Section 441.78.56. Community-based neurobehavioral rehabilitation services.

Payment will be made for community-based neurobehavioral rehabilitation services that do not duplicate other services covered in this chapter.

         78.56(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 care” means the services provided by trained and licensed health care professionals to restore or maintain the member’s health.

“Intermittent community-based neurobehavioral rehabilitation services” are provided to a Medicaid member on an as-needed basis to support the member and the member’s family or caregivers to assist the member to increase adaptive behaviors, decrease maladaptive behaviors, and adapt and accommodate to challenging behaviors to support the member to remain in the member’s own home and community.

“Member” means a person who has been determined to be eligible for Medicaid under 441—Chapter 75.

“Neurobehavioral rehabilitation” refers to a specialized category of neurorehabilitation provided by a multidisciplinary team that has been trained in, and delivers, services individually designed to address cognitive, medical, behavioral and psychosocial challenges, as well as the physical manifestations of acquired brain injury. Services concurrently work to optimize functioning at personal, family and community levels, by supporting the increase of adaptive behaviors, decrease of maladaptive behaviors and adaptation and accommodation to challenging behaviors to support a member to maximize the member’s independence in activities of daily living and ability to live in the member’s home and community.

“Program” means a set of related resources and services directed to the accomplishment of a fixed set of goals for eligible members.

“Standardized assessment” means a valid, reliable, and comprehensive functional assessment tool(s) or process, or both, approved by the department for use in the assessment of a member’s individual needs.

         78.56(2) Member eligibility. To be eligible to receive community-based neurobehavioral rehabilitation services, a member shall meet the following criteria:

            a.               Brain injury diagnosis. To be eligible for community-based neurobehavioral rehabilitation services, the member must have a brain injury diagnosis as set forth in rule 441—83.81(249A).

            b.                Risk factors. The member has the following post-brain injury risk factors:

             (1)             The member is exhibiting neurobehavioral symptoms in such frequency or severity that the member has undergone or is currently undergoing treatment more intensive than outpatient care and is currently hospitalized, institutionalized, incarcerated or homeless or is at risk of hospitalization, institutionalization, incarceration or homelessness; or

             (2)             The member has a history of presenting with neurobehavioral or psychiatric symptoms resulting in at least one episode that required professional supportive care more intensive than outpatient care more than once in a lifetime (e.g., emergency services, alternative home care, partial hospitalization, or inpatient hospitalization).

            c.                Need for assistance. The member exhibits neurobehavioral symptoms in such frequency, severity or intensity that community-based neurobehavioral rehabilitation is required.

            d.                Needs assessment. The member shall have a standardized comprehensive functional neurobehavioral assessment reviewed or completed by a licensed neuropsychologist, neurologist, M.D., or D.O. The neurobehavioral assessment shall document the member’s need for community-based neurobehavioral rehabilitation, and the medical services unit of the Iowa Medicaid enterprise has determined that the member is in need of specialty neurobehavioral rehabilitation services.

            e.                Standards for assessment. Each member will have had a department-approved, standardized comprehensive functional neurobehavioral assessment completed within the 90 days prior to admission. Each needs assessment will include the assessment of a member’s individual physical, emotional, cognitive, medical and psychosocial residuals related to the member’s brain injury, which must include the following:

             (1)             Identification of the neurobehavioral needs that put the member at risk, including but not limited to verbal aggression, physical aggression, self-harm, unwanted sexual behavior, cognitive and or behavioral perseveration, wandering or elopement, lack of motivation, lack of initiation or other unwanted social behaviors not otherwise specified.

             (2)             Identification of triggers of unwanted behaviors and the member’s ability to self-manage the member’s symptoms.

             (3)             The member’s rehabilitation and medical care history to include medication history and status.

             (4)             The member’s employment history and the member’s barriers to employment.

             (5)             The member’s dietary and nutritional needs.

             (6)             The member’s community accessibility and safety.

             (7)             The member’s access to transportation.

             (8)             The member’s history of substance abuse.

             (9)             The member’s vulnerability to exploitation and history of risk of exploitation.

             (10)            The member’s history and status of relationships, natural supports and socialization.

            f.                 Emergency admission. In the event that emergency admission is required, the assessment shall be completed within ten calendar days of admission.

         78.56(3) Covered services.

            a.               Service setting.

             (1)             Community-based neurobehavioral residential rehabilitation services are provided to a member living in a three-to-five-bed residential care facility with a specialized license designation issued by the department of inspections and appeals; or

             (2)             Community-based neurobehavioral intermittent rehabilitation services are provided to a member living in the member’s own residence in the community.

No payment shall be made for community-based neurobehavioral rehabilitation when provided in a medical institution such as an intermediate care facility for persons with intellectual disabilities, nursing facility or skilled nursing facility.

            b.               Community-based neurobehavioral rehabilitation residential services identified in the treatment plan may include:

             (1)             Prescriptive programming to maintain and advance progress made in rehabilitation;

             (2)             Modifying or adapting the member’s environment to improve overall functioning;

             (3)             Assistance in obtaining preventative, appropriate and timely medical and dental care;

             (4)             Compensatory strategies to assist in managing ADLS (activities of daily living);

             (5)             Assistance with coordinating and obtaining physical, oral, or mental health care and any other professional services necessary to the member’s health and well-being;

             (6)             Behavioral and cognitive programming and supports;

             (7)             Medication management and consultation with pharmacy;

             (8)             Health and wellness management including dietary and nutritional programming;

