reglab/statecodes huggingface dataset:
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB PART: ENHANCED DEVELOPMENTAL DISABILITY SERVICES › Section 16.03.10.503 - DEVELOPMENTAL DISABILITY DETERMINATION: TEST INSTRUMENTS

Current through August 31, 2023
A variety of standardized test instruments are available.
				  Tests used to determine a developmental disability must reflect the current
				  functional status of the individual being evaluated. Tests over one (1) year
				  old must be verified to reflect the current status of the individual by an
				  appropriate professional. Instruments designed only for screening purposes must
				  not be used to determine eligibility. (3-17-22)
01.
Test Instruments For Adults
.
				A Department-approved assessment tool for conducting cognitive and functional
				assessments must be used to determine eligibility. (3-17-22)
02.
Test Instruments for
				Children
. The assessments utilized to determine eligibility must be
				based on age appropriate criteria. Evaluations must be performed by qualified
				personnel with experience and expertise with children; selected evaluation
				tools and practices should be age appropriate, based on consideration of the
				child's language and motor skills. A Department-approved assessment tool for
				conducting cognitive and functional assessments must be used with children.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB PART: ENHANCED DEVELOPMENTAL DISABILITY SERVICES › Section 16.03.10.507 - ADULT DEVELOPMENTAL DISABILITY SERVICES PRIOR AUTHORIZATION (PA)

Current through August 31, 2023
The purpose of adult developmental disability services prior
				  authorization is to assure the provision of the right care, in the right place,
				  at the right price, and with the right outcomes in order to enhance health and
				  safety, and to promote participants' rights, self-determination, and
				  independence. Prior authorization involves the assessment of the need for
				  services, development of a budget, development of a plan of services, prior
				  approval of services, and a quality improvement program. Services are
				  reimbursable if they are identified on the authorized plan of service and are
				  consistent with the purpose and rule for prior authorization as well as rules
				  for the specific service. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB PART: ENHANCED DEVELOPMENTAL DISABILITY SERVICES › Section 16.03.10.509 - ADULT DEVELOPMENTAL DISABILITY SERVICES PRIOR AUTHORIZATION: ELIGIBILITY DETERMINATION

Current through August 31, 2023
The Department will make the final determination of an
				  individual's eligibility, based upon the assessments and evaluations
				  administered by the Department. Initial and annual assessments will be
				  performed by the Department. The purpose of the assessment is to determine a
				  participant's eligibility for developmental disabilities services in accordance
				  with Section
				  66-402, Idaho Code, and Sections
				  500 through
				  506 of these rules and for ICF/IID
				  level of care for waiver services in accordance with Section
				  584 of these rules.
				  (3-17-22)
01.
Initial
				Assessment
. For new applicants, an assessment will be completed within
				thirty (30) days from the date a completed application is submitted.
				(3-17-22)
02.
Annual
				Assessments
. Assessments will also be completed for current participants
				at the time of their annual eligibility redetermination. The assessor will
				evaluate whether assessments are current and accurately describe the status of
				the participant. At least sixty (60) days before the expiration of the current
				plan of service: (3-17-22)
a. The assessment
				process will be completed; and (3-17-22)
b. The assessor will provide the results of
				the assessment to the participant. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB PART: ENHANCED DEVELOPMENTAL DISABILITY SERVICES › Section 16.03.10.511 - ADULT DEVELOPMENTAL DISABILITY SERVICES PRIOR AUTHORIZATION: COVERAGE AND LIMITATIONS

