California Code of Regulations
Title 22 - Social Security
Division 3 - Health Care Services
Subdivision 1 - California Medical Assistance Program
Chapter 3 - Health Care Services
Article 4 - Scope and Duration of Benefits
Section 51343.2 - Intermediate Care Facility Services for the Developmentally Disabled-Nursing
Current through Register 2024 Notice Reg. No. 12, March 22, 2024
(a) Intermediate care facility services for the developmentally disabled-nursing (ICF/DD-N) are covered subject to prior authorization by the Department for the ICF/DD-N level of care. Authorizations may be granted for up to six months. Requests for prior authorization of admission to an ICF/DD-N or for continuation of services shall be initiated by the facility on Certification for Special Treatment Program Services forms (HS 231). Certification documentation required by the Department of Developmental Services shall be completed by regional center personnel and submitted with the Treatment Authorization Request form. The attending physician shall sign the Treatment Authorization Request form and shall certify to the Department that the beneficiary requires this level of care.
(b) The request for reauthorization shall be received by the appropriate Medi-Cal consultant on or before the first working day following expiration of a current authorization. Certification shall be redetermined and a new certification form shall be completed by regional center personnel and shall be attached to the request for authorization. One day of authorization shall be denied for each day the reauthorization request is late.
(c) The Medi-Cal consultant shall deny any authorization request or reauthorization request, or shall cancel any authorization in effect when services or placement are not appropriate to the health and developmental needs of the beneficiary. When the reauthorization request is denied, or an existing authorization is cancelled, the facility shall be notified by the most expeditious means and a timely notice of action shall be sent to the beneficiary in accordance with Title 22, California Code of Regulations, Section 51014.1.
(d) Prior to the transfer of a beneficiary between facilities, the receiving facility shall originate an initial Treatment Authorization Request signed by the attending physician. This Treatment Authorization Request shall be approved by a Department Medi-Cal consultant prior to admission except in cases of emergency as specified in Section 51056, Title 22, California Code of Regulations.
(e) The beneficiary's medical condition shall be determined on an individual basis by the Department's Medi-Cal consultant. However, in determining the need for ICF/DD-N services the following conditions shall be met:
(f) The beneficiary must have a need for active treatment, defined at Section 73801, Title 22, California Code of Regulations, and intermittent skilled nursing services such as:
(g) Conditions which would exclude beneficiaries from placement in an ICF/DD-N are as follows:
(h) There shall be a written individual program plan of care for each beneficiary, which shall be established by a physician prior to the beneficiary's admission to the facility and reviewed and evaluated at least every 90 days by all members of the interdisciplinary staff/team involved in the care of the individual. The plan of care shall include the following:
(i) Each beneficiary shall have received a comprehensive medical evaluation within three months and a comprehensive social evaluation within six months prior to admission. A psychological evaluation (developmental evaluation for clients under 18 months of age) must have been completed within three months prior to admission. Subsequent medical, psychological and social evaluations shall be completed at least annually by staff involved in carrying out the beneficiary's plan of care. Each evaluation must include:
(j) Each beneficiary shall receive a complete dental examination within one month following admission unless such an examination was done within six months prior to admission. In either case, a comprehensive report prepared by the dentist shall be completed and entered into the beneficiary's record. Each beneficiary shall be reexamined as needed, but at least annually.
(k) There shall be a periodic review, no less often than annually, of all care and services provided to beneficiaries receiving intermediate care facility services for the developmentally disabled-nursing by the State Medi-Cal Utilization Review Team in accordance with the requirements of Title 42, Code of Federal Regulations, Sections 456.602 through 456.604.
(l) Each beneficiary shall receive preventive health services as follows:
(m) Regardless of frequency of contact, the attending physician shall recertify in writing, at least every 60 days, the beneficiary's need for continued care in the ICF/DD-N.
(n) Medi-Cal beneficiaries in the facility shall be seen by their attending physicians no less often than every 60 days.
(o) Services shall be provided at a level consistent with that described in the beneficiary's individual service plan.
1. New
section refiled by the Department of Health Services with the Secretary of
State on 5-30-89 as an emergency pursuant to Healthand Safety Code Section
1275.3;
operative 5-30-89. Submitted to OAL for printing only pursuant to Government
Code Section
11343.8
(Register 89, No. 23). For prior history, see Register 89, No. 1.
2.
Certificate of Compliance as to 5-30-89 order including amendment transmitted
to OAL 9-27-89 and filed 10-26-89 (Register 89, No.
44).
Note: Authority cited: Sections 14105 and 14124.5, Welfare and Institutions Code; and Sections 208 and 1275.3, Health and Safety Code. Reference: Sections 1250.1 and 1275.3, Health and Safety Code.