Iowa

Iowa

Iowa requires CONs within five broad categories—hospital beds, beds outside hospitals, equipment, facilities and services. Iowa maintains 29 independent CON requirements and 18 separate exceptions, one of which is in the form of an attorney general opinion concluding that Iowa’s air ambulance CON provision conflicts with federal aviation law and thus is unenforceable. Despite the attorney general opinion from 2016, the air ambulance CON provision remains codified in Iowa’s statutes. Iowa also maintains a CON requirement for activities such as reducing bed capacity and eliminating a health service.

COVID-19 Response

On March 17, 2020, Governor Reynolds suspended the requirement that institutional health facilities obtain a CON prior to increasing bed capacity. Proclamation of Disaster Emergency Relief (Mar. 17, 2020). The suspension expired April 16, 2020.

Application Process

In Iowa, the CON application review process takes between 60–90 days. Iowa Code § 135.69(1); Iowa Admin. Code §§ 641- 202.7(3), (6). Applications can be submitted at any time. The fee for a CON application can range from $600 to $21,000. Iowa Admin. Code § 641-202.4(2). Competitors can intervene in the application process and can offer evidence or argument as to why an application should be denied. Iowa Code § 135.66(4).

CON? Number of CONs Moratoria Temporary COVID-19 response:
Hospital Beds Yes 1 – Suspended at least some CON laws
Beds Outside Hospitals Yes 7 – Suspended at least some CON laws
Equipment Yes 4 – No action
Facilities/ Buildings Yes 8 – No action
Services Yes 9 – No action
Emergency Medical Transport No – – –

Note: these citations are accurate as of May 2020.

Iowa CONs in Detail

Category

Types of CONs

Iowa Code

Hospital Beds

1.A permanent change in the bed capacity of a hospital.

§§ 135.61(18)(d),(14)(a)

Beds Outside Hospitals

CON required for a permanent change in the bed capacity of:

1.A nursing facility.

§§ 135.61(18)(d), (14)(b), (9),

135C.1(7)

2.An intermediate care facility for persons with mental illness.

§§ 135.61(18)(d), (14)(b), (9),

135C.1(7)

3.An intermediate care facility for persons with an intellectual disability.

§§ 135.61(18)(d), (14)(b), (9),

135C.1(7)

4.An organized outpatient health facility.

§§ 135.61(18)(d), (14)(c)

5.An outpatient surgical facility.

§§ 135.61(18)(d), (14)(d)

6.A community mental health facility.

§§ 135.61(18)(d), (14)(e)

7.A birth center.

§§ 135.61(18)(d), (14)(f)

Equipment

1.Any acquisition by or on behalf of a health care provider or a group of health care providers of any piece of replacement equipment with a value in excess of $1.5 million.

§ 135.61(18)(g)

2.Any acquisition by or on behalf of a health care provider or group of health care providers of any piece of equipment with a value in excess of $1.5 million, which results in the offering or development of a health service not previously provided.

§ 135.61(18)(h)

3.Any acquisition of any piece of replacement equipment valued in excess of $1.5 million by:

»A hospital.

»A nursing facility.

»An intermediate care facility for persons with mental illness.

»An intermediate care facility for persons with an intellectual disability.

»An organized outpatient health facility.

»An outpatient surgical facility.

»A community mental health facility.

»A birth center.

§§ 135.61(18)(i), 135.61(14)

4.Any acquisition of any new piece of equipment valued in excess of $1.5 million, which results in in the offering or development of a service not previously provided by any of the following:

»A hospital.

»A nursing facility.

»An intermediate care facility for persons with mental illness.

»An intermediate care facility for persons with an intellectual disability.

»An organized outpatient health facility.

»An outpatient surgical facility.

»A community mental health facility.

»A birth center.

§§ 135.61(18)(j),

135.61(14)

Category

Types of CONs

Iowa Code

Facilities/Buildings

CON required for construction, development or other establishment of, or relocation of:

1.A hospital.

