Section 16.03.10.584 - ICF/IID: CRITERIA FOR DETERMINING ELIGIBILITYIndividuals who have intellectual disabilities or a related condition as defined in Section 66-402, Idaho Code, and Sections 500 through 503 of these rules, must be determined by an interdisciplinary team to need the consistent, intense, frequent services including active treatment provided in an ICF/IID or receive services under one of Idaho's programs to assist individuals with intellectual disabilities or a related condition to avoid institutionalization in an ICF/IID, as indicated in Section 584.02 of these rules. To meet Title XIX and Title XXI entitlement for ICF/IID level of care and be eligible for services provided in an ICF/IID. The following must be met in Subsections 584.01 through 584.08 of these rules.
01.Diagnosis. Persons must be financially eligible for Medicaid; must have a primary diagnosis of being intellectually disabled or have a related condition defined in Section 66-402, Idaho Code and Section 500 through 506 of these rules; and persons must qualify based on functional assessment, maladaptive behavior, a combination of both, or medical condition.02.Active Treatment. Persons living in an ICF/IID, must require and receive intensive inpatient active treatment as defined in Section 010 of these rules, to advance or maintain their functional level. a. Active treatment does not include: parenting activities directed toward the acquisition of age-appropriate developmental milestones; services to maintain generally independent individuals who are able to function with little supervision or in the absence of a continuous active treatment program or services; interventions that address age-appropriate limitations; or general supervision of children whose age is such that such supervision is required by all children of the same age.b. The following criteria/components will be utilized when evaluating the need for active treatment:i. Evaluation. Complete medical, social, and psychological evaluations. These evaluations must clearly indicate the functional level of the participant and the interventions needed; andii. Plan of Care. A written plan of care which sets forth initial goals and objectives, specifies further evaluations to be done, and training programs to be developed.03.Require Certain Level of Care. Persons living in the community must require the level of care provided in an ICF/IID, including active treatment, and in the absence of available intensive alternative services in the community, would require institutionalization, other than services in an institution for mental disease, in the near future.04.Care for a Child. The department may provide Medicaid to a child eighteen (18) years of age or younger, who would be eligible for Medicaid if they were in a medical institution and who are receiving, while living at home, medical care that would be provided in a medical institution, if the Department determines that the child requires the level of care provided in an ICF/IID.05.Functional Limitations.a. Persons Sixteen Years of Age or Older. Persons sixteen (16) years of age or older may qualify based on their functional skills. Persons with an age equivalency composite score of eight (8) years and zero (0) months or less on a full scale functional assessment using a Department-approved assessment tool would qualify; orb. Persons Under Sixteen Years of Age. Persons under sixteen (16) years of age qualify if their composite full scale functional age equivalency is less than fifty percent (50%) of their chronological age; or06.Maladaptive Behavior. a. A Minus Twenty-Two (-22) or Below Score. Individuals may qualify for ICF/IID level of care based on maladaptive behavior. Persons will be eligible if their General Maladaptive Index on a Department-approved assessment tool is minus twenty-two (-22) or less; orb. Above a Minus Twenty-Two (-22) Score. Individuals who score above minus twenty-two (-22) may qualify for ICF/IID level of care if they engage in aggressive or self injurious behaviors of such intensity that the behavior seriously endangers the safety of the individual or others, the behavior is directly related to developmental disability, and the person requires active treatment to control or decrease the behavior; or07.Combination Functional and Maladaptive Behaviors. Persons may qualify for ICF/IID level of care if they display a combination of criteria as described in Subsections 584.05 and 584.06 of these rules at a level that is significant and it can been determined they are in need of the level of services provided in an ICF/IID, including active treatment services. Significance would be defined as: a. Persons Sixteen Years of Age or Older. For persons sixteen (16) years of age or older, an overall age equivalency up to eight and one-half (8 1/2) years is significant in the area of functionality when combined with a General Maladaptive Index on a Department-approved assessment tool up to minus seventeen (-17), minus twenty-two (-22) inclusive; orb. Persons Under Sixteen Years of Age. For persons under sixteen (16) years of age, an overall age equivalency up to fifty-three percent (53%) of their chronological age is considered significant when combined with a General Maladaptive Index on a Department-approved assessment tool between minus seventeen (-17), and minus twenty-one (-21) inclusive; or08.Medical Condition. Individuals may meet ICF/IID level of care based on their medical condition if the medical condition significantly affects their functional level/capabilities and it can be determined that they are in need of the level of services provided in an ICF/IID, including active treatment services.09.Annual Redetermination for ICF/IID Level of Care for Community Services. The BLTC staff will redetermine the participant's continuing need for ICF/IID level of care for community services. Documentation will consist of the completion of a redetermination statement on the "Level of Care" form HW0083. Such documentation will be accomplished no later than every three hundred sixty-five (365) days from the most recent determination. a. Home Care for Certain Disabled Children (HCDC). Persons receiving HCDC Medicaid services through ICF/IID eligibility, will receive services until the end of the month in which the redetermination was made. These individuals must receive ten (10) days notification of termination of services. If the redetermination is made less than ten (10) days from the end of the month, payment continues until the end of the following month.b. Developmentally Disabled Waiver. Individuals receiving developmentally disabled waiver services will have thirty (30) days from the time of the determination to transition to other community supports.Idaho Admin. Code r. 16.03.10.584