,230A) to facilitate home management of the client and prevent institutionalization. Counseling services are nonpsychiatric services necessary for the management of depression, assistance with the grief process, alleviation of psychosocial isolation and support in coping with a disability or illness, including terminal illness. Counseling services may be provided both for the purpose of training the client’s family or other caregiver to provide care, and for the purpose of helping the client and those caring for the client to adjust to the client’s disability or terminal condition. Counseling services may be provided to the client’s caregiver only when included in the case plan for the client.
Payment will be made for individual and group counseling. A unit of individual counseling for the waiver client or the waiver client and the client’s caregiver is 15 minutes. A unit of group counseling is one hour. Payment for group counseling is based on the group rate divided by six, or, if the number of persons who comprise the group exceeds six, the actual number of persons who comprise the group.
	78.38(2) Home health aide services. Home health aide services are personal or direct care services provided to the client which are not payable under Medicaid as set forth in rule 441—78.9(249A). A unit of service is a visit. Components of the service are:
	a. 	Observation and reporting of physical or emotional needs.
	b. 	Helping a client with bath, shampoo, or oral hygiene.
	c. 	Helping a client with toileting.
	d. 	Helping a client in and out of bed and with ambulation.
	e. 	Helping a client reestablish activities of daily living.
	f. 	Assisting with oral medications ordinarily self-administered and ordered by a physician.
	g. 	Performing incidental household services which are essential to the client’s health care at home and are necessary to prevent or postpone institutionalization in order to complete a full unit of service.
	78.38(3) Homemaker services. Homemaker services are those services provided when the client lives alone or when the person who usually performs these functions for the client needs assistance with performing the functions. A unit of service is one hour. Components of the service are directly related to the care of the client and are:
	a. 	Essential shopping: shopping for basic need items such as food, clothing or personal care items, or drugs.
	b. 	Limited housecleaning: maintenance cleaning such as vacuuming, dusting, scrubbing floors, defrosting refrigerators, cleaning stoves, cleaning medical equipment, washing and mending clothes, washing personal items used by the client, and dishes.
	c. 	Accompaniment to medical or psychiatric services or for children aged 18 and under to school.
	d. 	Meal preparation: planning and preparing balanced meals.
	78.38(4) Nursing care services. Nursing care services are services provided by licensed agency nurses to clients in the home which are ordered by and included in the plan of treatment established by the physician. The services shall be reasonable and necessary to the treatment of an illness or injury and include: observation; evaluation; teaching; training; supervision; therapeutic exercise; bowel and bladder care; administration of medications; intravenous and enteral feedings; skin care; preparation of clinical and progress notes; coordination of services; and informing the physician and other personnel of changes in the patient’s conditions and needs. A unit of service is a visit.
	78.38(5) Respite care services. Respite care services are services provided to the consumer that give temporary relief to the usual caregiver and provide all the necessary care that the usual caregiver would provide during that time period. The purpose of respite care is to enable the consumer to remain in the consumer’s current living situation.
	a. 	Services provided outside the consumer’s home shall not be reimbursable if the living unit where respite is provided is otherwise reserved for another person on a temporary leave of absence.
	b. 	Staff-to-consumer ratios shall be appropriate to the individual needs of the consumer as determined by the consumer’s interdisciplinary team.
	c. 	A unit of service is one hour.
	d. 	The interdisciplinary team shall determine if the consumer will receive basic individual respite, specialized respite or group respite as defined in rule 441—83.41(249A).
	e. 	When respite care is provided, the provision of, or payment for, other duplicative services under the waiver is precluded.
	f. 	A maximum of 14 consecutive days of 24-hour respite care may be reimbursed.
	g. 	Respite services provided for a period exceeding 24 consecutive hours to three or more individuals who require nursing care because of a mental or physical condition must be provided by a health care facility licensed as described in Iowa Code chapter 135C.
	h. 	Respite care is not to be provided to persons during the hours in which the usual caregiver is employed except when the consumer is attending a camp. Respite cannot be provided to a consumer whose usual caregiver is a consumer-directed attendant care provider for the consumer.
	78.38(6) Home-delivered meals. Home-delivered meals means meals prepared elsewhere and delivered to a waiver recipient at the recipient’s residence. Each meal shall ensure the recipient receives a minimum of one-third of the daily recommended dietary allowance as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences. The meal may also be a liquid supplement which meets the minimum one-third standard. A maximum of 14 meals is allowed per week. A unit of service is a meal.
	78.38(7) Adult day care services. Adult day care services provide an organized program of supportive care in a group environment to persons who need a degree of supervision and assistance on a regular or intermittent basis in a day care center. A unit of service is a half day (1 to 4 hours), a full day (4 to 8 hours), or an extended day (8 to 12 hours). Components of the service are as set forth in rule 441—171.6(234) or the department of elder affairs rule 321—24.7(231).
	78.38(8) Consumer-directed attendant care service. Consumer-directed attendant care services are service activities performed by a person to help a consumer with self-care tasks which the consumer would typically do independently if the consumer were otherwise able.
	a. 	The service activities may include helping the consumer with any of the following nonskilled service activities:
	(1)	Dressing.
	(2)	Bath, shampoo, hygiene, and grooming.
	(3)	Access to and from bed or a wheelchair, transferring, ambulation, and mobility in general. It is recommended that the provider receive certification of training and return demonstration for transferring. Certification for this is available through the area community colleges.
	(4)	Toilet assistance, including bowel, bladder, and catheter assistance. It is recommended that the provider receive certification of training and return demonstration for catheter assistance. Certification for this is available through the area community colleges.
	(5)	Meal preparation, cooking, eating and feeding but not the cost of meals themselves.
	(6)	Housekeeping services which are essential to the consumer’s health care at home.
	(7)	Medications ordinarily self-administered including those ordered by a physician or other qualified health care provider. It is recommended the provider successfully complete a medication aide course administered by an area community college.
	(8)	Wound care.
	(9)	Assistance needed to go to or return from a place of employment and assistance with job-related tasks while the consumer is on the job site. The cost of transportation for the consumer and assistance with understanding or performing the essential job functions are not included in consumer-directed attendant care services.
	(10)	Cognitive assistance with tasks such as handling money and scheduling.
	(11)	Fostering communication through interpreting and reading services as well as assistive devices for communication.
	(12)	Assisting or accompanying a consumer in using transportation essential to the health and welfare of the consumer. The cost of the transportation is not included.
	b. 	The service activities may include helping the consumer with any of the following skilled services under the supervision of a licensed nurse or licensed therapist working under the direction of a physician. The licensed nurse or therapist shall retain accountability for actions that are delegated. The licensed nurse or therapist shall ensure appropriate assessment, planning, implementation, and evaluation. The licensed nurse or therapist shall make on-site supervisory visits every two weeks with the provider present. The cost of the supervision provided by the licensed nurse or therapist shall be paid from private insurance and other third-party payment sources, Medicare, the regular Medicaid program, or the early periodic screening diagnosis and treatment program before accessing the HCBS waiver.
	(1)	Tube feedings of consumers unable to eat solid foods.
	(2)	Intravenous therapy administered by a registered nurse.
	(3)	Parenteral injections required more than once a week.
	(4)	Catheterizations, continuing care of indwelling catheters with supervision of irrigations, and changing of Foley catheters when required.
	(5)	Respiratory care including inhalation therapy and tracheotomy care or tracheotomy care and ventilator.
	(6)	Care of decubiti and other ulcerated areas, noting and reporting to the nurse or therapist.
	(7)	Rehabilitation services including, but not limited to, bowel and bladder training, range of motion exercises, ambulation training, restorative nursing services, reteaching the activities of daily living, respiratory care and breathing programs, reality orientation, reminiscing therapy, remotivation, and behavior modification.
	(8)	Colostomy care.
	(9)	Care of medical conditions out of control which includes brittle diabetes and comfort care of terminal conditions.
	(10)	Postsurgical nursing care.
	(11)	Monitoring medications requiring close supervision because of fluctuating physical or psychological conditions, e.g., antihypertensives, digitalis preparations, mood-altering or psychotropic drugs, or narcotics.
	(12)	Preparing and monitoring response to therapeutic diets.
	(13)	Recording and reporting of changes in vital signs to the nurse or therapist.
	c. 	A unit of service is 1 hour, or one 8- to 24-hour day provided by an individual or an agency. Each service shall be billed in whole units.
	d. 	The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care shall be responsible for selecting the person or agency who will provide the components of the attendant care services to be provided.
	e. 	The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care shall determine the components of the attendant care services to be provided with the person who is providing the services to the consumer.
	f. 	The service activities may not include parenting or child care for or on behalf of the consumer.
	g. 	The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care and the provider shall complete and sign Form 470-3372, HCBS Consumer-Directed Attendant Care Agreement. A copy of the completed agreement shall be attached to the service plan, which is signed by the service worker prior to the initiation of services, and kept in the consumer’s and department’s records.
	h. 	If the consumer has a guardian or attorney in fact under a durable power of attorney for health care, the care plan shall address how consumer-directed attendant care services will be monitored to ensure the consumer’s needs are being adequately met. If the guardian or attorney in fact is the service provider, the service plan shall address how the service worker or case manager shall oversee service provision.
	i. 	If the consumer has a guardian or attorney in fact under a durable power of attorney for health care, the guardian or attorney in fact shall sign the claim form in place of the consumer, indicating that the service has been provided as presented on the claim.
	j. 	The frequency or intensity of services shall be indicated in the service plan.
	k. 	Consumer-directed attendant care services may not be simultaneously reimbursed with any other HCBS waiver services.
	l. 	Consumer-directed attendant care services may be provided to a recipient of in-home health-related care services, but not at the same time.
	m. 	Services may be provided in the absence of a parent or guardian if the parent or guardian has given advanced direction for the service provision.
	78.38(9) Consumer choices option. The consumer choices option provides a consumer with a flexible monthly individual budget that is based on the consumer’s service needs. With the individual budget, the consumer shall have the authority to purchase goods and services and may choose to employ providers of services and supports. Components of this service are set forth below.
	a. 	Agreement. As a condition of participating in the consumer choices option, a consumer shall sign Form 470-4289, HCBS Consumer Choices Informed Consent and Risk Agreement, to document that the consumer has been informed of the responsibilities and risks of electing the consumer choices option.
	b. 	Individual budget amount. A monthly individual budget amount shall be set for each consumer. The consumer’s department service worker or Medicaid targeted case manager shall determine the amount of each consumer’s individual budget, based on the services and supports authorized in the consumer’s service plan. The consumer shall be informed of the individual budget amount during the development of the service plan.
	(1)	Services that may be included in determining the individual budget amount for a consumer in the HCBS AIDS/HIV waiver are:
	1.	Consumer-directed attendant care (unskilled).
	2.	Home-delivered meals.
	3.	Homemaker service.
	4.	Basic individual respite care.
	(2)	The department shall determine an average unit cost for each service listed in subparagraph (1) based on actual unit costs from the previous fiscal year plus a cost-of-living adjustment.
	(3)	In aggregate, costs for individual budget services shall not exceed the current costs of waiver program services. In order to maintain cost neutrality, the department shall apply a utilization adjustment factor to the amount of service authorized in the consumer’s service plan before calculating the value of that service to be included in the individual budget amount.
	(4)	The department shall compute the utilization adjustment factor for each service by dividing the net costs of all claims paid for the service by the total of the authorized costs for that service, using at least 12 consecutive months of aggregate service data. The utilization adjustment factor shall be no lower than 60 percent. The department shall analyze and adjust the utilization adjustment factor at least annually in order to maintain cost neutrality.
	(5)	The individual budget amount may be changed only at the first of the month and shall remain fixed for the entire month.
	c. 	Required service components. To participate in the consumer choices option, a consumer must hire an independent support broker and must work with a financial management service that is enrolled as a Medicaid HCBS AIDS/HIV waiver services provider.
	(1)	Before hiring the individual support broker, the consumer shall receive the results of the background check conducted pursuant to 441—subrule 77.30(14).
	(2)	If the consumer chooses to hire a person who has a criminal record or founded abuse report, the consumer assumes the risk for this action and shall acknowledge this information on Form 470-4289, HCBS Consumer Choices Informed Consent and Risk Agreement.
	d. 	Optional service components. A consumer who elects the consumer choices option may purchase the following services and supports, which shall be provided in the consumer’s home or at an integrated community setting:
	(1)	Self-directed personal care services. Self-directed personal care services are services or goods that provide a range of assistance in activities of daily living and incidental activities of daily living that help the consumer remain in the home and community.
	(2)	Self-directed community supports and employment. Self-directed community supports and employment are services that support the consumer in developing and maintaining independence and community integration.
	(3)	Individual-directed goods and services. Individual-directed goods and services are services, equipment, or supplies not otherwise provided through the Medicaid program that address a need identified in the consumer’s service plan. The item or service shall decrease the consumer’s need for other Medicaid services, promote the consumer’s inclusion in the community, or increase the consumer’s safety in the community.
	e. 	Development of the individual budget. The individual support broker shall assist the consumer in developing and implementing the consumer’s individual budget. The individual budget shall include:
	(1)	The costs of the financial management service.
	(2)	The costs of the independent support broker. The independent support broker may be compensated for up to 6 hours of service for assisting with the implementation of the initial individual budget. After the initial implementation, the independent support broker shall not be paid for more than 20 hours of service during a 12-month period without prior approval by the department.
	(3)	The costs of any services and supports chosen by the consumer as described in paragraph “d.”
	f. 	Budget authority. The consumer shall have authority over the individual budget authorized by the department to perform the following tasks:
	(1)	Contract with entities to provide services and supports as described in this subrule.
	(2)	Determine the amount to be paid for services with the exception of the independent support broker and the financial management service. Reimbursement rates for the independent support broker and the financial management service are subject to the limits in 441—subrule 79.1(2).
	(3)	Schedule the provision of services.
	(4)	Authorize payment for waiver goods and services identified in the individual budget. Consumers shall not use the individual budget to purchase room and board, sheltered workshop services, child care, or personal entertainment items.
	(5)	Reallocate funds among services included in the budget.
	g. 	Delegation of budget authority. The consumer may delegate responsibility for the individual budget to a representative in addition to the independent support broker.
	(1)	The representative must be at least 18 years old.
	(2)	The representative shall not be a current provider of service to the consumer.
	(3)	The consumer shall sign a consent form that designates who the consumer has chosen as a representative and what responsibilities the representative shall have.
	(4)	The representative shall not be paid for this service.
	h. 	Employer authority. The consumer shall have the authority to be the common-law employer of employees providing services and support under the consumer choices option. A common-law employer has the right to direct and control the performance of the services. The consumer may perform the following functions:
	(1)	Recruit employees.
	(2)	Select employees from a worker registry.
	(3)	Verify employee qualifications.
	(4)	Specify additional employee qualifications.
	(5)	Determine employee duties.
	(6)	Determine employee wages and benefits.
	(7)	Schedule employees.
	(8)	Train and supervise employees.
	i. 	Employment agreement. Any person employed by the consumer to provide services under the consumer choices option shall sign an employment agreement with the consumer that outlines the employee’s and consumer’s responsibilities.
	j. 	Responsibilities of the independent support broker. The independent support broker shall perform the services specified in 78.34(13)“j.”
	k. 	Responsibilities of the financial management service. The financial management service shall perform all of the services specified in 78.34(13)“k.”
This rule is intended to implement Iowa Code section 249A.4.
441—78.39(249A) Federally qualified health centers. Payment shall be made for services as defined in Section 1905(a)(2)(C) of the Social Security Act.
	78.39(1) Utilization review. Utilization review shall be conducted of Medicaid members who access more than 24 outpatient visits in any 12-month period from physicians, advanced registered nurse practitioners, federally qualified health centers, other clinics, and emergency rooms. Refer to rule 441—76.9(249A) for further information concerning the member lock-in program.
	78.39(2) Risk assessment. Risk assessment, using Form 470-2942, Medicaid Prenatal Risk Assessment, shall be completed at the initial visit during a Medicaid member’s pregnancy.
	a. 	If the risk assessment reflects a low-risk pregnancy, the assessment shall be completed again at approximately the twenty-eighth week of pregnancy.
	b. 	If the risk assessment reflects a high-risk pregnancy, referral shall be made for enhanced services. (See description of enhanced services at subrule 78.25(3).)
	78.39(3) Vaccines. Vaccines available through the Vaccines for Children program under Section 1928 of the Social Security Act are not covered services. Federally qualified health centers that wish to administer those vaccines to Medicaid members shall enroll in the Vaccines for Children program and obtain the vaccines from the department of public health. However, vaccine administration is a covered service.
This rule is intended to implement Iowa Code section 249A.4.
441—78.40(249A) Advanced registered nurse practitioners. Payment shall be approved for services provided by advanced registered nurse practitioners within their scope of practice and the limitations of state law, with the exception of services not payable to physicians under rule 441—78.1(249A) or otherwise not payable under any other applicable rule.
	78.40(1) Direct payment. Payment shall be made to advanced registered nurse practitioners directly, without regard to whether the advanced registered nurse practitioner is employed by or associated with a physician, hospital, birth center, clinic or other health care provider recognized under state law. An established protocol between a physician and the advanced registered nurse practitioner shall not cause an advanced registered nurse practitioner to be considered auxiliary personnel of a physician, or an employee of a hospital, birth center, or clinic.
	78.40(2) Location of service. Payment shall be approved for services rendered in any location in which the advanced registered nurse practitioner is legally authorized to provide services under state law. The nurse practitioner shall have promptly available the necessary equipment and personnel to handle emergencies.
	78.40(3) Utilization review. Utilization review shall be conducted of Medicaid members who access more than 24 outpatient visits in any 12-month period from physicians, advanced registered nurse practitioners, other clinics, and emergency rooms. Refer to rule 441—76.9(249A) for further information concerning the member lock-in program.
	78.40(4) Vaccine administration. Vaccines available through the Vaccines for Children program under Section 1928 of the Social Security Act are not covered services. Advanced registered nurse practitioners who wish to administer those vaccines to Medicaid members shall enroll in the Vaccines for Children program and obtain the vaccines from the department of public health. Advanced registered nurse practitioners shall receive reimbursement for the administration of vaccines to Medicaid members.
	78.40(5) Prenatal risk assessment. Risk assessment, using Form 470-2942, Medicaid Prenatal Risk Assessment, shall be completed at the initial visit during a Medicaid member’s pregnancy.
	a. 	If the risk assessment reflects a low-risk pregnancy, the assessment shall be completed again at approximately the twenty-eighth week of pregnancy.
	b. 	If the risk assessment reflects a high-risk pregnancy, referral shall be made for enhanced services. (See description of enhanced services at subrule 78.25(3).)
This rule is intended to implement Iowa Code section 249A.4.
441—78.41(249A) HCBS MR waiver services. Payment will be approved for the following services to consumers eligible for the HCBS MR waiver services as established in 441—Chapter 83 and as identified in the consumer’s service plan. All services include the applicable and necessary instruction, supervision, assistance and support as required by the consumer in achieving the consumer’s life goals. The services, amount and supports provided under the HCBS MR waiver shall be delivered in the least restrictive environment and in conformity with the consumer’s service plan.
Reimbursement shall not be available under the waiver for any services that the consumer can obtain through the Medicaid state plan.
All services shall be billed in whole units.
	78.41(1) Supported community living services. Supported community living services are provided by the provider within the consumer’s home and community, according to the individualized consumer need as identified in the service plan pursuant to rule 441—83.67(249A).
	a. 	Available components of the service are personal and home skills training services, individual advocacy services, community skills training services, personal environment support services, transportation, and treatment services.
