MH/DD PLAN
Policies & Procedures Manual for


Geographical area covered: Jasper County, Iowa

Contact Person: Julie R. Bak 101 First Street N. Newton, IA 50208 Phone: (515) 791-2304 Fax: (515) 787-1101 E-mail:

VISION: The vision of Jasper County is to operate a mental health service system that will allow eligible citizens with disabilities to achieve and maintain positive community adjustment through a wide choice of services that are flexible, coordinated and adaptable to individual needs and cost effective. Service providers in Jasper County will make services available based on the principles of choice, empowerment, community, least restrictive environment and affordability. Jasper County seeks to be a leader in the State of Iowa in providing innovative programs and services to eligible individuals with more local control and oversight.




A. Plan Development The MH/DD Plan for Jasper County, which consists of the Policies and Procedures Manual, the Strategic Plan and any amendments to those documents, has been developed by the stakeholders and approved for implementation by the Jasper County Board of Supervisors. Public hearings are part of the development process. The central point of coordination process shall be readily accessible to consumers and their families or authorized representatives, incorporate consideration for individual consumer choice and facilitate prompt access to the service system. Consumers and their families or authorized representatives may initiate contact either directly with the central point of coordination office or through an access point. The process will include implementation of the intake process; determination of consumer eligibility; referral, if needed, to a service coordinator; referral, if needed, for clinical assessment; consumer enrollment into authorized services and supports; service and cost tracking; collection of data and reporting of data; authorizing funding within guidelines established in the county management plan; public education; collaboration with other funders, providers, consumers and their families or authorized representatives and advocates. B. Plan Administration: Jasper County will directly administer the county management plan according to Chapter 331.439(1)"c" of the Iowa Code and the corresponding administrative rules. The Board of Supervisors for Jasper County will retain full authority for the managed care system and the fixed budget. C. Financial Accountability Process Jasper County will not expend more that 100% of the amount in the MH/MR/DD budget for the fiscal year unless otherwise allowable by law. In the event of unforeseen circumstances, Jasper County may expend 106% of the MH/MR/DD budget in order to access The Risk Pool. Jasper County will pay for those services that are subject to funding mandates prior to allowing funds to be expended for other services listed in Appendix B. The 1% contingency fund is included in amounts budgeted for costs associated with services received at an MHI. Budget adjustments attributing to variations in service costs throughout the fiscal year will be noted. All submitted bills will be processed and paid within one month from the date of receipt by Jasper County. Providers will submit bills within ninety (90) days of the last date of service unless provider is waiting on third party payment. Jasper County will not supplement Merit payments or other third party payments of any kind to providers. Jasper County is the payor of last resort therefore, persons in the custody or supervision of the Department of Corrections are not eligible for county MH/MR/DD funding for services unless mandated by law. Jasper County will not fund mental health centers other than Capstone Center, Inc. D. Risk Bearing Managed Care Contracts Jasper County does not contract with a management organization for plan administration. E. Funding Policy Jasper County will be the payor of last resort. Consumers who meet the guidelines established in Appendix D are eligible for county funding. All available resources, contingent, discretionary, or otherwise will be considered in determining eligibility for county funding. Consumers must apply for and accept any and all other funding source for which they are eligible. Jasper County will fund only those services authorized in accordance with the process set forth in this management plan.

Jasper County will consider the expansion of consumer financial liability (consumer copayments) where cost effective. Liability on the part of the consumer will be in accordance with Iowa law and the consumer’s individual ability to pay. F. Conflict of Interest Policy The CPC Administrator and/or the Board of Supervisors shall make service authorization decisions. It is the intent of Jasper County that service authorizations will not be made by any individual or organization, which has a financial interest in the service or supports to be provided. Any such interest will be fully disclosed to consumers, counties and stakeholders in writing. G. Provider Network Selection Providers meeting one or more of the following criteria may be included in the Jasper County network of services: 1. Licensed or certified as a service provider by the State of Iowa. 2. Currently enrolled as a Medicaid provider, and/or certified as a member of the Merit Behavioral Care of Iowa provider panel. 3. Currently accredited by the Joint Commission on Accreditation of Healthcare Organizations, the Commission on Accreditation Rehabilitation Facilities, and any other national accrediting bodies recognized by Jasper County. 4. Jasper County will develop contracts with preferred providers and when appropriate will honor host county contracts for other providers. Jasper County will develop network membership criteria that will promote quality, performance and proper credentials of provider staff. Jasper County will explore alternative services and will develop criteria and a process for selecting and implementing alternative services prior to approving and contracting for such services. H. Delegated Functions The county may designate certain providers as access points. The county will coordinate training for all access points prior to the implementation of this management plan. This training will prepare staff at the designated access points to assist applicants in completing the universal Central Point of Coordination application form attached as Appendix E. I. Access Points See Appendix A for listing of designated access points. J. Plan for Staffing Jasper County will employ a CPC Administrator and an adequate number of staff to administer the plan. Julie Bak was appointed as administrator of mental health services on December 2, 1996. Ms. Bak has a Bachelors degree in Social Work and five years experience in program administration and planning. She reports directly to the Board of Supervisors in reference to all actions as CPC Administrator. K. Application Form See Appendix E for the universal central point of coordination application.


L. Consumer Access Jasper County will provide consumer access to needed services and supports through the implementation of a Central Point of Coordination (CPC) process. This process will be available to all consumers and their families or designated representatives. This process focuses on consumer choice and immediate access to funded services through multiple access points as outlined in Appendix A. M. Consumer Eligibility See Appendix B and D for consumer eligibility criteria. N. Confidentiality Confidentiality extends to all aspects of administration, to all applications and inquiries made throughout any continuing case and remains in effect after services to a consumer cease. This policy will be in compliance with state and federal confidential statutes. The CPC office will educate all office personnel with regards to issues of confidentiality. “Authorization to Release Information” must be signed and dated by the person empowered to authorize the release of confidential information. Information will be released only upon such written consent. The release of information form has been made a part of the universal application for services and is included in Appendix E. O. Emergency Services Prior to the full development of a flexible front-end response outlined in Goal #4, Jasper County will continue its current emergency efforts. Collaboration between local law enforcement agencies, Capstone Center‘s crisis line, Broadlawns Medical Center, Mary Greeley Medical Center and Skiff Medical Center will ensure appropriate and timely response for involuntary hospitalizations in emergency situations. Currently Jasper County utilizes Broadlawns Medical Center and Mary Greely Medical Center for respondents taken into immediate custody whose expenses are payable in whole or in part by the county. In addition, those respondents who are committed, whose expenses are payable in whole or in part by the county, will be committed to an MHI. Capstone Center, Inc., will perform the preliminary diagnostic evaluations for voluntary admissions to an MHI. Jasper County is in the Independence MHI catchment area. The provider shall attempt to notify the Central Point of Coordination Administrator of any emergency commitments within one working day of such committal. The application will be completed and forwarded to the CPC as soon thereafter as is possible. The CPC Administrator and DHS will continue to work closely with Capstone Center and other local providers in order to identify a consumer in crisis and develop the most appropriate response in the least restrictive environment. County of legal settlement and/or state case status will not affect the initiation of crisis services or hospital diversion services. P. Waiting Lists A consumer may be placed on a waiting list when funding is unavailable or when the appropriate provider does not have the resources to provide a particular service at the time requested. If there is another provider in the network providing the same service without a waiting list the consumer will be informed. If it is determined the consumer is in immediate need of stabilization and support, every effort will be made not to place the consumer on a waiting list. The CPC Administrator shall maintain updated information on provider waiting lists. The CPC Administrator will also monitor the length of time and desired services the consumer is on a waiting list for, for future planning purposes.

Q. Quality Assurance Jasper County will perform ongoing evaluation of the service delivery system to determine whether the goals and objectives set forth in the plan are being met. In addition, as a subcommittee of the Stakeholders, the Quality Assurance Committee will survey information regarding the quality of provider services and supports. The information collected will include consumer satisfaction, together with empowerment and quality of life, achievement of desired consumer outcomes, provider satisfaction, patterns of service utilization, responsiveness to consumer needs and desires, the number and disposition of consumer appeals and the implementation of corrective action plans based on those appeals. The county will also compare annual penetration rates for each service and cost effectiveness of the services and supports developed and provided in accordance with provider contracts. R. Collaboration Jasper County will continue to work with other funders, service providers, clients, families, targeted case management, local DHS service workers, advocates and individuals in the court system in the plan implementation process. The county will do so in order to ensure clients are receiving those chosen services for which they are eligible. Clients access many services funded by a source other than Jasper County. The county is committed to working with these sources either directly through the CPC office or with the assistance of targeted case management and/or adult DHS social services. All collaborative efforts will focus on delivering services and supports in a manner that is both cost effective and responsive to clients’ needs. S. Ongoing Education Process Jasper County will provide ongoing education in the community through a variety of methods including use of local media, speaking engagements, print materials and video training materials. Information available will include but not be limited to, the county management plan development process, intake and service authorization processes, service availability and provider enrollment. Targeted audiences will include consumers, family members, service providers and the community at large. T. Amendments Amendments to the policies and procedures component of the county management plan may be made upon a recommendation of the Stakeholder Planning Committee to the Board of Supervisors and must approved by the Board of Supervisors. After approval from the Supervisors, the amendment shall be submitted to the Department of Human Services at least 45 days prior to implementation. Once the amendment is approved by the Director of DHS, the amendment shall be implemented. U. Annual Review Each year the Stakeholders shall prepare a report addressing the following: progress update on the goals and objectives, statistical information including unduplicated listing of consumers served and services provided, number of appeals and outcome of those appeals and continuous quality improvement progress. This report will be made available to consumers, family members, providers and the general public. V. Three-year Strategic Plan The Stakeholder Committee with the assistance of consumers, family members and other concerned individuals, shall develop a three-year strategic plan outlining the goals and objectives, services and supports available, the provider network and the access points for the county management plan.



A. Application/Intake Procedure Clients or their representatives may obtain an application from the CPC Administrator or any designated access point within Jasper County. Staff at any designated access point may also independently identify individuals in need of services and offer such individuals an application for enrollment. The universal CPC application is attached as Appendix E. The completed application and supporting documentation if any should be forwarded to the office of the CPC by the end of the working day. If the applicant has legal settlement or residence in a county other than Jasper County, the application and any other qualifying documentation, including a signed release of information, shall be forwarded to the CPC office of the other county or the local Department of Human Services office for those applicants with state case status. B. Eligibility Determination See Appendix D for eligibility guidelines. C. Notice of Decision A written notice of decision will be made within ten (10) working days from the date the application was received. The CPC Administrator will send the written notice of decision to the applicant or the applicant’s designated representative immediately. This notice will contain an explanation of criteria used in arriving at the decision. This notification will include information on Jasper County’s appeals process. If needed, the notice of decision will also include waiting list information. D. Referral Determination of eligibility may result in a referral for appropriate assessment, service coordination, service(s) and support(s). Services necessary to address immediate needs for stabilization and support will be initiated as soon as possible. Targeted case managers or local DHS service workers may receive referrals for service coordination from the CPC Administrator. Targeted case managers and/or social workers will assess the consumer’s needs and determine appropriate services and supports. They may call on a county staffing team to assist in this determination. The appropriate payment source will be determined for all those eligible for services. If necessary, a referral to a qualified professional will be made for purposes of further clinical assessment. Jasper County shall retain the right to request psychological and or I.Q. testing for any consumer requesting county funding for services. This testing must be completed before any county funding shall be awarded. E. Consumer Plan Development Targeted Case Management staff will coordinate with the county for individual plan development, participate in child to adult transitioning and flexible case review in all eligible cases. Jasper County will coordinate with the local DHS service workers, and county social workers for individual plan development for those clients without Targeted Case Management.


F. Request for Funding Service requests that exceed the county portion of the current ICF/MR funding level will not be funded. For involuntary and voluntary hospitalizations Jasper County has an agreement for payment of services as payor of last resort at a rate below the usual and customary rate with Broadlawns Medical Center, Des Moines, Iowa. The Board of Supervisors have passed a resolution which states Jasper County will pay the costs for admission to those facilities with which the county has an agreement and Mental Health Institutes within the state of Iowa. Jasper County has capped service funds to Capstone Center, Inc. and Progress Industries, Inc. These service funds are subject to on-going review. G. Service Funding Authorization Services necessary to address immediate needs for stabilization and support will be initiated as soon as possible. The elapsed time from the service authorization to initiation of service(s) will be based on the availability of services. The targeted case manager, DHS social worker or service provider will supply a written funding request to the CPC Administrator setting forth the service need, provider, cost and anticipated length of time the applicant will need the service. Such request will state the expected outcome. Services will be authorized for a specific period of time. Service review and reauthorization will occur at specified intervals, or more frequently if requested by the client or recommended by local DHS service worker, targeted case manage, provider or CPC Administrator. CPC AUTHORIZATION CHECKLIST 1. Is there a universal application and release on file? 2. Is the requested service covered in the plan? 3. Is the requested service available? 4. Are funds available from another source? 5. Are county funds available? 6. Notice of eligibility decision to client? 7. Notice to case manager, service worker or provider? 8. Authorization of funding sent to provider? Clients with legal settlement in Jasper County residing in another Iowa County: The CPC Administrator from the client’s county of residence shall contact the Jasper County CPC Administrator when Jasper County is the county of legal settlement for the purpose of determining whether Jasper County will fund a service not included in its network of services. Jasper County will not deny legal settlement where legal settlement has been established as Jasper County. Clients residing in Jasper County with legal settlement in another Iowa county: When a client located in Jasper County needs and desires funding for a service not included in the network of services of the county of legal settlement, Jasper County’s CPC Administrator will contact the CPC Administrator of the county of settlement. The CPC Administrator of the county of settlement must approve the funding of such additional service. Not withstanding any other provision of the management plan to the contrary, Jasper County, Iowa does not intend to deny access to services, as outlined in the management plan and any later amendments thereto, for any current resident of the county regardless of legal settlement issues. Jasper County will work to assure that counties of legal settlement and the State of Iowa and any other available potential payors cooperate in funding appropriate services.

However, Jasper County shall not be deemed a guarantor for funding of services for residents of Jasper County whose legal settlement is other than Jasper County and Jasper County reserves all rights, including but not limited to the rights: to seek reimbursement for services from others, to require that the Central Point of Coordination Administrator of the recipient’s county of legal settlement assume all case management and payment responsibilities, and to provide services under protest subject to all such rights. Consumers with state payment program status: Jasper County‘s CPC Administrator will work with the local Department of Human Services office in developing and approving individualized services for residents of Jasper County with state payment program status. Issues of state payment program status won’t affect the initiation of crisis services or hospital diversion services. H. Service and Cost Tracking Client intake and enrollment information will be maintained and updated by the CPC office. The CPC is responsible for developing a system that will monitor service authorization and costs, per client, and per chart of accounts. This system will provide an unduplicated count of clients accessing county funding for services. Confidentiality will be honored in regard to any and all release of information by the CPC office. Information to be reported and tracked will include, but not be limited to: 1. Client eligibility 2. Legal settlement determination 3. Cost of service 4. Units of service (when applicable) 5. Payments from other sources (county or state) 6. Unduplicated client count I. Service Monitoring The CPC office will generate cost and utilization reports on a monthly basis in conjunction with the Jasper County Auditor ‘s Office. These reports will include services and cost information based on the chart of accounts, services and costs per consumer and year-to-date expenditure data. These reports will also reflect variances between billed services and authorized services. J. Appeals Clients, families of clients, client advocates or representatives, with the consent of clients, may appeal a decision made pursuant to this management plan by the CPC Administrator to the CPC Decisions Appeals Committee. The decision of the CPC Appeals Committee may be appealed to the Board of Supervisors. The appeals policy is attached as Appendix C.


AGENCY Jasper County Newton, Iowa Department of Human Services, Jasper County, Newton, Iowa Targeted Case Management Newton, Iowa Capstone Center, Inc. Newton, Iowa Progress Industries, Inc. Newton, Iowa Willowbrook Adult Day Care Ctr. Newton, Iowa Altoona Family Home Altoona, Iowa Behavioral Technologies Altoona, Iowa Bridgeway Macomb, Illinois Broadlawns Medical Center Des Moines, Iowa Career Development Center Grinnell, Iowa Cedar Valley Ranch Vinton, Iowa Central Iowa Residential Services Marshalltown, Iowa Charleston Place Keokuk, Iowa Christian Opportunity Center Pella, Iowa Crestview Charles City, Iowa Diamond Life Healthcare Montezuema, Iowa Easter Seals Des Moines, Iowa Exceptional Opportunity, Inc. Burt, Iowa Goodwill Industries of Central Iowa Des Moines, Iowa Hawkeye Health Services Des Moines, Iowa SERVICE(S) ICF/MR, HCBS, SCL,CSP, Assisted Living, Work Activity, Nursing Facility, Homemaker Program, Community Interaction Program, Service Management Adult Service Management Case Management Services for MR, DD and CMI CSP, SCL, Day Treatment, Respite, Community Outreach & Education, Crisis Services, Intensive Psych Rehab Outpatient Mental Health Services ICF/MR, RCF/MR, HCBS, SCL Vocational Services, Transportation Adult Day Care RCF/MR Sheltered Workshop Vocational Inpatient Psychiatric Services Outpatient Psychiatric Services Vocational, Social & Leisure Skills SCL RCF/MR SCL RCF/PMI RCF RCF/MR, HCBS,SCL Vocational Services ICF/MR RCF HCBS RCF Vocational Services HCBS Vocational Services HCBS ACCESS POINT (Y/N) Yes

Yes* Yes* Yes

Yes No No No No No No No No No No No No No No No No


AGENCY Highland Place Ottumwa, Iowa Hillcrest Family Services Dubuque, Iowa Hope Haven Rock Valley & Burlington, Iowa Horizons Unlimited Emmetsburg, Iowa Iowa Valley Comm. College District Marshalltown, Iowa Kathleen's Care Emmetsburg, Iowa Lutheran Family Services Ft. Dodge, Iowa Lutheran Social Services Des Moines, Iowa Mainstream Living Story City, Iowa Mary Greeley Medical Center Ames, Iowa Mediapolis Care Facility Mediapolis, Iowa Mental Health Institutes Independence, Iowa Mt. Pleasant, Iowa Nishna Productions Shenandoah, Iowa North Iowa Transition Center Mason City, Iowa Opportunity Village Clear Lake, Iowa Plymouth Life LeMars, Iowa State Hospital Schools Woodward, Iowa Glenwood, Iowa Story County Development Center Ames, Iowa The Homestead Runnells, Iowa Thiemer Street Cedar Falls, Iowa Ultimate Nursing Services of Iowa Des Moines, Iowa

SERVICE(S) RCF/PMI, RCF, SCL SCL RCF/MR Vocational Services SCL Vocational Services SCL Vocational services RCF/MR SCL HCBS HCBS Vocational Services Inpatient Psychiatric Services Outpatient Psychiatric Services RCF Inpatient Psychiatric Services Dual Diagnosis HCBS,CSP Vocational Services RCF, SCL SCL Vocational Services SCL ICF/MR, Evaluation SCL, HCBS Vocational Services ICF/MR ICF/MR HCBS

ACCESS POINT (Y/N) No No No No No No No No No No No No No No No No No No No No No

* Targeted Case Management, funded by Title XIX, is the exclusive access point for those clients eligible for case management services or already receiving case management services.


SERVICE TYPE Involuntary Hospitalization THRESHOLD ELIGIBILITY STANDARD MI SPMI FINANCIAL ELIGIBILITY STANDARD Available regardless of income, private insurance billed first, county may recover part or all of costs Income below 150% poverty, No resources over $2000 Available regardless of Income Per statute Medicaid Eligible SPECIAL CRITERIA DSM IV diagnosis and requires inpatient care DSM IV diagnosis and requires inpatient care, MHI prescreen by Capstone Chapter 229 Commitment status Chapter 229 Commitment status Medicaid ICF/MR as applied by the Iowa Foundation, approval by CPC Unable to live in community without constant supervision UTILIZATION REVIEW PROCESS Hearing within five days as per statute, involve patient advocate Review staffing required within first week N/A N/A

Voluntary Hospitalization


Patient Advocate Legal Representation ICF/MR


RCF RCF/MR RCF/PMI SCL (Supported Community Living Services) HCBS (Home & Community Based Services) Respite


Title XIX / SSA Eligible

Income below 150% poverty, No resources over $2000 Medicaid Eligible


Income below 150% poverty, No resources over $2000 Medicaid Eligible

Case Management Title XIX Match CSP (Community Support Program) Outpatient Treatment

Medicaid Eligible


Income below 150% poverty, No resources over $2000

Annual case management IPP Review , approval by CPC Annual case management IPP Review, approval by CPC Unable to live in Annual case community without management IPP supervision or Review, approval supports by CPC Meet ICF/MR Annual case standards as applied management IPP by the Iowa Review, approval Foundation by CPC No other placement Approval by CPC short of hospital, for specific time would benefit from period service Medicaid eligible Annual case and needs service management IPP Review, approval by CPC Medicaid eligible Annual case and needs service management IPP Review, approval by CPC DSM IV Diagnosis, Annual case would benefit from management IPP service Review, approval by CPC

SERVICE TYPE Homemaker / Home Health Adult Day Care


FINANCIAL ELIGIBILITY STANDARD Income below 150% poverty, No resources over $2000 Income below 150% poverty, No resources over $2000 Title XIX / MHAP eligible Title XIX / MHAP eligible Available regardless of income Income below 150% poverty, No resources over $2000 Income below 150% poverty, No resources over $2000 Income below 150% poverty, No resources over $2000

SPECIAL CRITERIA Would benefit from service and reduce cost of care Would benefit from service and reduce cost of care Title XIX / MHAP eligible and need service Title XIX / MHAP eligible and need service Would benefit from service and reduce cost of care Benefit from prevocational skill development – not ready for community employment Would benefit from interim assistance Would benefit from service and reduce cost of care

Day Treatment/ Partial Hospitalization Intensive Psychiatric Rehabilitation 24 Hour Crisis Intervention Vocational Services




UTILIZATION REVIEW PROCESS Annual case management IPP Review, approval by CPC Annual case management IPP Review, approval by CPC Annual case management IPP Review, approval by CPC Annual case management IPP Review, approval by CPC N/A Annual Case management IPP review with CPC approval GA Application approval, meets Plan guidelines Annual Case management IPP review with CPC approval N/A

General Assistance Transportation


Sheriff MR DD Per Statute Chapter 229 Transportation MI SPMI Commitment status * Services for DD consumers will be provided based upon funding availability.

Jasper County is payor of last resort in all cases unless otherwise provided by law.




A. An individual may request a review of a decision made pursuant to the management plan by the CPC Administrator or any designee of the Board of Supervisors. B. The individual must send a written request for review within ten (10) working days from the date of notice of the decision to: Jasper County Central Point of Coordination 101 1st. Street N. Newton, IA 50208 This request must include the individual’s name, address and phone number. C. The Appeals Committee shall send a written notice of the date, time and place set for the review. This review shall be held within thirty (30) days of receipt of written request unless all parties agree to an extension. D. The individual and/or a representative may appear in person or by telephone at the review and present any information or documentation relevant to the decision. Any individual requesting a review may waive the right to appear and present written documentation in lieu of an appearance. In an individual fails to appear at the review the review will consider all available information. E. The Appeals Committee will issue a written decision within ten (10) days of the review date. A copy of the decision will be sent by mail to the individual seeking the review. The decision will include the following: 1. Statement of reasons supporting the decision. 2. Notice of right to further review of the decision by the Board of Supervisors. 3. Notice of procedure for requesting further review. F. The decision may contain a recommendation to the Board of Supervisors for compromise pursuant to Iowa Code Chapter 230.17. G. An individual desiring further review by the Board of Supervisors must make such request within seven (7) days of receipt of the decision. This review will be held during a regularly scheduled Board of Supervisors meeting and may be a closed session at the consumers request. H. The Board of Supervisors must honor all such requests by way of further review. Further review will be arranged on a case-by-case basis with the requesting individual. It will be held no later than ten (10) days following the date of request unless the parties agree to an extension. I. The Board of Supervisors may call upon a county staffing team to assist in the review of the Appeals Committee decision. A final decision will follow within ten (10) days of the review unless the parties agree to an extension. J. All decisions rendered by the Board of Supervisors are final.


APPENDIX D “Indigent”, as defined for the Jasper County Mental Health Plan:
Shall pertain to any consumer requesting county funding for services Shall pertain to consumers who do not meet funding guidelines for specific programs with approved sliding fee scales, Medicaid Programs or other state/federal programs Excludes all persons in the custody or supervision of the Department of Corrections unless mandated by law. Financial guidelines shall be 150% of Health and Human Services Poverty Guidelines as established annually by the federal government. See table below. Consumers whose income exceeds poverty guidelines will be expected to pay for their own programming and services until their income meets those guidelines. Special consideration may be requested, on a case by case basis for extraordinary circumstances. All available resources, contingent, discretionary or otherwise will be considered in determining eligibility for county funding. Consumers must apply for and accept any and all other funding sources for which they are eligible. Resource exemptions shall include: a Homestead as defined by Iowa Code chapter 561; a vehicle valued at $10,000 or less (an exception will be made for vehicles modified for handicapped persons); $2,000 cash (on hand or in the bank); an irrevocable burial contract/trust not to exceed $7,500; life insurance with cash value not to exceed $2,500; professionally prescribed health aids, wedding and engagement rings; household belongings not to exceed $10,000 2000 Federal HHS Poverty Guidelines: Family Size 100% 150% 1 8,350 12,525 2 11,250 16,875 3 14,150 21,225 4 17,050 25,575 5 19,950 29,925 6 22,850 34,275 7 25,750 38,625 8 28,650 42,975

For family units with more than 8 members, add $2,900 for each additional member at 100% of poverty and $4,350 for each additional member at 150% of poverty.



Universal Central Point of Coordination Application

Application Date__________________________ SS# ____________________________________State ID# _________________________________ Name___________________________________Phone#___________________________________
Last First MI

Sex: [ ] Male

[ ] Female
Street/PO Box#

Birth Date_________________________________

Current Address _________________________How Long at this Address____________________ _______________________________________County_____________________________________
City State Zip

County of Legal Settlement_______________________________________ Ethnic Background (circle one) 0. Unknown; 1. White; 2. African American; 3. Native American; 4. Asian;
5. Hispanic; 6. Other

[ ] Legal Guardian [ ] Protective Payee [ ] Conservator [ ] Legal Guardian [ ] Protective Payee [ ] Conservator

Name__________________________________ Address________________________________ Phone_________________________________

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 Facility 6. RCF 13. Homeless/shelter/street 7. RCF/MR 14. Other

Applicant's Diagnosis (for requested service)
[ ] 40 Mental Illness___________________________ [ ] 41 Chronic Mental Illness____________________ [ ] 42 Mental Retardation_______________________ [ ] 43 Developmental Disability__________________ [ ] Other (describe)___________________________

Referral Source (circle applicable)
1. Self 2. Family/Friend 5. Community Corrections 6. Social Service Agency

Years of education__________________________ GED [ ] Yes [ ] No [ ] No

3. Targeted Case Manager7. Other________________ 4. Other Case Manager

H. S. Diploma [ ] Yes



Current Employment (circle applicable)
1. Unemployed, available for work 2. Unemployed, unavailable 3. Employed, Fulltime 4. Employed, Parttime 5. Retired 6. Student 7. Work Activity 8. Sheltered Work Employment 9. Supported Employment 10. Vocational Rehabilitation 11. Seasonally Employed 12. Armed Forces 13. Homemaker 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
(Check type, fill in 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 ______________

Applicant Amount
_______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________

Others in household amount
____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________

If not currently receiving, has the applicant applied for any of the following benefits?
[ ] 1. Unemployment Compensation [ ] 2. SSDI [ ] 3. SSI [ ] 4. FIP(AFDC)

What is the status of any such application?
[ ] 1. Approved, but not started [ ] 2. Denied [ ] 3. Pending


Resources (check and fill in amount and agency)
[ [ [ [ [ [ [ [ [ [ [ ] Cash ] Checking Account ] Savings Account ] Certificates of Deposit ] Trust Funds ] Life Insurance (cash value) ] Stocks and Bonds ] Vehicle ] Real Estate ] Burial Fund/Trust ] Other Resources Amount _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ Bank, Trustee or Company ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________

Where did you live before you moved to your current address?
____________________________________________________________________________________________________ Street Address City State Zip County When did you live at this address? ___ ___ / ___ ___ ___ ___ to ___ ___ / ___ ___ ___ ___ Month Year Month Year Employer_______________________________ Job___________________________ Dates___________________ Did you receive any mental health or substance abuse treatment services while at this address? [ ] Yes [ ] No Agency Name Address ______________________________ ______________________________ __________________________________________________ __________________________________________________

Where did you live prior to the above listed address?
Previous Addresses _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Dates (Month & Year) _____________to______________ _____________to______________ _____________to______________

List any previous services such as hospitalizations, group homes, mental health center, social services etc. Use separate sheet of paper if necessary.
_________________________________________________________________ _________________________________________________________________ _________________________________________________________________ ______________to_____________ ______________to_____________ ______________to_____________

Current Case Manager or Social Worker _______________________________________________ __________________________________________________________________________________
Agency Address Phone

Services being requested (based on ICP or Treatment Plan)
[ [ [ [ [ [ ]HCBS/SCL ]HCBS/Resp. ] HCBS/HVM ] HCBS/Voc. ] HCBS/Other ]Pers. Allow. [ [ [ [ [ [ ] ICF/MR ] Voc./SW ] Psych Rehab ] Med Mgmt ] Rent Subsidy ] Medical [ [ [ [ [ [ ] RCF [ ] RCF/MR [ ] RCF/PMI [ ] SCL ] Voc./WAC [ ] Voc./ADC [ ] Voc./SE [ ] Voc./Other ] ADT [ ] Evaluation [ ] Therapy/Treatment ] MHI [ ] Commitment [ ] Case Management ] Transp. [ ] Respite [ ] Protective Payee ] Other (describe)_____________________________________________________


Specify Services Requested
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. ________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

Emergency Contact
Name______________________________________________ Relationship_______________________________________ Address____________________________________________ Phone # __________________________________________

Person completing the form (if other than applicant)
Name______________________________________________ Relationship_______________________________________ Address____________________________________________ Phone # __________________________________________ [ ] 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. I understand that information in this document will remain confidential. Applicant's Signature (or Legal guardian) Date ======== ======================================================================= For CPC use only: Legal Settlement/Financial Decision____________________Date______________Reason for Denial___________________ Program Decision__________________________________Date______________Reason for Denial____________________ ______________________________________________________________________________________________


