Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) are Kentucky Medicaid Provider Type (11). To bill Kentucky Medicaid, ICF/IID facilities must be:
- Licensed in Kentucky. ICF/IIDs must contact the Office of Inspector General Division of Health Care for a survey/license.
- Enrolled as an active Kentucky Medicaid provider and, if applicable, enrolled with the managed care organization (MCO) of any beneficiary for whom it provides services.
Covered Services
ICF/IIDs provide facility-based care to individuals with intellectual and/or developmental disabilities 24 hours a day, seven days a week. This includes the medical, social, behavioral, and therapeutic services an individual needs to meet their goals and live fully.
ICF/IID providers must meet the coverage provisions and requirements of 907 KAR 1:022, 907 KAR 1:023, 907 KAR 1:037, and 907 KAR 1:755. Services must be performed within the scope of practice for any provider. Listing of services in an administrative regulation is not a guarantee of payment. Providers must follow all relevant Kentucky Medicaid regulations and the requirements of any MCO in which they participate, if applicable. All services must be medically necessary.
Eligibility
Individuals may be eligible for ICF/IID services if they:
- Have an intellectual disability as defined by the current Diagnostic and Statistical Manual of Mental Diseases with an onset of the condition prior to age 18 or have a related condition as defined by 42 CFR 435.1010 with an onset of the condition prior to age 21.
- Require physical or environmental management or habilitation, a planned program of active treatment, and a protected environment.
- Have substantial deficits in adaptive functioning that, without ongoing support, limit functioning in one or more activities of daily living (unrelated to age-appropriate dependencies with respect to a minor).
Individuals shall not be denied services based solely on advanced age, length of stay in an institution, or history of previous institutionalization if they qualify based on all other factors.
Individuals shall be excluded from coverage if they have care needs beyond the capability of the ICF/IID or if placement in the ICF/IID poses a risk to the health, safety, and welfare of the individual, other residents, or ICF/IID staff. Indivividuals who do not require a planned program of active treatment to attain or maintain their optimal level of functioning do not meet ICF/IID patient status.
Verify Eligibility
Verify eligibility by calling the automated voice response system at (800) 807-1301 or using the web-based KYHealth-Net System.
Reimbursement
ICF/IID facilities are reimbursed per 907 KAR 1:025, 907 KAR 1:042, 907 KAR 1:065, and 907 KAR 1:780.
For ICF/IID fee schedules, see the Nursing Facility provider page.
Find all Fee and Rate Schedules
Duplication of Service
Kentucky Medicaid will not reimburse for a service provided to a beneficiary by more than one provider of any program in which the same service is covered during the same time period.
Bed Reserve Days
If certain criteria are met, Medicaid reimburses an ICF/IID when a beneficiary is:
- Admitted to an acute care hospital; or
- Receiving therapeutic home visits.
Bed reservation days are not available for beneficiaries admitted to a psychiatric hospital.
When Medicaid is paying bed reservation days, the ICF/IID will allow the beneficiary to return any day of the week, including holidays or weekends. If the ICF/IID chooses not to reserve a bed for a beneficiary who is eligible for Medicaid bed reservation days, the ICF/IID must inform the beneficiary before departure from the facility.
The ICF/IID is responsible for assuring services and items ordered by a beneficiary's physician are provided when Medicaid is billed to reserve the bed, except when the beneficiary is hospitalized. During hospitalization, the hospital must provide any required services and items. If the ICF/IID cannot provide the required ancillaries directly, the facility must make arrangements with 10 qualified sources (i.e., pharmacy, physical therapist, speech therapist, etc.) for the resident to receive the required services and items. Pharmacies bill Medicaid directly. Therapists and other service providers bill the facility. If the beneficiary receives an ancillary service or item that Medicare Part B covers, the ICF/IID must bill Medicare before seeking reimbursement from Medicaid.
Criteria for Bed Reservation Days
- The beneficiary is in Medicaid long-term care vendor payment status and has been a resident of the facility at least overnight. Persons for whom Medicaid is making Part A coinsurance payments are not in Medicaid payment status for purposes of this policy.
- The beneficiary is reasonably expected to return to the same facility with Medicaid as the primary payer. If returning to the same facility with Medicare as the primary payer, bed reservation days will be available only up to the period Medicare eligibility is determined, provided the bed reservation day maximums are not exceeded.
- If, due to a demand for beds at the facility, it is likely the bed would be occupied by other residents were it not reserved.
- The hospitalization is in an acute care hospital or a Kentucky hospital certified to participate in the acute care hospital program. The hospitalization is approved by Gainwell/Carewise.
- If hospitalization is approved, and the bed occupied by the resident is also a Medicaid-certified acute care bed, the resident will have been transferred to a specialty unit of a hospital.
Limitations on Medicaid reimbursement for bed reservation days
- A maximum of 14 days per calendar year due to an acute care hospital stay.
- A maximum of 10 days per calendar year for leaves of absence other than hospitalization.
- Reimbursement is 75 percent of the facility rate if the facility has an occupancy rate of 95 percent or more.
- Reimbursement is 50 percent of the facility rate if the facility has an occupancy rate of less than 95 percent.
Maximums are applied per beneficiary per calendar year. Accumulated bed reserve days will follow a beneficiary rather than starting over at zero to a new relocation.
Prior Authorization
Gainwell Technologies/Carewise Health manages prior authorizations for fee-for-services (FFS) beneficiaries as part of the Kentucky Medicaid Utilization Management (UM) program. Each MCO provides prior authorization for its beneficiaries.
Claims Submission
Kentucky Medicaid contracts with Gainwell Technologies to process FFS claims. Each MCO processes its own claims.
Find FFS Billing Instructions
Coding
Kentucky Medicaid uses the National Correct Coding Initiative edits as well as the McKesson Claim Check System to verify incidental or mutually exclusive codes. Kentucky Medicaid also uses Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding system codes. Kentucky Medicaid requires the use of ICD-10 codes on all claims submitted for reimbursement. Kentucky Medicaid requires the use of UB-04 billing forms. Providers must bill Kentucky Medicaid using the CPT codes.
Claim Appeals
Appeal requests made on denied FFS claims must be submitted to Gainwell Technologies. The request must include the reason for the request along with a hard copy claim. Please refer to the MCO if appealing an MCO claim.
Timely Filing
Claims must be received the longer of either 12 months from the date of service or six months from the Medicare pay date or within 12 months of the last Kentucky Medicaid denial. Please refer to the MCO if appealing an MCO claim.
Regulations
907 KAR - Cabinet for Health and Family Services - DMS Title Page
907 KAR 1:022 - Nursing facility and ICF/IID services
907 KAR 1:023 - Selected therapies as ancillary services in nursing facilities
907 KAR 1:025 - Payment for services provided by an ICF/IID
907 KAR 1:037 - Hospital furnished nursing facility services
907 KAR 1:042 - Amounts payable for hospital furnished ICF services
907 KAR 1:065 - Payments for price-based nursing facility services
907 KAR 1:563 - Medicaid appeals and hearings unrelated to managed care
907 KAR 1:755 - PASRR
907 KAR 1:780 - Converted dual-licensed hospital-based nursing facility beds
907 KAR 3:130 - Medical necessity and clinically approporiate determination basis
Provider Support
If you can't find the information you need or have additional questions, please direct your inquiries to: