Section 51343 - Intermediate Care Facility Services for the Developmentally Disabled(a) Intermediate care facility services for the developmentally disabled are covered subject to prior authorization by the Department. Authorizations may be granted for up to six months. The authorization request shall be initiated by the facility. The attending physician shall sign the authorization request and shall certify to the Department that the beneficiary requires this level of care. Each authorization request and reauthorization request submitted shall have attached certification documentation as required by the Department of Developmental Services. Such documentation shall be completed by regional center personnel.
(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. When the request is received by the Medi-Cal consultant later than the first working day after the previously authorized period has expired, 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, reauthorization request, or shall cancel any authorization in effect when services or placement are not appropriate to the health needs of the patient. In the case of denial of a reauthorization request or cancellation of authorization, the facility shall be notified by the most expeditious means and payment may be made for up to 15 days following the date of giving notice.(d) The attending physician shall recertify, at least every 60 days, the patient's need for continued care in accordance with the procedures specified by the Director. The attending physician shall comply with this requirement prior to the 60-day period for which the patient is being recertified. The facility shall present proof of this recertification at the time of billing for services rendered.(e) Prior to the transfer of a beneficiary between facilities, a new initial Treatment Authorization Request shall be initiated by the receiving facility and signed by the attending physician. No transfer shall be made unless approved in advance by the Medi-Cal consultant for the district where the receiving facility is located.(f) Medi-Cal beneficiaries in the facility shall be visited by their attending physicians no less often than every 60 days. An alternative schedule of visits may be proposed subject to approval by the Medi-Cal consultant. An alternative schedule of visits shall not result in more than three months elapsing between physician visits.(g) There shall be a written plan of care for each beneficiary. The plan of care shall be reviewed and evaluated by a physician and other personnel involved in the care of the individual every 90 days. The plan of care shall meet the requirements of 42 CFR 456.380.(h) Each beneficiary shall receive a comprehensive medical, social and psychological evaluation prior to admission. Psychological evaluations shall be performed within a time period not exceeding three months before admission and shall meet the requirements of 42 CFR 456.370 (a) (1) (i).(i) Each beneficiary shall receive a complete dental examination within one month following admission unless such an examination was done within six months of admission, and the results are received and reviewed by the facilities and are entered into the resident's record. Each beneficiary shall be reexamined at specific intervals in accordance with his or her needs.(j) Each beneficiary shall receive an annual physical examination that includes:(1) Examination of vision and hearing.(2) Routine screening laboratory examinations as determined necessary by the physician and special studies when the index of suspicion is high.(k) There shall be a periodic medical review, not less often than annually, of all beneficiaries receiving intermediate care facility services for the developmentally disabled by an independent professional review team which meets the requirements of 42 CFR 456.602 through 456.604.(l) Services shall be covered only for developmentally disabled persons as defined in Section 51164. Intermediate care services for the developmentally disabled are limited to those persons who require and will benefit from services provided pursuant to the provisions of Sections 76301 through 76413 of Title 22 of the California Administrative Code. The "Manual of Criteria for Medi-Cal Authorization," published by the Department, shall be the basis for the professional judgments of Medi-Cal consultants in their decision on authorization for services provided pursuant to this section. In determining the need for intermediate care facility services in institutions for the developmentally disabled, the following factors shall be considered: (1) The extent of psychosocial and developmental service needs.(2) The need for specialized developmental and training services which are not available through other levels of care.(3) The extent to which provisions of specialized developmental and training services can reasonably be expected to result in a higher level of patient functioning and a lessening dependence on others in carrying out daily living activities.(4) The individual's score on an assessment form approved by the Department of Developmental Services for the determination of intermediate care facility/developmentally disabled eligibility.(5) Whether the patient has a qualifying developmental deficit in either a self-help area or social-emotional area as follows:(A) A qualifying developmental deficit shall be determined in the self-help skill area if the patient has two moderate or severe skill task impairments in eating, toileting, bladder control or dressing skill task; or(B) A qualifying developmental deficit shall be determined in the social-emotional area if the patient exhibits two moderate or severe impairments from a combination of the following assessment items: 3. Self-injurious behavior,5. Destruction of property,6. Running or wandering away,7. Temper tantrums, or emotional outbursts.(m) Services shall be provided at a level determined appropriate to the number and types of functional characteristics of the individual and the number of hours of direct staff time needed for each individual.(n) Payment for services shall be made in accordance with Section 51510.1.(o) Leave of absence from intermediate care facilities for the developmentally disabled is covered up to a maximum of 73 days in a calendar year for developmentally disabled Medi-Cal inpatients. Payment shall be made in accordance with Section 51535.Cal. Code Regs. Tit. 22, § 51343
1. Amendment filed 3-29-84 as an emergency; designated effective 4-1-84 (Register 84, No. 15). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 7-30-84. For prior history, see Registers 84, No. 2; 82, No. 31; 79, Nos. 48, 38 and 9.
2. Emergency language filed 3-29-84 repealed by operation of Government Code Section 11346.1(f) (Register 85, No. 19).
3. Amendment filed by the Department of Health Services with the Secretary of State on 8-1-84 as an emergency; effective upon filing. Submitted to OAL for printing only pursuant to Government Code Section 11343.8 (Register 85, No. 19).
4. Certificate of Compliance including amendment of subsection (l) filed by the Department of Health Services with the Secretary of State on 11-28-84. Submitted to OAL for printing only pursuant to Government Code Section 11343.8 (Register 85, No. 25).
5. Editorial correction of 11-28-84 order filed by the Department of Health Services with the Secretary of State on 6-27-85. Submitted to OAL for printing only pursuant to Government Code Section 11343.8 (Register 85, No. 32). Note: Authority cited: Sections 14105, 14108 and 14124.5, Welfare and Institutions Code; and Section 208.4, Health and Safety Code. Reference: Sections 14108 and 14132, Welfare and Institutions Code.
1. Amendment filed 3-29-84 as an emergency; designated effective 4-1-84 (Register 84, No. 15). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 7-30-84. For prior history, see Registers 84, No. 2; 82, No. 31; 79, Nos. 48, 38 and 9.
2. Emergency language filed 3-29-84 repealed by operation of Government Code Section 11346.1(f) (Register 85, No. 19).
3. Amendment filed by the Department of Health Services with the Secretary of State on 8-1-84 as an emergency; effective upon filing. Submitted to OAL for printing only pursuant to Government Code Section 11343.8 (Register 85, No. 19).
4. Certificate of Compliance including amendment of subsection (l) filed by the Department of Health Services with the Secretary of State on 11-28-84. Submitted to OAL for printing only pursuant to Government Code Section 11343.8 (Register 85, No. 25).
5. Editorial correction of 11-28-84 order filed by the Department of Health Services with the Secretary of State on 6-27-85. Submitted to OAL for printing only pursuant to Government Code Section 11343.8 (Register 85, No. 32).