CHAPTER 79
OTHER POLICIES RELATING TO PROVIDERS OF
MEDICAL AND REMEDIAL CARE
[Prior to 7/1/83, Social Services[770] Ch 79]
441—79.1(249A) Principles governing reimbursement of providers of medical and health services. The basis of payment for services rendered by providers of services participating in the medical assistance program is either a system based on the provider’s allowable costs of operation or a fee schedule. Generally, institutional types of providers such as hospitals and intermediate care facilities are reimbursed on a cost-related basis and practitioners such as physicians, dentists, optometrists, and similar providers are reimbursed on the basis of a fee schedule. Providers of service must accept reimbursement based upon the department’s methodology without making any additional charge to the recipient.
	79.1(1) Types of reimbursement.
	a. 	Prospective cost-related. Providers are reimbursed on the basis of a per diem rate calculated prospectively for each participating provider based on reasonable and proper costs of operation. The rate is determined by establishing a base year per diem rate to which an annual index is applied.
	b. 	Retrospective cost-related. Providers are reimbursed on the basis of a per diem rate calculated retrospectively for each participating provider based on reasonable and proper costs of operation with suitable retroactive adjustments based on submission of financial and statistical reports by the provider. The retroactive adjustment represents the difference between the amount received by the provider during the year for covered services and the amount determined in accordance with an accepted method of cost apportionment (generally the Medicare principles of apportionment) to be the actual cost of service rendered medical assistance recipients.
	c. 	Fee schedules. Fees for the various procedures involved are determined by the department with advice and consultation from the appropriate professional group. The fees are intended to reflect the amount of resources (time, training, experience) involved in each procedure. Individual adjustments will be made periodically to correct any inequity or to add new procedures or eliminate or modify others. If product cost is involved in addition to service, reimbursement is based either on a fixed fee, wholesale cost, or on actual acquisition cost of the product to the provider, or product cost is included as part of the fee schedule. Providers on fee schedules are reimbursed the lower of:
	(1)	The actual charge made by the provider of service.
	(2)	The maximum allowance under the fee schedule for the item of service in question.
Payment levels for fee schedule providers of service will be increased on an annual basis by an economic index reflecting overall inflation as well as inflation in office practice expenses of the particular provider category involved to the extent data is available. Annual increases will be made beginning July 1, 1988.
There are some variations in this methodology which are applicable to certain providers. These are set forth below in subrules 79.1(3) to 79.1(9) and 79.1(15).
Copies of fee schedules in effect for the providers covered by fee schedules can be obtained by contacting the department’s fiscal agent at the following address: Consultec, Inc., P.O. Box 14422, Des Moines, Iowa 50306-3422.
	1d. 	Monthly fee for service. Providers are reimbursed on the basis of a payment for a month’s provision of service for each client enrolled in a case management program for any portion of the month based on reasonable and proper costs for service provision. The fee will be determined by the department with advice and consultation from the appropriate professional group and will reflect the amount of resources involved in services provision.
	79.1(2) Basis of reimbursement of specific provider categories

Provider category	Basis of
reimbursement	Upper limit	
Ambulance	Fee schedule	Ground ambulance:
Fee schedule in effect 6/30/90 plus 2%.
Air ambulance: A base rate of $200 plus $7.50
per mile for each mile
the patient is carried.	
Ambulatory surgical centers	Base rate fee schedule
as determined by Medicare. See 79.1(3)	Rate determined
by Medicare	
Area education agencies	Fee schedule	Fee schedule in effect 6/30/90 plus 2%	
Audiologists	Fee schedule	Fee schedule in effect 6/30/90 plus 2%	
Birth centers	Fee schedule	Fee schedule in effect 6/30/90 plus 7.44% for
obstetrical service	
Case management providers	Retrospective cost-related	Retrospective rate	
Certified registered
nurse anesthetists	Fee schedule	Fee schedule in effect 6/30/90 plus 1.6%	
Chiropractors	Fee schedule	Fee schedule in effect 6/30/90 plus 2%	
Clinics	Fee schedule	Fees as determined
by the physician
fee schedule	
Community mental health
centers	Fee schedule	Reimbursement rate
for center in effect
6/30/90 plus 2%	
Dentists	Fee schedule	Fee schedule in effect 6/30/90 plus 2%	
Durable medical equipment,
prosthetic devices and
medical supply dealers	Fee schedule
See 79.1(4)	Fee schedule in effect 6/30/90 plus up to 6.4%*	
Family planning clinics	Fee schedule	Fees as determined by the physician fee schedule	
Provider category	Basis of
reimbursement	Upper limit	
Family or pediatric nurse
practitioner	Fee schedule	Fee schedule in effect 6/30/94 with the exception that screening services are
fee schedule in effect 6/30/94 plus 5%	
Federally qualified health
centers	Retrospective cost-related	Reasonable cost as
determined by Medicare cost reimbursement
principles	
Genetic consultation clinics	Fee schedule	Reimbursement rate for clinic in effect 6/30/90 plus 2%	
HCBS AIDS/HIV waiver
service providers, including:
1. Counseling
Individual:
Group:	Fee schedule
Fee schedule	$9.80 per unit
$39.20 per hour	
2. Home health aide	Agency’s financial and
statistical cost report and Medicare percentage
rate per visit	Cannot exceed Medicare percentage rate per visit	
3. Homemaker	Fee schedule	$18 per hour	
4. Nursing care	Agency’s financial and
statistical cost report
and Medicare percentage
rate per visit	Cannot exceed $72.80
per visit	

Provider category	Basis of
reimbursement	Upper limit	
5. Respite care providers,
including:
In-home:
Home health agency
Out-of-home:
Nursing facility, or
intermediate care facility
for the mentally retarded	Fee schedule
Prospective reimbursement	$104 per 4- to 8-hour unit
Limit for nursing facility level of care	
Hospital or skilled nursing
facility
Foster group care
Foster family home
Camps	Prospective reimbursement
Prospective reimbursement
Fee schedule
Fee schedule	Limit for skilled nursing facility level of care
P.O.S. contract rate
Emergency care rate
(See 156.11(2))
$115 per day	
Hourly rate providers
Adult day care
HCBS MR waiver
Home care agency
Home health agency
Day camp	Fee schedule
Fee schedule
See 79.1(15)
Fee schedule
Fee schedule
Fee schedule	$12 per hour
$12 per hour
$12 per hour
$12 per hour
$12 per hour	
6. Home-delivered meal
providers	Fee schedule	$7 per meal. Maximum of 14 meals per week	
7. Adult day care	Prospective reimbursement for P.O.S. providers. Fee schedule for others.	P.O.S. contract rate or
veterans administration contract rate or $20 per half day, $40 per full day, or $60 per extended day if no P.O.S. or veterans
administration contract.	
8. Consumer-directed
attendant care:
Agency provider
Individual provider	Fee agreed upon by
consumer and provider
Fee agreed upon by
consumer and provider	$18 per hour
$104 per day
$12 per hour
$70 per day	

Provider category	Basis of
reimbursement	Upper limit	
HCBS brain injury waiver
service providers, including:	 	 	
1. Supported community
living	Fee schedule determined
per day per month.
See 79.1(17)	$72.17 per day. Variance may be granted when
cost-effective and in
accordance with the ICP.	
 	Fee schedule determined
per hour. See 79.1(17)	$32 per hour.	
2. Respite	Fee schedule	$12 per hour	
3. Personal emergency
response system	Fee schedule	Initial one-time fee of $45.
Ongoing monthly fee
of $35.	
4. Case management	Fee schedule	$571.49 per month	
5. Supported employment:
a. Instructional activities
to obtain a job	Fee schedule
See 79.1(17)	$34.02 per day	
b. Initial instructional
activities on the job	Fee schedule
See 79.1(17)	$15.46 per hour	
c. Enclave	Fee schedule
See 79.1(17)	$5.67 per hour	
d. Follow-along	Fee schedule
See 79.1(17)	$257.75 per month	
6. Transportation	Fee schedule	State per mile rate	
7. Adult day care	Fee schedule	$20 per half day,
$40 per full day, or
$60 per extended day	
8. Consumer-directed
attendant care:
Agency provider
Individual provider	Fee agreed upon by
consumer and provider
Fee agreed upon by
consumer and provider	$18 per hour
$104 per day
$12 per hour
$70 per day	
9. Home and vehicle
modification	Fee schedule	$500 per month, not to
exceed $6,000 per year	
10. Specialized medical
equipment	Fee schedule	$500 per month, not to
exceed $6,000 per year	
11. Behavioral programming	Fee schedule	$9.80 per 15 minutes	
12. Family counseling and
training	Fee schedule	$39.20 per hour	
13. Prevocational services	Fee schedule.
See 79.1(17)	$34.02 per day	

Provider category	Basis of
reimbursement	Upper limit	
HCBS elderly waiver service
providers, including:	 	 	
1. Adult day care	Prospective reimbursement
for P.O.S. providers. Fee
schedule for others.	P.O.S. contract rate or
veterans administration contract rate or $20 per half day, $40 per full day,
or $60 per extended day if no P.O.S. contract.	
2. Emergency response system	Fee schedule	Initial one-time fee $45.
Ongoing monthly fee $35.	
3. Home health aides	Retrospective cost-related	Maximum Medicare rate	
4. Homemakers	Fee schedule	Maximum of $18 per hour	
5. Nursing care	Fee schedule as determined
by Medicare	$72.80 per visit	
6. Respite care providers,
including:
In-home:
Home health agency	Fee schedule	$104 per 4- to 8-hour unit	
Out-of-home:
Nursing facility	Prospective reimbursement	Limit for nursing
facility level of care	
Hospital or skilled
nursing facility	Prospective reimbursement	Limit for skilled nursing facility level of care	
Hourly rate providers
Adult day care
Day camp
Home care agency
Home health agency
HCBS MR waiver	Fee schedule
Fee schedule
Fee schedule
Fee schedule
Fee schedule
See 79.1(15)	$12 per hour
$12 per hour
$12 per hour
$12 per hour
$12 per hour	
7. Chore providers	Fee schedule	$7 per half hour	
8. Home delivered meal
providers	Fee schedule	$7 per meal. Maximum
of 14 meals per week.	
9. Home and vehicle
modification providers	Fee schedule	$1000 lifetime maximum	
10. Mental health outreach
providers	Fee schedule	On-site Medicaid
reimbursement rate
for center or provider.
Maximum of 1440
units per year	

Provider category	Basis of
reimbursement	Upper limit	
11. Transportation providers	Fee schedule	State per mile rate for
regional transit providers, or P.O.S. rate for P.O.S.
providers, or rate
established by area agency on aging. Reimbursement will be at the lowest cost
service rate consistent
with the consumer’s needs.	
12. Nutritional counseling	Fee schedule	$7.50 per quarter hour	
13. Assistive devices	Fee schedule	$100 per unit	
14. Senior companion	Fee schedule	$6 per hour	
15. Consumer-directed
attendant care:
Agency provider
Individual provider	Fee agreed upon by
consumer and provider
Fee agreed upon by
consumer and provider	$18 per hour
$104 per day
$12 per hour
$70 per day	

HCBS ill and handicapped waiver
service providers, including:	 	 	
1. Homemakers	Fee schedule	$18 per hour	
2. Home health aides	Agency’s financial and
statistical cost report and
Medicare percentage rate
per visit	Cannot exceed Medicare percentage rate per visit	
3. Adult day care	Prospective reimbursement
for P.O.S. providers.
Fee schedule for others.	P.O.S. contract rate or
veterans administration
contract rate or $20 per half day, $40 per full day, or $60 per extended day if no P.O.S. or veterans
administration contract.	

Provider category	Basis of
reimbursement	Upper limit	
4. Respite care providers,
including:	 	 	
In-home:
Home health agency	Fee schedule	$104 per 4- to 8-hour unit	
Out-of-home:
Hospital or skilled
nursing facility	Prospective reimbursement	Limit for skilled nursing facility level of care	
Nursing facility, or
intermediate care facility
for the mentally retarded	Prospective reimbursement	Limit for nursing
facility level of care	
Foster group care	Prospective reimbursement	P.O.S. contract rate	
Foster family home	Fee schedule	Emergency care rate
(See 156.11(2))	
Camps	Fee schedule	$115 per day	
Hourly rate provider
Adult day care
HCBS MR waiver
Home care agency
Home health agency
Day camp	Fee schedule
Fee schedule
Fee schedule
Fee schedule
Fee schedule	$12 per hour
$12 per hour
$12 per hour
$12 per hour
$12 per hour	
5. Nursing	Agency’s financial and
statistical cost report and
Medicare percentage
rate per visit	Cannot exceed
$72.80 per visit	
6. Counseling
Individual:
Group:	Fee schedule
Fee schedule	$9.80 per unit
$39.20 per hour	
7. Consumer-directed
attendant care:
Agency provider
Individual provider	Fee agreed upon by
consumer and provider
Fee agreed upon by
consumer and provider	$18 per hour
$104 per day
$12 per hour
$70 per day	

Provider category	Basis of
reimbursement	Upper limit	
HCBS MR waiver service
providers, including:	 	 	
1. Supported community
living	Prospective cost-related
reimbursement determined
per day per month.
See 79.1(15)	$72.17 per day. Variations may be granted by the
division of medical
services when cost-
effective and in
accordance with the ICP or service plan as long as the state-wide average remains
at or below $72.17 per day.	
 	Prospective cost-related
reimbursement determined
per hour.
See 79.1(15)	$32 per hour not to exceed a total per month of $72.17 times the number of days
in the month.
Variations may be granted by the division of medical
services when cost-
effective and in
accordance with the ICP or service plan as long as the
statewide average remains at or below $72.17 per day.	
2. Respite	Prospective cost-related
reimbursement.
See 79.1(15)	$12 per hour.
Limit 576 units per
year, 336 per month.	
3. Supported employment
a. Instructional activities to
obtain a job	Fee schedule
See 79.1(15)	$34.02 per day.
Maximum of 80 units,
5 per week, limit 16 weeks	
b. Initial instructional activities
on job	Prospective cost-related
reimbursement.
See 79.1(15)	$15.46 per hour.
Maximum of 40 units
per week, limit 16
weeks, 640 units	
c. Enclave	Prospective cost-related
reimbursement.
See 79.1(15)	$5.67 per hour.
Maximum of 40 units
per week	
d. Follow-along	Fee schedule
See 79.1(15)	$257.75 per month.
Maximum of 12 units per fiscal year or $8.45 per day for a partial month	

Provider category	Basis of
reimbursement	Upper limit	
4. Nursing	Fee schedule as determined
by Medicare	Maximum Medicare rate	
5. Home health aide	Retrospective cost-related	Maximum Medicare rate	
6. Personal emergency
response system	Fee schedule	Initial one-time fee
of $37.40.
Ongoing monthly
fee of $25.50	
7. Home and vehicle
modifications	Fee schedule
See 79.1(15)	Maximum amount of $5,000 per consumer through 2/28/95	
8. Consumer-directed
attendant care:
Agency provider
Individual provider	Fee agreed upon by
consumer and provider
Fee agreed upon by
consumer and provider	$18 per hour
$104 per day
$12 per hour
$70 per day	
Hearing aid dealers	Fee schedule plus product
acquisition cost	Reimbursement rate for provider in effect 6/30/90 plus 2% plus up to 3.2% for materials*	
Home health agencies
(Encounter services-
intermittent services)	Retrospective cost-related	Maximum Medicare rate	
(Private duty nursing or
personal care and VCF
vaccine administration for
persons aged 20 and under)	Interim fee schedule with
retrospective cost settling
based on Medicare
methodology	Retrospective cost settling according to Medicare
methodology	
Hospices	Fee schedule as determined
by Medicare	Medicare cap
(See 79.1(14)“d”)	

Provider category	Basis of
reimbursement	Upper limit	
Hospitals (Inpatient)	Prospective reimbursement.
See 79.1(5)	Reimbursement rate in
effect 6/30/97 increased
by 2.8%	
Hospitals (Outpatient)	Prospective reimbursement
for providers listed at
78.31(1)“a” to “f.”
See 79.1(16)	Ambulatory patient group rate (plus an evaluation rate) in effect on 6/30/97
increased by 2.8%	
 	Fee schedule for providers
listed at 78.31(1)“g” to “n.”
See 79.1(16)	Rates in effect on 6/30/97 increased by 2.8%	
Independent laboratories	Fee schedule
See 79.1(6)	Fee schedule in effect 6/30/90 plus 2%	
Intermediate care facilities
for the mentally retarded	Prospective reimbursement.
See 441—82.5(249A)	Eightieth percentile of
facility costs as calculated from 12/31/93 cost reports	
Lead inspection agency	Fee schedule	Fee schedule	
Maternal health centers	Reasonable cost per
procedure on a prospective
basis as determined by the
department based on
financial and statistical
data submitted annually
by the provider group	Reasonable cost in effect 6/30/91 as determined by the department	
Nurse-midwives	Fee schedule	Fee schedule in effect 6/30/95 plus 5%	
Nursing facilities:
1. Nursing facility care	Prospective reimbursement.
See 81.10(1) and
441—81.6(249A)	Seventieth percentile
of facility costs as
calculated from
6/30/97 cost reports	
2. Skilled nursing care providers,
including:
Hospital-based facilities	Prospective reimbursement.
See 79.1(9)	Facility base rate per diems used on 6/30/97
inflated by 3.3% subject to maximum payment rate at the sixtieth percentile
of costs of all hospital-
based skilled facilities	
Freestanding facilities	Prospective reimbursement.
See 79.1(9)	Facility base rate per diems used on 6/30/97
inflated by 3.3% subject to maximum payment rate at the sixty-ninth percentile
of costs of all freestanding skilled facilities	
Provider category	Basis of
reimbursement	Upper limit	
Opticians	Fee schedule. Fixed fee
for lenses and frames;
other optical materials at product acquisition cost	Reimbursement rate for provider in effect 6/30/90 for professional services plus 2% plus up to 3.2%
for optometric products2	
Optometrists	Fee schedule. Fixed fee
for lenses and frames;
other optical materials at product acquisition cost	Reimbursement rate for provider in effect 6/30/90 for professional services plus 2% plus up to 3.2%
for optometric products2	
Orthopedic shoe dealers	Fee schedule	Reimbursement rate for provider in effect 6/30/90 plus 2% plus up to 3.2% for materials2	
Physical therapists	Fee schedule	Fee schedule in effect
6/30/90 plus 2%	
Physicians (doctors of medicine
or osteopathy)	Fee schedule.
See 79.1(7)	Fee schedule in effect
6/30/90 plus 1.6% with the exception of obstetrical services as defined by the department and pediatric
primary care services as defined by the department.
Pediatric services will
receive a 10% increase over the fee schedule in
effect on 6/30/92.
Obstetrical services will receive a 5% increase over the rates in effect 6/30/95.
EPSDT screening services will receive a 5% increase over the rates in effect
6/30/94. The department may revise the fee
schedule.	
