Utah Admin. Code 414-502-8

Current through Bulletin No. 2024-21, November 1, 2024

Section R414-502-8 - Criteria for Intermediate Care Facility for Persons with Intellectual Disability

An intermediate care facility for persons with intellectual disabilities (ICF/ID) must demonstrate that the applicant meets the following criteria before the Department may authorize Medicaid coverage for an individual who resides in an ICF/ID.

(1) The individual must have a diagnosis of:

(a) an intellectual disability in accordance with 42 CFR 483.102(b)(3); or

(b) a condition closely related to intellectual disability in accordance with 42 CFR 435.1010.

(2) For individuals seven years of age and older, the presence of a diagnosis alone is not sufficient to qualify for admission to an intermediate care facility for persons with intellectual disabilities. The diagnosis identified in Subsection (1) must result in documented substantial functional limitations in three or more of the following seven areas of major life activity that include:

(a) self-care, wherein the individual requires assistance, training, and supervision to eat, dress, groom, bathe, or use the toilet;

(b) the use of receptive and expressive language, wherein the individual lacks functional communication skills, requires the use of assistive devices to communicate, does not demonstrate an understanding of requests, or cannot follow two-step instructions;

(c) difficulty learning, wherein the individual has a valid diagnosis of an intellectual disability based on criteria found in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 1994;

(d) lack of mobility, wherein the individual requires the use of assistive devices to be mobile and cannot physically self-evacuate from a building during an emergency without an assistive device;

(e) lack of self-direction, the individual is a danger to self or others without supervision, and wherein the individual is seven through 17 years of age and significantly at risk in making age-appropriate decisions, or, in the case of an adult, the individual cannot provide informed consent for medical care, personal safety, or for legal, financial, rehabilitative, and residential issues, and has been declared legally incompetent;

(f) lack of capacity for independent living, wherein the individual who is seven through 17 years of age cannot locate and use a telephone, cross the street safely, or understand that it is unsafe to accept rides, food or money from strangers, or an adult who lacks basic skills in the areas of shopping, preparing food, housekeeping, or paying bills; or

(g) lack of economic self-sufficiency, wherein the individual receives disability benefits, cannot work more than 20 hours a week, or is paid less than minimum wage without employment support. This does not apply to children under 18 years of age.

(3) The Department considers a child under seven years of age to be at risk for functional limitation in three or more areas of major life activity. The child may satisfy the criteria for functional limitations if the child has been diagnosed with an intellectual disability or a condition closely related to intellectual disability. The Department does not require separate documentation of the limitations defined in Subsection (2) until the child turns seven years of age.

(4) To meet the criteria of a condition closely related to an intellectual disability, an individual must manifest the condition before the individual turns 22 years of age and the condition must be likely to continue. The following criteria further specify the Department's consideration of a closely related condition.

(a) The Department does not require an individual to demonstrate an intellectual impairment of cerebral palsy, but the individual must demonstrate functional limitations as described in Subsection (2).

(b) The Department does not require an individual to demonstrate an intellectual impairment of epilepsy, but the individual must demonstrate functional limitations as described in Subsection (2).

(5)

(a) The Department requires an individual to meet the following criteria under the category of autism spectrum disorder:

(i) persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifested by the following:

(A) deficits in social-emotional reciprocity, ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction;

(B) deficits in non-verbal communicative behaviors used for social interaction, ranging from poorly integrated verbal and nonverbal communication through abnormalities in eye contact and body language, or deficits in understanding and use of non-verbal communication to total lack of facial expression or gestures; and

(C) deficits in developing and maintaining relationships appropriate to developmental level, ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and in making friends, to an apparent absence of interest in people; and

(ii) restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following:

(A) stereotyped or repetitive speech, motor movements, or use of objects;

(B) excessive adherence to routines, ritualized patterns of verbal or non-verbal behavior, or excessive resistance to change;

(C) highly restricted, fixated interests with abnormal intensity or focus, such as strong attachment to or preoccupation with unusual objects and excessively circumscribed or perseverative interests; or

(D) hyper or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment, such as apparent indifference to pain, heat and cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects.

(b) Symptoms must be present in early childhood.

(c) Symptoms must together limit and impair everyday functioning.

(d) An individual must have a severe brain injury that is the result of an acquired brain injury, traumatic brain injury, stroke, anoxia, or meningitis.

(e) An individual must have a diagnosis of fetal alcohol syndrome.

(f) An individual must have chromosomal disorders such as Down syndrome, fragile x syndrome, and Prader-Willi syndrome.

(g) Individuals with other genetic disorders that include Williams syndrome, spina bifida, and phenylketonuria may qualify.

(6) The following conditions do not qualify as conditions closely related to intellectual disabilities. Nevertheless, the Department may consider a person with any of these conditions if there is a simultaneous occurrence of a qualifying condition as cited in Subsections (1)(a) and (b):

(a) learning disability;

(b) behavior or conduct disorders;

(c) substance abuse;

(d) hearing or vision impairment;

(e) mental illness that includes psychotic disorders, adjustment disorders, reactive attachment disorders, impulse control disorders, and paraphilias;

(f) borderline intellectual functioning, a related condition that does not result in an intellectual impairment, developmental delay, or at risk designations;

(g) physical problems such as multiple sclerosis, muscular dystrophy, spinal cord injuries, and amputations;

(h) medical health problems such as cancer, acquired immune deficiency syndrome, and terminal illnesses;

(i) neurological problems not associated with intellectual deficits. Examples include Tourette's syndrome, fetal alcohol effects, and non-verbal learning disability; and

(j) mild traumatic brain injury such as minimal brain injury and post-concussion syndrome.

(7) An individual who was admitted to an ICF/ID before August 27, 2009, is eligible for continued stay as long as the individual continues to meet the requirements in effect before that date. A resident who was admitted to an ICF/ID before August 27, 2009, is only required to meet the revised eligibility criteria if there is a break in stay wherein the individual resides in a setting that is not a Medicaid-certified ICF/ID facility or hospital.

(8) Before admission to an ICF/ID, the facility must provide each potential resident with a two-sided fact sheet known as a Community Supports Waiver and ICF/ID Fact Sheet or Form IFS 10, which offers information about ICFs/IDs and the Community Supports Waiver for People with Intellectual Disabilities and Other Related Conditions. Each resident's record must also contain a Freedom of Choice Acknowledgement Form or Form IFS 20, signed by the resident or legal representative, which verifies that the facility provided the Form IFS 10 before admission.

Utah Admin. Code R414-502-8

Amended by Utah State Bulletin Number 2023-22, effective 10/30/2023