reglab/statecodes huggingface dataset:
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › COVERED SERVICES › Section 16.03.10.075 - ENHANCED PLAN BENEFITS: COVERED SERVICES

Current through August 31, 2023
Individuals who are eligible for the Medicaid Enhanced Plan
				  are enrolled in all benefits covered under IDAPA 16.03.09, "Medicaid Basic Plan
				  Benefits." In addition to those benefits, individuals in the enhanced plan are
				  eligible for enhanced benefits as described in this chapter of rules.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › COVERED SERVICES › Section 16.03.10.076 - MANAGED CARE FOR DUALS: DEFINITIONS

Current through August 31, 2023
For the purposes of the managed care service delivery system
				  for dual eligible beneficiaries described in Sections
				  076 through
				  079 of these rules, the following
				  definitions apply: (3-17-22)
01.
Dual Eligible
. A participant who is eligible for medical
				assistance under IDAPA 16.03.05, "Eligibility for Aid to the Aged, Blind, and
				Disabled (AABD)." The participant's Medicaid eligibility must not be based
				solely on the requirements found under IDAPA 16.03.05, "Eligibility for Aid to
				the Aged, Blind, and Disabled (AABD)," Section
				802. In addition, the participant
				must be eligible for and enrolled in both Medicare Part A and Medicare Part B.
				(3-17-22)
02.
Health
				Plan
. A health insurance company responsible for administering Medicaid
				benefits to dual eligible participants under a provider agreement with the
				Department. (3-17-22)
03.
Idaho Medicaid Plus
. A managed care program designed to administer
				Medicaid benefits for dual eligible participants administered under a provider
				agreement between the Department and participating health plans.
				(3-17-22)
04.
Medicare/Medicaid Coordinated Plan
. A managed care program as defined in
				IDAPA 16.03.17, "Medicare/Medicaid Coordinated Plan Benefits."
				(3-17-22)
05.
Passive
				Enrollment
. An enrollment process in which a participant is assigned to
				a participating health plan in a managed care service delivery structure unless
				the participant actively opts out of the enrollment process.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › COVERED SERVICES › Section 16.03.10.077 - MANAGED CARE FOR DUALS: PROGRAM AUTHORITY AND IMPLEMENTATION

Current through August 31, 2023
01.
Program Authority
. Idaho
				Medicaid Plus is a managed care program for dual eligible participants
				administered with approval from the Centers for Medicare and Medicaid Services
				(CMS). The Idaho Medicaid Plus program allows for a health plan to administer
				Medicaid benefits to dual eligible participants. (3-17-22)
02.
Implementation
. Idaho
				Medicaid Plus will be implemented using a phased-in approach. (3-17-22)
a. Idaho Medicaid Plus will be implemented in
				a pilot county upon approval from CMS and after the Department determines that
				participating health plans have passed a readiness review for implementation.
				(3-17-22)
b. Implementation in
				additional counties will occur in a phased-in manner upon successful
				implementation in the pilot county as determined by the Department. Phased-in
				implementation in any and all additional counties will be subject to Department
				approval. (3-17-22)
c.
				Participating health plans must meet established performance benchmarks prior
				to Idaho Medicaid Plus implementation in each successive geographic service
				area. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › COVERED SERVICES › Section 16.03.10.078 - MANAGED CARE FOR DUALS: PARTICIPANT ELIGIBILITY AND ENROLLMENT

Current through August 31, 2023
Idaho Medicaid Plus will be made available to dual eligible
				  participants over age twenty-one (21) who reside in a county with at least one
				  (1) participating health plan. (3-17-22)
01.
Excluded Populations
. Idaho
				Medicaid Plus is not available to the following populations: (3-17-22)
a. Dual eligible participants who have
				elected to enroll in the Medicare Medicaid Coordinated Plan as defined in IDAPA
				16.03.17, "Medicare/Medicaid Coordinated Plan Benefits." (3-17-22)
b. Individuals enrolled in the Adult
				Developmental Disabilities 1915(c) waiver program as defined in Section
				702 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 › COVERED SERVICES › Section 16.03.10.079 - MANAGED CARE FOR DUALS: COVERED SERVICES

Current through August 31, 2023
01.
Coverage and Limitations
. (3-17-22)
a. Idaho Medicaid Plus covered services
				include Medicaid benefits as described in this chapter and IDAPA 16.03.09,
				"Medicaid Basic Plan Benefits." (3-17-22)
b. Services for adults with developmental
				disabilities as described in Sections
				511,
				580, and
				703 of these rules are excluded
				from Idaho Medicaid Plus. (3-17-22)
c. Services administered under the managed
				care or brokerage contracts as described in Section
				080 of these rules, and IDAPA
				16.03.09, "Medicaid Basic Plan Benefits," Sections
				870 through
				872 are excluded from Idaho
				Medicaid Plus. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: ENHANCED HOSPITAL SERVICES › Section 16.03.10.090 - ORGAN TRANSPLANTS

