Section 191.72.3. Definitions.

“Asset disregard” means a $1 increase in the amount of assets an individual who purchases a certified long-term care policy may retain, upon qualification for Medicaid, for each $1 of benefit paid out under the individual’s certified long-term care policy for Medicaid-eligible long-term care services in determining eligibility for the Medicaid program.

“Asset protection” means the right extended by 441 IAC 75.5(5) to beneficiaries of certified long-term care insurance policies and certificates to an asset disregard under the Iowa long-term care asset preservation program.

“Authorized designee” means any person designated in writing to the insurance company by the policyholder or certificate holder of a certified long-term care policy or certificate for purposes of notification under paragraph 72.7(1)“h.”

“Average daily private pay rate” means the average statewide cost of nursing facility services to a private pay resident as determined by the department of human services in 441 IAC 75.23(3). The average statewide private pay rate is set annually on July 1 for one year by the Iowa department of human services.

“Case management” includes, but is not limited to, the development of a comprehensive individualized assessment and care plan and, as needed, coordination of appropriate services and the monitoring of the delivery of such services.

“Case management agency” means an agency or other entity approved by the Iowa department of human services as meeting Medicaid case management standards.

“Certificate” means any certificate delivered or issued for delivery in this state under a group long-term care policy.

“Certificate form” means the form on which the certificate is delivered or issued for delivery by the issuer.

“Certificate holder” means an owner of a certified long-term care insurance certificate or the beneficiary of a certified long-term care certificate.

“Certified long-term care insurance policy or certificate” means any long-term care insurance policy or certificate certified for sale to Iowa residents by the division of insurance as meeting standards promulgated under rules 191—72.6(249G) and 191—72.7(249G).

“Cognitive impairment” means confusion or disorientation resulting from a deterioration or loss of intellectual capacity that is not related to or a result of mental illness but which can result from Alzheimer’s disease or similar forms of senility or irreversible dementia. This deterioration or loss of intellectual capacity is established through use of standardized tests that reliably measure impairment in the following areas:

        1.            Short-term or long-term memory.

        2.            Orientation as to person, place, and time.

        3.            Deductive or abstract reasoning.

Cognitive impairment must result in an individual’s requiring 24-hour-a-day supervision or direct assistance to maintain the individual’s safety.

“Complex, yet stable medical condition” means that the individual requires 24-hour-a-day professional nursing observation or professional nursing intervention more than once a day in a setting other than an acute care wing of a hospital.

“Deficiency in activity of daily living” means that the individual cannot perform one or more of the following six activities of daily living without direct assistance:

        1.            Bathing, meaning cleaning the body using a tub, shower or sponge bath, including getting a basin of water, managing faucets, getting in and out of tub or shower, reaching head and body parts for soaping, rinsing, and drying.

        2.            Dressing, meaning putting on and taking off, fastening and unfastening garments and undergarments and special devices such as back or leg braces, corsets, elastic stockings/garments and artificial limbs or splints.

        3.            Toileting, meaning getting on and off toilet or commode and emptying commode, managing clothing and wiping and cleaning body after toileting, and assistance with using and emptying bedpans and urinals.

        4.            Transferring, meaning moving from one sitting or lying position to another sitting or lying position, e.g., from bed to or from a wheelchair or sofa, coming to a standing position or repositioning to promote circulation and prevent skin breakdown.

        5.            Continence, meaning the ability to control bowel and bladder as well as use ostomy or catheter receptacles and apply diapers and disposable barrier pads.

        6.            Eating, meaning reaching for, picking up, grasping utensil and cup; getting food on utensil, bringing food, utensil, cup to mouth; manipulating food on plate; and cleaning face and hands as necessary following meal.

“Department of human services” means the Iowa division of medical services.

“Direct assistance” means that the individual cannot perform an activity of daily living safely or appropriately without continual help or oversight. Direct assistance may vary from requiring a person to physically stand by or set up the activity to the activity being totally performed by others.

“Formal long-term care services” means long-term care service for which the provider is paid.

“Home health care services” means:

        1.            Part-time or intermittent skilled nursing services by licensed nursing personnel provided by a home health agency or by a registered nurse or a licensed vocational nurse, when a case management provider agency has determined that no home health agency exists in the area;

        2.            Home health aide services provided by a home health agency;

        3.            Physical therapy, occupational therapy, or speech therapy and audiology services provided by a home health agency; and

        4.            Medical social services by a social worker or social work assistant provided by a home health agency.

“Homemaker services incidental to personal care” means the policyholder or certificate holder is eligible to receive homemaker services if personal care is being received. Homemaker services incidental to personal care are limited to the following:

        1.            Domestic or cleaning services;

        2.            Laundry services;

        3.            Reasonable food shopping and errands;

        4.            Meal preparation and cleanup;

        5.            Transportation assistance to and from medical appointments; and

        6.            Heavy cleaning which involves thorough cleaning of the home to remove hazardous debris or dirt.

A certified long-term care insurance policy or certificate shall not, if it provides homemaker services incidental to personal care, limit or exclude benefits by requiring that the provision of such services be at a level of certification or licensure greater than that required by the eligible service or by limiting benefits to services provided by Medicare-certified agencies or providers.

“Informal long-term care services” means long-term care services for which the provider is not paid.

