441—78.37 (249A) HCBS elderly waiver services. Payment will be approved for the following services to consumers eligible for the HCBS elderly waiver services as established in 441—Chapter 83. The consumer shall have a billable waiver service each calendar quarter. Services must be billed in whole units.
	 78.37(1) Adult day care services. Adult day care services provide an organized program of supportive care in a group environment to persons who need a degree of supervision and assistance on a regular or intermittent basis in a day care center. A unit of service is a half day (1 to 4 hours), a full day (4 to 8 hours), or an extended day (8 to 12 hours). Components of the service are set forth in rule 441—171.6(234) or as indicated in the Iowa department of elder affairs Annual Service and Fiscal Reporting Manual.
	 78.37(2) Emergency response system. The emergency response system allows a person experiencing a medical emergency at home to activate electronic components that transmit a coded signal via digital equipment over telephone lines to a central monitoring station. The necessary components of a system are:
	  a.   	 An in-home medical communications transceiver.
	  b.   	 A remote, portable activator.
	  c.   	 A central monitoring station with backup systems staffed by trained attendants 24 hours per day, seven days per week.
	  d.   	 Current data files at the central monitoring station containing preestablished response protocols and personal, medical, and emergency information for each client.
	 78.37(3) Home health aide services. Home health aide services are personal or direct care services provided to the client which are not payable under Medicaid as set forth in rule 441—78.9(249A). A unit of service is a visit. Components of the service include:
	  a.   	 Observation and reporting of physical or emotional needs.
	  b.   	 Helping a client with bath, shampoo, or oral hygiene.
	  c.   	 Helping a client with toileting.
	  d.   	 Helping a client in and out of bed and with ambulation.
	  e.   	 Helping a client reestablish activities of daily living.
	  f.   	 Assisting with oral medications ordinarily self-administered and ordered by a physician.
	  g.   	 Performing incidental household services which are essential to the client’s health care at home and are necessary to prevent or postpone institutionalization in order to complete a full unit of service.
	 78.37(4) Homemaker services. Homemaker services are those services provided when the client lives alone or when the person who usually performs these functions for the client is incapacitated or occupied providing direct care to the client. A unit of service is one hour. Components of the service include:
	  a.   	 Essential shopping: shopping for basic need items such as food, clothing or personal care items, or drugs.
	  b.   	 Limited housecleaning: maintenance cleaning such as vacuuming, dusting, scrubbing floors, defrosting refrigerators, cleaning stoves, and washing and mending clothes.
	  c.   	 Accompaniment to medical or psychiatric services.
	  d.   	 Meal preparation: planning and preparing balanced meals.
	  e.   	 Bathing and dressing for self-directing recipients.
	 78.37(5) Nursing care services. Nursing care services are services provided by licensed agency nurses to clients in the home which are ordered by and included in the plan of treatment established by the physician. The services are reasonable and necessary to the treatment of an illness or injury and include: observation; evaluation; teaching; training; supervision; therapeutic exercise; bowel and bladder care; administration of medications; intravenous, hypodermoclysis, and enteral feedings; skin care; preparation of clinical and progress notes; coordination of services and informing the physician and other personnel of changes in the patient’s condition and needs.
A unit of service is one visit. Nursing care service can pay for a maximum of eight nursing visits per month for intermediate level of care persons. There is no limit on the maximum visits for skilled level of care persons.
	 78.37(6) Respite care services. Respite care services are services provided to the consumer that give temporary relief to the usual caregiver and provide all the necessary care that the usual caregiver would provide during that time period. The purpose of respite care is to enable the consumer to remain in the consumer’s current living situation.
	  a.   	 Services provided outside the consumer’s home shall not be reimbursable if the living unit where respite is provided is reserved for another person on a temporary leave of absence.
	  b.   	 Staff-to-consumer ratios shall be appropriate to the individual needs of the consumer as determined by the consumer’s interdisciplinary team.
	  c.   	 A unit of service is one hour.
