[46 Pa.B. 3177]
[Saturday, June 18, 2016]
[Continued from previous Web Page]
CHAPTER 4305. LIABILITY FOR COMMUNITY MENTAL HEALTH AND INTELLECTUAL DISABILITY SERVICES
GENERAL PROVISIONS § 4305.1. General.
One of the primary goals of the public mental health and intellectual disability program is to provide easy access to treatment or habilitation services and to encourage people to seek help.
§ 4305.2. Purpose.
The purpose of this chapter is to specify the liability and describe the procedures for establishing and collecting liability for clients receiving community mental health or intellectual disability services funded in whole or in part through the county mental health and intellectual disability program.
§ 4305.3. Applicability.
(a) This chapter applies to county mental health and intellectual disability programs.
(b) This chapter does not apply to a client who is receiving services covered by Medical Assistance under the Commonwealth's Medical Assistance Program.
§ 4305.4. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
Base service unit—The functional unit responsible for assessing and evaluating client needs, planning comprehensive treatment programs and making available the necessary services on a continuing basis.
County administrator—The administrator of the county mental health and intellectual disability program, or a designee.
Intellectual disability professional—A case manager or an individual who is responsible for the clinical treatment program for the client.
Liability—The maximum monthly amount the liable person is charged toward the cost of service for the client. The term does not include the cost of the client's room or board.
Liable person—The person responsible for payment of the liability. The term includes the following persons:
(i) If the client is 18 years of age or older, the client is not married and the client does not have a legal guardian of estate or a representative payee, the client is the liable person.
(ii) If the client is married, and the client does not have a legal guardian of estate or a representative payee, the client and the client's spouse are the liable persons.
(iii) If the client is under 18 years of age, the client is not married, the client is not an emancipated minor and the client does not have a legal guardian of estate or a representative payee, both of the client's parents are the liable persons.
(iv) If the client is under 18 years of age, the client is not married, the client is an emancipated minor and the client does not have a legal guardian of estate or a representative payee, the client is the liable person.
(v) If the client has a legal guardian of estate or a representative payee, the legal guardian of estate or the representative payee is the liable person.
Mental health client fee schedule—A list of the provider's usual and customary charges to the general public for a unit of service.
Mental health professional—An individual practicing in a generally recognized clinical discipline including, but not limited to, psychiatry, social work, psychology, nursing, rehabilitation or activity therapies, who has a graduate degree and clinical experience.
Net charge—The amount the provider bills for services provided.
Outpatient unit of service—One-half hour of treatment in a licensed mental health outpatient clinic/program.
Parent—A biological or adoptive mother or father of the client.
Partial hospitalization unit of service—Three hours per day of treatment in a licensed mental health partial hospitalization program.
Representative payee—A person or an organization selected by a benefit issuing agency to receive and manage benefits on behalf of a beneficiary.
§ 4305.5. Legal base.
The legal authority for this chapter is sections 201(2) and 504(d) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. §§ 4201(2) and 4504(d)).
GENERAL REQUIREMENTS § 4305.11. Exempt services.
The following mental health and intellectual disability community services are exempt from liability requirements specified in the chapter:
(1) Vocational, as defined in Chapter 2390 (relating to vocational facilities).
(2) Early intervention, as defined in Chapter 4226 (relating to early intervention services).
(3) Adult day care, as defined in Chapter 2380 (relating to adult training facilities).
(4) Respite care, as defined in Chapters 6350 and 6400 (relating to family resource services; and community homes for individuals with an intellectual disability).
(5) Family aid services, as defined in Chapter 6350.
(6) In-home therapy, as defined in Chapter 6350.
(7) Homemaker services, as defined in Chapter 6350.
(8) Family education and training, as defined in Chapter 6350.
(9) Recreation/leisure activities, as defined in Chapter 6350.
(10) Specialized vocational training services that are outside the scope of Chapter 2390.
(11) Other intellectual disability family support services including and limited to sitter and companionship services, parent and family training, speech therapy, aural rehabilitation, hearing aid evaluations, dactylogic therapy, physical therapy, occupational therapy, mobility training, behavioral programming, adaptive appliances, special diets and home rehabilitation.
§ 4305.13. Nonexempt service.
Liability requirements specified in this chapter apply to a mental health and intellectual disability community service not listed in § 4305.11 (relating to exempt services).
§ 4305.15. Delegation of authority.
(a) The county administrator has the authority to delegate the functions required in this chapter to base service units or providers of community mental health and intellectual disability services, except for the functions of adjusting liability amounts specified in §§ 4305.61—4305.69 (relating to adjustment of liability) and write-off of past due accounts specified in §§ 4305.91—4305.94 (relating to write-off of past due account).
(b) If functions required in this chapter are delegated to providers of community mental health and intellectual disability services, the county administrator shall retain responsibility for compliance with the requirements of this chapter.
§ 4305.17. Eligibility of expenditures.
Expenditures by a county mental health and intellectual disability program on behalf of a client are eligible for reimbursement by the Department only if a liability has been billed and collection has been pursued according to the requirements specified in this chapter.
§ 4305.21. Contributions.
Contributions made to the county mental health and intellectual disability program or the provider by charitable organizations, friends or neighbors on behalf of the client toward the cost of care shall be treated as payment by the liable person. Contributions may not be counted as income to the client as part of the total family income.
DETERMINATION OF LIABILITY § 4305.31. Determinations.
