Iowa Admin. Code r. 441-81.20

Current through Register Vol. 47, No. 11, December 11, 2024

Rule 441-81.20 - Out-of-state facilities

Payment will be made for care in out-of-state nursing facilities. For members enrolled with a managed care organization, authorization for admission must be obtained from the managed care organization prior to admission. Out-of-state facilities shall abide by the same policies as in-state facilities with the following exceptions:

(1)Out-of-state providers. Except for Medicare-certified hospital-based nursing facilities and special population nursing facilities, out-of-state providers shall be reimbursed at the same nursing facility rate they would receive from the Medicaid program in their state of residence or an amount equal to the sum of the Iowa non-state government owned nursing facility direct care rate component limit pursuant to subparagraph 81.6(16) "f"(1) plus the non-direct care rate limit pursuant to subparagraph 81.6(16) "f"(1), whichever is lower.

a. Medicare-certified hospital-based nursing facilities providing skilled care in other states shall be reimbursed at an amount equal to the sum of the Iowa Medicare-certified hospital-based nursing facility direct care rate component limit pursuant to subparagraph 81.6(16)"f"(3) plus the non-direct care rate component limit pursuant to subparagraph 81.6(16) "f"(3) if one of the following criteria is met:

(1) The placement is recommended because moving the resident back to Iowa would endanger the resident's health, because services are not readily available in Iowa, or because the out-of-state placement is cost-effective.

(2) The placement is temporary until services are available to the resident in Iowa or until the program of treatment is completed.

b. Special population nursing facilities shall be reimbursed at the same nursing facility rate they would receive from Medicaid in their state of residence or, if not participating in the Medicaid program in their state, they shall be reimbursed pursuant to subparagraph 81.6(16) "e"(2), if one of the following criteria is met:

(1) The placement is recommended because moving the resident back to Iowa would endanger the resident's health, because services are not readily available in Iowa, or because the out-of-state placement is cost-effective.

(2) The placement is temporary until services are available to the resident in Iowa or until the program of treatment is completed.

(2) Out-of-state facilities shall not submit financial and statistical reports as required in rule 441-81.6 (249A).

(3) Effective December 1, 2009, payment for periods when residents are absent for visitation or hospitalization will be made to out-of-state facilities at zero percent of the rate paid to the facility by the Iowa Medicaid program.

Iowa Admin. Code r. 441-81.20

ARC 8995B, lAB 8/11/10, effective 9/15/10

Amended by IAB January 06, 2016/Volume XXXVIII, Number 14, effective 1/1/2016

Amended by IAB March 8, 2023/Volume XLV, Number 18, effective 5/1/2023