Section 16.03.10.586 - ICF/IID: PROCEDURAL RESPONSIBILITIESEach long term care facility administrator, or their authorized representative, must report to the appropriate Field Office within three (3) working days of the date the facility has knowledge of the following.
01.Readmissions or Discharges. Any readmission or discharge of a participant, and any temporary absence of a participant due to hospitalization or therapeutic home visit.02.Changes to Participant's Income. Any changes in the amount of a participant's income.03.Participant's Account Exceeds Limitations. When a participant's account has exceed the following amount;a. For a single individual, one thousand eight hundred dollars ($1,800); orb. For a married couple, two thousand eight hundred dollars ($2,800).04.Other Financial Information for Participant. Other information about a participant's finances that may potentially affect eligibility for medical assistance.05.Annual Recertification Requirement. It is the responsibility of the ICF/IID to assure that the recertification is accomplished by the physician, physician's assistant or nurse practitioner no later than every three hundred sixty-five (365) days. a. Should the Medicaid Program receive a financial penalty from the Department of Health and Human Services due to the lack of appropriate recertification on the part of an ICF/IID, then such amount of money will be withheld from facility payments for services provided to Medicaid participants. For audit purposes, such financial losses are not reimbursable as a reasonable cost of participant care. Such losses cannot be made the financial responsibility of the Department's participant.b. Persons living in an ICF/IID will be transitioned to a less restrictive environment within thirty (30) days of the determination that the participant does not meet ICF/IID level of care.06.Level of Care Change. If during an on-site review of a resident's medical record and an interview with or observation of the resident an IOC/UC reviewer determines there is a change in the resident's status and the resident no longer meets criteria for ICF/IID care, the tentative decision is: a. Discussed with the facility administrator or the director of nursing services;b. The resident's physician is notified of the tentative decision;c. The case is submitted to the Regional Review Committee for a final decision; andd. The effective date of loss of payment will be no earlier than ten (10) days following the date of mailing of notice to the participant by the Eligibility Examiner.07.Appeal of Determinations. The resident or their representative may appeal the decisions under IDAPA 16.05.03, "Contested Case Proceedings and Declaratory Rulings."08.Supplemental On-Site Visit. The Regional Nurse Reviewer may conduct utilization control supplemental on-site visits in an ICF/IID when indicated. Some indications may be: b. A verification of a participant's appropriateness of placement or services; andc. Conduct complaint investigations at the Department's request.09.Determination of Entitlement to Long-Term Care. Entitlement to medical assistance participation in the cost of long-term care exists when the individual is eligible for medical assistance and the Regional Nurse Reviewer has determined that the individual meets the criteria for ICF/IID care and 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. a. The criteria for determining a Participant's need for intermediate care for the intellectually disabled is described in Sections 583 and 584 of these rules. In addition, the IOC/UC nurse must determine whether a Participant's needs could be met by non-participant inpatient alternatives including remaining in an independent living arrangement or residing in a room and board situation.b. The participant can select any certified facility to provide the care required.c. The final decision as to the level of care required by a participant must be made by the IOC/UC Nurse.d. The final decision as to the need for DD or MI active treatment will be made by the appropriate Department staff as a result of the Level II screening process.e. No payment will be made by the Department on behalf of any eligible participant to any long-term care facility that, in the judgment of the Inspection Of Care/Utilization Control Team is admitting individuals for care or services that are beyond the facility's licensed level of care or capability.10.Authorization of Long-Term Care Payment. If it has been determined that a person eligible for medical assistance is entitled to medical assistance participation in the cost of long-term care, and that the facility selected by the participant is licensed and certified to provide the level of care the participant requires, the Field Office will forward to such facility an "Authorization for Long-Term Care Payment" form HW 0459.Idaho Admin. Code r. 16.03.10.586