reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › PAYMENT CONDITIONS › Section 6210.48 - Reviews by the utilization review committee

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The utilization review committee of a
					 facility shall document in the medical record of the recipient the continued
					 stay review date and need determination of the committee.
(b) If the utilization review committee
					 recommends that a recipient's level of care be changed, the committee shall
					 notify the Department of the committee's recommendation on the Utilization
					 Review Request for Change Summary Form. A copy of the form shall be kept in the
					 recipient's medical record.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › PAYMENT CONDITIONS › Section 6210.49 - Adverse decisions by the Inspection of Care Team

Current through Register Vol. 54, No. 28, July 13, 2024
If the Department's Inspection of Care Team determines
						that a recipient no longer needs the level of care for which payment is
						authorized, the Inspection of Care team shall direct the Department to take
						action to authorize payment for alternate care.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › PAYMENT CONDITIONS › Section 6210.50 - Recipient notice of adverse decisions

Current through Register Vol. 54, No. 28, July 13, 2024
Upon notification of the recommended change in level of
						care, the Department will notify the recipient and facility of its decision. If
						the recipient or the representative of the recipient appeals the decision
						within 10 calendar days from the date the notice is mailed, payment for the
						present level of care will continue pending the outcome of the hearing. If the
						recipient does not respond to the notice within 10 calendar days, the
						Department will deny payment in a case where care is no longer needed or
						authorize payment for the appropriate level of care no earlier than 10 calendar
						days from the date the notice was mailed to the recipient.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › PAYMENT CONDITIONS › Section 6210.51 - Attending physician decision on level of care

Current through Register Vol. 54, No. 28, July 13, 2024
(a) In response to changes in the recipient's
					 medical condition, the attending physician may order a change in the
					 recipient's level of care which is different from the level of care for which
					 payment is authorized.
(b) If the
					 attending physician recommends that a recipient's level of care be changed, the
					 attending physician shall document the change in the recipient's medical record
					 and notify the Department of the level of care recommendation on the Attending
					 Physician Request for Change Summary Form. A copy of the form shall be kept in
					 the recipient's medical record.
(c)
					 If the recipient's level of care is changed as a result of a determination by
					 the Department's Inspection of Care Team, the attending physician may order a
					 change in the recipient's level of care only if the recipient's medical
					 condition changes subsequent to the date of the Inspection of Care Team's
					 determination and the change in the recipient's medical condition warrants
					 another level of care.
(d) The
					 physician shall date and sign the documentation of the change in the
					 recipient's medical condition and state the alternate care recommendation in
					 the recipient's record.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › PAYMENT CONDITIONS › Section 6210.52 - Payment pending appeal

Current through Register Vol. 54, No. 28, July 13, 2024
If the recipient or the facility acting on behalf of the
						recipient appeals an action of the Department to change the level of care for
						which payment is authorized within 10 calendar days from the date the notice is
						mailed, the Department will make payment to the facility for the level of care
						the recipient is presently receiving pending the outcome of the hearing. If the
						Department is sustained in its action, the Department will recover from the
						facility payment in excess of the amount that would have been made if the
						action of the Department had not been appealed. The period for which the
						Department will recover excess payment runs from 10 calendar days from the date
						the notice is mailed, to the date that the appropriate change in the level of
						care for which payment is authorized is made.
This section cited in 55 Pa. Code §
													6210.107 (relating to recipient
						  right of appeal of alternate care
						  determinations).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › ASSESSMENT › Section 6210.61 - Eligibility for an ICF/ID level of care

Current through Register Vol. 54, No. 28, July 13, 2024
An applicant or recipient shall receive active treatment
						to be determined eligible for an ICF/ID level of care. The ICF/ID Program shall
						have only one level of care. The level of care determination is based upon the
						developmental needs of each applicant or recipient.
The provisions of this §
													6210.61 amended under section
						  443.1(2) and (3)
						  of the Human Services Code (62 P.S. §
														443.1(2) and
						  (3)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › ASSESSMENT › Section 6210.62 - Level of care criteria

Current through Register Vol. 54, No. 28, July 13, 2024
(a) There
					 are three fundamental criteria which shall be met prior to an applicant or
					 recipient qualifying for an ICF/ID level of care. The ICF/ID level of care
					 shall be indicated only when the applicant or recipient:
(1) Requires active treatment.
(2) Has a diagnosis of an intellectual
					 disability.
(3) Has been
					 recommended for an ICF/ID level of care based on a medical
					 evaluation.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › ASSESSMENT › Section 6210.63 - Diagnosis of an intellectual disability