	  d.   	 The interdisciplinary team shall determine if the consumer will receive basic individual respite, specialized respite or group respite as defined in rule 441—83.21(249A).
	  e.   	 When respite care is provided, the provision of, or payment for, other duplicative services under the waiver is precluded.
	  f.   	 A maximum of 14 consecutive days of 24-hour respite care may be reimbursed.
	  g.   	 Respite services provided for a period exceeding 24 consecutive hours to three or more individuals who require nursing care because of a mental or physical condition must be provided by a health care facility licensed as described in Iowa Code chapter 135C.
	  h.   	 Respite care is not to be provided to persons during the hours in which the usual caregiver is employed except when the consumer is attending a camp. Respite cannot be provided to a consumer whose usual caregiver is a consumer-directed attendant care provider for the consumer.
	 78.37(7) Chore services. Chore services include the following services: window and door maintenance, such as hanging screen windows and doors, replacing windowpanes, and washing windows; minor repairs to walls, floors, stairs, railings and handles; heavy cleaning which includes cleaning attics or basements to remove fire hazards, moving heavy furniture, extensive wall washing, floor care or painting and trash removal; and yard work such as mowing lawns, raking leaves and shoveling walks. A unit of service is one-half hour.
	 78.37(8) Home-delivered meals. Home-delivered meals means meals prepared elsewhere and delivered to a waiver recipient at the recipient’s residence. Each meal shall ensure the recipient receives a minimum of one-third of the daily recommended dietary allowance as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences. The meal may also be a liquid supplement which meets the minimum one-third standard. When a restaurant provides the home-delivered meal, the recipient is required to have a nutritional consultation. The nutritional consultation includes contact with the restaurant to explain the dietary needs of the client and explain what constitutes the minimum one-third daily dietary allowance.
A maximum of 14 meals is allowed per week. A unit of service is a meal.
	 78.37(9) Home and vehicle modification. Covered home and vehicle modifications are those physical modifications to the consumer’s home or vehicle listed below that directly address the consumer’s medical or remedial need. Covered modifications must be necessary to provide for the health, welfare, or safety of the consumer and enable the consumer to function with greater independence in the home or vehicle.
	  a.   	 Modifications that are necessary or desirable without regard to the consumer’s medical or remedial need and that would be expected to increase the fair market value of the home or vehicle, such as furnaces, fencing, roof repair, or adding square footage to the residence, are excluded except as specifically included below. Repairs are also excluded.
	  b.   	 Only the following modifications are covered:
	 (1) 	 Kitchen counters, sink space, cabinets, special adaptations to refrigerators, stoves, and ovens.
	 (2) 	 Bathtubs and toilets to accommodate transfer, special handles and hoses for shower heads, water faucet controls, and accessible showers and sink areas.
	 (3) 	 Grab bars and handrails.
	 (4) 	 Turnaround space adaptations.
	 (5) 	 Ramps, lifts, and door, hall and window widening.
	 (6) 	 Fire safety alarm equipment specific for disability.
	 (7) 	 Voice-activated, sound-activated, light-activated, motion-activated, and electronic devices directly related to the consumer’s disability.
	 (8) 	 Vehicle lifts, driver-specific adaptations, remote-start systems, including such modifications already installed in a vehicle.
	 (9) 	 Keyless entry systems.
	 (10) 	 Automatic opening device for home or vehicle door.
	 (11) 	 Special door and window locks.
	 (12) 	 Specialized doorknobs and handles.
	 (13) 	 Plexiglas replacement for glass windows.
	 (14) 	 Modification of existing stairs to widen, lower, raise or enclose open stairs.
	 (15) 	 Motion detectors.
	 (16) 	 Low-pile carpeting or slip-resistant flooring.
	 (17) 	 Telecommunications device for the deaf.
	 (18) 	 Exterior hard-surface pathways.
	 (19) 	 New door opening.
	 (20) 	 Pocket doors.
	 (21) 	 Installation or relocation of controls, outlets, switches.
