reglab/statecodes huggingface dataset:
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.88 - Adverse Service Actions

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Denial.
An application for services shall be denied when it is
				determined by the department that:
a. The
				consumer is not eligible for the services because all of the medically
				necessary service needs cannot be met in a home- or community-based
				setting.
b. Service needs exceed
				the service unit or reimbursement maximums.
c. Service needs are not met by the services
				provided.
d. Needed services are
				not available or received from qualifying providers.
e. The brain injury waiver service is not
				identified in the consumer's service plan.
f. There is another community resource
				available to provide the service or a similar service free of charge to the
				consumer that will meet the consumer's needs.
g. The consumer receives services from other
				Medicaid waiver providers.
h. The
				consumer or legal representative through the interdisciplinary process requests
				termination from the services.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.89 - Appeal Rights

Current through Register Vol. 47, No. 3, July 24, 2024
Notice of adverse action and right to appeal shall be given
				  in accordance with 441-Chapter 7, rule 441-16.3 (17A) and rule
				  441-130.5
				  (234).
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.102 - Eligibility

Current through Register Vol. 47, No. 3, July 24, 2024
To be eligible for physical disability waiver services, a
				  consumer must meet eligibility criteria set forth in subrule 83.102(1) and be
				  determined to need a service allowable under the program per subrule
				  83.102(2).
(1)
Eligibility
				criteria.
All of the following criteria must be met. The person must:
a. Have a physical disability.
b. Be blind or disabled as determined by the
				receipt of social security disability benefits or by a disability determination
				made through the department. Disability determinations are made according to
				supplemental security income guidelines under Title XVI of the Social Security
				Act or the disability guidelines for the Medicaid employed people with
				disabilities coverage group.
c. Be
				ineligible for the HCBS intellectual disability waiver.
d. Have the ability to hire, supervise, and
				fire the provider as determined by the service worker, and be willing to do so,
				or have a parent or guardian named by probate court, or attorney in fact under
				a durable power of attorney for health care who will take this responsibility
				on behalf of the consumer.
e. Be
				eligible for Medicaid under 441-Chapter 75.
f. Be aged 18 years to 64 years.
g. Rescinded IAB 2/7/01, effective
				2/1/01.
h. Be in need of skilled
				nursing or intermediate care facility level of care based on information
				submitted on a completed interRAI - Pediatric Home Care (PEDS-HC) for those
				aged 18 to 20 or the interRAI - Home Care (HC) for those aged 21 and over and
				other supporting documentation as relevant. The interRAI - Pediatric Home Care
				(PEDS-HC) and the interRAI - Home Care (HC) are available on request from the
				IME medical services unit. Copies of the completed information submission tool
				for an individual are available to that individual from the individual's case
				manager or managed care organization.
(1)
				Initial decisions on level of care shall be made for the department by the IME
				medical services unit within two working days of receipt of medical
				information. The IME medical services unit determines whether the level of care
				requirement is met based on medical necessity and the appropriateness of the
				level of care under 441-subrules 79.9(1) and 79.9(2).
(2) Adverse decisions by the IME medical
				services unit may be appealed to the department pursuant to 441-Chapter 7.
i. Choose HCBS.
j. Use a minimum of one unit of service per
				calendar quarter under this program.
k. For the consumer choices option as set
				forth in 441-subrule 78.46(6), not be living in a residential care
				facility.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.103 - Application

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Application for financial eligibility.
The application process
				as specified in rules
				441-76.1 (249A) to
				441-76.6
				(249A) shall be followed. Applications for this program may only be filed on or
				after April 1, 1999.
(2)
Approval of application for eligibility.
a. Applications for this waiver shall be
				initiated on behalf of the applicant who is a resident of a medical institution
				with the applicant's consent or with the consent of the applicant's legal
				representative by the discharge planner of the medical facility where the
				applicant resides at the time of application.
(1) The discharge planner shall contact the
				member's managed care organization or designated case manager to arrange for
				completion of the appropriate information submission tool as listed in
				paragraph 83.102(1)
"h."
(2) After completing the determination of the
				level of care needed by the applicant, the IME medical services unit shall
				inform the income maintenance worker and the discharge planner of the IME
				medical services unit's decision.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.104 - Client Participation

