CHAPTER 83MEDICAID WAIVER SERVICESPreambleMedicaid waiver services are services provided to maintain persons in their own homes or communities who would otherwise require care in a medical institution, including support for persons to seek and maintain employment in the community. Provision of these services must be cost-effective. Services are limited to certain targeted client groups for whom a federal waiver has been requested and approved. Services provided through the waivers are not available to other Medicaid recipients as the services are beyond the scope of the Medicaid state plan.DIVISION I—HCBS HEALTH AND DISABILITY WAIVER SERVICES441—83.1(249A)  Definitions.  
"Attorney in fact under a durable power of attorney for health care" means an individual who is designated by a durable power of attorney for health care, pursuant to Iowa Code chapter 144B, as an agent to make health care decisions on behalf of an individual and who has consented to act in that capacity.
"Basic individual respite" means respite provided on a staff-to-consumer ratio of one to one or higher to individuals without specialized needs requiring the care of a licensed registered nurse or licensed practical nurse.
"Blind individual" means an individual who has a central visual acuity of 20/200 or less in the better eye with the use of corrective lens or visual field restriction to 20 degrees or less.
"Client participation" means the amount of the recipient income that the person must contribute to the cost of health and disability waiver services exclusive of medical vendor payments before Medicaid will participate.
"Deeming" means the specified amount of parental or spousal income and resources considered in determining eligibility for a child or spouse according to current supplemental security income guidelines.
"Disabled person" means an individual who is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which has lasted or is expected to last for a continuous period of not less than 12 months. A child under the age of 18 is considered disabled if the child suffers a medically determinable physical or mental impairment of comparable severity.
"Financial participation" means client participation and medical payments from a third party including veterans’ aid and attendance.
"Group respite" is respite provided on a staff-to-consumer ratio of less than one to one.
"Guardian" means a guardian appointed in probate court.
"Intermediate care facility for persons with an intellectual disability level of care" means that the individual has a diagnosis of intellectual disability made in accordance with the criteria provided in the current version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association; or has a related condition as defined in 42 CFR 435.1009; and needs assistance in at least three of the following major life areas: mobility, musculoskeletal skills, activities of daily living, domestic skills, toileting, eating skills, vision, hearing or speech or both, gross/fine motor skills, sensory-taste, smell, tactile, academic skills, vocational skills, social/community skills, behavior, and health care.
"Intermittent homemaker service" means homemaker service provided from one to three hours a day for not more than four days per week.
"Intermittent respite service" means respite service provided from one to three times a week.
"Managed care organization" means an entity that (1) is under contract with the department to provide services to Medicaid recipients and (2) meets the definition of “health maintenance organization” as defined in Iowa Code section 514B.1.
"Medical assessment" means a visual and physical inspection of the consumer, noting deviations from the norm, and a statement of the consumer’s mental and physical condition that can be amendable to or resolved by appropriate actions of the provider.
"Medical institution" means a nursing facility or an intermediate care facility for persons with an intellectual disability which has been approved as a Medicaid vendor.
"Medical intervention" means consumer care in the areas of hygiene, mental and physical comfort, assistance in feeding and elimination, and control of the consumer’s care and treatment to meet the physical and mental needs of the consumer in compliance with the plan of care in areas of health, prevention, restoration, and maintenance.
"Medical monitoring" means observation for the purpose of assessing, preventing, maintaining, and treating disease or illness based on the consumer’s plan of care.
"Nursing facility level of care" means that the following conditions are met:
  1. The presence of a physical or mental impairment which restricts the member’s daily ability to perform the essential activities of daily living, bathing, dressing, and personal hygiene, and impedes the member’s capacity to live independently.
  2. The member’s physical or mental impairment is such that self-execution of required nursing care is improbable or impossible.
"Service plan" means a person-centered, outcome-based plan of services which is written by the member’s case manager with input and direction from the member and which addresses all relevant services and supports being provided. The service plan is developed by the interdisciplinary team, which includes the member and, if appropriate, the member’s legal representative, member’s family, service providers, and others directly involved with the member.
"Skilled nursing facility level of care" means that the following conditions are met:
  1. The member’s medical condition requires skilled nursing services or skilled rehabilitation services as defined in 42 CFR 409.31(a), 409.32, and 409.34.
  2. Services are provided in accordance with the general provisions for all Medicaid providers and services as described in rule 441—79.9(249A).
  3. Documentation submitted for review indicates that the member has:
  1. A physician order for all skilled services.
  2. Services that require the skills of medical personnel, including registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech pathologists, or audiologists.
  3. An individualized care plan that identifies support needs.
  4. Confirmation that skilled services are provided to the member.
  5. Skilled services that are provided by, or under the supervision of, medical personnel as described above.
  6. Skilled nursing services that are needed and provided seven days a week or skilled rehabilitation services that are needed and provided at least five days a week.
"Specialized respite" means respite provided on a staff-to-consumer ratio of one to one or higher to individuals with specialized medical needs requiring the care, monitoring or supervision of a licensed registered nurse or licensed practical nurse.
"Substantial gainful activity" means productive activities which add to the economic wealth, or produce goods or services to which the public attaches a monetary value.
"Third-party payments" means payments from an attorney, individual, institution, corporation, or public or private agency which is liable to pay part or all of the medical costs incurred as a result of injury, disease or disability by or on behalf of an applicant or a past or present recipient of medical assistance.
"Usual caregiver" means a person or persons who reside with the consumer and are available on a 24-hour-per-day basis to assume responsibility for the care of the consumer.
Related ARC(s): 0306C, 0757C, 2361C, 3874C441—83.2(249A)  Eligibility.  To be eligible for health and disability waiver services, a person must meet certain eligibility criteria and be determined to need a service(s) allowable under the program.  83.2(1)    Eligibility criteria.    a.  The person must be under the age of 65 and blind or disabled as determined by the receipt of social security disability benefits or by a disability determination made through the department. Disability determinations are made according to supplemental security income guidelines under Title XVI of the Social Security Act.  b.  Rescinded IAB 1/2/19, effective 2/6/19.  c.  Persons shall meet the eligibility requirements of the supplemental security income program except for the following:  (1)  The person is under 18 years of age, unmarried and not the head of a household and is ineligible for supplemental security income because of the deeming of the parent’s(s’) income.  (2)  The person is married and is ineligible for supplemental security income because of the deeming of the spouse’s income or resources.  (3)  The person is ineligible for supplemental security income due to excess income and the person’s income does not exceed 300 percent of the maximum monthly payment for one person under supplemental security income.  (4)  The person is under 18 years of age and is ineligible for supplemental security income because of excess resources.  d.  The person must be certified as being in need of nursing facility or skilled nursing facility level of care or as being in need of care in an intermediate care facility for persons with an intellectual disability, based on information submitted on a completed information submission tool Form 470-4694 for children aged 3 and under, the interRAI - Pediatric Home Care (PEDS-HC) for those aged 4 to 20, or the interRAI - Home Care (HC) for those aged 21 to 64 and other supporting documentation as relevant. Form 470-4694, the interRAI - Pediatric Home Care (PEDS-HC) and the interRAI - Home Care (HC) are available upon request from the IME medical services unit. Copies of the completed information submission tool for an individual are available to that individual from the individual’s case manager or managed care organization.  (1)  The member’s designated case manager shall use the completed assessment to develop the comprehensive service plan as specified in 441—paragraph 90.4(1)“b.”  (2)  The IME medical services unit shall be responsible for the initial determination of the member’s level of care certification. The IME medical services unit or the member’s managed care organization shall be responsible for annual redetermination of the level of care.  (3)  Health and disability waiver services will not be provided when the person is an inpatient in a medical institution.  (4)  The managed care organization must submit documentation to the IME medical services unit for all reassessments, performed at least annually, which indicate a change in the member’s level of care. The IME medical services unit shall make a final determination for any reassessments which indicate a change in the level of care. If the level of care reassessment indicates no change in level of care, the member is approved to continue at the already established level of care.  e.  To be eligible for interim medical monitoring and treatment services the consumer must be:  (1)  Under the age of 21;  (2)  Currently receiving home health agency services under rule 441—78.9(249A) and require medical assessment, medical monitoring, and regular medical intervention or intervention in a medical emergency during those services. (The home health aide services for which the consumer is eligible must be maximized before the consumer accesses interim medical monitoring and treatment.);  (3)  Residing in the consumer’s family home or foster family home; and  (4)  In need of interim medical monitoring and treatment as ordered by a physician or a physician assistant.  f.  The person must meet income and resource guidelines for Medicaid as if in a medical institution pursuant to 441—Chapter 75. When a husband and wife who are living together both apply for the waiver, income and resource guidelines as specified at 441—paragraphs 75.5(2)“b” and 75.5(4)“c” shall be applied.  g.  The person must have service needs that can be met by this waiver program. At a minimum a person must receive one billable unit of service under the waiver per calendar quarter.  h.  To be eligible for the consumer choices option as set forth in 441—subrule 78.34(13), a person cannot be living in a residential care facility.  83.2(2)    Need for services.    a.  The member shall have a service plan approved by the department which is developed by the designated case manager. This service plan must be completed prior to services provision and annually thereafter.The designated case manager shall establish the interdisciplinary team for the member and, with the team, identify the member’s need for service based on the member’s needs and desires as well as the availability and appropriateness of services, using the following criteria:  (1)  This service plan shall be based, in part, on information in the completed information submission tool listed in paragraph 83.2(1)“d” and other supporting documentation as relevant. The designated case manager shall have a face-to-face visit with the member at least quarterly.  (2)  Service plans for persons aged 20 or under shall be developed to reflect use of all appropriate nonwaiver Medicaid services and so as not to replace or duplicate those services. The designated case manager shall list all nonwaiver Medicaid services in the service plan.  (3)  Service plans for persons aged 20 or under that include home health or nursing services shall not be approved until a home health agency has made a request to cover the member’s service needs through nonwaiver Medicaid services.  b.  Except as provided below, the total monthly cost of the health and disability waiver services, excluding the cost of home and vehicle modification services, shall not exceed the established aggregate monthly cost for level of care as follows:Skilled level of careNursing level of careICF/ID$2,792.65$959.50$3,742.93For members enrolled in the health and disability waiver in accordance with subrule 83.2(1), when a member turns 21 years of age, the average monthly cost of services received through 441—subrule 78.9(10) (state plan private duty nursing or personal care services for persons aged 20 and under) shall be used to increase the monthly waiver budget in accordance with the following:  (1)  The member must request the revised waiver budget through the member’s case manager no earlier than two months before, and no later than six months after, the member’s twenty-first birthday. A renewal request must be received annually no earlier than two months before, and no later than six months after, each subsequent birthday.   (2)  The member’s waiver budget shall be increased by the average monthly cost of state plan private duty nursing or personal care services for the member that was billed to and paid by Iowa Medicaid or an Iowa Medicaid-contracted managed care organization during the year in which the member is 20 years of age.   (3)  Once the request is received by the department, the department shall determine the average monthly cost pursuant to the claims data available at the time of the request. No subsequent claims data shall be considered.   (4)  The revised waiver budget reflecting the average cost of state plan private duty nursing or personal care services shall become effective on the later of the first day of the month of the member’s twenty-first birthday or the first day of the month of the completed review.   (5)  The revised waiver budget shall extend up to the first of the month following the member’s twenty-fifth birthday and shall remain at the initially authorized amount for the member while aged 21 through 24.   c.  Interim medical monitoring and treatment services must be needed because all usual caregivers are unavailable to provide care due to one of the following circumstances:  (1)  Employment. Interim medical monitoring and treatment services are to be received only during hours of employment.  (2)  Academic or vocational training. Interim medical monitoring and treatment services provided while a usual caregiver participates in postsecondary education or vocational training shall be limited to 24 periods of no more than 30 days each per caregiver as documented by the service worker or targeted case manager. Time spent in high school completion, adult basic education, GED, or English as a second language does not count toward the limit.  (3)  Absence from the home due to hospitalization, treatment for physical or mental illness, or death of the usual caregiver. Interim medical monitoring and treatment services under this subparagraph are limited to a maximum of 30 days.  (4)  Search for employment.
  1. Care during job search shall be limited to only those hours the usual caregiver is actually looking for employment, including travel time.
  2. Interim medical monitoring and treatment services may be provided under this paragraph only during the execution of one job search plan of up to 30 working days in a 12-month period, approved by the department service worker or targeted case manager pursuant to 441—subparagraph 170.2(2)“b”(5).
  3. Documentation of job search contacts shall be furnished to the department service worker or targeted case manager.
Related ARC(s): 0306C, 0548C, 0665C, 0757C, 0842C, 1056C, 1445C, 2361C, 2848C, 2936C, 3184C, 4209C, 4897C441—83.3(249A)  Application.    83.3(1)    Application for HCBS health and disability waiver services.  The application process as specified in rules 441—76.1(249A) to 441—76.6(249A) shall be followed.  83.3(2)    Application and services program limit.  The number of persons who may be approved for the HCBS health and disability waiver shall be subject to the number of members to be served as set forth in the federally approved HCBS health and disability waiver. The number of members to be served is set forth at the time of each five-year renewal of the waiver or in amendments to the waiver approved by the Centers for Medicare and Medicaid Services (CMS). When the number of applicants exceeds the number of members specified in the approved waiver, the applicant’s name shall be placed on a waiting list maintained by the bureau of long-term care.  a.  The county department office shall enter all waiver applications into the individualized services information system (ISIS) to determine if a payment slot is available.  (1)  For applicants not currently receiving Medicaid, the county department office shall make the entry by the end of the fifth working day after receipt of a completed Form 470-2927 or 470-2927(S), Health Services Application, or within five working days after receipt of disability determination, whichever is later.  (2)  For current Medicaid members, the county department office shall make the entry by the end of the fifth working day after receipt of a written request signed and dated by the applicant.  (3)  A payment slot shall be assigned to the applicant upon confirmation of an available slot.  (4)  Once a payment slot is assigned, the county department office shall give written notice to the applicant. The department shall hold the payment slot for the applicant as long as reasonable efforts are being made to arrange services and the applicant has not been determined to be ineligible for the program. If services have not been initiated and reasonable efforts are no longer being made to arrange services, the slot shall revert for use by the next person on the waiting list, if applicable. The applicant originally assigned the slot must reapply for a new slot.  b.  If no payment slot is available, the department shall enter persons on a waiting list according to the following:  (1)  Applicants not currently eligible for Medicaid shall be entered on the waiting list on the basis of the date a completed Form 470-2927 or 470-2927(S), Health Services Application, is received by the department or upon receipt of disability determination, whichever is later.  (2)  Applicants currently eligible for Medicaid shall be added to the waiting list on the basis of the date a request as specified in 83.3(2)“a”(2) is received by the department.  (3)  In the event that more than one application is received at one time, persons shall be entered on the waiting list on the basis of the month of birth, January being month one and the lowest number.  (4)  Applicants who do not fall within the available slots shall have their application rejected, and their names shall be maintained on the waiting list. They shall be contacted to reapply as slots become available based on their order on the waiting list so that the number of approved persons on the program is maintained. The bureau of long-term care shall contact the county department office when a slot becomes available.  (5)  Once a payment slot is assigned, the county department office shall give written notice to the person within five working days. The department shall hold the payment slot for 30 days for the person to file a new application. If an application has not been filed within 30 days, the slot shall revert for use by the next person on the waiting list, if applicable. The person originally assigned the slot must reapply for a new slot.  c.  The county department office shall notify the bureau of long-term care within five working days of the receipt of an application and of any action on or withdrawal of an application.  83.3(3)    Approval of application.    a.  Applications for the HCBS health and disability waiver program shall be processed in 30 days unless one or more of the following conditions exist:  (1)  An application has been filed and is pending for federal supplemental security income benefits.  (2)  The application is pending because the department has not received information which is beyond the control of the client or the department.  (3)  The application is pending due to the disability determination process performed through the department.  (4)  The application is pending because a level of care determination has not been made although the required assessment has been submitted to the IME medical services unit.  (5)  The application is pending because the required assessment has not been completed. When a determination is not completed 90 days from the date of application due to the lack of a completed assessment, the application shall be denied.  b.  Decisions shall be mailed or given to the applicant on the date when income maintenance eligibility and level of care determinations are completed.  c.  An applicant must be given the choice between HCBS health and disability waiver services and institutional care. The applicant, parent, guardian, or attorney in fact under a durable power of attorney for health care shall sign the assessment and indicate that the applicant has elected home- and community-based services.  d.  Waiver services provided prior to approval of eligibility for the waiver cannot be paid.  e.  A member may be enrolled in only one waiver program at a time. Costs for waiver services are not reimbursable while the member is in a medical institution (hospital or nursing facility) or residential facility. Services may not be simultaneously reimbursed for the same time period as Medicaid or other Medicaid waiver services.  83.3(4)    Effective date of eligibility.    a.  Deeming of parental or spousal income and resources ceases and eligibility shall be effective on the date the income and resource eligibility and level of care determinations are completed but shall not be earlier than the first of the month following the date of application.  b.  The effective date of eligibility for the health and disability waiver for persons who qualify for Medicaid due to eligibility for the waiver services and to whom paragraphs 83.3(4)“a” and “c” do not apply is the date on which the income eligibility and level of care determinations are completed.  c.  Eligibility for persons covered under subparagraph 83.2(1)“c”(3) shall exist on the date the income and resource eligibility and level of care determinations are completed but shall not be earlier than the first of the month following the date of application.  d.  Eligibility continues until the member has been in a medical institution for 120 consecutive days for other than respite care. Members who are inpatients in a medical institution for 120 or more consecutive days for other than respite care shall be terminated from health and disability waiver services and reviewed for eligibility for other Medicaid coverage groups. The member will be notified of that decision through Form 470-0602, Notice of Decision. If the member returns home before the effective date of the notice of decision and the member’s condition has not substantially changed, the denial may be rescinded and eligibility may continue.  83.3(5)    Attribution of resources.  For the purposes of attributing resources as provided in rule 441—75.5(249A), the date on which the waiver applicant met the level of care criteria in a medical institution as established by the peer review organization shall be used as the date of entry to the medical institution. Only one attribution of resources shall be completed per person. Attributions completed for prior institutionalizations shall be applied to the waiver application.Related ARC(s): 0306C, 0757C, 2361C, 3184C, 3234C441—83.4(249A)  Financial participation.  Persons must contribute their predetermined financial participation to the cost of health and disability waiver services or other Medicaid services, as applicable.  83.4(1)    Maintenance needs of the individual.  The maintenance needs of the individual shall be computed by deducting an amount which is 300 percent of the maximum monthly payment for one person under supplemental security income (SSI) from the client’s total income.  83.4(2)    Limitation on payment.  If the sum of the third-party payment and client participation equals or exceeds the reimbursement established by the service worker or targeted case manager for health and disability waiver services, Medicaid shall make no payments to health and disability waiver service providers. However, Medicaid shall make payments to other medical vendors, as applicable.  83.4(3)    Maintenance needs of spouse and other dependents.  Rescinded IAB 4/9/97, effective 6/1/97.Related ARC(s): 0757C441—83.5(249A)  Redetermination.  A complete redetermination of eligibility for the health and disability waiver shall be completed at least once every 12 months or when there is significant change in the person’s situation or condition.A redetermination of continuing eligibility factors shall be made in accordance with rules 441—76.7(249A) and 441—83.2(249A). A redetermination shall include verification of the existence of a current service plan meeting the requirements listed in rule 441—83.7(249A).  83.5(1)  The IME medical services unit or the member’s managed care organization shall be responsible for annual redetermination of the level of care.  83.5(2)  The managed care organization must submit documentation to the IME medical services unit for all reassessments, performed at least annually, which indicate a change in the member’s level of care. The IME medical services unit shall make a final determination for any reassessments which indicate a change in the level of care. If the level of care reassessment indicates no change in level of care, the member is approved to continue at the already established level of care.Related ARC(s): 0757C, 2361C441—83.6(249A)  Allowable services.  Services allowable under the health and disability waiver are homemaker, home health, adult day care, respite care, nursing, counseling, consumer-directed attendant care, interim medical monitoring and treatment, home and vehicle modification, personal emergency response system, home-delivered meals, nutritional counseling, financial management, independent support brokerage, self-directed personal care, self-directed community supports and employment, and individual-directed goods and services as set forth in rule 441—78.34(249A).Related ARC(s): 0757C441—83.7(249A)  Service plan.  A service plan shall be prepared for health and disability waiver members in accordance with 441—paragraph 90.4(1)“b.” Service plans for both children and adults shall be completed every 12 months or when there is significant change in the person’s situation or condition.  83.7(1)  The service plan shall include the frequency of the health and disability waiver services and the types of providers who will deliver the services.  83.7(2)  The service plan shall indicate whether the member has elected the consumer choices option. If the member has elected the consumer choices option, the service plan shall identify:  a.  The independent support broker selected by the member; and  b.  The financial management service selected by the member.  83.7(3)  The service plan shall also list all nonwaiver Medicaid services.  83.7(4)  The service plan shall identify a plan for emergencies and the supports available to the member in an emergency.Related ARC(s): 0757C, 2361C, 4897C441—83.8(249A)  Adverse service actions.    83.8(1)  Denial. An application for services shall be denied when it is determined by the department that:  a.  The client is not eligible for or in need of services.  b.  Needed services are not available or received from qualified providers.  c.  Service needs exceed the aggregate monthly costs established in 83.2(2)“b,” or are not met by the services provided.  d.  Needed services are not available or received from qualifying providers.  83.8(2)  Termination. A particular service may be terminated when the department determines that:  a.  The provisions of 441—paragraph 130.5(2)“a,” “b,” “c,” “g,” or “h” apply.  b.  The costs of the health and disability waiver service for the person exceed the aggregate monthly costs established in 83.2(2)“b.”  c.  The member receives care in a hospital, nursing facility, or intermediate care facility for persons with an intellectual disability for 120 days in any one stay for purposes other than respite care.  d.  The member receives health and disability waiver services and the physical or mental condition of the member requires more care than can be provided in the member’s own home as determined by the designated case manager.  e.  Service providers are not available.  83.8(3)  Reduction of services shall apply as in 441—subrule 130.5(3), paragraphs “a” and “b.”Related ARC(s): 0306C, 0757C, 3184C, 3234C441—83.9(249A)  Appeal rights.  Notice of adverse action and right to appeal shall be given in accordance with 441—Chapter 7, rule 441—16.3(17A) and rule 441—130.5(234). The applicant or recipient is entitled to have a review of the level of care determination by the IME medical services unit by sending a letter requesting a review to the IME medical services unit. If dissatisfied with that decision, the applicant or recipient may file an appeal with the department.Related ARC(s): 4973C441—83.10(249A)  County reimbursement.  Rescinded IAB 4/9/97, effective 6/1/97.441—83.11(249A)  Conversion to the X-PERT system.  Rescinded IAB 8/7/02, effective 10/1/02.These rules are intended to implement Iowa Code sections 249A.3 and 249A.4.441—83.12    Reserved.441—83.13    Reserved.441—83.14    Reserved.441—83.15    Reserved.441—83.16    Reserved.441—83.17    Reserved.441—83.18    Reserved.441—83.19    Reserved.441—83.20    Reserved.DIVISION II—HCBS ELDERLY WAIVER SERVICES441—83.21(249A)  Definitions.  