Current through Register Vol. 54, No. 28, July 13, 2024
The facility shall document the applicant's or
						recipient's diagnosis of an intellectual disability by meeting the following
						requirements:
(1) A licensed
					 psychologist, certified school psychologist or a licensed physician who
					 practices psychiatry shall certify that the applicant or recipient has
					 significantly subaverage intellectual functioning which is documented by one of
					 the following:
(i) Performance that is more
					 than two standard deviations below the mean as measurable on a standardized
					 general intelligence test.
(ii)
					 Performance that is slightly higher than two standard deviations below the mean
					 of a standardized general intelligence test during a period when the person
					 manifests serious impairments of adaptive behavior.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › ASSESSMENT › Section 6210.64 - Medical evaluation

Current through Register Vol. 54, No. 28, July 13, 2024
Applicants or recipients meeting the criteria for ICF/ID
						level of care shall have a medical evaluation completed by a licensed physician
						not more than 60 days prior to admission to an ICF/ID or before authorization
						for payment. The physician shall recommend the applicant or recipient for an
						ICF/ID level of care based on the medical evaluation.
The provisions of this §
													6210.64 amended under
						  section443.1(2) and (3)
						  of the Human Services Code (62 P.S. §
														443.1(2) and
						  (3)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › ASSESSMENT › Section 6210.65 - Recertification

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Recertification
					 shall be on a form specified by the Department and based on the applicant's or
					 recipient's continuing need for an ICF/ID level of care, progress toward
					 meeting plan objectives, the appropriateness of the plan of care and
					 consideration of alternate methods of care.
(b) Recertification of need for an ICF/ID
					 level of care shall be made at least once every 365 days after the initial
					 certification.
The provisions of this §
													6210.65 amended under section
						  443.1(2) and (3)
						  of the Human Services Code (62 P.S. §
														443.1(2) and
						  (3)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › PAYMENT LIMITATIONS › Section 6210.71 - Limitations on payment for reserved bed days

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Hospital leave is a reserve bed day,
					 limited in number, during which a client is temporarily absent from the
					 facility for hospitalization.
(b)
					 For each hospitalization, a recipient receiving intermediate care for
					 individuals with an intellectual disability, except for a recipient in a State
					 operated ICF/ID, is eligible for a maximum 15 consecutive reserve bed days for
					 hospital leave. The Department will pay a facility at the interim per diem rate
					 on file with the Department for a hospital reserve bed day. Subject to this
					 limit, a facility may include hospital reserve bed days in its census as client
					 days, and costs associated with hospital reserve bed days shall be included in
					 the facility's cost report. A reserve bed will be available for the recipient
					 upon the recipient's return to the facility.
(c) Therapeutic leave is a reserve bed day,
					 subject to limits, during which the recipient is temporarily absent from the
					 facility due to the need to obtain a component of the recipient's individual
					 program plan which cannot be provided directly by the facility. Therapeutic
					 leave is included in the recipient's individual program plan, and the facility
					 is required to monitor and document therapeutic leave. Therapeutic leave is
					 primarily intended to maintain and further enhance relationships between the
					 recipient and his family. Therapeutic leave includes leave for camp or other
					 special programs.
(d) The
					 Department will make payment to a facility for a reserved bed day when the
					 recipient is absent from the facility for a continuous 24-hour period because
					 of therapeutic leave. Each reserved bed day for therapeutic leave shall be
					 recorded on the facility's daily census record and invoice. A reserved bed
					 shall be available for the recipient upon the recipient's return to the
					 facility.
(e) A recipient receiving
					 intermediate care for individuals with an intellectual disability is eligible
					 for a maximum of 75 days per calendar year for therapeutic leave outside the
					 facility.
(f) For each continuous
					 24-hour period the recipient is absent from the facility, the facility shall
					 bill the Department for a therapeutic leave day, under the limitations in this
					 chapter. When the continuous 24-hour period is broken, this will not count as a
					 reserved bed day.
The provisions of this §
													6210.71 amended under section
						  443.1(2) and (3)
						  of the Human Services Code (62 P.S. §
														443.1(2) and
						  (3)).
This section cited in 55 Pa. Code §
													6210.75 (relating to
						  noncompensable services).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › PAYMENT LIMITATIONS › Section 6210.72 - Limitations on payment for prescription drugs

