Payment for inpatient hospital admission is approved when it
meets the criteria for inpatient hospital care as determined by the Iowa
Medicaid enterprise. All cases are subject to random retrospective review and
may be subject to a more intensive retrospective review if abuse is suspected.
In addition, transfers, outliers, and readmissions within 31 days are subject
to random review. Selected admissions and procedures are subject to a 100
percent review before the services are rendered. Medicaid payment for inpatient
hospital admissions and continued stays are approved when the admissions and
continued stays are determined to meet the criteria for inpatient hospital
care. (Cross reference 78.28(6)) The criteria are available from the IME
Medical Services Unit, 100 Army Post Road, Des Moines, Iowa 50315, or in local
hospital utilization review offices. No payment will be made for waiver
days.
See rule
441-78.31 (249A) for policies
regarding payment of hospital outpatient services.
If the recipient is eligible for inpatient or outpatient
hospital care through the Medicare program, payment will be made for
deductibles and coinsurance as set out in 441-subrule 79.1(22).
The DRG payment calculations include any special services
required by the hospital, including a private room.
(1) Payment for Medicaid-certified physical
rehabilitation units will be approved for the day of admission but not the day
of discharge or death.
(2) No
payment will be approved for private duty nursing.
(3) Certification of inpatient hospital care
shall be the same as that in effect in part A of Medicare. The hospital
admittance records are sufficient for the original certification.
(4) Services provided for intestinal or
gastric bypass surgery for treatment of obesity requires prior approval, which
must be obtained by the attending physician before surgery is
performed.
(5) Payment will be
approved for drugs provided inpatients subject to the same provisions specified
in 78.2(1) and 78.2(4)
"b"(1) to (10) except for
78.2(4)
"b"(7). The basis of payment for drugs administered to
inpatients is through the DRG reimbursement.
a. Payment will be approved for drugs and
supplies provided outpatients subject to the same provisions specified in
78.2(1) through 78.2(4) except for 78.2(4)"b"(7). The basis of
payment for drugs provided outpatients is through a combination of
Medicaid-determined fee schedules and ambulatory payment classification,
pursuant to 441-subrule 79.1(16).
b. In order to be paid for the administration
of a vaccine covered under the Vaccines for Children (VFC) Program, a hospital
must enroll in the VFC program. Payment for the vaccine will be approved only
if the VFC program stock has been depleted.
(6) Payment for nursing care provided by a
hospital shall be made to those hospitals which have been certified by the
department of inspections and appeals as meeting the standards for a nursing
facility.
(7) Payment for inpatient
hospital tests for purposes of diagnosis and treatment shall be made only when
the tests are specifically ordered for the diagnosis and treatment of a
particular patient's condition by the attending physician or other licensed
practitioner acting within the scope of practice as defined by law, who is
responsible for that patient's diagnosis or treatment.
(8) Payment will be made for medically
necessary inpatient acute psychiatric intensive care services that meet the
criteria in this subrule, pursuant to 441-paragraph
79.1(5)
"i." This inpatient rate is only applicable to
individuals 18 to 64 years of age. All inpatient acute psychiatric intensive
care services shall require prior authorization.
a. "Acute psychiatric intensive care" is
defined as care provided for a condition with rapid onset that is accompanied
by severe symptoms and is generally of brief duration, requiring emergency
treatment and critical care.
b. To
meet the need for acute psychiatric intensive care, the patient must:
(1) Have a serious mental illness as defined
in 441-subrule 77.47(1);
(2) Have a
current, severe, imminent risk of serious harm to self or others; and
(3) Display additional complexity of need
related to:
1. Complex comorbidities,
including intellectual or developmental disability, autism spectrum disorder,
substance use disorders, or traumatic brain injuries; or
2. A history of violence or current
aggression that is secondary to mental illness; or
3. A request for patient transfer that has
been rejected by inpatient level of care by one or more hospitals due to
severity of symptoms; or
4. Lack of
responsiveness to typical interventions or a condition that is treatment
refractory; or
5. Disorganized
psychotic state or manic thought process that impairs the ability to function
or risks the safety of the patient or others; or
6. Behavior that causes disruption to the
general milieu of the unit (i.e., instigating other patients in negative ways);
or
7. High elopement risk;
or
8. Any other atypical reason
that the treating mental health provider feels that additional resources are
needed to keep the patient and others around the patient safe.