Current through August 31, 2023
The scope of these rules defines prior authorization for the
				  following Medicaid developmental disability services for adults:
				  (3-17-22)
01.
DD Waiver
				Services
. DD Waiver services as described in Sections
				700 through
				719 of these rules; and
				(3-17-22)
02.
Developmental
				Therapy
. Developmental therapy as described in Sections
				649 through
				657 of these rules and IDAPA
				16.03.21, "Developmental Disabilities Agencies (DDA)"; and (3-17-22)
03.
Service Coordination
.
				Service Coordination for persons with developmental disabilities as described
				in Sections 720 through
				779 of these rules.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB PART: ENHANCED DEVELOPMENTAL DISABILITY SERVICES › Section 16.03.10.512 - ADULT DEVELOPMENTAL DISABILITY SERVICES PRIOR AUTHORIZATION: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
01.
Assessment for Plan of Service
. The assessment for a plan of service is
				required for all participants prior to the development of the plan of service.
				This assessment must include the following in Subsections
				512.02 through
				512.06 of these rules.
				(3-17-22)
02.
Physician's
				History and Physical
. The history and physical must include a
				physician's referral for nursing services under the DD waivers and for
				developmental disabilities agencies' services, if they are anticipated to be
				part of the plan of service. A physician's history and physical is required
				within the year prior to the initiation of service and thereafter on a
				frequency determined by the physician. For participants in Healthy Connections:
				(3-17-22)
a. The Healthy Connections physician
				may delegate to the Department the authority to approve developmental
				disability services. (3-17-22)
b.
				The Healthy Connections physician must conduct the history and physical, and
				may refer the participant for other evaluations. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB PART: ENHANCED DEVELOPMENTAL DISABILITY SERVICES › Section 16.03.10.513 - ADULT DEVELOPMENTAL DISABILITY SERVICES PRIOR AUTHORIZATION: PLAN OF SERVICE

Current through August 31, 2023
In collaboration with the participant, the Department will
				  assure that the participant has one (1) plan of service. This plan of service
				  is based on the individualized participant budget referred to in Section
				  514 of these rules and must
				  identify all services and supports. Participants may develop their own plan or
				  designate a paid or non-paid plan developer. In developing the plan of service,
				  the plan developer and the participant must identify services and supports
				  available outside of Medicaid-funded services that can help the participant
				  meet desired goals. Authorized services must be delivered by providers who are
				  selected by the participant. (3-17-22)
01.
Qualifications of a Paid Plan
				Developer
. Neither a provider of direct service to the participant nor
				the assessor may be chosen to be the paid plan developer. Family members and
				all others who wish to be paid for plan development must be employed as a
				service coordinator as defined in Sections
				729 through
				732 of these rules.
				(3-17-22)
02.
Plan
				Development
. All participants must direct the development of their
				service plan through a person-centered planning process. Individuals invited to
				participate in the person-centered planning process will be identified by the
				participant and may include family members, guardian, or individuals who are
				significant to the participant. In developing the plan of service, the plan
				developer and participant must identify any services and supports available
				outside of Medicaid-funded services that can help the participant meet desired
				goals and outcomes. (3-17-22)
a. The plan of
				service must be submitted within forty-five (45) days prior to the expiration
				of the existing plan of service unless delayed because of participant
				unavailability due to extenuating circumstances. If the plan is not submitted
				within this time period, authorization for provider payments may be terminated.
				(3-17-22)
b. The plan development
				process must meet the person-centered planning requirements described in
				Section 316 of these
				rules. (3-17-22)
c. The participant
				may facilitate their own person-centered planning meeting, or designate a paid
				or non-paid plan developer to facilitate the meeting. Individuals responsible
				for facilitating the person-centered planning meeting cannot be providers of
				direct services to the participant. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB PART: ENHANCED DEVELOPMENTAL DISABILITY SERVICES › Section 16.03.10.514 - ADULT DEVELOPMENTAL DISABILITY SERVICES PRIOR AUTHORIZATION: PROVIDER REIMBURSEMENT

Current through August 31, 2023
Providers are reimbursed on a fee for service basis based on
				  a participant budget. (3-17-22)
01.
Individualized Budget Beginning on October 1, 2006
. Beginning
				October 1, 2006, for DD waiver participants, and beginning January 1, 2007, for
				all other adult DD participants, the Department sets an individualized budget
				for each participant according to an individualized measurement of the
				participant's functional abilities, behavioral limitations, and medical needs,
				related to the participant's disability. Using these specific participant
				factors, the budget-setting methodology will correlate a participant's
				characteristics with the participant's individualized budget amount, so
				participants with higher needs will be assigned a higher individualized budget
				amount. (3-17-22)
a. The Department notifies
				each participant of their set budget amount as part of the eligibility
				determination process or annual redetermination process. The notification will
				include how the participant may appeal the set budget amount.
				(3-17-22)
b. Individualized budgets
				will be re-evaluated annually. At the request of the participant, the
				Department will also re-evaluate the set budget amount when there are
				documented changes in the participant's condition resulting in a need for
				services that meet medical necessity criteria, and this is not reflected on the
				current inventory of individual needs. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.520 - CHILDREN'S DD HCBS STATE PLAN OPTION