	 (22) 	 Air conditioning and air filtering if medically necessary.
	 (23) 	 Heightening of existing garage door opening to accommodate modified van.
	 (24) 	 Bath chairs.
	  c.   	 A unit of service is the completion of needed modifications or adaptations.
	  d.   	 All modifications and adaptations shall be provided in accordance with applicable federal, state, and local building and vehicle codes.
	  e.   	 Services shall be performed following department approval of a binding contract between the enrolled home and vehicle modification provider and the consumer.
	  f.   	 The contract shall include, at a minimum, the work to be performed, cost, time frame for work completion, and assurance of liability and workers’ compensation coverage.
	  g.   	 Service payment shall be made to the enrolled home and vehicle modification provider. If applicable, payment will be forwarded to the subcontracting agency by the enrolled home and vehicle modification provider following completion of the approved modifications.
	  h.   	 Services shall be included in the consumer’s service plan and shall exceed the Medicaid state plan services.
	 78.37(10) Mental health outreach. Mental health outreach services are services provided in a recipient’s home to identify, evaluate, and provide treatment and psychosocial support. The services can only be provided on the basis of a referral from the consumer’s interdisciplinary team established pursuant to 441—subrule 83.22(2). A unit of service is 15 minutes.
	 78.37(11) Transportation. Transportation services may be provided for recipients to conduct business errands, essential shopping, to receive medical services not reimbursed through medical transportation, and to reduce social isolation. A unit of service is per mile, per trip, or rate established by area agency on aging.
	 78.37(12) Nutritional counseling. Nutritional counseling services may be provided for a nutritional problem or condition of such a degree of severity that nutritional counseling beyond that normally expected as part of the standard medical management is warranted. A unit of service is 15 minutes.
	 78.37(13) Assistive devices. Assistive devices means practical equipment products to assist persons with activities of daily living and instrumental activities of daily living to allow the person more independence. They include, but are not limited to: long-reach brush, extra long shoehorn, nonslip grippers to pick up and reach items, dressing aids, shampoo rinse tray and inflatable shampoo tray, double-handled cup and sipper lid. A unit is an item.
	 78.37(14) Senior companion. Senior companion services are nonmedical care supervision, oversight, and respite. Companions may assist with such tasks as meal preparation, laundry, shopping and light housekeeping tasks. This service cannot provide hands-on nursing or medical care. A unit of service is one hour.
	 78.37(15) Consumer-directed attendant care service. Consumer-directed attendant care services are service activities performed by a person to help a consumer with self-care tasks which the consumer would typically do independently if the consumer were otherwise able.
	  a.   	 The service activities may include helping the consumer with any of the following nonskilled service activities:
	 (1) 	 Dressing.
	 (2) 	 Bath, shampoo, hygiene, and grooming.
	 (3) 	 Access to and from bed or a wheelchair, transferring, ambulation, and mobility in general. It is recommended that the provider receive certification of training and return demonstration for transferring. Certification for this is available through the area community colleges.
	 (4) 	 Toilet assistance, including bowel, bladder, and catheter assistance. It is recommended that the provider receive certification of training and return demonstration for catheter assistance. Certification for this is available through the area community colleges.
	 (5) 	 Meal preparation, cooking, eating and feeding but not the cost of meals themselves.
	 (6) 	 Housekeeping services which are essential to the consumer’s health care at home.
	 (7) 	 Medications ordinarily self-administered including those ordered by a physician or other qualified health care provider. It is recommended the provider successfully complete a medication aide course administered by an area community college.
	 (8) 	 Wound care.
	 (9) 	 Assistance needed to go to or return from a place of employment and assistance with job-related tasks while the consumer is on the job site. The cost of transportation for the consumer and assistance with understanding or performing the essential job functions are not included in consumer-directed attendant care services.
	 (10) 	 Cognitive assistance with tasks such as handling money and scheduling.
	 (11) 	 Fostering communication through interpreting and reading services as well as assistive devices for communication.
