ARC 6619C

ARC 6619C

HUMAN SERVICES DEPARTMENT[441]

Notice of Intended Action

Proposing rule making related to medical and remedial care

and providing an opportunity for public comment

The Human Services Department hereby proposes to amend Chapter 78, "Amount, Duration and Scope of Medical and Remedial Services," and Chapter 79, "Other Policies Relating to Providers of Medical and Remedial Care," Iowa Administrative Code.

Legal Authority for Rule Making

This rule making is proposed under the authority provided in Iowa Code chapter 249A.

State or Federal Law Implemented

This rule making implements, in whole or in part, Iowa Code chapter 249A and 2022 Iowa Acts, House Files 2546 and 2578.

Purpose and Summary

During the 2022 Legislative Session, 2022 Iowa Acts, House File 2546, which requires Iowa Medicaid to establish a rate for psychiatric intensive care in Iowa, was passed. 2022 Iowa Acts, House File 2578, which requires implementation of a tiered rate reimbursement methodology for psychiatric intensive patient care under the Medicaid program no later than January 1, 2023, was also passed.

This proposed rule making defines "acute psychiatric intensive care" and identifies how a patient meets the need for that level of care. This rule making also identifies the payment methodology for the acute psychiatric intensive care services.

Fiscal Impact

It is anticipated there will be a $1.5 million state cost in state fiscal year 2023 and a $3 million state cost in state fiscal year 2024 with the assumption that the implemented rate will be developed to align with the funding appropriated. The Legislature has not yet appropriated the full annualized cost.

Jobs Impact

The additional funding may be utilized for increased staffing ratios, but it is unlikely a significant number of jobs will be created.

Waivers

Any person who believes that the application of the discretionary provisions of this rule making would result in hardship or injustice to that person may petition the Department for a waiver of the discretionary provisions, if any, pursuant to rule 441—1.8(17A,217).

Public Comment

Any interested person may submit written comments concerning this proposed rule making. Written comments in response to this rule making must be received by the Department no later than 4:30 p.m.on November 22, 2022. Comments should be directed to:

Public Hearing

No public hearing is scheduled at this time. As provided in Iowa Code section 17A.4(1)"b," an oral presentation regarding this rule making may be demanded by 25 interested persons, a governmental subdivision, the Administrative Rules Review Committee, an agency, or an association having 25 or more members.

Review by Administrative Rules Review Committee

The Administrative Rules Review Committee, a bipartisan legislative committee which oversees rule making by executive branch agencies, may, on its own motion or on written request by any individual or group, review this rule making at its regular monthly meeting or at a special meeting. The Committee's meetings are open to the public, and interested persons may be heard as provided in Iowa Code section 17A.8(6).

The following rule-making actions are proposed:

Item 1. Adopt the following new subrule 78.3(8):

78.3(8) Payment will be made for medically necessary inpatient acute psychiatric intensive care services that meet the criteria in this subrule, pursuant to 441—paragraph 79.1(5)"i." This inpatient rate is only applicable to individuals 18 to 64 years of age. All inpatient acute psychiatric intensive care services shall require prior authorization.

a. "Acute psychiatric intensive care" is defined as care provided for a condition with rapid onset that is accompanied by severe symptoms and is generally of brief duration, requiring emergency treatment and critical care.

b. To meet the need for acute psychiatric intensive care, the patient must:

(1)Have a serious mental illness as defined in 441—subrule 77.47(1);

(2)Have a current, severe, imminent risk of serious harm to self or others; and

(3)Display additional complexity of need related to:

1.Complex comorbidities, including intellectual or developmental disability, autism spectrum disorder, substance use disorders, or traumatic brain injuries; or

2.A history of violence or current aggression that is secondary to mental illness; or

3.A request for patient transfer that has been rejected by inpatient level of care by one or more hospitals due to severity of symptoms; or

4.Lack of responsiveness to typical interventions or a condition that is treatment refractory; or

5.A highly disorganized psychotic state or a highly suicidal state; or

6.Behavior that causes disruption to the general milieu of the unit (i.e., instigating other patients in negative ways); or

7.High elopement risk; or

8.Any other atypical reason that the admitting psychiatrist feels that additional resources are needed to keep the patient and others around the patient safe.

c. The individual must have a documented need for acute intensive care requiring increased or specialized staffing, equipment, or facilities, based on two or more of the following:

(1)Fall risk,

(2)Restraints or seclusion room requirements,

(3)Requiring assistance with activities of daily living,

(4)Nursing care requirements,

(5)Patient status (alertness/orientation),

(6)Complexity of mental illness and comorbidities,

(7)Physical risk posed to staff, other patients, and infrastructure,

(8)Elopement risk.

Item 2. Amend paragraph 79.1(5)"i" as follows:

i. Payment for certified physical rehabilitation hospitals and units, and psychiatric units, and acute psychiatric intensive care services. Payment for services provided by a physical rehabilitation hospital or unit certified pursuant to paragraph 79.1(5)"r" and for services provided on or after October 1, 2006, in a psychiatric unit certified pursuant to paragraph 79.1(5)"r" is prospective. The payment is based on a per diem rate calculated for each hospital by establishing a base-year per diem rate to which an annual index is applied.

(1)Per diem calculation. The base rate shall be the medical assistance per diem rate as determined by the individual hospital's base-year cost report pursuant to paragraph 79.1(5)"a." No recognition will be given to the professional component of the hospital-based physicians except as noted under paragraph 79.1(5)"j."

(2)Reserved.

(3) (2)Per diem reimbursement. Hospitals shall be reimbursed the lower of actual charges or the medical assistance cost per diem rate. The determination of the applicable rate shall be based on the hospital fiscal year aggregate of actual charges and medical assistance cost per diem rate. If an overpayment exists, the hospital will refund or have the overpayment deducted from subsequent billings.

(4) (3)Per diem recalculation. Hospital prospective reimbursement rates shall be established as of October 1, 1987, for the remainder of the applicable hospital fiscal year. Beginning July 1, 1988, all updated rates shall be established based on the state's fiscal year.

(4)Acute psychiatric intensive care services. Services that meet the criteria at 441—subrule 78.3(8) shall be reimbursed as follows:

1.Services provided in a psychiatric unit certified pursuant to paragraph 79.1(5)"r" will be paid based on the hospital-specific per diem rate as calculated pursuant to subparagraph 79.1(5)"i"(1) plus a percentage increase as determined by the department for covered days billed with the appropriate psychiatric intensive care revenue code.

2.Services not provided in a psychiatric unit certified pursuant to paragraph 79.1(5)"r" will be paid based on the hospital-specific DRG payment rate as calculated pursuant to paragraph 79.1(5)"b" plus an add-on per diem rate as determined by the department for covered days billed with the appropriate psychiatric intensive care revenue code.

(5)Per diem billing. The current method for submitting billing and cost reports shall be maintained. All cost reports will be subject to desk review audit and, if necessary, a field audit.