Podiatrists	Fee schedule	Fee schedule in effect
6/30/90 plus 2%	
Prescribed drugs	See 79.1(8)	$4.02 or $6.25
dispensing fee
(See 79.1(8)“a” and “d”)	

Provider category	Basis of
reimbursement	Upper limit	
Psychiatric medical institutions
for children
(Inpatient)	Prospective reimbursement	Reimbursement rate for provider in effect 6/30/97 plus 3% to a maximum of $131.12 per day	
(Outpatient day treatment)	Fee schedule	Fee schedule in effect
6/01/93	
Psychologists	Fee schedule	Reimbursement rate
for provider in effect
6/30/90 plus 2%	
Rehabilitation agencies	Retrospective cost-related	Reimbursement rate
for agency in effect
6/30/90 plus 2%	
Rehabilitative treatment services	Reasonable and necessary
costs per unit of service
based on data included on
the Rehabilitative Treatment
and Supportive Services
Financial and Statistical
Report, Form 470-3049.
See 441—185.101(234) to
441—185.107(234). A
provider who is an individual
may choose between the
fee schedule in effect
November 1, 1993
(See 441—subrule 185.103(7)) and reasonable and necessary costs.	No cap	
Rural health clinics	Retrospective cost-related	Medicare upper limits	
Screening centers	Fee schedule	Reimbursement rate
for center in effect
6/30/94 plus 5%	
State operated institutions	Retrospective cost-related	 	
	79.1(3) Ambulatory surgical centers. Payment is made for facility services on a fee schedule which is determined by Medicare. These fees are grouped into eight categories corresponding to the difficulty or complexity of the surgical procedure involved. Procedures not classified by Medicare shall be included in the category with comparable procedures.
Services of the physician are reimbursed on the basis of a fee schedule (see subrule 79.1(1)“c”). This payment is made directly to the physician.
	79.1(4) Durable medical equipment, prosthetic devices, medical supply dealers. Fees for durable medical appliances, prosthetic devices and medical supplies are developed from several pricing sources and are based on pricing appropriate to the date of service; prices are developed using prior calendar year price information. The average wholesale price from all available sources is averaged to determine the fee for each item. Payment for used equipment will be no more than 80 percent of the purchase allowance. For supplies, equipment, and servicing of standard wheelchairs, standard hospital beds, enteral nutrients, and enteral and parenteral supplies and equipment, the fee for payment shall be the lowest price for which the devices are widely and consistently available in a locality.
	79.1(5) Reimbursement for hospitals.
	a. 	Definitions.
“Adolescent” shall mean a Medicaid patient 17 years or younger.
“Adult” shall mean a Medicaid patient 18 years or older.
“Average daily rate” shall mean the hospital’s final payment rate multiplied by the DRG weight and divided by the statewide average length of stay for a DRG.
“Base year cost report” shall mean the hospital’s cost report with fiscal-year-end on or after January 1, 1995, and prior to January 1, 1996, except as noted in 79.1(5)“x.” Cost reports shall be reviewed using Medicare’s cost reporting regulations for cost reporting periods ending on or after January 1, 1995, and prior to January 1, 1996.
“Blended base amount” shall mean the case-mix adjusted, hospital-specific operating cost per discharge associated with treating Medicaid patients, plus the statewide average case-mix adjusted operating cost per Medicaid discharge, divided by two. This base amount is the value to which add-on payments for inflation, capital costs, direct medical education costs, and costs associated with treating a disproportionate share of poor patients and indirect medical education are added to form a final payment rate.
“Capital costs” shall mean an add-on to the blended base amount which shall compensate for Medicaid’s portion of capital costs. Capital costs for buildings, fixtures and movable equipment are defined in the hospital’s base year cost report, are case-mix adjusted, are adjusted to reflect 80 percent of allowable costs, and are adjusted to be no greater than one standard deviation off the mean Medicaid blended capital rate.
“Case-mix adjusted” shall mean the division of the hospital-specific base amount or other applicable components of the final payment rate by the hospital-specific case-mix index.
“Case-mix index” shall mean an arithmetical index measuring the relative average costliness of cases treated in a hospital compared to the statewide average.
“Cost outlier” shall mean cases which have an extraordinarily high cost as established in 79.1(5)“f,” so as to be eligible for additional payments above and beyond the initial DRG payment.
“Diagnosis-related group (DRG)” shall mean a group of similar diagnoses combined based on patient age, procedure coding, comorbidity, and complications.
“Direct medical education costs” shall mean an add-on to the blended base amount which shall compensate for costs associated with direct medical education. Costs associated with direct medical education are determined from the hospital base year cost reports, and are inflated and case-mix adjusted. On or after July 1, 1997, the direct medical education payment shall be directly reimbursed from the graduate medical education and disproportionate share fund and shall not be added to the reimbursement for claims with discharge dates on or after July 1, 1997.
“Disproportionate share payment” shall mean an add-on to the blended base amount which shall compensate for treatment of a disproportionate share of poor patients. On or after July 1, 1997, the disproportionate share payment shall be directly reimbursed from the graduate medical education and disproportionate share fund and shall not be added to the reimbursement for claims with discharge dates on or after July 1, 1997.
“DRG weight” shall mean a number that reflects relative resource consumption as measured by the relative charges by hospitals for cases associated with each DRG. That is, the Iowa-specific DRG weight reflects the relative charge for treating cases classified in a particular DRG compared to the average charge for treating all Medicaid cases in all DRGs in Iowa hospitals.
“Final payment rate” shall mean the aggregate sum of the five components (the blended base amount, capital costs, direct medical education, disproportionate share and indirect medical education) that, when added together, form the final dollar value used to calculate each provider’s reimbursement amount when multiplied by the DRG weight. These dollar values are displayed on the rate table listing. On or after July 1, 1997, the direct and indirect medical education costs and the disproportionate share costs shall be directly reimbursed through the graduate medical education and disproportionate share fund and shall not be included in the final payment rate or displayed in the rate table listing.
“Full DRG transfer” shall mean that a case, coded as a transfer to another hospital, shall be considered to be a normal claim for recalibration or rebasing purposes if payment is equal to or greater than the full DRG payment.
“Graduate medical education and disproportionate share fund” shall mean a reimbursement fund developed as an adjunct reimbursement methodology to directly reimburse qualifying hospitals for the direct and indirect costs associated with the operation of graduate medical education programs and the costs associated with the treatment of a disproportionate share of poor, indigent, nonreimbursed or lowly reimbursed patients for inpatient services.
“Indirect medical education” shall mean costs that are not directly associated with running a medical education program, but that are incurred by the facility because of that program. Types of these costs would be costs of maintaining a more extensive library to serve educational needs.
“Inlier” shall mean those cases where the length of stay or cost of treatment falls within the actual calculated length of stay criteria, or the cost of treating a patient is within the cost boundaries of a DRG payment.
“Long stay outlier” shall mean cases which have an associated length of stay that is greater than the calculated length of stay parameters as defined within the length of stay calculations for that DRG. Payment is as established in 79.1(5)“f.”
“Medicaid-certified unit” shall mean a hospital-based substance abuse, psychiatric, neonatal, or physical rehabilitation unit that is certified for operation by the Iowa department of inspections and appeals on or after October 1, 1987, and is certified for reimbursement according to procedures contained in 79.1(5)“r” by the Iowa Medicaid fiscal agent.
These units may be certified for operation by the Iowa department of inspections and appeals, acting on behalf of the state of Iowa, or Medicare. Neonatal units may be certified using standards adopted by the Iowa department of public health and set forth by the American Academy of Pediatricians in “Recommendations Based on Standards for Hospital Care of the Newborn Infant.”
“Neonatal intensive care unit” shall mean a designated level II or level III neonatal unit.
“Peer review organization (PRO)” shall mean the organization that performs medical peer review of Medicaid claims, including review of validity of hospital diagnosis and procedure coding information; completeness, adequacy and quality of care; appropriateness of admission, discharge and transfer; and appropriateness of prospective payment outlier cases.
“Rate table listing” shall mean a schedule of rate payments for each provider. The rate table listing is defined as the output that shows the final payment rate by hospital before being multiplied by the appropriate DRG weight.
“Rebasing” shall mean the redetermination of the blended base amount or other applicable components of the final payment rate from more recent Medicaid cost report data.
“Recalibration” shall mean the adjustment of all DRG weights to reflect changes in relative resource consumption.
“Short stay day outlier” shall mean cases which have an associated length of stay that is less than the calculated length of stay parameters as defined within the length of stay calculations. Payment rates are established in 79.1(5)“f.”
“Transfer” shall mean the movement of a patient from a bed in a non-Medicaid-certified unit of a hospital to a bed in a non-Medicaid-certified unit of another hospital.
	b. 	Determination of final payment rate amount. The hospital DRG final payment amount reflects the sum of inflation adjustments to the blended base amount plus add-ons for capital costs, medical education costs, disproportionate share payment, and indirect medical education. This blended base amount plus add-ons is multiplied by the set of Iowa-specific DRG weights to establish a rate schedule for each hospital. For payments made to providers for claims with dates of discharge on or after July 1, 1997, the final payment rate shall not contain the add-on amounts for direct or indirect medical education or for disproportionate share payments. Federal DRG definitions are adopted except as provided below:
	(1)	Medicaid-certified substance abuse units. Three sets of DRG weights are developed for DRGs concerning rehabilitation of substance abuse patients. The first set of weights is developed from charges associated with treating adults in Medicaid-certified substance abuse units. The second set of weights reflects charges associated with treating adolescents in mixed-age Medicaid-certified substance abuse units. The third set of weights reflects charges associated with treating adolescents in designated adolescent-only Medicaid-certified substance abuse units. Hospitals with these units are reimbursed using the weight that reflects the age of each patient.
	(2)	Neonatal intensive care units. Three sets of weights are developed for DRGs concerning treatment of neonates. One set of weights is developed from charges associated with treating neonates in a designated level III neonatal intensive care unit for some portion of their hospitalization. The second set of weights is developed from charges associated with treating neonates in a designated level II neonatal intensive care unit for some portion of their hospitalization. The third set of weights reflects charges associated with neonates not treated in a designated level II or level III setting. Hospitals are reimbursed using the weight that reflects the setting for neonate treatment.
	(3)	Medicaid-certified psychiatric units. Four sets of DRG weights are developed for DRGs concerning psychiatric treatment. The first set of weights reflects charges associated with the treatment of adult psychiatric patients in Medicaid-certified psychiatric units. The second set of weights reflects charges associated with the treatment of adolescent patients in mixed-age Medicaid-certified psychiatric units. The third set of weights reflects charges associated with the treatment of adolescent patients in designated adolescent-only Medicaid-certified psychiatric units. The fourth set of weights reflects charges associated with the treatment of psychiatric patients in hospitals without Medicaid-certified psychiatric units. Hospitals are reimbursed using the weight that reflects the patient’s age and the setting for psychiatric treatment.
	c. 	Calculation of Iowa-specific weights and case-mix index. Using all applicable claims for the period January 1, 1994, through December 31, 1995, and paid through April 26, 1996, the recalibration will use all normal inlier claims, discard short stay outliers, discard transfers where the final payment is less than the full DRG payment and including transfers where the full payment is greater than or equal to the full DRG payment, and use only the estimated charge for the inlier portion of long stay outliers and cost outliers for weighting calculations. These are referred to as trimmed claims.
	(1)	Iowa-specific weights are calculated from Medicaid charge data on discharge dates occurring from January 1, 1994, to December 31, 1995, and paid through April 26, 1996. One weight is determined for each DRG with noted exceptions. Weights are determined through the following calculations:
	1.	Determine the statewide geometric mean charge for all cases classified in each DRG.
	2.	Compute the statewide aggregate geometric mean charge for each DRG by multiplying the statewide geometric mean charge for each DRG by the total number of cases classified in that DRG.
	3.	Sum the statewide aggregate geometric mean charges for all DRGs and divide by the total number of cases for all DRGs to determine the weighted average charge for all DRGs.
	4.	Divide the statewide geometric mean charge for each DRG by the weighted average charge for all DRGs to derive the Iowa-specific weight for each DRG.
	5.	Normalize the weights so that the average case has a weight of one.
	(2)	The hospital-specific case-mix index is computed by taking each hospital’s trimmed claims that match the hospital’s 1995 fiscal year and paid through April 26, 1996, summing the assigned DRG weights associated with those claims and dividing by the total number of Medicaid claims associated with that specific hospital for that period.
	d. 	Calculation of blended base amount. The DRG blended base amount reflects a 50/50 blend of statewide and hospital-specific base amounts.
	(1)	Calculation of statewide average case-mix adjusted cost per discharge. The statewide average cost per discharge is calculated by subtracting from the statewide total Iowa Medicaid inpatient expenditures the total calculated dollar expenditures based on hospitals’ base year cost reports for capital costs, medical education costs, and calculation of actual payments that will be made for additional transfers, outliers, physical rehabilitation services, and indirect medical education. The remaining amount (which has been case-mix adjusted and adjusted to reflect inflation if applicable) is divided by the statewide total number of Iowa Medicaid discharges reported in the Medicaid management information system (MMIS) less an actual number of nonfull DRG transfers and short stay outliers.
	(2)	Calculation of hospital-specific case-mix adjusted average cost per discharge. The hospital-specific case-mix adjusted average cost per discharge is calculated by subtracting from the lesser of total Iowa Medicaid costs, or covered reasonable charges as determined by the hospital’s base year cost report or MMIS claims system, the actual dollar expenditures for capital costs, direct medical education costs, the payments that will be made for nonfull DRG transfers, outliers, and physical rehabilitation services if included. The remaining amount is case-mix adjusted, adjusted to reflect inflation, and divided by the total number of Iowa Medicaid discharges from the MMIS claims system or cost report, whichever is greater, for that hospital during the applicable base year, less the nonfull DRG transfers and short stay outliers.
	(3)	Calculation of the blended statewide and hospital-specific base amount. The hospital-specific case-mix adjusted average cost per discharge is added to the case-mix adjusted statewide average cost per discharge and divided by two to arrive at a 50/50 blended base amount.
	e. 	Add-ons to the base amount. Four payments are added on to the blended base amount.
	(1)	Capital costs. Capital costs are included in the rate table listing and added to the blended base amount prior to setting the final payment rate schedule. This add-on reflects a 50/50 blend of the statewide average case-mix adjusted capital cost per discharge and the case-mix adjusted hospital-specific base year capital cost per discharge attributed to Iowa Medicaid patients. Allowable capital costs are determined by multiplying the capital amount from the base year cost report by 80 percent. The 50/50 blend is calculated by adding the case-mix adjusted hospital-specific per discharge capital cost to the statewide average case-mix adjusted per discharge capital costs and dividing by two. Hospitals whose blended capital add-on exceeds one standard deviation off the mean Medicaid blended capital rate will be subject to a reduction in their capital add-on to equal the greatest amount of the first standard deviation.
	(2)	Direct medical education costs. Direct medical education costs are included in the rate table listing if applicable to the provider, and added to the blended base amount plus other add-ons prior to setting the final payment rate if the date of the patient’s discharge is prior to July 1, 1997. The amount added on reflects Iowa Medicaid’s average cost per discharge for hospital-specific direct medical education adjusted for case-mix. This add-on is determined from the base year cost report and is adjusted to reflect inflation. If the date of discharge is on or after July 1, 1997, the costs for direct medical education are reimbursed according to policy at paragraph “y” from the graduate medical education and disproportionate share fund.
	(3)	Disproportionate share adjustment. Two separate and distinct groups are identified for the calculation of routine or supplemental disproportionate share payments. The first group eligible for routine disproportionate share payments includes all hospitals which qualify under the following rules without regard to the facility’s status as a teaching facility or bed size. The second group eligible for supplemental disproportionate share payments includes all in-state hospitals qualifying under either the low-income utilization rate or the Medicaid utilization rate which are state-owned, acute-care hospitals, and which have greater than 500 beds. In-state hospitals which qualify for both distinct groups may receive payment under both the routine and supplemental disproportionate share methodologies. However, supplemental disproportionate share payments will be made only for claims that have dates of discharge on or after October 1, 1992.
Compensation for routine disproportionate share payments for indigent patients is included in the rate table listing if applicable to the provider and the claim has a date of discharge before July 1, 1997. This amount is added to the blended base amount plus add-ons prior to setting the final payment rate. Compensation for supplemental disproportionate share payments is calculated and paid monthly. Hospitals qualify for disproportionate share payments based on information contained in the hospital’s available 1995 submitted Medicaid cost report, and other supporting schedules. Either routine or supplemental disproportionate share payments are determined when the hospital’s low-income utilization rate, as defined by the ratio of gross billings for all Medicaid, bad debt, and charity care patients to total billings for all patients, is 25 percent or greater. Gross billings do not include cash subsidies received by the hospital for inpatient hospital services except as provided from state or local governments. Hospitals also qualify for either routine or supplemental disproportionate share payments when the hospital’s inpatient Medicaid utilization rate, defined as the number of total Medicaid days, both in-state and out-of-state, and Iowa state indigent patient days divided by the number of total inpatient days for both in-state and out-of-state recipients, exceeds one standard deviation from the statewide average Medicaid utilization rate. Children’s hospitals, defined as hospitals with inpatients predominantly under 18 years of age, receive twice the percentage of inpatient hospital days attributable to Medicaid patients.
To qualify for routine or supplemental disproportionate share payments the hospital must also have at least two obstetricians who have staff privileges at the hospital and who have agreed to provide obstetric services to persons who are entitled to Medicaid for obstetric services. In the case of a hospital located in a rural area as defined in Section 1886 of the Social Security Act, the term “obstetrician” includes any physician with staff privileges at the hospital to perform nonemergency obstetric procedures.
Starting July 1, 1993, the routine disproportionate share payment add-on is established as a minimum payment of 1.00 percent of the hospital’s blended base cost per discharge plus add-ons if the claim has a discharge date prior to July 1, 1997. The scale increases 1.00 percent for each standard deviation above the mean Medicaid utilization rate for hospitals receiving Medicaid payments in the state. The standard deviation percentage rates will be increased to a maximum of 2.50 percent per standard deviation off the mean if additional federal funds for disproportionate share become available under the cap on disproportionate share payments imposed under Public Law 102-234. Disproportionate share hospitals will be notified of any change in disproportionate share payment rates within ten working days after the change.
The supplemental disproportionate share payment is established as an additional payment of 166 percent of the hospital’s total calculated reimbursement for a case. For this purpose, total calculated reimbursement includes any routine disproportionate share payment. Hospitals which are state-owned, acute-care facilities with over 500 beds may receive both the routine disproportionate share payment and the supplemental disproportionate share payment. The supplemental disproportionate share payment will be paid on a monthly cycle using the same paid inpatient DRG claims to calculate the reimbursement amount.
Hospitals that qualify for routine disproportionate share payments under both the low-income utilization and the Medicaid utilization guidelines shall qualify for routine disproportionate share payment under the Medicaid utilization payment scale.
Hospitals that qualify for routine disproportionate share payments under the low-income utilization guidelines and do not qualify under the Medicaid utilization guidelines shall be paid the minimum payment as established under the Medicaid utilization payment scale.
Out-of-state hospitals serving Iowa Medicaid patients qualify for routine disproportionate share payments based on their state’s Medicaid agency’s calculation of the Medicaid inpatient utilization rate. Payment is through the Iowa Medicaid utilization payment scale for routine disproportionate share payment, based on the number of standard deviations greater than the hospital’s own state average Medicaid utilization rate. Out-of-state hospitals may not qualify for supplemental disproportionate share payments.
In compliance with Medicaid Voluntary Contribution and Provider Specific Tax Amendments (Public Law 102-234) and 1992 Iowa Acts, chapter 1246, section 13, the total routine and supplemental disproportionate share payments cannot exceed the amount of the federal cap expressed under Public Law 102-234, and supplemental disproportionate share payments cannot exceed the lesser of (1) the applicable state appropriation or (2) the federal cap minus the routine disproportionate share payments.