Current through Register Vol. 47, No. 3, July 24, 2024
Consumers who are financially eligible under 441-subrule
				  75.1(7) (the 300 percent group) must contribute a client participation amount
				  to the cost of physical disability waiver services.
(1)
Computation of client
				participation.
Client participation shall be computed by deducting a
				maintenance needs allowance equal to 300 percent of the maximum SSI grant for
				an individual from the consumer's total income. For a couple, client
				participation is determined as if each person were an individual.
(2)
limitation on payment.
If the sum of the third-party payment and client participation equals or
				exceeds the reimbursement for the specific physical disability waiver service,
				Medicaid shall make no payments for the waiver service. However, Medicaid shall
				make payments to other medical providers.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.105 - Redetermination

Current through Register Vol. 47, No. 3, July 24, 2024
A complete financial redetermination of eligibility for the
				  physical disability waiver shall be completed at least once every 12 months. A
				  redetermination of continuing eligibility factors shall be made when a change
				  in circumstances occurs that affects eligibility in accordance with rule
				  441-83.102 (249A). A
				  redetermination shall contain the components listed in rule
				  441-83.102
				  (249A).
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.106 - Allowable Services

Current through Register Vol. 47, No. 3, July 24, 2024
The services allowable under the physical disability waiver
				  are consumer-directed attendant care, home and vehicle modification, personal
				  emergency response system, transportation, specialized medical equipment,
				  financial management, independent support brokerage, self-directed personal
				  care, self-directed community supports and employment, and individual-directed
				  goods and services as set forth in rule
				  441-78.46
				  (249A).
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.107 - Individual Service Plan

Current through Register Vol. 47, No. 3, July 24, 2024
An individualized service plan shall be prepared and used for
				  each HCBS physical disability waiver consumer. The service plan shall be
				  developed and approved by the consumer, the consumer's interdisciplinary team
				  and the designated case manager prior to services beginning and payment being
				  made to the provider.
(1)
Information in plan.
The
				plan shall be in accordance with 441-subrule 24.4(3) and shall additionally
				include the following information to assist in evaluating the program:
a. A listing of all services received by a
				consumer at the time of waiver program enrollment.
b. The name of all providers responsible for
				providing all services.
c. All
				service funding sources.
d. The
				amount of the service to be received by the consumer.
e. Whether the consumer has elected the
				consumer choices option and, if so:
(1) The
				independent support broker selected by the consumer; and
(2) The financial management service selected
				by the consumer.
f. A
				plan for emergencies and identification of the supports available to the
				consumer in an emergency.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.108 - Adverse Service Actions

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Denial.
An application for services shall be denied when it is
				determined by the department that:
a. All of
				the medically necessary service needs cannot be met in a home- or
				community-based setting.
b. Service
				needs exceed the reimbursement maximums.
c. Service needs are not met by the services
				provided.
d. Needed services are
				not available or received from qualifying providers.
e. The physical disability waiver service is
				not identified in the consumer's service plan.
f. There is another community resource
				available to provide the service or a similar service free of charge to the
				consumer that will meet the consumer's needs.
g. The consumer receives services from other
				Medicaid waiver providers.
h. The
				consumer or legal representative requests termination from the
				services.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.109 - Appeal Rights

Current through Register Vol. 47, No. 3, July 24, 2024
Notice of adverse action and right to appeal shall be given
				  in accordance with 441-Chapter 7, rule 441-16.3 (17A) and rule
				  441-130.5 (234).
(1)
Appeal to county.
Rescinded IAB 2/7/01, effective 2/1/01.
(2)
Reconsideration request to IME
				medical services unit.
Rescinded IAB 9/5/12, effective
				11/1/12.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.122 - Eligibility

Current through Register Vol. 47, No. 3, July 24, 2024
To be eligible for children's mental health waiver services,
				  a consumer must meet all of the following requirements:
(1)
Age.
The consumer must
				be under 18 years of age.
(2)
Diagnosis.
The consumer must be diagnosed with a serious
				emotional disturbance.
a.
Initial
				certification.
For initial application to the HCBS children's mental
				health waiver program, psychological documentation that substantiates a mental
				health diagnosis of serious emotional disturbance as determined by a mental
				health professional must be current within the 12-month period before the
				application date.
b.
Ongoing certification.
A mental health professional must
				complete an annual evaluation that substantiates a mental health diagnosis of
				serious emotional disturbance.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.123 - Application

