Iowa Admin. Code r. 441-78.49 - Infant and toddler program services
Subject to the following subrules, payment shall be made for medical services provided to Medicaid eligible children by infant and toddler program providers under the infants and toddlers with disabilities program administered by the Iowa Child Health Specialty Clinics and the departments of education, public health, and human services.
(1)
Covered services.
Covered services include, but are not limited to, audiology, psychological
evaluation and counseling, health and nursing services, nutrition services,
occupational therapy services, physical therapy services, developmental
services, speech-language services, vision services, case management, and
medical transportation.
(2)
Case management services. Payment shall also be approved for
infant and toddler case management services subject to the following
requirements:
a.
Definition.
"Case management" means services that will assist eligible children in gaining
access to needed medical, social, educational, and other services. Case
management is intended to address the complexities of coordinated service
delivery for children with medical needs. The case manager should be the focus
for coordinating and overseeing the effectiveness of all providers and programs
in responding to the assessed need. Case management does not include the direct
delivery of an underlying medical, educational, social, or other service to
which an eligible child has been referred or any activities that are an
integral part or an extension of the direct services.
b.
Choice of provider
Children who also are eligible to receive targeted case management services
under 441-Chapter 90 must choose whether to receive case management through the
infant and toddler program or through 441-Chapter 90. The chosen provider must
meet the requirements of this subrule.
(1)
When a child resides in a medical institution, the institution is responsible
for case management. The child is not eligible for any other case management
services. However, noninstitutional case management services may be provided
during the last 14 days before the child's planned discharge if the child's
stay in the institution has been less than 180 consecutive days. If the child
has been in the institution 180 consecutive days or longer, the child may
receive noninstitutional case management services during the last 60 days
before the child's planned discharge.
(2) If the case management agency also
provides direct services, the case management unit must be designed so that
conflict of interest is addressed and does not result in
self-referrals.
(3) If the costs of
any part of case management services are reimbursable under another program,
the costs must be allocated between those programs and Medicaid in accordance
with 0MB Circular No. A-87 or any related or successor guidance or regulations
regarding allocation of costs.
(4)
The case manager must complete a competency-based training program with content
related to knowledge and understanding of eligible children. Early ACCESS
rules, the nature and scope of services in Early ACCESS, and the system of
payments for services, as well as case management responsibilities and
strategies. The department of education or its designee shall determine whether
a person has successfully completed the training.
c.
Assessment. The case
manager shall conduct a comprehensive assessment and periodic reassessment of
an eligible child to identify all of the child's service needs, including the
need for any medical, educational, social, or other services. Assessment
activities are defined to include the following:
(1) Taking the child's history;
(2) Identifying the needs of the
child;
(3) Gathering information
from other sources, such as family members, medical providers, social workers,
and educators, if necessary, to form a complete assessment of the
child;
(4) Completing documentation
of the information gathered and the assessment results; and
(5) Repeating the assessment every six months
to determine whether the child's needs or preferences have changed.
d.
Plan of care.
The case manager shall develop a plan of care based on the information
collected through the assessment or reassessment. The plan of care shall:
(1) Include the child's strengths and
preferences;
(2) Consider the
child's physical and social environment;
(3) Specify goals of providing services to
the child; and
(4) Specify actions
to address the child's medical, social, educational, and other service needs.
These actions may include activities such as ensuring the active participation
of the child and working with the child or the child's authorized health care
decision maker and others to develop goals and identify a course of action to
respond to the assessed needs of the child.
e.
Other service components.
Case management must include the following components:
(1) Contacts with the child and family. The
case manager shall have face-to-face contact with the child and family within
the first 30 days of service and every three months thereafter In months in
which there is no face-to-face contact, a telephone contact between the service
coordinator and the family is required.
(2) Referral and related activities to help a
child obtain needed services. The case manager shall help to link the child
with medical, social, or educational providers or other programs and services
that are capable of providing needed services. Referral activities do not
include provision of the direct services, program, or activity to which the
child has been linked. Referral activities include:
1. Assisting the family in gaining access to
the infant and toddler program services and other services identified in the
child's plan of care.
2. Assisting
the family in identifying available service providers and funding resources and
documenting unmet needs and gaps in services.
3. Making referrals to providers for needed
services.
4. Scheduling
appointments for the child.
5.
Facilitating the timely delivery of services.
6. Arranging payment for medical
transportation.
(3)
Monitoring and follow-up activities. Monitoring activities shall take place at
least once annually for the duration of the child's eligibility, but may be
conducted as frequently as necessary to ensure that the plan of care is
effectively implemented and adequately addresses the needs of the child.
Monitoring and follow-up activities may be with the child, family members,
providers, or other entities. The purpose of these activities is to help
determine:
1. Whether services are being
furnished in accordance with the child's plan of care.
2. Whether the services in the plan of care
are adequate to meet the needs of the child.
3. Whether there are changes in the needs or
status of the child. If there are changes in the child's needs or status,
follow-up activities shall include making necessary adjustments to the plan of
care and to service arrangements with providers.
(4) Keeping records, including preparing
reports, updating the plan of care, making notes about plan activities in the
child's record, and preparing and responding to correspondence with the family
and others.
f.
Documentation of case management. For each child receiving
case management, case records must document:
(1) The name of the child;
(2) The dates of case management
services;
(3) The agency chosen by
the family to provide the case management services;
(4) The nature, content, and units of case
management services received;
(5)
Whether the goals specified in the care plan have been achieved;
(6) Whether the family has declined services
in the care plan;
(7) Time lines
for providing services and reassessment; and
(8) The need for and occurrences of
coordination with case managers of other programs.
(3)
Child's
eligibility. Payable services must be provided to a child under the
age of 3 6 months who is experiencing developmental delay or who has a
condition that is known to have a high probability of resulting in
developmental delay at a later date.
(4)
Delivery of services.
Services must be delivered directly by the infant and toddler program provider
or by a practitioner under contract with the infant and toddler program
provider
(5)
Remission of
nonfederal share of costs. Payment for services shall be made only
when the following conditions are met:
a.
Rescinded lAB 5/10/06, effective 7/1/06.
b. The infant and toddler program provider
has executed an agreement to remit the nonfederal share of the cost to the
department.
c. The infant and
toddler program provider shall sign and return Form 470-3 816, Medicaid Billing
Remittance, along with the funds remitted for the nonfederal share of the costs
of the services specified on the form.
This rule is intended to implement Iowa Code section 249A.4.
Notes
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