(a) The county administrator shall determine a liability for clients receiving a community mental health or intellectual disability service funded in whole or in part through the county mental health or intellectual disability program that is not listed as an exempt service in § 4305.11 (relating to exempt services).
(b) The liability shall be determined prior to client referral to or placement into community mental health and intellectual disability services, except for emergency referrals or placements in which the liability shall be determined within 15 days after emergency referral or placement.
§ 4305.33. Income to be considered.
(a) If the client is 18 years of age or older and the client is not married, the client's income alone shall be considered the total family income.
(b) If the client is married, the client's income and the client's spouse's income shall be combined to determine the total family income.
(c) If the client is under 18 years of age, the client is not married, and the client is not an emancipated minor, the client's income that is in excess of the Internal Revenue Service tax threshold, and both parents' income shall be combined to determine the total family income.
(d) If the client is under 18 years of age, the client is not married, and the client is an emancipated minor, the client's income alone shall be considered the total family income.
(e) If the parents of an unmarried, nonemancipated client under 18 years of age are separated or divorced and have a legally binding financial agreement, the parents are individually financially responsible in accordance with the terms of that financial agreement. If the client earns more than the Internal Revenue Service tax threshold, the client's income that is in excess of the Internal Revenue Service tax threshold shall be included in the total family income of the parent who has legal custody of the client. If there is joint custody, the client's income that is in excess of the Internal Revenue Service tax threshold shall be divided equally and included in the total family income of both parents.
(f) If the parents of an unmarried, nonemancipated client under 18 years of age are separated or divorced and there is no legally binding financial agreement, a separate total family income shall be determined for each parent. If the client earns more than the Internal Revenue Service tax threshold, the client's income that is in excess of the Internal Revenue Service tax threshold shall be included in the total family income of the parent who has legal custody of the client. If there is joint custody, the client's income that is in excess of the Internal Revenue Service tax threshold shall be divided equally and included in the total family income of both parents.
(g) Parents who adopt children under the Pennsylvania Adoption Assistance program, § 3140.207 (relating to entitlement to other services and benefits), have no liability for mental health and intellectual disability services. The child shall be considered a family of one and liability shall be determined based on the income of the child.
§ 4305.42. More than one client receiving service.
(a) If more than one client in the family is receiving services, only one liability shall be determined and billed.
(b) If at least one client in the family is receiving community mental health or intellectual disability residential services or short-term inpatient services, the liability shall be the amount listed in Appendix B.
(c) If clients in the family are receiving only community mental health or intellectual disability nonresidential services, the liability shall be the amount listed in Appendix A.
§ 4305.43. Client receiving more than one service.
(a) If services received by the client in a calendar month are community mental health and intellectual disability nonresidential services or noninpatient services, the liability shall be the amount listed in Appendix A.
(b) If services received by the client in a calendar month are community mental health and intellectual disability residential services or short-term inpatient services, even if community mental health and intellectual disability nonresidential services or short-term inpatient services are also provided, the liability shall be the amount listed in Appendix B.
BILLING FOR LIABILITY § 4305.51. Billing.
(a) The county administrator shall bill the liable person each month that community mental health and intellectual disability services are received.
(b) If the liability exceeds the actual cost of intellectual disability services or the net charge for mental health services received for a month, the county administrator shall bill the liable person for the actual cost of intellectual disability services or the net charge for mental health services received.
§ 4305.52. Insurance.
(a) If a client is receiving or is expected to receive a community mental health or intellectual disability service, or both, that is eligible for insurance, the county administrator or the provider of service shall bill the insurance company for the service prior to billing the liable person. The amount received from the insurance company for services provided over a calendar month shall be deducted from the liability for intellectual disability services or the client fee schedule per unit times the number of units delivered that month for mental health services. The liable person shall be billed the remainder up to the liability.
(b) If insurance benefits are not assignable, the provider shall bill the liable person for the total amount of the liability or the amount the insurance company will pay, whichever is greater, and shall assist the person in completing the insurance forms if necessary or requested.
ADJUSTMENT OF LIABILITY § 4305.61. Request for adjustment of liability.
(a) The liable person has the right to request adjustment of liability.
(b) Requests for adjustment of liability shall be made within 30 calendar days of the time that conditions warranting the adjustment occur.
(c) Requests for adjustment of liability shall be made by the liable person, the client, or the mental health or intellectual disability professional.
(d) Requests for adjustment of liability shall be submitted to the county administrator on a form prescribed by the Department.
§ 4305.66. Reason for adjustment of liability—nullify result of care.
(a) The county administrator shall have the power to reduce or eliminate the liability if the imposition of the liability would create a financial burden upon the client as to nullify the results of care, treatment, service or other benefits.
(b) Requests for an adjustment of the liability due to nullification of the result of care shall include documentation by a mental health/intellectual disability professional justifying the clinical reasons for the request and how the client's welfare would be seriously harmed if the liability is not adjusted.
APPENDIX A
Monthly Liability for Community Mental Health and Intellectual Disability Nonresidential Services * * * * *
APPENDIX B
Monthly Liability for Community Mental Health and Intellectual Disability Residential and Short-Term Inpatient Services * * * * *
CHAPTER 4310. CLIENT LIABILITY—STATE MH/ID FACILITIES
GENERAL PROVISIONS § 4310.1. Legal base.
The legal base for this chapter is sections 201(2) and 504(d) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. §§ 4201(2) and 4504(d)).
§ 4310.3. Applicability.
This chapter applies to State mental hospitals and State intellectual disability centers. Liability for services received at these facilities is determined according to this chapter.