Current through August 31, 2023
In accordance with Section
				  1915(i)  of the
				  Social Security Act, the Department will pay for home and communitybased
				  services provided by individuals or agencies that have entered into a provider
				  agreement with the Department. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.521 - CHILDREN'S DD HCBS STATE PLAN OPTION: DEFINITIONS

Current through August 31, 2023
For the purposes of Sections
				  520 through
				  528 of these rules, the following
				  terms are used as defined below. (3-17-22)
01.
Annual
. Every three hundred
				sixty-five (365) days, except during a leap year which equals three hundred
				sixty-six (366) days. (3-17-22)
02.
Community
. Natural, integrated environments outside of the
				participant's home, outside of DDA center-based settings, or at school outside
				of school hours. (3-17-22)
03.
Developmental Disabilities Agency (DDA)
. (3-17-22)
a. A type of developmental disabilities
				facility, as defined in Section
				39-4604, Idaho Code, that is
				non-residential and provides services on an outpatient basis;
				(3-17-22)
b. Certified by the
				Department to provide services to participants with developmental disabilities;
				and (3-17-22)
c. A business entity,
				open for business to the general public. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.522 - CHILDREN'S DD HCBS STATE PLAN OPTION: ELIGIBILITY DETERMINATION

Current through August 31, 2023
Final determination of a participant's eligibility will be
				  made by the Department. (3-17-22)
01.
Initial Eligibility Assessment Developmental Disability
				Determination
. The Department, or its contractor, will determine if a
				child meets established criteria for a developmental disability by completing
				the following: (3-17-22)
a. Documentation of a
				participant's developmental disability diagnosis, demonstrated by: (3-17-22)
i. A medical assessment that contains medical
				information that accurately reflects the current status of the participant or
				establishes categorical eligibility in accordance with Section
				66-402(5)(a),
				Idaho Code; or (3-17-22)
ii. The
				results of psychometric testing, if eligibility for developmental disabilities
				services is based on intellectual disability and there is no prior testing, or
				prior testing is inconclusive or invalid. Initial eligibility determinations
				also require documentation of diagnosis for a participant whose eligibility is
				based on developmental disabilities other than intellectual disability.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.525 - CHILDREN'S DD HCBS STATE PLAN OPTION: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
01.
Requirements for Prior
				Authorization
. Prior authorization is to ensure the provision of the
				right care, in the right place, at the right price, and with the right outcomes
				in order to enhance health and safety, and to promote participants' rights,
				self-determination, and independence. Prior authorization is intended to help
				ensure the provision of necessary and appropriate services and supports.
				Services are reimbursable if they are identified on the authorized plan of
				service and are consistent with rules for HCBS as described in Sections
				310 through
				313 and
				316 and
				317 of these rules, and for the
				specific services included on the plan. Delivery of each service identified on
				the plan of service cannot be initiated until the plan has been signed by the
				parent or participant's decision-making authority, the provider responsible for
				service provision, and has been authorized by the Department.
				(3-17-22)
02.
Requirements
				for Supervision
. All children's DD HCBS provided by a DDA or independent
				provider must be supervised. The supervisor must meet the intervention
				specialist or professional qualifications as outlined in IDAPA 16.03.09,
				"Medicaid Basic Plan Benefits," Section
				575, "Children's Habilitation
				Intervention Services." The observation and review of the direct services must
				be performed by all staff on at least a monthly basis, or more often as
				necessary, to ensure staff demonstrate the necessary skills to correctly
				provide the services as defined in this rule set. (3-17-22)
03.
Requirements for Quality
				Assurance
. Providers of DD HCBS state plan option must demonstrate high
				quality of services through an internal quality assurance review process.
				(3-17-22)
04.
General
				Requirements for Program Documentation
. The provider must maintain
				records for each participant served. Program documentation must be maintained
				by the independent provider or DDA in accordance with IDAPA 16.05.07,
				"Investigation and Enforcement of Fraud, Abuse, and Misconduct," Section
				101. Failure to maintain such
				documentation will result in the recoupment of funds paid for undocumented
				services. For each participant, the following program documentation is
				required: (3-17-22)
a. Date and time of visit;
				(3-17-22)
b. Support services
				provided during the visit; (3-17-22)
c. A summary of session or services provided;
				(3-17-22)
d. Length of visit,
				including time in and time out; (3-17-22)
e. Location of service; and
				(3-17-22)
f. Signature of the
				individual providing the service and date signed. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.526 - CHILDREN'S DD HCBS STATE PLAN OPTION: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
All providers of children's DD HCBS state plan option must
				  have a valid provider agreement with the Department. Performance under this
				  agreement will be monitored by the Department. (3-17-22)
01.
Respite
. Respite may be
				provided by an agency that is certified as a DDA or by an independent respite
				provider. An independent respite provider is an individual who has entered into
				a provider agreement with the Department. Providers of respite must meet the
				following minimum qualifications: (3-17-22)
a.
				Be at least sixteen (16) years of age when employed by a DDA; or
				(3-17-22)
b. Be at least eighteen
				(18) years of age and be a high school graduate, or have a GED, to act as an
				independent respite provider; and (3-17-22)
c. Have received instructions in the needs of
				the participant who will be provided the service; (3-17-22)
d. Demonstrate the ability to provide
				services according to a plan of service; (3-17-22)
e. Satisfactorily complete a criminal history
				background check in accordance with Section
				009 of these rules and IDAPA
				16.05.06, "Criminal History and Background Checks,"; and (3-17-22)
f. When employed by a DDA, be certified in
				CPR and first aid in accordance with the general training requirements under
				IDAPA 16.03.21, "Developmental Disabilities Agencies (DDA)." Independent
				respite providers must be certified in CPR and first aid prior to delivering
				services and must maintain current certification thereafter.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.527 - CHILDREN'S DD HCBS STATE PLAN OPTION: PROVIDER REIMBURSEMENT