Current through August 31, 2023
The Department will reimburse for organ transplant services
				  as detailed in the Idaho Medicaid Provider Handbook, when medically necessary
				  and provided by hospitals approved by the Centers for Medicare and Medicaid for
				  the Medicare program that have completed a provider agreement with the
				  Department. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: ENHANCED HOSPITAL SERVICES › Section 16.03.10.093 - ORGAN TRANSPLANTS: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Coverage Limitations
. No organ transplant will be covered by the
				Medical Assistance Program unless prior authorized by the Department, or its
				designee. Coverage is limited to organ transplants performed for the treatment
				of medical conditions in accordance with evidence-based standards of care.
				(3-17-22)
02.
Living Donor
				Costs
. The transplant costs for actual or potential living donors are
				fully covered by Medicaid and include all medically necessary preparatory,
				operation, and post-operation recovery expenses associated with the donation.
				Payments for post-operation expenses of a donor will be limited to the period
				of actual recovery. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: ENHANCED HOSPITAL SERVICES › Section 16.03.10.096 - ORGAN TRANSPLANTS: PROVIDER REIMBURSEMENT

Current through August 31, 2023
Organ transplant, procurement services, and follow-up care by
				  facilities will be reimbursed as specified in the provider agreement.
				  Reimbursement for organ procurement and histocompatibility laboratory tests
				  will be made to the facility performing the transplant. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: ENHANCED INPATIENT BEHAVIORAL HEALTH SERVICES › Section 16.03.10.100 - INPATIENT BEHAVIORAL HEALTH SERVICES

Current through August 31, 2023
The Medicaid Enhanced Plan Benefits include psychiatric
				  services covered under inpatient hospital services and inpatient behavioral
				  health services covered in 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 › SUB AREA: ENHANCED INPATIENT BEHAVIORAL HEALTH SERVICES › Section 16.03.10.101 - INPATIENT BEHAVIORAL HEALTH SERVICES: PARTICIPANT ELIGIBILITY

Current through August 31, 2023
The rules for Inpatient Behavioral Health Services are found
				  in IDAPA 16.03.09, "Medicaid Basic Plan Benefits," Sections
				  700 through
				  706 and apply to Inpatient
				  Behavioral Health Services in these rules. Individuals over age sixty-five (65)
				  are eligible for inpatient behavioral health services under these rules.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: ENHANCED HOME HEALTH CARE › Section 16.03.10.200 - PRIVATE DUTY NURSING SERVICES

Current through August 31, 2023
01.
Description of Private Duty Nursing (PDN) Services
. Private Duty Nursing
				(PDN) services are nursing services provided by a licensed registered nurse or
				licensed practical nurse to a non-institutionalized child under the age of
				twenty-one (21) requiring care for conditions of such medical severity or
				complexity that skilled nursing care is necessary. Sections
				200 through
				209 of these rules cover
				requirements for private duty nursing services. (3-17-22)
02.
Temporary Changes to PDN Rules
				During Declared State of Emergency Related to Novel Coronavirus Disease
				(COVID-19)
. In response to Idaho's declaration on 3/13/20 of a state of
				emergency related to COVID-19, the Department reserves the right to temporarily
				alter requirements and processes related to PDN services in order to mitigate
				spread of disease and to ensure the health and safety of our participants under
				the guidance and authority of the provisions in a CMS-approved 1135 waiver
				through the duration of the emergency state. Guidance for approved
				flexibilities is posted on the Medicaid Information Releases website at
https://www.idmedicaid.com/default.aspx
.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: ENHANCED HOME HEALTH CARE › Section 16.03.10.201 - PRIVATE DUTY NURSING: DEFINITIONS

Current through August 31, 2023
The following definitions apply to Sections
				  200 through Section
				  209 of these rules.
				  (3-17-22)
01.
Primary RN
.
				The RN identified by the family to be responsible for development,
				implementation, and maintenance of the Medical Plan of Care.
				(3-17-22)
02.
Private Duty
				Nursing (PDN) RN Supervisor
. An RN providing oversight of PDN services
				delegated to LPN's providing the child's care, in accordance with IDAPA
				24.34.01, "Rules of the Board of Nursing." (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: ENHANCED HOME HEALTH CARE › Section 16.03.10.202 - PRIVATE DUTY NURSING: ELIGIBILITY