	(1)	Personal and home skills training services are those activities which assist a consumer to develop or maintain skills for self-care, self-directedness, and care of the immediate environment.
	(2)	“Individual advocacy services” means the act or process of representing the individual’s rights and interests in order to realize the rights to which the individual is entitled and to remove barriers to meeting the individual’s needs.
	(3)	“Community skills training services” means activities which assist a person to develop or maintain skills allowing better participation in the community. Services shall focus on the following areas as they are applicable to individuals being served:
	1.	Personal management skills training services are activities which assist a person to maintain or develop skills necessary to sustain oneself in the physical environment and are essential to the management of one’s personal business and property. This includes self-advocacy skills. Examples of personal management skills are the ability to maintain a household budget; plan and prepare nutritional meals; ability to use community resources such as public transportation, libraries, etc., and ability to select foods at the grocery store.
	2.	Socialization skills training services are those activities which assist a consumer to develop or maintain skills which include self-awareness and self-control, social responsiveness, community participation, social amenities, and interpersonal skills.
	3.	Communication skills training services are activities which assist a person to develop or maintain skills including expressive and receptive skills in verbal and nonverbal language and the functional application of acquired reading and writing skills.
	(4)	“Personal and environmental support services” means activities and expenditures provided to or on behalf of a person in the areas of personal needs in order to allow the person to function in the least restrictive environment.
	(5)	“Transportation services” means activities and expenditures designed to assist the person to travel from one place to another to obtain services or carry out life’s activities. The service excludes transportation to and from work.
	(6)	“Treatment services” means activities designed to assist the person to maintain or improve physiological, emotional and behavioral functioning and to prevent conditions that would present barriers to a person’s functioning. Treatment services include physical or physiological treatment and psychotherapeutic treatment.
	1.	Physiological treatment means activities including medication regimens designed to prevent, halt, control, relieve, or reverse symptoms or conditions which interfere with the normal functioning of the human body. The activities shall be provided by or under the supervision of a health care professional certified or licensed to provide the treatment activity specified.
	2.	Psychotherapeutic treatment means activities provided to assist a person in the identification or modification of beliefs, emotions, attitudes, or behaviors in order to maintain or improve the person’s functioning in response to the physical, emotional, and social environment.
	b. 	The supported community living services are intended to provide for the daily living needs of the consumer and shall be available as needed during any 24-hour period. Activities do not include those associated with vocational services, academics, day care, medical services, Medicaid case management or other case management. Services are individualized supportive services provided in a variety of community-based, integrated settings.
	(1)	Supported community living services shall be available at a daily rate to consumers living outside the home of their family, legal representative, or foster family and for whom a provider has primary responsibility for supervision or structure during the month. This service will provide supervision or structure in identified time periods when another resource is not available.
	(2)	Supported community living services shall be available at an hourly rate to consumers for whom a daily rate is not established.
	c. 	Services may be provided to a child or an adult. A maximum of three consumers receiving community-supported alternative living arrangements or HCBS MR services may reside in a living unit except providers meeting requirements set forth in 441—paragraph 77.37(14)“e.”
	(1)	Consumers may live within the home of their family or legal representative or within other types of typical community living arrangements.
	(2)	Consumers of services living with families or legal representatives are not subject to the maximum of three consumers in a living unit.
	(3)	Consumers may not live in licensed medical or health care facilities or in settings required to be licensed as medical or health care facilities.
	(4)	Consumers aged 17 or under living within the home of their family, legal representative, or foster families shall receive services based on development of adaptive, behavior, or health skills. Duration of services shall be based on age appropriateness and individual attention span.
	d. 	Rescinded IAB 2/5/03, effective 2/1/03.
	e. 	Transportation to and from a day program is not a reimbursable service. Maintenance and room and board costs are not reimbursable.
	f. 	Provider budgets shall reflect all staff-to-consumer ratios and shall reflect costs associated with consumers’ specific support needs for travel and transportation, consulting, instruction, and environmental modifications and repairs, as determined necessary by the interdisciplinary team for each consumer. The specific support needs must be identified in the Medicaid case manager’s service plan, the total costs shall not exceed $1570 per consumer per year, and the provider must maintain records to support the expenditures. A unit of service is:
	(1)	One full calendar day when a consumer residing in the living unit receives on-site staff supervision for 14 or more hours per day as an average over a 7-day week and the consumer’s individual comprehensive plan or case plan identifies and reflects the need for this amount of supervision.
	(2)	One hour when subparagraph (1) does not apply.
	g. 	The maximum number of units available per consumer is as follows:
	(1)	365 daily units per state fiscal year except a leap year when 366 daily units are available.
	(2)	5,110 hourly units are available per state fiscal year except a leap year when 5,124 hourly units are available.
	h. 	The service shall be identified in the consumer’s individual comprehensive plan.
	i. 	Services shall not be simultaneously reimbursed with other residential services, HCBS MR respite, Medicaid or HCBS MR nursing, or Medicaid or HCBS MR home health aide services.
	78.41(2) Respite services. Respite care services are services provided to the consumer that give temporary relief to the usual caregiver and provide all the necessary care that the usual caregiver would provide during that time period. The purpose of respite care is to enable the consumer to remain in the consumer’s current living situation.
	a. 	Services provided outside the consumer’s home shall not be reimbursable if the living unit where the respite is provided is reserved for another person on a temporary leave of absence.
	b. 	Staff-to-consumer ratios shall be appropriate to the individual needs of the consumer as determined by the consumer’s interdisciplinary team.
	c. 	A unit of service is one hour.
	d. 	Payment for respite services shall not exceed $7,050 per the consumer’s waiver year.
	e. 	The service shall be identified in the consumer’s individual comprehensive plan.
	f. 	Respite services shall not be simultaneously reimbursed with other residential or respite services, HCBS MR waiver supported community living services, Medicaid or HCBS MR nursing, or Medicaid or HCBS MR home health aide services.
	g. 	Respite care is not to be provided to persons during the hours in which the usual caregiver is employed except when the consumer is attending a camp. Respite cannot be provided to a consumer whose usual caregiver is a consumer-directed attendant care provider for the consumer.
	h. 	The interdisciplinary team shall determine if the consumer will receive basic individual respite, specialized respite or group respite as defined in rule 441—83.60(249A).
	i. 	A maximum of 14 consecutive days of 24-hour respite care may be reimbursed.
	j. 	Respite services provided for a period exceeding 24 consecutive hours to three or more individuals who require nursing care because of a mental or physical condition must be provided by a health care facility licensed as described in Iowa Code chapter 135C.
	78.41(3) Personal emergency response system. The personal emergency response system is an electronic component that transmits a coded signal via digital equipment to a central monitoring station. The electronic device allows a person to access assistance in the event of an emergency when alone.
	a. 	The necessary components of the system are:
	(1)	An in-home medical communications transceiver.
	(2)	A remote, portable activator.
	(3)	A central monitoring station with backup systems staffed by trained attendants 24 hours per day, seven days per week.
	(4)	Current data files at the central monitoring station containing response protocols and personal, medical and emergency information for each consumer.
	b. 	The service shall be identified in the consumer’s individual comprehensive plan.
	c. 	A unit is a one-time installation fee or one month of service.
	d. 	Maximum units per state fiscal year are the initial installation and 12 months of service.
	78.41(4) Home and vehicle modifications. Covered home and vehicle modifications are those physical modifications to the consumer’s home or vehicle listed below that directly address the consumer’s medical or remedial need. Covered modifications must be necessary to provide for the health, welfare, or safety of the consumer and enable the consumer to function with greater independence in the home or vehicle.
	a. 	Modifications that are necessary or desirable without regard to the consumer’s medical or remedial need and that would be expected to increase the fair market value of the home or vehicle, such as furnaces, fencing, roof repair, or adding square footage to the residence, are excluded except as specifically included below. Repairs are also excluded.
	b. 	Only the following modifications are covered:
	(1)	Kitchen counters, sink space, cabinets, special adaptations to refrigerators, stoves, and ovens.
	(2)	Bathtubs and toilets to accommodate transfer, special handles and hoses for shower heads, water faucet controls, and accessible showers and sink areas.
	(3)	Grab bars and handrails.
	(4)	Turnaround space adaptations.
	(5)	Ramps, lifts, and door, hall and window widening.
	(6)	Fire safety alarm equipment specific for disability.
	(7)	Voice-activated, sound-activated, light-activated, motion-activated, and electronic devices directly related to the consumer’s disability.
	(8)	Vehicle lifts, driver-specific adaptations, remote-start systems, including such modifications already installed in a vehicle.
	(9)	Keyless entry systems.
	(10)	Automatic opening device for home or vehicle door.
	(11)	Special door and window locks.
	(12)	Specialized doorknobs and handles.
	(13)	Plexiglas replacement for glass windows.
	(14)	Modification of existing stairs to widen, lower, raise or enclose open stairs.
	(15)	Motion detectors.
	(16)	Low-pile carpeting or slip-resistant flooring.
	(17)	Telecommunications device for the deaf.
	(18)	Exterior hard-surface pathways.
	(19)	New door opening.
	(20)	Pocket doors.
	(21)	Installation or relocation of controls, outlets, switches.
	(22)	Air conditioning and air filtering if medically necessary.
	(23)	Heightening of existing garage door opening to accommodate modified van.
	(24)	Bath chairs.
	c. 	A unit of service is the completion of needed modifications or adaptations.
	d. 	All modifications and adaptations shall be provided in accordance with applicable federal, state, and local building and vehicle codes.
	e. 	Services shall be performed following department approval of a binding contract between the enrolled home and vehicle modification provider and the consumer.
	f. 	The contract shall include, at a minimum, the work to be performed, cost, time frame for work completion, and assurance of liability and workers’ compensation coverage.
	g. 	Service payment shall be made to the enrolled home and vehicle modification provider. If applicable, payment will be forwarded to the subcontracting agency by the enrolled home and vehicle modification provider following completion of the approved modifications.
	h. 	Services shall be included in the consumer’s service plan and shall exceed the Medicaid state plan services.
	78.41(5) Nursing services. Nursing services are individualized in-home medical services provided by licensed nurses. Services shall exceed the Medicaid state plan services and be included in the consumer’s individual comprehensive plan.
	a. 	A unit of service is one hour.
	b. 	A maximum of ten units are available per week.
	78.41(6) Home health aide services. Home health aide services are personal or direct care services provided to the consumer which are not payable under Medicaid as set forth in rule 441—78.9(249A). Services shall include unskilled medical services and shall exceed those services provided under HCBS MR supported community living. Instruction, supervision, support or assistance in personal hygiene, bathing, and daily living shall be provided under supported community living.
	a. 	Services shall be included in the consumer’s individual comprehensive plan.
	b. 	A unit is one hour.
	c. 	A maximum of 14 units are available per week.
	78.41(7) Supported employment services. Supported employment services are individualized services associated with obtaining and maintaining competitive paid employment in the least restrictive environment possible, provided to individuals for whom competitive employment at or above minimum wage is unlikely and who, because of their disability, need intense and ongoing support to perform in a work setting. Individual placements are the preferred service model. Covered services are those listed in paragraphs “a” and “b” that address the disability-related challenges to securing and keeping a job.
	a. 	Activities to obtain a job. Covered services directed to obtaining a job must be provided to or on behalf of a consumer for whom competitive employment is reasonably expected within less than one year. Services must be focused on job placement, not on teaching generalized employment skills or habilitative goals. Three conditions must be met before services are provided. First, the consumer and the interdisciplinary team described in 441—subrule 83.67(1) must complete the form that Iowa vocational rehabilitation services uses to identify the supported employment services appropriate to meet a person’s employment needs. Second, the consumer’s interdisciplinary team must determine that the identified services are necessary. Third, the consumer’s case manager must approve the services. Available components of activities to obtain a job are as follows:
	(1)	Job development services. Job development services are directed toward obtaining competitive employment. A unit of service is a job placement that the consumer holds for 30 consecutive calendar days or more. Payment is available once the service is authorized in the member’s service plan. A consumer may receive two units of job development services during a 12-month period. The activities provided to the consumer may include:
	1.	Job procurement training, including grooming and hygiene, application, résumé development, interviewing skills, follow-up letters, and job search activities.
	2.	Job retention training, including promptness, coworker relations, transportation skills, disability-related supports, job benefits, and an understanding of employee rights and self-advocacy.
	3.	Customized job development services specific to the consumer.
	(2)	Employer development services. The focus of employer development services is to support employers in hiring and retaining consumers in their workforce and to communicate expectations of the employers to the interdisciplinary team described in 441—subrule 83.67(1). Employer development services may be provided only to consumers who are reasonably expected to work for no more than 10 hours per week. A unit of service is one job placement that the consumer holds for 30 consecutive calendar days or more. Payment for this service may be made only after the consumer holds the job for 30 days. A consumer may receive two units of employer development services during a 12-month period if the consumer is competitively employed for 30 or more consecutive calendar days and the other conditions for service approval are met. The services provided may include:
	1.	Developing relationships with employers and providing leads for individual consumers when appropriate.
	2.	Job analysis for a specific job.
	3.	Development of a customized training plan identifying job-specific skill requirements, employer expectations, teaching strategies, time frames, and responsibilities.
	4.	Identifying and arranging reasonable accommodations with the employer.
	5.	Providing disability awareness and training to the employer when it is deemed necessary.
	6.	Providing technical assistance to the employer regarding the training progress as identified on the consumer’s customized training plan.
	(3)	Enhanced job search activities. Enhanced job search activities are associated with obtaining initial employment after job development services have been provided for a minimum of 30 days or with assisting the consumer in changing jobs due to layoff, termination, or personal choice. The interdisciplinary team must review and update the Iowa vocational rehabilitation services supported employment readiness analysis form to determine if this service remains appropriate for the consumer’s employment goals. A unit of service is an hour. A maximum of 26 units may be provided in a 12-month period. The services provided may include:
	1.	Job opening identification with the consumer.
	2.	Assistance with applying for a job, including completion of applications or interviews.
	3.	Work site assessment and job accommodation evaluation.
	b. 	Supports to maintain employment.
	(1)	Covered services provided to or on behalf of the consumer associated with maintaining competitive paid employment are the following:
	1.	Individual work-related behavioral management.
	2.	Job coaching.
	3.	On-the-job or work-related crisis intervention.
	4.	Assisting the consumer to use skills related to sustaining competitive paid employment, including assistance with communication skills, problem solving, and safety.
	5.	Consumer-directed attendant care services as defined in subrule 78.41(8).
	6.	Assistance with time management.
	7.	Assistance with appropriate grooming.
	8.	Employment-related supportive contacts.
	9.	Employment-related transportation between work and home and to or from activities related to employment and disability. Other forms of community transportation (including car pools, coworkers, self or public transportation, families, and volunteers) must be attempted before transportation is provided as a supported employment service.
	10.	On-site vocational assessment after employment.
	11.	Employer consultation.
	(2)	Services for maintaining employment may include services associated with sustaining consumers in a team of no more than eight individuals with disabilities in a teamwork or “enclave” setting.
	(3)	A unit of service is one hour.
	(4)	A maximum of 40 units may be received per week.
	c. 	The following requirements apply to all supported employment services:
	(1)	Employment-related adaptations required to assist the consumer within the performance of the consumer’s job functions shall be provided by the provider as part of the services.
	(2)	Employment-related transportation between work and home and to or from activities related to employment and disability shall be provided by the provider as part of the services. Other forms of community transportation (car pools, coworkers, self or public transportation, families, volunteers) must be attempted before the service provider provides transportation.
	(3)	The majority of coworkers at any employment site with more than two employees where consumers seek, obtain, or maintain employment must be persons without disabilities. In the performance of job duties at any site where consumers seek, obtain, or maintain employment, the consumer must have daily contact with other employees or members of the general public who do not have disabilities, unless the absence of daily contact with other employees or the general public is typical for the job as performed by persons without disabilities.
	(4)	All supported employment services shall provide individualized and ongoing support contacts at intervals necessary to promote successful job retention. Each provider contact shall be documented.
	(5)	Documentation that services provided are not currently available under a program funded under the Rehabilitation Act of 1973 or Public Law 94-142 shall be maintained in the provider file of each consumer.
	(6)	All services shall be identified in the consumer’s service plan maintained pursuant to rule 441—83.67(249A).
	(7)	The following services are not covered:
	1.	Services involved in placing or maintaining consumers in day activity programs, work activity programs or sheltered workshop programs;
	2.	Supports for volunteer work or unpaid internships;
	3.	Tuition for education or vocational training; or
	4.	Individual advocacy that is not consumer specific.
	(8)	Services to maintain employment shall not be provided simultaneously with day activity programs, work activity programs, sheltered workshop programs, other HCBS services, or other Medicaid services. However, services to obtain a job and services to maintain employment may be provided simultaneously for the purpose of job advancement or job change.
	78.41(8) Consumer-directed attendant care service. Consumer-directed attendant care services are service activities performed by a person to help a consumer with self-care tasks which the consumer would typically do independently if the consumer were otherwise able.
	a. 	The service activities may include helping the consumer with any of the following nonskilled service activities:
	(1)	Dressing.
	(2)	Bath, shampoo, hygiene, and grooming.
	(3)	Access to and from bed or a wheelchair, transferring, ambulation, and mobility in general. It is recommended that the provider receive certification of training and return demonstration for transferring. Certification for this is available through the area community colleges.
	(4)	Toilet assistance, including bowel, bladder, and catheter assistance. It is recommended that the provider receive certification of training and return demonstration for catheter assistance. Certification for this is available through the area community colleges.
	(5)	Meal preparation, cooking, eating and feeding but not the cost of meals themselves.
	(6)	Housekeeping services which are essential to the consumer’s health care at home.
	(7)	Medications ordinarily self-administered including those ordered by a physician or other qualified health care provider. It is recommended the provider successfully complete a medication aide course administered by an area community college.
	(8)	Wound care.
	(9)	Assistance needed to go to or return from a place of employment and assistance with job-related tasks while the consumer is on the job site. The cost of transportation for the consumer and assistance with understanding or performing the essential job functions are not included in consumer-directed attendant care services.
	(10)	Cognitive assistance with tasks such as handling money and scheduling.
	(11)	Fostering communication through interpreting and reading services as well as assistive devices for communication.
	(12)	Assisting or accompanying a consumer in using transportation essential to the health and welfare of the consumer. The cost of the transportation is not included.
	b. 	The service activities may include helping the consumer with any of the following skilled services under the supervision of a licensed nurse or licensed therapist working under the direction of a physician. The licensed nurse or therapist shall retain accountability for actions that are delegated. The licensed nurse or therapist shall ensure appropriate assessment, planning, implementation, and evaluation. The licensed nurse or therapist shall make on-site supervisory visits every two weeks with the provider present. The cost of the supervision provided by the licensed nurse or therapist shall be paid from private insurance and other third-party payment sources, Medicare, the regular Medicaid program, or the early periodic screening diagnosis and treatment program before accessing the HCBS waiver.
	(1)	Tube feedings of consumers unable to eat solid foods.
	(2)	Intravenous therapy administered by a registered nurse.
	(3)	Parenteral injections required more than once a week.
	(4)	Catheterizations, continuing care of indwelling catheters with supervision of irrigations, and changing of Foley catheters when required.
	(5)	Respiratory care including inhalation therapy and tracheotomy care or tracheotomy care and ventilator.
	(6)	Care of decubiti and other ulcerated areas, noting and reporting to the nurse or therapist.