§ 4310.4. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
Abatement—The reduction by the Department of an assessed liability amount to zero for a specified period.
Assets—Any resource available to the client to meet the cost of services, except real estate constituting the home residence of the client, his spouse or dependent children.
Benefit—A payment or other assistance given by an insurance company, mutual retirement fund, or public or private agency.
Benefit recipient—A client receiving income in the form of a benefit for which no services have been rendered.
Client—A patient/resident of a State mental hospital or State intellectual disability center.
Department—The Department of Human Services of this Commonwealth.
Head of household—The adult member of the household who is recognized by other family members as the primary household representative.
Home maintenance exemption—Documented and verified expenses currently being paid and necessary to maintain a home or rental residence, which includes mortgage or rental payments, utility bills and taxes on the home residence during the period of hospitalization.
Household—A group of persons living together, consisting of the head of household and all other household members for whom the head of household has a legal responsibility to provide support.
Household member—A person, including the head of household, for whom the head of household is liable.
IRS tax form—The forms filed by the household for Federal income tax purposes—most commonly Forms 1040 and 1040A.
Institutional collections officer—The Department's employee responsible for applying for all resources available to meet the costs of services and establishing client and legally liable relative liability.
Intellectual disability professional—A case manager or an individual who is responsible for the clinical treatment program of the resident.
LLR—Legally liable relative—A parent or spouse responsible for the costs of service for a client in a State mental hospital or State intellectual disability center, or a client who is legally responsible for the support of his spouse or dependent children.
Liability—The portion of the cost of service for which the client or legally liable relative is required to pay.
Liable person—A person who has responsibility to pay the assessed liability. Liable persons are the client and the legally liable relative. In the event that assets, income, or benefits, or both, of the client or legally liable relative are controlled by a representative payee, a guardian of the estate, or trustee, these persons are responsible for assessments made against assets, income, or benefits, or both, belonging to the client or legally liable relative.
MAMIS—The Medical Assistance Management Information System responsible for reimbursement to facilities providing care to Medical Assistance eligible clients.
Maximum liability—The most which a liable person is required to pay toward the costs of service.
Mental health professional—An individual practicing in a generally recognized clinical discipline including, but not limited to, psychiatry, social work, psychology, nursing, rehabilitation or activity therapies, who has a graduate degree and clinical experience.
Modification—A reduction of an assessed liability, by the Department, to an amount greater than zero, but less than the original amount for a specified period.
Nonresident property—Real property is considered ''nonresident'' if the property:
(i) Is not used as a home by the client.
(ii) Has been the home of the client or his spouse but has not been used for 6 consecutive months and there appears to be little likelihood that either will return to it.
Resident property—A client's real property, used as the client's primary residence, during the first 6 months of institutionalization.
MAXIMUM LIABILITY FOR SERVICES PROVIDED § 4310.6. Maximum liability—payors/liable persons.
The maximum liability for services provided is established by the institutional collections officer for both payors and liable persons within the following:
* * * * * (6) Client/resident maximum liability.
(i) Maximum client liability is based on income or assets of the client, or both, in excess of amounts paid by third party payors or other agencies, up to the per diem rate established for the facility. Monthly charges for services provided to mental health and intellectual disability clients may not exceed the product of the per diem rate multiplied by the number of days in the month.
* * * * *
DETERMINING LIABILITY AND ASSESSMENTS § 4310.9. Working client income.
When a client residing in a State mental hospital or State intellectual disability center receives income for services rendered at sheltered workshops or other employment, 50% of all income over $65 per month is assessed for his cost of service provided. Any amount less than $65 per month is exempted as personal use monies. Personal use monies may be conserved for his use up to a maximum of $1,500. When the conserved fund maximum is reached, the full amount of income is assessed less $25 per month personal use monies. If, after the assessment, the conserved fund level still exceeds the maximum of $1,500, the excess income over $1,500 is assessed. If the conserved fund account falls below $1,500, the assessment returns to 50% of all income over $65 until funds again reach $1,500.
BILLING AND COLLECTION § 4310.17. Abatement or modification of liability.
(a) Only in extraordinary circumstances will consideration be given to abatement or modification of liability in accordance with the following criteria under section 504(a) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § 4504(a)). The imposition of such liability would:
(1) ''result in the loss of financial payments or other benefits from any public or private source which the mentally disabled person would receive, would be eligible to receive or which would be expended on his behalf except for such liability'';
(2) ''result in a substantial hardship upon the mentally disabled person, a person owing a legal duty to support such person or the family of either'';
(3) ''result in a greater financial burden upon the people of the Commonwealth''; or
(4) ''create such a financial burden upon such mentally disabled person as to nullify the results of care and treatment, service or other benefits afforded to such person under any of this act.''
(b) The institutional collections officer may assist the client or his legally liable relative, or both, in the preparation of a request for an abatement or modification, if so requested. This may include checking to insure the inclusion of all required information, typing the final copy, and forwarding the request to the Secretary of Human Services or his designee. (Complete PW-83 and PW-833.)
§ 4310.20. Clinical abatement or modification of liability.
(a) The Department may make a clinical abatement or modification of liability if the imposition of liability would result in a greater financial burden upon the people of this Commonwealth or would create such a financial burden upon such mentally disabled person as to nullify the result of care and treatment, service, or other benefits afforded to the person under the Mental Health and Intellectual Disability Act of 1966 (50 P.S. §§ 4101—4704). Clinical abatements will be granted only if:
(1) The imposition of liability would be likely to negate the effectiveness of treatment, or prohibit the client's entry into treatment.
