Section 144.25  ICF/MR Service Criteria

a)         Need for ICF/MR Services

1)         The need for ICF/MR services shall be established through a comprehensive assessment (see 89 Ill. Adm. Code 140.642), the Level II assessment, that demonstrates that the individual needs active treatment and has either:

A)        mental retardation; or

B)        a related condition that meets all of the following conditions:

i)          It is attributed to cerebral palsy, epilepsy, autism, or any other condition, other than mental illness or infirmities of aging, found to be closely related to mental retardation because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of mentally retarded persons, and requires treatment or services similar to those required for these persons.

ii)         It is manifested before the person reaches age 22.

iii)        It is likely to continue indefinitely.

iv)        It results in substantial functional limitations in three or more of the following areas of major life activity:  self care, understanding and use of language, learning, mobility, self direction, capacity for independent living.

2)         Active treatment is defined by federal regulations at 42 CFR 483.440(a) as a program of specialized and generic training, treatment, health services and related services, that is directed toward the acquisition of the behaviors necessary for the client to function with as much self determination and independence as possible and the prevention or deceleration of regression or loss of current optimal functional status.  Active treatment does not include services to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous active treatment program.

3)         No applicant for ICF/MR services meeting the above criteria shall be found to be inappropriate for such services due to a need for the treatment of a severe or profound sensory handicap, motor deficit, or mental retardation; nor shall such an applicant be denied ICF/MR services due to age, medical needs, or maladaptive behavior, except as otherwise described in this Section.

b)         Need for ICF/MR (SNF/PED License) Services

1)         ICF/MR (SNF/PED license) services will only be approved for individuals who are under the age of 21 at the time of admission to the facility.

2)         The need for such services shall be established through a comprehensive assessment, the Level II assessment, that demonstrates that the individual has a medical (physical) condition requiring skilled level nursing care; or has mental retardation or a related condition and/or a severe medical or physical disability or a combination of severe disabilities.

(Source:  Section repealed at 18 Ill. Reg. 16619, effective October 27, 1994; new Section adopted at 20 Ill. Reg. 9072, effective June 28, 1996)