441—92.8 (249A,249J) Benefits. Under IowaCare, payment will be made only for services and providers as specified in this rule. No payment will be made for any service provided elsewhere or by another provider.
	 92.8(1) Provider network. Except as provided in subrules 92.8(3) through 92.8(6), IowaCare members shall have medical assistance only for services provided to the member by:
	  a.   	 The University of Iowa Hospitals and Clinics; or
	  b.   	 Broadlawns Medical Center in Des Moines; or
	  c.   	 A federally qualified health center that the department has designated as part of the IowaCare network using a phased-in approach based on the degree to which the area is underserved, medical home readiness, and the availability of funds; or
	  d.   	 Any physician, advanced registered nurse practitioner, or physician assistant who is part of a medical institution listed in this subrule. Physician assistants are able to render covered services as auxiliary personnel of a physician pursuant to 441—subrule 78.1(13).
	 92.8(2) Covered services. Services shall be limited to the services covered by the Iowa Medicaid program pursuant to 441—Chapter 78 or 441—79.9(249A) and to medical home services required by subrule 92.8(7). All conditions of service provision shall apply in the same manner as under the regular Iowa Medicaid program and pursuant to 441—Chapter 78, 441—79.3(249A), 441—79.5(249A), 441—79.6(249A), 441—79.8(249A) through 441—79.14(249A), and applicable provider manuals. These conditions include, but are not limited to, prior authorization requirements and exclusions for cosmetic procedures or those otherwise determined not to be required to meet the medical need of the patient.
	 92.8(3) Obstetric and newborn coverage. IowaCare members who qualify under 92.2(1)“b” or “c” are also eligible for the services specified in paragraph “a” or “b” from the providers specified in paragraph “c” or “d.”
	  a.   	 Covered services for pregnant women shall be limited to:
	 (1) 	 Inpatient hospital services when the diagnosis-related group (DRG) submitted for payment is between 370 and 384 and the primary or secondary diagnosis code is V22 through V24.9.
	 (2) 	 Obstetrical services provided in an outpatient hospital setting when the primary or secondary diagnosis code is V22 through V24.9.
	 (3) 	 Services from another provider participating in Medicaid if the claim form reflects that the primary or secondary diagnosis code is V22 through V24.9.
	  b.   	 Newborns will be eligible while hospitalized and for a period not to exceed 60 days from the date of birth.
	 (1) 	 Inpatient hospital services shall be payable when the diagnosis-related group (DRG) submitted for payment is between 385 and 391.7.
	 (2) 	 Services provided by a health care provider other than a hospital shall be covered as provided in subrule 92.8(2).
	  c.   	 For persons who reside in Cedar, Clinton, Iowa, Johnson, Keokuk, Louisa, Muscatine, Scott, or Washington County, the services listed in this subrule are covered only when provided by the University of Iowa Hospitals and Clinics.
	  d.   	 Persons who do not live in Cedar, Clinton, Iowa, Johnson, Keokuk, Louisa, Muscatine, Scott, or Washington County may obtain the services listed in this subrule from any provider that participates in Iowa Medicaid.
	 92.8(4) Routine preventive medical examinations. A routine preventive medical examination is one that is performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury.
	  a.   	 IowaCare members who qualify under paragraph 92.2(1)“b” or “c” and who have not been enrolled with a medical home are eligible to receive routine preventive medical examinations from:
	 (1) 	 Any provider specified under subrule 92.8(1), or
	 (2) 	 Any physician, advanced registered nurse practitioner, or physician assistant who participates in Iowa Medicaid, including but not limited to providers available through a free clinic, a rural health clinic, or a federally qualified health center that has not been designated as an IowaCare provider pursuant to paragraph 92.8(1)“c.” Physician assistants are able to render covered services as auxiliary personnel of a physician pursuant to 441—subrule 78.1(13).
	  b.   	 A provider that bills IowaCare for a routine preventive medical examination shall use diagnosis code V70 and evaluation and management CPT code 99202, 99203, 99204, 99212, 99213, or 99214, as appropriate to the level of service provided. Basic laboratory work may also be billed in association with the medical examination, as appropriate and necessary.