Current through Register Vol. 54, No. 28, July 13, 2024
The Department's interim per diem rate for non-State
						operated ICFs/ID does not include prescription drugs. Prescribed drugs for
						categorically needy recipients are reimbursable directly to a licensed pharmacy
						according to regulations contained in Chapter 1121 (relating to pharmaceutical
						services).
The provisions of this §
													6210.72 amended under section
						  443.1(2) and (3)
						  of the Human Services Code (62 P.S. §
														443.1(2) and
						  (3)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › PAYMENT LIMITATIONS › Section 6210.73 - Limitations on payment during strike or disaster situations requiring recipient evacuation

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 Payment may continue to be made to a facility that has temporarily transferred
					 recipients, as the result or threat of a strike or disaster situation, to the
					 closest medical institution able to meet the recipients' needs, if the
					 institution receiving the recipients is licensed and certified to provide the
					 required level of care.
(b) If the
					 facility transferring the recipients can demonstrate that there is no certified
					 facility available for the safe and orderly transfer of the recipients, the
					 payments may be made so long as the institution receiving the recipients is
					 certifiable and licensed to provide the required level of care.
(c) If the facility to which the recipients
					 are transferred has a different interim per diem rate, the transferring
					 facility will be reimbursed at the lower rate.
(d) The facility shall immediately notify the
					 Department, Office of Medical Assistance Programs, in writing of an impending
					 strike or a disaster situation and shall include a listing of MA recipients and
					 the facility to which they will be or were transferred.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › PAYMENT LIMITATIONS › Section 6210.74 - Services included in the interim per diem rate

Current through Register Vol. 54, No. 28, July 13, 2024
The Department's interim per diem rate of reimbursement
						includes allowable costs for routine services. Services include the following:
(1) Regular room, habilitation
					 services, personal care services, social services, therapeutic services,
					 dietary services, general nursing services, other services required to
					 implement the recipient's plan of care and to meet certification standards,
					 medical supplies and the use of equipment and facilities.
(2) Items furnished routinely and relatively
					 uniformly to recipients, such as personal clothing, furniture and recreational
					 equipment.
(3) Items furnished,
					 distributed or used individually in small quantities such as personal hygiene
					 supplies, health care supplies and nonprescription drugs ordinarily kept on
					 hand.
(4) Items used by recipients
					 but which are reusable and expected to be available, such as household
					 furniture, therapeutic equipment and durable medical equipment.
(5) Special dietary supplements used for tube
					 feeding or oral feeding, such as an elemental high nitrogen diet, even if
					 written as a prescription item by a physician.
(6) Laundry services including the laundering
					 of the recipient's personal clothing.
(7) Other special medical services of a
					 rehabilitative, restorative or maintenance nature, designed to restore or
					 sustain the recipient's physical and social capacities.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › PAYMENT LIMITATIONS › Section 6210.75 - Noncompensable services

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will not be made for:
(1) Services provided to a recipient who no
					 longer requires the level of care for which payment is authorized by the
					 CAO.
(2) Reserved bed days that
					 exceed the limits specified in §
											6210.71 (relating to limitations
					 on payment for reserved bed days).
(3) Services provided to a recipient
					 occupying a bed which is not certified for the level of care for which payment
					 is authorized by the CAO.
(4)
					 Services covered but disallowed by Medicare.
(5) Services rendered by a provider that do
					 not meet the conditions for payment established by this chapter and Chapters
					 1101 and 6211 (relating to general provisions; and allowable cost reimbursement
					 for non-State operated intermediate care facilities for individuals with an
					 intellectual disability).
(6)
					 Services directly reimbursable under the MA Program.
The provisions of this §
													6210.75 amended under section
						  443.1(2) and (3)
						  of the Human Services Code (62 P.S. §
														443.1(2) and
						  (3)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › PAYMENT LIMITATIONS › Section 6210.76 - Cost reporting

