CHAPTER 83
MEDICAID WAIVER SERVICES
Preamble
Medicaid waiver services are services provided to maintain persons in their own homes or communities who would otherwise require care in medical institutions. Provision of these services must be cost-effective. Services are limited to certain targeted client groups for whom a federal waiver has been requested and approved. Services provided through the waivers are not available to other Medicaid recipients as the services are beyond the scope of the Medicaid state plan.
DIVISION I—HCBS ILL AND HANDICAPPED WAIVER SERVICES
441—83.1(249A) Definitions.
“Attorney in fact under a durable power of attorney for health care” means an individual who is designated by a durable power of attorney for health care, pursuant to Iowa Code chapter 144B, as an agent to make health care decisions on behalf of an individual and who has consented to act in that capacity.
“Basic individual respite” means respite provided on a staff-to-consumer ratio of one to one or higher to individuals without specialized needs requiring the care of a licensed registered nurse or licensed practical nurse.
“Blind individual” means an individual who has a central visual acuity of 20/200 or less in the better eye with the use of corrective lens or visual field restriction to 20 degrees or less.
“Client participation” means the amount of the recipient income that the person must contribute to the cost of ill and handicapped waiver services exclusive of medical vendor payments before Medicaid will participate.
“Deeming” means the specified amount of parental or spousal income and resources considered in determining eligibility for a child or spouse according to current supplemental security income guidelines.
“Disabled person” means an individual who is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which has lasted or is expected to last for a continuous period of not less than 12 months. A child under the age of 18 is considered disabled if the child suffers a medically determinable physical or mental impairment of comparable severity.
“Financial participation” means client participation and medical payments from a third party including veterans’ aid and attendance.
“Group respite” is respite provided on a staff-to-consumer ratio of less than one to one.
“Guardian” means a guardian appointed in probate court.
“Intermittent homemaker service” means homemaker service provided from one to three hours a day for not more than four days per week.
“Intermittent respite service” means respite service provided from one to three times a week.
“Medical assessment” means a visual and physical inspection of the consumer, noting deviations from the norm, and a statement of the consumer’s mental and physical condition that can be amendable to or resolved by appropriate actions of the provider.
“Medical institution” means a nursing facility or an intermediate care facility for the mentally retarded which has been approved as a Medicaid vendor.
“Medical intervention” means consumer care in the areas of hygiene, mental and physical comfort, assistance in feeding and elimination, and control of the consumer’s care and treatment to meet the physical and mental needs of the consumer in compliance with the plan of care in areas of health, prevention, restoration, and maintenance.
“Medical monitoring” means observation for the purpose of assessing, preventing, maintaining, and treating disease or illness based on the consumer’s plan of care.
“Service plan” means a written consumer-centered, outcome-based plan of services developed using an interdisciplinary process, which addresses all relevant services and supports being provided. It may involve more than one provider.
“Specialized respite” means respite provided on a staff-to-consumer ratio of one to one or higher to individuals with specialized medical needs requiring the care, monitoring or supervision of a licensed registered nurse or licensed practical nurse.
“Substantial gainful activity” means productive activities which add to the economic wealth, or produce goods or services to which the public attaches a monetary value.
“Third-party payments” means payments from an attorney, individual, institution, corporation, or public or private agency which is liable to pay part or all of the medical costs incurred as a result of injury, disease or disability by or on behalf of an applicant or a past or present recipient of medical assistance.
“Usual caregiver” means a person or persons who reside with the consumer and are available on a 24-hour-per-day basis to assume responsibility for the care of the consumer.
441—83.2(249A) Eligibility. To be eligible for ill and handicapped waiver services a person must meet certain eligibility criteria and be determined to need a service(s) allowable under the program.
	83.2(1) Eligibility criteria.
	a. 	The person must be under the age of 65 and blind or disabled as determined by the receipt of social security disability benefits or by a disability determination made through the department. Disability determinations are made according to supplemental security income guidelines under Title XVI of the Social Security Act.
	b. 	The person must be ineligible for Supplemental Security Income (SSI) if the person is 21 years of age or older, except that persons who are receiving ill and handicapped waiver services upon reaching the age of 21 may continue to be eligible regardless of SSI eligibility until they reach the age of 25.
	c. 	Persons shall meet the eligibility requirements of the supplemental security income program except for the following:
	(1)	The person is under 18 years of age, unmarried and not the head of a household and is ineligible for supplemental security income because of the deeming of the parent’s(s’) income.
	(2)	The person is married and is ineligible for supplemental security income because of the deeming of the spouse’s income or resources.
	(3)	The person is ineligible for supplemental security income due to excess income and the person’s income does not exceed 300 percent of the maximum monthly payment for one person under supplemental security income.
	(4)	The person is under 18 years of age and is ineligible for supplemental security income because of excess resources.
	d. 	The person must be certified as being in need of nursing facility or skilled nursing facility level of care or as being in need of care in an intermediate care facility for the mentally retarded. The IME medical services unit shall be responsible for approval of the certification of the level of care.
Ill and handicapped waiver services will not be provided when the individual is an inpatient in a medical institution.
	e. 	To be eligible for interim medical monitoring and treatment services the consumer must be:
	(1)	Under the age of 21;
	(2)	Currently receiving home health agency services under rule 441—78.9(249A) and require medical assessment, medical monitoring, and regular medical intervention or intervention in a medical emergency during those services. (The home health aide services for which the consumer is eligible must be maximized before the consumer accesses interim medical monitoring and treatment.);
	(3)	Residing in the consumer’s family home or foster family home; and
	(4)	In need of interim medical monitoring and treatment as ordered by a physician.
	f. 	The person must meet income and resource guidelines for Medicaid as if in a medical institution pursuant to 441—Chapter 75. When a husband and wife who are living together both apply for the waiver, income and resource guidelines as specified at paragraphs 441—75.5(2)“b” and 441—75.5(4)“c” shall be applied.
	g. 	The person must have service needs that can be met by this waiver program. At a minimum a person must receive one billable unit of service under the waiver per calendar quarter.
	h. 	To be eligible for the consumer choices option as set forth in 441—subrule 78.34(13), a person cannot be living in a residential care facility.
	83.2(2) Need for services.
	a. 	The consumer shall have a service plan approved by the department which is developed by the service worker identified by the county of residence. This service plan must be completed prior to services provision and annually thereafter.
The service worker shall establish the interdisciplinary team for the consumer and, with the team, identify the consumer’s need for service based on the consumer’s needs and desires as well as the availability and appropriateness of services using the following criteria:
	(1)	This service plan shall be based, in part, on information in the completed Home- and Community-Based Services Assessment or Reassessment, Form 470-0659. Form 470-0659 is completed annually, or more frequently upon request or when there are changes in the consumer’s condition. The service worker shall have a face-to-face visit with the consumer at least annually.
	(2)	Service plans for persons aged 20 or under shall be developed to reflect use of all appropriate nonwaiver Medicaid services and so as not to replace or duplicate those services. The service worker shall list all nonwaiver Medicaid services in the service plan.
	(3)	Service plans for persons aged 20 or under that include home health or nursing services shall not be approved until a home health agency has made a request to cover the consumer’s service needs through nonwaiver Medicaid services.
	b. 	Except as provided below, the total monthly cost of the ill and handicapped waiver services shall not exceed the established aggregate monthly cost for level of care as follows:

Skilled level of care	Nursing level of care	ICF/MR	
$2,631	$904	$3,203	
	(1)	For consumers eligible for SSI who remain eligible for ill and handicapped waiver services until the age of 25 because they are receiving ill and handicapped waiver services upon reaching the age of 21, these amounts shall be increased by the cost of services for which the consumer would be eligible under 441—subrule 78.9(10) if still under 21 years of age.
	(2)	If more than $505 is paid for home and vehicle modification services, the service worker shall encumber up to $505 per month within the monthly dollar cap allowed for the consumer until the total amount of the modification is reached within a 12-month period.
	c. 	Interim medical monitoring and treatment services must be needed because all usual caregivers are unavailable to provide care due to one of the following circumstances:
	(1)	Employment. Interim medical monitoring and treatment services are to be received only during hours of employment.
	(2)	Academic or vocational training. Interim medical monitoring and treatment services provided while a usual caregiver participates in postsecondary education or vocational training shall be limited to 24 periods of no more than 30 days each per caregiver as documented by the service worker. Time spent in high school completion, adult basic education, GED, or English as a second language does not count toward the limit.
	(3)	Absence from the home due to hospitalization, treatment for physical or mental illness, or death of the usual caregiver. Interim medical monitoring and treatment services under this subparagraph are limited to a maximum of 30 days.
	(4)	Search for employment.
	1.	Care during job search shall be limited to only those hours the usual caregiver is actually looking for employment, including travel time.
	2.	Interim medical monitoring and treatment services may be provided under this paragraph only during the execution of one job search plan of up to 30 working days in a 12-month period, approved by the department service worker or targeted case manager pursuant to 441—subparagraph 170.2(2)“b”(5).
	3.	Documentation of job search contacts shall be furnished to the department service worker or targeted case manager.
441—83.3(249A) Application.
	83.3(1) Application for HCBS ill and handicapped waiver services. The application process as specified in rules 441—76.1(249A) to 441—76.6(249A) shall be followed.
	83.3(2) Application and services program limit. The number of persons who may be approved for the HCBS ill and handicapped waiver shall be subject to the number of consumers to be served as set forth in the federally approved HCBS ill and handicapped waiver. The number of consumers to be served is set forth at the time of each five-year renewal of the waiver or in amendments to the waiver approved by the Centers for Medicare and Medicaid Services (CMS). When the number of applicants exceeds the number of consumers specified in the approved waiver, the applicant’s name shall be placed on a waiting list maintained by the bureau of long-term care.
	a. 	The county department office shall contact the bureau of long-term care for all applicants for the waiver to determine if a payment slot is available.
	(1)	For applicants not currently receiving Medicaid, the county department office shall contact the bureau by the end of the fifth working day after receipt of a completed Form 470-2927 or 470-2927(S), Health Services Application, or within five working days after receipt of disability determination, whichever is later.
	(2)	For current Medicaid recipients, the county department office shall contact the bureau by the end of the fifth working day after receipt of either Form 470-0659, Home- and Community-Based Services Assessment or Reassessment, with the choice of HCBS waiver indicated by signature of the consumer or a written request signed and dated by the consumer.
	(3)	A payment slot shall be assigned to the applicant upon confirmation of an available slot.
	(4)	Once a payment slot is assigned, the county department office shall give written notice to the applicant. The department shall hold the payment slot for the applicant as long as reasonable efforts are being made to arrange services and the applicant has not been determined to be ineligible for the program. If services have not been initiated and reasonable efforts are no longer being made to arrange services, the slot shall revert for use by the next person on the waiting list, if applicable. The applicant originally assigned the slot must reapply for a new slot.
	b. 	If no payment slot is available, the bureau of long-term care shall enter persons on a waiting list according to the following:
	(1)	Consumers not currently eligible for Medicaid shall be entered on the waiting list on the basis of the date a completed Form 470-2927 or 470-2927(S), Health Services Application, is date-stamped in the county department office or upon the county department office’s receipt of disability determination, whichever is later.
	(2)	Consumers currently eligible for Medicaid shall be added to the waiting list on the basis of the date a request as specified in 83.3(2)“a”(2) is date-stamped in the county department office.
	(3)	In the event that more than one application is received at one time, persons shall be entered on the waiting list on the basis of the month of birth, January being month one and the lowest number.
	(4)	Applicants who do not fall within the available slots shall have their application rejected, and their names shall be maintained on the waiting list. They shall be contacted to reapply as slots become available based on their order on the waiting list so that the number of approved persons on the program is maintained. The bureau of long-term care shall contact the county department office when a slot becomes available.
	(5)	Once a payment slot is assigned, the county department office shall give written notice to the person within five working days. The department shall hold the payment slot for 30 days for the person to file a new application. If an application has not been filed within 30 days, the slot shall revert for use by the next person on the waiting list, if applicable. The person originally assigned the slot must reapply for a new slot.
	c. 	The county department office shall notify the bureau of long-term care within five working days of the receipt of an application and of any action on or withdrawal of an application.
	83.3(3) Approval of application.
	a. 	Applications for the HCBS ill and handicapped waiver program shall be processed in 30 days unless one or more of the following conditions exist:
	(1)	An application has been filed and is pending for federal supplemental security income benefits.
	(2)	The application is pending because the department has not received information which is beyond the control of the client or the department.
	(3)	The application is pending due to the disability determination process performed through the department.
	(4)	The application is pending because a level of care determination has not been made although the completed assessment, Form 470-0659, Home- and Community-Based Services Assessment or Reassessment, has been submitted to the IME medical services unit.
	(5)	The application is pending because the assessment, Form 470-0659, or the service plan has not been completed. When a determination is not completed 90 days from the date of application due to the lack of a completed assessment, Form 470-0659, or service plan, the application shall be denied. The consumer shall have the right to appeal.
	b. 	Decisions shall be mailed or given to the applicant on the date when income maintenance eligibility and level of care determinations and the client case plan are completed.
	c. 	A consumer must be given the choice between HCBS ill and handicapped waiver services and institutional care. The income maintenance or service worker shall have the consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care complete and sign Form 470-0659, Home- and Community-Based Services Assessment or Reassessment, indicating the consumer’s choice of home- and community-based services or institutional care.
	d. 	Waiver services provided prior to approval of eligibility for the waiver cannot be paid.
	e. 	A consumer may be enrolled in only one waiver program at a time. Costs for waiver services are not reimbursable while the consumer is in a medical institution (hospital or nursing facility) or residential facility. Services may not be simultaneously reimbursed for the same time period as Medicaid or other Medicaid waiver services.
	83.3(4) Effective date of eligibility.
	a. 	Deeming of parental or spousal income and resources ceases and eligibility shall be effective on the date the income and resource eligibility and level of care determinations and the case plan are completed, but shall not be earlier than the first of the month following the date of application.
	b. 	The effective date of eligibility for the ill and handicapped waiver for persons who qualify for Medicaid due to eligibility for the waiver services and to whom paragraphs “a” and “c” of this subrule do not apply is the date on which the income eligibility and level of care determinations and the case plan are completed.
	c. 	Eligibility for persons covered under subrule 83.2(1)“c”(3) shall exist on the date the income and resource eligibility and level of care determinations and case plan are completed, but shall not be earlier than the first of the month following the date of application.
	d. 	Eligibility continues until the consumer has been in a medical institution for 30 consecutive days for other than respite care. Consumers who are inpatients in a medical institution for 30 or more consecutive days for other than respite care shall be terminated from ill and handicapped waiver services and reviewed for eligibility for other Medicaid coverage groups. The consumer will be notified of that decision through Form 470-0602, Notice of Decision. If the consumer returns home before the effective date of the notice of decision and the consumer’s condition has not substantially changed, the denial may be rescinded and eligibility may continue.
	83.3(5) Attribution of resources. For the purposes of attributing resources as provided in rule 441—75.5(249A), the date on which the waiver applicant met the level of care criteria in a medical institution as established by the peer review organization shall be used as the date of entry to the medical institution. Only one attribution of resources shall be completed per person. Attributions completed for prior institutionalizations shall be applied to the waiver application.
441—83.4(249A) Financial participation. Persons must contribute their predetermined financial participation to the cost of ill and handicapped waiver services or other Medicaid services, as applicable.
	83.4(1) Maintenance needs of the individual. The maintenance needs of the individual shall be computed by deducting an amount which is 300 percent of the maximum monthly payment for one person under supplemental security income (SSI) from the client’s total income.
	83.4(2) Limitation on payment. If the sum of the third-party payment and client participation equals or exceeds the reimbursement established by the service worker for ill and handicapped waiver services, Medicaid shall make no payments to ill and handicapped waiver service providers. However, Medicaid shall make payments to other medical vendors, as applicable.
	83.4(3) Maintenance needs of spouse and other dependents. Rescinded IAB 4/9/97, effective 6/1/97.
441—83.5(249A) Redetermination. A complete redetermination of eligibility for the ill and handicapped waiver shall be completed at least once every 12 months or when there is significant change in the person’s situation or condition.
A redetermination of continuing eligibility factors shall be made in accordance with rules 441—76.7(249A) and 441—83.2(249A). A redetermination shall include verification of the existence of a current case plan meeting the requirements listed in rule 441—83.7(249A).
441—83.6(249A) Allowable services. Services allowable under the ill and handicapped waiver are homemaker, home health, adult day care, respite care, nursing, counseling, consumer-directed attendant care, interim medical monitoring and treatment, home and vehicle modification, personal emergency response system, home-delivered meals, nutritional counseling, financial management, independent support brokerage, self-directed personal care, self-directed community supports and employment, and individual-directed goods and services as set forth in rule 441—78.34(249A).
441—83.7(249A) Service plan. A service plan shall be prepared for ill and handicapped waiver consumers in accordance with rule 441—130.7(234) except that service plans for both children and adults shall be completed every 12 months or when there is significant change in the person’s situation or condition.
	83.7(1) The service plan shall include the frequency of the ill and handicapped waiver services and the types of providers who will deliver the services.
	83.7(2) The service plan shall indicate whether the consumer has elected the consumer choices option. If the consumer has elected the consumer choices option, the service plan shall identify:
	a. 	The independent support broker selected by the consumer; and
	b. 	The financial management service selected by the consumer.
