The purpose of the amendment to Rule 59G-4.170 is to incorporate by reference the Florida Medicaid Intermediate Care Facility Services Coverage Policy, _____. The incorporated coverage policy will specify recipient eligibility, provider requirements,...

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.: RULE TITLE:

59G-4.170Intermediate Care Facility for the Developmentally Disabled Services, ICF/DD

PURPOSE AND EFFECT: The purpose of the amendment to Rule 59G-4.170, F.A.C. is to incorporate by reference the Florida Medicaid Intermediate Care Facility Services Coverage Policy, _____. The incorporated coverage policy will specify recipient eligibility, provider requirements, coverage policies, and reimbursement information. The amendment also revises the rule title to Intermediate Care Facility Services.

SUBJECT AREA TO BE ADDRESSED: Intermediate Care Facility for the Developmentally Disabled Services, ICF/DD.

An additional area to be addressed during the workshop will be the potential regulatory impact Rule 59G-4.170, Florida Administrative Code, will have as provided for under sections 120.54 and 120.541, Florida Statutes.

RULEMAKING AUTHORITY: 409.919 FS.

LAW IMPLEMENTED: 409.906, 409.908, 409.913 FS.

A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: October 29, 2015 from 1:00 p.m. to 2:30 p.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room C, Tallahassee, Florida 32308-5407

Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 48 hours before the workshop/meeting by contacting: Tracy Thompson. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Tracy Thompson, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail].

Please note that a preliminary draft of the reference material, if available, will be posted prior to the workshop at http://ahca.myflorida.com/Medicaid/review/index.shtml. Comments will be received until 5:00 p.m., on the day of the workshop.

 

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

59G-4.170 Intermediate Care Facility Services for the Developmentally Disabled Services, ICF/DD.

(1) This rule applies to all providers of iIntermediate cCare fFacility services for the Developmentally Disabled (ICF/DD) Services providers who are enrolled in or registered with the Florida Medicaid program.

(2) All providers of iIntermediate cCare fFacility services for the Developmentally Disabled (ICF/DD) Services must be in compliance with the provisions of the Florida Medicaid Intermediate Care Facility Services Coverage Policy,            , incorporated by reference providers enrolled in the Medicaid program must comply with the Florida Medicaid Intermediate Care Facility for the Developmentally Disabled (ICF/DD) Services Coverage and Limitations Handbook, October 2003, incorporated by reference, and the Florida Medicaid Provider Reimbursement Handbook, Institutional 021, which is incorporated by reference in Rule 59G-4.200, F.A.C. The policy is available from the Medicaid fiscal agent’s Web site at http://portal.flmmis.com/flpublic. Both handbooks are available from the Medicaid fiscal agent. The assessment tool included in the Handbook is incorporated by reference: Florida Status Tracking Survey August 1999 Version 4.4. This tool is available by photocopying from the Handbook.

(3) Purpose. Intermediate care services for the mentally retarded are Medicaid services available for the diagnosis, treatment or rehabilitation of the mentally retarded or persons with related conditions which are provided in a protected residential setting to help each individual function at his greatest ability. This rule applies to all intermediate care facilities for the mentally retarded certified by the Agency for Health Care Administration, AHCA, for participation in the Medicaid program for ICF/MR care.

(4) Definitions.

(a) Agency for Health Care Administration, AHCA. The single state agency responsible for the administration of the Medicaid program in Florida. AHCA is responsible for the formulation of policy in conformance with state and federal requirements and for the monitoring of providers for compliance with such policy.

(b) Infirmary. That area of an ICF/MR facility where the infirm or sick are lodged for temporary care or treatment.

(c) Intermediate Care Facility for the Mentally Retarded. A facility licensed under state law, and certified under federal regulations, to provide health care and related services to individuals who are mentally retarded or who have related conditions.

(d) Intermediate Care Facility for the Mentally Retarded Services. Those services required by an ICF/MR resident including room and board, continuous 24-hour supervision and participation in professionally developed and supervised activities, experiences or therapies.

