Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.101 - 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 physical
				  disability aged 18 years to 64 years.
"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.
"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.
"Client participation"
means the amount of
				  the consumer's income that the person must contribute to the cost of physical
				  disability waiver services, exclusive of medical vendor payments, before
				  Medicaid will provide additional reimbursement.
"Department"
means the Iowa department of
				  human services.
"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.
"Guardian"
means a guardian appointed in
				  probate court for an adult.
"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.
"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, a skilled nursing facility, intermediate care facility for persons
				  with an intellectual disability, or hospital 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.
"Physical disability"
means a severe,
				  chronic condition that is attributable to a physical impairment that results in
				  substantial limitations of physical functioning in three or more of the
				  following areas of major life activities: self-care, receptive and expressive
				  language, learning, mobility, self-direction, capacity for independent living,
				  and economic self-sufficiency.
"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.
"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.
"Waiver year"
means a 12-month period
				  commencing on April 1 of each year.