reglab/statecodes huggingface dataset:
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › INVESTIGATIONS, AUDITS, AND ENFORCEMENT › SUB AREA: LIENS AND ESTATE RECOVERY › Section 16.03.09.900 - LIENS AND ESTATE RECOVERY

Current through August 31, 2023
In accordance with Sections
					 55-819,
					 56-218,
					 56-218A, and
					 56-225, Idaho Code, this Section
					 of rule sets forth the provisions for recovery of medical assistance, the
					 filing of liens against the property of deceased persons, the filing of liens
					 against the property of permanently institutionalized participants, and the
					 recording of requests for notice. (3-17-22)
01.
Medical Assistance Incorrectly
				  Paid
. The Department may, in accordance with a judgment of a court, file
				  a lien against the property of a living or deceased person of any age to
				  recover the costs of medical assistance incorrectly paid. (3-17-22)
02.
Administrative Appeals
.
				  Permanent institutionalization determination, undue hardship waiver, and
				  request for notice hearings are governed by the fair hearing provisions of
				  IDAPA 16.05.03, "Contested Case Proceedings and Declaratory Rulings."
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › INVESTIGATIONS, AUDITS, AND ENFORCEMENT › SUB AREA: LIENS AND ESTATE RECOVERY › Section 16.03.09.902 - LIENS AND ESTATE RECOVERY - NOTIFICATION TO DEPARTMENT

Current through August 31, 2023
All notification regarding liens, estate claims, and
					 requests for notice must be directed to the Department of Health and Welfare,
					 Estate Recovery Unit, 450 W. State Street, 6th Floor, Boise, Idaho 83702.
					 (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › INVESTIGATIONS, AUDITS, AND ENFORCEMENT › SUB AREA: LIENS AND ESTATE RECOVERY › Section 16.03.09.903 - LIENS AND ESTATE RECOVERY: LIEN DURING LIFETIME OF PARTICIPANT

Current through August 31, 2023
01.
Lien Imposed During Lifetime of
				  Participant
. During the lifetime of the permanently institutionalized
				  participant, and subject to the restrictions set forth in Subsection
				  903.04 of this rule, the
				  Department may impose a lien against the real property of the participant for
				  medical assistance correctly paid on their behalf. The lien must be filed
				  within ninety (90) days of the Department's final determination, after notice
				  and opportunity for a hearing, that the participant is permanently
				  institutionalized. The lien is effective from the beginning of the most recent
				  continuous period of the participant's institutionalization, but not before
				  July 1, 1995. Any lien imposed will dissolve upon the participant's discharge
				  from the medical institution and return home. (3-17-22)
02.
Determination of Permanent
				  Institutionalization
. The Department must determine that the participant
				  is permanently institutionalized prior to the lien being imposed. An
				  expectation or plan that the participant will return home with the support of
				  Home and Community Based Services does not, in and of itself, justify a
				  decision that they are reasonably expected to be discharged to return home. The
				  following factors must be considered when making the determination of permanent
				  institutionalization: (3-17-22)
a. The
				  participant must meet the criteria for nursing facility or ICF/IID level of
				  care and services as set forth in IDAPA 16.03.10, "Medicaid Enhanced Plan
				  Benefits," Sections 220 through
				  299, and
				  580 through
				  649; (3-17-22)
b. The medical records must be reviewed to
				  determine if the participant's condition is expected to improve to the extent
				  that they will not require nursing facility or ICF/IID level of care; and
				  (3-17-22)
c. Where the prognosis
				  indicated in the medical records is uncertain or inconclusive, the Department
				  may request additional medical information, or may delay the determination
				  until the next utilization control review or annual Inspection of Care review,
				  as appropriate. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › INVESTIGATIONS, AUDITS, AND ENFORCEMENT › SUB AREA: LIENS AND ESTATE RECOVERY › Section 16.03.09.904 - LIENS AND ESTATE RECOVERY: REQUIREMENTS FOR ESTATE RECOVERY

Current through August 31, 2023
01.
Estate Recovery
				  Requirements
. In accordance Sections
				  56-218 and
				  56-218 A, Idaho Code, the
				  Department is required to recover the following: (3-17-22)
a. The costs of all medical assistance
				  correctly paid on or after July 1, 1995, on behalf of a participant who was
				  permanently institutionalized; (3-17-22)
b. The costs of medical assistance correctly
				  paid on behalf of a participant who received medical assistance at age
				  fifty-five (55) or older on or after July 1, 1994; and (3-17-22)
c. The costs of medical assistance correctly
				  paid on behalf of a participant who received medical assistance at age
				  sixty-five (65) or older on or after July 1, 1988.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › INVESTIGATIONS, AUDITS, AND ENFORCEMENT › SUB AREA: LIENS AND ESTATE RECOVERY › Section 16.03.09.905 - LIENS AND ESTATE RECOVERY: LIMITATIONS AND EXCLUSIONS