	 (12) 	 Assisting or accompanying a consumer in using transportation essential to the health and welfare of the consumer. The cost of the transportation is not included.
	  b.   	 The service activities may include helping the consumer with any of the following skilled services under the supervision of a licensed nurse or licensed therapist working under the direction of a physician. The licensed nurse or therapist shall retain accountability for actions that are delegated. The licensed nurse or therapist shall ensure appropriate assessment, planning, implementation, and evaluation. The licensed nurse or therapist shall make on-site supervisory visits every two weeks with the provider present. The cost of the supervision provided by the licensed nurse or therapist shall be paid from private insurance and other third-party payment sources, Medicare, the regular Medicaid program, or the early periodic screening diagnosis and treatment program before accessing the HCBS waiver.
	 (1) 	 Tube feedings of consumers unable to eat solid foods.
	 (2) 	 Intravenous therapy administered by a registered nurse.
	 (3) 	 Parenteral injections required more than once a week.
	 (4) 	 Catheterizations, continuing care of indwelling catheters with supervision of irrigations, and changing of Foley catheters when required.
	 (5) 	 Respiratory care including inhalation therapy and tracheotomy care or tracheotomy care and ventilator.
	 (6) 	 Care of decubiti and other ulcerated areas, noting and reporting to the nurse or therapist.
	 (7) 	 Rehabilitation services including, but not limited to, bowel and bladder training, range of motion exercises, ambulation training, restorative nursing services, reteaching the activities of daily living, respiratory care and breathing programs, reality orientation, reminiscing therapy, remotivation, and behavior modification.
	 (8) 	 Colostomy care.
	 (9) 	 Care of medical conditions out of control which includes brittle diabetes and comfort care of terminal conditions.
	 (10) 	 Postsurgical nursing care.
	 (11) 	 Monitoring medications requiring close supervision because of fluctuating physical or psychological conditions, e.g., antihypertensives, digitalis preparations, mood-altering or psychotropic drugs, or narcotics.
	 (12) 	 Preparing and monitoring response to therapeutic diets.
	 (13) 	 Recording and reporting of changes in vital signs to the nurse or therapist.
	  c.   	 A unit of service provided by an individual or an agency, other than an assisted living program, is 1 hour, or one 8- to 24-hour day. When provided by an assisted living program, a unit of service is one calendar month. If services are provided by an assisted living program for less than one full calendar month, the monthly reimbursement rate shall be prorated based on the number of days service is provided. Except for services provided by an assisted living program, each service shall be billed in whole units.
	  d.   	 The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care shall be responsible for selecting the person or agency who will provide the components of the attendant care services to be provided.
	  e.   	 The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care shall determine the components of the attendant care services to be provided with the person who is providing the services to the consumer.
	  f.   	 The service activities may not include parenting or child care for or on behalf of the consumer.
	  g.   	 The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care and the provider shall complete and sign Form 470-3372, HCBS Consumer-Directed Attendant Care Agreement. A copy of the completed agreement shall be attached to the service plan, which is signed by the service worker prior to the initiation of services, and kept in the consumer’s and department’s records.
	  h.   	 If the consumer has a guardian or attorney in fact under a durable power of attorney for health care, the care plan shall address how consumer-directed attendant care services will be monitored to ensure the consumer’s needs are being adequately met. If the guardian or attorney in fact is the service provider, the service plan shall address how the service worker or case manager shall oversee service provision.
	  i.   	 If the consumer has a guardian or attorney in fact under a durable power of attorney for health care, the guardian or attorney in fact shall sign the claim form in place of the consumer, indicating that the service has been provided as presented on the claim.
	  j.   	 The frequency or intensity of services shall be indicated in the service plan.
	  k.   	 Consumer-directed attendant care services may not be simultaneously reimbursed with any other HCBS waiver services.
	  l.   	 Consumer-directed attendant care services may be provided to a recipient of in-home health-related care services, but not at the same time.
	  m.   	 Services may be provided in the absence of a parent or guardian if the parent or guardian has given advanced direction for the service provision.
