Payment shall be approved for the following services to
members eligible for the HCBS physical disability waiver 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)
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 78.46(1)
"f" and the skilled activities listed in
paragraph 78.46(1)
"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.
(2)
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.
(4)
Specialized medical
equipment.
a. Specialized medical
equipment shall include medically necessary items which are for personal use by
members with a physical disability and which:
(1) Provide for the health and safety of the
member,
(2) Are not ordinarily
covered by Medicaid,
(3) Are not
funded by educational or vocational rehabilitation programs, and
(4) Are not provided by voluntary
means.
b. Coverage
includes, but is not limited to:
(1)
Electronic aids and organizers.
(2)
Medicine dispensing devices.
(3)
Communication devices.
(4) Bath
aids.
(5) Noncovered environmental
control units.
(6) Repair and
maintenance of items purchased through the waiver.
c. Payment of up to $6,872.85 per year may be
made to enrolled specialized medical equipment providers upon satisfactory
receipt of the service.
d. The need
for specialized medical equipment shall be:
(1) Documented by a health care professional
as necessary for the member's health and safety, and
(2) Identified in the member's service
plan.
e. 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).
(7)
General service
standards. All physical 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.