441—78.46 (249A) Physical disability waiver service. Payment shall be approved for the following services to consumers eligible for the HCBS physical disability waiver established in 441—Chapter 83 when 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 and those delineated in Form 470-3372, HCBS Consumer-Directed Attendant Care Agreement. The service shall be delivered in the least restrictive environment consistent with the consumer’s needs 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 or from any other funding source.
All services shall be billed in whole units as specified in the following subrules.
	 78.46(1) Consumer-directed attendant care service. Consumer-directed attendant care services are service activities listed below 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. The services must be cost-effective and necessary to prevent institutionalization.
Providers must demonstrate proficiency in delivery of the services in the consumer’s plan of care. Proficiency must be demonstrated through documentation of prior training or experience or a certificate of formal training. All training or experience will be detailed on Form 470-3372, HCBS Consumer-Directed Attendant Care Agreement, which must be reviewed and approved by the service worker for appropriateness of training or experience prior to the provision of services. Form 470-3372 becomes an attachment to and part of the case plan. Consumers shall give direction and training for activities which are not medical in nature to maintain independence. Licensed registered nurses and therapists must provide on-the-job training and supervision to the provider for skilled activities listed below and described on Form 470-3372. The training and experience must be sufficient to protect the health, welfare and safety of the consumer.
	  a.   	 Nonskilled service activities covered are:
	 (1) 	 Help with dressing.
	 (2) 	 Help with bath, shampoo, hygiene, and grooming.
	 (3) 	 Help with access to and from bed or a wheelchair, transferring, ambulation, and mobility in general. Certification for this is available through the area community colleges.
	 (4) 	 Toilet assistance, including bowel, bladder, and catheter assistance which includes emptying the catheter bag, collecting a specimen and cleaning the external area around the catheter. Certification of training which includes demonstration of competence for catheter assistance is available through the area community colleges.
	 (5) 	 Meal preparation, cooking, eating and feeding assistance but not the cost of meals themselves.
	 (6) 	 Housekeeping services which are essential to the consumer’s health care at home.
	 (7) 	 Help with medications ordinarily self-administered including those ordered by a physician or other qualified health care provider. Certification of training in a medication aide course is available through the area community colleges.
	 (8) 	 Minor wound care which does not require skilled nursing 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 assistance in use of assistive devices for communication.
	 (12) 	 Assisting and accompanying a consumer in using transportation essential to the health and welfare of the consumer, but not the cost of the transportation.
	  b.   	 Skilled service activities covered are the following performed under the supervision of a licensed nurse or licensed therapist working under the direction of a licensed 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 not be included in the reimbursement for consumer-directed attendant care services.
	 (1) 	 Tube feedings of consumers unable to eat solid foods.
	 (2) 	 Assistance with intravenous therapy which is 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 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 such as brittle diabetes and comfort care of terminal conditions.
	 (10) 	 Postsurgical nurse-delegated activities under the supervision of the registered nurse.
	 (11) 	 Monitoring medication reactions 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 for up to 7 hours per day 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 on behalf of the consumer.
	  g.   	 The consumer, parent, guardian, or attorney in fact under a durable power of attorney for health care and the provider shall complete and sign Form 470-3372, HCBS Consumer-Directed Attendant Care Agreement. A copy of the completed agreement shall be attached to the service plan, which is signed by the service worker prior to the initiation of services, and kept in the consumer’s and department’s records.
	  h.   	 If the consumer has a guardian or attorney in fact under a durable power of attorney for health care, the care plan shall address how consumer-directed attendant care services will be monitored to ensure the consumer’s needs are being adequately met. If the guardian or attorney in fact is the service provider, the service plan shall address how the service worker or case manager shall oversee service provision.
	  i.   	 If the consumer has a guardian or attorney in fact under a durable power of attorney for health care, the guardian or attorney in fact shall sign the claim form in place of the consumer, indicating that the service has been provided as presented on the claim.
	  j.   	 The frequency or intensity of services shall be indicated in the service plan.
	  k.   	 Consumer-directed attendant care services may not be simultaneously reimbursed with any other HCBS waiver services.
	  l.   	 Consumer-directed attendant care services may be provided to a recipient of in-home health-related care services, but not at the same time.
	  m.   	 Services may be provided in the absence of a parent or guardian if the parent or guardian has given advanced direction for the service provision.
	 78.46(2) 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.
	 78.46(3) 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 service shall be identified in the consumer’s service plan. A unit is a one-time installation fee or one month of service. Maximum units per state fiscal year are the initial installation and 12 months of service. 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 a week.
	  d.   	 Current data files at the central monitoring station containing response protocols and personal, medical, and emergency information for each consumer.
	 78.46(4) Specialized medical equipment. Specialized medical equipment shall include medically necessary items for personal use by consumers with a physical disability which provide for the health and safety of the consumer that are not covered by Medicaid, are not funded by 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 costs.
	  a.   	 Consumers may receive specialized medical equipment once a 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 shall be identified in the consumer’s service plan.
	 78.46(5) Transportation. Transportation services may be provided for consumers to conduct business errands and essential shopping, to receive medical services when not reimbursed through Medicaid as 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.
	 78.46(6) 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 physical disability waiver are:
	  1. 	 Consumer-directed attendant care (unskilled).
	  2. 	 Home and vehicle modification.
	  3. 	 Specialized medical equipment.
	  4. 	 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 when calculating the value of that service to be included in the individual budget.
	 (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 physical disability 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 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.