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