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Department of Human Services Department of Human Services  
 
Intermediate Care Facilities (ICF/DDs)

Revised: 07-19-2012


Overview
An Intermediate Care Facility for Persons with Developmental Disabilities (ICF/DD) is a residential facility that:

• Is licensed as a health care institution and certified by the Minnesota Department of Health (MDH)
• Provides health or rehabilitative services for persons who require active treatment for developmental disabilities

ICF/DDs are located in 58 counties throughout Minnesota and serve from four to 64 persons.


Key Points
Plan of Care
Each recipient must have an individual service plan (ISP) developed by an interdisciplinary team with representation from the professions, disciplines or service areas specific to the individual needs and program design. This plan must be based on the results of a comprehensive functional assessment as defined by federal regulations. This plan must state the objectives needed to meet the recipients’ needs as identified by the comprehensive assessment and document a sequenced plan for meeting the objectives. The objectives must:

• Be stated separately, in terms of a single behavioral outcome
• Be assigned projected completion dates
• Be expressed in behavioral terms that provide measurable indices of performance
• Be organized to reflect a developmental progression appropriate to the individual
• Be assigned priorities
• Address Day Training and Habilitation (DT&H), Services During the Day, and retirement, as well as activities in the ICF/DD

The plan must describe relevant interventions to support the recipient toward independence. The interventions must:

• Identify the location where program strategy information can be found
• Include training in personal skills essential for privacy and independence, if the individual lacks them
• Identify the need for mechanical supports to achieve proper body position, balance or alignments, when they are to be applied, and a schedule for the use of each support
• Provide that individuals who have multiple disabling conditions spend a major portion of each waking day out of bed and outside the bedroom area
• Include opportunities for individual choice and self-management

The plan must be completed within 30 days after admission. The Qualified Developmental Disability Professional (QDDP) must review the plan when the recipient (not an all-inclusive list):

• Has successfully completed an identified objective(s)
• Is regressing or losing skills already gained
• Is failing to progress toward identified objectives after reasonable efforts have been made
• Is being considered for training towards new objectives

The plan must be reviewed and documented by the interdisciplinary team, per case management guidelines.

The ICF/DD is to provide outcome-based services in response to the needs of a person as identified in the Individual Service Plan. Services must be based on the needs, preferences and goals of the individual and be consistent with the principles of the least restrictive environment and self-determination. The ICF/DD must make available to each person:

• Functional skill development
• Opportunities for development of decision-making skills
• Opportunities to participate in the community
• Reduced dependency on care providers

Utilization Control
A physician must certify the need for a certified NF, certified boarding care facility, or ICF/DD. A Physician Certification form (DHS-1503) must be completed in the following instances:

• Upon initial admission or upon readmission following discharge
• When a recipient transfers from one LTC facility to another
• When a recipient transfers within a facility from a NF1 (SNF/NF) to a NF2 (Certified Boarding Care Home) level of care
• When a recipient returns from an unauthorized leave exceeding 24 hours
• When a recipient returns from hospitalization, if their level of care changes

Telephone orders cannot be used for physician certification purposes. Written orders signed and dated by a physician are permissible for this purpose, or a physician may sign and date the Physician Certification form

Utilization Review
The initial utilization review date for a recipient must be established at the time of admission and documented on the Physician Certification (DHS1503). The initial utilization review date for an MA applicant must be established when notified of MA eligibility. The Utilization Review Group documentation must indicate the recipient was reviewed at least every six months, or more often if the group deems it necessary. Each time a Physician Certification (DHS1503) is required, the utilization review process must be re-established.

Medical/Social Evaluation
Each recipient must have a medical evaluation whenever a Physician Certification (DHS1503) is required. The minimum requirements of this evaluation include all of the following:

• Diagnosis, symptoms, complaints/complications, present medical/developmental findings, and medical/social family history, including:
• Mental/physical functioning levels
• Prognosis
• Range of needs, objectives, and plans for continuing care
• The physician's recommendation for admission
• Alternatives to long term care available in the home, family, and community
• Results of a psychological evaluation performed within three months prior to admission (not required upon return from hospitalization)

In the situation where a recipient is readmitted from a hospital stay or unauthorized leave, providers must document the review and any update of the evaluation.

