Iowa Administrative Code

77.4(1) Qualifications. All hospitals licensed in the state of Iowa or in another state and certified as eligible to participate in Part A of the Medicare program (Title XVIII of the Social Security Act as amended to July 1, 2026) are eligible to participate in the medical assist…

waiver services shall be rendered by providers meeting the standards and qualifications outlined in the HCBS Waiver Provider Manual as amended to July 1, 2026. 77.40(1) Review of providers. Reviews of compliance with standards as indicated in this chapter and the requirements set…

(ACT) program shall be rendered by a multidisciplinary team composed of practitioners from the disciplines described in this rule. The team shall be under the clinical supervision of a psychiatrist. The program shall designate an individual team member who shall be responsible fo…

providers shall meet the standards and qualifications outlined in the HCBS Waiver Provider Manual as amended to July 1, 2026. Providers initially enrolling to deliver BI waiver services and each of their staff members involved in direct member service must have completed the depa…

service providers shall meet the standards and qualifications outlined in the HCBS Waiver Provider Manual as amended to July 1, 2026. The integrated, community-based settings standards in subrule 77.30(5) apply to all HCBS physical disability waiver service providers. 77.43(1) En…

assistance program when the public health agency serves as a public health entity within a local board of health jurisdiction pursuant to rule 641—77.3(137). [ARC 0314D, IAB 5/27/26, effective 7/1/26]

the medical assistance program as a provider of infant and toddler program services under rule

department of education pursuant to 281—Chapter 12 and Iowa educational services for the blind and the Iowa school for the deaf, both of which are governed by the department of education pursuant to Iowa Code section 256.95, are eligible to participate in the medical assistance p…

Service or under the Indian Self-Determination and Education Assistance Act (P.L. 93-638 as amended to July 1, 2026) by an “Indian tribe,” “tribal organization,” or “Urban Indian organization,” as those terms are defined in 25 U.S.C. 1603 as amended to July 1, 2026, is eligible t…

health waiver services shall be rendered by provider agencies that meet the general provider standards in subrule 77.48(1) and the integrated, community-based settings standards in subrule 77.30(5) and also meet the standards in subrules 77.48(2) through 77.48(5) that are specifi…

orders and referrals, to a Medicaid member shall be enrolled as a Medicaid provider as a condition of payment eligibility for services rendered to that Medicaid member. A provider who does not individually bill for services rendered due to, for example, payment arrangements with …

in the program. Dentists in other states are also eligible if duly licensed to practice in that state. Note, however, that payment will not be made to a dental laboratory. [ARC 0314D, IAB 5/27/26, effective 7/1/26]

medical assistance program when they comply with the standards of 441—Chapter 109. A child care center in another state is eligible to participate when duly licensed in that state. The provider of child care medical services implements a comprehensive protocol of care that is dev…

77.51(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 c…

enrolled as an Iowa Medicaid provider for the general Medicaid population may enroll to be a QMB provider. A QMB-eligible member must meet the criteria outlined in 441—paragraph 75.6(5)“a”. 77.52(1) Reimbursement. A QMB provider may only bill the department for the QMB-eligible m…

an Iowa Medicaid provider for the general Medicaid population may enroll to be a HIPP provider. A HIPP provider may bill the department for the HIPP-eligible member’s out-of-pocket, cost-sharing obligations. Reimbursement is limited to in-network coinsurance, copayments, and dedu…

77.54(1) Definitions. The terms used in this rule shall have the same meaning as those set out in 441—Chapter 24. 77.54(2) Eligible providers. Agencies that are accredited under the mental health service provider standards set forth in 441—Chapter 24 are eligible to participate i…

77.55(1) Definitions. The terms used in this rule shall have the same meaning as set out in Iowa Code section 135G.1. 77.55(2) Subacute mental health services. Subacute mental health services are intended to be short- term, intensive, recovery-oriented services designed to stabil…

participate in the program. Podiatrists in other states are also eligible if duly licensed to practice in that state. [ARC 0314D, IAB 5/27/26, effective 7/1/26]

participate in the program. Optometrists in other states are also eligible if duly licensed to practice in that state. [ARC 0314D, IAB 5/27/26, effective 7/1/26]

Opticians in other states are also eligible to participate. Note: Opticians in states having licensing requirements for this professional group must be duly licensed in that state. [ARC 0314D, IAB 5/27/26, effective 7/1/26]

to participate provided that they have been determined eligible to participate in Title XVIII of the Social Security Act (Medicare) as amended to July 1, 2026, by the Social Security Administration. Chiropractors in other states are also eligible if duly licensed to practice in t…