(e) Level of Care. The type of care required by a Medicaid applicant or recipient based on medical and related needs as defined by the criteria established in Chapter 65B-38, F.A.C.

(f) Medicaid Payment. The amount due an ICF/MR provider for an individual’s care based on the facility’s reimbursement rate and an individual’s personal income available to meet the cost of care. The Medicaid payment is expressed in dollars and cents and shall not exceed the cost of care recognized by AHCA for that level of ICF/MR care.

(5) Recipient Eligibility.

(a) In order to be eligible for ICF/MR services, an individual shall be a resident of the State of Florida, shall meet all the categorical eligibility criteria established under Title XVI, Supplemental Security Income for Aged, Blind, and Disabled, of the Social Security Act, and all the institutional eligibility criteria established under Title XIX, Medicaid, of the Social Security Act.

1. The categorical eligibility criteria established under Title XVI.

2. The institutional eligibility criteria established under Title XIX are as follows:

a. Need. An individual’s income shall not exceed the federal Medicaid income cap amount, or the state income standard; and

b. Age. An individual shall be any age to receive ICF/MR services; and

c. Medical Necessity. An individual shall be certified to need ICF/MR care by a doctor of medicine or osteopathy; and

d. Appropriate Placement. An individual shall be placed in an ICF/MR licensed and certified to provide the type of care required by the individual. The ICF/MR shall have executed a provider agreement with AHCA and have an active Medicaid provider number.

(b) All individuals receiving assistance under the Medicaid program are entitled to receive a personal needs allowance. These personal funds shall not be utilized to supplement the Medicaid payment nor to reimburse an ICF/MR for items covered by the Medicaid payment.

(6) Provider Eligibility.

(a) ICF/MR providers participating in the Medicaid ICF/MR program shall:

1. Be licensed pursuant to Chapter 393, F.S., and be in compliance with Chapter 65B-38, F.A.C.

2. Be in compliance with applicable federal, state and local laws and regulations. Medicaid certification conditions and standards in 42 C.F.R. 442 are adopted by reference.

3. Have a Medicaid reimbursement rate established.

a. The provider shall submit a cost report in compliance with the provisions of Rule 59G-6.040, F.A.C. The cost report shall be analyzed and a reimbursement rate established by the agency as specified in Rule 59G-6.040, F.A.C.

b. An interim Medicaid reimbursement rate shall be established for providers entering or reentering the Medicaid program. Providers entering the Medicaid program as a result of a change of ownership, as defined in 42 C.F.R. 489.18, may elect to receive the reimbursement of the prior provider. If so, the Medicaid reimbursement rate of the prior provider shall be the interim Medicaid reimbursement rate for the provider entering the Medicaid program.

4. Execute an agreement for participation in Florida’s medical assistance program, HRS-MED Form 1019, Jun 88, which is incorporated by reference into this rule.

a. A 30-day cancellation notice shall be given by either party, state or provider, to the other, prior to termination of this agreement.

b. After termination of the provider agreement, payment may be continued for up to 30 days for those eligible individuals who are in the process of being relocated and who were receiving care immediately prior to the termination date.

5. Not be currently under suspension from Florida’s, or any other state’s, Medicaid program.

6. The ICF/MR Provider shall comply with Chapters 59G-5, 59G-7 and Rule 59G-3.010, F.A.C.

(b) In situations involving a provider change of ownership, the following requirements shall be met:

1. The current provider shall submit to AHCA a written notice of intent to terminate participation in the Medicaid program 60 days before a contemplated change of ownership.

2. The prospective owner, if wanting to participate in Medicaid, shall submit to AHCA a request to continue participation in the Medicaid program 60 days prior to the transfer.

(c) Providers shall be terminated from participation in the Medicaid program for noncompliance with any provisions of this rule.

