Iowa Admin. Code r. 441-78.34 - HCBS health and disability waiver services
Payment will be approved for the following services to members eligible for HCBS health and disability waiver services as established in 441-Chapter 83 and as identified in the member's service plan. Effective March 17, 2022, payment shall only be made for services provided in integrated, community-based settings that support full access of members receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS.
(1)
Homemaker services.
Homemaker services are those services provided when the member lives alone or
when the person who usually performs these functions for the member needs
assistance with performing the functions. A unit of service is 15 minutes.
Components of the service must be directly related to the care of the member
and may include only the following:
a.
Essential shopping: shopping for basic need items such as food, clothing or
personal care items, or drugs.
b.
Limited housecleaning: maintenance cleaning such as vacuuming, dusting,
scrubbing floors, defrosting refrigerators, cleaning stoves, cleaning medical
equipment, washing and mending clothes, washing personal items used by the
member, and washing dishes.
c. Meal
preparation: planning and preparing balanced meals.
(2)
Home health services.
Home health services are personal or direct care services provided to the
client which are not payable under Medicaid as set forth in rule
441-78.9 (249A). A unit of
service is a visit.
a. Components of the
service include, but are not limited to:
(1)
Observation and reporting of physical or emotional needs.
(2) Helping a client with bath, shampoo, or
oral hygiene.
(3) Helping a client
with toileting.
(4) Helping a
client in and out of bed and with ambulation.
(5) Helping a client reestablish activities
of daily living.
(6) Assisting with
oral medications ordered by the physician which are ordinarily
self-administered.
(7) Performing
incidental household services which are essential to the client's health care
at home and are necessary to prevent or postpone institutionalization in order
to complete a full unit of service.
(8) Accompaniment to medical services or
transport to and from school.
b. In some cases, a nurse may provide home
health services if the health of the client is such that the agency is unable
to place an aide in that situation due to limitations by state law or in the
event that the agency's Medicare certification requirements prohibit the aide
from providing the service. It is not permitted for the convenience of the
provider.
c. Skilled nursing care
is not covered.
(3)
Adult day care services. Adult day care services provide an
organized program of supportive care in a group environment to persons who need
a degree of supervision and assistance on a regular or intermittent basis in a
day care center. A unit of service is 15 minutes (up to four units per day), a
half day (1.25 to 4 hours per day), a full day (4.25 to 8 hours per day), or an
extended day (8.25 to 12 hours per day). Components of the service include
health-related care, social services, and other related support
services.
(4)
Nursing care
services. Nursing care services are services which are included in the
plan of treatment approved by the physician and which are provided by licensed
nurses to consumers in the home and community. The services shall be reasonable
and necessary to the treatment of an illness or injury and include all nursing
tasks recognized by the Iowa board of nursing. A unit of service is a
visit.
(5)
Respite care
services. Respite care services are services provided to the member
that give temporary relief to the usual caregiver and provide all the necessary
care that the usual caregiver would provide during that period. The purpose of
respite care is to enable the member to remain in the member's current living
situation.
a. Services provided outside the
member's home shall not be reimbursable if the living unit where respite is
provided is reserved for another person on a temporary leave of
absence.
b. Member-to-staff ratios
shall be appropriate to the individual needs of the member as determined by the
member's interdisciplinary team.
c.
A unit of service is 15 minutes.
d.
Respite care is not to be provided to members during the hours in which the
usual caregiver is employed except when the member is attending a 24-hour
residential camp. Respite care shall not be used as a substitute for a child's
day care. Respite cannot be provided to a member whose usual caregiver is a
consumer-directed attendant care provider for the member.
e. The interdisciplinary team shall determine
if the member will receive basic individual respite, specialized respite, or
group respite as defined in 441-Chapter 83.
f. A maximum of 14 consecutive days of
24-hour respite care may be reimbursed.
g. Respite services provided for a period
exceeding 24 consecutive hours to three or more individuals who require nursing
care because of a mental or physical condition must be provided by a health
care facility licensed as described in Iowa Code chapter 135C.
h. Respite services shall not be provided
simultaneously with other residential, nursing, or home health aide services
provided through the medical assistance program.
(6)
Counseling services.
Counseling services are face-to-face mental health services provided to the
member and caregiver by a mental health professional as defined in rule
441-24.1(225C) to facilitate home management of the member and prevent
institutionalization. Counseling services are nonpsychiatric services necessary
for the management of depression, assistance with the grief process,
alleviation of psychosocial isolation and support in coping with a disability
or illness, including terminal illness. Counseling services may be provided
both for the purpose of training the member's family or other caregiver to
provide care and for the purpose of helping the member and those caring for the
member to adjust to the member's disability or terminal condition. Counseling
services may be provided to the member's caregiver only when included in the
case plan for the member.
Payment will be made for individual and group counseling. A unit of individual counseling for the waiver member or the waiver member and the member's caregiver is 15 minutes. A unit of group counseling is 15 minutes. Payment for group counseling is based on the group rate divided by six, or, if the number of persons who comprise the group exceeds six, the actual number of persons who comprise the group.
(7)
Consumer-directed attendant care
service. Consumer-directed attendant care services are service
activities performed by a person to help a member with self-care tasks which
the member would typically do independently if the member were otherwise able.
