Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.21 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
"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.
"Client participation"
means the amount of
				  the recipient income that the person must contribute to the cost of elderly
				  waiver services exclusive of medical vendor payments before Medicaid will
				  participate.
"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.
"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.
"Interdisciplinary team"
means a collection
				  of persons with varied professional backgrounds who develop one plan of care to
				  meet a client's need for services.
"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 institution"
means a nursing
				  facility which has been approved as a Medicaid vendor.
"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.
"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.
"Third-party payments"
means payments from
				  an individual, institution, corporation, 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 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.