Iowa Admin. Code r. 441-83.125 - Redetermination
The
(1)
Eligibility review.
a. Every 12 months, the department shall
review a consumer 's eligibility in accordance with procedures in rule
441-76.7 (249A). The review shall verify continuing eligibility factors as specified in
rule
441-83.122 (249A).
b. The IME medical services
unit or a managed care organization shall review the member's need for
continued care annually and recertify the member's need for long-term care
services, pursuant to rule
441-83.122 (249A) and
the appeal process at rule
441-83.129 (249A),
based on the completed information submission tool designated in 83.122(3) and
other supporting documentation as relevant.
c. The IME medical services unit or the
member's managed care organization shall be responsible for annual
redetermination of the level of care.
d. The managed care organization must submit
documentation to the IME medical services unit for all reassessments, performed
at least annually, which indicate a change in the member's level of care. The
IME medical services unit shall make a final determination for any
reassessments which indicate a change in the level of care. If the level of
care reassessment indicates no change in level of care, the member is approved
to continue at the already established level of care.
(2)
Continuation of
eligibility. A consumer 's waiver eligibility shall continue until one
of the following conditions occurs.
b. The consumer is an
inpatient of a medical institution for 120 or more consecutive days.
(1) After the consumer has spent 120
consecutive days in a medical institution , the local office shall terminate the
consumer 's waiver eligibility and review the consumer for eligibility under
other Medicaid coverage groups. The local office shall notify the consumer and
the consumer 's parents or legal guardian through Form 470-0602, Notice of
Decision.
(2) If the consumer
returns home after 120 consecutive days, the consumer must reapply for
children's mental health waiver services, and the IME medical services unit
must redetermine the consumer 's level of care.
c. The consumer does not reside at the
consumer 's natural home for a period of 60 consecutive days. After the consumer
has resided outside the home for 60 consecutive days, the local office shall
terminate the consumer 's waiver eligibility and review the consumer for
eligibility under other Medicaid coverage groups. The local office shall notify
the consumer and the consumer 's parents or legal guardian through Form
470-0602, Notice of Decision.
(3)
Payment slot. When a
consumer loses waiver eligibility, the consumer 's assigned payment slot shall
revert for use to the next consumer on the waiting list.
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.