reglab/statecodes huggingface dataset:
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.550 - ENVIRONMENTAL SANITATION

Current through August 31, 2023
The hospital shall be responsible for the prevention of disease
				and the maintenance of sanitary conditions. (3-17-22)
01.
Water Supply
. The water
			 supply of a hospital shall meet the following requirements: (3-17-22)
a. An approved public or municipal water
			 supply shall be used whenever available; and (3-17-22)
b. In areas where an approved public or
			 municipal water supply is not available, a private water supply shall be
			 provided, and it shall meet the standards approved by the Department; and
			 (3-17-22)
c. Public or private
			 water supplies shall meet the Idaho Department of Environmental Quality Rules,
			 IDAPA 58.01.08, "Idaho Rules for Public Drinking Water Systems"; and
			 (3-17-22)
d. If water is from a
			 private supply, water samples shall be submitted to an approved laboratory for
			 bacteriological examination at least quarterly. Copies of the laboratory
			 reports shall be kept on file in the facility; and (3-17-22)
e. There shall be a sufficient amount of
			 water under adequate pressure to meet the sanitary requirements of the facility
			 at all times. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.14 - HOSPITALS › Section 16.03.14.600 - NEW CONSTRUCTION AND NEW HOSPITAL STANDARDS

Current through August 31, 2023
The standards set forth in this section together with the
				standards set out in the Section
				510 (entitled Fire and Life Safety
				Standards), shall apply to all new construction or new hospitals begun after
				the effective date of these rules (see Subsection
				002.26). These standards are
				intended to specify the minimum essential facilities that shall be included in
				a hospital. (3-17-22)
01.
Additions, Conversions, Remodelings, Etc
. Additions to existing
			 hospitals, conversions of existing buildings or portions thereof for use as a
			 hospital, and portions of a hospital undergoing remodeling, alteration,
			 addition or upgrading of a hospital or hospital building system that affects
			 the structural integrity of the building, that changes functional operation,
			 that affects fire safety or that adds beds, departments or services over those
			 for which the hospital is currently licensed (herein simply "remodeling or
			 remodels") shall be required to meet these standards. (3-17-22)
02.
General Requirements of
			 Constructions
. General requirements for construction of a hospital are
			 that: (3-17-22)
a. All new construction or new
			 hospitals (see Subsection
			 002.26) shall comply with any
			 and all state and local building, fire, electrical, plumbing, zoning, heating,
			 or other applicable codes adopted by the jurisdiction in which the hospital is
			 located and that are in effect when construction is begun. Where a conflict in
			 code requirements occurs, the most restrictive shall govern.
			 (3-17-22)
b. Minimum construction
			 standards shall be in accordance with the DHHS Publication No. (HRS-M-HF)84-1,
			 "Construction and Equipment of Hospitals and Medical Facilities" as are
			 applicable to a hospital and is incorporated herein by reference, available in
			 the licensing agency of the Department. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.17 - MEDICARE/MEDICAID COORDINATED PLAN BENEFITS › Section 16.03.17.000 - LEGAL AUTHORITY

Current through August 31, 2023
The Department is authorized to promulgate these rules under
				Sections 56-202(b),
				56-251(2)(c), and
				56-255(4), Idaho
				Code. (4-6-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.17 - MEDICARE/MEDICAID COORDINATED PLAN BENEFITS › Section 16.03.17.001 - SCOPE

Current through August 31, 2023
These rules cover the Medicaid benefit plan option that
				coordinates and integrates health plan benefits for individuals eligible for
				and enrolled in both Medicare and Medicaid, referred to as the
				Medicare/Medicaid Coordinated Plan (MMCP). (4-6-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.17 - MEDICARE/MEDICAID COORDINATED PLAN BENEFITS › Section 16.03.17.010 - DEFINITIONS

Current through August 31, 2023
01.
Department
. The Idaho
			 Department of Health and Welfare or designee. (4-6-23)
02.
Dual-Eligible
. Individuals
			 meeting eligibility requirements under Section
			 100 of these rules.
			 (4-6-23)
03.
Fully Integrated
			 Dual-Eligible Special Needs Plan (FIDE-SNP)
. A health plan fully
			 integrating care for dual-eligible participants under a single MAO.
			 (4-6-23)
04.
Idaho Medicaid
			 Plus (IMPlus)
. A health plan option for certain dual-eligible
			 participants where Medicaid covered services are provided under a managed care
			 organization, under IDAPA 16.03.10, "Medicaid Enhanced Plan Benefits," Sections
			 076 through
			 079. (4-6-23)
05.
Evidence of Coverage
. The
			 Medicare Advantage Plan contract between the MAO and the participant that
			 explains the covered services, including services under Medicare Parts A, B,
			 and D. (4-6-23)
06.
Medicare
			 Advantage Organizations (MAOs)
. Insurance companies approved by the
			 Centers for Medicare/Medicaid Services (CMS) to offer Medicare Advantage Plans.
			 (4-6-23)
07.
Medicare
			 Advantage Plan
. A private health plan approved by and contracted with
			 CMS to provide Medicare Parts A, B, and D benefits as described in its
			 "Evidence of Coverage." (4-6-23)
08.
Medicare/Medicaid Coordinated Plan
			 (MMCP)
. FIDE-SNP for certain dual-eligible participants integrating
			 Medicare and Medicaid covered services under one (1) managed care organization.
			 (4-6-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.17 - MEDICARE/MEDICAID COORDINATED PLAN BENEFITS › GENERAL PARTICIPANT PROVISIONS › Section 16.03.17.100 - MMCP: PARTICIPANT ELIGIBILITY

