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



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For each service listed in Appendix C-1, provide the information specified below. State laws, regulations and policies referenced in the specification are readily available through the Medicaid agency or the operating agency (if applicable).


Service Specification

Service Title:

Chore 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):

Services needed to maintain the home in a clean sanitary and safe environment. This service includes heavy household chores such as washing floors, windows and walls, tacking down loose rugs and tiles, moving heavy items of furniture in order to provide safe access and egress, mowing lawns and snow removal. These services are provided only when neither the participant nor anyone else in the household is capable of performing and where no other relative, caregiver, landlord, is capable or responsible for their provision


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

A half hour is a unit of service. There is an 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):




Individual. List types:

X

Agency. List the types of agencies:




Area agencies on aging




Community Action agencies




Home health aid providers







Nursing facilities





Providers certified under the HCBS MR waiver

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 216A.93


Home Health aide providers




Certified to participate in the Medicare program




Nursing facilities







Pursuant to Iowa code chapter 135C

Providers certified under the HCBS waiver




Certified by the Iowa Medicaid Enterprise as a MR waiver provider




Verification of Provider Qualifications

Provider Type:

Entity Responsible for Verification:

Frequency of Verification

Area agencies on aging


The Department of Human Services Iowa Medicaid Enterprise

Verified based on the length of certification

Community Action agencies

The Department of Human Services Iowa Medicaid Enterprise

The same as above

Home Health Aide providers

The Department of Human Services Iowa Medicaid Enterprise

The same as above




Nursing facilities

The Department of Human Services Iowa Medicaid Enterprise

The same as above




Providers certified under the HCBS waiver

The Department of Human Services Iowa Medicaid Enterprise

The same as above

Service Delivery Method


Service Delivery Method (check each that applies):




Participant-directed as specified in Appendix E

X

Provider managed

For each service listed in Appendix C-1, provide the information specified below. State laws, regulations and policies referenced in the specification are readily available through the Medicaid agency or the operating agency (if applicable).

Service Specification

Service Title:

Transportation

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):

Transportation services are services offered to enable waiver participants to gain access to waiver and other community services activities and resources as specified in the service plan. Transportation services can be provided to receive medical services when the service is not reimbursed under medical transportation under the state plan. Whenever possible, family neighbors friends or community agencies which can provide these without charge are utilized

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

A unit can either be a trip or a mile. County contract rate or, in the absence of a contract rate, the rate set by the area agency on aging. 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:




Area agencies on aging




Transportation providers subcontracting with the area agencies on aging




Community action agencies







Regional transit agencies







Nursing Facilities

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

Transportation providers subcontracting with the area agencies on aging







Letter of approval from the Area agencies on aging

Community action agencies







As designated in Iowa code Section 216A. 93

Regional transit agencies







As recognizes by the Iowa department of Transportation

Nursing facilities

Licensed pursuant to Iowa code 135 C





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 certification`

Transportation providers subcontracting with area agencies on aging

Iowa Department of Human Services Iowa Medicaid Enterprise

The same as above

Community action agencies

Iowa Department of Human Services Iowa Medicaid Enterprise

The same as above




Regional transit agencies

Iowa Department of Human Services Iowa Medicaid Enterprise

The same as above





Nursing facilities

Iowa Department of Human Services Iowa Medicaid Enterprise

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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