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CHAPTER 78AMOUNT, DURATION AND SCOPE OF MEDICAL AND REMEDIAL SERVICES[Prior to 7/1/83, Social Services[770] Ch 78][Prior to 2/11/87, Human Services[498]]Chapter rescission date pursuant to Iowa Code section 17A.7: 2031-07-01441—78.1(249A) Physicians’ services. Payment will be approved for all medically necessary services and supplies provided by the physician, including services rendered in the physician’s office or clinic, the home, in a hospital, nursing home or elsewhere.Payment will be made for all services rendered by a doctor of medicine or osteopathy within the scope of this practice and the limitations of state law subject to the following limitations and exclusions: 78.1(1) Payment will not be made for: a. Drugs dispensed by a physician or other legally qualified practitioner (dentist, podiatrist, optometrist, physician associate (PA), or advanced registered nurse practitioner (ARNP)) unless it is established that there is no licensed retail pharmacy in the community in which the legally qualified practitioner’s office is maintained. Rate of payment shall be established as in subrule 78.2(2), but no professional fee shall be paid. Payment will not be made for biological supplies and drugs provided free of charge to practitioners by the department. b. Treatment of certain foot conditions as specified in paragraphs 78.15(3)“a” and “b.” c. Acupuncture treatments. d. Unproven or experimental medical and surgical procedures. The criteria in effect in the Medicare program will be utilized in determining when a given procedure is unproven or experimental in nature. e. Charges for surgical procedures on the “Outpatient/Same Day Surgery List” produced by Iowa Medicaid or associated inpatient care charges when the procedure is performed in a hospital on an inpatient basis unless the physician has secured approval from the hospital’s utilization review department prior to the patient’s admission to the hospital. Approval will be granted only when inpatient care is deemed to be medically necessary based on the condition of the patient or when the surgical procedure is not performed as a routine, primary, independent procedure. The “Outpatient/Same Day Surgery List” will be published by the department in the provider manuals for hospitals and physicians as amended to July 1, 2026. The “Outpatient/Same Day Surgery List” will be developed by Iowa Medicaid and will include procedures that can safely and effectively be performed in a doctor’s office or on an outpatient basis in a hospital. Iowa Medicaid may add, delete, or modify entries on the “Outpatient/Same Day Surgery List.” f. Elective, non-medically necessary cesarean section (C-section) deliveries. 78.1(2) Drugs and supplies may be covered when prescribed by a legally qualified practitioner as provided in this rule. a. Drugs are covered as provided by rule 441—78.2(249A). b. Medical supplies are payable when ordered by a legally qualified practitioner for a specific rather than incidental use, subject to the conditions specified in rule 441—78.10(249A). When a member is receiving care in a nursing facility or residential care facility, payment will be approved only for the following supplies when prescribed by a legally qualified practitioner: (1) Colostomy and ileostomy appliances. (2) Colostomy and ileostomy care dressings, liquid adhesive and adhesive tape. (3) Disposable irrigation trays or sets. (4) Disposable catheterization trays or sets. (5) Indwelling Foley catheter. (6) Disposable saline enemas. (7) Diabetic supplies including needles and syringes, blood glucose test strips, and diabetic urine test supplies. c. Prescription records are required for all drugs as specified in Iowa Code sections 124.308 and 155A.27. For the purposes of the medical assistance program, prescriptions for medical supplies are required and will be subject to the same provisions. d. In order to be paid for the administration of a vaccine covered under the Vaccines for Children (VFC) Program, a physician must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted. 78.1(3) Payment will be approved for injections provided they are reasonable, necessary, and related to the diagnosis and treatment of an illness or injury. When billing for an injection, the legally qualified practitioner must specify the brand name of the drug and the manufacturer, the strength of the drug, the amount administered, and the charge of each injection. When the strength and dosage of the drug are not included, payment will be made based on the customary dosage. The following exclusions are applicable. a. Payment will not be approved for injections when they are considered by standards of medical practice not to be specific or effective treatment for the particular condition for which they are administered. b. Payment will not be approved for an injection when administered for a reason other than the treatment of a particular condition, illness, or injury. c. Payment will not be approved when injection is not an indicated method of administration according to accepted standards of medical practice. d. Allergenic extract materials provided the patient for self-administration shall not exceed a 90-day supply. e. Payment will not be approved when an injection is determined to fall outside of what is medically reasonable or necessary based on basic standards of medical practice for the required level of care for a particular condition. f. Payment for vaccines available through the VFC program will be approved only if the VFC program stock has been depleted. g. Payment will not be approved for injections of “covered Part D drugs” as defined by 42 U.S.C. Section 1395w-102(e)(1)-(2) as amended to July 1, 2026, for any “Part D eligible individual” as defined in 42 U.S.C. Section 1395w-101(a)(3)(A) as amended to July 1, 2026, including an individual who is not enrolled in a Part D plan. 78.1(4) For the purposes of this program, cosmetic, reconstructive, or plastic surgery is surgery that can be expected primarily to improve physical appearance or that is performed primarily for psychological purposes or that restores form but that does not correct or materially improve the bodily functions. When a surgical procedure primarily restores bodily function, whether or not there is also a concomitant improvement in physical appearance, the surgical procedure does not fall within the provisions set forth in this subrule. Surgeries for the purpose of sex reassignment are not considered as restoring bodily function and are excluded from coverage. a. Coverage under the program is generally not available for cosmetic, reconstructive, or plastic surgery. However, under certain limited circumstances payment for otherwise covered services and supplies may be provided in connection with cosmetic, reconstructive, or plastic surgery as follows: (1) Correction of a congenital anomaly; or (2) Restoration of body form following an accidental injury; or (3) Revision of disfiguring and extensive scars resulting from neoplastic surgery. (4) Generally, coverage is limited to those cosmetic, reconstructive, or plastic surgery procedures performed no later than 12 months subsequent to the related accidental injury or surgical trauma. However, special consideration for exception will be given to cases involving children who may require a growth period. b. Cosmetic, reconstructive, or plastic surgery performed in connection with certain conditions is specifically excluded. These conditions are: (1) Dental congenital anomalies, such as absent tooth buds, malocclusion, and similar conditions. (2) Procedures related to transsexualism, hermaphroditism, gender identity disorders, or body dysmorphic disorders. This subparagraph is intended to implement Iowa Code section 249A.14. (3) Cosmetic, reconstructive, or plastic surgery procedures performed primarily for psychological reasons or as a result of the aging process. (4) Breast augmentation mammoplasty, surgical insertion of prosthetic testicles, penile implant procedures, and surgeries for the purpose of sex reassignment. c. When it is determined that a cosmetic, reconstructive, or plastic surgery procedure does not qualify for coverage under the program, all related services and supplies, including any institutional costs, are also excluded. d. Following is a partial list of cosmetic, reconstructive, or plastic surgery procedures that are not covered under the program. This list is for example purposes only and is not considered all-inclusive. (1) Any procedure performed for personal reasons to improve the appearance of an obvious feature or part of the body that would be considered by an average observer to be normal and acceptable for the patient’s age or ethnic or racial background. (2) Cosmetic, reconstructive, or plastic surgical procedures that are justified primarily on the basis of a psychological or psychiatric need. (3) Augmentation mammoplasties. (4) Facelifts and other procedures related to the aging process. (5) Reduction mammoplasties, unless there is medical documentation of intractable pain not amenable to other forms of treatment as the result of increasingly large pendulous breasts. (6) Panniculectomy and body sculpture procedures. (7) Repair of sagging eyelids unless there is demonstrated and medically documented significant impairment of vision. (8) Rhinoplasties unless there is evidence of accidental injury occurring within the past six months that resulted in significant obstruction of breathing. (9) Chemical peeling for facial wrinkles. (10) Dermabrasion of the face. (11) Revision of scars resulting from surgery or a disease process, except disfiguring and extensive scars resulting from neoplastic surgery. (12) Removal of tattoos. (13) Hair transplants. (14) Electrolysis. (15) Sex reassignment. (16) Penile implant procedures. (17) Insertion of prosthetic testicles. e. Coverage is available for otherwise covered services and supplies required in the treatment of complications resulting from a noncovered incident or treatment, but only when the subsequent complications represent a separate medical condition such as systemic infection, cardiac arrest, acute drug reaction, or similar conditions. Coverage will not be extended for any subsequent care or procedure related to the complication that is essentially similar to the initial noncovered care. An example of a complication similar to the initial period of care would be repair of facial scarring resulting from dermabrasion for acne. 78.1(5) The legally qualified practitioner’s prescription for medical equipment, appliances, or prosthetic devices shall include the patient’s diagnosis and prognosis, the reason the item is required, and an estimate in months of the duration of the need. Payment will be made in accordance with rule 441—78.10(249A). 78.1(6) Payment will be approved for the examination to establish the need for orthopedic shoes in accordance with rule 441—78.15(249A). 78.1(7) No payment will be made for the services of a private duty nurse. 78.1(8) Payment for mileage will be the same as that in effect in part B of Medicare. 78.1(9) Payment will be approved for visits to patients in nursing facilities subject to the following conditions: a. Payment will be approved for only one visit to the same patient in a calendar month. Payment for further visits will be made only when the need for the visits is adequately documented by the physician. b. When only one patient is seen in a single visit, the allowance will be based on a follow-up home visit. When more than one patient is seen in a single visit, payment will be based on a follow-up office visit. In the absence of information on the claim, the carrier will assume that more than one patient was seen, and payment approved on that basis. c. Payment will be approved for mileage in connection with nursing home visits when: (1) It is necessary for the physician to travel outside the home community, and (2) There are not physicians in the community in which the nursing home is located. d. Payment will be approved for tasks related to a resident receiving nursing facility care that are performed by a nurse practitioner or PA as specified in 42 CFR 483.30(f) as amended to July 1, 2026. On-site supervision of the physician is not required for these services. 78.1(10) Payment will be approved in independent laboratory when it has been certified as eligible to participate in Medicare. 78.1(11) Reserved. 78.1(12) Payment will be made on the same basis as in Medicare for services associated with treatment of chronic renal disease including physician’s services, hospital care, renal transplantation, and hemodialysis, whether performed on an inpatient or outpatient basis. Payment will be made for deductibles and coinsurance for those persons eligible for Medicare. 78.1(13) Payment will be made to the physician for services rendered by auxiliary personnel employed by the physician and working under the direct personal supervision of the physician, when such services are performed incident to the physician’s professional service. a. Auxiliary personnel are nurses, psychologists, social workers, audiologists, occupational therapists and physical therapists. b. An auxiliary person is considered to be an employee of the physician if the physician: (1) Is able to control the manner in which the work is performed, i.e., is able to control when, where and how the work is done. This control need not be actually exercised by the physician. (2) Sets work standards. (3) Establishes job description. (4) Withholds taxes from the wages of the auxiliary personnel. c. Direct personal supervision. (1) Direct personal supervision in the office setting means the physician must be present in the same office suite, not necessarily the same room, and be available to provide immediate assistance and direction. (2) Direct personal supervision outside the office setting, such as the member’s home, hospital, emergency room, or nursing facility, means the physician must be present in the same room as the auxiliary person. (3) ARNPs certified under board of nursing rules in 481—Chapter 621 performing services within their scope of practice are exempt from the direct personal supervision requirement for the purpose of reimbursement to the employing physicians. In these exempted circumstances, the employing physicians must still provide general supervision and be available to provide immediate needed assistance by telephone. ARNPs who prescribe drugs and medical devices are subject to the guidelines in effect for physicians as specified in rule 441—78.1(249A). (4) A PA licensed under board of PAs’ professional licensure rules in 481—Chapters 780 through 784 is exempt from the direct personal supervision requirement, except as expressly required by Iowa Code chapter 148C or 481—Chapters 780 through 784. A physician shall be accessible at all times for consultation with a PA unless the PA is providing emergency medical services pursuant to 481—subrule 781.1(3). PAs who prescribe drugs and medical devices are subject to the guidelines in effect for physicians as specified in rule 441—78.1(249A) or required by rules in 481—Chapters 780 through 784. PAs who prescribe drugs and medical devices are subject to the guidelines in effect for physicians as specified in rule 441—78.1(249A). d. Services incident to the professional services of the physician means the service provided by the auxiliary person must be related to the physician’s professional service to the member. If the physician has not or will not perform a personal professional service to the member, the clinical records must document that the physician assigned treatment of the member to the auxiliary person. 78.1(14) Payment will be made for persons aged 20 and under for nutritional counseling provided by a licensed dietitian employed by or under contract with a physician for a nutritional problem or condition of a degree of severity that nutritional counseling beyond that normally expected as part of the standard medical management is warranted. For persons eligible for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), a WIC referral is required. Medical necessity for nutritional counseling services exceeding those available through WIC shall be documented. 78.1(15) The certification of inpatient hospital care will be the same as that in effect in part A of Medicare. The hospital admittance record is sufficient for the original certification. 78.1(16) No payment will be made for sterilization of an individual under the age of 21 or who is mentally incompetent or institutionalized. Payment will be made for sterilization performed on an individual who is aged 21 or older at the time the informed consent is obtained and who is mentally competent and not institutionalized when all the conditions in this subrule are met. a. The following definitions are pertinent to this subrule: (1) Sterilization means any medical procedure, treatment, or operation performed for the purpose of rendering an individual permanently incapable of reproducing and that is not a necessary part of the treatment of an existing illness or medically indicated as an accompaniment of an operation on the genital urinary tract. Mental illness is not considered an illness or injury. (2) Hysterectomy means a medical procedure or operation to remove the uterus. (3) Mentally incompetent individual means a person who has been declared mentally incompetent by a federal, state or local court of jurisdiction for any purpose unless the individual has been declared competent for purposes that include the ability to consent to sterilization. (4) Institutionalized individual means an individual who is involuntarily confined or detained, under a civil or criminal statute, in a correctional or rehabilitative facility, including a mental hospital or other facility for the care and treatment of mental illness, or an individual who is confined under a voluntary commitment in a mental hospital or other facility for the care and treatment of mental illness. b. The sterilization shall be performed as the result of a voluntary request for the services made by the person on whom the sterilization is performed. The person’s consent for sterilization shall be documented on: (1) A department consent form, or (2) An official sterilization consent form from another state’s Medicaid program that contains all information found on the department form and complies with all applicable federal regulations. c. The person shall be advised prior to the receipt of consent that no benefits provided under the medical assistance program or other programs administered by the department may be withdrawn or withheld by reason of a decision not to be sterilized. d. The person shall be informed that the consent can be withheld or withdrawn any time prior to the sterilization without prejudicing future care and without loss of other project or program benefits. e. The person shall be given a complete explanation of the sterilization. The explanation shall include: (1) A description of available alternative methods and the effect and impact of the proposed sterilization including the fact that it must be considered to be an irreversible procedure. (2) A thorough description of the specific sterilization procedure to be performed and benefits expected. (3) A description of the attendant discomforts and risks including the type and possible effects of any anesthetic to be used. (4) An offer to answer any inquiries the person to be sterilized may have concerning the procedure to be performed. The individual shall be provided a copy of the informed consent form in addition to the oral presentation. f. At least 30 days and not more than 180 days shall have elapsed following the signing of the informed consent, except in the case of premature delivery or emergency abdominal surgery that occurs not less than 72 hours after the informed consent was signed. The informed consent shall have been signed at least 30 days before the expected delivery date for premature deliveries. g. The information in paragraphs 78.1(16)“b” through “f” shall be effectively presented to a blind, deaf, hard-of-hearing, or otherwise disabled individual and an interpreter shall be provided when the individual to be sterilized does not understand the language used on the consent form or used by the person obtaining consent. The individual to be sterilized may have a witness of the individual’s choice present when consent is obtained. h. The consent form described in paragraph 78.1(16)“b” shall be attached to the claim for payment and shall be signed by all parties required by the form. i. Informed consent shall not be obtained while the individual to be sterilized is: (1) In labor or childbirth, (2) Seeking to obtain or obtaining an abortion, or (3) Under the influence of alcohol or other substance that affects the individual’s state of awareness. j. Payment will be made for a medically necessary hysterectomy only when it is performed for a purpose other than sterilization and only when one or more of the following conditions is met: (1) The individual or representative has signed an acknowledgment of having been informed orally and in writing from the person authorized to perform the hysterectomy that the hysterectomy will make the individual permanently incapable of reproducing, (2) The individual was already sterile before the hysterectomy, the physician has certified in writing that the individual was already sterile at the time of the hysterectomy, and the physician has stated the cause of the sterility, or (3) The hysterectomy was performed as a result of a life-threatening emergency situation in which the physician determined that prior acknowledgment was not possible and the physician includes a description of the nature of the emergency. 78.1(17) Abortions. Payment for an abortion or related service is made when a Certification Regarding Abortion form is completed for the applicable circumstances and is attached to each claim for services. Payment for an abortion is made under one of the following circumstances: a. The physician certifies that the pregnant woman’s life would be endangered if the fetus were carried to term. b. The physician certifies that the fetus is physically deformed, mentally deficient or afflicted with a congenital illness and the physician states the medical indication for determining the fetal condition. c. The pregnancy was the result of rape reported to a law enforcement agency or public or private health agency which may include a family physician within 45 days of the date of occurrence of the incident. The report shall include the name, address, and signature of the person making the report. The Certification Regarding Abortion form shall be signed by the person receiving the report of the rape. d. The pregnancy was the result of incest reported to a law enforcement agency or public or private health agency including a family physician no later than 150 days after the date of occurrence. The report shall include the name, address, and signature of the person making the report. The Certification Regarding Abortion form shall be signed by the person receiving the report of incest. 78.1(18) Payment and procedure for obtaining eyeglasses, contact lenses, and visual aids shall be the same as described in rule 441—78.6(249A). 78.1(19) Preprocedure review by Iowa Medicaid will be required if payment under Medicaid is to be made for certain frequently performed surgical procedures that have a wide variation in the relative frequency the procedures are performed. Preprocedure surgical review applies to surgeries performed in hospitals (outpatient and inpatient) and ambulatory surgical centers. Approval by Iowa Medicaid will be granted only if the procedures are determined to be medically necessary based on the condition of the patient and the criteria established by Iowa Medicaid. If not so approved by Iowa Medicaid, payment will not be made under the program to the physician or to the facility in which the surgery is performed. The criteria are available from Iowa Medicaid. 78.1(20) Transplants. a. Payment will be made only for the following organ and tissue transplant services: (1) Kidney, cornea, skin, and bone transplants. (2) Allogeneic stem cell transplants for the treatment of aplastic anemia, severe combined immunodeficiency disease (SCID), Wiskott-Aldrich syndrome, follicular lymphoma, Fanconi anemia, paroxysmal nocturnal hemoglobinuria, pure red cell aplasia, amegakaryocytosis/congenital thrombocytopenia, beta thalassemia major, sickle cell disease, Hurler’s syndrome (mucopolysaccharidosis type 1 [MPS-1]), adrenoleukodystrophy, metachromatic leukodystrophy, refractory anemia, agnogenic myeloid metaplasia (myelofibrosis), familial erythrophagocytic lymphohistiocytosis and other histiocytic disorders, acute myelofibrosis, Diamond-Blackfan anemia, epidermolysis bullosa, or the following types of leukemia: acute myelocytic leukemia, chronic myelogenous leukemia, juvenile myelomonocytic leukemia, chronic myelomonocytic leukemia, acute myelogenous leukemia, and acute lymphocytic leukemia. (3) Autologous stem cell transplants for treatment of the following conditions: acute leukemia; chronic lymphocytic leukemia; plasma cell leukemia; non-Hodgkin’s lymphomas; Hodgkin’s lymphoma; relapsed Hodgkin’s lymphoma; lymphomas presenting poor prognostic features; follicular lymphoma; neuroblastoma; medulloblastoma; advanced Hodgkin’s disease; primitive neuroendocrine tumor (PNET); atypical/rhabdoid tumor (ATRT); Wilms’ tumor; Ewing’s sarcoma; metastatic germ cell tumor; or multiple myeloma. (4) Liver transplants for persons with extrahepatic biliary atresia or any other form of end-stage liver disease, except that coverage is not provided for persons with a malignancy extending beyond the margins of the liver.Liver transplants require preprocedure review by Iowa Medicaid. Covered liver transplants are payable only when performed in a facility that meets the requirements of subrule 78.3(10). (5) Heart transplants for persons with inoperable congenital heart defects, heart failure, or related conditions. Artificial hearts and ventricular assist devices as a temporary life-support system until a human heart becomes available for transplants are covered. Artificial hearts and ventricular assist devices as a permanent replacement for a human heart are not covered. Heart-lung transplants are covered where bilateral or unilateral lung transplantation with repair of a congenital cardiac defect is contraindicated.Heart transplants, heart-lung transplants, artificial hearts, and ventricular assist devices described above require preprocedure review by Iowa Medicaid. Covered heart transplants are payable only when performed in a facility that meets the requirements of subrule 78.3(10). (6) Lung transplants. Lung transplants for persons having end-stage pulmonary disease. Lung transplants require preprocedure review by Iowa Medicaid. Covered transplants are payable only when performed in a facility that meets the requirements of subrule 78.3(10). Heart-lung transplants are covered consistent with criteria in subparagraph 78.1(2)“a”(5). (7) Pancreas transplants for persons with type I diabetes mellitus, as follows: 1. Simultaneous pancreas-kidney transplants and pancreas after kidney transplants are covered. 2. Pancreas transplants alone are covered for persons exhibiting any of the following:A history of frequent, acute, and severe metabolic complications (e.g., hypoglycemia, hyperglycemia, or ketoacidosis) requiring medical attention. Clinical problems with exogenous insulin therapy that are so severe as to be incapacitating. Consistent failure of insulin-based management to prevent acute complications. 3. The pancreas transplants listed under this subparagraph require preprocedure review by Iowa Medicaid. 4. Covered transplants are payable only when performed in a facility that meets the requirements of subrule 78.3(10). 5. Transplantation of islet cells or partial pancreatic tissue is not covered. b. Donor expenses incurred directly in connection with a covered transplant are payable. Expenses incurred for complications that arise with respect to the donor are covered only if they are directly and immediately attributed to surgery. Expenses of searching for a donor are not covered. c. All transplants must be medically necessary and meet other general requirements of this chapter for physician and hospital services. d. Payment will not be made for any transplant not specifically listed in paragraph 78.1(20)“a.” 78.1(21) Utilization review. Utilization review will be conducted for Medicaid members who access more than 24 outpatient visits in any 12-month period from physicians, ARNPs, federally qualified health centers, other clinics, and emergency rooms. For the purposes of utilization review, the term “physician” does not include a psychiatrist. 78.1(22) Risk assessment. Risk assessment, using the Medicaid Prenatal Risk Assessment form, will be completed at the initial visit during a Medicaid member’s pregnancy. a. If the risk assessment reflects a low-risk pregnancy, the assessment shall be completed again at approximately the twenty-eighth week of pregnancy. b. If the risk assessment reflects a high-risk pregnancy, referral will be made for enhanced services. Enhanced services include health education, social services, nutrition education, and a postpartum home visit. Additional reimbursement will be provided for obstetrical services related to a high-risk pregnancy. (See description of enhanced services at subrule 78.25(3).) 78.1(23) Reserved. 78.1(24) Topical fluoride varnish. Payment will be made for application of an FDA-approved topical fluoride varnish, as defined by the Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association as amended to July 1, 2026, for the purpose of preventing the worsening of early childhood caries in children aged 0 to 36 months of age, when rendered by physicians or other appropriately licensed practitioners under the supervision of or in collaboration with a physician and who are acting within the scope of their practice, licensure, and other applicable state law, subject to the following provisions and limitations: a. Application of topical fluoride varnish must be provided in conjunction with an early and periodic screening, diagnosis, and treatment (EPSDT) examination which includes a limited oral screening. b. Separate payment will be available only for application of topical fluoride varnish, which will be at the same rate of reimbursement paid to dentists for providing this service. Separate payment for the limited oral screening will not be available, as this service is already part of and paid under the EPSDT screening examination. c. Parents, legal guardians, or other authorized caregivers of children receiving application of topical fluoride varnish as part of an EPSDT screening examination shall be informed by the physician or auxiliary staff employed by and under the physician’s supervision that this application is not a substitute for comprehensive dental care. d. Physicians rendering the services under this subrule shall make every reasonable effort to refer or facilitate referral of these children for comprehensive dental care rendered by a dental professional. 78.1(25) Prior authorization for medication-assisted treatment will be governed pursuant to subrule 78.28(2).Related ARC(s): 0315D441—78.2(249A) Prescribed outpatient drugs. Payment will be made for “covered outpatient drugs” as defined in 42 U.S.C. Section 1396r-8(k)(2)-(4) as amended to July 1, 2026, subject to the conditions and limitations specified in this rule. 78.2(1) Qualified prescriber. All drugs are covered only if prescribed or ordered by an Iowa Medicaid-enrolled practitioner licensed or registered to prescribe as specified in Iowa Code section 155A.3(39). 78.2(2) Prescription required. As a condition of payment for all drugs, including “nonprescription” or “over-the-counter” drugs that may otherwise be dispensed without a prescription or drug order, a prescription or drug order shall be transmitted as specified in Iowa Code sections 124.308, 155A.3 and 155A.27 by the practitioner to the pharmacy. All prescriptions or drug orders shall be available for audit by the department. 78.2(3) Qualified source. All drugs are covered only if marketed by manufacturers that have signed a Medicaid rebate agreement with the Secretary of Health and Human Services in accordance with Public Law 101-508 (Omnibus Budget Reconciliation Act of 1990 as amended to July 1, 2026). 78.2(4) Prescription drugs. Drugs that may be dispensed only upon a prescription are covered subject to the following limitations. a. Prior authorization is required as specified in the preferred drug list published by the department pursuant to Iowa Code section 249A.20A. (1) For any drug requiring prior authorization, reimbursement will be made for a 72-hour or three-day supply dispensed in an emergency when a prior authorization request cannot be submitted. (2) Unless the manufacturer or labeler of a mental health prescription drug that has a significant variation in therapeutic or side effect profile from other drugs in the same therapeutic class enters into a contract to provide the state with a supplemental rebate, the drug may be placed on the preferred drug list as nonpreferred, with prior authorization required. (3) For mental health prescription drugs requiring prior authorization that have a significant variation in therapeutic or side effect profile from other drugs in the same therapeutic class, reimbursement will be made for up to a seven-day supply pending prior authorization. A request for prior authorization shall be deemed approved if the prescriber: 1. Has on file with the department current contact information, including a current fax number, and a signed department Fax Confidentiality Certificate, and 2. Does not receive a notice of approval or disapproval within 48 hours of a request for prior authorization. (4) Prior authorization for medication-assisted treatment will be governed pursuant to subrule 78.28(2). b. Payment is not made for: (1) Drugs whose prescribed use is not for a medically accepted indication as defined by Section 1927(k)(6) of the Social Security Act as amended to July 1, 2026. (2) Drugs used for anorexia, weight gain, or weight loss. (3) Drugs used for cosmetic purposes or hair growth. (4) Reserved. (5) Otherwise covered outpatient drugs if the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or the manufacturer’s designee. (6) Drugs described in Section 107(c)(3) of the Drug Amendments of 1962 as amended to July 1, 2026, and identical, similar, or related drugs (within the meaning of Section 310.6(b)(1) of Title 21 of the Code of Federal Regulations as amended to July 1, 2026 (drugs identified through the Drug Efficacy Study Implementation (DESI) review)). (7) “Covered Part D drugs” as defined by 42 U.S.C. Section 1395w-102(e)(1)-(2) as amended to July 1, 2026, for any “Part D eligible individual” as defined by 42 U.S.C. Section 1395w-101(a)(3)(A) as amended to July 1, 2026, including a member who is not enrolled in a Medicare Part D plan. (8) Drugs prescribed for fertility purposes. (9) Drugs used for the treatment of sexual or erectile dysfunction, except when used to treat a condition other than sexual or erectile dysfunction for which the drug has been approved by the U.S. Food and Drug Administration (FDA). (10) Prescription drugs for which the prescription was executed in written (and nonelectronic) form unless the prescription was executed on a tamper-resistant pad, as required by Section 1903(i)(23) of the Social Security Act (42 U.S.C. Section 1396b(i)(23)). (11) Drugs used for symptomatic relief of cough and colds, except for nonprescription drugs listed at subrule 78.2(5). (12) Investigational drugs, including drugs that are the subject of an investigational new drug (IND) application allowed to proceed by the FDA but that do not meet the definition of a covered outpatient drug in 42 U.S.C. 1396r-8(k)(2)-(4) as amended to July 1, 2026. 78.2(5) Nonprescription drugs. a. Nonprescription or over-the-counter (OTC) refers to a drug that may be lawfully sold without a prescription; however, Iowa Medicaid requires a prescription for covered OTC drugs. These drugs are subject to prior authorization requirements as specified in the preferred drug list (PDL) published by the department pursuant to Iowa Code section 249A.20A. The drugs are identified on the nonprescription (OTC) prescribed list by therapeutic category located on the PDL website (www.iowamedicaidpdl.com) under the PDL/PA tab. b. Nonprescription drugs for use in a nursing facility, psychiatric medical institution for children (PMIC), or intermediate care facility for persons with an intellectual disability (ICF/ID) will be included in the per diem rate paid to the nursing facility, PMIC, or ICF/ID, with the exception of OTC insulin and pseudoephedrine. 78.2(6) Quantity prescribed. a. Quantity prescribed. When it is not therapeutically contraindicated, the legally qualified practitioner shall prescribe not less than a one-month supply of covered prescription and nonprescription medication. Contraceptives may be prescribed in three-month quantities. b. Prescription refills. (1) Prescription refills shall be performed and recorded in a manner consistent with existent state and federal laws, rules and regulations. (2) Automatic refills. 1. Automatic refills are allowed. Participation in an automatic refill program is voluntary and opt-in only, on a drug-by-drug basis. 2. The program must have:Easy-to-locate contact information through telephone, the program’s website, or both; Easy-to-understand patient materials on how to select or unselect drug(s) for inclusion and how to disenroll; Confirmation that the member wants to continue in the automatic refill program at least annually; Confirmation of continued medical necessity provided by the Medicaid member or person acting as an authorized representative of the member, before the member receives the medication at the pharmacy or before the medication is mailed or delivered to the member, without which confirmation the drug(s) must be credited back to the Medicaid program; and Records of all consents, which must be in electronic or written format and must be available for review by auditors. 78.2(7) Lowest cost item. The pharmacist shall dispense the lowest cost item in stock that meets the requirements of the practitioner as shown on the prescription. 78.2(8) Consultation. In accordance with Public Law 101-508 (Omnibus Budget Reconciliation Act of 1990) as amended to July 1, 2026, a pharmacist shall offer to discuss information regarding the use of the medication with each Medicaid member or the caregiver of a member presenting a prescription. The consultation is not required if the person refuses the consultation. Standards for the content of the consultation can be found in rules of the Iowa board of pharmacy.Related ARC(s): 0315D441—78.3(249A) Inpatient hospital services. Payment for inpatient hospital admission is approved when it meets the criteria for inpatient hospital care as determined by Iowa Medicaid. All cases are subject to random retrospective review and may be subject to a more intensive retrospective review if abuse is suspected. In addition, transfers, outliers, and readmissions within 31 days are subject to random review. Selected admissions and procedures are subject to a 100 percent review before the services are rendered. Medicaid payment for inpatient hospital admissions and continued stays are approved when the admissions and continued stays are determined to meet the criteria for inpatient hospital care. The criteria are available from Iowa Medicaid or in local hospital utilization review offices. No payment will be made for waiver days.See rule 441—78.31(249A) for policies regarding payment of hospital outpatient services.If the recipient is eligible for inpatient or outpatient hospital care through the Medicare program, payment will be made for deductibles and coinsurance as set out in 441—subrule 79.1(22).The DRG payment calculations include any special services required by the hospital, including a private room. 78.3(1) Payment for Medicaid-certified physical rehabilitation units will be approved for the day of admission but not the day of discharge or death. 78.3(2) No payment will be approved for private duty nursing. 78.3(3) Certification of inpatient hospital care shall be the same as that in effect in part A of Medicare. The hospital admittance records are sufficient for the original certification. 78.3(4) Services provided for intestinal or gastric bypass surgery for treatment of obesity require prior approval, which must be obtained by the attending physician before surgery is performed. 78.3(5) Payment will be approved for drugs provided to inpatients subject to the same provisions specified in subrule 78.2(1) and subparagraphs 78.2(4)“b”(1) through “b”(10), except for “b”(7). The basis of payment for drugs administered to inpatients is through the DRG reimbursement. a. Payment will be approved for drugs and supplies provided to outpatients subject to the same provisions specified in subrules 78.2(1) through 78.2(4), except for subparagraph 78.2(4)“b”(7). The basis of payment for drugs provided to outpatients is through a combination of Medicaid-determined fee schedules and ambulatory payment classification, pursuant to 441—subrule 79.1(16). b. In order to be paid for the administration of a vaccine covered under the VFC program, a hospital must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted. 78.3(6) Payment for nursing care provided by a hospital will be made to those hospitals certified by the department of inspections, appeals, and licensing as meeting the standards for a nursing facility. 78.3(7) Payment for inpatient hospital tests for purposes of diagnosis and treatment will be made only when the tests are specifically ordered for the diagnosis and treatment of a particular patient’s condition by the attending physician or other licensed practitioner acting within the scope of practice as defined by law, who is responsible for that patient’s diagnosis or treatment. 78.3(8) Payment will be made for medically necessary inpatient acute psychiatric intensive care services that meet the criteria in this subrule, pursuant to 441—paragraph 79.1(5)“i.” This inpatient rate is only applicable to individuals 18 to 64 years of age. All inpatient acute psychiatric intensive care services require prior authorization. a. “Acute psychiatric intensive care” is defined as care provided for a condition with rapid onset that is accompanied by severe symptoms and is generally of brief duration, requiring emergency treatment and critical care. b. To meet the need for acute psychiatric intensive care, the patient must: (1) Have a serious and persistent mental illness as defined in 441—subrule 77.25(1); (2) Have a current, severe, imminent risk of serious harm to self or others; and (3) Display additional complexity of need related to: 1. Complex comorbidities, including intellectual or developmental disability, autism spectrum disorder, substance use disorders, or traumatic brain injuries; or 2. A history of violence or current aggression that is secondary to mental illness; or 3. A request for patient transfer that has been rejected by inpatient level of care by one or more hospitals due to severity of symptoms; or 4. Lack of responsiveness to typical interventions or a condition that is treatment refractory; or 5. Disorganized psychotic state or manic thought process that impairs the ability to function or risks the safety of the patient or others; or 6. Behavior that causes disruption to the general milieu of the unit (i.e., instigating other patients in negative ways); or 7. High elopement risk; or 8. Any other atypical reason that the treating mental health provider feels that additional resources are needed to keep the patient and others around the patient safe. c. The individual must have a documented need for acute intensive care requiring increased or specialized staffing, equipment, or facilities, based on two or more of the following: (1) Fall precaution protocol in place; (2) Restraints or seclusion room requirements; (3) Requiring assistance with activities of daily living; (4) Requirements for complex nursing care; (5) Acutely impaired cognitive functioning from baseline; (6) Documentation of interventions to address acute complex mental illness and comorbidities; (7) Safety protocols in place to address the physical risk posed to staff, other patients, and infrastructure; (8) Elopement risk precaution protocol in place. 78.3(9) Payment will be made for sterilizations in accordance with 78.1(16). 78.3(10) Payment will be approved for organ and tissue transplant services, as specified in subrule 78.1(20). Kidney, cornea, skin, bone, allogeneic bone marrow, autologous bone marrow, heart, liver, and lung transplants are covered as specified in subrule 78.1(20). Lung transplants are payable at Medicare-designated lung transplant centers only. Heart and liver transplants are payable when performed at facilities that meet the following criteria: a. Recipient selection and education. (1) Selection. The transplant center must have written criteria based on medical need for transplantation for final facility selection of recipients. These criteria should include an equitable, consistent and practical protocol for selection of recipients. The criteria must be at least as strict as those specified by Medicare. (2) Education. The transplant center will provide a written plan for recipient education. It shall include educational plans for recipient, family and significant others during all phases of the program. These phases shall include:Intake.Preparation and waiting period.Preadmission.Hospitalization.Discharge planning.Follow-up. b. Staffing and resource commitment. (1) Transplant surgeon. The transplant center must have on staff a qualified transplant surgeon.The surgeon must have received at least one year of training at a transplant center approved by the American Society of Transplant Surgeons under the direction of an experienced transplant surgeon and must have had at least two years of experience in all facets of transplant surgery specific to the surgeon’s specialty. This experience must include management of recipients’ presurgical and postsurgical care and actual experience as a member of a transplant team at the institution. The transplant surgeon will have an understanding of the principles of and demonstrated expertise in the use of immunosuppressive therapy.The transplant surgeon will be certified by the American Board of Thoracic Surgery or equivalent for heart transplants and the American Board of Surgery or equivalent for liver transplants.The transplant surgeon will be the defined leader of a stable, established transplant team that has a strong commitment to the transplant program. (2) Transplant team. The transplant team will be clearly defined with leadership and corresponding responsibilities of all team members identified. The team should consist of: 1. A surgeon director. 2. A board-certified internist or pediatrician with training and expertise in organ transplantation medicine and clinical use of immunosuppressive regimens.The transplant center will assume responsibility for initial training and continuing education of the transplant team and ancillary personnel. The center will maintain records that demonstrate competency in achieving, maintaining and improving skills in the distinct areas of expertise of each of the team members. (3) Physicians. The transplant center will have on staff or available for consultation physicians with the following areas of expertise: 1. Anesthesiology. 2. Cardiology. 3. Dialysis. 4. Gastroenterology. 5. Hepatology. 6. Immunology. 7. Infectious diseases. 8. Nephrology. 9. Neurology. 10. Pathology. 11. Pediatrics. 12. Psychiatry. 13. Pulmonary medicine. 14. Radiology. 15. Rehabilitation medicine.Liaison with the recipient’s permanent physician is established for the purpose of providing continuity and management of the recipient’s long-term care. (4) Support personnel and resources. The center must have a commitment of sufficient resources and planning for implementation and operation of the transplant program. Indicators of the commitment will include persons with expertise in the following areas available at the transplant center: 1. Anesthesiology. 2. Blood bank services. 3. Cardiology. 4. Cardiovascular surgery. 5. Dialysis. 6. Dietary services. 7. Gastroenterology. 8. Infection control. 9. Laboratory services (pathology, microbiology, immunology, tissue typing, and immunosuppressive drug monitoring). 10. Legal counsel familiar with transplantation laws and regulations. 11. Nursing service department with staff available who have expertise in the care of transplant recipients, especially in managing immunosuppressed patients and hemodynamic support. 12. Respiratory therapy. 13. Pharmaceutical services. 14. Physical therapy. 15. Psychiatry. 16. Psychosocial.The center will have active cardiovascular, medical, and surgical programs with the ability and willingness to perform diagnostic and evaluative procedures appropriate to transplants on an emergency and ongoing basis.The center will have designated an adequate number of intensive care and general service beds to support the transplant center. (5) Laboratory. Each transplant center must have direct local 24-hour per day access to histocompatibility testing facilities. These facilities must meet the Standards for Histocompatibility Testing set forth by the Committee on Quality Assurance and Standards of the American Society for Histocompatibility and Immunogenetics (ASHI) as amended to July 1, 2026. As specified by ASHI, the director of the facility shall hold a doctoral degree in biological science, or be a physician, and subsequent to graduation shall have had four years’ experience in immunology, two of which were devoted to formal training in human histocompatibility testing, documented to be professionally competent by external measures such as national proficiency testing, participation in national or international workshops or publications in peer-reviewed journals. The laboratory must successfully participate in a regional or national testing program. c. Experience and survival rates. (1) Experience. Centers will be given a minimum volume requirement of 12 heart or 12 liver transplants that should be met within one year. Due to special considerations such as patient case mix or donor availability, an additional one year conditional approval may be given if the minimum volume is not met the first year. For approval of an extrarenal organ transplant program it is highly desirable that the institution: 1. Has available a complete team of surgeons, physicians, and other specialists with specific experience in transplantation of that organ, or 2. Has an established approved renal transplant program at that institution and personnel with expertise in the extrarenal organ system itself. (2) Survival rates. The transplant center will achieve a record of acceptable performance consistent with the performance and outcomes at other successful designated transplant centers. The center will collect and maintain recipient and graft survival and complication rates. A level of satisfactory success and safety will be demonstrated with bases for substantial probability of continued performance at an acceptable level. To encourage a high level of performance, transplant programs must achieve and maintain a minimum one-year patient survival rate of 70 percent for heart transplants and 50 percent for liver transplants. d. Organ procurement. The transplant center will participate in a nationwide organ procurement and typing network. Detailed plans must exist for organ procurement yielding viable transplantable organs in reasonable numbers, meeting established legal and ethical criteria. The transplant center must be a member of the National Organ Procurement and Transplant Network. e. Maintenance of data, research, review and evaluation. (1) Maintenance of data. The transplant center will collect and maintain data on the following: 1. Risk and benefit. 