Allamakee COUNTY

 

MENTAL HEALTH & DEVELOPMENTAL DISABILITIES SERVICES

 

POLICIES AND PROCEDURES MANUAL

 

 

 

 

 

 

 

 

 

 

 

Approved December 4, 2001

Allamakee County Board of Supervisors

 


Table OF Contents

Section I—Consumer Manual...................................................................................................................... 2

A.      WHERE DO I GO TO GET SERVICES?..................................................................................................... 2

B.      HOW DO I KNOW IF I AM ELIGIBLE FOR SERVICES AND FUNDING?....................................... 3

C.      HOW ARE DECISIONS MADE ABOUT MY SERVICES AND FUNDING?...................................... 4

D.      WHAT TYPES OF SERVICES ARE AVAILABLE?................................................................................ 6

E.      WILL I HAVE TO PAY FOR MY SERVICES?....................................................................................... 11

F.      WHAT IF I’M APPROVED TO RECEIVE SERVICE FUNDING BUT THERE ISN’T ENOUGH MONEY?  12

G.      WHAT SHOULD I EXPECT FROM MY SERVICES?.......................................................................... 13

H.      WHAT ARE MY RESPONSIBILITIES AND RIGHTS?....................................................................... 13

I.       CAN THE PERSON MAKING DECISIONS ABOUT MY SERVICE BENEFIT PERSONALLY? 14

J.       HOW CAN I BE SURE MY PRIVACY WILL BE RESPECTED?....................................................... 14

K.      WHAT IF I HAVE A COMPLAINT OR DISAGREE WITH A DECISION ABOUT MY ELIGIBILITY, SERVICES OR FUNDING?................................................................................................................................................................. 17

Appeal Procedure................................................................................................................................................ 17

Step One:  Central Point of Coordination Administrator Review.............................................................. 17

Step Two: Optional Appeals Board Hearing.................................................................................................. 18

Step Three:  Board of Supervisors Hearing.................................................................................................... 18

Step Four:  Administrative Law Judge Hearing............................................................................................. 19

Section II—System Administrative Manual................................................................................. 20

A.      GENERAL INFORMATION....................................................................................................................... 20

B.      ORGANIZATIONAL STRUCTURE.......................................................................................................... 20

C.      STAFFING...................................................................................................................................................... 21

D.      PROVIDER APPLICATION & CREDENTIALING............................................................................... 21

1.  Selection of Providers.................................................................................................................................... 21

2.  Network Membership Criteria...................................................................................................................... 22

3.       Contracts................................................................................................................................................... 22

E.      PROVIDER ROLE IN SERVICE PROVISION....................................................................................... 22

1.  Accessing Services.......................................................................................................................................... 22

2.  Application Process....................................................................................................................................... 23

F.      FUNDING AUTHORIZATION................................................................................................................... 24

G.      PROVIDER REIMBURSEMENT FOR SERVICES............................................................................... 25

H.          PLAN DEVELOPMENT......................................................................................................................... 25

1.  Process.............................................................................................................................................................. 25

I.       BUDGET......................................................................................................................................................... 26

J.       TRACKING.................................................................................................................................................... 26

K.      ANNUAL REPORT....................................................................................................................................... 27

L.      QUALITY ASSURANCE............................................................................................................................. 27

1.  System Evaluation.......................................................................................................................................... 27

2.  Service and Supports Evaluation................................................................................................................ 28

M.     CONFIDENTIALITY................................................................................................................................... 28

N.      INTERFACES & COLLABORATIONS.................................................................................................... 28

APPENDIX.................................................................................................................................................................... 31

A.      DIAGNOSTIC DEFINITIONS.................................................................................................................... 31

B.      LEGAL SETTLEMENT............................................................................................................................... 32

C.      CPC APPLICATION FORM....................................................................................................................... 34

D.      RECERTIFICATION FORM...................................................................................................................... 38

E.      NOTICE OF DECISION FORM................................................................................................................. 39

F.      APPEAL PROCESS FORM......................................................................................................................... 40

G.      CONSENT TO OBTAIN AND RELEASE INFORMATION................................................................. 41

H   CO-PAYMENT SCHEDULE........................................................................................................................... 45

 

Allamakee County

Mental Health/Developmental Disabilities Services

Policies and Procedures Manual

 

MISSION STATEMENT

Allamakee County is dedicated to providing appropriate and cost effective mental health services.  Toward this end, the county management plan will provide a vehicle for identifying the type and amount of service consumers require to live and work in the least restrictive environment.  The county plan will reflect consumer choice and empowerment and give priority to community-based services when appropriate.

Section I—Consumer Manual

 

A.      WHERE DO I GO TO GET SERVICES?

 

            In the case of emergency, call the Northeast Iowa Mental Health Center 24-Hour Crisis Line at 1-800-400-8923 or go to the Veterans’ Memorial Hospital, 40 First St. SE in Waukon right away.   This will give you immediate access to care and insure your health and safety.

 

            If it is not an emergency or you are not sure which agency provides the service you need, contact:

 

            Allamakee County Central Point of Coordination Office      563-568-6227

            Allamakee County Courthouse, First Floor                            563-568-6417 (FAX)

            110 Allamakee St.                                                                  

            Waukon, IA  52172

 

            Allamakee County Targeted Case Management                    563-568-6227

            Allamakee County Courthouse, First Floor

110 Allamakee St.                                                                  

            Waukon, IA  52172

 

            Northeast Iowa Mental Health Center                                   319-382-3649

            905 Montgomery                                                                    1-800-400-8923

            Decorah, IA  52101                                                                (available 24 hours)

 

           


The following local agencies are access points to the CPC office and can also help you start the process of getting services:

 

            Makee Manor                                                                          563-568-4266

            877 Highway 9

            Waukon, IA  52172

 

            Martin Luther Homes of Iowa                                                563-568-3992

            22 Second St. NW

            Waukon, IA  52172

 

TASC, Inc.                                                                              563-568-4060

            2213 Mt. Olivet Road NW

            Waukon, IA  52172

 

B.      HOW DO I KNOW IF I AM ELIGIBLE FOR SERVICES AND FUNDING?

 

            All Allamakee County residents are eligible for free information and referral services through Northeast Iowa Mental Health Center regardless of clinical or financial need.  All residents are also eligible for crisis and commitment services. 

 

            To determine if you are eligible for other county funded services you must make application to the Central Point of Coordination (CPC) office in the Allamakee County Courthouse.  Applications are available at all local network service agencies and the CPC office.  The following steps determine if you are eligible for funding:

 

            1.  You Must Apply

            You must complete and sign a Central Point of Coordination Application, and sign all necessary release of information forms to obtain verification of covered diagnosis and financial eligibility.  Staff at any access point will accommodate anyone who may have special needs in accessing services and filling out applications.  In the case of emergencies and commitments, a CPC application will be mailed to you.

 

           


2.  You Must Be In Financial Need

            Your average monthly gross income must be below 150% of the current Federal Poverty Guidelines.  You may deduct your average monthly daycare and medical expenses when figuring your monthly gross income.  Resources must not exceed $2,000 cash ($3,000 for couple; $500 for each additional child), a home, a car and a burial trust fund (up to current Department of Human Services guidelines) to qualify for total county funding.  Outpatient psychotherapeutic services are funded for individuals with family incomes between 150-250% according the co-payment schedule.

 

            Transferring ownership to gain eligibility is not allowed and may disqualify you or require payment towards service in the amount transferred.  Medicaid guidelines will apply.

 

            3.  You Must Have a Covered Diagnosis

            You must have an established diagnosis of mental illness, chronic mental illness, mental retardation or developmental disability.  The specific definitions appear in the Appendix.

 

            4.  Your County of Legal Settlement Must Be Determined

            Legal settlement refers to a legal concept, which determines which county is legally responsible for the cost of your service.  Your eligibility does not depend on the county of legal settlement but may affect the services available and the way your service is administered.  More specific details are in the Appendix.

 

            5.  You Will Be Notified of the Eligibility Decision

            A notice of decision will be mailed to you and your service coordinator within 10 working days of receiving the completed CPC application.  The decision will state whether you have been approved or denied for funding, or if the decision is pending and more information is needed.  If you have legal settlement in another county or the state of Iowa, you will be given information about how to proceed.

 

C.      HOW ARE DECISIONS MADE ABOUT MY SERVICES AND FUNDING?

 

            Once you are determined eligible for county funded services, a service coordinator will be assigned to you.  Your service coordinator will work with you through the following process to determine how much and what kind of service you may receive. 

 

            1.  Assessment

            The service coordinator will do an assessment.  An assessment is information collected by interviewing you, and other interested people or providers of your choosing, to give the best picture of your needs.  Other assessments may be used instead of, or in addition to, the service coordinator’s assessment.

 

            2.  Development of an Individual Comprehensive Plan

            After the assessment, the service coordinator will work with you and others you have identified as being part of your treatment team to develop a plan to meet your needs and accomplish your goals.

 

            3.  Service Funding Request

            After the service coordinator verifies that county funded services are the least restrictive and most cost effective services appropriate for your needs, and that alternative funding and supports were considered first, a service funding request is submitted to the Central Point of Coordination (CPC) Administrator.

 

            The CPC Administrator will then decide if the treatment, rehabilitative or supportive services are:

 

            (1) Appropriate and necessary to the symptoms, diagnoses or treatment;

            (2) Within standards of good practice for the type of service requested;

            (3) Not primarily for your convenience or that of the service provided;

            (4) The most appropriate level of service which can safely be provided;

            (5) Of benefit to you and not available from alternative sources;

            (6) For a service available to your covered diagnosis.

 

            The funding request decision will not supersede approval of services mandated by federal or state statue, code, or rule.

 

            4.  Funding Decision

            A notice of decision will be mailed to you, your service coordinator, and providers of the services requested within 10 working days after receiving the service funding request.  If approved, funding is for the time frame requested on the request form (not to exceed one year) unless otherwise stated.  Only services with prior approval by the CPC Administrator will be reimbursed.

 

            If funding is reduced or denied, the reason will be stated along with your right to appeal and the procedure to do so.

 

            If you are approved but funding is not available, you will be placed on a waiting list.  You will be informed of the approximate time you may expect to be on the waiting list.  (See question F for more details.)

 

            5.  Ongoing Approval of Service Funding

            Financial eligibility must be redetermined annually.  This generally occurs in May/June to be effective July 1.  Your service coordinator will coordinate this process.  You and your service coordinator must also submit a new service-funding request at the time that you need additional services.