Covered service activities are limited to the nonskilled activities listed in
paragraph 78.34(7)"f" and the skilled activities listed in
paragraph 78.34(7)"g." Covered service activities must be
essential to the health, safety, and welfare of the member. Services may be
provided in the absence of a parent or guardian if the parent or guardian has
given advance direction for the service provision.
a.
Service planning.
(1) The member, parent, guardian, or attorney
in fact under a durable power of attorney for health care shall:
1. Select the individual or agency that will
provide the components of the attendant care services.
2. Determine with the selected provider what
components of attendant care services the provider shall perform, subject to
confirmation by the service worker or case manager that those components are
consistent with the assessment and are authorized covered services.
3. Complete, sign, and date Form 470-3372,
HCBS Consumer-Directed Attendant Care Agreement, to indicate the frequency,
scope, and duration of services (a description of each service component and
the time agreed on for that component). The case manager or service worker and
provider shall also sign the agreement.
4. Submit the completed agreement to the
service worker or case manager. The agreement shall be part of the member's
service plan and shall be kept in the member's records, in the provider's
records, and in the service worker's or case manager's records. Any service
component that is not listed in the agreement shall not be payable.
(2) Whenever a legal
representative acts as a provider of consumer-directed attendant care as
allowed by 441-paragraph 79.9(7)"b," the following shall
apply:
1. The payment rate for the legal
representative must be based on the skill level of the legal representative and
may not exceed the median statewide reimbursement rate for the service unless
the higher rate receives prior approval from the department;
2. The legal representative may not be paid
for more than 40 hours of service per week; and
3. A contingency plan must be established in
the member's service plan to ensure service delivery in the event the legal
representative is unable to provide services due to illness or other unexpected
event.
b.
Supervision of skilled services. Skilled consumer-directed
attendant care services shall be provided under the supervision of a licensed
nurse or licensed therapist working under the direction of a physician. The
licensed nurse or therapist shall:
(1) Retain
accountability for actions that are delegated.
(2) Ensure appropriate assessment, planning,
implementation, and evaluation.
(3)
Make on-site supervisory visits every two weeks with the service provider
present.
c.
Service documentation. The consumer-directed attendant care
provider shall document evidence of compliance with the requirements of this
chapter and rule 441-79.3 (249A). The
documentation or copies of the documentation must be maintained or be
electronically accessible by the consumer-directed attendant care provider.
Providers must use an electronic visit verification system that captures all
documentation requirements of the Consumer-Directed Attendant Care (CDAC)
Service Record (Form 470-4389) or use Form 470-4389. Any service component that
is not documented in accordance with rule
441-79.3 (249A) shall not be
payable.
d.
Role of
guardian or attorney. If the member has a guardian or attorney in fact
under a durable power of attorney for health care:
(1) The service worker's or case manager's
service plan shall address how consumer-directed attendant care services will
be monitored to ensure that the member's needs are being adequately met. If the
guardian or attorney in fact is the service provider, the service plan shall
address how the service worker or case manager shall oversee service
provision.
(2) The guardian or
attorney in fact shall sign the claim form in place of the member, indicating
that the service has been provided as presented on the claim.
e.
Service units and
billing. A unit of service is 15 minutes provided by an individual or
agency. Each service shall be billed in whole units.
f.
Nonskilled services.
Covered nonskilled service activities are limited to help with the following
activities:
(1) Dressing.
(2) Bathing, shampooing, hygiene, and
grooming.
(3) Access to and from
bed or a wheelchair, transferring, ambulation, and mobility in
general.
(4) Toileting, including
bowel, bladder, and catheter assistance (emptying the catheter bag, collecting
a specimen, and cleaning the external area around the catheter).
(5) Meal preparation, cooking, and assistance
with feeding, not including the cost of meals themselves. Meal preparation and
cooking shall be provided only in the member's home.
(6) Housekeeping, laundry, and shopping
essential to the member's health care at home.
(7) Taking medications ordinarily
self-administered, including those ordered by a physician or other qualified
health care provider.
(8) Minor
wound care.
(9) Going to or
returning from a place of employment and job-related tasks while the member is
on the job site. Transportation for the member and assistance with
understanding or performing the essential job functions are not included in
consumer-directed attendant care services.
(10) Tasks, such as financial management and
scheduling, that require cognitive or physical assistance.
(11) Communication essential to the health
and welfare of the member, through interpreting and reading services and use of
assistive devices for communication.
(12) Using transportation essential to the
health and welfare of the member. The cost of the transportation is not
included.
g.
Skilled services. Covered skilled service activities are
limited to help with the following activities:
(1) Tube feedings of members unable to eat
solid foods.
(2) Intravenous
therapy administered by a registered nurse.
(3) Parenteral injections required more than
once a week.
(4) Catheterizations,
continuing care of indwelling catheters with supervision of irrigations, and
changing of Foley catheters when required.
(5) Respiratory care including inhalation
therapy and tracheotomy care or tracheotomy care and ventilator.
(6) Care of decubiti and other ulcerated
areas, noting and reporting to the nurse or therapist.
(7) Rehabilitation services including, but
not limited to, bowel and bladder training, range of motion exercises,
ambulation training, restorative nursing services, respiratory care and
breathing programs, reality orientation, reminiscing therapy, remotivation,
behavior modification, and reteaching of the activities of daily
living.