Current through August 31, 2023
To be eligible for PDN, the nursing needs must be of such a
				  nature that the Idaho Nursing Practice Act, Rules, Regulations, or policy
				  require the service to be provided by an Idaho Licensed Registered Nurse (RN),
				  or by an Idaho Licensed Practical Nurse (LPN), and require more individual and
				  continuous care than is available from Home Health nursing services. PDN
				  service will be authorized by the Department prior to delivery of service.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: ENHANCED HOME HEALTH CARE › Section 16.03.10.203 - PRIVATE DUTY NURSING: FACTORS ASSESSED FOR ELIGIBILITY AND REDETERMINATION

Current through August 31, 2023
Factors assessed for eligibility/redetermination include:
				  (3-17-22)
01.
Age for
				Eligibility
. The individual is under the age of twenty-one (21) years.
				(3-17-22)
02.
Maintained in
				Personal Residence
. That the child is maintained in their personal
				residence and receives safe and effective services through PDN services.
				(3-17-22)
03.
Medical
				Justification
. The child receiving PDN services has medical
				justification and physician's orders. (3-17-22)
04.
Written Plan of Care
. That
				there is an updated written plan of care signed by the attending physician, the
				parent or legal guardian, PDN, RN supervisor, and a representative from the
				Department. (3-17-22)
05.
Attending Physician
. That the attending physician has determined the
				number of PDN hours needed to ensure the health and safety of the child in
				their home. (3-17-22)
06.
Redetermination
. Redetermination will be at least annually. The purpose
				of an annual redetermination for PDN is to: (3-17-22)
a. Determine if the child continues to meet
				the PDN criteria in Subsection
				203.01 through
				203.05 of these rules; and
				(3-17-22)
b. Assure that services
				and care are medically necessary and appropriate. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: ENHANCED HOME HEALTH CARE › Section 16.03.10.204 - PRIVATE DUTY NURSING: COVERAGE AND LIMITATIONS

Current through August 31, 2023
PDN services are functions that cannot be delegated to an
				  Unlicensed Assistive Personnel (UAP) as defined by Idaho Code and IDAPA
				  23.01.01, "Rules of the Idaho Board of Nursing." (3-17-22)
01.
Ordered by a Physician
. PDN
				Services must be ordered by a physician and include: (3-17-22)
a. A medical status that is so complex or
				unstable, as determined by the attending physician, that licensed or
				professional nursing assessment is needed to determine the need for changes in
				medications or other interventions; or (3-17-22)
b. An assessment by a licensed registered
				nurse of a child's health status for unstable chronic conditions that includes
				an evaluation of the child's responses to interventions or medications.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: ENHANCED HOME HEALTH CARE › Section 16.03.10.209 - PRIVATE DUTY NURSING: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
01.
Primary RN Responsibility For PDN
				Redetermination
. Primary RN responsibility for PDN redetermination is to
				submit a current plan of care to the Department at least annually or as the
				child's needs change. Failure to submit an updated plan of care to the
				Department prior to the end date of the most recent authorization will cause
				payments to cease until completed information is received and evaluated and
				authorization given for further PDN services. The plan of care must include all
				requested material outlined in Subsection
				204.02 of these rules.
				(3-17-22)
02.
Physician
				Responsibilities
. Physician responsibilities include: (3-17-22)
a. Medical Information. Provide the
				Department the necessary medical information in order to establish the child's
				medical eligibility for services based on an EPSDT screen. (3-17-22)
b. Order Services. Order all services to be
				delivered by the private duty nurse. (3-17-22)
c. Sign Medical Plan of Care. Review, sign,
				and date child's Medical Plan of Care and orders at least annually or as
				condition changes. (3-17-22)
d.
				Community Resources. Determine if the combination of PDN Services along with
				other community resources are sufficient to ensure the health or safety of the
				child. If it is determined that the resources are not sufficient to ensure the
				health and safety of the child, notify the family and the Department and
				facilitate the admission of the child to the appropriate medical facility.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: ENHANCED HOME HEALTH CARE › Section 16.03.10.210 - PRIVATE DUTY NURSING SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
Provider claims for PDN Services require EVV compliance as
				  described in Section 041 of these
				  rules in order to be eligible for payment. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.220 - NURSING FACILITY

Current through August 31, 2023
The Enhanced Plan Benefit includes nursing facilities
				  services permitted under Section
				  1905(a)(4)(A)  of
				  the Social Security Act. These services include nursing facilities services
				  (other than services in an institution for mental diseases) for individuals
				  determined to be in need of such care. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.222 - NURSING FACILITY SERVICES: ELIGIBILITY

