In Iowa:
  • There were a total of 440,993 beneficiaries enrolled in Iowa Medicaid as of July 2011. Of these, 401,785 were enrolled in managed care.
  • Physical health services are delivered through a primary care case management  (PCCM) system, known as the Medicaid Patient Access to Services System (MediPASS).  Children and adults who qualify for Medicaid because they belong to an income-eligible family (Section 1931) are required to enroll. Of these, 196,450 were enrolled into the PCCM program. A number of categories of beneficiaries are excluded, including children with special health care needs. Those not enrolled in the PCCM program receive their health services through a fee-for-service system.
  • Mental health and substance abuse services are delivered to almost all Medicaid beneficiaries through a behavioral health organization (BHO). Both 1931-eligible and SSI children are required to enroll.  Only a few groups, such as dual eligibles and presumptive eligibles are excluded. As of July 2011 401,785 Medicaid beneficiaries were enrolled into this BHO.
  • Iowa’s Children’s Mental Health Waiver provides home and community-based services to Medicaid-eligible children with serious emotional disturbance (SED). Medicaid-eligible children with an SED diagnosis can choose to enroll in the waiver, at which point a targeted case manager helps to coordinate services for the child and family.
As of 2012, 323,333 individuals (aged 0-20) were eligible for EPSDT Care for Kids, Iowa’s Medicaid benefit for children and adolescents. According to CMS data from 2012, EPSDT Care for Kids achieved a screening ratio of 100% and a participation ratio of 81%. 142,276 children received dental services of any kind, with 128,501 receiving preventive dental services.
Last updated December 2013.
Medical Necessity
Iowa’s Medicaid program covers medically necessary services offered by participating providers. It has a single medical necessity definition for all services.  It does not have distinct definitions for children, oral health services, or behavioral health services. In Iowa, in order to be medically necessary, services must:
  1. Be consistent with the diagnosis and treatment of the patient’s condition.
  2. Be in accordance with standards of good medical practice.
  3. Be required to meet the medical need of the patient and be for reasons other than the convenience of the patient or the patient’s practitioner or caregiver.
  4. Be the least costly type of service which would reasonably meet the medical need of the patient.
Initiatives to Improve Access
Primary care providers (also known as patient managers) in the primary care case management (PCCM) program are required to provide 24-hour access for their members and must establish a 24-hour access telephone number for scheduling appointments, accessing information, and for use by members when the provider’s office is closed.
When a child or adolescent is due for an EPSDT Care for Kids screening provided through the PCCM program, the Department of Public Health is required to issue a reminder to the family.
Iowa uses specialized software, verification of provider appointment availability and 24-hour access, and a review of referral documentation to monitor access to the PCCM program.  
Reporting & Data Collection
Iowa uses its fee-for-service claims payment system to keep track of services for mandatory reporting to CMS. The state also analyzes its CMS Form-416 data at a county-by-county level and uses this data to pinpoint where in the state Medicaid-enrolled children face issues in accessing dental and physical health services.
Primary Care Case Management
As outlined in the procedural guide for the primary care case management (PCCM) program, known as the Medicaid Patient Access to Services System (MediPASS), Iowa Medicaid provides participating providers with information on the utilization of enrolled families and children on a quarterly basis. Providers may also receive a Quarterly Member Utilization Exception Report.  Quality Assurance/Utilization Reviews are performed by Medicaid on a quarterly basis to collect and analyze provider information on 24-hour access, appointment access for urgent and routine care, and proper use of referral numbers.
Child and Adolescent Reporting System
The Title V child health agencies that deliver many services under the Medicaid benefit all use a Child and Adolescent Reporting system electronic health record to record the provision of services. The system provides a clinical record for all children receiving services at one of the agencies, not only children enrolled in Medicaid.
Behavioral Health
Currently, Medicaid pays for general developmental screens, social-emotional developmental screens, and autism screens all under the 96110 CPT code. Iowa uses claims data to, among other things, produce the CHIPRA core measure on developmental screening.
Contract language for the Iowa Plan for Behavioral Health requires the behavioral health organization (BHO), Magellan Health Services, to submit monthly or quarterly reports (depending on the specific indicator) to the Department of Public Health and the Department of Health Services on child-specific measures, including 7-, 30-, and 90-day mental health readmission, integrated services and supports, involuntary hospitalizations, and improvement in the psychosocial domain of Medicaid children and adolescents who are receiving services.  
Behavioral Health
In Iowa, Medicaid behavioral health services are carved out of physical care and are available through the Iowa Plan for Behavioral Health. The Iowa Plan is a managed care program that delivers mental health and substance abuse services to almost all Medicaid beneficiaries in Iowa through a behavioral health organization (BHO), Magellan Health Services.