	83.7(3) The service plan shall also list all nonwaiver Medicaid services.
	83.7(4) The service plan shall identify a plan for emergencies and the supports available to the consumer in an emergency.
441—83.8(249A) Adverse service actions.
	83.8(1) Denial. An application for services shall be denied when it is determined by the department that:
	a. 	The client is not eligible for or in need of services.
	b. 	Needed services are not available or received from qualified providers.
	c. 	Service needs exceed the aggregate monthly costs established in 83.2(2)“b,” or are not met by the services provided.
	d. 	Needed services are not available or received from qualifying providers.
	83.8(2) Termination. A particular service may be terminated when the department determines that:
	a. 	The provisions of 130.5(2)“a,” “b,” “c,” “g,” or “h” apply.
	b. 	The costs of the ill and handicapped waiver service for the person exceed the aggregate monthly costs established in 83.2(2)“b.”
	c. 	The client receives care in a hospital, nursing facility, or intermediate care facility for the mentally retarded for 30 days in any one stay for purposes other than respite care.
	d. 	The client receives ill and handicapped waiver services and the physical or mental condition of the client requires more care than can be provided in the client’s own home as determined by the service worker.
	e. 	Service providers are not available.
	83.8(3) Reduction of services shall apply as in subrule 130.5(3), paragraphs “a” and “b.”
441—83.9(249A) Appeal rights. Notice of adverse action and right to appeal shall be given in accordance with 441—Chapter 7 and rule 441—130.5(234). The applicant or recipient is entitled to have a review of the level of care determination by the IME medical services unit by sending a letter requesting a review to the IME medical services unit. If dissatisfied with that decision, the applicant or recipient may file an appeal with the department.
441—83.10(249A) County reimbursement. Rescinded IAB 4/9/97, effective 6/1/97.
441—83.11(249A) Conversion to the X-PERT system. Rescinded IAB 8/7/02, effective 10/1/02.
These rules are intended to implement Iowa Code sections 249A.3 and 249A.4.
441—83.12 to 83.20 Reserved.
DIVISION II—HCBS ELDERLY WAIVER SERVICES
441—83.21(249A) Definitions.
“Attorney in fact under a durable power of attorney for health care” means an individual who is designated by a durable power of attorney for health care, pursuant to Iowa Code chapter 144B, as an agent to make health care decisions on behalf of an individual and who has consented to act in that capacity.
“Basic individual respite” means respite provided on a staff-to-consumer ratio of one to one or higher to individuals without specialized needs requiring the care of a licensed registered nurse or licensed practical nurse.
“Client participation” means the amount of the recipient income that the person must contribute to the cost of elderly waiver services exclusive of medical vendor payments before Medicaid will participate.
“Group respite” is respite provided on a staff-to-consumer ratio of less than one to one.
“Guardian” means a guardian appointed in probate court.
“Interdisciplinary team” means a collection of persons with varied professional backgrounds who develop one plan of care to meet a client’s need for services.
“Medical institution” means a nursing facility which has been approved as a Medicaid vendor.
“Service plan” means a written consumer-centered, outcome-based plan of services developed using an interdisciplinary process, which addresses all relevant services and supports being provided. It may involve more than one provider.
“Specialized respite” means respite provided on a staff-to-consumer ratio of one to one or higher to individuals with specialized medical needs requiring the care, monitoring or supervision of a licensed registered nurse or licensed practical nurse.
“Third-party payments” means payments from an individual, institution, corporation, or public or private agency which is liable to pay part or all of the medical costs incurred as a result of injury, disease or disability by or on behalf of an applicant or a past or present recipient of medical assistance.
“Usual caregiver” means a person or persons who reside with the consumer and are available on a 24-hour-per-day basis to assume responsibility for the care of the consumer.
441—83.22(249A) Eligibility. To be eligible for elderly waiver services a person must meet certain eligibility criteria and be determined to need a service(s) allowable under the program.
	83.22(1) Eligibility criteria. All of the following criteria must be met. The person must be:
	a. 	Sixty-five years of age or older.
	b. 	A resident of the state of Iowa.
	c. 	Eligible for Medicaid as if in a medical institution pursuant to 441—Chapter 75. When a husband and wife who are living together both apply for the waiver, income and resource guidelines as specified at 441—paragraphs 75.5(2)“b” and 75.5(4)“c” shall be applied.
	d. 	Certified as being in need of the intermediate or skilled level of care. The IME medical services unit shall be responsible for approval of the certification of the level of care.
Elderly waiver services will not be provided when the person is an inpatient in a medical institution.
	e. 	Determined to need services as described in subrule 83.22(2).
	f. 	Rescinded IAB 10/11/06, effective 10/1/06.
	g. 	For the consumer choices option as set forth in rule 441—subrule 78.37(16), residing in a living arrangement other than a residential care facility.
	83.22(2) Need for services, service plan, and cost.
	a. 	Case management. As a condition of eligibility, all consumers under the elderly waiver shall receive case management services from a provider qualified pursuant to 441—subrule 77.33(21). The case manager shall be responsible for doing the following:
	(1)	Making a comprehensive assessment of the consumer’s needs within 30 days of referral to case management.
	(2)	Initiating development and review of the service plan as required by this subrule.
	(3)	Ensuring that the consumer exhausts all services available under the state Medicaid plan before accessing the waiver.
	(4)	Ensuring that all unmet needs of the consumer are identified in the service plan.
	(5)	Explaining the following to the consumer:
	1.	What abuse is and how to report abuse.
	2.	How to file a complaint about the consumer’s services or providers.
	3.	The consumer’s right to freedom of choice.
	(6)	Verifying that providers of consumer-directed attendant care are adequately skilled to meet the needs of the consumer.
	b. 	Interdisciplinary team. The case manager shall establish an interdisciplinary team for the consumer.
	(1)	Composition. The interdisciplinary team shall include the case manager and the consumer and, if appropriate, the consumer’s legal representative, family, service providers, and others directly involved in the consumer’s care.
	(2)	Role. The team shall identify:
	1.	The consumer’s need for services based on the consumer’s needs and desires.
	2.	Available and appropriate services to meet the consumer’s needs.
	3.	Health and safety issues for the consumer that indicate the need for an emergency plan, based on a risk assessment conducted before the team meeting.
	4.	Emergency backup support and a crisis response system to address problems or issues arising when support services are interrupted or delayed or when the consumer’s needs change.
	c. 	Service plan. An applicant for elderly waiver services shall have a service plan developed by a qualified provider of case management services under the elderly waiver.
	(1)	Services included in the service plan shall be appropriate to the problems and specific needs or disabilities of the consumer.
	(2)	Services must be the least costly available to meet the service needs of the consumer. The total monthly cost of the elderly waiver services exclusive of case management services shall not exceed the established monthly cost of the level of care. Aggregate monthly costs are limited as follows:

Skilled level of care	Nursing level of care	
$2,631	$1,117	
	(3)	The service plan must be completed before services are provided.
	(4)	The service plan must be reviewed at least annually and when there is any significant change in the consumer’s needs.
	d. 	Content of service plan. The service plan shall include the following information based on the consumer’s current assessment and service needs:
	(1)	Observable or measurable individual goals.
	(2)	Interventions and supports needed to meet those goals.
	(3)	Incremental action steps, as appropriate.
	(4)	The names of staff, people, businesses, or organizations responsible for carrying out the interventions or supports.
	(5)	The desired individual outcomes.
	(6)	The identified activities to encourage the consumer to make choices, to experience a sense of achievement, and to modify or continue participation in the service plan.
	(7)	Description of any restrictions on the consumer’s rights, including the need for the restriction and a plan to restore the rights. For this purpose, rights include maintenance of personal funds and self-administration of medications.
	(8)	A list of all Medicaid and non-Medicaid services that the consumer received at the time of waiver program enrollment that includes:
	1.	The name of the service provider responsible for providing the service.
	2.	The funding source for the service.
	3.	The amount of service that the consumer is to receive.
	(9)	Indication of whether the consumer has elected the consumer choice option and, if so, the independent support broker and the financial management service that the consumer has selected.
	(10)	The determination that the services authorized in the service plan are the least costly.
	(11)	A plan for emergencies that identifies the supports available to the consumer in situations for which no approved service plan exists and which, if not addressed, may result in injury or harm to the consumer or other persons or in significant amounts of property damage. Emergency plans shall include:
	1.	The consumer’s risk assessment and the health and safety issues identified by the consumer’s interdisciplinary team.
	2.	The emergency backup support and crisis response system identified by the interdisciplinary team.
	3.	Emergency, backup staff designated by providers for applicable services.
	83.22(3) Providers—standards. Rescinded IAB 10/11/06, effective 10/1/06.
441—83.23(249A) Application.
	83.23(1) Application for HCBS elderly waiver. The application process as specified in rules 441—76.1(249A) to 441—76.6(249A) shall be followed.
	83.23(2) Application for services. Rescinded IAB 12/6/95, effective 2/1/96.
	83.23(3) Approval of application.
	a. 	Applications for the elderly waiver program shall be processed in 30 days unless the worker can document difficulty in locating and arranging services or circumstances beyond the worker’s control. In these cases a decision shall be made as soon as possible.
	b. 	Decisions shall be mailed or given to the applicant on the date when both service and income maintenance eligibility determinations are completed.
	c. 	An applicant must be given the choice between elderly waiver services and institutional care. The consumer, guardian, or attorney in fact under a durable power of attorney for health care shall sign the service plan indicating the consumer’s choice of caregiver.
	d. 	Waiver services provided prior to approval of eligibility for the waiver cannot be paid.
	83.23(4) Effective date of eligibility.
	a. 	The effective date of eligibility cannot precede the date the case manager signs the case plan.
	b. 	Eligibility for persons whose income exceeds supplemental security income guidelines shall not exist until the persons require care in a medical institution for a period of 30 consecutive days and shall be effective no earlier than the first day of the month in which the 30-day period begins.
	c. 	Eligibility continues until the consumer has been in a medical institution for 30 consecutive days for other than respite care or fails to meet eligibility criteria listed in rule 441—83.22(249A). Consumers who are inpatients in a medical institution for 30 or more consecutive days for other than respite care shall be terminated from elderly waiver services and reviewed for eligibility for other Medicaid coverage groups. The consumer will be notified of that decision through Form 470-0602, Notice of Decision. If the consumer returns home before the effective date of the notice of decision and the consumer’s condition has not substantially changed, the denial may be rescinded and eligibility may continue.
	83.23(5) Attribution of resources. For the purposes of attributing resources as provided in rule 441—75.5(249A), the date on which the waiver applicant met the level of care criteria in a medical institution as established by the peer review organization shall be used as the date of entry to the medical institution. Only one attribution of resources shall be completed per person. Attributions completed for prior institutionalizations shall be applied to the waiver application.
441—83.24(249A) Client participation. Persons must contribute their predetermined client participation to the cost of elderly waiver services.
	83.24(1) Computation of client participation. Client participation shall be computed by deducting an amount for the maintenance needs of the individual which is 300 percent of the maximum SSI grant for an individual from the client’s total income.
	83.24(2) Limitation on payment. If the sum of the third-party payment and client participation equals or exceeds the reimbursement established by the service worker, Medicaid will make no payments for elderly waiver service providers. However, Medicaid will make payments to other medical vendors.
441—83.25(249A) Redetermination. A complete redetermination of eligibility for elderly waiver services shall be done at least once every 12 months.
A redetermination of continuing eligibility factors shall be made when a change in circumstances occurs that affects eligibility in accordance with rule 441—83.22(249A). A redetermination shall contain the components listed in rule 441—83.27(249A).
441—83.26(249A) Allowable services. Services allowable under the elderly waiver are case management, adult day care, emergency response system, homemaker, home health aide, nursing, respite care, chore, home-delivered meals, home and vehicle modification, mental health outreach, transportation, nutritional counseling, assistive devices, senior companions, consumer-directed attendant care, financial management, independent support brokerage, self-directed personal care, self-directed community supports and employment, and individual-directed goods and services as set forth in rule 441—78.37(249A).
441—83.27(249A) Service plan. The service plan shall be completed jointly by the consumer, the elderly waiver case manager, and any other person identified by the consumer.
	83.27(1) The service plan shall indicate whether the consumer has elected the consumer choices option. If the consumer has elected the consumer choices option, the service plan shall identify:
	a. 	The independent support broker selected by the consumer; and
	b. 	The financial management service selected by the consumer.
	83.27(2) The service plan shall identify a plan for emergencies and the supports available to the consumer in an emergency.
441—83.28(249A) Adverse service actions.
	83.28(1) Denial. An application for services shall be denied when it is determined by the department that:
	a. 	The client is not eligible for or in need of services.
	b. 	Except for respite care, the elderly waiver services are not needed on a regular basis.
	c. 	Service needs exceed the aggregate monthly costs established in 83.22(2)“b,” or are not met by services provided.
	d. 	Needed services are not available or received from qualifying providers.
	e. 	Rescinded IAB 3/2/94, effective 3/1/94.
	83.28(2) Termination. A particular service may be terminated when the department determines that:
	a. 	The provisions of 441—subrule 130.5(2), paragraph “a,” “b,” “c,” “d,” “g,” or “h” apply.
	b. 	The costs of the elderly waiver services for the person exceed the aggregate monthly costs established in 83.22(2)“b.”
	c. 	The client receives care in a hospital or nursing facility for 30 days in any one stay for purposes other than respite care.
	d. 	The client receives elderly waiver services and the physical or mental condition of the client requires more care than can be provided in the client’s own home as determined by the case manager and the interdisciplinary team.
	e. 	Service providers are not available.
	83.28(3) Reduction of services shall apply as in 441—subrule 130.5(3), paragraphs “a” and “b.”
441—83.29(249A) Appeal rights. Notice of adverse action and right to appeal shall be given in accordance with 441—Chapter 7 and rule 441—130.5(234). The applicant or recipient is entitled to have a review of the level of care determination by the IME medical services unit by sending a letter requesting a review to the IME medical services unit. If dissatisfied with that decision, the applicant or recipient may file an appeal with the department.
441—83.30(249A) Enhanced services. When a household has one person receiving service in accordance with rules set forth in 441—Chapter 24 and another receiving elderly waiver services, the persons providing case management shall cooperate to make the best plan for both clients. When a person is eligible for services as set forth in 441—Chapter 24 and eligible for services under the elderly waiver, the person’s primary diagnosis will determine which services shall be used.
441—83.31(249A) Conversion to the X-PERT system. Rescinded IAB 8/7/02, effective 10/1/02.
These rules are intended to implement Iowa Code sections 249A.3 and 249A.4.
441—83.32 to 83.40 Reserved.
DIVISION III—HCBS AIDS/HIV WAIVER SERVICES
441—83.41(249A) Definitions.
“AIDS” means a medical diagnosis of acquired immunodeficiency syndrome based on the Centers for Disease Control “Revision of the CDC Surveillance Case Definition for Acquired Immunodeficiency Syndrome,” August 14, 1987, Vol. 36, No.	1S issue of “Morbidity and Mortality Weekly Report.”
“Attorney in fact under a durable power of attorney for health care” means an individual who is designated by a durable power of attorney for health care, pursuant to Iowa Code chapter 144B, as an agent to make health care decisions on behalf of an individual and who has consented to act in that capacity.
“Basic individual respite” means respite provided on a staff-to-consumer ratio of one to one or higher to individuals without specialized needs requiring the care of a licensed registered nurse or licensed practical nurse.
“Client participation” means the amount of the recipient’s income that the person must contribute to the cost of AIDS/HIV waiver services exclusive of medical vendor payments before Medicaid will participate.
“Deeming” means the specified amount of parental or spousal income and resources considered in determining eligibility for a child or spouse according to current supplemental security income guidelines.
“Financial participation” means client participation and medical payments from a third party including veterans’ aid and attendance.
“Group respite” is respite provided on a staff-to-consumer ratio of less than one to one.
“Guardian” means a guardian appointed in probate court.
“HIV” means a medical diagnosis of human immunodeficiency virus infection based on a positive HIV-related test.
“Medical institution” means a nursing facility or hospital which has been approved as a Medicaid vendor.
“Service plan” means a written consumer-centered, outcome-based plan of services developed using an interdisciplinary process, which addresses all relevant services and supports being provided. It may involve more than one provider.
“Specialized respite” means respite provided on a staff-to-consumer ratio of one to one or higher to individuals with specialized medical needs requiring the care, monitoring or supervision of a licensed registered nurse or licensed practical nurse.
“Third-party payments” means payments from an attorney, individual, institution, corporation, or public or private agency which is liable to pay part or all of the medical costs incurred as a result of injury, disease or disability by or on behalf of an applicant or a past or present recipient of medical assistance.
“Usual caregiver” means a person or persons who reside with the consumer and are available on a 24-hour-per-day basis to assume responsibility for the care of the consumer.
441—83.42(249A) Eligibility. To be eligible for AIDS/HIV waiver services a person must meet certain eligibility criteria and be determined to need a service(s) allowable under the program.
	83.42(1) Eligibility criteria. All of the following criteria must be met. The person must:
	a. 	Be diagnosed by a physician as having AIDS or HIV infection.
	b. 	Be certified in need of the level of care that, but for the waiver, would otherwise be provided in a nursing facility or hospital. The IME medical services unit shall be responsible for approval of the certification of the level of care. AIDS/HIV waiver services shall not be provided when the person is an inpatient in a medical institution.
	c. 	Be eligible for medical assistance under SSI, SSI-related, FMAP, or FMAP-related coverage groups; medically needy at hospital level of care; or a special income level (300 percent group); or become eligible through application of the institutional deeming rules.
	d. 	Require, and use at least quarterly, one service available under the waiver as determined through an evaluation of need described in subrule 83.42(2).
	e. 	Have service needs such that the costs of the waiver services are not likely to exceed the costs of care that would otherwise be provided in a medical institution.
	f. 	Have income which does not exceed 300 percent of the maximum monthly payment for one person under supplemental security income.
	g. 	For the consumer choices option as set forth in 441—subrule 78.38(9), not be living in a residential care facility.
	83.42(2) Need for services.
	a. 	The county social worker shall perform an assessment of the person’s need for waiver services and determine the availability and appropriateness of services. This assessment shall be based, in part, on information in the completed Home- and Community-Based Services Assessment or Reassessment, Form 470-0659. Form 470-0659 shall be completed annually.
	b. 	The total monthly cost of the AIDS/HIV waiver services shall not exceed the established aggregate monthly cost for level of care. The monthly cost of AIDS/HIV waiver services cannot exceed the established limit of $1,751.
441—83.43(249A) Application.
	83.43(1) Application for HCBS AIDS/HIV waiver services. The application process as specified in rules 441—76.1(249A) to 441—76.6(249A) shall be followed.
	83.43(2) Application for services. Rescinded IAB 12/6/95, effective 2/1/96.
	83.43(3) Approval of application.
	a. 	Applications for the HCBS AIDS/HIV waiver program shall be processed in 30 days unless one or more of the following conditions exist:
	(1)	The application is pending because the department has not received information, which is beyond the control of the client or the department.
	(2)	The application is pending because a level of care determination has not been made or pended although the completed assessment, Form 470-0659, has been submitted to the IME medical services unit.
	(3)	Rescinded IAB 3/7/01, effective 5/1/01.
	b. 	Decisions shall be mailed or given to the applicant on the date when income maintenance eligibility and level of care determinations and the consumer service plan are completed.
	c. 	A consumer must be given the choice between HCBS AIDS/HIV waiver services and institutional care. The income maintenance or service worker shall have the consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care complete and sign Form 470-0659, Home- and Community-Based Services Assessment or Reassessment, indicating the consumer’s choice of home- and community-based services or institutional care.
	d. 	Waiver services provided prior to approval of eligibility for the waiver cannot be paid.
	83.43(4) Effective date of eligibility.
	a. 	The effective date of eligibility for the AIDS/HIV waiver for persons who are already determined eligible for Medicaid is the date on which the income and resource eligibility and level of care determinations and the service plan are completed.
	b. 	The effective date of eligibility for the AIDS/HIV waiver for persons who qualify for Medicaid due to eligibility for the waiver services and to whom 441—subrule 75.1(7) and rule 441—75.5(249A) do not apply is the date on which income and resource eligibility and level of care determinations and the service plan are completed.
	c. 	Eligibility for the waiver continues until the recipient has been in a medical institution for 30 consecutive days for other than respite care or fails to meet eligibility criteria listed in rule 441—83.42(249A). Recipients who are inpatients in a medical institution for 30 or more consecutive days for other than respite care shall be reviewed for eligibility for other Medicaid coverage groups and terminated from AIDS/HIV waiver services if found eligible under another coverage group. The recipient will be notified of that decision through Form 470-0602, Notice of Decision. If the consumer returns home before the effective date of the notice of decision and the person’s condition has not substantially changed, the denial may be rescinded and eligibility may continue.
	d. 	The effective date of eligibility for the AIDS/HIV waiver for persons who qualify for Medicaid due to eligibility for the waiver services and to whom the eligibility factors set forth in 441—subrule 75.1(7) and, for married persons, in rule 441—75.5(249A) have been satisfied is the date on which the income eligibility and level of care determinations and the service plan are completed, but shall not be earlier than the first of the month following the date of application.
	83.43(5) Attribution of resources. For the purposes of attributing resources as provided in rule 441—75.5(249A), the date on which the waiver applicant met the level of care criteria in a medical institution as established by the peer review organization shall be used as the date of entry to the medical institution. Only one attribution of resources shall be completed per person. Attributions completed for prior institutionalizations shall be applied to the waiver application.
441—83.44(249A) Financial participation. Persons must contribute their predetermined financial participation to the cost of AIDS/HIV waiver services or other Medicaid services, as applicable.
	83.44(1) Maintenance needs of the individual. The maintenance needs of the individual shall be computed by deducting an amount which is 300 percent of the maximum monthly payment for one person under supplemental security income (SSI) from the client’s total income.
	83.44(2) Limitation on payment. If the amount of the financial participation equals or exceeds the reimbursement established by the service worker for AIDS/HIV services, Medicaid will make no payments to AIDS/HIV waiver service providers. Medicaid will, however, make payments to other medical vendors.
	83.44(3) Maintenance needs of spouse and other dependents. Rescinded IAB 4/9/97, effective 6/1/97.
441—83.45(249A) Redetermination. A complete redetermination of eligibility for AIDS/HIV waiver services shall be completed at least once every 12 months or when there is significant change in the person’s situation or condition. A redetermination of continuing eligibility factors shall be made in accordance with rules 441—76.7(249A) and 441—83.42(249A). A redetermination shall include the components listed in rule 441—83.47(249A).
441—83.46(249A) Allowable services. Services allowable under the AIDS/HIV waiver are counseling, home health aide, homemaker, nursing care, respite care, home-delivered meals, adult day care, consumer-directed attendant care, financial management, independent support brokerage, self-directed personal care, self-directed community supports and employment, and individual-directed goods and services as set forth in rule 441—78.38(249A).
441—83.47(249A) Service plan. A service plan shall be prepared for AIDS/HIV waiver consumers in accordance with rule 441—130.7(234) except that service plans for both children and adults shall be completed every 12 months or when there is significant change in the person’s situation or condition.
	83.47(1) The service plan shall include the frequency of the AIDS/HIV waiver services and the types of providers who will deliver the services.
	83.47(2) The service plan shall indicate whether the consumer has elected the consumer choices option. If the consumer has elected the consumer choices option, the service plan shall identify:
	a. 	The independent support broker selected by the consumer; and
	b. 	The financial management service selected by the consumer.
	83.47(3) Service plans for consumers aged 20 or under must be developed to reflect use of all appropriate nonwaiver Medicaid services so as not to replace or duplicate those services.
	83.47(4) The service plan shall identify a plan for emergencies and the supports available to the consumer in an emergency.
441—83.48(249A) Adverse service actions.
	83.48(1) Denial. An application for services shall be denied when it is determined by the department that:
	a. 	The client is not eligible for or in need of services.
	b. 	Except for respite care, the AIDS/HIV waiver services are not needed on a regular basis.
	c. 	Service needs exceed the aggregate monthly costs established in 83.42(2)“b” or cannot be met by the services provided under the waiver.
	d. 	Needed services are not available from qualified providers.
	83.48(2) Termination. Participation in the AIDS/HIV waiver program may be terminated when the department determines that:
	a. 	The provisions of 441—subrule 130.5(2), paragraph “a,” “b,” “c,” “d,” “g,” or “h” apply.
	b. 	The costs of the AIDS/HIV waiver services for the person exceed the aggregate monthly costs established in 83.42(2)“b.”
	c. 	The client receives care in a hospital or nursing facility for 30 days or more in any one stay for purposes other than respite care.
	d. 	The client receives AIDS/HIV waiver services and the physical or mental condition of the client requires more care than can be provided in the client’s own home as determined by the service worker.
	e. 	Service providers are not available.
	83.48(3) Reduction of services shall apply as in 441—subrule 130.5(3), paragraphs “a” and “b.”
441—83.49(249A) Appeal rights. Notice of adverse action and right to appeal shall be given in accordance with 441—Chapter 7 and rule 441—130.5(234). The applicant or recipient is entitled to have a review of the level of care determination by the IME medical services unit by sending a letter requesting a review to the IME medical services unit. If dissatisfied with that decision, an appeal may be filed with the department.
441—83.50(249A) Conversion to the X-PERT system. Rescinded IAB 8/7/02, effective 10/1/02.
These rules are intended to implement Iowa Code section 249A.4.
441—83.51 to 83.59 Reserved.
DIVISION IV—HCBS MR WAIVER SERVICES
441—83.60(249A) Definitions.
“Adaptive” means age-appropriate skills related to taking care of one’s self and one’s ability to relate to others in daily living situations. These skills include limitations that occur in the areas of communication, self-care, home-living, social skills, community use, self-direction, safety, functional activities of daily living, leisure or work.
“Adult” means a person with mental retardation aged 18 or over.
“Appropriate” means that the services or supports or activities provided or undertaken by the organization are relevant to the consumer’s needs, situation, problems, or desires.
“Assessment” means the review of the consumer’s current functioning in regard to the consumer’s situation, needs, strengths, abilities, desires and goals.
“Attorney in fact under a durable power of attorney for health care” means an individual who is designated by a durable power of attorney for health care, pursuant to Iowa Code chapter 144B, as an agent to make health care decisions on behalf of an individual and who has consented to act in that capacity.
“Basic individual respite” means respite provided on a staff-to-consumer ratio of one to one or higher to individuals without specialized needs requiring the care of a licensed registered nurse or licensed practical nurse.
“Behavior” means skills related to regulating one’s own behavior including coping with demands from others, making choices, controlling impulses, conforming conduct to laws, and displaying appropriate sociosexual behavior.
“Case management services” means those services established pursuant to Iowa Code chapter 225C.
“Child” means a person with mental retardation aged 17 or under.
“Client participation” means the posteligibility amount of the consumer’s income that persons eligible through a special income level must contribute to the cost of the home and community-based waiver service.
“Counseling” means face-to-face mental health services provided to the consumer and caregiver by a qualified mental retardation professional (QMRP) to facilitate home management of the consumer and prevent institutionalization.
“Deemed status” means acceptance of certification or licensure of a program or service by another certifying body in place of certification based on review and evaluation.
“Department” means the Iowa department of human services.
“Direct service” means services involving face-to-face assistance to a consumer such as transporting a consumer or providing therapy.
“Fiscal accountability” means the development and maintenance of budgets and independent fiscal review.
“Group respite” is respite provided on a staff-to-consumer ratio of less than one to one.
“Guardian” means a guardian appointed in probate court.
“Health” means skills related to the maintenance of one’s health including eating; illness identification, treatment and prevention; basic first aid; physical fitness; regular physical checkups and personal habits.
“Immediate jeopardy” means circumstances where the life, health, or safety of a person will be severely jeopardized if the circumstances are not immediately corrected.
“Intermediate care facility for the mentally retarded (ICF/MR)” means an institution that is primarily for the diagnosis, treatment, or rehabilitation of persons who are mentally retarded or persons with related conditions and that provides, in a protected residential setting, ongoing evaluation, planning, 24-hour supervision, coordination and integration of health or related services to help each person function at the greatest ability and is an approved Medicaid vendor.
“Intermittent supported community living service” means supported community living service provided not more than 52 hours per month.
“Maintenance needs” means costs associated with rent or mortgage, utilities, telephone, food and household supplies.
“Managed care” means a system that provides the coordinated delivery of services and supports that are necessary and appropriate, delivered in the least restrictive settings and in the least intrusive manner. Managed care seeks to balance three factors:
	1.	Achieving high-quality outcomes for participants.
	2.	Coordinating access.
	3.	Containing costs.
“Medical assessment” means a visual and physical inspection of the consumer, noting deviations from the norm, and a statement of the consumer’s mental and physical condition that can be amendable to or resolved by appropriate actions of the provider.
“Medical institution” means a nursing facility, intermediate care facility for the mentally retarded, or hospital which has been approved as a Medicaid vendor.
“Medical intervention” means consumer care in the areas of hygiene, mental and physical comfort, assistance in feeding and elimination, and control of the consumer’s care and treatment to meet the physical and mental needs of the consumer in compliance with the plan of care in areas of health, prevention, restoration, and maintenance.
“Medical monitoring” means observation for the purpose of assessing, preventing, maintaining, and treating disease or illness based on the consumer’s plan of care.
“Mental retardation” means a diagnosis of mental retardation under this division which shall be made only when the onset of the person’s condition was prior to the age of 18 years and shall be based on an assessment of the person’s intellectual functioning and level of adaptive skills. The diagnosis shall be made by a person who is a psychologist or psychiatrist who is professionally trained to administer the tests required to assess intellectual functioning and to evaluate a person’s adaptive skills. A diagnosis of mental retardation shall be made in accordance with the criteria provided in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, published by the American Psychiatric Association.
“Natural supports” means services and supports identified as wanted or needed by the consumer and provider by persons not for pay (family, friends, neighbors, coworkers, and others in the community) and organizations or entities that serve the general public.
“Organization” means the entity being certified.
“Organizational outcome” means a demonstration by the organization of actions taken by the organization to provide for services or supports to consumers.
“Outcome” means an action or event that follows as a result or consequence of the provision of a service or support.
“Person with a related condition” means an individual who has a severe, chronic disability that meets all the following conditions:
	1.	It is attributable to cerebral palsy, epilepsy, or any other condition, other than mental illness, found to be closely related to mental retardation because the condition results in impairment of general intellectual functioning or adaptive behavior similar to that of a mentally retarded person and requires treatment or services similar to those required for a mentally retarded person.
	2.	It is manifested before the age of 22.
	3.	It is likely to continue indefinitely.
	4.	It results in substantial functional limitations in three or more of the following areas of major life activity:
	●	Self-care.
	●	Understanding and use of language.
	●	Learning.
	●	Mobility.
	●	Self-direction.
	●	Capacity for independent living.
“Procedures” means the steps to be taken to implement a policy.
“Process” means service or support provided by an agency to a consumer that will allow the consumer to achieve an outcome. This can include a written, formal, consistent trackable method or an informal process that is not written but is trackable.
“Program” means a set of related resources and services directed to the accomplishment of a fixed set of goals and objectives for the population of a specified geographic area or for special target populations. It can mean an agency, organization, or unit of an agency, organization or institution.
“Qualified mental retardation professional” means a person who has at least one year of experience working directly with persons with mental retardation or other developmental disabilities and who is one of the following:
	1.	A doctor of medicine or osteopathy.
	2.	A registered nurse.
	3.	An occupational therapist eligible for certification as an occupational therapist by the American Occupational Therapy Association or another comparable body.
	4.	A physical therapist eligible for certification as a physical therapist by the American Physical Therapy Association or another comparable body.
	5.	A speech-language pathologist or audiologist eligible for certification of Clinical Competence in Speech-Language Pathology or Audiology by the American Speech-Language Hearing Association or another comparable body or who meets the educational requirements for certification and who is in the process of accumulating the supervised experience required for certification.
	6.	A psychologist with a master’s degree in psychology from an accredited school.
	7.	A social worker with a graduate degree from a school of social work, accredited or approved by the Council on Social Work Education or another comparable body or who holds a bachelor of social work degree from a college or university accredited or approved by the Council of Social Work Education or another comparable body.
	8.	A professional recreation staff member with a bachelor’s degree in recreation or in a specialty area such as art, dance, music or physical education.
	9.	A professional dietitian who is eligible for registration by the American Dietetics Association.
	10.	A human services professional who must have at least a bachelor’s degree in a human services field including, but not limited to, sociology, special education, rehabilitation counseling and psychology.
“Service plan” means a written consumer-centered, outcome-based plan of services developed using an interdisciplinary process, which addresses all relevant services and supports being provided. It may involve more than one provider.
“Specialized respite” means respite provided on a staff-to-consumer ratio of one to one or higher to individuals with specialized medical needs requiring the care, monitoring or supervision of a licensed registered nurse or licensed practical nurse.
“Staff” means a person under the direction of the organization to perform duties and responsibilities of the organization.
“Third-party payments” means payments from an attorney, individual, institution, corporation, insurance company, or public or private agency which is liable to pay part or all of the medical costs incurred as a result of injury, disease or disability by or on behalf of an applicant or a past or present recipient of Medicaid.
“Usual caregiver” means a person or persons who reside with the consumer and are available on a 24-hour-per-day basis to assume responsibility for the care of the consumer.
441—83.61(249A) Eligibility. To be eligible for HCBS MR waiver services a person must meet certain eligibility criteria and be determined to need a service(s) available under the program.
