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.  Routine physical examinations. Rescinded IAB 8/1/07, effective 8/1/07.  c.  Treatment of certain foot conditions as specified in 78.5(2)“a,” “b,” and “c.”  d.  Acupuncture treatments.  e.  Rescinded 9/6/78.  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.  Rescinded IAB 1/30/08, effective 4/1/08.  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.  f.  Nonprescription drugs. Rescinded IAB 1/30/08, effective 4/1/08.  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)  Rescinded, effective 8/1/87.  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, or otherwise handicapped 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:
  1. Simultaneous pancreas-kidney transplants and pancreas after kidney transplants are covered.
  2. Pancreas transplants alone are covered for persons exhibiting any of the following:
  • A history of frequent, acute, and severe metabolic complications (e.g., hypoglycemia, hyperglycemia, or ketoacidosis) requiring medical attention.
  • Clinical problems with exogenous insulin therapy that are so severe as to be incapacitating.
  • Consistent failure of insulin-based management to prevent acute complications.
  • 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)  EPSDT care coordination. Rescinded IAB 12/3/08, effective 2/1/09.  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, 5418C441—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:
    1. Has on file with the department current contact information, including a current fax number, and a signed Form 470-4914, Fax Confidentiality Certificate, and
    2. Does not receive a notice of approval or disapproval within 48 hours of a request for prior authorization.
      (4)  Prior authorization for medication-assisted treatment shall be governed pursuant to subrule 78.28(2).
      b.  Payment is not made for:  (1)  Drugs whose prescribed use is not for a medically accepted indication as defined by Section 1927(k)(6) of the Social Security Act.  (2)  Drugs used for anorexia, weight gain, or weight loss.  (3)  Drugs used for cosmetic purposes or hair growth.  (4)  Rescinded IAB 2/8/12, effective 3/14/12.  (5)  Otherwise covered outpatient drugs if the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or the manufacturer’s designee.  (6)  Drugs described in Section 107(c)(3) of the Drug Amendments of 1962 and identical, similar, or related drugs (within the meaning of Section 310.6(b)(1) of Title 21 of the Code of Federal Regulations (drugs identified through the Drug Efficacy Study Implementation (DESI) review)).  (7)  “Covered Part D drugs” as defined by 42 U.S.C. Section 1395w-102(e)(1)-(2) for any “Part D eligible individual” as defined by 42 U.S.C. Section 1395w-101(a)(3)(A), including a member who is not enrolled in a Medicare Part D plan.  (8)  Drugs prescribed for fertility purposes.  (9)  Drugs used for the treatment of sexual or erectile dysfunction, except when used to treat a condition other than sexual or erectile dysfunction for which the drug has been approved by the U.S. Food and Drug Administration.  (10)  Prescription drugs for which the prescription was executed in written (and nonelectronic) form unless the prescription was executed on a tamper-resistant pad, as required by Section 1903(i)(23) of the Social Security Act (42 U.S.C. Section 1396b(i)(23)).  (11)  Drugs used for symptomatic relief of cough and colds, except for nonprescription drugs listed at subrule 78.2(5).  (12)  Investigational drugs, including drugs that are the subject of an investigational new drug (IND) application allowed to proceed by the U.S. Food and Drug Administration (FDA) but that do not meet the definition of a covered outpatient drug in 42 U.S.C. 1396r-8(k)(2)-(4).
      78.2(5)    Nonprescription drugs.    a.  The following drugs that may otherwise be dispensed without a prescription are covered subject to the prior authorization requirements stated below and as specified in the preferred drug list published by the department pursuant to Iowa Code section 249A.20A:Acetaminophen tablets 325 mg, 500 mgAcetaminophen elixir 160 mg/5 mlAcetaminophen solution 100 mg/mlAcetaminophen suppositories 120 mgArtificial tears ophthalmic solutionArtificial tears ophthalmic ointmentAspirin tablets 81 mg, chewableAspirin tablets 81 mg, 325 mg, and 650 mg oralAspirin tablets, enteric coated 325 mg, 650 mg, 81 mgAspirin tablets, buffered 325 mgBacitracin ointment 500 units/gmBenzoyl peroxide 5%, gel, lotionBenzoyl peroxide 10%, gel, lotionCetirizine hydrochloride liquid 1 mg/mlCetirizine hydrochloride tablets 5 mgCetirizine hydrochloride tablets 10 mgChlorpheniramine maleate tablets 4 mgClotrimazole vaginal cream 1%Diphenhydramine hydrochloride capsules 25 mgDiphenhydramine hydrochloride elixir, liquid, and syrup 12.5 mg/5 mlEpinephrine racemic solution 2.25%Ferrous sulfate solution 75 mg/0.6 ml (15 mg/0.6 ml elemental iron)Ferrous sulfate tablets 325 mgFerrous sulfate elixir 220 mg/5 mlFerrous sulfate drops 75 mg/0.6 mlFerrous gluconate tablets 325 mgFerrous fumarate tablets 325 mgGuaifenesin 100 mg/5 ml with dextromethorphan 10 mg/5 ml liquidIbuprofen suspension 100 mg/5 mlIbuprofen tablets 200 mgInsulinLactic acid (ammonium lactate) lotion 12%Levonorgestrel 1.5 mgLoperamide hydrochloride liquid 1 mg/5 mlLoperamide hydrochloride liquid 1 mg/7.5 mlLoperamide hydrochloride tablets 2 mgLoratadine syrup 5 mg/5 mlLoratadine tablets 10 mgMagnesium hydroxide suspension 400 mg/5 mlMeclizine hydrochloride tablets 12.5 mg, 25 mg oral and chewableMiconazole nitrate cream 2% topical and vaginalMiconazole nitrate vaginal suppositories, 100 mg Mineral products with prior authorizationNeomycin-bacitracin-polymyxin ointmentNicotine gum 2 mg, 4 mgNicotine lozenge 2 mg, 4 mgNicotine patch 7 mg/day, 14 mg/day and 21 mg/dayPediatric oral electrolyte solutionsPermethrin lotion 1%Polyethylene glycol 3350 powderPseudoephedrine hydrochloride tablets 30 mg, 60 mgPseudoephedrine hydrochloride liquid 30 mg/5 mlPyrethrins-piperonyl butoxide liquid 0.33-4%Pyrethrins-piperonyl butoxide shampoo 0.3-3%Pyrethrins-piperonyl butoxide shampoo 0.33-4%Salicylic acid liquid 17%Senna tablets 187 mgSennosides-docusate sodium tablets 8.6 mg-50 mgSennosides syrup 8.8 mg/5 mlSennosides tablets 8.6 mgSodium bicarbonate tablets 325 mgSodium bicarbonate tablets 650 mgSodium chloride hypertonic ophthalmic ointment 5%Sodium chloride hypertonic ophthalmic solution 5%Tolnaftate 1% cream, solution, powderVitamins, single and multiple with prior authorizationOther nonprescription drugs listed as preferred in the preferred drug list published by the department pursuant to Iowa Code section 249A.20A.  b.  Nonprescription drugs for use in a nursing facility, PMIC, or ICF/ID shall be included in the per diem rate paid to the nursing facility, PMIC, or ICF/ID.  78.2(6)    Quantity prescribed.    a.    Quantity prescribed.  When it is not therapeutically contraindicated, the legally qualified practitioner shall prescribe not less than a one-month supply of covered prescription and nonprescription medication. Contraceptives may be prescribed in three-month quantities.  b.    Prescription refills.    (1)  Prescription refills shall be performed and recorded in a manner consistent with existent state and federal laws, rules and regulations.  (2)  Automatic refills.  1.  Automatic refills are allowed. Participation in an automatic refill program is voluntary and opt-in only, on a drug-by-drug basis.  2.  The program must have:
  • Easy-to-locate contact information through telephone, the program’s website, or both;
  • Easy-to-understand patient materials on how to select or unselect drug(s) for inclusion and how to disenroll;
  • Confirmation that the member wants to continue in the automatic refill program at least annually;
  • Confirmation of continued medical necessity provided by the Medicaid member or person acting as an authorized representative of the member, before the member receives the medication at the pharmacy or before the medication is mailed or delivered to the member, without which confirmation the drug(s) must be credited back to the Medicaid program; and
  • Records of all consents, which must be in electronic or written format and must be available for review by auditors.
  •   78.2(7)    Lowest cost item.  The pharmacist shall dispense the lowest cost item in stock that meets the requirements of the practitioner as shown on the prescription.  78.2(8)    Consultation.  In accordance with Public Law 101-508 (Omnibus Budget Reconciliation Act of 1990), 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)  Rescinded IAB 2/6/91, effective 4/1/91.  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:
    1. Complete a level of care (LOC) determination describing a member’s LOC needs, using Form 470-5156, Swing Bed Certification.
    2. Contact skilled nursing facilities within a 30-mile radius of the hospital regarding available beds to meet the member’s LOC needs.
    3. Certify that no freestanding skilled nursing facility beds are available for the member within a 30-mile radius of the hospital, which will be able to appropriately meet the member’s needs and that home-based care for the member is not available or appropriate.
      (5)  Swing-bed stays beyond 14 days will only be approved when there is no appropriate freestanding nursing facility bed available within a 30-mile radius and home-based care for the member is not available or appropriate, as documented by the hospital seeking the swing-bed admission. For the purpose of these criteria, an “appropriate” nursing facility bed is a bed in a Medicaid-participating freestanding nursing facility that provides the LOC required for the member’s medical condition and corresponding LOC needs.  (6)  A Medicaid member who has been in a swing bed beyond 14 days must be discharged to an appropriate nursing facility bed within a 30-mile radius of the swing-bed hospital or to appropriate home-based care within 72 hours of an appropriate nursing facility bed becoming available.Preadmission screening and resident review (PASRR) rules still apply for members being transferred to a nursing facility.
      78.3(17)  Rescinded IAB 8/9/89, effective 10/1/89.  78.3(18)  Preprocedure review by the IME medical services unit is required if hospitals are to be reimbursed for certain frequently performed surgical procedures as set forth under subrule 78.1(19). Preprocedure review is also required for other types of major surgical procedures, such as organ transplants. Criteria are available from the IME medical services unit. (Cross reference 78.28(6))  78.3(19)  Rescinded IAB 10/8/97, effective 12/1/97.This rule is intended to implement Iowa Code section 249A.4.
    Related ARC(s): 0065C, 0194C, 0354C, 0844C, 1054C, 2361C, 4899C441—78.4(249A)  Dentists.  Payment will be made for medical and surgical services furnished by a dentist to the extent these services may be performed under state law either by doctors of medicine, osteopathy, dental surgery or dental medicine and would be covered if furnished by doctors of medicine or osteopathy. Services must be reasonable, necessary, and cost-effective for the prevention, diagnosis, and treatment of dental disease or injuries or for oral devices necessary for a medical condition. Payment will also be made for the following dental procedures:  78.4(1)    Preventive services.  Payment shall be made for the following preventive services:  a.  Oral prophylaxis, including necessary scaling and polishing, is payable only once in a six-month period except for persons who, because of a physical or mental condition, need more frequent care. Documentation supporting the need for oral prophylaxis performed more than once in a six-month period must be maintained.  b.  Topical application of fluoride is payable once every 90 days. (This does not include the use of fluoride prophylaxis paste as fluoride treatment.)  c.  Pit and fissure sealants are payable for placement on deciduous and permanent posterior teeth only. Reimbursement for sealants is restricted to work performed on members through 18 years of age and on members who have a physical or mental condition that impairs their ability to maintain adequate oral hygiene. Replacement sealants are covered when medically necessary, as documented in the patient record.  d.  Space management services are payable in mixed dentition when premature loss of teeth would permit existing teeth to shift and cause a handicapping malocclusion or there is too little dental ridge to accommodate either the number or the size of teeth and significant dental disease will result if the condition is not corrected.  78.4(2)    Diagnostic services.  Payment shall be made for the following diagnostic services:  a.  A comprehensive oral evaluation is payable once per member per dental practice in a three-year period when the member has not been seen by a dentist in the dental practice during the three-year period.  b.  A periodic oral examination is payable once in a six-month period.  c.  A full mouth radiograph survey, consisting of a minimum of 14 periapical films and bite-wing films, or a panoramic radiograph with bite-wings is a payable service once in a five-year period, except when medically necessary to evaluate development and to detect anomalies, injuries and diseases. Full mouth radiograph surveys are not payable under the age of six except when medically necessary. A panographic-type radiography with bite-wings is considered the same as a full mouth radiograph survey.  d.  Supplemental bitewing films are payable only once in a 12-month period.  e.  Single periapical films are payable when necessary.  f.  Intraoral radiograph, occlusal.  g.  Extraoral radiograph.  h.  Posterior-anterior and lateral skull and facial bone radiograph, survey film.  i.  Temporomandibular joint radiograph.  j.  Cephalometric film.  k.  Diagnostic casts are payable only for orthodontic cases or dental implants or when requested by the Iowa Medicaid enterprise medical services unit’s dental consultant.  l.  Cone beam images are payable when medically necessary for situations including, but not limited to, detection of tumors, positioning of severely impacted teeth, supernumerary teeth or dental implants.  78.4(3)    Restorative services.  Payment shall be made for the following restorative services:  a.  Treatment of dental caries is payable in those areas which require immediate attention. Restoration of incipient or nonactive carious lesions are not payable. Carious activity may be considered incipient when there is no penetration of the dento-enamel junction as demonstrated in diagnostic radiographs.  b.  Amalgam alloy and composite resin-type filling materials are reimbursable only once for the same restoration in a two-year period.  c.  Rescinded IAB 5/1/02, effective 7/1/02.  d.  Crowns are payable when there is at least a fair prognosis for maintaining the tooth as determined by the Iowa Medicaid enterprise medical services unit and a more conservative procedure would not be serviceable.  (1)  Stainless steel crowns are limited to primary and permanent posterior teeth and are covered when coronal loss of tooth structure does not allow restoration with an amalgam or composite restoration. Placement on permanent posterior teeth is allowed only for members who have a mental or physical condition that limits their ability to tolerate the procedure for placement of a different crown.  (2)  Aesthetic coated stainless steel crowns and stainless steel crowns with a resin window are limited to primary anterior teeth.  (3)  Laboratory-fabricated crowns, other than stainless steel, are limited to permanent teeth and require prior authorization. Approval shall be granted when coronal loss of tooth structure does not allow restoration with an amalgam or composite restoration or there is evidence of recurring decay surrounding a large existing restoration, a fracture, a broken cusp(s), or an endodontic treatment.  (4)  Crowns with noble or high noble metals require prior authorization. Approval shall be granted for members who meet the criteria for a laboratory-fabricated crown, other than stainless steel, and who have a documented allergy to all other restorative materials.  e.  Cast post and core, post and composite or post and amalgam in addition to a crown are payable when a tooth is functional and the integrity of the tooth would be jeopardized by no post support.  f.  Payment as indicated will be made for the following restoration procedures:  (1)  Amalgam or acrylic buildups, including any pins, are considered a core buildup.  (2)  One, two, or more restorations on one surface of a tooth shall be paid as a one-surface restoration, i.e., mesial occlusal pit and distal occlusal pit of a maxillary molar or mesial and distal occlusal pits of a lower bicuspid.  (3)  Occlusal lingual groove of a maxillary molar that extends from the distal occlusal pit and down the distolingual groove will be paid as a two-surface restoration. This restoration and a mesial occlusal pit restoration on the same tooth will be paid as one, two-surface restoration.  (4)  Rescinded IAB 5/1/02, effective 7/1/02.  (5)  Two separate one-surface restorations are payable as a two-surface restoration (i.e., an occlusal pit restoration and a buccal pit restoration are a two-surface restoration).  (6)  Tooth preparation, temporary restorations, cement bases, pulp capping, impressions, and local anesthesia are included in the restorative fee and may not be billed separately.  (7)  Pin retention will be paid on a per-tooth basis and in addition to the final restoration.  (8)  More than four surfaces on an amalgam restoration will be reimbursed as a “four-surface” amalgam.  (9)  An amalgam or composite restoration is not payable following a sedative filling in the same tooth unless the sedative filling was placed more than 30 days previously.  78.4(4)    Periodontal services.  Payment may be made for the following periodontal services:  a.  Full-mouth debridement to enable comprehensive periodontal evaluation and diagnosis is payable once every 24 months. This procedure is not payable on the same date of service when other prophylaxis or periodontal services are performed.  b.  Periodontal scaling and root planing is payable once every 24 months when prior approval has been received. Prior approval shall be granted per quadrant when radiographs demonstrate subgingival calculus or loss of crestal bone and when the periodontal probe chart shows evidence of pocket depths of 4 mm or greater. (Cross reference 78.28(3)“a”(1))  c.  Periodontal surgical procedures which include gingivoplasty, osseous surgery, and osseous allograft are payable services when prior approval has been received. Payment for these surgical procedures will be approved after periodontal scaling and root planing has been provided, a reevaluation examination has been completed, and the member has demonstrated reasonable oral hygiene. Payment is also allowed for members who are unable to demonstrate reasonable oral hygiene due to a physical or mental condition, or who exhibit evidence of gingival hyperplasia, or who have a deep carious lesion that cannot be otherwise accessed for restoration.  d.  Tissue grafts. Pedicle soft tissue graft, free soft tissue graft, and subepithelial connective tissue graft are payable services with prior approval. Authorization shall be granted when the amount of tissue loss is causing problems such as continued bone loss, chronic root sensitivity, complete loss of attached tissue, or difficulty maintaining adequate oral hygiene. (Cross reference 78.28(3)“a”(2))  e.  Periodontal maintenance therapy requires prior authorization. Approval shall be granted for members who have completed periodontal scaling and root planing at least three months prior to the initial periodontal maintenance therapy and the periodontal probe chart shows evidence of pocket depths of 4 mm or greater. (Cross reference 78.28(3)“a”(3))  f.  Tissue regeneration procedures require prior authorization. Approval shall be granted when radiographs show evidence of recession in relation to the muco-gingival junction and the bone level indicates the tooth has a fair to good long-term prognosis.  g.  Localized delivery of antimicrobial agents requires prior authorization. Approval shall be granted when at least one year has elapsed since periodontal scaling and root planing was completed, the member has maintained regular periodontal maintenance, and pocket depths remain at a moderate to severe depth with bleeding on probing. Authorization is limited to once per site every 12 months.  78.4(5)    Endodontic services.  Payment shall be made for the following endodontic services:  a.  Root canal treatments on permanent anterior and posterior teeth when there is presence of extensive decay, infection, draining fistulas, severe pain upon chewing or applied pressure, prolonged sensitivity to temperatures, or a discolored tooth indicative of a nonvital tooth.  b.  Vital pulpotomies. Cement bases, pulp capping, and insulating liners are considered part of the restoration and may not be billed separately.  c.  Surgical endodontic treatment, including an apicoectomy, performed as a separate surgical procedure; an apicoectomy, performed in conjunction with endodontic procedure; an apical curettage; a root resection; or excision of hyperplastic tissue is payable when nonsurgical treatment has been attempted and a reasonable time of approximately one year has elapsed after which failure has been demonstrated. Surgical endodontic procedures may be indicated when:  (1)  Conventional root canal treatment cannot be successfully completed because canals cannot be negotiated, debrided or obturated due to calcifications, blockages, broken instruments, severe curvatures, and dilacerated roots.  (2)  Correction of problems resulting from conventional treatment including gross underfilling, perforations, and canal blockages with restorative materials. (Cross reference 78.28(3)“c”)  d.  Endodontic retreatment when prior authorization has been received. Authorization for retreatment of a tooth with previous endodontic treatment shall be granted when the conventional treatment has been completed, a reasonable time has elapsed since the initial treatment, and failure has been demonstrated with a radiograph and narrative history. A reasonable period of time is approximately one year if the treating dentist is the same and may be less if the member must see a different dentist.  78.4(6)    Oral surgery—medically necessary.  Payment shall be made for medically necessary oral surgery services furnished by dentists to the extent that these services may be performed under state law either by doctors of medicine, osteopathy, dental surgery or dental medicine and would be covered if furnished by doctors of medicine or osteopathy, as defined in rule 441—78.1(249A). These services will be reimbursed in a manner consistent with the physician’s reimbursement policy. The following surgical procedures are also payable when performed by a dentist:  a.  Extractions, both surgical and nonsurgical.  b.  Impaction (soft tissue impaction, upper or lower) that requires an incision of overlying soft tissue and the removal of the tooth.  c.  Impaction (partial bony impaction, upper or lower) that requires incision of overlying soft tissue, elevation of a flap, removal of bone and removal of the tooth.  d.  Impaction (complete bony impaction, upper or lower) that requires incision of overlying soft tissue, elevation of a flap, removal of bone and section of the tooth for removal.  e.  Root recovery (surgical removal of residual root).  f.  Oral antral fistula closure (or antral root recovery).  g.  Surgical exposure of impacted or unerupted tooth for orthodontic reasons, including ligation when indicated.  h.  Surgical exposure of impacted or unerupted tooth to aid eruption.  i.  Routine postoperative care is considered part of the fee for surgical procedures and may not be billed separately.  j.  Payment may be made for postoperative care where need is shown to be beyond normal follow-up care or for postoperative care where the original service was performed by another dentist.  78.4(7)    Prosthetic services.  Payment may be made for the following prosthetic services:  a.  An immediate denture or a first-time complete denture. Six months’ postdelivery care is included in the reimbursement for the denture.  b.  A removable partial denture replacing anterior teeth when prior approval has been received. Approval shall be granted when radiographs demonstrate adequate space for replacement of a missing anterior tooth. Six months’ postdelivery care is included in the reimbursement for the denture.  c.  A removable partial denture replacing posterior teeth including six months’ postdelivery care when prior approval has been received. Approval shall be granted when the member has fewer than eight posterior teeth in occlusion, excluding third molars, or the member has a full denture in one arch and a partial denture replacing posterior teeth is required in the opposing arch to balance occlusion. When one removable partial denture brings eight posterior teeth in occlusion, no additional removable partial denture will be approved. Six months’ postdelivery care is included in the reimbursement for the denture. (Cross reference 78.28(3)“b”(1))  d.  A fixed partial denture (including an acid etch fixed partial denture) replacing anterior teeth when prior approval has been received. Approval shall be granted for members who:  (1)  Have a physical or mental condition that precludes the use of a removable partial denture, or  (2)  Have an existing bridge that needs replacement due to breakage or extensive, recurrent decay.High noble or noble metals shall be approved only when the member is allergic to all other restorative materials. (Cross reference 78.28(3)“b”(2))  e.  A fixed partial denture replacing posterior teeth when prior approval has been received. Approval shall be granted for members who meet the criteria for a removable partial denture and:  (1)  Have a physical or mental condition that precludes the use of a removable partial denture, or  (2)  Have a full denture in one arch and a partial fixed denture replacing posterior teeth is required in the opposing arch to balance occlusion.High noble or noble metals will be approved only when the member is allergic to all other restorative materials.  f.  Obturator for surgically excised palatal tissue or deficient velopharyngeal function of cleft palate patients.  g.  Chairside relines and laboratory-processed relines are payable only once per prosthesis every 12 months, beginning 6 months after placement of the denture.  h.  Tissue conditioning is a payable service twice per prosthesis in a 12-month period.  i.  Two repairs per prosthesis in a 12-month period are payable.  j.  Adjustments to a complete or removable partial denture are payable when medically necessary after six months’ postdelivery care. An adjustment consists of removal of acrylic material or adjustment of teeth to eliminate a sore area or to make the denture fit better. Warming dentures and massaging them for better fit or placing them in a sonic device does not constitute an adjustment.  k.  Dental implants and related services when prior authorization has been received. Prior authorization shall be granted when the member is missing significant oral structures due to cancer, traumatic injuries, or developmental defects such as cleft palate and cannot use a conventional denture.  l.  Replacement of complete or partial dentures in less than a five-year period requires prior authorization. Approval shall be granted once per denture replacement per arch in a five-year period when the denture has been lost, stolen or broken beyond repair or cannot be adjusted for an adequate fit. Approval shall also be granted for more than one denture replacement per arch within five years for members who have a medical condition that necessitates thorough mastication. Approval will not be granted in less than a five-year period when the reason for replacement is resorption.  m.  A complete or partial denture rebase requires prior approval. Approval shall be granted when the acrylic of the denture is cracked or has had numerous repairs and the teeth are in good condition.  n.  An oral appliance for obstructive sleep apnea requires prior approval and must be custom-fabricated. Approval shall be granted in accordance with Medicare criteria.  78.4(8)    Orthodontic procedures.  Payment may be made for the following orthodontic procedures:  a.  Minor treatment to control harmful habits when prior approval has been received. Approval shall be granted when it is cost-effective to lessen the severity of a malformation such that extensive treatment is not required. (Cross reference 78.28(3)“c”)  b.  Interceptive orthodontic treatment of the transitional dentition when prior approval has been received. Approval shall be granted when it is cost-effective to lessen the severity of a malformation such that extensive treatment is not required.  c.  Comprehensive orthodontic treatment when prior approval has been received. Approval is limited to members under 21 years of age and shall be granted when the member has a severe handicapping malocclusion with a score of 26 or above using the index from the “Handicapping Malocclusion Assessment to Establish Treatment Priority,” by J.A. Salzmann, D.D.S., American Journal of Orthodontics, October 1968.  78.4(9)    Adjunctive general services.  Payment may be made for the following:  a.  Treatment in a hospital. Payment will be approved for dental treatment rendered to a hospitalized member only when the mental, physical, or emotional condition of the member prevents the dentist from providing necessary care in the office.  b.  Treatment in a nursing facility. Payment will be approved for dental treatment provided in a nursing facility. When more than one patient is examined during the same nursing home visit, payment will be made by the Medicaid program for only one visit to the nursing home.  c.  Office visit. Payment will be approved for an office visit for care of injuries or abnormal conditions of the teeth or supporting structure when treatment procedures or examinations are not billed for that visit.  d.  Office calls after hours. Payment will be approved for office calls after office hours in emergency situations. The office call will be paid in addition to treatment procedures.  e.  Drugs. Payment will be made for drugs dispensed by a dentist only if there is no licensed retail pharmacy in the community where the dentist’s office is located. If eligible to dispense drugs, the dentist should request a copy of the Prescribed Drugs Manual from the Iowa Medicaid enterprise provider services unit. Payment will not be made for the writing of prescriptions.  f.  Anesthesia. General anesthesia, intravenous sedation, and nonintravenous conscious sedation are payable services when the extensiveness of the procedure indicates it or there is a concomitant disease or impairment which warrants use of anesthesia. Inhalation of nitrous oxide is payable when the age or physical or mental condition of the member necessitates the use of minimal sedation for dental procedures.  g.  Occlusal guard. A removable dental appliance to minimize the effects of bruxism and other occlusal factors requires prior approval. Approval shall be granted when the documentation supports evidence of significant loss of tooth enamel, tooth chipping, headaches or jaw pain.  78.4(10)    Orthodontic services to members 21 years of age or older.  Orthodontic procedures are not covered for members 21 years of age or older.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 9702B, 9883B, 0631C, 4899C441—78.5(249A)  Podiatrists.  Payment will be approved only for certain podiatric services.  78.5(1)  Payment will be approved for the following orthotic appliances and treatment of nail pathologies:  a.  Durable plantar foot orthotic.  b.  Plaster impressions for foot orthotic.  c.  Molded digital orthotic.  d.  Shoe padding when appliances are not practical.  e.  Custom molded space shoes for rheumatoid arthritis, congenital defects and deformities, neurotropic, diabetic and ischemic intractable ulcerations and deformities due to injuries.  f.  Rams horn (hypertrophic) nails.  g.  Onychomycosis (mycotic) nails.  78.5(2)  Payment will be made for the same scope of podiatric services available through Part B of Title XVIII (Medicare) except as listed below:  a.  Treatment of flatfoot. The term “flatfoot” is defined as a condition in which one or more arches have flattened out.  b.  Treatment of subluxations of the foot are defined as partial dislocations or displacements of joint surfaces, tendons, ligaments, or muscles of the foot. Surgical or nonsurgical treatments undertaken for the sole purpose of correcting a subluxated structure in the foot as an isolated entity are not covered.Reasonable and necessary diagnosis of symptomatic conditions that result from or are associated with partial displacement of foot structures is a covered service. Surgical correction in the subluxated foot structure that is an integral part of the treatment of a foot injury or is undertaken to improve the function of the foot or to alleviate an induced or associated symptomatic condition is a covered service.  c.  Routine foot care. Routine foot care includes the cutting or removal of corns or callouses, the trimming of nails and other hygienic and preventive maintenance care in the realm of self-care such as cleaning and soaking the feet, the use of skin creams to maintain skin tone of both ambulatory and bedfast patients and any services performed in the absence of localized illness, injury, or symptoms involving the foot.  d.  Orthopedic shoes. Payment will not be made for orthopedic shoes or for any device to be worn in or attached to orthopedic shoes or other types of shoes when provided by the podiatrist. Payment will be made to the podiatrist for the examination including tests to establish the need for orthopedic shoes.  78.5(3)  Prescriptions are required for drugs and supplies as specified in paragraph 78.1(2)“c.” Payment shall be made for drugs dispensed by a podiatrist only if there is no licensed retail pharmacy in the community where the podiatrist’s office is located. If eligible to dispense drugs, the podiatrist should request a copy of the Prescribed Drugs Manual from the Iowa Medicaid enterprise provider services unit. Payment will not be made for writing prescriptions.This rule is intended to implement Iowa Code section 249A.4.441—78.6(249A)  Optometrists.  Payment will be approved for medically necessary services and supplies provided by the optometrist within the scope of practice of optometry and the limitations of state law, subject to the following limitations and exclusions. Covered optometric services include a professional component and materials.  78.6(1)    Payable professional services.  Payable professional services are:  a.  Eye examinations. The coverage of eye examinations depends on the purpose of the examination. Services are covered if the examination is the result of a complaint or symptom of an eye disease or injury. Routine eye examinations are covered once in a 12-month period. These services are rendered in the optometrist’s office or clinic, the home, a nursing facility, or other appropriate setting. Payment for mileage shall be subject to the same approval and payment criteria as those in effect for Medicare Part B. The following levels of service are recognized for optometric examinations:  (1)  Intermediate examination. A level of optometric or ophthalmological services pertaining to medical examination and evaluation, with initiation or continuation of a diagnostic and treatment program.  (2)  Comprehensive examination. A level of optometric or ophthalmological services pertaining to medical examination and evaluation, with initiation or continuation of a diagnostic and treatment program, and a general evaluation of the complete visual system.  b.  Medical services. Payment will be approved for medically necessary services and supplies within the scope of practice of the optometrist, including services rendered in the optometrist’s office or clinic, the home, a nursing facility, or other appropriate setting. Payment for mileage shall be subject to the same approval and payment criteria as those in effect for Medicare Part B.  c.  Auxiliary procedures. The following auxiliary procedures and special tests are payable when performed by an optometrist. Auxiliary procedures and special tests are reimbursed as a separate procedure only when warranted by case history or diagnosis.  (1)  Serial tonometry. Single tonometry is part of the intermediate and comprehensive exams and is not payable as a separate procedure as is serial tonometry.  (2)  Gonioscopy.  (3)  Extended ophthalmoscopy. Routine ophthalmoscopy is part of the intermediate and comprehensive examination and is not payable as a separate procedure. Generally, extended ophthalmoscopy is considered to be part of the comprehensive examination and, if performed in conjunction with that level of service, is not payable as a separate procedure.  (4)  Visual fields. Gross visual field testing is part of general optometric services and is not reported separately.  (5)  External photography.  (6)  Fundus photography.  (7)  Retinal integrity evaluation with a three-mirror lens.  d.  Single vision and multifocal spectacle lens service, verification and subsequent service. When lenses are necessary, the following enumerated professional and technical optometric services are to be provided:  (1)  When spectacle lenses are necessary, the following enumerated professional and technical optometric services are to be provided:
    1. Ordering of corrective lenses.
    2. Verification of lenses after fabrication.
    3. Adjustment and alignment of completed lens order.
      (2)  New spectacle lenses are subject to the following limitations:
    1. Up to three times for children up to one year of age.
    2. Up to four times per year for children one through three years of age.
    3. Once every 12 months for children four through seven years of age.
    4. Once every 24 months after eight years of age when there is a change in the prescription.
      (3)  Spectacle lenses made from polycarbonate or equivalent material are allowed for:
    1. Children through seven years of age.
    2. Members with vision in only one eye.
    3. Members with a diagnosis-related illness or disability where regular lenses would pose a safety risk.
      e.  Rescinded IAB 4/3/02, effective 6/1/02.  f.  Frame service.  (1)  When a new frame is necessary, the following enumerated professional and technical optometric services are to be provided:
    1. Selection and styling.
    2. Sizing and measurements.
    3. Fitting and adjustment.
    4. Readjustment and servicing.
      (2)  New frames are subject to the following limitations:
    1. One frame every six months is allowed for children through three years of age.
    2. One frame every 12 months is allowed for children four through seven years of age.
    3. When there is a covered lens change and the new lenses cannot be accommodated by the current frame.
      (3)  Safety frames are allowed for:
    1. Children through seven years of age.
    2. Members with a diagnosis-related disability or illness where regular frames would pose a safety risk or result in frequent breakage.
      g.  Rescinded IAB 4/3/02, effective 6/1/02.  h.  Repairs or replacement of frames, lenses or component parts. Payment shall be made for service in addition to materials. The service fee shall not exceed the dispensing fee for a replacement frame. Payment shall be made for replacement of glasses when the original glasses have been lost or damaged beyond repair. Replacement of lost or damaged glasses is limited to one pair of frames and two lenses once every 12 months for adults aged 21 and over, except for people with a mental or physical disability.  i.  Contact lenses. Payment shall be made for documented keratoconus, aphakia, high myopia, anisometropia, trauma, severe ocular surface disease, irregular astigmatism, for treatment of acute or chronic eye disease, or when the member’s vision cannot be adequately corrected with spectacle lenses. Contact lenses are subject to the following limitations:  (1)  Up to 16 gas permeable contact lenses are allowed for children up to one year of age.  (2)  Up to 8 gas permeable contact lenses are allowed every 12 months for children one through three years of age.  (3)  Up to 6 gas permeable contact lenses are allowed every 12 months for children four through seven years of age.  (4)  Two gas permeable contact lenses are allowed every 24 months for members eight years of age or older.  (5)  Soft contact lenses and replacements are allowed when medically necessary.
      78.6(2)    Ophthalmic materials.  Ophthalmic materials which are provided in connection with any of the foregoing professional optometric services shall provide adequate vision as determined by the optometrist and meet the following standards:  a.  Corrected curve lenses, unless clinically contraindicated.  b.  Standard plastic, plastic and metal combination, or metal frames.  c.  Prescription standards according to the American National Standards Institute (ANSI) standards and tolerance.  78.6(3)    Reimbursement.  The reimbursement for allowed ophthalmic material is subject to a fee schedule established by the department or to actual laboratory cost as evidenced by an attached invoice. Reimbursement for rose tint is included in the fee for the lenses.  a.  Materials payable by fee schedule are:  (1)  Spectacle lenses, single vision and multifocal.  (2)  Frames.  (3)  Case for glasses.  b.  Materials payable at actual laboratory cost as evidenced by an attached invoice are:  (1)  Contact lenses.  (2)  Schroeder shield.  (3)  Ptosis crutch.  (4)  Safety frames.  (5)  Subnormal visual aids.  (6)  Photochromatic lenses.  78.6(4)    Prior authorization.  Prior authorization is required for the following:  a.  A second lens correction within a 24-month period for members eight years of age and older. Approval shall be given when the member’s vision has at least a five-tenths diopter of change in sphere or cylinder or ten-degree change in axis in either eye.  b.  Visual therapy may be authorized when warranted by case history or diagnosis for a period of time not greater than 90 days. Should continued therapy be warranted, the prior approval process shall be reaccomplished, accompanied by a report showing satisfactory progress. Approved diagnoses are convergence insufficiency and amblyopia. Visual therapy is not covered when provided by opticians.  c.  Subnormal visual aids where near visual acuity is at or better than 20/100 at 16 inches, 2M print. Prior authorization is not required if near visual acuity as described above is less than 20/100. Subnormal visual aids include, but are not limited to, hand magnifiers, loupes, telescopic spectacles, or reverse Galilean telescope systems. Payment shall be actual laboratory cost as evidenced by an attached invoice.  d.  Approval for photochromatic tint shall be given when the member has a documented medical condition that causes photosensitivity and less costly alternatives are inadequate.  e.  Approval for press-on prisms shall be granted for members whose vision cannot be adequately corrected with other covered prisms.(Cross reference 78.28(4))  78.6(5)    Noncovered services.  Noncovered services include, but are not limited to, the following services:  a.  Glasses with cosmetic gradient tint lenses or other eyewear for cosmetic purposes.  b.  Glasses for occupational eye safety.  c.  A second pair of glasses or spare glasses.  d.  Cosmetic surgery and experimental medical and surgical procedures.  e.  Sunglasses.  f.  Progressive bifocal or trifocal lenses.  78.6(6)    Therapeutically certified optometrists.  Rescinded IAB 9/5/12, effective 11/1/12.This rule is intended to implement Iowa Code section 249A.4.
    Related ARC(s): 7548B, 0305C, 4899C441—78.7(249A)  Opticians.  Payment will be approved only for certain services and supplies provided by opticians when prescribed by a physician (MD or DO) or an optometrist. Payment and procedure for obtaining services and supplies shall be the same as described in rule 441—78.6(249A). (Cross reference 78.28(4))  78.7(1)  Rescinded IAB 4/3/02, effective 6/1/02.  78.7(2)  Rescinded IAB 4/3/02, effective 6/1/02.  78.7(3)  Rescinded IAB 4/3/02, effective 6/1/02.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 4899C441—78.8(249A)  Chiropractors.  Payment will be made for the same chiropractic procedures payable under Title XVIII of the Social Security Act (Medicare).  78.8(1)    Covered services.  Chiropractic manipulative therapy (CMT) eligible for reimbursement is specifically limited by Medicaid to the manual manipulation (i.e., by use of the hands) of the spine for the purpose of correcting a subluxation demonstrated by X-ray. Subluxation means an incomplete dislocation, off-centering, misalignment, fixation, or abnormal spacing of the vertebrae.  78.8(2)    Indications and limitations of coverage.    a.  The subluxation must have resulted in a neuromusculoskeletal condition set forth in the table below for which CMT is appropriate treatment. The symptoms must be directly related to the subluxation that has been diagnosed. The mere statement or diagnosis of “pain” is not sufficient to support the medical necessity of CMT. CMT must have a direct therapeutic relationship to the patient’s condition. No other diagnostic or therapeutic service furnished by a chiropractor is covered under the Medicaid program.ICDCATEGORY IICDCATEGORY IIICDCATEGORY IIIG44.1Vascular headache NEC*G54.0-G54.4Nerve root and plexus disorders, brachial plexus disorders, lumbosacral plexus disorders, cervical root disorders NEC, thoracic root disorders NEC, lumbosacral root disorders NECM48.30-M48.33Traumatic spondylopathy, site unspecified, occipito-atlanto-axial region, cervical region, cervicothoracic regionG44.209Tension headache, unspecified, not intractableG54.8Other nerve root and plexus disordersM48.35-M48.38Traumatic spondylopathy, thoracolumbar region, lumbar region, lumbosacral region, sacral and sacrococcygeal regionM47.21-M47.28Other spondylosis with radiculopathy, occipito-atlanto-axial region, cervical region, cervicothoracic region, thoracic region, thoracolumbar region, lumbar region, lumbosacral region, sacral and sacrococcygeal regionG54.9Nerve root and plexus disorder, unspecifiedM50.20-M50.23Other cervical disc displacementM47.811-M47.818 Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region, cervical region, cervicothoracic region, thoracic region, thoracolumbar region, lumbar region, lumbosacral region, sacral and sacrococcygeal regionG55Nerve root and plexus compressions in diseases classified elsewhereM50.30-M50.33 Other cervical disc degenerationM47.891-M47.898 Other spondylosis, occipito-atlanto-axial region, cervical region, cervicothoracic region, thoracic region, thoracolumbar region, lumbar region, lumbosacral region, sacral and sacrococcygeal regionM43.00-M43.28Spondylolysis; spondylolisthesis; fusion of spineM51.24-M51.27 Other thoracic, thoracolumbar and lumbosacral intervertebral disc displacementM54.2CervicalgiaM43.6 TorticollisM51.34-M51.37Other thoracic, thoracolumbar and lumbosacral intervertebral disc degenerationM54.5Low back painM46.00-M46.09Spinal enthesopathyM54.30-M54.32SciaticaM54.6Pain in the thoracic spineM46.41-M46.47Discitis, unspecified, occipito-atlanto-axial region, cervical region, cervicothoracic region, thoracic region, thoracolumbar region, lumbar region, lumbosacral region M54.40-M54.42Lumbago with sciaticaM54.81Occipital neuralgiaM48.00-M48.08Spinal stenosisM96.1 Postlaminectomy syndrome, NECM54.89Other dorsalgia M48.34Traumatic spondylopathy, thoracic regionM54.9Dorsalgia, unspecifiedM50.10-M50.13Cervical disc disorder with radiculopathy R51HeadacheM50.80-M50.83Other cervical disc disordersM50.90-M50.93Cervical disc disorder, unspecifiedM51.14-M51.17Intervertebral disc disorders with radiculopathy, thoracic region, thoracolumbar region, lumbar region, lumbosacral region M51.84-M51.87Other thoracic, thoracolumbar and lumbosacral intervertebral disc disordersM53.0Cervicocranial syndromeM53.1Cervicobrachial syndromeM53.2X1-M53.2X9Spinal instabilitiesM53.3 Sacrococcygeal disorders NECM53.80Other specified dorsopathies, site unspecifiedM53.84-M53.88Other specified dorsopathies, thoracic region, thoracolumbar region, lumbar region, lumbosacral region, sacral and sacrococcygeal regionM53.9Dorsopathy, unspecifiedM54.10-M54.18RadiculopathyM60.80Other myositis, unspecified siteM60.811,M60.812 Other myositis, shoulder, right, leftM60.819 Other myositis, unspecified shoulderM60.821,M60.822 Other myositis, upper arm, right, leftM60.829 Other myositis, unspecified upper armM60.831,M60.832 Other myositis, forearm, right, leftM60.839 Other myositis, unspecified forearmM60.841,M60.842 Other myositis, hand, right, leftM60.849 Other myositis, unspecified handM60.851,M60.852 Other myositis, thigh, right, leftM60.859 Other myositis, unspecified thighM60.861,M60.862 Other myositis, lower leg, right, leftM60.869 Other myositis, unspecified lower legM60.871,M60.872 Other myositis, ankle and foot, right, leftM60.879 Other myositis, unspecified ankle and footM60.88,M60.89Other myositis, other site, multiple sitesM60.9Myositis, unspecifiedM62.830 Muscle spasm of backM72.9Fibroblastic disorder, unspecifiedM79.1MyalgiaM79.2Neuralgia and neuritis, unspecifiedM79.7FibromyalgiaM99.20-M99.23Subluxation stenosis of neural canal, head region, cervical region, thoracic region, lumbar regionM99.30-M99.33Osseous stenosis of neural canal, head region, cervical region, thoracic region, lumbar regionM99.40-M99.43Connective tissue stenosis of neural canal, head region, cervical region, thoracic region, lumbar regionM99.50-M99.53Intervertebral disc stenosis of neural canal, head region, cervical region, thoracic region, lumbar regionM99.60-M99.63Osseous and subluxation stenosis of intervertebral foramina, head region, cervical region, thoracic region, lumbar regionM99.70-M99.73Connective tissue and disc stenosis of intervertebral foramina, head region, cervical region, thoracic region, lumbar regionQ76.2 Congenital spondylolisthesisS13.4XXA,S13.4XXDSprain of ligaments of cervical spine, initial encounter, subsequent encounterS13.8XXA,S13.8XXDSprain of joints and ligaments of other parts of neck, initial encounter, subsequent encounterS16.1XXA,S16.1XXDStrain of muscle, fascia and tendon at neck level, initial encounter, subsequent encounter S23.3XXA,S23.3XXDSprain of ligaments of thoracic spine, initial encounter, subsequent encounterS23.8XXA,S23.8XXDSprain of other specified parts of thorax, initial encounter, subsequent encounterS33.5XXA,S33.5XXDSprain of ligaments of lumbar spine, initial encounter, subsequent encounterS33.6XXA,S33.6XXDSprain of sacroiliac joint, initial encounter, subsequent encounter* NEC means not elsewhere classified.  b.  The neuromusculoskeletal conditions listed in the table in paragraph “a” generally require short-, moderate-, or long-term CMT. A diagnosis or combination of diagnoses within Category I generally requires short-term CMT of 12 per 12-month period. A diagnosis or combination of diagnoses within Category II generally requires moderate-term CMT of 18 per 12-month period. A diagnosis or combination of diagnoses within Category III generally requires long-term CMT of 24 per 12-month period. For diagnostic combinations between categories, 28 CMTs are generally required per 12-month period. If the CMT utilization guidelines are exceeded, documentation supporting the medical necessity of additional CMT must be submitted with the Medicaid claim form or the claim will be denied for failure to provide information.  c.  CMT is not a covered benefit when:  (1)  The maximum therapeutic benefit has been achieved for a given condition.  (2)  There is not a reasonable expectation that the continuation of CMT would result in improvement of the patient’s condition.  (3)  The CMT seeks to prevent disease, promote health and prolong and enhance the quality of life.  78.8(3)    Documenting X-ray.  An X-ray must document the primary regions of subluxation being treated by CMT.  a.  The documenting X-ray must be taken at a time reasonably proximate to the initiation of CMT. An X-ray is considered to be reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of CMT. X-rays need not be repeated unless there is a new condition and no payment shall be made for subsequent X-rays, absent a new condition, consistent with paragraph “c” of this subrule. No X-ray is required for pregnant women and for children aged 18 and under.  b.  The X-ray films shall be labeled with the patient’s name and date the X-rays were taken and shall be marked right or left. The X-ray shall be made available to the department or its duly authorized representative when requested. A written and dated X-ray report, including interpretation and diagnosis, shall be present in the patient’s clinical record.  c.  Chiropractors shall be reimbursed for documenting X-rays at the physician fee schedule rate. Payable X-rays shall be limited to those Current Procedural Terminology (CPT) procedure codes that are appropriate to determine the presence of a subluxation of the spine. Criteria used to determine payable X-ray CPT codes may include, but are not limited to, the X-ray CPT codes for which major commercial payors reimburse chiropractors. The Iowa Medicaid enterprise shall publish in the Chiropractic Services Provider Manual the current list of payable X-ray CPT codes. Consistent with CPT, chiropractors may bill the professional, technical, or professional and technical components for X-rays, as appropriate. Payment for documenting X-rays shall be further limited to one per condition, consistent with the provisions of paragraph “a” of this subrule. A claim for a documenting X-ray related to the onset of a new condition is only payable if the X-ray is reasonably proximate to the initiation of CMT for the new condition, as defined in paragraph “a” of this subrule. A chiropractor is also authorized to order a documenting X-ray whether or not the chiropractor owns or possesses X-ray equipment in the chiropractor’s office. Any X-rays so ordered shall be payable to the X-ray provider, consistent with the provisions in this paragraph.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 2164C441—78.9(249A)  Home health agencies.  Payment shall be approved for medically necessary home health agency services prescribed by a physician, nurse practitioner, clinical nurse specialist, or physician assistant in a plan of home health care provided by a Medicare-certified home health agency.The number of hours of home health agency services shall be reasonable and appropriate to meet an established medical need of the member that cannot be met by a family member, significant other, friend, or neighbor. Services must be medically necessary in the individual case and be related to a diagnosed medical impairment or disability.The member need not be homebound to be eligible for home health agency services; however, the services provided by a home health agency shall only be covered when provided in the member’s residence with the following exception. Private duty nursing and personal care services for persons aged 20 and under as described at 78.9(10)“a” may be provided in settings other than the member’s residence when medically necessary.Medicaid members of home health agency services need not first require skilled nursing care to be entitled to home health aide services.Further limitations related to specific components of home health agency services are noted in subrules 78.9(3) to 78.9(10).Payment shall be made on an encounter basis. An encounter is defined as separately identifiable hours in which home health agency staff provide continuous service to a member.Payment for supplies shall be approved when the supplies are incidental to the patient’s care, e.g., syringes for injections, and do not exceed $15 per month. Dressings, durable medical equipment, and other supplies shall be obtained from a durable medical equipment dealer or pharmacy. Payment of supplies may be made to home health agencies when a durable medical equipment dealer or pharmacy is not available in the member’s community.Payment may be made for restorative and maintenance home health agency services.Payment may be made for teaching, training, and counseling in the provision of health care services.Treatment plans for these services shall additionally reflect: to whom the services are to be provided (patient, family member, etc.); prior teaching training, or counseling provided; medical necessity for the rendered service; identification of specific services and goals; date of onset of the teaching, training, or counseling; frequency of services; progress of member in response to treatment; and estimated length of time these services will be needed.The following are not covered: services provided in the home health agency office, homemaker services, well child care and supervision, and medical equipment rental or purchase.Services shall be authorized by a physician, nurse practitioner, clinical nurse specialist, or physician assistant, evidenced by the physician’s, nurse practitioner’s, clinical nurse specialist’s, or physician assistant’s signature and date on a plan of treatment.  78.9(1)    Treatment plan.  A plan of treatment shall be completed prior to the start of care and at a minimum reviewed every 60 days thereafter. There must be a face-to-face encounter between a physician, a nurse practitioner, a clinical nurse specialist, a certified nurse-midwife, or a physician assistant and the Medicaid member no more than 90 days before or 30 days after the start of service. The plan of care shall support the medical necessity and intensity of services to be provided by reflecting the following information:  a.  Place of service.  b.  Type of service to be rendered and the treatment modalities being used.  c.  Frequency of the services.  d.  Assistance devices to be used.  e.  Date home health services were initiated.  f.  Progress of member in response to treatment.  g.  Medical supplies to be furnished.  h.  Member’s medical condition as reflected by the following information, if applicable:  (1)  Dates of prior hospitalization.  (2)  Dates of prior surgery.  (3)  Date last seen by a physician, nurse practitioner, clinical nurse specialist, or physician assistant.  (4)  Diagnoses and dates of onset of diagnoses for which treatment is being rendered.  (5)  Prognosis.  (6)  Functional limitations.  (7)  Vital signs reading.  (8)  Date of last episode of instability.  (9)  Date of last episode of acute recurrence of illness or symptoms.  (10)  Medications.  i.  Discipline of the person providing the service.  j.  Certification period (no more than 60 days).  k.  Estimated date of discharge from the hospital or home health agency services, if applicable.  l.  Physician’s, nurse practitioner’s, clinical nurse specialist’s, or physician assistant’s signature and date. The plan of care must be signed and dated by the physician, nurse practitioner, clinical nurse specialist, or physician assistant before the claim for service is submitted for reimbursement.  78.9(2)    Supervisory visits.  Payment shall be made for supervisory visits two times a month when a registered nurse acting in a supervisory capacity provides supervisory visits of services provided by a home health aide under a home health agency plan of treatment or when services are provided by an in-home health care provider under the department’s in-home health-related care program as set forth in 441—Chapter 177.  78.9(3)    Skilled nursing services.  Skilled nursing services are services that when performed by a home health agency require a licensed registered nurse or licensed practical nurse to perform. Situations when a service can be safely performed by the member or other nonskilled person who has received the proper training or instruction or when there is no one else to perform the service are not considered a “skilled nursing service.” Skilled nursing services shall be available only on an intermittent basis. Intermittent services for skilled nursing services shall be defined as a medically predictable recurring need requiring a skilled nursing service at least once every 60 days, not to exceed five days per week (except as provided below), with an attempt to have a predictable end. Daily visits (six or seven days per week) that are reasonable and necessary and show an attempt to have a predictable end shall be covered for up to three weeks. Coverage of additional daily visits beyond the initial anticipated time frame may be appropriate for a short period of time, based on the medical necessity of service. Medical documentation shall be submitted justifying the need for continued visits, including the physician’s, nurse practitioner’s, clinical nurse specialist’s, or physician assistant’s estimate of the length of time that additional visits will be necessary. Daily skilled nursing visits or multiple daily visits for wound care or insulin injections shall be covered when ordered by a physician, nurse practitioner, clinical nurse specialist, or a physician assistant and included in the plan of care. Other daily skilled nursing visits which are ordered for an indefinite period of time and designated as daily skilled nursing care do not meet the intermittent definition and shall be denied.Skilled nursing services shall be evaluated based on the complexity of the service and the condition of the patient.Private duty nursing for persons aged 21 and over is not a covered service. See subrule 78.9(10) for guidelines for private duty nursing for persons aged 20 or under.  78.9(4)    Physical therapy services.  Payment shall be made for physical therapy services when the services relate directly to an active written treatment plan, follow a treatment plan established by the physician, nurse practitioner, clinical nurse specialist, or physician assistant after any needed consultation with the qualified physical therapist, are reasonable and necessary to the treatment of the patient’s illness or injury, and meet the guidelines defined for restorative, maintenance, or trial therapy as set forth in subrule 78.19(1), paragraphs “a” and “b.”For physical therapy services, the treatment plan shall additionally reflect goals, modalities of treatment, date of onset of conditions being treated, restorative potential, and progress notes.  78.9(5)    Occupational therapy services.  Payment shall be made for occupational therapy services when the services relate directly to an active written treatment plan, follow a treatment plan established by the physician, nurse practitioner, clinical nurse specialist, or physician assistant, are reasonable and necessary to the treatment of the patient’s illness or injury, and meet the guidelines defined for restorative, maintenance, or trial therapy as set forth in subrule 78.19(1), paragraphs “a” and “c.”For occupational therapy services, the treatment plan shall additionally reflect goals, modalities of treatment, date of onset of conditions being treated, restorative potential, and progress notes.  78.9(6)    Speech therapy services.  Payment shall be made for speech therapy services when the services relate directly to an active written treatment plan, follow a treatment plan established by the physician, nurse practitioner, clinical nurse specialist, or physician assistant, are reasonable and necessary to the treatment of the patient’s illness or injury, and meet the guidelines defined for restorative, maintenance, or trial therapy as set forth in subrule 78.19(1), paragraphs “a” and “d.”For speech therapy services, the treatment plan shall additionally reflect goals, modalities of treatment, date of onset of conditions being treated, restorative potential, and progress notes.  78.9(7)    Home health aide services.  Payment shall be made for unskilled services provided by a home health aide if the following conditions are met:  a.  The service as well as the frequency and duration are stated in a written plan of treatment established by a physician, nurse practitioner, clinical nurse specialist, or physician assistant. The home health agency is encouraged to collaborate with the member, or in the case of a child with the child’s caregiver, in the development and implementation of the plan of treatment.  b.  The member requires personal care services as determined by a registered nurse or other appropriate therapist. The services shall be given under the supervision of a registered nurse, physical, speech, or occupational therapist and the registered nurse or therapist shall assign the aide who will provide the care.  c.  Services shall be provided on an intermittent basis. “Intermittent basis” for home health agency services is defined as services that are usually two to three times a week for two to three hours at a time. Services provided for four to seven days per week, not to exceed 28 hours per week, when ordered by a physician, nurse practitioner, clinical nurse specialist, or physician assistant and included in a plan of care shall be allowed as intermittent services. Increased services provided when medically necessary due to unusual circumstances on a short-term basis of two to three weeks may also be allowed as intermittent services when the home health agency documents the need for the excessive time required for home health aide services.Home health aide daily care may be provided for persons employed or attending school whose disabling conditions require the persons to be assisted with morning and evening activities of daily living in order to support their independent living.Personal care services include the activities of daily living, e.g., helping the member to bathe, get in and out of bed, care for hair and teeth, exercise, and take medications specifically ordered by the physician, but ordinarily self-administered, and retraining the member in necessary self-help skills.Certain household services may be performed by the aide in order to prevent or postpone the member’s institutionalization when the primary need of the member for home health aide services furnished is for personal care. If household services are incidental and do not substantially increase the time spent by the aide in the home, the entire visit is considered a covered service. Domestic or housekeeping services which are not related to patient care are not a covered service if personal care is not rendered during the visit.For home health aide services, the treatment plan shall additionally reflect the number of hours per visit and the living arrangement of the member, e.g., lives alone or with family.  78.9(8)    Medical social services.  Rescinded IAB 3/29/17, effective 5/3/17.  78.9(9)    Home health agency care for maternity patients and children.  The intent of home health agency services for maternity patients and children shall be to provide services when the members are unable to receive the care outside of their home and require home health care due to a high-risk factor. Routine prenatal, postpartum, or child health care is a covered service in a physician’s office or clinic and, therefore, is not covered by Medicaid when provided by a home health agency.  a.  Treatment plans for maternity patients and children shall identify:  (1)  The potential risk factors,  (2)  The medical factor or symptom which verifies the child is at risk,  (3)  The reason the member is unable to obtain care outside of the home,   (4)  The medically related task of the home health agency,  (5)  The member’s diagnosis,  (6)  Specific services and goals, and  (7)  The medical necessity for the services to be rendered. A single high-risk factor does not provide sufficient documentation of the need for services.  b.  The following list of potential high-risk factors may indicate a need for home health services to prenatal maternity patients:  (1)  Aged 16 or under.  (2)  First pregnancy for a woman aged 35 or over.  (3)  Previous history of prenatal complications such as fetal death, eclampsia, C-section delivery, psychosis, or diabetes.  (4)  Current prenatal problems such as hypertensive disorders of pregnancy, diabetes, cardiac disease, sickle cell anemia, low hemoglobin, mental illness, or drug or alcohol abuse.  (5)  Sociocultural or ethnic problems such as language barriers, lack of family support, insufficient dietary practices, history of child abuse or neglect, or single mother.  (6)  Preexisting disabilities such as sensory deficits, or mental or physical disabilities.  (7)  Second pregnancy in 12 months.  (8)  Death of a close family member or significant other within the previous year.  c.  The following list of potential high-risk factors may indicate a need for home health services to postpartum maternity patients:  (1)  Aged 16 or under.  (2)  First pregnancy for a woman aged 35 or over.  (3)  Major postpartum complications such as severe hemorrhage, eclampsia, or C-section delivery.  (4)  Preexisting mental or physical disabilities such as deaf, blind, hemiplegic, activity-limiting disease, sickle cell anemia, uncontrolled hypertension, uncontrolled diabetes, mental illness, or intellectual disability.  (5)  Drug or alcohol abuse.  (6)  Symptoms of postpartum psychosis.  (7)  Special sociocultural or ethnic problems such as lack of job, family problems, single mother, lack of support system, or history of child abuse or neglect.  (8)  Demonstrated disturbance in maternal and infant bonding.  (9)  Discharge or release from hospital against medical advice before 36 hours postpartum.  (10)  Insufficient antepartum care by history.  (11)  Multiple births.  (12)  Nonhospital delivery.  d.  The following list of potential high-risk factors may indicate a need for home health services to infants:  (1)  Birth weight of five pounds or under or over ten pounds.  (2)  History of severe respiratory distress.  (3)  Major congenital anomalies such as neonatal complications which necessitate planning for long-term follow-up such as postsurgical care, poor prognosis, home stimulation activities, or periodic development evaluation.  (4)  Disabling birth injuries.  (5)  Extended hospitalization and separation from other family members.  (6)  Genetic disorders, such as Down’s syndrome, and phenylketonuria or other metabolic conditions that may lead to intellectual disability.  (7)  Noted parental rejection or indifference toward baby such as never visiting or calling the hospital about the baby’s condition during the infant’s extended stay.  (8)  Family sociocultural or ethnic problems such as low education level or lack of knowledge of child care.  (9)  Discharge or release against medical advice before 36 hours of age.  (10)  Nutrition or feeding problems.  e.  The following list of potential high-risk factors may indicate a need for home health services to preschool or school-age children:  (1)  Child or sibling victim of child abuse or neglect.  (2)  Intellectual disability or other physical disabilities necessitating long-term follow-up or major readjustments in family lifestyle.  (3)  Failure to complete the basic series of immunizations by 18 months, or boosters by 6 years.  (4)  Chronic illness such as asthma, cardiac, respiratory or renal disease, diabetes, cystic fibrosis, or muscular dystrophy.  (5)  Malignancies such as leukemia or carcinoma.  (6)  Severe injuries necessitating treatment or rehabilitation.  (7)  Disruption in family or peer relationships.  (8)  Suspected developmental delay.  (9)  Nutritional deficiencies.  78.9(10)    Private duty nursing or personal care services for persons aged 20 and under.  Payment for private duty nursing or personal care services for persons aged 20 and under shall be approved if determined to be medically necessary. Payment shall be made on an hourly unit of service.  a.  Definitions.  (1)  Private duty nursing services are those services which are provided by a registered nurse or a licensed practical nurse under the direction of the member’s physician to a member in the member’s place of residence or outside the member’s residence, when normal life activities take the member outside the place of residence. Place of residence does not include nursing facilities, intermediate care facilities for the mentally retarded, or hospitals.Services shall be provided according to a written plan of care authorized by a licensed physician. The home health agency is encouraged to collaborate with the member, or in the case of a child with the child’s caregiver, in the development and implementation of the plan of treatment. These services shall exceed intermittent guidelines as defined in subrule 78.9(3). Private duty nursing and personal care services shall be inclusive of all home health agency services personally provided to the member. Enhanced payment under the interim fee schedule shall be made available for services to children who are technology dependent, i.e., ventilator dependent or whose medical condition is so unstable as to otherwise require intensive care in a hospital.Private duty nursing or personal care services do not include:
    1. Respite care, which is a temporary intermission or period of rest for the caregiver.
    2. Nurse supervision services including chart review, case discussion or scheduling by a registered nurse.
    3. Services provided to other persons in the member’s household.
    4. Services requiring prior authorization that are provided without regard to the prior authorization process.
    5. Transportation services.
    6. Homework assistance.
      (2)  Personal care services are those services provided by a home health aide or certified nurse’s aide and which are delegated and supervised by a registered nurse under the direction of the member’s physician to a member in the member’s place of residence or outside the member’s residence, when normal life activities take the member outside the place of residence. Place of residence does not include nursing facilities, intermediate care facilities for the mentally retarded, or hospitals. Payment for personal care services for persons aged 20 and under that exceed intermittent guidelines may be approved if determined to be medically necessary as defined in subrule 78.9(7). These services shall be in accordance with the member’s plan of care and authorized by a physician. The home health agency is encouraged to collaborate with the member, or in the case of a child with the child’s caregiver, in the development and implementation of the plan of treatment.Medical necessity means the service is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions that endanger life, cause pain, result in illness or infirmity, threaten to cause or aggravate a disability or chronic illness, and no other equally effective course of treatment is available or suitable for the member requesting a service.
      b.  Requirements.  (1)  Private duty nursing or personal care services shall be ordered in writing by a physician as evidenced by the physician’s signature on the plan of care.  (2)  Private duty nursing or personal care services shall be authorized by the department or the department’s designated review agent prior to payment.  (3)  Prior authorization shall be requested at the time of initial submission of the plan of care or at any time the plan of care is substantially amended and shall be renewed with the department or the department’s designated review agent. Initial request for and request for renewal of prior authorization shall be submitted to the department’s designated review agent. The provider of the service is responsible for requesting prior authorization and for obtaining renewal of prior authorization.The request for prior authorization shall include a nursing assessment, the plan of care, and supporting documentation. The request for prior authorization shall include all items previously identified as required treatment plan information and shall further include: any planned surgical interventions and projected time frame; information regarding caregiver’s desire to become involved in the member’s care, to adhere to program objectives, to work toward treatment plan goals, and to work toward maximum independence; and identify the types and service delivery levels of all other services to the member whether or not the services are reimbursable by Medicaid. Providers shall indicate the expected number of private duty nursing RN hours, private duty nursing LPN hours, or home health aide hours per day, the number of days per week, and the number of weeks or months of service per discipline. If the member is currently hospitalized, the projected date of discharge shall be included.Prior authorization approvals shall not be granted for treatment plans that exceed 16 hours of home health agency services per day. (Cross reference 78.28(10))
      78.9(11)    Vaccines.  In order to be paid for the administration of a vaccine covered under the Vaccines for Children (VFC) Program, a home health agency must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted.This rule is intended to implement Iowa Code section 249A.4.
    Related ARC(s): 7548B, 9315B, 0065C, 3005C, 4899C, 5487C441—78.10(249A)  Durable medical equipment (DME), prosthetic devices and medical supplies.    78.10(1)    General payment requirements.  Payment will be made for items of DME, prosthetic devices and medical supplies, subject to the following general requirements and the requirements of subrule 78.10(2), 78.10(3), or 78.10(4), as applicable:  a.  DME, prosthetic devices, and medical supplies must be required by the member because of the member’s medical condition.  b.  The item shall be necessary and reasonable either for the treatment of an illness or injury, or to improve the functioning of a malformed body part. Determination will be made by the Iowa Medicaid enterprise medical services unit.  (1)  An item is necessary when it can be expected to make a meaningful contribution to the treatment of a specific illness or injury or to the improvement in function of a malformed body part.  (2)  Although an item may be necessary, it must also be a reasonable expenditure for the Medicaid program. The following considerations enter into the determination of reasonableness: Whether the expense of the item to the program would be clearly disproportionate to the therapeutic benefits which could ordinarily be derived from use of the item; whether the item would be substantially more costly than a medically appropriate and realistically feasible alternative pattern of care; and whether the item serves essentially the same purpose as an item already available to the beneficiary.  c.  A physician’s (doctor of medicine, osteopathy, or podiatry), physician assistant’s, or advanced registered nurse practitioner’s prescription is required to establish medical necessity. The prescription shall state the member’s name, diagnosis, prognosis, item(s) to be dispensed, quantity, and length of time the item is to be required and shall include the signature of the prescriber and the date of signature.For items requiring prior authorization, a request shall include a physician’s, physician assistant’s, or advanced registered nurse practitioner’s written order or prescription and sufficient medical documentation to permit an independent conclusion that the requirements for the equipment or device are met and the item is medically necessary and reasonable. A request for prior authorization is made using Form 470-5595, Outpatient Prior Authorization Request. See rule 441—78.28(249A) for prior authorization requirements.  d.  Nonmedical items will not be covered. These include but are not limited to:  (1)  Physical fitness equipment, e.g., an exercycle, weights.  (2)  First-aid or precautionary-type equipment, e.g., preset portable oxygen units.  (3)  Self-help devices, e.g., safety grab bars, raised toilet seats.  (4)  Training equipment, e.g., speech teaching machines, braille training texts.  (5)  Equipment used for environmental control or to enhance the environmental setting, e.g., room heaters, air conditioners, humidifiers, dehumidifiers, and electric air cleaners.  (6)  Equipment which basically serves comfort or convenience functions or is primarily for the convenience of a person caring for the member, e.g., elevators, stairway elevators and posture chairs.  e.  The amount payable is based on the least expensive item which meets the member’s medical needs. Payment will not be approved for items that serve duplicate functions. Exception:A second ventilator for which prior authorization has been granted. See 78.10(5)“k” for prior authorization requirements.  f.  Consideration will be given to rental or purchase based on the price of the item and the length of time it would be required. The decision on rental or purchase shall be made by the Iowa Medicaid enterprise and be based on the most reasonable method to provide the equipment.  (1)  The provider shall monitor rental payments up to 100 percent of the purchase price. At the point that total rent paid equals 100 percent of the purchase allowance, the member will be considered to own the item and no further rental payments will be made to the provider.  (2)  Payment may be made for the purchase of an item even though rental payments may have been made for prior months. The rental of the equipment may be necessary for a period of time to establish that it will meet the identified need before the purchase of the equipment. When a decision is made to purchase after renting an item, all of the rental payments will be applied to the purchase allowance.  (3)  Exception:Ventilators and oxygen systems shall be maintained on a rental basis for the duration of use.  (4)  A deposit shall not be charged by a provider to a Medicaid member or any other person on behalf of a Medicaid member for rental of medical equipment.  g.  Payment may be made for necessary repair, maintenance, and supplies for member-owned equipment. No payment may be made for repairs, maintenance, or supplies when the member is renting the item.  h.  Replacement of member-owned equipment is covered in cases of loss or irreparable damage or when required because of a change in the member’s condition.  i.  No allowance will be made for delivery, freight, postage, or other provider operating expenses for DME, prosthetic devices or medical supplies.  j.  Reimbursement over the established fee schedule amount is allowed when prior authorization has been obtained. See 78.10(5)“n” for prior authorization requirements.  78.10(2)    Durable medical equipment.  DME is equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, is generally not useful to a person in the absence of an illness or injury, and is appropriate for use in the home.  a.  Durable medical equipment provided in a hospital, nursing facility, or intermediate care facility for persons with an intellectual disability is not separately payable.Exceptions:  (1)  Oxygen services in a nursing facility or an intermediate care facility for persons with an intellectual disability when all of the following requirements and conditions have been met:
    1. 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.
    2. Additional documentation shows that the member requires oxygen for 12 hours or more per day for at least 30 days.
    3. Oxygen logs must be maintained by the provider. The time between any reading shall not exceed more than 45 days. The documentation maintained in the provider record must contain the following:
    4. The initial, periodic and ending reading on the time meter clock on each oxygen system, and
    5. The dates of each initial, periodic and ending reading, and
    6. Evidence of ongoing need for oxygen services.
    7. The maximum Medicaid payment shall be based on the least costly method of oxygen delivery.
    8. Oxygen prescribed “PRN” or “as necessary” is not payable.
    9. 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.
    10. 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).
      (2)  Speech generating devices for which prior authorization has been obtained. See 78.10(5)“f” for prior authorization requirements.  (3)  Wheelchairs for members in an intermediate care facility for persons with an intellectual disability.
      b.  The types of durable medical equipment covered through the Medicaid program include, but are not limited to:Automated medication dispenser. Bathtub/shower chair, bench. See 78.10(5)“g” and “j” for prior authorization requirements.Commode, shower commode chair. See 78.10(5)“j” for prior authorization requirements.Decubitus equipment.Dialysis equipment.Diaphragm (contraceptive device).Enclosed bed. See 78.10(5)“a” for prior authorization requirements.Enuresis alarm system (bed-wetting alarm device) for members five years of age or older.Heat/cold application device.Hospital bed and accessories.Inhalation equipment. See 78.10(5)“c” for prior authorization requirements.Insulin infusion pump. See 78.10(5)“b” and 78.10(5)“e” for prior authorization requirements.Lymphedema pump.Mobility device and accessories. See 78.10(5)“i” for prior authorization requirements.Neuromuscular stimulator.Oximeter.Oxygen, subject to the limitations in 78.10(2)“a” and 78.10(2)“c.”Patient lift. See 78.10(5)“h” for prior authorization requirements.Phototherapy bilirubin light.Protective helmet.Seat lift chair.Speech generating device. See 78.10(5)“f” for prior authorization requirements.Traction equipment.Ventilator.  c.  Coverage of home oxygen equipment and oxygen will be considered reasonable and necessary for members in accordance with Medicare criteria and as shown by supporting medical documentation. The physician, physician assistant, or advanced registered nurse practitioner shall document that other forms of treatment are contraindicated or have been tried and have not been successful and that oxygen therapy is required. Exception:Home oxygen equipment and oxygen are covered for children through three years of age when prescribed by a physician, physician assistant or advanced registered nurse practitioner. A pulse oximeter reading must be obtained yearly and documented in the provider and physician record.  (1)  To identify the medical necessity for oxygen therapy, a Certificate of Medical Necessity for Oxygen, Form CMS-484, or a reasonable facsimile completed by a physician, physician assistant, or advanced registered nurse practitioner, shall qualify the member in accordance with Medicare criteria.  (2)  If the member’s condition or need for oxygen services changes, the attending physician, physician assistant, or advanced registered nurse practitioner must adjust the documentation accordingly.  (3)  A second oxygen system is not covered by Medicaid when used as a backup for oxygen concentrators or as a standby in case of emergency. Members may be provided with a portable oxygen system to complement a stationary oxygen system, or to be used by itself, with documentation from the physician, physician assistant, or advanced registered nurse practitioner of the specific activities for which portable oxygen is medically necessary.  (4)  Payment for oxygen systems shall be made only on a rental basis for the duration of use.  (5)  All accessories, disposable supplies, servicing, and repairing of oxygen systems are included in the monthly Medicaid payment for oxygen systems.  (6)  Oxygen prescribed “PRN” or “as necessary” is not allowed.  d.  Wheelchairs, wheelchair accessories, and wheelchair modifications are covered when they are medically necessary for mobility within the home, nursing facility, or intermediate care facility. Wheelchairs are defined as:   (1)  Standard manual wheelchairs. Coverage of a standard manual wheelchair includes the following:   1.  Complete set of tires/wheels and casters, any type;  2.  Hand rims with or without projections;  3.  Weight-specific components required by the patient-weight capacity of the wheelchair;  4.  Elevating legrest, lower extension tube and upper hanger bracket;  5.  Armrest (detachable, non-adjustable or adjustable) with or without arm pad;  6.  Footrest (swingaway, detachable), including lower extension tube(s) and upper hanger bracket;  7.  Standard size footplates;  8.  Wheelchair bearings;  9.  Caster fork, replacement only; and  10.  All labor charges involved in the assembly of the wheelchair (including, but not limited to: front caster assembly, rear wheel assembly, ratchet assembly, wheel lock assembly, footrest assembly).  (2)  Standard manual wheelchair accessories that are separately billable and require prior authorization include the following:  1.  Headrest extensions;  2.  One-arm drive attachments;  3.  Positioning accessories;  4.  Specialized skin protection seat and back cushions; and  5.  Anti-rollback devices.  (3)  Standard power wheelchair. Coverage of a standard power wheelchair requires prior authorization and includes the following:  1.  Lap belt or safety belt;  2.  Battery charger, single mode;  3.  Complete set of tires/wheels and casters, any type;  4.  Legrests (fixed, swingaway, or detachable non-elevation legrests with or without calf pad);  5.  Footrests/foot platform (fixed, swingaway, detachable footrests or a foot platform without angle adjustment, single adjustable footplate);  6.  Armrests (fixed, swingaway, detachable non-adjustable height armrests with arm pad provided);  7.  Any weight-specific components (braces, bars, upholstery, brackets, motors, gears, etc.) as required by patient-weight capacity of the wheelchair;  8.  Any seat width and depth. For power wheelchairs with a sling/solid seat/back, the following may be billed separately:
  • For standard duty, seat width and/or depth greater than 20 inches;
  • For heavy duty, seat width and/or depth greater than 22 inches;
  • For very heavy duty, seat width and/or depth greater than 24 inches;
  • Exception: For extra heavy duty, there is no separate billing;
  •   9.  Any back width. For power wheelchairs with a sling/solid seat/back, the following may be billed separately:
  • For standard duty, seat width and/or depth greater than 20 inches;
  • For heavy duty, seat width and/or depth greater than 22 inches;
  • For very heavy duty, seat width and/or depth greater than 24 inches;
  • Exception: For extra heavy duty, there is no separate billing;
  •   10.  Non-expandable controller or standard proportional joystick (integrated or remote); and  11.  All labor charges involved in the assembly of the wheelchair (including, but not limited to: front caster assembly, rear wheel assembly, ratchet assembly, wheel lock assembly, footrest assembly).
      (4)  Standard power wheelchair accessories that are billed separately and require a prior authorization include the following:  1.  Shoulder harness/straps or chest straps/vest;  2.  Elevating legrest;  3.  Angle adjustable footplates;  4.  Adjustable height armrests; and  5.  Expandable controller or nonstandard joystick (i.e., non-proportional or mini, compact or short throw proportional, or other alternative control device).   (5)  Customized items are payable with a prior authorization, in accordance with 42 CFR §414.224.
      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:
    1. Cephalic index at least two standard deviations above the mean for the member’s gender and age; or
    2. Asymmetry of 12 millimeters or more in the cranial vault, skull base, or orbitotragial depth.
      78.10(4)    Medical supplies.  Medical supplies are nondurable items consumed in the process of giving medical care, for example, nebulizers, gauze, bandages, sterile pads, adhesive tape, and sterile absorbent cotton. Medical supplies are payable for a specific medicinal purpose. This does not include food or drugs. However, active pharmaceutical ingredients and excipients that are identified as preferred on the preferred drug list published by the department pursuant to Iowa Code section 249A.20A are covered. Medical supplies shall not be dispensed at any one time in quantities exceeding a 31-day supply for active pharmaceutical ingredients and excipients or a three-month supply for all other items. After the initial dispensing of medical supplies, the provider must document a refill request from the Medicaid member or the member’s caregiver for each refill.  a.  The types of medical supplies and supplies necessary for the effective use of a payable item covered through the Medicaid program include, but are not limited to:Active pharmaceutical ingredients and excipients identified as preferred on the preferred drug list published pursuant to Iowa Code section 249A.20A.Catheter (indwelling Foley).Colostomy and ileostomy appliances.Colostomy and ileostomy care dressings, liquid adhesive, and adhesive tape.Diabetic supplies (including but not limited to blood glucose test strips, lancing devices, lancets, needles, syringes, and diabetic urine test supplies). See 78.10(5)“e” for prior authorization requirements.Dialysis supplies.Disposable catheterization trays or sets (sterile).Disposable irrigation trays or sets (sterile).Disposable saline enemas (e.g., sodium phosphate type).Dressings.Elastic antiembolism support stocking.Enema.Hearing aid batteries.Incontinence products (for members three years of age and older).Oral nutritional products. See 78.10(5)“m” for prior authorization requirements.Ostomy appliances and supplies.Respirator supplies.Shoes, diabetic.Surgical supplies.Urinary collection supplies.  b.  Only the following types of medical supplies will be approved for payment for members receiving care in a nursing facility or an intermediate care facility for persons with an intellectual disability when prescribed by the physician, physician assistant, or advanced registered nurse practitioner:Catheter (indwelling Foley).Diabetic supplies (including but not limited to lancing devices, lancets, needles and syringes, blood glucose test strips, and diabetic urine test supplies).Disposable catheterization trays or sets (sterile).Disposable irrigation trays or sets (sterile).Disposable saline enemas (e.g., sodium phosphate type).Ostomy appliances and supplies.Shoes, diabetic.  78.10(5)    Prior authorization requirements.  Prior authorization pursuant to rule 441—79.8(249A) is required for the following medical equipment and supplies (Cross reference 78.28(1)):  a.  Enclosed beds. Payment for an enclosed bed shall be approved when prescribed for a member who meets all of the following conditions:  (1)  The member has a diagnosis-related cognitive or communication impairment that results in risk to safety.  (2)  The member’s mobility puts the member at risk for injury.  b.  External insulin infusion pumps. Payment will be approved according to Medicare coverage criteria.  c.  Vest airway clearance systems. Payment will be approved for a vest airway clearance system when prescribed by a pulmonologist for a member with a diagnosis of a lung disorder if all of the following conditions are met:  (1)  Pulmonary function tests for the 12 months before the initiation of the vest demonstrate an overall significant decrease in lung function.  (2)  The member resides in an independent living situation or has a medical condition that precludes the caregiver from administering traditional chest physiotherapy.  (3)  Treatment by flutter device failed or is contraindicated.  (4)  Treatment by intrapulmonary percussive ventilation failed or is contraindicated.  (5)  All other less costly alternatives have been tried.  d.  Rescinded IAB 12/30/20, effective 3/1/21.  e.  DME rebate agreements. If the department has a current agreement for a rebate with at least one manufacturer of a particular category of diabetic equipment or supplies (by healthcare common procedure coding system (HCPCS) code), prior authorization is required for any equipment or supplies in that category produced by a manufacturer that does not have a current agreement to provide a rebate to the department (other than supplies for members receiving care in a nursing facility or an intermediate care facility for persons with an intellectual disability). Prior approval shall be granted when the member’s medical condition necessitates use of equipment or supplies produced by a manufacturer that does not have a current rebate agreement with the department.  f.  Speech generating device. Payment shall be approved according to Medicare coverage criteria. Form 470-2145, Speech Generating Device System Selection, completed by a speech-language pathologist and a physician’s, physician assistant’s, or advanced registered nurse practitioner’s prescription for a particular device shall be submitted with the request for prior authorization. In addition, documentation from a speech-language pathologist must include information on the member’s educational ability and needs, vocational potential, anticipated duration of need, prognosis regarding oral communication skills, prognosis with a particular device, and recommendations. A minimum one-month trial period is required for all devices. The Iowa Medicaid enterprise consultant with expertise in speech-language pathology will evaluate each prior authorization request and make recommendations to the department.  g.  Bathtub/shower chair, bench. Payment shall be approved for specialized bath equipment for members whose medical condition necessitates additional body support while bathing.  h.  Patient lift, nonstandard. Payment shall be approved for a nonstandard lift, such as a portable, ceiling or electric lifter, when the member meets the Medicare criteria for a patient lift and a standard lifter (Hoyer type) will not work.  i.  Power wheelchair attendant control. Payment shall be approved when the member has a power wheelchair and:  (1)  Has a sip ’n puff attachment, or  (2)  The medical documentation demonstrates the member’s difficulty operating the wheelchair in tight space, or  (3)  The medical documentation demonstrates the member becomes fatigued.  j.  Shower commode chairs. Prior authorization shall be granted when documentation from a physician, physician assistant, advanced registered nurse practitioner, physical therapist or occupational therapist indicates that the member:  (1)  Is unable to stand for the duration of a shower or is unable to get in or out of a bathtub, and  (2)  Needs upper body support while sitting, and  (3)  Needs to be tilted back for safety or pressure relief, if a tilt-in-space chair is requested.  k.  Ventilator, secondary. Payment shall be approved according to the Medicare coverage criteria.  l.  Enteral products and enteral delivery pumps and supplies. Payment shall be approved according to Medicare coverage criteria. Exception:The Medicare criteria for permanence is not required.  m.  Oral nutritional products. Payment shall be approved when the member is not able to ingest or absorb sufficient nutrients from regular food due to a metabolic, digestive, or psychological disorder or pathology, to the extent that supplementation is necessary to provide 51 percent or more of the daily caloric intake, or when the use of oral nutritional products is otherwise determined medically necessary in accordance with evidence-based guidelines for treatment of the member’s condition. Nutritional products consumed orally are not covered for members in nursing facilities or intermediate care facilities for persons with an intellectual disability.  n.  Reimbursement over the established Medicaid fee schedule amount. Payment shall be approved for bariatric equipment, pediatric equipment or other specialized medical equipment, supply, prosthetic or orthotic which:  (1)  Meets the definition of a code in the current healthcare common procedure coding system (HCPCS), and  (2)  Has an established Medicaid fee schedule amount that is inadequate to cover the provider’s cost to obtain the equipment or supply.  o.  Customized wheelchairs, subject to the requirements of 78.10(2)“d.”This rule is intended to implement Iowa Code sections 249A.3, 249A.4 and 249A.12.
    Related ARC(s): 7548B, 8344B, 8643B, 8714B, 8993B, 9256B, 0632C, 0823C, 1151C, 4575C, 4899C, 5362C441—78.11(249A)  Ambulance service.  Payment will be approved for ambulance service if it is required by the recipient’s condition and the recipient is transported to the nearest hospital with appropriate facilities or to one in the same locality, from one hospital to another, to the patient’s home or to a nursing facility. Payment for ambulance service to the nearest hospital for outpatient service will be approved only for emergency treatment. Ambulance service must be medically necessary and not merely for the convenience of the patient.  78.11(1)  Partial payment may be made when an individual is transported beyond the destinations specified, and is limited to the amount that would have been paid had the individual been transported to the nearest institution with appropriate facilities. When transportation is to the patient’s home, partial payment is limited to the amount that would have been paid from the nearest institution with appropriate facilities. When a recipient who is a resident of a nursing care facility is hospitalized and later discharged from the hospital, payment will be made for the trip to the nursing care facility where the recipient resides even though it may not in fact be the nearest nursing care facility.  78.11(2)  The Iowa Medicaid enterprise medical services unit shall determine that the ambulance transportation was medically necessary and that the condition of the patient precluded any other method of transportation. Payment can be made without the physician’s confirmation when:  a.  The individual is admitted as a hospital inpatient or in an emergency situation.  b.  Previous information on file relating to the patient’s condition clearly indicates ambulance service was necessary.  78.11(3)  When a patient is transferred from one nursing home to another because of the closing of a facility or from a nursing home to a custodial home because the recipient no longer requires nursing care, the conditions of medical necessity and the distance requirements shall not be applicable. Approval for transfer shall be made by the local office of the department of human services prior to the transfer. When such a transfer is made, the following rate schedule shall apply:One patient - normal allowanceTwo patients - 3/4 normal allowance per patientThree patients - 2/3 normal allowance per patientFour patients - 5/8 normal allowance per patient  78.11(4)  Transportation of hospital inpatients. When an ambulance service provides transport of a hospital inpatient to a provider and returns the recipient to the same hospital (the recipient continuing to be an inpatient of the hospital), the ambulance service shall bill the hospital for reimbursement as the hospital’s DRG reimbursement system includes all costs associated with providing inpatient services as stated in 441—paragraph 79.1(5)“j.”  78.11(5)  In the event that more than one ambulance service is called to provide ground ambulance transport, payment shall be made only to one ambulance company. When a paramedic from one ambulance service joins a ground ambulance company already in transport, coverage is not available for the services and supplies provided by the paramedic.This rule is intended to implement Iowa Code section 249A.4.441—78.12(249A)  Behavioral health intervention.  Payment will be made for behavioral health intervention services not otherwise covered under this chapter that are designed to minimize or, if possible, eliminate the symptoms or causes of a mental disorder, subject to the limitations in this rule.  78.12(1)    Definitions.  
    "Behavioral health intervention" means skill-building services that focus on:
    1. Addressing the mental and functional disabilities that negatively affect a member’s integration and stability in the community and quality of life;
    2. 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
    3. 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:
    1. Behavior intervention,
    2. Crisis intervention,
    3. Skill training and development, and
    4. Family training.
      (2)  Residential behavioral health intervention is available to members eligible for foster group care payment pursuant to 441—subrule 156.20(1). Services have the primary goal of assisting the member to prepare to transition to the community through learning age-appropriate skills to manage behavior and regain or retain self-control. Specific services offered include:
    1. Behavior intervention,
    2. Crisis intervention, and
    3. Family training.
      (3)  Behavioral health intervention is not covered for members who are in an acute care or psychiatric hospital, a long-term care facility, or a psychiatric medical institution for children.
      b.    Crisis intervention.  Crisis intervention services shall provide a focused intervention and rapid stabilization of acute symptoms of mental illness or emotional distress. The intervention shall be designed to de-escalate situations in which a risk to self, others, or property exists.  (1)  Services shall assist a member to regain self-control and reestablish effective management of behavioral symptoms associated with a psychological disorder in an age-appropriate manner.  (2)  Crisis intervention is covered only for Medicaid members who are aged 20 or under and shall be provided as outlined in a written treatment plan.  (3)  Crisis intervention services do not include control room or other restraint activities.  c.    Behavior intervention.  Behavior intervention includes services designed to modify the psychological, behavioral, emotional, cognitive, and social factors affecting a member’s functioning.  (1)  Interventions may address the following skills for effective functioning with family, peers, and community in an age-appropriate manner:
    1. Cognitive flexibility skills,
    2. Communication skills,
    3. Conflict resolution skills,
    4. Emotional regulation skills,
    5. Executive skills,
    6. Interpersonal relationship skills,
    7. Problem-solving skills, and
    8. Social skills.
      (2)  Behavior intervention shall be provided in a location appropriate for skill identification, teaching and development. Intervention may be provided in an individual, family, or group format as appropriate to meet the member’s needs.  (3)  Behavior intervention is covered only for Medicaid members aged 20 or under.  (4)  Covered services include only direct teaching or development of skills and not general recreation, non-skill-based activities, mentoring, or interruption of school.
      d.    Family training.  Family training is covered only for Medicaid members aged 20 or under.  (1)  Family training services shall:
    1. Enhance the family’s ability to effectively interact with the child and support the child’s functioning in the home and community, and
    2. Teach parents to identify and implement strategies to reduce target behaviors and reinforce the appropriate skills.
      (2)  Training provided must:
    1. Be for the direct benefit of the member, and
    2. Be based on a curriculum with a training manual.
      e.    Skill training and development.  Skill training and development services are covered for Medicaid members aged 18 or over.  (1)  Skill training and development shall consist of interventions to:
    1. Enhance a member’s independent living, social, and communication skills;
    2. Minimize or eliminate psychological barriers to a member’s ability to effectively manage symptoms associated with a psychological disorder; and
    3. Maximize a member’s ability to live and participate in the community.
      (2)  Interventions may include training in the following skills for effective functioning with family, peers, and community:
    1. Communication skills,
    2. Conflict resolution skills,
    3. Daily living skills,
    4. Employment-related skills,
    5. Interpersonal relationship skills,
    6. Problem-solving skills, and
    7. Social skills.
      78.12(3)    Excluded services.    a.  Services that are habilitative in nature are not covered under behavioral health intervention. For purposes of this subrule, “habilitative services” means services that are designed to assist individuals in acquiring skills that they never had, as well as associated training to acquire self-help, socialization, and adaptive skills necessary to reside successfully in a home or community setting.  b.  Respite, day care, education, and recreation services are not covered under behavioral health intervention.  78.12(4)    Coverage requirements.  Medicaid covers behavioral health intervention only when the following conditions are met:  a.  A licensed practitioner of the healing arts acting within the practitioner’s scope of practice under state law has diagnosed the member with a psychological disorder.  b.  The licensed practitioner of the healing arts has recommended the behavioral health intervention as part of a plan of treatment designed to treat the member’s psychological disorder. The plan of treatment shall be comprehensive in nature and shall detail all behavioral health services that the member may require, not only services included under behavioral health intervention.  (1)  The member’s need for services must meet specific individual goals that are focused to address:
    1. Risk of harm to self or others,
    2. Behavioral support in the community,
    3. Specific skills impaired due to the member’s mental illness, and
    4. Needs of children at risk of out-of-home placement due to mental health needs or the transition back to the community or home following an out-of-home placement.
      (2)  Diagnosis and treatment plan development are covered services.
      c.  For a member under the age of 21, the licensed practitioner of the healing arts:  (1)  Has, in cooperation with the managed care contractor, selected a standardized assessment instrument appropriate for baseline measurement of the member’s current skill level in managing mental health needs;  (2)  Has completed an initial formal assessment of the member using the instrument selected; and  (3)  Completes a formal assessment every six months thereafter if continued services are ordered.  d.  The behavioral health intervention provider has prepared a written services implementation plan that meets the requirements of subrule 78.12(5).
      78.12(5)    Approval of plan.  The behavioral health intervention provider shall contact the member’s managed care plan for authorization of the services.  a.    Initial plan.  The initial services implementation plan must meet all of the following criteria:  (1)  The plan conforms to the medical necessity requirements in subrule 78.12(6);  (2)  The plan is consistent with the written diagnosis and treatment recommendations made by the licensed practitioner of the healing arts;  (3)  The plan is sufficient in amount, duration, and scope to reasonably achieve its purpose;  (4)  The provider meets the requirements of rule 441—77.12(249A); and  (5)  The plan does not exceed six months’ duration.  b.    Subsequent plans.  The member’s managed care plan may approve a subsequent services implementation plan according to the conditions in paragraph 78.12(5)“a” if the services are recommended by a licensed practitioner of the healing arts who has:  (1)  Reexamined the member;  (2)  Reviewed the original diagnosis and treatment plan; and  (3)  Evaluated the member’s progress, including a formal assessment as required by 78.12(4)“c”(3).  78.12(6)    Medical necessity.  Nothing in this rule shall be deemed to exempt coverage of behavioral health intervention from the requirement that services be medically necessary. For purposes of behavioral health intervention, “medically necessary” means that the service is:  a.  Consistent with the diagnosis and treatment of the member’s condition and specific to a daily impairment caused by a mental disorder;  b.  Required to meet the medical needs of the member and is needed for reasons other than the convenience of the member or the member’s caregiver;  c.  The least costly type of service that can reasonably meet the medical needs of the member; and  d.  In accordance with the standards of evidence-based medical practice. The standards of practice for each field of medical and remedial care covered by the Iowa Medicaid program are those standards of practice identified by:  (1)  Knowledgeable Iowa clinicians practicing or teaching in the field; and  (2)  The professional literature regarding evidence-based practices in the field.This rule is intended to implement Iowa Code section 249A.4 and 2010 Iowa Acts, chapter 1192, section 31.
    Related ARC(s): 8504B, 9487B, 1850C, 2164C, 2361C, 5305C441—78.13(249A)  Nonemergency medical transportation.  The department makes available nonemergency medical transportation through a transportation brokerage. Medicaid members who are eligible for full Medicaid benefits and need transportation services so that they can receive Medicaid-covered services from providers enrolled with the Iowa Medicaid program may obtain transportation services consistent with this rule.  78.13(1)    Covered services.  Nonemergency medical transportation services available are limited to:   a.  The most economical transportation appropriate to the needs of the member, provided to members eligible for nonemergency transportation when those members need transportation to providers enrolled in the Iowa Medicaid program for the receipt of goods or services covered by the Iowa Medicaid program. Consistent with the member’s needs and subject to the limitations and restrictions set forth in this rule, subject to the advance approval of the broker, such transportation may include:  (1)  Mileage reimbursement to the member, if the member is the driver.  (2)  Mileage reimbursement to a volunteer or other responsible person, if the volunteer or other responsible person is the driver.  (3)  Taxi service.  (4)  Public transportation when public transportation is reasonably available and the member’s condition does not preclude its use.  (5)  Wheelchair and stretcher vans.  (6)  Airfare costs when the most appropriate mode of transport is by air, based on the member’s medical condition.  b.  Reimbursement for costs of the member’s meals necessary during periods of transportation and medical treatment.  c.  Reimbursement of lodging expenses incurred by the member during periods of transportation and medical treatment.  d.  Reimbursement of car rental costs incurred by the member during periods of transportation and medical treatment.  e.  Reimbursement of a medically necessary escort’s travel expenses when an escort is required because of the member’s needs.  78.13(2)    Exclusions.  Nonemergency medical transportation is not available through the Iowa Medicaid program for:  a.  Transportation to obtain services not covered by Iowa Medicaid;  b.  Transportation to providers that are not enrolled in Iowa Medicaid;  c.  Transportation for members residing in nursing facilities or ICF/ID facilities when such facilities provide the transportation (i.e., within 30 miles, one way, of the facility);  d.  Transportation of family members to visit or participate in therapy when the member is hospitalized or institutionalized;  e.  Transportation to durable medical equipment providers when such providers offer a delivery service that can be accessed at no cost to the member, unless the equipment requires a fitting that cannot be provided without transporting the member;  f.  Reimbursement to HCBS and Medicaid providers for transportation provided as part of other covered services, such as personal care, home health, and supported community living services;  g.  Transportation to a pharmacy that provides a free delivery service, with the exception of new prescription fills that are otherwise not available to the patient in the absence of nonemergency medical transportation services; and  h.  Emergency transportation.  78.13(3)    Conditions and limitations on covered services.  Nonemergency medical transportation services are subject to the following limitations and conditions:  a.    Member request.  When a member needs nonemergency transportation to receive medical care provided by the Iowa Medicaid program, the member must contact the broker with as much advance notice as possible, but not more than 30 days’ advance notice.  (1)  Generally, members who require a ride from a transportation provider scheduled by the broker must contact the broker at least two business days in advance of the member’s appointment to schedule the transportation. For purposes of calculating the two-business-day notice obligation, the advance notice includes the day of the medical appointment but not the day of the telephone call.  (2)  If the member’s nonemergency transportation need for a ride from a transportation provider scheduled by the broker makes the provision of two business days’ notice impossible because of the member’s urgent transportation need, the member must provide as much advance notice as is possible before the transportation need so that the broker can appropriately schedule the most economical form of transportation for the member. Urgent transportation needs for a ride from a transportation provider scheduled by the broker are limited to unscheduled episodic situations in which there is no immediate threat to life or limb but which require that the broker schedule transportation with less than two business days’ notice. Examples of urgent trips include, but are not limited to:
    1. Postsurgical or medical follow-up care specified by a health care provider;
    2. Unexpected preoperative appointments;
    3. Hospital discharges;
    4. Appointments for new medical conditions or tests; and
    5. Dialysis.
      (3)  The two-business-day advance notice obligation does not apply when the member requests only mileage reimbursement. To be eligible for mileage reimbursement:
    1. The member must notify the broker no later than the day of the trip;
    2. The transportation must be provided by a driver with a valid driver’s license and insurance coverage on the vehicle at the time of the transport; and
    3. The other requirements of rule 441—78.13(249A) must be met.
      b.    No free transportation alternatives available.  Member transportation through the nonemergency medical transportation broker is not available to the member when the member is capable of securing the member’s own transportation at no cost to the member (e.g., free-gas voucher programs).  c.    No member transportation alternatives available.  Members who have their own transportation available to them are required to use their own vehicle and seek mileage reimbursement. For purposes of determining whether or not the member has the member’s own transportation that is available to the member, the broker shall take into consideration:  (1)  Whether the member owns a vehicle;  (2)  Whether a member-owned vehicle is in working mechanical order and is licensed;  (3)  Whether the member has a valid driver’s license and auto insurance;  (4)  Whether the member is unable to drive because of age, physical condition, cognitive impairment, or developmental limitations; and  (5)  Whether friends or family are available to transport the member to the member’s medical appointment and receive mileage reimbursement.  d.    Limitations on reimbursement for meals.  Reimbursement for costs of members’ meals necessary during periods of transportation and medical treatment is limited to situations in which:  (1)  The transportation being provided spans the entire meal period;  (2)  The one-way distance to or from the medical appointment is more than 50 miles;  (3)  The meal is necessary to satisfy the needs of the member or medically necessary escort; and  (4)  The meal reimbursement is limited to the subsistence allowance amounts applicable to state officers and state employees pursuant to Iowa Administrative Code rule 11—41.6(8A) and is supported by detailed receipts.  e.    Limitations on reimbursement for lodging expenses.  Reimbursement of lodging expenses incurred by members during periods of transportation and medical treatment is limited to reasonable reimbursement for expenses incurred by the member or the medically necessary escort, or both, during a nonemergency trip provided by the broker when the one-way distance to or from the medical appointment is more than 50 miles, supported by detailed receipts, and required for treatment.  f.    Closest medical provider.  Nonemergency medical transportation will only be provided to members to the closest qualified and enrolled Medicaid provider unless:   (1)  The difference between the closest qualified and enrolled Medicaid provider and the enrolled provider requested by the member is less than 10 miles one way; or  (2)  The additional cost of transportation to the enrolled provider requested by the member is medically justified based on:
    1. The member’s previous relationship with the requested provider; or
    2. The member’s prior experience with the requested provider; or
    3. The requested provider’s special expertise or experience; or
    4. A referral requiring the member to be seen by the requested provider.
      g.    Member scheduling obligations.  Members who require a ride will need to schedule medical appointments on days the transportation provider sends a shuttle to facilitate the provision of the most economical nonemergency medical transportation available, subject to reasonable medical exceptions.   h.    Abusive behavior.  Members who are abusive or inappropriate may be restricted by the department to only receiving mileage reimbursement. Such restricted members will be responsible for finding their own way to their medical appointments.  i.    Member claim submission.  Members must submit claims and supporting documentation to the broker within 120 days of the date of service. The broker shall deny member claims submitted more than 120 days from the date of service.
      78.13(4)    Grievance procedure.  The broker shall establish an internal grievance procedure for members and transportation providers.  a.  Members may appeal to the department pursuant to 441—Chapter 7 as an “aggrieved person.”  b.  Transportation providers.  (1)  Consent for state fair hearing.
    1. Transportation providers that are contracted with the broker and are in good standing with the broker may request a state fair hearing only for disputes regarding payment of claims, specifically, disputes concerning the denial of a claim or reduction in payment, and only when acting on behalf of the member.
    2. The transportation provider requesting such a state fair hearing must have the prior, express, signed written consent of the member or the member’s lawfully appointed guardian in order to request such a hearing. Notwithstanding any contrary provision in 441—Chapter 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.
    3. The document must specifically inform the member that protected health information (PHI) may be discussed at the hearing and may be made public in the course of the hearing and subsequent administrative and judicial proceedings. The document must contain language that indicates the knowledge of the potential for PHI to become public and that the member knowingly, voluntarily and intelligently consents to the network provider’s bringing the state fair hearing on the member’s behalf.
      (2)  For all transportation provider grievances not addressed by paragraph 78.13(4)“b,” the grievance process shall end with binding arbitration, with a designee of the Iowa Medicaid enterprise as arbitrator.