2. Morbidity and mortality. 3. Long-term survival. 4. Quality of life. 5. Recipient demographic information.These data should be compiled and maintained at the transplant center monthly. The transplant center will submit the above data to the United Network for Organ Sharing yearly. (2) Research. The transplant center will have a plan for and a commitment to research. Ongoing research regarding the transplanted organs is required. The transplant center will have a program in graduate medical education or have a formal agreement with a teaching institution for affiliation with a graduate medical education program. (3) Review and evaluation. The transplant center will have a plan for ongoing evaluation of the transplantation program. The transplant center will have a detailed plan for review and evaluation of recipient selection, preoperative, operative, postoperative and long-term management of the recipient. The transplant center will conduct concurrent ongoing studies to ensure high quality services are provided in the transplantation program. The transplant center will provide information to members of the transplant team and ancillary staff regarding the findings of the quality assurance studies. This information will be utilized to provide education geared toward interventions to improve staff performance and reduce complications occurring in the transplant process. The transplant center will maintain records of all quality assurance and peer review activities concerning the transplantation program to document identification of problems or potential problems, intervention, education and follow-up. f. Application procedure. A Medicare-designated heart, liver, or lung transplant facility needs only to submit evidence of this designation to Iowa Medicaid. The application procedure for other heart and liver facilities is as follows: (1) An original and two copies of the application must be submitted on 8½-by-11-inch paper, signed by a person authorized to do so. The facility must be a participating hospital under Medicaid and must specify its provider number, and the name and telephone number of a contact person should there be questions regarding the application. (2) Information and data must be clearly stated, well organized and appropriately indexed to aid in its review against the criteria specified in this rule. Each page must be numbered. (3) To the extent possible, the application should be organized into five sections corresponding to each of the five major criteria and addressing, in order, each of the subcriteria identified. (4) The application should be mailed to Iowa Medicaid. g. Review and approval of facilities. An organized review committee will be established to evaluate performance and survival statistics and make recommendations regarding approval as a designated transplant center based on acceptable performance standards established by the review organization and approved by the Medicaid agency. (1) There will be established protocol for the systematic evaluation of patient outcome including survival statistics. (2) Once a facility applies for approval and is approved as a heart or liver transplant facility for Medicaid purposes, it is obliged to report immediately to the department any events or changes that would affect its approved status. Specifically, a facility must report any significant decrease in its experience level or survival rates, the transplantation of patients who do not meet its patient selection criteria, the loss of key members of the transplant team, or any other major changes that could affect the performance of heart or liver transplants at the facility. Changes from the terms of approval may lead to withdrawal of approval for Medicaid coverage of heart or liver transplants performed at the facility. 78.3(11) Payment will be approved for inpatient hospital care rendered a patient in connection with dental treatment only when the mental, physical, or emotional condition of the patient prevents the dentist from providing this necessary care in the office. 78.3(12) Payment will be approved for an assessment fee as specified in 441—paragraphs 79.1(16)“a” and “r” to determine if a medical emergency exists. Medical emergency is defined as a sudden or unforeseen occurrence or combination of circumstances presenting a substantial risk to an individual’s health unless immediate medical treatment is given. The determination of whether a medical emergency exists will be based on the patient’s medical condition including presenting symptoms and medical history prior to treatment or evaluation. 78.3(13) Payment for patients in acute hospital beds who are determined by Iowa Medicaid to require the skilled nursing care level of care shall be made at an amount equal to the sum of the direct care rate component limit for Medicare-certified hospital-based nursing facilities pursuant to 441—paragraph 81.5(16)“f” plus the non-direct care rate component limit for Medicare-certified hospital-based nursing facilities pursuant to 441—paragraph 81.5(16)“f,” with the rate component limits being revised July 1, 2001, and every second year thereafter. This rate is effective: a. As of the date of notice by Iowa Medicaid that the lower level of care is required, or b. For the days Iowa Medicaid determines in an outlier review that the lower level of care was required. 78.3(14) Payment for patients in acute hospital beds who are determined by Iowa Medicaid to require nursing facility level of care shall be made at an amount equal to the sum of the direct care rate component limit for Medicaid nursing facilities pursuant to 441—paragraph 81.5(16)“f” plus the non-direct care rate component limit for Medicaid nursing facilities pursuant to 441—paragraph 81.5(16)“f,” with the rate component limits being revised July 1, 2001, and every second year thereafter. This rate is effective: a. As of the date of notice by Iowa Medicaid that the lower level of care is required, or b. For the days Iowa Medicaid determines in an outlier review that the lower level of care was required. 78.3(15) Payment for inpatient hospital charges associated with surgical procedures normally done and billed on an outpatient hospital basis is subject to review by Iowa Medicaid. Such reviews are based on random claim samples that are pulled on a monthly basis. If the information on a given inpatient claim included in that sample does not appear to support the appropriateness of inpatient level of care, that claim is sent to the Iowa Medicaid medical director for further review. If the medical director approves the inpatient level of care, the claim is paid. However, if the medical director determines that the care provided could have been rendered at a lower level of care, the hospital and attending physician are notified accordingly. If the hospital agrees with the finding that a lower level of care was appropriate, the hospital submits a new claim for the lower level of care. If the hospital disagrees with the lower level of care finding, the hospital can submit additional documentation for further review. The hospital or attending physician or both may appeal any final determination by Iowa Medicaid pursuant to 441—Chapter 2506. 78.3(16) Skilled nursing care in “swing beds.” a. Payment will be made for medically necessary skilled nursing care when provided by a hospital participating in the swing-bed program certified by the department of inspections, appeals, and licensing and approved by the U.S. Department of Health and Human Services. Payment shall be at an amount equal to the sum of the direct care rate component limit for Medicare-certified hospital-based nursing facilities pursuant to 441—paragraph 81.5(16)“f” and the non-direct care rate component limit for Medicare-certified hospital-based nursing facilities pursuant to 441—paragraph 81.5(16)“f” with the rate component limits being revised July 1, 2001, and every second year thereafter. Swing-bed placement is only intended to be short-term in nature. b. Any payment for skilled nursing care provided in a hospital with a certified swing-bed program, for either initial admission or continued stay, will require prior authorization, subject to the following requirements: (1) The hospital has fewer than 100 beds, excluding beds for newborns and intensive care. (2) The hospital has an existing certification for a swing-bed program, pursuant to paragraph 78.3(16)“a.” (3) The member is being admitted for nursing facility or skilled level of care (if the member has Medicare and skilled coverage has been exhausted). (4) As part of the discharge planning process for a member requiring ongoing skilled nursing care, the hospital must: 1. Complete a level of care (LOC) determination describing a member’s LOC needs, using a department Swing Bed Certification form. 2. Contact skilled nursing facilities within a 30-mile radius of the hospital regarding available beds to meet the member’s LOC needs. 3. Certify that no freestanding skilled nursing facility beds are available for the member within a 30-mile radius of the hospital, which will be able to appropriately meet the member’s needs and that home-based care for the member is not available or appropriate. (5) Swing-bed stays beyond 14 days will only be approved when there is no appropriate freestanding nursing facility bed available within a 30-mile radius and home-based care for the member is not available or appropriate, as documented by the hospital seeking the swing-bed admission. For the purpose of these criteria, an “appropriate” nursing facility bed is a bed in a Medicaid-participating freestanding nursing facility that provides the LOC required for the member’s medical condition and corresponding LOC needs. (6) A Medicaid member who has been in a swing bed beyond 14 days must be discharged to an appropriate nursing facility bed within a 30-mile radius of the swing-bed hospital or to appropriate home-based care within 72 hours of an appropriate nursing facility bed becoming available.Preadmission screening and resident review (PASRR) rules still apply for members being transferred to a nursing facility. 78.3(17) Reserved. 78.3(18) Preprocedure review by Iowa Medicaid is required if hospitals are to be reimbursed for certain frequently performed surgical procedures as set forth under subrule 78.1(19). Preprocedure review is also required for other types of major surgical procedures, such as organ transplants. Criteria are available from Iowa Medicaid.Related ARC(s): 0315D441—78.4(249A) Dental services. Payment is authorized only for medically necessary dental and oral surgery services provided by a dentist to the extent these services are permitted to be performed under state law either by doctors of medicine, osteopathy, dental surgery or dental medicine and would be covered if furnished by doctors of medicine or osteopathy. Services must be reasonable, necessary, and cost-effective for the prevention, diagnosis, and treatment of dental disease or injuries or for oral devices necessary for a medical condition. Payment will also be made for the following dental procedures. 78.4(1) Preventive services. Payment will be made for the following preventive services: a. Oral prophylaxis, including necessary scaling and polishing, once in a six-month period except for persons who, because of a physical or mental condition, need more frequent care. Documentation supporting the need for oral prophylaxis performed more than once in a six-month period must be maintained. b. Topical application of fluoride, once every 90 days. (This does not include the use of fluoride prophylaxis paste as fluoride treatment.) c. Pit and fissure sealants for placement on deciduous and permanent posterior teeth only. Reimbursement for sealants is restricted to work performed on members through 18 years of age and on members who have a physical or mental condition that impairs their ability to maintain adequate oral hygiene. Replacement sealants are covered when medically necessary, as documented in the patient record. d. Space management services in mixed dentition when premature loss of teeth would permit existing teeth to shift and cause a handicapping malocclusion, or there is too little dental ridge to accommodate either the number or the size of teeth and significant dental disease will result if the condition is not corrected. 78.4(2) Diagnostic services. Payment will be made for the following diagnostic services: a. A comprehensive oral evaluation once per member per dental practice in a three-year period when the member has not been seen by a dentist in the dental practice during the three-year period. b. A periodic oral examination once in a six-month period. c. A full mouth radiograph survey, consisting of a minimum of 14 periapical films and bite-wing films, or a panoramic radiograph with bite-wings once in a five-year period, except when medically necessary to evaluate development and to detect anomalies, injuries and diseases. Full mouth radiograph surveys are not payable under the age of six except when medically necessary. A panographic-type radiography with bite-wings is considered the same as a full mouth radiograph survey. d. Supplemental bite-wing films only once in a 12-month period. e. Single periapical films when necessary. f. Intraoral radiograph, occlusal. g. Extraoral radiograph. h. Posterior-anterior and lateral skull and facial bone radiograph, survey film. i. Temporomandibular joint radiograph. j. Cephalometric film. k. Diagnostic casts only for orthodontic cases or dental implants or when requested by Iowa Medicaid. l. Cone beam images when medically necessary for situations including but not limited to detection of tumors, positioning of severely impacted teeth, supernumerary teeth or dental implants. 78.4(3) Restorative services. Payment will be made for the following restorative services: a. Treatment of dental caries in those areas that require immediate attention. Restoration of incipient or nonactive carious lesions are not payable. Carious activity may be considered incipient when there is no penetration of the dento-enamel junction as demonstrated in diagnostic radiographs. b. Amalgam alloy and composite resin-type filling materials only once for the same restoration in a two-year period. c. Crowns when there is at least a fair prognosis for maintaining the tooth as determined by Iowa Medicaid and when a more conservative procedure would not be serviceable. (1) Stainless steel crowns are limited to primary and permanent posterior teeth and are covered when coronal loss of tooth structure does not allow restoration with an amalgam or composite restoration. Placement on permanent posterior teeth is allowed only for members who have a mental or physical condition that limits their ability to tolerate the procedure for placement of a different crown. (2) Aesthetic coated stainless steel crowns and stainless steel crowns with a resin window are limited to primary anterior teeth. (3) Laboratory-fabricated crowns, other than stainless steel, are limited to permanent teeth and require prior authorization. Approval will be granted when coronal loss of tooth structure does not allow restoration with an amalgam or composite restoration or when there is evidence of recurring decay surrounding a large existing restoration, a fracture, a broken cusp(s), or an endodontic treatment. (4) Crowns with noble or high noble metals require prior authorization. Approval will be granted for members who meet the criteria for a laboratory-fabricated crown, other than stainless steel, and who have a documented allergy to all other restorative materials. d. Cast post and core, post and composite or post and amalgam in addition to a crown when a tooth is functional and the integrity of the tooth would be jeopardized by no post support. e. The following restoration procedures, as indicated: (1) Amalgam or acrylic buildups, including any pins, are considered a core buildup. (2) One, two, or more restorations on one surface of a tooth will be paid as a one-surface restoration (i.e., mesial occlusal pit and distal occlusal pit of a maxillary molar or mesial and distal occlusal pits of a lower bicuspid). (3) Occlusal lingual groove of a maxillary molar that extends from the distal occlusal pit and down the distolingual groove will be paid as a two-surface restoration. This restoration and a mesial occlusal pit restoration on the same tooth will be paid as one, two-surface restoration. (4) Two separate one-surface restorations are payable as a two-surface restoration (i.e., an occlusal pit restoration and a buccal pit restoration are a two-surface restoration). (5) Tooth preparation, temporary restorations, cement bases, pulp capping, impressions, and local anesthesia are included in the restorative fee and may not be billed separately. (6) Pin retention will be paid on a per-tooth basis and in addition to the final restoration. (7) More than four surfaces on an amalgam restoration will be reimbursed as a “four-surface” amalgam. (8) An amalgam or composite restoration is not payable following a sedative filling in the same tooth unless the sedative filling was placed more than 30 days previously. 78.4(4) Periodontal services. Payment may be made for the following periodontal services: a. Full-mouth debridement to enable comprehensive periodontal evaluation and diagnosis once every 24 months. This procedure is not payable on the same date of service when other prophylaxis or periodontal services are performed. b. Periodontal scaling and root planing once every 24 months when prior approval has been received. Prior approval will be granted per quadrant when radiographs demonstrate subgingival calculus or loss of crestal bone and when the periodontal probe chart shows evidence of pocket depths of 4 mm or greater. c. Periodontal surgical procedures including gingivoplasty, osseous surgery, and osseous allograft when prior approval has been received. Payment for these surgical procedures will be approved after periodontal scaling and root planing has been provided, a reevaluation examination has been completed, and the member has demonstrated reasonable oral hygiene. Payment is also allowed for members who are unable to demonstrate reasonable oral hygiene due to a physical or mental condition, or who exhibit evidence of gingival hyperplasia, or who have a deep carious lesion that cannot be otherwise accessed for restoration. d. Pedicle soft tissue graft, free soft tissue graft, and subepithelial connective tissue graft with prior approval. Authorization will be granted when the amount of tissue loss is causing problems such as continued bone loss, chronic root sensitivity, complete loss of attached tissue, or difficulty maintaining adequate oral hygiene. e. Periodontal maintenance therapy, which requires prior authorization. Approval will be granted for members who have completed periodontal scaling and root planing at least three months prior to the initial periodontal maintenance therapy and the periodontal probe chart shows evidence of pocket depths of 4 mm or greater. f. Tissue regeneration procedures, which require prior authorization. Approval will be granted when radiographs show evidence of recession in relation to the muco-gingival junction and the bone level indicates the tooth has a fair to good long-term prognosis. g. Localized delivery of antimicrobial agents, which requires prior authorization. Approval will be granted when at least one year has elapsed since periodontal scaling and root planing was completed, the member has maintained regular periodontal maintenance, and pocket depths remain at a moderate to severe depth with bleeding on probing. Authorization is limited to once per site every 12 months. 78.4(5) Endodontic services. Payment will be made for the following endodontic services: a. Root canal treatments on permanent anterior and posterior teeth when there is presence of extensive decay, infection, draining fistulas, severe pain upon chewing or applied pressure, prolonged sensitivity to temperatures, or a discolored tooth indicative of a nonvital tooth. b. Vital pulpotomies. Cement bases, pulp capping, and insulating liners are considered part of the restoration and may not be billed separately. c. Surgical endodontic treatment, including an apicoectomy, performed as a separate surgical procedure; an apicoectomy, performed in conjunction with endodontic procedure; an apical curettage; a root resection; or excision of hyperplastic tissue when nonsurgical treatment has been attempted and a reasonable time of approximately one year has elapsed after which failure has been demonstrated. Surgical endodontic procedures may be indicated when: (1) Conventional root canal treatment cannot be successfully completed because canals cannot be negotiated, debrided or obturated due to calcifications, blockages, broken instruments, severe curvatures, and dilacerated roots. (2) Correction of problems resulting from conventional treatment, including gross underfilling, perforations, and canal blockages with restorative materials. d. Endodontic retreatment when prior authorization has been received. Authorization for retreatment of a tooth with previous endodontic treatment will be granted when the conventional treatment has been completed, a reasonable time has elapsed since the initial treatment, and failure has been demonstrated with a radiograph and narrative history. A reasonable period of time is approximately one year if the treating dentist is the same and may be less if the member must see a different dentist. 78.4(6) Oral surgery—medically necessary. Payment will be made for medically necessary oral surgery services furnished by dentists to the extent that these services may be performed under state law either by doctors of medicine, osteopathy, dental surgery or dental medicine and would be covered if furnished by doctors of medicine or osteopathy as defined in rule 441—78.1(249A). These services will be reimbursed in a manner consistent with the physician’s reimbursement policy. The following surgical procedures are also payable when performed by a dentist: a. Extractions, both surgical and nonsurgical. b. Impaction (soft tissue impaction, upper or lower) that requires an incision of overlying soft tissue and the removal of the tooth. c. Impaction (partial bony impaction, upper or lower) that requires incision of overlying soft tissue, elevation of a flap, removal of bone and removal of the tooth. d. Impaction (complete bony impaction, upper or lower) that requires incision of overlying soft tissue, elevation of a flap, removal of bone and section of the tooth for removal. e. Root recovery (surgical removal of residual root). f. Oral antral fistula closure (or antral root recovery). g. Surgical exposure of impacted or unerupted tooth for orthodontic reasons, including ligation when indicated. h. Surgical exposure of impacted or unerupted tooth to aid eruption. i. Postoperative care where need is shown to be beyond normal follow-up care or for postoperative care where the original service was performed by another dentist.Routine postoperative care is considered part of the fee for surgical procedures and may not be billed separately. 78.4(7) Prosthetic services. Payment may be made for the following prosthetic services: a. An immediate denture or a first-time complete denture. Six months’ postdelivery care is included in the reimbursement for the denture. b. A removable partial denture replacing anterior teeth when prior approval has been received. Approval will be granted when radiographs demonstrate adequate space for replacement of a missing anterior tooth. Six months’ postdelivery care is included in the reimbursement for the denture. c. A removable partial denture replacing posterior teeth including six months’ postdelivery care when prior approval has been received. Approval will be granted when the member has fewer than eight posterior teeth in occlusion, excluding third molars, or the member has a full denture in one arch and a partial denture replacing posterior teeth is required in the opposing arch to balance occlusion. When one removable partial denture brings eight posterior teeth in occlusion, no additional removable partial denture will be approved. Six months’ postdelivery care is included in the reimbursement for the denture. d. A fixed partial denture (including an acid etch fixed partial denture) replacing anterior teeth when prior approval has been received. Approval will be granted for members who: (1) Have a physical or mental condition that precludes the use of a removable partial denture, or (2) Have an existing bridge that needs replacement due to breakage or extensive, recurrent decay.High noble or noble metals will be approved only when the member is allergic to all other restorative materials. e. A fixed partial denture replacing posterior teeth when prior approval has been received. Approval will be granted for members who meet the criteria for a removable partial denture and: (1) Have a physical or mental condition that precludes the use of a removable partial denture, or (2) Have a full denture in one arch and a partial fixed denture replacing posterior teeth is required in the opposing arch to balance occlusion.High noble or noble metals will be approved only when the member is allergic to all other restorative materials. f. Obturator for surgically excised palatal tissue or deficient velopharyngeal function of cleft palate patients. g. Chairside relines and laboratory-processed relines only once per prosthesis every 12 months, beginning 6 months after placement of the denture. h. Tissue conditioning twice per prosthesis in a 12-month period. i. Two repairs per prosthesis in a 12-month period. j. Adjustments to a complete or removable partial denture when medically necessary after six months’ postdelivery care. An adjustment consists of removal of acrylic material or adjustment of teeth to eliminate a sore area or to make the denture fit better. Warming dentures and massaging them for better fit or placing them in a sonic device does not constitute an adjustment. k. Dental implants and related services when prior authorization has been received. Prior authorization will be granted when the member is missing significant oral structures due to cancer, traumatic injuries, or developmental defects such as cleft palate and cannot use a conventional denture. l. Replacement of complete or partial dentures in less than a five-year period, which requires prior authorization. Approval will be granted once per denture replacement per arch in a five-year period when the denture has been lost, stolen or broken beyond repair or cannot be adjusted for an adequate fit. Approval will also be granted for more than one denture replacement per arch within five years for members who have a medical condition that necessitates thorough mastication. Approval will not be granted in less than a five-year period when the reason for replacement is resorption. m. A complete or partial denture rebase, which requires prior approval. Approval will be granted when the acrylic of the denture is cracked or has had numerous repairs and the teeth are in good condition. n. An oral appliance for obstructive sleep apnea, which requires prior approval and must be custom-fabricated. Approval will be granted in accordance with Medicare criteria. 78.4(8) Orthodontic procedures. Payment may be made for the following orthodontic procedures: a. Minor treatment to control harmful habits when prior approval has been received. Approval will be granted when it is cost-effective to lessen the severity of a malformation such that extensive treatment is not required. b. Interceptive orthodontic treatment of the transitional dentition when prior approval has been received. Approval will be granted when it is cost-effective to lessen the severity of a malformation such that extensive treatment is not required. c. Comprehensive orthodontic treatment when prior approval has been received. Approval is limited to members under 21 years of age and will be granted when the member has a severe handicapping malocclusion as defined by the department and when determined to be medically necessary. 78.4(9) Adjunctive general services. Payment may be made for the following: a. Treatment in a hospital. Payment will be approved for dental treatment rendered to a hospitalized member only when the mental, physical, or emotional condition of the member prevents the dentist from providing necessary care in the office. b. Treatment in a nursing facility. Payment will be approved for dental treatment provided in a nursing facility. When more than one patient is examined during the same nursing home visit, payment will be made by the Medicaid program for only one visit to the nursing home. c. Office visit. Payment will be approved for an office visit for care of injuries or abnormal conditions of the teeth or supporting structure when treatment procedures or examinations are not billed for that visit. d. Office calls after hours. Payment will be approved for office calls after office hours in emergency situations. The office call will be paid in addition to treatment procedures. e. Drugs. Payment will be made for drugs dispensed by a dentist only if there is no licensed retail pharmacy in the community where the dentist’s office is located. Payment will not be made for writing prescriptions. f. Anesthesia. General anesthesia, intravenous sedation, and nonintravenous conscious sedation are payable services when the extensiveness of the procedure indicates it or there is a concomitant disease or impairment that warrants use of anesthesia. Inhalation of nitrous oxide is payable when the age or physical or mental condition of the member necessitates the use of minimal sedation for dental procedures. g. Occlusal guard. A removable dental appliance to minimize the effects of bruxism and other occlusal factors requires prior approval. Approval will be granted when the documentation supports evidence of significant loss of tooth enamel, tooth chipping, headaches or jaw pain. 78.4(10) Orthodontic services to members 21 years of age or older. Orthodontic procedures are not covered for members 21 years of age or older. 78.4(11) Emergency services. Payment will be made for emergency services as defined in and pursuant to the requirements set forth in 42 CFR 438.114 as amended to July 1, 2026. 78.4(12) Prior authorization. Certain dental services require prior authorization as set forth in this rule. Covered dental service categories requiring prior approval are further defined and outlined in the Iowa Medicaid Dental Services Provider Manual as amended to July 1, 2026. 78.4(13) Service setting. When dental services cannot be safely performed in a dental office, they may be provided in a hospital or ambulatory surgical center and reimbursed in accordance with rule 441—78.26(249A). 78.4(14) Compliance. Payment requires compliance with Iowa Medicaid policies, clinical criteria, and documentation requirements as specified in the Iowa Medicaid Dental Services Provider Manual as amended to July 1, 2026. 78.4(15) Annual benefit maximum. a. Members 21 years of age or older have an annual benefit maximum of $1,000 per state fiscal year for coverage of dental services set forth in this rule. Payment for services exceeding the $1,000 annual benefit maximum is the responsibility of the member. b. The following services do not count toward the annual benefit maximum: (1) Preventive services; (2) Diagnostic services; (3) Fabrication of removable dentures and related services; (4) Anesthesia when provided in conjunction with oral surgery codes approved for payment; or (5) Emergency services.Related ARC(s): 0315D441—78.5(249A) Podiatrists. Payment will be approved only for certain podiatric services. 78.5(1) Payment will be approved for the following orthotic appliances and treatment of nail pathologies: a. Durable plantar foot orthotic. b. Plaster impressions for foot orthotic. c. Molded digital orthotic. d. Shoe padding when appliances are not practical. e. Custom molded space shoes for rheumatoid arthritis, congenital defects and deformities, neurotropic, diabetic and ischemic intractable ulcerations and deformities due to injuries. f. Rams horn (hypertrophic) nails. g. Onychomycosis (mycotic) nails. 78.5(2) Payment will be made for the same scope of podiatric services available through Part B of Title XVIII (Medicare) except as listed below: a. Treatment of flatfoot. The term “flatfoot” is defined as a condition in which one or more arches have flattened out. b. Treatment of subluxations of the foot are defined as partial dislocations or displacements of joint surfaces, tendons, ligaments, or muscles of the foot. Surgical or nonsurgical treatments undertaken for the sole purpose of correcting a subluxated structure in the foot as an isolated entity are not covered. Reasonable and necessary diagnosis of symptomatic conditions that result from or are associated with partial displacement of foot structures is a covered service. Surgical correction in the subluxated foot structure that is an integral part of the treatment of a foot injury or is undertaken to improve the function of the foot or to alleviate an induced or associated symptomatic condition is a covered service. c. Routine foot care. Routine foot care includes the cutting or removal of corns or calluses, the trimming of nails and other hygienic and preventive maintenance care in the realm of self-care such as cleaning and soaking the feet, the use of skin creams to maintain skin tone of both ambulatory and bedfast patients and any services performed in the absence of localized illness, injury, or symptoms involving the foot. d. Orthopedic shoes. Payment will not be made for orthopedic shoes or for any device to be worn in or attached to orthopedic shoes or other types of shoes when provided by the podiatrist. Payment will be made to the podiatrist for the examination including tests to establish the need for orthopedic shoes. 78.5(3) Prescriptions are required for drugs and supplies as specified in paragraph 78.1(2)“c.” Payment will be made for drugs dispensed by a podiatrist only if there is no licensed retail pharmacy in the community where the podiatrist’s office is located. If eligible to dispense drugs, the podiatrist should request a copy of the Prescribed Drugs Provider Manual as amended to July 1, 2026, from Iowa Medicaid. Payment will not be made for writing prescriptions.Related ARC(s): 0315D441—78.6(249A) Optometrists. Payment will be approved for medically necessary services and supplies provided by the optometrist within the scope of practice of optometry and the limitations of state law, subject to the following limitations and exclusions. Covered optometric services include a professional component and materials. 78.6(1) Payable professional services. Payable professional services are: a. Eye examinations. The coverage of eye examinations depends on the purpose of the examination. Services are covered if the examination is the result of a complaint or symptom of an eye disease or injury. Routine eye examinations are covered once in a 12-month period. These services are rendered in the optometrist’s office or clinic, the home, a nursing facility, or other appropriate setting. Payment for mileage will be subject to the same approval and payment criteria as those in effect for Medicare Part B. The following levels of service are recognized for optometric examinations: (1) Intermediate examination. A level of optometric or ophthalmological services pertaining to medical examination and evaluation, with initiation or continuation of a diagnostic and treatment program. (2) Comprehensive examination. A level of optometric or ophthalmological services pertaining to medical examination and evaluation, with initiation or continuation of a diagnostic and treatment program, and a general evaluation of the complete visual system. b. Medical services. Payment will be approved for medically necessary services and supplies within the scope of practice of the optometrist, including services rendered in the optometrist’s office or clinic, the home, a nursing facility, or other appropriate setting. Payment for mileage will be subject to the same approval and payment criteria as those in effect for Medicare Part B. c. Auxiliary procedures. The following auxiliary procedures and special tests are payable when performed by an optometrist. Auxiliary procedures and special tests are reimbursed as a separate procedure only when warranted by case history or diagnosis. (1) Serial tonometry. Single tonometry is part of the intermediate and comprehensive exams and is not payable as a separate procedure as is serial tonometry. (2) Gonioscopy. (3) Extended ophthalmoscopy. Routine ophthalmoscopy is part of the intermediate and comprehensive examination and is not payable as a separate procedure. Generally, extended ophthalmoscopy is considered to be part of the comprehensive examination and, if performed in conjunction with that level of service, is not payable as a separate procedure. (4) Visual fields. Gross visual field testing is part of general optometric services and is not reported separately. (5) External photography. (6) Fundus photography. (7) Retinal integrity evaluation with a three-mirror lens. d. Single vision and multifocal spectacle lens service, verification and subsequent service. When lenses are necessary, the following enumerated professional and technical optometric services are to be provided: (1) When spectacle lenses are necessary, the following enumerated professional and technical optometric services are to be provided: 1. Ordering of corrective lenses. 2. Verification of lenses after fabrication. 3. Adjustment and alignment of completed lens order. (2) New spectacle lenses are subject to the following limitations: 1. Up to three times for children up to one year of age. 2. Up to four times per year for children one through three years of age. 3. Once every 12 months for children four through seven years of age. 4. Once every 24 months after eight years of age when there is a change in the prescription. (3) Spectacle lenses made from polycarbonate or equivalent material are allowed for: 1. Children through seven years of age. 2. Members with vision in only one eye. 3. Members with a diagnosis-related illness or disability where regular lenses would pose a safety risk. e. Reserved. f. Frame service. (1) When a new frame is necessary, the following enumerated professional and technical optometric services are to be provided: 1. Selection and styling. 2. Sizing and measurements. 3. Fitting and adjustment. 4. Readjustment and servicing. (2) New frames are subject to the following limitations: 1. One frame every six months is allowed for children through three years of age. 2. One frame every 12 months is allowed for children four through seven years of age. 3. When there is a covered lens change and the new lenses cannot be accommodated by the current frame. (3) Safety frames are allowed for: 1. Children through seven years of age. 2. Members with a diagnosis-related disability or illness where regular frames would pose a safety risk or result in frequent breakage. g. Reserved. h. Repairs or replacement of frames, lenses or component parts. Payment will be made for service in addition to materials. The service fee shall not exceed the dispensing fee for a replacement frame. Payment will be made for replacement of glasses when the original glasses have been lost or damaged beyond repair. Replacement of lost or damaged glasses is limited to one pair of frames and two lenses once every 12 months for adults aged 21 and over, except for people with a mental or physical disability. i. Contact lenses. Payment will be made for documented keratoconus, aphakia, high myopia, anisometropia, trauma, severe ocular surface disease, irregular astigmatism, for treatment of acute or chronic eye disease, or when the member’s vision cannot be adequately corrected with spectacle lenses. Contact lenses are subject to the following limitations: (1) Up to 16 gas permeable contact lenses are allowed for children up to one year of age. (2) Up to eight gas permeable contact lenses are allowed every 12 months for children one through three years of age. (3) Up to six gas permeable contact lenses are allowed every 12 months for children four through seven years of age. (4) Two gas permeable contact lenses are allowed every 24 months for members eight years of age or older. (5) Soft contact lenses and replacements are allowed when medically necessary. 78.6(2) Ophthalmic materials. Ophthalmic materials that are provided in connection with any of the foregoing professional optometric services shall provide adequate vision as determined by the optometrist and meet the following standards: a. Corrected curve lenses, unless clinically contraindicated. b. Standard plastic, plastic and metal combination, or metal frames. c. Prescription standards according to the American National Standards Institute (ANSI) standards and tolerance as amended to July 1, 2026. 78.6(3) Reimbursement. The reimbursement for allowed ophthalmic material is subject to a fee schedule established by the department or to actual laboratory cost as evidenced by an attached invoice. Reimbursement for rose tint is included in the fee for the lenses. a. Materials payable by fee schedule are: (1) Spectacle lenses, single vision and multifocal. (2) Frames. (3) Case for glasses. b. Materials payable at actual laboratory cost as evidenced by an attached invoice are: (1) Contact lenses. (2) Schroeder shield. (3) Ptosis crutch. (4) Safety frames. (5) Subnormal visual aids. (6) Photochromatic lenses. 78.6(4) Prior authorization. Prior authorization is required for the following: a. A second lens correction within a 24-month period for members eight years of age and older. Approval will be given when the member’s vision has at least a five-tenths diopter of change in sphere or cylinder or ten-degree change in axis in either eye. b. Visual therapy may be authorized when warranted by case history or diagnosis for a period of time not greater than 90 days. Should continued therapy be warranted, the prior approval process will be reaccomplished, accompanied by a report showing satisfactory progress. Approved diagnoses are convergence insufficiency and amblyopia. Visual therapy is not covered when provided by opticians. c. Subnormal visual aids where near visual acuity is at or better than 20/100 at 16 inches, 2M print. Prior authorization is not required if near visual acuity as described above is less than 20/100. Subnormal visual aids include but are not limited to hand magnifiers, loupes, telescopic spectacles, or reverse Galilean telescope systems. Payment will be actual laboratory cost as evidenced by an attached invoice. d. Approval for photochromatic tint will be given when the member has a documented medical condition that causes photosensitivity and less costly alternatives are inadequate. e. Approval for press-on prisms will be granted for members whose vision cannot be adequately corrected with other covered prisms. 78.6(5) Noncovered services. Noncovered services include but are not limited to the following services: a. Glasses with cosmetic gradient tint lenses or other eyewear for cosmetic purposes. b. Glasses for occupational eye safety. c. A second pair of glasses or spare glasses. d. Cosmetic surgery and experimental medical and surgical procedures. e. Sunglasses. f. Progressive bifocal or trifocal lenses.Related ARC(s): 0315D441—78.7(249A) Opticians. Payment will be approved only for certain services and supplies provided by opticians when prescribed by a physician (MD or DO) or an optometrist. Payment and procedure for obtaining services and supplies are the same as described in rule 441—78.6(249A).Related ARC(s): 0315D441—78.8(249A) Chiropractors. Payment will be made for the same chiropractic procedures payable under Title XVIII of the Social Security Act (Medicare). 78.8(1) Covered services. Chiropractic manipulative therapy (CMT) eligible for reimbursement is specifically limited by Medicaid to the manual manipulation (i.e., by use of the hands) of the spine for the purpose of correcting a subluxation demonstrated by X-ray. Subluxation means an incomplete dislocation, off-centering, misalignment, fixation, or abnormal spacing of the vertebrae. 78.8(2) Indications and limitations of coverage. a. The subluxation must have resulted in a neuromusculoskeletal condition for which CMT is appropriate treatment. The symptoms must be directly related to the subluxation that has been diagnosed. The mere statement or diagnosis of “pain” is not sufficient to support the medical necessity of CMT. CMT must have a direct therapeutic relationship to the patient’s condition. No other diagnostic or therapeutic service furnished by a chiropractor is covered under the Medicaid program. b. The neuromusculoskeletal conditions listed on the department’s website indicate whether the conditions require short-, moderate-, or long-term CMT. If the CMT utilization guidelines are exceeded, documentation supporting the medical necessity of additional CMT must be submitted with the Medicaid claim form or the claim will be denied for failure to provide information. c. CMT is not a covered benefit when: (1) The maximum therapeutic benefit has been achieved for a given condition. (2) There is not a reasonable expectation that the continuation of CMT would result in improvement of the patient’s condition. (3) The CMT seeks to prevent disease, promote health and prolong and enhance the quality of life. 78.8(3) Documenting X-ray. An X-ray must document the primary regions of subluxation being treated by CMT. a. The documenting X-ray must be taken at a time reasonably proximate to the initiation of CMT. An X-ray is considered to be reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of CMT. X-rays need not be repeated unless there is a new condition and no payment will be made for subsequent X-rays, absent a new condition, consistent with paragraph 78.8(3)“c.” No X-ray is required for pregnant women and for children aged 18 and under. b. The X-ray films shall be labeled with the patient’s name and date the X-rays were taken and shall be marked right or left. The X-ray shall be made available to the department or its duly authorized representative when requested. A written and dated X-ray report, including interpretation and diagnosis, shall be present in the patient’s clinical record. c. Chiropractors will be reimbursed for documenting X-rays at the physician fee schedule rate. Payable X-rays will be limited to those Current Procedural Terminology (CPT) procedure codes that are appropriate to determine the presence of a subluxation of the spine. Consistent with CPT, chiropractors may bill the professional, technical, or professional and technical components for X-rays, as appropriate. Payment for documenting X-rays will be further limited to one per condition, consistent with the provisions of paragraph 78.8(3)“a.” A claim for a documenting X-ray related to the onset of a new condition is only payable if the X-ray is reasonably proximate to the initiation of CMT for the new condition, as defined in paragraph 78.8(3)“a.” A chiropractor is also authorized to order a documenting X-ray whether or not the chiropractor owns or possesses X-ray equipment in the chiropractor’s office. Any X-rays so ordered will be payable to the X-ray provider, consistent with the provisions in this paragraph.Related ARC(s): 0315D441—78.9(249A) Home health agencies. Payment will be approved for medically necessary home health agency services prescribed by a physician, nurse practitioner, clinical nurse specialist, or PA in a plan of home health care provided by a Medicare-certified home health agency.Respite care, which is a temporary intermission or period of rest for the caregiver. Nurse supervision services including chart review, case discussion or scheduling by a registered nurse. Services provided to other persons in the member’s household. Services requiring prior authorization that are provided without regard to the prior authorization process. Transportation services. Homework assistance. (2) Personal care services are those services provided by a home health aide or certified nurse’s aide and which are delegated and supervised by a registered nurse under the direction of the member’s physician to a member in the member’s place of residence or outside the member’s residence, when normal life activities take the member outside the place of residence. Place of residence does not include nursing facilities, ICFs/ID, or hospitals. Payment for personal care services for persons aged 20 and under that exceed intermittent guidelines may be approved if determined to be medically necessary as defined in subrule 78.9(7). These services shall be in accordance with the member’s plan of care and authorized by a physician. The home health agency is encouraged to collaborate with the member, or in the case of a child with the child’s caregiver, in the development and implementation of the plan of treatment.Medical necessity means the service is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions that endanger life, cause pain, result in illness or infirmity, threaten to cause or aggravate a disability or chronic illness, and no other equally effective course of treatment is available or suitable for the member requesting a service. b. Requirements. (1) Private duty nursing or personal care services shall be ordered in writing by a physician as evidenced by the physician’s signature on the plan of care. (2) Private duty nursing or personal care services will be authorized by the department or the department’s designated review agent prior to payment. (3) Prior authorization shall be requested at the time of initial submission of the plan of care or at any time the plan of care is substantially amended and shall be renewed with the department or the department’s designated review agent. Initial request for and request for renewal of prior authorization shall be submitted to the department’s designated review agent. The provider of the service is responsible for requesting prior authorization and for obtaining renewal of prior authorization.The request for prior authorization shall include a nursing assessment, the plan of care, and supporting documentation. The request for prior authorization shall include all items previously identified as required treatment plan information and shall further include: any planned surgical interventions and projected time frame; information regarding caregiver’s desire to become involved in the member’s care, to adhere to program objectives, to work toward treatment plan goals, and to work toward maximum independence; and identify the types and service delivery levels of all other services to the member whether or not the services are reimbursable by Medicaid. Providers shall indicate the expected number of private duty nursing RN hours, private duty nursing LPN hours, or home health aide hours per day, the number of days per week, and the number of weeks or months of service per discipline. If the member is currently hospitalized, the projected date of discharge shall be included.Prior authorization approvals will not be granted for treatment plans that exceed 16 hours of home health agency services per day. 78.9(11) Vaccines. In order to be paid for the administration of a vaccine covered under the VFC program, a home health agency must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted.Related ARC(s): 0315D441—78.10(249A) Durable medical equipment (DME), prosthetic devices and medical supplies. 