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CHAPTER 78AMOUNT, DURATION AND SCOPE OFMEDICAL AND REMEDIAL SERVICES[Prior to 7/1/83, Social Services[770] Ch 78][Prior to 2/11/87, Human Services[498]]441—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 shall 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 assistant, or advanced registered nurse practitioner) 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 state department of public health. b. Reserved. c. Treatment of certain foot conditions as specified in 78.5(2)“a,” “b,” and “c.” d. Acupuncture treatments. e. Reserved. f. Unproven or experimental medical and surgical procedures. The criteria in effect in the Medicare program shall be utilized in determining when a given procedure is unproven or experimental in nature. g. Charges for surgical procedures on the “Outpatient/Same Day Surgery List” produced by the IME medical services unit 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 admittance to the hospital. Approval shall 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” shall be published by the department in the provider manuals for hospitals and physicians. The “Outpatient/Same Day Surgery List” shall be developed by the IME medical services unit and shall include procedures which can safely and effectively be performed in a doctor’s office or on an outpatient basis in a hospital. The IME medical services unit may add, delete, or modify entries on the “Outpatient/Same Day Surgery List.” h. 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, 155A.27 and 155A.29. For the purposes of the medical assistance program, prescriptions for medical supplies are required and shall be subject to the same provisions. d. Reserved. e. 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 is 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. When injecting an amphetamine or legend vitamin, prior approval must be obtained as specified in 78.1(2)“a”(3). 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 Vaccines for Children (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) for any “Part D eligible individual” as defined in 42 U.S.C. Section 1395w-101(a)(3)(A), 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 which can be expected primarily to improve physical appearance or which is performed primarily for psychological purposes or which restores form but which 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. (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 which 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 which 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 which are justified primarily on the basis of a psychological or psychiatric need. (3) Augmentation mammoplasties. (4) Face lifts 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 which 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 shall 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 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 shall be made for the services of a private duty nurse. 78.1(8) Payment for mileage shall 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 shall be based on a follow-up home visit. When more than one patient is seen in a single visit, payment shall 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 which are performed by a nurse practitioner, clinical nurse specialist, or physician assistant as specified in 441—paragraph 81.13(13)“e.” 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 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.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.Advanced registered nurse practitioners certified under board of nursing rules in655—Chapter 7 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. Advanced registered nurse practitioners who prescribe drugs and medical devices are subject to the guidelines in effect for physicians as specified in rule 441—78.1(249A).A physician assistant licensed under board of physician assistants’ professional licensure rules in 645—Chapters 326 to 329 is exempt from the direct personal supervision requirement except as expressly required by Iowa Code chapter 148C or required by rules in 645—Chapters 326 to 329. A physician shall be accessible at all times for consultation with a physician assistant unless the physician assistant is providing emergency medical services pursuant to 645—paragraph 327.1(2)“n.” Physician assistants 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 WIC program, 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 shall 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 which 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 or retardation 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 which 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) Form 470-0835 or 470-0835(S), Consent Form, or (2) An official sterilization consent form from another state’s Medicaid program that contains all information found on the Iowa 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 which 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 “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: (1) The person to be sterilized, (2) The interpreter, when one was necessary, (3) The physician, and (4) The person who provided the required information. i. Informed consent shall not be obtained while the individual to be sterilized is: (1) In labor or childbirth, or (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 that she has 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, or (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 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 Form 470-0836 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. Form 470-0836 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. Form 470-0836 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 441—78.6(249A). (Cross reference 78.28(4)) 78.1(19) Preprocedure review by the IME medical services unit will be required if payment under Medicaid is to be made for certain frequently performed surgical procedures which 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 the IME medical services unit 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 the IME medical services unit and the department. If not so approved by the IME medical services unit, 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 the IME medical services unit. 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 the IME medical services unit. (Cross references 78.1(19) and 78.28(1)“f”)Covered liver transplants are payable only when performed in a facility that meets the requirements of 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 the IME medical services unit. (Cross references 78.1(19) and 78.28(1)“f”) Covered heart transplants are payable only when performed in a facility that meets the requirements of 78.3(10). (6) Lung transplants. Lung transplants for persons having end-stage pulmonary disease. Lung transplants require preprocedure review by the IME medical services unit. (Cross references 78.1(19) and 78.28(1)“f”) Covered transplants are payable only when performed in a facility that meets the requirements of 78.3(10). Heart-lung transplants are covered consistent with criteria in subparagraph (5) above. (7) Pancreas transplants for persons with type I diabetes mellitus, as follows: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. The pancreas transplants listed under this subparagraph require preprocedure review by the IME medical services unit. (Cross references 78.1(19) and 78.28(1)“f”)Covered transplants are payable only when performed in a facility that meets the requirements of 78.3(10).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 “a.” 78.1(21) Utilization review. Utilization review shall be conducted of Medicaid members who access more than 24 outpatient visits in any 12-month period from physicians, advanced registered nurse practitioners, federally qualified health centers, other clinics, and emergency rooms. For the purposes of utilization review, the term “physician” does not include a psychiatrist. Refer to rule 441—76.9(249A) for further information concerning the member lock-in program. 78.1(22) Risk assessment. Risk assessment, using Form 470-2942, Medicaid Prenatal Risk Assessment, 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. Enhanced services include health education, social services, nutrition education, and a postpartum home visit. Additional reimbursement shall 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 shall be made for application of an FDA-approved topical fluoride varnish, as defined by the current version of the Code on Dental Procedures and Nomenclature (CDT) published by the American Dental Association, 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 shall be available only for application of topical fluoride varnish, which shall be at the same rate of reimbursement paid to dentists for providing this service. Separate payment for the limited oral screening shall 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 shall be governed pursuant to subrule 78.28(2).This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 8714B, 0065C, 0305C, 0846C, 1052C, 1297C, 2164C, 2361C, 4899C, 5418C, 5808C441—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) 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(38). 