	(4)	Indirect medical education costs. Recognition for indirect medical education costs incurred by hospitals is made through an add-on to the blended base rate cost per discharge for claims with dates of discharge before July 1, 1997. Hospitals qualify for indirect medical education payments when they receive a direct medical education add-on payment from Iowa Medicaid and qualify for indirect medical education payments from Medicare. For those qualifying hospitals, two distinct classes of indirect medical education add-on payments shall be established. The add-on payment for the first class (routine) is determined by qualifying for an indirect medical education payment from Medicare without regard to the individual components of the specific hospital’s teaching program, state ownership, or bed size. The add-on payment for the first class shall be determined by multiplying the hospital’s Medicaid indirect medical education factor by the sum of 50 percent of the statewide average base cost per discharge and 50 percent of the statewide average capital cost per discharge. The second class (supplemental) is determined by qualifying for an indirect medical education payment from Medicare, being an Iowa state-owned hospital with greater than 500 beds, and having eight or more separate and distinct residency specialty or subspecialty programs recognized by the American College of Graduate Medical Education. The add-on payment for the second class shall be paid monthly and shall be determined by multiplying the hospital’s Medicaid indirect medical education factor by the sum of five times the statewide average base cost per discharge and five times the statewide average capital cost per discharge. The Medicaid indirect medical education factor is determined from the following equation:

(residents + interns)	× 1.159	
(beds)		
The number of interns, residents and beds is based on information contained in the hospital’s Medicare cost report which will be updated when rebasing and recalibration are performed. A hospital may qualify to receive both classes of indirect medical education payments.
	f. 	Outlier payment policy. Additional payment is made for approved cases meeting or exceeding Medicaid criteria for day and cost outliers for each DRG. Effective for claims with dates of services ending July 1, 1993, and after, 100 percent of outlier costs will be paid to facilities at the time of claim reimbursement. The PRO will select a 10 percent random sample of outlier cases identified on fiscal agent claims data from all Iowa and bordering state hospitals. At least one case every six months per facility will be selected for review if available.
Staff will review the cases to perform admission review, quality review, discharge review, and DRG validation. Questionable cases will be referred to a physician reviewer for medical necessity and quality of care concerns. Day outlier cases will be reviewed to identify any medically unnecessary days which will be “carved out” in determining the qualifying outlier days. Cost outlier cases will be reviewed for medical necessity of all services provided and to ensure that services were not duplicately billed, to determine if services were actually provided, and to determine if all services were ordered by a physician. The hospital’s itemized bill and remittance statement will be reviewed in addition to the medical record.
On a quarterly basis, the PRO will calculate denial rates for each facility based on completed reviews during the quarter. All outlier cases reviewed will be included in the computation or error rates. Cases with denied charges which exceed $1000 for inappropriate or nonmedically necessary services or days will be counted as errors.
Intensified review may be initiated for hospitals whose error rate reaches or exceeds the norm for similar cases in other hospitals. The error rate is determined based on the completed outlier reviews in a quarter per hospital and the number of those cases with denied charges exceeding $1000. The number of cases sampled for hospitals under intensified review may change based on further professional review and the specific hospital’s outlier denial history.
Specific areas for review will be identified based on prior outlier experience. When it is determined that a significant number of the errors identified for a hospital is attributable to one source, review efforts will be focused on the specific cause of the error. Intensified review will be discontinued when the error rate falls below the norm for a calendar quarter. Providers will continue to be notified of all pending adverse decisions prior to a final determination by the PRO. If intensified review is required, hospitals will be notified in writing and provided with a list of the cases that met or exceeded the error rate threshold. When intensified review is no longer required, hospitals will be notified in writing. Hospitals with cases under review must then submit all supporting data from the medical record to the PRO within 60 days of receipt of the outlier review notifications, or outlier payment will be recouped and forfeited.
	(1)	Long stay outliers. Long stay outliers are incurred when a patient’s stay exceeds the upper day limit threshold. This threshold is defined as the greater of 23 days of care or two standard deviations above the average statewide length of stay for a given DRG. Reimbursement for long stay outliers is calculated at 60 percent of the average daily rate for the given DRG for each approved day of stay beyond the upper day limit. Payment for long stay outliers shall be paid at 100 percent of the calculated amount and made at the time the claim is originally filed for DRG payment.
	(2)	Short stay outliers. Short stay outliers are incurred when a patient’s length of stay is greater than two standard deviations below the average statewide length of stay for a given DRG, rounded to the next highest whole number of days. Payment for short stay outliers will be 200 percent of the average daily rate for each day the patient qualifies up to the full DRG payment. Short stay outlier claims will be subject to PRO review and payment denied for inappropriate admissions.
	(3)	Cost outliers. Cases qualify as cost outliers when costs of service in a given case exceed the cost threshold. This cost threshold is determined to be the greater of two times the statewide average DRG payment for that case or the hospital’s individual DRG payment for that case plus $16,000. Costs are calculated using hospital-specific cost to charge ratios determined in the base year cost reports. Additional payment for cost outliers is 80 percent of the excess between the hospital’s cost for the discharge and the cost threshold established to define cost outliers. Payment of cost outlier amounts shall be paid at 100 percent of the calculated amount and made at the time the claim is paid. Those hospitals that are notified of any outlier review initiated by the PRO must submit all requested supporting data to the PRO within 60 days of the receipt of outlier review notification, or outlier payment will be forfeited and recouped. In addition, any hospital may request a review for outlier payment by submitting documentation to the PRO within 365 days of receipt of the outlier payment. If requests are not filed within 365 days, the provider loses the right to appeal or contest that payment.
	(4)	Day and cost outliers. Cases qualifying as both day and cost outliers are given additional payment as cost outliers only.
	g. 	Billing for patient transfers and readmissions.
	(1)	Transfers between hospitals. When a Medicaid patient is transferred the initial hospital or unit is paid 100 percent of the average daily rate of the transferring hospital’s payment for each day the patient remained in that hospital or unit, up to 100 percent of the entire DRG payment. The hospital or unit that received the transferred patient receives the entire DRG payment.
	(2)	Medicaid-certified substance abuse and psychiatric units. When a patient is discharged to or from an acute care hospital and is admitted to or from a Medicaid-certified substance abuse or psychiatric unit, both the discharging and admitting hospitals will receive 100 percent of the DRG payment.
	(3)	Medicaid-certified physical rehabilitation units. When a patient requiring physical rehabilitation is discharged from an acute care hospital and admitted to a Medicaid-certified rehabilitation unit and the admission is medically appropriate, then payment for time spent in the unit is through a per diem. The discharging hospital will receive 100 percent of the DRG payment. When a patient is discharged from a physical rehabilitation unit and admitted to an acute care hospital, the acute care hospital will receive 100 percent of the DRG payment.
	h. 	Covered DRGs. Medicaid DRGs cover services provided in acute care general hospitals, with the exception of services provided in Medicaid-certified physical rehabilitation units which are paid per diem.
	i. 	Payment for Medicaid-certified physical rehabilitation units. Medicaid-certified physical rehabilitation payment is prospective based on a per diem rate calculated for each hospital by establishing a base year per diem rate to which an annual index is applied.
	(1)	Per diem calculation. The base rate shall be the medical assistance per diem rate as determined by the individual hospital’s cost report for the hospital’s 1988 fiscal year. No recognition will be given to the professional component of the hospital-based physicians except as noted under 79.1(5)“j.”
	(2)	Rescinded IAB 5/12/93, effective 7/1/93.
	(3)	Per diem reimbursement. Hospitals shall be reimbursed the lower of actual charges or the medical assistance cost per diem rate. The determination of the applicable rate shall be based on the hospital fiscal year aggregate of actual charges and medical assistance cost per diem rate. If an overpayment exists, the hospital will refund or have the overpayment deducted from subsequent billings.
	(4)	Per diem recalculation. Hospital prospective reimbursement rates shall be established as of October 1, 1987, for the remainder of the applicable hospital fiscal year. Beginning July 1, 1988, all updated rates shall be established based on the state’s fiscal year.
	(5)	Per diem billing. The current method for submitting billing and cost reports shall be maintained. All cost reports will be subject to desk review audit and, if necessary, a field audit.
	j. 	Services covered by DRG payments. Medicaid adopts the Medicare definition of inpatient hospital services covered by the DRG prospective payment system except as indicated herein. As a result, combined billing for physician services is eliminated unless the hospital has approval from Medicare to combine bill the physician and hospital services. Teaching hospitals having Medicare’s approval to receive reasonable cost reimbursement for physician services under 42 CFR 415.58 as amended to November 25, 1991, are eligible for combined billing status if they have the Medicare approval notice on file with Iowa Medicaid as verification. Reasonable cost settlement will be made during the year-end settlement process. Services provided by certified nurse anesthetists (CRNAs) employed by a physician are covered by the physician reimbursement. Payment for the services of CRNAs employed by the hospital are included in the hospital’s reimbursement.
The cost for hospital-based ambulance transportation that results in an inpatient admission and hospital-based ambulance services performed while the recipient is an inpatient, in addition to all other inpatient services, is covered by the DRG payment. If, during the inpatient stay at the originating hospital, it becomes necessary to transport but not transfer the patient to another hospital or provider for treatment, with the patient remaining an inpatient at the originating hospital after that treatment, the originating hospital shall bear all costs incurred by that patient for the medical treatment or the ambulance transportation between the originating hospital and the other provider. The services furnished to the patient by the other provider shall be the responsibility of the originating hospital. Reimbursement to the originating hospital for all services is under the DRG payment. (See 441—subrule 78.11(4).)
	k. 	Updating, rebasing, and recalibration. Updating of base payment amounts by the Data Resources, Inc. hospital market basket index shall be performed annually if funds permit. Base amounts shall be rebased and weights recalibrated every three years.
	l. 	Eligibility and payment. When a client is eligible for Medicaid for less than or equal to the average length of stay for that DRG, then payment equals 100 percent of the hospital’s average daily rate times the number of eligible hospital stay days up to the amount of the DRG payment. When a Medicaid client is eligible for greater than the average length of stay but less than the entire stay, then payment is treated as if the client were eligible for the entire length of stay.
Long stay outlier days are determined as the number of Medicaid eligible days beyond the outlier limits. The date of patient admission is the first date of service. Long stay outlier costs are accrued only during eligible days.
	m. 	Payment to out-of-state hospitals. Payment made to out-of-state hospitals providing care to beneficiaries of Iowa’s Medicaid program is equal to either the Iowa statewide average blended base amount plus the statewide average capital cost add-on, multiplied by the DRG weight, or blended base and capital rates calculated by using 80 percent of the hospital’s submitted capital costs. For those hospitals which wish to submit a cost report no less than 120 days prior to rebasing using data for Iowa Medicaid patients only, that provider will receive a case-mix adjusted blended base rate using hospital-specific, Iowa-only Medicaid data and the Iowa statewide average cost per discharge amount. Capital costs will be reimbursed at either the statewide average rate in place at the time of discharge, or the blended capital rate computed by using submitted cost report data. Hospitals that qualify for disproportionate share payment based on the definition established by their state’s Medicaid agency for the calculation of the Medicaid inpatient utilization rate will be eligible to receive disproportionate share add-ons if the last date of service is prior to July 1, 1997, or disproportionate share payments according to paragraph “y” if the last date of services is on or after July 1, 1997. If a hospital qualifies for reimbursement for the direct medical education or indirect medical education component under Medicare guidelines, it shall qualify for this add-on component for reimbursement purposes in Iowa if the date of service is prior to July 1, 1997, or shall be reimbursed for those components according to paragraph “y” if the date of service is on or after July 1, 1997. Hospitals which wish to submit the HCFA 2552 (or HCFA accepted substitute) cost report must do so within 60 days from the date of patient discharge to the state of Iowa’s fiscal agent. Hospitals which elect to submit cost reports for the determination of blended rates must submit new reports on an annual basis within 90 days of the close of the hospital’s fiscal year end. When audited, finalized reports become available from the Medicare intermediary, these should be submitted to the Iowa Medicaid fiscal agent.
	n. 	Preadmission, preauthorization, or inappropriate services. Medicaid adopts most Medicare PRO regulations to control increased admissions or reduced services. Exceptions to the Medicare review practice are that the PRO reviews Medicaid short stay outliers and all Medicaid patients readmitted within 31 days. Payment can be denied if either admissions or discharges are performed without medical justification as determined by the PRO. Inpatient or outpatient services which require preadmission or preprocedure approval by the PRO are updated yearly by the department and are listed in the provider manual. Preauthorization for any of these services is transmitted directly from the PRO to the fiscal agent and no additional information needs to be submitted as part of the claim filing for inpatient or outpatient services. To safeguard against these and other inappropriate practices, the department through the PRO will monitor admission practices and quality of care. If an abuse of the prospective payment system is identified, payments for abusive practices may be reduced or denied. In reducing or denying payment, Medicaid adopts the Medicare PRO regulations.
	o. 	Hospital billing. Hospitals shall normally submit claims for DRG reimbursement to the fiscal intermediary after a patient’s discharge. Payment for outlier days or costs is determined when the claim is filed with the fiscal agent, as described in paragraph “f.” When a Medicaid patient requires acute care in the same facility for a period of no less than 120 days, a request for partial payment may be made. Written requests for this interim DRG payment shall be addressed to the Administrator, Division of Medical Services, Iowa Department of Human Services, Fifth Floor, Hoover State Office Building, Des Moines, Iowa 50309-0114, and shall include the patient’s name, state identification number, date of admission, brief summary of the case, current listing of charges, and physician’s attestation that the recipient has been an inpatient for 120 days and is expected to remain in the hospital for a period of no less than 60 additional days. A departmental employee will then contact the facility to assist the facility in filing the interim claim.
	p. 	Determination of inpatient admission. A person is considered to be an inpatient when a formal inpatient admission occurs, when a physician intends to admit a person as an inpatient, or when a physician determines that a person being observed as an outpatient in an observation or holding bed should be admitted to the hospital as an inpatient. In cases involving outpatient observation status, the determinant of patient status is not the length of time the patient was being observed, but rather that the observation period was medically necessary for the physician to determine whether a patient should be released from the hospital or admitted to the hospital as an inpatient. Outpatient observation lasting greater than a 24-hour period will be subject to review by the Iowa foundation for medical care (IFMC) to determine the medical necessity of each case. For those outpatient observation cases where medical necessity is not established by the IFMC and cannot be found to be medically necessary on other grounds, reimbursement shall be denied for the services found to be unnecessary for the provision of that care, such as the use of the observation room.
	q. 	Inpatient admission after outpatient services. A patient may be admitted to the hospital as an inpatient after receiving outpatient services. If the patient is admitted as an inpatient within three days of the day outpatient services were rendered, all outpatient services related to the principal diagnosis are considered inpatient services for billing purposes. The day of formal admission as an inpatient is considered as the first day of hospital inpatient services.
	r. 	Certification of special units. Medicaid certification of substance abuse, psychiatric and rehabilitation units is based on the Medicare reimbursement criteria for these units. Neonatal units are certified using standards adopted by the department of public health in accordance with recommendations set forth by the American Academy of Pediatrics for newborn care. In Iowa, the department of inspections and appeals is responsible for Medicaid certification of these units for in-state hospitals.
Additional certification for reimbursement by the Iowa Medicaid fiscal agent is required for reimbursement of physical rehabilitation services on a per diem basis, for reimbursement of psychiatric or substance abuse services in adolescent-only or adult-only units, and for reimbursement of neonatal units as a level II or level III unit. To receive additional certification, the Medicare PPS exemption notice must be forwarded to the Iowa Medicaid fiscal agent every fiscal year when it becomes available. Supplemental Form 2977, indicating all the various certified programs for which the hospital may become certified, must also accompany the PPS exemption notice. This form will be available from the fiscal agent as part of the enrollment process or on request. Hospitals that elect to receive additional certification for substance abuse units must submit approved documentation of the Iowa substance abuse inspection to the Medicaid fiscal agent, plus additional documentation of the specific substance abuse programs available at the facility, staffing, facility information, treatment standards, and description of the population served by the facility. The Medicaid fiscal agent will notify the facility of the additional reimbursement certification for the provider after review of those documentation submissions. The additional reimbursement certification will be retroactive to the first day of the month during which the application is received by the Medicaid fiscal agent. Hospitals that have had additional reimbursement certification prior to July 1, 1993, do not have to reapply for certification by Medicaid but must submit the appropriate PPS exemption notices as they become due and available.
An out-of-state hospital may receive Medicaid-certified unit status as a qualifying psychiatric unit when the unit is eligible for reimbursement under the Medicare prospective payment system. Out-of-state hospitals must submit a copy of the Medicare PPS exemption notice to the Iowa Medicaid fiscal agent in order to receive Medicaid certification as a substance abuse unit or certification for reimbursement as an adolescent-only or adult-only psychiatric unit. Neonatal units are accepted as being certified when the hospital is inspected by the home state agency responsible for licensing, using standards set forth by the American Academy of Pediatrics for newborn care and that notice is forwarded to the Medicaid fiscal agent for reimbursement certification as a level II or level III neonatal unit. Out-of-state hospitals are not recognized as having special units for substance abuse or physical rehabilitation treatment. Reimbursement for physical rehabilitation is through the DRG payment. Out-of-state hospitals may not receive reimbursement for the rehabilitation portion of substance abuse treatment. There will be no retroactive payment adjustment made (to a certified higher level payment) when the hospital fails to make timely application for reimbursement certification.
	s. 	Cost report adjustments. Hospitals with cost reports adjusted by Medicare through the cost settlement process on or after October 1, 1996, may appeal to the department the hospital-specific base amount and add-ons used in calculating the Medicaid DRG payment, if the Medicare adjustment results in material changes to the rates. Any appeal of the DRG rate due to Medicare’s adjustment process must be made in writing to the department within 30 days of Medicare’s finalization and notification to the provider. If the provider does not notify the department of the adjusted amounts within the 30-day period, no costs shall be reconsidered for adjustment by Iowa Medicaid. Claims adjustment reflecting the changed rates shall only be made to claims that have been processed within one year prior to the notification from the provider or the beginning of the rebasing period, whichever is less.
	t. 	Limitations and application of limitations on payment. Diagnosis related group payments are subject to the upper payment limits as stated in 42 CFR 447.271 and 42 CFR 447.272 as amended to September 26, 1991.
Payment limits as stated in subparagraphs (1) and (2) below are applied in the aggregate during the cost settlement process at the completion of the hospital’s fiscal year end. The payment limit stated in subparagraph (3) is applied to aggregate Medicaid payments at the end of the state’s fiscal year.
	(1)	Except as provided in subparagraph (2) below, the department may not pay a provider more for inpatient hospital services under Medicaid than the provider’s customary charges to the general public for the services.
	(2)	The department may pay a public provider that provides services free or at a nominal charge at the same rate that would be used if the provider’s charges were equal to or greater than its costs.