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Each
					 facility shall submit a cost report to the Department within 90 days following
					 the close of each fiscal year as designated by the facility in accordance with
					 §
											6210.91 (relating to annual
					 reporting).
(b) The time frame for
					 submission of cost reports may be extended for an additional 30 days with
					 written approval from the Department's Office of Developmental Programs for
					 non-State operated ICFs/ID and from the Department's Bureau of Financial
					 Operations for State operated ICFs/ID.
(c) Cost reports shall be submitted on
					 Department form MA-11.
(d) The cost
					 report shall be prepared using the accrual basis of accounting and shall cover
					 a fiscal period of 12 consecutive months.
(e) Facilities beginning operations during a
					 fiscal period shall prepare a cost report from the date of approval for
					 participation to the end of the facility's fiscal year.
(f) The cost report shall identify costs of
					 services, facilities and supplies furnished by organizations related to the
					 provider by common ownership or control.
The provisions of this §
													6210.76 amended under section
						  443.1(2) and (3)
						  of the Human Services Code (62 P.S. §
														443.1(2) and
						  (3)).
This section cited in 55 Pa. Code §
													6210.111 (relating to failure to
						  file a cost report).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › PAYMENT LIMITATIONS › Section 6210.77 - Cost finding

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
					 direct allocation method of cost finding shall be used.
(b) The costs of ancillary and administrative
					 services shall be apportioned directly to the appropriate level of care based
					 on appropriate statistical data.
(c) A facility's direct or indirect allowable
					 costs related to care shall be considered in the finding and allocation of
					 costs to the MA Program for its eligible recipients. Total allowable costs of a
					 facility shall be apportioned between third-party payors and other recipients
					 so that the share borne by MA is based upon actual services and costs related
					 to MA recipients. For purposes of MA reimbursement, the return on net equity
					 and net worth is not reimbursable.
This section cited in 55 Pa. Code §
													6210.35 (relating to ongoing
						  provider responsibilities).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › PAYMENT LIMITATIONS › Section 6210.78 - Allowable costs

Current through Register Vol. 54, No. 28, July 13, 2024
(a) For State
					 operated ICFs/ID, allowable costs shall be determined by the Department's "Cost
					 Apportionment Manual for State Mental Hospitals and Intellectual Disability
					 Centers" and HIM-15.
(b) For
					 non-State operated ICFs/ID, allowable costs shall be determined based on
					 Chapter 6211 (relating to allowable cost reimbursement for non-State operated
					 intermediate care facilities for individuals with an intellectual disability)
					 and HIM-15.
(c) State operated
					 ICFs/ID shall be reimbursed actual allowable costs under the Statewide Cost
					 Allocation Plan and Medicare principles, subject to MA regulations.
(d) Non-State operated ICFs/ID shall be
					 reimbursed actual, allowable reasonable costs under Chapter 6211 and other
					 applicable MA regulations.
The provisions of this §
													6210.78 amended under section
						  443.1(2) and (3)
						  of the Human Services Code (62 P.S. §
														443.1(2) and
						  (3)).
This section cited in 55 Pa. Code §
													6210.92 (relating to final
						  reporting); and 55 Pa. Code §
													6210.93 (relating to auditing
						  requirements related to cost
						  reports).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › PAYMENT LIMITATIONS › Section 6210.79 - Setting interim per diem rates

Current through Register Vol. 54, No. 28, July 13, 2024
(a) For State operated ICFs/ID, interim per
					 diem rates shall be established by the Department based on the latest adjusted
					 reported costs and approved budgets.
(b) For non-State operated ICFs/ID, interim
					 per diem rates shall be established by the Department based on the latest
					 adjusted cost report plus an inflationary factor, or a submitted budget if a
					 waiver is granted in accordance with Chapter 6211 (relating to allowable cost
					 reimbursement for non-State operated intermediate care facilities for
					 individuals with an intellectual disability).
The provisions of this §
													6210.79 amended under section
						  443.1(2) and (3)
						  of the Human Services Code (62 P.S. §
														443.1(2) and
						  (3)).
This section cited in 55 Pa. Code §
													6210.35 (relating to ongoing
						  provider responsibilities).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › PAYMENT LIMITATIONS › Section 6210.80 - Maximum rate of payment