Current through August 31, 2023
01.
Limitations on Estate
				  Claims
. Limits on the Department's claim against the assets of a
				  deceased participant or spouse are subject to Sections
				  56-218 and
				  56-218A, Idaho Code. A claim
				  against the estate of a spouse of a participant is limited to the value of the
				  assets of the estate that had been, at any time after October 1, 1993,
				  community property, or the deceased participant's share of the separate
				  property, and jointly owned property. Recovery will not be made until the
				  deceased participant no longer is survived by a spouse, a child who is under
				  age twenty-one (21), or a blind or disabled child, as defined in
				  42 U.S.C.
				  1382c as amended and, when applicable, as
				  provided in Subsection
				  903.05 of these rules. No
				  recovery will be made if the participant received medical assistance as the
				  result of a crime committed against the participant. (3-17-22)
02.
Expenses Deducted From
				  Estate
. The following expenses may be deducted from the available assets
				  to determine the amount available to satisfy the Department's claim: (3-17-22)
a. Burial expenses, which include only those
				  reasonably necessary for embalming, transportation of the body, cremation,
				  flowers, clothing, and services of the funeral director and staff may be
				  deducted. (3-17-22)
b. Other
				  legally enforceable and necessary debts with priority may be deducted. The
				  Department's claim is classified and paid as a debt with preference as defined
				  in Section
				  15-03-805, Idaho Code. Debts of
				  the deceased participant that may be deducted from the estate prior to
				  satisfaction of the Department's claim must be legally enforceable debts given
				  preference over the Department's claim under Section
				  15-03-805, Idaho Code.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › INVESTIGATIONS, AUDITS, AND ENFORCEMENT › SUB AREA: LIENS AND ESTATE RECOVERY › Section 16.03.09.906 - LIENS AND ESTATE RECOVERY: REQUEST FOR NOTICE

Current through August 31, 2023
01.
Request for Notice - Notice -
				  Hearing
. The Department must notify the participant or their authorized
				  representative, in writing, of its intention to record a request for notice,
				  and that they have the right to a fair hearing in accordance with Subsection
				  900.02 of these rules. The
				  notice must inform the participant of the following information, at a minimum:
				  (3-17-22)
a. The Department's determination
				  that they are the record titleholder or purchaser under a land sale contract of
				  real property subject to a request for notice; (3-17-22)
b. They or their authorized representative
				  may request a fair hearing prior to the Department's recording a request for
				  notice. The notice must include the time limits and instructions for requesting
				  a fair hearing; and (3-17-22)
c. If
				  they or their authorized representative do not request a fair hearing within
				  the time limits specified, a request for notice applying to their real
				  property, including their home, may be recorded. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › INVESTIGATIONS, AUDITS, AND ENFORCEMENT › SUB AREA: PARTICIPANT LOCK-IN › Section 16.03.09.910 - PARTICIPANT UTILIZATION CONTROL PROGRAM

Current through August 31, 2023
This Program is designed to promote improved and
					 cost-efficient medical management of essential health care by monitoring
					 participant activities and taking action to correct abuses. Participants
					 demonstrating unreasonable patterns of utilization or exceeding reasonable
					 levels of utilization, or both, will be reviewed for restriction. The
					 Department may require a participant to designate a primary physician or a
					 single pharmacy or both for exclusive provider services in an effort to protect
					 the individual's health and safety, provide continuity of medical care, avoid
					 duplication of services by providers, avoid inappropriate or unnecessary
					 utilization of medical assistance, and avoid excessive utilization of
					 prescription medications. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › INVESTIGATIONS, AUDITS, AND ENFORCEMENT › SUB AREA: PARTICIPANT LOCK-IN › Section 16.03.09.911 - LOCK-IN DEFINED

Current through August 31, 2023
Lock-in is the process of restricting the access of a
					 participant to a specific provider or providers. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › INVESTIGATIONS, AUDITS, AND ENFORCEMENT › SUB AREA: PARTICIPANT LOCK-IN › Section 16.03.09.912 - DEPARTMENT EVALUATION FOR LOCK-IN

Current through August 31, 2023
The Department will review participants to determine if
					 services are being utilized at a frequency or amount that results in a level of
					 utilization or a pattern of services that is not medically necessary.
					 Evaluation of utilization patterns can include review by the Department staff
					 of medical records or computerized reports, or both, generated by the
					 Department reflecting claims submitted for physician visits,
					 drugs/prescriptions, outpatient and emergency room visits, lab or diagnostic
					 procedures, or both, hospital admissions, and referrals. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › INVESTIGATIONS, AUDITS, AND ENFORCEMENT › SUB AREA: PARTICIPANT LOCK-IN › Section 16.03.09.913 - CRITERIA FOR LOCK-IN