Current through August 31, 2023
To be eligible to select the MMCP, the participant must meet
				  the following criteria. (4-6-23)
01.
Medicare Eligibility
. Be eligible for and enrolled in both
				Medicare Parts A and B. (4-6-23)
02.
Medicaid Eligibility
. Be
				eligible for medical assistance under IDAPA 16.03.05, "Eligibility for Aid to
				the Aged, Blind, and Disabled (AABD)." Eligibility must not be based solely on
				IDAPA 16.03.05, "Eligibility for Aid to the Aged, Blind, and Disabled (AABD),"
				Section 802.
				(4-6-23)
03.
Age
. Be
				age twenty-one (21) or older. (4-6-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.17 - MEDICARE/MEDICAID COORDINATED PLAN BENEFITS › GENERAL PARTICIPANT PROVISIONS › Section 16.03.17.101 - MMCP: PARTICIPANT ENROLLMENT

Current through August 31, 2023
To receive services under the MMCP, participants must contact
				  a participating managed care organization and request to enroll in the MMCP.
				  Participation in the MMCP begins the month after the participant signs the
				  application for the Medicare Advantage Plan and MMCP. (4-6-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.17 - MEDICARE/MEDICAID COORDINATED PLAN BENEFITS › GENERAL PARTICIPANT PROVISIONS › Section 16.03.17.102 - MMCP: PARTICIPANT RESPONSIBILITIES

Current through August 31, 2023
Participants who select the MMCP are required to do the
				  following: (4-6-23)
01.
Compliance with MAO Requirements
. Comply with all requirements under the
				MAO's "Evidence of Coverage." (4-6-23)
02.
Provider Notification
.
				Present their: (4-6-23)
a. MAO-issued card
				when seeking Medicare-covered services. (4-6-23)
b. Medicaid card when seeking any
				Medicaid-covered services under Subsection
				300.01 of these rules.
				(4-6-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.17 - MEDICARE/MEDICAID COORDINATED PLAN BENEFITS › MAO CONTRACT REQUIREMENT › Section 16.03.17.200 - CONTRACT REQUIREMENT

Current through August 31, 2023
Any MAO seeking to offer MMCP services must operate a
				  FIDE-SNP as approved by CMS and contracted with the Department. (4-6-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.17 - MEDICARE/MEDICAID COORDINATED PLAN BENEFITS › MAO CONTRACT REQUIREMENT › Section 16.03.17.201 - MAO REIMBURSEMENT

Current through August 31, 2023
Each MAO is paid a per member per month rate as defined in
				  the MAO contract. (4-6-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.17 - MEDICARE/MEDICAID COORDINATED PLAN BENEFITS › COVERED SERVICES › Section 16.03.17.300 - MMCP: COVERAGE AND LIMITATIONS

Current through August 31, 2023
An MMCP is subject to applicable federal managed care
				  requirements. (4-6-23)
01.
MMCP-Covered Services
. Include: (4-6-23)
a. MAO-Covered Services. Under the "Evidence
				of Coverage," the MAO may limit or expand the scope of services as defined in
				the "Evidence of Coverage." MAO-covered services, including Medicare Parts A,
				B, and D benefits, are detailed in the MMCP contract. (4-6-23)
b. Medicaid-Only Services. Under IDAPA
				16.03.09, "Medicaid Basic Plan Benefits," or IDAPA 16.03.10, "Medicaid Enhanced
				Plan Benefits," provided by Medicaid providers that are not MAOs. Medicaid may
				cover additional services that are not included in the MAO's "Evidence of
				Coverage." (4-6-23)
c. Supplemental
				services unavailable on Medicare or Medicaid. (4-6-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.17 - MEDICARE/MEDICAID COORDINATED PLAN BENEFITS › COVERED SERVICES › Section 16.03.17.301 - MMCP BENEFITS: PROVIDER REIMBURSEMENT

Current through August 31, 2023
01.
Medicaid-Only Service Providers
. Providers who only offer Medicaid
				services must be approved for the MMCP before receiving reimbursement and are
				subject to the General Provider Provisions under IDAPA 16.03.09, "Medicaid
				Basic Plan Benefits." Approved providers are reimbursed under the methodology
				in IDAPA 16.03.10, "Medicaid Enhanced Plan Benefits," related to the
				Medicaid-only service. (4-6-23)
02.
Medicare Service Providers
. Medicare service providers are
				reimbursed under the methodologies established by the MAO and approved by CMS.
				MAOs are responsible for participant Medicare cost-sharing as described in the
				approved MMCP contract. (4-6-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.18 - MEDICAID COST-SHARING › Section 16.03.18.000 - LEGAL AUTHORITY

Current through August 31, 2023
Under Section
				56-202(b), Idaho
				Code, the Legislature has delegated to the Department of Health and Welfare the
				responsibility to establish and enforce such rules as may be necessary or
				proper to administer public assistance programs within the state of Idaho.
				Under Sections
				56-253 and
				56-257, Idaho Code, the Department
				of Health and Welfare is to establish enforceable cost-sharing requirements
				within the limits of federal Medicaid law and regulations. Furthermore, the
				Idaho Department of Health and Welfare is the designated agency to administer
				programs under Title XIX and Title XXI of the Social Security Act.
				(3-15-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.18 - MEDICAID COST-SHARING › Section 16.03.18.001 - TITLE AND SCOPE

