Iowa Admin. Code r. 441-83.22 - Eligibility

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

To be eligible for elderly waiver services a person must meet certain eligibility criteria and be determined to need a service(s) allowable under the program.

(1) Eligibility criteria. All of the following criteria must be met. The person must be:
a. Sixty-five years of age or older.
b. A resident of the state of Iowa.
c. Eligible 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.
d. Certified as being in need of the intermediate or skilled level of care based, in part, on information submitted on the interRAI - Home Care (HC). The interRAI - Home Care (HC) is available on request from IME medical services unit and other supporting documentation as relevant. Copies of the completed interRAI - Home Care (HC) for an individual are available to that individual from the individual's case manager or managed care organization.
(1) The assessment shall be completed when the person applies for waiver services, upon request to report a significant change in the person's condition, and annually for reassessment of the person's level of care. The IME medical services unit shall be responsible for determination of the initial level of care.
(2) The IME medical services unit or the member's managed care organization shall be responsible for annual redetermination of the level of care.
(3) Elderly 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. Determined to need services as described in subrule 83.22(2).
f. Rescinded IAB 10/11/06, effective 10/1/06.
g. For the consumer choices option as set forth in rule 441-subrule 78.37(16), residing in a living arrangement other than a residential care facility.
(2) Need for services, service plan, and cost.
a. Case management. Consumers under the elderly waiver shall receive case management services from a provider qualified pursuant to rule 441-77.29 (249A). Case management services shall be provided as set forth in rules 441-90.4 (249A) through 441-90.7(249A).
b. Interdisciplinary team. The case manager shall establish an interdisciplinary team for the consumer.
(1) Composition. The interdisciplinary team shall include the case manager and the consumer and, if appropriate, the consumer's legal representative, family, service providers, and others directly involved in the consumer's care.
(2) Role. The team shall identify:
1. The consumer's need for services based on the consumer's needs and desires.
2. Available and appropriate services to meet the consumer's needs.
3. Health and safety issues for the consumer that indicate the need for an emergency plan, based on a risk assessment conducted before the team meeting.
4. Emergency backup support and a crisis response system to address problems or issues arising when support services are interrupted or delayed or when the consumer's needs change.
c. Service plan. An applicant for elderly waiver services shall have a service plan developed by a qualified provider of case management services under the elderly waiver.
(1) Services included in the service plan shall be appropriate to the problems and specific needs or disabilities of the consumer.
(2) Services must be the least costly available to meet the service needs of the member.
(3) The service plan must be completed before services are provided.
(4) The service plan must be reviewed at least annually and when there is any significant change in the consumer's needs.
d. Content of service plan. The service plan shall include the following information based on the consumer's current assessment and service needs:
(1) Observable or measurable individual goals.
(2) Interventions and supports needed to meet those goals.
(3) Incremental action steps, as appropriate.
(4) The names of staff, people, businesses, or organizations responsible for carrying out the interventions or supports.
(5) The desired individual outcomes.
(6) The identified activities to encourage the consumer to make choices, to experience a sense of achievement, and to modify or continue participation in the service plan.
(7) Description of any restrictions on the consumer's rights, including the need for the restriction and a plan to restore the rights. For this purpose, rights include maintenance of personal funds and self-administration of medications.
(8) A list of all Medicaid and non-Medicaid services that the consumer received at the time of waiver program enrollment that includes:
1. The name of the service provider responsible for providing the service.
2. The funding source for the service.
3. The amount of service that the consumer is to receive.
(9) Indication of whether the consumer has elected the consumer choice option and, if so, the independent support broker and the financial management service that the consumer has selected.
(10) The determination that the services authorized in the service plan are the least costly.
(11) A plan for emergencies that identifies the supports available to the consumer in situations for which no approved service plan exists and which, if not addressed, may result in injury or harm to the consumer or other persons or in significant amounts of property damage. Emergency plans shall include:
1. The consumer's risk assessment and the health and safety issues identified by the consumer's interdisciplinary team.
2. The emergency backup support and crisis response system identified by the interdisciplinary team.
3. Emergency, backup staff designated by providers for applicable services.
(3) Providers-standards. Rescinded IAB 10/11/06, effective 10/1/06.

Notes

Iowa Admin. Code r. 441-83.22
ARC 7957B, IAB 7/15/09, effective 7/1/09; ARC 0191C, IAB 7/11/12, effective 7/1/12; ARC 0306C, IAB 9/5/12, effective 11/1/12; ARC 0359C, IAB 10/3/12, effective 12/1/12; ARC 0548C, IAB 1/9/2013, effective 1/1/2013; ARC 0665C, IAB 4/3/2013, effective 6/1/2013; 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 February 12, 2020/Volume XLII, Number 17, effective 3/18/2020 Amended by IAB February 10, 2021/Volume XLIII, Number 17, effective 4/1/2021

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