    Related ARC(s): 8344B, 8643B, 8994B, 1264C, 1976C441—78.14(249A)  Hearing aids.  Payment shall be approved for a hearing aid and examinations subject to the following conditions:  78.14(1)    Physician examination.  The member shall have an examination by a physician to determine that the member has no condition which would contraindicate the use of a hearing aid. This report shall be documented in the patient record. The requirement for a physician evaluation shall be waived for members 18 years of age or older when the member has signed an informed consent statement acknowledging that the member:  a.  Has been advised that it may be in the member’s best health interest to receive a medical evaluation from a licensed physician before purchase of a hearing aid.  b.  Does not wish to receive a medical evaluation prior to purchase of a hearing aid.  78.14(2)    Audiological testings.  A physician or an audiologist shall perform audiological testing as a part of making a determination that a member could benefit from the use of a hearing aid. The department shall cover vestibular testing performed by an audiologist only when prescribed by a physician.  78.14(3)    Hearing aid evaluation.  A physician or an audiologist shall perform a hearing aid evaluation to establish if a member could benefit from a hearing aid. When a hearing aid is recommended for a member, the physician or audiologist recommending the hearing aid shall see the member at least one time within 30 days after purchase of the hearing aid to determine that the aid is adequate.  78.14(4)    Hearing aid selection.  A physician or audiologist may recommend a specific brand or model appropriate to the member’s condition. When a physician or an audiologist makes a general hearing aid recommendation, a hearing aid dispenser may perform the tests to determine the specific brand or model appropriate to the member’s condition.  78.14(5)    Travel.  When a member is unable to travel to the physician or audiologist because of health reasons, the department shall make payment for travel to the member’s place of residence or other suitable location. The department shall make payment to physicians as specified in 78.1(8) and payment to audiologists at the same rate it reimburses state employees for travel.  78.14(6)    Purchase of hearing aid.  The department shall pay for the type of hearing aid recommended when purchased from an eligible licensed hearing aid dispenser pursuant to rule 441—77.13(249A). The department shall pay for binaural amplification when:  a.  A child needs the aid for speech development,  b.  The aid is needed for educational or vocational purposes,  c.  The aid is for a blind member,  d.  The member’s hearing loss has caused marked restriction of daily activities and constriction of interests resulting in seriously impaired ability to relate to other people, or  e.  Lack of binaural amplification poses a hazard to a member’s safety.  78.14(7)    Payment for hearing aids.    a.  Payment for hearing aids shall be acquisition cost plus a dispensing fee covering the fitting and service for six months. The department shall make payment for routine service after the first six months. Dispensing fees and payment for routine service shall not exceed the fee schedule appropriate to the place of service. Shipping and handling charges are not allowed.  b.  Payment for ear mold and batteries shall be at the current audiologist’s fee schedule.  c.  Payment for repairs shall be made to the dealer for repairs made by the dealer. Payment for in-house repairs shall be made at the current fee schedule. Payment shall also be made to the dealer for repairs when the hearing aid is repaired by the manufacturer or manufacturer’s depot. Payment for out-of-house repairs shall be at the amount shown on the manufacturer’s invoice. Payment shall be allowed for a service or handling charge when it is necessary for repairs to be performed by the manufacturer or manufacturer’s depot and this charge is made to the general public.  d.  Prior approval. When prior approval is required, Form 470-4767, Examiner Report of Need for a Hearing Aid, shall be submitted along with the forms required by 441—paragraph 79.8(1)“a.”  (1)  Payment for the replacement of a hearing aid less than four years old shall require prior approval except when the member is under 21 years of age. The department shall approve payment when the original hearing aid is lost or broken beyond repair or there is a significant change in the member’s hearing that would require a different hearing aid. (Cross reference 78.28(5)“a”)  (2)  Payment for a hearing aid costing more than $650 shall require prior approval. The department shall approve payment for either of the following purposes (Cross reference 78.28(5)“b”):
    1. Educational purposes when the member is participating in primary or secondary education or in a postsecondary academic program leading to a degree and an in-office comparison of an analog aid and a digital aid matched (+/- 5dB) for gain and output shows a significant improvement in either speech recognition in quiet or speech recognition in noise or an in-office comparison of two aids, one of which is single channel, shows significantly improved audibility.
    2. Vocational purposes when documentation submitted indicates the necessity, such as varying amounts of background noise in the work environment and a need to converse in order to do the job, and an in-office comparison of an analog aid and a digital aid matched (+/- 5dB) for gain and output shows a significant improvement in either speech recognition in quiet or speech recognition in noise or an in-office comparison of two aids, one of which is single channel, shows significantly improved audibility.
    This rule is intended to implement Iowa Code section 249A.4.
    Related ARC(s): 8008B, 4899C441—78.15(249A)  Orthopedic shoes.  Payment shall be approved only for depth or custom-molded orthopedic shoes, inserts, and modifications, subject to the following definitions and conditions.  78.15(1)    Definitions.  
    "Custom-molded shoe" means a shoe that:
    1. Has been constructed over a cast or model of the recipient’s foot;
    2. Is made of leather or another suitable material of equal quality;
    3. Has inserts that can be removed, altered, or replaced according to the recipient’s conditions and needs; and
    4. Has some form of closure.
    "Depth shoe" means a shoe that:
    1. 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;
    2. Is made from leather or another suitable material of equal quality;
    3. Has some form of closure; and
    4. 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:
    1. Is soft enough and firm enough to take and hold an impression during use, and
    2. Is molded to the recipient’s foot or is made over a model of the foot.
      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:
    1. The date.
    2. The patient’s diagnosis.
    3. The reason orthopedic shoes are needed.
    4. The probable duration of need.
    5. A specific description of any required modification of the shoes.
      78.15(3)    Diagnosis.  The recipient shall have a diagnosis of an orthopedic, neuromuscular, vascular, or insensate foot condition, supported by applicable codes from the current version of the International Classification of Diseases (ICD). A diagnosis of flat feet is not covered.  a.  A recipient with diabetes must meet the Medicare criteria for therapeutic depth and custom-molded shoes.  b.  Custom-molded shoes are covered only when the recipient has a foot deformity and the provider has documentation of all of the following:  (1)  The reasons the recipient cannot be fitted with a depth shoe.  (2)  Pain.  (3)  Tissue breakdown or a high probability of tissue breakdown.  (4)  Any limitation on walking.  78.15(4)    Frequency.  Only two pairs of orthopedic shoes are allowed per recipient in a 12-month period unless documentation of change in size or evidence of excessive wear is submitted. Exception:School-aged children under the age of 21 may obtain athletic shoes in addition to the two pairs of shoes in a 12-month period.This rule is intended to implement Iowa Code section 249A.4.
    441—78.16(249A)  Community mental health centers.  Payment will be approved for all reasonable and necessary services provided by a psychiatrist on the staff of a community mental health center. Payment will be approved for services provided by a clinical psychologist, social worker or psychiatric nurse on the staff of the center, subject to the following conditions:  78.16(1)  Payment to a community mental health center will be approved for reasonable and necessary services provided to members by a psychiatrist, psychologist, social worker or psychiatric nurse on the staff of the center under the following conditions:  a.  Services must be rendered under the supervision of a board-eligible or board-certified psychiatrist. All services must be performed under the supervision of a board-eligible or board-certified psychiatrist subject to the conditions set forth in 78.16(1)“b” with the following exceptions:  (1)  Services by staff psychiatrists, or  (2)  Services rendered by psychologists meeting the requirements of the National Register of Health Service Providers in Psychology, or  (3)  Services provided by a staff member listed in this subrule performing the preliminary diagnostic evaluation of a member for voluntary admission to one of the state mental health institutes.  b.  Supervisory process.  (1)  Each patient shall have an initial evaluation completed which shall include at least one personal evaluation interview with a mental health professional, as defined under Iowa Code section 228.1. If the evaluation interview results indicate a need for an interview with a board-eligible or board-certified psychiatrist, then such referral shall be made. This must be accomplished before submission of the first claim for services rendered to that patient.  (2)  Ongoing review and assessment of patients’ treatment needs, treatment plans, and the appropriateness of services rendered shall be assured through the peer review process in effect for community mental health centers, as directed by 2002 Iowa Acts, chapter 1120, section 13.  (3)  Rescinded IAB 2/5/03, effective 2/1/03.  (4)  Rescinded IAB 2/5/03, effective 2/1/03.  78.16(2)  The treatment plans for and services rendered to patients of the center shall be evaluated and revised as necessary and appropriate, consistent with the standards of the peer review process described in subparagraph 78.16(1)“b”(1).  78.16(3)  The peer review process and related activities, as described under subparagraph 78.16(1)“b”(1), are not payable as separate services under the Medicaid program. The center shall maintain the results of and information related to the peer review process, and these records shall be subject to audit by the department of human services or department designees, as necessary and appropriate.  78.16(4)  Clinical records of medical assistance patients shall be available to the carrier on request. All these records shall be held confidential.  78.16(5)  At the time of application for participation in the program the center will be provided with a form on which to list its professional staff. The center shall report acquisitions or losses of professional staff to the carrier within ten days.  78.16(6)  Payment to a community mental health center will be approved for day treatment services for persons aged 21 or over if the center is certified by the department for day treatment services, the services are provided on the premises of the community mental health center or satellite office of the community mental health center, and the services meet the standards outlined herein.  a.  Community mental health centers providing day treatment services for persons aged 21 or over shall have available a written narrative providing the following day treatment information:  (1)  Documented need for day treatment services for persons aged 21 and over in the area served by the program, including studies, needs assessments, and consultations with other health care professionals.  (2)  Goals and objectives of the day treatment program for persons aged 21 and over that meet the day treatment program guidelines noted in 78.16(6)“b.”  (3)  Organization and staffing including how the day treatment program for persons aged 21 and over fits with the rest of the community mental health center, the number of staff, staff credentials, and the staff’s relationship to the program, e.g., employee, contractual, or consultant.  (4)  Policies and procedures for the program including admission criteria, patient assessment, treatment plan, discharge plan, postdischarge services, and the scope of services provided.  (5)  Any accreditations or other types of approvals from national or state organizations.  (6)  The physical facility and any equipment to be utilized.  b.  Day treatment services for persons aged 21 and over shall be structured, long-term services designed to assist in restoring, maintaining or increasing levels of functioning, minimizing regression, and preventing hospitalization.  (1)  Service components include training in independent functioning skills necessary for self-care, emotional stability and psychosocial interactions and training in medication management.  (2)  Services are structured with an emphasis on program variation according to individual need.  (3)  Services are provided for a period of three to five hours per day, three or four times per week.  c.  Payment will be approved for day treatment services provided by or under the general supervision of a mental health professional 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 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 meet the following minimum requirements:  (1)  Have a bachelor’s degree in a human services related field from an accredited college or university; or  (2)  Have an Iowa license to practice as a registered nurse with two years of experience in the delivery of nursing or human services.  d.  Persons aged 18 through 20 with chronic mental illness as defined by rule 441—24.1(225C) can receive day treatment services under this subrule or subrule 78.16(7).  78.16(7)  Payment to a community mental health center will be approved for day treatment services for persons aged 20 or under if the center is certified by the department for day treatment services and the services are provided on the premises of the community mental health center or satellite office of the community mental health center. Exception: Field trips away from the premises are a covered service when the trip is therapeutic and integrated into the day treatment program’s description and milieu plan.Day treatment coverage will be limited to a maximum of 15 hours per week. Day treatment services for persons aged 20 or under shall be outpatient services provided to persons who are not inpatients in a medical institution or residents of a group care facility licensed under 441—Chapter 114.  a.    Program documentation.  Community mental health centers providing day treatment services for persons aged 20 or under shall have available a written narrative which provides the following day treatment program information:  (1)  Documented need for day treatment services for persons aged 20 or under in the area served by the program, including studies, needs assessments, and consultations with other health care professionals.  (2)  Goals and objectives of the day treatment program for persons aged 20 or under that meet the guidelines noted in paragraphs “c” to “h” below.  (3)  Organization and staffing including how the day treatment program for persons aged 20 or under fits with the rest of the community mental health center, the number of staff, staff credentials, and the staff’s relationship to the program, e.g., employee, contractual, or consultant.  (4)  Policies and procedures for the program including admission criteria, patient assessment, treatment plan, discharge plan, postdischarge services, and the scope of services provided.  (5)  Any accreditations or other types of approvals from national or state organizations.  (6)  The physical facility and any equipment to be utilized.  b.    Program standards.  Medicaid day treatment program services for persons aged 20 and under shall meet the following standards:  (1)  Staffing shall:
    1. Be sufficient to deliver program services and provide stable, consistent, and cohesive milieu with a staff-to-patient ratio of no less than one staff for each eight participants. Clinical, professional, and paraprofessional staff may be counted in determining the staff-to-patient ratio. Professional or clinical staff are those staff who are either mental health professionals as defined in rule 441—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.
    2. Reflect how program continuity will be provided.
    3. Reflect an interdisciplinary team of professionals and paraprofessionals.
    4. Include a designated director who is a mental health professional as defined in rule 441—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.
    5. 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.
      (2)  There shall be written policies and procedures addressing the following: admission criteria; patient assessment; patient evaluation; treatment plan; discharge plan; community linkage with other psychiatric, mental health, and human service providers; a process to review the quality of care being provided with a quarterly review of the effectiveness of the clinical program; postdischarge services; and the scope of services provided.  (3)  The program shall have hours of operation available for a minimum of three consecutive hours per day, three days or evenings per week.  (4)  The length of stay in a day treatment program for persons aged 20 or under shall not exceed 180 treatment days per episode of care, unless the rationale for a longer stay is documented in the patient’s case record and treatment plan every 30 calendar days after the first 180 treatment days.  (5)  Programming shall meet the individual needs of the patient. A description of services provided for patients shall be documented along with a schedule of when service activities are available including the days and hours of program availability.  (6)  There shall be a written plan for accessing emergency services 24 hours a day, seven days a week.  (7)  The program shall maintain a community liaison with other psychiatric, mental health, and human service providers. Formal relationships shall exist with hospitals providing inpatient programs to facilitate referral, communication, and discharge planning. Relationships shall also exist with appropriate school districts and educational cooperatives. Relationships with other entities such as physicians, hospitals, private practitioners, halfway houses, the department, juvenile justice system, community support groups, and child advocacy groups are encouraged. The provider’s program description will describe how community links will be established and maintained.  (8)  Psychotherapeutic treatment services and psychosocial rehabilitation services shall be available. A description of the services shall accompany the application for certification.  (9)  The program shall maintain a distinct clinical record for each patient admitted. Documentation, at a minimum, shall include: the specific services rendered, the date and actual time services were rendered, who rendered the services, the setting in which the services were rendered, the amount of time it took to deliver the services, the relationship of the services to the treatment regimen described in the plan of care, and updates describing the patient’s progress.
      c.    Program services.  Day treatment services for persons aged 20 or under shall be a time-limited, goal-oriented active treatment program that offers therapeutically intensive, coordinated, structured clinical services within a stable therapeutic milieu. Time-limited means that the patient is not expected to need services indefinitely or lifelong, and that the primary goal of the program is to improve the behavioral functioning or emotional adjustment of the patient in order that the service is no longer necessary. Day treatment services shall be provided within the least restrictive therapeutically appropriate context and shall be community-based and family focused. The overall expected outcome is clinically adaptive behavior on the part of the patient and the family.At a minimum, day treatment services will be expected to improve the patient’s condition, restore the condition to the level of functioning prior to onset of illness, control symptoms, or establish and maintain a functional level to avoid further deterioration or hospitalization. Services are expected to be age-appropriate forms of psychosocial rehabilitation activities, psychotherapeutic services, social skills training, or training in basic care activities to establish, retain or encourage age-appropriate or developmentally appropriate psychosocial, educational, and emotional adjustment.Day treatment programs shall use an integrated, comprehensive and complementary schedule of therapeutic activities and shall have the capacity to treat a wide array of clinical conditions.The following services shall be available as components of the day treatment program. These services are not separately billable to Medicaid, as day treatment reimbursement includes reimbursement for all day treatment components.  (1)  Psychotherapeutic treatment services (examples would include individual, group, and family therapy).  (2)  Psychosocial rehabilitation services. Active treatment examples include, but are not limited to, individual and group therapy, medication evaluation and management, expressive therapies, and theme groups such as communication skills, assertiveness training, other forms of community skills training, stress management, chemical dependency counseling, education, and prevention, symptom recognition and reduction, problem solving, relaxation techniques, and victimization (sexual, emotional, or physical abuse issues).Other program components may be provided, such as personal hygiene, recreation, community awareness, arts and crafts, and social activities designed to improve interpersonal skills and family mental health. Although these other services may be provided, they are not the primary focus of treatment.  (3)  Evaluation services to determine need for day treatment prior to program admission. For persons for whom clarification is needed to determine whether day treatment is an appropriate therapy approach, or for persons who do not clearly meet admission criteria, an evaluation service may be performed. Evaluation services shall be individual and family evaluation activities made available to courts, schools, other agencies, and individuals upon request, who assess, plan, and link individuals with appropriate services. This service must be completed by a mental health professional. An evaluation from another source performed within the previous 12 months or sooner if there has not been a change may be substituted. Medicaid will not make separate payment for these services under the day treatment program.  (4)  Assessment services. All day treatment patients will receive a formal, comprehensive biopsychosocial assessment of day treatment needs including, if applicable, a diagnostic impression based on the current Diagnostic and Statistical Manual of Mental Disorders. An assessment from another source performed within the previous 12 months may be used if the symptomatology is the same as 12 months ago. If not, parts of the assessment which reflect current functioning may be used as an update. Using the assessment, a comprehensive summation will be produced, including the findings of all assessments performed. The summary will be used in forming a treatment plan including treatment goals. Indicators for discharge planning, including recommended follow-up goals and provision for future services, should also be considered, and consistently monitored.  (5)  The day treatment program may include an educational component as an additional service. The patient’s educational needs shall be served without conflict from the day treatment program. Hours in which the patient is involved in the educational component of the day treatment program are not included in the day treatment hours billable to Medicaid.  d.    Admission criteria.  Admission criteria for day treatment services for persons aged 20 or under shall reflect the following clinical indicators:  (1)  The patient is at risk for exclusion from normative community activities or residence.  (2)  The patient exhibits psychiatric symptoms, disturbances of conduct, decompensating conditions affecting mental health, severe developmental delays, psychological symptoms, or chemical dependency issues sufficiently severe to bring about significant or profound impairment in day-to-day educational, social, vocational, or interpersonal functioning.  (3)  Documentation is provided that the traditional outpatient setting has been considered and has been determined not to be appropriate.  (4)  The patient’s principal caretaker (family, guardian, foster family or custodian) must be able and willing to provide the support and monitoring of the patient, to enable adequate control of the patient’s behavior, and must be involved in the patient’s treatment. Persons aged 20 or under who have reached the age of majority, either by age or emancipation, are exempt from family therapy involvement.  (5)  The patient has the capacity to benefit from the interventions provided.  e.    Individual treatment plan.  Each patient receiving day treatment services shall have a treatment plan prepared. A preliminary treatment plan should be formulated within 3 days of participation after admission, and replaced within 30 calendar days by a comprehensive, formalized plan utilizing the comprehensive assessment. This individual treatment plan should reflect the patient’s strengths and weaknesses and identify areas of therapeutic focus. The treatment goals which are general statements of consumer outcomes shall be related to identified strengths, weaknesses, and clinical needs with time-limited, measurable objectives. Objectives shall be related to the goal and have specific anticipated outcomes. Methods that will be used to pursue the objectives shall be stated. The plan should be reviewed and revised as needed, but shall be reviewed at least every 30 calendar days. The treatment plan shall be developed or approved by a board-eligible or board-certified psychiatrist, a staff psychiatrist, physician, or a psychologist registered either on the “National Register of Health Service Providers in Psychology” or the “Iowa Register of Health Service Providers for Psychology.” Approval will be evidenced by a signature of the physician or health service provider.  f.    Discharge criteria.  Discharge criteria for the day treatment program for persons aged 20 or under shall incorporate at least the following indicators:  (1)  In the case of patient improvement:
    1. The patient’s clinical condition has improved as shown by symptom relief, behavioral control, or indication of mastery of skills at the patient’s developmental level. Reduced interference with and increased responsibility with social, vocational, interpersonal, or educational goals occurs sufficient to warrant a treatment program of less supervision, support, and therapeutic intervention.
    2. Treatment goals in the individualized treatment plan have been achieved.
    3. An aftercare plan has been developed that is appropriate to the patient’s needs and agreed to by the patient and family, custodian, or guardian.
      (2)  If the patient does not improve:
    1. The patient’s clinical condition has deteriorated to the extent that the safety and security of inpatient or residential care is necessary.
    2. Patient, family, or custodian noncompliance with treatment or with program rules exists.
      g.    Coordination of services.  Programming services shall be provided in accordance with the individual treatment plan developed by appropriate day treatment staff, in collaboration with the patient and appropriate caretaker figure (parent, guardian, or principal caretaker), and under the supervision of the program director, coordinator, or supervisor.The program for each patient will be coordinated by primary care staff of the community mental health center. A coordinated, consistent array of scheduled therapeutic services and activities shall comprise the day treatment program. These may include counseling or psychotherapy, theme groups, social skills development, behavior management, and other adjunctive therapies. At least 50 percent of scheduled therapeutic program hours exclusive of educational hours for each patient shall consist of active treatment that specifically addresses the targeted problems of the population served. Active treatment shall be defined as treatment in which the program staff assume significant responsibility and often intervene.Family, guardian, or principal caretaker shall be involved with the program through family therapy sessions or scheduled family components of the program. They will be encouraged to adopt an active role in treatment. Medicaid will not make separate payment for family therapy services. Persons aged 20 or under who have reached the age of majority, either by age or emancipation, are exempt from family therapy involvement.Therapeutic activities will be scheduled according to the needs of the patients, both individually and as a group.Scheduled therapeutic activities, which may include other program components as described above, shall be provided at least 3 hours per week up to a maximum of 15 hours per week.  h.    Stable milieu.  The program shall formally seek to provide a stable, consistent, and cohesive therapeutic milieu. In part this will be encouraged by scheduling attendance such that a stable core of patients exists as much as possible. The milieu will consider the developmental and social stage of the participants such that no patient will be significantly involved with other patients who are likely to contribute to retardation or deterioration of the patient’s social and emotional functioning. To help establish a sense of program identity, the array of therapeutic interventions shall be specifically identified as the day treatment program. Program planning meetings shall be held at least quarterly to evaluate the effectiveness of the clinical program. In the program description, the provider shall state how milieu stability will be provided.  i.    Chronic mental illness.  Persons aged 18 through 20 with chronic mental illness as defined by rule 441—24.1(225C) can receive day treatment services under this subrule or subrule 78.16(6).
    This rule is intended to implement Iowa Code section 249A.4.
    441—78.17(249A)  Physical therapists.  Payment will be approved for the same services payable under Title XVIII of the Social Security Act (Medicare).This rule is intended to implement Iowa Code section 249A.4.441—78.18(249A)  Screening centers.  Payment will be approved for health screening as defined in 441—subrule 84.1(1) for Medicaid members under 21 years of age.  78.18(1)  In order to be paid for the administration of a vaccine covered under the Vaccines for Children (VFC) Program, a screening center must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted.  78.18(2)  Payment will be approved for necessary laboratory service related to an element of screening when performed by the screening center and billed as a separate item.  78.18(3)  Periodicity schedules for health, hearing, vision, and dental screenings.  a.  Payment will be approved for health, vision, and hearing screenings as follows:  (1)  Six screenings in the first year of life.  (2)  Four screenings between the ages of 1 and 2.  (3)  One screening a year at ages 3, 4, 5, and 6.  (4)  One screening a year at ages 8, 10, 12, 14, 16, 18, and 20.  b.  Payment for dental screenings will be approved in conjunction with the health screenings up to age 12 months. Screenings will be approved at ages 12 months and 24 months and thereafter at six-month intervals up to age 21.  c.  Interperiodic screenings will be approved as medically necessary.  78.18(4)  When it is established by the periodicity schedule in 78.18(3) that an individual is in need of screening the individual will receive a notice that screening is due.  78.18(5)  When an individual is screened, a member of the screening center shall complete a medical history. The medical history shall become part of the individual’s medical record.  78.18(6)  Rescinded IAB 12/3/08, effective 2/1/09.  78.18(7)  Payment will be made for persons aged 20 and under for nutritional counseling provided by a licensed dietitian employed by or under contract with a screening center for a nutritional problem or condition of a degree of severity that nutritional counseling beyond that normally expected as part of the standard medical management is warranted. For persons eligible for the WIC program, a WIC referral is required. Medical necessity for nutritional counseling services exceeding those available through WIC shall be documented.  78.18(8)  Payment shall be made for dental services provided by a dental hygienist employed by or under contract with a screening center.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 0065C441—78.19(249A)  Rehabilitation agencies.    78.19(1)    Coverage of services.    a.    General provisions regarding coverage of services.    (1)  Services are provided in the member’s home or in a care facility (other than a hospital) by a speech therapist, physical therapist, or occupational therapist employed by or contracted by the agency. A nursing facility, an intermediate care facility for persons with an intellectual disability, or a hospital where services are provided is not considered a member’s home.  1.  Services provided to a member residing in a residential care facility licensed under Iowa Code section 135C.4 by the department of inspections and appeals are payable when the residential care facility submits a signed statement that the residential care facility does not have these services available. The statement need only be submitted at the start of care unless the situation changes.   2.  Under no circumstances will the IME or managed care organizations (MCOs) make payments to a rehabilitation agency for therapy provided to a member residing in a nursing facility or an intermediate care facility for persons with an intellectual disability. Physical, occupational, and speech therapy services for residents of the nursing facility, intermediate care facility for persons with an intellectual disability or hospital are the responsibility of the nursing facility, intermediate care facility for persons with an intellectual disability or hospital.  (2)  All services must be determined to be medically necessary, reasonable, and meet a significant need of the recipient that cannot be met by a family member, friend, medical staff personnel, or other caregiver; must meet accepted standards of medical practice; and must be a specific and effective treatment for a patient’s medical or disabling condition.  (3)  In order for a service to be payable, a licensed therapist must complete a plan of treatment every 30 days and indicate the type of service required. The plan of treatment must contain the information noted in subrule 78.19(2).  (4)  There is no specific limitation on the number of visits for which payment through the program will be made so long as that amount of service is medically necessary in the individual case, is related to a diagnosed medical impairment or disabling condition, and meets the current standards of practice in each related field. Documentation must be submitted with each claim to support the need for the number of services being provided.  (5)  Payments will be made both for restorative service and also for maintenance types of service. Essentially, maintenance services means services to a patient whose condition is stabilized and who requires observation by a therapist of conditions defined by the physician as indicating a possible deterioration of health status. This would include persons with long-term illnesses or a disabling condition whose status is stable rather than posthospital. Refer to 78.19(1)“b”(7) and (8) for guidelines under restorative and maintenance therapy.  (6)  Restorative or maintenance therapy sessions must meet the following criteria:
    1. There must be face-to-face patient contact interaction.
    2. Services must be provided primarily on an individual basis. Group therapy is covered, but total units of service in a month shall not exceed total units of individual therapy. Family members receiving therapy may be included as part of a group.
    3. Treatment sessions may be no less than 15 minutes of service and no more than 60 minutes of service per date unless more than 60 minutes of service is required for a treatment session due to the patient’s specific condition. If more than 60 minutes of service is required for a treatment session, additional documentation of the specific condition and the need for the longer treatment session shall be submitted with the claim. A unit of treatment shall be considered to be 15 minutes in length.
    4. 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.
      (7)  Payment will be made for an appropriate period of diagnostic therapy or trial therapy (up to two months) to determine a patient’s rehabilitation potential and establish appropriate short-term and long-term goals. Documentation must be submitted with each plan to support the need for diagnostic or trial therapy. Refer to 78.19(1)“b”(16) for guidelines under diagnostic or trial therapy.
      b.    Physical therapy services.    (1)  To be covered under rehabilitation agency services, physical therapy services must relate directly and specifically to an active written treatment plan, follow a treatment plan established by the licensed therapist after consultation with the physician, be reasonable and necessary to the treatment of the person’s illness, injury, or disabling condition, be specific and effective treatment for the patient’s medical or disabling condition, and be of such a level of complexity and sophistication, or the condition of the patient must be such that the services required can be safely and effectively performed only by a qualified physical therapist or under the supervision of the therapist.  (2)  A qualified physical therapist assistant may provide any restorative services performed by a licensed physical therapist under supervision of the therapist as set forth in the department of public health, professional licensure division, 645—subrule 200.20(7).  (3)  The initial physical therapy evaluation must be provided by a licensed physical therapist.  (4)  There must be an expectation that there will be a significant, practical improvement in the patient’s condition in a reasonable amount of time based on the patient’s restorative potential assessed by the physician.  (5)  It must be demonstrated there is a need to establish a safe and effective maintenance program related to a specific disease state, illness, injury, or disabling condition.  (6)  The amount, frequency, and duration of the services must be reasonable.  (7)  Restorative therapy must be reasonable and necessary to the treatment of the patient’s injury or disabling condition. The expected restorative potential must be practical and in relation to the extent and duration of the treatment. There must be an expectation that the patient’s medical or disabling condition will show functional improvement in a reasonable period of time. Functional improvement means that demonstrable measurable increases have occurred in the patient’s level of independence outside the therapeutic environment.  (8)  Generally, maintenance therapy means services to a patient whose condition is stabilized and who requires observation by a therapist of conditions defined by the physician as indicating a possible deterioration of health status. This includes persons with long-term illnesses or disabling conditions whose status is stable rather than posthospital. Maintenance therapy is also appropriate for individuals whose condition is such that a professionally established program of activities, exercises, or stimulation is medically necessary to prevent deterioration or maintain present functioning levels.Where a maintenance program is appropriate, the initial evaluation and the instruction of the patient, family members, home health aides, facility personnel, or other caregivers to carry out the program are considered a covered physical therapy service. Payment shall be made for a maximum of three visits to establish a maintenance program and instruct the caregivers. Payment for supervisory visits to monitor the program is limited to two per month for a maximum period of 12 months. The plan of treatment must specify the anticipated monitoring activity of the supervisor.Beyond evaluation, instruction, and monitoring, maintenance therapy is not reimbursable.After 12 months of maintenance therapy, a reevaluation is a covered service, if medically necessary. A reevaluation will be considered medically necessary only if there is a significant change in residential or employment situation or the patient exhibits an increase or decrease in functional ability or motivation, clearing of confusion, or the remission of some other medical condition which previously contraindicated restorative therapy. A statement by the interdisciplinary team of a person with developmental disabilities recommending a reevaluation and stating the basis for medical necessity will be considered as supporting the necessity of a reevaluation and may expedite approval.(Restorative and maintenance therapy definitions also apply to speech and occupational therapy.)When a patient is under a restorative physical therapy program, the patient’s condition is regularly reevaluated and the program adjusted by the physical therapist. It is expected that prior to discharge, a maintenance program has been designed by the physical therapist. Consequently, where a maintenance program is not established until after the restorative program has been completed, it would not be considered reasonable and necessary to the treatment of the patient’s condition and would be excluded from coverage.  (9)  Hot packs, hydrocollator, infrared treatments, paraffin baths, and whirlpool baths do not ordinarily require the skills of a qualified physical therapist. These are covered when the patient’s condition is complicated by other conditions such as a circulatory deficiency or open wounds or if the service is an integral part of a skilled physical therapy procedure.  (10)  Gait training and gait evaluation and training constitute a covered service if the patient’s ability to walk has been impaired by a neurological, muscular or skeletal condition or illness. The gait training must be expected to significantly improve the patient’s ability to walk or level of independence.Repetitious exercise to increase endurance of weak or unstable patients can be safely provided by supportive personnel, e.g., aides, nursing personnel. Therefore, it is not a covered physical therapy service.  (11)  Ultrasound, shortwave, and microwave diathermy treatments are considered covered services.  (12)  Range of motion tests must be performed by a qualified physical therapist. Range of motion exercises require the skills of a qualified physical therapist only when they are part of the active treatment of a specific disease or disabling condition which has resulted in a loss or restriction of mobility.Documentation must reflect the degree of motion lost, the normal range of motion, and the degree to be restored.Range of motion to unaffected joints only does not constitute a covered physical therapy service.  (13)  Reconditioning programs after surgery or prolonged hospitalization are not covered as physical therapy.  (14)  Therapeutic exercises would constitute a physical therapy service due either to the type of exercise employed or to the condition of the patient.  (15)  Use of isokinetic or isotonic type equipment in physical therapy is covered when normal range of motion of a joint is affected due to bone, joint, ligament or tendon injury or postsurgical trauma. Billing can only be made for the time actually spent by the therapist in instructing the patient and assessing the patient’s progress.  (16)  When recipients do not meet restorative or maintenance therapy criteria, diagnostic or trial therapy may be utilized. When the initial evaluation is not sufficient to determine whether there are rehabilitative goals that should be addressed, diagnostic or trial therapy to establish goals shall be considered appropriate. Diagnostic or trial therapy may be appropriate for recipients who need evaluation in multiple environments in order to adequately determine their rehabilitative potential. Diagnostic or trial therapy consideration may be appropriate when there is a need to assess the patient’s response to treatment in the recipient’s environment.When during diagnostic or trial therapy a recipient has been sufficiently evaluated to determine potential for restorative or maintenance therapy, or lack of therapy potential, diagnostic or trial therapy ends. When as a result of diagnostic or trial therapy, restorative or maintenance therapy is found appropriate, claims shall be submitted noting restorative or maintenance therapy (instead of diagnostic or trial therapy).At the end of diagnostic or trial therapy, the rehabilitation provider shall recommend continuance of services under restorative therapy, recommend continuance of services under maintenance therapy, or recommend discontinuance of services. Continuance of services under restorative or maintenance therapy will be reviewed based on the criteria in place for restorative or maintenance therapy.Trial therapy shall not be granted more often than once per year for the same issue. If the recipient has a previous history of rehabilitative services, trial therapy for the same type of services generally would be payable only when a significant change has occurred since the last therapy. Requests for subsequent diagnostic or trial therapy for the same issue would require documentation reflecting a significant change. See number 4 below for guidelines under a significant change. Further diagnostic or trial therapy for the same issue would not be considered appropriate when progress was not achieved, unless the reasons which blocked change previously are listed and the reasons the new diagnostic or trial therapy would not have these blocks are provided.The number of diagnostic or trial therapy hours authorized in the initial treatment period shall not exceed 12 hours per month. Documentation of the medical necessity and the plan for services under diagnostic trial therapy are required as they will be reviewed in the determination of the medical necessity of the number of hours of service provided.Diagnostic or trial therapy standards also apply to speech and occupational therapy.The following criteria additionally must be met:
    1. There must be face-to-face interaction with a licensed therapist. (An aide’s services will not be payable.)
    2. Services must be provided on an individual basis. (Group diagnostic or trial therapy will not be payable.)
    3. Documentation of the diagnostic therapy or trial therapy must reflect the provider’s plan for therapy and the recipient’s response.
    4. 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.
    5. 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.
    6. 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.
    7. 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.
    8. Claims for diagnostic or trial therapy shall reflect the progress being made toward the initial diagnostic or trial therapy plan.
      c.    Occupational therapy services.    (1)  To be covered under rehabilitation agency services, occupational therapy services must be included in a plan of treatment, improve or restore practical functions which have been impaired by illness, injury, or disabling condition, or enhance the person’s ability to perform those tasks required for independent functioning, be prescribed by a physician under a plan of treatment, be performed by a qualified licensed occupational therapist or a qualified licensed occupational therapist assistant under the general supervision of a qualified licensed occupational therapist as set forth in the department of public health, professional licensure division, rule 645—201.9(148B), and be reasonable and necessary for the treatment of the person’s illness, injury, or disabling condition.  (2)  Restorative therapy is covered when an expectation exists that the therapy will result in a significant practical improvement in the person’s condition.However, in these cases where there is a valid expectation of improvement met at the time the occupational therapy program is instituted, but the expectation goal is not realized, services would only be covered up to the time one would reasonably conclude the patient would not improve.The guidelines under restorative therapy, maintenance therapy, and diagnostic or trial therapy for physical therapy in 78.19(1)“b”(7), (8), and (16) apply to occupational therapy.  (3)  Maintenance therapy, or any activity or exercise program required to maintain a function at the restored level, is not a covered service. However, designing a maintenance program in accordance with the requirements of 78.19(1)“b”(8) and monitoring the progress would be covered.  (4)  The selection and teaching of tasks designed to restore physical function are covered.  (5)  Planning and implementing therapeutic tasks, such as activities to restore sensory-integrative functions are covered. Other examples include providing motor and tactile activities to increase input and improve responses for a stroke patient.  (6)  The teaching of activities of daily living and energy conservation to improve the level of independence of a patient which require the skill of a licensed therapist and meet the definition of restorative therapy is covered.  (7)  The designing, fabricating, and fitting of orthotic and self-help devices are considered covered services if they relate to the patient’s condition and require occupational therapy. A maximum of 13 visits is reimbursable.  (8)  Vocational and prevocational assessment and training are not payable by Medicaid. These include services which are related solely to specific employment opportunities, work skills, or work settings.  d.    Speech therapy services.    (1)  To be covered by Medicaid as rehabilitation agency services, speech therapy services must be included in a plan of treatment established by the licensed, skilled therapist after consultation with the physician, relate to a specific medical diagnosis which will significantly improve a patient’s practical, functional level in a reasonable and predictable time period, and require the skilled services of a speech therapist. Services provided by a speech aide are not reimbursable.  (2)  Speech therapy activities which are considered covered services include: restorative therapy services to restore functions affected by illness, injury, or disabling condition resulting in a communication impairment or to develop functions where deficiencies currently exist. Communication impairments fall into the general categories of disorders of voice, fluency, articulation, language, and swallowing disorders resulting from any condition other than mental impairment. Treatment of these conditions is payable if restorative criteria are met.  (3)  Aural rehabilitation, the instruction given by a qualified speech pathologist in speech reading or lip reading to patients who have suffered a hearing loss (input impairment), constitutes a covered service if reasonable and necessary to the patient’s illness or injury. Group treatment is not covered. Audiological services related to the use of a hearing aid are not reimbursable.  (4)  Teaching a patient to use sign language and to use an augmentative communication device is reimbursable. The patient must show significant progress outside the therapy sessions in order for these services to be reimbursable.  (5)  Where a maintenance program is appropriate, the initial evaluation, the instruction of the patient and caregivers to carry out the program, and supervisory visits to monitor progress are covered services. Beyond evaluation, instruction, and monitoring, maintenance therapy is not reimbursable. However, designing a maintenance program in accordance with the requirements of maintenance therapy and monitoring the progress are covered.  (6)  The guidelines and limits on restorative therapy, maintenance therapy, and diagnostic or trial therapy for physical therapy in 78.19(1)“b”(7), (8), and (16) apply to speech therapy. If the only goal of prior rehabilitative speech therapy was to learn the prerequisite speech components, then number “5” under 78.19(1)“b”(16) will not apply to trial therapy.
      78.19(2)    General guidelines for plans of treatment.    a.  The minimum information to be included on medical information forms and treatment plans includes:  (1)  The patient’s current medical condition and functional abilities, including any disabling condition.  (2)  The physician’s signature and date (within the certification period).  (3)  Certification period.  (4)  Patient’s progress in measurable statistics. (Refer to 78.19(1)“b”(16).)  (5)  The place services are rendered.  (6)  Dates of prior hospitalization (if applicable or known).  (7)  Dates of prior surgery (if applicable or known).  (8)  The date the patient was last seen by the physician (if available).  (9)  A diagnosis relevant to the medical necessity for treatment.  (10)  Dates of onset of any diagnoses for which treatment is being rendered (if applicable).  (11)  A brief summary of the initial evaluation or baseline.  (12)  The patient’s prognosis.  (13)  The services to be rendered.  (14)  The frequency of the services and discipline of the person providing the service.  (15)  The anticipated duration of the services and the estimated date of discharge (if applicable).  (16)  Assistive devices to be used.  (17)  Functional limitations.  (18)  The patient’s rehabilitative potential and the extent to which the patient has been able to apply the skills learned in the rehabilitation setting to everyday living outside the therapy sessions.  (19)  The date of the last episode of instability or the date of the last episode of acute recurrence of illness or symptoms (if applicable).  (20)  Quantitative, measurable, short-term and long-term functional goals.  (21)  The period of time of a session.  (22)  Prior treatment (history related to current diagnosis) if available or known.  b.  The information to be included when developing plans for teaching, training, and counseling include:  (1)  To whom the services were provided (patient, family member, etc.).  (2)  Prior teaching, training, or counseling provided.  (3)  The medical necessity of the rendered services.  (4)  The identification of specific services and goals.  (5)  The date of the start of the services.  (6)  The frequency of the services.  (7)  Progress in response to the services.  (8)  The estimated length of time the services are needed.This rule is intended to implement Iowa Code section 249A.4.
    Related ARC(s): 0994C, 5305C441—78.20(249A)  Independent laboratories.  Payment will be made for medically necessary laboratory services provided by laboratories that are independent of attending and consulting physicians’ offices, hospitals, and critical access hospitals and that are certified to participate in the Medicare program.This rule is intended to implement Iowa Code section 249A.4.441—78.21(249A)  Rural health clinics.  Payment will be made to rural health clinics for the same services payable under the Medicare program (Title XVIII of the Social Security Act). Payment will be made for sterilization in accordance with 78.1(16).  78.21(1)    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. Refer to rule 441—76.9(249A) for further information concerning the member lock-in program.  78.21(2)    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. (See description of enhanced services at subrule 78.25(3).)  78.21(3)    Vaccines.  In order to be paid for the administration of a vaccine covered under the Vaccines for Children (VFC) Program, a rural health center must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 0065C441—78.22(249A)  Family planning clinics.  Payments will be made on a fee schedule basis for services provided by family planning clinics.  78.22(1)  Payment will be made for sterilization in accordance with 78.1(16).  78.22(2)  In order to be paid for the administration of a vaccine covered under the Vaccines for Children (VFC) Program, a family planning clinic must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 0065C441—78.23(249A)  Other clinic services.  Payment will be made on a fee schedule basis to facilities not part of a hospital, funded publicly or by private contributions, which provide medically necessary treatment by or under the direct supervision of a physician or dentist to outpatients.  78.23(1)    Sterilization.  Payment will be made for sterilization in accordance with 78.1(16).  78.23(2)    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. Refer to rule 441—76.9(249A) for further information concerning the member lock-in program.  78.23(3)    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. (See description of enhanced services at subrule 78.25(3).)  78.23(4)    Vaccines.  In order to be paid for the administration of a vaccine covered under the Vaccines for Children (VFC) Program, a clinic must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 0065C441—78.24(249A)  Psychologists.  Payment will be approved for services authorized by state law when they are provided by the psychologist in the psychologist’s office, a hospital, nursing facility, or residential care facility.  78.24(1)  Payment for covered services provided by the psychologist shall be made on a fee for service basis.  a.  Payment shall be made only for time spent in face-to-face consultation with the client.  b.  Time spent with clients shall be rounded to the quarter hour.  78.24(2)  Payment will be approved for the following psychological procedures:  a.  Individual outpatient psychotherapy or other psychological procedures not to exceed one hour per week or 40 hours in any 12-month period, or  b.  Couple, marital, family, or group outpatient therapy not to exceed one and one-half hours per week or 60 hours in any 12-month period, or  c.  A combination of individual and group therapy not to exceed the cost of 40 individual therapy hours in any 12-month period.  d.  Psychological examinations and testing for purposes of evaluation, placement, psychotherapy, or assessment of therapeutic progress, not to exceed eight hours in any 12-month period.  e.  Mileage at the same rate as in 78.1(8) when the following conditions are met:  (1)  It is necessary for the psychologist to travel outside of the home community, and  (2)  There is no qualified mental health professional more immediately available in the community, and  (3)  The member has a medical condition which prohibits travel.  f.  Covered procedures necessary to maintain continuity of psychological treatment during periods of hospitalization or convalescence for physical illness.  g.  Procedures provided within a licensed hospital, residential treatment facility, day hospital, or nursing home as part of an approved treatment plan and a psychologist is not employed by the facility.  78.24(3)  Payment will not be approved for the following services:  a.  Psychological examinations performed without relationship to evaluations or psychotherapy for a specific condition, symptom, or complaint.  b.  Psychological examinations covered under Part B of Medicare, except for the Part B Medicare deductible and coinsurance.  c.  Psychological examinations employing unusual or experimental instrumentation.  d.  Individual and group psychotherapy without specification of condition, symptom, or complaint.  e.  Sensitivity training, marriage enrichment, assertiveness training, growth groups or marathons, or psychotherapy for nonspecific conditions of distress such as job dissatisfaction or general unhappiness.  78.24(4)  Rescinded IAB 10/12/94, effective 12/1/94.  78.24(5)  The following services shall require review by a consultant to the department.  a.  Protracted therapy beyond 16 visits. These cases shall be reviewed following the sixteenth therapy session and periodically thereafter.  b.  Any service which does not appear necessary or appears to fall outside the scope of what is professionally appropriate or necessary for a particular condition.This rule is intended to implement Iowa Code sections 249A.4 and 249A.15.441—78.25(249A)  Maternal health centers.  Payment will be made for prenatal and postpartum medical care, health education, and transportation to receive prenatal and postpartum services. Payment will be made for enhanced perinatal services for persons determined high risk. These services include additional health education services, nutrition counseling, social services, and one postpartum home visit. Maternal health centers shall provide trimester and postpartum reports to the referring physician. Risk assessment using Form 470-2942, Medicaid Prenatal Risk Assessment, shall be completed at the initial visit during a Medicaid member’s pregnancy. If the risk assessment reflects a low-risk pregnancy, the assessment shall be completed again at approximately the twenty-eighth week of pregnancy. If the risk assessment reflects a high-risk pregnancy, referral shall be made for enhanced services. (See description of enhanced services at subrule 78.25(3).)  78.25(1)    Provider qualifications.    a.  Prenatal and postpartum medical services shall be provided by a physician, a physician assistant, or a nurse practitioner employed by or on contract with the center. Medical services performed by maternal health centers shall be performed under the supervision of a physician. Nurse practitioners and physician assistants performing under the supervision of a physician must do so within the scope of practice of that profession, as defined by Iowa Code chapters 152 and 148C, respectively.  b.  Rescinded IAB 12/3/08, effective 2/1/09.  c.  Education services and postpartum home visits shall be provided by a registered nurse.  d.  Nutrition services shall be provided by a licensed dietitian.  e.  Psychosocial services shall be provided by a person with at least a bachelor’s degree in social work, counseling, sociology, psychology, family and community services, health or human development, health education, or individual and family studies.  78.25(2)    Services covered for all pregnant women.  Services provided may include:  a.  Prenatal and postpartum medical care.  b.  Health education, which shall include:  (1)  Importance of continued prenatal care.  (2)  Normal changes of pregnancy including both maternal changes and fetal changes.  (3)  Self-care during pregnancy.  (4)  Comfort measures during pregnancy.  (5)  Danger signs during pregnancy.  (6)  Labor and delivery including the normal process of labor, signs of labor, coping skills, danger signs, and management of labor.  (7)  Preparation for baby including feeding, equipment, and clothing.  (8)  Education on the use of over-the-counter drugs.  (9)  Education about HIV protection.  c.  Home visit.  d.  Transportation to receive prenatal and postpartum services that is not payable under rule 441—78.11(249A) or 441—78.13(249A).  e.  Dental hygiene services within the scope of practice as defined by the dental board at 650—paragraph 10.5(3)“b.”  78.25(3)    Enhanced services covered for women with high-risk pregnancies.  Enhanced perinatal services may be provided to a patient who has been determined to have a high-risk pregnancy as documented by Form 470-2942, Medicaid Prenatal Risk Assessment. An appropriately trained physician or advanced registered nurse practitioner must be involved in staffing the patients receiving enhanced services.Enhanced services are as follows:  a.  Rescinded IAB 12/3/08, effective 2/1/09.  b.  Education, which shall include as appropriate education about the following:  (1)  High-risk medical conditions.  (2)  High-risk sexual behavior.  (3)  Smoking cessation.  (4)  Alcohol usage education.  (5)  Drug usage education.  (6)  Environmental and occupational hazards.  c.  Nutrition assessment and counseling, which shall include:  (1)  Initial assessment of nutritional risk based on height, current and prepregnancy weight status, laboratory data, clinical data, and self-reported dietary information.  (2)  Ongoing nutritional assessment.  (3)  Development of an individualized nutritional care plan.  (4)  Referral to food assistance programs if indicated.  (5)  Nutritional intervention.  d.  Psychosocial assessment and counseling, which shall include:  (1)  A psychosocial assessment including: needs assessment, profile of client demographic factors, mental and physical health history and concerns, adjustment to pregnancy and future parenting, and environmental needs.  (2)  A profile of the client’s family composition, patterns of functioning and support systems.  (3)  An assessment-based plan of care, risk tracking, counseling and anticipatory guidance as appropriate, and referral and follow-up services.  e.  A postpartum home visit within two weeks of the child’s discharge from the hospital, which shall include:  (1)  Assessment of mother’s health status.  (2)  Physical and emotional changes postpartum.  (3)  Family planning.  (4)  Parenting skills.  (5)  Assessment of infant health.  (6)  Infant care.  (7)  Grief support for unhealthy outcome.  (8)  Parenting of a preterm infant.  (9)  Identification of and referral to community resources as needed.  78.25(4)    Vaccines.  In order to be paid for the administration of a vaccine covered under the Vaccines for Children (VFC) Program, a maternal health center must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 0065C441—78.26(249A)  Ambulatory surgical center services.  Ambulatory surgical center services are those services furnished by an ambulatory surgical center in connection with a covered surgical procedure or a covered dental procedure. Covered procedures are listed in the fee schedule published on the department’s website.  78.26(1)  Covered surgical procedures shall be those medically necessary procedures that are eligible for payment as physicians’ services, under the circumstances specified in rule 441—78.1(249A) and performed on a Medicaid member, that can safely be performed in an outpatient setting as determined by the department upon advice from the Iowa Medicaid enterprise medical services unit.  78.26(2)  Covered dental procedures are those medically necessary procedures that are eligible for payment as dentists’ services, under the circumstances specified in rule 441—78.4(249A) and performed on a Medicaid member, that can safely be performed in an outpatient setting for Medicaid members whose mental, physical, or emotional condition necessitates deep sedation or general anesthesia.  78.26(3)  The covered services provided by the ambulatory surgical center in connection with a Medicaid-covered surgical or dental procedure shall be those nonsurgical and nondental services that:  a.  Are medically necessary in connection with a Medicaid-covered surgical or dental procedure;  b.  Are eligible for payment as physicians’ services under the circumstances specified in rule 441—78.1(249A) or as dentists’ services under the circumstances specified in rule 441—78.4(249A); and  c.  Can safely and economically be performed in an outpatient setting, as determined by the department upon advice from the Iowa Medicaid enterprise medical services unit.  78.26(4)  Limits on covered services.  a.  Abortion procedures are covered only when criteria in subrule 78.1(17) are met.  b.  Sterilization procedures are covered only when criteria in subrule 78.1(16) are met.  c.  Preprocedure review by the IME medical services unit is required if ambulatory surgical centers are to be reimbursed for certain frequently performed surgical procedures as set forth under subrule 78.1(19). Criteria are available from the IME medical services unit. (Cross reference 78.28(7))This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 8205B, 2361C, 4899C441—78.27(249A)  Home- and community-based habilitation services.  Payment for habilitation services will only be made to providers enrolled to provide habilitation through the Iowa Medicaid enterprise. Effective March 17, 2022, payment shall only be made for services provided to members in integrated, community-based settings that support full access of members receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS.  78.27(1)    Definitions.  