Current through Register Vol. 54, No. 28, July 13, 2024
Except as provided in this section, the Department's
						maximum rate of payment to an enrolled facility will be the lower of the
						following:
(1) The facility's lowest
					 charge to private pay recipients for the same level of care.
(2) The facility's final interim per diem
					 rate.
This section cited in 55 Pa. Code §
													6210.111 (relating to failure to
						  file a cost report).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › PAYMENT LIMITATIONS › Section 6210.81 - Upper limits of payment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
					 upper limits of payment for State operated ICFs/ID are the full allowable costs
					 as specified in the Department's "Cost Apportionment Manual for State Mental
					 Hospitals and Intellectual Disability Centers" and HIM-15.
(b) The upper limits of payment for non-State
					 operated ICFs/ID are the lower of costs or the total projected operating cost
					 or if a waiver is granted under Chapter 6211 (relating to allowable cost
					 reimbursement for non-State operated intermediate care facilities for
					 individuals with an intellectual disability) an approved budget level as
					 specified in Chapter 6211.
The provisions of this §
													6210.81 amended under section
						  443.1(2) and (3)
						  of the Human Services Code (62 P.S. §
														443.1(2) and
						  (3)).
This section cited in 55 Pa. Code §
													6210.111 (relating to failure to
						  file a cost report).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › PAYMENT LIMITATIONS › Section 6210.82 - Annual adjustment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An
					 annual payment adjustment shall be made by the Department or facility based on
					 total audited costs related to the total Department interim claims for services
					 for the fiscal year.
(b) For cost
					 reporting periods ending on or after October 1, 1985, if the total amount of MA
					 payment for interim claims for services during the fiscal year exceeds the
					 total audited costs, the Department will recover the overpaid amount from the
					 provider in accordance with Chapter 1101 (relating to general
					 provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › REPORTING AND AUDITING › Section 6210.91 - Annual reporting

Current through Register Vol. 54, No. 28, July 13, 2024
The fiscal year, for purposes of MA payments, is July 1
						through June 30.
This section cited in 55 Pa. Code §
													6210.76 (relating to cost
						  reporting).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › REPORTING AND AUDITING › Section 6210.92 - Final reporting

Current through Register Vol. 54, No. 28, July 13, 2024
A facility that enters into a termination agreement or an
						agreement of sale, or is withdrawing or being terminated as a provider, or is
						otherwise undergoing a change of ownership shall file an acceptable final cost
						report and outstanding annual cost reports with the Department within 45 days
						of the effective date of the termination, transfer, withdrawal or change of
						ownership and is required to provide financial records to the Department for
						auditing. An acceptable cost report is one that meets the requirements of
						§
											6210.78 (relating to allowable
						costs).
This section cited in 55 Pa. Code §
													6210.35 (relating to ongoing
						  provider responsibilities); and 55 Pa. Code §
													6210.111 (relating to failure to
						  file a cost report).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › REPORTING AND AUDITING › Section 6210.93 - Auditing requirements related to cost reports

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Except in cases of provider delay or
					 delay requested by State or Federal agencies investigating possible criminal or
					 civil fraud, the Department will conduct either a field audit or desk review of
					 each cost report within 1 year of the latter of its receipt in acceptable form,
					 as defined in §
											6210.78 (relating to allowable
					 costs) or, if the facility participates in Medicare and has reported home
					 office costs to the Department on its cost report, the Department's receipt of
					 the facility's Medicare home office audit, to verify, to the extent possible,
					 that the facility has complied with:
(1) This
					 chapter.
(2) Chapter 1101 (relating
					 to general provisions).
(3) The
					 limits established in Chapter 6211 (relating to allowable cost reimbursement
					 for non-State operated intermediate care facilities for individuals with an
					 intellectual disability).
(4) The
					 Department's "Cost Apportionment Manual for State Mental Hospitals and
					 Intellectual Disability Centers" for State operated ICFs/ID.
(5) HIM-15.
(6) The Department's cost allocation plan for
					 State operated ICFs/ID.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › REPORTING AND AUDITING › Section 6210.94 - Auditing requirements related to recipient fund management

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Records
					 relating to the facility's management of MA recipients' personal funds shall be
					 maintained for at least 4 years.
(b) Records relating to the facility's
					 management of MA recipients' personal funds shall be available to Federal and
					 State representatives upon request.
(c) MA recipients' fund accounts shall be
					 audited at the time the annual cost reports are validated for a
					 facility.
(d) If discrepancies are
					 proven and the facility is found to be at fault, the facility shall make
					 restitution to the recipients for funds improperly handled, accounted for or
					 disbursed.
(e) The facility has the
					 right of appeal in accordance with §§
											6210.121-6210.125 (relating to right of
					 appeal).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › UTILIZATION CONTROL › Section 6210.101 - Scope of claims review procedures

