441—78.27 (249A) Home- and community-based habilitation services.
	 78.27(1) Definitions.
“Adult” means a person who is 18 years of age or older.
“Assessment” means the review of the current functioning of the member using the service in regard to the member’s situation, needs, strengths, abilities, desires, and goals.
“Case management” means case management services accredited under 441—Chapter 24 and provided according to 441—Chapter 90.
“Comprehensive service plan” means an individualized, goal-oriented plan of services written in language understandable by the member using the service and developed collaboratively by the member and the case manager.
“Department” means the Iowa department of human services.
“Emergency” means a situation for which no approved individual program plan exists that, if not addressed, may result in injury or harm to the member or to other persons or in significant amounts of property damage.
“HCBS” means home- and community-based services.
“Interdisciplinary team” means a group of persons with varied professional backgrounds who meet with the member to develop a comprehensive service plan to address the member’s need for services.
“ISIS” means the department’s individualized services information system.
“Member” means a person who has been determined to be eligible for Medicaid under 441—Chapter 75.
“Program” means a set of related resources and services directed to the accomplishment of a fixed set of goals for qualifying members.
	 78.27(2) Member eligibility. To be eligible to receive home- and community-based habilitation services, a member shall meet the following criteria:
	  a.   	 Risk factors. The member has at least one of the following risk factors:
	 (1) 	 The member has undergone or is currently undergoing psychiatric treatment more intensive than outpatient care (e.g., emergency services, alternative home care, partial hospitalization, or inpatient hospitalization) more than once in the member’s life; or
	 (2) 	 The member has a history of psychiatric illness resulting in at least one episode of continuous, professional supportive care other than hospitalization.
	  b.   	 Need for assistance. The member has a need for assistance demonstrated by meeting at least two of the following criteria on a continuing or intermittent basis for at least two years:
	 (1) 	 The member is unemployed, is employed in a sheltered setting, or has markedly limited skills and a poor work history.
	 (2) 	 The member requires financial assistance for out-of-hospital maintenance and is unable to procure this assistance without help.
	 (3) 	 The member shows severe inability to establish or maintain a personal social support system.
	 (4) 	 The member requires help in basic living skills such as self-care, money management, housekeeping, cooking, and medication management.
	 (5) 	 The member exhibits inappropriate social behavior that results in a demand for intervention.
	  c.   	 Income. The countable income used in determining the member’s Medicaid eligibility does not exceed 150 percent of the federal poverty level.
	  d.   	 Needs assessment. The member’s case manager has completed an assessment of the member’s need for service, and, based on that assessment, the Iowa Medicaid enterprise medical services unit has determined that the member is in need of home- and community-based habilitation services. A member who is not eligible for Medicaid case management services under 441—Chapter 90 shall receive case management as a home- and community-based habilitation service. The designated case manager shall:
	 (1) 	 Complete a needs-based evaluation that meets the standards for assessment established in 441—subrule 90.5(1) before services begin and annually thereafter.
	 (2) 	 Use the evaluation results to develop a comprehensive service plan as specified in subrule 78.27(4).
	  e.   	 Plan for service. The department has approved the member’s plan for home- and community-based habilitation services. A service plan that has been validated through ISIS shall be considered approved by the department. Home- and community-based habilitation services provided before department approval of a member’s eligibility for the program cannot be reimbursed.
	 (1) 	 The member’s comprehensive service plan shall be completed annually according to the requirements of subrule 78.27(4). A service plan may change at any time due to a significant change in the member’s needs.
	 (2) 	 The member’s habilitation services shall not exceed the maximum number of units established for each service in 441—subrule 79.1(2).
	 (3) 	 The cost of the habilitation services shall not exceed unit expense maximums established in 441—subrule 79.1(2).
	 78.27(3) Application for services. The case manager shall apply for services on behalf of a member by entering a program request for habilitation services in ISIS. The department shall issue a notice of decision to the applicant when financial eligibility, determination of needs-based eligibility, and approval of the service plan have been completed.
	 78.27(4) Comprehensive service plan. Individualized, planned, and appropriate services shall be guided by a member-specific comprehensive service plan developed with the member in collaboration with an interdisciplinary team, as appropriate. Medically necessary services shall be planned for and provided at the locations where the member lives, learns, works, and socializes.
	  a.   	 Development. A comprehensive service plan shall be developed for each member receiving home- and community-based habilitation services based on the member’s current assessment and shall be reviewed on an annual basis.
	 (1) 	 The case manager shall establish an interdisciplinary team for the member. The team shall include the case manager and the member and, if applicable, the member’s legal representative, the member’s family, the member’s service providers, and others directly involved.
