agency-health-and-welfare•Idaho Administrative Code — Health and Welfare, Department of
Idaho Administrative Code — Health and Welfare, Department of
agency-health-and-welfareIDAPA (Health and Welfare, Department of)Regulation
IDAPA 16 Health and Welfare, Department of
16.02.26 The Idaho Childrens Special Health Program
IDAPA 16.02.26.000 Legal Authority
Section 56-1003, Idaho Code, authorizes the Director of Health and Welfare to adopt rules related to personal health.
IDAPA 16.02.26.001 Scope
The Children’s Special Health Program (C SHP) provides medical and rehabilitative services to persons age birth to eighteen (18) years who meet the diagnostic eligibility criteria defined in Sections 101 through 108 of these rules.
The scope of activities provided by CSHP contractors and private providers such as diagnosis, case management, and treatment. The types of services for which reimbursement is made are related directly to program fiscal resources.
Funds available for CSHP are limited in amount. Changes in the scope of services and in rates of reimbursement may be made by administrative decision should budgetary reductions or cost overruns occur.(3-15-22)
IDAPA 16.02.26.002 Written Interpretation
This agency has written statements that pertain to the interpretation of the rules of this chapter, or to the documentation of compliance with the rules of this chapter. These documents are available for public inspection and copying at cost in the main office and each regional or district office of this agency.(3-15-22)
IDAPA 16.02.26.003 (Reserved)
IDAPA 16.02.26.010 Definitions
For the purposes of these rules, the fol lowing terms are used:(3-15-22)
01.Applicant. A person under age eighteen (18) seeking services provided by CSHP.(3-15-22)
02.Care Coordinator. A Department employee or contractor responsible for receiving and processing CSHP applications and supporting documentation from current and potential CSHP clients. A care coordinator issues authorization memos for services authorized by CSHP.(3-15-22)
03.Children's Special Health Program (CSHP). The program section within the Department’s Division of Health, which is responsible for the administration of services leading to the identification, diagnosis, and aftercare of children with special health care needs.(3-15-22)
04.Client. A person under age eighteen (18) with a chronic physically disabling condition which meets one (1) of the diagnostic categories of CSHP.(3-15-22)
05.Department. The Idaho Department of Health and Welfare.(3-15-22)
06.Diagnosis. The act of identifying a disease from its signs or symptoms.(3-15-22)
07.Medical Food. A food which is formulated to be consumed or administered enterally (i.e., passing through the stomach and digested in the intestine), under the supervision of a physician and metabolic nutritionist, and which is intended for the specific dietary management of PKU.(3-15-22)
08.Patient. The term “patient” is synonymous with the term “client.”(3-15-22)
IDAPA 16.02.26.011 (Reserved)
IDAPA 16.02.26.051 Diagnostic/Consultative Services
Clinical examination of a CSHP client to confirm or determine the extent of their condition and recommend treatment options. Physician specialists under contract to CSHP may continue to serve in consultative roles to clients’ primary care physicians following clinical examination.(3-15-22)
IDAPA 16.02.26.052 Treatment Services
Following the diagnostic process, individuals may be closed to further service as having “no eligible condition fo und.” Program-eligible clients are accepted for continuing service coordination under CSHP. Care is provided through clinics where treatment schedules are planned and periodic review of cases are conducted, and through private medical providers. An individual client’s treatment plan may cover a variety of related services.(3-15-22)
IDAPA 16.02.26.053 Follow Up and Case Management
CSHP will contract with care coordinators to follow-up on CSHP clients receiving treatment through the program to assure that a treatment plan is outlined. These staff will also implement timely scheduling of medical habilitative and rehabilitative services.(3-15-22)
IDAPA 16.02.26.054 Hospital in-Patient Services
If diagnostic evaluation requires hospitalization, a maximum of three (3) days inpatient care may be authorized. No inpatient hospital services are paid for emergency, acute or chronic medical care.(3-15-22)
IDAPA 16.02.26.055 (Reserved)
IDAPA 16.02.26.100 Diagnostic Categories
CSHP will serve clients in eight (8) general diagnostic categories: Cardiac, Cleft Lip and Palate, Craniofacial, Cystic Fibrosis, Neurological, Orthopedic, Phenylketonuria (PKU) and Plastic/Burn.(3-15-22)
101.CARDIAC. gible conditions include congenital heart disease or defects, acquired heart disease, and dysrhythmia.(3-15-22)
02.Excluded Conditions. The following conditions are excluded from care under CSHP: patent ductus arteriosus (PDA) in premature neonates, inpatient care for non-diagnostic and non-surgical admissions, and acute care, despite its potential relationship to an underlying covered condition.(3-15-22)
03.Spending Limit. Services provided to eligible patients under the Cardiac Program are subject to a per patient, annual spending limit of twenty five thousand dollars ($25,000) for each state fiscal year.(3-15-22)
IDAPA 16.02.26.102 Cleft Lip and Palate
01.Eligible Conditions. Eligi ble conditions include cleft lip, cleft palate, cleft palate with cleft lip, cleft nose, Pierre Robin syndrome, choanal atresia, palatal incompetence, severe malocclusions resulting from disease or trauma, severe structural deformities involving the growth, and development of the mandible or maxilla.
02.Excluded Conditions. The following conditions are specifically excluded from care under the CSHP Cleft Lip/Palate Program: isolated hyper/hyponasality, non-cleft-related malocclusions, and mild familial malocclusions.(3-15-22)
03.Spending Limits. Services provided to eligible patients under the CSHP Cleft Lip and Palate program are subject to a per patient, annual spending limit of fifteen thousand dollars ($15,000) for each state fiscal year.(3-15-22)
IDAPA 16.02.26.103 Craniofacial
01.Eligible Conditions. Elig ible conditions include congenital anomalies of the skull and face, acrocephalosyndactyly, craniosynostosis, Crouzon’s Disease, hyperterlorism (severe), platybasia, and hemifacial microsomia, including associated microtia.(3-15-22)
02.Excluded Conditions. The following conditions are excluded from care under the Idaho CSHP Craniofacial Program: isolated microtia, temporal mandibular joint disease (TMJ), and simple hemangioma not affecting other organ systems.(3-15-22)
03.Spending Limits. Services provided to eligible patients under the CSHP Craniofacial Program are subject to a per patient, annual spending limit of eighteen thousand dollars ($18,000) for each state fiscal year.
IDAPA 16.02.26.104 Cystic Fibrosis
01.Eligible Conditions.
In addition to cystic fibrosis, services are also provided under this program to clients eighteen (18) years of age and under who have Kartagener’s Syndrome or immotile cilia.(3-15-22)
02.Services Provided. Services available include Physician’s office or clinic visits, laboratory, x-ray and other tests ordered by physician, medications and drugs prescribed in connection with treatment of cystic fibrosis, transportation to out-of-state medical centers based on physician referral, and home therapy equipment prescribed by the physician. Genetic counseling clinics are available through the state or contractors, and cystic fibrosis patients and their families are encouraged to make use of this service.(3-15-22)
03.Excluded Services. Inpatient hospital care is not paid for under the CSHP Cystic Fibrosis Program, consistent with CSHP policy of not paying for emergency, acute, or chronic medical care.(3-15-22)
04.Spending Limit. Services provided to eligible patients under the CSHP Cystic Fibrosis Program are subject to a per patient, annual spending limit of eighteen thousand dollars ($18,000) for each state fiscal year.
IDAPA 16.02.26.105 Neurologic
01.Eligible Conditions. Eligi ble conditions include cerebral palsy, seizures/epilepsy, metabolic and storage diseases, central nervous system (CNS) degenerative disorders, congenital CNS anomalies, chronic encephalopathy and CNS injury (near drowning, birth asphyxia), neurocutaneous and neuromuscular syndromes, chronic residua of CNS infections, neuromuscular disorders, attention deficit hyperactive disorder (ADHD) (limited to two (2) visits per year after diagnosis), Tourette’s Syndrome, rehabilitation services associated with tumors, infections, trauma, and cerebral vascular disease (CVD).(3-15-22)
02.Excluded Conditions. The following conditions are excluded from care under the CSHP Neurologic Program: speech problems without associated CSHP eligibility, primary intellectual disabilities, autism, acute head and spinal cord injuries, primary psychiatric and emotional disorders, headache, and night terrors.
03.Spending Limit. Services for eligible patients under the CSHP Neurologic Program are subject to a per patient, annual spending limit of twelve thousand dollars ($12,000) for each state fiscal year.(3-15-22)
106.ORTHOPEDIC. gible conditions include juvenile rheumatoid arthritis (JRA), developmental dysplasia of the hip, cerebral palsy, neuromuscular dystrophies and atrophies, spinal column defects and deformities causing functional impairment, congenital anomalies of the extremities causing functional impairment, chronic conditions resulting from trauma, limb deficiencies and length discrepancies, chronic infections and inflammations of bones and joints, congenital developmental hip conditions, skeletal dysplasia and other forms of dwarfism, fractures associated with bracing or other long-term care, rehabilitation services associated with tumors and malignancies, metatarsus varus and adductus, and polydactyly.(3-15-22)
02.Excluded Conditions. The following conditions are excluded from care: simple fractures and other trauma without handicapping residual, acute infections of bone or joint, simple flat feet (painless), acute care for amputations, acute care for fractures or other injuries, benign genu valgum (knock knee), benign genu varum (bow legs), tibial torsion/femoral version, and growth hormone therapy for short stature.(3-15-22)
03.Spending Limits. Services provided to eligible patients under the CSHP Orthopedic Program are subject to a per patient, annual spending limit of fifteen thousand dollars ($15,000) for each state fiscal year.
IDAPA 16.02.26.107 Phenylketonuria (pku)
Under this program eligible patients are provided treatment services that include nutritional assessment, dietary counseling, and provision of medical foods, including formula, in compliance with the patient’s treatment plan. PKU patients under eighteen (18) years of age may purchase medical foods from CSHP or CSHP's contractor(s) by prepaying the appropriate percentage, if any, of CSHP's cost. The percentage of cost is based on the sliding fee scale in Section 157 of these rules.(3-15-22)
01.PKU Patients Under Eighteen Years of Age. PKU patients under eighteen (18) years of age may purchase medical foods from CSHP or CSHP's contractor(s) by pre-paying the appropriate percentage, if any, of CSHP's cost. The percentage of cost is based on the sliding fee scale in Section 157 of these rules.(3-15-22)
108.PLASTIC/BURN. gible conditions include hemangioma and lymphangioma depending on severity, location, and effect on function; cystic hygroma; and hemifacial microsomia, including associated microtia.
02.Excluded Conditions. The following conditions are excluded from care under the Idaho CSHP Plastic/Burn program: acute burn care, cosmetic surgery, and hemangioma, including port wine stain, not affecting physical function.(3-15-22)
03.Spending Limit. Services provided to eligible patients under the CSHP Plastic/Burn Program are subject to a per patient, annual spending limit of fifteen thousand dollars ($15,000) for each state fiscal year.
IDAPA 16.02.26.109 (Reserved)
IDAPA 16.02.26.149 Program Eligibility
Eligibility for participation in CSHP is based on the following:(3-15-22) 01.
Insurance Status. Any person with creditable medical insurance as determined by the Department is not eligible for this program, except for CF and PKU participants. Creditable insurance is determined by using IDAPA 16.03.01, “Eligibility For Health Care Assistance For Families and Children.”(3-15-22)
02.Age. Applications may be accepted on persons up to age eighteen (18). CSHP will pay for no services after the patient’s 18th birthday unless the person is receiving active inpatient treatment at the time of the birthday. In that case CSHP will pay for services until discharge if they fall within the guidelines described in Section 054 of these rules.(3-15-22)
03.Diagnosis. Eligible persons are those born with or who acquire physical disabilities or special health care needs as defined under Sections 101 through 108 of these rules and who require long-term multidisciplinary care to improve their ability to function.(3-15-22)
04.Residence. Applicants must be legal residents of the state of Idaho to receive services from CSHP.
Legal residents of neighboring states are not eligible for services. Non-citizens who are legal residents of Idaho are eligible to receive services, but undocumented aliens are not.(3-15-22)
05.Income. Income for a family is defined as “adjusted taxable income” from the family's most recent tax return. Financial eligibility is redetermined annually and may be redetermined more often if family circumstances change during the year.(3-15-22)
06.Family Size. Family is defined as a “group of related or non-related individuals who are not residents of an institution, but who are living together as one (1) economic unit.” Family size is the number of individuals included in that unit.(3-15-22)
IDAPA 16.02.26.150 (Reserved)
IDAPA 16.02.26.157 Sliding Fee Scale
The sliding fee scale in this rule is used to determine the family’s percentage of financial participation for a CSHP client’s treatment. Each percentage category includes an annual per-client maximum for which a family would be responsible in any given year. The percentage amount applies to all costs incurred for services provided to the client up to the annual maximum indicated.
IDAPA 16.02.26.158 Application for Other Resources
CSHP applicants are required to apply for benefits from other programs for which they may be eligible and which reduces the costs to CSHP. The use of all available other resources is required in order to supplement program dollars to the greatest degree possible. For new applicants and during redetermination there will be a review for possible eligibility for other programs and appropriate referrals will be made. Families who refuse to obtain benefits for which they are eligible or do not complete the application process will be closed to the program.(3-15-22)
IDAPA 16.02.26.159 (Reserved)
IDAPA 16.02.26.200 Applications
An application for services from CSHP must, at a minimum, consist of a completed Application Form and verification statement from medical provider confirming eligible diagnosis. A copy of the family’s most recent tax return will also be required in order to determine financial eligibility. CSHP may require additional forms such as a Request for Services, Consent for the Release of Information and an Authorization to Release Information.
Applications are processed by CSHP staff and contractors. Applicants are notified as to their acceptance or denial by a CSHP Care Coordinator.(3-15-22)
IDAPA 16.02.26.201 (Reserved)
IDAPA 16.02.26.250 Payments to Providers
CSHP payments are made on the basis of fee schedules or set allowances; where applicable, Idaho Medicaid rates are used.(3-15-22)
IDAPA 16.02.26.251 Prior Authorization
To qualify for payment by CSHP, services other than diagnost ic/consultative and follow-up/case management must be preauthorized by the CSHP Care Coordinator or designee. A CSHP Authorization Memo, obtained from the District CSHP Care Coordinator, must be issued for any service authorized under CSHP.(3-15-22)
IDAPA 16.02.26.252 Maximum on Hospital in-Patient Payments
There is a twelve thousand dollar ($12,000) maximum payment, per hospitalization, for inpatient hospital expenses, exclusive of surgeon, anesthesiologist or other physician costs related to the hospitalization. These costs are applied toward the annual program cap.(3-15-22)
IDAPA 16.02.26.253 Billing Third Parties First
Providers and parents or legal guardians must bill all other sources of direct third party payment before submitting their claims to CSHP for payment. Private insurance must be billed and benefits, or the denial of benefits, ascertained TABLE 157 - SLIDING FEE SCALE FOR CSHP SERVICES Percent of Federal Poverty Level Percentage of Cost Sharing Responsibility for Responsible Party Annual Maximum Responsibility Per Client 0% - 185%0%$0 186% -199%10%$1,800 200% - 224%20%$3,600 225% -249%30%$5,400 250% -274%50%$9,000 275% -299%75%$13,500 300% and above100%$18,000 before the CSHP will consider payment. Typically either an Explanation of Benefits (EOB) from the third party payor or a letter stating that the service is not covered will be required before CSHP payment will be made.(3-15-22)
IDAPA 16.02.26.254 Third Party Payments in Excess of Cshp Limits
CSHP will not reimburse providers for services rendered when the amount received by the provider from the third party payor is equal to or exceeds the level of reimbursement allowed by CSHP for those particular services. (3-15- 22)
IDAPA 16.02.26.255 Medicaid Eligibility
Any person who may be eligible for Medicaid is required to app ly before CSHP services are authorized. CSHP is always last payor to Medicaid.(3-15-22)
IDAPA 16.02.26.256 Out-of-State-Care
CSHP will not pay for care out-of-state that is available in-state. Any exceptions to this rule will be determined by the state of fice of the CSHP. All out-of-state care must be preauthorized through a CSHP clinic or other regular program mechanism.(3-15-22)
IDAPA 16.02.26.257 Durable Medical Equipment
The CSHP will always be payor of last resort for all durable medical equipment provided to clients.(3-15-22)
IDAPA 16.02.26.258 (Reserved)
16.05.01 Use and Disclosure of Department Records
IDAPA 16.05.01.000 Legal Authority
Sections 39-242, 56-221, 56-222, 56- 1003, and 56-1004, Idaho Code.(7-1-25)
IDAPA 16.05.01.001 Scope
These rules govern the use and disclosure of informatio n maintained by the Department, in compliance with applicable state and federal laws, and federal regulations.(7-1-25)
IDAPA 16.05.01.002 (Reserved)
IDAPA 16.05.01.011 Definitions for Vital Statistics
The definitions provided in Section 011 of these rules apply to Vital Statistics and to the disclosure provisions of Section 39-270, Idaho Code.(3-17-22)
01.Authorized Representative. An attorney, physician, funeral director, a legally designated agent, or an entity whose purpose for obtaining a vital record is to pay direct benefits to a person with a direct and tangible interest.(7-1-26)
02.Individuals with a Direct and Tangible Interest. Individuals who have a direct and tangible interest in a vital record are:(3-17-22)
a.The registrant and that person’s spouse, children, parents, grandparents, grandchildren, siblings, or guardian;(3-17-22)
b.Any other person who demonstrates that the record is needed for the determination or protection of that person’s property right;(3-17-22)
c.An authorized representative of any of these individuals;(3-17-22)
d.The surviving next-of-kin if a deceased registrant has no other surviving family member listed in this subsection;(3-17-22)
e.The Idaho Attorney General, and state and federal prosecuting attorneys, if such attorney submits an affidavit affirming that the record is necessary in the furtherance of the attorney’s official law enforcement duties, is not reasonably available from another source, and that reasonable steps will be taken to preserve the confidentiality of the record;(3-17-22)
f.Any person, upon the order of an Idaho court of competent jurisdiction, where the court finds that disclosure of the record is necessary in the interests of justice; and(3-17-22)
g.Any person with the right to control the disposition of remains of a deceased person or to determine provisions not clearly covered in a prearranged funeral plan as authorized in Section 54-1142(1) Idaho Code, in accordance with Section 39-270(b), Idaho Code.(3-17-22)
03.Parent. Does not include an individual whose parental rights have been terminated with respect to a specific child.(7-1-26)
04.Public Health. The science and practice of:(7-1-26)
a.Preventing disease, prolonging life, or promoting health within populations and communities;
(7-1-26)
b.Control of communicable infections;(7-1-26)
c.Education of the individual in healthy choices;(7-1-26)
d.Promotion of early diagnosis and prevention of disease; and(7-1-26)
e.The overall support and participation in systems that ensure everyone a standard of living to maintain health and longevity.(7-1-26)
05.Research. Organized scientific inquiry or examination of data in order to discover and interpret facts.(3-17-22)
06.Statistical Purposes. The collection, analysis, interpretation and presentation of masses of nonidentifying numerical information.(3-17-22)
IDAPA 16.05.01.012 (Reserved)
IDAPA 16.05.01.280 Vital Statistics -- Verification of Data
01.Verifications.
The Registrar will confirm or deny the presence and accuracy of data already known to a governmental agency that requests information from a vital record. Such verifications may be conducted by telephone for Idaho state agencies. Other requests for verification require a signed application on forms provided or approved by the Registrar, and a copy of the front and back of signed photo identification or such other information as the Registrar requests. Verifications may also be conducted via Department automated systems approved by the Registrar.(3-17-22)
02.Administrative Fact of Death Verifications. Upon agreement in writing to such conditions as the Registrar may impose, the Registrar may compare Idaho state agency administrative data to Idaho death data and return an indication of death, also known as fact of death verification, for administrative purposes only.(3-17-22)
03.Verifications to Protect a Person’s Property Right. The State Registrar may approve electronic fact of death verification by entities seeking to determine or protect a person’s property right.(3-17-22)
IDAPA 16.05.01.281 Vital Statistics: Disclosure for Researc
H, PUBLIC HEALTH OR STATISTICAL
PURPOSES.
Upon agreement in writing to such conditions as the Registrar may impose, the Registrar may permit the use of data from vital statistics records for research, public health or statistical purposes. The Registrar may deny a request for access to identifying information if the Registrar determines that the benefits would be outweighed by the possible adverse consequences to those individuals whose records would be used.(3-17-22)
IDAPA 16.05.01.282 (Reserved)
IDAPA 16.05.01.283 Vital Statistics: Procedures for Requesting Information
Individuals who request access to, information from, or copies of vital records must present a signed application on forms provided or approved by the Registrar, and a copy of the front and back of signed photo identification or such other information as the Registrar requests.(7-1-26)
01.Expedited Copy. An expedited certified copy of a vital record may be issued using Department automated systems.(3-17-22)
02.Certified Copy. When a certified copy is issued, it is certified as a true copy or abstract of the original vital record by the Registrar. The certified copy will include the date issued, the Registrar's signature or an authorized facsimile thereof, and the seal of the issuing office and excluding information contained in the statistical section of any record. Full or short form certified copies of vital records may be issued.(7-1-26)
IDAPA 16.05.01.284 (Reserved)
16.02.10 Idaho Reportable Diseases
IDAPA 16.02.10.000 Legal Authority
Sections 39-605, 39-1003, 39-1603, and 56-1005, Idaho Code, grant aut hority to the Board of Health and Welfare to adopt rules protecting the health of the people of Idaho. Section 39-906, Idaho Code, provides for the Director to administer rules adopted by the Board of Health and Welfare. Section 39-4505(2), Idaho Code, gives the Director authority to promulgate rules regarding the identification of blood- or body fluid-transmitted viruses or diseases.
Section 56-1003, Idaho Code, gives the Director the authority to adopt rules protecting the health of the people of Idaho and to recommend rules to the Board of Health and Welfare. Section 54-1119, Idaho Code, authorizes the Director to promulgate rules regarding the handling of dead human bodies as needed to preserve and protect the public health.(3-17-22)
IDAPA 16.02.10.001 Scope
These rules contain the official requiremen ts governing the reporting, control, and prevention of reportable diseases and conditions and requirements to prevent transmission of health hazards from dead human bodies. The purpose of these rules is to identify, control, and prevent the transmission of reportable diseases and conditions within Idaho.
IDAPA 16.02.10.002 Documents Incorporated by Reference
These documents are incorporated by reference and are available at the Idaho State Law Library or at the Department’s main office.(7-1-26)
01.Guideline for Isolation Precautions in Hospitals. Siegel, J.D., et al., “Guideline for Isolation Precautions in Hospitals.” Health Care Infection Control Practices Advisory Committee, Atlanta, GA: Centers for Disease Control and Prevention, 2007.(3-17-22)
02.National Notifiable Diseases Surveillance System - Case Definitions. http:// ndc.services.cdc.gov/.(3-17-22)
03.Human Rabies Prevention -- United States, 2008. Morbidity and Mortality Weekly Report, May 23, 2008, Vol. 57.RR-3. Centers for Disease Control and Prevention.(3-17-22)
04.Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis. Infection Control and Hospital Epidemiology, September 2013, Vol. 34, 9. The Society for Healthcare Epidemiology of America. These guidelines are found online at http://www.jstor.org/stable/10.1086/672271.(3-17-22)
05.Compendium of Animal Rabies Prevention and Control, 2016. National Association of State Public Health Veterinarians, Inc., Journal of American Veterinary Medical Association Vol. 248(5), March 1, 2016.
This document is found online at http://nasphv.org/documentsCompendia.html.(3-17-22)
06.Standards for Cancer Registries, Volume VI, Data Standards and Data Dictionary. North American Association of Central Cancer Registries, Twenty-sixth Edition, Record Layout Version 25, January 2025.
07.Use of Reduced (4-Dose) Vaccine Schedule for Postexposure Prophylaxis to Prevent Human Rabies: Recommendations of the Advisory Committee on Immunization Practices, 2010. Morbidity and Mortality Weekly Report, Recommendations and Reports, March 19, 2010/59(RR02);1-9. This document is found online at https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5902a1.htm.(3-17-22)
IDAPA 16.02.10.003 (Reserved)
IDAPA 16.02.10.010 Definitions a Through K
For the purposes of this chapter, the following definitions apply.(3-17-22)
01.Approved Fecal Specimens. Specimens of feces obtained from the designated person who has not taken any antibiotic orally or parenterally for two (2) days prior to the collection of the fecal specimen. The specimen must be collected and transported to the laboratory in a manner appropriate for the test to be performed.(3-17-22)
02.Bite or Other Exposure to Rabies. Bite or bitten means that the skin of the person or animal has been nipped or gripped, or has been wounded or pierced, including scratches, and includes probable contact of saliva with a break or abrasion of the skin. The term “exposure” also includes contact of saliva with any mucous membrane.
In the case of bats, even in the absence of an apparent bite, scratch, or mucous membrane contact, exposure may have occurred, as described in “Human Rabies Prevention -- United States.”(7-1-26)
03.Board. The Idaho State Board of Health and Welfare.(7-1-26)
04.Cancer Data Registry of Idaho (CDRI). The agency performing cancer registry services under a contractual agreement with the Department as described in Section 57-1703, Idaho Code.(3-17-22)
05.Carrier. A person who can transmit a communicable disease to another person, but may not have symptoms of the disease.(7-1-26)
06.Case. A person, who has been diagnosed as having a specific disease or condition by a physician or other health care provider. The diagnosis may be based on clinical judgment, on laboratory evidence, or on both criteria, will be evaluated for public health case classification.(7-1-26)
07.Communicable Disease. A disease that may be transmitted from one (1) person or an animal to another person either by direct contact or through an intermediate host, vector, inanimate object, or other means that may result in infection, illness, disability, or death.(3-17-22)
08.Contact. A person who has been exposed to a case or a carrier of a communicable disease while the disease was communicable, or a person by whom a case or carrier of a communicable disease could have been exposed to the disease.(7-1-26)
09.Daycare. Care as described by Section 39-1102, Idaho Code.(7-1-26)
10.Department. The Idaho Department of Health and Welfare or its designee.(3-17-22)
11.Director. The Director of the Idaho Department of Health and Welfare or their designee. (7-1-26)
12.Division of Public Health Administrator. A person appointed by the Director to oversee the administration of the Division of Public Health, Idaho Department of Health and Welfare, or their designee.
13.Extraordinary Occurrence of Illness Including Clusters. Rare or novel diseases and unusual outbreaks of illness that may be a risk to the public Even in the absence of a defined etiologic agent or toxic substance, clusters of unexplained acute illness and early stage disease symptoms, illnesses related to drugs, foods, contaminated medical devices, contaminated medical products, illnesses related to environmental contamination by infectious or toxic agents, unusual syndromes, or illnesses associated with occupational exposure to physical or chemical agents may be included in this definition.(7-1-26)
14.Fecal Incontinence. A condition in which temporarily, as with severe diarrhea, or long-term, as with a child or adult requiring diapers, there is an inability to hold feces in the rectum, resulting in involuntary voiding of stool.(3-17-22)
15.Foodborne Disease Outbreak. Two (2) or more persons experiencing a similar illness after ingesting a common food, and epidemiological investigation indicates food as the source of the illness.(7-1-26)
16.Food Employee . An individual working with unpackaged food, food equipment or utensils, or fo od-contact surfaces as defined in IDAPA 16.02.19, “Idaho Food Code.”(3-17-22)
17.Health Care Facility. An establishment organized and operated to provide health care to three (3) or more individuals who are not members of the immediate family. This definition includes hospitals, intermediate care facilities, residential care and assisted living facilities.(3-17-22)
18.Health Care Provider. A person who has direct or supervisory responsibility for the delivery of health care or medical services.(7-1-26)
19.Health District. Any one (1) of the seven (7) public health districts as established by Section 39- 409, Idaho Code.(7-1-26)
20.Health District Director. Any one (1) of the public health districts’ directors appointed by the Health District’s Board as described in Section 39-413, Idaho Code, or their designee.(3-17-22)
21.Idaho Food Code. Idaho Administrative Code that governs food safety, IDAPA 16.02.19, “Idaho Food Code.”(7-1-26)
22.Investigation. Public health methods used to determine exposure source, risk factors, susceptible contacts, transmission risks, and prevention measures necessary to limit additional cases of a disease or condition.
Investigations may be individual case investigations or epidemiologic investigations of more than one illness.
23.Isolation. The separation of a person known or suspected to be infected with an infectious agent, or contaminated from chemical or biological agents, from other persons to such places, under such conditions, and for such time as will prevent transmission of the infectious agent or further contamination.(7-1-26)
IDAPA 16.02.10.011 Definitions L Through Z
For the purposes of this chapter, the following definitions apply.(3-17-22) 01.
Laboratory Director. A person directly responsible for the operation of a licensed laboratory or their designee.(7-1-26)
02.Laboratory. A medical diagnostic laboratory that is inspected, licensed, or approved by the Department or licensed according to the provisions of the Clinical Laboratory Improvement Act by the United States Health Care and Financing Administration. Laboratory may also refer to the Idaho State Public Health Laboratory, and to the United States Centers for Disease Control and Prevention.(3-17-22)
03.Livestock. Livestock as defined by the Idaho Department of Agriculture in IDAPA 02.04.03, “Rules Governing Animal Industry.”(3-17-22)
04.Medical Record. Hospital or medical records compiled for the purpose of recording a medical history, diagnostic studies, laboratory tests, treatments, or rehabilitation.(7-1-26)
05.Outbreak. An unusual rise in the incidence of a disease. An outbreak may consist of a single case.
06.Personal Care. The service provided by one (1) person to another for the purpose of feeding, bathing, dressing, assisting with personal hygiene, changing diapers, changing bedding, and other services involving direct physical contact.(3-17-22)
07.Physician. A person as defined in Section 54-1803, Idaho Code.(3-17-22)
08.Quarantine. The restriction placed on a person exposed to an infectious or communicable disease, to a person displaying unknown symptoms, or to a contamination from a chemical, nuclear, or biological agent as defined in Section 56-1003, Idaho Code.(7-1-26)
09.Rabies Post-Exposure Prophylaxis (rPEP). The administration of a rabies vaccine series with or without the antirabies immune globulin, depending on pre-exposure vaccination status, following a documented or suspected rabies exposure.(7-1-26)
10.Residential Care Facility. A facility as defined in 39-3302(27), Idaho Code.(7-1-26)
11.Restriction. The limitation of a person’s activities to reduce the risk of transmitting a communicable disease.(7-1-26)
12.Restrictable Disease. A communicable disease, which if left unrestricted, may have serious consequences to the public's health. The determination of whether a disease is restrictable is based upon the specific environmental setting and the likelihood of transmission to susceptible persons.(7-1-26)
13.Severe Reaction to Any Immunization. Any serious or life-threatening condition that results directly from the administration of any immunization against a communicable disease.(3-17-22)
14.Significant Exposure to Blood or Body Fluids. A percutaneous injury, contact of mucous membrane or non-intact skin, or contact with intact skin when the duration of contact is prolonged or involves an extensive area, with blood, tissue, or other body fluids as defined in “Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis.”
15.State Epidemiologist. A person employed by the Department to serve as a statewide epidemiologist or their designee.(3-17-22)
16.Suspected Case. A person diagnosed with or thought to have a particular disease or condition by a licensed physician or other health care provider. Public health suspected case definitions are described in “National Notifiable Diseases Surveillance System Case Definitions.”(7-1-26)
17.Veterinarian. Any individual as defined in Section 54-2103, Idaho Code.(7-1-26)
18.Waterborne Outbreak. Two (2) or more persons with a similar illness after exposure to water from a common source and epidemiological evidence indicates water as the source of the illness.(7-1-26)
19.Working Day. As defined in 48-1002(1), Idaho Code.(7-1-26)
IDAPA 16.02.10.012 (Reserved)
IDAPA 16.02.10.020 Persons Required to Report Reportable Diseases, Conditions, and School
CLOSURES.
01.Physician.
A licensed physician who diagnoses, treats, or cares for a person with a reportable disease or condition must report the disease or condition to the Department or Health District. The physician is also responsible for reporting diseases and conditions diagnosed or treated by anyone under the physician’s supervision.
02.Hospital or Health Care Facility Administrator. The hospital or health care facility administrator must report all persons who are diagnosed, treated, or receive care for a reportable disease or condition in their facility unless the attending physician has reported the disease or condition.(3-17-22)
03.Laboratory Director. The laboratory director must report to the Department or Health District the identification of, or laboratory findings suggestive of, the presence of the organisms, diseases, or conditions listed in of these rules.(7-1-26)
04.School Administrator. A school administrator must report diseases and conditions to the Department or Health District. A school administrator must report the closure of any public, parochial, charter, or private school within one (1) working day when, in their opinion, such closing is related to a communicable disease.
05.Persons in Charge of Food Establishments. A person in charge of an eating or drinking establishment must report diseases and conditions to the Department or Health District.(7-1-26)
06.Others Required to Report Reportable Diseases. In addition to licensed physicians, reports must also be made by coroners and other health care providers as described in 39-7702, Idaho Code.(7-1-26)
IDAPA 16.02.10.021 Access to Medical Records
No physician, hospital administrative person, or patient may deny the Department, Health Districts, or the Board access to medical records in discharge of their duties in implementing the reportable disease rules.(3-17-22)
IDAPA 16.02.10.022 (Reserved)
IDAPA 16.02.10.030 Where to Report Reportable Diseases and Conditions
01.Department of Health and Welfare, Bureau of Environmental Health and Communicable Disease Epidemiology Program.(7-1-26)
a.Main Office Address: 450 West State Street, 4th Floor, Boise, ID 83720.(3-17-22)
b.Phone: (208) 334-5939 and FAX: (208) 332-7307.(3-17-22)
02.Health District I - Panhandle Health District. The Panhandle Health District covers the counties of Benewah, Bonner, Boundary, Kootenai, and Shoshone.(3-17-22)
a.Main Office Address: 8500 N. Atlas Road, Hayden, ID 83835.(3-17-22)
b.Phone: (208) 772-3920 and FAX: 1-866-716-2599 Toll Free.(3-17-22)
03.Health District II - Public Health Idaho North Central District. The North Central District covers the counties of Clearwater, Idaho, Latah, Lewis, and Nez Perce.(3-17-22)
a.Main Office Address: 215 10th Street, Lewiston, ID 83501.(3-17-22)
b.Phone: (208) 799-3100 and FAX: (208) 799-0349.(3-17-22)
04.Health District III - Southwest District Health. Southwest District Health covers the counties of Adams, Canyon, Gem, Owyhee, Payette, and Washington.(3-17-22)
a.Main Office Address: 13307 Miami Lane, Caldwell, ID 83607.(3-17-22)
b.Phone: (208) 455-5442 and FAX: (208) 455-5350.(3-17-22)
05.Health District IV - Central District Health. The Central District Health covers the counties of Ada, Boise, Elmore and Valley.(7-1-26)
a.Main Office Address: 707 N. Armstrong Place, Boise, ID 83704.(3-17-22)
b.Phone: (208) 327-8625 and FAX: (208) 327-7100.(3-17-22)
06.Health District V - South Central Public Health District. The South Central Public Health District covers the counties of Blaine, Camas, Cassia, Gooding, Jerome, Lincoln, Minidoka, and Twin Falls.
a.Main Office Address: 1020 Washington Street N., Twin Falls, ID 83301.(3-17-22)
b.Phone: (208) 737-5929 and FAX: (208) 736-3009.(3-17-22)
07.Health District VI - Southeastern Idaho Public Health. The Southeastern Idaho Public Health District covers the counties of Bannock, Bear Lake, Bingham, Butte, Caribou, Franklin, Oneida, and Power.
a.Main Office Address: 1901 Alvin Ricken Drive, Pocatello, ID 83201.(3-17-22)
b.Phone: (208) 233-9080 and FAX: (208) 233-1916.(3-17-22)
08.Health District VII - Eastern Idaho Public Health. Eastern Idaho Public Health covers the counties of Bonneville, Clark, Custer, Fremont, Jefferson, Lemhi, Madison and Teton.(7-1-26)
a.Main Office Address: 1250 Hollipark Drive, Idaho Falls, ID 83401.(3-17-22)
b.Phone: (208) 533-3152 and FAX: (208) 523-4365.(3-17-22)
09.Cancer Data Registry of Idaho (CDRI).(3-17-22)
a.Main Office Address: 615 N. 7th Street, P.O. Box 1278, Boise, ID 83701.(3-17-22)
b.Phone: (208) 338-5100.(3-17-22)
IDAPA 16.02.10.031 (Reserved)
IDAPA 16.02.10.040 Report Contents and After-Hours Reporting
01.Report Contents. Each report of a reportable disease or condition must include:(3-17-22)
a.The identity and address of the attending licensed physician or the person reporting;(3-17-22)
b.The diagnosed or suspected disease or condition;(3-17-22)
c.The name, current address, telephone number, birth date, age, race, ethnicity, and sex of the individual with the disease or other identifier from whom the specimen was obtained;(3-17-22)
d.The date of onset of the disease or the date the test results were received; and(3-17-22)
e.In addition, laboratory directors must report the identity of the organism or other significant test result.(3-17-22)
02.After Hours Notification. An after hours report of a disease or condition may be made through the Idaho State EMS Communications Center (State Comm) at (800) 632-8000.(7-1-26)
IDAPA 16.02.10.041 (Reserved)
IDAPA 16.02.10.050 Reportable or Restrictable Diseases, Conditions and Reporting
REQUIREMENTS.
Reportable diseases and conditions must be reported to the Dep artment or Health District and must be investigated to confirm the diagnosis, obtain specific clinical information, determine possible risk factors, identify clusters or outbreaks of the infection, and identify the source of infection. The table below identifies the reportable and restrictable diseases and conditions, the timeframe for reporting, and the person or facility required to report.
Restrictions, unless otherwise specified, are for the duration of time that the disease is in a communicable form, other than for Food Employees with Food Service restrictable conditions, who must be managed under IDAPA 16.02.19, “Idaho Food Code”.
Amebiasis and Free-living Amebae Within 3 working daysDC, FS, HCFood Service Facility Anthrax (Bacillus anthracis)ImmediatelyNone Arboviral Diseases, including suspected cases Botulism, including suspected cases ImmediatelyNone Brucellosis (Brucella species)Within 1 working dayNone Campylobacteriosis (Campylobacter species)
Within 3 working daysDC, FS, HCFood Service Facility Cancer Report to Cancer Data Registry of Idaho within 180 days of diagnosis or recurrence (including suspected cases)
ChancroidWithin 3 working daysNone Chlamydia trachomatis Within 3 working days HC ophthalmia neonatorum only Cholera (Vibrio cholerae)Within 1 working dayFS, HC, DCFood Service Facility ConjunctivitisNo reporting requiredDC, S Cryptosporidiosis (Cryptosporidium species)
Within 3 working daysFS, HC, DC Cutaneous Fungal InfectionsNo reporting requiredDC, S Diarrhea (until common communicable diseases have been ruled out)
Diphtheria (Corynebacterium diphtheriae)
ImmediatelyDC, FS, HC, SSchool EchinococcosisWithin 3 working daysNone Encephalitis, Viral or AsepticWithin 3 working daysNone Escherichia coli O157:H7 and other Shiga-Toxin Producing E. coli (STEC)
Within 1 working dayDC, FS, HC Extraordinary Occurrence of Illness, including Clusters FeverNo reporting requiredFS Food Poisoning, Foodborne Illness, and Waterborne Illnesses, including suspected cases and outbreaks Giardiasis (Giardia lamblia)Within 3 working daysDC, FS, HCFood Service Facility Haemophilus influenzae Within 1 working dayDC, SSchool Hantavirus Pulmonary Syndrome Hemolytic-Uremic Syndrome (HUS) or Thrombotic thrombocytopenic purpura-HUS (TTP- HUS)
Hepatitis AWithin 1 working dayDC, FS, HCFood Service Facility Hepatitis BWithin 1 working dayNone Hepatitis CWithin 3 working daysNone Human Immunodeficiency Virus (HIV)
JaundiceNo reporting requiredFS Lead PoisoningWithin 3 working daysNone LegionellosisWithin 3 working daysNone Leprosy (Hansen’s Disease)Within 3 working daysNone LeptospirosisWithin 3 working daysNone Listeriosis (Listeria species)Within 3 working daysNone Lyme DiseaseWithin 3 working daysNone Malaria (Plasmodium species)Within 3 working daysNone Measles (Rubeola)Within 1 working dayDC, HC, SSchool Meningitis, Viral or AsepticWithin 3 working daysNone Methicillin-resistant (MRSA and Vancomycin-resistant (VRSA)
Staphylococcus aureus Note: Only Laboratory Directors need to report.
Methicillin-resistant Staphylococcus aureus (MRSA)
Non-Invasive Disease No reporting requiredDC, FS, HC, S MumpsWithin 3 working daysDC, S, HCSchool Myocarditis, ViralWithin 3 working daysNone Neisseria gonorrhoeae Within 3 working days HC-ophthalmia neonatorum only Neisseria meningitidis Within 1 working dayDC, HC, SSchool NorovirusWithin 1 working dayDC, FS, HC, S Novel Influenza A VirusWithin 1 working dayDC, FS, HC, S PediculosisNo reporting requiredDC, S Pertussis (Bordetella pertussis)Within 1 working dayDC, HC, SSchool Plague (Yersinia pestis)ImmediatelyHC, SSchool Pneumococcal Invasive Disease in Children less than Eighteen (18) Years of Age (Streptococcus pneumoniae)
Within 3 working daysDC, SSchool Pneumocystis Pneumonia (PCP)
PoliomyelitisWithin 1 working dayDCSchool PsittacosisWithin 3 working daysNone Q FeverWithin 1 working dayNone Rabies - Human, Animal, and Post-Exposure Prophylaxis (rPEP)
Immediately (human), Within 1 working day (animal or rPEP)
Relapsing Fever, Tick-borne and Louse-borne Respiratory Syncytial Virus (RSV)
Note: Only Laboratory Directors need to report.
Spotted Fever RicketsiosisWithin 3 working daysNone Rubella (including Congenital Rubella Syndrome)
Within 1 working dayDC, HC, SSchool Salmonellosis (including Typhoid Fever)
(Salmonella species)
Within 1 working dayDC, FS, HCFood Service Facility ScabiesNo reporting requiredDC, S Severe Acute Respiratory Syndrome (SARS), including suspected cases Within 1 working dayDC, SSchool Severe Reaction to Any Immunization Shigellosis (Shigella species)Within 1 working dayDC, FS, HC, S Smallpox, including suspected cases ImmediatelyDC, HC, SSchool Sore Throat with FeverNo reporting requiredFS Staphylococcal Infections other than MRSA No reporting requiredDC, FS, S Streptococcal Pharyngeal No reporting requiredDC, S Streptococcus pyogenes (group A strep), Invasive or Resulting in Rheumatic Fever Within 3 working daysDC, HC, SSchool SyphilisWithin 3 working daysNone TaeniasisNo reporting requiredFS TetanusWithin 3 working daysNone Toxic Shock Syndrome Within 3 working daysNone Transmissible Spongiform Encephalopathies (TSE), including Creutzfeldt-Jakob Disease (CJD) and Variant CJD (vCJD)
TrichinosisWithin 3 working daysNone
IDAPA 16.02.10.051 (Reserved)
IDAPA 16.02.10.065 Investigation and Control of Reportable Diseases
01.Responsibility and Authority. The Department will use all reasonable means to confirm in a timely manner any case or suspected case of a reportable disease or condition, and will determine, when possible, all sources of infection and the extent of exposure. Reports of diseases and conditions enumerated in this chapter will be investigated. Investigations may be made when the Department or Health District determines a disease to be of public health significance.(7-1-26)
a.Every licensed physician or other health care provider attending to a person with a reportable disease or condition must inform the person on applicable control measures as outlined in these rules and cooperate with the Department in the investigation and control of the disease or condition.(7-1-26)
b.Any person providing emergency or medical services who believes they have experienced a significant exposure to blood or bodily fluids may report said exposure as soon as possible to the Department. When the state epidemiologist’s judges a significant exposure has occurred, the Department will inform the exposed individual that they may have been exposed to the HIV or HBV virus, or that there is no information available based on the Department's current HIV or HBV registry and will recommend appropriate counseling and testing for the exposed individual.(7-1-26)
02.Inviolability of Placards. If it is necessary to use placards, it is unlawful for any person to interfere with, conceal, mutilate or tear down any notices or placards on any house, building or premises placed by the Department. Such placards can only be removed by the health official.(3-17-22)
Tuberculosis (Mycobacterium tuberculosis)
Within 3 working daysDC, FS, HC, S Tularemia (Francisella tularensis)
Immediately;
Identification of Francisella tularensis within 1 working day Uncovered and Open or Draining Skin Lesions with Pus, such as a Boil or Open Wound Varicella (chickenpox)No reporting requiredDC, S Viral Hemorrhagic FeverImmediatelyDC, FS, HC, S Vomiting (until noninfectious cause is identified)
Yersiniosis (Yersinia enterocolitica and Yersinia pseudotuberculosis)
Within 3 working days;
Identification of Yersinia pestis - immediately FS
03.Verification of Diagnosis and Case Classification. Cases of diseases or conditions reported to the Department will be treated as such upon the statement of the attending licensed physician or other health care provider, unless there is reason to doubt the diagnosis. Final decision as to the case classification for administrative purposes will rest with the Division of Public Health Administrator or Health District Director.(7-1-26)
04.Closure of Schools and Places of Public Assembly. The Director may order the closing of any public, parochial, or private school, or other place of public assembly when, in their opinion, such closing is necessary to protect public health. The school or other place of public assembly must not reopen until permitted by the health official.(3-17-22)
05.Transportation of Patients With Communicable Disease. No person with a reportable disease in a communicable form, who is under orders of isolation, nor any contact who is restricted under an order of quarantine, may travel or be transported from one place to another without the permission of the Division of Public Health Administrator or Health District Director. An exception may be made in instances where the patient will be admitted directly to a hospital or treatment facility, provided adequate precautions are taken to prevent transmission of the disease by the patient en route to the hospital or treatment facility.(7-1-26)
06.Order to Report for Examination. The Division of Public Health Administrator or Health District Director may issue an order to report for examination. An order to report for examination must be served by delivering one (1) copy to the person to be examined, one (1) copy to the prosecuting attorney of the county or city in which the person resides, and filing one (1) copy bearing the notation of time and place of service and the signature of the person serving the notice with the issuing health authority.(3-17-22)
07.Order for Isolation. The Division of Public Health Administrator or Health District Director may issue and withdraw an order for isolation if they determine that it is necessary to protect the public from a significant risk of the spread of infectious or communicable diseases or from contamination from chemical or biological agents.
a.The order for isolation must be executed as follows:(3-17-22)
i.One (1) copy to the individual being isolated;(3-17-22)
ii.One (1) copy to the attending licensed physician;(3-17-22)
iii.One (1) copy to the prosecuting attorney of the county or city in which the person resides; and
iv.One (1) copy to be filed in the office of the issuing officer along with an affidavit of service signed by the person who served the order.(3-17-22)
b.The issuing officer will make an assessment and identify the least restrictive means of isolation that effectively protects unexposed and susceptible individuals from the public health threat. Orders of isolation require the individual to isolate himself at a certain place or places, and may require specific precautions to be taken when outside a designated place of isolation as the issuing officer deems appropriate and necessary. If the place of isolation is other than the individual’s place of residence, a copy of the order must be provided to the person in charge of that place.(3-17-22)
c.The Division of Public Health Administrator or Health District Director will withdraw an order for isolation once it is determined there is no longer a significant threat to the public’s health posed by the individual under order for isolation.(3-17-22)
08.Order for Quarantine. The Division of Public Health Administrator or Health District Director is empowered whenever a case of any communicable disease occurs in any household or other place within their jurisdiction and in their opinion it is necessary that persons residing within must be kept from contact with the public, to require that no persons will leave or enter during the period of quarantine except with specific permission of the issuing officer.(7-1-26)
a.The order for quarantine must be executed as follows:(3-17-22)
i.One (1) copy to any individual being quarantined;(3-17-22)
ii.One (1) copy to the attending licensed physician;(3-17-22)
iii.One (1) copy to the prosecuting attorney of the county or city in which the quarantine occurs;
iv.One (1) copy to be filed in the office of the issuing officer along with an affidavit of service signed by the person who served the order; and(3-17-22)
v.One (1) copy to the person in charge or owner of the place of quarantine.(3-17-22)
b.The issuing officer will make an assessment and identify the least restrictive timeframe of quarantine that effectively protects unexposed and susceptible individuals to the infection of public health threat.
c.The Division of Public Health Administrator or Health District Director will withdraw an order for quarantine when they determine there is no longer a significant threat to the public’s health posed by the individual or premises under the order for quarantine.(3-17-22)
09.Sexually Transmitted Infection Contacts. Any person infected with a sexually transmitted infection (venereal disease) as defined in Section 39-601, Idaho Code, is required to provide the name, address, and telephone number(s) of all persons from whom the disease may have been acquired and to whom the disease may have been transmitted, when such information is requested by the Department or Health District.(3-17-22)
IDAPA 16.02.10.066 (Reserved)
IDAPA 16.02.10.068 Preventing Spread of Health Hazards from Dead Human Bodies
01.Embalming.
a.The Division of Public Health Administrator or Health District Director may order a dead human body to be embalmed or prohibit embalming to prevent the spread of infectious or communicable diseases or exposure to hazardous substances.(3-17-22)
b.The dead human body of a person suspected of or confirmed as having a viral hemorrhagic fever at the time of death must not be embalmed, but wrapped in sealed leak-proof material and cremated or buried.
02.Burial. The Division of Public Health Administrator or Health District Director may order a dead human body to be buried or cremated, or prohibit burial or cremation, and may specify a time frame for final disposition to prevent the spread of infectious or communicable diseases or exposure to hazardous substances.
03.Notification of Health Hazard. Any person authorized to release a dead human body of a person suspected of or confirmed as having a prior disease, a viral hemorrhagic fever, other infectious health hazard, or contaminated with a hazardous substance, must notify the person taking possession of the body and indicate necessary precautions on a written notice to accompany the body.(3-17-22)
IDAPA 16.02.10.069 (Reserved)
IDAPA 16.02.10.070 Special Disease Investigations
The Department may conduct special investigations of diseases or conditions to identify causes and means of preventi on. All records of interviews, reports, studies, and statements obtained by or furnished to the Department or other authorized agency are confidential for the identity of all persons involved. Release of information to the Department as required or permitted by these rules does not subject any party furnishing such information to an action for damages as provided under IDAPA 16.05.01, “Use and Disclosure of Department Records.”(3-17-22)
IDAPA 16.02.10.071 (Reserved)
IDAPA 16.02.10.080 Daycare Facility - Reporting and Control Measures
01.Readily Transmissible Diseases. Daycare reportable and restrictable diseases are those diseases that are readily transmissible among children and staff in daycare.(7-1-26)
02.Restrictable Disease - Work. A person who is diagnosed to have a daycare restrictable disease must not work in any occupation in which there is direct contact with children in a daycare facility, as long as the disease is in a communicable form.(3-17-22)
03.Restrictable Disease - Attendance. A child who is diagnosed to have a daycare restrictable disease must not attend a daycare facility as long as the disease is in a communicable form. This restriction may be removed by the written certification of a licensed physician, public health nurse or school nurse that the person’s disease is no longer communicable.(3-17-22)
04.Prevention of the Transmission of Disease. When satisfactory measures have been taken to prevent the transmission of disease, the affected child or employee may continue to attend or to work in a daycare facility if approval is obtained from the Department or Health District.(3-17-22)
IDAPA 16.02.10.081 (Reserved)
IDAPA 16.02.10.085 Food Service Facility - Reporting and Control Measures
01.Food or Beverage Transmitted Disease in a Communicable Form.
A person who is determined to have a disease or conditions listed in this chapter as restrictable for food establishments must not work as a food employee as long as the disease is in a communicable form.(7-1-26)
02.Food Employee Health Examination. The Division of Public Health Administrator may require a food employee to submit to an examination to determine the presence of a disease that can be transmitted by means of food when there is reasonable cause to believe the food employee is afflicted with a disease listed as restrictable for food establishments and that disease is in a communicable form.(7-1-26)
03.Notification of Disease in a Communicable Form. If the person in charge of an eating or drinking establishment has reason to suspect that any employee has a disease as restrictable for food establishments, and that disease is in a communicable form, the person in charge must immediately notify the Department or Health District and obtain guidance on proper actions needed to protect the public.(7-1-26)
IDAPA 16.02.10.086 (Reserved)
IDAPA 16.02.10.090 School - Reporting and Control Measures
01.Restrictable Diseases. Scho ol reportable and restrictable diseases are those diseases that are readily transmissible among students and staff in schools as listed in these rules.(7-1-26)
02.Restrictions - Work. Any person who is diagnosed to have a school restrictable disease must not work in any occupation that involves direct contact with students in a private, parochial, charter, or public school as long as the disease is in a communicable form.(3-17-22)
03.Restrictions - Attendance. Any person who is diagnosed with or reasonably suspected to have a school restrictable disease must not attend a private, parochial, charter, or public school as long as the disease is in a communicable form.(3-17-22)
04.Determination Disease Is No Longer Communicable. A licensed physician, public health nurse, school nurse or other person designated by the Department or Health District may determine when a person with a school restrictable disease is no longer communicable.(3-17-22)
05.School Closure. A school administrator must report the closure of any public, parochial, charter, or private school within one (1) working day when, in their opinion, such closing is related to a communicable disease.
IDAPA 16.02.10.091 Handling of Report
The Department and Health Districts will exchange rep orted information within one (1) working day. The Department will notify the Idaho Department of Agriculture and any other necessary agency of any identified source or suspected source of any reported case of the following diseases:(7-1-26)
01.Anthrax;(7-1-26)
02.Brucellosis;(7-1-26)
03.Leptospirosis;(7-1-26)
04.Lyme Disease;(7-1-26)
05.Plague;(7-1-26)
06.Psittacosis;(7-1-26)
07.Q Fever;(7-1-26)
08.Trichinosis; and(7-1-26)
09.Tularemia.(7-1-26)
IDAPA 16.02.10.092 Restrictions
A person with the following diseases must not attend a daycare facility while fecally incontinent and must not work in any occupation that provides personal care to children while the disease is in a communicable form, unless otherwise specified:(7-1-26)
c.Cholera;(7-1-26)
d.Conjunctivitis;(7-1-26)
e.Cryptosporidiosis;(7-1-26)
f.Cutaneous Fungal Infections;(7-1-26)
g.Diphtheria;(7-1-26)
h.Escherichia Coli O157:H7 and Other Shiga-Toxin Producing E. Coli (STEC);(7-1-26)
i.Giardiasis;(7-1-26)
j.Haemophilus Influenzae Invasive Disease;(7-1-26)
k.Hepatitis A;(7-1-26)
l.Measles (Rubeola);(7-1-26)
m.Methicillin-Resistant Staphylococcus Aureus (MRSA);(7-1-26)
n.Mumps;(7-1-26)
o.Neisseria Meningitidis Invasive Disease;(7-1-26)
p.Norovirus;(7-1-26)
q.Novel A Influenza Virus;(7-1-26)
r.Pediculosis;(7-1-26)
s.Pertussis;(7-1-26)
t.Plague;(7-1-26)
u.Pneumococcal Invasive Disease In Children Less Than Eighteen Years Of Age;(7-1-26)
v.Poliomyelitis;(7-1-26)
w.Rubella – Including Congenital Rubella Syndrome;(7-1-26)
x.Salmonellosis;(7-1-26)
y.Scabies;(7-1-26)
z.Severe Acute Respitory Syndrome (SARS), including suspected cases;(7-1-26)
aa.Shigellosis;(7-1-26)
bb.Smallpox;(7-1-26)
cc.Staphylococcal Infections Other than MRSA;(7-1-26)
dd.Streptococcal Pharyngeal Infections;(7-1-26)
ee.Streptococcus Pyogenes (Group A Strep) Infections;(7-1-26)
ff.Tuberculosis;(7-1-26)
gg.Varicella (Chickenpox); and(7-1-26)
hh.Viral Hemorrhagic Fever.(7-1-26)
02.Restrictions - Food Service Facility. A symptomatic person with the following diseases is restricted from working as a food employee while communicable, unless otherwise specified:(7-1-26)
c.Cholera;(7-1-26)
d.Cryptosporidiosis;(7-1-26)
e.Diarrhea;(7-1-26)
f.Diphtheria;(7-1-26)
g.Escherichia Coli O157:H7 and Other Shiga-Toxin Producing E. Coli (STEC);(7-1-26)
h.Fever;(7-1-26)
i.Giardiasis;(7-1-26)
j.Hepatitis A;(7-1-26)
k.Jaundice;(7-1-26)
l.Methicillin-Resistant Staphylococcus Aureus (MRSA);(7-1-26)
m.Norovirus;(7-1-26)
n.Novel A Influenza Virus;(7-1-26)
o.Salmonellosis, Including Typhoid Fever;(7-1-26)
p.Shigellosis;(7-1-26)
q.Sore Throat with Fever;(7-1-26)
r.Staphylococcal Infections Other Than MRSA;(7-1-26)
s.Taeniasis;(7-1-26)
t.Tuberculosis;(7-1-26)
u.Uncovered and Open or Draining Skin Lesions with Pus;(7-1-26)
v.Vomiting;(7-1-26)
w.Yersiniosis; and(7-1-26)
x.Viral Hemorrhagic Fever.(7-1-26)
03.Restrictions - Health Care Facility. A symptomatic person with the following diseases must not provide personal care to persons in a health care facility unless otherwise specified:(7-1-26)
c.Chlamydia Trachomatis;(7-1-26)
d.Cholera;(7-1-26)
e.Cryptosporidiosis;(7-1-26)
f.Diphtheria;(7-1-26)
g.Escherichia Coli O157:H7 and Other Shiga-Toxin Producing E. Coli (STEC);(7-1-26)
h.Giardiasis;(7-1-26)
i.Hepatitis A;(7-1-26)
j.Measles (Rubeola);(7-1-26)
k.Methicillin-Resistant Staphylococcus Aureus (MRSA);(7-1-26)
l.Mumps;(7-1-26)
m.Neisseria Meningitidis Invasive Disease;(7-1-26)
n.Norovirus;(7-1-26)
o.Novel Influenza A Virus;(7-1-26)
p.Pertussis;(7-1-26)
q.Plague;(7-1-26)
r.Rubella – Including Congenital Rubella Syndrome;(7-1-26)
s.Salmonellosis;(7-1-26)
t.Shigellosis;(7-1-26)
u.Smallpox;(7-1-26)
v.Streptococcus Pyogenes (Group A Strep) Infections;(7-1-26)
w.Tuberculosis; and(7-1-26)
x.Viral Hemorrhagic Fever.(7-1-26)
04.Restrictions - School. A person with the following diseases must not attend a private, parochial, charter, or public school while fecally incontinent and must not work in any occupation that involves direct contact with students in a private, parochial, charter, or public school while the disease is in a communicable form, unless otherwise specified:(7-1-26)
a.Conjunctivitis;(7-1-26)
b.Cutaneous Fungal Infections;(7-1-26)
c.Diphtheria;(7-1-26)
d.Haemophilus Influenzae Invasive Disease;(7-1-26)
e.Measles (Rubeola);(7-1-26)
f.Methicillin-Resistant Staphylococcus Aureus (MRSA);(7-1-26)
g.Mumps;(7-1-26)
h.Neisseria Meningitidis Invasive Disease;(7-1-26)
i.Norovirus;(7-1-26)
j.Novel A Influenza Virus;(7-1-26)
k.Pediculosis;(7-1-26)
l.Pertussis;(7-1-26)
m.Plague;(7-1-26)
n.Pneumococcal Invasive Disease In Children Less Than Eighteen Years Of Age;(7-1-26)
o.Polio;(7-1-26)
p.Rubella – Including Congenital Rubella Syndrome;(7-1-26)
q.Scabies;(7-1-26)
r.Severe Acute Respiratory Syndrome (SARS), including suspect cases;(7-1-26)
s.Shigellosis;(7-1-26)
t.Smallpox;(7-1-26)
u.Staphylococcal Infections, other than MRSA;(7-1-26)
v.Streptococcal Pharyngeal Infections;(7-1-26)
w.Streptococcus Pyogenes (Group A Strep) Infections;(7-1-26)
x.Tuberculosis;(7-1-26)
y.Varicella (Chickenpox); and(7-1-26)
z.Viral Hemorrhagic Fever.(7-1-26)
IDAPA 16.02.10.093 Testing Without Informed Consent
A physician may order blood tests for the following diseases wh en an informed consent is not possible and there has been or is likely to be significant exposure to a person’s blood or body fluids by a person providing emergency or medical services, as per Section 39-4905, Idaho Code:(7-1-26)
01.Hepatitis A;(7-1-26)
02.Hepatitis B;(7-1-26)
03.Hepatitis C;(7-1-26)
04.HIV;(7-1-26)
05.Malaria; and(7-1-26)
06.Syphilis.(7-1-26)
IDAPA 16.02.10.094 (Reserved)
REPORTABLE DISEASES WITH SPECIAL CONTROL MEASURES
(Sections 100-949)
IDAPA 16.02.10.100 (Reserved)
IDAPA 16.02.10.110 Amebiasis and Free-Living Amebae
01.Reporting Requirements. Each case of amebiasis or infection with free-living amebae (Ancanthamoeba spp., Balamuthia mandrillaris, or Naegleria fowleri) must be reported within three (3) working days of identification.(7-1-26)
02.Restrictions - Daycare Facility. A person excreting Entamoeba histolytica must not attend a daycare facility while fecally incontinent and must not work in any occupation in which they provide personal care to children in a daycare facility, unless an exemption is made by the Department or Health District.(3-17-22)
a.This restriction may be withdrawn if an effective therapeutic regimen is completed; or(3-17-22)
b.At least two (2) successive approved fecal specimens collected at least twenty-four (24) hours apart fail to show Entamoeba histolytica upon testing by a licensed laboratory.(3-17-22)
03.Restrictions - Food Service Facility. A symptomatic person excreting Entamoeba histolytica is restricted from working as a food employee.(3-17-22)
a.This restriction may be withdrawn if an effective therapeutic regimen is completed; or(3-17-22)
b.At least two (2) successive approved fecal specimens collected at least twenty-four (24) hours apart fail to show Entamoeba histolytica upon testing by a licensed laboratory.(3-17-22)
04.Restrictions - Health Care Facility. A person excreting Entamoeba histolytica must not work in any occupation in which they provide personal care to persons confined to a health care facility, unless an exemption is made by the Department or Health District.(3-17-22)
a.This restriction may be withdrawn if an effective therapeutic regimen is completed; or(3-17-22)
b.At least two (2) successive approved fecal specimens collected at least twenty-four (24) hours apart fail to show Entamoeba histolytica upon testing by a licensed laboratory.(3-17-22)
05.Restrictions - Household Contacts. A member of the household in which there is a case of amebiasis may not work in any occupations in listed in this Section, unless approved by the Department or Health District. The household member must be asymptomatic and have at least one (1) approved fecal specimen found to be negative for ova and parasites on examination by a licensed laboratory prior to being approved for work.(7-1-26)
IDAPA 16.02.10.111 (Reserved)
IDAPA 16.02.10.160 Campylobacteriosis
01.Restrictions - Daycare Facility. A person excreting Campylobacter must not provide personal care in a daycare and an fecally incontinent person excreting Campylobacter must not attend a daycare facility unless an exemption is obtained from the Department or Health District. Before returning to work or daycare, the person must provide at least two (2) successive approved fecal specimens, collected at least twenty-four (24) hours apart, that fail to show Campylobacter upon testing by a licensed laboratory.(3-17-22)
02.Restrictions - Health Care Facility. A person excreting Campylobacter must not provide personal care to persons in a health care facility unless an exemption is obtained from the Department or Health District.
Before returning to work, the person must provide at least two (2) successive approved fecal specimens, collected at least twenty-four (24) hours apart, that fail to show Campylobacter upon testing by a licensed laboratory. (3-17-22)
IDAPA 16.02.10.161 (Reserved)
IDAPA 16.02.10.170 Cancer
01.Cancers Designated as Reportable. Cancers that are designated reportable to the CDRI are described in Section 57-1703, Idaho Code.(7-1-26)
a.The use of the words “apparently,” “appears to,” “comparable with,” “compatible with,”
“consistent with,” “favor,” “malignant appearing,” “most likely,” “presumed,” “probable,” “suspected,” “suspicious,” or “typical” is sufficient to make a case reportable.(3-17-22)
b.The use of the words “questionable,” “possible,” “suggests,” “equivocal,” “approaching,” “rule out,” “potentially malignant,” or “worrisome,” is not sufficient to make a case reportable.(3-17-22)
02.Report Content. Each reported case must include the patient's name, demographic information, date of diagnosis, primary site, metastatic sites, histology, stage of disease, initial treatments, subsequent treatment, and survival time. Reporting of cases must adhere to cancer reporting standards as provided in “Standards for Cancer Registries, Vol. II.”(7-1-26)
03.Reported By Whom. Every private, federal, or military hospital, out-patient surgery center, radiation treatment center, pathology laboratory, or physician providing a diagnosis or treatment related to a reportable cancer is responsible for reporting or furnishing cancer-related data, including annual follow-up, to CDRI.
IDAPA 16.02.10.171 (Reserved)
IDAPA 16.02.10.200 Cholera
A member of the household in which there is a case of cholera may not work in any occupations specified in this rule, unless approved by the Department or Health District. The household member must be asymptomatic and provide at least one (1) approved fecal specimen found to be negative on a culture by a licensed laboratory prior to being approved for work.(7-1-26)
IDAPA 16.02.10.201 (Reserved)
IDAPA 16.02.10.220 Cryptosporidiosis
A fecally incontinent person excreting Cryptosporidium must not attend a daycare facility. A person excreting Cryptosporidium must not provide personal care in a daycare facility, unless an exemption is obtained from the Department or Health District. This restriction will be withdrawn when:
a.At least two (2) successive fecal specimens collected at least twenty-four (24) hours apart fail to show Cryptosporidium upon testing by a licensed laboratory; or(3-17-22)
b.Diarrhea has ceased for twenty-four (24) hours.(3-17-22)
02.Restrictions - Health Care Facility. A person excreting Cryptosporidium must not provide personal care in a custodial institution, or health care facility while fecally incontinent, unless an exemption is obtained from the Department or Health District. This restriction will be withdrawn when:(3-17-22)
a.At least two (2) successive fecal specimens collected at least twenty-four (24) hours apart fail to show Cryptosporidium upon testing by a licensed laboratory; or(3-17-22)
b.Diarrhea has ceased for twenty-four (24) hours.(3-17-22)
IDAPA 16.02.10.221 (Reserved)
IDAPA 16.02.10.230 Diphtheria
01.Restrictions - Health Care Facility.
a.A person with oropharyngeal toxigenic diphtheria in a health care facility must be managed under the “Guideline for Isolation Precautions in Hospitals,”. The Department or Health District may withdraw this isolation requirement after two (2) cultures of the nose and two (2) cultures from the throat, taken at least twenty-four (24) hours apart and at least twenty-four (24) hours after the completion of antibiotic therapy, fail to show toxigenic Corynebacterium diphtheriae upon testing by a licensed laboratory.(7-1-26)
b.A person with cutaneous toxigenic diphtheria must be placed under contact precautions. The Department or Health District may withdraw these precautions after two (2) cultures from the wound fail to show toxigenic Corynebacterium diphtheriae upon testing by a licensed laboratory.(3-17-22)
02.Restrictions - Contacts. Contacts of a person with toxigenic diphtheria are restricted from working as food employees, working in health care facilities, or from attending or working in daycare facilities or schools until they are determined not to be carriers by means of a nasopharyngeal culture or culture of other site suspected to be infected. These restrictions may be withdrawn by the Department or Health District.(3-17-22)
IDAPA 16.02.10.231 (Reserved)
IDAPA 16.02.10.250 Escherichia Coli O157:h7 and Other Shiga-Toxin Producing E. Coli (stec)
01.Restrictions - Da ycare Facility. A person who is excreting E. coli O157:H7 or other STEC must not attend daycare facilities while fecally incontinent or provide personal care to children in a daycare facility while the disease is present in a communicable form without the approval of the Department or Health District. Before returning to work or attendance at a daycare, the person must provide two (2) successive approved fecal specimens collected at least twenty-four (24) hours apart, that fail to show E. coli O157:H7 or other STEC.(3-17-22)
02.Restrictions - Health Care Facility. A person who is excreting E. coli O157:H7 or other STEC must not provide personal care to persons in a health care facility while the disease is present in a communicable form without the approval of the Department or Health District. Before returning to work, the person must provide two (2) successive approved fecal specimens collected at least twenty-four (24) hours apart, that fail to show E. coli O157:H7 or other STEC.(3-17-22)
IDAPA 16.02.10.251 (Reserved)
IDAPA 16.02.10.290 Giardiasis
01.Restrictions - Daycare Facility. A person with diarrhea who is excreting Giardia lamblia must not attend daycare while fecally incontinent or provide personal care to children in a daycare facility while the disease is present in a communicable form or until therapy is completed. An asymptomatic person may provide these services or attend daycare with specific approval of the Department or Health District.(3-17-22)
02.Restrictions - Health Care Facility. A person with diarrhea who is excreting Giardia lamblia must not provide personal care to persons in a health care facility while the disease is present in a communicable form or until therapy is completed. An asymptomatic person may provide these services with specific approval of the Department or Health District.(3-17-22)
IDAPA 16.02.10.291 (Reserved)
IDAPA 16.02.10.330 Hepatitis a
01.Restrictions - Househ old Contacts. Any unvaccinated household member where there is a case of hepatitis A must not work in any of the occupations listed in this Section, unless an exemption is obtained from the Department or Health District.(7-1-26)
IDAPA 16.02.10.331 (Reserved)
IDAPA 16.02.10.340 Hepatitis B
01.Investigation. Each reported case of hepatitis B must be investigated to confirm the diagnosis, identify contacts and carriers, determine the need for prophylaxis with immune globulins, determine the need for hepatitis B vaccine, determine the exposure of any pregnant women, and identify possible sources of the infection.
02.Carrier Status. The carrier status of a person diagnosed with hepatitis B will be determined six (6) months after the initial diagnosis is established.(3-17-22)
a.A person who is a carrier of hepatitis B must be reported to the Department or Health District by the physician at the time of determination for inclusion in the hepatitis B carrier registry.(3-17-22)
IDAPA 16.02.10.341 (Reserved)
IDAPA 16.02.10.360 Human Immunodeficiency Virus (hiv)
01.Reporting Requirements. Each case of HIV infection, including clinical diagnosis, positive HIV laboratory tests for HIV antibody, HIV antigen (protein or nucleic acid), human immunodeficiency virus isolations, or other tests of infectiousness that indicate HIV infection, must be reported to the Department or Health District within three (3) working days of identification.(7-1-26)
IDAPA 16.02.10.361 (Reserved)
IDAPA 16.02.10.380 Lead Poisoning
01.Reporting Requirements.
Each case of lead poisoning must be reported to the Department or Health District within three (3) working days of the identification of the case when determined by symptoms or a blood level of:(3-17-22)
a.Ten (10) micrograms or more per deciliter (10 ug/dL) of blood in adults eighteen (18) years and older; or (3-17-22)
b. Three and a half (3.5) micrograms or more per deciliter (3.5 ug/dL) of blood in children under eighteen (18) years of age.(3-17-22)
IDAPA 16.02.10.381 (Reserved)
IDAPA 16.02.10.400 Leprosy (hansen’s Disease)
All household members or close contacts of a new case should be recommended to receive evaluation by a licensed physician for signs of leprosy and consideration of chemoprophylaxis.(7-1-26)
IDAPA 16.02.10.401 (Reserved)
IDAPA 16.02.10.460 Measles (rubeola)
01.Restrictions - Daycare Facility and School.
a.A child diagnosed with measles must not attend a daycare facility or school as long as the disease is in a communicable form.(3-17-22)
b.A person who is diagnosed as having measles must not work in any occupation in which there is direct contact with children, as long as the disease is in a communicable form.(3-17-22)
IDAPA 16.02.10.461 (Reserved)
IDAPA 16.02.10.475 Methicillin-Resistant Staphylococcus Aureus (mrsa)
01.Reporting Requirements. Ea ch case or suspected case of invasive methicillin-resistant Staphylococcus aureus (MRSA), defined as MRSA isolated from a normally sterile site, must be reported to the Department or Health District within three (3) working days of identification by the laboratory director.(3-17-22)
02.Restrictions - Daycare Facility. A person who is diagnosed with MRSA infection must not work in an occupation providing personal care to children, or attend a daycare facility, if the infection manifests as a lesion containing pus such as a boil or infected wound that is open or draining; and(3-17-22)
a.The lesion is on the hands, wrists, or exposed portions of the arms, and is not protected by an
b.The lesion is on another part of the body, and is not covered by a dry, durable, tight-fitting bandage.
03.Restrictions - Health Care Facility. A person who is diagnosed with MRSA infection must not provide personal care to persons in a health care facility if the infection manifests as a lesion containing pus such as a boil or infected wound that is open or draining; and(3-17-22)
a.The lesion is on the hands, wrists, or exposed portions of the arms, and is not protected by an
b.The lesion is on another part of the body, and is not covered by a dry, durable, tight-fitting bandage.
04.Restrictions - School. A person who is diagnosed with MRSA infection must not work in an occupation where there is direct contact with students or attend a private, parochial, charter, or public school, if the infection manifests as a lesion containing pus such as a boil or infected wound that is open or draining; and (3-17-22)
a.The lesion is on the hands, wrists, or exposed portions of the arms, and is not protected by an
b.The lesion is on another part of the body, and is not covered by a dry, durable, tight-fitting bandage.
IDAPA 16.02.10.476 (Reserved)
IDAPA 16.02.10.550 Plague
Household members and face-to-face contacts of a person with p neumonic plague must be offered chemoprophylaxis and placed under surveillance for seven (7) days. A person who refuses chemoprophylaxis must be maintained under surveillance for seven (7) days.(7-1-26)
IDAPA 16.02.10.551 (Reserved)
IDAPA 16.02.10.570 Pneumocystis Pneumonia (pcp)
Each reported case of Pneumocy stis pneumonia (PCP) must be investigated to confirm the diagnosis, and to determine whether HIV contributed to the disease.(7-1-26)
IDAPA 16.02.10.571 (Reserved)
IDAPA 16.02.10.580 Poliomyelitis
The immunization status of personal contacts should be determined and susceptible contacts recommended to receive immunization.(7-1-26)
IDAPA 16.02.10.581 (Reserved)
IDAPA 16.02.10.610 Rabies - Human, Animal, and Post-Exposure Prophylaxis (rpep)
01.Reporting Requirements.
a.Each case of rabies in animals or rabies post-exposure prophylaxis series initiation in a human must be reported to the Department or Health District within one (1) working day of identification.(7-1-26)
b.Each suspected or confirmed case of rabies in animals will be investigated to determine if potential human or animal exposure has occurred and identify persons who may need to undergo rPEP.(3-17-22)
c.Each reported rPEP series initiation must be investigated to determine if additional individuals require rPEP and identify the source of possible rabies exposure.(3-17-22)
02.Management of Exposure to Rabies. In the event that a human or animal case of rabies occurs, any designated representative of the Department, Health District, or Idaho State Department of Agriculture, will establish such isolation and quarantine of animals involved as deemed necessary to protect the public health.(7-1-26)
a.The management of a rabies-susceptible animal that has bitten or otherwise potentially exposed a person to rabies must be as follows:(3-17-22)
i.Any livestock that has bitten or otherwise potentially exposed a person to rabies will be referred to the Idaho State Department of Agriculture for management.(3-17-22)
ii.Any healthy domestic dog, cat, or ferret, regardless of rabies vaccination status, must be under the supervision of a licensed veterinarian or other person designated by the Idaho State Department of Agriculture, Health District, or the Department.(7-1-26)
iii.Any domestic dog, cat, or ferret that cannot be managed as described in this rule must be destroyed by a means other than shooting or other trauma to the head. The head must be submitted to an approved laboratory for rabies analysis.(7-1-26)
iv.It is the animal owner's responsibility to follow instructions provided for the management of the animal.(3-17-22)
v.Rabies susceptible animals other than domestic dogs, cats, or ferrets must be destroyed and the head submitted to an approved laboratory for rabies analysis, unless an exemption is given by the Department or Health District.(3-17-22)
vi.No person will destroy, or allow to be destroyed, the head of a rabies-susceptible animal that has bitten or otherwise potentially exposed a person to rabies without authorization from the Department or Health District.(3-17-22)
b.The management of a rabies-susceptible animal that has not bitten a person, but has been bitten, mouthed, mauled by, or closely confined in the same premises with a confirmed or suspected rabid animal must be as follows:(3-17-22)
i.Any exposed livestock will be referred to the Idaho State Department of Agriculture for management.(3-17-22)
ii.Any domestic dog, cat, or ferret that has never been vaccinated against rabies as recommended by the American Veterinary Medical Association, must be euthanized or appropriately vaccinated in accordance with guidance in the “Compendium of Animal Rabies Prevention and Control” and quarantined under the observation of a licensed veterinarian or a person designated by the Idaho State Department of Agriculture, Health District, or the Department. Quarantine of such an animal must be within an enclosure deemed adequate by a person designated by the Idaho State Department of Agriculture, Health District, or the Department. If signs suggestive of rabies develop, the managing veterinarian or other designee must immediately consult the Health District or Department to discuss euthanasia or rabies testing.(7-1-26)
iii.An animal considered currently vaccinated against rabies, or overdue for rabies vaccination but with documentation of at least one (1) prior rabies vaccination, should be revaccinated against rabies as soon as possible with an appropriate vaccine, kept under the owner’s control, and observed for illness for forty-five (45) days.