Current through Register Vol. 47, No. 3, July 24, 2024
The Medicaid application process as specified in rules
				  441-76.1 (249A) to
				  441-76.6 (249A) shall be
				  followed for an application for HCBS children's mental health waiver
				  services.
(1)
Program
				limit.
The number of persons who may be approved for the HCBS
				children's mental health waiver shall be subject to the number of consumers to
				be served as set forth in the federally approved HCBS children's mental health
				waiver. When the number of applicants exceeds the number of consumers specified
				in the approved waiver, the consumer's application shall be rejected and the
				consumer's name shall be placed on a waiting list.
a. The local office shall determine if a
				payment slot is available by the end of the fifth working day after receipt of:
(1) A completed Form 470-2297, Health
				Services Application, from a consumer who is not currently a Medicaid member;
				or
(2) A written request signed and
				dated by a Medicaid member's parent or legal guardian.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.124 - Financial Participation

Current through Register Vol. 47, No. 3, July 24, 2024
A consumer must contribute to the cost of children's mental
				  health waiver services to the extent of the consumer's total income less 300
				  percent of the maximum monthly payment for one person under the federal
				  Supplemental Security Income (SSI) program.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.125 - Redetermination

Current through Register Vol. 47, No. 3, July 24, 2024
The department shall redetermine a consumer's eligibility
				  for the children's mental health waiver at least once every 12 months or when
				  there is significant change in the consumer's situation or condition.
(1)
Eligibility review.
a. Every 12 months, the department shall
				review a consumer's eligibility in accordance with procedures in rule
				441-76.7
				(249A). The review shall verify continuing eligibility factors as specified in
				rule
				441-83.122
				(249A).
b. The IME medical services
				unit or a managed care organization shall review the member's need for
				continued care annually and recertify the member's need for long-term care
				services, pursuant to rule
				441-83.122 (249A) and
				the appeal process at rule
				441-83.129 (249A),
				based on the completed information submission tool designated in 83.122(3) and
				other supporting documentation as relevant.
c. The IME medical services unit or the
				member's managed care organization shall be responsible for annual
				redetermination of the level of care.
d. The managed care organization must submit
				documentation to the IME medical services unit for all reassessments, performed
				at least annually, which indicate a change in the member's level of care. The
				IME medical services unit shall make a final determination for any
				reassessments which indicate a change in the level of care. If the level of
				care reassessment indicates no change in level of care, the member is approved
				to continue at the already established level of care.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.126 - Allowable Services

Current through Register Vol. 47, No. 3, July 24, 2024
Services allowable under the children's mental health waiver
				  shall be provided as set forth in rule
				  441-78.52
				  (249A) and shall include:
1.
				Environmental modifications, adaptive devices and therapeutic
				resources;
2. Family and community
				support services;
3. In-home family
				therapy; and
4. Respite
				care.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.127 - Service Plan

Current through Register Vol. 47, No. 3, July 24, 2024
The consumer's case manager or integrated health home care
				  coordinator shall prepare an individualized service plan for each consumer that
				  meets the requirements set for case plans in rule
				  441-130.7 (234).
(1) The service plan shall be developed
				through an interdisciplinary team process.
(2) The service plan shall be developed
				annually or when there is significant change in the consumer's situation or
				condition.
(3) The service plan
				shall be based on information in the completed information submission tool
				designated in subrule 83.122(3) and other supporting documentation as
				relevant.
(4) The service plan
				shall specify the type and frequency of the waiver services and the providers
				that will deliver the services.
(5)
				The service plan shall identify and justify any restriction of the consumer's
				rights.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.128 - Adverse Service Actions

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Denial.
An application for children's mental health waiver
				services shall be denied when the department determines that:
a. The consumer is not eligible for or in
				need of waiver services.
b. Needed
				services are not available or received from qualified providers.
c. Service needs exceed the limit on
				aggregate monthly costs established in 83.122(6)
"c"
or are not
				met by the services provided.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.129 - Appeal Rights

