ARC 9016C

ARC 9016C

Proposing rulemaking related to behavioral health service system
and providing an opportunity for public comment

The new behavioral health service system will support equitable statewide access to all services offered through the behavioral health service system and offer specialized services with a focus on at-risk populations, including but not limited to children, youth, young adults, individuals with disabilities, pregnant and parenting women, older adults, and people with limited access to financial resources.

Citations in the proposed rules to Iowa Code chapter 225A and sections therein are to that chapter as enacted by 2024 Iowa Acts, House File 2673, effective July 1, 2025.

A Regulatory Analysis for this rulemaking was published in the Iowa Administrative Bulletin on February 5, 2025. A public hearing was held on the following date(s):

●February 25, 2025

Any persons who intend to attend a public hearing and have special requirements, such as those related to hearing or mobility impairments, should contact the Department and advise of specific needs.

ITEM 1.Rescind and reserve 441—Chapter 25.

ITEM 2.Rescind and reserve 441—Chapter 34.

ITEM 3.Adopt the following new Title XVIII to precede 441—Chapter 300:

TITLE XVIII

BEHAVIORAL HEALTH SERVICES

ITEM 4.Adopt the following new441—Chapter 300:

CHAPTER 300

DEFINITIONS

441—300.1(225A) Definitions.

“Access funds” means funding provided to a behavioral health safety net provider by a behavioral health administrative services organization to support enhanced service delivery, maintain access to services, and fund other necessary expenses that fall outside of the scope and payment structures of other available funding. Access funds may include but are not limited to startup funding to establish or expand access to services; costs associated with maintaining access to services; data and continuous quality improvement activities to identify, implement, and monitor critical performance measures; and workforce development to recruit, retain, and develop highly qualified staff to provide behavioral health services.

“Advocate” means advocate as defined in Iowa Code section 229.1.

“At-risk individuals” means individuals with access limits or functional needs (temporary or permanent) that indicate enhanced risk of development or exacerbation of a behavioral health condition or interfere with their ability to access care.

“At-risk populations” means groups of children, youth, young adults, adults, or older adults at higher risk of developing a behavioral health condition, including but not limited to individuals with disabilities, pregnant and parenting women, people with limited English proficiency, individuals with limited financial resources, people without access or means to access transportation, or individuals who lack a system of social support.

“Behavioral health” means mental health and addictive disorders and is inclusive of but not limited to mental illness, substance use, problem gambling, and tobacco and nicotine dependence.

“Behavioral health administrative services organization” or “BH-ASO” means the lead entities designated by the department to plan, develop, coordinate, and ensure behavioral health services throughout a district in accordance with the statewide behavioral health service system plan.

“Behavioral health care” means an integrated, recovery-oriented approach to care that acknowledges co-occurring conditions are the expectation, not the exception, and contemplates the full continuum of behavioral health prevention, education, early intervention, assessment, diagnosis, treatment, recovery, and crisis services and supports.

“Behavioral health condition” means the same as defined in Iowa Code section 225A.1.

“Behavioral health safety net service providers” or “safety net providers” means agencies that are primarily publicly funded; provide behavioral health services and supports with a focus onuninsured and underinsured individuals, at-risk populations and individuals, or special or targeted populations; coordinate care for individuals served; and meet minimum access standards.Behavioral health safety net service providers may receive access funds, training, tools, and technical assistance to provide a level of accessibility beyond that of other behavioral health providers.

“Behavioral health services” means services under any of the following domains on the behavioral health service continuum: prevention, early intervention, treatment, recovery, crisis services, and recovery supports.

“Behavioral health service system” means the same as defined in Iowa Code section 225A.1.

“Conflict of interest” means any activity that interferes or gives the appearance of interference with the exercise of professional discretion and impartial judgment.

“County of residence” means the same as defined in Iowa Code section331.190.

“County of venue” means the county in which the Iowa Code chapter 229 commitment was filed pursuant to Iowa Code section 229.44.

“County where the individual is located” means the individual’s county of residence as defined in Iowa Code section 331.190 or, if the individual has been ordered to receive treatment services under an Iowa Code chapter 229 commitment and is placed in a residential or other treatment facility, the county in which the residential or other treatment facility is located.

“Crisis navigation” means activities to ensure that an individual in crisis is able to access appropriate crisis services in a timely manner and to transition an individual from crisis services to postcrisis care. This includes but is not limited to bed finding, coordination of transportation, system navigation, coordination of warm handoffs, and securing placements appropriate to meet individual needs.

