Iowa Admin. Code r. 441-83.61 - Eligibility
To be eligible for
(1)
Eligibility criteria.
All of the following criteria must be met. The person must:
a. Have a diagnosis of intellectual
disability as defined in rule
441-83.60 (249A). The diagnosis
shall be initially established and recertified as follows:
|
Age |
Initial application to |
Recertification for persons with a diagnosis of moderate, severe or profound level of severity |
Recertification for persons with a diagnosis of mild or unspecified level of severity |
|
0 through 17 years |
Psychological documentation within three years of the
application date substantiating a diagnosis of |
After the initial psychological evaluation,
substantiate a diagnosis of |
After the initial psychological evaluation,
substantiate a diagnosis of |
|
18 years and above |
Current psychological documentation substantiating a
diagnosis of |
Psychological documentation substantiating a
diagnosis of |
Psychological documentation substantiating a
diagnosis of |
b. Be
eligible for Medicaid under SSI, SSI-related, FMAP, or FMAP-related coverage
groups; eligible under the special income level (300 percent) coverage group;
or become eligible through application of the institutional deeming rules or
would be eligible for Medicaid ifin a medical institution .
c. Be certified as being in need for
long-term care that, but for the waiver, would otherwise be provided in an
ICF/ID. The IME medical services unit shall be responsible for the initial
approval, and the IME medical services unit or a managed care organization will
be responsible for the annual approval of the certification of the level of
care based on the data collected by the case manager and interdisciplinary team
on a tool designated by the department .
d. Be a recipient of the Medicaid case
management services or be identified to receive Medicaid case management
services immediately following program enrollment.
e. Have service needs that can be met by this
waiver program . At a minimum, a consumer must receive one billable unit of
service per calendar quarter under this program .
f. Have a service plan completed annually and
approved by the department in accordance with rule
441-83.67 (249A).
g. For individual supported employment and
long-term job coaching services:
(1) Be at
least 16 years of age.
(2) The
services must not be available to the member through one of the following:
1. Special education and related services as
defined in the Individuals with Disabilities Education Act (
20
U.S.C. 1401 et seq.); or
(3) Not reside in a
medical institution .
(4) Have
documented in the waiver service plan a goal to achieve or to sustain
individual employment.
h.
For small-group supported employment services:
(1) Be at least 16 years of age.
(2) The services must not be available to the
member through one of the following:
1.
Special education and related services as defined in the Individuals with
Disabilities Education Act (
20
U.S.C. 1401 et seq.); or
(3) Have documented
in the waiver service plan a goal to achieve or to sustain individual
employment.
(4) Have documented in
the waiver service plan that the choice to receive individual supported
employment services was offered and explained in a manner sufficient to ensure
informed choice, after which the choice to receive small-group supported
employment services was made.
(5)
Not reside in a medical institution .
i. For prevocational services:
(1) Be at least 16 years of age.
(2) The services must not be available to the
member through one of the following:
1.
Special education and related services as defined in the Individuals with
Disabilities Education Act (
20
U.S.C. 1401 et seq.); or
(3) Have documented
in the waiver service plan a goal to achieve or to sustain individual
employment.
(4) Have documented in
the waiver service plan that the choice to receive individual supported
employment services was offered and explained in a manner sufficient to ensure
informed choice, after which the choice to receive small-group supported
employment services was made.
(5)
Not reside in a medical institution .
j. Choose HCBS intellectual disability waiver
services rather than ICF/ID services.
k. 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.
l. Be assigned an HCBS
intellectual disability payment slot pursuant to subrule 83.61(4).
m. For residential-based supported community
living services, meet all of the following additional criteria:
(1) Be less than 18 years of age.
(2) Be preapproved as appropriate for
residential-based supported community living services by the bureau of
long-term care. Requests for approval shall be submitted in writing to the DHS
Bureau of Long-Term Care, 1305 East Walnut Street, Des Moines, Iowa 50319-0114,
and shall include the following:
1. Social
history;
2. Case history that
includes previous placements and service programs;
3. Medical history that includes major
illnesses and current medications;
4. Current psychological evaluations and
consultations;
5. Summary of all
reasonable and appropriate service alternatives that have been tried or
considered;
6. Any current court
orders in effect regarding the child ;
7. Any legal history;
8. Whether the child is at risk of
out-of-home placement or the proposed placement would be less restrictive than
the child 's current placement for services;
9. Whether the proposed placement would be
safe for the child and for other children living in that setting; and
10. Whether the interdisciplinary team is in
agreement with the proposed placement.