If signs suggestive of rabies develop, the owner must immediately consult the Health District or Department to discuss euthanasia and rabies testing. These provisions apply only to animals for which an approved rabies vaccine is available.(7-1-26)
iv.The owner of the animal is financially responsible for the cost of managing and testing of the animal.(7-1-26)
c.Any rabies-susceptible animal other than domestic dogs, cats, ferrets, or livestock that are suspected of having rabies, or have been in close contact with an animal known to be rabid, must be euthanized, unless an exemption is granted by the Department or Health District.(7-1-26)
d.Any rabies susceptible animal other than domestic dogs, cats, ferrets, or other livestock that are suspected of having rabies, or have been in close contact with an animal known to be rabid, must be euthanized and tested by an approved laboratory for rabies if a person has been bitten or has had direct contact with the animal that might result in the person becoming infected.(7-1-26)
IDAPA 16.02.10.611 (Reserved)
IDAPA 16.02.10.660 Rubella - Including Congenital Rubella Syndrome
A person who is diagnosed with rubella must not attend daycare or work in any occupation in which there is close contact with children in a daycare facility as long as the disease is in a communicable form Infants with congenital rubella syndrome should be restricted from day care facilities until 2 clinical specimens obtained 1 month apart are negative for rubella virus.(7-1-26)
02.Restrictions - Personal Contact. A person who is diagnosed with rubella must not work in occupations in which there is close contact with women likely to be pregnant as long as the disease is in a communicable form.(7-1-26)
IDAPA 16.02.10.661 (Reserved)
IDAPA 16.02.10.670 Salmonellosis - Including Typhoid Fever
01.Restrictions - Chronic Carrier. Chronic carriers, which are those who excrete Salmonella for more than one (1) year after onset, are restricted from working as food employees. Chronic carriers must not work in any occupation in which they provide personal care to children in daycare facilities, or to persons who are confined to health care facilities or residential care facilities, until Salmonella is not identified by a licensed laboratory in any of three (3) successive approved fecal specimens collected at least seventy-two (72) hours apart.(3-17-22)
02.Restrictions - Non-Typhi Salmonella.(3-17-22)
a.A fecally incontinent person excreting non-Typhi Salmonella must not attend a daycare facility.
b.A person excreting non-Typhi Salmonella must not work in any occupation in which they provide personal care to children in a daycare facility or provide personal care to persons confined to a health care facility, unless an exemption is obtained from the Department or Health District.(3-17-22)
c.A symptomatic food employee excreting non-Typhi Salmonella must be managed under the IDAPA 16.02.19, “Idaho Food Code.”(3-17-22)
d.Before a person can attend or work in a daycare facility or a health care facility, or work as a food employee, the person must provide two (2) successive approved fecal specimens collected at least twenty-four (24) hours apart, that fail to show Salmonella.(3-17-22)
e.The Department may withdraw this restriction on a case of non-Typhi Salmonella provided that the person is asymptomatic.(3-17-22)
f.Any member of a household in which there is a case of non-Typhi salmonellosis must not work as a food employee until the member provides at least one (1) approved fecal specimen that fails to show Salmonella upon testing by a licensed laboratory.(3-17-22)
03.Restrictions - Salmonella Typhi.(3-17-22)
a.Any person with typhoid fever will remain subject to the supervision of the Department until Salmonella Typhi is not isolated by a licensed laboratory from three (3) successive approved fecal specimens collected at least twenty-four (24) hours apart, and at least forty-eight (48) hours after the last dose of antibiotics.
b.Any member of a household in which there is a case of Salmonella Typhi must not work in the occupations described in this Section until the member provides at least two (2) successive approved fecal specimens collected twenty-four (24) hours apart that fail to show Salmonella upon testing by a licensed laboratory.(7-1-26)
c.All chronic carriers of Salmonella Typhi must abide by a written agreement called a typhoid fever carrier agreement. This agreement is between the chronic carrier and the Department or Health District. Failure of the carrier to abide by the carrier agreement may cause the carrier to be isolated under Section 065 of these rules. The carrier agreement requires:(3-17-22)
i.The carrier cannot work as a food employee;(3-17-22)
ii.Specimens must be furnished for examination in a manner described by the Department or Health District; and(3-17-22)
iii.The Department or Health District must be notified immediately of any change of address, occupation, and cases of illness suggestive of typhoid fever in their family or among immediate associates, while there is a chronic carrier under a typhoid fever carrier agreement.(7-1-26)
d.Chronic carriers of typhoid fever may be released from carrier status when Salmonella Typhi is not identified by a licensed laboratory in any of six (6) consecutive approved fecal and urine specimens collected at least one (1) month apart.(3-17-22)
IDAPA 16.02.10.671 (Reserved)
IDAPA 16.02.10.700 Shigellosis
a.A person excreting Shigella must not attend a daycare facility while fecally incontinent. (3-17-22)
b.A person excreting Shigella must not work in any occupation in which they provide personal care to children in a daycare facility while the disease is present in a communicable form, unless an exemption is obtained from the Department or Health District. During an outbreak in a daycare facility, a cohort system may be approved.
c.The Department or Health District may withdraw the daycare restriction when the person has provided two (2) successive approved fecal specimens collected at least twenty-four (24) hours apart that fail to show Shigella upon testing by a licensed laboratory.(3-17-22)
02.Restrictions - Health Care Facility.(3-17-22)
a.A person excreting Shigella must not work in any occupation in which they provide personal care to persons who are confined to a health care facility while the disease is present in a communicable form, unless an exemption is obtained from the Department or Health District. During an outbreak in a facility, a cohort system may be approved.(3-17-22)
b.The Department or Health District may withdraw the health care facility restriction when the employee has provided two (2) successive approved fecal specimens collected at least twenty-four (24) hours apart that fail to show Shigella upon testing by a licensed laboratory.(3-17-22)
c.During an outbreak in a facility, a cohort system may be approved.(3-17-22)
03.Restrictions - Household Contacts. No member of a household, in which there is a case of shigellosis, may work in any occupations in this Section, unless the Department or Health District approves and at least one (1) approved fecal specimen is negative for Shigella upon testing by a licensed laboratory.(7-1-26)
IDAPA 16.02.10.701 (Reserved)
IDAPA 16.02.10.710 Smallpox
01.Restrictions - Public Gatherings.
A person diagnosed with smallpox must not attend public gatherings as long as the disease is in a communicable form.(3-17-22)
02.Restrictions - Working. A person diagnosed with smallpox must not work in any occupation as long as the disease is in a communicable form.(3-17-22)
IDAPA 16.02.10.711 (Reserved)
IDAPA 16.02.10.780 Tuberculosis
01.Active Pulmonary Tuberculosis - Definition.
Tuberculosis disease of the lungs, determined by a physician to be potentially contagious by clinical or bacteriological evidence or by evidence of the spread of the disease to others. Tuberculosis is considered active until cured.(3-17-22)
02.Cure of Tuberculosis - Definition. The completion of a course of antituberculosis treatment.
03.Restrictions - Health Care Facility.(3-17-22)
a.A person suspected to have pulmonary tuberculosis in a health care facility must be managed under the “Guideline for Isolation Precautions in Hospitals,” until the diagnosis of active pulmonary tuberculosis is excluded by a licensed physician.(7-1-26)
b.A person with active pulmonary tuberculosis in a health care facility must be managed under the “Guideline for Isolation Precautions in Hospitals,” until they are determined to be noninfectious by a licensed physician, the infection control committee of the facility, or the Department.(7-1-26)
c.A person with active pulmonary tuberculosis must not work in any occupation in which they have direct contact or provides personal care to persons confined to a health care or residential care facility, until they are determined to be noninfectious by a licensed physician, infection control committee of the facility, or the Department.
d.In the event that active pulmonary tuberculosis is diagnosed in an employee, patient, or resident, the health care facility must conduct an investigation to identify contacts. The Department or Health District may assist in the investigation.(3-17-22)
04.Restrictions - School. A person with active pulmonary tuberculosis must not attend or work in any occupation in which they have direct contact with students in a private, parochial, charter, or public school until they are determined to be noninfectious by a licensed physician, the Department, or Health District.(3-17-22)
05.Restrictions - Household Contacts. Any member of a household, in which there is a case of active pulmonary tuberculosis, must not attend or work in any occupation in which they provide direct supervision of students in a school, personal care to children in a daycare facility or persons confined to a health care facility, or works in a food service facility, until they have been determined to be noninfectious by a licensed physician, the Department, or Health District.(3-17-22)
IDAPA 16.02.10.781 (Reserved)
16.03.26 Medicaid Plan Benefits
IDAPA 16.03.26.000 Legal Authority
Sections 56-202(b), and 56-265, Idaho Code.(7-1-26)
IDAPA 16.03.26.001 Scope
These rules contain the general provisions regarding the adm inistration of Medicaid. All goods and services not specifically included in this chapter are excluded from coverage under Medicaid Benefit Plans. These rules also contain requirements for provider procurement and reimbursement. Individuals eligible for the Medicaid Enhanced Plan, including those enrolled in a duals managed care plan, also receive all Medicaid Basic Plan benefits.(7-1-26)
IDAPA 16.03.26.002 Incorporation by Reference
01.Estimated Useful Lives of Depreciable Hospital Assets, 2023 Revised Edition. The document may be obtained from the American Hospital Association, 155 North Wacker Drive, Ste. 400, Chicago, IL, 60606.
02.Provider Reimbursement Manual (PRM). The Provider Reimbursement Manual (PRM), Part I and Part II (CMS Publication 15-1 and 15-2), is available at: https://www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/Paper-Based-Manuals.html.(7-1-26)
IDAPA 16.03.26.003 Background Check Requirements
01.Background Check Compliance. Background checks are required for specific providers under these rules. Providers who are required to have a background check and their contractors must comply with IDAPA 16.05.06.(7-1-26)
02.Variances.(7-1-26)
a.The Department may allow variances to clearance requirements under certain circumstances.
Applicable providers must still complete an application for a background check.(7-1-26)
b.Applicants with prior convictions for disqualifying drug and alcohol-related offenses may, with prior written approval of the Department, deliver covered Medicaid Peer Support and Recovery Coaching services.
03.Subsequent Convictions, Charges, or Investigations. Once clearances are received, any subsequent criminal, adult, or child protection convictions, charges, or investigations must be immediately reported by the agency to the Department once known.(7-1-26)
04.Providers Subject to Background Check Requirements.(7-1-26)
a.Adult Day Health Agencies.(7-1-26)
b.Behavior Consultation or Crisis Management Providers.(7-1-26)
c.Chore Services Providers.(7-1-26)
d.Community Support Workers.(7-1-26)
e.Contracted Non-Emergency Medical Transportation (NEMT) Providers, with direct contact with participants except for Individual Contracted NEMT providers.(7-1-26)
f.Independent CHIS Providers.(7-1-26)
g.Non-Medical Transportation (NMT) Providers.(7-1-26)
h.Personal Assistance Agencies (PAA), including PAAs Acting as Fiscal Intermediaries.(7-1-26)
i.Provider types deemed by the Department to be at high risk for fraud, waste, or abuse.(7-1-26)
j.Respite Care Providers.(7-1-26)
k.Service Coordination Agencies.(7-1-26)
l.Support Brokers.(7-1-26)
m.Supported Employment Agencies.(7-1-26)
IDAPA 16.03.26.004 (Reserved)
IDAPA 16.03.26.005 Definitions: a Through H
01.Activities of Daily Living (ADL). Basic self-care activities that meet an individual's needs to sustain them in a daily living environment, and includes bathing, washing, dressing, toileting, grooming, eating, communication, continence, mobility, and associated tasks.(7-1-26)
02.Agency. A business entity comprised of an administrator and their employees providing a Medicaid service. Individuals cannot be an agency.(7-1-26)
03.Adult Day Health (ADH). Defined in Section 67-5006(5), Idaho Code, as adult day care. (7-1-26)
04.Amortization. The systematic recognition of the declining utility value of certain assets, usually not owned by the organization or intangible in nature.(7-1-26)
05.Audit. An examination of provider records and financial records to determine compliance with Medicaid requirements and regulations or quality assurance.(7-1-26)
06.Budget Adjustment Factor (BAF). Total budget for nursing facility (NF) payment established by the Idaho legislature effective on July 1 annually and compared to the annual expected Medicaid rates for the same rate year. BAF may be positive or negative and applies to all NF rates calculated under the established prospective rate system. BAF is not applied to the calculated customary charge for each NF nor applied to any retrospectively settled NF.(7-1-26)
07.Case Mix Adjustment Factor. Factor used to adjust a provider’s direct care rate component for the difference in the average Medicaid acuity and the average facility-wide acuity. The average Medicaid acuity is from the picture date immediately preceding the rate period. The facility-wide acuity is the average of the indexes corresponding to the cost reporting period.(7-1-26)
08.Case Mix Index (CMI). Numeric score assigned to each facility resident, based on their physical and mental condition projecting the relative resources needed to provide their care.(7-1-26)
a.Facility-Wide CMI. Average of the entire facility’s CMIs identified at each picture date during the cost reporting period. If CMIs are unavailable for applicable quarters due to lack of data, CMIs from available quarters are used.(7-1-26)
b.Medicaid CMI. Average of the weighting factors assigned to each Medicaid resident in a facility on the picture date, based on their PDPM classification. Medicaid status is based upon information contained in the MDS databases. When Medicaid identifiers are found to be incorrect, the Department adjusts the Medicaid CMI and reestablishes the rate.(7-1-26)
c.State-Wide Average CMI. Simple average of all facilities “facility-wide” CMIs used to establish the rate limitation July 1st of each year.(7-1-26)
09.Children’s Habilitation Intervention Services (CHIS). CHIS are medically necessary, evidenceinformed or evidence-based therapeutic techniques based on applied behavior analysis principles used to result in posit ive outcomes.(7-1-26)
10.Children’s Health Insurance Program (CHIP). Medical assistance for children under Idaho’s Title XXI State Plan. The term Medicaid for the purposes of this rule apply to CHIP.(7-1-26)
11.Claim. An itemized bill for services rendered to one (1) participant by a provider and submitted to the Department for payment.(7-1-26)
12.CMS. Centers for Medicare and Medicaid Services.(7-1-26)
13.Community Support Worker (CSW). An individual, agency, or vendor selected and paid by the participant to provide CSW services.(7-1-26)
14.Consumer-Directed Community Supports (CDCS). A flexible program option for participants eligible for the Children’s Home and Community Based Services (HCBS) State Plan Option, and Adult Developmental Disabilities (DD) waiver. Supports include SDCS and FDCS program options.(7-1-26)
15.Cost Report. A fiscal year report of provider costs required by the Medicare program and any supplemental schedules required by the Department.(7-1-26)
16.Customary Charges. The rates charged to Medicare participants and other paying patients as reflected in the facility’s records. Charges are adjusted downward, when the provider does not hold most patients liable for payment on a charge basis or, when there are not reasonable collection efforts. Reasonable effort to collect such charges is the same effort necessary for Medicare reimbursement as is needed for unrecovered costs attributable to certain bad debt under PRM.(7-1-26)
17.Date of Discharge. The day a participant is released from care that is not a day of care for nursing facilities.(7-1-26)
18.Day Treatment Services. Developmental services provided regularly during normal working hours on weekdays by, or on behalf of, an ICF/IID that do not include recreational, speech, physical, or occupational therapy, or other services paid for, or required to be provided by, a school or other entity.(7-1-26)
19.Department. The Idaho Department of Health and Welfare or its designee.(7-1-26)
20.Director. The Director of the Department or their designee.(7-1-26)
21.Developmental Disability (DD). As defined in Section 66-402(5), Idaho Code.(7-1-26)
22.Dual Eligible. Participants eligible for Medicaid under IDAPA 16.03.05, when their eligibility is not provided solely under the Woman Diagnosed with Breast or Cervical Cancer program, and who are enrolled in both Medicare Parts A and B.(7-1-26)
23.Durable Medical Equipment (DME). Equipment and appliances that are not orthotics or prosthetics; are primarily and customarily used to serve a medical purpose; are generally not useful to an individual in the absence of a disability, illness, or injury; can withstand repeated use; can be reusable or removable; and are suitable for use in any setting in which normal life activities take place.(7-1-26)
24.Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Services. Medically necessary services are health care, diagnostic services, treatment, and other measures necessary to correct or ameliorate defects, physical and mental illness, and conditions discovered by the screeni ng services as defined in Section 1905(r) of the SSA, whether such services are covered under the State Plan.(7-1-26)
25.Educational Services. Services provided online, in buildings or areas designated for use as a school or educational setting; provided during time periods in which educational instruction takes place in the school day; included in a participant’s individual educational plan for school age individuals.(7-1-26)
26.Evidence-Based Interventions. Interventions that have been scientifically researched and reviewed in peer-reviewed journals, replicated successfully by multiple independent investigators, have been shown to produce measurable and substantiated beneficial outcomes, and are delivered with fidelity by certified or credentialed individuals trained in the evidence-based model (EBM).(7-1-26)
27.Evidence-Informed Interventions. Interventions that use elements or components of evidencebased techniques and are delivered by a qualified individual, who are not certified or credentialed in an EBM.
28.Facility. Facility refers to a hospital, nursing facility (NF), or intermediate care facility for individuals with intellectual disabilities (ICF/IID).(7-1-26)
29.Family-Directed Community Supports (FDCS). A program option for children eligible for Children's HCBS State Plan Option.(7-1-26)
30.Financial Management Services (FMS). Services provided by an FEA.(7-1-26)
31.Fiscal Employer Agent (FEA). An agency that provides FMS selected by participants who have chosen the CDCS option. FEA is selected by the participant.(7-1-26)
32.Goods. Tangible products or merchandise that are authorized on the SSP.(7-1-26)
33.Home and Community Based Services (HCBS). Long-term services and supports that assist participants to remain in their home and community.(7-1-26)
34.Human Services Field. A diverse field that is focused on improving the quality of life for participants. Areas of academic study include, but are not limited to, sociology, special education, counseling, psychology, or other areas of academic study as referenced in the Medicaid Provider Handbook.(7-1-26)
IDAPA 16.03.26.006 Definitions: I Through O
01.Idaho Medicaid Provider Handbook.
A document that contains policy for the implementation and operations of the Medicaid program.(7-1-26)
02.In-State Care. Medical services not including long-term care provided within Idaho or in counties bordering Idaho.(7-1-26)
03.Inspection of Care Team (IOCT). Interdisciplinary team providing inspection of care in licensed ICFs/IID composed of:(7-1-26)
a.An RN; and(7-1-26)
b.A QIDP; and when required, a:(7-1-26)
i.Consultant physician;(7-1-26)
ii.Consultant social worker; or(7-1-26)
iii.When appropriate, other health and human services employees or consultants of the Department.
04.Instrumental Activities of Daily Living (IADL). Activities performed to support ADL, including, but not limited, to managing money, preparing meals, shopping, light housekeeping, communicating, or accessing the community.(7-1-26)
05.Integration. Promoting a lifestyle for HCBS participants like other community members, including those living in and accessing community resources to enhance the social image and personal competence of HCBS participants.(7-1-26)
06.Interim Reimbursement Rate (IRR). Rate paid for each Medicaid patient day intended to result in total Medicaid payments approximating the amount paid at audit settlement and intended to include any payments allowed over the percentile cap.(7-1-26)
07.Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID). An entity licensed as an ICF/IID and federally certified to provide care to Medicaid and Medicare participants with developmental disabilities.(7-1-26)
08.Level of Care. The classification in which a participant is placed, based on severity of need for institutional care.(7-1-26)
09.Level of Support. Amount of services and supports necessary to allow a participant to live independently and safely in the community, as derived from a Department-approved assessment tool.(7-1-26)
10.Licensed Bed Capacity. Number of beds approved by the State’s Licensure and Certification Agency for rendering patient care.(7-1-26)
11.Lower of Cost or Charges. Payment to providers (other than public providers furnishing services free of charge or at nominal charges to the public) that is the lesser of the reasonable cost of services or customary charges of like services. Public providers furnishing services free of charge or at a nominal charge are reimbursed fair compensation; considered reasonable cost.(7-1-26)
12.Major Movable Equipment. Major movable equipment as defined in Section 56-101(16), Idaho Code, that also has a unit cost of five thousand dollars ($5,000) or more.(7-1-26)
13.Medicaid-Related Ancillary Costs. Services considered to be ancillary by Medicare cost reporting principles. Medicaid-related ancillary costs are determined by apportioning direct and indirect costs associated with each ancillary service to Medicaid participants by dividing Medicaid charges into total charges for that service. The resulting percentage, when multiplied by the ancillary service cost, is considered Medicaid-related ancillaries.(7-1-26)
14.Medical Assistance (Medicaid). Payments for part or all of the cost of services, capitation payments, or managed care costs funded by Titles XIX or XXI of the federal Social Security Act (SSA).(7-1-26)
15.Medical Necessity (Medically Necessary). A service or item is medically necessary if:(7-1-26)
a.It is reasonably calculated to prevent, diagnose, or treat conditions in the participant that endanger life, cause pain, or cause functionally significant deformity or malfunction;(7-1-26)
b.There is no other equally effective course of treatment available or suitable for the participant requesting the service that is more conservative or substantially less costly;(7-1-26)
c.It meets any applicable Department criteria. Services that do not meet criteria require a PA;
d.Medical services must be of a quality that meets professionally recognized standards of health care and is substantiated by records including evidence of such medical necessity and quality. Those records must be made available to the Department upon request.(7-1-26)
16.Medical, Social, and Developmental Assessment (MSDA) Summary. Form used by the Department to gather a participant medical, social, and developmental history and other summary information req uired for all DD HCBS program participants under a service plan used to assess and authorize services. (7-1-26)
17.Medical Supplies. Healthcare-related items that are consumable, disposable, or cannot withstand repeated use by more than one (1) individual, are suitable for use in any setting in which normal life activities take place, and are reasonable and medically necessary for the treatment of a disability, illness, or injury for a Medicaid
18.Minimum Data Set (MDS). Set of screening, clinical, and functional status elements, including common definitions and coding categories, forming the foundation of a comprehensive assessment for all residents of long-term care facilities certified under Medicare or Medicaid. Updated versions of the MDS are evaluated and incorporated into rate setting as necessary.(7-1-26)
19.Minor Movable Equipment. Minor movable equipment as defined in Section 56-101(18), Idaho Code, with a unit cost under five thousand dollars ($5,000.)(7-1-26)
20.Nominal Charges. A public provider’s charges are nominal where aggregate charges amount to less than one-half (1/2) of the reasonable cost of the services provided.(7-1-26)
21.Order. Written instructions from a healthcare professional acting within the scope of their practice for a participant’s treatment, medications, tests or procedures. Orders shall include:(7-1-26)
a.Participant’s name;(7-1-26)
b.Description of item or service;(7-1-26)
c.Length of need, if applicable;(7-1-26)
d.Quantity, if applicable;(7-1-26)
e.Provider’s name, National Provider Identification (NPI) and signature; and(7-1-26)
f.Date of signature.(7-1-26)
22.Ordinary. Costs incurred that are customary for normal operation of a business.(7-1-26)
23.Orthotic. Pertaining to or promoting the support of an impaired joint or limb.(7-1-26)
IDAPA 16.03.26.007 Definitions: P Through Z
01.Participant.
A person eligible for and enrolled in Medicaid.(7-1-26)
02.Patient Driven Payment Model (PDPM). Process to group residents according to the clinical and functional status identified by responses to key elements of the MDS and used for rate setting and determining NF level of care.(7-1-26)
03.Personal Assistance Agency (PAA). An entity that recruits, hires, fires, trains, supervises, schedules, oversees quality of work, takes responsibility for services provided, provides payroll and benefits for personal assistants working for them, and is the employer of record as well as the actual employer.(7-1-26)
04.Plan Developer. A service coordinator identified by the participant responsible for developing a service plan and subsequent addenda covering all services and supports, based on a person-centered planning process.
A plan developer may be paid, unpaid or the unpaid participant themselves.(7-1-26)
05.Plan Monitor. A person who oversees service delivery on a paid or non-paid basis. For DD services, the plan monitor is a service coordinator.(7-1-26)
06.Plan of Care. A written description of medical, remedial, habilitative, or rehabilitative services to provide to a participant, developed by or under the direction and written approval of a provider. Medications, services, and treatments shall be identified specifically by amount, type, and duration of service.(7-1-26)
07.Primary Care Provider (PCP). A healthcare professional acting within the scope of their practice, who is the first point of contact for routine medical concerns.(7-1-26)
08.Prior Authorization (PA). PA means a written, faxed, or electronic approval from the Department that permits payment or coverage of a medical item or service that is covered only by such authorization.(7-1-26)
09.Property Rental Rate. Rate paid per Medicaid patient day to free-standing nursing facilities in lieu of payment for property costs other than property taxes, insurance, and, for ICF/IID providers, costs of major movable equipment.(7-1-26)
10.Prosthetic Device. Replacement, corrective, or supportive devices to:(7-1-26)
a.Artificially replace a missing portion of the body;(7-1-26)
b.Prevent or correct physical deformities or malfunctions; or(7-1-26)
c.Support a weak or deformed portion of the body.(7-1-26)
d.Computerized communication devices are not included in this definition.(7-1-26)
11.Provider. Any individual acting under Section 020 including, but not limited to certified registered nurse anesthetists, nurse practitioners, nurse midwives, clinical nurse specialists, pharmacists, physician assistants, and physicians. Alternatively, a partnership, association, corporation, or organization that furnishes medical goods or services in compliance with these rules.(7-1-26)
12.Provider Status Review. Written documentation identifying a participant's progress toward goals defined in their service plan.(7-1-26)
13.Qualified Intellectual Disabilities Professional (QIDP). As described in 42 CFR 483.430(a).
14.Quality Improvement Organization (QIO). An organization that performs utilization and quality control review of health care furnished to Medicare and Medicaid participants.(7-1-26)
15.Recoupment. As detailed in IDAPA 16.05.07.(7-1-26)
16.Recreational Services. Activities and goods that are generally perceived as recreation such as, but not limited to, fishing, hunting, camping, attendance or participation in sporting events or practices, attendance at concerts, fairs or rodeos, skiing, sightseeing, boating, bowling, swimming, and special day parties.(7-1-26)
17.Readiness Review. A review conducted by the Department to ensure that each FEA is prepared to enter into and comply with the requirements of the provider agreement and this chapter of rules.(7-1-26)
18.Referral. A documented recommendation from a healthcare professional to see another Medicaid provider for a specific service.(7-1-26)
19.Related Entity. An organization associated or affiliated to a significant extent, or has control of, or is controlled by, that furnishes the services, facilities, or supplies for the provider.(7-1-26)
20.Restrictive Intervention. Any intervention used to restrict rights or freedom of movement and includes chemical, mechanical, and physical restraints, or seclusion.(7-1-26)
21.Retrospective Review. A review of an item or service after it has been provided. The review determines medical necessity and conformity to Medicaid requirements. Claims that have already received payment may be subject to recoupment.(7-1-26)
22.Rural Hospital-Based Behavioral Care Unit. A Rural Hospital-Based Provider that qualifies as a behavioral care unit.(7-1-26)
23.Service Coordination. Case m anagement activity to assist participants with gaining and coordinating access to necessary care and services appropriate to their needs.(7-1-26)
24.Service Plan. An initial or annual plan that identifies all services and supports based on a personcentered planning process and authorized by the Department.(7-1-26)
25.Skilled Nursing Care. Level of care for patients requiring twenty-four (24) hour skilled nursing services.(7-1-26)
26.Supervision. Procedural guidance by a qualified person and initial direction and periodic inspection of the actual act, at the site of service delivery.(7-1-26)
27.Support and Spending Plan (SSP). A document that functions as a participant’s plan of care when the participant is eligible for and has chosen a CDCS option. This document identifies the goods, services, and supports selected by a participant, including those available outside of Medicaid-funded services that can help the participant meet desired goals, and the cost of each one. The participant uses this document to manage their individualized budget.(7-1-26)
28.Support Broker (SB). An individual who advocates on behalf of the participant and who is hired by the participant to provide SB services.(7-1-26)
29.Supports. Services provided for a participant, or a person who provides a support service. A support service may be a paid service provided by a CSW, or an unpaid service provided by a natural support, such as a family member, a friend, neighbor, or other volunteer.(7-1-26)
30.Third Party. Includes a person, institution, corporation, or public or private agency that is liable to pay all or part of the medical cost of injury, disease, or disability of a participant.(7-1-26)
31.Traditional Adult DD Waiver Services. A program option for participants eligible for the Adult DD Waiver consisting of specific Medicaid Enhanced Plan Benefits.(7-1-26)
32.Traditional Children's HCBS State Plan Option Services. A program option for children eligible for the Children's HCBS State Plan Option consisting of specific Medicaid Enhanced Plan Benefits. (7-1-26)
33.Utilization Control (UC). Program of prepayment screening and annual review by the Department determining the appropriateness of and the need for continued medical entitlement of applicants or participants in a NF.(7-1-26)
34.Utilization Control Team (UCT). Team of Regional nurse reviewers that conducts on-site reviews of the care and services in NFs approved by the Department as Medicaid providers.(7-1-26)
35.Vocational Services. Services directly related to the preparation for paid or unpaid employment.
Vocational services are provided with the expectation a participant will participate in a work services program or the general workforce within a year.(7-1-26)
IDAPA 16.03.26.008 (Reserved)
GENERAL PARTICIPANT PROVISIONS
(Sections 010-019)
IDAPA 16.03.26.010 Medical Assistance Procedures
The Department will issue a card to eligible participants wh ich will contain their name and Medicaid identification number. When requested, the Department will give providers eligibility information regarding participants. (7-1-26)
IDAPA 16.03.26.011 Choice of Providers
Participants may obtain services available from any parti cipating provider of their choice, unless enrolled in a Managed Care Organization, Prepaid Ambulatory Health Plan, or Prepaid Inpatient Health Plan that limits provider choice, or a lock-in program. This does not prohibit the Department from setting standards relating to the qualifications of providers.(7-1-26)
IDAPA 16.03.26.012 Participant Responsibility
Participants are responsible for keeping appointments with providers . The Department will not reimburse providers when participants do not attend appointments. Providers cannot bill participants for missed appointments.(7-1-26)
IDAPA 16.03.26.013 (Reserved)
GENERAL PROVIDER PROVISIONS
(Sections 020-039)
IDAPA 16.03.26.020 Individual Provider Requirements
01.Provider Eligibility. Be licensed or registered as required by the applicable jurisdiction for the profession, have a National Provider Identification (NPI) or Medicaid provider number, and enter into a written provider agreement with the Department.(7-1-26)
02.Practice Authority. Provide services within the practice authority for the applicable profession consistent with the laws and regulations of the state where services are provided.(7-1-26)
03.Standard of Care. Provide services within the accepted standard of care that would be provided in the same or similar setting by a reasonable and prudent provider with similar education, training, and experience as determined by the applicable oversight authority.(7-1-26)
04.Express Exclusions. Not perform any service that is expressly prohibited by state or federal regulations. Further, no reimbursement will be provided for any service that is expressly excluded for a provider in these rules.(7-1-26)
IDAPA 16.03.26.021 Provider Application Process
01.Application.
Providers who meet Medicaid enrollment requirements may apply for provider status with the Department. All providers eligible for an NPI must apply with that number. For providers not eligible for an NPI, the Department will assign a provider number upon approval of the application.(7-1-26)
02.Disclosure of Information. All enrolling providers and any additional disclosable party must comply with the disclosure requirements in 42 CFR Part 455, Subpart B, “Disclosure of Information by Providers and Fiscal Agents.”(7-1-26)
03.Denial of Provider Agreement. The Department may refuse a request to enter into a provider agreement, extend an existing agreement, or enter into additional agreements with any provider. Requests for a provider agreement are denied when:(7-1-26)
a.The provider fails to meet the qualifications required by rule or by any applicable licensing board.
b.The provider was a managing employee, or had an ownership interest, in any entity and: (7-1-26)
i.Previously found by the Department to have engaged in fraudulent or abusive conduct related to the Medicaid program; or(7-1-26)
ii.Demonstrated an inability to comply with the requirements related to the provider status for which application is made, including submitting false claims or violating provisions of any provider agreement;(7-1-26)
c.Failed to repay the Department for any overpayments or improper claims, whether the failure resulted from refusal, bankruptcy, or otherwise, unless prohibited by law.(7-1-26)
d.The provider employs as a managing employee, contracts for any management services, shares any ownership interests, or would be considered a related party to any individual or entity identified in this section.
e.The provider is currently suspended or terminated from Medicare or Medicaid in any state.
IDAPA 16.03.26.022 Provider Agreements
This section applies to all providers including Family-Directed Community Supports (FDCS).(7-1-26)
01.General. All individuals or entities must enter into a written provider agreement accepted by the Department prior to receipt of any reimbursement for services. Agreements may contain any terms or conditions deemed appropriate by the Department. All provider agreements must be signed by an authorized representative who has the legal authority to bind the provider in the agreement.(7-1-26)
02.Enforcement Actions and Terminations. The Department may take any of the following actions for cause based on the conduct of the provider, or its employees or agents, or when the provider fails to comply with the provider agreement, or any applicable state or federal regulation:(7-1-26)
a.Require corrective actions in IDAPA 16.05.07;(7-1-26)
b.Require a corrective action plan to be submitted by the provider to address noncompliance with requirements;(7-1-26)
c.Reduce, limit, or suspend payment of claims pending the submission, acceptance, or completion of a corrective action plan;(7-1-26)
d.Limit or suspend provision of services to participants who have not previously established services with the provider pending the submission, acceptance, or completion of a corrective action plan; or(7-1-26)
e.Terminate the provider’s agreement.(7-1-26)
i.The Department may terminate provider agreements with or without cause by giving written notice to the provider as set forth in the agreement.(7-1-26)
ii.Terminations without cause may result from elimination or change of programs or requirements, or the provider's inability to continue providing services due to the actions of another agency or board. Terminations without cause are not subject to contested case proceedings since the action will either affect a class of providers or will result from the discretionary act of another regulatory body. If an agreement does not provide a notice period, the period is twenty-eight (28) days.(7-1-26)
iii.Terminations for cause may be appealed.(7-1-26)
03.Crossover Only Providers. Providers of professional services may enroll as crossover only providers that bill for dual eligible participants’ Medicare coinsurance and deductible. Crossover only providers act as non-billing ORPs for all other participants.(7-1-26)
04.Non-billing Ordering, Referring, and Prescribing (ORP). Providers may enroll as non-billing ORPs, provided they follow the provider application process and sign a provider agreement. Non-billing ORPs are not eligible for reimbursement and are otherwise not Medicaid providers.(7-1-26)
IDAPA 16.03.26.023 (Reserved)
IDAPA 16.03.26.025 Conditions for Payment
01.Participant Eligibility.
The Department will reimburse providers for medically necessary services when a complete and properly submitted claim for payment has been received and each of the following conditions are met:(7-1-26)
a.The participant received services no earlier than the third month before an application was made on the participant's behalf;(7-1-26)
b.The provider verified the participant’s eligibility on the date of service and can provide proof of the eligibility verification;(7-1-26)
c.Services provided after the participant’s date of death cannot be reimbursed; and(7-1-26)
d.Not more than twelve (12) months have elapsed since the latest participant services for which such payment is being made. Medicare cross-over claims are excluded from the twelve (12) month submittal limitation.
When a participant is determined retroactively eligible, the Department will reimburse providers for services within the period of retroactive eligibility, if a claim is submitted within twelve (12) months of the participant’s eligibility determination.(7-1-26)
02.Comply With All Applicable Regulations.(7-1-26)
03.Comply With the Idaho Medicaid Provider Handbook.(7-1-26)
04.Acceptance of State Payment. Providers agree to accept as payment in full the amounts paid by the Department for covered services. Participants cannot be billed for covered services. Providers may only bill participants for non-covered services when the participant is notified in writing before the service is provided that it is non-covered and its cost.(7-1-26)
05.Medical Care Provided Outside the State of Idaho. Out-of-state medical care is subject to the same utilization review and other Medicaid coverage requirements and restrictions as medical care received within the state of Idaho.(7-1-26)
06.Ordering, Referring, and Prescribing Providers (ORP). Any service ordered, prescribed, or referred by a provider who is not an enrolled Medicaid provider will not be reimbursed by the Department. (7-1-26)
07.Referrals. Medicaid services may require a referral. Services requiring a referral are listed in the Idaho Medicaid Provider Handbook. Services provided without a required referral, are not covered and are subject to sanctions and recoupment.(7-1-26)
08.Prior Authorization (PA). The Department may require a PA for any service. Unless otherwise specified:(7-1-26)
a.Medicaid payment will be denied for the medical item or service or portions thereof that were provided prior to the submission of a valid PA request. An exception may be allowed on a case-by-case basis, when events beyond the provider's control prevented the request’s submission.(7-1-26)
b.The provider cannot bill the Medicaid participant for non-covered services solely because the authorization was not requested or obtained in a timely manner.(7-1-26)
c.An item or service will be deemed prior approved when the participant was not eligible for Medicaid when the service was provided, but was subsequently determined eligible under Medicaid eligibility rules, and the medical item or service provided is authorized by the Department.(7-1-26)
d.A Notice of Decision approving or denying a requested item will be issued to the participant by the Departm ent. The participant has twenty-eight (28) days from the date of the denial to request a fair hearing on the decision.(7-1-26)
09.Follow-up Communication. Medicaid services may require timely follow-up communication with the participant's PCP provider as listed in the Idaho Medicaid Provider Handbook. Services provided without timely communication are not covered and subject to sanctions and recoupment.(7-1-26)
IDAPA 16.03.26.026 Third-Party Liability
01.Determining Liability. The Department will take reasonable measures to determine liability of third parties for services rendered to a participant.(7-1-26)
02.Current Resource. The Department will treat any third-party liability as a current resource when payment by the third-party has been made or will be made within a reasonable time.(7-1-26)
03.Withholding Payment. The Department will not withhold payment because of the liability of a third party when liability cannot be currently established or available to pay the participant's medical expense.
04.Seeking Third-Party Reimbursement. The Department will seek reimbursement from a third party when liability existed, but was not treated as a current resource, with the exceptions provided under this rule.
The Department will seek reimbursement from a participant in any situation in which the participant has received direct payment from any third-party and not forwarded the money to the Department for services received. (7-1-26)
05.Billing Third Parties First. Medicaid providers must bill all other sources of direct third-party payment, with the following exceptions:(7-1-26)
a.When the resource is a court-ordered absent parent and there are no other viable resources available, the claims will be reimbursed, and the resources billed by the Department;(7-1-26)
b.Preventive pediatric care including early and periodic screening, diagnostic, and treatment services which includes:(7-1-26)
i.Well Child examinations for children under age twenty-one (21) years when provided according to guidance in the Idaho Medicaid Provider Handbook;(7-1-26)
ii.Diagnosis services to identify the nature of an illness or other problem by examination of the symptoms.(7-1-26)
c.When PA has been approved under these rules, treatment services to control, correct, or ameliorate health problems found through diagnosis and screenings;(7-1-26)
d.If the claim is for preventative pediatric care under this rule, the Department will make payment for the service provided in its fee schedule and will seek reimbursement from the third party under 42 U.S.C. 1396a(a)(25)(E).(7-1-26)
06.Accident Determination. When the participant's Medicaid card indicates private insurance or when the diagnosis indicates an accident for which private insurance is often carried, the claim will be suspended or denied until third party liability determination can occur.(7-1-26)
07.Third-Party Payments. The Department will pay the provider the lowest amount of the following:
a.The provider’s actual charge for the service;(7-1-26)
b.The maximum allowable charge for the service as established by the Department in its pricing file; or(7-1-26)
c.The third-party allowed amount minus the third-party payment, or the patient liability as indicated by the third-party.(
08.Subrogation of Third-Party Liability. In all cases where the Department will be required to pay for a participant who is entitled to recover any medical expenses from any third party, the Department will be subrogated to the rights of the participant to the extent of the amount of Medicaid benefits paid by the Department.
a.If litigation or a settlement in such a claim is pursued by the Medicaid participant, the participant must notify the Department.(7-1-26)
b.If the participant recovers funds from a third party, the participant must repay the amount of benefits paid by the Department.(7-1-26)
09.Subrogation of Legal Fees.(7-1-26)
a.If a participant incurs the obligation to pay attorney fees and court costs for the purpose of enforcing a monetary claim to which the Department is subrogated, the amount which the Department is entitled to recover, or any lesser amount which the Department may agree to accept, will be reduced by the total amount of attorney fees and court costs paid by the participant.(7-1-26)
b.If a settlement or judgment is received by the participant that does not specify which portion is for payment of medical expenses, it will be presumed that the settlement or judgment applies first to the medical expenses in an amount equal to that paid by the Department.(7-1-26)
IDAPA 16.03.26.027 (Reserved)
IDAPA 16.03.26.030 General Payment Procedures
01.Provided Services.
a.Providers must obtain the required information from the Electronic Verification System (EVS) by using the Medicaid number on the identification card from the EVS and transfer the required information onto the appropriate claim form.(7-1-26)
b.Upon providing the care and services to a participant, the provider or their agent must submit a properly completed claim to the Department including their usual and customary charge, which is the lowest charge by the provider to the general public for the same service including advertised specials. Each claim submitted by a provider constitutes an agreement to accept and abide by the Department’s requirements.(7-1-26)
c.The Department is to process each claim received and make payment directly to the provider.
d.The Department will not supply claim forms. Form examples needed to comply with the Department's unique billing requirements are included in the Idaho Medicaid Provider Handbook.(7-1-26)
02.Provider Reimbursement.(7-1-26)
a.The Department will pay the provider the lowest of:(7-1-26)
i.The provider's actual charge for service; or(7-1-26)
ii.The maximum allowable charge for the service as established by the Department on its pricing file and Idaho Medicaid Provider Handbook; or(7-1-26)
iii.The Medicaid-allowed amount minus the Medicare payment or the Medicare co-insurance and deductible amounts added together when a participant has both Medicare and Medicaid.(7-1-26)
b.Services and items without a Medicare price on file are priced for the maximum allowable charge at the Department’s discretion per the following:(7-1-26)
i.Historical cost or regional reimbursement data.(7-1-26)
ii.Percent of charge.(7-1-26)
iii.A copy of the manufacturer’s suggested retail pricing (MSRP) or an invoice or quote from the manufacturer or wholesaler. Reimbursement will be seventy-five percent (75%) of MSRP or quote. If the pricing documentation is an invoice for items, reimbursement will be at cost plus ten percent (10%), plus shipping. (7-1-26)
vi.An invoice with the usual and customary charges of the provider, and documentation in the form of operation reports, chart notes or medical records.(7-1-26)
v.HCBS are priced in accordance with approved service criteria.(7-1-26)
03.Services Normally Billed Directly to the Patient. If a provider bills services directly to patients, the provider must submit a claim form to the Department for reimbursement.(7-1-26)
04.Other Noninstitutional Services. The Department will reimburse for noninstitutional services unless otherwise specified.(7-1-26)
05.Cost Reporting. Providers subject to filing a Medicaid cost report must use the Department designated reporting forms, unless the Department approves an exception. Requests to use alternate forms must be sent to the Department in writing, with samples attached, ninety (90) days prior to the report due date. Requests are not a reason for late filing.(7-1-26)
06.For Providers Subject to Retrospective Cost Settlement. Following receipt of a finalized Medicare cost report and timely receipt of other requested information to fairly cost settle with a provider, the Department sends a certified letter with return receipt requested to the provider setting forth the underpayment or overpayment amounts made to the provider. The notice of results of a final retroactive adjustment are sent even when a provider intends to appeal or has appealed the Medicare Intermediary's determination of cost settlement. When the determination shows that a provider owes Medicaid because total interim and other payments exceeded cost limits, the state takes the necessary action to recover overpayments, including suspending interim payments sixty (60) days after the provider receives the notice. Recovery or suspension actions continue even after the state receives a request for an informal conference or hearing is filed with the state. If the hearing results in a revised determination, appropriate adjustments are made to the settlement amount.(7-1-26)
a.The Department makes every effort to issue a notice of program reimbursement within twelve (12) months of receiving a cost report.(7-1-26)
b.A Medicaid completed cost settlement may be reopened by a provider or the state within a three (3) year period from the date of the notice of program reimbursement. The issues must have been raised, appealed, and resolved by reopening the Medicare Intermediary’s cost report. Issues previously addressed and resolved by the state’s appeal process are not cause to reopen a finalized cost settlement.(7-1-26)
07.Procedures for Medicare Cross-Over Claims.(7-1-26)
a.If a Medicaid participant is eligible for Medicare, the provider must first bill Medicare for the services before billing the Department.(7-1-26)
b.If a provider accepts a Medicare assignment, the Department will forward payment to the provider automatically based upon the Medicare Summary Notice (MSN) that is received from the Medicare Part B Carrier. c.
If a provider does not accept a Medicare assignment, an MSN mus t be submitted with a claim to the
d.For all other services, an MSN must be submitted to the Department with a claim.(7-1-26)
e.The Department will pay the provider for the services up to the Medicaid allowable amount minus the Medicare payment.(7-1-26)
08.Appeals Process. Reimbursement for services originally denied by the Department will be made if such decision is reversed by the appeals process.(7-1-26)
IDAPA 16.03.26.031 Handling of Overpayments and Underpayments for Specified Providers
This section of rule applies only to providers that are retrospectively cost settl
ed.(7-1-26)
01.Interest Charges. Medicaid charges interest on overpayments, and pays interest on underpayments, as follows:(7-1-26)
a.If full repayment from an indebted party is not received within sixty (60) days after the provider received the Department reimbursement notice, interest accrues from the receipt date and is charged on any unpaid settlement balance for each thirty (30)-day period of delayed payment. Periods of less than thirty (30) days are treated as a full thirty (30)-day period, and the full interest charge is applied to any unpaid balance. Each payment is applied first to accrued interest, then to the principal. Interest accrued on overpayments and interest on funds borrowed by a provider to repay overpayments are not allowable interest expenses.(7-1-26)
b.When the Department determines an overpayment exists, it may waive interest charges if the administrative costs to collect exceeds the charges.(7-1-26)
c.The interest rate on overpayments and underpayments is compounded monthly.(7-1-26)
d.Balance and interest are retroactively adjusted to equal the amounts that would have been due based on any changes that occurred due to results of a final determination in an administrative or judicial appeals process. Interest penalties only apply to unpaid amounts and are subordinated to final interest determinations made in a judicial review process.(7-1-26)
02.Recovery Methods. One (1) of the following will be used for recovery of overpayments: (7-1-26)
a.Upon receiving a notice of program reimbursement, a provider voluntarily refunds, in a lump sum, the entire overpayment to the Department.(7-1-26)
b.The provider may:(7-1-26)
i.Request in writing to make overpayment recovery over a period of twelve (12) months or less; and
ii.Submit documentation demonstrating that their financial integrity would be irreparably compromised if repayments occurred over a shorter time period.(7-1-26)
c.If a provider does not respond to the program reimbursement notice within thirty (30) days of receipt, the Department initiates recovery of the entire unpaid balance in addition to accrued interest.(7-1-26)
IDAPA 16.03.26.032 (Reserved)
IDAPA 16.03.26.035 Records
Providers must maintain records in sufficient detail to allow the Department to audit for compliance, medical necessity , quality assurance, and determination of payment methodology. The Department, the U.S. Department of Health and Human Services, and the Bureau of Compliance have the right to review pertinent records of providers and related entities receiving Medicaid reimbursement. These reviews may be conducted for audit purposes outside of processes in IDAPA 16.05.07.(7-1-26)
- Provider Refusal. Refusal of a provider to permit the Department to review records pertinent to Medicaid will constitute grounds for:(7-1-26)
a.Withholding payments until access to the requested information is granted;(7-1-26)
b.Recoupment of payments; or(7-1-26)
c.Suspending the provider.(7-1-26)
02.Undocumented Services. Undocumented services are subject to recoupment.(7-1-26)
03.Availability of Records. Records must be available for audit, with or without prior notice, during any working day and regular business hours at the provider’s principal place of business.(7-1-26)
04.Retention of Records. Providers will retain records required under this rule for a period of five (5) years from the date of final payment under the provider agreement. Failure to retain records for the required period can void the Department’s obligation to pay for services.(7-1-26)
IDAPA 16.03.26.036 (Reserved)
GENERAL REIMBURSEMENT PROVISIONS FOR INSTITUTIONAL PROVIDERS
(Sections 040-049)
IDAPA 16.03.26.040 Documentation for Audits
01.Expenditure Documentation. Must i nclude the amount, date, purpose, payee, and the invoice or other verifiable evidence supporting an expenditure.(7-1-26)
02.Cost Allocation Process. Include depreciation or amortization of assets and indirect expenses allocated to activities or functions based on the original identity of the costs. Documentation to support basis for allocation must be available for verification. The assets referred to in this Section of rule are economic resources of the provider recognized and measured in conformity with GAAP.(7-1-26)
03.Revenue Documentation. Must include the amount, date, purpose, and source of revenue.
04.Additional Documentation.(7-1-26)
a.Providers are given an opportunity to provide documentation before an interim final audit report is issued.(7-1-26)
b.Providers are not allowed to submit additional documentation in support of cost items after issuance of the interim final audit report.(7-1-26)
IDAPA 16.03.26.041 (Reserved)
IDAPA 16.03.26.045 Related Party Transactions
01.Principle.
Allowability of costs applicable to services, facilities, and supplies furnished by entities related to the provider is subject to the regulations in 42 CFR 413.17, et al., and PRM.(7-1-26)
02.Determination of Common Ownership or Control. A provider organization is related to a supplying organization as defined under 42 CFR 413.17. If the elements of common ownership or control are not present in both organizations, the organizations are deemed unrelated.(7-1-26)
03.Cost to Related Organizations. The charges to a provider from related organizations may not exceed the billing to the related organization for these services.(7-1-26)
04.Costs Not Related to Patient Care. All home office costs not related to patient care are not allowed.(7-1-26)
05.Interest Expense. Interest expense on loans between related entities is not reimbursable under Chapters 2, 10, and 12, PRM.(7-1-26)
06.Exception. An exception to the general principle applicable to related organizations applies if the provider demonstrates they meet the requirements in 42 CFR 413.17(d). The exception is not applicable to sales, lease or rentals of hospitals, which do not meet the requirement that there be an open, competitive market for the facilities furnished under the PRM.(7-1-26)
a.Rental expense for transactions between related entities will not be recognized. Costs of ownership will be allowed.(7-1-26)
b.When a facility is purchased from a related entity, the purchaser's depreciable basis must not exceed the seller's net book value under the PRM.(7-1-26)
IDAPA 16.03.26.046 (Reserved)
IDAPA 16.03.26.047 Long-Term Care Facility Payment
Long-term care facilities are reimbursed the lower of their customary charges, their actual reasonable costs, adjusted by a BAF for NFs, or the standard costs for their class as set forth under the PRM. Upper payment limits must not exceed payments determined as reasonable costs under Medicare standards and principles.(7-1-26)
IDAPA 16.03.26.048 (Reserved)
SPECIFIC PROVIDER REIMBURSEMENT
(Sections 050-059)
IDAPA 16.03.26.050 Nf and Icf/Iid Reimbursement
01.Reasonable Cost Principles.
To be allowable, costs must be reasonable, ordinary, necessary, and related to patient care. Providers are expected to incur costs in such a manner that economical and efficient delivery of quality health care to participants results.(7-1-26)
02.Application of Reasonable Cost Principles. Reasonable costs of any services are determined under this rule and the PRM, as modified by exceptions contained herein, and used to identify cost items included on Idaho's Uniform Cost Report.(7-1-26)
a.Reasonable costs account for both direct and indirect costs of provider services, including normal standby costs.(7-1-26)
b.Costs may vary from one (1) facility to another due to a variety of factors. Medicaid intends to reimburse providers for the actual operating costs of providing high quality care, unless such costs exceed the applicable maximum base rate developed under provisions of Title 56, Idaho Code, or unallowable by application of promulgated regulation.(7-1-26)
c.The expectation of reasonable actual operating costs is that providers seek to minimize costs and that actual operating costs do not exceed what a prudent and cost-conscious buyer pays for a given item or service.
d.The Department does not pay for costs determined to exceed a level that buyers incur in the absence of clear evidence that higher costs were unavoidable.(7-1-26)
e.Form and substance of transactions prevails over the form. Financial transactions are disallowed to the extent that the substance of a transaction fails to meet reasonable cost principles or comply with rules and policy.
03.Home Office Cost Principles. Reasonable cost principles extend to home office costs allocated to individual providers. In addition, the home office, through a provider, provides documentation on the basis used to allocate costs among the various entities it administers or directs.(7-1-26)
04.Application of Related Party Transactions.(7-1-26)
a.Charges to a provider from related organizations may not exceed the billing to a related organization for these services.(7-1-26)
b.All home office costs unrelated to patient care are not allowable.(7-1-26)
05.Compensation to Relatives. Payment for relatives of owners or administrators is allowed only for actual services performed, when necessary, adequately documented, and reasonable.(7-1-26)
a.Compensation billed to the Department must be included in compensation reported for tax purposes and actually paid.(7-1-26)
i.When services are performed without pay, no cost may be reported.(7-1-26)
ii.Time records documenting actual hours worked are required for compensation to allow for reimbursement.(7-1-26)
iii.Compensation for undocumented work hours is not reimbursable.(7-1-26)
b.Related persons are defined as these relationships with a provider:(7-1-26)
i.Spouse;(7-1-26)
ii.Child or a descendant of a child;(7-1-26)
iii.Siblings, stepsiblings, or descendant thereof;(7-1-26)
iv.Parent, stepparent, siblings thereof, and their ancestors;(7-1-26)
v.Related by marriage;(7-1-26)
vi.Any other person without an arm’s length relationship.(7-1-26)
06.Idaho Owner-Administrative Compensation. Allowable compensation to owners and related persons providing any administrative services is based on bed count and limited to a set amount adjusted annually based upon changes in average hourly earnings in nursing and personal care facilities as published by a nationally recognized forecasting firm.(7-1-26)
a.Allowable compensation for providing administrative services is determined by:(7-1-26)
i.All licensed beds in every facility administrative services are provided.(7-1-26)
ii.More than fifty (50) beds being restricted to an upper limit for compensation based on bed count.
iii.Less than fifty-one (51) beds being reimbursed at an allowable hourly rate. Non-administrative services are allowable at the reasonable market rate. Hours for each service type is documented. In no event will the total compensation for administrative and non-administrative duties exceed the limit applicable for the same amount for providing administrative services to facilities with fifty-one (51) or more beds.(7-1-26)
b.Compensation for persons related to an owner is evaluated in the same manner as for an owner.
c.When an owner provides services to more than one facility, compensation is distributed on the same basis as costs allocated for non-owners.(7-1-26)
d.For more than one (1) owner or related party to receive compensation, services must be actually performed, documented, and necessary. Total compensation must be reasonable, and no greater than an amount for which the same services could be obtained on the open market. Standard full-time compensation is measured as two thousand eighty (2,080) hours. Compensation of an owner or relative of an owner will not exceed the compensation determined from the Administrative Compensation Schedule, and, when paid on an hourly basis, will not exceed compensation determined by the Administrative Compensation Schedule divided by two thousand eighty (2,080.)
07.Filing Dates.(7-1-26)
a.Deadlines for annual cost reports are the last day of the third month following a fiscal year end or the deadline imposed by Medicare for providers required to file Medicare cost reports.(7-1-26)
b.Waivers to delay filing by thirty (30) days may be granted for annual cost reports in unusual circumstances. Requests for waivers and reasons must be submitted prior to the deadline. A written decision is rendered within ten (10) days.(7-1-26)
08.Failure to File. Late reports result in reductions to the interim rate. Failure to file required cost reports, including required supplemental information, unless a waiver is granted, results in a reduction of ten percent (10%) of the provider's rate(s) the first day of the month following a deadline date. Continued failure to comply results in complete payment suspension on the first day of the following month. When suspension or reduction occurs and a provider filed the required cost reports, amounts accruing to the provider during a suspension or reduction period are restored. Loss of license or certification results in immediate termination of reimbursement, full scope audit, and settlement for the cost period.(7-1-26)
09.Accounting System. Providers must file reports using the accrual basis and conform with GAAP or within provisions of the specified guidelines. Recorded transactions must be capable of verification by Departmental audit.(7-1-26)
10.Audits.(7-1-26)
a.All financial reports are subject to audit to:(7-1-26)
i.Determine that transactions recorded in the books of record are substantially accurate and reliable as a basis to determine reasonable costs.(7-1-26)
ii.Determine that facility internal controls are sufficiently reliable to disclose the results of a provider's operations.(7-1-26)
iii.Determine that Medicaid participants received the required care based on economy and efficiency.
iv.Determine that GAAP is applied on a consistent basis in conformance with applicable federal and state regulations.(7-1-26)
v.Ensure policies and practices sufficiently meet fiduciary responsibilities for patients, funds, and property.(7-1-26)
vi.Effect final settlement when required.(7-1-26)
b.Normally, all annual statements are audited within the following year.(7-1-26)
c.Other statements and some annual audit recommendations are subject to limited scope audits evaluating provider compliance.(7-1-26)
d.Add itional audits are required for:(7-1-26)
i.Significant changes of ownership.(7-1-26)
ii.Changes in management.(7-1-26)
iii.When an overpayment of twenty-five percent (25%) or more resulted in a completed cost period.
e.Annual field audits are by appointment. Auditors identify themselves with a letter of authorization or Department I.D. cards.(7-1-26)
11.Audit Standards and Requirements.(7-1-26)
a.Before making any program payments to a prospective provider, the intermediary reviews a provider's accounting system and its capability of generating accurate statistical cost data. When a provider's record keeping capability fails to meet program requirements, the intermediary offers limited consultative services or suggests revisions of a provider's system to enable compliance.(7-1-26)
b.Examination of records and documents includes:(7-1-26)
i.Corporate charters or other ownership documents including those for parent or related companies and attachments describing property.(7-1-26)
ii.Minutes and memos of governing bodies, including committees and its agents.(7-1-26)
iii.All contracts.(7-1-26)
iv.Tax returns and records, including workpapers and other supporting documentation.(7-1-26)
v.All insurance contracts and policies including riders and attachments.(7-1-26)
vi.Leases.(7-1-26)
vii.Fixed asset records (see Capitalization of Assets).(7-1-26) viii.Schedules of patient charges.(7-1-26)
ix.Notes, bonds, and other evidence of liabilities.(7-1-26)
x.Capital expenditure records.(7-1-26)
xi.Bank statements, canceled checks, deposit slips, and bank reconciliations.(7-1-26)
xii.Evidence of litigations involving a facility or its owners.(7-1-26) xiii.All invoices, statements, and claims.(7-1-26)
xiv.Financial audit work papers prepared by any accounting firm a provider engages with are considered the provider’s property and must be available to the intermediary upon request, under PRM, Subparagraph 2404.4(Q).(7-1-26)
xv.Ledgers, journals, all working papers, subsidiary ledgers, records, and documents relating to financial operation.(7-1-26)
xvi.All patient records, including trust funds and property.(7-1-26) xvii.Time studies and other cost determining information.(7-1-26) xviii.All other sources of information needed to form an audit opinion.(7-1-26)
c.Adequate cost information developed by a provider must be current, accurate, and sufficient detail to support payments made for services rendered. This includes all ledgers, books, records, and original cost evidence including purchase requisitions, purchase orders, vouchers, requisitions for material, inventories, timecards, payrolls, bases for apportioning costs, and other documentation pertaining to determination of reasonable cost, capable of being audited under PRM, Section 2304.(7-1-26)
d.Adequate expense documentation includes invoices or statements with invoices attached supporting the statement and must include:(7-1-26)
i.Service or sale date;(7-1-26)
ii.Terms and discounts;(7-1-26)
iii.Quantity;(7-1-26)
iv.Price;(7-1-26)
v.Vendor name and address;(7-1-26)
vi.Delivery address if applicable;(7-1-26)
vii.Contract or agreement references; and(7-1-26) viii.Description including quantities, sizes, specifications, and brand names of services performed.
e.Minor movable equipment is not capitalized. The cost of fixed assets and major movable equipment is capitalized and depreciated over the estimated useful life of an asset under PRM, Section 108.1. This rule applies except for the provisions of PRM, Section 106 for small tools.(7-1-26)
f.Completed depreciation records must include the following for each asset:(7-1-26)
i.Description of the asset including serial number, make, model, accessories, and location. (7-1-26)
ii.Cost basis supported by invoices for purchase, installation, etc.(7-1-26)
iii.Estimated useful life.(7-1-26)
iv.Depreciation method (straight line, double declining balance, etc.).(7-1-26)
v.Salvage value.(7-1-26)
vi.Method of recording depreciation consistent with GAAP.(7-1-26)
vii.Additional information, such as additional first year depreciation, even when not an allowable expense.(7-1-26) viii.Reported depreciation expense for the year and accumulated depreciation tied to the asset ledger.
g.Depreciation methods are always acceptable. Methods of accelerated depreciation are only acceptable upon authorization by the Office of Audit or its successor organization. Additional first year depreciation is not allowable.(7-1-26)
h.An asset’s depreciable life may not be shorter than the useful life stated in the publication, Estimated Useful Lives of Depreciable Hospital Assets, Guidelines. Deviation from these guidelines is allowable only upon Department authorization.(7-1-26)
i.Lease purchase agreements are generally recognized by any the following characteristics: (7-1-26)
i.Lessee assumes normal ownership costs, such as taxes, maintenance, etc.;(7-1-26)
ii.Intent to create security interest;(7-1-26)
iii.Lessee acquires title by exercising a purchase option that requires little or no additional payment or, additional payments substantially less than the fair market value at purchase date;(7-1-26)
iv.Non-cancelable or cancelable only upon occurrence of a remote contingency; and(7-1-26)
v.Initial loan term significantly less than the useful life and lessee has the option to renew at a rental price substantially less than fair rental value.(7-1-26)
j.Assets acquired under such agreements are viewed as contractual purchases and treated accordingly. Normal costs of ownership such as depreciation, taxes, and maintenance are allowable. Rental or lease payments are not reimbursable.(7-1-26)
k.Complete personnel records including:(7-1-26)
i.Employment applications.(7-1-26)
ii.W-4 Forms.(7-1-26)
iii.Authorizations for any deductions such as insurance, credit union, etc.(7-1-26)
iv.Routine evaluations.(7-1-26)
v.Pay raise authorizations.(7-1-26)
vi.Statements of understanding of policies, procedures, etc.(7-1-26)
vii.Fidelity bond applications (when applicable).(7-1-26)
l.A system of internal control intended to provide a method of handling all routine and nonroutine tasks related to:(7-1-26)
i.Safeguarding assets and resources against waste, fraud, and inefficiency.(7-1-26)
ii.Promoting accuracy and reliability in financial records.(7-1-26)
iii.Encouraging and measuring compliance with company policy and legal requirements.(7-1-26)
iv.Determining the degree of efficiency related to various aspects of operations.(7-1-26)
m.An adequate system of internal control over cash disbursements including:(7-1-26)
i.Payment on invoices only, or statements supported by invoices.(7-1-26)
ii.Authorizations for purchase; a purchase order.(7-1-26)
iii.Verification of quantity received, description, terms, price, conditions, specifications, etc. (7-1-26)
iv.Verification of freight charges, discounts, credit memos, allowances, and returns.(7-1-26)
v.Check of invoice accuracy.(7-1-26)
vi.Invoice approval policy.(7-1-26)
vii.Method of invoice cancellation to prevent duplicating payment.(7-1-26) viii.Adequate separation of duties between ordering, recording, and paying.(7-1-26)
ix.System separation of duties between ordering, recording, and paying.(7-1-26)
x.Signature policy.(7-1-26)
xi.Pre-numbered checks.(7-1-26)
xii.Statement of policy regarding cash or check expenditures.(7-1-26) xiii.Adequate internal control over recording transactions in the books of record.(7-1-26)
xiv.An imprest system for petty cash.(7-1-26)
n.Sound accounting practices including:(7-1-26)
i.Documentation of accounting policies and procedures, including capitalization, depreciation, and expenditure classification criteria.(7-1-26)
ii.Chart of accounts.(7-1-26)
iii.Budget or operating plans.(7-1-26)
12.Patient Funds. The safekeeping of Medicaid patient funds is the responsibility of the provider.
Administration of these funds requires scrupulous care when recording all patient transactions.(7-1-26)
a.Funds provided for a patient’s personal needs are used at the patient's discretion. Providers agree to manage these funds and render an accounting of funds but may not use them in any way.(7-1-26)
b.Providers are subject to legal and financial liabilities for committing any of the following acts and any other acts contrary to federal regulations:(7-1-26)
i.Management fees are not charged to manage patient trust funds and constitute double payment as normally performed by a facility employee whose salary is included in reasonable cost reimbursement.(7-1-26)
ii.Nothing is to be deducted from these funds, unless deductions are authorized by the patient or their agent in writing.(7-1-26)
iii.Interest accruing to patient funds on deposit is the patient’s property and part of their personal funds. Interest from these funds is not available to the provider for any use, including patient benefits.(7-1-26)
c.Fund Management. Proper management includes the following at a minimum:(7-1-26)
i.Savings accounts, maintained separately from facility funds.(7-1-26)
ii.An accurate system of supporting receipts and disbursements to patients.(7-1-26)
iii.Written authorization for all deductions.(7-1-26)
iv.Signature verification.(7-1-26)
v.Deposit of all receipts on the same day received.(7-1-26)
vi.Minimal funds kept in a facility.(7-1-26)
vii.All funds must always be locked.(7-1-26) viii.Policy statement regarding patient's funds and property.(7-1-26)
ix.Periodic review of all policies with staff in training sessions and with all new employees upon employment.(7-1-26)
x.System of periodic review and correction of policies and financial records for patient property and funds.(7-1-26)
13.Legal Consultant Fees and Litigation Costs. When these costs are incurred by a provider, they are handled as follows:(7-1-26)
a.Legal consultant fees unrelated to preparation for or appealing of a Department audit, or costs incurred by a provider in an action unrelated to litigation with the Department are allowed as part of total per diem costs the Medicaid Program reimburses according to the percentage of Medicaid patient days.(7-1-26)
b.Costs of the provider’s legal counsel when appealing findings of a Department audit are reimbursed by Medicaid only to the extent a provider prevails on the issues involved. Determination of the extent a provider prevails is based on the ratio of the total dollars at issue for an audit period under appeal to the total dollars ultimately awarded to a provider for that audit period.(7-1-26)
c.All other litigation costs incurred by a provider for actions against the Department are not directly or indirectly reimbursable by Medicaid, unless court ordered.(7-1-26)
IDAPA 16.03.26.051 Reserved
IDAPA 16.03.26.053 Accounting Treatment
GAAP, concepts, and definitions are used unless otherwise specified. When alternative treatments are available under GAAP, the acceptable treatment is the one that most clearly attains program objectives.(7-1-26)
01.Final Payment. Final payment is made based on the reasonable cost of services as determined by audit under these rules.(7-1-26)
02.Overpayments. Recovery of overpayments is attempted as quickly as possible consistent with the financial integrity of the provider resulting in two (2) circumstances:(7-1-26)
a.For unfiled cost reports, all payments included in the recovery period and any subsequent payments are due.(7-1-26)
b.Excessive reimbursement or non-covered services may precipitate immediate audit and settlement for the periods in question. When such a determination is made, the interim reimbursement rate (IRR) is reduced.
This reduction is designated to discontinue overpayments (on an interim basis) or recover overpayments.(7-1-26)
IDAPA 16.03.26.054 Specialized Reimbursement: Electronic Visit Verification (evv)
01.Services Requiring EVV.
a.Home Health.(7-1-26)
b.State Plan PCS.(7-1-26)
c.Attendant Care, Homemaker and Respite under the A&D Waiver.(7-1-26)
02.EVV Requirements. Providers must:(7-1-26)
a.Select and maintain an EVV system and certified as compliant with the Department’s MMIS aggregator;(7-1-26)
b.Retain documented participant consent for the provider’s EVV methods;(7-1-26)
c.Develop and maintain policies and procedures for use of EVV technology, including strategies for safeguarding participant data and privacy; and(7-1-26)
d.Submit EVV data capturing six (6) system-validated data elements for services rendered: (7-1-26)
ii.Service start and end times;(7-1-26)
iii.Direct service provider;(7-1-26)
iv.Recipient of service;(7-1-26)
v.Billable service; and(7-1-26)
vi.Service delivery location.(7-1-26)
e.Submit EVV data to the State’s aggregator prior to billing claims.(7-1-26)
IDAPA 16.03.26.055 Exception to the Related Organization Principle
An exception is provided to the general rule applicable to related organizations if a provider demonstrates by convincing evidence to the satisfaction of an intermediary:(7-1-26)
01.Supplying Organization. Is a bona fide separate organization;(7-1-26)
02.Non-Exclusive Relationship. A substantial part of the supplying organization’s business activity type carried on with the provider is transacted with other organizations not related to the provider and the supplier by common ownership or control in an open, competitive market.(7-1-26)
03.Sales and Rental of Extended Care Facilities. The exception is not applicable to sales, leases, or rentals of NFs or extended care facilities and do not meet the requirement that there be an open, competitive market for the facilities furnished.(7-1-26)
a.Rental expense for transactions between related entities is not recognized. Costs of ownership are allowed.(7-1-26)
b.When a facility is purchased from a related entity, the purchaser's depreciable basis will not exceed the seller's net book value.(7-1-26)
IDAPA 16.03.26.056 (Reserved)
EXCLUDED SERVICES
(Sections 060-069)
IDAPA 16.03.26.060 Services, Treatments, and Procedures Not Covered by Medicaid
01.Service Categories Not Covered.
The following service categories are not covered for payment by Medicaid except as otherwise specified:(7-1-26)
a.Acupuncture services;(7-1-26)
b.Naturopathic services;(7-1-26)
c.Bio-feedback therapy;(7-1-26)
d.Group hydrotherapy;(7-1-26)
e.Fertility-related services, including testing;(7-1-26)
f.Vocational services except for supported employment services;(7-1-26)
g.Educational services;(7-1-26)
h.Recreational services;(7-1-26)
i.Duplicative services;(7-1-26)
j.Housing except when approved for a medical institution; and(7-1-26)
k.Food, except when medically necessary or the home-delivered meals benefit.(7-1-26)
02.Types of Treatments and Procedures Not Covered. The costs of provider and hospital services for the following types of treatments and procedures are not covered for payment by Medicaid:(7-1-26)
a.Elective medical and surgical treatment, except for family planning services, without Departmental approval. Procedures that are generally accepted by the medical community and are medically necessary may not require prior approval and may be eligible for payment;(7-1-26)
b.Services for convenience, comfort, or cosmetic reasons except when allowed elsewhere in rule.
Hospice services, and reconstructive surgery that has prior approval by the Department are covered benefits; (7-1-26)
c.Laetrile therapy;(7-1-26)
d.New procedures of unproven value and established procedures of questionable current usefulness as identified by the Public Health Service and that are excluded by the Medicare program or major commercial carriers;(7-1-26)
e.Drugs supplied to patients for self-administration other than those allowed under these rules;
f.The treatment of complications, consequences, or repair of any medical procedure where the original procedure was not covered by Medicaid, unless the resultant condition is life-threatening as determined by the Department;(7-1-26)
g.Medical transportation costs incurred for travel to medical facilities for the purpose of receiving a noncovered medical service;(7-1-26)
h.Surgical procedures on the cornea for myopia; or(7-1-26)
i.Services as detailed in Section 56-273, Idaho Code.(7-1-26)
03.Experimental Treatments or Procedures. Experimental treatments and procedures, and the costs for all follow-up medical treatment directly associated with such a procedure are not covered. Treatments and procedures are deemed experimental under the following circumstances:(7-1-26)
a.The treatment or procedure is in Phase I clinical trials;(7-1-26)
b.There is inadequate available clinical data to provide a reasonable expectation that the trial treatment or procedure will be at least as effective as non-investigational therapy; or(7-1-26)
c.Expert opinion suggests that additional information is needed to assess the safety or efficacy of the proposed treatment or procedure.(7-1-26)
IDAPA 16.03.26.061 Investigational Procedures or Treatments
The Department may cover investigational procedures or treatments on a case-by-case basis for life-threatening conditions when no other treatment options are available. For these cases, a focused case review is completed by the Department. The Department will determine coverage based on this review.(7-1-26)
01.Focused Case Review. A focused case review consists of assessment of:(7-1-26)
a.Health benefit to the participant;(7-1-26)
b.Risk to the participant;(7-1-26)
c.Standard treatment for the participant’s condition, including alternative treatments;(7-1-26)
d.Specific inclusion or exclusion by Medicare national coverage guidelines;(7-1-26)
e.Phase of the clinical trial of the proposed procedure or treatment;(7-1-26)
f.Guidance regarding the proposed procedure or treatment by national organizations;(7-1-26)
g.Pertinent clinical data and peer-reviewed literature; and(7-1-26)
h.Ethics Committee review, if appropriate.(7-1-26)
02.Additional Clinical Information. If there is insufficient information from the focused case review to render a coverage decision, the Department may seek an independent professional opinion.(7-1-26)
IDAPA 16.03.26.062 (Reserved)
MEDICAID BASIC PLAN COVERED SERVICES
(Sections 070-449)
SUB AREA: HOSPITAL SERVICES
(Sections 070-089)
IDAPA 16.03.26.070 Hospital Services: Definitions
01.Administratively Necessary Day (AND).
An Administratively Necessary Day (AND) is covered for an orderly transfer or discharge of participant inpatients who are no longer in need of a continued acute level of care. ANDs may be authorized for inpatients who are awaiting placement for NF level of care, or in-home services that are not available, or when catastrophic events prevent the scheduled discharge of an inpatient.(7-1-26)
02.All-Patient Refined Diagnosis Related Group (APR-DRG). A payment methodology outlined in the Medicaid Provider Agreement.(7-1-26)
03.Allowable Costs. The current year's Medicaid apportionment of a hospital's allowable costs determined at final or interim settlement if cost settlements are applicable or determined using the version of the cost report used for prospective payment system (PPS) rate setting, consist of those costs permitted by the principles of reimbursement contained in the PRM and do not include costs already having payment limited by Medicaid rate file or any other Medicaid charge limitation.(7-1-26)
04.Capital Costs. For the purposes of hospital reimbursement, capital costs are those allowable costs considered in the settlement that represent the cost to each hospital for its reasonable property related and financing expense, and property taxes.(7-1-26)
05.Charity Care. Charity care is care provided to individuals who have no source of payment, thirdparty or personal resources.(7-1-26)
06.Critical Access Hospitals (CAH). A rural hospital as set forth in 42 CFR Section 485.620.
07.Current Year. Any hospital cost reporting period for which reasonable cost is being determined will be termed the current year.(7-1-26)
08.Inpatient Customary Hospital Charges. Customary inpatient hospital charges reflect the regular rates for inpatient services charged to patient(s) liable for payment for their services on a charge basis. Implicit in the use of charges as the basis for comparability (or for apportionment under certain apportionment methods) is the objective that services are related to the cost of services billed to the Department.(7-1-26)
a.All in-state providers not described in b. through d. below will be paid a final prospective payment rate using the APR-DRG classification system as described in these rules.(7-1-26)
b.Idaho state-owned hospitals and the Department of Veteran’s Affairs Medical Center will be reimbursed at one hundred percent (100%) of allowable cost using a retrospective cost settlement upon receipt of a final Medicare cost report.(7-1-26)
c.In-state and those out-of-state within thirty-five (35) miles of the Idaho border, CAHs will be reimbursed at one hundred one percent (101%) of allowable cost using a retrospective cost settlement upon receipt of a final Medicare cost report.(7-1-26)
d.All out-of-state providers not described in a. through c. above will be paid a final prospective payment rate with no retrospective cost settlement using the APR-DRG classification system as described in these rules. The out-of-state APR-DRG rates were developed to provide a combined cost coverage of eighty-seven percent (87%) when all out-of-state providers are averaged together in keeping with Section 56-265(6)(b), Idaho Code.
09.Outpatient Services Customary Hospital Charges. Customary outpatient hospital charges reflect the regular rates for outpatient services charged to patient(s) liable for payment for their services on a charge basis.
Implicit in the use of charges as the basis for comparability (or for apportionment under certain apportionment methods) is the objective that services be related to the cost of services billed to the Department.(7-1-26)
a.Idaho state-owned hospitals and the Department of Veteran’s Affairs Medical Center will be reimbursed at one hundred percent (100%) of allowable cost.(7-1-26)
b.In-state and those out-of-state within thirty-five (35) miles of the Idaho border, CAHs will be reimbursed at one hundred one percent (101%) of allowable cost.(7-1-26) c.
