§ 249A.4 — Duties of director

Iowa § 249A.4

• Jurisdiction: Iowa
• Title VI: HUMAN SERVICES
• Ch. 249A: MEDICAL ASSISTANCE

Text

The director shall be responsible for the effective and impartial administration of this
chapter and shall, in accordance with the standards and priorities established by this
chapter, by applicable federal law, by the regulations and directives issued pursuant to
federal law, by applicable court orders, and by the state plan approved in accordance with
federal law, make rules, establish policies, and prescribe procedures to implement this
chapter. Without limiting the generality of the foregoing delegation of authority, the director
is hereby specifically empowered and directed to:
1. Determine the greatest amount, duration, and scope of assistance which may be
provided, and the broadest range of eligible individuals to whom assistance may effectively
be provided, under this chapter within the limitations of available funds.
2. Require providers to share information with the department as necessary to identify,
prevent, or respond to child abuse as defined in section 232.68, and dependent adult abuse
as defined in section 235B.2.
3. Have authority to provide for payment under this chapter of assistance rendered to any
applicant prior to the date the application is filed.
4. Have authority to contract with any corporation authorized to engage in this state
in insuring groups or individuals for all or part of the cost of medical, hospital, or other
health care or with any corporation maintaining and operating a medical, hospital, or health
service prepayment plan under the provisions of chapter 514 or with any health maintenance
organization authorized to operate in this state, for any or all of the benefits to which any
recipients are entitled under this chapter to be provided by such corporation or health
maintenance organization on a prepaid individual or group basis.
5. May, to the extent possible, contract with a private organization or organizations
whereby such organization will handle the processing of and the payment of claims for
servicesrenderedundertheprovisionsofthischapterandundersuchrulesandregulationsas
shall be promulgated by such department. The state department may give due consideration
to the advantages of contracting with any organization which may be serving in Iowa as
“intermediary” or “carrier” under Tit. XVIII of the federal Social Security Act, as amended.
6. Shall cooperate with any agency of the state or federal government in any manner as
maybenecessarytoqualifyforfederalaidandassistanceformedicalassistanceinconformity
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with the provisions of chapter 249, this chapter, and Tit. XVI and XIX of the federal Social
Security Act, as amended.
7. Shall provide for the professional freedom of those licensed practitioners who
determine the need for or provide medical care and services, and shall provide freedom of
choice to recipients to select the provider of care and services, except when the recipient is
eligible for participation in a health maintenance organization or prepaid health plan which
limits provider selection and which is approved by the department.
a. However, this shall not limit the freedom of choice to recipients to select providers in
instances where such provider services are eligible for reimbursement under the medical
assistance program but are not provided under the health maintenance organization or
under the prepaid health plan, or where the recipient has an already established program
of specialized medical care with a particular provider. The department may also restrict
the recipient’s selection of providers to control the individual recipient’s overuse of care
and services, provided the department can document this overuse. The department shall
promulgate rules for determining the overuse of services, including rights of appeal by the
recipient.
b. Advanced registered nurse practitioners licensed pursuant to chapter 152 and
physician assistants licensed pursuant to chapter 148C shall be regarded as approved
providers of health care services, including primary care, for purposes of managed care or
prepaid services contracts under the medical assistance program. This paragraph shall not
be construed to expand the scope of practice of an advanced registered nurse practitioner
pursuant to chapter 152 or physician assistants pursuant to chapter 148C.
8. Implement the premium assistance program options described under the federal
Children’s Health Insurance Program Reauthorization Act of 2009, Pub. L. No. 111-3, for the
medical assistance program. The department may adopt rules as necessary to administer
these options.
9. Adopt rules pursuant to chapter 17A in determining the method and level of
reimbursement for all medical and health services to be provided under the medical
assistance program, after considering all of the following:
a. The promotion of efficient and cost-effective delivery of medical and health services.
b. Compliance with federal law and regulations.
c. The level of state and federal appropriations for medical assistance.
d. Reimbursement at a level as near as possible to actual costs and charges after priority
is given to the considerations in paragraphs “a”, “b”, and “c”.
10. a. Allow supplementation of the combination of client participation and payment
made through the medical assistance program for those items and services identified in
42 C.F.R. §483.10(c)(8)(ii), by the resident of a nursing facility or the resident’s family.
Supplementation under this subsection may include supplementation for provision of a
private room not otherwise covered under the medical assistance program unless either of
the following applies:
(1) The private room is therapeutically required pursuant to 42 C.F.R. §483.10(c)(8)(ii).
(2) No room other than the private room is available.