 

            If funding is to be reduced or stopped, you and the service providers will receive notice 30 days prior to the effective date.  Your service coordinator will assist you in exercising your right to appeal and make alternative plans if the funding decision is not reversed.

 

D.      WHAT TYPES OF SERVICES ARE AVAILABLE?

 

            The following services funded in part or in whole by Allamakee County are available to individuals with an established diagnosis.  Criteria for each service may vary.  Specific details may be found in the “Service Matrix” in the Appendix.

 

            Information and Education Services (do not require CPC Application)

            Information and Referrals are activities designed to provide facts about resources that are available and help to access those resources.  This service is available 24 hours through the Northeast Iowa Mental Health Center to all Allamakee County residents regardless of financial or diagnostic eligibility.

 

            Public Education Services are activities provided to increase awareness and understanding of the causes and nature of conditions or situations, which affect a person’s functioning in society.  Services focus on prevention and public awareness activities.  This service is available to all Allamakee County residents regardless of financial or diagnostic eligibility.

 

            Coordination Services

            Case Management-Medicaid Match is an interdisciplinary process to assist individuals in obtaining appropriate services and living arrangements and is coordinated by a case manager.  Individual must be Medicaid eligible.

 

            Case Management-100% County Funded is the same service as above except that the funding comes totally from the county.  Service requires CPC approval on a case-by-case basis.

 

            Services Management is designed to help individuals and families identify service needs and coordinate service delivery but to a lesser degree than case management.  A service coordinator provides this service.

 

            Personal and Environmental Support Services

            Transportation services enable individuals to conduct business errands or essential shopping, to receive medical services not reimbursed through Title IXX, to go to and from work, recreation, education and day programs, and to reduce social isolation.

 

            Home Management Services provides for personal emergency response systems covered under Home and Community Based Waivers.

 

            Respite provides temporary care to an individual normally provided by the usual caregiver under Home and Community Based Waivers.

 

            Payee Services manage social security benefits and other finances for those individuals not in a residential program.  Representative payee designation if made by the Social Security Administration.

 

            Home/Vehicle Modification is for physical modifications to the individual’s home environment and/or vehicle which are necessary to provide for the health, welfare, and safety of the individual, and which enable the individual to function with greater independence in the home or vehicle.  This service is available under Home and Community Based Waivers.

 

            Supported Community Living provides services and supports necessary for individuals to live and work in a community setting while living with their families.  This service is available under Home and Community Based Waivers.

 

            Basic Needs-Other provides bedhold fees for licensed/certified living arrangements while an individual is hospitalized.  Private sources must be accessed first, and payment requires prior CPC Administrator approval.

 

            Treatment Services

            Physiological

            Prescription Medication provides funding for psychiatric medications on an ongoing basis for individuals who are at risk of a more restrictive placement without this funding.

 

            In-Home Nursing provides nursing services in the individual’s home through the Home and Community Based Waivers.

 

            Psychotherapeutic

            Outpatient Therapy is a planned process in which a therapist uses professional skills, knowledge and training to enable individuals to realize and use their strengths and abilities; take charge of their lives; and resolve their issues and problems.  This service can be provided by any licensed mental health professional in individual or group settings.  All Allamakee County residents are eligible for outpatient services. Outpatient psychotherapeutic services are funded for individuals with family incomes between 150-250% according to the co-payment schedule.

 

            24-hour Crisis Phone access to a trained crisis counselor through Northeast Iowa Mental Health Center.

 

            Partial Hospitalization is an active treatment program providing intensive group and clinical services within a structured therapeutic environment for those individuals who are exhibiting psychiatric symptoms of sufficient severity to cause significant impairment in day-to-day functioning.  Must be Medicaid eligible.

 

            Evaluation is the process of screening, diagnosing and assessing individual and family functioning, needs, abilities, and disabilities, and determining current status and functioning, recommendations for services, and need for further evaluation.

 

            Rehabilitative

            Day Treatment Services provide for individualized services emphasizing mental health treatment and intensive psychiatric rehabilitation activities designed to increase the individual’s ability to function independently or facilitate transition from a residential placement.  Other funding sources such as Medicaid must be utilized first before county funding is available.

 

            Community Support Programs are comprehensive programs to meet individual treatment and support needs of individuals to live and work in a community setting.  Individuals must need this service in order to remain in the community.  Other funding sources such as Medicaid and Community Services Block Grant funding must be utilized first before county funding is available.

 

            Vocational and Day Services

            The following services are funded by Allamakee County after Division of Vocational Rehabilitation Services benefits have been exhausted. Any individual under 21 must establish that services are not available through the responsible school district and area education agency.

 

            Sheltered Work Services are designed to lead to competitive employment, or long-term sheltered employment at an applicable certificate rate. 

 

            Work Activity Services are for those individuals whose impairment severely reduces their productive capacity so that ongoing employment is unlikely.

 

            Adult Day Care are services provided during the day in a protective environment where the program is therapeutic to meet the physical and psycho-social needs of the individual.

 

            Supported Employment/Follow Along is ongoing intermittent support provided by a job coach to a consumer who has been successfully placed in competitive employment.  Individual must be considered at risk of losing job without services.

 

            Supported Employment/Job Coaching is time limited job training and support provided to a consumer who has been newly employed in the community or requires job coach intervention to retain current position.

 

           

Licensed/Certified Living Arrangements

            Community Supervised Apartment Living Arrangement  Array of services (service coordination, community living skills training, self-care and support services) to promote consumer self-reliance and independence.  Must be at risk of needing residential placement and not served through the Medicaid Community Support Program.

 

            Residential Care Facility  Room, board, supervision, care and personal assistance.  Basic, social, and independent living skills training, health screening, leisure-time, recreational, special treatment, behavior therapy, support, transportation, and transition services.  Must need supervision, assistance or care on a daily basis in order to be reasonably safe and must not require ongoing care from a nurse.

 

            Residential Care Facility for Persons with Mental Retardation (RCF/MR)  Room, board, supervision, care and personal assistance.  Basic, social, and independent living skills training, health screening, leisure-time, recreational, special treatment, behavior therapy, support, transportation, and transition services.  Must need supervision, assistance or care on a daily basis in order to be reasonably safe and must not require ongoing care from a nurse.  Programming and services directed to the special needs of persons with persistent mental retardation.

 

            Residential Care Facility for Persons with Persistent Mental Illness (RCF/PMI) Room, board, supervision, care and personal assistance.  Basic, social, and independent living skills training, health screening, leisure-time, recreational, special treatment, behavior therapy, support, transportation, and transition services.  Must need supervision, assistance or care on a daily basis in order to be reasonably safe and must not require ongoing care from a nurse.  Programming and services directed to the special needs of persons with persistent mental illness.

 

            Intermediate Care Facility for Persons with Mental Retardation (ICF/MR)  Institutional care providing active treatment and psychological, medical, pharmacy, dental, opthamology, audiology, speech, occupational therapy, physical therapy, dietary, behavior, vocational, educational, residential, community, and recreational services and supports.  Iowa Foundation for Medical Care must approve consumers.

 

            Supported Community Living  Programs for those individuals living alone or with other consumers in a house or apartment receiving services and supports determined necessary to enable consumers to live and work in a community setting.  Must be at risk of needing residential placement and not being served through Medicaid Community Support Program.

 

            Institutional/Hospital and Commitment Services

Inpatient/State Mental Health Institutes  Treatment at Independence Mental Health Institute for individuals with an acute psychiatric illness who meet the criteria for medical necessity as defined in the Iowa Mental Health Access Plan.  All admissions, both voluntary and court-ordered, must be prescreened by Northeast Iowa Mental Health Center staff or have prior CPC administrator approval.

 

            State Hospital School for Persons with Mental Retardation Institutional care providing active treatment and psychological, medical, pharmacy, dental, ophthalmology, audiology, speech, occupational therapy, physical therapy, dietary, behavior, vocational, educational, residential, community, and recreational services and supports.  Iowa Foundation for Medical Care must approve consumers.  Individual must require a level of care not available from community-based providers.

 

            Inpatient/Community Hospital  Inpatient expenses incurred at public community based hospital.

 

            Commitments (under Iowa Code Section 229)

            Diagnostic Evaluations Related to Commitment provides for an evaluation performed as part of the commitment process.

 

            Sheriff Transportation provides for transportation costs as part of the commitment process.

 

            Legal Representation provides for legal services as part of the commitment process.

 

            Advocacy Services provide for an advocate for the individual while under commitment.

 

            Other Services Not Listed

            Allamakee County is committed to funding cost effective services, which help individuals live independently.  At times individuals may have special needs that are not included on this list.  Individuals, in collaboration with their service coordinators, are encouraged to make service-funding requests for services that meet these special needs.  Decisions to fund these services will be made by the CPC Administrator and viewed as “exceptions to policy”.

 


E.      WILL I HAVE TO PAY FOR MY SERVICES?

 

            Depending on your service and the guidelines, you may be required to repay or make a co-payment.  You must also apply for, accept, and maintain eligibility for any other benefits or funds that you are eligible to receive before the county will fund your services.  Allamakee County is the funder of last resort. 

 

            You will meet the requirements for income eligibility for county funding if your family’s gross income is at or below the 150% poverty guidelines as outlined annually by the United States Department of Health and Human Services.  If your income is higher than this, you will have to pay a portion of your own service cost.  You may deduct your average ongoing medical costs and day care expenses for work hours.  The following are guidelines for consumer co-payment guidelines for various services:

 

            Outpatient Psychotherapeutic Services

            The amount of your co-payment is determined by the amount of your family’s gross income.  There is no co-payment for individuals with incomes below 150% of poverty.  A co-payment is required for those individuals with incomes between 150-250%.  This amount is collected by the service agency.  See the co-payment schedule in the Appendix.

 

            Community Support and Supported Community Living Services

            Individuals receiving these services must pay 50% of their monthly income above the 150% poverty guideline.

 

            Residential Services

            Individuals living in RCF facilities must pay 100% of their monthly income less $70 for personal allowance and unmet medical needs towards their care.  If receiving State Supplementary Assistance (SS), the Department of Human Services Income Maintenance Worker determines the client participation.

 

            Medicaid Institutional Services

            Individuals in Intermediate Care Facilities for Mentally Retarded (ICF/MR) and Home and Community Based Waiver (HCBS/MR) programs will have their participation determined by the Department of Human Services Income Maintenance Worker.

