7 AAC 140.600 - ICF/IID enrollment and conditions for payment

(a) For an intermediate care facility for the mentally retarded (ICF/MR) to be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing intermediate care services for the mentally retarded, the following requirements must be met:

(1) the ICF/MR must

(A) be enrolled in accordance with 7 AAC 105.210 as an ICF/MR;

(B) if located out of state, be enrolled in the Medicaid program in the jurisdiction where services are provided;

(C) meet all federal standards for payment and certification requirements under 42 C.F.R. Part 442, adopted by reference in 7 AAC 160.900;

(D) meet all certification and licensing requirements of the jurisdiction in which the ICF/MR is located; if located in this state, the ICF/MR must be certified under AS 47.32;

(E) comply with 7 AAC 140.600 - 140.640, 7 AAC 150, and other applicable requirements of 7 AAC 105 - 7 AAC 160; and

(F) meet the requirements of (b) of this section;

(2) the department has determined that the recipient's medical needs require the level of care provided in an ICF/MR, as determined under (c) and (d) of this section.

(b) The department will authorize payment for services in an ICF/MR only if the facility

(1) provides a comprehensive medical, social, and psychological evaluation of each recipient, covering physical, emotional, social, and cognitive factors of each recipient's need for care and services; the facility must complete the evaluation no more than 30 days after the date of the

(A) recipient's admission to the facility; or

(B) request for payment under Medicaid, if the recipient is a resident of the facility who applies while in the facility; and

(2) submits annually, for each state fiscal year and on a form approved by the department, a request for ICF/MR authorization that, for

(A) the first request, explains the reason for admission and provides a detailed summary of the recipient's habilitative plan of care developed as required in 7 AAC 140.610(a); and

(B) subsequent requests, provides a detailed summary of the reevaluation of the recipient as required in 7 AAC 140.610(c).

(c) In determining whether a recipient qualifies under this section for ICF/MR services, the department will base its decision on the determination of a qualified mental retardation professional within the department that the recipient meets the functional criteria in (d) of this section, and that the recipient has at least one of the following conditions:

(1) mental retardation that meets the diagnostic criteria for code 317 or 318.0, 318.1, or 318.2, as set out in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, adopted by reference in 7 AAC 160.900; the recipient must have an intelligence quotient of 70 points or less as determined by an individual, standardized psychological evaluation, plus up to five points to account for any measurement error;

(2) a condition that is

(A) one other than mental illness, psychiatric impairment, or a serious emotional or behavioral disturbance; and

(B) found to be closely related to mental retardation because that condition results in impairment of general intellectual functioning and adaptive behavior similar to that of individuals with mental retardation; the condition must be diagnosed by a licensed physician and require treatment or services similar to those required for individuals with mental retardation;

(3) cerebral palsy that is diagnosed by a licensed physician; however, a deficit in intellectual ability need not be present;

(4) seizure disorder that is diagnosed by a licensed physician; however, a deficit in intellectual ability need not be present;

(5) autism that has been diagnosed by a mental health professional clinician and that meets the diagnostic criteria for code 299.00, as set out in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, adopted by reference in 7 AAC 160.900.

(d) Each condition identified in (c) of this section must

(1) have originated before the age of 22 years;

(2) be likely to continue indefinitely; and

(3) constitute a substantial disability to the individual's ability to function in society,

(A) as measured by the Inventory for Client and Agency Planning (ICAP), adopted by reference in 7 AAC 160.900, and as evidenced by a broad independence domain score equal to or less than the cutoff scores in the department's Table of ICAP Scores by Age, adopted by reference in 7 AAC 160.900; or

(B) for a recipient receiving services in an ICF/IID in another state, as measured by the assessment tool authorized for use in that state.

(e) No more than 120 days after the date it receives a request for ICF/MR authorization, the department will evaluate that request in accordance with (a) of this section and make a determination. In that determination, the department will concur in the placement and authorize payment, deny authorization for payment, or request that the interdisciplinary team assigned under 7 AAC 140.605 provide additional information.

(f) If the department, as part of its determination under (c) of this section, finds that sufficient justification does not exist to continue a recipient's placement in a facility, the department will recommend to the facility that alternative placement be found or the recipient be discharged. The department will give the facility 30 days after the date of the determination for the facility to arrange for discharge or alternative placement of a recipient. At the end of that 30-day period, if the recipient has been recommended for discharge and the facility has not yet discharged the recipient, the department will terminate payment to the facility.

(g) A facility that is denied authorization for payment may appeal under 7 AAC 105.280. A recipient whose continued placement is denied may request a hearing under 7 AAC 49.

Notes

7 AAC 140.600

Eff. 2/1/2010, Register 193; am 1/22/2023, Register 245, April 2023

Authority:AS 47.05.010

AS 47.07.030

AS 47.07.040