78.10(1) General payment requirements. Payment will be made for items of DME, prosthetic devices and medical supplies, subject to the following general requirements and the requirements of subrule 78.10(2), 78.10(3), or 78.10(4), as applicable: a. DME, prosthetic devices, and medical supplies must be required by the member because of the member’s medical condition. b. The item shall be necessary and reasonable either for the treatment of an illness or injury, or to improve the functioning of a malformed body part. Determination will be made by Iowa Medicaid. (1) An item is necessary when it can be expected to make a meaningful contribution to the treatment of a specific illness or injury or to the improvement in function of a malformed body part. (2) Although an item may be necessary, it must also be a reasonable expenditure for the Medicaid program. The following considerations enter into the determination of reasonableness: Whether the expense of the item to the program would be clearly disproportionate to the therapeutic benefits which could ordinarily be derived from use of the item; whether the item would be substantially more costly than a medically appropriate and realistically feasible alternative pattern of care; and whether the item serves essentially the same purpose as an item already available to the beneficiary. c. A physician’s (doctor of medicine, osteopathy, or podiatry), PA’s, or ARNP’s prescription is required to establish medical necessity. The prescription shall state the member’s name, diagnosis, prognosis, item(s) to be dispensed, quantity, and length of time the item is to be required and shall include the signature of the prescriber and the date of signature.For items requiring prior authorization, a request shall include a physician’s, PA’s, or ARNP’s written order or prescription and sufficient medical documentation to permit an independent conclusion that the requirements for the equipment or device are met and the item is medically necessary and reasonable. A request for prior authorization is made using an Outpatient Prior Authorization Request form. See rule 441—78.28(249A) for prior authorization requirements. d. Nonmedical items will not be covered. These include but are not limited to: (1) Physical fitness equipment, e.g., an exercycle, weights. (2) First-aid or precautionary-type equipment, e.g., preset portable oxygen units. (3) Self-help devices, e.g., safety grab bars, raised toilet seats. (4) Training equipment, e.g., speech teaching machines, braille training texts. (5) Equipment used for environmental control or to enhance the environmental setting, e.g., room heaters, air conditioners, humidifiers, dehumidifiers, and electric air cleaners. (6) Equipment that basically serves comfort or convenience functions or is primarily for the convenience of a person caring for the member, e.g., elevators, stairway elevators and posture chairs. e. The amount payable is based on the least expensive item that meets the member’s medical needs. Payment will not be approved for items that serve duplicate functions. Exception: A second ventilator, with approved medical necessity. f. Consideration will be given to rental or purchase based on the price of the item and the length of time it would be required. The decision on rental or purchase will be made by Iowa Medicaid and be based on the most reasonable method to provide the equipment. (1) The provider shall monitor rental payments up to 100 percent of the purchase price. At the point that total rent paid equals 100 percent of the purchase allowance, the member will be considered to own the item and no further rental payments will be made to the provider. (2) Payment may be made for the purchase of an item even though rental payments may have been made for prior months. The rental of the equipment may be necessary for a period of time to establish that it will meet the identified need before the purchase of the equipment. When a decision is made to purchase after renting an item, all rental payments will be applied to the purchase allowance. (3) Exception: Ventilators and oxygen systems shall be maintained on a rental basis for the duration of use. (4) A deposit shall not be charged by a provider to a Medicaid member or any other person on behalf of a Medicaid member for rental of medical equipment. g. Payment may be made for necessary repair, maintenance, and supplies for member-owned equipment. No payment may be made for repairs, maintenance, or supplies when the member is renting the item. h. Replacement of member-owned equipment is covered in cases of loss or irreparable damage or when required because of a change in the member’s condition. i. No allowance will be made for delivery, freight, postage, or other provider operating expenses for DME, prosthetic devices or medical supplies. j. Reimbursement over the established fee schedule amount is allowed when prior authorization has been obtained. See 78.10(5) for prior authorization requirements. 78.10(2) Durable medical equipment. DME is equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, is generally not useful to a person in the absence of an illness or injury, and is appropriate for use in the home. a. DME in a hospital, nursing facility, or ICF/ID is not separately payable.Exceptions: (1) Oxygen services in a nursing facility or an ICF/ID when all of the following requirements and conditions have been met: 1. Medical documentation or a reasonable facsimile is completed by a physician, PA, or ARNP and qualifies the member in accordance with Medicare criteria. 2. Additional documentation shows that the member requires oxygen for 12 hours or more per day for at least 30 days. 3. Oxygen logs must be maintained by the provider. The time between any reading shall not exceed more than 45 days. The documentation maintained in the provider record must contain the following:The initial, periodic and ending reading on the time meter clock on each oxygen system, and The dates of each initial, periodic and ending reading, and Evidence of ongoing need for oxygen services. 4. The maximum Medicaid payment will be based on the least costly method of oxygen delivery. 5. Oxygen prescribed “PRN” or “as necessary” is not payable. 6. Medicaid payment will be made for the rental of equipment only. All accessories and disposable supplies related to the oxygen delivery system and costs for servicing and repair of equipment are included in the Medicaid payment and shall not be separately payable. 7. Payment is not allowed for oxygen services that are not documented according to the department of inspections, appeals, and licensing requirements in 481—Chapter 58. (2) Speech generating devices with approved medical necessity. (3) Wheelchairs for members in an ICF/ID. b. The types of DME covered through the Medicaid program include but are not limited to:Automated medication dispenser. Bathtub/shower chair, bench. See subrule 78.10(5) for prior authorization requirements.Commode, shower commode chair. See subrule 78.10(5) for prior authorization requirements.Decubitus equipment.Dialysis equipment.Diaphragm (contraceptive device).Enclosed bed. See subrule 78.10(5) for prior authorization requirements.Enuresis alarm system (bed-wetting alarm device) for members five years of age or older.Heat/cold application device.Hospital bed and accessories.Inhalation equipment. See subrule 78.10(5) for prior authorization requirements.Insulin infusion pump. See subrule 78.10(5) for prior authorization requirements.Lymphedema pump.Mobility device and accessories. See subrule 78.10(5) for prior authorization requirements.Neuromuscular stimulator.Oximeter.Oxygen, subject to the limitations in paragraphs 78.10(2)“a” and “c.”Patient lift. See subrule 78.10(5) for prior authorization requirements.Phototherapy bilirubin light.Protective helmet.Seat lift chair.Speech generating device. See subrule 78.10(5) for prior authorization requirements.Traction equipment.Ventilator. c. Coverage of home oxygen equipment and oxygen will be considered reasonable and necessary for members in accordance with Medicare criteria and as shown by supporting medical documentation. The physician, PA, or ARNP shall document that other forms of treatment are contraindicated or have been tried and have not been successful and that oxygen therapy is required. Exception: Home oxygen equipment and oxygen are covered for children through three years of age when prescribed by a physician, PA, or ARNP. A pulse oximeter reading must be obtained yearly and documented in the provider and physician record. (1) To identify the medical necessity for oxygen therapy, medical documentation, or a reasonable facsimile completed by a physician, PA, or ARNP shall qualify the member in accordance with Medicare criteria. (2) If the member’s condition or need for oxygen services changes, the attending physician, PA, or ARNP must adjust the documentation accordingly. (3) A second oxygen system is not covered by Medicaid when used as a backup for oxygen concentrators or as a standby in case of emergency. Members may be provided with a portable oxygen system to complement a stationary oxygen system, or to be used by itself, with documentation from the physician, PA, or ARNP of the specific activities for which portable oxygen is medically necessary. (4) Payment for oxygen systems will be made only on a rental basis for the duration of use. (5) All accessories, disposable supplies, servicing, and repairing of oxygen systems are included in the monthly Medicaid payment for oxygen systems. (6) Oxygen prescribed “PRN” or “as necessary” is not allowed. d. Wheelchairs, wheelchair accessories, and wheelchair modifications are covered when they are medically necessary for mobility within the home, nursing facility, or intermediate care facility. Wheelchairs are defined as: (1) Standard manual wheelchairs. Coverage of a standard manual wheelchair includes the following: 1. Complete set of tires/wheels and casters, any type; 2. Hand rims with or without projections; 3. Weight-specific components required by the patient-weight capacity of the wheelchair; 4. Elevating legrest, lower extension tube and upper hanger bracket; 5. Armrest (detachable, non-adjustable or adjustable) with or without arm pad; 6. Footrest (swingaway, detachable), including lower extension tube(s) and upper hanger bracket; 7. Standard size footplates; 8. Wheelchair bearings; 9. Caster fork, replacement only; and 10. All labor charges involved in the assembly of the wheelchair (including but not limited to front caster assembly, rear wheel assembly, ratchet assembly, wheel lock assembly, footrest assembly). (2) Standard manual wheelchair accessories that are separately billable and require prior authorization include the following: 1. Headrest extensions; 2. One-arm drive attachments; 3. Positioning accessories; 4. Specialized skin protection seat and back cushions; and 5. Anti-rollback devices. (3) Standard power wheelchair. Coverage of a standard power wheelchair requires prior authorization and includes the following: 1. Lap belt or safety belt; 2. Battery charger, single mode; 3. Complete set of tires/wheels and casters, any type; 4. Legrests (fixed, swingaway, or detachable non-elevation legrests with or without calf pad); 5. Footrests/foot platform (fixed, swingaway, detachable footrests or a foot platform without angle adjustment, single adjustable footplate); 6. Armrests (fixed, swingaway, detachable non-adjustable height armrests with arm pad provided); 7. Any weight-specific components (braces, bars, upholstery, brackets, motors, gears, etc.) as required by patient-weight capacity of the wheelchair; 8. Any seat width and depth. For power wheelchairs with a sling/solid seat/back, the following may be billed separately:For standard duty, seat width and/or depth greater than 20 inches; For heavy duty, seat width and/or depth greater than 22 inches; For very heavy duty, seat width and/or depth greater than 24 inches; Exception: For extra heavy duty, there is no separate billing; 9. Any back width. For power wheelchairs with a sling/solid seat/back, the following may be billed separately: For standard duty, seat width and/or depth greater than 20 inches; For heavy duty, seat width and/or depth greater than 22 inches; For very heavy duty, seat width and/or depth greater than 24 inches; Exception: For extra heavy duty, there is no separate billing; 10. Non-expandable controller or standard proportional joystick (integrated or remote); and 11. All labor charges involved in the assembly of the wheelchair (including but not limited to front caster assembly, rear wheel assembly, ratchet assembly, wheel lock assembly, footrest assembly). (4) Standard power wheelchair accessories that are billed separately and require a prior authorization include the following: 1. Shoulder harness/straps or chest straps/vest; 2. Elevating legrest; 3. Angle adjustable footplates; 4. Adjustable height armrests; and 5. Expandable controller or nonstandard joystick (i.e., non-proportional or mini, compact or short throw proportional, or other alternative control device). (5) Customized items are payable with a prior authorization, in accordance with 42 CFR 414.224 as amended to July 1, 2026. 78.10(3) Prosthetic devices. Prosthetic devices mean replacement, corrective, or supportive devices prescribed by a physician (doctor of medicine, osteopathy or podiatry), PA, or ARNP within the scope of practice as defined by state law to artificially replace a missing portion of the body, prevent or correct a physical deformity or malfunction, or support a weak or deformed portion of the body. This does not require a determination that there is no possibility that the member’s condition may improve sometime in the future. a. Prosthetic devices are not covered when dispensed to a member prior to the time the member undergoes a procedure which will make necessary the use of the device. b. The types of prosthetic devices covered through the Medicaid program include but are not limited to: (1) Artificial eyes. (2) Artificial limbs. (3) Enteral delivery supplies and products. See subrule 78.10(5) for prior authorization requirements. (4) Hearing aids. See rule 441—78.14(249A). (5) Orthotic devices. See paragraph 78.10(3)“c” for limitations on coverage of cranial orthotic devices. (6) Ostomy appliances. (7) Parenteral delivery supplies and products. Daily parenteral nutrition therapy is considered necessary and reasonable for a member with severe pathology of the alimentary tract that does not allow absorption of sufficient nutrients to maintain weight and strength commensurate with the member’s general condition. (8) Prosthetic shoes, orthopedic shoes. See rule 441—78.15(249A). (9) Tracheotomy tubes. (10) Vibrotactile aids. Vibrotactile aids are payable only once in a four-year period unless the original aid is broken beyond repair or lost. c. Cranial orthotic device. Payment will be approved for cranial orthotic devices when the device is medically necessary for the postsurgical treatment of synostotic plagiocephaly. Payment shall also be approved when there is documentation supporting moderate to severe nonsynostotic positional plagiocephaly and meets minimum medical necessity requirements. 78.10(4) Medical supplies. Medical supplies are nondurable items consumed in the process of giving medical care, for example, nebulizers, gauze, bandages, sterile pads, adhesive tape, and sterile absorbent cotton. Medical supplies are payable for a specific medicinal purpose. This does not include food or drugs. However, active pharmaceutical ingredients and excipients that are identified as preferred on the preferred drug list published by the department pursuant to Iowa Code section 249A.20A are covered. Medical supplies shall not be dispensed at any one time in quantities exceeding a 31-day supply for active pharmaceutical ingredients and excipients or a three-month supply for all other items. After the initial dispensing of medical supplies, the provider must document a refill request from the Medicaid member or the member’s caregiver for each refill. a. The types of medical supplies and supplies necessary for the effective use of a payable item covered through the Medicaid program include but are not limited to:Active pharmaceutical ingredients and excipients identified as preferred on the preferred drug list published pursuant to Iowa Code section 249A.20A.Catheter (indwelling Foley).Colostomy and ileostomy appliances.Colostomy and ileostomy care dressings, liquid adhesive, and adhesive tape.Diabetic supplies (including but not limited to blood glucose test strips, lancing devices, lancets, needles, syringes, and diabetic urine test supplies). See subrule 78.10(5) for prior authorization requirements.Dialysis supplies.Disposable catheterization trays or sets (sterile).Disposable irrigation trays or sets (sterile).Disposable saline enemas (e.g., sodium phosphate type).Dressings.Elastic antiembolism support stocking.Enema.Hearing aid batteries.Incontinence products (for members three years of age and older).Oral nutritional products. See subrule 78.10(5) for prior authorization requirements.Ostomy appliances and supplies.Respirator supplies.Shoes, diabetic.Surgical supplies.Urinary collection supplies. b. Only the following types of medical supplies will be approved for payment for members receiving care in a nursing facility or an ICF/ID when prescribed by the physician, PA, or ARNP: (1) Catheter (indwelling Foley). (2) Diabetic supplies (including but not limited to lancing devices, lancets, needles and syringes, blood glucose test strips, and diabetic urine test supplies). (3) Disposable catheterization trays or sets (sterile). (4) Disposable irrigation trays or sets (sterile). (5) Disposable saline enemas (e.g., sodium phosphate type). (6) Ostomy appliances and supplies. (7) Shoes, diabetic. 78.10(5) Prior authorization requirements. Prior authorization pursuant to rule 441—79.9(249A) is required for some medical equipment and supplies. Refer to the department’s website for a list of items that require a prior authorization.Related ARC(s): 0315D441—78.11(249A) Ambulance service. Payment will be approved for ambulance service if it is required by the recipient’s condition and the recipient is transported to the nearest hospital with appropriate facilities or to one in the same locality, from one hospital to another, to the patient’s home, to a nursing facility, or to a mental health access center. Payment for ambulance service to the nearest hospital for outpatient service will be approved only for emergency treatment. Ambulance service must be medically necessary and not merely for the convenience of the patient. 78.11(1) Partial payment may be made when an individual is transported beyond the destinations specified, and is limited to the amount that would have been paid had the individual been transported to the nearest institution with appropriate facilities. When transportation is to the patient’s home, partial payment is limited to the amount that would have been paid from the nearest institution with appropriate facilities. When a recipient who is a resident of a nursing care facility is hospitalized and later discharged from the hospital, payment will be made for the trip to the nursing care facility where the recipient resides even though it may not in fact be the nearest nursing care facility. 78.11(2) Iowa Medicaid will determine that the ambulance transportation was medically necessary and that the condition of the patient precluded any other method of transportation. Payment can be made without the physician’s confirmation when: a. The individual is admitted as a hospital inpatient or is in an emergency situation. b. Previous information on file relating to the patient’s condition clearly indicates ambulance service was necessary. 78.11(3) When a patient is transferred from one nursing home to another because of the closing of a facility or from a nursing home to a custodial home because the recipient no longer requires nursing care, the conditions of medical necessity and the distance requirements will not be applicable. Approval for transfer will be made by the department prior to the transfer. When such a transfer is made, the following rate schedule will apply:One patient - normal allowanceTwo patients - 3/4 normal allowance per patientThree patients - 2/3 normal allowance per patientFour patients - 5/8 normal allowance per patient 78.11(4) Transportation of hospital inpatients. When an ambulance service provides transport of a hospital inpatient to a provider and returns the recipient to the same hospital (the recipient continuing to be an inpatient of the hospital), the ambulance service shall bill the hospital for reimbursement as the hospital’s DRG reimbursement system includes all costs associated with providing inpatient services as stated in 441—paragraph 79.1(5)“j.” 78.11(5) In the event that more than one ambulance service is called to provide ground ambulance transport, payment will be made only to one ambulance company. When a paramedic from one ambulance service joins a ground ambulance company already in transport, coverage is not available for the services and supplies provided by the paramedic.Related ARC(s): 0315D441—78.12(249A) Behavioral health intervention. Payment will be made for behavioral health intervention services not otherwise covered under this chapter that are designed to minimize or, if possible, eliminate the symptoms or causes of a mental disorder, subject to the limitations in this rule. 78.12(1) Definitions. There must be face-to-face interaction with a licensed therapist. (An aide’s services will not be payable.) Services must be provided on an individual basis. (Group diagnostic or trial therapy will not be payable.) Documentation of the diagnostic therapy or trial therapy must reflect the provider’s plan for therapy and the recipient’s response. If the recipient has a previous history of rehabilitative services, trial therapy for the same type of services generally would be payable only when a significant change has occurred since the last therapy. A significant change would be considered as having occurred when any of the following exist: new onset, new problem, new need, new growth issue, a change in vocational or residential setting that requires a reevaluation of potential, or surgical intervention that may have caused new rehabilitative potentials. For persons who received previous rehabilitative treatment, consideration of trial therapy generally should occur only if the person has incorporated any regimen recommended during prior treatment into the person’s daily life to the extent of the person’s abilities. Documentation should include any previous attempts to resolve problems using nontherapy personnel (residential group home staff, family members, etc.) and whether follow-up programs from previous therapy have been carried out. Referrals from residential, vocational or other rehabilitation personnel that do not meet present evaluation, restorative or maintenance criteria shall be considered for trial therapy. Documentation of the proposed service, the medical necessity and the current medical or disabling condition, including any secondary rehabilitative diagnosis, will need to be submitted with the claim. Claims for diagnostic or trial therapy shall reflect the progress being made toward the initial diagnostic or trial therapy plan. c. Occupational therapy services. (1) To be covered under rehabilitation agency services, occupational therapy services must be included in a plan of treatment, improve or restore practical functions that have been impaired by illness, injury, or disabling condition, or enhance the person’s ability to perform those tasks required for independent functioning, be prescribed by a physician under a plan of treatment, be performed by a qualified licensed occupational therapist or a qualified licensed occupational therapist assistant under the general supervision of a qualified licensed occupational therapist, and be reasonable and necessary for the treatment of the person’s illness, injury, or disabling condition. (2) Restorative therapy is covered when an expectation exists that the therapy will result in a significant practical improvement in the person’s condition.However, in these cases where there is a valid expectation of improvement met at the time the occupational therapy program is instituted, but the expectation goal is not realized, services would only be covered up to the time one would reasonably conclude the patient would not improve.The guidelines under restorative therapy, maintenance therapy, and diagnostic or trial therapy for physical therapy in subparagraphs 78.19(1)“b”(7), “b”(8), and “b”(16) apply to occupational therapy. (3) Maintenance therapy, or any activity or exercise program required to maintain a function at the restored level, is not a covered service. However, designing a maintenance program in accordance with the requirements of subparagraph 78.19(1)“b”(8) and monitoring the progress would be covered. (4) The selection and teaching of tasks designed to restore physical function are covered. (5) Planning and implementing therapeutic tasks, such as activities to restore sensory-integrative functions are covered. Other examples include providing motor and tactile activities to increase input and improve responses for a stroke patient. (6) The teaching of activities of daily living and energy conservation to improve the level of independence of a patient that require the skill of a licensed therapist and meet the definition of restorative therapy is covered. (7) The designing, fabricating, and fitting of orthotic and self-help devices are considered covered services if they relate to the patient’s condition and require occupational therapy. A maximum of 13 visits is reimbursable. (8) Vocational and prevocational assessment and training are not payable by Medicaid. These include services that are related solely to specific employment opportunities, work skills, or work settings. d. Speech therapy services. (1) To be covered by Medicaid as rehabilitation agency services, speech therapy services must be included in a plan of treatment established by the licensed, skilled therapist after consultation with the physician, relate to a specific medical diagnosis that will significantly improve a patient’s practical, functional level in a reasonable and predictable time period, and require the skilled services of a speech therapist. Services provided by a speech aide are not reimbursable. (2) Speech therapy activities that are considered covered services include: restorative therapy services to restore functions affected by illness, injury, or disabling condition resulting in a communication impairment or to develop functions where deficiencies currently exist. Communication impairments fall into the general categories of disorders of voice, fluency, articulation, language, and swallowing disorders resulting from any condition other than mental impairment. Treatment of these conditions is payable if restorative criteria are met. (3) Aural rehabilitation, the instruction given by a qualified speech pathologist in speech reading or lip reading to patients who have suffered a hearing loss or become hard of hearing (input impairment), constitutes a covered service if reasonable and necessary to the patient’s illness or injury. Group treatment is not covered. Audiological services related to the use of a hearing aid are not reimbursable. (4) Teaching a patient to use sign language and to use an augmentative communication device is reimbursable. The patient must show significant progress outside the therapy sessions in order for these services to be reimbursable. (5) Where a maintenance program is appropriate, the initial evaluation, the instruction of the patient and caregivers to carry out the program, and supervisory visits to monitor progress are covered services. Beyond evaluation, instruction, and monitoring, maintenance therapy is not reimbursable. However, designing a maintenance program in accordance with the requirements of maintenance therapy and monitoring the progress are covered. (6) The guidelines and limits on restorative therapy, maintenance therapy, and diagnostic or trial therapy for physical therapy in subparagraphs 78.19(1)“b”(7), “b”(8), and “b”(16) apply to speech therapy. If the only goal of prior rehabilitative speech therapy was to learn the prerequisite speech components, then the fifth paragraph under subparagraph 78.19(1)“b”(16) will not apply to trial therapy. 78.19(2) General guidelines for plans of treatment. a. The minimum information to be included on medical information forms and treatment plans includes: (1) The patient’s current medical condition and functional abilities, including any disabling condition. (2) The physician’s signature and date (within the certification period). (3) Certification period. (4) Patient’s progress in measurable statistics. (Refer to subparagraph 78.19(1)“b”(16).) (5) The place services are rendered. (6) Dates of prior hospitalization (if applicable or known). (7) Dates of prior surgery (if applicable or known). (8) The date the patient was last seen by the physician (if available). (9) A diagnosis relevant to the medical necessity for treatment. (10) Dates of onset of any diagnoses for which treatment is being rendered (if applicable). (11) A brief summary of the initial evaluation or baseline. (12) The patient’s prognosis. (13) The services to be rendered. (14) The frequency of the services and discipline of the person providing the service. (15) The anticipated duration of the services and the estimated date of discharge (if applicable). (16) Assistive devices to be used. (17) Functional limitations. (18) The patient’s rehabilitative potential and the extent to which the patient has been able to apply the skills learned in the rehabilitation setting to everyday living outside the therapy sessions. (19) The date of the last episode of instability or the date of the last episode of acute recurrence of illness or symptoms (if applicable). (20) Quantitative, measurable, short-term and long-term functional goals. (21) The period of time of a session. (22) Prior treatment (history related to current diagnosis) if available or known. b. The information to be included when developing plans for teaching, training, and counseling include: (1) To whom the services were provided (patient, family member, etc.). (2) Prior teaching, training, or counseling provided. (3) The medical necessity of the rendered services. (4) The identification of specific services and goals. (5) The date of the start of the services. (6) The frequency of the services. (7) Progress in response to the services. (8) The estimated length of time the services are needed.Related ARC(s): 0315D441—78.20(249A) Independent laboratories. Payment will be made for medically necessary laboratory services provided by laboratories that are independent of attending and consulting physicians’ offices, hospitals, and critical access hospitals and that are certified to participate in the Medicare program.Related ARC(s): 0315D441—78.21(249A) Rural health clinics. Payment will be made to rural health clinics for the same services payable under the Medicare program. Payment will be made for sterilization in accordance with subrule 78.1(16). 78.21(1) Utilization review. Utilization review will be conducted for Medicaid members who access more than 24 outpatient visits in any 12-month period from physicians, ARNPs, federally qualified health centers, other clinics, and emergency rooms. 78.21(2) Risk assessment. Risk assessment, using a Medicaid Prenatal Risk Assessment form, shall be completed at the initial visit during a Medicaid member’s pregnancy. a. If the risk assessment reflects a low-risk pregnancy, the assessment shall be completed again at approximately the twenty-eighth week of pregnancy. b. If the risk assessment reflects a high-risk pregnancy, referral shall be made for enhanced services described in subrule 78.25(3). 78.21(3) Vaccines. In order to be paid for the administration of a vaccine covered under the VFC program, a rural health center must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted.Related ARC(s): 0315D441—78.22(249A) Family planning clinics. Payments will be made on a fee schedule basis for services provided by family planning clinics. 78.22(1) Payment will be made for sterilization in accordance with subrule 78.1(16). 78.22(2) In order to be paid for the administration of a vaccine covered under the VFC program, a family planning clinic must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted.Related ARC(s): 0315D441—78.23(249A) Other clinic services. Payment will be made on a fee schedule basis to facilities not part of a hospital, funded publicly or by private contributions, that provide medically necessary treatment by or under the direct supervision of a physician or dentist to outpatients. 78.23(1) Sterilization. Payment will be made for sterilization in accordance with subrule 78.1(16). 78.23(2) Utilization review. Utilization review will be conducted for Medicaid members who access more than 24 outpatient visits in any 12-month period from physicians, ARNPs, federally qualified health centers, other clinics, and emergency rooms. 78.23(3) Risk assessment. Risk assessment, using a Medicaid Prenatal Risk Assessment form, shall be completed at the initial visit during a Medicaid member’s pregnancy. a. If the risk assessment reflects a low-risk pregnancy, the assessment shall be completed again at approximately the twenty-eighth week of pregnancy. b. If the risk assessment reflects a high-risk pregnancy, referral shall be made for enhanced services described in subrule 78.25(3). 78.23(4) Vaccines. In order to be paid for the administration of a vaccine covered under the VFC program, a clinic must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted.Related ARC(s): 0315D441—78.24(249A) Psychologists. Payment will be approved for services authorized by state law when they are provided by the psychologist in the psychologist’s office, a hospital, nursing facility, or residential care facility. 78.24(1) Payment for covered services provided by the psychologist will be made on a fee for service basis. a. Payment will be made only for time spent in face-to-face consultation with the client. b. Time spent with clients shall be rounded to the quarter hour. 78.24(2) Payment will be approved for the following psychological procedures: a. Individual outpatient psychotherapy or other psychological procedures not to exceed one hour per week or 40 hours in any 12-month period, or b. Couple, marital, family, or group outpatient therapy not to exceed one and one-half hours per week or 60 hours in any 12-month period, or c. A combination of individual and group therapy not to exceed the cost of 40 individual therapy hours in any 12-month period. d. Psychological examinations and testing for purposes of evaluation, placement, psychotherapy, or assessment of therapeutic progress, not to exceed eight hours in any 12-month period. e. Mileage at the same rate as in subrule 78.1(8) when the following conditions are met: (1) It is necessary for the psychologist to travel outside of the home community, and (2) There is no qualified mental health professional more immediately available in the community, and (3) The member has a medical condition which prohibits travel. f. Covered procedures necessary to maintain continuity of psychological treatment during periods of hospitalization or convalescence for physical illness. g. Procedures provided within a licensed hospital, residential treatment facility, day hospital, or nursing home as part of an approved treatment plan and a psychologist is not employed by the facility. 78.24(3) Payment will not be approved for the following services: a. Psychological examinations performed without relationship to evaluations or psychotherapy for a specific condition, symptom, or complaint. b. Psychological examinations covered under Part B of Medicare, except for the Part B Medicare deductible and coinsurance. c. Psychological examinations employing unusual or experimental instrumentation. d. Individual and group psychotherapy without specification of condition, symptom, or complaint. e. Sensitivity training, marriage enrichment, assertiveness training, growth groups or marathons, or psychotherapy for nonspecific conditions of distress such as job dissatisfaction or general unhappiness. 78.24(4) Reserved. 78.24(5) The following services shall require review by a consultant to the department. a. Protracted therapy beyond 16 visits. These cases shall be reviewed following the sixteenth therapy session and periodically thereafter. b. Any service that does not appear necessary or appears to fall outside the scope of what is professionally appropriate or necessary for a particular condition.Related ARC(s): 0315D441—78.25(249A) Maternal health centers. Payment will be made for prenatal and postpartum medical care, health education, and transportation to receive prenatal and postpartum services. Payment will be made for enhanced perinatal services for persons determined high risk. These services include additional health education services, nutrition counseling, social services, and one postpartum home visit. Maternal health centers shall provide trimester and postpartum reports to the referring physician. Risk assessment using a Medicaid Prenatal Risk Assessment form shall be completed at the initial visit during a Medicaid member’s pregnancy. If the risk assessment reflects a low-risk pregnancy, the assessment shall be completed again at approximately the twenty-eighth week of pregnancy. If the risk assessment reflects a high-risk pregnancy, referral shall be made for enhanced services described in subrule 78.25(3). 78.25(1) Provider qualifications. a. Prenatal and postpartum medical services shall be provided by a physician, a PA, or a nurse practitioner employed by or on contract with the center. Medical services performed by maternal health centers shall be performed under the supervision of a physician. Nurse practitioners and PAs performing under the supervision of a physician must do so within the scope of practice of that profession, as defined by Iowa Code chapters 152 and 148C, respectively. b. Reserved. c. Education services and postpartum home visits shall be provided by a registered nurse. d. Nutrition services shall be provided by a licensed dietitian. e. Psychosocial services shall be provided by a person with at least a bachelor’s degree in social work, counseling, sociology, psychology, family and community services, health or human development, health education, or individual and family studies. 78.25(2) Services covered for all pregnant women. Services provided may include: a. Prenatal and postpartum medical care. b. Health education, which will include: (1) Importance of continued prenatal care. (2) Normal changes of pregnancy including both maternal changes and fetal changes. (3) Self-care during pregnancy. (4) Comfort measures during pregnancy. (5) Danger signs during pregnancy. (6) Labor and delivery including the normal process of labor, signs of labor, coping skills, danger signs, and management of labor. (7) Preparation for baby including feeding, equipment, and clothing. (8) Education on the use of over-the-counter drugs. (9) Education about HIV protection. c. Home visit. d. Transportation to receive prenatal and postpartum services that is not payable under rule 441—78.11(249A) or 441—78.13(249A). e. Dental hygiene services within the scope of practice as defined by the dental board in 481—Chapter 576. 78.25(3) Enhanced services covered for women with high-risk pregnancies. Enhanced perinatal services may be provided to a patient who has been determined to have a high-risk pregnancy as documented on the Medicaid Prenatal Risk Assessment form. An appropriately trained physician or ARNP must be involved in staffing the patients receiving enhanced services.Enhanced services are as follows: a. Reserved. b. Education, which shall include as appropriate education about the following: (1) High-risk medical conditions. (2) High-risk sexual behavior. (3) Smoking cessation. (4) Alcohol usage education. (5) Drug usage education. (6) Environmental and occupational hazards. c. Nutrition assessment and counseling, which shall include: (1) Initial assessment of nutritional risk based on height, current and prepregnancy weight status, laboratory data, clinical data, and self-reported dietary information. (2) Ongoing nutritional assessment. (3) Development of an individualized nutritional care plan. (4) Referral to food assistance programs if indicated. (5) Nutritional intervention. d. Psychosocial assessment and counseling, which shall include: (1) A psychosocial assessment including: needs assessment, profile of client demographic factors, mental and physical health history and concerns, adjustment to pregnancy and future parenting, and environmental needs. (2) A profile of the client’s family composition, patterns of functioning and support systems. (3) An assessment-based plan of care, risk tracking, counseling and anticipatory guidance as appropriate, and referral and follow-up services. e. A postpartum home visit within two weeks of the child’s discharge from the hospital, which shall include: (1) Assessment of mother’s health status. (2) Physical and emotional changes postpartum. (3) Family planning. (4) Parenting skills. (5) Assessment of infant health. (6) Infant care. (7) Grief support for unhealthy outcome. (8) Parenting of a preterm infant. (9) Identification of and referral to community resources as needed. 78.25(4) Vaccines. In order to be paid for the administration of a vaccine covered under the VFC program, a maternal health center must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted.Related ARC(s): 0315D441—78.26(249A) Ambulatory surgical center services. Ambulatory surgical center services are those services furnished by an ambulatory surgical center in connection with a covered surgical procedure or a covered dental procedure. Covered procedures are listed in the fee schedule published on the department’s website. 78.26(1) Covered surgical procedures will be those medically necessary procedures that are eligible for payment as physicians’ services, under the circumstances specified in rule 441—78.1(249A) and performed on a Medicaid member, that can safely be performed in an outpatient setting as determined by the department. 78.26(2) Covered dental procedures are those medically necessary procedures that are eligible for payment as dentists’ services, under the circumstances specified in rule 441—78.4(249A) and performed on a Medicaid member, that can safely be performed in an outpatient setting for Medicaid members whose mental, physical, or emotional condition necessitates deep sedation or general anesthesia. 78.26(3) The covered services provided by the ambulatory surgical center in connection with a Medicaid-covered surgical or dental procedure will be those nonsurgical and nondental services that: a. Are medically necessary in connection with a Medicaid-covered surgical or dental procedure; b. Are eligible for payment as physicians’ services under the circumstances specified in rule 441—78.1(249A) or as dentists’ services under the circumstances specified in rule 441—78.4(249A); and c. Can safely and economically be performed in an outpatient setting, as determined by the department. 78.26(4) Limits on covered services. a. Abortion procedures are covered only when criteria in subrule 78.1(17) are met. b. Sterilization procedures are covered only when criteria in subrule 78.1(16) are met. c. Preprocedure review by Iowa Medicaid is required if ambulatory surgical centers are to be reimbursed for certain frequently performed surgical procedures as set forth under subrule 78.1(19). Criteria are available from Iowa Medicaid.Related ARC(s): 0315D441—78.27(249A) Home- and community-based habilitation services. Payment for habilitation services will only be made to providers enrolled to provide habilitation through Iowa Medicaid. Payment will only be made for services provided to members in integrated, community-based settings that support full access of members receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS. 78.27(1) Definitions. Individuals under the age of 18 may not reside in settings with individuals over the age of 21. The comprehensive service plan shall specifically identify educational services and supports for individuals who have not obtained a high school diploma or equivalent. For individuals who have obtained a high school diploma or equivalent, the comprehensive service plan shall include supported employment, additional training, or educational supports. (4) The member’s parent or guardian has consented to home-based habilitation services. (5) The member is able to pay room and board costs (funding sources may include but are not limited to supplemental security income, child support, adoptions subsidy, or private funds). (6) Youth under the age of 16 needing daily home-based habilitation outside the family home must receive services in a licensed or certified residential-based supported community living setting. e. Exclusions. Home-based habilitation payment will not be made for the following: (1) Room and board and maintenance costs, including the cost of rent or mortgage, utilities, telephone, food, household supplies, and building maintenance, upkeep, or improvement. (2) Service activities associated with vocational services, day care, medical services, or case management. (3) Transportation to and from a day program. (4) Services provided to a member who lives in a licensed residential care facility of more than 16 persons. (5) Services provided to a member who lives in a facility that provides the same service as part of an inclusive or “bundled” service rate, such as a nursing facility or an ICF/ID. (6) Personal care and protective oversight and supervision may be a component part of home-based habilitation services but may not comprise the entirety of the service. 78.27(8) Day habilitation. “Day habilitation” means services that provide opportunities and support for community inclusion and build interest in and develop skills for active participation in recreation, volunteerism and integrated community employment. Day habilitation provides assistance with acquisition, retention, or improvement of socialization, community participation, and daily living skills. a. Scope. Day habilitation activities and environments are designed to foster the acquisition of skills, positive social behavior, greater independence, and personal choice. Services focus on supporting the member to participate in the community, develop social roles and relationships, and increase independence and the potential for employment. Services are designed to assist the member to attain or maintain the member’s individual goals as identified in the member’s comprehensive service plan. Services may also provide wraparound support secondary to community employment. Day habilitation activities may include: (1) Identifying the member’s interests, preferences, skills, strengths and contributions, (2) Identifying the conditions and supports necessary for full community inclusion and the potential for competitive integrated employment, (3) Planning and coordination of the member’s individualized daily and weekly day habilitation schedule, (4) Developing skills and competencies necessary to pursue competitive integrated employment, (5) Participating in community activities related to hobbies, leisure, personal health, and wellness, (6) Participating in community activities related to cultural, civic, and religious interests, (7) Participating in adult learning opportunities, (8) Participating in volunteer opportunities, (9) Training and education in self-advocacy and self-determination to support the member’s ability to make informed choices about where to live, work, and recreate, (10) Assistance with behavior management and self-regulation, (11) Use of transportation and other community resources, (12) Assistance with developing and maintaining natural relationships in the community, (13) Assistance with identifying and using natural supports, (14) Assistance with accessing financial literacy and benefits education, (15) Other activities deemed necessary to assist the member with full participation in the community, developing social roles and relationships, and increasing independence and the potential for employment. b. Family training option. Day habilitation services may include training families in treatment and support methodologies or in the care and use of equipment. Family training may be provided in the member’s home. The unit of service is 15 minutes. The units of services payable are limited to a maximum of 40 units per month. c. Expected outcome of service. The expected outcome of day habilitation services is active participation in the community in which the member lives, works, and recreates. Members are expected to have opportunities to interact with individuals without disabilities in the community, other than those providing direct services, to the same extent as individuals without disabilities. d. Setting. Day habilitation shall take place in community-based, nonresidential settings separate from the member’s residence. Family training may be provided in the member’s home. e. Duration. Day habilitation services shall be furnished as specified in the member’s comprehensive service plan. Meals provided as part of day habilitation shall not constitute a full nutritional regimen (three meals per day). f. Unit of service. A unit of day habilitation is 15 minutes (up to 16 units per day) or a full day (4.25 to 8 hours). g. Concurrent services. A member’s comprehensive service plan may include two or more types of nonresidential habilitation services (e.g., day habilitation, individual supported employment, long-term job coaching, small-group supported employment, and prevocational services). However, more than one service may not be billed during the same period of time (e.g., the same hour). h. Transportation. When transportation is provided to the day habilitation service location from the member’s home and from the day habilitation service location to the member’s home, the day habilitation provider may bill for the time spent transporting the member. i. Exclusions. Day habilitation payment will not be made for the following: (1) Services that are available to the individual under a program funded under Section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq. as amended to July 1, 2026). Documentation that funding is not available to the individual for the service under these programs shall be maintained in the service plan of each member receiving day habilitation services. (2) Compensation to members for participating in day habilitation. (3) Support for members volunteering in for-profit organizations and businesses. (4) Support for members volunteering to benefit the day habilitation service provider. 