Iowa Code r. 441-78.52 - HCBS children's mental health waiver services
Payment will be approved for the following services to members eligible for the HCBS children's mental health waiver as established in 441-Chapter 83 and as identified in the member's service plan. Effective March 17, 2022, payment shall only be made for services provided in integrated, community-based settings that support full access of members receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS.
(1)
General service
standards. All children's mental health waiver services must be
provided in accordance with the following standards:
a. Reimbursement shall not be available under
the waiver for any services that the member can obtain as other nonwaiver
Medicaid services or through any other funding source.
b. All services provided under the waiver
must be delivered in the least restrictive environment possible and in
conformity with the member's service plan.
c. All rights restrictions must be
implemented in accordance with 441-subrule 77.25(4). The member service plan or
treatment plan shall include documentation of:
(1) Any restrictions on the member's rights,
including the rights of privacy, dignity, respect, and freedom from coercion
and restraint.
(2) The need for the
restriction.
(3) The less intrusive
methods of meeting the need that have been tried but did not work.
(4) Either a plan to restore those rights or
written documentation that a plan is not necessary or appropriate.
(5) Established time limits for periodic
reviews to determine if the restriction is still necessary or can be
terminated.
(6) The informed
consent of the member.
(7) An
assurance that the interventions and supports will cause no harm to the
member.
(8) A regular collection
and review of data to measure the ongoing effectiveness of the
restriction.
d. Services
must be billed in whole units.
e.
For all services with a 15-minute unit of service, the following rounding
process will apply:
(1) Add together the
minutes spent on all billable activities during a calendar day for a daily
total.
(2) For each day, divide the
total minutes spent on billable activities by 15 to determine the number of
full 15-minute units for that day.
(3) Round the remainder using these
guidelines: Round 1 to 7 minutes down to zero units; round 8 to 14 minutes up
to one unit.
(4) Add together the
number of full units and the number of rounded units to determine the total
number of units to bill for that day.
(2)
Environmental modifications and
adaptive devices.
a. Environmental
modifications and adaptive devices include medically necessary items installed
or used within the member's home that are used by the member to address
specific, documented health, mental health, or safety concerns. The following
items are excluded under this service:
(1)
Items ordinarily covered by Medicaid.
(2) Items funded by educational or vocational
rehabilitation programs.
(3) Items
provided by voluntary means.
(4)
Repair and maintenance of items purchased through the waiver.
(5) Fencing.
b. A unit of service is one modification or
device.
c. For each unit of service
provided, the case manager shall maintain in the member's case file a signed
statement from a mental health professional on the member's interdisciplinary
team that the service has a direct relationship to the member's diagnosis of
serious emotional disturbance.
d.
Payment for most items shall be based on a fee schedule. The amount of the fee
shall be determined as directed in 441-subrule 79.1(17).
(3)
Family and community support
services. Family and community support services shall support the
member and the member's family by the development and implementation of
strategies and interventions that will result in the reduction of stress and
depression and will increase the member's and the family's social and emotional
strength.
a. Dependent on the needs of the
member and the member's family members individually or collectively, family and
community support services may be provided to the member, to the member's
family members, or to the member and the family members as a family
unit.
b. Family and community
support services shall be provided under the recommendation and direction of a
mental health professional who is a member of the member's interdisciplinary
team pursuant to 441-Chapter 83.
c.
Family and community support services shall incorporate recommended support
interventions and activities, which may include the following:
(1) Developing and maintaining a crisis
support network for the member and for the member's family.
(2) Modeling and coaching effective coping
strategies for the member's family members.
(3) Building resilience to the stigma of
serious emotional disturbance for the member and the family.
(4) Reducing the stigma of serious emotional
disturbance by the development of relationships with peers and community
members.
(5) Modeling and coaching
the strategies and interventions identified in the member's crisis intervention
plan as defined in 441-24.1 (225C) for life
situations with the member's family and in the community.
(6) Developing medication management
skills.
(7) Developing personal
hygiene and grooming skills that contribute to the member's positive
self-image.
(8) Developing positive
socialization and citizenship skills.
d. Family and community support services may
include an amount not to exceed $1500 per member per year for transportation
within the community and purchase of therapeutic resources. Therapeutic
resources may include books, training materials, and visual or audio media.
(1) The interdisciplinary team must have
identified the transportation or therapeutic resource as a support need and
included that need in the case manager's plan.
(2) The annual amount available for
transportation and therapeutic resources must be listed in the member's service
plan.
(3) The member's parent or
legal guardian shall submit a signed statement that the transportation or
therapeutic resource cannot be provided by the member or the member's family or
legal guardian.
(4) The member's
Medicaid case manager shall maintain a signed statement that potential
community resources are unavailable and shall list the community resources
contacted to fund the transportation or therapeutic resource.
(5) The transportation or therapeutic
resource must not be otherwise eligible for Medicaid
reimbursement.
e. The
following components are specifically excluded from family and community
support services:
(1) Vocational
services.
(2) Prevocational
services.
(3) Supported employment
services.
(4) Room and
board.
(5) Academic
services.
(6) General supervision
and care.
f. A unit of
family and community support services is 15 minutes.
(4)
In-home family therapy.
In-home family therapy provides skilled therapeutic services to the member and
family that will increase their ability to cope with the effects of serious
emotional disturbance on the family unit and the familial relationships. The
service must support the family by the development of coping strategies that
will enable the member to continue living within the family environment.
a. The goal of in-home family therapy is to
maintain a cohesive family unit.
b.
In-home family therapy is exclusive of and cannot serve as a substitute for
individual therapy, family therapy, or other mental health therapy that may be
obtained through Medicaid or other funding sources.
c. A unit of in-home family therapy service
is 15 minutes.
(5)
Respite care services. Respite care services are services
provided to the member that give temporary relief to the usual caregiver and
provide all the necessary care that the usual caregiver would provide during
that period. The purpose of respite care is to enable the member to remain in
the member's current living situation.
a.
Respite services provided outside the member's home shall not be reimbursable
if the living unit where respite care is provided is reserved for another
person on a temporary leave of absence.
b. Member-to-staff ratios shall be
appropriate to the individual needs of the member as determined by the member's
interdisciplinary team.
c. A unit
of service is 15 minutes.
d.
Respite care is not to be provided to members during the hours in which the
usual caregiver is employed except when the member is attending a 24-hour
residential camp. Respite care shall not be used as a substitute for a child's
day care.
e. The interdisciplinary
team shall determine if the member will receive basic individual respite,
specialized respite or group respite as defined in 441-Chapter 83.
f. A maximum of 14 consecutive days of
24-hour respite care may be reimbursed.
g. Respite services provided for a period
exceeding 24 consecutive hours to three or more members who require nursing
care because of a mental or physical condition must be provided by a health
care facility licensed under Iowa Code chapter 135C.
h. Respite services shall not be provided
simultaneously with other residential, nursing, or home health aide services
provided through the medical assistance program.
This rule is intended to implement Iowa Code section 249A.4.
Notes
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