Current through August 31, 2023
Since it is impossible to identify all possible patterns of
					 over utilization, and since a particular pattern may be justified based on
					 individual conditions, no specific criteria for lock-in will be developed.
					 However, the Department may develop guidelines for purposes of uniformity. The
					 guidelines will not be binding on the Department and will not limit or restrict
					 the ability of the Department to impose lock-in when any pattern of over
					 utilization is identified. The following utilization patterns may be considered
					 abusive, not medically necessary, potentially endangering the participant's
					 health and safety, or over utilization of Medicaid services, and may result in
					 the restriction of Medicaid reimbursement for a participant to a single
					 provider or providers: (3-17-22)
01.
Unnecessary Use of Providers or Services
. Unnecessary use of
				  providers or Medicaid services, including excessive provider visits.
				  (3-17-22)
02.
Demonstrated
				  Abusive Patterns
. Recommendation from a medical professional or the
				  participant's primary care physician that the participant has demonstrated
				  abusive patterns and would benefit from the lock-in program.
				  (3-17-22)
03.
Use of
				  Emergency Room Facilities
. Frequent use of emergency room facilities for
				  non-emergent conditions. (3-17-22)
04.
Multiple Providers
. Use of
				  multiple providers. (3-17-22)
05.
Controlled Substances
. Use of multiple controlled substances.
				  (3-17-22)
06.
Prescribing
				  Physicians or Pharmacies
. Use of multiple prescribing physicians or
				  pharmacies, or both. (3-17-22)
07.
Prescription Drugs and Therapeutic Classes
. Overlapping
				  prescription drugs with the same therapeutic class. (3-17-22)
08.
Drug Abuse
. Diagnosis of
				  drug abuse or drug withdrawal, or both. (3-17-22)
09.
Drug Behavior
. Drug-seeking
				  behavior as identified by a medical professional. (3-17-22)
10.
Other Abusive Utilization
.
				  Use of drugs or other Medicaid services determined to be abusive by the
				  Department's medical or pharmacy consultant. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › INVESTIGATIONS, AUDITS, AND ENFORCEMENT › SUB AREA: PARTICIPANT LOCK-IN › Section 16.03.09.914 - LOCK-IN PARTICIPANT NOTIFICATION

Current through August 31, 2023
A participant who has been designated by the Department for
					 the Participant Utilization Control Program will be notified in writing by the
					 Department of the action and the participant's right of appeal by means of a
					 fair hearing. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › INVESTIGATIONS, AUDITS, AND ENFORCEMENT › SUB AREA: PARTICIPANT LOCK-IN › Section 16.03.09.915 - LOCK-IN PROCEDURES

Current through August 31, 2023
01.
Participant Responsibilities
. The participant will be given thirty-five
				  (35) days to contact the Regional Program Manager or designee and complete and
				  sign the lock-in agreement form and select designated provider(s) in each area
				  of misuse. (3-17-22)
02.
Appeal Stays Restriction
. The Department will not implement the
				  participant restriction if a valid appeal is noted in accordance with Section
				  917 of these rules.
				  (3-17-22)
03.
Lock-In
				  Duration
. The Department will restrict participants to their designated
				  providers for a time period determined by the Department. Upon review at the
				  end of that period, lock-in may be extended for an additional period determined
				  by the Department. (3-17-22)
04.
Payment to Providers
. Payment to provider(s) other than the
				  designated lock-in physician or pharmacy is limited to documented emergencies
				  or written referrals from the primary physician. (3-17-22)
05.
Regional Programs Manager
.
				  The Regional Programs Manager, or designee will: (3-17-22)
a. Clearly describe the participant's appeal
				  rights in accordance with the provisions in IDAPA 16.05.03, "Contested Case
				  Proceedings and Declaratory Rulings"; (3-17-22)
b. Specify the effective date and length of
				  the restriction; (3-17-22)
c. Have
				  the participant choose a designated provider or providers; and
				  (3-17-22)
d. Mail the completed
				  lock-in agreement to the Surveillance and Utilization Unit. Upon receipt of the
				  lock-in agreement, the participant's Medicaid services will be immediately
				  restricted to the designated provider(s). (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › INVESTIGATIONS, AUDITS, AND ENFORCEMENT › SUB AREA: PARTICIPANT LOCK-IN › Section 16.03.09.916 - PENALTIES FOR LOCK-IN NONCOMPLIANCE

Current through August 31, 2023
If a participant fails to respond to the notification of
					 medical restriction(s), fails to sign the lock-in agreement, or fails to select
					 a primary physician within the specified time period, the Medicaid benefits
					 will be restricted to documented emergencies only. If a participant continues
					 to abuse or over-utilize items or services after being identified for lock-in,
					 the Department may terminate medical assistance benefits for a specified period
					 of time as determined by the Department. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › INVESTIGATIONS, AUDITS, AND ENFORCEMENT › SUB AREA: PARTICIPANT LOCK-IN › Section 16.03.09.917 - APPEAL OF LOCK-IN

Current through August 31, 2023
Department determinations to lock-in a participant may be
					 appealed in accordance with the fair hearings provisions of IDAPA 16.05.03,
					 "Contested Case Proceedings and Declaratory Rulings," of the Department.
					 (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › INVESTIGATIONS, AUDITS, AND ENFORCEMENT › SUB AREA: PARTICIPANT LOCK-IN › Section 16.03.09.918 - RECIPIENT EXPLANATION OF MEDICAID BENEFITS (REOMBS)