Roles and Responsibilities
The state (DHS), counties and ICF/DD facilities all share responsibilities. The counties handle case management and logistical issues related to the facilities. More information on these roles and responsibilities of the parties may be found in the following sections of the ICF/DD System Manual:

County Responsibilities:


DHS Responsibilities:

• DHS (State Contracts)

ICF/DD Responsibilities:


Other:

• About ICF/DDs
• Appeals for ICF/DD Level of Care are handled by the Minnesota Department of Health (MDH)


Eligible Providers
Each ICF/DD provider agency is responsible to meet all federal, state and local requirements. ICF/DD’s must:

• Comply with all regulations and licensing laws applicable to ICF/DD
• Adhere to the biannual performance-based contract signed with DHS
• Provide quality care as identified by the recipients and county case managers in the ISP
• Collaborate with county and DHS ICF/DD staff on service planning, new initiatives and day-to-day operations

Providers serving MHCP recipients who reside in an ICF/DD must:

• Be Medicare certified by Minnesota Department of Health (MDH) and be licensed as a Class A or Class B Supervised Living Facility
• Obtain a state license number issued by MDH
• Be licensed by DHS for age and capacity
• Be enrolled as an MHCP provider
• Continuously maintain qualifications to provide waiver services, if applicable
• Be contracted with the State of Minnesota
• Be contracted with the county or tribal agency authorizing services for the waiver recipient
• Provide and maintain licensure/documentation supporting their qualifications to provide waiver services as indicated in their contract with the county/tribal agency
• Have a DHS approved service agreement (SA) to provide services for the recipient
• Pay the State of Minnesota an annual ICF/DD Surcharge for each licensed bed
• Submit an annual Income and Expense Report
• Complete the ICF/DD Physician Recertification Form (DHS-1743) annually, and at least 30 days after the completion of the Physician Certification (DHS1503)

For additional information, refer to:


Exemption: An SNF, ICF or ICF/DD that is operated, listed, and certified as a Christian Science sanatorium by the First Church of Christ Scientist, of Boston, Massachusetts, is not subject to the federal regulations for utilization control in order to receive MA payments for the cost of recipient care.


Eligible Recipients
MHCP recipients must be actively enrolled in either Medical Assistance (MA, Programs NM and IM) or Emergency Medical Assistance (EMA), or be eligible under the DD waiver program.

MA-eligible recipients must reside in a certified bed that matches their certified level of care. Eligibility for ICF/DD services is determined through a screening process. Refer to Admission to an ICF/DD. Minnesota Department of Health (MDH) certifies an ICF/DD to provide health or rehabilitative services for persons who:

• Have developmental disabilities or a related condition
• Manifest conditions before person’s 22nd birthday
• Need a 24-hour plan of care
• Need continuous active treatment
• Cannot apply skills learned in one environment to a new environment without aggressive and consistent training


Covered Services
Medical Assistance (MA) will cover the cost of care for a recipient who resides in a licensed ICF/DD, certified Nursing Facility (NF), or a certified Boarding Care Home (BCH), if the recipient:

• Meets admission criteria as determined by the admission review team, based on the preliminary evaluation prior to admission
• Is in need of and receives active treatment
• Receives an active treatment program that is integrated, coordinated and monitored by a qualified developmental disabilities professional

MHCP covers room and board care for an MA recipient in an ICF/DD. Items/services usually included in the per diem (not an all-inclusive list):

• Dietary services
• Laundry and linen services
• Nursing services
• Over-the-counter drugs or supplies used on an occasional, as needed basis (e.g., aspirin, acetaminophen, antacids, cough syrups, etc.)
• Personal hygiene items necessary for daily personal care (e.g., soap, shampoo, toothpaste, toothbrush, shaving cream, etc.)


Other covered services may include:
• Durable Medical Equipment (DME): Medical equipment and supplies are generally included in the Long-Term Care (LTC) ICF/DD per diem. The supplier may bill DHS directly for items supplied to ICF/DDs that are excluded from the LTC per diem or cost of doing business. Refer to the Medical Supply Coverage Guide (PDF) for information about coverage and limits for supplies and equipment.
• Hospital Leave Days
• Therapeutic Leave Days
• Personal Needs Allowance


Recipient Service Options
Alternative service options for persons who live in an ICF/DD provide flexibility and the choice to select and use the program option that best meets the person’s needs as identified in the Individual Service Plan (ISP). Current options for persons include:

1. Services During The Day provided by some entity other than the Day Training and Habilitation (DT&H)
2. DT&H program funded as a pass through payment of the ICF/DD
3. Retirement from DT&H, which may be funded using variable rate funding
4. Retirement from DT&H while remaining in the ICF/DD with no additional increase in the facility rate

The ICF/DD and DT&H provider are required to provide active treatment and meet all federal regulations that govern a person who resided in an ICF/DD, no matter which of the options above, is used.