“Crisis services” means services that focus on the immediate de-escalation and relief of the distress associated with a behavioral health crisis, reduce the risk that an individual in a crisis harms themselves or others, and provide aftercare and connection to ongoing follow-up to ensure postcrisis stabilization and reduce the reliance on high-acuity care or more restrictive environments.

“District” means a substate geographic area determined by the department to define the geographic boundaries of the behavioral health service system.

“District behavioral health service system plan” or “district plan” means a plan developed by the district BH-ASO and approved by the departmentto ensure access to behavioral health care and behavioral health services throughout a district.

“District contract” means a contract between the department and a BH-ASO. These contracts shall meet all applicable requirements of state and federal law.

“Early intervention” means intervention, service, or support provided to at-risk individuals to ameliorate or relieve early presenting symptoms prior to the development of a behavioral health condition or disorder.

“Education” means disseminating behavioral health knowledge or building resiliency skills through structured learning processes, including support of critical life and social skills such as decision-making, peer resistance and refusal, coping with stress, problem-solving, interpersonal communication, and improving judgment capabilities.

“Indicated prevention” means the same as defined in Iowa Code section 225A.1.

“Judicial district” means the same as described in Iowa Code section 602.6107.

“Minimum access standards” means standards to ensure equitable access to behavioral health services provided through the behavioral health service system, including but not limited to when and where services are made available, service and funding eligibility criteria, and behavioral health safety net service provider requirements.

“Prevention” means information dissemination; prevention education; alternative activities; wellness promotion; organizing, planning, and enhancing community-based processes; developing environmental approaches; and problem identification and referral designed to prevent the onset, reduce the impact, and mitigate the effects of a behavioral health condition.

“Primary substance use prevention” or “universal prevention” means activities designed to address the total population for the purpose of preventing exposures to hazards that cause disease or injury; altering unhealthy or unsafe behaviors that can lead to disease, disorder, or injury; and increasing resistance to disease, disorder, or injury should exposure occur.

“Provider contract” means a contract between a BH-ASO and a provider of behavioral health services. These contracts shall meet all applicable requirements of state and federal law.

“Recovery supports” means nonclinical assistance that facilitates recovery, wellness, and connection between individuals in recovery, service providers, and other supports known to enhance people’s quality of life, including system navigation, peer recovery coaching, and peer support.

“Selective prevention” means the same as defined in Iowa Code section 225A.1.

“Special populations,” for the purposes of the substance use prevention, treatment, and recovery services block grant (SUPTRS BG), means pregnant women, women with dependent children, individuals who use drugs through intravenous injection, and individuals who use substances and have tuberculosis.

“State behavioral health service system plan” or “state behavioral health plan” means the same as defined in Iowa Code section 225A.1.

“System navigation” means in-person, online, and telephonic support for problem-solving and navigation of the services and supports available. System navigators ensure individuals and families who encounter barriers in accessing services and support are able to navigate health care, social services, and legal systems.

“Treatment” means clinical inpatient, outpatient, and residential care for individuals with a behavioral health condition or disorder diagnosed utilizing the criteria provided in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association (APA) (published 2013, with all changes and updates approved by the APA through July 1, 2025, incorporated herein). The type, length, and intensity/frequency of interventions used by a behavioral health provider are based on the presenting symptoms of the individual.

“Underinsured” means an individual who has insurance coverage, but coverage limitations render reimbursement for behavioral health services ordered by a behavioral health service provider unavailable. Underinsured does not mean insurance coverage that has denied authorization of a service, denied payment of a covered service, or recouped a claim paid.

“Uninsured” means an individual who does not have insurance or whose insurance coverage is terminated for short periods of time.

This rule is intended to implement Iowa Code chapters 225A and 229.

ITEM 5.Adopt the following new441—Chapter 301:

CHAPTER 301

BEHAVIORAL HEALTH SERVICE SYSTEM ELIGIBILITY AND SERVICES

441—301.1(225A) Individual eligibilityfor behavioral health service system funding. To be eligible for behavioral health service system funding, an individual must meet the following financial and needs-based eligibility criteria.

301.1(1) Financial eligibility. Income requirements for adults and household income for children are as follows:

a.Income equal to or less than 200 percent of the federal poverty level.

b.Income will be verified using the best information available.

c.Financial eligibility will be reviewed on an annual basis and may be reviewed more often in response to increases or decreases in income.

d.An individual who is eligible for medical assistance must apply for and exhaust such funding for services and supports prior to utilization of behavioral health service system funding.

