Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.60 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
"Adaptive"
means age-appropriate skills
				  related to taking care of one's self and one's 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 activities of daily living, leisure or
				  work.
"Adult"
means a person with an intellectual
				  disability aged 18 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.
"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, controlling impulses, conforming conduct to laws, and displaying
				  appropriate sociosexual behavior.
"Case management services"
means those
				  services established pursuant to Iowa Code chapter 225C.
"Child"
means a person with an intellectual
				  disability aged 17 or under.
"Client participation"
means the
				  posteligibility amount of the consumer's income that persons eligible through a
				  special income level must contribute to the cost of the home and
				  community-based waiver service.
"Counseling"
means face-to-face mental
				  health services provided to the consumer and caregiver by a qualified
				  intellectual disability professional (QIDP) to facilitate home management of
				  the consumer and prevent institutionalization.
"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.
"Intellectual disability"
means a diagnosis
				  of intellectual disability (intellectual developmental disorder), global
				  developmental delay, or unspecified intellectual disability (intellectual
				  developmental disorder) which shall be made only when the onset of the person's
				  condition was during the developmental period and shall be based on an
				  assessment of the person's intellectual functioning and level of adaptive
				  skills. The diagnosis shall be made by a person who is a licensed psychologist
				  or psychiatrist who is professionally trained to administer the tests required
				  to assess intellectual functioning and to evaluate a person's adaptive skills.
				  The diagnosis shall be made in accordance with the criteria provided in the
				  Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),
				  published by the American Psychiatric Association.
"Intermediate care facility for persons with an
				  intellectual disability (ICF/ID)"
means an institution that is
				  primarily for the diagnosis, treatment, or rehabilitation of persons with an
				  intellectual disability or persons with related conditions and that provides,
				  in a protected residential setting, ongoing evaluation, planning, 24-hour
				  supervision, coordination and integration of health or related services to help
				  each person function at the greatest ability and is an approved Medicaid
				  vendor.
"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 not more
				  than 52 hours per month.
"Maintenance needs"
means costs associated
				  with rent or mortgage, utilities, telephone, food and household
				  supplies.
"Managed care"
means a system that provides
				  the coordinated delivery of services and supports that are necessary and
				  appropriate, delivered in the least restrictive settings and in the least
				  intrusive manner. Managed care seeks to balance three factors:
1. Achieving high-quality outcomes for
				participants.
2. Coordinating
				access.
3. Containing costs.
"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, 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.
"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 intellectual disability
				  professional"
means a person who has at least one year of experience
				  working directly with persons with an intellectual disability or other
				  developmental disabilities and who is one of the following:
1. A doctor of medicine or
				osteopathy.
2. A registered
				nurse.
3. An occupational therapist
				eligible for certification as an occupational therapist by the American
				Occupational Therapy Association or another comparable body.
4. A physical therapist eligible for
				certification as a physical therapist by the American Physical Therapy
				Association or another comparable body.
5. A speech-language pathologist or
				audiologist eligible for certification of Clinical Competence in
				Speech-Language Pathology or Audiology by the American Speech-Language Hearing
				Association or another comparable body or who meets the educational
				requirements for certification and who is in the process of accumulating the
				supervised experience required for certification.
6. A psychologist with a master's degree in
				psychology from an accredited school.
7. A social worker with a graduate degree
				from a school of social work, accredited or approved by the Council on Social
				Work Education or another comparable body or who holds a bachelor of social
				work degree from a college or university accredited or approved by the Council
				of Social Work Education or another comparable body.
8. A professional recreation staff member
				with a bachelor's degree in recreation or in a specialty area such as art,
				dance, music or physical education.
9. A professional dietitian who is eligible
				for registration by the American Dietetics Association.
10. A human services professional who must
				have at least a bachelor's degree in a human services field including, but not
				limited to, sociology, special education, rehabilitation counseling and
				psychology.
"Related condition"
means a severe, chronic
				  disability that meets all the following conditions:
1. It is attributable to cerebral palsy,
				epilepsy, or any other condition, other than mental illness, found to be
				closely related to intellectual disability because the condition results in
				impairment of general intellectual functioning or adaptive behavior similar to
				that of a person with an intellectual disability and requires treatment or
				services similar to those required for a person with an intellectual
				disability.
2. It is manifested
				before the age of 22.
3. It is
				likely to continue indefinitely.
4.
				It results in substantial functional limitations in three or more of the
				following areas of major life activity:
* Self-care.
* Understanding and use of language.
* Learning.
* Mobility.
* Self-direction.
* Capacity for independent living.
"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.
"SIS assessment"
means the Supports
				  Intensity Scale® assessment developed and licensed by the American
				  Association on Intellectual and Developmental Disabilities for use in the
				  assessment of the support and service needs of individuals.
"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 attorney, individual, institution, corporation, insurance company, or public
				  or private agency which is liable to pay part or all of the medical costs
				  incurred as a result of injury, disease or disability by or on behalf of an
				  applicant or a past or present recipient of Medicaid.
"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.