b. The rules adopted to administer this subsection shall require all of the following if a
nursing facility provides for supplementation for provision of a private room:
(1) The nursing facility shall inform all current and prospective residents and residents’
legal representatives of the following:
(a) If the resident desires a private room, the resident or resident’s family may
provide supplementation by directly paying the facility the amount of supplementation.
Supplementation by a resident’s family shall not be treated as income of the resident for
purposes of medical assistance program eligibility or client participation.
(b) The nursing facility’s policy if a resident residing in a private room converts from
private pay to payment under the medical assistance program, but the resident or resident’s
family is not willing or able to pay supplementation for the private room.
(c) A description and identification of the private rooms for which supplementation is
available.
(d) The process for an individual to take legal responsibility for providing
§249A.4, MEDICAL ASSISTANCE 12
supplementation, including identification of the individual and the extent of the legal
responsibility.
(2) For a resident for whom the nursing facility receives supplementation, the nursing
facility shall indicate in the resident’s record all of the following:
(a) A description and identification of the private room for which the nursing facility is
receiving supplementation.
(b) The identity of the individual making the supplemental payments.
(c) The private pay charge for the private room for which the nursing facility is receiving
supplementation.
(d) The total charge to the resident for the private room for which the nursing facility
is receiving supplementation, the portion of the total charge reimbursed under the medical
assistanceprogram, andtheportionofthetotalchargereimbursedthroughsupplementation.
(3) If the nursing facility only provides one type of room or all private rooms, the nursing
facility shall not be eligible to request supplementation.
(4) A nursing facility may base the supplementation amount on the difference between
the amount paid for a room covered under the medical assistance program and the private
pay rate for the private room identified for supplementation. However, the total payment
for the private room from all sources shall not be greater than the aggregate average private
room rate for the type of rooms covered under the medical assistance program for which the
resident would be eligible.
(5) Supplementation pursuant to this subsection shall not be required as a precondition
of admission, expedited admission, or continued stay in a facility.
(6) Supplementation shall not be applicable if the facility’s occupancy rate is less than
fifty percent.
(7) The nursing facility shall ensure that all appropriate care is provided to all residents
notwithstanding the applicability or availability of supplementation.
(8) Aprivateroomforwhichsupplementationisrequiredshallberetainedfortheresident
consistent with existing bed-hold policies.
c. (1) A nursing facility that utilizes the supplementation option and receives
supplementation under this subsection during any calendar year shall report to the
department annually, by January 15, the following information for the preceding calendar
year:
(a) The total number of nursing facility beds available at the nursing facility, the number
of such beds available in private rooms, and the number of such beds available in other types
of rooms.
(b) The average occupancy rate of the facility on a monthly basis.
(c) The total number of residents for which supplementation was utilized.
(d) The average private pay charge for a private room in the nursing facility.
(e) For each resident for whom supplementation was utilized, the total charge to the
resident for the private room, the portion of the total charge reimbursed under the Medicaid
program, and the total charge reimbursed through supplementation.
(2) The department shall compile the information received and shall submit the
compilation to the general assembly, annually by May 1.
11. Shall provide an opportunity for a fair hearing before the department of inspections,
appeals, and licensing to an individual whose claim for medical assistance under this chapter
is denied or is not acted upon with reasonable promptness. Upon completion of a hearing,
thedepartmentofinspections, appeals, andlicensingshallissueadecisionwhichissubjectto
review by the department. Judicial review of the decisions of the department may be sought
in accordance with chapter 17A. If a petition for judicial review is filed, the department shall
furnish the petitioner with a copy of the application and all supporting papers, a transcript of
the testimony taken at the hearing, if any, and a copy of its decision.
12. In determining the medical assistance eligibility of a pregnant woman, infant, or child
under the federal Social Security Act, §1902(l), resources which are used as tools of the trade
shall not be considered.
13. In implementing subsection 9, relating to reimbursement for medical and health
services under this chapter, when a selected out-of-state acute care hospital facility is
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involved, a contractual arrangement may be developed with the out-of-state facility that is
in accordance with the requirements of Tit. XVIII and XIX of the federal Social Security Act.
The contractual arrangement is not subject to other reimbursement standards, policies, and
rate setting procedures required under this chapter.
14. A medical assistance copayment shall only be applied to those services and products
specified in administrative rules of the department in effect on February 1, 1991, which under
federal medical assistance requirements, are provided at the option of the state.

Legislative History

[C62, 66, §249A.5, 249A.10; C71, 73, 75, 77, 79, 81, §249A.4; 82 Acts, ch 1260, §121, 122]