CHAPTER 85SERVICES IN PSYCHIATRIC INSTITUTIONSPreambleInpatient psychiatric services are provided in three types of psychiatric facilities in addition to general hospitals with psychiatric units: acute care psychiatric hospitals, psychiatric medical institutions for children, and nursing facilities for the mentally ill. Except for services in the state mental health institutes, Medicaid covers only persons under the age of 21 and persons aged 65 and older in acute care psychiatric hospitals. Medicaid covers only persons under the age of 21 in psychiatric medical institutions for children, and only persons aged 65 and older in nursing facilities for the mentally ill. These rules establish conditions of participation for providers, record-keeping requirements, reimbursement methodologies, and client eligibility requirements.DIVISION IPSYCHIATRIC HOSPITALS441—85.1(249A) Acute care in psychiatric hospitals. These rules do not apply to general hospitals with psychiatric units. 85.1(1) Psychiatric hospitals serving persons aged 21 and older. A psychiatric hospital serving persons aged 21 and older shall meet the federal criteria for an institution for mental disease and shall be licensed pursuant to department of inspections and appeals rule 481—51.36(135B). An out-of-state facility shall be licensed as a psychiatric hospital, shall meet the federal criteria for an institution for mental disease, and shall be certified to participate in the Medicare program. An institution is an institution for mental disease only if its overall character is that of a facility established and maintained primarily for the care and treatment of persons with mental diseases. The following guidelines are used by the department in evaluating the overall character of a facility. These guidelines are all useful in identifying institutions for mental disease; however, no single guideline is necessarily determinative in any given case. a. The facility: (1) Is licensed as a psychiatric facility for the care and treatment of persons with mental diseases. (2) Advertises or holds itself out as a facility for the care and treatment of persons with mental diseases. (3) Is accredited as a psychiatric facility by the Joint Commission on the Accreditation of Health Care Organizations or by any other federally recognized accrediting organization that has comparable standards or surveys and is approved by the department of inspections and appeals. (4) Specializes in providing psychiatric or psychological care and treatment. This may be ascertained through review of patients’ records. It may also be indicated by the fact that an unusually large proportion of the staff has specialized psychiatric or psychological training or that a large proportion of the patients are receiving psychopharmacological drugs. (5) Is under the jurisdiction of the department. b. More than 50 percent of all the patients in the facility have mental diseases which require inpatient treatment according to the patient’s medical records. c. A large proportion of the patients in the facility has been transferred from a state mental institution for continuing treatment of their mental disorders. d. Independent review teams report a preponderance of mental illness in the diagnoses of the patients in the facility. e. The average patient age is significantly lower than that of a typical nursing home. f. Part or all of the facility consists of locked wards. 85.1(2) Psychiatric hospitals serving persons under the age of 21. A psychiatric hospital serving persons under the age of 21 shall be licensed pursuant to department of inspections and appeals rule 481—51.36(135B) or shall be licensed in another state as a hospital, shall be accredited by the Joint Commission on the Accreditation of Health Care Organizations, the Commission of Accreditation of Rehabilitation Facilities, the Council on Accreditation of Services for Families and Children, or by any other federally recognized accrediting organization that has comparable standards or surveys and is approved by the department of inspections and appeals, and shall meet federal service requirements.Related ARC(s): 6714C441—85.2(249A) Out-of-state placement. Placement in an out-of-state psychiatric hospital for acute care requires prior approval by the bureau of managed care and clinical services and shall be approved only if special services are not available in Iowa.Related ARC(s): 6714C441—85.3(249A) Eligibility of persons under the age of 21. 85.3(1) Age. To be eligible for payment for the cost of care provided by a psychiatric hospital, the person shall be under 21 years of age. When treatment in the hospital is provided immediately preceding the person’s twenty-first birthday, coverage continues to be available until the twenty-second birthday or until service is no longer required, whichever is earlier. 85.3(2) Period of eligibility. The person is considered to be an inpatient until unconditionally discharged. Coverage extends until the last day of the month of the discharge or the twenty-second birthday. While on inpatient status the eligible person is entitled to the full scope of Medicaid benefits. 