(8) Colostomy
care.
(9) Care of uncontrolled
medical conditions, such as brittle diabetes, and comfort care of terminal
conditions.
(10) Postsurgical
nursing care.
(11) Monitoring
medications requiring close supervision because of fluctuating physical or
psychological conditions, e.g., antihypertensives, digitalis preparations,
mood-altering or psychotropic drugs, or narcotics.
(12) Preparing and monitoring response to
therapeutic diets.
(13) Recording
and reporting of changes in vital signs to the nurse or therapist.
h.
Excluded services and
costs. Services, activities, costs and time that are not covered as
consumer-directed attendant care include the following (not an exclusive list):
(1) Any activity related to supervising a
member. Only direct services are billable.
(2) Any activity that the member is able to
perform.
(3) Costs of
food.
(4) Costs for the supervision
of skilled services by the nurse or therapist. The supervising nurse or
therapist may be paid from private insurance, Medicare, or other third-party
payment sources, or may be paid as another Medicaid service, including early
and periodic screening, diagnosis and treatment services.
(5) Exercise that does not require skilled
services.
(6) Parenting or child
care for or on behalf of the member.
(7) Reminders and cueing.
(8) Services provided simultaneously with any
other similar service regardless of funding source, including other waiver
services and state supplementary assistance in-home health-related care
services.
(9) Transportation
costs.
(10) Wait times for any
activity.
(8)
Interim medical monitoring and treatment services. Interim
medical monitoring and treatment (IMMT) services are monitoring and treatment
of a medical nature for children or adults aged 18 to 20 whose medical needs
make alternative care unavailable, inadequate, or insufficient. IMMT services
are not intended to provide day care but to supplement available resources.
Services must be ordered by a physician.
a.
Need for service. The member must be 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 service worker
or case manager must identify the need for IMMT services after evaluating the
member's living environment, family and natural supports, ability to perform
activities of daily living, and health care needs. The services must be needed:
(1) To allow the member's usual caregivers to
be employed,
(2) During a search
for employment by a usual caregiver,
(3) To allow for academic or vocational
training of a usual caregiver,
(4)
Due to the hospitalization of a usual caregiver for treatment for physical or
mental illness, or
(5) Due to the
death of a usual caregiver.
b. Service requirements. Interim medical
monitoring and treatment services shall:
(1)
Provide experiences for each member's social, emotional, intellectual, and
physical development;
(2) Include
comprehensive developmental care and any special services for a member with
special needs; and
(3) Include
medical assessment, medical monitoring, and medical intervention as needed on a
regular or emergency basis. Medical intervention means the ability to assess
the situation and contact the appropriate medical professional, not the direct
application of medical care.
c. Interim medical monitoring and treatment
services may include supervision while the member is being transported to and
from school.
d. Limitations.
(1) A maximum of 12 hours of service is
available per day.
(2) Covered
services do not include a complete nutritional regimen.
(3) Interim medical monitoring and treatment
services may not duplicate any regular Medicaid or waiver services provided
under the state plan. Services under the state plan, including home health
agency services under rule
441-78.9 (249A), must be
exhausted before IMMT services are accessed.
(4) Interim medical monitoring and treatment
services shall be provided in the following settings that are approved by the
department as integrated, community-based settings: the member's home; a
registered child development home; a licensed child care center, residential
care facility, or adult day care facility; or during the time when the member
is being transported to and from school.
(5) The member-to-staff ratio shall not be
more than six members to one staff person.
(6) The parent or guardian of the member
shall be responsible for the usual and customary nonmedical cost of day care
during the time in which the member is receiving IMMT services. Medical care
necessary for monitoring and treatment is an allowable IMMT cost. If the cost
of care goes above the usual and customary cost of day care services due to the
member's medical condition, the costs above the usual and customary cost shall
be covered as IMMT services.
e. A unit of service is 15 minutes.
(9)
Home and vehicle
modification. Covered home or vehicle modifications are physical
modifications to the member's home or vehicle that directly address the
member's medical or remedial need. Covered modifications must be necessary to
provide for the health, welfare, or safety of the member and enable the member
to function with greater independence in the home or vehicle.
a. Modifications that are necessary or
desirable without regard to the member's medical or remedial need and that
would be expected to increase the fair market value of the home or vehicle,
such as furnaces, fencing, or adding square footage to the residence, are
excluded except as specifically included below. Purchasing or leasing of a
motorized vehicle is excluded. Home and vehicle repairs are also
excluded.
b. Only the following
modifications are covered:
(1) Kitchen
counters, sink space, cabinets, special adaptations to refrigerators, stoves,
and ovens.
(2) Bathtubs and toilets
to accommodate transfer, special handles and hoses for shower heads, water
faucet controls, and accessible showers and sink areas.
(3) Grab bars and handrails.
(4) Turnaround space adaptations.
(5) Ramps, lifts, and door, hall and window
widening.
(6) Fire safety alarm
equipment specific for disability.
(7) Voice-activated, sound-activated,
light-activated, motion-activated, and electronic devices directly related to
the member's disability.
(8)
Vehicle lifts, driver-specific adaptations, remote-start systems, including
such modifications already installed in a vehicle.
(9) Keyless entry systems.