	 92.8(5) Drugs for smoking cessation. IowaCare members may obtain outpatient prescription drugs for smoking cessation that are related to another appropriately billed IowaCare service from any pharmacy participating in the Iowa Medicaid program.
	 92.8(6) Medical home. As a condition of participation in the IowaCare program, network providers designated pursuant to subrule 92.8(1) must also qualify as medical homes, pursuant to Iowa Code chapter 135, division XXII.
	  a.   	 The provider shall meet medical home standards. If the Iowa department of public health adopts rules that provide statewide medical home standards or provide for a statewide medical home certification process, those rules shall apply to IowaCare medical home providers and shall take precedence over the requirements in this paragraph. At a minimum, medical homes shall:
	 (1) 	 Have National Committee for Quality Assurance (NCQA) Level 1 certification or equivalent certification. Effective July 1, 2011, medical homes that achieve a higher level of accreditation from NCQA or equivalent shall be designated as such for purposes of payment.
	 (2) 	 Provide provider-directed care coordination services.
	 (3) 	 Provide members with access to health care and information.
	 (4) 	 Provide wellness and disease prevention services.
	 (5) 	 Create and maintain chronic disease information in a searchable disease registry.
	 (6) 	 Demonstrate evidence of implementation of an electronic health record system.
	 (7) 	 Participate in and report on quality improvement processes.
	  b.   	 The provider shall execute a contract with the department to be an IowaCare medical home and receive enhanced medical home reimbursements pursuant to subrule 92.9(4). The contract shall include performance measurements and specify expectations and standards for a medical home.
	  c.   	 If an IowaCare member resides in a designated county near a designated medical home provider, the department shall assign the member to that provider. If an IowaCare member who is assigned to a medical home chooses to go to another provider without a referral from the medical home:
	 (1) 	 The service is not covered by the IowaCare program, and
	 (2) 	 The provider may bill the member according to the provider’s established criteria for billing other patients.
	 92.8(7) Services from nonparticipating providers.
	  a.   	 A nonparticipating provider hospital may be reimbursed for covered IowaCare services subject to the following conditions and limitations:
	 (1) 	 The patient is enrolled in IowaCare pursuant to the Iowa Medicaid enterprise eligibility verification system at the time the services are delivered.
	 (2) 	 The services are emergency services, as designated by the department, and it is not medically possible to postpone provision of those services.
	 (3) 	 It is not medically possible to transfer the member to an IowaCare provider, or the IowaCare provider does not have sufficient capacity to accept the member.
	 (4) 	 The provision of emergency services is followed by an inpatient admission at the nonparticipating provider.
	 (5) 	 Before submitting a medical claim for reimbursement, the treating nonparticipating provider has requested and received authorization for payment from the Iowa Medicaid enterprise medical services unit. The request shall include the claim listing the emergency and inpatient services.
	  b.   	 If the conditions listed in paragraph “a” are met as specified, a nonparticipating provider may be reimbursed for covered services provided to the member from the point of emergency room admission to the point of discharge or transfer from the inpatient unit, up to the amount appropriated. This reimbursement does not include emergency or nonemergency transportation services.
	  c.   	 Care coordination pool. A care coordination pool is established to provide payment for medically necessary services provided to IowaCare members for continuation of care provided by a participating IowaCare hospital. Reimbursement is available from designated care coordination pool funding subject to the following conditions:
	 (1) 	 Payment may be made for continuing care that is related to an IowaCare member’s hospital services as determined in a referral from the participating IowaCare hospital.
	 (2) 	 Payment for continuing care is available to providers that are enrolled in the Iowa medical assistance program, regardless of whether the provider is a participating provider for IowaCare and regardless of the member’s county of residence or medical home assignment.
	 (3) 	 A provider of continuing care that does not participate in the IowaCare program must include information regarding the referral on the claim form.
	 (4) 	 Payment shall be made only for services that are not otherwise covered under the IowaCare program. Payment shall not be made for services that would normally be provided by the IowaCare provider to other non-IowaCare patients.
