Opinion ID: 75587
Heading Depth: 5
Heading Rank: 1

Heading: Meet the following conditions:

Text: 1. Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain; 2. Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient’s needs; 3. Be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational; 4. Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available, statewide; and 5. Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker, or the provider. Fla. Admin. Code. § 59G-1.010(166). Under the amended plan, the defendants also look to the Code of Federal Regulations section 483.440 for further guidance Services in an Intermediate Care Facility for the Mentally Retarded The recipient’s need must be determined by the agency based on medical necessity. See Florida Medicaid Plan, Attachment 3.1-A, effective October 1, 1992, replaced by amendment 96-12, April 27, 1998. 9 on how to determine medical necessity. Subsection (b) of that section of the regulations provides that clients who are admitted into an ICF/DD “must be in need of . . . active treatment services.” 42 C.F.R. § 483.440(b). “Active treatment” is defined as “a continuous active treatment program, which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services described in this subpart,” and does not include “services to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous active treatment program.” 42 C.F.R. § 483.440(a); see also Fla. Stat. § 393.063(1) (defining “Active treatment”); Fla. Admin. Code §§ 59G-1.010(2) (defining “Active treatment plan”), & 59G-4.171(4) (establishing the recipient eligibility criteria for “Intermediate Care Facilities for the Mentally Retarded/Developmentally Disabled,” including the need for “continual active treatment”). Thus, under Florida’s Medicaid Plan, an individual will not be deemed eligible for ICF/DD services unless such services are “determined to be medically necessary for the individual as expressed by a need for continuous active treatment. . . .” See Central Admission Policy for Intermediate Care Facilities for Persons With Developmental Disabilities (ICF/DD) in Compliance With Doe v. Chiles. 10