Iowa Administrative Code

d. Nonmedical items will not be covered. These include but are not limited to: (1) Physical fitness equipment, e.g., an exercycle, weights. (2) First-aid or precautionary-type equipment, e.g., preset portable oxygen units. (3) Self-help devices, e.g., safety grab bars, raised toi…

health services provided by a participating marital and family therapist, independent social worker, master social worker, mental health counselor, or certified alcohol and drug counselor within the practitioner’s scope of practice pursuant to state law and subject to the limitat…

it meets the criteria for inpatient hospital care as determined by Iowa Medicaid. All cases are subject to random retrospective review and may be subject to a more intensive retrospective review if abuse is suspected. In addition, transfers, outliers, and readmissions within 31 d…

outlined in the Birth Centers Provider Manual as amended to July 1, 2026. [ARC 0315D, IAB 5/27/26, effective 7/1/26]

78.31(1) Covered hospital outpatient services. Payment will be approved only for the following outpatient hospital services and medical services when provided on the licensed premises of the hospital. Hospitals with alternate sites approved by the department of inspections, appea…

therapy, psychological evaluations and counseling, psychotherapy, speech-language therapy, and audiological, nursing, and vision services provided by an area education agency (AEA). Services shall be provided directly by the AEA or through contractual arrangement with the AEA. [A…

services that are provided pursuant to 441—Chapter 90 to: 1. Members who are 18 years of age or over and have a primary diagnosis of intellectual disability, developmental disabilities, or chronic mental illness as defined in rule 441—90.1(249A). 2. Members who are under 18 years…

following services to members eligible for HCBS health and disability waiver services as established in 441—Chapter 83 and as identified in the member’s service plan. Payment will only be made for services provided in integrated, community-based settings that support full access …

by an occupational therapist that follow a treatment plan established by the physician, nurse practitioner, clinical nurse specialist, or PA; are reasonable and necessary to the treatment of the patient’s illness or injury; and meet the guidelines defined for restorative, mainten…

78.36(1) General characteristics. A hospice is a public agency or private organization or a subdivision of either that is primarily engaged in providing care to terminally ill individuals. A hospice provides palliative and supportive services to meet the physical, psychosocial, s…

to members eligible for the HCBS elderly waiver services as established in 441—Chapter 83 and as identified in the member’s service plan. Payment will only be made for services provided in integrated, community-based settings that support full access of members receiving Medicaid…

services to members eligible for the HCBS AIDS/HIV waiver services as established in 441—Chapter 83 and as identified in the member’s service plan. Payment shall only be made for services provided in integrated, community-based settings that support full access of members receivi…

Section 1905(a)(2)(C) of the Social Security Act as amended to July 1, 2026. 78.39(1) Utilization review. Utilization review will be conducted for Medicaid members who access more than 24 outpatient visits in any 12-month period from physicians, ARNPs, federally qualified health …

surgery services provided by a dentist to the extent these services are permitted to be performed under state law either by doctors of medicine, osteopathy, dental surgery or dental medicine and would be covered if furnished by doctors of medicine or osteopathy. Services must be …

of practice and the limitations of state law, with the exception of services not payable to physicians under rule 441—78.1(249A) or otherwise not payable under any other applicable rule. 78.40(1) Direct payment. Payment will be made to ARNPs directly, without regard to whether th…

following services to members eligible for the HCBS intellectual disability waiver as established in 441—Chapter 83 and as identified in the member’s service plan. Payment will only be made for services provided in integrated, community-based settings that support full access of …

the vaccine meets all Iowa board of pharmacy expanded practice standards and Medicaid requirements, payment will be made for the following: 78.42(1) Vaccines administered to children. Payment will be made to an enrolled provider for an administration fee for vaccines available th…

services to members eligible for the HCBS brain injury waiver services as established in 441—Chapter 83 and as identified in the member’s service plan. Payment will only be made for services provided in integrated, community-based settings that support full access of members rece…

service shall be provided for children who have had two venous blood lead levels of 15 to 19 micrograms per deciliter or one venous level greater than or equal to 20 micrograms per deciliter. This service includes, but is not limited to, X-ray fluorescence analyzer (XRF) readings…

comprehensive, integrated, and intensive outpatient services provided by a multidisciplinary team under the supervision of a psychiatrist. ACT services are directed toward the rehabilitation of behavioral, social, or emotional deficits or the amelioration of symptoms of a mental …

services to members eligible for the HCBS physical disability waiver as established in 441—Chapter 83 and as identified in the member’s service plan. Payment will only be made for services provided in integrated, community-based settings that support full access of members receiv…

pharmaceutical case management services provided by an eligible physician and pharmacist for Medicaid recipients determined to be at high risk for medication-related problems. These services are designed to identify, prevent, and resolve medication-related problems and improve dr…

schedule basis for providing vaccine and vaccine administration and testing for communicable disease. In order to be paid for the administration of a vaccine covered under the VFC program, a public health agency must enroll in the VFC program. Payment for the vaccine will be appr…

will be made for medical services provided to Medicaid eligible children by infant and toddler program providers under the infants and toddlers with disabilities program administered by the department, Iowa child health specialty clinics, and the department of education. 78.49(1)…