	 78.37(16) Consumer choices option. The consumer choices option provides a consumer with a flexible monthly individual budget that is based on the consumer’s service needs. With the individual budget, the consumer shall have the authority to purchase goods and services and may choose to employ providers of services and supports. Components of this service are set forth below.
	  a.   	 Agreement. As a condition of participating in the consumer choices option, a consumer shall sign Form 470-4289, HCBS Consumer Choices Informed Consent and Risk Agreement, to document that the consumer has been informed of the responsibilities and risks of electing the consumer choices option.
	  b.   	 Individual budget amount. A monthly individual budget amount shall be set for each consumer. The consumer’s department service worker or Medicaid targeted case manager shall determine the amount of each consumer’s individual budget, based on the services and supports authorized in the consumer’s service plan. The consumer shall be informed of the individual budget amount during the development of the service plan.
	 (1) 	 Services that may be included in determining the individual budget amount for a consumer in the HCBS elderly waiver are:
	  1. 	 Assistive devices.
	  2. 	 Chore service.
	  3. 	 Consumer-directed attendant care (unskilled).
	  4. 	 Home and vehicle modification.
	  5. 	 Home-delivered meals.
	  6. 	 Homemaker service.
	  7. 	 Basic individual respite care.
	  8. 	 Senior companion.
	  9. 	 Transportation.
	 (2) 	 The department shall determine an average unit cost for each service listed in subparagraph (1) based on actual unit costs from the previous fiscal year plus a cost-of-living adjustment.
	 (3) 	 In aggregate, costs for individual budget services shall not exceed the current costs of waiver program services. In order to maintain cost neutrality, the department shall apply a utilization adjustment factor to the amount of service authorized in the consumer’s service plan before calculating the value of that service to be included in the individual budget amount.
	 (4) 	 The department shall compute the utilization adjustment factor for each service by dividing the net costs of all claims paid for the service by the total of the authorized costs for that service, using at least 12 consecutive months of aggregate service data. The utilization adjustment factor shall be no lower than 60 percent. The department shall analyze and adjust the utilization adjustment factor at least annually in order to maintain cost neutrality.
	 (5) 	 Anticipated costs for home and vehicle modification are not subject to the average cost in subparagraph (2) or the utilization adjustment factor in subparagraph (3). Costs for home and vehicle modification may be released in a one-time payment.
	 (6) 	 The individual budget amount may be changed only at the first of the month and shall remain fixed for the entire month.
	  c.   	 Required service components. To participate in the consumer choices option, a consumer must hire an independent support broker and must work with a financial management service that is enrolled as a Medicaid HCBS elderly waiver services provider.
	 (1) 	 Before hiring the individual support broker, the consumer shall receive the results of the background check conducted pursuant to 441—subrule 77.30(14).
	 (2) 	 If the consumer chooses to hire a person who has a criminal record or founded abuse report, the consumer assumes the risk for this action and shall acknowledge this information on Form 470-4289, HCBS Consumer Choices Informed Consent and Risk Agreement.
	  d.   	 Optional service components. A consumer who elects the consumer choices option may purchase the following services and supports, which shall be provided in the consumer’s home or at an integrated community setting:
	 (1) 	 Self-directed personal care services. Self-directed personal care services are services or goods that provide a range of assistance in activities of daily living and incidental activities of daily living that help the consumer remain in the home and community.
	 (2) 	 Self-directed community supports and employment. Self-directed community supports and employment are services that support the consumer in developing and maintaining independence and community integration.
	 (3) 	 Individual-directed goods and services. Individual-directed goods and services are services, equipment, or supplies not otherwise provided through the Medicaid program that address a need identified in the consumer’s service plan. The item or service shall decrease the consumer’s need for other Medicaid services, promote the consumer’s inclusion in the community, or increase the consumer’s safety in the community.
	  e.   	 Development of the individual budget. The individual support broker shall assist the consumer in developing and implementing the consumer’s individual budget. The individual budget shall include:
	 (1) 	 The costs of the financial management service.
