DAR File No. 42941

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-510

Intermediate Care Facility for Persons with Intellectual Disabilities Transition Program

Notice of Proposed Rule

(Repeal and Reenact)

DAR File No.: 42941
Filed: 05/31/2018 03:57:06 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to improve the education and participant selection process for the Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) Transition Program, in response to feedback the Department of Health (Department) received through conducting a series of stakeholder meetings on program improvement.

Summary of the rule or change:

The repealed rule requires individuals to submit an application to show interest in participating in the ICF/ID Transition Program. It also contains a provision that requires the state to contact potentially eligible individuals annually, even if the individual or guardian has informed state staff that they are not interested in participation. The selection process also enrolls an individual evenly from two lists based on length of stay in an ICF/ID and by random selection, and does not require onsite education. Conversely, the reenacted rule no longer requires individuals to submit an application to show interest in program participation, and individuals may "opt-out" of being contacted by the state for a three-year period. The new selection process also enrolls 70% of individuals on the weighted list based on the number of times they apply for the program, their presence on the Division of Services for People with Disabilities (DSPD) waiting list, and their length of stay in an ICF/ID. 30% of individuals will come from a random selection list. Finally, the new rule requires an onsite meeting to educate individuals and their guardians about the program.

Statutory or constitutional authorization for this rule:

• Section 26-1-5
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this change only updates and clarifies the purpose and operation of the ICF/ID Transition Program, which operates on available funding from previous allocations by the Legislature.

local governments:

There is no impact to local governments because they do not participate in the operation of the ICF/ID Transition Program.

small businesses:

Some small businesses may see a potential gain or loss of revenue when individuals move from facility-based services to home and community-based services. Nevertheless, there is not sufficient cost effective data to estimate an amount.

persons other than small businesses, businesses, or local governmental entities:

Medicaid providers may see a potential gain or loss of revenue when individuals move from facility-based services to home and community-based services, but there is not sufficient cost effective data to estimate an amount. There is no fiscal impact to Medicaid members as there is no change in ongoing waiver services.

Compliance costs for affected persons:

A single Medicaid provider or individual business may see a potential loss of revenue when individuals move from facility-based services to home and community-based services, but there is not sufficient cost effective data to estimate an amount.

Comments by the department head on the fiscal impact the rule may have on businesses:

Some businesses may see a potential gain or loss of revenue when individuals move from facility-based services to home and community-based services. Nevertheless, there is not sufficient cost effective data to estimate an amount.

Joseph K. Miner, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Office of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [email protected]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

07/16/2018

This rule may become effective on:

07/23/2018

Authorized by:

Joseph Miner, Executive Director

Appendix 1: Regulatory Impact Summary Table*

Fiscal Costs	FY 2019	FY 2020	FY 2021
State Government	$0	$0	$0
Local Government	$0	$0	$0
Small Businesses	$0	$0	$0
Non-Small Businesses	$0	$0	$0
Other Person	$0	$0	$0
Total Fiscal Costs:	$0	$0	$0
Fiscal Benefits
State Government	$0	$0	$0
Local Government	$0	$0	$0
Small Businesses	$0	$0	$0
Non-Small Businesses	$0	$0	$0
Other Persons	$0	$0	$0
Total Fiscal Benefits:	$0	$0	$0
Net Fiscal Benefits:	$0	$0	$0

 

*This table only includes fiscal impacts that could be measured. If there are inestimable fiscal impacts, they will not be included in this table. Inestimable impacts for State Government, Local Government, Small Businesses and Other Persons are described in the narrative. Inestimable impacts for Non - Small Businesses are described in Appendix 2.

 

Appendix 2: Regulatory Impact to Non - Small Businesses

Some of the 17 Intermediate Care Facilities for Persons with Intellectual Disabilities (ICFs/ID) may see a potential gain or loss of revenue, but there are not sufficient cost effective data to estimate an amount.

 

 

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

[R414-510. Intermediate Care Facility for Persons with Intellectual Disabilities Transition Program.

R414-510-1. Introduction and Authority.

(1) This rule implements the Intermediate Care Facility for Persons with Intellectual Disabilities (ICF/ID) Transition Program. Program participation is voluntary and allows an individual to transition out of an ICF/ID into the Community Supports Waiver for Individuals with Intellectual Disabilities and Other Related Conditions.

(2) This rule is authorized by Section 26-18-3. Waiver services are optional and provided in accordance with 42 CFR 440.225.

 

R414-510-2. Definitions.

