(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:
1. Social behavior,
2. Aggression,
3. Self-injurious behavior,
4. Smearing,
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.
Notes
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).