Current through August 31, 2023
Providers are reimbursed on a fee-for-service basis for
				  services identified on the participant's plan of service and within the
				  participant's individualized budget. The Department will monitor the budget
				  setting methodology on an ongoing basis to ensure that participant needs are
				  accurately reflected in the methodology. (3-17-22)
01.
Claim Forms
. Provider claims
				for payment will be submitted on claim forms provided or approved by the
				Department. Billing instructions will be provided by the Department.
				(3-17-22)
02.
Rates
.
				The reimbursement rates calculated for children's HCBS include both services
				and mileage. No separate charges for mileage will be paid by the Department for
				provider transportation to and from the participant's home or other service
				delivery location when the participant is not being provided transportation.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.528 - CHILDREN'S DD HCBS STATE PLAN OPTION: DEPARTMENT'S QUALITY ASSURANCE AND IMPROVEMENT PROCESSES

Current through August 31, 2023
Quality assurance activities will include the observation of
				  service delivery with participants, review of participant records, and complete
				  satisfaction interviews. All providers of support services must grant the
				  Department immediate access to all information required to review compliance
				  with these rules. (3-17-22)
01.
Quality Assurance
. The Department will conduct quality assurance by
				collaborating with providers to complete audits and reviews to ensure
				compliance with the Department's rules and regulations. These findings may lead
				to quality improvement activities to enhance provider processes and outcomes
				for the child. If problems are identified that impact health and safety or are
				not resolved through quality improvement activities, implementation of a
				corrective action process may occur. (3-17-22)
02.
Quality Improvement
. Quality
				improvement consists of the Department working with the provider to resolve
				identified issues and enhance services provided. Quality improvement activities
				must include: (3-17-22)
a. Consultation;
				(3-17-22)
b. Technical assistance
				and recommendations; or (3-17-22)
c. Corrective Action.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.529. - 579 - RESERVED

Current through August 31, 2023
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.580 - INTERMEDIATE CARE FACILITIES FOR PERSONS WITH INTELLECTUAL DISABILITIES (ICF/IID)

Current through August 31, 2023
The Department will pay for services in an ICF/IID. An
				  ICF/IID is an intermediate care facility whose primary purpose is to provide
				  habilitative services and maintain optimal health status for individuals with
				  intellectually disabilities or persons with related conditions.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.581 - ICF/IID: ELIGIBILITY

Current through August 31, 2023
Entitlement to medical assistance participation in the cost
				  of long-term care exists when the individual is eligible for medical assistance
				  and the Department has determined that the individual meets the criteria for
				  ICF/IID services. Entitlement will be determined prior to authorization of
				  payment for such care for an individual who is either a participant of or an
				  applicant for medical assistance. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.582 - ICF/IID: DETERMINATION OF ENTITLEMENT FOR MEDICAID PAYMENT

