405 IAC 5-13-3 - Services included in the per diem rate for large private and small ICFs/IID
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 3.
The per diem rate for large private and small ICFs/IID shall include the following services:
(1)
Room and board, which includes the following:
(A) Routine and special dietary
services.
(B) Personal laundry
services.
(C) Room
accommodations.
(2)
Nursing services and supervision of health services.
(3) Habilitation services as defined by
405 IAC 5-21.6-2(g)
provided in a setting approved by the office
that are required by the resident's program plan of active treatment developed
in accordance with 42 CFR
483.440, including, but not limited to, the
following:
(A) Training in activities of
daily living.
(B) Training in the
development of self-help and social skills.
(C) Development of program and evaluation
plans.
(D) Development and
execution of activity schedules.
(E) Vocational/habilitation
services.
(4) All medical
and nonmedical supplies and equipment furnished by the facility for the usual
care and treatment of residents are covered in the per diem rate and may not be
billed separately to Medicaid by the facility or by a pharmacy or other
provider.
(5) Physical and
occupational therapy, speech pathology, and audiology services provided by a
licensed therapist, as applicable, employed by the facility or under contract
with the facility are included in the all-inclusive rate. Therapy services
provided away from the facility must meet the criteria outlined in
405 IAC 5-22. All therapies must
be specific and effective treatment for the improvement of function.
Reimbursement is not available for services for remediation of learning
disabilities.
(6) The reasonable
cost of necessary transportation for the member is included in the per diem
rate, including transportation to vocational/habilitation services, except for
transportation that is provided to accommodate the delivery of emergency
services. Emergency transportation services must be billed to Medicaid directly
by the transportation provider.
(7)
Durable medical equipment (DME) as defined in
405 IAC 5-19-2 and associated
repair costs, including, but not limited to:
(A) ice bags;
(B) bed rails;
(C) canes;
(D) walkers;
(E) crutches;
(F) standard wheelchairs; or
(G) traction equipment;
are covered in the per diem rate and may not be billed to Medicaid by the facility, a pharmacy, or any other provider. Any other type of nonstandard DME requires prior authorization by the office and must be billed to Medicaid by the DME provider. Facilities shall not require members to purchase or rent DME with their personal funds. DME purchased with Medicaid funds becomes the property of the office. The facility must notify the office when the member no longer needs the equipment.
(8) Mental health services provided by the
ICF/IID are included in the all-inclusive residential per diem rate. These
services include the following:
(A) Behavior
management services and consulting.
(B) Psychiatric services.
(C) Psychological services.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 3.
The per diem rate for large private and small ICFs/IID shall include the following services:
(1) Room and board, which includes the following:
(A) Routine and special dietary services.
(B) Personal laundry services.
(C) Room accommodations.
(2) Nursing services and supervision of health services.
(3) Habilitation services as defined by 405 IAC 5-21.6-2(g) provided in a setting approved by the office that are required by the resident's program plan of active treatment developed in accordance with 42 CFR 483.440, including, but not limited to, the following:
(A) Training in activities of daily living.
(B) Training in the development of self-help and social skills.
(C) Development of program and evaluation plans.
(D) Development and execution of activity schedules.
(E) Vocational/habilitation services.
(4) All medical and nonmedical supplies and equipment furnished by the facility for the usual care and treatment of residents are covered in the per diem rate and may not be billed separately to Medicaid by the facility or by a pharmacy or other provider.
(5) Physical and occupational therapy, speech pathology, and audiology services provided by a licensed therapist, as applicable, employed by the facility or under contract with the facility are included in the all-inclusive rate. Therapy services provided away from the facility must meet the criteria outlined in 405 IAC 5-22. All therapies must be specific and effective treatment for the improvement of function. Reimbursement is not available for services for remediation of learning disabilities.
(6) The reasonable cost of necessary transportation for the member is included in the per diem rate, including transportation to vocational/habilitation services, except for transportation that is provided to accommodate the delivery of emergency services. Emergency transportation services must be billed to Medicaid directly by the transportation provider.
(7) Durable medical equipment (DME) as defined in 405 IAC 5-19-2 and associated repair costs, including, but not limited to:
(A) ice bags;
(B) bed rails;
(C) canes;
(D) walkers;
(E) crutches;
(F) standard wheelchairs; or
(G) traction equipment; are covered in the per diem rate and may not be billed to Medicaid by the facility, a pharmacy, or any other provider. Any other type of nonstandard DME requires prior authorization by the office and must be billed to Medicaid by the DME provider. Facilities shall not require members to purchase or rent DME with their personal funds. DME purchased with Medicaid funds becomes the property of the office. The facility must notify the office when the member no longer needs the equipment.
(8) Mental health services provided by the ICF/IID are included in the all-inclusive residential per diem rate. These services include the following:
(A) Behavior management services and consulting.
(B) Psychiatric services.
(C) Psychological services.