Employees’ Manual
Title 18, Chapter C(6) Revised February 17, 2023
In-Home Health-Related
Care Services
Title 18: Family Services Table of Contents
Chapter C(6): In-Home Health-Related Care Services
Revised February 17, 2023 Page 1
Page
Iowa Department of Health and Human Services Employees’ Manual
Overview ............................................................................................................................................... 1
Legal Basis .......................................................................................................................................................................... 1
Administration .................................................................................................................................................................. 2
Chapter Organization ..................................................................................................................................................... 2
List of Requirements ....................................................................................................................................................... 2
Determining Eligibility ......................................................................................................................... 7
Communicating with Income Maintenance ............................................................................................................... 7
Taking Applications .......................................................................................................................................................... 8
Pending Applications ....................................................................................................................................................... 9
Assessing Service Needs ................................................................................................................................................ 9
Planning Services ................................................................................................................................ 10
Available Services ........................................................................................................................................................... 11
Requirements for Skilled Services .............................................................................................................................. 12
Individual Service Plan ................................................................................................................................................... 13
Amount of Supplementation ....................................................................................................................................... 14
Qualifications of Service Providers ............................................................................................................................ 15
Reasonable Charges ...................................................................................................................................................... 16
Agreements for Service ................................................................................................................................................ 16
Requesting Approval .......................................................................................................................... 18
Notification ...................................................................................................................................................................... 18
Denial of Service ............................................................................................................................................................ 18
Eligibility for Medicaid ................................................................................................................................................... 19
Processing Payments ......................................................................................................................... 19
Authorized Payment Reduction ................................................................................................................................. 20
Direct Deposit ................................................................................................................................................................ 20
Remedying Payment Issues .......................................................................................................................................... 20
Canceling a Payment to Get a Duplicate Warrant .................................................................................... 20
Canceling a Payment Before It Is Issued ....................................................................................................... 21
Voiding a Payment to Change Payment Details .......................................................................................... 21
Fixing an Underpayment ................................................................................................................................... 21
Warrant Returns ............................................................................................................................................................ 22
Client Has Died or Is Incapacitated .......................................................................................................................... 22
Monitoring and Changing Services ................................................................................................... 23
Amending the Provider Agreement .......................................................................................................................... 24
Adding or Changing Providers .................................................................................................................................... 25
Adding or Changing a Payee ........................................................................................................................................ 26
Terminating Services ......................................................................................................................... 27
Client Absent From Home for More Than 15 Days ............................................................................................. 27
Termination Procedures .............................................................................................................................................. 28
Appeals ............................................................................................................................................................................. 28
Title 18: Family Services Page 1
Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Overview
Revised February 17, 2023 Legal Basis
Overview
In-home health-related care is a State Supplementary Assistance program to:
▪ Provide health care in the home
▪ Prevent out-of-home placement
▪ Preserve independent self-care
The purpose of the in-home health-related care (IHHRC) supplement is to provide personal services to
persons in their own homes when physical or mental problems prevent them from independent self-care.
The intent is to prevent or reduce time in institutional care by helping a person stay at home as long as
possible.
The services are approved by a physician. Any “skilled services” will be performed under the supervision of a
physician, nurse practitioner, clinical nurse specialist, or physician’s assistant.
The state supplements the person’s income to allow the person to pay for the needed services. The state
does not purchase the services directly. The cost of the services must be below a specified limit but above
what the person is determined able to pay.
IHHRC shall be provided only when other existing programs cannot meet the client’s need.
(441 IAC 177.7(1)(a)(2)). Please see Assessing Service Needs.
A client’s right to self-determination is paramount. You cannot mandate that a client apply or accept waiver
or any other service.
Legal Basis
Iowa Code Chapter 217 governs the establishment, purposes, and general duties of the Department of
Health and Human Services.
Iowa Code Chapter 249 provides that State Supplementary Assistance payments may be made to an
eligible person receiving “nursing care in the person’s own home, certified by a physician as being
required, so long as the cost of the nursing care does not exceed standards established by the
Department.”
Iowa Administrative Code 441, Chapter 177, “In-Home Health-Related Care,” establishes the rules for
the program. Chapters 50, 51, and 52 establish the rules for application, eligibility, and payment for
State Supplementary Assistance.
Title 18: Family Services Page 2
Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Overview
Revised February 17, 2023 Administration
Administration
The in-home health-related care (IHHRC) supplement is jointly administered by an income
maintenance worker and a designated service worker.
Both the service worker and IM worker have roles in determining eligibility for IHHRC services. Both
the service worker and IM worker are required to share information with each other.
IHHRC is not considered a long-term care program or a (231C) assisted living program. An individual
living in an assisted living facility can apply and receive IHHRC, however, the assisted living
program/facility cannot apply on behalf of the individual they are serving.
Chapter Organization
This chapter provides direction regarding the in-home health-related care (IHHRC) program in
relation to:
▪ Determining eligibility
▪ Planning services
▪ Requesting certification
▪ Processing payments
▪ Monitoring and changing services
▪ Termination of services
List of Requirements
Legal reference: 441 IAC 177 and 441 IAC 50
Application and Assessment
Medical Eligibility
▪ Person must be under a physician’s care.
▪ Skilled Services must be certified by a physician and must be
supervised by a supervising practitioner (physician, nurse
practitioner, clinical nurse specialist, or physician’s assistant).
Personal Care Services (non-skilled services) do not need to be
supervised by a practitioner.
Financial Eligibility
(Determined by income
maintenance (IM) worker)
▪ Person must require health care or personal care.
▪ Person’s income must be under the current Supplemental
Security Income (SSI) standard plus the current maximum
IHHRC payment.
▪ HHS service worker or designee helps the client complete form
470-5170 or 470-5170(S), Application for Health Coverage and
Help Paying Costs, if the client requests assistance. The Income
Maintenance (IM) worker may provide this form to the client or
the client can print it from the HHS web page.
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Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Overview
Revised February 17, 2023 List of Requirements
▪ Send the completed application to HHS, Imaging Center 4 at:
Imaging Center 4
PO Box 2027
Cedar Rapids, IA 52406
Email: imagingcenter4@dhs.state.ia.us
Fax: 515-564-4017
▪ Upon receipt the IM will then pend the case in IoWANS.
NOTE: The signed application form in the IM case file serves as
the application for both medical and service components of the
program. A copy of the application is not required to be kept in
the HHS service case file.
NOTE: At each step in the approval process the HHS service
worker will have IoWANS milestones to answer.
▪ If the person’s income is below the SSI benefit amount, refer the
person to apply for SSI. (The person is eligible for IHHRC when
IM is notified of the person’s SSI eligibility.)
Needs Assessment
▪ Complete form 470-5602, Service Worker Comprehensive
Assessment, to assess the medical and daily needs of the client.
Opening A Case
• Have the client sign form 470-3951 or 470-3951(S),
Authorization to Obtain or Release Health Care Information, for
the physician and supervising practitioner (if necessary).
