Iowa Admin. Code r. 441-73.1 - Definitions

Current through Register Vol. 44, No. 20, April 6, 2022

"Behavioral health services" means mental health and substance use disorder treatment services.

"Capitated payment" means a monthly payment to the contractor on behalf of each enrollee for the provision of health services under the contract. Payment is made regardless of whether the enrollee receives services during the month.

"Choice counseling" means the provision of unbiased information on managed care plans or provider options and answers to related questions and access to personalized assistance to help members understand the materials provided by the managed care organizations or the state, to answer questions about each of the options available, and to facilitate enrollment with a managed care organization.

"Claim" means a formal request for payment for benefits received or services rendered.

"Clean claim" means a claim that has no defect or impropriety (including any lack of required substantiating documentation) or particular circumstance requiring special treatment that prevents timely payment of the claim. "Clean claim" does not include a claim from a provider that is under investigation for fraud or abuse or a claim under review for medical necessity.

"CMS" means the Centers for Medicare and Medicaid Services, a division of the U.S. Department of Health and Human Services.

"Code of Federal Regulations (CFR)" means the codification of the general and permanent rules published in the Federal Register by the executive departments and agencies of the federal government.

"Community-based case management" means a collaborative process of planning, facilitation, and advocacy for options and services to meet a member's needs through communication and available resources to promote high-quality, cost-effective outcomes.

"Contract" means a contract between the department and a managed care organization. These contracts shall meet all applicable requirements of state and federal law, including the requirements of the Code of Federal Regulations, Title 42 CFR 434 as amended to October 16, 2015.

"Covered services" means physical health, behavioral health and long-term care services set forth in rule 441-73.5 (249A).

"Department" means the Iowa department of human services.

"Discharge planning" means the process, which begins at admission, of determining an enrollee's continued need for treatment services and of developing a plan to address ongoing needs.

"Electronic visit verification system" means, with respect to personal care services or home health care services defined in Section 12006 of the 21st Century Cures Act, a system under which visits conducted as part of such services are electronically verified with respect to:

(1) the type of service performed,
(2) the individual receiving the service,
(3) the date of the service,
(4) the location of service delivery,
(5) the individual providing the service, and
(6) the time the service begins and ends.

"Emergency medical condition" means a physical or behavioral condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in the following:

1. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
2. Serious impairment to bodily functions; or
3. Serious dysfunction of any bodily organ or part.

"Emergency services" means covered inpatient and outpatient services that are both furnished by a provider that is qualified to furnish these services and needed to evaluate or stabilize an emergency medical condition.

"EMTALA" means the Emergency Medical Treatment and Active Labor Act.

"Enrollee" means a hawki, Iowa Health and Wellness Plan or Medicaid member who is eligible for managed care organization enrollment and has been enrolled with a managed care organization as defined in subrule 73.3(2).

"Enrollment broker" means the entity the department uses to enroll persons in a managed care organization. The enrollment broker must be conflict free and meet all applicable requirements of state and federal law, including 42 CFR 438.10 as amended to October 16, 2015.

"Hawki program" means the healthy and well kids in Iowa program as set forth in 441-Chapter 86, the Iowa program to provide health care coverage for uninsured children of eligible families as authorized by Title XXI of the federal Social Security Act.

"Health maintenance organization" means a public or private organization which is licensed as a managed care organization or prepaid health plan under insurance division rules set forth in 191-Chapter 40.

"HIPP" means the health insurance premium payment program.

"Home- and community-based services (HCBS)" means services that are provided as an alternative to long-term care institutional services in a nursing facility or an intermediate care facility for persons with an intellectual disability (ICF/ID) or to delay or prevent placement in a nursing facility or ICF/ID.

"Incident reporting" means the reporting of critical events or incidents deemed sufficiently serious to warrant near-term review and follow-up by an appropriate authority. Such incidents may include but are not limited to:

1. Abuse and neglect;
2. The unauthorized use of restraint, seclusion or restrictive interventions;
3. Serious injuries that require medical intervention or result in hospitalization, or both;
4. Criminal victimization;
5. Death;
6. Financial exploitation;
7. Medication errors; and
8. Other incidents or events that involve harm or risk of harm to a participant.

