Iowa Admin. Code r. 441-90.1 - Definitions

Current through Register Vol. 44, No. 20, April 6, 2022

"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 rule 441-78.27(249A) or HCBS children's mental health waiver services pursuant to rules 441-83.121 (249A) through 441-83.129 (249A).

"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 at rule 441-24.1(225C). 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 rule 441-77.47 (249A). IHH covered services and member eligibility for IHH enrollment are also governed by rule 441-78.53(249A) 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 rule 441-83.61(249A).

"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. 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 rule 441-73.1 (249A).

"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. 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.

Notes

Iowa Admin. Code r. 441-90.1
ARC 7957B, lAB 7/15/09, effective 7/1/09 Amended by IAB September 30, 2015/Volume XXXVIII, Number 07, effective 10/1/2015 Amended by IAB February 12, 2020/Volume XLII, Number 17, effective 3/18/2020

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