• Provide the Physician’s Report/Health Care Plan, form 470-
0673, to the client.
▪ If skilled services are needed, send signed form 470-3951 or
470-3951(S), Authorization to Obtain or Release Health Care
Information, and completed form 470-0673, Physician’s
Report/Health Care Plan, to the supervising practitioner for
review and signature.
▪ Have the provider sign form 470-3951 or 470-3951(S),
Authorization to Obtain or Release Health Care Information, for the
provider’s health care provider.
▪ Give a copy of signed form 470-3951 or 470-3951(S),
Authorization to Obtain or Release Health Care Information, to the
provider along with form 470-0672, Provider Health Assessment,
which must be completed by the provider’s physician, advanced
registered nurse practitioner, or a physician assistant working
under the direction of a physician to certify the provider’s ability
to provide assistance.
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Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Overview
Revised February 17, 2023 List of Requirements
Approval
▪ If skilled services are needed, ensure both the physician and
supervising practitioner have reviewed and signed form 470-
0673, Physician’s Reporter/Plan of Care.
▪ Receive completed form 470-0672, Provider Health Assessment
from the provider.
▪ The provider must have a valid Medicaid provider number.
Before entering provider demographic information, search
IoWANS to determine if the provider has a Medicaid provider
number. If the provider does not have a traditional provider
number, IoWANS will generate a non-traditional provider
number upon entry of all required fields.
▪ Complete form 470-0636, Provider Agreement with the client and
the provider.
▪ The client must complete the W-9 form. The W-9 form can be
found in the Appendix.
▪ Scan the W-9 form in and email to
InHomeHealthDemograp[email protected].ia.us
▪ Enter the service plan and client participation in IoWANS.
▪ Answer milestones in IoWANS to approve the service plan.
▪ IM will determine the financial eligibility.
▪ Explain billing procedures, responsibilities, and limitations of the
program to the client and provider.
▪ Discuss termination procedures and time limits with the client
and the provider.
▪ Write the case plan using form 470-0583, Individual Service Plan.
▪ Submit copies of form 470-0636, Provider Agreement, and a copy
of the case plan, including health care plan, to service area
manager (or designee) for approval.
▪ When the service area manager (or designee) returns the signed
form 470-0636, Provider Agreement, file one copy in the HHS
service file and mail copies to the client and provider, along with
form 470-0602, Notice of Decision: Services, approving service.
Clarify who will receive the client participation, the amount, and
the type of service.
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Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Overview
Revised February 17, 2023 List of Requirements
Approval (Cont.)
▪ Before sending copies of form 470-0636, Provider Agreement to
the client and provider, use black marker pen to redact the
client’s Social Security number.
▪ Give each provider an adequate supply of form 470-0648,
Statements of Services Rendered, and self-addressed stamped
envelopes to mail to the assigned HHS service worker.
Case Maintenance
Monthly Billing
▪ Upon receipt of form 470-0648, Statement of Services Rendered,
from the client. Enter the invoice information in IoWANS.
▪ Attach form 470-0648, Statement of Services Rendered, to the
printed invoice page from IoWANS and place in the service case
file.
Case Review
Quarterly Review
▪ Review the entire care plan at least once every three months/90
days. If the client has an MCO Case Manager or supervising
practitioner, this review should include a consultation.
Document this review in the narrative.
Semiannual Review
▪ The physician reviews the need for continued in-home health
care services and provides a written recertification of the
continuing appropriateness of the care plan required every 180
days, upon initiation of Medicaid waiver services, or more
frequently as decided upon by physician or IHHRC service
worker.
Scheduled Supervising
Practitioner Review
▪ If skilled services are needed, the supervising practitioner
will set schedule for reviewing skilled services as documented on
page 3 of form 470-0673, Physician’s Report/Health Care Plan. This
review will occur either every 60 days, every 90 days, or every
180 days.
Annual Review
▪ Review and reassess all eligibility factors by conducting a home
visit once per year, minimum, and completing all paperwork
requirements, including form 470-5602, Service Worker
Comprehensive Assessment.
▪ Assist the client in completing form 470-5482 or
470-5482(S), Medicaid/State Supp Review, if needed. The IM
worker sends this form to the client when it is time for the
review.
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Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Chapter Overview
Revised February 17, 2023 List of Requirements
Annual Review (continued)
▪ Remind the client to obtain the required annual physician’s
physical examination. Provide form 470-0673, Physician’s
Report/Health Care Plan, to the client.
▪ Have the client sign a current form 470-3951, Authorization to
Obtain or Release Health Care Information, for the physician and
supervising practitioner (if necessary)
▪ If skilled services are needed, ensure the supervising practitioner
has reviewed and signed form 470-0673, Physician’s Report/Health
Care Plan after completed by physician
▪ Have the provider sign a current form 470-3951, Authorization to
Obtain or Release Health Care Information.
▪ Obtain a new form 470-0672, Provider Health Assessment from
provider.
▪ Send Notice of Decision: Services, form 470-0602 or 470-0602(S),
clarifying how much client participation is paid to each provider
for which service.
▪ If the provider changes, terminate the Provider Agreement and
complete the required steps for approving another provider.
▪ Notify the IM worker of any changes either by email or entries
in IoWANS, such as case termination and note reason.
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Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Determining Eligibility
Revised February 17, 2023 Communicating with Income Maintenance
Determining Eligibility
Legal reference: 441 IAC 177.4(249)
A person must meet the following requirements to be eligible for in-home health-related care (IHHRC):
▪ The person must be eligible for SSI in every respect except income, and
▪ The person must be certified by a physician as requiring skilled or personal care services and those
services can be provided in the person’s own home, and
▪ The person must be living in the person’s own home.
NOTE: “Own home” means a person’s house, apartment, or other living arrangement intended for single or
family residential use. A person is considered to be living in the person’s own home even though the person
may be sharing the household of another. Such arrangements may be temporary or permanent and may be
established for the purpose of providing health care.
Instructions for determining eligibility are divided into four sections:
▪ Communicating with income maintenance
▪ Taking applications
▪ Pending applications
▪ Assessing services needs
Communicating with Income Maintenance
Use the comment section in IoWANS or email to communicate with the IM worker as to what is
happening in the case. Examples of communication may include notice of service eligibility, payments
issued, and case closure.
Communication may also include the use of email to inform the IM worker of such things as:
▪ The client’s living arrangements and/or address have changed.
▪ The client has died.
▪ The client is no longer receiving the service.
▪ The service worker has a new application.
▪ Payment for services has begun.
Examples of times when the IM worker would use IoWANS or email to communicate with the service
worker:
▪ The amount of client participation on a new case has been determined.
▪ The client becomes eligible to receive Medicaid.
▪ The client’s income has increased or decreased.
▪ The client participation has increased or decreased.
▪ The client’s address has changed.
▪ The client is financially ineligible for services.