The state produced a behavioral provider manual that contains codes that providers in Iowa can bill for health and behavior assessments, including 96510 and 96511 (health and behavior assessment, initial assessment and re-assessment).
1st Five Healthy Mental Development Initiative
The Iowa Department of Public Health’s 1st Five Healthy Mental Development Initiative was designed to bridge public and private health care systems to improve early detection of social-emotional delays and promote prevention of mental health problems among young children. The model promotes the use of standardized screening tools, educates and supports medical practices in implementing developmental screening tools, and uses trained care coordinators who work with families to assure follow-up and access to services. 1st Five care coordination for Medicaid beneficiaries is reimbursed as a covered EPSDT service.
For more information about behavioral health services for children enrolled in Medicaid, see "Behavioral Health in the Medicaid Benefit for Children and Adolescents: Iowa."
Support to Providers and Families
Support to Families
The Iowa Department of Public Health (IDPH) has contracted with local Title V agencies to establish regional EPSDT Care for Kids Coordinators who are available in every county in Iowa. EPSDT Care For Kids Program Coordinators help families of children from birth to age 21 access health care services. These positions are funded by Medicaid through an Interagency Transfer Agreement with the IDPH to conduct outreach and care coordination functions for the EPSDT program.
Iowa’s EPSDT Care for Kids also offers the Healthy Families line, a 1-800 number that connects families to a local EPSDT Provider Training Consultant to facilitate access to additional screening, evaluation, or intervention services.
Support to Providers
The state operates the EPSDT Care for Kids provider website which provides information on screening codes, billing tools, and additional program resources. The EPSDT Care for Kids Newsletter, published three times per year, is also posted on the site to provide health care providers with information and resources on child preventive health topics.
Iowa Medicaid published a provider manual for screening centers, which are paid for health screenings for Medicaid members who are under 21 years of age. The manual outlines covered services, content of screening examinations, payment policies, and other procedures.
A handbook for EPSDT Care for Kids Program Coordinators is also available. In addition to their work with enrollees and their families, the EPSDT Care for Kids Program Coordinators help health care providers identify local resources for developmental services for children at risk. 
Care Coordination
Section 2703 Health Homes
Iowa has two approved Section 2703 health home state plan amendments. The first, approved in June 2012 and effective July 1, 2012, is for Medicaid enrollees with two qualifying chronic conditions, or one qualifying chronic condition and risk for a second; a body mass index over 85 for the pediatric population is one of the qualifying chronic conditions. The second health home state plan amendment is for adults with serious mental illness and children with a serious emotional disturbance, and was approved on June 18, 2013. Specifically, Iowa is planning to establish two types of health homes to serve three groups of children with at least one mental health condition:  
  • Primary care health homes would serve Medicaid-enrolled children with a single chronic mental health diagnosis and minor functional impairments.
  • Specialized health homes would serve both (1) children with a serious emotional disturbance and high risk or (2) complex children with multiple diagnoses that require a multi-system involvement. In addition to the features of the primary care health home, these specialized health homes would have competency in dual diagnosis, incorporate SED waiver services, and fully integrate case planning across school systems, juvenile courts, and the child welfare system.
Inter-Agency Agreements
Iowa’s Department of Public Health, under an agreement with Iowa Medicaid, has established contracts throughout the state with regional Title V agencies to both assist families in accessing EPSDT services and assist primary care providers in linking families to services. All of these agencies also participate in the State Medicaid program.  The regional Title V agencies have four responsibilities for EPSDT:  informing, care coordination, screening, and diagnosis and treatment. The agencies bill the Department of Public Health for informing and care coordination on a fee-for-service basis and bill the Medicaid agency for Medicaid-covered services (such as EPSDT screens) through the claims processing system, as would any other qualified provider. 
Oral Health
Dental hygienists at Title V agencies in Iowa can be reimbursed by Medicaid for providing oral screenings and fluoride varnish applications to Medicaid-enrolled children.
The state’s I-Smile dental home initiative began as a result of legislation passed in 2005 which stated:
“… every recipient of medical assistance who is a child 12 years of age or younger shall have a designated dental home and shall be provided with the dental screenings and preventive services, diagnostic services, treatment services, and emergency services as defined under the Early and Periodic Screening Diagnosis and Treatment (EPSDT) program.”
The I-Smile initiative seeks to connect children to dental services, and to promote the delivery of dental care in alternative settings as well as dentists’ offices.  It relies on dental hygienists employed by regional Title V agencies who serve as care coordinators. The I-Smile Oral Health Coordinators work in communities and establish relationships with local dentists and physicians. I-Smile coordinators also assist EPSDT beneficiaries with making appointments, keeping appointments, arranging transportation, and understanding the importance of good oral health.