    "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(1)“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.
    "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" means an evidence-based supported employment model that helps people with mental illness to seek and obtain employment.
    "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" means the provision of services to enrolled members as described in subrule 78.53(1).
    "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.
    "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.
    "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.    Risk factors.  The member has at least one of the following risk factors:  (1)  The member has undergone or is currently undergoing psychiatric treatment more intensive than outpatient care (e.g., emergency services, alternative home care, partial hospitalization, or inpatient hospitalization) more than once in the member’s life; or  (2)  The member has a history of psychiatric illness resulting in at least one episode of continuous, professional supportive care other than hospitalization.  b.    Need for assistance.  The member has a need for assistance demonstrated by meeting at least two of the following criteria on a continuing or intermittent basis for at least two years:  (1)  The member is unemployed, is employed in a sheltered setting, or has markedly limited skills and a poor work history.  (2)  The member requires financial assistance for out-of-hospital maintenance and is unable to procure this assistance without help.  (3)  The member shows severe inability to establish or maintain a personal social support system.  (4)  The member requires help in basic living skills such as self-care, money management, housekeeping, cooking, and medication management.  (5)  The member exhibits inappropriate social behavior that results in a demand for intervention.  c.    Income.  The countable income used in determining the member’s Medicaid eligibility does not exceed 150 percent of the federal poverty level.  d.    Needs assessment.  The interRAI - Child and Youth Mental Health (ChYMH) for youth aged 16 to 18 or the interRAI - Community Mental Health (CMH) for those aged 19 and older has been completed, 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 interRAI - Child and Youth Mental Health (ChYMH) and the interRAI - Community Mental Health (CMH) 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 interRAI, before services begin and annually thereafter.  (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), before services begin and annually thereafter.  e.    Plan for service.  The department 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 through ISIS 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). A service plan may change at any time due to a significant change in the member’s needs.  (2)  The member’s habilitation services shall not exceed the maximum number of units established for each service in 441—subrule 79.1(2).  (3)  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:
    1. The name of the provider responsible for delivering the service;
    2. The funding source for the service; and
    3. The number of units of service to be received by the member.
      (5)  Identify for a member receiving home-based habilitation:
    1. The member’s living environment at the time of enrollment;
    2. The number of hours per day of on-site staff supervision needed by the member; and
    3. The number of other members who will live with the member in the living unit.
      (6)  Include a separate, individualized, anticipated discharge plan that is specific to each service the member receives.
      c.    Rights restrictions.  Any rights restrictions must be implemented in accordance with 441—subrule 77.25(4). The comprehensive service plan or treatment plan shall include documentation of:  (1)  Any restrictions on the member’s rights, including maintenance of personal funds and self-administration of medications;  (2)  The need for the restriction; and  (3)  Either a plan to restore those rights or written documentation that a plan is not necessary or appropriate.  d.    Emergency plan.  The comprehensive service plan or treatment plan shall include a plan for emergencies and identification of the supports available to the member in an emergency. Emergency plans shall be developed as follows:  (1)  The member’s interdisciplinary team shall identify in the comprehensive service plan or treatment plan any health and safety issues applicable to the individual member based on information gathered before the team meeting, including a risk assessment.  (2)  The interdisciplinary team shall identify an emergency backup support and crisis response system to address problems or issues arising when support services are interrupted or delayed or the member’s needs change.  (3)  Providers of applicable services shall provide for emergency backup staff.  e.    Plan approval.  Services shall be entered into ISIS based on the comprehensive service plan. A comprehensive service plan or treatment plan that has been validated and authorized through ISIS shall be considered approved by the department. Services must be authorized in ISIS as specified in paragraph 78.27(2)“e.”
      78.27(5)    Requirements for services.  Home- and community-based habilitation services shall be provided in accordance with the following requirements:  a.  The services shall be based on the member’s needs as identified in the member’s comprehensive service plan.  b.  The services shall be delivered in the least restrictive environment appropriate to the needs of the member.  c.  The services shall include the applicable and necessary instruction, supervision, assistance, and support required by the member to achieve the member’s life goals.  d.  Service components that are the same or similar shall not be provided simultaneously.  e.  Service costs are not reimbursable while the member is in a medical institution, including but not limited to a hospital or nursing facility.  f.  Reimbursement is not available for room and board.  g.  Services shall be billed in whole units.  h.  Services shall be documented. Each unit billed must have corresponding financial and medical records as set forth in rule 441—79.3(249A).  78.27(6)    Case management.  Case management assists members in gaining access to needed medical, social, educational, housing, transportation, vocational, and other appropriate services in order to ensure the health, safety, and welfare of the member.  a.    Scope.  Case management services shall be provided as set forth in rules 441—90.4(249A) through 441—90.7(249A).  b.    Exclusions.    (1)  Payment shall not be made for case management provided to a member who is enrolled for integrated health home services under rule 441—78.53(249A) except during the transition to the integrated health homes.  (2)  Payment shall not be made for case management provided to a member who is eligible for case management services under 441—Chapter 90.  78.27(7)    Home-based habilitation.  “Home-based habilitation” means individually tailored supports that assist with the acquisition, retention, or improvement of skills related to living in the community.  a.    Scope.  Home-based habilitation services are individualized supportive services provided in the member’s home and community that assist the member to reside in the most integrated setting appropriate to the member’s needs. Services are intended to provide for the daily living needs of the member and shall be available as needed during any 24-hour period. The specific support needs for each member shall be determined necessary by the interdisciplinary team and shall be identified in the member’s comprehensive service plan. Covered supports include:  (1)  Adaptive skill development;  (2)  Assistance with activities of daily living;  (3)  Community inclusion;  (4)  Transportation;  (5)  Adult educational supports;  (6)  Social and leisure skill development;  (7)  Personal care; and  (8)  Protective oversight and supervision.  b.    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:
    1. Meeting with the member and the member’s family, guardian or legal representative to introduce them to supported employment and explore the member’s employment goals and experiences,
    2. Business tours,
    3. Informational interviews,
    4. Job shadows,
    5. Benefits education and financial literacy,
    6. Assistive technology assessment, and
    7. Job exploration events.
      (2)  Expected outcome of service.
    1. The expected outcome of prevocational services is individual employment in the general workforce, or self-employment, in a setting typically found in the community, where the member interacts with individuals without disabilities, other than those providing services to the member or other individuals with disabilities, to the same extent that individuals without disabilities in comparable positions interact with other persons; and for which the member is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities.
    2. The expected outcome of the career exploration activity is a written career plan that will guide employment services which lead to community employment or self-employment for the member.
      b.    Setting.  Prevocational services shall take place in community-based nonresidential settings.  c.    Concurrent services.  A member’s individual service plan may include two or more types of nonresidential habilitation services (e.g., individual supported employment, long-term job coaching, small-group supported employment, prevocational services, and day habilitation); however, more than one service may not be billed during the same period of time (e.g., the same hour).  d.    Exclusions.  Prevocational services payment shall not be made for the following:  (1)  Services that are available to the individual under a program funded under Section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.). Documentation that funding is not available to the individual for the service under these programs shall be maintained in the service plan of each member receiving prevocational services.   (2)  Services available to the individual that duplicate or replace education or related services defined in the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.).  (3)  Compensation to members for participating in prevocational services.  (4)  Support for members volunteering in for-profit organizations and businesses other than for-profit organizations, or businesses that have formal volunteer programs in place (e.g., hospitals, nursing homes), and support for members volunteering to benefit the service provider.   (5)  The provision of vocational services delivered in facility-based settings where individuals are supervised for the primary purpose of producing goods or performing services or where services are aimed at teaching skills for specific types of jobs rather than general skills.  (6)  A prevocational service plan with the goal or purpose of the service documented as maintaining or supporting the individual in continuing prevocational services or any employment situation similar to sheltered employment.  e.    Limitations.    (1)  Time limitation for members starting prevocational services. For members starting prevocational services after May 4, 2016, participation in these services is limited to 24 calendar months. This time limit can be extended to continue beyond 24 months if one or more of the following conditions apply:
    1. The member who is in prevocational services is also working in either individual or small-group community employment for at least the number of hours per week desired by the member, as identified in the member’s current service plan; or
    2. The member who is in prevocational services is also working in either individual or small-group community employment for less than the number of hours per week the member desires, as identified in the member’s current service plan, but the member has services documented in the member’s current service plan, or through another identifiable funding source (e.g., Iowa vocational rehabilitation services (IVRS)), to increase the number of hours the member is working in either individual or small-group community employment; or
    3. The member is actively engaged in seeking individual or small-group community employment or individual self-employment, and services for this are included in the member’s current service plan or services funded through another identifiable funding source (e.g., IVRS) are documented in the member’s service plan; or
    4. The member has requested supported employment services from Medicaid and IVRS in the past 24 months, and the member’s request has been denied or the member has been placed on a waiting list by both Medicaid and IVRS; or
    5. The member has been receiving individual supported employment services (or comparable services available through IVRS) for at least 18 months without obtaining individual or small-group community employment or individual self-employment; or
    6. The member is participating in career exploration activities as described in subparagraph 78.27(9)“a”(1).
      (2)  Time limitation for members enrolled in prevocational services. For members enrolled in prevocational services on or before May 4, 2016, participation in these services is limited to 90 business days beyond the completion of the career exploration activity including the development of the career plan described in subparagraph 78.27(9)“a”(1). This time limit can be extended as stated in paragraphs 78.27(9)“e”(1)“1” through “6.” If the criteria in paragraphs 78.27(9)“e”(1)“1” through “6” do not apply, the member will not be reauthorized to continue prevocational services.
      78.27(10)    Supported employment services.    a.    Individual supported employment.  Individual supported employment involves supports provided to, or on behalf of, the member that enable the member to obtain and maintain individual employment. Services are provided to members who need support because of their disabilities.   (1)  Scope. Individual supported employment services are services provided to, or on behalf of, the member that enable the member to obtain and maintain an individual job in competitive employment, customized employment or self-employment in an integrated work setting in the general workforce.  (2)  Expected outcome of service. The expected outcome of this service is sustained employment, or self-employment, paid at or above the minimum wage or the customary wage and level of benefits paid by an employer, in an integrated setting in the general workforce, in a job that meets personal and career goals. Successful transition to long-term job coaching, if needed, is also an expected outcome of this service. An expected outcome of supported self-employment is that the member earns income that is equal to or exceeds the average income for the chosen business within a reasonable period of time.  (3)  Setting. Individual supported employment services shall take place in integrated work settings. For self-employment, the member’s home can be considered an integrated work setting. Employment in the service provider’s organization (not including a sheltered workshop or similar type of work setting where members are paid for the production of goods or services) can be considered employment in an integrated work setting in the general workforce if the employment occurs in a work setting where interactions are predominantly with coworkers or business associates who do not have disabilities or with the general public.  (4)  Individual employment strategies include but are not limited to: customized employment, individual placement and support, and supported self-employment. Service activities are individualized and may include any combination of the following:
    1. Benefits education.
    2. Career exploration (e.g., tours, informational interviews, job shadows).
    3. Employment assessment.
    4. Assistive technology assessment.
    5. Trial work experience.
    6. Person-centered employment planning.
    7. Development of visual/traditional résumés.
    8. Job-seeking skills training and support.
    9. Outreach to prospective employers on behalf of the member (e.g., job development; negotiation with prospective employers to customize, create or carve out a position for the member; employer needs analysis).
    10. Job analysis (e.g., work site assessment or job accommodations evaluation).
    11. Identifying and arranging transportation.
    12. Career advancement services (e.g., assisting a member in making an upward career move or seeking promotion from an existing employer).
    13. Reemployment services (if necessary due to job loss).
    14. Financial literacy and asset development.
    15. Other employment support services deemed necessary to enable the member to obtain employment.
    16. Systematic instruction and support during initial on-the-job training including initial on-the-job training to stabilization.
    17. Engagement of natural supports during initial period of employment.
    18. Implementation of assistive technology solutions during initial period of employment.
    19. Transportation of the member during service hours.
    20. Initial on-the-job training to stabilization activity.
      (5)  Self-employment. Individual employment may also include support to establish a viable self-employment opportunity, including home-based self-employment. An expected outcome of supported self-employment is that the member earns income that is equal to or exceeds the average income for the chosen business within a reasonable period of time. In addition to the activities listed under subparagraph 78.27(10)“a”(4), assistance to establish self-employment may include:
    1. Aid to the member in identifying potential business opportunities.
    2. Assistance in the development of a business plan, including identifying potential sources of business financing and other assistance in developing and launching a business.
    3. Identification of the long-term supports necessary for the individual to operate the business.
      b.    Long-term job coaching.  Long-term job coaching is support provided to, or on behalf of, the member that enables the member to maintain an individual job in competitive employment, customized employment or self-employment in an integrated work setting in the general workforce.   (1)  Scope. Long-term job coaching services are provided to or on behalf of members who need support because of their disabilities and who are unlikely to maintain and advance in individual employment absent the provision of supports. Long-term job coaching services shall provide individualized and ongoing support contacts at intervals necessary to promote successful job retention and advancement.  (2)  Expected outcome of service. The expected outcome of this service is sustained employment paid at or above the minimum wage in an integrated setting in the general workforce, in a job that meets the member’s personal and career goals. An expected outcome of supported self-employment is that the member earns income that is equal to or exceeds the average income for the chosen business within a reasonable period of time.  (3)  Setting. Long-term job coaching services shall take place in integrated work settings. For self-employment, the member’s home can be considered an integrated work setting. Employment in the service provider’s organization (not including a sheltered workshop or similar type of work setting) can be considered employment in an integrated work setting in the general workforce if the employment occurs in a work setting where interactions are predominantly with coworkers or business associates who do not have disabilities, or with the general public, and if the position would exist within the provider’s organization were the provider not being paid to provide the job coaching to the member.   (4)  Service activities. Long-term job coaching services are designed to assist the member with learning and retaining individual employment, resulting in workplace integration, and which allows for the reduction of long-term job coaching over time. Services are individualized, and service plans are adjusted as support needs change and may include any combination of the following activities with or on behalf of the member:
    1. Job analysis.
    2. Job training and systematic instruction.
    3. Training and support for use of assistive technology/adaptive aids.
    4. Engagement of natural supports.
    5. Transportation coordination.
    6. Job retention training and support.
    7. Benefits education and ongoing support.
    8. Supports for career advancement.
    9. Financial literacy and asset development.
    10. Employer consultation and support.
    11. Negotiation with employer on behalf of the member (e.g., accommodations; employment conditions; access to natural supports; and wage and benefits).
    12. Other workplace support services may include services not specifically related to job skill training that enable the waiver member to be successful in integrating into the job setting.
    13. Transportation of the member during service hours.
    14. Career exploration services leading to increased hours or career advancement.
      (5)  Self-employment long-term job coaching. Self-employment long-term job coaching may include support to maintain a self-employment opportunity, including home-based self-employment. In addition to the activities listed under subparagraph 78.27(10)“b”(4), assistance to maintain self-employment may include:
    1. Ongoing identification of the supports necessary for the individual to operate the business;
    2. Ongoing assistance, counseling and guidance to maintain and grow the business; and
    3. Ongoing benefits education and support.
      (6)  The hours of support for long-term job coaching are based on the identified needs of the member as documented in the member’s comprehensive service plan.
      c.    Small-group supported employment.  Small-group supported employment services are training and support activities provided in regular business or industry settings for groups of two to eight workers with disabilities. The outcome of this service is sustained paid employment experience, skill development, career exploration and planning leading to referral for services to obtain individual integrated employment or self-employment for which an individual is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities.  (1)  Scope. Small-group supported employment services must be provided in a manner that promotes integration into the workplace and interaction between members and people without disabilities (e.g., customers, coworkers, natural supports) in those workplaces. Examples include but are not limited to mobile crews and other business-based workgroups employing small groups of workers with disabilities in employment in integrated business settings; and small-group activities focused on career exploration and development of strengths and skills that contribute to successful participation in individual community employment.  (2)  Expected outcome of service. Small-group supported employment services are expected to enable the member to make reasonable and continued progress toward individual employment. Participation in small-group supported employment services is not a prerequisite for individual supported employment services. The expected outcome of the service is sustained paid employment and skill development which leads to individual employment in the community.  (3)  Setting. Small-group supported employment services shall take place in integrated, community-based nonresidential settings separate from the member’s residence.  (4)  Service activities. Small-group supported employment services may include any combination of the following activities:
    1. Employment assessment.
    2. Person-centered employment planning.
    3. Job placement (limited to service necessary to facilitate hire into individual employment paid at minimum wage or higher for a member in small-group supported employment who receives an otherwise unsolicited offer of a job from a business where the member has been working in a mobile crew or enclave).
    4. Job analysis.
    5. On-the-job training and systematic instruction.
    6. Job coaching.
    7. Transportation planning and training.
    8. Benefits education.
    9. Career exploration services leading to career advancement outcomes.
    10. Other workplace support services may include services not specifically related to job skill training that enable the waiver member to be successful in integrating into the individual or community setting.
    11. Transportation of the member during service hours.
      d.    Service requirements for all supported employment services.    (1)  Community transportation options (e.g., transportation provided by family, coworkers, carpools, volunteers, self or public transportation) shall be identified by the member’s interdisciplinary team and utilized before the service provider provides the transportation to and from work for the member. If none of these options are available to a member, transportation between the member’s place of residence and the employment or service location may be included as a component part of supported employment services.   (2)  Personal care or personal assistance and protective oversight may be a component part of supported employment services, but may not comprise the entirety of the service.  (3)  Activities performed on behalf of a member receiving long-term job coaching or individual or small-group supported employment shall not comprise the entirety of the service.  (4)  Concurrent services. A member’s individual service plan may include two or more types of nonresidential services (e.g., individual supported employment, long-term job coaching, small-group supported employment, prevocational services, and day habilitation); however, more than one service may not be billed during the same period of time (e.g., the same hour).  (5)  Integration requirements. In the performance of job duties, the member shall have regular contact with other employees or members of the general public who do not have disabilities, unless the absence of regular contact with other employees or the general public is typical for the job as performed by persons without disabilities.  (6)  Compensation. Members receiving these services are compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. For supported self-employment, the member earns income that is equal to or exceeds the average income for the chosen business within a reasonable period of time. For small-group supported employment, if the member is not compensated at or above minimum wage, the compensation to the member shall be in accordance with all applicable state and federal labor laws and regulations.   e.    Limitations.  Supported employment services are limited as follows:  (1)  Total monthly costs of supported employment may not exceed the monthly cap on the cost of waiver services set for the individual waiver program.  (2)  In absence of a monthly cap on the cost of waiver services, the total monthly cost of all supported employment services may not exceed $3,059.29 per month.  (3)  Individual supported employment is limited to 60 hourly units per calendar year.   (4)  Long-term job coaching is limited in accordance with 441—subrule 79.1(2).  (5)  Small-group supported employment is limited to 160 units per week.  f.    Exclusions.  Supported employment services payments 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 the service is not available to the individual under these programs shall be maintained in the service plan of each member receiving individual supported employment or long-term job coaching services.  (2)  Incentive payments, not including payments for coworker supports, made to an employer to encourage or subsidize the employer’s participation in a supported employment program.  (3)  Subsidies or payments that are passed through to users of supported employment programs.  (4)  Training that is not directly related to a member’s supported employment program.  (5)  Services involved in placing and stabilizing members in day activity programs, work activity programs, sheltered workshop programs or other similar types of vocational or prevocational services furnished in specialized facilities that are not a part of the general workplace.  (6)  Supports for placement and stabilization in volunteer positions or unpaid internships. Such volunteer learning and unpaid training activities that prepare a person for entry into the general workforce are addressed through prevocational services and career exploration activities.   (7)  Tuition for education or vocational training.  (8)  Individual advocacy that is not related to integrated individual employment participation or is not member-specific.   (9)  Medicaid funds may not be used to defray the expenses associated with starting up or operating a business.
      78.27(11)    Adverse service actions.    a.    Denial.  Services shall be denied when the department determines that:  (1)  The member is not eligible for or in need of home- and community-based habilitation services.  (2)  The service is not identified in the member’s comprehensive service plan or treatment plan.  (3)  Needed services are not available or received from qualifying providers, or no qualifying providers are available.  (4)  The member’s service needs exceed the unit or reimbursement maximums for a service as set forth in 441—subrule 79.1(2).  (5)  Completion or receipt of required documents for the program has not occurred.  b.    Reduction.  A particular home- and community-based habilitation service may be reduced when the department determines that continued provision of service at its current level is not necessary.  c.    Termination.  A particular home- and community-based habilitation service may be terminated when the department determines that:  (1)  The member’s income exceeds the allowable limit, or the member no longer meets other eligibility criteria for the program established by the department.  (2)  The service is not identified in the member’s comprehensive service plan.  (3)  Needed services are not available or received from qualifying providers, or no qualifying providers are available.  (4)  The member’s service needs are not being met by the services provided.  (5)  The member has received care in a medical institution for 120 consecutive days in any one stay. When a member has been an inpatient in a medical institution for 120 consecutive days, the department will issue a notice of decision to inform the member of the service termination. If the member returns home before the effective date of the notice of decision and the member’s condition has not substantially changed, the decision shall be rescinded, and eligibility for home- and community-based habilitation services shall continue.  (6)  The member’s service needs exceed the unit or reimbursement maximums for a service as established by the department.  (7)  Duplication of services provided during the same period has occurred.  (8)  The member or the member’s legal representative, through the interdisciplinary process, requests termination of the service.  (9)  Completion or receipt of required documents for the program has not occurred, or the member refuses to allow documentation of eligibility as to need and income.  d.    Appeal rights.  The department shall give notice of any adverse action and the right to appeal in accordance with 441—Chapter 7. The member is entitled to have a review of the determination of needs-based eligibility by the Iowa Medicaid enterprise medical services unit by sending a letter requesting a review to the medical services unit. If dissatisfied with that decision, the member may file an appeal with the department.  78.27(12)    County reimbursement.  Rescinded IAB 7/11/12, effective 7/1/12.This rule is intended to implement Iowa Code section 249A.4.
    Related ARC(s): 7957B, 9311B, 9403B, 0191C, 0359C, 0709C, 0848C, 1051C, 2361C, 2471C, 2848C, 2936C, 3184C, 3874C, 4897C, 5305C, 5307C441—78.28(249A)  List of medical services and equipment requiring prior authorization, preprocedure review or preadmission review.    78.28(1)  Services, procedures, and medications prescribed by a physician, physician assistant, or advanced registered nurse practitioner which are subject to prior authorization or preprocedure review are as follows or as specified in the preferred drug list published by the department pursuant to Iowa Code section 249A.20A:  a.  Drugs require prior authorization as specified in the preferred drug list published by the department pursuant to Iowa Code section 249A.20A. For drugs requiring prior authorization, reimbursement will be made for a 72-hour supply dispensed in an emergency when a prior authorization request cannot be submitted.  b.  Rescinded IAB 12/30/20, effective 3/1/21.  c.  Enteral products and enteral delivery pumps and supplies. Payment shall be approved pursuant to the criteria at 78.10(5)“l.”  d.  Rescinded IAB 5/11/05, effective 5/1/05.  e.  Speech generating device. Payment shall be approved pursuant to the criteria at 78.10(5)“f.”  f.  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 on the criteria established by the department and the IME medical services unit. 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.  g.  Enclosed beds. Payment shall be approved pursuant to the criteria at 78.10(5)“a.”  h.  Prior authorization is required for external insulin infusion pumps and is granted according to Medicare coverage criteria. (Cross reference 78.10(2)“c”)  i.  Oral nutritional products. Payment shall be approved pursuant to the criteria at 78.10(5)“m.”  j.  Vest airway clearance system. Payment shall be approved pursuant to the criteria at 78.10(5)“c.”  k.  DME rebate agreements. Payment will be approved pursuant to the criteria at 78.10(5)“e.”  l.  Reimbursement over the established Medicaid fee schedule amount. Payment shall be approved pursuant to the criteria at 78.10(5)“n.”  m.  Bathtub/shower chair, bench. Payment shall be approved pursuant to the criteria at 78.10(5)“g.”  n.  Patient lift, nonstandard. Payment shall be approved pursuant to the criteria at 78.10(5)“h.”  o.  Power wheelchair attendant control. Payment shall be approved pursuant to the criteria at 78.10(5)“i.”  p.  Shower commode chair. Payment shall be approved pursuant to the criteria at 78.10(5)“j.”  q.  Ventilator, secondary. Payment shall be approved pursuant to the Medicare coverage criteria.  r.  Customized wheelchairs, subject to the requirements of 78.10(2)“d.”  78.28(2)  Notwithstanding the provisions of 78.28(1)“a,” under both Medicaid fee-for-service and managed care administration, at least one form of each of the following drugs for medication-assisted treatment as approved by the United States Food and Drug Administration for treatment of substance use disorder or overdose treatment will be available without prior authorization:  a.  Buprenorphine,  b.  Buprenorphine and naloxone combination,  c.  Methadone,  d.  Naltrexone, and  e.  Naloxone.For the purpose of this subrule, “medication-assisted treatment” means the medically monitored use of certain substance use disorder medications in combination with treatment services.  78.28(3)  Dental services. Dental services which require prior approval are as follows:  a.  The following periodontal services:  (1)  Periodontal scaling and root planing. Payment will be approved pursuant to the criteria at 78.4(4)“b.”  (2)  Pedicle soft tissue graft, free soft tissue graft, and subepithelial tissue graft. Payment will be approved pursuant to the criteria at 78.4(4)“d.”  (3)  Periodontal maintenance therapy. Payment will be approved pursuant to the criteria at 78.4(4)“e.”  (4)  Tissue regeneration. Payment will be approved pursuant to the criteria at 78.4(4)“f.”  (5)  Localized delivery of antimicrobial agents. Payment will be approved pursuant to the criteria at 78.4(4)“g.”  b.  The following prosthetic services:  (1)  A removable partial denture replacing anterior teeth. Payment will be approved pursuant to the criteria at 78.4(7)“b.”  (2)  A fixed partial denture replacing anterior teeth. Payment will be approved pursuant to the criteria at 78.4(7)“d.”  (3)  A removable partial denture replacing posterior teeth. Payment will be approved pursuant to the criteria at 78.4(7)“c.”  (4)  A fixed partial denture replacing posterior teeth. Payment will be approved pursuant to the criteria at 78.4(7)“e.”  (5)  Dental implants and related services. Payment will be approved pursuant to the criteria at 78.4(7)“k.”  (6)  Replacement of complete or partial dentures in less than a five-year period. Payment will be approved pursuant to the criteria at 78.4(7)“l.”  (7)  A complete or partial denture rebase. Payment will be approved pursuant to the criteria at 78.4(7)“m.”  (8)  An oral appliance for obstructive sleep apnea. Payment will be approved pursuant to the criteria at 78.4(7)“n.”  c.  The following orthodontic services:  (1)  Minor treatment to control harmful habits. Payment will be approved pursuant to the criteria at 78.4(8)“a.”  (2)  Interceptive orthodontic treatment. Payment will be approved pursuant to the criteria at 78.4(8)“b.”  (3)  Comprehensive orthodontic treatment. Payment will be approved pursuant to the criteria at 78.4(8)“c.”  d.  The following restorative services:  (1)  Laboratory-fabricated crowns other than stainless steel. Payment will be approved pursuant to the criteria at 78.4(3)“d”(3).  (2)  Crowns with noble or high noble metals. Payment will be approved pursuant to the criteria at 78.4(3)“d”(4).  e.  Endodontic retreatment of a tooth. Payment will be approved pursuant to the criteria at 78.4(5)“d.”  f.  Occlusal guard. Payment will be approved pursuant to the criteria at 78.4(9)“g.”  78.28(4)  Optometric services and ophthalmic materials which must be submitted for prior approval are as follows:  a.  A second lens correction within a 24-month period for members eight years of age and older. Payment shall be made when the member’s vision has at least a five-tenths diopter of change in sphere or cylinder or ten-degree change in axis in either eye.  b.  Visual therapy may be authorized when warranted by case history or diagnosis for a period of time not greater than 90 days. Should continued therapy be warranted, the prior approval process should be reaccomplished, accompanied by a report showing satisfactory progress. Approved diagnoses are convergence insufficiency and amblyopia. Visual therapy is not covered when provided by opticians.  c.  Subnormal visual aids where near visual acuity is better than 20/100 at 16 inches, 2M print. Prior authorization is not required if near visual acuity as described above is less than 20/100. Subnormal aids include, but are not limited to, hand magnifiers, loupes, telescopic spectacles or reverse Galilean telescope systems.  d.  Photochromatic tint. Approval shall be given when the member has a documented medical condition that causes photosensitivity and less costly alternatives are inadequate.  e.  Press-on prisms. Approval shall be granted for members whose vision cannot be adequately corrected with other covered prisms.For all of the above, the optometrist shall furnish sufficient information to clearly establish that these procedures are necessary in terms of the visual condition of the patient. (Cross references 78.6(4), 441—78.7(249A), and 78.1(18))  78.28(5)  Hearing aids that must be submitted for prior approval are:  a.  Replacement of a hearing aid less than four years old (except when the member is under 21 years of age). The department shall approve payment when the original hearing aid is lost or broken beyond repair or there is a significant change in the person’s hearing that would require a different hearing aid. (Cross reference 78.14(7)“d”(1))  b.  A hearing aid costing more than $650. The department shall approve payment for either of the following purposes (Cross reference 78.14(7)“d”(2)):  (1)  Educational purposes when the member is participating in primary or secondary education or in a postsecondary academic program leading to a degree and an in-office comparison of an analog aid and a digital aid matched (+/- 5dB) for gain and output shows a significant improvement in either speech recognition in quiet or speech recognition in noise or an in-office comparison of two aids, one of which is single channel, shows significantly improved audibility.  (2)  Vocational purposes when documentation submitted indicates the necessity, such as varying amounts of background noise in the work environment and a need to converse in order to do the job and an in-office comparison of an analog aid and a digital aid matched (+/- 5dB) for gain and output shows a significant improvement in either speech recognition in quiet or speech recognition in noise or an in-office comparison of two aids, one of which is single channel, shows significantly improved audibility.  78.28(6)  Hospital services which must be subject to prior approval, preprocedure review or preadmission review are:  a.  Any medical or surgical procedure requiring prior approval as set forth in Chapter 78 is subject to the conditions for payment set forth although a request form does not need to be submitted by the hospital as long as the approval is obtained by the physician. (Cross reference 441—78.1(249A))  b.  All inpatient hospital admissions are subject to retrospective review. Payment for inpatient hospital admissions which are retrospectively reviewed is approved when the claim meets the criteria for inpatient hospital care as determined by the IME medical services unit. Criteria are available from the IME medical services unit. (Cross reference 441—78.3(249A))  c.  Preprocedure review by the IME medical services unit is required if hospitals are to be reimbursed for the inpatient and outpatient surgical procedures set forth in subrule 78.1(19). 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 department. The criteria are available from the IME medical services unit.  78.28(7)  Ambulatory surgical centers are subject to prior approval and preprocedure review as follows:  a.  Any medical or surgical procedure requiring prior approval as set forth in Chapter 78 is subject to the conditions for payment set forth although a request form does not need to be submitted by the ambulatory surgical center as long as the prior approval is obtained by the physician.  b.  Preprocedure review is required if ambulatory surgical centers are to be reimbursed for surgical procedures as set forth in subrule 78.1(19). Approval will be granted only if the procedures are determined to be necessary based on the condition of the patient and criteria established by the department.   78.28(8)  All assertive community treatment (ACT) services require prior approval. Exception:If ACT services are initiated before Medicaid eligibility is established, prior approval is required for ACT services beginning with the second month following notice of Medicaid eligibility.  a.  Approval shall be granted if ACT services are determined to be medically necessary. Approval shall be limited to no more than 180 days.  b.  A new prior approval must be obtained to continue ACT services after the expiration of a previous approval.  78.28(9)  Nursing, psychosocial, developmental therapies and personal care services provided by a licensed child care center for members aged 20 or under require prior approval and shall be approved if the services are determined to be medically necessary. The request for prior authorization shall include a nursing assessment, the plan of care, and supporting documentation and shall identify the types and service delivery levels of all other services provided to the member whether or not the services are reimbursable by Medicaid. Providers shall indicate the expected number of nursing, home health aide or behavior intervention hours per day, the number of days per week, and the number of weeks or months of service based on the plan of care using a combined hourly rate.  78.28(10)  Private duty nursing or personal care services provided by a home health agency provider for persons aged 20 or under require prior approval and shall be approved if determined to be medically necessary. Payment shall be made on an hourly unit of service.  a.  Definitions.  (1)  Private duty nursing services are those services which are provided by a registered nurse or a licensed practical nurse under the direction of the member’s physician to a member in the member’s place of residence or outside the member’s residence, when normal life activities take the member outside the place of residence. Place of residence does not include nursing facilities, intermediate care facilities for the mentally retarded, or hospitals.Services shall be provided according to a written plan of care authorized by a licensed physician. The home health agency is encouraged to collaborate with the member, or in the case of a child with the child’s caregiver, in the development and implementation of the plan of treatment. These services shall exceed intermittent guidelines as defined in subrule 78.9(3). Private duty nursing and personal care services shall be inclusive of all home health agency services personally provided to the member.Private duty nursing services do not include:
    1. Respite care, which is a temporary intermission or period of rest for the caregiver.
    2. Nurse supervision services including chart review, case discussion or scheduling by a registered nurse.
    3. Services provided to other persons in the member’s household.
    4. Services requiring prior authorization that are provided without regard to the prior authorization process.
      (2)  Personal care services are those services provided by a home health aide or certified nurse’s aide and which are delegated and supervised by a registered nurse under the direction of the member’s physician to a member in the member’s place of residence or outside the member’s residence, when normal life activities take the member outside the place of residence. Place of residence does not include nursing facilities, intermediate care facilities for the mentally retarded, or hospitals. Payment for personal care services for persons aged 20 and under that exceed intermittent guidelines may be approved if determined to be medically necessary as defined in subrule 78.9(7). These services shall be in accordance with the member’s plan of care and authorized by a physician. The home health agency is encouraged to collaborate with the member, or in the case of a child with the child’s caregiver, in the development and implementation of the plan of treatment.Medical necessity means the service is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions that endanger life, cause pain, result in illness or infirmity, threaten to cause or aggravate a disability or chronic illness, and no other equally effective course of treatment is available or suitable for the member requesting a service.
      b.  Requirements.  (1)  Private duty nursing or personal care services shall be ordered in writing by a physician as evidenced by the physician’s signature on the plan of care.  (2)  Private duty nursing or personal care services shall be authorized by the department or the department’s designated review agent prior to payment.  (3)  Prior authorization shall be requested at the time of initial submission of the plan of care or at any time the plan of care is substantially amended and shall be renewed with the department or the department’s designated review agent. Initial request for and request for renewal of prior authorization shall be submitted to the department’s designated review agent. The provider of the service is responsible for requesting prior authorization and for obtaining renewal of prior authorization.The request for prior authorization shall include a nursing assessment, the plan of care, and supporting documentation. The request for prior authorization shall include all items previously identified as required treatment plan information and shall further include: any planned surgical interventions and projected time frame; information regarding caregiver’s desire to become involved in the member’s care, to adhere to program objectives, to work toward treatment plan goals, and to work toward maximum independence; and identify the types and service delivery levels of all other services to the member whether or not the services are reimbursable by Medicaid. Providers shall indicate the expected number of private duty nursing RN hours, private duty nursing LPN hours, or home health aide hours per day, the number of days per week, and the number of weeks or months of service per discipline. If the member is currently hospitalized, the projected date of discharge shall be included.Prior authorization approvals shall not be granted for treatment plans that exceed 16 hours of home health agency services per day. (Cross reference 78.9(10))
      78.28(11)  Replacement of vibrotactile aids less than four years old shall be approved when the original aid is broken beyond repair or lost. (Cross reference 78.10(3)“b”)  78.28(12)  High-technology radiology procedures.  a.  Except as provided in paragraph 78.28(12)“b,” the following radiology procedures require prior approval:  (1)  Magnetic resonance imaging (MRIs);  (2)  Computed tomography (CTs), including combined abdomen and pelvis CT scans;  (3)  Computed tomographic angiographs (CTAs);  (4)  Positron emission tomography (PETs); and   (5)  Magnetic resonance angiography (MRAs).  b.  Notwithstanding paragraph 78.28(12)“a,” prior authorization is not required when any of the following applies:  (1)  Radiology procedures are billed on a CMS 1500 claim for places of service “hospital inpatient” (POS 21) or “hospital emergency room” (POS 23), or on a UB04 claim with revenue code 45X;  (2)  The member has Medicare coverage;   (3)  A radiology procedure is ordered or requested by the department of human services, a state district court, law enforcement, or other similar entity for the purposes of a child abuse/neglect investigation, as documented by the provider.  c.  Prior approval will be granted if the procedure requested meets the requirements of 441—subrule 79.9(2), based on diagnosis, symptoms, history of illness, course of treatment, and treatment plan, as documented by the provider requesting prior approval.  d.  Required requests for prior approval of radiology procedures must be submitted to the department of human services.   e.  When a member has received notice of retroactive Medicaid eligibility after receiving a radiology procedure for a date of service prior to the member’s receipt of such notice and otherwise requiring prior approval pursuant to this rule, a retroactive authorization request must be submitted on Form 470-5595, Outpatient Prior Authorization Request, and approved before any claim for payment is submitted.This rule is intended to implement Iowa Code section 249A.4.
    Related ARC(s): 7548B, 8714B, 9440B, 9702B, 9883B, 0305C, 0631C, 0632C, 0823C, 1151C, 1696C, 2361C, 4575C, 4899C, 5362C441—78.29(249A)  Behavioral health services.  Payment shall be made for medically necessary behavioral health services provided by a participating marital and family therapist, independent social worker, master social worker, mental health counselor, or certified alcohol and drug counselor within the practitioner’s scope of practice pursuant to state law and subject to the limitations and exclusions set forth in this rule.  78.29(1)    Limitations.    a.  An assessment and a treatment plan are required.  b.  Services provided by a licensed master social worker must be provided under the supervision of an independent social worker qualified to participate in the Medicaid program.  78.29(2)    Exclusions.  Payment will not be approved for the following services:  a.  Services provided in a medical institution.  b.  Services performed without relationship to a specific condition, risk factor, symptom, or complaint.  c.  Services provided for nonspecific conditions of distress such as job dissatisfaction or general unhappiness.  d.  Sensitivity training, marriage enrichment, assertiveness training, and growth groups or marathons.  78.29(3)    Payment.    a.  Payment shall be made only for time spent in face-to-face consultation with the member.  b.  A unit of service is 15 minutes. Time spent with members shall be rounded to the quarter hour, where applicable.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 9649B441—78.30(249A)  Birth centers.  Payment will be made for prenatal, delivery, and postnatal services.  78.30(1)    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. (See description of enhanced services at subrule 78.25(3).)  78.30(2)    Vaccines.  In order to be paid for the administration of a vaccine covered under the Vaccines for Children (VFC) Program, a birth center must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 0065C441—78.31(249A)  Hospital outpatient services.    78.31(1)    Covered hospital outpatient services.  Payment will be approved only for the following outpatient hospital services and medical services when provided on the licensed premises of the hospital or pursuant to subrule 78.31(5). Hospitals with alternate sites approved by the department of inspections and appeals are acceptable sites. All outpatient services listed in paragraphs “g” to “m” are subject to a random sample retrospective review for medical necessity by the IME medical services unit. All services may also be subject to a more intensive retrospective review if abuse is suspected. Services in paragraphs “a” to “f” shall be provided in hospitals on an outpatient basis and are subject to no further limitations except medical necessity of the service.Services listed in paragraphs “g” to “m” shall be provided by hospitals on an outpatient basis and must be certified by the department before payment may be made. Other limitations apply to these services.  a.  Emergency service.  b.  Outpatient surgery.  c.  Laboratory, X-ray and other diagnostic services.  d.  General or family medicine.  e.  Follow-up or after-care specialty clinics.  f.  Physical medicine and rehabilitation.  g.  Alcoholism and substance abuse.  h.  Eating disorders.  i.  Cardiac rehabilitation.  j.  Mental health.  k.  Pain management.  l.  Diabetic education.  m.  Pulmonary rehabilitation.  n.  Nutritional counseling for persons aged 20 and under.  78.31(2)    Requirements for all outpatient services.    a.    Need for service.   It must be clearly established that the service meets a documented need in the area served by the hospital. There must be documentation of studies completed, consultations with other health care facilities and health care professionals in the area, community leaders, and organizations to determine the need for the service and to tailor the service to meet that particular need.  b.    Professional direction.  All outpatient services must be provided by or at the direction and under the supervision of a medical doctor or osteopathic physician except for mental health services which may be provided by or at the direction and under the supervision of a medical doctor, osteopathic physician, or certified health service provider in psychology.  c.    Goals and objectives.  The goals and objectives of the program must be clearly stated. Paragraphs “d” and “f” and the organization and administration of the program must clearly contribute to the fulfillment of the stated goals and objectives.  d.    Treatment modalities used.  The service must employ multiple treatment modalities and professional disciplines. The modalities and disciplines employed must be clearly related to the condition or disease being treated.  e.    Criteria for selection and continuing treatment of patients.  The condition or disease which is proposed to be treated must be clearly stated. Any indications for treatment or contraindications for treatment must be set forth together with criteria for determining the continued medical necessity of treatment.  f.    Length of program.  There must be established parameters that limit the program either in terms of its overall length or in terms of number of visits, etc.  g.    Monitoring of services.  The services provided by the program must be monitored and evaluated to determine the degree to which patients are receiving accurate assessments and effective treatment.The monitoring of the services must be an ongoing plan and systematic process to identify problems in patient care or opportunities to improve patient care.The monitoring and evaluation of the services are based on the use of clinical indicators that reflect those components of patient care important to quality.  h.    Vaccines.  In order to be paid for the outpatient administration of a vaccine covered under the 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.  78.31(3)    Application for certification.  Hospital outpatient programs listed in subrule 78.31(1), paragraphs “g” to “m,” must submit an application to the Iowa Medicaid enterprise provider services unit for certification before payment will be made. The provider services unit will review the application against the requirements for the specific type of outpatient service and notify the provider whether certification has been approved.Applications will consist of a narrative providing the following information:  a.  Documented need for the program including studies, needs assessments, and consultations with other health care professionals.  b.  Goals and objectives of the program.  c.  Organization and staffing including how the program fits with the rest of the hospital, the number of staff, staff credentials, and the staff’s relationship to the program, e.g., hospital employee, contractual consultant.  d.  Policies and procedures including admission criteria, patient assessment, treatment plan, discharge plan and postdischarge services, and the scope of services provided, including treatment modalities.  e.  Any accreditations or other types of approvals from national or state organizations.  f.  The physical facility and any equipment to be utilized, and whether the facility is part of the hospital license.  78.31(4)    Requirements for specific types of service.    a.  Alcoholism and substance abuse.  (1)  Approval by joint commission or substance abuse commission. In addition to certification by the department, alcoholism and substance abuse programs must also be approved by either the joint commission on the accreditation of hospitals or the Iowa substance abuse commission.  (2)  General characteristics. The services must be designed to identify and respond to the biological, psychological and social antecedents, influences and consequences associated with the recipient’s dependence.These needed services must be provided either directly by the facility or through referral, consultation or contractual arrangements or agreements.Special treatment needs of recipients by reason of age, gender, sexual orientation, or ethnic origin are evaluated and services for children and adolescents (as well as adults, if applicable) address the special needs of these age groups, including but not limited to, learning problems in education, family involvement, developmental status, nutrition, and recreational and leisure activities.  (3)  Diagnostic and treatment staff. Each person who provides diagnostic or treatment services shall be determined to be competent to provide the services by reason of education, training, and experience.Professional disciplines which must be represented on the diagnostic and treatment staff, either through employment by the facility (full-time or part-time), contract or referral, are a physician (M.D. or D.O.), a licensed psychologist and a substance abuse counselor certified by the Iowa board of substance abuse certification. Psychiatric consultation must be available and the number of staff should be appropriate to the patient load of the facility.  (4)  Initial assessment. A comprehensive assessment of the biological, psychological, social, and spiritual orientation of the patient must be conducted which shall include:A history of the use of alcohol and other drugs including age of onset, duration, patterns, and consequences of use; use of alcohol and drugs by family members and types of and responses to previous treatment.A comprehensive medical history and physical examination including the history of physical problems associated with dependence.Appropriate laboratory screening tests based on findings of the history and physical examination and tests for communicable diseases when indicated.Any history of physical abuse.A systematic mental status examination with special emphasis on immediate recall and recent and remote memory.A determination of current and past psychiatric and psychological abnormality.A determination of any degree of danger to self or others.The family’s history of alcoholism and other drug dependencies.The patient’s educational level, vocational status, and job performance history.The patient’s social support networks, including family and peer relationships.The patient’s perception of the patient’s strengths, problem areas, and dependencies.The patient’s leisure, recreational, or vocational interests and hobbies.The patient’s ability to participate with peers and in programs and social activities.Interview of family members and significant others as available with the patient’s written or verbal permission.Legal problems, if applicable.  (5)  Admission criteria. Both of the first two criteria and one additional criterion from the following list must be present for a patient to be accepted for treatment.Alcohol or drugs taken in greater amounts over a longer period than the person intended.Two or more unsuccessful efforts to cut down or control use of alcohol or drugs.Continued alcohol or drug use despite knowledge of having a persistent or recurrent family, social, occupational, psychological, or physical problem that is caused or exacerbated by the use of alcohol or drugs.Marked tolerance: the need for markedly increased amounts of alcohol or drugs (i.e., at least a 50 percent increase) in order to achieve intoxication or desired effect or markedly diminished effect with continued use of same amount.Characteristic withdrawal symptoms.Alcohol or drugs taken often to relieve or avoid withdrawal symptoms.  (6)  Plan of treatment. For each patient there is a written comprehensive and individualized description of treatment to be undertaken. The treatment plan is based on the problems and needs identified in the assessment and specifies the regular times at which the plan will be reassessed.The patient’s perception of needs and, when appropriate and available, the family’s perception of the patient’s needs shall be documented.The patient’s participation in the development of the treatment plan is sought and documented.Each patient is reassessed to determine current clinical problems, needs, and responses to treatment. Changes in treatment are documented.  (7)  Discharge plan. For each patient before discharge, a plan for discharge is designed to provide appropriate continuity of care which meets the following requirements:The plan for continuing care must describe and facilitate the transfer of the patient and the responsibility for the patient’s continuing care to another phase or modality of the program, other programs, agencies, persons or to the patient and the patient’s personal support system.The plan is in accordance with the patient’s reassessed needs at the time of transfer.The plan is developed in collaboration with the patient and, as appropriate and available, with the patient’s written verbal permission with family members.The plan is implemented in a manner acceptable to the patient and the need for confidentiality.Implementation of the plan includes timely and direct communication with and transfer of information to the other programs, agencies, or persons who will be providing continuing care.  (8)  Restrictions and limitations on payment. Medicaid will reimburse for a maximum of 28 treatment days. Payment beyond 28 days is made when documentation indicates that the patient has not reached an exit level.If an individual has completed all or part of the basic 28-day program, a repeat of the program will be reimbursed with justification. The program will include an aftercare component meeting weekly for at least one year without charge.  b.  Eating disorders.  (1)  General characteristics. Eating disorders are characterized by gross disturbances in eating behavior. Eating disorders include anorexia nervosa or bulimia nervosa. Compulsive overeaters are not approved for this program.  (2)  Diagnostic and treatment staff. Each person who provides diagnostic or treatment services shall be determined to be competent to provide the services by reason of education, training, and experience.Professional disciplines which must be represented on the diagnostic and treatment staff, either through employment by a facility (full-time or part-time), contract or referral, are a physician (M.D. or D.O.), a licensed psychologist, a counselor with a master’s or bachelor’s degree and experience, a dietitian with a bachelor’s degree and registered dietitian’s certificate, and a licensed occupational therapist. The number of staff should be appropriate to the patient load of the facility.  (3)  Initial assessment. A comprehensive assessment of the biological, psychological, social, and family orientation of the patient must be conducted. The assessment must include a weight history and a history of the patient’s eating and dieting behavior, including binge eating, onset, patterns, and consequences. The assessment shall include the following:A family history as well as self-assessment regarding chronic dieting, obesity, anorexia, bulimia, drug abuse, alcohol problems, depression, hospitalization for psychiatric reasons, and threatened or attempted suicide.A history of purging behavior including frequency and history of vomiting, use of laxatives, history and frequency of use of diuretics, history and frequency of use of diet pills, ipecac, or any other weight control measures, and frequency of eating normal meals without vomiting.A history of exercise behavior, including type, frequency, and duration.A complete history of current alcohol and other drug use.Any suicidal thoughts or attempts.Sexual history, including sexual preference and activity. Sexual interest currently as compared to prior to the eating disorder is needed.History of experiencing physical or sexual (incest or rape) abuse.History of other counseling experiences.Appropriate psychological assessment, including psychological orientation to the above questions.A medical history, including a physical examination, covering the information listed in subparagraph (4) below.Appropriate laboratory screening tests based on findings of the history and physical examination and tests for communicable diseases when indicated.The patient’s social support networks, including family and peer relationships.The patient’s educational level, vocational status, and job or school performance history, as appropriate.The patient’s leisure, recreational, or vocational interests and hobbies.The patient’s ability to participate with peers and programs and social activities.Interview of family members and significant others as available with the patient’s written or verbal permission as appropriate.Legal problems, if applicable.  (4)  Admission criteria. In order to be accepted for treatment, the patient shall meet the diagnostic criteria for anorexia nervosa or bulimia nervosa as established by the current version of the DSM (Diagnostic and Statistical Manual of Mental Disorders) published by the American Psychiatric Association.In addition to the diagnostic criteria, the need for treatment will be determined by a demonstrable loss of control of eating behaviors and the failure of the patient in recent attempts at voluntary self-control of the problem. Demonstrable impairment, dysfunction, disruption or harm of physical health, emotional health (e.g., significant depression withdrawal, isolation, suicidal ideas), vocational or educational functioning, or interpersonal functioning (e.g., loss of relationships, legal difficulties) shall have occurred.The need for treatment may be further substantiated by substance abuse, out-of-control spending, incidence of stealing to support habit, or compulsive gambling.The symptoms shall have been present for at least six months and three of the following criteria must be present:Medical criteria including endocrine and metabolic factors (e.g., amenorrhea, menstrual irregularities, decreased reflexes, cold intolerance, hypercarotenemia, parotid gland enlargement, lower respiration rate, hair loss, abnormal cholesterol or triglyceride levels).Other cardiovascular factors including hypotension, hypertension, arrhythmia, ipecac poisoning, fainting, or bradycardia.Renal considerations including diuretic abuse, dehydration, elevated BUN, renal calculi, edema, or hypokalemia.Gastrointestinal factors including sore throats, mallery-weiss tears, decreased gastric emptying, constipation, abnormal liver enzymes, rectal bleeding, laxative abuse, or esophagitis.Hematologic considerations including anemia, leukopenia, or thrombocytopenia.Ear, nose, and throat factors including headaches or dizziness.Skin considerations including lanugo or dry skin.Aspiration pneumonia, a pulmonary factor.The presence of severe symptoms and complications as evaluated and documented by the medical director may require a period of hospitalization to establish physical or emotional stability.  (5)  Plan of treatment. For each patient there is a written comprehensive and individualized description of treatment to be undertaken. The treatment plan is based on problems and needs identified in the assessment and specifies the regular times at which the plan will be reassessed.The patient’s perceptions of needs and, when appropriate and available, the family’s perceptions of the patient’s needs shall be documented.The patient’s participation in the development of the treatment plans is sought and documented.Each patient is reassessed to determine current clinical problems, needs, and responses to treatment. Changes in treatment are documented.  (6)  Discharge plan. Plans for discharge shall meet the requirements for discharge plans for alcohol and substance abuse patients in subrule 78.31(3), paragraph “a,” subparagraph (6).  (7)  Restriction and limitations on payment. Medicaid will pay for a maximum of 30 days of a structured outpatient treatment program. Payment beyond 30 days is made when documentation indicates that the patient has not reached an exit level.Eating disorder programs will include an aftercare component meeting weekly for at least one year without charge.Family counseling groups held in conjunction with the eating disorders program will be part of the overall treatment charge.  c.  Cardiac rehabilitation.  (1)  General characteristics. Cardiac rehabilitation programs shall provide a supportive educational environment in which to facilitate behavior change with respect to the accepted cardiac risk factors, initiate prescribed exercise as a mode of facilitating the return of the patient to everyday activities by improving cardiovascular functional capacity and work performance, and promote a long-term commitment to lifestyle changes that could positively affect the course of the cardiovascular disease process.  (2)  Treatment staff. Professional disciplines who must be represented on the treatment staff, either by employment by the facility (full-time or part-time), contract or referral, are as follows:At least one physician responsible for responding to emergencies must be physically present in the hospital when patients are receiving cardiac rehabilitation services. The physician must be trained and certified at least to the level of basic life support.A medical consultant shall oversee the policies and procedures of the outpatient cardiac rehabilitation area. The director shall meet with the cardiac rehabilitation staff on a regular basis to review exercise prescriptions and any concerns of the team.A cardiac rehabilitation nurse shall carry out the exercise prescription after assessment of the patient. The nurse shall be able to interpret cardiac disrhythmia and be able to initiate emergency action if necessary. The nurse shall assess and implement a plan of care for cardiac risk factor modification. The nurse shall have at least one year of experience in a coronary care unit.A physical therapist shall offer expertise in unusual exercise prescriptions where a patient has an unusual exercise problem.A dietitian shall assess the dietary needs of persons and appropriately instruct them on their prescribed diets.A social worker shall provide counseling as appropriate and facilitate a spouse support group. A licensed occupational therapist shall be available as necessary.  (3)  Admission criteria. Candidates for the program must be referred by the attending physician. The following conditions are eligible for the program:Postmyocardial infarction (within three months postdischarge).Postcardiac surgery (within three months postdischarge).Poststreptokinase.Postpercutaneous transluminal angioplasty (within three months postdischarge).Patient with severe angina being treated medically because of client or doctor preference or inoperable cardiac disease.  (4)  Physical environment and equipment. A cardiac rehabilitation unit must be an autonomous physical unit specifically equipped with the necessary telemetry monitoring equipment, exercise equipment, and appropriate equipment and supplies for cardiopulmonary resuscitation (CPR). The exercise equipment must have the capacity to measure the intensity, speed, and length of the exercises. The equipment must be periodically inspected and maintained in accordance with the hospital’s preventive maintenance program.  (5)  Medical records. Medical records for each cardiac rehabilitation patient shall consist of at least the following:Referral form.Physician’s orders.Laboratory reports.Electrocardiogram reports.History and physical examination.Angiogram report, if applicable.Operative report, if applicable.Preadmission interview.Exercise prescription.Rehabilitation plan, including participant’s goals.Documentation for exercise sessions and progress notes.Nurse’s progress reports.Discharge instructions.  (6)  Discharge plan. The patient will be discharged from the program when the physician, staff, and patient agree that the work level is functional for them and little benefit could be derived from further continuation of the program, disrhythmia disturbances are resolved, and appropriate cardiovascular response to exercise is accomplished.  (7)  Monitoring of services. The program should be monitored by the hospital on a periodic basis using measuring criteria for evaluating cardiac rehabilitation services provided.  (8)  Restrictions and limitations. Payment will be made for a maximum of three visits per week for a period of 12 weeks. Payment beyond 12 weeks is made when documentation indicates that the patient has not reached an exit level.  d.  Mental health.  (1)  General characteristics. To be covered, mental health services must be prescribed by a physician or certified health service provider in psychology, provided under an individualized treatment plan and reasonable and necessary for the diagnosis or treatment of the patient’s condition. This means the services must be for the purpose of diagnostic study or the services must reasonably be expected to improve the patient’s condition.  (2)  Individualized treatment plan. The individualized written plan of treatment shall be established by a physician or certified health service provider in psychology after any needed consultation with appropriate staff members. The plan must state the type, amount, frequency and duration of the services to be furnished and indicate the diagnoses and anticipated goals. (A plan is not required if only a few brief services will be furnished.)  (3)  Supervision and evaluation. Services must be supervised and periodically evaluated by a physician, certified health service provider in psychology, or both within the scopes of their respective practices if clinically indicated to determine the extent to which treatment goals are being realized. The evaluation must be based on periodic consultation and conference with therapists and staff. The physician or certified health service provider in psychology must also provide supervision and direction to any therapist involved in the patient’s treatment and see the patient periodically to evaluate the course of treatment and to determine the extent to which treatment goals are being realized and whether changes in direction or services are required.  (4)  Reasonable expectation of improvement. Services must be for the purpose of diagnostic study or reasonably be expected to improve the patient’s condition. The treatment must at a minimum be designed to reduce or control the patient’s psychiatric or psychological symptoms so as to prevent relapse or hospitalization and improve or maintain the patient’s level of functioning.It is not necessary that a course of therapy have as its goal restoration of the patient to the level of functioning exhibited prior to the onset of the illness although this may be appropriate for some patients. For many other patients, particularly those with long-term chronic conditions, control of symptoms and maintenance of a functional level to avoid further deterioration or hospitalization is an acceptable expectation of improvement. “Improvement” in this context is measured by comparing the effect of continuing versus discontinuing treatment. Where there is a reasonable expectation that if treatment services were withdrawn, the patient’s condition would deteriorate, relapse further, or require hospitalization, this criterion would be met.  (5)  Diagnostic and treatment staff. Each person who provides diagnostic or treatment services shall be determined to be competent to provide the services by reason of education, training, and experience. The number of the above staff employed by the facility must be appropriate to the facility’s patient load. The staff may be employees of the hospital, on contract, or the service may be provided through referral.The diagnostic and treatment staff shall consist of a physician, a psychologist, social workers or counselors meeting the requirements for “mental health professionals” as set forth in rule 441—33.1(225C,230A).  (6)  Initial assessment. A comprehensive assessment of the biological, psychological, social, and spiritual orientation of the patient must be conducted, which shall include:A history of the mental health problem, including age of onset, duration, patterns of symptoms, consequences of symptoms, and responses to previous treatment.A comprehensive clinical history, including the history of physical problems associated with the mental health problem. Appropriate referral for physical examination for determination of any communicable diseases.Any history of physical abuse.A systematic mental health examination, with special emphasis on any change in cognitive, social or emotional functioning.A determination of current and past psychiatric and psychological abnormality.A determination of any degree of danger to self or others.The family’s history of mental health problems.The patient’s educational level, vocational status, and job performance history.The patient’s social support network, including family and peer relationship.The patient’s perception of the patient’s strengths, problem areas, and dependencies.The patient’s leisure, recreational or vocational interests and hobbies.The patient’s ability to participate with peers in programs and social activities.Interview of family members and significant others, as available, with the patient’s written or verbal permission.Legal problems if applicable.  (7)  Covered services. Services covered for the treatment of psychiatric conditions are:
