Iowa Admin. Code r. 441-79.9 - General provisions for Medicaid coverage applicable to all Medicaid providers and services

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

(1) Medicare definitions and policies shall apply to services provided unless specifically defined differently.
(2) The services covered by Medicaid shall:
a. Be consistent with the diagnosis and treatment of the patient's condition.
b. Be in accordance with standards of good medical practice.
c. Be required to meet the medical need of the patient and be for reasons other than the convenience of the patient or the patient's practitioner or caregiver.
d. Be the least costly type of service which would reasonably meet the medical need of the patient.
e. Be eligible for federal financial participation unless specifically covered by state law or rule.
f. Be within the scope of the licensure of the provider.
g. Be provided with the full knowledge and consent of the recipient or someone acting in the recipient's behalf unless otherwise required by law or court order or in emergency situations.
h. Be supplied by a provider who is eligible to participate in the Medicaid program. The provider must use the billing procedures and documentation requirements described in 441-Chapters 78 and 80.
(3) Providers shall supply all the same services to Medicaid eligibles served by the provider as are offered to other clients of the provider.
(4) Recipients must be informed before the service is provided that the recipient will be responsible for the bill if a noncovered service is provided.
(5) Coverage in public institutions. Medical services provided to a person while the person is an inmate of a public jail, prison, juvenile detention center, or other public penal institution of more than four beds are not covered by Medicaid.
(6) The acceptance of Medicaid funds by means of a prospective or interim rate creates an express trust. The Medicaid funds received constitute the trustres. The trust terminates when the rate is retrospectively adjusted or otherwise finalized and, if applicable, any Medicaid funds determined to be owed are repaid in full to the department.
(7) Incorrect payment.
a. Except as provided in paragraph 79.9(7)"b, " medical assistance funds are incorrectly paid whenever an individual who provided the service to the member for which the department paid was at the time service was provided the parent of a minor child, spouse, or legal representative of the member.
b. Notwithstanding paragraph 79.9(7)"a, " medical assistance funds are not incorrectly paid when an individual who serves as a member's legal representative provides services to the member under a home- and community-based services waiver consumer-directed attendant care agreement or under a consumer choices option employment agreement in effect on or after December 31, 2013. For purposes of this paragraph, "legal representative" means a person, including an attorney, who is authorized by law to act on behalf of the medical assistance program member but does not include the spouse of a member or the parent or stepparent of a member aged 17 or younger.
(8) The rules of the medical assistance program shall not be construed to require payment of medical assistance funds, in whole or in part, directly or indirectly, overtly or covertly, for the provision of non-Medicaid services. The rules of the medical assistance program shall be interpreted in such a manner to minimize any risk that medical assistance funds might be used to subsidize services to persons other than members of the medical assistance program.

This rule is intended to implement Iowa Code section 249A.4 and 2014 Iowa Acts, Senate File 2320.


Iowa Admin. Code r. 441-79.9
ARC 1155C, IAB 10/30/2013, effective 1/1/2014 Amended by IAB September 3, 2014/Volume XXXVII, Number 5, effective 8/13/2014

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