	 (2) 	 With the interdisciplinary team, the case manager shall identify the member’s services based on the member’s needs, the availability of services, and the member’s choice of services and providers.
	 (3) 	 The comprehensive service plan development shall be completed at the member’s home or at another location chosen by the member.
	 (4) 	 The interdisciplinary team meeting shall be conducted before the current comprehensive service plan expires.
	 (5) 	 The comprehensive service plan shall reflect desired individual outcomes.
	 (6) 	 Services defined in the comprehensive service plan shall be appropriate to the severity of the member’s problems and to the member’s specific needs or disabilities.
	 (7) 	 Activities identified in the comprehensive service plan shall encourage the ability and right of the member to make choices, to experience a sense of achievement, and to modify or continue participation in the treatment process.
	 (8) 	 For members receiving home-based habilitation in a licensed residential care facility of 16 or fewer beds, the service plan shall address the member’s opportunities for independence and community integration.
	 (9) 	 The initial service plan and annual updates to the service plan must be approved by the Iowa Medicaid enterprise in the individualized services information system before services are implemented. Services provided before the approval date are not payable. The written case plan must be completed, signed and dated by the case manager or service worker within 30 calendar days after plan approval.
	 (10) 	 Any changes to the service plan must be approved by the Iowa Medicaid enterprise in the individualized services information system before the implementation of services. Services provided before the approval date are not payable.
	  b.   	 Service goals and activities. The comprehensive service plan shall:
	 (1) 	 Identify observable or measurable individual goals.
	 (2) 	 Identify interventions and supports needed to meet those goals with incremental action steps, as appropriate.
	 (3) 	 Identify the staff persons, businesses, or organizations responsible for carrying out the interventions or supports.
	 (4) 	 List all Medicaid and non-Medicaid services received by the member and identify:
	  1. 	 The name of the provider responsible for delivering the service;
	  2. 	 The funding source for the service; and
	  3. 	 The number of units of service to be received by the member.
	 (5) 	 Identify for a member receiving home-based habilitation:
	  1. 	 The member’s living environment at the time of enrollment;
	  2. 	 The number of hours per day of on-site staff supervision needed by the member; and
	  3. 	 The number of other members who will live with the member in the living unit.
	 (6) 	 Include a separate, individualized, anticipated discharge plan that is specific to each service the member receives.
	  c.   	 Rights restrictions. Any rights restrictions must be implemented in accordance with 441—subrule 77.25(4). The comprehensive service plan shall include documentation of:
	 (1) 	 Any restrictions on the member’s rights, including maintenance of personal funds and self-administration of medications;
	 (2) 	 The need for the restriction; and
	 (3) 	 Either a plan to restore those rights or written documentation that a plan is not necessary or appropriate.
	  d.   	 Emergency plan. The comprehensive service plan shall include a plan for emergencies and identification of the supports available to the member in an emergency. Emergency plans shall be developed as follows:
	 (1) 	 The member’s interdisciplinary team shall identify in the comprehensive service plan any health and safety issues applicable to the individual member based on information gathered before the team meeting, including a risk assessment.
	 (2) 	 The interdisciplinary team shall identify an emergency backup support and crisis response system to address problems or issues arising when support services are interrupted or delayed or the member’s needs change.
	 (3) 	 Providers of applicable services shall provide for emergency backup staff.
	  e.   	 Plan approval. Services shall be entered into ISIS based on the comprehensive service plan. A service plan that has been validated and authorized through ISIS shall be considered approved by the department. Services must be authorized in ISIS as specified in paragraph 78.27(2)“e.”
	 78.27(5) Requirements for services. Home- and community-based habilitation services shall be provided in accordance with the following requirements:
	  a.   	 The services shall be based on the member’s needs as identified in the member’s comprehensive service plan.
	  b.   	 The services shall be delivered in the least restrictive environment appropriate to the needs of the member.
	  c.   	 The services shall include the applicable and necessary instruction, supervision, assistance, and support required by the member to achieve the member’s life goals.
	  d.   	 Service components that are the same or similar shall not be provided simultaneously.
	  e.   	 Service costs are not reimbursable while the member is in a medical institution, including but not limited to a hospital or nursing facility.
	  f.   	 Reimbursement is not available for room and board.
	  g.   	 Services shall be billed in whole units.
	  h.   	 Services shall be documented. Each unit billed must have corresponding financial and medical records as set forth in rule 441—79.3(249A).