Current through August 31, 2023
01.
Title
. These rules are titled IDAPA 16.03.18, "Medicaid Cost-Sharing."
			 (3-15-22)
02.
Scope
.
			 These rules describe the general requirements regarding the administration of
			 the cost sharing provisions for participation in a medical assistance program
			 providing direct benefits in Idaho. (3-15-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.18 - MEDICAID COST-SHARING › Section 16.03.18.002 - WRITTEN INTERPRETATIONS

Current through August 31, 2023
This agency may have written statements which pertain to the
				interpretation of the rules of this chapter. These documents are available for
				public inspection. (3-15-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.18 - MEDICAID COST-SHARING › Section 16.03.18.025 - PARTICIPANTS EXEMPT FROM COST-SHARING

Current through August 31, 2023
Native American and Alaskan Native participants are exempt from
				the cost-sharing provisions of Sections
				200,
				205,
				215,
				320, and
				400 of these rules. The participant
				must declare his race to the Department to receive this exemption. Participants
				in the Medicaid Workers with Disabilities (MWD) program are exempt from the
				cost-sharing provisions of Sections
				200,
				205,
				207, and
				400 of these rules.
				(3-15-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.18 - MEDICAID COST-SHARING › Section 16.03.18.050 - GENERAL COST-SHARING

Current through August 31, 2023
01.
Cost-Sharing Maximum Amount
. A family will be required to pay out of
			 pocket costs not to exceed five percent (5%) of the family's anticipated gross
			 monthly income unless an exception is made as provided in Subsection
			 050.02 of this rule.
			 (3-15-22)
02.
Exception to
			 Cost-Sharing Maximum
. A family will be required to pay cost-sharing
			 amounts as provided in Sections
			 215 and
			 400 of these rules. These
			 cost-sharing amounts may exceed the family's five percent (5%) of anticipated
			 gross monthly income. (3-15-22)
03.
Proof of Cost-Sharing Payment
. If a participant believes that
			 their cost-sharing exceeded the five percent (5%) cost-sharing of the family's
			 anticipated gross monthly income, they must provide proof to the Department of
			 the copay amounts that were paid. (3-15-22)
04.
Excess Cost-Sharing
. A
			 family that establishes proof of payment for cost-sharing that exceeds the five
			 percent (5%) of the family's anticipated gross monthly income will be
			 reimbursed by the Department for the amount paid that exceeds the five percent
			 (5%), except as provided in Subsection
			 050.02 of this rule.
			 (3-15-22)
05.
Cost-Sharing
			 Suspended
. A family that exceeds the five percent (5%) maximum amount
			 for cost sharing will not be required to pay a cost-sharing portion for any
			 family participant for the remainder of the calendar month in which proof of
			 payment is established. (3-15-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.18 - MEDICAID COST-SHARING › Section 16.03.18.200 - PREMIUMS FOR PARTICIPATION UNDER THE STATE CHILDREN'S HEALTH INSURANCE PROGRAM (SCHIP)

Current through August 31, 2023
01.
Family
			 Income Above 133% of FPG
. Each SCHIP participant with family income
			 above one hundred thirty-three percent (133%) and equal to or less than one
			 hundred fifty percent (150%) of the current FPG must pay a monthly premium of
			 ten dollars ($10) to the Department. (3-15-22)
02.
Family Income Above 150% of
			 FPG
. Each SCHIP participant with family income above one hundred fifty
			 percent (150%) and equal to or less than one hundred eighty-five percent (185%)
			 of the current FPG must pay a monthly premium of fifteen dollars ($15) to the
			 Department. (3-15-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.18 - MEDICAID COST-SHARING › Section 16.03.18.205 - PREMIUMS FOR PARTICIPATION UNDER HOME CARE FOR CERTAIN DISABLED CHILDREN (HCCDC)

Current through August 31, 2023
01.
Family
			 Income Above 150% and Equal to or Less Than 185% of FPG
. Each HCCDC
			 participant with a family income above one hundred fifty percent (150%) and
			 equal to or less than one hundred eighty-five percent (185%) of the current FPG
			 must pay a monthly premium of fifteen dollars ($15) to the Department. The
			 maximum monthly premium a family must pay is limited to thirty dollars ($30).
			 (3-15-22)
02.
Family Income
			 Above 185% of FPG
. Each HCCDC family with income above one hundred
			 eighty-five percent (185%) of the current FPG must pay a monthly premium to the
			 Department. The monthly premium is a fixed percent of the family's income as
			 provided in the table below. (3-15-22)
TABLE 205.02 SLIDING FEE
							 SCHEDULE FOR MONTHLY PREMIUMS FOR HCCDC PARTICIPATION
Family Income Above 185% of
							 Current FPG
Premium Based on % of Family
							 Income
ABOVE
LESS THAN OR EQUAL TO
185%
250%
1.0%
250%
300%
1.5%
300%
400%
2.0%
400%
500%
2.5%
500%
600%
3.0%
600%
700%
3.5%
700%
800%
4.0%
800%
900%
4.5%
900%
No Upper Limit
5.0%
(3-15-22)
03.
Reduction of Premium for Creditable
			 Health Insurance
. A family who purchases creditable health insurance for
			 the participant may receive a twenty-five percent (25%) reduction of the
			 required monthly premium. (3-15-22)
04.
Failure to Provide
			 Information
. Failure to provide the Department with information needed
			 to determine family income and household size may subject the participant to a
			 monthly premium equal to the average monthly cost of coverage for participants
			 receiving Medicaid Enhanced Plan Benefits through HCCDC. (3-15-22)
05.
Failure to Pay Premium
.
			 Failure to pay the premium for an HCCDC participant will not cause the
			 participant to lose coverage or eligibility for services. A participant
			 eligible through HCCDC is exempt from the provisions of Section
			 250 of these rules.
			 (3-15-22)
06.
Waiver of
			 Premium
. The premium may be waived if the Department determines that
			 payment of the premium would cause undue hardship on the family. Undue hardship
			 exists when an unexpected expense would cause the family to forgo basic food or
			 shelter in order to make a premium payment. Detailed documentation of the
			 family's living and insurance expenses demonstrating such hardship must be
			 provided to the Department. (3-15-22)
07.
Premium Recalculation
. The
			 premium amount is recalculated at each annual eligibility renewal. If a
			 financially responsible adult reports a reduction in family income prior to
			 renewal, the premium will be reduced to the appropriate level upon verification
			 of the reduction to the family's income. When the family income is at a level
			 that does not require premium payments, the premium will no longer be assessed.
			 (3-15-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.18 - MEDICAID COST-SHARING › Section 16.03.18.207 - PREMIUMS FOR PARTICIPATION UNDER THE YOUTH EMPOWERMENT SERVICES (YES) PROGRAM

