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Intermediate Care Facility for People with Mental Retardation (ICF/MR)

The Intermediate Care Facility for People with Mental Retardation (ICF/MR) benefit is an optional Medicaid benefit. Section 1905(d) of the Social Security Act created this benefit to fund "institutions" (4 or more beds) for people with mental retardation, and specifies that these institutions must provide "active treatment," as defined by the Secretary of the U.S. Department of Health and Human Services.

Since the implementation of the regulations, there has been a major shift in thinking in the field of developmental disabilities. Emphasis is now on people living in their own homes, controlling their own lives and being an integral part of their home community. See The Olmstead Decision topic for more information about this movement.

You may read this topic in sequence, or jump immediately to a specific section:

·          Background

·          Definitions / Glossary

·          Related Organizations

·          See Also Topics

Background

The ICF/MR Program was established in 1971 when legislation was enacted which provided for Federal Financial Participation (FFP) for ICFs/MR as an optional Medicaid service. Congressional authorization for ICF/MR services as a state plan option under Medicaid allowed states to receive federal matching funds for institutional services that had been funded with state or local government money.

Currently, all 50 states have at least one ICF/MR facility. Nationally, there are more than 7,000 ICFs/MR. This program serves approximately 129,000 people with mental retardation and other related conditions. Most have other disabilities as well as MR. Many of the individuals are non-ambulatory, have seizure disorders, behavior problems, mental illness, visual or hearing impairments, or a combination of the above. All must qualify for Medicaid assistance financially.

To qualify for Medicaid reimbursement, ICFs/MR must be certified and comply with Federal standards (referred to as Conditions of Participation, found in federal regulations at 42 CFR Part 483, Subpart I, Sections 483.400- 483.480) in eight areas, including management, client protections, facility staffing, active treatment services, client behavior and facility practices, health care services, physical environment and dietetic services.

Definitions / Glossary

Definitions of terms used in conjunction with ICFs/MR are listed alphabetically below. The source of the definition is shown in parentheses at the beginning of the definition. Numbers refer to citations from the Code of Federal Regulations (CFR), Public Laws (P.L.), or other legislation (Act). Letters are acronyms that refer to one of the following organizations:

·          The Council on Quality and Leadership in Supports for People with Disabilities (The Council)

·          American Association Mental Retardation (AAMR)

·          American Health Care Association (AHCA)

Active Treatment

(42 CFR 483.440(a))

Refers to aggressive, consistent implementation of a program of specialized and generic training, treatment and health services. 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.

Assessment

(The Council)

Refers to the process of identifying an individual's specific strengths, developmental needs and need for services. This should include identification of the individual's present developmental level and health status and where possible, the cause of the disability; the expressed needs and desires of the individual and his or her family; and the environmental conditions that would facilitate or impede the individual's growth, development and performance.

Behavior Management

(42 CFR 483.450)

Policies and procedures that:

·          promote the growth, development and independence of the client;

·          address the extent to which client choice will be accommodated in daily decision- making, emphasizing self-determination and self-management, to the extent possible;

·          specify client conduct to be allowed or not allowed; and

·          be available to all staff, clients parents of minor children and legal guardians.

Community Integration

(The Council)

Refers to arrangements that enable individuals to live, work, learn and play side by side in the community with people who do not have disabilities.

Components of Active Treatment:

(42 CFR 483.440)

·          A. Comprehensive Functional Assessment (CFR42 CFR 483.440(c)(3)). The individual's interdisciplinary team must produce accurate, comprehensive functional assessment data, within 30 days after admission, that identify all of the individual's: Specific developmental strengths, including individual preferences; Specific functional and adaptive social skills the individual needs to acquire; Presenting disabilities and when possible their causes; and Need for services without regard to their availability.

·          B. Individual Program Plan (IPP) (42 CFR 483.440(c)). The interdisciplinary team must prepare an IPP which includes opportunities for individual choice and self management and identifies: the discrete, measurable, criteria based objectives the individual is to achieve; and the specific individualized program of specialized and generic strategies, supports and techniques to be employed. The IPP must be directed toward the acquisition of the behaviors necessary for the individual 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.

