Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 73 - Managed Care › Rule 441-73.1 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
"Behavioral health services"
means mental
				  health and substance use disorder treatment services.
"Capitated payment"
means a monthly payment
				  to the MCP on behalf of each enrollee for the provision of health or dental
				  services under the contract. Payment is made regardless of whether the enrollee
				  receives services during the month.
"Choice counseling"
means the provision of
				  unbiased information on MCPs or provider options and answers to related
				  questions and access to personalized assistance to help members understand the
				  materials provided by the MCPs or the state, to answer questions about each of
				  the options available, and to facilitate enrollment with an MCP.
"Claim"
means a formal request for payment
				  for benefits received or services rendered.
"Clean claim"
means a claim that has no
				  defect or impropriety (including any lack of required substantiating
				  documentation) or particular circumstance requiring special treatment that
				  prevents timely payment of the claim. "Clean claim" does not include a claim
				  from a provider that is under investigation for fraud or abuse or a claim under
				  review for medical necessity.
"CMS"
means the Centers for Medicare and
				  Medicaid Services, a division of the U.S. Department of Health and Human
				  Services.
"Code of Federal Regulations"
or
"CFR"
means the codification of the general and permanent
				  rules published in the Federal Register by the executive departments and
				  agencies of the federal government.
"Community-based case management"
means a
				  collaborative process of planning, facilitation, and advocacy for options and
				  services to meet an enrollee's needs through communication and available
				  resources to promote high-quality, cost-effective outcomes.
"Contract"
means a contract between the
				  department and an MCP. These contracts shall meet all applicable requirements
				  of state and federal law, including the requirements of
				  42 CFR
				  434 as amended to July 19, 2022.
"Covered services"
means physical health,
				  behavioral health, dental, and long-term care services set forth in rule
				  441-73.5 (249A).
"Department"
means the Iowa department of
				  human services.
"Discharge planning"
means the process,
				  which begins at admission, of determining a continued need for treatment
				  services and of developing a plan to address ongoing needs.
"Electronic visit verification system"
means, with respect to personal care services or home health care services
				  described in Section 12006 of the 21st Century Cures Act, a system under which
				  visits conducted as part of such services are electronically verified with
				  respect to:
(1) the type of service
				performed,
(2) the individual
				receiving the service,
(3) the date
				of the service,
(4) the location of
				service delivery,
(5)  the
				individual providing the service, and
(6) the time the service begins and ends.
"Emergency medical condition"
means a
				  medical condition manifesting itself by acute symptoms of sufficient severity
				  (including severe pain) that a prudent layperson who possesses an average
				  knowledge of health and medicine could reasonably expect the absence of
				  immediate medical attention to result in the following:
1. Placing the health of the individual (or,
				for a pregnant woman, the health of the woman or her unborn child) in serious
				jeopardy;
2. Serious impairment to
				bodily functions;
3. Serious
				dysfunction of any bodily organ or part.
"Emergency services"
means covered inpatient
				  and outpatient services that are as follows:
1. Furnished by a provider that is qualified
				to furnish these services.
2.
				Needed to evaluate or stabilize an emergency medical condition.
"EMTALA"
means the Emergency Medical
				  Treatment and Active Labor Act.
"Enrollee"
means a hawki, Iowa health and
				  wellness plan, dental wellness plan or Medicaid member who is eligible for MCP
				  enrollment and has been enrolled with an MCP as defined in subrule
				  73.3(2).
"Enrollment broker"
means the entity the
				  department uses to enroll persons in an MCP. The enrollment broker must be
				  conflict-free and meet all applicable requirements of state and federal law,
				  including 42 CFR
				  438.10 as amended to July 19, 2022.
"Hawki program"
means the healthy and well
				  kids in Iowa program as set forth in 441-Chapter 86, the Iowa program to
				  provide health care coverage for uninsured children of eligible families as
				  authorized by Title XXI of the federal Social Security Act.
"HIPP"
means the health insurance premium
				  payment program.
"Home- and community-based services"
or
"HCBS"
means services that are provided as an alternative to
				  long-term care institutional services in a nursing facility or an intermediate
				  care facility for persons with an intellectual disability (ICF/ID) or to delay
				  or prevent placement in a nursing facility or ICF/ID.