	 (5) 	 The type, scope, and duration of payable services shall be limited as determined by the department. Payable services are limited to:
	  1. 	 Durable medical equipment.
	  2. 	 Home health services.
	  3. 	 Rehabilitation and therapy services, including intravenous antibiotics and parenteral therapy delivered at home.
	 (6) 	 Types of items or services that are not covered include, but are not limited to:
	  1. 	 Adult diapers.
	  2. 	 Air compressors.
	  3. 	 Bedside commodes.
	  4. 	 Blood pressure kits or machines.
	  5. 	 Cardiac event monitors.
	  6. 	 Continuous passive motion machines.
	  7. 	 Continuous positive air pressure (CPAP) machines.
	  8. 	 Dental care (nonsurgical).
	  9. 	 Eyeglasses, contact lenses, and eye prostheses.
	  10. 	 Gel shoe inserts.
	  11. 	 Hearing aids.
	  12. 	 Heated oxygen.
	  13. 	 Laboratory tests and radiology procedures.
	  14. 	 Oral supplemental formula.
	  15. 	 Outpatient pharmaceuticals not specifically identified in 92.8(7)“c”(5) above.
	  16. 	 Ted hose, Sigvaris stockings, or Jobst stockings.
	  17. 	 Tennis shoes.
	  18. 	 Transcutaneous electrical nerve stimulation (TENS) units.
	  19. 	 Transportation.
	  20. 	 Work boots.
	 (7) 	 All other medical assistance program policies affecting the payable services shall apply, including those regarding prior authorization and level of care determination.
	 (8) 	 Payment is limited to the amount of available funds designated for the care coordination pool.
	  d.   	 Laboratory test and radiology pool. A funding pool is established to provide payment for medically necessary laboratory tests and radiology services provided to enrolled IowaCare members when authorized by a federally qualified health center that has been designated by the department as part of the IowaCare regional provider network. Payment from the pool shall be subject to the following conditions and limitations:
	 (1) 	 Payment may be made only for laboratory tests or radiology services which the participating federally qualified health center does not otherwise have the means to provide on site.
	 (2) 	 Each participating federally qualified health center shall designate no more than four laboratory testing facilities and no more than four radiology facilities to which the center will refer IowaCare patients for these services. The designated providers must participate in the Iowa medical assistance program. Payment shall be made only to the designated providers.
	 (3) 	 The designated provider must obtain a referral from the participating federally qualified health center for the services and must include information regarding the referral on the claim form.
	 (4) 	 All other medical assistance policies for coverage of laboratory and radiology services shall apply, including requirements for prior authorization.
	 (5) 	 Payment is limited to the amount of available funds designated for the laboratory test and radiology pool. If the amount appropriated for the pool is exhausted, laboratory tests and radiology services ordered by a participating federally qualified health center shall be provided or coordinated by the center.
	 92.8(8) Referral protocols. When an IowaCare primary care provider refers the member to an IowaCare specialty provider, the following conditions shall apply:
	  a.   	 By January 1, 2012, IowaCare providers shall ensure that referral and patient access processes for IowaCare members are no more restrictive than the processes required for any other payor.
	  b.   	 After an IowaCare provider makes a referral, the IowaCare provider receiving the referral shall report the following information to the referring provider in a manner chosen by the provider receiving the referral:
	 (1) 	 The date an appointment has been scheduled. The appointment date shall be reported to the referring provider within 15 calendar days of receiving the referral. If the referral is denied, the receiving provider shall offer a consultation by telephone, fax, E-mail, or Internet regarding the reason for the denial.
	 (2) 	 If authorized by the IowaCare member, the outcome of the appointment, including whether the appointment was kept, the treatment plan, and any follow-up instructions. This report shall be made no later than 15 calendar days following the appointment date.
	  c.   	 IowaCare providers shall work together to address any communication or coordination issues that arise. By October 1, 2011, IowaCare providers shall jointly develop and implement:
	 (1) 	 A process to resolve disputes regarding care needs, payment and referrals that includes regular meetings between providers.
	 (2) 	 A process to identify and address quality improvements with a goal to improve coordination of care between primary, specialty and hospital care. This process shall be monitored by the department but be managed and staffed by the providers.
[ARC 9135B, IAB 10/6/10, effective 10/1/10; ARC 9728B, IAB 9/7/11, effective 9/1/11; ARC 9890B, IAB 11/30/11, effective 1/4/12]