c. The individual must
have a documented need for acute intensive care requiring increased or
specialized staffing, equipment, or facilities, based on two or more of the
following:
(1) Fall precaution protocol in
place;
(2) Restraints or seclusion
room requirements;
(3) Requiring
assistance with activities of daily living;
(4) Requirements for complex nursing
care;
(5) Acutely impaired
cognitive functioning from baseline;
(6) Documentation of interventions to address
acute complex mental illness and comorbidities;
(7) Safety protocols in place to address the
physical risk posed to staff, other patients, and infrastructure;
(8) Elopement risk precaution protocol in
place.
(9)
Payment will be made for sterilizations in accordance with 78.1(16).
(10) Payment will be approved for organ and
tissue transplant services, as specified in subrule 78.1(20). Kidney, cornea,
skin, bone, allogeneic bone marrow, autologous bone marrow, heart, liver, and
lung transplants are covered as specified in subrule 78.1(20). Lung transplants
are payable at Medicare-designated lung transplant centers only. Heart and
liver transplants are payable when performed at facilities that meet the
following criteria:
a.
Recipient
selection and education.
(1)
Selection. The transplant center must have written criteria
based on medical need for transplantation for final facility selection of
recipients. These criteria should include an equitable, consistent and
practical protocol for selection of recipients. The criteria must be at least
as strict as those specified by Medicare.
(2)
Education. The
transplant center will provide a written plan for recipient education. It shall
include educational plans for recipient, family and significant others during
all phases of the program. These phases shall include:
Intake.
Preparation and waiting period.
Preadmission.
Hospitalization.
Discharge planning.
Follow-up.
b.
Staffing and resource
commitment.
(1)
Transplant
surgeon. The transplant center must have on staff a qualified
transplant surgeon.
The surgeon must have received at least one year of training
at a transplant center approved by the American Society of Transplant Surgeons
under the direction of an experienced transplant surgeon and must have had at
least two years of experience in all facets of transplant surgery specific to
the surgeon's specialty. This experience must include management of recipients'
presurgical and postsurgical care and actual experience as a member of a
transplant team at the institution. The transplant surgeon will have an
understanding of the principles of and demonstrated expertise in the use of
immunosuppressive therapy.
The transplant surgeon will be certified by the American
Board of Thoracic Surgery or equivalent for heart transplants and the American
Board of Surgery or equivalent for liver transplants.
The transplant surgeon will be the defined leader of a
stable, established transplant team that has a strong commitment to the
transplant program.
(2)
Transplant team. The transplant team will be clearly defined
with leadership and corresponding responsibilities of all team members
identified.
The team should consist of:
A surgeon director.
A board-certified internist or pediatrician with training and
expertise in organ transplantation medicine and clinical use of
immunosuppressive regimens.
The transplant center will assume responsibility for initial
training and continuing education of the transplant team and ancillary
personnel. The center will maintain records that demonstrate competency in
achieving, maintaining and improving skills in the distinct areas of expertise
of each of the team members.
(3)
Physicians. The
transplant center will have on staff or available for consultation physicians
with the following areas of expertise:
Anesthesiology.
Cardiology.
Dialysis.
Gastroenterology.
Hepatology.
Immunology.
Infectious diseases.
Nephrology.
Neurology.
Pathology.
Pediatrics.
Psychiatry.
Pulmonary medicine.
Radiology.
Rehabilitation medicine.
Liaison with the recipient's permanent physician is
established for the purpose of providing continuity and management of the
recipient's long-term care.
(4)
Support personnel and
resources. The center must have a commitment of sufficient resources
and planning for implementation and operation of the transplant program.
Indicators of the commitment will include the following:
Persons with expertise in the following areas available at
the transplant center:
Anesthesiology.
Blood bank services.
Cardiology.
Cardiovascular surgery.