“Insured event” means the insured is eligible to receive insurance benefits and to have these benefits qualify for an asset disregard if any one of the following criteria is met:

        1.            The insured has at least two deficiencies in activities of daily living (ADLs) (to qualify for home-and community-based services including, but not limited to, home health care, adult day health/social care, personal care, homemaker services incidental to personal care, respite care and residential care facility) or three deficiencies in activities of daily living (ADLs) (to qualify for nursing facility care); or

        2.            The insured has a cognitive impairment; or

        3.            The insured has a complex, yet stable medical condition.

“Integrated benefits” means the benefits contained in the policy or certificate can be used interchangeably among the various covered home- or community-based or nursing facility benefits, and there is no limit on the use of any specific covered benefit, except for monthly limits that may be set for home-and community-based care benefits and per diem limits that may be set on nursing facility services.

“Issuer” means:

        1.            Insurance companies;

        2.            Fraternal benefit societies;

        3.            Prepaid health care delivery plans;

        4.            Health care service plans;

        5.            Health maintenance organizations; and

        6.            Any other entity delivering or issuing for delivery in this state, long-term care policies or certificates.

“Long-term care asset preservation program” means the program authorized in Iowa Code chapter 249G.

“Medicaid-eligible long-term care services” include:

        1.            Long-term care services available under Iowa’s state Medicaid plan, including care in a licensed nursing facility and home health nursing and home health aide services provided by a home health agency.

        2.            Long-term care services covered under the Medicaid home- and community-based services waiver for the aged and disabled, as defined in paragraph 72.7(1)“d.”

“Medicaid waiver” refers to the home- and community-based services waiver for the aged and disabled approved by the United States Department of Health and Human Services Health Care Financing Administration under the provisions of Section 1915(c) of the Social Security Act which allows Iowa to provide certain community and in-home services not covered in the state Medicaid plan, which are instrumental in the avoidance or delay of institutionalization. Iowa’s Medicaid waiver services include:

        1.            Case management;

        2.            Homemaker;

        3.            Respite care;

        4.            Attendant care;

        5.            Adult day care; and

        6.            Other services which, independent of the preceding home- and community-based services, are essential to prevent institutionalization.

“Personal care services” means:

        1.            Ambulation assistance, including help in walking or moving around (e.g., wheelchair) inside the home, changing locations in a room, moving from room to room to gain access for the purpose of engaging in other activities. Ambulation assistance does not include movement solely for the purpose of exercise.

        2.            Bathing and grooming including cleaning the body using a tub, shower or sponge bath, including getting a basin of water, managing faucets, getting in and out of tub or shower, reaching head and body parts for soaping, rinsing, and drying. Grooming includes hair combing and brushing, shampooing, oral hygiene, shaving and fingernail and toenail care.

        3.            Dressing includes putting on and taking off, fastening and unfastening garments and undergarments and special devices such as back or leg braces, corsets, elastic stockings/garments and artificial limbs or splints.

        4.            Bowel, bladder and menstrual care including assisting the person on and off toilet or commode and emptying commode, managing clothing and wiping and cleaning body after toileting, assistance with using and emptying bedpans, ostomy or catheter receptacles and urinals, application of diapers and disposable barrier pads.

        5.            Reposition, transfer skin care, and range of motion exercises, including moving from one sitting or lying position to another sitting or lying position, e.g., from bed to or from a wheelchair or sofa, coming to a standing position or rubbing skin and repositioning to promote circulation and prevent skin breakdown. Motion exercises shall include the carrying out of maintenance programs, i.e., the performance of the repetitive exercises required to maintain function, improve gait, maintain strength or endurance, passive exercises to maintain range of motion in paralyzed extremities, and assistive walking.

        6.            Feeding and hydration assistance including reaching for, picking up, grasping utensil and cup; getting food on utensil; bringing food, utensil, cup to mouth, and manipulating food on plate; cleaning face and hands as necessary following meal.

        7.            Assistance with self-administration of medications.

        8.            A certified long-term care insurance policy or certificate shall not, if it provides personal care services, limit or exclude benefits by requiring that the provision of personal care be at a level of certification or licensure greater than that required by the eligible service, or by limiting benefits to services provided by Medicare-certified agencies or providers.

“Plan of care” means a written individualized plan of services approved by a case management provider agency which specifies the type, frequency, and providers of all formal and informal long-term care services required for the individual and the cost, if any, of any formal long-term care services prescribed. Changes in the plan of care must be documented to show that such alterations are required by changes in the client’s medical situation, functional or cognitive abilities, behavioral abilities or the availability of social supports.

“Preadmission screening program” means the program which requires that each person seeking admission to a nursing facility must be screened and approved for admission by the Iowa Foundation of Medical Care in accordance with 441 IAC 81.3(249A).

“Qualified insured” means the following:

1. An individual who by reason of age is eligible for parts “A” and “B” of the Medicare program (42 U.S.C. 1395 et seq.) who is either:

        ●             The beneficiary of a certified long-term care policy or certificate approved by the division of insurance; or

        ●             Enrolled in a prepaid health care delivery plan that provides long-term care services and qualifies under this rule; or

2. An individual who is eligible for an asset disregard under a certified long-term care policy or certificate. An individual does not have to be a qualified insured to purchase a certified long-term care policy or certificate.

“Quarterly/annually” refers to periods aligning with the state fiscal year of July 1 to June 30.

“Service summary” means a written summary, prepared by an issuer for a qualified insured, which identifies the following:

        1.            The specific certified policy or certificate.

        2.            The total benefits paid for services to date.

        3.            The amount of benefits qualifying for asset protection.