Iowa Admin. Code r. 441-81.7

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

Rule 441-81.7 - Continued review

(1)Level of care. The IME medical services unit shall review Medicaid members' need for continued care in nursing facilities, pursuant to the standards and subject to the appeals process in subrule 81.3(1). For all members enrolled with a managed care organization, the managed care organization shall review a Medicaid member's need for continued care in a nursing facility at least annually. The managed care organization must submit documentation to the IME medical services unit for all reviews that indicate a change in the member's level of care. The IME medical services unit shall make a final determination for any reviews that indicate a change in the level of care.

(2)PASRR. As a condition of payment for nursing facility care under the Medicaid program when there is a significant change in a resident's condition, the nursing facility shall, within 24 hours, initiate a PASRR review by the department's contractor for PASRR evaluations. For purposes of this subrule, "significant change in a resident's condition" means any admission or readmission to the facility immediately following an inpatient psychiatric hospitalization or any change that is likely to impact the resident's treatment needs related to a mental illness or intellectual disability. The evaluation shall determine:

a. Whether nursing facility care or skilled nursing care is medically necessary and appropriate for the resident under 441-subrules 79.9(1) and 79.9(2);

b. Whether nursing facility services continue to be appropriate for the resident, as opposed to care in a more specialized facility or in a community-based setting; and

c. Whether the resident needs specialized services for mental illness or intellectual disability, as described in paragraph 81.3(3)"b."

This rule is intended to implement Iowa Code sections 249A.2(1), 249A.3(3), and 249A.4.

Iowa Admin. Code r. 441-81.7

ARC 8445B, lAB 1/13/10, effective 12/11/09; ARC 9726B, lAB 9/7/11, effective 9/1/11; ARC 9888B, lAB 11/30/11, effective 1/4/12

Amended by IAB January 7, 2015/Volume XXXVII, Number 14, effective 3/1/2015

Amended by IAB January 06, 2016/Volume XXXVIII, Number 14, effective 1/1/2016