"Attorney in fact under a durable power of attorney for health care" means an individual who is designated by a durable power of attorney for health care, pursuant to Iowa Code chapter 144B, as an agent to make health care decisions on behalf of an individual and who has consented to act in that capacity.
"Basic individual respite" means respite provided on a staff-to-consumer ratio of one to one or higher to individuals without specialized needs requiring the care of a licensed registered nurse or licensed practical nurse.
"Client participation" means the amount of the recipient income that the person must contribute to the cost of elderly waiver services exclusive of medical vendor payments before Medicaid will participate.
"Group respite" is respite provided on a staff-to-consumer ratio of less than one to one.
"Guardian" means a guardian appointed in probate court.
"Interdisciplinary team" means a collection of persons with varied professional backgrounds who develop one plan of care to meet a client’s need for services.
"Managed care organization" means an entity that (1) is under contract with the department to provide services to Medicaid recipients and (2) meets the definition of “health maintenance organization” as defined in Iowa Code section 514B.1.
"Medical institution" means a nursing facility which has been approved as a Medicaid vendor.
"Nursing facility level of care" means that the following conditions are met:
  1. The presence of a physical or mental impairment which restricts the member’s daily ability to perform the essential activities of daily living, bathing, dressing, and personal hygiene, and impedes the member’s capacity to live independently.
  2. The member’s physical or mental impairment is such that self-execution of required nursing care is improbable or impossible.
"Service plan" means a person-centered, outcome-based plan of services which is written by the member’s case manager with input and direction from the member and which addresses all relevant services and supports being provided. The service plan is developed by the interdisciplinary team, which includes the member and, if appropriate, the member’s legal representative, member’s family, service providers, and others directly involved with the member.
"Skilled nursing facility level of care" means that the following conditions are met:
  1. The member’s medical condition requires skilled nursing services or skilled rehabilitation services as defined in 42 CFR 409.31(a), 409.32, and 409.34.
  2. Services are provided in accordance with the general provisions for all Medicaid providers and services as described in rule 441—79.9(249A).
  3. Documentation submitted for review indicates that the member has:
  1. A physician order for all skilled services.
  2. Services that require the skills of medical personnel, including registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech pathologists, or audiologists.
  3. An individualized care plan that identifies support needs.
  4. Confirmation that skilled services are provided to the member.
  5. Skilled services that are provided by, or under the supervision of, medical personnel as described above.
  6. Skilled nursing services that are needed and provided seven days a week or skilled rehabilitation services that are needed and provided at least five days a week.
"Specialized respite" means respite provided on a staff-to-consumer ratio of one to one or higher to individuals with specialized medical needs requiring the care, monitoring or supervision of a licensed registered nurse or licensed practical nurse.
"Third-party payments" means payments from an individual, institution, corporation, or public or private agency which is liable to pay part or all of the medical costs incurred as a result of injury, disease or disability by or on behalf of an applicant or a past or present recipient of medical assistance.
"Usual caregiver" means a person or persons who reside with the consumer and are available on a 24-hour-per-day basis to assume responsibility for the care of the consumer.
Related ARC(s): 2361C, 3874C441—83.22(249A)  Eligibility.  To be eligible for elderly waiver services a person must meet certain eligibility criteria and be determined to need a service(s) allowable under the program.  83.22(1)    Eligibility criteria.  All of the following criteria must be met. The person must be:  a.  Sixty-five years of age or older.  b.  A resident of the state of Iowa.  c.  Eligible for Medicaid as if in a medical institution pursuant to 441—Chapter 75. When a husband and wife who are living together both apply for the waiver, income and resource guidelines as specified at 441—paragraphs 75.5(2)“b” and 75.5(4)“c” shall be applied.  d.  Certified as being in need of the intermediate or skilled level of care based, in part, on information submitted on the interRAI - Home Care (HC). The interRAI - Home Care (HC) is available on request from IME medical services unit and other supporting documentation as relevant. Copies of the completed interRAI - Home Care (HC) for an individual are available to that individual from the individual’s case manager or managed care organization.  (1)  The assessment shall be completed when the person applies for waiver services, upon request to report a significant change in the person’s condition, and annually for reassessment of the person’s level of care. The IME medical services unit shall be responsible for determination of the initial level of care.  (2)  The IME medical services unit or the member’s managed care organization shall be responsible for annual redetermination of the level of care.  (3)  Elderly waiver services will not be provided when the person is an inpatient in a medical institution.  (4)  The managed care organization must submit documentation to the IME medical services unit for all reassessments, performed at least annually, which indicate a change in the member’s level of care. The IME medical services unit shall make a final determination for any reassessments which indicate a change in the level of care. If the level of care reassessment indicates no change in level of care, the member is approved to continue at the already established level of care.  e.  Determined to need services as described in subrule 83.22(2).  f.  Rescinded IAB 10/11/06, effective 10/1/06.  g.  For the consumer choices option as set forth in rule 441—subrule 78.37(16), residing in a living arrangement other than a residential care facility.  83.22(2)    Need for services, service plan, and cost.    a.    Case management.  Consumers under the elderly waiver shall receive case management services from a provider qualified pursuant to rule 441—77.29(249A). Case management services shall be provided as set forth in rules 441—90.4(249A) through 441—90.7(249A).  b.    Interdisciplinary team.  The case manager shall establish an interdisciplinary team for the consumer.  (1)  Composition. The interdisciplinary team shall include the case manager and the consumer and, if appropriate, the consumer’s legal representative, family, service providers, and others directly involved in the consumer’s care.  (2)  Role. The team shall identify:
  1. The consumer’s need for services based on the consumer’s needs and desires.
  2. Available and appropriate services to meet the consumer’s needs.
  3. Health and safety issues for the consumer that indicate the need for an emergency plan, based on a risk assessment conducted before the team meeting.
  4. Emergency backup support and a crisis response system to address problems or issues arising when support services are interrupted or delayed or when the consumer’s needs change.
  c.    Service plan.  An applicant for elderly waiver services shall have a service plan developed by a qualified provider of case management services under the elderly waiver.  (1)  Services included in the service plan shall be appropriate to the problems and specific needs or disabilities of the consumer.  (2)  Services must be the least costly available to meet the service needs of the member. The total monthly cost of the elderly waiver services exclusive of case management services shall not exceed the established monthly cost of the level of care. Aggregate monthly costs, excluding the cost of case management and home and vehicle modifications, are limited as follows:Skilled level of careNursing level of care $2,792.65 $1,365.78  (3)  The service plan must be completed before services are provided.  (4)  The service plan must be reviewed at least annually and when there is any significant change in the consumer’s needs.  d.    Content of service plan.  The service plan shall include the following information based on the consumer’s current assessment and service needs:  (1)  Observable or measurable individual goals.  (2)  Interventions and supports needed to meet those goals.  (3)  Incremental action steps, as appropriate.  (4)  The names of staff, people, businesses, or organizations responsible for carrying out the interventions or supports.  (5)  The desired individual outcomes.  (6)  The identified activities to encourage the consumer to make choices, to experience a sense of achievement, and to modify or continue participation in the service plan.  (7)  Description of any restrictions on the consumer’s rights, including the need for the restriction and a plan to restore the rights. For this purpose, rights include maintenance of personal funds and self-administration of medications.  (8)  A list of all Medicaid and non-Medicaid services that the consumer received at the time of waiver program enrollment that includes:
  1. The name of the service provider responsible for providing the service.
  2. The funding source for the service.
  3. The amount of service that the consumer is to receive.
  (9)  Indication of whether the consumer has elected the consumer choice option and, if so, the independent support broker and the financial management service that the consumer has selected.  (10)  The determination that the services authorized in the service plan are the least costly.  (11)  A plan for emergencies that identifies the supports available to the consumer in situations for which no approved service plan exists and which, if not addressed, may result in injury or harm to the consumer or other persons or in significant amounts of property damage. Emergency plans shall include:
  1. The consumer’s risk assessment and the health and safety issues identified by the consumer’s interdisciplinary team.
  2. The emergency backup support and crisis response system identified by the interdisciplinary team.
  3. Emergency, backup staff designated by providers for applicable services.
  83.22(3)    Providers—standards.  Rescinded IAB 10/11/06, effective 10/1/06.
Related ARC(s): 7957B, 0191C, 0306C, 0359C, 0548C, 0665C, 0842C, 1056C, 1445C, 2361C, 2848C, 2936C, 3184C, 4897C441—83.23(249A)  Application.    83.23(1)    Application for HCBS elderly waiver.  The application process as specified in rules 441—76.1(249A) to 441—76.6(249A) shall be followed.  83.23(2)    Application for services.  Rescinded IAB 12/6/95, effective 2/1/96.  83.23(3)    Approval of application.    a.  Applications for the elderly waiver program shall be processed in 30 days unless the worker can document difficulty in locating and arranging services or circumstances beyond the worker’s control. In these cases a decision shall be made as soon as possible.  b.  Decisions shall be mailed or given to the applicant on the date when both service and income maintenance eligibility determinations are completed.  c.  An applicant must be given the choice between elderly waiver services and institutional care. The applicant, guardian, or attorney in fact under a durable power of attorney for health care shall sign the information submission tool specified in 83.22(1)“d,” indicating that the applicant has elected waiver services.  d.  Waiver services provided prior to approval of eligibility for the waiver cannot be paid.  83.23(4)    Effective date of eligibility.    a.  The effective date of eligibility is the date on which the income eligibility and level of care determinations are completed.  b.  Eligibility for persons whose income exceeds supplemental security income guidelines shall not exist until the persons require care in a medical institution for a period of 30 consecutive days and shall be effective no earlier than the first day of the month in which the 30-day period begins.  c.  Eligibility continues until the consumer has been in a medical institution for 120 consecutive days for other than respite care or fails to meet eligibility criteria listed in rule 441—83.22(249A). Consumers who are inpatients in a medical institution for 120 or more consecutive days for other than respite care shall be terminated from elderly waiver services and reviewed for eligibility for other Medicaid coverage groups. The consumer will be notified of that decision through Form 470-0602, Notice of Decision. If the consumer returns home before the effective date of the notice of decision and the consumer’s condition has not substantially changed, the denial may be rescinded and eligibility may continue.  83.23(5)    Attribution of resources.  For the purposes of attributing resources as provided in rule 441—75.5(249A), the date on which the waiver applicant met the level of care criteria in a medical institution as established by the peer review organization shall be used as the date of entry to the medical institution. Only one attribution of resources shall be completed per person. Attributions completed for prior institutionalizations shall be applied to the waiver application.Related ARC(s): 0306C, 2361C, 3184C, 3234C441—83.24(249A)  Client participation.  Persons must contribute their predetermined client participation to the cost of elderly waiver services.  83.24(1)    Computation of client participation.  Client participation shall be computed by deducting an amount for the maintenance needs of the individual which is 300 percent of the maximum SSI grant for an individual from the client’s total income.  83.24(2)    Limitation on payment.  If the sum of the third-party payment and client participation equals or exceeds the reimbursement established by the service worker, Medicaid will make no payments for elderly waiver service providers. However, Medicaid will make payments to other medical vendors.441—83.25(249A)  Redetermination.  A complete redetermination of eligibility for elderly waiver services shall be done at least once every 12 months.A redetermination of continuing eligibility factors shall be made when a change in circumstances occurs that affects eligibility in accordance with rule 441—83.22(249A). A redetermination shall contain the components listed in rule 441—83.27(249A).  83.25(1)  The IME medical services unit or the member’s managed care organization shall be responsible for annual redetermination of the level of care.  83.25(2)  The managed care organization must submit documentation to the IME medical services unit for all reassessments, performed at least annually, which indicate a change in the member’s level of care. The IME medical services unit shall make a final determination for any reassessments which indicate a change in the level of care. If the level of care reassessment indicates no change in level of care, the member is approved to continue at the already established level of care.Related ARC(s): 2361C441—83.26(249A)  Allowable services.  Services allowable under the elderly waiver are case management, adult day care, emergency response system, homemaker, home health aide, nursing, respite care, chore, home-delivered meals, home and vehicle modification, mental health outreach, transportation, nutritional counseling, assistive devices, senior companions, consumer-directed attendant care, financial management, independent support brokerage, self-directed personal care, self-directed community supports and employment, and individual-directed goods and services as set forth in rule 441—78.37(249A).441—83.27(249A)  Service plan.  The service plan shall be completed jointly by the consumer, the elderly waiver case manager, and any other person identified by the consumer.  83.27(1)  The service plan shall indicate whether the consumer has elected the consumer choices option. If the consumer has elected the consumer choices option, the service plan shall identify:  a.  The independent support broker selected by the consumer; and  b.  The financial management service selected by the consumer.  83.27(2)  The service plan shall identify a plan for emergencies and the supports available to the consumer in an emergency.441—83.28(249A)  Adverse service actions.    83.28(1)    Denial.  An application for services shall be denied when it is determined by the department that:  a.  The client is not eligible for or in need of services.  b.  Except for respite care, the elderly waiver services are not needed on a regular basis.  c.  Service needs exceed the aggregate monthly costs established in 83.22(2)“b,” or are not met by services provided.  d.  Needed services are not available or received from qualifying providers.  e.  Rescinded IAB 3/2/94, effective 3/1/94.  83.28(2)    Termination.  A particular service may be terminated when the department determines that:  a.  The provisions of 441—subrule 130.5(2), paragraph “a,” “b,” “c,” “d,” “g,” or “h” apply.  b.  The costs of the elderly waiver services for the person exceed the aggregate monthly costs established in 83.22(2)“b.”  c.  The client receives care in a hospital or nursing facility for 120 days in any one stay for purposes other than respite care.  d.  The client receives elderly waiver services and the physical or mental condition of the client requires more care than can be provided in the client’s own home as determined by the case manager and the interdisciplinary team.  e.  Service providers are not available.  83.28(3)  Reduction of services shall apply as in 441—subrule 130.5(3), paragraphs “a” and “b.”Related ARC(s): 3234C441—83.29(249A)  Appeal rights.  Notice of adverse action and right to appeal shall be given in accordance with 441—Chapter 7, rule 441—16.3(17A) and rule 441—130.5(234).Related ARC(s): 0306C, 4973C441—83.30(249A)  Enhanced services.  When a household has one person receiving service in accordance with rules set forth in 441—Chapter 24 and another receiving elderly waiver services, the persons providing case management shall cooperate to make the best plan for both clients. When a person is eligible for services as set forth in 441—Chapter 24 and eligible for services under the elderly waiver, the person’s primary diagnosis will determine which services shall be used.441—83.31(249A)  Conversion to the X-PERT system.  Rescinded IAB 8/7/02, effective 10/1/02.These rules are intended to implement Iowa Code sections 249A.3 and 249A.4.441—83.32    Reserved.441—83.33    Reserved.441—83.34    Reserved.441—83.35    Reserved.441—83.36    Reserved.441—83.37    Reserved.441—83.38    Reserved.441—83.39    Reserved.441—83.40    Reserved.DIVISION III—HCBS AIDS/HIV WAIVER SERVICES441—83.41(249A)  Definitions.  