	 78.27(6) Case management. Case management assists members in gaining access to needed medical, social, educational, housing, transportation, vocational, and other appropriate services in order to ensure the health, safety, and welfare of the member.
	  a.   	 Scope. Case management services shall be provided as set forth in rules 441—90.5(249A) and 441—90.8(249A).
	  b.   	 Exclusion. Payment shall not be made for case management provided to a member who is eligible for case management services under 441—Chapter 90.
	 78.27(7) Home-based habilitation. “Home-based habilitation” means individually tailored supports that assist with the acquisition, retention, or improvement of skills related to living in the community.
	  a.   	 Scope. Home-based habilitation services are individualized supportive services provided in the member’s home and community that assist the member to reside in the most integrated setting appropriate to the member’s needs. Services are intended to provide for the daily living needs of the member and shall be available as needed during any 24-hour period. The specific support needs for each member shall be determined necessary by the interdisciplinary team and shall be identified in the member’s comprehensive service plan. Covered supports include:
	 (1) 	 Adaptive skill development;
	 (2) 	 Assistance with activities of daily living;
	 (3) 	 Community inclusion;
	 (4) 	 Transportation;
	 (5) 	 Adult educational supports;
	 (6) 	 Social and leisure skill development;
	 (7) 	 Personal care; and
	 (8) 	 Protective oversight and supervision.
	  b.   	 Exclusions. Home-based habilitation payment shall not be made for the following:
	 (1) 	 Room and board and maintenance costs, including the cost of rent or mortgage, utilities, telephone, food, household supplies, and building maintenance, upkeep, or improvement.
	 (2) 	 Service activities associated with vocational services, day care, medical services, or case management.
	 (3) 	 Transportation to and from a day program.
	 (4) 	 Services provided to a member who lives in a licensed residential care facility of more than 16 persons.
	 (5) 	 Services provided to a member who lives in a facility that provides the same service as part of an inclusive or “bundled” service rate, such as a nursing facility or an intermediate care facility for persons with mental retardation.
	 (6) 	 Personal care and protective oversight and supervision may be a component part of home-based habilitation services but may not comprise the entirety of the service.
	 78.27(8) Day habilitation. “Day habilitation” means assistance with acquisition, retention, or improvement of self-help, socialization, and adaptive skills.
	  a.   	 Scope. Day habilitation activities and environments are designed to foster the acquisition of skills, appropriate behavior, greater independence, and personal choice. Services focus on enabling the member to attain or maintain the member’s maximum functional level and shall be coordinated with any physical, occupational, or speech therapies in the comprehensive service plan. Services may serve to reinforce skills or lessons taught in other settings. Services must enhance or support the member’s:
	 (1) 	 Intellectual functioning;
	 (2) 	 Physical and emotional health and development;
	 (3) 	 Language and communication development;
	 (4) 	 Cognitive functioning;
	 (5) 	 Socialization and community integration;
	 (6) 	 Functional skill development;
	 (7) 	 Behavior management;
	 (8) 	 Responsibility and self-direction;
	 (9) 	 Daily living activities;
	 (10) 	 Self-advocacy skills; or
	 (11) 	 Mobility.
	  b.   	 Setting. Day habilitation shall take place in a nonresidential setting separate from the member’s residence. Services shall not be provided in the member’s home. When the member lives in a residential care facility of more than 16 beds, day habilitation services provided in the facility are not considered to be provided in the member’s home if the services are provided in an area apart from the member’s sleeping accommodations.
	  c.   	 Duration. Day habilitation services shall be furnished for four or more hours per day on a regularly scheduled basis for one or more days per week or as specified in the member’s comprehensive service plan. Meals provided as part of day habilitation shall not constitute a full nutritional regimen (three meals per day).
	  d.   	 Exclusions. Day habilitation payment shall not be made for the following:
	 (1) 	 Vocational or prevocational services.
	 (2) 	 Services that duplicate or replace education or related services defined in Public Law 94-142, the Education of the Handicapped Act.
	 (3) 	 Compensation to members for participating in day habilitation services.
	 78.27(9) Prevocational habilitation. “Prevocational habilitation” means services that prepare a member for paid or unpaid employment.
	  a.   	 Scope. Prevocational habilitation services include teaching concepts such as compliance, attendance, task completion, problem solving, and safety. Services are not oriented to a specific job task, but instead are aimed at a generalized result. Services shall be reflected in the member’s comprehensive service plan and shall be directed to habilitative objectives rather than to explicit employment objectives.
	  b.   	 Setting. Prevocational habilitation services may be provided in a variety of community-based settings based on the individual need of the member. Meals provided as part of these services shall not constitute a full nutritional regimen (three meals per day).
	  c.   	 Exclusions. Prevocational habilitation payment shall not be made for the following:
	 (1) 	 Services that are available under a program funded under Section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.). Documentation that funding is not available for the service under these programs shall be maintained in the file of each member receiving prevocational habilitation services.
