Title 7 . Health and Social Services

Chapter 43 . Hearings

Section 300. Eligibility, admission, and payment authorization

7 AAC 43.300. Eligibility, admission, and payment authorization

(a) The department will authorize payment for services in an intermediate care facility for the mentally retarded or persons with related conditions (ICF/MR), if the department determines that

(1) a recipient qualifies under this section and that the recipient requires a level of care provided in an ICF/MR, as determined under (c) and (d) of this section; and

(2) the facility is certified as an ICF/MR, and complies with 7 AAC 43.300 - 7 AAC 43.335, 7 AAC 43.670 - 7 AAC 43.709, and other applicable requirements of this chapter.

(b) The department will authorize payment for services in an ICF/MR only if the facility

(1) provides a comprehensive medical, social, and psychological evaluation of the recipient, covering physical, emotional, social, and cognitive factors of each recipient's need for care and services; the facility must complete the evaluation no more than 30 days after the date of a

(A) recipient's admission to the facility; or

(B) request for payment under Medicaid, if the recipient is a resident of the facility who applies while in the facility; and

(2) submits annually, for each state fiscal year and on a form approved by the department, a request for ICF/MR authorization that, for

(A) the first request, explains the reason for admission and provides a detailed summary of the recipient's habilitative plan of care developed as required in 7 AAC 43.305(a) ; and

(B) subsequent requests, provides a detailed summary of the reevaluation of the recipient as required in 7 AAC 43.305(c) .

(c) In determining whether a recipient qualifies under this section for ICF/MR services, the department will base its decision on the determination of a qualified mental retardation professional within the department that the recipient meets the functional criteria in (d) of this section, and that the recipient has at least one of the following conditions:

(1) mental retardation that meets the diagnostic criteria for code 317 or 318, as set out in American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision, 2000 (DSM-IV-TR), pages 41 - 49, adopted by reference; the recipient must have an intelligence quotient of 70 points or less as determined by an individual, standardized psychological evaluation, plus up to five points to account for any measurement error;

(2) a condition that is

(A) one other than mental illness, psychiatric impairment, or a serious emotional or behavioral disturbance; and

(B) found to be closely related to mental retardation because that condition results in impairment of general intellectual functioning and adaptive behavior similar to that of individuals with mental retardation; the condition must be diagnosed by a licensed physician and require treatment or services similar to those required for individuals with mental retardation;

(3) cerebral palsy that is diagnosed by a licensed physician; however, a deficit in intellectual ability need not be present;

(4) seizure disorder that is diagnosed by a licensed physician; however, a deficit in intellectual ability need not be present;

(5) autism that has been diagnosed by a mental health professional clinician and that meets the diagnostic criteria for code 299.00, as set out in American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision, 2000 (DSM-IV-TR), pages 70 - 75, adopted by reference.

(d) Each condition identified in (c) of this section must

(1) have originated before the age of 22 years;

(2) be likely to continue indefinitely; and

(3) constitute a substantial disability to the individual's ability to function in society, as

(A) measured by the Inventory for Client and Agency Planning (ICAP), as revised as of 1986 and adopted by reference; and

(B) evidenced by a broad independence domain score equal to or less than the cutoff scores in the department's Table of ICAP Scores by Age, as revised as of February 12, 2004 and adopted by reference.

(e) Within 120 days after the date it receives a request for ICF/MR authorization, the department will evaluate that request in accordance with (a) of this section and make a determination. In that determination, the department will concur in the placement and authorize payment, deny authorization for payment, or request that the interdisciplinary team assigned under 7 AAC 43.302 provide additional information.

(f) If the department, as part of its determination under (c) of this section, finds that sufficient justification does not exist to continue a recipient's placement in a facility, the department will recommend to the facility that alternative placement be found or the recipient be discharged. The department will give the facility 30 days after the date of the determination for the facility to arrange for discharge or alternative placement of a recipient. At the end of that 30-day period, if the recipient has been recommended for discharge and the facility has not yet discharged the recipient, the department will terminate payment.

(g) A facility that is denied authorization for payment may appeal under 7 AAC 43.085. A recipient whose continued placement is denied may request a hearing under 7 AAC 49.

History: Eff. 8/18/79, Register 71; am 12/19/93, Register 128; readopt 8/7/96, Register 139; am 05/15/2004, Register 170

Authority: AS 47.05.010

AS 47.07.050

Editor's note: Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.300 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department.

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders 4th edition, Text Revision 2000 (DSM-IV-TR), parts of which are adopted by reference in 7 AAC 43.300 may be obtained by writing to the American Psychiatric Association, 1400 K Street, N.W., Washington, D.C. 20005, and is available for inspection at the Department of Health and Social Services, Division of Senior and Disabilities Services, Court Plaza Building, Room 602, Juneau, Alaska.

The Inventory for Client and Agency Planning (ICAP) and the Department of Health and Social Services's Table of ICAP Scores by Age, adopted by reference in 7 AAC 43.300, are available for inspection at the Department of Health and Social Services, Division of Senior and Disabilities Services, Court Plaza Building, Room 602, Juneau, Alaska.