"Insolvency" means a financial condition that exists when an entity is unable to pay its debts as they become due in the usual course of business or when the liabilities of the entity exceed its assets.

"Iowa Health and Wellness Plan" means the medical assistance program set forth in 441-Chapter 74.

"Level of care" means an evaluation to determine and establish an individual's need for the level of care provided in a hospital, a nursing facility, or an ICF/ID within the near future.

"Long-term care (LTC)" or "long-term services and supports (LTSS)" means the services of a nursing facility (NF), an intermediate care facility for persons with an intellectual disability (ICF/ID), state resource centers or services funded through Section 1915(c) home- and community-based services waivers, Section 1915(i) state plan home- and community-based habilitation program and the PACE program.

"Managed care organization (MCO)" means an entity that (1) is under contract with the department to provide services to Medicaid recipients and (2) meets the definition of "health maintenance organization" in Iowa Code section 514B.1.

"Mandatory enrollment" means mandatory participation in a managed care organization as specified in subrule 73.3(2).

"Medical loss ratio (MLR)" means the percentage of capitation payments that is used to pay medical expenses.

"Medically necessary services" means those covered services that are, under the terms and conditions of the contract, determined through contractor utilization management to be:

1. Appropriate and necessary for the symptoms, diagnosis or treatment of the condition of the member;
2. Provided for the diagnosis or direct care and treatment of the condition of the member to enable the member to make reasonable progress in treatment;
3. Within standards of professional practice and given at the appropriate time and in the appropriate setting;
4. Not primarily for the convenience of the member, the member's physician or other provider; and
5. The most appropriate level of covered services that can safely be provided.

"Medical records" means all medical, behavioral health, and long-term care histories; records, reports and summaries; diagnoses; prognoses; record of treatment and medication ordered and given; X-ray and radiology interpretations; physical therapy charts and notes; lab reports; other individualized medical, behavioral health, and long-term care documentation in written or electronic format; and analyses of such information.

"Member" means any person determined by the department to be eligible for the hawki program, the Iowa Health and Wellness Plan, or the Medicaid program.

"Money Follows the Person (MFP) Rebalancing Demonstration Grant" means a federal grant that will assist Iowa in transitioning individuals from a nursing facility or ICF/ID into the community and in rebalancing long-term care expenditures.

"Needs-based eligibility" means an evaluation to determine and establish an individual's need for habilitation services.

"Network" or "provider network" means a group of participating health care providers (both individual and group practitioners) linked through contractual arrangements to the contractor to supply a range of health care services.

"Out-of-network provider" means any provider that is not directly or indirectly employed by or does not have a provider agreement with the contractor or any of its subcontractors pursuant to the contract between the department and the contractor.

"PACE" means the program for all-inclusive care for the elderly.

"Participating providers" means the providers of covered physical health, behavioral health and long-term care services that have contracted with a managed care organization.

"Passive enrollment process" means the process by which the department assigns a member to a managed care organization and which, in accordance with 42 CFR 438.54, seeks to preserve existing provider-member relationships and relationships with providers that have traditionally served Medicaid members, if possible. In the absence of existing relationships, the process ensures that members are equally distributed among all available managed care organizations.

"PMIC" means a psychiatric medical institution for children.

"Prior authorization" means the process of obtaining prior approval as to the appropriateness of a service or medication. Prior authorization does not guarantee coverage.

"Warm transfer" means a telecommunications mechanism in which the person answering the call facilitates transfer to a third party, announces the caller and issue and remains engaged as necessary to provide assistance.


Iowa Admin. Code r. 441-73.1
Adopted by IAB January 6, 2016/Volume XXXVIII, Number 14, effective 1/1/2016 Amended by IAB May 8, 2019/Volume XLI, Number 23, effective 7/1/2019 Amended by IAB May 5, 2021/Volume XLIII, Number 23, effective 7/1/2021

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