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Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Determining Eligibility
Revised February 17, 2023 Taking Applications
Taking Applications
Legal reference: 441 IAC 177.4
The client, or a responsible person acting on behalf of the client, may apply for services at the local
office of the Department. The initial application can be submitted to either the service worker or the
IM worker.
If received by a service worker, review the demographic information for accuracy and forward the
application to income maintenance.
Form 470-5170 or 470-5170 (S), Application for Health Coverage and Help Paying Costs, is the application
for both medical and service components of the in-home health-related care program. Keep the signed
application in the IM case file. It is not required that a copy of the Application for Health Coverage and
Help Paying Costs be kept in the HHS service case file.
NOTE: The Application for Health Coverage and Help Paying Costs serves the purpose of the Application for
All Social Services, form 470-0615 or 470-0615(S). It is not necessary for the client to sign the Application
for All Social Services also.
During the application process, the service worker determines if service criteria as defined in this
chapter are met and determines the value of the home health care the client will require.
A Department IM worker is responsible for determining financial eligibility. The service worker will
receive notice from the IM worker as to whether the client is initially financially eligible and if client
participation is required in IoWANS.
If the client’s income is above SSI standards, the IM worker determines the amount of countable
income and resources based on policies in 6-B, Resources, and 8-E, Income Policies for SSI-Related
Coverage Groups.
Countable income may be from any source: Veterans Administration, Railroad Retirement, Social
Security, pension, interest, farm, etc.
If income is below SSI standards and the client is not receiving SSI, it is essential that the client, the
client’s legal representative, or a responsible party immediately complete an application at the Social
Security Administration office, so SSI eligibility can be established. (Application for other benefits is an
eligibility factor for State Supplementary Assistance.)
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Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Determining Eligibility
Revised February 17, 2023 Pending Applications
Pending Applications
Legal reference: 441 IAC 177.4
Complete the eligibility determination within 30 days from the date of the application, unless one or
more or the following conditions exist:
▪ An application for Supplemental Security Income (SSI) benefits is pending.
▪ The receipt of information, which is beyond the control of the client or the Department, has not
yet been received.
▪ A disability determination is pending.
▪ Form 470-0636, Provider Agreement, has not yet been received.
NOTE: Communicate any delays due to the above reasons to IM by email.
EXCEPTION: The 30-day timeframe can be extended to 60 days if a provider cannot be located within
60 days from the date of application.
The client may reapply when a provider is located.
Assessing Service Needs
Legal reference: 441 IAC 177.7
In-home health-related care can be provided only when other existing programs cannot meet
the client’s needs. A person cannot receive the same service from in-home health-related care
(IHHRC) and another Medicaid program at the same time. A person who is eligible for more than one
Medicaid program that can provide the same service must select the most cost-effective program to
meet the client’s needs. The HHS service worker is responsible for determining if the needed services
can be met through programs other than IHHRC. A client’s right to self-determination is paramount.
You cannot mandate that a client apply or accept waiver or any other service.
▪ A client can be on IHHRC and waiver services at the same time.
▪ A client can be on habilitation waiver and another waiver at the same time.
▪ A client can receive IHHRC and be enrolled with an integrated health home.
IHHRC should not duplicate any service provided under waiver (including habilitation waiver). If a
service is being provided under another source (including waiver, IHHRC should not be providing the
same service.
1. Make an initial assessment of the client’s physical and emotional health care needs and protective
needs, based on all available information including information from other professionals (e.g.,
physician, public health nurse) and the completed Service Worker Comprehensive Assessment,
form 470-5602.
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Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Determining Eligibility
Revised February 17, 2023 Assessing Service Needs
2. Make the initial determination that the client’s needs can be met by an in-home program, and
cannot be adequately met by other community programs, including:
▪ Homemaker-health aide program
▪ Visiting nurse services
▪ Chore service
▪ Medicaid waiver programs
▪ Service organizations
▪ County-funded programs
3. Consult the physician to determine the health care needs of the client. The physician must make
the determination of whether or not the client needs the service and whether or not the client’s
health care needs can be met with this service. The physician must complete form 470-0673,
Physician’s Report/Health Care Plan.
4. If skilled services are a part of the service need, services must be supervised by a supervising
practitioner (physician, nurse practitioner, clinical nurse specialist or physician’s assistant). Consult
with supervising practitioner regarding the personal, nursing, and medical care required by the
client, the qualifications of the provider, and the amount of supervision the practitioner will
provide.
5. Assist the client and family with obtaining the necessary health care services, as stated in form
470-0673, Physician’s Report/Health Care Plan. The identified health care services can include a
registered nurse, licensed practical nurse, homemaker-home health aide, or volunteers (family or
otherwise) to be trained by a professional, either from another agency or private providers.
6. Help the client inform these persons about how the program will operate, including payment
procedures, and provide overall coordination of the health care services with other services being
provided to the client, e.g., chore service, mobile meals, homemaker, etc.
7. If the client is being transferred from a hospital or nursing facility, obtain a transfer form describing
the client’s current care plan, to be provided to the supervising practitioner in the event the care
plan contains skilled service needs.
Planning Services
This section covers the actions necessary to move from the assessment of service need to developing a plan
for using the in-home health-related care (IHHRC) program to meet the client’s assessed needs. It is
organized in the following parts:
▪ Available services
▪ Health care plan
▪ Case plan
▪ Determining amount of supplementation
▪ Qualifications of service providers
▪ Determining reasonable charges
▪ Agreements for service
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Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Planning Services
Revised February 17, 2023 Available Services
Available Services
Legal reference: 441 IAC 177.3(249)
The in-home health-related care (IHHRC) program includes both skilled and personal care services, as
follows:
▪ Skilled services include skilled nursing services or other services that based on a physician’s
certification, are required to be performed under the supervision of a physician, nurse practitioner,
clinical nurse specialist or physician’s assistant
▪ Skilled nursing services are services which an individualized assessment of a patient’s clinical
condition demonstrate that the specialized judgment, knowledge and skills or a registered nurse,
or when provided by regulation, a licensed practical (vocational) nurse (“skilled care”) are
necessary.
▪ Skilled services may include, but are not limited to:
• Gavage feedings (tube feeding of person unable to eat solid food).
• Intravenous therapy administered only by a registered nurse.
• Intramuscular injections, (excluding diabetes).
• Catheterizations, including continuing care of in dwelling catheters with supervision of
irrigations and changing of Foley catheter when required.
• Inhalation therapy.
• Care of decubiti and other ulcerated areas (requires noting and reporting to physician).
• Rehabilitation services, which include, but are not limited to: bowel and bladder training, range
of motion exercises, ambulation training, restorative nursing services, teaching the activities of
daily living, respiratory care and breathing programs, remotivation, and behavior modification.
• Tracheotomy care.
• Colostomy care, until the person is capable of maintaining the colostomy personally.
• Care of uncontrolled types of medical conditions, brittle diabetes/terminal conditions.
