Tobe eligible for health and disability waiver services, a
person must meet certain eligibility criteria and be determined to need a
service(s) allowable under the program.
(1)
Eligibility criteria.
a. The person must be under the age of 65 and
blind or disabled as determined by the receipt of social security disability
benefits or by a disability determination made through the department.
Disability determinations are made according to supplemental security income
guidelines under Title XVI of the Social Security Act.
b. Rescinded IAB 1/2/19, effective
2/6/19.
c. Persons shall meet the
eligibility requirements of the supplemental security income program except for
the following:
(1) The person is under 18
years of age, unmarried and not the head of a household and is ineligible for
supplemental security income because of the deeming of the parent's(s')
income.
(2) The person is married
and is ineligible for supplemental security income because of the deeming of
the spouse's income or resources.
(3) The person is ineligible for supplemental
security income due to excess income and the person's income does not exceed
300 percent of the maximum monthly payment for one person under supplemental
security income.
(4) The person is
under 18 years of age and is ineligible for supplemental security income
because of excess resources.
d. The person must be certified as being in
need of nursing facility or skilled nursing facility level of care or as being
in need of care in an intermediate care facility for persons with an
intellectual disability, based on information submitted on a completed
information submission tool Form 470-4694 for children aged 3 and under, the
interRAI - Pediatric Home Care (PEDS-HC) for those aged 4 to 20, or the
interRAI - Home Care (HC) for those aged 21 to 64 and other supporting
documentation as relevant. Form 470-4694, the interRAI - Pediatric Home Care
(PEDS-HC) and the interRAI - Home Care (HC) are available upon request from the
IME medical services unit. Copies of the completed information submission tool
for an individual are available to that individual from the individual's case
manager or managed care organization.
(1) The
member's designated case manager shall use the completed assessment to develop
the comprehensive service plan as specified in 441-paragraph
90.4(1)"b."
(2)
The IME medical services unit shall be responsible for the initial
determination of the member's level of care certification. The IME medical
services unit or the member's managed care organization shall be responsible
for annual redetermination of the level of care.
(3) Health and disability waiver services
will not be provided when the person is an inpatient in a medical
institution.
(4) The managed care
organization must submit documentation to the IME medical services unit for all
reassessments, performed at least annually, which indicate a change in the
member's level of care. The IME medical services unit shall make a final
determination for any reassessments which indicate a change in the level of
care. If the level of care reassessment indicates no change in level of care,
the member is approved to continue at the already established level of
care.
e. To be eligible
for interim medical monitoring and treatment services the consumer must be:
(1) Under the age of 21;
(2) Currently receiving home health agency
services under rule
441-78.9 (249A) and require
medical assessment, medical monitoring, and regular medical intervention or
intervention in a medical emergency during those services. (The home health
aide services for which the consumer is eligible must be maximized before the
consumer accesses interim medical monitoring and treatment.);
(3) Residing in the consumer's family home or
foster family home; and
(4) In need
of interim medical monitoring and treatment as ordered by a physician, nurse
practitioner, clinical nurse specialist, or physician assistant.
f. The person must meet income and
resource guidelines for Medicaid as ifin a medical institution pursuant to
441-Chapter 75. When a husband and wife who are living together both apply for
the waiver, income and resource guidelines as specified at 441-paragraphs
75.5(2)"b" and 75.5(4)"c" shall be
applied.
g. The person must have
service needs that can be met by this waiver program. At a minimum a person
must receive one billable unit of service under the waiver per calendar
quarter.
h. To be eligible for the
consumer choices option as set forth in 441-subrule 78.34(13), a person cannot
be living in a residential care facility.
(2)
Need for services.
a. The member shall have a service plan
approved by the department which is developed by the designated case manager.
This service plan must be completed prior to services provision and annually
thereafter.
The designated case manager shall establish the
interdisciplinary team for the member and, with the team, identify the member's
need for service based on the member's needs and desires as well as the
availability and appropriateness of services, using the following
criteria:
(1) This service plan shall
be based, in part, on information in the completed information submission tool
listed in paragraph 83.2(1)"d" and other supporting
documentation as relevant. The designated case manager shall have a
face-to-face visit with the member at least quarterly.
(2) Service plans for persons aged 20 or
under shall be developed to reflect use of all appropriate nonwaiver Medicaid
services and so as not to replace or duplicate those services. The designated
case manager shall list all nonwaiver Medicaid services in the service
plan.
(3) Service plans for persons
aged 20 or under that include home health or nursing services shall not be
approved until a home health agency has made a request to cover the member's
service needs through nonwaiver Medicaid services.
b. Except as provided below, the total
monthly cost of the health and disability waiver services, excluding the cost
of home and vehicle modification services, shall not exceed the established
aggregate monthly cost for level of care as follows:
Skilled level of care
|
Nursing level of care
|
ICF/ID
|
$3,014.69
|
$1,035.79
|
$4,040.52
|
For members enrolled in the health and disability waiver in
accordance with subrule 83.2(1), when a member turns 21 years of age, the
average monthly cost of services received through 441-subrule 78.9(10) (state
plan private duty nursing or personal care services for persons aged 20 and
under) shall be used to increase the monthly waiver budget in accordance with
the following:
(1) The member must
request the revised waiver budget through the member's case manager no earlier
than two months before, and no later than six months after, the member's
twenty-first birthday. A renewal request must be received annually no earlier
than two months before, and no later than six months after, each subsequent
birthday.
(2) The member's waiver
budget shall be increased by the average monthly cost of state plan private
duty nursing or personal care services for the member that was billed to and
paid by Iowa Medicaid or an Iowa Medicaid-contracted managed care organization
during the year in which the member is 20 years of age.
(3) Once the request is received by the
department, the department shall determine the average monthly cost pursuant to
the claims data available at the time of the request. No subsequent claims data
shall be considered.
(4) The
revised waiver budget reflecting the average cost of state plan private duty
nursing or personal care services shall become effective on the later of the
first day of the month of the member's twenty-first birthday or the first day
of the month of the completed review.
(5) The revised waiver budget shall extend up
to the first of the month following the member's twenty-fifth birthday and
shall remain at the initially authorized amount for the member while aged 21
through 24.
c. Interim
medical monitoring and treatment services must be needed because all usual
caregivers are unavailable to provide care due to one of the following
circumstances:
(1) Employment. Interim medical
monitoring and treatment services are to be received only during hours of
employment.
(2) Academic or
vocational training. Interim medical monitoring and treatment services provided
while a usual caregiver participates in postsecondary education or vocational
training shall be limited to 24 periods of no more than 30 days each per
caregiver as documented by the service worker or targeted case manager. Time
spent in high school completion, adult basic education, GED, or English as a
second language does not count toward the limit.
(3) Absence from the home due to
hospitalization, treatment for physical or mental illness, or death of the
usual caregiver. Interim medical monitoring and treatment services under this
subparagraph are limited to a maximum of 30 days.
(4) Search for employment.
1. Care during job search shall be limited to
only those hours the usual caregiver is actually looking for employment,
including travel time.
2. Interim
medical monitoring and treatment services may be provided under this paragraph
only during the execution of one job search plan of up to 30 working days in a
12-month period, approved by the department service worker or targeted case
manager pursuant to 441-subparagraph 170.2(2)"b"(5).
3. Documentation of job search contacts shall
be furnished to the department service worker or targeted case
manager.