§§ 135.61(18)(a), (b),

135.61(14)(a)

2.A nursing facility.

§§ 135.61(18)(a), (b),

135.61(14)(b),

135.61(9), 135C.1(7)

3.An intermediate care facility for persons with mental illness.

§§ 135.61(18)(a), (b),

135.61(14)(b), 135.61(9), 135C.1(7)

4.An intermediate care facility for persons with an intellectual disability.

§§ 135.61(18)(a), (b),

135.61(14)(b),

135.61(9), 135C.1(7)

5.An organized outpatient health facility.

§§ 135.61(18)(a), (b),

135.61(14)(c)

6.An outpatient surgical facility.

§§ 135.61(18)(a), (b),

135.61(14)(d)

7.A community mental health facility.

§§ 135.61(18)(a), (b),

135.61(14)(e)

8.A birth center.

§§ 135.61(18)(a), (b),

135.61(14)(f)

Services

1.Any capital expenditure, lease, or donation in excess of $1.5 million within a 12-month period by or on behalf of:

»A hospital.

»A nursing facility.

»An intermediate care facility for persons with mental illness.

»An intermediate care facility for persons with an intellectual disability.

»An organized outpatient health facility.

»An outpatient surgical facility.

»A community mental health facility.

»A birth center.

§§ 135.61(18)(c),

135.61(14),

135c.1(7)

2.Any expenditure in excess of $500,000 for health services which were not offered on a regular basis within the 12-month period prior to that time by or on behalf of:

»A hospital.

»A nursing facility.

»An intermediate care facility for persons with mental illness.

»An intermediate care facility for persons with an intellectual disability.

»An organized outpatient health facility.

»An outpatient surgical facility.

»A community mental health facility.

»A birth center.

§§ 135.61(18)(e),

135.61(14),

135c.1(7)

Category

Types of CONs

Iowa Code

Services

3.CON required for deletion of one or more health services, previously offered on a regular basis by:

»A hospital.

»A nursing facility.

»An intermediate care facility for persons with mental illness.

»An intermediate care facility for persons with an intellectual disability.

»An organized outpatient health facility.

»An outpatient surgical facility.

»A community mental health facility.

»A birth center.

§§ 135.61(18)(f), 135.61(14),

135c.1(7)

4.Any air transportation service for transportation of patients or medical personnel which was not offered on a regular basis within the 12-month period prior to the specific time offered by:

»A hospital.

»A nursing facility.

»An intermediate care facility for persons with mental illness.

»An intermediate care facility for persons with an intellectual disability.

»An organized outpatient health facility.

»An outpatient surgical facility.

»A community mental health facility.

»A birth center.

§§ 135.61(18)(k),

135.61(14),

135c.1(7)

5.Offering or developing any mobile health service with a value in excess of $1.5 million.

§ 135.61(18)(l)

6.Offering or developing cardiac catheterization service.

§135.61(18)(m)(1)

7.Offering or developing open heart surgical service.

§135.61(18)(m)(2)

8.Offering or developing organ transplantation service.

§135.61(18)(m)(3)

9.Offering or developing radiation therapy service applying ionizing radiation for the treatment of malignant disease using megavoltage external beam equipment.

§135.61(18)(m)(4)

Emergency Medical Transport

No CONs in this category.

Iowa CON Exceptions

No CON Required For:

Iowa Code

1.Private offices and private clinics of an individual physician, dentist or other practitioner or group of health care providers.

§ 135.63(2)(a)

2.Dispensaries and first aid stations, located within schools, businesses or industrial establishments, which are maintained solely for the use of students or employees of those establishments and which do not contain inpatient or resident beds that are customarily occupied by the same individual for more than 24 consecutive hours.

§ 135.63(2)(b)

3.Establishments such as motels, hotels and boarding houses which provide medical, nursing personnel and other health related services as an incident to their primary business or function.

