441—78.41 (249A) HCBS MR waiver services. Payment will be approved for the following services to consumers eligible for the HCBS MR waiver services as established in 441—Chapter 83 and as identified in the consumer’s service plan. All services include the applicable and necessary instruction, supervision, assistance and support as required by the consumer in achieving the consumer’s life goals. The services, amount and supports provided under the HCBS MR waiver shall be delivered in the least restrictive environment and in conformity with the consumer’s service plan.
Reimbursement shall not be available under the waiver for any services that the consumer can obtain through the Medicaid state plan.
All services shall be billed in whole units.
	 78.41(1) Supported community living services. Supported community living services are provided by the provider within the consumer’s home and community, according to the individualized consumer need as identified in the service plan pursuant to rule 441—83.67(249A).
	  a.   	 Available components of the service are personal and home skills training services, individual advocacy services, community skills training services, personal environment support services, transportation, and treatment services.
	 (1) 	 Personal and home skills training services are those activities which assist a consumer to develop or maintain skills for self-care, self-directedness, and care of the immediate environment.
	 (2) 	 “Individual advocacy services” means the act or process of representing the individual’s rights and interests in order to realize the rights to which the individual is entitled and to remove barriers to meeting the individual’s needs.
	 (3) 	 “Community skills training services” means activities which assist a person to develop or maintain skills allowing better participation in the community. Services shall focus on the following areas as they are applicable to individuals being served:
	  1. 	 Personal management skills training services are activities which assist a person to maintain or develop skills necessary to sustain oneself in the physical environment and are essential to the management of one’s personal business and property. This includes self-advocacy skills. Examples of personal management skills are the ability to maintain a household budget; plan and prepare nutritional meals; ability to use community resources such as public transportation, libraries, etc., and ability to select foods at the grocery store.
	  2. 	 Socialization skills training services are those activities which assist a consumer to develop or maintain skills which include self-awareness and self-control, social responsiveness, community participation, social amenities, and interpersonal skills.
	  3. 	 Communication skills training services are activities which assist a person to develop or maintain skills including expressive and receptive skills in verbal and nonverbal language and the functional application of acquired reading and writing skills.
	 (4) 	 “Personal and environmental support services” means activities and expenditures provided to or on behalf of a person in the areas of personal needs in order to allow the person to function in the least restrictive environment.
	 (5) 	 “Transportation services” means activities and expenditures designed to assist the person to travel from one place to another to obtain services or carry out life’s activities. The service excludes transportation to and from work.
	 (6) 	 “Treatment services” means activities designed to assist the person to maintain or improve physiological, emotional and behavioral functioning and to prevent conditions that would present barriers to a person’s functioning. Treatment services include physical or physiological treatment and psychotherapeutic treatment.
	  1. 	 Physiological treatment means activities including medication regimens designed to prevent, halt, control, relieve, or reverse symptoms or conditions which interfere with the normal functioning of the human body. The activities shall be provided by or under the supervision of a health care professional certified or licensed to provide the treatment activity specified.
	  2. 	 Psychotherapeutic treatment means activities provided to assist a person in the identification or modification of beliefs, emotions, attitudes, or behaviors in order to maintain or improve the person’s functioning in response to the physical, emotional, and social environment.
	  b.   	 The supported community living services are intended to provide for the daily living needs of the consumer and shall be available as needed during any 24-hour period. Activities do not include those associated with vocational services, academics, day care, medical services, Medicaid case management or other case management. Services are individualized supportive services provided in a variety of community-based, integrated settings.
	 (1) 	 Supported community living services shall be available at a daily rate to consumers living outside the home of their family, legal representative, or foster family and for whom a provider has primary responsibility for supervision or structure during the month. This service will provide supervision or structure in identified time periods when another resource is not available.
	 (2) 	 Supported community living services shall be available at an hourly rate to consumers for whom a daily rate is not established.
	  c.   	 Services may be provided to a child or an adult. A maximum of three consumers receiving community-supported alternative living arrangements or HCBS MR services may reside in a living unit except providers meeting requirements set forth in 441—paragraph 77.37(14)“e.”
	 (1) 	 Consumers may live within the home of their family or legal representative or within other types of typical community living arrangements.
	 (2) 	 Consumers of services living with families or legal representatives are not subject to the maximum of three consumers in a living unit.
