Iowa Admin. Code r. 441-83.82 - Eligibility
To be eligible for
(1)
Eligibility criteria. All of the following criteria must be
met. The person must:
a. Have a diagnosis of
brain injury .
b. Be eligible for
Medicaid under SSI, SSI-related, FMAP, or FMAP-related coverage groups or be
eligible under the special income level (300 percent) coverage group consistent
with a level of care in a medical institution .
c. Be at least one month of age.
d. Be a U.S. citizen and Iowa
resident.
e. Rescinded IAB 7/11/01,
effective 7/1/01.
f. Be determined
by the IME medical services unit as in need of intermediate care facility for
persons with an intellectual disability (ICF/ID), skilled nursing, or ICF level
of care based on information submitted on a completed 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 and
over, the most recent version of the Mayo-Portland Adaptability Inventory
(MPAI), and other supporting documentation as relevant. Form 470-4694, the
interRAI - Pediatric Home Care (PEDS-HC), and the interRAI - Home Care (HC),
Form 470-4694, and Form 470-5572, the Mayo-Portland Adaptability Inventory
(MPAI), are available on request from the member's managed care organization or
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 .
g. Be assessed by the IME medical services
unit as able to live in a home- or community-based setting where all medically
necessary service needs can be met within the scope of this waiver.
h. At a minimum, receive a waiver service
each quarter in addition to case management.
i. Choose HCBS .
j. 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.
k. Receive services in a
community, not an institutional, setting.
l. Be assigned a state payment slot within
the yearly total approved by the Centers for Medicare and Medicaid
Services.
m. For the consumer
choices option as set forth in rule 441-subrule 78.43(15), not be living in a
residential care facility.
n. 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 and an expectation that this service will result in this
outcome .
o. 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 .
p. 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 and an expectation that this service will result in community
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 prevocational services was
made.
(2)
Need for services.
a. The
applicant shall have a service plan approved by the department that is
developed by the certified case manager for this waiver as identified by the
county of residence. This must be completed before services provision and
annually thereafter. The case manager shall establish the interdisciplinary
team for the 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 using the following criteria:
(1) The assessment shall be based, in part,
on information provided to the IME medical services unit .
(2) Service plans must be developed to
reflect use of all appropriate nonwaiver Medicaid state 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 not be approved until a home health provider has made a request to cover
the service through all nonwaiver Medicaid services.
(4) Service plans for applicants aged 20 or
under which include supported community living services beyond intermittent
must be approved (signed and dated) by the designee of the bureau of long-term
care. The Medicaid case manager must request in writing more than intermittent
supported community living with a summary of services and service costs, and
submit a written justification with the service plan . The rationale must
contain sufficient information for the bureau's designee to make a decision
regarding the need for supported community living beyond
intermittent.
b. 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 .
c. The
consumer shall access, if a child , all other services for which the person is
eligible and which are appropriate to meet the person's needs as a precondition
of eligibility for the HCBS BI waiver.
(3)
HCBS brain injury (BI) waiver
program limit for persons requiring the ICF/MR level of care.
Rescinded IAB 7/11/01, effective 7/1/01.
(4)
Securing a state payment
slot.
a. The county department
office shall enter all waiver applications into the individualized services
information system (ISIS) to determine if a payment slot is available for all
new applicants for the HCBS BI waiver program .
(1) For applicants not currently receiving
Medicaid, the county department office shall make the entry by the end of the
fifth working day after receipt of a completed Form 470-2927 or 470-2927(S),
Health Services Application, or within five working days after receipt of
disability determination, whichever is later.
(2) For current Medicaid members, the county
department office shall make the entry by the end of the fifth working day
after receipt of a written request signed and dated by the waiver
applicant.
b. If no
payment slot is available, the department shall enter the applicant on a
waiting list according to the following:
(1)
Applicants not currently eligible for Medicaid shall be entered on the waiting
list on the basis of the date a completed Form 470-2927 or 470-2927(S), Health
Services Application, is received by the department or upon receipt of
disability determination, whichever is later. Applicants currently eligible for
Medicaid shall be added to the waiting list on the basis of the date the
applicant requests HCBS BI program services.
(2) In the event that more than one
application is received at one time, applicants shall be entered on the waiting
list on the basis of the month of birth, January being month one and the lowest
number.
c. Persons who do
not fall within the available slots shall have their applications rejected but
their names shall be maintained on the waiting list. As slots become available,
persons shall be selected from the waiting list to maintain the number of
approved persons on the program based on their order on the waiting
list.
d. Applicants who currently
reside in a community-based neurobehavioral rehabilitation residential setting,
an intermediate care facility for persons with an intellectual disability
(ICF/ID), a skilled nursing facility, or an ICF and have resided in that
setting for four or more months may request a reserved capacity slot through
the brain injury waiver.
(1) 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.
(2) 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.
(3) Persons who do not fall within the
available reserved capacity slots shall have their names 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 their order on the waiting list.
e. The department shall reserve a
set number of funding slots each waiver year for emergency need for all
applicants who are on the waiting list maintained by the state on July 1, 2019,
and for all new applications received on or after July 1, 2019. Applicants may
request an emergency need reserved capacity slot by submitting the completed
Home- and Community-Based Services (HCBS ) Brain Injury Waiver Emergency Need
Assessment , Form 470-5583, to the IME medical services unit .
(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 emergency reserved capacity
priority waiting list based on the total number of criteria in subparagraph
83.82(4)"e" (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
83.82(4)"e" (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 remain on the waiting list,
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 emergency needs assessment be completed. The outcome of the
assessment shall determine placement on the waiting list as directed in this
subrule.
f. 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.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.