Iowa Administrative Code

charged to the medical assistance program shall maintain complete and legible records as required in this rule. Failure to maintain records or failure to make records available to the department or to its authorized representative timely upon request shall result in claim denial …

79.4(1) Definitions. “Authorized representative,” within the context of this rule, means the person appointed to carry out audit or review procedures, including assigned auditors, reviewers or agents contracted for specific audits, reviews, or audit or review procedures. “Claim” …

with Section 504 of the Rehabilitation Act of 1973 and federal regulations 45 CFR Part 84, both as amended to July 1, 2026, which prohibit discrimination on the basis of handicap in all federal Department of Health and Human Services funded programs. [ARC 0316D, IAB 5/27/26, effe…

participate in the program shall execute an agreement with the department on an Agreement Between Provider of Medical and Health Services and the Iowa Department of Health and Human Services Regarding Participation in Medical Assistance Program. Exception: Dental providers are re…

79.7(1) Officers. a. The public co-chairperson’s term of office shall be two years. A public co-chairperson shall serve no more than two consecutive terms. b. The public co-chairperson shall have the right to vote on any issue before the council. c. The position of public co-chai…

and support a beneficiary advisory council. The council will be governed by bylaws, which are available on the department’s website. [ARC 0316D, IAB 5/27/26, effective 7/1/26]

services not provided through an MCO. For services provided through an MCO, the prior authorization request is submitted, reviewed, and authorized by the MCO. 79.9(1) Making the request. a. Providers may submit requests for prior authorization for any items or procedures, other t…

when reimbursing employees for personal items damaged or destroyed by clients of the department during the employee’s tour of duty. The claimant shall provide the department with a detailed written account of the incident, including an estimated cost of repair or replacement. Thi…

program shall submit claims for services rendered to Iowa Medicaid on at least a monthly basis. All nursing facilities and providers of home- and community-based services shall submit claims for services after the end of the calendar month in which the services are provided. Foll…

care organizations, and the Public Health Associate Program (PHAP). 80.2(1) Payments deducted. The amount of any payment made directly to the provider of care by the recipient, relatives, or any source will be deducted from the established cost standard for the service provided t…

80.3(1) Submission of claims. Payment will not be made on any claim when the amount of time that has elapsed between the date the service was rendered and the date the initial claim is received by Iowa Medicaid exceeds 365 days. The department will consider claims submitted beyon…

80.4(1) Identification cards. The department will issue a medical assistance eligibility card to members for use in securing medical and health services available under the program except as provided in 441—Chapter 76. a. The department will issue the medical assistance eligibili…

the provider of the services except as provided below. 80.5(1) Medical assistance corrective payments. Payment may be made to the client or county relief agency in accordance with 441—Chapter 75. 80.5(2) Assignment. Payment may be made in accordance with an assignment to a county…

insurers shall provide, upon the request of the state, information with respect to individuals who are eligible for or are provided medical assistance under the state’s medical assistance plan to determine (1) during what period the member or the member’s spouse or dependents may…

“Abuse” means any of the following that occurs as a result of the willful or negligent acts or omissions of a nursing facility employee: 1. Physical injury to, or injury that is at a variance with the history given of the injury, or unreasonable confinement or unreasonable punish…

department’s contracted managed care organizations with which the facility is enrolled shall be notified at least 60 days in advance of the closing. Plans for the transfer of residents receiving medical assistance shall be approved by the resident’s managed care organization or b…

a contractual agreement with the department that sets forth the terms under which they will participate in the program. 81.11(1) Procedures for establishing health care facilities as Medicaid facilities. All survey procedures and certification process shall be in accordance with …

81.12(1) Audit of financial and statistical report. Authorized representatives of the department or the U.S. Department of Health and Human Services shall have the right, upon proper identification, to audit, using generally accepted auditing procedures, the general financial rec…

81.13(1) Deemed meeting of requirements. A nurse aide is deemed to satisfy the requirement of completing a nurse aide training and competency evaluation approved by the department of inspections, appeals, and licensing if: a. The nurse aide successfully completed a nurse aide tra…

81.14(1) Penalty for falsification of a resident assessment. An individual, who willfully and knowingly certifies a material and false statement in a resident assessment, is subject to a civil money penalty in accordance with 42 CFR 483.20(j) (as amended to August 1, 2024). a. Fa…

For members enrolled with a managed care organization, authorization for admission must be obtained from the managed care organization prior to admission. Out-of-state facilities shall abide by the same policies as in-state facilities with the following exceptions: 81.15(1) Excep…

facilities are defined in the same way as the Medicare program. This rule is intended to implement Iowa Code section 249A.4 and 1991 Iowa Acts, chapter 267, section 132(1)“i.” [ARC 9279C, IAB 5/14/25, effective 7/1/25]

81.17(1) Maximum client participation. A nursing facility may not charge more client participation for Medicaid-eligible clients as determined in rule 441—75.16(249A) than the maximum monthly allowable payment for their facility as determined according to 441—subrule 79.1(9) or r…

facility who has countable income for purposes of rule 441—75.16(249A) of less than $55 per month shall receive a state-funded payment from the department for the difference between that countable income and $55 if the legislature has appropriated funding specifically for this pu…

in accordance with 42 CFR 488 (as amended to August 1, 2024). [ARC 9279C, IAB 5/14/25, effective 7/1/25]