(3) Either:
1. Be residing in an ICF/ID;
2. Be at risk of ICF/ID placement, as
documented by an interdisciplinary team assessment pursuant to paragraph
83.61(2)"a"; or
3.
Be a child whose long-term placement outside the home is necessary because
continued stay in the home would be a detriment to the health and welfare of
the child or the family, and all service options to keep the child in the home
have been reviewed by an interdisciplinary team , as documented in the service
file.
n. For
day habilitation, be 16 years of age or older.
o. For the consumer choices option as set
forth in 441-subrule 78.41(5), not be living in a residential care
facility.
(2)
Need for services.
a.
Applicants currently receiving Medicaid case management shall have the
applicable staff coordinate with the department to arrange completion of Form
470-4694 for children under the age of five and, for all others, a SIS
assessment .
b. Applicants not
receiving services as set forth in paragraph 83.61(2)"a" shall
have a department service worker or case manager :
(1) Arrange for completion of Form 470-4694
for children under the age of five and, for all others, a SIS assessment for
the initial level of care determination;
(2) Establish an initial interdisciplinary
team for HCBS intellectual disability waiver services; and
(3) With the initial interdisciplinary team ,
identify the applicant's needs and desires as well as the availability and
appropriateness of services.
c. Applicants meeting other eligibility
criteria who do not have a Medicaid case manager shall be referred to a
Medicaid case manager .
d. Services
shall not exceed the number of maximum units established for each
service.
e. The cost of services
shall not exceed unit expense maximums. Requests shall only be reviewed for
funding needs exceeding the supported community living service unit cost
maximum. Requests require special review by the department and may be denied as
not cost-effective.
f. The case
manager shall coordinate with the department for completion of Form 470-4694
for children under the age of five and, for all others, to arrange a SIS
assessment for the initial level of care determination within 30 days from the
date of the HCBS application unless the case manager can document difficulty in
locating information necessary to arrange the assessment or other circumstances
beyond the case manager 's control.
g. At initial enrollment, the case manager
shall establish an interdisciplinary team for each applicant and, with the
team, identify the applicant's need for service based on the applicant's needs
and desires as well as the availability and appropriateness of services. The
Medicaid case manager shall complete an annual review thereafter. The following
criteria shall be used for the initial and ongoing identification of need for
services:
(1) The assessment shall be based on
the results of the most recent Form 470-4694 for children under the age of five
and, for all others, the SIS assessment or of the SIS contractor's off-year
review.
(2) Service plans must be
developed or reviewed to reflect use of all appropriate nonwaiver Medicaid
services so as not to replace or duplicate those services.
(3) Service plans for applicants aged 20 or
under which include supported community living services beyond intermittent
shall be approved (signed and dated) by the designee of the bureau of long-term
care. The service worker, department QIDP, or Medicaid case manager shall
attach a written request for a variance from the maximum for intermittent
supported community living with a summary of services and service costs. The
written request for the variance shall provide a rationale for requesting
supported community living beyond intermittent. The rationale shall contain
sufficient information for the designee to make a decision regarding the need
for supported community living beyond intermittent.
h. 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 ofno more than 30 days each per
caregiver as documented by the service worker. 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 ofup 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 .
(3)
HCBS intellectual disability
waiver program limit. The number of persons receiving HCBS
intellectual disability waiver services in the state shall be limited to the
number of payment slots provided in the HCBS intellectual disability waiver
approved by the Centers for Medicare and Medicaid Services (CMS ). The
department shall make a request to CMS to adjust the program limit as deemed
necessary.
a. The payment slots are available
on a statewide basis. These slots shall be available based on the prioritized
need of an applicant pursuant to subrule 83.61(4).
b. When services are denied because the limit
is reached, a notice of decision denying service based on the limit and stating
that the person's name will be put on a waiting list shall be sent to the
person by the department .
(4)
Securing a payment slot.
The department shall determine if a payment slot is available for each
applicant for the HCBS intellectual disability waiver.
a. A payment slot shall be assigned to the
applicant upon confirmation of an available slot.
(1) Once a payment slot is assigned, the
department shall give written notice to the applicant.
(2) The department shall hold the payment
slot for the applicant as long as reasonable efforts are being made to arrange
services and the applicant has not been determined to be ineligible for the
program . If services have not been initiated and reasonable efforts are no
longer being made to arrange services, the slot shall revert for use by the
next person on the waiting list, if applicable. The applicant originally
assigned the slot must reapply for a new slot.
b. If no payment slot is available, the
applicant shall be placed on a statewide priority waiting list. The department
shall assess each applicant to determine the applicant's priority need. The
assessment shall be made for all applicants who are on a waiting list
maintained by the state or a county on September 30, 2011, and for all new
applications received on or after October 1, 2011.
