Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 79 - Other Policies Relating to Providers of Medical and Remedial Care › Rule 441-79.1 - Principles Governing Reimbursement of Providers of Medical and Health Services

Current through Register Vol. 47, No. 3, July 24, 2024
The basis of payment for services rendered by providers of
				  services participating in the medical assistance program is either a system
				  based on the provider's allowable costs of operation or a fee schedule.
				  Generally, institutional types of providers such as hospitals and nursing
				  facilities are reimbursed on a cost-related basis, and practitioners such as
				  physicians, dentists, optometrists, and similar providers are reimbursed on the
				  basis of a fee schedule. Providers of service must accept reimbursement based
				  upon the department's methodology without making any additional charge to the
				  member.
For purposes of this chapter, "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.
(1)
Types of reimbursement.
a.
Prospective cost-related.
Providers are reimbursed on the basis of a per diem rate calculated
				prospectively for each participating provider based on reasonable and proper
				costs of operation. The rate is determined by establishing a base year per diem
				rate to which an annual index is applied.
b.
Retrospective
				cost-related.
Providers are reimbursed on the basis of a per diem rate
				calculated retrospectively for each participating provider based on reasonable
				and proper costs of operation with suitable retroactive adjustments based on
				submission of financial and statistical reports by the provider. The
				retroactive adjustment represents the difference between the amount received by
				the provider during the year for covered services and the amount determined in
				accordance with an accepted method of cost apportionment (generally the
				Medicare principles of apportionment) to be the actual cost of service rendered
				medical assistance recipients.
c.
Fee schedules.
Fees for the various procedures involved are
				determined by the department with advice and consultation from the appropriate
				professional group. The fees are intended to reflect the amount of resources
				(time, training, experience) involved in each procedure. Individual adjustments
				will be made periodically to correct any inequity or to add new procedures or
				eliminate or modify others. If product cost is involved in addition to service,
				reimbursement is based either on a fixed fee, wholesale cost, or on actual
				acquisition cost of the product to the provider, or product cost is included as
				part of the fee schedule. Providers on fee schedules are reimbursed the lower
				of:
(1) The actual charge made by the provider
				of service.
(2) The maximum
				allowance under the fee schedule for the item of service in question.
Payment levels for fee schedule providers of service will be
				  increased on an annual basis by an economic index reflecting overall inflation
				  as well as inflation in office practice expenses of the particular provider
				  category involved to the extent data is available. Annual increases will be
				  made beginning July 1, 1988.
There are some variations in this methodology which are
				  applicable to certain providers. These are set forth below in subrules 79.1(3)
				  to 79.1(9) and 79.1(15).
Fee schedules in effect for the providers covered by fee
				  schedules can be obtained from the department's website at:
dhs.iowa.gov/ime/providers/csrp/fee-schedule
.
d.
Fee for service with
				cost settlement.
Rescinded IAB 10/10/18, effective 12/1/18.
e.
Retrospectively limited
				prospective rates.
Providers are reimbursed on the basis of a rate for
				a unit of service calculated prospectively for each participating provider
				(and, for supported community living daily rates, for each consumer or site)
				based on projected or historical costs of operation subject to the maximums
				listed in subrule 79.1(2) and to retrospective adjustment pursuant to
				subparagraph 79.1(1)
"e"
(3).
(1) The prospective rates for new providers
				who have not submitted six months of cost reports will be based on a projection
				of the provider's reasonable and proper costs of operation until the provider
				has submitted an annual cost report that includes a minimum of six months of
				actual costs.
(2) The prospective
				rates paid established providers who have submitted an annual report with a
				minimum of a six-month history are based on reasonable and proper costs in a
				base period and are adjusted annually for inflation.
(3) The prospective rates paid to both new
				and established providers are subject to the maximums listed in subrule 79.1(2)
				and to retrospective adjustment pursuant to paragraph
				79.1(15)
"f."
f.
Contractual rate.
Providers are reimbursed on a basis of costs incurred pursuant to a contract
				between the provider and subcontractor.
g.
Retrospectively adjusted
				prospective rates.
Critical access hospitals are reimbursed
				prospectively, with retrospective adjustments based on annual cost reports
				submitted by the hospital at the end of the hospital's fiscal year. The
				retroactive adjustment equals the difference between the reasonable costs of
				providing covered services to eligible fee-for-service Medicaid members
				(excluding members in managed care), determined in accordance with Medicare
				cost principles, and the Medicaid reimbursement received. Amounts paid that
				exceed reasonable costs shall be recovered by the department. See paragraphs
				79.1(5)
"aa"
and 79.1(16)
"h."
h.
Indian health facilities.
(1) Indian health facilities enrolled
				pursuant to rule 441-77.45 (249A) are paid for
				all Medicaid-covered services rendered to American Indian or Alaskan native
				persons who are Medicaid-eligible at the current daily visit rates approved by
				the U.S. Indian Health Service (IHS) for services provided by IHS facilities to
				Medicaid beneficiaries, as published in the Federal Register. For services
				provided to American Indians or Alaskan natives, Indian health facilities may
				bill for one visit per patient per calendar day for medical services (at the
				"outpatient per visit rate (excluding Medicare)"), which shall constitute
				payment in full for all medical services provided on that day, except as
				follows:
1. For services provided to American
				Indians and Alaskan natives, Indian health facilities may bill for multiple
				visits per patient per calendar day for medical services (at the "outpatient
				per visit rate (excluding Medicare)") only if medical services are provided for
				different diagnoses or if distinctly different medical services from different
				categories of services are provided for the same diagnoses in different units
				of the facility. For this purpose, the categories of medical services are
				vision services; dental services; mental health and addiction services; early
				and periodic screening, diagnosis, and treatment services for children; other
				outpatient services; and other inpatient services. A visit is a face-to-face
				contact between a patient and a health professional at or through the
				facility.
2. For services provided
				to American Indians or Alaskan natives, Indian health facilities may also bill
				for one visit per patient per calendar day for outpatient prescribed drugs
				provided by the facility (at the "outpatient per visit rate (excluding
				Medicare)"), which shall constitute payment in full for all outpatient
				prescribed drugs provided on that day.
(2) Services provided to Medicaid recipients
				who are not American Indians or Alaskan natives will be paid at the
				reimbursement rate otherwise allowed by Iowa Medicaid for the services provided
				and will be billed separately by CPT code on the CMS-1500 Health Insurance
				Claim Form or through pharmacy point of sale. Claims for nonpharmacy services
				provided to Medicaid recipients who are not American Indians or Alaskan natives
				must be submitted by the individual practitioner enrolled in the Iowa Medicaid
				program, but may be paid to the facility if the provider agreement so
				stipulates.
i.
Inflation factor.
When the department's reimbursement
				methodology for any provider includes an inflation factor, this inflation
				factor shall not exceed the amount by which the consumer price index for all
				urban consumers increased during the calendar year ending December 31,
				2002.