Current through August 31, 2023
Applications for Medicaid payment of an individual with an
				  intellectual disability or related condition, in an ICF/IID will be through the
				  Department. All required information necessary for a medical entitlement
				  determination must be submitted to the Department before a determination and
				  approval for payment is made. The effective date of Medicaid payment will be no
				  earlier than the physician's signed and dated certification for ICF/IID level
				  of care. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.583 - ICF/IID: INFORMATION REQUIRED FOR DETERMINATION

Current through August 31, 2023
Required information includes a medical evaluation, an
				  initial plan of care, social evaluation, psychological evaluation, and initial
				  plan of care by ICF/IID. (3-17-22)
01.
Medical Evaluation
. A complete medical evaluation, current within
				ninety (90) days of admission, signed and dated by the physician, an electronic
				physician's signature is permissible, that includes: (3-17-22)
a. Diagnosis (primary and secondary);
				(3-17-22)
b. Medical findings and
				history; (3-17-22)
c. Mental and
				physical functional capacity; (3-17-22)
d. Prognosis; mobility status; and
				(3-17-22)
e. A statement by the
				physician certifying the level of care needed as ICF/IID for a specific
				participant. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.584 - ICF/IID: CRITERIA FOR DETERMINING ELIGIBILITY

Current through August 31, 2023
Individuals who have intellectual disabilities or a related
				  condition as defined in Section
				  66-402, Idaho Code, and Sections
				  500 through
				  503 of these rules, must be
				  determined by an interdisciplinary team to need the consistent, intense,
				  frequent services including active treatment provided in an ICF/IID or receive
				  services under one of Idaho's programs to assist individuals with intellectual
				  disabilities or a related condition to avoid institutionalization in an
				  ICF/IID, as indicated in Section
				  584.02 of these rules. To meet
				  Title XIX and Title XXI entitlement for ICF/IID level of care and be eligible
				  for services provided in an ICF/IID. The following must be met in Subsections
				  584.01 through
				  584.08 of these rules.
				  (3-17-22)
01.
Diagnosis
.
				Persons must be financially eligible for Medicaid; must have a primary
				diagnosis of being intellectually disabled or have a related condition defined
				in Section
				66-402, Idaho Code and Section
				500 through
				506 of these rules; and persons
				must qualify based on functional assessment, maladaptive behavior, a
				combination of both, or medical condition. (3-17-22)
02.
Active Treatment
. Persons
				living in an ICF/IID, must require and receive intensive inpatient active
				treatment as defined in Section
				010 of these rules, to advance or
				maintain their functional level. (3-17-22)
a.
				Active treatment does not include: parenting activities directed toward the
				acquisition of age-appropriate developmental milestones; services to maintain
				generally independent individuals who are able to function with little
				supervision or in the absence of a continuous active treatment program or
				services; interventions that address age-appropriate limitations; or general
				supervision of children whose age is such that such supervision is required by
				all children of the same age. (3-17-22)
b. The following criteria/components will be
				utilized when evaluating the need for active treatment: (3-17-22)
i. Evaluation. Complete medical, social, and
				psychological evaluations. These evaluations must clearly indicate the
				functional level of the participant and the interventions needed; and
				(3-17-22)
ii. Plan of Care. A
				written plan of care which sets forth initial goals and objectives, specifies
				further evaluations to be done, and training programs to be developed.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.585 - ICF/IID: COVERAGE REQUIREMENTS AND LIMITATIONS

Current through August 31, 2023
The minimum content of care and services for ICF/IID must
				  include the services listed below and social and recreational activities.
				  (3-17-22)
01.
Care and Services
				Provided
. (3-17-22)
a. The minimum
				content of care and services for ICF/IID participants must include the
				following: (3-17-22)
i. Room and board; and
				(3-17-22)
ii. Bed and bathroom
				linens; and (3-17-22)
iii. Nursing
				care, including special feeding if needed; and (3-17-22)
iv. Personal services; and
				(3-17-22)
v. Supervision as
				required by the nature of the participant's illness; and (3-17-22)
vi. Special diets as prescribed by a
				participant's physician; and (3-17-22)
vii. All common medicine chest supplies that
				do not require a physician's prescription including mouthwashes, analgesics,
				laxatives, emollients, burn ointments, first aid cream, protective creams and
				liquids, cough and cold preparations, and simple eye preparations; and
				(3-17-22)
viii. Dressings; and
				(3-17-22)
ix. Administration of
				intravenous, subcutaneous, or intramuscular injections and infusions, enemas,
				catheters, bladder irrigations, and oxygen; and (3-17-22)
x. Application or administration of all
				drugs; and (3-17-22)
xi. All
				medical supplies including gauzes, bandages, tapes, compresses, cottons,
				sponges, hot water bags, ice bags, disposable syringes, thermometers,
				cellucotton or any other type of pads used to save labor or linen, and
				disposable gloves; and (3-17-22)
xii. Social and recreational activities; and
				(3-17-22)
xiii. Items that are
				utilized by individual participants but that are reusable and expected to be
				available, such as bed rails, canes, crutches, walkers, wheel chairs, traction
				equipment, and other durable medical equipment.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.586 - ICF/IID: PROCEDURAL RESPONSIBILITIES