(2) The failure to provide the treatment would result in serious harm to the client's welfare or in greater cost to this Commonwealth due to the deterioration of the client's condition.
(b) Requests for clinical abatement or modification may be initiated either by the MH or intellectual disability professional who is treating the client or by the liable person. If initiated by the liable person, the request shall be endorsed by the MH or intellectual disability professional who is treating the client.
(c) When making a request for clinical abatement, the treating MH or intellectual disability professional shall justify the request in the client's case record by stating why he believes that the client qualifies for clinical abatement or modification. The request for clinical abatement or modification shall be forwarded to the Secretary's designee on Form PW-1075. The Secretary's designee shall review the request and notify the MH or intellectual disability professional and the institutional collections officer of the decision.
APPENDIX A
LLR
MONTHLY LIABILITY SCALE* * * * * Dear
Under Sections 501, 502 and 503 of the Mental Health and Intellectual Disability Act of 1966, you are liable for services provided the client mentioned above. According to the Department of Human Service's Regulations promulgated as Chapter 4310 your monthly liability has been assessed in the maximum amount specified above. You will be billed monthly for services provided in accordance with charges established by the Department of Human Services or the amount of your liability, whichever is the lesser amount. It is your responsibility to report significant changes in income which may effect the amount of your liability.
* * * * *
REQUEST FOR DEPARTMENTAL REVIEW
CLINICAL ABATEMENT * * * * * ______ _________________
DateSignature of MH/ID Professional
PW 1075
PART VIII. INTELLECTUAL DISABILITY AND AUTISM MANUAL
Subpart C. ADMINISTRATION AND FISCAL MANAGEMENT
CHAPTER 6201. COUNTY INTELLECTUAL DISABILITY SERVICES
GENERAL PROVISIONS § 6201.1. Introduction.
(a) The county program is the means by which minimum services, as described in the Mental Health and Intellectual Disability Act of 1966 (50 P.S. §§ 4101—4704), are available to promote the social, personal, physical and economical habilitation or rehabilitation of persons with an intellectual disability with respect for the full human, social and legal rights of each person. This means that the health, social, educational, vocational, environmental and legal resources that serve the general population shall be marshalled and coordinated by the county program to meet the personal development goals of persons with an intellectual disability, in accordance with the principle of integration. Integration means to ensure for every person with an intellectual disability and his family the right to live a life as close as possible to that which is typical for the general population. The mandated services, the provision of service mechanisms and the fiscal support of the program shall be used to secure for each person and his family the conditions and circumstances of day-to-day life that comes as close as possible to representing typical life patterns.
(b) In keeping with this principle of integration, the county program shall serve as an advocate for persons with an intellectual disability and secure for them their full entitlement to existing and future human services available to the general population.
§ 6201.2. Purpose.
This chapter establishes county responsibilities and content of services for county MH/ID programs.
§ 6201.3. Applicability.
This chapter applies to county MH/ID programs.
§ 6201.4. Legal base.
The legal authority for this chapter is section 201(2) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § 4201(2)).
SERVICE DELIVERY § 6201.11. County program.
The county is responsible for the following objectives:
(1) Primary prevention of organic and functional intellectual disability.
(2) Earliest possible case finding and diagnosis.
(3) Medical and surgical correction or amelioration of systemic defects, when possible.
(4) Shaping and maintaining an environment most productive of basic human personality qualities involving parent-child and sibling relationships, environmental adaptation, self-awareness and learning motivation and ability.
(5) Specific training and learning situations designed and implemented to develop all potential.
(6) Community development and restructuring to achieve the maximum integration for individuals with an intellectual disability.
§ 6201.12. Base service unit.
(a) The county administrator is responsible for establishing an organizational unit consisting of multidisciplinary professional and nonprofessional staff capable of planning, directing and coordinating appropriate services for individuals with an intellectual disability and in need of service from the county program. This unit shall be called the base service unit, and the county administrator shall have the authority to direct, control and monitor the activities of the base service unit.
(b) The base service unit is responsible for performing the following functions in such a way as to carry out the following objectives of the county program:
(1) Establish or develop a system utilizing preventive services in the community for persons with an intellectual disability.
(2) Establish and operate a system for earliest possible casefinding.
(3) Maintain a continuing relationship with the person with an intellectual disability and with a facility or provider of service responsible for service to the person with an intellectual disability during any stage of his life-management process.
(4) Constitute a fixed point of referral and information for persons with an intellectual disability and their families.
(5) Initiate, develop and maintain a pattern of interaction between the diagnostic and evaluation team and others concerned with services to any person with an intellectual disability and his family. This pattern shall emphasize participation in the life-management planning process of persons such as the family, physician, local public health nurse, teacher, representative of human service resources, vocational rehabilitation counselor, other providers of service, advocates and the person with an intellectual disability, whenever possible.
(6) Provide opportunities for advancing the knowledge and understanding of persons inside and outside its immediate setting, particularly those who have a responsibility in carrying out the life-management process.
(7) Foster cooperation through the use of multidisciplinary approach.
(8) Ensure that if service to the person with an intellectual disability is provided by other than the base service unit and the person with an intellectual disability is referred for intake into the county program, the referring agency or the provider of service are invited to cooperate with the base service unit in diagnosis, evaluation and planning for the person.