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, subject to the provisions of Iowa Code section 155A.29 regarding refills. 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). 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. However, prior authorization shall not be required for such a drug for a member whose regimen on the drug was established before January 1, 2011, as verified by documented pharmacy claims. (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: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), 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 shall be found in rules of the Iowa board of pharmacy.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 8097B, 9175B, 9699B, 9834B, 9882B, 9981B, 0305C, 0580C, 2361C, 2930C, 4899C, 5175C, 5364C441—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 the Iowa Medicaid enterprise. 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. (Cross reference 78.28(6)) The criteria are available from the IME Medical Services Unit, 100 Army Post Road, Des Moines, Iowa 50315, 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 requires prior approval, which must be obtained by the attending physician before surgery is performed. 78.3(5) Payment will be approved for drugs provided inpatients subject to the same provisions specified in 78.2(1) and 78.2(4)“b”(1) to (10) except for 78.2(4)“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 outpatients subject to the same provisions specified in 78.2(1) through 78.2(4) except for 78.2(4)“b”(7). The basis of payment for drugs provided 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 Vaccines for Children (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 shall be made to those hospitals which have been certified by the department of inspections and appeals as meeting the standards for a nursing facility. 78.3(7) Payment for inpatient hospital tests for purposes of diagnosis and treatment shall 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 shall 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 mental illness as defined in 441—subrule 77.47(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:A surgeon director.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:Anesthesiology.Cardiology.Dialysis.Gastroenterology.Hepatology.Immunology.Infectious diseases.Nephrology.Neurology.Pathology.Pediatrics.Psychiatry.Pulmonary medicine.Radiology.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 the following:Persons with expertise in the following areas available at the transplant center:Anesthesiology.Blood bank services.Cardiology.Cardiovascular surgery.Dialysis.Dietary services.Gastroenterology.Infection control.Laboratory services (pathology, microbiology, immunology, tissue typing, and monitoring of immunosuppressive drugs).Legal counsel familiar with transplantation laws and regulations.Nursing service department with staff available who have expertise in the care of transplant recipients, especially in managing immunosuppressed patients and hemodynamic support.Respiratory therapy.Pharmaceutical services.Physical therapy.Psychiatry.Psycho-social.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 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:Risk and benefit.Morbidity and mortality.Long-term survival.Quality of life.Recipient demographic information.These data should be maintained in the computer at the transplant center monthly.The transplant center will submit the above data to the United Network of 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 the Iowa Medicaid enterprise provider services unit. 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 the Iowa Medicaid enterprise provider services unit. 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.There will be established protocol for the systematic evaluation of patient outcome including survival statistics.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 which 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 the IME medical services unit 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—subparagraph 81.6(16)“f”(3) plus the non-direct care rate component limit for Medicare-certified hospital-based nursing facilities pursuant to 441—subparagraph 81.6(16)“f”(3), 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 the IME medical services unit that the lower level of care is required or (b) for the days the IME medical services unit 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 the IME medical services unit 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—subparagraph 81.6(16)“f”(1) plus the non-direct care rate component limit for Medicaid nursing facilities pursuant to 441—subparagraph 81.6(16)“f”(1), 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 the IME medical services unit that the lower level of care is required or (b) for the days the IME medical services unit 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 the IME medical services acute retrospective review team. 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 IME 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 the IME. 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 and appeals 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—subparagraph 81.6(16)“f”(3) and the non-direct care rate component limit for Medicare-certified hospital-based nursing facilities pursuant to 441—subparagraph 81.6(16)“f”(3), 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: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. 78.10(3) Prosthetic devices. Prosthetic devices mean replacement, corrective, or supportive devices prescribed by a physician (doctor of medicine, osteopathy or podiatry), physician assistant, or advanced registered nurse practitioner 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 78.10(5)“l” for prior authorization requirements. (4) Hearing aids. See rule 441—78.14(249A). (5) Orthotic devices. See 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. (Cross reference 78.28(5)) c. Cranial orthotic device. Payment shall 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 either: (1) The member is 12 weeks of age but younger than 36 weeks of age and has failed to respond to a two-month trial of repositioning therapy; or (2) The member is 36 weeks of age but younger than 108 weeks of age and there is documentation of either of the following conditions:Individuals 17.5 to 18 years of age shall receive 24-hour site supervision and support. 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. 3. The member’s parent or guardian has consented to home-based habilitation 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). 5. A licensed setting, such as those approved to provide residential-based supported community living, is not available. f. Exclusions. Home-based habilitation payment shall 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 intermediate care facility for persons with mental retardation. (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 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.). 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:Having a body mass index (BMI) over 25 for an adult, or Weighing over the 85th percentile for the pediatric population. 7. Hypertension. 8. Chronic obstructive pulmonary disease. 9. Chronic pain. (2) “At risk” means a documented family history of a verified heritable condition described above, a diagnosed medical condition with an established comorbidity to a condition described above, or a verified environmental exposure to an agent or condition known to be the cause of a condition from the conditions described above. b. Integrated health home eligible member criteria. To be eligible for integrated health home services, the member must have a serious mental illness or serious emotional disturbance, as such terms are defined in 441—subrule 77.47(1). 78.53(4) Member identification and enrollment. a. Eligible members are identified through a referral from the department, lead entity, primary care provider, hospital, other providers, the member, or the member’s authorized representative. b. The health home confirms eligibility for health home services by obtaining assessment documentation from the member’s licensed mental health professional or the patient tiering assignment tool (PTAT). c. The health home must explain to the member, in a format easily understood by the member, how the team works together with the member at the center to improve the member’s care, as well as all team member roles and responsibilities. d. The health home must advise members of their ability and the process to opt out of health home services at any time. e. Eligible members must agree to participate in the health home program, and the health home must document the member’s agreement in the member’s record before submitting an enrollment request. A member cannot be in more than one health home at the same time. f. The health home must assess the member’s continued eligibility for health home services on an annual basis to ensure the member remains eligible to participate in the program. 