249J.11 - NURSING FACILITY LEVEL OF CARE DETERMINATION FOR FACILITY-BASED AND COMMUNITY-BASED SERVICES.
249J.11 NURSING FACILITY LEVEL OF CARE DETERMINATION
FOR FACILITY-BASED AND COMMUNITY-BASED SERVICES.
The department shall amend the medical assistance state plan to
provide for all of the following:
1. That nursing facility level of care services under the medical
assistance program shall be available to an individual admitted to a
nursing facility on or after July 1, 2005, who meets eligibility
criteria for the medical assistance program pursuant to section
249A.3, if the individual also meets any of the following criteria:
a. Based upon the minimum data set, the individual requires
limited assistance, extensive assistance, or has total dependence on
assistance, provided by the physical assistance of one or more
persons, with three or more activities of daily living as defined by
the minimum data set, section G, entitled "physical functioning and
structural problems".
b. Based on the minimum data set, the individual requires the
establishment of a safe, secure environment due to moderate or severe
impairment of cognitive skills for daily decision making.
c. The individual has established a dependency requiring
residency in a medical institution for more than one year.
2. That an individual admitted to a nursing facility prior to
July 1, 2005, and an individual applying for home and community-based
services waiver services at the nursing facility level of care on or
after July 1, 2005, who meets the eligibility criteria for the
medical assistance program pursuant to section 249A.3, shall also
meet any of the following criteria:
a. Based on the minimum data set, the individual requires
supervision, or limited assistance, provided on a daily basis by the
physical assistance of at least one person, for dressing and personal
hygiene activities of daily living as defined by the minimum data
set, section G, entitled "physical functioning and structural
problems".
b. Based on the minimum data set, the individual requires the
establishment of a safe, secure environment due to modified
independence or moderate impairment of cognitive skills for daily
decision making.
3. That, beginning July 1, 2005, if nursing facility level of
care is determined to be medically necessary for an individual and
the individual meets the nursing facility level of care requirements
for home and community-based services waiver services under
subsection 2, but appropriate home and community-based services are
not available to the individual in the individual's community at the
time of the determination or the provision of available home and
community-based services to meet the skilled care requirements of the
individual is not cost-effective, the criteria for admission of the
individual to a nursing facility for nursing facility level of care
services shall be the criteria in effect on June 30, 2005. The
department of human services shall establish the standard for
determining cost-effectiveness of home and community-based services
under this subsection.
4. The department shall develop a process to allow individuals
identified under subsection 3 to be served under the home and
community-based services waiver at such time as appropriate home and
community-based services become available in the individual's
community. Section History: Recent Form
2005 Acts, ch 167, §11, 66 Footnotes
Federal approval of state planning amendments related to nursing
home level of care pending at time of codification of this section;
section contingent upon federal approval; 2005 Acts, ch 167, §66