(1) The term "Intermediate Care Facility for the Mentally Retarded" (ICF/MR) has been replaced with the term "Intermediate Care Facility for Persons with Intellectual Disabilities" (ICF/ID). ICF/ID is equivalent to ICF/MR as described under federal law.

(2) "Program" means the Intermediate Care Facility for Persons with Intellectual Disabilities Transition Program.

(3) "Program applicant" means an individual who meets eligibility requirements and submits an application to the Department during the open application period.

(4) "Slot" refers to the funding available for one individual to participate in the Program.

(5) "Representative" means a parent or guardian who assists a potential Program participant.

(6) "Waiver" means the Community Supports Waiver for Individuals with Intellectual Disabilities and Other Related Conditions.

 

R414-510-3. Eligibility Requirements.

Waiver services are potentially available to an individual who:

(1) receives ICF/ID benefits under the Medicaid State Plan;

(2) has been diagnosed with an intellectual disability or a related condition;

(3) meets ICF/ID level of care criteria defined in Section R414-502-8;

(4) meets state funding eligibility criteria for the Division of Services for People with Disabilities (DSPD) found in Subsection 62A-5-102(4); and

(5) has resided in any Medicaid-certified, privately-owned ICF/ID located in Utah for at least 12 consecutive months.

 

R414-510-4. Program Access Requirements.

(1) Each fiscal year, the Department shall determine whether there are sufficient funds available to open slots in the Program. The Department shall stipulate to the amount of funds that it dedicates to the Program if funds are available.

(2) Based on funds dedicated to the Program, the Department shall estimate the number of slots available. The Department estimates the number of slots available by dividing the total amount of funds dedicated to the Program in a fiscal year by the state portion of the average daily ICF/ID rate.

(3) At its discretion, the Department may reserve a number of slots for individuals:

(a) who meet the eligibility requirements of Section R414-510-3;

(b) who receive a discharge notice from the ICF/ID in which they reside;

(c) who have no viable option for alternative ICF/ID placement; and

(d) who DSPD accepts for ICF/ID placement.

(4) During a fiscal year in which the Program receives funding for new applicants, the Department shall announce an open application period. The Department shall publicize the availability of the Transition Program in the following manner:

(a) The Department shall provide a letter to the administrator of each privately-owned ICF/ID, each ICF/ID resident and to the representative of each ICF/ID resident. The letter shall:

(i) describe the purpose and operation of the Program, including availability of funding;

(ii) identify the selection process utilized for the Program;

(iii) state that Program participation is voluntary; and

(iv) provide Program contact information.

(b) The Department shall post information about Program availability on the Utah Medicaid website.

(c) The Department shall hold at least one open and public meeting to introduce the Program and send notice of the meeting via letter to the administrator of each privately-owned ICF/ID, each ICF/ID resident and to the representative of each ICF/ID resident. The meeting must:

(i) cover the purpose of the Program;

(ii) cover how the Program operates with available funds;

(iii) cover how residents or guardians may apply for the Program; and

(iv) allow a time period for questions and answers.

(5) After the open application period, the Department places the name of each Program applicant on both a longevity list and a random list. On the longevity list, the Department ranks each Program applicant according to length of consecutive stay in any ICF/ID in the state of Utah. On the random list, the Department randomly ranks each Program applicant based on a computerized random selection.

(6) The Department then selects evenly first from the longevity list and then from the random list for placement in the Waiver until the amount of funding allocated to the Program is disbursed to care for the admitted individuals.

(7) The Department conducts a periodic alternate selection process as follows:

(a) The Department shall place the names of all ICF/ID residents who meet the eligibility requirements in Section R414-510-3 on both a longevity list and a random list. The use of longevity and random lists shall follow the same process as identified in Subsection R414-510-4(5) through (6), except that all eligible individuals are considered.

(b) The Department shall send a letter to each selected resident and their representative. The letter must comply with requirements noted in Subsection R414-510-4(4)(a)(i) through (iv), and describe how Department staff will contact the individual or representative by phone or in- person for the purpose of answering questions to allow the individual or representative to make an informed choice about participation in the Program.

(c) The Department shall make follow-up phone calls or in-person visits to each individual or representative to provide information that reiterates the requirements described in Subsection R414-510-4(a)(i) through (iv).

(d) In cases where a selected individual does not have or require a representative, a DSPD Transition Program coordinator will visit the selected individual in-person at the ICF/ID to verify if program participation is desired.

(e) When an individual or representative voluntarily confirms a desire to participate in the Program, the Department shall provide a letter to the ICF/ID administrator to inform the administrator of the choice of the individual or representative to participate in the Program.