	(3)	Aggregate payments to hospitals and state-operated hospitals may not exceed the amount that can reasonably be estimated would have been paid for those services under Medicare payment principles.
	u. 	Determination of payment amounts for outpatient hospitalization. Rescinded IAB 7/6/94, effective 7/1/94.
	v. 	Reimbursement of malpractice costs. In order to treat all hospitals equally and spread malpractice reimbursement payments equitably over future years, each hospital’s base-year payment amount reflects a direct apportionment of 7 ½ percent of malpractice premiums incurred in that year by Medicaid. This is the most recent average malpractice insurance rate information available and was determined by the Health Care Financing Administration using nationwide surveys from hospitals reporting malpractice data.
	w. 	Rate adjustments for hospital mergers. When one or more hospitals merge to form a distinctly different legal entity, the base rate plus applicable add-ons will be revised to reflect this new operation. Financial information from the original cost reports and original rate calculations will be added together and averaged to form the new rate for that entity.
	x. 	For cost reporting periods beginning on or after July 1, 1993, reportable Medicaid administrative and general expenses are allowable only to the extent that they are defined as allowable using Medicare Reimbursement Principles or Health Insurance Reimbursement Manual 15 (HIM-15). Appropriate, reportable costs are those that meet the Medicare (or HIM-15) principles, are reasonable, and are directly related to patient care. In instances where costs are not directly related to patient care or are not in accord with Medicare Principles of Reimbursement, inclusion of those costs in the cost report would not be appropriate. Examples of administrative and general costs that must be related to patient care to be included as a reportable cost in the report are:
	(1)	Advertising.
	(2)	Promotional items.
	(3)	Feasibility studies.
	(4)	Administrative travel and entertainment.
	(5)	Dues, subscriptions, or membership costs.
	(6)	Contributions made to other organizations.
	(7)	Home office costs.
	(8)	Public relations items.
	(9)	Any patient convenience items.
	(10)	Management fees for administrative services.
	(11)	Luxury employee benefits (i.e., country club dues).
	(12)	Motor vehicles for other than patient care.
	(13)	Reorganization costs.
	y. 	Graduate medical education and disproportionate share fund. Payment shall be made to all hospitals qualifying for direct medical education, indirect medical education or disproportionate share payments directly from the graduate medical education and disproportionate share fund. The amount in the fund and distributions from the fund shall be calculated from the following components:
	(1)	Allocation for direct medical education. To determine the total amount of funding that will be allocated to the graduate medical education and disproportionate share fund for direct medical education, the department shall:
	1.	Sum all direct medical education payments using claims reimbursed to qualifying providers with dates of discharge from October 1, 1996, through March 31, 1997, and paid through June 30, 1997. These claims shall then be multiplied by two to annualize the amount of money to be placed in the fund for distribution and the total amount of computed reimbursement shall be allocated to the fund.
	2.	Sum all direct medical education payments using claims reimbursed to qualifying providers when those claims have been used as a basis for the calculation of capitation rates and reimbursement with any health maintenance organization (HMO) or other prepaid health plan with which the department has entered into a contract effective on or after July 1, 1997.
For each prepaid health plan, divide the total dollar reimbursement from claims by the number of member months applicable to the rate-setting methodology for the per member per month (PMPM) allocation to calculate the amount of reimbursement to be allocated to the fund that represents capitation rate reimbursement allocation for direct medical education. The direct medical education PMPM allocation shall then be multiplied by the total number of members enrolled in the plan for state fiscal year 1997, allocating that amount of money to the fund.
3. Trend the total allocation for direct medical education (which includes money for both the fee for service population and the capitated risk-based population, calculated under numbers “1” and “2” above) forward using annually appropriated legislative update factors and determine the total amount of money that shall be allocated to the graduate medical education and disproportionate share fund for direct medical education Medicaid reimbursement. No adjustments shall be made to this fund beyond appropriated amounts.
	(2)	Distribution of direct medical education. Distribution of the fund for direct medical education shall be on a quarterly basis beginning October 1, 1997, and shall be calculated by taking the previous fiscal year’s percentage allocation of direct medical education reimbursement (based upon paid claims to qualifying hospitals) and multiplying that percentage by the amount in the fund for direct medical education.
If a hospital fails to qualify for the provision of medical education under Medicare regulations, the amount of money that could have been allocated to that hospital shall be removed from the total fund.
	(3)	Allocation for indirect medical education. To determine the total amount of funding that will be allocated for the graduate medical education and disproportionate share fund for indirect medical education the department shall:
	1.	Sum all routine indirect medical education payments using claims reimbursed to qualifying providers with dates of discharge from October 1, 1996, through March 31, 1997, and paid through June 30, 1997. These claims shall then be multiplied by two to annualize the amount of money to be placed in the fund for distribution and the total amount of reimbursement shall be applied to the fund.
	2.	Sum all routine indirect medical education payments from claims made to qualifying providers when those claims have been used as a basis for the calculation of capitation rates and reimbursement with any HMO or other prepaid health plan with which the department has entered into a contract effective on or after July 1, 1997.
For each prepaid health plan, divide the total dollar reimbursement from claims by the number of member months applicable to the rate-setting methodology for the per member per month (PMPM) allocation to calculate the amount of reimbursement to be allocated to the fund that represents capitation rate reimbursement allocation for routine indirect medical education. The indirect medical education PMPM allocation shall then be multiplied by the total number of members enrolled in the plan for state fiscal year 1997, allocating that amount of money to the fund.
3. Trend the total allocation for routine indirect medical education (which includes money for both the fee for service population and the capitated risk-based population, calculated under numbers “1” and “2” above) forward using annually appropriated legislative update factors and determine the total amount of money that shall be allocated to the graduate medical education and disproportionate share fund for indirect medical education Medicaid reimbursement. No adjustments shall be made to this fund beyond appropriated updates.
	(4)	Distribution of indirect medical education. Distribution of the fund for indirect medical education shall be on a quarterly basis beginning October 1, 1997, and shall be calculated by taking the previous fiscal year’s percentage allocation of indirect medical education reimbursement (based upon paid claims to qualifying hospitals) and multiplying the total amount of money allocated to the graduate medical education and disproportionate share fund for indirect medical education by each respective hospital’s percentage.
If a hospital fails to qualify for the provision of medical education under Medicare regulations, the amount of money that would otherwise be allocated to that hospital shall be removed from the total fund.
	(5)	Allocation for disproportionate share. To determine the total amount of funding that shall be allocated to the graduate medical education and disproportionate share fund for disproportionate share payments, the department shall:
	1.	Sum all routine disproportionate share payments for the fee for service population reimbursed to qualifying providers with dates of discharge from October 1, 1996, through March 31, 1997, and paid through June 30, 1997. These claims shall then be multiplied by two to annualize the amount of money to be placed in the fund for distribution and the total amount of reimbursement shall be applied to the fund.
	2.	Sum all routine disproportionate share payments from claims made to qualifying providers when those claims have been used as a basis for the calculation of capitation rates and reimbursement with either an HMO or other prepaid health plan with which the department has entered into a contract effective on or after July 1, 1997.
For each prepaid health plan, divide the total dollar reimbursement from claims by the number of member months applicable to the rate-setting methodology for the per member per month (PMPM) allocation to calculate the amount of reimbursement to be allocated to the fund that represents capitation rate reimbursement allocation for routine disproportionate share. The disproportionate share PMPM allocation shall then be multiplied by the total number of members enrolled in the plan for state fiscal year 1997, allocating that amount of money to the fund.
3. Trend the total allocation for routine disproportionate share (which includes money for both the fee for service population and the capitated risk-based population, calculated under numbers “1” and “2” above) forward using annually appropriated legislative update factors and determine the total amount of money that shall be allocated to the graduate medical education and disproportionate share fund for disproportionate share Medicaid reimbursement. No adjustments shall be made to this fund beyond appropriated updates. The total amount of disproportionate share reimbursement cannot exceed the cap that was implemented under Public Law 102-234.
	(6)	Distribution of disproportionate share fund. Distribution of the fund for disproportionate share shall be on a quarterly basis beginning October 1, 1997, and shall be calculated by taking the previous fiscal year’s percentage allocation of direct medical education reimbursement (based upon paid claims to qualifying hospitals) and dividing the total amount of money allocated to the graduate medical education and disproportionate share fund for disproportionate share by each respective hospital’s percentage.
If a hospital fails to qualify for reimbursement for disproportionate share under Iowa Medicaid regulations, the amount of money that would otherwise be allocated for that hospital shall be removed from the total fund.
	z. 	Adjustments to the graduate medical education and disproportionate share fund for changes in utilization. Money shall be added to or subtracted from the graduate medical education and disproportionate share fund when the average monthly Medicaid population deviates from the previous year’s averages by greater than 5 percent. The average annual population (expressed in a monthly total) shall be determined on June 30 for both the previous and current years by adding the total enrolled population for all respective months from both years’ B-1 MARS report and dividing each year’s totals by 12. If the average monthly number of enrolled persons for the current year is found to vary more than 5 percent from the previous year, a per member per month (PMPM) amount shall be calculated for each component (using the average number of eligibles for the previous year calculated above) and an annualized PMPM adjustment shall be made for each eligible person that is beyond the 5 percent variance.
	79.1(6) Independent laboratories. The maximum payment for clinical diagnostic laboratory tests performed by an independent laboratory will be the areawide fee schedule established by the Health Care Financing Administration (HCFA). The fee schedule is based on the definition of laboratory procedures from the Physician’s Current Procedural Terminology (CPT) published by the American Medical Association. The fee schedules are adjusted annually by HCFA to reflect changes in the Consumer Price Index for All Urban Consumers.
	79.1(7) Physicians. The fee schedule is based on the definitions of medical and surgical procedures given in the most recent edition of Physician’s Current Procedural Terminology (CPT). Refer to 441—paragraph 78.1(2)“e” for the guidelines for immunization replacement.
	79.1(8) Prescribed drugs. The amount of payment shall be based on several factors in accordance with 42 CFR 447.331—333 as amended to October 28, 1987:
	a. 	“Estimated acquisition cost (EAC)” is defined as the average wholesale price as published by First Data Bank less 10 percent.
“Maximum allowable cost (MAC)” is defined as the upper limit for multiple source drugs established in accordance with the methodology of the Health Care Financing Administration (HCFA) as described in 42 CFR 447.332(a)(i) and (ii).
The basis of payment for prescribed drugs for which the MAC has been established and for Schedule II controlled drugs shall be the lesser of the submitted acquisition cost or the MAC plus a professional dispensing fee which is the lower of the pharmacist’s customary fee to the general public, the 75th percentile of customary fees charged in the state of Iowa, or a fee of $4.02.
The basis of payment for drugs other than Schedule II controlled drugs for which the MAC has not been established shall be the lesser of the submitted acquisition cost or the EAC plus a professional dispensing fee which is the lower of the pharmacist’s customary fee to the general public, the 75th percentile of fees charged in the state of Iowa or a fee of $6.25.
If a physician certifies in the physician’s handwriting that, in the physician’s medical judgment, a specific brand is medically necessary for a particular recipient, the MAC does not apply and the payment equals the average wholesale price of the brand name product less 10 percent. If a physician does not so certify, and a lower cost equivalent product is not substituted by the pharmacist, the payment for the product equals the established MAC.
Equivalent products shall be defined as those products which meet therapeutic equivalent standards as published in the Federal Food and Drug Administration document, “Approved Prescription Drug Products With Therapeutic Equivalence Evaluations.”
	b. 	The determination of the unit cost component of the drug shall be based on the package size of drugs most frequently purchased by providers.
	c. 	No payment shall be made for sales tax.
	d. 	All hospitals which wish to administer vaccines which are available through the vaccines for children program to Medicaid recipients 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 recipients. Hospitals receive reimbursement for the administration of vaccines to Medicaid recipients through the DRG reimbursement for inpatients and APG reimbursement for outpatients.
	e. 	The basis of payment for nonprescription drugs shall be the same as specified in paragraph “a” except that a maximum allowable reimbursable cost for these drugs shall be established by the department at the median of the average wholesale prices of the chemically equivalent products available. No exceptions for reimbursement for higher cost products will be approved.
	f. 	An additional reimbursement amount of one cent per dose shall be added to the allowable ingredient cost of a prescription for an oral solid if the drug is dispensed to a patient in a nursing home in unit dose packaging prepared by the pharmacist.
	79.1(9) Nursing facility reimbursement for skilled nursing care. Reimbursement shall be prospective based on a per diem rate calculated for each facility by establishing a base year per diem to which an annual index is applied.
	a. 	The base year per diem rate shall be the Medicaid cost per diem as determined using the facility’s 1995 fiscal year-end cost report. The base per diem rate for facilities enrolled since 1995 will be determined using the facility’s first finalized cost report. Determination of allowable costs for the base year will be made using Medicare methods in place on December 31, 1995. A new skilled facility shall be reimbursed at an interim rate determined by Medicare or for facilities not participating in Medicare, an interim rate determined using Medicare methodology. The initial interim rate shall be either the rate used by Medicare or a per diem (using Medicare methodology) developed using a projected cost statement from the facility. When the facility submits the first cost report to Medicare, the facility shall send a copy to the Medicaid fiscal agent. A new prospective rate shall be established based on this cost report effective the first day of the month in which the cost report is received. The interim and prospective rate may not exceed the ceiling established in paragraph “d” below unless the facility meets the requirements in paragraph “e” below.
	b. 	In-state facilities serving Medicaid eligibles who require a ventilator at least six hours every day, are inappropriate for home care, have a failed attempt at weaning or are inappropriate for weaning, and have medical needs that require skilled care as determined by the Iowa foundation for medical care shall receive a $50 per day incentive factor. For ventilator care a facility may not receive a rate that exceeds the ceiling rate for its facility classification plus $50 per day. The facility may continue to receive the payment for 30 days for any person weaned from a respirator who continues to reside in the facility and continues to meet skilled criteria for those 30 days.
	c. 	Nursing facilities providing skilled nursing care shall be classified as either hospital-based or free-standing (non-hospital-based). A hospital-based facility is under the management and administration of a hospital regardless of where the skilled beds are physically located.
	d. 	Effective February 1, 1997, a ceiling of allowable cost shall be established at the sixtieth percentile for hospital-based facilities and the sixty-ninth percentile for free-standing facilities. The allowable cost shall be weighted by Medicaid patient days.
	e. 	Nursing facilities enrolled in the Iowa Medicaid program on May 31, 1993, providing skilled nursing care and serving a disproportionate share of Medicaid recipients shall be exempt from the payment ceiling. Nursing facilities which enroll in the Iowa Medicaid program on or after June 1, 1993, provide skilled care, and serve a disproportionate share of Medicaid recipients shall have an upper limit on their rate not to exceed 150 percent of the ceiling for the class of skilled nursing facility.
For nursing facilities providing skilled nursing care, a disproportionate share of Medicaid recipients shall exist when the total cost of skilled services rendered to Medicaid recipients in any one provider fiscal year is greater than or equal to 51 percent of the facility’s total allowable cost for skilled services for the same fiscal year except as provided in subparagraphs (1) and (2). The department shall determine which providers qualify for this exemption.
	(1)	Nursing facilities enrolled in the Iowa Medicaid program on May 31, 1993, and meeting disproportionate share requirements on that date shall continue to be exempted from the payment ceiling if the total cost of services rendered to Medicaid recipients in any one provider fiscal year drops below 51 percent, but the total cost of services to Medicaid recipients is greater than 35 percent of the facility skilled nursing allowable cost for the same fiscal year.
For facilities meeting this condition, a 10 percent reduction in the Medicaid payment rate shall be made. For each percentage point in the facility’s overall utilization rate (rounded to the nearest whole number) below 75 percent, a further 1 percent reduction shall be made in the Medicaid payment rate, in addition to any occupancy adjustment already made by the Medicare program.
	(2)	A facility meeting the conditions of subparagraph (1) as of July 1, 1996, or at a subsequent time, shall be subject to the following conditions and requirements:
	●	A census report shall be submitted to the department which verifies the Medicaid and overall occupancy of the facility for the entire year immediately preceding application by a facility to be reimbursed according to the conditions of this subrule.
	●	The initial rate for a facility approved for reimbursement under provisions of subparagraph (1) shall be the allowable Medicaid rate on the effective date less 10 percent and any further applicable percentage reduction.
Subsequent rate calculations shall be based on the annual cost report prepared by a facility subject to the limitations of this subparagraph and subject to an allowable rate of increase approved by the Iowa general assembly. These adjustments shall be effective July 1 of each year.
	f. 	The current method for submitting billings and cost reports shall be maintained. All cost reports will be subject to desk review audit and, if necessary, a field audit.
	g. 	Out-of-state nursing facilities providing skilled nursing services shall be reimbursed at the same level as in their state of residence.
	h. 	Payment for outpatient services by certified skilled nursing facilities shall be made at the Medicare rate of reimbursement.
	i. 	Rates for skilled nursing facilities shall be rebased every three years.
	79.1(10) Prohibition against reassignment of claims. No payment under the medical assistance program for any care or service provided to a patient by any health care provider shall be made to anyone other than the providers. However with respect to physicians, dentists or other individual practitioners direct payment may be made to the employer of the practitioner if the practitioner is required as a condition of employment to turn over fees to the employer; or where the care or service was provided in a facility, to the facility in which the care or service was provided if there is a contractual arrangement between the practitioner and the facility whereby the facility submits the claim for reimbursement; or to a foundation, plan or similar organization including a health maintenance organization which furnishes health care through an organized health care delivery system if there is a contractual agreement between organization and the person furnishing the service under which the organization bills or receives payment for the person’s services. Payment may be made in accordance with an assignment from the provider to a government agency or an assignment made pursuant to a court order. Payment may be made to a business agent, such as a billing service or accounting firm, which renders statements and receives payment in the name of the provider when the agent’s compensation for this service is (1) reasonably related to the cost or processing the billing; (2) not related on a percentage or other basis to the dollar amounts to be billed or collected; and (3) not dependent upon the actual collection of payment. Nothing in this rule shall preclude making payment to the estate of a deceased practitioner.
	79.1(11)  Prohibition against factoring. Payment under the medical assistance program for any care or service furnished to an individual by providers as specified in 79.1(1) shall not be made to or through a factor either directly or by virtue of power of attorney given by the provider to the factor. A factor is defined as an organization, collection agency, or service bureau which, or an individual who, advances money to a provider for accounts receivable which have been assigned or sold or otherwise transferred including transfer through the use of power of attorney to the organization or individual for an added fee or reduction of a portion of the accounts receivable. The term factor does not include business representatives such as billing agents or accounting firms which render statements and receive payments in the name of the individual provider provided that the compensation of the business representative for the service is reasonably related to the cost of processing the billings and is not related on a percentage or other basis to the dollar amounts to be billed or collected.
	79.1(12)  Reasonable charges for services, supplies, and equipment. For selected medical services, supplies, and equipment, including equipment servicing, which in the judgment of the Secretary of the Department of Health and Human Services generally do not vary significantly in quality from one provider to another, the upper limits for payments shall be the lowest charges for which the devices are widely and consistently available in a locality. For those selected services and items furnished under part B of Medicare and Medicaid, the upper limits shall be the lowest charge levels recognized under Medicare. For those selected services and items furnished only under Medicaid, the upper limits shall be the lowest charge levels determined by the department according to the Medicare reimbursement method.
	a. 	For any noninstitutional item or service furnished under both Medicare and Medicaid, the department shall pay no more than the reasonable charge established for that item or service by the part B Medicare carrier serving part or all of Iowa. Noninstitutional services do not include practitioner’s services, such as physicians, pharmacies, or out-patient hospital services.
	b. 	For all other noninstitutional items or services furnished only under Medicaid, the department shall pay no more than the customary charge for a provider or the prevailing charges in the locality for comparable items or services under comparable circumstances, whichever is lower.