301.1(2) Resource requirements. Individuals seeking behavioral services must have resources that are equal to or less than $2,000 in countable value for a single-person household or $3,000 in countable value for a multiperson household.

a.The countable value of all countable resources, both liquid and nonliquid, will be included in the eligibility determination, except as exempted in this subrule.

b.A transfer of property or other assets within five years of the time of application with the result of, or intent to, qualify for assistance may result in denial or discontinuation of funding.

c.The following resources will be exempt:

(1)A homestead, including equity in a family home or farm that is used as the individual household’s principal place of residence. The homestead will include all land that is contiguous to the home and the buildings located on the land.

(2)One automobile used for transportation.

(3)Tools of an actively pursued trade.

(4)General household furnishings and personal items.

(5)Burial account or trust limited in value as to that allowed in the medical assistance program.

(6)Cash surrender value of life insurance with a face value of less than $1,500 on any one person.

(7)Any resource determined excludable by the Social Security Administration as a result of an approved Social Security Administration work incentive.

d.If an individual does not qualify for federally funded or state-funded services or other support but meets all income, resource, and functional eligibility requirements of this chapter, the following types of resources will additionally be considered exempt from consideration in eligibility determination:

(1)A retirement account that is in the accumulation stage.

(2)A medical savings account.

(3)An assistive technology account.

(4)A burial account or trust limited in value as to that allowed in the medical assistance program.

301.1(3) Needs-based eligibility. An individual must:

a.Be a resident of Iowa or, if a minor, the custodial parent or legal guardian is a resident of Iowa.

b.At any time during the preceding 12-month period have hada behavioral health condition.

301.1(4) Service-specific eligibility. Individuals meeting financial and needs-based eligibility requirements may be subject to additional diagnostic, level of care, or admission requirements for services. Individuals receiving:

a.Twenty-three-hour observation and holding services must meet admission criteria set forth in 441—subrule 24.37(1).

b.Crisis stabilization community-based services must meet service eligibility requirements set forth in 441—subrule 24.38(1).

c.Crisis stabilization residential services must meet service eligibility requirements set forth in 441—subrule 24.39(1).

d.Substance usedisorder treatment services must meet the following levels of the third edition of the American Society of Addiction Medicine (ASAM) Criteria as published by the ASAM and as amended to July 1, 2025:

(1)Level 1.0 for outpatient treatment services.

(2)Level 2.1 for intensive outpatient treatment services.

(3)Level 2.5 for partial hospitalization services.

(4)Level 3.1 for clinically managed, low-intensity residential services.

(5)Level 3.3 for clinically managed, medium-intensity residential services.

(6)Level 3.5 for clinically managed, high-intensity residential services.

(7)Level 3.7 for medically monitored inpatient services.

e.Assertive community treatment (ACT)services must meet service eligibility requirements set forth in 441—subrule 78.45(1).

f.Subacute services must meet admission requirements set forth in 481—subrule 71.13(2).

g.Outpatient competency restoration must have a court order to receive the service pursuant to Iowa Code section 812.6.

h.Psychiatric medical institutions for children (PMIC) services must meet certification of need requirements set forth in rule 481—41.9(135H).

301.1(5) Exceptions. Receipt of the following behavioral health services is as defined and is not subject to individual eligibility criteria in subrule 301.1(1), 301.1(2), or 301.1(3):

a.Prevention.

b.Early intervention services.

c.Crisis services.

d.Outpatient competency restoration.

e.Jail-based behavioral health services.

f.System navigation.

441—301.2(225A) The behavioral health care continuum.

301.2(1) Behavioral health services. Behavioral health services overseen by a BH-ASO will include ensuring access to the full continuum of behavioral health care, including:

a.Prevention services, including indicated prevention, primary substance use prevention and universal prevention, and selective prevention.

b.Early identification.

c.Early intervention services.

d.Crisis services, including immediate access to crisis assessment and evaluation; access centers; sobering centers;mobile crisis response; crisis-stabilization, community-based services; and crisis-stabilization, residential services.

e.Mental health outpatient treatment services, including screening, assessment, diagnosis, risk assessment, and crisis planning.

f.Mental health, high-intensity outpatienttreatment services, including ACT, intensive outpatient programs (IOP), intensive psychiatric rehabilitation (IPR), partial hospitalization, and day treatment.

g.PMIC.

h.Mental health inpatient treatment.

i.Hospital alternatives, including subacute services, 23-hour observation and holding, and crisis respite services.

j.Substance usedisorderoutpatient treatment services, including assessment and evaluationservices.

