"Adaptive" means age-appropriate skills
related to taking care of one's self and the ability to relate to others in
daily living situations. These skills include limitations that occur in the
areas of communication, self-care, home living, social skills, community use,
self-direction, safety, functional academics, leisure and work.
"Adult" means a person with a physical
disability aged 18 years to 64 years.
"Appropriate" means that the services or
supports or activities provided or undertaken by the organization are relevant
to the consumer's needs, situation, problems, or desires.
"Assessment" means the review of the
consumer's current functioning in regard to the consumer's situation, needs,
strengths, abilities, desires and goals.
"Attorney in fact under a durable power of attorney
for health care" means an individual who is designated by a durable
power of attorney for health care, pursuant to Iowa Code chapter 144B, as an
agent to make health care decisions on behalf of an individual and who has
consented to act in that capacity.
"Behavior" means skills related to
regulating one's own behavior including coping with demands from others, making
choices, controlling impulses, conforming conduct to laws, and displaying
appropriate sociosexual behavior.
"Client participation" means the amount of
the consumer's income that the person must contribute to the cost of physical
disability waiver services, exclusive of medical vendor payments, before
Medicaid will provide additional reimbursement.
"Department" means the Iowa department of
human services.
"Electronic visit verification system"
means, with respect to personal care services or home health care services
defined in Section 12006 of the 21st Century Cures Act, a system under which
visits conducted as part of such services are electronically verified with
respect to:
(1) the type of service
performed,
(2) the individual
receiving the service,
(3) the date
of the service,
(4) the location of
service delivery,
(5) the individual
providing the service, and
(6) the
time the service begins and ends.
"Guardian" means a guardian appointed in
probate court for an adult.
"Intermediate care facility for persons with an
intellectual disability level of care" means that the individual has a
diagnosis of intellectual disability made in accordance with the criteria
provided in the current version of the Diagnostic and Statistical Manual of
Mental Disorders published by the American Psychiatric Association; or has a
related condition as defined in
42 CFR
435.1009; and needs assistance in at least
three of the following major life areas: mobility, musculoskeletal skills,
activities of daily living, domestic skills, toileting, eating skills, vision,
hearing or speech or both, gross/fine motor skills, sensory-taste, smell,
tactile, academic skills, vocational skills, social/community skills, behavior,
and health care.
"Managed care organization" means an entity
that (1) is under contract with the department to provide services to Medicaid
recipients and (2) meets the definition of "health maintenance organization" as
defined in Iowa Code section
514B.1.
"Medical institution" means a nursing
facility, a skilled nursing facility, intermediate care facility for persons
with an intellectual disability, or hospital which has been approved as a
Medicaid vendor.
"Nursing facility level of care" means that
the following conditions are met:
1.
The presence of a physical or mental impairment which restricts the member's
daily ability to perform the essential activities of daily living, bathing,
dressing, and personal hygiene, and impedes the member's capacity to live
independently.
2. The member's
physical or
mental impairment is such that self-execution of required nursing
care is improbable or impossible.
"Physical disability" means a severe,
chronic condition that is attributable to a physical impairment that results in
substantial limitations of physical functioning in three or more of the
following areas of major life activities: self-care, receptive and expressive
language, learning, mobility, self-direction, capacity for independent living,
and economic self-sufficiency.
"Service plan" means a person-centered,
outcome-based plan of services which is written by the member's case manager
with input and direction from the member and which addresses all relevant
services and supports being provided. The service plan is developed by the
interdisciplinary team, which includes the member and, if appropriate, the
member's legal representative, member's family, service providers, and others
directly involved with the member.
"Skilled nursing facility level of care"
means that the following conditions are met:
1. The member's medical condition requires
skilled nursing services or skilled rehabilitation services as defined in
42 CFR
409.31(a),
409.32,
and
409.34.
2. Services are provided in accordance with
the general provisions for all Medicaid providers and services as described in
rule
441-79.9 (249A).
3. Documentation submitted for review
indicates that the member has:
a. A physician
order for all skilled services.
b.
Services that require the skills of medical personnel, including registered
nurses, licensed practical nurses, physical therapists, occupational
therapists, speech pathologists, or audiologists.
c. An individualized care plan that
identifies support needs.
d.
Confirmation that skilled services are provided to the member.
e. Skilled services that are provided by, or
under the supervision of, medical personnel as described above.
f. Skilled nursing services that are needed
and provided seven days a week or skilled rehabilitation services that are
needed and provided at least five days a week.
"Third-party payments" means payments from
an individual, institution, corporation, or public or private provider which is
liable to pay part or all of the medical costs incurred as a result of injury
or disease on behalf of a consumer of medical assistance.
"Waiver year" means a 12-month period
commencing on April 1 of each year.
