Iowa Admin. Code r. 441-78.37 - HCBS elderly waiver services
Payment will be approved for the following services to members eligible for the HCBS elderly 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)
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.
(2)
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 necessary components of a
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.
(3)
Home health aide
services. Home health aide 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. Components of the service include:
a. Observation and reporting of physical or
emotional needs.
b. Helping a
client with bath, shampoo, or oral hygiene.
c. Helping a client with toileting.
d. Helping a client in and out of bed and
with ambulation.
e. Helping a
client reestablish activities of daily living.
f. Assisting with oral medications ordinarily
self-administered and ordered by a physician.
g. 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.
(4)
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.
(5)
Nursing care services.
Nursing care services are services provided by licensed agency nurses to
clients in the home which are ordered by and included in the plan of treatment
established by the physician. The services are reasonable and necessary to the
treatment of an illness or injury and include: observation; evaluation;
teaching; training; supervision; therapeutic exercise; bowel and bladder care;
administration of medications; intravenous, hypodermoclysis, and enteral
feedings; skin care; preparation of clinical and progress notes; coordination
of services and informing the physician and other personnel of changes in the
patient's condition and needs.
A unit of service is one visit. Nursing care service can pay for a maximum of eight nursing visits per month for intermediate level of care persons. There is no limit on the maximum visits for skilled level of care persons.
(6)
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 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.
(7)
Chore services. Chore
services provide assistance with the household maintenance activities listed in
paragraph 78.37(7)"a," as necessary to allow a member to
remain in the member's own home safely and independently. A unit of service is
15 minutes.
a. Chore services are limited to
the following services:
(1) Window and door
maintenance, such as hanging screen windows and doors, replacing windowpanes,
and washing windows;
(2) Minor
repairs to walls, floors, stairs, railings and handles;
(3) Heavy cleaning which includes cleaning
attics or basements to remove fire hazards, moving heavy furniture, extensive
wall washing, floor care, painting, and trash removal;
(4) Lawn mowing and removal of snow and ice
from sidewalks and driveways.
b. Leaf raking, bush and tree trimming, trash
burning, stick removal, and tree removal are not covered services.
(8)
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 which 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.
(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.
h. Services shall be
included in the member's service plan and shall exceed the Medicaid state plan
services.
(10)
Mental health outreach. Mental health outreach services are
services provided in a recipient's home to identify, evaluate, and provide
treatment and psychosocial support. The services can only be provided on the
basis of a referral from the consumer's interdisciplinary team established
pursuant to 441-subrule 83.22(2). A unit of service is 15 minutes.
(11)
Transportation.
Transportation services may be provided for members to conduct business errands
and essential shopping and to reduce social isolation. A unit of service is one
mile of transportation or one one-way trip.
(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)
Assistive devices. Assistive devices means practical equipment
products to assist persons with activities of daily living and instrumental
activities of daily living to allow the person more independence. They include,
but are not limited to: long-reach brush, extra long shoehorn, nonslip grippers
to pick up and reach items, dressing aids, shampoo rinse tray and inflatable
shampoo tray, double-handled cup and sipper lid. A unit is an item.
a. The service shall be included in the
member's service plan and shall exceed the services available under the
Medicaid state plan.
b. The service
shall be provided following prior approval by the Iowa Medicaid
enterprise.
c. Payment for most
items shall be based on a fee schedule. The amount of the fee shall be
determined as directed in 441-subrule 79.1(17).
(14)
Senior companion.
Senior companion services are nonmedical care supervision, oversight, and
respite. Companions may assist with such tasks as meal preparation, laundry,
shopping and light housekeeping tasks. This service cannot provide hands-on
nursing or medical care. A unit of service is 15 minutes.
(15)
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 78.37(15)"f" and the skilled activities listed in
paragraph 78.37(15)"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, agency or assisted
living facility 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) Assisted living agreements
with Iowa Medicaid members must specify the services to be considered covered
under the assisted living occupancy agreement and those CDAC services to be
covered under the elderly waiver. The funding stream for each service must be
identified.
(3) 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 individual
and agency providers 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,
agency or assisted living facility. 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.
(16)
Consumer choices
option. The consumer choices option is service activities provided
pursuant to subrule 78.34(13).
(17)
Case management services. Case management services are
services that assist Medicaid members who reside in a community setting or are
transitioning to a community setting in gaining access to needed medical,
social, educational, housing, transportation, vocational, and other appropriate
services in order to ensure the health, safety, and welfare of the member. Case
management is provided at the direction of the member and the interdisciplinary
team established pursuant to 441-subrule 83.22(2).
a. Case management services shall be provided
as set forth in rules
441-90.4 (249A) through
441-90.7 (249A).
b. Case management shall not include the
provision of direct services by the case managers.
c. Payment for case management shall not be
made until the consumer is enrolled in the waiver. Payment shall be made only
for case management services performed on behalf of the consumer during a month
when the consumer is enrolled.
(18)
Assisted living
service. The assisted living service includes unanticipated and
unscheduled personal care and supportive services that are furnished to waiver
participants who reside in a homelike, noninstitutional setting. The service
includes the 24-hour on-site response capability to meet unpredictable member
needs as well as member safety and security through incidental supervision.
Assisted living service is not reimbursable if performed at the same time as
any service included in an approved consumer-directed attendant care (CDAC)
agreement.
a. A unit of service is one
day.
b. A day of assisted living
service is billable only if both the following requirements are met:
(1) The member was present in the facility
during that day's bed census.
(2)
The assisted living provider has documented at least one assisted living
service encounter for that day, in accordance with rule
441-79.3 (249A). The
documentation must include the member's response to the service. The documented
assisted living service cannot also be an authorized CDAC service.
(19)
General
service standards. All elderly 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
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