1. Spring 2019 Q & A Your Questions Answered Gayla Harken, IACP Outreach Director

2. What we’ll cover IME Related Questions
MCO Information (including ITC updates)
State and Federal Rule Updates
Informational Letters
General Information as Requested by Providers….

3. General

4. What’s the best way to ask a TA question?
We have a new form to use!
UJLyBJ3yrHTlreow/viewform
Look for the link on the IACP homepage

5. Is IME moving? Yes! The move should be completed April 5th.
New Address:
Iowa Medicaid Enterprise
611 5th Avenue
Des Moines, IA 50309

6. How does IME tell us about changes made to the Provider agreement?
5.10 Amendment. The Department may amend this Agreement from time to time by posting an updated version on the Provider Services website at: and providing notice of the amended Agreement to the Provider by issuing a bulletin/informational letter. effective upon receipt of such notice.
The Provider shall be deemed to have accepted the amendment, unless the Provider notifies the Department of its non-acceptance of the new provisions of the Agreement within 30 days of the notice. Such notice of non-acceptance of the amendment shall constitute notice of termination of this Agreement

7. Final Rule: Heightened Scrutiny update
March 22, 2019
CMS is issuing this guidance in keeping with a letter from CMS Administrator Seema Verma to the nation’s Governors on March 14, 2017, indicating the intention to provide additional flexibility to states and to streamline implementation efforts associated with the home and community-based settings regulation.
Review the FAQ including the presumed not in compliance access to HCBS services in compliant settings

8. Q: Has medication manager training changed?
April 30 meeting scheduled.
To date, we know there have been proposed changes that have
Not been adopted by DIA. The standards have not
been changed at this time.

9. DOL Changes…..
DOL Overtime Rule Comment Period Open Through May 21,   On Thursday, March 7, The Department of Labor released its Notice of Proposed Rule Making (NPRM) for the Overtime Rule, which proposes to increase the salary threshold from the current $455 per week ($23,660 per year) to $679 per week ($35,308 per year).  The comment period for these rules is open through May 21,   Click here to access comment instructions and to read more about the proposed rule.

10. New Tiered ID SCL Daily rates?
FFS_New_Tiered_Rates_Reminder.pdf?
Went into effect March 15, 2019
Mid month was to meet 30 day notice requirement

11. Is there a standardized way to do the Off-Year SIS Assessments?
According to IME, there is no standardized approach to how off-years are done. Either way is acceptable as long as the appropriate information is being collected for consideration.
It is the responsibility of the case manager or community-based case manager to assure the assessment is initiated as required to complete the CSR.

12. Are we going to have to bill electronically?
on/ViewDocument.aspx?viewdocument=203a00 e0-3c14-4afc-98f1-f4988e0fb573
Yes, although a future date has not yet been determined. This is a heads up. CDAC will still be paper at this time.

13. Can Subacute and Crisis Stabilization Residential Services be done in an IMD?
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These services cannot be done in larger than 16 beds that specifically serve persons who have MI diagnosis
edicaid IMD exclusion
The Medicaid IMD exclusion prohibits the state from claiming Medicaid federal financial participation (FFP) for the cost of treating Medicaid beneficiaries 21 through 64 years of age in institutions that are IMDs.  
An IMD is a hospital, nursing facility, or other institution with more than 16 beds, that is primarily (i.e., more that 50 percent of the facility’s patients) engaged in providing diagnosis, treatment, or care of persons with mental diseases, including substance treatment, medical attention, nursing care and related services. The Federal exclusion on medical assistance for residents of Institutions for Mental Disease, Title 42, CFR, § , Institutionalized individuals. 

14. This should not be happening!
Please explain how some providers can implement blanket rights restrictions like no drinking, bed time, visitors, etc.
This should not be happening!
Rights Restrictions are specific to an individual
Agreed upon by the team
Have a plan to restore right
Reviewed at least quarterly
When we look at rights restrictions we consider them to be anything that limits the members that any other person would have the right to.