85.3(3) Certification of need for care. For persons eligible for Medicaid prior to admission, an independent team shall certify that ambulatory care resources available in the community do not meet the treatment needs of the recipient, that proper treatment of the recipient’s psychiatric condition requires services on an inpatient basis under the direction of a physician, and that the services can reasonably be expected to improve the recipient’s condition or prevent further regression so that the services will no longer be needed. Team members are independent when they are not employees of or consultants to the facility. Form 470-2780 may be used to document these criteria. a. For persons eligible for Medicaid prior to admission, this preadmission certification shall be performed within 45 days prior to the proposed date for admission to the facility by an independent team that includes a physician who has competence in diagnosis and treatment of mental illness, preferably in child psychiatry, and who has knowledge of the person’s situation. If a social worker is a part of the team, the social worker may be from the county office of the department of human services.The evaluation shall be submitted to the facility on or prior to the date of the patient’s admission. b. When a person makes application for Medicaid subsequent to admission or has an application in process at the time of admission, a certification by the team responsible for the plan of care shall be provided within 14 days after admission and shall cover any period prior to application for which claims are to be made. c. For emergency admissions, a certification shall be provided by the team responsible for the plan of care within 14 days after admission. 85.3(4) Financial eligibility for persons under the age of 21. To be eligible for payments for the cost of care provided by a psychiatric facility, persons under the age of 21 must be eligible under one of the coverage groups listed in 441—Chapter 75.Related ARC(s): 6714C441—85.4(249A) Eligibility of persons aged 65 and over. To be eligible for payment for the cost of care provided by an institution for mental disease, persons must be aged 65 or over and be eligible under one of the coverage groups listed in 441—Chapter 75.Related ARC(s): 6714C441—85.5(249A) Client participation. 85.5(1) Before July 2005. For months before July 2005, the resident shall be liable to pay client participation toward the cost of care on a monthly basis. The state will pay the balance of the cost of care for the month. The facility shall make arrangements directly with the resident for payment of client participation. Client participation is determined according to 441—Chapter 75. 85.5(2) July 2005 and after. Effective with the month of July 2005, the resident shall not be liable to pay client participation toward the cost of care, and no client participation amount shall be deducted from the state payment to the hospital.Related ARC(s): 6714C441—85.6(249A) Responsibilities of hospitals. 85.6(1) Medical record requirements. The medical records maintained by the psychiatric hospital shall permit determination of the degree and intensity of the treatment provided to persons who are furnished services in the hospital. a. Development of assessment and diagnostic data. Medical records shall stress the psychiatric components of the record, including history of findings and treatment provided for the psychiatric condition for which the patient is hospitalized. (1) The identification data shall include the patient’s legal status. (2) A provisional or admitting diagnosis shall be made on every patient at the time of admission, and shall include the diagnoses of intercurrent diseases as well as the psychiatric diagnoses. (3) The reasons for admission shall be clearly documented as stated by the patient or others significantly involved. (4) The social service records, including reports of interviews with patients, family members, and others, shall provide an assessment of home plans and family attitudes and community resource contacts, as well as a social history. (5) When indicated, a complete neurological examination shall be recorded at the time of the admission physical examination. b. Psychiatric evaluation. Each patient shall receive a psychiatric evaluation that shall: (1) Be completed within 60 hours of admission. (2) Include a medical history. (3) Contain a record of mental status. (4) Note the onset of illness and the circumstances leading to admission. (5) Describe attitudes and behavior. (6) Estimate intellectual functioning, memory functioning, and orientation. (7) Include an inventory of the patient’s assets in descriptive, not interpretive, fashion. c. Treatment plan. (1) Each patient shall have an individual comprehensive treatment plan that shall be based on an inventory of the patient’s strengths and disabilities. The written plan shall include a substantiated diagnosis, short-term and long-range goals, the specific treatment modalities utilized, the responsibilities of each member of the treatment team, and adequate documentation to justify the diagnosis and the treatment and rehabilitation activities carried out. (2) The treatment received by the patient shall be documented in a way to ensure that all active therapeutic efforts are included. d. Recording