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	  e.   	 Rescinded IAB 7/11/01, effective 7/1/01.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 $500 is paid for home and vehicle modification services, the service worker shall encumber up to $500 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.