15. Right’s Restriction new rules….
There was a change in rule that went into effect August 8, 2018 that required all HCBS waivers to match the requirement that has been in Habilitation to review existing rights restrictions at least quarterly.
The rights restriction requirements are in the HCBS rules that were adopted effective 07/04/2018. This language was adopted for all HCBS Waivers and HCBS Habilitation in Chapter 78 at (4) “c”, 78.34(14) “c”, 78.37(19)“c”, 78.38(10)“c”, 78.41(16)“c”, 78.43(16)“c”, 78.46(7)“c, 78.52(1)“c” and all of those rules reference back to the Hab rules in Chapter 77 at 77.25(4) for restraint, restriction, and behavioral intervention.

16. Right’s Restrictions
The case manager has to have all the rights restrictions in their plan, but the provider also must have those rights restrictions that apply to their environment.
Ie—person has a no contact order with a someone would need to be in both case manager plan and the provider plan. The provider, however, only needs to have the restrictions in their plan that pertain to the the member that would come up in their scope of work. Something pertaining to bathing, for instance, should not be in the employment provider’s plan.

17. Right’s Restrictions
Quarterly Reviews: There are no set rules as to how to do this, but you must do this!
You must document that your team has reviewed the RR quarterly and determined if it still is applicable and necessary.
If behavioral then progress, lack of progress, etc. should be documented and the determination to keep or change the RR should be supported by how effective the intervention has been.

18. Right’s Restrictions
Some restrictions will be on going (ie, due to physical limitation, the member must have assistance toileting) and a note that physical health has not changed would work, but you still need to review it

19. MCOs are wanting reports for things as Major Incidents that we don’t think qualify. What is a Major Incident?
Here is where you find the definitions for all the HCBS services:
Habilitation Services (1)
Health & Disability (HD) Waiver (18)
Elderly Waiver (22)
AIDS/HIV Waiver (14)
Intellectual Disability (ID) Waiver (8)
Brain Injury (BI) Waiver (6)
Physical Disability Waiver (12)
Children’s Mental Health (CMH) Waiver (1)

20. Incident Reports: What is a major report?
An occurrence involving a member enrolled in waiver (or Habilitation) services:
1. Results in a physical injury to or by the consumer that requires a physician’s treatment or admission to a hospital;
2. Results in the death of the member;
3. Requires emergency mental health treatment for the member;
4. Requires the intervention of law enforcement;

21. Incident Reports: What is a major report?
77.25(1) con’t:
5. Results in a report of child abuse pursuant to Iowa Code section or a report of dependent adult abuse pursuant to Iowa Code section 235B.3;
6. Constitutes a prescription medication error or a pattern of medication errors that leads to the outcome in paragraph “1,” “2,” or “3”; or “5”
7. Involves a member’s location being unknown by provider staff who are assigned protective oversight. (This is when services or supervision by staff is to be provided or is scheduled)

22. Do you have to notify a guardian of major/minor incidents?
Yes (8) Incident management and reporting.
c. Reporting procedure for major incidents. When a major incident occurs or a staff member becomes aware of a major incident:
(1) The staff member involved shall notify the following persons of the incident by the end of the next calendar day after the incident:
1. The staff consumer’s supervisor.

23. Do you have to notify a guardian of major/minor incidents?
2. The consumer or the consumer’s legal guardian. EXCEPTION: Notification to the consumer is required only if the incident took place outside of the provider’s service provision. Notification to the guardian, if any, is always required.
3. The consumer’s case manager.

24. Do you have to have Individual Releases of Information or can you use a multi entity release?
Shannon Miller from HCBS says:
A provider is not required to keep individual ROIs on file for members, although as best practice many providers just automatically do and update these annually. Providers are however required to have a process for notification of privacy practices and to utilize an authorization for release of information should the situation arise where one is needed. Provider policy and privacy practices should align with CFR 45 §
Thank you,
Shannon Miller

25. Are checklists allowed in documentation? How should they be used?
Checklists may be used in addition to service note documentation it does not replace it.
Checklists may be used to document the ongoing supports provided during the course of service provision. i.e. personal care supports, range of motion, routine daily tasks
Checklists are to be used as evidence of the interaction with the member, not as the documentation itself. It is supporting.