Current through Register Vol. 54, No. 28, July 13, 2024
Claims submitted for payment under the MA Program are
						subject to the utilization review procedures established in Chapter 1101
						(relating to general provisions). In addition, the Department will perform the
						reviews specified in this section and §§
											6210.102-6210.109 for controlling the
						utilization of ICF/ID services.
The provisions of this §
													6210.101 amended under section
						  443.1(2) and (3)
						  of the Human Services Code (62 P.S. §
														443.1(2) and
						  (3)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › UTILIZATION CONTROL › Section 6210.102 - Review of need for admission

Current through Register Vol. 54, No. 28, July 13, 2024
The Department's Inspection of Care Team will evaluate
						each applicant's or recipient's need for admission by reviewing and assessing
						the appropriate Departmental form completed by the attending physician or
						interdisciplinary team as required for the specifically prescribed level of
						care needed. The facility and recipient shall be notified of the decision on
						forms designated by the Department.
This section cited in 55 Pa. Code §
													6210.101 (relating to scope of
						  claims review procedures).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › UTILIZATION CONTROL › Section 6210.103 - Inspections of care

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
					 Department's Inspection of Care Team will inspect the care and services
					 provided to each recipient in a participating facility at least
					 annually.
(b) The Department will
					 not give the facility more than 48 hours notice of the time and date of the
					 schedule arrival of the team.
(c)
					 The facility shall make available to the team, in a readily reviewable format,
					 the recipient's complete medical records for the year since the last review of
					 the team.
This section cited in 55 Pa. Code §
													6210.101 (relating to scope of
						  claims review procedures).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › UTILIZATION CONTROL › Section 6210.104 - Content of inspections of care

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The inspection by the Inspection of Care
					 Team shall include:
(1) Personal contact with
					 and observation of each recipient.
(2) Review of each recipient's medical
					 record. The record shall include timely certification and recertifications by
					 the physician that the services are needed and a written individual plan of
					 care developed either by an interdisciplinary team or the attending or staff
					 physician, whichever is applicable. The plan of care shall indicate time limits
					 and measurable care objectives and goals to be accomplished and who is to give
					 each element of care.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › UTILIZATION CONTROL › Section 6210.105 - Inspection of care summary report

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Inspection of Care Team shall develop
					 a summary report at the conclusion of its inspection of each facility. The
					 report shall include:
(1) The alternate care
					 determinations.
(2) Findings of the
					 adequacy and quality of care rendered by the facility. The findings will
					 specify that the care rendered is acceptable or in need of
					 improvement.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › UTILIZATION CONTROL › Section 6210.106 - Facility course of action

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The facility shall return a copy of the
					 summary report with appropriate corrective actions written thereon to the
					 Department within 30 days of the control date indicated on the summary report.
					 The facility's planned course of corrective action shall include proposed time
					 frames for correcting findings of deficient care or services and narrative
					 recommendations.
(b) The Inspection
					 of Care Team may conduct a followup visit to determine if the deficiencies and
					 recommendations are corrected.
This section cited in 55 Pa. Code §
													6210.101 (relating to scope of
						  claims review procedures).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › UTILIZATION CONTROL › Section 6210.107 - Recipient right of appeal of alternate care determinations

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The recipient
					 or the person or the facility acting on the behalf of the recipient, in
					 accordance with Chapter 275 (relating to appeal and fair hearing and
					 administrative disqualification hearings), has 30 days in which to appeal the
					 Inspection of Care Team's alternate care determination.
(b) Neither the facility, the facility's
					 utilization review committee, nor the recipient's attending physician has the
					 right to appeal the alternate care determination on its own behalf.
(c) If the recipient or the person or the
					 facility acting on behalf of the recipient appeals the decision within 10
					 calendar days from the date the CAO issues the advance notice, payment for the
					 present level of care will continue pending the outcome of the hearing subject
					 to §
											6210.52 (relating to payment
					 pending appeal).
This section cited in 55 Pa. Code §
													6210.101 (relating to scope of
						  claims review procedures).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › UTILIZATION CONTROL › Section 6210.108 - Facility utilization review

