441—78.12 (249A) Remedial services. Payment will be made for remedial services not otherwise covered under this chapter that are designed to minimize or, if possible, eliminate the symptoms or causes of a psychological disorder, subject to the limitations in this rule.
	 78.12(1) Covered services. Medicaid covers the following remedial services:
	  a.   	 Community psychiatric supportive treatment, which offers intensive interventions to modify psychological, behavioral, emotional, cognitive, and social factors affecting a member’s functioning when less intensive remedial services do not meet the member’s needs.
	 (1) 	 Interventions must focus on the member’s remedial needs to minimize or eliminate psychological barriers to a member’s ability to effectively manage symptoms associated with a psychological disorder in an age-appropriate manner.
	 (2) 	 Interventions may assist the member in skills such as conflict resolution, problem solving, social skills, interpersonal relationship skills, and communication.
	 (3) 	 Community psychiatric supportive treatment is covered only for Medicaid members who are aged 20 or under.
	 (4) 	 Community psychiatric supportive treatment is not intended for members in congregate care.
	 (5) 	 Community psychiatric supportive treatment is not intended to be provided in a group.
	  b.   	 Crisis intervention to de-escalate situations in which a risk to self, others, or property exists.
	 (1) 	 Services shall assist a member to regain self-control and reestablish effective management of behavioral symptoms associated with a psychological disorder in an age-appropriate manner.
	 (2) 	 Crisis intervention is covered only for Medicaid members who are aged 20 or under and shall be provided as outlined in a written treatment plan.
	  c.   	 Health or behavior intervention, used to modify the psychological, behavioral, emotional, cognitive, and social factors affecting a member’s functioning.
	 (1) 	 Interventions may address the following skills for effective functioning with family, peers, and community: conflict resolution skills, problem-solving skills, social skills, interpersonal relationship skills, and communication skills.
	 (2) 	 The purpose of intervention shall be to minimize or eliminate psychological barriers to the member’s ability to effectively manage symptoms associated with a psychological disorder in an age-appropriate manner.
	 (3) 	 Health or behavior intervention is covered only for Medicaid members aged 20 or under.
	  d.   	 Rehabilitation program, which consists of interventions to enhance a member’s independent living, social, and communication skills; to minimize or eliminate psychological barriers to a member’s ability to effectively manage symptoms associated with a psychological disorder; and to maximize the member’s ability to live and participate in the community.
	 (1) 	 Interventions may address the following skills for effective functioning with family, peers, and community: communication skills, conflict resolution skills, problem-solving skills, social skills, interpersonal relationship skills, and employment-related skills.
	 (2) 	 Rehabilitation program services are covered only for Medicaid members who are aged 18 or over.
	  e.   	 Skills training and development, which consists of interventions to enhance independent living, social, and communication skills; to minimize or eliminate psychological barriers to a member’s ability to effectively manage symptoms associated with a psychological disorder; and to maximize a member’s ability to live and participate in the community.
	 (1) 	 Interventions may include the following skills for effective functioning with family, peers, and community: communication skills, conflict resolution skills, problem-solving skills, social skills, interpersonal relationship skills, and employment-related skills.
	 (2) 	 Skills training and development services are covered only for Medicaid members aged 18 or over.
	 78.12(2) Excluded services. Services that are habilitative in nature are not covered as remedial services. For purposes of this subrule, “habilitative services” means services that are designed to assist individuals in acquiring skills that they never had, as well as associated training to acquire self-help, socialization, and adaptive skills necessary to reside successfully in a home or community setting.
