Iowa Admin. Code r. 441-73.5

Current through Regsiter Vol. 46, No. 26, June 12, 2024

Rule 441-73.5 - MCP covered services

(1)Required services-MCOs. A managed care organization shall provide:

a. For enrollees other than Iowa health and wellness plan enrollees and hawki program enrollees, services as set forth in 441-Chapters 78, 81, 82, 83, 84, 85, and 87, with the exception of the following:

(1) Area education agency services.

(2) Dental services not provided in an outpatient hospital setting.

(3) Infant and toddler program services.

(4) Local education agency services.

(5) State of Iowa Veterans Home services.

(6) Money Follows the Person (MFP) Rebalancing Demonstration Grant-funded services.

b. Services as set forth in 441-Chapter 74 for Iowa health and wellness plan enrollees.

c. Services as set forth in 441-Chapter 86 for hawki program enrollees.

(2)Community-based case management service. The managed care organization is required to provide services that meet requirements specified in the contract and in 441-Chapter 90.

(3)Health home services. The managed care organization is required to provide services that meet the requirements specified in 441-Chapter 78 and as specified in the contract.

(4)Value-added services. A managed care organization may develop optional services and supports to address the needs of enrollees. These services and supports shall be implemented only after approval by the department.

(5)Required services-PAHPs. A PAHP shall provide services to enrollees under the contract with the state agency and on the bases of prepaid capitation payments or other payment arrangements that do not use state plan payment rates. PAHPs shall provide:

a. For enrollees other than Iowa health and wellness plan enrollees and hawki program enrollees, services as set forth in 441-Chapter 73, 74, 78, and 88 with the exception of the following:

(1) Area education agency services.

(2) Inpatient hospital or institutional services.

(3) Advance directive requirements in dental nonclinical services such as transportation.

(4) Long-term care (skilled nursing facilities, intermediate care facilities, residential care facilities, state resource centers, or intermediate care facilities for persons with an intellectual disability).

(5) Inpatient psychiatric care provided at the state-administered mental health institutes.

(6) Services provided at specialized adolescent psychiatric facilities.

(7) Day treatment and partial hospitalization services for persons aged 20 or under.

(8) Enhanced services provided to certain eligible recipients.

b. Services as set forth in 441-Chapter 74 for Iowa health and wellness plan enrollees.

c. Services as set forth in 441-Chapter 86 for hawki program enrollees.

Iowa Admin. Code r. 441-73.5

Adopted by IAB January 6, 2016/Volume XXXVIII, Number 14, effective 1/1/2016

Amended by IAB February 12, 2020/Volume XLII, Number 17, effective 3/18/2020

Amended by IAB April 5, 2023/Volume XLV, Number 20, effective 6/1/2023