Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.81 - 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 the 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 academics, leisure and work.
"Adult"
means a person with a brain injury
				  aged 18 years 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.
"Assessment"
means the review of the
				  consumer's current functioning in regard to the consumer's situation, needs,
				  strengths, abilities, desires and goals.
"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, conforming conduct to laws, and displaying appropriate sociosexual
				  behavior.
"Brain injury"
means clinically evident
				  damage to the brain resulting directly or indirectly from trauma, infection,
				  anoxia, vascular lesions or tumor of the brain, not primarily related to
				  degenerative or aging processes, which temporarily or permanently impairs a
				  person's physical, cognitive, or behavioral functions. The person must have a
				  diagnosis from the following list:
Malignant neoplasms of brain, cerebrum.
Malignant neoplasms of brain, frontal lobe.
Malignant neoplasms of brain, temporal lobe.
Malignant neoplasms of brain, parietal lobe.
Malignant neoplasms of brain, occipital lobe.
Malignant neoplasms of brain, ventricles.
Malignant neoplasms of brain, cerebellum.
Malignant neoplasms of brain, brain stem.
Malignant neoplasms of brain, other part of brain, includes
				  midbrain, peduncle, and medulla oblongata.
Malignant neoplasms of brain, cerebral meninges.
Malignant neoplasms of brain, cranial nerves.
Secondary malignant neoplasm of brain.
Secondary malignant neoplasm of other parts of the nervous
				  system, includes cerebral meninges.
Benign neoplasm of brain and other parts of the nervous
				  system, brain.
Benign neoplasm of brain and other parts of the nervous
				  system, cranial nerves.
Benign neoplasm of brain and other parts of the nervous
				  system, cerebral meninges.
Encephalitis, myelitis and encephalomyelitis.
Intracranial and intraspinal abscess.
Anoxic brain damage.
Subarachnoid hemorrhage.
Intracerebral hemorrhage.
Other and unspecified intracranial hemorrhage.
Occlusion and stenosis of precerebral arteries.
Occlusion of cerebral arteries.
Transient cerebral ischemia.
Acute, but ill-defined, cerebrovascular disease.
Other and ill-defined cerebrovascular diseases.
Fracture of vault of skull.
Fracture of base of skull.
Other and unqualified skull fractures.
Multiple fractures involving skull or face with other
				  bones.
Concussion.
Cerebral laceration and contusion.
Cerebral edema.
Cerebral palsy.
Subarachnoid, subdural, and extradural hemorrhage following
				  injury.
Other and unspecified intracranial hemorrhage following
				  injury.
Intracranial injury of other and unspecified nature.
Poisoning by drugs, medicinal and biological
				  substances.
Toxic effects of substances.
Effects of external causes.
Drowning and nonfatal submersion.
Asphyxiation and strangulation.
Child maltreatment syndrome.
Adult maltreatment syndrome.
Status epilepticus.
"Case management services"
means those
				  services established pursuant to Iowa Code chapter 225C.
"Child"
means a person with a brain injury
				  aged 17 years or under.
"Client participation"
means the amount of
				  the consumer's income that the person must contribute to the cost of brain
				  injury waiver services, exclusive of medical vendor payments, before Medicaid
				  will provide additional reimbursement.
"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.
"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 from one to
				  three hours a day for not more than four days a week.
"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, a skilled 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.
"Nursing facility level of care"
means that
				  the following conditions are met:
1. The presence of a physical or mental impairment which
				  restricts the member's daily ability to perform the essential activities of
				  daily living, bathing, dressing, and personal hygiene, and impedes the member's
				  capacity to live independently.
2. The member's physical or mental impairment is such that
				  self-execution of required nursing care is improbable or impossible.
"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 brain injury professional"
means
				  one of the following who meets the educational and licensure or certification
				  requirements for the profession as required in the state of Iowa and who has
				  two years' experience working with people living with a brain injury: a
				  psychologist; psychiatrist; physician; physician assistant; registered nurse;
				  certified teacher; licensed clinical social worker; mental health counselor;
				  physical, occupational, recreational, or speech therapist; or a person with a
				  bachelor of arts or science degree in human services, social work, psychology,
				  sociology, or public health or rehabilitation services plus 4,000 hours of
				  direct experience with people living with a brain injury.
"Service coordination"
means activities
				  designed to help individuals and families locate, access, and coordinate a
				  network of supports and services that will allow them to live a full life in
				  the community.
"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.
"Skilled nursing facility level of care"
means that the following conditions are met:
1. The member's medical condition requires skilled nursing
				  services or skilled rehabilitation services as defined in
				  42 CFR
				  409.31(a),
				  409.32,
				  and
				  409.34.
2. Services are provided in accordance with the general
				  provisions for all Medicaid providers and services as described in rule
				  441-79.9 (249A).
3. Documentation submitted for review indicates that the
				  member has:
a. A physician order for all skilled services.
b. Services that require the skills of medical personnel,
				  including registered nurses, licensed practical nurses, physical therapists,
				  occupational therapists, speech pathologists, or audiologists.
c. An individualized care plan that identifies support
				  needs.
d. Confirmation that skilled services are provided to the
				  member.
e. Skilled services that are provided by, or under the
				  supervision of, medical personnel as described above.
f. Skilled nursing services that are needed and provided
				  seven days a week or skilled rehabilitation services that are needed and
				  provided at least five days a week.
"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 individual, institution, corporation, or public or private provider which is
				  liable to pay part or all of the medical costs incurred as a result of injury
				  or disease on behalf of a consumer of medical assistance.
"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.