	(7)	Rehabilitation services including, but not limited to, bowel and bladder training, range of motion exercises, ambulation training, restorative nursing services, reteaching the activities of daily living, respiratory care and breathing programs, reality orientation, reminiscing therapy, remotivation, and behavior modification.
	(8)	Colostomy care.
	(9)	Care of medical conditions out of control which includes brittle diabetes and comfort care of terminal conditions.
	(10)	Postsurgical nursing care.
	(11)	Monitoring medications requiring close supervision because of fluctuating physical or psychological conditions, e.g., antihypertensives, digitalis preparations, mood-altering or psychotropic drugs, or narcotics.
	(12)	Preparing and monitoring response to therapeutic diets.
	(13)	Recording and reporting of changes in vital signs to the nurse or therapist.
	c. 	A unit of service is 1 hour, or one 8- to 24-hour day provided by an individual or an agency. Each service shall be billed in whole units.
	d. 	The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care shall be responsible for selecting the person or agency who will provide the components of the attendant care services to be provided.
	e. 	The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care shall determine the components of the attendant care services to be provided with the person who is providing the services to the consumer.
	f. 	The service activities may not include parenting or child care for or on behalf of the consumer.
	g. 	The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care and the provider shall complete and sign Form 470-3372, HCBS Consumer-Directed Attendant Care Agreement. A copy of the completed agreement shall be attached to the service plan, which is signed by the service worker or case manager prior to the initiation of services, and kept in the consumer’s and department’s records.
	h. 	If the consumer has a guardian or attorney in fact under a durable power of attorney for health care, the care plan shall address how consumer-directed attendant care services will be monitored to ensure the consumer’s needs are being adequately met. If the guardian or attorney in fact is the service provider, the service plan shall address how the service worker or case manager shall oversee service provision.
	i. 	If the consumer has a guardian or attorney in fact under a durable power of attorney for health care, the guardian or attorney in fact shall sign the claim form in place of the consumer, indicating that the service has been provided as presented on the claim.
	j. 	The frequency or intensity of services shall be indicated in the service plan.
	k. 	Consumer-directed attendant care services may not be simultaneously reimbursed with any other HCBS waiver services.
	l. 	Consumer-directed attendant care services may be provided to a recipient of in-home health-related care services, but not at the same time.
	m. 	Services may be provided in the absence of a parent or guardian if the parent or guardian has given advanced direction for the service provision.
	78.41(9) Interim medical monitoring and treatment services. Interim medical monitoring and treatment services are monitoring and treatment of a medical nature requiring specially trained caregivers beyond what is normally available in a day care setting. The services must be needed to allow the consumer’s usual caregivers to be employed or, for a limited period of time, for academic or vocational training of a usual caregiver; due to the hospitalization, treatment for physical or mental illness, or death of a usual caregiver; or during a search for employment by a usual caregiver.
	a. 	Service requirements. Interim medical monitoring and treatment services shall:
	(1)	Provide experiences for each consumer’s social, emotional, intellectual, and physical development;
	(2)	Include comprehensive developmental care and any special services for a consumer with special needs; and
	(3)	Include medical assessment, medical monitoring, and medical intervention as needed on a regular or emergency basis.
	b. 	Interim medical monitoring and treatment services may include supervision to and from school.
	c. 	Limitations.
	(1)	A maximum of 12 one-hour units of service is available per day.
	(2)	Covered services do not include a complete nutritional regimen.
	(3)	Interim medical monitoring and treatment services may not duplicate any regular Medicaid or waiver services provided under the state plan.
	(4)	Interim medical monitoring and treatment services may be provided only in the consumer’s home, in a registered group child care home, in a registered family child care home, in a licensed child care center, or during transportation to and from school.
	(5)	The staff-to-consumer ratio shall not be less than one to six.
	d. 	A unit of service is one hour.
	78.41(10) Residential-based supported community living services. Residential-based supported community living services are medical or remedial services provided to children under the age of 18 while living outside their home in a residential-based living environment furnished by the residential-based supported community living service provider. The services eliminate barriers to family reunification or develop self-help skills for maximum independence.
	a. 	Allowable service components are the following:
	(1)	Daily living skills development. These are services to develop the child’s ability to function independently in the community on a daily basis, including training in food preparation, maintenance of living environment, time and money management, personal hygiene, and self-care.
	(2)	Social skills development. These are services to develop a child’s communication and socialization skills, including interventions to develop a child’s ability to solve problems, resolve conflicts, develop appropriate relationships with others, and develop techniques for controlling behavior.
	(3)	Family support development. These are services necessary to allow a child to return to the child’s family or another less restrictive service environment. These services must include counseling and therapy sessions that involve both the child and the child’s family at least 50 percent of the time and that focus on techniques for dealing with the special care needs of the child and interventions needed to alleviate behaviors that are disruptive to the family or other group living unit.
	(4)	Counseling and behavior intervention services. These are services to halt, control, or reverse stress and social, emotional, or behavioral problems that threaten or have negatively affected the child’s stability. Activities under this service include counseling and behavior intervention with the child, including interventions to ameliorate problem behaviors.
	b. 	Residential-based supported community living services must also address the ordinary daily-living needs of the child, excluding room and board, such as needs for safety and security, social functioning, and other medical care.
	c. 	Residential-based supported community living services do not include services associated with vocational needs, academics, day care, Medicaid case management, other case management, or any other services that the child can otherwise obtain through Medicaid.
	d. 	Room and board costs are not reimbursable as residential-based supported community living services.
	e. 	The scope of service shall be identified in the child’s service plan pursuant to 441—paragraph 77.37(23)“d.”
	f. 	Residential-based supported community living services shall not be simultaneously reimbursed with other residential services provided under an HCBS waiver or otherwise provided under the Medicaid program.
	g. 	A unit of service is a day.
	h. 	The maximum number of units of residential-based supported community living services available per child is 365 daily units per state fiscal year, except in a leap year when 366 daily units are available.
	78.41(11) Transportation. Transportation services may be provided for consumers to conduct business errands and essential shopping, to receive medical services when not reimbursed through medical transportation, to travel to and from work or day programs, and to reduce social isolation. A unit of service is either per mile, per trip, or the unit established by an area agency on aging. Transportation may not be reimbursed simultaneously with HCBS MR waiver supported community living service.
	78.41(12) Adult day care services. Adult day care services provide an organized program of supportive care in a group environment to persons who need a degree of supervision and assistance on a regular or intermittent basis. A unit of service is a full day (4 to 8 hours) or a half-day (1 to 4 hours) or an extended day (8 to 12 hours).
	78.41(13) Prevocational services. Prevocational services are services that are aimed at preparing a consumer eligible for the HCBS MR waiver for paid or unpaid employment, but are not job-task oriented. These services include teaching the consumer concepts necessary as job readiness skills, such as following directions, attending to tasks, task completion, problem solving, and safety and mobility training.
	a. 	Prevocational services are intended to have a more generalized result as opposed to vocational training for a specific job or supported employment. Services include activities that are not primarily directed at teaching specific job skills but at more generalized habilitative goals, and are reflected in a habilitative plan that focuses on general habilitative rather than specific employment objectives.
	b. 	Prevocational services do not include:
	(1)	Services defined in Section 4(a)(4) of the 1975 amendments to the Education of the Handicapped Act (20 U.S.C. 1404(16) and (17)) that are otherwise available to the consumer through a state or local education agency.
	(2)	Vocational rehabilitation services that are otherwise available to the consumer through a program funded under Section 110 of the Rehabilitation Act of 1973 (29 U.S.C. 730).
	78.41(14) Day habilitation services.
	a. 	Scope. Day habilitation services are services that assist or support the consumer in developing or maintaining life skills and community integration. Services must enable or enhance the consumer’s intellectual functioning, physical and emotional health and development, language and communication development, cognitive functioning, socialization and community integration, functional skill development, behavior management, responsibility and self-direction, daily living activities, self-advocacy skills, or mobility.
	b. 	Family training option. Day habilitation services may include training families in treatment and support methodologies or in the care and use of equipment. Family training may be provided in the consumer’s home. The unit of service is an hour. The units of services payable are limited to a maximum of 10 hours per month.
	c. 	Unit of service. Except as provided in paragraph “b,” the unit of service may be an hour, a half-day (1 to 4 hours), or a full day (4 to 8 hours).
	d. 	Exclusions.
	(1)	Services shall not be provided in the consumer’s home, except as provided in paragraph “b.” For this purpose, services provided in a residential care facility where the consumer lives are not considered to be provided in the consumer’s home.
	(2)	Services shall not include vocational or prevocational services and shall not involve paid work.
	(3)	Services shall not duplicate or replace education or related services defined in Public Law 94-142, the Education of the Handicapped Act.
	(4)	Services shall not be provided simultaneously with other Medicaid-funded services.
	78.41(15) Consumer choices option. The consumer choices option provides a consumer with a flexible monthly individual budget that is based on the consumer’s service needs. With the individual budget, the consumer shall have the authority to purchase goods and services and may choose to employ providers of services and supports. Components of this service are set forth below.
	a. 	Agreement. As a condition of participating in the consumer choices option, a consumer shall sign Form 470-4289, HCBS Consumer Choices Informed Consent and Risk Agreement, to document that the consumer has been informed of the responsibilities and risks of electing the consumer choices option.
	b. 	Individual budget amount. A monthly individual budget amount shall be set for each consumer. The consumer’s department service worker or Medicaid targeted case manager shall determine the amount of each consumer’s individual budget, based on the services and supports authorized in the consumer’s service plan. The consumer shall be informed of the individual budget amount during the development of the service plan.
	(1)	Services that may be included in determining the individual budget amount for a consumer in the HCBS mental retardation waiver are:
	1.	Consumer-directed attendant care (unskilled).
	2.	Day habilitation.
	3.	Home and vehicle modification.
	4.	Prevocational services.
	5.	Basic individual respite care.
	6.	Supported community living.
	7.	Supported employment.
	8.	Transportation.
	(2)	The department shall determine an average unit cost for each service listed in subparagraph (1) based on actual unit costs from the previous fiscal year plus a cost-of-living adjustment.
	(3)	In aggregate, costs for individual budget services shall not exceed the current costs of waiver program services. In order to maintain cost neutrality, the department shall apply a utilization adjustment factor to the amount of service authorized in the consumer’s service plan before calculating the value of that service to be included in the individual budget amount.
	(4)	The department shall compute the utilization adjustment factor for each service by dividing the net costs of all claims paid for the service by the total of the authorized costs for that service, using at least 12 consecutive months of aggregate service data. The utilization adjustment factor shall be no lower than 60 percent. The department shall analyze and adjust the utilization adjustment factor at least annually in order to maintain cost neutrality.
	(5)	Anticipated costs for home and vehicle modification are not subject to the average cost in subparagraph (2) or the utilization adjustment factor in subparagraph (3). Costs for home and vehicle modification may be released in a one-time payment.
	(6)	The individual budget amount may be changed only at the first of the month and shall remain fixed for the entire month.
	c. 	Required service components. To participate in the consumer choices option, a consumer must hire an independent support broker and must work with a financial management service that is enrolled as a Medicaid HCBS mental retardation waiver services provider.
	(1)	Before hiring the individual support broker, the consumer shall receive the results of the background check conducted pursuant to 441—subrule 77.30(14).
	(2)	If the consumer chooses to hire a person who has a criminal record or founded abuse report, the consumer assumes the risk for this action and shall acknowledge this information on Form 470-4289, HCBS Consumer Choices Informed Consent and Risk Agreement.
	d. 	Optional service components. A consumer who elects the consumer choices option may purchase the following services and supports, which shall be provided in the consumer’s home or at an integrated community setting:
	(1)	Self-directed personal care services. Self-directed personal care services are services or goods that provide a range of assistance in activities of daily living and incidental activities of daily living that help the consumer remain in the home and community.
	(2)	Self-directed community supports and employment. Self-directed community supports and employment are services that support the consumer in developing and maintaining independence and community integration.
	(3)	Individual-directed goods and services. Individual-directed goods and services are services, equipment, or supplies not otherwise provided through the Medicaid program that address a need identified in the consumer’s service plan. The item or service shall decrease the consumer’s need for other Medicaid services, promote the consumer’s inclusion in the community, or increase the consumer’s safety in the community.
	e. 	Development of the individual budget. The individual support broker shall assist the consumer in developing and implementing the consumer’s individual budget. The individual budget shall include:
	(1)	The costs of the financial management service.
	(2)	The costs of the independent support broker. The independent support broker may be compensated for up to 6 hours of service for assisting with the implementation of the initial individual budget. After the initial implementation, the independent support broker shall not be paid for more than 20 hours of service during a 12-month period without prior approval by the department.
	(3)	The costs of any services and supports chosen by the consumer as described in paragraph “d.”
	f. 	Budget authority. The consumer shall have authority over the individual budget authorized by the department to perform the following tasks:
	(1)	Contract with entities to provide services and supports as described in this subrule.
	(2)	Determine the amount to be paid for services with the exception of the independent support broker and the financial management service. Reimbursement rates for the independent support broker and the financial management service are subject to the limits in 441—subrule 79.1(2).
	(3)	Schedule the provision of services.
	(4)	Authorize payment for waiver goods and services identified in the individual budget. Consumers shall not use the individual budget to purchase room and board, sheltered workshop services, child care, or personal entertainment items.
	(5)	Reallocate funds among services included in the budget.
	g. 	Delegation of budget authority. The consumer may delegate responsibility for the individual budget to a representative in addition to the independent support broker.
	(1)	The representative must be at least 18 years old.
	(2)	The representative shall not be a current provider of service to the consumer.
	(3)	The consumer shall sign a consent form that designates who the consumer has chosen as a representative and what responsibilities the representative shall have.
	(4)	The representative shall not be paid for this service.
	h. 	Employer authority. The consumer shall have the authority to be the common-law employer of employees providing services and support under the consumer choices option. A common-law employer has the right to direct and control the performance of the services. The consumer may perform the following functions:
	(1)	Recruit employees.
	(2)	Select employees from a worker registry.
	(3)	Verify employee qualifications.
	(4)	Specify additional employee qualifications.
	(5)	Determine employee duties.
	(6)	Determine employee wages and benefits.
	(7)	Schedule employees.
	(8)	Train and supervise employees.
	i. 	Employment agreement. Any person employed by the consumer to provide services under the consumer choices option shall sign an employment agreement with the consumer that outlines the employee’s and consumer’s responsibilities.
	j. 	Responsibilities of the independent support broker. The independent support broker shall perform the services specified in 78.34(13)“j.”
	k. 	Responsibilities of the financial management service. The financial management service shall perform all of the services specified in 78.34(13)“k.”
This rule is intended to implement Iowa Code section 249A.4.
441—78.42(249A) Rehabilitative treatment services. Rescinded IAB 8/1/07, effective 9/5/07.
441—78.43(249A) HCBS brain injury waiver services. Payment shall be approved for the following services to consumers eligible for the HCBS brain injury services as established in 441—Chapter 83 and as identified in the consumer’s service plan. All services shall include the applicable and necessary instructions, supervision, assistance and support as required by the consumer in achieving the goals written specifically in the service plan. The services, amount and supports provided under the HCBS brain injury waiver shall be delivered in the least restrictive environment and in conformity with the consumer’s service plan.
Reimbursement shall not be available under the waiver for any services that the consumer can obtain through regular Medicaid.
All services shall be billed in whole units.
	78.43(1) Case management services. Individual case management services means services that assist members who reside in a community setting or are transitioning to a community setting in gaining access to needed medical, social, educational, housing, transportation, vocational, and other appropriate services in order to ensure the health, safety, and welfare of the member.
	a. 	Case management services shall be provided as set forth in rules 441—90.5(249A) and 441—90.8(249A).
	b. 	The service shall be delivered in such a way as to enhance the capabilities of consumers and their families to exercise their rights and responsibilities as citizens in the community. The goal is to enhance the ability of the consumer to exercise choice, make decisions, take risks that are a typical part of life, and fully participate as members of the community.
	c. 	The case manager must develop a relationship with the consumer so that the abilities, needs and desires of the consumer can be clearly identified and communicated and the case manager can help to ensure that the system and specific services are responsive to the needs of the individual consumers.
	d. 	Members who are at the ICF/MR level of care whose county has voluntarily chosen to participate in the HCBS brain injury waiver are eligible for targeted case management and, therefore, are not eligible for case management as a waiver service.
	78.43(2) Supported community living services. Supported community living services are provided by the provider within the consumer’s home and community, according to the individualized consumer need as identified in the individual comprehensive plan (ICP) or department case plan. Intermittent service shall be provided as defined in rule 441—83.81(249A).
	a. 	The basic components of the service may include, but are not limited to, personal and home skills training services, individual advocacy services, community skills training services, personal environment support services, transportation, and treatment services.
	(1)	Personal and home skills training services are those activities which assist a consumer to develop or maintain skills for self-care, self-directedness, and care of the immediate environment.
	(2)	Individual advocacy is the act or process of representing the individual’s rights and interests in order to realize the rights to which the individual is entitled and to remove barriers to meeting the individual’s needs.
	(3)	Community skills training services are those activities which assist a person to develop or maintain skills allowing better participation in the community. Services shall focus on the following areas as they are applicable to individuals being served:
	1.	Personal management skills training services are activities which assist a person to maintain or develop skills necessary to sustain oneself in the physical environment and are essential to the management of one’s personal business and property. This includes self-advocacy skills. Examples of personal management skills are the ability to maintain a household budget, plan and prepare nutritional meals, use community resources such as public transportation and libraries, and select foods at the grocery store.
	2.	Socialization skills training services are those activities which assist a consumer to develop or maintain skills which include self-awareness and self-control, social responsiveness, community participation, social amenities, and interpersonal skills.
	3.	Communication skills training services are activities which assist a person to develop or maintain skills including expressive and receptive skills in verbal and nonverbal language and the functional application of acquired reading and writing skills.
	(4)	Personal and environmental support services are those activities and expenditures provided to or on behalf of a person in the areas of personal needs in order to allow the person to function in the least restrictive environment.
	(5)	Transportation services are those activities and expenditures designed to assist the consumer to travel from one place to another to obtain services or carry out life’s activities. The service excludes transportation to and from work or day programs.
	(6)	Treatment services are those activities designed to assist the person to maintain or improve physiological, emotional and behavioral functioning and to prevent conditions that would present barriers to a person’s functioning. Treatment services include physical or physiological treatment and psychotherapeutic treatment.
Physiological treatment means activities including medication regimens designed to prevent, halt, control, relieve, or reverse symptoms or conditions which interfere with the normal functioning of the human body. The activities shall be provided by or under the supervision of a health care professional certified or licensed to provide the treatment activity specified.
Psychotherapeutic treatment means activities provided to assist a person in the identification or modification of beliefs, emotions, attitudes, or behaviors in order to maintain or improve the person’s functioning in response to the physical, emotional, and social environment.
	b. 	The supported community living services are intended to provide for the daily living needs of the consumer and shall be available as needed during any 24-hour period. Activities do not include those associated with vocational services, academics, day care, medical services, Medicaid case management or other case management. Services are individualized supportive services provided in a variety of community-based, integrated settings.
	(1)	Supported community living services shall be available at a daily rate to consumers living outside the home of their family, legal representative, or foster family and for whom a provider has primary responsibility for supervision or structure during the month. This service shall provide supervision or structure in identified time periods when another resource is not available.
	(2)	Supported community living services shall be available at an hourly rate to consumers for whom a daily rate is not established.
	(3)	Intermittent service shall be provided as defined in rule 441—83.81(249A).
	c. 	Services may be provided to a child or an adult. Children must first access all other services for which they are eligible and which are appropriate to meet their needs before accessing the HCBS brain injury waiver services. A maximum of three consumers may reside in a living unit, except when the provider meets the requirements set forth in 441—paragraph 77.39(13)“e.”