	 (2) 	 Services that duplicate or replace education or related services defined in Public Law 94-142, the Education of the Handicapped Act.
	 (3) 	 Compensation to members for participating in prevocational services.
	 78.27(10) Supported employment habilitation. “Supported employment habilitation” means services associated with maintaining competitive paid employment.
	  a.   	 Scope. Supported employment habilitation services are intensive, ongoing supports that enable members to perform in a regular work setting. Services are provided to members who need support because of their disabilities and who are unlikely to obtain competitive employment at or above the minimum wage absent the provision of supports. Covered services include:
	 (1) 	 Activities to obtain a job. Covered services directed to obtaining a job must be provided to or on behalf of a member for whom competitive employment is reasonably expected within less than one year. Services must be focused on job placement, not on teaching generalized employment skills or habilitative goals. Three conditions must be met before services are provided. First, the member and the interdisciplinary team described in subrule 78.27(4) must complete the form that Iowa vocational rehabilitation services uses to identify the supported employment services appropriate to meet a person’s employment needs. Second, the member’s interdisciplinary team must determine that the identified services are necessary. Third, the Iowa Medicaid enterprise medical services unit must approve the services. Available components of activities to obtain a job are as follows:
	  1. 	 Job development services. Job development services are directed toward obtaining competitive employment. A unit of service is a job placement that the member holds for 30 consecutive calendar days or more. Payment is available once the service is authorized in the member’s service plan. A member may receive two units of job development services during a 12-month period. The activities provided to the member may include job procurement training, including grooming and hygiene, application, résumé development, interviewing skills, follow-up letters, and job search activities; job retention training, including promptness, coworker relations, transportation skills, disability-related supports, job benefits, and an understanding of employee rights and self-advocacy; and customized job development services specific to the member.
	  2. 	 Employer development services. The focus of employer development services is to support employers in hiring and retaining members in their workforce and to communicate expectations of the employers to the interdisciplinary team described in subrule 78.27(4). Employer development services may be provided only to members who are reasonably expected to work for no more than 10 hours per week. A unit of service is one job placement that the member holds for 30 consecutive calendar days or more. Payment for this service may be made only after the member holds the job for 30 days. A member may receive two units of employer development services during a 12-month period if the member is competitively employed for 30 or more consecutive calendar days and the other conditions for service approval are met. The services provided may include: developing relationships with employers and providing leads for individual members when appropriate; job analysis for a specific job; development of a customized training plan identifying job-specific skill requirements, employer expectations, teaching strategies, time frames, and responsibilities; identifying and arranging reasonable accommodations with the employer; providing disability awareness and training to the employer when it is deemed necessary; and providing technical assistance to the employer regarding the training progress as identified on the member’s customized training plan.
	  3. 	 Enhanced job search activities. Enhanced job search activities are associated with obtaining initial employment after job development services have been provided to the member for a minimum of 30 days or with assisting the member in changing jobs due to layoff, termination, or personal choice. The interdisciplinary team must review and update the Iowa vocational rehabilitation services supported employment readiness analysis form to determine if this service remains appropriate for the member’s employment goals. A unit of service is an hour. A maximum of 26 units may be provided in a 12-month period. The services provided may include: job opening identification with the member; assistance with applying for a job, including completion of applications or interviews; and work site assessment and job accommodation evaluation.
	 (2) 	 Supports to maintain employment, including the following services provided to or on behalf of the member:
	  1. 	 Individual work-related behavioral management.
	  2. 	 Job coaching.
	  3. 	 On-the-job or work-related crisis intervention.
	  4. 	 Assistance in the use of skills related to sustaining competitive paid employment, including assistance with communication skills, problem solving, and safety.
	  5. 	 Assistance with time management.
	  6. 	 Assistance with appropriate grooming.
	  7. 	 Employment-related supportive contacts.
	  8. 	 On-site vocational assessment after employment.
	  9. 	 Employer consultation.
	  b.   	 Setting. Supported employment may be conducted in a variety of settings, particularly work sites where persons without disabilities are employed.
	 (1) 	 The majority of coworkers at any employment site with more than two employees where members seek, obtain, or maintain employment must be persons without disabilities.
	 (2) 	 In the performance of job duties at any site where members seek, obtain, or maintain employment, the member must have daily contact with other employees or members of the general public who do not have disabilities, unless the absence of daily contact with other employees or the general public is typical for the job as performed by persons without disabilities.