26. With everything changing, how do we know our documentation is up to par?
Our best advice is to continue to follow 79.3 (2) a(3)
Document the specific procedure or treatments given that are approved in the person’s plan
Include date, time of service, and location
Document how the intervention went
Sign with your credentials (if any)

27. With everything changing, how do we know our documentation is up to par?
and…..
5. Be sure to document in a way that substantiates the time you have billed.
One interaction for a person in day hab for 8 hours is not enough. An hour to pass medications when you just document, gave meds, does not match the time.

28. UHC says we need to show progress on goals
UHC says we need to show progress on goals. How often are they expecting to see goals run in a daily site? A lot of the time, we only have time for Supports and there's no way to work on a goal each shift of the day at a daily site (house).
(answer on next slide)
(Answer next slide)

29. Answer to previous question:
UHC is stating everything need to be tied to a goal: They are stating this and this helps to prove the medical necessity of the services.
This should allow for goals to be worked on every shift as some goals are more supportive in nature, for example: Goal: I want to be safe in my home. Barrier: Due to Gayla's intellectual disability she is unable to understand basic safety concepts, such when it is cold out - you need to wear a jacket or how to adjust water temperature while bathing. Your goals should answer the question - Why is this service necessary?
See April 2019 and TA training regarding service planning and documentation

30. Can we provide only Supports during an SCL hourly service?
Yes you can. These should be tied to a support type goal that identifies why the service is necessary. They need to be specifically identified in the person's service plan and based on an identified need.
For instance if you have a person who you routinely support in going out for a meal after you have supported them in completing their grocery shopping, but their plan only specifies they need support in grocery shopping, you would not be able to bill for the time you spent supporting them in going out for a meal. Especially if they routinely go out for meals without paid supports.

31. If we are responsible for administering medications, is it required that the med pass is documented in the notes? It will already be on the MAR.
Typically you would include at least a statement in the narrative documentation that you administered the person's medications - the details - dosage, route, etc would be on the MAR.

32. For SCL Daily services - Do we need to show a break in the time entries if the consumer is only out of site for a few minutes? ie: blood draw, a walk around the block, etc.
Yes you do need to record anytime the person is not in your service. In a daily service this could be put in the narrative: Karen left at 9:32 am to go for a walk and return at 9:45 am. or Karen left with her sister to get her blood drawn at 8:00 am and returned at 8:15 am.

33. If an agency has taken over another agency and have their member documents, can they destroy those documents after 5 IME or 7 MCO 7 years?
IME suggests keeping these records if you are still serving the member.

34. Yes, the entire time the person did the work is recoupable.
If a person needs to meet a training requirement within a certain amount of time and they fail to do so, but provide service anyway, is the whole time they did the work recoupable?
Yes, the entire time the person did the work is recoupable.
The time that is given to accomplish the training is not a “grace” period. It is intended to give the provider time to meet the guideline.

35. Are there rules that say if a person is in SCL daily, they cannot have home health services such as skilled nursing?
78.41 that pertain to this - they should be billable as long as they fall into these scopes and are authorized in the person's services plan:
78.41(5) Nursing services. Nursing services are individualized in- home medical services provided by licensed nurses. Services shall exceed the Medicaid state plan services and be included in the consumer’s individual comprehensive plan. a. A unit of service is one hour. b. A maximum of ten units are available per week.
We know there is discussion around this between the MCOs and IME. We will have to see where it lands, but this is what is in rule

36. Are there rules that say if a person is in SCL daily, they cannot have home health services such as skilled nursing? (Con’t)
78.41(6) Home health aide services. Home health aide services are personal or direct care services provided to the member which are not payable under Medicaid as set forth in rule 441—78.9(249A). Services shall include unskilled medical services and shall exceed those services provided under HCBS intellectual disability waiver supported community living. Instruction, supervision, support or assistance in personal hygiene, bathing, and daily living shall be provided under supported community living. a. Services shall be included in the member’s service plan. b. A unit is one hour. c. A maximum of 14 units are available per week
We know there is discussion around this between the MCOs and IME. We will have to see where it lands, but this is what is in rule

37. A guardian got married, do we have to have them fill out all new paperwork for the member’s file?
No, According to Gary Jones, you just need proof that the person is married and have that in the file to explain the name changes.