	79.1(13)  Copayment by recipient. A copayment in the amount specified shall be charged to recipients for the following covered services:
	a. 	Nullified by 1992 Iowa Acts, H.J.R. 2015.
	b. 	The recipient shall pay $1.00 copayment on each covered drug prescription, including each refill, and for total covered service rendered on a given date for podiatrists’ services, chiropractors’ services, and services of independently practicing physical therapists.
	c. 	The recipient shall pay $2.00 copayment for total covered services rendered on a given date for medical equipment and appliances, prosthetic devices and sickroom supplies as defined in 441—78.10(249A), orthopedic shoes, services of audiologists, services of hearing aid dealers except the hearing aid, optometrists, opticians, rehabilitation agencies, psychologists, and ambulance services.
	d. 	The recipient shall pay $3.00 copayment for total covered service rendered on a given date for dental services and hearing aids.
	e. 	Copayment charges are not applicable to persons under age 21.
	f. 	Copayment charges are not applicable to family planning services or supplies.
	g. 	Copayment charges are not applicable for a recipient receiving care in a hospital, nursing facility, state mental health institution, or other medical institution if the person is required, as a condition of receiving services in the institution, to spend for costs of necessary medical care all but a minimal amount of income for personal needs.
	h. 	The recipient shall pay $1.00 for each federal Medicare Part B crossover claim submitted to the Medicaid program when the services provided have a Medicaid copayment as set forth above.
	i. 	Copayment charges are not applicable to services furnished pregnant women.
	j. 	All providers are prohibited from offering or providing copayment related discounts, rebates, or similar incentives for the purpose of soliciting the patronage of Medicaid recipients.
	k. 	Copayment charges are not applicable for emergency services. Emergency services are defined as services provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain), that the absence of immediate medical attention could reasonably be expected to result in:
	(1)	Placing the patient’s health in serious jeopardy,
	(2)	Serious impairment to bodily functions, or
	(3)	Serious dysfunction of any bodily organ or part.
	l. 	Copayment charges are not applicable for services rendered by a health maintenance organization in which the recipient is enrolled.
	m. 	No provider of service participating in the Medicaid program may deny care or services to a person eligible for care or services under the program because of the person’s inability to pay a copayment. However, this rule does not change the fact that a recipient is liable for the charges and it does not preclude the provider from attempting to collect them.
	79.1(14) Reimbursement for hospice services.
	a. 	Medicaid hospice rates. The Medicaid hospice rates are based on the methodology used in setting Medicare rates, adjusted to disregard cost offsets attributable to Medicare coinsurance amounts, and with application of the appropriate area wage adjustments for the categories of care provided.
Hospices are reimbursed at one of four predetermined rates based on the level of care furnished to the individual for that day. Payments to a hospice for inpatient care are subject to the limitations imposed by Medicare. The levels of care into which each day of care is classified are as follows:
	(1)	Routine home care.
	(2)	Continuous home care.
	(3)	Inpatient respite care.
	(4)	General inpatient care.
	b. 	Adjustment to hospice rates. An adjustment to hospice reimbursement is made when a recipient residing in a nursing facility elects the hospice benefit. The adjustment will be a room and board rate that is equal to the rate at which the facility is paid for reserved bed days or 95 percent of the facility’s Medicaid reimbursement rate, whichever is greater. Room and board services include the performance of personal care services, including assistance in activities of daily living, socializing activities, administration of medication, maintaining the cleanliness of a resident’s room and supervising and assisting in the use of durable medical equipment and prescribed therapies.
For hospice recipients entering a nursing facility the adjustment will be effective the date of entry. For persons in nursing facilities prior to hospice election, the adjustment rate shall be effective the date of election.
For individuals who have client participation amounts attributable to their cost of care, the adjustment to the hospice will be reduced by the amount of client participation as determined by the department. The hospice will be responsible for collecting the client participation amount due the hospice unless the hospice and the nursing facility jointly determine the nursing facility is to collect the client participation.
	c. 	Payment for day of discharge. For the day of discharge from an inpatient unit, the appropriate home care rate is to be paid unless the recipient dies as an inpatient. When the recipient is discharged as deceased, the inpatient rate (general or respite) is to be paid for the discharge date.
	d. 	Hospice cap. Overall aggregate payments made to a hospice during a hospice cap period are limited or capped. The hospice cap year begins November 1 and ends October 31 of the next year. The cap amount for each hospice is calculated by multiplying the number of beneficiaries electing hospice care from that hospice during the cap period by the base statutory amount, adjusted to reflect the percentage increase or decrease in the medical care expenditure category of the Consumer Price Index for all urban consumers published by the Bureau of Labor Statistics. Payments made to a hospice but not included in the cap include room and board payment to a nursing home. Any payment in excess of the cap must be refunded to the department by the hospice.
	e. 	Limitation of payments for inpatient care. Payments to a hospice for inpatient care shall be limited according to the number of days of inpatient care furnished to Medicaid patients. During the 12-month period beginning November 1 of each year and ending October 31, the aggregate number of inpatient days (both for general inpatient care and inpatient respite care) shall not exceed 20 percent of the aggregate total number of days of hospice care provided to all Medicaid recipients during that same period. Medicaid recipients afflicted with acquired immunodeficiency syndrome (AIDS) are excluded in calculating this inpatient care limitation. This limitation is applied once each year, at the end of the hospices’ “cap period” (November 1 to October 31). For purposes of this computation, if it is determined that the inpatient rate should not be paid, any days for which the hospice receives payment at a home care rate will not be counted as inpatient days. The limitation is calculated as follows:
	(1)	The maximum allowable number of inpatient days will be calculated by multiplying the total number of days of Medicaid hospice care by 0.2.
	(2)	If the total number of days of inpatient care furnished to Medicaid hospice patients is less than or equal to the maximum, no adjustment will be necessary.
	(3)	If the total number of days of inpatient care exceeded the maximum allowable number, the limitation will be determined by:
	1.	Calculating a ratio of the maximum allowable days to the number of actual days of inpatient care, and multiplying this ratio by the total reimbursement for inpatient care (general inpatient and inpatient respite reimbursement) that was made.
	2.	Multiplying excess inpatient care days by the routine home care rate.
	3.	Adding together the amounts calculated in “1” and “2.”
	4.	Comparing the amount in “3” with interim payments made to the hospice for inpatient care during the “cap period.”
Any excess reimbursement shall be refunded by the hospice.
This rule is intended to implement Iowa Code section 249A.4.
	79.1(15) Reimbursement for HCBS MR supported community living, respite, supported employment and home and vehicle modifications services.
a. To receive reimbursement for services a certified provider shall enter into an agreement with the department on Form 470-2918, HCBS Waiver Agreement, and have an approved individual comprehensive plan for the consumer.
b. Supported community living, respite, and supported employment initial instructional activities on the job and enclave setting payments.
(1) Effective January 1, 1997, the hourly prospective cost-related reimbursement rates for supported community living, respite, and supported employment initial instructional activities on the job and enclave settings shall be based on the provider’s costs for the services as reported on Form SS-1703-0, Financial and Statistical Report for Purchase of Service. Daily prospective cost-related reimbursement rates for supported community living services shall be based on the provider’s costs of services to individuals or groups of individuals living together as reported on Form SS-1703-0.
Prior to January 1, 1997, daily rates for supported community living services and hourly rates for supported community living, respite, and supported employment initial instructional activities on the job and enclave setting services shall be based on the Individual Service Budget, Form 470-2919. Hourly rates for supported community living services shall not be available except as provided in subparagraph (2).
(2) Providers may choose to convert from the individual service budget basis of payment for services to the daily or hourly cost report-based payment method prior to January 1, 1997, with the agreement of the department. Hourly rates for supported community living services shall not be available prior to January 1, 1997, unless the provider chooses to transition with the agreement of the department.
c. Home and vehicle modification payment. Payment is made for home and vehicle modifications on the basis of a prospective fee established through a binding contract between the supported community living service provider and subcontractor. All contracts shall be approved by the department and shall be justified by the consumer’s individual comprehensive plan. Payment for completed work shall be made to the supported community living service provider.
d. Costs reported under the waiver shall not be reported as costs for reimbursement under any other funding source. Costs incurred from other services shall not be reported as costs for reimbursement under the waiver.
e. Providers shall submit a cost report for each waiver service provided using Form SS-1703-0, Financial and Statistical Report for Purchase of Service. The cost reporting period is from July 1 to June 30. The completed Financial and Statistical Report shall be submitted to the department, division of medical services, by September 30 of each year.
(1) A provider’s initial rates shall be based on projected costs unless the provider has historical records upon which to base the costs. The initial rates shall be reviewed after 12 months or less if needed and shall be adjusted as necessary to be based on the provider’s actual costs.
(2) The rates a provider may charge are subject to the limits established in subrule 79.1(2).
(3) Financial information shall be based on the agency’s financial records. When the records are not kept on an accrual basis of accounting, the provider shall make the adjustments necessary to convert the information to an accrual basis for reporting. Providers who are multiple program agencies shall submit a cost allocation schedule, prepared in accordance with recognized methods and procedures.
(4) Failure to maintain records adequate to support the Financial and Statistical Report for Purchase of Service, Form SS-1703-0, may result in termination of the provider’s HCBS MR certification.
(5) The department may require that an opinion of a certified public accountant or public accountant accompany the report when adjustments made to prior reports indicate noncompliance with reporting instructions.
This rule is intended to implement Iowa Code section 249A.4.
	79.1(16) Outpatient reimbursement for hospitals.
a. Definitions.
“Ambulatory patient group (APG)” shall mean a group of similar outpatient procedures, encounters or ancillary services which are combined based on patient clinical characteristics and expected resource use. Data used to define APGs include ICD-9-CM diagnoses codes and CPT-4 procedure codes.
“Ancillary services” shall mean those tests and procedures ordered by a physician to assist in patient diagnosis or treatment. Ancillary procedures, such as immunizations, increase the time and resources expended during a visit, but do not dominate the visit.
“APG relative weight” shall mean a number that reflects the expected resource consumption for cases associated with each APG, relative to the average APG. That is, the Iowa-specific weight for a certain APG reflects the relative charge for treating all singleton cases classified in that particular APG, compared to the average charge for treating all Medicaid APGs in Iowa hospitals.
“Assessment payment” shall mean an additional payment made to a hospital for only the initial assessment and determination of medical necessity of a patient for the purpose of determining if the ER is the most appropriate treatment site. This payment shall be equal to 50 percent of the customary reimbursement rate for CPT-4 code 99281 (Evaluation and Management of a Patient in the Emergency Room) as of December 31, 1994.
“Base year cost report” shall mean the hospital’s cost report with fiscal-year-end on or after January 1, 1995, and prior to January 1, 1996, except as noted in paragraph “s.” Cost reports shall be reviewed using Medicare’s cost reporting and cost principles regulations for those cost reporting periods.
“Blended base amount” shall mean the case-mix adjusted, hospital-specific operating cost per visit associated with treating Medicaid outpatients, plus the statewide average case-mix adjusted operating cost per Medicaid visit, divided by two. This basic amount is the value to which add-on payments and inflation are added to form a final payment rate.
“Case-mix adjusted” shall mean the division of the hospital-specific base amount or other applicable components of the final payment rate by the hospital-specific case-mix index.
“Case-mix index” shall mean an arithmetical index measuring the relative average costliness of outpatient cases treated in a hospital, compared to the statewide average.
“Consolidation” shall mean the process by which the APG classification system determines whether separate payment is appropriate when a patient is assigned multiple significant procedure APGs. All significant procedures within a single APG are suppressed (or grouped) for payment purposes, into one APG. Multiple, related significant procedures in different APGs are consolidated into the highest weighted APG for reimbursement purposes. Multiple, unrelated significant procedures in different APGs are not consolidated; thus, each receives separate payment.
“Cost outlier” shall mean cases which have an extraordinarily high cost as established in paragraph “g” and, thus, are eligible for additional payments above and beyond the base APG payment.
“Current procedural terminology—fourth edition (CPT-4)” is the systematic listing and coding of procedures and services provided by physicians or other related health care providers. The CPT-4 coding is maintained by the American Medical Association and is updated yearly.
“Direct medical education costs” shall mean a per visit add-on to the APG payment amount which shall compensate for costs associated with outpatient direct medical education of interns and residents. Costs associated with direct medical education are determined from the hospital base year cost reports and are inflated.
“Discounting” shall mean a reduction in standard payment when related procedures or ancillary services are performed during a single visit. Discount rates are defined in paragraph “h.”
“Final payment rate” shall mean the blended base amount that forms the final dollar value used to calculate each provider’s reimbursement amount, when multiplied by the APG weight. These dollar values are displayed on the rate table listing.
“Graduate medical education and disproportionate share fund” shall mean a reimbursement fund developed as an adjunct reimbursement methodology to directly reimburse qualifying hospitals for the direct costs of interns and residents associated with the operation of graduate medical education programs for outpatient services.
“Grouper” shall mean the Version 2 Grouper software developed by Minnesota Mining and Manufacturing (3M) for the Health Care Financing Administration, with modifications for payable APGs made to support Medicaid program policy in Iowa. (See paragraph “i.”)
“Hospital-based clinic” means a clinic that is owned by the hospital, operated by the hospital under its hospital license, and on the premises of the hospital.
“Inlier” shall mean those cases where the cost of treatment falls within the established cost boundaries of APG payment.
“International classifications of diseases—fourth edition, ninth revision (ICD-9)” is a systematic method used to classify and provide standardization to coding practices which are used to describe the diagnosis, symptom, complaint, condition or cause of a person’s injury or illness.
“Outpatient visit” shall mean those hospital-based outpatient services which are billed on a single UB-92 claim form, and which occur within 72 hours of initiation of service, with exceptions as noted in paragraph “m.”
“Packaging” shall mean the inclusion of routinely performed ancillary services in the reimbursement of an APG. In the APG classification system, there are many routine, low-cost ancillary procedures or tests, such as routine urinalysis which are customarily ordered and performed during a visit. When this ancillary service is packaged, this indicates that the relative APG weight has been set to reflect the inclusion of the costs of the related ancillary procedures. The packaged APGs are 310 (plain film), 332 (simple pathology), 343 (simple immunology), 345 (simple microbiology), 347 (simple endocrinology), 350 (basic chemistry), 349 (simple chemistry), 351 (multichannel chemistry), 359 (urinalysis), 356 (simple clotting), 358 (simple hematology), 360 (blood and urine dipstick), 371 (simple pulmonary function tests), 373 (cardiogram), 383 (introduction of needles and catheter), 384 (dressings and other minor procedures), 385 (other ancillary procedures), and 321 (anesthesia).
“Peer review organization (PRO)” shall mean the organization that performs medical peer review of Medicaid claims, including review of validity of hospital diagnosis and procedure coding information; completeness, adequacy and quality of care; and appropriateness of prospective payments for outlier cases and nonemergent use of the emergency room.
“Rate table listing” shall mean a schedule of rate payments maintained by the department for each provider. The rate table listing is defined as the output that shows the final payment rate by hospital before being multiplied by the appropriate APG weight.
“Rebasing” shall mean the redetermination of the blended base amount or other applicable components of the final payment rate from more recent Medicaid cost report data.
“Recalibration” shall mean the adjustment of all APG weights to reflect changes in relative resource consumption.
“Risk corridor” shall mean payment limits to prevent immediate large financial gains or losses for Iowa hospitals due to APG implementation.
“Significant procedure APG” shall mean a procedure which constitutes the reason for the visit and which dominates the time and resources expended during the visit.
“Singleton APG” shall mean those APGs on a patient claim which, following consolidation of significant procedures and packaging of ancillaries, are part of a visit with no remaining multiple significant procedures. These singletons, as well as medical and ancillary visits, are used to calculate relative weights in the procedure described in paragraph “d.”
“Statewide visit expected payment (SVEP)” shall mean the expected payment for an outpatient visit, for use in defining cost outliers. This payment equals the sum of the statewide average case-mix adjusted operating cost per Medicaid visit multiplied by the relative weight for each valid APG within a visit (following packaging and discounting), which includes the applicable fee schedule amounts.
b. Determination of final payment rate amount. Each hospital’s APG-based payment equals the hospital’s case-mix index multiplied by the number of valid visits multiplied by the blended base amount. The blended base rate is then adjusted, so that statewide reimbursement equals statewide valid costs from cost reports. Payment is then recomputed using the adjusted blended base amount. The hospital’s final APG payment amount reflects the sum of inflation adjustments to the blended base amount.
c. Trimming of outpatient charge data. Trimming of outliers from charge data is necessary to minimize the impact of coding errors and to ensure that charges for one unusual case do not bias the resulting weights. Trimmed data is not excluded from analysis; instead, values outside the trim points are reset, as described below. Standard deviation methodology is used to set trim points. For each APG, the mean charge and standard deviation are computed geometrically, based on all singleton occurrences of that APG. In a first pass, the trim points equal the mean charge, plus or minus two times the standard deviation for that APG. The mean charge and standard deviation are then geometrically computed again, with charges trimmed at the first pass trim points. The final low trim point equals the new mean charge minus 1.5 times the new standard deviation and, correspondingly, the final high trim point equals the new mean charge plus 1.5 times the new standard deviation.
d. Calculation of Iowa-specific relative weights and case-mix index. Using all applicable claims with dates of service occurring in the period July 1, 1994, through March 22, 1996, and paid through March 22, 1996, relative weights were calculated using all valid singleton claims, which had been trimmed at high and low trim points, as discussed in paragraph “c.” Using all applicable claims with dates of service occurring within the individual hospital’s 1995 fiscal year and paid through March 22, 1996, the hospital-specific case-mix indices were calculated using all valid singleton claims, which had been trimmed at the high and low trim points, as discussed in paragraph “c.”
(1) A relative weight is determined for each APG through the following calculations:
	1.	The statewide geometric mean charge is determined for all singleton occurrences of each APG.
	2.	The statewide aggregate geometric mean charge is computed by summing the statewide geometric charge for all APGs and dividing by the total number of APG occurrences.
	3.	The statewide geometric mean charges for each APG are divided by the statewide aggregate geometric mean charge for all APGs to derive the Iowa-specific relative weight for each APG.
	4.	Relative weights for APGs which had low or no volume in the claims data, and those weights which were deemed too high or low by a committee of clinicians from the Iowa Foundation for Medical Care, shall be administratively adjusted.
	5.	The relative weights are then normalized, so that the average case has a weight of one.
(2) The hospital-specific case-mix index is computed by summing the relative weights for each valid occurrence of an APG at that hospital and dividing by the number of valid Medicaid visits for that hospital.
e. Calculation of blended base amount. The APG blended base amount reflects a 50/50 blend of statewide and hospital-specific base amounts.
(1) Calculation of statewide average case-mix adjusted cost per visit. The statewide average cost per visit is calculated by subtracting from the statewide total Iowa Medicaid outpatient expenditures: the total calculated dollar expenditures based on hospitals’ base year cost reports for medical education costs, and, using valid claims, calculation of actual payments that will be made for outliers, fee scheduled laboratory services, and services known as noninpatient programs as set forth at 441—subrule 78.31(1), paragraphs “g” to “n.” The remaining amount (which has been case-mix adjusted and adjusted to reflect inflation) is divided by the statewide total number of Iowa Medicaid visits reported in the Medicaid management information system (MMIS).