(9) Ensure that services will not be authorized for funding by the county program unless they are consistent with the life-management plan as developed by the base service unit and approved by the county administrator.
(10) Provide for comprehensive diagnosis and evaluation services to do all of the following:
(i) Diagnose, appraise and evaluate intellectual disability and associated disabilities; define the strengths, skills, abilities and potentials for improvement of the individual.
(ii) Assess the needs of the individual and his family.
(iii) Develop a practical life-management plan for individuals and their families and provide the necessary counseling and follow-along services.
(iv) Reassess the progress of the individual at regular intervals to determine continuing needs for service and for changes in his management plan.
§ 6201.13. Intake services.
(a) Intake into the county program shall be through the base service unit.
(b) The condition and circumstances of each individual presumed to require service shall be thoroughly assessed before a disposition is made of his referral.
(1) If it is determined after the assessment that the individual does not currently require further service from the base service unit, the presenting problem, the results of the assessment and the disposition of the case—alternative referral or recommendation—shall be recorded on Form MH/ID 10, Intake and Proposed Service Plan.
(2) If it is determined after assessment that the person requires service, he shall be provided with coordinated services necessary to identify the presence of an intellectual disability, its cause and complications, and the extent to which the intellectual disability limits or is likely limit the individual's daily living and work activities.
(c) Assessment services shall include a systematic appraisal of the findings in terms of pertinent physical, psychological, vocational, educational, cultural, social, economic, legal, environmental and other factors of the person with an intellectual disability and his family for all of the following:
(1) To determine how and to what extent the disabling condition may be expected to be removed, corrected or minimized by services.
(2) To determine the nature and scope of services to be provided.
(3) To select the service objectives which are commensurate to the individual's interests, capacities and limitations.
(4) To devise an individualized program of action to be followed, at the intervals needed, by periodic reappraisals.
(5) To reevaluate progress of the person at intervals as necessary for the periodic appraisal.
(d) Each program service authorized shall have a service objective in keeping with the personal development goal of the person with an intellectual disability; this goal shall be the basis for individualized life management planning.
(1) This information shall be recorded on the Intake and Proposed Service Plan, Form MH/ID 10, along with a listing of the counseling, follow-along, and other services to be provided within a specified period of time in coordinated association with the program service immediately authorized.
(2) A specific date for evaluation of the person's progress and reevaluation of his life-management plan shall also be part of the Intake and Proposed Service Plan.
(3) In all cases, the family of the person with an intellectual disability; the social, economic, cultural, educational, vocational, legal and environmental circumstances affecting him; and his physical and psychological condition shall be considered essential aspects of the life management plan.
§ 6201.14. Aftercare services.
(a) Aftercare services shall be available to prevent unnecessary and prolonged institutionalization and to facilitate the return of persons to their homes or communities. These services shall be designed to enable persons with an intellectual disability to achieve their maximum potential for self-care, self-support, self-sufficiency and social competence.
(b) Aftercare services shall include the following:
(1) Evaluation of persons currently in residential placement.
(2) Preparation of individual life-management plans for persons in placement, to include a definition of the special purpose served by the placement as part of the life-management plan of each individual.
(3) Establishment of an individually appropriate and realistic social development goal to be accomplished by each placement.
(4) Regular liaison with the facility to ensure that time spent in residence is limited to the time required to accomplish the established goal, and that service provided by the facility is consistently more suitable than the person might receive in the community.
(5) Prerelease counseling services to resident and family, referral with follow-through to appropriate community resources for post-release services and follow-along responsibility for post-release life management.
(6) Provision of short-term inpatient, emergency, out-patient, partial hospitalization and rehabilitation and training services, as indicated by individual life-management plans.
(7) Nursing home care for older individuals primarily in need of medically supervised nursing services.
(8) Supervised sheltered personal care living arrangements—groups or singly—for those whose primary need is not medical.
(9) Foster home care, individual and group living.
CHAPTER 6210. PARTICIPATION REQUIREMENTS FOR THE INTERMEDIATE CARE FACILITIES FOR THE INTELLECTUAL DISABILITY PROGRAM
GENERAL PROVISIONS § 6210.1. Purpose.
The purpose of this chapter is to specify the requirements for State operated and non-State operated ICFs/ID to receive payment for services through the MA Program.
§ 6210.2. Applicability.
(a) This chapter applies to State operated and non-State operated ICFs/ID.
(b) This chapter applies to non-State operated ICFs/ORC.
(c) Section 6210.63(1) (relating to diagnosis of an intellectual disability) does not apply to ICFs/ORC.
(d) If a provision specified in Chapter 1101 (relating to general provisions) is inconsistent with this chapter, this chapter prevails.
(e) If a provision specified in this chapter is inconsistent with Chapter 6211 (relating to allowable cost reimbursement for non-State operated intermediate care facilities for individuals with an intellectual disability), Chapter 6211 prevails.
§ 6210.3. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
* * * * * ICF/ID—Intermediate care facility for individuals with an intellectual disability (facility)—A State operated or non-State operated facility, licensed by the Department in accordance with Chapter 6600 (relating to intermediate care facilities for individuals with an intellectual disability), to provide a level of care specially designed to meet the needs of persons who have an intellectual disability, or persons with related conditions, who require specialized health and rehabilitative services; that is, active treatment.
* * * * *
GENERAL REQUIREMENTS § 6210.11. Payment.
(a) The MA Program provides payment for intermediate care for an individual with an intellectual disability provided to eligible recipients by providers enrolled in the MA Program.
