Section 441.78.57. Child care medical services.

Payments will be made to licensed child care centers that provide medical services in addition to child care. Medically necessary services are provided under a plan of care that is developed by licensed professionals within their scope of practice and authorized by the member’s physician. The services include and implement a comprehensive protocol of care that is developed in conjunction with the parent or guardian and specifies the medical, nursing, personal care, psychosocial and developmental therapies required by the medically dependent or technologically dependent child served.

         78.57(1) Nursing services are services which are provided by a registered nurse or a licensed practical nurse under the direction of the member’s physician to a member in a licensed child care center. Nursing services shall be provided according to a written plan of care authorized by a physician. Payment for nursing services may be approved if the services are determined to be medically necessary as defined in subrule 78.57(5). Nursing services include activities that require the expertise of a nurse, such as physical assessment, tracheostomy care, medication administration, and tube feedings.

         78.57(2) Personal care services are those services which are provided by an aide but are delegated and supervised by a registered nurse under the direction of the member’s physician. Payment for personal care services may be approved if the services are determined to be medically necessary as defined in subrule 78.57(5). Personal care services shall be in accordance with the member’s plan of care and authorized by a physician. Personal care services include the activities of daily living, oral hygiene, grooming, toileting, feeding, range of motion and positioning, and training the member in necessary self-help skills, including teaching prosocial skills and reinforcing positive interactions.

         78.57(3) Psychosocial services are those services that focus at decreasing or eliminating maladaptive behaviors. Payment for psychosocial services may be approved if the services are determined to be medically necessary as defined in subrule 78.57(5). Psychosocial services shall be in accordance with the member’s plan of care and authorized by a physician. Psychosocial services include implementing a plan using clinically accepted techniques for decreasing or eliminating maladaptive behaviors. Psychosocial intervention plans must be developed and reviewed by licensed mental health providers.

         78.57(4) Developmental therapies are those services which are provided by an aide but are delegated and supervised by a licensed therapist under the direction of the member’s physician. Payment for developmental therapies may be approved if the services are determined to be medically necessary as defined in subrule 78.57(5). Developmental therapies shall be in accordance with the member’s plan of care and authorized by a physician. Developmental therapies include activities based on the individual’s needs such as fine motor, gross motor, and receptive expressive language.

         78.57(5) “Medically necessary” means the service is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions that endanger life, cause pain, result in illness or infirmity, or threaten to cause or aggravate a disability or chronic illness and is an effective course of treatment for the member requesting a service.

         78.57(6) Requirements.

            a.               Nursing, psychosocial, developmental therapies and personal care services shall be ordered in writing.

            b.               Nursing, psychosocial, developmental therapies and personal care services shall be authorized by the department or the department’s designated review agent prior to payment.

            c.               Prior authorization shall be requested at the time of initial submission of the plan of care or at any time the plan of care is substantially amended and shall be renewed with the department or the department’s designated review agent. Initial request for and request for renewal of prior authorization shall be submitted to the department’s designated review agent. The provider of the service is responsible for requesting prior authorization and for obtaining renewal of prior authorization. The request for prior authorization shall include a nursing assessment, the plan of care, and supporting documentation. A treatment plan shall be completed prior to the start of care and at a minimum reviewed every 180 days thereafter. The plan of care shall support the medical necessity and intensity of services to be provided by reflecting the following information:

             (1)             Place of service.

             (2)             Type of service to be rendered and the treatment modalities being used.

             (3)             Frequency of the services.

             (4)             Assistance devices to be used.

             (5)             Date on which services were initiated.

             (6)             Progress of member in response to treatment.

             (7)             Medical supplies to be furnished.

             (8)             Member’s medical condition as reflected by the following information, if applicable:

            1.      Dates of prior hospitalization.

            2.      Dates of prior surgery.

            3.      Date last seen by a primary care provider.

            4.      Diagnoses and dates of onset of diagnoses for which treatment is being rendered.

            5.      Prognosis.

            6.      Functional limitations.

            7.      Vital signs reading.

            8.      Date of last episode of acute recurrence of illness or symptoms.

            9.      Medications.

             (9)             Discipline of the person providing the service.

             (10)            Certification period.

             (11)            Physician’s signature and date. The treatment plan must be signed and dated by the physician before the claim for service is submitted for reimbursement.

             (12)            Forms 470-4815 and 470-4816 are utilized during the prior authorization review.

         78.57(7) Nursing, personal care, and psychosocial services do not include:

            a.               Services provided to members aged 21 and older.

            b.               Services that require prior authorizations that are provided without regard to the prior authorization process.

            c.               Nursing services provided simultaneously with other Medicaid services (e.g., home health aide, physical, occupational, or speech therapy services, etc.).

            d.               Services that exceed the services that are approvable under the private duty nursing and personal care program pursuant to subrule 78.9(10).

            e.               Transportation services.

            f.                Services provided to a member while the member is in institutional care.

This rule is intended to implement Iowa Code chapter 249A.

[ARC 2361C, IAB 1/6/16, effective 1/1/16]