(d) All payments made by Medicaid shall constitute payment in full for covered services rendered and, in accordance with 42 C.F.R. 447.15, no additional or supplemental charges shall be assessed to the recipient or his representative.

(e) All providers shall be audited by AHCA.

(f) All financial and statistical records of the provider shall be retained for a period of 5 years.

(g) Medicaid claims received by the AHCA fiscal agent contractor shall be adjudicated as outlined in Chapter 59G-5, F.A.C.

(h) The disclosure of Medicaid information regarding both recipients and providers shall be handled in accordance with Chapter 119, F.S. and 42 C.F.R. 431, Subpart F, and Chapter 59G-7, F.A.C.

(7) Reimbursable ICF/MR Services.

(a) The Medicaid payment is an all inclusive payment designed to reimburse a facility for expenses incurred in providing daily care to Medicaid recipients.

(b) Items of necessary expense incurred by the ICF/MR provider in providing resident care shall be included as allowable costs in the ICF/MR’s cost report and shall not be charged to the recipient. These allowable costs are defined as items of expense that the provider is required to incur in furnishing intermediate care services or any expenses incurred in complying with state licensure or federal certification requirements.

(c) The Medicaid payment includes, but is not limited to, reimbursement for the following services:

1. Room and board including all of the items necessary to furnish the individual’s room;

2. Direct care and nursing services as required for each resident at his particular level of care;

3. A basic wardrobe as required by the client, including a 5-day supply of sleepwear, socks and shoes, outerclothing such as shirts, pants or dresses, a winter coat or covering and personal grooming items;

4. Training and assistance as required for the activities of daily living, including, but not limited to, toileting, bathing, personal hygiene, eating and ambulation as appropriate;

5. Walkers, wheelchairs, dental services, eyeglasses, hearing aids and other prosthetic or adaptive equipment as needed. The amount allowed in the Medicaid cost report is limited to the AHCA fee schedule as applicable. If any of these services are reimbursable under a separate Medicaid program, the cost will be disallowed in the cost report;

6. Therapies, including speech, recreational, physical, and occupational, as prescribed by the resident’s individual habilitation plan;

7. Transportation services, including vehicles with lifts or adaptive equipment, as needed.

(d) The Medicaid payment does not provide reimbursement for the following:

1. Legend drugs provided to the recipient through the prescribed drug program. The facility handles prescribed drugs for the resident by supplying the Medicaid identification card to the pharmacy.

2. Personal laundry services, unless part of a training program, may be charged to the resident by the facility.

(e) Paid Bed Reservation.

1. Payment to reserve a bed due to an absence from the ICF/MR shall be limited to necessary hospitalization, infirmary confinement or therapeutic leave days.

2. The day on which a resident begins a leave of absence is treated as a discharge day unless the ICF/MR provider is reserving the bed for the resident’s return.

3. Paid bed reservation limitations:

a. The Medicaid program shall reimburse an ICF/MR provider for a resident’s care for up to a maximum of 15 days per any single hospital stay.

(I) A single hospital stay shall begin each time the resident has been formally discharged from the hospital, administratively processed for transfer to the ICF/MR and formally readmitted to the hospital.

(II) All instances of hospitalization shall be determined medically necessary by the resident’s attending physician. The bed reservation must be approved by Developmental Services for Medicaid payment to be made to the ICF/MR provider to reserve a bed. If the hospitalization is medically unnecessary, Medicaid payment for the absence shall be denied.

(III) Reservation of a bed by the ICF/MR provider, and receipt of a Medicaid payment during the resident’s absence, requires that the ICF/MR provider shall make a bed available to the same resident should he return prior to, or at, the expiration of the 15-day hospitalization period. The provider shall advise the resident and responsible party of this policy prior to each hospitalization. In case of emergency hospitalization, the responsible party shall be notified of the bed reservation by the provider within 48 hours of the hospitalization.

b. The Medicaid program shall reimburse an ICF/MR provider for a resident’s care for up to a maximum of 15 days per single infirmary stay, with an annual maximum of 30 days.