(b) Payment for services is made in accordance with this chapter, Chapter 1101 (relating to general provisions), HIM-15, the Medicaid State Plan, Chapter 6211 (relating to allowable cost reimbursement for non-State operated intermediate care facilities for individuals with an intellectual disability) and the Department's ''Cost Apportionment Manual for State Mental Hospitals and Intellectual Disability Centers'' for State operated ICFs/ID.
§ 6210.13. Licensure.
ICFs/ID shall be licensed by the Department in accordance with Chapter 6600 (relating to intermediate care facilities for individuals with an intellectual disability).
SCOPE OF BENEFITS § 6210.21. Categorically needy and medically needy recipients.
Categorically needy and medically needy recipients are eligible for ICF/ID subject to the conditions specified in this chapter and Chapters 1101 and 6211 (relating to general provisions; and allowable cost reimbursement for non-State operated intermediate care facilities for individuals with an intellectual disability).
§ 6210.22. State Blind Pension recipients.
State Blind Pension recipients are not eligible for ICF/ID under the MA Program. Blind and visually impaired individuals are eligible for ICF/ID services if they qualify as categorically or medically needy recipients.
PROVIDER PARTICIPATION § 6210.32. Budgets and cost reports for State operated facilities.
(a) State operated ICFs/ID shall submit budgets to the Department's Office of Developmental Programs.
(b) State operated ICFs/ID shall submit cost reports to the Department's Bureau of Financial Operations.
§ 6210.33. Budgets and cost reports for non-State operated facilities.
(a) Non-State operated ICFs/ID shall submit cost reports or a budget, if a waiver is granted in accordance with Chapter 6211 (relating to allowable cost reimbursement for non-State operated intermediate care facilities for individuals with an intellectual disability), to the Department's Office of Developmental Programs.
(b) Cost reports and budgets shall be submitted on forms and by deadlines specified by the Department.
§ 6210.34. Approved funding level.
The Department's Office of Developmental Programs is responsible for establishing an approved funding level for non-State operated ICFs/ID.
§ 6210.35. Ongoing provider responsibilities.
* * * * * (c) A cost report shall be filed with the Department's Office of Developmental Programs for non-State operated ICFs/ID and with the Department's Bureau of Financial Operations for State operated ICFs/ID within the time limit specified in § 6210.77 (relating to cost finding) if the facility is continuing its participation in the MA Program or within the time limit specified in § 6210.92 (relating to final reporting) if the facility is sold, transferred by merger or consolidation, terminated or withdraws from participation in the MA Program.
* * * * *
PAYMENT CONDITIONS § 6210.42. Certification of initial need for care.
(a) A physician shall certify in writing in the medical record that the applicant or recipient needs intermediate care for individuals with an intellectual disability.
(b) A nurse practitioner or clinical nurse specialist, who is not an employee of the facility, but who is working in collaboration with a physician, may complete the certification specified in subsection (a).
(c) The certification specified in subsections (a) and (b) shall be signed and dated not more than 30 days prior to either the admission of an applicant or recipient to a facility, or, if an individual applies for assistance while in a facility before the Department authorizes payment for intermediate care for individuals with an intellectual disability.
§ 6210.43. Recertification of continued need for care.
(a) A physician, a physician's assistant under the supervision of a physician or a nurse practitioner, or clinical nurse specialist shall enter into the recipient's medical record a signed and dated statement that the recipient continued to need intermediate care for individuals with an intellectual disability.
(b) In a non-State operated ICF/ID, the person who certifies the need for continued care specified in subsection (a), may not be an employee of the facility but shall work in collaboration with the recipient's physician.
(c) The recertification specified in subsection (a) shall be completed at least once every 365 days after initial certification.
§ 6210.44. Evaluations.
(a) Before admission to a facility, or before authorization for payment, an interdisciplinary team of health professionals shall make a comprehensive medical, social and psychological evaluation of each applicant's or recipient's need for intermediate care for individuals with an intellectual disability. The psychological evaluation shall be completed within 3 months prior to admission.
(b) If a recipient moves from one facility to another facility, this is not considered a new admission and new evaluations as required in subsection (a) are not required, if the prior evaluations are transferred with the recipient.
(c) Medical, social and psychological evaluations shall be recorded in the recipient's medical record and if applicable on forms specified by the Department.
§ 6210.46. Plan of care.
Before admission to an ICF/ID, or before authorization for payment, the attending physician shall establish a written plan of care for each applicant or recipient. The plan of care shall indicate time-limited and measurable care objectives and goals to be accomplished and who is to give each element of care.
ASSESSMENT § 6210.61. Eligibility for an ICF/ID level of care.
An applicant or recipient shall receive active treatment to be determined eligible for an ICF/ID level of care. The ICF/ID Program shall have only one level of care. The level of care determination is based upon the developmental needs of each applicant or recipient.
§ 6210.62. Level of care criteria.
(a) There are three fundamental criteria which shall be met prior to an applicant or recipient qualifying for an ICF/ID level of care. The ICF/ID level of care shall be indicated only when the applicant or recipient:
(1) Requires active treatment.
(2) Has a diagnosis of an intellectual disability.
(3) Has been recommended for an ICF/ID level of care based on a medical evaluation.
(b) A physician shall certify the ICF/ID level of care on a form specified by the Department and that ICF/ID services are needed, for each applicant and current ICF/ID resident. Before the facility requests payment from MA, the certification shall have been made at the time of admission, or at the time a resident applied for assistance while in an ICF/ID.
