5101:3-3-15.3 Level of care review process for intermediate care facilities for the mentally retarded.

(A) "Level of care review", as used in this rule, is an assessment of an individual's physical, mental, habilitative and social/emotional needs to determine whether the individual requires intermediate care facility services for the mentally retarded. Level of care (LOC) review is conducted pursuant to paragraph 1902(a)(30)(A) of the Social Security Act and are those activities necessary to safeguard against unnecessary utilization. "Intermediate care facility services for the mentally retarded" are those services available in facilities certified as intermediate care facilities for the mentally retarded (ICF-MR) by the Ohio department of health.

The evaluation of an individual's LOC needs determines the appropriately certified facility type for which medicaid vendor payment can be made. Except as provided in paragraph (D) of this rule, vendor payment can be initiated to an ICF-MR only when the applicant is determined to need an ICF-MR LOC according to the criteria specified in rule 5101:3-3-07 of the Administrative Code.

(B) Definitions:

(1) "CDHS" means county department of human services.

(2) "ICF-MR" means intermediate care facility for the mentally retarded. An "ICF-MR" is a long term care facility certified to provide services to individuals with mental retardation or a related condition who require active treatment as defined at 42 CFR 483.440 . In order to be eligible for vendor payment in an ICF-MR, a medicaid recipient must be assessed and determined by ODHS to be in need of an ICF-MR level of care as outlined in rule 5101: 3-3-07 of the Administrative Code.

(3) "Individual" means a medicaid recipient or person with pending medicaid eligibility who is making application to a nursing facility (NF) or ICF-MR; or who resides in a NF or an ICF-MR; or is applying for home and community-based services (HCBS) waiver enrollment.

(4) "Physician" means a doctor of medicine or osteopathy who is licensed to practice medicine in the state of Ohio.

(5) "Psychologist" means a degreed psychologist who has been licensed by the Ohio board of psychology to practice psychology in the state of Ohio.

(C) Level of care review is required for individuals in the following situations:

(1) Hospitalized individuals who are not currently ICF-MR residents who are applying for ICF-MR placement.

(2) Hospitalized individuals who are current ICF-MR residents who are seeking admission to a different ICF-MR.

(3) Individuals seeking readmission to the ICF-MR after exhausting available paid hospital leave days (see rule 5101:3-3-03 of the Administrative Code requirements regarding available leave days).

(4) Individuals who are current ICF-MR residents who are seeking admission to a different ICF-MR.

(5) Individuals who are not currently ICF-MR residents who are seeking admission to an ICF-MR from community living arrangements.

(6) Individuals who were on paid leave days are not in a hospital setting and who have exhausted their paid leave days, who are seeking readmission to an ICF-MR.

(7) Current ICF-MR residents who are requesting medicaid reimbursement of their ICF-MR stay.

(8) Individuals applying for HCBS waiver services.

(D) Under the circumstances in paragraphs (D)(1), (D)(2) and (D)(3) of this rule, vendor payment shall be continued or reinstated when a change in institutional setting is sought.

(1) Current ICF-MR residents receiving medicaid vendor payment who wish to transfer to another ICF-MR must submit a completed ODHS 3697 form, not later than the day of transfer to the new ICF-MR, as specified in paragraphs (E)(1) and (E)(2) of this rule to initiate reimbursement in the new ICF-MR effective from the date of admission.

(a) Under this circumstance, vendor payment to the new ICF-MR will be authorized back to the date of the individual's admission to the facility. ODHS shall notify the appropriate CDHS to begin vendor payment. If ODHS determines that the individual is no longer in need of an ICF-MR LOC, ODHS will notify the recipient and the ICF-MR as to the adverse ODHS determination and ODHS's intent to terminate vendor payment. The notice shall set forth the recipient's hearing rights and the time frames within which they must be exercised. ODHS may instruct the appropriate CDHS, as its designee to issue this notice.

(b) If a hearing request is received in response to the notice specified in paragraph (D)(1)(a) of this rule within time frames specified in rule 5101:1-35-04 of the Administrative Code that require the continuation of benefits, authorization for payment will be continued pending the issuance of a state hearing decision.

(c) If the individual does not submit a hearing request within the time frame specified in paragraph (D)(1)(b) of this rule, vendor payment will automatically terminate on the date specified in the notice advising the recipient of ODHS' intent to terminate vendor payment.

(2) Hospitalized individuals who are current ICF-MR residents and are seeking admission to a different ICF-MR, must meet the requirements in paragraphs (D)(1)(a), (D)(1)(b) and (D)(1)(c) of this rule in order to have vendor payment authorized from the date of admission. These requirements must be met regardless of whether they have exhausted paid leave days.

(3) Hospitalized individuals who are seeking readmission to the same ICF-MR after exhaustion of paid leave days may be readmitted to that ICF-MR regardless of the results of the LOC determination if, not later than the date of readmission, the recipient submits a completed ODHS 3697 form to initiate reimbursement effective from the date of readmission. If the LOC determination does not match the certification of the facility as specified in paragraph (A) of this rule, the following procedures will apply:

(a) Vendor payment to the ICF-MR will be authorized back to the date of the individual's admission to the facility. ODHS shall notify the appropriate CDHS to begin vendor payment. If ODHS determines that the individual is no longer in need of an ICF-MR LOC, ODHS will notify the recipient and the ICF-MR as to the adverse ODHS determination and ODHS' intent to terminate vendor payment. The notice shall set forth the recipient's hearing rights and the time frames within which they must be exercised. ODHS may instruct the appropriate CDHS as its designee to issue this notice.