Current through Register Vol. 47, No. 3, July 24, 2024
Notice of adverse action and right to appeal shall be given
				  in accordance with 441-Chapter 7, rule 441-16.3 (17A) and rule
				  441-130.5
				  (234).
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 84 - Early and Periodic Screening, Diagnosis, and Treatment › Rule 441-84.1 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
"Diagnosis"
is the determination of the
				  nature of physical or mental disease or abnormality.
"Interperiodic screen"
means a screen that
				  occurs between the times stated in the periodicity schedule in 441-subrule
				  78.18(3).
"Screening "
is the use of quick, simple
				  procedures to sort out apparently well persons from those who may have a
				  disease or abnormality and to identify those in need of more definitive study.
				  These services shall be provided in accordance with reasonable standards of
				  medical and dental practice.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 84 - Early and Periodic Screening, Diagnosis, and Treatment › Rule 441-84.2 - Eligibility

Current through Register Vol. 47, No. 3, July 24, 2024
All persons eligible for medical assistance under age 21 are
				  eligible for early and periodic screening, diagnosis, and
				  treatment.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 84 - Early and Periodic Screening, Diagnosis, and Treatment › Rule 441-84.3 - Screening Services

Current through Register Vol. 47, No. 3, July 24, 2024
Screening may be done by a screening center or other
				  qualified providers. Other qualified providers are physicians, advanced
				  registered nurse practitioners, rural health centers, federally qualified
				  health centers, clinics, and dentists. Screening services shall include all of
				  the following services:
(1) A
				comprehensive health and developmental history including an assessment of both
				physical and mental health development. This includes:
a. A developmental assessment.
b. An assessment of nutritional
				status.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 84 - Early and Periodic Screening, Diagnosis, and Treatment › Rule 441-84.4 - Referral

Current through Register Vol. 47, No. 3, July 24, 2024
(1) The
				availability of early and periodic screening shall be discussed with the payee
				for any Medicaid-eligible child under the age of 21 at the time of application
				and periodically thereafter in compliance with federal regulations at Title 42,
				Part 441, Subpart B, as amended to March 29, 2022.
(2) Screening shall be offered to each
				eligible individual according to the periodicity schedule in 441-subrule
				78.18(3) when screening has been accepted, or on at least an annual basis when
				screening has been rejected. Interperiodic screens may be furnished when
				medically necessary to determine whether a child has a physical or mental
				illness or condition that may require further assessment, diagnosis, or
				treatment.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 84 - Early and Periodic Screening, Diagnosis, and Treatment › Rule 441-84.5 - Follow Up

Current through Register Vol. 47, No. 3, July 24, 2024
Follow-up services shall be provided when a referral for
				  screening was accepted, but 60 days have elapsed and no screening examination
				  has been performed, and when a screening examination discloses a possible
				  abnormal condition and a referral was made for further diagnosis or treatment
				  and such diagnosis or treatment has not been received within a period of 60
				  days from the date of the screening examination.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 85 - Services in Psychiatric Institutions › Rule 441-85.1 - Acute Care in Psychiatric Hospitals

Current through Register Vol. 47, No. 3, July 24, 2024
These rules do not apply to general hospitals with
				  psychiatric units.
(1)
Psychiatric hospitals serving persons aged 21 and older.
A
				psychiatric hospital serving persons aged 21 and older shall meet the federal
				criteria for an institution for mental disease and shall be licensed pursuant
				to department of inspections and appeals rule
				481-51.36
				(135B). An out-of-state facility shall be licensed as a psychiatric hospital,
				shall meet the federal criteria for an institution for mental disease, and
				shall be certified to participate in the Medicare program. An institution is an
				institution for mental disease only if its overall character is that of a
				facility established and maintained primarily for the care and treatment of
				persons with mental diseases. The following guidelines are used by the
				department in evaluating the overall character of a facility. These guidelines
				are all useful in identifying institutions for mental disease; however, no
				single guideline is necessarily determinative in any given case.
a. The facility:
(1) Is licensed as a psychiatric facility for
				the care and treatment of persons with mental diseases.
(2) Advertises or holds itself out as a
				facility for the care and treatment of persons with mental diseases.
(3) Is accredited as a psychiatric facility
				by the Joint Commission on the Accreditation of Health Care Organizations or by
				any other federally recognized accrediting organization that has comparable
				standards or surveys and is approved by the department of inspections and
				appeals.
(4) Specializes in
				providing psychiatric or psychological care and treatment. This may be
				ascertained through review of patients' records. It may also be indicated by
				the fact that an unusually large proportion of the staff has specialized
				psychiatric or psychological training or that a large proportion of the
				patients are receiving psychopharmacological drugs.
(5) Is under the jurisdiction of the
				department.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 85 - Services in Psychiatric Institutions › Rule 441-85.2 - Out-of-state Placement