·          C. Program Implementation (42 CFR 483.440(d)). Each individual must receive a continuous active treatment program consisting of needed interventions and services in sufficient intensity and frequency to support the achievement of IPP objectives.

·          D. Program Documentation (42 CFR 483.440(e)). Accurate, systematic, behaviorally stated data about the individual's performance toward meeting the criteria stated in IPP objectives serves as the basis for necessary change and revision to the program.

·          E. Program Monitoring and Change (42 CFR 483.440(f). At least annually, the comprehensive functional assessment of each individual is reviewed by the interdisciplinary team for its relevancy and updated, as needed. The IPP is revised as appropriate.

Developmental Disability

(P.L. 101-496)

A severe, chronic disability of a person 5 years of age or older which:

·          (a) Is attributable to a mental or physical impairment or is a combination of mental and physical impairments;

·          (b) Is manifested before the person attains age twenty-two;

·          (c) Results in substantial functional limitations in three or more of the following areas of major life activity: (i) self care;(ii) receptive and expressed language; (iii) learning; (iv) mobility; (v) self direction; (vi) capacity for independent living; and (vii) economic self sufficiency; and

·          (d) reflects the person's need for a combination and sequence of special, interdisciplinary or generic care, treatment or other services which are lifelong or extended duration and are individually planned and coordinated; except that such term, when applied to infants and young children (meaning individuals from birth to age 5, inclusive), who have substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in developmental disabilities if services are not provided.

Institution

(42 CFR 435.1009)

Institution means an establishment that furnishes (in single or multiple facilities) food, shelter, and some treatment or services to four or more persons unrelated to the proprietor.

Interdisciplinary Team

(AHCA)

A group of professionals, paraprofessionals and non-professionals who possess the knowledge, skill and expertise necessary to accurately identify the comprehensive array of the individual's needs and design appropriate services and specialized programs responsive to those needs.

Intermediate Care Facility for Persons with Mental Retardation

(1905(d) of the Social Security Act)

(d) ...means an institution (or distinct part thereof) for the mentally retarded or persons with related conditions if --

·          the primary purpose of such institution (or distinct part thereof) is to provide health or rehabilitative services mentally retarded individuals and the institution meets such standards as may be prescribed by the Secretary;

·          the mentally retarded individual with respect to whom a request for payment is made under a plan approved under this title is receiving active treatment under such a program; and

·          in the case of a public institution, the State or political subdivision responsible for the operation of such institution has agreed that the non-Federal expenditures in any calendar quarter prior to January 1, 1975, with respect to services furnished to patients in such institution (or distinct part thereof) in the State will not, because of payments made under this title, be reduced below the average amount expended for such services in such institution in the four quarters immediately preceding the quarter in which the State in which such institution is located elected to make such services available under its plan approved under this title.

Intermediate Care Facility for Persons with Mental Retardation

(42 CFR 435.1009)

Institution for persons with mental retardation means an institution (or distinct part of an institution) that --

·          Is primarily for the diagnosis, treatment, or rehabilitation of the mentally retarded or persons with related conditions; and

·          Provides, in a protected residential setting, ongoing evaluation, planning, 24-hour supervision, coordination, and integration of health or rehabilitative services to help each individual function at his greatest ability.

Mental Retardation

(AAMR, 2002)

Mental retardation is a disability characterized by significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills. This disability originates before age 18.

Five Assumptions Essential to the Application of the Definition:

·          1. Limitations in present functioning must be considered within the context of community environments typical of the individual's age peers and culture.

·          2. Valid assessment considers cultural and linguistic diversity as well as differences in communication, sensory, motor, and behavioral factors.

·          3. Within an individual, limitations often coexist with strengths.

·          4. An important purpose of describing limitations is to develop a profile of needed supports.

·          5. With appropriate personalized supports over a sustained period, the life functioning of the person with mental retardation generally will improve.

A complete and accurate understanding of mental retardation involves realizing that mental retardation refers to a particular state of functioning that begins in childhood, has many dimensions, and is affected positively by individualized supports. As a model of functioning, it includes the contexts and environment within which the person functions and interacts and requires a multidimensional and ecological approach that reflects the interaction of the individual with the environment, and the outcomes of that interaction with regards to independence, relationships, societal contributions, participation in school and community, and personal well being.

