reglab/statecodes huggingface dataset:
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.26 - Ambulatory Surgical Center Services

Current through Register Vol. 47, No. 3, July 24, 2024
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.
(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.
(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.
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.29 - Behavioral Health Services

Current through Register Vol. 47, No. 3, July 24, 2024
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.
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.30 - Birth Centers

Current through Register Vol. 47, No. 3, July 24, 2024
Payment will be made for prenatal, delivery, and postnatal
				  services.
(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).)
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.31 - Hospital Outpatient Services

Current through Register Vol. 47, No. 3, July 24, 2024
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.32 - Area Education Agencies

Current through Register Vol. 47, No. 3, July 24, 2024
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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.33 - Case Management Services

Current through Register Vol. 47, No. 3, July 24, 2024
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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.34 - Hcbs Health and Disability Waiver Services

Current through Register Vol. 47, No. 3, July 24, 2024
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.
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.35 - Occupational Therapist Services

Current through Register Vol. 47, No. 3, July 24, 2024
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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.36 - Hospice Services

Current through Register Vol. 47, No. 3, July 24, 2024
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.37 - Hcbs Elderly Waiver Services

Current through Register Vol. 47, No. 3, July 24, 2024
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.
(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.
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.39 - Federally Qualified Health Centers

Current through Register Vol. 47, No. 3, July 24, 2024
Payment shall be made for services as defined in Section
				  1905(a)(2)(C) of the Social Security Act.
(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 441-78.40 - Advanced Registered Nurse Practitioners

Current through Register Vol. 47, No. 3, July 24, 2024
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.
(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.
(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.
(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.
(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.
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.42 - Pharmacists Providing Covered Vaccines

Current through Register Vol. 47, No. 3, July 24, 2024
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:
(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.
(2)
Vaccines administered to
				adults.
Payment will be made to an enrolled provider for an
				administration fee and vaccine cost.
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.43 - Hcbs Brain Injury Waiver Services

Current through Register Vol. 47, No. 3, July 24, 2024
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.
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.44 - Lead Inspection Services

Current through Register Vol. 47, No. 3, July 24, 2024
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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.46 - Physical Disability Waiver Service

Current through Register Vol. 47, No. 3, July 24, 2024
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.
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.47 - Pharmaceutical Case Management Services

Current through Register Vol. 47, No. 3, July 24, 2024
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.
(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.
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.48 - Public Health Agencies

Current through Register Vol. 47, No. 3, July 24, 2024
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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.50 - Local Education Agency Services

Current through Register Vol. 47, No. 3, July 24, 2024
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.
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.51 - Indian Health Service 638 Facility Services

Current through Register Vol. 47, No. 3, July 24, 2024
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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.52 - Hcbs Children's Mental Health Waiver Services

Current through Register Vol. 47, No. 3, July 24, 2024
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.
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.54 - Speech-language Pathology Services

Current through Register Vol. 47, No. 3, July 24, 2024
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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.55 - Services Rendered via Telehealth

Current through Register Vol. 47, No. 3, July 24, 2024
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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.58 - Qualified Medicare Beneficiary (QMB) Provider Services

Current through Register Vol. 47, No. 3, July 24, 2024
(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).
(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 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.59 - Health Insurance Premium Payment (HIPP) Provider Services

Current through Register Vol. 47, No. 3, July 24, 2024
(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).
(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
				  "
or
"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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.60 - Crisis Response Services

Current through Register Vol. 47, No. 3, July 24, 2024
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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.61 - Subacute Mental Health Services

Current through Register Vol. 47, No. 3, July 24, 2024
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.
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 441-79.3 - Maintenance of Records by Providers of Service

Current through Register Vol. 47, No. 3, July 24, 2024
A provider of a service that is charged to the medical
				  assistance program shall maintain complete and legible records as required in
				  this rule. Failure to maintain records or failure to make records available to
				  the department or to its authorized representative timely upon request shall
				  result in claim denial or recoupment.
(1)
Financial (fiscal)
				records.
a. A provider of service
				shall maintain records as necessary to:
(1)
				Support the determination of the provider's reimbursement rate under the
				medical assistance program; and
(2)
				Support each item of service for which a charge is made to the medical
				assistance program. These records include financial records and other records
				as may be necessary for reporting and accountability.
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 441-79.5 - Nondiscrimination on the Basis of Handicap