Current through Register Vol. 47, No. 3, July 24, 2024
Placement in an out-of-state psychiatric hospital for acute
				  care requires prior approval by the bureau of managed care and clinical
				  services and shall be approved only if special services are not available in
				  Iowa.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 85 - Services in Psychiatric Institutions › Rule 441-85.3 - Eligibility of Persons Under the Age of 21

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Age.
To be eligible for payment for the cost of care provided
				by a psychiatric hospital, the person shall be under 21 years of age. When
				treatment in the hospital is provided immediately preceding the person's
				twenty-first birthday, coverage continues to be available until the
				twenty-second birthday or until service is no longer required, whichever is
				earlier.
(2)
Period of
				eligibility.
The person is considered to be an inpatient until
				unconditionally discharged. Coverage extends until the last day of the month of
				the discharge or the twenty-second birthday. While on inpatient status the
				eligible person is entitled to the full scope of Medicaid benefits.
(3)
Certification of need for
				care.
For persons eligible for Medicaid prior to admission, an
				independent team shall certify that ambulatory care resources available in the
				community do not meet the treatment needs of the recipient, that proper
				treatment of the recipient's psychiatric condition requires services on an
				inpatient basis under the direction of a physician, and that the services can
				reasonably be expected to improve the recipient's condition or prevent further
				regression so that the services will no longer be needed. Team members are
				independent when they are not employees of or consultants to the facility. Form
				470-2780 may be used to document these criteria.
a. For persons eligible for Medicaid prior to
				admission, this preadmission certification shall be performed within 45 days
				prior to the proposed date for admission to the facility by an independent team
				that includes a physician who has competence in diagnosis and treatment of
				mental illness, preferably in child psychiatry, and who has knowledge of the
				person's situation. If a social worker is a part of the team, the social worker
				may be from the county office of the department of human services.
The evaluation shall be submitted to the facility on or prior
				  to the date of the patient's admission.
b. When a person makes application for
				Medicaid subsequent to admission or has an application in process at the time
				of admission, a certification by the team responsible for the plan of care
				shall be provided within 14 days after admission and shall cover any period
				prior to application for which claims are to be made.
c. For emergency admissions, a certification
				shall be provided by the team responsible for the plan of care within 14 days
				after admission.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 85 - Services in Psychiatric Institutions › Rule 441-85.4 - Eligibility of Persons Aged 65 and Over

Current through Register Vol. 47, No. 3, July 24, 2024
To be eligible for payment for the cost of care provided by
				  an institution for mental disease, persons must be aged 65 or over and be
				  eligible under one of the coverage groups listed in 441-Chapter
				  75.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 85 - Services in Psychiatric Institutions › Rule 441-85.5 - Client Participation

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Before
				July 2005.
For months before July 2005, the resident shall be liable
				to pay client participation toward the cost of care on a monthly basis. The
				state will pay the balance of the cost of care for the month. The facility
				shall make arrangements directly with the resident for payment of client
				participation. Client participation is determined according to 441-Chapter
				75.
(2)
July 2005 and
				after.
Effective with the month of July 2005, the resident shall not
				be liable to pay client participation toward the cost of care, and no client
				participation amount shall be deducted from the state payment to the
				hospital.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 85 - Services in Psychiatric Institutions › Rule 441-85.6 - Responsibilities of Hospitals

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Medical
				record requirements.
The medical records maintained by the psychiatric
				hospital shall permit determination of the degree and intensity of the
				treatment provided to persons who are furnished services in the hospital.
a. Development of assessment and diagnostic
				data. Medical records shall stress the psychiatric components of the record,
				including history of findings and treatment provided for the psychiatric
				condition for which the patient is hospitalized.
(1) The identification data shall include the
				patient's legal status.
(2) A
				provisional or admitting diagnosis shall be made on every patient at the time
				of admission, and shall include the diagnoses of intercurrent diseases as well
				as the psychiatric diagnoses.
(3)
				The reasons for admission shall be clearly documented as stated by the patient
				or others significantly involved.
(4) The social service records, including
				reports of interviews with patients, family members, and others, shall provide
				an assessment of home plans and family attitudes and community resource
				contacts, as well as a social history.
(5) When indicated, a complete neurological
				examination shall be recorded at the time of the admission physical
				examination.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 85 - Services in Psychiatric Institutions › Rule 441-85.7 - Psychiatric Hospital Reimbursement

