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.