Payment will be made for community-based neurobehavioral
rehabilitation services that do not duplicate other services covered in this
chapter.
(1)
Definitions.
"Assessment" means the review of the current
functioning of the member using the service in regard to the member's
situation, needs, strengths, abilities, desires, and goals.
"Brain injury" means a diagnosis in
accordance with rule 441-83.81 (249A).
"Health care" means the services provided by
trained and licensed health care professionals to restore or maintain the
member's health.
"Intermittent community-based neurobehavioral
rehabilitation services" are provided to a Medicaid member on an
as-needed basis to support the member and the member's family or caregivers to
assist the member to increase adaptive behaviors, decrease maladaptive
behaviors, and adapt and accommodate to challenging behaviors to support the
member to remain in the member's own home and community.
"Member" means a person who has been
determined to be eligible for Medicaid under 441-Chapter 75.
"Neurobehavioral rehabilitation" refers to a
specialized category of neurorehabilitation provided by a multidisciplinary
team that has been trained in, and delivers, services individually designed to
address cognitive, medical, behavioral and psychosocial challenges, as well as
the physical manifestations of acquired brain injury. Services concurrently
work to optimize functioning at personal, family and community levels, by
supporting the increase of adaptive behaviors, decrease of maladaptive
behaviors and adaptation and accommodation to challenging behaviors to support
a member to maximize the member's independence in activities of daily living
and ability to live in the member's home and community.
"Program" means a set of related resources
and services directed to the accomplishment of a fixed set of goals for
eligible members.
"Standardized assessment" means a valid,
reliable, and comprehensive functional assessment tool(s) or process, or both,
approved by the department for use in the assessment of a member's individual
needs.
(2)
Member
eligibility. To be eligible to receive community-based neurobehavioral
rehabilitation services, a member shall meet the following criteria:
a.
Brain injury diagnosis.
To be eligible for community-based neurobehavioral rehabilitation services, the
member must have a brain injury diagnosis as set forth in rule
441-83.81 (249A).
b.
Risk factors. The member
has the following post-brain injury risk factors:
(1) The member is exhibiting neurobehavioral
symptoms in such frequency or severity that the member has undergone or is
currently undergoing treatment more intensive than outpatient care and is
currently hospitalized, institutionalized, incarcerated or homeless or is at
risk of hospitalization, institutionalization, incarceration or homelessness;
or
(2) The member has a history of
presenting with neurobehavioral or psychiatric symptoms resulting in at least
one episode that required professional supportive care more intensive than
outpatient care more than once in a lifetime (e.g., emergency services,
alternative home care, partial hospitalization, or inpatient
hospitalization).
c.
Need for assistance. The member exhibits neurobehavioral
symptoms in such frequency, severity or intensity that community-based
neurobehavioral rehabilitation is required.
d.
Needs assessment. The
member shall have an assessment of need completed prior to admission. The
member shall have the Mayo-Portland Adaptability Inventory (MPAI) assessment
completed by a qualified trained assessor. The assessment of need shall
document the member's need for community-based neurobehavioral rehabilitation,
and the medical services unit of the Iowa Medicaid enterprise or the member's
managed care organization has determined that the member is in need of
specialty neurobehavioral rehabilitation services.
e.
Standards for assessment.
Each member will have had the MPAI assessment completed within the 90 days
prior to admission. In addition to the functional assessment, the needs
assessment will have been completed and will include the assessment of a
member's individual physical, emotional, cognitive, medical and psychosocial
residuals related to the member's brain injury and must include the following:
(1) Identification of the neurobehavioral
needs that put the member at risk, including but not limited to verbal
aggression, physical aggression, self-harm, unwanted sexual behavior, cognitive
and or behavioral perseveration, wandering or elopement, lack of motivation,
lack of initiation or other unwanted social behaviors not otherwise
specified.
(2) Identification of
triggers of unwanted behaviors and the member's ability to self-manage the
member's symptoms.
(3) The member's
rehabilitation and medical care history to include medication history and
status.
(4) The member's employment
history and the member's barriers to employment.
(5) The member's dietary and nutritional
needs.
(6) The member's community
accessibility and safety.
(7) The
member's access to transportation.
(8) The member's history of substance
abuse.
(9) The member's
vulnerability to exploitation and history of risk of exploitation.
(10) The member's history and status of
relationships, natural supports and socialization.
f.
Emergency admission. In
the event that emergency admission is required, the assessment shall be
completed within ten calendar days of admission.
(3)
Covered services.
a. Service setting.
(1) Community-based neurobehavioral
residential rehabilitation services are provided to a member living in a
three-to-five-bed residential care facility with a specialized license
designation issued by the department of inspections and appeals; or
(2) Community-based neurobehavioral
intermittent rehabilitation services are provided to a member living in the
member's own residence in the community.