Services During the Day
The Services During the Day Option for persons who live in an ICF/DD provides an option for services other than DT&H. It provides the flexibility and choice to select the program option that best meets the recipient’s needs as identified in the Individual Service Plan (ISP). Services or supports provided using this option enables the recipient to fully integrate into the community. Services during the day may include a variety of supports to enable the recipient to exercise choices for community integration and inclusion activities. Services during the day may include but are not limited to: supported work, support during community activities, community volunteer programs, adult day care, recreational activities, and other individualized supports. Services during the day must comply with active treatment requirements for recipients residing in an ICF/DD. Services during the day can be provided by any of the following:

• ICF/DD where the recipient resides
• ICF/DD other than where the recipient resides
• Separate entity monitored and paid for by the ICF/DD where the recipient resides

Services may not be provided by the residential service provider, unless the recipient or their legal representative is:

• Given a choice of providers
• Agrees in writing to provision of services during the day by the residential service provider, consistent with the ISP

A recipient can receive services during the day from someone other than the ICF/DD when that is the choice of the recipient or their legally authorized representative. The ICF/DD where the recipient lives is responsible to arrange, oversee and bill for the services provided. The ICF/DD will pay the provider of the service at a rate that does not exceed the rate approved by DHS. The application for this option is available in Services During the Day Options for persons living in ICF/DD facilities. MA eligible residents of ICF/DDs and Nursing Facilities (NFs) who also meet hospice service eligibility may elect to receive hospice services where they live. Refer to the Hospice Services section.

Day Training & Habilitation (DT&H)
DT&H facilities are licensed supports to provide recipients with help to develop and maintain life skills, participate in community life and engage in proactive and satisfying activities of their own choosing. Services include:

• Supervision, training and assistance in the areas of self-care, communication, socialization and behavior management
• Supported employment and work-related activities
• Community integrated activities, including the use of leisure and recreation time
• Training in community survival skills, money management and therapeutic activities that increase adaptable living skills of a person
• Transportation services* for non-medical purposes to enable persons to participate in above listed services
• DT&H transportation can only be used for DT&H services

A recipient cannot attend both a DT&H and Services During the Day on the same day. Only one of these two services may be billed for one person on any given day of the week.

ICF/DD Non - DT&H Service
ICF/DD recipients have a choice of day services as do persons who receive a home and community-based waiver. The active treatment criteria for persons who reside in an ICF/DD remains in place, no matter which option is chosen.

• Residential Habilitation Services is a requirement of the DD Waiver
• Refer to HCBS Services section and the Disability Services Program Manual for additional information about Residential Habilitation Services

Non-covered Services
MA covers the majority of costs incurred while in an ICF/DD. However a resident may be responsible for some non-covered MA services, such as:

• Other services not covered by MA
• Spenddown amounts

Authorization Requirements
Refer to Admission to an ICF/DD
Refer to Preadmission Screening

On the DD screening document, code current services as ICF/DD community #28 with a risk status of 01: Person is at risk of ICF/DD placement.

Authorizations through Service Agreements are required for the following:

• Variable Rate requests
• All DD waiver recipients
• Rule 186 recipients

Billing
Billing Guidelines
• Bill electronic claims on the 837I format using the facility’s NPI
• Use Type of Bill 065x for Level I care and 066x for Level II care
• Report room and board as level of care using 019x series. Refer to the Long Term Care E3 Changes update
• The level of care services (per diem) cannot be billed until the beginning of the following month (e.g., January services cannot be billed until February 1)
• To file a claim with a variable rate, use the 837P claim format and information from the approved service agreement

• For questions regarding ICF/DD occupancy, e-mail: dhs.icf.occupancy@state.mn.us
• Refer to Billing Policy for additional ICF/DD payment rate information
• For information on equalization laws, please see Long Term Care section