	83.61(1) Eligibility criteria. All of the following criteria must be met. The person must:
	a. 	Have a diagnosis of mental retardation or, for residential-based supported community living services only, be a person with a related condition as defined in rule 441—83.60(249A). Those eligible based on a primary diagnosis of mental retardation must have the diagnosis initially established and recertified as follows:

Age	Initial application to HCBS MR waiver program	Recertification for persons
with an IQ range of 54 or
below, moderate range of MR or below	Recertification for persons with an IQ range of 55 or above, diagnosis of mild or
unspecified range of MR	
0 through 17 years	Psychological documentation within three years of the
application date substantiating a diagnosis of mental
retardation or mental disability equivalent to mental
retardation	After the initial psychological evaluation which listed the consumer in this range,
substantiate a diagnosis of mental retardation or a diagnosis of mental disability equivalent to mental retardation every six years and when a significant change occurs	After the initial psychological evaluation which listed the consumer in this range,
substantiate a diagnosis of mental retardation or mental disability equivalent to mental retardation every three years and when a significant change occurs	
18 through 21 years	• Psychological
documentation substantiating diagnosis of mental retardation or a diagnosis of mental
disability equivalent to mental retardation within three years prior to age 18, or
• Diagnosis of mental
retardation or mental disability equivalent to mental
retardation made before age 18 and current psychological
documentation substantiating a diagnosis of mental retardation or a diagnosis of mental
disability equivalent to mental retardation	Psychological documentation substantiating a diagnosis of mental retardation or a
diagnosis of mental disability equivalent to mental
retardation every ten years and whenever a significant change occurs	Psychological documentation substantiating a diagnosis of mental retardation or a
diagnosis of mental disability equivalent to mental
retardation every five years and whenever a significant change occurs	
22 years and above	Diagnosis made before age 18 and current psychological
documentation substantiating a diagnosis of mental retardation or a diagnosis of mental
disability equivalent to mental retardation, if the last testing date was (1) more than five years ago for consumers with an IQ range of 55 or above or with a diagnosis of mild
mental retardation, or (2) more than ten years ago for
consumers with an IQ range of 54 or below or with a
diagnosis of moderate MR or below	Psychological documentation substantiating a diagnosis of mental retardation or a
diagnosis of mental disability equivalent to mental
retardation every ten years and whenever a significant change occurs	Psychological documentation substantiating a diagnosis of mental retardation or a
diagnosis of mental disability equivalent to mental
retardation every five years and whenever a significant change occurs	
	b. 	Be eligible for Medicaid under SSI, SSI-related, FMAP, or FMAP-related coverage groups; eligible under the special income level (300 percent) coverage group; or become eligible through application of the institutional deeming rules or would be eligible for Medicaid if in a medical institution.
	c. 	Be certified as being in need for long-term care that, but for the waiver, would otherwise be provided in an ICF/MR. The IME medical services unit shall be responsible for annual approval of the certification of the level of care based on the data collected by the case manager and interdisciplinary team on a tool designated by the department.
	(1) to (3)	Rescinded IAB 3/7/01, effective 5/1/01.
	d. 	Be a recipient of the Medicaid case management services or be identified to receive Medicaid case management services immediately following program enrollment.
	e. 	Have service needs that can be met by this waiver program. At a minimum, a consumer must receive one billable unit of service per calendar quarter under this program.
	f. 	Have a service plan completed annually and approved by the department in accordance with rule 441—83.67(249A).
	g. 	For supported employment services:
	(1)	Be at least age 16.
	(2)	Rescinded IAB 7/1/98, effective 7/1/98.
	(3)	Not be eligible for supported employment service funding under Public Law 94-142 or for the Rehabilitation Act of 1973.
	(4)	Not reside in a medical institution.
	h. 	Choose HCBS MR waiver services rather than ICF MR services.
	i. 	To be eligible for interim medical monitoring and treatment services the consumer must be:
	(1)	Under the age of 21;
	(2)	Currently receiving home health agency services under rule 441—78.9(249A) and require medical assessment, medical monitoring, and regular medical intervention or intervention in a medical emergency during those services. (The home health aide services for which the consumer is eligible must be maximized before the consumer accesses interim medical monitoring and treatment.);
	(3)	Residing in the consumer’s family home or foster family home; and
	(4)	In need of interim medical monitoring and treatment as ordered by a physician.
	j. 	Be assigned an HCBS MR payment slot pursuant to subrule 83.61(4).
	k. 	For residential-based supported community living services, meet all of the following additional criteria:
	(1)	Be less than 18 years of age.
	(2)	Be preapproved as appropriate for residential-based supported community living services by the bureau of long-term care. Requests for approval shall be submitted in writing to the DHS Bureau of Long-Term Care, 1305 East Walnut Street, Des Moines, Iowa 50319-0114, and shall include the following:
	1.	Social history;
	2.	Case history that includes previous placements and service programs;
	3.	Medical history that includes major illnesses and current medications;
	4.	Current psychological evaluations and consultations;
	5.	Summary of all reasonable and appropriate service alternatives that have been tried or considered;
	6.	Any current court orders in effect regarding the child;
	7.	Any legal history;
	8.	Whether the child is at risk of out-of-home placement or the proposed placement would be less restrictive than the child’s current placement for services;
	9.	Whether the proposed placement would be safe for the child and for other children living in that setting; and
	10.	Whether the interdisciplinary team is in agreement with the proposed placement.
	(3)	Either:
	1.	Be residing in an ICF/MR;
	2.	Be at risk of ICF/MR placement, as documented by an interdisciplinary team assessment pursuant to paragraph 83.61(2)“a”; or
	3.	Be a child whose long-term placement outside the home is necessary because continued stay in the home would be a detriment to the health and welfare of the child or the family, and all service options to keep the child in the home have been reviewed by an interdisciplinary team, as documented in the service file.
	l. 	For day habilitation, be 16 years of age or older.
	m. 	For the consumer choices option as set forth in 441—subrule 78.41(5), not be living in a residential care facility.
	83.61(2) Need for services.
	a. 	Consumers currently receiving Medicaid case management or services of a department-qualified mental retardation professional (QMRP) shall have the applicable coordinating staff and other interdisciplinary team members complete the Functional Assessment Tool, Form 470-3073, and identify the consumer’s needs and desires as well as the availability and appropriateness of the services.
	b. 	Consumers not receiving services as set forth in paragraph “a” who are applying for the HCBS MR waiver service shall have a department service worker or a case manager paid by the county without Medicaid funds complete the Functional Assessment Tool, Form 470-3073, for the initial level of care determination; establish an initial interdisciplinary team for HCBS MR services; and, with the initial interdisciplinary team, identify the consumer’s needs and desires as well as the availability and appropriateness of services.
	c. 	Persons meeting other eligibility criteria who do not have a Medicaid case manager shall be referred to a Medicaid case manager.
	d. 	Services shall not exceed the number of maximum units established for each service.
	e. 	The cost of services shall not exceed unit expense maximums. Requests shall only be reviewed for funding needs exceeding the supported community living service unit cost maximum. Requests require special review by the department and may be denied as not cost-effective.
	f. 	The service worker, department QMRP, or Medicaid case manager shall complete the Functional Assessment Tool, Form 470-3073, for the initial level of care determination within 30 days from the date of the HCBS application unless the worker can document difficulty in locating information necessary for completion of Form 470-3073 or other circumstances beyond the worker’s control.
	g. 	At initial enrollment the service worker, department QMRP, case manager paid by the county without Medicaid funds, or Medicaid case manager shall establish an HCBS MR interdisciplinary team for each consumer and, with the team, identify the consumer’s need for service based on the consumer’s needs and desires as well as the availability and appropriateness of services. The Medicaid case manager shall complete an annual review thereafter. The following criteria shall be used for the initial and ongoing assessments:
	(1)	The assessment shall be based, in part, on information on the completed Functional Assessment Tool, Form 470-3073.
	(2)	Service plans must be developed or reviewed to reflect use of all appropriate nonwaiver Medicaid services so as not to replace or duplicate those services.
	(3)	Rescinded IAB 3/7/01, effective 5/1/01.
	(4)	Service plans for consumers aged 20 or under which include supported community living services beyond intermittent shall be approved (signed and dated) by the designee of the bureau of long-term care or the designee of the county board of supervisors. The service worker, department QMRP, or Medicaid case manager shall attach a written request for a variance from the maximum for intermittent supported community living with a summary of services and service costs. The written request for the variance shall provide a rationale for requesting supported community living beyond intermittent. The rationale shall contain sufficient information for the designee to make a decision regarding the need for supported community living beyond intermittent.
	h. 	Interim medical monitoring and treatment services must be needed because all usual caregivers are unavailable to provide care due to one of the following circumstances:
	(1)	Employment. Interim medical monitoring and treatment services are to be received only during hours of employment.
	(2)	Academic or vocational training. Interim medical monitoring and treatment services provided while a usual caregiver participates in postsecondary education or vocational training shall be limited to 24 periods of no more than 30 days each per caregiver as documented by the service worker. Time spent in high school completion, adult basic education, GED, or English as a second language does not count toward the limit.
	(3)	Absence from the home due to hospitalization, treatment for physical or mental illness, or death of the usual caregiver. Interim medical monitoring and treatment services under this subparagraph are limited to a maximum of 30 days.
	(4)	Search for employment.
	1.	Care during job search shall be limited to only those hours the usual caregiver is actually looking for employment, including travel time.
	2.	Interim medical monitoring and treatment services may be provided under this paragraph only during the execution of one job search plan of up to 30 working days in a 12-month period, approved by the department service worker or targeted case manager pursuant to 441—subparagraph 170.2(2)“b”(5).
	3.	Documentation of job search contacts shall be furnished to the department service worker or targeted case manager.
	83.61(3) HCBS MR program limit. The number of persons receiving HCBS MR waiver services in the state shall be limited to the number of payment slots provided in the HCBS MR waiver approved by the Centers for Medicare and Medicaid Services (CMS). The department shall make a request to CMS to adjust the program limit annually to be effective each July 1 based upon the county management plans submitted by the state and counties. The department shall also submit a request to CMS for changes to the program limit to be effective January 1 if requested by a county during the month of September.
	a. 	The payment slots are on a county basis for adults with legal settlement in a county and are on a statewide basis for children and adults without a county of legal settlement. These slots shall be available on a first-come, first-served basis.
	b. 	When services are denied because the limit is reached, a notice of decision denying service based on the limit and stating that the person’s name will be put on a waiting list shall be sent to the person by the department.
	83.61(4) Securing a payment slot.
	a. 	The county department office shall contact the bureau of long-term care for state cases and children or the central point of coordination administrator for the county of legal settlement for adults to determine if a payment slot is available for all new applications for the HCBS MR program.
	(1)	For applicants not currently receiving Medicaid, the county department office shall contact the bureau or the county by the end of the fifth working day after receipt of a completed Form 470-2927 or 470-2927(S), Health Services Application, or within five working days after receipt of disability determination, whichever is later.
	(2)	For current Medicaid recipients, the county department office shall contact the bureau or the county by the end of the fifth working day after receipt of either Form 470-0659, Home- and Community-Based Services Assessment or Reassessment, with the choice of HCBS waiver indicated by signature of the consumer or a written request signed and dated by the consumer.
	(3)	A payment slot is assigned to the applicant upon confirmation of an available slot.
	(4)	Once a payment slot is assigned, the county department office shall give written notice to the applicant. The department shall hold the payment slot for the applicant as long as reasonable efforts are being made to arrange services and the applicant has not been determined to be ineligible for the program. If services have not been initiated and reasonable efforts are no longer being made to arrange services, the slot shall revert for use by the next person on the waiting list, if applicable. The applicant originally assigned the slot must reapply for a new slot.
	b. 	If no payment slot is available, the bureau of long-term care shall enter persons on a waiting list according to the following:
	(1)	Consumers not currently eligible for Medicaid shall be entered on the waiting list on the basis of the date a completed Form 470-2927 or 470-2927(S), Health Services Application, is date-stamped in the county department office or upon county department office receipt of disability determination, whichever is later.
	(2)	Consumers currently eligible for Medicaid shall be added to the waiting list on the basis of the date the request as specified in 83.61(4)“a”(2) is date-stamped in the county department office.
	(3)	In the event that more than one application is received at one time, persons shall be entered on the waiting list on the basis of the month of birth, January being month one and the lowest number.
	(4)	Applicants who do not fall within the available slots shall have their application rejected, and their names shall be maintained on the waiting list. As slots become available, persons shall be selected from the waiting list to maintain the number of approved persons on the program based on their order on the waiting list. The county central point of coordination administrator (for adults) and the bureau of long-term care (for children and for adults with state case status) shall contact the county department office when a slot becomes available.
	(5)	Once a payment slot is assigned, the county department office shall give written notice to the person within five working days. The department shall hold the payment slot for 30 days for the person to file a new application. If an application has not been filed within 30 days, the slot shall revert for use by the next person on the waiting list, if applicable. The person originally assigned the slot must reapply for a new slot.
	c. 	The county department office shall notify the bureau of long-term care for state cases and children or the central point of coordination administrator for the county of legal settlement for adults within five working days of the receipt of an application and of any action on or withdrawal of an application.
441—83.62(249A) Application.
	83.62(1) Application for HCBS MR waiver services. The application process as specified in rules 441—76.1(249A) to 441—76.6(249A) shall be followed.
	83.62(2) Rescinded IAB 6/5/96, effective 8/1/96.
	83.62(3) Approval of application.
	a. 	Applications for the HCBS MR waiver program shall be processed in 30 days unless the case manager or worker can document difficulty in locating and arranging services or other circumstance beyond the worker’s control. In these cases a decision shall be made as soon as possible.
	b. 	Decisions shall be mailed or given to the applicant on the date when both service and income maintenance eligibility determinations are completed.
	c. 	An applicant shall be given the choice between HCBS waiver services and ICF/MR care. The case manager or worker shall have the consumer or legal representative complete and sign Part A of Form 470-3073, Mental Retardation Functional Assessment Tool, indicating the consumer’s choice of care.
	d. 	HCBS MR waiver services provided before eligibility for the waiver is approved shall not be reimbursed by the HCBS waiver program.
	e. 	Services provided when the person is a consumer of group foster care services or is an inpatient in a medical institution shall not be reimbursed.
	f. 	HCBS MR waiver services are not available in conjunction with other Medicaid waiver services or group foster care services.
	g. 	Children who were receiving rehabilitative treatment and supportive services under the group care program pursuant to 441—Chapter 185, division V, who were placed with a rehabilitative treatment and supportive service provider as a result of a delinquency or CINA adjudication will be ineligible unless a the department service area manager or the service area manager’s designee determines that the child would have been eligible and the services covered aside from the adjudication. The service area manager or designee shall base an approval or denial on documentation regarding the child’s individual situation. This documentation shall include, but is not limited to, the following:
	(1)	The reason for the adjudication.
	(2)	The existence of mental retardation or a related condition and the role of the child’s mental retardation or related condition in the adjudication.
	(3)	Other possible placements suitable for the child that would meet the child’s needs.
	83.62(4) Effective date of eligibility.
	a. 	Deeming of parental income and resources ceases the month following the month in which a person requires care in a medical institution.
	b. 	The effective date of eligibility for the waiver for persons who are already determined eligible for Medicaid is the date on which the person is determined to meet the criteria set forth in rule 441—83.61(249A).
	c. 	The effective date of eligibility for the waiver for persons who qualify for Medicaid due to eligibility for the waiver services is the date on which the person is determined to meet criteria set forth in rule 441—83.61(249A) and when the eligibility factor set forth in 441—subrule 75.1(7) and for married persons, in rule 441—75.5(249A) have been satisfied.
	d. 	Eligibility continues until the consumer fails to meet eligibility criteria listed in rule 441—83.61(249A). Consumers who are inpatients in a medical institution for 30 consecutive days shall receive a review by the interdisciplinary team to determine additional inpatient needs for possible termination from the HCBS program. Consumers shall be reviewed for eligibility under other Medicaid coverage groups. The consumer or legal representative shall participate in the review and receive formal notification of that decision through Form 470-0602, Notice of Decision.
If the consumer returns home before the effective date of the notice of decision and the consumer’s needs can still be met by the HCBS waiver services, the denial may be rescinded and eligibility may continue.
	e. 	Eligibility and service reimbursement are effective through the last day of the month of the previous annual service plan staffing meeting and the corresponding long-term care need determination.
	83.62(5) Attribution of resources. For the purposes of attributing resources as provided in rule 441—75.5(249A), the date on which the waiver applicant met the level of care criteria in a medical institution as established by the peer review organization shall be used as the date of entry to the medical institution. Only one attribution of resources shall be completed per person. Attributions completed for prior institutionalizations shall be applied to the waiver application.
441—83.63(249A) Client participation. Persons who are eligible under the 300 percent group must contribute a predetermined client participation amount to the costs of the services.
	83.63(1) Computation of client participation. Client participation shall be computed by deducting an amount for the maintenance needs of the individual which is 300 percent of the maximum SSI grant for an individual from the client’s total income.
	83.63(2) Limitation on payment. If the sum of the third-party payment and client participation equals or exceeds the reimbursement for the specific HCBS waiver service, Medicaid will make no payments for the HCBS waiver service. However, Medicaid will make payments to other medical vendors.
441—83.64(249A) Redetermination. A redetermination of eligibility for HCBS MR waiver services shall be completed at least once every 12 months.
A redetermination of continuing eligibility factors shall be made when a change in circumstances occurs that affects eligibility in accordance with rule 441—83.61(249A).
441—83.65(249A) Rescinded IAB 6/5/96, effective 8/1/96.
441—83.66(249A) Allowable services. Services allowable under the HCBS MR waiver are supported community living, respite, personal emergency response system, nursing, home health aide, home and vehicle modification, supported employment, consumer-directed attendant care, interim medical monitoring and treatment, transportation, adult day care, day habilitation, prevocational services, financial management, independent support brokerage, self-directed personal care, self-directed community supports and employment, and individual-directed goods and services as set forth in rule 441—78.41(249A).
441—83.67(249A) Service plan. A service plan shall be prepared for each HCBS MR waiver consumer.
	83.67(1) Development. The service plan shall be developed by the interdisciplinary team, which includes the consumer, and, if appropriate, the legal representative, consumer’s family, case manager or service worker, service providers, and others directly involved.