Current through August 31, 2023
Entitlement to medical assistance participation in the cost
				  of long-term care exists when the individual is eligible for medical assistance
				  and the Department has determined that the individual meets the criteria for
				  nursing facility services. Entitlement will be determined prior to
				  authorization of payment for such care for an individual who is either a
				  participant of or an applicant for medical assistance. (3-17-22)
01.
Criteria for Determination
.
				The criteria for determining a medical assistance participant's need for
				nursing facility care is described in Section
				223. In addition, the Inspection of
				Care/Utilization Control (IOC/UC) nurse must determine whether a medical
				assistance participant's needs could be met by alternatives other than residing
				in a nursing facility, such as an independent living arrangement or residing in
				a room and board situation. (3-17-22)
a. The
				participant can select any certified facility to provide the care required.
				(3-17-22)
b. The final decision as
				to the level of care required by a medical assistance participant must be made
				by the IOC/UC Nurse. (3-17-22)
c.
				The final decision as to the need for developmental disability (DD) or mental
				illness (MI) active treatment will be made by the appropriate Department staff
				as a result of the Level II screening process. (3-17-22)
d. No payment will be made by the Department
				on behalf of any eligible medical assistance participant to any long-term care
				facility that, in the judgment of the IOC/UC Team, is admitting individuals for
				care or services that are beyond the facility's licensed level of care or
				capability. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.223 - NURSING FACILITY: CRITERIA FOR DETERMINING NEED

Current through August 31, 2023
The participant requires nursing facility level of care when
				  an adult meets one (1) of the Resource Utilization Group (RUG III)
				  classifications or when a child meets one (1) or more of the criteria described
				  in Subsections 223.02,
				  223.03,
				  223.04 or
				  223.05 of this rule. A child is
				  an individual from age zero (0) through eighteen (18) years; an adult is an
				  individual more than eighteen (18) years of age. (3-17-22)
01.
Required Assessment for
				Adults
. A standard assessment will be approved by the Department for all
				adults requesting services with requirements for nursing facility level of
				care. The Department will specify the instrument to be used.
				(3-17-22)
02.
Supervision
				Required for Children
. Where the inherent complexity of a service
				prescribed by the physician is such that it can be safely and effectively
				performed only by or under the supervision of a licensed nurse or licensed
				physical or occupational therapist. (3-17-22)
03.
Preventing Deterioration for
				Children
. Skilled care is needed to prevent, to the extent possible,
				deterioration of the child's condition or to sustain current capacities,
				regardless of the restoration potential of a child, even where full recovery or
				medical improvement is not possible. (3-17-22)
04.
Specific Needs for Children
.
				When the plan of care, risk factors, and aggregate of health care needs is such
				that the assessments, interventions, or supervision of the child necessitates
				the skills of a licensed nurse or a licensed physical therapist or licensed
				occupational therapist. In such cases, the specific needs or activities must be
				documented by the physician's orders, progress notes, plan of care, and nursing
				and therapy notes. (3-17-22)
05.
Nursing Facility Level of Care for Children
. Using the criteria
				found in Subsections 223.02,
				223.03, and
				223.04 of these rules, plus
				consideration of the developmental milestones, based on the age of the child,
				the Department's BLTC will determine nursing facility level of care.
				(3-17-22)
06.
Conditions of
				Payment
. (3-17-22)
a. As a condition of
				payment by the Department for long-term care on behalf of medical assistance
				participants, each fully licensed long-term care facility is to be under the
				supervision of an administrator who is currently licensed under the laws of the
				state of Idaho and in accordance with the rules of the Bureau of Occupational
				Licenses. (3-17-22)
b. Payment by
				the Department for the cost of long-term care excludes the date of the
				participant's discharge, unless the day of discharge occurs on the same day as
				admission; then, one (1) day of care is deemed to exist. When a Medicaid
				patient dies in a nursing home, the date of death is covered, regardless of the
				time of death. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.224 - NURSING FACILITY: POST-ELIGIBILITY TREATMENT OF INCOME

Current through August 31, 2023
Where an individual is determined eligible for medical
				  assistance participation in the cost of their long term care, the Department
				  will reduce its payment to the long term care facility by the amount of their
				  income considered available to meet the cost of their care. This determination
				  is made in accordance with IDAPA 16.03.05, "Eligibility for Aid to the Aged,
				  Blind, and Disabled (AABD)," Sections
				  721 through
				  726. The amount that the medical
				  assistance participant receives from SSA as reimbursement for their payment of
				  the premium for Part B of Title XVIII (Medicare) is not considered income for
				  patient liability under IDAPA 16.03.05, "Eligibility for Aid to the Aged,
				  Blind, and Disabled (AABD),
"
Section
				  317. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.225 - NURSING FACILITY: COVERAGE AND LIMITATIONS