(I) The general circumstances under which a resident might be temporarily placed in an infirmary shall be described in the resident’s plan of care. The plan shall state that in the event of an acute medical condition where round-the-clock observation would be in the best interest of the safety and welfare of the resident, the resident may be admitted to the infirmary by the resident’s attending physician.

(II) An infirmary admission shall be limited to 15 consecutive days. At the end of the 15 days the resident shall be returned to the ICF/MR, or discharged from the ICF/MR if infirmary care remains necessary. Medicaid payment terminates upon the resident’s discharge from the ICF/MR. No resident shall be allowed more than 30 total infirmary days in any 12-month period.

(III) When a resident is hospitalized directly from an infirmary stay, the 15-day limit shall begin on the first day of the infirmary stay and continue into the hospital stay. The resident shall not be entitled to an additional 15 days of hospitalization immediately following 15 days, or less, of infirmary care.

c. The Medicaid program shall reimburse an ICF/MR provider for a resident’s absence due to therapeutic leave up to a maximum of 45 days per fiscal year, July 1 – June 30. A therapeutic leave day is defined as a temporary absence from the facility with the reason for the absence included as part of the resident’s habilitation plan.

(I) The ICF/MR provider shall notify the district Developmental Services program office prior to the planned absence by a resident receiving developmental medical services in order to receive Medicaid payment for reservation of a bed. Absences shall not be approved when the resident’s programming or therapy will be seriously affected. The district utilization control team shall review the level of care needed by developmental medical residents approved for therapeutic leave days.

(II) The ICF/MR provider shall notify the district Developmental Services program office prior to a planned absence that is to exceed 3 days by a resident receiving developmental residential, developmental institutional, or developmental nonambulatory services in order to receive Medicaid payment for reservation of a bed for any leave that is to exceed 3 days by a resident receiving developmental residential, developmental institutional or developmental nonambulatory services. One day is considered an overnight stay away from the facility. Three days means 3 nights, returning on the fourth day.

4. In order for a bed to be reserved in an ICF/MR, and paid for by Medicaid, because of a resident’s hospitalization or therapeutic leave, the following conditions shall be met:

a. Notification. The provider shall forward completed HRS-MED Form 1013, Medicaid Recipient Status Notice, to the district Developmental Services program office prior to a resident’s planned absence from the facility. On weekends and holidays, and for unplanned absences such as emergency hospitalization, the HRS-MED Form 1013 shall be forwarded to the district Developmental Services program office on the first working day after the resident leaves the ICF/MR. The district Developmental Services program office shall forward a copy of the HRS-MED Form 1013 to the district Medicaid office with approval or denial of the reason for the absence based upon the provisions of the resident’s habilitation plan. Failure to comply with this requirement shall result in denial of Medicaid payment during the resident’s absence. Unreported or unapproved paid absences, or extensions of absences, shall be considered overpayments repayable to HRS.

b. Resident Return. The provider shall notify the district Developmental Services Program Office, on completed HRS-MED Form 1013, of the date on which the resident returned to the ICF/MR following an absence. This notification shall be made on the day of return, or if a weekend or holiday, the first working day following the resident’s return.

5. There are situations in which individual ICF/MR residents may be in need of therapeutic leave away from the facility beyond the 45 days’ limitation. In such case an exception shall be granted by the HRS district administrator or designated representative.

6. In some situations, treatment staff from the ICF/MR accompany residents on therapeutic leave days and continue providing active treatment to the resident while living in an alternate setting. These situations shall not be included as part of the 45 days allowed for therapeutic leave.

(f) All ICF/MR providers enrolled in the Medicaid program must be in compliance with the provisions of the Medicaid Provider Handbook for Intermediate Care Facility for the Mentally Retarded Services, as updated December 1, 1992, which is incorporated by reference into this rule and available from the fiscal agent contractor.

(8) Payment Methodology for Covered Services.

(a) Each Medicaid resident shall be allowed a personal needs allowance as provided by law. This allowance shall not be used to meet any part of the cost of care covered by the Medicaid payment to the ICF/MR provider.

(b) The Medicaid payment for each resident shall be calculated by deducting the resident’s responsibility from the Medicaid reimbursement rate established for the ICF/MR. The resident’s responsibility is determined by the HRS eligibility worker using criteria as established by Chapter 10C-8, F.A.C.

(c) The exact amount of Medicaid payment shall be calculated by the provider and expressed in dollars and cents. Medicaid payment for a partial month’s care shall be made at the established daily rate for the number of days for which care was provided.

(d) Medicaid payment shall be made for the first day a resident receives care, the day of admission, but not for the last day of stay, the day of discharge. If admission and discharge, or death, occur on the same day, the day shall be considered an inpatient day and Medicaid payment shall be made.

(e) Payments to ICF/MR facilities by families and other parties interested in the Medicaid resident shall be applied to the cost of care, thus reducing the Medicaid payment. If the facility administrator and the contributor provide a statement to the effect that the contribution shall not be utilized by the ICF/MR to cover the care of a specific resident, the Medicaid payment shall not be adjusted.

1. Contributions made to an ICF/MR by a Medicaid resident’s family, or other party interested in the Medicaid resident, shall be reported by the provider to AHCA on the appropriate form, HRS-MED Form 1006, Jun 82, Nursing Home Contribution Notice, as filed in Rule 10-2.091, F.A.C.

2. The contribution notice shall be completed and submitted by the provider within 10 days after the receipt of the contribution, as required by Section 409.325(6), F.S.

3. The contribution notice shall be completed once during each HRS fiscal year unless the schedule, duration, or amount of the contribution changes, in which case it shall be completed with each change.

4. The requirement of a contribution from family or friends of a Medicaid applicant or recipient as a prerequisite, or condition, of admission or continued residence in an ICF/MR shall be a violation of this rule.

5. The provider shall be responsible for advising the contributor that Medicaid payment constitutes payment in full and that supplementation of the Medicaid payment shall be strictly prohibited.

(f) Payments made directly to a vendor for items not covered by the Medicaid program will not be applied to the cost of care and shall not affect the Medicaid payment.

(g) Reimbursement to participating ICFs/MR for services provided shall be in accordance with the provisions of Rule 59G-10.010, F.A.C.

(h) Reimbursement shall not be made to out-of-state facilities.

(9) Authorized Signature. The signature of the provider or persons empowered to act on his behalf shall be entered on submitted Medicaid claim forms. Authorized signatures shall be limited to the provider, his employees and authorized billing agent. The provider shall be responsible for ensuring that the original or facsimile signature on the claim form is that of an authorized individual.

(10) Payment Acceptance. Payment made by the Medicaid program for ICF/MR services shall be considered payment in full.

(a) The resident or responsible party shall not be billed in full or part for any service paid for under any service component of the Medicaid ICF/MR program except the resident’s share of the cost of ICF/MR services as calculated by DHRS staff.

(b) No person or entity, except a third party resource, shall be billed, in part or in full, for Medicaid covered services.

(c) No individual who has been determined Medicaid eligible or on whose behalf a Medicaid application has been filed shall be charged private rates for a specified period of time as a condition of admission to or continued stay in an ICF/MR.

(11) Single copies of HRS forms adopted by reference may be obtained without cost from the General Services office in each HRS district.

Rulemaking Authority: 409.919 FS. Law Implemented 409.906, 409.908, 409.913 FS. History–New 8-31-76, Amended 1-1-77, 10-16-77, 7-7-81, 4-12-83, 1-12-84, 7-2-84, 7-1-85, Formerly 10C-7.49, Amended 7-19-88, 6-4-92, 5-11-93, Formerly 10C-7.049, Amended 11-27-95, 10-4-01, 1-23-05,__________.