441—25.21 (331) Policies and procedures manual for the regional service system. The policies and procedures manual shall describe the policies and process developed to direct the management and administration of the regional service system. The initial manual is due on April 1, 2014, and will remain in effect subject to amendment.
	   25.21(1) Content. The manual shall include but not be limited to:
	      a.    	 Financing and delivery of services and supports. A description of the region’s process used to develop and ensure the ongoing financial accountability and delivery of services outlined in the region’s annual service and budget plan shall be included.
	      b.    	 Enrollment. The application and enrollment process that is readily accessible to applicants and their families or authorized representatives shall be included. This procedure shall identify regional access points and where applicants can apply for services and how and when the applications will reach the regional administrative entity’s designated staff for processing.
	      c.    	 Eligibility. The process utilized to determine eligibility shall be included in the manual and shall include but not be limited to:
	       (1)  	 The criteria used to authorize or deny funding for services and supports. This shall include guidelines for who is eligible to receive services and supports by eligibility group, and type of service or support.
	       (2)  	 Financial eligibility and copayment criteria, which shall meet the requirements of rule 441—25.16(331).
	       (3)  	 The time frames for conducting eligibility determination that provide for timely access to services, including necessary and immediate services not to exceed ten days.
	       (4)  	 The process for development of a written notice of decision. The time frame for sending a written notice of decision to the individual and guardian (if applicable) and the service providers identified in the notice shall be included. The notice of decision shall:
	      1. 	  Explain the action taken on the application and the reasons for that action.
	      2. 	  State what services are approved and name the service providers.
	      3. 	  Outline the applicant’s right to appeal.
	      4. 	  Describe the appeal process.
	      d.    	 Utilization of and access to services. The process for managing utilization of and access to services and other assistance shall be included. The process shall describe how coordination between the services included in the annual service and budget plan and the disability services administered by the state and others will be managed.
	      e.    	 Quality management and improvement process. The quality management and improvement process shall at a minimum meet the requirements of the department’s outcome and performance measures process as outlined in Iowa Code sections 225C.4(1)“j” and 225C.6A.
	      f.    	 Risk management and fiscal viability. If the region contracts with a private entity, the manual must include risk management provisions and fiscal viability of the annual services and budget plan.
	      g.    	 Targeted case management.
	       (1)  	 Designation of targeted case management providers. The process used to identify and designate targeted case management providers for the region shall be described. This process shall include the requirement for the implementation of evidence-based practice models of case management within the region. Requirements of this practice include:
	      1. 	  Providing the individual receiving the case management with a choice of providers.
	      2. 	  Allowing a service provider to be the case manager but prohibiting the provider from referring that individual only to services administered by the provider.
	      3. 	  Provisions to ensure compliance with, but not exceed, federal requirements for conflict-free case management.
	       (2)  	 Qualifications of targeted case managers. A region’s manual shall require that any targeted case managers or other persons providing service coordination while working for the designated provider meet the qualifications of qualified case managers and supervisors as defined in rule 441—24.1(225C).
	       (3)  	 Targeted case management and service coordination services. Targeted case management and service coordination services utilized in a regional service system shall include but are not limited to the following as defined in Iowa Code section 331.393(4)“g”:
	      1. 	  Performance and outcome measures relating to the health, safety, work performance, and community residency of the individuals receiving the services.
	      2. 	  Standards for delivery of the services, including but not limited to the social history, assessment, service planning, incident reporting, crisis planning, coordination, and monitoring for individuals receiving the services.
	      3. 	  Methodologies for complying with the requirements of paragraph 25.21(1)“g.” Methodologies may include the use of electronic record keeping and remote or Internet-based training.
	      h.    	 System of care approach plan.
	      i.    	 Decentralized service provision. Measures to provide services in a dispersed manner that meet the minimum access standards of core services and that utilize the strengths and assets of the service providers within and available to the region shall be included.
	      j.    	 Provider network formation and management. 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 regional administrative entity will use to contract with providers and manage the provider network to ensure it meets the needs of the individuals in the region. The provider network will include but is not limited to the following:
	       (1)  	 A contract with a community mental health center that provides services in the individual’s region or with a federally qualified health center that provides psychiatric and outpatient mental health services in the individual’s region.
	       (2)  	 Contracts with licensed and accredited providers to provide each service in the required core service domains.
	       (3)  	 Adequate numbers of licensed and accredited providers to ensure availability of core services so that there is no waiting list for services due to lack of available providers.
	       (4)  	 A contract with an inpatient psychiatric hospital unit or state mental health institute within reasonably close proximity.
	      k.    	 Service provider payment provisions. A policy for payment of service providers which describes the method and process of paying for services and supports delivered to the region shall be included.
	      l.    	 Grievance processes. The manual shall develop and implement processes for appealing the decisions of the regional administrative entity in the following circumstances:
	       (1)  	 Nonexpedited appeal process. The 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 individuals with disabilities using the process. Responsibility for the final step in the appeal process shall be a state administrative law judge in nonexpedited appeals.
	       (2)  	 Expedited appeal process. This appeal process is to be used when the decision of the regional administrative entity concerning an individual varies from the type and amount of service identified to be necessary for the individual in a clinical determination made by a mental health professional and the mental health professional believes that the failure to provide the type and amount of service identified could cause an immediate danger to an individual’s health or safety. This appeal process shall be performed by a mental health professional who is either the administrator of the division of mental health and disability services of the department of human services or the administrator’s designee.