Current through August 31, 2023
An institution must provide, on a regular basis,
				  health-related care and services to individuals; who because of their mental or
				  physical condition require care and services above the level of room, board,
				  and supervision. (3-17-22)
01.
Nursing Facility Care
. The minimum content of care and services for
				nursing facility patients must include the following: (3-17-22)
a. Room and board; (3-17-22)
b. Bed and bathroom linens;
				(3-17-22)
c. Nursing care,
				including special feeding if needed; (3-17-22)
d. Personal services; (3-17-22)
e. Supervision as required by the nature of
				the patient's illness and duration of their stay in the nursing facility;
				(3-17-22)
f. Special diets as
				prescribed by a patient's physician; (3-17-22)
g. All common medicine chest supplies that
				are over-the-counter including mouthwashes, analgesics, laxatives, emollients,
				burn ointments, first aid cream, protective creams and liquids, cough and cold
				preparations, and simple eye preparations; (3-17-22)
h. Dressings; (3-17-22)
i. Administration of intravenous,
				subcutaneous, or intramuscular injections and infusions, enemas, catheters,
				bladder irrigations, and oxygen; (3-17-22)
j. Application or administration of all
				drugs; (3-17-22)
k. All medical
				supplies including gauzes, bandages, tapes, compresses, cottons, sponges, hot
				water bags, ice bags, disposable syringes, thermometers, cellucotton,
				incontinent supplies, or any other type of pads used to save labor or linen,
				and disposable gloves; (3-17-22)
l.
				Social and recreational activities; and (3-17-22)
m. Each item that is utilized by individual
				patients and is reusable and expected to be available, such as bed rails,
				canes, crutches, walkers, wheel chairs, traction equipment, and other durable
				medical equipment. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.226 - NURSING FACILITY: PROCEDURAL RESPONSIBILITIES

Current through August 31, 2023
01.
Nursing Facility Responsibility
. Each nursing facility
				administrator, or their authorized representative must report the following
				information to the appropriate BLTC within three (3) working days of the date
				the facility has knowledge of the following. (3-17-22)
a. Any readmission or discharge of a
				participant, and any temporary absence of a participant due to hospitalization
				or therapeutic home visit. (3-17-22)
b. Any changes in the amount of a
				participant's income. (3-17-22)
c.
				When a participant's account has exceeded the following amount; (3-17-22)
i. For a single individual, one thousand
				eight hundred dollars ($1,800); or (3-17-22)
ii. For a married couple, two thousand eight
				hundred dollars ($2,800). (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.227 - PREADMISSION SCREENING AND RESIDENT REVIEW PROGRAM (PASRR)

Current through August 31, 2023
All Medicaid certified nursing facilities must participate
				  in, cooperate with, and meet all requirements imposed by, the Preadmission
				  Screening and Resident Review program, (PASRR) as set forth in 42 CFR, Part
				  483, Subpart C. (3-17-22)
01.
Background and Purpose
. The purpose of these provisions is to comply
				with and implement the PASRR requirements imposed on the state by federal law.
				The purpose of those requirements is to prevent the placement of individuals
				with mental illness (MI) or intellectual disabilities (ID) in a nursing
				facility unless their medical needs clearly indicate that they require the
				level of care provided by a nursing facility. This is accomplished by both
				pre-admission screening (PAS) and resident review (RR). Individuals, for whom
				it appears that a diagnosis of MI or ID is likely, are identified for further
				screening by means of a Level I screen. The actual PASRR is accomplished
				through a Level II screen where it is determined whether, because of the
				individual's physical and mental condition, they require the level of services
				provided by a nursing facility. If the individual with MI or ID is determined
				to require a nursing facility level of care, it must also be determined whether
				the individual requires specialized services. PASRR applies to all individuals
				entering or residing in a nursing facility, regardless of payment source.
				(3-17-22)
02.
Policy
.
				It is the policy of the Department that the difficulty in providing specialized
				services in the nursing facility setting makes it generally inappropriate to
				place individuals needing specialized services in an nursing facility. This
				policy is supported by the background and development of the federal PASRR
				requirements, including the narrow definition of mental illness adopted by
				federal law. While recognizing that there are exceptions, it is envisioned that
				most individuals appropriate for nursing facility placement will not require
				services in excess of those required to be provided by nursing facilities by
				42 CFR
				483.45. (3-17-22)
03.
Inter-Agency Agreement
. The
				state Medicaid agency will enter into a written agreement with the state mental
				health and intellectual disabilities authorities as required in
				42 CFR
				431.621(c). This agreement
				will, among other things, set forth respective duties and delegation of
				responsibilities, and any supplemental criteria to be used in making
				determinations. (3-17-22)
a. The "State
				Mental Health Authority" (SMHA) in the Division of Behavioral Health of the
				Department, or its successor entity. (3-17-22)
b. The "State Intellectual Disabilities or
				Developmental Disabilities Authority" (SDDA) in the Division of Family and
				Community Services of the Department, or its successor entity.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.228 - NURSING FACILITY: COORDINATION OF NURSING FACILITY ELIGIBILITY AND THE NEED FOR SPECIALIZED SERVICES

