California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51343.2 - Intermediate Care Facility Services for the Developmentally Disabled-Nursing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Intermediate
					 care facility services for the developmentally disabled-nursing (ICF/DD-N) are
					 covered subject to prior authorization by the Department for the ICF/DD-N level
					 of care. Authorizations may be granted for up to six months. Requests for prior
					 authorization of admission to an ICF/DD-N or for continuation of services shall
					 be initiated by the facility on Certification for Special Treatment Program
					 Services forms (HS 231). Certification documentation required by the Department
					 of Developmental Services shall be completed by regional center personnel and
					 submitted with the Treatment Authorization Request form. The attending
					 physician shall sign the Treatment Authorization Request form and shall certify
					 to the Department that the beneficiary requires this level of care.
(b) The request for reauthorization shall be
					 received by the appropriate Medi-Cal consultant on or before the first working
					 day following expiration of a current authorization. Certification shall be
					 redetermined and a new certification form shall be completed by regional center
					 personnel and shall be attached to the request for authorization. One day of
					 authorization shall be denied for each day the reauthorization request is
					 late.
(c) The Medi-Cal consultant
					 shall deny any authorization request or reauthorization request, or shall
					 cancel any authorization in effect when services or placement are not
					 appropriate to the health and developmental needs of the beneficiary. When the
					 reauthorization request is denied, or an existing authorization is cancelled,
					 the facility shall be notified by the most expeditious means and a timely
					 notice of action shall be sent to the beneficiary in accordance with Title 22,
					 California Code of Regulations, Section
					 51014.1.
(d) Prior to the transfer of a beneficiary
					 between facilities, the receiving facility shall originate an initial Treatment
					 Authorization Request signed by the attending physician. This Treatment
					 Authorization Request shall be approved by a Department Medi-Cal consultant
					 prior to admission except in cases of emergency as specified in Section
					 51056, Title 22, California Code
					 of Regulations.
(e) The
					 beneficiary's medical condition shall be determined on an individual basis by
					 the Department's Medi-Cal consultant. However, in determining the need for
					 ICF/DD-N services the following conditions shall be met:
(1) A regional center has diagnosed the
					 beneficiary as being developmentally disabled, or has determined that the
					 beneficiary demonstrates significant developmental delay that may lead to a
					 developmental disability if not treated.
(2) The beneficiary's medical condition is
					 such that 24-hour nursing supervision, in accordance with Title 22, California
					 Code of Regulations, Section
					 73839(a) personal
					 care, and developmental services are required. The stability of the
					 beneficiary's medical condition and frequency of required skilled nursing
					 services shall be the determining factors in evaluating whether beneficiaries
					 are appropriate for ICF/DD-N placements.
(3) Each beneficiary shall have a physician's
					 certification that continuous skilled nursing care is not required and that the
					 beneficiary's medical condition is stable. Beneficiaries convalescing from
					 surgical procedures shall be stable enough that only intermittent nursing care
					 is needed.
(4) The beneficiary
					 needs a level of developmental, training and habilitative program services and
					 recurring but intermittent skilled nursing services which are not available
					 through other small (4-15 bed) community-based health facilities.
(5) The beneficiary's condition is such that
					 there is a need for the provision of active treatment services as described at
					 Section 73801, thereby leading to a higher
					 level of beneficiary functioning and a lessening dependence on others in
					 carrying out daily living activities or in the prevention of regression or in
					 ameliorating developmental delay.
(6) The beneficiary shall have two or more
					 developmental deficits as measured on the Client Developmental Evaluation
					 Report prescribed by the Department of Developmental Services in any one or
					 combination of the following three domains:
(A) Self-help domain:
1. Eating
2. Toileting
3. Bladder control
4. Dressing
(B) Motor domain:
1. Ambulation
2. Crawling and standing
3. Wheelchair mobility
4. Rolling and sitting
(C) Social emotional domain:
1. Aggression--has had one or more violent
					 episodes causing minor physical injury within the past year or has resorted to
					 verbal abuse and threats but has not caused physical injury within the past
					 year.
2. Self-injurious
					 behavior--behavior exists but results only in minor injuries which require
					 first aid.
3. Smearing
					 feces--smears once a week or more but less than once a day.
4. Destruction of property.
5. Running or wandering away.
6. Temper tantrums, or emotional
					 outburst.
7. Unacceptable social
					 behavior--positive social participation is impossible unless closely supervised
					 or redirected.