	 (3) 	 When services for maintaining employment are provided to members in a teamwork or “enclave” setting, the team shall include no more than eight people with disabilities.
	  c.   	 Service requirements. The following requirements shall apply to all supported employment services:
	 (1) 	 All supported employment services shall provide individualized and ongoing support contacts at intervals necessary to promote successful job retention.
	 (2) 	 The provider shall provide employment-related adaptations required to assist the member in the performance of the member’s job functions as part of the service.
	 (3) 	 Community transportation options (such as carpools, coworkers, self or public transportation, families, volunteers) shall be attempted before the service provider provides transportation. When no other resources are available, employment-related transportation between work and home and to or from activities related to employment may be provided as part of the service.
	 (4) 	 Members may access both services to maintain employment and services to obtain a job for the purpose of job advancement or job change. A member may receive a maximum of three job placements in a 12-month period and a maximum of 40 units per week of services to maintain employment.
	  d.   	 Exclusions. Supported employment habilitation payment shall not be made for the following:
	 (1) 	 Services that are available under a program funded under Section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.). Documentation that funding is not available under these programs shall be maintained in the file of each member receiving supported employment services.
	 (2) 	 Incentive payments made to an employer to encourage or subsidize the employer’s participation in a supported employment program.
	 (3) 	 Subsidies or payments that are passed through to users of supported employment programs.
	 (4) 	 Training that is not directly related to a member’s supported employment program.
	 (5) 	 Services involved in placing or maintaining members in day activity programs, work activity programs, or sheltered workshop programs.
	 (6) 	 Supports for volunteer work or unpaid internships.
	 (7) 	 Tuition for education or vocational training.
	 (8) 	 Individual advocacy that is not member-specific.
	 78.27(11) Adverse service actions.
	  a.   	 Denial. Services shall be denied when the department determines that:
	 (1) 	 Rescinded IAB 12/29/10, effective 1/1/11.
	 (2) 	 The member is not eligible for or in need of home- and community-based habilitation services.
	 (3) 	 The service is not identified in the member’s comprehensive service plan.
	 (4) 	 Needed services are not available or received from qualifying providers, or no qualifying providers are available.
	 (5) 	 The member’s service needs exceed the unit or reimbursement maximums for a service as set forth in 441—subrule 79.1(2).
	 (6) 	 Completion or receipt of required documents for the program has not occurred.
	  b.   	 Reduction. A particular home- and community-based habilitation service may be reduced when the department determines that continued provision of service at its current level is not necessary.
	  c.   	 Termination. A particular home- and community-based habilitation service may be terminated when the department determines that:
	 (1) 	 The member’s income exceeds the allowable limit, or the member no longer meets other eligibility criteria for the program established by the department.
	 (2) 	 The service is not identified in the member’s comprehensive service plan.
	 (3) 	 Needed services are not available or received from qualifying providers, or no qualifying providers are available.
	 (4) 	 The member’s service needs are not being met by the services provided.
	 (5) 	 The member has received care in a medical institution for 30 consecutive days in any one stay. When a member has been an inpatient in a medical institution for 30 consecutive days, the department will issue a notice of decision to inform the member of the service termination. If the member returns home before the effective date of the notice of decision and the member’s condition has not substantially changed, the decision shall be rescinded, and eligibility for home- and community-based habilitation services shall continue.
	 (6) 	 The member’s service needs exceed the unit or reimbursement maximums for a service as established by the department.
	 (7) 	 Duplication of services provided during the same period has occurred.
	 (8) 	 The member or the member’s legal representative, through the interdisciplinary process, requests termination of the service.
	 (9) 	 Completion or receipt of required documents for the program has not occurred, or the member refuses to allow documentation of eligibility as to need and income.
	  d.   	 Appeal rights. The department shall give notice of any adverse action and the right to appeal in accordance with 441—Chapter 7. The member is entitled to have a review of the determination of needs-based eligibility by the Iowa Medicaid enterprise medical services unit by sending a letter requesting a review to the medical services unit. If dissatisfied with that decision, the member may file an appeal with the department.
	 78.27(12) County reimbursement. The county board of supervisors of the member’s county of legal settlement shall reimburse the department for all of the nonfederal share of the cost of home- and community-based habilitation services provided to an adult member with a chronic mental illness as defined in 441—Chapter 90. The department shall notify the county’s central point of coordination administrator through ISIS of the approval of the member’s service plan.
This rule is intended to implement Iowa Code section 249A.4.
[ARC 7957B, IAB 7/15/09, effective 7/1/09 (See Delay note at end of chapter); ARC 9311B, IAB 12/29/10, effective 1/1/11; ARC 9403B, IAB 3/9/11, effective 5/1/11]