441—78.43 (249A) HCBS brain injury waiver services. Payment shall be approved for the following services to consumers eligible for the HCBS brain injury services as established in 441—Chapter 83 and as identified in the consumer’s service plan. All services shall include the applicable and necessary instructions, supervision, assistance and support as required by the consumer in achieving the goals written specifically in the service plan. The services, amount and supports provided under the HCBS brain injury 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 regular Medicaid.
All services shall be billed in whole units.
	 78.43(1) Case management services. Individual case management services means activities provided, using an interdisciplinary process, to persons with a brain injury to ensure that the consumer has received a comprehensive evaluation and diagnosis, to give assistance to the consumer in obtaining appropriate services and living arrangements, to coordinate the delivery of services, and to provide monitoring to ensure the continued appropriate provision of services and the appropriateness of the selected living arrangement.
The service is to be delivered in such a way as to enhance the capabilities of consumers and their families to exercise their rights and responsibilities as citizens in the community. The goal is to enhance the ability of the consumer to exercise choice, make decisions, take risks which are a typical part of life, and fully participate as members of the community. It is essential that the case manager develop a relationship with the consumer so that the abilities, needs and desires of the consumer can be clearly identified and communicated and the case manager can help to ensure that the system and specific services are responsive to the needs of the individual consumers. Those who are at the ICF/MR level of care where the county has voluntarily chosen to participate in the HCBS brain injury waiver are eligible for targeted case management and, therefore, are not eligible for case management as a waiver service.
Case management services shall consist of the following components:
	  a.   	 Intake, which includes ensuring that there is sufficient information to identify all areas of need for services and appropriate living arrangements.
	  b.   	 Assurance that a service plan is developed which addresses the consumer’s total needs for services and living arrangements.
	  c.   	 Assistance to the consumer in obtaining the services and living arrangements identified in the service plan.
	  d.   	 Coordination and facilitation of decision making among providers to ensure consistency in the implementation of the service plan.
	  e.   	 Monitoring of the services and living arrangements to ensure their continued appropriateness for the consumer.
	  f.   	 Crisis assistance to facilitate referral to the appropriate providers to resolve the crisis. The intent and purpose of the individual case services are to facilitate the consumer’s access to the service system and to enable consumers and their families to make decisions on their own behalf by providing:
	 (1) 	 Information necessary for decision making.
	 (2) 	 Assistance with decision making and participation in the decision-making process affecting the consumer.
	 (3) 	 Assistance in problem solving.
	 (4) 	 Assistance in exercising the consumer’s rights.
	 78.43(2) 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 individual comprehensive plan (ICP) or department case plan. Intermittent service shall be provided as defined in rule 441—83.81(249A).
	  a.   	 The basic components of the service may include, but are not limited to, 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 is 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 are those 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, use community resources such as public transportation and libraries, and 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 are those 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 are those activities and expenditures designed to assist the consumer to travel from one place to another to obtain services or carry out life’s activities. The service excludes transportation to and from work or day programs.
	 (6) 	 Treatment services are those 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.
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.
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 shall 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.
	 (3) 	 Intermittent service shall be provided as defined in rule 441—83.81(249A).
	  c.   	 Services may be provided to a child or an adult. Children must first access all other services for which they are eligible and which are appropriate to meet their needs before accessing the HCBS brain injury waiver services. A maximum of three consumers may reside in a living unit, except when the provider meets the requirements set forth in 441—paragraph 77.39(13)“e.”
	 (1) 	 Consumers may live in the home of their family or legal representative or in 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 in 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.   	 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 19 or more hours during a 24-hour calendar day and the consumer’s individual comprehensive plan identifies and reflects the need for this amount of supervision.
	 (2) 	 One hour when subparagraph (1) does not apply.
	  f.   	 The maximum numbers of units available per consumer are as follows:
	 (1) 	 365 daily units per state fiscal year except a leap year, when 366 daily units are available.
	 (2) 	 8,395 hourly units are available per state fiscal year except a leap year, when 8,418 hourly units are available.
	  g.   	 The service shall be identified in the consumer’s individual comprehensive plan.
	  h.   	 Services shall not be simultaneously reimbursed with other residential services, HCBS brain injury waiver respite, transportation or personal assistance services, Medicaid nursing, or Medicaid home health aide services.
