Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 72 - Long-term Care Asset Preservation Program › Rule 191-72.3 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
"Asset disregard"
means a $1 increase in the
				  amount of assets an individual who purchases a certified long-term care policy
				  may retain, upon qualification for Medicaid, for each $1 of benefit paid out
				  under the individual's certified long-term care policy for Medicaid-eligible
				  long-term care services in determining eligibility for the Medicaid
				  program.
"Asset protection"
means the right extended
				  by 441"subrule 75.5(5) to beneficiaries of certified long-term care insurance
				  policies and certificates to an asset disregard under the Iowa long-term care
				  asset preservation program.
"Authorized designee"
means any person
				  designated in writing to the insurance company by the policyholder or
				  certificate holder of a certified long-term care policy or certificate for
				  purposes of notification under paragraph 72.7(1)
"h."
"Average daily private pay rate"
means the
				  average statewide cost of nursing facility services to a private pay resident
				  as determined by the department of human services in 441-subrule 75.23(3). The
				  average statewide private pay rate is set annually on July 1 for one year by
				  the Iowa department of human services.
"Case management"
includes, but is not
				  limited to, the development of a comprehensive individualized assessment and
				  care plan and, as needed, coordination of appropriate services and the
				  monitoring of the delivery of such services.
"Case management agency"
means an agency or
				  other entity approved by the Iowa department of human services as meeting
				  Medicaid case management standards.
"Certificate"
means any certificate
				  delivered or issued for delivery in this state under a group long-term care
				  policy.
"Certificate form"
means the form on which
				  the certificate is delivered or issued for delivery by the issuer.
"Certificate holder"
means an owner of a
				  certified long-term care insurance certificate or the beneficiary of a
				  certified long-term care certificate.
"Certified long-term care insurance policy or
				  certificate"
means any long-term care insurance policy or certificate
				  certified for sale to Iowa residents by the division of insurance as meeting
				  standards promulgated under rules
				  191-72.6 (514H) and
				  191-72.7 (514H).
"Cognitive impairment"
means confusion or
				  disorientation resulting from a deterioration or loss of intellectual capacity
				  that is not related to or a result of mental illness but which can result from
				  Alzheimer's disease or similar forms of senility or irreversible dementia. This
				  deterioration or loss of intellectual capacity is established through use of
				  standardized tests that reliably measure impairment in the following
				  areas:
1. Short-term or long-term memory.
2. Orientation as to person, place, and time.
3. Deductive or abstract reasoning.
Cognitive impairment must result in an individual's requiring
				  24-hour-a-day supervision or direct assistance to maintain the individual's
				  safety.
"Complex, yet stable medical condition"
means that the individual requires 24-hour-a-day professional nursing
				  observation or professional nursing intervention more than once a day in a
				  setting other than an acute care wing of a hospital.
"Deficiency in activity of daily living"
means that the individual cannot perform one or more of the following six
				  activities of daily living without direct assistance:
1. Bathing, meaning cleaning the body using a tub, shower or
				  sponge bath, including getting a basin of water, managing faucets, getting in
				  and out of tub or shower, reaching head and body parts for soaping, rinsing,
				  and drying.
2. Dressing, meaning putting on and taking off, fastening and
				  unfastening garments and undergarments and special devices such as back or leg
				  braces, corsets, elastic stockings/garments and artificial limbs or
				  splints.
3. Toileting, meaning getting on and off toilet or commode
				  and emptying commode, managing clothing and wiping and cleaning body after
				  toileting, and assistance with using and emptying bedpans and urinals.
4. Transferring, meaning moving from one sitting or lying
				  position to another sitting or lying position, e.g., from bed to or from a
				  wheelchair or sofa, coming to a standing position or repositioning to promote
				  circulation and prevent skin breakdown.
5. Continence, meaning the ability to control bowel and
				  bladder as well as use ostomy or catheter receptacles and apply diapers and
				  disposable barrier pads.