• Post-surgical nursing care for short time periods, primarily for persons with complications
following surgery, or with the need for frequent dressing changes.
• Monitoring medications when there is a need for close supervision of medications because of
fluctuating physical or mental conditions, such as hypertensives, digitalis preparations, or
narcotics.
• Need for therapeutic diets. Evaluation of diet at frequent intervals.
• Recording and reporting change in vital signs to the attending physician.
▪ Other technical procedures may be assigned at the discretion of the supervising practitioner, based
on evaluation of the training, experience, and ability of the provider.
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Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Planning Services
Revised February 17, 2023 Available Services
▪ Personal care services are services that:
• Assist a client with the activities of daily living, such as, but not limited to helping the client
with bathing, toileting, getting in and out of bed, ambulation, hair care, oral hygiene and
administering medications that are physician ordered but ordinarily self-administered.
• Help or retrain the client in necessary skills for daily living.
• Provide incidental household services that are essential to the client’s healthcare at home and
are necessary to prevent or postpone institutionalization.
▪ Personal care services do not require a supervising practitioner. Personal care services may
include, but are not limited to:
• Supervision on a 24-hour basis for physical or emotional needs. This may include the use of
volunteers or non-paid family, as well as the service provider, but only the cost of the health
care provider will be included.
• Helping client with bath, shampoo, and oral hygiene.
• Helping client with toileting.
• Helping client in and out of bed and with ambulation.
• Helping client to reestablish activities of daily living.
• Assisting with oral medications.
• Performing incidental household services that are essential to the client’s health care at home
and are necessary to prevent or postpone facility care.
Requirements for Skilled Services
Legal reference: 441 IAC 177.8 (249),
The physician’s certification as noted on form 470-0673, Physician’s Report/Health Care Plan will include a
health care plan which includes the specific types of services required, the method of providing those
services, and the expected duration of the services.
If skilled services are part of the service need, services must be supervised by a physician, nurse
practitioner, clinical nurse specialist or physician’s assistant. This supervising practitioner is responsible
for providing instruction to the IHHRC care provider specific to the IHHRC client. Instruction should
include, but is not limited to, instruction on documentation the IHHRC care provider is responsible for
as well as instructions on warning signs of which the IHHRC care provider should be aware.
The supervising practitioner will obtain from the client’s physician or the service worker form 470-
0673, Physician’s Report/Health Care Plan that has been completed by the physician. The supervising
practitioner will complete page 3 of form 470-0673, Physician’s Report/Health Care Plan, and shall set up
a schedule for reviewing documentation that is specific to the services being provided to the specific
IHHRC client.
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Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Planning Services
Revised February 17, 2023 Requirements for Skilled Services
The supervising practitioner is responsible to keep appropriate medical records, a copy of the service
plan, and the completed form 470-0673, Physician’s Report/Health Care Plan in their case file. The
medical records shall include the following items whenever appropriate:
▪ Transfer forms
▪ Physician’s certification and orders
▪ Progress notes
▪ Drug administration records
▪ Treatment records
▪ Incident reports
The Department may review medical records related to the In-Home Health-Related Care program.
Individual Service Plan
Legal reference: 441 IAC 177.7(1)
The service worker will develop an individual client case plan using form 470-0583, Individual Service
Plan. Include in the plan:
▪ Assessment: Include a summary of the client’s current home situation, informal supports, need
for services, and other services the client is currently receiving.
▪ Income Information: Source of income.
▪ Goals: List the goals of the plan.
▪ Objectives: List the objectives of the plan.
▪ Specific Services: List the services the client will be receiving through the In-Home Health-
Related Care (IHHRC) program and any other formal and informal services that the client is
receiving.
▪ Responsibilities: List the responsibilities of the client, provider, and the service worker.
▪ Reassessment/Termination: Note if this is a reassessment or termination. If reassessment,
update the information above. If termination, explain the reason for termination.
The individual client case plan should include a comprehensive outline of all service needs and plans for
meeting those needs. When preparing the plan, take into consideration:
▪ Whether needed services can be met through existing programs including, but not limited to:
• Homemaker-home health aide programs
• Visiting nurse services
• Medicaid waiver programs
• Service organizations
• County-funded programs
▪ That the cost of service paid for under this program cannot exceed the base SSI allowance plus the
service cost.
NOTE: The service worker is responsible for determining if the needed services can be met through
programs other than IHHRC. Do not use this program in place of valid referrals for homemaker, a
waiver service, etc.
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Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Planning Services
Revised February 17, 2023 Individual Service Plan
NOTE: The service plan documented on form 470-0583, Individual Service Plan, the description of
specific duties on form 470-0636, Provider Agreement, and the service plan entered in IoWANS must
match.
Amount of Supplementation
Legal reference: 441 IAC 51.2(249)
The HHS service worker determines the person’s services and the cost of those services. The IM
worker determines financial eligibility and the amount of client participation in the service cost. When
the IM worker has transmitted that information to the service worker through IoWANS, the
maximum dollar amount per month the client is eligible to receive through this program can be
determined.
The amount of supplementation is the difference between the cost of the service and the amount of
client participation, up to the current maximum cost per month for each person needing care. The
costs must be justified by the service plan.
The current maximum payment per month is $480.55.
The IM worker determines eligibility based on the family’s gross income. After eligibility is determined,
all other income available to the client is considered in determining client participation, with applicable
disregards. Some of these disregards are:
▪ Chapter C(6): In-Home Health-Related Care Services Planning Services
▪ Revised February 17, 2023 Amount of Supplementation
▪ The amount of the basic SSI income standard for an individual or a couple living in their own home
and for any dependents:
• For an individual $914.00
• For a couple $1,371.00
• For each dependent, add $457.00
▪ When income is earned, $65 plus one-half of the remainder.
▪ Diversion for established unmet medical needs of the client, the spouse, and any dependents.
“Established unmet medical needs” include costs such as visits to physicians, prescription medicines,
and related travel expenses needed on an ongoing basis and not covered by insurance or Medicaid.
Insurance premiums and unmet past bills are not included.
Any income remaining after the disregards is applied toward service costs under this program before
beginning supplementation. See 6-B, In-Home Health-Related Care for a complete discussion of income
eligibility and client participation policies for adults and children.
Then the potential supplementation is figured up to the maximum service cost.
Title 18: Family Services Page 15
Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Planning Services
Revised February 17, 2023 Amount of Supplementation
1. Mr. A has unearned income (SS, VA, etc.) totaling $1,200 per month and unmet medical needs of
$100 per month. He must pay the first $186 of service [($1,200 - $100) - $914]. No supplementation
is available to Mr. A if his total service need is $186 or less.
2. Mr. and Mrs. B have unearned income (SS, VA, etc.) totaling $1,750 per month, with no unmet
medical needs. They must pay the first $379 of service costs ($1,750 - $1,371). No supplementation
is available to Mr. and Mrs. B if their total service need is $379 or less.