78.53(5) Health home documentation. A health home must maintain adequate supporting documentation in readily reviewable form to ensure all state and federal requirements related to health home services have been met. All health home services must be documented in accordance with rule 441—79.3(249A). At a minimum, the health home must document the following: a. Eligibility. Eligibility documentation includes but is not limited to the following: (1) How the member presented to the health home, including the referral. (2) Identified needs and plan to assess for eligibility. (3) Documentation that the member is eligible for health home services. If a member is not eligible, the health home must document the plan to support the member. (4) Qualifying diagnosis that makes the member eligible for health home services. (5) Member agreement and understanding of the program. (6) Enrollment request. (7) Enrollment with the health home. (8) Plan to complete the comprehensive assessment. (9) Documentation of continued eligibility, reviewed annually and maintained in the member’s service record. b. Comprehensive assessment. The comprehensive assessment must include all aspects of a member’s life and satisfy the following requirements: (1) The comprehensive assessment must be completed within 30 days of enrollment, and at least every 365 days, or more frequently when the member’s needs or circumstances change significantly or at the request of the member or member’s support. (2) The comprehensive assessment for members enrolled to receive non-intensive care management or enrolled in the chronic condition health home must include: 1. Assessment of the member’s current and historical information provided by the member, the lead entity, and other health care providers that support the member; 2. Assessment of physical and behavioral health needs, medication reconciliation, functional limitations, and appropriate screenings; 3. Assessment of the member’s social environment so that the plan of care incorporates areas of needs, strengths, preferences, and risk factors; and 4. Assessment of the member’s readiness for self-management using screenings and assessments with standardized tools. (3) The comprehensive assessment for members enrolled to receive intensive care management must be in a format designated by the department and must include: 1. The member’s relevant history, including the findings from the independent evaluation of eligibility, medical records, an objective evaluation of functional ability, and any other records or information needed to complete the comprehensive assessment. 2. The member’s physical, cognitive, and behavioral health care and support needs; strengths and preferences; available service and housing options; and, if unpaid caregivers will be relied upon to implement any elements of the person-centered service plan, a caregiver assessment. 3. Documentation that no state plan HCBS is provided that would otherwise be available to the member through other Medicaid services or other federally funded programs. 4. For members receiving state plan HCBS and HCBS approved under 441—Chapter 83, documentation that HCBS provided through the state plan and waiver are not duplicative. c. Person-centered service plan and person-centered care plan. (1) For members receiving non-intensive care management or enrolled in the chronic condition health home, documentation must include a person-centered care plan that meets the requirements as defined in subrule 78.53(1) and the health home state plan amendment. (2) For members receiving intensive care management, documentation must include a service plan that meets the requirements of rule 441—78.27(249A) or 441—83.127(249A) and 441—paragraph 90.4(1)“b.” (3) Documentation must reflect an update of the plan no less often than every 365 days and when significant changes occur in the member’s support needs, situation, condition, or circumstances. d. Core services. Documentation must reflect monthly provision of one of the six core health home services as outlined in subrule 78.53(2). e. Intensive health home services. A health home must provide documentation to justify provision of more intensive health home services, including documentation that the member is enrolled to receive services through the HCBS habilitation or HCBS children’s mental health waiver programs. f. Continuity of care. (1) The health home must maintain a continuity of care document in each enrolled member’s record and provide this document to the department, the lead entity, and the member’s treating providers upon request. (2) The continuity of care document must include, at a minimum, all aspects of the member’s medical and behavioral health needs, treatment plan, and medication list. g. Disenrollment. Members are able to opt out of health home services at any time. The health home must document a member’s request to disenroll from health home services, the reason for disenrollment, how the member’s needs will be supported after disenrollment, and that the health home has advised the member of the ability to re-enroll if circumstances change. 78.53(6) Payment. a. Payment will be made for health home services when: (1) The member is eligible for Medicaid and enrolled in the health home for the month of service, and (2) The health home provides at least one of the six core health home services described in subrule 78.53(2) during the month, and (3) The health home maintains the documentation outlined in subrule 78.53(5). b. A unit of service is one member month. c. The health home must report the informational-only code in addition to the billing procedure code and modifier for one or more of the core services provided to the member during the month on the claim for payment.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 6310C441—78.54(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 (Medicare).This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 0360C, 6310C441—78.55(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 653—13.11(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.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 2166C, 6310C441—78.56(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. 78.56(1) Definitions.
- Simultaneous pancreas-kidney transplants and pancreas after kidney transplants are covered.
- Pancreas transplants alone are covered for persons exhibiting any of the following:
- Has on file with the department current contact information, including a current fax number, and a signed Form 470-4914, Fax Confidentiality Certificate, and
- Does not receive a notice of approval or disapproval within 48 hours of a request for prior authorization.
- Complete a level of care (LOC) determination describing a member’s LOC needs, using Form 470-5156, Swing Bed Certification.
- Contact skilled nursing facilities within a 30-mile radius of the hospital regarding available beds to meet the member’s LOC needs.
- 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.
- Ordering of corrective lenses.
- Verification of lenses after fabrication.
- Adjustment and alignment of completed lens order.
- Up to three times for children up to one year of age.
- Up to four times per year for children one through three years of age.
- Once every 12 months for children four through seven years of age.
- Once every 24 months after eight years of age when there is a change in the prescription.
- Children through seven years of age.
- Members with vision in only one eye.
- Members with a diagnosis-related illness or disability where regular lenses would pose a safety risk.
- Selection and styling.
- Sizing and measurements.
- Fitting and adjustment.
- Readjustment and servicing.
- One frame every six months is allowed for children through three years of age.
- One frame every 12 months is allowed for children four through seven years of age.
- When there is a covered lens change and the new lenses cannot be accommodated by the current frame.
- Children through seven years of age.
- Members with a diagnosis-related disability or illness where regular frames would pose a safety risk or result in frequent breakage.
- 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.
- A Certificate of Medical Necessity for Oxygen, Form CMS-484, or a reasonable facsimile is completed by a physician, physician assistant, or advanced registered nurse practitioner and qualifies the member in accordance with Medicare criteria.
- Additional documentation shows that the member requires oxygen for 12 hours or more per day for at least 30 days.
- 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.
- The maximum Medicaid payment shall be based on the least costly method of oxygen delivery.
- Oxygen prescribed “PRN” or “as necessary” is not payable.
- Medicaid payment shall 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.
- Payment is not allowed for oxygen services that are not documented according to the department of inspections and appeals requirements at 481—subrule 58.21(8).
- Cephalic index at least two standard deviations above the mean for the member’s gender and age; or
- Asymmetry of 12 millimeters or more in the cranial vault, skull base, or orbitotragial depth.
"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 physician assistant (PA), an advanced registered nurse practitioner (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 current version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, 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:- Behavior intervention,
- Crisis intervention,
- Skill training and development, and
- Family training.
- Behavior intervention,
- Crisis intervention, and
- Family training.