(10) Automatic opening device for home or
vehicle door.
(11) Special door and
window locks.
(12) Specialized
doorknobs and handles.
(13)
Plexiglas replacement for glass windows.
(14) Modification of existing stairs to
widen, lower, raise or enclose open stairs.
(15) Motion detectors.
(16) Low-pile carpeting or slip-resistant
flooring.
(17) Telecommunications
device for the deaf or hard of hearing.
(18) Exterior hard-surface
pathways.
(19) New door
opening.
(20) Pocket
doors.
(21) Installation or
relocation of controls, outlets, switches.
(22) Air conditioning and air filtering if
medically necessary.
(23)
Heightening of existing garage door opening to accommodate modified
van.
(24) Bath chairs.
c. A unit of service is the
completion of needed modifications or adaptations.
d. All modifications and adaptations shall be
provided in accordance with applicable federal, state, and local building and
vehicle codes.
e. Services shall be
performed following prior department approval of the modification as specified
in 441-subrule 79.1(17) and a binding contract between the provider and the
member.
f. All contracts for home
or vehicle modification shall be awarded through competitive bidding. The
contract shall include the scope of work to be performed, the time involved,
supplies needed, the cost, diagrams of the project whenever applicable, and an
assurance that the provider has liability and workers' compensation coverage
and the applicable permit and license.
g. Service payment shall be made to the
enrolled home or vehicle modification provider. If applicable, payment will be
forwarded to the subcontracting agency by the enrolled home or vehicle
modification provider following completion of the approved modifications.
Payment of up to $6,872.85 per year may be made to certified providers upon
satisfactory completion of the service.
h. Services shall be included in the member's
service plan and shall exceed the Medicaid state plan services.
(10)
Personal emergency
response or portable locator system.
a. A personal emergency response system is an
electronic device that transmits a signal to a central monitoring station to
summon assistance in the event of an emergency.
(1) The required components of the system
are:
1. An in-home medical communications
transceiver.
2. A remote, portable
activator.
3. A central monitoring
station with backup systems staffed by trained attendants at all
times.
4. Current data files at the
central monitoring station containing response protocols and personal, medical,
and emergency information for each member.
(2) The service shall be identified in the
member's service plan.
(3) A unit
of service is a one-time installation fee or one month of service.
(4) Maximum units per state fiscal year shall
be the initial installation and 12 months of service.
b. A portable locator system is an electronic
device that transmits a signal to a monitoring device. The system allows a
member to access assistance in the event of an emergency and allows law
enforcement or the monitoring system provider to locate a member who is unable
to request help or to activate a system independently. The member must be
unable to access assistance in an emergency situation due to the member's age
or disability.
(1) The required components of
the portable locator system are:
1. A portable
communications transceiver or transmitter to be worn or carried by the
member.
2. Monitoring by the
provider at a central location with response protocols and personal, medical,
and emergency information for each member as applicable.
(2) The service shall be identified in the
member's service plan.
(3) Payable
units of service are purchase of equipment, an installation or set-up fee, and
monthly fees.
(4) Maximum units per
state fiscal year shall be one equipment purchase, one installation or set-up
fee, and 12 months of service.
(11)
Home-delivered meals.
Home-delivered meals are meals prepared elsewhere and delivered to a member at
the member's residence.
a. Each meal shall
ensure the member receives a minimum of one-third of the daily recommended
dietary allowance as established by the Food and Nutrition Board of the
National Research Council of the National Academy of Sciences. The meal may
also be a liquid supplement that meets the minimum one-third
standard.
b. When a restaurant
provides the home-delivered meal, the member is required to have a nutritional
consultation. The nutritional consultation includes contact with the restaurant
to explain the dietary needs of the member and what constitutes the minimum
one-third daily dietary allowance.
c. A unit of service is a meal (morning,
noon, evening, or liquid supplement). Any maximum combination of any two meals
(morning, noon, evening, or liquid supplement) is allowed per day. Duplication
of a meal in any one day is not allowed. The number of approved meals (morning,
noon, evening, or liquid supplement) is contained in the member's service
plan.
d. The number of meals
delivered for any morning, noon, evening, or liquid supplement meal cannot
exceed the number of calendar days in a calendar month; nor can the number of
delivered meals exceed the number of authorized days in a month. Meals billed
in excess of the calendar days in a calendar month and those billed in excess
of the number of authorized days in a month are subject to recoupment or denial
of payment.
(12)
Nutritional counseling. Nutritional counseling services may be
provided for a nutritional problem or condition of such a degree of severity
that nutritional counseling beyond that normally expected as part of the
standard medical management is warranted. A unit of service is 15
minutes.
(13)
Consumer
choices option. The consumer choices option (CCO) provides a member
with a flexible monthly individual budget that is based on the member's service
needs. With the individual budget, the member shall have the authority to
purchase goods and services to meet the member's assessed needs and may choose
to employ providers of services and supports. The services, supports, and items
that are purchased with an individual budget must be directly related to a
member's assessed need or goal established in the member's service plan. The
consumer choices option is available to any member receiving the AIDS/HIV,
brain injury, elderly, health and disability, intellectual disability, or
physical disability waiver programs who has the ability and desire to perform
all budget authority tasks identified in paragraph
78.34(13)"g" and employer authority tasks identified in
paragraph 78.34(13)"h," or who delegates the budget or
employer authority tasks identified in paragraph 78.34(13)"i."