progress. Progress notes shall be recorded by the doctor of medicine or osteopathy responsible for the care of the patient, nurse, social worker and, when appropriate, others significantly involved in active treatment modalities. The frequency of progress notes is determined by the condition of the patient but shall be recorded at least weekly for the first two months and at least once a month thereafter and shall contain recommendations for revisions in the treatment plan as indicated, as well as precise assessment of the patient’s progress in accordance with the original or revised treatment plan. e. Discharge planning and discharge summary. The record of each patient who has been discharged shall have a discharge summary that includes a recapitulation of the patient’s hospitalization and recommendations from appropriate services concerning follow-up or aftercare, as well as a brief summary of the patient’s condition on discharge. f. The facility shall obtain a professional review organization (PRO) determination that the person requires acute psychiatric care when a person applying or eligible for Medicaid enters the facility, returns from an acute care general hospital, or enters the facility after 30 consecutive days of visitation. 85.6(2) Fiscal records. a. Form 470-0042 shall be submitted to the department whenever a Medicaid applicant or recipient enters the facility, changes level of care, is hospitalized in a general hospital, leaves for visitation, or is discharged from the facility. b. The facility shall bill after each calendar month for the previous month’s services. 85.6(3) Additional requirements. Additional requirements are mandated for persons under the age of 21. a. Active treatment. Inpatient psychiatric services shall involve active treatment. Active treatment means implementation of a professionally developed and supervised individual plan of care that is developed and implemented by an interdisciplinary team no later than 14 days after admission and is designed to achieve the recipient’s discharge from inpatient status at the earliest possible time. b. Individual plan of care. An individual plan of care is a written plan developed for each recipient to improve the recipient’s condition to the extent that inpatient care is no longer necessary. The plan shall be reviewed every 30 days by the team to determine that services being provided are or were required on an inpatient basis and to recommend changes in the plan as indicated by the recipient’s overall adjustment as an inpatient. The plan of care shall: (1) Be based on a diagnostic evaluation that includes examination of the medical, psychological, social, behavioral and developmental aspects of the recipient’s situation and reflects the need for inpatient psychiatric care. (2) Be developed by a team of professionals, as specified in paragraph “c” below, in consultation, if possible, with the recipient and the recipient’s parents, legal guardians or others in whose care the recipient will be released after discharge. (3) State the treatment objectives. (4) Prescribe an integrated program of therapies, activities and experiences designed to meet the objectives. (5) Include, at an appropriate time, postdischarge plans and coordination of inpatient services with partial discharge plans and related community services to ensure continuity of care with the recipient’s family, school and community upon discharge. c. Interdisciplinary team. The individual plan of care shall be developed by an interdisciplinary team of physicians and other personnel who are employed by the facility or who provide services to patients in the facility. (1) Based on education and experience, preferably including competence in child psychiatry, the team shall be capable of assessing the recipient’s immediate and long-range therapeutic needs, developmental priorities, and personal strengths and liabilities; assessing the potential resources of the recipient’s family; setting treatment objectives; and prescribing therapeutic modalities to achieve the plan’s objectives. (2) The team shall include, as a minimum, either a board-eligible or board-certified psychiatrist, a clinical psychologist who has a doctoral degree and a physician licensed to practice in medicine or osteopathy, or a physician licensed to practice medicine or osteopathy with specialized training and experience in the diagnosis and treatment of mental diseases and a psychologist who has a master’s degree in clinical psychology and has been licensed by the state. (3) The team shall also include one of the following: a social worker with a master’s degree in social work with specialized training or one year’s experience in treating persons with mental illness, a registered nurse with specialized training or one year’s experience in treating persons with mental illness, an occupational therapist who is licensed and who has specialized training or one year of experience in treating persons with mental illness, or a psychologist who has a master’s degree in clinical psychology or who has been licensed by the state.Related ARC(s): 6714C441—85.7(249A) Psychiatric hospital reimbursement. 