(1) Emergency need criteria are as follows:
1. The usual caregiver has died or is
incapable of providing care, and no other caregivers are available to provide
needed supports.
2. The applicant
has lost primary residence or will be losing housing within 30 days and has no
other housing options available.
3.
The applicant is living in a homeless shelter and no alternative housing
options are available.
4. There is
founded abuse or neglect by a caregiver or others living within the home of the
applicant, and the applicant must move from the home.
5. The applicant cannot meet basic health and
safety needs without immediate supports.
(2) Urgent need criteria are as follows:
1. The caregiver will need support within 60
days in order for the applicant to remain living in the current
situation.
2. The caregiver will be
unable to continue to provide care within the next 60 days.
3. The caregiver is 55 years of age or older
and has a chronic or long-term physical or psychological condition that limits
the ability to provide care.
4. The
applicant is living in temporary housing and plans to move within 31 to 120
days.
5. The applicant is losing
permanent housing and plans to move within 31 to 120 days.
6. The caregiver will be unable to be
employed if services are not available.
7. There is a potential risk of abuse or
neglect by a caregiver or others within the home of the applicant.
8. The applicant has behaviors that put the
applicant at risk.
9. The applicant
has behaviors that put others at risk.
10. The applicant is at risk of facility
placement when needs could be met through community-based services.
(3) Applicants who meet an
emergency need criterion shall be placed on the priority waiting list based on
the total number of criteria in subparagraph 83.61(4)"b" (1)
that are met. If applicants meet an equal number of criteria, the position on
the waiting list shall be based on the date of application and the age of the
applicant. The applicant who has been on the waiting list longer shall be
placed higher on the waiting list. If the application date is the same, the
older applicant shall be placed higher on the waiting list.
(4) Applicants who meet an urgent need
criterion shall be placed on the priority waiting list after applicants who
meet emergency need criteria. The position on the waiting list shall be based
on the total number of criteria in subparagraph 83.61(4)"b"
(2) that are met. If applicants meet an equal number of criteria, the position
on the waiting list shall be based on the date of application and the age of
the applicant. The applicant who has been on the waiting list longer shall be
placed higher on the waiting list. If the application date is the same, the
older applicant shall be placed higher on the waiting list.
(5) Applicants who do not meet emergency or
urgent need criteria shall be placed lower on the waiting list than the
applicants meeting urgent need criteria, based on the date of application. If
the application date is the same, the older applicant shall be placed higher on
the waiting list.
(6) Applicants
shall remain on the waiting list until a payment slot has been assigned to them
for use, they withdraw from the list, or they become ineligible for the waiver.
If there is a change in an applicant's need, the applicant may contact the
local department office and request that anew assessment be completed. The
outcome of the assessment shall determine placement on the waiting list as
directed in this subrule.
c. To maintain the approved number of members
in the program , persons shall be selected from the waiting list as payment
slots become available, based on their priority order on the waiting list.
(1) Once a payment slot is assigned, the
department shall give written notice to the person within five working
days.
(2) The department shall hold
the payment slot for 30 days for the person to file a new application. If an
application has not been filed within 30 days, the slot shall revert for use by
the next person on the waiting list, if applicable. The person originally
assigned the slot must reapply for a new slot.
d. The state reserves payment slots each
waiver year (July 1 to June 30) for use by children who must reside outside the
family home in a residential-based supported community living licensed
residential care facility. The state also reserves payment slots each waiver
year (July 1 to June 30) for use by members living in an ICF/ID, nursing
facility, or out-of-state placement, or transitioning from the Money Follows
the Person Grant, who choose to access services in the intellectual disability
waiver program and leave the ICF/ID, nursing facility, or out-of-state
placement to live in the community.
(1)
Applicants who currently reside in an ICF/ID or nursing facility and have
resided in that setting for four or more months may request a reserved capacity
slot through the intellectual disability waiver.
(2) Applicants shall be allocated a reserved
capacity slot on the basis of the date the request is received by the income
maintenance worker or the waiver slot manager.
(3) In the event that more than one request
for a reserved capacity slot is received at one time, applicants shall be
allocated the next available reserved capacity slot on the basis of the month
of birth, January being month one and the lowest number.
(4) Persons who do not fall within the
available reserved capacity slots shall have the person's name maintained on
the reserved capacity slot waiting list. As reserved capacity slots become
available at the beginning of the next waiver year , persons shall be selected
from the reserved capacity slot waiting list to utilize the number of approved
reserved capacity slots based on the person's order on the waiting
list.
Notes
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