All hospitals that are not described in a. through b. above will be subject to the outpatient rei mbursement parameters outlined in the Medicaid Provider Agreement and Section 56-265, Idaho Code.(7-1-26)
10.Disproportionate Share Hospital (DSH) Allotment Amount. The DSH allotment amount determined by CMS that is eligible for federal matching funds in any federal fiscal period for disproportionate share payments.(7-1-26)
11.Disproportionate Share Hospital (DSH) Survey. The DSH survey is an annual data request from the Department to the hospitals to obtain the information necessary to compute DSH payments.(7-1-26)
12.Disproportionate Share Threshold. The disproportionate share threshold is:(7-1-26)
a.The arithmetic mean plus one (1) standard deviation of the Medicaid Utilization Rates of all Idaho Hospitals; or(7-1-26)
b.A Low-Income Revenue Rate exceeding twenty-five percent (25%).(7-1-26)
13.Hospital Inflation Index. An index calculated through Department studies and used to adjust inpatient operating cost limits and interim rates for the current year.(7-1-26)
14.Low-Income Revenue Rate. The Low-Income Revenue Rate is the sum of the following fractions, expressed as a percentage, calculated as follows:(7-1-26)
a.Total Medicaid inpatient and outpatient revenues paid to the hospital, plus the amount of the cash subsidies received directly from state and local governments in a cost reporting period, divided by the total amount of revenues and cash subsidies of the hospital in the same cost reporting period; plus(7-1-26)
b.The total amount of the hospital's charges for inpatient hospital services attributable to charity care in the same cost reporting period, divided by the total amount of the hospital's charges for inpatient services in the hospital in the same period. The total inpatient charges attributed to charity care must not include contractual allowances and discounts and reduction in charges given to Medicare, Medicaid, other third-party payors, or cash for patient services received directly from state and local governments’ county assistance programs.(7-1-26)
15.Medicaid Inpatient Day. For purposes of DSH payments, an inpatient day is defined as a Medicaid inpatient day in a hospital for which there is also no Medicare inpatient day counted.(7-1-26)
16.Medicaid Utilization Rate (MUR). The MUR for each hospital will be computed using the Department's record of paid inpatient days for the fiscal year divided by the total inpatient days for the same fiscal year as reported in the DSH survey. Inpatient days includes ANDs, newborn days, days in specialized wards, days provided at an inappropriate level of care, and Medicaid inpatient days from other states.(7-1-26)
17.Obstetricians. For purposes of an adjustment for hospitals serving a disproportionate share of lowincome patients, and in the case of a hospital located in a rural area, as defined by the federal Executive Office of Management and Budget, the term “obstetrician” includes any physician with staff privileges at the hospital to perform nonemergency obstetric procedures.(7-1-26)
18.On-Site. A service location over which the hospital exercises financial and administrative control.
“Financial and administrative control” means a location whose relation to budgeting, cost reporting, staffing, policymaking, record keeping, business licensure, goodwill and decision-making are so interrelated to those of the hospital that the hospital has ultimate financial and administrative control over the service location. The service location must be near the hospital where it is based, and both facilities serve the same patient population (e.g., from the same area, or catchment, within Medicare's defined Metropolitan Statistical Area (MSA) for urban hospitals or thirty-five (35) miles from a rural hospital).(7-1-26)
19.Reasonable Costs. Reasonable costs include all necessary and ordinary costs incurred in rendering the services related to patient care that a prudent and cost-conscious hospital would pay for a given item or service.
20.Uninsured Patient Costs. Fo r the purposes of determining the additional costs beyond uncompensated Medicaid costs that may be reimbursed as a DSH payment without exceeding the state Allotment Amount, both inpatient and outpatient costs of uninsured patients will be considered.(7-1-26)
21.Upper Payment Limit. The Upper Payment Limit for hospital services is defined in the Code of Federal Regulations.(7-1-26)
IDAPA 16.03.26.071 Inpatient Hospital Services: Coverage and Limitations
The policy, rules, and regulations to be follow ed are 42 CFR 456.50 through 42 CFR 456.145.(7-1-26)
01.Initial Length of Stay. PA requirement for an initial length of stay will be established by the Department in the Idaho Medicaid Provider Handbook for hospitals not reimbursed under DRG methodologies.
02.Extended Stay. The Department will establish authorization requirements in the Idaho Medicaid Provider Handbook for hospitals not reimbursed under DRG methodologies. An authorization is necessary when the appropriate care of the participant indicates the need for hospital days more than the initial length of stay, or previously approved extended stay.(7-1-26)
03.Exceptions and Limitations. The following exceptions and limitations apply to in-patient hospital services for hospitals not reimbursed under DRG methodologies:(7-1-26)
a.Payment for accommodations is limited to the hospital's all-inclusive rate. The all-inclusive rate is a flat fee charge incurred daily that covers both room and board.(7-1-26)
b.The Department will not authorize reimbursement above the all-inclusive rate unless the attending provider orders a room that is not an all-inclusive rate room because of medical necessity.(7-1-26)
04.Diagnosis Related Group (DRG) Review and Audits. All services performed under DRG are subject to QIO reviews, retrospective reviews, and audits. The Department reserves the right to execute reviews as described in the Idaho Medicaid Provider Handbook as amended.(7-1-26)
IDAPA 16.03.26.072 Inpatient Hospital Services: Procedural Requirements
01.Certification of Medical Necessity.
At the time of admission, the physician must certify that inpatient services are necessary. Recertification must occur at least every sixty (60) days inpatient hospital services are required but may be required more frequently as determined by the Department.(7-1-26)
02.Individual Plan of Care. The individual plan of care is a written plan developed for the participant upon admission to a hospital and updated at least every sixty (60) days but may be required more frequently as determined by the Department. Requirements are defined in the Idaho Medicaid Provider Handbook.(7-1-26)
03.Request for Extended Stay. To qualify for reimbursement, authorization must be obtained from the Department. The request should be made before the initial length of stay or previously authorized extended stay ends and submitted as designated by the Department. Documentation for the request should include the most recent plan of care. The Department will set additional documentation requirements in the Idaho Medicaid Provider Handbook to ensure quality of care and integrity of services.(7-1-26)
IDAPA 16.03.26.073 Inpatient Hospital Services: Provider Qualifications and Duties
Only a Medicare certified hospital, licens ed by the state in which it operates, may enroll in the Idaho Medicaid program. Hospitals not participating as a Medicaid swing-bed provider, which are licensed for long-term care or as a specialty hospital that provides a nursing home level of care, will be reimbursed as a NF. Hospitals not eligible for enrollment which render emergency care will be paid rates established in these rules.(7-1-26)
IDAPA 16.03.26.074 Hospital Services: Provider Reimbursement
The upper payment limits observed by the Department in reimbursing each individual hospital must not exceed the payment that would be determined as a reasonable cost under the policies, definitions and procedures observed under Medicare principles of cost reimbursement.(7-1-26)
01.Payment Procedures. The following procedures are applicable to in-patient hospitals:(7-1-26)
a.The participant's admission and length of stay may be subject concurrent review, continued stay review, and retrospective review by a Quality Improvement Organization (QIO) designated by the Department. QIO review will be governed by provisions of the QIO Idaho Medicaid Provider Manual as amended. Failure to obtain a timely QIO review as required by these rules, and as outlined in the QIO Idaho Medicaid Provider Manual as amended, will result in the QIO conducting a late review.(7-1-26)
b.In reimbursing hospitals, the Department will pay the lesser of customary hospital charges or Medicaid reimbursement for in-patient hospital care as set forth in this rule, unless an exception applies. The upper limits for payment must not exceed the payment that would be determined as reasonable cost using Medicare standards and principles.(7-1-26)
02.Administratively Necessary Days (AND) Reimbursement Rate. Reimbursement for an AND will be made at the weighted average Medicaid payment rate for all Idaho NFs for routine services, as defined per 42 CFR 447.280(a)(1), furnished during the previous calendar year.(7-1-26)
a.The AND reimbursement rate will be calculated by the Department of each calendar year and made effective retroactively for dates of service on or after January 1 of the respective calendar year.(7-1-26)
b.Hospitals with an attached NF will be reimbursed the lesser of their Medicaid per diem routine rate or the established average rate for an AND; and(7-1-26)
c.The Department will pay the lesser of the established AND rate or a facility's customary hospital charge to private pay patients for an AND.(7-1-26)
03.Hospital Swing-Bed Reimbursement. The Department will pay for NF care in certain rural hospitals for participants in licensed hospital swing-beds who require NF level of care.(7-1-26)
a.Routine services include all medical care, supplies, and services that are included in the calculation of NF property and non-property costs as described in these rules. Reimbursement of ancillary services will be determined in the same manner as hospital outpatient reasonable costs in accordance with Medicare reasonable cost principles, except prescription drugs will be reimbursed under these rules.(7-1-26)
b.The Department will reimburse hospitals for participants under the following conditions: (7-1-26)
i.The participant is determined to be entitled to such services in accordance with IDAPA 16.03.05;
ii.The participant is authorized for payment of long-term care.(7-1-26)
c.The Department will reimburse swing-bed hospitals on a per diem basis utilizing a rate established as follows:(7-1-26)
i.Payment rates for routine NF services will be at the weighted average Medicaid rate per patient day paid to hospital-based NF for routine services furnished during the previous calendar year.(7-1-26)
ii.The rate will be calculated by the Department of each calendar year. The rate will be based on the previous calendar year and effective retroactively for dates of service on or after January 1 of the respective year.
iii.The weighted average rate for NF swing-bed days will be calculated by dividing total payments for routine services, including patient contribution amounts but excluding miscellaneous financial transactions relating to prior years, by total patient days for each respective level of care occurring in the previous calendar year.(7-1-26)
iv.Routine services include all medical care, supplies, and services that are included in the calculation of NF property and nonproperty costs.(7-1-26)
v.Reimbursement of ancillary services not included in the NF rates furnished for extended care services will be billed and determined in the same manner as hospital outpatient reasonable costs in accordance with Medicare reasonable cost principles, except that reimbursement for prescription drugs under these rules.(7-1-26)
04.Adjustment for Disproportionate Share Hospitals (DSH). All Idaho hospitals serving a disproportionate share of low-income patients must qualify either as a Mandatory DSH or as Deemed DSH to receive a DSH payment. The Department will send each hospital a DSH survey on or before January 31 of each calendar year. A hospital will not receive a DSH payment if the survey is not returned by the deadline, unless good cause is determined by the Department.(7-1-26)
a.Mandatory Eligibility for DSH status will be provided for hospitals that:(7-1-26)
i.Meet or exceed the disproportionate share threshold under these rules.(7-1-26)
ii.Have at least two (2) obstetricians with staff privileges at the hospital who have agreed to provide obstetric services.(7-1-26)
(1)This subsection does not apply to a hospital in which the inpatients are predominantly individuals under eighteen (18) years of age; or(7-1-26)
(2)Does not offer nonemergency inpatient obstetric services.(7-1-26)
iii.The MUR will not be less than one percent (1%).(7-1-26)
iv.If an Idaho hospital exceeds both disproportionate share thresholds and other mandatory eligibility is met, the payment adjustment will be the greater amount calculated using the methods of this rule except when less than one and one-half (1 1/2) standard deviations above the mean of all Idaho hospitals.(7-1-26)
v.Hospitals qualifying for Mandatory DSH eligibility with Medicaid Inpatient Utilization Rates equal to or exceeding one (1) standard deviation and less than one and one-half (1 1/2) standard deviations above the mean of all Idaho hospitals will receive a DSH payment equal to two percent (2%) of the payments related to the Medicaid inpatient days included in the MUR computation.(7-1-26)
vi.Hospitals qualifying for Mandatory DSH eligibility with Medicaid Inpatient Utilization Rates:
(1)Equal to or exceeding one and one-half (1 1/2) standard deviations and less than two (2) standard deviations of the mean of all Idaho hospitals will receive a DSH payment equal to four percent (4%) of the payments related to the Medicaid inpatient days included in the MUR computation.(7-1-26)
(2)Exceeding two (2) standard deviations of the mean of all Idaho hospitals will receive a DSH payment equal to six percent (6%) of the payments related to the Medicaid inpatient days included in the MUR computation.(7-1-26)
vii.Hospitals qualifying for Mandatory DSH eligibility with Low Income Utilization Rates equal to or exceeding:(7-1-26)
(1)Twenty-five percent (25%) will receive a DSH payment equal to four percent (4%) of the payments related to the Medicaid inpatient days included in the MUR computation.(7-1-26)
(2)Thirty percent (30%) will receive a DSH payment equal to six percent (6%) of the payments related to the Medicaid inpatient days included in the MUR computation.(7-1-26)
b.All hospitals in Idaho that have inpatient utilization rates of at least one percent (1%) only in Idaho inpatient days and meet the requirements unrelated to patient day utilization specified in this subsection will be designated a DSH Hospital. The disproportionate share payment to a Deemed DSH hospital will be the greater of:
i.Five dollars ($5) per Idaho Medicaid inpatient day included in the hospital's MUR computation; or
ii.An amount per Medicaid inpatient day used in the hospital's MUR computation that equals the DSH allotment amount, less the Mandatory DSH payment amount, divided by the number of Medicaid inpatient days used in the MUR computation for all Idaho DSH hospitals.(7-1-26)
c.When the DSH allotment amount is insufficient to make the aggregate amount of DSH payments to each DSH hospital, payments to each hospital will be reduced by the percentage by which the DSH allotment amount was exceeded.(7-1-26)
d.A DSH payment will not exceed the costs incurred during the year of furnishing services to individuals who are either eligible for medical assistance under the State Plan or were uninsured for health care services provided during the year.(7-1-26)
i.Payments made to a hospital for services provided to indigent patients by a state or a unit of local government within a state will not be considered a source of third-party payment.(7-1-26)
ii.Claims of uninsured costs that increase the maximum amount that a hospital may receive as a DSH payment must be documented.(7-1-26)
e.DSH Will be Calculated on an Annual Basis. A change in a provider's allowable costs as a result of a reopening or appeal will not result in the recomputation of the provider's annual DSH payment.(7-1-26)
f.To the extent that audit findings demonstrate that DSH payments exceed the documented hospital specific cost limits, the Department will collect overpayments and redistribute DSH payments.(7-1-26)
i.If at any time during an audit the Department discovers evidence suggesting fraud or abuse by a provider, that evidence, in addition to the Department’s final audit report regarding that provider, will be referred to the Medicaid Fraud Unit of the Idaho Attorney General’s Office.(7-1-26)
ii.The Department will submit an independent certified audit to CMS for each completed Medicaid State plan rate year, consistent with 42 CFR Part 455, Subpart D, “Independent Certified Audit of State Disproportionate Share Hospital Payment Adjustments.”(7-1-26)
iii.If based on the audit of the DSH allotment distribution, the Department determines that there was an overpayment to a provider, the Department will immediately:(7-1-26)
(1)Recover the overpayment from the provider; and(7-1-26)
(2)Redistribute the amount in overpayment to providers that had not exceeded the hospital-specific upper payment limit during the period in which the DSH payments were determined. The payments will be subject to hospital-specific upper payment limits.(7-1-26)
iv.Disproportionate share payments must not exceed the DSH state allotment, except as otherwise required by the SSA. In no event is the Department obligated to use State Medicaid funds to pay more than the State Medicaid percentage of DSH payments due a provider.(7-1-26)
05.Out-of-State Hospitals. Hospitals will have a cost settlement computed with the state of Idaho if the following conditions are met:(7-1-26)
a.Total inpatient and outpatient covered charges are more than fifty thousand dollars ($50,000) in the fiscal year; or(7-1-26)
b.When less than fifty thousand dollars ($50,000) of covered charges are billed to the state by the provider, and a probable significant underpayment or overpayment is identifiable, and the amount makes it administratively economical and efficient for cost settlement to be requested by either the provider or the state, a cost settlement will be made between the hospital and the Department.(7-1-26)
06.Audit Function. Under a common audit agreement, the Medicare Intermediary may perform any audit required for both Medicare and Medicaid purposes. The Department may elect to perform an audit even though the Medicare Intermediary does not choose to audit the facility.(7-1-26)
07.Adequacy of Cost Information. Cost information as developed by the provider must be current, accurate, and in sufficient detail and in such form as needed to support payments made for services rendered to participants. This includes all ledgers, books, reports, records and original evidences of cost (purchase requisitions, purchase orders, vouchers, requisitions for materials, inventories, labor timecards, payrolls, bases for apportioning costs, etc.), which pertain to the determination of reasonable costs, leaving an audit trail capable of being audited.
Financial and statistical records will be maintained in a consistent manner from one (1) settlement period to another.
08.Interim Cost Settlements. The Department may initiate, or a hospital may request an interim cost settlement based on the Medicare cost report as submitted, for hospitals subject to cost settlement.(7-1-26)
a.Interim settlement cost report data will be adjusted to reflect Medicaid payments and statistical summary reports sent to providers before the filing deadline.(7-1-26)
b.The Department may limit a recovery or payment of an interim settlement amount up to twentyfive percent (25%) of the total settlement amount when the cost report information is in dispute.(7-1-26)
09.Non-Appealable Items. The formula for the determination of the hospital inflation index, the principles of reimbursement that define allowable cost, non-Medicaid program issues, interim rates that follow state and federal rules, and the preliminary adjustments prior to final cost settlement determinations as supported by properly completed cost reports and audits are not acceptable as appealable items.(7-1-26)
10.Interim Reimbursement Rates for Providers Subject to Cost Settlement. The interim reimbursement rates must be reasonable and adequate to meet the necessary costs that are incurred by economically and efficiently operated providers that provide services in conformity with applicable state and federal laws, rules, and quality and safety standards.(7-1-26)
a.Interim rates will be adjusted at least annually based on the best information available to the
b.Interim rates will not be adjusted retrospectively upon request for rate review by the provider.
c.The Department may make an adjustment based on the Medicare cost report as submitted and accepted by the Intermediary after the provider's reporting year to bring interim payments made during the period into agreement with the tentative reimbursable amount due the provider at final settlement. If the settlement amount is equal to or greater than ten percent (10%) of the payments received or paid and equal to or greater than one hundred thousand dollars ($100,000), the interim rate will be adjusted to account for half (½) of the difference.
IDAPA 16.03.26.075 Inpatient Hospital Services: Quality Assurance
The designated QIO must prepare, distribute, and maintain a provider manual that is periodically updated. The manual must include the following:(7-1-26)
01.QIO Information. The QIO's policies, criteria, standards, operating procedures, and forms for performing: preadmission monitoring, assessment reviews, continued stay requests, and requests for retroactive medical reviews.(7-1-26)
02.Department Provisions. Department-selected diagnoses and procedures in which a hospital will request preauthorization of an admission, transfer, or continuing stay.(7-1-26)
03.Approval Timeframe. A provision that the QIO will inform the hospital of a certification within five (5) days, or other time frame as determined by the Department, of an approved admission, transfer, or continuing stay.(7-1-26)
04.Method of Notice. The method of notice to hospitals of QIO denials for specific admissions, transfers, continuing stays, or services rendered in post-payment reviews.(7-1-26)
05.Procedural Information. The procedures that providers or participants will use to obtain reconsideration of a denial by the QIO prior to appeal to the Department. Such requests for reconsideration by the QIO must be made in writing to the QIO within one hundred eighty (180) days of the issuance of the “Notice of Non- Certification of Hospital Days.”(7-1-26)
IDAPA 16.03.26.076 (Reserved)
IDAPA 16.03.26.080 Outpatient Hospital Services: Definitions
Outpatient hospital services include preventive, diagnostic, therapeut ic, rehabilitative or palliative items, and services furnished by or under the direction of a provider not in need of inpatient hospital care, unless excluded by any other provisions of this chapter.(7-1-26)
IDAPA 16.03.26.081 (Reserved)
IDAPA 16.03.26.082 Outpatient Hospital Services: Coverage and Limitations
01.Services Are Provided On-Site.
02.Co-Payments.(7-1-26)
a.When an emergency room physician determines that an emergency condition does not exist, the hospital can require the participant to pay a co-payment.(7-1-26)
b.Services may be refused when determined an emergency condition does not exist, and the participant does not make the co-payment at the time of service. The hospital will provide notification to the participant per Section 1916A(e) of the SSA.(7-1-26)
IDAPA 16.03.26.083 Outpatient Hospital Services: Pr
OCEDURAL REQUIREMENTS.
01.Review Prior to Delivery. Fai lure to obtain a timely review from the Department prior to delivery of listed procedure and diagnosis codes in the QIO Idaho Medicaid Providers Manual and the Hospital Provider Handbook, as amended, will result in a retrospective review.(7-1-26)
02.Follow-Up for Emergency Room Patients. Hospitals must coordinate care of patients who have a PCP.(7-1-26)
IDAPA 16.03.26.084 (Reserved)
IDAPA 16.03.26.085 Outpatient Hospital Services: Provider Reimbursement
The Department will not pay more than the combined payments the provider is allowed to receive from the participants and carriers or intermediaries for providing comparable services under comparable circumstances under Medicare. Providers subject to cost settlement, outpatient hospital services identified below that are not listed in the Department's fee schedules will be reimbursed reasonable costs based on a year-end cost settlement. Maximum payment for hospital-based ambulance services, hospital outpatient diagnostic laboratory and partial care services will be limited to the Department's fee schedule.(7-1-26)
IDAPA 16.03.26.086 (Reserved)
SUB AREA: AMBULATORY SURGICAL CENTERS
(Sections 090-099)
IDAPA 16.03.26.090 (Reserved)
IDAPA 16.03.26.092 Ambulatory Surgical Center Services: Coverage and Limitations
Surgical procedures identified by the Medicare pro gram as appropriately and safely performed in an ASC will be reimbursed by the Department. The Department may add surgical procedures to the list developed by the Medicare program if the procedures meet the criteria in 42 CFR 416.166.(7-1-26)
IDAPA 16.03.26.093 (Reserved)
IDAPA 16.03.26.094 Ambulatory Surgical Center Services: Provider Qualifications and
DUTIES.
The ASC must be surveyed as required by 42 CFR 416.25 through 416.52 and be approved by the U.S. Department of Health and Human Services for participation as a Medicare ASC provider.(7-1-26)
IDAPA 16.03.26.095 Ambulatory Surgical Center Ser
VICES: PROVIDER REIMBURSEMENT.
ASC services reimbursement is packaged for use of facilities and necessary supplies as recognized by the Medicare program under 42 CFR, Part 416.164. The Department will establish a reimbursement rate for any covered procedure not covered by Medicare.(7-1-26)
IDAPA 16.03.26.096 (Reserved)
SUB AREA: CASE MANAGEMENT SERVICES
(Sections 100-109)
IDAPA 16.03.26.100 Case Management
01.Home Visiting Services. Ho me visiting provides for parents of vulnerable children to receive education and support on parenting topics.(7-1-26)
02.Community Re-entry Services. Community re-entry services provide targeted case management for eligible incarcerated participants.(7-1-26)
IDAPA 16.03.26.101 Case Management: Participant Eligibility
01.Home Visiting Services.
Participants under five (5) years of age and pregnant women at risk for abuse, neglect, or child welfare involvement. Additional requirements are in the Idaho Medicaid Provider Handbook.
02.Community Re-entry Services. Eligible participants are those incarcerated with an adjudicated case up to age twenty-one (21) for the general population and up to age twenty-six (26) for those formerly in foster
IDAPA 16.03.26.102 Case Management: Coverage and Limitations
01.Home Visiting Coverage.
a.Assessment for medical, educational, social, or other service needs;(7-1-26)
b.Development and revision of a plan to address goals;(7-1-26)
c.Referral and related activities for necessary services; and(7-1-26)
d.Monitoring of progress.(7-1-26)
e.Services do not include case management integral to another covered service or that constitutes direct delivery of referred services.(7-1-26)
02.Community Re-entry Services. Medicaid will reimburse for targeted case management services for eligible incarcerated participants thirty (30) days prior to, and thirty (30) days after, their release into the community. Services include transitioning back into the community by providing access to behavioral, educational, social, and other services.(7-1-26)
03.Duplication. Services do not include case management integral to another covered service or that constitutes direct delivery of referred services.(7-1-26)
IDAPA 16.03.26.103 (Reserved)
IDAPA 16.03.26.104 Case Management: Provider Qualifications and Duties
Home visiting services are provided by the Public Health Districts or their designee. Eligible providers are certified in an evidence-based model including either Parents as Teachers, or Nurse-Family Partnership.(7-1-26)
IDAPA 16.03.26.105 (Reserved)
SUB AREA: MEDICAL SERVICES
(Sections 110-119)
IDAPA 16.03.26.110 Medical Services
Medical services include the treatment o f medical and surgical conditions by licensed professionals subject to the limitations of practice imposed by state law, and to the restrictions and exclusions of coverage under these rules.
IDAPA 16.03.26.111 Medical Services: Participant Eligibility
The Department will fund abortions under circumstances where the abortion is necessary to save the life of the woman.(7-1-26)
IDAPA 16.03.26.112 Medical Services: Coverage and Limitations
01.Adult Physicals. Ad ult preventive physical examinations are limited to one (1) per year. (7-1-26)
02.Injectable Vitamins. Payment for allowable injectable vitamins will be allowed when supported by the diagnosis. Injectable vitamin therapy is limited to Vitamin B12 (and analogues), Vitamin K (and analogues), folic acid, and mixtures consisting of Vitamin B12, folic acid, and iron salts in any combination.(7-1-26)
03.Reconstructive Surgery. Reconstruction or restorative procedures include procedures that restore function of the affected or related body part(s). Covered procedures include breast reconstruction after mastectomy, or the repair of other injuries resulting from physical trauma.(7-1-26)
04.Screening Mammograms. Screening mammograms are covered when aligned with the “A” or “B” recommendations of the United States Preventative Services Task Force.(7-1-26)
05.Tonometry. Payment for tonometry is limited to one (1) examination or, when the examination to determine visual acuity is not done, two (2) tonometry examinations per twelve (12) month period are allowed for participants over the age of forty (40). This limitation does not apply to participants receiving continuing treatment for glaucoma.(7-1-26)
06.Weight Loss Surgical Procedures. Abdominoplasty or panniculectomy is covered when the surgery is prior authorized by the Department. The request for PA must include the following documentation:
a.Photographs of the front, side and underside of the abdomen;(7-1-26)
b.Treatment of any ulceration and skin infections involving the panniculus;(7-1-26)
c.Failure of conservative treatment, including weight loss;(7-1-26)
d.That the panniculus severely inhibits the participant's walking;(7-1-26)
e.That the participant is unable to wear a garment to hold the panniculus up; and(7-1-26)
f.Other detrimental effects of the panniculus on the participant's health such as severe arthritis in the lower body.(7-1-26)
IDAPA 16.03.26.113 Medical Services: Procedural Requirements
Abortion procedures require a licensed physician to certify in writing that the woman may die if the fetus is carried to term.(7-1-26)
IDAPA 16.03.26.114 Medical Services: Provider Qualifications and Duties
01.Locum Tenens Claims and Reciprocal Billing. Locum Tenens is allowed as detailed in the Idaho Medicaid Provider Handbook.(7-1-26)
02.Misrepresentation of Services. Any representation of a service provided by a provider other than a physician as a physician service is prohibited.(7-1-26)
03.Weight Loss Surgical Procedures. Physicians and hospitals performing surgical procedures must meet national medical standards for weight loss surgery.(7-1-26)
IDAPA 16.03.26.115 (Reserved)
IDAPA 16.03.26.119 Medical Services: Diagnostic Screening Clinics
The Department will reimburse medical social service visits to clinics that coordinate the treatment between providers for participants which are diagnosed with cerebral palsy, myelomeningitis or other neurological diseases and injuries with comparable outcomes.(7-1-26)
01.Multidisciplinary Assessments and Consultations. The clinic must perform on site multidisciplinary assessments and consultations with each participant and responsible parent or guardian. Diagnostic and consultive services related to the diagnosis and treatment of the participant will be provided by board certified provider specialists in physical medicine, neurology and orthopedics.(7-1-26)
02.Billings. No more than five (5) hours of medical social services may be billed each state fiscal year for which the medical social worker monitors and arranges treatments and provides medical information to providers coordinating their care.(7-1-26)
03.Provider Qualifications. The clinic will be a separate and distinct entity from the hospital or other provider practices.(7-1-26)
SUB AREA: OTHER PROVIDER SERVICES
(Sections 120-179)
IDAPA 16.03.26.120 Chiropractic Services: Definitions
Subluxation is partial or incomplete dislocation of the spine.(7-1-26)
IDAPA 16.03.26.121 (Reserved)
IDAPA 16.03.26.122 Chiropractic Services: Coverage and Limitations
Only treatment involving manipulation of the spine to correct a subluxation condition is covered.(7-1-26)
IDAPA 16.03.26.123 (Reserved)
IDAPA 16.03.26.131 Diabetes Education and Training Services: Participant Eligibility
Medical necessity for diabetes education and training are evidenced by the following:(7-1-26)
01.Participants with Diabetes. Are eligible for a Diabetes Management Program when:(7-1-26)
a.A recent diagnosis of diabetes within ninety (90) days of enrollment with no history of prior diabetes education; or(7-1-26)
b.Uncontrolled diabetes manifested by two (2) or more fasting blood sugar of greater than one hundred forty milligrams per decaliter (140 mg/dL), hemoglobin A1c greater than eight percent (8%), or random blood sugar greater than one hundred eighty milligrams per decaliter (180 mg/dL), in addition to the manifestations; or(7-1-26)
c.Recent manifestations from poor diabetes control including neuropathy, retinopathy, recurrent hypoglycemia, repeated infections, or nonhealing wounds.(7-1-26)
02.Participants with Pre-Diabetes. Are eligible for the National Diabetes Prevention Program when they meet the program’s guidance.(7-1-26)
IDAPA 16.03.26.132 Diabetes Education and Training Services: Coverage and Limitations
01.Concurrent Diagnosis. Only services that are reasonable and necessary will be covered. Covered professional and educational services will address each participant's medical needs through scheduled outpatient group or individual training or counseling concerning diet and nutrition, exercise, medications, home glucose monitoring, insulin administration, foot care, or the effects of other current illnesses and complications.(7-1-26)
02.No Substitutions. Providers may not use the formally structured program, or a Certified Diabetes Care and Education Specialist (CDCES), as a substitute for basic diabetic care and instruction, which includes the disease process and pathophysiology of diabetes mellitus, and dosage administration of oral hypoglycemic agents.
03.Services Limited. Diabetes education and training services will be limited to twenty-four (24) hours of group sessions and twelve (12) hours of individual counseling every five (5) calendar years.(7-1-26)
IDAPA 16.03.26.133 Diabetes Education and Training Services: Procedural Requirements
To receive diabetes counseling, the participant must have a written order and referral.(7-1-26)
IDAPA 16.03.26.134 Diabetes Education and Training Services: Provider Qualifications and
DUTIES.
01.Diabetes Management Program.
The education and training services are provided through a diabetes management program recognized as meeting the program standards of the American Diabetes Association or Association of Diabetes Care and Education Specialists by a CDCES, dietitian, or pharmacist.(7-1-26)
02.The National Diabetes Prevention Program. The provider meets the requirements for the
IDAPA 16.03.26.135 (Reserved)
IDAPA 16.03.26.140 Licensed Midwife (lm) Services
The Department will reimburse LMs for maternal and newborn services performed within the scope of their practice.
This section of rule does not include services provided by a nurse midwife.(7-1-26)
IDAPA 16.03.26.141 Lm Services: Participant Eligibility
LM services are available for participants in materni ty, or newborn participants.(7-1-26)
IDAPA 16.03.26.142 Lm Services: Coverage and Limitations
01.Maternity and Newborn.
Antepartum, intrapartum, and postpartum maternity and newborn care are covered. Maternal or newborn services provided after the postpartum period are not covered when provided by a Certified Professional Midwife.(7-1-26)
02.Medication. Covered medication listed in the LM formulary under IDAPA 24.26.01.(7-1-26)
IDAPA 16.03.26.143 (Reserved)
IDAPA 16.03.26.146 Lm Services: Provider Quality Assurance Activities
Each LM provider must maintain for Department review do cumentation of informed consent and practice data.
IDAPA 16.03.26.147 (Reserved)
IDAPA 16.03.26.150 Nutritional Services
Nutritional services include intensive nutritional education, counseling, and monitoring. The need for nutritional servi ces must be discovered by screening services and ordered by the provider.(7-1-26)
IDAPA 16.03.26.151 (Reserved)
IDAPA 16.03.26.162 Optometrist Services: Coverage and Limitations
The Department will pay for vision services for the diagnosis and treatment of injury or disease of the eye. (7-1-26)
IDAPA 16.03.26.163 (Reserved)
IDAPA 16.03.26.170 Podiatrist Services: Definitions
01.Acute Foot Conditions.
An acute foot condition means any condition that hinders normal function, threatens the individual, or complicates any disease.(7-1-26)
02.Chronic Foot Diseases. Chronic foot diseases include:(7-1-26)
a.Diabetes mellitus;(7-1-26)
b.Peripheral neuropathy involving the feet;(7-1-26)
c.Chronic thrombophlebitis;(7-1-26)
d.Peripheral vascular disease;(7-1-26)
e.Other chronic conditions that require regular podiatric care for the purpose of preventing recurrent wounds, pressure ulcers, or amputation; or(7-1-26)
f.Other conditions that have the potential to seriously or irreversibly compromise overall health.
IDAPA 16.03.26.171 Podiatrist Services: Participant Eligibility
Participants eligible for podiatrist services are those wit h a(n):(7-1-26)
01.Chronic Disease.(7-1-26)
02.Acute Condition. An acute condition that, if left untreated, may cause an adverse outcome to the participant’s health.(7-1-26)
IDAPA 16.03.26.172 Podiatrist Services: Coverage and Limitations
Coverage for podiatrist services is limited to preventive foot care services for chronic foot conditions and acute conditions that if left untreated will result in chronic damage to the participant’s foot.(7-1-26)
IDAPA 16.03.26.173 (Reserved)
SUB AREA: CHIS
(Sections 180-189)
IDAPA 16.03.26.180 Chis: Definitions
01.Assessment and Clinical Treatment Plan (ACTP).
A comprehensive assessment that guides the formation of the implementation plan(s) that include developmentally appropriate objectives and strategies related to identified needs.(7-1-26)
- Aversive Intervention. Uses unpleasant physical or sensory stimuli to reduce undesired behavior.
The stimuli usually cannot be avoided or is pain inducing.(7-1-26)
03.Community. Natural, integrated environments outside the participant’s home, outside of DDA center-based settings, or at school outside of school hours.(7-1-26)
04.Developmental Disabilities Agency (DDA).(7-1-26)
05.Duplicate Services.(7-1-26)
a.Goals are not separate and unique to each service provided; or(7-1-26)
b.When more than one (1) service is provided at the same time, unless otherwise authorized.(7-1-26)
06.Fidelity. The consistent and accurate implementation of children’s habilitation services in accordance with the modality, manual, protocol, or model.(7-1-26)
IDAPA 16.03.26.181 Chis: Eligibility Requirements
Participants are eligible from birth through the month of t heir twenty-first birthday. Participants must have a demonstrated functional need or a combination of functional and behavioral needs that require intervention services to correct or ameliorate their condition. A functional or behavioral need is determined by the Department approved screening tool when a deficit is identified in three (3) or more of the following areas: self-care; receptive and expressive language; learning; mobility; self-direction; capacity for independent living; economic self-sufficiency; or maladaptive behavior. A deficit is defined as one-point-five (1.5) or more standard deviations below the mean for functional areas or above the mean for maladaptive behavior.(7-1-26)
IDAPA 16.03.26.182 Chis: Coverage and Limitations
01.Service Delivery. CHIS may b e delivered in the community, the participant's home, or in a DDA.
Duplication of services is not reimbursable.(7-1-26)
02.Required Order. CHIS must be ordered by a provider within their scope of practice.(7-1-26)
a.CHIS providers cannot seek reimbursement for services provided more than thirty (30) calendar days prior to the signed and dated order.(7-1-26)
b.The order is only required to be completed once and must be received prior to submitting the initial PA request. If the participant has not accessed CHIS for more than three hundred sixty-five (365) calendar days, a new order is required.(7-1-26)
03.Required Screening. Needs are determined through the current version of the Departmentapproved screening tools. The tool is only required to be completed once and must be completed prior to submitting the initial PA request. New screenings are required for participants who have not accessed CHIS for more than three hundred sixty-five (365) calendar days.(7-1-26)
04.Services. All CHIS ordered on a participant's ACTP must be prior authorized by the Department.
Group services must be provided by one (1) qualified staff providing direct services for two (2) or three (3) participants. As the number and needs of the participants increase, the participant ratio in the group must be adjusted from three (3) to two (2). Group services will only be reimbursed when the participant's objectives relate to benefiting from group interaction. The following CHIS are reimbursable services when provided under these rules:(7-1-26)
a.Habilitative Skill Building utilizes direct intervention techniques to develop, improve, and maintain, to the maximum extent possible, the developmentally appropriate functional abilities and daily living skills needed by a participant. This service may include teaching and coordinating methods of training with family members or others who regularly participate in caring for the eligible participant. Services include individual or group interventions.(7-1-26)
b.Behavioral Intervention utilizes direct intervention techniques to produce positive meaningful changes in behavior that incorporate functional replacement behaviors and reinforcement-based strategies while also addressing any identified habilitative skill building needs or interfering behaviors. Intervention services may include teaching and coordinating methods of training with family members or others who regularly participate in caring for the participant. Services include individual or group interventions.(7-1-26)
c.Interdisciplinary Training is a companion service to behavioral intervention and habilitative skill building and assists with implementing a participant's health and medication monitoring, positioning and physical transferring, use of assistive equipment, and intervention techniques in a manner that meets the participant's needs.
This service is for collaboration, with the participant present, during the provision of services between the intervention specialist or professional and a provider.(7-1-26)
d.Crisis Intervention includes providing training to staff directly involved with the participant, delivering intervention directly with the eligible participant, and developing a crisis plan that directly addresses the behavior occurring and the necessary intervention strategies to minimize the behavior and future occurrences. Crisis intervention is provided in the home or community on a short-term basis not to exceed thirty (30) days. Positive behavior interventions must be used prior to, and in conjunction with, the implementation of any restrictive intervention. Crisis intervention is available for participants who have an unanticipated event, circumstance, or life situation that places a participant at risk of at least one (1) of the following:(7-1-26)
i.Hospitalization;(7-1-26)
ii.Out-of-home placement;(7-1-26)
iii.Incarceration; or(7-1-26)
iv.Physical harm to self or others, including a family altercation or psychiatric relapse.(7-1-26)
e.The ACTP must contain the following:(7-1-26)
i.Clinical interviews must be completed with the parent or legal guardian;(7-1-26)
ii.Objective and validated comprehensive skills or developmental assessment. The most current assessment must be used and be from within the last year;(7-1-26)
iii.Review of assessments, reports, and relevant history;(7-1-26)
iv.Observations in at least one (1) environment;(7-1-26)
v.Clinical summary and orders;(7-1-26)
vi.A transition plan; and(7-1-26)
vii.Be signed by the individual completing the assessment and the parent or legal guardian.(7-1-26)
f.Case Management is available to assist participants accessing CHIS by the Department as described in the Medicaid Provider Handbook.(7-1-26)
IDAPA 16.03.26.183 Chis: Procedural Requirements
All CHIS identified on a participant's ACTP must be prior authorized by the Department and maintained in each participant's file. CHIS providers are responsible for documenting and submitting the ACTP and obtain PA before delivering any CHIS.(7-1-26)
01.Prior Authorization (PA) Request. Must be submitted to the Department. The provider, and parent or legal guardian will be notified of the decision.(7-1-26)
a.Once the initial request for PA is submitted, CHIS may be delivered for a maximum of twenty-four (24) hours and up to thirty (30) calendar days or until the PA is approved.(7-1-26)
b.Initial PA requests must include:(7-1-26)
i.An order from a provider; and(7-1-26)
ii.The ACTP.(7-1-26)
c.Ongoing PA requests must include:(7-1-26)
i.A list of the participant's goals and objectives;(7-1-26)
ii.A written summary of data regarding progress or lack of progress to meeting each objective, including graphs showing change lines;(7-1-26)
iii.A list of all CHIS hours being requested and the qualification of the individual(s) who will provide them; and(7-1-26)
iv.An updated annual ACTP, if applicable.(7-1-26)
d.The following services may be requested retroactively:(7-1-26)
i.The initial ACTP;(7-1-26)
ii.The screening tool; and(7-1-26)
iii.Crisis intervention within seventy-two (72) hours of the service initiation.(7-1-26)
02.Implementation Plan(s). A qualified provider will complete and sign an implementation plan with details on how intervention will be implemented. All implementation plan objectives must be related to a need identified on the ACTP. The provider must document that a copy of the participant’s implementation plan(s) was offered to the participant’s parent or legal guardian. Any restrictive or aversive interventions being implemented must be reviewed and approved by a licensed or certified individual working within the scope of their practice.(7-1-26)
03.Documentation. For each participant, the following program documentation is required for each visit made or service provided:(7-1-26)
a.Date, time, and duration;(7-1-26)
b.Summary of session or service provided, and if interdisciplinary training is provided, who the service was delivered to, and the content covered;(7-1-26)
c.Data documentation that corresponds to the implementation plans for habilitative skill building or behavioral intervention;(7-1-26)
d.Location of service delivery; and(7-1-26)
e.Signature of the individual providing the service, date signed, and credential.(7-1-26)
04.Supervision. Supervision includes both face-to-face observation and direction to the staff regarding developmental and behavioral techniques, progress measurement, data collection, function of behaviors, and generalization of acquired skills for a participant. Supervision must be provided under the requirements of the EBM or each provider qualification. Intervention specialists providing services to children birth to three (3) years old must be supervised by a specialist or professional who also meets the birth to three (3) years old requirements.
IDAPA 16.03.26.184 Chis: Provider Qualifications and Duties
CHIS are delivered by individuals who meet one (1) of the qualifying criteria below and are employed by a DDA, or who meet the criteria for enrolling as an independent CHIS provider.(7-1-26)
01.Crisis Intervention Technician. Crisis intervention technician is an employee of a DDA that can deliver crisis intervention directly with the eligible participant and meets the qualifications of a community-based supports staff. The technician must be under the supervision of a specialist or professional who is observing and reviewing the direct crisis intervention services performed. Supervision must occur monthly.(7-1-26)
02.Intervention Technician. Intervention technicians can deliver habilitative skill building, behavioral intervention, and crisis intervention. The technician must be an employee of a DDA and be under the supervision of a specialist or professional who is observing and reviewing the services performed. Supervision must occur monthly. As a provisional position status is limited to a single eighteen (18) successive month period. Providers are qualified who are working towards meeting the qualifications and competency requirements for an EBM paraprofessional, intervention specialist, or higher.(7-1-26)
03.Intervention Specialist. Intervention specialists can deliver all CHIS, complete assessments and implementation plans, and must be under the supervision of a specialist or professional who is observing and reviewing the services performed. Supervision must occur monthly. A specialist who will complete assessments or supervise an individual completing assessments must have a minimum of ten (10) hours of documented training and five (5) hours of supervised experience in completing comprehensive assessments and implementation plans for participants with functional or behavioral needs. Qualifications are as follows:(7-1-26)
a.Hold a Habilitative Intervention Certificate of Completion in Idaho. These providers will be allowed to continue providing services as an intervention specialist if there is not a gap of more than three (3) successive years of employment as an intervention specialist; or(7-1-26)
b.Hold a bachelor's degree from an accredited institution in a human services field or a bachelor's degree and a minimum of twenty-four (24) semester credits, or equivalent, in a human services field; and(7-1-26)
i.Can demonstrate one thousand forty (1,040) hours of supervised experience working with participants birth to twenty-one (21) years of age who demonstrate functional or behavioral needs; and(7-1-26)
ii.Meets the competency requirements by completing one (1) of the following:(7-1-26)
(1)A Department-approved competency checklist; or(7-1-26)
(2)A minimum of forty (40) hours of applied behavior analysis training delivered by an individual who is certified or credentialed to provide the training.(7-1-26)
04.Intervention Professional. Intervention professionals can deliver all CHIS and complete assessments and implementation plans. Qualifications are as follows:(7-1-26)
a.Hold a master's degree or higher from an accredited institution in psychology, education, applied behavior analysis, or have a related discipline and have a minimum of twenty-four (24) upper-division semester credits from an accredited college or university of relevant coursework in principles of child development, learning theory, positive behavior support techniques, dual diagnosis, psychology, education, or behavior analysis which may be documented within the individual's degree program, other coursework, or training; and(7-1-26)
b.Have one thousand two hundred (1,200) hours of relevant experience in completing and implementing comprehensive behavioral therapies for participants with functional or behavioral needs, which may be documented within the individual's degree program, other coursework, or training.(7-1-26)
05.Evidence-Based Model (EBM) Intervention Paraprofessional. EBM intervention paraprofessionals can deliver habilitative skill building, crisis intervention, and behavioral intervention, and must be supervised in accordance with the EBM. Providers must hold a para-level certification or credential in an EBM approved by the Department.(7-1-26)
06.Evidence-Based Model (EBM) Intervention Specialist. EBM intervention specialists can deliver all CHIS and complete assessments and implementation plans. Specialists must be supervised according to the EBM and may supervise EBM paraprofessionals working within the same EBM. Providers must hold a bachelor-level certification or credential in an EBM approved by the Department.(7-1-26)
07.Evidence-Based Model (EBM) Intervention Professional. EBM intervention professionals can deliver all CHIS and complete assessments and implementation plans. Providers must hold a masters-level degree and certification or credential in an EBM approved by the Department.(7-1-26)
08.Independent CHIS Provider. Independent CHIS Providers can deliver all types of CHIS, complete assessments and implementation plans according to their provider qualification as Intervention Specialists, Intervention Professionals, EBM Intervention Specialists, and EBM Intervention Professionals. Documentation of supervision must be maintained in accordance with the Department's record retention requirements. The following must be met:(7-1-26)
a.Obtain an independent Medicaid provider agreement through the Department and maintain in good standing;(7-1-26)
b. Be certified in CPR and first aid prior to delivering services and maintain current certification thereafter;(7-1-26)
c.Follow all applicable requirements in the CHIS sections; and(7-1-26)
d.Not receive supervision from an individual that they are directly supervising.(7-1-26)
09.Continuing Training Requirements. CHIS providers must complete a minimum of twelve (12) hours of training each calendar year, including one (1) hour of ethics and six (6) hours of behavior methodology or evidence-based intervention. Continuing training requirements for new independent providers or employees of a DDA who have not provided CHIS for a full calendar year, may be prorated.(7-1-26)
10.Intervention Specialists. Individuals acting as an intervention specialist or professional and who provide services to children birth to three (3) years of age must also demonstrate a minimum of two hundred forty (240) hours of professionally supervised experience providing assessment or evaluation, curriculum development, and service provision in the areas of communication, cognition, motor, adaptive (self-help), and social-emotional devel opment with infants and toddlers birth to five (5) years of age with developmental delays or disabilities.
a.An elementary education certificate or special education certificate with an endorsement in early childhood special education; or(7-1-26)
b.A blended Early Childhood or Early Childhood Special Education (EC or ECSE) certificate; or
c.This individual must have a minimum of twenty-four (24) semester credits from an accredited college or university, which can be within their bachelor's or master's degree coursework or can be in addition to the degree coursework. Courses must cover the following:(7-1-26)
i.Promotion of development and learning for children from birth to five (5) years of age.(7-1-26)
ii.Assessment and observation methods that are developmentally appropriate assessment of young children with developmental delays or disabilities;(7-1-26)
iii.Building family and community relationships to support early interventions;(7-1-26)
iv.Development of appropriate curriculum for young children;(7-1-26)
v.Implementation of instructional and developmentally effective approaches for early learning, including strategies for children and their families; and(7-1-26)
vi.Demonstration of knowledge of policies and procedures in special education and early intervention and demonstration of knowledge of exceptionalities in children's development.(7-1-26)
IDAPA 16.03.26.185 Chis: Provider Reimbursement
The reimbursement rates calculated for CHIS include both services and mileage. No separate charges for mileage will be paid by the Department for provider transportation to and from the participant's home or other service delivery location.(7-1-26)
IDAPA 16.03.26.186 Chis: Quality Assurance
The Department will establish performance criteria to meet federal assurances that measure the outcomes and effectiveness of CHIS.(7-1-26)
01.Quality Assurance. Quality assurance reviews assure compliance with the Department's rules and regulations for CHIS. Identified problems that impact health and safety or are not resolved through quality improvement activities, will have implementation of a corrective action process.(7-1-26)
02.Quality Improvement. Activities may include any of the following:(7-1-26)
a.Consultation;(7-1-26)
b.Technical assistance and recommendations; or(7-1-26)
c.A Corrective Action. A formal process used by the Department to address significant, ongoing, or unresolved deficient practices identified during the review process under these rules. Corrective action includes:
i.Issuance of a corrective action plan;(7-1-26)
ii.Reporting to Medicaid Program Integrity Unit; or(7-1-26)
iii.Action against a provider agreement.(7-1-26)
IDAPA 16.03.26.187 (Reserved)
SUB AREA: PREVENTION SERVICES
(Sections 190-199)
IDAPA 16.03.26.190 Preventive Health Assistance (pha): Definitions
Behavioral PHA are benefits to support weight control.(7-1-26)
IDAPA 16.03.26.191 Preventive Health Assistance (pha): P
ARTICIPANT ELIGIBILITY.
01.Behavioral PHA.
The participant must have their PCP determine eligibility for Behavioral PHA.
The participant qualifies by meeting one (1) of the following:(7-1-26)
a.For an adult, a body mass index (BMI) of thirty (30) or higher or eighteen and one-half (18 1/2) or lower.(7-1-26)
b.For a child, a body mass index (BMI) that falls in either the overweight or the underweight category as calculated using the Centers for Disease Control (CDC) Child and Teen BMI Calculator.(7-1-26)
02.Wellness PHA. A participant who is required to pay premiums for eligibility under state children’s health insurance program (SCHIP.)(7-1-26)
IDAPA 16.03.26.192 Preventive Health Assistance (pha): Coverage and Limitations
01.Point System.
The PHA benefit uses a point system to track points earned and used by a participant. Each point equals one (1) dollar.(7-1-26)
a.Maximum Benefit Points.(7-1-26)
i.The maximum number of points for a Behavioral PHA is two hundred (200) each benefit year.
ii.The maximum number of points for the Wellness PHA benefit is one hundred twenty (120) each benefit year.(7-1-26)
b.Points expire at the end of the participant's benefit year.(7-1-26)
c.Points cannot be transferred to, or combined with, points in another participant's PHA benefit.
02.Weight Management Program. Each program must provide weight management services with at least one (1) of the following:(7-1-26)
a.Physical fitness;(7-1-26)
b.Balanced diet; or(7-1-26)
c.Personal health education.(7-1-26)
03.Premiums. Wellness PHA benefit points are only used to offset a participant's premiums to maintain eligibility under IDAPA 16.03.01, if applicable. Only ten (10) points may be applied per month.(7-1-26)
IDAPA 16.03.26.193 Preventive Health Assistance (pha): Pr
OCEDURAL REQUIREMENTS.
01.Behavioral PHA.
A participant must complete a PHA Benefit Agreement Form to earn two hundred (200) points.(7-1-26)
02.Wellness PHA. Each participant must demonstrate that they have received recommended wellness visits and immunizations for their age prior to earning any points. Ten (10) points can be earned each month by for receiving all recommended wellness visits and immunizations for their age during the benefit year.(7-1-26)
IDAPA 16.03.26.194 (Reserved)
IDAPA 16.03.26.195 Preventive Health Assistance (pha): Provider Reimbursement
The provider may bill the participant for the dif ference between the Department’s reimbursement and the provider’s usual and customary charge for provided Behavioral PHA products or services with the prior agreement of the
IDAPA 16.03.26.196 Early Intervention Services
Early Intervention Services for participants are provided by the Idaho Infant Toddler Program (ITP). Services are coordinated through an intra-agency agreement published on the Department’s website. Reimbursement is in accordance with the intra-agency agreement.(7-1-26)
IDAPA 16.03.26.197 (Reserved)
SUB AREA: LABORATORY AND RADIOLOGY SERVICES
(Sections 200-209)
IDAPA 16.03.26.200 Laboratory and Radiology Services: Definitions
01.Independent Laboratory.
A laboratory not located in a provider’s office and that receives specimens from a source other than another laboratory.(7-1-26)
02.Laboratory or Clinical Laboratory. A facility for the biological, microbiological, serological, chemical, immunohematological, hematological, biophysical, cytological, pathological, or other examinations of material derived from the human body to provide information for the diagnosis, prevention, or treatment of any disease, or the impairment or assessment of human health.(7-1-26)
03.Proficiency Testing. Evaluation of a laboratory's ability to perform laboratory procedures within acceptable limits of accuracy through analysis of unknown specimens distributed at periodic intervals.(7-1-26)
04.Quality Control. Analysis of reference materials to ensure reproducibility and accuracy of laboratory results, and an acceptable system to assure proper functioning of instruments, equipment, and reagents.
05.Reference Laboratory. A laboratory that only accepts specimens from other laboratories. (7-1-26)
IDAPA 16.03.26.201 (Reserved)
IDAPA 16.03.26.203 Laboratory and Radiology Services: Coverage and Limitations
01.Laboratory Services.
02.Radiology Services.(7-1-26)
IDAPA 16.03.26.204 Laboratory and Radiology Services: Provider Qualifications and Duties
01.Laboratory and Radiology Requirements. Provi ders of laboratory and radiology services must be eligible for Medicare certification for these services.(7-1-26)
02.Use of Reference Laboratories. Laboratories using reference laboratories must ensure that all requirements of these rules are met by the reference laboratory.(7-1-26)
IDAPA 16.03.26.205 Laboratory and Radiology Services: Provider Reimbursement
01.Provider of Service.
Payment for laboratory tests can only be made to the actual provider of that service, except in the case of:(7-1-26)
a.An independent laboratory that can bill for a reference laboratory;(7-1-26)
b.A transplant facility that can bill for histocompatibility testing; and(7-1-26)
c.Healthcare professionals acting within the licensure and scope of their practice.(7-1-26)
02.Specimen Collection Fee. Collection fees for specimens drawn by venipuncture or catheterization are payable only to the provider or laboratory who draws the specimen. If done during an office visit on the same day the service is ordered, specimen collection is reimbursable even if PA is not approved.(7-1-26)
IDAPA 16.03.26.206 Laboratory and Radiology Services: Quality Assurance
Laboratories, as a condition of payment, must maintain a q uality-control program, including proficiency testing under 42 USC Section 263a. The laboratory must provide the results to the Department upon request.(7-1-26)
IDAPA 16.03.26.207 (Reserved)
SUB AREA: PRESCRIPTION DRUGS
(Sections 210-219)
IDAPA 16.03.26.210 Prescription Drugs: Definitions
Unit Dose: Drugs packaged in individual, sealed doses with tamper-evident packaging such as, but not limited to, single unit-of-use, blister packaging, unused injectable vials, and ampules.(7-1-26)
IDAPA 16.03.26.211 Prescription Drugs: Participant Eligibility
All participants are eligible for prescript ion drug coverage. Medicaid will also pay for Medicaid-covered drugs that are not covered by Medicare Part D. for dual eligibles, subject to the same limits and processes used for other Medicaid participants.(7-1-26)
IDAPA 16.03.26.212 Prescription Drugs: Coverage and Limitations
01.General Drug Coverage.
Medicaid covers prescription drugs not excluded under this rule that are legally obtainable by the order of a prescriber under Section 54-1705A, Idaho Code.(7-1-26)
02.Preferred Drug List (PDL).(7-1-26)
a.The PDL identifies preferred drugs and non-preferred drugs within a therapeutic class designated by the Department and reviewed by the Pharmacy and Therapeutics Committee (P&T Committee).(7-1-26)
b.A brand name drug may be designated as a preferred drug by the Department if the net cost of the brand name drug after consideration of all rebates is less than the cost of the generic equivalent.(7-1-26)
c.The Director makes final decisions regarding the designated preferred or non-preferred status of drugs based on therapeutic recommendations from the P&T Committee and cost analysis from the Medicaid Pharmacy Program.(7-1-26)
03.Covered Drug Products. Medicaid provides coverage to participants for the following drugs or classes of drugs, or their medical uses, which may be excluded from coverage or otherwise restricted under Section 1927(d)(2) of the SSA:(7-1-26)
a.Agents, when used to promote smoking cessation.(7-1-26)
b.Prescription vitamins and mineral products. Covered agents include the following:(7-1-26)
i.Injectable vitamin B12 (cyanocobalamin and analogues);(7-1-26)
ii.Vitamin K and analogues;(7-1-26)
iii.Prescription vitamin D and analogues;(7-1-26)
iv.Prescription pediatric vitamins, minerals, and fluoride preparations;(7-1-26)
v.Prenatal vitamins for pregnant or lactating individuals; and(7-1-26)
vi.Prescription folic acid and oral prescription drugs containing folic acid in combination with vitamin B12 or iron salts, or both, without additional ingredients.(7-1-26)
c.Certain prescribed non-prescription products, including the following:(7-1-26)
i.Permethrin;(7-1-26)
ii.Oral iron salts;(7-1-26)
iii.Disposable insulin syringes and needles; and(7-1-26)
iv.Insulin.(7-1-26)
d.Barbiturates.(7-1-26)
e.Benzodiazepines.(7-1-26)
04.Additional Criteria for Coverage. The Director, acting upon the recommendation of the P&T Committee, may determine a non-prescription drug product is covered that is therapeutically interchangeable with prescription drugs in the same pharmacological class following evidence-based comparisons of efficacy, effectiveness, clinical outcomes, and safety, and the product is deemed to be a cost-effective alternative.(7-1-26)
05.Excluded Drug Products. Medicaid excludes from coverage the following drugs or classes of drugs, or their medical uses, which may be excluded from coverage or otherwise restricted under Section 1927(d)(2) of the SSA:(7-1-26)
a.Agents, when used for the symptomatic relief of cough and colds.(7-1-26)
b.Agents, when used for the treatment of obesity.(7-1-26)
c.Covered outpatient drugs for which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee.(7-1-26)
d.Agents, when used for the treatment of sexual or erectile dysfunction, unless such agents are used to treat a condition, other than sexual or erectile dysfunction, for which the agents have been approved by the Food and Drug Administration (FDA).(7-1-26)
06.Additional Excluded Drugs. Drugs are not covered when ineligible for federal financial participation.(7-1-26)
07.Limitation of Quantities. Medication refills provided before at least seventy-five percent (75%) of the estimated days' supply has been utilized are not covered, unless an increase in dosage is ordered. Days' supply is the number of days a medication is expected to last when used at the dosage prescribed for the participant. No more than a thirty-four (34) days' supply of continuously required medication is to be purchased in a calendar month because of a single prescription except:(7-1-26)
a.Providers may be reimbursed for up to a three (3) month supply of select medications or classes of medications for a participant who has received the same dose of the same select medication or class of medications for two (2) months or longer. The Director, acting upon the recommendation of the P&T Committee, approves the list of covered maintenance medications, which targets medications that are administered continuously rather than intermittently, are used most commonly to treat a chronic disease state, and have a low probability for dosage changes. The list of covered maintenance medications is available on the Medicaid Pharmacy website at http:// medicaidpharmacy.idaho.gov.(7-1-26) b.
Contraceptive products may be dispense d in a quantity sufficient for up to six (6) months. (7-1-26)
IDAPA 16.03.26.213 Prescription Drugs: Procedural Requirements
01.Request for PA.
a.PA is initiated by the prescriber by submitting the request to the Department in the prescribed format.(7-1-26)
b.Whenever possible, the Department will use automated authorization, in which claims are adjudicated at point of sale using submitted National Council for Prescription Drug Programs (NCPDP) data elements or claims history to verify the Department's authorization requirements have been satisfied, without the need for the prescriber to submit additional clinical information.(7-1-26)
02.Response to Request. The Department will respond within twenty-four (24) hours to a request for PA of a covered outpatient prescription drug under 42 U.S.C. 1396r-8(d)(5)(A).(7-1-26)
03.Supplemental Rebates.(7-1-26)
a.Supplemental rebates may be one (1) factor considered in determining a drug’s preferred drug status, but secondary to considerations of the safety, effectiveness, and clinical outcomes of the drug in comparison with other therapeutically interchangeable drugs.(7-1-26)
b.The Department may negotiate with manufacturers supplemental rebates for prescription drugs that are in addition to those required by Title XIX of the SSA. There is no upper limit on the dollar amounts of the supplemental rebates the Department may negotiate.(7-1-26)
04.Dispensing Procedures. The following protocol is required for prescription filling:(7-1-26)
a.Refills must be authorized by the prescriber on the original or new prescription order on file and each refill must be recorded on the prescription, logbook, computer print-out, or participant’s medication profile.
Automatic refills are not allowed. All refills must be initiated by a request from the participant, prescriber, or another person, acting as an agent of the participant. Authorization for each refill must be received prior to the beginning of the filling process by the pharmacy.(7-1-26)
b.Prescriptions must be maintained on file in pharmacies and available for immediate review by the Department upon written request.(7-1-26)
05.Return of Unused Prescription Drugs. Drugs dispensed in unit dose packaging must be returned to the dispensing pharmacy when the participant no longer uses the medication. The pharmacy that receives the returned drugs must credit the Department the amount billed for the cost of the drug less the professional dispensing
fee.(7-1-26)
IDAPA 16.03.26.214 Prescription Drugs: Provider Qualifications and Duties
01.Enrollment. Pharmacies will enroll with the Department using the specific location where the service was performed.(7-1-26)
02.Out-of-State Providers. An out of state pharmacy shipping or mailing a prescription into Idaho must have a valid mail order license issued by the Idaho Board of Pharmacy.(7-1-26)
IDAPA 16.03.26.215 Prescription Drugs: Provider Reimbursement
Medicaid pharmacies are reimbursed based on Actual Acquisition Costs (AAC) except where noted. Medicaid may require providers to supply documentation of their AACs under the Medicaid Pharmacy Claims Submission Manual available at: https://idaho.fhsc.com/downloads/providers/IDRx_Pharmacy_Claims_Submission_Manual.pdf.
Reimbursement is restricted to drugs supplied from labelers participating in the CMS Medicaid Drug Rebate Program.(7-1-26)
01.Pharmacy Reimbursement. Prescriptions not filled according to dispensing procedures will be subject to nonpayment or recoupment. The following protocol is required for reimbursement.(7-1-26)
a.Reimbursement is limited to the lowest of the following:(7-1-26)
i.AAC based on results of the periodic state cost survey under this rule, plus professional dispensing fee. In cases where no AAC is available, reimbursement will be the Wholesale Acquisition Cost (WAC). WAC is the price, for a given calendar quarter, paid by a wholesaler for the drugs purchased from the wholesaler’s supplier. The wholesaler’s supplier is typically the manufacturer of the drug as published by a recognized compendium of drug pricing for the same calendar quarter;(7-1-26)
ii.State Maximum Allowable Cost (SMAC), as established by the Department, plus professional dispensing fee;(7-1-26)
iii.Federal Upper Limit (FUL), as established by CMS, plus professional dispensing fee; or (7-1-26)
iv.The provider’s usual and customary charge to the general public.(7-1-26)
b.The Department will utilize periodic state cost surveys to obtain the most accurate pharmacy drug AACs in establishing a pharmacy reimbursement fee schedule. Pharmacies participating in the Medicaid Pharmacy Program are required to participate in these periodic state cost surveys by disclosing the costs of all drugs. A pharmacy that is non-responsive to the periodic state cost surveys can be disenrolled as a Medicaid provider by the
c.Provider Administered Drugs.(7-1-26)
i.Reimbursement to providers that are not 340B-covered entities for medications administered to participants by providers will be:(7-1-26)
(1)Ninety percent (90%) of the published Medicare Average Sales Price plus six percent (6%) rate (ASP+6% rate).(7-1-26)
(2)If the ASP+6% rate is not available, payment will be at the WAC.(7-1-26)
(3)If the ASP and WAC are not available, an invoice from the manufacturer or wholesaler is required, reimbursement will be at cost plus ten percent (10%). Radiopharmaceuticals will be paid additionally for the cost of shipping.(7-1-26)
ii.Reimbursement to 340B covered entities for medications administered to participants by providers will be the actual 340B drug AAC, not to exceed the 340B ceiling price.(7-1-26)
d.Clotting Factors.(7-1-26)
i.Reimbursement to specialty pharmacies will be at a state-based price equivalent to the published Medicare ASP+6% rate, plus professional dispensing fee.(7-1-26)
ii.Reimbursement to Hemophilia Treatment Centers will be the 340B AAC, not to exceed the 340B ceiling price.(7-1-26)
e.Professional Dispensing Fee is a tier-based amount paid on a pharmacy claim, over and above the ingredient cost, to compensate the provider for the pharmacist's professional services related to dispensing a prescription to a participant, including:(7-1-26)
i.Verifying a participant’s coverage;(7-1-26)
ii.Performing drug use reviews and preferred drug list review activities;(7-1-26)
iii.Measuring or mixing the covered outpatient drug;(7-1-26)
iv.Filling the container;(7-1-26)
v.Participant counseling;(7-1-26)
vi.Physically providing the completed prescription to the participant;(7-1-26)
vii.Special packaging; and(7-1-26) viii.Overhead associated with maintaining the facility and equipment necessary to operate the dispensing entity.(7-1-26)
f.Only one (1) professional dispensing fee per month is allowed for the dispensing of each maintenance drug to any participant as an outpatient or a resident in a care facility except:(7-1-26)
i.Multiple dispensing of topical and injectable medication when dispensed in manufacturer's original package sizes, unless evidence exists, as determined by the Department, that the quantity dispensed does not relate to the prescriber's order;(7-1-26)
ii.Multiple dispensing of oral liquid maintenance medication if a reasonable quantity, as determined by the Department, is dispensed at each filling;(7-1-26)
iii.Multiple dispensing of tablets or capsules if the quantity needed for a thirty-four (34) day supply is excessively large or unduly expensive, in the judgment of the Department; or(7-1-26)
iv.When the dose is being titrated for maximum therapeutic response with a minimum of adverse effects.(7-1-26)
g.The Department will survey providers to establish a professional dispensing fee for each provider.
The professional dispensing fees will be paid based on the provider’s total annual claims volume. The provider must return the claims volume survey to the Department by May 31st each year. Providers who do not complete the survey will be assigned the lowest professional dispensing fee starting on July 1st until the next annual survey is completed.
Based upon the annual claims volume of the enrolled pharmacy, the professional dispensing fee is provided online at: https://healthandwelfare.idaho.gov/providers/pharmacy-providers/idaho-medicaid-pharmacy-program.(7-1-26) 02.340B-Covered Entity Reimbursement.(7-1-26)
a.Participation as a 340B-Covered Entity. Medicaid will reimburse 340B covered entities under Section 340B of the Public Health Service Act, defined in 42 U.S.C. 256b(a)(4), when the provider meets the following requirements:(7-1-26)
i.A 340B-covered entity submits its unique 340B identification number issued by the Health Resources and Services Administration (HRSA) and a copy of its completed HRSA 340B registration to Medicaid.
ii.A provider that elects to provide drugs to Medicaid participants through the 340B drug pricing program must use 340B-covered outpatient drugs for all dispensed or administered drugs, including those dispensed through the entity’s retail pharmacy or administered in an outpatient clinic. A 340B-covered entity must ensure that a contract pharmacy does not dispense drugs, or receive Medicaid reimbursement for drugs, acquired by the 340Bcovered entity through the 340B drug pricing program. An entity that does not comply will be carved out of the 340B drug pricing program.(7-1-26)
iii.A 340B-covered entity must provide Medicaid with thirty (30) days written notice of its intent to discontinue the provision of drugs acquired through the 340B drug pricing program to participants.(7-1-26)
b.Drugs acquired through the 340B drug pricing program and dispensed by 340B contract pharmacies are not covered.(7-1-26)
c.Reimbursement to 340B-covered entities is limited to their actual 340B drug AAC submitted, not to exceed the 340B ceiling price, plus professional dispensing fee.(7-1-26)
03.Reimbursement for Drugs Dispensed by Other Provider Types.(7-1-26)
a.Drugs acquired through non-340B Indian Health Service, Tribal, or Urban Indian pharmacies will be reimbursed at the AAC to the entity, plus professional dispensing fee.(7-1-26)
b.Drugs acquired via the Federal Supply Schedule (FSS) will be reimbursed at the FSS AAC, plus professional dispensing fee.(7-1-26)
c.Drugs acquired at nominal price, defined as pricing that is outside of 340B regulations or FSS, will be reimbursed at the AAC, plus professional dispensing fee.(7-1-26)
d.Specialty drugs not dispensed by retail community pharmacies and dispensed primarily through the mail will be reimbursed at the Idaho AAC, if such cost is available, plus professional dispensing fee. If the AAC is not available, drugs will be reimbursed at the lower of the WAC or SMAC as established by the Department, plus the assigned professional dispensing fee.(7-1-26)
e.Drugs not distributed by a retail community pharmacy, such as drugs dispensed in a long-term care facility or dispensed to participants receiving swing-bed services, under these rules, will be reimbursed at the actual ingredient cost, plus professional dispensing fee.(7-1-26)
04.Limitations on Payment.(7-1-26)
a.When the medication dispensed is for more than one (1) person, Medicaid will only pay for the amount prescribed for those covered by Medicaid.(7-1-26)
b.Medicaid may conduct drug utilization reviews and impose limitations for participants whose drug utilization exceeds the standard participant profile or disease management guidelines determined by the Department.
05.Cost Appeal Process. Cost appeals will be determined by the Department’s process provided online.(7-1-26)
IDAPA 16.03.26.216 (Reserved)
SUB AREA: FAMILY PLANNING
(Sections 220-229)
IDAPA 16.03.26.220 (Reserved)
IDAPA 16.03.26.221 Family Planning Services: Participant Eligibility
01.Sterilization Procedures. Sterilization procedures a re only a covered service when they meet the requirements in 42 CFR 441.253, 42 CFR 441.257, and 42 CFR 441.258.(7-1-26)
02.Hysterectomies. Payment can be made for a hysterectomy only if:(7-1-26)
a.The participant was advised orally and in writing that sterility would result in the inability to bear children; and(7-1-26)
b.The participant signs and dates a form that meets the requirements of the Idaho Medicaid Provider Handbook.(7-1-26)
c.Claims require supporting documentation attached to the claim.(7-1-26)
IDAPA 16.03.26.222 Family Planning Services: Coverage and Limitations
Family planning includes counseling and medical services prescribed or performed by a provider. Specific items covered are diagnosis, treatment, contraceptive supplies, related counseling, and restricted sterilization.(7-1-26)
01.Contraceptive Supplies.(7-1-26)
a.Contraceptive supplies include condoms, foams, creams and jellies, prescription diaphragms, intrauterine devices, or oral contraceptives.(7-1-26)
b.Payment for oral contraceptives is limited to purchase of a six (6) month supply.(7-1-26)
02.Sterilization.(7-1-26)
a.No sterilizations for individuals institutionalized in correctional facilities, mental hospitals, or other rehabilitative facilities are payable unless such sterilizations are ordered by a court of law.(7-1-26)
b.Hysterectomies are subject to these rules.(7-1-26)
c.All requirements of state or local law for obtaining consent, except for spousal consent, must be followed.(7-1-26)
03.Exceptions to Sterilization Time Requirements. If premature delivery occurs or emergency abdominal surgery is required, the physician must certify that the sterilization was performed because of the premature delivery or emergency abdominal surgery less than thirty (30) days, but no less than seventy-two (72) hours after the date of the participant's signature on the consent form; and(7-1-26)
a.In the case of premature delivery, the provider must also state the expected date of delivery and describe the emergency in detail; and(7-1-26)
b.Describe, in writing to the Department, the nature of any emergency necessitating emergency abdominal surgery; and(7-1-26)
c.Under no circumstance can the period between consent and sterilization exceed one hundred eighty (180) days.(7-1-26)
04.Requirements for Sterilization Performed Due to a Court Order. The performing provider must have been provided with a copy of the court order prior to the performance of the sterilization, and:(7-1-26)
a.Certify that all requirements have been met concerning sterilizations; and(7-1-26)
b.Submit a copy of the court order together with the “Consent Form” and claim.(7-1-26)
IDAPA 16.03.26.223 Family Planning Services: Procedural Requirements
Informed consent exists when a properly completed “Consent Form”, or its equivalent, is submitted to the Departm ent together with the physician's claim for the sterilization. Completed informed consent forms must meet all the requirements in 42 CFR 441.258, to be eligible for reimbursement. The person obtaining informed consent must ensure and certify all the requirements in 42 CFR 441.257 have been met. If the individual obtaining the consent and the physician who will perform the sterilization procedure are the same person, that person must sign both statements on the consent form.(7-1-26)
IDAPA 16.03.26.224 (Reserved)
IDAPA 16.03.26.225 Family Planning Services: Provider Reimbursement
Payment to providers of family planning services for contraceptiv e supplies is limited to estimated acquisition cost.
IDAPA 16.03.26.226 (Reserved)
SUB AREA: BEHAVIORAL HEALTH SERVICES
(Sections 230-239)
IDAPA 16.03.26.230 (Reserved)
IDAPA 16.03.26.231 Behavioral Health Services: Participant Eligibility
All participants eligible for Medicaid are automatically enrolled in the managed care plan to access medically necessary behavioral health services. A court-ordered admission or physician’s emergency certificate alone does not justify Medicaid reimbursement for inpatient services.(7-1-26)
IDAPA 16.03.26.232 Behavioral Health Services: Covera
GE AND LIMITATIONS.
Covered services are those which evaluate the need for and provide therapeutic and rehabilitative treatment to minimize symptoms of mental illness and substance use disorders and restore independent functioning.(7-1-26)
IDAPA 16.03.26.233 Behavioral Health Services: Procedur
AL REQUIREMENTS.
01.Enrollment. Providers will enroll in the managed care plan with the contractor and meet both the credentialing and quality assurance guidelines of the contractor.(7-1-26)
02.Authorization. The managed care contractor is responsible for authorization of covered behavioral health services that require PA.(7-1-26)
03.Complaints, Grievances, and Appeals. Complaints, grievances, and appeals are handled between the contractor and the Department in compliance with state and federal requirements. Participants will utilize the complaint, grievance, and appeal process required by the contractor prior to initiating an administrative appeal with the Department.(7-1-26)
IDAPA 16.03.26.234 Behavioral Health Services: Prov
IDER QUALIFICATIONS AND DUTIES.
01.All Services. Services are delivered by network providers who are enrolled with the contractor and meet reimbursement, quality, and utilization standards. The contractor will enter into agreements with enrolled providers to provide the services.(7-1-26)
02.Inpatient Services. Inpatient hospital psychiatric services must be provided under the direction of a physician in a facility accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and licensed by the state in which they provide services. To provide services beyond emergency medical screening and stabilization treatment, the hospital must have a separate psychiatric unit with staff qualified to provide psychiatric services. General hospitals licensed to provide services in their state, but are not JCAHO certified, may not bill for psychiatric services beyond emergency screening and stabilization. All inpatient services must comply with 42 CFR Part 456 when applicable.(7-1-26)
IDAPA 16.03.26.235 Behavioral Health Services: Provi
DER REIMBURSEMENT.
Provider agreements will include the reimbursement methodo logy agreed upon by the contractor and Department.
The cost of services that would be the responsibility of the Department of Education for school age children cannot be considered in the cost of inpatient psychiatric services.(7-1-26)
IDAPA 16.03.26.236 (Reserved)
SUB AREA: HOME HEALTH SERVICES
(Sections 240-249)
240 – 241.(RESERVED)
IDAPA 16.03.26.242 Home Health Services: Coverage and Limitations
01.Services.
Home health services and items include nursing services, home health aide services, physical therapy, occupational therapy, speech-language pathology services, audiology services, and medical supplies, equipment, and appliances provided under a home health plan of care.(7-1-26)
02.Settings. Home health services are covered in a participant’s residence and any setting in which normal life activities take place. Services are not covered in a:(7-1-26)
a.Any setting in which Medicaid covers inpatient services, including room and board; or(7-1-26)
b.ICF/IID, unless such services are not otherwise required to be provided by the ICF/IID.(7-1-26)
03.Limitations. Home health services are limited to one hundred (100) visits per calendar year per person. Provision of durable medical equipment or supplies is not a visit.(7-1-26)
04.Requirements. Services and items, when appropriate, will meet the requirements for:(7-1-26)
a.Audiology services under these rules;(7-1-26)
b.Medical supplies, items, and appliances under these rules;(7-1-26)
c.Physical therapy, occupational therapy, and speech-language pathology services under these rules;
d.Early Periodic, Screening, Diagnosis, and Treatment Services under these rules.(7-1-26)
IDAPA 16.03.26.243 Home Health Services: Procedural Requirements
01.Orders.(
a.Home health services require an order including the ordering provider’s NPI, the services or items to be provided, the frequency, and, where applicable, the expected duration of time for which the home health services will be needed.(7-1-26)
b.Home health services must be reordered at least every sixty (60) days for services and annually for medical supplies, equipment, and appliances.(7-1-26)
02.Home Health Plan of Care. All home health services must be provided under a home health plan of care that is established prior to beginning treatment and must be signed by the provider who established the plan.
IDAPA 16.03.26.244 Electronic Visit Verification (evv)
Home Health Agencies (HHAs) are required to submit claims using EVV for all services provided except for the provision of medical supplies and equipment.(7-1-26)
IDAPA 16.03.26.245 (Reserved)
IDAPA 16.03.26.246 Home Health Services: Provider Reimbursement
01.Home Health Services. Payme nt for home health must not exceed the lesser of reasonable cost as determined by a finalized Medicare cost report or the Medicaid percentile cap.(7-1-26)
a.The Medicaid percentile cap is revised annually, effective at the beginning of each state fiscal year.
Revisions are made using the data from the most recent finalized Medicare cost reports thirty (30) days prior to the effective date.(7-1-26)
b.Payment by the Department for home health will include mileage as part of the visit.(7-1-26)
c.Provider claims for services requiring EVV will include the corresponding EVV data elements.