Current through August 31, 2023
01.
Premium
			 Fee Schedule
. Each YES program participant, as that individual is
			 defined in IDAPA 16.03.10, "Medicaid Enhanced Plan Benefits," Section
			 636, is subject to assessment of a
			 premium based on family income. The Department will establish a premium fee
			 schedule at rates not to exceed maximums set forth in federal law and
			 regulations governing state Medicaid programs. The fee schedule will be
			 published on the Department's website and provided to families participating in
			 the YES program who are subject to premiums. (3-15-22)
02.
Enforcement of Premiums
.
			 Payment of premiums will be enforced within the limitations of federal laws and
			 regulations governing state Medicaid programs. (3-15-22)
03.
Waiver of Premium
. The
			 monthly premium described in Subsection
			 207.01 of this rule may be
			 waived if the Department determines that the family is unable to participate in
			 the cost of care. (3-15-22)
04.
Premium Recalculation
. The premium amount is recalculated at each
			 annual eligibility redetermination. If a financially responsible adult reports
			 a reduction in family income prior to eligibility redetermination, the premium
			 will be reduced to the appropriate level upon verification of the reduction in
			 the family's income. When the family income is reduced to a level that does not
			 require premium payments, the premium will no longer be assessed.
			 (3-15-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.18 - MEDICAID COST-SHARING › Section 16.03.18.210 - DEPARTMENT RESPONSIBILITIES

Current through August 31, 2023
01.
Assessed
			 Premiums
. A participant will not be assessed premiums during the time
			 initial eligibility is determined. Obligation for premium payments does not
			 begin for at least sixty (60) days after receipt of application, except for
			 workers with disabilities under Section
			 215 of these rules.
			 (3-15-22)
02.
Premiums Not
			 Assessed Due to Late Review
. A participant can not be assessed premiums
			 for extra months of eligibility received due solely to the Department's late
			 review of continuing eligibility, except for workers with disabilities under
			 Section 215 of these
			 rules. (3-15-22)
03.
No
			 Retroactive Premiums Assessed
. A participant can not be assessed
			 premiums for months of retroactive eligibility. (3-15-22)
04.
Notification of Premiums
.
			 The Department is required to routinely notify a participant of their premium
			 payment obligations including any delinquencies, if applicable.
			 (3-15-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.18 - MEDICAID COST-SHARING › Section 16.03.18.215 - PREMIUMS FOR PARTICIPATION IN MEDICAID ENHANCED PLAN

Current through August 31, 2023
01.
Workers with Disabilities
. A
			 participant in the Medicaid for Workers with Disabilities coverage group must
			 share in the cost of Medicaid coverage, if required. Countable income is
			 determined under IDAPA 16.03.05, "Eligibility for Aid to the Aged, Blind, and
			 Disabled (AABD)." A participant's premium for his share of Medicaid costs under
			 this coverage group is determined in Subsections
			 215.01.a. through 215.01.c. of
			 this rule. (3-15-22)
a. A participant who has
			 countable income at or below one hundred thirty-three percent (133%) of the
			 current federal poverty guideline is not required to pay a premium for
			 Medicaid. (3-15-22)
b. A
			 participant who has countable income above one hundred thirty-three percent
			 (133%) to two hundred fifty percent (250%) of the current federal poverty
			 guideline is required to pay a monthly premium of ten dollars ($10) to the
			 Department. (3-15-22)
c. A
			 participant who has countable income in excess of two hundred fifty percent
			 (250%) of the current federal poverty guideline is required to pay a monthly
			 premium to the Department. The amount due is the greater of ten dollars ($10);
			 or seven and one-half percent (7.5%) of the participant's income above two
			 hundred fifty percent (250%) of the current federal poverty guideline.
			 (3-15-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.18 - MEDICAID COST-SHARING › Section 16.03.18.250 - DELINQUENT PREMIUM PAYMENTS