	(1)	Consumers may live in the home of their family or legal representative or in other types of typical community living arrangements.
	(2)	Consumers of services living with families or legal representatives are not subject to the maximum of three consumers in a living unit.
	(3)	Consumers may not live in licensed medical or health care facilities or in settings required to be licensed as medical or health care facilities.
	(4)	Consumers aged 17 or under living in the home of their family, legal representative, or foster families shall receive services based on development of adaptive, behavior, or health skills. Duration of services shall be based on age appropriateness and individual attention span.
	d. 	Rescinded IAB 2/5/03, effective 2/1/03.
	e. 	Provider budgets shall reflect all staff-to-consumer ratios and shall reflect costs associated with consumers’ specific support needs for travel and transportation, consulting, instruction, and environmental modifications and repairs, as determined necessary by the interdisciplinary team for each consumer. The specific support needs must be identified in the Medicaid case manager’s service plan, the total costs shall not exceed $1570 per consumer per year, and the provider must maintain records to support the expenditures. A unit of service is:
	(1)	One full calendar day when a consumer residing in the living unit receives on-site staff supervision for 19 or more hours during a 24-hour calendar day and the consumer’s individual comprehensive plan identifies and reflects the need for this amount of supervision.
	(2)	One hour when subparagraph (1) does not apply.
	f. 	The maximum numbers of units available per consumer are as follows:
	(1)	365 daily units per state fiscal year except a leap year, when 366 daily units are available.
	(2)	8,395 hourly units are available per state fiscal year except a leap year, when 8,418 hourly units are available.
	g. 	The service shall be identified in the consumer’s individual comprehensive plan.
	h. 	Services shall not be simultaneously reimbursed with other residential services, HCBS brain injury waiver respite, transportation or personal assistance services, Medicaid nursing, or Medicaid home health aide services.
	78.43(3) Respite services. Respite care services are services provided to the consumer that give temporary relief to the usual caregiver and provide all the necessary care that the usual caregiver would provide during that time period. The purpose of respite care is to enable the consumer to remain in the consumer’s current living situation.
	a. 	Services provided outside the consumer’s home shall not be reimbursable if the living unit where respite is provided is reserved for another person on a temporary leave of absence.
	b. 	Staff-to-consumer ratios shall be appropriate to the individual needs of the consumer as determined by the consumer’s interdisciplinary team.
	c. 	A unit of service is one hour.
	d. 	Respite care is not to be provided to persons during the hours in which the usual caregiver is employed except when the consumer is attending a camp. Respite cannot be provided to a consumer whose usual caregiver is a consumer-directed attendant care provider for the consumer.
	e. 	Respite services shall not be simultaneously reimbursed with other residential or respite services, HCBS brain injury waiver supported community living services, Medicaid nursing, or Medicaid home health aide services.
	f. 	The interdisciplinary team shall determine if the consumer will receive basic individual respite, specialized respite or group respite as defined in rule 441—83.81(249A).
	g. 	A maximum of 14 consecutive days of 24-hour respite care may be reimbursed.
	h. 	Respite services provided for a period exceeding 24 consecutive hours to three or more individuals who require nursing care because of a mental or physical condition must be provided by a health care facility licensed as described in Iowa Code chapter 135C.
	78.43(4) Supported employment services. Supported employment services are individualized services associated with obtaining and maintaining competitive paid employment in the least restrictive environment possible, provided to individuals for whom competitive employment at or above minimum wage is unlikely and who, because of their disability, need intense and ongoing support to perform in a work setting. Individual placements are the preferred service model. Covered services are those listed in paragraphs “a” and “b” that address the disability-related challenges to securing and keeping a job.
	a. 	Activities to obtain a job. Covered services directed to obtaining a job must be provided to or on behalf of a consumer for whom competitive employment is reasonably expected within less than one year. Services must be focused on job placement, not on teaching generalized employment skills or habilitative goals. Three conditions must be met before services are provided. First, the consumer and the interdisciplinary team described in rule 441—83.87(249A) must complete the form that Iowa vocational rehabilitation services uses to identify the supported employment services appropriate to meet the consumer’s employment needs. Second, the consumer’s interdisciplinary team must determine that the identified services are necessary. Third, the consumer’s case manager must approve the services. Available components of activities to obtain a job are as follows:
	(1)	Job development services. Job development services are directed toward obtaining competitive employment. A unit of service is a job placement that the consumer holds for 30 consecutive calendar days or more. Payment is available once the service is authorized in the member’s service plan. A consumer may receive two units of job development services during a 12-month period. The activities provided to the consumer may include:
	1.	Job procurement training, including grooming and hygiene, application, résumé development, interviewing skills, follow-up letters, and job search activities.
	2.	Job retention training, including promptness, coworker relations, transportation skills, disability-related supports, job benefits, and an understanding of employee rights and self-advocacy.
	3.	Customized job development services specific to the consumer.
	(2)	Employer development services. The focus of employer development services is to support employers in hiring and retaining consumers in their workforce and to communicate expectations of the employers to the interdisciplinary team described in rule 441—83.87(249A). Employer development services may be provided only to consumers who are reasonably expected to work for no more than 10 hours per week. A unit of service is one job placement that the consumer holds for 30 consecutive calendar days or more. Payment for this service may be made only after the consumer holds the job for 30 days. A consumer may receive two units of employer development services during a 12-month period if the consumer is competitively employed for 30 or more consecutive calendar days and the other conditions for service approval are met. The services provided may include:
	1.	Developing relationships with employers and providing leads for individual consumers when appropriate.
	2.	Job analysis for a specific job.
	3.	Development of a customized training plan identifying job-specific skill requirements, employer expectations, teaching strategies, time frames, and responsibilities.
	4.	Identifying and arranging reasonable accommodations with the employer.
	5.	Providing disability awareness and training to the employer when it is deemed necessary.
	6.	Providing technical assistance to the employer regarding the training progress as identified on the consumer’s customized training plan.
	(3)	Enhanced job search activities. Enhanced job search activities are associated with obtaining initial employment after job development services have been provided to the consumer for a minimum of 30 days or with assisting the consumer in changing jobs due to layoff, termination, or personal choice. The interdisciplinary team must review and update the Iowa vocational rehabilitation services supported employment readiness analysis form to determine if this service remains appropriate for the consumer’s employment goals. A unit of service is an hour. A maximum of 26 units may be provided in a 12-month period. The services provided may include:
	1.	Job opening identification with the consumer.
	2.	Assistance with applying for a job, including completion of applications or interviews.
	3.	Work site assessment and job accommodation evaluation.
	b. 	Supports to maintain employment.
	(1)	Covered services provided to or on behalf of the consumer associated with maintaining competitive paid employment are the following:
	1.	Individual work-related behavioral management.
	2.	Job coaching.
	3.	On-the-job or work-related crisis intervention.
	4.	Assisting the consumer to use skills related to sustaining competitive paid employment, including assistance with communication skills, problem solving, and safety.
	5.	Consumer-directed attendant care services as defined in subrule 78.43(13).
	6.	Assistance with time management.
	7.	Assistance with appropriate grooming.
	8.	Employment-related supportive contacts.
	9.	Employment-related transportation between work and home and to or from activities related to employment and disability. Other forms of community transportation (including car pools, coworkers, self or public transportation, families, and volunteers) must be attempted before transportation is provided as a supported employment service.
	10.	On-site vocational assessment after employment.
	11.	Employer consultation.
	(2)	Services for maintaining employment may include services associated with sustaining consumers in a team of no more than eight individuals with disabilities in a teamwork or “enclave” setting.
	(3)	A unit of service is one hour.
	(4)	A maximum of 40 units may be received per week.
	c. 	The following requirements apply to all supported employment services:
	(1)	Employment-related adaptations required to assist the consumer within the performance of the consumer’s job functions shall be provided by the provider as part of the services.
	(2)	Employment-related transportation between work and home and to or from activities related to employment and disability shall be provided by the provider as part of the services. Other forms of community transportation (car pools, coworkers, self or public transportation, families, volunteers) must be attempted before the service provider provides transportation.
	(3)	The majority of coworkers at any employment site with more than two employees where consumers seek, obtain, or maintain employment must be persons without disabilities. In the performance of job duties at any site where consumers seek, obtain, or maintain employment, the consumer must have daily contact with other employees or members of the general public who do not have disabilities, unless the absence of daily contact with other employees or the general public is typical for the job as performed by persons without disabilities.
	(4)	All supported employment services shall provide individualized and ongoing support contacts at intervals necessary to promote successful job retention. Each provider contact shall be documented.
	(5)	Documentation that services provided are not currently available under a program funded under the Rehabilitation Act of 1973 or Public Law 94-142 shall be maintained in the provider file of each consumer.
	(6)	All services shall be identified in the consumer’s service plan maintained pursuant to rule 441—83.67(249A).
	(7)	The following services are not covered:
	1.	Services involved in placing or maintaining consumers in day activity programs, work activity programs or sheltered workshop programs;
	2.	Supports for volunteer work or unpaid internships;
	3.	Tuition for education or vocational training; or
	4.	Individual advocacy that is not consumer specific.
	(8)	Services to maintain employment shall not be provided simultaneously with day activity programs, work activity programs, sheltered workshop programs, other HCBS services, or other Medicaid services. However, services to obtain a job and services to maintain employment may be provided simultaneously for the purpose of job advancement or job change.
	78.43(5) Home and vehicle modifications. Covered home and vehicle modifications are those physical modifications to the consumer’s home or vehicle listed below that directly address the consumer’s medical or remedial need. Covered modifications must be necessary to provide for the health, welfare, or safety of the consumer and enable the consumer to function with greater independence in the home or vehicle.
	a. 	Modifications that are necessary or desirable without regard to the consumer’s medical or remedial need and that would be expected to increase the fair market value of the home or vehicle, such as furnaces, fencing, roof repair, or adding square footage to the residence, are excluded except as specifically included below. Repairs are also excluded.
	b. 	Only the following modifications are covered:
	(1)	Kitchen counters, sink space, cabinets, special adaptations to refrigerators, stoves, and ovens.
	(2)	Bathtubs and toilets to accommodate transfer, special handles and hoses for shower heads, water faucet controls, and accessible showers and sink areas.
	(3)	Grab bars and handrails.
	(4)	Turnaround space adaptations.
	(5)	Ramps, lifts, and door, hall and window widening.
	(6)	Fire safety alarm equipment specific for disability.
	(7)	Voice-activated, sound-activated, light-activated, motion-activated, and electronic devices directly related to the consumer’s disability.
	(8)	Vehicle lifts, driver-specific adaptations, remote-start systems, including such modifications already installed in a vehicle.
	(9)	Keyless entry systems.
	(10)	Automatic opening device for home or vehicle door.
	(11)	Special door and window locks.
	(12)	Specialized doorknobs and handles.
	(13)	Plexiglas replacement for glass windows.
	(14)	Modification of existing stairs to widen, lower, raise or enclose open stairs.
	(15)	Motion detectors.
	(16)	Low-pile carpeting or slip-resistant flooring.
	(17)	Telecommunications device for the deaf.
	(18)	Exterior hard-surface pathways.
	(19)	New door opening.
	(20)	Pocket doors.
	(21)	Installation or relocation of controls, outlets, switches.
	(22)	Air conditioning and air filtering if medically necessary.
	(23)	Heightening of existing garage door opening to accommodate modified van.
	(24)	Bath chairs.
	c. 	A unit of service is the completion of needed modifications or adaptations.
	d. 	All modifications and adaptations shall be provided in accordance with applicable federal, state, and local building and vehicle codes.
	e. 	Services shall be performed following department approval of a binding contract between the enrolled home and vehicle modification provider and the consumer.
	f. 	The contract shall include, at a minimum, the work to be performed, cost, time frame for work completion, and assurance of liability and workers’ compensation coverage.
	g. 	Service payment shall be made to the enrolled home and vehicle modification provider. If applicable, payment will be forwarded to the subcontracting agency by the enrolled home and vehicle modification provider following completion of the approved modifications. Payment of up to $6,060 per year may be made to certified providers upon satisfactory completion of the service. The service worker shall encumber up to $505 per month within the monthly dollar cap allowed for the consumer until the amount of the modification is reached within the 12-month period.
	h. 	Services shall be included in the consumer’s service plan and shall exceed the Medicaid state plan services.
	78.43(6) Personal emergency response system. The personal emergency response system allows a consumer experiencing a medical emergency at home to activate electronic components that transmit a coded signal via digital equipment over telephone lines to a central monitoring station. The necessary components of a system are:
	a. 	An in-home medical communications transceiver.
	b. 	A remote, portable activator.
	c. 	A central monitoring station with backup systems staffed by trained attendants 24 hours per day, seven days per week.
	d. 	Current data files at the central monitoring station containing response protocols and personal, medical and emergency information for each consumer.
	e. 	The service shall be identified in the consumer’s individual and comprehensive plan.
	f. 	A unit is a one-time installation fee or one month of service.
	g. 	Maximum units per state fiscal year are the initial installation and 12 months of service.
	78.43(7) Transportation. Transportation services may be provided for consumers to conduct business errands and essential shopping, to receive medical services when not reimbursed through medical transportation, to travel to and from work or day programs, and to reduce social isolation. A unit of service is either per mile, per trip, or the unit established by an area agency on aging. Transportation may not be reimbursed simultaneously with HCBS brain injury waiver supported community living service.
	78.43(8) Specialized medical equipment. Specialized medical equipment shall include medically necessary items for personal use by consumers with a brain injury which provide for health and safety of the consumer which are not ordinarily covered by Medicaid, and are not funded by educational or vocational rehabilitation programs, and are not provided by voluntary means. This includes, but is not limited to: electronic aids and organizers, medicine dispensing devices, communication devices, bath aids, and noncovered environmental control units. This includes repair and maintenance of items purchased through the waiver in addition to the initial purchase cost.
	a. 	Consumers may receive specialized medical equipment once per month until a maximum yearly usage of $6,060 has been reached.
	b. 	The need for specialized medical equipment shall be documented by a health care professional as necessary for the consumer’s health and safety and identified in the consumer’s individual comprehensive plan.
	78.43(9) Adult day care services. Adult day care services provide an organized program of supportive care in a group environment to persons who need a degree of supervision and assistance on a regular or intermittent basis in a day care center. A unit of service is a full day (4 to 8 hours) or a half day (1 to 4 hours) or an extended day (8 to 12 hours). Components of the service are set forth in rule 441—171.6(234).
	78.43(10) Family counseling and training services. Family counseling and training services are face-to-face mental health services provided to the consumer and the family with whom the consumer lives, or who routinely provide care to the consumer to increase the consumer’s or family members’ capabilities to maintain and care for the consumer in the community. Counseling may include helping the consumer or the consumer’s family members with crisis, coping strategies, stress reduction, management of depression, alleviation of psychosocial isolation and support in coping with the effects of a brain injury. It may include the use of treatment regimes as specified in the ITP. Periodic training updates may be necessary to safely maintain the consumer in the community.
Family may include spouse, children, friends, or in-laws of the consumer. Family does not include individuals who are employed to care for the consumer.
	78.43(11) Prevocational services. Prevocational services are services aimed at preparing a consumer eligible for the HCBS brain injury waiver for paid or unpaid employment, but which are not job task oriented. These services include teaching the consumer concepts necessary as job readiness skills, such as following directions, attending to tasks, task completion, problem solving, and safety and mobility training. Prevocational services are intended to have a more generalized result as opposed to vocational training for a specific job or supported employment. Services include activities which are not primarily directed at teaching specific job skills but more generalized habilitative goals and are reflected in a habilitative plan which focuses on general habilitative rather than specific employment objectives.
Prevocational services do not include services defined in Section 4(a)(4) of the 1975 amendments to the Education of the Handicapped Act (20 U.S.C. 1404(16) and (17)) which are otherwise available to the individual through a state or local education agency or vocational rehabilitation services which are otherwise available to the individual through a program funded under Section 110 of the Rehabilitation Act of 1973 (29 U.S.C. 730).
	78.43(12) Behavioral programming. Behavioral programming consists of individually designed strategies to increase the consumer’s appropriate behaviors and decrease the consumer’s maladaptive behaviors which have interfered with the consumer’s ability to remain in the community. Behavioral programming includes:
	a. 	A complete assessment of both appropriate and maladaptive behaviors.
	b. 	Development of a structured behavioral intervention plan which should be identified in the ITP.
	c. 	Implementation of the behavioral intervention plan.
	d. 	Ongoing training and supervision to caregivers and behavioral aides.
	e. 	Periodic reassessment of the plan.
Types of appropriate behavioral programming include, but are not limited to, clinical redirection, token economies, reinforcement, extinction, modeling, and over-learning.
	78.43(13) Consumer-directed attendant care service. Consumer-directed attendant care services are service activities performed by a person to help a consumer with self-care tasks which the consumer would typically do independently if the consumer were otherwise able.
	a. 	The service activities may include helping the consumer with any of the following nonskilled service activities:
	(1)	Dressing.
	(2)	Bath, shampoo, hygiene, and grooming.
	(3)	Access to and from bed or a wheelchair, transferring, ambulation, and mobility in general. It is recommended that the provider receive certification of training and return demonstration for transferring. Certification for this is available through the area community colleges.
	(4)	Toilet assistance, including bowel, bladder, and catheter assistance. It is recommended that the provider receive certification of training and return demonstration for catheter assistance. Certification for this is available through the area community colleges.
	(5)	Meal preparation, cooking, eating and feeding but not the cost of meals themselves.
	(6)	Housekeeping services which are essential to the consumer’s health care at home.
	(7)	Medications ordinarily self-administered including those ordered by a physician or other qualified health care provider. It is recommended the provider successfully complete a medication aide course administered by an area community college.
	(8)	Wound care.
	(9)	Assistance needed to go to or return from a place of employment and assistance with job-related tasks while the consumer is on the job site. The cost of transportation for the consumer and assistance with understanding of performing the essential job functions are not included in consumer-directed attendant care services.
	(10)	Cognitive assistance with tasks such as handling money and scheduling.
	(11)	Fostering communication through interpreting and reading services as well as assistive devices for communication.
	(12)	Assisting or accompanying a consumer in using transportation essential to the health and welfare of the consumer. The cost of the transportation is not included.
	b. 	The service activities may include helping the consumer with any of the following skilled services under the supervision of a licensed nurse or licensed therapist working under the direction of a physician. The licensed nurse or therapist shall retain accountability for actions that are delegated. The licensed nurse or therapist shall ensure appropriate assessment, planning, implementation, and evaluation. The licensed nurse or therapist shall make on-site supervisory visits every two weeks with the provider present. The cost of the supervision provided by the licensed nurse or therapist shall be paid from private insurance and other third-party payment sources, Medicare, the regular Medicaid program, or the early periodic screening diagnosis and treatment program before accessing the HCBS waiver.
	(1)	Tube feedings of consumers unable to eat solid foods.
	(2)	Intravenous therapy administered by a registered nurse.
	(3)	Parenteral injections required more than once a week.
	(4)	Catheterizations, continuing care of indwelling catheters with supervision of irrigations, and changing of Foley catheters when required.
	(5)	Respiratory care including inhalation therapy and tracheotomy care or tracheotomy care and ventilator.
	(6)	Care of decubiti and other ulcerated areas, noting and reporting to the nurse or therapist.