	83.67(2) Retention. The service plan shall be stored by the case manager for a minimum of three years.
	83.67(3) Interdisciplinary team meeting. The interdisciplinary team meeting shall be conducted before the current service plan expires.
	83.67(4) Information in plan. The plan shall be in accordance with 441—subrule 24.4(3) and shall additionally include the following information to assist in evaluating the program:
	a. 	A listing of all services received by a consumer at the time of waiver program enrollment.
	b. 	For supported community living:
	(1)	The consumer’s living environment at the time of waiver enrollment.
	(2)	The number of hours per day of on-site staff supervision needed by the consumer.
	(3)	The number of other waiver consumers who will live with the consumer in the living unit.
	c. 	An identification and justification of any restriction of the consumer’s rights including, but not limited to:
	(1)	Maintenance of personal funds.
	(2)	Self-administration of medications.
	d. 	The name of the service provider responsible for providing each service.
	e. 	The service funding source.
	f. 	The amount of the service to be received by the consumer.
	g. 	Whether the consumer has elected the consumer choices option and, if so:
	(1)	The independent support broker selected by the consumer; and
	(2)	The financial management service selected by the consumer.
	h. 	A plan for emergencies and identification of the supports available to the consumer in an emergency.
	83.67(5) Documentation. The Medicaid case manager shall ensure that the consumer’s case file contains the consumer’s service plan and documentation supporting the diagnosis of mental retardation.
	83.67(6) Approval of plan. The plan shall be approved through the Individualized Services Information System (ISIS). Services shall be entered into ISIS based on the service plan.
	a. 	Services must be authorized and entered into ISIS before the plan implementation date.
	b. 	The department or county has 15 working days after receipt of the summary and service costs in which to approve the services and service cost or request modification of the service plan unless the parties mutually agree to extend that time frame.
	c. 	If the department or county and service worker or case manager are unable to agree on the terms of the services or service cost within 10 days, the department or county has final authority regarding the services and service cost.
	d. 	If a notice of decision is not received from a county within 30 days from the date of request for services, the request shall be sent to the department of human services with documentation verifying the original submission of the request to the county. The department shall send a letter to the county central point of coordination and county board of supervisors requesting a response within 10 days. If no response is received within 10 days, the department will make the decision, as stated in paragraph “b.”
441—83.68(249A) Adverse service actions.
	83.68(1) Denial. An application for services shall be denied when it is determined by the department that:
	a. 	The applicant is not eligible for the services.
	b. 	Service needs exceed the service unit or reimbursement maximums.
	c. 	Service needs are not met by the services provided.
	d. 	Needed services are not available or received from qualifying providers.
	e. 	The HCBS MR service is not identified in the applicant’s service plan.
	f. 	There is another community resource available to provide the service or a similar service free of charge to the applicant that will meet the applicant’s needs.
	g. 	Completion or receipt of required documents by the department for the HCBS program applicant has not occurred.
	83.68(2) Reduction. A particular service may be reduced when the department determines that the provisions of 441—subrule 130.5(3), paragraph “a” or “b,” apply.
	83.68(3) Termination. A particular service may be terminated when the department determines that:
	a. 	The provisions of 441—subrule 130.5(2), paragraph “d,” “g,” or “h,” apply.
	b. 	Needed services are not available or received from qualifying providers.
	c. 	The HCBS MR service is not identified in the consumer’s annual service plan.
	d. 	Service needs are not met by the services provided.
	e. 	Services needed exceed the service unit or reimbursement maximums.
	f. 	Completion or receipt of required documents by the department for the HCBS program consumer has not occurred.
	g. 	The consumer receives services from other Medicaid waiver programs.
	h. 	The consumer or legal representative through the interdisciplinary process requests termination from the services.
441—83.69(249A) Appeal rights. Notice of adverse action and right to appeal shall be given in accordance with 441—Chapter 7 and rule 441—130.5(234). The applicant or consumer is entitled to have a review of the level of care determination by the IME medical services unit by sending a letter requesting a review to the IME medical services unit. If dissatisfied with that decision, the applicant or consumer may file an appeal with the department.
The applicant or consumer for whom the county has legal payment responsibility shall be entitled to a review of adverse decisions by the county by appealing to the county pursuant to 441—paragraph 25.13(2)“j.” If dissatisfied with the county’s decision, the applicant or consumer may file an appeal with the department pursuant to rule 441—83.69(249A).
441—83.70(249A) County reimbursement. The county board of supervisors of the consumer’s county of legal settlement shall reimburse the department for all the nonfederal share of the HCBS MR waiver service expenses to adults. The county shall enter into a payment agreement with the department for reimbursement of the nonfederal share of the cost of service provided to HCBS MR waiver adults by input through the Individualualized Services Information System (ISIS).
	83.70(1) County agreement. The county shall enter into the agreement using the criteria in subrules 83.61(2) and 83.62(1).
	83.70(2) Continuation of services for HCBS MR consumers. The county shall continue to provide HCBS MR services to consumers with mental retardation who are enrolled in the HCBS MR program on August 1, 1996. The county shall continue to provide HCBS MR services to children who are enrolled in the HCBS MR program after the children turn 18. The state slot for a child in the HCBS MR program will transfer to the county of legal settlement when the child turns 18.
	83.70(3) Continuation of services for children receiving residential-based supported community living services. The county of legal settlement shall be given the option to continue to provide funding for appropriate services to a child 18 to 21 years of age who is receiving residential-based supported community living services after the child turns 18. The case manager shall notify the county of legal settlement when the child in placement turns 16. For children placed after the age of 16, the case manager shall notify the county of legal settlement at the time of placement.
441—83.71(249A) Conversion to the X-PERT system. Rescinded IAB 8/7/02, effective 10/1/02.
441—83.72(249A) Rent subsidy program. Recipients of the HCBS MR waiver program may be eligible for a rent subsidy program. See 441—Chapter 53.
These rules are intended to implement Iowa Code sections 249A.3 and 249A.4.
441—83.73 to 83.80 Reserved.
DIVISION V—BRAIN INJURY WAIVER SERVICES
441—83.81(249A) Definitions.
“Adaptive” means age appropriate skills related to taking care of one’s self and the ability to relate to others in daily living situations. These skills include limitations that occur in the areas of communication, self-care, home living, social skills, community use, self-direction, safety, functional academics, leisure and work.
“Adult” means a person with a brain injury aged 18 years or over.
“Appropriate” means that the services or supports or activities provided or undertaken by the organization are relevant to the consumer’s needs, situation, problems, or desires.
“Assessment” means the review of the consumer’s current functioning in regard to the consumer’s situation, needs, strengths, abilities, desires and goals.
“Attorney in fact under a durable power of attorney for health care” means an individual who is designated by a durable power of attorney for health care, pursuant to Iowa Code chapter 144B, as an agent to make health care decisions on behalf of an individual and who has consented to act in that capacity.
“Basic individual respite” means respite provided on a staff-to-consumer ratio of one to one or higher to individuals without specialized needs requiring the care of a licensed registered nurse or licensed practical nurse.
“Behavior” means skills related to regulating one’s own behavior including coping with demands from others, making choices, conforming conduct to laws, and displaying appropriate sociosexual behavior.
“Brain injury” means clinically evident damage to the brain resulting directly or indirectly from trauma, infection, anoxia, vascular lesions or tumor of the brain, not primarily related to degenerative or aging processes, which temporarily or permanently impairs a person’s physical, cognitive, or behavioral functions. The person must have a diagnosis from the following list:
Malignant neoplasms of brain, cerebrum.
Malignant neoplasms of brain, frontal lobe.
Malignant neoplasms of brain, temporal lobe.
Malignant neoplasms of brain, parietal lobe.
Malignant neoplasms of brain, occipital lobe.
Malignant neoplasms of brain, ventricles.
Malignant neoplasms of brain, cerebellum.
Malignant neoplasms of brain, brain stem.
Malignant neoplasms of brain, other part of brain, includes midbrain, peduncle, and medulla oblongata.
Malignant neoplasms of brain, cerebral meninges.
Malignant neoplasms of brain, cranial nerves.
Secondary malignant neoplasm of brain.
Secondary malignant neoplasm of other parts of the nervous system, includes cerebral meninges.
Benign neoplasm of brain and other parts of the nervous system, brain.
Benign neoplasm of brain and other parts of the nervous system, cranial nerves.
Benign neoplasm of brain and other parts of the nervous system, cerebral meninges.
Encephalitis, myelitis and encephalomyelitis.
Intracranial and intraspinal abscess.
Anoxic brain damage.
Subarachnoid hemorrhage.
Intracerebral hemorrhage.
Other and unspecified intracranial hemorrhage.
Occlusion and stenosis of precerebral arteries.
Occlusion of cerebral arteries.
Transient cerebral ischemia.
Acute, but ill-defined, cerebrovascular disease.
Other and ill-defined cerebrovascular diseases.
Fracture of vault of skull.
Fracture of base of skull.
Other and unqualified skull fractures.
Multiple fractures involving skull or face with other bones.
Concussion.
Cerebral laceration and contusion.
Subarachnoid, subdural, and extradural hemorrhage following injury.
Other and unspecified intracranial hemorrhage following injury.
Intracranial injury of other and unspecified nature.
Poisoning by drugs, medicinal and biological substances.
Toxic effects of substances.
Effects of external causes.
Drowning and nonfatal submersion.
Asphyxiation and strangulation.
Child maltreatment syndrome.
Adult maltreatment syndrome.
“Case management services” means those services established pursuant to Iowa Code chapter 225C.
“Child” means a person with a brain injury aged 17 years or under.
“Client participation” means the amount of the consumer’s income that the person must contribute to the cost of brain injury waiver services, exclusive of medical vendor payments, before Medicaid will provide additional reimbursement.
“Deemed status” means acceptance of certification or licensure of a program or service by another certifying body in place of certification based on review and evaluation.
“Department” means the Iowa department of human services.
“Direct service” means services involving face-to-face assistance to a consumer such as transporting a consumer or providing therapy.
“Fiscal accountability” means the development and maintenance of budgets and independent fiscal review.
“Group respite” is respite provided on a staff-to-consumer ratio of less than one to one.
“Guardian” means a guardian appointed in probate court.
“Health” means skills related to the maintenance of one’s health including eating; illness identification, treatment and prevention; basic first aid; physical fitness; regular physical checkups and personal habits.
“Immediate jeopardy” means circumstances where the life, health, or safety of a person will be severely jeopardized if the circumstances are not immediately corrected.
“Intermittent supported community living service” means supported community living service provided from one to three hours a day for not more than four days a week.
“Medical assessment” means a visual and physical inspection of the consumer, noting deviations from the norm, and a statement of the consumer’s mental and physical condition that can be amendable to or resolved by appropriate actions of the provider.
“Medical institution” means a nursing facility, a skilled nursing facility, intermediate care facility for the mentally retarded, or hospital which has been approved as a Medicaid vendor.
“Medical intervention” means consumer care in the areas of hygiene, mental and physical comfort, assistance in feeding and elimination, and control of the consumer’s care and treatment to meet the physical and mental needs of the consumer in compliance with the plan of care in areas of health, prevention, restoration, and maintenance.
“Medical monitoring” means observation for the purpose of assessing, preventing, maintaining, and treating disease or illness based on the consumer’s plan of care.
“Natural supports” means services and supports identified as wanted or needed by the consumer and provider by persons not for pay (family, friends, neighbors, coworkers, and others in the community) and organizations or entities that serve the general public.
“Organization” means the entity being certified.
“Organizational outcome” means a demonstration by the organization of actions taken by the organization to provide for services or supports to consumers.
“Outcome” means an action or event that follows as a result or consequence of the provision of a service or support.
“Procedures” means the steps to be taken to implement a policy.
“Process” means service or support provided by an agency to a consumer that will allow the consumer to achieve an outcome. This can include a written, formal, consistent trackable method or an informal process that is not written but is trackable.
“Program” means a set of related resources and services directed to the accomplishment of a fixed set of goals and objectives for the population of a specified geographic area or for special target populations. It can mean an agency, organization, or unit of an agency, organization or institution.
“Qualified brain injury professional” means one of the following who meets the educational and licensure or certification requirements for the profession as required in the state of Iowa and who has two years’ experience working with people living with a brain injury: a psychologist; psychiatrist; physician; registered nurse; certified teacher; social worker; mental health counselor; physical, occupational, recreational, or speech therapist; or a person with a bachelor of arts or science degree in psychology, sociology, or public health or rehabilitation services.
“Service coordination” means activities designed to help individuals and families locate, access, and coordinate a network of supports and services that will allow them to live a full life in the community.
“Service plan” means a written consumer-centered, outcome-based plan of services developed using an interdisciplinary process, which addresses all relevant services and supports being provided. It may involve more than one provider.
“Specialized respite” means respite provided on a staff-to-consumer ratio of one to one or higher to individuals with specialized medical needs requiring the care, monitoring or supervision of a licensed registered nurse or licensed practical nurse.
“Staff” means a person under the direction of the organization to perform duties and responsibilities of the organization.
“Third-party payments” means payments from an individual, institution, corporation, or public or private provider which is liable to pay part or all of the medical costs incurred as a result of injury or disease on behalf of a consumer of medical assistance.
“Usual caregiver” means a person or persons who reside with the consumer and are available on a 24-hour-per-day basis to assume responsibility for the care of the consumer.
441—83.82(249A) Eligibility. To be eligible for brain injury waiver services a consumer must meet eligibility criteria and be determined to need a service allowable under the program.
	83.82(1) Eligibility criteria. All of the following criteria must be met. The person must:
	a. 	Have a diagnosis of brain injury.
	b. 	Be eligible for Medicaid under SSI, SSI-related, FMAP, or FMAP-related coverage groups or be eligible under the special income level (300 percent) coverage group consistent with a level of care in a medical institution.
	c. 	Be aged 1 month to 64 years.
	d. 	Be a U.S. citizen and Iowa resident.
	e. 	Rescinded IAB 7/11/01, effective 7/1/01.
	f. 	Be determined by the IME medical services unit as in need of intermediate care facility for the mentally retarded (ICF/MR), skilled nursing, or ICF level of care.
	g. 	Be assessed by the IME medical services unit as able to live in a home- or community-based setting where all medically necessary service needs can be met within the scope of this waiver.
	h. 	At a minimum, receive a waiver service each quarter in addition to case management.
	i. 	Choose HCBS.
	j. 	To be eligible for interim medical monitoring and treatment services the consumer must be:
	(1)	Under the age of 21;
	(2)	Currently receiving home health agency services under rule 441—78.9(249A) and require medical assessment, medical monitoring, and regular medical intervention or intervention in a medical emergency during those services. (The home health aide services for which the consumer is eligible must be maximized before the consumer accesses interim medical monitoring and treatment.);
	(3)	Residing in the consumer’s family home or foster family home; and
	(4)	In need of interim medical monitoring and treatment as ordered by a physician.
	k. 	Receive services in a community, not an institutional, setting.
	l. 	Be assigned a state payment slot within the yearly total approved by the Centers for Medicare and Medicaid Services.
	m. 	For the consumer choices option as set forth in rule 441—subrule 78.43(15), not be living in a residential care facility.
	83.82(2) Need for services.
	a. 	The consumer shall have a service plan approved by the department that is developed by the certified case manager for this waiver as identified by the county of residence. This must be completed prior to services provision and annually thereafter.
The case manager shall establish the interdisciplinary team for the consumer and, with the team, identify the consumer’s “need for service” based on the consumer’s needs and desires as well as the availability and appropriateness of services using the following criteria:
	(1)	The assessment shall be based, in part, on information provided to the IME medical services unit.
	(2)	Service plans must be developed to reflect use of all appropriate nonwaiver Medicaid state services so as not to replace or duplicate those services.
	(3)	Service plans for consumers aged 20 or under which include supported community living services beyond intermittent shall not be approved until a home health provider has made a request to cover the service through all nonwaiver Medicaid services.
	(4)	Service plans for consumers aged 20 or under which include supported community living services beyond intermittent must be approved (signed and dated) by the designee of the bureau of long-term care. The Medicaid case manager must request in writing more than intermittent supported community living with a summary of services and service costs, and submit a written justification with the service plan. The rationale must contain sufficient information for the bureau’s designee, or for a consumer at the ICF/MR level of care, the designee of the county of legal settlement’s board of supervisors, to make a decision regarding the need for supported community living beyond intermittent.
	b. 	Interim medical monitoring and treatment services must be needed because all usual caregivers are unavailable to provide care due to one of the following circumstances:
	(1)	Employment. Interim medical monitoring and treatment services are to be received only during hours of employment.
	(2)	Academic or vocational training. Interim medical monitoring and treatment services provided while a usual caregiver participates in postsecondary education or vocational training shall be limited to 24 periods of no more than 30 days each per caregiver as documented by the service worker. Time spent in high school completion, adult basic education, GED, or English as a second language does not count toward the limit.
	(3)	Absence from the home due to hospitalization, treatment for physical or mental illness, or death of the usual caregiver. Interim medical monitoring and treatment services under this subparagraph are limited to a maximum of 30 days.
	(4)	Search for employment.
	1.	Care during job search shall be limited to only those hours the usual caregiver is actually looking for employment, including travel time.