No payment shall be made for community-based neurobehavioral
rehabilitation when provided in a medical institution such as an intermediate
care facility for persons with intellectual disabilities, nursing facility or
skilled nursing facility.
b. Community-based neurobehavioral
rehabilitation residential services identified in the treatment plan may
include:
(1) Prescriptive programming to
maintain and advance progress made in rehabilitation;
(2) Modifying or adapting the member's
environment to improve overall functioning;
(3) Assistance in obtaining preventative,
appropriate and timely medical and dental care;
(4) Compensatory strategies to assist in
managing ADLs (activities of daily living);
(5) Assistance with coordinating and
obtaining physical, oral, or mental health care and any other professional
services necessary to the member's health and well-being;
(6) Behavioral and cognitive programming and
supports;
(7) Medication management
and consultation with pharmacy;
(8)
Health and wellness management including dietary and nutritional
programming;
(9) Progressive
physical strengthening, fitness and retraining;
(10) Assistance with obtaining and use of
assistive technology;
(11) Sobriety
support development;
(12)
Assistance with the self-identification of antecedent triggers;
(13) Assistance with preparation for
transition to less intensive services including accessing the
community;
(14) Flexibility in
programming to meet individual needs;
(15) Assistance with re-learning coping and
compensatory strategies;
(16)
Support and assistance in seeking substance abuse and co-occurring disorders
services;
(17) Support and
assistance with obtaining legal consultation and services;
(18) Assistance with community accessibility
and safety;
(19) Assistance with
re-learning household maintenance;
(20) Assistance with recreational and leisure
skill development;
(21) Assistance
with the development and application of self-advocacy skills to navigate the
service system;
(22) Opportunities
to learn about brain injury and individual needs following brain
injury;
(23) Support for carrying
out the member's individual goals in the rehabilitation treatment
plan;
(24) Assistance with pursuit
of education and employment goals;
(25) Protective oversight in the residential
setting and community;
(26)
Assistance and education to family, providers and other support system
interests that are supporting the member receiving neurobehavioral
rehabilitation services;
(27)
Transitional support and training;
(28) Transportation essential to the
attainment of the member's individual goals in the rehabilitation treatment
plan;
(29) Promotion of a program
structure and support for members served so they can relearn or regain skills
for maximum independence, community access, and integration.
c. Community-based neurobehavioral
rehabilitation intermittent services identified in the treatment plan may occur
in the member's own home with or on behalf of the member and may include:
(1) Promotion of a program structure and
support for members served so they can re-learn or regain skills for maximum
community inclusion and access;
(2)
Modifying or adapting the member's environment to improve overall
functioning;
(3) Compensatory
strategies to assist in managing ADLS (activities of daily living);
(4) Behavioral supports;
(5) Assistance with obtaining and use of
assistive technology;
(6)
Assistance with the self-identification of antecedent triggers;
(7) Flexibility in programming to meet the
member's individual needs;
(8)
Assistance with re-learning coping and compensatory strategies;
(9) Assistance with the development and
application of self-advocacy skills to navigate the service system;
(10) Support for carrying out the member's
individual goals in the rehabilitation treatment plan;
(11) Assistance and education to family,
providers and other support system interests that are supporting the member
receiving community-based neurobehavioral rehabilitation services;
(12) Transitional support and
training;
(13) Transportation
essential to the attainment of the member's individual goals in the
rehabilitation treatment plan.
d. Approval of treatment plan. The
community-based neurobehavioral services provider shall submit the proposed
plan of care, the results of the member's formal assessment, and medical
documentation supporting a brain injury diagnosis to the Iowa Medicaid
enterprise (IME) medical services unit for approval before providing the
services.
e. Initial treatment
plan. Within 30 days of admission, the provider shall submit the member's
treatment plan to the IME medical services unit.
(1) The IME medical services unit will
approve the provider's treatment plan if:
1.
The treatment plan conforms to the medical necessity requirements in subrule
78.55(4);
2. The treatment plan is
consistent with the written diagnosis and treatment recommendations made by a
licensed medical professional that is a licensed neuropsychologist or
neurologist, M.D., or D.O.;
3. The
treatment plan is sufficient in amount, duration, and scope to reasonably
achieve its purpose;
4. The
provider can demonstrate that the provider possesses the skills and resources
necessary to implement the plan; and
5. The treatment plan does not exceed 180
days in duration.
(2) A
treatment summary detailing the member's response to treatment during the
previous approval period must be submitted when approval for subsequent plans
is requested.
f.
Subsequent plans. The IME medical services unit may approve a subsequent
neurobehavioral rehabilitation treatment plan that conforms to the conditions
of medical necessity pursuant to subrule 78.56(4) and to the conditions
pursuant to subrule 78.56(3).
g.
Quality review. The IME medical services unit may perform the quality review to
evaluate:
(1) The time elapsed from referral
to rehabilitation treatment plan development;
(2) The continuity of treatment;
(3) The length of stay per member;
(4) The affiliation of the medical
professional recommending services with the neurobehavioral rehabilitation
services provider;
(5) Gaps in
service;
(6) The results
achieved;
(7) Member and
stakeholder satisfaction;
(8) The
provider's compliance with standards listed in rule
441-77.54 (249A).
(4)
Medical
necessity. Nothing in this rule shall be deemed to exempt coverage of
community-based neurobehavioral rehabilitation services from the requirement
that services be medically necessary. "Medically necessary" means that the
service is:
a. Consistent with the diagnosis
and treatment of the member's condition;
b. Required to meet the medical needs of the
member and is needed for reasons other than the convenience of the member or
the member's caregiver;
c. The
least costly type of service that can reasonably meet the medical needs of the
member; and
d. In accordance with
the standards of good medical practice. The standards of good practice for each
field of medical and remedial care covered by the Iowa Medicaid program are
those standards of good practice identified by:
(1) Knowledgeable Iowa clinicians practicing
or teaching in the field; and
(2)
The professional literature regarding best practices in the field.