Current through Register Vol. 47, No. 3, July 24, 2024
All providers of service shall comply with Section 504 of the
				  Rehabilitation Act of 1973 and Federal regulations 45 CFR Part 84, as amended
				  to December 19,1990, which prohibit discrimination on the basis of handicap in
				  all Department of Health and Human Services funded programs.
This rule is intended to implement Iowa Code subsection
				  249A.4(6).
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 441-79.6 - Provider Participation Agreement

Current through Register Vol. 47, No. 3, July 24, 2024
Providers of medical and health care wishing to participate
				  in the program shall execute an agreement with the department on Form 470-2965,
				  Agreement Between Provider of Medical and Health Services and the Iowa
				  Department of Human Services Regarding Participation in Medical Assistance
				  Program.
Exception: Dental providers are required to complete Form
				  470-3174, Addendum to Dental Provider Agreement for Orthodontia, to receive
				  reimbursement under the early and periodic screening, diagnosis, and treatment
				  program.
In these agreements, the provider agrees to the
				  following:
(1) To maintain clinical
				and fiscal records as specified in rule
				441-79.3
				(249A).
(2) That the charges as
				determined in accordance with the department's policy shall be the full and
				complete charge for the services provided and no additional payment shall be
				claimed from the recipient or any other person for services provided under the
				program.
(3) That it is understood
				that payment in satisfaction of the claim will be from federal and state funds
				and any false claims, statements, or documents, or concealment of a material
				fact may be prosecuted under applicable federal and state laws.
This rule is intended to implement Iowa Code section
				  249A.4.
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 441-79.7 - Medical Assistance Advisory Council

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Officers.
a. The public co-chairperson's term of office
				shall be two years. A public co-chairperson shall serve no more than two
				consecutive terms.
b. The public
				co-chairperson shall have the right to vote on any issue before the council.
				The public health director co-chairperson serves as a nonvoting member of the
				council.
c. The position of public
				co-chairperson shall be held by one of the five public council members. Ballots
				will be distributed to the public council members at the quarterly meeting
				closest to the beginning of the next state fiscal year and will be collected in
				paper and electronic format and administered by department of human services
				staff. The initial ballot following July 1, 2019, will be distributed by email
				prior to the first meeting in that fiscal year in order to identify the public
				co-chairperson prior to the council's first meeting.
d. The co-chairpersons shall appoint members
				to other committees approved by the council.
e. Responsibilities.
(1) The co-chairpersons shall be responsible
				for development of the agendas for meetings of the council. Agendas will be
				developed and distributed in compliance with the advance notice requirements of
				Iowa Code section
				21.4. Agendas will
				be developed in consultation with the staff and director of human services,
				taking into consideration the following:
1.
				Workplans. Items will be added to the council's agenda as various tasks for the
				council are due to be discussed based on calendar requirements. Council
				deliberations are to be conducted within a time frame to allow the council to
				receive and make recommendations to the director and for the director to
				consider those recommendations as budgets and policy for the medical assistance
				program are developed for the review of the council on human services and the
				governor, as well as for the upcoming legislative session.
2. Requests from the director of human
				services.
3. Discussion and action
				items from council members. The co-chairpersons will review any additional
				suggestions from council members at any time, including after the draft agenda
				has been distributed. The agenda will be distributed in draft form five
				business days prior to the council meeting, and the final agenda will be
				distributed no later than 24 hours prior to the council meeting.
(2) The co-chairpersons shall
				preside over all council meetings, calling roll, determining a quorum, counting
				votes, and following the agenda for the meeting.
(3) The co-chairpersons shall consult with
				the department of human services on other administrative tasks to oversee the
				council and shall participate in workgroups and subcommittees as appropriate.