- Cognitive flexibility skills,
- Communication skills,
- Conflict resolution skills,
- Emotional regulation skills,
- Executive skills,
- Interpersonal relationship skills,
- Problem-solving skills, and
- Social skills.
- Enhance the family’s ability to effectively interact with the child and support the child’s functioning in the home and community, and
- Teach parents to identify and implement strategies to reduce target behaviors and reinforce the appropriate skills.
- Be for the direct benefit of the member, and
- Be based on a curriculum with a training manual.
- Enhance a member’s independent living, social, and communication skills;
- Minimize or eliminate psychological barriers to a member’s ability to effectively manage symptoms associated with a psychological disorder; and
- Maximize a member’s ability to live and participate in the community.
- Communication skills,
- Conflict resolution skills,
- Daily living skills,
- Employment-related skills,
- Interpersonal relationship skills,
- Problem-solving skills, and
- Social skills.
- Risk of harm to self or others,
- Behavioral support in the community,
- Specific skills impaired due to the member’s mental illness, and
- 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.
- Postsurgical or medical follow-up care specified by a health care provider;
- Unexpected preoperative appointments;
- Hospital discharges;
- Appointments for new medical conditions or tests; and
- Dialysis.
- The member must notify the broker no later than the day of the trip;
- 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
- The other requirements of rule 441—78.13(249A) must be met.
- The member’s previous relationship with the requested provider; or
- The member’s prior experience with the requested provider; or
- The requested provider’s special expertise or experience; or
- A referral requiring the member to be seen by the requested provider.
- 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.
- 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 7, 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.
- 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.
- 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.
- 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.
"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 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 physician assistant, or an advanced registered nurse practitioner that includes all of the following:- 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.
- The date.
- The patient’s diagnosis.
- The reason orthopedic shoes are needed.
- The probable duration of need.
- A specific description of any required modification of the shoes.
- 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—33.1(225C,230A) 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.
- Reflect how program continuity will be provided.
- Reflect an interdisciplinary team of professionals and paraprofessionals.
- Include a designated director who is a mental health professional as defined in rule 441—33.1(225C,230A). The director shall be responsible for direct supervision of the individual treatment plans for participants and the ongoing assessment of program effectiveness.
- Be provided by or under the general supervision of a mental health professional as defined in rule 441—33.1(225C,230A). 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 consumer 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.
- 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.
- Treatment goals in the individualized treatment plan have been achieved.
- 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.
- The patient’s clinical condition has deteriorated to the extent that the safety and security of inpatient or residential care is necessary.
- Patient, family, or custodian noncompliance with treatment or with program rules exists.
- There must be face-to-face patient contact interaction.
- 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.
- 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 in length.
- Progress must be documented in measurable statistics in the progress notes in order for services to be reimbursed. Refer to 78.19(1)“b”(7) and (8) for guidelines under restorative and maintenance therapy.
- 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 (i.e., 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.
"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.
"Care coordinator" means the professional who assists members in care coordination as described in paragraph 78.53(2)“b.”
"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 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 which 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.
"Department" means the Iowa department of human services.
"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, and as measured by its most recently published 25-item supported employment fidelity scale available online at ipsworks.org/wp-content/uploads/2017/08/ips-fidelity-manual-3rd-edition_2-4-16.pdf. The IPS practice principles are:
- Focus on competitive employment: Agencies providing IPS services are committed to competitive employment as an attainable goal for people with behavioral health conditions seeking employment. Mainstream education and specialized training may enhance career paths.
- Zero exclusion criteria based on client choice: People are not excluded on the basis of readiness, diagnoses, symptoms, substance use history, psychiatric hospitalizations, homelessness, level of disability, or legal system involvement.
- Integration of rehabilitation and mental health services: IPS programs are closely integrated with mental health treatment teams.
- Attention to worker preferences: Services are based on each person’s preferences and choices, rather than providers’ judgments.
- Personalized benefits counseling: Employment specialists help people obtain personalized, understandable, and accurate information about their social security, Medicaid, and other government entitlements.
- Rapid job search: IPS programs use a rapid job search approach to help job seekers obtain jobs directly, rather than providing lengthy preemployment assessment, training, and counseling. If further education is part of their plan, IPS specialists assist in these activities as needed.
- Systematic job development: Employment specialists systematically visit employers, who are selected based on job seeker preferences, to learn about their business needs and hiring preferences.
- Time-unlimited and individualized support: Job supports are individualized and continue for as long as each worker wants and needs the support.
"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 which 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.
"Integrated health home services" means the provision of services to enrolled members as described in subrule 78.53(2).
"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 or HCBS intellectual disability waiver supported community living and meet additional criteria specified in 441—subrule 25.6(8).
"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.
"ISIS" means the department’s individualized services information system.
"Level of Care Utilization System" or "LOCUS" means the comprehensive functional assessment tool utilized to determine eligibility for the habilitation program and service authorization for the home-based habilitation service for individuals aged 19 and older.
"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.
"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" means the same as defined in rule 441—25.1(331).