78.27(9) Prevocational service habilitation. “Prevocational services” means services that provide career exploration, learning and work experiences, including volunteer opportunities, where the member can develop non-job-task-specific strengths and skills that lead to paid employment in individual community settings. a. Scope. Prevocational services are provided to persons who are expected to be able to join the general workforce with the assistance of supported employment. Prevocational services are intended to develop and teach general employability skills relevant to successful participation in individual employment. These skills include but are not limited to the ability to communicate effectively with supervisors, coworkers and customers; an understanding of generally accepted community workplace conduct and dress; the ability to follow directions; the ability to attend to tasks; workplace problem-solving skills and strategies; general workplace safety and mobility training; the ability to navigate local transportation options; financial literacy skills; and skills related to obtaining employment.Prevocational services include career exploration activities to facilitate successful transition to individual employment in the community. Participation in prevocational services is not a prerequisite for individual or small-group supported employment services. (1) Career exploration. Career exploration activities are designed to develop an individual career plan and facilitate the member’s experientially based informed choice regarding the goal of individual employment. Career exploration may be provided in small groups of no more than four members to participate in career exploration activities that include business tours, attending industry education events, benefit information, financial literacy classes, and attending career fairs. Career exploration may be authorized for up to 34 hours, to be completed over 90 days in the member’s local community or nearby communities and may include but is not limited to the following activities: 1. Meeting with the member and the member’s family, guardian or legal representative to introduce them to supported employment and explore the member’s employment goals and experiences, 2. Business tours, 3. Informational interviews, 4. Job shadows, 5. Benefits education and financial literacy, 6. Assistive technology assessment, and 7. Job exploration events. (2) Expected outcome of service. 1. The expected outcome of prevocational services is individual employment in the general workforce, or self-employment, in a setting typically found in the community, where the member interacts with individuals without disabilities, other than those providing services to the member or other individuals with disabilities, to the same extent that individuals without disabilities in comparable positions interact with other persons; and for which the member is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. 2. The expected outcome of the career exploration activity is a written career plan that will guide employment services that lead to community employment or self-employment for the member. b. Setting. Prevocational services shall take place in community-based nonresidential settings. c. Concurrent services. A member’s individual service plan may include two or more types of nonresidential habilitation services (e.g., individual supported employment, long-term job coaching, small-group supported employment, prevocational services, and day habilitation); however, more than one service may not be billed during the same period of time (e.g., the same hour). d. Exclusions. Prevocational services payment shall not be made for the following: (1) Services that are available to the individual under a program funded under Section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq. as amended to July 1, 2026). Documentation that funding is not available to the individual for the service under these programs shall be maintained in the service plan of each member receiving prevocational services. (2) Services available to the individual that duplicate or replace education or related services defined in the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq. as amended to July 1, 2026). (3) Compensation to members for participating in prevocational services. (4) Support for members volunteering in for-profit organizations and businesses other than for-profit organizations, or businesses that have formal volunteer programs in place (e.g., hospitals, nursing homes), and support for members volunteering to benefit the service provider. (5) The provision of vocational services delivered in facility-based settings where individuals are supervised for the primary purpose of producing goods or performing services or where services are aimed at teaching skills for specific types of jobs rather than general skills. (6) A prevocational service plan with the goal or purpose of the service documented as maintaining or supporting the individual in continuing prevocational services or any employment situation similar to sheltered employment. e. Limitations. (1) Time limitation for members starting prevocational services. For members starting prevocational services, participation in these services is limited to 24 calendar months. This time limit can be extended to continue beyond 24 months if one or more of the following conditions apply: 1. The member who is in prevocational services is also working in either individual or small-group community employment for at least the number of hours per week desired by the member, as identified in the member’s current service plan; or 2. The member who is in prevocational services is also working in either individual or small-group community employment for less than the number of hours per week the member desires, as identified in the member’s current service plan, but the member has services documented in the member’s current service plan, or through another identifiable funding source (e.g., Iowa vocational rehabilitation services (IVRS)), to increase the number of hours the member is working in either individual or small-group community employment; or 3. The member is actively engaged in seeking individual or small-group community employment or individual self-employment, and services for this are included in the member’s current service plan or services funded through another identifiable funding source (e.g., IVRS) are documented in the member’s service plan; or 4. The member has requested supported employment services from Medicaid and IVRS in the past 24 months, and the member’s request has been denied or the member has been placed on a waiting list by both Medicaid and IVRS; or 5. The member has been receiving individual supported employment services (or comparable services available through IVRS) for at least 18 months without obtaining individual or small-group community employment or individual self-employment; or 6. The member is participating in career exploration activities as described in subparagraph 78.27(9)“a”(1). (2) Time limitation for members enrolled in prevocational services. For members enrolled in prevocational services, participation in these services is limited to 90 business days beyond the completion of the career exploration activity including the development of the career plan described in subparagraph 78.27(9)“a”(1). This time limit can be extended as stated in numbered paragraphs 78.27(9)“e”(1)“1” through “6.” If the criteria in numbered paragraphs 78.27(9)“e”(1)“1” through “6” do not apply, the member will not be reauthorized to continue prevocational services. 78.27(10) Supported employment services. a. Individual supported employment. Individual supported employment involves supports provided to, or on behalf of, the member that enable the member to obtain and maintain individual employment. Services are provided to members who need support because of their disabilities. (1) Scope. Individual supported employment services are services provided to, or on behalf of, the member that enable the member to obtain and maintain an individual job in competitive employment, customized employment or self-employment in an integrated work setting in the general workforce. (2) Expected outcome of service. The expected outcome of this service is sustained employment, or self-employment, paid at or above the minimum wage or the customary wage and level of benefits paid by an employer, in an integrated setting in the general workforce, in a job that meets personal and career goals. Successful transition to long-term job coaching, if needed, is also an expected outcome of this service. An expected outcome of supported self-employment is that the member earns income that is equal to or exceeds the average income for the chosen business within a reasonable period of time. (3) Setting. Individual supported employment services shall take place in integrated work settings. For self-employment, the member’s home can be considered an integrated work setting. Employment in the service provider’s organization (not including a sheltered workshop or similar type of work setting where members are paid for the production of goods or services) can be considered employment in an integrated work setting in the general workforce if the employment occurs in a work setting where interactions are predominantly with coworkers or business associates who do not have disabilities or with the general public. (4) Individual employment strategies include but are not limited to customized employment, individual placement and support, and supported self-employment. Service activities are individualized and may include any combination of the following: 1. Benefits education. 2. Career exploration (e.g., tours, informational interviews, job shadows). 3. Employment assessment. 4. Assistive technology assessment. 5. Trial work experience. 6. Person-centered employment planning. 7. Development of visual/traditional résumés. 8. Job-seeking skills training and support. 9. Outreach to prospective employers on behalf of the member (e.g., job development; negotiation with prospective employers to customize, create or carve out a position for the member; employer needs analysis). 10. Job analysis (e.g., work site assessment or job accommodations evaluation). 11. Identifying and arranging transportation. 12. Career advancement services (e.g., assisting a member in making an upward career move or seeking promotion from an existing employer). 13. Reemployment services (if necessary due to job loss). 14. Financial literacy and asset development. 15. Other employment support services deemed necessary to enable the member to obtain employment. 16. Systematic instruction and support during initial on-the-job training including initial on-the-job training to stabilization. 17. Engagement of natural supports during initial period of employment. 18. Implementation of assistive technology solutions during initial period of employment. 19. Transportation of the member during service hours. 20. Initial on-the-job training to stabilization activity. (5) Self-employment. Individual employment may also include support to establish a viable self-employment opportunity, including home-based self-employment. An expected outcome of supported self-employment is that the member earns income that is equal to or exceeds the average income for the chosen business within a reasonable period of time. In addition to the activities listed under subparagraph 78.27(10)“a”(4), assistance to establish self-employment may include: 1. Aid to the member in identifying potential business opportunities. 2. Assistance in the development of a business plan, including identifying potential sources of business financing and other assistance in developing and launching a business. 3. Identification of the long-term supports necessary for the individual to operate the business. b. Long-term job coaching. Long-term job coaching is support provided to, or on behalf of, the member that enables the member to maintain an individual job in competitive employment, customized employment or self-employment in an integrated work setting in the general workforce. (1) Scope. Long-term job coaching services are provided to or on behalf of members who need support because of their disabilities and who are unlikely to maintain and advance in individual employment absent the provision of supports. Long-term job coaching services shall provide individualized and ongoing support contacts at intervals necessary to promote successful job retention and advancement. (2) Expected outcome of service. The expected outcome of this service is sustained employment paid at or above the minimum wage in an integrated setting in the general workforce, in a job that meets the member’s personal and career goals. An expected outcome of supported self-employment is that the member earns income that is equal to or exceeds the average income for the chosen business within a reasonable period of time. (3) Setting. Long-term job coaching services shall take place in integrated work settings. For self-employment, the member’s home can be considered an integrated work setting. Employment in the service provider’s organization (not including a sheltered workshop or similar type of work setting) can be considered employment in an integrated work setting in the general workforce if the employment occurs in a work setting where interactions are predominantly with coworkers or business associates who do not have disabilities, or with the general public, and if the position would exist within the provider’s organization were the provider not being paid to provide the job coaching to the member. (4) Service activities. Long-term job coaching services are designed to assist the member with learning and retaining individual employment, resulting in workplace integration, which allows the reduction of long-term job coaching over time. Services are individualized, and service plans are adjusted as support needs change and may include any combination of the following activities with or on behalf of the member: 1. Job analysis. 2. Job training and systematic instruction. 3. Training and support for use of assistive technology/adaptive aids. 4. Engagement of natural supports. 5. Transportation coordination. 6. Job retention training and support. 7. Benefits education and ongoing support. 8. Supports for career advancement. 9. Financial literacy and asset development. 10. Employer consultation and support. 11. Negotiation with employer on behalf of the member (e.g., accommodations; employment conditions; access to natural supports; and wage and benefits). 12. Other workplace support services may include services not specifically related to job skill training that enable the waiver member to be successful in integrating into the job setting. 13. Transportation of the member during service hours. 14. Career exploration services leading to increased hours or career advancement. (5) Self-employment long-term job coaching. Self-employment long-term job coaching may include support to maintain a self-employment opportunity, including home-based self-employment. In addition to the activities listed under subparagraph 78.27(10)“b”(4), assistance to maintain self-employment may include: 1. Ongoing identification of the supports necessary for the individual to operate the business; 2. Ongoing assistance, counseling and guidance to maintain and grow the business; and 3. Ongoing benefits education and support. (6) The hours of support for long-term job coaching are based on the identified needs of the member as documented in the member’s comprehensive service plan. c. Small-group supported employment. Small-group supported employment services are training and support activities provided in regular business or industry settings for groups of two to eight workers with disabilities. The outcome of this service is sustained paid employment experience, skill development, career exploration and planning leading to referral for services to obtain individual integrated employment or self-employment for which an individual is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. (1) Scope. Small-group supported employment services must be provided in a manner that promotes integration into the workplace and interaction between members and people without disabilities (e.g., customers, coworkers, natural supports) in those workplaces. Examples include but are not limited to mobile crews and other business-based workgroups employing small groups of workers with disabilities in employment in integrated business settings; and small-group activities focused on career exploration and development of strengths and skills that contribute to successful participation in individual community employment. (2) Expected outcome of service. Small-group supported employment services are expected to enable the member to make reasonable and continued progress toward individual employment. Participation in small-group supported employment services is not a prerequisite for individual supported employment services. The expected outcome of the service is sustained paid employment and skill development that leads to individual employment in the community. (3) Setting. Small-group supported employment services shall take place in integrated, community-based nonresidential settings separate from the member’s residence. (4) Service activities. Small-group supported employment services may include any combination of the following activities: 1. Employment assessment. 2. Person-centered employment planning. 3. Job placement (limited to service necessary to facilitate hire into individual employment paid at minimum wage or higher for a member in small-group supported employment who receives an otherwise unsolicited offer of a job from a business where the member has been working in a mobile crew or enclave). 4. Job analysis. 5. On-the-job training and systematic instruction. 6. Job coaching. 7. Transportation planning and training. 8. Benefits education. 9. Career exploration services leading to career advancement outcomes. 10. Other workplace support services may include services not specifically related to job skill training that enable the waiver member to be successful in integrating into the individual or community setting. 11. Transportation of the member during service hours. d. Individual placement and support (IPS). (1) IPS shall include the following activities, which shall be described and documented in the member’s employment plan: 1. Development of the career profile, including previous work experience, goals, preferences, strengths, barriers, skills, disclosure preferences, career advancement, education and plan for graduation. 2. Integration of IPS team members and the behavioral health team, including routine staffing meetings regarding IPS clients. 3. Addressing barriers to employment, which may be actual or perceived. Support may include addressing justice system involvement, a lack of work history, limited housing, child care, and transportation. 4. Rapid job search and systematic job development. Community and employment supports (CESs) help members seek jobs directly and do not provide extensive preemployment assessment and training or intermediate work experiences. The job process begins within 30 days of starting IPS services. This rapid job search is supported by CESs developing relationships with employers through multiple face-to-face meetings. CESs take time to learn about the employers’ needs and the work environment while gathering information about job opportunities that might be a good fit for individuals they are working with. 5. Disclosure counseling, to assist the member in making an informed decision on disclosure of a disability to a prospective or current employer. 6. Identification and implementation of job accommodations and assistive technology supports. 7. Ongoing benefits counseling. The member must receive information on available work incentive programs, or referral to professional benefits counselors for a personalized work incentives plan for any state or federal entitlement. 8. Time-unlimited follow-along supports. These supports are planned for early in the employment process, are personalized, and follow the member for as long as the member needs support. The focus is supporting the member in becoming as independent as possible and involving family members, co-workers, and other natural supports. These supports can be provided on or off the job site and focus on the continued acquisition and development of skills needed to maintain employment. (2) Units of service. Reimbursement is made for each outcome achieved for the member participating in the IPS supported employment model. Outcomes are as follows: 1. Outcome #1: Completed employment plan. 2. Outcome #2: First day of successful job placement. 3. Outcome #3: 45 days successful job retention. 4. Outcome #4: 90 days successful job retention. e. Service requirements for all supported employment services. (1) Community transportation options (e.g., transportation provided by family, coworkers, carpools, volunteers, self or public transportation) shall be identified by the member’s interdisciplinary team and utilized before the service provider provides the transportation to and from work for the member. If none of these options are available to a member, transportation between the member’s place of residence and the employment or service location may be included as a component part of supported employment services. (2) Personal care or personal assistance and protective oversight may be a component part of supported employment services, but may not comprise the entirety of the service. (3) Activities performed on behalf of a member receiving long-term job coaching or individual or small-group supported employment shall not comprise the entirety of the service. (4) Concurrent services. A member’s individual service plan may include two or more types of nonresidential services (e.g., individual supported employment, long-term job coaching, small-group supported employment, prevocational services, and day habilitation); however, more than one service may not be billed during the same period of time (e.g., the same hour). (5) Integration requirements. In the performance of job duties, the member shall have regular contact with other employees or members of the general public who do not have disabilities, unless the absence of regular contact with other employees or the general public is typical for the job as performed by persons without disabilities. (6) Compensation. Members receiving these services are compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. For supported self-employment, the member earns income that is equal to or exceeds the average income for the chosen business within a reasonable period of time. For small-group supported employment, if the member is not compensated at or above minimum wage, the compensation to the member shall be in accordance with all applicable state and federal labor laws and regulations. f. Limitations. Supported employment services are limited as follows: (1) Total monthly costs of supported employment may not exceed the monthly cap on the cost of waiver services set for the individual waiver program. (2) In absence of a monthly cap on the cost of waiver services, the total monthly cost of all supported employment services may not exceed the cost limitations published on the Iowa Medicaid fee schedule webpage. (3) Individual supported employment is limited to 60 hourly units per calendar year. (4) Long-term job coaching is limited in accordance with 441—subrule 79.1(2). (5) Small-group supported employment is limited to 160 units per week. g. Exclusions. Supported employment services payments will not be made for the following: (1) Services that are available to the individual under a program funded under Section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq. as amended to July 1, 2026). Documentation that the service is not available to the individual under these programs shall be maintained in the service plan of each member receiving individual supported employment or long-term job coaching services. (2) Incentive payments, not including payments for coworker supports, made to an employer to encourage or subsidize the employer’s participation in a supported employment program. (3) Subsidies or payments that are passed through to users of supported employment programs. (4) Training that is not directly related to a member’s supported employment program. (5) Services involved in placing and stabilizing members in day activity programs, work activity programs, sheltered workshop programs or other similar types of vocational or prevocational services furnished in specialized facilities that are not a part of the general workplace. (6) Supports for placement and stabilization in volunteer positions or unpaid internships. Such volunteer learning and unpaid training activities that prepare a person for entry into the general workforce are addressed through prevocational services and career exploration activities. (7) Tuition for education or vocational training. (8) Individual advocacy that is not related to integrated individual employment participation or is not member-specific. (9) Medicaid funds may not be used to defray the expenses associated with starting up or operating a business. 78.27(11) Adverse service actions. a. Denial. Services will be denied when the department determines that: (1) The member is not eligible for or in need of home- and community-based habilitation services. (2) The service is not identified in the member’s comprehensive service plan or treatment plan. (3) Needed services are not available or received from qualifying providers, or no qualifying providers are available. (4) The member’s service needs exceed the unit or reimbursement maximums for a service as set forth in 441—subrule 79.1(2). (5) Completion or receipt of required documents for the program has not occurred. b. Reduction. A particular home- and community-based habilitation service may be reduced when the department determines that continued provision of service at its current level is not necessary. c. Termination. A particular home- and community-based habilitation service may be terminated when the department determines that: (1) The member’s income exceeds the allowable limit, or the member no longer meets other eligibility criteria for the program established by the department. (2) The service is not identified in the member’s comprehensive service plan. (3) Needed services are not available or received from qualifying providers, or no qualifying providers are available. (4) The member’s service needs are not being met by the services provided. (5) The member has received care in a medical institution for 120 consecutive days in any one stay. When a member has been an inpatient in a medical institution for 120 consecutive days, the department will issue a notice of decision pursuant to 441—Chapter 16 to inform the member of the service termination. If the member returns home before the effective date of the notice of decision and the member’s condition has not substantially changed, the decision will be rescinded, and eligibility for home- and community-based habilitation services shall continue. (6) The member’s service needs exceed the unit or reimbursement maximums for a service as established by the department. (7) Duplication of services provided during the same period has occurred. (8) The member or the member’s legal representative, through the interdisciplinary process, requests termination of the service. (9) Completion or receipt of required documents for the program has not occurred, or the member refuses to allow documentation of eligibility as to need and income. d. Appeal rights. The department shall give notice of any adverse action pursuant to 441—Chapter 16 and the right to appeal in accordance with 441—Chapter 2506. The member is entitled to have a review of the determination of needs-based eligibility or of the actual disposition score by sending a letter requesting a review to Iowa Medicaid at the department’s address. If dissatisfied with that decision, the member may file an appeal with the department.Related ARC(s): 0315D441—78.28(249A) List of medical services and equipment requiring prior authorization, preprocedure review or preadmission review. 78.28(1) Services, procedures, and medications prescribed by a physician, PA, or ARNP that are subject to prior authorization or preprocedure review are as follows or as specified in the preferred drug list published by the department pursuant to Iowa Code section 249A.20A: a. Drugs require prior authorization as specified in the preferred drug list published by the department pursuant to Iowa Code section 249A.20A. For drugs requiring prior authorization, reimbursement will be made for a 72-hour supply dispensed in an emergency when a prior authorization request cannot be submitted. b. Reserved. c. Enteral products and enteral delivery pumps and supplies. Payment will be approved pursuant to the criteria in subrule 78.10(5). d. Reserved. e. Speech generating device. Payment will be approved pursuant to the criteria in subrule 78.10(5). f. Preprocedure review by Iowa Medicaid will be required if payment under Medicaid is to be made for certain frequently performed surgical procedures that have a wide variation in the relative frequency the procedures are performed. Preprocedure surgical review applies to surgeries performed in hospitals (outpatient and inpatient) and ambulatory surgical centers. Approval by Iowa Medicaid will be granted only if the procedures are determined to be medically necessary based on the condition of the patient and on the criteria established by the department. If not approved by Iowa Medicaid, payment will not be made under the program to the physician or to the facility in which the surgery is performed. The criteria are available from Iowa Medicaid. g. Enclosed beds. Payment will be approved pursuant to the criteria in subrule 78.10(5). h. Prior authorization is required for external insulin infusion pumps and is granted according to Medicare coverage criteria. i. Oral nutritional products. Payment will be approved pursuant to the criteria in subrule 78.10(5). j. Vest airway clearance system. Payment will be approved pursuant to the criteria in subrule 78.10(5). k. DME rebate agreements. Payment will be approved pursuant to the criteria in subrule 78.10(5). l. Reimbursement over the established Medicaid fee schedule amount. Payment will be approved pursuant to the criteria in subrule 78.10(5). m. Bathtub/shower chair, bench. Payment will be approved pursuant to the criteria in subrule 78.10(5). n. Patient lift, nonstandard. Payment will be approved pursuant to the criteria in subrule 78.10(5). o. Power wheelchair attendant control. Payment will be approved pursuant to the criteria in subrule 78.10(5). p. Shower commode chair. Payment will be approved pursuant to the criteria in subrule 78.10(5). q. Ventilator, secondary. Payment will be approved pursuant to the Medicare coverage criteria. r. Customized wheelchairs, subject to the requirements of paragraph 78.10(2)“d.” 78.28(2) Notwithstanding the provisions of paragraph 78.28(1)“a,” under both Medicaid fee-for-service and managed care administration, at least one form of each of the following drugs for medication-assisted treatment as approved by the United States Food and Drug Administration for treatment of substance use disorder or overdose treatment will be available without prior authorization: a. Buprenorphine, b. Buprenorphine and naloxone combination, c. Methadone, d. Naltrexone, and e. Naloxone.For the purpose of this subrule, “medication-assisted treatment” means the medically monitored use of certain substance use disorder medications in combination with treatment services. 78.28(3) Dental services. Dental services requiring prior approval are outlined in the Iowa Medicaid Dental Provider Manual as amended to July 1, 2026. 78.28(4) Optometric services and ophthalmic materials that must be submitted for prior approval are as follows: a. A second lens correction within a 24-month period for members eight years of age and older. Payment will be made when the member’s vision has at least a five-tenths diopter of change in sphere or cylinder or ten-degree change in axis in either eye. b. Visual therapy may be authorized when warranted by case history or diagnosis for a period of time not greater than 90 days. Should continued therapy be warranted, the prior approval process should be reaccomplished, accompanied by a report showing satisfactory progress. Approved diagnoses are convergence insufficiency and amblyopia. Visual therapy is not covered when provided by opticians. c. Subnormal visual aids where near visual acuity is better than 20/100 at 16 inches, 2M print. Prior authorization is not required if near visual acuity as described above is less than 20/100. Subnormal aids include but are not limited to hand magnifiers, loupes, telescopic spectacles or reverse Galilean telescope systems. d. Photochromatic tint. Approval will be given when the member has a documented medical condition that causes photosensitivity and less costly alternatives are inadequate. e. Press-on prisms. Approval will be granted for members whose vision cannot be adequately corrected with other covered prisms.For all of the above, the optometrist shall furnish sufficient information to clearly establish that these procedures are necessary in terms of the visual condition of the patient pursuant to rule 441—78.7(249A) and subrule 78.1(18). 78.28(5) Hearing aids that must be submitted for prior approval are: a. Replacement of a hearing aid less than four years old (except when the member is under 21 years of age). The department will approve payment when the original hearing aid is lost or broken beyond repair or there is a significant change in the person’s hearing that would require a different hearing aid. b. A hearing aid costing more than $650. The department will approve payment for either of the following purposes: (1) Educational purposes when the member is participating in primary or secondary education or in a postsecondary academic program leading to a degree and an in-office comparison of an analog aid and a digital aid matched (+/- 5dB) for gain and output shows a significant improvement in either speech recognition in quiet or speech recognition in noise or an in-office comparison of two aids, one of which is single channel, shows significantly improved audibility. (2) Vocational purposes when documentation submitted indicates the necessity, such as varying amounts of background noise in the work environment and a need to converse in order to do the job and an in-office comparison of an analog aid and a digital aid matched (+/- 5dB) for gain and output shows a significant improvement in either speech recognition in quiet or speech recognition in noise or an in-office comparison of two aids, one of which is single channel, shows significantly improved audibility. 78.28(6) Hospital services requiring prior approval, preprocedure review or preadmission review are outlined in the Acute Hospitals Provider Manual as amended to July 1, 2026. 78.28(7) Ambulatory surgical centers are subject to prior approval and preprocedure review as set forth in the Ambulatory Surgical Centers Provider Manual as amended to July 1, 2026. 78.28(8) All assertive community treatment (ACT) services require prior approval. Exception: If ACT services are initiated before Medicaid eligibility is established, prior approval is required for ACT services beginning with the second month following notice of Medicaid eligibility. a. Approval will be granted if ACT services are determined to be medically necessary. Approval will be limited to no more than 180 days. b. A new prior approval must be obtained to continue ACT services after the expiration of a previous approval. 78.28(9) Nursing, psychosocial, developmental therapies and personal care services provided by a licensed child care center for members aged 20 or under require prior approval and will be approved if the services are determined to be medically necessary. The request for prior authorization shall include a nursing assessment, the plan of care, and supporting documentation and shall identify the types and service delivery levels of all other services provided to the member whether or not the services are reimbursable by Medicaid. Providers shall indicate the expected number of nursing, home health aide or behavior intervention hours per day, the number of days per week, and the number of weeks or months of service based on the plan of care using a combined hourly rate. 78.28(10) Private duty nursing or personal care services provided by a home health agency provider for persons aged 20 or under require prior approval and will be approved if determined to be medically necessary. Payment will be made on an hourly unit of service. a. Definitions. (1) Private duty nursing services are those services provided by a registered nurse or a licensed practical nurse under the direction of the member’s physician to a member in the member’s place of residence or outside the member’s residence, when normal life activities take the member outside the place of residence. Place of residence does not include nursing facilities, ICFs/ID, or hospitals.Services shall be provided according to a written plan of care authorized by a licensed physician. The home health agency is encouraged to collaborate with the member, or in the case of a child with the child’s caregiver, in the development and implementation of the plan of treatment. These services shall exceed intermittent guidelines as defined in subrule 78.9(3). Private duty nursing and personal care services shall be inclusive of all home health agency services personally provided to the member.Private duty nursing services do not include: 1. Respite care, which is a temporary intermission or period of rest for the caregiver. 2. Nurse supervision services including chart review, case discussion or scheduling by a registered nurse. 3. Services provided to other persons in the member’s household. 4. Services requiring prior authorization that are provided without regard to the prior authorization process. (2) Personal care services are those services provided by a home health aide or certified nurse’s aide and that are delegated and supervised by a registered nurse under the direction of the member’s physician to a member in the member’s place of residence or outside the member’s residence, when normal life activities take the member outside the place of residence. Place of residence does not include nursing facilities, ICFs/ID, or hospitals. Payment for personal care services for persons aged 20 and under that exceed intermittent guidelines may be approved if determined to be medically necessary as defined in subrule 78.9(7). These services shall be in accordance with the member’s plan of care and authorized by a physician. The home health agency is encouraged to collaborate with the member, or in the case of a child with the child’s caregiver, in the development and implementation of the plan of treatment.Medical necessity means the service is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions that endanger life, cause pain, result in illness or infirmity, threaten to cause or aggravate a disability or chronic illness, and no other equally effective course of treatment is available or suitable for the member requesting a service. b. Requirements. (1) Private duty nursing or personal care services shall be ordered in writing by a physician as evidenced by the physician’s signature on the plan of care. (2) Private duty nursing or personal care services will be authorized by the department or the department’s designated review agent prior to payment. (3) Prior authorization shall be requested at the time of initial submission of the plan of care or at any time the plan of care is substantially amended and will be renewed with the department or the department’s designated review agent. Initial request for and request for renewal of prior authorization shall be submitted to the department’s designated review agent. The provider of the service is responsible for requesting prior authorization and for obtaining renewal of prior authorization.The request for prior authorization shall include a nursing assessment, the plan of care, and supporting documentation. The request for prior authorization shall include all items previously identified as required treatment plan information and shall further include: any planned surgical interventions and projected time frame; information regarding caregiver’s desire to become involved in the member’s care, to adhere to program objectives, to work toward treatment plan goals, and to work toward maximum independence; and identify the types and service delivery levels of all other services to the member whether or not the services are reimbursable by Medicaid. Providers shall indicate the expected number of private duty nursing RN hours, private duty nursing LPN hours, or home health aide hours per day, the number of days per week, and the number of weeks or months of service per discipline. If the member is currently hospitalized, the projected date of discharge shall be included.Prior authorization approvals will not be granted for treatment plans that exceed 16 hours of home health agency services per day. 78.28(11) Replacement of vibrotactile aids less than four years old will be approved when the original aid is broken beyond repair or lost. 78.28(12) High-technology radiology procedures. a. Except as provided in paragraph 78.28(12)“b,” the following radiology procedures require prior approval: (1) Magnetic resonance imaging (MRIs); (2) Computed tomography (CTs), including combined abdomen and pelvis CT scans; (3) Computed tomographic angiographs (CTAs); (4) Positron emission tomography (PETs); and (5) Magnetic resonance angiography (MRAs). b. Notwithstanding paragraph 78.28(12)“a,” prior authorization is not required when any of the following applies: (1) Radiology procedures are billed on a CMS 1500 claim for places of service “hospital inpatient” (POS 21) or “hospital emergency room” (POS 23), or on a UB04 claim with revenue code 45X; (2) The member has Medicare coverage; (3) A radiology procedure is ordered or requested by the department, a state district court, law enforcement, or other similar entity for the purposes of a child abuse/neglect investigation, as documented by the provider. c. Prior approval will be granted if the procedure requested meets the requirements of 441—subrule 79.10(2), based on diagnosis, symptoms, history of illness, course of treatment, and treatment plan, as documented by the provider requesting prior approval. d. Required requests for prior approval of radiology procedures must be submitted to the department. e. When a member has received notice of retroactive Medicaid eligibility after receiving a radiology procedure for a date of service prior to the member’s receipt of such notice and otherwise requiring prior approval pursuant to this rule, a retroactive authorization request must be submitted on an Outpatient Prior Authorization Request form and approved before any claim for payment is submitted.Related ARC(s): 0315D441—78.29(249A) Behavioral health services. Payment will be made for medically necessary behavioral health services provided by a participating marital and family therapist, independent social worker, master social worker, mental health counselor, or certified alcohol and drug counselor within the practitioner’s scope of practice pursuant to state law and subject to the limitations and exclusions set forth in this rule. 78.29(1) Limitations. a. An assessment and a treatment plan are required. b. Services provided by a licensed master social worker must be provided under the supervision of an independent social worker qualified to participate in the Medicaid program. 78.29(2) Exclusions. Payment will not be approved for the following services: a. Services provided in a medical institution. b. Services performed without relationship to a specific condition, risk factor, symptom, or complaint. c. Services provided for nonspecific conditions of distress such as job dissatisfaction or general unhappiness. d. Sensitivity training, marriage enrichment, assertiveness training, and growth groups or marathons. 78.29(3) Payment. a. Payment will be made only for time spent in face-to-face consultation with the member. b. A unit of service is 15 minutes. Time spent with members shall be rounded to the quarter hour, where applicable.Related ARC(s): 0315D441—78.30(249A) Birth centers. Payment will be made for prenatal, delivery, and postnatal services as outlined in the Birth Centers Provider Manual as amended to July 1, 2026.Related ARC(s): 0315D441—78.31(249A) Hospital outpatient services. 78.31(1) Covered hospital outpatient services. Payment will be approved only for the following outpatient hospital services and medical services when provided on the licensed premises of the hospital. Hospitals with alternate sites approved by the department of inspections, appeals, and licensing are acceptable sites. All outpatient services listed in paragraphs 78.31(1)“g” through “m” are subject to a random sample retrospective review for medical necessity by Iowa Medicaid. All services may also be subject to a more intensive retrospective review if abuse is suspected. Services in paragraphs 78.31(1)“a” through “f” shall be provided in hospitals on an outpatient basis and are subject to no further limitations except medical necessity of the service.Services listed in paragraphs 78.31(1)“g” through “m” shall be provided by hospitals on an outpatient basis and must be certified by the department before payment may be made. Other limitations apply to these services. a. Emergency service. b. Outpatient surgery. c. Laboratory, X-ray and other diagnostic services. d. General or family medicine. e. Follow-up or after-care specialty clinics. f. Physical medicine and rehabilitation. g. Substance use disorder. h. Eating disorders. i. Cardiac rehabilitation. j. Mental health. k. Pain management. l. Diabetic education. m. Pulmonary rehabilitation. n. Nutritional counseling for persons aged 20 and under. 78.31(2) Requirements for all outpatient services. a. Need for service. It must be clearly established that the service meets a documented need in the area served by the hospital. There must be documentation of studies completed, consultations with other health care facilities and health care professionals in the area, community leaders, and organizations to determine the need for the service and to tailor the service to meet that particular need. b. Professional direction. All outpatient services must be provided by or at the direction and under the supervision of a medical doctor or osteopathic physician except for mental health services which may be provided by or at the direction and under the supervision of a medical doctor, osteopathic physician, or certified health service provider in psychology. c. Goals and objectives. The goals and objectives of the program must be clearly stated. Paragraphs 78.31(2)“d” and “f” and the organization and administration of the program must clearly contribute to the fulfillment of the stated goals and objectives. d. Treatment modalities used. The service must employ multiple treatment modalities and professional disciplines. The modalities and disciplines employed must be clearly related to the condition or disease being treated. e. Criteria for selection and continuing treatment of patients. The condition or disease proposed to be treated must be clearly stated. Any indications for treatment or contraindications for treatment must be set forth together with criteria for determining the continued medical necessity of treatment. f. Length of program. There must be established parameters that limit the program either in terms of its overall length or in terms of number of visits, etc. g. Monitoring of services. The services provided by the program must be monitored and evaluated to determine the degree to which patients are receiving accurate assessments and effective treatment.The monitoring of the services must be an ongoing plan and systematic process to identify problems in patient care or opportunities to improve patient care.The monitoring and evaluation of the services are based on the use of clinical indicators that reflect those components of patient care important to quality. h. Vaccines. In order to be paid for the outpatient administration of a vaccine covered under the VFC program, a hospital must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted. 78.31(3) Application for certification. Hospital outpatient programs listed in paragraphs 78.31(1)“g” through “m” must submit an application to Iowa Medicaid for certification before payment will be made. Iowa Medicaid will review the application against the requirements for the specific type of outpatient service and notify the provider whether certification has been approved.Applications will consist of a narrative providing the following information: a. Documented need for the program including studies, needs assessments, and consultations with other health care professionals. b. Goals and objectives of the program. c. Organization and staffing including how the program fits with the rest of the hospital, the number of staff, staff credentials, and the staff’s relationship to the program, e.g., hospital employee, contractual consultant. d. Policies and procedures including admission criteria, patient assessment, treatment plan, discharge plan and postdischarge services, and the scope of services provided, including treatment modalities. e. Any accreditations or other types of approvals from national or state organizations. f. The physical facility and any equipment to be utilized, and whether the facility is part of the hospital license. 