EVV data will be submitted to the state’s aggregator prior to billing claims.(7-1-26)
d.If a person is eligible for Medicare, all services ordered by the provider will be purchased by Medicare. The Department will pay for the deductible and co-insurance.(7-1-26)
02.Medical Supplies, Equipment, and Appliances. Payment uses general procedures.(7-1-26)
IDAPA 16.03.26.247 (Reserved)
SUB AREA: THERAPY SERVICES
(Sections 250-259)
IDAPA 16.03.26.250 Therapy Services: Definitions
01.Duplicate Services.
Services are considered duplicate:(7-1-26)
a.When participants receive any combination of physical therapy, occupational therapy, or speechlanguage pathology services with treatments, evaluations, treatment plans, or goals that are not separate and unique to each service provided; or(7-1-26)
b.When more than one (1) type of therapy is provided at the same time.(7-1-26)
02.Feeding Therapy. Services necessary for the treatment of feeding disorders.(7-1-26)
03.Maintenance Program. A program that requires the skills of a therapist or therapy professional and consists of activities and mechanisms to assist a participant in maximizing or maintaining the progress they have made during therapy or to prevent or slow further deterioration due to a disease or illness.(7-1-26)
04.Occupational Therapy Services. Therapy services that:(7-1-26)
a.Are necessary for the evaluation and treatment of impairments, functional disabilities, or changes in physical function and health status; and(7-1-26)
b.Improve the ability to perform tasks required for independent functioning.(7-1-26)
05.Physical Therapy Services. Therapy services that:(7-1-26)
a.Are necessary for the evaluation and treatment of physical impairment or injury using therapeutic exercise and the application of modalities to restore optimal function or normal development; and(7-1-26)
b.Focus on the rehabilitation and prevention of neuromuscular, musculoskeletal, integumentary, and cardiopulmonary disabilities.(7-1-26)
06.Speech-Language Pathology Services. Therapy services that are:(7-1-26)
a.Necessary for the evaluation and treatment of speech and language disorders that result in communication disabilities; or(7-1-26)
b.Necessary for the evaluation and treatment of swallowing disorders (dysphagia), regardless of the presence of a communication disability.(7-1-26)
07.Therapeutic Procedures. Therapeutic procedures are the application of clinical skills, services, or both, that attempt to improve function.(7-1-26)
08.Therapist. An individual licensed by the appropriate state licensing board as an occupational therapist, physical therapist, or speech-language pathologist.(7-1-26)
09.Therapy Professional. An individual licensed by the appropriate state licensing board as an occupational therapist or occupational therapist assistant, physical therapist or physical therapist assistant, or speechlanguage pathologist or speech-language pathology assistant.(7-1-26)
10.Therapy Services. Occupational therapy, physical therapy, and speech-language pathology services are therapy services. These services are ordered as part of a plan of care.(7-1-26)
IDAPA 16.03.26.251 Therapy Services: Participant Eligibility
Participants are eligible with an evaluatio n showing a need for therapy due to a functional limitation, a loss or delay of skill, or both that establishes the participant will demonstrate progress because of therapy services.(7-1-26)
IDAPA 16.03.26.252 Therapy Services: Coverage and Limitations
Therapy services are covered under these rules when delivered by a therapy professional and provided by one (1) of the following providers: outpatient hospitals, outpatient rehabilitation facilities, comprehensive outpatient rehabilitative facilities, NFs, school-based services, independent practitioners, and home health agencies.(7-1-26)
01.Therapy Services. Services described in the Idaho Medicaid Provider Handbook are covered with the following limitations:(7-1-26)
a.Any evaluation or re-evaluation may only be performed by the therapist. Any changes in the participant's condition not consistent with planned progress or treatment goals necessitate a documented re-evaluation by the therapist before further treatment is carried out.(7-1-26)
b.The therapist may be reimbursed for the technical component of muscle testing, joint range of motion, electromyography, or nerve velocity determinations as described in the CPT Manual when ordered by a provider.(7-1-26)
c.The services of therapy assistants used when providing covered benefits are included as part of the reimbursed service. These services are billed by the supervising therapist. Therapy assistants may not provide evaluation services. The therapist has full responsibility for the service provided.(7-1-26)
02.Non-Covered Therapy Services.(7-1-26)
a.Continuing services for participants who do not exhibit the capability to achieve measurable improvement or meet the criteria for a maintenance program.(7-1-26)
b.Services for developmentally acceptable error patterns.(7-1-26)
c.Services that do not require the skills of a therapy professional.(7-1-26)
d.Massage, work hardening, and conditioning.(7-1-26)
e.Biofeedback, unless provided to treat urinary incontinence.(7-1-26)
03.Service Limitations.(7-1-26)
a.Therapy provided through school-based services, or the Idaho Infant Toddler Program is not included in the service limitations under this subsection.(7-1-26)
b.Maintenance therapy is covered when an individualized assessment demonstrates that skilled care is required to carry out a safe and effective maintenance program.(7-1-26)
IDAPA 16.03.26.253 Therapy Services: Procedural Requirements
The Department will pay for therapy services rendered by a therapy profe ssional if such services are ordered by a provider as part of a plan of care.(7-1-26)
01.Orders.(7-1-26)
a.Services must be reordered at least every ninety (90) days or for individuals with long-term medical conditions, as documented by a provider, at least every three hundred sixty-five (365) days.(7-1-26)
b.Therapy services provided under home health must comply with the order requirements in home health instead.(7-1-26)
02.Therapy Plan of Care. All therapy services must be provided under a therapy plan of care that is based on an evaluation and is established prior to beginning treatment.(7-1-26)
a.The plan of care must be signed by the person who established the plan and sent to the ordering provider within thirty (30) days of the evaluation to continue therapy services.(7-1-26)
b.The plan of care must be consistent with the therapy evaluation and contain:(7-1-26)
i.Diagnoses;(7-1-26)
ii.Treatment goals that are measurable and pertain to the identified functional impairment(s); and
iii.Type, frequency, and duration of therapy services.(7-1-26)
c.Therapy services provided under home health must comply with the home health plan of care requirements.(7-1-26)
IDAPA 16.03.26.254 (Reserved)
IDAPA 16.03.26.255 Therapy Services: Provider Reimbursement
The payment for therapy includes the use of therapeut ic equipment to provide the modality or therapy. No additional charge may be made to either the Medicaid program or the participant for the use of such equipment. Reimbursement is paid as:(7-1-26)
01.Home Health Agencies. A per visit rate.(7-1-26)
02.Independent Therapists. Fee-for-service. A therapy assistant cannot bill Medicaid directly.
03.Hospital Services. A rate not to exceed the payment determined as reasonable cost using Medicare standards and principles.(7-1-26)
04.Long-term Care Facilities. Bundled into the facility reimbursement for participants.(7-1-26)
05.School-based Services. As per its subsection.(7-1-26)
IDAPA 16.03.26.256 Therapy Services: Quality Assurance Activities
01.Therapist Conditions and Requirements.
The therapist is required to formulate all therapy interventions in accordance with the applicable licensure rules as well as the applicable association's professional code of ethics and standards supporting best practice.(7-1-26)
02.Documentation. The following documentation must be maintained in the files of the provider:
a.Provider orders for therapy services;(7-1-26)
b.Therapy plans of care; and(7-1-26)
c.Progress or other notes documenting each assessment, therapy session, and results of tests and measurements related to therapy services.(7-1-26)
IDAPA 16.03.26.257 (Reserved)
SUB AREA: AUDIOLOGY SERVICES
(Sections 260-269)
IDAPA 16.03.26.260 Audiology Services
Audiology services are diagnostic, screening, preventive, or correcti ve services provided by an audiologist, and in accordance with Title 54, Chapter 29, Idaho Code, require the order of a provider. Audiology services do not include equipment needed by the patient such as communication devices or environmental controls.(7-1-26)
IDAPA 16.03.26.261 (Reserved)
IDAPA 16.03.26.262 Audiology Services: Coverage and Limitations
All participants are eligible to receive diagnostic screening services necessary to obtain a differential diagnosis.
Participants under the age of twenty-one (21) are eligible for routine audiometric examination and testing once per calendar year, and audiometric services and supplies as follows:(7-1-26)
01.Non-Implantable Hearing Aids. Coverage includes, batteries purchased monthly, follow-up testing, necessary repairs not covered by warranty, the refitting of the hearing aid after the first two (2) years, and additional ear molds every six (6) months.(7-1-26)
02.Implantable Hearing Aids. The Department covers surgically implantable hearing aids when there is a documented hearing loss and non-implantable options have been tried unsuccessfully.(7-1-26)
03.Binaural Hearing Aids. The Department covers binaural hearing aids if documented to the Department's satisfaction, that the participant's ability to learn would be severely restricted.(7-1-26)
IDAPA 16.03.26.263 Audiology Services: Procedural Requirements
01.Additional Testing.
Any hearing testing beyond the basic comprehensive audiometry and impedance testing must be ordered in writing.(7-1-26)
02.Provider Documentation Requirements. Documentation of the following must be kept on file by the provider:(7-1-26)
a.The participant's diagnosis;(7-1-26)
b.The results of the basic comprehensive audiometric exam that include pure tone, air and bone conduction, speech reception threshold, most comfortable loudness, discrimination and impedance testing; and
c.The brand name and model type of the hearing aid with warranty and insurance information.
03.Warranties. Providers will exercise the use of warranties or insurance during the first year following the purchase of the hearing aid when applicable. Provider services are included in the purchase of the nonimplantable hearing aid for the first two (2) years and one (1) year for implantable hearing aid including proper fitting and refitting of the ear mold or aid, instructions on the aid’s use, and extended insurance coverage.(7-1-26)
04.Waiver of Impedance Test. The Department will allow a physician or non-physician practitioner to waive the impedance test based on their documented judgment.(7-1-26)
IDAPA 16.03.26.264 (Reserved)
SUB AREA: DURABLE MEDICAL EQUIPMENT, PROSTHETICS,
ORTHOTICS, AND SUPPLIES (DMEPOS)
(Sections 270-279)
IDAPA 16.03.26.270 (Reserved)
IDAPA 16.03.26.272 Dmepos: Coverage and Limitations
The Department will purchase, repair, or rent medically necessary DMEPOS that are suitable for use in any setting in which normal life activities take place. Department standards for medical necessity and coverage limitations are those national standards set by CMS in the CMS/Medicare DME coverage manual. Exceptions are described in the Idaho Medicaid Provider Handbook.(7-1-26)
01.Supply Coverage. The Department will purchase no more than three (3) months of necessary medical supplies in a three (3) month period.(7-1-26)
02.New Equipment. All equipment must be new at the time of purchase, or for capped rentals, at the time of dispensing.(7-1-26)
03.Custom Fitting. All prosthetic and orthotic devices that require fitting must be provided by a qualified provider.(7-1-26)
04.Guaranteed Fit. Prosthetic limbs must be guaranteed to fit properly for three (3) months from the date of service; any modifications, adjustments, or replacements within the three (3) months are included in the cost of purchase.(7-1-26)
05.Modification and Repairs. Modification to existing prosthetic or orthotic equipment is covered.
Refitting, repairs, or additional parts are limited to once per calendar year for all prosthetics or orthotics unless documented that a major medical change has occurred to the limb.(7-1-26)
06.Replacement Prosthesis or Orthotic Device. Documentation as the least costly alternative to repairing or modifying the current device is required. No replacement will be allowed within sixty (60) months of the date of purchase except in cases where there is clear documentation that there has been major physical change to the residual limb.(7-1-26)
07.Corsets and Braces. Corsets and canvas braces with plastic or metal bones are not covered.
Special braces enabling a participant to ambulate will be covered when a provider documents the only other method of treatment for this condition would be a cast.(7-1-26)
08.Electronically Powered or Enhanced Prosthetic or Orthotics. These items are non-covered.
09.Shoes and Accessories. Shoes, accessories, and modifications are not covered except when provided for the treatment of diabetes, or when attached to an orthosis or prosthesis, or when to provide for a totally or partially missing foot.(7-1-26)
10.Temporary Lower Limb Prosthesis. Covered when documented by the ordering provider that for the participant's rehabilitation the prosthesis is necessary prior to a permanent limb prosthesis. A new permanent limb prosthesis will only be requested after the residual limb size is considered stable.(7-1-26)
IDAPA 16.03.26.273 Dmepos: Procedural Requirements
01.Orders.(
a.All equipment and medical supplies must be ordered by a provider within the scope of their licensure. Orders must meet the requirements in the CMS/Medicare DME coverage manual, be kept on file with the DME provider, and include:(7-1-26)
i.The medical diagnosis requiring the use of the item; and(7-1-26)
ii.How long the item will be necessary and frequency of use, and for pro re nata (PRN) orders the conditions for use.(7-1-26)
b.Medical equipment and supplies must be reordered at least annually.(7-1-26)
c.Not more than ninety (90) days may elapse between the order date and date of a PA request.
02.Rental Procedures. When specified by the Department, equipment must be rented.(7-1-26)
a.Rental payments, including intermittent payments, are applied to the purchase of the equipment.
b.The Department may choose to rent equipment without purchasing it.(7-1-26)
c.The monthly rental payment will be one-tenth (1/10) of the purchase price.(7-1-26)
IDAPA 16.03.26.274 (Reserved)
IDAPA 16.03.26.275 Dmepos: Provider Reimbursement
01.Items Included in Per Diem Excluded. No payment will be made for any items included in the per diem payment for inpatient care in a hospital, NF, or ICF/IID.(7-1-26)
02.Date of Service. Unless specifically authorized by the Department, the date of services for DME and supplies is the date of delivery for items provided in-person or the date of shipment for supplies mailed through a third-party courier.(7-1-26)
03.Warranties and Cost of Repairs. No reimbursement will be made for the cost of repairs (materials or labor) covered under the manufacturer's warranty. The date of purchase and the warranty period must be kept on file by the DME provider. The following warranty periods are required to be provided on equipment purchased by the Department:(7-1-26)
a.An ultra-light or high-strength lightweight wheelchair must have a lifetime warranty period on the frame and crossbraces;(7-1-26)
b.All electrical components and new or replacement parts must have a minimum six (6) month warranty period;(7-1-26)
c.All other DME not specified under this rule must have a minimum one (1) year warranty period;
d.If the manufacturer denies the warranty due to user misuse or abuse, that information must be forwarded to the Department at the time of the request for repair or replacement; and(7-1-26)
e.The monthly rental payment must include a full-service warranty. All routine maintenance, repairs, and replacement of rental equipment are the responsibility of the provider.(7-1-26)
IDAPA 16.03.26.276 Dmepos: Quality Assurance
The Department has no obligation to repair or replace any piece of DME that has been damaged, defaced, lost, or destroyed because of neglect, abuse, or misuse.(7-1-26)
IDAPA 16.03.26.277 (Reserved)
SUB AREA: VISION SERVICES
(Sections 280-289)
IDAPA 16.03.26.280 (Reserved)
IDAPA 16.03.26.282 Vision Services: Coverage and Limitations
Vision services are administered through a managed care contractor.(7-1-26)
Eye Examinations. One (1) eye examination is covered during any twelve (12) month period to determine the need for glasses to correct a refractive error.(7-1-26)
02.Eyeglasses and Contacts. Eyewear is covered when needed for correction of a refractive error.
a.Lenses will be covered once every four (4) years except when there is documentation of a major visual change.(7-1-26)
i.Scratch resistant coating is required for all plastic and polycarbonate lenses.(7-1-26)
ii.Tinted lenses are restricted to extreme medical conditions defined by the Department.(7-1-26)
b.Contact lenses will be covered only for:(7-1-26)
i.A need for correction equal to or greater than plus or minus ten (±10) diopters; or(7-1-26)
ii.An extreme medical condition that does not allow correction using conventional lenses, such as cataract surgery, keratoconus, anisometropia, or other conditions defined by the Department.(7-1-26)
c.One (1) set of frames is covered once every four (4) years except when receiving new lenses that do not fit in existing frames.(7-1-26)
d.Fitting fees are covered only when the participant is eligible for the associated supplies.(7-1-26)
03.Vision Therapy. Vision therapy is covered for participants between the ages of nine (9) and twenty-one (21) with a diagnosis of convergence insufficiency.(7-1-26)
04.Non-Covered Items. Trifocal lenses, Progressive lenses, and photo gray.(7-1-26)
05.Participant Responsibility. Participants are responsible for replacement of broken, lost, or missing glasses.(7-1-26)
IDAPA 16.03.26.283 (Reserved)
IDAPA 16.03.26.285 Vision Services: Provider Reimbursement
The Department will designate a supplier to provide all eyeglass frames and lenses.(7-1-26)
IDAPA 16.03.26.286 (Reserved)
SUB AREA: DENTAL SERVICES
(Sections 290-299)
IDAPA 16.03.26.290 Dental Services: Selective Contract
FOR DENTAL COVERAGE.
Dental benefits are provided through a managed care contractor.(7-1-26)
IDAPA 16.03.26.291 Dental Services: Definitions
01.Adults. Participants past the month of their twenty-first birthday.(7-1-26)
02.Children. Participants from birth through the month of their twenty-first birthday.(7-1-26)
IDAPA 16.03.26.292 Dental Services: Participant Eligibility
All participants are eligible for dental benefits.(7-1-26)
IDAPA 16.03.26.293 Dental Services: Coverage and Limitations
Covered dental services may be subject to limitations from the managed care contractor or benefit restrictions according to the terms of its contract with the Department, in addition to these rules.(7-1-26)
01.Dental Coverage for Children. Children are covered for dental services that include preventative screenings, problem-focused and comprehensive exams, diagnostic, restorative, endodontic services (including root canals and crowns), periodontics, prosthodontic, orthodontic treatments, dentures, and oral surgery. Orthodontics are limited to children who meet Medicaid eligibility requirements as determined by the State’s contractor.(7-1-26)
02.Dental Coverage for Adults. Adults are covered for dental services that include preventative screenings, problem-focused and comprehensive exams, diagnostic, restorative, periodontics, prosthodontic, dentures, oral surgery, and endodontic services with limitations. Root canals and crowns are not covered.(7-1-26)
IDAPA 16.03.26.294 Dental Services: Procedural Requirements
01.Administer the Dental Benefit.
The managed care contractor is responsible for administering the dental benefit, including dental claims processing, payments to providers, customer service, eligibility verification, and data reporting.(7-1-26)
02.Authorization. The contractor is responsible for authorization of covered dental services that require authorization prior to claim payment.(7-1-26)
03.Grievances. The contractor is responsible for tracking and reporting all grievances to the State’s contract monitor.(7-1-26)
04.Appeals. Appeals are handled by a process between the contractor and the Department as specified by the Office of Administrative Hearings, and in compliance with state and federal requirements.(7-1-26)
IDAPA 16.03.26.295 Dental Services: Provider Qualifications and Duties
Providers must enroll in the managed care contractor network with the dental insurance contractor and meet both credentialing and quality assurance guidelines of the contractor , and the licensing requirements of the Idaho Board of Dentistry standards or the applicable state in which services are provided. Providers' duties are based on the contract requirements and are monitored and enforced by the contractor.(7-1-26)
IDAPA 16.03.26.296 Dental Services: Provider Reimbursement
The contractor reimburses dental providers on a fee-for-service basis under a Department-approved fee schedule. The State will collaborate with the contractor to establish rates that promote and ensure adequate access to dental services.
IDAPA 16.03.26.297 Dental Services: Quality Assurance
Providers are subject to the contractor' s Quality Assurance guidelines including monitoring for potential fraud, overutilization, or abuse of Medicaid. The contractor is required to share such potential cases with the Medicaid Fraud Unit as discovered.(7-1-26)
IDAPA 16.03.26.298 (Reserved)
SUB AREA: ESSENTIAL PROVIDERS
(Sections 300-329)
IDAPA 16.03.26.300 Fqhc and Rhc Services: Definitions
01.Change in Intensity of Services. A change in the intensity of services means a change in the quantity and complexity of services delivered that could change the total allowable cost per encounter. This does not include an expansion or remodeling of an existing provider. This may include the addition of new services or the deletion of existing services.(7-1-26)
02.Encounter. An encounter, for payment purposes, is a face-to-face contact for the provision of medical, mental or dental services between a FQHC or RHC patient and a provider as specified in Subsections 303.01 through 303.15.(7-1-26)
03.Federally Qualified Health Centers (FQHCs). FQHCs are defined in federal law at 42 USC Section 1396d(l)(2)(A), (B), and 42 USC Section 1395x(aa)(4), and includes community health centers, migrant health centers, providers of care for the homeless, and outpatient health programs or clinics operated by a tribe or tribal organizations under the Indian Self-Determination Act (P.L. 93-638). It also includes clinics that qualify for, but are not actually receiving, grant funds according to Sections 329, 330, or 340 of the Public Health Service Act (42 USC Sections 201, et seq.) that may provide ambulatory services to Medicaid participants.(7-1-26)
04.Medicare Cost Report Period. The period of time covered by the Medicare-required annual report of cost.(7-1-26)
05.Medicare Economic Index (MEI). An annual measure of inflation designed to estimate the increase in the total cost for the average physician to operate a medical practice and takes into account cost categories such as a physician’s own time, non-physician employee’s compensation, rents, and medical equipment. The MEI is used in establishing the annual changes to the payment conversion factors used in the methodology for determining reimbursement rates.(7-1-26)
06.Rural Health Clinic (RHC). An RHC is located in a rural area designated as a physician shortage area and is neither a rehabilitation agency nor does it primarily provide for the care and treatment of mental diseases.
IDAPA 16.03.26.301 (Reserved)
IDAPA 16.03.26.303 Fqhc and Rhc Services: Coverage and Limitations
FQHC and RHC services are defined as follows:(7-1-26)
Physician Services.(7-1-26)
02.Physician Assistant Services.(7-1-26)
03.Nurse Practitioner or Clinical Nurse Specialist Services.(7-1-26)
04.Visiting Nurse Services. Part-time or intermittent nursing care, and related medical services to a home bound individual, when an RHC located in an area with a shortage of home health agencies.(7-1-26)
05.Chiropractor Services.(7-1-26)
06.Podiatrist Services.(7-1-26)
07.Clinical Psychologist Services.(7-1-26)
08.Licensed Social Worker Services.(7-1-26)
09.Licensed Clinical Social Worker Services.(7-1-26)
10.Licensed Masters Social Worker Services.(7-1-26)
11.Licensed Professional Counselor Services.(7-1-26)
12.Licensed Clinical Professional Counselor Services.(7-1-26)
13.Licensed Marriage and Family Therapist Services.(7-1-26)
14.Other DOPL Licenses. Any other behavioral health or substance use disorder license type recognized by the Idaho Division of Occupational and Professional Licensing (DOPL).(7-1-26)
15.Licensed Dentist and Dental Hygienist Services.(7-1-26)
16.Pharmacist Services.(7-1-26)
17.Incidental Services and Supplies. Services and supplies incident to a provider listed in Subsections 303.01 through 303.15 as would otherwise be covered by a physician service are part of an encounter; or
18.Other Payable Services. Other ambulatory services covered by Medicaid that the FQHC or RHC undertakes to provide, including immunizations. These services are billed separately from an encounter.(7-1-26)
IDAPA 16.03.26.304 (Reserved)
IDAPA 16.03.26.306 Fqhc and Rhc Services: Reimbursement Methodology
01.Payment. Payment for FQHC and RHC services must be made in accordance with Section 702 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, P.L. 106-554, 42USC Section 1396a(bb), Subsections (1) through (4).(7-1-26)
02.FQHC or RHC Encounter. Each contact with a separate discipline of health professional (medical, mental or dental), on the same day at the same location, is reimbursed as a separate encounter. All contact with all practitioners within a disciplinary category (medical, mental or dental) on the same day is a single encounter.
a.Reimbursement for services is limited to one (1) encounter per discipline per participant per day.
b.An additional encounter may be reimbursed, if the encounter is caused by an illness or injury that occurs later than the first encounter and requires additional diagnosis or treatment.(7-1-26)
c.The encounter rate does not include drugs for biologicals which cannot be self-administered, longacting reversible contraception (LARC) or non-surgical transcervical permanent female contraceptive devices.
IDAPA 16.03.26.307 Fqhc and Rhc: Rate Setting Method
OLOGY.
01.Prospective Payment System.
a.The Department will establish separate, finalized rates for medical/mental and dental encounters.
The Department will prospectively set these finalized encounter rates using the FQHC’s medical/mental and dental encounter costs.(7-1-26)
b.The Department will pay each provider an encounter rate equal to the amount paid in the previous federal fiscal year. The Department will adjust the encounter rate for inflation using the Medicaid Economic Index (MEI), as published by CMS.(7-1-26)
c.If an out-of-state FQHC becomes an Idaho Medicaid provider and provides less than one hundred (100) Idaho Medicaid encounters or receives less than ten thousand dollars ($10,000) in Idaho Medicaid payments in the first year after entering the program, the Department will deem the FQHC a low utilization provider. The finalized encounter rate for low utilization providers will be the same as the interim encounter rate as defined under these rules.
If there is an increase in the number of encounters or the amount of payments over any twelve (12) month Medicare cost report period, the Department reserves the right to audit a low utilization provider’s Medicare cost report in order to set a new interim encounter rate as defined under these rules.(7-1-26)
02.New Providers to Idaho Medicaid.(7-1-26)
a.If the provider is new, the Department will set the interim encounter rate by referring to the encounter rates paid to other providers in the same or adjacent regional areas with similar caseloads. Regional areas are defined by the Department. If encounter rate information for others in the same or adjacent regional areas with similar caseloads is not available, the Department will set the interim encounter rate using historical cost information.
If historical cost information is not available, the Department will use budgeted cost and encounter information submitted by the provider.(7-1-26)
b.If the provider has been designated as an FQHC or RHC for at least twenty-four (24) consecutive months and provides the historical cost and encounter information for this period to the Department, the Department will use the second full twelve (12) month audited Medicare cost report to calculate a finalized encounter rate. The Department will provide the provider a supplemental information worksheet to complete. This worksheet will be used by the Department to identify dental encounters and other incidental costs related to either medical/mental or dental encounters.(7-1-26)
c.For both new and existing providers that become Idaho Medicaid providers, the Department will audit the Medicare cost report for the twenty-four (24) consecutive months that represent two (2) complete fiscal years after the FQHC has become a Medicaid provider. The Department will also audit the Medicare cost report for any partial year prior to the twenty-four (24) consecutive months.(7-1-26)
d.For both new and existing FQHCs that become Idaho Medicaid providers, the Department will adjust the finalized encounter rate annually for inflation in accordance with these rules.(7-1-26)
e.The Department will adjust the claim payments for all provider claims paid at the interim encounter rate(s). These adjustments will reflect the payment at the finalized encounter rate(s). The Department will pay the provider for any total adjustment amount over what was reimbursed. The provider must pay the Department for any total adjustment amount that is under what was reimbursed.(7-1-26)
03.Change in an Encounter Rate Due to a Change in Scope of Services.(7-1-26)
a.After an approval is obtained for a change in scope of service from the federal Health Resources and Services Administration (HRSA), Bureau of Primary Health Care, the provider must request the Department to review the encounter rate(s). This will include reviewing the addition of a new service(s), deletion of an existing service(s), or other changes in the intensity of services offered by the provider that could change the total cost per encounter . The provider must request the Department to review the encounter rate(s) within sixty (60) days after the approval from the HRSA Bureau of Primary Health Care for a change in scope of service. The Department requires the same supporting documentation required by the HRSA Bureau of Primary Health Care.(7-1-26)
b.When the provider does not have to file a change in scope of service with the HRSA Bureau of Primary Health Care, but plans an increase or decrease in the intensity of services to be offered that will result in a change to the scope of services, the provider must request the Department to review the request for a change in intensity and determine if there will be an increase or decrease in the encounter rate(s). The Department will review the request for a change in intensity within sixty (60) days of the planned change.(7-1-26)
c.The Department reserves the right to audit the Medicare cost report and recalculate the encounter rates when a change in the scope of service is reported.(7-1-26)
d.The Department will determine the encounter rate in accordance with this rule when the provider had reported a change in scope of service. The Department will audit the most recent twenty-four (24) consecutive months of Medicare cost reports following any change(s) in the scope of service. The Department will also audit the Medicare cost report for any partial year prior to the twenty-four (24) consecutive months. The finalized encounter rate(s) for both medical/mental and dental encounters will be recalculated and audited using the Medicare cost report for the second full twelve (12) month period.(7-1-26)
04.Annual Filing Requirements. Each provider is required to file a copy of its Medicare cost report on an annual basis. Department deadlines are the same as those imposed by Medicare.(7-1-26)
IDAPA 16.03.26.308 (Reserved)
IDAPA 16.03.26.312 Indian Health Service (ihs) Clinic Services: Coverage and Limitations
Payment will be available to Indian Health Service (IHS) clinics for any service provided within the conditions of the scope of care and services described for FQHC and RHC services.(7-1-26)
IDAPA 16.03.26.313 (Reserved)
IDAPA 16.03.26.315 Indian Health Service (ihs) Clinic Services: Provider Reimbursement
01.Payment Procedure.
Payment for services other than prescribed drugs will be made on a per visit basis at a rate not exceeding the outpatient visit rate established by the Federal Office of Management and Budget as published annually in the Federal Register.(7-1-26)
02.Dispensing Fee for Prescriptions. The allowed dispensing fee used to compute maximum payment for each prescription will be the midpoint dispensing fee of the range of fees in effect at the date of service unless a higher fee is justified by a pharmacy cost of operations report on file with the Department.(7-1-26)
03.Third-Party Liability Not Applicable.(7-1-26)
IDAPA 16.03.26.316 (Reserved)
IDAPA 16.03.26.320 School-Based Service: Definitions
- Individual Educational Plan (IEP).
02.School-Based Services (SBS). SBS are health-related and rehabilitative services provided by Idaho public school districts and charter schools under the Individuals with Disabilities Education Act (IDEA).
03.Serious and Persistent Mental Illness (SPMI). A participant must meet the criteria for SMI, have at least one (1) additional functional impairment, and have a diagnosis under DSM-5-TR with one (1) of the following: Schizophrenia, Schizoaffective Disorder, Bipolar I Disorder, Bipolar II Disorder, Major Depressive Disorder Recurrent Severe, Delusional Disorder, or Borderline Personality Disorder. The only Not Otherwise Specified (NOS) diagnosis included is Psychotic Disorder NOS for a maximum of one hundred twenty (120) days without a conclusive diagnosis.(7-1-26)
IDAPA 16.03.26.321 Sbs: Participant Eligibility
01.Age.
Twenty-one (21) years of age or younger and the semester in which their twenty-first birthday falls is not finished.(7-1-26)
02.Parental Consent. A one-time parental consent to access public benefits or insurance from a parent or legal guardian for Medicaid reimbursement.(7-1-26)
IDAPA 16.03.26.322 Sbs: Service-Specific Participant Eligibility
01.Skills Building/Community Based Rehabilitation Servic es (CBRS). To be eligible for Skills Building/CBRS, the student must meet one (1) of the following:(7-1-26)
a.A student under eighteen (18) years of age meeting the Serious Emotional Disturbance (SED) eligibility criteria in the Children’s Mental Health Services Act, Section 16-2403(13), Idaho Code. The child must experience a substantial impairment in functioning. The level and type of impairment must be documented in the school record. A Department-approved assessment must be used for an initial functional impairment score.
Subsequent scores must be obtained annually to determine changes in functioning as a result of mental health treatment.(7-1-26)
b.A student eighteen (18) years old or older meeting the criteria of Serious and Persistent Mental Illness (SPMI). This requires that a student participant meet the criteria described in 42 CFR 483.102(b)(1), have at least one (1) additional functional impairment, and have a diagnosis under DSM-V, or later edition, with one (1) of the following: Schizophrenia, Schizoaffective Disorder, Bipolar I Disorder, Bipolar II Disorder, Major Depressive Disorder Recurrent Severe, Delusional Disorder, or Borderline Personality Disorder. The only Not Otherwise Specified (NOS) diagnosis included is Psychotic Disorder NOS for a maximum of one hundred twenty (120) days without a conclusive diagnosis. In addition, the psychiatric disorder must be of sufficient severity to affect the participant’s functional skills negatively, causing a substantial disturbance in role performance or coping skills in at least two (2) of the areas listed below on either a continuous or intermittent basis, at least once per year. The skill areas that are targeted must be consistent with the participant’s ability to engage and benefit from treatment. The detail of the participant’s level and type of functional impairment must be documented in the medical record in the following areas:(7-1-26)
i.Vocational or educational;(7-1-26)
ii.Financial;(7-1-26)
iii.Social relationships or support;(7-1-26)
iv.Family;(7-1-26)
v.Basic living skills;(7-1-26)
vi.Housing;(7-1-26)
vii.Community or legal; or(7-1-26) viii.Health or medical.(7-1-26)
02.CHIS. Students are eligible to receive CHIS services in accordance with EPSDT, and behavioral consultation of these rules.(7-1-26)
03.Personal Care Services. To be eligible for personal care services (PCS), the student must have a completed children’s PCS assessment and allocation tool approved by the Department that finds the student requires PCS due to a medical condition that impairs physical or functional abilities.(7-1-26)
IDAPA 16.03.26.323 Sbs: Coverage and Limitations
The Department will pay for services including medical or rem edial services provided by school districts or other cooperative service agencies, as defined in Section 33-317, Idaho Code.(7-1-26)
01.Excluded Services.(7-1-26)
a.Payment for school-related services will not be provided to students who are inpatients in nursing homes or hospitals.(7-1-26)
b.Services provided more than thirty (30) days prior to the signed and dated recommendation or referral.(7-1-26)
02.Evaluation and Diagnostic Services. Evaluations to determine eligibility or the need for healthrelated services may be reimbursed even if the student is not found eligible for health-related services. Evaluations completed for educational services only cannot be billed. Evaluations completed must:(7-1-26)
a.Be conducted by providers for the respective SBS discipline;(7-1-26)
b.Be directed toward a diagnosis;(7-1-26)
c.Include recommended interventions to address each need; and(7-1-26)
d.Include name, title, and signature of the person conducting the evaluation.(7-1-26)
03.Reimbursable Services. Providers can bill for the following health-related services provided under the recommendation of a provider for reimbursement. The recommendations or referrals are valid up to three hundred sixty-five (365) days.(7-1-26)
a.Behavioral Intervention is a direct intervention used to promote positive, meaningful changes in behavior that incorporate functional replacement behaviors and reinforcement-based strategies, while also addressing any identified habilitative skill building needs and the student’s ability to participate in educational services through a consistent, assertive, and continuous intervention process to address behavior goals identified on the IEP. Behavioral intervention includes conducting a functional behavior assessment and developing a behavior implementation plan for preventing or treating behavioral conditions. This service is provided to students who exhibit maladaptive behaviors. Services include individual or group behavioral interventions.(7-1-26)
i.Group services provided by one (1) qualified staff providing direct services for two (2) or three (3) students.(7-1-26)
ii.As the severity of the students with behavioral issues increases, the student ratio in the group must be adjusted from three (3) to two (2).(7-1-26)
iii.Group services should only be delivered when the student’s goals relate to benefiting from group interaction.(7-1-26)
b.Behavioral consultation assists other service professionals by consulting with the IEP team during the assessment process, performing advanced assessment, coordinating the implementation of the behavior implementation plan and providing ongoing training to the behavioral interventionist and other team members.
i.Behavioral consultation cannot be provided as a direct intervention service.(7-1-26)
ii.Behavioral consultation must be limited to thirty-six (36) hours per year.(7-1-26)
c.Crisis intervention as defined for CHIS services. This service is provided on a short-term basis, typically not exceeding thirty (30) school days.(7-1-26)
d.Habilitative skill building as defined for CHIS services.(7-1-26)
e.Interdisciplinary training as defined for CHIS services.(7-1-26)
f.Durable Medical Equipment and Supplies for use at the school where the service is provided. The equipment and supplies must be for the student's exclusive use. All equipment purchased by Medicaid belongs to the student.(7-1-26)
g.Nursing services including emergency, first aid, or non-routine medications not identified on the plan as a health-related service are not reimbursed.(7-1-26)
h.Occupational Therapy.(7-1-26)
i.PCS include medically oriented tasks having to do with the student's physical or functional requirements. PCS do not require a goal on the plan of service. The provider must deliver at least one (1) of the following services:(7-1-26)
i.Basic personal care and grooming to include bathing, hair care, assistance with clothing, and basic skin care;(7-1-26)
ii.Assistance with bladder or bowel requirements that may include helping the student to and from the bathroom or assisting the student with bathroom routines;(7-1-26)
iii.Assistance with food, nutrition, and diet activities including preparation of meals if incidental to medical need;(7-1-26)
iv.Assisting the student with provider-ordered medications that are ordinarily self-administered, under IDAPA 24.34.01;(7-1-26)
v.Non-nasogastric gastrostomy tube feedings meeting the requirements under personal care services.
j.Physical Therapy.(7-1-26)
k.Psychological Evaluation.(7-1-26)
l.Psychotherapy.(7-1-26)
m.Skills Building/Community-Based Rehabilitation Services (CBRS) are interventions to reduce the student’s disability by assisting in gaining and utilizing skills necessary to participate in school. They are designed to build competency and confidence while increasing mental health and/or decreasing behavioral symptoms. Skills Building/CBRS provides training in behavior control, social skills, communication skills, appropriate interpersonal behavior, symptom management, activities of daily living, and coping skills to prevent placement in a more restrictive situation.(7-1-26)
n.Speech/Audiological Therapy and Evaluation.(7-1-26)
o.Social History and Evaluation.(7-1-26)
p.Transportation Services. Providers can receive reimbursement for mileage for transporting a student between home and school when:(7-1-26)
i.The student requires special transportation assistance, a wheelchair lift or an attendant, when medically necessary;(7-1-26)
ii.The vehicle is specifically adapted to meet the needs of a disability;(7-1-26)
iii.The student receives Medicaid-reimbursable services billed by the provider, other than transportation, on the day transportation is provided;(7-1-26)
iv.The transportation is included on the student's plan; and(7-1-26)
v.The mileage, as well as the services performed by the attendant, are documented.(7-1-26)
q.Interpretive services for a student requiring an interpreter to communicate with the professional or paraprofessional providing a health-related service may be billed when services are:(7-1-26)
i.Limited to the specific time the health-related service is received. Documentation must include the service provided.(7-1-26)
ii.Included on the student's plan; and(7-1-26)
iii.Provided by a professional or paraprofessional unable to communicate in the student's primary language.(7-1-26)
IDAPA 16.03.26.324 Sbs: Procedural Requirements
Documentation requirements:(7-1-26)
IEP and Other Service Plans. Providers may bill for services covered by a current IEP, transitional Individualized Family Service Plan (IFSP), or Services Plan (SP) defined in the Idaho Special Education Manual for parentally placed private school students with disabilities when designated funds are available for special education and related services. The plan must be within the previous three hundred sixty-five (365) days and the need for one (1) or more medically necessary health-related service and lists all the Medicaid reimbursable services for which the provider is requesting reimbursement. The IEP and transitional IFSP must include:(7-1-26)
a.Type, frequency, and duration of the service provided;(7-1-26)
b.Title of the provider, including the direct care staff delivering services under the supervision of the professional;(7-1-26)
c.Measurable goals, when goals are required for the service; and(7-1-26)
d.Specific place of service, if provided in a location other than school.(7-1-26)
02.Evaluations and Assessments.(7-1-26)
03.Service Detail Reports. A service detail report that includes:(7-1-26)
a.Name of student;(7-1-26)
b.Name, title, and signature of the person providing the service;(7-1-26)
c.Date, time, and duration of service;(7-1-26)
d.Place of service, if provided in a location other than school;(7-1-26)
e.Category of service and brief description of the specific areas addressed; and(7-1-26)
f.Student’s response to the service when required for the service.(7-1-26)
04.One Hundred Twenty Day Review. A documented review of progress toward each service plan goal completed at least every one hundred twenty (120) days from the date of the annual plan.(7-1-26)
05.Documentation of Qualifications of Providers.(7-1-26)
06.Recommendations or Referrals Required. SBS require a recommendation or referral within thirty (30) days of the provision of services and at least every three hundred sixty-five (365) days.(7-1-26)
07.Requirements for Cooperation. Each provider must act in cooperation with students’ parent or guardian, and with community and state agencies and professionals who provide like Medicaid services to the student. This includes:(7-1-26)
a.Documentation that parents or guardians were notified of the services billed to Medicaid that describes the service, provider, and the type, location, frequency, and duration of the service.(7-1-26)
b.Documentation that parents or guardian were provided with a current copy of the child’s plan and any pertinent addenda.(7-1-26)
c.Requesting the name of the student’s PCP with a written consent to release and obtain information between the PCP and the school from the parent or guardian.(7-1-26)
d.Upon receiving a request for a copy of the evaluations or the current plan, the provider furnishing the requesting agency or professional with a copy of the plan or appropriate evaluation after obtaining consent for release of information from the student's parent or guardian.(7-1-26)
IDAPA 16.03.26.325 Sbs: Provider Qualifications and Duties
Qualifications for covered services include licensure and acting within the scope of practice, where applicable.
01.Behavioral Intervention. Provided by, or under the supervision of, an intervention specialist or professional. Individuals providing behavioral intervention must be one (1) of the following:(7-1-26)
a.Intervention Paraprofessional. Provides direct services. The specialist or professional observes and reviews the direct services performed by the paraprofessional monthly, or more often as necessary, to ensure the paraprofessional demonstrates the necessary skills to correctly provide the direct service. An intervention paraprofessional under the direction of a qualified intervention specialist or professional must:(7-1-26)
i.Be at least eighteen (18) years of age;(7-1-26)
ii.Demonstrate the knowledge, have the skills needed to support the program to which they are assigned;(7-1-26)
iii.Meet the paraprofessional requirements under IDAPA 08.02.02.(7-1-26)
b.Intervention Technician. As defined for CHIS services but does not need to be the employee of a DDA.(7-1-26)
c.Intervention Specialist. Provides direct services, completes assessments, and develops implementation plans. Intervention specialists who will complete assessments must have documented training and experience in completing assessments and designing and implementing comprehensive therapies for students with functional or behavioral needs, or both. The qualifications for this provider type can be met by one (1) of the
i.An individual who holds an Idaho Standard Instructional Certificate who meets qualifications for an endorsement specific to special education as defined in State Board of Education Policy Section IV.B;(7-1-26)
ii.An individual who holds a Habilitative Intervention Certificate of Completion in Idaho with an expiration date of July 1, 2019, or later, and does not have a gap of more than three (3) years of employment as an intervention specialist; or(7-1-26)
iii.An individual who holds a bachelor's degree from an accredited institution in a human services field or has a bachelor's degree and a minimum of twenty-four (24) semester credits in a human services field, can demonstrate one thousand forty (1,040) hours of supervised experience working with children who demonstrate functional or behavioral needs, and meets the competency requirements by completing one (1) of the following:
(1)A Department-approved competency checklist referenced in the Idaho Medicaid Provider Handbook;(7-1-26)
(2)A minimum of forty (40) hours of applied behavior analysis training delivered by an individual who is certified or credentialed to provide the training; or(7-1-26)
(3)Other Department-approved competencies as defined in the Idaho Medicaid Provider Handbook.
d.Intervention Professional. The services and qualifications for this provider type can be met by one (1) of the requirements for a CHIS intervention professional.(7-1-26)
e.Evidence-Based Model (EBM) Intervention Paraprofessional. As defined for CHIS services.
f.Evidence Based Model (EBM) Intervention Specialist. As defined for CHIS services.(7-1-26)
g.Evidence-Based Model (EBM) Intervention Professional. As defined for CHIS services provides direct services, completes assessments, develops implementation plans, and may supervise EBM intervention paraprofessionals or specialists working within the same evidence-based model in which they are certified or credentialed.(7-1-26)
02.Behavioral Consultation. Must be provided by a professional who has a Doctoral or Master’s degree in psychology, education, applied behavioral analysis, or has a related discipline with one thousand five hundred (1,500) hours of relevant coursework or training, or both, in principles of child development, learning theory, positive behavior support techniques, dual diagnosis psychology, education, or behavior analysis (may be included as part of degree program), and who meets one (1) of the following:(7-1-26)
a.An individual who holds an Idaho Standard Instructional Certificate who meets qualifications for an endorsement specific to special education as defined in State Board of Education Policy Section IV.B;(7-1-26)
b.An individual with a Pupil Personnel Certificate who meets the qualifications defined under IDAPA 08.02.02, excluding an RN or audiologist;(7-1-26)
c.An occupational therapist;(7-1-26)
d.An intervention professional; or(7-1-26)
e.An EBM intervention professional.(7-1-26)
03.Crisis Intervention. Must be provided by, or under the supervision of, an intervention specialist or professional. Individuals providing crisis intervention must be one (1) of the following:(7-1-26)
a.An intervention paraprofessional;(7-1-26)
b.An intervention technician;(7-1-26)
c.An intervention specialist;(7-1-26)
d.An intervention professional;(7-1-26)
e.An EBM intervention paraprofessional;(7-1-26)
f.An EBM intervention specialist;(7-1-26)
g.An EBM intervention professional;(7-1-26)
h.A licensed physician, licensed practitioner of the healing arts;(7-1-26)
i.An advanced practice registered nurse;(7-1-26)
j.A licensed psychologist;(7-1-26)
k.A licensed clinical professional counselor or professional counselor;(7-1-26)
l.A licensed marriage and family therapist;(7-1-26)
m.A licensed Masters social worker, licensed clinical social worker, or licensed social worker;
n.A psychologist extender;(7-1-26)
o.An RN;(7-1-26)
p.A licensed occupational therapist; or(7-1-26)
q.An endorsed or certified school psychologist.(7-1-26)
04.Habilitative Skill Building. Must be provided by, or under the supervision of, an intervention specialist or professional. Individuals providing habilitative skill building must be one (1) of the following under behavioral intervention:(7-1-26)
a.An intervention paraprofessional;(7-1-26)
b.An EBM intervention paraprofessional;(7-1-26)
c.An EBM intervention specialist; or(7-1-26)
d.An EBM intervention professional.(7-1-26)
05.Interdisciplinary Training. Must be provided by one (1) of the following under behavioral intervention:(7-1-26)
a.An intervention specialist;(7-1-26)
b.An intervention professional;(7-1-26)
c.An EBM intervention specialist;(7-1-26)
d.An EBM intervention professional.(7-1-26)
06.Medical Equipment and Supplies.(7-1-26)
07.Nursing Services.(7-1-26)
08.Occupational Therapy and Evaluation. Therapy rules apply.(7-1-26)
09.Personal Care Services (PCS). Must be provided by or under the direction of an RN.(7-1-26)
a.Providers of PCS must have at least one (1) of the following qualifications:(7-1-26)
i.Licensed Registered Nurse (RN).(7-1-26)
ii.Licensed Practical Nurse (LPN).(7-1-26)
iii.Certified Nursing Assistant (CNA).(7-1-26)
iv.Personal Assistant. A person with training to ensure the quality of services who is at least eighteen (18) years of age.(7-1-26)
b.The RN must review or complete, or both, the PCS assessment and develop or review, or both, the written plan of care annually. Oversight provided by the RN must include all of the following:(7-1-26)
i.Development of the written PCS plan of care;(7-1-26)
ii.Review of the treatment given by the personal assistant through a review of the student’s PCS service detail reports as maintained by the provider; and(7-1-26)
iii.Reevaluation of the plan of care as necessary, but at least annually.(7-1-26)
c.The RN must conduct supervisory visits on a quarterly basis, or more frequently as determined by the IEP team and defined as part of the PCS plan of care.(7-1-26)
10.Physical Therapy and Evaluation. Therapy rules apply.(7-1-26)
11.Psychological Evaluation.(7-1-26)
12.Psychotherapy.(7-1-26)
13.Skills Building/Community-Based Rehabilitation Services (CBRS). Skills Building/CBRS must be provided by one (1) of the following:(7-1-26)
a.Licensed physician, licensed practitioner of the healing arts;(7-1-26)
b.Advanced practice registered nurse;(7-1-26)
c.Licensed psychologist;(7-1-26)
d.Licensed clinical professional counselor or professional counselor;(7-1-26)
e.Licensed marriage and family therapist;(7-1-26)
f.Licensed master’s social worker, licensed clinical social worker, or licensed social worker;
g.Psychologist extender registered with the Division of Occupational and professional Licenses;
h.Licensed registered nurse (RN);(7-1-26)
i.Licensed occupational therapist;(7-1-26)
j.Endorsed or certified school psychologist;(7-1-26)
k.Skills Building/Community Based Rehabilitation Services specialist who must:(7-1-26)
i.Be an individual who has a bachelor’s degree or higher and is under the supervision of a licensed behavioral health professional, a physician, nurse, or an endorsed or certified school psychologist. The supervising practitioner is required to have regular one-to-one (1:1) supervision of the specialist monthly to review treatment provided to student participants on an ongoing basis. Supervision can be conducted using synchronous virtual care when it is equally effective as direct on-site supervision; and(7-1-26)
ii.Have a credential required for CBRS specialists.(7-1-26)
14.Speech/Audiological Therapy. Therapy rules apply.(7-1-26)
15.Social History and Evaluation.(7-1-26)
16.Transportation. Must be provided by an individual who has a current Idaho driver's license and is covered under vehicle liability insurance that covers passengers for business use.(7-1-26)
17.Therapy Paraprofessionals. The schools may use paraprofessionals to provide occupational therapy, physical therapy, and speech therapy. The portions of the treatment plan delegated to the paraprofessional must be identified in the IEP or transitional IFSP.(7-1-26)
IDAPA 16.03.26.326 Sbs: Provider Reimbursement
Only school districts and charter schools can be reimbursed for SBS.(7-1-26)
01.Recoupment of Federal Share. Failure to provide services for which reimbursement has been received or to comply with these rules will be cause for recoupment of the Federal share of payments for services, sanctions, or both.(7-1-26)
02.Matching Funds. Federal funds cannot be used as the State's portion of match for Medicaid service reimbursement. Providers must, for their own internal record keeping, calculate and document the non-federal funds (maintenance of effort assurance) that have been designated as their certified match. This documentation needs to include the source of all funds that have been submitted to the State and the original source of those dollars. The appropriate matching funds will be handled in the following manner:(7-1-26)
a.Schools will estimate the amount needed to meet match requirements based on their anticipated monthly billings.(7-1-26)
b.Providers will send the Department the matching funds, either by check or automated clearing house (ACH) electronic funds transfers.(7-1-26)
c.The Department will hold matching funds in an interest-bearing trust account. The average daily balance during a month must exceed one hundred dollars ($100) in order to receive interest for that month. (7-1-26)
d.The payments to the districts will include both the federal and non-federal share (matching funds).
e.Matching fund payments must be received and posted in advance of the weekly Medicaid payment cycle.(7-1-26)
f.If sufficient matching funds are not received in advance, all Medicaid payments to the school district will be suspended and the school district will be notified of the shortage. Once sufficient matching funds are received, suspended payments will be processed, and reimbursement will be made during the next payment cycle.
g.The Department will provide the school districts a monthly statement that will show the matching amounts received, interest earned, total claims paid, the matching funds used for the paid claims, and the balance of their funds in the trust account.(7-1-26)
h.The school districts will estimate the amount of their next billing, and the amount of matching funds needed to pay the Department.(7-1-26)
i.The estimated match requirement may be adjusted up or down based on the remaining balance held in the trust account.(7-1-26)
IDAPA 16.03.26.327 Sbs: Quality Assurance and Improvement
01.Audit. If probl ems are identified during an audit, the provider must implement a corrective action plan within forty-five (45) days after the results are received. The Department will work with the school to answer questions and provide clear direction regarding the corrective action plan.(7-1-26)
02.Quality Improvement. The Department may gather and utilize information from providers to evaluate student satisfaction, outcomes monitoring, quality assurance, quality improvement activities, and health and safety. These findings may lead to quality improvement activities to improve provider processes and outcomes for the students.(7-1-26)
IDAPA 16.03.26.328 (Reserved)
SUB AREA: MEDICAL TRANSPORTATION SERVICES
(Sections 330-349)
IDAPA 16.03.26.330 (Reserved)
IDAPA 16.03.26.331 Emergency Transportation Services: Participant Eligibility
Ambulance services are medically necessary when an emer gency condition exists. For purposes of reimbursement, an emergency condition exists when a participant manifests acute symptoms or signs, or both, which, by reasonable medical judgment of the Department, represent a condition of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in death, serious impairment of a bodily function or major organ, or serious jeopardy to the overall health of the participant. If such condition exists, and treatment is required at the participant's location, or transport of the participant for treatment in another location by ambulance is the only appropriate mode of travel, the Department will review such claims and consider authorization for emergency ambulance services.(7-1-26)
IDAPA 16.03.26.332 Emergency Transportation Services: Coverage and Limitations
01.Local Transport Only. Onl y local transportation by ambulance is covered. In exceptional situations where the ambulance transportation originates beyond the locality to which the participant was transported, payment may be made for such services only if the evidence clearly establishes that such institution is the nearest one with appropriate facilities and the service is authorized by the Department.(7-1-26)
02.Air Ambulance Service. In some areas, transportation by airplane or helicopter may qualify as ambulance services. Air ambulance services are covered only when:(7-1-26)
a.The point of pickup is inaccessible by land vehicle; or(7-1-26)
b.Great distances or other obstacles are involved in getting the participant to the nearest appropriate facility and speedy admission is essential; and(7-1-26)
c.Air ambulance service will be covered where the participant's condition and other circumstances necessitate the use of this type of transportation; however, where land ambulance service will suffice, payment will be based on the amount payable for land ambulance, or the lowest cost.(7-1-26)
03.Co-Payments. When the Department determines that the participant did not require emergency transportation, the provider can bill the participant for the co-payment.(7-1-26)
IDAPA 16.03.26.333 Emergency Transportation Services: Procedural Requirements
01.Services Subject to Review.
Ambulance service review is governed by provisions of the Transportation Policies and Procedures Manual as amended.(7-1-26)
02.Non-Emergency Transport PA Required. If an emergency does not exist, prior written authorization to transport by ambulance must be secured from the Department. The provider must provide justification to the Department that any other mode of travel would, by reasonable medical judgment of the Department, result in death, serious impairment of a bodily function or major organ, or serious jeopardy to the overall health of the participant.(7-1-26)
03.Air Ambulance. Air ambulance services must be approved in advance by the Department, except in emergency situations. Emergency air ambulance services will be authorized by the Department on a retrospective basis.(7-1-26)
IDAPA 16.03.26.334 Emergency Transportation Services: Provider Qualifications and Duties
01.Licensure Required. All Emergency Medical Services (EMS) Providers must hold a current license issued by their states' EMS licensing authority. Payment will not be made to ambulances that do not hold a current license.(7-1-26)
02.Air Ambulance. The operator of the air service must bill the Department directly.(7-1-26)
IDAPA 16.03.26.335 Emergency Transportation Services: Provider Reimbursement
Payment for ambulance services is su bject to the following:(7-1-26)
01.Ambulance Reimbursement Base Rate.(7-1-26)
a.The base rate for ambulance services includes customary patient care equipment and items such as stretchers, clean linens, reusable devices and equipment. The base rate also includes nonreusable items, and disposable supplies such as oxygen, triangular bandages and dressings that may be required for the care of the participant during transport. In addition to the base rate, the Department will reimburse mileage.(7-1-26)
b.Licensed personnel are required to be in the patient compartment of the vehicle for every ambulance trip. The Department will reimburse a base rate according to the following:(7-1-26)
i.The level of personnel required to be in the patient compartment of the ambulance;(7-1-26)
ii.The level of ambulance license the unit has been issued; and(7-1-26)
iii.The level of life support authorized by the Department.(7-1-26)
c.Units with Emergency Medical Technician - Basic (EMT-B) or equivalent personnel in the patient compartment of the vehicle will be reimbursed up to the Basic Life Support (BLS) rate. Units with Advanced Emergency Medical Technician-Ambulance (AEMT-A) or equivalent personnel in the patient compartment of the vehicle will be reimbursed up to the Advanced Life Support, Level I (ALSI) rate. Units with Emergency Medical Technician - Paramedic (EMT-P) or equivalent personnel in the patient compartment of the vehicle will be reimbursed up to the Advanced Life Support, Level II (ALSII) rate. When a participant's condition requires hospitalto-hospital transport with ongoing care that must be furnished by one (1) or more health care professionals in an appropriate specialty area, including emergency or critical care nursing, emergency medicine, or a paramedic with additional training, Specialty Care Transport (SCT) may be authorized by the Department.(7-1-26)
02.Multiple Providers. If multiple licensed EMS providers are involved in the transport of a participant, only providers who transport the participant will be reimbursed for services.(7-1-26)
a.In situations where personnel and equipment from a licensed ALSII provider boards an ALSI or BLS ambulance, the transporting ambulance may bill for ALSII services as authorized by the Department.(7-1-26)
b.In situations where personnel and equipment from a licensed ALSI provider boards an ALSII or BLS ambulance, the transporting ambulance may bill for ALSI services as authorized by the Department.(7-1-26)
c.In situations where medical personnel and equipment from a medical facility are present during the transport of the participant, the transporting ambulance may bill at the ALSI or ALSII level of service. The transporting provider must arrange to pay the other provider for their services.(7-1-26)
d.If multiple licensed EMS providers transport a participant for different legs of a trip, each provider must bill their base rate and mileage.(7-1-26)
e.Charges for extra attendants are not covered except for justified situations and must be authorized by the Department.(7-1-26)
f.If a physician is in attendance during transport, they are responsible for the billing of their services.
03.Round Trips and Standby.(7-1-26)
a.If an ambulance returns to a base station after having transported a participant to a facility and the participant's provider orders the participant to be transferred from this facility to another facility because of medical need, two (2) base rate charges, in addition to the mileage, will be considered for reimbursement. If an ambulance vehicle and crew do not return to a base station and the patient is transferred from one (1) facility to another facility, charges for only one (1) base rate, waiting time, and mileage will be considered.(7-1-26)
b.Round trip charges will be allowed only when a facility in-patient is transported to the nearest facility with necessary specialized services not available in the original facility.(7-1-26)
c.Reimbursement for waiting time will not be considered unless documentation submitted to the Department identifies the length of the waiting time and established its medical necessity or indicates that it was physician ordered. Limited waiting time will be allowed for round trips.(7-1-26)
04.Treat and Release. The Department may reimburse the EMS provider at the appropriate base rate if they respond to an emergency situation and treat and release the participant without transport.(7-1-26)
05.Response and Evaluation. The Department may reimburse the EMS provider if they respond to a participant’s location, and no treatment or transport is necessary. No payment will be made if the EMS provider responds and no evaluation is done, or the participant has left the scene. No payment will be made to an EMS provider who is licensed as a non-transporting provider.(7-1-26)
IDAPA 16.03.26.336 (Reserved)
IDAPA 16.03.26.340 Nemt Services: Definitions
01.Contracted Transportation Provider.
A provider who is under contract with the transportation broker to provide NEMT for participants.(7-1-26)
02.NEMT. NEMT is transportation that is:(7-1-26)
a.Not of an emergency nature; and(7-1-26)
b.Required for a Medicaid participant to access services covered by Medicaid when the participant’s own transportation resources, family transportation resources, or community transportation resources do not allow the participant to reach those services.(7-1-26)
03.Transportation Broker. An entity under contract with the Department to administer, coordinate, and manage a statewide network of NEMT providers.(7-1-26)
04.Travel-Related Services. Travel-related services are meals, lodging, and attendant care required for NEMT to be completed for a Medicaid participant.(7-1-26)
IDAPA 16.03.26.341 Nemt Services: Duties of the Transpor
TATION BROKER.
The transportation broker under contract with the Department is required to:(7-1-26)
01.Coordinate and Manage. Coordinate and manage all NEMT services for Medicaid participants statewide.(7-1-26)
02.Contract With Transportation Providers. Contract with transportation providers throughout the state to provide NEMT services for Medicaid participants.(7-1-26)
03.Call Center. Operate a call center to receive and review NEMT for Medicaid participants meeting NEMT requirements.(7-1-26)
04.Authorize NEMT Services. Authorize NEMT services for Medicaid participants requesting transportation and who meet NEMT requirements.(7-1-26)
05.Reimburse Contracted Transportation Providers. Reimburse contracted transportation providers for NEMT services meeting the NEMT requirements.(7-1-26)
06.Safe and Professional Transportation. Assure that contracted transportation providers deliver NEMT services in a safe and professional manner.(7-1-26)
IDAPA 16.03.26.342 Nemt Services: Coverage and Limitations
01.NEMT Services.
The transportation broker will reimburse contracted transportation providers for NEMT services under the following conditions:(7-1-26)
a.The travel is essential to get to or from a covered service;(7-1-26)
b.The mode of transportation is the least costly that is appropriate for the medical needs of the participant;(7-1-26)
c.The transportation is to the nearest medical provider appropriate to perform the needed services, and transportation is by the most direct route practicable;(7-1-26)
d.Other modes of transportation, including personal vehicle, assistance by family, friends, and charitable organizations, are unavailable or impractical under the circumstances;(7-1-26)
e.The travel is authorized and scheduled by the transportation broker; and(7-1-26)
f.The contracted transportation provider follows the terms of its contract with the transportation broker.(7-1-26)
02.Travel-Related Services. The transportation broker will reimburse a contracted transportation provider for travel-related services under the following circumstances:(7-1-26)
a.The reasonable cost of meals actually incurred in transit will be reimbursed for the participant when there is no other practical means of obtaining food.(7-1-26)
b.The reasonable cost for lodging actually incurred for the participant will be reimbursed when:
i.The round trip and the needed medical service cannot be completed in the same day; and (7-1-26)
ii.No less costly alternative is available.(7-1-26)
c.The reasonable cost of wages for a non-family member attendant will be reimbursed when:
i.An attendant is medically necessary or when the vulnerability of the participant requires accompaniment for safety; and(7-1-26)
ii.No other unpaid attendant is available to accompany the participant.(7-1-26)
d.The reasonable cost of meals actually incurred in transit will be reimbursed for one (1) family member or one (1) attendant, when:(7-1-26)
i.Attendant care is medically necessary or when the vulnerability of the participant requires accompaniment for safety; and(7-1-26)
ii.There is no other practical means of obtaining food.(7-1-26)
e.The reasonable cost of lodging actually incurred will be reimbursed for one (1) family member or one (1) attendant when:(7-1-26)
i.An overnight stay is required to receive the service;(7-1-26)
ii.It is medically necessary, or the vulnerability of the participant requires accompaniment for safety;
iii.No less costly alternative is available.(7-1-26)
IDAPA 16.03.26.343 Nemt Services: Reimbursement Methodology
The Department will reimburse the transportation broker a fixed, actuarially sound amount per member per month based on the cost of efficiently delivered, timely, and safe NEMT for eligible Idaho Medicaid participants and the cost for efficient administration of the brokerage program.(7-1-26)
IDAPA 16.03.26.344 (Reserved)
SUB AREA: EPSDT SERVICES
(Sections 350-359)
IDAPA 16.03.26.350 Epsdt Services: Definitions
01.Interperiodic Medical Screens. Screen s done at intervals other than those identified in the American Academy of Pediatrics periodicity schedule.(7-1-26)
02.Periodic Medical Screens. Screens done per the American Academy of Pediatrics periodicity schedule.(7-1-26)
IDAPA 16.03.26.351 Epsdt Services: Participant Eligibility
EPSDT services are available to partici pants from birth through the month of their twenty-first birthday.(7-1-26)
IDAPA 16.03.26.352 Epsdt Services: Coverage and Limitations
Services must be considered safe, effective, and meet acceptable standards of medical practice with the need for additional services documented by the screening provider as medically necessary.(7-1-26)
01.Additional Services. Idaho Medicaid will cover services under the scope of the program as a result of an EPSDT screen regardless of inclusion in this rule or any existing amount, scope, and duration. Services must meet any applicable Department criteria and be prior authorized.(7-1-26)
02.Interperiodic Screens. Interperiodic screens will be performed when indicated by medical necessity to determine whether a physical or mental illness or condition may require further assessment, diagnosis, or treatment. Interperiodic screens may occur for existing diagnoses when there is indication that the illness or condition may have changed sufficiently that further examination is medically necessary.(7-1-26)
03.Eyeglasses Under EPSDT.(7-1-26)
a.In the case of a major visual change, the Department can authorize purchase of a second pair of eyeglasses and can authorize a second eye examination to determine that visual change.(7-1-26)
b.The Department may pay for replacement of lost glasses or replacement of broken frames or lenses.
New frames will not be purchased if the broken frame can be repaired for less than the cost of new frames if the provider indicates one (1) of these reasons on their claim. If repair costs are greater than the cost of new frames, new frames may be authorized.(7-1-26)
IDAPA 16.03.26.353 (Reserved)
IDAPA 16.03.26.354 Epsdt Services: Provider Qualifications and Duties
Interperiodic and periodic medical screens must be perform ed by a physician, NP, or Physicians Assistant.(7-1-26)
IDAPA 16.03.26.355 (Reserved)
SUB AREA: SPECIFIC PREGNANCY-RELATED SERVICES
(Sections 360-369)
IDAPA 16.03.26.360 Pregnancy-Related Services: Definitions
01.Individual and Family Social Services. Services directed at helping a participant to overcome social or behavioral problems that may adversely affect the outcome of the pregnancy.(7-1-26)
02.Maternity Nursing Visit. Office visits by a licensed registered nurse, acting within the limits of the Nurses Practices Act, for the purpose of checking the progress of the pregnancy.(7-1-26)
03.Nursing Services. Home visits by a licensed registered nurse to assess the participant's living situation and provide appropriate education and referral during the covered period.(7-1-26)
04.Risk Reduction Follow-Up. Services to assist the participant in obtaining medical, educational, social, and other services necessary to assure a positive pregnancy outcome.(7-1-26)
IDAPA 16.03.26.361 (Reserved)
IDAPA 16.03.26.362 Pregnancy-Related Services: Coverage and Limitations
When ordered by the participant's attending provider, paym ent of the following services is available after confirmation of pregnancy and extending through the end of the month in which the sixtieth day following delivery occurs.(7-1-26)
01.Individual and Family Social Services. Limited to two (2) visits during the covered period.
02.Maternity Nursing Visit. These services are only available to women unable to obtain a provider to provide prenatal care. This service is to end immediately when a primary physician is found. A maximum of nine (9) visits can be authorized.(7-1-26)
03.Nursing Services. Limited to two (2) visits during the covered period.(7-1-26)
04.Qualified Provider Risk Assessment and Plan of Care. When prior authorized by the Department, payment is made for qualified provider services in completion of a standard risk assessment and plan of care for women unable to obtain a PCP for the provision of antepartum care.(7-1-26)
05.Risk Reduction Follow-Up.(7-1-26)
IDAPA 16.03.26.363 (Reserved)
IDAPA 16.03.26.364 Pregnancy-Related Services: Provider Qualifications and Duties
01.Risk Reduction Follow-Up.
A licensed social worker, RN, nurse midwife, physician, NP, or Physician’s Assistant either in independent practice or as employees of entities that have provider agreements.
02.Individual and Family Social Services. A licensed social worker qualified to provide individual counseling.(7-1-26)
IDAPA 16.03.26.365 Pregnancy-Related Services: Provider Reimbursement
A single payment will be made for each month of risk reduction follow-up services provided.(7-1-26)
IDAPA 16.03.26.366 (Reserved)
MEDICAID ENHANCED PLAN COVERED SERVICES
(Sections 450-979)
SUB AREA: ORGAN TRANSPLANTS
(Sections 450-459)
IDAPA 16.03.26.450 (Reserved)
IDAPA 16.03.26.452 Organ Transplants: Coverage and Limitations
The Department reimburses medically necessary organ transpl ant services when provided by CMS approved Medicare hospitals.(7-1-26)
IDAPA 16.03.26.453 (Reserved)
IDAPA 16.03.26.455 Organ Transplants: Reimbursement
01.General. Or gan transplant, procurement services, and follow-up care by facilities are reimbursed as specified in the provider agreement. Payment for organ procurement and histocompatibility laboratory tests is made to the facility performing the transplant.(7-1-26)
02.Living Donor Costs. Transplant costs for actual or potential living donors are fully covered by Medicaid and include all medically necessary preparatory, operation, and post-operation recovery expenses related to the donation. Payments for a donor’s post-operation expenses are limited to the actual recovery period.(7-1-26)
IDAPA 16.03.26.456 (Reserved)
SUB AREA: PRIVATE DUTY NURSING (PDN)
(Sections 460-469)
IDAPA 16.03.26.460 Pdn: Definitions
01.Primary RN.
An RN identified by the family who develops, implements, and maintains the Service Plan.(7-1-26)
02.PDN RN Supervisor. An RN providing oversight of PDN delegated to LPNs providing a child's
03.PDN Services. Nursing services provided to a non-institutionalized child under age twenty-one (21) requiring care for conditions of such medical severity or complexity that skilled nursing care is necessary and cannot be delegated to Unlicensed Assistive Personnel (UAP).(7-1-26)
IDAPA 16.03.26.461 Pdn: Participant Eligibility
A child’s nursing needs are such that the Idaho Nursing Practice Act , Rules, Regulations, or policy require services be provided by an RN or LPN and require more individual and continuous care unavailable from Home Health nursing services. PDN is authorized by the Department prior to service delivery. Annual redetermination is required.
01.Provider Ordered.(7-1-26)
a.An attending provider determines the medical status is so complex or unstable that licensed or professional nursing assessment is needed to determine changes in medications or other interventions; or(7-1-26)
b.A determination of total PDN hours needed to ensure a child’s health and safety in their home.
02.RN Assessment. Identifying a child's health status for unstable chronic conditions including an evaluation of the child's responses to interventions or medications.(7-1-26)
03.Service Plan.(7-1-26)
a.Developed by a multi-disciplinary team including the parent or legal guardian, the primary RN, or RN Supervisor, and a Department representative;(7-1-26)
b.Includes all medically necessary aspects of the medical and licensed services (including PCS) to be performed (amount, type, and frequency of service) ordered by the physician;(7-1-26)
c.Approved and signed by an attending provider, parent or legal guardian, the primary RN or RN supervisor, and a Department representative; and(7-1-26)
d.Revised at least annually and updated as a child's needs change or upon significant change of condition, submitted to the Department for review and PA of service.(7-1-26)
04.Status Updates. Must be completed every ninety (90) days from the start of services. Annual plan reviews replace fourth quarter Status Updates. Status Updates must be signed by both the parent or legal guardian and the RN supervisor completing the form.(7-1-26)
IDAPA 16.03.26.462 Pdn: Limitations
PDN Services are provided only in a child's personal residence or when normal life activities take a child outside of the ho me. If PDN is requested only to attend school or activities out of the home, but the child does not need PDN at home, PDN is not authorized. Excluded residences include NFs, ICFs/IID, Residential Assisted Living Facilities, hospitals, and public or private schools.(7-1-26)
IDAPA 16.03.26.463 (Reserved)
IDAPA 16.03.26.464 Pdn: Provider Qualifications and Duties
01.PDN Redetermination.
The primary RN is responsible for submitting a current service plan to the Department at least annually or as a child's needs change. Failure to submit an updated service plan prior to the end date of the most recent authorization will cause payments to cease until completed information is received and evaluated and authorization given for further PDN.(7-1-26)
02.Physician Responsibility. Determine if the combination of PDN along with other community resources are sufficient to ensure the child’s health or safety. If these resources do not ensure the child’s health and safety, notify the family and the Department to facilitate the child’s admission to an appropriate facility.(7-1-26)
03.RN Responsibilities. RN supervisors or a provider of PDN must:(7-1-26)
a.Notify the physician immediately of any significant changes in a child's medical condition or response to PDN;(7-1-26)
b.Notify the Department within forty-eight (48) hours or on the first business day following a weekend or holiday of any significant changes in a child's condition or a child is hospitalized at any time;(7-1-26)
c.Evaluate changes of condition;(7-1-26)
d.Provide PDN under the PDN service plan; and(7-1-26)
e.Ensure copies of records are maintained in the child's home including:(7-1-26)
i.Service delivery date and start and end times;(7-1-26) ii Comments on the child's response to PDN;(7-1-26)
iii.Nursing assessment of child's status and any changes in status each shift;(7-1-26)
iv.Services provided during each shift; and(7-1-26)
v.Current signed Service Plan.(7-1-26)
04.Oversight of LPNs. RN Supervisory visits occur at least once every thirty (30) days for PDN provided by an LPN.(7-1-26)
IDAPA 16.03.26.465 (Reserved)
SUB AREA: NURSING FACILITIES (NF)
(Sections 470-499)
IDAPA 16.03.26.470 Nf: Definitions
NF services include long term care services provided in a faci lity other than an institution for mental diseases (IMD).
IDAPA 16.03.26.471 Nf: Eligibility
The Department determines whether a participant meets criteria for NF services, any patient liability and whether a participant's needs can be met in alternative living situations other than residing in a NF. The participant can select any certified NF to provide the level of care (LOC) required, if approved.(7-1-26)
01.Determination. The Department determines a participant’s level of care requirement and any need for DD or mental illness (MI) active treatment during the Level II screen.(7-1-26)
a.Adult LOC. The Department uses a standard assessment to determine adults meet one (1) of the PDPM classifications.(7-1-26)
b.Children’s LOC. A child meets LOC when the age-appropriate developmental milestones, risk factors, and aggregate care or intervention needs identified in assessments indicate one (1) or more of the following applies as documented by physician's orders, progress notes, a service plan, and nursing or therapy notes:(7-1-26)
i.A complex provider prescribed service that requires skills of an RN or licensed physical or occupational therapist or only under equivalent supervision for safe and effective delivery.(7-1-26)
ii.The child's condition requires skilled care to sustain current capacities, regardless of their restoration potential, even when improvement is not possible.(7-1-26)
02.Authorization. The Department does not authorize payment to any NF for care or services beyond the NF's licensed level of care or capability. The Department notifies the NF with the authorized payment for services and any patient liability prior to admission.(7-1-26)
IDAPA 16.03.26.472 Nf: Patient Liability
The Department reduces payment to the NF by each participant’s pat ient liability as determined during the financial eligibility process.(7-1-26)
IDAPA 16.03.26.473 Nf: Coverage and Limitations
NFs must provide regular, health-related care and services to participants who require additional care and services due to a mental or physical condition above room, board, and supervision alone.(7-1-26)
01.Minimum Coverage. Minimum services and supplies include:(7-1-26)
a.Room and board;(7-1-26)
b.Bed and bathroom linens;(7-1-26)
c.Nursing care, including special feeding if needed;(7-1-26)
d.Personal services;(7-1-26)
e.Supervision when required by the patient's condition;(7-1-26)
f.Special diets prescribed by a physician;(7-1-26)
g.All common over-the counter medicine chest supplies;(7-1-26)
h.Dressings. Applications using prescription medications or aseptic techniques must be completed by an RN;(7-1-26)
i.Administration of intravenous, subcutaneous, or intramuscular injections and infusions, enemas, catheters, bladder irrigations, and oxygen;(7-1-26)
j.Application or administration of all drugs;(7-1-26)
k.All common disposable medical supplies;(7-1-26)
l.Social and recreational activities; and(7-1-26)
m.Any reusable item commonly needed by patients expected to be available in a NF, such as bed rails, canes, crutches, walkers, wheelchairs, traction equipment, and other DME.(7-1-26)
02.Skilled Services.(7-1-26)
a.Overall development, management, and evaluation of a resident’s service plan, based on a physician's orders, when a patient's physical or mental condition or aggregate PCS tasks require technical or professional staff to meet their needs, promote recovery, and assure medical safety.(7-1-26)
b.Ongoing assessment of rehabilitation needs concurrent with the management of a resident's service plan, including tests and measurements of range of motion, strength, balance, coordination, endurance, functional ability, ADLs, perceptual deficits, and speech, language, or hearing disorders.(7-1-26)
c.Professional observation and assessment of a resident's changing condition required to identify and evaluate whether treatment modification or additional medical procedures to stabilize a condition are needed.
03.Limitations.(7-1-26)
a.Services requiring skilled nursing staff include:(7-1-26)
i.Intravenous injections or feedings and intramuscular or subcutaneous injections required on more than one (1) shift;(7-1-26)
ii.Nasopharyngeal feedings and aspiration;(7-1-26)
iii.Tracheotomy aspiration;(7-1-26)
iv.Catheter insertion, sterile irrigation, and replacement;(7-1-26)
v.Treating extensive decubitus ulcers or other widespread skin disorders;(7-1-26)
vi.Heat treatments specifically ordered by a physician as part of treatment and requiring nurse observation to adequately evaluate a resident's progress; and(7-1-26)
vii.Initial phases of a regimen involving oxygen administration.(7-1-26)
b.Services requiring physical or occupational therapists include:(7-1-26)
i.Therapeutic exercises or activities must be performed by or under supervision to ensure resident safety and treatment effectiveness;(7-1-26)
ii.Gait evaluation and training to restore function in a resident whose ability to walk is impaired by neurological, muscular, or skeletal abnormality;(7-1-26)
iii.Ultrasound, short-wave, and microwave therapy treatments; and(7-1-26)
iv.Other treatment and modalities including hot pack, hydroculator, infrared treatments, paraffin baths, and whirlpool for residents with circulatory deficiency, desensitization, open wounds, fractures, or other complications.(7-1-26)
IDAPA 16.03.26.474 Nf: Procedural Responsibilities
Each NF administrator, or their authorized represen tative must report the following information to the Department within three (3) working days of the date a NF is aware of:(7-1-26)
01.Change of Status. Any participant readmission, discharge, or any temporary absence due to hospitalization or therapeutic home visit.(7-1-26)
02.Changes of Resident’s Income.(7-1-26)
03.Amount Exceeded. When a resident’s account exceeds one thousand eight hundred dollars ($1,800) for single participants, or two thousand eight hundred dollars ($2,800) for married couples.(7-1-26)
04.Other Patient Financial Information. Other information about a resident’s finances that potentially affects eligibility for Medicaid.(7-1-26)
IDAPA 16.03.26.475 Preadmission Screening and Reside
NT REVIEW PROGRAM (PASRR).