85.7(1) Reimbursement formula. Acute care in psychiatric hospitals shall be reimbursed on a per diem rate based on Medicare principles. a. The reimbursement principles follow and comply with the retrospective Principles of Medicare reimbursement found in Title 18 of the Social Security Act and amendments to that Act, Medicare regulations found in the Health Insurance Regulation Manual (HIRM-1), and General Instructions-Health Insurance Manual sections 10, 11, 12 and 15 when applicable. b. Allowable costs are those defined as allowable in 42 CFR, Subpart A, Sections 413.5 and 413.9, as amended to June 15, 2022, and 42 CFR 447.250 as amended to June 15, 2022. Only those costs are considered in calculating the Medicaid inpatient reimbursement. c. Medicare and Medicaid principles of reimbursement require hospitals to be paid at the lower of customary charges or reasonable cost and to adhere to all Medicare cost principles in the calculation of the facility rates. d. Payment for inpatient hospital care for recipients for whom the PRO has determined that the level of care that is medically necessary is only that of skilled care or nursing care will be made at a rate equal to the statewide average Medicaid skilled nursing facility rate or the average state nursing facility rate. Periodic PRO determinations of the need for continuing care are also required. e. Each participating Medicaid provider shall file a CMS 2552 Medicare Cost Report or a substitute accepted by the Centers for Medicare and Medicaid Services. In addition, supplemental information sheets are furnished to all Medicaid providers to be filed with the annual cost report. This report must be filed with the Iowa Medicaid enterprise provider audits and rate-setting unit for Iowa within 150 days after the close of the hospital’s fiscal year. f. Compensation for a disproportionate share of indigent patients is determined as described in 441—subrule 79.1(5). g. Medicaid reimbursement shall be reduced by any payments from a third party toward the cost of a patient’s care. 85.7(2) Medical necessity. The medical necessity of admission and continued stay will be determined by the PRO. Payment shall not be made for admissions which are determined not to be medically necessary nor will payment be approved for stays beyond the time at which inpatient specialized hospital care at the acute level has been determined not to be medically necessary. 85.7(3) Reserve bed day payment. No reserve bed day payments are made to acute care psychiatric hospitals. 85.7(4) Outpatient services. No coverage is available for outpatient psychiatric hospital services.Related ARC(s): 6714CThese rules are intended to implement Iowa Code section 249A.4.441—85.8(249A, 81GA, ch167) Eligibility of persons aged 21 through 64. 85.8(1) Facility. Acute care in a psychiatric hospital is covered for persons aged 21 through 64 only at the state mental health institutes at Cherokee and Independence. 85.8(2) Basis of eligibility. To be eligible for payment for the cost of care provided by one of the covered facilities, a person aged 21 through 64 must be eligible for one of the coverage groups listed in 441—Chapter 75. 85.8(3) Period of eligibility. A person is considered to be an inpatient until unconditionally discharged. Coverage extends until the last day of the month of discharge. 85.8(4) Extent of eligibility. While on inpatient status, a person eligible under a coverage group listed in 441—75.1(249A) is entitled to the full scope of Medicaid benefits.Related ARC(s): 6714C441—85.9 Reserved.441—85.10 Reserved.441—85.11 Reserved.441—85.12 Reserved.441—85.13 Reserved.441—85.14 Reserved.441—85.15 Reserved.441—85.16 Reserved.441—85.17 Reserved.441—85.18 Reserved.441—85.19 Reserved.441—85.20 Reserved.DIVISION IIPSYCHIATRIC MEDICAL INSTITUTIONS FOR CHILDREN441—85.21(249A) Conditions for participation. Psychiatric medical institutions for children shall be issued a license by the department of inspections and appeals under Iowa Code chapter 135H and shall hold either a license from the department of human services under Iowa Code section 237.3, subsection 2, paragraph “a,” subparagraph (3) or, for facilities which provide substance abuse treatment, a license from the department of public health under Iowa Code section 125.13.This rule is intended to implement Iowa Code sections 135H.4 and 249A.4.441—85.22(249A) Eligibility of persons under the age of 21. 85.22(1) Age. To be eligible for payment for the cost of care provided by a psychiatric medical institution for children, the person shall be under 21 years of age. When treatment in the facility is provided immediately preceding the individual’s twenty-first birthday, coverage continues to be available until the twenty-second birthday or until service is no longer required, whichever is earlier. 85.22(2) Period of eligibility. The person is considered to be an inpatient until unconditionally discharged. Coverage extends until the last day of the month of the discharge or the twenty-second birthday. While on inpatient status, the eligible individual is entitled to the full scope of Medicaid benefits. 