	 78.12(3) Coverage requirements. Medicaid covers remedial services only when the following conditions are met:
	  a.   	 A licensed practitioner of the healing arts acting within the practitioner’s scope of practice under state law has diagnosed the member with a psychological disorder. For example, licensed practitioners of the healing arts include physicians (M.D. or D.O.), advanced registered nurse practitioners (ARNP), psychologists (Ph.D. or Psy.D.), independent social workers (LISW), marital and family therapists (LMFT), and mental health counselors (LMHC). For purposes of this rule, the licensed practitioner of the healing arts must be:
	 (1) 	 Enrolled in the Iowa Plan pursuant to 441—Chapter 88, Division IV; and
	 (2) 	 Qualified to provide clinical assessment services under the Iowa Plan pursuant to 441—Chapter 88, Division IV (Current Procedural Terminology code 90801).
	  b.   	 The licensed practitioner of the healing arts has recommended the remedial services as part of a plan of treatment designed to treat the member’s psychological disorder. Diagnosis and treatment plan development provided in connection with this rule for members enrolled in the Iowa Plan are covered services under the Iowa Plan pursuant to 441—Chapter 88, Division IV.
	  c.   	 For a member under the age of 21, the licensed practitioner of the healing arts:
	 (1) 	 Has, in cooperation with the managed care contractor, selected a standardized assessment instrument appropriate for baseline measurement of the member’s current skill level in managing mental health needs;
	 (2) 	 Has completed an initial formal assessment of the member using the instrument selected; and
	 (3) 	 Completes a formal assessment using the same instrument every six months thereafter if continued services are ordered.
	  d.   	 The remedial services provider has prepared a written remedial services implementation plan that has been approved by:
	 (1) 	 The member or the member’s parent or guardian; and
	 (2) 	 The medical services unit of the Iowa Medicaid enterprise.
	 78.12(4) Approval of plan. The remedial services provider shall submit the treatment plan, the results of the formal assessment, and the remedial services implementation plan to the Iowa Medicaid enterprise (IME) medical services unit for approval before providing the services.
	  a.   	 Initial plan. The IME medical services unit shall approve the provider’s initial remedial services implementation plan if:
	 (1) 	 The plan conforms to the medical necessity requirements in subrule 78.12(3);
	 (2) 	 The plan is consistent with the written diagnosis and treatment recommendations made by the licensed practitioner of the healing arts;
	 (3) 	 The plan is sufficient in amount, duration, and scope to reasonably achieve its purpose;
	 (4) 	 The provider can demonstrate that the provider possesses the skills and resources necessary to implement the plan, as required in rule 441—77.12(249A);
	 (5) 	 The plan does not exceed six months’ duration; and
	 (6) 	 The plan requires that written progress notes be submitted no less often than every six weeks to the IME medical services unit.
	  b.   	 Subsequent plans. The IME medical services unit may approve a subsequent remedial services implementation plan according to the conditions in paragraph “a” if the services are recommended by a licensed practitioner of the healing arts who has:
	 (1) 	 Reexamined the member;
	 (2) 	 Reviewed the original diagnosis and treatment plan;
	 (3) 	 Evaluated the member’s progress, including a formal assessment as required by 78.12(3)“c”(3); and
	 (4) 	 Submitted the results of the formal assessment with the recommendation for continued services.
	  c.   	 Quality review. The IME medical services unit will establish a quality review process. Reviews will evaluate:
	 (1) 	 The time elapsed from referral to remedial plan development;
	 (2) 	 The continuity of treatment;
	 (3) 	 The affiliation of the licensed practitioner of the healing arts with the remedial services provider;
	 (4) 	 Gaps in service;
	 (5) 	 The results achieved; and
	 (6) 	 Member satisfaction.
	 78.12(5) Medical necessity. Nothing in this rule shall be deemed to exempt coverage of remedial services from the requirement that services be medically necessary. “Medically necessary” means that the service is:
	  a.   	 Consistent with the diagnosis and treatment of the member’s condition;
	  b.   	 Required to meet the medical needs of the member and is needed for reasons other than the convenience of the member or the member’s caregiver;
	  c.   	 The least costly type of service that can reasonably meet the medical needs of the member; and
	  d.   	 In accordance with the standards of good medical practice. The standards of good practice for each field of medical and remedial care covered by the Iowa Medicaid program are those standards of good practice identified by:
	 (1) 	 Knowledgeable Iowa clinicians practicing or teaching in the field; and
	 (2) 	 The professional literature regarding best practices in the field.
This rule is intended to implement Iowa Code section 249A.4.
[ARC 8504B, IAB 2/10/10, effective 3/22/10]