Current through August 31, 2023
If the participant is sixty (60) days or more past due on its
				premium payments, the participant is contacted to determine the reason for the
				delinquency. If the participant's countable income is less than the amount used
				for the most recent eligibility determination, the participant is offered a new
				eligibility determination. If a participant's family income is at a level that
				does not require premium payments, the premium will no longer be assessed. The
				change is effective the month after the participant becomes eligible for such
				benefits. The following Subsections
				250.01 through
				250.03 of this rule apply to
				delinquent premium payments. (3-15-22)
01.
Delinquent Payments
. A
			 participant must not be approved for or renewed for coverage that requires
			 premium payments, if their premium payments are sixty (60) days or more
			 delinquent as of the last working day of their twelve (12) month eligibility
			 period. (3-15-22)
02.
Reestablishing Eligibility
. A participant can reestablish eligibility by
			 paying the premium debt in full, unless one (1) of the conditions listed in
			 Subsection 250.03 applies.
			 (3-15-22)
03.
Premium
			 Debt
. Any premium debt assessed, but not paid, will be forgiven if one
			 (1) of the following applies: (3-15-22)
a. The
			 participant reports and the Department determines that the participant's family
			 income is below one hundred and thirty-three percent (133%) FPG. This may occur
			 at any time during the eligibility period; or (3-15-22)
b. A participant in the Medicaid Basic Plan
			 has a medical condition that requires the participant to receive the benefits
			 provided in IDAPA 16.03.10 "Medicaid Enhanced Plan Benefits."
			 (3-15-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.18 - MEDICAID COST-SHARING › Section 16.03.18.300 - PARTICIPANTS EXEMPT FROM COPAYMENT

Current through August 31, 2023
01.
Exempt
			 Participants
. Certain participants are exempt from copayments for
			 services described in Section
			 320.03 through
			 320.10 of these rules. Exempt
			 participants include: (3-15-22)
a. A child
			 under the age of nineteen (19) with family income less than or equal to one
			 hundred and thirty-three percent (133%) of the current federal poverty
			 guidelines (FPG); (3-15-22)
b. An
			 individual age of nineteen (19) or older with family income less than or equal
			 to one hundred percent (100%) of the current federal poverty guidelines (FPG);
			 (3-15-22)
c. A pregnant or
			 post-partum woman when the services provided are related to the pregnancy;
			 (3-15-22)
d. An inpatient in a
			 hospital, nursing facility, intermediate care facility for persons with
			 intellectual disabilities (ICF/IID), or other medical institution, who is
			 required to pay all but a nominal amount of their income to the institution for
			 their care; (3-15-22)
e. An adult
			 participant who receives services provided under a waiver of Section
			 1915c of the Social Security Act
			 (SSA); (3-15-22)
f. A participant
			 who has other health care coverage that is the primary payor for the services
			 provided; (3-15-22)
g. A
			 participant receiving hospice care; (3-15-22)
h. A child in foster care receiving aid or
			 assistance under the Social Security Act (SSA), Title IV, Part B;
			 (3-15-22)
i. A participant
			 receiving adoption or foster care assistance under the Social Security Act
			 (SSA), Title IV, Part E, regardless of age; and (3-15-22)
j. A woman eligible under the breast and
			 cervical cancer eligibility group. (3-15-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.18 - MEDICAID COST-SHARING › Section 16.03.18.310 - COPAYMENT FEE AMOUNTS

Current through August 31, 2023
01.
Nominal
			 Amount
. The amount of the copayment must be a nominal amount as provided
			 in 42 CFR
			 447.54. This nominal amount is set by the
			 U.S. Department of Health and Human Services. (3-15-22)
02.
Fee Amount
. Beginning on
			 November 1, 2011, the nominal fee amount required to be paid by the participant
			 as a copayment is three dollars and sixty-five cents ($3.65). This copayment
			 amount will be adjusted annually as determined by the Secretary of Human
			 Services. (3-15-22)
03.
Annual Increase
. The nominal fee amount will be increased annually
			 by an adjusted percentage rate determined by the Secretary of Health and Human
			 Services as set in the Social Security Act Section
			 1916. (3-15-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.18 - MEDICAID COST-SHARING › Section 16.03.18.320 - MEDICAID OUTPATIENT SERVICES SUBJECT TO COPAYMENTS

Current through August 31, 2023
Medicaid participants are responsible for making copayments for
				the outpatient services described in Subsections
				320.01 through
				320.10 of this rule, unless
				exempted. The amount of the copayment is provided in Section
				310 of these rules.
				(3-15-22)
01.
Accessing
			 Hospital Emergency Department for Non-Emergency Medical Conditions
. A
			 participant who seeks care at a hospital emergency department for services that
			 do not meet the definition of an emergency medical condition as defined in
			 IDAPA 16.03.09, "Medicaid Basic Plan Benefits," may be required to pay a
			 copayment to the provider. A participant who must access a hospital emergency
			 department in order to receive routine services for their medical condition is
			 exempt from this provision. (3-15-22)
02.
Accessing Emergency Transportation
			 Services for Non-Emergency Medical Conditions
. A participant who
			 accesses emergency transportation services for a condition that is determined
			 by the Department to be a non-emergency medical condition may be required to
			 pay a copayment to the provider of the service. (3-15-22)
03.
Chiropractic Services
. Those
			 services for spinal manipulation performed by a chiropractor.
			 (3-15-22)
04.
Occupational
			 Therapy
. (3-15-22)
05.
Optometric Services
. Those services performed by a optometrist
			 that fall into the "General Ophthalmological Services" category of Current
			 Procedural Terminology (CPT). (3-15-22)
06.
Outpatient Hospital
			 Services
. Any of the services included in Subsections
			 320.03 through
			 320.05 and Subsections
			 320.07 through
			 320.10 of this rule performed in
			 an outpatient hospital setting. Services performed in a Hospital Emergency
			 Department are excluded, except as provided for in Subsection
			 320.01 of this rule.
			 (3-15-22)
07.
Physical
			 Therapy
. (3-15-22)
08.
Podiatry Services
. Services provided by a podiatrist during an
			 office visit. (3-15-22)
09.
Physician Office Visit
. Each physician office visit, unless: (3-15-22)
a. The visit is for a preventive wellness
			 exam, immunizations, or family planning: (3-15-22)
b. The visit is for urgent care provided at a
			 clinic billing as an urgent care facility. (3-15-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.18 - MEDICAID COST-SHARING › Section 16.03.18.325 - EXCEPTION TO CHARGING A COPAYMENT