85.22(3) Certification for need for care. For persons eligible for Medicaid prior to admission, an independent team shall certify that ambulatory care resources available in the community do not meet the treatment needs of the recipient, that proper treatment of the recipient’s psychiatric condition requires services on an inpatient basis under the direction of a physician, and that the services can reasonably be expected to improve the recipient’s condition or prevent further regression so that the services will no longer be needed. Team members are independent when they are not employees of or consultants to the facility. Form 470-2780 may be used to document these criteria. a. For persons determined eligible for Medicaid prior to admission, this preadmission certification shall be performed within 45 days prior to the proposed date for admission to the facility by an independent team that includes a physician who has competence in diagnosis and treatment of mental illness, preferably in child psychiatry, and who has knowledge of the person’s situation. If a social worker is a part of the team, the social worker may be from the county office of the department of human services.The evaluation shall be submitted to the facility on or prior to the date of the patient’s admission. b. When a person makes application for Medicaid subsequent to admission or has an application in process at the time of admission, a certification by the team responsible for the plan of care shall be provided within 14 days after admission and shall cover any period prior to application for which claims are to be made. c. For emergency admissions, a certification shall be provided by the team responsible for the plan of care within 14 days after admission. 85.22(4) Financial eligibility for persons under the age of 21. To be eligible for payments for the cost of care provided by psychiatric medical institutions, persons under the age of 21 shall be eligible under one of the coverage groups listed in 441—Chapter 75, except medically needy.Related ARC(s): 6714C441—85.23(249A) Client participation. The resident’s client participation and medical payments from a third party shall be paid toward the total cost of care on a monthly basis. The state will pay the balance of the cost of care for the month. The facility shall make arrangements directly with the resident for payment of client participation. Client participation is determined according to 441—Chapter 75.Related ARC(s): 6714C441—85.24(249A) Responsibilities of facilities. 85.24(1) Medical record requirements. The medical records maintained by psychiatric medical institutions for children shall permit determination of the degree and intensity of the treatment provided to persons who are furnished services in the facility. a. Development of assessment and diagnostic data. Medical records shall stress the psychiatric components of the record, including history of findings and treatment provided for the psychiatric condition for which the patient is admitted. (1) The identification data shall include the patient’s legal status. (2) A provisional or admitting diagnosis shall be made on every patient at the time of admission, and shall include the diagnoses of intercurrent diseases as well as the psychiatric diagnoses. (3) The reasons for admission shall be clearly documented as stated by the patient or others significantly involved. (4) The social service records, including reports of interviews with patients, family members, and others, shall provide an assessment of home plans and family attitudes and community resource contacts, as well as a social history. (5) When indicated, a complete neurological examination shall be recorded at the time of the admission physical examination. b. Psychiatric evaluation. Each patient shall receive a psychiatric evaluation that shall: (1) Be completed within seven days of admission. (2) Include a medical history. (3) Contain a record of mental status. (4) Note the onset of illness and the circumstances leading to admission. (5) Describe attitudes and behavior. (6) Estimate intellectual functioning, memory functioning, and orientation. (7) Include an inventory of the patient’s assets in descriptive, not interpretive, fashion. c. Treatment plan. (1) Each patient shall have an individual comprehensive treatment plan that shall be based on an inventory of the patient’s strengths and disabilities. The written plan shall include a substantiated diagnosis, short-term and long-range goals, the specific treatment modalities utilized, the responsibilities of each member of the treatment team, and adequate documentation to justify the diagnosis and the treatment and rehabilitation activities carried out. (2) The treatment received by the patient shall be documented in a way to ensure that all active therapeutic efforts are included. d. Recording progress. Progress notes shall be recorded by the doctor of medicine or osteopathy responsible for the care of the patient, nurse, social worker and, when appropriate, others significantly involved in active treatment modalities. The frequency of progress notes is determined by the condition of the patient but shall be recorded at least weekly for the first two months and at least once a month thereafter and shall contain recommendations for revisions in the treatment plan as indicated, as well as precise assessment of the patient’s progress in accordance with the original or