(2) Calculation of hospital-specific case-mix adjusted average cost per visit. The hospital-specific case-mix adjusted average cost per visit is calculated by subtracting from the lesser of total Iowa Medicaid costs, or covered reasonable charges as determined by the hospital’s base year cost report or MMIS claims system, the actual dollar expenditures for direct medical education costs for interns and residents and, using valid claims, calculation of actual payments that will be made for outliers, fee scheduled laboratory services and services known as noninpatient programs as set forth at 441—subrule 78.31(1), paragraphs “g” to “n.”  The remaining amount is case-mix adjusted, adjusted to reflect inflation and divided by the total number of Iowa Medicaid visits from the MMIS claims system or cost report, whichever is greater, for that hospital during the applicable base year.
(3) Calculation of the blended statewide and hospital-specific base amount. The hospital-specific case-mix adjusted average cost per visit is added to the case-mix adjusted statewide average cost per visit and divided by two to arrive at a 50/50 blended base amount.
f. Payment add-ons. If applicable to the provider, direct outpatient costs associated with education of interns and residents will be added to the base APG amount prior to setting the final APG payment rate and shall be reimbursed to qualifying hospitals on a per claim basis if the claim has a first date of service prior to July 1, 1997. The amount added on reflects Iowa Medicaid’s average cost per visit for hospital-specific direct medical education adjusted to case-mix. This add-on is determined from the base year cost reports and is adjusted to reflect inflation. For claims with a first date of service on or after July 1, 1997, all applicable reimbursement for graduate medical education shall be calculated and distributed according to policy at paragraph “v.”
g. Outlier payment policy. Additional payment is made for approved cases meeting or exceeding the following Medicaid criteria of cost outliers for each APG.
Cases qualify as cost outliers when costs of service in a given case exceed the cost threshold. For visits with a “statewide visit expected payment (SVEP)” equal to or between $150 and $700, this cost threshold is determined to be two times the statewide average APG-based payment or SVEP for that visit. For SVEPs greater than $700, the outlier cost threshold for a hospital outpatient visit equals the statewide average payment plus $500. There is no outlier threshold (or additional payment) for hospital visits with an SVEP less than $150. Costs are calculated using hospital-specific cost-to-charge ratios determined in the base year cost reports. Additional payment for cost outliers is 60 percent of the excess between the hospital’s cost for the visit and the cost threshold established to define cost outliers.
h. Discounting policy. The purpose of reducing standard payment for multiple procedures or ancillaries in a single visit is to encourage efficient provision of these services. The discount factor reflects the fact that fixed costs are reduced for multiple procedures. Examples of fixed costs are: operating room charges, anesthesia, and specimen collection. Claims for multiple medical visits within a 72-hour period and claims for services billed in “batches” (see paragraph “m”) are not subject to discounted payment. Multiple, nonconsolidated significant procedures will be paid at 100 percent of the expected APG payment for the procedure with the highest relative weight for that APG occurrence, 60 percent of next highest weighted APG payment for the second occurrence and 40 percent for the third or more occurrence. Multiple nonpackaged laboratory tests within the same APG will be paid at 100 percent of the expected APG payment for the first APG occurrence, and 80 percent of expected APG payment for each subsequent occurrence. Multiple, nonpackaged nonlaboratory ancillaries in the same APG will be paid at 100 percent of the expected APG payment for the first APG occurrence, 60 percent of expected APG payment for the second occurrence and 40 percent for the third or more occurrence.
Clinical laboratory testing performed by a hospital shall be paid using the Medicare fee schedule as set forth at rule 441—78.20(249A) in instances when the only procedure performed by the hospital is the collection or testing of the specimen.
i. Services covered by APG payments. Medicaid adopts the Medicare definition of outpatient hospital services at 42 CFR 414.32, as amended to September 15, 1992, which will be covered by the APG-based prospective payment system, except as indicated herein. As a result, combined billing for physician services is eliminated unless the hospital has approval from the Health Care Financing Administration (HCFA) to combine bills. Teaching hospitals having HCFA’s approval to receive reasonable cost reimbursement for physician services under 42 CFR 415.58 as amended to November 25, 1991, are eligible for combined billing status if they have filed the approval notice with the department’s fiscal agent. Reasonable cost settlement for teaching physicians for those costs not included in the APG cost-finding process will be made during the year-end settlement process. Services provided by certified nurse anesthetists (CRNAs) employed by a physician are covered by physician reimbursement. Payment for the services of CRNAs employed by the hospital are included in the hospital’s reimbursement.
Ambulance transportation will not be reimbursed by APG payment. A hospital-based ambulance service must be an enrolled Medicaid ambulance provider and follow policy as specified at rule 441—78.11(249A) unless the recipient’s condition results in an inpatient admission to the hospital. In the case of an inpatient admission, the reimbursement for ambulance services is included in the hospital’s DRG reimbursement rate. Enrollment information and claim submission for ambulance services should be directed to the Medicaid fiscal agent.
Claims for all noninpatient services (NIP), including outpatient mental health, substance abuse, eating disorders, cardiac rehabilitation, pulmonary rehabilitation, diabetic education, pain management, and nutritional counseling, should be billed to Iowa Medicaid and will be paid under the respective NIP program on a fixed fee schedule.
Upon implementation of the managed mental health care program (MHAP), all psychiatric services for recipients with a primary diagnosis of mental illness, except for reference lab services and radiology services, in those eligibility groups targeted under the MHAP program will be the responsibility of the MHAP contractor and will not be otherwise payable by Iowa Medicaid. Emergency psychiatric evaluations for recipients who are covered by the MHAP program will be the responsibility of the contractor. For those recipients who are not covered by the MHAP program, services will be payable under either the APG for emergency psychiatric evaluation or under the respective NIP program. Additionally, laboratory services to monitor Clozaril are payable under the APG system only if the recipient is not MHAP eligible. Eligibility groups served under the managed substance abuse care plan (MSACP) program, will be the responsibility of the MSACP contractor and not payable through the APG system. The only exceptions to this policy are reference laboratory and radiology services, which will be payable by fee schedule or APG.
Claims for the following APGs, as defined in Version 2 of the Grouper software, will not be accepted by Iowa Medicaid for payment: APG 005—Nail Procedures, APG 171—Artificial Fertilization, APG 212—Fitting of Contact Lenses, APG 386—Biofeedback and hypnotherapy, and APG 382—Provision of vision aids.
Claims grouping into APG 702 (Well Child Exam) shall meet all early and periodic screening, diagnosis and treatment requirements as set forth at rule 441—84.3(249A).
j. System implementation, rebasing, and recalibration. For state fiscal years 1995 and 1996, a risk corridor has been established to ensure that APG payments to each hospital will not be less than 95 percent or greater than 105 percent of Medicaid allowable costs. For the state fiscal year 1997, a risk corridor has been established to ensure that hospital payments will not be less than 90 percent or greater than 110 percent of Medicaid allowable costs.
Periodic interim payments, made quarterly to ensure adequate cash flow to hospitals during the transition, will begin 30 days after the quarter ending March 31, 1995. No periodic interim payment will be made to any hospital within the corridor limits. Money may also be requested to be refunded if an overpayment exists.
The APG system will be rebased and recalibrated every three years beginning October 1, 1996. Cost reports used will be hospital fiscal year-end reports within the calendar year ending no later than December 31, 1995. Case-mix indices shall be calculated using valid claims most nearly matching each hospital’s fiscal year end.
k. Payment to out-of-state hospitals. Payment made to out-of-state hospitals providing care to beneficiaries of Iowa’s Medicaid program is equal to either the Iowa statewide average case-mix adjusted base amount or the Iowa statewide average case-mix adjusted base amount blended with the hospital-specific base amount. Hospitals that submit a cost report with data for Iowa Medicaid patients only, no less than 120 days prior to rebasing, will receive a case-mix adjusted blended base rate using hospital-specific Iowa only Medicaid data and the Iowa statewide average cost per visit amount. If a hospital qualifies for reimbursement for the direct medical education component under Medicare guidelines, it shall qualify for this add-on component for reimbursement purposes in Iowa. Hospitals wishing to submit the HCFA 2552 (or HCFA accepted substitute) cost report must do so within 60 days from the date of patient visit to the state of Iowa’s fiscal agent. Hospitals which elect to submit cost reports for the determination of blended rates shall submit new reports to the department’s fiscal agent on an annual basis within 90 days of the close of the hospital’s fiscal year end. When audited, finalized reports become available from the Medicare intermediary, the facility may submit them to the Iowa Medicaid fiscal agent.
l. Preadmission, preauthorization or inappropriate services. Inpatient or outpatient services which require preadmission or preprocedure approval by the PRO are updated yearly and are available from the PRO. The hospital shall provide the PRO authorization number on the UB-92 claim form to receive payment. Claims submitted for payment without this authorization number will be denied. To safeguard against other inappropriate practices, the department, through the PRO, will monitor admission practices and quality of care. If an abuse of the prospective payment system is identified, payments for abusive practices may be reduced or denied. In reducing or denying payment, Medicaid adopts the Medicare PRO regulations.
m. Hospital billing. Hospitals shall normally submit a UB-92 claim, with all services occurring within a 72-hour period, for APG reimbursement to the fiscal intermediary after a patient’s outpatient “visit” is complete. Payment for outlier costs is determined when the claim is filed with the fiscal agent, as described in paragraph “g.” However, the following exceptions are allowed:
(1) Bills for multiple visits may be submitted on a single claim for the following services: noninpatient units (substance abuse, pain management, nutritional counseling, diabetic education, pulmonary rehabilitation, cardiac rehabilitation, eating disorders and mental health), physical, occupational and speech therapies, chemotherapy, radiation therapy, and renal dialysis. For these services, each unit of service on the UB-92 claim form will be considered a separate visit.
(2) Bills for multiple medical encounters (for unrelated diagnoses), such as clinic visits, occurring within a 72-hour period shall be submitted on separate UB-92 claim forms in order to generate full APG payment for these encounters. In the case of hospital-based clinics where multiple, unrelated medical visits occur on the same day, an individual claim form will need to be filed for each separate visit.
n. Determination of inpatient admission. A person is considered to be an inpatient when a formal inpatient admission occurs, when a physician intends to admit a person as an inpatient, or when a physician determines that a person being observed as an outpatient in an observation or holding bed should be admitted to the hospital as an inpatient. In cases involving outpatient observation status, the determinant of patient status is not the length of time the patient was being observed, rather whether the observation period was medically necessary to determine whether a patient should be admitted to the hospital as an inpatient. Outpatient observation lasting greater than a 24-hour period will be subject to review by the PRO to determine the medical necessity of each case. For those outpatient observation cases where medical necessity is not established, reimbursement shall be denied for the services found to be unnecessary for the provision of that care, such as the use of the observation room.
o. Inpatient admission after outpatient services. A patient may be admitted to the hospital as an inpatient after receiving outpatient services. If the patient is admitted as an inpatient within three days of the day in which outpatient services were rendered, all outpatient services related to the principal diagnosis are considered inpatient services for billing purposes. The day of formal admission as an inpatient is considered as the first day of hospital inpatient services.
p. Cost report adjustments. Hospitals with 1995 cost reports adjusted by Medicare through the cost settlement process for cost reports applicable to the APG base year, may appeal to the department the hospital-specific base and add-on costs used in calculating the Medicaid APG rates if the Medicare adjustment results in a material change to the rate. Any appeal of the APG rate due to Medicare’s adjustment process must be made in writing to the department within 30 days of Medicare’s finalization and notification to the provider. If the provider does not notify the department of the adjusted amounts within the 30-day period, no costs shall be reconsidered for adjustment by Iowa Medicaid. Claims adjustment reflecting the changed rates shall only be made to claims that have been processed within one year prior to the notification from the provider or the beginning of the rebasing period, whichever is less.
q. Determination of payment amounts for mental health noninpatient (NIP) services. Mental health NIP services are limited as set forth at 441—78.31(4)“d”(7) and are reimbursed on a fee schedule basis. Upon implementation of a managed mental health care program, mental health NIP services will become the responsibility of the managed mental health contractor for persons eligible for managed mental health care.
r. Payment for outpatient services delivered in the emergency room. Payment for outpatient services delivered in the emergency room shall be based on the following criteria. All visits to hospital emergency rooms by Medicaid beneficiaries which do not result in inpatient admission shall result in the hospital receiving payment, at a level to be determined by the department, for patient assessment. All treatment conducted in the emergency room for either a regular Medicaid recipient or a Medipass participant, for conditions defined as emergent in accord with diagnoses codes found in the provider manual, shall receive the full APG payment plus the assessment payment. If a regular Medicaid patient is referred by a non-emergency room based physician, as documented in the record and on the claim, and is treated in the emergency room but does not have an emergency diagnosis, the hospital shall receive the assessment payment plus 75 percent of the APG payment. If the patient is assessed in the emergency room, found to be nonemergent and referred for further treatment to a hospital-based clinic, regular clinic, physician’s office, or other similar site, only the assessment payment shall be made to the hospital for the emergency room. The responsible clinic or physician’s office shall subsequently bill for any additional services provided. If the patient is not referred by a physician and does not have an emergent condition, but was treated in the emergency room setting, the hospital will receive 50 percent of the APG payment plus an assessment payment.
For Medicaid beneficiaries participating in the Medipass program, an assessment payment plus 75 percent of the full APG payment shall be paid for treatment of nonemergent conditions contingent upon documentation in the claim and medical record of permission or referral from the recipient’s primary care physician. Should treatment for nonemergent conditions be provided to Medipass participants without this documentation, payment shall consist only of the assessment payment. When a Medipass patient is treated in a hospital-based clinic and that clinic is the Medipass patient manager, the full APG payment will be made. When the patient is treated in a hospital-based clinic, the clinic is not the patient manager and has not obtained the permission of the recipient’s patient manager to perform the treatment, no payment shall be made to the clinic.
s. Rescinded IAB 7/31/96, effective 10/1/96.
t. Limitations on payments. Ambulatory patient groups, as well as other outpatient services, are subject to upper limits rules set forth in Sections 42 CFR 447.321 and 447.325 as amended to July 28, 1987. Requirements under these sections state that in general, Medicaid may not make payments to providers that would exceed the amount that would be payable to providers under comparable circumstances under Medicare. In aggregate, the total Medicaid payments may not exceed the total payments received by all providers from recipients, carriers or intermediaries for providing comparable services under comparable circumstances under Medicare.
u. PRO review. For outpatient claims with dates of service ending July 1, 1994, and after, the PRO will review a yearly random sample of at least 500 hospital outpatient service cases performed for Medicaid recipients and identified on fiscal agent claims data from all Iowa and bordering state hospitals. The PRO will perform review activities on all APG categories for concerns relating to admission review, quality review, and APG validation. Questionable cases will be referred to a physician reviewer for concerns relating to medical necessity and quality of care. The PRO will also conduct a retrospective review of hospital claims assessing observation bed status lasting more than 24 hours. The review will consist of an evaluation for the appropriateness of the admission and continued stay in the observation bed status. Questionable cases will be referred to a physician reviewer for determination of the medical necessity.
When a review identifies a potential adverse determination by the PRO, an initial letter informing the provider about the adverse action will be sent and the provider will be given an opportunity to submit additional information about the case. This information will be taken into account prior to the final review determination. If the final review decision is upheld, a final letter will be sent to all parties. A reconsideration process will be available to all parties when there are payment consequences associated with the decision. The fiscal agent will be notified of all decisions resulting in payment consequences and appropriate adjustments will be made to claims.
Hospitals with cases under review must submit all requested supporting data from the medical record to the PRO within 60 days of receipt of the request or payment for those services may be recouped and forfeited. The hospital may request a review by submitting documentation to the PRO within 365 calendar days of the claim adjudication date. If a request is not filed by the hospital within that time, the hospital loses the right to appeal or contest that payment.
v. Graduate medical education and disproportionate share fund. Payment shall be made to all hospitals qualifying for direct medical education directly from the graduate medical education and disproportionate share fund. The amount in the fund and distributions from the fund shall be calculated as follows:
(1) Allocation for direct medical education. To determine the total amount of funding that will be allocated to the graduate medical education and disproportionate share fund, the department shall:
	1.	Sum all direct medical education add-on payments for outpatient services using claims reimbursed to qualifying providers with the first date of service on or after October 1, 1996, prior to March 31, 1997, and paid through June 30, 1997. These amounts shall then be multiplied by two to annualize the amount of money to be placed in the fund for distribution and the total amount of computed reimbursement shall be allocated to the fund.
	2.	Sum all direct medical education add-on payments for outpatient services, using claims reimbursed to qualifying providers, when those claims have been used as a basis for the calculation of capitation rates and reimbursement with any health maintenance organization (HMO) or other prepaid health plan with which the department has entered into a contract effective on or after July 1, 1997.
For each prepaid health plan, divide the total dollar reimbursement from claims by the number of member months applicable to the rate-setting methodology for the per member per month (PMPM) allocation to calculate the amount of reimbursement to be allocated to the fund that represents capitation rate reimbursement allocation for direct medical education. The direct medical education PMPM allocation shall then be multiplied by the total number of members enrolled in the plan for state fiscal year 1997, allocating that amount of money to the fund.
3. Trend the total allocation for direct medical education (which includes money for both the fee for service population and the capitated risk-based population, calculated under numbers “1” and “2” above) forward using annually appropriated legislative update factors and determine the total amount of money that shall be allocated to the graduate medical education and disproportionate share fund for direct medical education Medicaid reimbursement. No adjustments shall be made to this fund beyond appropriated amounts.
(2) Distribution of direct medical education. Distribution of the fund for direct medical education shall be on a quarterly basis beginning October 1, 1997, and shall be calculated by taking the previous fiscal year’s percentage allocation of direct medical education reimbursement (based upon paid outpatient claims to qualifying hospitals) and multiplying that percentage by the amount in the fund for direct medical education.
If a hospital fails to qualify for the provision of medical education under Medicare regulations, the amount of money that would have been allocated that hospital shall be removed from the total fund.
w. Adjustments to the graduate medical education and disproportionate share fund for changes in utilization. Money shall be added to or subtracted from the graduate medical education and disproportionate share fund, when the average monthly Medicaid population deviates from the previous year’s averages by greater than 5 percent. The average annual population (expressed in a monthly total) shall be determined on June 30 for both the previous and current years by adding the total enrolled population for all respective months from both years’ B-1 MARS report and dividing each year’s totals by 12. If the average monthly number of enrolled persons for the current year is found to vary more than 5 percent from the previous year, a PMPM amount shall be calculated for each component (using the average number of eligibles for the previous year calculated above) and an annualized PMPM adjustment shall be made for each eligible person that is beyond the 5 percent variance.
	79.1(17)  Reimbursement for HCBS brain injury waiver services.
a. To receive reimbursement for services a certified provider shall enter into an agreement with the department on Form 470-2918, HCBS Waiver Agreement, and have an approved individual comprehensive plan for the consumer.
b. Costs reported under the waiver shall not be reported as costs for reimbursement under any other funding source. Costs incurred from other services shall not be reported as costs for reimbursement under the waiver.
c. Providers shall submit a cost report for each waiver service provided using Form SS-1703-0, Financial and Statistical Report for Purchase of Service. The cost reporting period is from July 1 to June 30. The completed Financial and Statistical Report shall be submitted to the department, division of medical services, by September 30 of each year.