NFs must assure that all screens are obt ained and coordinated with the Department, independent mental illness (MI) evaluators, the State Mental Health Authority (SMHA) and State Intellectual Disabilities or Developmental Disabilities Authority (SDDA), and designees.(7-1-26)
01.Level I Screening. All required Level I screens and level of care reviews are completed and submitted to the Department prior to NF admission.(7-1-26)
02.Level II Screening.When a NF identifies an individual with MI or DD (typically through a Level I screen), they must contact the SMHA or SDDA (as appropriate), and to complete a Level II screen prior to admission, or for existing residents, to continue residing in the NF.(7-1-26)
03.Change in Status. Resident reviews for residents with MI or DD must occur and a new determination made after any significant change in their physical or mental condition renders them incapable of responding to program interventions. NFs must notify the Department of any changes within two (2) working days of occurrence when any significant change requires new or increased specialized services.(7-1-26)
IDAPA 16.03.26.476 Nf: Eligibility Coordination and Specialized Service Needs
When an individual identified with MI and DD is admitted to a NF, the NF must meet that individual's needs, except for specialized services.(7-1-26)
01.Categorical Determinations. When NF level of care is determined categorical, an individual may be conditionally admitted prior to completion of a determination for specialized services. However, conditional admissions cannot exceed seven (7) days, except for respite admissions which cannot exceed thirty (30) consecutive days in a calendar year.(7-1-26)
02.Specialized Services. Needs must be documented and included in both the resident assessment and
03.Non-Compliance Penalty. No payment is made for any services rendered by a NF prior to completion of a Level I screen and, if required, a Level II screen.(7-1-26)
04.Appeals. A Level I determination of MI or ID is not appealable but may be disputed as part of a Level II determination appeal.(7-1-26)
IDAPA 16.03.26.477 Nf: Prepayment Screen and Determination of Entitlement to Medicaid
PAYMENT FOR NF CARE AND SERVICES.
A current Minimum Data Set (MDS) assessment is provided to the Department. Additional supporting information may be requested. In the event a required Level II screen was not completed prior to admission, entitlement for Medicaid payment is not earlier than the date of Level II screen completion, indicating NF placement is appropriate.
IDAPA 16.03.26.478 Nf: Provider Qualifica
TIONS AND DUTIES.
01.Application.
02.Licensure and Certification (L&C).(7-1-26)
a.Upon receipt of a NF application, the State determines compliance with certification standards for the type of care the NF proposes to provide to Medicaid participants.(7-1-26)
b.NFs applying to participate as a Skilled Nursing Facility must meet Medicare certification and program participation requirements before Medicaid certification. The State determines NF compliance with Medicare and recommends certification to the Medicare Agency.(7-1-26)
c.The Department certifies to the appropriate branch of government when the State determines a NF meets certification standards for NF care.(7-1-26)
IDAPA 16.03.26.479 (Reserved)
IDAPA 16.03.26.481 Nf: Cost Limits
The Idaho Medicaid Provider Agreement Additional Terms – Nursing Facility provides requirements necessary to implement the provisions and accomplish the objectives of the NF reimbursement system.(7-1-26)
IDAPA 16.03.26.482 Nf: Rate Setting
01.Payments. Payments to NFs through a prospective price-based system, which includes NF-specific case mix adjustments, separate margin payments for indirect care costs and direct care costs, and applied BAF.
02.Rate Adjustment. To set rates based on each NF's CMI on a quarterly basis and establish rates reflecting the case mix of each NF's Medicaid residents as of a certain date during the prior quarter.(7-1-26)
IDAPA 16.03.26.483 Nf: Principle for Rate Setting
Rates are set based on projected cost data from cost and audi t reports for freestanding and hospital-based NFs. In general, methodology uses a cost-based prospective reimbursement system with an acuity adjustment for direct care costs, allowances for margin payments related to indirect and direct care costs, and subject to the application of a BAF.(7-1-26)
IDAPA 16.03.26.484 Nf: Rate Development
NF rates are prospective, with new rates ef fective July 1st of each year, and are recalculated annually with quarterly case mix adjustments. In no case will a rate be set higher than the charge for like services to private pay patients in effect for the period for which payment is made as computed by the lower of costs or customary charges. Rates are calculated using audited cost reports for the periods ending in the calendar year two (2) years prior to each July 1, including inflation adjustments from the midpoint of the cost report period to the mid-point of a rate period, except for property costs.(7-1-26)
IDAPA 16.03.26.485 Nf: Out-of-State Facilities
Medicaid reimburses for out-of-state NF placements when services are not available in Idaho to meet the medical need, or in temporary situations for safe transportation to an Idaho NF. Services are paid the per diem rate, except where noted, for the state where the NF is located.(7-1-26)
IDAPA 16.03.26.486 Nf: Distressed Facility
01.Department Determination. NFs in an under -served area, or addressing an under-served need, may receive an alternative rate.(7-1-26)
02.Discretionary Factors. A NF is not guaranteed increased payment. The Department considers factors for a higher rate on a NF-by-NF basis:(7-1-26)
a.Prudent spending patterns and cost allocation as evidenced by a Department review of the NF’s accounts.(7-1-26)
b.A NF diligently attempted to cover costs of care, hire qualified staff, and otherwise operate effectively and efficiently, but cannot due to causes beyond the NF’s reasonable control.(7-1-26)
c.The same costs of care used to determine special rates are not applied toward a determination of distressed facility status.(7-1-26)
d.The determination of distressed status focuses on whether the NF’s distress stems from patient care costs, and not expenses unrelated to patient care costs.(7-1-26)
e.A NF’s payment cannot exceed the lower of its actual costs or customary charge to private-pay patients unless except by federal law. The Department’s cost caps can be exceeded through the distressed facility process up to the federal UPL.(7-1-26)
03.Annual Review. Distressed facility payments are short-term and redetermined for each fiscal year a NF requests a distressed facility rate.(7-1-26)
04.Prospective Application. Only NFs currently distressed or entering a period of distress are eligible.(7-1-26)
IDAPA 16.03.26.487 Nf: Reviews
01.Facility Review.
The Department may send information for NF review for rate setting. The NF must confirm its accuracy in writing or communicate errors to the Department with supporting documentation. If nothing is provided, the Department may rely on other available information for rate setting. Once information is used to set rates, it is considered final unless modified by subsequent Department review.(7-1-26)
02.Department Review. The Department may retroactively adjust a NF's rate for incorrect information and calculate an overpayment. Adjustments do not include residents who received a default classification due to incomplete or inconsistent MDS data.(7-1-26)
IDAPA 16.03.26.488 Nf: Behavioral Care Unit (bcu) Rates
01.Direct Care Costs.
Additional direct care costs for BCU residents remain in direct care costs subject to the direct care cost limitation. Qualifying BCU NFs may have a direct care cost limitation higher than non- -BCU NFs, and do not receive an increased indirect care cost limitation.(7-1-26)
02.New Owner. The prior owner's cost report is used for rate calculations until the new owner has a qualifying cost report. The BCU continues to qualify for the same higher direct care cost limit as the previous owner.
If the BCU is discontinued, the direct care cost limit is adjusted down to match a non-BCU NF.(7-1-26)
IDAPA 16.03.26.489 Nf: Bcu Qualifications
Facilities must meet the qualifications for a BCU described in the Idaho Medicaid Provider Agreement Additional Terms – Behavioral Care Units.(7-1-26)
IDAPA 16.03.26.490 Nf: Bcu Eligible Days
NFs must demonstrate BCU days from a minimum of sixty (6 0) calendar days, regardless of payer source, divided by total census days for that same 60-day period, equals or exceeds a minimum of thirty percent (30%).(7-1-26)
IDAPA 16.03.26.491 Nf: Special Rates
The Department pays NFs an addition to their daily rate when a patient’s needs exceed the scope of NF services, and the cost is not adequately reflected in the calculated rates. This rate is in addition to any payments under other provisions and excluded from the computation of payments or rates under other sections of these rules.(7-1-26)
01.Determination. The Department approves special rates per patient based on identified conditions expected to continue for more than thirty (30) days. No rate is allowed if payment for these needs is available from a non-Medicaid source.(7-1-26)
02.Effective Date. Upon approval, a special rate is effective on the date set by the Department.
03.Reporting. Costs equivalent to payments for special rate add-on amounts are removed from cost components subject to limits and reported separately.(7-1-26)
04.Limitation. Special rates cannot exceed a NF's charges to other patients for similar services.
05.Prospective Rate Treatment. Special rates are paid under a prospective payment system. (7-1-26)
06.Payment for Qualifying Residents. The Department calculates special rate add-on amounts using one (1) of the following methods:(7-1-26)
a.For NFs operating as a one hundred percent (100%) special care unit including Medicaid residents, the direct care cost per diem is not subject to the direct care cost limit. However, the direct care costs are case mix adjusted based on the ratio of a NF's Medicaid CMI for the rate period to the NF-wide CMI for the cost reporting period.(7-1-26)
b.The Department pays for equipment and non-therapy supplies not addressed in the coverage and limitations section in accordance with DMEPOS, as an add-on amount.(7-1-26)
c.NFs providing care to residents who are ventilator-dependent or receive tracheostomy care are eligible to submit requests for a fixed add-on amount, in addition to the NF’s rate for residents receiving this type of care. Approved requests are effective the date a resident needs this care, no earlier than sixty (60) days prior to request receipt. Add-on rates include the cost for equipment and supplies and for additional RN and CNA hours, as appropriate for each care type. Costs for equipment and supplies are adjusted annually for inflation, and skilled nursing costs are adjusted according to annual WAHR survey results.(7-1-26)
i.The Department reviews approved add-on rates for these residents annually to ensure the add-on rate remains necessary for the resident’s care needs.(7-1-26)
ii.NFs must inform the Department when an approved add-on rate is no longer needed or a resident’s special needs change.(7-1-26)
iii.The hourly add-on rate for staffing in an out-of-state NF equals the current WAHR CNA or RN wage rate plus a benefits allowance based on annual cost report data and weighted to remove CNA minimum daily staffing time adjusted for the appropriate staff skill level.(7-1-26)
07.Treatment of Special Rates In Future Rate Setting Periods. Special rates are established on a prospective basis as with the overall NF rate. When a cost report used to set rates contains a special add-on cost, the Department makes an adjustment to reduce costs by an amount equal to total incremental revenues, or add-on payments received by the NF during the cost reporting period. The amount received is calculated by multiplying the special rate add-on amount paid for each qualifying resident by the number of days paid. No related adjustment is made to the NF's CMIs.(7-1-26)
08.Special Rate for NF Ownership Change or Closure. The Department does not require a closing cost report, and reviews special rates made in the closing cost reporting period.(7-1-26)
IDAPA 16.03.26.492 Nf: Occupancy Adjustment Factor
The Department makes adjustments to equitably allocate fixed costs for patients when a NF fails to maintain reasonable occupancy levels. No occupancy adjustment is made against costs used to calculate a property rental rate.
Adjustments are made against all other property costs:(7-1-26)
01.Occupancy Levels. If a NF maintains an average occupancy of less than eighty percent (80%) of capacity, the total property costs not including cost paid under a property rental rate, are prorated based upon an eighty percent (80%) occupancy rate. A NF's average occupancy percentage is subtracted from eighty percent (80%) and the result is multiplied by the total fixed costs to determine nonallowable fixed costs. When a NF changes designed capacity, average occupancy for the period before and after the change is computed for each period.
02.Occupancy Adjustment. NF capacity is computed based on the greater of the largest number of beds under a NF’s license during the reporting period, except when a portion of the NF was converted to use for nonroutine NF activities, or a newly constructed facility enters the Medicaid Program. If a NF's designed capacity changes, the number of beds used to determine occupancy is lowered by the capacity amount converted to nonroutine NF activities. New NF capacity is based on the number of beds approved by the certificate of need process minus any capacity converted to non-routine NF activities.(7-1-26)
03.Fixed Costs. Occupancy adjustments to fixed costs are considered allowable and reimbursable costs when reported under property cost categories.(7-1-26)
04.Adjustment Exemption. An increase in number of beds and new NFs are not subject to an adjustment for the first six (6) months of licensure or operation.(7-1-26)
IDAPA 16.03.26.493 Nf: Recapture of Depreciation
When depreciable assets reimbursed by Medicaid based o n cost are sold for an amount exceeding their net book value, depreciation is recaptured from the NF buyer in an amount equal to reimbursed depreciation or gain on the sale, whichever is less.(7-1-26)
01.Amount Recaptured. Depreciation is recaptured in full when a sale of a depreciated NF occurs within the first five (5) years of ownership. For every year an asset is held beyond the first five (5) years, total depreciation recaptured is reduced by ten percent (10%) per year.(7-1-26)
02.Time Frame. The Department recaptures depreciation from a NF buyer over no more than five (5) years from the sale date, with no less than one-fifth (1/5) of the total recaptured amount for each year after. (7-1-26)
IDAPA 16.03.26.494 Nf: Nurse Aide Training and Competency Evaluation Programs (natceps)
NATCEP costs are outside the content of NF care and must be re ported by all NFs. Costs are reported separately as exempt costs and not included in the percentile cap.(7-1-26)
IDAPA 16.03.26.495 Nf: Payments for Temporary Absences
Limitations for payments made to reserve beds in NFs during a temporary absence if the NF charges private pay patients for reserve bed days:(7-1-26)
01.NF Occupancy Limits. Payment for temporary absences from NFs are made according to the number of licensed and unoccupied beds.(7-1-26)
a.Payments are not allowed for NFs with less than one hundred (100) licensed beds when five (5) or more are unoccupied.(7-1-26)
b.Payments may be allowed for NFs with one hundred (100) or more licensed beds when the minimum occupancy rate is ninety-five percent (95%).(7-1-26)
02.Time Limits. Payments for temporary absences are made for therapeutic home visits for residents up to three (3) days per visit, not exceeding fifteen (15) days per calendar year for days included as part of a treatment plan ordered by a provider.(7-1-26)
03.Payment Limits. Reserve bed days payments are the lesser of seventy-five percent (75%) of the audited allowable NF costs or the rate charged to private pay residents.(7-1-26)
IDAPA 16.03.26.496 (Reserved)
SUB AREA: ICF/IID
(Sections 500-529)
IDAPA 16.03.26.500 (Reserved)
IDAPA 16.03.26.501 Icf/Iid: Participant Eligibility
Approval for services will be no earlier than the medical provider' s signed and dated certification for ICF/IID level of
01.Required Information for Applications.(7-1-26)
a.A complete and current medical examination within ninety (90) days of admission, signed and dated by a medical provider, primary and secondary diagnoses, medical findings and history, mental and physical functional capacity, prognosis, mobility status, and medical provider’s statement certifying ICF/IID level of care is needed.(7-1-26)
b.An initial plan of care current within ninety (90) days of admission, signed and dated by a medical provider, and includes orders for medications and treatments, diet, and professional rehabilitative and restorative services and special procedures, when needed.(7-1-26)
c.A social evaluation current within ninety (90) days of admission, that includes condition at birth, age at onset of condition, summary of functional status, such as skills level, ADL, and family social information.
d.A psychological evaluation conducted by a provider current within ninety (90) days of admission, or infants under three (3) years old may be evaluated by a DD specialist using developmental milestones congruent with the infant’s age. Evaluations include diagnosis, summary of developmental findings, mental and physical functioning capacity, and recommendations for placement and primary need for active treatment.(7-1-26)
e.An initial plan of care developed by the admitting ICF/IID.(7-1-26)
02.ICF/IID Eligibility Criteria.(7-1-26)
a.Individuals with a primary DD diagnosis or a related condition and qualify based on functional limitations, maladaptive behavior, a combination of both, or medical condition significantly affects their functional level/capabilities.(7-1-26)
b.Individual requires and receives intensive inpatient active treatment to advance or maintain their functional level. Active treatment does not include parenting activities directed toward the acquisition of ageappropriate developmental milestones, interventions that address age-appropriate limitations, or general supervision required by all children of the same age. The following criteria evaluate the need for active treatment:(7-1-26)
i.Complete medical, social, and psychological evaluations that clearly indicate the functional level of the participant and interventions needed; and(7-1-26)
ii.A written plan of care with initial goals and objectives, specifying further evaluations required, and training programs to be developed.(7-1-26)
c.Individual requires the level of care provided in an ICF/IID, including active treatment, and, in the absence of available intensive alternative services in the community, would require institutionalization, other than services in an IMD.(7-1-26)
d.ICF/IID level of care is redetermined annually related to continued need of community services.
i.Home Care for Certain Disabled Children receive services until the end of the month their redetermination was made. When the redetermination is made less than ten (10) days from the end of a month, payment continues until the end of the following month.(7-1-26)
ii.Individuals receiving DD waiver services have thirty (30) days from the determination to transition to other community supports.(7-1-26)
IDAPA 16.03.26.502 Icf/Iid: Coverage and Limitations
The Department pays for services in an ICF/IID whose primary purpose is providing habilitative services and maintaining optimal health status for individuals with intellectual disabilities or related conditions.(7-1-26)
01.Coverage. The minimum content of care and services for ICF/IID residents includes:(7-1-26)
a.Room and board;(7-1-26)
b.Bed and bathroom linens;(7-1-26)
c.Nursing care, including special feeding if needed;(7-1-26)
d.Personal services;(7-1-26)
e.Supervision;(7-1-26)
f.Special diets as prescribed by a participant's provider;(7-1-26)
g.All common medicinal supplies that do not require a prescription;(7-1-26)
h.Dressings;(7-1-26)
i.Administration of intravenous, subcutaneous, or intramuscular injections and infusions, enemas, catheters, bladder irrigations, and oxygen;(7-1-26)
j.Application or administration of all drugs;(7-1-26)
k.All medical supplies;(7-1-26)
l.Social and recreational activities; and(7-1-26)
m.Items used by individuals that are reusable and expected to be available.(7-1-26)
02.Limitations. Specialized wheelchairs and seating systems, including repair, designed to fit the needs of a specific resident and cannot be altered to fit another resident cost effectively are not included in ICF/IID content of care. These are paid directly to the supplier.(7-1-26)
03.Temporary Absence. Reimbursement is available for reserving beds for during a temporary absence if the facility charges private payors for reserve bed days. Therapeutic home visits are allowed for up to thirty-six (36) days per calendar year when days are part of a written treatment plan ordered by the attending physician. Prior authorization is required for any home visits exceeding fourteen (14) consecutive days.
Reimbursement is the lesser of audited allowable costs, or usual and customary charges.(7-1-26)
IDAPA 16.03.26.503 Icf/Iid: Procedural Responsibilities
01.Reporting Requirements. Each ICF/IID administrator , or their authorized representative, must report to the Department within three (3) working days of the date the facility is aware of the following:(7-1-26)
a.Readmissions or discharges, including any participant’s temporary absence due to hospitalization or therapeutic home visit.(7-1-26)
b.Changes to participant's income.(7-1-26)
c.Participant's account exceeds one thousand eight hundred dollars ($1,800) for single individuals or two thousand eight hundred dollars ($2,800) for married couples.(7-1-26)
d.Other changes to participant’s finances that may potentially affect their eligibility for Medicaid.
02.Annual Recertification. ICF/IIDs must assure that participant annual recertifications are completed.(7-1-26)
a.When Medicaid receives a federal financial penalty due to the lack of appropriate recertification on the part of an ICF/IID, then that amount is withheld from facility payments for participants. For audit purposes, these financial losses are not a reimbursable cost of participant care and cannot be billed to the participant.(7-1-26)
b.ICF/IID residents are transitioned to a less restrictive environments within thirty (30) days of a determination when a participant fails to meet ICF/IID level of care.(7-1-26)
03.Supplemental On-Site Visit. The Department conducts utilization control supplemental on-site visits in an ICF/IID to review these indications to complete follow-up activities, verify a participant's appropriateness of placement or services, and conduct complaint investigations.(7-1-26)
04.Determinations. The Department issues the final decision for eligibility and level of care, including the need for DD or MI active treatment through the Level II screening process. If eligible, the Department forwards authorization for payment to the facility chosen by the individual. The participant can select any certified facility to provide care. No payment is made to any facility for services that are beyond the facility’s licensed level of
IDAPA 16.03.26.504 Icf/Iid: Provider Qualifica
TIONS AND DUTIES.
01.Direct Care Staffing Levels.
A reasonable level of direct care staff provided to an ICF/IID resident is dependent upon the level of involvement and their need for services and supports as determined by the Department.
Level of involvement relates to the severity of a resident’s intellectual disability. Those levels, in decreasing level of severity, are profound, severe, moderate, and mild. Direct care staffing levels are limited to the following maximum hours per week:(7-1-26)
a.Sixty-eight and twenty-five hundredths (68.25) hours for a severely and profoundly intellectually disabled resident.(7-1-26)
b.Fifty-four and six tenths (54.6) hours for a moderately intellectually disabled resident.(7-1-26)
c.Thirty-four and one hundred twenty-five thousandths (34.125) hours for a mildly intellectually disabled resident.(7-1-26)
02.Direct Care Staff Hours. The annual sum level of allowable direct care staff hours for each residential living unit is determined in the aggregate as the sum total of the level of staffing allowable for each resident.(7-1-26)
03.Phase-In Period. If these rules require a facility to reduce its direct care staffing, a six (6) month phase-in period is allowed from the date of adjustment, without any resulting disallowances. Should disallowances result, the hourly rate of direct care staff used in determining disallowances is the weighted average of the hourly rates paid to the direct care staff, plus associated benefits, at the end of the phase-in period.(7-1-26)
IDAPA 16.03.26.505 Icf/Iid: Reimbursement
These rules do not apply to ICF/IID facilities owned or operated by the state of Idaho. ICF/IIDs are reimbursed per patient day with the ICF/IID methodology implemented by the Department.(7-1-26)
IDAPA 16.03.26.506 (Reserved)
IDAPA 16.03.26.507 Icf/Iid: Allowable Costs
01.Auto and Travel Expense.
02.Bad Debts.(7-1-26)
03.Bank or Finance Charges.(7-1-26)
04.Compensation of Owners.(7-1-26)
05.Contracted Service.(7-1-26)
06.Depreciation.(7-1-26)
07.Dues, Licenses, or Subscriptions.(7-1-26)
08.Employee Benefits.(7-1-26)
09.Employee Recruitment.(7-1-26)
10.Entertainment Costs Related to Patient Care.(7-1-26)
11.Food.(7-1-26)
12.Home Office Costs.(7-1-26)
13.Insurance.(7-1-26)
14.Interest.(7-1-26)
15.Lease or Rental Payments.(7-1-26)
16.Malpractice or Public Liability Insurance.(7-1-26)
17.Payroll Taxes.(7-1-26)
18.Principle. Costs for services, facilities, and supplies furnished to the provider by organizations or persons related to a provider by common ownership, control, etc., are allowable at the cost to the related party. Such costs are allowable when they relate to care, are reasonable, ordinary, and necessary, and do not exceed costs incurred by a prudent cost-conscious buyer.(7-1-26)
19.Property Costs.(7-1-26)
20.Property Insurance.(7-1-26)
21.Repairs or Maintenance.(7-1-26)
22.Salaries.(7-1-26)
23.Supplies.(7-1-26)
24.Taxes.(7-1-26)
IDAPA 16.03.26.508 Icf/Iid: Non-Allowable Costs
01.Accelerated Depreciation.
02.Acquisitions.(7-1-26)
03.Charity Allowances.(7-1-26)
04.Consultant Fees.(7-1-26)
05.Franchise Fees.(7-1-26)
06.Fund Raising.(7-1-26)
07.Goodwill.(7-1-26)
08.Holding Companies.(7-1-26)
09.Interest to Finance Unallowable Costs.(7-1-26)
10.Medicare Costs.(7-1-26)
11.Non-patient Care Related Activities.(7-1-26)
12.Organization.(7-1-26)
13.Pharmacist Salaries.(7-1-26)
14.Prescription Drugs.(7-1-26)
15.Related Party Interest.(7-1-26)
16.Related Party Non-allowable Costs.(7-1-26)
17.Related Party Refunds.(7-1-26)
18.Self-Employment Taxes.(7-1-26)
19.Vending Machines.(7-1-26)
IDAPA 16.03.26.509 (Reserved)
IDAPA 16.03.26.510 Icf/Iid: Occupancy Adjustment Factor
Adjustments are to equitably allocate fixed costs for Medicaid patients when a facility falls below reasonable occupancy levels. No occupancy adjustment is made against costs used to calculate the property rental rate.
Adjustments are made against all other property costs:(7-1-26)
01.Occupancy Levels. If a facility maintains an average occupancy of less than eighty percent (80%) of capacity, the total property costs not including cost paid for property rental rate, is prorated based on an eighty percent (80%) occupancy rate. A facility's average occupancy percentage is subtracted from eighty percent (80%) and the resultant percentage is multiplied by the total fixed costs to determine non-allowable fixed costs. When a provider changes the designed capacity, the average occupancy for the period before and after the change is computed for each period. If the designed capacity is increased, the increased number of beds will not be subject to this adjustment for the first six (6) months following their licensure.(7-1-26)
02.Occupancy Adjustment. Facility capacity is computed based on the greater of the largest number of beds a facility was licensed for during the reporting period or the largest number of beds for which the facility was licensed during calendar year 1981, except where a portion of the facility has been converted to use for nonroutine nursing home activities or the facility is newly constructed. If a facility's designed capacity changes, the number of beds used to determine occupancy is lowered by the capacity amount converted to non-routine ICF/IID activities. The new capacity is based on the number of beds approved by the certificate of need process less any capacity converted to non-routine ICF/IID activities.(7-1-26)
03.Fixed Costs. Occupancy adjustment to fixed costs is considered allowable and reimbursable when reported under property cost categories.(7-1-26)
04.New Facility. For newly licensed and occupied facilities, the first six (6) months occupancy level is not subject to an adjustment.(7-1-26)
IDAPA 16.03.26.511 Icf/Iid: Recapture of Depreciation
Depreciable assets reimbursed based on cost, and sold for an amount over net book value, are recaptured from the facility’s buyer in an amount equal to reimbursed depreciation, or gain on the sale, whichever is less.(7-1-26)
01.Amount Recaptured. Depreciation is recaptured in full when sale of a depreciated facility occurs within the first five (5) years of ownership. For every year an asset is held beyond the first five (5) years, total depreciation recaptured is reduced by ten percent (10%) per year.(7-1-26)
02.Time Frame. The Department recaptures depreciation from the facility buyer over no more than five (5) years from the sale date, with no less than one fifth (1/5) of the total amount recaptured each year after.
IDAPA 16.03.26.512 Icf/Iid: Reporting System
A uniform system of periodic reports is used to allow:(7-1-26)
Basis for Reimbursement. By approximating actual costs.(7-1-26)
02.Adequate Financial Disclosure.(7-1-26)
03.Statistical Resources. As a basis for measuring reasonable costs and comparative analysis.
04.Criteria For Evaluating Policies and Procedures.(7-1-26)
IDAPA 16.03.26.513 Icf/Iid: Reporting System Princi
PLE AND APPLICATION.
Providers must file annual cost reports.(7-1-26)
01.Cost Report Requirements. The fiscal year end filings include:(7-1-26)
a.Annual income statement;(7-1-26)
b.Balance sheet;(7-1-26)
c.Statement of ownership;(7-1-26)
d.Schedule of patient days;(7-1-26)
e.Schedule of private patient charges;(7-1-26)
f.Statement of additional charges to residents above usual monthly rates; and(7-1-26)
g.Other schedules, statements, and documents as requested.(7-1-26)
02.Special Reports. When required, specific instructions are issued, based upon the circumstance.
03.Report Criteria.(7-1-26)
a.Use of State-approved formats.(7-1-26)
b.Presented on accrual basis.(7-1-26)
c.Prepared according to GAAP and principles of reimbursement.(7-1-26)
d.Providing appropriate detail on supporting schedules or as requested.(7-1-26)
04.Preparer. Statements do not require a CPA.(7-1-26)
05.Reporting by Chain Organizations or Relative Providers. Filing combined or consolidated cost reports as a basis for reimbursement is prohibited. Each facility must file a separate set of reports for each level of organization allocating expenses to a provider. Consolidated financial statements are considered supplementary information and do not meet primary reporting requirements.(7-1-26)
06.Change of Management or Ownership. To properly pay separate entities or individuals after a change of management or ownership, the following requirements apply:(7-1-26)
a.Outgoing management or administration must file an adjusted-period cost report when necessary.
This report will meet the criteria for annual cost reports and be filed no later than sixty (60) days after the change.
b.The Department may require an appraisal for a change in ownership.(7-1-26)
07.Reporting Period. When required to establish rates, new ICF/IIDs are required to submit cost projections for the first year of operations. Thereafter, the normal reporting period coincides with the facility’s standard fiscal year. If a facility withdraws from the program and later re-enters, new provider reporting requirements apply.(7-1-26)
IDAPA 16.03.26.514 (Reserved)
IDAPA 16.03.26.515 Icf/Iid: Principle Prospective Rates
ICF/IID are paid a per diem rate that, with certain exceptions, is not subject to audit settlements. The rate for a fiscal period is based on audited historical costs not adjusted for inflation. Facilities must report these costs. Total payments include property reimbursement, capped costs, exempt costs, and excluded costs. Rates are calculated using audited cost reports for the calendar year two (2) years prior to July 1st, with no cost or cost limit adjustments for inflation.
IDAPA 16.03.26.516 Icf/Iid: Property Reimbursement
ICF/IID property costs are reim bursed using a rental rate or based on cost. The following are reimbursed based on cost under these rules and PRM: ICF/IID living unit property taxes, living unit property insurance, and major movable equipment not related to home office or day treatment services. Reimbursement of other property costs is included in the property rental rate. Any property cost related to home offices and day treatment services are not considered property costs and are not reported in the property cost portion of the cost report. These costs are reported in the home office and day treatment section of the cost report. Property costs, including costs reimbursed based on a rental rate, are reported in the property cost portion of the cost report. The Department may require and use an appraisal to establish those components identified as an integral part of an appraisal. Property costs include the following allowable components:(7-1-26)
01.Straight-Line Depreciation.(7-1-26)
02.Interest.(7-1-26)
03.Property Insurance.(7-1-26)
04.Lease Payments.(7-1-26)
05.Property Taxes.(7-1-26)
06.Costs of Related Party Leases.(7-1-26)
IDAPA 16.03.26.517 Icf/Iid: Capped Cost
01.Costs Subject to the Cap. Include all allowable costs except property costs under property reimbursement and exempt excluded costs.(7-1-26)
02.Per Diem Costs. Costs are divided by total resident days for a facility in the cost reporting period to arrive at allowable per diem costs. If costs for services provided any non-Medicaid residents are not included in the total costs submitted, the facility must determine these costs and combine them with submitted costs so a total per diem cost for that facility is determined for both determining the ICF/IID cap and computing final reimbursement.
03.Cost Data to Determine the Cap. Cost data from the final cost report used for rate setting, per prospective principles, will be used. Cost reports are final when the final audit report is issued, or earlier if the Department informs the facility the report is final for rate setting purposes. However, the final cost reports covering a period of less than twelve (12) months are included in data to determine the cap at the option of the Department.
04.Payments to Non ICF/IIDs. Payments made by the Department directly to non-ICF/IIDs are excluded from the ICF/IID prospective rates and cap. Services covered under EPSDT or “Medicaid Basic Plan Benefits” are not included in ICF/IID costs. Providers must bill Medicaid directly for these services under their own provider number.(7-1-26)
05.Cost Ranking. Prior to annual rate setting, the Director will determine the percent above the median used in the cap calculation. That percent will apply to the cap and rates set per prospective principles. Per diem capped costs, by facility, as determined in this section will be ranked from the highest to the lowest, with the median being the 50th percentile. The cap for the applicable rate period will not exceed the 75th percentile of these ranked per diems.(7-1-26)
a.The median of the range is computed based on the available data points considered the total population of data points.(7-1-26)
b.A new cap and rate are set annually for each facility July 1st.(7-1-26)
c.The cap and prospective rate are determined and set annually for each facility July 1st and is not changed by any subsequent events or information unless the computations are found to contain mathematical or clerical errors. These errors are then corrected, and the cap is adjusted using corrected figures.(7-1-26)
d.Payment of costs subject to the cap are limited to the cap unless the Department determines the exclusions.(7-1-26)
IDAPA 16.03.26.518 (Reserved)
IDAPA 16.03.26.519 Icf/Iid: Retrospective Settlement
When applicable, settlements are based on allowable reimbursement under these rules, based on an audit report, and subject to the same caps and limits determined for prospective payments.(7-1-26)
01.Failure to Meet Conditions.(7-1-26)
02.First Time Provider.(7-1-26)
03.New ICF/IID Living Unit.(7-1-26)
04.Ownership Change.(7-1-26)
05.Fraudulent Claims.(7-1-26)
06.Excluded Costs.(7-1-26)
IDAPA 16.03.26.520 Icf/Iid: Exempt Costs
Day treatment services and major movable equipment costs are not subject to the ICF/IID cap.(7-1-26)
IDAPA 16.03.26.521 Icf/Iid: Costs Excluded from Cap
Certain costs excluded from the ICF/IID cap are subject to retrospective settlement at the discretion of the Department, and result in changes to a prospective rate to assure equitable reimbursement:(7-1-26)
- Increases to Per Participant Day Costs.(7-1-26)
02.Excess Inflation.(7-1-26)
03.Cost Increases Over 3%.(7-1-26)
04.Decreases.(7-1-26)
05.Prospective Negotiated Rates.(7-1-26)
IDAPA 16.03.26.522 (Reserved)
IDAPA 16.03.26.523 Icf/Iid: Property Rental Rate Reimbursement
ICFs/IID are paid a property rental rate. Property taxes, property ins urance, depreciation expense, and major moveable equipment are reimbursed as costs exempt from limitations. The property rental rate does not include compensation for minor movable equipment. The property rental rate is paid in lieu of payment for amortization, depreciation, and interest for financing the cost of land and depreciable assets.(7-1-26)
01.Rate Calculation. Property rental rates are based upon current construction costs, age of a facility, type of facility, and major expenditures made to improve a facility, or a rate based upon current property costs.
Amounts paid for each Medicaid day of care are phased in as follows:(7-1-26) a.“R” = “Property Base” x forty (40) - “Age” / forty (40) x “change in building costs” where: b.“R” = the property rental rate.(7-1-26) c.“Property Base”:(7-1-26)
i.Eleven dollars and twenty-two cents ($11.22) for ICF/IID with wheelchair accommodations.
ii.Seven dollars and twenty-two cents ($7.22) for ICF/IID without wheelchair accommodations. d.“Change in building costs” = the most recent CMI available to set a prospective rate for a period including all or part of the calendar year.(7-1-26) e.“Age” of facility = The effective age of the facility in years is set by subtracting the year in which a facility, or a new section, was constructed from the year in which the rate is applied. No facility or new section is assigned an age over thirty (30) years, however:(7-1-26)
i.The age is set at thirty (30) years unless documentation is received to the contrary. Adequate documentation includes, but is not limited to, copies of building permits, tax assessors' records, receipts, invoices, building contracts, and original notes of indebtedness. An age is determined for each building. A weighted average using the age and square footage of the buildings becomes the effective age of a facility. The age of each building is based upon the date when construction on that building was completed.(7-1-26)
ii.An effective age of a facility is further adjusted when the cost of major repairs, replacements, remodeling, or renovation of a building results in a change in age by at least one (1) year when applied to this formula: r = A x E / S x C Where:
These changes do not decrease an effective age of a facility beyond the point where an increase in the property rental rate is more than three fourths (3/4) of the difference between the property rental rate “r” for a new facility at the time of a proposed rate revision and the property rental rate a facility was eligible for immediately before an adjustment.
The cost for “C” is adjusted according to costs published by Marshall Swift Valuation Service reflecting current construction costs for average Class D convalescent hospitals. Providers must notify the Department with documented costs. The Department adjusts the age.(7-1-26)
iii.The Department reimburses expenditures directly related to new requirements imposed by state or federal agencies, as an increase to the property rental rate if the expense exceeds one hundred dollars ($100) per bed.
When costs related to a requirement are less than one hundred dollars ($100) per bed, the Department reimburses the Medicaid share of the entire cost of new requirements in a one-time payment to a facility within twelve (12) months of expense verification.(7-1-26) iv.“Age of facility” will be a revised age that is lesser of either the age established under this section, or the age that most closely yields the rate allowable to existing facilities. This revised age will not increase over time.(7-1-26) r=Reduction in the age of a facility in years.
A=Age of a building at the time construction was completed.
E= Actual expenses for construction provided the total costs were incurred within 24 months of completion of the construction.
S=The number of square feet in a building at the end of construction.
C=The cost of construction for buildings in the year construction was completed.
02.Facility Sale. When a facility, or asset of a facility, is sold, the buyer receives the property rental rate as calculated.(7-1-26)
IDAPA 16.03.26.524 Icf/Iid: Property Reimbursement Limitations
Property costs of an ICF/IID are reimbursed except as follows:(7-1-26)
01.Property Leases. No grandfathered rates or lease provisions other than the following apply:
a.Property costs related to living units other than costs for major movable equipment are paid the property rental rate.(7-1-26)
b.Leases for property other than ICF/IID living units are allowable based on lease cost to a facility not exceeding reasonable market rate, subject to principles associated with related party leases.(7-1-26)
02.Home Office and Day Treatment Property Costs. Distinct parts of buildings containing ICF/IID living units may be used for home office or day treatment purposes. Reimbursement for the property costs of these parts is allowed when the areas are used exclusively for these services. The portion of property cost attributed to these areas is reimbursed as part of home office or day treatment costs without a reduction in the property rental rate.
Reimbursement for these costs does not include costs reimbursed by, or covered by the property rental rate, and are only reimbursed as property cost when the facility clearly included space in excess of space normally used in a facility. To qualify for reimbursement, a structure must have square feet per licensed bed exceeding the average square feet per licensed bed for other ICF/IID living units with four (4) licensable beds.(7-1-26)
IDAPA 16.03.26.525 Icf/Iid: Special Rates
The Department pays special rates for care for residents wi th long-term medical or behavioral care needs beyond the normal scope of facility services. Payment for specialized care is in addition to any payments made under these rules and based on a per diem rate applicable to the incremental additional costs incurred by a facility. Incremental costs to a facility exceeding the rate for services provided are excluded from the computation of payments. Costs equivalent to payments at the special rate will be removed from the cost components subject to limits and will be reported separately. Special rates are determined on an individual basis, must be prior authorized by the Department, and may be used in one (1) of the following circumstances:(7-1-26)
01.New Admissions to a Community ICF/IID.(7-1-26)
02.Significant Change in Condition. Residents of a community ICF/IID experiencing a significant change in condition not reflected in their current rate.(7-1-26)
03.Altered Services. A facility altered services to achieve or maintain compliance with state or federal requirements resulting in additional costs not reflected in their current rate.(7-1-26)
04.Emergency. An emergency exists when a facility must incur additional behavioral or medical costs to prevent more restrictive placements.(7-1-26)
IDAPA 16.03.26.526 (Reserved)
SUB AREA: HOME AND COMMUNITY-BASED SERVICES (HCBS)
(Sections 530-539)
IDAPA 16.03.26.530 Hcbs
Services and supports to assist eligi ble participants to remain in their home and community. Federal HCBS requirements and adherence to the person-centered service plan implementation apply to Medicaid providers, where applicable. HCBS includes:(7-1-26)
01.A&D Waiver Services.(7-1-26)
02.Consumer-Directed Services.(7-1-26)
03.DD HCBS State Plan and Waiver Services.(7-1-26)
04.PCS.(7-1-26)
05.Youth Empowerment Services (YES) for Children with Serious Emotional Disturbance (SED).(7-1-26)
IDAPA 16.03.26.531 Hcbs Exceptions
These rules do not supersede decision-making authority leg ally assigned on the participant's behalf including:
01.Payees appointed by the SSA.(7-1-26)
02.Judicial Restrictions. Court-imposed restrictions due to probation, parole, or for commitments to the Department; and(7-1-26)
03.Legal Guardians. It is presumed that the parents of participants birth through seventeen (17) years of age have full decision-making authority unless a minor child has another legally assigned decision-making authority.(7-1-26)
IDAPA 16.03.26.532 (Reserved)
IDAPA 16.03.26.533 Hcbs: Provider Qualifications and Duties
Providers must develop and implement policies and procedures to address the HCBS setting requirements. (7-1-26)
IDAPA 16.03.26.534 (Reserved)
IDAPA 16.03.26.535 Exceptions to Residential Provider-Owned or Controlled Setting
QUALITIES.
Exceptions to residential setting requirements must be based on a participant’s needs identified through personcentered planning. Service plans with exceptions must be submitted to the Department or its designee for review and approval.(7-1-26)
IDAPA 16.03.26.536 Hcbs Person-Centered Plan Requ
IREMENTS.
In addition to federal requirements, legal guardians without full decision-making authority hold a participatory role as iden tified by the participant.(7-1-26)
01.Setting Selection. Identify and document the alternative HCBS options considered by the participant, or the participant's decision-making authority.(7-1-26)
02.Plan Signatures. The plan must also be signed by the plan developer and all individuals and providers responsible for its implementation.(7-1-26)
03.Residential Requirements. Any exception to residential provider-owned or controlled setting qualities must be documented in the person-centered plan.(7-1-26)
IDAPA 16.03.26.537 (Reserved)
IDAPA 16.03.26.539 Hcbs: Participant Eligibility
01.Federal and State Eligibil ity Requirements. To be enrolled in an HCBS waiver or State Plan option program, a participant must meet the following eligibility requirements:(7-1-26)
a.An independent assessment;(7-1-26)
b.A state-approved person-centered plan;(7-1-26)
c.Annual eligibility redetermination; and(7-1-26)
d.Other state-established criteria for determining Medicaid eligibility.(7-1-26)
02.Failure to Meet Requirements. A participant who does not meet eligibility criteria is subject to termination of enrollment.(7-1-26)
03.Conditions for Termination. The Department will terminate participant enrollment if they:
a.Do not have an identified need for a waiver or State Plan option service;(7-1-26)
b.Elect not to use services offered under the HCBS waiver or State Plan option;(7-1-26)
c.Decline to engage in person-centered planning;(7-1-26)
d.Do not meet other HCBS eligibility requirements; or(7-1-26)
e.Are non-responsive to three or more contact attempts by the Department or its designee.(7-1-26)
04.Continuous Eligibility for Children Under Age Nineteen. Continuous health care assistance eligibility for children under age nineteen (19), as provided in IDAPA 16.03.01, does not apply for a participant under the age of nineteen (19) who is enrolled in an HCBS waiver or State Plan option program or who has accessed Medicaid coverage through an HCBS waiver or State Plan option program.(7-1-26)
SUB AREA: AGED AND DISABLED (A&D) WAIVER SERVICES
(Sections 540-548)
IDAPA 16.03.26.540 A&d Waiver Services: Definitions
01.A&D Waiver Services.
Services for the elderly and physically disabled to maintain selfsufficiency, individuality, independence, dignity, choice, and privacy in a cost-effective home-like or communitybased setting. It does not include participants in skilled, or intermediate care facilities, nursing facilities, ICF/IID or hospitals. When possible, services should be available in the participant’s own home and community regardless of their age, income, or ability and should encourage the involvement of natural supports.(7-1-26)
02.Employer of Record. An entity that bills for services, withholds required taxes, and conducts other administrative activities for a waiver participant. Such an entity is also called a PAA functioning as a fiscal intermediary (FI).(7-1-26)
03.Employer of Fact. A participant or representative of a participant who hires, fires, and directs the services delivered by a waiver provider. This individual may be a family member.(7-1-26)
04.Fiscal Intermediary. An entity that providing services allowing the participant receiving waiver services, their designee or legal representative, to choose their level of control to recruit, select, manage, train, and dismiss direct care staff regardless of the employer of record, and allows the participant control over their service delivery.(7-1-26)
IDAPA 16.03.26.541 A&d Waiver Services: Eligibility
The number of Medicaid participants to receive waiver services under the A&D HCBS waiver is limited to the projected number of users identified in the Department's approved waiver. Participants who apply for waiver services after the waiver maximum is reached are placed on a waiting list and will have their applications processed after the new waiver year begins. The earliest waiver approval date for these participants is the first date of a new waiver year.
Participants are eligible when they meet the following criteria:(7-1-26)
01.Age. Are eighteen (18) years of age or older.(7-1-26)
02.Disabling Condition. Have a disabling condition that impairs their mental or physical function or independence;(7-1-26)
03.Non-Institutional Setting. Can be maintained safely and effectively in a non-institutional setting;
04.Require Services. In the absence of such services, require the level of care provided in a NF;
05.Average Daily Cost. Cannot exceed the participant’s waiver and other medical services for the average daily cost of NF care;(7-1-26)
06.Non-Use. A participant who does not use a waiver service for thirty (30) consecutive days will be terminated from the waiver program unless services were inaccessible; and(7-1-26)
07.Admission to a NF. A participant determined by the Department to be eligible for services under the waiver may elect to not utilize waiver services and may choose admission to a NF.(7-1-26)
08.NF Level of Care, Adults. Based on assessment results, the level of impairment of an individual is established by the Department.(7-1-26)
IDAPA 16.03.26.542 A&d Waiver Services: Coverage and Limitations
Waiver services are provided to prevent institutional placement, provide for the greatest degree of independence possible, enhance quality of life, encourage individual choice, and achieve and maintain community integration.
01.Adult Day Health. Supervised, structured services provided outside the participant’s home in a non-institutional, community-based setting, and encompassing health and social services, recreation, supervision for safety, and assistance with ADL needed to ensure optimal function of the participant. Services do not include room and board payments.(7-1-26)
- Adult Residential Care. A range of services provided in a homelike, noninstitutional setting that includes licensed Residential Assisted Living Facilities and CFHs. Administrative oversight must be provided for all services provided or available in these settings. Payment does not include room and board. The number of residents in a setting is limited by an amount in the Idaho Medicaid Provider Handbook, unless otherwise authorized by the Department. Services are provided in a congregate setting and include:(7-1-26)
a.Medication assistance, to the extent permitted under State law;(7-1-26)
b.Assistance with ADL;(7-1-26)
c.Meals, including special diets;(7-1-26)
d.Housekeeping;(7-1-26)
e.Laundry;(7-1-26)
f.Transportation;(7-1-26)
g.Opportunities for socialization for participants in a RALF;(7-1-26)
h.Recreation; and(7-1-26)
i.Assistance with personal finances.(7-1-26)
03.Specialized Medical Equipment and Supplies.(7-1-26)
a.Devices, controls, or appliances enabling a participant to increase their abilities to perform ADL, or to perceive, control, or communicate with the environment in which they live; and(7-1-26)
b.Items necessary for life support, ancillary supplies and equipment necessary for the proper functioning of such items, and DME and non-DME not available under State Plan or EPSDT.(7-1-26)
04.Non-Medical Transportation (NMT). Transportation enabling a participant to access waiver and other community services and resources. Whenever possible, non-paid supports or public transit providers are used.
05.Attendant Care. Services involving tasks dealing with the functional needs of the participant and accommodating their needs for long-term maintenance, supportive care, or ADL. These services include personal assistance and medical tasks that can be done by unlicensed persons or delegated to an unlicensed person by a licensed health care professional or the participant. Services are based on a participant’s abilities and limitations, regardless of age, medical diagnosis, or other category of disability. Assistance may be hands-on assistance or prompts to perform a task.(7-1-26)
06.Chore Services. Include intermittent assistance or chore activities when necessary to maintain functional use of the participant’s home or to provide a clean, sanitary, and safe environment. Services are only available when neither the participant, nor anyone else in the home, is capable of performing or financially providing for them, and when no other non-paid support, landlord, agency, or third-party payer is willing or able to provide.
Services are limited to those provided in a home rented or owned by the participant. For rental property, the Department examines the lease agreement for landlord responsibilities prior to any authorization of service. (7-1-26)
07.Companion Services. In-home services that include non-medical care, supervision, and socialization provided to a functionally impaired adult ensuring the safety and well-being of a person who cannot be left alone due to their condition. The provider may live with a participant. The provider may provide cuing and occasional assistance ADL and perform light housekeeping tasks that are incidental to the care and supervision of the participant, but the primary responsibility is to provide companionship and be accessible in case of emergency.
08.Consultation (Self-Direction). Services provided by a PAA to a participant or family member to increase their skills as an employer or manager of their own care. Services are directed at achieving the highest level of independence and self-reliance possible for the participant and the participant’s family by consulting with the participant and family to gain a better understanding of the special needs of the participant and the role of the caregiver.(7-1-26)
09.Home-Delivered Meals. Meals delivered to the participant’s home that promote adequate nutrition. Participants can receive one (1) to two (2) meals per day when they rent or own a home, are alone for exten ded periods with no caregiver, and are unable to prepare a meal without assistance.(7-1-26)
10.Homemaker Services. Performing for or assisting the participant with essential errands and other routine housekeeping duties when no one else in the household is capable of performing these tasks.(7-1-26)
11.Environmental Accessibility Adaptations. Minor housing adaptations necessary for a participant to function with greater independence in their home, or without which, would require institutionalization or pose a risk to health, or safety including:(7-1-26)
a.Installations or modifications necessary to accommodate medical equipment and supplies necessary for the health and safety of the participant but excludes those that are not of direct medical or remedial benefit to the participant.(7-1-26)
b.Unless otherwise authorized, permanent modifications are limited to the participant's principal residence that is owned by the participant or their non-paid family.(7-1-26)
c.Portable or non-stationary modifications may be made when a participant or their non-paid family rents a home, and modifications follow a participant to their next residence.(7-1-26)
12.Personal Emergency Response System (PERS). Electronic devices enabling participants to secure help in an emergency which connects to a participant’s phone and is programmed to signal a response center when activated. The response center is staffed by trained professionals. PERS is limited to participants who rent or own a home, or live with unpaid caregivers, are alone for extended periods with no caregiver, and require extensive, routine supervision.(7-1-26)
13.Respite Care. Short-term breaks from caregiving responsibilities to non-paid caregivers. The caregiver or participant selects, trains, and directs the provider. While receiving respite care, participants cannot receive other duplicative services. Respite care does not include room and board payments. Services may be provided in a participant’s residence, CFH, DDA, RALF, or ADH facility.(7-1-26)
14.Skilled Nursing. Intermittent or continuous oversight, training, or skilled care within the scope of the Nurse Practice Act provided by an RN or LPN under the supervision of an RN. Services cannot be less costeffective than a Home Health visit.(7-1-26)
15.Residential Habilitation. Habilitation services to help an individual acquire, retain, or improve their ability to reside as independently as possible in the community or maintain family unity, and includes training in one of the following:(7-1-26)
a.Self-direction;(7-1-26)
b.Money management;(7-1-26)
c.Daily living skills;(7-1-26)
d.Socialization not including participation in non-therapeutic activities that are diversional or recreational in nature;(7-1-26)
e.Mobility;(7-1-26)
f.Behavior shaping and management.(7-1-26)
g.Personal assistance services that assist an individual in ADL, household tasks, and other routine activities as the participant or their primary caregivers are unable to accomplish on their own behalf.(7-1-26)
h.Skills training to teach participants and supports to perform activities with greater independence and to reinforce habilitation training.(7-1-26)
16.Day Habilitation. Assistance with acquisition, retention, or improvement in self-help, socialization, and adaptive skills that take place in a non-residential setting. Services focus on enabling the participant to attain or maintain their maximum functional level and are coordinated with any physical, occupational, or speechlanguage therapy services listed in the plan of care. Services may reinforce skills taught in school, therapy, or other settings.(7-1-26)
17.Supported Employment. Competitive work in integrated work settings for individuals for whom competitive employment has not traditionally occurred, or when competitive employment is interrupted or int ermittent due to severe disability. The nature and severity of an individual’s disability requires intensive supported employment services or extended services for them to work. This service is not available when funded under another
18.Transition Services. Goods and services enabling a participant residing in a NF, hospital, IMD, or ICF/IID to transition to a community-based setting immediately following discharge from a qualified institution after a minimum of forty-five (45) days.(7-1-26)
a.Services may include:(7-1-26)
i.Security deposits required to obtain a lease on an apartment or home;(7-1-26)
ii.Cost of essential household furnishings;(7-1-26)
iii.Set-up fees or deposits for utility or service access;(7-1-26)
iv.Services necessary for health and safety prior to occupancy;(7-1-26)
v.Moving expenses; and(7-1-26)
vi.Activities to assess need, arrange for, and procure transition services.(7-1-26)
b.Exclusions. Ongoing expenses (including utilities), real property, décor, or entertainment and recreational items.(7-1-26)
c.Limitations. A total cost of two thousand dollars ($2,000) per participant and only accessed every two (2) years, following a qualifying transition. Services are furnished when a participant is unable to meet an expense or when a support cannot be obtained from other sources.(7-1-26)
19.A&D Case Management. To assist participants with gaining and coordinating access to necessary care and services appropriate to the needs of the individual.(7-1-26)
IDAPA 16.03.26.543 A&d Waiver Services: Procedural Requirements
01.Individual Service Plan.
The Department administers the assessment and develops the initial individual service plan. The Department reviews and approves all individual service plans based on information from the assessment and any other medical information that verifies the need for services, and authorizes services by type, scope, and amount. All individual service plans must meet HCBS person-centered planning requirements.(7-1-26)
a.Services not in the individual service plan or exceeding those approved by the Department are not eligible for Medicaid payment.(7-1-26)
b.The earliest services can be approved is on the date an individual service plan is signed by the participant or their designee.(7-1-26)
c.All services that are provided must be based on a documented service plan.(7-1-26)
d.A new plan must be developed and approved annually.(7-1-26)
e.The plan may be adjusted during the year with an addendum. These adjustments must be based on changes in participant’s need or demonstrated outcomes. Additional assessments or information may be clinically necessary. Adjustment is subject to Department PA.(7-1-26)
02.Provider Records.(7-1-26)
a.Providers must document each visit made or service provided to the participant, and record the
ii.Services provided;(7-1-26)
iii.Statement of participant's response to services when applicable, including any changes in their condition; and(7-1-26)
iv.Length of visit, including time in and out. Unless the Department determines a participant is unable to, service delivery is verified by the participant by signing a service record.(7-1-26)
b.Providers must maintain service delivery records accessible to participants.(7-1-26)
c.The individual service plan must be available to all providers and the Department. The individual service plan and assessment are available from the Department for providers with a release of information signed by the participant or legal representative.(7-1-26)
d.EVV Systems do not replace documentation requirements but may be used to generate documentation.(7-1-26)
03.Provider Notification. Providers must document in the service record and notify the Department, medical provider, case manager, and family when any significant changes in the participant's condition are noted.
IDAPA 16.03.26.544 A&d Waiver Services: Provider Qualifications and Duties
01.Employment Status. Unless otherwise specified by the Department, each individual service provider must be an employee of an agency. The Department may enter into provider agreements with individuals in situations when no agency exists, or no FI is willing to provide services. Such agreements are reviewed annually to verify whether coverage by a PAA or FI is still not available.(7-1-26)
02.Fiscal Intermediary Services (FI). An FI providing Consultation services supporting selfdirection must:(7-1-26)
a.Assure compliance with legal requirements related to employment of providers;(7-1-26)
b.Offer supportive services to enable participants or their families to perform the required employer tasks themselves;(7-1-26)
c.Bill Medicaid for services authorized by the Department;(7-1-26)
d.Collect any participant participation due;(7-1-26)
e.Pay providers for service;(7-1-26)
f.Perform all necessary withholding as required by state and federal regulations;(7-1-26)
g.Assure that providers meet the required standards and qualifications;(7-1-26)
h.Maintain liability insurance coverage;(7-1-26)
i.Conduct annual participant satisfaction or quality control reviews made available to the Department and the public; and(7-1-26)
j.Obtain required background checks and health screens on employees.(7-1-26)
03.Provider Qualifications. Providers of homemaker, respite care, ADH, transportation, chore services, companion services, attendant care, adult residential care, A&D Case Management, and home-delivered meals must meet, either by formal training or demonstrated competency, the training requirements contained in the provider training matrix and the standards for direct care staff and allowable tasks or activities in the Department's A&D waiver as approved by CMS. Direct care workers cannot be a participant’s spouse.(7-1-26)
04.Quality Assurance (QA). Providers must respond to QA reviews within forty-five (45) days of receiving results. If problems are identified, the provider must implement a quality improvement plan and report the results to the Department upon request.(7-1-26)
05.Specialized Medical Equipment and Supplies. Must be enrolled with Medicaid as a supplier.
Providers must ensure all items meet applicable standards of manufacture, design, and installation. Preference is given to the most cost-effective option to meet a participant’s needs.(7-1-26)
06.Consultation Services. Must be provided through a PAA by a person with demonstrated skills in training participants/family members to hire, fire, train, and supervise their own care providers.(7-1-26)
07.Adult Residential Care. Must ensure that adequate staff are provided to meet the needs of the participants accepted for admission.(7-1-26)
08.Home-Delivered Meals.(7-1-26)
a.Each meal meets one third (1/3) of the Recommended Daily Allowance, as defined by the United States Department of Agriculture (USDA);(7-1-26)
b.Meals are delivered under the service plan, in a sanitary manner, and at the correct temperature for the specific type of food;(7-1-26)
c.Documentation is maintained demonstrating that the meals served are made from the highest USDA grade for each specific food served; and(7-1-26)
d.A Registered Dietitian documents the review and approval of menus, menu cycles, and any changes or substitutions.(7-1-26)
09.PERS. Must demonstrate that devices installed in a participant’s home meet Federal Communications Commission (FCC) standards.(7-1-26)
10.Adult Day Health.(7-1-26)
a.Providers must notify the Department for the participant when the service is provided in a CFH other than the participant's primary residence.(7-1-26)
b.Providers must be free from communicable disease.(7-1-26)
11.Non-Medical Transportation. Possess a valid driver’s license and vehicle insurance.(7-1-26)
12.Attendant Care. Must be employees of an agency.(7-1-26)
13.Homemaker Services. Must be employees of an agency.(7-1-26)
14.Environmental Accessibility Adaptations. Must meet applicable state or local building codes and meet state or local building, plumbing, and electrical requirements for certification.(7-1-26)
15.Residential Habilitation. Employment by a certified residential habilitation agency. Prior to delivering services, complete an orientation program and additional training requirements must be completed within six (6) months of employment.(7-1-26)
16.Day Habilitation. Employed by a certified residential habilitation agency. Prior to delivering services, staff must complete an orientation program and complete additional training within six (6) months of employment.(7-1-26)
17.Respite Care. Receive instructions in the participant’s needs, demonstrate the ability to follow the service plan, and be free of communicable disease.(7-1-26)
18.Supported Employment. Provided by an agency that meets State requirements.(7-1-26)
19.Chore Services. Be skilled in the service to be provided; and demonstrate the ability to follow a
20.Transition Services. Transition managers.(7-1-26)
21.A&D Case Management. Case Managers must be employed by an agency that is not an FI. Case Managers may not provide other services.(7-1-26)
IDAPA 16.03.26.545 A&d Waiver Services: Provider Reimbursement
01.Rates.
Reimbursement for services include both services and mileage. Mileage for provider transportation to and from the service delivery location is not reimbursable.(7-1-26)
02.Electronic Visit Verification (EVV) Compliance. Claims for Attendant Care, Homemaker, and Respite services require EVV compliance to be reimbursable.(7-1-26)
IDAPA 16.03.26.546 (Reserved)
SUB AREA: TRANSITION MANAGEMENT
(Section 549)
IDAPA 16.03.26.549 Transition Management
Provides relocation assistance and intensive service coordination activities to assist NF, hospital, IMD, and ICF/IID residents to transition to community settings of their choice. Transition managers provide oversight and coordination activities for participants during a transitional period up to twelve (12) months following a return to the community, functioning as a liaison between the participant, institutional or facility discharge staff, and other individuals identified by the participant. Participants are eligible to receive transition management when planning to discharge from a qualifying institution after residing within that institution for a minimum of forty-five (45) days.(7-1-26)
01.Provider Qualifications. Transition managers must:(7-1-26)
a.Successfully complete of a Department-approved Transition Manager training prior to providing any transition management or transition services;(7-1-26)
b.Have a Bachelor's degree in a human services field or three (3) years' supervised work experience with the population served; and(7-1-26)
c.Be employed by an agency.(7-1-26)
02.Service Description. Includes the following activities:(7-1-26)
a.A comprehensive assessment of health, social, and housing needs;(7-1-26)
b.Development of housing options, including assistance with housing choices, applications, waitlist follow-up, roommate selection, and introductory visits;(7-1-26)
c.Assistance with tasks necessary to accomplish a move from the institutional setting;(7-1-26)
d.Securing Transition Services to coordinate the move, including:(7-1-26)
i.Obtaining DME, assistive technology, and medical supplies;(7-1-26)
ii.Arranging for home modifications;(7-1-26)
iii.Applying for public assistance; or(7-1-26)
iv.Arranging household preparations including scheduling moving or cleaning services, utility set-up, purchasing furniture, and household supplies.(7-1-26)
e.Coordinating with others involved in plan development for the participant to ensure successful transition and establishment in a community setting; and(7-1-26)
f.Providing post-transition support, including assistance with problem solving, dependency and isolation concerns, consumer-directed services and supports, post-secondary educational institutions and proprietary schools, and community inclusion.(7-1-26)
03.Limitations. Transition management is limited to seventy-two (72) hours per participant per qualifying transition.(7-1-26)
SUB AREA: PERSONAL CARE SERVICES (PCS)
(Sections 550-559)
IDAPA 16.03.26.550 Pcs: Definitions
01.PCS. Medically oriented care services for a participant’s physical or functional requirements in the participant’s home or personal residence but does not include housekeeping or skilled nursing care.(7-1-26)
02.PCS Family Alternate Care Home. A private home licensed by the Department to provide PCS to one (1) or two (2) children, who are unable to reside in their own home and require medically oriented tasks related to the child's physical or functional needs.(7-1-26)
IDAPA 16.03.26.551 Pcs: Eligibility
01.Level of Care.
The Department conducts an assessment to determine whether a participant’s medical condition impairs their physical or mental functions or independence, and whether they can remain safely and effectively in their personal residence when supported by authorized PCS.(7-1-26)
02.Redetermination. Required annually to reauthorize PCS or to refer a participant to a NF. (7-1-26)
03.Significant Changes. An assessment can be requested due to changes in a participant’s needs at any time.(7-1-26)
IDAPA 16.03.26.552 Pcs: Coverage and Limitations
01.Medical Care and Services.
Tasks related to a participant's physical or functional requirements provided in the participant's personal residence including assistance with:(7-1-26)
a.Basic personal care and grooming;(7-1-26)
b.Bladder or bowel routines or requirements;(7-1-26)
c.Food, nutrition, and diet activities;(7-1-26)
d.Continuation of at home active treatment programs to increase or maintain independence for participants with DD;(7-1-26)
e.Physician-ordered medications ordinarily self-administered;(7-1-26)
f.Non-nasogastric gastrostomy tube feedings that meet the following requirements:(7-1-26)
i.Non-complex tasks that can be safely performed in a participant’s location;(7-1-26)
ii.An RN assessed a participant's needs and developed a written procedure according to a participant’s individualized needs;(7-1-26)
iii.An RN delegates by name who can perform this procedure only after an individual demonstrates safe performance of the individualized procedure. RNs must document the strengths and weaknesses of any delegates, and evaluate their performance monthly;(7-1-26)
iv.Delegates must report any change in participant status or problems with the procedure immediately to the RN;(7-1-26)
v.The supervisor RN maintains documentation of the individualized procedure, the supervised performance of the procedure, and follow-up evaluations of delegates readily available for review, in the participant's record; and(7-1-26)
vi.Direct care workers only give routine medication through a non-nasogastric tube as authorized by a supervisor RN.(7-1-26)
02.Non-Medical Care and Services. Includes the following tasks, when no natural supports are available:(7-1-26)
a.Minimal housekeeping tasks incidental to the delivery of an ADL care task essential to participant comfort or health and excludes services for any other residents.(7-1-26)
b.Accompanying a participant to medical appointments or other trips reasonably required for medical diagnosis or treatment.(7-1-26)
c.Shopping for food or other items specific to a participant’s health and maintenance.(7-1-26)
03.Place of Service. PCS may be provided in a participant's personal residence, including a CFH, a RALF, or a PCS Family Alternate Care Home (FACH), and in the community only when an individual’s daily activities take them out of the home and are limited to tasks in their approved service plan.(7-1-26)
04.Service Exclusions.(7-1-26)
a.Irrigating or suctioning any body cavity requiring sterile procedures or applying dressings with prescription medication or aseptic techniques;(7-1-26)
b.Catheter insertion or sterile irrigation;(7-1-26)
c.Injecting fluids into veins, muscles or skin; and(7-1-26)
d.Administering medication not authorized by a supervisor RN.(7-1-26)
05.Participant Limitations. Sixteen (16) hours per week unless authorized under EPSDT.(7-1-26)
06.Provider Limitations. No home, regardless of the number of providers in a home, may serve more than two (2) children authorized for eight (8) or more hours of PCS per day.(7-1-26)
IDAPA 16.03.26.553 Pcs: Procedural Requirements
01.Service Plan.
All PCS are provided based on a documented service plan according to place of service.(7-1-26)
a.PAAs prepare the service plan with participants in their own home or a PCS FACH, based on applicable physician or authorized provider information, assessment results (including any, QIDP assessments or observations), and participant provided information. Service plans must include all medical and non-medical tasks the provider performs, including amount, type, and frequency. Plans must be updated annually or based on treatment results or significant changes in participant needs.(7-1-26)
b.CFH/RALF service plans must meet applicable licensing requirements for each residence type.
02.Supervision. An RN or QIDP provides oversight of PCS as required by the Department. Activities include:(7-1-26)
a.Service plan development assistance, including in-home active treatment plans.(7-1-26)
b.Review of treatment provided and verified by service delivery records and through on-site participant interviews.(7-1-26)
c.Service plan re-evaluations, including on-site visits to evaluate change in a participant’s condition as needed.(7-1-26)
d.Immediate notification to any guardian, emergency contact, or family member when a significant change in a participant's physical condition or response to services occurs.(7-1-26)
03.PA. Authorizations are based on the participant’s assessment, individual service plan, and any other medical information supporting medical needs.(7-1-26)
04.Record Requirements in Participant Homes. PCS records must be maintained for all participants in their own homes or in a PCS (FACH), in a format accessible to the participant.(7-1-26)
a.Providers must document every visit made to a participant's home and record the date, time, duration, services provided, and any changes noted in a participant’s condition or deviations from the service plan.
b.Participants or legal guardians must verify service delivery by signing the record.(7-1-26)
c.Providers must sign the service plan indicating they will deliver services according to the authorization and consistent with HCBS requirements.(7-1-26)
d.EVV systems described do not replace documentation requirements but may be used to generate documentation.(7-1-26)
05.Provider Notification. Providers must notify the Department and the medical provider for any significant changes in a participant's condition occur, and document in the participant record.(7-1-26)
IDAPA 16.03.26.554 Pcs: Provider Qualifications and Duties
01.Direct Care Workers.
All providers must be an RN, an LPN, or meet personal assistant standards.
All staff must receive training for service quality. The Department may require a CNA for personal assistance when a participant's medical condition warrants.(7-1-26)
02.Training for Participants with DD. When services provided in a participant's home require more than physical assistance, providers must complete a Department-approved DD training course or have experience providing direct services to people with DD unless the provider qualifies as a QIDP. The Department may temporarily approve staff meeting all qualifications except for the required training course or experience, when the Department verifies:(7-1-26)
a.No other qualified providers are available;(7-1-26)
b.The direct care worker is enrolled in the next available training course with a graduation date no more than six (6) months from the request for temporary provider status; and(7-1-26)
c.A supervising QIDP provides monthly oversight visits until the direct care worker graduates from the training program.(7-1-26)
03.Children’s PCS Delivered in a Provider’s Home. Providers must be licensed or certified as a child foster care or PCS FACH.(7-1-26)
04.Health Screen. Direct Care staff must complete a health questionnaire, kept in their personnel files. If they have a medical issue, a statement from a medical provider must verify they are able to perform all required duties. Misrepresentation of information is cause for termination of employment and disqualifies an employee from providing Medicaid services.(7-1-26)
05.Personal Assistance Agency (PAA) and Fiscal Intermediaries.(7-1-26)
a.Recruit, hire, fire, train, supervise, schedule, process payroll, and ensure all direct care staff are qualified to provide quality services;(7-1-26)
b.Maintain liability insurance coverage;(7-1-26)
c.Ensure staffing of an RN or, when applicable, a QIDP supervisor to develop and complete service plans and provide supervision of service delivery;(7-1-26)
d.Assign qualified staff to participants honoring their choices; and(7-1-26)
e.Conduct annual participant satisfaction or quality control reviews available to the Department and the public.(7-1-26)
IDAPA 16.03.26.555 Pcs: Reimbursement
01.Calculated Fee. Fees include a basic rate for PCS and mileage. No separate charges are paid for provider transportation to and from a participant's home or non-medical transportation, unless authorized by the Department under another billable service.(7-1-26)
02.Rate Methodology. Rates are calculated using an annual survey of all Idaho NFs and ICFs/IID to establish the WAHR for Idaho NF employees in comparable positions.(7-1-26)
03.PAA Rates. The Department establishes PAA rates for PCS based on the WAHR multiplied by a supplemental component composed of costs reported for travel, administration, training, and all payroll taxes and fringe benefits collected during the most recent State Fiscal Year.(7-1-26)
04.CFH and RALF Rates. PCS rates for residents are paid based on their assessed care level as follows:(7-1-26)
a.Level I, any diagnosis EXCEPT Serious and Persistent Mental Illness (SPMI), DD, Alzheimer’s Disease and Related Dementias (ADRD) = one and twenty-five hundredths (1.25) hrs/day.(7-1-26)
b.Level II, any diagnosis EXCEPT SPMI, DD, ADRD = one and five tenths (1.5) hrs/day.(7-1-26)
c.Level III, any diagnosis = two and twenty-five hundredths (2.25) hrs/day.(7-1-26)
d.Level IV, ONLY SPMI, DD, ADRD who scores at level one (1) or two (2) = one and seventy-nine hundredths (1.79) hrs/day.(7-1-26)
05.Supervisor RN and QIDP Rates. The Department authorizes oversight activities paid per visit to conduct participant evaluations and for Service Plan development and may authorize additional evaluations or emergency visits as needed.(7-1-26)
IDAPA 16.03.26.556 Pcs: Quality Improvement (qi)
Providers must respond within forty-five (45) days of receiving results of a Department review. Providers must implement a QI plan for identified problems and provide results upon request.(7-1-26)
IDAPA 16.03.26.557 (Reserved)
SUB PART: ENHANCED DD SERVICES
(Sections 560-579)
IDAPA 16.03.26.560 Dd Services: Requirements
DD services, including Family-Directed Community Supports (FDCS), are covered when provided with the right care, in the right place, at the right price, and with the right outcomes to enhance health and safety, and promote participants' rights, self-determination, and independence. Services require an assessment of the need for services, development of a service plan with the budget assigned by the Department, PA of services, and a quality improvement program.(7-1-26)
01.Right Care. Standard of care for the diagnosis, functional needs, and abilities to achieve the desired outcome.(7-1-26)
02.Right Place. Services delivered in the most integrated setting in which they normally occur, based on the participant's choice to promote independence.(7-1-26)
03.Right Price. The most integrated and least expensive services that are sufficient to address the participant's needs as identified in the assessment.(7-1-26)
04.Right Outcomes. Services based on assessed need that ensure the health and safety of the participant and result in progress, maintenance, or delay or prevention of regression for the participant.(7-1-26)
IDAPA 16.03.26.561 Dd Determination Standards: Participant Eligibility
Assessments required for determining eligibility are completed prior to the participant receiving services and include documentation of a DD, an MSDA, and a functional assessment. For adult DD waiver services, an assessor must determine the participant meets ICF/IID level of care. DD as under Section 66-402, Idaho Code, is a chronic disability that appears before the age of twenty-two (22) years evidenced by:(7-1-26)
01.Impairment. Impairment is attributed to one (1) of the following:(7-1-26)
a.Intellectual Disability.(7-1-26)
i.IQ test score of seventy (70) or below with a five (5) point standard error of measurement; or
ii.A delay of thirty percent (30%) overall on a functional assessment when under the age of five (5).
b.Cerebral Palsy.(7-1-26)
c.Epilepsy, except when seizure-free and not on medication for three (3) years.(7-1-26)
d.Autism.(7-1-26)
e.Other conditions closely related or similar to a-d. requiring similar treatment or services: (7-1-26)
i.IQ test score above seventy-five (75) when functional limitations create a condition like intellectual disability.(7-1-26)
ii.Disruption in motor function like cerebral palsy.(7-1-26)
iii.Disorder causing interruption of consciousness like epilepsy.(7-1-26)
iv.Not a mental illness.(7-1-26)
f.Dyslexia resulting from a-e.(7-1-26)
02.Substantial Functional Limitations. The impairment requires a combination and sequence of services that need to be individually planned and coordinated for substantial functional limitations within three (3) major life activities in b-h.(7-1-26)
a.Substantial functional limitations are demonstrated by having a score of two (2) standard deviations below the mean. Participants under three (3) years of age can alternatively by:(7-1-26)
i.Scoring thirty percent (30%) below age norm; or(7-1-26)
ii.Exhibiting a six (6) month delay.(7-1-26)
b.Self-care.(7-1-26)
i.Under Age twenty-one (21): Manifested when age-appropriate skills are limited, and substantial assistance is required.(7-1-26)
ii.Age twenty-one (21) and Over: Manifested when the person requires assistance in performing eating, hygiene, grooming, or health care skills, or the time to complete these tasks causes substantial impairment of conducting other ADL or retaining employment.(7-1-26)
c.Receptive and expressive language.(7-1-26)
i.Under Age three (3): Manifested when they have been diagnosed with performance thirty percent (30%) below age norm (adjusted for prematurity up to two (2) years) or demonstrated at least two (2) standard deviations below the mean in either area or one-and-one half (1 1/2) below in both areas of language development.
ii.Age three (3) and Above: Manifest when a person is unable to communicate effectively without the aid of a third person, a person with special skills, or without an assistive device (such as sign language).(7-1-26)
d.Learning manifested when cognition, retention, reasoning, visual or aural communications, or other learning processes or mechanisms are impaired to the extent that interventions beyond normal are required for the development of social, self-care, language, academic, or vocational skills.(7-1-26)
e.Mobility.(7-1-26)
i.Under Age twenty-one (21): Measured by an age-appropriate instrument that compares the child's skills for postural control and movement and coordinated use of the small muscles with skills expected of children of the same age.(7-1-26)
ii.Age twenty-one (21) and Over: Manifested when fine or gross motor skills are impaired to the extent that the assistance of another person or an assistive device is required for movement from place to place.
f.Self-direction.(7-1-26)
i.Under Age twenty-one (21): Manifested when the child is unable to help themselves or cooperate with others with age-appropriate assistance to meet personal needs, learn new skills, follow rules, and adapt to environments.(7-1-26)
ii.Age twenty-one (21) and Over: Manifested when assistance is required in managing personal finances, protecting self-interest, or making decisions that may affect well-being.(7-1-26)
g.Capacity for independent living.(7-1-26)
i.Under Age twenty-one (21): Measured by an age-appropriate instrument that compares personal independence and social responsibility expected of comparable age and cultural groups.(7-1-26)
ii.Age twenty-one (21) and Over: A substantial functional limitation is manifest when, for a person's own safety or well-being, supervision or assistance is required, at least on a daily basis, in the performance of health maintenance, housekeeping, budgeting, or leisure time activities and in the utilization of community resources.
h.Economic self-sufficiency.(7-1-26)
i.Under Age five (5): Evidenced by eligibility for SSI, early intervention, or early childhood special education under the Individuals with Disabilities Education Act (IDEA).(7-1-26)
ii.Age five (5) to Age Twenty-one (21): Use the pre-vocational area of a standardized functional assessment to document a limitation in this area.(7-1-26)
iii.Age twenty-one (21) and Over: Manifested when unable to perform the tasks necessary for regular employment or limited in productive capacity to the extent that their earned annual income, after extraordinary expenses occasioned by the disability, is insufficient for self-support.(7-1-26)
03.Necessity of Care. The need for a combination and sequence of special, interdisciplinary or generic care, treatment or other services that are of life-long or extended duration and individually planned and coordinated.
a.Under Age five (5): Determined by a multi-disciplinary team for early intervention services through SSI, an IFSP, child study team or early childhood special education services through an IEP.(7-1-26)
b.Age five (5) and Over: Life-long or extended duration means the condition has reasonable likelihood of continuing for a protracted period, including continuation throughout life.(7-1-26)
IDAPA 16.03.26.562 (Reserved)
IDAPA 16.03.26.563 Dd Determination Standards: Test Instruments
01.Assessments.
A Department-approved tool for conducting cognitive and functional assessments is used to determine eligibility. An appropriate professional must verify tests over one (1) year old reflect the individual’s status.(7-1-26)
02.Children’s Test Instruments. Evaluations must be performed by qualified personnel with experience and expertise with children using age-appropriate evaluation tools and practices, considering the child's language and motor skills.(7-1-26)
IDAPA 16.03.26.564 Dd Services: Quality Improvement
01.Quality Improvement (QI).