revised treatment plan. e. Discharge planning and discharge summary. The record of each patient who has been discharged shall have a discharge summary that includes a recapitulation of the patient’s stay at the facility and recommendations from appropriate services concerning follow-up or aftercare, as well as a brief summary of the patient’s condition on discharge. f. The facility shall obtain a professional review organization (PRO) determination that the person requires psychiatric medical institution level of care when a person applying or eligible for Medicaid enters the facility, returns from an acute care hospital stay longer than 10 days, or enters the facility after 30 consecutive days of visitation. Periodic PRO determinations of the need for continuing care are also required. 85.24(2) Fiscal records. a. Form 470-0042 shall be submitted to the department whenever a Medicaid applicant or recipient enters the facility, changes level of care, is hospitalized, leaves for visitation, or is discharged from the facility. b. The facility shall bill after each calendar month for the previous month’s services. 85.24(3) Additional requirements. Additional requirements are mandated for persons under the age of 21. a. Active treatment. Inpatient psychiatric services shall involve active treatment. Active treatment means implementation of a professionally developed and supervised individual plan of care that is developed and implemented by an interdisciplinary team no later than 14 days after admission and is designed to achieve the recipient’s discharge from inpatient status at the earliest possible time. b. Individual plan of care. An individual plan of care is a written plan developed for each recipient to improve the recipient’s condition to the extent that inpatient care is no longer necessary. The plan shall be reviewed every 30 days by the team to determine that services being provided are or were required on an inpatient basis and to recommend changes in the plan as indicated by the recipient’s overall adjustment as an inpatient. The plan of care shall: (1) Be based on a diagnostic evaluation that includes examination of the medical, psychological, social, behavioral and developmental aspects of the recipient’s situation and reflects the need for inpatient psychiatric care. (2) Be developed by a team of professionals, as specified in paragraph “c” below, in consultation, if possible, with the recipient and the recipient’s parents, legal guardians or others in whose care the recipient will be released after discharge. (3) State the treatment objectives. (4) Prescribe an integrated program of therapies, activities and experiences designed to meet the objectives. (5) Include, at an appropriate time, postdischarge plans and coordination of inpatient services with partial discharge plans and related community services to ensure continuity of care with the recipient’s family, school and community upon discharge. c. Interdisciplinary team. The individual plan of care shall be developed by an interdisciplinary team of physicians and other personnel who are employed by the facility or who provide services to patients in the facility. Membership in the interdisciplinary plan of care team includes those physicians and other professionals who are involved in the direct provision of treatment services, involved in the organization of the plan of care, or involved in consulting with or supervising those professionals involved in the direct provision of care. (1) Based on education and experience, preferably including competence in child psychiatry, the team shall be capable of assessing the recipient’s immediate and long-range therapeutic needs, developmental priorities, and personal strengths and liabilities; assessing the potential resources of the recipient’s family; setting treatment objectives; and prescribing therapeutic modalities to achieve the plan’s objectives. (2) The team shall include, as a minimum, either a board-eligible or board-certified psychiatrist, a clinical psychologist who has a doctoral degree and a physician licensed to practice in medicine or osteopathy, or a physician licensed to practice medicine or osteopathy with specialized training and experience in the diagnosis and treatment of mental diseases and a psychologist who has a master’s degree in clinical psychology and has been licensed by the state. (3) The team shall also include one of the following: a social worker with a master’s degree in social work with specialized training or one year’s experience in treating persons with mental illness, a registered nurse with specialized training or one year’s experience in treating persons with mental illness, an occupational therapist who is licensed and who has specialized training or one year of experience in treating persons with mental illness, or a psychologist who has a master’s degree in clinical psychology or who has been licensed by the state.Related ARC(s): 6714C441—85.25(249A) Reimbursement to psychiatric medical institutions for children. 