	 (3) 	 Consumers may not live in licensed medical or health care facilities or in settings required to be licensed as medical or health care facilities.
	 (4) 	 Consumers aged 17 or under living within the home of their family, legal representative, or foster families shall receive services based on development of adaptive, behavior, or health skills. Duration of services shall be based on age appropriateness and individual attention span.
	  d.   	 Rescinded IAB 2/5/03, effective 2/1/03.
	  e.   	 Transportation to and from a day program is not a reimbursable service. Maintenance and room and board costs are not reimbursable.
	  f.   	 Provider budgets shall reflect all staff-to-consumer ratios and shall reflect costs associated with consumers’ specific support needs for travel and transportation, consulting, instruction, and environmental modifications and repairs, as determined necessary by the interdisciplinary team for each consumer. The specific support needs must be identified in the Medicaid case manager’s service plan, the total costs shall not exceed $1570 per consumer per year, and the provider must maintain records to support the expenditures. A unit of service is:
	 (1) 	 One full calendar day when a consumer residing in the living unit receives on-site staff supervision for 14 or more hours per day as an average over a 7-day week and the consumer’s individual comprehensive plan or case plan identifies and reflects the need for this amount of supervision.
	 (2) 	 One hour when subparagraph (1) does not apply.
	  g.   	 The maximum number of units available per consumer is as follows:
	 (1) 	 365 daily units per state fiscal year except a leap year when 366 daily units are available.
	 (2) 	 5,110 hourly units are available per state fiscal year except a leap year when 5,124 hourly units are available.
	  h.   	 The service shall be identified in the consumer’s individual comprehensive plan.
	  i.   	 Services shall not be simultaneously reimbursed with other residential services, HCBS MR respite, Medicaid or HCBS MR nursing, or Medicaid or HCBS MR home health aide services.
	 78.41(2) Respite 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 the 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.   	 Payment for respite services shall not exceed $7,050 per the consumer’s waiver year.
	  e.   	 The service shall be identified in the consumer’s individual comprehensive plan.
	  f.   	 Respite services shall not be simultaneously reimbursed with other residential or respite services, HCBS MR waiver supported community living services, Medicaid or HCBS MR nursing, or Medicaid or HCBS MR home health aide services.
	  g.   	 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.
	  h.   	 The interdisciplinary team shall determine if the consumer will receive basic individual respite, specialized respite or group respite as defined in rule 441—83.60(249A).
	  i.   	 A maximum of 14 consecutive days of 24-hour respite care may be reimbursed.
	  j.   	 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.
	 78.41(3) Personal emergency response system. The personal emergency response system is an electronic component that transmits a coded signal via digital equipment to a central monitoring station. The electronic device allows a person to access assistance in the event of an emergency when alone.
	  a.   	 The necessary components of the system are:
	 (1) 	 An in-home medical communications transceiver.
	 (2) 	 A remote, portable activator.
	 (3) 	 A central monitoring station with backup systems staffed by trained attendants 24 hours per day, seven days per week.
	 (4) 	 Current data files at the central monitoring station containing response protocols and personal, medical and emergency information for each consumer.
	  b.   	 The service shall be identified in the consumer’s individual comprehensive plan.
	  c.   	 A unit is a one-time installation fee or one month of service.
	  d.   	 Maximum units per state fiscal year are the initial installation and 12 months of service.
	 78.41(4) Home and vehicle modifications. 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.
	 78.41(5) Nursing services. Nursing services are individualized in-home medical services provided by licensed nurses. Services shall exceed the Medicaid state plan services and be included in the consumer’s individual comprehensive plan.
	  a.   	 A unit of service is one hour.
	  b.   	 A maximum of ten units are available per week.
	 78.41(6) Home health aide services. Home health aide services are personal or direct care services provided to the consumer which are not payable under Medicaid as set forth in rule 441—78.9(249A). Services shall include unskilled medical services and shall exceed those services provided under HCBS MR supported community living. Instruction, supervision, support or assistance in personal hygiene, bathing, and daily living shall be provided under supported community living.
	  a.   	 Services shall be included in the consumer’s individual comprehensive plan.
	  b.   	 A unit is one hour.
	  c.   	 A maximum of 14 units are available per week.