"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 has at least one of the following risk factors: (1) The individual has a history of inpatient, partial hospitalization, or emergency psychiatric treatment more than once in the individual’s life; or (2) The individual has a history of continuous professional psychiatric supportive care other than hospitalization; or (3) The individual has a history of involvement with the criminal justice system; or (4) Services available in the individual’s community have not been able to meet the individual’s needs; or (5) The individual has a history of unemployment or employment in a sheltered setting or poor work history; or (6) The individual has a history of homelessness or is at risk of homelessness. c. Need for assistance. The individual 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 individual needs assistance to obtain or maintain employment. (2) The individual requires financial assistance to reside independently in the community. (3) The individual needs significant assistance to establish or maintain a personal social support system. (4) The individual 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 individual 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 LOCUS or CALOCUS tool has been completed in the LOCUS online system, and using the algorithm developed by Deerfield Solutions to derive the actual disposition score based on the comprehensive assessment and social history (CASH) completed by the integrated health home (IHH) or community-based case manager (CBCM) during a face-to-face interview with the member and the member’s representative as applicable, and based on information submitted on the information submission tool and other supporting documentation as relevant, the IME medical services unit has determined that the member is in need of home- and community-based habilitation services. The LOCUS/CALOCUS information submission tools are available on request from the IME medical services unit. Copies of the information submission tool for an individual are available to that individual from the individual’s case manager, integrated health home care coordinator, or managed care organization. The designated case manager or integrated health home care coordinator shall: (1) Arrange for the completion of the LOCUS or CALOCUS, 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. f. Plan for service. The department or the member’s managed care organization 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 the IME or the member’s managed care organization shall 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 LOCUS/CALOCUS actual disposition, the LOCUS/CALOCUS composite score, and each individual domain score for each of the six LOCUS/CALOCUS 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, case manager or integrated health home care coordinator shall apply for habilitation services on behalf of a member by contacting the IME medical services unit. The department shall issue a notice of decision to the applicant 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. (1) The case manager or the integrated health home care coordinator shall establish an interdisciplinary team as selected by the member or the member’s legal representative. The team shall include the case manager or integrated health home care coordinator and the member and, if applicable, the member’s legal representative, the member’s family, the member’s service providers, and others directly involved with the member. (2) With assistance from the member and the interdisciplinary team, the case manager or integrated health home care coordinator shall identify the member’s services based on the member’s needs, the availability of services, and the member’s choice of services and providers. (3) The comprehensive service plan development shall be completed at the member’s home or at another location chosen by the member. (4) The interdisciplinary team meeting shall be conducted before the current comprehensive service plan expires. (5) The comprehensive service plan shall reflect desired individual outcomes. (6) Services defined in the comprehensive service plan shall be appropriate to the severity of the member’s problems and to the member’s specific needs or disabilities. (7) Activities identified in the comprehensive service plan shall encourage the ability and right of the member to make choices, to experience a sense of achievement, and to modify or continue participation in the treatment process. (8) For members receiving home-based habilitation in a licensed residential care facility of 16 or fewer beds, the service plan shall address the member’s opportunities for independence and community integration. (9) The initial comprehensive service plan or treatment plan and annual updates to the comprehensive service plan or treatment plan must be approved by the IME medical services unit in ISIS before services are implemented. Services provided before the approval date are not payable. The written comprehensive service plan or treatment plan must be completed, signed and dated by the case manager or integrated health home care coordinator within 30 calendar days after plan approval. (10) Any changes to the comprehensive service plan or treatment plan must be approved by the IME medical services unit for members not eligible to enroll in a managed care organization in ISIS before the implementation of services. Services provided before the approval date are not payable. b. Service goals and activities. The comprehensive service plan shall: (1) Identify observable or measurable individual goals. (2) Identify interventions and supports needed to meet those goals with incremental action steps, as appropriate. (3) Identify the staff persons, businesses, or organizations responsible for carrying out the interventions or supports. (4) List all Medicaid and non-Medicaid services received by the member and identify:- The name of the provider responsible for delivering the service;
- The funding source for the service; and
- The number of units of service to be received by the member.
- The member’s living environment at the time of enrollment;
- The number of hours per day of on-site staff supervision needed by the member; and
- The number of other members who will live with the member in the living unit.
- 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,
- Business tours,
- Informational interviews,
- Job shadows,
- Benefits education and financial literacy,
- Assistive technology assessment, and
- Job exploration events.
- 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.
- The expected outcome of the career exploration activity is a written career plan that will guide employment services which lead to community employment or self-employment for the member.
- 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
- 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
- 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
- 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
- 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
- The member is participating in career exploration activities as described in subparagraph 78.27(9)“a”(1).
- Benefits education.
- Career exploration (e.g., tours, informational interviews, job shadows).
- Employment assessment.
- Assistive technology assessment.
- Trial work experience.
- Person-centered employment planning.
- Development of visual/traditional résumés.
- Job-seeking skills training and support.
- 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).
- Job analysis (e.g., work site assessment or job accommodations evaluation).
- Identifying and arranging transportation.
- Career advancement services (e.g., assisting a member in making an upward career move or seeking promotion from an existing employer).
- Reemployment services (if necessary due to job loss).
- Financial literacy and asset development.
- Other employment support services deemed necessary to enable the member to obtain employment.
- Systematic instruction and support during initial on-the-job training including initial on-the-job training to stabilization.
- Engagement of natural supports during initial period of employment.
- Implementation of assistive technology solutions during initial period of employment.
- Transportation of the member during service hours.
- Initial on-the-job training to stabilization activity.
- Aid to the member in identifying potential business opportunities.
- Assistance in the development of a business plan, including identifying potential sources of business financing and other assistance in developing and launching a business.
- Identification of the long-term supports necessary for the individual to operate the business.
- Job analysis.
- Job training and systematic instruction.
- Training and support for use of assistive technology/adaptive aids.
- Engagement of natural supports.
- Transportation coordination.
- Job retention training and support.
- Benefits education and ongoing support.
- Supports for career advancement.
- Financial literacy and asset development.
- Employer consultation and support.
- Negotiation with employer on behalf of the member (e.g., accommodations; employment conditions; access to natural supports; and wage and benefits).
- 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.
- Transportation of the member during service hours.
- Career exploration services leading to increased hours or career advancement.
- Ongoing identification of the supports necessary for the individual to operate the business;
- Ongoing assistance, counseling and guidance to maintain and grow the business; and
- Ongoing benefits education and support.
- Employment assessment.
- Person-centered employment planning.
- 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).
- Job analysis.
- On-the-job training and systematic instruction.
- Job coaching.
- Transportation planning and training.
- Benefits education.
- Career exploration services leading to career advancement outcomes.
- 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.
- Transportation of the member during service hours.
- 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.
- Individual and group therapy with physicians, psychologists, social workers, counselors, or psychiatric nurses.
- 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.
- Drugs and biologicals furnished to outpatients for therapeutic purposes only if they are of the type which cannot be self-administered and are not “covered Part D drugs” as defined by 42 U.S.C. Section 1395w-102(e)(1)-(2) for a “Part D eligible individual” as defined in 42 U.S.C. Section 1395w-101(a)(3)(A), including an individual who is not enrolled in a Part D plan.
- Activity therapies which 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.
- Family counseling services are covered only if the primary purpose of the counseling is the treatment of the patient’s condition.
- 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.
- 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.
- The specific services rendered.
- The date and actual time the 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.
- Updates describing the patient’s progress.
- 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 receiving services under the HCBS intellectual disability waiver or children’s mental health waiver.
- Select the individual or agency that will provide the components of the attendant care services.