Components of this service are set forth below.
a.
Agreement. As a condition
of participating in the consumer choices option, a member shall sign Form
470-4289, HCBS Consumer Choices Informed Consent and Risk Agreement, to
document that the member has been informed of the responsibilities and risks of
electing the consumer choices option.
b.
Individual budget amount.
A monthly individual budget amount shall be established for each member based
on the assessed needs of the member and based on the services and supports
authorized in the member's service plan. The member shall be informed of the
individual budget amount during the development of the service plan.
(1) Services that may be included in
determining the individual budget amount for a member in the HCBS health and
disability waiver are:
1. Consumer-directed
attendant care (unskilled).
2. Home
and vehicle modification.
3.
Home-delivered meals.
4. Homemaker
service.
5. Basic individual
respite care.
(2)
Services that may be included in determining the individual budget amount for a
member in the HCBS elderly waiver are:
1.
Assistive devices.
2. Chore
service.
3. Consumer-directed
attendant care (unskilled).
4. Home
and vehicle modification.
5.
Home-delivered meals.
6. Homemaker
service.
7. Basic individual
respite care.
8. Senior
companion.
9.
Transportation.
(3)
Services that may be included in determining the individual budget amount for a
member in the HCBS AIDS/HIV waiver are:
1.
Consumer-directed attendant care (unskilled).
2. Home-delivered meals.
3. Homemaker service.
4. Basic individual respite care.
(4) Services that may be included
in determining the individual budget amount for a member in the HCBS
intellectual disability waiver are:
1.
Consumer-directed attendant care (unskilled).
2. Day habilitation.
3. Home and vehicle modification.
4. Prevocational services.
5. Basic individual respite care.
6. Supported community living.
7. Supported employment.
8. Transportation.
(5) Services that may be included in
determining the individual budget amount for a member in the HCBS brain injury
waiver are:
1. Consumer-directed attendant
care (unskilled).
2. Home and
vehicle modification.
3.
Prevocational services.
4. Basic
individual respite care.
5.
Specialized medical equipment.
6.
Supported community living.
7.
Supported employment.
8.
Transportation.
(6)
Services that may be included in determining the individual budget amount for a
member in the HCBS physical disability waiver are:
1. Consumer-directed attendant care
(unskilled).
2. Home and vehicle
modification.
3. Specialized
medical equipment.
4.
Transportation.
(7) The
department shall determine an average unit cost for each service listed in
subparagraphs 78.34(13)"b"(1) to (6) based on actual unit
costs from the previous fiscal year plus a cost-of-living adjustment.
(8) In aggregate, costs for
individual budget services shall not exceed the current costs of waiver program
services. In order to maintain cost neutrality, the department shall apply a
utilization adjustment factor to the amount of service authorized in the
member's service plan before calculating the value of that service to be
included in the individual budget amount.
(9) The department shall compute the
utilization adjustment factor for each service by dividing the net costs of all
claims paid for the service by the total of the authorized costs for that
service, using at least 12 consecutive months of aggregate service data. The
utilization adjustment factor shall be no lower than 60 percent.
(10) Individual budgets for respite services
shall be computed based on the average cost for services identified in
subparagraph 78.34(13)"b"(7). Respite services are not subject
to the utilization adjustment factor in subparagraph
78.34(13)"b"(8).
(11) Anticipated costs for home and vehicle
modification, assistive devices, and specialized medical equipment are not
subject to the average cost in subparagraph 78.34(13)"b"(7) or
the utilization adjustment factor in subparagraph
78.34(13)"b"(8). The anticipated costs may include the costs
of the financial management services and the independent support broker when
the home and vehicle modification, assistive device, or specialized medical
equipment is the only service included in the CCO monthly budget and the total
cost for the home and vehicle modification, assistive device, or specialized
medical equipment, including the cost of the financial management services and
the independent support broker, is approved by the Iowa Medicaid enterprise or
managed care organization as the least costly option to meet the member's need.
Costs for the home and vehicle modification, assistive device, or specialized
medical equipment may be paid to the financial management services provider in
a one-time payment. Before becoming part of the CCO monthly budget, all home
and vehicle modifications, assistive device, and specialized medical equipment
shall be identified in the member's service plan and authorized by the case
manager or community-based case manager.
(12) The individual budget amount may be
changed only at the first of the month and shall remain fixed for the entire
month.
c.
Required service components. To participate in the consumer
choices option, a member must hire an independent support broker and must work
with a financial management service that is enrolled as a Medicaid provider.
Before hiring the independent support broker, the member shall receive the
results of the background check conducted pursuant to 441-Chapter
119.
d.
Optional service
components. A member who elects the consumer choices option may
purchase the following goods, services and supports, which shall be provided in
the member's home or at an integrated community setting:
(1) Self-directed personal care services.
Self-directed personal care services are services that provide a range of
assistance in activities of daily living and incidental activities of daily
living that help the member remain in the home and community. These services
must be identified in the member's service plan developed by the member's case
manager or community-based case manager.
(2) Self-directed community supports and
employment. Self-directed community supports and employment are services that
support the member in developing and maintaining independence and community
integration. These services must be identified in the member's service plan
developed by the member's case manager or community-based case
manager.
