California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51343.1 - Intermediate Care Facility Services for the Developmentally Disabled Habilitative

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Intermediate care facility services for the developmentally disabled
					 habilitative (ICF-DDH) are covered subject to prior authorization by the
					 Department of Health Services for the ICF-DDH level of care. Authorizations may
					 be granted for up to six months. Requests for prior authorization of admission
					 to an ICF-DDH or for continuation of services shall be initiated by the
					 facility on forms designated by the Department. Certification documentation
					 required by the Department of Developmental Services must be completed by
					 regional center personnel and submitted with the Treatment Authorization
					 Request form. The attending physician shall sign the Treatment Authorization
					 Request form and shall certify to the Department that the beneficiary requires
					 this level of care.
(b) The request
					 for reauthorization shall be received by the appropriate Medi-Cal consultant on
					 or before the first working day following the expiration of a current
					 authorization. Certification shall be redetermined and a new certification form
					 shall be completed by regional center personnel and shall be attached to the
					 request for authorization. One day of authorization shall be denied for each
					 day the reauthorization request is late.
(c) The Medi-Cal consultant shall deny any
					 authorization request or reauthorization request, or shall cancel any
					 authorization in effect when services or placement are not appropriate to the
					 health and developmental needs of the beneficiary. Where the reauthorization
					 request is denied, or an existing authorization is cancelled, the facility
					 shall be notified by the most expeditious means. A copy of the denial letter
					 and the denied Treatment of Authorization Request shall serve as the official
					 notice of action and shall be returned to the provider. Payment will be made up
					 to 15 days following the postmark date of the denial letter.
(d) Prior to the transfer of a beneficiary
					 between facilities, the receiving facility shall originate an initial Treatment
					 Authorization Request signed by the attending physician. This Treatment
					 Authorization Request must be approved by a DHS Medi-Cal consultant prior to
					 admission except in cases of emergency as specified in Section
					 51056.
(e) Covered services shall be limited to
					 individuals who are defined as developmentally disabled in Welfare and
					 Institutions Code, Section
					 4512.
					 In determining the need for intermediate care facility services for the
					 developmentally disabled habilitative, the following criteria shall be
					 considered:
(1) The complexity of the
					 beneficiary's medical problems is such that skilled nursing care on an ongoing
					 but intermittent basis is needed. Individuals shall be placed in an ICF-DDH
					 only if their predominant skilled nursing needs are predictable and advance
					 arrangements can be made for licensed nurses to provide needed services at
					 prescribed intervals. Individuals who require skilled nursing procedures on an
					 "as needed basis" are not candidates for placement in an ICF-DDH.
(2) Medication may be mainly supportive or
					 stabilizing but still requires professional nurse evaluation on an intermittent
					 basis.
(3) The beneficiary needs
					 specialized developmental, training and habilitative program services which are
					 not available through other levels of care.
(4) The extent to which provision of
					 specialized developmental, training and habilitative program services can be
					 expected to result in a higher level of beneficiary functioning and a lessening
					 dependence on others in carrying out daily living activities or in the
					 prevention of regression.
(5) The
					 beneficiary must have two or more developmental deficits as measured on
					 standardized evaluation forms prescribed and furnished by the Department of
					 Developmental Services in any one of the following two domains:
(A) Self-help domain:
1. Eating
2. Toileting
3. Bladder Control
4. Dressing
(B) Social-emotional domain:
1. Aggression--has had one or more violent
					 episodes causing minor physical injury within the past year or has resorted to
					 verbal abuse and threats but has not caused physical injury within the past
					 year.
2. Self-injurious
					 behavior--behavior exists but result only in minor injuries which require first
					 aid.
3. Smearing feces--smears once
					 a week or more but less than once a day.
4. Destruction of property.
5. Running or wandering away.
6. Temper tantrums, or emotional
					 outbursts.
7. Unacceptable social
					 behavior--positive social participation is impossible unless closely supervised
					 or redirected.
(6) Beneficiaries shall not have any of the
					 following extreme developmental deficits in the socio-emotional area:
(A) Aggression--has had violent episodes
					 which have caused serious physical injury in the past year.
(B) Self-injurious behavior--causes severe
					 injury which requires physician attention at least once per year.
(C) Smearing--smears at every
					 opportunity.
(7)
					 Beneficiaries shall not be admitted to or approved for service in an
					 intermediate care facility for the developmentally disabled habilitative if
					 those beneficiaries have a decubitis ulcer.
(8) Beneficiaries shall not be admitted with
					 clinical evidence of an active communicable disease that is required to be
					 reported in accordance with Section
					 2500 of Title 17 of he California
					 Administrative Code.
(9)
					 Beneficiaries shall not be admitted to an ICF/DDH for purposes of respite care
					 with the exception of clients enrolled in a federally approved home and
					 community-based care program under Section
					 1915(c) of the
					 Social Security Act.