k.Substance usedisorder intensive outpatient treatment services.

l.Substance usedisorder partial hospitalization services.

m.Substance use disorder clinically managed residential treatment services.

n.Substance usedisorder medically monitored inpatient services.

o.Recovery supports.

p.Peer support and peer recovery coaching.

q.Peer wellness and recovery community centers.

r.Transitional living and recovery housing programs.

s.Jail-based behavioral health services, including provision of behavioral health treatment and medications in jails.

t.Commitment-related services, including prescreening, secure transportation, legal representation, and mental health advocates.

u.Outpatient competency restoration.

v.Outreach, education, and engagement services.

w.Additional services deemed necessaryfor a district or statewide as determined by the district behavioral health service system plan and approved by the department.

301.2(2) Additional requirements. Additional requirements related to behavioral health services include crisis system navigation that must be available 24 hours per day, 7 days per week, 365 days per year.

301.2(3) Option for waiting lists. The department will maintain a waiting list of individuals denied access to the program due to lack of available funds.Waiting list information will include the date on which the individual was placed on the waiting list. If additional funds become available, the department will contact individuals on the list.

441—301.3(225A) Provider qualifications.

301.3(1) Behavioral health safety net service providers. Behavioral health safety net service providers, which are defined in rule 441—300.1(225A), are required to:

a.Adhere to minimum access standards as set forth in 441—subrule 302.2(1).

b.Accept behavioral health service system funds aspayment in full for individuals served through behavioral health service systemfunding. The safety net provider may not bill individuals for missed appointments, or for copayments or other cost-sharing arrangements, except as described in individual eligibility standards in rule 441—301.1(225A).

c.Work with BH-ASOs to coordinate care for the individuals the safety net provider serves, including making referrals to secure services and supports appropriate for the individual, coordinating warm handoffs to ensure continuity of care, coordinating transportation, and performing post-discharge follow-up.

d.Notify the BH-ASO within seven days when a safety net provider is at or above 90 percent capacity to admit individuals in need of behavioral health services.

301.3(2) Behavioral health service system provider eligibility. The following persons or organizations are eligible to participate as behavioral health service system providers to the extent allowed under the scope of their licensure, certification, or accreditation:

a.Hospitals providing inpatient psychiatric treatmentor emergency department services licensed pursuant to Iowa Code chapter 135B.

b.Providers of outpatient mental health services licensed to practice in the state of Iowa or accredited under 441—Chapter 24.

c.Providers of crisis services accredited under 441—Chapter 24.

d.Community mental health centers (CMHCs) accredited under 441—Chapter 24.

e.Certified community behavioral health clinics (CCBHCs) certified by the department.

f.Federally qualified health centers (FQHCs) certified by the Centers for Medicare and Medicaid Services (CMS).

g.Providers of substance use disorder treatment programs and problem gambling treatment programs licensed pursuant to 641—Chapter 155.

h.Local tobacco control programs designated by the department.

i.Recovery community centers (RCCs) designated by the department.

j.Providers of recovery support services (RSSs) designated by the department.

k.Subacute mental health facilities licensed pursuant to 481—Chapter 71.

l.PMICs licensed pursuant to 481—Chapter 41.

m.Providers of prevention services designated by the department.

n.Providers of early intervention services designated by the department.

o.Recovery and peer support providers trained or certified through approved programs designated by the department.

441—301.4(225A) Appeal rights. The department will issue a notice of adverse action in accordance with 441—Chapter 16. The right to appeal will be given by the department in accordance with 441—Chapter 7.

These rules are intended to implement Iowa Code chapter 225A.

ITEM 6.Adopt the following new441—Chapter 302:

CHAPTER 302

BEHAVIORAL HEALTH ADMINISTRATIVE SERVICE ORGANIZATIONS

441—302.1(225A) Implementation and maintenance of programs and services.

302.1(1) Authority to designate BH-ASOs. The department will designate one BH-ASO for each district as set forth in Iowa Code chapter 225A. The department will enter into a contract with a designated BH-ASO to coordinate and oversee behavioral health services in one or more behavioral health district. If the department terminates its contract with a BH-ASO for any reason, the entity is no longer designated by the department as a BH-ASO.

302.1(2) Community needs assessment. A BH-ASO will complete an assessment of community needs to identify behavioral health service system strengths, gaps, and emerging issues within its district.

302.1(3) District behavioral health service system plan. A BH-ASO will collaborate with the district behavioral health advisory council and other stakeholders to develop a district behavioral health service system plan to describe all behavioral health services and supports and other activities in support of the behavioral health system to be delivered by the BH-ASO.