	(7)	Rehabilitation services including, but not limited to, bowel and bladder training, range of motion exercises, ambulation training, restorative nursing services, reteaching the activities of daily living, respiratory care and breathing programs, reality orientation, reminiscing therapy, remotivation, and behavior modification.
	(8)	Colostomy.
	(9)	Care of medical conditions out of control which includes brittle diabetes and comfort care of terminal conditions.
	(10)	Postsurgical nursing care.
	(11)	Monitoring medications requiring close supervision because of fluctuating physical or psychological conditions, e.g., antihypertensives, digitalis preparations, mood-altering or psychotropic drugs, or narcotics.
	(12)	Preparing and monitoring response to therapeutic diets.
	(13)	Recording and reporting of changes in vital signs to the nurse or therapist.
	c. 	A unit of service is 1 hour, or one 8- to 24-hour day provided by an individual or an agency. Each service shall be billed in whole units.
	d. 	The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care shall be responsible for selecting the person or agency who will provide the components of the attendant care services to be provided.
	e. 	The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care shall determine the components of the attendant care services to be provided with the person who is providing the services to the consumer.
	f. 	The service activities may not include parenting or child care for or on behalf of the consumer.
	g. 	The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care and the provider shall complete and sign Form 470-3372, HCBS Consumer-Directed Attendant Care Agreement. A copy of the completed agreement shall be attached to the service plan, which is signed by the service worker or case manager prior to the initiation of services, and kept in the consumer’s and department’s records.
	h. 	If the consumer has a guardian or attorney in fact under a durable power of attorney for health care, the care plan shall address how consumer-directed attendant care services will be monitored to ensure the consumer’s needs are being adequately met. If the guardian or attorney in fact is the service provider, the service plan shall address how the service worker or case manager shall oversee service provision.
	i. 	If the consumer has a guardian or attorney in fact under a durable power of attorney for health care, the guardian or attorney in fact shall sign the claim form in place of the consumer, indicating that the service has been provided as presented on the claim.
	j. 	The frequency or intensity of services shall be indicated in the service plan.
	k. 	Consumer-directed attendant care services may not be simultaneously reimbursed with any other HCBS waiver services.
	l. 	Consumer-directed attendant care services may be provided to a recipient of in-home health-related care services, but not at the same time.
	m. 	Services may be provided in the absence of a parent or guardian if the parent or guardian has given advanced direction for the service provision.
	78.43(14) Interim medical monitoring and treatment services. Interim medical monitoring and treatment services are monitoring and treatment of a medical nature requiring specially trained caregivers beyond what is normally available in a day care setting. The services must be needed to allow the consumer’s usual caregivers to be employed or, for a limited period of time, for academic or vocational training of a usual caregiver; due to the hospitalization, treatment for physical or mental illness, or death of a usual caregiver; or during a search for employment by a usual caregiver.
	a. 	Service requirements. Interim medical monitoring and treatment services shall:
	(1)	Provide experiences for each consumer’s social, emotional, intellectual, and physical development;
	(2)	Include comprehensive developmental care and any special services for a consumer with special needs; and
	(3)	Include medical assessment, medical monitoring, and medical intervention as needed on a regular or emergency basis.
	b. 	Interim medical monitoring and treatment services may include supervision to and from school.
	c. 	Limitations.
	(1)	A maximum of 12 one-hour units of service is available per day.
	(2)	Covered services do not include a complete nutritional regimen.
	(3)	Interim medical monitoring and treatment services may not duplicate any regular Medicaid or waiver services provided under the state plan.
	(4)	Interim medical monitoring and treatment services may be provided only in the consumer’s home, in a registered group child care home, in a registered family child care home, in a licensed child care center, or during transportation to and from school.
	(5)	The staff-to-consumer ratio shall not be less than one to six.
	d. 	A unit of service is one hour.
	78.43(15) Consumer choices option. The consumer choices option provides a consumer with a flexible monthly individual budget that is based on the consumer’s service needs. With the individual budget, the consumer shall have the authority to purchase goods and services and may choose to employ providers of services and supports. Components of this service are set forth below.
	a. 	Agreement. As a condition of participating in the consumer choices option, a consumer shall sign Form 470-4289, HCBS Consumer Choices Informed Consent and Risk Agreement, to document that the consumer has been informed of the responsibilities and risks of electing the consumer choices option.
	b. 	Individual budget amount. A monthly individual budget amount shall be set for each consumer. The consumer’s department service worker or Medicaid targeted case manager shall determine the amount of each consumer’s individual budget, based on the services and supports authorized in the consumer’s service plan. The consumer shall be informed of the individual budget amount during the development of the service plan.
	(1)	Services that may be included in determining the individual budget amount for a consumer in the HCBS brain injury waiver are:
	1.	Consumer-directed attendant care (unskilled).
	2.	Day habilitation.
	3.	Home and vehicle modification.
	4.	Prevocational services.
	5.	Basic individual respite care.
	6.	Specialized medical equipment.
	7.	Supported community living.
	8.	Supported employment.
	9.	Transportation.
	(2)	The department shall determine an average unit cost for each service listed in subparagraph (1) based on actual unit costs from the previous fiscal year plus a cost-of-living adjustment.
	(3)	In aggregate, costs for individual budget services shall not exceed the current costs of waiver program services. In order to maintain cost neutrality, the department shall apply a utilization adjustment factor to the amount of service authorized in the consumer’s service plan before calculating the value of that service to be included in the individual budget amount.
	(4)	The department shall compute the utilization adjustment factor for each service by dividing the net costs of all claims paid for the service by the total of the authorized costs for that service, using at least 12 consecutive months of aggregate service data. The utilization adjustment factor shall be no lower than 60 percent. The department shall analyze and adjust the utilization adjustment factor at least annually in order to maintain cost neutrality.
	(5)	Anticipated costs for home and vehicle modification are not subject to the average cost in subparagraph (2) or the utilization adjustment factor in subparagraph (3). Costs for home and vehicle modification may be released in a one-time payment.
	(6)	The individual budget amount may be changed only at the first of the month and shall remain fixed for the entire month.
	c. 	Required service components. To participate in the consumer choices option, a consumer must hire an independent support broker and must work with a financial management service that is enrolled as a Medicaid HCBS brain injury waiver services provider.
	(1)	Before hiring the individual support broker, the consumer shall receive the results of the background check conducted pursuant to 441—subrule 77.30(14).
	(2)	If the consumer chooses to hire a person who has a criminal record or founded abuse report, the consumer assumes the risk for this action and shall acknowledge this information on Form 470-4289, HCBS Consumer Choices Informed Consent and Risk Agreement.
	d. 	Optional service components. A consumer who elects the consumer choices option may purchase the following services and supports, which shall be provided in the consumer’s home or at an integrated community setting:
	(1)	Self-directed personal care services. Self-directed personal care services are services or goods that provide a range of assistance in activities of daily living and incidental activities of daily living that help the consumer remain in the home and community.
	(2)	Self-directed community supports and employment. Self-directed community supports and employment are services that support the consumer in developing and maintaining independence and community integration.
	(3)	Individual-directed goods and services. Individual-directed goods and services are services, equipment, or supplies not otherwise provided through the Medicaid program that address a need identified in the consumer’s service plan. The item or service shall decrease the consumer’s need for other Medicaid services, promote the consumer’s inclusion in the community, or increase the consumer’s safety in the community.
	e. 	Development of the individual budget. The individual support broker shall assist the consumer in developing and implementing the consumer’s individual budget. The individual budget shall include:
	(1)	The costs of the financial management service.
	(2)	The costs of the independent support broker. The independent support broker may be compensated for up to 6 hours of service for assisting with the implementation of the initial individual budget. After the initial implementation, the independent support broker shall not be paid for more than 20 hours of service during a 12-month period without prior approval by the department.
	(3)	The costs of any services and supports chosen by the consumer as described in paragraph “d.”
	f. 	Budget authority. The consumer shall have authority over the individual budget authorized by the department to perform the following tasks:
	(1)	Contract with entities to provide services and supports as described in this subrule.
	(2)	Determine the amount to be paid for services with the exception of the independent support broker and the financial management service. Reimbursement rates for the independent support broker and the financial management service are subject to the limits in 441—subrule 79.1(2).
	(3)	Schedule the provision of services.
	(4)	Authorize payment for waiver goods and services identified in the individual budget. Consumers shall not use the individual budget to purchase room and board, sheltered workshop services, child care, or personal entertainment items.
	(5)	Reallocate funds among services included in the budget.
	g. 	Delegation of budget authority. The consumer may delegate responsibility for the individual budget to a representative in addition to the independent support broker.
	(1)	The representative must be at least 18 years old.
	(2)	The representative shall not be a current provider of service to the consumer.
	(3)	The consumer shall sign a consent form that designates who the consumer has chosen as a representative and what responsibilities the representative shall have.
	(4)	The representative shall not be paid for this service.
	h. 	Employer authority. The consumer shall have the authority to be the common-law employer of employees providing services and support under the consumer choices option. A common-law employer has the right to direct and control the performance of the services. The consumer may perform the following functions:
	(1)	Recruit employees.
	(2)	Select employees from a worker registry.
	(3)	Verify employee qualifications.
	(4)	Specify additional employee qualifications.
	(5)	Determine employee duties.
	(6)	Determine employee wages and benefits.
	(7)	Schedule employees.
	(8)	Train and supervise employees.
	i. 	Employment agreement. Any person employed by the consumer to provide services under the consumer choices option shall sign an employment agreement with the consumer that outlines the employee’s and consumer’s responsibilities.
	j. 	Responsibilities of the independent support broker. The independent support broker shall perform the services specified in 78.34(13)“j.”
	k. 	Responsibilities of the financial management service. The financial management service shall perform all of the services specified in 78.34(13)“k.”
This rule is intended to implement Iowa Code section 249A.4.
[ARC 7957B, IAB 7/15/09, effective 7/1/09]
441—78.44(249A) Lead inspection services. Payment shall be approved for lead inspection services. This service shall be provided for children who have had two venous blood lead levels of 15 to 19 micrograms per deciliter or one venous level greater than or equal to 20 micrograms per deciliter. This service includes, but is not limited to, X-ray fluorescence analyzer (XRF) readings, visual examination of paint, preventive education of the resident and homeowner, health education about lead poisoning, and a written report to the family, homeowner, medical provider, and local childhood lead poisoning prevention program.
This rule is intended to implement Iowa Code section 249A.4.
441—78.45(249A) Teleconsultive services. Rescinded IAB 9/6/00, effective 11/1/00.
441—78.46(249A) Physical disability waiver service. Payment shall be approved for the following services to consumers eligible for the HCBS physical disability waiver established in 441—Chapter 83 when identified in the consumer’s service plan. All services shall include the applicable and necessary instructions, supervision, assistance and support as required by the consumer in achieving the goals written specifically in the service plan and those delineated in Form 470-3372, HCBS Consumer-Directed Attendant Care Agreement. The service shall be delivered in the least restrictive environment consistent with the consumer’s needs and in conformity with the consumer’s service plan.
Reimbursement shall not be available under the waiver for any services that the consumer can obtain through regular Medicaid or from any other funding source.
All services shall be billed in whole units as specified in the following subrules.
	78.46(1) Consumer-directed attendant care service. Consumer-directed attendant care services are service activities listed below performed by a person to help a consumer with self-care tasks which the consumer would typically do independently if the consumer were otherwise able. The services must be cost-effective and necessary to prevent institutionalization.
Providers must demonstrate proficiency in delivery of the services in the consumer’s plan of care. Proficiency must be demonstrated through documentation of prior training or experience or a certificate of formal training. All training or experience will be detailed on Form 470-3372, HCBS Consumer-Directed Attendant Care Agreement, which must be reviewed and approved by the service worker for appropriateness of training or experience prior to the provision of services. Form 470-3372 becomes an attachment to and part of the case plan. Consumers shall give direction and training for activities which are not medical in nature to maintain independence. Licensed registered nurses and therapists must provide on-the-job training and supervision to the provider for skilled activities listed below and described on Form 470-3372. The training and experience must be sufficient to protect the health, welfare and safety of the consumer.
	a. 	Nonskilled service activities covered are:
	(1)	Help with dressing.
	(2)	Help with bath, shampoo, hygiene, and grooming.
	(3)	Help with access to and from bed or a wheelchair, transferring, ambulation, and mobility in general. Certification for this is available through the area community colleges.
	(4)	Toilet assistance, including bowel, bladder, and catheter assistance which includes emptying the catheter bag, collecting a specimen and cleaning the external area around the catheter. Certification of training which includes demonstration of competence for catheter assistance is available through the area community colleges.
	(5)	Meal preparation, cooking, eating and feeding assistance but not the cost of meals themselves.
	(6)	Housekeeping services which are essential to the consumer’s health care at home.
	(7)	Help with medications ordinarily self-administered including those ordered by a physician or other qualified health care provider. Certification of training in a medication aide course is available through the area community colleges.
	(8)	Minor wound care which does not require skilled nursing care.
	(9)	Assistance needed to go to or return from a place of employment and assistance with job-related tasks while the consumer is on the job site. The cost of transportation for the consumer and assistance with understanding or performing the essential job functions are not included in consumer-directed attendant care services.
	(10)	Cognitive assistance with tasks such as handling money and scheduling.
	(11)	Fostering communication through interpreting and reading services as well as assistance in use of assistive devices for communication.
	(12)	Assisting and accompanying a consumer in using transportation essential to the health and welfare of the consumer, but not the cost of the transportation.
	b. 	Skilled service activities covered are the following performed under the supervision of a licensed nurse or licensed therapist working under the direction of a licensed physician. The licensed nurse or therapist shall retain accountability for actions that are delegated. The licensed nurse or therapist shall ensure appropriate assessment, planning, implementation, and evaluation. The licensed nurse or therapist shall make on-site supervisory visits every two weeks with the provider present. The cost of the supervision provided by the licensed nurse or therapist shall not be included in the reimbursement for consumer-directed attendant care services.
	(1)	Tube feedings of consumers unable to eat solid foods.
	(2)	Assistance with intravenous therapy which is administered by a registered nurse.
	(3)	Parenteral injections required more than once a week.
	(4)	Catheterizations, continuing care of indwelling catheters with supervision of irrigations, and changing of Foley catheters when required.
	(5)	Respiratory care including inhalation therapy and tracheotomy care or tracheotomy care and ventilator.
	(6)	Care of decubiti and other ulcerated areas, noting and reporting to the nurse or therapist.
	(7)	Rehabilitation services including bowel and bladder training, range of motion exercises, ambulation training, restorative nursing services, reteaching the activities of daily living, respiratory care and breathing programs, reality orientation, reminiscing therapy, remotivation, and behavior modification.
	(8)	Colostomy care.
	(9)	Care of medical conditions such as brittle diabetes and comfort care of terminal conditions.
	(10)	Postsurgical nurse-delegated activities under the supervision of the registered nurse.
	(11)	Monitoring medication reactions requiring close supervision because of fluctuating physical or psychological conditions, e.g., antihypertensives, digitalis preparations, mood altering or psychotropic drugs or narcotics.
	(12)	Preparing and monitoring response to therapeutic diets.
	(13)	Recording and reporting of changes in vital signs to the nurse or therapist.
	c. 	A unit of service is 1 hour for up to 7 hours per day or one 8- to 24-hour day provided by an individual or an agency. Each service shall be billed in whole units.
	d. 	The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care shall be responsible for selecting the person or agency who will provide the components of the attendant care services to be provided.
	e. 	The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care shall determine the components of the attendant care services to be provided with the person who is providing the services to the consumer.
	f. 	The service activities may not include parenting or child care on behalf of the consumer.
	g. 	The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care and the provider shall complete and sign Form 470-3372, HCBS Consumer-Directed Attendant Care Agreement. A copy of the completed agreement shall be attached to the service plan, which is signed by the service worker prior to the initiation of services, and kept in the consumer’s and department’s records.
	h. 	If the consumer has a guardian or attorney in fact under a durable power of attorney for health care, the care plan shall address how consumer-directed attendant care services will be monitored to ensure the consumer’s needs are being adequately met. If the guardian or attorney in fact is the service provider, the service plan shall address how the service worker or case manager shall oversee service provision.
	i. 	If the consumer has a guardian or attorney in fact under a durable power of attorney for health care, the guardian or attorney in fact shall sign the claim form in place of the consumer, indicating that the service has been provided as presented on the claim.
	j. 	The frequency or intensity of services shall be indicated in the service plan.
	k. 	Consumer-directed attendant care services may not be simultaneously reimbursed with any other HCBS waiver services.
	l. 	Consumer-directed attendant care services may be provided to a recipient of in-home health-related care services, but not at the same time.
	m. 	Services may be provided in the absence of a parent or guardian if the parent or guardian has given advanced direction for the service provision.
	78.46(2) Home and vehicle modifications. Covered home and vehicle modifications are those physical modifications to the consumer’s home or vehicle listed below that directly address the consumer’s medical or remedial need. Covered modifications must be necessary to provide for the health, welfare, or safety of the consumer and enable the consumer to function with greater independence in the home or vehicle.
	a. 	Modifications that are necessary or desirable without regard to the consumer’s medical or remedial need and that would be expected to increase the fair market value of the home or vehicle, such as furnaces, fencing, roof repair, or adding square footage to the residence, are excluded except as specifically included below. Repairs are also excluded.
	b. 	Only the following modifications are covered:
	(1)	Kitchen counters, sink space, cabinets, special adaptations to refrigerators, stoves, and ovens.
	(2)	Bathtubs and toilets to accommodate transfer, special handles and hoses for shower heads, water faucet controls, and accessible showers and sink areas.
	(3)	Grab bars and handrails.
	(4)	Turnaround space adaptations.
	(5)	Ramps, lifts, and door, hall and window widening.
	(6)	Fire safety alarm equipment specific for disability.
	(7)	Voice-activated, sound-activated, light-activated, motion-activated, and electronic devices directly related to the consumer’s disability.
	(8)	Vehicle lifts, driver-specific adaptations, remote-start systems, including such modifications already installed in a vehicle.
	(9)	Keyless entry systems.
	(10)	Automatic opening device for home or vehicle door.
	(11)	Special door and window locks.
	(12)	Specialized doorknobs and handles.
	(13)	Plexiglas replacement for glass windows.
	(14)	Modification of existing stairs to widen, lower, raise or enclose open stairs.
	(15)	Motion detectors.
	(16)	Low-pile carpeting or slip-resistant flooring.
	(17)	Telecommunications device for the deaf.
	(18)	Exterior hard-surface pathways.
	(19)	New door opening.
	(20)	Pocket doors.
	(21)	Installation or relocation of controls, outlets, switches.
	(22)	Air conditioning and air filtering if medically necessary.
	(23)	Heightening of existing garage door opening to accommodate modified van.
	(24)	Bath chairs.
	c. 	A unit of service is the completion of needed modifications or adaptations.
	d. 	All modifications and adaptations shall be provided in accordance with applicable federal, state, and local building and vehicle codes.
	e. 	Services shall be performed following department approval of a binding contract between the enrolled home and vehicle modification provider and the consumer.
	f. 	The contract shall include, at a minimum, the work to be performed, cost, time frame for work completion, and assurance of liability and workers’ compensation coverage.
	g. 	Service payment shall be made to the enrolled home and vehicle modification provider. If applicable, payment will be forwarded to the subcontracting agency by the enrolled home and vehicle modification provider following completion of the approved modifications. Payment of up to $6,060 per year may be made to certified providers upon satisfactory completion of the service. The service worker shall encumber up to $505 per month within the monthly dollar cap allowed for the consumer until the amount of the modification is reached within the 12-month period.
	h. 	Services shall be included in the consumer’s service plan and shall exceed the Medicaid state plan services.
