CHAPTER 13
PROGRAM EVALUATION
Preamble
The purpose of this chapter is to define the methods and procedures used by the department to provide a systematic process for measuring the validity of the eligibility determinations in the family investment program (FIP), food assistance program, child care assistance program, and medical assistance program; to provide a basis for establishing state agency liability for errors; and to provide program information that can be used by the department in determining a corrective action plan to ensure the rules and regulations are implemented in accordance with the program rules.
[ARC 4750C, IAB 11/6/19, effective 12/11/19]
441—13.1(234,239B,249A,514I) Definitions.
“Active case” means a case that was receiving assistance for the month of review.
“Case record” means the record used to establish a client’s eligibility.
“Client” means a current or former applicant or recipient of the family investment program (FIP), food assistance program, child care assistance program, or medical assistance program.
“Department” means the Iowa department of human services.
“Field investigation” means a contact involving the public or other agencies to obtain information about the client’s circumstances for the appropriate month of review.
“Local agency” means the local or service area office of the department.
“Medical assistance programs” means those programs funded by Medicaid or the Children’s Health Insurance Program (CHIP).
“Month of review” means the specific calendar or fiscal month for which the assistance under review is received.
“Negative case” means a case that was terminated or denied assistance in the month of review.
“Public assistance programs” means those programs involving federal funds, i.e., family investment program (FIP), food assistance program, child care assistance program, and medical assistance program.
“Random sample” means a systematic (or every nth unit) sample drawn monthly for which each item in the universe has an equal probability of being selected. Sample size is determined by federal guidelines or state corrective action needs.
“State policies” means the rules and regulations used by the department to administer the family investment program (FIP), food assistance program, child care assistance program, and medical assistance program.
This rule is intended to implement Iowa Code sections 234.12, 239B.4, 249A.4 and 514I.4.
[ARC 4750C, IAB 11/6/19, effective 12/11/19]
441—13.2(234,239B,249A,514I) Review of public assistance records by the department.
	13.2(1) Authorized representatives of the department shall have the right to review case records to determine the following:
	a. 	If the client has provided complete, correct and accurate information to the local agency to be used in the determination of the assistance benefits.
	b. 	If the local agency has correctly administered the state policies in determination of assistance for the public assistance programs.
	c. 	Whether overpayments or underpayments have been made correctly to the public assistance client during the month of review.
	d. 	If there is indication of fraudulent practice or abuse of the public assistance programs by either the client or local agency.
	13.2(2) All pertinent case records within the department may be used by the reviewer to assist in substantiating an accurate reflection as to the correctness of the assistance received by the client.
This rule is intended to implement Iowa Code sections 234.12, 239B.4, 249A.4 and 514I.4.
[ARC 4750C, IAB 11/6/19, effective 12/11/19]
441—13.3(234,239B,249A,514I) Who shall be reviewed. Any active or negative public assistance case may be reviewed at any time at the discretion of the department based upon a random sample to:
	13.3(1) Ensure federal and state requirements for quality control are met.
	13.3(2) Detect error prone case issues to assist in corrective action.
	13.3(3) Maintain public assistance program integrity.
This rule is intended to implement Iowa Code sections 234.6, 234.12, 239B.4, 249A.4, and 514I.4.
[ARC 4750C, IAB 11/6/19, effective 12/11/19]
441—13.4(234,239B,249A,514I) Notification of review. On positive case actions, clients shall be notified, either orally or in writing, that their case has been selected for review when contact is required by federal guidelines, or when contact is allowed and additional information is required to complete the review. The client will be contacted in a negative case only if a discrepancy exists that cannot be resolved from the case record and contact is allowed by federal guidelines.
This rule is intended to implement Iowa Code sections 234.6, 234.12, 239B.4, 249A.4, and 514I.4.
[ARC 4750C, IAB 11/6/19, effective 12/11/19]
441—13.5(234,239B,249A,514I) Review procedure. The department will select the appropriate method of conducting the review. Review procedures may include, but are not limited to, the following:
	13.5(1) A random sampling of active and negative case actions shall be used to determine the case records to be studied.
	13.5(2) The case record shall be analyzed for discrepancies and correct application of policies and procedures and shall be used as the basis for a field investigation.
	13.5(3) Client interviews shall be required as follows:
	a. 	Personal interviews are required on all active food assistance reviews.
	b. 	An appointment letter may be sent to the client on department letterhead to schedule or confirm the appointment date, time and location.
	c. 	Client contacts are only required in negative case reviews when there is a discrepancy that cannot be resolved from the case record.
	13.5(4) Collateral contacts are made whenever the client is unable to furnish information needed or the reviewer needs additional information to establish the correctness of eligibility and payment but only when allowed by federal guidelines. Verification to confirm the accuracy of statements or information may be obtained by documentary evidence or a contact with a third party.
	a. 	The client shall be required to release specific information whenever necessary to verify information essential to the determination of eligibility and payment.
	b. 	Should the client refuse to authorize the department to contact an informant to verify information that is necessary for the completion of the review, collateral contacts shall still be made through use of the general release statement contained in the financial support application or the review/recertification eligibility document.
This rule is intended to implement Iowa Code sections 234.6, 234.12, 239B.4, 249A.4, and 514I.4.
[ARC 4750C, IAB 11/6/19, effective 12/11/19]
441—13.6(234) Failure to cooperate. Client cooperation with quality control is a program eligibility requirement as set forth in rule 441—65.3(234). When quality control determines that the client has refused to cooperate with the review process, the client is no longer eligible for the program benefits and will not be eligible for the program benefits until the client has cooperated.
This rule is intended to implement Iowa Code section 234.12.
[ARC 4750C, IAB 11/6/19, effective 12/11/19]
441—13.7(234,239B,249A,514I) Report of findings. The quality control review findings are utilized by the department in the following ways:
	13.7(1) The local agency will use the findings in taking the appropriate case actions where an overpayment or underpayment has been found in a client’s case record.
	13.7(2) The department will use the overall findings to identify error-prone program issues to be used in planning its corrective action plan.
	13.7(3) The department will use the findings of the overall sample period to determine the error rate used to establish state agency liability.
This rule is intended to implement Iowa Code sections 234.12, 239B.4, 249A.4, and 514I.4.
[ARC 4750C, IAB 11/6/19, effective 12/11/19]
441—13.8(234,237A,239B,249A,514I) Federal rereview. A sample of cases may also be reviewed by the applicable federal agency to determine the correctness of the department’s action or of the department’s review of the case.
This rule is intended to implement Iowa Code sections 234.12, 237A.12, 239B.4, 249A.4, and 514I.4.
[ARC 4750C, IAB 11/6/19, effective 12/11/19]
[Filed 3/26/87, Notice 1/28/87—published 4/22/87, effective 6/1/87]
[Filed emergency 10/10/03—published 10/29/03, effective 11/1/03]
[Filed emergency 11/16/05—published 12/7/05, effective 12/1/05]
[Filed ARC 4750C (Notice ARC 4601C, IAB 8/14/19), IAB 11/6/19, effective 12/11/19]