Audit findings may lead to quality improvement (QI) activities, which consist of the Department and providers working to resolve identified issues and enhance services provided including consultation, technical assistance, and recommendations. If deficiencies are not resolved, corrective action occurs.(7-1-26)
02.Corrective Action. A formal process to address significant or unresolved deficiencies identified during the review process that includes issuance of a corrective action plan, reporting to Medicaid Program Integrity Unit, or termination of a provider agreement.(7-1-26)
03.Abuse, Fraud, or Substandard Care. Suspected abuse, fraud, or substandard care is referred to the Department and other applicable agencies.(7-1-26)
IDAPA 16.03.26.565 (Reserved)
IDAPA 16.03.26.566 Dd Services: Administrative Appeals
Applicants and participants may file an administrative appeal if they dis agree with Department decisions affecting individual rights, including eligibility determinations, assessment results, budget assignments, exception reviews, and authorization of services or service plans.(7-1-26)
IDAPA 16.03.26.567 (Reserved)
IDAPA 16.03.26.568 Adult Dd Services: Definitions
01.Clinical Review.
Process of professional review to validate the need for continued services.
02.Exception Review. Clinical review of a plan falling outside established standards due to a health or safety risk.(7-1-26)
03.Health. The prevention of deterioration of one’s physical or mental health condition, cognitive functioning, or an increase in maladaptive behavior, and is related to the effects of one’s disability.(7-1-26)
04.Health Risks. Must be established through written documentation and current treatment recommendations from a licensed practitioner of the healing arts under these rules, or other professional licensed by the State of Idaho whose recommendation is within the scope of their license. Such documentation must establish:
a.The current physical or mental condition, or cognitive functioning that will likely deteriorate, or the current maladaptive behavior(s) that will likely increase; and(7-1-26)
b.The specific supports or services being requested, including type and frequency if applicable, that will address the identified need.(7-1-26)
c.To comply with the documentation requirement, the Department may require the participant to obtain additional consultation or assessment, available to the participant and covered by Medicaid, from a professional licensed by the State of Idaho acting within the scope of their license. If the Department requires additional consultation or assessment, the Department will specify the nature of the consultation or assessment and the necessary documentation.(7-1-26)
05.Safety. Prevention of criminal activity, destruction of property, or injury or harm to self or others.
06.Safety Risks. Must be documented by the following:(7-1-26)
a.Current incident reports;(7-1-26)
b.Police reports;(7-1-26)
c.Assessments from a licensed practitioner of the healing arts under these rules or a professional licensed in Idaho and whose assessment is within the scope of their license; or(7-1-26)
d.Status reports and implementation plans that reflect the type and frequency of intervention(s) in place to prevent the risk and the participant’s progress under such intervention(s).(7-1-26)
e.Such documentation must establish:(7-1-26)
i.An imminent or likely safety risk; and(7-1-26)
ii.The specific supports or services that are being requested, including the type and frequency if applicable, that are likely to prevent that risk.(7-1-26)
IDAPA 16.03.26.569 Adult Dd Services: Eligibility Determination
Participants aged eighteen (18) or older are eligible for adult DD services when they meet DD determination standards.(7-1-26)
IDAPA 16.03.26.570 (Reserved)
IDAPA 16.03.26.571 Adult Dd Services: Coverage and Limitations
PA is required for service coordination, DD waiver and DD state plan services. Services must be delivered under a service plan by providers selected by the participant.(7-1-26)
IDAPA 16.03.26.572 Adult Dd Services: Procedural Requirements
Providers must immediately report all allegations or suspicio ns of mistreatment, abuse, neglect, or exploitation, and injuries of unknown origin to the agency administrator, the Department, the adult protection authority, and any other required entity.(7-1-26)
IDAPA 16.03.26.573 Adult Dd Services: Service Plan Requirements
The service plan identifies the type of service to be delivered, g oals to be addressed within the plan year, frequency of supports and services, and providers. The service plan must include activities to promote progress, maintain functional skills, or delay or prevent regression. Unless the participant has a guardian, who retains full decisionmaking authority, the participant must make decisions regarding the type and amount of services. The Department, with the participant, ensures the service plan is based on the individualized participant budget. The plan developer must distribute a copy of the service plan, in whole or part, to any other provider identified by the participant during the person-centered planning process.(7-1-26)
01.Assessment. The assessment with a Department-approved tool for DD service eligibility is required for all participants prior to plan development and includes:(7-1-26)
a.History and Physical. A medical provider’s assessment and referral for nursing services and developmental therapy if anticipated to be part of the service plan. A history and physical is required within the year prior to the initiation of service and updated annually, by the medical provider.(7-1-26)
b.Medical, Social, and Developmental Assessment (MSDA). An assessment reviewed annually to assure it accurately reflects the participant’s status. The current assessment must be evaluated prior to the initiation of adult DD services. Providers obtain and use this assessment documentation for adult program or service plan development.(7-1-26)
c.Medical Condition. The participant’s medical conditions, risk of deterioration, living conditions, and individual goals.(7-1-26)
d.Behavioral or Psychiatric Needs. Behavioral or psychiatric needs that require special consideration.
02.Paid Plan Developer Qualifications. Providers of direct services to the participant, or the assessor, cannot be chosen to be a paid plan developer. Plan development requires an individual be employed as a service coordinator.(7-1-26)
03.Plan Development. The plan development process must meet the HCBS person-centered planning requirements. The participant may facilitate their own person-centered planning meeting or designate a paid or nonpaid plan developer.(7-1-26)
04.No Duplication of Services. The plan developer ensures that there is no duplication of services.
05.Plan Monitoring. The planning team, including a plan monitor, must identify the frequency of monitoring, which must be at least every ninety (90) days. Plan monitoring includes contacting providers to identify barriers to service delivery, discussing participant satisfaction with the quality and quantity of their services, and review of provider status reviews.(7-1-26)
06.Provider Status Reviews. Providers required to develop a PIP must report the participant's progress toward goals to the plan monitor on the provider status review when the plan has been in effect for six (6) months and at the annual person-centered planning meeting. The semi-annual review is due fifteen (15) days after the end of the sixth month. The annual review is due thirty (30) days after plan’s end. Semi-annual and annual reviews include status of supports and services to identify progress, maintenance, or delay or prevention of regression.
07.Informed Choice. Prior to plan development, the plan developer must document they provided information and support to the participant to maximize their ability to make informed choices regarding the services and supports they receive and from whom. Planning team members must each indicate whether they believe the service plan meets the needs of the participant and represents the participant's choice. If there is a conflict that cannot be resolved among person-centered planning members or if a member does not believe the plan meets the participant’s needs or represents the participant’s choice, the service plan or amendment may be referred to the Department to negotiate a resolution.(7-1-26)
08.Provider Implementation Plan (PIP). Providers must develop a PIP that complies with HCBS setting requirements and identifies specific measurable objectives that relate to goals finalized and agreed to in the participant’s authorized service plan. These objectives must demonstrate how the provider will assist the participant to meet the participant's goals, desired outcomes, and needs identified in the service plan.(7-1-26)
a.Exceptions. A PIP is not required for providers of:(7-1-26)
i.Specialized medical equipment;(7-1-26)
ii.Home-delivered meals;(7-1-26)
iii.Environmental accessibility adaptations;(7-1-26)
iv.Non-Medical Transportation;(7-1-26)
v.Personal Emergency Response System;(7-1-26)
vi.Respite care;(7-1-26)
vii.Chore services;(7-1-26) viii.Community crisis support services;(7-1-26)
ix.Adult DD service coordination; and(7-1-26)
x.Adult Day Health.(7-1-26)
b.Time To Complete. PIPs must be completed within fourteen (14) days of receipt of the authorized service plan, or the service start date, whichever is later. If the authorized service plan is received after the service start date, providers must support billing by documenting service delivery as agreed to by the participant and consistent with these rules. PIP revisions must be based on changes to the needs of the participant.(7-1-26)
c.PIP changes must be included in the participant's record, stating the reason for the change, documentation of coordination with other providers, the date a change was made, and the name and title of the person making the change.(7-1-26)
09.Addendum to the Service Plan.(7-1-26)
a.A service plan may be adjusted during the year with an addendum, subject to Department PA.
These adjustments must be based on a change to a cost, addition or increase of a service, change of provider, addition of a restrictive intervention, or addition or increase of alone time. Additional assessments or information may be clinically necessary.(7-1-26)
b.The Department distributes a copy of the authorized addendum to providers responsible for the implementation of the plan.(7-1-26)
c.Upon receipt of the addendum, the provider must sign the addendum indicating they have reviewed the plan adjustment and will deliver services accordingly. Documentation must include the signature of the professional responsible for service provision with their title and the date signed and maintained in the participant's record. Provider signatures are completed each time an addendum is authorized.(7-1-26)
10.Annual Service Reauthorization. A new service plan must be provided to the Department by the plan developer at least forty-five (45) days prior to the expiration date of the current service plan for personal assistance unless delayed because of participant unavailability due to extenuating circumstances. If the service plan is not submitted within the period, authorization for provider payments may be terminated. Prior to submission, the plan developer must notify the providers who appear on the service plan of the annual review date, obtain a copy of the most recent provider status review, and convene the person-centered planning team to develop a new service plan.
11.Notifications. The Department notifies participants of its decision on their service plan.
Notification includes an individualized explanation and how to appeal.(7-1-26)
IDAPA 16.03.26.574 Adult Dd Services: Provider Reimbursement
Providers are reimbursed on a fee-for-service basis based on a participant budget.(7-1-26)
Individualized Budget. The Department sets an individualized budget annually for each participant and notifies them of their set budget amount as part of the eligibility process. Notification includes information on appealing the set budget amount. Individualized budgets may be re-evaluated at the participant’s request when there are documented changes in their condition with medical necessity for services not reflected in the current inventory of needs.(7-1-26)
02.Exception Review. Service plans or addenda requesting services exceeding the assigned budget authorized by the assessor are reviewed and authorized by the Department. Requests are authorized when one (1) of the following is met:(7-1-26)
a.Services requested on the plan or addendum are needed to assure participant health and safety or to mitigate a documented health or safety risk.(7-1-26)
b.Supported employment is needed for the participant to obtain or maintain employment.(7-1-26)
03.Supported Living Levels of Support. Reimbursement for supported living is based on the participant's assessed level of support need. All service plans for supported living must include community integration goals that provide for maintained or enhanced independence, quality of life, and self-determination. As a participant’s independence increases and they are less dependent on supports, they must transition to less intense supports.(7-1-26)
a.High support is for participants who require twenty-four (24) hour per day supports and supervision. A blend of one-to-one and group staffing is allowed. Developmental therapy, ADH, and NMT are included in this daily rate.(7-1-26)
b. Intense support is for participants who require one-on-one, twenty-four (24) hour per day supports and supervision. Requests for a blend of one-on-one and group staffing will be reviewed on a case-by-case basis.
Developmental therapy, ADH, and NMT are included in this daily rate. To qualify for intense support, participants must be evaluated to meet one of the following criteria:(7-1-26)
i.Recent felony convictions or charges for offenses related to the serious injury or harm of another person.(7-1-26)
ii.History of predatory sexual offenses and at high risk to re-offend.(7-1-26)
iii.Documented, sustained history of serious aggressive behavior showing a pattern of causing harm to themselves or others.(7-1-26)
iv.Chronic or acute medical conditions that are so complex or unstable that one-to-one staffing is required to provide frequent interventions and constant monitoring, without which would require placement in a NF, hospital, or ICF/IID with twenty-four- (24) hour on-site nursing.(7-1-26)
c.Hourly support is for individuals whose needs can be met with less than twenty-four (24) hour per day support. The combination of hourly supported living, developmental therapy, supported employment, and ADH cannot exceed the maximum set daily amount established by the Department, except when:(7-1-26)
i.A participant is eligible for high support;(7-1-26)
ii.Supported employment is included in the service plan, causing the combination to exceed the daily limit;(7-1-26)
iii.Documentation confirming the Person-Centered Planning team explored other options including lower-cost services and supports; and(7-1-26)
iv.A participant's health and safety needs can be met using hourly services.(7-1-26)
IDAPA 16.03.26.575 (Reserved)
SUB-PART: CHILDREN’S DD HCBS STATE PLAN OPTION
(Sections 580-589)
IDAPA 16.03.26.580 Children’s Dd Hcbs State Plan Option: Definitions
Definitions also apply to Family-Directed Community Supports (FDCS).(7-1-26)
Community. Natural, integrated environments outside of the participant’s home, outside of DDA center-based settings, or at school outside of school hours.(7-1-26)
02.Family-Centered Planning Process. A participant-focused planning process facilitated by the plan developer and directed by the participant or the participant’s decision-making authority to help them make informed choices about the services and supports included on the service plan.(7-1-26)
03.Family-Centered Planning Team. A group who discusses the participant’s strengths, needs, and preferences, including their safety and the safety of those around them to develop the participant’s service plan. This group includes the participant, the participant’s decision-making authority, plan developer, and people chosen by the participant and the family.(7-1-26)
IDAPA 16.03.26.581 Children’s Dd Hcbs State Plan Option: Eligibility Determination
Eligibility also applies to Family-Directed Com munity Supports (FDCS).(7-1-26)
01.Eligibility Determination. A participant is eligible for the children's DD HCBS state plan option from birth through age seventeen (17), when they have a DD and a demonstrated need for these services.(7-1-26)
02.Individualized Budget Methodology. The following categories are used to determine individualized budgets for children with DD.(7-1-26)
a.Level I. Children meeting DD criteria.(7-1-26)
b.Level II. Children who qualify based on functional limitations when their composite full-scale standard score of less than fifty (50) or have an overall standard score up to fifty-three (53) when combined with a maladaptive behavior score of greater than one (1) to less than two (2) standard deviations from the mean.(7-1-26)
c.Level III. Children who qualify based on functional limitations with a composite full-scale standard score less than fifty (50) with an autism spectrum disorder diagnosis.(7-1-26)
d.Level IV. Children who qualify based on maladaptive behaviors when their maladaptive behavior score is two (2) standard deviations or greater from the mean.(7-1-26)
03.Annual Re-Evaluation. Budgets are re-evaluated annually or at the request of the participant, the Department when there are documented changes that may support placement in a different budget category. (7-1-26)
04.Lapse in Service. For participants re-applying for services, the assessor evaluates whether assessments are current and accurately describe the status of the participant.(7-1-26)
IDAPA 16.03.26.582 Children's Dd Hcbs State Plan Option: Coverage and Limitations
All children's DD HCBS are ident ified on a service plan developed by the family-centered planning team and must be prior authorized.(7-1-26)
01.Respite. Supervision on an intermittent or short-term basis for unpaid caregiver relief or in response to a family emergency or crisis, provided by a DDA or an independent provider. Payment does not include room and board. Respite may be provided in a participant's home, the private home of the independent provider, a DDA, or in the community. The following limitations apply:(7-1-26)
a.Not be provided to enable an unpaid caregiver to work.(7-1-26)
b.Only participants living with an unpaid caregiver are eligible.(7-1-26)
c.Cannot exceed fourteen (14) consecutive days.(7-1-26)
d.Must not be provided at the same time as other Medicaid services except family education for an unpaid caregiver.(7-1-26)
e.Providers must not use restraints on participants, other than physical restraints in the case of an emergency, to prevent injury to the participant or others and as documented in the participant's record.(7-1-26)
f.When group respite is community or center-based, there must be at least one (1) qualified staff member providing direct services to every two (2) to six (6) participants. As the number and severity of the participants with functional impairments or behavioral needs increase, the participant ratio must be adjusted accordingly.(7-1-26)
g.Independent providers cannot provide center-based respite and may only provide group respite when the provider is a relative and the service is delivered in the participant’s or provider’s home.(7-1-26)
02.Community-Based Supports. Facilitates a participant's independence and integration into the community by providing an opportunity to explore their interests, practice skills learned in other therapeutic environments and learn through interactions in typical community activities. Community-based supports must:
a.Not supplant services provided in school or therapy, or the role of a primary caregiver;(7-1-26)
b.Ensure involvement in age-appropriate activities in integrated settings; and(7-1-26)
c.Have at least one (1) qualified staff providing direct services for up to six (6) participants when provided as group community-based supports. As the number and severity of the participants with functional impairments or behavioral needs increase, the staff participant ratio must be adjusted accordingly.(7-1-26)
03.Family Education. Professional assistance to caregivers to help them meet the participant’s needs by providing an orientation to DDs and to educate them on generalized strategies for behavioral modification and intervention techniques specific to a participant’s diagnosis and the needs identified on the service plan. Training may be provided in a group setting not exceeding five (5) families. Providers must survey the parent or legal guardian's satisfaction of services immediately following a family education session.(7-1-26)
04.Family-Directed Community Supports (FDCS). Families of eligible participants may choose to direct an individualized budget rather than receive traditional children's DD HCBS state plan option services when the participant lives at home with their parent or legal guardian. FDCS must be delivered on a one-to-one basis as identified on the service plan and requires PA and quality assurance.(7-1-26)
05.Limitations for State Plan and Family-Directed Community Supports (FDCS).(7-1-26)
a.Services are limited by the participant's individualized budget amount.(7-1-26)
b.Services offered under the Medicaid Basic Plan cannot be authorized.(7-1-26)
c.Duplication of services cannot be provided:(7-1-26)
i.Goals are not separate and unique to each item or service provided; or(7-1-26)
ii.When more than one (1) service is provided at the same time, unless otherwise authorized.
IDAPA 16.03.26.583 Children’s Dd Hcbs State Plan Option: Service Plan
In collaboration with the participant, the Department ensures the participant develops one (1) service plan within their individualized participant budget. Paid plan development is provided by the Department.(7-1-26)
01.History and Physical. Prior to the development of the service plan, the plan developer must obtain a current history and physical completed by a medical provider annually, or earlier as determined by the medical provider. Also, required for Family-Directed Community Supports (FDCS).(7-1-26)
02.Service Plan Development. The service plan is developed with the participant, their decisionmaking authority, facilitated by the Department. If the participant is unable to attend the family-centered planning meeting, the service plan must contain documentation justifying their absence. Also, required for Family-Directed Community Supports (FDCS).(7-1-26)
03.Requirements for Collaboration. Providers must coordinate with the family-centered planning team as specified on the service plan. Also, required for Family-Directed Community Supports (FDCS).(7-1-26)
04.Plan Monitoring. The family-centered planning team must identify the frequency of monitoring, which must be at least every six (6) months. The plan monitor meets face-to-face with the participant and their decision-making authority at least annually.(7-1-26)
05.Provider Status Reviews. Community-Based Support providers must submit six (6) month and annual provider status reviews to the plan monitor. Six-month status reviews must be submitted thirty (30) days prior to the six-month date listed on the plan. Annual provider status reviews must be submitted forty-five (45) days prior to expiration of the existing plan.(7-1-26)
06.Addendums. A service plan may be adjusted with an addendum when based on changes in participant needs, requested and signed by a decision-making authority, and PA by the Department. The Department distributes the addendum to providers involved in implementation. Providers must review an addendum upon receipt, and sign and return it to the Department, maintaining a copy in the participant's record.(7-1-26)
07.Annual Reauthorization for State Plan and Family-Directed Community Supports (FDCS).
IDAPA 16.03.26.584 Children's Dd Hcbs State Plan Option: Procedural Requirements
01.Supervision.
All providers must be supervised by an intervention specialist or professional.
Observation and review of direct services must be performed monthly, or more often as needed, ensuring staff demonstrate the necessary skills to correctly provide services.(7-1-26)
02.Quality Assurance. Providers must demonstrate high quality of services through internal quality assurance reviews.(7-1-26)
03.Documentation. Providers must maintain records for each participant served. Failure to maintain documentation results in recoupment of payments for undocumented services. Documentation must include:
a.Visit date and time in and out;(7-1-26)
b.Services provided;(7-1-26)
c.Session summary;(7-1-26)
d.Service location; and(7-1-26)
e.Signature of the provider and date signed.(7-1-26)
IDAPA 16.03.26.585 Children's Dd Hcbs State Plan Option:
PROVIDER QUALIFICATIONS AND DUTIES.
01.Respite. Provi ded by a DDA or an independent provider meeting these minimum qualifications:
a.Be at least sixteen (16) years old when employed by a DDA or eighteen (18) years old when an independent provider;(7-1-26)
b.Receive instructions in the participant’s needs;(7-1-26)
c.Demonstrate ability to provide services according to a service plan; and(7-1-26)
d.Obtain and maintain CPR and first aid certification prior to delivering services.(7-1-26)
02.Community-Based Support. Provided by a DDA or an independent provider meeting these minimum qualifications:(7-1-26)
a.Be at least eighteen (18) years old;(7-1-26)
b.Receive instructions in the participant’s needs;(7-1-26)
c.Demonstrate ability to provide services according to a service plan;(7-1-26)
d.Be supervised or have six (6) months supervised experience working with children with DD.
e.Complete coursework approved by the Department demonstrating competencies related to providing community-based supports; and(7-1-26)
f.Obtain and maintain CPR and first aid certification prior to delivering services alone.(7-1-26)
03.Family Education. Provided by a DDA or an independent intervention specialist or professional.
IDAPA 16.03.26.586 Children’s Dd Hcbs State Plan Option: Reimbursement
Providers are reimbursed on a fee-for-service basis for services identified on a participant's service plan.(7-1-26)
IDAPA 16.03.26.587 (Reserved)
ADULT DD HCBS STATE PLAN OPTION
(Sections 590-609)
IDAPA 16.03.26.590 Adult Dd Hcbs State Plan Option
DD state plan services are provided through an HCBS State Plan option for adults with DD, and who do not meet ICF/IID level of care.(7-1-26)
IDAPA 16.03.26.591 Adult Dd Hcbs State Plan Option: Eligibility
Individuals must be eighteen (18) years or older, live in th e community, and meet DD determination standards.
IDAPA 16.03.26.592 Community Crisis Supports
Interventions for participants determined eligible for Adult DD HCBS State Plan services who risk losing housing, emp loyment, income, or at risk of incarceration, physical harm, or family altercations.(7-1-26)
IDAPA 16.03.26.593 Community Crisis Supports: Coverage and Limitations
Services are authorized after an intervention when a documented need for immed iate intervention exists, no other supports were available, and services were appropriate to rectify the crisis. Services are limited to a maximum of twenty (20) hours during any consecutive 5-day period.(7-1-26)
01.Emergency Room (ER). Services may be provided in an ER during the evaluation process if the goal is to prevent hospitalization and return to the community.(7-1-26)
02.Before Plan Development. Services may be provided before completion of the service plan when the service plan includes identification of the factors contributing to the crisis and a strategy for addressing those factors in the future.(7-1-26)
03.Crisis Resolution Plan. After services are provided, the provider must complete and submit a crisis resolution plan to the Department for approval within five (5) business days.(7-1-26)
IDAPA 16.03.26.594 (Reserved)
IDAPA 16.03.26.600 Developmental Therapy
The Department pays for services to eligible participan ts with recommendations from a medical provider and provided by licensed DDAs.(7-1-26)
IDAPA 16.03.26.601 (Reserved)
IDAPA 16.03.26.602 Developmental Therapy: Coverage and Limitations
01.Coverage. Devel opmental therapy is delivered in a DDA center-based program, the community, or the participant’s home, and includes individual developmental therapy and group developmental therapy. Services must:(7-1-26)
a.Be directed toward rehabilitation or habilitation of physical or DDs in the areas of self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, or economic self-sufficiency.(7-1-26)
b.Include age-appropriate instruction in ADLs not gained by a participant during normal developmental stages or not likely to develop without training or therapy.(7-1-26)
c.Not include tutorial activities or assistance with educational tasks associated with educational needs resulting from a disability.(7-1-26)
d.Both individual and group therapy must be available based on participant needs, interests, or choices.(7-1-26)
e.Include a minimum of one (1) qualified staff member providing direct services for every twelve (12) participants when center based.(7-1-26)
f.Occur in integrated, inclusive settings with no more than three (3) participants per qualified staff at each community-based session. Additional staff must be added when necessary to meet the needs of each individual served.(7-1-26)
02.Limitations. Developmental therapy may not exceed these limitations:(7-1-26)
a.No more than twenty-two (22) hours per week.(7-1-26)
b.No more than forty (40) hours per week in combination with ADH and supported employment.
c.Only one (1) type of Medicaid-reimbursable therapy during a single period.(7-1-26)
d.Cannot be reimbursed when providing transportation to and from the agency.(7-1-26)
IDAPA 16.03.26.603 Developmental Therapy: Individual Service Plan (isp) Requirements
01.Intake. Prior to serv ice delivery, DDAs must obtain a participant’s current MSDA and authorized ISP.(7-1-26)
02.Plan Changes. Changes to the ISP or PIP must be documented in the participant's record, and include the reason for the change, the date of change, and the name and title of the professional making the change.
IDAPA 16.03.26.604 Developmental Therapy: Individual Program Plan (ipp) Procedural
REQUIREME
NTS.
01.Intake. Participants receiving HCBS A&D waiver services or PCS only requesting Developmental Therapy, may access services using an IPP, which does not require a DD plan developer. Services delivered through an IPP must be authorized by the Department and be based on the A&D waiver Service Plan. Prior to service delivery, a DDA must complete an IPP that meets the standards below.(7-1-26)
02.IPP Development. IPPs must:(7-1-26)
a.Be developed after completion of all required assessments;(7-1-26)
b.Be signed prior to delivery of services by a medical provider, the participant, and their legal guardian if applicable;(7-1-26)
c.Be developed at least annually, or more often, when necessary, to review or update the IPP to reflect any changes in the participant’s needs or status; and(7-1-26)
d.Promote self-sufficiency, participant choice in program objectives and activities, encourage participant’s participation and inclusion in the community, and contain age-appropriate objectives.(7-1-26)
03.IPP Changes. Changes to an IPP require notification and written authorization by the participant and their legal guardian if one (1) exists. Changes in type, amount, or duration of services must be recommended by a medical provider in writing. If the signatures of the participant or their legal guardian cannot be obtained, the DDA must document in the participant's record why signatures were not obtained. PIP changes must include the following documentation in the participant's record:(7-1-26)
a.Reason for a change;(7-1-26)
b.Coordination with other service providers, when applicable;(7-1-26)
c.Date of change; and(7-1-26)
d.Signature, date, credentials, and title of the professional making the change.(7-1-26)
IDAPA 16.03.26.605 Developmental Therapy: Procedural Requirements
DDAs must obtain all assessments required for DD services eligibility, billing no more than four (4) hours for the combination of all assessment, evaluation, or diagnostic services provided in a calendar year. The following assessment and diagnostic services are reimbursable:(7-1-26)
01.Comprehensive Developmental Assessment. Assessments must:(7-1-26)
a.Be conducted by a Developmental Specialist and determine necessity of a service, guide treatment, and identify the participant's current strengths, needs, and interests.(7-1-26)
b.Be signed and dated by the professional completing the assessment, including their appropriate professional credentials or qualifications.(7-1-26)
c.Reflect the current status of the participant with assessments completed or updated at least every two (2) years.(7-1-26)
d.Reflect a person's developmental status in the following areas:(7-1-26)
i.Self-care;(7-1-26)
ii.Receptive and expressive language;(7-1-26)
iii.Learning;(7-1-26)
iv.Gross and fine motor development;(7-1-26)
v.Self-direction;(7-1-26)
vi.Capacity for independent living; and(7-1-26) vii Economic self-sufficiency.(7-1-26)
02.Specific Skill Assessments. These assessments must:(7-1-26)
a.Further assess an area of limitation or deficit identified on a comprehensive developmental assessment.(7-1-26)
b.Relate to a goal on an IPP or ISP.(7-1-26)
c.Be conducted by qualified professionals to determine a participant’s skill level within an area.
d.Be used to determine baselines and develop a PIP.(7-1-26)
03.Documentation Requirements. DDAs must maintain records for each participant served. Each record must include documentation of the participant's involvement in and response to the services provided. For each participant, the following documentation is required:(7-1-26)
a.Daily entry of all activities conducted toward meeting their objectives.(7-1-26)
b.Sufficient progress data accurately assessing a participant's progress toward each objective;
c.Review of data, and, when applicable, changes in the daily activities or implementation procedures by the qualified professional, including their dated initials.(7-1-26)
d.Documentation for six (6) month and annual reviews by the Developmental Specialist including a written description of the participant's progress toward their achievement of therapeutic goals, and reasons they continue to need services.(7-1-26)
e.Authorized service plan.(7-1-26)
04.PIP Requirements. The DDA must develop a PIP for each DDA objective included on the participant's IPP or ISP. All PIPs must relate to a goal or objective on the participant's IPP or ISP. PIPs must be developed within fourteen (14) days of service start date or receipt of an authorized IPP or ISP and be revised whenever participant needs change. If the PIP is not completed within fourteen (14) days, the participant's records must contain participant-based documentation justifying the delay. The provider addresses goals and objectives as agreed to by the participant until the annual PIP is completed and documents service delivery related to their interim goals and objectives. The PIP must include:(7-1-26)
a.Participant’s name.(7-1-26)
b.A baseline statement addressing the participant's skill level and abilities related to specific skills to be learned.(7-1-26)
c.Measurable, behaviorally stated objectives corresponding to the goals or objectives authorized in the service plan.(7-1-26)
d.Written instructions for staff that include curriculum, interventions, task analyses, activity schedules, type and frequency of reinforcement, and data collection including probe, directed at the achievement of each objective. These instructions must be individualized and revised as necessary to promote participant progress toward stated objectives.(7-1-26)
e.Identification of the environments where services are provided.(7-1-26)
f.Target date for completion.(7-1-26)
05.Informed Objectives. Results from a psychological or psychiatric assessment must be used when developing objectives to ensure therapies provided by the DDA accommodate the participant’s mental health needs and none of the therapeutic methods are contra-indicated or delivered in a manner that presents risks to the participant's mental health status.(7-1-26)
IDAPA 16.03.26.606 Developmental Therapy: Provider Qualifications and Duties
01.Developmental Specialists.
Developmental Specialists for adults must have two hundred forty (240) hours of professionally supervised experience with individuals with DD and either:(7-1-26)
a.Possess a bachelor's or master's degree in the human services field; or(7-1-26)
b.Possess a bachelor's or master's degree in any area and have:(7-1-26)
i.Completed a competency course approved by the Department relating to Developmental Specialist job requirements; and(7-1-26)
ii.Passed a Department-approved competency examination.(7-1-26)
c.Any person employed as a Developmental Specialist in Idaho prior to May 30, 1997, unless previously disallowed by the Department, may continue providing services as a Developmental Specialist as long as there is not a gap of more than three (3) years of employment as a Developmental Specialist.(7-1-26)
02.Developmental Therapy Paraprofessionals. Paraprofessionals who are at least seventeen (17) years old may be used by a DDA to provide developmental therapy when under the supervision of a Developmental Specialist.(7-1-26)
03.Collaboration with Other Providers. When participants receive rehabilitative or habilitative services from other providers, the DDA must coordinate each participant’s program with their providers to maximize skill acquisition and generalization of skills across environments and avoid duplication of services. DDAs must maintain documentation of any collaboration that includes other service plans. Participant’s files must also reflect how all services are integrated into a DDA’s plan for each participant.(7-1-26)
IDAPA 16.03.26.607 Staffing Requirements
01.Paraprofessional Standards.
When a paraprofessional provides developmental therapy, the DDA must ensure adequate supervision by a Developmental Specialist during service hours. The following standards apply:(7-1-26)
a.DDAs must ensure paraprofessionals do not conduct assessments, establish service plan, or develop a PIP. These activities are conducted by a Developmental Specialist.(7-1-26)
b.On a weekly basis or more often, if necessary, DDAs must ensure a Developmental Specialist is available for all paraprofessionals under their supervision to give instructions, review progress, and provide training on the programs and procedures.(7-1-26)
c.DDAs must ensure that a Developmental Specialist, on a monthly basis or more often, if necessary, observes and reviews the work performed by paraprofessionals under their supervision, to ensure they are trained on the programs and demonstrate necessary skills to correctly implement them.(7-1-26)
02.Agency Staffing Requirements. Each DDA must employ an administrator accountable for all service elements and who is employed on a continuous, regularly scheduled basis. The administrator is accountable for the overall operations of the DDA including ensuring compliance with rules, overseeing and managing staff, developing and implementing written policies and procedures, and overseeing the agency's quality assurance
a.When the administrator is not a Developmental Specialist, the DDA must employ a Developmental Specialist on a continuous, regularly scheduled basis who is responsible for the service elements of the agency; and
b.The Developmental Specialist responsible for the service elements of the agency must have two (2) years of supervisory or management experience providing DD services to individuals with DD.(7-1-26)
IDAPA 16.03.26.608 (Reserved)
ADULT DD HCBS WAIVER SERVICES
(Sections 610-629)
IDAPA 16.03.26.610 Adult Dd Waiver Services
The Department provides waiver services to eligible particip ants, preventing unnecessary institutionalization, allowing the greatest degree of independence possible, enhancing the quality of life, encouraging individual choice, and achieving and maintaining community integration.(7-1-26)
IDAPA 16.03.26.611 Adult Dd Waiver Services: Participant Eligibility
The Department determines waiver eligibility. The participant must meet the following:(7-1-26)
01.Age. Be eighteen (18) years or older.(7-1-26)
02.Eligibility. The Department must determine whether:(7-1-26)
a.The participant would qualify for ICF/IID level of care if the DD waiver services were not available;(7-1-26)
b.The participant can reside safely and effectively in a non-institutional setting; and(7-1-26)
c.The average annual cost of a participant’s waiver and other medical services do not exceed the average annual cost to Medicaid for ICF/IID care and other medical costs.(7-1-26)
03.DD Waiver Eligibility. Participants eligible for DD waiver services may instead choose admission to an ICF/IID.(7-1-26)
04.Redetermination.(7-1-26)
a.Financial and medical redetermination are conducted annually or sooner at the request of the participant, self-reliance, a provider agency, or medical provider.(7-1-26)
b.The redetermination process will assess the participant's continued need and eligibility for waiver services and discharge from the waiver services program.(7-1-26)
05.Notifications. The Department notifies participants of the eligibility decision after an assessment.
Notification includes an individualized explanation of the decision and how they may appeal.(7-1-26)
06.Adult DD Waiver Limits. The number of Medicaid participants to receive waiver services under the Adult DD waiver is limited to the projected number of users in a CMS-approved waiver. Individuals applying for this waiver after the maximum is reached are placed on a waiting list to have their applications processed after September 30th for the new DD waiver year.(7-1-26)
IDAPA 16.03.26.612 Adult Dd Waiver Services: Coverage and Limitations
01.Residential Habilitation.
An integrated array of individually tailored services and supports designed to assist participants reside successfully in their own homes, with their families, or in CFHs. The number of residents in a setting will be limited by an amount in the Idaho Medicaid Provider Handbook, unless otherwise authorized by the Department. Residential Habilitation consists of the following:(7-1-26)
a.Habilitation services to help an individual acquire, retain, or improve their ability to reside as independently as possible in the community or maintain family unity, and include training in at least one (1) of the following areas:(7-1-26)
i.Self-direction, including the identification of and response to dangerous or threatening situations, making decisions and choices affecting the individual's life, and initiating changes in living arrangements or life activities;(7-1-26)
ii.Money management;(7-1-26)
iii.Daily living skills;(7-1-26)
iv.Socialization not including participation in non-therapeutic activities that are diversional or recreational in nature;(7-1-26)
v.Mobility; and(7-1-26)
vi.Behavior shaping and management.(7-1-26)
b.Personal Assistance Services that assist an individual in ADL, household tasks, and other routine activities as the participant or their primary caregivers are unable to accomplish on their own.(7-1-26)
c.Skills training to teach participants and supports to perform activities with greater independence and to reinforce habilitation training.(7-1-26)
02.Chore Services. Intermittent assistance or chore activities when necessary to maintain functional use of the participant’s home or to provide a clean, sanitary, and safe environment. Services are only available when neither the participant, nor anyone else in the home, is capable of performing or financially providing for them, and when no other non-paid support, landlord, agency, or third-party payer is willing or able to provide. Services are limited to those provided in a home rented or owned by the participant. For rental property, the Department examines the lease agreement for landlord responsibilities prior to any authorization of service.(7-1-26)
03.Respite Care. Short-term breaks from caregiving responsibilities to non-paid caregivers. The caregiver or participant selects, trains, and directs the provider. While receiving respite care, participants cannot receive other duplicative services. Respite care does not include room and board payments. Services may be provided in the participant’s residence, the respite provider’s home, the community, a CFH, a DDA, or an ADH facility.
04.Supported Employment. Competitive work in integrated work settings for individuals for whom competitive employment has not traditionally occurred; or when competitive employment is interrupted or intermittent due to severe disability. The nature and severity of an individual’s disability requires intensive supported employment services or extended services to work. This service is not available when funded under another program.
05.Non-Medical Transportation (NMT). Transportation enabling a participant to access waiver and other community services and resources. Whenever possible, non-paid supports or public transit providers are used.
06.Environmental Accessibility Adaptations. Minor housing adaptations necessary for a participant to function with greater independence in their home, or without which, would require institutionalization or pose a risk to health or safety, including:(7-1-26)
a.Installations or modifications necessary to accommodate medical equipment and supplies necessary for the health and safety of the participant but excludes those that are not of direct medical or remedial benefit to the participant.(7-1-26)
b.Unless otherwise authorized, permanent modifications are limited to the participant's principal residence that is owned by the participant or their non-paid family.(7-1-26)
c.Portable or non-stationary modifications may be made when the participant or their non-paid family rents a home, and modifications follow a participant to their next residence.(7-1-26)
07.Specialized Medical Equ ipment and Supplies.(7-1-26)
a.Devices, controls, or appliances enabling a participant to increase their abilities to perform ADL, or to perceive, control, or communicate with the environment in which they live.(7-1-26)
b.Items necessary for life support, ancillary supplies, and equipment necessary for the proper functioning of such items, and DME and non-DME not available under State Plan or EPSDT.(7-1-26)
c.Items reimbursed under this waiver exclude items that are not of direct medical or remedial benefit to the participant.(7-1-26)
08.Personal Emergency Response System (PERS). Electronic devices enabling participants to secure help in an emergency which connects to a participant’s phone and is programmed to signal a response center when activated. The response center is staffed by trained professionals. PERS is limited to participants who rent or own a home, or live with unpaid caregivers, are alone for extended periods with no caregiver, and require extensive, routine supervision.(7-1-26)
09.Home Delivered Meals. Meals delivered to a participant’s home that promote adequate nutrition.
Participants can receive one (1) to two (2) meals per day when they rent or own a home, are alone for extended periods with no caregiver, and are unable to prepare a meal without assistance.(7-1-26)
10.Skilled Nursing. Intermittent or continuous oversight, training, or skilled care within the scope of the Nurse Practice Act provided by an RN or LPN under the supervision of an RN. Services cannot cost more than a Home Health visit.(7-1-26)
11.Behavior Consultation/Crisis Management. Direct consultation and clinical evaluation of participants currently experiencing, or expected to experience, a psychological, behavioral, or emotional crisis.
Services may provide training and staff development related to the participant’s needs and provide emergency backup involving the direct support for a participant in crisis.(7-1-26)
12.Adult Day Health. Supervised, structured services provided outside the participant’s home in a non-institutional, community-based setting, and encompassing health and social services, recreation, supervision for safety, and assistance with ADL needed to ensure optimal function of the participant. Services do not include room and board payments.(7-1-26)
13.Self-Directed Community Supports. DD waiver participants may choose to self-direct an individualized budget rather than receive traditional waiver services.(7-1-26)
14.Transition Services. Goods and services enabling a participant residing in a NF, hospital, IMD, or ICF/IID to transition to a community-based setting immediately following discharge from a facility after a minimum of forty-five (45) days.(7-1-26)
a.Services may include:(7-1-26)
i.Security deposits required to obtain a lease on an apartment or home;(7-1-26)
ii.Cost of essential household furnishings;(7-1-26)
iii.Set-up fees or deposits for utility or service access;(7-1-26)
iv.Services necessary for health and safety prior to occupancy;(7-1-26)
v.Moving expenses; and(7-1-26)
vi.Activities to assess need, arrange for, and procure transition services.(7-1-26)
b.Exclusions. Ongoing expenses (including utilities), real property, décor, or entertainment and recreational items.(7-1-26)
c.Limitations: A total cost of two thousand dollars ($2,000) per participant and only accessed every two (2) years, following a qualifying transition. Services are furnished when a participant is unable to meet an expense or when a support cannot be obtained from other sources.(7-1-26)
15.Limitations. Participants cannot receive DD waiver services in non-HCBS settings or RALFs.
IDAPA 16.03.26.613 Adult Dd Waiver Services: Procedural Requirements
01.Service Authorization.
All waiver services must be identified on a service plan and authorized by the Department. The service plan must be reviewed by a plan monitor or service coordinator at a frequency determined by the person-centered planning team, but at least every ninety (90) days.(7-1-26)
02.Documentation Required.(7-1-26)
a.Written documentation of each visit made or service provided to a participant including:(7-1-26)
ii.Service(s) provided;(7-1-26)
iii.Statement of the participant's response to services, including any changes in the participant's condition;(7-1-26)
iv.Length of visit, including time in and out. Unless a participant is determined by a Service Coordinator to be unable to do so, the delivery is verified by the participant by signing the service record; and
v.A copy of the above information is maintained in the participant's home unless the Department authorizes elsewhere. Failure to maintain documentation results in recoupment for undocumented services. (7-1-26)
b.Service plans must specify the services required by a participant. A copy maintained in the participant's home must be available to all service providers and the Department.(7-1-26)
c.PIP and provider status reviews, if required.(7-1-26)
03.Provider Notification. Providers must notify the plan monitor and document on the service record when any significant changes in participant's condition are noted during service delivery.(7-1-26)
IDAPA 16.03.26.614 Adult Dd Waiver Services: Provider Qualifications and Duties
01.Residential Habilitation – Supported Living. Em ployment by a licensed residential habilitation agency. Direct care staff must:(7-1-26)
a.Be at least eighteen (18) years old;(7-1-26)
b.Be free from communicable disease;(7-1-26)
c.Demonstrate the ability to administer the plan of service;(7-1-26)
d.Have a valid driver's license and vehicle insurance, if transporting participants;(7-1-26)
e.Receive training by a QIDP who has demonstrated experience in writing skill training programs.
Training programs must include an orientation program completed before providing services, and additional ongoing training during employment.(7-1-26)
02.Residential Habilitation – CFH. Individuals providing direct services in their own home must be a CFH, receive program coordination provided through the Department, and:(7-1-26)
a.Be free from communicable disease;(7-1-26)
b.Have a valid driver's license and vehicle insurance, if transporting participants; and(7-1-26)
c.Have certification or licensure to perform tasks requiring certification or licensure.(7-1-26)
d.Prior to delivering services to a participant, complete an orientation training provided by the Department and additional training requirements for CFH providers within six (6) months of certification date.
03.Chore Services. Be skilled in the service to be provided and demonstrate the ability to follow a
04.Respite Care. Receive instructions in the participant’s needs, demonstrate the ability to follow a service plan, and be free of communicable disease.(7-1-26)
05.Supported Employment. Provided by an agency accredited by CARF or meet State requirements to be an agency.(7-1-26)
06.Non-Medical Transportation. Possess a valid driver's license and vehicle insurance.(7-1-26)
07.Specialized Medical Equipment. Enrollment as a supplier and ensure all items meet applicable standards of manufacture, design, and installation. Preference is given to the most cost-effective option to meet the participant’s needs.(7-1-26)
08.PERS. Demonstration that the devices installed in a participant’s home meet FCC standards.
09.Home-Delivered Meals. Provided by a public agency or business ensuring:(7-1-26)
a.Each meal meets one-third (1/3) of the Recommended Daily Allowance, as defined by the USDA;
b.Meals are delivered in a sanitary manner, and at the correct temperature for the specific type of food; and(7-1-26)
c.A Registered Dietitian documents the review and approval of menus, menu cycles, and any changes or substitutions.(7-1-26)
10.Behavior Consultation or Crisis Management.(7-1-26)
a.Work under the direct supervision of a psychologist or PhD in Special Education with training and experience treating severe behavior problems and applied behavior analysis; and(7-1-26)
i.Have a Master’s degree in a behavioral science or a closely related field;(7-1-26)
ii.Be a licensed pharmacist; or(7-1-26)
iii.Be a QIDP.(7-1-26)
b.Emergency back-up providers must meet the qualifications of a residential habilitation agency.
11.Adult Day Health.(7-1-26)
a.Services provided in a facility must meet the building and health standards under IDAPA 16.03.21;
b.Provide care and supervision appropriate to the participant’s needs as identified on the plan.
c.Free from communicable disease.(7-1-26)
12.Transition Services. Transition managers.(7-1-26)
IDAPA 16.03.26.615 Adult Dd Waiver Services: Provider Reimbursement
Reimbursement rates for services include both services and m ileage. Mileage for provider transportation to and from the service delivery location is not reimbursable.(7-1-26)
IDAPA 16.03.26.616 (Reserved)
IDAPA 16.03.26.620 Health Home
The Intellectual Disability/Mental Illness (ID/MI) Health H ome is a multi-disciplinary team providing an array of person-centered healthcare services to eligible participants transitioning across systems of care and living in the least restrictive environment possible.(7-1-26)
IDAPA 16.03.26.621 Health Home: Eligibility Requirements
Participants diagnosed with an intelle ctual disability and a Serious Mental Illness, or Autism, and their acuity exceeds the existing level of traditional community services. Eligibility will be determined by the Department. Participants must receive one (1) Health Home service per month to maintain eligibility.(7-1-26)
IDAPA 16.03.26.622 Health Home: Coverage and Limitations
Health home services include comprehensive case management , care coordination, health promotion, comprehensive transitional care, individual and family support services, and referral to community and social support services.
IDAPA 16.03.26.623 Health Home: Procedural Requirements
Idaho Medicaid and ID/MI Health Home will coordinate Health Home services through an intra-agency agreement pub lished on the Department’s website.(7-1-26)
IDAPA 16.03.26.624 Health Home: Provider Qualifications and Duties
The ID/MI Health Home will be administ ered by the Department. Providers of Health Home services must be employed by, or contracted with, the ID/MI Health Home and meet all staff qualifications as specified in the intraagency agreement.(7-1-26)
IDAPA 16.03.26.625 Health Home: Provider Reimbursement
Reimbursement for Health Home services will be paid per the fee schedule.(7-1-26)
IDAPA 16.03.26.626 (Reserved)
SUB AREA: SERVICE COORDINATION
(Sections 630-639)
IDAPA 16.03.26.630 Service Coordination: Definitions
01.Conflict of Interest.
A situation in which an agency or person directly or indirectly influences, or appears to influence, the direction of a participant to other services for financial gain.(7-1-26)
02.Crisis. An unanticipated event, circumstance, or life situation placing a participant at risk of hospitalization, loss of housing, loss of employment or major source of income, incarceration, or physical harm to self or others, including family altercation or psychiatric relapse.(7-1-26)
IDAPA 16.03.26.631 Service Coordination: Participant Eligibility
01.Adults.
A DD diagnosis and a need for assistance to access service and supports necessary to maintain their independence.(7-1-26)
02.Children. All information necessary to make an eligibility determination must be received by the Department twenty (20) business days prior to the anticipated service coordination start date. The Department determines eligibility based on information provided by the service coordination agency or the family prior to the initiation of initial and ongoing plan development and services. Participants must meet the following requirements:
a.Age of thirty-seven (37) months through the month of their 21st birthday.(7-1-26)
b.A diagnosis with special health care needs requiring medical and multidisciplinary rehabilitation services identified by a medical provider to prevent or minimize disability.(7-1-26)
c.Reimbursement for services is not available for participants whose needs can be met by other paid or unpaid sources. The child must require service coordination for one (1) or more of the following:(7-1-26)
i.A condition resulting in functioning below normal age level in one (1) or more life areas; (7-1-26)
ii.At risk of placement in a more restrictive environment or returning a child from an out of home placement due to their condition;(7-1-26)
iii.Danger to the health or safety of the child exists or a parent is unable to meet the child’s needs;
iv.Further complications may occur due to the condition without service coordination; or(7-1-26)
v.Requires multiple service providers and treatments.(7-1-26)
IDAPA 16.03.26.632 Service Coordination: Coverage and Limitations
The Department covers service coordination for individuals who are unable, or have limited ability to gain access, coordinate, or maintain services on their own or through other means. These rules are not applicable to case management services provided under the managed care contracts.(7-1-26)
01.Plan Assessment and Reassessment. Activities required when determining participant needs during plan development and reassessment that include completing documentation related to a participant’s history, identifying a participant’s needs, and gathering information to form a complete assessment of the participant.
02.Plan Development. Development and revision of a service coordination plan including information collected through the assessment and specifying goals and actions needed by the participant. Plans must be updated annually or as needed to meet participant needs.(7-1-26)
03.Monitoring and Follow-Up. Contacts necessary to ensure a plan is implemented and adequately addresses a participant's needs and conducted as frequently as necessary. Activities must include one (1) or more face-to-face contacts with a participant at least every ninety (90) days and may occur via synchronous virtual care to determine:(7-1-26)
a.Services are provided according to the plan;(7-1-26)
b.Services in the plan are adequate; and(7-1-26)
c.Whether there are changes in the needs or status of a participant, requiring adjustments to the plan or service arrangements with providers.(7-1-26)
04.Crisis Assistance. Coordination used to help a participant access community resources to resolve a crisis that does not include crisis counseling, transportation to emergency service providers, or direct skill-building services.(7-1-26)
a.Crisis Assistance hours are unavailable until all available hours of service coordination have already been provided in the month.(7-1-26)
b.Authorization for crisis assistance is requested retroactively due to a crisis when a participant’s service coordination benefits are exhausted, and no other support is available. A service coordinator must complete a crisis resolution plan and submit a request for crisis services to the Department within five (5) business days of the last day of providing the service.(7-1-26)
05.Contacts. Service coordination may include contacts with non-eligible individuals only when a contact directly relates to identifying the needs and supports to help a participant access services.(7-1-26)
06.Exclusions. Service coordination does not include activities that are integral components of another covered service, integral to administration of foster care programs, or integral to administration of another program a participant is eligible for, except case management required by IDEA.(7-1-26)
07.Limitations.(7-1-26)
a.Providers may only deliver service coordination and direct services to the same Medicaid participant when they receive children's services coordination.(7-1-26)
b.Service coordination cannot exceed four point five (4.5) hours per month, unless accessing unused hours in an individual's current plan from previous months.(7-1-26)
c.Reimbursement for annual assessment and plan development cannot exceed twelve (12) hours per year.(7-1-26)
d.Participants receiving hospice services or who live in hospitals, NFs, or ICF/IIDs are not eligible for service coordination.(7-1-26)
e.Participants are only eligible for one (1) type of service coordination. Participants who qualify for more than one (1) type, must choose one (1) that best meets their needs.(7-1-26)
f.Group services are not reimbursable.(7-1-26)
g.Missed appointments, attempted contacts, travel to provide services, leaving messages, scheduling appointments with a Medicaid-enrolled service coordinator, transporting participants, or documenting services are not reimbursable.(7-1-26)
IDAPA 16.03.26.633 Service Coordination: Procedural Requirements
01.Prior Authorization.
02.Plan Development. A plan must be developed and implemented within sixty (60) days after a participant chooses a service coordinator.(7-1-26)
03.Documentation. Agencies must maintain documentation describing services provided, reviewing the continued need for service coordination, and progression towards each service coordination goal.(7-1-26)
04.Freedom of Choice. A participant must have freedom of choice when selecting providers. (7-1-26)
05.Contact and Availability. The plan must identify the frequency, mode of contact, and provider to be contacted, which must meet the participant’s needs. The plan must also identify the frequency of face-to-face contact with each participant.(7-1-26)
a.When a provider must conduct a face-to-face contact with a child without a parent or legal guardian present, the provider must notify them prior to the contact and document the notification in the participant’s file.
b.Providers do not have to be available twenty-four (24) hours a day but must include an individualized objective on the plan describing who to contact in an emergency and how the provider will obtain needed services during an emergency.(7-1-26)
06.Conflict of Interest. Providers must be alert to, and avoid, conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. They must inform the participant, parent, or legal guardian when a real or potential conflict of interest arises, take reasonable steps to resolve the issue with the participant’s interests first, and protect their interests to the greatest extent possible.(7-1-26)
a.Providers developing a participant’s plan cannot:(7-1-26)
i.Be related by blood or marriage to the participant or to any paid caregiver of the participant;
ii.Be financially responsible for the participant;(7-1-26)
iii.Make financial or health-related decisions on behalf of the participant;(7-1-26)
iv.Hold financial interests in any entity paid to provide care for the participant; or(7-1-26)
v.Provide any State Plan HCBS or waiver services to the participant or have an interest in or be employed by providers for the participant.(7-1-26)
b.Agencies must guard against conflicts of interest and ensure its employees and contractors meet the conflict-of-interest standards. They must include documentation in each participant’s file, signed by the participant, parent and or legal guardian, that defines “conflict of interest,” and includes a provider-signed statement verifying that conflict of interest was reviewed and explained.(7-1-26)
IDAPA 16.03.26.634 Service Coordination: Provider Qualifications and Duties
01.Provider Agreement. Prov iders must be employees or contractors of an agency.(7-1-26)
02.Supervision. Agencies must provide supervision to all providers by clearly documenting each supervisor's ability to address concerns about the services provided under their supervision.(7-1-26)
03.Supervisor Requirements.(7-1-26)
a.Master's Degree in a human services field, and twelve (12) months supervised work experience with the population served; or(7-1-26)
b.Bachelor's degree in a human services field or RN, and twenty-four (24) months supervised work experience with the population served.(7-1-26)
04.Service Coordinator Requirements.(7-1-26)
a.Bachelor's degree in a human services field or RN and twelve (12) months supervised work experience with the population served.(7-1-26)
b.Individuals meeting education or licensing requirements but without the required supervised work experience must be supervised by a qualified service coordinator while gaining the required work experience.
05.Paraprofessional Requirements. Under the supervision of a qualified service coordinator, a paraprofessional can assist in the implementation of the plan. Paraprofessionals cannot conduct assessments, evaluations, person-centered planning meetings, 90-day face-to-face contacts, 180-day progress reviews, plan development, or plan changes. Paraprofessionals cannot be identified as a service coordinator on the plan and cannot supervise service coordinators or other paraprofessionals. They must:(7-1-26)
a.Be eighteen (18) years or older with a high school diploma or equivalency and twelve (12) months supervised work experience with the population served; and(7-1-26)
b.Be able to read and write at a level necessary to process all paperwork and forms required for service delivery.(7-1-26)
06.Health, Safety, and Fraud Reporting. Providers must report any concerns about fraud, health, and safety to the appropriate governing agency and the Department.(7-1-26)
07.Case Loads. The total caseload of a provider must assure quality service delivery and participant satisfaction.(7-1-26)
IDAPA 16.03.26.635 Service Coordination: Plan Development – Assessment
Service coordinators must complete th e service coordination assessment as part of person-centered planning to identify a participant’s need for assistance accessing and coordinating care and services. The participant’s needs and supports must be documented in the assessment. The participant, parent, legal guardian, and other providers identified by the participant must be included in the process. The assessment is used to determine a participant’s prioritized needs and services which must be documented in the plan. For children, assessments must identify the family’s needs to ensure their child’s needs are met.(7-1-26)
IDAPA 16.03.26.636 Service Coordination Plan
The plan must specify goals and actions addressing the service coordin ation needs of a participant identified in the assessment. The service coordination plan for adults with DD must comply with and be incorporated into their DD
IDAPA 16.03.26.637 Service Coordination: Reimbursement
01.Duplication.
Payments must not duplicate payment made under similar programs.(7-1-26)
02.Payment. Reimbursable services include plan development, face-to-face contact, two-way communication between a service coordinator and a participant, their other providers, family members, primary caregivers, legal guardian or other interested persons, and referrals or related activities to obtain needed services identified in the plan.(7-1-26)
03.Medical Institutionalization. Service coordination reimbursement for the day a participant is admitted to or discharged from a medical facility is allowed when the service occurs prior to admission or after discharge.(7-1-26)
a.Services that help a participant reintegrate into the community are only reimbursable when provided during the last fourteen (14) days for inpatient stays under one hundred eighty (180) days or the last sixty (60) days for inpatient stays one hundred eighty (180) days or more. Claims cannot be filed for services provided until after participant discharge.(7-1-26)
b.Services must not duplicate activities provided during a facility’s admission or discharge process.
04.Delivered Prior to Assessment. On-going service coordination is not allowable prior to completion of a plan.(7-1-26)
IDAPA 16.03.26.638 (Reserved)
YOUTH EMPOWERMENT SERVICES (YES) HCBS STATE PLAN OPTION
(Sections 640-649)
IDAPA 16.03.26.640 Yes Hcbs State Plan Option: Independent Assessment
Comprehensive clinical diagnostic assessment using a Depart ment-approved tool identifying a child’s needs, strengths, and degree of functional impairment, administered by a Department-designated independent assessor. The assessment process includes:(7-1-26)
01.Evaluation. The child’s current behavioral health, living situation, relationships, and family functioning;(7-1-26)
02.Contact. Necessary contacts with significant individuals; and(7-1-26)
03.History. Review of a child’s clinical, educational, social, and behavioral health, and juvenile justice history.(7-1-26)
IDAPA 16.03.26.641 Yes Hcbs State Plan Option: Redetermination
Eligibility is redetermined by an independent assessment every twelve (12) months. The Department may extend eligibility to allow for unavoidable delays.(7-1-26)
IDAPA 16.03.26.642 Yes Hcbs State Plan Option: Coverage and Limitations
01.Respite Care. Sup ervision of a participant on an intermittent or short-term basis allowing relief to a primary unpaid caregiver of a YES participant in response to a family emergency or crisis, or on a regular basis to provide caregiver relief. Payment and administration of respite care is done through managed care contracts.
02.Person-Centered Planning. A person-centered planning team directs the development of the
IDAPA 16.03.26.643 (Reserved)
SUB AREA: HOSPICE
(Sections 650-659)
IDAPA 16.03.26.650 Hospice
Medicaid pays for hospice services based on Medicare program coverage.(7-1-26)
IDAPA 16.03.26.651 Hospice: Definitions
01.Benefit Period. Perio d beginning the first day of the month a participant elects hospice and ending the last day of the 11th successive calendar month.(7-1-26)
02.Election Period. One (1) of eight (8) periods within a benefit period that a participant may elect to receive hospice care. Each period consists of any calendar month, or portion thereof, chosen within a benefit period.
03.Hospice Agency. Public agency or private organization that primarily provides care to terminally ill participants and meets the Medicare conditions for certification.(7-1-26)
IDAPA 16.03.26.652 Hospice: Eligibility
Hospice eligibility requires:(
01.Certification of Participant Terminal Illness.(7-1-26)
02.Medically Necessary. For the palliation and management of a terminal illness and related conditions.(7-1-26)
03.Participant Election of Services.(7-1-26)
04.Informed Consent. Participants must receive education on the reason for and nature of hospice care prior to service delivery.(7-1-26)
IDAPA 16.03.26.653 Hospice: Coverage and Limitations
Core services and requirements include those in 42 CFR 418.64, 42 CFR 418.76, 42 CFR 418.106, 42 CFR 418.108, 42 CFR 418 .110, 42 CFR 418.112, and physical, occupational, and speech-language therapy services provided for symptom control or enabling a participant to maintain ADLs and basic functional skills.(7-1-26)
IDAPA 16.03.26.654 Hospice: Procedural Requirements
01.Physician Certification.
The hospice must obtain certification of a participant’s terminal illness as follows:(7-1-26)
a.For any period of coverage, the provider must obtain, no later than two (2) calendar days after initiating care, written certification statements signed by the hospice medical director or a physician member of a hospice interdisciplinary group and the participant’s attending physician, when applicable. Certification must verify a participant’s life expectancy is six (6) months or less. If a participant’s medical prognosis or the appropriateness of hospice care is questionable, the Department can obtain another physician’s opinion to verify a participant’s medical status.(7-1-26)
b.Maintain monthly certification statements for review.(7-1-26)
c.Notify Medicaid when a participant’s designated attending physician is not a hospice employee.
02.Election Procedures. A participant or their representative must request hospice care by submitting an election statement to a hospice of their choice.(7-1-26)
a.Elections for hospice care are effective through any subsequent election periods without a break in care when a participant does not change providers or revoke an election.(7-1-26)
b.A participant who elects less than eight (8) monthly election periods within a benefit period may request additional election periods available when they meet the following conditions:(7-1-26)
i.Available hospice days did not exceed two hundred ten (210) days in a benefit period due to loss of financial eligibility;(7-1-26)
ii.Hospices were not changed excessively; and(7-1-26)
iii.More than eight (8) election periods were not revoked.(7-1-26)
c.A participant cannot request an effective date earlier than the date of their election.(7-1-26)
d.A participant twenty-one (21) years of age or older must waive all rights to Medicaid payments for the duration of an election period of hospice care for services related to their terminal condition except when provided under hospice services.(7-1-26)
03.Hospice Election. Participant statements must identify their choice of hospice provider and an effective date, acknowledge their informed choice of hospice care and waiver of any non-excepted Medicaid services during hospice benefit periods, and be signed and dated by the participant or their representative.(7-1-26)
04.Election Revocation. Participants or their representatives may revoke an election at any time by filing a signed statement with the hospice that includes their request to revoke an election of hospice care and an effective date. Medicaid coverage is reinstated upon revocation.(7-1-26)
05.Hospice Change. Participants may request a change of provider during any eligible election period, but no more than six (6) times during a benefit period. Participants must submit a signed and dated statement to the current provider and the new provider during the monthly election period, that includes the current hospice care provider, new hospice provider requested, and effective date. Changes in provider ownership do not apply. (7-1-26)
06.Plan of Care. Must be established and reviewed at least monthly and include all covered services and supplies. The basic interdisciplinary group member assessing a patient’s needs must confer with at least one (1) other member before writing an initial plan of care. At least one (1) person involved in developing an initial plan must be an RN or ph ysician. Plans must be established on the same day as an assessment to be covered as part of hospice care. The other two (2) basic interdisciplinary group members must review an initial care plan and provide input to the process of establishing the plan within two (2) calendar days following the assessment.(7-1-26)
IDAPA 16.03.26.655 Hospice: Provider Qualifications and Duties
Providers must submit a list of physicians, including volunteer physi cians, employed by the hospice in their provider application and update any changes to this list.(7-1-26)
IDAPA 16.03.26.656 Hospice: Reimbursement
Except for payment of physician services, Medicaid pays for hospice care under one (1) of five (5) predetermined daily rates depending on type and intensity of services. There are no retroactive rate adjustments other than application of a “cap” on overall payments, a service intensity add-on, and limitations on inpatient care payments.
Payment levels include:(7-1-26)
01.Routine Home Care. Payment includes one (1) of two (2) routine home care rates for each day of residence, under hospice care, and not receiving continuous home care. The rate paid disregarding the volume or intensity of routine services provided any given day. The two-rate payment methodology results in a higher payment for days one (1) through sixty (60) of hospice care and a reduced rate for all subsequent days. If a participant leaves hospice care and later resumes hospice care, regardless of provider, a minimum 60-day gap in hospice services is required for payment of the higher base routine home care rate. If a minimum 60-day gap in hospice services is not met, providers are paid the lower base rate.(7-1-26)
02.Continuous Home Care. Continuous home care is provided only during crisis periods when a patient requires continuous nursing care to achieve palliation and manage acute medical symptoms. Care must be provided by either an RN or LPN for at least half the total period of care. A minimum of eight (8) hours of care must be provided during a 24-hour day beginning and ending at midnight and does not need to be continuous and uninterrupted. Less skilled care needed on a continuous basis to enable a person to remain at home is covered as routine home care. For every hour or part of an hour of continuous care furnished, the hourly rate is paid to the hospice up to twenty-four (24) hours per day.(7-1-26)
03.Inpatient Respite Care. Payment is the inpatient respite care rate for each day a participant resides in an approved inpatient facility receiving respite care. Payment for a maximum of five (5) days includes the admission date but not the discharge date in any monthly election period. Payment for the sixth and any subsequent days is made at an appropriate rate: routine, continuous, or general inpatient rate.(7-1-26)
04.General Inpatient Care. Payments are made for general inpatient care provided. No other fixed payment rates are applicable for a day a participant receives hospice general inpatient care except qualifying physician services.(7-1-26)
a.An appropriate home care rate is paid for discharge dates unless a patient dies in an inpatient unit.
Date of a patient death is considered the discharge date and paid at the inpatient rate.(7-1-26)
b.Medicaid hospice rates are the same as Medicare hospice rates, adjusted to disregard cost offsets for Medicare coinsurance amounts. No cost sharing is imposed for participants receiving hospice services. (7-1-26)
c.Medicaid hospice benefits continue after a participant’s Medicare hospice benefit expires. The hospice must continue providing care until a patient dies or revokes a hospice care election.(7-1-26)
05.Service Intensity Add-On. Add-on payments are made for visits by an RN or social worker during the last seven (7) days of life in addition to the routine home care rate, calculated by multiplying the continuous home care rate per fifteen (15) minutes by the number of units for combined daily visits. Payments do not exceed sixteen (16) units per day, are adjusted for geographic wage differences, and do not include a social worker’s phone time.
IDAPA 16.03.26.657 Hospice: Inpatient Payment Limitations
If the Department determines an inpatient rate should not be paid, any days a provider receives payment at a home care rate is not counted as inpatient days. Limitations include:(7-1-26)
01.Maximum Allowable Inpatient Days. Calculated by multiplying the total number of a provider’s Medicaid hospice days by twenty percent (20%). If the total amount exceeds the maximum number of allowable inpatient days, a payment limitation is determined by:(7-1-26)
a.Calculating the ratio of the maximum allowable inpatient days to the number of actual inpatient care days and multiplying the ratio by the total payment for inpatient care made.(7-1-26)
b.Multiplying excess inpatient care days by the routine home care rate.(7-1-26)
c.Adding the two (2) calculated amounts and comparing the sum to interim inpatient hospice care payments made during the “cap period.”(7-1-26)
02.Limitation Cap. When any interim payments for inpatient care exceed the limitation, a provider must return the amount over the limitation.(7-1-26)
IDAPA 16.03.26.658 Hospice: Physician Payments
Basic hospice care rates represent full payment to the provider for all costs of covered services, including administrative and general activities performed by physicians employed by or working under a hospice.(7-1-26)
01.Hospice Employed Physicians. Payment for direct patient services is made under the Medicaid rate methodology for physician services and related payments are counted in the overall hospice cap. Providers may only bill for physician’s direct patient care services. Laboratory and X-ray services are included in the hospice daily rate.(7-1-26)
02.Volunteer Physicians. Volunteer services are excluded from Medicaid payment except when the hospice is reimbursed on behalf of a volunteer physician for specific direct patient care services not rendered on a volunteer basis, and a hospice must reimburse a physician for services rendered. A physician must not provide voluntary services based on a patient’s ability to pay.(7-1-26)
03.Independent Physicians. These services are reimbursed outside of the hospice benefit. Laboratory or X-ray services are excluded and must be provided by the hospice.(7-1-26)
IDAPA 16.03.26.659 Hospice: Reimbursement Cap
Aggregate payments to each hospice are limited during a hospice cap period. Total payments made for services during this period are compared to the “cap amount” for each period. Providers must return any payments more than the cap.(7-1-26)
01.Overall Cap. The cap is compared to reimbursement after computing the inpatient limitation and subtracting from the total reimbursement amount.(7-1-26)
02.Total Payment. All payments for services rendered during a cap year, regardless of when payment is made.(7-1-26)
03.Calculation of Cap. “Cap amount” is calculated by multiplying the number of participants of hospice care during the period by an amount adjusted for each cap year reflecting the percentage change in the medical care expenditure category of the Consumer Price Index for all urban consumers as published by the U.S.
Bureau of Labor and Statistics.(7-1-26)
04.Number of Participants. Providers must report the number of Medicaid participants receiving hospice care during each period to the Department within thirty (30) days after the end of a cap period. For participants transferred to a non-certified hospice where no payment is made to the non-certified hospice, the certified provider may count a complete participant benefit period in their cap amount.(7-1-26)
05.Certified Mid-Month. A weighted average cap amount based on the number of days falling within each cap period is used.(7-1-26)
06.Adjustment to Overall Cap. Amounts in each hospice’s cap period are adjusted to reflect changes in the cap periods and designated hospices during a participant’s election period. The proportion of each hospice’s service days to the total number of hospice days rendered to a participant during an election period is multiplied by the cap amount to determine an adjusted cap amount.(7-1-26)
a.Each hospice’s adjusted cap amount is computed as follows:(7-1-26)
i.The share of the “cap amount” allowed by each hospice is based on the proportion of total covered days provided by each hospice in a “cap period.”(7-1-26)
ii.The maximum number of allowable inpatient days for each certified hospice is multiplied by the “cap amount” specified for the “cap period” in which the participant first elected hospice.(7-1-26)
b.The participant must file an initial election during the period beginning September 28 of the previous year through September 27 of the current cap year for it to count as an election during the current cap year.
07.Additional Amount for NF Residents. Additional per diem amounts are paid for “room and board” of hospice residents in a NF who receive routine or continuous care services. Room and board include all assistance with ADLs, socializing activities, medication administration, maintaining cleanliness of resident rooms, and supervising and assisting use of DME and prescribed therapies. Additional payments are not subject to payment caps. Room and board rates are ninety-five percent (95%) of per diem interim rates assigned to a facility for the dates a participant resides in a NF.(7-1-26)
IDAPA 16.03.26.660 Hospice: Patient Liability
The Department reduces payments for the hospice benefit, incl uding supplementary room and board amounts, by an amount determined during the participant eligibility process.(7-1-26)
IDAPA 16.03.26.661 (Reserved)
CONSUMER-DIRECTED COMMUNITY SUPPORTS (CDCS) OPTION
(Sections 800-846)
IDAPA 16.03.26.800 Participant Eligibility
01.Eligibility Determination. In order to choose the CDCS option, the participant must first be determined Medicaid-eligible and determined to meet existing Adult DD waiver or Children’s HCBS State Plan Option requirements.(7-1-26)
02.Participant Agreement. The participant, if able, and their legal representative, if one exists, must agree in writing using a Department-approved form to the following:(7-1-26)
a.Accept the following guiding principles for the CDCS option;(7-1-26)
i.Freedom for the participant to make choices and plan their own life;(7-1-26)
ii.Authority for the participant to control resources allocated to them to acquire needed supports;
iii.Opportunity for the participant to choose their own supports;(7-1-26)
iv.Responsibility for the participant to make choices and take responsibility for the result of those choices; and(7-1-26)
v.Shared responsibility between the participant and their community to help the participant become an involved and contributing member of that community.(7-1-26)
b.Agree to meet the participant responsibilities outlined in these rules;(7-1-26)
c.Take responsibility for and accept potential risks, and any resulting consequences, for their support choices. If the participant is unable to give consent, this falls to their legal representative; and(7-1-26)
d.Acknowledge and follow the applicable HCBS rules.(7-1-26)
03.Involuntary Removal. Participants involuntarily removed from the CDCS option will be ineligible for this option for a period of five (5) years. Re-application will be reviewed on a case-by-case basis and will include consideration of the previous conditions for removal.(7-1-26)
IDAPA 16.03.26.801 Participant Responsibilities
With the assistance of the SB, and the legal representative, if one exists, the participant is responsible for the
01.Guiding Principles. Accepting and honoring the guiding principles for the CDCS option defined in the participant agreement.(7-1-26)
02.Person-Centered Planning. Directing the person-centered planning process in order to identify and document paid and unpaid support and service needs, wants, and preferences.(7-1-26)
03.Rates. Negotiating payment rates for all paid community supports they want to purchase. They must also ensure rates negotiated for supports and services do not exceed the prevailing market rate, are cost-effective when comparing them to reasonable alternatives, and include the details in the employment agreements.(7-1-26)
04.Agreements. Completing and implementing agreements for the FEA, the SB, and CSWs, and submitting the agreements to the FEA. These agreements must be submitted on Department-approved forms and must specifically identify the type of support being purchased, the rate negotiated for the support, and the frequency and duration of the scheduled support or service. The participant is responsible for ensuring that each employment agreement; clearly identifies the qualifications needed to provide the support or services; includes a statement signed by the hired worker that they possess the needed skills; and the signature of the participant that verifies the same.
Additionally, each employment agreement will include statements that; the participant is the employer even though payment comes from a third party; employees are under the direction and control of the participant; services must be delivered consistent with the HCBS rules and no employer related claims will be filed against the Department.
05.SSP. Developing a comprehensive SSP, based on the information gathered during person-centered planning.(7-1-26)
06.Time Sheets and Invoices. Reviewing and verifying that goods and services being billed were provided and indicating that they approve of the bill by signing the timesheet or invoice.(7-1-26)
07.Quality Assurance and Improvement. Providing feedback to the best of their ability regarding their satisfaction with the goods and services they receive and the performance of their workers.(7-1-26)
08.Sufficient Staffing. Hiring enough CSWs to ensure services are rendered in a manner for the health and safety of the participant.(7-1-26)
09.Required Classes. The participant must attend classes on Guide Training by the Department and FEA Training.(7-1-26)
IDAPA 16.03.26.802 Continuation of the Consumer-Directed Community
SUPPORTS (CDCS)
OPTION.
The following requirements must be met or the Department may require the participant to discontinue the CDCS option:(7-1-26)
01.Required Supports. The participant is willing to work with an SB.(7-1-26)
a.The participant can only change FEA services by providing a written request to their current FEA provider at least sixty (60) days in advance, and this change must occur at the end of a fiscal quarter. The request must include the name of the new FEA chosen by the participant and provide the specific date the change will occur.
b.When a participant provides a written request to their current FEA provider to change to a different FEA provider, the current FEA provider must notify the participant of the specific date that the last payroll run will occur at the end of the fiscal quarter.(7-1-26)
02.SSP. The participant's SSP is followed.(7-1-26)
03.Risk and Safety Back-Up Plans. Back-up plans to manage risks and safety are followed. (7-1-26)
04.Health and Safety Choices. The participant's choices do not directly endanger their health, welfare, and safety or endanger or harm others.(7-1-26)
IDAPA 16.03.26.803 Circle of Supports
01.Focus.
The participant's COS is built and operates with the primary goal of working in the interest of the participant. The group's role is to give and get support for the participant and to develop an SSP, along with and on behalf of the participant, to help the participant accomplish their personal goals.(7-1-26)
02.Members. A COS is unpaid, selected by the participant, and may include family members, friends, neighbors, co-workers, and other community members. For the SDCS, when the participant's legal guardian is selected as a CSW, the COS must include at least one (1) non-family member who is not the SB. For the purposes of this chapter a family member is anyone related by blood or marriage to the participant or legal guardian.(7-1-26)
03.Selection and Duties. Members are selected by the participant and commit to work within the group to:(7-1-26)
a.Promote and improve the life of the participant in accordance with the participant's choices and preferences; and(7-1-26)
b.Meet regularly to assist the participant to accomplish their expressed goals.(7-1-26)
04.Natural Supports. Natural supports may perform any duty of the SB as long as the SB still completes the required responsibilities listed in these rules. Additionally, any CSW task may be performed by a qualified natural support person. Supports provided by a natural support person must be identified on the participant's SSP, but time worked does not need to be recorded or reported to the FEA.(7-1-26)
IDAPA 16.03.26.804 (Reserved)
IDAPA 16.03.26.805 Paid Consumer-Directed Community Supports (cdcs)
Participants must purchase FMS and SB services to participat e in the CDCS option. Participants must purchase goods and community supports through an FEA who is providing the FMS.(7-1-26)
01.FMS. The Department will enter into a provider agreement with qualified FEAs, as defined in these rules, to provide FMS for payroll and reporting functions to participants who choose the CDCS option.
