"AIDS" means a medical diagnosis of acquired
immunodeficiency syndrome based on the Centers for Disease Control "Revision of
the CDC Surveillance Case Definition for Acquired Immunodeficiency Syndrome,"
August 14, 1987, Vol. 36, No. 1S issue of "Morbidity and Mortality Weekly
Report."
"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.
"Basic individual respite" means respite
provided on a staff-to-consumer ratio of one to one or higher to individuals
without specialized needs requiring the care of a licensed registered nurse or
licensed practical nurse.
"Client participation" means the amount of
the recipient's income that the person must contribute to the cost of AIDS/HIV
waiver services exclusive of medical vendor payments before Medicaid will
participate.
"Deeming" means the specified amount of
parental or spousal income and resources considered in determining eligibility
for a child or spouse according to current supplemental security income
guidelines.
"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.
"Financial participation" means client
participation and medical payments from a third party including veterans' aid
and attendance.
"Group respite" is respite provided on a
staff-to-consumer ratio of less than one to one.
"Guardian" means a guardian appointed in
probate court.
"HIV" means a medical diagnosis of human
immunodeficiency virus infection based on a positive HIV-related test.
"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 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.
"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.
"Specialized respite" means respite provided
on a staff-to-consumer ratio of one to one or higher to individuals with
specialized medical needs requiring the care, monitoring or supervision of a
licensed registered nurse or licensed practical nurse.
"Third-party payments" means payments from
an attorney, individual, institution, corporation, or public or private agency
which is liable to pay part or all of the medical costs incurred as a result of
injury, disease or disability by or on behalf of an applicant or a past or
present recipient of medical assistance.
"Usual caregiver" means a person or persons
who reside with the consumer and are available on a 24-hour-per-day basis to
assume responsibility for the care of the consumer.
Notes
Iowa Admin. Code r. 441-83.41
Amended by
IAB
January 06, 2016/Volume XXXVIII, Number 14, effective
1/1/2016
Amended by
IAB
July 4, 2018/Volume XLI, Number 1, effective
8/8/2018
Amended by
IAB
May 5, 2021/Volume XLIII, Number 23, effective
7/1/2021