"AIDS" means a medical diagnosis of acquired immunodeficiency syndrome based on the Centers for Disease Control “Revision of the CDC Surveillance Case Definition for Acquired Immunodeficiency Syndrome,” August 14, 1987, Vol. 36, No.1S issue of “Morbidity and Mortality Weekly Report.”
"Attorney in fact under a durable power of attorney for health care" means an individual who is designated by a durable power of attorney for health care, pursuant to Iowa Code chapter 144B, as an agent to make health care decisions on behalf of an individual and who has consented to act in that capacity.
"Basic individual respite" means respite provided on a staff-to-consumer ratio of one to one or higher to individuals without specialized needs requiring the care of a licensed registered nurse or licensed practical nurse.
"Client participation" means the amount of the recipient’s income that the person must contribute to the cost of AIDS/HIV waiver services exclusive of medical vendor payments before Medicaid will participate.
"Deeming" means the specified amount of parental or spousal income and resources considered in determining eligibility for a child or spouse according to current supplemental security income guidelines.
"Financial participation" means client participation and medical payments from a third party including veterans’ aid and attendance.
"Group respite" is respite provided on a staff-to-consumer ratio of less than one to one.
"Guardian" means a guardian appointed in probate court.
"HIV" means a medical diagnosis of human immunodeficiency virus infection based on a positive HIV-related test.
"Managed care organization" means an entity that (1) is under contract with the department to provide services to Medicaid recipients and (2) meets the definition of “health maintenance organization” as defined in Iowa Code section 514B.1.
"Medical institution" means a nursing facility or hospital which has been approved as a Medicaid vendor.
"Nursing facility level of care" means that the following conditions are met:
  1. The presence of a physical or mental impairment which restricts the member’s daily ability to perform the essential activities of daily living, bathing, dressing, and personal hygiene, and impedes the member’s capacity to live independently.
  2. The member’s physical or mental impairment is such that self-execution of required nursing care is improbable or impossible.
"Service plan" means a person-centered, outcome-based plan of services which is written by the member’s case manager with input and direction from the member and which addresses all relevant services and supports being provided. The service plan is developed by the interdisciplinary team, which includes the member and, if appropriate, the member’s legal representative, member’s family, service providers, and others directly involved with the member.
"Skilled nursing facility level of care" means that the following conditions are met:
  1. The member’s medical condition requires skilled nursing services or skilled rehabilitation services as defined in 42 CFR 409.31(a), 409.32, and 409.34.
  2. Services are provided in accordance with the general provisions for all Medicaid providers and services as described in rule 441—79.9(249A).
  3. Documentation submitted for review indicates that the member has:
  1. A physician order for all skilled services.
  2. Services that require the skills of medical personnel, including registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech pathologists, or audiologists.
  3. An individualized care plan that identifies support needs.
  4. Confirmation that skilled services are provided to the member.
  5. Skilled services that are provided by, or under the supervision of, medical personnel as described above.
  6. Skilled nursing services that are needed and provided seven days a week or skilled rehabilitation services that are needed and provided at least five days a week.
"Specialized respite" means respite provided on a staff-to-consumer ratio of one to one or higher to individuals with specialized medical needs requiring the care, monitoring or supervision of a licensed registered nurse or licensed practical nurse.
"Third-party payments" means payments from an attorney, individual, institution, corporation, or public or private agency which is liable to pay part or all of the medical costs incurred as a result of injury, disease or disability by or on behalf of an applicant or a past or present recipient of medical assistance.
"Usual caregiver" means a person or persons who reside with the consumer and are available on a 24-hour-per-day basis to assume responsibility for the care of the consumer.
Related ARC(s): 2361C, 3874C441—83.42(249A)  Eligibility.  To be eligible for AIDS/HIV waiver services a person must meet certain eligibility criteria and be determined to need a service(s) allowable under the program.  83.42(1)    Eligibility criteria.  All of the following criteria must be met. The person must:  a.  Be diagnosed by a physician as having AIDS or HIV infection.  b.  Be certified in need of the level of care that, but for the waiver, would otherwise be provided in a nursing facility or hospital based, in part, on information submitted on a completed Form 470-4694 for children aged 3 and under, the interRAI - Pediatric Home Care (PEDS-HC) for those aged 4 to 20, or the interRAI - Home Care (HC) for those aged 21 and over and other supporting documentation as relevant. Form 470-4694, the interRAI - Pediatric Home Care (PEDS-HC), and the interRAI - Home Care (HC) are available on request from the IME medical services unit. Copies of the completed information submission tool for an individual are available to that individual from the individual’s case manager or managed care organization.  (1)  The assessment as listed in 83.42(1)“b” shall be completed when the person applies for waiver services, upon request to report a significant change in the person’s condition, and annually for reassessment of the person’s level of care.  (2)  The IME medical services unit shall be responsible for approval of the certification of the level of care, and the IME medical services unit or a managed care organization will be responsible for annual redeterminations.  (3)  AIDS/HIV waiver services shall not be provided when the person is an inpatient in a medical institution.  c.  Be eligible for medical assistance under SSI, SSI-related, FMAP, or FMAP-related coverage groups; medically needy at hospital level of care; or a special income level (300 percent group); or become eligible through application of the institutional deeming rules.  d.  Require, and use at least quarterly, one service available under the waiver as determined through an evaluation of need described in subrule 83.42(2).  e.  Have service needs such that the costs of the waiver services are not likely to exceed the costs of care that would otherwise be provided in a medical institution.  f.  Have income which does not exceed 300 percent of the maximum monthly payment for one person under supplemental security income.  g.  For the consumer choices option as set forth in 441—subrule 78.38(9), not be living in a residential care facility.  83.42(2)    Need for services.    a.  The designated case manager shall review the assessment of the person’s need for waiver services and determine the availability and appropriateness of services. This review shall be based, in part, on information in the completed information submission tool designated in 83.42(1)“b” and other supporting documentation as relevant.   b.  The total monthly cost of the AIDS/HIV waiver services shall not exceed the established aggregate monthly cost for level of care. The monthly cost of AIDS/HIV waiver services cannot exceed the established limit of $1,876.80.Related ARC(s): 0306C, 0548C, 0665C, 0842C, 1056C, 2361C, 2848C, 2936C, 3184C441—83.43(249A)  Application.    83.43(1)    Application for HCBS AIDS/HIV waiver services.  The application process as specified in rules 441—76.1(249A) to 441—76.6(249A) shall be followed.  83.43(2)    Application for services.  Rescinded IAB 12/6/95, effective 2/1/96.  83.43(3)    Approval of application.    a.  Applications for the HCBS AIDS/HIV waiver program shall be processed in 30 days unless one or more of the following conditions exist:  (1)  The application is pending because the department has not received information, which is beyond the control of the client or the department.  (2)  The application is pending because a level of care determination has not been made although the completed assessment has been submitted to the IME medical services unit.  (3)  Rescinded IAB 3/7/01, effective 5/1/01.  b.  Decisions shall be mailed or given to the applicant on the date when income maintenance eligibility and level of care determinations and the consumer service plan are completed.  c.  An applicant must be given the choice between HCBS AIDS/HIV waiver services and institutional care. The applicant, parent, guardian, or attorney in fact under a durable power of attorney for health care shall sign the assessment and indicate that the applicant has elected home- and community-based services.  d.  Waiver services provided prior to approval of eligibility for the waiver cannot be paid.  83.43(4)    Effective date of eligibility.    a.  The effective date of eligibility for the AIDS/HIV waiver for persons who are already determined eligible for Medicaid is the date on which the income and resource eligibility and level of care determinations are completed.  b.  The effective date of eligibility for the AIDS/HIV waiver for persons who qualify for Medicaid due to eligibility for the waiver services and to whom 441—subrule 75.1(7) and rule 441—75.5(249A) do not apply is the date on which income and resource eligibility and level of care determinations are completed.  c.  Eligibility for the waiver continues until the recipient has been in a medical institution for 120 consecutive days for other than respite care or fails to meet eligibility criteria listed in rule 441—83.42(249A). Recipients who are inpatients in a medical institution for 120 or more consecutive days for other than respite care shall be reviewed for eligibility for other Medicaid coverage groups and terminated from AIDS/HIV waiver services if found eligible under another coverage group. The recipient will be notified of that decision through Form 470-0602, Notice of Decision. If the consumer returns home before the effective date of the notice of decision and the person’s condition has not substantially changed, the denial may be rescinded and eligibility may continue.  d.  The effective date of eligibility for the AIDS/HIV waiver for persons who qualify for Medicaid due to eligibility for the waiver services and to whom the eligibility factors set forth in 441—subrule 75.1(7) and, for married persons, in rule 441—75.5(249A) have been satisfied is the date on which the income eligibility and level of care determinations are completed but shall not be earlier than the first of the month following the date of application.  83.43(5)    Attribution of resources.  For the purposes of attributing resources as provided in rule 441—75.5(249A), the date on which the waiver applicant met the level of care criteria in a medical institution as established by the peer review organization shall be used as the date of entry to the medical institution. Only one attribution of resources shall be completed per person. Attributions completed for prior institutionalizations shall be applied to the waiver application.Related ARC(s): 0306C, 2361C, 3184C, 3234C441—83.44(249A)  Financial participation.  Persons must contribute their predetermined financial participation to the cost of AIDS/HIV waiver services or other Medicaid services, as applicable.  83.44(1)    Maintenance needs of the individual.  The maintenance needs of the individual shall be computed by deducting an amount which is 300 percent of the maximum monthly payment for one person under supplemental security income (SSI) from the client’s total income.  83.44(2)    Limitation on payment.  If the amount of the financial participation equals or exceeds the reimbursement established by the service worker for AIDS/HIV services, Medicaid will make no payments to AIDS/HIV waiver service providers. Medicaid will, however, make payments to other medical vendors.  83.44(3)    Maintenance needs of spouse and other dependents.  Rescinded IAB 4/9/97, effective 6/1/97.441—83.45(249A)  Redetermination.  A complete redetermination of eligibility for AIDS/HIV waiver services shall be completed at least once every 12 months or when there is significant change in the person’s situation or condition. A redetermination of continuing eligibility factors shall be made in accordance with rules 441—76.7(249A) and 441—83.42(249A). A redetermination shall include the components listed in rule 441—83.47(249A).  83.45(1)  The IME medical services unit or the member’s managed care organization shall be responsible for annual redetermination of the level of care.  83.45(2)  The managed care organization must submit documentation to the IME medical services unit for all reassessments, performed at least annually, which indicate a change in the member’s level of care. The IME medical services unit shall make a final determination for any reassessments which indicate a change in the level of care. If the level of care reassessment indicates no change in level of care, the member is approved to continue at the already established level of care.Related ARC(s): 2361C441—83.46(249A)  Allowable services.  Services allowable under the AIDS/HIV waiver are counseling, home health aide, homemaker, nursing care, respite care, home-delivered meals, adult day care, consumer-directed attendant care, financial management, independent support brokerage, self-directed personal care, self-directed community supports and employment, and individual-directed goods and services as set forth in rule 441—78.38(249A).441—83.47(249A)  Service plan.  A service plan shall be prepared for AIDS/HIV waiver consumers in accordance with rule 441—130.7(234) except that service plans for both children and adults shall be completed every 12 months or when there is significant change in the person’s situation or condition.  83.47(1)  The service plan shall include the frequency of the AIDS/HIV waiver services and the types of providers who will deliver the services.  83.47(2)  The service plan shall indicate whether the consumer has elected the consumer choices option. If the consumer has elected the consumer choices option, the service plan shall identify:  a.  The independent support broker selected by the consumer; and  b.  The financial management service selected by the consumer.  83.47(3)  Service plans for consumers aged 20 or under must be developed to reflect use of all appropriate nonwaiver Medicaid services so as not to replace or duplicate those services.  83.47(4)  The service plan shall identify a plan for emergencies and the supports available to the consumer in an emergency.441—83.48(249A)  Adverse service actions.    83.48(1)  Denial. An application for services shall be denied when it is determined by the department that:  a.  The client is not eligible for or in need of services.  b.  Except for respite care, the AIDS/HIV waiver services are not needed on a regular basis.  c.  Service needs exceed the aggregate monthly costs established in 83.42(2)“b” or cannot be met by the services provided under the waiver.  d.  Needed services are not available from qualified providers.  83.48(2)  Termination. Participation in the AIDS/HIV waiver program may be terminated when the department determines that:  a.  The provisions of 441—subrule 130.5(2), paragraph “a,” “b,” “c,” “d,” “g,” or “h” apply.  b.  The costs of the AIDS/HIV waiver services for the person exceed the aggregate monthly costs established in 83.42(2)“b.”  c.  The client receives care in a hospital or nursing facility for 120 days or more in any one stay for purposes other than respite care.  d.  The client receives AIDS/HIV waiver services and the physical or mental condition of the client requires more care than can be provided in the client’s own home as determined by the service worker.  e.  Service providers are not available.  83.48(3)  Reduction of services shall apply as in 441—subrule 130.5(3), paragraphs “a” and “b.”Related ARC(s): 3234C441—83.49(249A)  Appeal rights.  Notice of adverse action and right to appeal shall be given in accordance with 441—Chapter 7, rule 441—16.3(17A) and rule 441—130.5(234).Related ARC(s): 0306C, 4973C441—83.50(249A)  Conversion to the X-PERT system.  Rescinded IAB 8/7/02, effective 10/1/02.These rules are intended to implement Iowa Code section 249A.4.441—83.51    Reserved.441—83.52    Reserved.441—83.53    Reserved.441—83.54    Reserved.441—83.55    Reserved.441—83.56    Reserved.441—83.57    Reserved.441—83.58    Reserved.441—83.59    Reserved.DIVISION IV—HCBS INTELLECTUAL DISABILITY WAIVER SERVICES441—83.60(249A)  Definitions.  
"Adaptive" means age-appropriate skills related to taking care of one’s self and one’s ability to relate to others in daily living situations. These skills include limitations that occur in the areas of communication, self-care, home-living, social skills, community use, self-direction, safety, functional activities of daily living, leisure or work.
"Adult" means a person with an intellectual disability aged 18 or over.
"Appropriate" means that the services or supports or activities provided or undertaken by the organization are relevant to the consumer’s needs, situation, problems, or desires.
"Attorney in fact under a durable power of attorney for health care" means an individual who is designated by a durable power of attorney for health care, pursuant to Iowa Code chapter 144B, as an agent to make health care decisions on behalf of an individual and who has consented to act in that capacity.
"Basic individual respite" means respite provided on a staff-to-consumer ratio of one to one or higher to individuals without specialized needs requiring the care of a licensed registered nurse or licensed practical nurse.
"Behavior" means skills related to regulating one’s own behavior including coping with demands from others, making choices, controlling impulses, conforming conduct to laws, and displaying appropriate sociosexual behavior.
"Case management services" means those services established pursuant to Iowa Code chapter 225C.
"Child" means a person with an intellectual disability aged 17 or under.
"Client participation" means the posteligibility amount of the consumer’s income that persons eligible through a special income level must contribute to the cost of the home and community-based waiver service.
"Counseling" means face-to-face mental health services provided to the consumer and caregiver by a qualified intellectual disability professional (QIDP) to facilitate home management of the consumer and prevent institutionalization.
"Deemed status" means acceptance of certification or licensure of a program or service by another certifying body in place of certification based on review and evaluation.
"Department" means the Iowa department of human services.
"Direct service" means services involving face-to-face assistance to a consumer such as transporting a consumer or providing therapy.
"Fiscal accountability" means the development and maintenance of budgets and independent fiscal review.
"Group respite" is respite provided on a staff-to-consumer ratio of less than one to one.
"Guardian" means a guardian appointed in probate court.
"Health" means skills related to the maintenance of one’s health including eating; illness identification, treatment and prevention; basic first aid; physical fitness; regular physical checkups and personal habits.
"Immediate jeopardy" means circumstances where the life, health, or safety of a person will be severely jeopardized if the circumstances are not immediately corrected.
"Intellectual disability" means a diagnosis of intellectual disability (intellectual developmental disorder), global developmental delay, or unspecified intellectual disability (intellectual developmental disorder) which shall be made only when the onset of the person’s condition was during the developmental period and shall be based on an assessment of the person’s intellectual functioning and level of adaptive skills. The diagnosis shall be made by a person who is a licensed psychologist or psychiatrist who is professionally trained to administer the tests required to assess intellectual functioning and to evaluate a person’s adaptive skills. The diagnosis shall be made in accordance with the criteria provided in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association.
"Intermediate care facility for persons with an intellectual disability (ICF/ID)" means an institution that is primarily for the diagnosis, treatment, or rehabilitation of persons with an intellectual disability or persons with related conditions and that provides, in a protected residential setting, ongoing evaluation, planning, 24-hour supervision, coordination and integration of health or related services to help each person function at the greatest ability and is an approved Medicaid vendor.
"Intermediate care facility for persons with an intellectual disability level of care" means that the individual has a diagnosis of intellectual disability made in accordance with the criteria provided in the current version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association; or has a related condition as defined in 42 CFR 435.1009; and needs assistance in at least three of the following major life areas: mobility, musculoskeletal skills, activities of daily living, domestic skills, toileting, eating skills, vision, hearing or speech or both, gross/fine motor skills, sensory-taste, smell, tactile, academic skills, vocational skills, social/community skills, behavior, and health care.
"Intermittent supported community living service" means supported community living service provided not more than 52 hours per month.
"Maintenance needs" means costs associated with rent or mortgage, utilities, telephone, food and household supplies.
"Managed care" means a system that provides the coordinated delivery of services and supports that are necessary and appropriate, delivered in the least restrictive settings and in the least intrusive manner. Managed care seeks to balance three factors:
  1. Achieving high-quality outcomes for participants.
  2. Coordinating access.
  3. Containing costs.
"Managed care organization" means an entity that (1) is under contract with the department to provide services to Medicaid recipients and (2) meets the definition of “health maintenance organization” as defined in Iowa Code section 514B.1.
"Medical assessment" means a visual and physical inspection of the consumer, noting deviations from the norm, and a statement of the consumer’s mental and physical condition that can be amendable to or resolved by appropriate actions of the provider.
"Medical institution" means a nursing facility, intermediate care facility for persons with an intellectual disability, or hospital which has been approved as a Medicaid vendor.
"Medical intervention" means consumer care in the areas of hygiene, mental and physical comfort, assistance in feeding and elimination, and control of the consumer’s care and treatment to meet the physical and mental needs of the consumer in compliance with the plan of care in areas of health, prevention, restoration, and maintenance.