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Reimbursement formula.
Acute care in psychiatric hospitals
				shall be reimbursed on a per diem rate based on Medicare principles.
a. The reimbursement principles follow and
				comply with the retrospective Principles of Medicare reimbursement found in
				Title 18 of the Social Security Act and amendments to that Act, Medicare
				regulations found in the Health Insurance Regulation Manual (HIRM-1), and
				General Instructions-Health Insurance Manual sections 10, 11, 12 and 15 when
				applicable.
b. Allowable costs are
				those defined as allowable in
				42 CFR, Subpart A, Sections
				413.5 and
				413.9,
				as amended to June 15, 2022, and
				42 CFR 447.250
				as amended to June 15, 2022. Only those costs are considered in calculating the
				Medicaid inpatient reimbursement.
c. Medicare and Medicaid principles of
				reimbursement require hospitals to be paid at the lower of customary charges or
				reasonable cost and to adhere to all Medicare cost principles in the
				calculation of the facility rates.
d. Payment for inpatient hospital care for
				recipients for whom the PRO has determined that the level of care that is
				medically necessary is only that of skilled care or nursing care will be made
				at a rate equal to the statewide average Medicaid skilled nursing facility rate
				or the average state nursing facility rate. Periodic PRO determinations of the
				need for continuing care are also required.
e. Each participating Medicaid provider shall
				file a CMS 2552 Medicare Cost Report or a substitute accepted by the Centers
				for Medicare and Medicaid Services. In addition, supplemental information
				sheets are furnished to all Medicaid providers to be filed with the annual cost
				report. This report must be filed with the Iowa Medicaid enterprise provider
				audits and rate-setting unit for Iowa within 150 days after the close of the
				hospital's fiscal year.
f.
				Compensation for a disproportionate share of indigent patients is determined as
				described in 441-subrule 79.1(5).
g. Medicaid reimbursement shall be reduced by
				any payments from a third party toward the cost of a patient's care.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 85 - Services in Psychiatric Institutions › Rule 441-85.8 - Eligibility of Persons Aged 21 Through 64

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Facility.
Acute care in a psychiatric hospital is covered for
				persons aged 21 through 64 only at the state mental health institutes at
				Cherokee and Independence.
(2)
Basis of eligibility.
To be eligible for payment for the cost
				of care provided by one of the covered facilities, a person aged 21 through 64
				must be eligible for one of the coverage groups listed in 441-Chapter
				75.
(3)
Period of
				eligibility.
A person is considered to be an inpatient until
				unconditionally discharged. Coverage extends until the last day of the month of
				discharge.
(4)
Extent of
				eligibility.
While on inpatient status, a person eligible under a
				coverage group listed in
				441-75.1 (249A)
				is entitled to the full scope of Medicaid benefits.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 85 - Services in Psychiatric Institutions › Rule 441-85.21 - Conditions for Participation

Current through Register Vol. 47, No. 3, July 24, 2024
Psychiatric medical institutions for children shall be issued
				  a license by the department of inspections and appeals under Iowa Code chapter
				  135H and shall hold either a license from the department of human services
				  under Iowa Code section
				  237.3, subsection 2,
				  paragraph
"a, "
subparagraph (3) or, for facilities which
				  provide substance abuse treatment, a license from the department of public
				  health under Iowa Code section
				  125.13.
This rule is intended to implement Iowa Code sections
				  135H.4 and
				  249A.4.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 85 - Services in Psychiatric Institutions › Rule 441-85.22 - Eligibility of Persons Under the Age of 21