78.31(4) Requirements for specific types of service. a. Substance use disorder. (1) Approval by joint commission. In addition to certification by the department, substance use disorder programs must also be approved by the joint commission. (2) General characteristics. The services must be designed to identify and respond to the biological, psychological and social antecedents, influences and consequences associated with the recipient’s dependence.These needed services must be provided either directly by the facility or through referral, consultation or contractual arrangements or agreements.Special treatment needs of recipients by reason of age, sex, sexual orientation, or ethnic origin are evaluated and services for children and adolescents (as well as adults, if applicable) address the special needs of these age groups including but not limited to learning problems in education, family involvement, developmental status, nutrition, and recreational and leisure activities. (3) Diagnostic and treatment staff. Each person who provides diagnostic or treatment services shall be determined to be competent to provide the services by reason of education, training, and experience.Professional disciplines that must be represented on the diagnostic and treatment staff, either through employment by the facility (full-time or part-time), contract or referral, are a physician (M.D. or D.O.), a licensed psychologist and a substance use counselor certified by the Iowa board of certification. Psychiatric consultation must be available and the number of staff should be appropriate to the patient load of the facility. (4) Initial assessment. A comprehensive assessment of the biological, psychological, social, and spiritual orientation of the patient must be conducted that shall include: 1. A history of the use of alcohol and other drugs including age of onset, duration, patterns, and consequences of use; use of alcohol and drugs by family members and types of and responses to previous treatment. 2. A comprehensive medical history and physical examination including the history of physical problems associated with dependence. 3. Appropriate laboratory screening tests based on findings of the history and physical examination and tests for communicable diseases when indicated. 4. Any history of physical abuse. 5. A systematic mental status examination with special emphasis on immediate recall and recent and remote memory. 6. A determination of current and past psychiatric and psychological abnormality. 7. A determination of any degree of danger to self or others. 8. The family’s history of substance use disorders. 9. The patient’s educational level, vocational status, and job performance history. 10. The patient’s social support networks, including family and peer relationships. 11. The patient’s perception of the patient’s strengths, problem areas, and dependencies. 12. The patient’s leisure, recreational, or vocational interests and hobbies. 13. The patient’s ability to participate with peers and in programs and social activities. 14. Interviews of family members and significant others as available with the patient’s written or verbal permission. 15. The patient’s legal problems, if applicable. (5) Admission criteria. Both of the first two criteria and one additional criterion from the following list must be present for a patient to be accepted for treatment. 1. Alcohol or drugs taken in greater amounts over a longer period than the person intended. 2. Two or more unsuccessful efforts to cut down or control use of alcohol or drugs. 3. Continued alcohol or drug use despite knowledge of having a persistent or recurrent family, social, occupational, psychological, or physical problem that is caused or exacerbated by the use of alcohol or drugs. 4. Marked tolerance: the need for markedly increased amounts of alcohol or drugs (i.e., at least a 50 percent increase) in order to achieve intoxication or desired effect or markedly diminished effect with continued use of same amount. 5. Characteristic withdrawal symptoms. 6. Alcohol or drugs taken often to relieve or avoid withdrawal symptoms. (6) Plan of treatment. For each patient, there is a written comprehensive and individualized description of treatment to be undertaken. The treatment plan is based on the problems and needs identified in the assessment and specifies the regular times at which the plan will be reassessed to determine current clinical problems, needs, and responses to treatment. The plan shall include documentation of: 1. The patient’s perception of needs and, when appropriate and available, the family’s perception of the patient’s needs. 2. The patient’s participation in the development of the treatment plan. 3. Changes in treatment. (7) Discharge plan. For each patient before discharge, a plan for discharge is designed to provide appropriate continuity of care that meets the following requirements: 1. The plan for continuing care must describe and facilitate the transfer of the patient and the responsibility for the patient’s continuing care to another phase or modality of the program, other programs, agencies, persons or to the patient and the patient’s personal support system. 2. The plan is in accordance with the patient’s reassessed needs at the time of transfer. 3. The plan is developed in collaboration with the patient and, as appropriate and available, with the patient’s written verbal permission with family members. 4. The plan is implemented in a manner acceptable to the patient and the need for confidentiality. 5. Implementation of the plan includes timely and direct communication with and transfer of information to the other programs, agencies, or persons who will be providing continuing care. (8) Restrictions and limitations on payment. Medicaid will reimburse for a maximum of 28 treatment days. Payment beyond 28 days is made when documentation indicates that the patient has not reached an exit level. If an individual has completed all or part of the basic 28-day program, a repeat of the program will be reimbursed with justification. The program will include an aftercare component meeting weekly for at least one year without charge. b. Eating disorders. (1) General characteristics. Eating disorders are characterized by gross disturbances in eating behavior. Eating disorders include anorexia nervosa or bulimia nervosa. Compulsive overeaters are not approved for this program. (2) Diagnostic and treatment staff. Each person who provides diagnostic or treatment services shall be determined to be competent to provide the services by reason of education, training, and experience.Professional disciplines that must be represented on the diagnostic and treatment staff, either through employment by a facility (full-time or part-time), contract or referral, are a physician (M.D. or D.O.), a licensed psychologist, a counselor with a master’s or bachelor’s degree and experience, a dietitian with a bachelor’s degree and registered dietitian’s certificate, and a licensed occupational therapist. The number of staff should be appropriate to the patient load of the facility. (3) Initial assessment. A comprehensive assessment of the biological, psychological, social, and family orientation of the patient must be conducted. The assessment must include a weight history and a history of the patient’s eating and dieting behavior, including binge eating, onset, patterns, and consequences. The assessment shall include the following: 1. A family history as well as self-assessment regarding chronic dieting, obesity, anorexia, bulimia, drug abuse, alcohol problems, depression, hospitalization for psychiatric reasons, and threatened or attempted suicide. 2. A history of purging behavior including frequency and history of vomiting, use of laxatives, history and frequency of use of diuretics, history and frequency of use of diet pills, ipecac, or any other weight control measures, and frequency of eating normal meals without vomiting. 3. A history of exercise behavior, including type, frequency, and duration. 4. A complete history of current alcohol and other drug use. 5. Any suicidal thoughts or attempts. 6. Sexual history, including sexual preference and activity. Sexual interest currently as compared to prior to the eating disorder is needed. 7. History of experiencing physical or sexual (incest or rape) abuse. 8. History of other counseling experiences. 9. Appropriate psychological assessment, including psychological orientation to the above questions. 10. A medical history, including a physical examination, covering the information listed in subparagraph 78.31(4)“b”(4). 11. Appropriate laboratory screening tests based on findings of the history and physical examination and tests for communicable diseases when indicated. 12. The patient’s social support networks, including family and peer relationships. 13. The patient’s educational level, vocational status, and job or school performance history, as appropriate. 14. The patient’s leisure, recreational, or vocational interests and hobbies. 15. The patient’s ability to participate with peers and programs and social activities. 16. Interview of family members and significant others as available with the patient’s written or verbal permission as appropriate. 17. Legal problems, if applicable. (4) Admission criteria. In order to be accepted for treatment, the patient shall meet the diagnostic criteria for anorexia nervosa or bulimia nervosa as established by the DSM (Diagnostic and Statistical Manual of Mental Disorders as amended to July 1, 2026) published by the American Psychiatric Association. In addition to the diagnostic criteria, the need for treatment will be determined by a demonstrable loss of control of eating behaviors and the failure of the patient in recent attempts at voluntary self-control of the problem. Demonstrable impairment, dysfunction, disruption or harm of physical health, emotional health (e.g., significant depression withdrawal, isolation, suicidal ideas), vocational or educational functioning, or interpersonal functioning (e.g., loss of relationships, legal difficulties) shall have occurred. The need for treatment may be further substantiated by substance use, out-of-control spending, incidence of stealing to support habit, or compulsive gambling. The symptoms shall have been present for at least six months and three of the following criteria must be present: 1. Medical criteria including endocrine and metabolic factors (e.g., amenorrhea, menstrual irregularities, decreased reflexes, cold intolerance, hypercarotenemia, parotid gland enlargement, lower respiration rate, hair loss, abnormal cholesterol or triglyceride levels). 2. Other cardiovascular factors including hypotension, hypertension, arrhythmia, ipecac poisoning, fainting, or bradycardia. 3. Renal considerations including diuretic abuse, dehydration, elevated BUN, renal calculi, edema, or hypokalemia. 4. Gastrointestinal factors including sore throats, Mallory-Weiss tears, decreased gastric emptying, constipation, abnormal liver enzymes, rectal bleeding, laxative abuse, or esophagitis. 5. Hematologic considerations including anemia, leukopenia, or thrombocytopenia. 6. Ear, nose, and throat factors including headaches or dizziness. 7. Skin considerations including lanugo or dry skin. 8. Aspiration pneumonia, a pulmonary factor.The presence of severe symptoms and complications as evaluated and documented by the medical director may require a period of hospitalization to establish physical or emotional stability. (5) Plan of treatment. For each patient, there is a written comprehensive and individualized description of treatment to be undertaken. The treatment plan is based on problems and needs identified in the assessment and specifies the regular times at which the plan will be reassessed to determine current clinical problems, needs, and responses to treatment. The plan shall document: 1. The patient’s perceptions of needs and, when appropriate and available, the family’s perceptions of the patient’s needs. 2. The patient’s participation in the development of the treatment plans. 3. Changes in treatment. (6) Discharge plan. Plans for discharge shall meet the requirements for discharge plans for alcohol and substance use patients in subparagraph 78.31(4)“a”(7). (7) Restriction and limitations on payment. Medicaid will pay for a maximum of 30 days of a structured outpatient treatment program. Payment beyond 30 days is made when documentation indicates that the patient has not reached an exit level.Eating disorder programs will include an aftercare component meeting weekly for at least one year without charge.Family counseling groups held in conjunction with the eating disorders program will be part of the overall treatment charge. c. Cardiac rehabilitation. (1) General characteristics. Cardiac rehabilitation programs shall provide a supportive educational environment in which to facilitate behavior change with respect to the accepted cardiac risk factors, initiate prescribed exercise as a mode of facilitating the return of the patient to everyday activities by improving cardiovascular functional capacity and work performance, and promote a long-term commitment to lifestyle changes that could positively affect the course of the cardiovascular disease process. (2) Treatment staff. Professional disciplines who must be represented on the treatment staff, either by employment by the facility (full-time or part-time), contract or referral, are as follows: 1. At least one physician, ARNP, or PA responsible for responding to emergencies must be physically present in the hospital when patients are receiving cardiac rehabilitation services. The physician, ARNP, or PA must be trained and certified at least to the level of basic life support. 2. A medical consultant shall oversee the policies and procedures of the outpatient cardiac rehabilitation area. The director shall meet with the cardiac rehabilitation staff on a regular basis to review exercise prescriptions and any concerns of the team. 3. A cardiac rehabilitation nurse shall carry out the exercise prescription after assessment of the patient. The nurse shall be able to interpret cardiac dysrhythmia and be able to initiate emergency action if necessary. The nurse shall assess and implement a plan of care for cardiac risk factor modification. The nurse shall have at least one year of experience in a coronary care unit. 4. A physical therapist shall offer expertise in unusual exercise prescriptions where a patient has an unusual exercise problem. 5. A dietitian shall assess the dietary needs of persons and appropriately instruct them on their prescribed diets. 6. A social worker shall provide counseling as appropriate and facilitate a spouse support group. A licensed occupational therapist shall be available as necessary. (3) Admission criteria. Candidates for the program must be referred by the attending physician. The following conditions are eligible for the program: 1. Postmyocardial infarction (within three months postdischarge). 2. Postcardiac surgery (within three months postdischarge). 3. Poststreptokinase. 4. Postpercutaneous transluminal angioplasty (within three months postdischarge). 5. Patient with severe angina being treated medically because of client or doctor preference or inoperable cardiac disease. (4) Physical environment and equipment. A cardiac rehabilitation unit must be an autonomous physical unit specifically equipped with the necessary telemetry monitoring equipment, exercise equipment, and appropriate equipment and supplies for cardiopulmonary resuscitation (CPR). The exercise equipment must have the capacity to measure the intensity, speed, and length of the exercises. The equipment must be periodically inspected and maintained in accordance with the hospital’s preventive maintenance program. (5) Medical records. Medical records for each cardiac rehabilitation patient shall consist of at least the following: 1. Referral form. 2. Physician’s orders. 3. Laboratory reports. 4. Electrocardiogram reports. 5. History and physical examination. 6. Angiogram report, if applicable. 7. Operative report, if applicable. 8. Preadmission interview. 9. Exercise prescription. 10. Rehabilitation plan, including participant’s goals. 11. Documentation for exercise sessions and progress notes. 12. Nurse’s progress reports. 13. Discharge instructions. (6) Discharge plan. The patient will be discharged from the program when the physician, staff, and patient agree that the work level is functional for them and little benefit could be derived from further continuation of the program, dysrhythmia disturbances are resolved, and appropriate cardiovascular response to exercise is accomplished. (7) Monitoring of services. The program should be monitored by the hospital on a periodic basis using measuring criteria for evaluating cardiac rehabilitation services provided. (8) Restrictions and limitations. Payment will be made for a maximum of three visits per week for a period of 12 weeks. Payment beyond 12 weeks is made when documentation indicates that the patient has not reached an exit level. d. Mental health. (1) General characteristics. To be covered, mental health services must be prescribed by a physician or certified health service provider in psychology, provided under an individualized treatment plan and reasonable and necessary for the diagnosis or treatment of the patient’s condition. This means the services must be for the purpose of diagnostic study or the services must reasonably be expected to improve the patient’s condition. (2) Individualized treatment plan. The individualized written plan of treatment shall be established by a physician or certified health service provider in psychology after any needed consultation with appropriate staff members. The plan must state the type, amount, frequency and duration of the services to be furnished and indicate the diagnoses and anticipated goals. (A plan is not required if only a few brief services will be furnished.) (3) Supervision and evaluation. Services must be supervised and periodically evaluated by a physician, certified health service provider in psychology, or both within the scopes of their respective practices if clinically indicated to determine the extent to which treatment goals are being realized. The evaluation must be based on periodic consultation and conference with therapists and staff. The physician or certified health service provider in psychology must also provide supervision and direction to any therapist involved in the patient’s treatment and see the patient periodically to evaluate the course of treatment and to determine the extent to which treatment goals are being realized and whether changes in direction or services are required. (4) Reasonable expectation of improvement. Services must be for the purpose of diagnostic study or reasonably be expected to improve the patient’s condition. The treatment must at a minimum be designed to reduce or control the patient’s psychiatric or psychological symptoms so as to prevent relapse or hospitalization and improve or maintain the patient’s level of functioning.It is not necessary that a course of therapy have as its goal restoration of the patient to the level of functioning exhibited prior to the onset of the illness although this may be appropriate for some patients. For many other patients, particularly those with long-term chronic conditions, control of symptoms and maintenance of a functional level to avoid further deterioration or hospitalization is an acceptable expectation of improvement. “Improvement” in this context is measured by comparing the effect of continuing versus discontinuing treatment. Where there is a reasonable expectation that if treatment services were withdrawn, the patient’s condition would deteriorate, relapse further, or require hospitalization, this criterion would be met. (5) Diagnostic and treatment staff. Each person who provides diagnostic or treatment services shall be determined to be competent to provide the services by reason of education, training, and experience. The number of the above staff employed by the facility must be appropriate to the facility’s patient load. The staff may be employees of the hospital, on contract, or the service may be provided through referral. The diagnostic and treatment staff shall consist of a physician, a psychologist, social workers or counselors meeting the requirements for “mental health professionals” as set forth in rule 441—24.1(225A). (6) Initial assessment. A comprehensive assessment of the biological, psychological, social, and spiritual orientation of the patient must be conducted, including: 1. A history of the mental health problem, including age of onset, duration, patterns of symptoms, consequences of symptoms, and responses to previous treatment. 2. A comprehensive clinical history, including the history of physical problems associated with the mental health problem. Appropriate referral for physical examination for determination of any communicable diseases. 3. Any history of physical abuse. 4. A systematic mental health examination, with special emphasis on any change in cognitive, social or emotional functioning. 5. A determination of current and past psychiatric and psychological abnormality. 6. A determination of any degree of danger to self or others. 7. The family’s history of mental health problems. 8. The patient’s educational level, vocational status, and job performance history. 9. The patient’s social support network, including family and peer relationship. 10. The patient’s perception of the patient’s strengths, problem areas, and dependencies. 11. The patient’s leisure, recreational or vocational interests and hobbies. 12. The patient’s ability to participate with peers in programs and social activities. 13. Interview of family members and significant others, as available, with the patient’s written or verbal permission. 14. Legal problems if applicable. (7) Covered services. Services covered for the treatment of psychiatric conditions are: 1. Individual and group therapy with physicians, psychologists, social workers, counselors, or psychiatric nurses. 2. Occupational therapy services if the services require the skills of a qualified occupational therapist and must be performed by or under the supervision of a licensed occupational therapist or by an occupational therapy assistant. 3. Drugs and biologicals furnished to outpatients for therapeutic purposes only if they are of the type that cannot be self-administered and are not “covered Part D drugs” as defined by 42 U.S.C. Section 1395w-102(e)(1)-(2) as amended to July 1, 2026, for a “Part D eligible individual” as defined in 42 U.S.C. Section 1395w-101(a)(3)(A) as amended to July 1, 2026, including an individual who is not enrolled in a Part D plan. 4. Activity therapies that are individualized and essential for the treatment of the patient’s condition. The treatment plan must clearly justify the need for each particular therapy utilized and explain how it fits into the patient’s treatment. 5. Family counseling services are covered only if the primary purpose of the counseling is the treatment of the patient’s condition. 6. Partial hospitalization and day treatment services to reduce or control a person’s psychiatric or psychological symptoms so as to prevent relapse or hospitalization, improve or maintain the person’s level of functioning and minimize regression. These services include all psychiatric services needed by the patient during the day.Partial hospitalization services means an active treatment program that provides intensive and structured support that assists persons during periods of acute psychiatric or psychological distress or during transition periods, generally following acute inpatient hospitalization episodes. Service components may include individual and group therapy, reality orientation, stress management and medication management. Services are provided for a period for four to eight hours per day. Day treatment services means structured, long-term services designed to assist in restoring, maintaining or increasing levels of functioning, minimizing regression and preventing hospitalization. Service components include training in independent functioning skills necessary for self-care, emotional stability and psychosocial interactions, and training in medication management. Services are structured with an emphasis on program variation according to individual need. Services are provided for a period of three to five hours per day, three or four times per week. 7. Partial hospitalization and day treatment for persons aged 20 or under. Payment to a hospital will be approved for day treatment services for persons aged 20 or under if the hospital is certified by the department for hospital outpatient mental health services. All conditions for the day treatment program for persons aged 20 or under as outlined in subrule 78.16(7) for community mental health centers shall apply to hospitals. All conditions of the day treatment program for persons aged 20 or under as outlined in subrule 78.16(7) for community mental health centers shall be applicable for the partial hospitalization program for persons aged 20 or under with the exception that the maximum hours shall be 25 hours per week. (8) Restrictions and limitations on coverage. The following are generally not covered, except as indicated: 1. Activity therapies, group activities, or other services and programs that are primarily recreational or diversional in nature. Outpatient psychiatric day treatment programs that consist entirely of activity therapies are not covered. 2. Geriatric day-care programs, which provide social and recreational activities to older persons who need some supervision during the day while other family members are away from home. These programs are not covered because they are not considered reasonable and necessary for a diagnosed psychiatric disorder. 3. Vocational training. While occupational therapy may include vocational and prevocational assessment of training, when the services are related solely to specific employment opportunities, work skills, or work setting, they are not covered. (9) Frequency and duration of services. There are no specific limits on the length of time that services may be covered. There are many factors that affect the outcome of treatment. Among them are the nature of the illness, prior history, the goals of treatment, and the patient’s response. As long as the evidence shows that the patient continues to show improvement in accordance with the individualized treatment plan and the frequency of services is within acceptable norms of medical practice, coverage will be continued. (10) Documentation requirements. The provider shall develop and maintain sufficient written documentation to support each medical or remedial therapy, service, activity, or session for which billing is made. All outpatient mental health services shall include: 1. The specific services rendered. 2. The date and actual time the services were rendered. 3. Who rendered the services. 4. The setting in which the services were rendered. 5. The amount of time it took to deliver the services. 6. The relationship of the services to the treatment regimen described in the plan of care. 7. Updates describing the patient’s progress.For services that are not specifically included in the patient’s treatment plan, a detailed explanation of how the services being billed relate to the treatment regimen and objectives contained in the patient’s plan of care and the reason for the departure from the plan shall be given. e. Pain management. (1) Approval by commission on accreditation of rehabilitation facilities. In addition to certification by the department, pain management programs must also be approved by the commission on accreditation of rehabilitation facilities (CARF). (2) General characteristics. A chronic pain management program shall provide coordinated, goal-oriented, interdisciplinary team services to reduce pain, improve quality of life, and decrease dependence on the health care system for persons with pain which interferes with physical, psychosocial, and vocational functioning. (3) Treatment staff. Each person who provides treatment services shall be determined to be competent to provide the services by reason of education, training, and experience. Professional disciplines which must be represented on the treatment staff, either through employment by the facility (full-time or part-time), contract or referral, are a physician (M.D. or D.O.), a registered nurse, a licensed physical therapist and a licensed clinical psychologist or psychiatrist. The number of staff should be appropriate to the patient load of the facility. (4) Admission criteria. Candidates for the program shall meet the following guidelines: 1. The person must have had adequate medical evaluation and treatment in the months preceding admission to the program including an orthopedic or neurological consultation if the problem is back pain or a neurological evaluation if the underlying problem is headaches. 2. The person must be free of any underlying psychosis or severe neurosis. 3. The person cannot be toxic on any addictive drugs. 4. The person must be capable of self-care, including being able to get to meals and to perform activities of daily living. (5) Plan of treatment. For each patient there is a written comprehensive and individualized description of treatment to be undertaken. The treatment plan is based on the problems and needs identified in the assessment and specifies the times at which the plan will be reassessed to determine current clinical problems, needs, and responses to treatment. The plan shall document: 1. The patient’s perception of needs and, when appropriate and available, the family’s perception of the patient’s needs. 2. The patient’s participation in the development of the treatment plan. 3. Changes in treatment are documented. (6) Discharge plan. For each patient before discharge, a plan for discharge is designed to provide appropriate continuity of care that meets the following requirements: 1. The plan for continuing care must describe and facilitate the transfer of the patient and the responsibility for the patient’s continuing care to another phase or modality of the program, other programs, agencies, persons or to the patient and the patient’s personal support system. 2. The plan is in accordance with the patient’s reassessed needs at the time of transfer. 3. The plan is developed in collaboration with the patient and, as appropriate and available, with the patient’s written verbal permission with the family members. 4. The plan is implemented in a manner acceptable to the patient and the need for confidentiality.Implementation of the plan includes timely and direct communication with and transfer of information to the other programs, agencies, or persons who will be providing continuing care. (7) Restrictions and limitations on payment. Medicaid will pay for a maximum of three weeks of a structured outpatient treatment program. When documentation indicates that the patient has not reached an exit level, coverage may be extended an extra week.A repeat of the entire program for any patient will be covered only if a different disease process is causing the pain or a significant change in life situation can be demonstrated. f. Diabetic education. (1) General characteristics. An outpatient diabetes self-management education program shall provide instruction that will enable people with diabetes and their families to understand the diabetes disease process and the daily management of diabetes. People with diabetes must learn to balance their special diet and exercise requirements with drug therapy (insulin or oral agents). They must learn self-care techniques such as monitoring their own blood glucose. And often, they must learn to self-treat insulin reactions, protect feet that are numb and have seriously compromised circulation, and accommodate their regimen to changes in blood glucose because of stress or infections. (2) Program staff. Each person who provides services shall be determined to be competent to provide the services by reason of education, training and experience. Professional disciplines which must be represented on the staff, either through employment by the facility (full-time or part-time), contract or referral, are a physician (M.D. or D.O.), a registered nurse, a registered dietitian and a licensed pharmacist. The number of staff should be appropriate to the patient load of the facility. (3) Admission criteria. Candidates for the program shall meet the following guidelines: 1. The person must have Type I or Type II diabetes. 2. The person must be referred by the attending physician. 3. The person shall demonstrate an ability to follow through with self-management. (4) Health assessment. An individualized and documented assessment of needs shall be developed with the patient’s participation. Follow-up assessments, planning and identification of problems shall be provided. (5) Restrictions and limitations on payment. Medicaid will pay for a diabetic self-management education program. Diabetic education programs will include follow-up assessments at 3 and 12 months without charge. g. Pulmonary rehabilitation. (1) General characteristics. Pulmonary rehabilitation is an individually tailored, multidisciplinary program through which accurate diagnosis, therapy, emotional support, and education stabilizes or reverses both the physio- and psychopathology of pulmonary diseases and attempts to return the patient to the highest possible functional capacity allowed by the pulmonary handicap and overall life situation. (2) Diagnostic and treatment staff. Each person who provides diagnostic or treatment services shall be determined to be competent to provide the services by reason of education, training, and experience.Professional disciplines that must be represented by the diagnostic and treatment staff, either through employment by the facility (full-time or part-time), contract, or referral, are a physician (doctor of medicine or osteopathy), a respiratory therapist, a licensed physical therapist, and a registered nurse. (3) Initial assessment. A comprehensive assessment must occur initially, including: 1. A diagnostic workup that entails proper identification of the patient’s specific respiratory ailment, appropriate pulmonary function studies, a chest radiograph, an electrocardiogram and, when indicated, arterial blood gas measurements at rest and during exercise, sputum analysis and blood theophylline measurements. 2. Behavioral considerations, including an emotional screening assessment and treatment or counseling when required, estimating the patient’s learning skills and adjusting the program to the patient’s ability, assessing family and social support, potential employment skills, employment opportunities, and community resources. (4) Admission criteria. Criteria include a patient’s being diagnosed and symptomatic of chronic obstructive pulmonary disease (COPD); having cardiac stability and social, family, and financial resources; having the ability to tolerate periods of sitting time; and being a nonsmoker for six months or, if a smoker, willingness to quit and having a physician’s order to participate anyway. Factors that would make a person ineligible include acute or chronic illness that may interfere with rehabilitation, any illness or disease state that affects comprehension or retention of information, a strong history of medical noncompliance, unstable cardiac or cardiovascular problems, and orthopedic difficulties that would prohibit exercise. (5) Plan of treatment. Individualized long- and short-term goals will be developed for each patient. The treatment goals will be based on the problems and needs identified in the assessment and specify the regular times at which the plan will be reassessed to determine current clinical problems, needs, and responses to treatment. The patients and their families need to help determine and fully understand the goals, so that they realistically approach the treatment phase. Changes in treatment must be documented. Components of pulmonary rehabilitation to be included are: 1. Physical therapy and relaxation techniques, 2. Exercise conditioning or physical conditioning for those with exercise limitations, 3. Respiratory therapy, education, an emphasis on the importance of smoking cessation, and 4. Nutritional information. (6) Discharge plan. Ongoing care will generally be the responsibility of the primary care physician. Periodic reassessment will be conducted to evaluate progress and allow for educational reinforcement. (7) Restrictions and limitations on payment. Medicaid will pay for a maximum of 25 treatment days. Payment beyond 25 days is made when documentation indicates that the patient has not reached an exit level. h. Nutritional counseling. Payment will be made for persons aged 20 and under for nutritional counseling provided by a licensed dietitian employed by or under contract with a hospital for a nutritional problem or condition of a degree of severity that nutritional counseling beyond that normally expected as part of the standard medical management is warranted. For persons eligible for the WIC program, a WIC referral is required. Medical necessity for nutritional counseling services exceeding those available through WIC shall be documented.Related ARC(s): 0315D441—78.32(249A) Area education agencies. Payment will be made for physical therapy, occupational therapy, psychological evaluations and counseling, psychotherapy, speech-language therapy, and audiological, nursing, and vision services provided by an area education agency (AEA). Services shall be provided directly by the AEA or through contractual arrangement with the AEA.Related ARC(s): 0315D441—78.33(249A) Case management services. Payment will be approved for targeted case management services that are provided pursuant to 441—Chapter 90 to:Members 16 to 18 years of age shall receive 24-hour site supervision and support. Members under the age of 18 may not reside in settings with individuals over the age of 21. The comprehensive service plan shall specifically identify educational services and supports for individuals who have not obtained a high school diploma or equivalent. For individuals who have obtained a high school diploma or equivalent, the comprehensive service plan shall include supported employment, additional training, or educational supports. 3. The member’s parent or guardian has consented to supported community living services. 4. The member is able to pay room and board costs (funding sources may include but are not limited to supplemental security income, child support, adoptions subsidy, or private funds). f. Youth under the age of 16 needing supported community living outside the family home must receive services in a licensed or certified residential-based supported community living setting. g. Maintenance and room and board costs are not reimbursable. h. Provider budgets shall reflect costs associated with members’ specific support needs as determined necessary by the interdisciplinary team for each member. The specific support needs must be identified in the Medicaid case manager’s service plan, and the provider must maintain records to support the expenditures. i. A unit of service is: (1) One full calendar day when a member receives on-site staff supervision for eight or more hours per day as an average over a calendar month and the member’s service plan identifies and reflects the need for this amount of supervision. (2) Fifteen minutes when subparagraph 78.41(1)“i”(1) does not apply. j. The maximum number of units available per member is as follows: (1) 365 daily units per state fiscal year, except a leap year, when 366 daily units are available. (2) 20,440 15-minute units per state fiscal year, except a leap year, when 20,496 15-minute units are available. k. The service shall be identified in the member’s service plan. l. Supported community living services will not be simultaneously reimbursed with other residential services or with respite, nursing, or home health aide services provided through Medicaid or the waiver. 78.41(2) Respite care services. Respite care services are services provided pursuant to subrule 78.34(5). 78.41(3) Personal emergency response or portable locator system. The personal emergency response or portable locator system are services provided pursuant to subrule 78.34(10). 78.41(4) Home and vehicle modification. Covered home or vehicle modifications are activities provided pursuant to subrule 78.34(9). 78.41(5) Nursing services. Nursing services are individualized in-home medical services provided by licensed nurses. Services shall exceed the Medicaid state plan services and be included in the member’s individual comprehensive plan. a. A unit of service is one hour. b. A maximum of ten units are available per week. 78.41(6) Home health aide services. Home health aide services are personal or direct care services provided to the member that are not payable under Medicaid as set forth in rule 441—78.9(249A). Services shall include unskilled medical services and shall exceed those services provided under HCBS intellectual disability waiver supported community living. Instruction, supervision, support or assistance in personal hygiene, bathing, and daily living shall be provided under supported community living. a. Services shall be included in the member’s service plan. b. A unit is one hour. c. A maximum of 14 units are available per week. 78.41(7) Supported employment services. Supported employment services are service activities provided pursuant to subrule 78.27(10). 78.41(8) Attendant care service. Attendant care services are service activities performed pursuant to subrule 78.34(7). 78.41(9) IMMT services. IMMT services are activities performed pursuant to subrule 78.34(8). 78.41(10) Residential-based supported community living services. Residential-based supported community living services are medical or remedial services provided to children under the age of 18 while living outside their home in a certified residential-based supported community living environment furnished by the residential-based supported community living service provider. The services eliminate barriers to family reunification or assist in developing self-help skills for maximum independence. a. Allowable service components are: (1) Daily living skills development. These are services to develop the child’s ability to function independently in the community on a daily basis, including training in food preparation, maintenance of living environment, time and money management, personal hygiene, and self-care. (2) Social skills development. These are services to develop a child’s communication and socialization skills, including interventions to develop a child’s ability to solve problems, resolve conflicts, develop appropriate relationships with others, and develop techniques for controlling behavior. (3) Family support development. These are services necessary to allow a child to return to the child’s family or another less restrictive service environment. These services must include counseling and therapy sessions that involve both the child and the child’s family at least 50 percent of the time and that focus on techniques for dealing with the special care needs of the child and interventions needed to alleviate behaviors that are disruptive to the family or other group living unit. (4) Counseling and behavior intervention services. These are services to halt, control, or reverse stress and social, emotional, or behavioral problems that threaten or have negatively affected the child’s stability. Activities under this service include counseling and behavior intervention with the child, including interventions to ameliorate problem behaviors. b. Residential-based supported community living services must also address the ordinary daily-living needs of the child, excluding room and board, such as needs for safety and security, social functioning, and other medical care. c. Residential-based supported community living services do not include services associated with vocational needs, academics, day care, Medicaid case management, other case management, or any other services that the child can otherwise obtain through Medicaid. d. Room and board costs are not reimbursable as residential-based supported community living services. e. The scope of service shall be identified in the child’s service plan pursuant to 441—paragraph 77.40(11)“d.” f. Residential-based supported community living services will not be simultaneously reimbursed with other residential services provided under an HCBS waiver or otherwise provided under the Medicaid program. g. A unit of service is a day. A day is 24 hours of supervision and support. h. The maximum number of units of residential-based supported community living services available per child is 365 daily units per state fiscal year, except in a leap year when 366 daily units are available. 78.41(11) Transportation. Transportation services may be provided for members to conduct business errands and essential shopping, to travel to and from work or day programs, and to reduce social isolation. A unit of service is one mile of transportation or one one-way trip. Transportation may not be reimbursed when HCBS intellectual disability waiver daily supported community living service is authorized in a member’s service plan. 78.41(12) Adult day care services. Adult day care services are activities provided pursuant to subrule 78.34(3). 78.41(13) Prevocational services. Prevocational services are service activities provided pursuant to subrule 78.27(9). 78.41(14) Day habilitation. Day habilitation services will be provided pursuant to subrule 78.27(8). 78.41(15) CCO. The CCO is service activities provided pursuant to subrule 78.34(13). 78.41(16) General service standards. All intellectual disability waiver services must be provided in accordance with the following standards: a. Reimbursement will not be available under the waiver for any services the member can obtain as other nonwaiver Medicaid services or through any other funding source. b. All services provided under the waiver must be delivered in the least restrictive environment possible and in conformity with the member’s service plan. c. All rights restrictions must be implemented in accordance with 441—subrule 77.30(4). d. Services must be billed in whole units. e. For all services with a 15-minute unit of service, the rounding process outlined in paragraph 78.34(14)“e” will apply.Related ARC(s): 0315D441—78.42(249A) Pharmacists providing covered vaccines. When the authorized pharmacist providing the vaccine meets all Iowa board of pharmacy expanded practice standards and Medicaid requirements, payment will be made for the following: 78.42(1) Vaccines administered to children. Payment will be made to an enrolled provider for an administration fee for vaccines available through the VFC program administered by the department if the provider is enrolled in the VFC program. Payment will be made for the vaccine cost only if the VFC program stock has been depleted. 78.42(2) Vaccines administered to adults. Payment will be made to an enrolled provider for an administration fee and vaccine cost. 78.42(3) Verification and reporting. Prior to the ordering and administration of an immunization pursuant to statewide protocol, the authorized pharmacist shall consult and review the Iowa Immunization Registry Information System (IRIS) or Iowa Health Information Network (IHIN). Within 30 calendar days following administration of any vaccine, the pharmacist shall report such administration to the patient’s primary health care provider, primary physician, and IRIS or IHIN. If a patient does not have a primary health care provider, the pharmacist shall provide the patient with a written record of the vaccine administered to the patient and shall advise the patient to consult a physician.Related ARC(s): 0315D441—78.43(249A) HCBS brain injury waiver services. Payment will be approved for the following services to members eligible for the HCBS brain injury waiver services as established in 441—Chapter 83 and as identified in the member’s service plan. Payment will only be made for services provided in integrated, community-based settings that support full access of members receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS. 78.43(1) Case management services. Individual case management services means services that assist members who reside in a community setting or are transitioning to a community setting in gaining access to needed medical, social, educational, housing, transportation, vocational, and other appropriate services in order to ensure the health, safety, and welfare of the member. a. Case management services shall be provided as set forth in rules 441—90.4(249A) through 441—90.7(249A). b. The service shall be delivered in such a way as to enhance the capabilities of members and their families to exercise their rights and responsibilities as citizens in the community. The goal is to enhance the ability of the member to exercise choice, make decisions, take risks that are a typical part of life, and fully participate as members of the community. c. The case manager must develop a relationship with the member so that the abilities, needs and desires of the member can be clearly identified and communicated and the case manager can help to ensure that the system and specific services are responsive to the needs of the individual members. d. Members who are eligible for targeted case management are not eligible for case management as a waiver service. 78.43(2) Supported community living services. Supported community living services are provided by the provider within the member’s home and community according to the individualized member need as identified in the service plan. a. The basic components of the service may include but are not limited to personal and home skills training services, individual advocacy services, community skills training services, personal environment support services, transportation, and treatment services. (1) Personal and home skills training services are activities that assist a member to develop or maintain skills for self-care, self-directedness, and care of the immediate environment. (2) Individual advocacy is the act or process of representing the member’s rights and interests in order to realize the rights to which the member is entitled and to remove barriers to meeting the member’s needs. (3) Community skills training services are activities that assist a member to develop or maintain skills allowing better participation in the community. Services shall focus on the following areas as they apply to the member being served: 1. Personal management skills training services are activities that assist a member to maintain or develop skills necessary to sustain the member in the physical environment and that are essential to the management of the member’s personal business and property. This includes self-advocacy skills. Examples of personal management skills are the ability to maintain a household budget, plan and prepare nutritional meals, use community resources such as public transportation and libraries, and select foods at the grocery store. 