[ARC 0315D, IAB 5/27/26, effective 7/1/26]

and supplies provided by the physician, including services rendered in the physician’s office or clinic, the home, in a hospital, nursing home or elsewhere. Payment will be made for all services rendered by a doctor of medicine or osteopathy within the scope of this practice and …

78.10(1) General payment requirements. Payment will be made for items of DME, prosthetic devices and medical supplies, subject to the following general requirements and the requirements of subrule 78.10(2), 78.10(3), or 78.10(4), as applicable: a. DME, prosthetic devices, and med…

by the recipient’s condition and the recipient is transported to the nearest hospital with appropriate facilities or to one in the same locality, from one hospital to another, to the patient’s home, to a nursing facility, or to a mental health access center. Payment for ambulance…

intervention services not otherwise covered under this chapter that are designed to minimize or, if possible, eliminate the symptoms or causes of a mental disorder, subject to the limitations in this rule. 78.12(1) Definitions. “Behavioral health intervention” means skill-buildin…

nonemergency medical transportation through a transportation brokerage. Medicaid members who are eligible for full Medicaid benefits and need transportation services so they can receive Medicaid-covered services from providers enrolled with the Iowa Medicaid program may obtain tr…

the following conditions: 78.14(1) Physician examination. The member shall have an examination by a physician to determine that the member has no condition that would contraindicate the use of a hearing aid. This report shall be documented in the patient record. The requirement f…

orthopedic shoes, inserts, and modifications, subject to the following definitions and conditions. 78.15(1) Definitions. “Custom-molded shoe” means a shoe that: 1. Has been constructed over a cast or model of the recipient’s foot; 2. Is made of leather or another suitable materia…

necessary services provided by a psychiatrist on the staff of a community mental health center. Payment will be approved for services provided by a clinical psychologist, social worker or psychiatric nurse on the staff of the center, subject to the following conditions: 78.16(1) …

directly to an active written treatment plan; follow a treatment plan established by the physician, nurse practitioner, clinical nurse specialist, or PA after any needed consultation with the qualified physical therapist; are reasonable and necessary to the treatment of the patie…

78.19(1) Coverage of services. a. General provisions regarding coverage of services. (1) Services are provided in the member’s home or in a care facility (other than a hospital) by a speech therapist, physical therapist, or occupational therapist employed by or contracted by the …

defined in 42 U.S.C. Section 1396r-8(k)(2)-(4) as amended to July 1, 2026, subject to the conditions and limitations specified in this rule. 78.2(1) Qualified prescriber. All drugs are covered only if prescribed or ordered by an Iowa Medicaid-enrolled practitioner licensed or reg…

services provided by laboratories that are independent of attending and consulting physicians’ offices, hospitals, and critical access hospitals and that are certified to participate in the Medicare program. [ARC 0315D, IAB 5/27/26, effective 7/1/26]

payable under the Medicare program. Payment will be made for sterilization in accordance with subrule 78.1(16). 78.21(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,…

provided by family planning clinics. 78.22(1) Payment will be made for sterilization in accordance with subrule 78.1(16). 78.22(2) In order to be paid for the administration of a vaccine covered under the VFC program, a family planning clinic must enroll in the VFC program. Payme…

part of a hospital, funded publicly or by private contributions, that provide medically necessary treatment by or under the direct supervision of a physician or dentist to outpatients. 78.23(1) Sterilization. Payment will be made for sterilization in accordance with subrule 78.1(…

they are provided by the psychologist in the psychologist’s office, a hospital, nursing facility, or residential care facility. 78.24(1) Payment for covered services provided by the psychologist will be made on a fee for service basis. a. Payment will be made only for time spent …

care, health education, and transportation to receive prenatal and postpartum services. Payment will be made for enhanced perinatal services for persons determined high risk. These services include additional health education services, nutrition counseling, social services, and o…

services furnished by an ambulatory surgical center in connection with a covered surgical procedure or a covered dental procedure. Covered procedures are listed in the fee schedule published on the department’s website. 78.26(1) Covered surgical procedures will be those medically…

will only be made to providers enrolled to provide habilitation through Iowa Medicaid. Payment will only be made for services provided to members in integrated, community-based settings that support full access of members receiving Medicaid HCBS to the greater community, includin…

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]