Current through August 31, 2023
In order for a copay to be charged by the provider, the
				Medicaid payment amount for the services rendered during a visit must be equal
				to or greater than ten (10) times the amount of the copay described in Section
				310 of these rules. The Medicaid
				payment amount is determined by the Department and published in the Medicaid
				Fee Schedule. (3-15-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.18 - MEDICAID COST-SHARING › Section 16.03.18.330 - COLLECTION OF COPAYMENTS

Current through August 31, 2023
01.
Responsibility for Collection
. The provider of services is responsible
			 for collection of the copayment from the participant. (3-15-22)
02.
Denial of Services
. The
			 provider may require payment of an applicable copay prior to rendering
			 services. (3-15-22)
03.
Waiver of Copayment
. The provider may choose to waive payment of any
			 copay. The provider must have a written policy describing the criteria for
			 enforcing collection of copayments and when the copay may be waived.
			 (3-15-22)
04.
Reduction in
			 Reimbursement
.When a copay is applicable, the provider's reimbursement
			 will be reduced by the amount of the copay regardless of whether or not a copay
			 was charged or collected by the provider. (3-15-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.19 - CERTIFIED FAMILY HOMES › Section 16.03.19.000 - LEGAL AUTHORITY

Current through August 31, 2023
Sections
				56-1005 and
				39-3505, Idaho Code, authorize the
				Idaho Board of Health and Welfare to adopt and enforce rules and standards for
				Certified Family Homes. Sections
				56-264 and
				56-1007, Idaho Code, authorize the
				Department to adopt and develop application and certification criteria, and to
				charge and collect application and certification fees. Under Sections
				56-1002,
				56-1003,
				56-1004,
				56-1004A,
				56-1005, and
				56-1009, Idaho Code, the
				Department and the Board of Health and Welfare have prescribed powers and
				duties to provide for the administration and enforcement of Department programs
				and rules. (3-28-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.19 - CERTIFIED FAMILY HOMES › Section 16.03.19.001 - SCOPE AND EXCEPTIONS

Current through August 31, 2023
01.
Scope
. These rules set the administrative requirements for care
			 providers who are paid to care for an adult living in the care provider's home,
			 when the adult is elderly or has a developmental disability, mental illness, or
			 physical disability, and needs personal assistance. (3-28-23)
02.
Exceptions
. These rules do
			 not apply to the following: (3-28-23)
a.
			 Individuals who provide only housing, meals, transportation, housekeeping, or
			 recreational and social activities. (3-28-23)
b. Health facilities defined by Title
			 39, Chapter 13, Idaho Code.
			 (3-28-23)
c. Residential assisted
			 living facilities defined by Title 39, Chapter 33, Idaho Code.
			 (3-28-23)
d. Any arrangement for
			 care in a relative's home that is not compensated through a publicly funded
			 program. (3-28-23)
e. Homes
			 approved by the Department of Veterans Affairs as a "medical foster home"
			 described in 38 CFR Part 17 and Sections
			 39-3502 and 39-
			 3512, Idaho Code. Care providers
			 who provide care to both veterans and non-veterans living in a "medical foster
			 home" are not exempt from these rules. (3-28-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.19 - CERTIFIED FAMILY HOMES › Section 16.03.19.002 - INCORPORATION BY REFERENCE

Current through August 31, 2023
The Americans with Disabilities Act Accessibility Guidelines,
				28 CFR Part 36 - 2010 ADA Standards for Accessible Design, is incorporated by
				reference. The website is
http://www.ada.gov/2010ADAstandards_index.htm
.
				(3-28-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.19 - CERTIFIED FAMILY HOMES › Section 16.03.19.009 - CRIMINAL HISTORY AND BACKGROUND CHECK REQUIREMENTS