	 78.41(7) Supported employment services. Supported employment services are individualized services associated with obtaining and maintaining competitive paid employment in the least restrictive environment possible, provided to individuals for whom competitive employment at or above minimum wage is unlikely and who, because of their disability, need intense and ongoing support to perform in a work setting. Individual placements are the preferred service model. Covered services are those listed in paragraphs “a” and “b” that address the disability-related challenges to securing and keeping a job.
	  a.   	 Activities to obtain a job. Covered services directed to obtaining a job must be provided to or on behalf of a consumer 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 consumer and the interdisciplinary team described in 441—subrule 83.67(1) 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 consumer’s interdisciplinary team must determine that the identified services are necessary. Third, the consumer’s case manager 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 consumer holds for 30 consecutive calendar days or more. Payment is available once the service is authorized in the member’s service plan. A consumer may receive two units of job development services during a 12-month period. The activities provided to the consumer may include:
	  1. 	 Job procurement training, including grooming and hygiene, application, résumé development, interviewing skills, follow-up letters, and job search activities.
	  2. 	 Job retention training, including promptness, coworker relations, transportation skills, disability-related supports, job benefits, and an understanding of employee rights and self-advocacy.
	  3. 	 Customized job development services specific to the consumer.
	 (2) 	 Employer development services. The focus of employer development services is to support employers in hiring and retaining consumers in their workforce and to communicate expectations of the employers to the interdisciplinary team described in 441—subrule 83.67(1). Employer development services may be provided only to consumers who are reasonably expected to work for no more than 10 hours per week. A unit of service is one job placement that the consumer holds for 30 consecutive calendar days or more. Payment for this service may be made only after the consumer holds the job for 30 days. A consumer may receive two units of employer development services during a 12-month period if the consumer is competitively employed for 30 or more consecutive calendar days and the other conditions for service approval are met. The services provided may include:
	  1. 	 Developing relationships with employers and providing leads for individual consumers when appropriate.
	  2. 	 Job analysis for a specific job.
	  3. 	 Development of a customized training plan identifying job-specific skill requirements, employer expectations, teaching strategies, time frames, and responsibilities.
	  4. 	 Identifying and arranging reasonable accommodations with the employer.
	  5. 	 Providing disability awareness and training to the employer when it is deemed necessary.
	  6. 	 Providing technical assistance to the employer regarding the training progress as identified on the consumer’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 for a minimum of 30 days or with assisting the consumer 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 consumer’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:
	  1. 	 Job opening identification with the consumer.
	  2. 	 Assistance with applying for a job, including completion of applications or interviews.
	  3. 	 Work site assessment and job accommodation evaluation.
	  b.   	 Supports to maintain employment.
	 (1) 	 Covered services provided to or on behalf of the consumer associated with maintaining competitive paid employment are the following:
	  1. 	 Individual work-related behavioral management.
	  2. 	 Job coaching.
	  3. 	 On-the-job or work-related crisis intervention.
	  4. 	 Assisting the consumer to use skills related to sustaining competitive paid employment, including assistance with communication skills, problem solving, and safety.
	  5. 	 Consumer-directed attendant care services as defined in subrule 78.41(8).
	  6. 	 Assistance with time management.
	  7. 	 Assistance with appropriate grooming.
	  8. 	 Employment-related supportive contacts.
	  9. 	 Employment-related transportation between work and home and to or from activities related to employment and disability. Other forms of community transportation (including car pools, coworkers, self or public transportation, families, and volunteers) must be attempted before transportation is provided as a supported employment service.
	  10. 	 On-site vocational assessment after employment.
	  11. 	 Employer consultation.
	 (2) 	 Services for maintaining employment may include services associated with sustaining consumers in a team of no more than eight individuals with disabilities in a teamwork or “enclave” setting.
	 (3) 	 A unit of service is one hour.
	 (4) 	 A maximum of 40 units may be received per week.
	  c.   	 The following requirements apply to all supported employment services:
	 (1) 	 Employment-related adaptations required to assist the consumer within the performance of the consumer’s job functions shall be provided by the provider as part of the services.
	 (2) 	 Employment-related transportation between work and home and to or from activities related to employment and disability shall be provided by the provider as part of the services. Other forms of community transportation (car pools, coworkers, self or public transportation, families, volunteers) must be attempted before the service provider provides transportation.
