R414-502-8. Criteria for Intermediate Care Facility for Persons with Intellectual Disability

An intermediate care facility for persons with intellectual disabilities (ICF/ID) must demonstrate that the applicant meets the following criteria before the Department may authorize Medicaid coverage for an individual who resides in an ICF/ID.

(1) The individual must have a diagnosis of:

(a) An intellectual disability in accordance with 42 CFR 483.102(b)(3); or

(b) A condition closely related to intellectual disability in accordance with 42 CFR 435.1010.

(2) For individuals seven years of age and older, the presence of a diagnosis alone is not sufficient to qualify for admission to an intermediate care facility for persons with intellectual disabilities. The diagnosis identified in Subsection R414-502-8(1) must result in documented substantial functional limitations in three or more of the following seven areas of major life activity that include:

(a) Self-care;

(i) The individual requires assistance, training and supervision to eat, dress, groom, bathe, or use the toilet.

(b) Receptive and expressive language;

(i) The individual lacks functional communication skills, requires the use of assistive devices to communicate, does not demonstrate an understanding of requests, or cannot follow two-step instructions.

(c) Learning;

(i) The individual has a valid diagnosis of an intellectual disability based on criteria found in the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fourth Edition, 1994.

(d) Mobility;

(i) The individual requires the use of assistive devices to be mobile and cannot physically self-evacuate from a building during an emergency without an assistive device.

(e) Self-direction;

(i) The individual is seven through 17 years of age and significantly at risk in making age appropriate decisions. Or, in the case of an adult, cannot provide informed consent for medical care, personal safety, or for legal, financial, rehabilitative, and residential issues, and has been declared legally incompetent. The individual is a danger to himself or others without supervision.

(f) The capacity for independent living;

(i) The individual who is seven through 17 years of age cannot locate and use a telephone, cross the street safely, or understand that it is unsafe to accept rides, food or money from strangers, or an adult who lacks basic skills in the areas of shopping, preparing food, housekeeping, or paying bills.

(g) Economic self-sufficiency (not applicable to children under 18 years of age);

(i) The individual receives disability benefits, cannot work more than 20 hours a week, or is paid less than minimum wage without employment support.

(3) The Department considers a child under the age of seven to be at risk for functional limitation in three or more areas of major life activity. The child may satisfy this criteria if the child has been with an intellectual disability or a condition closely related to intellectual disability. The Department does not require separate documentation of the limitations defined in Subsection R414-502-8(2) until the child turns seven years of age.

(4) To meet the criteria of a condition closely related to an intellectual disability, an individual must manifest the condition before the individual turns 22 years of age and the condition must be likely to continue. A diagnosis may qualify as a condition closely related to an intellectual disability only if the child meets the criteria defined in 42 CFR 435.1010. The following is a list of diagnoses the Department considers to be conditions closely related to an intellectual disability:

(a) Cerebral palsy. The Department does not require individuals to demonstrate an intellectual impairment for this diagnosis, but they must demonstrate they have functional limitations as described in Subsection R414-502-8(2);

(b) Epilepsy. The Department does not require individuals to demonstrate an intellectual impairment for this diagnosis, but they must demonstrate they have functional limitations as described in Subsection R414-502-8(2);

(c) Autism Spectrum Disorder. The Department requires an individual to meet the following criteria under this category:

(i) Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifests by all three of the following:

(A) Deficits in social-emotional reciprocity, ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction;

(B) Deficits in non-verbal communicative behaviors used for social interaction, ranging from poorly integrated verbal and non-verbal communication through abnormalities in eye contact and body language, or deficits in understanding and use of non-verbal communication to total lack of facial expression or gestures;

(C) Deficits in developing and maintaining relationships appropriate to developmental level (beyond those with caregivers), ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play, and in making friends to an apparent absence of interest in people.

(ii) Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following:

(A) Stereotyped or repetitive speech, motor movements, or use of objects (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases);

(B) Excessive adherence to routines, ritualized patterns of verbal or non-verbal behavior, or excessive resistance to change (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes);

(C) Highly restricted, fixated interests with abnormal intensity or focus (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests);

(D) Hyper or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment (such as apparent indifference to pain, heat and cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects).

(iii) Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities).

(iv) Symptoms together limit and impair everyday functioning.

(d) Severe brain injury. May be the result of an acquired brain injury, traumatic brain injury, stroke, anoxia, meningitis;

(e) Fetal alcohol syndrome;

(f) Chromosomal disorders such as Down syndrome, fragile x syndrome, and Prader-Willi syndrome;

(g) Other genetic disorders. Examples include Williams syndrome, spina bifida, and phenylketonuria.

(5) The following conditions do not qualify as conditions closely related to intellectual disabilities. Nevertheless, the Department may consider a person with any of these conditions if there is a simultaneous occurrence of a qualifying condition as cited in Subsection R414-502-8(1)(a) and (b):

(a) Learning disability;

(b) Behavior or conduct disorders;

(c) Substance abuse;

(d) Hearing impairment or vision impairment;

(e) Mental illness that includes psychotic disorders, adjustment disorders, reactive attachment disorders, impulse control disorders, and paraphilias;

(f) Borderline intellectual functioning, a related condition that does not result in an intellectual impairment, developmental delay, or "at risk" designations;

(g) Physical problems such as multiple sclerosis, muscular dystrophy, spinal cord injuries, and amputations;

(h) Medical health problems such as cancer, acquired immune deficiency syndrome, and terminal illnesses;

(i) Neurological problems not associated with intellectual deficits. Examples include Tourette's syndrome, fetal alcohol effects, and non-verbal learning disability;

(j) Mild traumatic brain injury such as minimal brain injury and post-concussion syndrome.

(6) An individual who was admitted to an ICF/ID before August 27, 2009, is eligible for continued stay as long as the individual continues to meet the requirements in effect before that date. A resident who was admitted to an ICF/ID before August 27, 2009, is only required to meet the revised eligibility criteria when there is a break in stay wherein the individual resides in a setting that is not a Medicaid-certified ICF/ID nursing facility or hospital.

(7) Before admission to an ICF/ID, the facility must provide each potential resident with a two-sided fact sheet (Form IFS 10) that offers information about ICFs/ID and the Community Supports Waiver for People with Intellectual Disabilities and Other Related Conditions. Each resident's record must contain an acknowledgement (Form IFS 20) signed by the resident or legal representative, which verifies that the facility provided the Form IFS 10 before admission.