 

            Vocational Services

            Individuals receiving Work Activity or Sheltered Work Services will have their income calculated by deducting the first $65 and will be responsible for paying 50% of the difference between their income and the 150% poverty guideline.

 

            Individuals receiving Supported Employment Services will be responsible for paying 50% of the difference between their income and the 150% poverty guideline.

 

F.      WHAT IF I’M APPROVED TO RECEIVE SERVICE FUNDING BUT THERE ISN’T ENOUGH MONEY?

 

            The notice you receive approving your funding will indicate that you have been placed on the waiting list.

 

            Waiting List

            You are placed on a waiting list if at the time of your application the Mental Health/Developmental Disabilities Service Fund is projected to be fully encumbered (ear marked for individuals currently in system) for the fiscal year (July 1st to June 30th) and the funding request is not mandated.  This means that the money available is already committed to pay for the services already being provided.  If you are currently receiving services and are seeking additional or different services, you will also be placed on a waiting list if funds are not available.

 

            As funds become available, individuals on the waiting list will be approved for admission based on the following criteria:

 

            (1) Individuals who, if they did not receive the service for which they are applying, would likely access a mandated service will be considered first.

 

            (2) Individuals with the most severe need for service will be considered next.  Examples of this would include:  being homeless without the services; children in foster care who are becoming adults and are ineligible for state funding; dependent adults in abusive or neglectful situations; or situations where the caretaker is subject to violence or aggressiveness by the individual.

 

            (3) Individuals applying for services which have been designated as high priority services shall be considered next:  residential programs, case management, medications, supported employment, sheltered work, work activity.

 

            (4) If all other criteria are equal, the application with the earliest date of application shall be considered next.

 

            (5) Admission to services is also dependent on the availability of the service, and situations could arise in which applicants who are lower on the order of criteria are admitted ahead of applicants who are higher on the order for the reason that the higher priority service is unavailable.

 

G.      WHAT SHOULD I EXPECT FROM MY SERVICES?

 

·         That they are available when you need them.

·         That they respond to your individual needs.

·         That you are involved in the planning of the services.

·         That you have a choice of who provides the service.

·         That you have a choice of where and with whom you live.

·         That you have a choice of the type job and where you work.

·         That you and your family are satisfied with the quality of your life and services.

·         That your services lead to greater independence.

 

            We will strive to meet your expectations by involving you, your family and all       interested people in the program planning, operations and evaluation of the mental   health/developmental disabilities system.

 

H.      WHAT ARE MY RESPONSIBILITIES AND RIGHTS?

 

            1.  Responsibilities

            You have a responsibility to get the most from the services provided:

            (1) Treat those giving you service with the same respect and kindness you expect to receive.

            (2) Ask questions about your service so you understand what is expected of you.

            (3) Seek help before you are in a crisis situation.

            (4) Keep your appointments and be on time.  Call ahead if you must cancel.

            (5) Follow the procedures for complaints, care review and appeals if you are unhappy with your service.

            (6) Work towards the goals identified in your service plan.

 

            2.  Rights

            In addition to your constitutional rights, you have the following specific rights:

            (1) The right to privacy, including the right to private conversation, and to confidentiality.

            (2) The right to be treated with respect and to be addressed in a manner that is       appropriate to your chronological age.

            (3) The right to appeal any staff or provider action.

            (4) The right to enter into contracts.

            (5) The right to due process.

            (6) The right to receive a written Notice of Decision that specifies the type of

service, the amount of service, and the cost of service approved to be funded by

the County.

(7)    The right to legal representation at your own expense.

 

            Individuals with mental illness, mental retardation, and other developmental          disabilities have the same fundamental rights as all persons.  Rights can be limited       only with the informed consent of the individual’s guardian or legal authorities    with the following guidelines:  limit is based on an identified individual need;        skill training is in place to meet the identified need; periodic evaluation of the

limits is conducted to determine the continuing need for limitation.

 

            In the event you feel any of your rights have been infringed upon, you may request advocacy assistance from your service coordinator or other advocates.  At any point, you may refuse all or part of services, which are being offered.

 

 

            If you are not responsible, services may be reduced or terminated, so it is important that you do your part.

 

I.       CAN THE PERSON MAKING DECISIONS ABOUT MY SERVICE BENEFIT PERSONALLY?

           

            The CPC Administrator will make funding decisions.  It is the intent of Allamakee County that an individual or organization, which has a financial interest in the services or supports to be provided, will not make funding decisions.  In the event that such a situation occurs, that interest must be fully disclosed to all involved on the service notification of decision form.

 

J.       HOW CAN I BE SURE MY PRIVACY WILL BE RESPECTED?

 

            Overview and General Principles:

The purpose of this section is to describe what happens to personal information and records provided by, for and about consumers who apply for mental health and developmental disability service funding in our county.  It explains the general rules and practical safeguards that apply to each and every stage of the application, service delivery and appeals process.  Also discussed are release of information forms, medical emergencies, and the state and federal laws that govern the disclosure of mental health, HIV/AIDS, substance abuse and other personal information.

 

We are committed to providing cost-effective services that match your unique strengths, circumstances, priorities, abilities and capabilities.  To do so, and with your written permission, our staff must obtain and exchange records, information and impressions.    Our written application asks for details about disability, health care, finances, employment, living arrangements, benefits and other personal matters.  Developing a comprehensive service plan usually involves many individuals and organizations.  Bringing people together is the best way we know to help you choose and begin receiving supports, referrals, case management and other services. 

 

Confidentiality Safeguards:

We are equally committed to respecting your privacy and keeping confidential the information, records, and files we compile, or that your share with us.  In date-to-day terms, confidentiality means:

·         We will get your written consent, or your legal guardian’s written consent, before we information to others.  During medical or other emergencies when you are not able to give your consent, we will only release information required by law to address and resolve the crisis.

·         We will only release information and records to others when they need to know the information to accomplish a specific task.  For example, persons hearing appeals on a limited issue do not need to review, or enter into evidence, a person’s entire clinical or medical history or file.

·         We will let you, or a person designated by you, review and copy your records.  No fees will be charged for reviewing records but you will be responsible for copying costs.

·         We will conduct interviews with consumers and with others in private settings where the public cannot overhear any of the discussions.

·         We will make referrals and discuss and transact other consumer-related business in similarly private settings.  We will not discuss information about you in elevators, restaurants or other public places or gatherings, or at our homes.

·         We store and maintain paper and computer files in a manner that prevents the public from seeing or having access to them.  This means that records will be returned each day to a file cabinet that is locked.  It also means that a person cannot get into a computer file without a password.

·         We will remove information that identifies you, such as your name, address and social security number, from various documents.  These documents include e-mail, billing, quality control and other reports. 

·         We will make sure that fax machine transmissions are directed to the proper persons.

·         We will train other county staff about our practices and the laws and safeguards relating to personal information.

 

Release of Information Authorization Forms: 

 

            When you apply for services, you will be asked to read, review, date and sign a release of information form.  You can always change your mind at any time and revoke your consent to release information.  Also, you can decide that only certain people or agencies can receive this information.  Services will no be automatically denied if you refuse to sign the release.  However, without supporting information, it will be difficult, if not impossible for us to act on or approve any request.  If you are not able to sign the form or grant your consent, your legal guardian can do so on your behalf. 

 

A copy of the Release of Information form used by us can be found in the Appendix on page 42 and is included with our Application Form.  The release identifies the persons and organizations that are free to share information and records about you.  It also describes the types of information that can be released, the purposes for which the information can be used, and whether or not mental health, substance abuse or HIV/AIDS information can be released.  It also notes that you have the right to withdraw or revoke your consent, request a list of persons and agencies that received and used the releases, and inspect the materials that were disclosed.  It must be signed and dated.  You must sign and initial the form in two separate places to signify that you give us permission to release mental health, substance abuse or HIV/AIDS information or records. 

 

Medical or Other Emergencies:

In medical or other emergencies you may be unable to give your consent to the release of information.  When this happens, our first priority is to see that you receive emergency services.  We will only release information that is necessary and required by law to address and resolve the crisis.  We will keep track of the information we shared or obtained.  After the emergency ends, if you request, we will tell you who received the information and why they were entitled to receive the information.

 

The Right To Review Records:

You or your authorized representative may review your mental health and developmental disability files and records.  This can be done during office hours and for any reason.  You have the right to review your files and records during the appeals process, which is discussed in Section K. 

 

We ask that you call 563-568-6227 to schedule an appointment to review the records.  Please give us three (3) working days advance notice for time to gather the information.  A representative of our office may be present while you review the files.  There is no charge for reviewing records but you will be responsible for copying costs.  Special rules and protections apply to mental health, substance abuse and HIV/AIDS information, and are summarized below. 

 

Overview of Confidentiality Laws and Where to Find More Information:

A host of federal and state laws and regulations apply to the disclosure of personal information.  They are far too numerous for us to mention or detail in this policy and procedures manual section.  Each has its own set of definitions and terms.  The Iowa Code contains the laws of Iowa, many of which touch upon matters and set forth our duties and responsibilities.  All of these laws and regulations can be found in your public library and are available on the Internet.  It is not intended to provide you with legal counsel or advice and you should not consider this to be legal counsel or advice.  Only a licensed and qualified attorney can provide you with legal counsel, advice or representation.

K.      WHAT IF I HAVE A COMPLAINT OR DISAGREE WITH A DECISION ABOUT MY ELIGIBILITY, SERVICES OR FUNDING?

           

Contact your service coordinator who helped you fill out the form or the CPC Office at 563-568-6227.  If you are still not satisfied, you may request an appeal as follows:

Appeal Procedure

 

If you believe that a decision was in error, you may seek a review of that decision.  This procedure will be written on the back of every notice of decision issued by the CPC Administrator.  Any decision may go through the appeal process.

 

At an appeal hearing, you have the right to have an attorney or other advocate accompany and represent you at your own expense.  If you cannot afford an attorney, you may contact Legal Services Corporation of Iowa, the Iowa Volunteer Lawyer Project, or Iowa Protection and Advocacy Services, Inc. for assistance.  Telephone numbers for these agencies are available from the CPC Office.

Step One:  Central Point of Coordination Administrator Review

 

1.      To initiate a review, you must send a written request for review within ten (10) working days from the date of the CPC Administrator’s signature on the Notice of Decision.  It shall include:

·         Your name, address, and telephone number.