38. Cannabidiol--What are the rules?
From the Department of Inspections and Appeals:
- There is currently no provision in state law for a "facility caregiver". Only the patient and/or a designated caregiver would be able to pick up the medication from the dispensary.
- There are no rules/requirements regarding who could "administer" the cannabidiol as long as it was a patient or designated caregiver (no specific licensure or certification required, e.g., RN, CMA, etc.). However, since cannabidiol is a Schedule I drug, the applicable storage and handling requirements would apply. That is, only the resident and the designated caregiver would be able to store, access and administer the drug. Facility staff could not do so.
- Iowa law does NOT prohibit a physician from writing an order for medical cannabidiol, However, physicians may be unlikely to do so. Many physicians are reluctant to provide the certification required, let alone write an "order" for the use of cannabidiol.
- The use of medical cannabidiol in regulated entities would be extremely difficult to implement within the current law. Changes will possibly occur that will change the landscape in the future.
The Department has received many inquiries regarding the use of cannabidiol in regulated healthcare facilities. Department staff met with staff from the Iowa Department of Public Health (IDPH) and the Iowa Board of Pharmacy to gather information on some of the questions that we've received regarding the storage, handling, and administration of medical cannabidiol in health care facilities. Information received included:

39. Who has to pay for interpreters?
The cost of interpreters is a Medicaid covered expense. Work with your case manager/MCO to access the service

40. If a medicaid member dies and has no family, what happens to anything they have (estate)
The State generally is the beneficiary of a Medicaid recipient’s estate. This FAQ explains this:
Recovery_FAQ_FINAL_0.pdf?

41. How soon do CMs have to have a social history done on a member?
Legal reference: 441 IAC 90.5(1)“a”441—90.5(249A) Service provision.
90.5(1) Covered services. The following shall be included in the assistance that case managers provide to members in obtaining services:
a. Assessment. The case manager shall perform a comprehensive assessment and periodic reassessment of the member’s individual needs using Form , Comprehensive Assessment, to determine the need for any medical, social, educational, housing, transportation, vocational or other services.

42. How soon do CMs have to have a social history done on a
member? (con’t)
The comprehensive assessment shall address all of the member’s areas of need, strengths, preferences, and risk factors, considering the member’s physical and social environment. A face-to-face reassessment must be conducted at a minimum annually and more frequently if changes occur in the member’s condition. The assessment and reassessment activities include the following:
(1) Taking the member’s history, including current and past information and social history in accordance with 441—subrule 24.4(1), and updating the history annually

43. DirectCourse funding
IME will not be contracting with IACP starting July 1, 2019.
IACP has discounted funding for DC IACP members.
Non-members may purchase at the rack rate of $129 per learner

44. Employment Services

45. What are the rounding rules for SE?
Hourly services should be rounded as follows:
Add all the minutes provided for a day
• When the total minutes for the day is less than 60, round up to one (1) whole unit
• When the total minutes for the day is more than 60, divide the total by 60 to get the number of hours for the day. This should be rounded to the nearest whole unit, by rounding down for 1-30 minutes, and rounding up for minutes

46. What are the rounding rules for SE?
For the month...
The Tier is based on the average hours worked over the course of a calendar month. The member remains in Tier 3 (H2025 U5) for the entire month. If the average hours over the course of the month fall below the 9 hour threshold and that is the new “ average” for the person then the Tier would be changed to Tier 2 for the following month. The provider would bill for the Tier authorized for the current month and would then bill at the new Tier for the following month.