Current through August 31, 2023
Each long term care facility administrator, or their
				  authorized representative, must report to the appropriate Field Office within
				  three (3) working days of the date the facility has knowledge of the following.
				  (3-17-22)
01.
Readmissions or
				Discharges
. Any readmission or discharge of a participant, and any
				temporary absence of a participant due to hospitalization or therapeutic home
				visit. (3-17-22)
02.
Changes
				to Participant's Income
. Any changes in the amount of a participant's
				income. (3-17-22)
03.
Participant's Account Exceeds Limitations
. When a participant's account
				has exceed the following amount; (3-17-22)
a.
				For a single individual, one thousand eight hundred dollars ($1,800); or
				(3-17-22)
b. For a married couple,
				two thousand eight hundred dollars ($2,800). (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.587 - ICF/IID: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
01.
Provider Application and Certification
. A facility must apply to
				participate as an ICF/IID facility. (3-17-22)
02.
Licensure and Certification
.
				(3-17-22)
a. Upon receipt of an application
				from a facility, the Licensing and Certification Agency will conduct a survey
				to determine the facility's compliance with certification standards for the
				type of care the facility proposes to provide to participants.
				(3-17-22)
b. If the Licensing and
				Certification Agency determines that a facility meets Title XIX certification
				standards for ICF/IID, the Department will certify to the appropriate branch of
				government that the facility meets the standards for ICF/IID types of care.
				(3-17-22)
c. Upon receipt of the
				certification from the Licensing and Certification Agency, the Bureau may enter
				into a provider agreement with the long-term care facility. (3-17-22)
d. After the provider agreement has been
				executed by the Facility Administrator and by the bureau chief, one (1) copy
				will be sent by certified mail to the facility and the original is to be
				retained by the Bureau. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.588 - ICF/IID: PROVIDER REIMBURSEMENT

Current through August 31, 2023
01.
Payment
				Methodology
. ICF/IID facilities will be reimbursed in accordance with
				the methodology listed in Sections
				588 through
				633 of these rules.
				(3-17-22)
02.
Date of
				Discharge
. Payment by the Department for the cost of ICF/IID care is to
				include the date of the participant's discharge only if the discharge occurred
				after 3 p.m. and is not discharged to a related provider. If a Medicaid patient
				dies in an ICF/IID, their date of death is covered regardless of the time of
				occurrence. If an admission and a discharge occur on the same date, then one
				(1) day of care will be deemed to exist. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.589 - ICF/IID: REASONABLE COST PRINCIPLES

Current through August 31, 2023
To be allowable, costs must be reasonable, ordinary,
				  necessary and related to patient care. It will be expected that providers will
				  incur costs in such a manner that economical and efficient delivery of quality
				  health care to beneficiaries will result. (3-17-22)
01.
Application of Reasonable Cost
				Principles
. (3-17-22)
a. Reasonable
				costs of any services are determined in accordance with rules found in the
				Provider Reimbursement Manual (PRM), Sections
				100 through
				2600, as modified by the
				exceptions contained herein, is used to identify cost items to be included on
				Idaho's Uniform Cost Report. (3-17-22)
i.
				Reasonable cost takes into account both direct and indirect costs of providers
				of services, including normal standby costs. (3-17-22)
ii. The objectives of these methods are that:
				first, the costs with respect to individuals covered by the program will not be
				borne by others not so covered. Second, the costs with respect to individuals
				not covered will not be paid by the program. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.592 - ICF/IID: HOME OFFICE COST PRINCIPLES