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Age.
To be eligible for payment for the cost of care provided
				by a psychiatric medical institution for children, the person shall be under 21
				years of age. When treatment in the facility is provided immediately preceding
				the individual's twenty-first birthday, coverage continues to be available
				until the twenty-second birthday or until service is no longer required,
				whichever is earlier.
(2)
Period of eligibility.
The person is considered to be an
				inpatient until unconditionally discharged. Coverage extends until the last day
				of the month of the discharge or the twenty-second birthday. While on inpatient
				status, the eligible individual is entitled to the full scope of Medicaid
				benefits.
(3)
Certification
				for need for care.
For persons eligible for Medicaid prior to
				admission, an independent team shall certify that ambulatory care resources
				available in the community do not meet the treatment needs of the recipient,
				that proper treatment of the recipient's psychiatric condition requires
				services on an inpatient basis under the direction of a physician, and that the
				services can reasonably be expected to improve the recipient's condition or
				prevent further regression so that the services will no longer be needed. Team
				members are independent when they are not employees of or consultants to the
				facility. Form 470-2780 may be used to document these criteria.
a. For persons determined eligible for
				Medicaid prior to admission, this preadmission certification shall be performed
				within 45 days prior to the proposed date for admission to the facility by an
				independent team that includes a physician who has competence in diagnosis and
				treatment of mental illness, preferably in child psychiatry, and who has
				knowledge of the person's situation. If a social worker is a part of the team,
				the social worker may be from the county office of the department of human
				services.
The evaluation shall be submitted to the facility on or prior
				  to the date of the patient's admission.
b. When a person makes application for
				Medicaid subsequent to admission or has an application in process at the time
				of admission, a certification by the team responsible for the plan of care
				shall be provided within 14 days after admission and shall cover any period
				prior to application for which claims are to be made.
c. For emergency admissions, a certification
				shall be provided by the team responsible for the plan of care within 14 days
				after admission.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 85 - Services in Psychiatric Institutions › Rule 441-85.23 - Client Participation

Current through Register Vol. 47, No. 3, July 24, 2024
The resident's client participation and medical payments from
				  a third party shall be paid toward the total cost of care on a monthly basis.
				  The state will pay the balance of the cost of care for the month. The facility
				  shall make arrangements directly with the resident for payment of client
				  participation. Client participation is determined according to 441-Chapter
				  75.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 85 - Services in Psychiatric Institutions › Rule 441-85.24 - Responsibilities of Facilities

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Medical
				record requirements.
The medical records maintained by psychiatric
				medical institutions for children shall permit determination of the degree and
				intensity of the treatment provided to persons who are furnished services in
				the facility.
a. Development of assessment and
				diagnostic data. Medical records shall stress the psychiatric components of the
				record, including history of findings and treatment provided for the
				psychiatric condition for which the patient is admitted.
(1) The identification data shall include the
				patient's legal status.
(2) A
				provisional or admitting diagnosis shall be made on every patient at the time
				of admission, and shall include the diagnoses of intercurrent diseases as well
				as the psychiatric diagnoses.
(3)
				The reasons for admission shall be clearly documented as stated by the patient
				or others significantly involved.
(4) The social service records, including
				reports of interviews with patients, family members, and others, shall provide
				an assessment of home plans and family attitudes and community resource
				contacts, as well as a social history.
(5) When indicated, a complete neurological
				examination shall be recorded at the time of the admission physical
				examination.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 85 - Services in Psychiatric Institutions › Rule 441-85.25 - Reimbursement to Psychiatric Medical Institutions for Children

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Computation of inpatient rate for non-state-owned facilities prior to
				July 1, 2014, and for state-owned facilities.
For services rendered by
				non-state-owned facilities on or before June 30, 2014, or by state-owned
				facilities, facilities are paid at a per diem rate based on the facility's
				actual and allowable cost for the service not to exceed the upper limit as
				provided in 441-subrule 79.1(2).
a. Rates for
				new facilities are based on historical costs submitted on Form 470-0664 if the
				institution is established and has the historical data. If the institution is
				newly established, the rate shall be based on a proposed budget submitted on
				Form 470-0664. A Form 470-0664 with actual cost data shall be submitted after
				at least six months of participation in the program for a new rate
				adjustment.
b. After the initial
				cost report period, the institution shall submit Form 470-0664 annually within
				three months of the close of the facility's fiscal year. Failure to submit the
				report within this time shall reduce payment to 75 percent of the current rate.
				The reduced rate shall be paid for no longer than three months, after which
				time no further payments will be made.
c. For services rendered on or after August
				1, 2011, rates paid shall be adjusted to 100 percent of the facility's actual
				and allowable average costs per patient day, based on the cost information
				submitted pursuant to paragraphs 85.25(1)
"a"
and
"b,"
subject to the upper limit provided in 441-subrule
				79.1(2) for non-state-owned facilities. Before rate adjustment, providers shall
				be paid a prospective interim rate equal to the previous year's retrospectively
				calculated unit-of-service rate.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 85 - Services in Psychiatric Institutions › Rule 441-85.26 - Outpatient Day Treatment for Persons Aged 20 or Under