47. Can providers use Relias as part of the employment training requirement?
Yes! LeAnn Moskowitz says:
The Department will accept the RELIAS Continuing Education Platform courses for Community Employment to meet the 9.5 hours of employment service training and to meet the 4 hours of annual continuing education requirement for both Prevocational and Supported Employment services. The Department intends to promulgate rules to formalize the change ( ).

48. If a member has a job in the community and is placed on the abuse registry, do they have to tell their employer?
Our legal council says the employee has to follow their employer’s policies regarding self reporting.
If you are aware of a member having a restriction as to where they can work, you should discuss it with member and ensure they understand the restriction.

49. Can the VR webinars be used for meeting the continuing education for Job Coaches?
Yes, they can.
You can use any training as long as it directly relates to providing employment services.
In checking with IVRS and IME, it is up to the agency to determine if the training meets the requirements. It needs to directly relate to employment services.

50. Where can you access these trainings?
IVRS is hosting a series of informational webinars. IVRS partners are welcome to join by clicking on the zoom link below. We anticipate ongoing training as outlined:
(First Monday of the month at 10 am)
May- Specific Industry-Federal Resume
June-VIDEO RESUMES
July through December - TBD
In checking with IVRS and IME, it is up to the agency to determine if the training meets the requirements. It needs to directly relate to employment services.

51. Managed Care

52. UHC is leaving Iowa MCO Market
Effective June 30, 2019, United Health Care will no longer be providing managed Medicaid services in Iowa.
Transition planning is going on now

53. UHC FAQs relating to exit
plan-home/ia-cp-news.html
Transition planning is going on now

54. How will UHC unpaid claims be handled ?
United Healthcare will be required to fulfill its obligations under the contract with the state. UHC will be required to maintain claims processing functions as necessary for a minimum period of time in order to complete adjudication of all claims for services delivered prior to the effective date of the termination of the contract.
Informational Letters in the days to come.

55. Will there be a transition grace period for authorizations?
Per rules now:
90 days for ITC
30 days for Amerigroup
Director Randol mentioned trying to get dates to be aligned
Providers should follow the prior authorization requirements for the member’s new MCO.
AGP must honor authorizations for a minimum of 30 days
ITC must honor authorizations for a minimum of 90 days during year 1 of the contract..
There are other requirements for LTSS and Residential Services in the contracts

56. Q: Iowa Total Care info….?
LTSS contact at ITC:
ITC Provider Directory as of
ITC Billing Manual
MCO Contracts&Amendment Links

57. Who will ITC use as a clearinghouse
There are a variety of vendors that ITC is planning to work with.
Change Healthcare (Emdeon) is one of them.
Their payer ID is 68069

58. Q: Iowa Total Care info?
Contracting is still ongoing. Check provider manual to check status
FFS_MCO_Credentialing.pdf?

59. MCO Selection Process
An IL should be forthcoming if not currently available.
What we think we know:
Current AG members will stay with AG
UHC members will be auto assigned
Open Enrollment now and members can
change without cause for 90 days
Letters going out May 1
Remember, informing a member is not influencing a member!

60. Are the 120 units UHC gave to all UA/UB all they get for a year?
No.
120 units were given as a uniform amount to give time to meet and get the authorizations done as they were not previously required.
UHC has said, if more are needed, contact them prior to those expiring to arrange for what is required in the member’s plan

61. Do plans serve as the authorization?
The plan is only the authorization for Day Hab (hab or MI services) and Child Mental Health Respite. You need to have an actual authorization you get faxed or get it off the portal for all Hab H2016 codes.

62. Upcoming trainings
Mark your calendar!

63. Annual Provider Training
FFS_Annual_Provider_Training_2019.pdf?

64. Documentation for Direct Care Professionals!
Webinar 1 pm June 20
Will be recorded and added to the 5 part series!

67. Copies should be shared with providers, you will want to request these if you do not have them.