85.25(1) Computation of inpatient rate for non-state-owned facilities prior to July 1, 2014, and for state-owned facilities. For services rendered by non-state-owned facilities on or before June 30, 2014, or by state-owned facilities, facilities are paid at a per diem rate based on the facility’s actual and allowable cost for the service not to exceed the upper limit as provided in 441—subrule 79.1(2). a. Rates for new facilities are based on historical costs submitted on Form 470-0664 if the institution is established and has the historical data. If the institution is newly established, the rate shall be based on a proposed budget submitted on Form 470-0664. A Form 470-0664 with actual cost data shall be submitted after at least six months of participation in the program for a new rate adjustment. b. After the initial cost report period, the institution shall submit Form 470-0664 annually within three months of the close of the facility’s fiscal year. Failure to submit the report within this time shall reduce payment to 75 percent of the current rate. The reduced rate shall be paid for no longer than three months, after which time no further payments will be made. c. For services rendered on or after August 1, 2011, rates paid shall be adjusted to 100 percent of the facility’s actual and allowable average costs per patient day, based on the cost information submitted pursuant to paragraphs 85.25(1)“a” and “b,” subject to the upper limit provided in 441—subrule 79.1(2) for non-state-owned facilities. Before rate adjustment, providers shall be paid a prospective interim rate equal to the previous year’s retrospectively calculated unit-of-service rate. 85.25(2) Inpatient reimbursement for non-state-owned facilities effective January 1, 2016. Services rendered by non-state-owned facilities on or after January 1, 2016, are paid on a fee-for-service basis. 85.25(3) Reserve bed payments. a. Reserve bed day payment for days a resident of a psychiatric medical institution for children is absent from the facility for hospitalization in an acute care general hospital is paid in accordance with the following policies: (1) The intent of the department and the facility shall be for the resident to return to the facility after the hospitalization. (2) Staff from the psychiatric medical institution shall be available to provide support to the child and family during the hospitalization. (3) Payment for reserve bed days shall be canceled and payment returned if the facility refuses to accept the child back except when the department and the facility agree that the return would not be in the child’s best interests. If the department and the facility agree that the return would not be in the child’s best interests, payment shall be canceled effective the day after the joint decision not to return the child. (4) Payment will not be authorized for over ten days per calendar month and will not be authorized for over ten days for any continuous hospital stay. b. Reserve bed days for visitation shall be made for days a resident is absent from a psychiatric medical institution for children at the time of a nightly census for the purpose of visitation when the absence is in accordance with the following policies: (1) The visits are consistent with the child’s case permanency plan and the facility’s individual case plan. (2) The intent of the department and the facility shall be for the child to return to the facility after the visitation. (3) Staff from the psychiatric medical institution shall be available to provide support to the child and family during the visit. (4) Payment for reserve bed days shall be canceled and payments returned if the facility refuses to accept the child back except when the department and the facility agree that the return would not be in the child’s best interests. If the department and the facility agree that the return would not be in the child’s best interests, payment shall be canceled effective the day after the joint decision not to return the child. (5) Payment for reserve bed days shall be canceled effective the day after a decision not to return the child is made by the court or, in a voluntary placement, by the parent. (6) Payment for reserve bed days shall not exceed 14 consecutive days or 30 days per year, except upon written approval of the regional administrator. In no case shall payment exceed 60 days per year for visitation or other absences. c. Reserve bed payment shall be made for days a resident is absent from a psychiatric medical institution for children at the time of the nightly census for reasons such as detention, shelter care, or running away when the absence is in accordance with the following policies: (1) The intent of the department and the psychiatric medical institution for children shall be for the child to return to the facility after the absence. (2) Payment for reserve bed days shall be canceled and payments returned if the facility refuses to accept the child back except when the department and the facility agree that the return would not be in the child’s best interests. If the department and the facility agree that the return would not be in the child’s best interests, payment shall be canceled effective the day after the joint decision not to return the child. (3) Payment for reserve bed days shall be canceled effective the day after a decision is made not to return the child by the court or, in a voluntary placement, by the parent. (4) Payment for reserve bed days shall not exceed 14 consecutive days or 30 days per year, except upon written approval of the regional administrator. In no case shall payment exceed 60 days per year for visitation or other absences. (5) Reserve bed day payment is not available until the child has been physically admitted to the psychiatric medical institution. (6) The psychiatric medical institution shall notify the department social worker within 24 hours after the child is out of the facility for running away or other unplanned reasons. 