·         The name, address and telephone number of any person helping you with your appeal.

·         Your complaint and the reason you feel the decision should be changed.

2.      Within five (5) working days of the receipt of the written request for review, the CPC Administrator shall deliver to you personally or by certified mail a written notice of the date and time set for the review.

3.      The review will be held within ten (10) working days of the receipt of the request for review.

4.      You have the right to appear in person at the review and present any evidence or documents of support of your position.  You are encouraged to have an advocate of your choice, family member, guardian, friend, or case manager accompany you to the review.  If you fail to appear for the scheduled review, the reviewer may proceed and issue a decision.  You may waive the right to personally appear at the review and may present your documents only.

5.      Within ten (10) working days of the review, the CPC Administrator shall issue a written decision sent by first-class mail that will include a statement of the reasons supporting the decision.  This written decision will inform you of your right to further review by either the Appeals Board for recommendation or the Board of Supervisors. 

Step Two: Optional Appeals Board Hearing

 

You may request a further review by the MH/ DD Appeals Board.  This is a three-member board made up of citizens knowledgeable about the local MH/DD service system, but that have no vested interest in the case being reviewed.  This written Request of Appeal must be sent to the CPC Administrator within seven (7) days of the receipt of the adverse decision. 

 

A meeting of the Appeals Board will be scheduled as soon as possible but no more than ten (10) working days from receipt of Appeal Request.  This meeting will allow you to present your case to an objective person familiar with mental health / mental retardation services and the policies of County Government.  The Appeals Board will hear your case and make a written recommendation to the Winneshiek County Board of Supervisors.  At no time will the Appeals Board have the authority to overrule or exceed the provisions of this plan. 

 

Step Three:  Board of Supervisors Hearing

 

If you do not wish to have an optional Appeals Board Review or appeal the Appeals Boards’ decision, you may request further review by the Allamakee County Board of Supervisors.  This request will be made by giving notice to the Board in writing within seven (7) days of receipt of the adverse decision rendered by the CPC Administrator.

 

The Allamakee County Board of Supervisors will hear the appeal at the time scheduled in the agenda unless continuance is requested by the Applicant and granted by the Board.

 

At the time of the hearing, the Board will ask you or your representative to present the reasons for the appeal.  The CPC Administrator will present the reasons for the determination.  You may be questioned at that time. The appeal may be tape-recorded.  If you request, the hearing before the Board will not be an open meeting under Chapter 21, Code of Iowa, since your confidential files will be in evidence.  When the Board deliberates on the appeal, no person other than Board members, the County Attorney, the County Auditor, and/or assistants to those elected officials will be present.  The Board’s deliberations will not be tape-recorded.

 

The Board will make a decision on the appeal within ten (10) days after the hearing.  The Board’s findings of fact and decision will be based only on the evidence submitted during the hearing.  Immediately after making its decision, the Board will mail you by first-class mail its decision in writing.  The decision will state the reasons for the actions. 

Step Four:  Administrative Law Judge Hearing

 

If you wish to appeal the Board’s decision, you must send a written request as outlined in Step One to the CPC Office within ten (10) working days of the Board of Supervisors’ written decision.

           

Within five (5) working days of the receipt of the written request for an appeal, the CPC Administrator shall contact the Administrative Law Judge.  The Administrative Law Judge will render a decision according to administrative procedures.

 

If you are not satisfied with the result of this process, you may pursue the matter in Iowa District Court in accordance to procedures established under the Iowa Administrative Procedures Act, Chapter 17A, Code of Iowa.

 

           


Section II—System Administrative Manual

 

MISSION STATEMENT

Allamakee County is dedicated to providing appropriate and cost effective mental health services.  Toward this end, the county management plan will provide a vehicle for identifying the type and amount of service consumers require to live and work in the least restrictive environment.  The county plan will reflect consumer choice and empowerment and give priority to community-based services when appropriate.

 

A.      GENERAL INFORMATION

 

This management plan serves the area of Allamakee County that has a population of 13,855 (US Census 1990).  This plan provides for total coverage of costs of services for individuals with incomes below 150% of poverty.  Partial coverage of outpatient psychotherapeutic services is provided for those individuals with incomes between 150-250%.

 

B.      ORGANIZATIONAL STRUCTURE

 

Allamakee County will directly administer its Mental Health Management Plan and does not intend to contract management responsibility for any aspect of the management plan.  The Board of Supervisors, acting through the Central Point of Coordination Administrator, will retain full authority and full risk for the managed system of care and the fixed budget. The Central Point of Coordination Administrator reports directly to the Allamakee County Board of Supervisors.

 

A Citizens’ Advisory Board provides input to the direction to the CPC Administrator.  Final policy and budget decisions remain the responsibility of the Board of Supervisors.

 

            Central Point of Coordination Administrator

                        Allamakee County Central Point of Coordination Office

                        Courthouse, 110 Allamakee Street

                        Waukon, Iowa 52171

                        563-568-6227

563-568-6417 (fax)

                       

 


C.      STAFFING

 

Allamakee County shall employ an adequate number of staff to administer the plan.  Staff currently consists of the Central Point of Administration Administrator and a half-time administrative assistant. 

D.      PROVIDER APPLICATION & CREDENTIALING

1.  Selection of Providers

 

Traditional Providers

Service providers will be chosen on the basis of quality of services, responsiveness to consumers' needs and desires, responsiveness to County needs, rates for service, and accessibility.  All providers who are required to be certified, licensed, or accredited, shall be and shall continue to be in order to receive payment for services.

 

Providers meeting one or more of the following criteria and demonstrating a willingness to work with Allamakee County in improving existing services will be included in the service network:

·         Currently certified, licensed or accredited as a service provider with the state,

·         Currently under contract with a County in Iowa,

·         Currently enrolled as a Medicaid provider, and/or certified contracted member of the Merit Behavioral Care of Iowa (MBCI) provider network,

·         Currently accredited by the Joint Commission on the Accreditation of Health Care Organizations (JCAHO), the Council for Accreditation of Rehabilitation Facilities (CARF), or other national entities.

 

Non-Traditional Providers      Allamakee County will make serious efforts to recruit and approve non-traditional providers in its service provider network.  The following is the criteria and process for selecting and approving providers not currently subject to license, certification, or other state approval standards:

·         The service outcomes achieved by the non-traditional provider, as identified by the consumer must be comparable to services provided by traditional licensed providers.

·         Any non-traditional provider who is expected to work directly with consumers will be subjected to the following checks:

·         A check of the criminal registry

·         A check of the sexual predators registry

·         A check of the child abuse/dependent adult registry

·         The applicant shall provide evidence of applicable insurance (including liability insurance) and the mental/physical abilities or other qualifications needed to perform the service (i.e. driver’s license, ability to lift, ability to read label, etc.)

2.  Network Membership Criteria

 

Providers that are part of the Allamakee County network are required to submit the following to the Central Point of Coordination office:

·         Documentation of appropriate corporate structure and governance as evidenced by a copy of agency bylaws.

·         Current license, certification, and/or accreditation.

·         Current accreditation survey from Inspections and Appeals and/or similar accrediting body along with any corrective action recommendations and plan for corrective action by agency.

·         Independent financial audit.

·         Documentation of appropriate credentialing of program staff.

·         Summary of previous year’s appeals and outcomes (due Sept. 1st).

 

The above criteria may be waived for those providers located outside of Allamakee County, which have needed documentation on file with the host county.

3.      Contracts

 

Provider contracts will be negotiated by the CPC Administrator and must be signed by the Chair of the Board of Supervisors.  Only those services negotiated in the contract will be purchased and no rate increases will be recognized without a signed contract or addendum.  Termination of services will occur as outlined in the contract.

 

E.      PROVIDER ROLE IN SERVICE PROVISION

 

1.  Accessing Services

Allamakee County holds the philosophy that the role of the Central Point of Coordination staff is to manage the service system not individual consumer cases.  Therefore, the following CPC functions are delegated to local services providers:

·         Intake

·         Referral for case management (if needed)

·         Referral for clinical assessment (if needed)

·         Development of an individualized service plan

 


When an individual requests services directly from an agency, the individual will be assigned a service coordinator.  All consumers will have a designated service coordinator to help navigate the service system.  The service coordinator will perform the following functions:

1.       Assist consumer in completion of initial CPC application and collection of supporting data if needed.

2.       Complete initial assessment and with consumer complete service request based on assessment.

3.       Serve as liaison between CPC office & consumer.

4.       Make referrals and coordinate services between all service providers.

 

Service Coordinators will be assigned based on the following premises:

1.       If consumer has a T19 Case Manager, that person is the service coordinator.

2.       If not, then a county social worker.

3.       If not, then a worker from a residential unit.

4.       If not, then a worker from a sheltered work setting.

5.       If not, then a worker from the outpatient therapy provider.

2.  Application Process

 

The following guidelines should insure the timely provision of services to consumers.  In unusual cases, agency staff should contact the CPC Administrator for further direction.  Agency staff will receive ongoing training as deemed appropriate by agency administration and the CPC office.

 

1.  Access points will forward CPC Application and appropriate release of information forms to the CPC Office by the first business day following initial request for service.

2.  The CPC Administrator will review the application and make the initial eligibility determination based on the information in the application and based on the eligibility guidelines outlined in this plan.  The individual and providers will be mailed a notice of decision within 10 days of receiving the completed application.

3.  If the application came from a source other than a provider access point a referral to a case manager or service coordinator will be made within five business days.  If additional eligibility information is needed, the service coordinator will secure it and will set up an individual service plan to determine service needs.

4.  The service coordinator will request funding authorization from the CPC following completion of the individual service plan.  This step may occur with step 1 if an assessment and individual service plan are complete.

5.  The CPC Administrator will review the request and authorize funding on the basis of guidelines outlined in the plan.

6.  The time from service application to funding determination will not exceed 10     days with the exception being difficulty in obtaining eligibility documentation.

7.  Services necessary to address immediate needs for stabilization and support will be initiated as soon as possible.

8.  Written notice of decision will be sent as soon as funding authorization is made.  This notice will explain action taken and reasons for that action.  The notice will go to the consumer or his/her legal representative and will outline the consumer’s right to appeal and include a description of the appeal process.

 

F.      FUNDING AUTHORIZATION

 

Allamakee County shall be responsible for funding only those services in the Mental Health/Developmental Disabilities Services Management Plan.  Consumers, in conjunction with the service coordinator, may request additional services.  The decision to approve or deny the request will be made by the CPC administrator based on outlined service guidelines and available funds.  Allamakee County shall not authorize funding new services provided out of state.

 

All services funded in whole or in part by Allamakee County must be pre-approved by the CPC Administrator in order to receive reimbursement.  Pre-approval of funding does not guarantee payment.

 

Emergency Services

The Mental Health Institute in Independence is the designated provider for voluntary and court-ordered hospitalization for individuals with mental illness.  The staff from Northeast Iowa Mental Health Center must prescreen all individuals.  Staff are available by phone 24 hours and will conduct a face-to-face assessment if possible.

 

Hospital and mental health center staff must notify the CPC Administrator of admissions by the end of the next working day.  Messages may be left of the CPC Office answering machine.  A completed CPC application and releases of information must be forwarded within 3 working days.


G.      PROVIDER REIMBURSEMENT FOR SERVICES

 

Allamakee County will only reimburse for those services that are authorized and at the rate approved in the contract.  The following billing protocol should be followed:

 

1.     Invoices must provide the following information:

a)     Name of each consumer with corresponding ID number served during the reporting period.

b)     Number of units of service delivered to each consumer.

c)     Unit rate and total cost of units provided to each individual consumer.

d)    Reimbursement billed to other sources, and therefore deducted from the county costs, for each individual consumer.

e)     Summary of total costs to county by service.

 

2.     Invoices shall be submitted to:  Allamakee County CPC Office

                                                         Courthouse

                                                         110 Allamakee St.

                                                         Waukon, IA  52172

 

3.     Providers must submit invoices within 60 days of the service unless the provider is waiting for third party payment.  Allamakee County reviews claims for payment on the 2nd and 4th Mondays of each month.  Only invoices received prior to noon on the previous Wednesday will be processed for the next claim session.

 

No bill will be paid that is over one year old from the date of service rendered without specific approval from the Board of Supervisors with the exception of bills from the Iowa Department of Human Services.

 

H.      PLAN DEVELOPMENT

1.  Process

 

The Strategic Plan shall be developed to describe the actual services and service providers funded by Allamakee County.  This plan shall include the following:

1.      Needs assessment

2.      Goals and objectives

3.      Services and supports

4.      Provider network

5.      Access points

 

This plan shall be developed with the cooperation and input from stakeholders   (consumers, providers, family members, and advocates) in Allamakee County.  The CPC Administrator will locate meetings in the community where stakeholders mentioned above are already or schedule public meetings at times and locations that are convenient for stakeholders to attend.

 

This time will be used to evaluate the MH/DD System and determine what things are going well, and what areas need improvement.  Three-year goals will be established from the input that is gathered at these meetings.

 

Every 3 years a public hearing will be held no later than the 3rd Monday in March for approval of the Allamakee County MH/DD Strategic Plan.  This plan must be sent to the state no later than April 2000 and every third year thereafter.

 

I.       BUDGET

 

Funding for MH/DD services is limited to the budget that published on an annual basis by the Allamakee County Auditor.  The total amount budgeted is less then the total dollars available in the Mental Health Service Fund.  The additional dollars in the reserve were accumulated through strict management of spending from the MH/DD fund.  The amount of reserves has been decreasing since FY99.  The cost of providing services has risen higher than the growth funds provided by the State of Iowa.  As this trend continues, Allamakee County will eventually not have enough dollars to meet the needed budget.  This could result in the need to develop a waiting list.  See Section 1-F for details on the waiting list process.

 

J.       TRACKING

 

Allamakee County is utilizing the management information system (CoMIS) developed by the State of Iowa to track consumer usage and dollars spent.  A quarterly utilization and cost report will be generated and will include the following information.

·         Total service utilization and costs by individual consumers including all service types and providers.

·         Analysis of total county funds expended to date, and amount remaining in the fiscal period to pay for services.

·         Total units delivered and billed by each provider

·         Analysis of the variance between service authorizations and service actually billed to and paid by the county.

Identification of high cost consumers to receive special attention from case management and the CPC administrator.

 


K.      ANNUAL REPORT

 

The Allamakee County CPC Administrator will complete an annual report each year by December 1st.  This report will be submitted to the Department of Human Services, for informational purposes only, beginning December 1, 2000 and every December 1st thereafter.

 

The months of June - November will be used in the following way:

·         Collect outcome, satisfaction and performance data.

·         Close out the previous fiscal year.

·         Collect all final utilization and cost information.

·         Complete the annual report.

 

The annual report will include the following information:

1.      An overview of the past year’s activities and major events.

2.      A review of the progress on the past year’s goals and objectives.

3.      Documentation of stakeholder involvement over the past year.

4.      Annual statistical report documenting unduplicated consumers served by:

·         Category of diagnosis served

·         Age of consumers

·         Category of service

·         Service dollars allocated per service type

5.      A review of consumer, family, or provider satisfaction surveys.

6.      Annual report of appeals (number, type, and resolution).

7.      Annual report of the continuous quality improvement process.

8.      Waiting list information and unmet service needs.

 

The annual report will be presented to the Allamakee County Board of Supervisors and the Allamakee County Citizens’ Advisory Board for review and use in the development of future Strategic Plans.

L.      QUALITY ASSURANCE

           

1.  System Evaluation

 

Consumer Outcomes and Satisfaction

Over the year a system will be developed to measure consumer satisfaction, choice, and quality of life.  Additionally, a system to measure consumer outcomes will be developed addressing the issues of independence and level of functioning.

 

Review of Grievances

The CPC will monitor the number and disposition of consumer appeals and the actions as a result of appeals.

 

Tracking & Utilization Review

Patterns of service utilization and cost effectiveness will be monitored through use of COMIS, an integrated database program supplied by the State. The CPC Administrator continues to explore ways to incorporate the COMIS into a meaningful utilization review process.

 

2.  Service and Supports Evaluation

 

            Onsite Provider Visits

The CPC Administrator shall conduct an onsite visit to each local provider, and to out-of-county providers as time permits, which shall include a random sample review of consumer plans and progress and talking with the consumer.

 

Monitoring Provider Appeal Process

Providers will be asked to document their internal appeal process including the number and disposition of appeals and implementation of corrective action plans based on those appeals.  Yearly documentation will be due Sept. 1st.

M.     CONFIDENTIALITY

 

Allamakee County has locked file cabinets that contain the records of individuals who have applied for county funding.  The files are only available to the CPC staff.  The computer containing demographic information on consumers is placed in a locked office with access to authorized personnel only.  All courthouse staff are trained in aspects of confidentiality.  A release of information is obtained from potential clients applying for county funding.  These releases of information forms comply with state and federal confidentiality rules.  Allamakee County utilizes Case Managers for coordination and consumer assessments.  CPC and case management staff have been trained in confidentiality procedures.

 

N.      INTERFACES & COLLABORATIONS

 

Allamakee County consumers routinely access a variety of services that are not funded by or under control of the county.  These include:

·         Income assistance such as SSI, AFDC, Food Stamps, Social Security, General Assistance, etc.,

·         Housing assistance such as rental subsidies, public housing, etc.,

·         Employment assistance such as vocational rehabilitation and job training,

·         Primary medical care,

·         Education through Adult Basic Education and local colleges,

·         Court services,

·         Substance abuse services,

·         Medicaid Mental Health Access Plan.

 

During the next year the CPC office will work to extend the present informal relationships with these agencies and identify ways to better coordinate services for individuals with mental illness, mental retardation, or developmental disabilities by:

·         Identifying the roles and responsibilities of each agency in terms of service delivery,

·         Defining referral and communication mechanisms, including points of contact, types of information shared, and reports generated,

·         Defining a process for dispute mediation and resolution.

 

These interfaces are further discussed in the following section:

 

            Vocational Rehabilitation

Allamakee County will continue to work closely with the Department of Vocational Rehabilitation Services in securing medical/psychological assessments, vocational evaluations, counseling/guidance, physical and/or mental restoration services, special adaptive equipment/devices, training, occupational tools, equipment or licenses, and job placements designed to assist individuals with disabilities in preparation for employment.  DVRS at times acts a service coordinator as defined in earlier sections.

 

            School System

Allamakee County will continue to work with the school system, including Keystone Area Education Association, to identify consumers coming into the adult service system so that adequate services and resources may be identified.

 

            Court System

Integration of the CPC role in involuntary hospitalizations has been formalized over the past year.  As problems arise, the CPC Administrator will continue to work with the Clerk of Court, the judicial referees, judges, and sheriff to create a system that is efficient yet responsive to consumer needs.

 

Department of Human Services-State of Iowa

The local DHS office processes state papers and refers eligible

consumers for services.

 

            Medical Community

Veterans’ Memorial Hospital and local physicians are generally involved in most psychiatric hospitalizations.  Training regarding the CPC process has occurred.  Public Health Nurses provide many services to the MI/MR/DD population. Funding and service streams continue to be clarified.

 

 


Northland Area Agency on Aging

As the MI/MR/DD population ages, funding and service streams will need clarification with Northland Area on Agency.  Staff continue to clarify funding streams.

 

Community at Large

CPC staff continue to inform the public about the services available in the area, and provide information regarding funding of these services.  Other community agencies often refer individuals who “fall between the cracks” of the typical service system.  Staff maintain membership in ARC and AMI to keep abreast of issues from a consumer/family perspective.  The Citizens’ Advisory Board provides a wider outreach into the county.

 

MBC of Iowa

Allamakee County will be involved in the ongoing communication process with MBC of Iowa, and or any other Management Company contracted with the State of Iowa for the following purposes:

·         To assure that MBC of Iowa pays of all qualified behavioral health care services for Medicaid (Title 19) enrollees, and does not attempt to use county-paid services as a method of managing risk.

·         To work with MBC of Iowa in the possible development and funding to create new community based services that are cost effective for both entities and effective for the consumers.

 


APPENDIX

 

A.      DIAGNOSTIC DEFINITIONS

 

            Mental Illness: This includes people who have a current diagnosis of a mental illness as defined in the Diagnostic & Statistical Manual, Fourth Edition (DSM IV).  Diagnoses that fall into this category include, but are not limited to, the following: schizophrenia, major depression, manic-depressive (bipolar) disorder, adjustment disorder, and personality disorder.  Also included are organic disorders such as dementias, substance-induced disorders, and “other organic disorders, including physical disorders such as brain tumors.  (Excluded are V Code diagnoses, psychoactive substance use disorders, and developmental disorders.)