78.5(1) Payment will be approved for the following orthotic appliances and treatment of nail pathologies: a. Durable plantar foot orthotic. b. Plaster impressions for foot orthotic. c. Molded digital orthotic. d. Shoe padding when appliances are not practical. e. Custom molded sp…

made for medical services provided by local education agency services providers to Medicaid members under the age of 21. 78.50(1) Covered services. Covered services include but are not limited to audiology services, behavior services, consultation services, medical transportation…

necessary services and supplies provided by a licensed practitioner at an Indian health service 638 facility, as defined at rule 441—77.47(249A), within the practitioner’s scope of practice and subject to the limitations and exclusions set forth in subrule 78.1(1). [ARC 0315D, IA…

following services to members eligible for the HCBS children’s mental health waiver as established in 441—Chapter 83 and as identified in the member’s service plan. Payment will only be made for services provided in integrated, community-based settings that support full access of…

provided by a speech-language pathologist that are payable under Title XVIII of the Social Security Act as amended to July 1, 2026 (Medicare). [ARC 0315D, IAB 5/27/26, effective 7/1/26]

professional and a patient is not required as a prerequisite for payment for otherwise-covered services appropriately provided through telehealth in accordance with generally accepted health care practices and standards prevailing in the applicable professional community at the t…

for community-based neurobehavioral rehabilitation services that do not duplicate other services covered in this chapter. 78.55(1) Definitions. “Assessment” means the review of the current functioning of the member using the service in regard to the member’s situation, needs, str…

that provide medical services in addition to child care. Medically necessary services are provided under a plan of care that is developed by licensed professionals within their scope of practice and authorized by the member’s physician. The services include and implement a compre…

78.57(1) Payment. Payment will be made to QMB providers for a QMB-eligible member’s coinsurance, copayment, and deductible for Medicare-covered services. The eligible member may be responsible for copayments pursuant to 441—subrule 79.1(13). 78.57(2) Definitions. “Coinsurance” me…

78.58(1) Reimbursement. A HIPP provider may bill the department for the HIPP-eligible member’s out-of-pocket cost-sharing obligations. Reimbursement of claims is limited to in-network coinsurance, copayments, and deductibles of the HIPP-eligible member’s health insurance, paid fo…

441—77.54(249A)) of crisis response services, crisis stabilization community-based services, and crisis stabilization residential services delivered as set forth in 441—Chapter 24. [ARC 0315D, IAB 5/27/26, effective 7/1/26]

provided by the optometrist within the scope of practice of optometry and the limitations of state law, subject to the following limitations and exclusions. Covered optometric services include a professional component and materials. 78.6(1) Payable professional services. Payable …

pursuant to rule 441—77.55(249A)) for the provision of subacute mental health care facility services that meet the standards outlined in 481—Chapter 71. [ARC 0315D, IAB 5/27/26, effective 7/1/26] These rules are intended to implement Iowa Code chapter 249A. [Filed 3/11/70; amende…

by opticians when prescribed by a physician (MD or DO) or an optometrist. Payment and procedure for obtaining services and supplies are the same as described in rule 441—78.6(249A). [ARC 0315D, IAB 5/27/26, effective 7/1/26]

under Title XVIII of the Social Security Act (Medicare). 78.8(1) Covered services. Chiropractic manipulative therapy (CMT) eligible for reimbursement is specifically limited by Medicaid to the manual manipulation (i.e., by use of the hands) of the spine for the purpose of correct…

agency services prescribed by a physician, nurse practitioner, clinical nurse specialist, or PA in a plan of home health care provided by a Medicare-certified home health agency. 1. The number of hours of home health agency services shall be reasonable and appropriate to meet an …

The basis of payment for services rendered by providers of services participating in the medical assistance program is either a system based on the provider’s allowable costs of operation or a fee schedule. Generally, institutional types of providers such as hospitals and nursing…

and services. 79.10(1) Medicare definitions and policies apply to services provided unless specifically defined differently. 79.10(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 sta…

recipients is subject to preadmission review by Iowa Medicaid as required in rule 441—78.3(249A). 79.11(1) The patient’s admitting physician, the physician’s designee, or the hospital will contact Iowa Medicaid to request approval of Medicaid coverage for the hospitalization acco…

review of certain frequently performed surgical procedures to determine the necessity of the procedures and if Medicaid payment will be approved according to requirements found in 441—subrules 78.1(19), 78.3(18), and 78.26(3). 79.12(1) The physician must request approval from Iow…

will or durable power of attorney for health care, recognized under state law and related to the provision of health care when the person is incapacitated. All hospitals, home health agencies, home health providers of waiver services, hospice programs, and health maintenance orga…

Medicaid-enrolled entities providing laboratory services are subject to the provisions of the Clinical Laboratory Improvement Amendments of 1988 (CLIA) and Public Law 100-578, both as amended to July 1, 2026, and implementing federal regulations published at 42 CFR Part 493 as am…

79.15(1) Application request. Iowa Medicaid providers, including those enrolled with an MCO, shall begin the enrollment process by completing the appropriate application on the department’s website. Managed care organizations and fiscal agents are exempt from completing an applic…

that has received medical assistance payments totaling at least $5 million during a federal fiscal year (ending on September 30). For entities whose payments reach this threshold, compliance with this rule is a condition of receiving payments under the medical assistance program …

79.17(1) Review of Iowa prescription monitoring program database. A prescribing practitioner, as defined in Iowa Code section 124.550, or the prescribing practitioner’s designated agent, shall review patient information in the Iowa prescription monitoring program (PMP) database p…

79.2(1) Definitions. “Affiliates” means persons having an overt or covert relationship such that any one of them directly or indirectly controls or influences or has the power to control or influence another. “Iowa Medicaid” means the entity comprised of department staff and cont…