Virginia Law

A. Utilization control regulations require that the level of care criteria be formulated for guidance for appropriate levels of care. Traditionally, intermediate care for the mentally retarded has been institutionally based; however, this level of care need not be confined to a specific setting. The habilitative and health needs of the client are the determining issues.

B. The purpose of this chapter is to establish standard criteria to measure eligibility for Medicaid payment. Medicaid can pay for care only when the client is in the appropriate level of care and when "active treatment" is being provided. An individual's need for care must meet these criteria before any authorization for payment by Medicaid will be made for either institutional or waivered rehabilitative services for the mentally retarded.

C. Intermediate care for the mentally retarded requires planned programs for habilitative needs or health related services which exceed the level or room, board, combination of habilitative, rehabilitative, and health services directed toward increasing the functional capacity of the retarded person. Examples of services will include training in the activities of daily living, task-learning skills, socially acceptable behaviors, basic community living programming, or health care and health maintenance. The overall objective of programming shall be the attainment of the optimal physical, intellectual, social, or task learning level which the person can presently or potentially achieve.

D. The evaluation and reevaluation for intermediate care are based on the needs of the person, the reasonable expectations of the resident's capabilities, the appropriateness of programming, whether progress is demonstrated from the training and, in an institution, whether the services could reasonably be provided in a less restrictive environment.

E. The final determination of a person's need for intermediate level of care is a professional decision based on total needs. Mentally retarded persons as individuals present an infinite variety of needs, making it virtually impossible to establish an evaluation system that will eliminate the need for professional judgement within the confines of program criteria.

F. The following criteria are divided into broad categories of needs, or services provided. These must be evaluated in detail to determine the abilities/skills which the client has acquired. The evaluation will then identify training needs/skills which will be the basis for the development of a plan of care.