§ 135.63(2)(c)

4.The remedial care or treatment of residents or patients in any home or institution conducted only for those who rely solely upon treatment by prayer or spiritual means in accordance with the creed or tenets of any recognized church or religious denomination.

§ 135.63(2)(d)

5.Health maintenance organization or combination of health maintenance organizations except when the health maintenance organization or combination of health maintenance organizations does any of the following:

(1) Constructs, develops, renovates, relocates or otherwise establishes an institutional health facility; and

(2) Acquires major medical equipment as provided by § 135.61, subsection 18, paragraphs “i” and “j.”

§ 135.63(2)(e)

6.Residential care facilities.

§ 135.63(2)(f)

7.A reduction in bed capacity of an institutional health facility, notwithstanding any provision in this subchapter to the contrary, if all of the following conditions exist:

(a) The institutional health facility reports to the department the number and type of beds reduced on a form prescribed by the department at least 30 days before the reduction. In the case of a health care facility, the new bed total must be consistent with the number of licensed beds at the facility. In the case of a hospital, the number of beds must be consistent with bed totals reported to the department of inspections and appeals for purposes of licensure and certification; and

(b) The institutional health facility reports the new bed total on its next annual report to the department.

§ 135.63(2)(g)(1)

8.The deletion of one or more health services, previously offered on a regular basis by an institutional health facility or health maintenance organization, notwithstanding any provision of this subchapter to the contrary, if all of the following conditions exist:

(a) The institutional health facility or health maintenance organization reports to the department the deletion of the service or services at least thirty days before the deletion on a form prescribed by the department; and

(b) The institutional health facility or health maintenance organization reports the deletion of the service or services on its next annual report to the department.

§ 135.63(2)(h)(1)

9.A residential program exempt from licensing as a health care facility under chapter 135C.6, subsection 8.

§ 135.63(2)(i)

10.The construction, modification or replacement of nonpatient care services.

§ 135.63(2)(j)

No CON Required For:

Iowa Code

11.The redistribution of beds by a hospital within the acute care category of bed usage, notwithstanding any provision in this subchapter to the contrary, if all of the following conditions exist:

(a) The hospital reports to the department the number and type of beds to be redistributed on a form prescribed by the department at least 30 days before the redistribution.

(b) The hospital reports the new distribution of beds on its next annual report to the department.

§ 135.63(2)(k)(1)

12.The replacement or modernization of any institutional health facility if the replacement or modernization does not add new health services or additional bed capacity for existing health services—with special rules for nursing home and hospital “replacement.”

§ 135.63(2)(l)

13.Hemodialysis services provided by a hospital or freestanding facility.

§ 135.63(2)(m)

14.Hospice services provided by a hospital.

§ 135.63(2)(n)

15.The change in ownership, licensure, organizational structure or designation of the type of institutional health facility if the health services offered by the successor institutional health facility are unchanged. This exclusion is applicable only if the institutional health facility consents to the change in ownership, licensure, organizational structure, or designation of the type of institutional health facility and ceases offering the health services simultaneously with the initiation of the offering of health services by the successor institutional health facility.

§ 135.63(2)(o)

16.The conversion of an existing number of beds by an intermediate care facility for persons with an intellectual disability to a smaller facility environment, if all the following conditions are met:

(1) The intermediate care facility for persons with an intellectual disability reports the number and type of beds to be converted on a form prescribed by the department at least thirty days before the conversion.

(2) The intermediate care facility for persons with an intellectual disability reports the conversion of beds on its next annual report to the department.

§ 135.63(2)(p)

17.Health care facility operated by and for the exclusive use of members of a religious order, which does not admit more than two individuals to the facility from the general public, and which was in operation prior to July 1, 1986.

§ 135.63(3)

18.Air ambulance service.

Iowa Dep’t of Justice, Air Ambulances and Certificate of Need (Feb 26, 2016)38 (concluding Iowa’s air ambulance CON requirement is preempted by federal aviation laws and should not be enforced by the department).

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