    1. Individual and group therapy with physicians, psychologists, social workers, counselors, or psychiatric nurses.
    2. Occupational therapy services if the services require the skills of a qualified occupational therapist and must be performed by or under the supervision of a licensed occupational therapist or by an occupational therapy assistant.
    3. Drugs and biologicals furnished to outpatients for therapeutic purposes only if they are of the type 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.
    4. 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.
    5. Family counseling services are covered only if the primary purpose of the counseling is the treatment of the patient’s condition.
    6. Partial hospitalization and day treatment services to reduce or control a person’s psychiatric or psychological symptoms so as to prevent relapse or hospitalization, improve or maintain the person’s level of functioning and minimize regression. These services include all psychiatric services needed by the patient during the day.Partial hospitalization services means an active treatment program that provides intensive and structured support that assists persons during periods of acute psychiatric or psychological distress or during transition periods, generally following acute inpatient hospitalization episodes.Service components may include individual and group therapy, reality orientation, stress management and medication management.Services are provided for a period for four to eight hours per day.Day treatment services means structured, long-term services designed to assist in restoring, maintaining or increasing levels of functioning, minimizing regression and preventing hospitalization.Service components include training in independent functioning skills necessary for self-care, emotional stability and psychosocial interactions, and training in medication management.Services are structured with an emphasis on program variation according to individual need.Services are provided for a period of three to five hours per day, three or four times per week.
    7. Partial hospitalization and day treatment for persons aged 20 or under. Payment to a hospital will be approved for day treatment services for persons aged 20 or under if the hospital is certified by the department for hospital outpatient mental health services. All conditions for the day treatment program for persons aged 20 or under as outlined in subrule 78.16(7) for community mental health centers shall apply to hospitals. All conditions of the day treatment program for persons aged 20 or under as outlined in subrule 78.16(7) for community mental health centers shall be applicable for the partial hospitalization program for persons aged 20 or under with the exception that the maximum hours shall be 25 hours per week.
      (8)  Restrictions and limitations on coverage. The following are generally not covered except as indicated:Activity therapies, group activities, or other services and programs which are primarily recreational or diversional in nature. Outpatient psychiatric day treatment programs that consist entirely of activity therapies are not covered.Geriatric day-care programs, which provide social and recreational activities to older persons who need some supervision during the day while other family members are away from home. These programs are not covered because they are not considered reasonable and necessary for a diagnosed psychiatric disorder.Vocational training. While occupational therapy may include vocational and prevocational assessment of training, when the services are related solely to specific employment opportunities, work skills, or work setting, they are not covered.  (9)  Frequency and duration of services. There are no specific limits on the length of time that services may be covered. There are many factors that affect the outcome of treatment. Among them are the nature of the illness, prior history, the goals of treatment, and the patient’s response. As long as the evidence shows that the patient continues to show improvement in accordance with the individualized treatment plan and the frequency of services is within acceptable norms of medical practice, coverage will be continued.  (10)  Documentation requirements. The provider shall develop and maintain sufficient written documentation to support each medical or remedial therapy, service, activity, or session for which billing is made. All outpatient mental health services shall include:
    1. The specific services rendered.
    2. The date and actual time the services were rendered.
    3. Who rendered the services.
    4. The setting in which the services were rendered.
    5. The amount of time it took to deliver the services.
    6. The relationship of the services to the treatment regimen described in the plan of care.
    7. Updates describing the patient’s progress.
    For services that are not specifically included in the patient’s treatment plan, a detailed explanation of how the services being billed relate to the treatment regimen and objectives contained in the patient’s plan of care and the reason for the departure from the plan shall be given.
      e.  Pain management.  (1)  Approval by commission on accreditation of rehabilitation facilities. In addition to certification by the department, pain management programs must also be approved by the commission on accreditation of rehabilitation facilities (CARF).  (2)  General characteristics. A chronic pain management program shall provide coordinated, goal-oriented, interdisciplinary team services to reduce pain, improve quality of life, and decrease dependence on the health care system for persons with pain which interferes with physical, psychosocial, and vocational functioning.  (3)  Treatment staff. Each person who provides treatment services shall be determined to be competent to provide the services by reason of education, training, and experience. Professional disciplines which must be represented on the treatment staff, either through employment by the facility (full-time or part-time), contract or referral, are a physician (M.D. or D.O.), a registered nurse, a licensed physical therapist and a licensed clinical psychologist or psychiatrist. The number of staff should be appropriate to the patient load of the facility.  (4)  Admission criteria. Candidates for the program shall meet the following guidelines:The person must have had adequate medical evaluation and treatment in the months preceding admission to the program including an orthopedic or neurological consultation if the problem is back pain or a neurological evaluation if the underlying problem is headaches.The person must be free of any underlying psychosis or severe neurosis.The person cannot be toxic on any addictive drugs.The person must be capable of self-care; including being able to get to meals and to perform activities of daily living.  (5)  Plan of treatment. For each patient there is a written comprehensive and individualized description of treatment to be undertaken. The treatment plan is based on the problems and needs identified in the assessment and specifies the times at which the plan will be reassessed.The patient’s perception of needs and, when appropriate and available, the family’s perception of the patient’s needs shall be documented.The patient’s participation in the development of the treatment plan is sought and documented.Each patient is reassessed to determine current clinical problems, needs, and responses to treatment. Changes in treatment are documented.  (6)  Discharge plan. For each patient before discharge, a plan for discharge is designed to provide appropriate continuity of care which meets the following requirements:The plan for continuing care must describe and facilitate the transfer of the patient and the responsibility for the patient’s continuing care to another phase or modality of the program, other programs, agencies, persons or to the patient and the patient’s personal support system.The plan is in accordance with the patient’s reassessed needs at the time of transfer.The plan is developed in collaboration with the patient and, as appropriate and available, with the patient’s written verbal permission with the family members.The plan is implemented in a manner acceptable to the patient and the need for confidentiality.Implementation of the plan includes timely and direct communication with and transfer of information to the other programs, agencies, or persons who will be providing continuing care.  (7)  Restrictions and limitations on payment. Medicaid will pay for a maximum of three weeks of a structured outpatient treatment program. When documentation indicates that the patient has not reached an exit level, coverage may be extended an extra week.A repeat of the entire program for any patient will be covered only if a different disease process is causing the pain or a significant change in life situation can be demonstrated.  f.  Diabetic education.  (1)  Certification by department of public health. In addition to certification by the department for Medicaid, diabetic education programs must also be certified by the department of public health. (See department of public health rules 641—Chapter 9.)  (2)  General characteristics. An outpatient diabetes self-management education program shall provide instruction which will enable people with diabetes and their families to understand the diabetes disease process and the daily management of diabetes. People with diabetes must learn to balance their special diet and exercise requirements with drug therapy (insulin or oral agents). They must learn self-care techniques such as monitoring their own blood glucose. And often, they must learn to self-treat insulin reactions, protect feet that are numb and have seriously compromised circulation, and accommodate their regimen to changes in blood glucose because of stress or infections.  (3)  Program staff. Each person who provides services shall be determined to be competent to provide the services by reason of education, training and experience. Professional disciplines which must be represented on the staff, either through employment by the facility (full-time or part-time), contract or referral, are a physician (M.D. or D.O.), a registered nurse, a registered dietitian and a licensed pharmacist. The number of staff should be appropriate to the patient load of the facility.  (4)  Admission criteria. Candidates for the program shall meet the following guidelines:The person must have Type I or Type II diabetes.The person must be referred by the attending physician.The person shall demonstrate an ability to follow through with self-management.  (5)  Health assessment. An individualized and documented assessment of needs shall be developed with the patient’s participation. Follow-up assessments, planning and identification of problems shall be provided.  (6)  Restrictions and limitations on payment. Medicaid will pay for a diabetic self-management education program. Diabetic education programs will include follow-up assessments at 3 and 12 months without charge. A complete diabetic education program is payable once in the lifetime of a recipient.  g.  Pulmonary rehabilitation.  (1)  General characteristics. Pulmonary rehabilitation is an individually tailored, multidisciplinary program through which accurate diagnosis, therapy, emotional support, and education stabilizes or reverses both the physio- and psychopathology of pulmonary diseases and attempts to return the patient to the highest possible functional capacity allowed by the pulmonary handicap and overall life situation.  (2)  Diagnostic and treatment staff. Each person who provides diagnostic or treatment services shall be determined to be competent to provide the services by reason of education, training, and experience.Professional disciplines which must be represented by the diagnostic and treatment staff, either through employment by the facility (full-time or part-time), contract, or referral, are a physician (doctor of medicine or osteopathy), a respiratory therapist, a licensed physical therapist, and a registered nurse.  (3)  Initial assessment. A comprehensive assessment must occur initially, including:A diagnostic workup which entails proper identification of the patient’s specific respiratory ailment, appropriate pulmonary function studies, a chest radiograph, an electrocardiogram and, when indicated, arterial blood gas measurements at rest and during exercise, sputum analysis and blood theophylline measurements.Behavioral considerations include emotional screening assessments and treatment or counseling when required, estimating the patient’s learning skills and adjusting the program to the patient’s ability, assessing family and social support, potential employment skills, employment opportunities, and community resources.  (4)  Admission criteria. Criteria include a patient’s being diagnosed and symptomatic of chronic obstructive pulmonary disease (COPD), having cardiac stability, social, family, and financial resources, ability to tolerate periods of sitting time; and being a nonsmoker for six months, or if a smoker, willingness to quit and a physician’s order to participate anyway.Factors which would make a person ineligible include acute or chronic illness that may interfere with rehabilitation, any illness or disease state that affects comprehension or retention of information, a strong history of medical noncompliance, unstable cardiac or cardiovascular problems, and orthopedic difficulties that would prohibit exercise.  (5)  Plan of treatment. Individualized long- and short-term goals will be developed for each patient. The treatment goals will be based on the problems and needs identified in the assessment and specify the regular times at which the plan will be reassessed.The patients and their families need to help determine and fully understand the goals, so that they realistically approach the treatment phase.Patients are reassessed to determine current clinical problems, needs, and responses to treatment. Changes in treatment are documented.Components of pulmonary rehabilitation to be included are physical therapy and relaxation techniques, exercise conditioning or physical conditioning for those with exercise limitations, respiratory therapy, education, an emphasis on the importance of smoking cessation, and nutritional information.  (6)  Discharge plan. Ongoing care will generally be the responsibility of the primary care physician. Periodic reassessment will be conducted to evaluate progress and allow for educational reinforcement.  (7)  Restrictions and limitations on payment. Medicaid will pay for a maximum of 25 treatment days. Payment beyond 25 days is made when documentation indicates that the patient has not reached an exit level.  h.  Nutritional counseling. Payment will be made for persons aged 20 and under for nutritional counseling provided by a licensed dietitian employed by or under contract with a hospital for a nutritional problem or condition of a degree of severity that nutritional counseling beyond that normally expected as part of the standard medical management is warranted. For persons eligible for the WIC program, a WIC referral is required. Medical necessity for nutritional counseling services exceeding those available through WIC shall be documented.
      78.31(5)    Services rendered by advanced registered nurse practitioners certified in family, pediatric, or psychiatric mental health specialties and employed by a hospital.  Rescinded IAB 10/15/03, effective 12/1/03.This rule is intended to implement Iowa Code section 249A.4.
    Related ARC(s): 0065C, 2164C, 2361C441—78.32(249A)  Area education agencies.  Payment will be made for physical therapy, occupational therapy, psychological evaluations and counseling, psychotherapy, speech-language therapy, and audiological, nursing, and vision services provided by an area education agency (AEA). Services shall be provided directly by the AEA or through contractual arrangement with the AEA.This rule is intended to implement Iowa Code section 249A.4.441—78.33(249A)  Case management services.  Payment will be approved for targeted case management services that are provided pursuant to 441—Chapter 90 to:
    1. 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).
    2. Members who are under 18 years of age and are receiving services under the HCBS intellectual disability waiver or children’s mental health waiver.
    This rule is intended to implement Iowa Code section 249A.4.
    Related ARC(s): 9403B, 9588B, 0848C, 1051C, 2361C441—78.34(249A)  HCBS health and disability waiver services.  Payment will be approved for the following services to members eligible for HCBS health and disability waiver services as established in 441—Chapter 83 and as identified in the member’s service plan. Effective March 17, 2022, payment shall only be made for services provided in integrated, community-based settings that support full access of members receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS.  78.34(1)    Homemaker services.  Homemaker services are those services provided when the member lives alone or when the person who usually performs these functions for the member needs assistance with performing the functions. A unit of service is 15 minutes. Components of the service must be directly related to the care of the member and may include only the following:  a.  Essential shopping: shopping for basic need items such as food, clothing or personal care items, or drugs.  b.  Limited housecleaning: maintenance cleaning such as vacuuming, dusting, scrubbing floors, defrosting refrigerators, cleaning stoves, cleaning medical equipment, washing and mending clothes, washing personal items used by the member, and washing dishes.  c.  Meal preparation: planning and preparing balanced meals.  78.34(2)    Home health services.  Home health services are personal or direct care services provided to the client which are not payable under Medicaid as set forth in rule 441—78.9(249A). A unit of service is a visit.  a.  Components of the service include, but are not limited to:  (1)  Observation and reporting of physical or emotional needs.  (2)  Helping a client with bath, shampoo, or oral hygiene.  (3)  Helping a client with toileting.  (4)  Helping a client in and out of bed and with ambulation.  (5)  Helping a client reestablish activities of daily living.  (6)  Assisting with oral medications ordered by the physician which are ordinarily self-administered.  (7)  Performing incidental household services which are essential to the client’s health care at home and are necessary to prevent or postpone institutionalization in order to complete a full unit of service.  (8)  Accompaniment to medical services or transport to and from school.  b.  In some cases, a nurse may provide home health services if the health of the client is such that the agency is unable to place an aide in that situation due to limitations by state law or in the event that the agency’s Medicare certification requirements prohibit the aide from providing the service. It is not permitted for the convenience of the provider.  c.  Skilled nursing care is not covered.  78.34(3)    Adult day care services.  Adult day care services provide an organized program of supportive care in a group environment to persons who need a degree of supervision and assistance on a regular or intermittent basis in a day care center. A unit of service is 15 minutes (up to four units per day), a half day (1.25 to 4 hours per day), a full day (4.25 to 8 hours per day), or an extended day (8.25 to 12 hours per day). Components of the service include health-related care, social services, and other related support services.  78.34(4)    Nursing care services.  Nursing care services are services which are included in the plan of treatment approved by the physician and which are provided by licensed nurses to consumers in the home and community. The services shall be reasonable and necessary to the treatment of an illness or injury and include all nursing tasks recognized by the Iowa board of nursing. A unit of service is a visit.  78.34(5)    Respite care services.  Respite care services are services provided to the member that give temporary relief to the usual caregiver and provide all the necessary care that the usual caregiver would provide during that period. The purpose of respite care is to enable the member to remain in the member’s current living situation.  a.  Services provided outside the member’s home shall not be reimbursable if the living unit where respite is provided is reserved for another person on a temporary leave of absence.  b.  Member-to-staff ratios shall be appropriate to the individual needs of the member as determined by the member’s interdisciplinary team.  c.  A unit of service is 15 minutes.  d.  Respite care is not to be provided to members during the hours in which the usual caregiver is employed except when the member is attending a 24-hour residential camp. Respite care shall not be used as a substitute for a child’s day care. Respite cannot be provided to a member whose usual caregiver is a consumer-directed attendant care provider for the member.  e.  The interdisciplinary team shall determine if the member will receive basic individual respite, specialized respite, or group respite as defined in 441—Chapter 83.  f.  A maximum of 14 consecutive days of 24-hour respite care may be reimbursed.  g.  Respite services provided for a period exceeding 24 consecutive hours to three or more individuals who require nursing care because of a mental or physical condition must be provided by a health care facility licensed as described in Iowa Code chapter 135C.  h.  Respite services shall not be provided simultaneously with other residential, nursing, or home health aide services provided through the medical assistance program.  78.34(6)    Counseling services.  Counseling services are face-to-face mental health services provided to the member and caregiver by a mental health professional as defined in rule 441—24.1(225C) to facilitate home management of the member and prevent institutionalization. Counseling services are nonpsychiatric services necessary for the management of depression, assistance with the grief process, alleviation of psychosocial isolation and support in coping with a disability or illness, including terminal illness. Counseling services may be provided both for the purpose of training the member’s family or other caregiver to provide care and for the purpose of helping the member and those caring for the member to adjust to the member’s disability or terminal condition. Counseling services may be provided to the member’s caregiver only when included in the case plan for the member.Payment will be made for individual and group counseling. A unit of individual counseling for the waiver member or the waiver member and the member’s caregiver is 15 minutes. A unit of group counseling is 15 minutes. Payment for group counseling is based on the group rate divided by six, or, if the number of persons who comprise the group exceeds six, the actual number of persons who comprise the group.  78.34(7)    Consumer-directed attendant care service.  Consumer-directed attendant care services are service activities performed by a person to help a member with self-care tasks which the member would typically do independently if the member were otherwise able. Covered service activities are limited to the nonskilled activities listed in paragraph 78.34(7)“f” and the skilled activities listed in paragraph 78.34(7)“g.” Covered service activities must be essential to the health, safety, and welfare of the member. Services may be provided in the absence of a parent or guardian if the parent or guardian has given advance direction for the service provision.  a.    Service planning.    (1)  The member, parent, guardian, or attorney in fact under a durable power of attorney for health care shall:
    1. Select the individual or agency that will provide the components of the attendant care services.
    2. 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.
    3. 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.
    4. 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.
      (2)  Whenever a legal representative acts as a provider of consumer-directed attendant care as allowed by 441—paragraph 79.9(7)“b,” the following shall apply:
    1. 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;
    2. The legal representative may not be paid for more than 40 hours of service per week; and
    3. 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.
      b.    Supervision of skilled services.  Skilled consumer-directed attendant care services shall be provided under the supervision of a licensed nurse or licensed therapist working under the direction of a physician. The licensed nurse or therapist shall:  (1)  Retain accountability for actions that are delegated.  (2)  Ensure appropriate assessment, planning, implementation, and evaluation.  (3)  Make on-site supervisory visits every two weeks with the service provider present.  c.    Service documentation.  The consumer-directed attendant care provider shall document evidence of compliance with the requirements of this chapter and rule 441—79.3(249A). The documentation or copies of the documentation must be maintained or be electronically accessible by the consumer-directed attendant care provider. Providers must use an electronic visit verification system that captures all documentation requirements of the Consumer-Directed Attendant Care (CDAC) Service Record (Form 470-4389) or use Form 470-4389. Any service component that is not documented in accordance with rule 441—79.3(249A) shall not be payable.  d.    Role of guardian or attorney.  If the member has a guardian or attorney in fact under a durable power of attorney for health care:  (1)  The service worker’s or case manager’s service plan shall address how consumer-directed attendant care services will be monitored to ensure that the member’s needs are being adequately met. If the guardian or attorney in fact is the service provider, the service plan shall address how the service worker or case manager shall oversee service provision.  (2)  The guardian or attorney in fact shall sign the claim form in place of the member, indicating that the service has been provided as presented on the claim.  e.    Service units and billing.  A unit of service is 15 minutes provided by an individual or agency. Each service shall be billed in whole units.  f.    Nonskilled services.  Covered nonskilled service activities are limited to help with the following activities:  (1)  Dressing.  (2)  Bathing, shampooing, hygiene, and grooming.  (3)  Access to and from bed or a wheelchair, transferring, ambulation, and mobility in general.  (4)  Toileting, including bowel, bladder, and catheter assistance (emptying the catheter bag, collecting a specimen, and cleaning the external area around the catheter).  (5)  Meal preparation, cooking, and assistance with feeding, not including the cost of meals themselves. Meal preparation and cooking shall be provided only in the member’s home.  (6)  Housekeeping, laundry, and shopping essential to the member’s health care at home.  (7)  Taking medications ordinarily self-administered, including those ordered by a physician or other qualified health care provider.  (8)  Minor wound care.  (9)  Going to or returning from a place of employment and job-related tasks while the member is on the job site. Transportation for the member and assistance with understanding or performing the essential job functions are not included in consumer-directed attendant care services.  (10)  Tasks, such as financial management and scheduling, that require cognitive or physical assistance.  (11)  Communication essential to the health and welfare of the member, through interpreting and reading services and use of assistive devices for communication.  (12)  Using transportation essential to the health and welfare of the member. The cost of the transportation is not included.  g.    Skilled services.  Covered skilled service activities are limited to help with the following activities:  (1)  Tube feedings of members unable to eat solid foods.  (2)  Intravenous therapy administered by a registered nurse.  (3)  Parenteral injections required more than once a week.  (4)  Catheterizations, continuing care of indwelling catheters with supervision of irrigations, and changing of Foley catheters when required.  (5)  Respiratory care including inhalation therapy and tracheotomy care or tracheotomy care and ventilator.  (6)  Care of decubiti and other ulcerated areas, noting and reporting to the nurse or therapist.  (7)  Rehabilitation services including, but not limited to, bowel and bladder training, range of motion exercises, ambulation training, restorative nursing services, respiratory care and breathing programs, reality orientation, reminiscing therapy, remotivation, behavior modification, and reteaching of the activities of daily living.  (8)  Colostomy care.  (9)  Care of uncontrolled medical conditions, such as brittle diabetes, and comfort care of terminal conditions.  (10)  Postsurgical nursing care.  (11)  Monitoring medications requiring close supervision because of fluctuating physical or psychological conditions, e.g., antihypertensives, digitalis preparations, mood-altering or psychotropic drugs, or narcotics.  (12)  Preparing and monitoring response to therapeutic diets.  (13)  Recording and reporting of changes in vital signs to the nurse or therapist.  h.    Excluded services and costs.  Services, activities, costs and time that are not covered as consumer-directed attendant care include the following (not an exclusive list):  (1)  Any activity related to supervising a member. Only direct services are billable.  (2)  Any activity that the member is able to perform.  (3)  Costs of food.  (4)  Costs for the supervision of skilled services by the nurse or therapist. The supervising nurse or therapist may be paid from private insurance, Medicare, or other third-party payment sources, or may be paid as another Medicaid service, including early and periodic screening, diagnosis and treatment services.  (5)  Exercise that does not require skilled services.  (6)  Parenting or child care for or on behalf of the member.  (7)  Reminders and cueing.  (8)  Services provided simultaneously with any other similar service regardless of funding source, including other waiver services and state supplementary assistance in-home health-related care services.  (9)  Transportation costs.  (10)  Wait times for any activity.
      78.34(8)    Interim medical monitoring and treatment services.  Interim medical monitoring and treatment (IMMT) services are monitoring and treatment of a medical nature for children or adults aged 18 to 20 whose medical needs make alternative care unavailable, inadequate, or insufficient. IMMT services are not intended to provide day care but to supplement available resources. Services must be ordered by a physician.  a.  Need for service. The member must be currently receiving home health agency services under rule 441—78.9(249A) and require medical assessment, medical monitoring, and regular medical intervention or intervention in a medical emergency during those services. The service worker or case manager must identify the need for IMMT services after evaluating the member’s living environment, family and natural supports, ability to perform activities of daily living, and health care needs. The services must be needed:  (1)  To allow the member’s usual caregivers to be employed,  (2)  During a search for employment by a usual caregiver,  (3)  To allow for academic or vocational training of a usual caregiver,  (4)  Due to the hospitalization of a usual caregiver for treatment for physical or mental illness, or  (5)  Due to the death of a usual caregiver.  b.  Service requirements. Interim medical monitoring and treatment services shall:  (1)  Provide experiences for each member’s social, emotional, intellectual, and physical development;  (2)  Include comprehensive developmental care and any special services for a member with special needs; and  (3)  Include medical assessment, medical monitoring, and medical intervention as needed on a regular or emergency basis. Medical intervention means the ability to assess the situation and contact the appropriate medical professional, not the direct application of medical care.  c.  Interim medical monitoring and treatment services may include supervision while the member is being transported to and from school.  d.  Limitations.  (1)  A maximum of 12 hours of service is available per day.  (2)  Covered services do not include a complete nutritional regimen.  (3)  Interim medical monitoring and treatment services may not duplicate any regular Medicaid or waiver services provided under the state plan. Services under the state plan, including home health agency services under rule 441—78.9(249A), must be exhausted before IMMT services are accessed.  (4)  Interim medical monitoring and treatment services shall be provided in the following settings that are approved by the department as integrated, community-based settings: the member’s home; a registered child development home; a licensed child care center, residential care facility, or adult day care facility; or during the time when the member is being transported to and from school.  (5)  The member-to-staff ratio shall not be more than six members to one staff person.  (6)  The parent or guardian of the member shall be responsible for the usual and customary nonmedical cost of day care during the time in which the member is receiving IMMT services. Medical care necessary for monitoring and treatment is an allowable IMMT cost. If the cost of care goes above the usual and customary cost of day care services due to the member’s medical condition, the costs above the usual and customary cost shall be covered as IMMT services.  e.  A unit of service is 15 minutes.  78.34(9)    Home and vehicle modification.  Covered home or vehicle modifications are physical modifications to the member’s home or vehicle that directly address the member’s medical or remedial need. Covered modifications must be necessary to provide for the health, welfare, or safety of the member and enable the member to function with greater independence in the home or vehicle.  a.  Modifications that are necessary or desirable without regard to the member’s medical or remedial need and that would be expected to increase the fair market value of the home or vehicle, such as furnaces, fencing, or adding square footage to the residence, are excluded except as specifically included below. Purchasing or leasing of a motorized vehicle is excluded. Home and vehicle repairs are also excluded.  b.  Only the following modifications are covered:  (1)  Kitchen counters, sink space, cabinets, special adaptations to refrigerators, stoves, and ovens.  (2)  Bathtubs and toilets to accommodate transfer, special handles and hoses for shower heads, water faucet controls, and accessible showers and sink areas.  (3)  Grab bars and handrails.  (4)  Turnaround space adaptations.  (5)  Ramps, lifts, and door, hall and window widening.  (6)  Fire safety alarm equipment specific for disability.  (7)  Voice-activated, sound-activated, light-activated, motion-activated, and electronic devices directly related to the member’s disability.  (8)  Vehicle lifts, driver-specific adaptations, remote-start systems, including such modifications already installed in a vehicle.  (9)  Keyless entry systems.  (10)  Automatic opening device for home or vehicle door.  (11)  Special door and window locks.  (12)  Specialized doorknobs and handles.  (13)  Plexiglas replacement for glass windows.  (14)  Modification of existing stairs to widen, lower, raise or enclose open stairs.  (15)  Motion detectors.  (16)  Low-pile carpeting or slip-resistant flooring.  (17)  Telecommunications device for the deaf.  (18)  Exterior hard-surface pathways.  (19)  New door opening.  (20)  Pocket doors.  (21)  Installation or relocation of controls, outlets, switches.  (22)  Air conditioning and air filtering if medically necessary.  (23)  Heightening of existing garage door opening to accommodate modified van.  (24)  Bath chairs.  c.  A unit of service is the completion of needed modifications or adaptations.  d.  All modifications and adaptations shall be provided in accordance with applicable federal, state, and local building and vehicle codes.  e.  Services shall be performed following prior department approval of the modification as specified in 441—subrule 79.1(17) and a binding contract between the provider and the member.  f.  All contracts for home or vehicle modification shall be awarded through competitive bidding. The contract shall include the scope of work to be performed, the time involved, supplies needed, the cost, diagrams of the project whenever applicable, and an assurance that the provider has liability and workers’ compensation coverage and the applicable permit and license.  g.  Service payment shall be made to the enrolled home or vehicle modification provider. If applicable, payment will be forwarded to the subcontracting agency by the enrolled home or vehicle modification provider following completion of the approved modifications. Payment of up to $6,366.64 per year may be made to certified providers upon satisfactory completion of the service.  h.  Services shall be included in the member’s service plan and shall exceed the Medicaid state plan services.  78.34(10)    Personal emergency response or portable locator system.    a.  A personal emergency response system is an electronic device that transmits a signal to a central monitoring station to summon assistance in the event of an emergency.  (1)  The required components of the system are:
    1. An in-home medical communications transceiver.
    2. A remote, portable activator.
    3. A central monitoring station with backup systems staffed by trained attendants at all times.
    4. Current data files at the central monitoring station containing response protocols and personal, medical, and emergency information for each member.
      (2)  The service shall be identified in the member’s service plan.  (3)  A unit of service is a one-time installation fee or one month of service.  (4)  Maximum units per state fiscal year shall be the initial installation and 12 months of service.
      b.  A portable locator system is an electronic device that transmits a signal to a monitoring device. The system allows a member to access assistance in the event of an emergency and allows law enforcement or the monitoring system provider to locate a member who is unable to request help or to activate a system independently. The member must be unable to access assistance in an emergency situation due to the member’s age or disability.  (1)  The required components of the portable locator system are:
    1. A portable communications transceiver or transmitter to be worn or carried by the member.
    2. Monitoring by the provider at a central location with response protocols and personal, medical, and emergency information for each member as applicable.
      (2)  The service shall be identified in the member’s service plan.  (3)  Payable units of service are purchase of equipment, an installation or set-up fee, and monthly fees.  (4)  Maximum units per state fiscal year shall be one equipment purchase, one installation or set-up fee, and 12 months of service.
      78.34(11)    Home-delivered meals.  Home-delivered meals are meals prepared elsewhere and delivered to a member at the member’s residence.  a.  Each meal shall ensure the member receives a minimum of one-third of the daily recommended dietary allowance as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences. The meal may also be a liquid supplement that meets the minimum one-third standard.  b.  When a restaurant provides the home-delivered meal, the member is required to have a nutritional consultation. The nutritional consultation includes contact with the restaurant to explain the dietary needs of the member and what constitutes the minimum one-third daily dietary allowance.  c.  A unit of service is a meal (morning, noon, evening, or liquid supplement). Any maximum combination of any two meals (morning, noon, evening, or liquid supplement) is allowed per day. Duplication of a meal in any one day is not allowed. The number of approved meals (morning, noon, evening, or liquid supplement) is contained in the member’s service plan.  d.  The number of meals delivered for any morning, noon, evening, or liquid supplement meal cannot exceed the number of calendar days in a calendar month; nor can the number of delivered meals exceed the number of authorized days in a month. Meals billed in excess of the calendar days in a calendar month and those billed in excess of the number of authorized days in a month are subject to recoupment or denial of payment.  78.34(12)    Nutritional counseling.  Nutritional counseling services may be provided for a nutritional problem or condition of such a degree of severity that nutritional counseling beyond that normally expected as part of the standard medical management is warranted. A unit of service is 15 minutes.  78.34(13)    Consumer choices option.  The consumer choices option (CCO) provides a member with a flexible monthly individual budget that is based on the member’s service needs. With the individual budget, the member shall have the authority to purchase goods and services to meet the member’s assessed needs and may choose to employ providers of services and supports. The services, supports, and items that are purchased with an individual budget must be directly related to a member’s assessed need or goal established in the member’s service plan. The consumer choices option is available to any member receiving the AIDS/HIV, brain injury, elderly, health and disability, intellectual disability, or physical disability waiver programs who has the ability and desire to perform all budget authority tasks identified in paragraph 78.34(13)“g” and employer authority tasks identified in paragraph 78.34(13)“h,” or who delegates the budget or employer authority tasks identified in paragraph 78.34(13)“i.” Components of this service are set forth below.  a.    Agreement.  As a condition of participating in the consumer choices option, a member shall sign Form 470-4289, HCBS Consumer Choices Informed Consent and Risk Agreement, to document that the member has been informed of the responsibilities and risks of electing the consumer choices option.  b.    Individual budget amount.  A monthly individual budget amount shall be established for each member based on the assessed needs of the member and based on the services and supports authorized in the member’s service plan. The member shall be informed of the individual budget amount during the development of the service plan.  (1)  Services that may be included in determining the individual budget amount for a member in the HCBS health and disability waiver are:
    1. Consumer-directed attendant care (unskilled).
    2. Home and vehicle modification.
    3. Home-delivered meals.
    4. Homemaker service.
    5. Basic individual respite care.
      (2)  Services that may be included in determining the individual budget amount for a member in the HCBS elderly waiver are:  1.  Assistive devices.  2.  Chore service.  3.  Consumer-directed attendant care (unskilled).  4.  Home and vehicle modification.  5.  Home-delivered meals.  6.  Homemaker service.  7.  Basic individual respite care.  8.  Senior companion.  9.  Transportation.  (3)  Services that may be included in determining the individual budget amount for a member in the HCBS AIDS/HIV waiver are:  1.  Consumer-directed attendant care (unskilled).  2.  Home-delivered meals.  3.  Homemaker service.  4.  Basic individual respite care.  (4)  Services that may be included in determining the individual budget amount for a member in the HCBS intellectual disability waiver are:  1.  Consumer-directed attendant care (unskilled).  2.  Day habilitation.  3.  Home and vehicle modification.  4.  Prevocational services.  5.  Basic individual respite care.  6.  Supported community living.  7.  Supported employment.  8.  Transportation.  (5)  Services that may be included in determining the individual budget amount for a member in the HCBS brain injury waiver are:  1.  Consumer-directed attendant care (unskilled).  2.  Home and vehicle modification.  3.  Prevocational services.  4.  Basic individual respite care.  5.  Specialized medical equipment.  6.  Supported community living.  7.  Supported employment.  8.  Transportation.  (6)  Services that may be included in determining the individual budget amount for a member in the HCBS physical disability waiver are:  1.  Consumer-directed attendant care (unskilled).  2.  Home and vehicle modification.  3.  Specialized medical equipment.  4.  Transportation.  (7)  The department shall determine an average unit cost for each service listed in subparagraphs 78.34(13)“b”(1) to (6) based on actual unit costs from the previous fiscal year plus a cost-of-living adjustment.  (8)  In aggregate, costs for individual budget services shall not exceed the current costs of waiver program services. In order to maintain cost neutrality, the department shall apply a utilization adjustment factor to the amount of service authorized in the member’s service plan before calculating the value of that service to be included in the individual budget amount.  (9)  The department shall compute the utilization adjustment factor for each service by dividing the net costs of all claims paid for the service by the total of the authorized costs for that service, using at least 12 consecutive months of aggregate service data. The utilization adjustment factor shall be no lower than 60 percent.   (10)  Individual budgets for respite services shall be computed based on the average cost for services identified in subparagraph 78.34(13)“b”(7). Respite services are not subject to the utilization adjustment factor in subparagraph 78.34(13)“b”(8).  (11)  Anticipated costs for home and vehicle modification, assistive devices, and specialized medical equipment are not subject to the average cost in subparagraph 78.34(13)“b”(7) or the utilization adjustment factor in subparagraph 78.34(13)“b”(8). The anticipated costs may include the costs of the financial management services and the independent support broker when the home and vehicle modification, assistive device, or specialized medical equipment is the only service included in the CCO monthly budget and the total cost for the home and vehicle modification, assistive device, or specialized medical equipment, including the cost of the financial management services and the independent support broker, is approved by the Iowa Medicaid enterprise or managed care organization as the least costly option to meet the member’s need. Costs for the home and vehicle modification, assistive device, or specialized medical equipment may be paid to the financial management services provider in a one-time payment. Before becoming part of the CCO monthly budget, all home and vehicle modifications, assistive device, and specialized medical equipment shall be identified in the member’s service plan and authorized by the case manager or community-based case manager.  (12)  The individual budget amount may be changed only at the first of the month and shall remain fixed for the entire month.
      c.    Required service components.  To participate in the consumer choices option, a member must hire an independent support broker and must work with a financial management service that is enrolled as a Medicaid provider. Before hiring the independent support broker, the member shall receive the results of the background check conducted pursuant to 441—Chapter 119.  d.    Optional service components.  A member who elects the consumer choices option may purchase the following goods, services and supports, which shall be provided in the member’s home or at an integrated community setting:  (1)  Self-directed personal care services. Self-directed personal care services are services that provide a range of assistance in activities of daily living and incidental activities of daily living that help the member remain in the home and community. These services must be identified in the member’s service plan developed by the member’s case manager or community-based case manager.  (2)  Self-directed community supports and employment. Self-directed community supports and employment are services that support the member in developing and maintaining independence and community integration. These services must be identified in the member’s service plan developed by the member’s case manager or community-based case manager.  (3)  Individual-directed goods and services. Individual-directed goods and services are services, equipment, or supplies not otherwise provided through the Medicaid program that address an assessed need or goal identified in the member’s service plan. The item or service shall meet the following requirements:
    1. Promote opportunities for community living and inclusion.
    2. Increase independence or substitute for human assistance, to the extent the expenditures would otherwise be made for that human assistance.
    3. Be accommodated within the member’s budget without compromising the member’s health and safety.
    4. Be provided to the member or directed exclusively toward the benefit of the member.
    5. Be the least costly to meet the member’s needs.
    6. Not be available through another source.
      e.    Development of the individual budget.  The independent support broker shall assist the member in developing and implementing the member’s individual budget. The individual budget shall include:  (1)  The costs of the financial management service.  (2)  The costs of the independent support broker. The independent support broker may be compensated for up to 6 hours of service for assisting with the implementation of the initial individual budget. The independent support broker shall not be paid for more than 30 hours of service for an individual member during a 12-month period without prior approval by the department.  (3)  The costs of any optional service component chosen by the member as described in paragraph 78.34(13)“d.” At a minimum, the CCO monthly budget must include the purchase of self-directed personal care, individual-directed goods and services, or self-directed community supports and services needed to meet the amount of service authorized for use in CCO identified in the member’s service plan. After funds have been budgeted to meet the identified needs, remaining funds from the monthly budget amount may be used to purchase additional self-directed personal care, individual-directed goods and services, or self-directed community supports and services as allowed by the monthly budget. The additional self-directed personal care, individual-directed goods and services, or self-directed community supports and services may exceed the amount of service or supports authorized in the member’s service plan. Costs of the following items and services shall not be covered by the individual budget:
    1. Child care services.
    2. Clothing not related to an assessed medical need.
    3. Conference, meeting or similar venue expenses other than the costs of approved services the member needs while attending the conference, meeting or similar venue.
    4. Costs associated with shipping items to the member.
    5. Experimental and non-FDA-approved medications, therapies, or treatments.
    6. Goods or services covered by other Medicaid programs.
    7. Home furnishings.
    8. Home repairs or home maintenance.
    9. Homeopathic treatments.
    10. Insurance premiums or copayments.
    11. Items purchased on installment payments.
    12. Motorized vehicles.
    13. Nutritional supplements.
    14. Personal entertainment items.
    15. Repairs and maintenance of motor vehicles.
    16. Room and board, including rent or mortgage payments.
    17. School tuition.
    18. Service animals.
    19. Services covered by third parties or services that are the responsibility of a non-Medicaid program.
    20. Sheltered workshop services.
    21. Social or recreational purchases not related to an assessed need or goal identified in the member’s service plan.
    22. Vacation expenses, other than the costs of approved services the member needs while on vacation.
    1. 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.
    2. Residential services provided to three or more members living in the same residential setting.
      (4)  The costs of any approved home or vehicle modification, assistive device, or specialized medical equipment. When authorized, the budget may include an amount allocated for a home or vehicle modification, an assistive device, or specialized medical equipment. Before becoming part of the individual budget, all home and vehicle modifications, assistive devices, and specialized medical equipment shall be identified in the member’s service plan and approved by the case manager or community-based case manager. The authorized amount shall not be used for anything other than the specific modification, assistive device, or specialized medical equipment, as identified in subparagraph 78.34(13)“b”(11).  (5)  Any amount set aside in a savings plan to reserve funds for the future purchase of self-directed personal care, individual-directed goods and services, or self-directed community supports and services as defined in paragraph 78.34(13)“d.” The savings plan shall meet the requirements in paragraph 78.34(13)“f.”
      f.    Savings plan.  A member savings plan must be in writing and be approved before the start of the savings plan by the department for fee-for-service members or by the member’s managed care organization for members in managed care. Budget amounts allocated to the savings plan must result from efficiencies in meeting the member’s service needs identified in the member’s service plan.  (1)  The savings plan shall identify:
    1. The specific goods, services, supports or supplies to be purchased through the savings plan.
    2. The amount of the individual budget allocated each month to the savings plan.
    3. The amount of the individual budget allocated each month to meet the member’s identified service needs.
    4. How the member’s assessed needs will continue to be met through the individual budget when funds are placed in savings.
    1. Specific time spans for accumulating the savings allocation, not to exceed the member’s current service plan year end date.