             (9)             Progressive physical strengthening, fitness and retraining;

             (10)            Assistance with obtaining and use of assistive technology;

             (11)            Sobriety support development;

             (12)            Assistance with the self-identification of antecedent triggers;

             (13)            Assistance with preparation for transition to less intensive services including accessing the community;

             (14)            Flexibility in programming to meet individual needs;

             (15)            Assistance with re-learning coping and compensatory strategies;

             (16)            Support and assistance in seeking substance abuse and co-occurring disorders services;

             (17)            Support and assistance with obtaining legal consultation and services;

             (18)            Assistance with community accessibility and safety;

             (19)            Assistance with re-learning household maintenance;

             (20)            Assistance with recreational and leisure skill development;

             (21)            Assistance with the development and application of self-advocacy skills to navigate the service system;

             (22)            Opportunities to learn about brain injury and individual needs following brain injury;

             (23)            Support for carrying out the member’s individual goals in the rehabilitation treatment plan;

             (24)            Assistance with pursuit of education and employment goals;

             (25)            Protective oversight in the residential setting and community;

             (26)            Assistance and education to family, providers and other support system interests that are supporting the member receiving neurobehavioral rehabilitation services;

             (27)            Transitional support and training;

             (28)            Transportation essential to the attainment of the member’s individual goals in the rehabilitation treatment plan;

             (29)            Promotion of a program structure and support for members served so they can relearn or regain skills for maximum independence, community access, and integration.

            c.               Community-based neurobehavioral rehabilitation intermittent services identified in the treatment plan may occur in the member’s own home with or on behalf of the member and may include:

             (1)             Promotion of a program structure and support for members served so they can re-learn or regain skills for maximum community inclusion and access;

             (2)             Modifying or adapting the member’s environment to improve overall functioning;

             (3)             Compensatory strategies to assist in managing ADLS (activities of daily living);

             (4)             Behavioral supports;

             (5)             Assistance with obtaining and use of assistive technology;

             (6)             Assistance with the self-identification of antecedent triggers;

             (7)             Flexibility in programming to meet the member’s individual needs;

             (8)             Assistance with re-learning coping and compensatory strategies;

             (9)             Assistance with the development and application of self-advocacy skills to navigate the service system;

             (10)            Support for carrying out the member’s individual goals in the rehabilitation treatment plan;

             (11)            Assistance and education to family, providers and other support system interests that are supporting the member receiving community-based neurobehavioral rehabilitation services;

             (12)            Transitional support and training;

             (13)            Transportation essential to the attainment of the member’s individual goals in the rehabilitation treatment plan.

            d.               Approval of treatment plan. The community-based neurobehavioral services provider shall submit the proposed plan of care, the results of the member’s formal assessment, and medical documentation supporting a brain injury diagnosis to the Iowa Medicaid enterprise (IME) medical services unit for approval before providing the services.

            e.               Initial treatment plan. Within 30 days of admission, the provider shall submit the member’s treatment plan to the IME medical services unit.

             (1)             The IME medical services unit will approve the provider’s treatment plan if:

            1.      The treatment plan conforms to the medical necessity requirements in subrule 78.55(4);

            2.      The treatment plan is consistent with the written diagnosis and treatment recommendations made by a licensed medical professional that is a licensed neuropsychologist or neurologist, M.D., or D.O.;

            3.      The treatment plan is sufficient in amount, duration, and scope to reasonably achieve its purpose;

            4.      The provider can demonstrate that the provider possesses the skills and resources necessary to implement the plan; and

            5.      The treatment plan does not exceed 180 days in duration.

             (2)             A treatment summary detailing the member’s response to treatment during the previous approval period must be submitted when approval for subsequent plans is requested.

            f.                Subsequent plans. The IME medical services unit may approve a subsequent neurobehavioral rehabilitation treatment plan that conforms to the conditions of medical necessity pursuant to subrule 78.56(4) and to the conditions pursuant to subrule 78.56(3).

            g.               Quality review. The IME medical services unit may perform the quality review to evaluate:

             (1)             The time elapsed from referral to rehabilitation treatment plan development;

             (2)             The continuity of treatment;

             (3)             The length of stay per member;

             (4)             The affiliation of the medical professional recommending services with the neurobehavioral rehabilitation services provider;

             (5)             Gaps in service;

             (6)             The results achieved;

             (7)             Member and stakeholder satisfaction;

             (8)             The provider’s compliance with standards listed in rule 441—77.54(249A).

         78.56(4) Medical necessity. Nothing in this rule shall be deemed to exempt coverage of community-based neurobehavioral rehabilitation services from the requirement that services be medically necessary. “Medically necessary” means that the service is:

            a.               Consistent with the diagnosis and treatment of the member’s condition;

            b.               Required to meet the medical needs of the member and is needed for reasons other than the convenience of the member or the member’s caregiver;

            c.               The least costly type of service that can reasonably meet the medical needs of the member; and

            d.               In accordance with the standards of good medical practice. The standards of good practice for each field of medical and remedial care covered by the Iowa Medicaid program are those standards of good practice identified by:

             (1)             Knowledgeable Iowa clinicians practicing or teaching in the field; and

             (2)             The professional literature regarding best practices in the field.

         78.56(5) Documentation standards. Community-based neurobehavioral rehabilitation service providers shall maintain service provision records, financial records, and clinical records in accordance with the provisions of rule 441—79.3(249A).

[ARC 2341C, IAB 1/6/16, effective 2/10/16]