	78.46(3) Personal emergency response system. The personal emergency response system allows a consumer experiencing a medical emergency at home to activate electronic components that transmit a coded signal via digital equipment over telephone lines to a central monitoring station. The service shall be identified in the consumer’s service plan. A unit is a one-time installation fee or one month of service. Maximum units per state fiscal year are the initial installation and 12 months of service. The necessary components of a system are:
	a. 	An in-home medical communications transceiver.
	b. 	A remote, portable activator.
	c. 	A central monitoring station with backup systems staffed by trained attendants 24 hours per day, seven days a week.
	d. 	Current data files at the central monitoring station containing response protocols and personal, medical, and emergency information for each consumer.
	78.46(4) Specialized medical equipment. Specialized medical equipment shall include medically necessary items for personal use by consumers with a physical disability which provide for the health and safety of the consumer that are not covered by Medicaid, are not funded by vocational rehabilitation programs, and are not provided by voluntary means. This includes, but is not limited to: electronic aids and organizers, medicine-dispensing devices, communication devices, bath aids and noncovered environmental control units. This includes repair and maintenance of items purchased through the waiver in addition to the initial costs.
	a. 	Consumers may receive specialized medical equipment once a month until a maximum yearly usage of $6,060 has been reached.
	b. 	The need for specialized medical equipment shall be documented by a health care professional as necessary for the consumer’s health and safety and shall be identified in the consumer’s service plan.
	78.46(5) Transportation. Transportation services may be provided for consumers to conduct business errands and essential shopping, to receive medical services when not reimbursed through Medicaid as medical transportation, to travel to and from work or day programs, and to reduce social isolation. A unit of service is either per mile, per trip, or the unit established by an area agency on aging.
	78.46(6) Consumer choices option. The consumer choices option provides a consumer with a flexible monthly individual budget that is based on the consumer’s service needs. With the individual budget, the consumer shall have the authority to purchase goods and services and may choose to employ providers of services and supports. Components of this service are set forth below.
	a. 	Agreement. As a condition of participating in the consumer choices option, a consumer shall sign Form 470-4289, HCBS Consumer Choices Informed Consent and Risk Agreement, to document that the consumer has been informed of the responsibilities and risks of electing the consumer choices option.
	b. 	Individual budget amount. A monthly individual budget amount shall be set for each consumer. The consumer’s department service worker or Medicaid targeted case manager shall determine the amount of each consumer’s individual budget, based on the services and supports authorized in the consumer’s service plan. The consumer shall be informed of the individual budget amount during the development of the service plan.
	(1)	Services that may be included in determining the individual budget amount for a consumer in the HCBS physical disability waiver are:
	1.	Consumer-directed attendant care (unskilled).
	2.	Home and vehicle modification.
	3.	Specialized medical equipment.
	4.	Transportation.
	(2)	The department shall determine an average unit cost for each service listed in subparagraph (1) based on actual unit costs from the previous fiscal year plus a cost-of-living adjustment.
	(3)	In aggregate, costs for individual budget services shall not exceed the current costs of waiver program services. In order to maintain cost neutrality, the department shall apply a utilization adjustment factor to the amount of service authorized in the consumer’s service plan when calculating the value of that service to be included in the individual budget.
	(4)	The department shall compute the utilization adjustment factor for each service by dividing the net costs of all claims paid for the service by the total of the authorized costs for that service, using at least 12 consecutive months of aggregate service data. The utilization adjustment factor shall be no lower than 60 percent. The department shall analyze and adjust the utilization adjustment factor at least annually in order to maintain cost neutrality.
	(5)	Anticipated costs for home and vehicle modification are not subject to the average cost in subparagraph (2) or the utilization adjustment factor in subparagraph (3). Costs for home and vehicle modification may be released in a one-time payment.
	(6)	The individual budget amount may be changed only at the first of the month and shall remain fixed for the entire month.
	c. 	Required service components. To participate in the consumer choices option, a consumer must hire an independent support broker and must work with a financial management service that is enrolled as a Medicaid HCBS physical disability waiver services provider.
	(1)	Before hiring the individual support broker, the consumer shall receive the results of the background check conducted pursuant to 441—subrule 77.30(14).
	(2)	If the consumer chooses to hire a person who has a criminal record or founded abuse report, the consumer shall acknowledge this information on Form 470-4289, HCBS Consumer Choices Informed Consent and Risk Agreement.
	d. 	Optional service components. A consumer who elects the consumer choices option may purchase the following services and supports, which shall be provided in the consumer’s home or at an integrated community setting:
	(1)	Self-directed personal care services. Self-directed personal care services are services or goods that provide a range of assistance in activities of daily living and incidental activities of daily living that help the consumer remain in the home and community.
	(2)	Self-directed community supports and employment. Self-directed community supports and employment are services that support the consumer in developing and maintaining independence and community integration.
	(3)	Individual-directed goods and services. Individual-directed goods and services are services, equipment, or supplies not otherwise provided through the Medicaid program that address a need identified in the consumer’s service plan. The item or service shall decrease the consumer’s need for other Medicaid services, promote the consumer’s inclusion in the community, or increase the consumer’s safety in the community.
	e. 	Development of the individual budget. The individual support broker shall assist the consumer in developing and implementing the consumer’s individual budget. The individual budget shall include:
	(1)	The costs of the financial management service.
	(2)	The costs of the independent support broker. The independent support broker may be compensated for up to 6 hours of service for assisting with the implementation of the initial individual budget. After the initial implementation, the independent support broker shall not be paid for more than 20 hours of service during a 12-month period without prior approval by the department.
	(3)	The costs of any services and supports chosen by the consumer as described in paragraph “d.”
	f. 	Budget authority. The consumer shall have authority over the individual budget authorized by the department to perform the following tasks:
	(1)	Contract with entities to provide services and supports as described in this subrule.
	(2)	Determine the amount to be paid for services with the exception of the independent support broker and the financial management service. Reimbursement rates for the independent support broker and the financial management service are subject to the limits in 441—subrule 79.1(2).
	(3)	Schedule the provision of services.
	(4)	Authorize payment for waiver goods and services identified in the individual budget. Consumers shall not use the individual budget to purchase room and board, sheltered workshop services, child care, or personal entertainment items.
	(5)	Reallocate funds among services included in the budget.
	g. 	Delegation of budget authority. The consumer may delegate responsibility for the individual budget to a representative in addition to the independent support broker.
	(1)	The representative must be at least 18 years old.
	(2)	The representative shall not be a current provider of service to the consumer.
	(3)	The consumer shall sign a consent form that designates who the consumer has chosen as a representative and what responsibilities the representative shall have.
	(4)	The representative shall not be paid for this service.
	h. 	Employer authority. The consumer shall have the authority to be the common-law employer of employees providing services and support under the consumer choices option. A common-law employer has the right to direct and control the performance of the services. The consumer may perform the following functions:
	(1)	Recruit employees.
	(2)	Select employees from a worker registry.
	(3)	Verify employee qualifications.
	(4)	Specify additional employee qualifications.
	(5)	Determine employee duties.
	(6)	Determine employee wages and benefits.
	(7)	Schedule employees.
	(8)	Train and supervise employees.
	i. 	Employment agreement. Any person employed by the consumer to provide services under the consumer choices option shall sign an employment agreement with the consumer that outlines the employee’s and consumer’s responsibilities.
	j. 	Responsibilities of the independent support broker. The independent support broker shall perform the services specified in 78.34(13)“j.”
	k. 	Responsibilities of the financial management service. The financial management service shall perform all of the services specified in 78.34(13)“k.”
This rule is intended to implement Iowa Code section 249A.4.
441—78.47(249A) Pharmaceutical case management services. Payment will be approved for pharmaceutical case management services provided by an eligible physician and pharmacist for Medicaid recipients determined to be at high risk for medication-related problems. These services are designed to identify, prevent, and resolve medication-related problems and improve drug therapy outcomes.
	78.47(1) Medicaid recipient eligibility. Patients are eligible for pharmaceutical case management services if they have active prescriptions for four or more regularly scheduled nontopical medications, are ambulatory, do not reside in a nursing facility, and have at least one of the eligible disease states of congestive heart disease, ischemic heart disease, diabetes mellitus, hypertension, hyperlipidemia, asthma, depression, atrial fibrillation, osteoarthritis, gastroesophageal reflux, or chronic obstructive pulmonary disease.
	78.47(2) Provider eligibility. Physicians and pharmacists shall meet the following criteria to provide pharmaceutical case management services.
	a. 	Physicians and pharmacists must be enrolled in the Iowa Medicaid program, have an Iowa Medicaid provider number, and receive training under the direction of the department regarding the provision of pharmaceutical case management services under the Iowa Medicaid program.
A copy of pharmaceutical case management records, including documentation of services provided, shall be maintained on file in each provider’s facility and be made available for audit by the department on request.
	b. 	Physicians shall be licensed to practice medicine.
	c. 	Pharmacists shall present to the department evidence of competency including state licensure, submit five acceptable patient care plans, and have successfully completed professional training on patient-oriented, medication-related problem prevention and resolution. Pharmacists shall also maintain problem-oriented patient records, provide a private patient consultation area, and submit a statement indicating that the submitted patient care plans are representative of the pharmacists’ usual patient care plans.
Acceptable professional training programs are:
	(1)	A doctor of pharmacy degree program.
	(2)	The Iowa Center for Pharmaceutical Care (ICPC) training program, which is a cooperative training initiative of the University of Iowa College of Pharmacy, Drake University College of Pharmacy and Health Sciences, and the Iowa Pharmacy Foundation.
	(3)	Other programs containing similar coursework and supplemental practice site evaluation and reengineering, approved by the department with input from a peer review advisory committee.
	78.47(3) Services. Eligible patients may choose whether to receive the services. If patients elect to receive the services, they must receive the services from any eligible physician and pharmacist acting as a pharmaceutical case management (PCM) team. Usually the eligible physician and pharmacist will be the patient’s primary physician and pharmacist. Pharmaceutical case management services are to be value-added services complementary to the basic medical services provided by the primary physician and pharmacist.
The PCM team shall provide the following services:
	a. 	Initial assessment. The initial assessment shall consist of:
	(1)	A patient evaluation by the pharmacist, including:
	1.	Medication history;
	2.	Assessment of indications, effectiveness, safety, and compliance of medication therapy;
	3.	Assessment for the presence of untreated illness; and
	4.	Identification of medication-related problems such as unnecessary medication therapy, suboptimal medication selection, inappropriate compliance, adverse drug reactions, and need for additional medication therapy.
	(2)	A written report and recommendation from the pharmacist to the physician.
	(3)	A patient care action plan developed by the PCM team with the patient’s agreement and implemented by the PCM team. Specific components of the action plan will vary based on patient needs and conditions but may include changes in medication regimen, focused patient or caregiver education, periodic assessment for changes in the patient’s condition, periodic monitoring of the effectiveness of medication therapy, self-management training, provision of patient-specific educational and informational materials, compliance enhancement, and reinforcement of healthy lifestyles. An action plan must be completed for each initial assessment.
	b. 	New problem assessments. These assessments are initiated when a new medication-related problem is identified. The action plan is modified and new components are implemented to address the new problem. This assessment may occur in the interim between scheduled follow-up assessments.
	c. 	Problem follow-up assessments. These assessments are based on patient need and a problem identified by a prior assessment. The patient’s status is evaluated at an appropriate interval. The effectiveness of the implemented action plan is determined and modifications are made as needed.
	d. 	Preventive follow-up assessments. These assessments occur approximately every six months when no current medication-related problems have been identified in prior assessments. The patient is reassessed for newly developed medication-related problems and the action plan is reviewed.
This rule is intended to implement Iowa Code section 249A.4 and 2000 Iowa Acts, chapter 1228, section 9.
441—78.48(249A) Rehabilitation services for adults with chronic mental illness. Rescinded IAB 8/1/07, effective 9/5/07.
441—78.49(249A) Infant and toddler program services. Subject to the following subrules, payment shall be made for medical services provided to Medicaid eligible children by infant and toddler program providers under the infants and toddlers with disabilities program administered by the Iowa Child Health Specialty Clinics and the departments of education, public health, and human services.
	78.49(1) Covered services. Covered services include, but are not limited to, audiology, psychological evaluation and counseling, health and nursing services, nutrition services, occupational therapy services, physical therapy services, developmental services, speech-language services, vision services, case management, and medical transportation.
	78.49(2) Case management services. Payment shall also be approved for infant and toddler case management services subject to the following requirements:
	a. 	Definition. “Case management” means services that will assist eligible children in gaining access to needed medical, social, educational, and other services. Case management is intended to address the complexities of coordinated service delivery for children with medical needs. The case manager should be the focus for coordinating and overseeing the effectiveness of all providers and programs in responding to the assessed need. Case management does not include the direct delivery of an underlying medical, educational, social, or other service to which an eligible child has been referred or any activities that are an integral part or an extension of the direct services.
	b. 	Choice of provider. Children who also are eligible to receive targeted case management services under 441—Chapter 90 must choose whether to receive case management through the infant and toddler program or through 441—Chapter 90. The chosen provider must meet the requirements of this subrule.
	(1)	When a child resides in a medical institution, the institution is responsible for case management. The child is not eligible for any other case management services.— However, noninstitutional case management services may be provided during the last 14 days before the child’s planned discharge if the child’s stay in the institution has been less than 180 consecutive days. If the child has been in the institution 180 consecutive days or longer, the child may receive noninstitutional case management services during the last 60 days before the child’s planned discharge.
	(2)	If the case management agency also provides direct services, the case management unit must be designed so that conflict of interest is addressed and does not result in self-referrals.
	(3)	If the costs of any part of case management services are reimbursable under another program, the costs must be allocated between those programs and Medicaid in accordance with OMB Circular No. A-87 or any related or successor guidance or regulations regarding allocation of costs.
	(4)	The case manager must complete a competency-based training program with content related to knowledge and understanding of eligible children, Early ACCESS rules, the nature and scope of services in Early ACCESS, and the system of payments for services, as well as case management responsibilities and strategies. The department of education or its designee shall determine whether a person has successfully completed the training.
	c. 	Assessment. The case manager shall conduct a comprehensive assessment and periodic reassessment of an eligible child to identify all of the child’s service needs, including the need for any medical, educational, social, or other services. Assessment activities are defined to include the following:
	(1)	Taking the child’s history;
	(2)	Identifying the needs of the child;
	(3)	Gathering information from other sources, such as family members, medical providers, social workers, and educators, if necessary, to form a complete assessment of the child;
	(4)	Completing documentation of the information gathered and the assessment results; and
	(5)	Repeating the assessment every six months to determine whether the child’s needs or preferences have changed.
	d. 	Plan of care. The case manager shall develop a plan of care based on the information collected through the assessment or reassessment. The plan of care shall:
	(1)	Include the child’s strengths and preferences;
	(2)	Consider the child’s physical and social environment;
	(3)	Specify goals of providing services to the child; and
	(4)	Specify actions to address the child’s medical, social, educational, and other service needs. These actions may include activities such as ensuring the active participation of the child and working with the child or the child’s authorized health care decision maker and others to develop goals and identify a course of action to respond to the assessed needs of the child.
	e. 	Other service components. Case management must include the following components:
	(1)	Contacts with the child and family. The case manager shall have face-to-face contact with the child and family within the first 30 days of service and every three months thereafter. In months in which there is no face-to-face contact, a telephone contact between the service coordinator and the family is required.
	(2)	Referral and related activities to help a child obtain needed services. The case manager shall help to link the child with medical, social, or educational providers or other programs and services that are capable of providing needed services. Referral activities do not include provision of the direct services, program, or activity to which the child has been linked. Referral activities include:
	1.	Assisting the family in gaining access to the infant and toddler program services and other services identified in the child’s plan of care.
	2.	Assisting the family in identifying available service providers and funding resources and documenting unmet needs and gaps in services.
	3.	Making referrals to providers for needed services.
	4.	Scheduling appointments for the child.
	5.	Facilitating the timely delivery of services.
	6.	Arranging payment for medical transportation.
	(3)	Monitoring and follow-up activities. Monitoring activities shall take place at least once annually for the duration of the child’s eligibility, but may be conducted as frequently as necessary to ensure that the plan of care is effectively implemented and adequately addresses the needs of the child. Monitoring and follow-up activities may be with the child, family members, providers, or other entities. The purpose of these activities is to help determine:
	1.	Whether services are being furnished in accordance with the child’s plan of care.
	2.	Whether the services in the plan of care are adequate to meet the needs of the child.
	3.	Whether there are changes in the needs or status of the child. If there are changes in the child’s needs or status, follow-up activities shall include making necessary adjustments to the plan of care and to service arrangements with providers.
	(4)	Keeping records, including preparing reports, updating the plan of care, making notes about plan activities in the child’s record, and preparing and responding to correspondence with the family and others.
	f. 	Documentation of case management. For each child receiving case management, case records must document:
	(1)	The name of the child;
	(2)	The dates of case management services;
	(3)	The agency chosen by the family to provide the case management services;
	(4)	The nature, content, and units of case management services received;
	(5)	Whether the goals specified in the care plan have been achieved;
	(6)	Whether the family has declined services in the care plan;
	(7)	Time lines for providing services and reassessment; and
	(8)	The need for and occurrences of coordination with case managers of other programs.
	78.49(3) Child’s eligibility. Payable services must be provided to a child under the age of 36 months who is experiencing developmental delay or who has a condition that is known to have a high probability of resulting in developmental delay at a later date.
	78.49(4) Delivery of services. Services must be delivered directly by the infant and toddler program provider or by a practitioner under contract with the infant and toddler program provider.
	78.49(5) Remission of nonfederal share of costs. Payment for services shall be made only when the following conditions are met:
	a. 	Rescinded IAB 5/10/06, effective 7/1/06.
	b. 	The infant and toddler program provider has executed an agreement to remit the nonfederal share of the cost to the department.
	c. 	The infant and toddler program provider shall sign and return Form 470-3816, Medicaid Billing Remittance, along with the funds remitted for the nonfederal share of the costs of the services specified on the form.
This rule is intended to implement Iowa Code section 249A.4.
441—78.50(249A) Local education agency services. Subject to the following subrules, payment shall be made for medical services provided by local education agency services providers to Medicaid members under the age of 21.
	78.50(1) Covered services. Covered services include, but are not limited to, audiology services, behavior services, consultation services, medical transportation, nursing services, nutrition services, occupational therapy services, personal assistance, physical therapy services, psychologist services, speech-language services, social work services, vision services, and school-based clinic visit services.
	a. 	Vaccines available through the Vaccines for Children program under Section 1928 of the Social Security Act are not covered as local education agency services. Agencies that wish to administer those vaccines to Medicaid members shall enroll in the Vaccines for Children program and obtain the vaccines from the department of public health. However, the administration of vaccines is a covered service.
	b. 	Payment for supplies shall be approved when the supplies are incidental to the patient’s care, e.g., syringes for injections, and do not exceed $25 per month. Durable medical equipment and other supplies are not covered as local education agency services.
	c. 	To the extent that federal funding is not available under Title XIX of the Social Security Act, payment for transportation between home and school is not a covered service.
	78.50(2) Coordination services. Rescinded IAB 12/3/08, effective 2/1/09.
	78.50(3) Delivery of services. Services must be delivered directly by the local education agency services providers or by a practitioner under contract with the local education agency services provider.