Refer to the ICF/DD Systems Manual for:


Variable Rate Process
• Effective 06/01/10 providers may continue to apply for variable rates with a start date of 07/01/10 or after
• Variable rates, which are in place prior to 07/01/2009, can be renewed
• Refer to Variable Rate Adjustments for information including ICF/DD Variable Rate Reporting Form and Instructions

Special Needs Rate Exceptions
DHS governs the authorization of special needs rate exceptions for very dependent persons with special needs residing in an ICF/DD. Once a request is approved, a vendor and recipient specific service agreement and approval letter are generated and sent to the provider. Billing codes on the approved service agreement are as follows:

• X7010: Direct care staff
• X7020: Equipment
• X5628: Professional/practitioner consultant

Special Needs Rate Exceptions for the Developmental Disabilities (DD) Waiver
The county cannot negotiate an individual rate for a recipient that is different from the established DT&H rates unless authorization is received from DHS in accordance with Rule 186 criteria. Recipients who receive a rate exception are considered to have the same level of need as recipients who reside in an ICF/DD. There is allowance for additional dollars to be available a maximum of 12 months to allow a recipient to continue to receive DT&H services.

Request Process
• The provider submits a proposal to the CFR for the person. The proposal should be based "above and beyond the current rate that they are receiving." This is what will be needed to continue to serve the person. The proposal is based on services, which are clearly special services not covered under the established rate. For example, the provider's current full time rate is $50.00 and they need _____ amount above this rate to serve a recipient due to medical or behavior issues. This could also be applied to just the transportation rate.
• Typically the provider comes up with a rate based on 1:1 staff serving the recipient. This may include wages and a benefit component.
• The case manager will verify the recipient meets the eligibility criteria and is screened and authorized for DD waivered services.
• The county then submits the rate exception proposal to the MHCP. In addition to the provider information. The case manager should include the ISP, which indicates a need for a habilitation component that cannot be met within the established rate of the DT&H.
• The maximum approval period is 12 months and cannot be renewed except in exceptional circumstances. It is expected that the need for the rate exception will be eliminated in the 12 month period. Costs for the rate exception must be managed within the county waiver pool.

MHCP grants final approval and will override the rate file on the service agreement for the person who receives the special needs rate exception. Counties do not have the ability to override the rate file.


Definitions
Active Treatment: Refers to aggressive, consistent implementation of a program of specialized and generic training, treatment and health services. Active treatment does not include services to maintain generally independent recipients able to function with little supervision or in the absence of a continuous active treatment program.

Day Training and Habilitation Services (DT&H): These are services related to a person's employment or work, self-care, communication skills, socialization, community orientation, transportation needs, emotional development, development of adaptive behavior, cognitive development, and physical mobility. It includes training, supervision assistance, and other support activities designed and implemented in accordance with a person’s individual service plan to help that person attain and maintain the highest level of independence, productivity, and integration into the community where the person lives and works. The ISP for each person requiring a 24-hour plan of care must provide services during the day outside the residence unless otherwise specified in their plan.

Developmental Disability (DD): Severe, chronic disability attributable to mental/physical impairment, which manifests before age 22 years and is likely to continue indefinitely. The disability results in substantial limitations in three or more of the following areas: self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living and economic self-sufficiency as well as the continuous need for individually planned and coordinated services.

Developmental Disabilities (DD) Waiver: The DD Waiver provides funding for home and community-based services for children and adults with developmental disabilities. Assessed waiver service needs, as identified in the person’s service plan, may be provided in a person’s own home, in his/her biological or adoptive family’s home, in a relative’s home (e.g., sibling, aunt, grandparent, etc.), in a family foster care home or corporate foster care home.

Facility with Distinct Part Certification: Sections of the facility certified as psychiatric, NF, or ICF/DD; must admit and care for those MA recipients certified as requiring the same level of care as the bed certification.

Individual Service Plan (ISP): Each person with developmental disabilities or a related condition, who is receiving services, must have an ISP. The ISP is developed after an assessment of the person’s preferences, functional skills and need for services and supports is completed before services are authorized. The ISP is based on the service recommendations from the completed assessment(s) and the service needs identified by the team.