2. Socialization skills training services are activities that assist a member to develop or maintain skills that include self-awareness and self-control, social responsiveness, community participation, social amenities, and interpersonal skills. 3. Communication skills training services are activities that assist a member to develop or maintain skills, including expressive and receptive skills in verbal and nonverbal language and the functional application of acquired reading and writing skills. (4) Personal and environmental support services are those activities and expenditures provided to or on behalf of a member in the areas of personal needs in order to allow the member to function in the least restrictive environment. (5) Transportation services are activities and expenditures designed to assist the member to travel from one place to another to obtain services or carry out life’s activities. The services exclude transportation provided as nonemergency medical transportation pursuant to rule 441—78.13(249A). (6) Treatment services are activities designed to assist the member to maintain or improve physiological, emotional and behavioral functioning and to prevent conditions that would present barriers to the member’s functioning. Treatment services include physical or physiological treatment and psychotherapeutic treatment. 1. Physiological treatment includes medication regimens designed to prevent, halt, control, relieve, or reverse symptoms or conditions which interfere with the normal functioning of the human body. Physiological treatment shall be provided by or under the direct supervision of a certified or licensed health care professional. 2. Psychotherapeutic treatment means activities provided to assist a member in the identification or modification of beliefs, emotions, attitudes, or behaviors in order to maintain or improve the member’s functioning in response to the physical, emotional, and social environment. b. The supported community living services are intended to provide for the daily living needs of the member and shall be available as needed during any 24-hour period. Activities do not include those associated with vocational services, academics, day care, medical services, Medicaid case management or other case management. Services are individualized supportive services provided in a variety of community-based, integrated settings. (1) Supported community living services shall be available at a daily rate to members living outside the home of their family, legal representative, or foster family and for whom a provider has primary responsibility for supervision or structure during the month. This service shall provide supervision or structure in identified periods when another resource is not available. (2) Supported community living services shall be available at a 15-minute rate to members for whom a daily rate is not established. c. Services may be provided to a child or an adult. Children must first access all other services for which they are eligible and that are appropriate to meet their needs before accessing the HCBS brain injury waiver services. A maximum of four persons may reside in a living unit. (1) A member may live in the home of the member’s family or legal representative or in another typical community living arrangement. (2) A member living with the member’s family or legal representative is not subject to the maximum of four residents in a living unit. (3) A member may not live in a licensed medical or health care facility or in a setting that is required to be licensed as a medical or health care facility. d. A member aged 17 or under living in the home of the member’s family, legal representative, or foster family shall receive services based on development of adaptive, behavior, or health skills. Duration of services shall be based on age-appropriateness and individual attention span. e. Provider budgets shall reflect all staff-to-member ratios and shall reflect costs associated with members’ specific support needs for travel and transportation, consulting, instruction, and environmental modifications and repairs, as determined necessary by the interdisciplinary team for each member. The specific support needs must be identified in the Medicaid case manager’s service plan, the total costs shall not exceed $1,570 per member per year, and the provider must maintain records to support the expenditures. A unit of service is: (1) One full calendar day when a member residing in the living unit receives on-site staff supervision for eight or more hours per day as an average over a calendar month and the member’s service plan identifies and reflects the need for this amount of supervision. (2) Fifteen minutes when subparagraph 78.43(2)“e”(1) does not apply. f. The maximum number of units available per member is as follows: (1) 365 daily units per state fiscal year except a leap year, when 366 daily units are available. (2) 33,580 15-minute units per state fiscal year except a leap year, when 33,672 15-minute units are available. g. The service shall be identified in the member’s service plan. h. Supported community living services shall not be simultaneously reimbursed with other residential services or with respite, transportation, personal assistance, nursing, or home health aide services provided through Medicaid or the HCBS brain injury waiver. 78.43(3) Respite care services. Respite care services are services provided to the member that give temporary relief to the usual caregiver and provide all the necessary care that the usual caregiver would provide during that period. The purpose of respite care is to enable the member to remain in the member’s current living situation. a. Services provided outside the member’s home shall not be reimbursable if the living unit where respite is provided is reserved for another person on a temporary leave of absence. b. Member-to-staff ratios shall be appropriate to the individual needs of the member as determined by the member’s interdisciplinary team. c. A unit of service is 15 minutes. d. Respite care is not to be provided to members during the hours in which the usual caregiver is employed except when the member is attending a 24-hour residential camp. Respite care shall not be used as a substitute for a child’s day care. Respite care cannot be provided to a member whose usual caregiver is an attendant care provider for the member. e. The interdisciplinary team shall determine if the member will receive basic individual respite, specialized respite or group respite as defined in 441—Chapter 83. f. A maximum of 14 consecutive days of 24-hour respite care may be reimbursed. g. Respite services provided for a period exceeding 24 consecutive hours to three or more individuals who require nursing care because of a mental or physical condition must be provided by a health care facility licensed as described in Iowa Code chapter 135C. h. Respite services shall not be provided simultaneously with other residential, supported community living services, nursing, or home health aide services provided through the medical assistance program. 78.43(4) Supported employment services. Supported employment services are service activities provided pursuant to subrule 78.27(10). 78.43(5) Home and vehicle modification. Covered home or vehicle modifications are activities provided pursuant to subrule 78.34(9). 78.43(6) Personal emergency response or portable locator system. A personal emergency response or portable locator system are services provided pursuant to subrule 78.34(10). 78.43(7) Transportation. Transportation services may be provided for members to conduct business errands and essential shopping, to travel to and from work or day programs, and to reduce social isolation. A unit of service is one mile of transportation or one one-way trip. Transportation may not be reimbursed simultaneously with HCBS brain injury waiver supported community living service when the transportation costs are included within the supported community living reimbursement rate. 78.43(8) Specialized medical equipment. a. Specialized medical equipment includes medically necessary items that are for personal use by members with a brain injury and that: (1) Provide for health and safety of the member, (2) Are not ordinarily covered by Medicaid, (3) Are not funded by educational or vocational rehabilitation programs, and (4) Are not provided by voluntary means. b. Coverage includes but is not limited to: (1) Electronic aids and organizers. (2) Medicine dispensing devices. (3) Communication devices. (4) Bath aids. (5) Noncovered environmental control units. (6) Repair and maintenance of items purchased through the waiver. c. Payment may be made to enrolled specialized medical equipment providers upon satisfactory receipt of the service not to exceed the service limitations published on the Iowa Medicaid fee schedule webpage. d. The need for specialized medical equipment shall be: (1) Documented by a health care professional as necessary for the member’s health and safety, and (2) Identified in the member’s service plan. e. Payment for most items will be based on a fee schedule. The amount of the fee will be determined as directed in 441—subrule 79.1(17). 78.43(9) Adult day care services. Adult day care services are activities provided pursuant to subrule 78.34(3). 78.43(10) Family counseling and training services. Family counseling and training services are face-to-face mental health services provided to the member and the family with whom the member lives, or who routinely provide care to the member to increase the member’s or family members’ capabilities to maintain and care for the member in the community. Counseling may include helping the member or the member’s family members with crisis, coping strategies, stress reduction, management of depression, alleviation of psychosocial isolation and support in coping with the effects of a brain injury. It may include the use of treatment regimens as specified in the individual treatment plan. Periodic training updates may be necessary to safely maintain the member in the community.Family may include spouse, children, friends, or in-laws of the member. Family does not include individuals who are employed to care for the member. 78.43(11) Prevocational services. Prevocational services are service activities provided pursuant to subrule 78.27(9). 78.43(12) Behavioral programming. Behavioral programming consists of individually designed strategies to increase the member’s appropriate behaviors and decrease the member’s maladaptive behaviors which have interfered with the member’s ability to remain in the community. Behavioral programming includes: a. A complete assessment of both appropriate and maladaptive behaviors. b. Development of a structured behavioral intervention plan which should be identified in the individual treatment plan. 78.43(13) Attendant care service. Attendant care services are service activities performed pursuant to subrule 78.34(7). 78.43(14) IMMT services. IMMT services are activities performed pursuant to subrule 78.34(8). 78.43(15) CCO. The CCO is service activities provided pursuant to subrule 78.34(13). 78.43(16) General service standards. All brain injury waiver services must be provided in accordance with the following standards: a. Reimbursement will not be available under the waiver for any services that the member can obtain as other nonwaiver Medicaid services or through any other funding source. b. All services provided under the waiver must be delivered in the least restrictive environment possible and in conformity with the member’s service plan. c. All rights restrictions must be implemented in accordance with 441—subrule 77.30(4). d. Services must be billed in whole units. e. For all services with a 15-minute unit of service, the rounding process outlined in paragraph 78.34(14)“e” will apply.Related ARC(s): 0315D441—78.44(249A) Lead inspection services. Payment will be approved for lead inspection services. This service shall be provided for children who have had two venous blood lead levels of 15 to 19 micrograms per deciliter or one venous level greater than or equal to 20 micrograms per deciliter. This service includes, but is not limited to, X-ray fluorescence analyzer (XRF) readings, visual examination of paint, preventive education of the resident and homeowner, health education about lead poisoning, and a written report to the family, homeowner, medical provider, and local childhood lead poisoning prevention program.Related ARC(s): 0315D441—78.45(249A) Assertive community treatment. Assertive community treatment (ACT) services are comprehensive, integrated, and intensive outpatient services provided by a multidisciplinary team under the supervision of a psychiatrist. ACT services are directed toward the rehabilitation of behavioral, social, or emotional deficits or the amelioration of symptoms of a mental disorder. Most services are delivered in the member’s home or another community setting. 78.45(1) Applicability. ACT services may be provided only to a member who meets all of the following criteria: a. The member is at least 17 years old. b. The member has a severe and persistent mental illness or complex mental health symptomatology. A severe and persistent mental illness is a psychiatric disorder that causes symptoms and impairments in basic mental and behavioral processes that produce distress and major functional disability in adult role functioning (such as social, personal, family, educational or vocational roles). Specifically, the member has a degree of impairment arising from a psychiatric disorder such that: (1) The member does not have the resources or skills necessary to maintain an adequate level of functioning in the home or community environment without assistance or support; (2) The member’s judgment, impulse control, or cognitive perceptual abilities are compromised; and (3) The member exhibits significant impairment in social, interpersonal, or familial functioning. c. The member has a validated principal mental health diagnosis consistent with a severe and persistent mental illness. For this purpose, a mental health diagnosis means a disorder, dysfunction, or dysphoria diagnosed pursuant to the DSM, excluding neurodevelopmental disorders, substance-related disorders, personality disorders, medication-induced movement disorders and other adverse effects of medication, and other conditions that may be a focus of clinical attention. Members with a primary diagnosis of substance-related disorder, developmental disability, or organic disorder are not eligible for ACT services. d. The member needs a consistent team of professionals and multiple mental health and support services to maintain the member in the community and reduce hospitalizations, as evidenced by: (1) A pattern of repeated treatment failures with at least two hospitalizations within the previous 24 months, or (2) A need for multiple or combined mental health and basic living supports to prevent the need for a more intrusive level of care. e. The member presents a reasonable likelihood that ACT services will lead to specific, observable improvements in the member’s functioning and assist the member in achieving or maintaining community tenure. Specifically, the member: (1) Is medically stable; (2) Does not require a level of care that includes more intensive medical monitoring; (3) Presents a low risk to self, others, or property, with treatment and support; and (4) Lives independently in the community or demonstrates a capacity to live independently and move from a dependent residential setting to independent living. f. At the time of admission, the member has a comprehensive assessment that includes psychiatric history, medical history, work and educational history, substance use, problems with activities of daily living, social interests, and family relationships. g. The member has a written treatment plan containing a work evaluation and the necessary psychiatric rehabilitation treatment and support services. The plan shall identify: (1) Treatment objectives and outcomes, (2) The expected frequency and duration of each service, (3) The location where the services will be provided, (4) A crisis plan, and (5) The schedule for updates of the treatment plan. 78.45(2) Services. The ACT team shall participate in all mental health services provided to the member and shall provide 24-hour service for the psychiatric needs of the member. Available ACT services are: a. Evaluation and medication management. (1) The evaluation portion of ACT services consists of a comprehensive mental health evaluation and assessment of the member by a psychiatrist, ARNP, or PA. (2) Medication management consists of the prescription and management of medication by a psychiatrist, ARNP, or PA to respond to the member’s complaints and symptoms. A psychiatric registered nurse assists in this management by contact with the member regarding medications and their effect on the member’s complaints and symptoms. b. Integrated therapy and counseling for mental health and substance use. This service consists of direct counseling for treatment of mental health and substance use symptoms by a psychiatrist, licensed mental health professional, ARNP, PA, or substance use specialist. Individual counseling is provided by other team members under the supervision of a psychiatrist or licensed mental health practitioner. c. Skill teaching. Skill teaching consists of side-by-side demonstration and observation of daily living activities by a registered nurse, licensed mental health professional, psychologist, substance use counselor, peer specialist, community support specialist, ARNP, or PA. d. Community support. Community support is provided by a licensed mental health professional, psychologist, substance use counselor, peer specialist, community support specialist, ARNP, or PA. Community support consists of the following activities focused on recovery and rehabilitation: (1) Personal and home skills training to assist the member to develop and maintain skills for self-direction and coping with the living situation. (2) Community skills training to assist the member in maintaining a positive level of participation in the community through development of socialization skills and personal coping skills. e. Medication monitoring. Medication monitoring services are provided by a psychiatric nurse and other team members under the supervision of a psychiatrist or psychiatric nurse and consist of: (1) Monitoring the member’s day-to-day functioning, medication compliance, and access to medications; and (2) Ensuring that the member keeps appointments. f. Case management for treatment and service plan coordination. Case management consists of the development by the ACT team of an individualized treatment and service plan, including personalized goals and outcomes, to address the member’s medical symptoms and remedial functional impairments. (1) Case management includes: 1. Assessments, referrals, follow-up, and monitoring. 2. Assisting the member in gaining access to necessary medical, social, educational, and other services. 3. Assessing the member to determine service needs by collecting relevant historical information through member records and other information from relevant professionals and natural supports. (2) The team shall: 1. Develop a specific care plan based on the assessment of needs, including goals and actions to address the needed medical, social, educational, and other necessary services. 2. Make referrals to services and related activities to assist the member with the assessed needs. 3. Monitor and perform follow-up activities necessary to ensure that the plan is carried out and that the member has access to necessary services. Activities may include monitoring contacts with providers, family members, natural supports, and others. 4. Hold daily team meetings to facilitate ACT services and coordinate the member’s care with other members of the team. g. Crisis response. Crisis response consists of direct assessment and treatment of the member’s urgent or crisis symptoms in the community by a registered nurse, licensed mental health professional, psychologist, substance use counselor, community support specialist, case manager, ARNP, or PA, as appropriate. h. Work-related services. Work-related services may be provided by a registered nurse, licensed mental health professional, psychologist, substance use counselor, community support specialist, case manager, ARNP, or PA. Services consist of assisting the member in managing mental health symptoms as they relate to job performance. Services may include: (1) Collaborating with the member to look for job situations that may cause symptoms to increase and creating strategies to manage these situations. (2) Assisting the member to develop or enhance skills to obtain a work placement, such as individual work-related behavioral management. (3) Providing supports to maintain employment, such as crisis intervention related to employment. (4) Teaching communication, problem solving, and safety skills. (5) Teaching personal skills such as time management and appropriate grooming for employment.Related ARC(s): 0315D441—78.46(249A) Physical disability waiver service. Payment will be approved for the following services to members eligible for the HCBS physical disability waiver as established in 441—Chapter 83 and as identified in the member’s service plan. Payment will only be made for services provided in integrated, community-based settings that support full access of members receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS. 78.46(1) Attendant care service. Attendant care services are service activities performed pursuant to subrule 78.34(7). 78.46(2) Home and vehicle modification. Covered home or vehicle modifications are activities provided pursuant to subrule 78.34(9). 78.46(3) Personal emergency response or portable locator system. A personal emergency response or portable locator are services provided pursuant to subrule 78.34(10). 78.46(4) Specialized medical equipment. Specialized medical equipment are provided pursuant to subrule 78.43(8). 78.46(5) Transportation. Transportation services may be provided for members to conduct business errands and essential shopping, to travel to and from work or day programs, and to reduce social isolation. A unit of service is one mile of transportation or one one-way trip. 78.46(6) CCO. The CCO is service activities provided pursuant to subrule 78.34(13). 78.46(7) General service standards. All physical disability waiver services must be provided in accordance with the following standards: a. Reimbursement will not be available under the waiver for any services that the member can obtain as other nonwaiver Medicaid services or through any other funding source. b. All services provided under the waiver must be delivered in the least restrictive environment possible and in conformity with the member’s service plan. c. All rights restrictions must be implemented in accordance with 441—subrule 77.30(4). d. Services must be billed in whole units. e. For all services with a 15-minute unit of service, the rounding process outlined in paragraph 78.34(14)“e” will apply.Related ARC(s): 0315D441—78.47(249A) Pharmaceutical case management services. Payment will be approved for pharmaceutical case management services provided by an eligible physician and pharmacist for Medicaid recipients determined to be at high risk for medication-related problems. These services are designed to identify, prevent, and resolve medication-related problems and improve drug therapy outcomes. 78.47(1) Medicaid recipient eligibility. Patients are eligible for pharmaceutical case management services if they have active prescriptions for four or more regularly scheduled nontopical medications, are ambulatory, do not reside in a nursing facility, and have at least one of the eligible disease states of congestive heart disease, ischemic heart disease, diabetes mellitus, hypertension, hyperlipidemia, asthma, depression, atrial fibrillation, osteoarthritis, gastroesophageal reflux, or chronic obstructive pulmonary disease. 78.47(2) Provider eligibility. Physicians and pharmacists shall meet the following criteria to provide pharmaceutical case management services. a. Physicians and pharmacists must be enrolled in the Iowa Medicaid program, have an Iowa Medicaid provider number, and receive training under the direction of the department regarding the provision of pharmaceutical case management services under the Iowa Medicaid program.A copy of pharmaceutical case management records, including documentation of services provided, shall be maintained on file in each provider’s facility and be made available for audit by the department on request. b. Physicians shall be licensed to practice medicine. c. Pharmacists shall present to the department evidence of competency including state licensure, submit five acceptable patient care plans, and have successfully completed professional training on patient-oriented, medication-related problem prevention and resolution. Pharmacists shall also maintain problem-oriented patient records, provide a private patient consultation area, and submit a statement indicating that the submitted patient care plans are representative of the pharmacists’ usual patient care plans.Acceptable professional training programs are: (1) A doctor of pharmacy degree program. (2) The Iowa Center for Pharmaceutical Care (ICPC) training program, which is a cooperative training initiative of the University of Iowa College of Pharmacy, Drake University College of Pharmacy and Health Sciences, and the Iowa Pharmacy Foundation. (3) Other programs containing similar coursework and supplemental practice site evaluation and reengineering, approved by the department with input from a peer review advisory committee. 78.47(3) Services. Eligible patients may choose whether to receive the services. If patients elect to receive the services, they must receive the services from any eligible physician and pharmacist acting as a pharmaceutical case management (PCM) team. Usually the eligible physician and pharmacist will be the patient’s primary physician and pharmacist. Pharmaceutical case management services are to be value-added services complementary to the basic medical services provided by the primary physician and pharmacist.The PCM team shall provide the following services: a. Initial assessment. The initial assessment shall consist of: (1) A patient evaluation by the pharmacist, including: 1. Medication history; 2. Assessment of indications, effectiveness, safety, and compliance of medication therapy; 3. Assessment for the presence of untreated illness; and 4. Identification of medication-related problems such as unnecessary medication therapy, suboptimal medication selection, inappropriate compliance, adverse drug reactions, and need for additional medication therapy. (2) A written report and recommendation from the pharmacist to the physician. (3) A patient care action plan developed by the PCM team with the patient’s agreement and implemented by the PCM team. Specific components of the action plan will vary based on patient needs and conditions but may include changes in medication regimen, focused patient or caregiver education, periodic assessment for changes in the patient’s condition, periodic monitoring of the effectiveness of medication therapy, self-management training, provision of patient-specific educational and informational materials, compliance enhancement, and reinforcement of healthy lifestyles. An action plan must be completed for each initial assessment. b. New problem assessments. These assessments are initiated when a new medication-related problem is identified. The action plan is modified and new components are implemented to address the new problem. This assessment may occur in the interim between scheduled follow-up assessments. c. Problem follow-up assessments. These assessments are based on patient need and a problem identified by a prior assessment. The patient’s status is evaluated at an appropriate interval. The effectiveness of the implemented action plan is determined and modifications are made as needed. d. Preventive follow-up assessments. These assessments occur approximately every six months when no current medication-related problems have been identified in prior assessments. The patient is reassessed for newly developed medication-related problems and the action plan is reviewed.Related ARC(s): 0315D441—78.48(249A) Public health agencies. Payments will be made to local public health agencies on a fee schedule basis for providing vaccine and vaccine administration and testing for communicable disease. In order to be paid for the administration of a vaccine covered under the VFC program, a public health agency must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted.Related ARC(s): 0315D441—78.49(249A) Infant and toddler program services. Subject to the following subrules, payment will be made for medical services provided to Medicaid eligible children by infant and toddler program providers under the infants and toddlers with disabilities program administered by the department, Iowa child health specialty clinics, and the department of education. 78.49(1) Covered services. Covered services include but are not limited to audiology, psychological evaluation and counseling, health and nursing services, nutrition services, occupational therapy services, physical therapy services, developmental services, speech-language services, vision services, case management, and medical transportation. 78.49(2) Case management services. Payment will also be approved for infant and toddler case management services subject to the following requirements: a. Definition. “Case management” means services that will assist eligible children in gaining access to needed medical, social, educational, and other services. Case management is intended to address the complexities of coordinated service delivery for children with medical needs. The case manager should be the focus for coordinating and overseeing the effectiveness of all providers and programs in responding to the assessed need. Case management does not include the direct delivery of an underlying medical, educational, social, or other service to which an eligible child has been referred or any activities that are an integral part or an extension of the direct services. b. Choice of provider. Children who also are eligible to receive targeted case management services under 441—Chapter 90 must choose whether to receive case management through the infant and toddler program or through 441—Chapter 90. The chosen provider must meet the requirements of this subrule. (1) When a child resides in a medical institution, the institution is responsible for case management. The child is not eligible for any other case management services. However, noninstitutional case management services may be provided during the last 14 days before the child’s planned discharge if the child’s stay in the institution has been less than 180 consecutive days. If the child has been in the institution 180 consecutive days or longer, the child may receive noninstitutional case management services during the last 60 days before the child’s planned discharge. (2) If the case management agency also provides direct services, the case management unit must be designed so that conflict of interest is addressed and does not result in self-referrals. (3) If the costs of any part of case management services are reimbursable under another program, the costs must be allocated between those programs and Medicaid in accordance with OMB Circular No. A-87 as amended to July 1, 2026, or any related or successor guidance or regulations regarding allocation of costs. (4) The case manager must complete a competency-based training program with content related to knowledge and understanding of eligible children, Early ACCESS rules, the nature and scope of services in Early ACCESS, and the system of payments for services, as well as case management responsibilities and strategies. The department of education or its designee will determine whether a person has successfully completed the training. c. Assessment. The case manager shall conduct a comprehensive assessment and periodic reassessment of an eligible child to identify all of the child’s service needs, including the need for any medical, educational, social, or other services. Assessment activities are defined to include the following: (1) Taking the child’s history; (2) Identifying the needs of the child; (3) Gathering information from other sources, such as family members, medical providers, social workers, and educators, if necessary, to form a complete assessment of the child; (4) Completing documentation of the information gathered and the assessment results; and (5) Repeating the assessment every six months to determine whether the child’s needs or preferences have changed. d. Plan of care. The case manager shall develop a plan of care based on the information collected through the assessment or reassessment. The plan of care shall: (1) Include the child’s strengths and preferences; (2) Consider the child’s physical and social environment; (3) Specify goals of providing services to the child; and (4) Specify actions to address the child’s medical, social, educational, and other service needs. These actions may include activities such as ensuring the active participation of the child and working with the child or the child’s authorized health care decision maker and others to develop goals and identify a course of action to respond to the assessed needs of the child. e. Other service components. Case management must include the following components: (1) Contacts with the child and family. The case manager shall have face-to-face contact with the child and family within the first 30 days of service and every three months thereafter. In months in which there is no face-to-face contact, a telephone contact between the service coordinator and the family is required. (2) Referral and related activities to help a child obtain needed services. The case manager shall help to link the child with medical, social, or educational providers or other programs and services that are capable of providing needed services. Referral activities do not include provision of the direct services, program, or activity to which the child has been linked. Referral activities include: 1. Assisting the family in gaining access to the infant and toddler program services and other services identified in the child’s plan of care. 2. Assisting the family in identifying available service providers and funding resources and documenting unmet needs and gaps in services. 3. Making referrals to providers for needed services. 4. Scheduling appointments for the child. 5. Facilitating the timely delivery of services. 6. Arranging payment for medical transportation. (3) Monitoring and follow-up activities. Monitoring activities shall take place at least once annually for the duration of the child’s eligibility, but may be conducted as frequently as necessary to ensure that the plan of care is effectively implemented and adequately addresses the needs of the child. Monitoring and follow-up activities may be with the child, family members, providers, or other entities. The purpose of these activities is to help determine: 1. Whether services are being furnished in accordance with the child’s plan of care. 2. Whether the services in the plan of care are adequate to meet the needs of the child. 3. Whether there are changes in the needs or status of the child. If there are changes in the child’s needs or status, follow-up activities shall include making necessary adjustments to the plan of care and to service arrangements with providers. (4) Keeping records, including preparing reports, updating the plan of care, making notes about plan activities in the child’s record, and preparing and responding to correspondence with the family and others. f. Documentation of case management. For each child receiving case management, case records must document: (1) The name of the child; (2) The dates of case management services; (3) The agency chosen by the family to provide the case management services; (4) The nature, content, and units of case management services received; (5) Whether the goals specified in the care plan have been achieved; (6) Whether the family has declined services in the care plan; (7) Time lines for providing services and reassessment; and (8) The need for and occurrences of coordination with case managers of other programs. 78.49(3) Child’s eligibility. Payable services must be provided to a child under the age of 36 months who is experiencing developmental delay or who has a condition that is known to have a high probability of resulting in developmental delay at a later date. 78.49(4) Delivery of services. Services must be delivered directly by the infant and toddler program provider or by a practitioner under contract with the infant and toddler program provider. 78.49(5) Remission of nonfederal share of costs. Payment for services shall be made only when the following conditions are met: a. The infant and toddler program provider has executed an agreement to remit the nonfederal share of the cost to the department. b. The infant and toddler program provider shall sign and return a Medicaid Billing Remittance form along with the funds remitted for the nonfederal share of the costs of the services specified on the form.Related ARC(s): 0315D441—78.50(249A) Local education agency services. Subject to the following subrules, payment will be made for medical services provided by local education agency services providers to Medicaid members under the age of 21. 78.50(1) Covered services. Covered services include but are not limited to audiology services, behavior services, consultation services, medical transportation, nursing services, nutrition services, occupational therapy services, personal assistance, physical therapy services, psychologist services, speech-language services, social work services, vision services, and school-based clinic visit services. a. In order to be paid for the administration of a vaccine covered under the VFC program, a local education agency must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted. b. Payment for supplies will be approved when the supplies are incidental to the patient’s care, e.g., syringes for injections, and do not exceed $25 per month. Durable medical equipment and other supplies are not covered as local education agency services. c. To the extent that federal funding is not available under Title XIX of the Social Security Act as amended to July 1, 2026, payment for transportation between home and school is not a covered service. 78.50(2) Delivery of services. Services must be delivered directly by the local education agency services providers or by a practitioner under contract with the local education agency services provider. 78.50(3) Remission of nonfederal share of costs. Payment for services shall be made only when the following conditions are met: a. The local education agency services provider has executed an agreement to remit the nonfederal share of the cost to the department. b. The local education agency provider shall sign and return a Medicaid Billing Remittance form along with the funds remitted for the nonfederal share of the costs of the services as specified on the form.Related ARC(s): 0315D441—78.51(249A) Indian health service 638 facility services. Payment will be made for all medically necessary services and supplies provided by a licensed practitioner at an Indian health service 638 facility, as defined at rule 441—77.47(249A), within the practitioner’s scope of practice and subject to the limitations and exclusions set forth in subrule 78.1(1).Related ARC(s): 0315D441—78.52(249A) HCBS children’s mental health waiver services. Payment will be approved for the following services to members eligible for the HCBS children’s mental health waiver as established in 441—Chapter 83 and as identified in the member’s service plan. Payment will only be made for services provided in integrated, community-based settings that support full access of members receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS. 78.52(1) General service standards. All children’s mental health waiver services must be provided in accordance with the following standards: a. Reimbursement will not be available under the waiver for any services that the member can obtain as other nonwaiver Medicaid services or through any other funding source. b. All services provided under the waiver must be delivered in the least restrictive environment possible and in conformity with the member’s service plan. c. All rights restrictions must be implemented in accordance with 441—subrule 77.30(4). d. Services must be billed in whole units. e. For all services with a 15-minute unit of service, the rounding process outlined in paragraph 78.34(14)“e” will apply. 78.52(2) Environmental modifications and adaptive devices. a. Environmental modifications and adaptive devices include medically necessary items installed or used within the member’s home that are used by the member to address specific, documented health, mental health, or safety concerns. The following items are excluded under this service: (1) Items ordinarily covered by Medicaid. (2) Items funded by educational or vocational rehabilitation programs. (3) Items provided by voluntary means. (4) Repair and maintenance of items purchased through the waiver. (5) Fencing. b. A unit of service is one modification or device. c. For each unit of service provided, the case manager shall maintain in the member’s case file a signed statement from a mental health professional on the member’s interdisciplinary team that the service has a direct relationship to the member’s diagnosis of serious emotional disturbance. d. Payment for most items will be based on a fee schedule. The amount of the fee will be determined as directed in 441—subrule 79.1(17). 78.52(3) Family and community support services. Family and community support services shall support the member and the member’s family by the development and implementation of strategies and interventions that will result in the reduction of stress and depression and will increase the member’s and the family’s social and emotional strength. a. Dependent on the needs of the member and the member’s family members individually or collectively, family and community support services may be provided to the member, to the member’s family members, or to the member and the family members as a family unit. b. Family and community support services shall be provided under the recommendation and direction of a mental health professional who is a member of the member’s interdisciplinary team pursuant to 441—Chapter 83. c. Family and community support services shall incorporate recommended support interventions and activities, which may include the following: (1) Developing and maintaining a crisis support network for the member and for the member’s family. (2) Modeling and coaching effective coping strategies for the member’s family members. (3) Building resilience to the stigma of serious emotional disturbance for the member and the family. (4) Reducing the stigma of serious emotional disturbance by the development of relationships with peers and community members. (5) Modeling and coaching the strategies and interventions identified in the member’s crisis intervention plan as defined in 441—24.1(225A) for life situations with the member’s family and in the community. (6) Developing medication management skills. (7) Developing personal hygiene and grooming skills that contribute to the member’s positive self-image. (8) Developing positive socialization and citizenship skills. d. Family and community support services may include an amount not to exceed $1,500 per member per year for transportation within the community and purchase of therapeutic resources. Therapeutic resources may include books, training materials, and visual or audio media. (1) The interdisciplinary team must have identified the transportation or therapeutic resource as a support need and included that need in the case manager’s plan. (2) The annual amount available for transportation and therapeutic resources must be listed in the member’s service plan. (3) The member’s parent or legal guardian shall submit a signed statement that the transportation or therapeutic resource cannot be provided by the member or the member’s family or legal guardian. (4) The member’s Medicaid case manager will maintain a signed statement that potential community resources are unavailable and will list the community resources contacted to fund the transportation or therapeutic resource. (5) The transportation or therapeutic resource must not be otherwise eligible for Medicaid reimbursement. e. The following components are specifically excluded from family and community support services: (1) Vocational services. (2) Prevocational services. (3) Supported employment services. (4) Room and board. (5) Academic services. (6) General supervision and care. f. A unit of family and community support services is 15 minutes. 78.52(4) In-home family therapy. In-home family therapy provides skilled therapeutic services to the member and family that will increase their ability to cope with the effects of serious emotional disturbance on the family unit and the familial relationships. The service must support the family by the development of coping strategies that will enable the member to continue living within the family environment. a. The goal of in-home family therapy is to maintain a cohesive family unit. b. In-home family therapy is exclusive of and cannot serve as a substitute for individual therapy, family therapy, or other mental health therapy that may be obtained through Medicaid or other funding sources. c. A unit of in-home family therapy service is 15 minutes. 78.52(5) Respite care services. Respite care services are services provided pursuant to subrule 78.34(5).Related ARC(s): 0315D441—78.53(249A) Speech-language pathology services. Payment will be approved for the same services provided by a speech-language pathologist that are payable under Title XVIII of the Social Security Act as amended to July 1, 2026 (Medicare).Related ARC(s): 0315D441—78.54(249A) Services rendered via telehealth. An in-person contact between a health care professional and a patient is not required as a prerequisite for payment for otherwise-covered services appropriately provided through telehealth in accordance with generally accepted health care practices and standards prevailing in the applicable professional community at the time the services are provided, as well as being in accordance with provisions under rule 481—655.9(147,148,272C). Health care services provided through in-person consultations or through telehealth shall be treated as equivalent services for the purposes of reimbursement.Related ARC(s): 0315D441—78.55(249A) Community-based neurobehavioral rehabilitation services. Payment will be made for community-based neurobehavioral rehabilitation services that do not duplicate other services covered in this chapter. 78.55(1) Definitions.
- The number of hours of home health agency services shall be reasonable and appropriate to meet an established medical need of the member that cannot be met by a family member, significant other, friend, or neighbor. Services must be medically necessary in the individual case and be related to a diagnosed medical impairment or disability.
- The member need not be homebound to be eligible for home health agency services; however, the services provided by a home health agency will only be covered when provided in the member’s residence with the following exception. Private duty nursing and personal care services for persons aged 20 and under as described at paragraph 78.9(10)“a” may be provided in settings other than the member’s residence when medically necessary.
- Medicaid members of home health agency services need not first require skilled nursing care to be entitled to home health aide services.
- Further limitations related to specific components of home health agency services are noted in subrules 78.9(3) through 78.9(10).
- Payment will be made on an encounter basis. An encounter is defined as separately identifiable hours in which home health agency staff provide continuous service to a member.
- Dressings, durable medical equipment, and other supplies shall be obtained from a durable medical equipment dealer or pharmacy.
- Payment may be made for restorative and maintenance home health agency services.
- Payment may be made for teaching, training, and counseling in the provision of health care services.
- Treatment plans for these services shall additionally reflect: to whom the services are to be provided (patient, family member, etc.); prior teaching training, or counseling provided; medical necessity for the rendered service; identification of specific services and goals; date of onset of the teaching, training, or counseling; frequency of services; progress of member in response to treatment; and estimated length of time these services will be needed.
- The following are not covered: services provided in the home health agency office, homemaker services, well child care and supervision, and medical equipment rental or purchase.
- Services shall be authorized by a physician, nurse practitioner, clinical nurse specialist, or PA, evidenced by the physician’s, nurse practitioner’s, clinical nurse specialist’s, or PA’s signature and date on a plan of treatment.
"Behavioral health intervention" means skill-building services that focus on:
- Addressing the mental and functional disabilities that negatively affect a member’s integration and stability in the community and quality of life;
- Improving a member’s health and well-being related to the member’s mental disorder by reducing or managing the symptoms or behaviors that prevent the member from functioning at the member’s best possible functional level; and
- Promoting a member’s mental health recovery and resilience through increasing the member’s ability to manage symptoms.
"Licensed practitioner of the healing arts" "LPHA," as used in this rule, means a practitioner such as a physician (M.D. or D.O.), a PA, an ARNP, a psychologist, a social worker (LMSW or LISW), a marital and family therapist (LMFT), or a mental health counselor (LMHC) who is licensed by the applicable state authority for that profession.
"Managed care organization" means an entity that (1) is under contract with the department to provide services to Medicaid recipients and (2) meets the definition of “health maintenance organization” as defined in Iowa Code section 514B.1.
"Mental disorder" means a disorder, dysfunction, or dysphoria diagnosed pursuant to the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association as amended to July 1, 2026, excluding intellectual disabilities, personality disorders, medication-induced movement disorders and other adverse effects of medication, and other conditions that may be a focus of clinical attention.