"Medical monitoring" means observation for the purpose of assessing, preventing, maintaining, and treating disease or illness based on the consumer’s plan of care.
"Natural supports" means services and supports identified as wanted or needed by the consumer and provider by persons not for pay (family, friends, neighbors, coworkers, and others in the community) and organizations or entities that serve the general public.
"Organization" means the entity being certified.
"Organizational outcome" means a demonstration by the organization of actions taken by the organization to provide for services or supports to consumers.
"Outcome" means an action or event that follows as a result or consequence of the provision of a service or support.
"Procedures" means the steps to be taken to implement a policy.
"Process" means service or support provided by an agency to a consumer that will allow the consumer to achieve an outcome. This can include a written, formal, consistent trackable method or an informal process that is not written but is trackable.
"Program" means a set of related resources and services directed to the accomplishment of a fixed set of goals and objectives for the population of a specified geographic area or for special target populations. It can mean an agency, organization, or unit of an agency, organization or institution.
"Qualified intellectual disability professional" means a person who has at least one year of experience working directly with persons with an intellectual disability or other developmental disabilities and who is one of the following:
  1. A doctor of medicine or osteopathy.
  2. A registered nurse.
  3. An occupational therapist eligible for certification as an occupational therapist by the American Occupational Therapy Association or another comparable body.
  4. A physical therapist eligible for certification as a physical therapist by the American Physical Therapy Association or another comparable body.
  5. A speech-language pathologist or audiologist eligible for certification of Clinical Competence in Speech-Language Pathology or Audiology by the American Speech-Language Hearing Association or another comparable body or who meets the educational requirements for certification and who is in the process of accumulating the supervised experience required for certification.
  6. A psychologist with a master’s degree in psychology from an accredited school.
  7. A social worker with a graduate degree from a school of social work, accredited or approved by the Council on Social Work Education or another comparable body or who holds a bachelor of social work degree from a college or university accredited or approved by the Council of Social Work Education or another comparable body.
  8. A professional recreation staff member with a bachelor’s degree in recreation or in a specialty area such as art, dance, music or physical education.
  9. A professional dietitian who is eligible for registration by the American Dietetics Association.
  10. A human services professional who must have at least a bachelor’s degree in a human services field including, but not limited to, sociology, special education, rehabilitation counseling and psychology.
"Related condition" means a severe, chronic disability that meets all the following conditions:
  1. It is attributable to cerebral palsy, epilepsy, or any other condition, other than mental illness, found to be closely related to intellectual disability because the condition results in impairment of general intellectual functioning or adaptive behavior similar to that of a person with an intellectual disability and requires treatment or services similar to those required for a person with an intellectual disability.
  2. It is manifested before the age of 22.
  3. It is likely to continue indefinitely.
  4. It results in substantial functional limitations in three or more of the following areas of major life activity:
  5. Self-care.
  6. Understanding and use of language.
  7. Learning.
  8. Mobility.
  9. Self-direction.
  10. Capacity for independent living.
"Service plan" means a person-centered, outcome-based plan of services which is written by the member’s case manager with input and direction from the member and which addresses all relevant services and supports being provided. The service plan is developed by the interdisciplinary team, which includes the member and, if appropriate, the member’s legal representative, member’s family, service providers, and others directly involved with the member.
"SIS assessment" means the Supports Intensity Scale® assessment developed and licensed by the American Association on Intellectual and Developmental Disabilities for use in the assessment of the support and service needs of individuals.
"Specialized respite" means respite provided on a staff-to-consumer ratio of one to one or higher to individuals with specialized medical needs requiring the care, monitoring or supervision of a licensed registered nurse or licensed practical nurse.
"Staff" means a person under the direction of the organization to perform duties and responsibilities of the organization.
"Third-party payments" means payments from an attorney, individual, institution, corporation, insurance company, or public or private agency which is liable to pay part or all of the medical costs incurred as a result of injury, disease or disability by or on behalf of an applicant or a past or present recipient of Medicaid.
"Usual caregiver" means a person or persons who reside with the consumer and are available on a 24-hour-per-day basis to assume responsibility for the care of the consumer.
Related ARC(s): 9650B, 0306C, 2050C, 2168C, 2361C, 3874C441—83.61(249A)  Eligibility.  To be eligible for HCBS intellectual disability waiver services a person must meet certain eligibility criteria and be determined to need a service(s) available under the program.  83.61(1)    Eligibility criteria.  All of the following criteria must be met. The person must:  a.  Have a diagnosis of intellectual disability as defined in rule 441—83.60(249A). The diagnosis shall be initially established and recertified as follows:AgeInitial application to HCBS intellectual disability waiver programRecertification for persons with a diagnosis of moderate, severe or profound level of severityRecertification for persons with a diagnosis of mild or unspecified level of severity0 through 17 yearsPsychological documentation within three years of the application date substantiating a diagnosis of intellectual disability as defined in rule 441—83.60(249A)After the initial psychological evaluation, substantiate a diagnosis of intellectual disability as defined in rule 441—83.60(249A) every six years and when a significant change occursAfter the initial psychological evaluation, substantiate a diagnosis of intellectual disability as defined in rule 441—83.60(249A) every three years and when a significant change occurs18 years and aboveCurrent psychological documentation substantiating a diagnosis of intellectual disability if the last testing date was (1) more than six years ago for an applicant with a diagnosis of mild or unspecified severity, or (2) more than ten years ago for an applicant with a diagnosis of moderate, severe or profound level of severityPsychological documentation substantiating a diagnosis of intellectual disability made since the member reached 22 years of agePsychological documentation substantiating a diagnosis of intellectual disability every six years and whenever a significant change occurs  b.  Be eligible for Medicaid under SSI, SSI-related, FMAP, or FMAP-related coverage groups; eligible under the special income level (300 percent) coverage group; or become eligible through application of the institutional deeming rules or would be eligible for Medicaid if in a medical institution.  c.  Be certified as being in need for long-term care that, but for the waiver, would otherwise be provided in an ICF/ID. The IME medical services unit shall be responsible for the initial approval, and the IME medical services unit or a managed care organization will be responsible for the annual approval of the certification of the level of care based on the data collected by the case manager and interdisciplinary team on a tool designated by the department.  d.  Be a recipient of the Medicaid case management services or be identified to receive Medicaid case management services immediately following program enrollment.  e.  Have service needs that can be met by this waiver program. At a minimum, a consumer must receive one billable unit of service per calendar quarter under this program.  f.  Have a service plan completed annually and approved by the department in accordance with rule 441—83.67(249A).  g.  For individual supported employment and long-term job coaching services:  (1)  Be at least 16 years of age.  (2)  The services must not be available to the member through one of the following:
  1. Special education and related services as defined in the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.); or
  2. A program funded under Section 110 of the Rehabilitation Act of 1973 (29 U.S.C. 730).
  (3)  Not reside in a medical institution.  (4)  Have documented in the waiver service plan a goal to achieve or to sustain individual employment.
  h.  For small-group supported employment services:  (1)  Be at least 16 years of age.  (2)  The services must not be available to the member through one of the following:
  1. Special education and related services as defined in the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.); or
  2. A program funded under Section 110 of the Rehabilitation Act of 1973 (29 U.S.C. 730).
  (3)  Have documented in the waiver service plan a goal to achieve or to sustain individual employment.   (4)  Have documented in the waiver service plan that the choice to receive individual supported employment services was offered and explained in a manner sufficient to ensure informed choice, after which the choice to receive small-group supported employment services was made.  (5)  Not reside in a medical institution.
  i.  For prevocational services:  (1)  Be at least 16 years of age.  (2)  The services must not be available to the member through one of the following:
  1. Special education and related services as defined in the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.); or
  2. A program funded under Section 110 of the Rehabilitation Act of 1973 (29 U.S.C. 730).
  (3)  Have documented in the waiver service plan a goal to achieve or to sustain individual employment.  (4)  Have documented in the waiver service plan that the choice to receive individual supported employment services was offered and explained in a manner sufficient to ensure informed choice, after which the choice to receive small-group supported employment services was made.  (5)  Not reside in a medical institution.
  j.  Choose HCBS intellectual disability waiver services rather than ICF/ID services.  k.  To be eligible for interim medical monitoring and treatment services the consumer must be:  (1)  Under the age of 21;  (2)  Currently receiving home health agency services under rule 441—78.9(249A) and require medical assessment, medical monitoring, and regular medical intervention or intervention in a medical emergency during those services. (The home health aide services for which the consumer is eligible must be maximized before the consumer accesses interim medical monitoring and treatment.);  (3)  Residing in the consumer’s family home or foster family home; and  (4)  In need of interim medical monitoring and treatment as ordered by a physician.  l.  Be assigned an HCBS intellectual disability payment slot pursuant to subrule 83.61(4).  m.  For residential-based supported community living services, meet all of the following additional criteria:  (1)  Be less than 18 years of age.  (2)  Be preapproved as appropriate for residential-based supported community living services by the bureau of long-term care. Requests for approval shall be submitted in writing to the DHS Bureau of Long-Term Care, 1305 East Walnut Street, Des Moines, Iowa 50319-0114, and shall include the following:
  1. Social history;
  2. Case history that includes previous placements and service programs;
  3. Medical history that includes major illnesses and current medications;
  4. Current psychological evaluations and consultations;
  5. Summary of all reasonable and appropriate service alternatives that have been tried or considered;
  6. Any current court orders in effect regarding the child;
  7. Any legal history;
  8. Whether the child is at risk of out-of-home placement or the proposed placement would be less restrictive than the child’s current placement for services;
  9. Whether the proposed placement would be safe for the child and for other children living in that setting; and
  10. Whether the interdisciplinary team is in agreement with the proposed placement.
  (3)  Either:
  1. Be residing in an ICF/ID;
  2. Be at risk of ICF/ID placement, as documented by an interdisciplinary team assessment pursuant to paragraph 83.61(2)“a”; or
  3. Be a child whose long-term placement outside the home is necessary because continued stay in the home would be a detriment to the health and welfare of the child or the family, and all service options to keep the child in the home have been reviewed by an interdisciplinary team, as documented in the service file.
  n.  For day habilitation, be 16 years of age or older.  o.  For the consumer choices option as set forth in 441—subrule 78.41(5), not be living in a residential care facility.
  83.61(2)    Need for services.    a.  Applicants currently receiving Medicaid case management shall have the applicable staff coordinate with the department to arrange completion of Form 470-4694 for children under the age of five and, for all others, a SIS assessment.  b.  Applicants not receiving services as set forth in paragraph 83.61(2)“a” shall have a department service worker or case manager:  (1)  Arrange for completion of Form 470-4694 for children under the age of five and, for all others, a SIS assessment for the initial level of care determination;  (2)  Establish an initial interdisciplinary team for HCBS intellectual disability waiver services; and  (3)  With the initial interdisciplinary team, identify the applicant’s needs and desires as well as the availability and appropriateness of services.  c.  Applicants meeting other eligibility criteria who do not have a Medicaid case manager shall be referred to a Medicaid case manager.  d.  Services shall not exceed the number of maximum units established for each service.  e.  The cost of services shall not exceed unit expense maximums. Requests shall only be reviewed for funding needs exceeding the supported community living service unit cost maximum. Requests require special review by the department and may be denied as not cost-effective.  f.  The case manager shall coordinate with the department for completion of Form 470-4694 for children under the age of five and, for all others, to arrange a SIS assessment for the initial level of care determination within 30 days from the date of the HCBS application unless the case manager can document difficulty in locating information necessary to arrange the assessment or other circumstances beyond the case manager’s control.  g.  At initial enrollment, the case manager shall establish an interdisciplinary team for each applicant and, with the team, identify the applicant’s need for service based on the applicant’s needs and desires as well as the availability and appropriateness of services. The Medicaid case manager shall complete an annual review thereafter. The following criteria shall be used for the initial and ongoing identification of need for services:  (1)  The assessment shall be based on the results of the most recent Form 470-4694 for children under the age of five and, for all others, the SIS assessment or of the SIS contractor’s off-year review.  (2)  Service plans must be developed or reviewed to reflect use of all appropriate nonwaiver Medicaid services so as not to replace or duplicate those services.  (3)  Service plans for applicants aged 20 or under which include supported community living services beyond intermittent shall be approved (signed and dated) by the designee of the bureau of long-term care. The service worker, department QIDP, or Medicaid case manager shall attach a written request for a variance from the maximum for intermittent supported community living with a summary of services and service costs. The written request for the variance shall provide a rationale for requesting supported community living beyond intermittent. The rationale shall contain sufficient information for the designee to make a decision regarding the need for supported community living beyond intermittent.  h.  Interim medical monitoring and treatment services must be needed because all usual caregivers are unavailable to provide care due to one of the following circumstances:  (1)  Employment. Interim medical monitoring and treatment services are to be received only during hours of employment.  (2)  Academic or vocational training. Interim medical monitoring and treatment services provided while a usual caregiver participates in postsecondary education or vocational training shall be limited to 24 periods of no more than 30 days each per caregiver as documented by the service worker. Time spent in high school completion, adult basic education, GED, or English as a second language does not count toward the limit.  (3)  Absence from the home due to hospitalization, treatment for physical or mental illness, or death of the usual caregiver. Interim medical monitoring and treatment services under this subparagraph are limited to a maximum of 30 days.  (4)  Search for employment.
  1. Care during job search shall be limited to only those hours the usual caregiver is actually looking for employment, including travel time.
  2. Interim medical monitoring and treatment services may be provided under this paragraph only during the execution of one job search plan of up to 30 working days in a 12-month period, approved by the department service worker or targeted case manager pursuant to 441—subparagraph 170.2(2)“b”(5).
  3. Documentation of job search contacts shall be furnished to the department service worker or targeted case manager.
  83.61(3)    HCBS intellectual disability waiver program limit.  The number of persons receiving HCBS intellectual disability waiver services in the state shall be limited to the number of payment slots provided in the HCBS intellectual disability waiver approved by the Centers for Medicare and Medicaid Services (CMS). The department shall make a request to CMS to adjust the program limit as deemed necessary.  a.  The payment slots are available on a statewide basis. These slots shall be available based on the prioritized need of an applicant pursuant to subrule 83.61(4).  b.  When services are denied because the limit is reached, a notice of decision denying service based on the limit and stating that the person’s name will be put on a waiting list shall be sent to the person by the department.  83.61(4)    Securing a payment slot.  The department shall determine if a payment slot is available for each applicant for the HCBS intellectual disability waiver.  a.  A payment slot shall be assigned to the applicant upon confirmation of an available slot.  (1)  Once a payment slot is assigned, the department shall give written notice to the applicant.  (2)  The department shall hold the payment slot for the applicant as long as reasonable efforts are being made to arrange services and the applicant has not been determined to be ineligible for the program. If services have not been initiated and reasonable efforts are no longer being made to arrange services, the slot shall revert for use by the next person on the waiting list, if applicable. The applicant originally assigned the slot must reapply for a new slot.  b.  If no payment slot is available, the applicant shall be placed on a statewide priority waiting list. The department shall assess each applicant to determine the applicant’s priority need. The assessment shall be made for all applicants who are on a waiting list maintained by the state or a county on September 30, 2011, and for all new applications received on or after October 1, 2011.  (1)  Emergency need criteria are as follows:
  1. The usual caregiver has died or is incapable of providing care, and no other caregivers are available to provide needed supports.
  2. The applicant has lost primary residence or will be losing housing within 30 days and has no other housing options available.
  3. The applicant is living in a homeless shelter and no alternative housing options are available.
  4. There is founded abuse or neglect by a caregiver or others living within the home of the applicant, and the applicant must move from the home.
  5. The applicant cannot meet basic health and safety needs without immediate supports.
  (2)  Urgent need criteria are as follows:
  1. The caregiver will need support within 60 days in order for the applicant to remain living in the current situation.
  2. The caregiver will be unable to continue to provide care within the next 60 days.
  3. The caregiver is 55 years of age or older and has a chronic or long-term physical or psychological condition that limits the ability to provide care.
  4. The applicant is living in temporary housing and plans to move within 31 to 120 days.
  5. The applicant is losing permanent housing and plans to move within 31 to 120 days.
  6. The caregiver will be unable to be employed if services are not available.
  7. There is a potential risk of abuse or neglect by a caregiver or others within the home of the applicant.
  8. The applicant has behaviors that put the applicant at risk.
  9. The applicant has behaviors that put others at risk.
  10. The applicant is at risk of facility placement when needs could be met through community-based services.
  (3)  Applicants who meet an emergency need criterion shall be placed on the priority waiting list based on the total number of criteria in subparagraph 83.61(4)“b”(1) that are met. If applicants meet an equal number of criteria, the position on the waiting list shall be based on the date of application and the age of the applicant. The applicant who has been on the waiting list longer shall be placed higher on the waiting list. If the application date is the same, the older applicant shall be placed higher on the waiting list.  (4)  Applicants who meet an urgent need criterion shall be placed on the priority waiting list after applicants who meet emergency need criteria. The position on the waiting list shall be based on the total number of criteria in subparagraph 83.61(4)“b”(2) that are met. If applicants meet an equal number of criteria, the position on the waiting list shall be based on the date of application and the age of the applicant. The applicant who has been on the waiting list longer shall be placed higher on the waiting list. If the application date is the same, the older applicant shall be placed higher on the waiting list.  (5)  Applicants who do not meet emergency or urgent need criteria shall be placed lower on the waiting list than the applicants meeting urgent need criteria, based on the date of application. If the application date is the same, the older applicant shall be placed higher on the waiting list.  (6)  Applicants shall remain on the waiting list until a payment slot has been assigned to them for use, they withdraw from the list, or they become ineligible for the waiver. If there is a change in an applicant’s need, the applicant may contact the local department office and request that a new assessment be completed. The outcome of the assessment shall determine placement on the waiting list as directed in this subrule.
  c.  To maintain the approved number of members in the program, persons shall be selected from the waiting list as payment slots become available, based on their priority order on the waiting list.  (1)  Once a payment slot is assigned, the department shall give written notice to the person within five working days.  (2)  The department shall hold the payment slot for 30 days for the person to file a new application. If an application has not been filed within 30 days, the slot shall revert for use by the next person on the waiting list, if applicable. The person originally assigned the slot must reapply for a new slot.