	2.	Interim medical monitoring and treatment services may be provided under this paragraph only during the execution of one job search plan of up to 30 working days in a 12-month period, approved by the department service worker or targeted case manager pursuant to 441—subparagraph 170.2(2)“b”(5).
	3.	Documentation of job search contacts shall be furnished to the department service worker or targeted case manager.
	c. 	The consumer shall access, if a child, all other services for which the person is eligible and which are appropriate to meet the person’s needs as a precondition of eligibility for the HCBS BI waiver.
	d. 	The total cost of brain injury waiver services shall not exceed $2,812 per month. If more than $505 is paid for home and vehicle modification services, the service worker shall encumber up to $505 per month within the monthly dollar cap allowed for the consumer until the total amount of the modification is reached within a 12-month period.
	83.82(3) HCBS brain injury (BI) waiver program limit for persons requiring the ICF/MR level of care. Rescinded IAB 7/11/01, effective 7/1/01.
	83.82(4) Securing a state payment slot.
	a. 	The county department office shall contact the bureau of long-term care to determine if a payment slot is available for all new applications for the HCBS BI waiver program. For new applications for people who require the ICF/MR level of care when the county of legal settlement has payment responsibility pursuant to rule 441—83.90(249A), the county department office shall inform the county of legal settlement of the application.
	(1)	For applicants not currently receiving Medicaid, the county department office shall contact the bureau and notify the county of those applicants for whom the county has payment responsibility by the end of the second working day after receipt of a completed Form 470-2927 or 470-2927(S), Health Services Application.
	(2)	For current Medicaid recipients, the county department office shall contact the bureau and notify the county of those persons for whom the county has payment responsibility by the end of the second working day after receipt of either Form 470-3349, Brain Injury Functional Assessment, with the choice of the HCBS waiver indicated by the consumer’s signature, or a written request signed and dated by the consumer.
	b. 	On the third day after the receipt of the completed Form 470-2927 or 470-2927(S), if no payment slot is available, the bureau of long-term care shall enter the consumer on a waiting list according to the following:
	(1)	Consumers not currently eligible for Medicaid shall be entered on the waiting list on the basis of the date a completed Form 470-2927 or 470-2927(S), Health Services Application, is date-stamped in the county department office. Consumers currently eligible for Medicaid shall be added to the waiting list on the basis of the date the consumer requests HCBS BI program services as documented by the date of the consumer’s signature on Form 470-2927 or 470-2927(S). In the event that more than one application is received at one time, consumers shall be entered on the waiting list on the basis of the month of birth, January being month one and the lowest number.
	(2)	Persons who do not fall within the available slots shall have their applications rejected but their names shall be maintained on the waiting list. As slots become available, persons shall be selected from the waiting list to maintain the number of approved persons on the program based on their order on the waiting list.
The county shall have financial responsibility for the state share of the costs of services for these consumers as stated in rule 441—83.90(249A). The county shall include these ICF/MR level of care brain-injured consumers in their annual county management plan which is approved by the state.
441—83.83(249A) Application.
	83.83(1) Application for financial eligibility. The application process as specified in rules 441—76.1(249A) to 441—76.6(249A) shall be followed.
	83.83(2) Approval of application for eligibility.
	a. 	Applications for the determination of ability of the consumer to have all medically necessary service needs met within the scope of this waiver shall be initiated on behalf of the consumer and with the consumer’s consent or with the consent of the consumer’s legal representative by the discharge planner of the medical facility where the consumer resides at the time of application or the case manager. The discharge planner or case manager shall provide to the IME medical services unit all appropriate information needed regarding all the medically necessary service needs of the consumer. After completing the determination of ability to have all medically necessary service needs met within the scope of this waiver, the IME medical services unit shall inform the discharge planner or case manager on behalf of the consumer or the consumer’s legal representative and send to the income maintenance worker a copy of the decision as to whether all of the consumer’s service needs can be met in a home- or community-based setting.
	b. 	Eligibility for the HCBS BI waiver shall be effective as of the date when both the service eligibility and financial eligibility have been completed. Decisions shall be mailed or given to the consumer or the consumer’s legal representative on the date when each eligibility determination is completed.
	c. 	A consumer shall be given the choice between waiver services and institutional care. The consumer or legal representative shall complete and sign Form 470-3349, Brain Injury Functional Assessment, indicating the consumer’s choice of caregiver. This shall be arranged by the medical facility discharge planner or case manager.
	d. 	The medical facility discharge planner, if there is one involved, shall contact the appropriate case manager for the consumer’s county of residence to initiate development of the consumer’s service plan and initiation of waiver services.
	e. 	HCBS BI waiver services provided prior to both approvals of eligibility for the waiver cannot be paid.
	f. 	HCBS BI waiver services are not available in conjunction with other HCBS waiver programs or group foster care services.
	g. 	The Medicaid case manager shall establish an HCBS BI waiver interdisciplinary team for each consumer and, with the team, identify the consumer’s “need for service” based on the consumer’s needs and desires as well as the availability and appropriateness of services.
	83.83(3) Effective date of eligibility.
	a. 	The effective date of eligibility for the waiver for persons who are already determined eligible for Medicaid is the date on which the person is determined to meet all of the criteria set forth in rule 441—83.82(249A).
	b. 	The effective date of eligibility for the waiver for persons who qualify for Medicaid due to eligibility for the waiver services is the date on which the person is determined to meet all of the criteria set forth in rule 441—83.82(249A) and when the eligibility factors set forth in 441—subrule 75.1(7) and for married persons, in rule 441—75.5(249A), have been satisfied.
	c. 	Eligibility for the waiver continues until the consumer fails to meet eligibility criteria listed in rule 441—83.82(249A). Consumers who return to inpatient status in a medical institution for more than 30 consecutive days shall be reviewed by the IME medical services unit to determine additional inpatient needs for possible termination from the brain injury waiver. The consumer shall be reviewed for eligibility under other Medicaid coverage groups in accordance with rule 441—76.11(249A). The consumer shall be notified of that decision through Form 470-0602, Notice of Decision.
If the consumer returns home before the effective date of the notice of decision and the consumer’s condition has not substantially changed, the denial may be rescinded and eligibility may continue.
	83.83(4) Attribution of resources. For the purposes of attributing resources as provided in rule 441—75.5(249A), the date on which the waiver consumer meets the level of care criteria in a medical institution as established by the peer review organization shall be used as the date of entry to the medical institution. Only one attribution of resources shall be completed per person. Attributions completed for prior institutionalizations shall be applied to the waiver application.
441—83.84(249A) Client participation. Consumers who are financially eligible under 441—subrule 75.1(7) (the 300 percent group) must contribute a predetermined participation amount to the cost of brain injury waiver services.
	83.84(1) Computation of client participation. Client participation shall be computed by deducting an amount for the maintenance needs of the consumer which is 300 percent of the maximum SSI grant for an individual from the consumer’s total income. For a couple, client participation is determined as if each person were an individual.
	83.84(2) Limitation on payment. If the sum of the third-party payment and client participation equals or exceeds the reimbursement for the specific brain injury waiver service, Medicaid shall make no payments for the waiver service. However, Medicaid shall make payments to other medical providers.
441—83.85(249A) Redetermination. A complete financial redetermination of eligibility for brain injury waiver shall be completed at least once every 12 months. A redetermination of continuing eligibility factors shall be made when a change in circumstances occurs that affects eligibility in accordance with rule 441—83.82(249A). A redetermination shall contain the components listed in rule 441—83.82(249A).
441—83.86(249A) Allowable services. Services allowable under the brain injury waiver are case management, respite, personal emergency response, supported community living, behavioral programming, family counseling and training, home and vehicle modification, specialized medical equipment, prevocational services, transportation, supported employment, adult day care, consumer-directed attendant care, interim medical monitoring and treatment, financial management, independent support brokerage, self-directed personal care, self-directed community supports and employment, and individual-directed goods and services as set forth in rule 441—78.43(249A).
441—83.87(249A) Service plan. A service plan shall be prepared and utilized for each HCBS BI waiver consumer. The service plan shall be developed by an interdisciplinary team, which includes the consumer, and, if appropriate, the legal representative, consumer’s family, case manager, providers, and others directly involved. The service plan shall be stored by the case manager for a minimum of three years. The service plan staffing shall be conducted before the current service plan expires.
	83.87(1) Information in plan. The plan shall be in accordance with 441—subrule 24.4(3) and shall additionally include the following information to assist in evaluating the program:
	a. 	A listing of all services received by a consumer at the time of waiver program enrollment.
	b. 	For supported community living:
	(1)	The consumer’s living environment at the time of waiver enrollment.
	(2)	The number of hours per day of on-site staff supervision needed by the consumer.
	(3)	The number of other waiver consumers who will live with the consumer in the living unit.
	c. 	An identification and justification of any restriction of a consumer’s rights including, but not limited to:
	(1)	Maintenance of personal funds.
	(2)	Self-administration of medications.
	d. 	The names of all providers responsible for providing all services.
	e. 	All service funding sources.
	f. 	The amount of the service to be received by the consumer.
	g. 	Whether the consumer has elected the consumer choices option and, if so:
	(1)	The independent support broker selected by the consumer; and
	(2)	The financial management service selected by the consumer.
	h. 	A plan for emergencies and identification of the supports available to the consumer in an emergency.
	83.87(2) Use of nonwaiver services. Service plans must be developed to reflect use of all appropriate nonwaiver Medicaid services and so as not to replace or duplicate those services.
Service plans for consumers aged 20 or under which include supported community living services beyond intermittent must be approved (signed and dated) by the designee of the bureau of long-term care, or when a county voluntarily chooses to participate, by the county board of supervisors’ designee or the bureau’s designee. The Medicaid case manager shall attach a written request for a variance from the limitation on supported community living to intermittent.
	83.87(3) Annual assessment. The IME medical services unit shall assess the consumer annually and certify the consumer’s need for long-term care services. The IME medical services unit shall be responsible for determining the level of care based on the completed Brain Injury Waiver Functional Assessment, Form 470-3283, and supporting documentation as needed.
	83.87(4) Service file. The Medicaid case manager must ensure that the consumer service file contains the consumer’s service plan.
	a.  to d.  Rescinded IAB 8/7/02, effective 10/1/02.
441—83.88(249A) Adverse service actions.
	83.88(1) Denial. An application for services shall be denied when it is determined by the department that:
	a. 	The consumer is not eligible for the services because all of the medically necessary service needs cannot be met in a home- or community-based setting.
	b. 	Service needs exceed the service unit or reimbursement maximums.
	c. 	Service needs are not met by the services provided.
	d. 	Needed services are not available or received from qualifying providers.
	e. 	The brain injury waiver service is not identified in the consumer’s service plan.
	f. 	There is another community resource available to provide the service or a similar service free of charge to the consumer that will meet the consumer’s needs.
	g. 	The consumer receives services from other Medicaid waiver providers.
	h. 	The consumer or legal representative through the interdisciplinary process requests termination from the services.
	83.88(2) Reduction. A particular service may be reduced when the department determines that the provisions of 441—subrule 130.5(3), paragraph “a” or “b,” apply.
	83.88(3) Termination. A particular service may be terminated when the department determines that:
	a. 	The provisions of 441—subrule 130.5(2), paragraph “d,” “g,” or “h,” apply.
	b. 	Needed services are not available or received from qualifying providers.
	c. 	The brain injury waiver service is not identified in the consumer’s annual service plan.
	d. 	Service needs are not met by the services provided.
	e. 	Services needed exceed the service unit or reimbursement maximums.
	f. 	Completion or receipt of required documents by the department or the medical facility discharge planner for the brain injury waiver service consumer has not occurred.
	g. 	The consumer receives services from other Medicaid providers.
	h. 	The consumer or legal representative through the interdisciplinary process requests termination from the services.
441—83.89(249A) Appeal rights. Notice of adverse actions and right to appeal shall be given in accordance with 441—Chapter 7 and rule 441—130.5(234). The applicant or consumer is entitled to have a review of the level of care determination by the IME medical services unit by sending a letter requesting a review to the IME medical services unit. If dissatisfied with that decision, the applicant or consumer may file an appeal with the department.
The applicant or consumer for whom the county has legal payment responsibility shall be entitled to a review of adverse decisions by the county by appealing to the county pursuant to 441—paragraph 25.13(2)“j.” If dissatisfied with the county’s decision, the applicant or consumer may file an appeal with the department pursuant to rule 441—83.69(249A).
441—83.90(249A) County reimbursement. The county board of supervisors of the consumer’s county of legal settlement shall reimburse the department for all the nonfederal share of the cost of brain injury waiver services to consumers at the ICF/MR level of care with legal settlement in the county who are coming onto the waiver from an ICF/MR facility or who have been receiving other services for which the county has been financially responsible or would become liable due to the person’s reaching the age of majority. The county shall enter into a payment agreement with the department for reimbursement of the nonfederal share of the cost of services provided to adults who meet the criteria stated above by input through the Individualized Services Information System (ISIS). Waiver slots for these persons shall be identified in the county management plan submitted to the department pursuant to 441—Chapter 25.
The county shall enter into the agreement using the criteria in subrule 83.82(2).
441—83.91(249A) Conversion to the X-PERT system. Rescinded IAB 8/7/02, effective 10/1/02.
These rules are intended to implement Iowa Code sections 249A.3 and 249A.4.
441—83.92 to 83.100 Reserved.
DIVISION VI—PHYSICAL DISABILITY WAIVER SERVICES
441—83.101(249A) Definitions.
“Adaptive” means age-appropriate skills related to taking care of one’s self and the ability to relate to others in daily living situations. These skills include limitations that occur in the areas of communication, self-care, home living, social skills, community use, self-direction, safety, functional academics, leisure and work.
“Adult” means a person with a physical disability aged 18 years to 64 years.
“Appropriate” means that the services or supports or activities provided or undertaken by the organization are relevant to the consumer’s needs, situation, problems, or desires.
“Assessment” means the review of the consumer’s current functioning in regard to the consumer’s situation, needs, strengths, abilities, desires and goals.
“Attorney in fact under a durable power of attorney for health care” means an individual who is designated by a durable power of attorney for health care, pursuant to Iowa Code chapter 144B, as an agent to make health care decisions on behalf of an individual and who has consented to act in that capacity.
“Behavior” means skills related to regulating one’s own behavior including coping with demands from others, making choices, controlling impulses, conforming conduct to laws, and displaying appropriate sociosexual behavior.
“Client participation” means the amount of the consumer’s income that the person must contribute to the cost of physical disability waiver services, exclusive of medical vendor payments, before Medicaid will provide additional reimbursement.
“Department” means the Iowa department of human services.
“Guardian” means a guardian appointed in probate court for an adult.
“Medical institution” means a nursing facility, a skilled nursing facility, intermediate care facility for the mentally retarded, or hospital which has been approved as a Medicaid vendor.
“Physical disability” means a severe, chronic condition that is attributable to a physical impairment that results in substantial limitations of physical functioning in three or more of the following areas of major life activities: self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, and economic self-sufficiency.
“Service plan” means a written consumer-centered, outcome-based plan of services developed using an interdisciplinary process which addresses all relevant services and supports being provided. It may involve more than one provider.
“Third-party payments” means payments from an individual, institution, corporation, or public or private provider which is liable to pay part or all of the medical costs incurred as a result of injury or disease on behalf of a consumer of medical assistance.
“Waiver year” means a 12-month period commencing on April 1 of each year.
441—83.102(249A) Eligibility. To be eligible for physical disability waiver services, a consumer must meet eligibility criteria set forth in subrule 83.102(1) and be determined to need a service allowable under the program per subrule 83.102(2).
	83.102(1) Eligibility criteria. All of the following criteria must be met. The person must:
	a. 	Have a physical disability.
	b. 	Be blind or disabled as determined by the receipt of social security disability benefits or by a disability determination made through the department. Disability determinations are made according to supplemental security income guidelines under Title XVI of the Social Security Act or the disability guidelines for the Medicaid employed people with disabilities coverage group.
	c. 	Be ineligible for the HCBS MR waiver.
	d. 	Have the ability to hire, supervise, and fire the provider as determined by the service worker, and be willing to do so, or have a parent or guardian named by probate court, or attorney in fact under a durable power of attorney for health care who will take this responsibility on behalf of the consumer.
	e. 	Be eligible for Medicaid under 441—Chapter 75.
	f. 	Be aged 18 years to 64 years.
	g. 	Rescinded IAB 2/7/01, effective 2/1/01.
	h. 	Be in need of skilled nursing or intermediate care facility level of care. Initial decisions on level of care shall be made for the department by the IME medical services unit within two working days of receipt of medical information. After notice of an adverse decision by the IME medical services unit, the Medicaid applicant or recipient or the applicant’s or recipient’s representative may request reconsideration by the IME medical services unit pursuant to subrule 83.109(2). On initial and reconsideration decisions, the IME medical services unit determines whether the level of care requirement is met based on medical necessity and the appropriateness of the level of care under 441—subrules 79.9(1) and 79.9(2). Adverse decisions by the IME medical services unit on reconsiderations may be appealed to the department pursuant to 441—Chapter 7 and rule 441—83.109(249A).
	i. 	Choose HCBS.
	j. 	Use a minimum of one unit of service per calendar quarter under this program.
	k. 	For the consumer choices option as set forth in 441—subrule 78.46(6), not be living in a residential care facility.
