reglab/statecodes huggingface dataset:
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 77 - Conditions of Participation for Providers of Medical and Remedial Care › Rule 441-77.42 - Public Health Agencies

Current through Register Vol. 47, No. 3, July 24, 2024
Public health agencies are eligible to participate in the
				  medical assistance program when they serve as a public health entity within the
				  local board of health jurisdiction pursuant to 641-subrule 77.3(3).
This rule is intended to implement Iowa Code section
				  249A.4.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 77 - Conditions of Participation for Providers of Medical and Remedial Care › Rule 441-77.45 - Indian Health Facilities

Current through Register Vol. 47, No. 3, July 24, 2024
A health care facility operated by the U.S. Indian Health
				  Service or under the Indian Self-Determination and Education Assistance Act (
				  P.L. 93-638) by an "Indian tribe," "tribal organization," or "Urban Indian
				  organization," as those terms are defined in
				  25
				  U.S.C. 1603, is eligible to participate in
				  the medical assistance program if the following conditions are met:
(1)
Licensure.
Services must
				be rendered by practitioners who meet applicable professional licensure
				requirements.
(2)
Documentation.
Medical records must be maintained at the same
				standards as are required for the applicable licensed medical practitioner.
This rule is intended to implement Iowa Code section
				  249A.4.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 77 - Conditions of Participation for Providers of Medical and Remedial Care › Rule 441-77.48 - Speech-language Pathologists

Current through Register Vol. 47, No. 3, July 24, 2024
Speech-language pathologists who are enrolled in the Medicare
				  program are eligible to participate in Medicaid. Speech-language pathologists
				  who are not enrolled in the Medicare program are eligible to participate in
				  Medicaid if they are licensed and in independent practice, as an individual or
				  as a group.
(1) Speech-language
				pathologists in another state are eligible to participate if they are licensed
				in that state and meet the Medicare criteria for enrollment.
(2) Speech-language pathologists who provide
				services to Medicaid members who are also Medicare beneficiaries must be
				enrolled in the Medicare program.
This rule is intended to implement Iowa Code section 249A.4
				  and 2012 Iowa Acts, Senate File 2158.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 77 - Conditions of Participation for Providers of Medical and Remedial Care › Rule 441-77.49 - Physician Assistants

Current through Register Vol. 47, No. 3, July 24, 2024
All physician assistants licensed to practice in the state of
				  Iowa are eligible for participation in the program. Physician assistants duly
				  licensed to practice in other states are also eligible for
				  participation.
This rule is intended to implement Iowa Code section
				  249A.4.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 77 - Conditions of Participation for Providers of Medical and Remedial Care › Rule 441-77.50 - Ordering and Referring Providers

Current through Register Vol. 47, No. 3, July 24, 2024
A provider who provides services, including orders and
				  referrals, to a Medicaid member shall be enrolled as a Medicaid provider as a
				  condition of payment eligibility for services rendered to that Medicaid member.
				  A provider who does not individually bill for services rendered due to, for
				  example, payment arrangements with a facility or supervising provider, shall
				  also be required to enroll. Enrollment will be for the purpose of ordering or
				  referring items and providing professional services to Medicaid members and
				  will not affect the provider's payment arrangements with such facilities or
				  supervising providers.
This rule is intended to implement Iowa Code section
				  249A.4.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 77 - Conditions of Participation for Providers of Medical and Remedial Care › Rule 441-77.51 - Child Care Medical Services

Current through Register Vol. 47, No. 3, July 24, 2024
Child care centers are eligible to participate in the medical
				  assistance program when they comply with the standards of 441-Chapter 109. A
				  child care center in another state is eligible to participate when duly
				  licensed in that state. The provider of child care medical services implements
				  a comprehensive protocol of care that is developed in conjunction with the
				  parent or guardian and specifies the medical, nursing, psychosocial,
				  developmental therapies and personal care required by the medically dependent
				  or technologically dependent child served. Nursing services must be
				  provided.
This rule is intended to implement Iowa Code section
				  249A.4.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 77 - Conditions of Participation for Providers of Medical and Remedial Care › Rule 441-77.52 - Community-based Neurobehavioral Rehabilitation Services