Related ARC(s): 9650B, 0191C, 0306C, 0359C, 2050C, 2168C, 2361C, 2471C, 3184C441—83.62(249A)  Application.    83.62(1)    Application for HCBS intellectual disability waiver services.  The application process as specified in rules 441—76.1(249A) to 441—76.6(249A) shall be followed.  83.62(2)  Rescinded IAB 6/5/96, effective 8/1/96.  83.62(3)    Approval of application.    a.  Applications for the HCBS intellectual disability waiver program shall be processed in 30 days unless the case manager or worker can document difficulty in locating and arranging services or other circumstance beyond the worker’s control. In these cases a decision shall be made as soon as possible.  b.  Decisions shall be mailed or given to the applicant on the date when both service and income maintenance eligibility determinations are completed.  c.  An applicant shall be given the choice between HCBS waiver services and ICF/ID care. The case manager or worker shall have the consumer or legal representative indicate the consumer’s choice of care.  d.  HCBS intellectual disability waiver services provided before eligibility for the waiver is approved shall not be reimbursed by the HCBS waiver program.  e.  Services provided when the person is a consumer of group foster care services or is an inpatient in a medical institution shall not be reimbursed.  f.  HCBS intellectual disability waiver services are not available in conjunction with other Medicaid waiver services or group foster care services.  g.  Rescinded IAB 5/6/09, effective 7/1/09.  83.62(4)    Effective date of eligibility.    a.  Deeming of parental income and resources ceases the month following the month in which a person requires care in a medical institution.  b.  The effective date of eligibility for the waiver for persons who are already determined eligible for Medicaid is the date on which the person is determined to meet the criteria set forth in rule 441—83.61(249A).  c.  The effective date of eligibility for the waiver for persons who qualify for Medicaid due to eligibility for the waiver services is the date on which the person is determined to meet criteria set forth in rule 441—83.61(249A) and when the eligibility factor set forth in 441—subrule 75.1(7) and for married persons, in rule 441—75.5(249A) have been satisfied.  d.  Eligibility continues until the consumer fails to meet eligibility criteria listed in rule 441—83.61(249A). Consumers who are inpatients in a medical institution for 120 consecutive days shall receive a review by the interdisciplinary team to determine additional inpatient needs for possible termination from the HCBS program. Consumers shall be reviewed for eligibility under other Medicaid coverage groups. The consumer or legal representative shall participate in the review and receive formal notification of that decision through Form 470-0602, Notice of Decision.If the consumer returns home before the effective date of the notice of decision and the consumer’s needs can still be met by the HCBS waiver services, the denial may be rescinded and eligibility may continue.  e.  Eligibility and service reimbursement are effective through the last day of the month of the previous annual service plan staffing meeting and the corresponding long-term care need determination.  83.62(5)    Attribution of resources.  For the purposes of attributing resources as provided in rule 441—75.5(249A), the date on which the waiver applicant met the level of care criteria in a medical institution as established by the peer review organization shall be used as the date of entry to the medical institution. Only one attribution of resources shall be completed per person. Attributions completed for prior institutionalizations shall be applied to the waiver application.Related ARC(s): 7741B, 9650B, 0306C, 2168C, 3234C441—83.63(249A)  Client participation.  Persons who are eligible under the 300 percent group must contribute a predetermined client participation amount to the costs of the services.  83.63(1)    Computation of client participation.  Client participation shall be computed by deducting an amount for the maintenance needs of the individual which is 300 percent of the maximum SSI grant for an individual from the client’s total income.  83.63(2)    Limitation on payment.  If the sum of the third-party payment and client participation equals or exceeds the reimbursement for the specific HCBS waiver service, Medicaid will make no payments for the HCBS waiver service. However, Medicaid will make payments to other medical vendors.441—83.64(249A)  Redetermination.  A redetermination of nonfinancial eligibility for HCBS intellectual disability waiver services shall be completed at least once every 12 months. In years in which a SIS assessment is not completed for an individual five years of age or older, the SIS contractor shall conduct a review in collaboration with the case manager, documenting any changes in the member’s functional status since the previous SIS or other full assessment. Form 470-4694 shall be completed annually for children under the age of five.A redetermination of continuing eligibility factors shall be made when a change in circumstances occurs that affects eligibility in accordance with rule 441—83.61(249A).  83.64(1)  The IME medical services unit or the member’s managed care organization shall be responsible for annual redetermination of the level of care.  83.64(2)  The managed care organization must submit documentation to the IME medical services unit for all reassessments, performed at least annually, which indicate a change in the member’s level of care. The IME medical services unit shall make a final determination for any reassessments which indicate a change in the level of care. If the level of care reassessment indicates no change in level of care, the member is approved to continue at the already established level of care.Related ARC(s): 9650B, 2168C, 2361C, 3184C441—83.65(249A)    Rescinded IAB 6/5/96, effective 8/1/96.441—83.66(249A)  Allowable services.  Services allowable under the HCBS intellectual disability waiver are supported community living, respite, personal emergency response system, nursing, home health aide, home and vehicle modification, supported employment, consumer-directed attendant care, interim medical monitoring and treatment, transportation, adult day care, day habilitation, prevocational services, financial management, independent support brokerage, self-directed personal care, self-directed community supports and employment, and individual-directed goods and services as set forth in rule 441—78.41(249A).Related ARC(s): 9650B441—83.67(249A)  Service plan.  A service plan shall be prepared for each HCBS intellectual disability waiver consumer.  83.67(1)    Development.  The service plan shall be developed by the interdisciplinary team, which includes the consumer, and, if appropriate, the legal representative, consumer’s family, case manager or service worker, service providers, and others directly involved.  83.67(2)    Retention.  The service plan shall be stored by the case manager for a minimum of three years.  83.67(3)    Interdisciplinary team meeting.  The interdisciplinary team meeting shall be conducted before the current service plan expires.  83.67(4)    Information in plan.  The plan shall be in accordance with 441—subrule 24.4(3) and shall additionally include the following information to assist in evaluating the program:  a.  A listing of all services received by a consumer at the time of waiver program enrollment.  b.  For supported community living:  (1)  The consumer’s living environment at the time of waiver enrollment.  (2)  The number of hours per day of on-site staff supervision needed by the consumer.  (3)  The number of other waiver consumers who will live with the consumer in the living unit.  c.  An identification and justification of any restriction of the consumer’s rights including, but not limited to:  (1)  Maintenance of personal funds.  (2)  Self-administration of medications.  d.  The name of the service provider responsible for providing each service.  e.  The service funding source.  f.  The amount of the service to be received by the consumer.  g.  Whether the consumer has elected the consumer choices option and, if so:  (1)  The independent support broker selected by the consumer; and  (2)  The financial management service selected by the consumer.  h.  A plan for emergencies and identification of the supports available to the consumer in an emergency.  i.  For members receiving daily supported community living, day habilitation or adult day care: the following standard scores from the most recently completed SIS assessment:  (1)  Score on subsection 1A: Exceptional Medical Support Needs.  (2)  Score on subsection 1B: Exceptional Behavioral Support Needs.  (3)  Sum total of standard scores on the following subsections:  1.  Subsection 2A: Home Living Activities;  2.  Subsection 2B: Community Living Activities;  3.  Subsection 2E: Health and Safety Activities; and  4.  Subsection 2F: Social Activities.  83.67(5)    Documentation.  The Medicaid case manager shall ensure that the consumer’s case file contains the consumer’s service plan and documentation supporting the diagnosis of mental retardation.  83.67(6)    Approval of plan.  The plan shall be approved through the Individualized Services Information System (ISIS). Services shall be entered into ISIS based on the service plan.  a.  Services must be authorized and entered into ISIS before the plan implementation date.  b.  The department has 15 working days after receipt of the summary and service costs in which to approve the services and service cost or request modification of the service plan unless the parties mutually agree to extend that time frame.  c.  If the department and the service worker or case manager are unable to agree on the terms of the services or service cost within 10 days, the department has final authority regarding the services and service cost.Related ARC(s): 9650B, 0191C, 0359C, 3481C, 3790C441—83.68(249A)  Adverse service actions.    83.68(1)    Denial.  An application for services shall be denied when it is determined by the department that:  a.  The applicant is not eligible for the services.  b.  Service needs exceed the service unit or reimbursement maximums.  c.  Service needs are not met by the services provided.  d.  Needed services are not available or received from qualifying providers.  e.  No HCBS intellectual disability waiver service is identified in the applicant’s service plan.  f.  There is another community resource available to provide the service or a similar service free of charge to the applicant that will meet the applicant’s needs.  g.  Completion or receipt of required documents by the department for the HCBS program applicant has not occurred.  83.68(2)    Reduction.  A particular service may be reduced when the department determines that the provisions of 441—subrule 130.5(3), paragraph “a” or “b,” apply.  83.68(3)    Termination.  A particular service may be terminated when the department determines that:  a.  The provisions of 441—subrule 130.5(2) paragraph “d,”“g,” or “h,”, apply.  b.  Needed services are not available or received from qualifying providers.  c.  No HCBS intellectual disability waiver service is identified in the member’s annual service plan.  d.  Service needs are not met by the services provided.  e.  Services needed exceed the service unit or reimbursement maximums.  f.  Completion or receipt of required documents by the department for the HCBS program consumer has not occurred.  g.  The consumer receives services from other Medicaid waiver programs.  h.  The consumer or legal representative through the interdisciplinary process requests termination from the services.Related ARC(s): 9650B441—83.69(249A)  Appeal rights.  Notice of adverse action and right to appeal shall be given in accordance with 441—Chapter 7, rule 441—16.3(17A) and rule 441—130.5(234).Related ARC(s): 0191C, 0306C, 0359C, 4973C441—83.70(249A)  County reimbursement.  Rescinded ARC 0191C, IAB 7/11/12, effective 7/1/12.441—83.71(249A)  Conversion to the X-PERT system.  Rescinded IAB 8/7/02, effective 10/1/02.441—83.72(249A)  Rent subsidy program.  Members in the HCBS intellectual disability waiver program may be eligible for a rent subsidy. See 265—Chapter 24.Related ARC(s): 9650BThese rules are intended to implement Iowa Code sections 249A.3 and 249A.4.441—83.73    Reserved.441—83.74    Reserved.441—83.75    Reserved.441—83.76    Reserved.441—83.77    Reserved.441—83.78    Reserved.441—83.79    Reserved.441—83.80    Reserved.DIVISION V—BRAIN INJURY WAIVER SERVICES441—83.81(249A)  Definitions.  
"Adaptive" means age appropriate skills related to taking care of one’s self and the ability to relate to others in daily living situations. These skills include limitations that occur in the areas of communication, self-care, home living, social skills, community use, self-direction, safety, functional academics, leisure and work.
"Adult" means a person with a brain injury aged 18 years or over.
"Appropriate" means that the services or supports or activities provided or undertaken by the organization are relevant to the consumer’s needs, situation, problems, or desires.
"Assessment" means the review of the consumer’s current functioning in regard to the consumer’s situation, needs, strengths, abilities, desires and goals.
"Attorney in fact under a durable power of attorney for health care" means an individual who is designated by a durable power of attorney for health care, pursuant to Iowa Code chapter 144B, as an agent to make health care decisions on behalf of an individual and who has consented to act in that capacity.
"Basic individual respite" means respite provided on a staff-to-consumer ratio of one to one or higher to individuals without specialized needs requiring the care of a licensed registered nurse or licensed practical nurse.
"Behavior" means skills related to regulating one’s own behavior including coping with demands from others, making choices, conforming conduct to laws, and displaying appropriate sociosexual behavior.
"Brain injury" means clinically evident damage to the brain resulting directly or indirectly from trauma, infection, anoxia, vascular lesions or tumor of the brain, not primarily related to degenerative or aging processes, which temporarily or permanently impairs a person’s physical, cognitive, or behavioral functions. The person must have a diagnosis from the following list:Malignant neoplasms of brain, cerebrum.Malignant neoplasms of brain, frontal lobe.Malignant neoplasms of brain, temporal lobe.Malignant neoplasms of brain, parietal lobe.Malignant neoplasms of brain, occipital lobe.Malignant neoplasms of brain, ventricles.Malignant neoplasms of brain, cerebellum.Malignant neoplasms of brain, brain stem.Malignant neoplasms of brain, other part of brain, includes midbrain, peduncle, and medulla oblongata.Malignant neoplasms of brain, cerebral meninges.Malignant neoplasms of brain, cranial nerves.Secondary malignant neoplasm of brain.Secondary malignant neoplasm of other parts of the nervous system, includes cerebral meninges.Benign neoplasm of brain and other parts of the nervous system, brain.Benign neoplasm of brain and other parts of the nervous system, cranial nerves.Benign neoplasm of brain and other parts of the nervous system, cerebral meninges.Encephalitis, myelitis and encephalomyelitis.Intracranial and intraspinal abscess.Anoxic brain damage.Subarachnoid hemorrhage.Intracerebral hemorrhage.Other and unspecified intracranial hemorrhage.Occlusion and stenosis of precerebral arteries.Occlusion of cerebral arteries.Transient cerebral ischemia.Acute, but ill-defined, cerebrovascular disease.Other and ill-defined cerebrovascular diseases.Fracture of vault of skull.Fracture of base of skull.Other and unqualified skull fractures.Multiple fractures involving skull or face with other bones.Concussion.Cerebral laceration and contusion.Cerebral edema.Cerebral palsy.Subarachnoid, subdural, and extradural hemorrhage following injury.Other and unspecified intracranial hemorrhage following injury.Intracranial injury of other and unspecified nature.Poisoning by drugs, medicinal and biological substances.Toxic effects of substances.Effects of external causes.Drowning and nonfatal submersion.Asphyxiation and strangulation.Child maltreatment syndrome.Adult maltreatment syndrome.Status epilepticus.
"Case management services" means those services established pursuant to Iowa Code chapter 225C.
"Child" means a person with a brain injury aged 17 years or under.
"Client participation" means the amount of the consumer’s income that the person must contribute to the cost of brain injury waiver services, exclusive of medical vendor payments, before Medicaid will provide additional reimbursement.
"Deemed status" means acceptance of certification or licensure of a program or service by another certifying body in place of certification based on review and evaluation.
"Department" means the Iowa department of human services.
"Direct service" means services involving face-to-face assistance to a consumer such as transporting a consumer or providing therapy.
"Fiscal accountability" means the development and maintenance of budgets and independent fiscal review.
"Group respite" is respite provided on a staff-to-consumer ratio of less than one to one.
"Guardian" means a guardian appointed in probate court.
"Health" means skills related to the maintenance of one’s health including eating; illness identification, treatment and prevention; basic first aid; physical fitness; regular physical checkups and personal habits.
"Immediate jeopardy" means circumstances where the life, health, or safety of a person will be severely jeopardized if the circumstances are not immediately corrected.
"Intermediate care facility for persons with an intellectual disability level of care" means that the individual has a diagnosis of intellectual disability made in accordance with the criteria provided in the current version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association; or has a related condition as defined in 42 CFR 435.1009; and needs assistance in at least three of the following major life areas: mobility, musculoskeletal skills, activities of daily living, domestic skills, toileting, eating skills, vision, hearing or speech or both, gross/fine motor skills, sensory-taste, smell, tactile, academic skills, vocational skills, social/community skills, behavior, and health care.
"Intermittent supported community living service" means supported community living service provided from one to three hours a day for not more than four days a week.
"Managed care organization" means an entity that (1) is under contract with the department to provide services to Medicaid recipients and (2) meets the definition of “health maintenance organization” as defined in Iowa Code section 514B.1.
"Medical assessment" means a visual and physical inspection of the consumer, noting deviations from the norm, and a statement of the consumer’s mental and physical condition that can be amendable to or resolved by appropriate actions of the provider.
"Medical institution" means a nursing facility, a skilled nursing facility, intermediate care facility for persons with an intellectual disability, or hospital which has been approved as a Medicaid vendor.
"Medical intervention" means consumer care in the areas of hygiene, mental and physical comfort, assistance in feeding and elimination, and control of the consumer’s care and treatment to meet the physical and mental needs of the consumer in compliance with the plan of care in areas of health, prevention, restoration, and maintenance.
"Medical monitoring" means observation for the purpose of assessing, preventing, maintaining, and treating disease or illness based on the consumer’s plan of care.
"Natural supports" means services and supports identified as wanted or needed by the consumer and provider by persons not for pay (family, friends, neighbors, coworkers, and others in the community) and organizations or entities that serve the general public.
"Nursing facility level of care" means that the following conditions are met:
  1. The presence of a physical or mental impairment which restricts the member’s daily ability to perform the essential activities of daily living, bathing, dressing, and personal hygiene, and impedes the member’s capacity to live independently.
  2. The member’s physical or mental impairment is such that self-execution of required nursing care is improbable or impossible.
"Organization" means the entity being certified.
"Organizational outcome" means a demonstration by the organization of actions taken by the organization to provide for services or supports to consumers.
"Outcome" means an action or event that follows as a result or consequence of the provision of a service or support.
"Procedures" means the steps to be taken to implement a policy.
"Process" means service or support provided by an agency to a consumer that will allow the consumer to achieve an outcome. This can include a written, formal, consistent trackable method or an informal process that is not written but is trackable.
"Program" means a set of related resources and services directed to the accomplishment of a fixed set of goals and objectives for the population of a specified geographic area or for special target populations. It can mean an agency, organization, or unit of an agency, organization or institution.
"Qualified brain injury professional" means one of the following who meets the educational and licensure or certification requirements for the profession as required in the state of Iowa and who has two years’ experience working with people living with a brain injury: a psychologist; psychiatrist; physician; physician assistant; registered nurse; certified teacher; licensed clinical social worker; mental health counselor; physical, occupational, recreational, or speech therapist; or a person with a bachelor of arts or science degree in human services, social work, psychology, sociology, or public health or rehabilitation services plus 4,000 hours of direct experience with people living with a brain injury.
"Service coordination" means activities designed to help individuals and families locate, access, and coordinate a network of supports and services that will allow them to live a full life in the community.
"Service plan" means a person-centered, outcome-based plan of services which is written by the member’s case manager with input and direction from the member and which addresses all relevant services and supports being provided. The service plan is developed by the interdisciplinary team, which includes the member and, if appropriate, the member’s legal representative, member’s family, service providers, and others directly involved with the member.
"Skilled nursing facility level of care" means that the following conditions are met:
  1. The member’s medical condition requires skilled nursing services or skilled rehabilitation services as defined in 42 CFR 409.31(a), 409.32, and 409.34.
  2. Services are provided in accordance with the general provisions for all Medicaid providers and services as described in rule 441—79.9(249A).
  3. Documentation submitted for review indicates that the member has:
  1. A physician order for all skilled services.
  2. Services that require the skills of medical personnel, including registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech pathologists, or audiologists.
  3. An individualized care plan that identifies support needs.
  4. Confirmation that skilled services are provided to the member.
  5. Skilled services that are provided by, or under the supervision of, medical personnel as described above.
  6. Skilled nursing services that are needed and provided seven days a week or skilled rehabilitation services that are needed and provided at least five days a week.
"Specialized respite" means respite provided on a staff-to-consumer ratio of one to one or higher to individuals with specialized medical needs requiring the care, monitoring or supervision of a licensed registered nurse or licensed practical nurse.
"Staff" means a person under the direction of the organization to perform duties and responsibilities of the organization.
"Third-party payments" means payments from an individual, institution, corporation, or public or private provider which is liable to pay part or all of the medical costs incurred as a result of injury or disease on behalf of a consumer of medical assistance.
"Usual caregiver" means a person or persons who reside with the consumer and are available on a 24-hour-per-day basis to assume responsibility for the care of the consumer.