(3) Individual-directed
goods and services. Individual-directed goods and services are services,
equipment, or supplies not otherwise provided through the Medicaid program that
address an assessed need or goal identified in the member's service plan. The
item or service shall meet the following requirements:
1. Promote opportunities for community living
and inclusion.
2. Increase
independence or substitute for human assistance, to the extent the expenditures
would otherwise be made for that human assistance.
3. Be accommodated within the member's budget
without compromising the member's health and safety.
4. Be provided to the member or directed
exclusively toward the benefit of the member.
5. Be the least costly to meet the member's
needs.
6. Not be available through
another source.
e.
Development of the individual
budget. The independent support broker shall assist the member in
developing and implementing the member's individual budget. The individual
budget shall include:
(1) The costs of the
financial management service.
(2)
The costs of the independent support broker. The independent support broker may
be compensated for up to 6 hours of service for assisting with the
implementation of the initial individual budget. The independent support broker
shall not be paid for more than 30 hours of service for an individual member
during a 12-month period without prior approval by the department.
(3) The costs of any optional service
component chosen by the member as described in paragraph
78.34(13)"d." At a minimum, the CCO monthly budget must
include the purchase of self-directed personal care, individual-directed goods
and services, or self-directed community supports and services needed to meet
the amount of service authorized for use in CCO identified in the member's
service plan. After funds have been budgeted to meet the identified needs,
remaining funds from the monthly budget amount may be used to purchase
additional self-directed personal care, individual-directed goods and services,
or self-directed community supports and services as allowed by the monthly
budget. The additional self-directed personal care, individual-directed goods
and services, or self-directed community supports and services may exceed the
amount of service or supports authorized in the member's service plan. Costs of
the following items and services shall not be covered by the individual budget:
1. Child care services.
2. Clothing not related to an assessed
medical need.
3. Conference,
meeting or similar venue expenses other than the costs of approved services the
member needs while attending the conference, meeting or similar
venue.
4. Costs associated with
shipping items to the member.
5.
Experimental and non-FDA-approved medications, therapies, or
treatments.
6. Goods or services
covered by other Medicaid programs.
7. Home furnishings.
8. Home repairs or home
maintenance.
9. Homeopathic
treatments.
10. Insurance premiums
or copayments.
11. Items purchased
on installment payments.
12.
Motorized vehicles.
13. Nutritional
supplements.
14. Personal
entertainment items.
15. Repairs
and maintenance of motor vehicles.
16. Room and board, including rent or
mortgage payments.
17. School
tuition.
18. Service
animals.
19. Services covered by
third parties or services that are the responsibility of a non-Medicaid
program.
20. Sheltered workshop
services.
21. Social or
recreational purchases not related to an assessed need or goal identified in
the member's service plan.
22.
Vacation expenses, other than the costs of approved services the member needs
while on vacation.
23. Services
provided in the family home by a parent, stepparent, legal representative,
sibling, or stepsibling during overnight sleeping hours unless the parent,
stepparent, legal representative, sibling, or stepsibling is awake and actively
providing direct services as authorized in the member's service plan.
24. Residential services provided to three or
more members living in the same residential setting.
(4) The costs of any approved home or vehicle
modification, assistive device, or specialized medical equipment. When
authorized, the budget may include an amount allocated for a home or vehicle
modification, an assistive device, or specialized medical equipment. Before
becoming part of the individual budget, all home and vehicle modifications,
assistive devices, and specialized medical equipment shall be identified in the
member's service plan and approved by the case manager or community-based case
manager. The authorized amount shall not be used for anything other than the
specific modification, assistive device, or specialized medical equipment, as
identified in subparagraph 78.34(13)"b"(11).
(5) Any amount set aside in a savings plan to
reserve funds for the future purchase of self-directed personal care,
individual-directed goods and services, or self-directed community supports and
services as defined in paragraph 78.34(13)"d." The savings
plan shall meet the requirements in paragraph
78.34(13)"f."
f.
Savings plan. A member
savings plan must be in writing and be approved before the start of the savings
plan by the department for fee-for-service members or by the member's managed
care organization for members in managed care. Budget amounts allocated to the
savings plan must result from efficiencies in meeting the member's service
needs identified in the member's service plan.
(1) The savings plan shall identify:
1. The specific goods, services, supports or
supplies to be purchased through the savings plan.
2. The amount of the individual budget
allocated each month to the savings plan.
3. The amount of the individual budget
allocated each month to meet the member's identified service needs.
4. How the member's assessed needs will
continue to be met through the individual budget when funds are placed in
savings.
5. Specific time spans for
accumulating the savings allocation, not to exceed the member's current service
plan year end date.
(2)
With the exception of funds allocated for respite care, the savings plan shall
not include funds budgeted for direct services or supports that were not
received. Funds from unused respite services may be allocated to the savings
plan but shall not be used for anything other than future respite
care.
(3) Funds allocated to a
savings plan may be used to purchase additional self-directed personal care,
individual-directed goods and services, or self-directed community supports and
services. The additional self-directed personal care, individual-directed goods
and services, or self-directed community supports and services included in the
monthly budget may exceed the amount of service or supports authorized in the
member's service plan. The self-directed personal care, individual-directed
goods and services, or self-directed community supports and services purchased
with funds from a savings plan must:
1. Be
used to meet a member's identified need,
2. Be medically necessary, and
3. Be approved by the member's case manager
or community-based case manager.