	78.50(4) Remission of nonfederal share of costs. Payment for services shall be made only when the following conditions are met:
	a. 	Rescinded IAB 5/10/06, effective 7/1/06.
	b. 	The local education agency services provider has executed an agreement to remit the nonfederal share of the cost to the department.
	c. 	The local education agency provider shall sign and return Form 470-3816, Medicaid Billing Remittance, along with the funds remitted for the nonfederal share of the costs of the services as specified on the form.
This rule is intended to implement Iowa Code section 249A.4.
441—78.51(249A) Indian health service 638 facility services. Payment shall be made for all medically necessary services and supplies provided by a licensed practitioner at an Indian health service 638 facility, as defined at rule 441—77.45(249A), within the practitioner’s scope of practice and subject to the limitations and exclusions set forth in subrule 78.1(1).
This rule is intended to implement Iowa Code section 249A.4.
441—78.52(249A) HCBS children’s mental health waiver services. Payment will be approved for the following services to consumers eligible for the HCBS children’s mental health waiver as established in 441—Chapter 83. All services shall be provided in accordance with the general standards in subrule 78.52(1), as well as standards provided specific to each waiver service in subrules 78.52(2) through 78.52(5).
	78.52(1) General service standards. All children’s mental health waiver services shall be provided in accordance with the following standards:
	a. 	Services must be based on the consumer’s needs as identified in the consumer’s service plan developed pursuant to 441—83.127(249A).
	(1)	Services must be delivered in the least restrictive environment consistent with the consumer’s needs.
	(2)	Services must include the applicable and necessary instruction, supervision, assistance and support as required by the consumer to achieve the consumer’s goals.
	b. 	Payment for services shall be made only upon departmental approval of the services. Waiver services provided before approval of the consumer’s eligibility for the waiver shall not be paid.
	c. 	Services or service components must not be duplicative.
	(1)	Reimbursement shall not be available under the waiver for any services that the consumer may obtain through the Iowa Medicaid program outside of the waiver.
	(2)	Reimbursement shall not be available under the waiver for any services that the consumer may obtain through natural supports or community resources.
	(3)	Services may not be simultaneously reimbursed for the same period as nonwaiver Medicaid services or other Medicaid waiver services.
	(4)	Costs for waiver services are not reimbursable while the consumer is in a medical institution.
	78.52(2) Environmental modifications and adaptive devices.
	a. 	Environmental modifications and adaptive devices include items installed or used within the consumer’s home that address specific, documented health, mental health, or safety concerns.
	b. 	A unit of service is one modification or device.
	c. 	For each unit of service provided, the case manager shall maintain in the consumer’s case file a signed statement from a mental health professional on the consumer’s interdisciplinary team that the service has a direct relationship to the consumer’s diagnosis of serious emotional disturbance.
	78.52(3) Family and community support services. Family and community support services shall support the consumer and the consumer’s family by the development and implementation of strategies and interventions that will result in the reduction of stress and depression and will increase the consumer’s and the family’s social and emotional strength.
	a. 	Dependent on the needs of the consumer and the consumer’s family members individually or collectively, family and community support services may be provided to the consumer, to the consumer’s family members, or to the consumer and the family members as a family unit.
	b. 	Family and community support services shall be provided under the recommendation and direction of a mental health professional who is a member of the consumer’s interdisciplinary team pursuant to 441—83.127(249A).
	c. 	Family and community support services shall incorporate recommended support interventions and activities, which may include the following:
	(1)	Developing and maintaining a crisis support network for the consumer and for the consumer’s family.
	(2)	Modeling and coaching effective coping strategies for the consumer’s family members.
	(3)	Building resilience to the stigma of serious emotional disturbance for the consumer and the family.
	(4)	Reducing the stigma of serious emotional disturbance by the development of relationships with peers and community members.
	(5)	Modeling and coaching the strategies and interventions identified in the consumer’s crisis intervention plan as defined in 441—24.1(225C) for life situations with the consumer’s family and in the community.
	(6)	Developing medication management skills.
	(7)	Developing personal hygiene and grooming skills that contribute to the consumer’s positive self-image.
	(8)	Developing positive socialization and citizenship skills.
	d. 	Family and community support services may include an amount not to exceed $1500 per consumer per year for transportation within the community and purchase of therapeutic resources. Therapeutic resources may include books, training materials, and visual or audio media.
	(1)	The interdisciplinary team must identify the transportation or therapeutic resource as a support need.
	(2)	The annual amount available for transportation and therapeutic resources must be listed in the consumer’s service plan.
	(3)	The consumer’s parent or legal guardian shall submit a signed statement that the transportation or therapeutic resource cannot be provided by the consumer or the consumer’s family or legal guardian.
	(4)	The consumer’s Medicaid targeted case manager shall maintain a signed statement that potential community resources are unavailable and shall list the community resources contacted to fund the transportation or therapeutic resource.
	(5)	The transportation or therapeutic resource must not be otherwise eligible for Medicaid reimbursement.
	(6)	Family and community support services providers shall maintain records to:
	1.	Ensure that the transportation and therapeutic resources provided to not exceed the maximum amount authorized; and
	2.	Support the annual reporting requirements in 441—subparagraph 79.1(15)“a”(1).
	e. 	The following components are specifically excluded from family and community support services:
	(1)	Vocational services.
	(2)	Prevocational services.
	(3)	Supported employment services.
	(4)	Room and board.
	(5)	Academic services.
	(6)	General supervision and consumer care.
	f. 	A unit of family and community support services is one hour.
	78.52(4) In-home family therapy. In-home family therapy provides skilled therapeutic services to the consumer and family that will increase their ability to cope with the effects of serious emotional disturbance on the family unit and the familial relationships. The service must support the family by the development of coping strategies that will enable the consumer to continue living within the family environment.
	a. 	The goal of in-home family therapy is to maintain a cohesive family unit.
	b. 	In-home family therapy is exclusive of and cannot serve as a substitute for individual therapy, family therapy, or other mental health therapy that may be obtained through the Iowa Plan or other funding sources.
	c. 	A unit of in-home family therapy service is one hour. Any period less than one hour shall be prorated.
	78.52(5) Respite care services. Respite care services are services provided to the consumer that give temporary relief to the usual caregiver and provide all the necessary care that the usual caregiver would provide during that period. The “usual caregiver” means a person or persons who reside with the consumer and are available on a 24-hour-per-day basis to assume responsibility for the care of the consumer.
	a. 	Respite care shall not be provided to consumers during the hours in which the usual caregiver is employed, except when the consumer is attending a camp.
	b. 	The usual caregiver cannot be absent from the home for more than 14 consecutive days during respite provision.
	c. 	Staff-to-consumer ratios shall be appropriate to the individual needs of the consumer as determined by the consumer’s interdisciplinary team. The team shall determine the type of respite care to be provided according to these definitions:
	(1)	Basic individual respite is provided on a ratio of one staff to one consumer. The consumer does not have specialized medical needs that require the direct services of a registered nurse or licensed practical nurse.
	(2)	Specialized respite is provided on a ratio of one or more nursing staff to one consumer. The consumer has specialized medical needs that require the direct services of a registered nurse or licensed practical nurse.
	(3)	Group respite is provided on a ratio of one staff to two or more consumers receiving respite. These consumers do not have specialized medical needs that require the direct services of a registered nurse or licensed practical nurse.
	d. 	Respite services provided for a period exceeding 24 consecutive hours to three or more consumers who require nursing care because of a mental or physical condition must be provided by a health care facility licensed under Iowa Code chapter 135C.
	e. 	Respite services provided outside the consumer’s home shall not be reimbursable if the living unit where respite care is provided is reserved for another person on a temporary leave of absence.
	f. 	A unit of service is one hour.
This rule is intended to implement Iowa Code section 249A.4 and 2005 Iowa Acts, chapter 167, section 13, and chapter 117, section 3.
[Filed 3/11/70; amended 3/20/74]
[Filed 11/25/75, Notice 10/6/75—published 12/15/75, effective 1/19/76]
[Filed emergency 12/23/75—published 1/12/76, effective 2/1/76]
[Filed emergency 1/16/76—published 2/9/76, effective 2/1/76]
[Filed emergency 1/29/76—published 2/9/76, effective 1/29/76]
[Filed 4/30/76, Notice 3/22/76—published 5/17/76, effective 6/21/76]
[Filed emergency 6/9/76—published 6/28/76, effective 6/9/76]
[Filed 6/25/76, Notice 5/17/76—published 7/12/76, effective 8/16/76]
[Filed emergency 12/17/76—published 1/12/77, effective 1/1/77]
[Filed 2/25/77, Notice 1/12/77—published 3/23/77, effective 4/27/77]
[Filed emergency 4/13/77—published 5/4/77, effective 4/13/77]
[Filed emergency 7/20/77—published 8/10/77, effective 7/20/77]
[Filed emergency 8/24/77—published 9/21/77, effective 8/26/77]
[Filed emergency 9/1/77—published 9/21/77, effective 9/1/77]
[Filed 11/22/77, Notice 9/7/77—published 12/14/77, effective 2/1/78]
[Filed 12/6/77, Notice 10/19/77—published 12/28/77, effective 2/1/78]
[Filed 1/16/78, Notice 11/30/77—published 2/8/78, effective 4/1/78]
[Filed 3/27/78, Notice 2/8/78—published 4/19/78, effective 5/24/78]
[Filed without Notice 3/31/78—published 4/19/78, effective 7/1/78]
[Filed emergency 6/9/78—published 6/28/78, effective 7/5/78]
[Filed emergency 6/28/78—published 7/26/78, effective 7/1/78]
[Filed 8/9/78, Notice 6/28/78—published 9/6/78, effective 10/11/78]
[Filed 8/18/78, Notice 5/31/78—published 9/6/78, effective 10/11/78]
[Filed 9/12/78, Notice 4/19/78—published 10/4/78, effective 11/8/78]
[Filed 9/12/78, Notice 7/26/78—published 10/4/78, effective 12/1/78]
[Filed 11/20/78, Notice 10/4/78—published 12/13/78, effective 1/17/79]
[Filed 12/6/78, Notice 10/4/78—published 12/27/78, effective 2/1/79]
[Filed 12/6/78, Notice 5/31/78—published 12/27/78, effective 2/1/79]
[Filed 1/4/79, Notice 11/29/78—published 1/24/79, effective 3/1/79]
[Filed emergency 1/31/79—published 2/21/79, effective 3/8/79]
[Filed 3/30/79, Notice 2/21/79—published 4/18/79, effective 6/1/79]
[Filed 7/3/79, Notice 4/18/79—published 7/25/79, effective 8/29/79]
[Filed emergency 6/26/79—published 7/25/79, effective 7/1/79]
[Filed 9/6/79, Notice 6/27/79—published 10/3/79, effective 11/7/79]
[Filed emergency 9/6/79 after Notice 7/11/79—published 10/3/79, effective 10/1/79]
[Filed 10/24/79, Notice 5/30/79—published 11/14/79, effective 12/19/79]
[Filed 10/24/79, Notice 8/22/79—published 11/14/79, effective 12/19/79]
[Filed emergency 1/23/80—published 2/20/80, effective 1/23/80]
[Filed 4/4/80, Notice 1/23/80—published 4/30/80, effective 6/4/80]
[Filed emergency 6/30/80—published 7/23/80, effective 7/1/80]
[Filed emergency 7/3/80—published 7/23/80, effective 7/8/80 to 1/1/81]
[Filed 7/3/80, Notice 4/14/80—published 7/23/80, effective 8/27/80]
[Filed 9/25/80, Notice 8/6/80—published 10/15/80, effective 11/19/80]
[Filed without Notice 9/26/80—published 10/15/80, effective 12/1/80]
[Filed 10/23/80, Notice 7/23/80—published 11/12/80, effective 12/17/80]
[Filed 11/21/80, Notice 9/3/80—published 12/10/80, effective 1/14/81]
[Filed 12/19/80, Notices 10/15/80, 10/29/80—published 1/7/81, effective 2/11/81]
[Filed emergency 1/20/81—published 2/18/81, effective 1/20/81]
[Filed 2/12/81, Notice 11/12/80—published 3/4/81, effective 7/1/81]
[Filed 3/24/81, Notice 2/4/81—published 4/15/81, effective 6/1/81]
[Filed emergency 6/30/81—published 7/22/81, effective 7/1/81]
[Filed emergency 8/24/81 after Notice 7/8/81—published 9/16/81, effective 9/1/81]
[Filed 10/23/81, Notice 9/2/81—published 11/11/81, effective 1/1/82]
[Filed emergency 12/3/81—published 12/23/81, effective 1/1/82]
[Filed 1/28/82, Notice 10/28/81—published 2/17/82, effective 4/1/82]
[Filed 1/28/82, Notice 11/25/81—published 2/17/82, effective 4/1/82]
[Filed 2/26/82, Notice 10/14/81—published 3/17/82, effective 5/1/82]
[Filed emergency 3/26/82—published 4/14/82, effective 4/1/82]
[Filed 4/5/82, Notice 1/20/82—published 4/28/82, effective 6/2/82]
[Filed 4/29/82, Notice 12/9/81—published 5/26/82, effective 7/1/82]
[Filed 7/30/82, Notices 3/3/82, 4/28/82—published 8/18/82, effective 10/1/82]
[Filed emergency 9/23/82 after Notice 6/23/82—published 10/13/82, effective 10/1/82]
[Filed 11/5/82, Notice 9/15/82—published 11/24/82, effective 1/1/83]
[Filed 2/25/83, Notice 1/5/83—published 3/16/83, effective 5/1/83]
[Filed 5/20/83, Notices 3/30/83, 4/13/83—published 6/8/83, effective 8/1/83]◊
[Filed emergency 6/17/83—published 7/6/83, effective 7/1/83]
[Filed emergency 7/29/83—published 8/17/83, effective 8/1/83]◊
[Filed 7/29/83, Notice 5/25/83—published 8/17/83, effective 10/1/83]
[Filed emergency 10/7/83—published 10/26/83, effective 11/1/83]
[Filed without Notice 10/7/83—published 10/26/83, effective 12/1/83]
[Filed 10/28/83, Notices 8/31/83, 9/14/83—published 11/23/83, effective 1/1/84]◊
[Filed emergency 11/18/83—published 12/7/83, effective 12/1/83]
[Filed 11/18/83, Notice 10/12/83—published 12/7/83, effective 2/1/84]
[Filed 5/4/84, Notice 3/14/84—published 5/23/84, effective 7/1/84]
[Filed emergency 6/15/84—published 7/4/84, effective 7/1/84]
[Filed 6/15/84, Notice 5/9/84—published 7/4/84, effective 9/1/84]
[Filed emergency 8/31/84—published 9/26/84, effective 10/1/84]
[Filed 11/1/84, Notice 9/12/84—published 11/21/84, effective 1/1/85]
[Filed 12/11/84, Notice 10/10/84—published 1/2/85, effective 3/1/85]
[Filed 1/21/85, Notice 10/24/84—published 2/13/85, effective 4/1/85]
[Filed 4/29/85, Notice 12/19/84—published 5/22/85, effective 7/1/85]
[Filed 4/29/85, Notice 2/27/85—published 5/22/85, effective 7/1/85]
[Filed 5/29/85, Notice 3/27/85—published 6/19/85, effective 8/1/85]
[Filed emergency 8/23/85—published 9/11/85, effective 9/1/85]
[Filed emergency 10/1/85—published 10/23/85, effective 11/1/85]
[Filed without Notice 10/1/85—published 10/23/85, effective 12/1/85]
[Filed emergency 10/18/85 after Notice 9/11/85—published 11/6/85, effective 11/1/85]
[Filed 11/15/85, Notice 9/25/85—published 12/4/85, effective 2/1/86]
[Filed emergency 12/2/85—published 12/18/85, effective 1/1/86]
[Filed 12/2/85, Notice 10/23/85—published 12/18/85, effective 2/1/86]
[Filed 1/22/86, Notice 12/4/85—published 2/12/86, effective 4/1/86]
[Filed 2/21/86, Notices 12/18/85, 1/1/86, 1/15/86—published 3/12/86, effective 5/1/86]
[Filed emergency 6/26/86—published 7/16/86, effective 7/1/86]
[Filed 9/26/86, Notice 8/13/86—published 10/22/86, effective 12/1/86]
[Filed emergency 12/22/86—published 1/14/87, effective 2/1/87]
[Filed 12/22/86, Notice 11/5/86—published 1/14/87, effective 3/1/87]
[Filed emergency 1/15/87—published 2/11/87, effective 1/15/87]
[Filed 3/3/87, Notices 12/17/86, 12/31/86, 1/14/87—published 3/25/87, effective 5/1/87]
[Filed 4/29/87, Notice 3/11/87—published 5/20/87, effective 7/1/87]
[Filed 5/29/87, Notices 4/8/87, 4/22/87—published 6/17/87, effective 8/1/87]