78.12(2) Covered services. a. Service setting. (1) Community-based behavioral health intervention is available to a member living in a community-based environment. Services have a primary goal of assisting the member and the member’s family to learn age-appropriate skills to manage behavior and regain or retain self-control. Depending on the member’s age and diagnosis, specific services offered may include: 1. Behavior intervention, 2. Crisis intervention, 3. Skill training and development, and 4. Family training. (2) Residential behavioral health intervention is available to members eligible for foster group care payment pursuant to 441—subrule 156.20(1). Services have the primary goal of assisting the member to prepare to transition to the community through learning age-appropriate skills to manage behavior and regain or retain self-control. Specific services offered include: 1. Behavior intervention, 2. Crisis intervention, and 3. Family training. (3) Behavioral health intervention is not covered for members who are in an acute care or psychiatric hospital, a long-term care facility, or a psychiatric medical institution for children. b. Crisis intervention. Crisis intervention services shall provide a focused intervention and rapid stabilization of acute symptoms of mental illness or emotional distress. The intervention shall be designed 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. (3) Crisis intervention services do not include control room or other restraint activities. c. Behavior intervention. Behavior intervention includes services designed 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 in an age-appropriate manner: 1. Cognitive flexibility skills, 2. Communication skills, 3. Conflict resolution skills, 4. Emotional regulation skills, 5. Executive skills, 6. Interpersonal relationship skills, 7. Problem-solving skills, and 8. Social skills. (2) Behavior intervention shall be provided in a location appropriate for skill identification, teaching and development. Intervention may be provided in an individual, family, or group format as appropriate to meet the member’s needs. (3) Behavior intervention is covered only for Medicaid members aged 20 or under. (4) Covered services include only direct teaching or development of skills and not general recreation, non-skill-based activities, mentoring, or interruption of school. d. Family training. Family training is covered only for Medicaid members aged 20 or under. (1) Family training services shall: 1. Enhance the family’s ability to effectively interact with the child and support the child’s functioning in the home and community, and 2. Teach parents to identify and implement strategies to reduce target behaviors and reinforce the appropriate skills. (2) Training provided must: 1. Be for the direct benefit of the member, and 2. Be based on a curriculum with a training manual. e. Skill training and development. Skill training and development services are covered for Medicaid members aged 18 or over. (1) Skill training and development shall consist of interventions to: 1. Enhance a member’s independent living, social, and communication skills; 2. Minimize or eliminate psychological barriers to a member’s ability to effectively manage symptoms associated with a psychological disorder; and 3. Maximize a member’s ability to live and participate in the community. (2) Interventions may include training in the following skills for effective functioning with family, peers, and community: 1. Communication skills, 2. Conflict resolution skills, 3. Daily living skills, 4. Employment-related skills, 5. Interpersonal relationship skills, 6. Problem-solving skills, and 7. Social skills. 78.12(3) Excluded services. a. Services that are habilitative in nature are not covered as behavioral health interventions. 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. b. Respite, day care, education, and recreation services are not covered as behavioral health interventions. 78.12(4) Coverage requirements. Medicaid covers behavioral health intervention 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. b. The licensed practitioner of the healing arts has recommended the behavioral health intervention as part of a plan of treatment designed to treat the member’s psychological disorder. The plan of treatment shall be comprehensive in nature and shall detail all behavioral health services that the member may require, not only services included under behavioral health intervention. (1) The member’s need for services must meet specific individual goals that are focused to address: 1. Risk of harm to self or others, 2. Behavioral support in the community, 3. Specific skills impaired due to the member’s mental illness, and 4. Needs of children at risk of out-of-home placement due to mental health needs or the transition back to the community or home following an out-of-home placement. (2) Diagnosis and treatment plan development are covered services. 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 every six months thereafter if continued services are ordered. d. The behavioral health intervention provider has prepared a written services implementation plan that meets the requirements of subrule 78.12(5). 78.12(5) Approval of plan. The behavioral health intervention provider shall contact the member’s managed care plan for authorization of the services. a. Initial plan. The initial services implementation plan must meet all of the following criteria: (1) The plan conforms to the medical necessity requirements in subrule 78.12(6); (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 meets the requirements of rule 441—77.13(249A); and (5) The plan does not exceed six months’ duration. b. Subsequent plans. The member’s managed care plan may approve a subsequent services implementation plan according to the conditions in paragraph 78.12(5)“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; and (3) Evaluated the member’s progress, including a formal assessment as required by subparagraph 78.12(4)“c”(3). 78.12(6) Medical necessity. Nothing in this rule shall be deemed to exempt coverage of behavioral health intervention from the requirement that services be medically necessary. For purposes of behavioral health intervention, “medically necessary” means that the service is: a. Consistent with the diagnosis and treatment of the member’s condition and specific to a daily impairment caused by a mental disorder; 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 evidence-based medical practice. The standards of practice for each field of medical and remedial care covered by the Iowa Medicaid program are those standards of practice identified by: (1) Knowledgeable Iowa clinicians practicing or teaching in the field; and (2) The professional literature regarding evidence-based practices in the field.Related ARC(s): 0315D441—78.13(249A) Nonemergency medical transportation. The department makes available nonemergency medical transportation through a transportation brokerage. Medicaid members who are eligible for full Medicaid benefits and need transportation services so they can receive Medicaid-covered services from providers enrolled with the Iowa Medicaid program may obtain transportation services consistent with this rule. 78.13(1) Covered services. Nonemergency medical transportation services available are limited to: a. The most economical transportation appropriate to the needs of the member, provided to members eligible for nonemergency transportation when those members need transportation to providers enrolled in the Iowa Medicaid program for the receipt of goods or services covered by the Iowa Medicaid program. Consistent with the member’s needs and subject to the limitations and restrictions set forth in this rule, subject to the advance approval of the broker, such transportation may include: (1) Mileage reimbursement to the member, if the member is the driver. (2) Mileage reimbursement to a volunteer or other responsible person, if the volunteer or other responsible person is the driver. (3) Taxi service. (4) Public transportation when public transportation is reasonably available and the member’s condition does not preclude its use. (5) Wheelchair and stretcher vans. (6) Airfare costs when the most appropriate mode of transport is by air, based on the member’s medical condition. b. Reimbursement for costs of the member’s meals necessary during periods of transportation and medical treatment. c. Reimbursement of lodging expenses incurred by the member during periods of transportation and medical treatment. d. Reimbursement of car rental costs incurred by the member during periods of transportation and medical treatment. e. Reimbursement of a medically necessary escort’s travel expenses when an escort is required because of the member’s needs. 78.13(2) Exclusions. Nonemergency medical transportation is not available through the Iowa Medicaid program for: a. Transportation to obtain services not covered by Iowa Medicaid; b. Transportation to providers that are not enrolled in Iowa Medicaid; c. Transportation for members residing in nursing facilities or ICF/ID facilities when such facilities provide the transportation (i.e., within 30 miles, one way, of the facility); d. Transportation of family members to visit or participate in therapy when the member is hospitalized or institutionalized; e. Transportation to DME providers when such providers offer a delivery service that can be accessed at no cost to the member, unless the equipment requires a fitting that cannot be provided without transporting the member; f. Reimbursement to HCBS and Medicaid providers for transportation provided as part of other covered services, such as personal care, home health, and supported community living services; g. Transportation to a pharmacy that provides a free delivery service, with the exception of new prescription fills that are otherwise not available to the patient in the absence of nonemergency medical transportation services; and h. Emergency transportation. 78.13(3) Conditions and limitations on covered services. Nonemergency medical transportation services are subject to the following limitations and conditions: a. Member request. When a member needs nonemergency transportation to receive medical care provided by the Iowa Medicaid program, the member must contact the broker with as much advance notice as possible, but not more than 30 days’ advance notice. (1) Generally, members who require a ride from a transportation provider scheduled by the broker must contact the broker at least two business days in advance of the member’s appointment to schedule the transportation. For purposes of calculating the two-business-day notice obligation, the advance notice includes the day of the medical appointment but not the day of the telephone call. (2) If the member’s nonemergency transportation need for a ride from a transportation provider scheduled by the broker makes the provision of two business days’ notice impossible because of the member’s urgent transportation need, the member must provide as much advance notice as is possible before the transportation need so that the broker can appropriately schedule the most economical form of transportation for the member. Urgent transportation needs for a ride from a transportation provider scheduled by the broker are limited to unscheduled episodic situations in which there is no immediate threat to life or limb but which require that the broker schedule transportation with less than two business days’ notice. Examples of urgent trips include but are not limited to: 1. Postsurgical or medical follow-up care specified by a health care provider; 2. Unexpected preoperative appointments; 3. Hospital discharges; 4. Appointments for new medical conditions or tests; and 5. Dialysis. (3) The two-business-day advance notice obligation does not apply when the member requests only mileage reimbursement. To be eligible for mileage reimbursement: 1. The member must notify the broker no later than the day of the trip; 2. The transportation must be provided by a driver with a valid driver’s license and insurance coverage on the vehicle at the time of the transport; and 3. The other requirements of rule 441—78.13(249A) must be met. b. No free transportation alternatives available. Member transportation through the nonemergency medical transportation broker is not available to the member when the member is capable of securing the member’s own transportation at no cost to the member (e.g., free-gas voucher programs). c. No member transportation alternatives available. Members who have their own transportation available to them are required to use their own vehicle and seek mileage reimbursement. For purposes of determining whether or not the member has the member’s own transportation that is available to the member, the broker shall take into consideration: (1) Whether the member owns a vehicle; (2) Whether a member-owned vehicle is in working mechanical order and is licensed; (3) Whether the member has a valid driver’s license and auto insurance; (4) Whether the member is unable to drive because of age, physical condition, cognitive impairment, or developmental limitations; and (5) Whether friends or family are available to transport the member to the member’s medical appointment and receive mileage reimbursement. d. Limitations on reimbursement for meals. Reimbursement for costs of members’ meals necessary during periods of transportation and medical treatment is limited to situations in which: (1) The transportation being provided spans the entire meal period; (2) The one-way distance to or from the medical appointment is more than 50 miles; (3) The meal is necessary to satisfy the needs of the member or medically necessary escort; and (4) The meal reimbursement is limited to the subsistence allowance amounts applicable to state officers and state employees pursuant to rule 11—41.6(8A) and is supported by detailed receipts. e. Limitations on reimbursement for lodging expenses. Reimbursement of lodging expenses incurred by members during periods of transportation and medical treatment is limited to reasonable reimbursement for expenses incurred by the member or the medically necessary escort, or both, during a nonemergency trip provided by the broker when the one-way distance to or from the medical appointment is more than 50 miles, supported by detailed receipts, and required for treatment. f. Closest medical provider. Nonemergency medical transportation will only be provided to members to the closest qualified and enrolled Medicaid provider unless: (1) The difference between the closest qualified and enrolled Medicaid provider and the enrolled provider requested by the member is less than 10 miles one way; or (2) The additional cost of transportation to the enrolled provider requested by the member is medically justified based on: 1. The member’s previous relationship with the requested provider; or 2. The member’s prior experience with the requested provider; or 3. The requested provider’s special expertise or experience; or 4. A referral requiring the member to be seen by the requested provider. g. Member scheduling obligations. Members who require a ride will need to schedule medical appointments on days the transportation provider sends a shuttle to facilitate the provision of the most economical nonemergency medical transportation available, subject to reasonable medical exceptions. h. Abusive behavior. Members who are abusive or inappropriate may be restricted by the department to only receiving mileage reimbursement. Such restricted members will be responsible for finding their own way to their medical appointments. i. Member claim submission. Members must submit claims and supporting documentation to the broker within 120 days of the date of service. The broker shall deny member claims submitted more than 120 days from the date of service. 78.13(4) Grievance procedure. The broker shall establish an internal grievance procedure for members and transportation providers. a. Members may appeal to the department pursuant to 441—Chapter 2506 as an “aggrieved person.” b. Transportation providers. (1) Consent for state fair hearing. 1. Transportation providers that are contracted with the broker and are in good standing with the broker may request a state fair hearing only for disputes regarding payment of claims, specifically, disputes concerning the denial of a claim or reduction in payment, and only when acting on behalf of the member. 2. The transportation provider requesting such a state fair hearing must have the prior, express, signed written consent of the member or the member’s lawfully appointed guardian in order to request such a hearing. Notwithstanding any contrary provision in 441—Chapter 2506, no state fair hearing will be granted unless the transportation provider submits a document providing such member approval with the request for a state fair hearing. 3. The document must specifically inform the member that protected health information (PHI) may be discussed at the hearing and may be made public in the course of the hearing and subsequent administrative and judicial proceedings. The document must contain language that indicates the knowledge of the potential for PHI to become public and that the member knowingly, voluntarily and intelligently consents to the network provider’s bringing the state fair hearing on the member’s behalf. (2) For all transportation provider grievances not addressed by paragraph 78.13(4)“b,” the grievance process shall end with binding arbitration, with a designee of Iowa Medicaid as arbitrator.Related ARC(s): 0315D441—78.14(249A) Hearing aids. Payment will be approved for a hearing aid and examinations subject to the following conditions: 78.14(1) Physician examination. The member shall have an examination by a physician to determine that the member has no condition that would contraindicate the use of a hearing aid. This report shall be documented in the patient record. The requirement for a physician evaluation shall be waived for members 18 years of age or older when the member has signed an informed consent statement acknowledging that the member: a. Has been advised that it may be in the member’s best health interest to receive a medical evaluation from a licensed physician before purchase of a hearing aid. b. Does not wish to receive a medical evaluation prior to purchase of a hearing aid. 78.14(2) Audiological testings. A physician or an audiologist shall perform audiological testing as a part of making a determination that a member could benefit from the use of a hearing aid. The department will cover vestibular testing performed by an audiologist only when prescribed by a physician. 78.14(3) Hearing aid evaluation. A physician or an audiologist shall perform a hearing aid evaluation to establish if a member could benefit from a hearing aid. When a hearing aid is recommended for a member, the physician or audiologist recommending the hearing aid shall see the member at least one time within 30 days after purchase of the hearing aid to determine that the aid is adequate. 78.14(4) Hearing aid selection. A physician or audiologist may recommend a specific brand or model appropriate to the member’s condition. When a physician or an audiologist makes a general hearing aid recommendation, a hearing aid dispenser may perform the tests to determine the specific brand or model appropriate to the member’s condition. 78.14(5) Travel. When a member is unable to travel to the physician or audiologist because of health reasons, the department will make payment for travel to the member’s place of residence or other suitable location. The department will make payment to physicians as specified in 78.1(8) and payment to audiologists at the same rate it reimburses state employees for travel. 78.14(6) Purchase of hearing aid. The department will pay for the type of hearing aid recommended when purchased from an eligible licensed hearing aid dispenser pursuant to rule 441—77.14(249A). The department will pay for binaural amplification when: a. A child needs the aid for speech development, b. The aid is needed for educational or vocational purposes, c. The aid is for a blind member, d. The member’s hearing loss has caused marked restriction of daily activities and constriction of interests resulting in seriously impaired ability to relate to other people, or e. Lack of binaural amplification poses a hazard to a member’s safety. 78.14(7) Payment for hearing aids. a. Payment for hearing aids will be acquisition cost plus a dispensing fee covering the fitting and service for six months. The department will make payment for routine service after the first six months. Dispensing fees and payment for routine service shall not exceed the fee schedule appropriate to the place of service. Shipping and handling charges are not allowed. b. Payment for ear mold and batteries will be at the current audiologist’s fee schedule. c. Payment for repairs will be made to the dealer for repairs made by the dealer. Payment for in-house repairs will be made at the current fee schedule. Payment will also be made to the dealer for repairs when the hearing aid is repaired by the manufacturer or manufacturer’s depot. Payment for out-of-house repairs will be at the amount shown on the manufacturer’s invoice. Payment will be allowed for a service or handling charge when it is necessary for repairs to be performed by the manufacturer or manufacturer’s depot and this charge is made to the general public. d. Prior approval. When prior approval is required, an Examiner Report of Need for a Hearing Aid form shall be submitted along with the forms required by 441—paragraph 79.8(1)“a.” (1) Payment for the replacement of a hearing aid less than four years old will require prior approval except when the member is under 21 years of age. The department will approve payment when the original hearing aid is lost or broken beyond repair or there is a significant change in the member’s hearing that would require a different hearing aid. (2) Payment for a hearing aid costing more than $650 will require prior approval. The department will approve payment for either of the following purposes: 1. Educational purposes when the member is participating in primary or secondary education or in a postsecondary academic program leading to a degree and an in-office comparison of an analog aid and a digital aid matched (+/- 5dB) for gain and output shows a significant improvement in either speech recognition in quiet or speech recognition in noise or an in-office comparison of two aids, one of which is single channel, shows significantly improved audibility. 2. Vocational purposes when documentation submitted indicates the necessity, such as varying amounts of background noise in the work environment and a need to converse in order to do the job, and an in-office comparison of an analog aid and a digital aid matched (+/- 5dB) for gain and output shows a significant improvement in either speech recognition in quiet or speech recognition in noise or an in-office comparison of two aids, one of which is single channel, shows significantly improved audibility.Related ARC(s): 0315D441—78.15(249A) Orthopedic shoes. Payment will be approved only for depth or custom-molded orthopedic shoes, inserts, and modifications, subject to the following definitions and conditions. 78.15(1) Definitions. "Custom-molded shoe" means a shoe that:
- Has been constructed over a cast or model of the recipient’s foot;
- Is made of leather or another suitable material of equal quality;
- Has inserts that can be removed, altered, or replaced according to the recipient’s conditions and needs; and
- Has some form of closure.
"Depth shoe" means a shoe that:
- Has a full length, heel-to-toe filler that when removed provides a minimum of 3/16 inch of additional depth used to accommodate custom-molded or customized inserts;
- Is made from leather or another suitable material of equal quality;
- Has some form of closure; and
- Is available in full and half sizes with a minimum of three widths, so that the sole is graded to the size and width of the upper portions of the shoe according to the American Standard last sizing schedule as amended to July 1, 2026, or its equivalent.
"Insert" means a foot mold or orthosis constructed of more than one layer of a material that:
78.15(2) Prescription. The recipient shall present to the provider a written prescription by a physician, a podiatrist, a PA, or an ARNP that includes all of the following: a. The date. b. The patient’s diagnosis. c. The reason orthopedic shoes are needed. d. The probable duration of need. e. A specific description of any required modification of the shoes. 78.15(3) Diagnosis. The recipient shall have a diagnosis of an orthopedic, neuromuscular, vascular, or insensate foot condition, supported by applicable codes from the International Classification of Diseases (ICD) as amended to July 1, 2026. A diagnosis of flat feet is not covered. a. A recipient with diabetes must meet the Medicare criteria for therapeutic depth and custom-molded shoes. b. Custom-molded shoes are covered only when the recipient has a foot deformity and the provider has documentation of all of the following: (1) The reasons the recipient cannot be fitted with a depth shoe. (2) Pain. (3) Tissue breakdown or a high probability of tissue breakdown. (4) Any limitation on walking. 78.15(4) Frequency. Only two pairs of orthopedic shoes are allowed per recipient in a 12-month period unless documentation of change in size or evidence of excessive wear is submitted. Exception: School-aged children under the age of 21 may obtain athletic shoes in addition to the two pairs of shoes in a 12-month period.Related ARC(s): 0315D441—78.16(249A) Community mental health centers. Payment will be approved for all reasonable and necessary services provided by a psychiatrist on the staff of a community mental health center. Payment will be approved for services provided by a clinical psychologist, social worker or psychiatric nurse on the staff of the center, subject to the following conditions: 78.16(1) Payment to a community mental health center will be approved for reasonable and necessary services provided to members by a psychiatrist, psychologist, social worker or psychiatric nurse on the staff of the center under the following conditions: a. Services must be rendered under the supervision of a board-eligible or board-certified psychiatrist. All services must be performed under the supervision of a board-eligible or board-certified psychiatrist subject to the conditions set forth in 78.16(1)“b” with the following exceptions: (1) Services by staff psychiatrists, or (2) Services rendered by psychologists meeting the requirements of the National Register of Health Service Providers in Psychology as amended to July 1, 2026, or (3) Services provided by a staff member listed in this subrule performing the preliminary diagnostic evaluation of a member for voluntary admission to one of the state mental health institutes. b. Supervisory process. (1) Each patient shall have an initial evaluation completed that shall include at least one personal evaluation interview with a mental health professional, as defined under Iowa Code section 228.1. If the evaluation interview results indicate a need for an interview with a board-eligible or board-certified psychiatrist, then such referral shall be made. This must be accomplished before submission of the first claim for services rendered to that patient. (2) Ongoing review and assessment of patients’ treatment needs, treatment plans, and the appropriateness of services rendered shall be assured through the peer review process in effect for community mental health centers, as directed by 2002 Iowa Acts, chapter 1120, section 13. 78.16(2) The treatment plans for and services rendered to patients of the center shall be evaluated and revised as necessary and appropriate, consistent with the standards of the peer review process described in subparagraph 78.16(1)“b”(1). 78.16(3) The peer review process and related activities, as described under subparagraph 78.16(1)“b”(1), are not payable as separate services under the Medicaid program. The center shall maintain the results of and information related to the peer review process, and these records shall be subject to audit by the department or its designees, as necessary and appropriate. 78.16(4) Clinical records of medical assistance patients shall be available to the carrier on request. All these records shall be held confidential. 78.16(5) At the time of application for participation in the program the center will be provided with a form on which to list its professional staff. The center shall report acquisitions or losses of professional staff to the carrier within ten days. 78.16(6) Payment to a community mental health center will be approved for day treatment services for persons aged 21 or over if the center is certified by the department for day treatment services, the services are provided on the premises of the community mental health center or satellite office of the community mental health center, and the services meet the standards outlined herein. a. Community mental health centers providing day treatment services for persons aged 21 or over shall have available a written narrative providing the following day treatment information: (1) Documented need for day treatment services for persons aged 21 and over in the area served by the program, including studies, needs assessments, and consultations with other health care professionals. (2) Goals and objectives of the day treatment program for persons aged 21 and over that meet the day treatment program guidelines noted in 78.16(6)“b.” (3) Organization and staffing including how the day treatment program for persons aged 21 and over fits with the rest of the community mental health center, the number of staff, staff credentials, and the staff’s relationship to the program, e.g., employee, contractual, or consultant. (4) Policies and procedures for the program including admission criteria, patient assessment, treatment plan, discharge plan, postdischarge services, and the scope of services provided. (5) Any accreditations or other types of approvals from national or state organizations. (6) The physical facility and any equipment to be utilized. b. Day treatment services for persons aged 21 and over shall be structured, long-term services designed to assist in restoring, maintaining or increasing levels of functioning, minimizing regression, and preventing hospitalization. (1) Service components include training in independent functioning skills necessary for self-care, emotional stability and psychosocial interactions and training in medication management. (2) Services are structured with an emphasis on program variation according to individual need. (3) Services are provided for a period of three to five hours per day, three or four times per week. c. Payment will be approved for day treatment services provided by or under the general supervision of a mental health professional. When services are provided by an employee or consultant of the community mental health center who is not a mental health professional, the employee or consultant shall be supervised by a mental health professional who gives professional direction and active guidance to the employee or consultant and who retains responsibility for member care. The supervision shall be timely, regular, and documented. The employee or consultant shall meet the following minimum requirements: (1) Have a bachelor’s degree in a human services related field from an accredited college or university; or (2) Have an Iowa license to practice as a registered nurse with two years of experience in the delivery of nursing or human services. d. Persons aged 18 through 20 with chronic mental illness as defined by rule 441—24.1(225A) can receive day treatment services under this subrule or subrule 78.16(7). 78.16(7) Payment to a community mental health center will be approved for day treatment services for persons aged 20 or under if the center is certified by the department for day treatment services and the services are provided on the premises of the community mental health center or satellite office of the community mental health center. Exception: Field trips away from the premises are a covered service when the trip is therapeutic and integrated into the day treatment program’s description and milieu plan.Day treatment coverage will be limited to a maximum of 15 hours per week. Day treatment services for persons aged 20 or under shall be outpatient services provided to persons who are not inpatients in a medical institution or residents of a group care facility licensed under 441—Chapter 114. a. Program documentation. Community mental health centers providing day treatment services for persons aged 20 or under shall have available a written narrative that provides the following day treatment program information: (1) Documented need for day treatment services for persons aged 20 or under in the area served by the program, including studies, needs assessments, and consultations with other health care professionals. (2) Goals and objectives of the day treatment program for persons aged 20 or under that meet the guidelines noted in paragraphs “c” through “h” below. (3) Organization and staffing including how the day treatment program for persons aged 20 or under fits with the rest of the community mental health center, the number of staff, staff credentials, and the staff’s relationship to the program, e.g., employee, contractual, or consultant. (4) Policies and procedures for the program including admission criteria, patient assessment, treatment plan, discharge plan, postdischarge services, and the scope of services provided. (5) Any accreditations or other types of approvals from national or state organizations. (6) The physical facility and any equipment to be utilized. b. Program standards. Medicaid day treatment program services for persons aged 20 and under shall meet the following standards: (1) Staffing shall: 1. Be sufficient to deliver program services and provide stable, consistent, and cohesive milieu with a staff-to-patient ratio of no less than one staff for each eight participants. Clinical, professional, and paraprofessional staff may be counted in determining the staff-to-patient ratio. Professional or clinical staff are those staff who are either mental health professionals as defined in rule 441—24.1(225A) or persons employed for the purpose of providing offered services under the supervision of a mental health professional. All other staff (administrative, adjunctive, support, nonclinical, clerical, and consulting staff or professional clinical staff) when engaged in administrative or clerical activities shall not be counted in determining the staff-to-patient ratio or in defining program staffing patterns. Educational staff may be counted in the staff-to-patient ratio. 2. Reflect how program continuity will be provided. 3. Reflect an interdisciplinary team of professionals and paraprofessionals. 4. Include a designated director who is a mental health professional as defined in rule 441—24.1(225A). The director shall be responsible for direct supervision of the individual treatment plans for participants and the ongoing assessment of program effectiveness. 5. Be provided by or under the general supervision of a mental health professional. When services are provided by an employee or consultant of the community mental health center who is not a mental health professional, the employee or consultant shall be supervised by a mental health professional who gives direct professional direction and active guidance to the employee or consultant and who retains responsibility for member care. The supervision shall be timely, regular and documented. The employee or consultant shall have a bachelor’s degree in a human services related field from an accredited college or university or have an Iowa license to practice as a registered nurse with two years of experience in the delivery of nursing or human services. Exception: Other certified or licensed staff, such as certified addiction counselors or certified occupational and recreational therapy assistants, are eligible to provide direct services under the general supervision of a mental health professional, but they shall not be included in the staff-to-patient ratio. (2) There shall be written policies and procedures addressing the following: admission criteria; patient assessment; patient evaluation; treatment plan; discharge plan; community linkage with other psychiatric, mental health, and human service providers; a process to review the quality of care being provided with a quarterly review of the effectiveness of the clinical program; postdischarge services; and the scope of services provided. (3) The program shall have hours of operation available for a minimum of three consecutive hours per day, three days or evenings per week. (4) The length of stay in a day treatment program for persons aged 20 or under shall not exceed 180 treatment days per episode of care, unless the rationale for a longer stay is documented in the patient’s case record and treatment plan every 30 calendar days after the first 180 treatment days. (5) Programming shall meet the individual needs of the patient. A description of services provided for patients shall be documented along with a schedule of when service activities are available including the days and hours of program availability. (6) There shall be a written plan for accessing emergency services 24 hours a day, seven days a week. (7) The program shall maintain a community liaison with other psychiatric, mental health, and human service providers. Formal relationships shall exist with hospitals providing inpatient programs to facilitate referral, communication, and discharge planning. Relationships shall also exist with appropriate school districts and educational cooperatives. Relationships with other entities such as physicians, hospitals, private practitioners, halfway houses, the department, juvenile justice system, community support groups, and child advocacy groups are encouraged. The provider’s program description will describe how community links will be established and maintained. (8) Psychotherapeutic treatment services and psychosocial rehabilitation services shall be available. A description of the services shall accompany the application for certification. (9) The program shall maintain a distinct clinical record for each patient admitted. Documentation, at a minimum, shall include: the specific services rendered, the date and actual time services were rendered, who rendered the services, the setting in which the services were rendered, the amount of time it took to deliver the services, the relationship of the services to the treatment regimen described in the plan of care, and updates describing the patient’s progress. c. Program services. Day treatment services for persons aged 20 or under shall be a time-limited, goal-oriented active treatment program that offers therapeutically intensive, coordinated, structured clinical services within a stable therapeutic milieu. Time-limited means that the patient is not expected to need services indefinitely or lifelong, and that the primary goal of the program is to improve the behavioral functioning or emotional adjustment of the patient in order that the service is no longer necessary. Day treatment services shall be provided within the least restrictive therapeutically appropriate context and shall be community-based and family focused. The overall expected outcome is clinically adaptive behavior on the part of the patient and the family.At a minimum, day treatment services will be expected to improve the patient’s condition, restore the condition to the level of functioning prior to onset of illness, control symptoms, or establish and maintain a functional level to avoid further deterioration or hospitalization. Services are expected to be age-appropriate forms of psychosocial rehabilitation activities, psychotherapeutic services, social skills training, or training in basic care activities to establish, retain or encourage age-appropriate or developmentally appropriate psychosocial, educational, and emotional adjustment.Day treatment programs shall use an integrated, comprehensive and complementary schedule of therapeutic activities and shall have the capacity to treat a wide array of clinical conditions.The following services shall be available as components of the day treatment program. These services are not separately billable to Medicaid, as day treatment reimbursement includes reimbursement for all day treatment components. (1) Psychotherapeutic treatment services, including individual, group, and family therapy. (2) Psychosocial rehabilitation services. Active treatment examples include but are not limited to individual and group therapy, medication evaluation and management, expressive therapies, and theme groups such as communication skills, assertiveness training, other forms of community skills training, stress management, chemical dependency counseling, education, and prevention, symptom recognition and reduction, problem solving, relaxation techniques, and victimization (sexual, emotional, or physical abuse issues).Other program components may be provided, such as personal hygiene, recreation, community awareness, arts and crafts, and social activities designed to improve interpersonal skills and family mental health. Although these other services may be provided, they are not the primary focus of treatment. (3) Evaluation services to determine need for day treatment prior to program admission. For persons for whom clarification is needed to determine whether day treatment is an appropriate therapy approach, or for persons who do not clearly meet admission criteria, an evaluation service may be performed. Evaluation services shall be individual and family evaluation activities made available to courts, schools, other agencies, and individuals upon request, who assess, plan, and link individuals with appropriate services. This service must be completed by a mental health professional. An evaluation from another source performed within the previous 12 months or sooner if there has not been a change may be substituted. Medicaid will not make separate payment for these services under the day treatment program. (4) Assessment services. All day treatment patients will receive a formal, comprehensive biopsychosocial assessment of day treatment needs including, if applicable, a diagnostic impression based on the Diagnostic and Statistical Manual of Mental Disorders as amended to July 1, 2026. An assessment from another source performed within the previous 12 months may be used if the symptomatology is the same as 12 months ago. If not, parts of the assessment that reflect current functioning may be used as an update. Using the assessment, a comprehensive summation will be produced, including the findings of all assessments performed. The summary will be used in forming a treatment plan including treatment goals. Indicators for discharge planning, including recommended follow-up goals and provision for future services, should also be considered, and consistently monitored. (5) The day treatment program may include an educational component as an additional service. The patient’s educational needs shall be served without conflict from the day treatment program. Hours in which the patient is involved in the educational component of the day treatment program are not included in the day treatment hours billable to Medicaid. d. Admission criteria. Admission criteria for day treatment services for persons aged 20 or under shall reflect the following clinical indicators: (1) The patient is at risk for exclusion from normative community activities or residence. (2) The patient exhibits psychiatric symptoms, disturbances of conduct, decompensating conditions affecting mental health, severe developmental delays, psychological symptoms, or chemical dependency issues sufficiently severe to bring about significant or profound impairment in day-to-day educational, social, vocational, or interpersonal functioning. (3) Documentation is provided that the traditional outpatient setting has been considered and has been determined not to be appropriate. (4) The patient’s principal caretaker (family, guardian, foster family or custodian) must be able and willing to provide the support and monitoring of the patient, to enable adequate control of the patient’s behavior, and must be involved in the patient’s treatment. Persons aged 20 or under who have reached the age of majority, either by age or emancipation, are exempt from family therapy involvement. (5) The patient has the capacity to benefit from the interventions provided. e. Individual treatment plan. Each patient receiving day treatment services shall have a treatment plan prepared. A preliminary treatment plan should be formulated within 3 days of participation after admission, and replaced within 30 calendar days by a comprehensive, formalized plan utilizing the comprehensive assessment. This individual treatment plan should reflect the patient’s strengths and weaknesses and identify areas of therapeutic focus. The treatment goals that are general statements of member outcomes shall be related to identified strengths, weaknesses, and clinical needs with time-limited, measurable objectives. Objectives shall be related to the goal and have specific anticipated outcomes. Methods that will be used to pursue the objectives shall be stated. The plan should be reviewed and revised as needed, but shall be reviewed at least every 30 calendar days. The treatment plan shall be developed or approved by a board-eligible or board-certified psychiatrist, a staff psychiatrist, physician, or a psychologist registered on the “National Register of Health Service Providers in Psychology” as amended to July 1, 2026. Approval will be evidenced by a signature of the physician or health service provider. f. Discharge criteria. Discharge criteria for the day treatment program for persons aged 20 or under shall incorporate at least the following indicators: (1) In the case of patient improvement: 1. The patient’s clinical condition has improved as shown by symptom relief, behavioral control, or indication of mastery of skills at the patient’s developmental level. Reduced interference with and increased responsibility with social, vocational, interpersonal, or educational goals occurs sufficient to warrant a treatment program of less supervision, support, and therapeutic intervention. 2. Treatment goals in the individualized treatment plan have been achieved. 3. An aftercare plan has been developed that is appropriate to the patient’s needs and agreed to by the patient and family, custodian, or guardian. (2) If the patient does not improve: 1. The patient’s clinical condition has deteriorated to the extent that the safety and security of inpatient or residential care is necessary. 2. Patient, family, or custodian noncompliance with treatment or with program rules exists. g. Coordination of services. Programming services shall be provided in accordance with the individual treatment plan developed by appropriate day treatment staff, in collaboration with the patient and appropriate caretaker figure (parent, guardian, or principal caretaker), and under the supervision of the program director, coordinator, or supervisor. (1) The program for each patient will be coordinated by primary care staff of the community mental health center. A coordinated, consistent array of scheduled therapeutic services and activities shall comprise the day treatment program. These may include counseling or psychotherapy, theme groups, social skills development, behavior management, and other adjunctive therapies. At least 50 percent of scheduled therapeutic program hours exclusive of educational hours for each patient shall consist of active treatment that specifically addresses the targeted problems of the population served. Active treatment shall be defined as treatment in which the program staff assume significant responsibility and often intervene. (2) Family, guardian, or principal caretaker shall be involved with the program through family therapy sessions or scheduled family components of the program. They will be encouraged to adopt an active role in treatment. Medicaid will not make separate payment for family therapy services. Persons aged 20 or under who have reached the age of majority, either by age or emancipation, are exempt from family therapy involvement. (3) Therapeutic activities will be scheduled according to the needs of the patients, both individually and as a group. (4) Scheduled therapeutic activities, which may include other program components as described above, shall be provided at least 3 hours per week up to a maximum of 15 hours per week. h. Stable milieu. The program shall formally seek to provide a stable, consistent, and cohesive therapeutic milieu. In part this will be encouraged by scheduling attendance such that a stable core of patients exists as much as possible. The milieu will consider the developmental and social stage of the participants such that no patient will be significantly involved with other patients who are likely to contribute to retardation or deterioration of the patient’s social and emotional functioning. To help establish a sense of program identity, the array of therapeutic interventions shall be specifically identified as the day treatment program. Program planning meetings shall be held at least quarterly to evaluate the effectiveness of the clinical program. In the program description, the provider shall state how milieu stability will be provided. i. Chronic mental illness. Persons aged 18 through 20 with chronic mental illness as defined by rule 441—24.1(225A) can receive day treatment services under this subrule or subrule 78.16(6).Related ARC(s): 0315D441—78.17(249A) Physical therapists. Payment will be approved when the services provided relate directly to an active written treatment plan; follow a treatment plan established by the physician, nurse practitioner, clinical nurse specialist, or PA after any needed consultation with the qualified physical therapist; are reasonable and necessary to the treatment of the patient’s illness or injury; and meet the guidelines defined for restorative, maintenance, or trial therapy as set forth in paragraphs 78.19(1)“a” and “b.”Related ARC(s): 0315D441—78.18(249A) Screening centers. Payment will be approved for health screening as defined in rule 441—84.1(249A) for Medicaid members under 21 years of age. 78.18(1) In order to be paid for the administration of a vaccine covered under the VFC program, a screening center must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted. 78.18(2) Payment will be approved for necessary laboratory service related to an element of screening when performed by the screening center and billed as a separate item. 78.18(3) Periodicity schedules for health, hearing, vision, and dental screenings. a. Payment will be approved for health, vision, and hearing screenings as follows: (1) Seven screenings in the first year of life. (2) Four screenings between the ages of 13 months and 30 months. (3) One screening per year at ages three, four, five, and six. (4) One screening per year at ages 7 through 21. b. Payment for dental screenings will be approved in conjunction with the health screenings up to age 12 months. Screenings will be approved at ages 12 months and 24 months and thereafter at six-month intervals up to age 21. c. Interperiodic screenings will be approved as medically necessary. 78.18(4) When it is established by the periodicity schedule in 78.18(3) that an individual is in need of screening, the individual will receive a notice that screening is due. 78.18(5) When an individual is screened, a member of the screening center shall complete a medical history. The medical history shall become part of the individual’s medical record. 78.18(6) Reserved. 78.18(7) Payment will be made for persons aged 20 and under for nutritional counseling provided by a licensed dietitian employed by or under contract with a screening center for a nutritional problem or condition of a degree of severity that nutritional counseling beyond that normally expected as part of the standard medical management is warranted. For persons eligible for the WIC program, a WIC referral is required. Medical necessity for nutritional counseling services exceeding those available through WIC shall be documented. 78.18(8) Payment will be made for dental services provided by a dental hygienist employed by or under contract with a screening center.Related ARC(s): 0315D441—78.19(249A) Rehabilitation agencies. 78.19(1) Coverage of services. a. General provisions regarding coverage of services. (1) Services are provided in the member’s home or in a care facility (other than a hospital) by a speech therapist, physical therapist, or occupational therapist employed by or contracted by the agency. A nursing facility, an ICF/ID, or a hospital where services are provided is not considered a member’s home. 1. Services provided to a member residing in a residential care facility licensed under Iowa Code section 135C.4 by the department of inspections, appeals, and licensing are payable when the residential care facility submits a signed statement that the residential care facility does not have these services available. The statement need only be submitted at the start of care unless the situation changes. 2. Under no circumstances will Iowa Medicaid or managed care organizations (MCOs) make payments to a rehabilitation agency for therapy provided to a member residing in a nursing facility or an ICF/ID. Physical, occupational, and speech therapy services for residents of the nursing facility, ICF/ID, or hospital are the responsibility of the nursing facility, ICF/ID, or hospital. (2) All services must be determined to be medically necessary, reasonable, and meet a significant need of the recipient that cannot be met by a family member, friend, medical staff personnel, or other caregiver; must meet accepted standards of medical practice; and must be a specific and effective treatment for a patient’s medical or disabling condition. (3) In order for a service to be payable, a licensed therapist must complete a plan of treatment every 30 days and indicate the type of service required. The plan of treatment must contain the information noted in subrule 78.19(2). (4) There is no specific limitation on the number of visits for which payment through the program will be made so long as that amount of service is medically necessary in the individual case, is related to a diagnosed medical impairment or disabling condition and meets the current standards of practice in each related field. Documentation must be submitted with each claim to support the need for the number of services being provided. (5) Payments will be made both for restorative service and also for maintenance types of service. Essentially, maintenance services means services to a patient whose condition is stabilized and who requires observation by a therapist of conditions defined by the physician as indicating a possible deterioration of health status. This would include persons with long-term illnesses or a disabling condition whose status is stable rather than posthospital. Refer to subparagraphs 78.19(1)“b”(7) and “b”(8) for guidelines under restorative and maintenance therapy. (6) Restorative or maintenance therapy sessions must meet the following criteria: 1. There must be face-to-face patient contact interaction. 2. Services must be provided primarily on an individual basis. Group therapy is covered, but total units of service in a month shall not exceed total units of individual therapy. Family members receiving therapy may be included as part of a group. 3. Treatment sessions may be no less than 15 minutes of service and no more than 60 minutes of service per date unless more than 60 minutes of service is required for a treatment session due to the patient’s specific condition. If more than 60 minutes of service is required for a treatment session, additional documentation of the specific condition and the need for the longer treatment session shall be submitted with the claim. A unit of treatment shall be considered to be 15 minutes unless an untimed or encounter billing code is used. 4. Progress must be documented in measurable statistics in the progress notes in order for services to be reimbursed. Refer to subparagraphs 78.19(1)“b”(7) and “b”(8) for guidelines under restorative and maintenance therapy. (7) Payment will be made for an appropriate period of diagnostic therapy or trial therapy (up to two months) to determine a patient’s rehabilitation potential and establish appropriate short-term and long-term goals. Documentation must be submitted with each plan to support the need for diagnostic or trial therapy. Refer to subparagraph 78.19(1)“b”(16) for guidelines under diagnostic or trial therapy. b. Physical therapy services. (1) To be covered under rehabilitation agency services, physical therapy services must relate directly and specifically to an active written treatment plan, follow a treatment plan established by the licensed therapist after consultation with the physician, be reasonable and necessary to the treatment of the person’s illness, injury, or disabling condition, be specific and effective treatment for the patient’s medical or disabling condition, and be of such a level of complexity and sophistication, or the condition of the patient must be such that the services required can be safely and effectively performed only by a qualified physical therapist or under the supervision of the therapist. (2) A qualified physical therapist assistant may provide any restorative services performed by a licensed physical therapist under supervision of the therapist. (3) The initial physical therapy evaluation must be provided by a licensed physical therapist. (4) There must be an expectation that there will be a significant, practical improvement in the patient’s condition in a reasonable amount of time based on the patient’s restorative potential assessed by the physician. (5) It must be demonstrated there is a need to establish a safe and effective maintenance program related to a specific disease state, illness, injury, or disabling condition. (6) The amount, frequency, and duration of the services must be reasonable. (7) Restorative therapy must be reasonable and necessary to the treatment of the patient’s injury or disabling condition. The expected restorative potential must be practical and in relation to the extent and duration of the treatment. There must be an expectation that the patient’s medical or disabling condition will show functional improvement in a reasonable period of time. Functional improvement means that demonstrable measurable increases have occurred in the patient’s level of independence outside the therapeutic environment. (8) Generally, maintenance therapy means services to a patient whose condition is stabilized and who requires observation by a therapist of conditions defined by the physician as indicating a possible deterioration of health status. This includes persons with long-term illnesses or disabling conditions whose status is stable rather than posthospital. Maintenance therapy is also appropriate for individuals whose condition is such that a professionally established program of activities, exercises, or stimulation is medically necessary to prevent deterioration or maintain present functioning levels. 1. Where a maintenance program is appropriate, the initial evaluation and the instruction of the patient, family members, home health aides, facility personnel, or other caregivers to carry out the program are considered a covered physical therapy service. Payment shall be made for a maximum of three visits to establish a maintenance program and instruct the caregivers. Payment for supervisory visits to monitor the program is limited to two per month for a maximum period of 12 months. The plan of treatment must specify the anticipated monitoring activity of the supervisor. 2. Beyond evaluation, instruction, and monitoring, maintenance therapy is not reimbursable. 3. After 12 months of maintenance therapy, a reevaluation is a covered service, if medically necessary. A reevaluation will be considered medically necessary only if there is a significant change in residential or employment situation or the patient exhibits an increase or decrease in functional ability or motivation, clearing of confusion, or the remission of some other medical condition which previously contraindicated restorative therapy. A statement by the interdisciplinary team of a person with developmental disabilities recommending a reevaluation and stating the basis for medical necessity will be considered as supporting the necessity of a reevaluation and may expedite approval.(Restorative and maintenance therapy definitions also apply to speech and occupational therapy.) 4. When a patient is under a restorative physical therapy program, the patient’s condition is regularly reevaluated and the program adjusted by the physical therapist. It is expected that prior to discharge, a maintenance program has been designed by the physical therapist. Consequently, where a maintenance program is not established until after the restorative program has been completed, it would not be considered reasonable and necessary to the treatment of the patient’s condition and would be excluded from coverage. (9) Hot packs, hydrocollator, infrared treatments, paraffin baths, and whirlpool baths do not ordinarily require the skills of a qualified physical therapist. These are covered when the patient’s condition is complicated by other conditions such as a circulatory deficiency or open wounds or if the service is an integral part of a skilled physical therapy procedure. (10) Gait training and gait evaluation and training constitute a covered service if the patient’s ability to walk has been impaired by a neurological, muscular or skeletal condition or illness. The gait training must be expected to significantly improve the patient’s ability to walk or level of independence.Repetitious exercise to increase endurance of weak or unstable patients can be safely provided by supportive personnel, e.g., aides, nursing personnel. Therefore, it is not a covered physical therapy service. (11) Ultrasound, shortwave, and microwave diathermy treatments are considered covered services. (12) Range of motion tests must be performed by a qualified physical therapist. Range of motion exercises require the skills of a qualified physical therapist only when they are part of the active treatment of a specific disease or disabling condition which has resulted in a loss or restriction of mobility.Documentation must reflect the degree of motion lost, the normal range of motion, and the degree to be restored.Range of motion to unaffected joints only does not constitute a covered physical therapy service. (13) Reconditioning programs after surgery or prolonged hospitalization are not covered as physical therapy. (14) Therapeutic exercises would constitute a physical therapy service due either to the type of exercise employed or to the condition of the patient. (15) Use of isokinetic or isotonic type equipment in physical therapy is covered when normal range of motion of a joint is affected due to bone, joint, ligament or tendon injury or postsurgical trauma. Billing can only be made for the time actually spent by the therapist in instructing the patient and assessing the patient’s progress. (16) When recipients do not meet restorative or maintenance therapy criteria, diagnostic or trial therapy may be utilized. When the initial evaluation is not sufficient to determine whether there are rehabilitative goals that should be addressed, diagnostic or trial therapy to establish goals will be considered appropriate. Diagnostic or trial therapy may be appropriate for recipients who need evaluation in multiple environments in order to adequately determine their rehabilitative potential. Diagnostic or trial therapy consideration may be appropriate when there is a need to assess the patient’s response to treatment in the recipient’s environment. 1. When during diagnostic or trial therapy a recipient has been sufficiently evaluated to determine potential for restorative or maintenance therapy, or lack of therapy potential, diagnostic or trial therapy ends. When as a result of diagnostic or trial therapy, restorative or maintenance therapy is found appropriate, claims shall be submitted noting restorative or maintenance therapy (instead of diagnostic or trial therapy). 2. At the end of diagnostic or trial therapy, the rehabilitation provider shall recommend continuance of services under restorative therapy, recommend continuance of services under maintenance therapy, or recommend discontinuance of services. Continuance of services under restorative or maintenance therapy will be reviewed based on the criteria in place for restorative or maintenance therapy. 3. Trial therapy shall not be granted more often than once per year for the same issue. If the recipient has a previous history of rehabilitative services, trial therapy for the same type of services generally would be payable only when a significant change has occurred since the last therapy. Requests for subsequent diagnostic or trial therapy for the same issue would require documentation reflecting a significant change. See numbered paragraph “4” below for guidelines under a significant change. Further diagnostic or trial therapy for the same issue would not be considered appropriate when progress was not achieved unless the reasons that blocked change previously are listed and the reasons the new diagnostic or trial therapy would not have these blocks are provided. 4. The number of diagnostic or trial therapy hours authorized in the initial treatment period shall not exceed 12 hours per month. Documentation of the medical necessity and the plan for services under diagnostic trial therapy are required as they will be reviewed in the determination of the medical necessity of the number of hours of service provided.Diagnostic or trial therapy standards also apply to speech and occupational therapy.The following criteria additionally must be met:- Is soft enough and firm enough to take and hold an impression during use, and
- Is molded to the recipient’s foot or is made over a model of the foot.
