Iowa Admin. Code r. 441-78.53 - Health home services
(1)
Definitions.
"Chronic condition" means, for purposes of this rule, one of the conditions outlined in subparagraph 78.53(3)"a"(1).
"Chronic condition health home" means a health home that meets the criteria in 441-subrule 77.47(2).
"Health home" means a chronic condition health home or an integrated health home.
"Integrated health home" means a health home that meets the criteria in 441-subrule 77.47(3).
"Person-centered care plan" means a care plan created through the person-centered planning process, directed by the member or the member's guardian or representative, for a member receiving non-intensive care management or chronic condition health home services, to identify the member's strengths, capabilities, preferences, needs, goals, and desired outcomes.
"Person-centered service plan" or "service plan" means a service plan (1) created through the person-centered planning process in accordance with subrule 78.27(4), rule 441-83.127 (249A) and 441-paragraph 90.4(1)"b"; (2) directed by the member or the member's guardian or representative; (3) for a member receiving intensive care management services; and (4) for the purposes of identifying the member's strengths, capabilities, preferences, needs, and desired outcomes.
(2)
Covered services. A health home provides team-based, whole
person, person-centered, coordinated care for all aspects of the member's life
and for transitions of care that the member may experience. A health home
provides the following core services:
a.
Comprehensive care management. Comprehensive care management
is the initial and ongoing assessment and care management services aimed at the
integration of primary, behavioral and specialty health care, and community
support services, using a comprehensive person-centered care plan or service
plan that addresses all clinical and nonclinical needs and promotes wellness
and management of chronic conditions in pursuit of optimal health
outcomes.
b.
Care
coordination. Care coordination includes assisting members with
medication adherence, appointments, referral scheduling, understanding health
insurance coverage, reminders, transition of care, wellness education, health
support, lifestyle modification, and behavior changes. The health home must
work with providers to coordinate, direct, and ensure results are communicated
back to the health home.
c.
Health promotion. Health promotion includes the education and
engagement of a member in making decisions that promote health management,
improved disease outcomes, disease prevention, safety, and an overall healthy
lifestyle.
d.
Comprehensive
transitional care. Comprehensive transitional care is the facilitation
of services for the member that provides support when the member is
transitioning between levels of care (nursing facility, hospital,
rehabilitation facility, community-based group home, family, self-care, or
another health home).
e.
Individual and family support. Individual and family support
services include communication with the member and the member's family and
caregivers to maintain and promote quality of life, with particular focus on
community living options. Support will be provided in a culturally appropriate
manner.
f.
Referral to
community and social support services. Referral to community and
social support services includes coordinating or providing recovery services
and social health services available in the community, including resources for
understanding eligibility for various health care programs, disability
benefits, and identifying housing programs.
(3)
Member eligibility for health
home services.
a.
Chronic
condition health home member eligibility criteria.
(1) To be eligible for chronic condition
health home services, the member must have one of the following chronic
conditions and be at risk of having a second chronic condition:
1. A mental health disorder.
2. A substance use disorder.
3. Asthma.
4. Diabetes.
5. Heart disease.
6. Being overweight, as evidenced by:
* Having a body mass index (BMI) over 25 for an adult, or
* Weighing over the 85th percentile for the pediatric population.
7.
Hypertension.
8. Chronic
obstructive pulmonary disease.
9.
Chronic pain.
(2) "At
risk" means a documented family history of a verified heritable condition
described above, a diagnosed medical condition with an established comorbidity
to a condition described above, or a verified environmental exposure to an
agent or condition known to be the cause of a condition from the conditions
described above.
b.
Integrated health home eligible member criteria. To be
eligible for integrated health home services, the member must have a serious
mental illness or serious emotional disturbance, as such terms are defined in
441-subrule 77.47(1).
(4)
Member identification and
enrollment.
a. Eligible members are
identified through a referral from the department, lead entity, primary care
provider, hospital, other providers, the member, or the member's authorized
representative.
b. The health home
confirms eligibility for health home services by obtaining assessment
documentation from the member's licensed mental health professional or the
patient tiering assignment tool (PTAT).
c. The health home must explain to the
member, in a format easily understood by the member, how the team works
together with the member at the center to improve the member's care, as well as
all team member roles and responsibilities.
d. The health home must advise members of
their ability and the process to opt out of health home services at any
time.
e. Eligible members must
agree to participate in the health home program, and the health home must
document the member's agreement in the member's record before submitting an
enrollment request. A member cannot be in more than one health home at the same
time.
f. The health home must
assess the member's continued eligibility for health home services on an annual
basis to ensure the member remains eligible to participate in the
program.