(b) If a hearing request is received in response to the notice specified in paragraph (D)(3)(a) of this rule within the time frames specified in rule 5101:1-35-04 of the Administrative Code that require the continuation of benefits, authorization for payment will be continued pending the issuance of a state hearing decision.

(c) If the individual does not submit a hearing request within the time frame specified in paragraph (D)(3)(b) of this rule, vendor payment will automatically terminate on the date specified in the notice advising the recipient of ODHS' intent to terminate vendor payment.

(E) In order to obtain a LOC determination, an ODHS 3697, or an alternative form specified by ODHS, which has been appropriately completed, accurately reflects the individual's current mental and physical condition, and is certified by a physician must be submitted for review by ODHS.

(1) The ODHS 3697, or another ODHS-authorized alternative form must include the following components and/or attachments:

(a) Individual's name; medicaid number; date of original admission to the facility, if applicable; current address; name and address of residence if current residence is a licensed or certified residential setting or hospital; and county where the individual's medicaid case is active.

(b) A comprehensive medical, social and psychological evaluation of the individual. The psychological evaluation must be made before admission, but not more than three months before admission. Each evaluation must include:

(i) Diagnosis, including medical, psychiatric and developmental diagnoses, including dates of onset, if the date of onset is significant in determining whether the individual has a developmental disability;

(ii) Summary of medical, social and developmental findings;

(iii) Medical and social family history;

(iv) Mental and physical functional capacity;

(v) Prognoses;

(vi) Kinds of services needed including medical treatments, medications, and other professional medical services;

(vii) Evaluation of the resources available in the home, family and community;

(viii) A physician's certification of the individual's need for ICF-MR care made at the time of admission, or if the individual applies for medicaid while a resident of an ICF-MR, prior to the initiation of vendor payment.

(2) The ODHS 3697 must be complete when it is submitted to ODHS in order for a LOC determination to be made. Any entity (a CDHS, hospital or ICF-MR) who submits a LOC request must ensure that all required components are included before submission.

(a) Following receipt by ODHS of the ODHS 3697, ODHS shall make a determination of whether the ODHS 3697 is sufficiently complete for its personnel to perform the LOC review. If the ODHS 3697 is not complete, ODHS shall notify, in writing, the recipient, the contact person indicated on the ODHS 3697, and the ICF-MR or any other entity responsible for the submission of the ODHS 3697, that additional documentation is necessary in order to complete the LOC review. This notice shall specify the additional documentation that is needed and shall indicate that the individual or another entity has twenty days from the date ODHS mails the notice to submit additional documentation or the ODHS 3697 will be denied for incompleteness with no LOC authorized. In the event an individual or other entity is not able to complete an ODHS 3697 in the time specified, ODHS shall, upon good cause, grant one extension of no more than five days when an extension is requested by the recipient or other entity.

(b) If the ODHS 3697 is complete upon receipt by ODHS, or, if within the periods specified in paragraph (E)(2)(a) of this rule, the recipient submits the required documentation, ODHS shall issue a LOC determination within sixty days of the original receipt of the ODHS 3697 by ODHS. A LOC determination will be issued pursuant to the criteria specified in rules 5101:3-3-05 , 5101:3-3-06 and 5101:3-3-07 of the Administrative Code.

(3) A request for an ICF-MR LOC will not be denied by ODHS for the reason that the individual does not need ICF-MR services until a qualified professional whose qualifications include being a registered nurse or a qualified mental retardation professional (as specified at 42 CFR 483.430 ) conducts a face-to-face assessment of the individual, reviews the medical records that accurately reflect the individual's condition for the time period for which payment is being requested; makes a reasonable effort to contact the individual's physician; and investigates and documents alternative community resources including resources available in the home and family which may be available to meet the needs of the individual. Authorized personnel other than the person who conducted the face-to-face assessment will review the face-to-face assessment and make the final LOC decision.

(F) The LOC review process:

(1) ODHS reviews the application material submitted for the individual and completes the payment authorization (ODHS 3670) and sends it, along with the ODHS 3697, to the CDHS designated on the ODHS 3697. The CDHS shall send a copy of the ODHS 3697 and ODHS 3670 to the ICF-MR.

(2) Authorization of payment to an ICF-MR shall correspond with the effective date of the LOC determination specified on the ODHS 3670. This date shall be:

(a) The date of admission to the ICF-MR if it is within thirty days of the physician's signature; or

(b) A date other than that specified in paragraph (F)(2)(a) of this rule. This alternative date may be authorized only upon receipt of a letter which contains a credible explanation for the delay from the originator of the LOC request. If the request is to backdate the LOC more than thirty days from the physician's signature, the physician must verify the continuing accuracy of the information and need for inpatient care by either adding a statement to that effect on the ODHS 3697 or by attaching a separate letter of explanation.

Replaces: 5101:3-3-15

R.C. 119.032 review dates: 4/24/2002 and 04/24/2007

Promulgated Under: 119.03

Statutory Authority: RC 5111.02

Rule Amplifies: RC 5111.01, 5111.02

Prior Effective Dates: 4/7/77, 10/14/77, 7/1/80, 8/1/84, 1/17/92 (Emer.), 4/16/92