Related ARC(s): 0306C, 2361C, 3184C, 3874C, 4792C441—83.82(249A)  Eligibility.  To be eligible for brain injury waiver services a consumer must meet eligibility criteria and be determined to need a service allowable under the program.  83.82(1)    Eligibility criteria.  All of the following criteria must be met. The person must:  a.  Have a diagnosis of brain injury.  b.  Be eligible for Medicaid under SSI, SSI-related, FMAP, or FMAP-related coverage groups or be eligible under the special income level (300 percent) coverage group consistent with a level of care in a medical institution.  c.  Be at least one month of age.  d.  Be a U.S. citizen and Iowa resident.  e.  Rescinded IAB 7/11/01, effective 7/1/01.  f.  Be determined by the IME medical services unit as in need of intermediate care facility for persons with an intellectual disability (ICF/ID), skilled nursing, or ICF level of care based on information submitted on a completed Form 470-4694 for children aged 3 and under, the interRAI - Pediatric Home Care (PEDS-HC) for those aged 4 to 20, or the interRAI - Home Care (HC) for those aged 21 and over, the most recent version of the Mayo-Portland Adaptability Inventory (MPAI), and other supporting documentation as relevant. Form 470-4694, the interRAI - Pediatric Home Care (PEDS-HC), and the interRAI - Home Care (HC), Form 470-4694, and Form 470-5572, the Mayo-Portland Adaptability Inventory (MPAI), are available on request from the member’s managed care organization or the IME medical services unit. Copies of the completed information submission tool for an individual are available to that individual from the individual’s case manager or managed care organization.  g.  Be assessed by the IME medical services unit as able to live in a home- or community-based setting where all medically necessary service needs can be met within the scope of this waiver.  h.  At a minimum, receive a waiver service each quarter in addition to case management.  i.  Choose HCBS.  j.  To be eligible for interim medical monitoring and treatment services the consumer must be:  (1)  Under the age of 21;  (2)  Currently receiving home health agency services under rule 441—78.9(249A) and require medical assessment, medical monitoring, and regular medical intervention or intervention in a medical emergency during those services. (The home health aide services for which the consumer is eligible must be maximized before the consumer accesses interim medical monitoring and treatment.);  (3)  Residing in the consumer’s family home or foster family home; and  (4)  In need of interim medical monitoring and treatment as ordered by a physician.  k.  Receive services in a community, not an institutional, setting.  l.  Be assigned a state payment slot within the yearly total approved by the Centers for Medicare and Medicaid Services.  m.  For the consumer choices option as set forth in rule 441—subrule 78.43(15), not be living in a residential care facility.  n.  For individual supported employment and long-term job coaching services:  (1)  Be at least 16 years of age.  (2)  The services must not be available to the member through one of the following:
  1. Special education and related services as defined in the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.); or
  2. A program funded under Section 110 of the Rehabilitation Act of 1973 (29 U.S.C. 730).
  (3)  Not reside in a medical institution.  (4)  Have documented in the waiver service plan a goal to achieve or to sustain individual employment and an expectation that this service will result in this outcome.
  o.  For small-group supported employment services:  (1)  Be at least 16 years of age.  (2)  The services must not be available to the member through one of the following:
  1. Special education and related services as defined in the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.); or
  2. A program funded under Section 110 of the Rehabilitation Act of 1973 (29 U.S.C. 730).
  (3)  Have documented in the waiver service plan a goal to achieve or to sustain individual employment.  (4)  Have documented in the waiver service plan that the choice to receive individual supported employment services was offered and explained in a manner sufficient to ensure informed choice, after which the choice to receive small-group supported employment services was made.  (5)  Not reside in a medical institution.
  p.  For prevocational services:  (1)  Be at least 16 years of age.  (2)  The services must not be available to the member through one of the following:
  1. Special education and related services as defined in the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.); or
  2. A program funded under Section 110 of the Rehabilitation Act of 1973 (29 U.S.C. 730).
  (3)  Have documented in the waiver service plan a goal to achieve or to sustain individual employment and an expectation that this service will result in community employment.  (4)  Have documented in the waiver service plan that the choice to receive individual supported employment services was offered and explained in a manner sufficient to ensure informed choice, after which the choice to receive prevocational services was made.
  83.82(2)    Need for services.    a.  The applicant shall have a service plan approved by the department that is developed by the certified case manager for this waiver as identified by the county of residence. This must be completed before services provision and annually thereafter. The case manager shall establish the interdisciplinary team for the applicant and, with the team, identify the applicant’s need for service based on the applicant’s needs and desires as well as the availability and appropriateness of services using the following criteria:  (1)  The assessment shall be based, in part, on information provided to the IME medical services unit.  (2)  Service plans must be developed to reflect use of all appropriate nonwaiver Medicaid state services so as not to replace or duplicate those services.  (3)  Service plans for applicants aged 20 or under which include supported community living services beyond intermittent shall not be approved until a home health provider has made a request to cover the service through all nonwaiver Medicaid services.  (4)  Service plans for applicants aged 20 or under which include supported community living services beyond intermittent must be approved (signed and dated) by the designee of the bureau of long-term care. The Medicaid case manager must request in writing more than intermittent supported community living with a summary of services and service costs, and submit a written justification with the service plan. The rationale must contain sufficient information for the bureau’s designee to make a decision regarding the need for supported community living beyond intermittent.  b.  Interim medical monitoring and treatment services must be needed because all usual caregivers are unavailable to provide care due to one of the following circumstances:  (1)  Employment. Interim medical monitoring and treatment services are to be received only during hours of employment.  (2)  Academic or vocational training. Interim medical monitoring and treatment services provided while a usual caregiver participates in postsecondary education or vocational training shall be limited to 24 periods of no more than 30 days each per caregiver as documented by the service worker. Time spent in high school completion, adult basic education, GED, or English as a second language does not count toward the limit.  (3)  Absence from the home due to hospitalization, treatment for physical or mental illness, or death of the usual caregiver. Interim medical monitoring and treatment services under this subparagraph are limited to a maximum of 30 days.  (4)  Search for employment.
  1. Care during job search shall be limited to only those hours the usual caregiver is actually looking for employment, including travel time.
  2. Interim medical monitoring and treatment services may be provided under this paragraph only during the execution of one job search plan of up to 30 working days in a 12-month period, approved by the department service worker or targeted case manager pursuant to 441—subparagraph 170.2(2)“b”(5).
  3. Documentation of job search contacts shall be furnished to the department service worker or targeted case manager.
  c.  The consumer shall access, if a child, all other services for which the person is eligible and which are appropriate to meet the person’s needs as a precondition of eligibility for the HCBS BI waiver.
  83.82(3)    HCBS brain injury (BI) waiver program limit for persons requiring the ICF/MR level of care.  Rescinded IAB 7/11/01, effective 7/1/01.  83.82(4)    Securing a state payment slot.    a.  The county department office shall enter all waiver applications into the individualized services information system (ISIS) to determine if a payment slot is available for all new applicants for the HCBS BI waiver program.  (1)  For applicants not currently receiving Medicaid, the county department office shall make the entry by the end of the fifth working day after receipt of a completed Form 470-2927 or 470-2927(S), Health Services Application, or within five working days after receipt of disability determination, whichever is later.  (2)  For current Medicaid members, the county department office shall make the entry by the end of the fifth working day after receipt of a written request signed and dated by the waiver applicant.  b.  If no payment slot is available, the department shall enter the applicant on a waiting list according to the following:  (1)  Applicants not currently eligible for Medicaid shall be entered on the waiting list on the basis of the date a completed Form 470-2927 or 470-2927(S), Health Services Application, is received by the department or upon receipt of disability determination, whichever is later. Applicants currently eligible for Medicaid shall be added to the waiting list on the basis of the date the applicant requests HCBS BI program services.  (2)  In the event that more than one application is received at one time, applicants shall be entered on the waiting list on the basis of the month of birth, January being month one and the lowest number.  c.  Persons who do not fall within the available slots shall have their applications rejected but their names shall be maintained on the waiting list. As slots become available, persons shall be selected from the waiting list to maintain the number of approved persons on the program based on their order on the waiting list.  d.  Applicants who currently reside in a community-based neurobehavioral rehabilitation residential setting, an intermediate care facility for persons with an intellectual disability (ICF/ID), a skilled nursing facility, or an ICF and have resided in that setting for six or more months may request a reserved capacity slot through the brain injury waiver.  (1)  Applicants shall be allocated a reserved capacity slot on the basis of the date the request is received by the income maintenance worker or the waiver slot manager.  (2)  In the event that more than one request for a reserved capacity slot is received at one time, applicants shall be allocated the next available reserved capacity slot on the basis of the month of birth, January being month one and the lowest number.  (3)  Persons who do not fall within the available reserved capacity slots shall have their names maintained on the reserved capacity slot waiting list. As reserved capacity slots become available at the beginning of the next waiver year, persons shall be selected from the reserved capacity slot waiting list to utilize the number of approved reserved capacity slots based on their order on the waiting list.  e.  The department shall reserve a set number of funding slots each waiver year for emergency need for all applicants who are on the waiting list maintained by the state on July 1, 2019, and for all new applications received on or after July 1, 2019. Applicants may request an emergency need reserved capacity slot by submitting the completed Home- and Community-Based Services (HCBS) Brain Injury Waiver Emergency Need Assessment, Form 470-5583, to the IME medical services unit.   (1)  Emergency need criteria are as follows:  1.  The usual caregiver has died or is incapable of providing care, and no other caregivers are available to provide needed supports.   2.  The applicant has lost primary residence or will be losing housing within 30 days and has no other housing options available.  3.  The applicant is living in a homeless shelter, and no alternative housing options are available.  4.  There is founded abuse or neglect by a caregiver or others living within the home of the applicant, and the applicant must move from the home.  5.  The applicant cannot meet basic health and safety needs without immediate supports.  (2)  Urgent need criteria are as follows:  1.  The caregiver will need support within 60 days in order for the applicant to remain living in the current situation.  2.  The caregiver will be unable to continue to provide care within the next 60 days.  3.  The caregiver is 55 years of age or older and has a chronic or long-term physical or psychological condition that limits the ability to provide care.  4.  The applicant is living in temporary housing and plans to move within 31 to 120 days.  5.  The applicant is losing permanent housing and plans to move within 31 to 120 days.  6.  The caregiver will be unable to be employed if services are not available.  7.  There is a potential risk of abuse or neglect by a caregiver or others within the home of the applicant.  8.  The applicant has behaviors that put the applicant at risk.  9.  The applicant has behaviors that put others at risk.  10.  The applicant is at risk of facility placement when needs could be met through community-based services.  (3)  Applicants who meet an emergency need criterion shall be placed on the emergency reserved capacity priority waiting list based on the total number of criteria in subparagraph 83.82(4)“e”(1) that are met. If applicants meet an equal number of criteria, the position on the waiting list shall be based on the date of application and the age of the applicant. The applicant who has been on the waiting list longer shall be placed higher on the waiting list. If the application date is the same, the older applicant shall be placed higher on the waiting list.  (4)  Applicants who meet an urgent need criterion shall be placed on the priority waiting list after applicants who meet emergency need criteria. The position on the waiting list shall be based on the total number of criteria in subparagraph 83.82(4)“e”(2) that are met. If applicants meet an equal number of criteria, the position on the waiting list shall be based on the date of application and the age of the applicant. The applicant who has been on the waiting list longer shall be placed higher on the waiting list. If the application date is the same, the older applicant shall be placed higher on the waiting list.  (5)  Applicants who do not meet emergency or urgent need criteria shall remain on the waiting list, based on the date of application. If the application date is the same, the older applicant shall be placed higher on the waiting list.  (6)  Applicants shall remain on the waiting list until a payment slot has been assigned to them for use, they withdraw from the list, or they become ineligible for the waiver. If there is a change in an applicant’s need, the applicant may contact the local department office and request that a new emergency needs assessment be completed. The outcome of the assessment shall determine placement on the waiting list as directed in this subrule.  f.  To maintain the approved number of members in the program, persons shall be selected from the waiting list as payment slots become available, based on their priority order on the waiting list.  (1)  Once a payment slot is assigned, the department shall give written notice to the person within five working days.  (2)  The department shall hold the payment slot for 30 days for the person to file a new application. If an application has not been filed within 30 days, the slot shall revert for use by the next person on the waiting list, if applicable. The person originally assigned the slot must reapply for a new slot.
Related ARC(s): 0191C, 0306C, 0359C, 0548C, 0665C, 0842C, 1056C, 1445C, 2471C, 2848C, 2936C, 3184C, 4792C, 4974C441—83.83(249A)  Application.    83.83(1)    Application for financial eligibility.  The application process as specified in rules 441—76.1(249A) to 441—76.6(249A) shall be followed.  83.83(2)    Approval of application for eligibility.    a.  Applications for the determination of ability of the consumer to have all medically necessary service needs met within the scope of this waiver shall be initiated on behalf of the consumer and with the consumer’s consent or with the consent of the consumer’s legal representative by the discharge planner of the medical facility where the consumer resides at the time of application or the case manager. The discharge planner or case manager shall provide to the IME medical services unit all appropriate information needed regarding all the medically necessary service needs of the consumer. After completing the determination of ability to have all medically necessary service needs met within the scope of this waiver, the IME medical services unit shall inform the discharge planner or case manager on behalf of the consumer or the consumer’s legal representative and send to the income maintenance worker a copy of the decision as to whether all of the consumer’s service needs can be met in a home- or community-based setting.  b.  Eligibility for the HCBS BI waiver shall be effective as of the date when both the service eligibility and financial eligibility have been completed. Decisions shall be mailed or given to the consumer or the consumer’s legal representative on the date when each eligibility determination is completed.  c.  An applicant shall be given the choice between waiver services and institutional care. The applicant or legal representative shall sign the applicable information submission tool listed in paragraph 83.82(1)“f,” indicating that the applicant has elected home- and community-based services. This shall be arranged by the medical facility discharge planner or case manager.  d.  The medical facility discharge planner, if there is one involved, shall contact the consumer’s managed care organization or the designated case manager to initiate development of the consumer’s service plan and initiation of waiver services.  e.  HCBS BI waiver services provided prior to both approvals of eligibility for the waiver cannot be paid.  f.  HCBS BI waiver services are not available in conjunction with other HCBS waiver programs or group foster care services.  g.  The Medicaid case manager shall establish an HCBS BI waiver interdisciplinary team for each consumer and, with the team, identify the consumer’s “need for service” based on the consumer’s needs and desires as well as the availability and appropriateness of services.  83.83(3)    Effective date of eligibility.    a.  The effective date of eligibility for the waiver for persons who are already determined eligible for Medicaid is the date on which the person is determined to meet all of the criteria set forth in rule 441—83.82(249A).  b.  The effective date of eligibility for the waiver for persons who qualify for Medicaid due to eligibility for the waiver services is the date on which the person is determined to meet all of the criteria set forth in rule 441—83.82(249A) and when the eligibility factors set forth in 441—subrule 75.1(7) and for married persons, in rule 441—75.5(249A), have been satisfied.  c.  Eligibility for the waiver continues until the consumer fails to meet eligibility criteria listed in rule 441—83.82(249A). Consumers who return to inpatient status in a medical institution for more than 120 consecutive days shall be reviewed by the IME medical services unit to determine additional inpatient needs for possible termination from the brain injury waiver. The consumer shall be reviewed for eligibility under other Medicaid coverage groups in accordance with rule 441—76.11(249A). The consumer shall be notified of that decision through Form 470-0602, Notice of Decision.If the consumer returns home before the effective date of the notice of decision and the consumer’s condition has not substantially changed, the denial may be rescinded and eligibility may continue.  83.83(4)    Attribution of resources.  For the purposes of attributing resources as provided in rule 441—75.5(249A), the date on which the waiver consumer meets the level of care criteria in a medical institution as established by the peer review organization shall be used as the date of entry to the medical institution. Only one attribution of resources shall be completed per person. Attributions completed for prior institutionalizations shall be applied to the waiver application.Related ARC(s): 0306C, 3184C, 3234C441—83.84(249A)  Client participation.  Consumers who are financially eligible under 441—subrule 75.1(7) (the 300 percent group) must contribute a predetermined participation amount to the cost of brain injury waiver services.  83.84(1)    Computation of client participation.  Client participation shall be computed by deducting an amount for the maintenance needs of the consumer which is 300 percent of the maximum SSI grant for an individual from the consumer’s total income. For a couple, client participation is determined as if each person were an individual.  83.84(2)    Limitation on payment.  If the sum of the third-party payment and client participation equals or exceeds the reimbursement for the specific brain injury waiver service, Medicaid shall make no payments for the waiver service. However, Medicaid shall make payments to other medical providers.441—83.85(249A)  Redetermination.  A complete financial redetermination of eligibility for brain injury waiver shall be completed at least once every 12 months. A redetermination of continuing eligibility factors shall be made when a change in circumstances occurs that affects eligibility in accordance with rule 441—83.82(249A). A redetermination shall contain the components listed in rule 441—83.82(249A).441—83.86(249A)  Allowable services.  Services allowable under the brain injury waiver are case management, respite, personal emergency response, supported community living, behavioral programming, family counseling and training, home and vehicle modification, specialized medical equipment, prevocational services, transportation, supported employment, adult day care, consumer-directed attendant care, interim medical monitoring and treatment, financial management, independent support brokerage, self-directed personal care, self-directed community supports and employment, and individual-directed goods and services as set forth in rule 441—78.43(249A).441—83.87(249A)  Service plan.  A service plan shall be prepared and utilized for each HCBS BI waiver consumer. The service plan shall be developed by an interdisciplinary team, which includes the consumer, and, if appropriate, the legal representative, consumer’s family, case manager, providers, and others directly involved. The service plan shall be stored by the case manager for a minimum of three years. The service plan staffing shall be conducted before the current service plan expires.  83.87(1)    Information in plan.  The plan shall be in accordance with 441—subrule 24.4(3) and shall additionally include the following information to assist in evaluating the program:  a.  A listing of all services received by a consumer at the time of waiver program enrollment.  b.  For supported community living:  (1)  The consumer’s living environment at the time of waiver enrollment.  (2)  The number of hours per day of on-site staff supervision needed by the consumer.  (3)  The number of other waiver consumers who will live with the consumer in the living unit.  c.  An identification and justification of any restriction of a consumer’s rights including, but not limited to:  (1)  Maintenance of personal funds.  (2)  Self-administration of medications.  d.  The names of all providers responsible for providing all services.  e.  All service funding sources.  f.  The amount of the service to be received by the consumer.  g.  Whether the consumer has elected the consumer choices option and, if so:  (1)  The independent support broker selected by the consumer; and  (2)  The financial management service selected by the consumer.  h.  A plan for emergencies and identification of the supports available to the consumer in an emergency.  83.87(2)    Use of nonwaiver services.  Service plans must be developed to reflect use of all appropriate nonwaiver Medicaid services and so as not to replace or duplicate those services. Service plans for members aged 20 or under which include supported community living services beyond intermittent must be approved (signed and dated) by the designee of the bureau of long-term care. The Medicaid case manager shall attach a written request for a variance from the limitation on supported community living to intermittent.  83.87(3)    Annual assessment.  The IME medical services unit shall assess the member annually and certify the member’s need for long-term care services. The IME medical services unit shall be responsible for determining the level of care based on the completed information submission tool listed in paragraph 83.82(1)“f” and other supporting documentation as relevant.  a.  The IME medical services unit or the member’s managed care organization shall be responsible for annual redetermination of the level of care.  b.  The managed care organization must submit documentation to the IME medical services unit for all reassessments, performed at least annually, which indicate a change in the member’s level of care. The IME medical services unit shall make a final determination for any reassessments which indicate a change in the level of care. If the level of care reassessment indicates no change in level of care, the member is approved to continue at the already established level of care.  83.87(4)    Service file.  The Medicaid case manager must ensure that the consumer service file contains the consumer’s service plan.  a.  Rescinded IAB 8/7/02, effective 10/1/02.  b.  Rescinded IAB 8/7/02, effective 10/1/02.  c.  Rescinded IAB 8/7/02, effective 10/1/02.  d.  Rescinded IAB 8/7/02, effective 10/1/02.Related ARC(s): 0191C, 0306C, 0359C, 2361C, 3184C441—83.88(249A)  Adverse service actions.    83.88(1)    Denial.  An application for services shall be denied when it is determined by the department that:  a.  The consumer is not eligible for the services because all of the medically necessary service needs cannot be met in a home- or community-based setting.  b.  Service needs exceed the service unit or reimbursement maximums.  c.  Service needs are not met by the services provided.  d.  Needed services are not available or received from qualifying providers.  e.  The brain injury waiver service is not identified in the consumer’s service plan.  f.  There is another community resource available to provide the service or a similar service free of charge to the consumer that will meet the consumer’s needs.  g.  The consumer receives services from other Medicaid waiver providers.  h.  The consumer or legal representative through the interdisciplinary process requests termination from the services.  83.88(2)    Reduction.  A particular service may be reduced when the department determines that the provisions of 441—subrule 130.5(3), paragraph “a” or “b,” apply.  83.88(3)    Termination.  A particular service may be terminated when the department determines that:  a.  The provisions of 441—subrule 130.5(2), paragraph “d,” “g,” or “h,” apply.  b.  Needed services are not available or received from qualifying providers.  c.  The brain injury waiver service is not identified in the consumer’s annual service plan.  d.  Service needs are not met by the services provided.  e.  Services needed exceed the service unit or reimbursement maximums.  f.  Completion or receipt of required documents by the department or the medical facility discharge planner for the brain injury waiver service consumer has not occurred.  g.  The consumer receives services from other Medicaid providers.  h.  The consumer or legal representative through the interdisciplinary process requests termination from the services.441—83.89(249A)  Appeal rights.  Notice of adverse action and right to appeal shall be given in accordance with 441—Chapter 7, rule 441—16.3(17A) and rule 441—130.5(234).Related ARC(s): 0191C, 0306C, 0359C, 4973C441—83.90(249A)  County reimbursement.  Rescinded ARC 0191C, IAB 7/11/12, effective 7/1/12.441—83.91(249A)  Conversion to the X-PERT system.  Rescinded IAB 8/7/02, effective 10/1/02.These rules are intended to implement Iowa Code sections 249A.3 and 249A.4.441—83.92    Reserved.441—83.93    Reserved.441—83.94    Reserved.441—83.95    Reserved.441—83.96    Reserved.441—83.97    Reserved.441—83.98    Reserved.441—83.99    Reserved.441—83.100    Reserved.DIVISION VI—PHYSICAL DISABILITY WAIVER SERVICES441—83.101(249A)  Definitions.  