Current through Register Vol. 47, No. 3, July 24, 2024
Payment to a psychiatric medical institution for children
				  will be approved for day treatment services for persons aged 20 or under if the
				  psychiatric medical institution for children is certified by the department of
				  inspections and appeals for day treatment services and the services are
				  provided on the licensed premises of the psychiatric medical institution for
				  children.
Exception: Field trips away from the premises are a covered
				  service when the trip is therapeutic and integrated into the day treatment
				  program's description and milieu plan. All conditions for the day treatment
				  program for persons aged 20 or under as outlined in 441-subrule 78.16(7) for
				  community mental health centers shall apply to psychiatric medical institutions
				  for children.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 85 - Services in Psychiatric Institutions › Rule 441-85.41 - Conditions of Participation

Current through Register Vol. 47, No. 3, July 24, 2024
A nursing facility for persons with mental illness shall be
				  licensed pursuant to department of inspections and appeals rules 481-Chapter
				  65, or, if the facility is a distinct part of a hospital, pursuant to
				  department of inspections and appeals rule 481-51.33 (135B). A distinct part of
				  a general hospital may be considered a psychiatric institution. In addition,
				  the facility shall be certified to participate in the Iowa Medicaid program as
				  a nursing facility pursuant to 441-Chapter 81 and shall be 16 beds or more. The
				  facility shall also meet the criteria set forth in subrule
				  85.1(1).
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 85 - Services in Psychiatric Institutions › Rule 441-85.43 - Eligibility of Persons Aged 65 and Over

Current through Register Vol. 47, No. 3, July 24, 2024
To be eligible for payment for the cost of care provided by
				  nursing facilities for persons with mental illness, persons must be aged 65 or
				  over and be eligible under one of the coverage groups listed in 441-Chapter 75,
				  except for medically needy.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 85 - Services in Psychiatric Institutions › Rule 441-85.44 - Client Participation

Current through Register Vol. 47, No. 3, July 24, 2024
The resident's client participation and medical payments from
				  a third party shall be paid toward the total cost of care on a monthly basis.
				  The state will pay the balance of the cost of care for the month. The facility
				  shall make arrangements directly with the resident for payment of client
				  participation. Client participation is determined according to rule
				  441-75.16
				  (249A).
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 85 - Services in Psychiatric Institutions › Rule 441-85.45 - Responsibilities of Nursing Facility

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Medical record
				requirements.
The facility shall obtain a PRO determination that the
				person requires psychiatric care when a person applying or eligible for
				Medicaid enters the facility, returns from an acute care hospital stay longer
				than 10 days, or enters the facility after 30 consecutive days of visitation.
				Periodic PRO determinations of the need for continuing care are also
				required.
(2)
Fiscal
				records.
a. A Case Activity Report,
				Form 470-0042, shall be submitted to the department whenever a Medicaid
				applicant or recipient enters the facility, changes level of care, is
				hospitalized, leaves for visitation, or is discharged from the
				facility.
b. The facility shall
				bill after each calendar month for the previous month's services.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 85 - Services in Psychiatric Institutions › Rule 441-85.46 - Policies Governing Reimbursement

Current through Register Vol. 47, No. 3, July 24, 2024
Cost reporting, reserve bed day payment, and reimbursement
				  shall be the same for nursing facilities for persons with mental illness as for
				  nursing facilities as set forth in 441-Chapter 81.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 85 - Services in Psychiatric Institutions › Rule 441-85.47 - State-funded Personal Needs Supplement

Current through Register Vol. 47, No. 3, July 24, 2024
A Medicaid member living in an intermediate care facility for
				  persons with mental illness who has countable income for purposes of rule
				  441-75.16
				  (249A) of less than $50 per month shall receive a state-funded payment from the
				  department for the difference between that countable income and $50 if the
				  legislature has appropriated funding specifically for this purpose. This
				  payment shall not be considered a benefit under Title XIX of the Social
				  Security Act.
This rule is intended to implement Iowa Code section
				  249A.30A.