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CHAPTER 56BRAIN INJURY SERVICES PROGRAM641—56.1(135) Definitions. For purposes of this chapter, the following definitions apply:
"Assessment" means the review of the consumer’s current functioning with regard to the consumer’s situation, needs, strengths, abilities, desires and goals.
"Brain injury services waiver" means the state’s medical assistance home- and community-based services waiver for persons with brain injury.
"Consumer" means an individual who has applied for and been found eligible to participate in the waiver-eligible component or the cost-share component of the brain injury services program.
"Cost share" means the portion an individual is responsible to pay for services received by the individual.
"Countable income," when determining initial and ongoing eligibility for the brain injury services program, means all earned and unearned income, unless specifically exempted in 441—subrule 86.2(2).
"Department" means the Iowa department of public health.
"Family size," for purposes of establishing initial and ongoing eligibility under the brain injury services program, means all persons living together who are children and who are parents of those children as defined in 441—subrule 86.2(3).
"Program administrator" means the division of behavioral health and professional licensure within the department of public health.
641—56.2(135) Purpose. The purpose of the brain injury services program is to provide services, service funding, or other support for persons with a brain injury under one of the program components established pursuant to Iowa Code section 135.22B. The overall purpose of this chapter is to establish administrative rules in accordance with Iowa Code section 135.22B relative to the financial eligibility requirements for services under the waiver-eligible and cost-share components of the brain injury services program.641—56.3(135) Waiver-eligible component. Persons eligible for the brain injury services waiver and on the waiting list for the waiver are eligible for the waiver-eligible component. The brain injury services program may provide funding for the nonfederal share of the cost of services if the appropriation for the medical assistance program does not have sufficient funding designated to do so. 56.3(1) Provision of funding under this component is not an entitlement and is subject to funding availability. 56.3(2) A person who receives support under the waiver-eligible component of the brain injury services program is not eligible to receive support under the cost-share component of the program.641—56.4(135) Cost-share component. Persons determined ineligible for the brain injury services waiver, due to fiscal or functional criteria, or persons who are eligible for the waiver but for whom funding was not authorized or available to provide waiver eligibility are eligible for the cost-share component of the brain injury services program. 56.4(1) An individual must meet all of the following requirements: a. The individual is aged one month through 64 years. b. The individual has a diagnosed brain injury as defined in Iowa Code section 135.22. c. The individual is a resident of Iowa and either a United States citizen or a qualified alien as defined in 8 U.S.C. Section 1641. d. The individual must meet the cost-share component’s financial eligibility requirements and be willing to pay a cost share for the cost-share component. 56.4(2) Cost-share financial eligibility. Countable income shall be used when determining initial and ongoing eligibility for the program. All of the following criteria must be met. a. Individuals who are at 300 percent or below the federal poverty level for a family of the same size will not be assessed a cost share. b. Individuals whose countable income is between 301 percent and 350 percent of the federal poverty level for a family of the same size will be assessed a 10 percent cost share for services that will be payable to the service provider. c. Individuals whose countable income is between 351 percent and 400 percent of the federal poverty level for a family of the same size will be assessed a 20 percent cost share for services that will be payable to the service provider. d. Individuals whose countable income is above 400 percent of the federal poverty level for a family of the same size will be assessed a 30 percent cost share for services that will be payable to the service provider. 56.4(3) The cost-share component must be the source of last resort for payment; the program shall not pay for services when the provision of those services is mandated by law or administrative rule to be the responsibility of another governmental unit, private agency or program. Brain injury cost-share services are not available to an individual who receives services or funding under any type of medical assistance home- and community-based services waiver.641—56.5(135) Application process. 56.5(1) The applicant must authorize the department of human services to provide the applicant’s brain injury services waiver application materials to the brain injury services program. 56.5(2) The department of human services will provide the department the application materials, which shall include but are not limited to the waiver application and any denial letter, financial assessment, and functional assessment regarding the person in an agreed-upon format. 56.5(3) The department will determine eligibility within 45 days of receipt of complete application materials. a. After determining if the applicant’s service needs fit within the scope of the brain injury services program, the department shall inform the discharge planner or case manager on behalf of the applicant or the applicant’s legal representative of the applicant’s eligibility. b. The case manager shall establish an interdisciplinary team for each consumer and, with the team, identify the consumer’s plan based on the consumer’s needs and desires as well as the availability and appropriateness of services. The case manager shall notify the department of the service plan. c. The date of eligibility for applicants deemed eligible for the cost-share component will be the date when both the service eligibility and financial eligibility assessments have been completed. d. Notification of eligibility shall be mailed or given to the applicant or the applicant’s legal representative within seven days of the date eligibility determination is completed. 56.5(4) After determining an applicant’s eligibility, if no payment slot is available, the brain injury services program shall enter the applicant on a waiting list according to the following: a. The date a completed Form 470-2927 or 470-2927(S), Health Services Application, is date-stamped in the county department of human services office. If more than one application is received on the same date, applicants shall be entered on the waiting list on the basis of the applicant’s month of birth, with January designated as month one. b. As slots become available, applicants shall be selected from the waiting list based on their order on the waiting list to maintain the number of persons approved for participation in the program. 56.5(5) The consumer or the consumer’s legal representative shall complete and sign Iowa department of human services Form 470-3349, Brain Injury Functional Assessment, indicating the consumer’s choice of caregiver. 56.5(6) The case manager for the consumer will initiate development of the consumer’s service plan and commencement of services. All service plans must be approved by the program administrator. 56.5(7) The department will not pay the cost of services provided to a consumer prior to approval of eligibility. 56.5(8) The program administrator shall make the final determination as to whether program funding will be authorized under the cost-share component.641—56.6(135) Service providers and reimbursement. 56.6(1) A service provider must either be certified to provide services under the brain injury services waiver or have a contract with a county to provide services and apply to become certified to provide services under the brain injury services waiver within 90 days of the date that services commence. 56.6(2) The reimbursement rate payable for the cost of a service provided under the cost-share component is the rate payable under the medical assistance program. However, if the service provider does not have a medical assistance program reimbursement rate, the rate shall be the amount payable under the county contract. 56.6(3) All service providers must contract with the department and will be paid retroactively to the date of service eligibility. 56.6(4) Service providers will be responsible for billing and collection of any cost share from an individual as determined by the program administrator within the department.641—56.7(135) Available services/service plan. 56.7(1) Services available shall be consistent with the services offered through the Medicaid home- and community-based services waiver. 56.7(2) Service plans must reflect use of all services, including non-cost-shared services, to ensure that no duplication of services occurs. 56.7(3) All service plans must be submitted, either electronically or in hard-copy format, to the program administrator for approval prior to implementation. 56.7(4) Any change to the service plan must be approved by the program administrator.641—56.8(135) Redetermination. 56.8(1) A complete financial redetermination of continuing eligibility for the brain injury services program shall be completed annually by the department, after consultation with the case manager and the interdisciplinary team. 56.8(2) A redetermination of continuing eligibility shall also be made when a change in financial or functional circumstances occurs that affects eligibility.641—56.9(135) Appeal rights. Appeal rights for any individual denied funding under either the waiver-eligible or the cost-share component of the program are as defined in 641—176.8(135,17A) with the following exception: An appeal must be submitted within 45 days of receipt of notification of an adverse decision.These rules are intended to implement Iowa Code section 135.22B.