- Determine with the selected provider what components of attendant care services the provider shall perform, subject to confirmation by the service worker or case manager that those components are consistent with the assessment and are authorized covered services.
- Complete, sign, and date Form 470-3372, HCBS Consumer-Directed Attendant Care Agreement, to indicate the frequency, scope, and duration of services (a description of each service component and the time agreed on for that component). The case manager or service worker and provider shall also sign the agreement.
- Submit the completed agreement to the service worker or case manager. The agreement shall be part of the member’s service plan and shall be kept in the member’s records, in the provider’s records, and in the service worker’s or case manager’s records. Any service component that is not listed in the agreement shall not be payable.
- The payment rate for the legal representative must be based on the skill level of the legal representative and may not exceed the median statewide reimbursement rate for the service unless the higher rate receives prior approval from the department;
- The legal representative may not be paid for more than 40 hours of service per week; and
- A contingency plan must be established in the member’s service plan to ensure service delivery in the event the legal representative is unable to provide services due to illness or other unexpected event.
- An in-home medical communications transceiver.
- A remote, portable activator.
- A central monitoring station with backup systems staffed by trained attendants at all times.
- Current data files at the central monitoring station containing response protocols and personal, medical, and emergency information for each member.
- A portable communications transceiver or transmitter to be worn or carried by the member.
- Monitoring by the provider at a central location with response protocols and personal, medical, and emergency information for each member as applicable.
- Consumer-directed attendant care (unskilled).
- Home and vehicle modification.
- Home-delivered meals.
- Homemaker service.
- Basic individual respite care.
- Promote opportunities for community living and inclusion.
- Increase independence or substitute for human assistance, to the extent the expenditures would otherwise be made for that human assistance.
- Be accommodated within the member’s budget without compromising the member’s health and safety.
- Be provided to the member or directed exclusively toward the benefit of the member.
- Be the least costly to meet the member’s needs.
- Not be available through another source.
- Child care services.
- Clothing not related to an assessed medical need.
- Conference, meeting or similar venue expenses other than the costs of approved services the member needs while attending the conference, meeting or similar venue.
- Costs associated with shipping items to the member.
- Experimental and non-FDA-approved medications, therapies, or treatments.
- Goods or services covered by other Medicaid programs.
- Home furnishings.
- Home repairs or home maintenance.
- Homeopathic treatments.
- Insurance premiums or copayments.
- Items purchased on installment payments.
- Motorized vehicles.
- Nutritional supplements.
- Personal entertainment items.
- Repairs and maintenance of motor vehicles.
- Room and board, including rent or mortgage payments.
- School tuition.
- Service animals.
- Services covered by third parties or services that are the responsibility of a non-Medicaid program.
- Sheltered workshop services.
- Social or recreational purchases not related to an assessed need or goal identified in the member’s service plan.
- Vacation expenses, other than the costs of approved services the member needs while on vacation.
- Services provided in the family home by a parent, stepparent, legal representative, sibling, or stepsibling during overnight sleeping hours unless the parent, stepparent, legal representative, sibling, or stepsibling is awake and actively providing direct services as authorized in the member’s service plan.
- Residential services provided to three or more members living in the same residential setting.
- The specific goods, services, supports or supplies to be purchased through the savings plan.
- The amount of the individual budget allocated each month to the savings plan.
- The amount of the individual budget allocated each month to meet the member’s identified service needs.
- How the member’s assessed needs will continue to be met through the individual budget when funds are placed in savings.
- Specific time spans for accumulating the savings allocation, not to exceed the member’s current service plan year end date.
- Be used to meet a member’s identified need,
- Be medically necessary, and
- Be approved by the member’s case manager or community-based case manager.
- Verifying that hourly wages comply with federal and state labor rules.
- Collecting and processing timecards.
- Withholding, filing, and paying federal, state and local income taxes, Medicare and Social Security (FICA) taxes, and federal (FUTA) and state (SUTA) unemployment and disability insurance taxes, as applicable.
- Computing and processing other withholdings, as applicable.
- Processing all judgments, garnishments, tax levies, or other withholding on an employee’s pay as may be required by federal, state, or local laws.
- Preparing and issuing employee payroll checks.
- Preparing and disbursing IRS Forms W-2 and W-3 annually.
- Processing federal advance earned income tax credit for eligible employees.
- Refunding over-collected FICA, when appropriate.
- Refunding over-collected FUTA, when appropriate.
- Identification of the hospice that will provide the care.
- Acknowledgment that the recipient has been given a full understanding of hospice care.
- Acknowledgment that the recipient waives the right to regular Medicaid benefits, except for payment to the regular physician and treatment for medical conditions unrelated to the terminal illness.
- Acknowledgment that recipients are not responsible for copayment or other deductibles.
- The recipient’s Medicaid number.
- The effective date of election.
- The recipient’s signature.
- The individual dies.
- The individual or the individual’s representative revokes the election.
- The individual’s situation changes so that the individual no longer qualifies for the hospice benefit.
- The hospice elects to terminate the recipient’s enrollment in accordance with the hospice’s established discharge policy.
- An in-home medical communications transceiver.
- A remote, portable activator.
- A central monitoring station with backup systems staffed by trained attendants at all times.
- Current data files at the central monitoring station containing response protocols and personal, medical, and emergency information for each member.
- A portable communications transceiver or transmitter to be worn or carried by the member.
- Monitoring by the provider at a central location with response protocols and personal, medical, and emergency information for each member as applicable.
- Select the individual, agency or assisted living facility that will provide the components of the attendant care services.
- Determine with the selected provider what components of attendant care services the provider shall perform, subject to confirmation by the service worker or case manager that those components are consistent with the assessment and are authorized covered services.
- Complete, sign, and date Form 470-3372, HCBS Consumer-Directed Attendant Care Agreement, to indicate the frequency, scope, and duration of services (a description of each service component and the time agreed on for that component). The case manager or service worker and provider shall also sign the agreement.
- Submit the completed agreement to the service worker or case manager. The agreement shall be part of the member’s service plan and shall be kept in the member’s records, in the provider’s records, and in the service worker’s or case manager’s records. Any service component that is not listed in the agreement shall not be payable.