      (2)  With the exception of funds allocated for respite care, the savings plan shall not include funds budgeted for direct services or supports that were not received. Funds from unused respite services may be allocated to the savings plan but shall not be used for anything other than future respite care.  (3)  Funds allocated to a savings plan may be used to purchase additional self-directed personal care, individual-directed goods and services, or self-directed community supports and services. The additional self-directed personal care, individual-directed goods and services, or self-directed community supports and services included in the monthly budget may exceed the amount of service or supports authorized in the member’s service plan. The self-directed personal care, individual-directed goods and services, or self-directed community supports and services purchased with funds from a savings plan must:
    1. Be used to meet a member’s identified need,
    2. Be medically necessary, and
    3. Be approved by the member’s case manager or community-based case manager.
      (4)  All funds allocated to a savings plan to purchase additional self-directed personal care, individual-directed goods and services, or self-directed community supports and services must be used during the member’s waiver year in which the saving occurred.  (5)  The annual reassessment of a member’s needs must take into account the purchases of goods and services that substitute for human assistance. Adjustments shall be made to the services used to determine the individual budget based on the reassessment.
      g.    Budget authority.  The member shall have authority over the individual budget authorized by the department or managed care organization to perform the following tasks:  (1)  Contract with entities to provide services and supports as described in this subrule.  (2)  Determine the amount to be paid for services. Reimbursement rates for employees shall be consistent with employee reimbursement rates or the prevailing wages paid by others in the community for the same or substantially similar services. Reimbursement rates for the independent support broker and the financial management service are subject to the limits in 441—subrule 79.1(2).   (3)  Schedule the provision of services. A contingency plan must be established in the member’s service plan to ensure service delivery in the event the member’s employee is unable to provide services due to illness or other unexpected event.  (4)  Authorize payment for optional service components identified in the individual budget. When the member’s guardian or legal representative is a paid employee, payment authorization for optional service components must be delegated to a representative pursuant to paragraph 78.34(13)“i.”  (5)  Reallocate funds among services included in the budget. Every purchase of a good or service must be identified and approved in the individual budget before the purchase is made.  h.    Employer authority.  The member shall have the authority to be the common-law employer of employees providing services and support under the CCO. A common-law employer has the right to direct and control the performance of the services. If the member is a child, the parent or the legal representative shall be responsible for completing all employer authority tasks. Adult members who do not have the ability to complete all employer authority tasks shall have a representative delegated to complete the employer authority tasks identified in this paragraph. Documentation of the person responsible for the employer authority tasks, whether the member or another entity, shall be included in the member’s service plan. The member or the delegated employer authority may perform the following functions:  (1)  Recruit and hire employees.  (2)  Verify employee qualifications.  (3)  Specify additional employee qualifications.  (4)  Determine employee duties.  (5)  Determine employee wages and benefits.  (6)  Schedule employees.  (7)  Train and supervise employees.   i.    Delegation of budget and employer authority.   The member may delegate responsibilities for the individual budget or employer authority functions to a representative. If the member is a child, the parent or the legal representative shall be delegated all budget and employer authority tasks. Adult members aged 18 and older who do not have the ability to complete all budget or employer authority tasks shall have a representative delegated to complete the applicable budget authority tasks identified in paragraph 78.34(13)“g” and employer authority tasks identified in paragraph 78.34(13)“h.” Documentation of the person responsible for the budget and employer authority tasks, whether the member or a representative, shall be included in the member’s service plan.   (1)  The representative must be at least 18 years old.  (2)  The representative shall not be a current provider of service to the member.  (3)  The member shall sign a consent form that designates who the member has chosen as a representative and the responsibilities of the representative.  (4)  The representative shall not be paid for this service.  j.    Employment agreement.  Any person employed by the member to provide services under the consumer choices option shall sign an employment agreement with the member that outlines the employee’s and member’s responsibilities.  k.    Responsibilities of the independent support broker.  The independent support broker shall perform the following services as directed by the member or the member’s representative:  (1)  Assist the member with developing the member’s initial and subsequent individual budgets and with making any changes to the individual budget.  (2)  Have monthly contact with the member for the first four months of implementation of the initial individual budget and have, at a minimum, quarterly contact thereafter.  (3)  Complete the required employment packet with the financial management service.  (4)  Assist with interviewing potential employees and entities providing services and supports if requested by the member.  (5)  Assist the member with determining whether a potential employee meets the qualifications necessary to perform the job.  (6)  Assist the member with obtaining a signed consent from a potential employee to conduct background checks if requested by the member.  (7)  Assist the member with negotiating with entities providing services and supports if requested by the member.  (8)  Assist the member with contracts and payment methods for services and supports if requested by the member.  (9)  Assist the member with developing an emergency backup plan. The emergency backup plan shall address any health and safety concerns.  (10)  Review expenditure reports from the financial management service to ensure that services and supports in the individual budget are being provided.  (11)  Document in writing on the independent support broker timecard every contact the broker has with the member. Contact documentation shall include information on the extent to which the member’s individual budget has addressed the member’s needs and the satisfaction of the member.  l.    Responsibilities of the financial management service.  The financial management service shall perform all of the following services:  (1)  Receive Medicaid funds in an electronic transfer.  (2)  Process and pay invoices for approved goods and services included in the individual budget.  (3)  Monitor and track the approved individual budget amount authorized each month and document all expenditures as they are paid.  (4)  Provide real-time individual budget account balances for the member, the independent support broker, and the department, available at a minimum during normal business hours (9 a.m.to 5 p.m., Monday through Friday).  (5)  Conduct criminal background checks on potential employees pursuant to 441—Chapter 119.  (6)  Verify for the member an employee’s citizenship or alien status.  (7)  Assist the member with fiscal and payroll-related responsibilities including, but not limited to:
    1. Verifying that hourly wages comply with federal and state labor rules.
    2. Collecting and processing timecards.
    3. 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.
    4. Computing and processing other withholdings, as applicable.
    5. Processing all judgments, garnishments, tax levies, or other withholding on an employee’s pay as may be required by federal, state, or local laws.
    6. Preparing and issuing employee payroll checks.
    7. Preparing and disbursing IRS Forms W-2 and W-3 annually.
    8. Processing federal advance earned income tax credit for eligible employees.
    9. Refunding over-collected FICA, when appropriate.
    10. Refunding over-collected FUTA, when appropriate.
      (8)  Assist the member in completing required federal, state, and local tax and insurance forms.  (9)  Establish and manage documents and files for the member and the member’s employees.  (10)  Monitor timecards, receipts, and invoices to ensure that they are consistent with the individual budget. Keep records of all timecards and invoices for each member for a total of five years.  (11)  Provide to the department, the independent support broker, and the member monthly and quarterly status reports that include a summary of expenditures paid and amount of budget unused.  (12)  Establish an accessible customer service system and a method of communication for the member and the independent support broker that includes alternative communication formats.  (13)  Establish a customer services complaint reporting system.  (14)  Develop a policy and procedures manual that is current with state and federal regulations and update as necessary.  (15)  Develop a business continuity plan in the case of emergencies and natural disasters.  (16)  Provide to the department an annual independent audit of the financial management service.  (17)  Assist in implementing the state’s quality management strategy related to the financial management service.  (18)  The department may request that the financial management service provider withhold payment to any member or member’s employee to offset any overpayment or enforce any sanction placed on the service provider pursuant to rule 441—79.3(249A).
      m.    Responsibilities of the member and the employee.  A member participating in the CCO and the member’s employee(s) are responsible for the following:  (1)  A member participating in the CCO shall be jointly and severally liable with any of the member’s employees for any overpayment of medical assistance funds used through a CCO budget.  (2)  A member may not employ any person who has been sanctioned, or who is affiliated with a person or an entity that has been sanctioned, under 441—Chapter 79. For purposes of this subparagraph, “sanction” also includes anyone who has been temporarily suspended for a credible allegation of fraud under 42 CFR Part 455. Any CCO funds paid to any employee who or which has been sanctioned is an overpayment that the department shall recoup under 441—Chapter 79.  (3)  A member may not employ any person who has been excluded by the Office of the Inspector General of the Department of Health and Human Services under Sections 1128 or 1156 of the Social Security Act and is not eligible to receive federal funds.  (4)  For personal care services, employees shall use an electronic visit verification system that captures all documentation requirements of the Consumer Choices Option Semi-Monthly Time Sheet (Form 470-4429) or use Form 470-4429. All other employees shall complete, sign and date Form 470-4429, Consumer Choices Option Semi-Monthly Time Sheet, for each date of service provided to a member. All employees shall maintain documentation that complies with rule 441—79.3(249A).  (5)  Members shall sign, and certify under penalty of perjury, each employee timecard identified in subparagraph 78.34(13)“m”(4) prior to the timecard’s submission to the financial management service provider for payment in order to verify that all information on the submitted timecard accurately describes the amount, duration, and scope of services provided. When timecard information is submitted to the financial management service provider in an electronic format, the member shall retain the signed employee timecard for five years from the date of service.
      78.34(14)    General service standards.  All health and disability waiver services must be provided in accordance with the following standards:  a.  Reimbursement shall not be available under the waiver for any services that the member can obtain as other nonwaiver Medicaid services or through any other funding source.  b.  All services provided under the waiver must be delivered in the least restrictive environment possible and in conformity with the member’s service plan.  c.  All rights restrictions must be implemented in accordance with 441—subrule 77.25(4). The member service plan or treatment plan shall include documentation of:   (1)  Any restrictions on the member’s rights, including the rights of privacy, dignity, respect, and freedom from coercion and restraint.  (2)  The need for the restriction.  (3)  The less intrusive methods of meeting the need that have been tried but did not work.  (4)  Either a plan to restore those rights or written documentation that a plan is not necessary or appropriate.   (5)  Established time limits for periodic reviews to determine if the restriction is still necessary or can be terminated.  (6)  The informed consent of the member.  (7)  An assurance that the interventions and supports will cause no harm to the member.  (8)  A regular collection and review of data to measure the ongoing effectiveness of the restriction.  d.  Services must be billed in whole units.  e.  For all services with a 15-minute unit of service, the following rounding process will apply:  (1)  Add together the minutes spent on all billable activities during a calendar day for a daily total.  (2)  For each day, divide the total minutes spent on billable activities by 15 to determine the number of full 15-minute units for that day.  (3)  Round the remainder using these guidelines: Round 1 to 7 minutes down to zero units; round 8 to 14 minutes up to one unit.  (4)  Add together the number of full units and the number of rounded units to determine the total number of units to bill for that day.This rule is intended to implement Iowa Code section 249A.4.
    Related ARC(s): 9045B, 9403B, 9704B, 9884B, 0707C, 0709C, 0757C, 0842C, 1056C, 1610C, 2848C, 2936C, 3552C, 3874C, 4430C, 5305C, 5597C441—78.35(249A)  Occupational therapist services.  Payment will be approved for the same services provided by an occupational therapist that are payable under Title XVIII of the Social Security Act (Medicare).This rule is intended to implement Iowa Code section 249A.4.441—78.36(249A)  Hospice services.    78.36(1)    General characteristics.  A hospice is a public agency or private organization or a subdivision of either that is primarily engaged in providing care to terminally ill individuals. A hospice provides palliative and supportive services to meet the physical, psychosocial, social and spiritual needs of a terminally ill individual and the individual’s family or other persons caring for the individual regardless of where the individual resides. Hospice services are those services to control pain and provide support to individuals to continue life with as little disruption as possible.  a.  Covered services. Covered services shall include, in accordance with Medicare guidelines, the following:  (1)  Nursing care.  (2)  Medical social services.  (3)  Physician services.  (4)  Counseling services provided to the terminally ill individual and the individual’s family members or other persons caring for the individual at the individual’s place of residence, including bereavement, dietary, and spiritual counseling.  (5)  Short-term inpatient care provided in a participating hospice inpatient unit or a participating hospital or nursing facility that additionally meets the special hospice standards regarding staffing and patient areas for pain control, symptom management and respite purposes.  (6)  Medical appliances and supplies, including drugs and biologicals, as needed for the palliation and management of the individual’s terminal illness and related conditions, except for “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.  (7)  Homemaker and home health aide services.  (8)  Physical therapy, occupational therapy and speech-language pathology unless this provision has been waived under the Medicare program for a specific provider.  (9)  Other items or services specified in the resident’s plan that would otherwise be paid under the Medicaid program.Nursing care, medical social services, and counseling are core hospice services and must routinely be provided directly by hospice employees. The hospice may contract with other providers to provide the remaining services. Bereavement counseling, consisting of counseling services provided after the individual’s death to the individual’s family or other persons caring for the individual, is a required hospice service but is not reimbursable.  b.  Noncovered services.  (1)  Covered services not related to the terminal illness. In accordance with Medicare guidelines, all medical services related to the terminal illness are the responsibility of the hospice. Services unrelated to the terminal illness are to be billed separately by the respective provider.  (2)  Administrative duties performed by the medical director, any hospice-employed physician, or any consulting physician are included in the normal hospice rates. Patient care provided by the medical director, hospice-employed physician, attending physician, or consulting physician is separately reimbursable. Payment to the attending or consulting physician includes other partners in practice.  (3)  Hospice care provided by a hospice other than the hospice designated by the individual unless provided under arrangements made by the designated hospice.  (4)  AZT (Retrovir) and other curative antiviral drugs targeted at the human immunodeficiency virus for the treatment of AIDS.  78.36(2)    Categories of care.  Hospice care entails the following four categories of daily care. Guidelines for core and other services must be adhered to for all categories of care.  a.  Routine home care is care provided in the place of residence that is not continuous.  b.  Continuous home care is provided only during a period of crisis when an individual requires continuous care which is primarily nursing care to achieve palliation or management of acute medical symptoms. Nursing care must be provided by either a registered nurse or a licensed practical nurse and a nurse must be providing care for more than half of the period of care. A minimum of eight hours of care per day must be provided during a 24-hour day to qualify as continuous care. Homemaker and aide services may also be provided to supplement the nursing care.  c.  Inpatient respite care is provided to the individual only when necessary to relieve the family members or other persons caring for the individual at home. Respite care may be provided only on an occasional basis and may not be reimbursed for more than five consecutive days at a time. Respite care may not be provided when the individual is a resident of a nursing facility.  d.  General inpatient care is provided in periods of acute medical crisis when the individual is hospitalized or in a participating hospice inpatient unit or nursing facility for pain control or acute or chronic symptom management.  78.36(3)    Residence in a nursing facility.  For purposes of the Medicaid hospice benefit, a nursing facility can be considered the residence of a beneficiary. When the person does reside in a nursing facility, the requirement that the care of a resident of a nursing facility must be provided under the immediate direction of either the facility or the resident’s personal physician does not apply if all of the following conditions are met:  a.  The resident is terminally ill.  b.  The resident has elected to receive hospice services under the Medicaid program from a Medicaid-enrolled hospice program.  c.  The nursing facility and the Medicaid-enrolled hospice program have entered into a written agreement under which the hospice program takes full responsibility for the professional management of the resident’s hospice care and the facility agrees to provide room and board to the resident.  78.36(4)    Approval for hospice benefits.  Payment will be approved for hospice services to individuals who are certified as terminally ill, that is, the individuals have a medical prognosis that their life expectancy is six months or less if the illness runs its normal course, and who elect hospice care rather than active treatment for the illness.  a.    Physician certification process.  The hospice must obtain certification that an individual is terminally ill in accordance with the following procedures:  (1)  The hospice may obtain verbal orders to initiate hospice service from the medical director of the hospice or the physician member of the hospice interdisciplinary group and by the individual’s attending physician (if the individual has an attending physician). The verbal order shall be noted in the patient’s record. The verbal order must be given within two days of the start of care and be followed up in writing no later than eight calendar days after hospice care is initiated. The certification must include the statement that the individual’s medical prognosis is that the individual’s life expectancy is six months or less if the illness runs its normal course.  (2)  When verbal orders are not secured, the hospice must obtain, no later than two calendar days after hospice care is initiated, written certification signed by the medical director of the hospice or the physician member of the hospice interdisciplinary group and by the individual’s attending physician (if the individual has an attending physician). The certification must include the statement that the individual’s medical prognosis is that the individual’s life expectancy is six months or less, if the illness runs its normal course.  (3)  Hospice care benefit periods consist of up to two periods of 90 days each and an unlimited number of subsequent 60-day periods as elected by the individual. The medical director or a physician must recertify at the beginning of each benefit period that the individual is terminally ill.  b.    Election procedures.  Individuals who are dually eligible for Medicare and Medicaid must receive hospice coverage under Medicare.  (1)  Election statement. An individual, or individual’s representative, elects to receive the hospice benefit by filing an election statement, Form 470-2618, Election of Medicaid Hospice Benefit, or a Medicare election of hospice benefit form, with a particular hospice. The hospice may provide the individual with another election form to use provided the form includes the following information:
    1. Identification of the hospice that will provide the care.
    2. Acknowledgment that the recipient has been given a full understanding of hospice care.
    3. 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.
    4. Acknowledgment that recipients are not responsible for copayment or other deductibles.
    5. The recipient’s Medicaid number.
    6. The effective date of election.
    7. The recipient’s signature.
      (2)  Change of designation. An individual may change the designation of the particular hospice from which the individual elects to receive hospice care one time only.  (3)  Effective date. An individual may designate an effective date for the hospice benefit that begins with the first day of the hospice care or any subsequent day of hospice care, but an individual may not designate an effective date that is earlier than the date that the election is made.  (4)  Duration of election. The election to receive hospice care will be considered to continue until one of the following occurs:
    1. The individual dies.
    2. The individual or the individual’s representative revokes the election.
    3. The individual’s situation changes so that the individual no longer qualifies for the hospice benefit.
    4. The hospice elects to terminate the recipient’s enrollment in accordance with the hospice’s established discharge policy.
      (5)  Revocation. Form 470-2619, Revocation of Medicaid Hospice Benefit, is completed when an individual or the individual’s representative revokes the hospice benefit allowed under Medicaid. When an individual revokes the election of Medicaid coverage of hospice care, the individual resumes Medicaid coverage of the benefits waived when hospice care was elected.
    This rule is intended to implement Iowa Code section 249A.4.
    Related ARC(s): 3553C441—78.37(249A)  HCBS elderly waiver services.  Payment will be approved for the following services to members eligible for the HCBS elderly waiver services as established in 441—Chapter 83 and as identified in the member’s service plan. Effective March 17, 2022, payment shall only be made for services provided in integrated, community-based settings that support full access of members receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS.  78.37(1)    Adult day care services.  Adult day care services provide an organized program of supportive care in a group environment to persons who need a degree of supervision and assistance on a regular or intermittent basis in a day care center. A unit of service is 15 minutes (up to four units per day), a half day (1.25 to 4 hours per day), a full day (4.25 to 8 hours per day), or an extended day (8.25 to 12 hours per day). Components of the service include health-related care, social services, and other related support services.  78.37(2)    Personal emergency response or portable locator system.    a.  A personal emergency response system is an electronic device that transmits a signal to a central monitoring station to summon assistance in the event of an emergency.  (1)  The necessary components of a system are:
    1. An in-home medical communications transceiver.
    2. A remote, portable activator.
    3. A central monitoring station with backup systems staffed by trained attendants at all times.
    4. Current data files at the central monitoring station containing response protocols and personal, medical, and emergency information for each member.
      (2)  The service shall be identified in the member’s service plan.  (3)  A unit of service is a one-time installation fee or one month of service.  (4)  Maximum units per state fiscal year shall be the initial installation and 12 months of service.
      b.  A portable locator system is an electronic device that transmits a signal to a monitoring device. The system allows a member to access assistance in the event of an emergency and allows law enforcement or the monitoring system provider to locate a member who is unable to request help or to activate a system independently. The member must be unable to access assistance in an emergency situation due to the member’s age or disability.  (1)  The required components of the portable locator system are:
    1. A portable communications transceiver or transmitter to be worn or carried by the member.
    2. Monitoring by the provider at a central location with response protocols and personal, medical, and emergency information for each member as applicable.
      (2)  The service shall be identified in the member’s service plan.  (3)  Payable units of service are purchase of equipment, an installation or set-up fee, and monthly fees.  (4)  Maximum units per state fiscal year shall be one equipment purchase, one installation or set-up fee, and 12 months of service.
      78.37(3)    Home health aide services.  Home health aide services are personal or direct care services provided to the client which are not payable under Medicaid as set forth in rule 441—78.9(249A). A unit of service is a visit. Components of the service include:  a.  Observation and reporting of physical or emotional needs.  b.  Helping a client with bath, shampoo, or oral hygiene.  c.  Helping a client with toileting.  d.  Helping a client in and out of bed and with ambulation.  e.  Helping a client reestablish activities of daily living.  f.  Assisting with oral medications ordinarily self-administered and ordered by a physician.  g.  Performing incidental household services which are essential to the client’s health care at home and are necessary to prevent or postpone institutionalization in order to complete a full unit of service.  78.37(4)    Homemaker services.  Homemaker services are those services provided when the member lives alone or when the person who usually performs these functions for the member needs assistance with performing the functions. A unit of service is 15 minutes. Components of the service must be directly related to the care of the member and may include only the following:  a.  Essential shopping: shopping for basic need items such as food, clothing or personal care items, or drugs.  b.  Limited housecleaning: maintenance cleaning such as vacuuming, dusting, scrubbing floors, defrosting refrigerators, cleaning stoves, cleaning medical equipment, washing and mending clothes, washing personal items used by the member, and washing dishes.  c.  Meal preparation: planning and preparing balanced meals.  78.37(5)    Nursing care services.  Nursing care services are services provided by licensed agency nurses to clients in the home which are ordered by and included in the plan of treatment established by the physician. The services are reasonable and necessary to the treatment of an illness or injury and include: observation; evaluation; teaching; training; supervision; therapeutic exercise; bowel and bladder care; administration of medications; intravenous, hypodermoclysis, and enteral feedings; skin care; preparation of clinical and progress notes; coordination of services and informing the physician and other personnel of changes in the patient’s condition and needs.A unit of service is one visit. Nursing care service can pay for a maximum of eight nursing visits per month for intermediate level of care persons. There is no limit on the maximum visits for skilled level of care persons.  78.37(6)    Respite care services.  Respite care services are services provided to the member that give temporary relief to the usual caregiver and provide all the necessary care that the usual caregiver would provide during that period. The purpose of respite care is to enable the member to remain in the member’s current living situation.  a.  Services provided outside the member’s home shall not be reimbursable if the living unit where respite is provided is reserved for another person on a temporary leave of absence.  b.  Member-to-staff ratios shall be appropriate to the individual needs of the member as determined by the member’s interdisciplinary team.  c.  A unit of service is 15 minutes.  d.  Respite care is not to be provided to members during the hours in which the usual caregiver is employed except when the member is attending a 24-hour residential camp. Respite cannot be provided to a member whose usual caregiver is a consumer-directed attendant care provider for the member.  e.  The interdisciplinary team shall determine if the member will receive basic individual respite, specialized respite or group respite as defined in 441—Chapter 83.  f.  A maximum of 14 consecutive days of 24-hour respite care may be reimbursed.  g.  Respite services provided for a period exceeding 24 consecutive hours to three or more individuals who require nursing care because of a mental or physical condition must be provided by a health care facility licensed as described in Iowa Code chapter 135C.  h.  Respite services shall not be provided simultaneously with other residential, nursing, or home health aide services provided through the medical assistance program.  78.37(7)    Chore services.  Chore services provide assistance with the household maintenance activities listed in paragraph 78.37(7)“a,” as necessary to allow a member to remain in the member’s own home safely and independently. A unit of service is 15 minutes.  a.  Chore services are limited to the following services:  (1)  Window and door maintenance, such as hanging screen windows and doors, replacing windowpanes, and washing windows;  (2)  Minor repairs to walls, floors, stairs, railings and handles;  (3)  Heavy cleaning which includes cleaning attics or basements to remove fire hazards, moving heavy furniture, extensive wall washing, floor care, painting, and trash removal;  (4)  Lawn mowing and removal of snow and ice from sidewalks and driveways.  b.  Leaf raking, bush and tree trimming, trash burning, stick removal, and tree removal are not covered services.  78.37(8)    Home-delivered meals.  Home-delivered meals are meals prepared elsewhere and delivered to a member at the member’s residence.  a.  Each meal shall ensure the member receives a minimum of one-third of the daily recommended dietary allowance as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences. The meal may also be a liquid supplement which meets the minimum one-third standard.  b.  When a restaurant provides the home-delivered meal, the member is required to have a nutritional consultation. The nutritional consultation includes contact with the restaurant to explain the dietary needs of the member and what constitutes the minimum one-third daily dietary allowance.  c.  A unit of service is a meal (morning, noon, evening, or liquid supplement). Any maximum combination of any two meals (morning, noon, evening, or liquid supplement) is allowed per day. Duplication of a meal in any one day is not allowed. The number of approved meals (morning, noon, evening, or liquid supplement) is contained in the member’s service plan.  d.  The number of meals delivered for any morning, noon, evening, or liquid supplement meal cannot exceed the number of calendar days in a calendar month; nor can the number of delivered meals exceed the number of authorized days in a month. Meals billed in excess of the calendar days in a calendar month and those billed in excess of the number of authorized days in a month are subject to recoupment or denial of payment.  78.37(9)    Home and vehicle modification.  Covered home or vehicle modifications are physical modifications to the member’s home or vehicle that directly address the member’s medical or remedial need. Covered modifications must be necessary to provide for the health, welfare, or safety of the member and enable the member to function with greater independence in the home or vehicle.  a.  Modifications that are necessary or desirable without regard to the member’s medical or remedial need and that would be expected to increase the fair market value of the home or vehicle, such as furnaces, fencing, or adding square footage to the residence, are excluded except as specifically included below. Purchasing or leasing of a motorized vehicle is excluded. Home and vehicle repairs are also excluded.  b.  Only the following modifications are covered:  (1)  Kitchen counters, sink space, cabinets, special adaptations to refrigerators, stoves, and ovens.  (2)  Bathtubs and toilets to accommodate transfer, special handles and hoses for shower heads, water faucet controls, and accessible showers and sink areas.  (3)  Grab bars and handrails.  (4)  Turnaround space adaptations.  (5)  Ramps, lifts, and door, hall and window widening.  (6)  Fire safety alarm equipment specific for disability.  (7)  Voice-activated, sound-activated, light-activated, motion-activated, and electronic devices directly related to the member’s disability.  (8)  Vehicle lifts, driver-specific adaptations, remote-start systems, including such modifications already installed in a vehicle.  (9)  Keyless entry systems.  (10)  Automatic opening device for home or vehicle door.  (11)  Special door and window locks.  (12)  Specialized doorknobs and handles.  (13)  Plexiglas replacement for glass windows.  (14)  Modification of existing stairs to widen, lower, raise or enclose open stairs.  (15)  Motion detectors.  (16)  Low-pile carpeting or slip-resistant flooring.  (17)  Telecommunications device for the deaf.  (18)  Exterior hard-surface pathways.  (19)  New door opening.  (20)  Pocket doors.  (21)  Installation or relocation of controls, outlets, switches.  (22)  Air conditioning and air filtering if medically necessary.  (23)  Heightening of existing garage door opening to accommodate modified van.  (24)  Bath chairs.  c.  A unit of service is the completion of needed modifications or adaptations.  d.  All modifications and adaptations shall be provided in accordance with applicable federal, state, and local building and vehicle codes.  e.  Services shall be performed following prior department approval of the modification as specified in 441—subrule 79.1(17) and a binding contract between the provider and the member.  f.  All contracts for home or vehicle modification shall be awarded through competitive bidding. The contract shall include the scope of work to be performed, the time involved, supplies needed, the cost, diagrams of the project whenever applicable, and an assurance that the provider has liability and workers’ compensation coverage and the applicable permit and license.  g.  Service payment shall be made to the enrolled home or vehicle modification provider. If applicable, payment will be forwarded to the subcontracting agency by the enrolled home or vehicle modification provider following completion of the approved modifications.  h.  Services shall be included in the member’s service plan and shall exceed the Medicaid state plan services.  78.37(10)    Mental health outreach.  Mental health outreach services are services provided in a recipient’s home to identify, evaluate, and provide treatment and psychosocial support. The services can only be provided on the basis of a referral from the consumer’s interdisciplinary team established pursuant to 441—subrule 83.22(2). A unit of service is 15 minutes.  78.37(11)    Transportation.  Transportation services may be provided for members to conduct business errands and essential shopping and to reduce social isolation. A unit of service is one mile of transportation or one one-way trip.  78.37(12)    Nutritional counseling.  Nutritional counseling services may be provided for a nutritional problem or condition of such a degree of severity that nutritional counseling beyond that normally expected as part of the standard medical management is warranted. A unit of service is 15 minutes.  78.37(13)    Assistive devices.  Assistive devices means practical equipment products to assist persons with activities of daily living and instrumental activities of daily living to allow the person more independence. They include, but are not limited to: long-reach brush, extra long shoehorn, nonslip grippers to pick up and reach items, dressing aids, shampoo rinse tray and inflatable shampoo tray, double-handled cup and sipper lid. A unit is an item.  a.  The service shall be included in the member’s service plan and shall exceed the services available under the Medicaid state plan.  b.  The service shall be provided following prior approval by the Iowa Medicaid enterprise.  c.  Payment for most items shall be based on a fee schedule. The amount of the fee shall be determined as directed in 441—subrule 79.1(17).  78.37(14)    Senior companion.  Senior companion services are nonmedical care supervision, oversight, and respite. Companions may assist with such tasks as meal preparation, laundry, shopping and light housekeeping tasks. This service cannot provide hands-on nursing or medical care. A unit of service is 15 minutes.  78.37(15)    Consumer-directed attendant care service.  Consumer-directed attendant care services are service activities performed by a person to help a member with self-care tasks which the member would typically do independently if the member were otherwise able. Covered service activities are limited to the nonskilled activities listed in paragraph 78.37(15)“f” and the skilled activities listed in paragraph 78.37(15)“g.” Covered service activities must be essential to the health, safety, and welfare of the member. Services may be provided in the absence of a parent or guardian if the parent or guardian has given advance direction for the service provision.  a.    Service planning.    (1)  The member, parent, guardian, or attorney in fact under a durable power of attorney for health care shall:
    1. Select the individual, agency or assisted living facility that will provide the components of the attendant care services.
    2. 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.
    3. 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.
    4. 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.
      (2)  Assisted living agreements with Iowa Medicaid members must specify the services to be considered covered under the assisted living occupancy agreement and those CDAC services to be covered under the elderly waiver. The funding stream for each service must be identified.  (3)  Whenever a legal representative acts as a provider of consumer-directed attendant care as allowed by 441—paragraph 79.9(7)“b,” the following shall apply:
    1. 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;
    2. The legal representative may not be paid for more than 40 hours of service per week; and
    3. 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.
      b.    Supervision of skilled services.  Skilled consumer-directed attendant care services shall be provided under the supervision of a licensed nurse or licensed therapist working under the direction of a physician. The licensed nurse or therapist shall:  (1)  Retain accountability for actions that are delegated.  (2)  Ensure appropriate assessment, planning, implementation, and evaluation.  (3)  Make on-site supervisory visits every two weeks with the service provider present.  c.    Service documentation.  The consumer-directed attendant care individual and agency providers shall document evidence of compliance with the requirements of this chapter and rule 441—79.3(249A). The documentation or copies of the documentation must be maintained or be electronically accessible by the consumer-directed attendant care provider. Providers must use an electronic visit verification system that captures all documentation requirements of the Consumer-Directed Attendant Care (CDAC) Service Record (Form 470-4389) or use Form 470-4389. Any service component that is not documented in accordance with rule 441—79.3(249A) shall not be payable.  d.    Role of guardian or attorney.  If the member has a guardian or attorney in fact under a durable power of attorney for health care:  (1)  The service worker’s or case manager’s service plan shall address how consumer-directed attendant care services will be monitored to ensure that the member’s needs are being adequately met. If the guardian or attorney in fact is the service provider, the service plan shall address how the service worker or case manager shall oversee service provision.  (2)  The guardian or attorney in fact shall sign the claim form in place of the member, indicating that the service has been provided as presented on the claim.  e.    Service units and billing.  A unit of service is 15 minutes provided by an individual, agency or assisted living facility. Each service shall be billed in whole units.  f.    Nonskilled services.  Covered nonskilled service activities are limited to help with the following activities:  (1)  Dressing.  (2)  Bathing, shampooing, hygiene, and grooming.  (3)  Access to and from bed or a wheelchair, transferring, ambulation, and mobility in general.  (4)  Toileting, including bowel, bladder, and catheter assistance (emptying the catheter bag, collecting a specimen, and cleaning the external area around the catheter).  (5)  Meal preparation, cooking, and assistance with feeding, not including the cost of meals themselves. Meal preparation and cooking shall be provided only in the member’s home.  (6)  Housekeeping, laundry, and shopping essential to the member’s health care at home.  (7)  Taking medications ordinarily self-administered, including those ordered by a physician or other qualified health care provider.  (8)  Minor wound care.  (9)  Going to or returning from a place of employment and job-related tasks while the member is on the job site. Transportation for the member and assistance with understanding or performing the essential job functions are not included in consumer-directed attendant care services.  (10)  Tasks, such as financial management and scheduling, that require cognitive or physical assistance.  (11)  Communication essential to the health and welfare of the member, through interpreting and reading services and use of assistive devices for communication.  (12)  Using transportation essential to the health and welfare of the member. The cost of the transportation is not included.  g.    Skilled services.  Covered skilled service activities are limited to help with the following activities:  (1)  Tube feedings of members unable to eat solid foods.  (2)  Intravenous therapy administered by a registered nurse.  (3)  Parenteral injections required more than once a week.  (4)  Catheterizations, continuing care of indwelling catheters with supervision of irrigations, and changing of Foley catheters when required.  (5)  Respiratory care including inhalation therapy and tracheotomy care or tracheotomy care and ventilator.  (6)  Care of decubiti and other ulcerated areas, noting and reporting to the nurse or therapist.  (7)  Rehabilitation services including, but not limited to, bowel and bladder training, range of motion exercises, ambulation training, restorative nursing services, respiratory care and breathing programs, reality orientation, reminiscing therapy, remotivation, behavior modification, and reteaching of the activities of daily living.  (8)  Colostomy care.  (9)  Care of uncontrolled medical conditions, such as brittle diabetes, and comfort care of terminal conditions.  (10)  Postsurgical nursing care.  (11)  Monitoring medications requiring close supervision because of fluctuating physical or psychological conditions, e.g., antihypertensives, digitalis preparations, mood-altering or psychotropic drugs, or narcotics.  (12)  Preparing and monitoring response to therapeutic diets.  (13)  Recording and reporting of changes in vital signs to the nurse or therapist.  h.    Excluded services and costs.  Services, activities, costs and time that are not covered as consumer-directed attendant care include the following (not an exclusive list):  (1)  Any activity related to supervising a member. Only direct services are billable.  (2)  Any activity that the member is able to perform.  (3)  Costs of food.  (4)  Costs for the supervision of skilled services by the nurse or therapist. The supervising nurse or therapist may be paid from private insurance, Medicare, or other third-party payment sources, or may be paid as another Medicaid service, including early and periodic screening, diagnosis and treatment services.  (5)  Exercise that does not require skilled services.  (6)  Parenting or child care for or on behalf of the member.  (7)  Reminders and cueing.  (8)  Services provided simultaneously with any other similar service regardless of funding source, including other waiver services and state supplementary assistance in-home health-related care services.  (9)  Transportation costs.  (10)  Wait times for any activity.
      78.37(16)    Consumer choices option.  The consumer choices option is service activities provided pursuant to subrule 78.34(13).   78.37(17)    Case management services.  Case management services are services that assist Medicaid members who reside in a community setting or are transitioning to a community setting in gaining access to needed medical, social, educational, housing, transportation, vocational, and other appropriate services in order to ensure the health, safety, and welfare of the member. Case management is provided at the direction of the member and the interdisciplinary team established pursuant to 441—subrule 83.22(2).  a.  Case management services shall be provided as set forth in rules 441—90.4(249A) through 441—90.7(249A).  b.  Case management shall not include the provision of direct services by the case managers.  c.  Payment for case management shall not be made until the consumer is enrolled in the waiver. Payment shall be made only for case management services performed on behalf of the consumer during a month when the consumer is enrolled.  78.37(18)    Assisted living service.  The assisted living service includes unanticipated and unscheduled personal care and supportive services that are furnished to waiver participants who reside in a homelike, noninstitutional setting. The service includes the 24-hour on-site response capability to meet unpredictable member needs as well as member safety and security through incidental supervision. Assisted living service is not reimbursable if performed at the same time as any service included in an approved consumer-directed attendant care (CDAC) agreement.  a.  A unit of service is one day.   b.  A day of assisted living service is billable only if both the following requirements are met:  (1)  The member was present in the facility during that day’s bed census.  (2)  The assisted living provider has documented at least one assisted living service encounter for that day, in accordance with rule 441—79.3(249A). The documentation must include the member’s response to the service. The documented assisted living service cannot also be an authorized CDAC service.  78.37(19)    General service standards.  All elderly waiver services must be provided in accordance with the following standards:  a.  Reimbursement shall not be available under the waiver for any services that the member can obtain as other nonwaiver Medicaid services or through any other funding source.  b.  All services provided under the waiver must be delivered in the least restrictive environment possible and in conformity with the member’s service plan.  c.  All rights restrictions must be implemented in accordance with 441—subrule 77.25(4). The member service plan or treatment plan shall include documentation of:   (1)  Any restrictions on the member’s rights, including the rights of privacy, dignity, respect, and freedom from coercion and restraint.  (2)  The need for the restriction.  (3)  The less intrusive methods of meeting the need that have been tried but did not work.  (4)  Either a plan to restore those rights or written documentation that a plan is not necessary or appropriate.   (5)  Established time limits for periodic reviews to determine if the restriction is still necessary or can be terminated.  (6)  The informed consent of the member.  (7)  An assurance that the interventions and supports will cause no harm to the member.  (8)  A regular collection and review of data to measure the ongoing effectiveness of the restriction.  d.  Services must be billed in whole units.  e.  For all services with a 15-minute unit of service, the following rounding process will apply:  (1)  Add together the minutes spent on all billable activities during a calendar day for a daily total.  (2)  For each day, divide the total minutes spent on billable activities by 15 to determine the number of full 15-minute units for that day.  (3)  Round the remainder using these guidelines: Round 1 to 7 minutes down to zero units; round 8 to 14 minutes up to one unit.  (4)  Add together the number of full units and the number of rounded units to determine the total number of units to bill for that day.This rule is intended to implement Iowa Code section 249A.4.
    Related ARC(s): 7957B, 9045B, 9403B, 9704B, 9884B, 0545C, 0707C, 0709C, 1071C, 1610C, 2050C, 2340C, 3552C, 3874C, 4430C, 4897C, 5597C441—78.38(249A)  HCBS AIDS/HIV waiver services.  Payment will be approved for the following services to members eligible for the HCBS AIDS/HIV waiver services as established in 441—Chapter 83 and as identified in the member’s service plan. Effective March 17, 2022, payment shall only be made for services provided in integrated, community-based settings that support full access of members receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS.  78.38(1)    Counseling services.  Counseling services are face-to-face mental health services provided to the member and caregiver by a mental health professional as defined in rule 441—24.1(225C) to facilitate home management of the member and prevent institutionalization. Counseling services are nonpsychiatric services necessary for the management of depression, assistance with the grief process, alleviation of psychosocial isolation and support in coping with a disability or illness, including terminal illness. Counseling services may be provided both for the purpose of training the member’s family or other caregiver to provide care, and for the purpose of helping the member and those caring for the member to adjust to the member’s disability or terminal condition. Counseling services may be provided to the member’s caregiver only when included in the case plan for the member.Payment will be made for individual and group counseling. A unit of individual counseling for the waiver member or the waiver member and the member’s caregiver is 15 minutes. A unit of group counseling is 15 minutes. Payment for group counseling is based on the group rate divided by six, or, if the number of persons who comprise the group exceeds six, the actual number of persons who comprise the group.  78.38(2)    Home health aide services.  Home health aide services are personal or direct care services provided to the client which are not payable under Medicaid as set forth in rule 441—78.9(249A). A unit of service is a visit. Components of the service are:  a.  Observation and reporting of physical or emotional needs.  b.  Helping a client with bath, shampoo, or oral hygiene.  c.  Helping a client with toileting.  d.  Helping a client in and out of bed and with ambulation.  e.  Helping a client reestablish activities of daily living.  f.  Assisting with oral medications ordinarily self-administered and ordered by a physician.  g.  Performing incidental household services which are essential to the client’s health care at home and are necessary to prevent or postpone institutionalization in order to complete a full unit of service.  78.38(3)    Homemaker services.  Homemaker services are those services provided when the member lives alone or when the person who usually performs these functions for the member needs assistance with performing the functions. A unit of service is 15 minutes. Components of the service must be directly related to the care of the member and may include only the following:  a.  Essential shopping: shopping for basic need items such as food, clothing or personal care items, or drugs.  b.  Limited housecleaning: maintenance cleaning such as vacuuming, dusting, scrubbing floors, defrosting refrigerators, cleaning stoves, cleaning medical equipment, washing and mending clothes, washing personal items used by the member, and washing dishes.  c.  Meal preparation: planning and preparing balanced meals.  78.38(4)    Nursing care services.  Nursing care services are services provided by licensed agency nurses to clients in the home which are ordered by and included in the plan of treatment established by the physician. The services shall be reasonable and necessary to the treatment of an illness or injury and include: observation; evaluation; teaching; training; supervision; therapeutic exercise; bowel and bladder care; administration of medications; intravenous and enteral feedings; skin care; preparation of clinical and progress notes; coordination of services; and informing the physician and other personnel of changes in the patient’s conditions and needs. A unit of service is a visit.  78.38(5)    Respite care services.  Respite care services are services provided to the member that give temporary relief to the usual caregiver and provide all the necessary care that the usual caregiver would provide during that period. The purpose of respite care is to enable the member to remain in the member’s current living situation.  a.  Services provided outside the member’s home shall not be reimbursable if the living unit where respite is provided is reserved for another person on a temporary leave of absence.  b.  Member-to-staff ratios shall be appropriate to the individual needs of the member as determined by the member’s interdisciplinary team.  c.  A unit of service is 15 minutes.  d.  Respite care is not to be provided to members during the hours in which the usual caregiver is employed except when the member is attending a 24-hour residential camp. Respite cannot be provided to a member whose usual caregiver is a consumer-directed attendant care provider for the member.  e.  The interdisciplinary team shall determine if the member will receive basic individual respite, specialized respite or group respite as defined in 441—Chapter 83.  f.  A maximum of 14 consecutive days of 24-hour respite care may be reimbursed.  g.  Respite services provided for a period exceeding 24 consecutive hours to three or more individuals who require nursing care because of a mental or physical condition must be provided by a health care facility licensed as described in Iowa Code chapter 135C.  h.  Respite services shall not be provided simultaneously with other residential, nursing, or home health aide services provided through the medical assistance program.  78.38(6)    Home-delivered meals.  Home-delivered meals are meals prepared elsewhere and delivered to a member at the member’s residence.  a.  Each meal shall ensure the member receives a minimum of one-third of the daily recommended dietary allowance as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences. The meal may also be a liquid supplement which meets the minimum one-third standard.  b.  When a restaurant provides the home-delivered meal, the member is required to have a nutritional consultation. The nutritional consultation includes contact with the restaurant to explain the dietary needs of the member and what constitutes the minimum one-third daily dietary allowance.  c.  A unit of service is a meal (morning, noon, evening, or liquid supplement). Any maximum combination of any two meals (morning, noon, evening, or liquid supplement) is allowed per day. Duplication of a meal in any one day is not allowed. The number of approved meals (morning, noon, evening, or liquid supplement) is contained in the member’s service plan.   d.  The number of meals delivered for any morning, noon, evening, or liquid supplement meal cannot exceed the number of calendar days in a calendar month; nor can the number of delivered meals exceed the number of authorized days in a month. Meals billed in excess of the calendar days in a calendar month and those billed in excess of the number of authorized days in a month are subject to recoupment or denial of payment.  78.38(7)    Adult day care services.  Adult day care services provide an organized program of supportive care in a group environment to persons who need a degree of supervision and assistance on a regular or intermittent basis in a day care center. A unit of service is 15 minutes (up to four units per day), a half day (1.25 to 4 hours per day), a full day (4.25 to 8 hours per day), or an extended day (8.25 to 12 hours per day). Components of the service include health-related care, social services, and other related support services.  78.38(8)    Consumer-directed attendant care service.  Consumer-directed attendant care services are service activities performed by a person to help a member with self-care tasks which the member would typically do independently if the member were otherwise able. Covered service activities are limited to the nonskilled activities listed in paragraph 78.38(8)“f” and the skilled activities listed in paragraph 78.38(8)“g.” Covered service activities must be essential to the health, safety, and welfare of the member. Services may be provided in the absence of a parent or guardian if the parent or guardian has given advance direction for the service provision.  a.    Service planning.    (1)  The member, parent, guardian, or attorney in fact under a durable power of attorney for health care shall:
    1. Select the individual or agency that will provide the components of the attendant care services.
    2. 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.
    3. 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.
    4. 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.
      (2)  Whenever a legal representative acts as a provider of consumer-directed attendant care as allowed by 441—paragraph 79.9(7)“b,” the following shall apply:
    1. 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;
    2. The legal representative may not be paid for more than 40 hours of service per week; and
    3. 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.
      b.    Supervision of skilled services.  Skilled consumer-directed attendant care services shall be provided under the supervision of a licensed nurse or licensed therapist working under the direction of a physician. The licensed nurse or therapist shall:  (1)  Retain accountability for actions that are delegated.  (2)  Ensure appropriate assessment, planning, implementation, and evaluation.  (3)  Make on-site supervisory visits every two weeks with the service provider present.  c.    Service documentation.  The consumer-directed attendant care provider shall document evidence of compliance with the requirements of this chapter and rule 441—79.3(249A). The documentation or copies of the documentation must be maintained or be electronically accessible by the consumer-directed attendant care provider. Providers must use an electronic visit verification system that captures all documentation requirements of the Consumer-Directed Attendant Care (CDAC) Service Record (Form 470-4389) or use Form 470-4389. Any service component that is not documented in accordance with rule 441—79.3(249A) shall not be payable.  d.    Role of guardian or attorney.  If the member has a guardian or attorney in fact under a durable power of attorney for health care:  (1)  The service worker’s or case manager’s service plan shall address how consumer-directed attendant care services will be monitored to ensure that the member’s needs are being adequately met. If the guardian or attorney in fact is the service provider, the service plan shall address how the service worker or case manager shall oversee service provision.  (2)  The guardian or attorney in fact shall sign the claim form in place of the member, indicating that the service has been provided as presented on the claim.  e.    Service units and billing.  A unit of service is 15 minutes provided by an individual or agency. Each service shall be billed in whole units.  f.    Nonskilled services.  Covered nonskilled service activities are limited to help with the following activities:  (1)  Dressing.  (2)  Bathing, shampooing, hygiene, and grooming.  (3)  Access to and from bed or a wheelchair, transferring, ambulation, and mobility in general.  (4)  Toileting, including bowel, bladder, and catheter assistance (emptying the catheter bag, collecting a specimen, and cleaning the external area around the catheter).  (5)  Meal preparation, cooking, and assistance with feeding, not including the cost of meals themselves. Meal preparation and cooking shall be provided only in the member’s home.  (6)  Housekeeping, laundry, and shopping essential to the member’s health care at home.  (7)  Taking medications ordinarily self-administered, including those ordered by a physician or other qualified health care provider.  (8)  Minor wound care.  (9)  Going to or returning from a place of employment and job-related tasks while the member is on the job site. Transportation for the member and assistance with understanding or performing the essential job functions are not included in consumer-directed attendant care services.  (10)  Tasks, such as financial management and scheduling, that require cognitive or physical assistance.  (11)  Communication essential to the health and welfare of the member, through interpreting and reading services and use of assistive devices for communication.  (12)  Using transportation essential to the health and welfare of the member. The cost of the transportation is not included.  g.    Skilled services.  Covered skilled service activities are limited to help with the following activities:  (1)  Tube feedings of members unable to eat solid foods.  (2)  Intravenous therapy administered by a registered nurse.  (3)  Parenteral injections required more than once a week.  (4)  Catheterizations, continuing care of indwelling catheters with supervision of irrigations, and changing of Foley catheters when required.  (5)  Respiratory care including inhalation therapy and tracheotomy care or tracheotomy care and ventilator.  (6)  Care of decubiti and other ulcerated areas, noting and reporting to the nurse or therapist.  (7)  Rehabilitation services including, but not limited to, bowel and bladder training, range of motion exercises, ambulation training, restorative nursing services, respiratory care and breathing programs, reality orientation, reminiscing therapy, remotivation, behavior modification, and reteaching of the activities of daily living.  (8)  Colostomy care.  (9)  Care of uncontrolled medical conditions, such as brittle diabetes, and comfort care of terminal conditions.  (10)  Postsurgical nursing care.  (11)  Monitoring medications requiring close supervision because of fluctuating physical or psychological conditions, e.g., antihypertensive, digitalis preparations, mood-altering or psychotropic drugs, or narcotics.  (12)  Preparing and monitoring response to therapeutic diets.  (13)  Recording and reporting of changes in vital signs to the nurse or therapist.  h.    Excluded services and costs.  Services, activities, costs and time that are not covered as consumer-directed attendant care include the following (not an exclusive list):  (1)  Any activity related to supervising a member. Only direct services are billable.  (2)  Any activity that the member is able to perform.  (3)  Costs of food.  (4)  Costs for the supervision of skilled services by the nurse or therapist. The supervising nurse or therapist may be paid from private insurance, Medicare, or other third-party payment sources, or may be paid as another Medicaid service, including early and periodic screening, diagnosis and treatment services.  (5)  Exercise that does not require skilled services.  (6)  Parenting or child care for or on behalf of the member.  (7)  Reminders and cueing.  (8)  Services provided simultaneously with any other similar service regardless of funding source, including other waiver services and state supplementary assistance in-home health-related care services.  (9)  Transportation costs.  (10)  Wait times for any activity.
      78.38(9)    Consumer choices option.  The consumer choices option is service activities provided pursuant to subrule 78.34(13).  78.38(10)    General service standards.  All AIDS/HIV waiver services must be provided in accordance with the following standards:  a.  Reimbursement shall not be available under the waiver for any services that the member can obtain as other nonwaiver Medicaid services or through any other funding source.  b.  All services provided under the waiver must be delivered in the least restrictive environment possible and in conformity with the member’s service plan.  c.  All rights restrictions must be implemented in accordance with 441—subrule 77.25(4). The member service plan or treatment plan shall include documentation of:   (1)  Any restrictions on the member’s rights, including the rights of privacy, dignity, respect, and freedom from coercion and restraint.  (2)  The need for the restriction.  (3)  The less intrusive methods of meeting the need that have been tried but did not work.  (4)  Either a plan to restore those rights or written documentation that a plan is not necessary or appropriate.   (5)  Established time limits for periodic reviews to determine if the restriction is still necessary or can be terminated.  (6)  The informed consent of the member.  (7)  An assurance that the interventions and supports will cause no harm to the member.  (8)  A regular collection and review of data to measure the ongoing effectiveness of the restriction.  d.  Services must be billed in whole units.  e.  For all services with a 15-minute unit of service, the following rounding process will apply:  (1)  Add together the minutes spent on all billable activities during a calendar day for a daily total.  (2)  For each day, divide the total minutes spent on billable activities by 15 to determine the number of full 15-minute units for that day.  (3)  Round the remainder using these guidelines: Round 1 to 7 minutes down to zero units; round 8 to 14 minutes up to one unit.  (4)  Add together the number of full units and the number of rounded units to determine the total number of units to bill for that day.This rule is intended to implement Iowa Code section 249A.4.
