Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 83 - Medicaid Waiver Services › Rule 441-83.1 - 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.
"Blind individual"
means an individual who
				  has a central visual acuity of 20/200 or less in the better eye with the use of
				  corrective lens or visual field restriction to 20 degrees or less.
"Client participation"
means the amount of
				  the recipient income that the person must contribute to the cost of health and
				  disability waiver services exclusive of medical vendor payments before Medicaid
				  will participate.
"Deeming"
means the specified amount of
				  parental or spousal income and resources considered in determining eligibility
				  for a child or spouse according to current supplemental security income
				  guidelines.
"Disabled person"
means an individual who is
				  unable to engage in any substantial gainful activity by reason of any medically
				  determinable physical or mental impairment which has lasted or is expected to
				  last for a continuous period of not less than 12 months. A child under the age
				  of 18 is considered disabled if the child suffers a medically determinable
				  physical or mental impairment of comparable severity.
"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.
"Financial participation"
means client
				  participation and medical payments from a third party including veterans' aid
				  and attendance.
"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.
"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 homemaker service"
means
				  homemaker service provided from one to three hours a day for not more than four
				  days per week.
"Intermittent respite service"
means respite
				  service provided from one to three times 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 or an intermediate care facility for persons with an intellectual
				  disability 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.
"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.
"Substantial gainful activity"
means
				  productive activities which add to the economic wealth, or produce goods or
				  services to which the public attaches a monetary value.
"Third-party payments"
means payments from
				  an attorney, 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.