Current through August 31, 2023
Determinations as to the need for nursing facility care and
				  determinations as to the need for specialized services should not be made
				  independently. Such determinations will often be made on an individual basis,
				  taking into account the condition of the resident and the capability of the
				  facility to which admission is proposed to furnish the care needed. When an
				  individual identified with MI and ID is admitted to a nursing facility, the
				  nursing facility is responsible for meeting that individual's needs, except for
				  the provision of specialized services. (3-17-22)
01.
Level of Care
. (3-17-22)
a. Individual determinations must be based on
				evaluations and data as required by these rules. (3-17-22)
b. Categorical determinations. Recognizing
				that individual determinations of level of care are not always necessary, those
				categories set forth as examples at
				42 CFR
				483.130(d) are hereby
				adopted as appropriate for categorical determinations. When nursing facility
				level of care is determined appropriate categorically, the individual may be
				conditionally admitted prior to completion of the determination for specialized
				services. However, conditional admissions cannot exceed seven (7) days, except
				for respite admissions which cannot exceed thirty (30) consecutive days in one
				(1) calendar year. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.229 - NURSING FACILITY: PREPAYMENT SCREEN AND DETERMINATION OF ENTITLEMENT TO MEDICAID PAYMENT FOR NURSING FACILITY CARE AND SERVICES

Current through August 31, 2023
The level of care for Title XIX and Title XXI payment
				  purposes is determined by the Department. Necessity for payment is determined
				  in accordance with 42 CFR
				  483 Subpart C and Section
				  1919(e) (7)  of
				  the Social Security Act. In the event a required Level II screen was not
				  accomplished prior to admission, entitlement for Medicaid payment as
				  established by the BLTC will not be earlier than the date the Level II screen
				  is completed, indicating that nursing facility placement is appropriate.
				  (3-17-22)
01.
Information
				Required for Medical Evaluation Determination
. A current Minimum Data
				Set (MDS) assessment will be provided to the Department. Additional supporting
				information may be requested. (3-17-22)
02.
Information Required for Level I
				and II Screen Determination
. An accurate Level I screen and when
				required, a Level II screen. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.230 - NURSING FACILITY: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
01.
Provider Application and
				Certification
. A facility must apply to participate as a nursing
				facility. (3-17-22)
02.
Licensure and Certification
. (3-17-22)
a. Upon receipt of an application from a
				facility, the Licensing and Certification Agency determines the facility's
				compliance with certification standards for the type of care the facility
				proposes to provide to medical assistance participants. (3-17-22)
b. If a facility proposes to participate as a
				skilled nursing facility, Medicare (Title XVIII) certification and program
				participation is required before the facility can be certified for Medicaid.
				The Licensing and Certification Agency will determine the facility's compliance
				with Medicare requirements and recommend certification to the Medicare Agency.
				(3-17-22)
c. If the Licensing and
				Certification Agency determines that a facility meets Title XIX certification
				standards for nursing facility care. The Department will certify to the
				appropriate branch of government that the facility meets the standards for
				nursing facility level of care. (3-17-22)
d. Upon receipt of the certification from the
				Licensing and Certification Agency, the Department may enter into a provider
				agreement with the long-term care facility. (3-17-22)
e. After the provider agreement has been
				executed by the Facility Administrator and by the Department, one (1) copy will
				be sent by certified mail to the facility and the original is to be retained by
				the Department. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.235 - NURSING FACILITY: PROVIDER REIMBURSEMENT

Current through August 31, 2023
01.
Payment Methodology
. Nursing facilities will be reimbursed in
				accordance with the payment methodologies as described in Sections
				236 through
				295 of these rules.
				(3-17-22)
02.
Date of
				Discharge
. Payment by the Department for the cost of long term care is
				to exclude the date of the participant's discharge. If a Medicaid patient dies
				in a nursing home, their date of death is covered regardless of the time of
				occurrence. If an admission and a discharge occur on the same date, then one
				(1) day of care will be deemed to exist. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.236 - NURSING FACILITY: REASONABLE COST PRINCIPLES