3. Mr. and Mrs. C have earned income of $3,500 gross per month and unmet medical needs of $50.
Only Mr. C needs care. The first $65 earned income is disregarded plus half of the remainder. The
couple’s adjusted monthly income is $1,717.50 [($3,500 - $65) 2]. They must pay the first $296.50
of service [($1,717.50 - $50) - $1,371]. No supplementation is available to Mr. C if his total service
need is $296.50 or less.
If the first month of service for a person receiving in-home health-related care is less than a full month,
there is no required client participation for that month. The program will pay for the actual days of
service provided according to the agreed-upon rate.
Client participation can be split between more than one service and more than one provider. When
developing the Provider Agreement, identify who will receive the client participation with the client and
providers.
Once approved, IHHRC services may be paid from the date of application or the date all eligibility
requirements are met, whichever is later.
Qualifications of Service Providers
Legal reference: 441 IAC 177.5(249)
The primary responsibility for locating a provider is with the client or the client’s family, however, the
service worker may assist if needed.
All providers of service under this program must meet the following criteria:
▪ The provider shall be at least 18 years of age.
▪ The provider must have a valid Medicaid provider number.
▪ The provider shall obtain a health assessment report at the beginning of the service and annually
thereafter. A physician, advanced registered nurse practitioner or physician assistant working
under the direction of a physician shall complete form 470-0672, Provider Health Assessment.
▪ Providers shall have the training and experience necessary to carry out the service plan. If skilled
services are a part of the service plan, the supervising practitioner approves the provider’s
training and experience. The Department assumes no liability for the actions of any of the
providers, professional or nonprofessional.
Title 18: Family Services Page 16
Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Planning Services
Revised February 17, 2023 Qualifications of Service Providers
▪ The provider may be related to the client, as long as the provider is not a member of the family.
“Family” means:
• Legal spouses (including common law) who reside in the same household.
• Natural, adoptive, or step mother or father, and children (under 18) who reside in the same
household.
• An individual or a child who lives alone or who resides with a person or persons not legally
responsible for the child’s support.
▪ A temporary absence does not change the composition of the family. When adults other than
spouses reside together, each is considered a separate family.
NOTE: A spouse, including common law spouse, should not be the provider to the client. An ex-
spouse may be a provider so long as HHS has a copy of the divorce decree.
NOTE: The supervising practitioner cannot be a care provider for the specific IHHRC client for
which they are supervising services.
NOTE: An agent under a health care power of attorney cannot be a care provider for the specific
IHHRC client which is the principal in a healthcare power of attorney pursuant to Iowa Code
144B.4
Reasonable Charges
Legal reference: 441 IAC 177.10(249)
Determine reasonable charges for payment of IHHRC service by:
▪ Prevailing (usual and customary) community standards for cost of similar services.
▪ Availability of service providers at no cost to the Department.
Agreements for Service
Legal reference: 441 IAC 177.9(249)
Before provision of service, ensure the client and each IHHRC care provider negotiate a Provider
Agreement, form 470-0636, as found in the Appendix. The Provider Agreement includes a statement of
the work to be performed, the rate of payment in 15-minute increments, and the maximum monthly
payment allowed. The distribution of client participation should also be identified at this time.
Discuss with providers (individuals and agencies) their responsibilities and liabilities, including
discontinuance of payment upon termination of service.
Form 470-0636, Provider Agreement will include written instructions for dealing with emergency
situations. Include any instructions that might be contained in form 470-0673, Physician’s Report/Health
Care Plan. The emergency instructions will include:
▪ The name and telephone number of the client’s:
• Physician
• Supervising Practitioner (if applicable)
• Family members or other significant person
• IHHRC service worker
Title 18: Family Services Page 17
Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Planning Services
Revised February 17, 2023 Agreements for Service
▪ Information as to which hospital to use.
▪ Information as to ambulance service or other emergency transportation to use.
The provider of services under this agreement is not considered an agent, employee, or servant of the
state of Iowa, the Department of Health and Human Services, or any of its employees. It is the
provider’s responsibility to determine employment status in regards to income tax and social security.
Providers of service have no recourse to the Department to collect payments due as a result of this
agreement.
Discuss the termination procedures and time limits with the client and provider.
Each provider must have a valid Medicaid provider number in the IoWANS system. Before entering
provider demographic information search IoWANS to determine if the provider has a Medicaid
provider number. If the provider does not have a traditional provider number, IoWANS will generate a
non-traditional provider number upon entry of all required fields.
A client must have a separate Form 470-0636, Provider Agreement for each provider the client is using.
A provider that has more than one client must have a different Provider Agreement for each client. If the
provider has more than one client, the provider will have the same provider number for each client.
To change anything on a Provider Agreement, complete a new form and check “Amendment.” See
Monitoring and Changing Services: Amending the Provider Agreement.
Title 18: Family Services Page 18
Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Requesting Approval
Revised February 17, 2023 Notification
Requesting Approval
The service area manager (or designee) approves the in-home health-related care service program by signing
the Provider Agreement, form 470-0636. Send the following to the service area manager (or designee) for
approval:
▪ A copy of the completed form 470-0583, Individual Client Case Plan,
▪ A copy of completed form 470-0673, Physician’s Report/Health Care Plan,
▪ Three copies of the Provider Agreement, form 470-0636.
A signed Provider Agreement, form 470-0636, returned to the assigned service worker constitutes program
approval and approval for payment.
Distribute copies of the Provider Agreement to the client and the provider. Place the original in the HHS service
case file.
When the agreement is approved, give each provider an adequate supply of form 470-0648, Statement of
Services Rendered, with self-addressed stamped envelopes to mail to the assigned service worker.
Notification
Legal reference: 441 IAC 7.4(4)
Notify the client of approval, denial, or termination of service and when changes occur, using form
470-0602, Notice of Decision: Services located in the Appendix. Include in the Notice of Decision: Services
the following:
▪ A statement of what action is being taken.
▪ The reasons for the intended action.
▪ The manual chapter number and subheading supporting the action, along with the Iowa
Administrative Code reference.
▪ The amount of client participation, if any, and the distribution of client participation.
NOTE: For approvals, the Notice of Decision can be generated by IoWANS, but does not have the
ability to be altered with additional information.
Information entered into IoWANS will alert the IM worker to:
▪ The approval and certification of case plan.
▪ The maximum amount of payment approved.
Denial of Service
Legal reference: 441 IAC 51 (177)
If the client is ineligible to receive State Supplementary Assistance because the income or resources
exceed the program maximum limits or the client did not provide financial information, the IM worker
will deny the application and sends form 470-0490, Notice of Decision: Medical Assistance or State
Supplementary Assistance or 470-0485, Notice of Decision (IABC generated) or 470-0485 Notice of Action
(ELIAS generated) to the client. If the client is denied based upon IM procedures, the service
worker does not need to do a separate Notice of Decision.