(5)
Health home documentation. A health home must maintain
adequate supporting documentation in readily reviewable form to ensure all
state and federal requirements related to health home services have been met.
All health home services must be documented in accordance with rule
441-79.3 (249A). At a minimum,
the health home must document the following:
a.
Eligibility. Eligibility
documentation includes but is not limited to the following:
(1) How the member presented to the health
home, including the referral.
(2)
Identified needs and plan to assess for eligibility.
(3) Documentation that the member is eligible
for health home services. If a member is not eligible, the health home must
document the plan to support the member.
(4) Qualifying diagnosis that makes the
member eligible for health home services.
(5) Member agreement and understanding of the
program.
(6) Enrollment
request.
(7) Enrollment with the
health home.
(8) Plan to complete
the comprehensive assessment.
(9)
Documentation of continued eligibility, reviewed annually and maintained in the
member's service record.
b.
Comprehensive assessment.
The comprehensive assessment must include all aspects of a member's life and
satisfy the following requirements:
(1) The
comprehensive assessment must be completed within 30 days of enrollment, and at
least every 365 days, or more frequently when the member's needs or
circumstances change significantly or at the request of the member or member's
support.
(2) The comprehensive
assessment for members enrolled to receive non-intensive care management or
enrolled in the chronic condition health home must include:
1. Assessment of the member's current and
historical information provided by the member, the lead entity, and other
health care providers that support the member;
2. Assessment of physical and behavioral
health needs, medication reconciliation, functional limitations, and
appropriate screenings;
3.
Assessment of the member's social environment so that the plan of care
incorporates areas of needs, strengths, preferences, and risk factors;
and
4. Assessment of the member's
readiness for self-management using screenings and assessments with
standardized tools.
(3)
The comprehensive assessment for members enrolled to receive intensive care
management must be in a format designated by the department and must include:
1. The member's relevant history, including
the findings from the independent evaluation of eligibility, medical records,
an objective evaluation of functional ability, and any other records or
information needed to complete the comprehensive assessment.
2. The member's physical, cognitive, and
behavioral health care and support needs; strengths and preferences; available
service and housing options; and, if unpaid caregivers will be relied upon to
implement any elements of the person-centered service plan, a caregiver
assessment.
3. Documentation that
no state plan HCBS is provided that would otherwise be available to the member
through other Medicaid services or other federally funded programs.
4. For members receiving state plan HCBS and
HCBS approved under 441-Chapter 83, documentation that HCBS provided through
the state plan and waiver are not duplicative.
c.
Person-centered service plan and
person-centered care plan.
(1) For
members receiving non-intensive care management or enrolled in the chronic
condition health home, documentation must include a person-centered care plan
that meets the requirements as defined in subrule 78.53(1) and the health home
state plan amendment.
(2) For
members receiving intensive care management, documentation must include a
service plan that meets the requirements of rule
441-78.27 (249A) or
441-83.127 (249A) and
441-paragraph 90.4(1)"b."
(3) Documentation must reflect an update of
the plan no less often than every 365 days and when significant changes occur
in the member's support needs, situation, condition, or
circumstances.
d.
Core services. Documentation must reflect monthly provision of
one of the six core health home services as outlined in subrule
78.53(2).
e.
Intensive
health home services. A health home must provide documentation to
justify provision of more intensive health home services, including
documentation that the member is enrolled to receive services through the HCBS
habilitation or HCBS children's mental health waiver programs.
f.
Continuity of care.
(1) The health home must maintain a
continuity of care document in each enrolled member's record and provide this
document to the department, the lead entity, and the member's treating
providers upon request.
(2) The
continuity of care document must include, at a minimum, all aspects of the
member's medical and behavioral health needs, treatment plan, and medication
list.
g.
Disenrollment. Members are able to opt out of health home
services at any time. The health home must document a member's request to
disenroll from health home services, the reason for disenrollment, how the
member's needs will be supported after disenrollment, and that the health home
has advised the member of the ability to re-enroll if circumstances
change.
(6)
Payment.
a. Payment will be
made for health home services when:
(1) The
member is eligible for Medicaid and enrolled in the health home for the month
of service, and
(2) The health home
provides at least one of the six core health home services described in subrule
78.53(2) during the month, and
(3)
The health home maintains the documentation outlined in subrule
78.53(5).
b. A unit of
service is one member month.
c. The
health home must report the informational-only code in addition to the billing
procedure code and modifier for one or more of the core services provided to
the member during the month on the claim for payment.
This rule is intended to implement Iowa Code section 249A.4.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.