Section 16.03.10.222 - NURSING FACILITY SERVICES: ELIGIBILITYEntitlement to medical assistance participation in the cost of long-term care exists when the individual is eligible for medical assistance and the Department has determined that the individual meets the criteria for nursing facility 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.
01.Criteria for Determination. The criteria for determining a medical assistance participant's need for nursing facility care is described in Section 223. In addition, the Inspection of Care/Utilization Control (IOC/UC) nurse must determine whether a medical assistance participant's needs could be met by alternatives other than residing in a nursing facility, such as an independent living arrangement or residing in a room and board situation.a. The participant can select any certified facility to provide the care required.b. The final decision as to the level of care required by a medical assistance participant must be made by the IOC/UC Nurse.c. The final decision as to the need for developmental disability (DD) or mental illness (MI) active treatment will be made by the appropriate Department staff as a result of the Level II screening process.d. No payment will be made by the Department on behalf of any eligible medical assistance participant to any long-term care facility that, in the judgment of the IOC/UC Team, is admitting individuals for care or services that are beyond the facility's licensed level of care or capability.02.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. 16.03.10.222