Current through August 31, 2023
01.
Monthly Surveys
. The
				  Department will conduct monthly surveys of services rendered to medical
				  assistance participants using REOMBs. (3-17-22)
02.
Participant Response
. A
				  medical assistance participant is required to respond to the Department's
				  explanation of medical benefits survey whenever they are aware of
				  discrepancies. (3-17-22)
03.
Participant Unable to Respond
. If the participant is unable, because of
				  medical or physical limitations, to respond to the survey personally, then a
				  responsible family member or friend can respond on their behalf.
				  (3-17-22)
04.
Medicare-to-Medicaid Cross-Over Claims
. All claims processed through the
				  cross-over system will be subject to these rules. All providers submitting
				  cross-over claims must comply with the terms of their provider agreements.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › Section 16.03.10.000 - LEGAL AUTHORITY

Current through August 31, 2023
01.
Rulemaking Authority
. The Idaho Department of Health and Welfare has the
			 authority to promulgate public assistance rules under Section
			 56-202(b),
			 56-264, and
			 56-1610, Idaho Code.
			 (3-17-22)
02.
General
			 Administrative Authority
. Title XIX and Title XXI, of the Social
			 Security Act, as amended, and the companion federal regulations, are the basic
			 authority for administration of the federal program. General administrative
			 duties for the Department are found under Section
			 56-202, Idaho Code.
			 (3-17-22)
03.
Administration
			 of the Medical Assistance Program
. (3-17-22)
a. Section
			 56-203(7), Idaho
			 Code, empowers the Department to define persons entitled to medical assistance.
			 (3-17-22)
b. Section
			 56-203(9), Idaho
			 Code, empowers the Department to identify the amount, duration, scope of care,
			 and services to be purchased as medical assistance on behalf of individuals
			 eligible to receive benefits under the Medical Assistance Program.
			 (3-17-22)
c. Sections
			 56-250 through
			 56-257, and
			 56-260 through
			 56-266, Idaho Code, establish
			 minimum standards that enable these rules. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › Section 16.03.10.001 - TITLE AND SCOPE

Current through August 31, 2023
01.
Title
. The title of these rules is IDAPA 16.03.10, "Medicaid Enhanced
			 Plan Benefits." (3-17-22)
02.
Scope.
These rules establish the Medicaid Enhanced Plan Benefits
			 covered under Title XIX and Title XXI. Participants who are eligible for
			 Enhanced Plan Benefits are also eligible for benefits under IDAPA 16.03.09,
			 "Medicaid Basic Plan Benefits." Dental benefits and outpatient behavioral
			 health benefits are contained in IDAPA 16.03.09. "Medicaid Basic Plan
			 Benefits." (3-17-22)
03.
Scope of Reimbursement System Audits
. These rules also provide for the
			 audit of providers' claimed costs against these rules and Medicare standards.
			 The Department reserves the right to audit financial and other records of the
			 provider, and, when warranted, the records of entities related to the provider.
			 Audits consist of the following types of records: (3-17-22)
a. Cost verification of actual costs for
			 providing goods and services; (3-17-22)
b. Evaluation of provider's compliance with
			 the provider agreement, reporting form instructions, and any applicable law,
			 rule, or regulation; (3-17-22)
c.
			 Effectiveness of the service to achieve desired results or benefits; and
			 (3-17-22)
d. Reimbursement rates or
			 settlement calculated under this chapter. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › Section 16.03.10.002 - WRITTEN INTERPRETATIONS

Current through August 31, 2023
This agency may have written statements that pertain to the
				interpretations of the rules of this chapter. These documents are available for
				public inspection. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › Section 16.03.10.004 - INCORPORATION BY REFERENCE

Current through August 31, 2023
The Department has incorporated by reference the following
				document: (3-17-22)
01.
42 CFR
			 Part 447
. 42 CFR Part 447 , "Payment for Services," revised as of
			 October 1, 2001, is available from CMS, 7500 Security Blvd, Baltimore, M.D.,
			 21244-1850 or on the Code of Federal Regulations website at
http://www.ecfr.gov/cgi-bin/text-idx?SID=3ec1965dbf5044d8f79b25d4d58c4cd1&mc=true&tpl=/ecfrbrowse/Title42/42cfrv4_02.tpl#0
.
			 (3-17-22)
02.
Estimated
			 Useful Lives of Depreciable Hospital Assets, 2004 Revised Edition, Guidelines
			 Lives.
This document may be obtained from American Hospital Publishing,
			 Inc., 211 E. Chicago Ave., Chicago, IL. 60611. (3-17-22)
03.
Medicare Region D Durable Medical
			 Equipment Regional Carrier (DMERC) Supplier Manual or Its Successor
. The
			 full text of the Medicare Region D DMERC Supplier Manual Chapters IX and X,
			 date April 2001, is available via the Internet at
www.cignamedicare.com
. A copy
			 is also available at the Idaho State Supreme Court Law Library.
			 (3-17-22)
04.
Provider
			 Reimbursement Manual (PRM)
. The Provider Reimbursement Manual (PRM),
			 Part I and Part II CMS Publication 15-1 and 15-2), is available on the CMS
			 website at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals.html
.
			 (3-17-22)
05.
Resource
			 Utilization Groups (RUG) Grouper
. The RUG III, version 5.12, 34 Grouper,
			 nursing weights only, with index maximization. The RUG Grouper is available
			 from CMS, 7500 Security Blvd., Baltimore, MD, 21244-1850. (3-17-22)
06.
Travel Policies and Procedures of
			 the Idaho State Board of Examiners
. The text of "Idaho State Travel
			 Policies and Procedures of the Idaho State Board of Examiners," Appendices A
			 and B, June 13, 2000, is available at the Office of the State Controller, 700
			 W. State St., 5th Fl., Box 83720, Boise, Idaho 83720-0011 or on the Internet at
http://www.sco.idaho.gov/
.
			 (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › Section 16.03.10.008 - AUDIT, INVESTIGATION AND ENFORCEMENT