Current through August 31, 2023
The reasonable cost principles will extend to the home office
				  costs allocated to individual providers. In addition, the home office, through
				  the provider, will provide documentation as to the basis used to allocate its
				  costs among the various entities it administers or otherwise directs.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.593 - ICF/IID: RELATED PARTY TRANSACTIONS

Current through August 31, 2023
01.
Principle
. Costs applicable to services, facilities and supplies
				furnished to the provider by organizations or persons related to the provider
				by common ownership, control, etc., are allowable at the cost to the related
				party. Such costs are allowable to the extent that they relate to patient care,
				are reasonable, ordinary, and necessary, and are not in excess of those costs
				incurred by a prudent cost-conscious buyer. (3-17-22)
02.
Cost Allowability -
				Regulation
. Allowability of costs is subject to the regulations
				prescribing the treatment of specific items as outlined in
				42 CFR
				413.17, et al, and the Providers
				Reimbursement Manual, PRM Chapter 10 and other applicable chapters of the PRM.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.594 - ICF/IID: APPLICATION OF RELATED PARTY TRANSACTIONS

Current through August 31, 2023
01.
Determination of Common Ownership
				or Control in the Provider Organization and Supply Organization
. In
				determining whether a provider organization is related to a supplying
				organization, the tests of common ownership and control are to be applied
				separately. If the elements of common ownership or control are not present in
				both organizations, the organizations are deemed not to be related to each
				other. (3-17-22)
a. A determination as to
				whether an individual(s) possesses ownership or equity in the provider
				organization and the supplying organization, so that the organizations will be
				considered to be related by common ownership, will be made on the basis of the
				facts and circumstances in each case. (3-17-22)
b. The term "control" includes any kind of
				control whether or not it is legally enforceable and however it is exercisable
				or exercised. It is the reality of the control that is decisive, not its form
				or the mode of its exercise. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.595 - ICF/IID: COMPENSATION OF RELATED PERSONS

Current through August 31, 2023
Compensation paid to persons related to owners or
				  administrators is allowable only to the extent that services are actually
				  performed and are necessary and adequately documented and the compensation for
				  the services is reasonable. (3-17-22)
01.
Compensation Claimed
.
				Compensation claimed for reimbursement must be included in compensation
				reported for tax purposes and be actually paid. (3-17-22)
a. Where such persons perform services
				without pay, no cost may be imputed. (3-17-22)
b. Time records documenting actual hours
				worked are required in order that the compensation be allowable for
				reimbursement. (3-17-22)
c.
				Compensation for undocumented hours worked will not be a reimbursable cost.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.596 - ICF/IID: INTEREST EXPENSE

Current through August 31, 2023
Generally interest on loans between related entities is not
				  an allowable expense. The loan will usually be considered invested capital. See
				  PRM, Chapter 2 for specifics. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.597 - ICF/IID: IDAHO OWNER-ADMINISTRATIVE COMPENSATION

Current through August 31, 2023
Allowable compensation to owners and persons related to
				  owners who provide any administrative services will be limited based on the
				  schedule in this section. (3-17-22)
01.
Allowable Owner Administrative
				Compensation
. The following schedule will be used in determining the
				maximum amount of owner administrative compensation allowable for the calendar
				year ending December 31, 2002.
Licensed Bed
								Range
Upper limit
51 - 100
86,951
101 - 150
95,641
151 - 250
129,878
251 - up
186,435
(3-17-22)
02.
The Administrative Compensation
				Schedule
. The administrative compensation schedule in this Section will
				be adjusted annually based upon the change in average hourly earnings in
				nursing and personal care facilities as published by Data Resources
				Incorporated, its successor organization or, if unavailable, another nationally
				recognized forecasting firm. (3-17-22)
03.
The Maximum Allowable
				Compensation
. The maximum allowable compensation for an owner providing
				administrative services is determined from the schedule in Subsection
				597.01. of these rules.
				Allowable compensation will be determined as follows: (3-17-22)
a. In determining the number of beds
				applicable on the schedule, all licensed beds for which the individual provides
				administrative services will be counted, regardless of whether they are in the
				same facility. (3-17-22)
b. For an
				owner providing services to more than fifty (50) beds, the amounts shown on the
				schedule for the applicable number of beds will determine the upper limit for
				allowable compensation. (3-17-22)
c. For owners providing services to less than
				fifty-one (51) beds, such services related to administrative duties will be
				reimbursed at the hourly rate allowable if the owner was providing services to
				fifty-one (51) beds. Additionally, services other than administrative services
				may be performed by the owner and will be allowable at the reasonable market
				rate for such services. To be allowable, hours for each type of service will be
				documented. In no event will the total compensation for administrative and
				non-administrative duties paid to an owner or related party to an owner of a
				facility or facilities with fifty (50) licensed beds or less exceed the limit
				that would be applicable to an owner with the same number of points providing
				administrative services to facilities with fifty-one (51) beds as set forth in
				the schedule of Subsection
				597.01 of these rules.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.598. - 599 - RESERVED