(1) A provider’s initial rates shall be based on projected costs unless the provider has historical records upon which to base the costs. The initial rate shall be reviewed after six months and shall be adjusted as necessary to be based on the provider’s actual cost.
(2) The rates a provider may charge are subject to the limits established in subrule 79.1(2).
(3) Financial information shall be based on the provider’s financial records. When the records are not kept on an accrual basis of accounting, the provider shall make the adjustments necessary to convert the information to an accrual basis for reporting when the financial and statistical report is completed. Records of cash receipts and disbursements shall be adjusted to reflect accruals of income and expenses. Providers who are multiple program agencies shall submit a cost allocation schedule prepared in accordance with recognized methods and procedures.
(4) Failure to maintain records adequate to support the Financial and Statistical Report for Purchase of Services, Form SS-1703-0, may result in termination of the provider’s HCBS brain injury certification.
(5) Providers not using the accrual basis of accounting shall adjust amounts to the accrual basis when the financial and statistical report is completed. Records of cash receipts and disbursements shall be adjusted to reflect accruals of income and expenses.
(6) The department may require that an opinion of a certified public accountant or public accountant accompany the report when adjustments made to prior reports indicate noncompliance with reporting instructions.
This rule is intended to implement Iowa Code section 249A.4.
1	Effective 1/l/89, IAB 12/14/88
2	The department may utilize flexibility in allocating the increase for medical equipment and supplies so that equipment and supplies which have greater wholesale cost increases may be reimbursed at a higher rate and those which have a lower or no wholesale cost increase may be reimbursed at a lower rate or have no increase.
441—79.2(249A) Sanctions against provider of care. The department reserves the right to impose sanctions against any practitioner or provider of care who has violated the requirements for participation in the medical assistance program.
	79.2(1) Definitions.
“Affiliates” means persons having an overt or covert relationship such that any one of them directly or indirectly controls or has the power to control another.
“Fiscal agent” means an organization which processes and pays provider claims on behalf of the department.
“Person” means any natural person, company, firm, association, corporation, or other legal entity.
“Probation” means a specified period of conditional participation in the medical assistance program.
“Provider” means an individual, firm, corporation, association, or institution which is providing or has been approved to provide medical assistance to a recipient pursuant to the state medical assistance program.
“Suspension from participation” means an exclusion from participation for a specified period of time.
“Suspension of payments” means the withholding of all payments due a provider until the resolution of the matter in dispute between the provider and the department.
“Termination from participation” means a permanent exclusion from participation in the medical assistance program.
“Withholding of payments” means a reduction or adjustment of the amounts paid to a provider on pending and subsequently submitted bills for purposes of offsetting overpayments previously made to the provider.
	79.2(2) Grounds for sanctioning providers. Sanctions may be imposed by the department against a provider for any one or more of the following reasons:
	a. 	Presenting or causing to be presented for payment any false or fraudulent claim for services or merchandise.
	b. 	Submitting or causing to be submitted false information for the purpose of obtaining greater compensation than that to which the provider is legally entitled, including charges in excess of usual and customary charges.
	c. 	Submitting or causing to be submitted false information for the purpose of meeting prior authorization requirements.
	d. 	Failure to disclose or make available to the department or its authorized agent, records of services provided to medical assistance recipients and records of payments made for those services.
	e. 	Failure to provide and maintain the quality of services to medical assistance recipients within accepted medical community standards as adjudged by professional peers.
	f. 	Engaging in a course of conduct or performing an act which is in violation of state or federal regulations of the medical assistance program, or continuing that conduct following notification that it should cease.
	g. 	Failure to comply with the terms of the provider certification on each medical assistance check endorsement.
	h. 	Overutilization of the medical assistance program by inducing, furnishing or otherwise causing the recipient to receive services or merchandise not required or requested by the recipient.
	i. 	Rebating or accepting a fee or portion of a fee or a charge for medical assistance patient referral.
	j. 	Violating any provision of Iowa Code chapter 249A, or any rule promulgated pursuant thereto.
	k. 	Submission of a false or fraudulent application for provider status under the medical assistance program.
	l. 	Violations of any laws, regulations, or code of ethics governing the conduct of occupations or professions or regulated industries.
	m. 	Conviction of a criminal offense relating to performance of a provider agreement with the state or for negligent practice resulting in death or injury to patients.
	n. 	Failure to meet standards required by state or federal law for participation, for example, licensure.
	o. 	Exclusion from Medicare because of fraudulent or abusive practices.
	p. 	Documented practice of charging recipients for covered services over and above that paid for by the department, except as authorized by law.
	q. 	Failure to correct deficiencies in provider operations after receiving notice of these deficiencies from the department.
	r. 	Formal reprimand or censure by an association of the provider’s peers for unethical practices.
	s. 	Suspension or termination from participation in another governmental medical program such as workers’ compensation, crippled children’s services, rehabilitation services or Medicare.
	t. 	Indictment for fraudulent billing practices, or negligent practice resulting in death or injury to the provider’s patients.
	u. 	Failure to repay or reach written agreement for the repayment of overpayments or other erroneous payments within 60 days of receipt of the overpayment.
	79.2(3) Sanctions. The following sanctions may be imposed on providers based on the grounds specified in 79.2(2).
	a. 	A term of probation for participation in the medical assistance program.
	b. 	Termination from participation in the medical assistance program.
	c. 	Suspension from participation in the medical assistance program. This includes when the department is notified by the Health Care Financing Administration, Department of Health and Human Services, that a practitioner has been suspended from participation under the Medicare program. These practitioners shall be suspended from participation in the medical assistance program effective on the date established by the Health Care Financing Administration and at least for the period of time of the Medicare suspension.
	d. 	Suspension or withholding of payments to provider.
	e. 	Referral to peer review.
	f. 	Prior authorization of services.
	g. 	One hundred percent review of the provider’s claim prior to payment.
	h. 	Referral to the state licensing board for investigation.
	i. 	Referral to appropriate federal or state legal authorities for investigation and prosecution under applicable federal or state laws.
	j. 	Providers with a total Medicaid credit balance of more than $500 for more than 60 consecutive days without repaying or reaching written agreement to repay the balance shall be charged interest at 10 percent per year on each overpayment. The interest shall begin to accrue retroactively to the first full month that the provider had a credit balance over $500.
Nursing facilities shall make repayment or reach agreement with the division of medical services. All other providers shall make repayment or reach agreement with the Medicaid fiscal agent. Overpayments and interest charged may be withheld from future payments to the provider.
	79.2(4) Imposition and extent of sanction.
	a. 	The decision on the sanction to be imposed shall be the commissioner’s or designated representative’s except in the case of a provider terminated from the Medicare program.
	b. 	The following factors shall be considered in determining the sanction or sanctions to be imposed:
	(1)	Seriousness of the offense.
	(2)	Extent of violations.
	(3)	History of prior violations.
	(4)	Prior imposition of sanctions.
	(5)	Prior provision of provider education.
	(6)	Provider willingness to obey program rules.
	(7)	Whether a lesser sanction will be sufficient to remedy the problem.
	(8)	Actions taken or recommended by peer review groups or licensing boards.
	79.2(5) Scope of sanction.
	a. 	The sanction may be applied to all known affiliates of a provider, provided that each decision to include an affiliate is made on a case-by-case basis after giving due regard to all relevant facts and circumstances. The violation, failure, or inadequacy of performance may be imputed to a person with whom the violator is affiliated where the conduct was accomplished in the course of official duty or was effectuated with the knowledge or approval of that person.
	b. 	Suspension or termination from participation shall preclude the provider from submitting claims for payment whether personally or through claims submitted by any clinic, group, corporation, or other association to the department or its fiscal agent for any services or supplies provided under the medical assistance program except for those services provided prior to the suspension or termination.
	c. 	No clinic, group, corporation, or other association which is the provider of services shall submit claims for payment to the department or its fiscal agent for any services or supplies provided by a person within the organization who has been suspended or terminated from participation in the medical assistance program except for those services provided prior to the suspension or termination.
	d. 	When the provisions of paragraph 79.2(5)“c” are violated by a provider of services which is a clinic, group, corporation, or other association, the department may suspend or terminate the organization, or any other individual person within the organization who is responsible for the violation.
	79.2(6) Notice of sanction. When a provider has been sanctioned, the department shall notify as appropriate the applicable professional society, board of registration or licensure, and federal or state agencies of the findings made and the sanctions imposed.
	79.2(7) Notice of violation. Should the department have information that indicates that a provider may have submitted bills or has been practicing in a manner inconsistent with the program requirements, or may have received payment for which the provider may not be properly entitled, the department shall notify the provider of the discrepancies noted. Notification shall set forth:
	a. 	The nature of the discrepancies or violations,
	b. 	The known dollar value of the discrepancies or violations,
	c. 	The method of computing the dollar value,
	d. 	Notification of further actions to be taken or sanctions to be imposed by the department, and
	e. 	Notification of any actions required of the provider. The provider shall have 15 days subsequent to the date of the notice prior to the department action to show cause why the action should not be taken.
	79.2(8) Suspension or withholding of payments pending a final determination. Where the department has notified a provider of a violation pursuant to 79.2(7) or an overpayment, the department may withhold payments on pending and subsequently received claims in an amount reasonably calculated to approximate the amounts in question or may suspend payment pending a final determination. Where the department intends to withhold or suspend payments it shall notify the provider in writing.
This rule is intended to implement Iowa Code section 249A.4.
441—79.3(249A) Maintenance of clinical and fiscal records by provider of service. Providers of service shall maintain clinical and fiscal records in support of services for which a charge is made to the program and shall make such records available to duly authorized representatives of the department on request. The fiscal records shall support each item of service for which a charge is made to the program and the clinical records shall specify the procedure or procedures performed, the dates of service, the medications or other supplies or services prescribed or provided to the recipient together with information concerning progress of treatment. The clinical and fiscal records shall be retained for a minimum of five years. After five years the records may be destroyed.
This rule is intended to implement Iowa Code section 249A.4.
441—79.4(249A) Appeal by provider of care. Providers may appeal decisions of the department according to rules in 441—Chapter 7, Iowa Administrative Code.
This rule is intended to implement Iowa Code section 249A.4.
441—79.5(249A) Nondiscrimination on the basis of handicap. All providers of service shall comply with Section 504 of the Rehabilitation Act of 1973 and Federal regulations 45 CFR Part 84, as amended to December 19, 1990, which prohibit discrimination on the basis of handicap in all Department of Health and Human Services funded programs.
This rule is intended to implement Iowa Code subsection 249A.4(6).
441—79.6(249A) Provider participation agreement. Providers of medical and health care wishing to participate in the program shall execute an agreement with the department on Form XIX (PA-1), Agreement Between Provider of Medical and Health Services and the Iowa Department of Human Services re Participation in the Medical Assistance Program.
Exception:  Dental providers are required to complete Form 470-3174, Addendum to Dental Provider Agreement for Orthodontia, to receive reimbursement under the early and periodic screening, diagnosis, and treatment program. Rehabilitative treatment service providers wishing to participate in the program shall execute an agreement with the department on Form 470-3052, Rehabilitative Treatment and Supportive Services Contract.
In these agreements, the provider agrees to the following:
	79.6(1) To maintain clinical and fiscal records as specified in rule 79.3(249A).
	79.6(2) That the charges as determined in accordance with the department’s policy shall be the full and complete charge for the services provided and no additional payment shall be claimed from the recipient or any other person for services provided under the program.
	79.6(3) That it is understood that payment in satisfaction of the claim will be from federal and state funds and any false claims, statements, or documents, or concealment of a material fact may be prosecuted under applicable federal and state laws.
This rule is intended to implement Iowa Code section 249A.4.
441—79.7(249A) Medical assistance advisory council.
	79.7(1) Officers. Officers shall be a chairperson, and a vice-chairperson.
	a. 	Elections will be held the first meeting after the beginning of the calendar year.
	b. 	The term of office shall be one year. Officers shall serve no more than two terms.
	c. 	The vice-chairperson shall serve in the absence of the chairperson.
	d. 	The chairperson and vice-chairperson shall have the right to vote on any issue before the council.
	e. 	The chairperson shall appoint a nominating committee of not less than three members and shall appoint other committees approved by the council.
	79.7(2) Alternates. Each organization represented may select one alternate as representative when the primary appointee is unable to be present. Alternates may attend any and all meetings of the council, but only one representative of each organization shall be allowed to vote.
	79.7(3) Expenses. The travel expenses of the public representatives and other expenses, such as those for clerical services, mailing, telephone, and meeting place, shall be the responsibility of the department of human services. The department shall arrange for a meeting place, related services, and accommodations.
	79.7(4) Meetings. The council shall meet at least four times each year. At least two of these meetings shall be with the department of human services. Additional meetings may be called by the chairperson, upon written request of at least 50 percent of the members, or by the commissioner of the department of human services.
	a. 	Meetings shall be held in the Des Moines, Iowa, area, unless other notification is given.
	b. 	Written notice of council meetings shall be mailed at least two weeks in advance of such meetings. Each notice shall include an agenda for the meeting.
	79.7(5) Procedures.
	a. 	A quorum shall consist of 50 percent of the voting members.
	b. 	Where a quorum is present, a position is carried by two-thirds of the council members present.
	c. 	Minutes of council meetings and other written materials developed by the council shall be distributed by the department to each member and alternate and to the executive office of each organization or body represented.
	d. 	Notice shall be made to the representing organization when the member, or alternate, has been absent from three consecutive meetings.
	e. 	In cases not covered by these rules, Robert’s Rules of Order shall govern.
	79.7(6) Duties. The medical assistance advisory council shall:
	a. 	Make recommendations on the reimbursement for medical services rendered by providers of services.
	b. 	Assist in identifying unmet medical needs and maintenance needs which affect health.
	c. 	Make recommendations for objectives of the program and for methods of program analysis and evaluation, including utilization review.
	d. 	Reserved.
	e. 	Reserved.
	f. 	Recommend ways in which needed medical supplies and services can be made available most effectively and economically to the program recipients.
	g. 	Advise on such administrative and fiscal matters as the commissioner of the department of human services may request.
	h. 	Advise professional groups and act as liaison between them and the department.
	i. 	Report at least annually to the appointing authority.
	j. 	Perform other functions as may be provided by state or federal law or regulation.
	k. 	Communicate information considered by the council to the member organizations and bodies.
	79.7(7) Responsibilities.
	a. 	Recommendations of the council shall be advisory and not binding upon the department of human services or the member organizations and bodies. The department will consider all advice and counsel of the council.
	b. 	The council may choose subjects for consideration and recommendation. It shall consider all matters referred to it by the department of human services.
	c. 	Any matter referred by a member organization or body shall be considered upon an affirmative vote of the council.
	d. 	The department shall provide the council with reports, data, and proposed and final amendments to rules, regulations, laws, and guidelines, for its information, review, and comment.
	e. 	The department shall present the biennial budget for the medical assistance program for review and comment.
	f. 	The department shall permit staff members to appear before the council to review and discuss specific information and problems.
	g. 	The department shall maintain a current list of members and alternates on the council.
441—79.8(249A) Requests for prior authorization. When the fiscal agent has not reached a decision on a request for prior authorization after 60 days from the date of receipt by the fiscal agent, the request will be approved.
	79.8(1) Requests for prior approval for any items or procedures other than prescription drugs shall be made using Form XIX P Auth, Request for Prior Authorization. For prior authorization of prescription drugs, requests may be made by telephone, facsimile (fax) or mail. Requests for prior authorization made by fax or by mail shall be made using Form XIX Drug P Auth, Request For Drug Prior Authorization.
Requests for prior approval shall be sent to Consultec, Inc., P.O. Box 14422, Des Moines, Iowa 50306-3422. The request should include the relevant criteria applicable to the particular service, medication or equipment, for which prior approval is sought, according to the criteria outlined in rule 441—78.28(249A). Copies of history and examination results may be attached rather than incorporated in the letter.
	79.8(2) The policy applies to services or items specifically designated as requiring prior authorization.
	79.8(3) The provider shall receive a notice of approval or denial for all requests. In the case of prescription drugs, the requesting provider shall be notified of approval or denial using the same manner of transmission as the request, if possible, or by mail. Decisions regarding approval or denial will be made within 24 hours from the receipt of the prior authorization request. In cases where the request is received during nonworking hours, the time limitation will be construed to start with the first hour of the normal working day following the receipt of the request.
	79.8(4) Prior authorizations approved because a decision is not timely made shall not be considered a precedent for future similar requests.
	79.8(5) Approved prior authorization applies to covered services and does not apply to the recipient’s eligibility for medical assistance.
	79.8(6) If a provider is unsure if an item or service is covered because it is rare or unusual, the provider may submit a request for prior approval in the same manner as other requests for prior approval in 79.8(1).
	79.8(7) Requests for prior approval of services shall be reviewed according to rule 441—79.9(249A) and the conditions for payment as established by rule in 441—Chapter 78. Where ambiguity exists as to whether a particular item or service is covered, requests for prior approval shall be reviewed according to the following criteria in order of priority:
	a. 	The conditions for payment outlined in the provider manual with reference to coverage and duration.
	b. 	The determination made by the Medicare program unless specifically stated differently in state law or rule.
	c. 	The recommendation to the department from the appropriate advisory committee.
	d. 	Whether there are other less expensive procedures which are covered and which would be as effective.
	e. 	The advice of an appropriate professional consultant.
	79.8(8) The amount, duration and scope of the Medicaid program is outlined in 441—Chapters 78, 79, 81, 82 and 85. Additional clarification of the policies is available in the provider manual distributed and updated to all participating providers.
	79.8(9) Unless the prior authorization request is made for prescription drugs, recipients shall receive a notice of decision upon a denial of request for prior approval pursuant to 441—Chapter 7. The notice of decision to the recipient, Form MA-3028, shall be mailed within five working days of the date the prior approval form is returned to the provider. In the case of prior authorization for drugs, no notice of denial will be issued to recipients.
	79.8(10) If a request for prior approval is denied by the fiscal agent, the request may be resubmitted for reconsideration with additional information justifying the request. The aggrieved party may file an appeal in accordance with 441—Chapter 7.
This rule is intended to implement Iowa Code section 249A.4.
441—79.9(249A) General provisions for Medicaid coverage applicable to all Medicaid providers and services.
	79.9(1) Medicare definitions and policies shall apply to services provided unless specifically defined differently.
	79.9(2) The services covered by Medicaid shall:
	a. 	Be consistent with the diagnosis and treatment of the patient’s condition.
	b. 	Be in accordance with standards of good medical practice.
	c. 	Be required to meet the medical need of the patient and be for reasons other than the convenience of the patient or the patient’s practitioner or caregiver.
	d. 	Be the least costly type of service which would reasonably meet the medical need of the patient.
	e. 	Be eligible for federal financial participation unless specifically covered by state law or rule.
	f. 	Be within the scope of the licensure of the provider.
	g. 	Be provided with the full knowledge and consent of the recipient or someone acting in the recipient’s behalf unless otherwise required by law or court order or in emergency situations.
	h. 	Be supplied by a provider who is eligible to participate in the Medicaid program. The provider must use the billing procedures and documentation requirements described in 441—Chapters 78 and 80.
	79.9(3) Providers shall supply all the same services to Medicaid eligibles served by the provider as are offered to other clients of the provider.