Current through August 31, 2023
To be allowable, costs must be reasonable, ordinary,
				  necessary and related to patient care. It will be expected that providers will
				  incur costs in such a manner that economical and efficient delivery of quality
				  health care to participants will result. (3-17-22)
01.
Application of Reasonable Cost
				Principles
. (3-17-22)
a. Reasonable
				costs of any services are determined in accordance with this chapter of rules
				found in Sections 236 through
				295 of these rules, and Provider
				Reimbursement Manual (PRM), Sections
				100 through
				2600, as modified by the
				exceptions contained herein, is used to identify cost items to be included on
				Idaho's Uniform Cost Report. (3-17-22)
i.
				Reasonable cost takes into account both direct and indirect costs of providers
				of services, including normal standby costs. (3-17-22)
ii. The objectives of these methods are that:
				first, the costs with respect to individuals covered by the program will not be
				borne by others not so covered. Second, the costs with respect to individuals
				not covered will not be paid by the program. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.237 - NURSING FACILITY: NOTICE OF PROGRAM REIMBURSEMENT

Current through August 31, 2023
Following receipt of the finalized Medicare Cost Report and
				  the timely receipt of any other information requested by the Department to
				  fairly cost settle with the provider, a certified letter with the return
				  receipt requested will be sent to the provider that sets forth the amounts of
				  underpayment or overpayment made to the provider. (3-17-22)
01.
Notice
. The notice of the
				results of the final retroactive adjustment will be sent even though the
				provider intends to request a hearing on the determination, or has appealed the
				Medicare Intermediary's determination of cost settlement. Where the
				determination shows that the provider is indebted to the Medicaid program
				because total interim and other payments exceed cost limits, the state will
				take the necessary action to recover overpayment, including the suspension of
				interim payments sixty (60) days after the provider's receipt of the notice.
				(3-17-22)
02.
Recovery or
				Suspension
. Such action of recovery or suspension will continue even
				after a request for an informal conference or hearing is filed with the state.
				If the hearing results in a revised determination, appropriate adjustments will
				be made to the settlement amount. (3-17-22)
03.
Timing of Notice
. The
				Department will make every effort to issue a notice of program reimbursement
				within twelve (12) months of receipt of the Cost Report from the Medicare
				Intermediary. (3-17-22)
04.
Reopening of Completed Settlements
. A Medicaid completed cost settlement
				may be reopened by the provider or the state within a three-year (3) period
				from the date of the letter of notice of program reimbursement. The issues must
				have been raised, appealed and resolved through the reopening of the Cost
				Report by the Medicare Intermediary. Issues previously addressed and resolved
				by the Department's appeal process are not cause for reopening of the finalized
				cost settlement. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.238 - NURSING FACILITY: INTEREST CHARGES ON OVERPAYMENTS AND UNDERPAYMENTS

Current through August 31, 2023
The Title XIX and Title XXI programs will charge interest on
				  overpayments, and pay interest on underpayments. (3-17-22)
01.
Interest After Sixty Days of
				Notice
. If full repayment from the indebted party is not received within
				sixty (60) days after the provider has received notice of program
				reimbursement, interest will accrue from the date of receipt of the notice of
				program reimbursement, and will be charged on the unpaid settlement balance for
				each thirty- day (30) period that payment is delayed. Periods of less than
				thirty (30) days will be treated as a full thirty-day (30) period, and the
				thirty-day (30) interest charge will be applied to any unpaid balance. Each
				payment will be applied first to accrued interest, then to the principal.
				Interest accrued on overpayments and interest on funds borrowed by a provider
				to repay overpayments are not an allowable interest expense.
				(3-17-22)
02.
Waiver of
				Interest Charges
. When the Department determines an overpayment exists,
				it may waive interest charges if it determines that the administrative costs of
				collecting them exceed the charges. (3-17-22)
03.
Rate of Interest
. The
				interest rate on overpayments and underpayments will be the statutory rate as
				set forth in Section
				28-22-104(1),
				Idaho Code, compounded monthly. (3-17-22)
04.
Retroactive Adjustment
. The
				balance and interest will be retroactively adjusted to equal the amounts that
				would have been due based on any changes that occur as a result of the final
				determination in the administrative appeal and judicial appeal process.
				Interest penalties will only be applied to unpaid amounts and will be
				subordinated to final interest determinations made in the judicial review
				process. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.239 - NURSING FACILITY: RECOVERY METHODS FOR OVERPAYMENTS