6. Eating, meaning reaching for, picking up, grasping utensil
				  and cup; getting food on utensil, bringing food, utensil, cup to mouth;
				  manipulating food on plate; and cleaning face and hands as necessary following
				  meal.
"Department of human services"
means the
				  Iowa division of medical services.
"Direct assistance"
means that the
				  individual cannot perform an activity of daily living safely or appropriately
				  without continual help or oversight. Direct assistance may vary from requiring
				  a person to physically stand by or set up the activity to the activity being
				  totally performed by others.
"Formal long-term care services"
means
				  long-term care service for which the provider is paid.
"Home health care services"
means:
1. Part-time or intermittent skilled nursing services by
				  licensed nursing personnel provided by a home health agency or by a registered
				  nurse or a licensed vocational nurse, when a case management provider agency
				  has determined that no home health agency exists in the area;
2. Home health aide services provided by a home health
				  agency;
3. Physical therapy, occupational therapy, or speech therapy
				  and audiology services provided by a home health agency; and
4. Medical social services by a social worker or social work
				  assistant provided by a home health agency.
"Homemaker services incidental to personal
				  care"
means the policyholder or certificate holder is eligible to
				  receive homemaker services if personal care is being received. Homemaker
				  services incidental to personal care are limited to the following:
1. Domestic or cleaning services;
2. Laundry services;
3. Reasonable food shopping and errands;
4. Meal preparation and cleanup;
5. Transportation assistance to and from medical
				  appointments; and
6. Heavy cleaning which involves thorough cleaning of the
				  home to remove hazardous debris or dirt.
A certified long-term care insurance policy or certificate
				  shall not, if it provides homemaker services incidental to personal care, limit
				  or exclude benefits by requiring that the provision of such services be at a
				  level of certification or licensure greater than that required by the eligible
				  service or by limiting benefits to services provided by Medicare-certified
				  agencies or providers.
"Informal long-term care services"
means
				  long-term care services for which the provider is not paid.
"Insured event"
means the insured is
				  eligible to receive insurance benefits and to have these benefits qualify for
				  an asset disregard if any one of the following criteria is met:
1. The insured has at least two deficiencies in activities of
				  daily living (ADLs) (to qualify for home-and community-based services
				  including, but not limited to, home health care, adult day health/social care,
				  personal care, homemaker services incidental to personal care, respite care and
				  residential care facility) or three deficiencies in activities of daily living
				  (ADLs) (to qualify for nursing facility care); or
2. The insured has a cognitive impairment; or
3. The insured has a complex, yet stable medical condition.
"Integrated benefits"
means the benefits
				  contained in the policy or certificate can be used interchangeably among the
				  various covered home- or community-based or nursing facility benefits, and
				  there is no limit on the use of any specific covered benefit, except for
				  monthly limits that may be set for home-and community-based care benefits and
				  per diem limits that may be set on nursing facility services.
"Issuer"
means:
1. Insurance companies;
2. Fraternal benefit societies;
3. Prepaid health care delivery plans;
4. Health care service plans;
5. Health maintenance organizations; and
6. Any other entity delivering or issuing for delivery in
				  this state, long-term care policies or certificates.
"Long-term care asset preservation program"
means the program authorized in former Iowa Code chapter 249G.
"Medicaid-eligible long-term care services"
include:
1. Long-term care services available under Iowa's state
				  Medicaid plan, including care in a licensed nursing facility and home health
				  nursing and home health aide services provided by a home health agency.
2. Long-term care services covered under the Medicaid home-
				  and community-based services waiver for the aged and disabled, as defined in
				  paragraph 72.7(1)
"d."
"Medicaid waiver"
refers to the home- and
				  community-based services waiver for the aged and disabled approved by the
				  United States Department of Health and Human Services Health Care Financing
				  Administration under the provisions of Section 1915(c) of the Social Security
				  Act which allows Iowa to provide certain community and in-home services not
				  covered in the state Medicaid plan, which are instrumental in the avoidance or
				  delay of institutionalization. Iowa's Medicaid waiver services include:
1. Case management;
2. Homemaker;
3. Respite care;
4. Attendant care;
5. Adult day care; and
6. Other services which, independent of the preceding home-
				  and community-based services, are essential to prevent institutionalization.