Current through August 31, 2023
In addition to any actions specified in these rules, the
				Department may audit, investigate and take enforcement action under the
				provisions of IDAPA 16.05.07, "Investigation and Enforcement of Fraud, Abuse,
				or Misconduct." (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › Section 16.03.10.011 - DEFINITIONS: E THROUGH K

Current through August 31, 2023
For the purposes of these rules, the following terms are used
				as defined below: (3-17-22)
01.
Educational Services
. Services that are provided in buildings, rooms or
			 areas designated or used as a school or as educational facilities; that are
			 provided during the specific hours and time periods in which the educational
			 instruction takes place in the normal school day and period of time for these
			 students; and that are included in the individual educational plan for the
			 participant or required by federal and state educational statutes or
			 regulations; are not related services
;
and such services are
			 provided to school age individuals as defined in Section
			 33-201, Idaho Code.
			 (3-17-22)
02.
Eligibility
			 Rules
. IDAPA 16.03.01, "Eligibility for Health Care Assistance for
			 Families and Children," and IDAPA 16.03.05, "Eligibility for Aid to the Aged,
			 Blind and Disabled (AABD)." (3-17-22)
03.
Emergency Medical Condition
.
			 A medical condition manifesting itself by acute symptoms of sufficient
			 severity, including severe pain, that a prudent lay person, who possesses an
			 average knowledge of health and medicine, could reasonably expect the absence
			 of immediate medical attention to result in the following: (3-17-22)
a. Placing the health of the individual, or,
			 with respect to a pregnant woman, the health of the woman or unborn child, in
			 serious jeopardy. (3-17-22)
b.
			 Serious impairment to bodily functions. (3-17-22)
c. Serious dysfunction of any bodily organ or
			 part. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › Section 16.03.10.012 - DEFINITIONS: L THROUGH O

Current through August 31, 2023
For the purposes of these rules, the following terms are used
				as defined below: (3-17-22)
01.
Lease
. A contract arrangement for use of another's property, usually for
			 a specified time period, in return for period rental payments.
			 (3-17-22)
02.
Leasehold
			 Improvements
. Additions, adaptations, corrections, etc., made to the
			 physical components of a building or construction by the lessee for their use
			 or benefit. Such additions may revert to the owner. Such costs are usually
			 capitalized and amortized over the life of the lease. (3-17-22)
03.
Legal Representative
. A
			 parent with custody of a minor child, one who holds a legally-executed and
			 effective power of attorney for health decisions, or a court-appointed guardian
			 whose powers include the power to make health care decisions.
			 (3-17-22)
04.
Level of
			 Care
. The classification in which a participant is placed, based on
			 severity of need for institutional care. (3-17-22)
05.
Licensed Bed Capacity
. The
			 number of beds that are approved by the Licensure and Certification Agency for
			 use in rendering patient care. (3-17-22)
06.
Licensed, Qualified
			 Professionals
. Individuals licensed, registered, or certified by
			 national certification standards in their respective discipline, or otherwise
			 qualified within the state of Idaho. (3-17-22)
07.
Lower of Cost or Charges
.
			 Payment to providers (other than public providers furnishing such services free
			 of charge or at nominal charges to the public) is the lesser of the reasonable
			 cost of such services or the customary charges with respect to such services.
			 Public providers that furnish services free of charge or at a nominal charge
			 are reimbursed fair compensation; which is the same as reasonable cost.
			 (3-17-22)
08.
MAI
			 Appraisal
. An appraisal that conforms to the standards, practices, and
			 ethics of the Appraisal Institute and is performed by a member of the Appraisal
			 Institute. (3-17-22)
09.
Major Movable Equipment
. Major movable equipment means such items as
			 beds, wheelchairs, desks, furniture, vehicles, etc. The general characteristics
			 of this equipment are: (3-17-22)
a. A
			 relatively fixed location in the building; (3-17-22)
b. Capable of being moved, as distinguished
			 from building equipment; (3-17-22)
c. A unit cost of five thousand dollars
			 ($5000) or more; (3-17-22)
d.
			 Sufficient size and identity to make control feasible by means of
			 identification tags; and (3-17-22)
e. A minimum life of three (3) years.
			 (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › Section 16.03.10.013 - DEFINITIONS: P THROUGH Z