(8) If an individual is selected for the Program and has a spouse who also resides in a Utah ICF/ID and who meets the eligibility criteria in Section R414-510-3, the Department shall provide an additional slot for the spouse to participate in the Program without affecting the number of available slots from the longevity and random lists.

(9) Based on available funding, the Department shall continue to select eligible individuals through the aforementioned process until the Department exhausts the amount of funds committed to the Program.

(10) The Department shall keep the longevity list and random lists open for the sole purpose of filling slots vacated through Program attrition. If a Waiver participant who is admitted through the Program leaves the Waiver program for any reason, the Department shall contact and enroll the next person on the list who is interested in moving through the Program.

(11) The Department shall create new lists in accordance with Subsection R414-510-4(4) through (6) or (7) when there is funding available to open new Program slots.

 

R414-510-5. Service Coverage.

Services and limitations of the Program may be found in the Waiver State Implementation Plan.

 

R414-510-6. Reimbursement Methodology.

The Department of Human Services (DHS) contracts with the Department to set rates for Waiver-covered services. The DHS rate-setting process is designed to comply with the requirements of Subsection 1915(c) of the Social Security Act and other applicable Medicaid rules. Medicaid requires that rates for services not exceed customary charges.]

R414-510. Intermediate Care Facility for Persons with Intellectual Disabilities Transition Program.

R414-510-1. Introduction and Authority.

(1) This rule implements the Intermediate Care Facility for Persons with Intellectual Disabilities (ICF/ID) Transition Program. Program participation is voluntary and allows an individual to transition from an ICF/ID to the Community Supports Waiver for Individuals with Intellectual Disabilities and Other Related Conditions.

(2) This rule is authorized by Section 26-18-3. Waiver services are optional and provided in accordance with 42 CFR 440.225.

 

R414-510-2. Definitions.

(1) "Division of Services for People with Disabilities (DSPD)" means the entity within the Department of Human Services that has responsibility to plan and deliver an appropriate array of services and supports to persons with disabilities in accordance with Section 62a-5-102.

(2) "Guardian" means an individual, who is legally authorized to make decisions on an individual's behalf.

(3) "Interested individual" means an individual who meets eligibility requirements and expresses interest, either directly or through a guardian, in participating in the Transition Program.

(4) "Length of stay" means the length of time an individual has continuously resided in ICFs in the state of Utah. The Department considers a continuous stay to include a stay in which an individual has a temporary break in stay of no more than 31 days due to inpatient hospitalization, admission to a nursing facility, or a temporary leave of absence.

(5) "Representative" means an individual, who is not a guardian, and does not have decision-making authority, but is identified as an individual who assists a potential Transition Program participant.

(6) "State staff" means employees of the Division of Medicaid and Health Financing or the Division of Services for People with Disabilities.

(7) "Transition Program" means the Intermediate Care Facility for Persons with Intellectual Disabilities Transition Program.

(8) "Waiver" means the Community Supports Waiver for Individuals with Intellectual Disabilities and Other Related Conditions (CSW).

 

R414-510-3. Eligibility Requirements for the Transition Program.

Waiver services are potentially available to an individual who:

(1) receives ICF/ID benefits under the Medicaid State Plan;

(2) has been diagnosed with an intellectual disability or a related condition;

(3) meets ICF/ID level of care criteria defined in Section R414-502-8;

(4) meets state funding eligibility criteria for the Division of Services for People with Disabilities (DSPD) found in Subsection 62A-5-102(4); and

(5) has at least a 12-month length of stay in any Medicaid-certified, privately-owned ICF/ID located in Utah.

 

R414-510-4. Transition Program Access.

(1) Each fiscal year, the Utah Department of Health (Department) shall determine if there are sufficient funds available to initiate the Transition Program and identify the amount of funds available for the Transition Program.

(2) Based on the funds available for the Transition Program, the Department shall enroll individuals into the CSW through the Transition Program until available funds are exhausted.

(3) If the Department has initiated the Transition Program in a given year, the Department shall make direct contact with potentially eligible ICF/ID residents by phone or in person to determine interest in participating in the Transition Program.

(4) If the Department has initiated the Transition Program in a given year, the Department shall publicize the availability of the Transition Program in the following manner:

(a) The Department shall provide a letter to each potentially eligible ICF/ID resident (or to the guardian or other identified representative, if the individual has a guardian or other identified representative). The letter shall, at a minimum:

(i) describe the purpose and operation of the Transition Program, including the availability of funding;

(ii) identify the enrollment method to be used for the Transition Program in the given year;

(iii) state that Transition Program participation is voluntary; and

(iv) provide the phone number and other contact information for state staff who are available to answer questions about the Transition Program.