02.SB Services. Services provided by a qualified SB to assist in making informed choices, participate in a person-centered planning process, and become skilled at managing their own supports such as negotiating and budgeting. SBs have to apply for requalification annually.(7-1-26)
03.CSW Services. The CSWs provide identified supports to the participant. If the identified support requires specific licensing or certification within the state of Idaho, the identified CSW must obtain the applicable license or certification. Identified supports include activities that address the participant's preference in both FDCS and SDCS, unless otherwise specified, for:(7-1-26)
a.Job support for SDCS to help the participant secure and maintain employment or attain job advancement;(7-1-26)
b.Personal support to help the participant maintain health, safety, and basic quality of life;(7-1-26)
c.Relationship support to help the participant establish and maintain positive relationships with immediate family members, friends, spouse, or others in order to build a natural support network and community;
d.Emotional support to help the participant learn and practice behaviors consistent with their goals and wishes while minimizing interfering behaviors;(7-1-26)
e.Learning support for SDCS to help the participant learn new skills or improve existing skills that relate to their identified goals;(7-1-26)
f.Transportation support to help the participant accomplish their identified goals; and(7-1-26)
g.Skilled nursing support for SDCS identified in the participant's plan that is within the scope of the Nurse Practice Act and is provided by a licensed registered nurse (RN) or licensed practical nurse (LPN) under the supervision of an RN, licensed to practice in Idaho.(7-1-26)
04.Medically Necessary Equipment. Adaptive and therapeutic equipment is medically necessary, meets a medical or accessibility need, and promotes increased independence. FDCS may substitute medical necessity for minimizing the participant’s need for institutionalization. Items may be covered when:(7-1-26)
a.Not available through another source;(7-1-26)
b.Identified in the participant’s plan;(7-1-26)
c.Safe and effective treatment that meets evidence – based treatment criteria;(7-1-26)
d.Optimal for the participant’s health, safety and welfare;(7-1-26)
e.Least costly alternative that reasonably meets the identified need;(7-1-26)
f.For the sole benefit of the participant; and(7-1-26)
g.Meets at least one (1) of the following:(7-1-26)
i.Assist the ability of the participant to remain in the community;(7-1-26)
ii.Enhance community inclusion and family involvement; and(7-1-26)
iii.Decrease dependency on formal support services.(7-1-26)
05.Limitations. Services have the following limitations:(7-1-26)
a.CDCS Purchased items and services must meet needs related to a developmental disability diagnosis. The use of CDCS and FDCS purchased items by an individual other than the participant is prohibited. The following types of items or services are not covered:(7-1-26)
i.For the convenience of a caregiver;(7-1-26)
ii.Educational;(7-1-26)
iii.Recreational; or(7-1-26)
iv.Vocational except pre-vocational and job supports.(7-1-26)
b.CDCS services may only be rendered by (1) staff to one (1) participant at a time. Staff may not:
i.Render any other support, service, or supervision, paid or unpaid, to any other individual; or
ii.Perform multiple services concurrently.(7-1-26)
c.CDCS and FDCS transportation support is limited to one thousand eight hundred (1,800) miles annually, unless otherwise authorized.(7-1-26)
IDAPA 16.03.26.806 Unpaid Community Supports and Services
The Department requires that participants and their SB identify and prioritize the use of any goods, services and supports available outside of Medicaid-funded services that can be provided by an unpaid natural support such as a family member, a friend, a neighbor or other volunteer.(7-1-26)
IDAPA 16.03.26.807 (Reserved)
IDAPA 16.03.26.810 Support Broker (sb) Requirements and Limitations
01.SB Requirements. In dividuals interested in becoming an SB must:(7-1-26)
a.Be eighteen (18) years of age or older;(7-1-26)
b.Have skills and knowledge typically gained by completing college courses or community classes or workshops that count toward a degree in the human services field; and(7-1-26)
c.Have at least two (2) years verifiable experience with the target population and(7-1-26)
d.Knowledge of services and resources in the developmental disabilities field.(7-1-26)
02.Application Exam. Applicants that meet the minimum requirements under this rule will receive training materials and resources to prepare for the application exam. Under FDCS, children's SBs must attend an initial training. Applicants must earn a score of seventy percent (70%) or higher to pass. Applicants may take the exam up to three (3) times. After the third time, the applicant will not be allowed to retest for twelve (12) months from the date of the last exam. Applicants who pass the exam, and meet all other requirements under these rules, will be eligible to enter into a Medicaid Support Broker Agreement with the Department.(7-1-26)
03.Required Ongoing Training. All SBs must document a minimum of twelve (12) hours per year of ongoing, relevant training in the provision of SB services. Up to six (6) hours may be obtained through independent self-study. The remaining hours must consist of classroom training.(7-1-26)
04.Termination. The Department may terminate the Medicaid Support Broker Agreement in accordance with Section 56-209h(6), Idaho Code, or when the SB:(7-1-26)
a.Is no longer able to pass a background check under these rules.(7-1-26)
b.Puts the health or safety of the participant at risk by failing to perform job duties under the employment agreement.(7-1-26)
c.Does not receive and document the required ongoing training and requalification.(7-1-26)
05.Limitations. The SB must:(7-1-26)
a.Not provide, or be employed by an agency that provides CSW services to the same participant; and
b.For SDCS, meet the conflict of interest standards;(7-1-26)
c.SBs are limited to reimbursement for three thousand one hundred twenty (3,120) hours per calendar year across all participants served unless otherwise authorized by the Department.(7-1-26)
06.Time Sheets and Invoices. SBs must submit accurate time sheets and invoices for reimbursement or be subject to recoupment.(7-1-26)
IDAPA 16.03.26.811 Support Broker (sb) Duties and Responsibilities
01.Initial Documentation. Prio r to beginning employment for the participant, the SB must type and complete and submit to the participant, the packet of information provided by the FEA. This packet must include documentation of:(7-1-26)
a.SB application approval by the Department;(7-1-26)
b.A completed background check, including clearance; and(7-1-26)
c.A completed employment agreement in accordance with these rules. The negotiated rate must not exceed the maximum hourly rate for SB services established by the Department.(7-1-26)
02.Documentation. SB must complete all documentation required by the Department including documentation of the date and type of service provided and billed for. All documentation for services will be retained by the SB for five (5) years.(7-1-26)
03.Required Duties. SB services may include only a few required tasks or may be provided as a comprehensive service package depending on the participant's needs and preferences. At a minimum, the SB must:
a.Assist in facilitating the person-centered planning process as directed by the participant and consistent with the HCBS rules;(7-1-26)
b.Develop a written SSP with the participant that includes the paid and unpaid supports that the participant needs and wants, related risks identified with the participant's wants and preferences, and a comprehensive risk plan for each potential risk that includes at least three (3) backup plans should a support fail. The SSP must be authorized by the Department;(7-1-26)
c.Assist the participant to monitor and review their budget;(7-1-26)
d.Submit documentation regarding the participant's satisfaction with identified supports as requested by the Department;(7-1-26)
e.Adhere to Department quality assurance measures;(7-1-26)
f.Assist the participant to complete the annual re-determination process as needed, including updating the SSP and submitting it to the Department for authorization;(7-1-26)
g.Assist the participant, as needed, to meet the participant responsibilities outlined in these rules and assist the participant, as needed, to protect their own health and safety;(7-1-26)
h.Complete the Department-approved background check waiver form when a participant chooses to waive the background check requirement for a CSW. Completion of this form requires that the SB provide education and counseling to the participant and their COS regarding the risks of waiving a background check and assist with detailing the rationale for waiving the background check and how health and safety will be protected;(7-1-26)
i.Assist children enrolled in the FDCS option as they transition to adult DD services;(7-1-26)
j.Sign the written SSP;(7-1-26)
k.Report concerns or discrepancies in documentation and services provided to the Department immediately.(7-1-26)
04.Additional Duties. In addition to the required SB duties, each SB must be able to provide the following services when requested by the participant:(7-1-26)
a.Assist the participant to develop and maintain a COS;(7-1-26)
b.Help the participant learn and implement the skills needed to recruit, hire, and monitor community supports;(7-1-26)
c.Assist the participant to negotiate rates for paid CSW;(7-1-26)
d.Maintain documentation of supports provided by each CSW and participant's satisfaction with these supports;(7-1-26)
e.Assist the participant to monitor community supports;(7-1-26)
f.Assist the participant to resolve employment-related problems;(7-1-26)
g.Assist the participant to identify and develop community resources to meet specific needs; and
h.Assist the participant in distributing the SSP to CSWs or vendors.(7-1-26)
05.Termination of Services. If an SB decides to end services with a participant, they must give the participant and the Department at least thirty (30) days’ written notice prior to terminating services. The SB must assist the participant to identify a new SB and provide the participant and new SB with a written service transition plan by the date of termination. The transition plan must include an updated SSP that reflects current supports being received, details about the existing CSWs, and unmet needs.(7-1-26)
IDAPA 16.03.26.812 (Reserved)
IDAPA 16.03.26.815 Community Support Worker (csw) Limitations
A paid CSW must not be the spouse of the participant. For F DCS, they must: 1) not be the parent or legal guardian of the participant; 2) not have direct control over the participant’s choices; 3) avoid any conflict of interest; and 4) not receive undue financial benefit from the participant’s choices.(7-1-26)
01.Work Limit. A CSW for SDCS cannot work more than twelve (12) hours in a day without authorization from the Department.(7-1-26)
02.SDCS. SDCS CSW cannot be younger than seventeen (17) years of age except when providing chore services and then may be sixteen (16) years of age.(7-1-26)
03.FDCS. A paid CSW may provide unskilled supervision, but cannot:(7-1-26)
a.Supplant the role of the parent or legal guardian;(7-1-26)
b.Be paid to fulfill any obligations that the parent or legal guardian is legally responsible to fulfill for their child;(7-1-26)
c.Be under the age of sixteen (16) years old; or(7-1-26)
d.Transport or be left alone with a participant under the age of eighteen (18) years old.(7-1-26)
IDAPA 16.03.26.816 Paid Community Support Worker (csw) Duties and Responsibilities
01.Initial Documentation. Prior to p roviding goods or services to the participant, the CSW must type and complete the packet of information provided by the FEA and submit to the FEA. When the CSW will be providing services, this packet must include documentation of:(7-1-26)
a.A completed background check, including clearance or documentation that this requirement has been waived by the participant in accordance with these rules. Individuals listed on a state or federal provider exclusion list must not provide paid supports;(7-1-26)
b.A completed employment agreement with the participant in accordance with these rules. If the CSW is provided through an agency, the employment agreement must include the specific individual who will provide the support and the agency's responsibility for tax-related obligations;(7-1-26)
c.Current state licensure or certification if identified support requires certification or licensure; and
d.A statement of qualifications to provide supports identified in the employment agreement. (7-1-26)
02.Employment Agreement. The CSW must deliver supports as defined in the employment agreement.(7-1-26)
03.Documentation. The CSW must track and document the time required to perform the identified supports and accurately report the time on the time sheets provided by the participant's FEA or complete an invoice that reflects the type of support provided, the date the support was provided, and the negotiated rate for the support provided, for submission to the participant's FEA. Failure to do so may result in recoupment.(7-1-26)
04.Time Sheets and Invoices. The CSW must obtain the signature of the participant or their legal representative on each completed timesheet or invoice prior to submitting the document to the FEA for payment.
Time sheets or invoices that are not signed by the CSW and the participant or their legal representative will not be paid.(7-1-26)
IDAPA 16.03.26.817 (Reserved)
IDAPA 16.03.26.820 Support and Spending Plan (ssp) Development
01.Requirements.
The participant, with the help of their SB, must develop a comprehensive SSP based on the information gathered during person-centered planning. The person-centered planning process must meet all HCBS requirements. The SSP is not valid until authorized by the Department. The SSP must include:(7-1-26)
a.The participant's preferences and interests by identifying all the supports and services, both paid and non-paid, the participant wants and needs to live successfully in their community.(7-1-26)
b.Paid or non-paid supports that focus on the participant's wants, needs, and goals in the following areas:(7-1-26)
i.Personal health and safety including quality of life preferences;(7-1-26)
ii.Securing and maintaining employment for SDCS;(7-1-26)
iii.Establishing and maintaining relationships with family, friends, and others to build the participant's COS;(7-1-26)
iv.Learning and practicing ways to recognize and minimize interfering behaviors for SDCS; and
v.Learning new or improving existing skills to accomplish set goals for SDCS.(7-1-26)
c.Support needs such as:(7-1-26)
i.Medical care and medicine for SDCS;(7-1-26)
ii.Skilled care including therapies or nursing needs for SDCS;(7-1-26)
iii.Community involvement;(7-1-26)
iv.Preferred living arrangements including possible roommate(s); and(7-1-26)
v.Response to emergencies including access to emergency assistance and care. This plan should reflect the wants, preferences, and needs of the whole person, regardless of payment source, if any.(7-1-26)
d.Risks or safety concerns in relation to the identified support needs on the participant's SSP. The plan must be active and specify the goods, supports or services needed to address the risks for each issue listed, with at least three (3) backup plans for each identified risk to implement in case the need arises;(7-1-26)
e.Sources of payment for the listed supports and services, including the frequency, duration, and main task of the listed supports and services;(7-1-26)
f.The budgeted amounts planned in relation to the participant's needed supports. The FEA will compare and match the employment agreements to the appropriate support categories identified on the initial SSP prior to processing time sheets or invoices for payment; and(7-1-26)
02.Limitations.(7-1-26)
a.Traditional Adult DD waiver services, rehabilitative, or habilitative services must not be purchased under the CDCS option. Because a participant cannot receive these traditional services and CDCS at the same time, the participant, the SB, and the Department must all work together to ensure that there is no interruption of required services when moving between traditional services and the CDCS option;(7-1-26)
b.Traditional Adult DD waiver services, rehabilitative, or habilitative services must not be purchased under the CDCS option. Because a participant cannot receive these traditional services and CDCS at the same time, the participant, the SB, and the Department must all work together to ensure that there is no interruption of required services when moving between traditional services and the CDCS option;(7-1-26)
c.All paid community supports must fit into a type of community support described in these rules.
The SSP must not include supports or services that are illegal, that adversely affect the health and safety of the participant, that do harm, or that violate or infringe on the rights of others;(7-1-26)
d. SSPs that exceed the approved budget amount will not be authorized; and(7-1-26)
e.Time sheets or invoices exceeding the authorized SSP amount will not be paid by the FEA.
IDAPA 16.03.26.821 (Reserved)
IDAPA 16.03.26.825 Individualized Budget
The Department will assign budgets based on the criteria und er Subsection 574.01 for adults and Subsection 581.02 for children.(7-1-26)
IDAPA 16.03.26.826 (Reserved)
IDAPA 16.03.26.829 Quality Assurance
The Department will implement quality assurance process es to ensure: access to CDCS; participant direction of SSPs and services; participant choice and direction of providers; safe and effective environments; and participant satisfaction with services and outcomes.(7-1-26)
01.Adult Services Outcome Review (ASOR). Each participant will have the opportunity to provide feedback to the Department about their satisfaction with consumer-directed services utilizing the ASOR.(7-1-26)
02.Adult Service Outcomes. Participant experience information will be gathered at least annually in an interview by the Department, and will address the following participant outcomes:(7-1-26)
a.Access to care;(7-1-26)
b.Choice and control;(7-1-26)
c.Respect and dignity;(7-1-26)
d.Community integration; and(7-1-26)
e.Inclusion.(7-1-26)
03.CSWs and SBs Quality Assurance Activities. CSWs and SBs must participate and comply with quality assurance activities identified by the Department including performance evaluations, satisfaction surveys, quarterly review of services provided by a legal guardian, if applicable, and spot audits of time sheets and billing records.(7-1-26)
04.Participant Choice of Paid CSW. Paid CSWs must be selected by the participant, or their chosen representative, and meet the qualifications identified in this rule.(7-1-26)
05.Complaint Reporting and Tracking Process. The Department will maintain a complaint reporting and tracking process to ensure participants, workers, and other supports have the opportunity to readily report instances of abuse, neglect, exploitation, or other complaints regarding the HCBS program.(7-1-26)
06.Quality Oversight Committee. A Quality Oversight Committee consisting of participants, family members, community providers, and Department designees will review information and data collected from the quality assurance processes to formulate recommendations for program improvement.(7-1-26)
07.Quarterly Quality Assurance Reviews. On a quarterly basis, the Department will perform an enhanced review of services for those participants who have waived the criminal history check requirement for a community support worker or who have their legal guardian providing paid services. These reviews will assess ongoing participant health and safety and compliance with the approved SSP.(7-1-26)
08.HCBS Specific Reviews. The Department will implement quality assurance and improvement activities to ensure compliance with HCBS rules.(7-1-26)
IDAPA 16.03.26.830 Fiscal Employer Agent (fea): Definitions
For purposes of Sections 830 through 846, the follo wing definitions apply:(7-1-26)
01.Employee. A CSW employed by a participant receiving services under the CDCS option. (7-1-26)
02.Employer. A participant receiving services under the CDCS option.(7-1-26)
03.Provider. The term “provider” specifically refers to the FEA providing FMS to individuals participating in the CDCS option.(7-1-26)
04.Secure File Transfer Protocol (SFTP). A secure means of transferring data that allows certain Department staff to access information regarding CDCS participants.(7-1-26)
05.Vendor. Agencies and independent contractors that provide goods and services in accordance with a participant’s SSP.(7-1-26)
06.Medicaid Billing Report. A report generated every payroll period by the provider; it provides a list and count of unduplicated participants and payroll expenditures by service code, based on the date of service time frame specified by the user.(7-1-26)
IDAPA 16.03.26.831 Fiscal Employer Agent (fea): Requirements and Limitations
01.Limitations.
The FEA must not:(7-1-26)
a.Provide any other direct services to the participant, to ensure there is no conflict of interest; or
b.Employ the guardian, parent spouse, payee, or conservator of the participant or have direct control over the participant’s choice.(7-1-26)
IDAPA 16.03.26.832 Fiscal Employer Agent (fea): Duties
AND RESPONSIBILITIES.
The FEA performs FMS for each participant. Prior to providing FMS the participant and the FEA must enter into a written agreement. FMS include:(7-1-26)
01.Payroll and Accounting. Providing supports to participants that have chosen the CDCS option including:(7-1-26)
a.An online electronic time sheet entry for participants;(7-1-26)
b.Processing time sheets for CSWs and SBs, as authorized by the participant, according to the participant’s Department-authorized SSP; and(7-1-26)
c.Issuing payroll checks after receipt of completed, approved time sheets.(7-1-26)
02.Recoupment. Recoup payments made in error when identified by the FEA or the Department by either deducting from future payments or requiring repayment.(7-1-26)
03.Financial Reporting. Performing financial reporting for employees of each participant.(7-1-26)
04.Information Packet. Preparing and distributing a packet of information, including Departmentapproved forms for agreement, for the participant hiring their own staff.(7-1-26)
05.Labor Laws. Ensure each participant’s compliance with all applicable labor laws.(7-1-26)
06.Taxes. Ensure each participant’s compliance with regulations for both federal and state taxes, including preparation and submission of all federal and state forms for each participant and their employees. Manage and process payment of required state and federal employment taxes for the participant’s CSWs and SB.(7-1-26)
07.Payments of Goods and Services. Process and pay invoices for goods and services, as authorized by the participant, according to the participant’s SSP.(7-1-26)
08.Spending Information. Providing each participant with reporting information that will assist the participant with managing the individualized budget.(7-1-26)
09.Quality Assurance and Improvement. Participating in Department quality assurance activities.
IDAPA 16.03.26.833 Fiscal Employer Agent (fea): Consumer-Directed Community Supports
(CDCS).
01.Federal Tax ID Requirement.
The FEA must obtain a separate Federal Employer Identification Number (FEIN) specifically to file tax forms and to make tax payments on behalf of program participants. In addition, the provider must:(7-1-26)
a.Maintain copies of the participant’s FEIN, IRS FEIN notification letter, and Form SS-4 Request for FEIN in the participant’s file.(7-1-26)
b.Retire participant's FEIN when the participant is no longer an employer under CDCS.(7-1-26)
02.Requirement to Report Irregular Activities or Practices. The provider must report to the Department any facts regarding irregular activities or practices that may conflict with federal or state rules and regulations.(7-1-26)
03.Policies and Procedures. The provider must maintain a current manual containing comprehensive policies and procedures. The provider must submit the manual and any updates to the Department for approval.
04.Key Contact Person. The provider must provide a key contact person and at least (2) two other people for backup who are responsible for answering calls and responding to e-mails from Department staff and respond to the Department within one (1) business day.(7-1-26)
05.Face-to-Face Transitional Participant Enrollment. The provider must conduct face-to-face transitional participant enrollment sessions in group settings or with individual participants in their homes or other designated locations. The provider must work with the regional Department staff to coordinate and conduct enrollment sessions. The face-to-face encounter may occur via virtual care.(7-1-26)
06.SFTP Site. The provider must provide an SFTP site for the Department to access with the capability of allowing participants and their employees to access individual specific information such as time cards and account statements. The site must be user name and password protected. The provider must have the site accessible to the Department upon commencement of the readiness review.(7-1-26)
07.Required IRS Forms. The provider must prepare, submit, and revoke the following IRS forms in accordance with IRS requirements and must maintain relevant documentation in each participant’s file including:
a.IRS Form 2678;(7-1-26)
b.IRS Approval Letter;(7-1-26)
c.IRS Form 2678 revocation process;(7-1-26)
d.Initial IRS Form 2848; and(7-1-26)
e.Renewal IRS Form 2848.(7-1-26)
08.Requirement to Obtain and Revoke Power of Attorney. The provider must obtain an Idaho State Tax Commission Power of Attorney (ID-POA) from each participant it represents, revoke the Form ID-POA when the provider no longer represents the participant, and maintain the relevant documentation in each participant’s file.
IDAPA 16.03.26.834 Fiscal Employer Agent (fea): Customer Service
01.Customer Service System.
The provider must provide a customer service system to respond to all inquiries from participants, employees, agencies, and vendors. The provider must:(7-1-26)
a.Provide staff with customer service training with an emphasis on consumer-direction.(7-1-26)
b.Ensure staff are trained and have the skills to assist participants with enrollment and to help them understand their account statements.(7-1-26)
c.Ensure that FEA personnel are available during regular business hours.(7-1-26)
d.Provide translation and interpreter services.(7-1-26)
e.Provide prompt and consistent response to verbal and written communication. Specifically:
i.All calls and voice mails must be responded to within one (1) business day; and(7-1-26)
ii.All written and electronic correspondence must be responded to within five (5) business days.
f.Maintain a toll-free phone line where callers speak to a live person during business hours and are provided the option to leave voice mail at any time.(7-1-26)
g.Maintain a toll-free fax line that is available at any time, exclusively for participants and their employees.(7-1-26)
h.Maintain an e-mail address.(7-1-26)
02.Complaint Resolution and Tracking System. The provider is responsible for receiving, responding to, and tracking all complaints from any source under this agreement and corrective actions. A complaint is defined as a verbal or written expression of dissatisfaction about FEA services. The provider must:(7-1-26)
a.Respond to all written and electronic correspondence within five business (5) days.(7-1-26)
b.Respond to all calls and voicemails within one (1) business day.(7-1-26)
c.Maintain an electronic tracking system and log of complaints and resolutions accessible for Department review through the SFTP site.(7-1-26)
d.Log and track complaints received from the Department pertaining to FEA services.(7-1-26)
e.Compile a quarterly summary report analyzing complaints to determine the quality of services to participants and to identify any corrective action necessary.(7-1-26)
f.Implement corrective action within one (1) business day of the complaint response.(7-1-26)
g.Post the complaint to the SFTP site within one (1) business day. Failure to comply will result in a fifty dollar ($50) penalty payable to Medicaid within ninety (90) days of incident.(7-1-26)
IDAPA 16.03.26.835 Fiscal Employer Agent (fea): Personal and Confidential Information
The provider must implement and enforce policies and procedures regarding documents that are mailed, faxed, or emailed to and from the provider to ensure documents are tracked and that confidential information is not compromised, is stored appropriately and not lost, and is traceable for historical research purposes.(7-1-26)
IDAPA 16.03.26.836 Fiscal Employer Agent (fe
A): ENROLLMENT PROCESS.
01.Submission of Participant E nrollment and Employee Packets for Department Approval. The provider must submit the following for participant enrollment and employee packets to the Department for approval.
a.The participant enrollment packet must include:(7-1-26)
i.FEA authorization form;(7-1-26)
ii.Employer Appointment of Agent - IRS Form;(7-1-26)
iii.Tax Information Form; and(7-1-26)
iv.Employer information including;(7-1-26)
(1)Instructions for completing forms;(7-1-26)
(2)Payroll schedule, including deadlines for submission of time cards;(7-1-26)
(3)Sample employment agreements;(7-1-26)
(4)Sample Request for Vendor Payment form;(7-1-26)
(5)Sample independent provider agreement; and(7-1-26)
(6)Other sample employment agreements as needed.(7-1-26)
b.The employee enrollment packet must contain:(7-1-26)
i.Employee Information Form;(7-1-26)
ii.I-9 Employment Eligibility Form;(7-1-26)
iii.W-4 Employee Withholding Allowance Certificate;(7-1-26)
iv.Pay selection agreement;(7-1-26)
v.Direct deposit authorization (optional); and(7-1-26)
vi.Sample time sheets and instructions for completion.(7-1-26)
02.Distribution of Participant Enrollment and Employee Packets to Participant after Department Approval. The provider must distribute Department-approved participant enrollment packets and employment packets to the participant within two (2) business days after the participant requests the packets.
a.To enroll a participant, the provider must:(7-1-26)
i.Enroll the participant within two (2) business days of receipt of completed paperwork; and(7-1-26)
ii.Log and maintain an electronic record of all enrollment paperwork, which includes participant SSP cost and authorization sheets.(7-1-26)
b.To enroll an employee, the provider must:(7-1-26)
i.Enroll the employee within two (2) business days of receipt of completed paperwork; and (7-1-26)
ii.Log and maintain an electronic record of all the employee’s paperwork that includes the employment agreements.(7-1-26)
IDAPA 16.03.26.837 Fiscal Employer Agent (fea): Payment Process
01.Process Payroll. The provider must process payroll, including time sheets and taxes, in accordance with the participant’s SSP. The payroll process must include:(7-1-26)
a.Payment of employer and withholding taxes to State Tax Commission and Internal Revenue Service.(7-1-26)
b.Payment of invoices to vendors.(7-1-26)
c.Management of participant budget funds as per authorized SSP.(7-1-26)
d.Garnishment of wages as per court orders.(7-1-26)
e.Preparation of year-end federal and state tax forms.(7-1-26)
f.Payment of worker's compensation insurance premiums.(7-1-26)
02.Requirement to Track and Log Time Sheet Billing Errors. The provider must track and log time sheet billing errors or time sheets that cannot be paid due to late arrival, missing, or erroneous information. The provider must notify the employee and participant within one (1) business day of when errors are identified on the time sheets.(7-1-26)
03.Requirement to Track and Log Improperly Cashed or Improperly Issued Checks. The provider must track and log occurrences of improperly cashed or improperly issued checks and stop payment on checks when necessary. The provider must reissue lost, stolen, or improperly issued checks at no expense to the participant or the Department within fourteen (14) calendar days of when the error occurred.(7-1-26)
04.Process Employee Payments. The provider must verify documentation and process payments via the preference of employees. The employee payment process includes:(7-1-26)
a.Receipt of time cards from employees via mail, fax, or website by specified due dates.(7-1-26)
b.Review time cards for accuracy and verify that timecards contain the following information:
i.Employer name and ID number.(7-1-26)
ii.Employee name and ID number.(7-1-26)
iii.Hours of work.(7-1-26)
iv.Code for service.(7-1-26)
c.Match codes to employment agreement to verify rate of pay.(7-1-26)
d.Verify that rate of pay multiplied by the hours worked per each pay period is equal to the gross pay.
e.Calculate all taxes and other withholding.(7-1-26)
f.Pay employees every two (2) weeks or semi-monthly.(7-1-26)
g.Contact participant and representative to resolve problems with timecards or other documents prior to pay-date, if possible.(7-1-26)
h.Maintain an electronic complaint log of payroll issues and resolutions.(7-1-26)
i.Verification of any money remaining in each participant’s budget and specific service category prior to issuing payment.(7-1-26)
05.Process Vendor Payments. When participants submit requests for payment to vendors, the provider must:(7-1-26)
a.Review, and maintain on file, the vendor payment request with attached voided vendor receipt submitted by the participant.(7-1-26)
b.Ensure item or payment is authorized on the participant’s SSP.(7-1-26)
c.Issue payment to the vendor on the same schedule as payroll.(7-1-26)
06.Process Independent Contractor or Outside Agency Payments. When the participant hires an independent contractor or outside agency, in accordance with the SSP, the provider must:(7-1-26)
a.Obtain a W-9 from the contractor or agency.(7-1-26)
b.Review, and maintain on file, the independent contractor or agency agreement submitted by the
c.Review, and maintain on file, the independent contractor or agency invoice for services submitted by the participant.(7-1-26)
d.Ensure service or payment is authorized on the SSP.(7-1-26)
e.Issue payment directly to the independent contractor or agency.(7-1-26)
07.End-of-Year Processing. For purposes of end-of-year processing, the provider must maintain relevant documentation and must:(7-1-26)
a.Refund over-collected Federal Insurance Contributions Act tax (FICA) to applicable employees, or to state government;(7-1-26)
b.Prepare, file, and distribute IRS Form W-2 for each employee;(7-1-26)
c.Prepare and file IRS Form W-3 for each participant represented;(7-1-26)
d.Prepare and file State Form 967 for state income taxes withheld for each employer;(7-1-26)
e.Report and pay any Unclaimed Property per Idaho State Tax Commission rules; and(7-1-26)
f.Report and pay all state and federal unemployment insurance premiums.(7-1-26)
08.Transition to New FEA. The following items must be addressed if a participant transitions to a new FEA provider. For the purposes of a smooth transition between FEA providers, the two (2) providers must work closely with one (1) another to transfer the participant from the services one (1) is no longer providing to the services the other is providing. The following items must be transferred:(7-1-26)
a.Participant’s FEIN and FEIN mailing address.(7-1-26)
b.IRS Form 2678 Agent/Payer Authorization.(7-1-26)
c.Depositing taxes and filing report. This includes Federal and State tax withholdings and Federal Unemployment Tax Act tax (FUTA).(7-1-26)
d.Participant’s FUTA Liability Status.(7-1-26)
e.FICA and FUTA Exemption Status of Participant Employees.(7-1-26)
f.Unemployment Insurance (U/I).(7-1-26)
g.Unemployment Insurance Experience Rate and Taxable Wage Base.(7-1-26)
h.State Unemployment Insurance Liability Status of the Participant and Exempt Employees. (7-1-26)
i.Unemployment Insurance Filing and Depositing.(7-1-26)
j.State Income Tax - Account Number Agent Authorization, Filing and Depositing.(7-1-26)
k.Budget Authorization - Authorized Services Spent and Remaining, Authorized Providers, and Authorized Provider Rates.(7-1-26)
l.Participant’s Representative, and Participant’s Employee and Provider Demographic Information.
m.Participant’s Employee New Hire Reporting, Liens and Garnishments, and Tax and Other Information.(7-1-26)
n.Participant’s Independent contract and other information.(7-1-26)
IDAPA 16.03.26.838 Fiscal Employer Agent (fea): Annual Participant Survey
01.Requirement to Conduct Annual Participant Sati sfaction Survey. Starting October 1 of each calendar year, each provider who has been providing services for at least six (6) months must conduct an annual participant satisfaction survey.(7-1-26)
a.Three (3) weeks prior to the survey launch, the provider must present the questions to the Department staff for approval.(7-1-26)
b.Once the questions are approved by the Department, the provider can send out the survey. (7-1-26)
c.The provider must survey its participants who receive services under the CDCS option, including those whose primary language is other than English.(7-1-26)
d.The provider must provide options for participants to respond to the surveys, other than by mail.
02.Requirement to Provide Results of Annual Participant Satisfaction Survey. The provider must provide the results of the surveys to the Department in a comprehensive report, along with the completed surveys, by the 15th of December each calendar year.(7-1-26)
IDAPA 16.03.26.839 Fiscal Employer Agent (fea): Quality Assurance
01.Quality Assurance Activities.
The FEA must participate in quality assurance activities identified by the Department such as readiness reviews, periodic audits, maintaining a list of background check waivers, and timely reporting of accounting and satisfaction data.(7-1-26)
02.Elements of Quality Assurance Process. The provider must provide a quality assurance process that includes:(7-1-26)
a.Implementation of a quality management plan;(7-1-26)
b.Preparation of a quarterly, quality management analysis report;(7-1-26)
c.Distribution, collection, and analysis of an annual participant satisfaction survey; and(7-1-26)
d.A review of the monthly complaint summary and resolutions, monitoring of standards, and implementation of program improvements as needed.(7-1-26)
03.Formal Quality Assurance Review. Every two (2) years, the provider must participate in a formal quality assurance review conducted in collaboration with the Department.(7-1-26)
IDAPA 16.03.26.840 Fiscal Employer Agent (fea): Disaster Recovery Plan
01.Disaster Recovery Plan.
The provider must develop and maintain a Disaster Recovery Plan for electronic and hard copy files that includes restoring software and data files, and hardware backup if management information systems are disabled or servers are inoperative. The results of the Disaster Recovery Plan must ensure the continuation of payroll and invoice payment systems. The provider must submit the Disaster Recovery Plan for Department approval during the readiness review.(7-1-26)
02.Requirement to Report a Disaster. The provider must report to the Department if management information systems are disabled or servers are inoperative within twenty-four (24) hours of the event.(7-1-26)
IDAPA 16.03.26.841 Fiscal Employer Agent (fea): Transition Plan
01.Transition Plan Objectives.
The provider must provide a transition plan to the Department for the readiness review. The objectives of the transition plan are to minimize the disruption of services and provide an orderly and controlled transition of the provider’s responsibilities to a successor at the conclusion of the agreement period or for any other reason the provider cannot complete responsibilities described in this chapter of rules.
02.Transition Plan Requirements. The transition plan must:(7-1-26)
a.Be updated at least ninety (90) days prior to termination of the provider agreement.(7-1-26)
b.Include tasks, and subtasks for transition, a schedule for transition, operational resource requirements, and training to be provided.(7-1-26)
c.Provide for transfer of data, documentation, files, and other records relevant to the agreement in an electronic format accepted by the Department.(7-1-26)
d.Provide for the transfer of any current, Idaho-specific policy and procedure manuals, brochures, pamphlets, and all other written materials developed in support of agreement activity to the Department.(7-1-26)
IDAPA 16.03.26.842 Fiscal Employer Agent (fea): Performance Metrics
01.Readiness Review. Com plete a readiness review conducted by the Department with the provider prior to providing FEA services.(7-1-26)
a.The Department will access SFTP site for review of provider documents and conduct an onsite reviews.(7-1-26)
02.Fiscal Support and Financial Consultation. The provider must provide each participant with fiscal support and financial consultation.(7-1-26)
03.Quarterly Reconciliation. Each fiscal quarter after initiating service, the provider must reconcile its Medicaid Billing Report to a zero-dollar ($0) balance with the Medicaid Bureau of Financial Operations. The provider has ninety (90) days to comply with reconciling each participant’s SSP balance to a zero dollar ($0) balance with Medicaid’s reimbursements. The provider must:(7-1-26)
a.Show one hundred percent (100%) compliance with the required quarterly reconciliation of the Medicaid Billing Report.(7-1-26)
b.Notify the Department immediately if an issue is identified that may result in the provider not reconciling the Medicaid Billing Report. The Department will notify the provider when a performance issue is identified. The Department may require the provider to submit a written corrective action plan for Department approval within two (2) business days after notification. If the provider fails to reconcile within ninety (90) days after the end of each quarter, the provider will be penalized fifty dollars ($50) each week until the provider has reconciled with Medicaid to a zero dollar ($0) balance.(7-1-26)
04.Cash Management Plan. Each provider’s cash management plan must equal one point five (1.5) times the monthly payroll cycle amount and can be forms of liquid cash and lines of credit. For example, if a provider’s current payroll minimum has averaged one hundred thousand dollars ($100,000) per payroll cycle, the provider would be required to have one hundred fifty thousand dollars ($150,000) in a cash management plan. The Department must be on the notification list if any lines of credit are decreased in the amount accessible or terminated.
The expectation is to provide a seamless payroll cycle to the participant, without loss of pay to their employees.
IDAPA 16.03.26.843 Fiscal Employer Agent (fea): Reports
01.Account Summary Statements.
This report provides an overview of each participant account and includes the services accessed and the remaining dollar amount in the budget as well as information on how to read the report. In addition to providing this monthly report, a participant may request this report for a specified timeframe. Each month, the provider must at the participant’s preference mail a hard copy of the report to each participant or make the report available on a secure website. The provider must generate the report after every payroll and post it on a secure SFTP site for the Department to access. This SFTP site must have a user name and password protection.(7-1-26)
02.Medicaid Billing Report. This report provides a detailed breakdown of CSW services rendered by service date per employee, per employer. Each line on this report must provide the following information: employee name and ID number, hours worked, period start, and period end, pay rate, service date, check number and date, participant’s name, participant’s date of birth, participant’s ID number, service code, taxes, and billing amount. This report collects information based on the timeframe specified by the user. The provider must generate the report after every payroll and post it on a secure SFTP site for the Department to access.(7-1-26)
03.Demographic Report. This report provides general client demographics in the region and the employee count per participant for each participant in the database. The provider must generate the report after every payroll and post it on a secure SFTP site for the Department to access.(7-1-26)
04.Background Check Report. This report provides a breakdown, by participant, of which employees the participant waived the background check, which employees passed or failed the background check, the background check reference number, and the date the background check was submitted. This report does not include SBs. The provider must generate the report after every payroll and post it on a secure SFTP site for the Department to access.(7-1-26)
05.Medicaid Billing Report. This report provides a list and count of the unduplicated participants and expenditures by services code based on the time frame specified by the user. The provider must generate the report after every payroll and post it on a SFTP site. Additionally, the provider must provide a quarterly Medicaid Billing Report that can been reconciled quarterly and work with the Department to reconcile the annual report.(7-1-26)
06.Complaint and Resolution Summary Report. The provider must analyze complaints received on a quarterly basis to determine the quality of services to participants and identify any corrective actions and program improvements needed and implemented. The provider must post the report on a secure SFTP site for Department review.(7-1-26)
b.Report Due Date: The 10th day of the month following the end of each annual quarter.(7-1-26)
07.Customer Satisfaction Survey Report. The provider must provide a comprehensive report summarizing the results of the customer satisfaction survey completed by each participant.(7-1-26)
b.Report Due Date: December 1st of each year.(7-1-26)
08.Quarterly Financial Statements. The provider must provide the Department a quarterly balance sheet and income statement that shows the provider’s quarterly financial status and cash management plan cash reserve.(7-1-26)
b.Report Due Date: The 25th day of the month following the end of each annual quarter.(7-1-26)
IDAPA 16.03.26.844 Fiscal Employer Agent (fea): Payment Requirements
01.Per Member Per Month (PMPM) Payment.
The Department will pay, and the provider must accept a PMPM payment that covers a comprehensive set of FEA services. The Department will set allowable reimbursement rates for PMPM based on a methodology approved by CMS in the Adult DD Waiver. The provider can only bill the PMPM rate for the months services are actually provided for participants, The provider must provide transition, training, and closeout services during the active agreement, at no additional cost to the Department.
02.PMPM Payment Process Requirements. The PMPM payment must include all administrative costs, travel, transition, training, and closeout services. The Department will not pay for participants who do not have an SSP. For the purposes of PMPM payment, one (1) month must include all payroll batch dates within that specific calendar month.(7-1-26)
03.Readiness Review. The provider must complete a readiness review prior to billing for services.
IDAPA 16.03.26.845 Termination of Fiscal Employer Agent
(FEA) PROVIDER AGREEMENTS.
In the event of termination of a provider agreement, the provider must:(7-1-26)
01.Continuation of Services. Ensure continuation of services to participants for the period in which a PMPM payment has been made, and submit the information, reports and records, including the Medicaid Billing Report as specified in these rules.(7-1-26)
02.Advanced Notice. Provide to the Department a written notice ninety (90) days in advance and the change notification must occur at the end of the next calendar quarter.(7-1-26)
03.Termination of Service. Provide to the participant a written notice ninety (90) days in advance.
The change notification must occur at the end of the next calendar quarter.(7-1-26)
IDAPA 16.03.26.846 Remedies to Nonperformance of a Fiscal Employer Agent (fea) Service
PROVIDER.
01.Remedial Action. If any of th e services do not comply with the performance metrics under these rules, the Department will consult with the provider and may, at its sole discretion, require any of the following remedial actions, taking into account the scope and severity of the noncompliance, compliance history, the integrity of the program, and the potential risk to participants.(7-1-26)
a.Require the provider to take corrective action to ensure that performance meets the performance metrics under Section 842 of these rules;(7-1-26)
b.Reduce payment to reflect the reduced value of services received;(7-1-26)
c.Require the provider to subcontract all or part of the service at no additional cost to the Department;
d.Terminate the provider agreement with notice.(7-1-26)
02.Direct Monetary Action. If any of the performance metrics under Section 842 of these rules are not met, the Department will enforce a fifty dollar ($50) a week penalty for each performance metric not met. The penalty will be captured prior to any payment from the Department to the provider.(7-1-26)
IDAPA 16.03.26.847 (Reserved)
DUAL ELIGIBLES
(Sections 960 - 979)
SUB AREA: MEDICARE SAVINGS PROGRAM
(Sections 960-969)
IDAPA 16.03.26.960 Medicare Savings Program
01.AABD Effective Date. Ef fective date for participants approved for Medicaid and AABD cash is the first month of AABD cash eligibility.(7-1-26)
02.SSI Effective Date. Effective date for participants approved for Medicaid who also receive SSI, but not AABD cash, is the first month of Medicaid eligibility.(7-1-26)
03.Neither AABD nor SSI Effective Date. Effective date for participants approved for Medicaid who do not receive AABD cash or SSI is the third month of Medicaid eligibility.(7-1-26)
IDAPA 16.03.26.961 (Reserved)
SUB AREA: MEDICARE/MEDICAID COORDINATED PLAN (MMCP)
(Sections 970-979)
IDAPA 16.03.26.970 Managed Care for Duals
Medicaid benefit plan, referred to collectively as the Medicare/Medicaid Coordinated Plan (MMCP), for dual-eligible participants to enroll in a managed care organization (MCO) offering Idaho Medicaid Plus (IMPlus) or MMCP health plans.(7-1-26)
IDAPA 16.03.26.971 Managed Care for Duals: Definitions
01.Dual Eligible. Participants with enhanced plan benefits, except those from Breast and Cervical Cancer eligibility, who are also enrolled in both Medicare Parts A and B.(7-1-26)
02.Evidence of Coverage. Contract between an MCO and the participant detailing covered services.
03.Fully Integrated Dual-Eligible Special Needs Plan (FIDE-SNP). Health plan option that fully integrates Medicare and Medicaid benefits under a single MAO.(7-1-26)
04.Idaho Medicaid Plus (IMPlus). MMCP health plan option where most Medicaid covered services are provided by one MCO.(7-1-26)
05.Medicare Advantage Organizations (MAOs). MCO approved by CMS to offer Medicare Advantage Plans.(7-1-26)
06.Medicare Advantage Plan. Private health plans contracted with CMS to provide Medicare Parts A, B, and D benefits.(7-1-26)
07.Medicare/Medicaid Coordinated Plan (MMCP). MMCP health plan option integrating Medicare and Medicaid covered services under a FIDE-SNP provided by one MCO.(7-1-26)
08.Passive Enrollment. Process where the Department assigns a participant to an IMPlus plan unless the participant actively enrolls in MMCP or opts out of IMPlus.(7-1-26)
IDAPA 16.03.26.972 Managed Care for Duals: Program Authority
MCOs seeking to offer IMPlus and/or MMCP health plans operate under Department contract and appropriate CMS approval.(7-1-26)
01.IMPlus. CMS approval of MCO under 1915(b) authority.(7-1-26)
02.MMCP. CMS approval of MAO to operate a Medicare Advantage Plan.(7-1-26)
IDAPA 16.03.26.973 Managed Care for Duals: Eligibility and Enrollment
Only dual eligible participants over age twenty-one (21) may enroll in IMPlus or MMCP plans. Enrollment req uirements vary by county.(7-1-26)
01.Exclusions. Individuals receiving Adult DD 1915(c) waiver benefits are excluded from IMPlus enrollment.(7-1-26)
02.Exemptions. Tribal members and pregnant women are exempt from mandatory enrollment requirements but may voluntarily enroll in MMCP plan options when available in their county of residence and retain the right to disenroll at any time.(7-1-26)
03.Voluntary Counties. Participants residing in a county with at least one (1) participating MCO may voluntarily enroll in MMCP under an available IMPlus or MMCP plan and may terminate from a plan at any time.
Coverage continues until the end of the month of termination. Once disenrolled, MMIS reenrolls participants under fee-for-service Medicaid.(7-1-26)
04.Mandatory Counties. Participants without an exclusion and residing in a county with two (2) or more active MCOs must enroll in either an IMPlus or MMCP plan. The Department assigns participants who fail to choose a plan into an IMPlus MCO.(7-1-26)
05.Passive Counties. The Department enrolls participants without an exclusion and residing in a county with only one (1) participating MCO into the MCO’s IMPlus plan unless they enroll in the MCO’s MMCP plan or opt out by contacting the Department. These participants may opt out of IMPlus at any time.(7-1-26)
IDAPA 16.03.26.974 Managed Care for Duals: Coverage and Limitations
01.Coverage.
All MMCP plan options include Medicaid-only Basic and Enhanced Plan services provided by Medicaid providers that are not MAOs. Medicaid may cover additional services not included in the MCO’s Evidence of Coverage. MAOs providing MMCP plans may limit or expand MAO-covered services, including Medicare Parts A, B, and D benefits or supplemental services unavailable on Medicaid or Medicare, as detailed in the contract and Evidence of Coverage.(7-1-26)
02.Limitations. Services not included in the Evidence of Coverage are carved out and provided under fee-for-service Medicaid or other contracted entities.(7-1-26)
IDAPA 16.03.26.975 (Reserved)
INVESTIGATIONS, AUDITS, AND ENFORCEMENT
(Sections 980 - 999)
SUB AREA: LIENS AND ESTATE RECOVERY
(Sections 980-989)
IDAPA 16.03.26.980 (Reserved)
IDAPA 16.03.26.981 Liens and Estate Recovery: Definitions
01.Adequate Consideration.
An act, object, services, or other benefit which has a tangible and/or intrinsic value that is equivalent to or greater than the fair market value of the transferred asset.(7-1-26)
02.Authorized Representative. The person appointed by the court as the personal representative in a probate proceeding or the person identified by the participant to receive notice and make decisions on estate matters.
03.Discharge From a Medical Institution. A medical decision made by a competent provider that the participant no longer needs nursing home care because the participant's condition has improved, or the discharge is not medically contraindicated.(7-1-26)
04.Home. The dwelling in which the participant has an ownership interest, and which the participant occupied as their primary dwelling prior to, or subsequent to, their admission to a medical institution.(7-1-26)
05.Institutionalized Participant. An inpatient in a NF, ICF/IID, or other medical institution, who is a Medicaid participant subject to post-eligibility treatment of income in IDAPA 16.03.05.(7-1-26)
06.Lawfully Residing. Residing in a manner not contrary to or forbidden by law, and with the participant's knowledge and consent.(7-1-26)
07.Permanently Institutionalized. An institutionalized participant of any age who the Department has determined cannot reasonably be expected to be discharged from the institution and return home. Discharge refers to a medical decision made by a competent provider that the participant is physically able to leave the institution and return to live at home.(7-1-26)
08.Personal Property. Any property that is not real property, including cash, jewelry, household goods, tools, life insurance policies, boats, and wheeled vehicles.(7-1-26)
09.Real Property. Any land, including buildings or immovable objects attached permanently to the land.(7-1-26)
10.Residing in the Home on a Continuous Basis. Occupying and continuing to occupy the home as the primary residence.(7-1-26)
11.Termination of a Lien. The release or dissolution of a lien from property.(7-1-26)
12.Undue Hardship. Conditions that justify waiver or deferral of all or a part of the Department's claim against an estate.(7-1-26)
13.Undue Hardship Waiver. A decision made by the Department to relinquish, limit, or defer its claim to any or all estate assets of a deceased participant based on good cause.(7-1-26)
IDAPA 16.03.26.982 Liens and Estate Recovery: Notification to Department
All notification regarding liens, estate claims, and requests for notice must be directed to the Department of Health and Welfare, Estate Recovery Unit, 450 W. State Street, 6th Floor, Boise, Idaho 83702.(7-1-26)
IDAPA 16.03.26.983 Liens and Estate Recovery: Lien During Lifetime of Participant
01.Lien Imposed During Lif etime of Participant. During the lifetime of the permanently institutionalized participant, except as noted, the Department may impose a lien against the real property of the participant for medical assistance correctly paid on their behalf. The lien must be filed within ninety (90) days of the Department's final determination, after notice and opportunity for a hearing, that the participant is permanently institutionalized. The lien is effective from the beginning of the most recent continuous period of the participant's institutionalization. Any lien imposed will dissolve upon the participant's discharge from the medical institution and return home.(7-1-26)
02.Determination of Permanent Institutionalization. The Department must determine that the participant is permanently institutionalized prior to the lien being imposed. An expectation or plan that the participant will return home with the support of HCBS does not, in and of itself, justify a decision that they are reasonably expected to be discharged to return home. The following factors must be considered when making the determination of permanent institutionalization:(7-1-26)
a.The participant must meet the criteria for NF or ICF/IID level of care and services;(7-1-26)
b.The medical records must be reviewed to determine if the participant's condition is expected to improve to the extent that they will not require NF or ICF/IID level of care; and(7-1-26)
c.Where the prognosis indicated in the medical records is uncertain or inconclusive, the Department may request additional medical information or may delay the determination until the next utilization control review or annual Inspection of Care review, as appropriate.(7-1-26)
03.Notice of Determination of Permanent Institutionalization and Hearing Rights. The Department must notify the participant or their authorized representative, in writing, of its intention to decide that the participant is permanently institutionalized, and that they have the right to a fair hearing. This notice must inform the participant of the following information, at a minimum:(7-1-26)
a.The Department's decision that they cannot reasonably be expected to be discharged from the medical institution to return home is based upon a review of the medical records and plan of care, but that this does not preclude them from returning home with services necessary to support NF or ICF/IID level of care; and (7-1-26)
b.They or their authorized representative may request a fair hearing prior to the Department's final determination that they are permanently institutionalized. The notice must include information that a pre-hearing conference may be scheduled prior to a fair hearing. The notice must include the time limits and instructions for requesting a fair hearing.(7-1-26)
c.If they or their authorized representative does not request a fair hearing within the time limits specified, their real property, including their home, may be subject to a lien, except as noted.(7-1-26)
04.Recovery Upon Sale of Property Subject to Lien Imposed During Lifetime of Participant.
Should the property upon which a lien is imposed be sold, the Department will seek recovery of all medical assistance paid on behalf of the participant, except as noted. Recovery of the medical assistance paid on behalf of the participant from the proceeds from the sale of the property does not preclude the Department from recovering additional medical assistance paid from the participant's estate.(7-1-26)
05.Filing of Lien During Lifetime of Participant. When appropriate, the Department will file, in the office of the Recorder of the county in which the real property of the participant is located, a verified statement, in writing, setting forth the following:(7-1-26)
a.The name and last known address of the participant; and(7-1-26)
b.The name and address of the official or agent of the Department filing the lien; and(7-1-26)
c.A brief description of the medical assistance received by the participant; and(7-1-26)
d.The amount paid by the Department, as of a given date, and, if applicable, a statement that the amount of the lien will increase as long as medical assistance benefits are paid on behalf of the participant. (7-1-26)
06.Renewal of Lien Imposed During Lifetime of Participant. The lien, or any extension thereof, must be renewed every five (5) years by filing a new verified statement, or as required by Idaho law.(7-1-26)
07.Termination of Lien Imposed During Lifetime of Participant. The lien will be released as provided by Idaho Code, upon satisfaction of the Department's claim. The lien will dissolve in the event of the participant's discharge from the medical institution and return home. Such dissolution of the lien does not discharge the underlying debt, and the estate remains subject to recovery under estate recovery provisions under this rule.
IDAPA 16.03.26.984 Liens and Estate Recovery: Requirements for Estate Recovery
01.Recovery From Estate of Spouse. Reco very from the estate of the spouse of a Medicaid participant may be made as permitted in Sections 56-218 and 56-218A, Idaho Code.(7-1-26)
02.Lien Imposed Against Estate of Deceased Participant. Liens may be imposed against the estates of deceased Medicaid participants and their spouses as permitted by Section 56-218, Idaho Code.(7-1-26)
03.Notice of Estate Claim. The Department will notify the authorized representative of the amount of the estate claim after the death of the participant, or after the death of the surviving spouse. The notice must include instructions for applying for an undue hardship waiver.(7-1-26)
04.Assets in Estate Subject to Claims. Assets in the estate from which the claim can be satisfied must include all real or personal property that the deceased participant owned or in which they had an ownership interest, including the following:(7-1-26)
a.Payments to the participant under an installment contract will be included among the assets of the deceased participant. This includes an installment contract on any real or personal property to which the deceased participant had a property right. The value of a promissory note, loan or property agreement is its outstanding principal balance at the date of death of the participant. When a promissory note, loan, or property agreement is secured by a Deed of Trust, the Department may request evidence of a reasonable and just underlying debt. (7-1-26)
b.The deceased participant's ownership interest in another person’s estate, probated or not probated, is an asset of their estate when:(7-1-26)
i.Documents show the deceased participant is an eligible devisee or donee of property of another deceased person; or(7-1-26)
ii.The deceased participant received income from property of another person; or(7-1-26)
iii.State intestacy laws award the deceased participant a share in the distribution of the property of another estate.(7-1-26)
c.Any trust instrument that is designed to hold or to distribute funds or property, real or personal, in which the deceased participant had a beneficial interest is an asset of the estate.(7-1-26)
d.Life insurance is considered an asset when it has reverted to the estate.(7-1-26)
e.Burial insurance is considered an asset when a funeral home is the primary beneficiary or when there are unspent funds in the burial contract. Any funds remaining after payment to the funeral home will be considered assets of the estate.(7-1-26)
f.Checking and savings accounts that hold and accumulate funds designated for the deceased participant are assets of the estate, including joint accounts that accumulate funds for the benefit of the participant.
g.In a conservatorship situation, if a court order under state law specifically requires funds be made available for the care and maintenance of a participant prior to their death, absent evidence to the contrary, such funds are an asset of the deceased participant's estate, even if a court has to approve release of the funds.(7-1-26)
h.Shares of stocks, bonds, and mutual funds to the benefit of the deceased participant are assets of the estate.(7-1-26)
05.Value of Estate Assets. The Department will use fair market value as the value of the estate assets.
IDAPA 16.03.26.985 Liens and Estate Recovery: Limitations and Exclusions
01.Limitations on Estate Claims. Limits on the Department's claim against the ass ets of a deceased participant or spouse are subject to Sections 56-218 and 56-218A, Idaho Code. A claim against the estate of a spouse of a participant is limited to the value of the assets of the estate that had been, at any time after October 1, 1993, community property, or the deceased participant's share of the separate property, and jointly owned property.(7-1-26)
02.Expenses Deducted From Estate. The following expenses may be deducted from the available assets to determine the amount available to satisfy the Department's claim:(7-1-26)
a.Funeral expenses reasonably necessary for burial or cremation services approved on a case-by-case basis at the discretion of the Department.(7-1-26)
b.Administrative expenses of the estate may be deducted in accordance with Section 56-218, Idaho Code.(7-1-26)
03.Interest on Claim. The Department's claim does not bear interest until the claim becomes recoverable. Interest on the claim accrues at the legal rate of interest.(7-1-26)
04.Excluded Land. Restricted allotted land, owned by a deceased participant who was an enrolled member of a federally recognized American Indian tribe, or eligible for tribal membership, which cannot be sold or transferred without permission from the Indian tribe or an agency of the Federal Government, will not be subject to estate recovery.(7-1-26)
05.Certain Life Estates. The value of a life estate owned by a Medicaid participant, or their spouse will not be subject to estate recovery if:(7-1-26)
a.Neither the Medicaid participant or their spouse ever owned the remainder interest; or(7-1-26)
b.The life estate was created prior to July 1, 1995.(7-1-26)
06.Marriage Settlement Agreement or Other Such Agreement. A marriage settlement agreement or other such agreement that separates assets for a married couple does not eliminate the debt against the estate of the deceased participant or the spouse. Transfers under a marriage settlement agreement or other such agreement may be voided if not for adequate consideration.(7-1-26)
07.Undue Hardship Exception. It is not considered undue hardship when family members anticipate or expect an inheritance or will be inconvenienced economically by the lack of an inheritance.(7-1-26)
a.An applicant for an undue hardship waiver must be family with a beneficial interest in the estate and must apply for the waiver within ninety (90) days of the death of the participant or within thirty (30) days of receiving notice of the Department's claim, whichever is later. The filing of a claim by the Department in a probate proceeding constitutes notice to all heirs.(7-1-26)
b.Undue hardship waivers will be considered in the following circumstances:(7-1-26)
i.The estate subject to recovery is income-producing property that provides the sole source of support for heirs; or(7-1-26)
ii.Payment of the Department's claim would cause heirs of the deceased participant to be eligible for public assistance; or(7-1-26)
iii.The Department's claim is less than five hundred dollars ($500) or the total assets of the entire estate are less than five hundred dollars ($500), excluding trust accounts or other bank accounts.(7-1-26)
c.Any claim may be waived or deferred by the Department, partially or fully, because of undue hardship. An undue hardship does not exist if action taken by the participant prior to their death, or by their legal representative, divested or diverted assets from the estate. The Department grants undue hardship waivers on a caseby-case basis upon review of all facts and circumstances, including any action taken to diminish assets available for estate recovery or to circumvent estate recovery.(7-1-26)
08.Set Aside of Transfers. Transfers of real or personal property of the participant without adequate consideration are voidable and may be set aside by the district court whether the asset transfer resulted, or could have resulted, in a period of ineligibility.(7-1-26)
IDAPA 16.03.26.986 Liens and Estate Recovery: Request for Notice
01.Notice - Hearing.
The Department must notify the participant or their authorized representative, in writing, of its intention to record a request for notice, and that they have the right to a fair hearing. The notice must inform the participant of the following information:(7-1-26)
a.The Department's determination that they are the record titleholder or purchaser under a land sale contract of real property subject to a request for notice;(7-1-26)
b.They or their authorized representative may request a fair hearing prior to the Department's recording a request for notice. The notice must include the time limits and instructions for requesting a fair hearing;
c.If they or their authorized representative do not request a fair hearing within the time limits specified, a request for notice applying to their real property, including their home, may be recorded.(7-1-26)
02.Forms - Content. The notices must include the following information:(7-1-26)
a.The name of the public assistance recipient and the spouse of such public assistance recipient, if any;(7-1-26)
b.The Medicaid number for the public assistance recipient and spouse, if any;(7-1-26)
c.The legal description of the real property affected or to be affected;(7-1-26)
d.The mailing address at which the Department is to receive notice;(7-1-26)
e.If the document is a Notice of Transfer or Encumbrance, the name and address of the transferee or lien holder; and(7-1-26)
f.A fully executed acknowledgment as required for recording under Section 55-805, Idaho Code.
03.Webpages for Forms. These forms may be found at http://healthandwelfare.idaho.gov.(7-1-26)
a.Notice of Transfer or Encumbrance.(7-1-26)
b.Request for Notice.(7-1-26)
c.Termination of Request for Notice.(7-1-26)
IDAPA 16.03.26.987 (Reserved)
SUB AREA: PARTICIPANT LOCK-IN
(Sections 990 - 999)
IDAPA 16.03.26.990 Participant Utilization Control Program
This Program is to promote improved and cost-ef ficient medical management of essential health care by monitoring participant activities and taking action to correct abuses. Participants demonstrating unreasonable patterns of utilization or exceeding reasonable levels of utilization will be reviewed for restriction. The Department may require a participant to designate a primary provider or a single pharmacy for exclusive provider services to protect the individual's health and safety, provide continuity of medical care, avoid duplication of services by providers, avoid inappropriate or unnecessary utilization of medical assistance.(7-1-26)
IDAPA 16.03.26.991 Lock-in Defined
Lock-in is the process of restricting the acces s of a participant to a specific provider or providers.(7-1-26)
IDAPA 16.03.26.992 Department Evaluation for Lock-in
The Department will determine if services are being utilized at a frequency or amount that is not medically necessary.
Evaluations can include review of medical records or computerized reports reflecting claims.(7-1-26)
IDAPA 16.03.26.993 Criteria for Lock-in
There are no specific criteria for loc k-in as each case is unique. The Department may develop non-binding guidelines for purposes of uniformity. The following utilization patterns may be considered abusive, not medically necessary, potentially endangering the participant's health and safety, or over utilization of Medicaid services, and may result in the restriction of Medicaid reimbursement for a participant to a single provider or providers:(7-1-26)
01.Unnecessary Use of Providers or Services, Including Excessive Provider Visits.(7-1-26)
02.Demonstrated Abusive Patterns. Recommendation from a provider that the participant has demonstrated abusive patterns and would benefit from the lock-in program.(7-1-26)
03.Use of Emergency Room. Frequent use of emergency room for non-emergent conditions. (7-1-26)
04.Multiple Providers.(7-1-26)
05.Controlled Substances.(7-1-26)
06.Use of Multiple Prescribing Providers or Pharmacies.(7-1-26)
07.Overlapping Prescription Drugs With the Same Therapeutic Classes.(7-1-26)
08.Drug Abuse.(7-1-26)
09.Drug-Seeking Behavior. As identified by a provider.(7-1-26)
10.Other Abusive Utilization. As determined by the Department's medical or pharmacy consultant.
IDAPA 16.03.26.994 Lock-in Participant Notification
A participant designated by the Department for the Participant Utilization Control Program will be notified in writing by the Department of the action and the participant's right of appeal by means of a fair hearing.(7-1-26)
IDAPA 16.03.26.995 Lock-in Procedures
01.Participant Responsibilities.
The participant will be given thirty-five (35) days to contact the Regional Program Manager and complete and sign the lock-in agreement form and select designated provider(s) in each area of misuse.(7-1-26)
02.Appeal Stays Restriction. The Department will not implement the participant restriction if a valid appeal is noted.(7-1-26)
03.Lock-In Duration. The Department will restrict participants to their designated providers for a period determined by the Department. Upon review at the end of that period, lock-in may be extended for an additional period determined by the Department.(7-1-26)
04.Payment to Providers. Payment to providers other than the designated lock-in provider or pharmacy is limited to documented emergencies or referrals.(7-1-26)
05.Regional Programs Manager. The Regional Programs Manager will:(7-1-26)
a.Clearly describe the participant's appeal rights;(7-1-26)
b.Specify the effective date and length of the restriction;(7-1-26)
c.Have the participant choose a designated provider or providers; and(7-1-26)
d.Mail the completed lock-in agreement to the Surveillance and Utilization Unit. Upon receipt of the lock-in agreement, the participant's Medicaid services will be immediately restricted to the designated providers.
IDAPA 16.03.26.996 Penalties for Lock-in Noncompliance
If a participant fails to respond to the notification of medical restrictions, fails to sign the lock-in agreement, or fails to select a primary provider within the specified period, the Medicaid benefits will be restricted to documented emergencies only. If a participant continues to abuse or over-utilize items or services after being identified for lock-in, the Department may terminate Medicaid benefits for a specified period as determined by the Department.(7-1-26)
IDAPA 16.03.26.997 Appeal of Lock-in
Department determinations to lock-in a participant may be appealed.(7-1-26)
IDAPA 16.03.26.998 Recipient Explanation of Medicaid Benefits (reombs)
01.Participant Response.
A participant is required to respond to the Department's explanation of medical benefits survey whenever they are aware of discrepancies.(7-1-26)
02.Participant Unable to Respond. If the participant is unable, because of medical or physical limitations, to respond to the survey personally, then a responsible family member or friend can respond on their behalf.(7-1-26)
IDAPA 16.03.26.999 (Reserved)
16.03.05 Eligibility for Aid to the Aged, Blind, and Disabled (AABD)
IDAPA 16.03.05.000 Legal Authority
Section 56-202, Idaho Code, authorizes the Department to ad opt rules for the administration of public assistance programs.(7-1-24)
IDAPA 16.03.05.001 (Reserved)
IDAPA 16.03.05.002 Incorporation by Reference
The following are incorporated by reference(7-1-24)
“Medicare Modernization Act - Prescription Drug Program Guidance to States for the Low Income Subsidy (LIS),” dated May 25, 2005. The guidelines may be viewed at the main office of the Department.
It is also available online at https://www.cms.gov/Medicare/Eligibility-and-Enrollment/ LowIncSubMedicarePresCov/Downloads/StateLISGuidance021009.pdf.(7-1-24)
02.Social Security Administration Program Operations Manual System (POMS) SI 01320.00, Deeming Resources, effective date: 10/17/2022. This Deeming of Income section is available at: https:// secure.ssa.gov/apps10/poms.nsf/lnx/0501320000.(7-1-24)
03.Social Security Administration Program Operations Manual System (POMS) SI 01330.00, Deeming Resources, effective date: 02/24/2010. This Deeming of Resources section is available at: https:// secure.ssa.gov/apps10/poms.nsf/lnx/0501330000.(7-1-24)
04.Social Security Administration Program Operations Manual System (POMS) SI 02302.200 Charted Threshold Amounts for Calendar Year 2023, effective date: 01/24/2023. This Charted Threshold Amounts table is available at: https://secure.ssa.gov/apps10/poms.nsf/lnx/0502302200.(7-1-24)
IDAPA 16.03.05.003 (Reserved)
IDAPA 16.03.05.010 Definitions
01.AABD Cash.
An EBT payment to a participant, a participant’s guardian, or a holder of a limited power of attorney for EBT payments. AABD Cash is a payment of a supplemental cash amount to an individual who meets the program requirements. This payment may be made through direct deposit or an electronic benefits card.
02.Applicant. A person applying for public assistance from the Department, including individuals referred to the Department from a health insurance exchange or marketplace.(7-1-24)
03.Annuity. A right to receive periodic payments, either for life, a term of years, or other interval of time, whether or not the initial payment or investment has been annuitized. It includes contracts for single payments where the single payment represents an initial payment or investment together with increases or deductions for interest or fees rather than an actuarially based payment from an insurance pool.(7-1-24)
04.Asset. Includes all income and resources of the individual and the individual’s spouse, including any income or resources that the individual or their spouse is entitled to, but does not receive because of action by:
a.The individual or their spouse;(7-1-24)
b.A person, including a court or administrative body, with legal authority to act in place of or on behalf of the individual or their spouse; or(7-1-24)
c.A person, including any court or administrative body, acting at the direction or upon the request of the individual or their spouse.(7-1-24)
05.Asset Transfer for Sole Benefit. An asset transfer is considered to be for the sole benefit of a spouse, blind or disabled child, or disabled individual if the transfer is arranged in such a way that no individual or entity except the spouse, blind or disabled child, or disabled individual can benefit from the assets transferred in any way, whether at the time of transfer or at any time in the future.(7-1-24)
06.Child. Any individual from birth through the end of the month of their nineteenth birthday. (7-1- 24)
07.Citizen. A person having status as a “national of the United States” defined in 8 USC 1101(a)(22) that includes both citizens of the United States and non-citizen nationals of the United States.(7-1-24)
08.Department. The Department of Health and Welfare.(7-1-24)
09.Direct Deposit. The electronic deposit of a participant’s AABD cash to the participant’s personal account with a financial institution.(7-1-24)
10.Electronic Benefits Transfer (EBT). A method of issuing AABD cash to a participant, a participant’s guardian, or a holder of a limited power of attorney for EBT payments for a participant.(7-1-24)
11.Essential Person. A person of the participant’s choice whose presence in the household is essential to the participant’s well-being. The essential person provides the services a participant needs to live at home.
12.Fair Market Value. The price for which an asset can be reasonably expected to sell on the open market, in the geographic area involved.(7-1-24)
13.Long-Term Care. Services provided to an institutionalized individual as defined in 42 USC 1396p(c)(1)(C).(7-1-24)
14.Medicaid. Idaho’s Medical Assistance Program administered by the Department. See Title XIX.
15.Needy. A person is considered needy for AABD cash payments if the person meets the nonfinancial requirements of Title XVI of the Social Security Act and the criteria in Section 514 of these rules. Title XVI of the Social Security Act, known as “Grants to States for Aid to the Aged, Blind, or Disabled,” is a program for financial assistance to needy individuals who are sixty-five (65) years of age or over, are blind, or are eighteen (18) years of age or over and permanently and totally disabled.(7-1-24)
16.Non-Citizen. Same as “alien” defined in Section 101(a)(3) of the Immigration and Nationality Act (INA) (8 USC 1101 (a)(3)), and includes any individual who is not a citizen or national of the United States. (7-1-24)
17.Participant. An individual who is eligible for, and enrolled in, a Health Care Assistance Program or Medicaid.(7-1-24)
18.Partnership Policy. A qualified long-term care insurance policy under Section 7702B(b) of the Internal Revenue Code of 1986, which meets the requirements of the long-term care insurance model regulation and Long-term Care Insurance Model Act promulgated by the National Association of Insurance Commissioners (NAIC), as incorporated in 42 USC 1396p(b)(5)(A).(7-1-24)
19.Premium. A regular, periodic charge or payment for health coverage.(7-1-24)
20.Reasonable Opportunity Period. A period allowed for an individual to provide requested proof of citizenship or identity. A reasonable opportunity period extends for ninety (90) days beginning on the 5th day after the notice requesting the proof has been mailed to the applicant. This period may be extended if the Department determines that the individual is making a good faith effort to obtain necessary documentation.(7-1-24)
21.Pension Funds. Retirement funds held in individual retirement accounts (IRAs), as described by the Internal Revenue Code, or in work-related pension plans, including plans for self-employed individuals sometimes referred to as Keogh plans.(7-1-24)
22.Sole Beneficiary.
The only beneficiary of a trust, including a beneficiary during the grantor’s life, a beneficiary with a future interest, and a beneficiary by the grantor’s will.(7-1-24)
23.Title XIX. Of the Social Security Act, known as Medicaid, is a medical benefits program jointly financed by the federal and state governments and administered by the states that provides medical care for eligible individuals. Please see https://www.ssa.gov/OP_Home/ssact/title19/1900.htm.(7-1-24)
24.Title XXI. Of the Social Security Act, known as the Children's Health Insurance Program (CHIP), is a federal and state partnership that provides health insurance to targeted, low-income children. Please see https:// www.ssa.gov/OP_Home/ssact/title21/2100.htm.(7-1-24)
25.Treasury Rate. The five (5) year security note rate listed in the “Daily Treasury Yield Curve Rate” by the US Treasury on January 1 of each year, and is used for the entire calendar year.(7-1-24)
26.Working Day. A calendar day when regular office hours are observed by the state of Idaho.
Weekends and state holidays are not considered working days.(7-1-24)
IDAPA 16.03.05.011 (Reserved)
IDAPA 16.03.05.020 Abbreviations
01.AABD.
Aid to the Aged, Blind, and Disabled.(7-1-24)
02.COLA. Cost of Living Adjustment.(7-1-24)
03.CSA. Community Spouse Allowance.(7-1-24)
04.CSNS. Community Spouse Need Standard.(7-1-24)
05.CSRA. Community Spouse Resource Allowance.(7-1-24)
06.EBT. Electronic Benefits Transfer.(7-1-24)
07.EITC. Earned Income Tax Credit.(7-1-24)
08.FSI. Federal Spousal Impoverishment.(7-1-24)
09.HCBS. Home and Community Based Services.(7-1-24)
10.ICF/IID. Intermediate Care Facility for Individuals with Intellectual Disabilities.(7-1-24)
11.INA. Immigration and Nationality Act.(7-1-24)
12.PASS. Plan for Achieving Self-Support.(7-1-24)
13.RSDI. Retirement, Survivors, and Disability Insurance.(7-1-24)
14.SSA. Social Security Administration.(7-1-24)
15.SSI. Supplemental Security Income.(7-1-24)
16.SSN. Social Security Number.(7-1-24)
17.TAFI. Temporary Assistance for Families in Idaho.(7-1-24)
18.VA. Veterans Administration.(7-1-24)
IDAPA 16.03.05.021 (Reserved)
IDAPA 16.03.05.049 Signatures
An individual applying for benefits, receiving benefits, or providing additional information as required by these rules, may do so with the depiction of the individual's name either handwritten, electronic, or recorded telephonically. Such signature serves as intention to execute or adopt the sound, symbol, or process for the purpose of signing the related record.(7-1-24)
IDAPA 16.03.05.050 Application for Assistance
01.Application Submitted by Participant.
The participant must submit an application form to the Department. An adult participant, a legal guardian, or a representative must sign the application form.(7-1-24)
02.Application Submitted Through SSA Low-Income Subsidy Data Transmission. For lowincome subsidy applicants identified on the SSA data transmission, the protected Medicare Savings Program application date is the day they applied for the low-income subsidy.(7-1-24)
IDAPA 16.03.05.051 Effective Date
The effective date for aid is the first day of the month of appli cation. Medicaid eligibility begins as described in this rule.(7-1-24)
01.AABD Cash. AABD cash aid is effective on the application date.(7-1-24)
02.Normal Medicaid Eligibility. Medicaid coverage begins on the first day of the application month.
03.Retroactive (Backdated) Medicaid Eligibility. Medicaid benefits must be backdated to the first day of the calendar month, for each of the three (3) months before the month of application, if the participant was Medicaid-eligible during that month. If the participant is not eligible for Medicaid when they apply, retroactive eligibility is evaluated.(7-1-24)
04.Ineligible Non-Citizen Medicaid. Ineligible legal or illegal non-citizen coverage is restricted to emergency services. Coverage begins when the emergency treatment is required. Coverage ends with the last day emergency treatment is required.(7-1-24)
IDAPA 16.03.05.052 (Reserved)
IDAPA 16.03.05.070 Time Limits
The application must be processed within forty-five (45) days for an applicant sixty-five (65) years of age or older.
The application must be processed within ninety (90) days for a disabled applicant. The time limit can be extended by events beyond the Department’s control.(7-1-24)
IDAPA 16.03.05.071 Death of Applicant
An application may be filed for a deceased person. The appli cation must be filed within the backdated eligibility period. Medicaid can be approved, through the date of death, if an AABD applicant dies before eligibility is determined.(7-1-24)
IDAPA 16.03.05.072 Required Verification
Applicants must prove their eligibility for aid. The participan t is allowed ten (10) calendar days to provide requested proof. The application is denied if the applicant does not provide proof in ten (10) calendar days of the written request and does not have good cause for not providing proof. The Department may also use electronic verification sources when they are available.(7-1-24)
IDAPA 16.03.05.073 (Reserved)
IDAPA 16.03.05.091 Out-of-State Applicants
A participant receiving AABD cash from another s tate must not receive AABD cash in Idaho until they are living in Idaho and the cash benefit has ended in the other state. A participant may receive Medicaid in Idaho before AABD cash or Medicaid stops in another state. AABD cash from another state is unearned income for Medicaid. Out-of-state medical coverage is a Medicaid third-party resource. Idaho residents temporarily out of the state, and not receiving aid, may apply for aid in Idaho.(7-1-24)
IDAPA 16.03.05.092 Concurrent Benefit Prohibition
If a person is potentially eligible for AAB D cash, TAFI, or foster care, only one (1) program may be chosen. (7-1-24)
IDAPA 16.03.05.093 (Reserved)
IDAPA 16.03.05.100 Residency
The participant must be living in Idaho and have no immediate intention of leaving. For Medicaid, other persons are Idaho residents if they meet any of the following criteria.(7-1-24)
01.Foster Child. A participant living in Idaho and receiving child foster care payments from another state.(7-1-24)
02.Incapable Participant. A participant who is incapable of indicating their state of residency after age twenty-one (21) is considered a resident of Idaho when:(7-1-24)
a.Their parent or guardian lives in Idaho; or(7-1-24)
b.They reside in an Idaho institution.(7-1-24)
03.Placed in Another State by Idaho. A participant placed by the state of Idaho in an institution in another state.(7-1-24)
04.Homeless. A participant not maintaining a permanent home or having a fixed address who intends to remain in Idaho.(7-1-24)
05.Migrant. A migrant working and living in Idaho.(7-1-24)
IDAPA 16.03.05.101 Temporary Absence
A participant may be temporarily absent from their home an d still receive AABD cash and Medicaid. A participant is temporarily absent if they intend to return home within one (1) month. Temporary absence may exceed one (1) month for a child attending school or vocational training or a participant in a medical institution, hospital, or nursing home.
IDAPA 16.03.05.102 Us Citizenship Verification Requirements
Any individual who participates in AABD cash, Health Care Assistance, or Medicaid benefits must provide proof of US citizenship unless they have otherwise met the requirements under 42 CFR 435.406, Citizenship and Non-Citizen Eligibility.(7-1-24)
IDAPA 16.03.05.103 Social Security Number (ssn) Requirement
01.SSN Required.
The applicant must provide their SSN, or proof they have applied for an SSN, to the Department before approval of eligibility. If the applicant has more than one (1) SSN, all numbers must be provided.(7-1-24)
a.The SSN must be verified by the SSA electronically. An applicant with an unverified SSN is not eligible for AABD cash, Health Care Assistance, or Medicaid benefits.(7-1-24)
b.The Department must notify the applicant in writing if eligibility is denied or lost for failure to meet the SSN requirement.(7-1-24)
02.Application for SSN. To be eligible, the applicant must apply for an SSN, or a duplicate SSN when they cannot provide their SSN to the Department. If the SSN has been applied for but not issued by the SSA, the Department cannot deny, delay, or stop benefits. The Department will help an applicant with required documentation when the applicant applies for an SSN.(7-1-24)
03.Failure to Apply for SSN. The applicant may be granted a good cause exception for failure to apply for an SSN if they have a well-established religious objection to applying for an SSN. A well-established religious objection means the applicant:(7-1-24)
a.Is a member of a recognized religious sect or division of the sect; and(7-1-24)
b.Adheres to the tenets or teachings of the sect or division of the sect and for that reason is conscientiously opposed to applying for or using a national identification number.(7-1-24)
04.SSN Requirement Waived. An applicant may have the SSN requirement waived when they are:
a.Only eligible for emergency medical services under 42 CFR 440.255, Emergency and Poststabilization Services; or(7-1-24)
b.A newborn child deemed eligible under 42 CFR 435.117, Deemed Newborn Children.(7-1-24)
IDAPA 16.03.05.104 (Reserved)
IDAPA 16.03.05.106 Emergency Medical Condition
An individual who meets eligibility criteria for a category of assistance but does not meet US citizenship requirements or eligible non-citizen requirements may receive medical assistance under a Title XIX or Title XXI coverage group as follows:(7-1-24)
01.Emergency Medical Conditions. An individual not meeting the US citizenship requirement may receive medical services necessary to treat an emergency medical condition, including labor and delivery. Emergency medical conditions have acute symptoms of severity, including severe pain.(7-1-24)
02.Determination of Emergency Medical Conditions. The Department determines if a condition meets criteria of an emergency medical condition.(7-1-24)
03.Limitation on Medical Assistance. Medical assistance is limited to the period established for the emergency medical condition.(7-1-24)
04.Documentation Waived. For undocumented individuals with emergency medical conditions, the SSN requirement is waived because an SSN cannot be issued. Individuals must be otherwise eligible for Title XIX or XXI.(7-1-24)
IDAPA 16.03.05.107 Institutional Status
An institution provides treatment, services, food, and shelter to four (4) or more people, not related to the owner. A particip ant living in an ineligible institution an entire calendar month is not eligible for AABD cash, unless they qualify for the institution payment exception.(7-1-24)
01.Eligible Institutions for AABD and Medicaid. Are listed below.(7-1-24)
a.Medical institution. A public or private medical institution, including a hospital, nursing care facility, or an ICF/IID is an eligible institution. A participant is not eligible for AABD cash if they are a resident of a medical institution the full month.(7-1-24)
b.Child care institution. A non-profit private child care institution is an eligible institution. A public child care institution with no more than twenty-five (25) beds is an eligible institution. A child care institution must be licensed or approved by the Department. A detention facility for delinquent children is not a child care institution.