Current through August 31, 2023
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.600 - ICF/IID: OCCUPANCY ADJUSTMENT FACTOR

Current through August 31, 2023
In order to equitably allocate fixed costs to the Medicaid
				  patients in cases where a facility is not maintaining reasonable occupancy
				  levels, an adjustment will be made. No occupancy adjustment will be made
				  against the costs that are used to calculate the property rental rate; however
				  adjustment will be made against all other property costs. The adjustment will
				  be made as follows: (3-17-22)
01.
Occupancy Levels
. If a facility maintains an average occupancy of
				less than eighty percent (80%) of a facility's capacity, the total property
				costs not including cost paid under the property rental rate, will be prorated
				based upon an eighty percent (80%) occupancy rate. Property costs and property
				rental rates are defined in Section
				013 of these rules. The facility's
				average occupancy percentage will be subtracted from eighty percent (80%) and
				the resultant percentage will be taken times the total fixed costs to determine
				the nonallowable fixed costs. (3-17-22)
02.
Occupancy Adjustment
. For
				purposes of an occupancy adjustment, facility capacity will be computed based
				upon the greater of the largest number of beds for which the facility was
				licensed during the period being reported on or the largest number of beds for
				which the facility was licensed during calendar year 1981, except where a
				portion of the facility has been converted to use for nonroutine nursing home
				activities or the facility is newly constructed and has entered the Medicaid
				Program subsequent to January 1, 1982. If the facility's designed capacity has
				been changed, the number of beds used to determine occupancy will be lowered by
				the amount of capacity being converted to nonroutine nursing home activities.
				Facility capacity for a new facility will be based on the number of beds
				approved by the certificate of need process less any capacity converted to
				nonroutine nursing home activities. (3-17-22)
03.
Fixed Costs
. For purposes of
				an occupancy adjustment fixed costs will be considered all allowable and
				reimbursable costs reported under the property cost categories.
				(3-17-22)
04.
Change in
				Designed Capacity
. In cases where a provider changes the designed
				capacity of a facility, the average occupancy for the period prior to the
				change and subsequent to the change will be computed and each period will be
				adjusted separately. If the designed capacity is increased, the increased
				number of beds will not be subject to this adjustment for the first six (6)
				months following their licensure. (3-17-22)
05.
New Facility
. In the case of
				a new facility being licensed and occupied, the first six (6) months occupancy
				level will not be subject to this adjustment. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB-PART: CHILDREN'S DEVELOPMENTAL DISABILITIES (DD) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN OPTION › Section 16.03.10.601 - ICF/IID: RECAPTURE OF DEPRECIATION

Current through August 31, 2023
Where depreciable assets that were reimbursed based on cost
				  and were used in the Medicaid Program by a facility subsequent to January 1,
				  1982, and for which depreciation has been reimbursed by the Program, are sold
				  for an amount in excess of their net book value, depreciation so reimbursed
				  will be recaptured from the buyer of the facility in an amount equal to
				  reimbursed depreciation after January 1, 1982, or gain on the sale, whichever
				  is less. (3-17-22)
01.
Amount
				Recaptured
. Depreciation will be recaptured in full if a sale of a
				depreciated facility takes place within the first five (5) years of a seller's
				ownership. Credit will be given for the period of ownership prior to January 1,
				1982. For every year the asset is held beyond the first five (5) years, the
				total depreciation recaptured will be reduced by ten percent (10%) per year of
				the total depreciation taken. (3-17-22)
02.
Time Frame
. Depreciation
				will be recaptured by the Medicaid Program from the buyer of the facility over
				a period of time not to exceed five (5) years from the date of sale, with not
				less than one-fifth (1/5) of the total amount being recaptured for each year
				after such date. (3-17-22)