(b) The Department shall notify the administrator of each privately-owned ICF/ID.

(c) The Department shall post information about the Transition Program on the Utah Medicaid website and the DSPD website.

(5) To introduce and provide general education about the Transition Program in a given year, state staff shall hold at least one meeting at each private ICF/ID. The Department will send notice of the meeting via letter to each eligible ICF/ID resident (or to the guardian or other identified representative, if the individual has a guardian or other identified representative). The Department shall notify the administrator of each privately-owned ICF/ID of the date and time of the meeting. The meeting shall provide detailed education about the Transition Program to allow the individual or their guardian, the freedom to make an informed choice regarding the setting for receiving services. Meeting elements shall include:

(a) a description of the purpose of the Transition Program;

(b) a provision of materials and detailed information regarding how individuals' needs can be met in home and community based services or in the ICF/ID where the individual currently resides;

(c) a description of how the Transition Program operates with available funds;

(d) a description of how residents or guardians can express interest in participating in the Transition Program;

(e) a time period for questions and answers;

(f) the opportunity for state staff to schedule more detailed individual meetings with interested individuals, and their guardians or representatives; and

(g) the phone number and other contact information for state staff who are available to answer questions about the Transition Program.

(6) At the time of the meeting, individuals or their guardians may inform state staff of their choice regarding participation in the Transition Program.

(7) For individuals who express a choice at this time, state staff will document the choice in writing.

(8) Using a method described below in Subsection R414-510-4(8)(a) or (b), the Department will place the name of each potentially interested individual on both a weighted-score list and a random list.

(a) On the weighted-score list, the Department will rank each individual, from highest to lowest score. Scores shall be based on:

(i) the number of times the person has applied to participate in the Transition Program since Fiscal Year 2013;

(ii) whether the applicant has applied for home and community based services and is currently on the DSPD waiting list; and

(iii) length of consecutive stay in an ICF/ID in the state of Utah.

(A) If there are multiple individuals on the weighted-score list with the same score, the Department will rank individuals based on greatest length of stay.

(b) On the random list, the Department ranks each interested individual based on a computerized random selection.

(c) At least 70 percent of the individuals selected to participate in the Transition Program in a given year will be selected based on their ranking in the weighted-score list.

(9) Except for individuals who have made their preferences known as per Subsection R414-510-4(6) and (7), state staff will contact individuals on the two lists to provide detailed education about the Transition Program in order to allow the individual or their guardian the freedom to make an informed choice regarding the setting to receive services. The contact will also be used to determine if additional education is needed or wanted.

(a) For individuals without guardians, state staff will contact the individual and will provide Transition Program education. Upon completion of the education process, state staff will ask the individual to express their preference regarding whether they want to participate in the Transition Program. State staff will document and act upon the individual's decision.

(b) For individuals with guardians, state staff will contact the guardian and will rely on the decision rendered by the guardian regarding whether they want additional Transition Program education.

(i) If more in-depth, individualized training is requested by the guardian, state staff will schedule the training, and will document the guardian's choice regarding an individual's participation in the Transition Program.

(ii) If additional, training is not requested, state staff will document and act upon the guardian's decision.

(10) For individuals who express a desire to participate in the Transition Program, state staff will:

(a) work with the individual or their guardian, if the individual has a guardian, to schedule a meeting to conduct a service needs assessment and develop the individual's support plan and a timeline for anticipated transition;

(b) inform the ICF/ID administration of the individual's intent to transition, including information about the likely transition timeline;

(c) facilitate collaboration between the ICF/ID and home and community-based services providers to assist the individual in a safe and orderly transition.

(11) If an individual is selected for the Transition Program and has a spouse who also resides in a Utah ICF/ID and who meets the eligibility criteria in Section R414-510-3, the Department shall include the spouse in the Transition Program.

(12) Based on available funding, the Department shall continue to select eligible individuals through the aforementioned process until the Department exhausts the amount of funds committed to the Transition Program.

 

R414-510-5. Service Coverage.

Services and limitations of the Transition Program may be found in the Waiver State Implementation Plan.

R414-510-6. Reimbursement Methodology.

The Department of Human Services (DHS) contracts with the Department to set rates for waiver-covered services. The DHS rate-setting process is designed to comply with the requirements of Subsection 1915(c) of the Social Security Act and other applicable Medicaid rules. Medicaid requires that rates for services not exceed customary charges.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [September 29, 2015]2018

Notice of Continuation: October 12, 2016

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3