Dialysis.
Dietary services.
Gastroenterology.
Infection control.
Laboratory services (pathology, microbiology, immunology,
tissue typing, and monitoring of immunosuppressive drugs).
Legal counsel familiar with transplantation laws and
regulations.
Nursing service department with staff available who have
expertise in the care of transplant recipients, especially in managing
immunosuppressed patients and hemodynamic support.
Respiratory therapy.
Pharmaceutical services.
Physical therapy.
Psychiatry.
Psycho-social.
The center will have active cardiovascular, medical, and
surgical programs with the ability and willingness to perform diagnostic and
evaluative procedures appropriate to transplants on an emergency and ongoing
basis.
The center will have designated an adequate number of
intensive care and general service beds to support the transplant
center.
(5)
Laboratory. Each transplant center must have direct local
24-hour per day access to histocompatibility testing facilities. These
facilities must meet the Standards for Histocompatibility Testing set forth by
the Committee on Quality Assurance and Standards of the American Society for
Histocompatibility and Immunogenetics (ASHI). As specified by ASHI, the
director of the facility shall hold a doctoral degree in biological science, or
be a physician, and subsequent to graduation shall have had four years'
experience in immunology, two of which were devoted to formal training in human
histocompatibility testing, documented to be professionally competent by
external measures such as national proficiency testing, participation in
national or international workshops or publications in peer-reviewed journals.
The laboratory must successfully participate in a regional or national testing
program.
c.
Experience and survival rates.
(1)
Experience. Centers will
be given a minimum volume requirement of 12 heart or 12 liver transplants that
should be met within one year. Due to special considerations such as patient
case mix or donor availability, an additional one year conditional approval may
be given if the minimum volume is not met the first year.
For approval of an extrarenal organ transplant program it is
highly desirable that the institution:
1. has available a complete team of surgeons,
physicians, and other specialists with specific experience in transplantation
of that organ, or
2. has an
established approved renal transplant program at that institution and personnel
with expertise in the extrarenal organ system itself.
(2)
Survival rates. The
transplant center will achieve a record of acceptable performance consistent
with the performance and outcomes at other successful designated transplant
centers. The center will collect and maintain recipient and graft survival and
complication rates. A level of satisfactory success and safety will be
demonstrated with bases for substantial probability of continued performance at
an acceptable level.
To encourage a high level of performance, transplant programs
must achieve and maintain a minimum one-year patient survival rate of 70
percent for heart transplants and 50 percent for liver
transplants.
d.
Organ procurement. The transplant center will participate in a
nationwide organ procurement and typing network.
Detailed plans must exist for organ procurement yielding
viable transplantable organs in reasonable numbers, meeting established legal
and ethical criteria.
The transplant center must be a member of the National Organ
Procurement and Transplant Network.
e.
Maintenance of data, research,
review and evaluation.
(1)
Maintenance of data. The transplant center will collect and
maintain data on the following: Risk and benefit.
Morbidity and mortality.
Long-term survival.
Quality of life.
Recipient demographic information.
These data should be maintained in the computer at the
transplant center monthly.
The transplant center will submit the above data to the
United Network of Organ Sharing yearly.
(2)
Research. The transplant
center will have a plan for and a commitment to research.
Ongoing research regarding the transplanted organs is
required.
The transplant center will have a program in graduate medical
education or have a formal agreement with a teaching institution for
affiliation with a graduate medical education program.
(3)
Review and evaluation.
The transplant center will have a plan for ongoing evaluation of the
transplantation program.
The transplant center will have a detailed plan for review
and evaluation of recipient selection, preoperative, operative, postoperative
and long-term management of the recipient.
The transplant center will conduct concurrent ongoing studies
to ensure high quality services are provided in the transplantation
program.
The transplant center will provide information to members of
the transplant team and ancillary staff regarding the findings of the quality
assurance studies. This information will be utilized to provide education
geared toward interventions to improve staff performance and reduce
complications occurring in the transplant process.
The transplant center will maintain records of all quality
assurance and peer review activities concerning the transplantation program to
document identification of problems or potential problems, intervention,
education and follow-up.
f.
