Payment will be approved for the following services to
members eligible for the HCBS AIDS/HIV 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)
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.
(2)
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 are:
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.
(3)
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.
(4)
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 shall be 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 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
conditions and needs. 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 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)
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.
(7)
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.
(8)
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 78.38(8)
"f" and
the skilled activities listed in paragraph 78.38(8)
"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., antihypertensive, 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.
(9)
Consumer choices option. The consumer choices option is
service activities provided pursuant to subrule 78.34(13).
(10)
General service
standards. All AIDS/HIV 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
Iowa Admin. Code r. 441-78.38
ARC 9045B, lAB 9/8/10,
effective 11/1/10; ARC 9403B, lAB 3/9/11, effective 5/1/11 (See Delay note at
end of chapter)
Amended by
IAB
September 3, 2014/Volume XXXVII, Number 5, effective
8/13/2014
Amended by
IAB
January 3, 2018/Volume XL, Number 14, effective
2/7/2018
Amended by
IAB
July 4, 2018/Volume XLI, Number 1, effective
8/8/2018
Amended by
IAB
May 8, 2019/Volume XLI, Number 23, effective
7/1/2019
Amended by
IAB
May 5, 2021/Volume XLIII, Number 23, effective
7/1/2021