302.1(4) BH-ASO operations. A BH-ASO will implement its approved district plan and maintain operations necessary to meet its obligations under state and federal laws and regulations and as established in the district contract.

441—302.2(225A) Service availability and accessibility.

302.2(1) Minimum access standards. A BH-ASO will ensure available, accessible, and adequate numbers of providers, locations, and personnel for the provision of behavioral health services. At a minimum, access to services provided by behavioral health safety net service providers will meet the following standards:

a.Crisis assessment and evaluation. An individual will have immediate access to a crisis screening and will have a crisis assessment by an appropriately licensed or credentialed mental healthor substance use disorder treatment professional within 24 hours of referral.

b.Access centers. An individual will have access to services within 60 minutes or 60 miles of an individual’s residence.

c.Mobile crisis response. An individual will have an in-person, community-based response within 60 minutes.

d.Crisis-stabilization, community-based services. An individual will have access to services within the time frames set forth in 441—Chapter 24.

e.Crisis-stabilization, residential services. An individual will have access to services within the time frames set forth in 441—Chapter 24.

f.Mental health outpatient.

(1)The service will be locatedwithin 60 minutes or 60 miles of an individual’s residence.

(2)During an emergency, outpatient services shall be initiated to an individual within 15 minutes of telephone contact. When the assessed need is urgent, outpatient services shall be provided to an individual within one hour of presentation or 24 hours of telephone contact. When the assessed need is for routine care, outpatient services shall be provided to an individual within four weeks of the individual’s request for appointment.

g.Assertive community treatment. The service will be available to all individuals within a district.

h.Mental health intensive psychiatric rehabilitation. An individual will have access to services within the time frames set forth in 441—Chapter 24.

i.Mental health inpatient. The service will be located within 60 minutes or 60 miles of an individual’s residence in urban areas and within 90 minutes or 90 miles of an individual’s residence in rural areas.

j.Substance use disorder outpatient treatment. An individual will have access to services within 60 minutes or 60 miles of the individual’s residence.

k.Substance use disorder intensive outpatient services. An individual will have access to services within 60 minutes or 60 miles of an individual’s residence.

l.Substance use disorder residential treatment services. An individual will have access to services within 60 minutes or 60 miles of an individual’s residence.

m.Substance use disorder inpatient services. The service will be located within 60 minutes or 60 miles of an individual’s residence in urban areas and within 90 minutes or 90 miles of an individual’s residence in rural areas.

n.Outpatient competency restoration. The service will be available to all individuals within a district.

o.Twenty-three-hour observation and holding. An individual will have access to services within the time frames set forth in 441—Chapter 24.

p.Crisis respite. An individual will have access to services within the time frames set forth in 441—Chapter 24.

302.2(2) Priority populations for substance use disorder treatment. In addition to the standards in subrule 302.2(1), behavioral health safety net service providers of substance use disorder treatment will meet the following standards:

a.In accordance with 45 CFR Part 96, Subpart L, as amended to July 1, 2025, priority admission to substance use disorder treatment services must be offered to the following populations in this order:

(1)Individuals who are pregnant and who use injection drugs.

(2)Individuals who are pregnant.

(3)Individuals who use injection drugs.

(4)All others.

b.Individuals who are pregnant must be admitted to the recommended American Society of Addiction Medicine (ASAM) level of care within 48 hours of receiving the recommendation for treatment from a licensed substance use disorder treatment provider. If admission is not possible within 48 hours, the individual must be offered interim services as defined in 45 CFR 96.121 as amended to July 1, 2025, and must be referred to the statewide waitlist maintained by the department.

c.Individuals who report the use of injection drugs and are not pregnant must be admitted to the recommended ASAM level of care within 14 days of receiving the recommendation for treatment from a licensed substance use disorder treatment provider. If admission is not possible within 14 days, interim services must be offered within 48 hours and the admission deadline is then extended to 120 days.

302.2(3) Free choice of providers. A BH-ASO will ensure that individuals may receive services from any qualified network provider of the individual’s choosing that is available to provide the services to them.

441—302.3(225A) Provider oversight and monitoring.

302.3(1) Provider contracts. To receive payment for services through a BH-ASO, providers of behavioral health services must have a provider contract with the BH-ASO. Providers that are eligible to enroll with the Iowa Medicaid program must also be enrolled as an Iowa Medicaid provider.