Title 18: Family Services Page 19
Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Requesting Approval
Revised February 17, 2023 Denial of Service
If the client is ineligible for any other reason, the service worker will then deny the application and
send form 470-0602, Notice of Decision: Services stating the reason for the denial. Reasons include one
of the following:
▪ The client is ineligible because the client participation exceeds the cost of care.
▪ The client does not need supplementation to meet the cost of care.
▪ The physician does not approve the in-home health care plan.
▪ An appropriate provider cannot be located within 60 days from the date of application.
▪ Other programs or services available in the community can meet the client’s needs.
Eligibility for Medicaid
Legal reference: 441 IAC 75
Most recipients of State Supplementary Assistance are eligible for Medicaid. The IM worker makes that
determination. Eligibility is reviewed at least annually. When the client is eligible for Medicaid, the IM
worker issues the Notice of Decision or Notice of Action to the client.
NOTE: Never approve a client to receive in-home health-related care solely for the purpose of
obtaining Medicaid coverage.
Processing Payments
Legal reference: 441 IAC 177.7(3)
IoWANS is the computer system that provides the means to enter the service plan information and the
invoice to generate payment for IHHRC services.
The provider and the client complete form 470-0648, Statement of Services Rendered and submit it to the
assigned service worker.
The service worker completes the invoice on IoWANS for all IHHRC providers that have submitted a signed
Statement of Services Rendered. Complete only one invoice per month for each agreement.
Do not enter an invoice until after the month is over. The first day an invoice may be entered is the first
day of the following month.
The client is the sole payee for payments made under this program. The client is responsible for making
payment to the provider, except when either of the following circumstances applies:
▪ One payment may be made to the provider on behalf of a client who dies or becomes incapacitated
while receiving services.
▪ The client has a legally designated person to handle finances, such as a court-appointed conservator, a
representative payee established by the Social Security Administration, or an agent under a financial
power of attorney agreement. See Adding Or Changing a Payee for more information.
After entering the invoice information in the IoWANS system, attach the Statement of Services Rendered to
the printed invoice screen from IoWANS and file in the client’s service file.
NOTE: To avoid potential payment issues enter all agreement information into IoWANS at least two weeks
before entering the invoice in IoWANS.
Title 18: Family Services Page 20
Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Processing Payments
Revised February 17, 2023 Authorized Payment Reduction
Maintain the original invoices in the local office for the current fiscal year plus the next fiscal year. Invoices
may then be sent to record storage for an additional three years using reference # BUD 2-10-1, Accounts
Payable Records. (RECORDS MANAGEMENT MANUAL, Records Retention and Disposition Schedule BUD.)
The following sections provide additional information on:
▪ Authorized reductions in payments
▪ Direct deposits
▪ Warrant returns
▪ Clients who have died or are incapacitated
Authorized Payment Reduction
When the Department authorizes a payment reduction, have the IHHRC car provider and client
complete an amendment to Provider Agreement, form 470-0636, found in the Appendix.
NOTE: “Amendment” must be checked in the upper right hand corner of the form. Have
both the IHHRC client and care provider sign the form. This will verify that the client and provider
have been made aware that the payment will be reduced.
Direct Deposit
A client who wishes to have the IHHRC payment deposited directly into a bank account must
complete a Direct Deposit Authorization form authorizing direct deposit into the client’s account. Submit
the Direct Deposit Authorization form to the Iowa Department of Administrative Services. The Direct
Deposit Authorization form can be found in the manual Appendix.
A client who wishes to cancel the Electronic Funds Transfer (EFT) authorization and revert to the
state paper warrant (check) for the IHHRC payment needs to complete the Direct Deposit Authorization
form and check “Cancel” in the top right corner. The form can then be returned to the Bureau of
Purchasing, Payments, Receipts and Payroll by mail or email
(InHomeHealthDemogr[email protected]ate.ia.us).
Payments made by direct deposit usually appear in the account the third business day after payment
issuance. Payments issued via direct deposit cannot be cancelled after payment is issued (like the
warrant is cancelled). In the event of an overpayment or adjustment, the funds must be repaid by check
or money order.
Remedying Payment Issues
Canceling a Payment to Get a Duplicate Warrant
When you cancel a payment, you will get a duplicate payment the way it was originally issued
(same name/same payee/same amount). Canceling a payment results in a duplicate payment be
re-issued. The payment is cancelled when the original payment is lost and an exact copy needs to
be issued. We can have a duplicate payment sent to a different address (manually addressed) if
the person moved and the address doesn’t match, but we cannot change the names on the
payment. Cancel is done by fiscal in the I/3 database if payment is no longer valid.
Title 18: Family Services Page 21
Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Processing Payments
Revised February 17, 2023 Remedying Payment Issues
Checks are only valid for 6 months. A duplicate payment can be issued for an original payment
that has not been redeemed after 10 days. When a duplicate payment is issued, it renders the
original payment null and void.
To cancel a payment and get a duplicate payment issued, complete form SAE0120, Request for
Warrant Action, and send to the Bureau of Purchasing, Payment, and Receipts. The form and its
instructions can be found in the manual Appendix.
Canceling a Payment Before It Is Issued
Use the cancel/delete function in IoWANS only when you are creating a payment and there is an
error. The cancel/delete function exits the worksheet abandoning all entries made. The
cancel/delete function must be done before 5:00 PM on the same day as the payment is entered.
Voiding a Payment to Change Payment Details
When there is something wrong with the payment (amount is wrong/address is wrong/payee is
wrong), you need to void the payment to have an altered payment issued. While voiding a
payment might be necessary, try to avoid voiding payments if at all possible because this creates
a manual audit file. The payment should only be voided and re-issued when something about the
payment has changed (payee or the amount) and we have the original payment in hand.
Prior to having a new payment issued, the service worker should fix any incorrect information
related to the case.
▪ If information in IoWANS needs corrected, use form 470-3923, Request for Medicaid Services
Data Changes and Verification and send to the IoWANS helpdesk at
IoWANSHelp[email protected]ate.ia.us
▪ If information on the W-9 needs corrected, use form W-9 and send to
InHomeHealthDemographic[email protected]ate.ia.us
▪ Notify and request the IM worker to change address and name information in IABC/ELIAS.
Once the corrections have been made to the appropriate databases, the service worker can void
a previous invoice and create a new invoice for those same service dates in IoWANS.
Removing the payee is a valid reason for voiding the payment. See Adding or Changing a Payee
on steps to add or change the payee before getting a payment reissued.
Fixing an Underpayment
If an underpayment occurred due to a clerical error, the service worker can email the Bureau of
Purchasing, Payments, and Receipts in order to issue a second check to the client to total the
maximum payment (both checks cannot exceed $480.55). The service worker should send a
detailed email outlining the request to the Bureau of Purchasing, Payments, and Receipts with
that payment’s Statement of Services Rendered (form 470-0648). The service worker will also
provide the Vendor Customer ID which can be found in IoWANS.