Application procedure. A
Medicare-designated heart, liver, or lung transplant facility needs only to
submit evidence of this designation to the Iowa Medicaid enterprise provider
services unit. The application procedure for other heart and liver facilities
is as follows:
(1) An original and two copies
of the application must be submitted on 81/2by 11 inch paper, signed by a
person authorized to do so. The facility must be a participating hospital under
Medicaid and must specify its provider number, and the name and telephone
number of a contact person should there be questions regarding the
application.
(2) Information and
data must be clearly stated, well organized and appropriately indexed to aid in
its review against the criteria specified in this rule. Each page must be
numbered.
(3) To the extent
possible, the application should be organized into five sections corresponding
to each of the five major criteria and addressing, in order, each of the
subcriteria identified.
(4) The
application should be mailed to the Iowa Medicaid enterprise provider services
unit.
g.
Review
and approval of facilities. An organized review committee will be
established to evaluate performance and survival statistics and make
recommendations regarding approval as a designated transplant center based on
acceptable performance standards established by the review organization and
approved by the Medicaid agency.
There will be established protocol for the systematic
evaluation of patient outcome including survival statistics.
Once a facility applies for approval and is approved as a
heart or liver transplant facility for Medicaid purposes, it is obliged to
report immediately to the department any events or changes which would affect
its approved status. Specifically, a facility must report any significant
decrease in its experience level or survival rates, the transplantation of
patients who do not meet its patient selection criteria, the loss of key
members of the transplant team, or any other major changes that could affect
the performance of heart or liver transplants at the facility. Changes from the
terms of approval may lead to withdrawal of approval for Medicaid coverage of
heart or liver transplants performed at the facility.
(11) Payment will be approved for
inpatient hospital care rendered a patient in connection with dental treatment
only when the mental, physical, or emotional condition of the patient prevents
the dentist from providing this necessary care in the office.
(12) Payment will be approved for an
assessment fee as specified in 441-paragraphs 79.1(16)
"a" and
"r" to determine if a medical emergency exists.
Medical emergency is defined as a sudden or unforeseen
occurrence or combination of circumstances presenting a substantial risk to an
individual's health unless immediate medical treatment is given.
The determination of whether a medical emergency exists will
be based on the patient's medical condition including presenting symptoms and
medical history prior to treatment or evaluation.
(13) Payment for patients in acute hospital
beds who are determined by the IME medical services unit to require the skilled
nursing care level of care shall be made at an amount equal to the sum of the
direct care rate component limit for Medicare-certified hospital-based nursing
facilities pursuant to 441-subparagraph 81.6(16)"f"(3) plus
the non-direct care rate component limit for Medicare-certified hospital-based
nursing facilities pursuant to 441-subparagraph
81.6(16)"f"(3), with the rate component limits being revised
July 1, 2001, and every second year thereafter. This rate is effective (a) as
of the date of notice by the IME medical services unit that the lower level of
care is required or (b) for the days the IME medical services unit determines
in an outlier review that the lower level of care was required.
(14) Payment for patients in acute hospital
beds who are determined by the IME medical services unit to require nursing
facility level of care shall be made at an amount equal to the sum of the
direct care rate component limit for Medicaid nursing facilities pursuant to
441-subparagraph 81.6(16)"f"(1) plus the non-direct care rate
component limit for Medicaid nursing facilities pursuant to 441-subparagraph
81.6(16)"f"(1), with the rate component limits being revised
July 1, 2001, and every second year thereafter. This rate is effective (a) as
of the date of notice by the IME medical services unit that the lower level of
care is required or (b) for the days the IME medical services unit determines
in an outlier review that the lower level of care was required.