	83.102(2) Need for services.
	a. 	The consumer shall have a service plan which is developed by the consumer and a department service worker. This must be completed and approved prior to service provision and at least annually thereafter.
The service worker shall identify the need for service based on the needs of the consumer as well as the availability and appropriateness of services.
	b. 	The total cost of physical disability waiver services shall not exceed $659 per month. If more than $505 is paid for home and vehicle modification services, the service worker shall encumber up to $505 per month within the monthly dollar cap allowed for the consumer until the total amount of the modification is reached within a 12-month period.
	83.102(3) Slots. The total number of persons receiving HCBS physical disability waiver services in the state shall be limited to the number provided in the waiver approved by the Secretary of the U.S. Department of Health and Human Services. These slots shall be available on a first-come, first-served basis.
	83.102(4) County payment slots for persons requiring the ICF/MR level of care. Rescinded IAB 10/6/99, effective 10/1/99.
	83.102(5) Securing a slot.
	a. 	The county department office shall contact the bureau of long-term care for all cases to determine if a slot is available for all new applications for the HCBS physical disability waiver program.
	(1)	For applicants not currently receiving Medicaid, the county department office shall contact the bureau by the end of the second working day after receipt of a completed Form 470-2927 or 470-2927(S), Health Services Application, submitted on or after April 1, 1999.
	(2)	For current Medicaid recipients, the county department office shall contact the bureau by the end of the second working day after receipt of Form 470-3502, Physical Disability Waiver Assessment Tool, with the choice of HCBS waiver indicated by the signature of the consumer or a written request signed and dated by the consumer.
	b. 	On the third day after the receipt of the completed Form 470-2927 or 470-2927(S), Health Services Application, if no slot is available, the bureau of long-term care shall enter consumers on the HCBS physical disabilities waiver waiting list according to the following:
	(1)	Consumers not currently eligible for Medicaid shall be entered on the basis of the date a completed Form 470-2927 or 470-2927(S), Health Services Application, is submitted on or after April 1, 1999, and date-stamped in the county department office. Consumers currently eligible for Medicaid shall be added on the basis of the date the consumer requests HCBS physical disability program services as documented by the date of the consumer’s signature on Form 470-2927 or 470-2927(S). In the event that more than one application is received on the same day, consumers shall be entered on the waiting list on the basis of the day of the month of their birthday, the lowest number being first on the list. Any subsequent tie shall be decided by the month of birth, January being month one and the lowest number.
	(2)	Persons who do not fall within the available slots shall have their applications rejected but their names shall be maintained on the waiting list. As slots become available, persons shall be selected from the waiting list to maintain the number of approved persons on the program based on their order on the waiting list.
	83.102(6) Securing a county payment slot. Rescinded IAB 10/6/99, effective 10/1/99.
	83.102(7) HCBS physical disability waiver waiting list. When services are denied because the limit on the number of slots is reached, a notice of decision denying service based on the limit and stating that the person’s name shall be put on a waiting list shall be sent to the person by the department.
441—83.103(249A) Application.
	83.103(1) Application for financial eligibility. The application process as specified in rules 441—76.1(249A) to 441—76.6(249A) shall be followed. Applications for this program may only be filed on or after April 1, 1999.
	83.103(2) Approval of application for eligibility.
	a. 	Applications for this waiver shall be initiated on behalf of the applicant who is a resident of a medical institution with the applicant’s consent or with the consent of the applicant’s legal representative by the discharge planner of the medical facility where the applicant resides at the time of application. The discharge planner shall complete Form 470-3502, Physical Disability Waiver Assessment Tool, and submit it to the IME medical services unit. After completing the determination of the level of care needed by the applicant, the IME medical services unit shall inform the income maintenance worker and the discharge planner of the IME medical services unit’s decision.
	b. 	Applications for this waiver shall be initiated by the applicant, the applicant’s parent or legal guardian, or the applicant’s attorney in fact under a durable power of attorney for health care on behalf of the applicant who is residing in the community. The applicant, the applicant’s parent, the applicant’s legal guardian, or the applicant’s attorney in fact under a durable power of attorney for health care shall complete Form 470-3502, Physical Disability Waiver Assessment Tool, and submit it to the IME medical services unit. After completing the determination of the level of care needed by the applicant, the IME medical services unit shall inform the income maintenance worker and the applicant, the applicant’s parent or legal guardian, or the applicant’s attorney in fact under a durable power of attorney for health care.
	c. 	Eligibility for this waiver shall be effective as of the date when both the eligibility criteria in subrule 83.102(1) and need for services in subrule 83.102(2) have been established. Decisions shall be mailed or given to the applicant, the applicant’s parent or legal guardian, or the applicant’s attorney in fact under a durable power of attorney for health care on the date when each eligibility determination is completed.
	d. 	An applicant shall be given the choice between waiver services and institutional care. The applicant or the applicant’s parent, legal guardian, or attorney in fact under a durable power of attorney for health care shall sign Form 470-3502, Physical Disability Waiver Assessment Tool, indicating the applicant’s choice of caregiver.
	e. 	The applicant, the applicant’s parent or guardian, or the applicant’s attorney in fact under a durable power of attorney for health care shall cooperate with the service worker in the development of the service plan, which must be approved by the department service worker prior to the start of services.
	f. 	HCBS physical disability waiver services provided prior to both approvals of eligibility for the waiver cannot be paid.
	g. 	HCBS physical disability waiver services are not available in conjunction with other HCBS waiver programs. The consumer may also receive in-home health-related care service if eligible for that program.
	83.103(3) Effective date of eligibility.
	a. 	The effective date of eligibility for the waiver for persons who are already determined eligible for Medicaid is the date on which the person is determined to meet all of the criteria set forth in rule 441—83.102(249A).
	b. 	The effective date of eligibility for the waiver for persons who qualify for Medicaid due to eligibility for the waiver services is the date on which the person is determined to meet all of the criteria set forth in rule 441—83.102(249A) and when the eligibility factors set forth in 441—subrule 75.1(7) and, for married persons, in rule 441—75.5(249A), have been satisfied.
	c. 	Eligibility for the waiver continues until the consumer fails to meet eligibility criteria listed in rule 441—83.102(249A). Consumers who return to inpatient status in a medical institution for more than 30 consecutive days shall be reviewed by the IME medical services unit to determine additional inpatient needs for possible termination from the physical disability waiver. The consumer shall be reviewed for eligibility under other Medicaid coverage groups in accordance with rule 441—76.11(249A). The consumer shall be notified of that decision through Form 470-0602, Notice of Decision.
If the consumer returns home before the effective date of the notice of decision and the consumer’s condition has not substantially changed, the denial may be rescinded and eligibility may continue.
	83.103(4) Attribution of resources. For the purposes of attributing resources as provided in rule 441—75.5(249A), the date on which the waiver consumer meets the institutional level of care requirement as determined by the IME medical services unit or an appeal decision shall be used as the date of entry to the medical institution. Only one attribution of resources shall be completed per person. Attributions completed for a prior institutionalization shall be applied to the waiver application.
441—83.104(249A) Client participation. Consumers who are financially eligible under 441—subrule 75.1(7) (the 300 percent group) must contribute a client participation amount to the cost of physical disability waiver services.
	83.104(1) Computation of client participation. Client participation shall be computed by deducting a maintenance needs allowance equal to 300 percent of the maximum SSI grant for an individual from the consumer’s total income. For a couple, client participation is determined as if each person were an individual.
	83.104(2) Limitation on payment. If the sum of the third-party payment and client participation equals or exceeds the reimbursement for the specific physical disability waiver service, Medicaid shall make no payments for the waiver service. However, Medicaid shall make payments to other medical providers.
441—83.105(249A) Redetermination. A complete financial redetermination of eligibility for the physical disability waiver shall be completed at least once every 12 months. A redetermination of continuing eligibility factors shall be made when a change in circumstances occurs that affects eligibility in accordance with rule 441—83.102(249A). A redetermination shall contain the components listed in rule 441—83.102(249A).
441—83.106(249A) Allowable services. The services allowable under the physical disability waiver are consumer-directed attendant care, home and vehicle modification, personal emergency response system, transportation, specialized medical equipment, financial management, independent support brokerage, self-directed personal care, self-directed community supports and employment, and individual-directed goods and services as set forth in rule 441—78.46(249A).
441—83.107(249A) Individual service plan. An individualized service plan shall be prepared and used for each HCBS physical disability waiver consumer. The service plan shall be developed and approved by the consumer and the DHS service worker prior to services beginning and payment being made to the provider. The plan shall be reviewed by the consumer and the service worker annually, and the current version approved by the service worker.
	83.107(1) Information in plan. The plan shall be in accordance with 441—subrule 24.4(3) and shall additionally include the following information to assist in evaluating the program:
	a. 	A listing of all services received by a consumer at the time of waiver program enrollment.
	b. 	The name of all providers responsible for providing all services.
	c. 	All service funding sources.
	d. 	The amount of the service to be received by the consumer.
	e. 	Whether the consumer has elected the consumer choices option and, if so:
	(1)	The independent support broker selected by the consumer; and
	(2)	The financial management service selected by the consumer.
	f. 	A plan for emergencies and identification of the supports available to the consumer in an emergency.
	83.107(2) Annual assessment. The IME medical services unit shall review the consumer’s need for continued care annually and recertify the consumer’s need for long-term care services, pursuant to the standards and subject to the reconsideration and appeal processes at paragraph 83.102(1)“h” and rule 441—83.109(249A), based on the completed Form 470-3502, Physical Disability Waiver Assessment Tool, and supporting documentation as needed. Form 470-3502 is completed by the service worker at the time of recertification.
	83.107(3) Case file. Rescinded IAB 8/7/02, effective 10/1/02.
441—83.108(249A) Adverse service actions.
	83.108(1) Denial. An application for services shall be denied when it is determined by the department that:
	a. 	All of the medically necessary service needs cannot be met in a home- or community-based setting.
	b. 	Service needs exceed the reimbursement maximums.
	c. 	Service needs are not met by the services provided.
	d. 	Needed services are not available or received from qualifying providers.
	e. 	The physical disability waiver service is not identified in the consumer’s service plan.
	f. 	There is another community resource available to provide the service or a similar service free of charge to the consumer that will meet the consumer’s needs.
	g. 	The consumer receives services from other Medicaid waiver providers.
	h. 	The consumer or legal representative requests termination from the services.
	83.108(2) Reduction. A particular service may be reduced when the department determines that the provisions of 441—subrule 130.5(3), paragraph “a” or “b,” apply.
	83.108(3) Termination. A particular service may be terminated when the department determines that:
	a. 	The provisions of 441—subrule 130.5(2), paragraph “d,” “g,” or “h,” apply.
	b. 	Needed services are not available or received from qualifying providers.
	c. 	The physical disability waiver service is not identified in the consumer’s annual service plan.
	d. 	Service needs are not met by the services provided.
	e. 	Services needed exceed the service unit or reimbursement maximums.
	f. 	Completion or receipt of required documents by the consumer for the physical disability waiver service has not occurred.
	g. 	The consumer receives services from other Medicaid providers.
	h. 	The consumer or legal representative requests termination from the services.
441—83.109(249A) Appeal rights. Notice of adverse actions and right to appeal shall be given in accordance with 441—Chapter 7 and rule 441—130.5(234).
	83.109(1) Appeal to county. Rescinded IAB 2/7/01, effective 2/1/01.
	83.109(2) Reconsideration request to IME medical services unit. After notice of an adverse decision by the IME medical services unit on the level of care requirement pursuant to paragraph 83.102(1)“h,” the Medicaid applicant or recipient or the applicant’s or recipient’s representative may request reconsideration by the IME medical services unit by sending a letter requesting a review to the IME medical services unit not more than 60 days after the date of the notice of adverse decision. Adverse decisions by the IME medical services unit on reconsiderations may be appealed to the department pursuant to 441—Chapter 7.
	a. 	If a timely request for reconsideration of an initial denial determination is made, the IME medical services unit shall complete the reconsideration determination and send written notice including appeal rights to the Medicaid applicant or recipient and the applicant’s or recipient’s representative within ten working days after the IME medical services unit receives the request for reconsideration and a copy of the medical record.
	b. 	If a copy of the medical record is not submitted with the reconsideration request, the IME medical services unit will request a copy from the facility within two working days.
	c. 	The notice to parties. Written notice of the IME medical services unit’s reconsidered determination will contain the following:
	(1)	The basis for the reconsidered determination.
	(2)	A detailed rationale for the reconsidered determination.
	(3)	A statement explaining the Medicaid payment consequences of the reconsidered determination.
	(4)	A statement informing the parties of their appeal rights, including the information that must be included in the request for hearing, the locations for submitting a request for an administrative hearing, and the time period for filing a request.
	d. 	If the request for reconsideration is mailed or delivered to the IME medical services unit within ten days of the date of the initial determination, any medical assistance payments previously approved will not be terminated until the decision on reconsideration. If the initial decision is upheld on reconsideration, medical assistance benefits continued pursuant to this rule will be treated as an overpayment to be paid back to the department.
441—83.110(249A) County reimbursement. Rescinded IAB 10/6/99, effective 10/1/99.
441—83.111(249A) Conversion to the X-PERT system. Rescinded IAB 8/7/02, effective 10/1/02.
These rules are intended to implement Iowa Code sections 249A.3 and 249A.4.
441—83.112 to 83.120 Reserved.
DIVISION VII—HCBS CHILDREN’S MENTAL HEALTH WAIVER SERVICES
441—83.121(249A) Definitions.
“Assessment” means the review of the consumer’s current functioning in regard to the consumer’s situation, needs, abilities, desires, and goals.
“Case manager” means the person designated to provide Medicaid targeted case management services for the consumer.
“CMS” means the Centers for Medicare and Medicaid Services, a division of the U.S. Department of Health and Human Services.
“Consumer” means an individual up to the age of 18 who is included in a Medicaid coverage group listed in 441—75.1(249A) and is a recipient of children’s mental health waiver services.
“Deeming” means considering parental or spousal income or resources as income or resources of a consumer in determining eligibility for a consumer according to Supplemental Security Income program guidelines.
“Department” means the Iowa department of human services.
“Guardian” means a parent of a consumer or a legal guardian appointed by the court.
“HCBS” means home- and community-based services provided under a Medicaid waiver.
“IME” means the Iowa Medicaid enterprise.
“IME medical services unit” means the contracted entity in the Iowa Medicaid enterprise that determines level of care for consumers initially applying for or continuing to receive children’s mental health waiver services.
“Interdisciplinary team” means the consumer, the consumer’s family, and persons of varied professional and nonprofessional backgrounds with knowledge of the consumer’s needs, as designated by the consumer and the consumer’s family, who meet to develop a service plan based on the individualized needs of the consumer.
“ISIS” means the department’s individualized services information system.
“Local office” means a department of human services office as described in 441—subrule 1.4(2).
“Medical institution” means a nursing facility, an intermediate care facility for the mentally retarded, a psychiatric hospital or psychiatric medical institution for children, or a state mental health institute that has been approved as a Medicaid vendor.
“Mental health professional” means a person who meets all of the following conditions:
	1.	Holds at least a master’s degree in a mental health field including, but not limited to, psychology, counseling and guidance, psychiatric nursing and social work; or is a doctor of medicine or osteopathic medicine; and
	2.	Holds a current Iowa license when required by the Iowa professional licensure laws (such as a psychiatrist, a psychologist, a marital and family therapist, a mental health counselor, an advanced registered nurse practitioner, a psychiatric nurse, or a social worker); and
	3.	Has at least two years of postdegree experience supervised by a mental health professional in assessing mental health problems, mental illness, and service needs and in providing mental health services.
“Serious emotional disturbance” means a diagnosable mental, behavioral, or emotional disorder that (1) is of sufficient duration to meet diagnostic criteria for the disorder specified by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR), published by the American Psychiatric Association; and (2) has resulted in a functional impairment that substantially interferes with or limits a consumer’s role or functioning in family, school, or community activities. “Serious emotional disturbance” shall not include developmental disorders, substance-related disorders, or conditions or problems classified in DSM-IV-TR as “other conditions that may be a focus of clinical attention” (V codes), unless these conditions co-occur with another diagnosable serious emotional disturbance.
“Service plan” means a written, consumer-centered, outcome-based plan of services developed by the consumer’s interdisciplinary team that addresses all relevant services and supports being provided. The service plan may involve more than one provider.
“Skill development” means that the service provided is habilitative and is intended to impart an ability or capacity to the consumer. Supervision without habilitation is not skill development.
“Targeted case management” means Medicaid case management services accredited under 441—Chapter 24 and provided according to 441—Chapter 90 for consumers eligible for the children’s mental health waiver.
“Waiver year” for the children’s mental health waiver means a 12-month period commencing on July 1 of each year.
441—83.122(249A) Eligibility. To be eligible for children’s mental health waiver services, a consumer must meet all of the following requirements:
	83.122(1) Age. The consumer must be under 18 years of age.
	83.122(2) Diagnosis. The consumer must be diagnosed with a serious emotional disturbance.
	a. 	Initial certification. For initial application to the HCBS children’s mental health waiver program, psychological documentation that substantiates a mental health diagnosis of serious emotional disturbance as determined by a mental health professional must be current within the 12-month period before the application date.
	b. 	Ongoing certification. A mental health professional must complete an annual evaluation that substantiates a mental health diagnosis of serious emotional disturbance.