Current through August 31, 2023
For the purposes of these rules, the following terms are used
				as defined below: (3-17-22)
01.
Patient Day
. (3-17-22)
a. For ICF/IID,
			 a calendar day of care includes the day of admission and excludes the day of
			 discharge, unless discharge occurs after 3:00 p.m. or it is the date of death.
			 When admission and discharge occur on the same day, one (1) day of care is
			 deemed to exist. (3-17-22)
b. For a
			 nursing facility, a calendar day of care includes the day of admission and
			 excludes the day of discharge, unless it is the date of death. When admission
			 and discharge occur on the same day, one (1) day of care is 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 › GENERAL PARTICIPANT PROVISIONS › Section 16.03.10.020 - PARTICIPATION IN THE COST OF WAIVER SERVICES

Current through August 31, 2023
01.
Waiver Services and Income Limit
. A participant is not required to
				participate in the cost of Home and Community-Based (HCBS) waiver services
				unless: (3-17-22)
a. The participant's
				eligibility for medical assistance is based on approval for and receipt of a
				waiver service; and (3-17-22)
b.
				The participant is eligible for Medicaid if they meet the conditions referred
				to under IDAPA 16.03.05, "Eligibility for Aid to the Aged, Blind, and Disabled
				(AABD)," Section 787.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › GENERAL PARTICIPANT PROVISIONS › Section 16.03.10.021 - MEDICARE SAVINGS PROGRAM FOR PARTICIPANTS COVERED BY MEDICARE

Current through August 31, 2023
The Department has an agreement with the Centers for Medicare
				  and Medicaid Services (CMS) to pay the premiums for Parts A and B of Title
				  XVIII for each participant eligible for Medicare and medical assistance
				  regardless of whether the participant receives a financial grant from the
				  Department. (3-17-22)
01.
AABD
				Effective Date
. The effective date of the Medicare Savings Program for a
				participant approved for medical assistance and an AABD grant is the first
				month of eligibility for the AABD grant. (3-17-22)
02.
SSI Effective Date
. The
				effective date of the Medicare Savings Program for a participant approved for
				medical assistance who also receives SSI, but not AABD, is the first month of
				eligibility for medical assistance. (3-17-22)
03.
Neither AABD or SSI Effective
				Date
. The effective date of the Medicare Savings Program for a
				participant approved for medical assistance who does not receive an AABD grant
				or SSI is the first day of the second month following the month in which they
				became eligible for medical assistance. This would mean the third month of
				medical assistance eligibility for the participant. (3-17-22)
04.
Update of Records
. After the
				effective date of the Medicare Savings Program it takes the Social Security
				Administration up to one (1) month to update its records to show the
				Department's payment of the Medicare Savings Program premium.
				(3-17-22)
05.
Policies for
				Treatment of the Medicare Savings Program
. The Department advises each
				participant who is paying Parts A and B Medicare premiums to discontinue
				payments beginning the month the Medicare Savings Program becomes effective.
				Policies for treatment of the Medicare Savings Program for determining
				eligibility for medical assistance or AABD, grant amount for AABD, or patient
				liability are in IDAPA 16.03.05, "Eligibility for Aid to the Aged, Blind and
				Disabled (AABD)." Policies for treatment of the Medicare Savings Program for
				determining participation of an HCBS participant are found in Section
				020 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 › GENERAL PARTICIPANT PROVISIONS › Section 16.03.10.022 - PARTICIPANT'S REQUIREMENTS FOR ESTATE RECOVERY

Current through August 31, 2023
A participant's estate may be obligated to pay the Medicaid
				  program back for the amount Medicaid paid out for medical assistance during the
				  participant's life. The requirements for that estate recovery are found in
				  IDAPA 16.03.09, "Medicaid Basic Plan Benefits," Section
				  900. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › GENERAL PARTICIPANT PROVISIONS › Section 16.03.10.025 - GENERAL SERVICE LIMITATIONS

Current through August 31, 2023
Service limitations stated in these rules include any
				  services received by a participant under IDAPA 16.03.09, "Medicaid Basic Plan
				  Benefits." (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › GENERAL PARTICIPANT PROVISIONS › Section 16.03.10.026 - SELECTIVE CONTRACTING

Current through August 31, 2023
The Department may contract with a limited number of
				  providers of certain Medicaid products and services. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › GENERAL REIMBURSEMENT PROVISIONS › Section 16.03.10.030 - COST REPORTING

Current through August 31, 2023
The provider's Medicaid cost report must be filed using the
				  Department designated reporting forms, unless the Department has approved an
				  exception. The request to use alternate forms must be sent to the Department in
				  writing, with samples attached, a minimum of ninety (90) days prior to the due
				  date for the cost report. The request for approval of alternate forms cannot be
				  used as a reason for late filing. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › GENERAL REIMBURSEMENT PROVISIONS › Section 16.03.10.036 - GENERAL REIMBURSEMENT