302.3(2) Claim submission. Providers of behavioral health services will submit claims forservices on at least a monthly basis.

a.Claims for services rendered for persons eligible for Medicaid will be submitted to the managed care organization with which the person is enrolled in accordance with the managed care organization’s claim submission policies.

b.Claims for services rendered for persons not eligible for Medicaid will be submitted to the Iowa Medicaid program according to the process set by the department for BH-ASO claims and will meet the following requirements:

(1)Claims will be submitted electronically on the proper claim forms following the requirements set forth in rule 441—80.2(249A).

(2)Claims will follow the time limits for claim submission set forth in rule 441—80.4(249A).

302.3(3) Provider monitoring. A BH-ASO will conduct monitoring activities to oversee providersof behavioral health services within the district and monitor the Iowa Medicaid provider sanction list and take the following actions:

a.For any behavioral health provider suspended by Medicaid, suspend participation in the BH-ASO provider network within 30 days.

b.For any behavioral health provider terminated by Medicaid, terminate participation in the BH-ASO provider network within 30 days.

These rules are intended to implement Iowa Code chapter 225A.

ITEM 7.Adopt the following new441—Chapter 304:

CHAPTER 304

DISTRICT BEHAVIORAL HEALTH ADVISORY COUNCILS

441—304.1(225A) Definitions. For the purpose of this chapter, the following definitions apply:

“Chairperson” means the chairperson of the district behavioral health advisory council who has been elected by a majority of advisory council members.

“District behavioral health advisory council” or “advisory council” means the same as defined in Iowa Code section 225A.1.

441—304.2(225A) Appointment.

304.2(1) The members of the advisory council will be appointed by the BH-ASO in accordance with the parameters of Iowa Code section 225A.5.

304.2(2) The appointments will be for three-year staggered terms that expire on June 30.

304.2(3) Vacancies will be filled in accordance with requirements established in the district contract. Members appointed to fill a vacancy will serve for the balance of the unexpired term.

304.2(4) Absences.

a.Three unexcused absences in a 12-month period constitutes grounds for the BH-ASO to request nomination of an alternate representative to fill the position.

b.Absences may be excused by notification provided to the chairperson prior to the meeting.

c.The chairperson of the advisory council is charged with providing notification of absences to the BH-ASO.

441—304.3(225A) Officers.

304.3(1) Officers of the advisory councilwill consist of a chairperson and a vice chairperson, who will be elected at the first meeting of each fiscal year.

a.An officer may serve no more than three consecutive terms as chairperson or vice chairperson.

b.A vacancy in the office of chairperson will be filled by elevation of the vice chairperson.

c.A vacancy in the office of vice chairperson will be filled by election at the next meeting after the vacancy occurs.

d.A vacancy must be filled by an individual meeting the same qualifications as the departing advisory council member in accordance with Iowa Code section 225A.5.

304.3(2) Duties of officers.

a.The chairperson will:

(1)Preside at all meetings of the advisory council;

(2)Appoint subcommittees as deemed necessary; and

(3)Designate the chairperson of each subcommittee.

b.The vice chairperson will:

(1)Perform the duties of the chairperson if the chairperson is absent or unable to act. When so acting, the vice chairperson will have all the powers of and be subject to all restrictions upon the chairperson.

(2)Perform other duties as may be assigned by the chairperson.

441—304.4(225A) Meetings.

304.4(1) The advisory councilwill establish a meeting schedule on an annual basis to conduct its business. There will be a minimum of four meetings per year.

304.4(2) A majority of appointed members constitutes a quorum.

304.4(3) When a quorum is present, a position is carried by affirmative vote of the majority of those present. No official business that requires a vote of the membership will be conducted without a quorum present.

441—304.5(225A) Subcommittees. The advisory council may designate one or more subcommittees to perform such duties as may be deemed necessary.

441—304.6(225A) Advisory councilcomposition. The advisory council’s composition will be developed and maintained pursuant to Iowa Code chapter225A.

These rules are intended to implement Iowa Code section 225A.5.

ITEM 8.Adopt the following new441—Chapter 305:

CHAPTER 305

MENTAL HEALTH ADVOCATES

441—305.1(229) Advocate appointment and qualifications. The board of supervisors of each county will appoint a person to act as an advocate representing the interests of individuals involuntarily hospitalized by the court under Iowa Code chapter 229. The advocate is hired by the board of supervisors and employed by the county.

305.1(1) Appointment. A person may be appointed and employed or contracted with as the advocate by one county or by multiple counties. Advocates may be appointed for counties in more than one judicial district or more than one district.