(4) All funds allocated to a savings plan to
purchase additional self-directed personal care, individual-directed goods and
services, or self-directed community supports and services must be used during
the member's waiver year in which the saving occurred.
(5) The annual reassessment of a member's
needs must take into account the purchases of goods and services that
substitute for human assistance. Adjustments shall be made to the services used
to determine the individual budget based on the reassessment.
g.
Budget
authority. The member shall have authority over the individual budget
authorized by the department or managed care organization to perform the
following tasks:
(1) Contract with entities to
provide services and supports as described in this subrule.
(2) Determine the amount to be paid for
services. Reimbursement rates for employees shall be consistent with employee
reimbursement rates or the prevailing wages paid by others in the community for
the same or substantially similar services. Reimbursement rates for the
independent support broker and the financial management service are subject to
the limits in 441-subrule 79.1(2).
(3) Schedule the provision of services. A
contingency plan must be established in the member's service plan to ensure
service delivery in the event the member's employee is unable to provide
services due to illness or other unexpected event.
(4) Authorize payment for optional service
components identified in the individual budget. When the member's guardian or
legal representative is a paid employee, payment authorization for optional
service components must be delegated to a representative pursuant to paragraph
78.34(13)"i."
(5)
Reallocate funds among services included in the budget. Every purchase of a
good or service must be identified and approved in the individual budget before
the purchase is made.
h.
Employer authority. The member shall have the authority to be
the common-law employer of employees providing services and support under the
CCO. A common-law employer has the right to direct and control the performance
of the services. If the member is a child, the parent or the legal
representative shall be responsible for completing all employer authority
tasks. Adult members who do not have the ability to complete all employer
authority tasks shall have a representative delegated to complete the employer
authority tasks identified in this paragraph. Documentation of the person
responsible for the employer authority tasks, whether the member or another
entity, shall be included in the member's service plan. The member or the
delegated employer authority may perform the following functions:
(1) Recruit and hire employees.
(2) Verify employee qualifications.
(3) Specify additional employee
qualifications.
(4) Determine
employee duties.
(5) Determine
employee wages and benefits.
(6)
Schedule employees.
(7) Train and
supervise employees.
i.
Delegation of budget and employer authority. The member may
delegate responsibilities for the individual budget or employer authority
functions to a representative. If the member is a child, the parent or the
legal representative shall be delegated all budget and employer authority
tasks. Adult members aged 18 and older who do not have the ability to complete
all budget or employer authority tasks shall have a representative delegated to
complete the applicable budget authority tasks identified in paragraph
78.34(13)"g" and employer authority tasks identified in
paragraph 78.34(13)"h." Documentation of the person
responsible for the budget and employer authority tasks, whether the member or
a representative, shall be included in the member's service plan.
(1) The representative must be at least 18
years old.
(2) The representative
shall not be a current provider of service to the member.
(3) The member shall sign a consent form that
designates who the member has chosen as a representative and the
responsibilities of the representative.
(4) The representative shall not be paid for
this service.
j.
Employment agreement. Any person employed by the member to
provide services under the consumer choices option shall sign an employment
agreement with the member that outlines the employee's and member's
responsibilities.
k.
Responsibilities of the independent support broker. The
independent support broker shall perform the following services as directed by
the member or the member's representative:
(1)
Assist the member with developing the member's initial and subsequent
individual budgets and with making any changes to the individual
budget.
(2) Have monthly contact
with the member for the first four months of implementation of the initial
individual budget and have, at a minimum, quarterly contact
thereafter.
(3) Complete the
required employment packet with the financial management service.
(4) Assist with interviewing potential
employees and entities providing services and supports if requested by the
member.
(5) Assist the member with
determining whether a potential employee meets the qualifications necessary to
perform the job.
(6) Assist the
member with obtaining a signed consent from a potential employee to conduct
background checks if requested by the member.
(7) Assist the member with negotiating with
entities providing services and supports if requested by the member.
(8) Assist the member with contracts and
payment methods for services and supports if requested by the member.
(9) Assist the member with developing an
emergency backup plan. The emergency backup plan shall address any health and
safety concerns.
(10) Review
expenditure reports from the financial management service to ensure that
services and supports in the individual budget are being provided.
(11) Document in writing on the independent
support broker timecard every contact the broker has with the member. Contact
documentation shall include information on the extent to which the member's
individual budget has addressed the member's needs and the satisfaction of the
member.
l.
Responsibilities of the financial management service. The
financial management service shall perform all of the following services:
(1) Receive Medicaid funds in an electronic
transfer.
(2) Process and pay
invoices for approved goods and services included in the individual
budget.
(3) Monitor and track the
approved individual budget amount authorized each month and document all
expenditures as they are paid.
(4)
Provide real-time individual budget account balances for the member, the
independent support broker, and the department, available at a minimum during
normal business hours (9 a.m. to 5 p.m., Monday through Friday).
(5) Conduct criminal background checks on
potential employees pursuant to 441-Chapter 119.
(6) Verify for the member an employee's
citizenship or alien status.