81.2(1) Need for nursing facility care. Residents of nursing facilities must be in need of either nursing facility care or skilled nursing care. Payment will be made for nursing facility care residents only upon certification of the need for the level of care by a licensed physic…

81.20(1) A facility may request a hearing on a determination of noncompliance leading to an enforcement remedy. The affected nursing facility, or its legal representative or other authorized official, shall file the request for hearing in writing to the department of inspections,…

penalties is made as provided in rule 441—81.24(249A). [ARC 9279C, IAB 5/14/25, effective 7/1/25]

and licensing has the authority to settle cases at any time before an evidentiary hearing. [ARC 9279C, IAB 5/14/25, effective 7/1/25]

81.23(1) The amount of the penalty, when determined, may be deducted from any sum then or later owing by the department to the facility. 81.23(2) Interest of 10 percent per year is assessed on the unpaid balance of the penalty, beginning on the due date. [ARC 9279C, IAB 5/14/25, …

department will be applied to the protection of the health or property of residents of facilities that the department of inspections, appeals, and licensing finds deficient. Funds may be used for: 1. Time-limited expenses incurred in the process of relocating residents to home- a…

81.3(1) Financial participation by resident. A resident’s payment for care may include any voluntary payments made by family members toward cost of care of the resident. The resident’s client participation and medical payments from a third party shall be paid toward the total cos…

81.4(1) Notice. When a Medicaid member requests transfer or discharge, or another person requests this for the member, the administrator shall promptly notify the department. This shall be done in sufficient time to permit a social service worker or case manager to assist in the …

the facility any maintenance item included in the computation of the audit cost that is charged to the resident’s personal needs when the charge constitutes double payment. Unverifiable expenditures charged to personal needs accounts may be charged back to the facility. The accou…

81.6(1) Level of care. The department will review Medicaid members’ need for continued care in nursing facilities, pursuant to the standards and subject to the appeals process in subrule 81.2(1). For all members enrolled with a managed care organization, the managed care organiza…

81.7(1) Content. The facility shall as a minimum maintain the following records: a. All records required by the department and the department of inspections, appeals, and licensing. b. Records of all treatments, drugs, and services for which vendors’ payments have been made or ar…

81.8(1) Method of payment. Except for Medicaid accountability measures payment established in paragraph 81.5(16)“g,” facilities will be reimbursed under a modified price-based vendor payment program. A per diem rate will be established based on information submitted according to …

of service and within 365 days of the date of service. Claims must be submitted electronically through the department’s electronic clearinghouse. A remittance advice of the claims paid may be obtained through the Iowa Medicaid portal access (IMPA) system. Adjustments to submitted…

“Intermediate care facility for persons with an intellectual disability” or “ICF/ID” means an institution that is primarily for the diagnosis, treatment, or rehabilitation of persons with an intellectual disability or persons with related conditions and that provides, in a protec…

82.10(1) Content. The facility shall at a minimum maintain the following records: a. All records required by the department and the department of inspections, appeals, and licensing. b. Medical records as required by Section 1902(a)(31) of Title XIX of the Social Security Act (as…

82.11(1) Method of payment. Facilities will be reimbursed under a cost-related vendor payment program. A per diem rate will be established based on information submitted according to rule 441—82.4(249A). 82.11(2) Periods authorized for payment. a. Payment will be made on a per di…

organization must be sent to the department after the month of service and within 365 days of the date of service. Such claims must be submitted electronically through the department’s electronic clearinghouse. 82.12(1) A remittance advice of the claims paid may be obtained throu…

department’s contracted managed care organizations with which the facility is enrolled shall be notified at least 60 days in advance of the closing. Plans for the transfer of residents receiving Medicaid shall be approved by the resident’s managed care organization or by the depa…

82.14(1) Audits of financial and statistical report. Authorized representatives of the department or the U.S. Department of Health and Human Services shall have the right, upon proper identification, to audit, using generally accepted auditing procedures, the general financial re…

facilities for persons with an intellectual disability. Out-of-state facilities shall abide by the same policies as in-state facilities with the following exceptions: 82.15(1) Out-of-state providers will be reimbursed at the same intermediate care facility rate they are receiving…

intermediate care facility for persons with an intellectual disability who has countable income for purposes of rule 441—75.16(249A) of less than $55 per month will receive a state-funded payment from the department for the difference between that countable income and $55 if the …

licensed as an intermediate care facility for persons with an intellectual disability by the department of inspections, appeals, and licensing pursuant to 481—Chapter 64. The facility shall meet the following conditions of participation. 82.2(1) Governing body and management—disc…

intellectual disability. All intermediate care facilities for persons with an intellectual disability must enter into a contractual agreement with the department that sets forth the terms under which they will participate in the program. This rule is intended to implement Iowa Co…

shall submit a financial and statistical report to the department. These reports shall be based on the following rules. 82.4(1) Failure to maintain records. Failure to maintain and submit adequate accounting or statistical records shall result in termination or suspension of part…

82.5(1) Interdisciplinary team. The initial evaluation for admission shall be conducted by an interdisciplinary team. The team shall consist of a physician, a social worker, and other professionals. At least one member of the team shall be a qualified intellectual disability prof…