(15) Payment for inpatient hospital charges
associated with surgical procedures normally done and billed on an outpatient
hospital basis is subject to review by the IME medical services acute
retrospective review team. Such reviews are based on random claim samples that
are pulled on a monthly basis. If the information on a given inpatient claim
included in that sample does not appear to support the appropriateness of
inpatient level of care, that claim is sent to the IME medical director for
further review. If the medical director approves the inpatient level of care,
the claim is paid. However, if the medical director determines that the care
provided could have been rendered at a lower level of care, the hospital and
attending physician are notified accordingly. If the hospital agrees with the
finding that a lower level of care was appropriate, the hospital submits a new
claim for the lower level of care. If the hospital disagrees with the lower
level of care finding, the hospital can submit additional documentation for
further review. The hospital or attending physician or both may appeal any
final determination by the IME.
(16) Skilled nursing care in "swing beds."
a. Payment will be made for medically
necessary skilled nursing care when provided by a hospital participating in the
swing-bed program certified by the department of inspections and appeals and
approved by the U.S. Department of Health and Human Services. Payment shall be
at an amount equal to the sum of the direct care rate component limit for
Medicare-certified hospital-based nursing facilities pursuant to
441-subparagraph 81.6(16)"f"(3) and the non-direct care rate
component limit for Medicare-certified hospital-based nursing facilities
pursuant to 441-subparagraph 81.6(16)"f"(3), with the rate
component limits being revised July 1, 2001, and every second year thereafter.
Swing-bed placement is only intended to be short-term in nature.
b. Any payment for skilled nursing care
provided in a hospital with a certified swing-bed program, for either initial
admission or continued stay, will require prior authorization, subject to the
following requirements:
(1) The hospital has
fewer than 100 beds, excluding beds for newborns and intensive care.
(2) The hospital has an existing
certification for a swing-bed program, pursuant to paragraph
78.3(16)"a."
(3)
The member is being admitted for nursing facility or skilled level of care (if
the member has Medicare and skilled coverage has been exhausted).
(4) As part of the discharge planning process
for a member requiring ongoing skilled nursing care, the hospital must:
1. Complete a level of care (LOC)
determination describing a member's LOC needs, using Form 470-5156, Swing Bed
Certification.
2. Contact skilled
nursing facilities within a 30-mile radius of the hospital regarding available
beds to meet the member's LOC needs.
3. Certify that no freestanding skilled
nursing facility beds are available for the member within a 30-mile radius of
the hospital, which will be able to appropriately meet the member's needs and
that home-based care for the member is not available or appropriate.
(5) Swing-bed stays beyond 14 days
will only be approved when there is no appropriate freestanding nursing
facility bed available within a 30-mile radius and home-based care for the
member is not available or appropriate, as documented by the hospital seeking
the swing-bed admission. For the purpose of these criteria, an "appropriate"
nursing facility bed is a bed in a Medicaid-participating freestanding nursing
facility that provides the LOC required for the member's medical condition and
corresponding LOC needs.
(6) A
Medicaid member who has been in a swing bed beyond 14 days must be discharged
to an appropriate nursing facility bed within a 30-mile radius of the swing-bed
hospital or to appropriate home-based care within 72 hours of an appropriate
nursing facility bed becoming available.
Preadmission screening and resident review (PASRR) rules
still apply for members being transferred to a nursing
facility.
(17) Reserved.
(18) Preprocedure review by the IME medical
services unit is required if hospitals are to be reimbursed for certain
frequently performed surgical procedures as set forth under subrule 78.1(19).
Preprocedure review is also required for other types of major surgical
procedures, such as organ transplants. Criteria are available from the IME
medical services unit. (Cross reference 78.28(6))
This rule is intended to implement Iowa Code section
249A.4.
Notes
Iowa Admin. Code r. 441-78.3
ARC 0065C, IAB 4/4/12,
effective 6/1/12; ARC 0194C, IAB 7/11/12, effective 7/1/12; ARC 0354C, IAB
10/3/12, effective 12/1/12; ARC 0844C, IAB 7/24/2013, effective 7/1/2013; ARC
1054C, IAB 10/2/2013, effective 11/6/2013
Amended by
IAB
January 6, 2016/Volume XXXVIII, Number 14, effective
1/1/2016
Amended by
IAB
February 12, 2020/Volume XLII, Number 17, effective
3/18/2020
Amended by
IAB
December 28, 2022/Volume XLV, Number 13, effective
1/1/2023
