Section 441.22.1. Definitions.

“Administrator”   means the entity selected by the department through a request for proposal process or other contractual arrangement to administer the autism support program.

“Applicant”   means an individual on whose behalf an application has been submitted but who has not been identified as an eligible individual, or an individual who has received a denial of eligibility for the program.

“Applied behavioral analysis”    or   “ABA”    means the same as defined in Iowa Code section 225D.1.

“Autism”   means autism spectrum disorders as defined in Iowa Code section 514C.28.

“Autism service provider”   means a person providing applied behavioral analysis, who meets both of the following criteria:

“Autism support fund”    or   “fund”    means the autism support fund created in Iowa Code section 225D.2.

“Autism support program”    or   “program”    means the program created in Iowa Code section 225D.2 to provide funding for applied behavioral analysis and care coordination for eligible individuals with a diagnosis of autism.

“Clinically relevant”   means medically necessary and resulting in the development, maintenance, or restoration, to the maximum extent practicable, of the functioning of an individual.

“Department”   means the department of human services.

“Diagnostic assessment of autism”   means medically necessary assessment, evaluations, or tests performed by a licensed child psychiatrist, developmental pediatrician, or clinical psychologist.

“Eligible individual”   means a child less than nine years of age who has been diagnosed with autism based on a diagnostic assessment of autism, is not otherwise eligible for coverage for applied behavioral analysis treatment under the medical assistance program, Iowa Code section 514C.28, or private insurance coverage, and whose household income does not exceed 400 percent of the federal poverty level.

“Federal poverty level”   means the most recently revised poverty income guidelines published by the United States Department of Health and Human Services.

“Household income”   means household income, reported on the tax return on which the eligible individual is claimed as a dependent, as determined using the modified adjusted gross income methodology pursuant to Section 2002 of the federal Patient Protection and Affordable Care Act, Pub.  L.         No.       111-148. If the eligible individual’s parents live together and file separate tax returns, the income reported on both parents’ tax returns must be combined.

“Household size”   means the total number of personal and dependent exemptions claimed on the tax return on which the eligible individual is claimed as a dependent plus any child under the age of 19 living in the household who is claimed for tax purposes by a noncustodial parent through a release of claim to exemption by the custodial parent.

“Integrated health home”   means the same as defined in 441—subrule 78.53(1).

“Maximum amount of treatment”   means a maximum of 24 months of applied behavioral analysis funded by the autism support program. Months of service are not required to be consecutive.

“Maximum annual benefit”   means a maximum annual benefit amount of $36,000 per year for autism support program services for an eligible individual. For the purposes of this program, the annual benefit is calculated by using as a starting date the date the first service is reimbursed by the program and an ending date 12 months from the starting date. Expenditures included in the calculation of the maximum annual benefit include reimbursements to autism service providers for provision of applied behavioral analysis and reimbursements to integrated health homes for costs of care coordination. Cost-sharing paid by the eligible individual is not included in the calculation of the individual’s annual benefit.

“Medical assistance”    or   “Medicaid”    means assistance provided under the medical assistance program pursuant to Iowa Code chapter 249A and Title XIX of the Social Security Act.

“Month of service”   means any month in which an individual receives at least one billable unit of applied behavioral analysis service funded by the autism support program.

“Provider network”   means a network of autism service providers approved by the department to provide services to eligible individuals through the autism support program.

“Regional autism assistance program”    or   “RAP”    means the regional autism assistance program created in Iowa Code section 256.35.

“Treatment plan”   means a plan for the treatment of autism developed by a licensed physician or licensed psychologist pursuant to a comprehensive evaluation or reevaluation performed in consultation with the patient and the patient’s representative.

[ ARC 1329C , IAB 2/19/14, effective 4/1/14;    ARC 2816C , IAB 11/23/16, effective 1/1/17]