(c) For purposes of an ICF/ORC, subsection (a)(2) means a diagnosis of other related condition.
§ 6210.63. Diagnosis of an intellectual disability.
The facility shall document the applicant's or recipient's diagnosis of an intellectual disability by meeting the following requirements:
(1) A licensed psychologist, certified school psychologist or a licensed physician who practices psychiatry shall certify that the applicant or recipient has significantly subaverage intellectual functioning which is documented by one of the following:
(i) Performance that is more than two standard deviations below the mean as measurable on a standardized general intelligence test.
(ii) Performance that is slightly higher than two standard deviations below the mean of a standardized general intelligence test during a period when the person manifests serious impairments of adaptive behavior.
(2) A qualified intellectual disability professional as defined in 42 CFR 483.430 (relating to condition of participation: facility staffing) shall certify that the applicant or recipient has impairments in adaptive behavior as provided by a standardized assessment of adaptive functioning which shows that the applicant or recipient has one of the following:
(i) Significant limitations in meeting the standards of maturation, learning, personal independence or social responsibility of his age and cultural group.
(ii) Substantial functional limitation in three or more of the following areas of major life activity:
(A) Self-care.
(B) Receptive and expressive language.
(C) Learning.
(D) Mobility.
(E) Self-direction.
(F) Capacity for independent living.
(G) Economic self-sufficiency.
(3) It has been certified that documentation to substantiate that the applicant's or recipient's conditions were manifest before the applicant's or recipient's 22nd birthday, as established in section 102 of the Developmental Disabilities Assistance and Bill of Rights Act (42 U.S.C.A. § 6001) (Repealed).
§ 6210.64. Medical evaluation.
Applicants or recipients meeting the criteria for ICF/ID level of care shall have a medical evaluation completed by a licensed physician not more than 60 days prior to admission to an ICF/ID or before authorization for payment. The physician shall recommend the applicant or recipient for an ICF/ID level of care based on the medical evaluation.
§ 6210.65. Recertification.
(a) Recertification shall be on a form specified by the Department and based on the applicant's or recipient's continuing need for an ICF/ID level of care, progress toward meeting plan objectives, the appropriateness of the plan of care and consideration of alternate methods of care.
(b) Recertification of need for an ICF/ID level of care shall be made at least once every 365 days after the initial certification.
PAYMENT LIMITATIONS § 6210.71. Limitations on payment for reserved bed days.
(a) Hospital leave is a reserve bed day, limited in number, during which a client is temporarily absent from the facility for hospitalization.
(b) For each hospitalization, a recipient receiving intermediate care for individuals with an intellectual disability, except for a recipient in a State operated ICF/ID, is eligible for a maximum 15 consecutive reserve bed days for hospital leave. The Department will pay a facility at the interim per diem rate on file with the Department for a hospital reserve bed day. Subject to this limit, a facility may include hospital reserve bed days in its census as client days, and costs associated with hospital reserve bed days shall be included in the facility's cost report. A reserve bed will be available for the recipient upon the recipient's return to the facility.
(c) Therapeutic leave is a reserve bed day, subject to limits, during which the recipient is temporarily absent from the facility due to the need to obtain a component of the recipient's individual program plan which cannot be provided directly by the facility. Therapeutic leave is included in the recipient's individual program plan, and the facility is required to monitor and document therapeutic leave. Therapeutic leave is primarily intended to maintain and further enhance relationships between the recipient and his family. Therapeutic leave includes leave for camp or other special programs.
(d) The Department will make payment to a facility for a reserved bed day when the recipient is absent from the facility for a continuous 24-hour period because of therapeutic leave. Each reserved bed day for therapeutic leave shall be recorded on the facility's daily census record and invoice. A reserved bed shall be available for the recipient upon the recipient's return to the facility.
(e) A recipient receiving intermediate care for individuals with an intellectual disability is eligible for a maximum of 75 days per calendar year for therapeutic leave outside the facility.
(f) For each continuous 24-hour period the recipient is absent from the facility, the facility shall bill the Department for a therapeutic leave day, under the limitations in this chapter. When the continuous 24-hour period is broken, this will not count as a reserved bed day.
§ 6210.72. Limitations on payment for prescription drugs.
The Department's interim per diem rate for non-State operated ICFs/ID does not include prescription drugs. Prescribed drugs for categorically needy recipients are reimbursable directly to a licensed pharmacy according to regulations contained in Chapter 1121 (relating to pharmaceutical services).
§ 6210.75. Noncompensable services.
Payment will not be made for:
(1) Services provided to a recipient who no longer requires the level of care for which payment is authorized by the CAO.
(2) Reserved bed days that exceed the limits specified in § 6210.71 (relating to limitations on payment for reserved bed days).
(3) Services provided to a recipient occupying a bed which is not certified for the level of care for which payment is authorized by the CAO.
(4) Services covered but disallowed by Medicare.
(5) Services rendered by a provider that do not meet the conditions for payment established by this chapter and Chapters 1101 and 6211 (relating to general provisions; and allowable cost reimbursement for non-State operated intermediate care facilities for individuals with an intellectual disability).
(6) Services directly reimbursable under the MA Program.
§ 6210.76. Cost reporting.
(a) Each facility shall submit a cost report to the Department within 90 days following the close of each fiscal year as designated by the facility in accordance with § 6210.91 (relating to annual reporting).