- The payment rate for the legal representative must be based on the skill level of the legal representative and may not exceed the median statewide reimbursement rate for the service unless the higher rate receives prior approval from the department;
- The legal representative may not be paid for more than 40 hours of service per week; and
- A contingency plan must be established in the member’s service plan to ensure service delivery in the event the legal representative is unable to provide services due to illness or other unexpected event.
- Select the individual or agency that will provide the components of the attendant care services.
- Determine with the selected provider what components of attendant care services the provider shall perform, subject to confirmation by the service worker or case manager that those components are consistent with the assessment and are authorized covered services.
- Complete, sign, and date Form 470-3372, HCBS Consumer-Directed Attendant Care Agreement, to indicate the frequency, scope, and duration of services (a description of each service component and the time agreed on for that component). The case manager or service worker and provider shall also sign the agreement.
- Submit the completed agreement to the service worker or case manager. The agreement shall be part of the member’s service plan and shall be kept in the member’s records, in the provider’s records, and in the service worker’s or case manager’s records. Any service component that is not listed in the agreement shall not be payable.
- The payment rate for the legal representative must be based on the skill level of the legal representative and may not exceed the median statewide reimbursement rate for the service unless the higher rate receives prior approval from the department;
- The legal representative may not be paid for more than 40 hours of service per week; and
- A contingency plan must be established in the member’s service plan to ensure service delivery in the event the legal representative is unable to provide services due to illness or other unexpected event.
- Personal management skills training services are activities which assist a member to maintain or develop skills necessary to sustain the member in the physical environment and 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.
- Socialization skills training services are activities which assist a member to develop or maintain skills which include self-awareness and self-control, social responsiveness, community participation, social amenities, and interpersonal skills.
- Communication skills training services are activities which 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.
- Physiological treatment includes medication regimens designed to prevent, halt, control, relieve, or reverse symptoms or conditions that 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.
- 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.
- An in-home medical communications transceiver.
- A remote, portable activator.
- A central monitoring station with backup systems staffed by trained attendants at all times.
- Current data files at the central monitoring station containing response protocols and personal, medical and emergency information for each member.
- A portable communications transceiver or transmitter to be worn or carried by the member.
- Monitoring by the provider at a central location with response protocols and personal, medical, and emergency information for each member as applicable.
- Select the individual or agency that will provide the components of the attendant care services.
- Determine with the selected provider what components of attendant care services the provider shall perform, subject to confirmation by the service worker or case manager that those components are consistent with the assessment and are authorized covered services.
- Complete, sign, and date Form 470-3372, HCBS Consumer-Directed Attendant Care Agreement, to indicate the frequency, scope, and duration of services (a description of each service component and the time agreed on for that component). The case manager or service worker and provider shall also sign the agreement.
- Submit the completed agreement to the service worker or case manager. The agreement shall be part of the member’s service plan and shall be kept in the member’s records, in the provider’s records, and in the service worker’s or case manager’s records. Any service component that is not listed in the agreement shall not be payable.
- The payment rate for the legal representative must be based on the skill level of the legal representative and may not exceed the median statewide reimbursement rate for the service unless the higher rate receives prior approval from the department;
- The legal representative may not be paid for more than 40 hours of service per week; and
- A contingency plan must be established in the member’s service plan to ensure service delivery in the event the legal representative is unable to provide services due to illness or other unexpected event.
- Personal management skills training services are activities which assist a member to maintain or develop skills necessary to sustain the member in the physical environment and 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.
- Socialization skills training services are activities which assist a member to develop or maintain skills which include self-awareness and self-control, social responsiveness, community participation, social amenities, and interpersonal skills.
- Communication skills training services are activities which 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.
- 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.
- 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.
- An in-home medical communications transceiver.
- A remote, portable activator.
- A central monitoring station with backup systems staffed by trained attendants at all times.
- Current data files at the central monitoring station containing response protocols and personal, medical and emergency information for each member.
- A portable communications transceiver or transmitter to be worn or carried by the member.
- Monitoring by the provider at a central location with response protocols and personal, medical, and emergency information for each member as applicable.
- Select the individual or agency that will provide the components of the attendant care services.
- Determine with the selected provider what components of attendant care services the provider shall perform, subject to confirmation by the service worker or case manager that those components are consistent with the assessment and are authorized covered services.
- Complete, sign, and date Form 470-3372, HCBS Consumer-Directed Attendant Care Agreement, to indicate the frequency, scope, and duration of services (a description of each service component and the time agreed on for that component). The case manager or service worker and provider shall also sign the agreement.
- Submit the completed agreement to the service worker or case manager. The agreement shall be part of the member’s service plan and shall be kept in the member’s records, in the provider’s records, and in the service worker’s or case manager’s records. Any service component that is not listed in the agreement shall not be payable.
- The payment rate for the legal representative must be based on the skill level of the legal representative and may not exceed the median statewide reimbursement rate for the service unless the higher rate receives prior approval from the department;
- The legal representative may not be paid for more than 40 hours of service per week; and
- A contingency plan must be established in the member’s service plan to ensure service delivery in the event the legal representative is unable to provide services due to illness or other unexpected event.
- Assessments, referrals, follow-up, and monitoring.
- Assisting the member in gaining access to necessary medical, social, educational, and other services.
- Assessing the member to determine service needs by collecting relevant historical information through member records and other information from relevant professionals and natural supports.
- 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.
- Make referrals to services and related activities to assist the member with the assessed needs.
- 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.
- Hold daily team meetings to facilitate ACT services and coordinate the member’s care with other members of the team.
- Select the individual or agency that will provide the components of the attendant care services.
- Determine with the selected provider what components of attendant care services the provider shall perform, subject to confirmation by the service worker or case manager that those components are consistent with the assessment and are authorized covered services.
- Complete, sign, and date Form 470-3372, HCBS Consumer-Directed Attendant Care Agreement, to indicate the frequency, scope, and duration of services (a description of each service component and the time agreed on for that component). The case manager or service worker and provider shall also sign the agreement.
- Submit the completed agreement to the service worker or case manager. The agreement shall be part of the member’s service plan and shall be kept in the member’s records, in the provider’s records, and in the service worker’s or case manager’s records. Any service component that is not listed in the agreement shall not be payable.
- The payment rate for the legal representative must be based on the skill level of the legal representative and may not exceed the median statewide reimbursement rate for the service unless the higher rate receives prior approval from the department;
- The legal representative may not be paid for more than 40 hours of service per week; and
- A contingency plan must be established in the member’s service plan to ensure service delivery in the event the legal representative is unable to provide services due to illness or other unexpected event.