Title 18: Family Services Page 22
Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Processing Payments
Revised February 17, 2023 Warrant Returns
Warrant Returns
Any warrants returned to the Department’s central office from the client will be kept in the Bureau of
Purchasing, Payments, Receipts and Payroll until the service worker can verify the address. When the
address is verified and corrected, the Bureau will mail the warrant again.
If the warrant cannot be delivered, this could be due to several reasons. Ensure the correct address is
displaying on IoWANS. Contact the Bureau of Purchasing, Payments and Receipts to make sure the
correct address is displaying in the I/3 database by emailing
InHomeHealthDemogr[email protected].ia.us
Notify the IM worker of the correct address information to be entered into IABC/ELIAS and uploaded
into IoWANS.
Client Has Died or Is Incapacitated
Legal reference: 441 IAC 177.4(1)
When a client dies or becomes incapacitated:
1. Complete an amended Provider Agreement reflecting the client’s changed condition and listing the
provider as the payee. (you do not need documentation of payee status to have this one-time
payment issued).
2. Change the client’s name and address to the provider’s name and address. Leave the provider’s
information. Change the social security number to the provider’s social security number.
3. Complete a new W-9 with the provider’s information. Keep a copy in the HHS service case file.
4. Submit the original statement of services rendered (signed by the provider) and the new W-9 form
to the address below.
Department of Health and Human Services
Bureau of Purchasing, Payments, Receipts and Payroll
1305 E. Walnut St.
Des Moines, Iowa 50319-0114
5. If a warrant was issued to the client, make a copy for the service file, then return the check to
central office at the address:
Department of Health and Human Services
Bureau of Purchasing, Payments, Receipts and Payroll
1305 E. Walnut St.
Des Moines, Iowa 50319-0114
NOTE: This is a one-time only procedure. If an incapacitated client will remain in the program, assist
the client’s family to have a person legally designated to handle the client’s finances and become payee
on behalf of the client. See Adding Or Changing a Payee for instructions.
Title 18: Family Services Page 23
Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Monitoring and Changing Services
Revised February 17, 2023
Monitoring and Changing Services
Legal reference: 441 IAC 177.7 and 441 50.4
The IHHRC service worker, physician, supervising practitioner, or the provider may request a review of the
care services at any time. While more frequent reviews may be held, at a minimum, a review of the
continuing need for IHHRC services should occur at the following intervals:
▪ Monthly/Every 30 days:
▪ The service worker shall review form 470-0648, Statement of Services Rendered submitted by the IHHRC
client and IHHRC care provider. The service worker will enter invoice information in IoWANS to
render payment for services rendered. If there are concerns upon such a review, a change in the service
plan will result.
▪ Bimonthly/Every 60 days:
• If skilled services are needed and the supervising practitioner set a schedule for reviewing skilled
services as documented on page 3 of form 470-0673, Physician’s Report/Health Care Plan as every 60
days.
▪ Quarterly/Every 90 days:
• The service worker shall review the entire care plan at least once every 3 months/90 day. If the
IHHRC client has an MCO Case Manager or supervising practitioner, this review should also include
a consultation. Document this review in case narrative.
• If skilled services are needed and the supervising practitioner set a schedule for reviewing skilled
services as documented on page 3 of form 470-0673, Physician’s Report/Health Care Plan as every 90
days.
▪ Semiannually/Every 180 days:
• The physician reviews the need for continued in-home health care services and provides a written
recertification of the continuing appropriateness of the care plan required every 180 days, upon
initiation of Medicaid waiver services, or more frequently as decided upon by physician or
IHHRC service worker.
• If skilled services are needed and the supervising practitioner set a schedule for reviewing skilled
services as documented on page 3 of form 470-0673, Physician’s Report/Health Care Plan as every 180
days.
▪ Annually: Review the entire care plan annually.
• Complete a new case plan annually.
• Form 470-5482, Medicaid/State Supp Review will be automatically sent to the client. This form serves
the same function as form 470-5170, Application for Health Coverage and Help Paying Costs. Upon
receipt of the Medicaid/State Supp Review the form will be kept in the IM case file.
NOTE: Failure of the client in returning the Medicaid Review form could result in IHHRC ineligibility
and termination.
• Have the IHHRC care provider sign a current form 470-3951, Authorization to Obtain or Release
Health Care Information. Have the provider complete a new Provider Health Assessment, form
470-0672.
Title 18: Family Services Page 24
Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Monitoring and Changing Services
Revised February 17, 2023 Amending the Provider Agreement
• Have the client sign a current form 470-3951, Authorization to Obtain or Release Health Care
Information, for the physician and supervising practitioner (if necessary)
• Request an updated Physician’s Report/Health Care Plan, form 470-0673. File them in the HHS service
case file.
• Complete a new Service Worker Comprehensive Assessment, form 470-5602.
• Update the Provider Agreement, form 470-0636, reviewing client participation payments.
Document each review in the narrative section of the HHS service case file.
NOTE: Upon initiation of Medicaid waiver services, the physician is required recertify the client’s service
needs by reviewing the certification and withdraw, renew or amend the existing certification. The service
worker is required to review and complete a new service plan to determine if continuing IHHRC
services are warranted. Consultation is required with the MCO case manager.
It can take 2-3 months after being approved for waiver for wavier services to start. If care needs are
being fully met by services provided under waiver, end IHHRC services when wavier services have
started.
• MCO Case Manager contact information can be obtained from IMPA database system.
▪ Under File Tab, click on MCO-Member Lookup
▪ Enter state ID of member
▪ Click program/services tab
▪ Click LTC case record
Amending the Provider Agreement
To change anything on the Provider Agreement, form 470-0636, (other than client and provider name) fill
out a new form, but check “amendment.”
An amendment is required when there is a Department authorized reduction, client participation
changes, or the client dies or becomes incapacitated.
An amendment cannot be used when there is a change regarding a client or a provider. There must be
a new Provider Agreement when there is a new client or a new provider.
If a provider has more than one IHHRC client, the provider must have a different form 470-0636,
Provider Agreement for every IHHRC client. A client and a provider could each have more than one
valid Provider Agreement. Each of the client’s providers would have a different Medicaid provider
number. The IHHRC care provider’s Medicaid provider number would be the same for each client
they serve.
When a client dies or becomes incapacitated while receiving services and the client is the payee, an
amendment should be prepared listing the provider as payee for a single payment. See Client Has Died
or Is Incapacitated.
The instructions are the same for each line item as those for the agreement. See the Appendix for
form instructions.
Title 18: Family Services Page 25
Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Monitoring and Changing Services
Revised February 17, 2023 Amending the Provider Agreement
To change form 470-0636, Provider Agreement, complete items in all sections and check “yes” for
amendment.