Access Point - a starting point for clients who meet the criteria to receive county funded services; a place where clients can get assistance in filling out an application for services Available Resources – other government or private programs, insurance or similar plan, personal funds, entitlements (contingent, discretionary, or otherwise as a beneficiary or recipient under any trust or benefit plan). Block Grant - a lump-sum dollar amount given by the county to a service provider to help fund services Case Manager - a person assigned to help clients and their families develop, locate, access and coordinate a network of supports and services which allow the client to live a full life in the community; clients must be Title 19 eligible Chart of Accounts - the county’s record of funds used for individuals and services for each budget year Client - sometimes called a consumer, is a person who is eligible to receive services and supports from the county’s service system CMI - (Chronic Mental Illness) People 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 arrangements 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 criteria on a continuous or intermittent basis for at least two years. Treatment History Criteria: 1) Has undergone psychiatric treatment more intensive than outpatient care more than once in a lifetime. 2) Have experienced at least one episode of continuous, structured supportive residential care other than hospitalization. Functioning History Criteria: 1) Are unemployed, employed in a sheltered setting, or have markedly limited skills and a poor work history. 2) Require financial assistance for out-of-hospital maintenance and may be unable to procure this assistance without help. 3) Show severe inability to establish or maintain a personal social support system. 4) Require help in basic living skills. 5) Exhibit inappropriate social behavior that results in demand for intervention by the mental health or judicial system. Reference IAC Chapter 441-24.1 (225C). CoMIS - (County Management Information System) a computerized system used to track data for clients, services and cost of those services CPC - (Central Point of Coordination) the state mandated process by which counties manage their mental health services and budget. CSP - (Community Support Program) SCL programs funded by Merit. See SCL DD - (Developmental Disability) People with developmental disabilities have severe, chronic disabilities, which meet all of the following criteria: 1) Is attributable to mental or physical impairment or a combination of mental and physical impairments. 2) Is manifested before the person attains the age of 22. 3) Is likely to continue indefinitely. Reference IAC Chapter 441-24.1 (225C). HCBS - (Home and Community Based Services) a Medicaid funded program for qualified persons which allows clients a choice of community living and employment options


ICF/MR - (Intermediate Care Facility for Persons with Mental Retardation) Programs licensed by the Department of Inspections and Appeals as licensed living arrangements to provide ongoing active treatment to developmentally disabled residents. Iowa Plan - a state funded program operated by Merit Behavioral Corporation, which provides funding for services, needed by eligible chronically mentally ill persons and substance abusers Legal Settlement – a legal concept defined in Chapter 252 of the Iowa Code that explains which county is responsible for funding a client’s services; county of legal settlement can be different from county of residence for some clients Managed Care - a system for monitoring the quality, cost and delivery of services to clients MI - (Mental Illness) People who have a current diagnosis of a mental illness as defined in the Diagnostic and Statistical Manual, Fourth Edition (DSM IV). Diagnoses which 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 is V Code diagnoses, psychoactive substance use disorders and developmental disorders.) Reference IAC Chapter 441-22.1 (225C). MR - (Mental Retardation) People with mental retardation have significantly sub-average general intellectual functioning existing concurrent with deficits in adaptive behavior, manifested during the developmental period. All of the following criteria must be met: 1) 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. 2) 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. 3) Sub-average intellectual functioning and deficits in adaptive behavior are manifested during the developmental period, the time period between conception and the eighteenth birthday. Reference IAC Chapter 441-24.1 (225C). Provider - a person, group or agency offering services and supports for people with disabilities RCF - (Residential Care Facility) Programs certified by the Department of Human Services MH/DD Division for persons needing residential care RCF/MR - (Residential Care Facility for Persons with Mental Retardation) Programs certified by the Department of Human Services MH/DD Division as a living arrangement for persons with mental retardation RCF/PMI - (Residential Care Facility for Persons with Mental Illness) Programs certified by the Department of Human Services MH/DD Division as living arrangement for persons with a persistent or chronic mental illness. Residence – the place where a person actually lives Respite - services designed to provide alternative short term care and support for clients and/or primary caregivers SCL - (Supported Community Living) Programs licensed, certified, accredited or approved by the Department of Inspections and Appeals or the Department of Human Services as Supported Community Living Providers. These programs meet individual treatment and support needs of clients

with chronic mental illness, mental retardation or developmental disabilities to live and work in a community setting. Social Worker - a person assigned to help clients and their families develop, locate, access and coordinate a network of supports and services which will allow the client live a full life in the community; clients may or may not be Title 19 eligible SPMI - (Serious and Persistent Mental Illness) See CMI Stakeholder - an individual having an interest in services provided for persons with mental illness, mental retardation and developmental disability State Payment Program Status - a person who does not have legal settlement in any county in Iowa Targeted Case Management – an agency designated by the county, which helps eligible Title 19 clients and their families develop, locate, access and coordinate a network of supports and services which will allow the client to live a full life in the community Transitioning Process - an individual’s progress from childhood to adulthood Waiver Program - a variety of medicaid programs of which some federal rules pertaining to facility based placements have been waived. These programs are designed to allow clients to live in their communities.


The Jasper County Board of Supervisors has approved this Policies and Procedures Manual for the county management plan for Jasper County. We the undersigned, do respectfully submit this manual for approval by the State of Iowa for implementation beginning July 1, 2000.

__________________________________________ Leo Van Elswyk, Chairman of the Board Date

__________________________________________ Loren “Pat” Milligan, Supervisor Date

__________________________________________ Glen Jesse, Supervisor Date


To top