"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 brain injury
aged 18 years or over.
"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.
"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.
"Behavior" means skills related to
regulating one's own behavior including coping with demands from others, making
choices, conforming conduct to laws, and displaying appropriate sociosexual
behavior.
"Brain injury" means clinically evident
damage to the brain resulting directly or indirectly from trauma, infection,
anoxia, vascular lesions or tumor of the brain, not primarily related to
degenerative or aging processes, which temporarily or permanently impairs a
person's physical, cognitive, or behavioral functions. The person must have a
diagnosis from the following list:
Malignant neoplasms of brain, cerebrum.
Malignant neoplasms of brain, frontal lobe.
Malignant neoplasms of brain, temporal lobe.
Malignant neoplasms of brain, parietal lobe.
Malignant neoplasms of brain, occipital lobe.
Malignant neoplasms of brain, ventricles.
Malignant neoplasms of brain, cerebellum.
Malignant neoplasms of brain, brain stem.
Malignant neoplasms of brain, other part of brain, includes
midbrain, peduncle, and medulla oblongata.
Malignant neoplasms of brain, cerebral meninges.
Malignant neoplasms of brain, cranial nerves.
Secondary malignant neoplasm of brain.
Secondary malignant neoplasm of other parts of the nervous
system, includes cerebral meninges.
Benign neoplasm of brain and other parts of the nervous
system, brain.
Benign neoplasm of brain and other parts of the nervous
system, cranial nerves.
Benign neoplasm of brain and other parts of the nervous
system, cerebral meninges.
Encephalitis, myelitis and encephalomyelitis.
Intracranial and intraspinal abscess.
Anoxic brain damage.
Subarachnoid hemorrhage.
Intracerebral hemorrhage.
Other and unspecified intracranial hemorrhage.
Occlusion and stenosis of precerebral arteries.
Occlusion of cerebral arteries.
Transient cerebral ischemia.
Acute, but ill-defined, cerebrovascular disease.
Other and ill-defined cerebrovascular diseases.
Fracture of vault of skull.
Fracture of base of skull.
Other and unqualified skull fractures.
Multiple fractures involving skull or face with other
bones.
Concussion.
Cerebral laceration and contusion.
Cerebral edema.
Cerebral palsy.
Subarachnoid, subdural, and extradural hemorrhage following
injury.
Other and unspecified intracranial hemorrhage following
injury.
Intracranial injury of other and unspecified nature.
Poisoning by drugs, medicinal and biological
substances.
Toxic effects of substances.
Effects of external causes.
Drowning and nonfatal submersion.
Asphyxiation and strangulation.
Child maltreatment syndrome.
Adult maltreatment syndrome.
Status epilepticus.
"Case management services" means those
services established pursuant to Iowa Code chapter 225C.
"Child" means a person with a brain injury
aged 17 years or under.
"Client participation" means the amount of
the consumer's income that the person must contribute to the cost of brain
injury waiver services, exclusive of medical vendor payments, before Medicaid
will provide additional reimbursement.
"Deemed status" means acceptance of
certification or licensure of a program or service by another certifying body
in place of certification based on review and evaluation.
"Department" means the Iowa department of
human services.
"Direct service" means services involving
face-to-face assistance to a consumer such as transporting a consumer or
providing therapy.
"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.
"Fiscal accountability" means the
development and maintenance of budgets and independent fiscal review.
"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.
"Health" means skills related to the
maintenance of one's health including eating; illness identification, treatment
and prevention; basic first aid; physical fitness; regular physical checkups
and personal habits.
"Immediate jeopardy" means circumstances
where the life, health, or safety of a person will be severely jeopardized if
the circumstances are not immediately corrected.
"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.
"Intermittent supported community living
service" means supported community living service provided from one to
three hours a day for not more than four days a week.
"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 assessment" means a visual and
physical inspection of the consumer, noting deviations from the norm, and a
statement of the consumer's mental and physical condition that can be amendable
to or resolved by appropriate actions of the provider.
"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.
"Medical intervention" means consumer care
in the areas of hygiene, mental and physical comfort, assistance in feeding and
elimination, and control of the consumer's care and treatment to meet the
physical and mental needs of the consumer in compliance with the plan of care
in areas of health, prevention, restoration, and maintenance.
"Medical monitoring" means observation for
the purpose of assessing, preventing, maintaining, and treating disease or
illness based on the consumer's plan of care.
"Natural supports" means services and
supports identified as wanted or needed by the consumer and provider by persons
not for pay (family, friends, neighbors, coworkers, and others in the
community) and organizations or entities that serve the general public.
"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.
"Organization" means the entity being
certified.
"Organizational outcome" means a
demonstration by the organization of actions taken by the organization to
provide for services or supports to consumers.
"Outcome" means an action or event that
follows as a result or consequence of the provision of a service or
support.
"Procedures" means the steps to be taken to
implement a policy.
"Process" means service or support provided
by an agency to a consumer that will allow the consumer to achieve an outcome.
This can include a written, formal, consistent trackable method or an informal
process that is not written but is trackable.
"Program" means a set of related resources
and services directed to the accomplishment of a fixed set of goals and
objectives for the population ofa specified geographic area or for special
target populations. It can mean an agency, organization, or unit of an agency,
organization or institution.
"Qualified brain injury professional" means
one of the following who meets the educational and licensure or certification
requirements for the profession as required in the state of Iowa and who has
two years' experience working with people living with a brain injury: a
psychologist; psychiatrist; physician; physician assistant; registered nurse;
certified teacher; licensed clinical social worker; mental health counselor;
physical, occupational, recreational, or speech therapist; or a person with a
bachelor of arts or science degree in human services, social work, psychology,
sociology, or public health or rehabilitation services plus 4,000 hours of
direct experience with people living with a brain injury.
"Service coordination" means activities
designed to help individuals and families locate, access, and coordinate a
network of supports and services that will allow them to live a full life in
the community.
"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.
"Staff" means a person under the direction
of the organization to perform duties and responsibilities of the
organization.
"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.
"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.