Current through August 31, 2023
01.
Long-Term Care Facility Payment
. Long-term care facilities will be
				reimbursed the lower of their customary charges, their actual reasonable costs,
				adjusted by a budget adjustment factor (BAF) for nursing facilities, or the
				standard costs for their class as set forth in the Provider Reimbursement
				Manual, but the upper limits for payment must not exceed the payment that would
				be determined as reasonable costs using the Title XVIII Medicare standards and
				principles. (3-17-22)
02.
Individual Provider Payment
. The Department will not pay the individual
				provider more than the lowest of: (3-17-22)
a.
				The provider's actual charge for service; or (3-17-22)
b. The maximum allowable charge for the
				service as established by the Department on its pricing file, if the service or
				item does not have a specific price on file, the provider must submit
				documentation to the Department and reimbursement will be based on the
				documentation; or (3-17-22)
c. The
				Medicaid upper limitation of payment on those services, minus the Medicare
				payment, where a participant is eligible for both Medicare and Medicaid. The
				Department will not reimburse providers an amount in excess of the amount
				allowed by Medicaid, minus the Medicare payment. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › GENERAL REIMBURSEMENT PROVISIONS › Section 16.03.10.037 - GENERAL REIMBURSEMENT: PARTICIPANT SERVICES

Current through August 31, 2023
The Department will evaluate provider reimbursement rates
				  that comply with 42 U.S.C.
				  1396a(a)(30)(A). This
				  evaluation will assure payments are consistent with efficiency, economy, and
				  quality of care and safeguards against unnecessary utilization of care and
				  services. Reimbursements will be sufficient to enlist enough providers so that
				  care and services are available under the plan at least to the extent that such
				  care and services are available to the general population in the geographic
				  area. (3-17-22)
01.
Applicable
				Participant Services
. Unless otherwise provided in this chapter of
				rules, the following types of services are reimbursed as provided in this rule:
				(3-17-22)
a. The Personal Care Services (PCS)
				described in Sections
				300-308 of these rules.
				(3-17-22)
b. The Aged and Disabled
				Waiver services described in Sections
				320-330 of these rules.
				(3-17-22)
c. The Children's
				Developmental Disabilities Home and Community-Based State Plan Option Services
				described in Sections
				520-528 of these rules.
				(3-17-22)
d. The Adult
				Developmental Disabilities Waiver services described in Sections
				700-706 of these rules.
				(3-17-22)
e. The Adult
				Developmental Disabilities Home and Community-Based State Plan Option Services
				described in Sections
				645-657 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 › GENERAL REIMBURSEMENT PROVISIONS › Section 16.03.10.038 - SPECIALIZED REIMBURSEMENT: CERTAIN HOME AND COMMUNITY-BASED SERVICES

Current through August 31, 2023
The Department will review provider reimbursement rates to
				  ensure compliance with 42
				  U.S.C. 1396a(a)(30)(A). This
				  review will assure payments are consistent with efficiency, economy, quality of
				  care, and safeguard against unnecessary utilization of care and services.
				  Reimbursements will be sufficient to enlist enough providers so that care and
				  services are available under the plan at least to the extent that such care and
				  services are available to the general population in the geographic area.
				  (3-17-22)
01.
Applicable Home
				and Community-Based Services
. The home and community-based services
				provided by the following types of providers are reimbursed as described in
				this rule: (3-17-22)
a. Developmental
				Disability Agencies providing services to adults; (3-17-22)
b. Developmental Disability Agencies
				providing services to children; (3-17-22)
c. Residential Habilitation Agencies;
				(3-17-22)
d. Supported Employment
				Agencies; and (3-17-22)
e. Targeted
				Service Coordination Agencies. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › GENERAL REIMBURSEMENT PROVISIONS › Section 16.03.10.039 - ACCOUNTING TREATMENT

Current through August 31, 2023
Generally accepted accounting principles, concepts, and
				  definitions will be used except as otherwise specified. Where alternative
				  treatments are available under GAAP, the acceptable treatment will be the one
				  that most clearly attains program objectives. (3-17-22)
01.
Final Payment
. A final
				settlement will be made based on the reasonable cost of services as determined
				by audit, limited in accordance with other sections of this chapter.
				(3-17-22)
02.
Overpayments
. As a matter of policy, recovery of overpayments will be
				attempted as quickly as possible consistent with the financial integrity of the
				provider. (3-17-22)
03.
Other Actions
. Generally, overpayment will result in two (2)
				circumstances: (3-17-22)
a. If the cost report
				is not filed, the sum of the following will be due: (3-17-22)
i. All payments included in the period
				covered by the missing report(s). (3-17-22)
ii. All subsequent payments.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › GENERAL REIMBURSEMENT PROVISIONS › Section 16.03.10.040 - PROVIDER'S RESPONSIBILITY TO MAINTAIN RECORDS

Current through August 31, 2023
The provider must maintain financial and other records in
				  sufficient detail to allow the Department to audit them as described in
				  Subsection 001.03 of these rules.
				  (3-17-22)
01.
Expenditure
				Documentation
. Documentation of expenditures must include the amount,
				date, purpose, payee, and the invoice or other verifiable evidence supporting
				the expenditure. (3-17-22)
02.
Cost Allocation Process
. Costs such as depreciation or
				amortization of assets and indirect expenses are allocated to activities or
				functions based on the original identity of the costs. Documentation to support
				basis for allocation must be available for verification. (3-17-22)
03.
Revenue Documentation
.
				Documentation of revenues must include the amount, date, purpose, and source of
				the revenue. (3-17-22)
04.
Availability of Records
. Records must be available for and subject to
				audit by the auditor, with or without prior notice, during any working day
				between the hours of 8:00 a.m. and 5:00 p.m. at the provider's principal place
				of business in the state of Idaho. (3-17-22)
a. The provider is given the opportunity to
				provide documentation before the interim final audit report is issued.
				(3-17-22)
b. The provider is not
				allowed to submit additional documentation in support of cost items after the
				issuance of the interim final audit report. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › GENERAL REIMBURSEMENT PROVISIONS › Section 16.03.10.041 - SPECIALIZED REIMBURSEMENT: ELECTRONIC VISIT VERIFICATION (EVV)