"Adaptive" means age-appropriate skills related to taking care of one’s self and the ability to relate to others in daily living situations. These skills include limitations that occur in the areas of communication, self-care, home living, social skills, community use, self-direction, safety, functional academics, leisure and work.
"Adult" means a person with a physical disability aged 18 years to 64 years.
"Appropriate" means that the services or supports or activities provided or undertaken by the organization are relevant to the consumer’s needs, situation, problems, or desires.
"Assessment" means the review of the consumer’s current functioning in regard to the consumer’s situation, needs, strengths, abilities, desires and goals.
"Attorney in fact under a durable power of attorney for health care" means an individual who is designated by a durable power of attorney for health care, pursuant to Iowa Code chapter 144B, as an agent to make health care decisions on behalf of an individual and who has consented to act in that capacity.
"Behavior" means skills related to regulating one’s own behavior including coping with demands from others, making choices, controlling impulses, conforming conduct to laws, and displaying appropriate sociosexual behavior.
"Client participation" means the amount of the consumer’s income that the person must contribute to the cost of physical disability waiver services, exclusive of medical vendor payments, before Medicaid will provide additional reimbursement.
"Department" means the Iowa department of human services.
"Guardian" means a guardian appointed in probate court for an adult.
"Intermediate care facility for persons with an intellectual disability level of care" means that the individual has a diagnosis of intellectual disability made in accordance with the criteria provided in the current version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association; or has a related condition as defined in 42 CFR 435.1009; and needs assistance in at least three of the following major life areas: mobility, musculoskeletal skills, activities of daily living, domestic skills, toileting, eating skills, vision, hearing or speech or both, gross/fine motor skills, sensory-taste, smell, tactile, academic skills, vocational skills, social/community skills, behavior, and health care.
"Managed care organization" means an entity that (1) is under contract with the department to provide services to Medicaid recipients and (2) meets the definition of “health maintenance organization” as defined in Iowa Code section 514B.1.
"Medical institution" means a nursing facility, a skilled nursing facility, intermediate care facility for persons with an intellectual disability, or hospital which has been approved as a Medicaid vendor.
"Nursing facility level of care" means that the following conditions are met:
  1. The presence of a physical or mental impairment which restricts the member’s daily ability to perform the essential activities of daily living, bathing, dressing, and personal hygiene, and impedes the member’s capacity to live independently.
  2. The member’s physical or mental impairment is such that self-execution of required nursing care is improbable or impossible.
"Physical disability" means a severe, chronic condition that is attributable to a physical impairment that results in substantial limitations of physical functioning in three or more of the following areas of major life activities: self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, and economic self-sufficiency.
"Service plan" means a person-centered, outcome-based plan of services which is written by the member’s case manager with input and direction from the member and which addresses all relevant services and supports being provided. The service plan is developed by the interdisciplinary team, which includes the member and, if appropriate, the member’s legal representative, member’s family, service providers, and others directly involved with the member.
"Skilled nursing facility level of care" means that the following conditions are met:
  1. The member’s medical condition requires skilled nursing services or skilled rehabilitation services as defined in 42 CFR 409.31(a), 409.32, and 409.34.
  2. Services are provided in accordance with the general provisions for all Medicaid providers and services as described in rule 441—79.9(249A).
  3. Documentation submitted for review indicates that the member has:
  1. A physician order for all skilled services.
  2. Services that require the skills of medical personnel, including registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech pathologists, or audiologists.
  3. An individualized care plan that identifies support needs.
  4. Confirmation that skilled services are provided to the member.
  5. Skilled services that are provided by, or under the supervision of, medical personnel as described above.
  6. Skilled nursing services that are needed and provided seven days a week or skilled rehabilitation services that are needed and provided at least five days a week.
"Third-party payments" means payments from an individual, institution, corporation, or public or private provider which is liable to pay part or all of the medical costs incurred as a result of injury or disease on behalf of a consumer of medical assistance.
"Waiver year" means a 12-month period commencing on April 1 of each year.
Related ARC(s): 0306C, 2361C, 3874C441—83.102(249A)  Eligibility.  To be eligible for physical disability waiver services, a consumer must meet eligibility criteria set forth in subrule 83.102(1) and be determined to need a service allowable under the program per subrule 83.102(2).  83.102(1)    Eligibility criteria.  All of the following criteria must be met. The person must:  a.  Have a physical disability.  b.  Be blind or disabled as determined by the receipt of social security disability benefits or by a disability determination made through the department. Disability determinations are made according to supplemental security income guidelines under Title XVI of the Social Security Act or the disability guidelines for the Medicaid employed people with disabilities coverage group.  c.  Be ineligible for the HCBS intellectual disability waiver.  d.  Have the ability to hire, supervise, and fire the provider as determined by the service worker, and be willing to do so, or have a parent or guardian named by probate court, or attorney in fact under a durable power of attorney for health care who will take this responsibility on behalf of the consumer.  e.  Be eligible for Medicaid under 441—Chapter 75.  f.  Be aged 18 years to 64 years.  g.  Rescinded IAB 2/7/01, effective 2/1/01.  h.  Be in need of skilled nursing or intermediate care facility level of care based on information submitted on a completed interRAI - Pediatric Home Care (PEDS-HC) for those aged 18 to 20 or the interRAI - Home Care (HC) for those aged 21 and over and other supporting documentation as relevant. The interRAI - Pediatric Home Care (PEDS-HC) and the interRAI - Home Care (HC) are available on request from the IME medical services unit. Copies of the completed information submission tool for an individual are available to that individual from the individual’s case manager or managed care organization.  (1)  Initial decisions on level of care shall be made for the department by the IME medical services unit within two working days of receipt of medical information. The IME medical services unit determines whether the level of care requirement is met based on medical necessity and the appropriateness of the level of care under 441—subrules 79.9(1) and 79.9(2).  (2)  Adverse decisions by the IME medical services unit may be appealed to the department pursuant to 441—Chapter 7.  i.  Choose HCBS.  j.  Use a minimum of one unit of service per calendar quarter under this program.  k.  For the consumer choices option as set forth in 441—subrule 78.46(6), not be living in a residential care facility.  83.102(2)    Need for services.    a.  The applicant shall have a service plan which is developed by the applicant and a department service worker. The plan must be completed and approved before service provision.  (1)  The designated case manager shall identify the need for service based on the needs of the applicant, as documented in the information submission tool listed in 83.102(1)“h,” as well as the availability and appropriateness of services.  (2)  The service worker shall have a face-to-face visit with the member at least annually.  b.  The total cost of physical disability waiver services, excluding the cost of home and vehicle modifications, shall not exceed $705.84 per month.  83.102(3)    Slots.  The total number of persons receiving HCBS physical disability waiver services in the state shall be limited to the number provided in the waiver approved by the Secretary of the U.S. Department of Health and Human Services. These slots shall be available on a first-come, first-served basis.  83.102(4)    County payment slots for persons requiring the ICF/MR level of care.  Rescinded IAB 10/6/99, effective 10/1/99.  83.102(5)    Securing a slot.    a.  The county department office shall enter all waiver applications into the individualized services information system (ISIS) to determine if a slot is available for all new applicants for the HCBS physical disability waiver program.  (1)  For applicants not currently receiving Medicaid, the county department office shall make the entry by the end of the fifth working day after receipt of a completed Form 470-2927 or 470-2927(S), Health Services Application, or within five working days after receipt of disability determination, whichever is later.  (2)  For current Medicaid members, the county department office shall make the entry by the end of the fifth working day after receipt of a written request signed and dated by the waiver applicant.  b.  If no slot is available, the department shall enter applicants on the HCBS physical disabilities waiver waiting list according to the following:  (1)  Applicants not currently eligible for Medicaid shall be entered on the basis of the date a completed Form 470-2927 or 470-2927(S), Health Services Application, is received by the department or upon receipt of disability determination, whichever is later. Applicants currently eligible for Medicaid shall be added on the basis of the date the applicant requests HCBS physical disability program services. In the event that more than one application is received on the same day, applicants shall be entered on the waiting list on the basis of the day of the month of their birthday, the lowest number being first on the list. Any subsequent tie shall be decided by the month of birth, January being month one and the lowest number.  (2)  Persons who do not fall within the available slots shall have their applications rejected but their names shall be maintained on the waiting list. As slots become available, persons shall be selected from the waiting list to maintain the number of approved persons on the program based on their order on the waiting list.  83.102(6)    Securing a county payment slot.  Rescinded IAB 10/6/99, effective 10/1/99.  83.102(7)    HCBS physical disability waiver waiting list.  When services are denied because the limit on the number of slots is reached, a notice of decision denying service based on the limit and stating that the person’s name shall be put on a waiting list shall be sent to the person by the department.Related ARC(s): 9650B, 0306C, 0548C, 0665C, 0842C, 1056C, 1445C, 2848C, 2936C, 3184C441—83.103(249A)  Application.    83.103(1)    Application for financial eligibility.  The application process as specified in rules 441—76.1(249A) to 441—76.6(249A) shall be followed. Applications for this program may only be filed on or after April 1, 1999.  83.103(2)    Approval of application for eligibility.    a.  Applications for this waiver shall be initiated on behalf of the applicant who is a resident of a medical institution with the applicant’s consent or with the consent of the applicant’s legal representative by the discharge planner of the medical facility where the applicant resides at the time of application.  (1)  The discharge planner shall contact the member’s managed care organization or designated case manager to arrange for completion of the appropriate information submission tool as listed in paragraph 83.102(1)“h.”  (2)  After completing the determination of the level of care needed by the applicant, the IME medical services unit shall inform the income maintenance worker and the discharge planner of the IME medical services unit’s decision.  b.  Applications for this waiver shall be initiated by the applicant, the applicant’s parent or legal guardian, or the applicant’s attorney in fact under a durable power of attorney for health care on behalf of the applicant who is residing in the community.  (1)  The applicant’s managed care organization or the designated case manager shall arrange for the completion of the appropriate information submission tool as listed in paragraph 83.102(1)“h” and submit it to the IME medical services unit.  (2)  After completing the determination of the level of care needed by the applicant, the IME medical services unit shall inform the income maintenance worker and the applicant, the applicant’s parent or legal guardian, or the applicant’s attorney in fact under a durable power of attorney for health care.  c.  Eligibility for this waiver shall be effective as of the date when both the eligibility criteria in subrule 83.102(1) and need for services in subrule 83.102(2) have been established. Decisions shall be mailed or given to the applicant, the applicant’s parent or legal guardian, or the applicant’s attorney in fact under a durable power of attorney for health care on the date when each eligibility determination is completed.  d.  An applicant shall be given the choice between waiver services and institutional care. The applicant or the applicant’s parent, legal guardian, or attorney in fact under a durable power of attorney for health care shall sign the information submission tool, indicating that the applicant has elected home- and community-based services.  e.  The applicant, the applicant’s parent or guardian, or the applicant’s attorney in fact under a durable power of attorney for health care shall cooperate with the designated case manager in the development of the service plan prior to the start of services.  f.  HCBS physical disability waiver services provided prior to both approvals of eligibility for the waiver cannot be paid.  g.  HCBS physical disability waiver services are not available in conjunction with other HCBS waiver programs. The consumer may also receive in-home health-related care service if eligible for that program.  83.103(3)    Effective date of eligibility.    a.  The effective date of eligibility for the waiver for persons who are already determined eligible for Medicaid is the date on which the person is determined to meet all of the criteria set forth in subrule 83.102(1).  b.  The effective date of eligibility for the waiver for persons who qualify for Medicaid due to eligibility for the waiver services is the date on which the person is determined to meet all of the criteria set forth in subrule 83.102(1) and when the eligibility factors set forth in 441—subrule 75.1(7) and, for married persons, in rule 441—75.5(249A), have been satisfied.  c.  Eligibility for the waiver continues until the consumer fails to meet eligibility criteria listed in subrule 83.102(1). Consumers who return to inpatient status in a medical institution for more than 120 consecutive days shall be reviewed by the IME medical services unit to determine additional inpatient needs for possible termination from the physical disability waiver. The consumer shall be reviewed for eligibility under other Medicaid coverage groups in accordance with rule 441—76.11(249A). The consumer shall be notified of that decision through Form 470-0602, Notice of Decision.If the consumer returns home before the effective date of the notice of decision and the consumer’s condition has not substantially changed, the denial may be rescinded and eligibility may continue.  83.103(4)    Attribution of resources.  For the purposes of attributing resources as provided in rule 441—75.5(249A), the date on which the waiver consumer meets the institutional level of care requirement as determined by the IME medical services unit or an appeal decision shall be used as the date of entry to the medical institution. Only one attribution of resources shall be completed per person. Attributions completed for a prior institutionalization shall be applied to the waiver application.Related ARC(s): 0306C, 2361C, 3184C, 3234C441—83.104(249A)  Client participation.  Consumers who are financially eligible under 441—subrule 75.1(7) (the 300 percent group) must contribute a client participation amount to the cost of physical disability waiver services.  83.104(1)    Computation of client participation.  Client participation shall be computed by deducting a maintenance needs allowance equal to 300 percent of the maximum SSI grant for an individual from the consumer’s total income. For a couple, client participation is determined as if each person were an individual.  83.104(2)    Limitation on payment.  If the sum of the third-party payment and client participation equals or exceeds the reimbursement for the specific physical disability waiver service, Medicaid shall make no payments for the waiver service. However, Medicaid shall make payments to other medical providers.441—83.105(249A)  Redetermination.  A complete financial redetermination of eligibility for the physical disability waiver shall be completed at least once every 12 months. A redetermination of continuing eligibility factors shall be made when a change in circumstances occurs that affects eligibility in accordance with rule 441—83.102(249A). A redetermination shall contain the components listed in rule 441—83.102(249A).441—83.106(249A)  Allowable services.  The services allowable under the physical disability waiver are consumer-directed attendant care, home and vehicle modification, personal emergency response system, transportation, specialized medical equipment, financial management, independent support brokerage, self-directed personal care, self-directed community supports and employment, and individual-directed goods and services as set forth in rule 441—78.46(249A).441—83.107(249A)  Individual service plan.  An individualized service plan shall be prepared and used for each HCBS physical disability waiver consumer. The service plan shall be developed and approved by the consumer, the consumer’s interdisciplinary team and the designated case manager prior to services beginning and payment being made to the provider.   83.107(1)    Information in plan.  The plan shall be in accordance with 441—subrule 24.4(3) and shall additionally include the following information to assist in evaluating the program:  a.  A listing of all services received by a consumer at the time of waiver program enrollment.  b.  The name of all providers responsible for providing all services.  c.  All service funding sources.  d.  The amount of the service to be received by the consumer.  e.  Whether the consumer has elected the consumer choices option and, if so:  (1)  The independent support broker selected by the consumer; and  (2)  The financial management service selected by the consumer.  f.  A plan for emergencies and identification of the supports available to the consumer in an emergency.  83.107(2)    Annual assessment.  The IME medical services unit or a managed care organization shall review the member’s need for continued care annually and recertify the member’s need for long-term care services, pursuant to paragraph 83.102(1)“h” and the appeal process at rule 441—83.109(249A), based on the appropriate information submission tool as listed in paragraph 83.102(1)“h” and other supporting documentation as relevant.  a.  The IME medical services unit or the member’s managed care organization shall be responsible for annual redetermination of the level of care.  b.  The managed care organization must submit documentation to the IME medical services unit for all reassessments, performed at least annually, which indicate a change in the member’s level of care. The IME medical services unit shall make a final determination for any reassessments which indicate a change in the level of care. If the level of care reassessment indicates no change in level of care, the member is approved to continue at the already established level of care.  83.107(3)    Case file.  Rescinded IAB 8/7/02, effective 10/1/02.Related ARC(s): 0306C, 2361C, 3184C441—83.108(249A)  Adverse service actions.    83.108(1)    Denial.  An application for services shall be denied when it is determined by the department that:  a.  All of the medically necessary service needs cannot be met in a home- or community-based setting.  b.  Service needs exceed the reimbursement maximums.  c.  Service needs are not met by the services provided.  d.  Needed services are not available or received from qualifying providers.  e.  The physical disability waiver service is not identified in the consumer’s service plan.  f.  There is another community resource available to provide the service or a similar service free of charge to the consumer that will meet the consumer’s needs.  g.  The consumer receives services from other Medicaid waiver providers.  h.  The consumer or legal representative requests termination from the services.  83.108(2)    Reduction.  A particular service may be reduced when the department determines that the provisions of 441—subrule 130.5(3), paragraph “a” or “b,” apply.  83.108(3)    Termination.  A particular service may be terminated when the department determines that:  a.  The provisions of 441—subrule 130.5(2), paragraph “d,” “g,” or “h,” apply.  b.  Needed services are not available or received from qualifying providers.  c.  The physical disability waiver service is not identified in the consumer’s annual service plan.  d.  Service needs are not met by the services provided.  e.  Services needed exceed the service unit or reimbursement maximums.  f.  Completion or receipt of required documents by the consumer for the physical disability waiver service has not occurred.  g.  The consumer receives services from other Medicaid providers.  h.  The consumer or legal representative requests termination from the services.441—83.109(249A)  Appeal rights.  Notice of adverse action and right to appeal shall be given in accordance with 441—Chapter 7, rule 441—16.3(17A) and rule 441—130.5(234).  83.109(1)    Appeal to county.  Rescinded IAB 2/7/01, effective 2/1/01.  83.109(2)    Reconsideration request to IME medical services unit.  Rescinded IAB 9/5/12, effective 11/1/12.Related ARC(s): 0306C, 4973C441—83.110(249A)  County reimbursement.  Rescinded IAB 10/6/99, effective 10/1/99.441—83.111(249A)  Conversion to the X-PERT system.  Rescinded IAB 8/7/02, effective 10/1/02.These rules are intended to implement Iowa Code sections 249A.3 and 249A.4.441—83.112    Reserved.441—83.113    Reserved.441—83.114    Reserved.441—83.115    Reserved.441—83.116    Reserved.441—83.117    Reserved.441—83.118    Reserved.441—83.119    Reserved.441—83.120    Reserved.DIVISION VII—HCBS CHILDREN’S MENTAL HEALTH WAIVER SERVICES441—83.121(249A)  Definitions.  