    Related ARC(s): 9045B, 9403B, 0707C, 0709C, 1610C, 3552C, 3874C, 4430C, 5597C441—78.39(249A)  Federally qualified health centers.  Payment shall be made for services as defined in Section 1905(a)(2)(C) of the Social Security Act.  78.39(1)    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. Refer to rule 441—76.9(249A) for further information concerning the member lock-in program.  78.39(2)    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. (See description of enhanced services at subrule 78.25(3).)  78.39(3)    Vaccines.  In order to be paid for the administration of a vaccine covered under the Vaccines for Children (VFC) Program, a federally qualified health center must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 0065C441—78.40(249A)  Advanced registered nurse practitioners.  Payment shall be approved for services provided by advanced registered nurse practitioners within their scope of practice and the limitations of state law, with the exception of services not payable to physicians under rule 441—78.1(249A) or otherwise not payable under any other applicable rule.  78.40(1)    Direct payment.  Payment shall be made to advanced registered nurse practitioners directly, without regard to whether the advanced registered nurse practitioner is employed by or associated with a physician, hospital, birth center, clinic or other health care provider recognized under state law. An established protocol between a physician and the advanced registered nurse practitioner shall not cause an advanced registered nurse practitioner to be considered auxiliary personnel of a physician, or an employee of a hospital, birth center, or clinic.  78.40(2)    Location of service.  Payment shall be approved for services rendered in any location in which the advanced registered nurse practitioner is legally authorized to provide services under state law. The nurse practitioner shall have promptly available the necessary equipment and personnel to handle emergencies.  78.40(3)    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, other clinics, and emergency rooms. Refer to rule 441—76.9(249A) for further information concerning the member lock-in program.  78.40(4)    Vaccines.  In order to be paid for the administration of a vaccine covered under the Vaccines for Children (VFC) Program, an advanced registered nurse practitioner must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted.  78.40(5)    Prenatal 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. (See description of enhanced services at subrule 78.25(3).)This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 0065C441—78.41(249A)  HCBS intellectual disability waiver services.  Payment will be approved for the following services to members eligible for the HCBS intellectual disability waiver as established in 441—Chapter 83 and as identified in the member’s service plan. Effective March 17, 2022, payment shall only be made for services provided in integrated, community-based settings that support full access of members receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS.  78.41(1)    Supported community living services.  Supported community living services are provided by the provider within the member’s home and community, according to the individualized member need as identified in the service plan.  a.  Available components of the service are personal and home skills training services, individual advocacy services, community skills training services, personal environment support services, transportation, and treatment services.  (1)  Personal and home skills training services are activities which assist a member to develop or maintain skills for self-care, self-directedness, and care of the immediate environment.  (2)  Individual advocacy is the act or process of representing the member’s rights and interests in order to realize the rights to which the member is entitled and to remove barriers to meeting the member’s needs.  (3)  Community skills training services are activities which assist a member to develop or maintain skills allowing better participation in the community. Services shall focus on the following areas as they apply to the member being served:
    1. Personal management skills training services are activities 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.
    2. 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.
    3. 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.
      (4)  Personal and environmental support services are activities and expenditures provided to or on behalf of a member in the areas of personal needs in order to allow the member to function in the least restrictive environment.  (5)  Transportation services are activities and expenditures designed to assist the member to travel from one place to another to obtain services or carry out life’s activities. The services exclude transportation provided as nonemergency medical transportation pursuant to rule 441—78.13(249A).  (6)  Treatment services are activities designed to assist the member to maintain or improve physiological, emotional and behavioral functioning and to prevent conditions that would present barriers to the member’s functioning. Treatment services include physical or physiological treatment and psychotherapeutic treatment.
    1. Physiological treatment includes medication regimens designed to prevent, halt, control, relieve, or reverse symptoms or conditions 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.
    2. Psychotherapeutic treatment means activities provided to assist a member in the identification or modification of beliefs, emotions, attitudes, or behaviors in order to maintain or improve the member’s functioning in response to the physical, emotional, and social environment.
      b.  The supported community living services are intended to provide for the daily living needs of the member and shall be available as needed during any 24-hour period. Activities do not include those associated with vocational services, academics, day care, medical services, Medicaid case management or other case management. Services are individualized supportive services provided in a variety of community-based, integrated settings.  (1)  Supported community living services shall be available at a daily rate to members living outside the home of their family, legal representative, or foster family and for whom a provider has primary responsibility for supervision or structure during the month. This service will provide supervision or structure in identified periods when another resource is not available.  (2)  Supported community living services shall be available at a 15-minute rate to members for whom a daily rate is not established.  c.  Services may be provided to a child or an adult. A maximum of four persons may reside in a living unit.  (1)  A member may live within the home of the member’s family or legal representative or in another typical community living arrangement.  (2)  A member living with the member’s family or legal representative is not subject to the maximum of four residents in a living unit.  (3)  A member may not live in a licensed medical or health care facility or in a setting that is required to be licensed as a medical or health care facility.  d.  A member aged 17 or under living in the home of the member’s family, legal representative, or foster family shall receive services based on development of adaptive, behavior, or health skills. Duration of services shall be based on age-appropriateness and individual attention span.  e.  Maintenance and room and board costs are not reimbursable.  f.  Provider budgets shall reflect costs associated with members’ specific support needs as determined necessary by the interdisciplinary team for each member. The specific support needs must be identified in the Medicaid case manager’s service plan, and the provider must maintain records to support the expenditures. A unit of service is:  (1)  One full calendar day when a member residing in the living unit receives on-site staff supervision for eight or more hours per day as an average over a calendar month and the member’s service plan identifies and reflects the need for this amount of supervision.  (2)  Fifteen minutes when subparagraph 78.41(1)“f”(1) does not apply.  g.  The maximum number of units available per member is as follows:  (1)  365 daily units per state fiscal year except a leap year when 366 daily units are available.  (2)  20,440 15-minute units are available per state fiscal year except a leap year when 20,496 15-minute units are available.  h.  The service shall be identified in the member’s service plan.  i.  Supported community living services shall not be simultaneously reimbursed with other residential services or with respite, nursing, or home health aide services provided through Medicaid or the HCBS intellectual disability waiver.
      78.41(2)    Respite care services.  Respite care services are services provided to the member that give temporary relief to the usual caregiver and provide all the necessary care that the usual caregiver would provide during that period. The purpose of respite care is to enable the member to remain in the member’s current living situation.  a.  Services provided outside the member’s home shall not be reimbursable if the living unit where respite is provided is reserved for another person on a temporary leave of absence.  b.  Member-to-staff ratios shall be appropriate to the individual needs of the member as determined by the member’s interdisciplinary team.  c.  A unit of service is 15 minutes.  d.  Respite care is not to be provided to members during the hours in which the usual caregiver is employed except when the member is attending a 24-hour residential camp. Respite care shall not be used as a substitute for a child’s day care. Respite cannot be provided to a member whose usual caregiver is a consumer-directed attendant care provider for the member.  e.  The interdisciplinary team shall determine if the member will receive basic individual respite, specialized respite or group respite as defined in 441—Chapter 83.  f.  A maximum of 14 consecutive days of 24-hour respite care may be reimbursed.  g.  Respite services provided for a period exceeding 24 consecutive hours to three or more individuals who require nursing care because of a mental or physical condition must be provided by a health care facility licensed as described in Iowa Code chapter 135C.  h.  Respite services shall not be simultaneously reimbursed with other residential, supported community living, nursing, or home health aide services provided through the medical assistance program.  i.  Payment for respite services shall not exceed $7,334.62 per the member’s waiver year.  78.41(3)    Personal emergency response or portable locator system.    a.  The personal emergency response system is an electronic device that transmits a signal to a central monitoring station to summon assistance in the event of an emergency.  (1)  The necessary components of the system are:
    1. An in-home medical communications transceiver.
    2. A remote, portable activator.
    3. A central monitoring station with backup systems staffed by trained attendants at all times.
    4. Current data files at the central monitoring station containing response protocols and personal, medical and emergency information for each member.
      (2)  The service shall be identified in the member’s service plan.  (3)  A unit of service is a one-time installation fee or one month of service.  (4)  Maximum units per state fiscal year shall be the initial installation and 12 months of service.
      b.  A portable locator system is an electronic device that transmits a signal to a monitoring device. The system allows a member to access assistance in the event of an emergency and allows law enforcement or the monitoring system provider to locate a member who is unable to request help or to activate a system independently. The member must be unable to access assistance in an emergency situation due to the member’s age or disability.  (1)  The required components of the portable locator system are:
    1. A portable communications transceiver or transmitter to be worn or carried by the member.
    2. Monitoring by the provider at a central location with response protocols and personal, medical, and emergency information for each member as applicable.
      (2)  The service shall be identified in the member’s service plan.  (3)  Payable units of service are purchase of equipment, an installation or set-up fee, and monthly fees.  (4)  Maximum units per state fiscal year shall be one equipment purchase, one installation or set-up fee, and 12 months of service.
      78.41(4)    Home and vehicle modification.  Covered home or vehicle modifications are physical modifications to the member’s home or vehicle that directly address the member’s medical or remedial need. Covered modifications must be necessary to provide for the health, welfare, or safety of the member and enable the member to function with greater independence in the home or vehicle.  a.  Modifications that are necessary or desirable without regard to the member’s medical or remedial need and that would be expected to increase the fair market value of the home or vehicle, such as furnaces, fencing, or adding square footage to the residence, are excluded except as specifically included below. Purchasing or leasing of a motorized vehicle is excluded. Home and vehicle repairs are also excluded.  b.  Only the following modifications are covered:  (1)  Kitchen counters, sink space, cabinets, special adaptations to refrigerators, stoves, and ovens.  (2)  Bathtubs and toilets to accommodate transfer, special handles and hoses for shower heads, water faucet controls, and accessible showers and sink areas.  (3)  Grab bars and handrails.  (4)  Turnaround space adaptations.  (5)  Ramps, lifts, and door, hall and window widening.  (6)  Fire safety alarm equipment specific for disability.  (7)  Voice-activated, sound-activated, light-activated, motion-activated, and electronic devices directly related to the member’s disability.  (8)  Vehicle lifts, driver-specific adaptations, remote-start systems, including such modifications already installed in a vehicle.  (9)  Keyless entry systems.  (10)  Automatic opening device for home or vehicle door.  (11)  Special door and window locks.  (12)  Specialized doorknobs and handles.  (13)  Plexiglas replacement for glass windows.  (14)  Modification of existing stairs to widen, lower, raise or enclose open stairs.  (15)  Motion detectors.  (16)  Low-pile carpeting or slip-resistant flooring.  (17)  Telecommunications device for the deaf.  (18)  Exterior hard-surface pathways.  (19)  New door opening.  (20)  Pocket doors.  (21)  Installation or relocation of controls, outlets, switches.  (22)  Air conditioning and air filtering if medically necessary.  (23)  Heightening of existing garage door opening to accommodate modified van.  (24)  Bath chairs.  c.  A unit of service is the completion of needed modifications or adaptations.  d.  All modifications and adaptations shall be provided in accordance with applicable federal, state, and local building and vehicle codes.  e.  Services shall be performed following prior department approval of the modification as specified in 441—subrule 79.1(17) and a binding contract between the provider and the member.  f.  All contracts for home or vehicle modification shall be awarded through competitive bidding. The contract shall include the scope of work to be performed, the time involved, supplies needed, the cost, diagrams of the project whenever applicable, and an assurance that the provider has liability and workers’ compensation coverage and the applicable permit and license.  g.  Service payment shall be made to the enrolled home or vehicle modification provider. If applicable, payment will be forwarded to the subcontracting agency by the enrolled home or vehicle modification provider following completion of the approved modifications.  h.  Services shall be included in the member’s service plan and shall exceed the Medicaid state plan services.  78.41(5)    Nursing services.  Nursing services are individualized in-home medical services provided by licensed nurses. Services shall exceed the Medicaid state plan services and be included in the consumer’s individual comprehensive plan.  a.  A unit of service is one hour.  b.  A maximum of ten units are available per week.  78.41(6)    Home health aide services.  Home health aide services are personal or direct care services provided to the member which are not payable under Medicaid as set forth in rule 441—78.9(249A). Services shall include unskilled medical services and shall exceed those services provided under HCBS intellectual disability waiver supported community living. Instruction, supervision, support or assistance in personal hygiene, bathing, and daily living shall be provided under supported community living.  a.  Services shall be included in the member’s service plan.  b.  A unit is one hour.  c.  A maximum of 14 units are available per week.  78.41(7)    Supported employment services.  Supported employment services are service activities provided pursuant to subrule 78.27(10).  78.41(8)    Consumer-directed attendant care service.  Consumer-directed attendant care services are service activities performed by a person to help a member with self-care tasks which the member would typically do independently if the member were otherwise able. Covered service activities are limited to the nonskilled activities listed in paragraph 78.41(8)“f” and the skilled activities listed in paragraph 78.41(8)“g.” Covered service activities must be essential to the health, safety, and welfare of the member. Services may be provided in the absence of a parent or guardian if the parent or guardian has given advance direction for the service provision.  a.    Service planning.    (1)  The member, parent, guardian, or attorney in fact under a durable power of attorney for health care shall:
    1. Select the individual or agency that will provide the components of the attendant care services.
    2. 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.
    3. 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.
    4. 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.
      (2)  Whenever a legal representative acts as a provider of consumer-directed attendant care as allowed by 441—paragraph 79.9(7)“b,” the following shall apply:
    1. 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;
    2. The legal representative may not be paid for more than 40 hours of service per week; and
    3. 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.
      b.    Supervision of skilled services.  Skilled consumer-directed attendant care services shall be provided under the supervision of a licensed nurse or licensed therapist working under the direction of a physician. The licensed nurse or therapist shall:  (1)  Retain accountability for actions that are delegated.  (2)  Ensure appropriate assessment, planning, implementation, and evaluation.  (3)  Make on-site supervisory visits every two weeks with the service provider present.  c.    Service documentation.  The consumer-directed attendant care provider shall document evidence of compliance with the requirements of this chapter and rule 441—79.3(249A). The documentation or copies of the documentation must be maintained or be electronically accessible by the consumer-directed attendant care provider. Providers must use an electronic visit verification system that captures all documentation requirements of the Consumer-Directed Attendant Care (CDAC) Service Record (Form 470-4389) or use Form 470-4389. Any service component that is not documented in accordance with rule 441—79.3(249A) shall not be payable.  d.    Role of guardian or attorney.  If the member has a guardian or attorney in fact under a durable power of attorney for health care:  (1)  The service worker’s or case manager’s service plan shall address how consumer-directed attendant care services will be monitored to ensure that the member’s needs are being adequately met. If the guardian or attorney in fact is the service provider, the service plan shall address how the service worker or case manager shall oversee service provision.  (2)  The guardian or attorney in fact shall sign the claim form in place of the member, indicating that the service has been provided as presented on the claim.  e.    Service units and billing.  A unit of service is 15 minutes provided by an individual or agency. Each service shall be billed in whole units.  f.    Nonskilled services.  Covered nonskilled service activities are limited to help with the following activities:  (1)  Dressing.  (2)  Bathing, shampooing, hygiene, and grooming.  (3)  Access to and from bed or a wheelchair, transferring, ambulation, and mobility in general.  (4)  Toileting, including bowel, bladder, and catheter assistance (emptying the catheter bag, collecting a specimen, and cleaning the external area around the catheter).  (5)  Meal preparation, cooking, and assistance with feeding, not including the cost of meals themselves. Meal preparation and cooking shall be provided only in the member’s home.  (6)  Housekeeping, laundry, and shopping essential to the member’s health care at home.  (7)  Taking medications ordinarily self-administered, including those ordered by a physician or other qualified health care provider.  (8)  Minor wound care.  (9)  Going to or returning from a place of employment and job-related tasks while the member is on the job site. Transportation for the member and assistance with understanding or performing the essential job functions are not included in consumer-directed attendant care services.  (10)  Tasks, such as financial management and scheduling, that require cognitive or physical assistance.  (11)  Communication essential to the health and welfare of the member, through interpreting and reading services and use of assistive devices for communication.  (12)  Using transportation essential to the health and welfare of the member. The cost of the transportation is not included.  g.    Skilled services.  Covered skilled service activities are limited to help with the following activities:  (1)  Tube feedings of members unable to eat solid foods.  (2)  Intravenous therapy administered by a registered nurse.  (3)  Parenteral injections required more than once a week.  (4)  Catheterizations, continuing care of indwelling catheters with supervision of irrigations, and changing of Foley catheters when required.  (5)  Respiratory care including inhalation therapy and tracheotomy care or tracheotomy care and ventilator.  (6)  Care of decubiti and other ulcerated areas, noting and reporting to the nurse or therapist.  (7)  Rehabilitation services including, but not limited to, bowel and bladder training, range of motion exercises, ambulation training, restorative nursing services, respiratory care and breathing programs, reality orientation, reminiscing therapy, remotivation, behavior modification, and reteaching of the activities of daily living.  (8)  Colostomy care.  (9)  Care of uncontrolled medical conditions, such as brittle diabetes, and comfort care of terminal conditions.  (10)  Postsurgical nursing care.  (11)  Monitoring medications requiring close supervision because of fluctuating physical or psychological conditions, e.g., antihypertensives, digitalis preparations, mood-altering or psychotropic drugs, or narcotics.  (12)  Preparing and monitoring response to therapeutic diets.  (13)  Recording and reporting of changes in vital signs to the nurse or therapist.  h.    Excluded services and costs.  Services, activities, costs and time that are not covered as consumer-directed attendant care include the following (not an exclusive list):  (1)  Any activity related to supervising a member. Only direct services are billable.  (2)  Any activity that the member is able to perform.  (3)  Costs of food.  (4)  Costs for the supervision of skilled services by the nurse or therapist. The supervising nurse or therapist may be paid from private insurance, Medicare, or other third-party payment sources, or may be paid as another Medicaid service, including early and periodic screening, diagnosis and treatment services.  (5)  Exercise that does not require skilled services.  (6)  Parenting or child care for or on behalf of the member.  (7)  Reminders and cueing.  (8)  Services provided simultaneously with any other similar service regardless of funding source, including other waiver services and state supplementary assistance in-home health-related care services.  (9)  Transportation costs.  (10)  Wait times for any activity.
      78.41(9)    Interim medical monitoring and treatment services.  Interim medical monitoring and treatment (IMMT) services are monitoring and treatment of a medical nature for children or adults aged 18 to 20 whose medical needs make alternative care unavailable, inadequate, or insufficient. IMMT services are not intended to provide day care but to supplement available resources. Services must be ordered by a physician.  a.  Need for service. The member must be currently receiving home health agency services under rule 441—78.9(249A) and require medical assessment, medical monitoring, and regular medical intervention or intervention in a medical emergency during those services. The service worker or case manager must identify the need for IMMT services after evaluating the member’s living environment, family and natural supports, ability to perform activities of daily living, and health care needs. The services must be needed:  (1)  To allow the member’s usual caregivers to be employed,  (2)  During a search for employment by a usual caregiver,  (3)  To allow for academic or vocational training of a usual caregiver,  (4)  Due to the hospitalization of a usual caregiver for treatment for physical or mental illness, or  (5)  Due to the death of a usual caregiver.  b.  Service requirements. Interim medical monitoring and treatment services shall:  (1)  Provide experiences for each member’s social, emotional, intellectual, and physical development;  (2)  Include comprehensive developmental care and any special services for a member with special needs; and  (3)  Include medical assessment, medical monitoring, and medical intervention as needed on a regular or emergency basis. Medical intervention means the ability to assess the situation and contact the appropriate medical professional, not the direct application of medical care.  c.  Interim medical monitoring and treatment services may include supervision while the member is being transported to and from school.  d.  Limitations.  (1)  A maximum of 12 hours of service is available per day.  (2)  Covered services do not include a complete nutritional regimen.  (3)  Interim medical monitoring and treatment services may not duplicate any regular Medicaid or waiver services provided under the state plan. Services under the state plan, including home health agency services under rule 441—78.9(249A), must be exhausted before IMMT services are accessed.  (4)  Interim medical monitoring and treatment services shall be provided in the following settings that are approved by the department as integrated, community-based settings: the member’s home; a registered child development home; a licensed child care center, residential care facility, or adult day care facility; or during the time when the member is being transported to and from school.  (5)  The member-to-staff ratio shall not be more than six members to one staff person.  (6)  The parent or guardian of the member shall be responsible for the usual and customary nonmedical cost of day care during the time in which the member is receiving IMMT services. Medical care necessary for monitoring and treatment is an allowable IMMT cost. If the cost of care goes above the usual and customary cost of day care services due to the member’s medical condition, the costs above the usual and customary cost shall be covered as IMMT services.  e.  A unit of service is 15 minutes.  78.41(10)    Residential-based supported community living services.  Residential-based supported community living services are medical or remedial services provided to children under the age of 18 while living outside their home in a residential-based living environment furnished by the residential-based supported community living service provider. The services eliminate barriers to family reunification or develop self-help skills for maximum independence.  a.  Allowable service components are the following:  (1)  Daily living skills development. These are services to develop the child’s ability to function independently in the community on a daily basis, including training in food preparation, maintenance of living environment, time and money management, personal hygiene, and self-care.  (2)  Social skills development. These are services to develop a child’s communication and socialization skills, including interventions to develop a child’s ability to solve problems, resolve conflicts, develop appropriate relationships with others, and develop techniques for controlling behavior.  (3)  Family support development. These are services necessary to allow a child to return to the child’s family or another less restrictive service environment. These services must include counseling and therapy sessions that involve both the child and the child’s family at least 50 percent of the time and that focus on techniques for dealing with the special care needs of the child and interventions needed to alleviate behaviors that are disruptive to the family or other group living unit.  (4)  Counseling and behavior intervention services. These are services to halt, control, or reverse stress and social, emotional, or behavioral problems that threaten or have negatively affected the child’s stability. Activities under this service include counseling and behavior intervention with the child, including interventions to ameliorate problem behaviors.  b.  Residential-based supported community living services must also address the ordinary daily-living needs of the child, excluding room and board, such as needs for safety and security, social functioning, and other medical care.  c.  Residential-based supported community living services do not include services associated with vocational needs, academics, day care, Medicaid case management, other case management, or any other services that the child can otherwise obtain through Medicaid.  d.  Room and board costs are not reimbursable as residential-based supported community living services.  e.  The scope of service shall be identified in the child’s service plan pursuant to 441—paragraph 77.37(23)“d.”  f.  Residential-based supported community living services shall not be simultaneously reimbursed with other residential services provided under an HCBS waiver or otherwise provided under the Medicaid program.  g.  A unit of service is a day.  h.  The maximum number of units of residential-based supported community living services available per child is 365 daily units per state fiscal year, except in a leap year when 366 daily units are available.  78.41(11)    Transportation.  Transportation services may be provided for members to conduct business errands and essential shopping, to travel to and from work or day programs, and to reduce social isolation. A unit of service is one mile of transportation or one one-way trip. Transportation may not be reimbursed when HCBS intellectual disability waiver daily supported community living service is authorized in a member’s service plan.  78.41(12)    Adult day care services.  Adult day care services provide an organized program of supportive care in a group environment to persons who need a degree of supervision and assistance on a regular or intermittent basis in a day care center. A unit of service is 15 minutes (up to four units per day), a half day (1.25 to 4 hours per day), or a full day (4.25 to 12 hours per day). Components of the service include health-related care, social services, and other related support services.  78.41(13)    Prevocational services.  Prevocational services are service activities provided pursuant to subrule 78.27(9).   78.41(14)    Day habilitation.  Day habilitation services will be provided pursuant to subrule 78.27(8).  78.41(15)    Consumer choices option.  The consumer choices option is service activities provided pursuant to subrule 78.34(13).  78.41(16)    General service standards.  All intellectual disability waiver services must be provided in accordance with the following standards:  a.  Reimbursement shall not be available under the waiver for any services that the member can obtain as other nonwaiver Medicaid services or through any other funding source.  b.  All services provided under the waiver must be delivered in the least restrictive environment possible and in conformity with the member’s service plan.  c.  All rights restrictions must be implemented in accordance with 441—subrule 77.25(4). The member service plan or treatment plan shall include documentation of:   (1)  Any restrictions on the member’s rights, including the rights of privacy, dignity, respect, and freedom from coercion and restraint.  (2)  The need for the restriction.  (3)  The less intrusive methods of meeting the need that have been tried but did not work.  (4)  Either a plan to restore those rights or written documentation that a plan is not necessary or appropriate.   (5)  Established time limits for periodic reviews to determine if the restriction is still necessary or can be terminated.  (6)  The informed consent of the member.  (7)  An assurance that the interventions and supports will cause no harm to the member.  (8)  A regular collection and review of data to measure the ongoing effectiveness of the restriction.  d.  Services must be billed in whole units.  e.  For all services with a 15-minute unit of service, the following rounding process will apply:  (1)  Add together the minutes spent on all billable activities during a calendar day for a daily total.  (2)  For each day, divide the total minutes spent on billable activities by 15 to determine the number of full 15-minute units for that day.  (3)  Round the remainder using these guidelines: Round 1 to 7 minutes down to zero units; round 8 to 14 minutes up to one unit.  (4)  Add together the number of full units and the number of rounded units to determine the total number of units to bill for that day.This rule is intended to implement Iowa Code section 249A.4.
    Related ARC(s): 9045B, 9403B, 9650B, 9704B, 9884B, 0707C, 0709C, 0842C, 1056C, 1071C, 1610C, 2050C, 2471C, 2848C, 2936C, 3481C, 3790C, 3874C, 4430C, 5305C, 5307C, 5597C441—78.42(249A)  Pharmacists providing covered vaccines.  When the authorized pharmacist providing the vaccine meets all Iowa board of pharmacy expanded practice standards and Medicaid requirements, payment will be made for the following:   78.42(1)    Vaccines administered to children.  Payment will be made to an enrolled provider for an administration fee for vaccines available through the Vaccines for Children (VFC) program administered by the department of public health if the provider is enrolled in the VFC program. Payment will be made for the vaccine cost only if the VFC program stock has been depleted.   78.42(2)    Vaccines administered to adults.  Payment will be made to an enrolled provider for an administration fee and vaccine cost.   78.42(3)    Verification and reporting.  Prior to the ordering and administration of an immunization pursuant to statewide protocol, the authorized pharmacist shall consult and review the Iowa Immunization Registry Information System (IRIS) or Iowa Health Information Network (IHIN). Within 30 calendar days following administration of any vaccine, the pharmacist shall report such administration to the patient’s primary health care provider, primary physician, and IRIS or IHIN. If a patient does not have a primary health care provider, the pharmacist shall provide the patient with a written record of the vaccine administered to the patient and shall advise the patient to consult a physician.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 5175C441—78.43(249A)  HCBS brain injury waiver services.  Payment shall be approved for the following services to members eligible for the HCBS brain injury waiver services as established in 441—Chapter 83 and as identified in the member’s service plan. Effective March 17, 2022, payment shall only be made for services provided in integrated, community-based settings that support full access of members receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS.  78.43(1)    Case management services.  Individual case management services means services that assist members who reside in a community setting or are transitioning to a community setting in gaining access to needed medical, social, educational, housing, transportation, vocational, and other appropriate services in order to ensure the health, safety, and welfare of the member.  a.  Case management services shall be provided as set forth in rules 441—90.4(249A) through 441—90.7(249A).  b.  The service shall be delivered in such a way as to enhance the capabilities of consumers and their families to exercise their rights and responsibilities as citizens in the community. The goal is to enhance the ability of the consumer to exercise choice, make decisions, take risks that are a typical part of life, and fully participate as members of the community.  c.  The case manager must develop a relationship with the consumer so that the abilities, needs and desires of the consumer can be clearly identified and communicated and the case manager can help to ensure that the system and specific services are responsive to the needs of the individual consumers.  d.  Members who are eligible for targeted case management are not eligible for case management as a waiver service.  78.43(2)    Supported community living services.  Supported community living services are provided by the provider within the member’s home and community, according to the individualized member need as identified in the service plan.  a.  The basic components of the service may include, but are not limited to, personal and home skills training services, individual advocacy services, community skills training services, personal environment support services, transportation, and treatment services.  (1)  Personal and home skills training services are activities which assist a member to develop or maintain skills for self-care, self-directedness, and care of the immediate environment.  (2)  Individual advocacy is the act or process of representing the member’s rights and interests in order to realize the rights to which the member is entitled and to remove barriers to meeting the member’s needs.  (3)  Community skills training services are activities which assist a member to develop or maintain skills allowing better participation in the community. Services shall focus on the following areas as they apply to the member being served:
    1. Personal management skills training services are activities 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.
    2. 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.
    3. 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.
      (4)  Personal and environmental support services are those activities and expenditures provided to or on behalf of a member in the areas of personal needs in order to allow the member to function in the least restrictive environment.  (5)  Transportation services are activities and expenditures designed to assist the member to travel from one place to another to obtain services or carry out life’s activities. The services exclude transportation provided as nonemergency medical transportation pursuant to rule 441—78.13(249A).  (6)  Treatment services are activities designed to assist the member to maintain or improve physiological, emotional and behavioral functioning and to prevent conditions that would present barriers to the member’s functioning. Treatment services include physical or physiological treatment and psychotherapeutic treatment.
    1. Physiological treatment includes medication regimens designed to prevent, halt, control, relieve, or reverse symptoms or conditions which interfere with the normal functioning of the human body. Physiological treatment shall be provided by or under the direct supervision of a certified or licensed health care professional.
    2. Psychotherapeutic treatment means activities provided to assist a member in the identification or modification of beliefs, emotions, attitudes, or behaviors in order to maintain or improve the member’s functioning in response to the physical, emotional, and social environment.
      b.  The supported community living services are intended to provide for the daily living needs of the member and shall be available as needed during any 24-hour period. Activities do not include those associated with vocational services, academics, day care, medical services, Medicaid case management or other case management. Services are individualized supportive services provided in a variety of community-based, integrated settings.  (1)  Supported community living services shall be available at a daily rate to members living outside the home of their family, legal representative, or foster family and for whom a provider has primary responsibility for supervision or structure during the month. This service shall provide supervision or structure in identified periods when another resource is not available.  (2)  Supported community living services shall be available at a 15-minute rate to members for whom a daily rate is not established.  c.  Services may be provided to a child or an adult. Children must first access all other services for which they are eligible and which are appropriate to meet their needs before accessing the HCBS brain injury waiver services. A maximum of four persons may reside in a living unit.  (1)  A member may live in the home of the member’s family or legal representative or in another typical community living arrangement.  (2)  A member living with the member’s family or legal representative is not subject to the maximum of four residents in a living unit.  (3)  A member may not live in a licensed medical or health care facility or in a setting that is required to be licensed as a medical or health care facility.  d.  A member aged 17 or under living in the home of the member’s family, legal representative, or foster family shall receive services based on development of adaptive, behavior, or health skills. Duration of services shall be based on age-appropriateness and individual attention span.  e.  Provider budgets shall reflect all staff-to-member ratios and shall reflect costs associated with members’ specific support needs for travel and transportation, consulting, instruction, and environmental modifications and repairs, as determined necessary by the interdisciplinary team for each member. The specific support needs must be identified in the Medicaid case manager’s service plan, the total costs shall not exceed $1570 per member per year, and the provider must maintain records to support the expenditures. A unit of service is:  (1)  One full calendar day when a member residing in the living unit receives on-site staff supervision for eight or more hours per day as an average over a calendar month and the member’s service plan identifies and reflects the need for this amount of supervision.  (2)  Fifteen minutes when subparagraph 78.43(2)“e”(1) does not apply.  f.  The maximum number of units available per member is as follows:  (1)  365 daily units per state fiscal year except a leap year, when 366 daily units are available.  (2)  33,580 15-minute units per state fiscal year except a leap year, when 33,672 15-minute units are available.  g.  The service shall be identified in the member’s service plan.  h.  Supported community living services shall not be simultaneously reimbursed with other residential services or with respite, transportation, personal assistance, nursing, or home health aide services provided through Medicaid or the HCBS brain injury waiver.
      78.43(3)    Respite care services.  Respite care services are services provided to the member that give temporary relief to the usual caregiver and provide all the necessary care that the usual caregiver would provide during that period. The purpose of respite care is to enable the member to remain in the member’s current living situation.  a.  Services provided outside the member’s home shall not be reimbursable if the living unit where respite is provided is reserved for another person on a temporary leave of absence.  b.  Member-to-staff ratios shall be appropriate to the individual needs of the member as determined by the member’s interdisciplinary team.  c.  A unit of service is 15 minutes.  d.  Respite care is not to be provided to members during the hours in which the usual caregiver is employed except when the member is attending a 24-hour residential camp. Respite care shall not be used as a substitute for a child’s day care. Respite care cannot be provided to a member whose usual caregiver is a consumer-directed attendant care provider for the member.  e.  The interdisciplinary team shall determine if the member will receive basic individual respite, specialized respite or group respite as defined in 441—Chapter 83.  f.  A maximum of 14 consecutive days of 24-hour respite care may be reimbursed.  g.  Respite services provided for a period exceeding 24 consecutive hours to three or more individuals who require nursing care because of a mental or physical condition must be provided by a health care facility licensed as described in Iowa Code chapter 135C.  h.  Respite services shall not be provided simultaneously with other residential, supported community living services, nursing, or home health aide services provided through the medical assistance program.  78.43(4)    Supported employment services.  Supported employment services are service activities provided pursuant to subrule 78.27(10).  78.43(5)    Home and vehicle modification.  Covered home or vehicle modifications are physical modifications to the member’s home or vehicle that directly address the member’s medical or remedial need. Covered modifications must be necessary to provide for the health, welfare, or safety of the member and enable the member to function with greater independence in the home or vehicle.  a.  Modifications that are necessary or desirable without regard to the member’s medical or remedial need and that would be expected to increase the fair market value of the home or vehicle, such as furnaces, fencing, or adding square footage to the residence, are excluded except as specifically included below. Purchasing or leasing of a motorized vehicle is excluded. Home and vehicle repairs are also excluded.  b.  Only the following modifications are covered:  (1)  Kitchen counters, sink space, cabinets, special adaptations to refrigerators, stoves, and ovens.  (2)  Bathtubs and toilets to accommodate transfer, special handles and hoses for shower heads, water faucet controls, and accessible showers and sink areas.  (3)  Grab bars and handrails.  (4)  Turnaround space adaptations.  (5)  Ramps, lifts, and door, hall and window widening.  (6)  Fire safety alarm equipment specific for disability.  (7)  Voice-activated, sound-activated, light-activated, motion-activated, and electronic devices directly related to the member’s disability.  (8)  Vehicle lifts, driver-specific adaptations, remote-start systems, including such modifications already installed in a vehicle.  (9)  Keyless entry systems.  (10)  Automatic opening device for home or vehicle door.  (11)  Special door and window locks.  (12)  Specialized doorknobs and handles.  (13)  Plexiglas replacement for glass windows.  (14)  Modification of existing stairs to widen, lower, raise or enclose open stairs.  (15)  Motion detectors.  (16)  Low-pile carpeting or slip-resistant flooring.  (17)  Telecommunications device for the deaf.  (18)  Exterior hard-surface pathways.  (19)  New door opening.  (20)  Pocket doors.  (21)  Installation or relocation of controls, outlets, switches.  (22)  Air conditioning and air filtering if medically necessary.  (23)  Heightening of existing garage door opening to accommodate modified van.  (24)  Bath chairs.  c.  A unit of service is the completion of needed modifications or adaptations.  d.  All modifications and adaptations shall be provided in accordance with applicable federal, state, and local building and vehicle codes.  e.  Services shall be performed following prior department approval of the modification as specified in 441—subrule 79.1(17) and a binding contract between the provider and the member.  f.  All contracts for home or vehicle modification shall be awarded through competitive bidding. The contract shall include the scope of work to be performed, the time involved, supplies needed, the cost, diagrams of the project whenever applicable, and an assurance that the provider has liability and workers’ compensation coverage and the applicable permit and license.  g.  Service payment shall be made to the enrolled home or vehicle modification provider. If applicable, payment will be forwarded to the subcontracting agency by the enrolled home or vehicle modification provider following completion of the approved modifications. Payment of up to $6,366.64 per year may be made to certified providers upon satisfactory completion of the service.   h.  Services shall be included in the member’s service plan and shall exceed the Medicaid state plan services.  78.43(6)    Personal emergency response or portable locator system.    a.  A personal emergency response system is an electronic device that transmits a signal to a central monitoring station to summon assistance in the event of an emergency.  (1)  The necessary components of a system are:
    1. An in-home medical communications transceiver.
    2. A remote, portable activator.
    3. A central monitoring station with backup systems staffed by trained attendants at all times.
    4. Current data files at the central monitoring station containing response protocols and personal, medical and emergency information for each member.
      (2)  The service shall be identified in the member’s service plan.  (3)  A unit is a one-time installation fee or one month of service.  (4)  Maximum units per state fiscal year shall be the initial installation and 12 months of service.
      b.  A portable locator system is an electronic device that transmits a signal to a monitoring device. The system allows a member to access assistance in the event of an emergency and allows law enforcement or the monitoring system provider to locate a member who is unable to request help or to activate a system independently. The member must be unable to access assistance in an emergency situation due to the member’s age or disability.  (1)  The required components of the portable locator system are:
    1. A portable communications transceiver or transmitter to be worn or carried by the member.
    2. Monitoring by the provider at a central location with response protocols and personal, medical, and emergency information for each member as applicable.
      (2)  The service shall be identified in the member’s service plan.  (3)  Payable units of service are purchase of equipment, an installation or set-up fee, and monthly fees.  (4)  Maximum units per state fiscal year shall be one equipment purchase, one installation or set-up fee, and 12 months of service.
      78.43(7)    Transportation.  Transportation services may be provided for members to conduct business errands and essential shopping, to travel to and from work or day programs, and to reduce social isolation. A unit of service is one mile of transportation or one one-way trip. Transportation may not be reimbursed simultaneously with HCBS brain injury waiver supported community living service when the transportation costs are included within the supported community living reimbursement rate.  78.43(8)    Specialized medical equipment.    a.  Specialized medical equipment shall include medically necessary items which are for personal use by members with a brain injury and which:  (1)  Provide for health and safety of the member,  (2)  Are not ordinarily covered by Medicaid,  (3)  Are not funded by educational or vocational rehabilitation programs, and  (4)  Are not provided by voluntary means.  b.  Coverage includes, but is not limited to:  (1)  Electronic aids and organizers.  (2)  Medicine dispensing devices.  (3)  Communication devices.  (4)  Bath aids.  (5)  Noncovered environmental control units.  (6)  Repair and maintenance of items purchased through the waiver.  c.  Payment of up to $6,366.64 per year may be made to enrolled specialized medical equipment providers upon satisfactory receipt of the service. Each month within the 12-month period, the service worker shall encumber an amount within the monthly dollar cap allowed for the member until the amount of the equipment cost is reached.  d.  The need for specialized medical equipment shall be:  (1)  Documented by a health care professional as necessary for the member’s health and safety, and  (2)  Identified in the member’s service plan.  e.  Payment for most items shall be based on a fee schedule. The amount of the fee shall be determined as directed in 441—subrule 79.1(17).  78.43(9)    Adult day care services.  Adult day care services provide an organized program of supportive care in a group environment to persons who need a degree of supervision and assistance on a regular or intermittent basis in a day care center. A unit of service is 15 minutes (up to four units per day), a half day (1.25 to 4 hours per day), a full day (4.25 to 8 hours per day), or an extended day (8.25 to 12 hours per day). Components of the service include health-related care, social services, and other related support services.  78.43(10)    Family counseling and training services.  Family counseling and training services are face-to-face mental health services provided to the consumer and the family with whom the consumer lives, or who routinely provide care to the consumer to increase the consumer’s or family members’ capabilities to maintain and care for the consumer in the community. Counseling may include helping the consumer or the consumer’s family members with crisis, coping strategies, stress reduction, management of depression, alleviation of psychosocial isolation and support in coping with the effects of a brain injury. It may include the use of treatment regimes as specified in the ITP. Periodic training updates may be necessary to safely maintain the consumer in the community.Family may include spouse, children, friends, or in-laws of the consumer. Family does not include individuals who are employed to care for the consumer.  78.43(11)    Prevocational services.  Prevocational services are service activities provided pursuant to subrule 78.27(9).  78.43(12)    Behavioral programming.  Behavioral programming consists of individually designed strategies to increase the consumer’s appropriate behaviors and decrease the consumer’s maladaptive behaviors which have interfered with the consumer’s ability to remain in the community. Behavioral programming includes:  a.  A complete assessment of both appropriate and maladaptive behaviors.  b.  Development of a structured behavioral intervention plan which should be identified in the ITP.  c.  Implementation of the behavioral intervention plan.  d.  Ongoing training and supervision to caregivers and behavioral aides.  e.  Periodic reassessment of the plan.Types of appropriate behavioral programming include, but are not limited to, clinical redirection, token economies, reinforcement, extinction, modeling, and over-learning.  78.43(13)    Consumer-directed attendant care service.  Consumer-directed attendant care services are service activities performed by a person to help a member with self-care tasks which the member would typically do independently if the member were otherwise able. Covered service activities are limited to the nonskilled activities listed in paragraph 78.43(13)“f” and the skilled activities listed in paragraph 78.43(13)“g.” Covered service activities must be essential to the health, safety, and welfare of the member. Services may be provided in the absence of a parent or guardian if the parent or guardian has given advance direction for the service provision.  a.    Service planning.    (1)  The member, parent, guardian, or attorney in fact under a durable power of attorney for health care shall:
    1. Select the individual or agency that will provide the components of the attendant care services.
    2. 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.
    3. 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.
    4. 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.
      (2)  Whenever a legal representative acts as a provider of consumer-directed attendant care as allowed by 441—paragraph 79.9(7)“b,” the following shall apply:
    1. 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;
    2. The legal representative may not be paid for more than 40 hours of service per week; and
    3. 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.
      b.    Supervision of skilled services.  Skilled consumer-directed attendant care services shall be provided under the supervision of a licensed nurse or licensed therapist working under the direction of a physician. The licensed nurse or therapist shall:  (1)  Retain accountability for actions that are delegated.  (2)  Ensure appropriate assessment, planning, implementation, and evaluation.  (3)  Make on-site supervisory visits every two weeks with the service provider present.  c.    Service documentation.  The consumer-directed attendant care provider shall document evidence of compliance with the requirements of this chapter and rule 441—79.3(249A). The documentation or copies of the documentation must be maintained or be electronically accessible by the consumer-directed attendant care provider. Providers must use an electronic visit verification system that captures all documentation requirements of the Consumer-Directed Attendant Care (CDAC) Service Record (Form 470-4389) or use Form 470-4389. Any service component that is not documented in accordance with rule 441—79.3(249A) shall not be payable.  d.    Role of guardian or attorney.  If the member has a guardian or attorney in fact under a durable power of attorney for health care:  (1)  The service worker’s or case manager’s service plan shall address how consumer-directed attendant care services will be monitored to ensure that the member’s needs are being adequately met. If the guardian or attorney in fact is the service provider, the service plan shall address how the service worker or case manager shall oversee service provision.  (2)  The guardian or attorney in fact shall sign the claim form in place of the member, indicating that the service has been provided as presented on the claim.  e.    Service units and billing.  A unit of service is 15 minutes provided by an individual or agency. Each service shall be billed in whole units.  f.    Nonskilled services.  Covered nonskilled service activities are limited to help with the following activities:  (1)  Dressing.  (2)  Bathing, shampooing, hygiene, and grooming.  (3)  Access to and from bed or a wheelchair, transferring, ambulation, and mobility in general.  (4)  Toileting, including bowel, bladder, and catheter assistance (emptying the catheter bag, collecting a specimen, and cleaning the external area around the catheter).  (5)  Meal preparation, cooking, and assistance with feeding, not including the cost of meals themselves. Meal preparation and cooking shall be provided only in the member’s home.  (6)  Housekeeping, laundry, and shopping essential to the member’s health care at home.  (7)  Taking medications ordinarily self-administered, including those ordered by a physician or other qualified health care provider.  (8)  Minor wound care.  (9)  Going to or returning from a place of employment and job-related tasks while the member is on the job site. Transportation for the member and assistance with understanding or performing the essential job functions are not included in consumer-directed attendant care services.  (10)  Tasks, such as financial management and scheduling, that require cognitive or physical assistance.  (11)  Communication essential to the health and welfare of the member, through interpreting and reading services and use of assistive devices for communication.  (12)  Using transportation essential to the health and welfare of the member. The cost of the transportation is not included.  g.    Skilled services.  Covered skilled service activities are limited to help with the following activities:  (1)  Tube feedings of members unable to eat solid foods.  (2)  Intravenous therapy administered by a registered nurse.  (3)  Parenteral injections required more than once a week.  (4)  Catheterizations, continuing care of indwelling catheters with supervision of irrigations, and changing of Foley catheters when required.  (5)  Respiratory care including inhalation therapy and tracheotomy care or tracheotomy care and ventilator.  (6)  Care of decubiti and other ulcerated areas, noting and reporting to the nurse or therapist.  (7)  Rehabilitation services including, but not limited to, bowel and bladder training, range of motion exercises, ambulation training, restorative nursing services, respiratory care and breathing programs, reality orientation, reminiscing therapy, remotivation, behavior modification, and reteaching of the activities of daily living.  (8)  Colostomy care.  (9)  Care of uncontrolled medical conditions, such as brittle diabetes, and comfort care of terminal conditions.  (10)  Postsurgical nursing care.  (11)  Monitoring medications requiring close supervision because of fluctuating physical or psychological conditions, e.g., antihypertensives, digitalis preparations, mood-altering or psychotropic drugs, or narcotics.  (12)  Preparing and monitoring response to therapeutic diets.  (13)  Recording and reporting of changes in vital signs to the nurse or therapist.  h.    Excluded services and costs.  Services, activities, costs and time that are not covered as consumer-directed attendant care include the following (not an exclusive list):  (1)  Any activity related to supervising a member. Only direct services are billable.  (2)  Any activity that the member is able to perform.  (3)  Costs of food.  (4)  Costs for the supervision of skilled services by the nurse or therapist. The supervising nurse or therapist may be paid from private insurance, Medicare, or other third-party payment sources, or may be paid as another Medicaid service, including early and periodic screening, diagnosis and treatment services.  (5)  Exercise that does not require skilled services.  (6)  Parenting or child care for or on behalf of the member.  (7)  Reminders and cueing.  (8)  Services provided simultaneously with any other similar service regardless of funding source, including other waiver services and state supplementary assistance in-home health-related care services.  (9)  Transportation costs.  (10)  Wait times for any activity.
      78.43(14)    Interim medical monitoring and treatment services.  Interim medical monitoring and treatment (IMMT) services are monitoring and treatment of a medical nature for children or adults aged 18 to 20 whose medical needs make alternative care unavailable, inadequate, or insufficient. IMMT services are not intended to provide day care but to supplement available resources. Services must be ordered by a physician.  a.  Need for service. The member must be currently receiving home health agency services under rule 441—78.9(249A) and require medical assessment, medical monitoring, and regular medical intervention or intervention in a medical emergency during those services. The service worker or case manager must identify the need for IMMT services after evaluating the member’s living environment, family and natural supports, ability to perform activities of daily living, and health care needs. The services must be needed:  (1)  To allow the member’s usual caregivers to be employed,  (2)  During a search for employment by a usual caregiver,  (3)  To allow for academic or vocational training of a usual caregiver,  (4)  Due to the hospitalization of a usual caregiver for treatment for physical or mental illness, or  (5)  Due to the death of a usual caregiver.  b.  Service requirements. Interim medical monitoring and treatment services shall:  (1)  Provide experiences for each member’s social, emotional, intellectual, and physical development;  (2)  Include comprehensive developmental care and any special services for a member with special needs; and  (3)  Include medical assessment, medical monitoring, and medical intervention as needed on a regular or emergency basis. Medical intervention means the ability to assess the situation and contact the appropriate medical professional, not the direct application of medical care.  c.  Interim medical monitoring and treatment services may include supervision while the member is being transported to and from school.  d.  Limitations.  (1)  A maximum of 12 hours of service is available per day.  (2)  Covered services do not include a complete nutritional regimen.  (3)  Interim medical monitoring and treatment services may not duplicate any regular Medicaid or waiver services provided under the state plan. Services under the state plan, including home health agency services under rule 441—78.9(249A), must be exhausted before IMMT services are accessed.  (4)  Interim medical monitoring and treatment services shall be provided in the following settings that are approved by the department as integrated, community-based settings: the member’s home; a registered child development home; a licensed child care center, residential care facility, or adult day care facility; or during the time when the member is being transported to and from school.  (5)  The member-to-staff ratio shall not be more than six members to one staff person.  (6)  The parent or guardian of the member shall be responsible for the usual and customary nonmedical cost of day care during the time in which the member is receiving IMMT services. Medical care necessary for monitoring and treatment is an allowable IMMT cost. If the cost of care goes above the usual and customary cost of day care services due to the member’s medical condition, the costs above the usual and customary cost shall be covered as IMMT services.  e.  A unit of service is 15 minutes.  78.43(15)    Consumer choices option.  The consumer choices option is service activities provided pursuant to subrule 78.34(13).  78.43(16)    General service standards.  All brain injury waiver services must be provided in accordance with the following standards:  a.  Reimbursement shall not be available under the waiver for any services that the member can obtain as other nonwaiver Medicaid services or through any other funding source.  b.  All services provided under the waiver must be delivered in the least restrictive environment possible and in conformity with the member’s service plan.  c.  All rights restrictions must be implemented in accordance with 441—subrule 77.25(4). The member service plan or treatment plan shall include documentation of:   (1)  Any restrictions on the member’s rights, including the rights of privacy, dignity, respect, and freedom from coercion and restraint.  (2)  The need for the restriction.  (3)  The less intrusive methods of meeting the need that have been tried but did not work.  (4)  Either a plan to restore those rights or written documentation that a plan is not necessary or appropriate.   (5)  Established time limits for periodic reviews to determine if the restriction is still necessary or can be terminated.  (6)  The informed consent of the member.  (7)  An assurance that the interventions and supports will cause no harm to the member.  (8)  A regular collection and review of data to measure the ongoing effectiveness of the restriction.  d.  Services must be billed in whole units.  e.  For all services with a 15-minute unit of service, the following rounding process will apply:  (1)  Add together the minutes spent on all billable activities during a calendar day for a daily total.  (2)  For each day, divide the total minutes spent on billable activities by 15 to determine the number of full 15-minute units for that day.  (3)  Round the remainder using these guidelines: Round 1 to 7 minutes down to zero units; round 8 to 14 minutes up to one unit.  (4)  Add together the number of full units and the number of rounded units to determine the total number of units to bill for that day.This rule is intended to implement Iowa Code section 249A.4.