 

            Chronic Mental Illness: This includes people who are 18 and over with persistent mental or emotional disorders that seriously impair their functioning relative to such primary aspects of daily living as personal relations, living arrangement, or employment.  People with chronic mental illness will typically have histories that meet at least one of the treatment history criteria and at least two of the functioning history criteria.

 

A.    Treatment History Criteria:  People with chronic mental illness will typically meet at least one of the following criteria:

1.     Have undergone psychiatric treatment more intensive than outpatient care more than once in a lifetime (i.e. emergency service, alternative home care, partial hospitalization or inpatient hospitalization);

2.     Have experienced at least one episode of continuous, structured supportive residential care other than hospitalization.

 

B.    Functioning History Criteria:  People with chronic mental illness will typically meet at least two of the following criteria on a continuous or intermittent basis for at least two years: 

1.     Are unemployed, employed in a sheltered setting, or have markedly limited skills and a poor work history.

2.     Require financial assistance or out-of-hospital maintenance and may not be able to procure such assistance without help.

3.     Show severe inability to establish or maintain a personal support system.

4.     Require help in basic living skills.

5.     Exhibit inappropriate social behavior that results in demand for intervention by the mental health and/or judicial system.

 

           
Mental Retardation: People with mental retardation have significantly sub-average general intellectual functioning existing concurrently with deficits in adaptive behavior, manifested during the developmental period.  All of the following criteria must be met:

 

A.   A score of approximately 70 intelligence quotient (IQ) or below, as obtained by assessment with one or more of the individually administered general intelligence tests developed for the purpose of assessing intellectual functioning.

B.    Deficits in adaptive behavior, defined as the effectiveness or degree with which individuals meet the standards of personal independence and social responsibility expected for age and cultural group.

C.    Sub-average intellectual functioning and deficits in adaptive behavior manifested during the developmental period, the time period between conception and the eighteenth birthday.

 

            Other Developmental Disabilities: People with developmental disabilities have severe, chronic disabilities that meet all of the following criteria:

A.   Is attributable to mental or physical impairment or a combination of mental and physical impairments.

B.    Is manifested before the person attains the age of 22.

C.    Is likely to continue indefinitely.

D.   Results in substantial functional limitation in three or more of the following areas of life activity:  self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, and economic self-sufficiency. 

E.    Reflects the individual’s need for a combination and sequence of services which are of lifelong or extended duration and are individually planned and coordinated; unless this term is applied to infants and young children from birth to the age of five inclusive, who have substantial developmental delay or specific congenital or acquired conditions with high probability of resulting in developmental disabilities if services are not provided.

 

B.      LEGAL SETTLEMENT

“Legal Settlement” is a term used to define which County in Iowa is responsible for providing individuals with funding for mental health/developmental disabilities services.  Legal settlement is not equal to legal residency.  To establish legal settlement an individual must live in an Iowa county for one year without receiving any county funded mental health or substance abuse treatment.  If someone moves to Allamakee County for less than one year, he or she will not have established Allamakee County legal settlement.  If someone moves from out of state and has not lived in Allamakee County for one year without services, he or she will have legal settlement with the State of Iowa.  The following process will be used to determine legal settlement:

 

1.     If after reviewing the completed application, the CPC Administrator determines that an individual’s legal settlement is not in Allamakee County, the completed application will be forwarded to the appropriate county CPC Administrator or the local DHS office if legal settlement appears to be with the State of Iowa.  Notice of this action with further instructions will be sent to the applicant.

 

2.     The Allamakee County CPC Administrator will work with other county CPC Administrators or state DHS workers to assure that all eligible applicants receive identified services needed.  If the county of legal settlement agrees to pay for any service authorized by the county of residence, the process for funding approval will be the same as for individuals with legal settlement in Allamakee County.

 

      For applicants having legal settlement in another county, the CPC Administrator will bill the county of legal settlement for services provided that have already been paid for by Allamakee County.  However, it is Allamakee County’s intent that these services shall be paid for directly by the county of legal settlement.

 

3.   It is the intent of Allamakee County to assure that all individuals requesting services in Allamakee County receive the same degree of access to services contained in the Management Plan regardless of legal settlement.

 

 


C.      CPC APPLICATION FORM

ALLAMAKEE COUNTY MH/DD SERVICES FUND

APPLICATION FORM

Application Date: ________________________

SS #: _________________________________________ State ID# :_________________________________

 

Name: ________________________________________Phone #: __________________________________

                      Last                  First                        MI

Sex:    [  ]  Male       [  ]   Female                                        Birth Date: ________________________________

 

Current Address:  _______________________________     How Long at this Address: ___________

Street/P.O. Box #

______________________________________________________     ___________________________________

City                                        State                       Zip                          County

County of legal settlement:  ________________________________

 

Ethnic Background: (circle one)     0. Unknown;         1. White;                2. African American;          3. Native American;

4. Asian;                5. Hispanic;          6. Other

 


Guardian/Payee/Conservator:

[  ] Legal Guardian   [  ] Protective Payee   [  ] Conservator

( Check any that are appointed and write in name etc.)

 

Name: _______________________________________

 

Address: ______________________________________

 

Phone: _______________________________________

 

[  ] Legal Guardian   [  ] Protective Payee   [  ] Conservator

( Check any that are appointed and write in name etc.)

 

Name: _______________________________________

 

Address: ______________________________________

 

Phone: _______________________________________

 


Veteran:  [  ]  Yes;   [  ]  No

Marital Status: (Circle one)  1. Single, never married; 2 Married; 3. Divorced; 4. Separated; 5. Widowed

Legal Status: (Circle one)  1. Voluntary;  2. Involuntary, civil;  3. Involuntary, criminal

Living Arrangement: (Circle one)  1. Alone;  2. With relatives;  3.  With unrelated individuals

 


Residential Arrangement: (Circle applicable)

1.  Private Residence                           8.  RCF/PMI

2.  State MHI                                        9.   ICF

3.  State Hospital School                    10.  ICF/MR

4.  Supported Comm Living              11.  ICF/PMI

5.  Foster Care/FLH                            12.  Correctional Fac.

6.  RCF                                                  13.  Homeless/Shelter/Street

7.       RCF/MR                                       14.  Other

 

Applicant’s Primary Diagnosis(specify type)

[  ]  40  Mental Illness ________________________

[  ]  41 Chronic Mental Illness_______________

[  ] 42  Mental Retardation ____________________

[  ] 43  Developmental Disability _______________

[  ] Other: Describe: _____________________

____________________________________

 


Referral Source: (Circle applicable)

1.  Self                                                    5.  Community Corrections

2.  Family/Friend                                 6.  Social Service Agency

3.  Targeted Case Management       7.  Other ______________

4.  Other Case Management

 

Education:

Years of education ________________________

GED   [  ] Yes    [  ]  No

H.S. Diploma  [  ]  Yes    [  ]  No

Degree  ________________________________

 


Current Employment: (Circle applicable)

1. Unemployed, available for work                                 8.  Sheltered Work Employment

2. Unemployed, unavailable for work                              9.  Supported Employment

3. Employed, Full time                                                       10. Vocational Rehabilitation

4. Employed, Part time                                                       11.  Seasonally Employed

5. Retired                                                                               12.  Armed Forces

6. Student                                                                              13.  Homemaker

7. Work Activity                                                                  14.  Other ______________________________________


Primary Income Source: ____________________________________________________

 

Health Insurance Information:  (Check all that apply)


Primary Carrier (pays first)

[  ]  Applicant Pays [  ]  Title-19  [  ]  Medicaid  [  ]  Medicare

[  ] Private Insurance [  ] No Insurance  [  ] Medically Needy

 

Company Name___________________________________

 

Address  ______________________________________

 

__________________________________

 

Policy Number: __________________________

(or Medicaid/Title 19 or Medicare Claim Number)

 

Secondary Carrier (pays second)

[  ]  Applicant Pays [  ]  Title-19  [  ]  Medicaid  [  ]  Medicare

[  ] Private Insurance [  ] No Insurance  [  ] Medically Needy

 

Company Name ___________________________________

 

Address  ___________________________________________

 

__________________________________

 

Policy Number: __________________________

(or Medicaid/Title 19 or Medicare Claim Number)


Others in Household:

         Name                                                                                         Relationship                                            Birth Date

_________________________________________         ________________________                        __________________

__________________________________________       ________________________             __________________

__________________________________________       ________________________             __________________

__________________________________________       ________________________             __________________

__________________________________________       ________________________             __________________

 

Monthly Income:                                                                Applicant Amount:                            Others in Household

(Check Type, Fill in amount)                                                                                                                       Amount:

 

[  ]   1.  Employment  Wages                                             _________________                        __________________

[  ]   2.  Public Assistance                                    _________________                        __________________

[  ]   3.  Social Security                                                        _________________                        __________________

[  ]   4.  SSDI                                                                          _________________                        __________________

[  ]   5.  SSI                                                                             _________________                        __________________

[  ]   6.  Veterans Benefits                                                   _________________                        __________________

[  ]   7.  Railroad Pension                                                    _________________                        __________________

[  ]   8.  Child Support                                                          _________________                        __________________

[  ]   9.  Dividends, Interest, Etc.                                        _________________                        __________________

[  ]  10.  Other                                                                        _________________                        __________________

 

If not currently receiving, has the applicant applied for any of the following benefits?

[  ]  1.  Unemployment Compensation                            [  ]  2.  Social  Security Disability

[  ]  3.  SSI                                                                              [  ]  4.  FIP(AFDC)

What is the status of any such application?

[  ]  Approved, but not started                           [  ]  Denied                             [  ] Pending

 

Resources: (Check and fill in amount and agency)

     Type                                                  Amount                                                 Bank, Trustee, or Company

[  ]  Cash                                                ____________________                 __________________________________

[  ]  Checking Account                        ____________________                 __________________________________

[  ]  Savings Account                           ____________________                 __________________________________

[  ]  Certificates of Deposit ____________________                 __________________________________

[  ]  Trust Funds                                    ____________________                 __________________________________

[  ]  Life Insurance (cash value)        _____________________                               __________________________________

[  ]  Stocks and Bonds                         _____________________                               __________________________________

[  ]  Vehicle                                            Value:________________                               Year:_____________________________

[  ]  Real Estate                                     Value:________________                               Location:__________________________

[  ]  Burial Fund/Trust                         _____________________                               __________________________________

[  ]  Other Resources                            _____________________                               __________________________________

 

 


 

 

Where did you live before you moved to your current address?