	79.9(4) Recipients must be informed before the service is provided that the recipient will be responsible for the bill if a noncovered service is provided.
	79.9(5) Coverage in public institutions. Medical services provided to a person while the person is an inmate of a public jail, prison, juvenile detention center, or other public penal institution of more than four beds are not covered by Medicaid.
This rule is intended to implement Iowa Code section 249A.4.
441—79.10(249A) Requests for preadmission review. The inpatient hospitalization of Medicaid recipients is subject to preadmission review by the Iowa Foundation for Medical Care (IFMC) as required in rule 441—78.3(249A).
	79.10(1) The patient’s admitting physician, the physician’s designee or the hospital will contact the IFMC to request approval of Medicaid coverage for the hospitalization, according to instructions issued to providers by the IFMC and instructions in the Medicaid provider’s manual.
	79.10(2) Medicaid payment will not be made to the hospital if the IFMC denies the procedure requested in the preadmission review.
	79.10(3) A letter of denial will be issued by the IFMC to the patient, physician and hospital when a request is denied. The patient, physician or hospital can request a reconsideration of the decision by filing a written request with the IFMC within 60 days of the date of the denial letter.
	79.10(4) A denial by the IFMC of a request for reconsideration can be appealed by the aggrieved party to the department according to 441—Chapter 7.
	79.10(5) The requirement to obtain preadmission review is waived when the patient is enrolled in the managed health care option known as patient management and proper authorization for the admission has been obtained from the patient manager as described in 441—Chapter 88.
This rule is intended to implement Iowa Code section 249A.4.
441—79.11(249A) Requests for preprocedure surgical review. The Iowa Foundation for Medical Care (IFMC) conducts a preprocedure review of certain frequently performed surgical procedures to determine the necessity of the procedures and if Medicaid payment will be approved according to requirements found in subrules 78.1(19), 78.3(18), and 78.26(3).
	79.11(1) Approval must be requested by the physician from the IFMC when the physician expects to perform a surgical procedure appearing on the department’s preprocedure surgical review list published in the Medicaid providers’ manual.
All requests for preprocedure surgical review shall be made according to instructions issued to physicians, hospitals and ambulatory surgical centers appearing in the Medicaid providers’ manual and instructions issued to providers by the IFMC.
	79.11(2) The physician shall be issued a validation number for each request by the IFMC and advised if payment for the procedure will be approved or denied.
	79.11(3) Medicaid payment will not be made to the physician and other medical personnel or the facility in which the procedure is performed, i.e., hospital or ambulatory surgical center, if the IFMC does not give approval.
	79.11(4) A denial letter will be issued by the IFMC to the patient, physician and facility when the requested procedure is not approved. The patient, physician or facility can request a reconsideration of the decision by filing a written request with the IFMC within 60 days of the date of the denial letter.
	79.11(5) A denial letter of a request for reconsideration by the IFMC can be appealed by the aggrieved party to the department in accordance with 441—Chapter 7.
	79.11(6) The requirement to obtain preprocedure surgical review is waived when the patient is enrolled in the managed health care option known as patient management and proper authorization for the procedure has been obtained from the patient manager as described in 441—Chapter 88.
This rule is intended to implement Iowa Code section 249A.4.
441—79.12(249A) Advance directives. “Advance directive” means a written instruction, such as a living will or durable power of attorney for health care, recognized under state law and related to the provision of health care when the person is incapacitated. All hospitals, home health agencies, home health providers of waiver services, hospice programs, and health maintenance organizations (HMOs) participating in Medicaid shall establish policies and procedures with respect to all adults receiving medical care through the provider or organization to comply with state law regarding advance directives as follows:
	79.12(1) A hospital at the time of a person’s admission as an inpatient, a home health care provider in advance of a person’s coming under the care of the provider, a hospice provider at the time of initial receipt of hospice care by a person, and a health maintenance organization at the time of enrollment of the person with the organization shall provide written information to each adult which explains the person’s rights under state law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives, and the provider’s policies regarding the implementation of these rights.
	79.12(2) The provider or organization shall document in the person’s medical record whether or not the person has executed an advance directive.
	79.12(3) The provider or organization shall not condition the provision of care or otherwise discriminate against a person based on whether or not the person has executed an advance directive.
	79.12(4) The provider or organization shall ensure compliance with requirements of state law regarding advance directives.
	79.12(5) The provider or organization shall provide for education for staff and the community on issues concerning advance directives.
Nothing in this rule shall be construed to prohibit the application of a state law which allows for an objection on the basis of conscience for any provider or organization which as a matter of conscience cannot implement an advance directive.
This rule is intended to implement Iowa Code section 249A.4.
441—79.13(249A) Requirements for enrolled Medicaid providers supplying laboratory services. Medicaid enrolled entities providing laboratory services are subject to the provisions of the Clinical Laboratory Improvement Amendments of 1988 (CLIA), Public Law 100-578, and implementing federal regulations published at 42 CFR Part 493 as amended to February 28, 1992. Medicaid payment shall not be afforded for services provided by an enrolled Medicaid provider supplying laboratory services that fails to meet these requirements. For the purposes of this rule, laboratory services are defined as services to examine human specimens for the diagnosis, prevention or treatment of any disease or impairment of, or assessment of, the health of human beings.
This rule is intended to implement Iowa Code section 249A.4.
441—79.14(249A) Provider enrollment.
	79.14(1) All providers of medical services interested in enrolling as Medicaid providers shall begin the enrollment process by contacting the fiscal agent at Provider Enrollment, Consultec, Inc., P.O. Box 14422, Des Moines, Iowa 50306-3422, to request an application, with the following exceptions: HCBS MR waiver service providers shall complete the application process set forth in 441—subrule 77.37(21); nursing facility providers shall complete the process set forth in rule 441—81.13(249A); and intermediate care facilities for the mentally retarded shall complete the process set forth in rule 441—82.3(249A). Consultec shall send the provider the appropriate application forms for completion as set forth below.
	a. 	The following institutional providers shall complete the Institutional Medicaid Provider Enrollment, Form 470-2967:
	(1)	Ambulatory surgical centers.
	(2)	Home health agencies.
	(3)	Hospital and swing beds.
	(4)	Medicare-certified skilled facilities.
	(5)	Nursing facilities for the mentally ill.
	(6)	Psychiatric hospitals.
	(7)	Psychiatric medical institutions for children.
	(8)	Rehabilitation agencies. Rehabilitation agencies shall also complete Form 470-2971, Rehabilitation Agency Information Sheet.
	(9)	Inpatient and outpatient general hospitals. Inpatient and outpatient general hospitals shall also complete Form 2977, Supplemental Hospital Information.
	b. 	The following noninstitutional Medicaid providers shall complete the Noninstitutional Medicaid Provider Application, Form 470-2966:
	(1)	Ambulances.
	(2)	Area education agencies.
	(3)	Audiologists.
	(4)	Birth centers.
	(5)	Chiropractors.
	(6)	Clinics.
	(7)	Community mental health centers. Community mental health centers shall also complete Form 470-2970, Group Practice Information.
	(8)	Dentists.
	(9)	Durable medical equipment and supply dealers.
	(10)	Early and periodic screening centers.
	(11)	Family or pediatric nurse practitioners.
	(12)	Family planning clinics.
	(13)	Federally qualified health centers. Federally qualified health centers shall also complete Form 470-2969, Federally Qualified Health Professionals Listing, and submit a copy of their federal grant.
	(14)	Genetic consultation clinics.
	(15)	Hearing aid dealers.
	(16)	Independent laboratories.
	(17)	Maternal health centers. Maternal health centers shall also complete Form 470-2970, Group Practice Information.
	(18)	Nurse midwives.
	(19)	Orthopedic shoe dealers.
	(20)	Opticians.
	(21)	Optometrists.
	(22)	Physical therapists.
	(23)	Physicians.
	(24)	Podiatrists.
	(25)	Providers of prescribed drugs.
	(26)	Psychologists. Psychologists not on the National Register of Health Service Providers shall also complete Form 470-2968, Equivalency Form.
	(27)	Rural health clinics.
	c. 	Hospices, health maintenance providers (HMOs), case management providers, and enhanced service providers shall submit Form 470-2976, Medicaid Provider Application for Hospices, HMOs, and Enhanced Service Providers.
	d. 	Certified registered nurse anesthetists shall submit Form 470-2972, Medicaid Provider Application for Certified Registered Nurse Anesthetists.
	e. 	HCBS AIDS/HIV waiver service providers shall complete Form 470-2974, Medicaid AIDS/HIV Waiver Provider Application.
	f. 	HCBS elderly waiver providers shall complete Form 470-2973, Medicaid Elderly Waiver Provider Application.
	g. 	HCBS ill and handicapped waiver providers shall complete Form 470-2975, Medicaid Ill and Handicapped Waiver Provider Application.
	h. 	Rehabilitative treatment service providers shall complete Form 470-3052, Rehabilitative Treatment and Support Services Contract.
	79.14(2) The provider shall submit the appropriate application forms to Paramax.
	79.14(3) Providers shall be notified of the decision on their application by Paramax within 30 calendar days.
	79.14(4) Providers not approved as the type of Medicaid provider requested shall have the right to appeal under 441—Chapter 7.
	79.14(5) Applications shall be approved retroactive to the date requested by the provider or the date the provider meets the applicable participation criteria, whichever is later, not to exceed 12 months retroactive from the receipt of the application forms by Paramax.
	79.14(6) Providers approved for certification as a Medicaid provider shall complete Form 470-2965, Medicaid Provider Agreement.
	79.14(7) No payment shall be made to a provider for care or services provided prior to the effective date of the department’s approval of an application, unless the provider was enrolled and participating in the Iowa Medicaid program as of April 1, 1993.
	79.14(8) Payment rates dependent on the nature of the provider or the nature of the care or services provided shall be based on information on the application form, together with information on claim forms, or on rates paid the provider prior to April 1, 1993.
	79.14(9) Amendments to application forms shall be submitted to the department’s fiscal agent and shall be approved or denied within 30 calendar days. Approval of an amendment shall be retroactive to the date requested by the provider or the date the provider meets all applicable criteria, whichever is later, not to exceed 30 days prior to the receipt of the amendment by the fiscal agent. Denial of an amendment may be appealed under 441—Chapter 7.
	79.14(10) Providers who have not submitted claims in the last 24 months will be sent a notice asking if they wish to continue participation. Providers failing to reply to the notice within 30 calendar days of the date on the notice will be terminated as providers. Providers who do not submit any claims in 48 months will be terminated as providers without further notification.
This rule is intended to implement Iowa Code section 249A.4.
[Filed March 11, 1970]
[Filed 6/25/76, Notice 5/17/76—published 7/12/76, effective 8/16/76]
[Filed 3/25/77, Notice 12/1/76—published 4/20/77, effective 5/25/77]
[Filed 6/10/77, Notice 5/4/77—published 6/29/77, effective 8/3/77]
[Filed 10/24/77, Notice 9/7/77—published 11/16/77, effective 12/21/77]
[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 8/9/78, Notice 6/28/78—published 9/6/78, effective 10/11/78]
[Filed 10/10/78, Notice 7/26/78—published 11/1/78, effective 12/6/78]
[Filed 3/30/79, Notice 2/21/79—published 4/18/79, effective 5/23/79]
[Filed 9/6/79, Notice 7/11/79—published 10/3/79, effective 11/7/79]
[Filed 12/5/79, Notice 10/3/79—published 12/26/79, effective 1/30/80]
[Filed emergency 6/30/80—published 7/23/80, effective 7/1/80]
[Filed 11/21/80, Notice 9/3/80—published 12/10/80, effective 1/14/81]
[Filed 3/24/81, Notice 2/4/81—published 4/15/81, effective 6/1/81]
[Filed emergency 4/23/81—published 5/13/81, effective 4/23/81]
[Filed 8/24/81, Notice 3/4/81—published 9/16/81, effective 11/1/81]
[Filed 1/28/82, Notice 11/11/81—published 2/17/82, effective 4/1/82]
[Filed emergency 3/26/82—published 4/14/82, effective 4/1/82]
[Filed emergency 5/21/82—published 6/9/82, effective 7/1/82]
[Filed 7/30/82, Notice 6/9/82—published 8/18/82, effective 10/1/82]
[Filed emergency 8/20/82 after Notice of 6/23/82—published 9/15/82, effective 10/1/82]
[Filed 11/19/82, Notice 9/29/82—published 12/8/82, effective 2/1/83]
[Filed 2/25/83, Notice 1/5/83—published 3/16/83, effective 5/1/83]
[Filed 5/20/83, Notice 3/30/83—published 6/8/83, effective 8/1/83]
[Filed emergency 6/17/83—published 7/6/83, effective 7/1/83]
[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 emergency 10/28/83—published 11/23/83, effective 12/1/83]
[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 1/13/84, Notice 11/23/84—published 2/1/84, effective 3/7/84]
[Filed 2/10/84, Notice 12/7/83—published 2/29/84, effective 5/1/84]
[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 after Notice 11/1/84, Notice 7/18/84—published 11/21/84, effective 11/1/84]
[Filed 4/29/85, Notice 2/27/85—published 5/22/85, effective 7/1/85]
[Filed emergency 6/14/85—published 7/3/85, effective 7/1/85]
[Filed 8/23/85, Notice 7/3/85—published 9/11/85, effective 11/1/85]
[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 12/2/85—published 12/18/85, effective 1/1/86]
[Filed 12/2/85, Notice 10/9/85—published 12/18/85, effective 2/1/86]
[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, 1/15/86—published 3/12/86, effective 5/1/86]
[Filed emergency 6/26/86—published 7/16/86, effective 7/1/86]
[Filed 10/17/86, Notice 8/27/86—published 11/5/86, effective 1/1/87]
[Filed emergency 1/15/87—published 2/11/87, effective 1/15/87]
[Filed 3/3/87, Notice 12/31/86—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 emergency 6/19/87—published 7/15/87, effective 7/1/87]
[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 10/23/87, Notice 7/15/87—published 11/18/87, effective 1/1/88]
[Filed 10/23/87, Notice 8/26/87—published 11/18/87, effective 1/1/88]
[Filed without Notice 11/25/87—published 12/16/87, effective 2/1/88]
[Filed 11/30/87, Notice 10/7/87—published 12/16/87, effective 2/1/88]
[Filed 12/10/87, Notice 10/21/87—published 12/30/87, effective 3/1/88]1
[Filed 1/21/88, Notice 12/16/87—published 2/10/88, effective 4/1/88]
[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 10/28/88—published 11/16/88, effective 11/1/88]
[Filed emergency 11/23/88 after Notices of 7/13/88, 9/21/88—published 12/14/88, effective 12/1/88, 1/1/89]
[Filed emergency 12/22/88 after Notice of 11/16/88—published 1/11/89, effective 1/1/89]
[Filed 12/22/88, Notices 11/16/88—published 1/11/89, effective 3/1/89]◊
[Filed emergency 6/9/89—published 6/28/89, effective 7/1/89]
[Filed 7/14/89, Notice 4/19/89—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 emergency 1/10/90 after Notice of 10/4/89—published 1/10/90, effective 1/1/90]
[Filed 1/17/90, Notice 8/23/90—published 2/7/90, effective 4/1/90]2
[Filed emergency 2/14/90—published 3/7/90, effective 4/1/90]
[Filed 4/13/90, Notices 2/21/90, 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 5/11/90—published 5/30/90, effective 6/1/90]
[Filed 5/11/90, Notice 4/4/90—published 5/30/90, effective 8/1/90]
[Filed emergency 6/14/90 after Notice 5/2/90—published 7/11/90, effective 7/1/90]
[Filed emergency 6/20/90—published 7/11/90, effective 7/1/90]
[Filed 7/13/90, Notice 5/30/90—published 8/8/90, effective 10/1/90]
[Filed 8/16/90, Notices 7/11/90—published 9/5/90, effective 11/1/90]◊
[Filed 10/12/90, Notice 8/8/90—published 10/31/90, effective 2/1/91]
[Filed emergency 1/17/91 after Notice 11/28/90—published 2/6/91, effective 2/1/91]
[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 4/1/91]
[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 5/17/91, Notice 4/3/91—published 6/12/91, effective 8/1/91]
[Filed emergency 6/14/91—published 7/10/91, effective 7/1/91]
[Filed 6/14/91, Notices 3/20/91, 5/1/91—published 7/10/91, effective 9/1/91]3
[Filed 7/10/91, Notice 5/29/91—published 8/7/91, effective 10/1/91]
[Filed emergency 9/18/91 after Notice 7/24/91—published 10/16/91, 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 4/8/92]
[Filed emergency 4/15/92—published 5/13/92, effective 4/16/92]
[Filed emergency 5/13/92 after Notice 4/1/92—published 6/10/92, effective 5/14/92]
[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 without Notice 6/11/92—published 7/8/92, effective 9/1/92]
[Filed 8/14/92, Notice 7/8/92—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, Notice 7/8/92—published 9/30/92, effective 12/1/92]
[Filed 10/15/92, Notice 8/19/92—published 11/11/92, effective 1/1/93]
[Filed 11/10/92, Notice 9/30/92—published 12/9/92, effective 2/1/93]
[Filed emergency 12/30/92 after Notice 11/25/92—published 1/20/93, effective 1/1/93]
[Filed 1/14/93, Notice 11/11/92—published 2/3/93, effective 4/1/93]
[Filed 3/11/93, Notice 1/20/93—published 3/31/93, effective 6/1/93]
[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 6/11/93, Notice 4/28/93—published 7/7/93, effective 9/1/93]
[Filed emergency 6/25/93—published 7/21/93, effective 7/1/93]
[Filed emergency 7/13/93 after Notice 5/12/93—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, Notices 4/28/93, 7/7/93—published 9/1/93, effective 11/1/93]
[Filed 9/17/93, Notice 7/21/93—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 9/29/93—published 12/8/93, effective 2/1/94]
[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 3/10/94, Notices 1/19/94, 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 9/15/94, Notice 7/6/94—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 3/1/95]
[Filed 3/20/95, Notice 2/1/95—published 4/12/95, effective 6/1/95]
[Filed 5/11/95, Notice 3/29/95—published 6/7/95, effective 8/1/95]
[Filed emergency 6/7/95—published 7/5/95, effective 7/1/95]
[Filed 8/10/95, Notice 7/5/95—published 8/30/95, effective 11/1/95]
[Filed 11/16/95, Notices 8/2/95, 9/27/95—published 12/6/95, effective 2/1/96]◊
[Filed 5/15/96, Notice 2/14/96—published 6/5/96, effective 8/1/96]
[Filed emergency 6/13/96—published 7/3/96, effective 7/1/96]
[Filed 7/10/96, Notice 6/5/96—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 11/13/96, Notice 9/11/96—published 12/4/96, effective 2/1/97]
[Filed 2/12/97, Notice 12/18/96—published 3/12/97, effective 5/1/97]
[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]
◊	Two or more ARCs
1	Effective date of 79.1(2) and 79.1(5)“t” delayed 70 days by the Administrative Rules Review Committee at its January 1988, meeting.
2	Effective date of 4/1/90 delayed 70 days by the Administrative Rules Review Committee at its March 12, 1990, meeting; delay lifted by this Committee, effective May 11, 1990.
3	Effective date of subrule 79.1(13) delayed until adjournment of the 1992 Sessions of the General Assembly by the Administrative Rules Review Committee at its meeting held July 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.