Iowa Admin. Code r. 441-83.2 - Eligibility

Current through Register Vol. 44, No. 12, December 15, 2021

To be 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b. Rescinded IAB 1/2/19, effective 2/6/19.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 if in 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

$2,792.65

$959.50

$3,742.93

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.

Notes

Iowa Admin. Code r. 441-83.2
ARC 0306C, IAB 9/5/12, effective 11/1/12; ARC 0548C, IAB 1/9/2013, effective 1/1/2013; ARC 0665C, IAB 4/3/2013, effective 6/1/2013; ARC 0757C, IAB 5/29/2013, effective 8/1/2013; ARC 0842C, IAB 7/24/2013, effective 7/1/2013; ARC 1056C, IAB 10/2/2013, effective 11/6/2013; ARC 1445C, IAB 4/30/2014, effective 7/1/2014 Amended by IAB January 06, 2016/Volume XXXVIII, Number 14, effective 1/1/2016 Amended by IAB December 7, 2016/Volume XXXIX, Number 12, effective 11/15/2016 Amended by IAB February 1, 2017/Volume XXXIX, Number 16, effective 3/8/2017 Amended by IAB July 5, 2017/Volume XL, Number 01, effective 8/9/2017 Amended by IAB January 2, 2019/Volume XLI, Number 14, effective 2/6/2019 Amended by IAB February 12, 2020/Volume XLII, Number 17, effective 3/18/2020 Amended by IAB March 10, 2021/Volume XLIII, Number 19, effective 4/14/2021 Amended by IAB September 8, 2021/Volume XLIV, Number 5, effective 8/17/2021

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