Idaho Admin. Code r. 16.03.10.632

Current through September 2, 2024

Section 16.03.10.632 - ICF/IID: SPECIAL RATES

Section 56-117, Idaho Code, provides that the Department may pay facilities a special rate for care given to consumers who have medical or behavior long-term care needs beyond the normal scope of facility services. These individuals must have one (1) or more of the following behavior needs; additional personnel for supervision, additional behavior management, or additional psychiatric or pharmacology services. A special rate may also be given to consumers having medical needs that may include individuals needing ventilator assistance, certain medical pediatric needs, or individuals requiring nasogastric or intravenous feeding devices. These medical and behavior needs are not adequately reflected in the rates calculated pursuant to the principles set in Section 56-265, Idaho Code. The payment for such specialized care will be in addition to any payments made in accordance with other provisions of this chapter and will be based on a per diem rate applicable to the incremental additional costs incurred by the facility. Payment for special rates will start with approval by the Department and be and reviewed at least yearly for continued need. The incremental cost to a facility that exceeds the rate for services provided pursuant to the provisions of Section 632 of these rules, will be excluded from the computation of payments or rates under other provisions of Section 56-265, Idaho Code, IDAPA 16.03.09, "Medicaid Basic Plan Benefits," and IDAPA 16.03.10, "Medicaid Enhanced Plan Benefits."

01.Determinations. A determination to approve or not approve a special rate will be made on a consumer-by-consumer basis. No rate will be allowed if reimbursement for these needs is available from a non-Medicaid source.

02.Approval. Special rates will not be paid unless prior authorized by the Department. A special rate may be used in the following circumstances:

a. New admissions to a community ICF/IID;

b. For individuals currently living in a community ICF/IID when there has been a significant change in condition not reflected in the current rate; or

c. The facility has altered services to achieve and maintain compliance with state licensing or federal certification requirements that have resulted in additional cost to the facility not reflected in their current rate.

d. For the purpose of this rule, an emergency exists when the facility must incur additional behavioral or medical costs to prevent a more restrictive placement.

03.Reporting. Costs equivalent to payments at the special rate will be removed from the cost components subject to limits, and will be reported separately.

04.Limitations. The reimbursement rate paid will not exceed the provider's charges to other participants for similar services.

Idaho Admin. Code r. 16.03.10.632

Effective March 17, 2022