(b) The time frame for submission of cost reports may be extended for an additional 30 days with written approval from the Department's Office of Developmental Programs for non-State operated ICFs/ID and from the Department's Bureau of Financial Operations for State operated ICFs/ID.
(c) Cost reports shall be submitted on Department form MA-11.
(d) The cost report shall be prepared using the accrual basis of accounting and shall cover a fiscal period of 12 consecutive months.
(e) Facilities beginning operations during a fiscal period shall prepare a cost report from the date of approval for participation to the end of the facility's fiscal year.
(f) The cost report shall identify costs of services, facilities and supplies furnished by organizations related to the provider by common ownership or control.
§ 6210.78. Allowable costs.
(a) For State operated ICFs/ID, allowable costs shall be determined by the Department's ''Cost Apportionment Manual for State Mental Hospitals and Intellectual Disability Centers'' and HIM-15.
(b) For non-State operated ICFs/ID, allowable costs shall be determined based on Chapter 6211 (relating to allowable cost reimbursement for non-State operated intermediate care facilities for individuals with an intellectual disability) and HIM-15.
(c) State operated ICFs/ID shall be reimbursed actual allowable costs under the Statewide Cost Allocation Plan and Medicare principles, subject to MA regulations.
(d) Non-State operated ICFs/ID shall be reimbursed actual, allowable reasonable costs under Chapter 6211 and other applicable MA regulations.
§ 6210.79. Setting interim per diem rates.
(a) For State operated ICFs/ID, interim per diem rates shall be established by the Department based on the latest adjusted reported costs and approved budgets.
(b) For non-State operated ICFs/ID, interim per diem rates shall be established by the Department based on the latest adjusted cost report plus an inflationary factor, or a submitted budget if a waiver is granted in accordance with Chapter 6211 (relating to allowable cost reimbursement for non-State operated intermediate care facilities for individuals with an intellectual disability).
§ 6210.81. Upper limits of payment.
(a) The upper limits of payment for State operated ICFs/ID are the full allowable costs as specified in the Department's ''Cost Apportionment Manual for State Mental Hospitals and Intellectual Disability Centers'' and HIM-15.
(b) The upper limits of payment for non-State operated ICFs/ID are the lower of costs or the total projected operating cost or if a waiver is granted under Chapter 6211 (relating to allowable cost reimbursement for non-State operated intermediate care facilities for individuals with an intellectual disability) an approved budget level as specified in Chapter 6211.
REPORTING AND AUDITING § 6210.93. Auditing requirements related to cost reports.
(a) Except in cases of provider delay or delay requested by State or Federal agencies investigating possible criminal or civil fraud, the Department will conduct either a field audit or desk review of each cost report within 1 year of the latter of its receipt in acceptable form, as defined in § 6210.78 (relating to allowable costs) or, if the facility participates in Medicare and has reported home office costs to the Department on its cost report, the Department's receipt of the facility's Medicare home office audit, to verify, to the extent possible, that the facility has complied with:
(1) This chapter.
(2) Chapter 1101 (relating to general provisions).
(3) The limits established in Chapter 6211 (relating to allowable cost reimbursement for non-State operated intermediate care facilities for individuals with an intellectual disability).
(4) The Department's ''Cost Apportionment Manual for State Mental Hospitals and Intellectual Disability Centers'' for State operated ICFs/ID.
(5) HIM-15.
(6) The Department's cost allocation plan for State operated ICFs/ID.
(b) An onsite field audit will be performed on a periodic basis at reporting facilities. Participating facilities will receive a field audit or a desk audit each year. Full scope field audits will be conducted in accordance with auditing requirements in Federal regulations and generally accepted auditing standards.
(c) An auditor may validate the costs and statistics of the annual report by an onsite visit to the facility. The auditors will then certify to the Department the allowable cost for the facility as a basis for calculating a per diem and an annual adjustment. Based on the certification and total interim payments received by the facility, the Department will compute adjustments due the facility or due the Department for the fiscal year. The Department will notify the facility of the annual adjustment due after the annual cost report is audited.
(d) Financial and statistical records to support cost reports shall be available to State and Federal agents upon request.
UTILIZATION CONTROL § 6210.101. Scope of claims review procedures.
Claims submitted for payment under the MA Program are subject to the utilization review procedures established in Chapter 1101 (relating to general provisions). In addition, the Department will perform the reviews specified in this section and §§ 6210.102—6210.109 for controlling the utilization of ICF/ID services.
§ 6210.108. Facility utilization review.
(a) Each facility furnishing services to eligible MA recipients shall have in effect a written utilization review plan that provides for review of each recipient's need for the services.
(b) If the utilization review committee of a facility finds that the continued stay of a recipient at a specific level of care is not needed, the committee shall, within 1 working day of its decision, request additional information from the recipient's qualified intellectual disability professional, who shall respond within 2 working days. A physician member of the committee, in cases involving a medical determination, or the utilization review committee, in cases not involving a medical determination, shall review the additional information and make the final recommendation. If the additional information is not received within 2 working days, the committee's decision will be deemed final.
(c) The utilization review committee shall send written notice of adverse final decisions on the need for continued stay to:
(1) The facility administrator.
(2) The qualified intellectual disability professional of the recipient.
(3) The CAO.
(d) The CAO shall notify the recipient or the person acting on behalf of the recipient and the facility of the recommended change in the level of care. The recipient has the right of appeal in accordance with Chapter 275 (relating to appeal and fair hearing and administrative disqualification hearings). Neither the facility nor the attending physician may appeal the decision of the utilization review committee on its own behalf.
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