441—25.13 (331) Policies and procedures manual. The policies and procedures manual shall describe system management and plan administration.
	 25.13(1) System management section. The system management section of the manual shall describe, but shall not be limited to, the following:
	  a.   	 Plan development. The process for the development of the policies and procedures manual, the strategic plan, and amendments to those documents shall involve the various stakeholders in a meaningful way. These stakeholders shall include, but not be limited to, consumers, family members, county officials, advocates, and providers. The process used to involve the stakeholders shall be documented in the strategic plan including how stakeholder input was considered in the development of the final plan. Each process shall include at least one public hearing.
	  b.   	 Plan administration. A statement that the county will directly administer the plan or a description of the management organization responsible for plan administration shall be included in the plan. If the county contracts for plan administration, the plan shall contain a description of how the county will monitor the management organization’s performance through designated county staff or through another contractor independent of the management organization. The management organization shall comply with Iowa Code section 331.439(1)“c.”
	  c.   	 The financial accountability process. The process to ensure the ongoing financial accountability of the plan shall be included. Financial accountability shall include the rate-setting and reimbursement methods used to reimburse service and support providers, which may include vouchers and other nontraditional payment mechanisms.
	  d.   	 Risk-bearing managed care contracts. A county that enters a risk-bearing contract shall include the methodology used to determine the solvency of any plan administered by a management organization in its policies and procedures manual. This shall include, but not be limited to:
	 (1) 	 A required annual independent audit of the management organization responsible for plan administration.
	 (2) 	 The rate-setting and reimbursement methods used by the county to reimburse the management organization.
	 (3) 	 Description of contract requirements prohibiting a management organization from achieving administrative costs or profit from elimination or reduction of services appropriate to consumer needs.
	  e.   	 A funding policy. A policy shall be included indicating that the county is responsible for funding only those services and supports that are authorized in accordance with the process described in the county management plan (including those that are required by law).
	  f.   	 Conflict of interest policy. The manual shall describe a conflict of interest policy that shall, at a minimum, ensure that service authorization decisions are either made by individuals or organizations which have no financial interest in the services or supports to be provided, or that such interest is fully disclosed to consumers, counties, and other stakeholders. The process for this disclosure shall be described in the manual.
	  g.   	 Provider network selection. The manual shall require that providers that are subject to license, accreditation or approval meet established standards. The manual shall detail the approval process, including criteria, developed to select providers that are not currently subject to license, accreditation or approval standards. The manual shall identify the process the county will use to contract with providers.
	  h.   	 Delegated functions. A county may contract with providers to perform functions of the central point of coordination for persons coming to the designated provider for service or may contract with a management organization to carry out the functions of the central point of coordination. When delegation is made, the county shall be responsible for ensuring that the contractor complies with Iowa Code section 331.440 as well as 441—Chapter 25 for any delegated duties and responsibilities.
	  i.   	 Access points. The county shall designate access points and their function in the enrollment process. A process shall be included to ensure that applications received by an access point are forwarded by the end of the working day during which they are received to the consumer’s county of residence and, when known, county of legal settlement, or the county departmental office for those with state case status. The county shall provide training to designated access points on the intake process and use of the application form.
	  j.   	 Staffing plan. The county shall employ, directly or through contract, an adequate number of staff persons to administer the plan. At least one person who meets the qualifications of a central point of coordination administrator shall be designated to implement the central point of coordination process. Elected county or state officials shall not be hired or appointed as the central point of coordination administrator.
	  k.   	 Application form. The policies and procedures manual shall designate the use of an application form, which shall be available in formats and languages appropriate to consumers’ needs.
	  l.   	 Consumer access. The manual shall describe how the county will provide access to appropriate, flexible, cost-effective community services and supports to meet the consumer needs in the least restrictive environment possible. This may include guidelines for individualized services and supports and may vary by eligibility group and type of service and support. The manual shall describe how the county will ensure access to services and supports while legal settlement is determined or in dispute.
	  m.   	 Consumer eligibility. The manual shall describe the eligibility criteria for services and supports. This description shall include, but not be limited to, a description of who is eligible to receive services and supports by eligibility group and type of service or support. Financial eligibility and copayment criteria shall meet the requirements of rule 441—25.20(331).
	  n.   	 Confidentiality. The manual shall describe a confidentiality policy that shall ensure compliance with all applicable state and federal statutes on confidentiality.
	  o.   	 Emergency services. The manual shall specify the policy for accessing emergency services, including the county’s protocol for voluntary and involuntary commitments. The policy shall include the criteria and time frames for application for emergency services.
	  p.   	 Waiting lists. The policies and procedures manual shall specify if the county will use waiting lists, when needed. If the policies and procedures manual specifies the use of waiting lists for funding services and supports, it shall specify criteria for the use and review of each waiting list, including the criteria to be used to determine how and when a consumer will be placed on a waiting list. The manual shall specify how waiting list data will be used in future planning. If the county enters into a risk-bearing contract with a management organization, the contract shall specify that the management organization shall not use waiting lists.
	  q.   	 Quality assurance. The policies and procedures manual shall describe a detailed quality improvement process that provides for ongoing and periodic evaluation of the service system and of the providers of services and supports in the system. The stakeholders shall be involved in the development and implementation of the quality assurance process and evaluation of the system with emphasis on consumer input. The quality assurance policies shall include, but not be limited to, the following:
	 (1) 	 System evaluation. The system evaluation shall include, but not be limited to, an evaluation of consumer satisfaction, including empowerment and quality of life; provider satisfaction; patterns of service utilization; responsiveness to consumer needs and desires; the number and disposition of consumer appeals and the implementation of corrective action plans based on these appeals; and cost-effectiveness.
