Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.61 - Eligibility

Current through Register Vol. 47, No. 3, July 24, 2024
To be eligible for HCBS intellectual disability waiver
				  services a person must meet certain eligibility criteria and be determined to
				  need a service(s) available under the program.
(1)
Eligibility criteria.
All of the following criteria must be met. The person must:
a. Have a diagnosis of intellectual
				disability as defined in rule
				441-83.60 (249A). The diagnosis
				shall be initially established and recertified as follows:
Age
Initial application to HCBS intellectual disability
							 waiver program
Recertification for persons with a diagnosis of
							 moderate, severe or profound level of severity
Recertification for persons with a diagnosis of mild
							 or unspecified level of severity
0 through 17 years
Psychological documentation within three years of the
							 application date substantiating a diagnosis of intellectual disability as
							 defined in rule 441-83.60 (249A)
After the initial psychological evaluation,
							 substantiate a diagnosis of intellectual disability as defined in rule
							 441-83.60 (249A) every six years
							 and when a significant change occurs
After the initial psychological evaluation,
							 substantiate a diagnosis of intellectual disability as defined in rule
							 441-83.60 (249A) every three
							 years and when a significant change occurs
18 years and above
Current psychological documentation substantiating a
							 diagnosis of intellectual disability if the last testing date was (1) more than
							 six years ago for an applicant with a diagnosis of mild or unspecified
							 severity, or (2) more than ten years ago for an applicant with a diagnosis of
							 moderate, severe or profound level of severity
Psychological documentation substantiating a
							 diagnosis of intellectual disability made since the member reached 22 years of
							 age
Psychological documentation substantiating a
							 diagnosis of intellectual disability every six years and whenever a significant
							 change occurs
b. Be
				eligible for Medicaid under SSI, SSI-related, FMAP, or FMAP-related coverage
				groups; eligible under the special income level (300 percent) coverage group;
				or become eligible through application of the institutional deeming rules or
				would be eligible for Medicaid ifin a medical institution.
c. Be certified as being in need for
				long-term care that, but for the waiver, would otherwise be provided in an
				ICF/ID. The IME medical services unit shall be responsible for the initial
				approval, and the IME medical services unit or a managed care organization will
				be responsible for the annual approval of the certification of the level of
				care based on the data collected by the case manager and interdisciplinary team
				on a tool designated by the department.
d. Be a recipient of the Medicaid case
				management services or be identified to receive Medicaid case management
				services immediately following program enrollment.
e. Have service needs that can be met by this
				waiver program. At a minimum, a consumer must receive one billable unit of
				service per calendar quarter under this program.
f. Have a service plan completed annually and
				approved by the department in accordance with rule
				441-83.67 (249A).
g. For individual supported employment and
				long-term job coaching services:
(1) Be at
				least 16 years of age.
(2) The
				services must not be available to the member through one of the following:
1. Special education and related services as
				defined in the Individuals with Disabilities Education Act (
				20
				U.S.C. 1401 et seq.); or
2. A program funded under Section 110 of the
				Rehabilitation Act of 1973 (
				29 U.S.C. 730
				).
(3) Not reside in a
				medical institution.
(4) Have
				documented in the waiver service plan a goal to achieve or to sustain
				individual employment.
h.
				For small-group supported employment services:
(1) Be at least 16 years of age.
(2) The services must not be available to the
				member through one of the following:
1.
				Special education and related services as defined in the Individuals with
				Disabilities Education Act (
				20
				U.S.C. 1401 et seq.); or
2. A program funded under Section 110 of the
				Rehabilitation Act of 1973 (
				29 U.S.C. 730
				).
(3) Have documented
				in the waiver service plan a goal to achieve or to sustain individual
				employment.
(4) Have documented in
				the waiver service plan that the choice to receive individual supported
				employment services was offered and explained in a manner sufficient to ensure
				informed choice, after which the choice to receive small-group supported
				employment services was made.
(5)
				Not reside in a medical institution.
i. For prevocational services:
(1) Be at least 16 years of age.
(2) The services must not be available to the
				member through one of the following:
1.
				Special education and related services as defined in the Individuals with
				Disabilities Education Act (
				20
				U.S.C. 1401 et seq.); or
2. A program funded under Section 110 of the
				Rehabilitation Act of 1973 (
				29 U.S.C. 730
				).
(3) Have documented
				in the waiver service plan a goal to achieve or to sustain individual
				employment.
(4) Have documented in
				the waiver service plan that the choice to receive individual supported
				employment services was offered and explained in a manner sufficient to ensure
				informed choice, after which the choice to receive small-group supported
				employment services was made.
(5)
				Not reside in a medical institution.
j. Choose HCBS intellectual disability waiver
				services rather than ICF/ID services.
k. To be eligible for interim medical
				monitoring and treatment services the consumer must be:
(1) Under the age of 21;
(2) Currently receiving home health agency
				services under rule 441-78.9 (249A) and require
				medical assessment, medical monitoring, and regular medical intervention or
				intervention in a medical emergency during those services. (The home health
				aide services for which the consumer is eligible must be maximized before the
				consumer accesses interim medical monitoring and treatment.);
(3) Residing in the consumer's family home or
				foster family home; and
(4) In need
				of interim medical monitoring and treatment as ordered by a physician, nurse
				practitioner, clinical nurse specialist, or physician assistant.
l. Be assigned an HCBS
				intellectual disability payment slot pursuant to subrule 83.61(4).
m. For residential-based supported community
				living services, meet all of the following additional criteria:
(1) Be less than 18 years of age.
(2) Be preapproved as appropriate for
				residential-based supported community living services by the bureau of
				long-term care. Requests for approval shall be submitted in writing to the DHS
				Bureau of Long-Term Care, 1305 East Walnut Street, Des Moines, Iowa 50319-0114,
				and shall include the following:
1. Social
				history;
2. Case history that
				includes previous placements and service programs;
3. Medical history that includes major
				illnesses and current medications;
4. Current psychological evaluations and
				consultations;
5. Summary of all
				reasonable and appropriate service alternatives that have been tried or
				considered;
6. Any current court
				orders in effect regarding the child;
7. Any legal history;
8. Whether the child is at risk of
				out-of-home placement or the proposed placement would be less restrictive than
				the child's current placement for services;
9. Whether the proposed placement would be
				safe for the child and for other children living in that setting; and
10. Whether the interdisciplinary team is in
				agreement with the proposed placement.
(3) Either:
1. Be residing in an ICF/ID;
2. Be at risk of ICF/ID placement, as
				documented by an interdisciplinary team assessment pursuant to paragraph
				83.61(2)
"a"
; or
3.
				Be a child whose long-term placement outside the home is necessary because
				continued stay in the home would be a detriment to the health and welfare of
				the child or the family, and all service options to keep the child in the home
				have been reviewed by an interdisciplinary team, as documented in the service
				file.
n. For
				day habilitation, be 16 years of age or older.
o. For the consumer choices option as set
				forth in 441-subrule 78.41(5), not be living in a residential care
				facility.