Current through August 31, 2023
One (1) of the following methods will be used for recovery of
				  overpayments: (3-17-22)
01.
Lump Sum Voluntary Repayment
. Upon receipt of the notice of program
				reimbursement, the provider voluntarily refunds, in a lump sum, the entire
				overpayment to the Department. (3-17-22)
02.
Periodic Voluntary
				Repayment
. The provider must request in writing that recovery of the
				overpayment be made over a period of twelve (12) months or less. The provider
				must adequately document the request by demonstrating that the financial
				integrity of the provider would be irreparably compromised if repayments
				occurred over a shorter period of time than requested. (3-17-22)
03.
Department Initiated
				Recovery
. The Department will recover the entire unpaid balance of the
				overpayment of any settlement amount in which the provider does not respond to
				the notice of program reimbursement within thirty (30) days of receiving the
				notice. (3-17-22)
04.
Recovery From Medicare Payments
. The Department can request that
				Medicare payments be withheld in accordance with
				42 CFR, Section
				405.377. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.242 - NURSING FACILITY: HOME OFFICE COST PRINCIPLES

Current through August 31, 2023
The reasonable cost principles will extend to the home office
				  costs allocated to individual providers. In addition, the home office, through
				  the provider, will provide documentation as to the basis used to allocate its
				  costs among the various entities it administers or otherwise directs.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.243 - NURSING FACILITY: RELATED PARTY TRANSACTIONS

Current through August 31, 2023
01.
Principle
. Costs applicable to services, facilities and supplies
				furnished to the provider by organizations or persons related to the provider
				by common ownership, control, etc., are allowable at the cost to the related
				party. Such costs are allowable to the extent that they relate to patient care,
				are reasonable, ordinary, and necessary, and are not in excess of those costs
				incurred by a prudent cost-conscious buyer. (3-17-22)
02.
Cost Allowability -
				Regulation
. Allowability of costs is subject to the regulations
				prescribing the treatment of specific items as outlined in
				42 CFR
				413.17, et al, and the Providers
				Reimbursement Manual, PRM Chapter 10 and other applicable chapters of the PRM.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.244 - NURSING FACILITY: APPLICATION OF RELATED PARTY TRANSACTIONS

Current through August 31, 2023
01.
Determination of Common Ownership
				or Control in the Provider Organization and Supply Organization
. In
				determining whether a provider organization is related to a supplying
				organization, the tests of common ownership and control are to be applied
				separately. If the elements of common ownership or control are not present in
				both organizations, the organizations are deemed not to be related to each
				other. (3-17-22)
a. A determination as to
				whether an individual(s) possesses ownership or equity in the provider
				organization and the supplying organization, so that the organizations will be
				considered to be related by common ownership, will be made on the basis of the
				facts and circumstances in each case. (3-17-22)
b. The term "control" includes any kind of
				control whether or not it is legally enforceable and however it is exercisable
				or exercised. It is the reality of the control that is decisive, not its form
				or the mode of its exercise. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.245 - NURSING FACILITY: COMPENSATION OF RELATED PERSONS

Current through August 31, 2023
Compensation paid to persons related to owners or
				  administrators is allowable only to the extent that services are actually
				  performed and are necessary and adequately documented and the compensation for
				  the services is reasonable. (3-17-22)
01.
Compensation Claimed
.
				Compensation claimed for reimbursement must be included in compensation
				reported for tax purposes and be actually paid. (3-17-22)
a. Where such persons perform services
				without pay, no cost may be imputed. (3-17-22)
b. Time records documenting actual hours
				worked are required in order that the compensation be allowable for
				reimbursement. (3-17-22)
c.
				Compensation for undocumented hours worked will not be a reimbursable cost.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.246 - NURSING FACILITY: INTEREST EXPENSE

Current through August 31, 2023
Generally interest on loans between related entities is not
				  an allowable expense. The loan will usually be considered invested capital. See
				  PRM, Chapter 2 for specifics. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.250 - NURSING FACILITY: COST LIMITS

Current through August 31, 2023
Sections
				  250 through
				  267 of these rules and the Idaho
				  Medicaid Provider Agreement Additional Terms - Nursing Facility, provide
				  procedures and specifications necessary to implement the provisions and
				  accomplish the objectives of the nursing home reimbursement system as specified
				  in Sections
				  56-101 through
				  56-135, Idaho Code. All audits
				  related to fiscal years ending on or before December 31, 1999, are subject to
				  rules in effect before July 1, 1999. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.255 - NURSING FACILITY: RATE SETTING

Current through August 31, 2023
The objectives of the rate setting mechanism for nursing
				  facilities are: (3-17-22)
01.
Payments
. To make payments to nursing facilities through a prospective
				price-based system, which includes facility-specific case mix adjustments,
				separate margin payments for indirect care costs and direct care costs, and
				applied BAF. (3-17-22)
02.
Rate Adjustment
. To set rates based on each facility's case mix index on
				a quarterly basis and establishing rates that reflect the case mix of that
				facility's Medicaid residents as of a certain date during the preceding
				quarter. (3-17-22)