The following items may be amended with no client or provider signature:
▪ Addresses and phone numbers
▪ Incorrect social security number
▪ Maximum payment if it is increased
▪ Addition of or change in a payee
▪ Unit cost, if increased
▪ Termination date, if the client has requested termination, has died, or has entered a long-term
care facility
The following amendments require client and provider signatures:
▪ Decrease in unit cost
▪ Decrease in maximum payment per month
▪ Change in client participation
▪ Termination date that is adverse to the client (Death or client move out of home does not require
signature)
▪ Renewal of agreement for the next time period (List new beginning and termination dates.)
Send the agreement amendments to the service area manager (or designee) for signature. When the
signed Provider Agreement is returned from the service area manager (or designee), enter the changes in
IoWANS.
Adding or Changing Providers
When a new provider begins:
1. Ensure the provider has a valid Medicaid provider number.
2. Explain the billing procedures, responsibilities, and limitations of the program to the new provider.
3. Have the IHHRC care provider sign a current form 470-3951, Authorization to Obtain or Release
Health Care Information. Give the provider form 470-0672, Provider Health Assessment, to be
completed by a physician, advanced registered nurse practitioner, or a physician assistant working
under the direction of a physician.
4. Complete a Provider Agreement, form 470-0636, with the new provider and the client.
5. Submit three copies of the Provider Agreement to the service area manager (or designee) for
approval.
6. When the service area manager (or designee) returns the three copies of the signed Provider
Agreement, file the original copy and mail one each to the client and the provider. Before sending
copies of the Provider Agreement to the client and provider, use a black marker pen to redact the
client’s social security number.
7. Give the new provider an adequate supply of form 470-0648, Statement of Services Rendered, and
self-addressed stamped envelopes to mail to the assigned service worker.
Title 18: Family Services Page 26
Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Monitoring and Changing Services
Revised February 17, 2023 Adding or Changing Providers
8. If skilled services are a part of the service plan, notify the supervising practitioner of the
new provider and change the name of the provider on the case plan.
When a Provider Agreement is canceled before the expiration date:
1. End the service line for that provider in IoWANS.
2. Complete a new Provider Agreement.
3. Enter new service line or lines in IoWANS for the new provider.
4. Send a notice of decision to the client and the provider.
To inactivate the provider in IoWANS:
1. Manage nontraditional provider.
2. Enter provider number and then enter the Update button.
3. Change provider status to “other state termed.”
4. Enter new enrollment status date.
Adding or Changing a Payee
In order to add or change a payee, we need documentation verifying the payee relationship. Payee
documentation can include but is not limited to: Social Security Administration award letter for payee,
court order for conservator, or financial power of attorney agreement.
Documentation must first be provided to the IM worker for the payee to be added into IABC/ELIAS
and IoWANS. The IM worker can be noted on the role screen in IoWANS.
After the change has been made to IABC/ELIAS and IoWANS, provide the documentation to the
Bureau of Purchasing, Payments and Receipts. Purchasing, Payments and Receipts must have a copy to
add the payee to the I/3 account.
Once all of the changes have been made by IM and the Bureau of Purchasing, Payment and Receipts,
the service worker can VOID the old invoice and create a NEW invoice for those same service dates
in IoWANS.
The service worker will need to send the old uncashed check/invoice into Purchasing, Payments, &
Receipts. A copy of the new invoice along with a request that the old invoice be cancelled noting the
amount will be paid on the new invoice.
A payment will generate with the correct information (because you will have already corrected I/3).
Title 18: Family Services Page 27
Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Terminating Services
Revised February 17, 2023 Client Absent From Home for More Than 15 Days
Terminating Services
Legal reference: 441 IAC 177.11 (249)
Terminate in-home health-related care service under the following conditions:
▪ Upon the request of the IHHRC client or legal representative (441 IAC 177.11(1)).
If termination of the program would result in the client being unable to protect the client’s own interests,
provide assistance with making any necessary arrangements to ensure the client’s needs will be met in a
safe environment.
▪ When the client becomes sufficiently able to remain in the client’s own home with services that can be
provided by other sources as determined by the HHS IHHRC service worker (441 IAC 177.11(2))
▪ When the physical or mental condition of the client requires more care than can be provided in the
client’s own home as determined by the HHS IHHRC service worker in consultation with the certifying
physician (441 IAC 177.11(3))
▪ When the cost of care exceeds the maximum established in subrule 177.10(3) (441 IAC 177 11(4))
▪ When the HHD IHHRC service worker determines that other services can be utilized to better meet
the client’s needs. (441 IAC 177.11(5))
▪ When it has been determined by the HHS IHHRC service worker that the terms of form 470-0636,
Provider Agreement, have not been met by the client or the provider. (441 IAC 177.11(6))
▪ When the client is not following the program requirements or cooperating with program objectives
including, but not limited to, a failure to provide information to program representatives (441 IAC
177.11(7))
▪ A Notice of Decision/Notice of Action from income maintenance is issued that the client is no longer
financially eligible.
The following sections give more information on:
▪ When the client is absent from home for more than 15 days
▪ Termination procedures
▪ Appeals
Client Absent From Home for More Than 15 Days
Allow the client to remain eligible and make payment for services for no more than 15 days in any
calendar month when the client is absent from home for a temporary period. Do not authorize
payment for over 15 days of continuous absence, whether or not the absence extends into a
succeeding month or months.
When it is known that the out-of-home stay will exceed 15 days, tell the IM worker to send a
termination notice to the client. Notify the IHHRC care provider and supervising practitioner (if
applicable).
Title 18: Family Services Page 28
Iowa Department of Health and Human Services Employees’ Manual
Chapter C(6): In-Home Health-Related Care Services Terminating Services
Revised February 17, 2023 Termination Procedures
Termination Procedures
To terminate IHHRC services, use the following procedures:
1. Notify the client of the termination on form 470-0602, Notice of Decision: Services, allowing timely
and adequate notice except as described in 1-E, Dispensing With Timely Notice. Always send a copy
to the IM worker so they can end the program request in IoWANS.
EXCEPTION: When the IM worker has terminated IHHRC benefits due to the client no longer being
financially eligible, do not send a Notice of Decision. The IM worker will send the service worker a
copy of the IM Notice of Decision. That notice will serve as the notice of termination. Keep the
notice of termination in the HHS service case file.
2. Notify the IHHRC care provider and supervising practitioner (if applicable) of the termination of
service.
3. Continue payment during the ten-day notice period if service is provided during that time. For
situations not requiring timely notice, payment shall be stopped immediately upon the date of the
termination notice.
Appeals
Legal reference: 441 IAC 7.6(217)
Advise each applicant and recipient of the right to appeal any adverse action affecting the person’s
status. Assist in the filing process as needed.
If an appeal is received, immediately complete Part II of form 470-0487, Appeal and Request for Hearing.
Send the written appeal, and a copy of the notice that the client is appealing to the Appeals Section
within one day of receiving the appeal request.
Forward a summary and supporting documentation to the Appeals Section within 10 days of receiving
the appeal request. Send a copy to the client and the client’s representative, if any.
Follow the appeal processes outlined in 1-E, Appeals and Hearing.