305.1(2) Qualifications. The advocate will meet the following qualifications:

a.Possess a bachelor’s degree with 30 semester hours or equivalent quarter hours in a human services field, including but not limited to psychology, social work, mental health counseling, marriage and family therapy, nursing, education, occupational therapy, and recreational therapy, and at least one year of experience in the delivery of services to persons with mental illness; or

b.Hold an Iowa license to practice as a registered nurse and have at least three years of experience in delivery of services to persons with mental illness.

c.A person employed as an advocate on or before July 1, 2015, who does not meet the requirements of paragraph 305.1(2)“a” or “b” will be considered to meet those requirements so long as the person is continuously appointed as an advocate in the employing county.

d.A person employed as an advocate must pass criminal background, sex offender registry, and child and dependent adult abuse registry checks prior to the advocate’s hire.

441—305.2(229) Advocate assignment. The committing court will assign the advocate from the county where the individual is located.

305.2(1) If the advocate assigned cannot serve the individual in an effective and efficient manner, the advocate may request another advocate to perform advocate duties on the individual’s behalf. In the event that another advocate can better represent the individual on a longer-term basis, the advocate will request that the court transfer the individual to another advocate.

305.2(2) When a conflict of interest is identified between an advocate and an individual, the court and the advocate’s county of employment will be notified and an alternative advocate will be assigned. The advocate’s direct supervisor is responsible to monitor and ensure that the advocate does not have a conflict of interest. In instances when dual or multiple relationships are unavoidable, advocates should take steps to protect individuals and are responsible for setting clear, appropriate, and culturally sensitive boundaries. Advocates who anticipate a conflict of interest among the individuals receiving services should clarify the advocate’s role with the parties involved and take appropriate action to minimize any conflict of interest.

305.2(3) When the advocate assigned is not the advocate from the individual’s county of residence, the advocate’s county of employment may seek reimbursement from the BH-ASO for the district in which the individual’s county of residence is located as outlined in Iowa Code section 229.19(1)“b.”

305.2(4) An advocate will only be assigned to a child 17 years of age or under when the child is not represented by an attorney due to an existing child in need of assistance (CINA) or other juvenile court action pursuant to the Iowa Code.

441—305.3(229) Advocate responsibilities. The minimum duties of the advocate are outlined in Iowa Code section 229.19. The role of the advocate is to ensure that the rights of the individual are upheld.

305.3(1) The advocate will be readily accessible to communication from the individual and will initiate contact within five days of the individual’s commitment. The advocate will inform the individual regarding the role of the advocate.

305.3(2) The advocate will meet the individual in person within 15 days of the individual’s commitment. The advocate will present the county grievance procedure process, in writing, to the individual. The presentation will include the county grievance procedure, county contact information, and ombudsman contact information. The advocate will inform the individual about the mental health crisis services that are available.

305.3(3) The advocate will review each report submitted to the court and communicate with the individual’s medical and treatment team. Advocates will abide by all federal, state, and local confidentiality laws.

305.3(4) The advocate will file in a form prescribed by the court as the advocate feels necessary or as required for each individual assigned to the advocate.

305.3(5) The advocate will maintain an organized, confidential, and secure file for each individual served. The file will contain but not be limited to:

a.Copies of quarterly reports submitted to the court.

b.Copies of correspondence sent to and received from the individual, family members, providers, andothers.

c.Releases of information.

d.Case notes describing the date, time, and type of contact with the individuals or others and a brief narrative summary of the content or outcome of the contact.

e.Documents filed with the court electronically will be considered as part of the individual’s file.

305.3(6) The advocate will register as provided in Iowa R. Elec. P.16.305(1) to participate in the court’s electronic document management system and will submit all documents to be filed with the court electronically. The documents will be stored as electronic records that are retrievable and readable through the electronic document management system.

305.3(7) The advocate, as an employee of the county, will comply with all county policies and procedures, including but not limited to hiring, supervision, grievance procedures, and training.

305.3(8) All advocate records are the property of the county, which is responsible for the provision of confidential storage, transfer, and destruction of client files, including those maintained on electronic and digital devices, with access limited according to the county’s policy on confidentiality as described in subrule 305.4(6).

305.3(9) The advocate may attend the hospitalization hearing of an individual represented by an attorney; however, payment for the advocate’s attendance is at the discretion of the county of employment.

441—305.4(229) County responsibilities. As the employer of the advocate, the county will provide qualified staff to support and facilitate the provision of quality advocate services. The county will:

305.4(1) Assign a single supervisor, a single contract manager, or the county board of supervisors as the supervising entity to carry out responsibilities in this chapter.

