Application for a §1915 (c) hcbs waiver Submitted by



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Service Specification

Service Title:

Home and Vehicle Modification

Complete this part for a renewal application or a new waiver that replaces an existing waiver. Select one:

X

Service is included in current waiver. There is no change in service specifications.



Service is included in current waiver. The service specifications have been modified.



Service is not included in the current waiver.

Service Definition (Scope):

Covered home and vehicle modifications are those physical modifications to the consumer’s home or vehicle listed below that directly address the consumer’s medical or remedial need. Covered modifications must be necessary to provide for the health, welfare, or safety of the consumer and enable the consumer to function with greater independence.



a. Excluded modification include the following

(1)Modifications that would be expected to increase the fair market value of the home or vehicle are excluded except as specially included below.

(2) Adaptations which add to the total square footage of the home

(3) Repairs



b. Only the following modifications are covered:

(1) Kitchen counters, sink space, cabinets, special adaptations to refrigerators, stoves, and ovens.

(2) Bathtubs and toilets to accommodate transfer, special handles and hoses for shower heads, water

faucet controls, and accessible showers and sink areas.

(3) Grab bars and handrails.

(4) Turnaround space adaptations.

(5) Ramps, lifts, and door, hall and window widening.

(6) Fire safety alarm equipment specific for disability.

(7) Voice-activated, sound-activated, light-activated, motion-activated, and electronic devices directly

related to the consumer’s disability.

(8) Vehicle lifts, driver-specific adaptations, remote-start systems, including such modifications

already installed in a vehicle.

(9) Keyless entry systems.

(10) Automatic opening device for home or vehicle door.

(11) Special door and window locks.

(12) Specialized doorknobs and handles.

(13) Plexiglas replacement for glass windows.

(14) Modification of existing stairs to widen, lower, raise or enclose open stairs.

(15) Motion detectors.

(16) Low-pile carpeting or slip-resistant flooring.

(17) Telecommunications device for the deaf.

(18) Exterior hard-surface pathways.

(19) New door opening.

(20) Pocket doors.

(21) Installation or relocation of controls, outlets, switches.

(22) Air conditioning and air filtering if medically necessary.

(23) Heightening of existing garage door opening to accommodate modified van.

(24) Bath chairs.


c. A unit of service is the completion of needed modifications or adaptations.

d. All modifications and adaptations shall be provided in accordance with applicable federal,

state, and local building and vehicle codes.



e. Services shall be performed following department approval of a binding contract between the

enrolled home and vehicle modification provider and the consumer.



f. The contract shall include, at a minimum, the work to be performed, cost, time frame for work

completion, and assurance of liability and workers’ compensation coverage.




Specify applicable (if any) limits on the amount, frequency, or duration of this service:

There is a limit of $1,000 lifetime that may be made. The individuals’ plan of care will address how the consumer health care needs are being met. The individuals’ plan of care will address how the consumer health care needs are being met. Services must be authorized in the service plan. The Case manager will monitor the plan.



Provider Specifications

Provider Category(s)

(check one or both):

x

Individual. List types:

X

Agency. List the types of agencies:

Any community Business or individuals that have all necessary licenses and permits to operate in conformity with federal, state, local laws and regulations and that submit verification of current liability and workers compensation


Community Action Agencies






Area agencies on aging







Specify whether the service may be provided by (check each that applies):



Legally Responsible Person



Relative/Legal Guardian

Provider Qualifications (provide the following information for each type of provider):

Provider Type:

License (specify)

Certificate (specify)

Other Standard (specify)

Community Business/individual





Has all necessary licenses and permits to operate in conformity with federal, state and local laws and regulations and that submit verification of current liability and workers compensation

Area agencies on aging







As designated in Iowa Administrative Code 321-4.4

Community Action agencies







As designated in Iowa Code 216a.93

Verification of Provider Qualifications

Provider Type:

Entity Responsible for Verification:

Frequency of Verification

Individual

Iowa Department Of Human Services Iowa Medicaid Enterprise

Verified as claim is submitted. Service worker verifies when the plan of care is written

Area agencies


Same as above

Same as above

Community Action agencies

Same as above

Same as above

Service Delivery Method

Service Delivery Method (check each that applies):



Participant-directed as specified in Appendix E

X

Provider managed




Service Specification

Service Title:

Home-Delivered Meals

Complete this part for a renewal application or a new waiver that replaces an existing waiver. Select one:

X

Service is included in current waiver. There is no change in service specifications.




Service is included in current waiver. The service specifications have been modified.



Service is not included in the current waiver.

Service Definition (Scope):

Home Delivered Meals are prepared elsewhere and delivered to a waiver recipient at the recipients residence or communal dining area. Each meal shall ensure the recipient receives a minimum of one-third of the daily recommended dietary allowance as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences. The meal may also be a liquid supplement that meets the minimum one-third standard. When a restaurant provides the home delivered meal the recipient is required to have a nutritional consultation. The nutritional consultation includes contact with the restaurant to explain the dietary needs of the client and what constitutes the minimum one-third daily dietary allowance



Specify applicable (if any) limits on the amount, frequency, or duration of this service:

A maximum of 14 meals is allowed per week. A unit of service is a meal. There is an upper limit for the meal that is subject to change each year. The individuals’ plan of care will address how the consumer health care needs are being met. Services must be authorized in the service plan. The Case Manager will monitor the plan.


Provider Specifications


Provider Category(s)

(check one or both):



Individual. List types:

X

Agency. List the types of agencies:




Area Agencies on Aging as well as home delivered meals providers subcontracting with Area Agencies on Aging or with letters of approval from the area agencies on aging stating the organization is qualified to provide home-delivered meals services.




Community Action Agencies




Home Health Care Agencies




Hospitals







Medicaid Equipment and Supply Dealers






Nursing Facilities








Restaurants

Specify whether the service may be provided by (check each that applies):



Legally Responsible Person



Relative/Legal Guardian

Provider Qualifications (provide the following information for each type of provider):

Provider Type:

License (specify)

Certificate (specify)

Other Standard (specify)

Area Agencies on Aging







As designated in Iowa Administrative Code 321-4.4

Community Action Agencies







As designated in Iowa Code section A.93

Home Care Agencies








Must have a contract with Iowa Public Health Department

Home Health Agencies







Enrolled as a Medicaid Provider

Hospitals







Enrolled as a Medicaid Provider

Medical Equipment and Supply Dealers







Enrolled as a Medicaid Provider

Nursing facilities

Licensed pursuant to Iowa Code chapter 135 C





Restaurants


Licensed and inspected under Iowa Code Chapter 137 B







Verification of Provider Qualifications

Provider Type:

Entity Responsible for Verification:

Frequency of Verification

Area Agencies on Aging

Iowa Department Of Human Services Iowa Medicaid Enterprise

Verified based on the length of the Certification or license or other standards.

Community Action Agencies

The Same as above

The Same as Above

Home Care Agencies

The Same as above

The same as above




Home Health Agencies

The same as above

The same as above





Hospitals

The same as above

The same as above




Medical Equipment and Supply Dealers

The same as above

The same as above




Nursing Facilities

The same as above

The same as aboe




Restaurants

The same as above

The same as above

Service Delivery Method

Service Delivery Method (check each that applies):



Participant-directed as specified in Appendix E

X

Provider managed




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