"Assessment" means the review of the consumer’s current functioning in regard to the consumer’s situation, needs, abilities, desires, and goals.
"Care coordinator" means the professional who assists members in care coordination as described in 441—paragraph 78.53(1)“b.”
"Case manager" means the person designated to provide Medicaid targeted case management services for the consumer.
"CMS" means the Centers for Medicare and Medicaid Services, a division of the U.S. Department of Health and Human Services.
"Consumer" means an individual up to the age of 18 who is included in a Medicaid coverage group listed in 441—75.1(249A) and is a recipient of children’s mental health waiver services.
"Deeming" means considering parental or spousal income or resources as income or resources of a consumer in determining eligibility for a consumer according to Supplemental Security Income program guidelines.
"Department" means the Iowa department of human services.
"Guardian" means a parent of a consumer or a legal guardian appointed by the court.
"HCBS" means home- and community-based services provided under a Medicaid waiver.
"IME" means the Iowa Medicaid enterprise.
"IME medical services unit" means the contracted entity in the Iowa Medicaid enterprise that determines level of care for consumers initially applying for or continuing to receive children’s mental health waiver services.
"Integrated health home" means the provision of services to enrolled members as described in 441—subrule 78.53(1).
"Interdisciplinary team" means the consumer, the consumer’s family, and persons of varied professional and nonprofessional backgrounds with knowledge of the consumer’s needs, as designated by the consumer and the consumer’s family, who meet to develop a service plan based on the individualized needs of the consumer.
"ISIS" means the department’s individualized services information system.
"Local office" means a department of human services office as described in 441—subrule 1.4(2).
"Managed care organization" means an entity that (1) is under contract with the department to provide services to Medicaid recipients and (2) meets the definition of “health maintenance organization” as defined in Iowa Code section 514B.1.
"Medical institution" means a nursing facility, an intermediate care facility for persons with an intellectual disability, a psychiatric hospital or psychiatric medical institution for children, or a state mental health institute that has been approved as a Medicaid vendor.
"Mental health professional" means a person who meets all of the following conditions:
  1. Holds at least a master’s degree in a mental health field including, but not limited to, psychology, counseling and guidance, psychiatric nursing and social work; or is a doctor of medicine or osteopathic medicine; and
  2. Holds a current Iowa license when required by the Iowa professional licensure laws (such as a psychiatrist, a psychologist, a marital and family therapist, a mental health counselor, an advanced registered nurse practitioner, a psychiatric nurse, or a social worker); and
  3. Has at least two years of postdegree experience supervised by a mental health professional in assessing mental health problems, mental illness, and service needs and in providing mental health services.
"Psychiatric medical institution for children level of care" means that the member has been diagnosed with a serious emotional disturbance and an independent team as identified in 441—subrule 85.22(3) has certified that ambulatory care resources available in the community do not meet the treatment needs of the recipient, that proper treatment of the recipient’s psychiatric condition requires services on an inpatient basis under the direction of a physician, and that the services can reasonably be expected to improve the recipient’s condition or prevent further regression so that the services will no longer be needed.
"Serious emotional disturbance" means a diagnosable mental, behavioral, or emotional disorder that (1) is of sufficient duration to meet diagnostic criteria for the disorder specified by the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association; and (2) has resulted in a functional impairment that substantially interferes with or limits a consumer’s role or functioning in family, school, or community activities. “Serious emotional disturbance” shall not include neurodevelopmental disorders, substance-related disorders, or conditions or problems classified in the current version of the DSM as “other conditions that may be a focus of clinical attention,” unless these conditions co-occur with another diagnosable serious emotional disturbance.
"Service plan" means a person-centered, outcome-based plan of services that is written by the member’s case manager with input and direction from the member and that addresses all relevant services and supports being provided. The service plan is developed by the interdisciplinary team, which includes the member and, if appropriate, the member’s legal representative, member’s family, service providers, and others directly involved with the member.
"Skill development" means that the service provided is habilitative and is intended to impart an ability or capacity to the consumer. Supervision without habilitation is not skill development.
"Targeted case management" means Medicaid case management services accredited under 441—Chapter 24 and provided according to 441—Chapter 90 for consumers eligible for the children’s mental health waiver.
"Waiver year" for the children’s mental health waiver means a 12-month period commencing on July 1 of each year.
Related ARC(s): 0306C, 2164C, 2361C, 3184C, 3874C441—83.122(249A)  Eligibility.  To be eligible for children’s mental health waiver services, a consumer must meet all of the following requirements:  83.122(1)    Age.  The consumer must be under 18 years of age.  83.122(2)    Diagnosis.  The consumer must be diagnosed with a serious emotional disturbance.  a.    Initial certification.  For initial application to the HCBS children’s mental health waiver program, psychological documentation that substantiates a mental health diagnosis of serious emotional disturbance as determined by a mental health professional must be current within the 12-month period before the application date.  b.    Ongoing certification.  A mental health professional must complete an annual evaluation that substantiates a mental health diagnosis of serious emotional disturbance.  83.122(3)    Level of care.  The applicant must be certified as being in need of a level of care that, but for the waiver, would be provided in a psychiatric hospital serving children under the age of 21. The IME medical services unit or a managed care organization shall certify the applicant’s level of care annually based on information submitted on Form 470-4694, Case Management Comprehensive Assessment, for children aged 3 and under or on the interRAI - Child and Youth Mental Health (ChYMH) for those aged 4 to 20 and other supporting documentation as relevant. For those aged 12 to 18, the interRAI - Adolescent Supplement shall also be completed in addition to the interRAI - Child and Youth Mental Health (ChYMH). Form 470-4694, the interRAI - Child and Youth Mental Health (ChYMH), and the interRAI - Adolescent Supplement are available on request from the IME medical services unit. Copies of the completed information submission tool for an individual are available to that individual from the individual’s case manager, integrated health home care coordinator or managed care organization.  83.122(4)    Financial eligibility.  The consumer must be eligible for Medicaid as follows:  a.  Be eligible for Medicaid under an SSI, SSI-related, FMAP, or FMAP-related coverage group; or  b.  Be eligible under the special income level (300 percent) coverage group; or  c.  Become eligible through application of the institutional deeming rules; or   d.  Would be eligible for Medicaid if in a medical institution. For this purpose, deeming of parental or spousal income or resources ceases in the month after the month of application.  83.122(5)    Choice of program.  The applicant must choose HCBS children’s mental health waiver services over institutional care, as indicated by the signature of the applicant’s parent or legal guardian on the assessment.  83.122(6)    Need for service.  The consumer must have service needs that can be met under the children’s mental health waiver program, as documented in the service plan developed in accordance with rule 441—83.12(249A).  a.  The consumer must be a recipient of case management or integrated health home services or be identified to receive case management or integrated health home services immediately following program enrollment.  b.  The total cost of children’s mental health waiver services needed to meet the member’s needs, excluding the cost of environmental modifications, adaptive devices and therapeutic resources, may not exceed $2,006.34 per month.  c.  At a minimum, each consumer must receive one billable unit of a children’s mental health waiver service per calendar quarter.  d.  A consumer may not receive children’s mental health waiver services and foster family care services under 441—Chapter 202 at the same time.  e.  A consumer may be enrolled in only one HCBS waiver program at a time.Related ARC(s): 7741B, 0306C, 0548C, 0665C, 0842C, 1056C, 1445C, 2361C, 2848C, 2936C, 3184C441—83.123(249A)  Application.  The Medicaid application process as specified in rules 441—76.1(249A) to 441—76.6(249A) shall be followed for an application for HCBS children’s mental health waiver services.  83.123(1)    Program limit.  The number of persons who may be approved for the HCBS children’s mental health waiver shall be subject to the number of consumers to be served as set forth in the federally approved HCBS children’s mental health waiver. When the number of applicants exceeds the number of consumers specified in the approved waiver, the consumer’s application shall be rejected and the consumer’s name shall be placed on a waiting list.  a.  The local office shall determine if a payment slot is available by the end of the fifth working day after receipt of:  (1)  A completed Form 470-2297, Health Services Application, from a consumer who is not currently a Medicaid member; or  (2)  A written request signed and dated by a Medicaid member’s parent or legal guardian.  b.  When a payment slot is available, the local office shall enter the application into ISIS to begin the waiver approval process.  (1)  The department shall hold the payment slot for the consumer as long as reasonable efforts are being made to arrange services and the consumer has not been determined to be ineligible for the program.  (2)  If services have not been initiated and reasonable efforts are no longer being made to arrange services, the slot shall revert for use by the next consumer on the waiting list, if applicable. The consumer must reapply for a new slot.  c.  If no payment slot is available, the department shall enter the names of persons on a waiting list according to the following:  (1)  The names of applicants not currently eligible for Medicaid shall be entered on the waiting list on the basis of the date a completed Form 470-2927 or 470-2927(S), Health Services Application, is received by the department;  (2)  The names of Medicaid members shall be added to the waiting list on the date as specified in paragraph 83.123(1)“a.”  (3)  In the event that more than one application is received at one time, the names of consumers shall be entered on the waiting list on the basis of the month of birth, January being month one and the lowest number.  d.  Consumers whose names are on the waiting list shall be contacted to reapply as slots become available, based on the order of the waiting list, so that the number of approved consumers on the program is maintained.  (1)  Once a payment slot is assigned, the department shall give written notice to the consumer within five working days.  (2)  The department shall hold the payment slot for 30 days for the consumer to file a new application.  (3)  If an application has not been filed within 30 days, the slot shall revert for use by the next consumer on the waiting list, if applicable. The consumer originally assigned the slot must reapply for a new slot.  83.123(2)    Approval of waiver eligibility.    a.    Time limit.  Applications for the HCBS children’s mental health waiver program shall be processed within 30 days unless one or more of the following conditions exist:  (1)  An application has been filed and is pending for federal Supplemental Security Income (SSI) benefits.  (2)  The application is pending because the department has not received information for a reason that is beyond the control of the consumer or the department.  (3)  The application is pending because the assessment has not been completed. When a determination is not completed 90 days after the date of application due to the lack of a completed assessment, the application shall be denied.  b.    Notice of decisions.  The department shall mail or give decisions to the applicant on the dates when eligibility and level of care determinations are completed.  83.123(3)    Effective date of eligibility.  The effective date of a consumer’s eligibility for children’s mental health waiver services shall be the first date that all of the following conditions exist:  a.  All eligibility requirements are met; and  b.  Eligibility and level of care determinations have been made.Related ARC(s): 0306C, 2361C, 3184C441—83.124(249A)  Financial participation.  A consumer must contribute to the cost of children’s mental health waiver services to the extent of the consumer’s total income less 300 percent of the maximum monthly payment for one person under the federal Supplemental Security Income (SSI) program.441—83.125(249A)  Redetermination.  The department shall redetermine a consumer’s eligibility for the children’s mental health waiver at least once every 12 months or when there is significant change in the consumer’s situation or condition.  83.125(1)    Eligibility review.    a.  Every 12 months, the department shall review a consumer’s eligibility in accordance with procedures in rule 441—76.7(249A). The review shall verify continuing eligibility factors as specified in rule 441—83.122(249A).  b.  The IME medical services unit or a managed care organization shall review the member’s need for continued care annually and recertify the member’s need for long-term care services, pursuant to rule 441—83.122(249A) and the appeal process at rule 441—83.129(249A), based on the completed information submission tool designated in 83.122(3) and other supporting documentation as relevant.  c.  The IME medical services unit or the member’s managed care organization shall be responsible for annual redetermination of the level of care.  d.  The managed care organization must submit documentation to the IME medical services unit for all reassessments, performed at least annually, which indicate a change in the member’s level of care. The IME medical services unit shall make a final determination for any reassessments which indicate a change in the level of care. If the level of care reassessment indicates no change in level of care, the member is approved to continue at the already established level of care.  83.125(2)    Continuation of eligibility.  A consumer’s waiver eligibility shall continue until one of the following conditions occurs.  a.  The consumer fails to meet eligibility criteria listed in rule 441—83.122(249A).  b.  The consumer is an inpatient of a medical institution for 120 or more consecutive days.  (1)  After the consumer has spent 120 consecutive days in a medical institution, the local office shall terminate the consumer’s waiver eligibility and review the consumer for eligibility under other Medicaid coverage groups. The local office shall notify the consumer and the consumer’s parents or legal guardian through Form 470-0602, Notice of Decision.  (2)  If the consumer returns home after 120 consecutive days, the consumer must reapply for children’s mental health waiver services, and the IME medical services unit must redetermine the consumer’s level of care.  c.  The consumer does not reside at the consumer’s natural home for a period of 60 consecutive days. After the consumer has resided outside the home for 60 consecutive days, the local office shall terminate the consumer’s waiver eligibility and review the consumer for eligibility under other Medicaid coverage groups. The local office shall notify the consumer and the consumer’s parents or legal guardian through Form 470-0602, Notice of Decision.  83.125(3)    Payment slot.  When a consumer loses waiver eligibility, the consumer’s assigned payment slot shall revert for use to the next consumer on the waiting list.Related ARC(s): 2361C, 3184C, 3234C441—83.126(249A)  Allowable services.  Services allowable under the children’s mental health waiver shall be provided as set forth in rule 441—78.52(249A) and shall include:
  1. Environmental modifications, adaptive devices and therapeutic resources;
  2. Family and community support services;
  3. In-home family therapy; and
  4. Respite care.
441—83.127(249A)  Service plan.  The consumer’s case manager or integrated health home care coordinator shall prepare an individualized service plan for each consumer that meets the requirements set for case plans in rule 441—130.7(234).  83.127(1)  The service plan shall be developed through an interdisciplinary team process.  83.127(2)  The service plan shall be developed annually or when there is significant change in the consumer’s situation or condition.  83.127(3)  The service plan shall be based on information in the completed information submission tool designated in subrule 83.122(3) and other supporting documentation as relevant.  83.127(4)  The service plan shall specify the type and frequency of the waiver services and the providers that will deliver the services.  83.127(5)  The service plan shall identify and justify any restriction of the consumer’s rights.Related ARC(s): 0306C, 3184C441—83.128(249A)  Adverse service actions.    83.128(1)    Denial.  An application for children’s mental health waiver services shall be denied when the department determines that:  a.  The consumer is not eligible for or in need of waiver services.  b.  Needed services are not available or received from qualified providers.  c.  Service needs exceed the limit on aggregate monthly costs established in 83.122(6)“c” or are not met by the services provided.  83.128(2)    Termination.  A consumer’s participation in the children’s mental health waiver program may be terminated when the department determines that:  a.  The provisions of 441—paragraph 130.5(2)“a,” “b,” “c,” “g,” or “h” apply.  b.  The costs of the children’s mental health waiver services for the consumer exceed the aggregate monthly costs established in 83.122(6)“c.”  c.  The consumer receives care in a hospital, nursing facility, psychiatric hospital serving children under the age of 21, or psychiatric medical institution for children for 120 days in any one stay.  d.  The physical or mental condition of the consumer requires more care than can be provided in the consumer’s own home, as determined by the consumer’s case manager or integrated health home care coordinator.  e.  Service providers are not available.  83.128(3)    Reduction.  Reduction of services shall apply as specified in 441—paragraphs 130.5(3)“a” and “b.”Related ARC(s): 3184C, 3234C441—83.129(249A)  Appeal rights.  Notice of adverse action and right to appeal shall be given in accordance with 441—Chapter 7, rule 441—16.3(17A) and rule 441—130.5(234).Related ARC(s): 0306C, 4973CThese rules are intended to implement Iowa Code section 249A.4 and 2005 Iowa Acts, chapter 167, section 13, and chapter 117, section 3.
Related ARC(s): 7741B, 7957B, 9650B, 0191C, 0306C, 0359C, 0548C, 0665C, 0757C, 0842C, 1056C, 1445C, 2050C, 2164C, 2168C, 2361C, 2471C, 2848C, 2936C, 3184C, 3234C, 3481C, 3790C, 3874C, 4209C, 4792C, 4897C, 4973C, 4974C