"Adult" means a person who is 18 years of age or older.
"Assessment" means the review of the current functioning of the member using the service in regard to the member’s situation, needs, strengths, abilities, desires, and goals.
"Benefits education" means providing basic information to understand and access appropriate resources to pursue employment, and knowledge of work incentives and the Medicaid for employed persons with disabilities (MEPD) program. Benefits education may include gathering information needed to pursue work incentives and offering basic financial management information to members, families, guardians and legal representatives.
"Career exploration," also referred to as “career planning,” means a person-centered, comprehensive employment planning and support service that provides assistance for waiver program participants to obtain, maintain or advance in competitive employment or self-employment. Career exploration is a focused, time-limited service engaging a participant in identifying a career direction and developing a plan for achieving competitive, integrated employment at or above the state’s minimum wage. The outcome of this service is documentation of the participant’s stated career objective and a career plan used to guide individual employment support.
"Career plan" means a written plan documenting the member’s stated career objective and used to guide individual employment support services for achieving competitive, integrated employment at or above the state’s minimum wage.
"Case management" means case management services accredited under 441—Chapter 24 and provided according to 441—Chapter 90.
"Certified employment specialist" "CES" means a person who has demonstrated a sufficient level of knowledge and skill to provide integrated employment support services to a variety of client populations and has earned a CES certification through a nationally recognized accrediting body.
"Child and Adolescent Level of Care Utilization System" or "CALOCUS" means the comprehensive functional assessment tool utilized to determine eligibility for the habilitation program and service authorization for the home-based habilitation service and intensive residential habilitation services for individuals aged 16 to 18.
"Comprehensive service plan" means an individualized, person-centered, and goal-oriented plan of services written in language understandable by the member using the service and developed collaboratively by the member and the case manager.
"Customized employment" means an approach to supported employment that individualizes the employment relationship between employees and employers in ways that meet the needs of both. Customized employment is based on an individualized determination of the strengths, needs, and interests of the person with a disability and is also designed to meet the specific needs of the employer. Customized employment may include employment developed through job carving, self-employment or entrepreneurial initiatives, or other job development or restructuring strategies that result in job responsibilities being customized and individually negotiated to fit the needs of the individual with a disability. Customized employment assumes the provision of reasonable accommodations and supports necessary for the individual to perform the functions of a job that is individually negotiated and developed.
"Emergency" means a situation for which no approved individual program plan exists that, if not addressed, may result in injury or harm to the member or to other persons or in significant amounts of property damage.
"HCBS" means home- and community-based services.
"Individual employment" means employment in the general workforce where the member interacts with the general public to the same degree as nondisabled persons in the same job, and for which the member is paid at or above minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by persons without disabilities.
"Individual placement and support" "IPS" means the evidence-based practice of supported employment that is guided by IPS practice principles outlined by the IPS Employment Center at Westat as amended to July 1, 2026, and as measured by its employment fidelity scale available online at ipsworks.org as amended to July 1, 2026.
"Integrated community employment" means work (including self-employment) for which an individual with a disability is paid at or above minimum wage and not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by employees who are not disabled, where the individual interacts with other persons who are not disabled to the same extent as others who are in comparable positions, and that presents opportunities for advancement that are similar to those for employees who are not disabled. In the case of an individual who is self-employed, the business results in an income that is comparable to the income received by others who are not disabled and are self-employed in similar occupations.
"Intensive residential service homes" or "intensive residential services" means intensive, community-based services provided 24 hours per day, 7 days per week, 365 days per year to individuals with a severe and persistent mental illness who have functional impairments and may also have multi-occurring conditions. Providers of intensive residential service homes are enrolled with Medicaid as providers of HCBS habilitation, home-based habilitation, or HCBS intellectual disability waiver supported community living and meet additional criteria specified in rule 441—77.30(249A) and the provider manual as amended to July 1, 2026.
"Interdisciplinary team" means a group of persons with varied professional backgrounds who meet with the member to develop a comprehensive service plan to address the member’s need for services.
"IoWANS" means the department’s Institutional and Waiver Authorization and Narrative System.
"Level of Care Utilization System" "LOCUS" means the comprehensive functional assessment tool utilized to determine eligibility for the habilitation program and service authorization for the home-based habilitation and intensive residential services for individuals aged 19 and older.
"Managed care organization" "MCO" means an entity that (1) is under contract with the department to provide services to Medicaid recipients and (2) meets the definition of “health maintenance organization” as defined in Iowa Code section 514B.1.
"Member" means a person who has been determined to be eligible for Medicaid under 441—Chapter 75.
"Program" means a set of related resources and services directed to the accomplishment of a fixed set of goals for qualifying members.
"Severe and persistent mental illness" "SPMI" means a documented primary mental health disorder diagnosed by a mental health professional that causes symptoms and impairments in basic mental and behavioral processes that produce distress and major functional disability in adult role functioning inclusive of social, personal, family, educational, or vocational roles.
"Supported employment" means the ongoing supports to participants who, because of their disabilities, need intensive ongoing support to obtain and maintain an individual job in competitive or customized employment, or self-employment, in an integrated work setting in the general workforce at or above the state’s minimum wage or at or above the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. The outcome of this service is sustained paid employment at or above the minimum wage in an integrated setting in the general workforce in a job that meets personal and career goals. Supported employment services can be provided through many different service models.
"Supported self-employment" includes services and supports that assist the participant in achieving self-employment through the operation of a business; however, Medicaid funds may not be used to defray the expenses associated with starting up or operating a business. Assistance for self-employment may include aid to the individual in identifying potential business opportunities; assistance in the development of a business plan, including potential sources of business financing and other assistance in developing and launching a business; identification of the supports necessary for the individual to operate the business; and ongoing assistance, counseling and guidance once the business has been launched.
"Sustained employment" means an individual employment situation that the member maintains over time but not for less than 90 calendar days following the receipt of employment services and supports.
78.27(2) Member eligibility. To be eligible to receive home- and community-based habilitation services, a member shall meet the following criteria. a. LOCUS/CALOCUS actual disposition. The member has a LOCUS/CALOCUS actual disposition of level one recovery maintenance and health management or higher on the most current LOCUS/CALOCUS assessment completed within the past 30 days. b. Risk factors. The member meets at least one of the following risk-based criteria: (1) The member has a history of inpatient, partial hospitalization, or emergency psychiatric treatment more than once in the member’s life; or (2) The member has a history of continuous professional psychiatric supportive care other than hospitalization; or (3) The member has a history of involvement with the criminal justice system; or (4) Services available in the member’s community have not been able to meet the member’s needs; or (5) The member has a history of unemployment or employment in a sheltered setting or poor work history; or (6) The member has a history of homelessness or is at risk of homelessness. c. Need for assistance. The member has a need for assistance demonstrated by meeting at least two of the following criteria on a continuing or intermittent basis for at least 12 months: (1) The member needs assistance to obtain or maintain employment. (2) The member requires financial assistance to reside independently in the community. (3) The member needs significant assistance to establish or maintain a personal social support system. (4) The member needs assistance with at least one of the activities of daily living (ADLs) or instrumental activities of daily living (IADLs) to reside independently in the community. (5) The member needs assistance with management and intervention of maladaptive or antisocial behaviors to ensure the safety of the individual or others. d. Income. The countable income used in determining the member’s Medicaid eligibility does not exceed 150 percent of the federal poverty level. e. Needs assessment. The department-approved assessment tool has been completed, and Iowa Medicaid has determined that the member is in need of home- and community-based habilitation services. f. Designated case manager. The designated case manager shall: (1) Arrange for the completion of the needs-based assessment before services begin, and annually thereafter, and more frequently if significant observable changes occur in the member’s situation, condition, or circumstances. (2) Use the information submission tool and other supporting documentation as relevant to develop a comprehensive service plan as specified in subrule 78.27(4) and 441—paragraph 90.4(1)“b” before services begin and annually thereafter, and when there is a significant observable change in the member’s situation, condition, or circumstances. g. Plan for service. The department or the member’s MCO has approved the member’s comprehensive service plan for home- and community-based habilitation services. Home- and community-based habilitation services included in a comprehensive service plan or treatment plan that has been validated by Iowa Medicaid or the member’s MCO will be considered approved by the department. Home- and community-based habilitation services provided before approval of a member’s eligibility for the program cannot be reimbursed. (1) The member’s comprehensive service plan shall be completed annually according to the requirements of subrule 78.27(4) and 441—paragraph 90.4(1)“b.” A service plan may change when requested by the member or the member’s interdisciplinary team when there is a significant observable change in the member’s situation, condition, or circumstances. (2) For members receiving home-based habilitation, the service plan shall include the member’s needs-based assessment, actual disposition, the composite score, and each individual domain score for each of the six assessed domains. (3) The member’s habilitation services shall not exceed the maximum number of units established for each service in 441—subrule 79.1(2). (4) The cost of the habilitation services shall not exceed unit expense maximums established in 441—subrule 79.1(2). 78.27(3) Application for services. The member or case manager shall apply for habilitation services on behalf of a member by contacting Iowa Medicaid. The department will issue a notice of decision to the applicant in accordance with 441—Chapter 16 when financial eligibility and needs-based eligibility determinations have been completed. 78.27(4) Comprehensive service plan. Individualized, planned, and appropriate services shall be guided by a member-specific comprehensive service plan or treatment plan developed with the member in collaboration with an interdisciplinary team, as appropriate. Medically necessary services shall be planned for and provided at the locations where the member lives, learns, works, and socializes. a. Development. A comprehensive service plan or treatment plan shall be developed for each member receiving home- and community-based habilitation services based on the member’s current assessment and shall be reviewed on an annual basis. The comprehensive service plan will meet the criteria described in the HCBS habilitation manual. b. Rights restrictions. Any rights restrictions must be implemented in accordance with 441—subrule 77.30(4). c. Emergency plan. The comprehensive service plan or treatment plan shall include a plan for emergencies and identification of the supports available to the member in an emergency. Emergency plans shall be developed as detailed in the HCBS habilitation manual. d. Plan approval. Services shall be entered into IoWANS based on the comprehensive service plan. A comprehensive service plan or treatment plan that has been validated and authorized through IoWANS will be considered approved by the department. Services must be authorized in IoWANS as specified in paragraph 78.27(2)“g.” 78.27(5) Requirements for services. Home- and community-based habilitation services shall be provided in accordance with the following requirements: a. The services shall be based on the member’s needs as identified in the member’s comprehensive service plan. b. The services shall be delivered in the least restrictive environment appropriate to the needs of the member. c. The services shall include the applicable and necessary instruction, supervision, assistance, and support required by the member to achieve the member’s life goals. d. Service components that are the same or similar shall not be provided simultaneously. e. Service costs are not reimbursable while the member is in a medical institution, including but not limited to a hospital or nursing facility. f. Reimbursement is not available for room and board. g. Services shall be billed in whole units. h. Services shall be documented. Each unit billed must have corresponding financial and medical records as set forth in rule 441—79.3(249A). 78.27(6) Case management. Case management assists members in gaining access to needed medical, social, educational, housing, transportation, vocational, and other appropriate services in order to ensure the health, safety, and welfare of the member. a. Scope. Case management services shall be provided as set forth in rules 441—90.4(249A) through 441—90.7(249A). b. Exclusions. Payment will not be made for case management provided to a member who is eligible for targeted case management services under 441—Chapter 90. 78.27(7) Home-based habilitation. “Home-based habilitation” means individually tailored supports that assist with the acquisition, retention, or improvement of skills related to living, working, and recreating in the community. a. Scope. Home-based habilitation services are individualized supportive services provided in the member’s home and community that assist the member to reside in the most integrated setting appropriate to the member’s needs. Services are intended to provide for the daily living needs of the member and shall be available as needed during any 24-hour period. The specific support needs for each member shall be determined necessary by the interdisciplinary team and shall be identified in the member’s comprehensive service plan. Covered supports include: (1) Adaptive skill development; (2) Assistance with activities to address daily living needs; (3) Assistance with symptom management and participation in mental health treatment; (4) Assistance with accessing physical and mental health care treatment, communication, and implementation of health care recommendations and treatment; (5) Assistance with accessing and participating in substance use disorder treatment and services; (6) Assistance with medication administration and medication management; (7) Assistance with understanding communication whether verbal or written; (8) Community inclusion and active participation in the community; (9) Transportation; (10) Adult educational supports, which may include assistance and support with enrolling in educational opportunities and participation in education and training; (11) Social and leisure skill development; (12) Personal care; and (13) Protective oversight and supervision. b. Setting requirements. Home-based habilitation services shall occur in the member’s home and community. (1) A member may live in the member’s own home, within the home of the member’s family or legal representative, or in another community living arrangement that meets the criteria in 441—subrule 77.30(5). (2) A member living with the member’s family or legal representative is not subject to the criteria in 441—paragraphs 77.30(7)“d” and “e.” (3) A member may not reside in a licensed medical or health care facility or in a setting that is required to be licensed as a medical or health care facility. c. Home-based habilitation level of service criteria. Home-based habilitation services shall be available to members based on the member’s most current LOCUS/CALOCUS actual disposition score, according to the following criteria: (1) Intensive IV residential habilitation services. Intensive IV services are provided 24 hours per day. To be eligible for intensive IV services, a member must meet the following criteria: 1. The member has a LOCUS/CALOCUS actual disposition of level six medically managed residential services, and 2. The member is in need of 24-hour supervised and monitored treatment to maintain or improve functioning and avoid relapse that would require a higher level of treatment; (2) Intensive III services are provided 17 to 24 hours per day. To be eligible for intensive III services, the member must have a LOCUS/CALOCUS actual disposition of level five. (3) Intensive II services are provided 13 to 16.75 hours per day. To be eligible for intensive II services, the member must have a LOCUS/CALOCUS actual disposition of level four. (4) Intensive I services are provided 9 to 12.75 hours per day. To be eligible for intensive I services, the member must have a LOCUS/CALOCUS actual disposition of level three. (5) Medium need services are provided 4.25 to 8.75 hours per day as needed. To be eligible for medium need services, the member must have a LOCUS/CALOCUS actual disposition of level two. (6) Recovery transitional services are provided 2.25 to 4 hours per day as needed. To be eligible for recovery transitional services, the member must have a LOCUS/CALOCUS actual disposition of level one. (7) High recovery services are provided 0.25 to 2 hours per day as needed. To be eligible for high recovery services, the member must have a LOCUS/CALOCUS actual disposition of level one. d. Additional criteria for receiving home-based habilitation services for transition-age youth 16 to 18 years of age. (1) Members residing in the family home may receive home-based habilitation services as needed, subject to the criteria set forth in this rule. (2) Individuals 16 to 18 years of age shall receive 24-hour site supervision and support. (3) Members residing outside of the family home may receive daily home-based habilitation in a provider-owned or controlled setting when the following criteria are met: 1. The proposed living environment must meet HCBS setting requirements in accordance with 441—subrule 77.30(5). 2. All providers of the service setting being requested must meet the following additional safety and service requirements for serving youth under the age of 18: - Members who are 18 years of age or over and have a primary diagnosis of intellectual disability, developmental disabilities, or chronic mental illness as defined in rule 441—90.1(249A).
- Members who are under 18 years of age and are eligible to receive services under the HCBS intellectual disability waiver or children’s mental health waiver.
"Assessment" means the review of the current functioning of the member using the service in regard to the member’s situation, needs, strengths, abilities, desires, and goals.
"Brain injury" means a diagnosis in accordance with rule 441—83.81(249A).
"Health care" means the services provided by trained and licensed health care professionals to restore or maintain the member’s health.
"Intermittent community-based neurobehavioral rehabilitation services" are provided to a Medicaid member on an as-needed basis to support the member and the member’s family or caregivers to assist the member to increase adaptive behaviors, decrease maladaptive behaviors, and adapt and accommodate to challenging behaviors to support the member to remain in the member’s own home and community.
"Member" means a person who has been determined to be eligible for Medicaid under 441—Chapter 75.
"Neurobehavioral rehabilitation" refers to a specialized category of neurorehabilitation provided by a multidisciplinary team that has been trained in, and delivers, services individually designed to address cognitive, medical, behavioral and psychosocial challenges, as well as the physical manifestations of acquired brain injury. Services concurrently work to optimize functioning at personal, family and community levels, by supporting the increase of adaptive behaviors, decrease of maladaptive behaviors and adaptation and accommodation to challenging behaviors to support a member to maximize the member’s independence in activities of daily living and ability to live in the member’s home and community.
"Program" means a set of related resources and services directed to the accomplishment of a fixed set of goals for eligible members.
"Standardized assessment" means a valid, reliable, and comprehensive functional assessment tool(s) or process, or both, approved by the department for use in the assessment of a member’s individual needs.
78.55(2) Member eligibility. To be eligible to receive community-based neurobehavioral rehabilitation services, a member shall meet the following criteria: a. Brain injury diagnosis. To be eligible for community-based neurobehavioral rehabilitation services, the member must have a brain injury diagnosis as set forth in rule 441—83.81(249A). b. Risk factors. The member has the following post-brain injury risk factors: (1) The member is exhibiting neurobehavioral symptoms in such frequency or severity that the member has undergone or is currently undergoing treatment more intensive than outpatient care and is currently hospitalized, institutionalized, incarcerated or homeless or is at risk of hospitalization, institutionalization, incarceration or homelessness; or (2) The member has a history of presenting with neurobehavioral or psychiatric symptoms resulting in at least one episode that required professional supportive care more intensive than outpatient care more than once in a lifetime (e.g., emergency services, alternative home care, partial hospitalization, or inpatient hospitalization). c. Need for assistance. The member exhibits neurobehavioral symptoms in such frequency, severity or intensity that community-based neurobehavioral rehabilitation is required. d. Needs assessment. The member shall have an assessment of need completed prior to admission. The member shall have the Mayo-Portland Adaptability Inventory (MPAI) assessment as amended to July 1, 2026, completed by a qualified trained assessor. The assessment of need shall document the member’s need for community-based neurobehavioral rehabilitation, and Iowa Medicaid or the member’s MCO has determined that the member is in need of specialty neurobehavioral rehabilitation services. e. Standards for assessment. Each member will have had the MPAI assessment completed within the 90 days prior to admission. In addition to the functional assessment, the needs assessment will have been completed and will include the assessment of a member’s individual physical, emotional, cognitive, medical and psychosocial residuals related to the member’s brain injury and must include the following: (1) Identification of the neurobehavioral needs that put the member at risk, including but not limited to verbal aggression, physical aggression, self-harm, unwanted sexual behavior, cognitive and or behavioral perseveration, wandering or elopement, lack of motivation, lack of initiation or other unwanted social behaviors not otherwise specified. (2) Identification of triggers of unwanted behaviors and the member’s ability to self-manage the member’s symptoms. (3) The member’s rehabilitation and medical care history to include medication history and status. (4) The member’s employment history and the member’s barriers to employment. (5) The member’s dietary and nutritional needs. (6) The member’s community accessibility and safety. (7) The member’s access to transportation. (8) The member’s history of substance use. (9) The member’s vulnerability to exploitation and history of risk of exploitation. (10) The member’s history and status of relationships, natural supports and socialization. f. Emergency admission. In the event that emergency admission is required, the assessment shall be completed within ten calendar days of admission. 78.55(3) Covered services. a. Service setting. (1) Community-based neurobehavioral residential rehabilitation services are provided to a member living in a three-to-five-bed residential care facility with a specialized license designation issued by the department of inspections, appeals, and licensing; or (2) Community-based neurobehavioral intermittent rehabilitation services are provided to a member living in the member’s own residence in the community. No payment shall be made for community-based neurobehavioral rehabilitation when provided in a medical institution such as an ICF/ID, nursing facility or skilled nursing facility. b. Community-based neurobehavioral rehabilitation residential services identified in the treatment plan may include: (1) Prescriptive programming to maintain and advance progress made in rehabilitation; (2) Modifying or adapting the member’s environment to improve overall functioning; (3) Assistance in obtaining preventative, appropriate and timely medical and dental care; (4) Compensatory strategies to assist in managing ADLs; (5) Assistance with coordinating and obtaining physical, oral, or mental health care and any other professional services necessary to the member’s health and well-being; (6) Behavioral and cognitive programming and supports; (7) Medication management and consultation with pharmacy; (8) Health and wellness management including dietary and nutritional programming; (9) Progressive physical strengthening, fitness and retraining; (10) Assistance with obtaining and use of assistive technology; (11) Sobriety support development; (12) Assistance with the self-identification of antecedent triggers; (13) Assistance with preparation for transition to less intensive services including accessing the community; (14) Flexibility in programming to meet individual needs; (15) Assistance with re-learning coping and compensatory strategies; (16) Support and assistance in seeking substance use and co-occurring disorders services; (17) Support and assistance with obtaining legal consultation and services; (18) Assistance with community accessibility and safety; (19) Assistance with re-learning household maintenance; (20) Assistance with recreational and leisure skill development; (21) Assistance with the development and application of self-advocacy skills to navigate the service system; (22) Opportunities to learn about brain injury and individual needs following brain injury; (23) Support for carrying out the member’s individual goals in the rehabilitation treatment plan; (24) Assistance with pursuit of education and employment goals; (25) Protective oversight in the residential setting and community; (26) Assistance and education to family, providers and other support system interests that are supporting the member receiving neurobehavioral rehabilitation services; (27) Transitional support and training; (28) Transportation essential to the attainment of the member’s individual goals in the rehabilitation treatment plan; (29) Promotion of a program structure and support for members served so they can relearn or regain skills for maximum independence, community access, and integration. c. Community-based neurobehavioral rehabilitation intermittent services identified in the treatment plan may occur in the member’s own home with or on behalf of the member and may include: (1) Promotion of a program structure and support for members served so they can re-learn or regain skills for maximum community inclusion and access; (2) Modifying or adapting the member’s environment to improve overall functioning; (3) Compensatory strategies to assist in managing ADLs; (4) Behavioral supports; (5) Assistance with obtaining and use of assistive technology; (6) Assistance with the self-identification of antecedent triggers; (7) Flexibility in programming to meet the member’s individual needs; (8) Assistance with re-learning coping and compensatory strategies; (9) Assistance with the development and application of self-advocacy skills to navigate the service system; (10) Support for carrying out the member’s individual goals in the rehabilitation treatment plan; (11) Assistance and education to family, providers and other support system interests that are supporting the member receiving community-based neurobehavioral rehabilitation services; (12) Transitional support and training; (13) Transportation essential to the attainment of the member’s individual goals in the rehabilitation treatment plan. d. Approval of treatment plan. The community-based neurobehavioral services provider shall submit the proposed plan of care, the results of the member’s formal assessment, and medical documentation supporting a brain injury diagnosis to Iowa Medicaid for approval before providing the services. e. Initial treatment plan. Within 30 days of admission, the provider shall submit the member’s treatment plan to Iowa Medicaid. (1) Iowa Medicaid will approve the provider’s treatment plan if: 1. The treatment plan conforms to the medical necessity requirements in subrule 78.55(4); 2. The treatment plan is consistent with the written diagnosis and treatment recommendations made by a licensed medical professional that is a licensed neuropsychologist or neurologist, M.D., or D.O.; 3. The treatment 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; and 5. The treatment plan does not exceed 180 days in duration. (2) A treatment summary detailing the member’s response to treatment during the previous approval period must be submitted when approval for subsequent plans is requested. f. Subsequent plans. Iowa Medicaid may approve a subsequent neurobehavioral rehabilitation treatment plan that conforms to the conditions of medical necessity pursuant to subrule 78.55(4) and to the conditions pursuant to subrule 78.55(3). g. Quality review. Iowa Medicaid may perform the quality review to evaluate: (1) The time elapsed from referral to rehabilitation treatment plan development; (2) The continuity of treatment; (3) The length of stay per member; (4) The affiliation of the medical professional recommending services with the neurobehavioral rehabilitation services provider; (5) Gaps in service; (6) The results achieved; (7) Member and stakeholder satisfaction; (8) The provider’s compliance with standards listed in rule 441—77.53(249A). 78.55(4) Medical necessity. Nothing in this rule will be deemed to exempt coverage of community-based neurobehavioral rehabilitation 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. 78.55(5) Documentation standards. Community-based neurobehavioral rehabilitation service providers shall maintain service provision records, financial records, and clinical records in accordance with the provisions of rule 441—79.3(249A).Related ARC(s): 0315D441—78.56(249A) Child care medical services. Payments will be made to licensed child care centers that provide medical services in addition to child care. Medically necessary services are provided under a plan of care that is developed by licensed professionals within their scope of practice and authorized by the member’s physician. The services include and implement a comprehensive protocol of care that is developed in conjunction with the parent or guardian and specifies the medical, nursing, personal care, psychosocial and developmental therapies required by the medically dependent or technologically dependent child served. 78.56(1) Nursing services are services that are provided by a registered nurse or a licensed practical nurse under the direction of the member’s physician to a member in a licensed child care center. Nursing services shall be provided according to a written plan of care authorized by a physician. Payment for nursing services may be approved if the services are determined to be medically necessary as defined in subrule 78.56(5). Nursing services include activities that require the expertise of a nurse, such as physical assessment, tracheostomy care, medication administration, and tube feedings. 78.56(2) Personal care services are those services that are provided by an aide but are delegated and supervised by a registered nurse under the direction of the member’s physician. Payment for personal care services may be approved if the services are determined to be medically necessary as defined in subrule 78.56(5). Personal care services shall be in accordance with the member’s plan of care and authorized by a physician. Personal care services include the activities of daily living, oral hygiene, grooming, toileting, feeding, range of motion and positioning, and training the member in necessary self-help skills, including teaching prosocial skills and reinforcing positive interactions. 78.56(3) Psychosocial services are those services that focus at decreasing or eliminating maladaptive behaviors. Payment for psychosocial services may be approved if the services are determined to be medically necessary as defined in subrule 78.56(5). Psychosocial services shall be in accordance with the member’s plan of care and authorized by a physician. Psychosocial services include implementing a plan using clinically accepted techniques for decreasing or eliminating maladaptive behaviors. Psychosocial intervention plans must be developed and reviewed by licensed mental health providers. 78.56(4) Developmental therapies are those services that are provided by an aide but are delegated and supervised by a licensed therapist under the direction of the member’s physician. Payment for developmental therapies may be approved if the services are determined to be medically necessary as defined in subrule 78.56(5). Developmental therapies shall be in accordance with the member’s plan of care and authorized by a physician. Developmental therapies include activities based on the individual’s needs such as fine motor, gross motor, and receptive expressive language. 78.56(5) “Medically necessary” means the service is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions that endanger life, cause pain, result in illness or infirmity, or threaten to cause or aggravate a disability or chronic illness and is an effective course of treatment for the member requesting a service. 78.56(6) Requirements. a. Nursing, psychosocial, developmental therapies and personal care services shall be ordered in writing. b. Nursing, psychosocial, developmental therapies and personal care services shall be authorized by the department or the department’s designated review agent prior to payment. c. Prior authorization shall be requested at the time of initial submission of the plan of care or at any time the plan of care is substantially amended and shall be renewed with the department or the department’s designated review agent. Initial request for and request for renewal of prior authorization shall be submitted to the department’s designated review agent. The provider of the service is responsible for requesting prior authorization and for obtaining renewal of prior authorization. The request for prior authorization shall include a nursing assessment, the plan of care, and supporting documentation. A treatment plan shall be completed prior to the start of care and at a minimum reviewed every 180 days thereafter. The plan of care shall support the medical necessity and intensity of services to be provided by reflecting the following information: (1) Place of service. (2) Type of service to be rendered and the treatment modalities being used. (3) Frequency of the services. (4) Assistance devices to be used. (5) Date on which services were initiated. (6) Progress of member in response to treatment. (7) Medical supplies to be furnished. (8) Member’s medical condition as reflected by the following information, if applicable: 1. Dates of prior hospitalization. 2. Dates of prior surgery. 3. Date last seen by a primary care provider. 4. Diagnoses and dates of onset of diagnoses for which treatment is being rendered. 5. Prognosis. 6. Functional limitations. 7. Vital signs reading. 8. Date of last episode of acute recurrence of illness or symptoms. 9. Medications. (9) Discipline of the person providing the service. (10) Certification period. (11) Physician’s signature and date. The treatment plan must be signed and dated by the physician before the claim for service is submitted for reimbursement. (12) The appropriate department form is utilized during the prior authorization review. 78.56(7) Nursing, personal care, and psychosocial services do not include: a. Services provided to members aged 21 and older. b. Services that require prior authorizations that are provided without regard to the prior authorization process. c. Nursing services provided simultaneously with other Medicaid services (e.g., home health aide, physical, occupational, or speech therapy services, etc.). d. Services that exceed the services that are approvable under the private duty nursing and personal care program pursuant to subrule 78.9(10). e. Transportation services. f. Services provided to a member while the member is in institutional care.Related ARC(s): 0315D441—78.57(249A) Qualified Medicare beneficiary (QMB) provider services. 78.57(1) Payment. Payment will be made to QMB providers for a QMB-eligible member’s coinsurance, copayment, and deductible for Medicare-covered services. The eligible member may be responsible for copayments pursuant to 441—subrule 79.1(13). 78.57(2) Definitions. "Coinsurance" means a percentage of costs of a covered health care service that has to be paid.
"Copayment" means a fixed amount a member pays for a covered health care service.
"Deductible" means the amount paid for covered health care services before the insurance plan will effect payment.
"Medicare cost sharing" means the Medicare member’s responsibility for a Medicare-covered service. “Medicare cost sharing” includes coinsurance, copayments, and deductibles.
"Qualified Medicare beneficiary" "QMB" means an individual who has been determined eligible for the QMB program pursuant to 441—paragraph 75.6(5)“a.” Under the QMB program, Medicaid pays the individual’s Medicare Part A and B premiums, coinsurance, copayment, and deductible (except for Part D).
Related ARC(s): 0315D441—78.58(249A) Health insurance premium payment (HIPP) provider services. 78.58(1) Reimbursement. A HIPP provider may bill the department for the HIPP-eligible member’s out-of-pocket cost-sharing obligations. Reimbursement of claims is limited to in-network coinsurance, copayments, and deductibles of the HIPP-eligible member’s health insurance, paid for through the HIPP program. The HIPP-eligible member may be responsible for a copayment pursuant to 441—subrule 79.1(13). 78.58(2) Definitions. "Coinsurance" means a percentage of costs of a covered health care service that has to be paid.
"Copayment" means a fixed amount a member pays for a covered health care service.
"Cost sharing" means the member’s health insurance in-network responsibility for a covered service. “Cost sharing” includes coinsurance, copayments, and deductibles.
"Deductible" means the amount paid for covered health care services before the insurance plan will effect payment.
"Eligible member" means an individual eligible for Medicaid pursuant to rule 441—75.1(249A) et seq. and who qualifies for and is participating in the department’s HIPP program prescribed under rule 441—75.21(249A).
"Health insurance premium payment program" "HIPP program" has the same meaning as provided in rule 441—75.21(249A).
Related ARC(s): 0315D441—78.59(249A) Crisis response services. Payment will be made to providers (eligible pursuant to rule 441—77.54(249A)) of crisis response services, crisis stabilization community-based services, and crisis stabilization residential services delivered as set forth in 441—Chapter 24.Related ARC(s): 0315D441—78.60(249A) Subacute mental health services. Payment will be made to providers (eligible pursuant to rule 441—77.55(249A)) for the provision of subacute mental health care facility services that meet the standards outlined in 481—Chapter 71.Related ARC(s): 0315DThese rules are intended to implement Iowa Code chapter 249A.Related ARC(s): 7548B, 7957B, 8008B, 8097B, 8205B, 8344B, 8504B, 8643B, 8714B, 8993B, 8994B, 9045B, 9132B, 9175B, 9256B, 9311B, 9315B, 9316B, 9403B, 9440B, 9487B, 9588B, 9649B, 9650B, 9699B, 9702B, 9704B, 9834B, 9882B, 9883B, 9884B, 9981B, 0065C, 0191C, 0194C, 0198C, 0305C, 0358C, 0359C, 0354C, 0360C, 0545C, 0580C, 0631C, 0632C, 0707C, 0709C, 0757C, 0823C, 0838C, 0842C, 0844C, 0846C, 0848C, 0994C, 1071C, 1052C, 1056C, 1054C, 1051C, 1151C, 1264C, 1297C, 1610C, 1696C, 1850C, 1976C, 2050C, 2164C, 2166C, 2361C, 2340C, 2341C, 2471C, 2848C, 2930C, 2936C, 3005C, 3184C, 3481C, 3494C, 3551C, 3552C, 3553C, 3790C, 3874C, 4430C, 4575C, 4792C, 4897C, 4899C, 5175C, 5305C, 5307C, 5362C, 5364C, 5418C, 5487C, 5597C, 5808C, 5809C, 5896C, 5889C, 6122C, 6222C, 6310C, 6389C, 6390C, 6624C, 6735C, 6781C, 6937C, 8204C, 8958C, 8959C, 9494C, 9615C, 0315D