	 (2) 	 The costs of the independent support broker. The independent support broker may be compensated for up to 6 hours of service for assisting with the implementation of the initial individual budget. After the initial implementation, the independent support broker shall not be paid for more than 20 hours of service during a 12-month period without prior approval by the department.
	 (3) 	 The costs of any services and supports chosen by the consumer as described in paragraph “d.”
	  f.   	 Budget authority. The consumer shall have authority over the individual budget authorized by the department to perform the following tasks:
	 (1) 	 Contract with entities to provide services and supports as described in this subrule.
	 (2) 	 Determine the amount to be paid for services with the exception of the independent support broker and the financial management service. Reimbursement rates for the independent support broker and the financial management service are subject to the limits in 441—subrule 79.1(2).
	 (3) 	 Schedule the provision of services.
	 (4) 	 Authorize payment for waiver goods and services identified in the individual budget. Consumers shall not use the individual budget to purchase room and board, sheltered workshop services, child care, or personal entertainment items.
	 (5) 	 Reallocate funds among services included in the budget.
	  g.   	 Delegation of budget authority. The consumer may delegate responsibility for the individual budget to a representative in addition to the independent support broker.
	 (1) 	 The representative must be at least 18 years old.
	 (2) 	 The representative shall not be a current provider of service to the consumer.
	 (3) 	 The consumer shall sign a consent form that designates who the consumer has chosen as a representative and what responsibilities the representative shall have.
	 (4) 	 The representative shall not be paid for this service.
	  h.   	 Employer authority. The consumer shall have the authority to be the common-law employer of employees providing services and support under the consumer choices option. A common-law employer has the right to direct and control the performance of the services. The consumer may perform the following functions:
	 (1) 	 Recruit employees.
	 (2) 	 Select employees from a worker registry.
	 (3) 	 Verify employee qualifications.
	 (4) 	 Specify additional employee qualifications.
	 (5) 	 Determine employee duties.
	 (6) 	 Determine employee wages and benefits.
	 (7) 	 Schedule employees.
	 (8) 	 Train and supervise employees.
	  i.   	 Employment agreement. Any person employed by the consumer to provide services under the consumer choices option shall sign an employment agreement with the consumer that outlines the employee’s and consumer’s responsibilities.
	  j.   	 Responsibilities of the independent support broker. The independent support broker shall perform the services specified in 78.34(13)“j.”
	  k.   	 Responsibilities of the financial management service. The financial management service shall perform all of the services specified in 78.34(13)“k.”
	 78.37(17) Case management services. Case management services are services that assist a consumer in gaining access to medical, social, and other appropriate services needed for the consumer to remain in the consumer’s home. Case management is provided at the direction of the consumer and the interdisciplinary team established pursuant to 441—subrule 83.22(2).
	  a.   	 Case management services shall include:
	 (1) 	 A comprehensive assessment of the consumer’s needs, which must be made within 30 days of referral to case management.
	 (2) 	 Development and implementation of a service plan to meet those needs.
	 (3) 	 Coordination, authorization, and monitoring of all services.
	 (4) 	 A face-to-face meeting by the case manager with the consumer at least quarterly.
	 (5) 	 Monitoring of the consumer’s health, safety, and welfare.
	 (6) 	 Evaluation of outcomes.
	 (7) 	 Periodic reassessment and revision of the service plan as needed but at least annually.
	 (8) 	 Assurance that consumers have a choice of providers.
	  b.   	 Case management shall not include the provision of direct services by the case managers.
	  c.   	 Payment for case management shall not be made until the consumer is enrolled in the waiver. Payment shall be made only for case management activity performed on behalf of the consumer during a month when the consumer is enrolled.
	  d.   	 A unit of service is one month.
This rule is intended to implement Iowa Code section 249A.4.