Current through August 31, 2023
01.
Background Check Clearance
.
			 The provider, staff, substitute caregivers, and all adults living in the home,
			 except for residents, are required to complete a background check and receive a
			 clearance affiliated with the certified family home program (i.e., Agency ID
			 1104) under IDAPA 16.05.06, "Criminal History and Background Checks.".
			 (3-28-23)
02.
When
			 Certification Can Be Granted
. Prior to certification, all adults living
			 in the home, except for residents, must complete the background check and
			 receive a clearance. (3-28-23)
03.
New Adults in the Home After Certification
. An adult who plans to
			 live in the home must, prior to moving, complete a self-declaration form, be
			 fingerprinted, and not have any designated crimes under IDAPA 16.05.06,
			 "Criminal History and Background Checks." (3-28-23)
04.
Visitors
. No unsupervised
			 contact with residents unless the visitor first clears a background check.
			 (3-28-23)
05.
Minor Child
			 Turning Eighteen
. A minor child turning eighteen (18) and living in the
			 home must complete a self-declaration form, be fingerprinted, and not have any
			 designated crimes under IDAPA 16.05.06, "Criminal History and Background
			 Checks," within thirty (30) days following the month of their eighteenth
			 birthday. (3-28-23)
06.
Substitute Caregivers and Staff
. Any staff or substitute caregiver must
			 complete a self-declaration form, be fingerprinted, and not have any designated
			 crimes under IDAPA 16.05.06, "Criminal History and Background Checks," prior to
			 any unsupervised contact with the resident. (3-28-23)
07.
Renewal of Clearance
. The
			 Department can require a new background check at any time. Renewed clearance
			 from the Department must also be obtained as follows: (3-28-23)
a. Every five (5) years through the first
			 fifteen (15) consecutive years, except as noted below, then every ten (10)
			 years; (3-28-23)
b. For adults
			 continuously affiliated (i.e., holding the certificate, living in, or providing
			 substitute care) for at least five (5) years with an existing CFH in operation
			 on or before July 1, 2015, who renewed their clearance after July 1, 2020, a
			 second renewal is needed during the fifth year after the previous clearance,
			 then every ten (10) years; or (3-28-23)
c. For adults continuously affiliated for at
			 least fifteen (15) years with an existing CFH in operation on or before July 1,
			 2005, who received clearance after July 1, 2020, a renewed clearance is needed
			 every ten (10) years. (3-28-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.19 - CERTIFIED FAMILY HOMES › Section 16.03.19.100 - CERTIFICATION REQUIREMENTS

Current through August 31, 2023
An individual is required to obtain certification to operate a
				CFH under Section
				39-3512, Idaho Code.
				(3-28-23)
01.
Certification
			 Limitations
. The Department cannot certify or maintain the certification
			 of any individual who: (3-28-23)
a. Charges
			 room or board to any person who is not a resident, full-time staff, or a
			 relative under these rules. A variance may be granted by the Department under
			 Section 39-3505(3), Idaho
			 Code. (3-28-23)
b. Holds a current
			 license for a children's foster home, unless a variance is granted by the
			 Department under Section
			 39-3505(4), Idaho
			 Code. (3-28-23)
c. Is appointed, is
			 a relative of, or resides in the home with the legal guardian of the resident,
			 except if any of the aforementioned is a relative of the resident. A variance
			 may be granted by the Department when it is determined the guardianship is in
			 the best interest of the resident. (3-28-23)
d. Is absent from the CFH for more than
			 thirty (30) consecutive days when the home has an admitted resident.
			 (3-28-23)
e. Has a primary
			 residence somewhere other than the CFH. (3-28-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.19 - CERTIFIED FAMILY HOMES › Section 16.03.19.101 - APPLICATION FOR CERTIFICATION

Current through August 31, 2023
The applicant must apply for certification on Department forms
				and submit the following to the Department: (3-28-23)
01.
Completed Application Signed by
			 Applicant
. (3-28-23)
02.
Statement to Comply
. A written statement that the applicant has
			 thoroughly read and reviewed all CFH requirements, and is prepared to comply.
			 (3-28-23)
03.
Statement
			 Disclosing Revocation or Disciplinary Actions
. A written statement
			 disclosing any past, current, or pending revocation, or other disciplinary
			 action, against the applicant as a care provider in any jurisdiction.
			 (3-28-23)
04.
Electrical
			 Inspection
. A written statement from a licensed electrician or the
			 local/state electrical inspector within the past twelve (12) months indicating
			 that all electrical installations in the home comply with applicable local code
			 and are in good working order. (3-28-23)
05.
Plumbing Inspection
. A
			 written statement from a licensed plumber within the last twelve (12) months
			 that the water supply and sewage disposal system in the home are in good
			 working order. (3-28-23)
06.
Heating and Air Conditioning Inspection
. A written statement within the
			 last twelve (12) months by a person licensed to service heating and cooling
			 systems that these systems in the applicant's home are in good operating
			 condition. (3-28-23)
07.
Proof of Insurance
. Proof of homeowner's or renter's insurance on the
			 applicant's home. For continued certification, the provider must ensure that
			 insurance is kept current. (3-28-23)
08.
List of Individuals Living in the
			 Home
. A list of all individuals living in the home at the time of
			 application and their relationship to the applicant. (3-28-23)
09.
Other Information as
			 Requested
. Other information that may be requested by the Department for
			 the proper administration and enforcement of the CFH requirements.
			 (3-28-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.19 - CERTIFIED FAMILY HOMES › Section 16.03.19.102 - TERMINATION OF APPLICATION

Current through August 31, 2023
01.
Failure
			 to Cooperate
. Failure of the applicant to cooperate with the Department
			 in the application process will result in the termination of the application.
			 Failure to cooperate means the applicant does not submit in the form requested
			 or within a reasonable timeframe as determined by the Department: (3-28-23)
a. Information under Section
			 101 of these rules; or
			 (3-28-23)
b. Payment of the
			 application fee under Section
			 109 of these rules.
			 (3-28-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.19 - CERTIFIED FAMILY HOMES › Section 16.03.19.109 - APPLICATION AND CERTIFICATION FEES