[Filed emergency 6/19/87—published 7/15/87, effective 7/1/87]
[Filed 6/19/87, Notice 5/6/87—published 7/15/87, effective 9/1/87]
[Filed 7/24/87, Notice 5/20/87—published 8/12/87, effective 10/1/87]
[Filed emergency 8/28/87—published 9/23/87, effective 9/1/87]
[Filed 8/28/87, Notices 6/17/87, 7/15/87—published 9/23/87, effective 11/1/87]
[Filed 9/24/87, Notice 8/12/87—published 10/21/87, effective 12/1/87]
[Filed 12/10/87, Notice 10/21/87—published 12/30/87, effective 3/1/881]
[Filed emergency 4/28/88 after Notice 3/23/88—published 5/18/88, effective 6/1/88]
[Filed emergency 6/9/88—published 6/29/88, effective 7/1/88]
[Filed 9/2/88, Notice 6/29/88—published 9/21/88, effective 11/1/88]
[Filed emergency 11/16/88 after Notice 10/5/88—published 12/14/88, effective 1/1/89]
[Filed emergency 11/23/88 after Notices 7/13/88, 9/21/88—published 12/14/88, effective 12/1/88, 1/1/89]
[Filed 12/8/88, Notice 10/19/88—published 12/28/88, effective 2/1/89]
[Filed 3/15/89, Notice 2/8/89—published 4/5/89, effective 6/1/89]
[Filed emergency 6/8/89 after Notice 2/22/89—published 6/28/89, effective 7/1/89]
[Filed emergency 6/9/89—published 6/28/89, effective 7/1/89]
[Filed 7/14/89, Notices 4/19/89, 5/31/89—published 8/9/89, effective 10/1/89]
[Filed 8/17/89, Notice 6/28/89—published 9/6/89, effective 11/1/89]
[Filed 9/15/89, Notice 8/9/89—published 10/4/89, effective 12/1/89]
[Filed 10/11/89, Notice 8/23/89—published 11/1/89, effective 1/1/90]
[Filed 11/16/89, Notice 8/23/89—published 12/13/89, effective 2/1/90]
[Filed emergency 12/15/89 after Notice 10/4/89—published 1/10/90, effective 1/1/90]
[Filed 1/17/90, Notice 8/23/89—published 2/7/90, effective 4/1/90]2
[Filed emergency 2/14/90—published 3/7/90, effective 2/14/90]
[Filed 3/16/90, Notices 11/15/89, 1/24/90, 2/7/90—published 4/4/90, effective 6/1/90]
[Filed 4/13/90, Notice 3/7/90—published 5/2/90, effective 7/1/90]
[Filed 4/13/90, Notice 11/29/89—published 5/2/90, effective 8/1/90]
[Filed emergency 6/20/90—published 7/11/90, effective 7/1/90]
[Filed 7/13/90, Notices 5/16/90, 5/30/90—published 8/8/90, effective 10/1/90]
[Filed 8/16/90, Notice 7/11/90—published 9/5/90, effective 11/1/90]
[Filed 9/28/90, Notices 7/11/90, 7/25/90, 8/8/90—published 10/17/90, effective 12/1/90]
[Filed 10/12/90, Notice 7/11/90—published 10/31/90, effective 1/1/91]
[Filed 10/12/90, Notice 8/8/90—published 10/31/90, effective 2/1/91]
[Filed 11/16/90, Notices 9/19/90, 10/3/90—published 12/12/90, effective 2/1/91]
[Filed 12/13/90, Notice 10/31/90—published 1/9/91, effective 3/1/91]
[Filed emergency 1/17/91—published 2/6/91, effective 2/1/91]
[Filed 1/17/91, Notices 11/14/90, 11/28/90—published 2/6/91, effective 4/1/913]
[Filed emergency 2/22/91—published 3/20/91, effective 3/1/91]
[Filed 3/14/91, Notice 2/6/91—published 4/3/91, effective 6/1/91]
[Filed 4/11/91, Notice 3/6/91—published 5/1/91, effective 7/1/91]
[Filed emergency 6/14/91—published 7/10/91, effective 7/1/91]
[Filed 6/14/91, Notice 3/20/91—published 7/10/91, effective 9/1/91]
[Filed 7/10/91, Notice 5/29/91—published 8/7/91, effective 10/1/91]
[Filed 9/18/91, Notices 7/10/91, 7/24/91—published 10/16/91, effective 12/1/91]
[Filed 12/11/91, Notice 10/16/91—published 1/8/92, effective 3/1/92]
[Filed 12/11/91, Notice 10/30/91—published 1/8/92, effective 3/1/92]
[Filed emergency 1/16/92 after Notice 11/27/91—published 2/5/92, effective 3/1/92]4
[Filed 2/13/92, Notice 1/8/92—published 3/4/92, effective 5/1/92]
[Filed emergency 4/15/92—published 5/13/92, effective 4/16/92]
[Filed emergency 6/12/92—published 7/8/92, effective 7/1/92]
[Filed 6/11/92, Notices 3/18/92, 4/29/92—published 7/8/92, effective 9/1/92]
[Filed emergency 7/17/92—published 8/5/92, effective 8/1/92]
[Filed 7/17/92, Notices 5/27/92—published 8/5/92, effective 10/1/92]◊
[Filed emergency 8/14/92—published 9/2/92, effective 9/1/92]
[Filed 8/14/92, Notices 6/24/92, 7/8/92, 8/5/92—published 9/2/92, effective 11/1/92]
[Filed emergency 9/11/92—published 9/30/92, effective 10/1/92]
[Filed 9/11/92, Notices 7/8/92, 8/5/92—published 9/30/92, effective 12/1/92]
[Filed 9/11/92, Notice 8/5/92—published 9/30/92, effective 1/1/93]
[Filed 10/15/92, Notices 8/19/92, 9/2/92—published 11/11/92, effective 1/1/93]
[Filed emergency 11/10/92—published 12/9/92, effective 11/10/92]
[Filed 11/10/92, Notice 9/30/92—published 12/9/92, effective 2/1/93]
[Filed 1/14/93, Notices 10/28/92, 11/25/92—published 2/3/93, effective 4/1/93]
[Filed emergency 4/15/93 after Notice 3/3/93—published 5/12/93, effective 5/1/93]
[Filed 4/15/93, Notice 3/3/93—published 5/12/93, effective 7/1/93]
[Filed emergency 5/14/93 after Notice 3/31/93—published 6/9/93, effective 6/1/93]
[Filed 5/14/93, Notice 3/31/93—published 6/9/93, effective 8/1/93]
[Filed emergency 6/11/93—published 7/7/93, effective 7/1/93]
[Filed emergency 7/13/93 after Notice 5/12/93—published 8/4/93, effective 8/1/93]
[Filed emergency 7/14/93—published 8/4/93, effective 8/1/93]
[Filed without Notice 8/12/93—published 9/1/93, effective 11/1/93]
[Filed 8/12/93, Notice 7/7/93—published 9/1/93, effective 11/1/93]
[Filed 9/17/93, Notice 8/4/93—published 10/13/93, effective 12/1/93]
[Filed 10/14/93, Notice 8/18/93—published 11/10/93, effective 1/1/94]
[Filed 11/12/93, Notice 9/15/93—published 12/8/93, effective 2/1/94]
[Filed emergency 12/16/93 after Notice 10/13/93—published 1/5/94, effective 1/1/94]
[Filed 12/16/93, Notice 9/1/93—published 1/5/94, effective 3/1/94]
[Filed 1/12/94, Notice 11/10/93—published 2/2/94, effective 4/1/94]
[Filed emergency 2/10/94 after Notice 12/22/93—published 3/2/94, effective 3/1/94]
[Filed 3/10/94, Notice 2/2/94—published 3/30/94, effective 6/1/94]
[Filed emergency 6/16/94—published 7/6/94, effective 7/1/94]
[Filed 8/12/94, Notice 6/22/94—published 8/31/94, effective 11/1/94]
[Filed 9/15/94, Notices 7/6/94, 8/3/94—published 10/12/94, effective 12/1/94]
[Filed 11/9/94, Notice 9/14/94—published 12/7/94, effective 2/1/95]
[Filed 12/15/94, Notices 10/12/94, 11/9/94—published 1/4/95, effective 3/5/95]
[Filed 5/11/95, Notices 3/29/95—published 6/7/95, effective 8/1/95]
[Filed 6/7/95, Notice 4/26/95—published 7/5/95, effective 9/1/95]
[Filed 6/14/95, Notice 5/10/95—published 7/5/95, effective 9/1/95]
[Filed 10/12/95, Notice 8/30/95—published 11/8/95, effective 1/1/96]
[Filed 11/16/95, Notices 8/2/95, 9/27/95◊—published 12/6/95, effective 2/1/96]
[Filed 12/12/95, Notice 10/25/95—published 1/3/96, effective 3/1/96]
[Filed 5/15/96, Notice 2/14/96—published 6/5/96, effective 8/1/96]
[Filed 6/13/96, Notice 4/24/96—published 7/3/96, effective 9/1/96]
[Filed 7/10/96, Notice 4/24/96—published 7/31/96, effective 10/1/96]
[Filed 8/15/96, Notice 7/3/96—published 9/11/96, effective 11/1/96]
[Filed 9/17/96, Notice 7/31/96—published 10/9/96, effective 12/1/96]
[Filed 1/15/97, Notice 12/4/96—published 2/12/97, effective 4/1/97]
[Filed 3/12/97, Notices 1/1/97, 1/29/97—published 4/9/97, effective 6/1/97]
[Filed 4/11/97, Notice 2/12/97—published 5/7/97, effective 7/1/97]
[Filed emergency 5/14/97 after Notice 3/12/97—published 6/4/97, effective 7/1/97]
[Filed emergency 6/12/97—published 7/2/97, effective 7/1/97]
[Filed 6/12/97, Notice 4/23/97—published 7/2/97, effective 9/1/97]
[Filed 7/9/97, Notice 5/21/97—published 7/30/97, effective 10/1/97]
[Filed 9/16/97, Notice 7/2/97—published 10/8/97, effective 12/1/97]
[Filed 11/12/97, Notice 9/10/97—published 12/3/97, effective 2/1/98]
[Filed 1/14/98, Notice 11/19/97—published 2/11/98, effective 4/1/98]
[Filed 4/8/98, Notices 2/11/98, 2/25/98—published 5/6/98, effective 7/1/98]
[Filed 5/13/98, Notice 3/25/98—published 6/3/98, effective 8/1/98]
[Filed emergency 6/10/98—published 7/1/98, effective 6/10/98]
[Filed without Notice 6/10/98—published 7/1/98, effective 8/15/98]
[Filed 8/12/98, Notice 7/1/98—published 9/9/98, effective 11/1/98]
[Filed 9/15/98, Notice 7/15/98—published 10/7/98, effective 12/1/98]
[Filed 10/14/98, Notice 7/1/98—published 11/4/98, effective 12/9/98]
[Filed 12/9/98, Notice 10/7/98—published 12/30/98, effective 3/1/99]
[Filed 1/13/99, Notice 11/4/98—published 2/10/99, effective 4/1/99]
[Filed 2/10/99, Notice 12/16/98—published 3/10/99, effective 5/1/99]
[Filed 3/10/99, Notice 1/27/99—published 4/7/99, effective 6/1/99]
[Filed emergency 6/10/99—published 6/30/99, effective 7/1/99]
[Filed 7/15/99, Notice 6/2/99—published 8/11/99, effective 10/1/99]
[Filed 8/12/99, Notice 6/30/99—published 9/8/99, effective 11/1/99]
[Filed 10/13/99, Notice 6/30/99—published 11/3/99, effective 1/1/00]
[Filed 4/12/00, Notice 2/23/00—published 5/3/00, effective 7/1/00]
[Filed emergency 6/8/00—published 6/28/00, effective 7/1/00]
[Filed 6/8/00, Notice 4/19/00—published 6/28/00, effective 8/2/00]
[Filed 6/8/00, Notices 1/26/00, 4/19/00—published 6/28/00, effective 9/1/00]
[Filed 8/9/00, Notices 6/14/00, 6/28/00—published 9/6/00, effective 11/1/00]
[Filed emergency 9/12/00 after Notice 7/26/00—published 10/4/00, effective 10/1/00]
[Filed 9/12/00, Notice 6/14/00—published 10/4/00, effective 12/1/00]
[Filed 10/11/00, Notice 4/19/00—published 11/1/00, effective 1/1/01]
[Filed emergency 12/14/00 after Notice 9/20/00—published 1/10/01, effective 1/1/01]
[Filed 12/14/00, Notice 11/1/00—published 1/10/01, effective 3/1/01]
[Filed 2/14/01, Notice 12/13/00—published 3/7/01, effective 5/1/01]
[Filed 5/9/01, Notice 3/21/01—published 5/30/01, effective 7/4/01]
[Filed 5/9/01, Notices 1/24/01, 3/7/01—published 5/30/01, effective 8/1/01]
[Filed emergency 6/13/01 after Notice 4/18/01—published 7/11/01, effective 7/1/01]
[Filed emergency 6/13/01—published 7/11/01, effective 7/1/01]◊
[Filed 6/13/01, Notice 4/18/01—published 7/11/01, effective 9/1/01]
[Filed 7/11/01, Notice 5/16/01—published 8/8/01, effective 10/1/01]
[Filed 11/14/01, Notices 9/19/01, 10/3/01—published 12/12/01, effective 2/1/02]
[Filed emergency 12/12/01 after Notice 10/17/01—published 1/9/02, effective 12/12/01]
[Filed 12/12/01, Notice 7/11/01—published 1/9/02, effective 3/1/02]
[Filed 12/12/01, Notice 10/17/01—published 1/9/02, effective 3/1/02]◊
[Filed emergency 1/9/02 after Notice 11/14/01—published 2/6/02, effective 2/1/02]◊
[Filed emergency 1/16/02—published 2/6/02, effective 2/1/025]
[Filed emergency 2/14/02—published 3/6/02, effective 3/1/02]
[Filed 3/13/02, Notice 1/9/02—published 4/3/02, effective 6/1/02]
[Filed 3/13/02, Notice 1/23/02—published 4/3/02, effective 6/1/02]
[Filed emergency 4/12/02—published 5/1/02, effective 4/12/02]
[Filed 4/10/02, Notice 1/9/02—published 5/1/02, effective 7/1/02]
[Filed 4/10/02, Notice 3/6/02—published 5/1/02, effective 7/1/02]
[Filed emergency 7/11/02—published 8/7/02, effective 7/11/02]
[Filed 7/15/02, Notice 5/1/02—published 8/7/02, effective 10/1/02]
[Filed emergency 8/15/02—published 9/4/02, effective 9/1/02]
[Filed 9/12/02, Notice 8/7/02—published 10/2/02, effective 12/1/02]
[Filed emergency 11/18/02—published 12/11/02, effective 12/1/02]
[Filed emergency 11/18/02—published 12/11/02, effective 12/15/02]6
[Filed 11/18/02, Notice 9/4/02—published 12/11/02, effective 2/1/03]
[Filed emergency 12/12/02 after Notice 10/16/02—published 1/8/03, effective 1/1/03]
[Filed 12/12/02, Notice 10/30/02—published 1/8/03, effective 3/1/03]
[Filed emergency 1/9/03—published 2/5/03, effective 2/1/03]◊
[Filed 2/13/03, Notice 11/27/02—published 3/5/03, effective 5/1/03]
[Filed 2/13/03, Notice 12/11/02—published 3/5/03, effective 5/1/03]
[Filed emergency 6/12/03—published 7/9/03, effective 7/1/03]◊
[Filed 9/22/03, Notice 7/9/03—published 10/15/03, effective 12/1/03]◊
[Filed emergency 11/19/03—published 12/10/03, effective 1/1/04]
[Filed 1/16/04, Notices 9/17/03, 10/29/03—published 2/4/04, effective 3/10/04]
[Filed 3/11/04, Notice 1/21/04—published 3/31/04, effective 6/1/04]
[Filed emergency 6/14/04 after Notice 4/28/04—published 7/7/04, effective 7/1/04]
[Filed 8/12/04, Notice 6/23/04—published 9/1/04, effective 11/1/04]◊
[Filed emergency 4/15/05—published 5/11/05, effective 5/1/05]
[Filed without Notice 5/4/05—published 5/25/05, effective 7/1/05]
[Filed 7/15/05, Notice 5/25/05—published 8/3/05, effective 10/1/05]
[Filed emergency 9/21/05—published 10/12/05, effective 10/1/05]
[Filed emergency 10/21/05—published 11/9/05, effective 11/1/05]
[Filed 10/21/05, Notices 5/11/05 and 7/6/05—published 11/9/05, effective 12/14/05]◊
[Filed 10/21/05, Notice 8/31/05—published 11/9/05, effective 1/1/06]
[Filed 1/12/06, Notice 11/9/05—published 2/1/06, effective 3/8/06]
[Filed 3/10/06, Notice 10/12/05—published 3/29/06, effective 5/3/06]
[Filed 4/17/06, Notice 2/15/06—published 5/10/06, effective 7/1/06]
[Filed 5/12/06, Notice 3/15/06—published 6/7/06, effective 8/1/06]
[Filed emergency 6/16/06—published 7/5/06, effective 7/1/06]
[Filed emergency 8/10/06 after Notice 3/15/06—published 8/30/06, effective 10/1/06]
[Filed emergency 9/14/06—published 10/11/06, effective 10/1/06]
[Filed 9/19/06, Notice 7/5/06—published 10/11/06, effective 11/16/06]
[Filed emergency 10/12/06 after Notice 8/30/06—published 11/8/06, effective 11/1/06]
[Filed 10/20/06, Notice 8/2/06—published 11/8/06, effective 1/1/07]
[Filed emergency 12/13/06—published 1/3/07, effective 1/1/07]
[Filed emergency 3/14/07 after Notice 1/3/07—published 4/11/07, effective 4/1/07]
[Filed emergency 3/14/07 after Notice 1/17/07—published 4/11/07, effective 4/1/07]
[Filed 3/14/07, Notice 10/11/06—published 4/11/07, effective 5/16/07]
[Filed emergency 7/12/07—published 8/1/07, effective 7/12/07]
[Filed emergency 7/12/07 after Notice 5/23/07—published 8/1/07, effective 8/1/07]
[Filed 7/12/07, Notice 5/23/07—published 8/1/07, effective 9/5/07]
[Filed without Notice 7/20/07—published 8/15/07, effective 10/1/07]
[Filed 8/9/07, Notice 6/20/07—published 8/29/07, effective 11/1/07]
[Filed emergency 9/12/07 after Notice 7/18/07—published 10/10/07, effective 10/1/07]
[Filed emergency 1/9/08 after Notice 10/10/07—published 1/30/08, effective 2/1/08]
[Filed 1/9/08, Notice 11/7/07—published 1/30/08, effective 4/1/08]
[Filed emergency 5/14/08 after Notice 3/26/08—published 6/4/08, effective 5/15/08]
[Filed emergency 5/14/08 after Notice 3/26/08—published 6/4/08, effective 6/1/08]
[Filed emergency 6/11/08 after Notice 3/12/08—published 7/2/08, effective 7/1/08]
[Filed emergency 6/12/08—published 7/2/08, effective 7/1/08]
[Filed 6/11/08, Notice 4/23/08—published 7/2/08, effective 9/1/08]
[Filed emergency 8/18/08—published 9/10/08, effective 9/1/08]
[Filed emergency 8/18/08 after Notice 7/2/08—published 9/10/08, effective 10/1/08]
[Filed 9/17/08, Notice 7/2/08—published 10/8/08, effective 11/12/08]
[Filed emergency 10/14/08 after Notice 7/16/08—published 11/5/08, effective 12/1/08]
[Filed 10/14/08, Notice 8/13/08—published 11/5/08, effective 1/1/09]
[Filed emergency 11/12/08 after Notice 9/10/08—published 12/3/08, effective 12/1/08]
[Filed 11/12/08, Notice 9/24/08—published 12/3/08, effective 2/1/09]
[Filed 12/11/08, Notice 9/10/08—published 1/14/09, effective 2/18/09]
[Filed 12/11/08, Notice 10/22/08—published 1/14/09, effective 3/1/09]
[Filed ARC 7548B (Notice ARC 7369B, IAB 11/19/08), IAB 2/11/09, effective 4/1/09]
[Filed Emergency After Notice ARC 7957B (Notice ARC 7631B, IAB 3/11/09; Amended Notice ARC 7732B, IAB 4/22/09), IAB 7/15/09, effective 7/1/09]7
[Filed Emergency After Notice ARC 8008B (Notice ARC 7771B, IAB 5/20/09), IAB 7/29/09, effective 8/1/09]
[Filed ARC 8097B (Notice ARC 7816B, IAB 6/3/09), IAB 9/9/09, effective 11/1/09]
[Filed ARC 8205B (Notice ARC 7827B, IAB 6/3/09), IAB 10/7/09, effective 11/11/09]
[Filed Emergency ARC 8344B, IAB 12/2/09, effective 12/1/09]
[Filed ARC 8504B (Notice ARC 8247B, IAB 10/21/09), IAB 2/10/10, effective 3/22/10]
[Filed Emergency After Notice ARC 8643B (Notice ARC 8345B, IAB 12/2/09), IAB 4/7/10, effective 3/11/10]
◊	Two or more ARCs
1	Effective date of 78.3 and 78.31 delayed 70 days by the Administrative Rules Review Committee at its January 1, 1988 meeting.
2	Effective date of 4/1/90 delayed 70 days by the Administrative Rules Review Committee at its March 12, 1990, meeting.
3	Effective date of 4/1/91 delayed until adjournment of the 1991 session of the General Assembly by the Administrative Rules Review Committee at its meeting held February 12, 1991.
4	Effective date of 3/1/92 delayed until adjournment of the 1992 General Assembly by the Administrative Rules Review Committee at its meeting held February 3, 1992.
5	At a special meeting held January 24, 2002, the Administrative Rules Review Committee voted to delay until adjournment of the 2002 Session of the General Assembly the effective date of amendments published in the February 6, 2002, Iowa Administrative Bulletin as ARC 1365B.
6	Effective date of 12/15/02 delayed 70 days by the Administrative Rules Review Committee at its December 10, 2002, meeting.
7	July 1, 2009, effective date of amendments to 78.27(2)“d” delayed 70 days by the Administrative Rules Review Committee at a special meeting held June 25, 2009.