    Related ARC(s): 7957B, 9045B, 9403B, 9704B, 9884B, 0191C, 0359C, 0707C, 0709C, 0842C, 1056C, 1071C, 1610C, 2050C, 2471C, 2848C, 2936C, 3874C, 4430C, 4897C, 5305C, 5597C441—78.44(249A)  Lead inspection services.  Payment shall be approved for lead inspection services. This service shall be provided for children who have had two venous blood lead levels of 15 to 19 micrograms per deciliter or one venous level greater than or equal to 20 micrograms per deciliter. This service includes, but is not limited to, X-ray fluorescence analyzer (XRF) readings, visual examination of paint, preventive education of the resident and homeowner, health education about lead poisoning, and a written report to the family, homeowner, medical provider, and local childhood lead poisoning prevention program.This rule is intended to implement Iowa Code section 249A.4.441—78.45(249A)  Assertive community treatment.  Assertive community treatment (ACT) services are comprehensive, integrated, and intensive outpatient services provided by a multidisciplinary team under the supervision of a psychiatrist. ACT services are directed toward the rehabilitation of behavioral, social, or emotional deficits or the amelioration of symptoms of a mental disorder. Most services are delivered in the member’s home or another community setting.  78.45(1)    Applicability.  ACT services may be provided only to a member who meets all of the following criteria:  a.  The member is at least 17 years old.  b.  The member has a severe and persistent mental illness or complex mental health symptomatology. A severe and persistent mental illness is a psychiatric disorder that causes symptoms and impairments in basic mental and behavioral processes that produce distress and major functional disability in adult role functioning (such as social, personal, family, educational or vocational roles). Specifically, the member has a degree of impairment arising from a psychiatric disorder such that:  (1)  The member does not have the resources or skills necessary to maintain an adequate level of functioning in the home or community environment without assistance or support;  (2)  The member’s judgment, impulse control, or cognitive perceptual abilities are compromised; and  (3)  The member exhibits significant impairment in social, interpersonal, or familial functioning.  c.  The member has a validated principal mental health diagnosis consistent with a severe and persistent mental illness. For this purpose, a mental health diagnosis means a disorder, dysfunction, or dysphoria diagnosed pursuant to the current version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, excluding neurodevelopmental disorders, substance-related disorders, personality disorders, medication-induced movement disorders and other adverse effects of medication, and other conditions that may be a focus of clinical attention. Members with a primary diagnosis of substance-related disorder, developmental disability, or organic disorder are not eligible for ACT services.  d.  The member needs a consistent team of professionals and multiple mental health and support services to maintain the member in the community and reduce hospitalizations, as evidenced by:  (1)  A pattern of repeated treatment failures with at least two hospitalizations within the previous 24 months, or  (2)  A need for multiple or combined mental health and basic living supports to prevent the need for a more intrusive level of care.  e.  The member presents a reasonable likelihood that ACT services will lead to specific, observable improvements in the member’s functioning and assist the member in achieving or maintaining community tenure. Specifically, the member:  (1)  Is medically stable;  (2)  Does not require a level of care that includes more intensive medical monitoring;  (3)  Presents a low risk to self, others, or property, with treatment and support; and  (4)  Lives independently in the community or demonstrates a capacity to live independently and move from a dependent residential setting to independent living.  f.  At the time of admission, the member has a comprehensive assessment that includes psychiatric history, medical history, work and educational history, substance use, problems with activities of daily living, social interests, and family relationships.   g.  The member has a written treatment plan containing a work evaluation and the necessary psychiatric rehabilitation treatment and support services. The plan shall identify:  (1)  Treatment objectives and outcomes,  (2)  The expected frequency and duration of each service,  (3)  The location where the services will be provided,  (4)  A crisis plan, and  (5)  The schedule for updates of the treatment plan.  78.45(2)    Services.  The ACT team shall participate in all mental health services provided to the member and shall provide 24-hour service for the psychiatric needs of the member. Available ACT services are:  a.    Evaluation and medication management.    (1)  The evaluation portion of ACT services consists of a comprehensive mental health evaluation and assessment of the member by a psychiatrist, advanced registered nurse practitioner, or physician assistant.  (2)  Medication management consists of the prescription and management of medication by a psychiatrist, advanced registered nurse practitioner, or physician assistant to respond to the member’s complaints and symptoms. A psychiatric registered nurse assists in this management by contact with the member regarding medications and their effect on the member’s complaints and symptoms.  b.    Integrated therapy and counseling for mental health and substance abuse.  This service consists of direct counseling for treatment of mental health and substance abuse symptoms by a psychiatrist, licensed mental health professional, advanced registered nurse practitioner, physician assistant, or substance abuse specialist. Individual counseling is provided by other team members under the supervision of a psychiatrist or licensed mental health practitioner.  c.    Skill teaching.  Skill teaching consists of side-by-side demonstration and observation of daily living activities by a registered nurse, licensed mental health professional, psychologist, substance abuse counselor, peer specialist, community support specialist, advanced registered nurse practitioner, or physician assistant.  d.    Community support.  Community support is provided by a licensed mental health professional, psychologist, substance abuse counselor, peer specialist, community support specialist, advanced registered nurse practitioner, or physician assistant. Community support consists of the following activities focused on recovery and rehabilitation:  (1)  Personal and home skills training to assist the member to develop and maintain skills for self-direction and coping with the living situation.  (2)  Community skills training to assist the member in maintaining a positive level of participation in the community through development of socialization skills and personal coping skills.  e.    Medication monitoring.  Medication monitoring services are provided by a psychiatric nurse and other team members under the supervision of a psychiatrist or psychiatric nurse and consist of:  (1)  Monitoring the member’s day-to-day functioning, medication compliance, and access to medications; and  (2)  Ensuring that the member keeps appointments.  f.    Case management for treatment and service plan coordination.  Case management consists of the development by the ACT team of an individualized treatment and service plan, including personalized goals and outcomes, to address the member’s medical symptoms and remedial functional impairments.  (1)  Case management includes:
    1. Assessments, referrals, follow-up, and monitoring.
    2. Assisting the member in gaining access to necessary medical, social, educational, and other services.
    3. Assessing the member to determine service needs by collecting relevant historical information through member records and other information from relevant professionals and natural supports.
      (2)  The team shall:
    1. Develop a specific care plan based on the assessment of needs, including goals and actions to address the needed medical, social, educational, and other necessary services.
    2. Make referrals to services and related activities to assist the member with the assessed needs.
    3. Monitor and perform follow-up activities necessary to ensure that the plan is carried out and that the member has access to necessary services. Activities may include monitoring contacts with providers, family members, natural supports, and others.
    4. Hold daily team meetings to facilitate ACT services and coordinate the member’s care with other members of the team.
      g.    Crisis response.  Crisis response consists of direct assessment and treatment of the member’s urgent or crisis symptoms in the community by a registered nurse, licensed mental health professional, psychologist, substance abuse counselor, community support specialist, case manager, advanced registered nurse practitioner, or physician assistant, as appropriate.  h.    Work-related services.  Work-related services may be provided by a registered nurse, licensed mental health professional, psychologist, substance abuse counselor, community support specialist, case manager, advanced registered nurse practitioner, or physician assistant. Services consist of assisting the member in managing mental health symptoms as they relate to job performance. Services may include:  (1)  Collaborating with the member to look for job situations that may cause symptoms to increase and creating strategies to manage these situations.  (2)  Assisting the member to develop or enhance skills to obtain a work placement, such as individual work-related behavioral management.  (3)  Providing supports to maintain employment, such as crisis intervention related to employment.  (4)  Teaching communication, problem solving, and safety skills.  (5)  Teaching personal skills such as time management and appropriate grooming for employment.This rule is intended to implement Iowa Code section 249A.4.
    Related ARC(s): 9440B, 1850C, 2164C441—78.46(249A)  Physical disability waiver service.  Payment shall be approved for the following services to members eligible for the HCBS physical disability waiver as established in 441—Chapter 83 and as identified in the member’s service plan. Effective March 17, 2022, payment shall only be made for services provided in integrated, community-based settings that support full access of members receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS.  78.46(1)    Consumer-directed attendant care service.  Consumer-directed attendant care services are service activities performed by a person to help a member with self-care tasks which the member would typically do independently if the member were otherwise able. Covered service activities are limited to the nonskilled activities listed in paragraph 78.46(1)“f” and the skilled activities listed in paragraph 78.46(1)“g.” Covered service activities must be essential to the health, safety, and welfare of the member. Services may be provided in the absence of a parent or guardian if the parent or guardian has given advance direction for the service provision.  a.    Service planning.    (1)  The member, parent, guardian, or attorney in fact under a durable power of attorney for health care shall:
    1. Select the individual or agency that will provide the components of the attendant care services.
    2. 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.
    3. 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.
    4. 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.
      (2)  Whenever a legal representative acts as a provider of consumer-directed attendant care as allowed by 441—paragraph 79.9(7)“b,” the following shall apply:
    1. 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;
    2. The legal representative may not be paid for more than 40 hours of service per week; and
    3. 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.
      b.    Supervision of skilled services.  Skilled consumer-directed attendant care services shall be provided under the supervision of a licensed nurse or licensed therapist working under the direction of a physician. The licensed nurse or therapist shall:   (1)  Retain accountability for actions that are delegated.  (2)  Ensure appropriate assessment, planning, implementation, and evaluation.  (3)  Make on-site supervisory visits every two weeks with the service provider present.  c.    Service documentation.  The consumer-directed attendant care provider shall document evidence of compliance with the requirements of this chapter and rule 441—79.3(249A). The documentation or copies of the documentation must be maintained or be electronically accessible by the consumer-directed attendant care provider. Providers must use an electronic visit verification system that captures all documentation requirements of the Consumer-Directed Attendant Care (CDAC) Service Record (Form 470-4389) or use Form 470-4389. Any service component that is not documented in accordance with rule 441—79.3(249A) shall not be payable.   d.    Role of guardian or attorney.  If the member has a guardian or attorney in fact under a durable power of attorney for health care:  (1)  The service worker’s or case manager’s service plan shall address how consumer-directed attendant care services will be monitored to ensure that the member’s needs are being adequately met. If the guardian or attorney in fact is the service provider, the service plan shall address how the service worker or case manager shall oversee service provision.  (2)  The guardian or attorney in fact shall sign the claim form in place of the member, indicating that the service has been provided as presented on the claim.  e.    Service units and billing.  A unit of service is 15 minutes provided by an individual or agency. Each service shall be billed in whole units.  f.    Nonskilled services.  Covered nonskilled service activities are limited to help with the following activities:  (1)  Dressing.  (2)  Bathing, shampooing, hygiene, and grooming.   (3)  Access to and from bed or a wheelchair, transferring, ambulation, and mobility in general.  (4)  Toileting, including bowel, bladder, and catheter assistance (emptying the catheter bag, collecting a specimen, and cleaning the external area around the catheter).  (5)  Meal preparation, cooking, and assistance with feeding, not including the cost of meals themselves. Meal preparation and cooking shall be provided only in the member’s home.  (6)  Housekeeping, laundry, and shopping essential to the member’s health care at home.  (7)  Taking medications ordinarily self-administered, including those ordered by a physician or other qualified health care provider.  (8)  Minor wound care.  (9)  Going to or returning from a place of employment and job-related tasks while the member is on the job site. Transportation for the member and assistance with understanding or performing the essential job functions are not included in consumer-directed attendant care services.  (10)  Tasks, such as financial management and scheduling, that require cognitive or physical assistance.  (11)  Communication essential to the health and welfare of the member, through interpreting and reading services and use of assistive devices for communication.  (12)  Using transportation essential to the health and welfare of the member. The cost of the transportation is not included.  g.    Skilled services.  Covered skilled service activities are limited to help with the following activities:  (1)  Tube feedings of members unable to eat solid foods.  (2)  Intravenous therapy administered by a registered nurse.  (3)  Parenteral injections required more than once a week.  (4)  Catheterizations, continuing care of indwelling catheters with supervision of irrigations, and changing of Foley catheters when required.  (5)  Respiratory care including inhalation therapy and tracheotomy care or tracheotomy care and ventilator.  (6)  Care of decubiti and other ulcerated areas, noting and reporting to the nurse or therapist.  (7)  Rehabilitation services including, but not limited to, bowel and bladder training, range of motion exercises, ambulation training, restorative nursing services, respiratory care and breathing programs, reality orientation, reminiscing therapy, remotivation, behavior modification, and reteaching of the activities of daily living.  (8)  Colostomy care.  (9)  Care of uncontrolled medical conditions, such as brittle diabetes, and comfort care of terminal conditions.  (10)  Postsurgical nursing care.  (11)  Monitoring medications requiring close supervision because of fluctuating physical or psychological conditions, e.g., antihypertensives, digitalis preparations, mood-altering or psychotropic drugs, or narcotics.  (12)  Preparing and monitoring response to therapeutic diets.  (13)  Recording and reporting of changes in vital signs to the nurse or therapist.  h.    Excluded services and costs.  Services, activities, costs and time that are not covered as consumer-directed attendant care include the following (not an exclusive list):  (1)  Any activity related to supervising a member. Only direct services are billable.  (2)  Any activity that the member is able to perform.  (3)  Costs of food.  (4)  Costs for the supervision of skilled services by the nurse or therapist. The supervising nurse or therapist may be paid from private insurance, Medicare, or other third-party payment sources, or may be paid as another Medicaid service, including early and periodic screening, diagnosis and treatment services.  (5)  Exercise that does not require skilled services.  (6)  Parenting or child care for or on behalf of the member.  (7)  Reminders and cueing.  (8)  Services provided simultaneously with any other similar service regardless of funding source, including other waiver services and state supplementary assistance in-home health-related care services.  (9)  Transportation costs.  (10)  Wait times for any activity.
      78.46(2)    Home and vehicle modification.  Covered home or vehicle modifications are physical modifications to the member’s home or vehicle that directly address the member’s medical or remedial need. Covered modifications must be necessary to provide for the health, welfare, or safety of the member and enable the member to function with greater independence in the home or vehicle.  a.  Modifications that are necessary or desirable without regard to the member’s medical or remedial need and that would be expected to increase the fair market value of the home or vehicle, such as furnaces, fencing, or adding square footage to the residence, are excluded except as specifically included below. Purchasing or leasing of a motorized vehicle is excluded. Home and vehicle repairs are also excluded.  b.  Only the following modifications are covered:  (1)  Kitchen counters, sink space, cabinets, special adaptations to refrigerators, stoves, and ovens.  (2)  Bathtubs and toilets to accommodate transfer, special handles and hoses for shower heads, water faucet controls, and accessible showers and sink areas.  (3)  Grab bars and handrails.  (4)  Turnaround space adaptations.  (5)  Ramps, lifts, and door, hall and window widening.  (6)  Fire safety alarm equipment specific for disability.  (7)  Voice-activated, sound-activated, light-activated, motion-activated, and electronic devices directly related to the member’s disability.  (8)  Vehicle lifts, driver-specific adaptations, remote-start systems, including such modifications already installed in a vehicle.  (9)  Keyless entry systems.  (10)  Automatic opening device for home or vehicle door.  (11)  Special door and window locks.  (12)  Specialized doorknobs and handles.  (13)  Plexiglas replacement for glass windows.  (14)  Modification of existing stairs to widen, lower, raise or enclose open stairs.  (15)  Motion detectors.  (16)  Low-pile carpeting or slip-resistant flooring.  (17)  Telecommunications device for the deaf.  (18)  Exterior hard-surface pathways.  (19)  New door opening.  (20)  Pocket doors.  (21)  Installation or relocation of controls, outlets, switches.  (22)  Air conditioning and air filtering if medically necessary.  (23)  Heightening of existing garage door opening to accommodate modified van.  (24)  Bath chairs.  c.  A unit of service is the completion of needed modifications or adaptations.  d.  All modifications and adaptations shall be provided in accordance with applicable federal, state, and local building and vehicle codes.  e.  Services shall be performed following prior department approval of the modification as specified in 441—subrule 79.1(17) and a binding contract between the provider and the member.  f.  All contracts for home or vehicle modification shall be awarded through competitive bidding. The contract shall include the scope of work to be performed, the time involved, supplies needed, the cost, diagrams of the project whenever applicable, and an assurance that the provider has liability and workers’ compensation coverage and the applicable permit and license.  g.  Service payment shall be made to the enrolled home or vehicle modification provider. If applicable, payment will be forwarded to the subcontracting agency by the enrolled home or vehicle modification provider following completion of the approved modifications. Payment of up to $6,366.64 per year may be made to certified providers upon satisfactory completion of the service.   h.  Services shall be included in the member’s service plan and shall exceed the Medicaid state plan services.  78.46(3)    Personal emergency response or portable locator system.    a.  A personal emergency response system is an electronic device that transmits a signal to a central monitoring station to summon assistance in the event of an emergency.  (1)  The necessary components of a system are:
    1. An in-home medical communications transceiver.
    2. A remote, portable activator.
    3. A central monitoring station with backup systems staffed by trained attendants at all times.
    4. Current data files at the central monitoring station containing response protocols and personal, medical, and emergency information for each member.
      (2)  The service shall be identified in the member’s service plan.  (3)  A unit of service is a one-time installation fee or one month of service.  (4)  Maximum units per state fiscal year shall be the initial installation and 12 months of service.
      b.  A portable locator system is an electronic device that transmits a signal to a monitoring device. The system allows a member to access assistance in the event of an emergency and allows law enforcement or the monitoring system provider to locate a member who is unable to request help or to activate a system independently. The member must be unable to access assistance in an emergency situation due to the member’s age or disability.  (1)  The required components of the portable locator system are:
    1. A portable communications transceiver or transmitter to be worn or carried by the member.
    2. Monitoring by the provider at a central location with response protocols and personal, medical, and emergency information for each member as applicable.
      (2)  The service shall be identified in the member’s service plan.  (3)  Payable units of service are purchase of equipment, an installation or set-up fee, and monthly fees.  (4)  Maximum units per state fiscal year shall be one equipment purchase, one installation or set-up fee, and 12 months of service.
      78.46(4)    Specialized medical equipment.    a.  Specialized medical equipment shall include medically necessary items which are for personal use by members with a physical disability and which:  (1)  Provide for the health and safety of the member,  (2)  Are not ordinarily covered by Medicaid,  (3)  Are not funded by educational or vocational rehabilitation programs, and  (4)  Are not provided by voluntary means.  b.  Coverage includes, but is not limited to:  (1)  Electronic aids and organizers.  (2)  Medicine dispensing devices.  (3)  Communication devices.  (4)  Bath aids.  (5)  Noncovered environmental control units.  (6)  Repair and maintenance of items purchased through the waiver.  c.  Payment of up to $6,366.64 per year may be made to enrolled specialized medical equipment providers upon satisfactory receipt of the service.   d.  The need for specialized medical equipment shall be:  (1)  Documented by a health care professional as necessary for the member’s health and safety, and   (2)  Identified in the member’s service plan.  e.  Payment for most items shall be based on a fee schedule. The amount of the fee shall be determined as directed in 441—subrule 79.1(17).  78.46(5)    Transportation.  Transportation services may be provided for members to conduct business errands and essential shopping, to travel to and from work or day programs, and to reduce social isolation. A unit of service is one mile of transportation or one one-way trip.  78.46(6)    Consumer choices option.  The consumer choices option is service activities provided pursuant to subrule 78.34(13).  78.46(7)    General service standards.  All physical disability waiver services must be provided in accordance with the following standards:  a.  Reimbursement shall not be available under the waiver for any services that the member can obtain as other nonwaiver Medicaid services or through any other funding source.  b.  All services provided under the waiver must be delivered in the least restrictive environment possible and in conformity with the member’s service plan.  c.  All rights restrictions must be implemented in accordance with 441—subrule 77.25(4). The member service plan or treatment plan shall include documentation of:   (1)  Any restrictions on the member’s rights, including the rights of privacy, dignity, respect, and freedom from coercion and restraint.  (2)  The need for the restriction.  (3)  The less intrusive methods of meeting the need that have been tried but did not work.  (4)  Either a plan to restore those rights or written documentation that a plan is not necessary or appropriate.   (5)  Established time limits for periodic reviews to determine if the restriction is still necessary or can be terminated.  (6)  The informed consent of the member.  (7)  An assurance that the interventions and supports will cause no harm to the member.  (8)  A regular collection and review of data to measure the ongoing effectiveness of the restriction.  d.  Services must be billed in whole units.  e.  For all services with a 15-minute unit of service, the following rounding process will apply:  (1)  Add together the minutes spent on all billable activities during a calendar day for a daily total.  (2)  For each day, divide the total minutes spent on billable activities by 15 to determine the number of full 15-minute units for that day.  (3)  Round the remainder using these guidelines: Round 1 to 7 minutes down to zero units; round 8 to 14 minutes up to one unit.  (4)  Add together the number of full units and the number of rounded units to determine the total number of units to bill for that day.This rule is intended to implement Iowa Code section 249A.4.
    Related ARC(s): 9045B, 9403B, 9704B, 9884B, 0707C, 0842C, 1056C, 1071C, 1610C, 2050C, 2848C, 2936C, 3874C, 4430C, 5597C441—78.47(249A)  Pharmaceutical case management services.  Payment will be approved for pharmaceutical case management services provided by an eligible physician and pharmacist for Medicaid recipients determined to be at high risk for medication-related problems. These services are designed to identify, prevent, and resolve medication-related problems and improve drug therapy outcomes.  78.47(1)    Medicaid recipient eligibility.  Patients are eligible for pharmaceutical case management services if they have active prescriptions for four or more regularly scheduled nontopical medications, are ambulatory, do not reside in a nursing facility, and have at least one of the eligible disease states of congestive heart disease, ischemic heart disease, diabetes mellitus, hypertension, hyperlipidemia, asthma, depression, atrial fibrillation, osteoarthritis, gastroesophageal reflux, or chronic obstructive pulmonary disease.  78.47(2)    Provider eligibility.  Physicians and pharmacists shall meet the following criteria to provide pharmaceutical case management services.  a.  Physicians and pharmacists must be enrolled in the Iowa Medicaid program, have an Iowa Medicaid provider number, and receive training under the direction of the department regarding the provision of pharmaceutical case management services under the Iowa Medicaid program.A copy of pharmaceutical case management records, including documentation of services provided, shall be maintained on file in each provider’s facility and be made available for audit by the department on request.  b.  Physicians shall be licensed to practice medicine.  c.  Pharmacists shall present to the department evidence of competency including state licensure, submit five acceptable patient care plans, and have successfully completed professional training on patient-oriented, medication-related problem prevention and resolution. Pharmacists shall also maintain problem-oriented patient records, provide a private patient consultation area, and submit a statement indicating that the submitted patient care plans are representative of the pharmacists’ usual patient care plans.Acceptable professional training programs are:  (1)  A doctor of pharmacy degree program.  (2)  The Iowa Center for Pharmaceutical Care (ICPC) training program, which is a cooperative training initiative of the University of Iowa College of Pharmacy, Drake University College of Pharmacy and Health Sciences, and the Iowa Pharmacy Foundation.  (3)  Other programs containing similar coursework and supplemental practice site evaluation and reengineering, approved by the department with input from a peer review advisory committee.  78.47(3)    Services.  Eligible patients may choose whether to receive the services. If patients elect to receive the services, they must receive the services from any eligible physician and pharmacist acting as a pharmaceutical case management (PCM) team. Usually the eligible physician and pharmacist will be the patient’s primary physician and pharmacist. Pharmaceutical case management services are to be value-added services complementary to the basic medical services provided by the primary physician and pharmacist.The PCM team shall provide the following services:  a.    Initial assessment.  The initial assessment shall consist of:  (1)  A patient evaluation by the pharmacist, including:
    1. Medication history;
    2. Assessment of indications, effectiveness, safety, and compliance of medication therapy;
    3. Assessment for the presence of untreated illness; and
    4. Identification of medication-related problems such as unnecessary medication therapy, suboptimal medication selection, inappropriate compliance, adverse drug reactions, and need for additional medication therapy.
      (2)  A written report and recommendation from the pharmacist to the physician.  (3)  A patient care action plan developed by the PCM team with the patient’s agreement and implemented by the PCM team. Specific components of the action plan will vary based on patient needs and conditions but may include changes in medication regimen, focused patient or caregiver education, periodic assessment for changes in the patient’s condition, periodic monitoring of the effectiveness of medication therapy, self-management training, provision of patient-specific educational and informational materials, compliance enhancement, and reinforcement of healthy lifestyles. An action plan must be completed for each initial assessment.
      b.    New problem assessments.  These assessments are initiated when a new medication-related problem is identified. The action plan is modified and new components are implemented to address the new problem. This assessment may occur in the interim between scheduled follow-up assessments.  c.    Problem follow-up assessments.  These assessments are based on patient need and a problem identified by a prior assessment. The patient’s status is evaluated at an appropriate interval. The effectiveness of the implemented action plan is determined and modifications are made as needed.  d.    Preventive follow-up assessments.  These assessments occur approximately every six months when no current medication-related problems have been identified in prior assessments. The patient is reassessed for newly developed medication-related problems and the action plan is reviewed.
    This rule is intended to implement Iowa Code section 249A.4 and 2000 Iowa Acts, chapter 1228, section 9.
    441—78.48(249A)  Public health agencies.  Payments will be made to local public health agencies on a fee schedule basis for providing vaccine and vaccine administration and testing for communicable disease. In order to be paid for the administration of a vaccine covered under the Vaccines for Children (VFC) Program, a public health agency must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 0358C441—78.49(249A)  Infant and toddler program services.  Subject to the following subrules, payment shall be made for medical services provided to Medicaid eligible children by infant and toddler program providers under the infants and toddlers with disabilities program administered by the Iowa Child Health Specialty Clinics and the departments of education, public health, and human services.  78.49(1)    Covered services.  Covered services include, but are not limited to, audiology, psychological evaluation and counseling, health and nursing services, nutrition services, occupational therapy services, physical therapy services, developmental services, speech-language services, vision services, case management, and medical transportation.  78.49(2)    Case management services.  Payment shall also be approved for infant and toddler case management services subject to the following requirements:  a.    Definition.  “Case management” means services that will assist eligible children in gaining access to needed medical, social, educational, and other services. Case management is intended to address the complexities of coordinated service delivery for children with medical needs. The case manager should be the focus for coordinating and overseeing the effectiveness of all providers and programs in responding to the assessed need. Case management does not include the direct delivery of an underlying medical, educational, social, or other service to which an eligible child has been referred or any activities that are an integral part or an extension of the direct services.  b.    Choice of provider.  Children who also are eligible to receive targeted case management services under 441—Chapter 90 must choose whether to receive case management through the infant and toddler program or through 441—Chapter 90. The chosen provider must meet the requirements of this subrule.  (1)  When a child resides in a medical institution, the institution is responsible for case management. The child is not eligible for any other case management services. However, noninstitutional case management services may be provided during the last 14 days before the child’s planned discharge if the child’s stay in the institution has been less than 180 consecutive days. If the child has been in the institution 180 consecutive days or longer, the child may receive noninstitutional case management services during the last 60 days before the child’s planned discharge.  (2)  If the case management agency also provides direct services, the case management unit must be designed so that conflict of interest is addressed and does not result in self-referrals.  (3)  If the costs of any part of case management services are reimbursable under another program, the costs must be allocated between those programs and Medicaid in accordance with OMB Circular No. A-87 or any related or successor guidance or regulations regarding allocation of costs.  (4)  The case manager must complete a competency-based training program with content related to knowledge and understanding of eligible children, Early ACCESS rules, the nature and scope of services in Early ACCESS, and the system of payments for services, as well as case management responsibilities and strategies. The department of education or its designee shall determine whether a person has successfully completed the training.  c.    Assessment.  The case manager shall conduct a comprehensive assessment and periodic reassessment of an eligible child to identify all of the child’s service needs, including the need for any medical, educational, social, or other services. Assessment activities are defined to include the following:  (1)  Taking the child’s history;  (2)  Identifying the needs of the child;  (3)  Gathering information from other sources, such as family members, medical providers, social workers, and educators, if necessary, to form a complete assessment of the child;  (4)  Completing documentation of the information gathered and the assessment results; and  (5)  Repeating the assessment every six months to determine whether the child’s needs or preferences have changed.  d.    Plan of care.  The case manager shall develop a plan of care based on the information collected through the assessment or reassessment. The plan of care shall:  (1)  Include the child’s strengths and preferences;   (2)  Consider the child’s physical and social environment;   (3)  Specify goals of providing services to the child; and  (4)  Specify actions to address the child’s medical, social, educational, and other service needs. These actions may include activities such as ensuring the active participation of the child and working with the child or the child’s authorized health care decision maker and others to develop goals and identify a course of action to respond to the assessed needs of the child.  e.    Other service components.  Case management must include the following components:  (1)  Contacts with the child and family. The case manager shall have face-to-face contact with the child and family within the first 30 days of service and every three months thereafter. In months in which there is no face-to-face contact, a telephone contact between the service coordinator and the family is required.  (2)  Referral and related activities to help a child obtain needed services. The case manager shall help to link the child with medical, social, or educational providers or other programs and services that are capable of providing needed services. Referral activities do not include provision of the direct services, program, or activity to which the child has been linked. Referral activities include:
    1. Assisting the family in gaining access to the infant and toddler program services and other services identified in the child’s plan of care.
    2. Assisting the family in identifying available service providers and funding resources and documenting unmet needs and gaps in services.
    3. Making referrals to providers for needed services.
    4. Scheduling appointments for the child.
    5. Facilitating the timely delivery of services.
    6. Arranging payment for medical transportation.
      (3)  Monitoring and follow-up activities. Monitoring activities shall take place at least once annually for the duration of the child’s eligibility, but may be conducted as frequently as necessary to ensure that the plan of care is effectively implemented and adequately addresses the needs of the child. Monitoring and follow-up activities may be with the child, family members, providers, or other entities. The purpose of these activities is to help determine:
    1. Whether services are being furnished in accordance with the child’s plan of care.
    2. Whether the services in the plan of care are adequate to meet the needs of the child.
    3. Whether there are changes in the needs or status of the child. If there are changes in the child’s needs or status, follow-up activities shall include making necessary adjustments to the plan of care and to service arrangements with providers.
      (4)  Keeping records, including preparing reports, updating the plan of care, making notes about plan activities in the child’s record, and preparing and responding to correspondence with the family and others.
      f.    Documentation of case management.  For each child receiving case management, case records must document:  (1)  The name of the child;  (2)  The dates of case management services;  (3)  The agency chosen by the family to provide the case management services;  (4)  The nature, content, and units of case management services received;  (5)  Whether the goals specified in the care plan have been achieved;  (6)  Whether the family has declined services in the care plan;  (7)  Time lines for providing services and reassessment; and  (8)  The need for and occurrences of coordination with case managers of other programs.
      78.49(3)    Child’s eligibility.  Payable services must be provided to a child under the age of 36 months who is experiencing developmental delay or who has a condition that is known to have a high probability of resulting in developmental delay at a later date.  78.49(4)    Delivery of services.  Services must be delivered directly by the infant and toddler program provider or by a practitioner under contract with the infant and toddler program provider.  78.49(5)    Remission of nonfederal share of costs.  Payment for services shall be made only when the following conditions are met:  a.  Rescinded IAB 5/10/06, effective 7/1/06.  b.  The infant and toddler program provider has executed an agreement to remit the nonfederal share of the cost to the department.  c.  The infant and toddler program provider shall sign and return Form 470-3816, Medicaid Billing Remittance, along with the funds remitted for the nonfederal share of the costs of the services specified on the form.This rule is intended to implement Iowa Code section 249A.4.
    441—78.50(249A)  Local education agency services.  Subject to the following subrules, payment shall be made for medical services provided by local education agency services providers to Medicaid members under the age of 21.  78.50(1)    Covered services.  Covered services include, but are not limited to, audiology services, behavior services, consultation services, medical transportation, nursing services, nutrition services, occupational therapy services, personal assistance, physical therapy services, psychologist services, speech-language services, social work services, vision services, and school-based clinic visit services.  a.  In order to be paid for the administration of a vaccine covered under the Vaccines for Children (VFC) Program, a local education agency must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted.  b.  Payment for supplies shall be approved when the supplies are incidental to the patient’s care, e.g., syringes for injections, and do not exceed $25 per month. Durable medical equipment and other supplies are not covered as local education agency services.  c.  To the extent that federal funding is not available under Title XIX of the Social Security Act, payment for transportation between home and school is not a covered service.  78.50(2)    Coordination services.  Rescinded IAB 12/3/08, effective 2/1/09.  78.50(3)    Delivery of services.  Services must be delivered directly by the local education agency services providers or by a practitioner under contract with the local education agency services provider.  78.50(4)    Remission of nonfederal share of costs.  Payment for services shall be made only when the following conditions are met:  a.  Rescinded IAB 5/10/06, effective 7/1/06.  b.  The local education agency services provider has executed an agreement to remit the nonfederal share of the cost to the department.  c.  The local education agency provider shall sign and return Form 470-3816, Medicaid Billing Remittance, along with the funds remitted for the nonfederal share of the costs of the services as specified on the form.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 0065C441—78.51(249A)  Indian health service 638 facility services.  Payment shall be made for all medically necessary services and supplies provided by a licensed practitioner at an Indian health service 638 facility, as defined at rule 441—77.45(249A), within the practitioner’s scope of practice and subject to the limitations and exclusions set forth in subrule 78.1(1).This rule is intended to implement Iowa Code section 249A.4.441—78.52(249A)  HCBS children’s mental health waiver services.  Payment will be approved for the following services to members eligible for the HCBS children’s mental health waiver as established in 441—Chapter 83 and as identified in the member’s service plan. Effective March 17, 2022, payment shall only be made for services provided in integrated, community-based settings that support full access of members receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS.  78.52(1)    General service standards.  All children’s mental health waiver services must be provided in accordance with the following standards:  a.  Reimbursement shall not be available under the waiver for any services that the member can obtain as other nonwaiver Medicaid services or through any other funding source.  b.  All services provided under the waiver must be delivered in the least restrictive environment possible and in conformity with the member’s service plan.  c.  All rights restrictions must be implemented in accordance with 441—subrule 77.25(4). The member service plan or treatment plan shall include documentation of:   (1)  Any restrictions on the member’s rights, including the rights of privacy, dignity, respect, and freedom from coercion and restraint.  (2)  The need for the restriction.  (3)  The less intrusive methods of meeting the need that have been tried but did not work.  (4)  Either a plan to restore those rights or written documentation that a plan is not necessary or appropriate.   (5)  Established time limits for periodic reviews to determine if the restriction is still necessary or can be terminated.  (6)  The informed consent of the member.  (7)  An assurance that the interventions and supports will cause no harm to the member.  (8)  A regular collection and review of data to measure the ongoing effectiveness of the restriction.  d.  Services must be billed in whole units.  e.  For all services with a 15-minute unit of service, the following rounding process will apply:  (1)  Add together the minutes spent on all billable activities during a calendar day for a daily total.  (2)  For each day, divide the total minutes spent on billable activities by 15 to determine the number of full 15-minute units for that day.  (3)  Round the remainder using these guidelines: Round 1 to 7 minutes down to zero units; round 8 to 14 minutes up to one unit.  (4)  Add together the number of full units and the number of rounded units to determine the total number of units to bill for that day.  78.52(2)    Environmental modifications and adaptive devices.    a.  Environmental modifications and adaptive devices include medically necessary items installed or used within the member’s home that are used by the member to address specific, documented health, mental health, or safety concerns. The following items are excluded under this service:  (1)  Items ordinarily covered by Medicaid.  (2)  Items funded by educational or vocational rehabilitation programs.  (3)  Items provided by voluntary means.  (4)  Repair and maintenance of items purchased through the waiver.  (5)  Fencing.  b.  A unit of service is one modification or device.  c.  For each unit of service provided, the case manager shall maintain in the member’s case file a signed statement from a mental health professional on the member’s interdisciplinary team that the service has a direct relationship to the member’s diagnosis of serious emotional disturbance.  d.  Payment for most items shall be based on a fee schedule. The amount of the fee shall be determined as directed in 441—subrule 79.1(17).  78.52(3)    Family and community support services.  Family and community support services shall support the member and the member’s family by the development and implementation of strategies and interventions that will result in the reduction of stress and depression and will increase the member’s and the family’s social and emotional strength.  a.  Dependent on the needs of the member and the member’s family members individually or collectively, family and community support services may be provided to the member, to the member’s family members, or to the member and the family members as a family unit.  b.  Family and community support services shall be provided under the recommendation and direction of a mental health professional who is a member of the member’s interdisciplinary team pursuant to 441—Chapter 83.  c.  Family and community support services shall incorporate recommended support interventions and activities, which may include the following:  (1)  Developing and maintaining a crisis support network for the member and for the member’s family.  (2)  Modeling and coaching effective coping strategies for the member’s family members.  (3)  Building resilience to the stigma of serious emotional disturbance for the member and the family.  (4)  Reducing the stigma of serious emotional disturbance by the development of relationships with peers and community members.  (5)  Modeling and coaching the strategies and interventions identified in the member’s crisis intervention plan as defined in 441—24.1(225C) for life situations with the member’s family and in the community.  (6)  Developing medication management skills.  (7)  Developing personal hygiene and grooming skills that contribute to the member’s positive self-image.  (8)  Developing positive socialization and citizenship skills.  d.  Family and community support services may include an amount not to exceed $1500 per member per year for transportation within the community and purchase of therapeutic resources. Therapeutic resources may include books, training materials, and visual or audio media.  (1)  The interdisciplinary team must have identified the transportation or therapeutic resource as a support need and included that need in the case manager’s plan.  (2)  The annual amount available for transportation and therapeutic resources must be listed in the member’s service plan.  (3)  The member’s parent or legal guardian shall submit a signed statement that the transportation or therapeutic resource cannot be provided by the member or the member’s family or legal guardian.  (4)  The member’s Medicaid case manager shall maintain a signed statement that potential community resources are unavailable and shall list the community resources contacted to fund the transportation or therapeutic resource.  (5)  The transportation or therapeutic resource must not be otherwise eligible for Medicaid reimbursement.  e.  The following components are specifically excluded from family and community support services:  (1)  Vocational services.  (2)  Prevocational services.  (3)  Supported employment services.  (4)  Room and board.  (5)  Academic services.  (6)  General supervision and care.  f.  A unit of family and community support services is 15 minutes.  78.52(4)    In-home family therapy.  In-home family therapy provides skilled therapeutic services to the member and family that will increase their ability to cope with the effects of serious emotional disturbance on the family unit and the familial relationships. The service must support the family by the development of coping strategies that will enable the member to continue living within the family environment.  a.  The goal of in-home family therapy is to maintain a cohesive family unit.  b.  In-home family therapy is exclusive of and cannot serve as a substitute for individual therapy, family therapy, or other mental health therapy that may be obtained through Medicaid or other funding sources.  c.  A unit of in-home family therapy service is 15 minutes.  78.52(5)    Respite care services.  Respite care services are services provided to the member that give temporary relief to the usual caregiver and provide all the necessary care that the usual caregiver would provide during that period. The purpose of respite care is to enable the member to remain in the member’s current living situation.  a.  Respite services provided outside the member’s home shall not be reimbursable if the living unit where respite care is provided is reserved for another person on a temporary leave of absence.  b.  Member-to-staff ratios shall be appropriate to the individual needs of the member as determined by the member’s interdisciplinary team.  c.  A unit of service is 15 minutes.  d.  Respite care is not to be provided to members during the hours in which the usual caregiver is employed except when the member is attending a 24-hour residential camp. Respite care shall not be used as a substitute for a child’s day care.  e.  The interdisciplinary team shall determine if the member will receive basic individual respite, specialized respite or group respite as defined in 441—Chapter 83.  f.  A maximum of 14 consecutive days of 24-hour respite care may be reimbursed.  g.  Respite services provided for a period exceeding 24 consecutive hours to three or more members who require nursing care because of a mental or physical condition must be provided by a health care facility licensed under Iowa Code chapter 135C.  h.  Respite services shall not be provided simultaneously with other residential, nursing, or home health aide services provided through the medical assistance program.This rule is intended to implement Iowa Code section 249A.4 and 2005 Iowa Acts, chapter 167, section 13, and chapter 117, section 3.Related ARC(s): 9403B, 9704B, 9884B, 0707C, 0709C, 3874C, 5305C441—78.53(249A)  Health home services.  Subject to federal approval in the Medicaid state plan, payment shall be made for health home services as described in subrule 78.53(1) provided to an eligible Medicaid member as described in subrule 78.53(2) who has selected a health home services provider as provided in subrule 78.53(3).  78.53(1)    Covered services.  Health home services consist of the following services provided in a comprehensive, timely, and high-quality manner using health information technology to link services, as feasible and appropriate:  a.  Comprehensive care management, which means:  (1)  Providing for all the member’s health care needs or taking responsibility for arranging care with other qualified professionals;  (2)  Developing and maintaining for each member a continuity of care document that details all important aspects of the member’s medical needs, treatment plan, and medication list; and  (3)  Implementing a formal screening tool to assess behavioral health treatment needs and physical health care needs.  b.  Care coordination, which means assisting members with:  (1)  Medication adherence;  (2)  Chronic disease management;  (3)  Appointments, referral scheduling, and reminders; and  (4)  Understanding health insurance coverage.  c.  Health promotion, which means coordinating or providing behavior modification interventions aimed at:  (1)  Supporting health management;  (2)  Improving disease control; and   (3)  Enhancing safety, disease prevention, and an overall healthy lifestyle.  d.  Comprehensive transitional care following a member’s move from an inpatient setting to another setting. Comprehensive transitional care includes:  (1)  Updates of the member’s continuity of care document and case plan to reflect the member’s short-term and long-term care coordination needs; and   (2)  Personal follow-up with the member regarding all needed follow-up after the transition.  e.  Member and family support (including authorized representatives). This support may include:  (1)  Communicating with and advocating for the member or family for the assessment of care decisions;  (2)  Assisting with obtaining and adhering to medications and other prescribed treatments;  (3)  Increasing health literacy and self-management skills; and   (4)  Assessing the member’s physical and social environment so that the plan of care incorporates needs, strengths, preferences, and risk factors.  f.  Referral to community and social support services available in the community.  78.53(2)    Members eligible for health home services.    a.  Subject to the authority of the Secretary of the United States Department of Health and Human Services pursuant to 42 U.S.C. §1396w-4(h)(1)(B) to establish higher levels for the number or severity of chronic or mental health conditions for purposes of determining eligibility for receipt of health home services, payment shall be made only for health home services provided to a Medicaid member who:  (1)  Has at least two chronic conditions;  (2)  Has one chronic condition and is at risk of having a second chronic condition;  (3)  Has a serious mental illness; or  (4)  Has a serious emotional disturbance.  b.  For purposes of this rule, the term “chronic condition” means:  (1)  A mental health disorder.  (2)  A substance use disorder.  (3)  Asthma.  (4)  Diabetes.  (5)  Heart disease.  (6)  Being overweight, as evidenced by:
    1. Having a body mass index (BMI) over 25 for an adult, or
    2. Weighing over the 85th percentile for the pediatric population.
      (7)  Hypertension.
      c.  For purposes of this rule, the term “serious mental illness” means:  (1)  A psychotic disorder;  (2)  Schizophrenia;  (3)  Schizoaffective disorder;  (4)  Major depression;  (5)  Bipolar disorder;  (6)  Delusional disorder; or  (7)  Obsessive-compulsive disorder.  d.  For purposes of this rule, the term “serious emotional disturbance” means a diagnosable mental, behavioral, or emotional disorder (not including substance use disorders, learning disorders, or intellectual disorders) that is of sufficient duration to meet diagnostic criteria specified in the most current Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association and that results in a functional impairment. For this purpose, the term “functional impairment” means episodic, recurrent, or continuous difficulties that substantially interfere with or limit a person from achieving or maintaining one or more developmentally appropriate social, behavioral, cognitive, communicative, or adaptive skills and that substantially interfere with or limit the person’s role or functioning in family, school, or community activities, not including difficulties resulting from temporary and expected responses to stressful events in a person’s environment.
      78.53(3)    Selection of health home services provider.  As a condition of payment for health home services, the eligible member receiving the services must have selected the billing provider as the member’s health home, as reported by the provider. A member must select a provider located in the member’s county of residence or in a contiguous county.This rule is intended to implement Iowa Code section 249A.4 and 2011 Iowa Acts, chapter 129, section 10.
    Related ARC(s): 0198C, 0838C441—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 and 2012 Iowa Acts, Senate File 2158.Related ARC(s): 0360C441—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 and 2015 Iowa Acts, Senate File 505, division V, section 12(23).Related ARC(s): 2166C441—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.  
    "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:
    1. The treatment plan conforms to the medical necessity requirements in subrule 78.55(4);
    2. The treatment plan is consistent with the written diagnosis and treatment recommendations made by a licensed medical professional that is a licensed neuropsychologist or neurologist, M.D., or D.O.;
    3. The treatment plan is sufficient in amount, duration, and scope to reasonably achieve its purpose;
    4. The provider can demonstrate that the provider possesses the skills and resources necessary to implement the plan; and
    5. The treatment plan does not exceed 180 days in duration.
      (2)  A treatment summary detailing the member’s response to treatment during the previous approval period must be submitted when approval for subsequent plans is requested.
      f.  Subsequent plans. The IME medical services unit may approve a subsequent neurobehavioral rehabilitation treatment plan that conforms to the conditions of medical necessity pursuant to subrule 78.56(4) and to the conditions pursuant to subrule 78.56(3).  g.  Quality review. The IME medical services unit may perform the quality review to evaluate:  (1)  The time elapsed from referral to rehabilitation treatment plan development;  (2)  The continuity of treatment;  (3)  The length of stay per member;  (4)  The affiliation of the medical professional recommending services with the neurobehavioral rehabilitation services provider;  (5)  Gaps in service;  (6)  The results achieved;  (7)  Member and stakeholder satisfaction;  (8)  The provider’s compliance with standards listed in rule 441—77.54(249A).
      78.56(4)    Medical necessity.  Nothing in this rule shall be deemed to exempt coverage of community-based neurobehavioral rehabilitation services from the requirement that services be medically necessary. “Medically necessary” means that the service is:  a.  Consistent with the diagnosis and treatment of the member’s condition;  b.  Required to meet the medical needs of the member and is needed for reasons other than the convenience of the member or the member’s caregiver;  c.  The least costly type of service that can reasonably meet the medical needs of the member; and  d.  In accordance with the standards of good medical practice. The standards of good practice for each field of medical and remedial care covered by the Iowa Medicaid program are those standards of good practice identified by:  (1)  Knowledgeable Iowa clinicians practicing or teaching in the field; and  (2)  The professional literature regarding best practices in the field.  78.56(5)    Documentation standards.  Community-based neurobehavioral rehabilitation service providers shall maintain service provision records, financial records, and clinical records in accordance with the provisions of rule 441—79.3(249A).
    Related ARC(s): 2341C, 4792C441—78.57(249A)  Child care medical services.  Payments will be made to licensed child care centers that provide medical services in addition to child care. Medically necessary services are provided under a plan of care that is developed by licensed professionals within their scope of practice and authorized by the member’s physician. The services include and implement a comprehensive protocol of care that is developed in conjunction with the parent or guardian and specifies the medical, nursing, personal care, psychosocial and developmental therapies required by the medically dependent or technologically dependent child served.   78.57(1)  Nursing services are services which are provided by a registered nurse or a licensed practical nurse under the direction of the member’s physician to a member in a licensed child care center. Nursing services shall be provided according to a written plan of care authorized by a physician. Payment for nursing services may be approved if the services are determined to be medically necessary as defined in subrule 78.57(5). Nursing services include activities that require the expertise of a nurse, such as physical assessment, tracheostomy care, medication administration, and tube feedings.   78.57(2)  Personal care services are those services which are provided by an aide but are delegated and supervised by a registered nurse under the direction of the member’s physician. Payment for personal care services may be approved if the services are determined to be medically necessary as defined in subrule 78.57(5). Personal care services shall be in accordance with the member’s plan of care and authorized by a physician. Personal care services include the activities of daily living, oral hygiene, grooming, toileting, feeding, range of motion and positioning, and training the member in necessary self-help skills, including teaching prosocial skills and reinforcing positive interactions.  78.57(3)  Psychosocial services are those services that focus at decreasing or eliminating maladaptive behaviors. Payment for psychosocial services may be approved if the services are determined to be medically necessary as defined in subrule 78.57(5). Psychosocial services shall be in accordance with the member’s plan of care and authorized by a physician. Psychosocial services include implementing a plan using clinically accepted techniques for decreasing or eliminating maladaptive behaviors. Psychosocial intervention plans must be developed and reviewed by licensed mental health providers.  78.57(4)  Developmental therapies are those services which are provided by an aide but are delegated and supervised by a licensed therapist under the direction of the member’s physician. Payment for developmental therapies may be approved if the services are determined to be medically necessary as defined in subrule 78.57(5). Developmental therapies shall be in accordance with the member’s plan of care and authorized by a physician. Developmental therapies include activities based on the individual’s needs such as fine motor, gross motor, and receptive expressive language.  78.57(5)  “Medically necessary” means the service is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions that endanger life, cause pain, result in illness or infirmity, or threaten to cause or aggravate a disability or chronic illness and is an effective course of treatment for the member requesting a service.  78.57(6)  Requirements.  a.  Nursing, psychosocial, developmental therapies and personal care services shall be ordered in writing.  b.  Nursing, psychosocial, developmental therapies and personal care services shall be authorized by the department or the department’s designated review agent prior to payment.  c.  Prior authorization shall be requested at the time of initial submission of the plan of care or at any time the plan of care is substantially amended and shall be renewed with the department or the department’s designated review agent. Initial request for and request for renewal of prior authorization shall be submitted to the department’s designated review agent. The provider of the service is responsible for requesting prior authorization and for obtaining renewal of prior authorization. The request for prior authorization shall include a nursing assessment, the plan of care, and supporting documentation. A treatment plan shall be completed prior to the start of care and at a minimum reviewed every 180 days thereafter. The plan of care shall support the medical necessity and intensity of services to be provided by reflecting the following information:  (1)  Place of service.  (2)  Type of service to be rendered and the treatment modalities being used.  (3)  Frequency of the services.  (4)  Assistance devices to be used.  (5)  Date on which services were initiated.  (6)  Progress of member in response to treatment.  (7)  Medical supplies to be furnished.  (8)  Member’s medical condition as reflected by the following information, if applicable:
    1. Dates of prior hospitalization.
    2. Dates of prior surgery.
    3. Date last seen by a primary care provider.
    4. Diagnoses and dates of onset of diagnoses for which treatment is being rendered.
    5. Prognosis.
    6. Functional limitations.
    7. Vital signs reading.
    8. Date of last episode of acute recurrence of illness or symptoms.
    9. Medications.
      (9)  Discipline of the person providing the service.  (10)  Certification period.   (11)  Physician’s signature and date. The treatment plan must be signed and dated by the physician before the claim for service is submitted for reimbursement.  (12)  Forms 470-4815 and 470-4816 are utilized during the prior authorization review.
      78.57(7)  Nursing, personal care, and psychosocial services do not include:  a.  Services provided to members aged 21 and older.  b.  Services that require prior authorizations that are provided without regard to the prior authorization process.  c.  Nursing services provided simultaneously with other Medicaid services (e.g., home health aide, physical, occupational, or speech therapy services, etc.).   d.  Services that exceed the services that are approvable under the private duty nursing and personal care program pursuant to subrule 78.9(10).  e.  Transportation services.  f.  Services provided to a member while the member is in institutional care.This rule is intended to implement Iowa Code chapter 249A.
    Related ARC(s): 2361C441—78.58(249A)  Qualified Medicare beneficiary (QMB) provider services.    78.58(1)    Payment.  Payment will be made to QMB providers for a QMB-eligible member’s coinsurance, copayment, and deductible for Medicare-covered services. The eligible member may be responsible for copayments pursuant to 441—subrule 79.1(13).  78.58(2)    Definitions.  
    "Coinsurance" means a percentage of costs of a covered health care service that has to be paid.
    "Copayment" means a fixed amount a member pays for a covered health care service.
    "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): 3551C
    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