	 (3) 	 The majority of coworkers at any employment site with more than two employees where consumers seek, obtain, or maintain employment must be persons without disabilities. In the performance of job duties at any site where consumers seek, obtain, or maintain employment, the consumer 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.
	 (4) 	 All supported employment services shall provide individualized and ongoing support contacts at intervals necessary to promote successful job retention. Each provider contact shall be documented.
	 (5) 	 Documentation that services provided are not currently available under a program funded under the Rehabilitation Act of 1973 or Public Law 94-142 shall be maintained in the provider file of each consumer.
	 (6) 	 All services shall be identified in the consumer’s service plan maintained pursuant to rule 441—83.67(249A).
	 (7) 	 The following services are not covered:
	  1. 	 Services involved in placing or maintaining consumers in day activity programs, work activity programs or sheltered workshop programs;
	  2. 	 Supports for volunteer work or unpaid internships;
	  3. 	 Tuition for education or vocational training; or
	  4. 	 Individual advocacy that is not consumer specific.
	 (8) 	 Services to maintain employment shall not be provided simultaneously with day activity programs, work activity programs, sheltered workshop programs, other HCBS services, or other Medicaid services. However, services to obtain a job and services to maintain employment may be provided simultaneously for the purpose of job advancement or job change.
	 78.41(8) 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 is 1 hour, or one 8- to 24-hour day provided by an individual or an agency. 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 or case manager 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.
	 78.41(9) Interim medical monitoring and treatment services. Interim medical monitoring and treatment services are monitoring and treatment of a medical nature requiring specially trained caregivers beyond what is normally available in a day care setting. The services must be needed to allow the consumer’s usual caregivers to be employed or, for a limited period of time, for academic or vocational training of a usual caregiver; due to the hospitalization, treatment for physical or mental illness, or death of a usual caregiver; or during a search for employment by a usual caregiver.
	  a.   	 Service requirements. Interim medical monitoring and treatment services shall:
	 (1) 	 Provide experiences for each consumer’s social, emotional, intellectual, and physical development;
	 (2) 	 Include comprehensive developmental care and any special services for a consumer with special needs; and
	 (3) 	 Include medical assessment, medical monitoring, and medical intervention as needed on a regular or emergency basis.
	  b.   	 Interim medical monitoring and treatment services may include supervision to and from school.
	  c.   	 Limitations.
	 (1) 	 A maximum of 12 one-hour units of service is available per day.
	 (2) 	 Covered services do not include a complete nutritional regimen.
	 (3) 	 Interim medical monitoring and treatment services may not duplicate any regular Medicaid or waiver services provided under the state plan.
	 (4) 	 Interim medical monitoring and treatment services may be provided only in the consumer’s home, in a registered group child care home, in a registered family child care home, in a licensed child care center, or during transportation to and from school.
	 (5) 	 The staff-to-consumer ratio shall not be less than one to six.
	  d.   	 A unit of service is one hour.
	 78.41(10) Residential-based supported community living services. Residential-based supported community living services are medical or remedial services provided to children under the age of 18 while living outside their home in a residential-based living environment furnished by the residential-based supported community living service provider. The services eliminate barriers to family reunification or develop self-help skills for maximum independence.
	  a.   	 Allowable service components are the following:
	 (1) 	 Daily living skills development. These are services to develop the child’s ability to function independently in the community on a daily basis, including training in food preparation, maintenance of living environment, time and money management, personal hygiene, and self-care.
	 (2) 	 Social skills development. These are services to develop a child’s communication and socialization skills, including interventions to develop a child’s ability to solve problems, resolve conflicts, develop appropriate relationships with others, and develop techniques for controlling behavior.
	 (3) 	 Family support development. These are services necessary to allow a child to return to the child’s family or another less restrictive service environment. These services must include counseling and therapy sessions that involve both the child and the child’s family at least 50 percent of the time and that focus on techniques for dealing with the special care needs of the child and interventions needed to alleviate behaviors that are disruptive to the family or other group living unit.
	 (4) 	 Counseling and behavior intervention services. These are services to halt, control, or reverse stress and social, emotional, or behavioral problems that threaten or have negatively affected the child’s stability. Activities under this service include counseling and behavior intervention with the child, including interventions to ameliorate problem behaviors.
	  b.   	 Residential-based supported community living services must also address the ordinary daily-living needs of the child, excluding room and board, such as needs for safety and security, social functioning, and other medical care.
	  c.   	 Residential-based supported community living services do not include services associated with vocational needs, academics, day care, Medicaid case management, other case management, or any other services that the child can otherwise obtain through Medicaid.
	  d.   	 Room and board costs are not reimbursable as residential-based supported community living services.
	  e.   	 The scope of service shall be identified in the child’s service plan pursuant to 441—paragraph 77.37(23)“d.”
	  f.   	 Residential-based supported community living services shall not be simultaneously reimbursed with other residential services provided under an HCBS waiver or otherwise provided under the Medicaid program.
	  g.   	 A unit of service is a day.
	  h.   	 The maximum number of units of residential-based supported community living services available per child is 365 daily units per state fiscal year, except in a leap year when 366 daily units are available.
	 78.41(11) Transportation. Transportation services may be provided for consumers to conduct business errands and essential shopping, to receive medical services when not reimbursed through medical transportation, to travel to and from work or day programs, and to reduce social isolation. A unit of service is either per mile, per trip, or the unit established by an area agency on aging. Transportation may not be reimbursed simultaneously with HCBS MR waiver supported community living service.
	 78.41(12) 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. A unit of service is a full day (4 to 8 hours) or a half-day (1 to 4 hours) or an extended day (8 to 12 hours).
	 78.41(13) Prevocational services. Prevocational services are services that are aimed at preparing a consumer eligible for the HCBS MR waiver for paid or unpaid employment, but are not job-task oriented. These services include teaching the consumer concepts necessary as job readiness skills, such as following directions, attending to tasks, task completion, problem solving, and safety and mobility training.
	  a.   	 Prevocational services are intended to have a more generalized result as opposed to vocational training for a specific job or supported employment. Services include activities that are not primarily directed at teaching specific job skills but at more generalized habilitative goals, and are reflected in a habilitative plan that focuses on general habilitative rather than specific employment objectives.
	  b.   	 Prevocational services do not include:
	 (1) 	 Services defined in Section 4(a)(4) of the 1975 amendments to the Education of the Handicapped Act (20 U.S.C. 1404(16) and (17)) that are otherwise available to the consumer through a state or local education agency.
	 (2) 	 Vocational rehabilitation services that are otherwise available to the consumer through a program funded under Section 110 of the Rehabilitation Act of 1973 (29 U.S.C. 730).
	 78.41(14) Day habilitation services.
	  a.   	 Scope. Day habilitation services are services that assist or support the consumer in developing or maintaining life skills and community integration. Services must enable or enhance the consumer’s intellectual functioning, physical and emotional health and development, language and communication development, cognitive functioning, socialization and community integration, functional skill development, behavior management, responsibility and self-direction, daily living activities, self-advocacy skills, or mobility.
	  b.   	 Family training option. Day habilitation services may include training families in treatment and support methodologies or in the care and use of equipment. Family training may be provided in the consumer’s home. The unit of service is an hour. The units of services payable are limited to a maximum of 10 hours per month.
	  c.   	 Unit of service. Except as provided in paragraph “b,” the unit of service may be an hour, a half-day (1 to 4 hours), or a full day (4 to 8 hours).
	  d.   	 Exclusions.
	 (1) 	 Services shall not be provided in the consumer’s home, except as provided in paragraph “b.” For this purpose, services provided in a residential care facility where the consumer lives are not considered to be provided in the consumer’s home.
	 (2) 	 Services shall not include vocational or prevocational services and shall not involve paid work.
	 (3) 	 Services shall not duplicate or replace education or related services defined in Public Law 94-142, the Education of the Handicapped Act.
	 (4) 	 Services shall not be provided simultaneously with other Medicaid-funded services.
	 78.41(15) 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 mental retardation waiver are:
	  1. 	 Consumer-directed attendant care (unskilled).
	  2. 	 Day habilitation.
	  3. 	 Home and vehicle modification.
	  4. 	 Prevocational services.
	  5. 	 Basic individual respite care.
	  6. 	 Supported community living.
	  7. 	 Supported employment.
	  8. 	 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 mental retardation 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.”
This rule is intended to implement Iowa Code section 249A.4.