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Each facility furnishing services to
					 eligible MA recipients shall have in effect a written utilization review plan
					 that provides for review of each recipient's need for the services.
(b) If the utilization review committee of a
					 facility finds that the continued stay of a recipient at a specific level of
					 care is not needed, the committee shall, within 1 working day of its decision,
					 request additional information from the recipient's qualified intellectual
					 disability professional, who shall respond within 2 working days. A physician
					 member of the committee, in cases involving a medical determination, or the
					 utilization review committee, in cases not involving a medical determination,
					 shall review the additional information and make the final recommendation. If
					 the additional information is not received within 2 working days, the
					 committee's decision will be deemed final.
(c) The utilization review committee shall
					 send written notice of adverse final decisions on the need for continued stay
					 to:
(1) The facility administrator.
(2) The qualified intellectual disability
					 professional of the recipient.
(3)
					 The CAO.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › UTILIZATION CONTROL › Section 6210.109 - Provider misutilization

Current through Register Vol. 54, No. 28, July 13, 2024
Facilities determined to have billed for services
						inconsistent with MA Program regulations, to have provided services outside the
						scope of customary standards of practice or to have otherwise violated the
						standards set forth in the provider agreement, are subject to the sanctions
						described in this chapter and Chapter 1101 (relating to general provisions).
This section cited in 55 Pa. Code §
													6210.101 (relating to scope of
						  claims review procedures).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › ADMINISTRATIVE SANCTIONS › Section 6210.111 - Failure to file a cost report

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Failure to file a cost report, other than
					 a final cost report, may result in termination of the provider agreement and
					 shall result in the suspension of interim payments to the provider until the
					 reports are filed in acceptable form. If the reports are not filed by the end
					 of the fifth month after the due date established by §
											6210.76 (relating to cost
					 reporting), including extensions of that date granted by the Department, the
					 Department may either determine payment for the cost reporting period involved
					 on the basis of the method established with respect to untimely final cost
					 reports in subsection (b) or seek injunctive relief to require proper filing,
					 as the Department may deem is in the best interest of the efficient and
					 economic administration of the program.
(b) Failure to file a final cost report and
					 outstanding annual cost reports, when due, under §
											6210.92 (relating to final
					 reporting) shall result in payment to the provider for the cost reporting
					 periods involved being determined on the basis of the lowest audited rate for a
					 provider, including a rate limited by §§
											6210.80 and
					 6210.81 (relating to maximum rate
					 of payment; and upper limits of payment) for the same level of care without
					 regard to the type of provider for services rendered during the 6 months
					 immediately preceding the beginning of the fiscal periods involved. Payment
					 will not be made for depreciation expenses incurred by the provider with
					 respect to services during the 365 days preceding the effective date of the
					 event described in §
											6210.92 which required the final
					 cost report to be filed. Interim payments or payments after audit of the
					 depreciation expenses shall be offset against payments due to the provider or
					 shall be repaid to the Department by the provider if no payment is
					 due.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › ADMINISTRATIVE SANCTIONS › Section 6210.112 - Failure to maintain adequate records

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If the Department determines that the
					 facility has not maintained financial and statistical records in accordance
					 with the Department's regulations, thus preventing the Department from
					 conducting an audit of the facility's records, the facility shall be notified,
					 by certified mail, that it has 60 days to correct the problem.
(b) The facility shall be advised that for
					 failure to comply with the Department's notice, the Department will terminate
					 the MA Provider Agreement, unless the problem is corrected within the 60-day
					 period.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › ADMINISTRATIVE SANCTIONS › Section 6210.113 - Failure to correct deficiencies

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If the facility fails to correct a
					 deficiency cited by the Department's Inspection of Care Team or causes delay in
					 the review process which results in a penalty being imposed by the United
					 States Department of Health and Human Services on the Department, the penalty
					 shall be imposed on the facility.
(b) Failure to correct deficiencies in
					 recipient care and services within 6 months following the receipt of the
					 Inspection of Care Team's review report may result in the termination of the
					 facility's MA Provider Agreement.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VIII - Intellectual Disability and Autism Manual › Subpart C - Administration and Fiscal Management › Chapter 6210 - PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM › ADMINISTRATIVE SANCTIONS › Section 6210.114 - Failure to adhere to certification requirements

Current through Register Vol. 54, No. 28, July 13, 2024
If the facility's failure to comply with the requirements
						that the physician certify and recertify the need for care as described under
						§§
											6210.42 and
						6210.43 (relating to certification
						of initial need for care; and recertification of continued need for care)
						results in a penalty being imposed by the United States Department of Health
						and Human Services on the Department, the penalty will be imposed on the
						facility.