Published on 03/3/2006

March 3, 2006

Dearest Advocates:

As promised, please find below the new eligibility Level of Care criteria for Intermediate Care Facility / MR for Katie Beckett Waiver from the Dept of Community Health.

Please note: I have not had a chance to review these criteria in detail. Therefore, I'm sure we will all have questions that will need to be addressed BUT at least we know what the new rules are right now.

If you have concerns about the new criteria, please send me a BRIEF e-mail explaining your concerns and your child's disability and age so I can put together a composite listing to be given to Dept. of Community Health for review and clarification.

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INTERMEDIATE CARE FACILITY (ICF/MR) LEVEL OF CARE

Summary:

1. ICF/MR level of care is appropriate for individuals who require the type of active treatment typically provided by a facility whose primary purpose is to furnish health and rehabilitative services to persons with mental retardation or related conditions.

2. An ICF/MR level of care is generally indicated if one condition of Column A is satisfied in addition to the conditions Column B and Column C being satisfied. Conditions derived from 42 C.F.R. 440.150, 435.1009, and 483.440(a).

3. Column B refers to “an aggressive, consistent implementation of a program of specialized and generic training, treatment, health services, and related services.” These active treatment services, as defined in 42 C.F.R. 483.440, provide aggressive, consistent monitoring, supervision and/or assistance as defined in the plan of care to address the specific medical conditions, developmental and behavioral needs, and/or functional limitations identified in the comprehensive functional assessment. This comprehensive functional assessment must be age appropriate.

4. The following conditions meet ICF/MR institutional level of care criteria, as these individuals would be institutionalized regardless of ability to participate in an aggressive program of specialized and generic training, treatment, health services, and related services as outlined in Column B:

· Those children with an IQ of 50 or below (moderate to profound mental retardation) or

· Those children who meet the criteria for Autism, Autism-Spectrum, Asperger’s, Pervasive Developmental Disorder, Developmental Delay, Mental Retardation, Down’s Syndrome, and any other Developmental Disability as evidenced by:

i. a score on a standardized adaptive functioning tool of 2 standard deviations below the norm in three or more of any of the following behavior domains: self care skills, understanding and use of verbal and nonverbal language learning in communication with others, mobility, self-direction, and age-appropriate ability to live without extraordinary assistance or an overall standard score < 70, or

ii. if their age equivalency composite score is less than 50% of their chronological age, and/or

iii. the child has a Childhood Autism Rating Scale (CARS) score of above 37, a Gilliam Autism Rating Scale (GARS) of 121 or greater, or any other equivalent standardized assessment tool which indicate severe autism.

COLUMN A (Diagnosis)

COLUMN B (Plan of Care)

COLUMN C (Functional Need)

1. The individual has mental retardation.

2. The individual has a severe chronic disability attributable to cerebral palsy or epilepsy.

3. The individual has a condition, other than mental illness, (i.e. Autism, Autism-spectrum, Asperger’s, Pervasive Developmental Disorder, Down’s Syndrome or Developmental Delay) which is found to be closely related to mental retardation because it is likely to last indefinitely, and requires similar treatment and services.

AND

4. The impairment for those conditions outlined above constitutes an impairment of general intellectual functioning, and results in substantial limitations in three or more of the following functional limitations:

· Self-care skills such as feeding, toileting, dressing and bathing;

· Understanding and use of verbal and nonverbal language learning in communication with others;

· Mobility;

· Self-direction in managing one’s social and personal life and the ability to make decisions necessary to protect one’s self as per age-appropriate ability; and/or

· Age-appropriate ability to live without extraordinary assistance

On a continuous basis, the individual requires aggressive consistent implementation of a program of specialized and generic training, treatment, health services, and related services which is directed towards—

a. The acquisition of the skills necessary for the individual to function with as much self-determination and independence as possible; and

b. The prevention of further decline of the current functional status or loss of current optimal functional status. This is evidenced in the Plan of Care by the individual’s participation (at least five (5) days a week) in interventions which are required to correct or ameliorate the conditions/diagnosis; and are compatible with acceptable professional practices in light of the condition(s) at the time of treatment.

Active treatment does not include:

interventions that address age-appropriate limitations; or
general supervision of children whose age is such that supervision is required by all children of the same age or
physical assistance for persons who are unable to physically perform tasks but who understand the process needed to do them

1. The services have been ordered by a licensed

physician.

AND

2. The services will be furnished either directly

by, or under the supervision of, appropriately

qualified providers (see definitions):

AND

3. The services, as a practical matter, would have ordinarily been provided in an ICF-MR, in the absence of community services.

Revised 3/3/06

Hope this information helps.

Sincerely,

Heidi