Current through Register Vol. 47, No. 3, July 24, 2024
(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"
means services 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
				  needs.
(2)
Eligible
				providers.
The following agencies may provide community-based
				neurobehavioral rehabilitation residential and intermittent services:
a. An organization that is accredited by a
				department-approved, nationally recognized accreditation organization as a
				specialty brain injury rehabilitation service provider.
b. Agencies not accredited by a
				department-approved, nationally recognized accreditation organization as a
				specialty brain injury rehabilitation service provider that have applied for
				accreditation within the last 16 months to provide services may be enrolled.
				However, an organization that has not received accreditation within 16 months
				after application shall no longer be a qualified provider.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 77 - Conditions of Participation for Providers of Medical and Remedial Care › Rule 441-77.53 - Qualified Medicare Beneficiary (QMB) Providers

Current through Register Vol. 47, No. 3, July 24, 2024
Any Medicare provider not enrolled as an Iowa Medicaid
				  provider for the general Medicaid population may enroll to be a QMB
				  provider.
(1)
Reimbursement.
A QMB provider may only bill the department for
				the QMB-eligible member's Medicare cost-sharing obligations. Reimbursement is
				limited to coinsurance, copayments, and deductibles for Medicare-covered
				services.
(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"
or
"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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 77 - Conditions of Participation for Providers of Medical and Remedial Care › Rule 441-77.54 - Health Insurance Premium Payment (HIPP) Providers

Current through Register Vol. 47, No. 3, July 24, 2024
Any provider not enrolled as an Iowa Medicaid provider for
				  the general Medicaid population may enroll to be a HIPP provider. A HIPP
				  provider may bill the department for the HIPP-eligible member's out-of-pocket
				  cost-sharing obligations. Reimbursement is limited to in-network coinsurance,
				  copayments, and deductibles of the HIPP-eligible member's health insurance paid
				  for through the HIPP program.
This rule is intended to implement Iowa Code section
				  249A.4.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 77 - Conditions of Participation for Providers of Medical and Remedial Care › Rule 441-77.55 - Crisis Response Services

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Definitions.
The terms
				used in this rule shall have the same meaning as set out in 441-Chapter 24,
				Division II.
(2)
Eligible
				providers.
Agencies which are accredited under the mental health
				service provider standards established by the mental health and disability
				services commission, set forth in 441-Chapter 24, Division II, are eligible to
				participate in the program by providing crisis response services, crisis
				stabilization community-based services, and crisis stabilization residential
				services.
(3)
Provider
				standards.
All providers of crisis response services, crisis
				stabilization community-based services, and crisis stabilization residential
				services shall meet the standards criteria as set forth in 441-Chapter 24,
				Division II.
This rule is intended to implement Iowa Code section
				  249A.4.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 77 - Conditions of Participation for Providers of Medical and Remedial Care › Rule 441-77.56 - Subacute Mental Health Services

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Definitions.
The terms
				used in this rule shall have the same meaning as set out in Iowa Code section
				135G.1.
(2)
Subacute mental health
				services.
Subacute mental health services are intended to be
				short-term, intensive, recovery-oriented services designed to stabilize an
				individual who is experiencing a decreased level of functioning due to a mental
				health condition.
(3)
Eligible provider.
Subacute mental health care facilities
				which are licensed by the department of inspections and appeals in accordance
				with 481-Chapter 71 are eligible to participate in the program by providing
				subacute mental health services.
(4)
Provider standards.
All
				providers of subacute mental health services shall meet the standards criteria
				as set forth in 481-Chapter 71.
This rule is intended to implement Iowa Code section
				  249A.4.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 77 - Conditions of Participation for Providers of Medical and Remedial Care › Rule 441-77.57 - Pharmacists

Current through Register Vol. 47, No. 3, July 24, 2024
An authorized pharmacist licensed to practice in the state of
				  Iowa is eligible to participate in the program.
This rule is intended to implement Iowa Code section
				  249A.4.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.1 - Physicians' Services

Current through Register Vol. 47, No. 3, July 24, 2024
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:
(1) Payment will not be made for:
a. Drugs dispensed by a physician or other
				legally qualified practitioner (dentist, podiatrist, optometrist, physician
				assistant, or advanced registered nurse practitioner) unless it is established
				that there is no licensed retail pharmacy in the community in which the legally
				qualified practitioner's office is maintained. Rate of payment shall be
				established as in subrule 78.2(2), but no professional fee shall be paid.
				Payment will not be made for biological supplies and drugs provided free of
				charge to practitioners by the state department of public health.
b. Reserved.
c. Treatment of certain foot conditions as
				specified in 78.5(2)
"a," "b,"
and
"c."
d. Acupuncture
				treatments.
e. Reserved.
f. Unproven or experimental medical and
				surgical procedures. The criteria in effect in the Medicare program shall be
				utilized in determining when a given procedure is unproven or experimental in
				nature.
g. Charges for surgical
				procedures on the "Outpatient/Same Day Surgery List" produced by the IME
				medical services unit or associated inpatient care charges when the procedure
				is performed in a hospital on an inpatient basis unless the physician has
				secured approval from the hospital's utilization review department prior to the
				patient's admittance to the hospital. Approval shall be granted only when
				inpatient care is deemed to be medically necessary based on the condition of
				the patient or when the surgical procedure is not performed as a routine,
				primary, independent procedure. The "Outpatient/Same Day Surgery List" shall be
				published by the department in the provider manuals for hospitals and
				physicians. The "Outpatient/Same Day Surgery List" shall be developed by the
				IME medical services unit and shall include procedures which can safely and
				effectively be performed in a doctor's office or on an outpatient basis in a
				hospital. The IME medical services unit may add, delete, or modify entries on
				the "Outpatient/Same Day Surgery List."
h. Elective, non-medically necessary cesarean
				section (C-section) deliveries.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.3 - Inpatient Hospital Services

Current through Register Vol. 47, No. 3, July 24, 2024
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.
(1) Payment for Medicaid-certified physical
				rehabilitation units will be approved for the day of admission but not the day
				of discharge or death.
(2) No
				payment will be approved for private duty nursing.
(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.
(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.
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.4 - Dentists

Current through Register Vol. 47, No. 3, July 24, 2024
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:
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.5 - Podiatrists

Current through Register Vol. 47, No. 3, July 24, 2024
Payment will be approved only for certain podiatric
				  services.
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.6 - Optometrists

Current through Register Vol. 47, No. 3, July 24, 2024
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.
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.7 - Opticians

Current through Register Vol. 47, No. 3, July 24, 2024
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))
(1) to
(3)
Rescinded IAB 4/3/02, effective 6/1/02.
This rule is intended to implement Iowa Code section
				  249A.4.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.11 - Ambulance Service

Current through Register Vol. 47, No. 3, July 24, 2024
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.
(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.
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.12 - Behavioral Health Intervention

Current through Register Vol. 47, No. 3, July 24, 2024
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.
(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"
or
"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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.13 - Nonemergency Medical Transportation

Current through Register Vol. 47, No. 3, July 24, 2024
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.
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.14 - Hearing Aids

Current through Register Vol. 47, No. 3, July 24, 2024
Payment shall be approved for a hearing aid and examinations
				  subject to the following conditions:
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.15 - Orthopedic Shoes

Current through Register Vol. 47, No. 3, July 24, 2024
Payment shall be approved only for depth or custom-molded
				  orthopedic shoes, inserts, and modifications, subject to the following
				  definitions and conditions.
(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.
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.16 - Community Mental Health Centers

Current through Register Vol. 47, No. 3, July 24, 2024
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:
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.17 - Physical Therapists

Current through Register Vol. 47, No. 3, July 24, 2024
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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.18 - Screening Centers

Current through Register Vol. 47, No. 3, July 24, 2024
Payment will be approved for health screening as defined in
				  441-subrule 84.1(1) for Medicaid members under 21 years of age.
(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.
(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.
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.19 - Rehabilitation Agencies

Current through Register Vol. 47, No. 3, July 24, 2024
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.20 - Independent Laboratories

Current through Register Vol. 47, No. 3, July 24, 2024
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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.21 - Rural Health Clinics

Current through Register Vol. 47, No. 3, July 24, 2024
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).
(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.
(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).)
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.22 - Family Planning Clinics

Current through Register Vol. 47, No. 3, July 24, 2024
Payments will be made on a fee schedule basis for services
				  provided by family planning clinics.
(1) Payment will be made for sterilization in
				accordance with 78.1(16).
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.23 - Other Clinic Services

Current through Register Vol. 47, No. 3, July 24, 2024
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.
(1)
Sterilization.
Payment
				will be made for sterilization in accordance with 78.1(16).
(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.
(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).)
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.24 - Psychologists

Current through Register Vol. 47, No. 3, July 24, 2024
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.
(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
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.25 - Maternal Health Centers

Current through Register Vol. 47, No. 3, July 24, 2024
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).)
(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 lAB 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.