	      1. 	  The appeal shall be filed within five days of receipt of the notice of decision by the regional administrative entity.
	      2. 	  The expedited review by the division administrator or designee shall take place within two days of receipt of the request, unless more information is needed. There is an extension of two days from the time the new information is received.
	      3. 	  The administrator shall issue an order, including a brief statement of findings of fact, conclusions of law, and policy reasons for the order, to justify the decision made concerning the expedited review. If the decision concurs with the contention that there is an immediate danger to the individual’s health or safety, the order shall identify the type and amount of service which shall be provided for the individual. The administrator or designee shall give such notice as is practicable to individuals who are required to comply with the order. The order is effective when issued.
	      4. 	  The decision of the administrator or designee shall be considered a final agency action and is subject to judicial review in accordance with Iowa Code section 17A.19.
	      m.    	 Implementation of interagency and multisystem collaboration and care coordination. The policies and procedures manual shall describe how the region will collaborate with other funders, other regional service systems, service providers, case management, individuals and their families or authorized representatives, and advocates to ensure that authorized services and supports are responsive to individuals’ needs, consistent with system principles, and cost-efficient. The manual shall describe the process for collaboration with the court to ensure alternatives to commitment and to coordinate funding for services to individuals who are under court-ordered commitment services pursuant to Iowa Code chapter 229.
	      n.    	 Addressing multioccurring needs. The policies and procedures manual shall include criteria and measures to be used to address the needs of individuals who have two or more co-occurring mental health, intellectual or other developmental disability, brain injury, or substance-related disorders. The manual shall also include criteria and measures to be used to address the needs of individuals with specialized needs.
	      o.    	 Service management and functional assessment. The policies and procedures manual shall describe how functional assessments and service management will be incorporated in accordance with applicable requirements.
	      p.    	 Service system management. The policies and procedures manual shall identify whether the region will be directly implementing a system of service management or will contract with a private entity to manage the regional service system. If the region contracts with a private entity, the region will ensure that all requirements of Iowa Code section 331.393 and these administrative rules are fulfilled.
	      q.    	 Assistance to other than core service populations. The policies and procedures manual shall specify the services populations, other than core service populations, to whom the region will provide assistance if funding is available.
	      r.    	 Waiting list criteria. The policies and procedures manual shall specify whether the region will use waiting lists. If the policy 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 an individual will be placed on a waiting list. The criteria will include how core services and additional core services will be impacted the least by budgetary limitations. The manual shall specify how waiting list data will be used in future planning.
	   25.21(2) Approval. The manual shall be submitted by April 1, 2014, as a part of the region’s management plan for the fiscal year beginning July 1, 2014. The manual shall be approved by the region’s governing board and is subject to approval by the director of human services. The director shall review all regional annual service and budget plans submitted by the dates specified. If the director finds the manual in compliance with these rules and state and federal laws, the director may approve the plan. A plan approved by the director for the fiscal year beginning July 1, 2014, shall remain in effect subject to amendment.
	      a.    	  Criteria for acceptance. The director shall determine a plan is acceptable when it contains all the required information, meets the criteria described in this division, and is in compliance with all applicable state and federal laws. The director may request additional information to determine whether or not the plan contains all the required information and meets criteria described in this division.
	      b.    	  Notification.
	       (1)  	 Except as specified in subparagraph 25.21(2)“b”(2), the director shall notify the region in writing of the decision on the plan by June 1, 2014. The decision shall specify that either:
	      1. 	  The policies and procedures manual is approved as it was submitted, either with or without supplemental information already requested and received.
	      2. 	  The policies and procedures manual will not be approved until revisions are made. The letter will specify the nature of the revisions requested and the time frames for their submission.
	       (2)  	 Review of late submittals. The director may review manuals not submitted by April 1, 2014, after all manuals submitted by that date have been reviewed. The director will proceed with the late submittals in a timely manner.
	   25.21(3) Amendments. An amendment to the policy and procedures manual shall be approved by the regional governance board and submitted to the department at least 45 days before the date of implementation. Before implementation of any amendment to the manual, the director must approve the amendment.
	      a.    	  Criteria for acceptance. The director, in consultation with the state commission, shall determine an amendment is acceptable when it contains all the required information and meets the criteria described in this division for the applicable part of the policy and procedures manual and is in compliance with all applicable state and federal laws. The director may request additional information to determine whether or not the amendment contains all the required information and meets criteria described in this division.
	      b.    	  Notification. The director shall notify the region, in writing, of the decision on the amendment within 45 days of receipt of the amendment. The decision shall specify either that:
	       (1)  	 The amendment is approved as it was submitted, either with or without supplemental information already requested and received.
	       (2)  	 The amendment is not approved. The notification will explain why the amendment is not approved.
	   25.21(4) Reconsideration. Regions dissatisfied with the director’s decision on a manual or an amendment may file a letter with the director requesting reconsideration. The letter of reconsideration must be received within 30 working days of the date of the notice of decision and shall include a request for the director to review the decision and the reasons for dissatisfaction. Within 30 working days of the receipt of the letter requesting reconsideration, the director will review both the reconsideration request and evidence provided. The director shall issue a final decision in writing.
These rules are intended to implement Iowa Code sections 331.388 to 331.398.
[ARC 1173C, IAB 11/13/13, effective 1/1/14]