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



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Service Specification

Service Title:

Nursing Care Services (skilled nursing services)

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):

Nursing care services are services which are included in the plan of treatment approved by the physician and which are provided by licensed nurses to consumers in the home and community. The services shall be reasonable and necessary to the treatment of an illness or injury and include all nursing tasks recognized by the Iowa board of nursing. Nursing services under the Medicaid state plan must be exhausted first. Nursing Care Services differ only in duration of services from Medicaid state plan. Nursing care services under the waiver do not need to show an attempt to have a predictable end.



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

A unit of service is a visit. There is an upper limit per visit that is subject to change each year. The individuals service plan will 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:




Home Health Agencies













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)

Home Health Agencies




Certified to participate in the Medicare Program




























Verification of Provider Qualifications

Provider Type:

Entity Responsible for Verification:

Frequency of Verification

Home Health Agencies


Iowa Department of Human Services

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



















Service Delivery Method

Service Delivery Method (check each that applies):



Participant-directed as specified in Appendix E

X

Provider managed




Service Specification

Service Title:

Nutritional Counseling


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

XC

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):

Nutritional counseling services may be provided for a nutritional problem or condition such a degree of severity that nutritional counseling beyond that normally expected as part of the standard medical management is warranted. The services must be face-to face contact and specified in the services plan based on recommendations from a licensed dietician.


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

A unit of services is 15 minutes. The upper limit per unit that is subject to change each year. The individuals service plan will 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:

Licensed dietitians

Hospitals




Community action agencies




Nursing facilities







Home Health agencies

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)

Hospitals






Enrolled as a Medicaid provider



Community Action agencies







Designated in Iowa Code section 2161.93

Nursing facilities

Licensed pursuant to Iowa code chapter 135 C







Home Health agencies




Certified to participate in the Medicare program




Licensed dietitians





As approved by an area agency on aging

Verification of Provider Qualifications

Provider Type:

Entity Responsible for Verification:

Frequency of Verification

Hospitals

Iowa Department of Human Services Iowa Medicaid Enterprise

Verified based on the length of certification or license or other standard

Community Action agencies

The same as above

The same as above

Nursing facilities

The same as above

The same as above




Home health agencies

The same as above

The same as above




Licensed dietitians

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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