85.25(4) Day treatment rates. Outpatient day treatment services are paid on a fixed fee basis.Related ARC(s): 8649B, 8899B, 9176B, 9710B, 0028C, 2026C, 2361C, 6714C441—85.26(249A) Outpatient day treatment for persons aged 20 or under. Payment to a psychiatric medical institution for children will be approved for day treatment services for persons aged 20 or under if the psychiatric medical institution for children is certified by the department of inspections and appeals for day treatment services and the services are provided on the licensed premises of the psychiatric medical institution for children.Exception: Field trips away from the premises are a covered service when the trip is therapeutic and integrated into the day treatment program’s description and milieu plan. All conditions for the day treatment program for persons aged 20 or under as outlined in 441—subrule 78.16(7) for community mental health centers shall apply to psychiatric medical institutions for children.These rules are intended to implement Iowa Code section 249A.4.441—85.27 Reserved.441—85.28 Reserved.441—85.29 Reserved.441—85.30 Reserved.441—85.31 Reserved.441—85.32 Reserved.441—85.33 Reserved.441—85.34 Reserved.441—85.35 Reserved.441—85.36 Reserved.441—85.37 Reserved.441—85.38 Reserved.441—85.39 Reserved.441—85.40 Reserved.DIVISION IIINURSING FACILITIES FOR PERSONS WITH MENTAL ILLNESS441—85.41(249A) Conditions of participation. A nursing facility for persons with mental illness shall be licensed pursuant to department of inspections and appeals rules 481—Chapter 65, or, if the facility is a distinct part of a hospital, pursuant to department of inspections and appeals rule 481—51.33(135B). A distinct part of a general hospital may be considered a psychiatric institution. In addition, the facility shall be certified to participate in the Iowa Medicaid program as a nursing facility pursuant to 441—Chapter 81 and shall be 16 beds or more. The facility shall also meet the criteria set forth in subrule 85.1(1).441—85.42(249A) Out-of-state placement. Placement in out-of-state nursing facilities for persons with mental illness is not payable.441—85.43(249A) Eligibility of persons aged 65 and over. To be eligible for payment for the cost of care provided by nursing facilities for persons with mental illness, persons must be aged 65 or over and be eligible under one of the coverage groups listed in 441—Chapter 75, except for medically needy.Related ARC(s): 6714C441—85.44(249A) Client participation. The resident’s client participation and medical payments from a third party shall be paid toward the total cost of care on a monthly basis. The state will pay the balance of the cost of care for the month. The facility shall make arrangements directly with the resident for payment of client participation. Client participation is determined according to rule 441—75.16(249A).441—85.45(249A) Responsibilities of nursing facility. 85.45(1) Medical record requirements. The facility shall obtain a PRO determination that the person requires psychiatric care when a person applying or eligible for Medicaid enters the facility, returns from an acute care hospital stay longer than 10 days, or enters the facility after 30 consecutive days of visitation. Periodic PRO determinations of the need for continuing care are also required. 85.45(2) Fiscal records. a. A Case Activity Report, Form 470-0042, shall be submitted to the department whenever a Medicaid applicant or recipient enters the facility, changes level of care, is hospitalized, leaves for visitation, or is discharged from the facility. b. The facility shall bill after each calendar month for the previous month’s services.441—85.46(249A) Policies governing reimbursement. Cost reporting, reserve bed day payment, and reimbursement shall be the same for nursing facilities for persons with mental illness as for nursing facilities as set forth in 441—Chapter 81.441—85.47(249A) State-funded personal needs supplement. A Medicaid member living in an intermediate care facility for persons with mental illness who has countable income for purposes of rule 441—75.16(249A) of less than $50 per month shall receive a state-funded payment from the department for the difference between that countable income and $50 if the legislature has appropriated funding specifically for this purpose. This payment shall not be considered a benefit under Title XIX of the Social Security Act.This rule is intended to implement Iowa Code section 249A.30A.Related ARC(s): 6714CThese rules are intended to implement Iowa Code section 249A.4.Related ARC(s): 8649B, 8899B, 9176B, 9710B, 0028C, 2026C, 2361C, 6714C
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