"Personal care services"
means:
1. Ambulation assistance, including help in walking or moving
				  around (e.g., wheelchair) inside the home, changing locations in a room, moving
				  from room to room to gain access for the purpose of engaging in other
				  activities. Ambulation assistance does not include movement solely for the
				  purpose of exercise.
2. Bathing and grooming including cleaning the body using a
				  tub, shower or sponge bath, including getting a basin of water, managing
				  faucets, getting in and out of tub or shower, reaching head and body parts for
				  soaping, rinsing, and drying. Grooming includes hair combing and brushing,
				  shampooing, oral hygiene, shaving and fingernail and toenail care.
3. Dressing includes putting on and taking off, fastening and
				  unfastening garments and undergarments and special devices such as back or leg
				  braces, corsets, elastic stockings/garments and artificial limbs or
				  splints.
4. Bowel, bladder and menstrual care including assisting the
				  person on and off toilet or commode and emptying commode, managing clothing and
				  wiping and cleaning body after toileting, assistance with using and emptying
				  bedpans, ostomy or catheter receptacles and urinals, application of diapers and
				  disposable barrier pads.
5. Reposition, transfer skin care, and range of motion
				  exercises, including moving from one sitting or lying position to another
				  sitting or lying position, e.g., from bed to or from a wheelchair or sofa,
				  coming to a standing position or rubbing skin and repositioning to promote
				  circulation and prevent skin breakdown. Motion exercises shall include the
				  carrying out of maintenance programs, i.e., the performance of the repetitive
				  exercises required to maintain function, improve gait, maintain strength or
				  endurance, passive exercises to maintain range of motion in paralyzed
				  extremities, and assistive walking.
6. Feeding and hydration assistance including reaching for,
				  picking up, grasping utensil and cup; getting food on utensil; bringing food,
				  utensil, cup to mouth, and manipulating food on plate; cleaning face and hands
				  as necessary following meal.
7. Assistance with self-administration of medications.
8. A certified long-term care insurance policy or certificate
				  shall not, if it provides personal care services, limit or exclude benefits by
				  requiring that the provision of personal care be at a level of certification or
				  licensure greater than that required by the eligible service, or by limiting
				  benefits to services provided by Medicare-certified agencies or providers.
"Plan of care"
means a written
				  individualized plan of services approved by a case management provider agency
				  which specifies the type, frequency, and providers of all formal and informal
				  long-term care services required for the individual and the cost, if any, of
				  any formal long-term care services prescribed. Changes in the plan of care must
				  be documented to show that such alterations are required by changes in the
				  client's medical situation, functional or cognitive abilities, behavioral
				  abilities or the availability of social supports.
"Preadmission review"
means the program
				  which requires that each person seeking admission to a nursing facility must be
				  screened and approved for admission in accordance with rule
				  441-81.3 (249A).
"Qualified insured"
means the
				  following:
1. An individual who by reason of age is eligible for parts
				  "A" and "B" of the Medicare program (
				  42 U.S.C.
				  1395 et seq.) who is either:
* The beneficiary of a certified long-term care policy or
				  certificate approved by the division of insurance; or
* Enrolled in a prepaid health care delivery plan that
				  provides long-term care services and qualifies under this rule; or
2. An individual who is eligible for an asset disregard under
				  a certified long-term care policy or certificate. An individual does not have
				  to be a qualified insured to purchase a certified long-term care policy or
				  certificate.
"Quarterly/annually"
refers to periods
				  aligning with the state fiscal year of July 1 to June 30.
"Service summary"
means a written summary,
				  prepared by an issuer for a qualified insured, which identifies the
				  following:
1. The specific certified policy or certificate.
2. The total benefits paid for services to date.
3. The amount of benefits qualifying for asset
				  protection.