Current through August 31, 2023
01.
Services Subject to EVV
				Requirement
. Effective July 1, 2021, agencies providing the following
				services are required to submit claims using a compliant EVV system as mandated
				by Section 12006 of the 21st Century Cures
				Act: (3-17-22)
a. Private Duty Nursing
				Services as described in Sections
				200 through
				210 of these rules;
				(3-17-22)
b. Personal Care Services
				(PCS) as described in Sections
				300 through
				309 of these rules;
				(3-17-22)
c. The following Aged and
				Disabled Waiver Services as described in Sections
				320 through
				329 of these rules: (3-17-22)
i. Attendant Care; (3-17-22)
ii. Homemaker; and (3-17-22)
iii. Respite.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › GENERAL REIMBURSEMENT PROVISIONS › Section 16.03.10.050 - DRAFT AUDIT REPORT

Current through August 31, 2023
Following completion of the audit field work on a hospital,
				  nursing facility, or an ICF/IID, and before issuing the interim final audit
				  report to the Department, the auditor will issue a draft audit report and
				  forward a copy to the provider for review and comment. (3-17-22)
01.
Review Period
. The provider
				will have a period of forty-five (45) days, beginning on the date of
				transmittal, to review and provide additional comments or evidence pertaining
				to the draft audit report. The review period may be extended, to a maximum of
				an additional fifteen (15) days past the original due date, when the provider:
				(3-17-22)
a. Requests an extension prior to
				the expiration of the original review period; and (3-17-22)
b. Clearly demonstrates the need for
				additional time to properly respond. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › GENERAL REIMBURSEMENT PROVISIONS › Section 16.03.10.051 - FINAL AUDIT REPORT

Current through August 31, 2023
The auditor will incorporate the provider's response and an
				  analysis of the response into the interim final report as appendices and
				  transmit it to the Department. The Department will issue a final audit report
				  and a notice of program reimbursement, if applicable, that sets forth
				  settlement amounts due to the Department or the provider. The final audit
				  report and notice of program reimbursement, if applicable, will take into
				  account the findings made in the final audit report and the response of the
				  provider to the draft audit report (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › GENERAL REIMBURSEMENT PROVISIONS › Section 16.03.10.060 - CRITERIA FOR PARTICIPATION IN THE IDAHO TITLE XIX AND TITLE XXI PROGRAMS

Current through August 31, 2023
01.
Application for Participation and
				Reimbursement
. Prior to participation in the Medical Assistance Program,
				facilities must be licensed or certified by the Department. The Department
				issues a provider number to the facility that becomes the primary provider
				identification number. The Division of Medicaid will establish an interim rate
				for the new applicant facility. This facility is now authorized to offer
				services at the level for which the provider agreement was issued.
				(3-17-22)
02.
Reimbursement
. The reimbursement mechanism for payment to provider
				facilities is specified in IDAPA 16.03.09, "Medicaid Basic Plan Benefits," and
				in IDAPA 16.03.10, "Medicaid Enhanced Plan Benefits." The Medical Assistance
				Program will not reimburse a facility until it is certified, has a signed
				agreement for participation and an established interim per diem rate.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › GENERAL REIMBURSEMENT PROVISIONS › Section 16.03.10.070 - EXCEPTION TO THE RELATED ORGANIZATION PRINCIPLE

Current through August 31, 2023
An exception is provided to the general rule applicable to
				  related organizations. The exception applies if the provider demonstrates by
				  convincing evidence to the satisfaction of the intermediary: (3-17-22)
01.
Supplying Organization
. That
				the supplying organization is a bona fide separate organization;
				(3-17-22)
02.
Nonexclusive
				Relationship
. That a substantial part of the supplying organization's
				business activity of the type carried on with the provider is transacted with
				other organizations not related to the provider and the supplier by common
				ownership or control and there is an open, competitive market.
				(3-17-22)
03.
Sales and
				Rental of Extended Care Facilities
. The exception is not applicable to
				sales, lease or rentals of nursing homes or extended care facilities. These
				transactions would not meet the requirement that there be an open, competitive
				market for the facilities furnished. See PRM, Sections
				1008 and
				1012. (3-17-22)
a. Rental expense for transactions between
				related entities will not be recognized. Costs of ownership will be allowed.
				(3-17-22)
b. When a facility is
				purchased from a related entity, the purchaser's depreciable basis will not
				exceed the seller's net book value. See PRM, Section
				1005.
				(3-17-22)