	83.122(3) Level of care. The consumer must be certified as being in need of a level of care that, but for the waiver, would be provided in a psychiatric hospital serving children under the age of 21. The IME medical services unit shall certify the consumer’s level of care annually based on Form 470-4211, Children’s Mental Health Waiver Assessment.
	83.122(4) Financial eligibility. The consumer must be eligible for Medicaid as follows:
	a. 	Be eligible for Medicaid under an SSI, SSI-related, FMAP, or FMAP-related coverage group; or
	b. 	Be eligible under the special income level (300 percent) coverage group; or
	c. 	Become eligible through application of the institutional deeming rules; or
	d. 	Would be eligible for Medicaid if in a medical institution. For this purpose, deeming of parental or spousal income or resources ceases in the month after the month of application.
	83.122(5) Choice of program. The consumer must choose HCBS children’s mental health waiver services over institutional care, as indicated by the signature of the consumer’s parent or legal guardian on Form 470-4211, Children’s Mental Health Waiver Assessment.
	83.122(6) Need for service. The consumer must have service needs that can be met under the children’s mental health waiver program, as documented in the service plan developed in accordance with rule 441—83.12(249A).
	a. 	The consumer must be a recipient of targeted case management services or be identified to receive targeted case management services immediately following program enrollment.
	b. 	The total cost of children’s mental health waiver services needed to meet the consumer’s needs may not exceed $1,873 per month.
	c. 	At a minimum, each consumer must receive one billable unit of a children’s mental health waiver service per calendar quarter.
	d. 	A consumer may not receive children’s mental health waiver services and any of the following services at the same time:
	(1)	Rehabilitative treatment services under 441—Chapter 185; or
	(2)	Family foster care under 441—Chapter 202.
	e. 	A consumer may be enrolled in only one HCBS waiver program at a time.
441—83.123(249A) Application. The Medicaid application process as specified in rules 441—76.1(249A) to 441—76.6(249A) shall be followed for an application for HCBS children’s mental health waiver services.
	83.123(1) Program limit. The number of persons who may be approved for the HCBS children’s mental health waiver shall be subject to the number of consumers to be served as set forth in the federally approved HCBS children’s mental health waiver. When the number of applicants exceeds the number of consumers specified in the approved waiver, the consumer’s application shall be rejected and the consumer’s name shall be placed on a waiting list.
	a. 	The local office shall determine if a payment slot is available by the end of the fifth working day after receipt of:
	(1)	A completed Form 470-2297, Health Services Application, from a consumer who is not currently a Medicaid member;
	(2)	Form 470-4211, Children’s Mental Health Waiver Assessment, with HCBS waiver choice indicated by signature of a Medicaid member’s parent or legal guardian; or
	(3)	A written request signed and dated by a Medicaid member’s parent or legal guardian.
	b. 	When a payment slot is available, the local office shall enter the application into ISIS to begin the waiver approval process.
	(1)	The department shall hold the payment slot for the consumer as long as reasonable efforts are being made to arrange services and the consumer has not been determined to be ineligible for the program.
	(2)	If services have not been initiated and reasonable efforts are no longer being made to arrange services, the slot shall revert for use by the next consumer on the waiting list, if applicable. The consumer must reapply for a new slot.
	c. 	If no payment slot is available, the department shall enter the names of persons on a waiting list according to the following:
	(1)	The names of consumers not currently eligible for Medicaid shall be entered on the waiting list on the basis of the date a completed Form 470-2927 or 470-2927(S), Health Services Application, is submitted and date-stamped in the local office;
	(2)	The names of Medicaid members shall be added to the waiting list on the date Form 470-4211, Children’s Mental Health Waiver Assessment, or a written request as specified in 83.123(2)“a”(3) is date-stamped in the local office.
	(3)	In the event that more than one application is received at one time, the names of consumers shall be entered on the waiting list on the basis of the month of birth, January being month one and the lowest number.
	d. 	Consumers whose names are on the waiting list shall be contacted to reapply as slots become available, based on the order of the waiting list, so that the number of approved consumers on the program is maintained.
	(1)	Once a payment slot is assigned, the department shall give written notice to the consumer within five working days.
	(2)	The department shall hold the payment slot for 30 days for the consumer to file a new application.
	(3)	If an application has not been filed within 30 days, the slot shall revert for use by the next consumer on the waiting list, if applicable. The consumer originally assigned the slot must reapply for a new slot.
	83.123(2) Approval of waiver eligibility.
	a. 	Time limit. Applications for the HCBS children’s mental health waiver program shall be processed within 30 days unless one or more of the following conditions exist:
	(1)	An application has been filed and is pending for federal Supplemental Security Income (SSI) benefits.
	(2)	The application is pending because the department has not received information for a reason that is beyond the control of the consumer or the department.
	(3)	The application is pending because the assessment or the service plan has not been completed. When a determination is not completed 90 days after the date of application due to the lack of a service plan, the application shall be denied.
	b. 	Notice of decisions. The department shall mail or give decisions to the applicant on the dates when eligibility and level-of-care determinations and the consumer’s service plan are completed.
	83.123(3) Effective date of eligibility. The effective date of a consumer’s eligibility for children’s mental health waiver services shall be the first date that all of the following conditions exist:
	a. 	All eligibility requirements are met;
	b. 	Eligibility and level-of-care determinations have been made; and
	c. 	The service plan has been completed.
441—83.124(249A) Financial participation. A consumer must contribute to the cost of children’s mental health waiver services to the extent of the consumer’s total income less 300 percent of the maximum monthly payment for one person under the federal Supplemental Security Income (SSI) program.
441—83.125(249A) Redetermination. The department shall redetermine a consumer’s eligibility for the children’s mental health waiver at least once every 12 months or when there is significant change in the consumer’s situation or condition.
	83.125(1) Eligibility review. Every 12 months, the local office shall review a consumer’s eligibility in accordance with procedures in rule 441—76.7(249A). The review shall verify:
	a. 	Continuing eligibility factors as specified in rule 441—83.122(249A).
	b. 	The existence of a current service plan meeting the requirements listed in rule 441—83.125(249A).
	83.125(2) Continuation of eligibility. A consumer’s waiver eligibility shall continue until one of the following conditions occurs.
	a. 	The consumer fails to meet eligibility criteria listed in rule 441—83.122(249A).
	b. 	The consumer is an inpatient of a medical institution for 30 or more consecutive days.
	(1)	After the consumer has spent 30 consecutive days in a medical institution, the local office shall terminate the consumer’s waiver eligibility and review the consumer for eligibility under other Medicaid coverage groups. The local office shall notify the consumer and the consumer’s parents or legal guardian through Form 470-0602, Notice of Decision.
	(2)	If the consumer returns home after 30 consecutive days but no more than 60 days, the consumer must reapply for children’s mental health waiver services, and the IME medical services unit must redetermine the consumer’s level of care.
	c. 	The consumer does not reside at the consumer’s natural home for a period of 60 consecutive days. After the consumer has resided outside the home for 60 consecutive days, the local office shall terminate the consumer’s waiver eligibility and review the consumer for eligibility under other Medicaid coverage groups. The local office shall notify the consumer and the consumer’s parents or legal guardian through Form 470-0602, Notice of Decision.
	83.125(3) Payment slot. When a consumer loses waiver eligibility, the consumer’s assigned payment slot shall revert for use to the next consumer on the waiting list.
441—83.126(249A) Allowable services. Services allowable under the children’s mental health waiver shall be provided as set forth in rule 441—78.52(249A) and shall include:
	1.	Environmental modifications, adaptive devices and therapeutic resources;
	2.	Family and community support services;
	3.	In-home family therapy; and
	4.	Respite care.
441—83.127(249A) Service plan. The consumer’s case manager shall prepare an individualized service plan for each consumer that meets the requirements set for case plans in rule 441—130.7(234).
	83.127(1) The service plan shall be developed through an interdisciplinary team process.
	83.127(2) The service plan shall be developed annually or when there is significant change in the consumer’s situation or condition.
	83.127(3) The service plan shall be based on information in Form 470-4211, Children’s Mental Health Waiver Assessment.
	83.127(4) The service plan shall specify the type and frequency of the waiver services and the providers that will deliver the services.
	83.127(5) The service plan shall identify and justify any restriction of the consumer’s rights.
441—83.128(249A) Adverse service actions.
	83.128(1) Denial. An application for children’s mental health waiver services shall be denied when the department determines that:
	a. 	The consumer is not eligible for or in need of waiver services.
	b. 	Needed services are not available or received from qualified providers.
	c. 	Service needs exceed the limit on aggregate monthly costs established in 83.122(6)“c” or are not met by the services provided.
	83.128(2) Termination. A consumer’s participation in the children’s mental health waiver program may be terminated when the department determines that:
	a. 	The provisions of 441—paragraph 130.5(2)“a,” “b,” “c,” “g,” or “h” apply.
	b. 	The costs of the children’s mental health waiver services for the consumer exceed the aggregate monthly costs established in 83.122(6)“c.”
	c. 	The consumer receives care in a hospital, nursing facility, psychiatric hospital serving children under the age of 21, or psychiatric medical institution for children for 30 days in any one stay.
	d. 	The physical or mental condition of the consumer requires more care than can be provided in the consumer’s own home, as determined by the consumer’s case manager.
	e. 	Service providers are not available.
	83.128(3) Reduction. Reduction of services shall apply as specified in 441—paragraphs 130.5(3)“a” and “b.”
441—83.129(249A) Appeal rights. Notice of adverse action and right to appeal shall be given in accordance with 441—Chapter 7 and rule 441—130.5(234). An applicant or consumer may obtain a review of the IME medical services unit’s level-of-care determination by sending a letter requesting a review to the IME Medical Services Unit, P.O. Box 36478, Des Moines, Iowa 50315. If dissatisfied with the IME medical services unit’s review decision, the applicant or consumer may file an appeal with the department in accordance with 441—Chapter 7.
These rules are intended to implement Iowa Code section 249A.4 and 2005 Iowa Acts, chapter 167, section 13, and chapter 117, section 3.
[Filed emergency 8/31/84—published 9/26/84, effective 10/1/84]
[Filed 1/22/86, Notice 12/4/85—published 2/12/86, effective 4/1/86]
[Filed emergency 1/15/87—published 2/11/87, effective 1/15/87]
[Filed emergency 5/13/88 after Notice 3/23/88—published 6/1/88, effective 6/1/88]
[Filed 7/14/89, Notice 4/19/89—published 8/9/89, effective 10/1/89]
[Filed 3/16/90, Notice 2/7/90—published 4/4/90, effective 6/1/90]
[Filed 4/13/90, Notice 11/29/89—published 5/2/90, effective 8/1/90]
[Filed emergency 6/13/90—published 7/11/90, effective 6/14/90]
[Filed 10/12/90, Notice 8/8/90—published 10/31/90, effective 2/1/91]
[Filed 1/17/91, Notices 11/14/90, 11/28/90—published 2/6/91, effective 4/1/91]
[Filed emergency 5/17/91 after Notice of 4/3/91—published 6/12/91, effective 7/1/91]
[Filed 10/10/91, Notice 9/4/91—published 10/30/91, effective 1/1/92]
[Filed emergency 1/16/92, Notice 11/27/91—published 2/5/92, effective 3/1/92]
[Filed 2/13/92, Notice 1/8/92—published 3/4/92, effective 5/1/92]
[Filed emergency 6/12/92—published 7/8/92, effective 7/1/92]
[Filed 7/17/92, Notice 5/13/92—published 8/5/92, effective 10/1/92]
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[Filed 9/11/92, Notice 7/8/92—published 9/30/92, effective 12/1/92]
[Filed emergency 7/13/93 after Notice 5/12/93—published 8/4/93, effective 8/1/93]
[Filed 8/12/93, Notice 4/28/93—published 9/1/93 effective 11/1/93]
[Filed 10/14/93, Notice 8/18/93—published 11/10/93, effective 1/1/94]
[Filed emergency 12/16/93 after Notice 10/27/93—published 1/5/94, effective 1/1/94]
[Filed emergency 2/10/94 after Notice 1/5/94—published 3/2/94, effective 3/1/94]
[Filed emergency 7/15/94 after Notice 6/8/94—published 8/3/94, effective 8/1/94]
[Filed 11/9/94, Notice 9/14/94—published 12/7/94, effective 2/1/95]
[Filed 12/15/94, Notice 11/9/94—published 1/4/95, effective 3/1/95]
[Filed 2/16/95, Notice 11/23/94—published 3/15/95, effective 5/1/95]
[Filed 5/11/95, Notice 3/29/95—published 6/7/95, effective 8/1/95]
[Filed emergency 6/7/95—published 7/5/95, effective 7/1/95]
[Filed 8/10/95, Notice 7/5/95—published 8/30/95, effective 11/1/95]
[Filed 11/16/95, Notices 8/2/95, 9/13/95, 9/27/95—published 12/6/95, effective 2/1/96]
[Filed 5/15/96, Notice 2/14/96—published 6/5/96, effective 8/1/96]
[Filed 6/13/96, Notice 4/24/96—published 7/3/96, effective 9/1/96]
[Filed 7/10/96, Notice 4/24/96—published 7/31/96, effective 10/1/96]
[Filed 8/15/96, Notice 6/19/96—published 9/11/96, effective 11/1/96]
[Filed emergency 10/9/96 after Notice 8/14/96—published 11/6/96, effective 11/1/96]
[Filed 1/15/97, Notice 11/20/96—published 2/12/97, effective 4/1/97]
[Filed 3/12/97, Notices 1/1/97, 1/29/97—published 4/9/97, effective 6/1/97]
[Filed emergency 5/14/97 after Notice 3/12/97—published 6/4/97, effective 7/1/97]
[Filed 6/12/97, Notice 4/23/97—published 7/2/97, effective 10/1/97]
[Filed 11/12/97, Notice 9/10/97—published 12/3/97, effective 2/1/98]
[Filed 12/10/97, Notice 11/5/97—published 12/31/97, effective 4/1/98]
[Filed 4/8/98, Notice 2/11/98—published 5/6/98, effective 7/1/98]
[Filed emergency 6/10/98—published 7/1/98, effective 7/1/98]
[Filed 6/10/98, Notice 5/6/98—published 7/1/98, effective 10/1/98]
[Filed 8/12/98, Notices 6/17/98, 7/1/98—published 9/9/98, effective 11/1/98]
[Filed 12/9/98, Notice 10/7/98—published 12/30/98, effective 4/1/99]
[Filed 1/13/99, Notice 11/4/98—published 2/10/99, effective 4/1/99]
[Filed 2/10/99, Notice 12/16/98—published 3/10/99, effective 5/1/99]
[Filed emergency 6/10/99—published 6/30/99, effective 7/1/99]
[Filed 8/11/99, Notice 6/30/99—published 9/8/99, effective 11/1/99]
[Filed emergency 9/13/99—published 10/6/99, effective 10/1/99]
[Filed 11/10/99, Notice 10/6/99—published 12/1/99, effective 2/1/00]
[Filed emergency 6/8/00—published 6/28/00, effective 7/1/00]
[Filed 9/12/00, Notice 6/14/00—published 10/4/00, effective 12/1/00]
[Filed emergency 1/10/01 after Notice 11/29/00—published 2/7/01, effective 2/1/01]
[Filed 2/14/01, Notice 12/13/00—published 3/7/01, effective 5/1/01]
[Filed emergency 6/13/01 after Notice 4/18/01—published 7/11/01, effective 7/1/01]
[Filed emergency 6/13/01—published 7/11/01, effective 7/1/01]
[Filed 9/11/01, Notice 7/11/01—published 10/3/01, effective 12/1/01]
[Filed 7/15/02, Notice 5/1/02—published 8/7/02, effective 10/1/02]
[Filed 10/10/02, Notice 8/21/02—published 10/30/02, effective 1/1/03]
[Filed emergency 6/12/03 after Notice 4/30/03—published 7/9/03, effective 6/15/03]
[Filed emergency 6/12/03—published 7/9/03, effective 7/1/03]
[Filed 9/22/03, Notice 7/9/03—published 10/15/03, effective 12/1/03]
[Filed emergency 6/14/04 after Notice 4/28/04—published 7/7/04, effective 7/1/04]
[Filed 8/12/04, Notice 6/23/04—published 9/1/04, effective 11/1/04]
[Filed emergency 9/23/04—published 10/13/04, effective 10/1/04]
[Filed 12/14/04, Notice 10/13/04—published 1/5/05, effective 2/9/05]
[Filed without Notice 5/4/05—published 5/25/05, effective 7/1/05]
[Filed emergency 9/21/05—published 10/12/05, effective 10/1/05]
[Filed emergency 11/16/05—published 12/7/05, effective 12/1/05]
[Filed 3/10/06, Notice 10/12/05—published 3/29/06, effective 5/3/06]
[Filed emergency 8/10/06 after Notice 3/15/06—published 8/30/06, effective 10/1/06]
[Filed emergency 9/14/06—published 10/11/06, effective 10/1/06]
[Filed emergency 11/8/06—published 12/6/06, effective 12/1/06]
[Filed 1/12/07, Notice 12/6/06—published 2/14/07, effective 3/21/07]
[Filed 3/14/07, Notice 10/11/06—published 4/11/07, effective 5/16/07]
[Filed emergency 6/12/08—published 7/2/08, effective 7/1/08]
[Filed 9/17/08, Notice 7/2/08—published 10/8/08, effective 11/12/08]