(7)
Assist the member with fiscal and payroll-related responsibilities including,
but not limited to:
1. Verifying that hourly
wages comply with federal and state labor rules.
2. Collecting and processing
timecards.
3. Withholding, filing,
and paying federal, state and local income taxes, Medicare and Social Security
(FICA) taxes, and federal (FUTA) and state (SUTA) unemployment and disability
insurance taxes, as applicable.
4.
Computing and processing other withholdings, as applicable.
5. Processing all judgments, garnishments,
tax levies, or other withholding on an employee's pay as may be required by
federal, state, or local laws.
6.
Preparing and issuing employee payroll checks.
7. Preparing and disbursing IRS Forms W-2 and
W-3 annually.
8. Processing federal
advance earned income tax credit for eligible employees.
9. Refunding over-collected FICA, when
appropriate.
10. Refunding
over-collected FUTA, when appropriate.
(8) Assist the member in completing required
federal, state, and local tax and insurance forms.
(9) Establish and manage documents and files
for the member and the member's employees.
(10) Monitor timecards, receipts, and
invoices to ensure that they are consistent with the individual budget. Keep
records of all timecards and invoices for each member for a total of five
years.
(11) Provide to the
department, the independent support broker, and the member monthly and
quarterly status reports that include a summary of expenditures paid and amount
of budget unused.
(12) Establish an
accessible customer service system and a method of communication for the member
and the independent support broker that includes alternative communication
formats.
(13) Establish a customer
services complaint reporting system.
(14) Develop a policy and procedures manual
that is current with state and federal regulations and update as
necessary.
(15) Develop a business
continuity plan in the case of emergencies and natural disasters.
(16) Provide to the department an annual
independent audit of the financial management service.
(17) Assist in implementing the state's
quality management strategy related to the financial management
service.
(18) The department may
request that the financial management service provider withhold payment to any
member or member's employee to offset any overpayment or enforce any sanction
placed on the service provider pursuant to rule
441-79.3 (249A).
m.
Responsibilities of the
member and the employee. A member participating in the CCO and the
member's employee(s) are responsible for the following:
(1) A member participating in the CCO shall
be jointly and severally liable with any of the member's employees for any
overpayment of medical assistance funds used through a CCO budget.
(2) A member may not employ any person who
has been sanctioned, or who is affiliated with a person or an entity that has
been sanctioned, under 441-Chapter 79. For purposes of this subparagraph,
"sanction" also includes anyone who has been temporarily suspended for a
credible allegation of fraud under 42 CFR Part 455 . Any CCO funds paid to any
employee who or which has been sanctioned is an overpayment that the department
shall recoup under 441-Chapter 79.
(3) A member may not employ any person who
has been excluded by the Office of the Inspector General of the Department of
Health and Human Services under Sections 1128 or 1156 of the Social Security
Act and is not eligible to receive federal funds.
(4) For personal care services, employees
shall use an electronic visit verification system that captures all
documentation requirements of the Consumer Choices Option Semi-Monthly Time
Sheet (Form 470-4429) or use Form 470-4429. All other employees shall complete,
sign and date Form 470-4429, Consumer Choices Option Semi-Monthly Time Sheet,
for each date of service provided to a member. All employees shall maintain
documentation that complies with rule
441-79.3 (249A).
(5) Members shall sign, and certify under
penalty of perjury, each employee timecard identified in subparagraph
78.34(13)"m"(4) prior to the timecard's submission to the
financial management service provider for payment in order to verify that all
information on the submitted timecard accurately describes the amount,
duration, and scope of services provided. When timecard information is
submitted to the financial management service provider in an electronic format,
the member shall retain the signed employee timecard for five years from the
date of service.
(14)
General service
standards. All health and disability waiver services must be provided
in accordance with the following standards:
a.
Reimbursement shall not be available under the waiver for any services that the
member can obtain as other nonwaiver Medicaid services or through any other
funding source.
b. All services
provided under the waiver must be delivered in the least restrictive
environment possible and in conformity with the member's service
plan.
c. All rights restrictions
must be implemented in accordance with 441-subrule 77.25(4). The member service
plan or treatment plan shall include documentation of:
(1) Any restrictions on the member's rights,
including the rights of privacy, dignity, respect, and freedom from coercion
and restraint.
(2) The need for the
restriction.
(3) The less intrusive
methods of meeting the need that have been tried but did not work.
(4) Either a plan to restore those rights or
written documentation that a plan is not necessary or appropriate.
(5) Established time limits for periodic
reviews to determine if the restriction is still necessary or can be
terminated.
(6) The informed
consent of the member.
(7) An
assurance that the interventions and supports will cause no harm to the
member.
(8) A regular collection
and review of data to measure the ongoing effectiveness of the
restriction.
d. Services
must be billed in whole units.
e.
For all services with a 15-minute unit of service, the following rounding
process will apply:
(1) Add together the
minutes spent on all billable activities during a calendar day for a daily
total.
(2) For each day, divide the
total minutes spent on billable activities by 15 to determine the number of
full 15-minute units for that day.
(3) Round the remainder using these
guidelines: Round 1 to 7 minutes down to zero units; round 8 to 14 minutes up
to one unit.
(4) Add together the
number of full units and the number of rounded units to determine the total
number of units to bill for that day.
This rule is intended to implement Iowa Code section 249A.4.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.