Current through August 31, 2023
01.
Application Fee
. An applicant is required to pay the Department a
			 non-refundable application fee of one hundred fifty ($150) dollars for each of
			 the following: (3-28-23)
a. As part of the
			 initial application to become a CFH care provider; (3-28-23)
b. As part of any reapplication after the
			 initial application is terminated, withdrawn, or the CFH closed; or
			 (3-28-23)
c. When the home will be
			 operated by a new care provider. (3-28-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.19 - CERTIFIED FAMILY HOMES › Section 16.03.19.110 - ISSUANCE OF CERTIFICATE

Current through August 31, 2023
The Department will issue a certificate when certification
				requirements are met. Each certificate must be available at the home upon
				request. (3-28-23)
01.
Full
			 Certificate
. The Department will issue a full certificate upon a finding
			 that the CFH is compliant with CFH requirements. A full certificate is
			 effective for no more than twelve (12) months from the issue date.
			 (3-28-23)
02.
Temporary
			 Certificate
. The Department may issue a temporary certificate to allow
			 time for the provider to meet all certification requirements without a lapse in
			 certification when the provider plans to relocate to a residence within the
			 state and continue operation of a CFH. A temporary certificate is effective for
			 no more than sixty (60) days from the issue date. (3-28-23)
a. At least thirty (30) days prior to moving
			 into a new residence, the provider must notify the certifying agent for the
			 region in which the new home will be located. Prior to moving into the new
			 residence, the provider must submit to the certifying agent the following:
			 (3-28-23)
i. A completed application form
			 under Section 101 of these
			 rules; (3-28-23)
ii. Copies of all
			 inspection reports for the new residence under Section
			 101 of these rules; and
			 (3-28-23)
iii. Other information
			 requested by the Department to ensure the new residence is appropriate for use
			 as a CFH and safe for occupation. (3-28-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.19 - CERTIFIED FAMILY HOMES › Section 16.03.19.111 - RENEWAL OF CERTIFICATE

Current through August 31, 2023
01.
Home
			 Inspection
. A home inspection by a certifying agent is required the year
			 after the initial certification study and at least every twenty-four (24)
			 months thereafter. The home inspection will consist of the elements of the
			 certification study under Section
			 100 of these rules.
			 (3-28-23)
02.
Desk
			 Review
. When the Department determines a home inspection is not required
			 to renew the certificate, the Department may conduct a desk review by written
			 notification to the provider. The provider must submit copies of the following
			 documentation to the certifying agent at least thirty (30) days prior to the
			 expiration of the certificate: (3-28-23)
a.
			 Current first aid and adult CPR certifications; (3-28-23)
b. Private well water testing report, as
			 applicable; (3-28-23)
c. Updated
			 septic system inspection or pumping report, as applicable, when the previous
			 inspection is older than five (5) years; (3-28-23)
d. Annual fire extinguisher inspection
			 reports, or sales receipts for fire extinguishers that comply with Section
			 600 of these rules that are less
			 than twelve (12) months old; (3-28-23)
e. Logs of smoke and carbon monoxide detector
			 tests and battery replacement, fire extinguisher examinations, and emergency
			 plan reviews; (3-28-23)
f.
			 Emergency drill summaries or recordings; (3-28-23)
g. Training logs; (3-28-23)
h. Proof of current homeowner's or renter's
			 insurance; (3-28-23)
i. Requests
			 for renewed exceptions that meet the requirements in Sections
			 120 through
			 140 of these rules as applicable;
			 and (3-28-23)
j. Other information
			 as requested by the Department. (3-28-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.19 - CERTIFIED FAMILY HOMES › Section 16.03.19.112 - DENIAL OF APPLICATION FOR CERTIFICATE

Current through August 31, 2023
01.
Causes For Denial
. Causes for denial of an application for issuance of a
			 certificate, besides those under Section
			 39-3523, Idaho Code, include the
			 following: (3-28-23)
a. The applicant or
			 provider has willfully misrepresented or omitted information on the application
			 or other submitted documents; (3-28-23)
b. A required background check results in an
			 Unconditional Denial; (3-28-23)
c.
			 The applicant or provider has been denied or has had revoked any child care
			 (including foster home) or health facility license, residential assisted living
			 facility license, or CFH certificate; (3-28-23)
d. The applicant or provider has been found
			 to have operated a health facility, residential assisted living facility, or
			 CFH without a license or certificate; (3-28-23)
e. A court has ordered that the applicant or
			 provider must not operate a health facility, residential assisted living
			 facility, or CFH; (3-28-23)
f. The
			 applicant or provider is directly under the control or influence of any person
			 who is described in Subsection
			 112.01 of this rule.
			 (3-28-23)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.19 - CERTIFIED FAMILY HOMES › Section 16.03.19.113 - OPERATING WITHOUT A CERTIFICATE

Current through August 31, 2023
01.
Operating Without Certificate
. A person found to be operating as a CFH
			 as described under Section
			 39-3512, Idaho Code, without first
			 obtaining a certificate may be referred for criminal prosecution under Section
			 39-3528, Idaho Code.
			 (3-28-23)
02.
Placement or
			 Transfer of Resident
. Upon discovery of such a person described in
			 Subsection 113.01 of this rule, the
			 Department may transfer residents to the appropriate placements when: (3-28-23)
a. There is an immediate threat to any
			 resident's health and safety; or (3-28-23)
b. The individual operating the home does not
			 cooperate with the Department to apply for certification, meet certification
			 standards, and obtain a valid certificate. (3-28-23)