"Incident reporting"
means the reporting of
				  critical events or incidents deemed sufficiently serious to warrant near-term
				  review and follow-up by an appropriate authority. Such incidents may include
				  but are not limited to:
1. Abuse and
				neglect;
2. The unauthorized use of
				restraint, seclusion or restrictive interventions;
3. Serious injuries that require medical
				intervention or result in hospitalization, or both;
4. Criminal victimization;
5. Death;
6. Financial exploitation;
7. Medication errors; and
8. Other incidents or events that involve
				harm or risk of harm to a participant.
"Insolvency"
means a financial condition
				  that exists when an entity is unable to pay its debts as they become due in the
				  usual course of business or when the liabilities of the entity exceed its
				  assets.
"Iowa health and wellness plan"
means the
				  medical assistance program set forth in 441-Chapter 74.
"Level of care"
means an evaluation to
				  determine and establish an individual's need for the level of care provided in
				  a hospital, a nursing facility, or an ICF/ID within the near future.
"Long-term care (LTC)"
or
"long-term
				  services and supports (LTSS)"
means the services of a nursing facility
				  (NF), an intermediate care facility for persons with an intellectual disability
				  (ICF/ID), state resource centers or services funded through Section 1915(c)
				  home- and community-based services waivers, Section 1915(i) state plan home-
				  and community-based habilitation program and the PACE program.
"Managed care organization"
or
"MCO"
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" in Iowa Code section
				  514B.1.
"Managed care plan"
or
"MCP"
refers to managed care organizations (MCOs) and prepaid
				  ambulatory health plans (PAHPs).
"Mandatory enrollment"
means mandatory
				  participation in a managed care plan as specified in subrule 73.3(2).
"Medical loss ratio"
or
"MLR"
means the percentage of capitation payments that is used
				  to pay medical or dental expenses.
"Medically necessary services"
means those
				  covered services that are, under the terms and conditions of the contract,
				  determined through MCP utilization management to be:
1. Appropriate and necessary for the
				symptoms, diagnosis or treatment of the condition of the member.
2. Provided for the diagnosis or direct care
				and treatment of the condition of the member to enable the member to make
				reasonable progress in treatment.
3. Within standards of professional practice
				and given at the appropriate time and in the appropriate setting.
4. Not primarily for the convenience of the
				member, the member's physician or other provider; and
5. The most appropriate level of covered
				services that can safely be provided.
"Medical records"
means all medical, dental,
				  behavioral health, and long-term care histories; records, reports and
				  summaries; diagnoses; prognoses; record of treatment and medication ordered and
				  given; X-ray and radiology interpretations; physical therapy charts and notes;
				  lab reports; other individualized medical, behavioral health, and long-term
				  care documentation in written or electronic format; and analyses of such
				  information.
"Member"
means any person determined by the
				  department to be eligible for the hawki program, the Iowa health and wellness
				  plan, the dental wellness plan, or the Medicaid program.
"Money Follows the Person (MFP) Rebalancing
				  Demonstration Grant"
means a federal grant that will assist Iowa in
				  transitioning individuals from a nursing facility or ICF/ID into the community
				  and in rebalancing long-term care expenditures.
"Needs-based eligibility"
means an
				  evaluation to determine and establish an individual's need for habilitation
				  services.
"Network"
or
"provider
				  network"
means a group of participating health or dental care
				  providers (both individual and group practitioners) linked through contractual
				  arrangements to the MCP to supply a range of health or dental care
				  services.
"Out-of-network provider"
means any provider
				  that is not directly or indirectly employed by or does not have a provider
				  agreement with the MCP or any of its subcontractors pursuant to the contract
				  between the department and the MCP.
"PACE"
means the program of all-inclusive
				  care for the elderly.
"Participating providers"
means the
				  providers of covered physical health, behavioral health, dental, and long-term
				  care services that have contracted with a managed care plan.
"Passive enrollment process"
means the
				  process by which the department assigns a member to a managed care plan and
				  which, in accordance with 42
				  CFR 438.54 as amended to July 19, 2022, seeks
				  to preserve existing provider-member relationships and relationships with
				  providers that have traditionally served Medicaid members, if possible. In the
				  absence of existing relationships, the process ensures that members are equally
				  distributed among all available managed care plans.
"Prepaid ambulatory health plan"
or
"PAHP"
has the meaning set forth in
				  42 CFR
				  438.2 as amended to July 19, 2022.
"Prior authorization"
means the process of
				  obtaining prior approval as to the appropriateness of a service or medication.
				  Prior authorization does not guarantee coverage.
"Warm transfer"
means a telecommunications
				  mechanism in which the person answering the call facilitates transfer to a
				  third party, announces the caller and issue and remains engaged as necessary to
				  provide assistance.