 

1.  Previous Address ______________________________________________________________________

                                     Street Address                               City                  State          Zip Code       County

                When did you live at this address?  ___ ___/__ __ __  __  To ___ ___/__ __ __ __

                                                                                    Month      Year                Month       Year

                Employer: ________________________  Job: ________________________ Dates:______________

                Did you receive mental health or substance abuse services while at this address?  [  ]  Yes  [  ]  No

                                      Agency Name                                Address

                _________________________      ______________________________________________________

 

                _________________________      ______________________________________________________

 

                _________________________                      ______________________________________________________

 

Where did you live prior to the above listed address?

Previous Address:                                                                                                Dates  (Month and Year)

 

___________________________________________    _________________to______________

 

___________________________________________    _________________to _____________

 

___________________________________________    _________________to _____________            

 

___________________________________________    _________________to _____________

 

List any previous services such as hospitalization, group homes, mental health center,

 social service, etc.  Use separate sheet if necessary.

 

___________________________________________   _________________to_______________

 

___________________________________________   _________________to_______________

 

___________________________________________   _________________to_______________

 

___________________________________________   _________________to_______________

 

Current Case Manager or Social Worker ___________________________________

 

_______________________________________________________________________

                                Agency                                                                  Address                                                  Phone

 

 

Services Being Requested: (based on ICP or Treatment Plan)

[  ]  HCBS/SCL    [  ] ICF/MR           [  ]  RCF                 [  ]  RCF/MR         [  ]  RCF/PMI                        [  ] SCL

[  ]  HCBS/Resp.  [  ] Voc./SW          [  ]  Voc./WAC      [  ]  Voc./ ADC      [  ]  Voc./SE                           [  ] Voc./Other

[  ]  HCBS/HVM  [  ] Psych Rehab   [  ]  ADT [  ]  Evaluation     [  ]  Therapy/Treatment

[  ]  HCBS/Voc.    [  ]  Med. Mgm.    [  ]  MHI                [  ]  Commitment [  ] Case Management

[  ]  HCBS/Other  [  ] Rent Subsidy [  ]  Transp.             [  ]  Respite            [  ]  Protective Payee

[  ]  Pers. Allow.     [  ]  Medical           [  ]  Other: Describe _______________________________________  

 


MH/DD SERVICE REQUEST FORM

1.             Type of Service __________________________  Agency ______________________________

                Units requested__________________________   Unit =  hour   day   month   other  (circle one)

                Expected Unit Cost ______________________    COA # ______________________________

                Expected Start Date _____________________    Expected End Date ____________________

                Expected Outcomes:  Describe what you expect to happen as a result of this service. _________

                _____________________________________________________________________________

            _____________________________________________________________________________

                _____________________________________________________________________________           

 

2.             Type of Service __________________________  Agency ______________________________

                Units requested__________________________   Unit =  hour   day   month   other  (circle one)

                Expected Unit Cost _____________________      COA # ______________________________

                Expected Start Date _____________________    Expected End Date ____________________

                Expected Outcomes:  Describe what you expect to happen as a result of this service. _________

                ______________________________________________________________________________

                ______________________________________________________________________________

                ______________________________________________________________________________

 

3.             Type of Service __________________________  Agency _______________________________

                Units requested__________________________   Unit =  hour   day   month   other  (circle one)

                Expected Unit Cost _____________________      COA # _______________________________

                Expected Start Date _____________________    Expected End Date _____________________

                Expected Outcomes:  Describe what you expect to happen as a result of this service. _________

                ______________________________________________________________________________

                ______________________________________________________________________________

                ______________________________________________________________________________

 

Contact:

Name: _____________________________________            Relationship: ______________________________

Address:  ___________________________________             Phone #:  _________________________________

 

Person Completing the Form (if other than applicant)

Name: _____________________________________            Relationship: ______________________________

Address: ___________________________________              Phone#: __________________________________

 

Outpatient Counseling Services Co-Payment (Due to agency each visit)             $____________

 

[  ]  Yes  [  ]  No   My social security number can be used by the CPC as my identification number.

 

The above listed services have been discussed with me and are requested with my knowledge and consent.  As a signatory of this document, I certify that the above information is true and complete to the best of my knowledge, and I authorize the County CPC staff to check for verification of the information provided.   I understand that the information gathered in this document is for the use of the County in establishing my ability to pay for services requested, in assuring the appropriateness of services requested, and in confirming legal settlement.  If any changes occur, I will notify the CPC Office within 30 days.  I understand that information in this document will remain confidential.

 

____________________________    _______________________________  _______________________

 Applicant’s Signature     Date            Legal Guardian                   Date                Service Coordinator   Date

The information provided in this application indicates that you are eligible for service funding provided by Allamakee County.  The above requested services have been approved for the stated period of time at the stated rates.  Any exceptions and reasons are listed below.  If you do not agree with the decision, you may appeal by following the process printed on the back of this form.  ________________________________________________________________________________________________________________________________________________________________________________________________

Cc:  Applicant File                                                              

       Agencies                                                                                         _____________________________________________

Allamakee Co. CPC Administrator        Date

 

D.      RECERTIFICATION FORM

Allamakee County MH/DD Service Recertification Request

Date______________

Participant  ___________________                              Social Security #_____________________

Address______________________                              Date of Birth________________________

_____________________________                            DSM Diagnosis______________________

Phone________________________                             (Circle one)           MI    CMI    MR    DD

Gross Family Income (before taxes)                               Resources

    Employment Wages................$________       Cash.............................$_________

    Public Assistance Payments......_________                    Checking........................_________

    Social Security.........................._________       Savings..........................._________

    Social Security/Disability.........._________                     Stocks/Bonds.................._________

    Supplemental Security Income.._________                  Certificates....................._________

    Veterans Benefits......................_________      Trust Funds...................._________

    Railroad Pension......................._________      Other............................. _________

    Child Support..........................._________                  

    Dividends, interest, etc.............._________          Total Resources.........$_________

    Other........................................_________

                                                                                                Co-Payment (CPC use only)

         Total Monthly Income........$_________                                                              $___________

Deductable Monthly Expenses                                                                        

    Child care................................$_________

    Medical....................................._________   Number in Household  _________

         Total Monthly Deductions...$_________

 

Type of Service _________________________ Agency ______________________________

                Units requested__________________________ Unit = hour   day   month   other  (circle one)

                Expected Unit Cost ______________________ COA # ______________________________

                Expected Start Date _____________________ Expected End Date ____________________

                Expected Outcomes:  Describe what you expect to happen as a result of this service. _________

                _____________________________________________________________________________

                           

2.             Type of Service _________________________ Agency ______________________________

                Units requested__________________________ Unit = hour   day   month   other  (circle one)

                Expected Unit Cost ______________________ COA # ______________________________

                Expected Start Date ______________________Expected End Date ____________________

                Expected Outcomes:  Describe what you expect to happen as a result of this service. _________

                ______________________________________________________________________________

               

3.             Type of Service __________________________ Agency _______________________________

                Units requested__________________________ _Unit = hour   day   month   other  (circle one)

                Expected Unit Cost _______________________ COA # _______________________________

                Expected Start Date ______________________ Expected End Date _____________________

                Expected Outcomes:  Describe what you expect to happen as a result of this service. _________

                ______________________________________________________________________________

               

The above requested services and fees have been discussed with me and are part of my Individual Treatment Plan developed with my therapist.  I do solemnly swear or affirm that the above information is true & correct.  If any changes occur, I will notify the CPC Office within 30 days. 

__________________________   ____________________________               ____________________________

Participant                            Date          Guardian                             Date      Service Coordinator            Date

The above requested services have been approved for the stated period of time at the stated rates.  Any exceptions and reasons are listed below.  If you do not agree with the decision, you may appeal by following the appeal process printed on the back of this form. 

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

cc:  Applicant File                                                                ________________________________________  

       Agencies                                                                                         CPC Administrator                                              Date

E.      NOTICE OF DECISION FORM

Allamakee County

Mental Health & Developmental Disabilities Services

Central Point of Coordination Office

110 Allamakee Street

Waukon, Iowa  52171

563-568-6227

563-568-6417 (FAX)

 

Notice of Decision

 

(Date)

 

(Name)

(Address)

(Address)

 

Dear <Name>:

 

Your application for service funding was received on <Date> and the following action was taken:

 

_____  We have received your application, but it has not been fully completed.  You will

not be eligible for service funding unless you complete the highlighted areas and return the completed form in the enclosed envelope.

 

_____  Your application has been received and referred to Targeted Case Management staff to obtain more information in the areas marked.  Staff will contact you within the next week.                   

_____ Legal settlement clarification

                                                _____ Diagnosis clarification

                                                _____ Financial clarification

                                                _____ Identification of services needed

 

_____ Your application for funding has been denied for the following reason:

 

 

If you disagree with this decision, you may appeal by using the procedure outlined on the back on this form.  Your complaint must be received by <date>.

 

Sincerely,

 

 

Janice K. Heikes, LISW

CPC Administrator

 

 

 


F.      APPEAL PROCESS FORM

Allamakee County

Mental Health & Developmental Disabilities Services

Appeal Process

 

This action was taken in accordance with policy established in the Allamakee County MH/DD Policies and Procedures Manual (Section K).  You or your representative may appeal this decision by using the following procedure:

 

1.   All the following information must be submitted in writing:

·         Your name, address and telephone number.

·         The name, address, and telephone number of any person helping you with your appeal.

·         Your complaint and the reason you feel the decision should be changed.

 

2.       Send this information to the CPC Administrator within ten (10) days of receiving the Notice of Decision.  The address is:  Allamakee County MH/DD Services

                                                      Courthouse, 110 Allamakee St.

                                                      Waukon, IA  52172

 

3.   The Allamakee County CPC Administrator will arrange a meeting with you no less than five (5) working days after the appeal has been received.  If an agreement cannot be made, the CPC Administrator will immediately notify you of the following options:

 

A.  Your appeal may be heard by the Appeals Board at a meeting scheduled as soon as schedules will allow.  This will allow you to present your case to objective persons familiar with the County MH/DD System.  The Appeals Board will make a written recommendation to be submitted to the Allamakee County Board of Supervisors for consideration. 