305.4(2) Have a job description in the personnel file of the advocate that clearly defines the advocate’s responsibilities and qualifications as defined in Iowa Code section 229.19 and this chapter.

305.4(3) Have a process to verify, prior to the advocate’s hire, qualification of the advocate, including degrees and certifications obtained from a primary source.

305.4(4) Provide or arrange for training and education relevant to the position, including but not limited to overview of mental health diagnosis and treatment, the behavioral health service system, confidentiality, individual rights, professional conduct, the role of advocacy and service coordination within an interdisciplinary team, the Iowa Code and administrative rules, and court procedures.

305.4(5) Provide or arrange for approved training on child and dependent adult abuse reporter requirements.

305.4(6) Provide, to any employee with access to individuals’ files, training on state and federal laws regarding nondisclosure and confidentiality of client-protected health information during and after employment and maintain in the personnel files a signed document indicating the employee’s awareness of the county’s policy on confidentiality.

305.4(7) Complete criminal background, sex offender registry, and child and dependent adult abuse registry checks before employment of the advocate. Any person who does not pass these checks is prohibited from being hired, or continuing to serve, as an advocate.

305.4(8) Provide advocate staff to cover the county’s caseload at all times, according to but not limited to each county’s unique number of individuals assigned to the advocate, travel required, types of settings where the individuals reside, services available, and extended staff absences.

441—305.5(229) Data collection requirements.

305.5(1) Annual submission. By December 1 of each year, each county will submit to the department data regarding each individual who received advocate services during the previous state fiscal year.

305.5(2) Required data. The data to be submitted are as follows:

a.Basic information about the individual, including a unique identifier and county of residence.

b.Demographic information, including the individual’s date of birth, sex, ethnicity, education, and diagnosis made in accordance with the criteria provided in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association (APA) (published 2013, with all changes and updates approved by the APA through July 1, 2025, incorporated herein).

c.Commitment information, including the date of the individual’s initial commitment, type of commitment order, whether a juvenile or adult case, date of commitment and name of treatment facility to which the individual is committed, any subsequent changes in treatment facility, and date commitment is terminated.

441—305.6(229) Quality assurance system. The county will implement a quality assurance system that:

305.6(1) Annually measures and assesses advocates’ activities and services.

305.6(2) Gathers feedback from stakeholders, including individuals using advocate services, family members, court staff, service provider staff, and regional staff regarding advocate services.

305.6(3) Implements an internal review of individual records.

305.6(4) Identifies areas in need of improvement.

305.6(5) Develops a plan to address the areas in need of improvement.

305.6(6) Implements the plan and documents the results.

These rules are intended to implement Iowa Code chapter 229.

ITEM 9.Adopt the following new441—Chapter 310:

CHAPTER 310

DATA COLLECTION

441—310.1(225A) Authority. The director is the principal officer of the state to administer BH-ASO data reporting. On behalf of the department, each BH-ASO will collect and maintain data on all clients served.

310.1(1) Submission of data. Each BH-ASO will submit to the department the data regarding each individual the BH-ASO serves.

a.BH-ASOs will submit data according to the frequency, file layouts, format, and naming conventions prescribed by the department.

b.When aBH-ASO is notified by the department that the data is incomplete or is not compliant with the prescribed file layouts, format, or naming conventions, the BH-ASO must correct the issue within 30 days of the notification.

c.The state supplementary assistance program, mental health institutes, state resource center, Medicaid program, Medicaid managed care organizations, and targeted case management program will provide to the department team responsible for BH-ASO evaluation and oversight the equivalent data in a compatible format on the same schedule as the required submission from the BH-ASOs as requested.

310.1(2) Data required. The data to be submitted are as follows:

a.Individual client-level information, including a unique identifier, name, address, demographic information, service delivery information, referral information, and any other information as prescribed by the department.

b.The state ID number when applicable.

c.Demographic information, including but not limited to date of birth, sex, ethnicity, marital status, education, residential living arrangement, current employment status, monthly income, income sources, type of insurance, insurance carrier, veterans’ status, guardianship status, legal status in the system, source of referral, and diagnosis code in the International Classification of Diseases (ICD) as amended to July 1, 2025.

d.Service information, including but not limited to the decision on services, date of decision, termination date and reason for termination, residence, approved service, service beginning dates, service ending dates, reason for terminating each service, approved units of services, unit rate for service, expenditure data, and provider data.

This rule is intended to implement Iowa Code sections 225A.3 and 225A.6.