Material in this definition of Mental Retardation ©2002 American Association on Mental Retardation.

Normalization

(The Council)

Refers to making the commonly accepted patterns and conditions of everyday life available to people with developmental disabilities.

Patient

(42 CFR 435.1009)

An individual who is receiving needed professional services that are directed by a licensed practitioner of the healing arts toward maintenance, improvement or protection of health or lessening of illness, disability or pain.

Persons with related conditions

(42 CFR 435.1009)

Persons with related conditions relates to individuals who have a severe, chronic disability that meets all of the following conditions:

·          (a) it is attributable to, (1)cerebral palsy or epilepsy or (2) any other condition, other than mental illness, 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 and requires treatment or services similar to those required for these persons,

·          (b) it is manifested before the person reaches the age of 22,

·          (c) it is likely to continue indefinitely

·          (d) results in substantial functional limitations in three or more of the following areas of major life activities: (1) self care; (2) understanding and use of language; (3) learning; (4) mobility; (5) self direction; (6) capacity for independent living.

Qualified Mental Retardation Professional (QMRP)

(42 CFR 483.430)

Each client's active treatment program must be integrated, coordinated and monitored by a qualified mental retardation professional who (1) has at least one year of experience working directly with persons with mental retardation or other developmental disabilities; and (2) is one of the following: (i) a doctor of medicine or osteopathy; (ii) a registered nurse; (iii) an individual who holds at least a bachelor's degree in a professional category specified in paragraph (b)(5) of section 483.430.

Support Services

(The Council)

Those physical and social modifications or interventions which assist the individual in functioning in and adapting to physical and social environments.

Related Organizations

American Association on Mental Retardation (AAMR)

AAMR promotes global development and dissemination of progressive policies, sound research, effective practices, and universal human rights for people with intellectual disabilities.
URL: http://www.aamr.org/

American Health Care Association (AHCA)

AHCA is a federation of 50 state health organizations, together representing nearly 12,000 non-profit and for-profit assisted living, nursing facility, developmentally-disabled, and subacute care providers that care for more than one and one-half million elderly and disabled individuals nationally.
URL: http://www.ahca.org/

American Network of Community Options and Resources (ANCOR)

The purpose of ANCOR is to represent and assist private agencies that provide residential and other supports and services to people with mental retardation and other disabilities, to enable them to appropriately meet the needs and improve the quality of life of the people they serve.
URL: http://www.ancor.org/

The Arc of the United States

The Arc (formerly Association for Retarded Citizens of the United States) is the country's largest voluntary organization committed to the welfare of all children and adults with mental retardation and their families.
URL: http://thearc.org/

The Council on Quality and Leadership (CQL)

The Council on Quality and Leadership (CQL) has been at the forefront of the movement to improve the quality of services and supports for people with intellectual disabilities and people with mental illness. As a leader in the definition, measurement, and evaluation of quality of life for people with disabilities, CQL has provided strong vision and leadership to human services organizations It holds the fundamental belief that everyone has a right to a life of dignity, opportunity and community inclusion.
URL: http://www.thecouncil.org/

The President's Committee for People with Intellectual Disabilities (PCPID)

The President's Committee for People with Intellectual Disabilities (PCPID), formerly The President's Committee on Mental Retardation (PCMR), is a federal advisory committee, established to provide advice on issues concerning citizens with intellectual disabilities, coordinate activities between different federal agencies, and assess the impact of their policies upon the lives of citizens with intellectual disabilities and their families.
URL: http://www.acf.hhs.gov/programs/pcpid/

Voice of the Retarded (VOR)

VOR is a national, non-profit 501(c)(3) organization dedicated to ensuring that people with mental retardation and their families are able to access a full array of quality residential services and support options, including community and facility-based care.
URL: http://www.vor.net/

See Also

The Olmstead Decision

Protection and Advocacy Systems - Overview

Source

http://www.aamr.org/Policies/faq_mental_retardation.shtml

http://www.cms.hhs.gov/CertificationandComplianc/09_ICFMRs.asp

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