	 78.43(3) 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 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.   	 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.
	  e.   	 Respite services shall not be simultaneously reimbursed with other residential or respite services, HCBS brain injury waiver supported community living services, Medicaid nursing, or Medicaid home health aide services.
	  f.   	 The interdisciplinary team shall determine if the consumer will receive basic individual respite, specialized respite or group respite as defined in rule 441—83.81(249A).
	  g.   	 A maximum of 14 consecutive days of 24-hour respite care may be reimbursed.
	  h.   	 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.
	 78.43(4) 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 rule 441—83.87(249A) must complete the form that Iowa vocational rehabilitation services uses to identify the supported employment services appropriate to meet the consumer’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 rule 441—83.87(249A). 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 to the consumer 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 78.43(13).
	  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.
	 78.43(5) 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. Payment of up to $6,060 per year may be made to certified providers upon satisfactory completion of the service. The service worker shall encumber up to $505 per month within the monthly dollar cap allowed for the consumer until the amount of the modification is reached within the 12-month period.
	  h.   	 Services shall be included in the consumer’s service plan and shall exceed the Medicaid state plan services.
	 78.43(6) Personal emergency response system. The personal emergency response system allows a consumer 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 response protocols and personal, medical and emergency information for each consumer.
	  e.   	 The service shall be identified in the consumer’s individual and comprehensive plan.
	  f.   	 A unit is a one-time installation fee or one month of service.
	  g.   	 Maximum units per state fiscal year are the initial installation and 12 months of service.
	 78.43(7) 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 brain injury waiver supported community living service.
	 78.43(8) Specialized medical equipment. Specialized medical equipment shall include medically necessary items for personal use by consumers with a brain injury which provide for health and safety of the consumer which are not ordinarily covered by Medicaid, and are not funded by educational or vocational rehabilitation programs, and are not provided by voluntary means. This includes, but is not limited to: electronic aids and organizers, medicine dispensing devices, communication devices, bath aids, and noncovered environmental control units. This includes repair and maintenance of items purchased through the waiver in addition to the initial purchase cost.
	  a.   	 Consumers may receive specialized medical equipment once per month until a maximum yearly usage of $6,060 has been reached.
	  b.   	 The need for specialized medical equipment shall be documented by a health care professional as necessary for the consumer’s health and safety and identified in the consumer’s individual comprehensive plan.
	 78.43(9) 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 full day (4 to 8 hours) or a half day (1 to 4 hours) or an extended day (8 to 12 hours). Components of the service are set forth in rule 441—171.6(234).
	 78.43(10) Family counseling and training services. Family counseling and training services are face-to-face mental health services provided to the consumer and the family with whom the consumer lives, or who routinely provide care to the consumer to increase the consumer’s or family members’ capabilities to maintain and care for the consumer in the community. Counseling may include helping the consumer or the consumer’s family members with crisis, coping strategies, stress reduction, management of depression, alleviation of psychosocial isolation and support in coping with the effects of a brain injury. It may include the use of treatment regimes as specified in the ITP. Periodic training updates may be necessary to safely maintain the consumer in the community.
Family may include spouse, children, friends, or in-laws of the consumer. Family does not include individuals who are employed to care for the consumer.
	 78.43(11) Prevocational services. Prevocational services are services aimed at preparing a consumer eligible for the HCBS brain injury waiver for paid or unpaid employment, but which 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. 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 which are not primarily directed at teaching specific job skills but more generalized habilitative goals and are reflected in a habilitative plan which focuses on general habilitative rather than specific employment objectives.
Prevocational services do not include 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)) which are otherwise available to the individual through a state or local education agency or vocational rehabilitation services which are otherwise available to the individual through a program funded under Section 110 of the Rehabilitation Act of 1973 (29 U.S.C. 730).
	 78.43(12) Behavioral programming. Behavioral programming consists of individually designed strategies to increase the consumer’s appropriate behaviors and decrease the consumer’s maladaptive behaviors which have interfered with the consumer’s ability to remain in the community. Behavioral programming includes:
	  a.   	 A complete assessment of both appropriate and maladaptive behaviors.
	  b.   	 Development of a structured behavioral intervention plan which should be identified in the ITP.
	  c.   	 Implementation of the behavioral intervention plan.
	  d.   	 Ongoing training and supervision to caregivers and behavioral aides.
	  e.   	 Periodic reassessment of the plan.
Types of appropriate behavioral programming include, but are not limited to, clinical redirection, token economies, reinforcement, extinction, modeling, and over-learning.
	 78.43(13) 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 of 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.
	 (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.
	 78.43(14) 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.
	 78.43(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 brain injury 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. 	 Specialized medical equipment.
	  7. 	 Supported community living.
	  8. 	 Supported employment.
	  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 brain injury 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.