	 (2) 	 Quality of provider services. The services and supports evaluation shall include, but not be limited to, an evaluation of the quality of provider services and supports based on consumer satisfaction and achievement of desired consumer outcomes; the number and disposition of appeals of provider actions and the implementation of corrective action plans based on these appeals; and the cost-effectiveness of the services and supports developed and provided by individual providers. The evaluation shall ensure that services and supports are provided in accordance with provider contracts.
	  r.   	 Collaboration. The policies shall describe the county’s collaboration with other funders, service providers, consumers and their families or authorized representatives, and advocates to ensure that authorized services and supports are responsive to consumers’ needs and desires and are cost-efficient. The manual shall specifically describe the process for collaboration with the court to ensure that the court is aware of the services and supports available through the county management plan as alternatives to commitment and to coordinate funding for services to persons who are under court-ordered commitment pursuant to Iowa Code chapter 222 or 229.
	  s.   	 The ongoing education process. The plan shall include the process the county will use to provide ongoing education, in various accessible formats, on its planning process and the intake and service authorization process to the community, including consumers, family members, and providers.
	 25.13(2) Plan administration section. The plan administration section of the policies and procedures manual shall specifically outline procedures for administering the plan at the consumer level. These procedures shall include, but shall not be limited to:
	  a.   	 Application (intake) procedure. The plan administration section of the manual shall describe an application process that is readily accessible to applicants and their families or authorized representatives. This procedure shall describe where applicants can apply for services and how and when the applications will reach the CPC office. It shall outline an application review process including, but not limited to, how additional needed information shall be gathered to complete an application, a timeline for the review process, and qualifications of the professional reviewing the application.
	  b.   	 Eligibility determination. Eligibility determination shall include, but not be limited to, the criteria used to authorize or deny funding for services and supports. This may include guidelines for individualized services and supports and may vary by eligibility group and type of service and support. The procedure shall specify the time frames for conducting eligibility determination that provides for timely access to services, including necessary and immediate services.
	  c.   	 Notice of decision. The review process shall ensure a prompt screening for eligibility and initial decision to approve or reject the application or to gather more information. A written notice of decision which explains the action taken on the application and the reasons for that action shall be sent to the applicant or authorized representative or, in the case of minors, the family or the applicant’s authorized representative. The time frame for sending a written notice of decision shall be included. If the consumer is placed on a waiting list for funding, the notice of decision shall include an estimate of how long the consumer is expected to be on the waiting list and the process for the consumer or authorized representative to obtain information regarding the consumer’s status on the waiting list. The notice of decision shall outline the applicant’s right to appeal and include a description of the appeal process.
	  d.   	 Referral. The plan administration section of the manual shall describe to whom and for what purpose referral of the application is made. This may include, but is not limited to, description of referral directly to a provider for services and supports, referral for service coordination, or referral for clinical assessment.
	  e.   	 Consumer plan development. The plan administration section of the manual shall describe the role of the service coordinator in consumer plan development and how the service coordinator will interface with the CPC. If review of the service request is deemed necessary, a qualified professional shall do the review.
	  f.   	 Request for funding. The plan administration section shall indicate the process and format for a funding request.
	  g.   	 Service funding authorization. The plan administration section of the manual shall describe who makes the funding authorization decisions and the qualifications of that individual. The procedures shall describe the criteria for authorization of funding and a timeline for responding to the request for funding. The procedures shall describe a process for coordinating the authorization of payment for services and supports with the county of legal settlement for persons with legal settlement in another county, or with the county departmental office for those with state case status. If the county of legal settlement and the county of residence mutually decide, the county of legal settlement may perform the intake and enrollment procedures.
	  h.   	 Service and cost tracking. The plan administration section of the manual shall include a description of a system to track services and supports and payments made on behalf of all approved consumers. The tracking system shall provide an unduplicated consumer count and expenditure data. The tracking system shall also record denials of services and supports and indicate the reason why the applications were denied.
	  i.   	 Service monitoring. The plan administration section of the manual shall outline the process of service and funding monitoring.
	  j.   	 Appeals. The county shall develop and implement a process for appealing the decisions of the county or its agent. This appeal process shall be based on objective criteria, specify time frames, provide for notification in accessible formats of the decisions to all parties, and provide some assistance to consumers in using the process. Responsibility for the final administrative decision on an appeal shall not rest with the county board of supervisors. If the appellant has state case status, responsibility for the final administrative decision on an appeal shall rest with the department, following the procedures established in 441—Chapter 7.
	 25.13(3) Management plan annual review. The policies and procedures manual shall address the process for preparation and distribution of the management plan annual review.
	 25.13(4) Three-year strategic plan. The policies and procedures manual shall address the process for development and approval of the three-year strategic plan.