- An in-home medical communications transceiver.
- A remote, portable activator.
- A central monitoring station with backup systems staffed by trained attendants at all times.
- Current data files at the central monitoring station containing response protocols and personal, medical, and emergency information for each member.
- A portable communications transceiver or transmitter to be worn or carried by the member.
- Monitoring by the provider at a central location with response protocols and personal, medical, and emergency information for each member as applicable.
- Medication history;
- Assessment of indications, effectiveness, safety, and compliance of medication therapy;
- Assessment for the presence of untreated illness; and
- Identification of medication-related problems such as unnecessary medication therapy, suboptimal medication selection, inappropriate compliance, adverse drug reactions, and need for additional medication therapy.
- Assisting the family in gaining access to the infant and toddler program services and other services identified in the child’s plan of care.
- Assisting the family in identifying available service providers and funding resources and documenting unmet needs and gaps in services.
- Making referrals to providers for needed services.
- Scheduling appointments for the child.
- Facilitating the timely delivery of services.
- Arranging payment for medical transportation.
- Whether services are being furnished in accordance with the child’s plan of care.
- Whether the services in the plan of care are adequate to meet the needs of the child.
- 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.
"Chronic condition" means, for purposes of this rule, one of the conditions outlined in subparagraph 78.53(3)“a”(1).
"Chronic condition health home" means a health home that meets the criteria in 441—subrule 77.47(2).
"Health home" means a chronic condition health home or an integrated health home.
"Integrated health home" means a health home that meets the criteria in 441—subrule 77.47(3).
"Person-centered care plan" means a care plan created through the person-centered planning process, directed by the member or the member’s guardian or representative, for a member receiving non-intensive care management or chronic condition health home services, to identify the member’s strengths, capabilities, preferences, needs, goals, and desired outcomes.
"Person-centered service plan" or "service plan" means a service plan (1) created through the person-centered planning process in accordance with subrule 78.27(4), rule 441—83.127(249A) and 441—paragraph 90.4(1)“b”; (2) directed by the member or the member’s guardian or representative; (3) for a member receiving intensive care management services; and (4) for the purposes of identifying the member’s strengths, capabilities, preferences, needs, and desired outcomes.
78.53(2) Covered services. A health home provides team-based, whole person, person-centered, coordinated care for all aspects of the member’s life and for transitions of care that the member may experience. A health home provides the following core services: a. Comprehensive care management. Comprehensive care management is the initial and ongoing assessment and care management services aimed at the integration of primary, behavioral and specialty health care, and community support services, using a comprehensive person-centered care plan or service plan that addresses all clinical and nonclinical needs and promotes wellness and management of chronic conditions in pursuit of optimal health outcomes. b. Care coordination. Care coordination includes assisting members with medication adherence, appointments, referral scheduling, understanding health insurance coverage, reminders, transition of care, wellness education, health support, lifestyle modification, and behavior changes. The health home must work with providers to coordinate, direct, and ensure results are communicated back to the health home. c. Health promotion. Health promotion includes the education and engagement of a member in making decisions that promote health management, improved disease outcomes, disease prevention, safety, and an overall healthy lifestyle. d. Comprehensive transitional care. Comprehensive transitional care is the facilitation of services for the member that provides support when the member is transitioning between levels of care (nursing facility, hospital, rehabilitation facility, community-based group home, family, self-care, or another health home). e. Individual and family support. Individual and family support services include communication with the member and the member’s family and caregivers to maintain and promote quality of life, with particular focus on community living options. Support will be provided in a culturally appropriate manner. f. Referral to community and social support services. Referral to community and social support services includes coordinating or providing recovery services and social health services available in the community, including resources for understanding eligibility for various health care programs, disability benefits, and identifying housing programs. 78.53(3) Member eligibility for health home services. a. Chronic condition health home member eligibility criteria. (1) To be eligible for chronic condition health home services, the member must have one of the following chronic conditions and be at risk of having a second chronic condition: 1. A mental health disorder. 2. A substance use disorder. 3. Asthma. 4. Diabetes. 5. Heart disease. 6. Being overweight, as evidenced by:"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.
78.56(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 completed by a qualified trained assessor. The assessment of need shall document the member’s need for community-based neurobehavioral rehabilitation, and the medical services unit of the Iowa Medicaid enterprise or the member’s managed care organization 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 abuse. (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. 78.56(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 and appeals; 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 intermediate care facility for persons with intellectual disabilities, 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 (activities of daily living); (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 abuse 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 (activities of daily living); (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 the Iowa Medicaid enterprise (IME) medical services unit 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 the IME medical services unit. (1) The IME medical services unit will approve the provider’s treatment plan if:- The treatment plan conforms to the medical necessity requirements in subrule 78.55(4);
- 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.;
- The treatment plan is sufficient in amount, duration, and scope to reasonably achieve its purpose;
- The provider can demonstrate that the provider possesses the skills and resources necessary to implement the plan; and
- The treatment plan does not exceed 180 days in duration.
- Dates of prior hospitalization.
- Dates of prior surgery.
- Date last seen by a primary care provider.
- Diagnoses and dates of onset of diagnoses for which treatment is being rendered.
- Prognosis.
- Functional limitations.
- Vital signs reading.
- Date of last episode of acute recurrence of illness or symptoms.
- Medications.
"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—subrule 75.1(29). Under the QMB program, Medicaid pays the individual’s Medicare Part A and B premiums; coinsurance; copayment; and deductible (except for Part D).
This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 3494C441—78.59(249A) Health insurance premium payment (HIPP) provider services. 78.59(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). 78.59(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 (HIPP) program" "HIPP program" has the same meaning as provided in rule 441—75.21(249A).
This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 3494C441—78.60(249A) Crisis response services. Payment will be made to providers (eligible pursuant to rule 441—77.55(249A)) of crisis response services, crisis stabilization community-based services, and crisis stabilization residential services delivered as set forth in 441—Chapter 24, Division II.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 3551C441—78.60(249A) Subacute mental health services. Payment will be made to providers (eligible pursuant to rule 441—77.56(249A)) for the provision of subacute mental health care facility services that meet the standards outlined in 481—Chapter 71.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 3551CThese 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