Intermediate Care Facility for Persons with Developmental Disabilities (ICF/DD): Residential facility licensed as a health care institution and certified by the Minnesota Department of Health to provide health or rehabilitative services for persons with developmental disabilities or a related condition who require active treatment.

Leave Day: An overnight absence of more than 23 hours. After the first 23 hours, additional leave days are accumulated each time the clock passes midnight. Absence must be for hospital or therapeutic cause.

Level of Care (LOC): Care and services associated with a particular facility type, for example:

• Intermediate Care Facility for persons with developmental disabilities.(ICF/DD)
• Hospital
• Nursing Facility (NF)
• Neurobehavioral Hospital (NBH)

An LOC must be determined for all persons seeking a Medicaid waiver. It is an eligibility requirement for its receipt and identifies the type of waiver and services available to eligible recipients.

Long Term Care (LTC): Services received in a nursing facility, an intermediate care facility for persons with developmental disabilities (ICF/DD), or a swing bed when the individual in the facility is screened or certified as requiring the services provided in the facility.

LTC Facility: A residential facility certified by the MDH as a skilled nursing facility or as an intermediate care facility, including an ICF/DD.

DD Conversion: A recipient in an existing ICF/DD bed is provided home and community-based services and the ICF/DD bed the recipient previously occupied is decertified and removed from the community ICF/DD system.

Qualified Developmental Disability Professional (QDDP): Individual qualified to work as an expert with persons with developmental disabilities. The QDDP has a four-year college degree in an area related to developmental disabilities and a minimum of one-year experience working in that field.

Regional Treatment Center (RTC): State facility for treating persons with mental illness, developmental disabilities or chemical dependency that is under the direct administrative authority of the Commissioner.

Reserved Bed: The same bed that a recipient occupied before leaving the facility for hospital leave or therapeutic leave, or an appropriately certified bed if the recipient's physical condition upon returning to the facility prohibits access to the bed he/she occupied before the leave. It is commonly referred to as a “bed hold”.

Residential Care Services: Supportive and health supervision services provided in a licensed residential setting as identified in an Individual Service Plan.

Services During the Day: Services or supports provided to a person that enables the person to be fully integrated into the community. These may include a variety of supports to enable the person to exercise choices for community integration and inclusion activities. Services during the day may include, but are not limited to: supported work, support during community activities, community volunteer activities, adult daycare, recreational activities and other individualized integrated supports.

Therapeutic Leave: Absence of a recipient from an ICF/DD for a non-medical purpose with the expectation the recipient will return to the facility. The recipient may be at any of the following:

• Camp which meets the applicable licensure requirements of the MN Department of Health
• Home/family visit
• Residential setting other than ICF/DD, hospital or other entity eligible to receive federal, state or county funds to maintain the recipient
• Vacation

Utilization Review: A review of the use of medical resources at a medical facility for purposes of cost control

Waivered Service: Home or community-based service authorized and defined in the Minnesota state plan for the provision of medical assistance services. Waivered services include, at a minimum, case management, family training and support, developmental training homes, supervised living arrangements, semi-independent living services, respite care, and training and habilitation services.


Legal References
State
MS 252.282
Local System Needs Planning
MS 256B.092
County of Financial Responsibility
MS 256B.27
, subd.1 MA Reports and Audits
MS 256B.0625
, subd.2 MA Covered Services
MS
256B.0926
Admission Review Team
MS 256B.48
Conditions for Participation
MS 256B.501
Community-Based Service Rates
MS 256B.501
, subd.8; 8a Payment for persons with special needs for crisis intervention services
MS 256B.5011
ICF/DD Reimbursement
MS 256B.5012
ICF/DD Payment System
MS 256B.5013
Payment Rate Adjustments
MS 256B.5014
Financial Reporting
MS 256B.5015
Pass-Through of Other Services Costs
Minnesota Rules 4665.0500
Building Classification
Minnesota Rules 9510.1020 to 9510.1140
Rule 186 Definitions and Appeals
Minnesota Rules 9549.0060
, subp.11 Capacity
Minnesota Rules 9549.0070
Payment Rate
Minnesota Rules 9553.0010 to 9553.0080
Costs/Payment Rate

Federal
42CFR440
Services: General Provisions
42CFR441
Services: Requirements and Limits Applicable to Specific Services
42CFR442
Standards for Payment to Nursing Facilities and ICF/DDs


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