"Adult" means a person 18 years of age or
older on the first day of the month in which service begins.
"Applicant" means a person who has applied
for an HCBS waiver or habilitation program.
"Care coordination" means the case
management services provided by an integrated health home to members who are
also receiving home- and community-based habilitation services pursuant to
441-Chapter 78 or HCBS children's mental health waiver services pursuant to
441-Chapter 83.
"Case management" means the categories of
case management: targeted case management, case management provided to members
enrolled in a 1915(c) waiver, community-based case management provided through
managed care, and integrated health home (IHH) care coordination provided to
the habilitation and children's mental health waiver populations.
"Case manager" means the staff person
providing all categories of case management services regardless of the entity
providing the service or the program in which the member is enrolled, including
IHH care coordination.
"Child" means a person other than an
adult.
"Chronic mental illness" means a condition
present in adults who have a persistent mental or emotional disorder that
seriously impairs their functioning relative to such primary aspects of daily
living as personal relations, living arrangements, or employment. The
definition of chronic mental illness and qualifying criteria are found in
441-Chapter 24. For purposes of this chapter, people with mental disorders
resulting from Alzheimer's disease or substance abuse shall not be considered
chronically mentally ill.
"Community-based case manager" means the
employee of a Medicaid-contracted managed care organization (MCO) who provides
case management services to MCO-enrolled members.
"Core standardized assessment" or
"CSA" means an assessment instrument for determining the
suitability of non-institutionally based long-term services and supports for an
individual. The instrument shall be used in a uniform manner throughout the
state to determine an applicant's or member's needs for training, support
services, medical care, transportation, and other services and to develop an
individual service plan to address such needs. The core standardized assessment
shall be performed by a contractor under the direction of the department for
the fee-for-service population. MCOs shall perform core standardized
assessments for MCO-enrolled members or shall delegate the responsibility for
completion of assessments. 441-Chapter 83 designates the assessment and
reassessment tools to be used for each HCBS waiver. 441-Chapter 78 designates
the assessment and reassessment tools to be used for habilitation.
"Department" means the department of human
services.
"Developmental disability" means a severe,
chronic disability that is determined through professionally administered
screening and evaluations and that:
1.
Is attributable to a mental or physical impairment or combination of mental and
physical impairments;
2. Is
manifested before the age of 22;
3.
Is likely to continue indefinitely;
4. Results in substantial functional
limitations in three or more of the following areas of major life activity:
(a) self-care,
(b) receptive and expressive
language,
(c) learning,
(d) mobility,
(e) self-direction,
(f) capacity for independent living,
and
(g) economic self-sufficiency;
and
5. Reflects the
person's need for a combination and sequence of special, interdisciplinary, or
generic services, individualized supports, or other forms of assistance that
are of lifelong or extended duration and are individually planned and
coordinated.
"Fee-for-service member" or "FFS
member" means a member who is not enrolled with a managed care
organization because the member is exempt from managed care organization
enrollment.
"Home- and community-based services" or
"HCBS" means services provided pursuant to Sections 1915(c)
and 1915(i) of the Social Security Act.
"Integrated health home" or
"IHH" means a provider of health home services that is a
Medicaid-enrolled provider and that is determined through the provider
enrollment process to have the qualifications, systems and infrastructure in
place to provide IHH services pursuant to 441-Chapter 77. IHH covered services
and member eligibility for IHH enrollment are also governed by 441-Chapter 78
and the health home state plan amendment. The IHH provides care coordination
services for enrolled habilitation and children's mental health waiver
members.
"Intellectual disability" means a diagnosis
of intellectual disability (intellectual developmental disorder), global
developmental delay, or unspecified intellectual disability (intellectual
developmental disorder). Diagnosis criteria are outlined in 441-Chapter
83.
"Major incident" means an occurrence that
involves a member who is enrolled in an HCBS waiver, targeted case management,
or habilitation services and that:
1.
Results in a physical injury to or by the member that requires a physician's
treatment or admission to a hospital;
2. Results in the death of any
person;
3. Requires emergency
mental health treatment for the member;
4. Requires the intervention of law
enforcement;
5. Requires a report
of child abuse pursuant to Iowa Code section
232.69, a report of dependent
adult abuse pursuant to Iowa Code section
235B.3, or a report of elder
abuse pursuant to Iowa Code chapter 235F; or
6. Constitutes a prescription medication
error or a pattern of medication errors that leads to the outcome in numbered
paragraph "1," "2," or "3"; or
7.
Involves a
member's location being unknown by provider staff who are
responsible for protective oversight.
"Managed care organization" or
"MCO" means the same as defined in 441-Chapter 73.
"Medical institution" means an institution
that is organized, staffed, and authorized to provide medical care as set forth
in the most recent amendment to 42 Code of Federal Regulations Section 435.1009
as amended to October 20, 2022. A residential care facility is not a medical
institution.
"Member" means a person who has been
determined to be eligible for Medicaid under 441-Chapter 75.
"Minor incident" means an occurrence that
involves a member who is enrolled in an HCBS waiver, targeted case management,
or habilitation services and that is not a major incident but that:
1. Results in the application of basic first
aid;
2. Results in
bruising;
3. Results in seizure
activity;
4. Results in injury to
self, to others, or to property; or
5. Constitutes a prescription medication
error.
"Person-centered service plan" or
"service plan" means a service plan created through the
person-centered planning process, directed by the member with long-term care
needs or the member's guardian or representative, to identify the member's
strengths, capabilities, preferences, needs, and desired outcomes.
"Rights restriction" means limitations not
imposed on the general public in the areas of communication, mobility,
finances, medical or mental health treatment, intimacy, privacy, type of work,
religion, place of residence, and people with whom a member may share a
residence.
"Targeted case management" means case
management services furnished to assist members who are part of a targeted
population.
"Targeted population" means people who meet
one of the following criteria:
1. An
adult who is identified with a primary diagnosis of intellectual disability,
chronic mental illness, or developmental disability; or
2. A
child who is eligible to receive
HCBS
intellectual disability waiver services or
HCBS children's mental health waiver
services according to 441-Chapter 83.
A member enrolled with a managed care organization or
integrated health home is not part of the targeted
population.