OR

B.  The CPC Administrator will immediately put the appeal upon the Allamakee County Board of Supervisors’ Agenda in accordance of Chapter 21, Code of Iowa.

 

4.      If you are not satisfied with the decision of the Board of Supervisors, you may appeal in writing to have your case heard by an Administrative Law Judge within ten (10) working days of the Board of Supervisors’ written decision. 

 

5.   At an appeal hearing, you have the right to have an attorney or other advocate accompany and represent you at your own expense.  If you cannot afford an attorney, you may contact Legal Services Corporation of Iowa, the Iowa Volunteer Lawyer Project, or Iowa Protection and Advocacy Services, Inc. for assistance.  Telephone numbers for these agencies are available from the CPC Office upon request.

 

For further information, call 563-568-6227.

 


G.      CONSENT TO OBTAIN AND RELEASE INFORMATION

Client Name

ID#

Telephone #

Address

Parent/Guardian

Date of Birth

Address

I authorize Allamakee County CPC Office, and the following individuals or agencies to share written and oral information about my needs and the services I receive:


Name/Agency

 

 

 

 

 


Allamakee Co. CPC Staff

Name

Address

Phone


The information released or shared may include:

Evaluation/Assessment

Agency participation, plans, and progress reporting

Educational assessment

Family and social data

Physical status (including vision and hearing), communication skills, cognitive skills, and health status (including medical, dental, nutrition), X-rays, charts, photographs

 

Other (note exception or limits to this release)

 

 

 

 

 

SPECIFIC AUTHORIZATION FOR RELEASE

I authorize the release of the following information which requires specific consent under federal or state law:

Type of Information

Nature and Source of Information

Authorizing Initials

Mental health evaluation/treatment *

 

 

AIDS/HIV-related

 

 

Substance abuse **

 

 

I understand this information shall be kept confidential and shall be used for the purpose of planning and delivering my services.  I understand that I have the right to see this information at any time.  This consent is valid for information already in existence and any information which may be generated during future service involvement.  I understand that I can revoke my consent at any time by providing written notifi­cation.  This consent shall expire upon termination of services, or on the date specified below by the authorizing party.  I have read this form, or it has been read and explained to me, and I understand its content. A photocopy of this signed Authorization shall have the same force and effect as this original.

Authorizing signature

Date

Relationship to client

Expiration date


RECORD OF DISCLOSURES

(Required for mental health information)

Date

Name of Recipient

Contents disclosed

Sent by

1.

 

 

 

2.

 

 

 

3.

 

 

 

4.

 

 

 

5.

 

 

 

  *    Only a person 18 years of age or older or such a person’s legal representative can authorize release of mental health information.

**   Only the subject can authorize release of substance abuse information unless the subject is of such age and mental maturity that they are unable to authorize release.

NOTICE TO RECIPIENTS OF MENTAL HEALTH INFORMATION

In accordance with the Iowa Mental Health Information Disclosure Act (Iowa Code, Chapter 228), a recipient of mental health information may further disclose this information only with the written authorization of the subject or the subject’s legal representative or as otherwise provided in Chapters 228 and 229.  Unauthorized disclosure is unlawful and civil damages and criminal penalties may apply.  Federal confidentiality rules (42 CFR Part 2) restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

NOTICE TO RECIPIENTS OF SUBSTANCE ABUSE INFORMATION

This information has been disclosed from records whose confidentiality is protected by Federal law.  Iowa Code, Chapter 125 and Federal regulations (42 CFR, Part 2) prohibit any further disclosure without the specific written consent of the person to whom the information pertains, or as otherwise permitted by such statute and regulations.  A general authorization for the release of medical or other information is not sufficient for this purpose.  Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

NOTICE TO RECIPIENTS OF HIV-RELATED TESTING INFORMATION

This information has been disclosed to you from records whose confidentiality is protected by state law.  State law prohibits you from making any further disclosure of the information without specific written consent of the person to whom it pertains, or as otherwise permitted by law.  A general authorization for the release of medical or other information is not sufficient for this purpose.  (Iowa Code Section 141.23)  Federal confidentiality rules (42 CFR, Part 2) restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

POLICY ON NONDISCRIMINATION

No person shall be discriminated against because of race, color, creed, national origin, sex, age, religion, political belief, or physical or mental disability, regarding employment or when applying for or receiving benefits or services from the Iowa Department of Human Services, the county, or any of their vendors, purchased service providers, or contractors.

If you have reason to believe that you have been discriminated against for any of the reasons stated above, you may file a complaint with the Iowa Department of Human Services (IDHS) by completing a Discrimination Complaint form.  Any IDHS office, institution, or the IDHS Office of Equal Opportunity can provide you with this form.  If you have reason to believe that you have been discriminated against by the county for any of the reasons stated above, you may contact the county.  You may also file a complaint with the Iowa Civil Rights Commission (if you feel you were discriminated against BECAUSE OF your race, creed, color, national origin, sex, religion, or disability); or the United States Department of Health and Human Services, Office for Civil Rights.

For assistance or consultation you may contact the IDHS Office of Equal Opportunity.  Complaints should be filed  promptly, but in most instances, no later than 180 days of the alleged discriminatory act.


Iowa Department of Human Services
Office of Equal Opportunity, 5th floor
Hoover State Office Building
Des Moines, Iowa  50319-0114

Iowa Civil Rights Commission
211 East Maple Street, 2nd Floor
Des Moines, Iowa  50309-1858

County Central Point of Coordination Administrator

    


H   CO-PAYMENT SCHEDULE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FY 2001

 

 

 

 

 

 

                                   Family of 1

 

 

 

 

Family of 2

 

 

 

 

Family of 3

 

 

 

                                Gross Income

 

Monthly-To

Fee

 

Gross Income

 

Monthly-To

Fee

 

Gross Income

 

Monthly-To

 

$13,360

160%

$1,113

$3

 

$18,000

160%

$1,500

$5

 

$22,640

160%

$1,887

$6

 

$14,195

170%

$1,183

$7

 

$19,125

170%

$1,594

$9

 

$24,055

170%

$2,005

$12

 

$15,030

180%

$1,253

$10

 

$20,250

180%

$1,688

$14

 

$25,470

180%

$2,123

$18

 

$15,865

190%

$1,322

$14

 

$21,375

190%

$1,781

$19

 

$26,885

190%

$2,240

$24

 

$16,700

200%

$1,392

$17

 

$22,500

200%

$1,875

$23

 

$28,300

200%

$2,358

$29

 

$17,535

210%

$1,461

$21

 

$23,625

210%

$1,969

$28

 

$29,715

210%

$2,476

$35

 

$18,370

220%

$1,531

$24

 

$24,750

220%

$2,063

$33

 

$31,130

220%

$2,594

$41

 

$19,205

230%

$1,600

$28

 

$25,875

230%

$2,156

$38

 

$32,545

230%

$2,712

$47

 

$20,040

240%

$1,670

$31

 

$27,000

240%

$2,250

$42

 

$33,960

240%

$2,830

$53

 

$20,875

250%

$1,740

$35

 

$28,125

250%

$2,344

$47

 

$35,375

250%

$2,948

$59

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                                   Family of 4

 

 

 

 

Family of 5

 

 

 

 

Family of 6

 

 

 

 

                                 Gross Income

Monthly-To

Fee

 

Gross Income

Monthly-To

Fee

 

Gross Income

Monthly-To

Fee

 

$25,575

150%

$2,131

$0

 

$29,925

150%

$2,494

$0

 

$34,275

150%

$2,856

$0

 

$27,280

160%

$2,273

$7

 

$31,920

160%

$2,660

$8

 

$36,560

160%

$3,047

$10

 

$28,985

170%

$2,415

$14

 

$33,915

170%

$2,826

$17

 

$38,845

170%

$3,237

$19

 

$30,690

180%

$2,558

$21

 

$35,910

180%

$2,993

$25

 

$41,130

180%

$3,428

$29

 

$32,395

190%

$2,700

$28

 

$37,905

190%

$3,159

$33

 

$43,415

190%

$3,618

$38

 

$34,100

200%

$2,842

$36

 

$39,900

200%

$3,325

$42

 

$45,700

200%

$3,808

$48

 

$35,805

210%

$2,984

$43

 

$41,895

210%

$3,491

$50

 

$47,985

210%

$3,999

$57

 

$37,510

220%

$3,126

$50

 

$43,890

220%

$3,658

$58

 

$50,270

220%

$4,189

$67

 

$39,215

230%

$3,268

$57

 

$45,885

230%

$3,824

$67

 

$52,555

230%

$4,380

$76

 

$40,920

240%

$3,410

$64

 

$47,880

240%

$3,990

$75

 

$54,840

240%

$4,570

$86

 

$42,625

250%

$3,552

$71

 

$49,875

250%

$4,156

$83

 

$57,125

250%

$4,760

$95

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                                   Family of 7

 

 

 

 

Family of 8

 

 

 

 

 

 

 

 

 

                                Gross Income

Monthly-To

Fee

 

Gross Income

Monthly-To

Fee

 

 

 

 

 

 

$38,625

150%

$3,219

$0

 

$42,975

150%

$3,581

$0

 

 

 

 

 

 

$41,200

160%

$3,433

$11

 

$45,840

160%

$3,820

$12

 

 

 

 

 

 

$43,775

170%

$3,648

$21

 

$48,705

170%

$4,059

$24

 

 

 

 

 

 

$46,350

180%

$3,863

$32

 

$51,570

180%

$4,298

$36

 

 

 

 

 

 

$48,925

190%

$4,077

$43

 

$54,435

190%

$4,536

$48

 

 

 

 

 

 

$51,500

200%

$4,292

$54

 

$57,300

200%

$4,775

$60

 

 

 

 

 

 

$54,075

210%

$4,506

$64

 

$60,165

210%

$5,014

$72

 

 

 

 

 

 

$56,650

220%

$4,721

$75

 

$63,030

220%

$5,253

$84

 

 

 

 

 

 

$59,225

230%

$4,935

$86

 

$65,895

230%

$5,491

$96

 

 

 

 

 

 

$61,800

240%

$5,150

$97

 

$68,760

240%

$5,730

$107

 

 

 

 

 

 

$64,375

250%

$5,365

$107

 

$71,625

250%

$5,969

$119