A child care institution for mental diseases is an eligible institution if it has sixteen (16) beds or less. A participant is not eligible for AABD cash if they are a resident of a child care institution for the full month.(7-1-24)
c.Community residence. A community residence is a facility providing food, shelter, and services to residents. A privately operated community residence is an eligible institution. A publicly operated community residence serving no more than sixteen (16) residents is an eligible institution. The Community Restorium in Bonners Ferry, Idaho, is an eligible institution even though more than sixteen (16) residents are served.(7-1-24)
02.Ineligible Institutions for AABD and Medicaid. Are listed below.(7-1-24)
a.Public institutions, unless listed in Subsection 108.01 of these rules.(7-1-24)
b.Institution for mental diseases, a facility maintained primarily for the care and treatment of persons with mental diseases.(7-1-24)
c.Institution for tuberculosis, a facility maintained primarily for the care and treatment of persons with tuberculosis.(7-1-24)
d.Correctional institution, a facility for prisoners, persons detained pending disposition of charges, or held under court order as material witnesses or juveniles.(7-1-24)
03.Medicaid Exception for Inmates. An inmate can receive Medicaid while they are an inpatient in a medical facility. The inmate must meet all Medicaid eligibility requirements.(7-1-24)
IDAPA 16.03.05.108 Aabd Eligibility in Ineligible Institutions
A participant may get AABD cash in an ineligible institution or a medical institution if they meet one (1) of the conditions listed below.(7-1-24)
01.First Month in Institution. An AABD participant can get AABD cash for the month they entered the institution. Eligibility for the entry month applies to these residents:(7-1-24)
a.Resident of a public institution. The person is a resident if they, or anyone, pays for their food, shelter, and other services in the institution.(7-1-24)
b.Patient in a medical institution. A person receiving room, board, and professional services in a medical institution, including an institution for tuberculosis or mental diseases.(7-1-24)
02.Temporary Institution Stay. An AABD participant can get up to three (3) months’ AABD payment during a temporary stay in an institution. A participant entering a public medical or psychiatric institution, a hospital, a nursing facility, or an ICF/IID may continue to get AABD payments. The Department must receive the temporary stay data no later than the ninetieth full day of confinement, or the release date, whichever is first. The payments may continue up to three (3) months if these conditions are met:(7-1-24)
a.The Department is informed of the institutional stay.(7-1-24)
b.A physician certifies the participant’s stay is not likely to exceed three (3) full months.(7-1-24)
c.A signed statement from the participant or a responsible party showing the participant’s need to continue to maintain and pay for the place they intend to return to live.(7-1-24)
IDAPA 16.03.05.109 Conditions for Temporary Aabd in Institutions
Special conditions for AABD when a participant is in an institution are listed below:(7-1-24)
01.Living Arrangement. AABD cash is paid based on the participant’s living arrangement the month before the first month in the institution. Changes in living arrangement costs are used to determine AABD cash eligibility and benefit amount.(7-1-24)
02.Participant Becomes Ineligible. If the participant becomes ineligible for AABD during their temporary institutional stay, their AABD payment must be ended after proper notice.(7-1-24)
03.AABD Status. A participant must get AABD for the month they enter the institution to receive continued AABD payments.(7-1-24)
04.Counting Three Full Months. A full month is a month the participant is in the institution every day of the month. If the participant enters after the first day of a month, the month of entry is not included in the three (3) full months. If the participant is discharged before the last day of the month, the month of discharge is not included in the three (3) full months.(7-1-24)
05.SSI Benefits. If SSA decides a participant’s SSI benefit will continue while the participant is in the institution, AABD payments can also continue.(7-1-24)
IDAPA 16.03.05.110 (Reserved)
IDAPA 16.03.05.130 Estate Not in Probate
An administrator for public aid for a deceased participant’s AABD cash can be court-appointed. The administrator must spend AABD cash, accessible through EBT before the participant’s death, for the estate. The AABD cash can only be spent to meet the needs of the participant, or their dependents, for the month it was paid. If a participant had no debts for themself, or their dependents, the administrator must return the AABD cash to the Department. AABD benefits paid by direct deposit or posted to the participant’s EBT account, after the participant’s death, are the property of the State of Idaho.(7-1-24)
IDAPA 16.03.05.131 Estate in Probate
AABD cash received by a participant before their death is disbursed as part of the participant’s estate if it is probated.
The probate administrator spends the AABD cash under their oath of administration.(7-1-24)
IDAPA 16.03.05.132 (Reserved)
IDAPA 16.03.05.155 Aabd for the Aged
To qualify for AABD for the aged, a person must be age sixty-five (65) or older.(7-1-24)
IDAPA 16.03.05.156 Aabd for the Blind or Disabled
To qualify for AABD for the blind or disabled, a person must meet the definition of blindness or disability used by the SSA for RSDI and SSI benefits.(7-1-24)
01.SSA Decision for Disabled. SSA’s disability decision is binding on the Department unless:
a.The participant states their disabling condition is different from, or in addition to, their condition considered by SSA, and the participant has not reapplied for SSI; or(7-1-24)
b.More than twelve (12) months have passed since the SSA made a final determination the participant was not disabled, and the participant states their condition has changed or become worse since that final determination, and the participant has not reapplied for SSI.(7-1-24)
02.Medicaid Pending SSA Appeal. When SSA decides a participant is no longer disabled, they meet the AABD disability requirement and can continue receiving Medicaid if they appeal SSA’s decision. Medicaid ends if the SSA decision is upheld.(7-1-24)
03.Grandfathered Participant for Aid to the Permanently and Totally Disabled or Aid to the Blind. A participant is disabled if they were eligible as disabled in December 1973, and continues to meet the disability requirement in effect in December 1, 1973. They must also meet the other current eligibility requirements.
IDAPA 16.03.05.157 (Reserved)
IDAPA 16.03.05.166 Fugitive Felon or Probation or Parole Violator
A participant is ineligible to receive AABD for any month during which they are fleeing to avoid prosecution for a felony, fleeing to avoid custody or confinement after a felony conviction, or violating a federal or state condition of probation or parole.(7-1-24)
IDAPA 16.03.05.167 Fraudulent Misrepresentation of Residency
A participant is ineligible for AABD for ten (10) years if they were convicted in a federal or state court of having fraudulently misrepresented residence to get AABD, SSI, TAFI, Food Stamps, or Medicaid from two (2) or more states at the same time.(7-1-24)
IDAPA 16.03.05.168 (Reserved)
IDAPA 16.03.05.200 Resources Defined
Resources are cash, personal property, real property , and notes receivable. A participant, or spouse, must have the right, authority, or power to convert the resource to cash. The participant must have the legal right to use the resource for support and maintenance. Liquid resources are resources in cash or resources convertible to cash within twenty (20) workdays. Nonliquid resources are any resources, not in the form of cash, which cannot be converted to cash within twenty (20) workdays.(7-1-24)
IDAPA 16.03.05.201 Resource Limit
The value of countable resources must be t wo thousand dollars ($2,000) or less, for a single person to be AABD eligible. A married person must have countable resources of three thousand dollars ($3,000) or less to be eligible for AABD cash. Resources are counted the first moment of each calendar month and apply to the entire month. (7-1-24)
IDAPA 16.03.05.202 Change in Value of Resources
A change in the value of resources is counted the fi rst moment of the next month.(7-1-24)
IDAPA 16.03.05.203 Resources and Change in Marital Status
A change in marital status changes the resource limit. Th e resource limit change is effective the month after individual participants are married, divorced, separated, or one (1) spouse dies.(7-1-24)
IDAPA 16.03.05.204 Factors Making Property a Resource
Property of any kind is a resource if the participant has an ow nership interest in the property and the legal right to spend or convert the property to cash.(7-1-24)
IDAPA 16.03.05.205 Counting Resources and Income
An asset cannot be counted as income and resources in the same month. Assets received in cash or in-kind during a month are income. Income held past the month received is a resource.(7-1-24)
IDAPA 16.03.05.206 (Reserved)
IDAPA 16.03.05.208 Shared Ownership Rule
Except for checking and savings accounts and time depos its, each owner of shared property owns only their fractional interest in the property. The total value of the property is divided among the owners, in direct proportion to each owner’s share.(7-1-24)
IDAPA 16.03.05.209 Conversion or Sale of a Resource Not Income
Payment from the sale, exchange, or replacement of a resource is not income. The payment is a resource.(7-1-24)
IDAPA 16.03.05.210 Resources Excluded by Federal Law
A resource excluded by federal law is not counted in determining the resource amount available to the participant.
IDAPA 16.03.05.211 (Reserved)
IDAPA 16.03.05.215 Deeming Resources
Resource deeming is determined by the SSA Program Operati ons Manual System (POMS) SI 01330.00, Deeming Resources, incorporated by reference under Section 002 of these rules. The participant’s circumstances are assessed the first moment of the month. Deeming starts the first full calendar month the participant is in a deeming situation.
Deeming ends the first full calendar month the participant is not in a deeming situation. Deeming to a child ends the month after the child’s eighteenth birthday.(7-1-24)
IDAPA 16.03.05.216 Household for Resource Computations
A participant living in an institution is not a household for resource computations.(7-1-24)
IDAPA 16.03.05.217 Unknown Resources
An asset is not a resource if the participant is unaware of thei r ownership. The asset is a resource the month after discovery.(7-1-24)
IDAPA 16.03.05.218 (Reserved)
IDAPA 16.03.05.222 Vehicles as a Resource
If more than one (1) vehicle is owned, the exclusion applies in the best way for the participant.(7-1-24)
01.One Vehicle Excluded. One (1) vehicle is excluded, regardless of value.(7-1-24)
02.Other Vehicles Not Excluded. The equity value of a vehicle not excluded under Subsection 222.01 of this rule is a resource.(7-1-24)
IDAPA 16.03.05.223 Burial Funds Excluded from Resource Limit
Burial funds up to one thousand five hundred dollars ($1,50 0) per person, set aside for the burial expenses of the participant or spouse, are excluded from resources. To be excluded, burial funds must be kept separate from assets not burial-related. A burial contract that can be revoked or sold, without significant hardship, is a resource. Any portion of the contract for the purchase of burial spaces is excluded from resources. A burial contract that cannot be revoked, and cannot be sold without significant hardship, is not a resource. The burial fund portion of the contract counts against the one thousand five hundred dollar ($1,500) burial funds exclusion. The burial space portion of the contract does not count against the burial funds exclusion. Interest earned on excluded burial funds is also excluded.
01.Life Insurance Policy as Burial Funds. The participant can designate a countable life insurance policy as a burial fund. The face value of excluded life insurance policies on the participant counts against the burial funds exclusion.(7-1-24)
02.Face Value of Burial Insurance Policies Not Counted. The face value of burial insurance policies does not count toward the one thousand five hundred dollar ($1,500) life insurance limit, when computing the total face value of life insurance policies owned by a participant. Interest on excluded burial funds does not count toward the one thousand five hundred dollar ($1,500) burial funds exclusion.(7-1-24)
03.Effective Date of Burial Funds Exclusion. The exclusion is effective the month after the month the funds were set aside. Burial funds can be designated retroactively, back to the first day of the month the participant intended the funds to be set aside. The participant must confirm the designation in writing.(7-1-24)
04.Penalty for Misusing Burial Funds. If the participant does not get SSI, burial funds used for another purpose lose the exclusion. An overpayment must be recovered. If the participant gets SSI, and is penalized by SSA because they used excluded burial funds for another purpose, their AABD payment must not be increased to compensate the SSA penalty.(7-1-24)
IDAPA 16.03.05.224 Burial Space or Plot Exclusion
A burial space is a burial plot, grave s ite, crypt, mausoleum, casket, urn, niche, or other repository normally used for the deceased’s remains. A burial space, or burial space purchase agreement, held for the burial of the participant, spouse, or other member of their immediate family, is an excluded resource.(7-1-24)
01.Burial Space Contract. Must list all burial spaces and include a value for each space or the total value of all the spaces. The contract must not require further payment after the contract is signed.(7-1-24)
02.Space Held by Ineligibles Excluded. A space held by an ineligible spouse or parent, for the burial of a participant, spouse, and any member of the participant’s immediate family, is excluded. A space held by a legal non-citizen sponsor, or essential person, for their own burial is excluded only if the sponsor is a member of the participant’s immediate family.(7-1-24)
IDAPA 16.03.05.225 (Reserved)
IDAPA 16.03.05.235 Excluded Household Goods and Personal Effects
Household goods and personal effects are excluded from resources, regardless of their dollar value.(7-1-24)
IDAPA 16.03.05.236 (Reserved)
IDAPA 16.03.05.237 Real Property Definition
Real property is land, including buildings or immovable objects attached permanently to the land. Real property is a resource unless excluded.(7-1-24)
IDAPA 16.03.05.238 Home as Resource
An individual’s home is property they own, and serves as their princ ipal place of residence. Their principal place of residence is the place they consider their principal home. If the individual is absent from their home, it is still their principal place of residence if they intend to return.(7-1-24)
01.AABD Cash, and Medicaid With the Exception of Long-Term Care. For AABD Cash and Medicaid except for long-term care, the value of an individual’s home is an excluded resource.(7-1-24)
02.Long-Term Care Services. For long-term care services, when the value of a participant’s equity in the home is seven hundred fifty thousand dollars ($750,000) or less, the home is excluded as a resource. When the equity value exceeds seven hundred fifty thousand dollars ($750,000), the individual is ineligible for long-term care services. The equity value, regardless of the amount, is an excluded resource when one (1) of the following applies:
a.The spouse of the individual lives in the home; or(7-1-24)
b.The individual’s child, who is under age twenty-one (21), or is blind, or meets the disability requirements for AABD cash, lives in the home.(7-1-24)
IDAPA 16.03.05.239 Sale of Excluded Home and Replacement
If the participant plans to buy another excluded home, proceeds from the sale of a participant’s excluded home are excluded resources. Proceeds from the sale of an excluded home must be used to replace the home within three (3) calendar months. Proceeds retained beyond three (3) calendar months are a countable resource.(7-1-24)
IDAPA 16.03.05.240 Replacement of Excluded Resources
Cash and in-kind payments for replacement or repair of lost, damaged, or stolen excluded resources, are excluded resources for nine (9) months from the date received. This exclusion can be extended for cash payments, up to an additional nine (9) months. The extension can be made if, for the first nine (9) months, circumstances beyond the participant’s control prevent repair or replacement of the lost, damaged, or stolen property and keep the participant from contracting for repair or replacement. This exclusion can be extended for twelve (12) more months for a catastrophe the President declares a major disaster. Interest earned by funds excluded under this provision is excluded from resources.(7-1-24)
IDAPA 16.03.05.241 Undue Hardship Exclusion from Sale of Jointly Owned Real Property
A participant’s ownership interest, in jointly owned real prop erty, is an excluded resource as long as sale of the property will cause undue hardship to a co-owner. Undue hardship results if a coowner uses the property as their principal place of residence, would have to move if the property were sold, and has no other readily available housing.(7-1-24)
IDAPA 16.03.05.242 American Indian Property Excluded
For the purposes of determining eligibility for an individual who is an American Indian, the following property is excluded:(7-1-24)
01.Property. Real property and improvements located on a reservation, including any federally recognized Indian Tribe's reservation, pueblo, or colony, and Indian allotments on or near a reservation as designated and approved by the Bureau of Indian Affairs.(7-1-24)
02.Natural Resources. Ownership interest in rents, leases, royalties, or usage rights related to natural resources resulting from the exercise of federally protected rights.(7-1-24)
03.Other Ownership Interests or Usage Rights. Ownership interests in or usage rights to property not covered by Subsections 242.01 or 242.02 of this rule that have a unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or traditional lifestyle under applicable tribal law or custom. (7-1-24)
IDAPA 16.03.05.243 Resources Associated with Property
Resources associated with real property are mineral rights, timber rights, easements, leaseholds, water rights, remainder interests, and sale of natural resources. These resources are counted as real property.(7-1-24)
IDAPA 16.03.05.244 Resources Essential for Self-Support Excluded
Resources are excluded as essential to self-sup port, if they fall into one (1) of the categories described below.
01.Essential Property in Current Use. Property in current use in the type of activity that qualifies it as essential to self-support is excluded, regardless of value or rate of return. Trade or business property, government permits, and personal property used by an employee for work are excluded regardless of value or rate of return. If the property is not in current use, for reasons beyond the participant’s control, there must be a reasonable expectation the required use will resume. If the participant does not intend to resume the self-support activity, the property is a countable resource for the month after the month of last use.(7-1-24)
02.Nonbusiness Property Producing Goods or Services. Up to six thousand dollars ($6,000) of the equity value of nonbusiness property, used to produce goods or services essential to daily activities, is excluded regardless of rate of return. Equity value over six thousand dollars ($6,000) is not excluded. This exclusion is not used for income-producing property.(7-1-24)
03.Nonbusiness Income-Producing Property. Up to six thousand dollars ($6,000) equity in nonbusiness income-producing property is excluded if the property produces a net annual return equal to at least six percent (6%) of the excluded equity. If a participant owns more than one (1) piece of income-producing property, the six percent (6%) return requirement applies to each. The six thousand dollars ($6,000) equity value limit applies to the total equity value of all the properties meeting the six percent (6%) return requirement. If the earnings decline is for reasons beyond the participant’s control, up to twenty-four (24) months can be allowed for the property to resume producing a six percent (6%) return. If the property still is not producing a six percent (6%) return at the end of the twenty-four (24) month extension, the resource exclusion must end the month after the month the twenty-four (24) month period ends.(7-1-24)
IDAPA 16.03.05.245 Resources Set Aside as Part of a Plan for
ACHIEVING SELF-SUPPORT (PASS)
EXCLUDED.
PASS allows blind and disabled participants to set aside inc ome and resources necessary for the achievement of its goals. Resources set aside as part of an approved PASS are excluded. The PASS disregard must not be applied to resources unless the participant would be ineligible due to excess resources. To disregard resources, the PASS must show how resources the participant has or will receive under the plan, will be used to obtain the PASS goal. The PASS must show how the disregarded resources will be identified separately from the participant’s other resources, list items or activities requiring savings or purchases and the amounts the participant anticipates saving or spending, and show a specific target date to achieve the objective.(7-1-24)
IDAPA 16.03.05.246 Life Estate Interest in Another’s Home
The purchase of a life estate interest in another individual’s h ome is a resource unless the purchaser resides in the home for a period of at least twelve (12) consecutive months after the date of purchase.(7-1-24)
IDAPA 16.03.05.247 (Reserved)
IDAPA 16.03.05.256 Retroactive Ssi and Rsdi Benefits
Retroactive SSI and RSDI benefits are issued after the calendar month for which they are paid. Retroactive SSI and RSDI benefits are excluded from resources for nine (9) calendar months after the month they are received. Interest earned by excluded funds is counted as income.(7-1-24)
IDAPA 16.03.05.257 Disaster Assistance
Assistance received because of a major disaster declared by the President is excluded from resources. Interest earned on excluded funds is excluded from income and resources.(7-1-24)
IDAPA 16.03.05.258 Cash to Purchase Medical or Social Services
Cash paid by a recognized medical or s ocial services program, for the participant to purchase medical or social services, is not a resource for one (1) calendar month after receipt. The cash must not be repayment for a bill already paid.(7-1-24)
IDAPA 16.03.05.259 (Reserved)
IDAPA 16.03.05.260 Alaska Native Claims Settlement Act
Payments to Alaska Natives and their descendants from the Alaska Native Claims Settlement Act, under PL 100-241, are excluded from resources.(7-1-24)
IDAPA 16.03.05.261 Stock in Alaska Regional or
VILLAGE CORPORATIONS.
Stock held by Alaska natives in regional or village corporations is inalienable for a twenty (20) year period under Sections 7(h) and 8(c) of the Alaska Native Claims Settlement Act.(7-1-24)
IDAPA 16.03.05.262 Victims' Compensation Payments
Payments, from a fund set up by a State to aid victims of crime, are ex cluded from resources for nine (9) months.
Interest earned on unspent victims’ compensation payments is counted for income and resources.(7-1-24)
IDAPA 16.03.05.263 (Reserved)
IDAPA 16.03.05.265 Tax Advances and Refunds Related to Earned Income Tax Credits
A federal tax refund or payment made by an employer, relat ed to Earned Income Tax Credits (EITC), is excluded from resources for the month after the month the refund or payment is received. Interest earned on unspent tax refunds related to EITC is counted for income and resources.(7-1-24)
IDAPA 16.03.05.266 Identifying Excluded Funds Commingled
WITH FUNDS NOT EXCLUDED.
Excluded funds must be separately identifiable to remain excluded.(7-1-24)
IDAPA 16.03.05.267 Dedicated Account for Ssi Participant
A dedicated account for past-due SSI benefits, set up in a fi nancial institution for an SSI participant under age eighteen (18) is an excluded resource. The account must be set up by the child’s SSI representative payee, and excluded by SSA.(7-1-24)
IDAPA 16.03.05.268 Support and Maintenance Assistance
Support and Maintenance Assistance (SMA) is in-kind support and maintenance, or cash paid for food or shelter needs. It includes Home Maintenance Assistance aid to cover costs of heating or cooling a home. SMA is an excluded resource.(7-1-24)
IDAPA 16.03.05.269 (Reserved)
IDAPA 16.03.05.272 Walker V. Bayer Payments
Class action settlement payments in Susan Walker v. Bayer C orporation, et al., are excluded from resources for Medicaid by PL 105-33. These payments are not excluded for AABD cash.(7-1-24)
IDAPA 16.03.05.273 (Reserved)
IDAPA 16.03.05.276 Excluded Real Estate Contract
The principal balance of a real estate contract is excluded fro m resources of a participant in long-term care when the Department determines it is in the Department’s best interest to exclude the contract. The determination by the Department of its best interest is final.(7-1-24)
IDAPA 16.03.05.277 Fees Paid to a Continuing Care Retirement Community (ccrc) or Life Care
COMMUNITY.
An entrance fee to a CCRC or a life care community is a res ource if the participant or applicant for long-term care has discretion to spend the fee or if the fee may be used to pay for care in a contingency. A CCRC or life care community is a type of long-term care facility that offers varying levels of care and in which a resident contracts with the facility to obtain care that is intended to endure for the remainder of the resident’s life in exchange for valuable consideration.
IDAPA 16.03.05.278 Trusts
A trust is a resource to a participant wit h the legal right to revoke the trust, and use the principal for their own support and maintenance. See Sections 838 through 873 in these rules for treatment of trusts for Medicaid.(7-1-24)
IDAPA 16.03.05.279 Retirement Funds
Retirement funds are work-related plans for providing income or pensions when employment ends. A retirement fu nd, owned by a participant, is a resource if they have the option of withdrawing a lump sum, even though they are not yet eligible for periodic retirement payments. If the participant is eligible for periodic retirement payments, the fund is not a countable resource. The value of a retirement fund is the amount of money a participant can currently withdraw from the fund.(7-1-24)
IDAPA 16.03.05.280 Inheritance
An inheritance is cash, a right, including probate allowances, trust payments and annuities, or noncash items received as the result of someone’s death. Cash or noncash items in an inheritance are income the month received and a resource the next month. Participants are required to make claims and take all reasonable action necessary to obtain any inheritance to which they may be entitled. Failure to make such claims or take reasonable steps to obtain an inheritance is an asset transfer. A contested inheritance is not counted as a resource until the contest is settled and money is distributed.(7-1-24)
IDAPA 16.03.05.281 Life Insurance
A life insurance policy is an excluded resource if its face value, plus the face value of all other life insurance policies the participant owns on the same insured person, totals one thousand five hundred dollars ($1,500) or less. If the face values exceed one thousand five hundred dollars ($1,500) the policies are a resource in the amount of the cash surrender value.(7-1-24)
IDAPA 16.03.05.282 Conservatorship
Funds required to be made available for the care and maintenance of a participant, under a court order , are the participant’s resource. This is true even if the participant or their agent is required to petition the court to withdraw funds for the participant’s care.(7-1-24)
IDAPA 16.03.05.283 Conditional Benefits
A participant ineligible due solely to excess nonliquid resou rces, can receive AABD cash and related Medicaid. The participant must meet two (2) conditions. First, their countable liquid resources must not exceed three (3) times the participant’s AABD cash budgeted needs. Second, the participant agrees, in writing, to sell excess nonliquid resources at their fair market value, within three (3) months. The value of excess real property is not counted as a resource, if the participant makes reasonable efforts to sell the property at its fair market value, and their reasonable efforts to sell are not successful. This exclusion is also used to compute deemed resources.(7-1-24)
01.Conditional Benefits Payments Disposal/Exclusion Period. The disposal and exclusion period for excess nonliquid resources begins on the date the participant signs the Agreement to Sell Property. The disposal and exclusion periods can begin earlier for a participant who met all requirements to receive conditional benefits before their first opportunity to sign the Agreement to Sell Property. The participant must sign the Agreement to Sell Property before their application is approved.(7-1-24)
02.Period for Disposal of Excess Resources. The disposal period for excess nonliquid personal property is three (3) months. One (1) three (3) month extension, for sale of personal property, is allowed when good cause exists.(7-1-24)
03.Good Cause for Not Making Efforts to Sell Excess Property. The participant has good cause for not making efforts to sell property, when circumstances beyond their control prevent their taking the required actions.
Without good cause, the participant's countable resources include the value of the excess property, retroactive to the beginning of the conditional benefits period.(7-1-24)
IDAPA 16.03.05.284 Resource Transfer for Less Than Fair Market Value
AABD cash participants are subject to a period of ineligibility if they transfer resources for less than fair market value. The participant is not subject to a period of ineligibility if their total countable resources in the transfer month were under two thousand dollars ($2,000), even if they have kept the transferred resources. Excluded resources, except for the excluded home and associated property, are not subject to the resource transfer period of ineligibility.
The exceptions to the period of ineligibility for transfer of resources are listed in Section 292 of these rules. (7-1-24)
01.Transfer of Resources. Includes reducing or eliminating the participant's ownership or control of the resource. Transfer of resources includes giving away cash resources without receiving fair market value. (7-1-24)
02.Transfer of Participant’s Resources by a Spouse of Either Spouse’s Resources. Subjects the participant to the resource transfer period of ineligibility.(7-1-24)
03.Transfer of Participant’s Resources by a Co-Owner. Subjects the participant to a period of ineligibility based on their share of the co-owed resources.(7-1-24)
04.Transfer of Participant’s Resources by a Legal Representative Such as a Legal Guardian or Parent of Minor Child. Subjects the participant to a period of ineligibility.(7-1-24)
IDAPA 16.03.05.285 Aabd Period of Ineligibility for Resource Transfers
The resource transfer period of ineligibility is a period of AABD ineligibility for up to sixty (60) months. The period of inel igibility begins the first day of the month after the transfer month. The participant must be notified in writing at least ten (10) days before a resource transfer period of ineligibility is imposed.(7-1-24)
IDAPA 16.03.05.286 Resource Transfer Look-Back Period
The resource transfer penalty applies to any transfer for less than fair market value made during a period preceding a request for cash assistance. Any resource transferred, regardless of type, is subject to a look-back period of sixty (60) months. The look-back period is counted from the date of the application for cash, or the date of the transfer, whichever is later in time.(7-1-24)
IDAPA 16.03.05.287 Calculating the Period of Ineligibility for Resource Transfers
The period of ineligibility is the number of months computed by dividing the difference between the fair market value of the resource and the amount the participant received for the resource by the full AABD allowances for the participant's living arrangement. For an applicant, the Department will use the full AABD allowance for the application month. For a participant, the Department will use the full AABD allowances for the transfer month. For an AABD couple, the period of ineligibility is computed by dividing the difference between the fair market value of the resource and the amount the participant received for the resource by the full AABD allowances for the couple's living arrangement. The number of months of ineligibility is computed to two (2) decimal places and rounded down to the nearest whole number. If the amount transferred is less than the participant's AABD allowances for one (1) month, the participant is not subject to a period of ineligibility.(7-1-24)
IDAPA 16.03.05.288 Length of Period of Ineligibility
The period of ineligibility begins with the month after the month the transfer took place. The period of ineligibility continues whether or not the participant receives AABD. Ineligibility continues until all the resources are returned to the participant or spouse, adequate consideration for all the resources is received, sixty (60) months passes, or the penalty period ends.(7-1-24)
IDAPA 16.03.05.289 Spouse Applies After Period of
INELIGIBILITY IS COMPUTED.
If the spouse applies after the period of ineligibility is computed, the Department will compute the spouse's period of ineligibility by multiplying the number of months in the period of ineligibility already expired by the full AABD allowances for the couple's living arrangement. The Department will subtract the total from the original difference between the fair market value of the resource and the amount the participant received for the resource. The Department will divide the remaining difference between the fair market value of the resource and the amount the participant received for the resource by the full AABD allowances for the couple's living arrangement for the first month of ineligibility.(7-1-24)
IDAPA 16.03.05.290 Multiple Resource Transfers
If the participant makes more than one (1) res ource transfer, the difference between the fair market value of all the transferred resources and the amount the participant received for all the transferred resources is used to determine the length of the period of ineligibility. The period of ineligibility begins with the month after the month of the first transfer.(7-1-24)
IDAPA 16.03.05.291 Transfers to Trusts
A trust established from the participant's resources is a resource tran sfer for less than fair market value, unless it meets an exception in Section 292 of these rules. If the trust includes resources of another person, the resource transfer period of ineligibility applies to the participant's share of the trust.(7-1-24)
01.Payment from Trust Not for Participant. If a payment is made to another individual from a trust counted as a resource, and the payment is not for the benefit of the participant, the payment is a resource transfer for less than fair market value.(7-1-24)
02.Payment from Trust Restricted. If the participant acts so no payment from a trust counted as a resource can be made for any reason, the trust is a resource transfer for less than fair market value. By taking the action, the participant causes the trust to be no longer counted as a resource and the participant is subject to the period of ineligibility. The date of the action restricting payment is the date of the transfer.(7-1-24)
IDAPA 16.03.05.292 Period of Ineligibility Exceptions
A participant or spouse is not subject to the resource transfer period of ineligibility if one (1) of the following cond itions is satisfied.(7-1-24)
01.Home to Spouse. Title to the home is transferred solely to the spouse.(7-1-24)
02.Home to Minor Child or Disabled Adult Child. Title to the home is transferred to the child of the participant or spouse. The child must be under age twenty-one (21), blind or totally disabled under Social Security and SSI rules in 20 CFR Part 416.(7-1-24)
03.Home to Sibling. Title to the home is transferred to a sibling of the participant or spouse who must have had an equity interest or life estate in the transferred home and was residing in that home for at least one (1) year immediately before the month the home was transferred.(7-1-24)
04.Home to Adult Child. Title to the home was transferred to a child of the participant or spouse, other than a child under the age of twenty-one (21). The child must have resided in that home for at least two (2) years immediately before the month the participant entered a medical facility or long-term care. The child must have provided care to the participant, which permitted them to live at home rather than enter a medical facility or long-term care.(7-1-24)
05.Benefit of Spouse. Resources, other than the home, were transferred to the participant's spouse or to another person for the sole benefit of the spouse.(7-1-24)
06.Transfer from Spouse. The resources were transferred from the participant's spouse to another person for the sole benefit of the participant's spouse.(7-1-24)
07.Transfer to Child. The resources were transferred to the participant's child or to a trust established solely for the benefit of the participant's child. The child must be blind or totally disabled under Social Security and SSI rules in 20 CFR Part 416. The child may be any age.(7-1-24)
08.Transfer to Trust for Person Under Sixty-Five. The resources were transferred to a trust for the sole benefit of a person under age sixty-five (65) who is blind or totally disabled under Social Security and SSI rules in 20 CFR Part 416.(7-1-24)
09.Transfer to a Trust That Is a Countable Resource. The resources were transferred to a trust and the trust is a countable resource for AABD in the amount of the transfer.(7-1-24)
10.Intent to Receive Fair Market Value. The participant or spouse proves they intended to dispose of the resources at fair market value or for other adequate consideration, but can prove good cause for not doing so.
11.Resources Returned. All resources transferred for less than fair market value have been returned to the participant.(7-1-24)
12.No AABD Purpose. The participant or spouse proves the resources were transferred exclusively for a purpose other than qualifying for AABD. Purposes other than qualifying for AABD include:(7-1-24)
a.After the resource transfer the participant has a traumatic onset of disability.(7-1-24)
b.After the resource transfer a previously unknown disabling condition is diagnosed.(7-1-24)
c.After the resource transfer the participant has an unexpected loss of income or resources resulting in eligibility for AABD.(7-1-24)
d.The resource was excludable in the transfer month.(7-1-24)
e.The transfer of resources was court-ordered, provided the participant did not petition the court to order the transfer.(7-1-24)
f.The participant took a vow of poverty and gave the resources to a religious order.(7-1-24)
13.Undue Hardship. The participant proves failure to receive AABD would deprive them of food or shelter and their total available funds, including income and liquid resources, are less than their AABD allowances for the month they claim undue hardship. Undue hardship must be proven for each month of the period of ineligibility. When determining total available funds for a child, the Department will count any income and resources deemed from their parents.(7-1-24)
14.Exception to Fair Market Value. The amount received is reasonable, even if less than fair market value if a forced sale was done under reasonable circumstances, and little or no market demand exists for the type of resource transferred, or the resource was transferred to settle a legal debt approximately equal to the fair market value of the transferred resource.(7-1-24)
15.No Benefit to Participant. The participant received no benefit from the resource because they or their spouse held title to the property only as a trustee for another person, or the transfer was done to clear title to property and the participant or spouse had no interest in the property that would benefit them.(7-1-24)
16.Fraud Victim. The resource was transferred because the participant or spouse was the victim of fraud, misrepresentation, or coercion. The participant or spouse must take all possible steps to recover the resources or property or its equivalent in damages. The participant must assign recovery rights to the State of Idaho.(7-1-24)
IDAPA 16.03.05.293 Effect on Medicaid Eligibility
Ineligibility for AABD cash becaus e of property transfer does not make the participant ineligible for Medicaid.
IDAPA 16.03.05.294 (Reserved)
IDAPA 16.03.05.300 Income Definition
Income is anything that can be used to meet needs for food, or shelter. Income is cash, wages, pensions, in-kind payments, inheritances, gifts, awards, rent, dividends, interest, or royalties the participant receives during a month.
01.Cash Income. Is currency, checks, money orders, or electronic funds transfers. Cash income includes Social Security checks, unemployment checks, and payroll checks.(7-1-24)
02.In-Kind Income. Is not cash. In-kind income is food or shelter. Wages paid as in-kind earnings, such as food or shelter, are counted as unearned income. Other in-kind income is not counted.(7-1-24)
03.Inheritances. Is cash, a right, or noncash items received as the result of someone’s death. Cash or noncash items in an inheritance are income the month received and a resource the next month. A contested inheritance is not counted as income until the contest is settled and money is distributed.(7-1-24)
IDAPA 16.03.05.301 Application for Potential Benefits
The participant must apply for benefits, including RSDI, VA, pensions, Workman’s Compensation, or Unemployment Insurance, when there is potential eligibility. The participant must apply when they reach the earliest age to qualify for the benefit.(7-1-24)
01.SSI. To get AABD cash, the participant must apply for SSI benefits, if they are potentially eligible.
To get AABD-Medicaid, the participant does not have to apply for SSI benefits.(7-1-24)
02.VAIP. Participants entitled to a VA pension as of December 31, 1978, are not required to file for Veterans Administration Improved Pension Plan (VAIP), to get AABD cash or AABD-related Medicaid.(7-1-24)
03.Other Benefits. EITC, TAFI, BIA General Assistance, and victim’s compensation benefits are exempt from the filing requirement.(7-1-24)
IDAPA 16.03.05.302 Relationship of Income to Resources
Income is counted as income in the current month. If the participant keep s countable income after the month received, it is counted as a resource.(7-1-24)
IDAPA 16.03.05.303 When Income Is Counted
Income is counted the earliest of when receive d, when credited to a participant’s account, or when set aside for the participant’s use. Income from SSA, SSI, or VA is counted for the month it is intended to cover.(7-1-24)
IDAPA 16.03.05.304 Prospective Eligibility
Eligibility for AABD cash and Medicaid is prospective. Expected income for the month is compared to the participant’s income limit that month.(7-1-24)
IDAPA 16.03.05.305 Projecting Monthly Income
Income is projected for each month to determine AABD cash amount. Past income may be used to project future income. Expected changes must be considered. Income received less often than monthly and patient liability income are not prorated or converted.(7-1-24)
IDAPA 16.03.05.306 Criteria for Projecting Monthly Income
Monthly income is projected as described below.(7-1-24)
01.Converting Income to a Monthly Amount. If a full month’s income is expected, but is received on other than a monthly basis, the Department will convert the income to a monthly amount using one (1) of the formulas in the table below.
TABLE 306.01 MONTHLY CONVERSION OF INCOME
ConversionProcedure
a.Weekly to MonthlyMultiply weekly amounts by 4.3.
02.Income Already Received. The Department will count income already received during the month and will convert the actual income to a monthly amount if a full month’s income has been received or is expected to be received as described below.(7-1-24)
a.If the actual amount of income from any pay period a month is known, the Department will use the actual pay period amounts to determine the total month’s income and will convert the actual income to a monthly amount if a full month’s income has been received or is expected.(7-1-24)
b.If no pay changes are expected, the Department will use the known actual pay period amounts for the past thirty (30) days to project future income and will convert the actual income to a monthly amount if a full month’s income has been received or is expected.(7-1-24)
03.Expected Income. The Department will count income that the participant and the Department believe the participant will get. The Department will convert expected income to a monthly amount as described below.(7-1-24)
a.If the exact income amount is uncertain or unknown, the uncertain or unknown portion must not be counted. The certain or known amount is counted.(7-1-24)
b.If the income has not changed and no changes are expected, past income can be used to project future income.(7-1-24)
c.If income changes, and income received in the past thirty (30) days does not reflect expected income, income received over a longer period is used to project future income.(7-1-24)
d.If income changes seasonally, income from the last comparable season is used to project future income.(7-1-24)
04.Ongoing Income. Comes from an ongoing source. It was received in the past and is expected to be received in the future. The Department will convert ongoing income to a monthly amount as described below.
a.If a full month’s income is not expected from an ongoing source, the Department will count the amount of income expected for the month. If actual income is known, the Department will use actual income. If actual income is unknown, the Department will project expected income and will convert income to a monthly amount. The Department will use zero (0) income for any pay period in which income was not received that month.
b.If a full month’s income from a new source is not expected, the Department will count the actual income expected for the month. The Department will not convert the income to a monthly amount.(7-1-24)
c.If income stops and no additional income is expected from the terminated source, the Department will count the actual income received during the month. The Department will not convert the terminated source of inco
me.(7-1-24)
d.If a full month’s income is not expected from a new or terminated source, the Department will
b.Biweekly to MonthlyMultiplying bi-weekly amounts by 2.15.
c.Semimonthly to MonthlyMultiplying semi-monthly amounts by 2.
d.Exact AmountUse the exact monthly income if it is expected for each month.
TABLE 306.01 MONTHLY CONVERSION OF INCOME
ConversionProcedure count the income expected for the month. If the actual income is known, the Department will use the known income.
If the actual income is unknown, the Department will project the income and will not convert the income to a monthly amount if a full month’s income from a new or terminated source is not expected.(7-1-24)
05.Income Paid on Salary. Income paid on salary, rather than an hourly wage, is counted at the expected monthly salary rate.(7-1-24)
06.Income Paid at Hourly Rate. The Department will compute expected income paid on an hourly basis by multiplying the hourly pay by the expected number of hours the participant will work in the pay period. The Department will convert the pay period amount to a monthly basis.(7-1-24)
07.Monthly Income Varies. When monthly income varies each pay period and the rate of pay remains the same, the Department will average the income from the past thirty (30) days to determine the average pay period amount and will convert the average pay period amount to a monthly amount. When income changes and income from the past thirty (30) days is not a valid indicator of future income, a longer period of income history is used to project income.(7-1-24)
08.Income Received Less Often Than Monthly. Recurring income, such as quarterly payments or annual income, is counted in the month received, even if the payment is for multiple months. The income is not prorated or converted. If the amount is known, the Department will use the actual. If the amount is unknown, the Department will use the best information available to project income.(7-1-24)
IDAPA 16.03.05.307 Counting Resources and Income
An asset cannot be counted as income and resources in the same month. Assets received in cash or in-kind during a month are income. Income held past the month received is a resource.(7-1-24)
IDAPA 16.03.05.308 (Reserved)
IDAPA 16.03.05.310 Adoption Assistance Under Title Iv-B or Title Xx
Adoption assistance payments, provided under Title IV-B or Title XX of the Social Security Act, are excluded income. Adoption assistance payments using funds provided under Title IV-E are income. The twenty dollar ($20) standard disregard is not subtracted.(7-1-24)
IDAPA 16.03.05.311 (Reserved)
IDAPA 16.03.05.313 Assistance Based on Need (abon)
ABON is aid paid under a program using income as a factor of eligibility. ABON is funded wholly by a State, or a political subdivision of a State, or an Indian tribe, or a combination of these sources. Federal funds are not used.
ABON is excluded income.(7-1-24)
IDAPA 16.03.05.314 (Reserved)
IDAPA 16.03.05.315 Bureau of Indian Affairs (bia) Foster Care
BIA foster care payments are social services. They are excluded income for the foster child and foster family.
IDAPA 16.03.05.316 Blind or Disabled Student Earned Income
To qualify for this exclusion, the student must be blind or disabled and be under age twenty-two (22). The student mu st be regularly attending high school, college, university, or a course of vocational or technical training designed to prepare them for gainful employment. The maximum monthly and annual exclusions cannot exceed the limits set by SSI for the current year.(7-1-24)
IDAPA 16.03.05.317 “Buy-In” Reimbursement
The SSA reimbursement for self-paid Medicare Part B “Buy-In” premiums is excluded.(7-1-24)
IDAPA 16.03.05.318 (Reserved)
IDAPA 16.03.05.320 Conversion or Sale of a Resource Not Income
Payment from the sale, exchange, or replacement of a resource is excluded. The payment is a resource that changed form.(7-1-24)
IDAPA 16.03.05.321 Credit Life or Disability Insurance Payments
Credit life or credit disability insurance covers payments on loans and mortgages, in case of death or disability.
Insurance payments are made directly to loan or mortgage companies and are not available to the participant. These payments are excluded.(7-1-24)
IDAPA 16.03.05.322 Department of Education Scholarships
Any grant, scholarship, or loan to an undergraduate for educational purposes, made or insured under any program administered by the Commissioner of Education, is excluded.(7-1-24)
IDAPA 16.03.05.323 (Reserved)
IDAPA 16.03.05.324 Grants, Scholarships, and Fellowships
Any grant, scholarship, or fellowship, not administered by the Com missioner of Education, and used for paying tuition, fees, or required educational expenses is excluded. This exclusion does not apply to any portion set aside or used for food or shelter.(7-1-24)
IDAPA 16.03.05.325 Disaster Assistance
Payments received because of a major dis aster, declared by the President, are excluded. This includes payments to repair or replace the person’s own home or other property and disaster unemployment aid.(7-1-24)
IDAPA 16.03.05.326 Domestic Volunteer Service Act Payments
Compensation, other than wages, provided to volunteers in the Fo ster Grandparents Program, RSVP, and similar National Senior Volunteer Corps programs under Sections 404(g) and 418 of the Domestic Volunteer Service Act is
IDAPA 16.03.05.327 Earned Income Tax Credits
Earned Income Tax Credits advance payments and re funds are excluded.(7-1-24)
IDAPA 16.03.05.328 Federal Housing Assistance
Federal housing assistance is excluded.
IDAPA 16.03.05.329 Foster Care Payments
Foster care payments using funds provided under Title IV-B o r Title XX of the Social Security Act are excluded.
Payments for foster care of a non-SSI child placed by a public or private non-profit child placement or child care agency are excluded. Foster care payments using funds provided under Title IV-E are income. The twenty dollar ($20) standard disregard is not subtracted.(7-1-24)
IDAPA 16.03.05.330 Expense of Obtaining Income
Essential expenses of obtaining unearned income are subtracted from the income. An expense is essential if the participant would not receive the income unless they paid the expense. Expenses of receiving income, such as withheld taxes, are not subtracted.(7-1-24)
IDAPA 16.03.05.331 Garnishments
Garnishments of unearned income are counted as unearned income. Garnishments of earned income are counted as earned income.(7-1-24)
IDAPA 16.03.05.332 (Reserved)
IDAPA 16.03.05.333 Government Medical or Social Services
Governmental payments authorized by federal, state, or local law, for medical or social services, are excluded. Any cash provided by a nongovernmental medical or social services organization (including medical and liability insurers) for medical or social services already received is excluded.(7-1-24)
01.Medical Services. Are diagnostic, preventive, therapeutic, or palliative treatment. Treatment must be performed, directed, or supervised by a state-licensed health professional. Medical services include room and board provided during a medical confinement and in-kind medical items.(7-1-24)
02.Social Service. Any service, other than medical. Housebound and Aid and Attendance Allowances, including Unusual Medical Expense Allowances, received from the Veterans Administration are excluded. (7-1-24)
IDAPA 16.03.05.334 Home Energy Assistance (hea) and Support and Maintenance Assistance
(SMA).
HEA and SMA are excluded.(7-1-24)
IDAPA 16.03.05.335 (Reserved)
IDAPA 16.03.05.336 In-Home Supportive Services
Payments made by Title XX or other governmental programs to pay an ineligible spouse or ineligible parent for inhome supportive services provided to a participant are excluded. In-home supportive services include attendant care, chore services, and homemaker services.(7-1-24)
IDAPA 16.03.05.337 Income Excluded by Law
Any income excluded by federal statute is excluded.(7-1-24)
IDAPA 16.03.05.338 Infrequent or Irregular Income
The first thirty dollars ($30) of earned income and the f irst sixty dollars ($60) of unearned income per calendar quarter are excluded when they are infrequent or irregular payments. Income is infrequent if the participant receives it once in a calendar quarter from a single source. Income is irregular if the participant could not reasonably expect to receive it.(7-1-24)
IDAPA 16.03.05.339 (Reserved)
IDAPA 16.03.05.340 Loans
Loans are excluded if the participant has signed a written repayment agreement. The signed agreement must state how the loan will be repaid. The signed written agreement can be obtained after the loan is received. Items bought on credit are paid with a loan and are not income. Money repaid to a participant on the principal of a loan is not income, it is a resource. Interest received by a participant on money loaned by them is countable income.(7-1-24)
IDAPA 16.03.05.341 (Reserved)
IDAPA 16.03.05.342 Native American Payments
Payments authorized by law made to people of Native American ancestry are excluded.(7-1-24)
IDAPA 16.03.05.343 (Reserved)
IDAPA 16.03.05.344 Nutrition Programs for Older Americans
Payments, other than a wage or salary, made under Chapter 35, Title 42, USC, Programs for Older Americans, are
IDAPA 16.03.05.345 Personal Services
A personal service performed for a participant is excluded. Person al services include lawn mowing, house cleaning, grocery shopping, and babysitting.(7-1-24)
IDAPA 16.03.05.346 (Reserved)
IDAPA 16.03.05.347 Rebates, Refunds, Aabd Underpayments, and Replacement Checks
Rebates, refunds, AABD underpayments, and returns of money already paid are excluded. A replacement check is
IDAPA 16.03.05.348 Relocation Assistance
Relocation payments under Title II of the Uniform Relocation Assistance and Real Property Acquisitions Policies Act of 1970, Subchapter II, Chapter 61, Title 42, USC, are excluded. Relocation payments paid to civilians of World War II per PL 100-383, are excluded.(7-1-24)
IDAPA 16.03.05.349 Replacement of Income Already Received
Replacement of a participant’s lost, stolen, or destroyed income is excluded.(7-1-24)
IDAPA 16.03.05.350 Return of Mistaken Payments
A returned mistaken payment is e xcluded. If the participant keeps the mistaken payment, it is income.(7-1-24)
IDAPA 16.03.05.351 Tax Refunds
Refunds of federal, State, or local taxes paid on income, real property, or food bought by the participant and their family, are excluded.(7-1-24)
IDAPA 16.03.05.352 Utility Payments
Payments for utility costs made to low-income housing tenants by a local housing authority are excluded when paid directly to the tenant or jointly to the tenant and the utility company.(7-1-24)
IDAPA 16.03.05.353 (Reserved)
IDAPA 16.03.05.354 Victims' Compensation Payments
Any payment made from a State-sponsored fund to aid victims of crime is excluded.(7-1-24)
IDAPA 16.03.05.355 Vocational Rehabilitation Ser
VICES PAYMENTS.
Payments other than wages made to an eligible handicapped in dividual employed in a Vocational Rehabilitation Services project under Title VI of the Rehabilitation Act of 1973, are excluded.(7-1-24)
IDAPA 16.03.05.356 Volunteer Services Income
Payments to volunteers under Chapter 66, Title 42, USC Domestic Volunteer Services (ACTION programs) are excluded. Payments are not excluded if the Director of the ACTION agency determines the value, adjusted for hours served, is equal to or greater than the federal or state minimum wage.(7-1-24)
IDAPA 16.03.05.357 Walker V. Bayer Payments
Class action settlement payments in Susan Walker v. Bayer Corporation, et al., are excluded for Medicaid but not for AABD cash.(7-1-24)
IDAPA 16.03.05.358 Weatherization Assistance
Weatherization assistance is excluded.(7-1-24)
IDAPA 16.03.05.359 Temporary Census Income
For Medicaid only, all wages paid by the Census Bureau for temporary employment related to US Census activities are excluded.(7-1-24)
IDAPA 16.03.05.360 (Reserved)
IDAPA 16.03.05.400 Earned Income
Earned income remaining after disregards and exclusions are subtracted, is counted in computing AABD cash. Wages are counted the month they become available to the participant.(7-1-24)
IDAPA 16.03.05.401 Computing Self-Employment Income
Countable self-employment income is the dif ference between the gross receipts and the allowable costs of producing the income, if the amount is expected to continue. Self-employment income is computed using one (1) of the methods listed in Subsections 401.01 through 401.03 of this rule. Subsection 401.04 of this rule can be used as an income deduction, if applicable.(7-1-24)
01.Self-Employed at Least One Year. For individuals who are self-employed for at least one (1) year, income and expenses are averaged over the past twelve (12) months.(7-1-24)
02.Self-Employed Less Than One Year. For individuals who are self-employed for less than one (1) year, income and expenses are averaged over the months the business has been in operation.(7-1-24)
03.Monthly Increase or Decrease. If a monthly average does not reflect actual monthly income because of an increase or decrease in business, the self-employment income is counted monthly. This method is not used for businesses with seasonal or unusual income peaks at certain times of the year.(7-1-24)
04.Net Self-Employment Income Seven and Sixty-Five Hundredths Percent Deduction. If net self-employment income is over four hundred dollars ($400) per year, seven and sixty-five hundredths percent (7.65%) is deducted. This deduction compensates for Social Security taxes paid. If self-employment Social Security tax is not paid, this deduction is not allowed.(7-1-24)
IDAPA 16.03.05.402 Self-Employment Allowable Expenses
Allowable operating expenses subtracted from self-employment income are the allowable Internal Revenue Service self-employment expenses, except for those listed under Section 403 of these rules.(7-1-24)
IDAPA 16.03.05.403 Self-Employment Expenses Not Allowed
Self-employment expenses not allowed are as follows:(7-1-24)
01.Payments on the Principal of Real Estate. Payments on the principal of real estate mortgages on income-producing property.(7-1-24)
02.Purchase of Capital Assets or Durable Goods. Purchases of capital assets, equipment, machinery, and other durable goods. Payments on the principal of loans for these items.(7-1-24)
03.Federal, State, and Local Income Taxes.(7-1-24)
04.Savings. Monies set aside for future use such as retirement or work-related expenses.(7-1-24)
05.Labor Paid to Any Family Member.(7-1-24)
06.Loss of Farm Income Subtracted From Other Income.(7-1-24)
07.Personal Transportation.(7-1-24)
08.Net Losses from Previous Periods.(7-1-24)
IDAPA 16.03.05.404 Royalties
Royalties received as part of a trade or bus iness, or for publication of the participant’s work, are earned income. Other royalties are unearned income.(7-1-24)
IDAPA 16.03.05.405 Honoraria
An honorarium for services rendered is earned income. An honorarium for travel expenses and lodging for a guest speaker is unearned inc ome in the amount it exceeds the expenses. The portion that equals the expenses is excluded as an expense of obtaining the income.(7-1-24)
IDAPA 16.03.05.406 Sheltered Workshop or Work Activities Center Payments
Payments for services performed in a sheltered workshop or work activities center are earned income.(7-1-24)
IDAPA 16.03.05.407 Job Training Partnership Act (jtpa)
JTPA payments are earned income. JTPA payments for child care, transportation, medical care, meals , and other reasonable expenses, provided in cash or in-kind, are not income.(7-1-24)
IDAPA 16.03.05.408 Programs for Older Americans
Wages or salary paid under Chapter 35, Title 42, USC, Pro grams for Older Americans, is earned income.(7-1-24)
IDAPA 16.03.05.409 Uniformed Services Pay and Allowances
Basic pay is earned income. All other pay and allowances are unearned income.(7-1-24)
IDAPA 16.03.05.410 Rental Income
Net rental income is unearned income, unless from the business o f renting real property. Net unearned rental income is gross rent less the expenses on the rental property as listed below. Net rental income from the business of renting properties is self-employment earned income.(7-1-24)
01.Interest. Interest and escrow portions of a mortgage payment.(7-1-24)
02.Real Estate Insurance.(7-1-24)
03.Repairs. Minor repairs to an existing rental structure.(7-1-24)
04.Property Taxes.(7-1-24)
05.Yard Care. Lawn care, including tree and shrub care and snow removal.(7-1-24)
06.Advertising Costs for Tenants.(7-1-24)
IDAPA 16.03.05.411 Overpayment Withholding of Unearned Income
Money withheld by any benefit program to recover an overpay ment is counted as income. Money withheld is not income if the overpaid benefit amount was used to compute AABD cash.(7-1-24)
IDAPA 16.03.05.412 Retirement, Survivors, and Disability Insurance (rsdi)
RSDI monthly benefits are unearned income. The income is the amount reported by SSA, regardless of penalties to recover an SSI overpayment.
IDAPA 16.03.05.413 Ssi Payments
SSI monthly payments are unearned income. The income is the amount reported by SSA, regardless of penalties to recover an SSI overpayment. An advance SSI payment to an applicant appearing SSI-eligible with a financial emergency, is not income the month received. When SSA reduces ongoing SSI to recover the advance, the SSI payment before the reduction continues to be counted as income.(7-1-24)
IDAPA 16.03.05.414 Black Lung Benefits
Black Lung payments are unearned income.(7-1-24)
IDAPA 16.03.05.415 Railroad Retirement Payments
Railroad Retirement Board payments are unearned income.(7-1-24)
IDAPA 16.03.05.416 Unemployment Insurance Benefits
Unemployment insurance benefits received under state and federal unemployment laws are unearned income.
IDAPA 16.03.05.417 Uniform Gifts to Minors Act (ugma)
UGMA payments from the custodian to t he minor are income to the minor. UGMA property, including earnings or additions, are not income to the minor until the month the minor becomes eighteen (18) years old.(7-1-24)
IDAPA 16.03.05.418 Workers' Compensation
Workers’ compensation, less expenses required to get th e payment, is unearned income.(7-1-24)
IDAPA 16.03.05.419 Military Pensions
Military pensions are unearned income.(7-1-24)
IDAPA 16.03.05.420 Va Pension Payments
VA pension payments are unearned income. The twenty dollar ($20) stan dard disregard is not subtracted, except by a special act of Congress.(7-1-24)
IDAPA 16.03.05.421 Va Compensation Payments
VA compensation payments to a v eteran, spouse, child, or widow(er) are unearned income.(7-1-24)
IDAPA 16.03.05.422 Va Educational Benefits
VA educational payments funded by the government are excluded.(7-1-24)
IDAPA 16.03.05.423 Alimony, Spousal, and Adult Support
Alimony, spousal, and other adult support payments are unearned income.(7-1-24)
IDAPA 16.03.05.424 Child Support Payments
Child support payments are unearned income. One-third (1/3) of a child support payment is excluded for the child receiving support. Child support collected by a State and retained for TAFI payments is not income.(7-1-24)
IDAPA 16.03.05.425 Dividends and Interest
Dividends and interest are unearned income.(7-1-24)
IDAPA 16.03.05.426 Awards, Gifts, Prizes
Awards, gifts, and prizes are unea rned income.(7-1-24)
IDAPA 16.03.05.427 Work-Related Unearned Income
Work-related payments that are not salary or wages are unearned income.(7-1-24)
428 – 430.(RESERVED)
IDAPA 16.03.05.431 Federal Emergency Management Agency (fema) Emergency Food
DISTRIBUTION AND SHELTER PROGRAMS.
FEMA funds are unearned income, unless excluded by the type of aid, such as medical services or Support and Maintenance Assistance.(7-1-24)
IDAPA 16.03.05.432 Bureau of Indian Affairs General Assistance (bia Ga)
BIA GA payments are unearned income and are fed erally funded income based on need. They are paid in cash or inkind. The twenty dollar ($20) standard disregard is not subtracted.(7-1-24)
IDAPA 16.03.05.433 Bia Adult Custodial Care (acc) and Child Welfare Assistance (cwa)
P AYMENTS.
BIA ACC and CWA payments, other than foster care made to particip ants out of an institution, are unearned income.
IDAPA 16.03.05.434 Individual Indian Money (iim) Accounts
Deposits to an unrestricted IIM account are income in the month deposited.(7-1-24)
IDAPA 16.03.05.435 Accelerated Life Insurance I
NCOME.
Accelerated life insurance payments are unearned inc ome in the month received.(7-1-24)
IDAPA 16.03.05.436 Real Estate Contract Income
Payments received on the interest of a negotiable real estate contract are unearned income for Medicaid eligibility.
Payments received on the principal of a negotiable real estate contract are a resource for Medicaid eligibility.
Payments received on a nonnegotiable real estate contract are unearned income. Principal and interest payments received on an excluded real estate contract of a long-term care participant are unearned income for patient liability.
IDAPA 16.03.05.437 Limited Award to Child with Life-Threatening Condition
Any gift from a tax-exempt nonprofit organization to a ch ild under age eighteen (18), who has a life-threatening condition, is excluded from income under the conditions below.(7-1-24)
01.In-Kind Gift. Is excluded if the gift is not converted to cash.(7-1-24)
02.Cash Gifts. Are excluded up to two thousand dollars ($2,000) for the calendar year the cash gifts are made.(7-1-24)
IDAPA 16.03.05.438 (Reserved)
IDAPA 16.03.05.451 Deeming Income
Income deeming counts the income of another person as avail able to an AABD participant, for eligibility and the amount of AABD cash. Income is deemed to the participant from their ineligible spouse, and to the child participant from their ineligible parent. Income deeming starts the first full calendar month the participant is in a deeming situation. Deeming ends the first full calendar month the participant is not in a deeming situation. Deeming to a child ends the month after the child’s eighteenth birthday.(7-1-24)
01.Ineligible Parent. A natural or adoptive parent or stepparent, who does not receive AABD and lives in the same household as a child.(7-1-24)
02.Ineligible Spouse. A participant’s spouse living with the participant and not receiving AABD is an ineligible spouse. The ineligible spouse of the parent of a child participant, living with the child participant and their parent, is an ineligible spouse.(7-1-24)
03.Ineligible Child. A child under age twenty-one (21) who does not receive AABD, and lives with the AABD participant.(7-1-24)
04.Income Deeming Exclusions. Income excluded from deeming is listed in POMS Chapter SI 01320.000, incorporated by reference under Subsection 002.02 of these rules.(7-1-24)
IDAPA 16.03.05.452 Deeming Income from Ineligible Spouse to Participant
Income is deemed from an ineligible spouse to the participant, if they live together. Income is deemed as described in Subsections 452.01 through 452.08 POMS Chapter SI 01320.000, incorporated by reference under Subsection 002.02 of these rules.(7-1-24)
IDAPA 16.03.05.453 Deeming Income from Ineligible Parent to Aabd Child
Income is deemed from an ineligible parent, or their ineli gible spouse, to a child participant under age eighteen (18) living in the same household. A stepparent’s income is deemed to the child for AABD cash, but not Medicaid. The income is deemed as described in POMS Chapter SI 01320.000, incorporated by reference under Subsection 002.02 of these rules.(7-1-24)
IDAPA 16.03.05.454 Deeming Income from Essential Person to Participant
If a participant and an essential person live in the same hou sehold, the essential person’s income is deemed to the participant. If essential person deeming makes the participant ineligible, the Department will not use essential person deeming. The income is deemed as described in Subsections 454.01 through 454.06 POMS Chapter SI 01320.000, incorporated by reference under Subsection 002.02 of these rules.(7-1-24)
IDAPA 16.03.05.455 Deeming Income from Ineligible Spouse
TO PARTICIPANT AND CHILD
PARTICIPANT.
If a participant, their ineligible spouse, and their child partici pant live in the same household, income is deemed from the participant to the child participant. The income is deemed as described in POMS Chapter SI 01320.000, incorporated by reference under Subsection 002.02 of these rules.(7-1-24)
IDAPA 16.03.05.456 Deeming Income from Sponsor to Legal
NON-CITIZEN PARTICIPANT -- NO I-864
AFFIDAVIT OF SUPPORT.
The Department will deem income as described in this rule, i f the legal non-citizen’s sponsor signed an affidavit of support other than the I-864. The deemed income is counted, even if the participant does not live in the sponsor’s household. The sponsor’s income is not deemed to the participant for Medicaid.(7-1-24)
01.Three-Year Limit. The deeming period, regardless of admission date, is three (3) years after the date the legal non-citizen is lawfully admitted. Deeming stops the end of the month, three (3) years from the date the sponsored participant lawfully entered the US for permanent residence.(7-1-24)
02.Sponsored Legal Non-Citizen Exempt from Deeming. A lawfully admitted legal non-citizen participant is exempt from sponsor deeming if one (1) or more of the following conditions applies.(7-1-24)
a.The legal non-citizen was admitted to the US as a refugee, asylee, or parolee.(7-1-24)
b.The legal non-citizen first applied for AABD before October 1, 1980.(7-1-24)
c.The legal non-citizen is a lawful permanent resident.(7-1-24)
d.The legal non-citizen’s entry into the US was sponsored by a church, other social service organization, or an employer who has offered them a job.(7-1-24)
e.The legal non-citizen becomes blind or disabled after they are admitted to the US.(7-1-24)
f.The legal non-citizen was sponsored by and resides in the same household with their ineligible spouse or ineligible parent. The Department will use ineligible spouse and ineligible parent deeming, not sponsor deeming.(7-1-24)
g.The legal non-citizen’s sponsor dies.(7-1-24)
h.The legal non-citizen was legalized under the Immigration Reform and Control Act of 1986.
i.The legal non-citizen has lived in the US for thirty-six (36) months beginning with the month they were admitted for permanent residence or granted permanent residence status.(7-1-24)
j.The legal non-citizen was admitted under Section 249 of the INA as a registry legal non-citizen.
k.The legal non-citizen is an applicant for permanent residence who is an Amerasian or a specified relative of an Amerasian. The Amerasian must be born in Vietnam between January 1, 1962, and January 1, 1976. A specified relative is a spouse, child, parent, or stepparent of the Amerasian, or someone who has acted in the place of a parent of an Amerasian and/or their spouse or child.(7-1-24)
l.The legal non-citizen is an applicant for adjustment under the Cuban/Haitian provisions of Section 202 of the Immigration Reform and Control Act of 1986.(7-1-24)
03.Sponsor/Legal Non-Citizen Relationships. Sponsor/legal non-citizen relationships and deeming rules are listed in POMS Chapter SI 01320.000, incorporated by reference under Subsection 002.02 of these rules.
04.Sponsor to Legal Non-Citizen Deeming Procedures. The Department will budget the legal noncitizen’s actual needs, as if they are a single person living alone. The Department will subtract the legal non-citizen’s own income, less exclusions and disregards. The Department will subtract the couple’s income, less exclusions, from their needs. If there is no budget deficit, the participant is not eligible. If there is a budget deficit, the Department will follow the procedures in POMS Chapter SI 01320.000, incorporated by reference under Subsection 002.02 of these rules, to compute sponsor deemed income.(7-1-24)
IDAPA 16.03.05.457 Deeming Income from Sponsor to Legal Non-Citizen -- Sponsor Signed Ins
FORM I-864 AFFIDAVIT OF SUPPORT.
If the legal non-citizen’s sponsor has sig ned an INS form I-864 Affidavit of Support, all income of the sponsor and the sponsor’s spouse is deemed to the legal non-citizen for AABD cash and Medicaid eligibility. Deeming continues until the legal non-citizen becomes a naturalized citizen or has forty (40) quarters of work. Exceptions are listed below:(7-1-24)
01.Battery Exception. The legal non-citizen or the legal non-citizen child's parent was battered or subjected to extreme cruelty in the US. There is a substantial connection between the battery and the participant's need for assistance. The person subjected to the battery or cruelty no longer lives with the person responsible for the battery or cruelty.(7-1-24)
02.Indigence. Alien sponsor deeming is suspended for twelve (12) months, if the legal non-citizen is not able to get food and shelter without AABD cash.(7-1-24)
IDAPA 16.03.05.458 (Reserved)
IDAPA 16.03.05.500 Financial Need
The participant has financial need if their allowances, as described in Sections 501 through 513 of these rules, are more than their income.(7-1-24)
IDAPA 16.03.05.501 Basic Allowance
Each participant receives a basic allowance unless they live in a nursing facility. The basic allowance for each living arrangement is listed in this rule. The Semi-Independent Group Residential Facility, Room and Board, Residential and Assisted Living Facility, and Certified Family Home basic allowances do not change with the annual cost-ofliving increase in the federal SSI benefit amount.(7-1-24)
01.Single Participant. A participant is budgeted five hundred forty-five dollars ($545) monthly as a basic allowance when living in a situation listed below. Beginning January 1, 2001, the basic allowance increase for a single participant is the dollar amount of the annual cost-of-living increase in the federal SSI benefit rate for a single person.(7-1-24)
a.Living alone.(7-1-24)
b.Living with their ineligible spouse.(7-1-24)
c.Living with another participant who is not their spouse.(7-1-24)
d.Living in another’s household. This includes a living arrangement where the participant purchases lodging (room) and meals (board) from their parent, child, or sibling.(7-1-24)
e.Living with their TAFI child.(7-1-24)
02.Couple or Participant Living with Essential Person. A participant living with their participant spouse or their essential person is budgeted seven hundred sixty-eight dollars ($768) monthly as a basic allowance.
Beginning January 1, 2001, the basic allowance increase for a couple is the dollar amount of the annual cost-of-living increase in the federal SSI benefit rate for a couple. The increase may be rounded up.(7-1-24)
03.SIGRIF. A participant living in a semi-independent group residential facility (SIGRIF) is budgeted three hundred forty-nine dollars ($349) monthly as a basic allowance.(7-1-24)
IDAPA 16.03.05.502 Special Needs Allowances
Special needs allowances are a restaura nt meals allowance and a service animal food allowance.(7-1-24)
01.Restaurant Meals Allowance. Is fifty dollars ($50) monthly. A physician must state the participant is physically unable to prepare food in their home. A participant able to prepare their food, but living in a place where cooking is not permitted, may be budgeted the restaurant meals allowance for up to three (3) months.
02.Service Animal Food Allowance. Is seventeen dollars ($17) monthly. The allowance is budgeted for a blind or disabled participant using a trained service animal.(7-1-24)
IDAPA 16.03.05.503 (Reserved)
IDAPA 16.03.05.512 Room and Board Home Allowance
Room and board is a living arrangement where the participant purchases lodging (room) and meals (board) from a person they live with who is not their parent, child, or sibling.(7-1-24)
01.Budgeted Room and Board Allowance. Beginning January 1, 2006, a participant living in a room and board home is budgeted six hundred ninety-three dollars ($693). Beginning July 1, 2013, the Room and Board allowance will be adjusted annually by the percentage of the annual cost-of-living increase in the federal SSI benefit rate for a single person. This adjustment will be effective on January 1st of each year. The room and board allowance increase will be rounded to the next dollar.(7-1-24)
02.Basic Allowance for Participant in Room and Board Home. A participant living in a room and board home is budgeted seventy-seven dollars ($77) monthly as a basic allowance. Beginning July 1, 2013, this basic allowance will be adjusted annually by the percentage of the annual cost-of-living increase in the federal SSI benefit rate for a single person. This adjustment will be effective on January 1st of each year. The basic allowance increase will be rounded to the nearest dollar.(7-1-24)
IDAPA 16.03.05.513 Residential Assisted Living Facility
(RALF) AND CERTIFIED FAMILY HOME
(CFH) ALLOWANCES.
A participant living in a RALF under IDAPA 16.03.22, “Residen tial Assisted Living Facilities,” or a CFH, under IDAPA 16.03.19, “Certified Family Homes,” is budgeted a basic allowance of ninety-six dollars ($96) monthly.
Beginning July 1, 2013, this basic allowance will be adjusted annually by the percentage of the annual cost-of-living increase in the federal SSI benefit rate for a single person. This adjustment will be effective on January 1st of each year. The basic allowance increase will be rounded to the nearest dollar.(7-1-24)
01.Budgeted Monthly Allowance Based on Level of Care. A participant is budgeted a monthly allowance for care based on the level of care received as described in Section 515 of these rules. If the participant does not require State Plan Personal Care Services (PCS), their eligibility and allowances are based on the Room and Board rate in Section 512 of these rules.(7-1-24)
02.Care Levels and Monthly Allowances. Beginning January 1, 2006, care levels and monthly allowances are those listed in Table 513.02 below. Beginning July 1, 2013, the RALF and CFH allowances for participants living in a RALF or CFH on State Plan PCS will be adjusted annually by the percentage of the annual cost-of-living increase in the federal SSI benefit rate for a single person. This adjustment will be effective on January 1st of each year. This increase will be rounded to the next dollar.
03.CFH Operated by Relative. A participant living in a CFH operated by their parent, child, or sibling is not entitled to the CFH State Plan PCS allowances. They may receive the allowance for a person living with a relative as described in Section 501 of these rules. A relative for this purpose is the participant’s parent, child, sibling, aunt, uncle, cousin, niece, nephew, grandparent, or grandchild by birth, marriage, or adoption.(7-1-24)
IDAPA 16.03.05.514 Aabd Cash Payments
Only a participant who receives an SSI payment for the month is eligible for an AABD cash payment in the same month. The AABD cash payment amount is based on the participant’s living arrangement described in Subsections 514.01 through 514.04 of this rule. An AABD cash payment is the difference between a participant’s financial need TABLE 513.02 - STATE PLAN PCS CARE LEVELS AND ALLOWANCES AS OF 1-1-06 Level of CareMonthly Allowance
a.Level IEight hundred and thirty-five dollars ($835)
b.Level IINine hundred and two dollars ($902)
c.Level IIINine hundred and sixty-nine dollars ($969) and their countable income. If the difference is not an even dollar amount, AABD cash is paid at the next higher dollar.(7-1-24)
01.Single Participant Maximum Payment. For a single participant described in Subsection 501.01 of these rules, the maximum monthly AABD cash payment amount is fifty-three dollars ($53).(7-1-24)
02.Couple or Participant Living with Essential Person Maximum Amount. For participants described in Subsection 501.02 of these rules, the maximum monthly AABD cash payment amounts are:(7-1-24)
a.A couple receives twenty dollars ($20); or(7-1-24)
b.A participant living with essential person receives eighteen dollars ($18).(7-1-24)
03.Semi-Independent Group Maximum Payment. For a participant described in Subsection 501.03 of these rules, the maximum monthly AABD cash payment amount is one hundred sixty-nine dollars ($169).
04.Room and Board Maximum Payment. For a participant described in Section 512 of these rules, the maximum monthly AABD cash payment is one hundred ninety-eight dollars ($198).(7-1-24)
05.RALF and CFH. A participant residing in a RALF or CFH is not eligible for an AABD cash payment.(7-1-24)
IDAPA 16.03.05.515 Ralf Care and Cfh Assessment and Level of Care
The participant’s need for care, level of care, plan of care, and the RALF’s or CFH’s ability to provide care is assessed by the Bureau of Long-Term Care (BLTC) when a participant is admitted. The BLTC must approve the placement before Medicaid can be approved.(7-1-24)
IDAPA 16.03.05.516 Change in Level of Care
A change in the participant's level of care affects eligibility as listed below.(7-1-24)
Increase in Level of Care. Is effective the month the BLTC reassesses the level of care. (7-1-24)
02.Decrease in Level of Care. When the BLTC verifies the participant has a decrease in their level of care, and their income exceeds their new level of care, their Medicaid must be stopped after timely notice. When the BLTC determines the participant no longer meets any level of care, their eligibility and allowances are based on the Room and Board rate in Section 512 of these rules.(7-1-24)
IDAPA 16.03.05.517 (Reserved)
IDAPA 16.03.05.524 Move from Nursing Home or Hospital
If a participant moves from a nursing home or hospi tal to a different living situation, other than a RALF or CFH, their AABD cash for the month is determined as if they lived in their new situation the entire month. Their AABD cash is their AABD allowances less their countable income.(7-1-24)
IDAPA 16.03.05.525 (Reserved)
IDAPA 16.03.05.531 Couple Budgeting
Income of an AABD participant and their participant spouse living in the same household is combined. The twenty dollar ($20) standard income disregard and the sixty-five dollar ($65) earned income disregard are subtracted once a month, per couple. Each member of a couple living in an institution must have income budgeted as a single person. A couple living together as of the first day of a month, is counted as living together throughout that month. Budgeting as a couple continues through the month the couple stops living together. For couple budgeting, a household is a home, a rental, another’s household, or room and board.(7-1-24)
IDAPA 16.03.05.532 (Reserved)
IDAPA 16.03.05.540 Standard Disregard
The standard disregard is twenty dollars ($ 20), and is first subtracted from unearned income. If the unearned income is less than the standard disregard, the remainder of the standard disregard is subtracted from earned income. The participant retains the standard disregard for their personal use.(7-1-24)
01.Standard Disregard and a Couple. The Department will subtract the standard disregard only once a month from the combined income of a couple in the same household.(7-1-24)
02.Standard Disregard Exception. The standard disregard must not be subtracted from nonserviceconnected VA payments, Title IV-E foster care payments, or BIA General Assistance.(7-1-24)
IDAPA 16.03.05.541 Subtraction of Earned Income Disregards
Earned income disregards are subtracted from AABD earned incom e in the order listed in Sections 542 through 547.
They are subtracted the month the income is paid.(7-1-24)
IDAPA 16.03.05.542 Sixty-Five Dollar Earned Income Disregard
Sixty-five dollars ($65) of earned income in a month are no t counted. The Department will subtract the sixty-five dollar ($65) disregard only once a month from the combined income of a couple in the same household. The sixtyfive dollar ($65) disregard is a work incentive. The participant retains the sixty-five dollar ($65) disregard for their personal use.(7-1-24)
IDAPA 16.03.05.543 Impairment-Related Work Expense (irwe) Disregard
IRWEs are items and services needed and used by a disabled AABD participant to work. The items must be needed because of the participant’s impairment, and may be bought or rented. The cost for IRWEs is subtracted from the participant’s earned income, for eligibility and AABD cash amount. An item disregarded as a blindness work expense, or as part of a PASS, cannot be disregarded as an IRWE.(7-1-24)
IDAPA 16.03.05.544 One-Half Remaining Earned Income Disregard
One-half (1/2) of remaining earned income, after the IRWE is su btracted, is not counted. The one-half (1/2) of remaining earned income is a work incentive. The participant retains the one-half (1/2) of remaining earned income for their personal use.(7-1-24)
IDAPA 16.03.05.545 Blindness Work Expense Di
SREGARD.
The cost of earning income is subtracted from the earned income of a blind person. The blind person must be under age sixty-five (65). If the blind person is age sixty-five (65) or older, they must receive SSI for blindness, or have received AABD the month before they became sixty-five (65).(7-1-24)
01.Blind Work Expense Limit. Blindness work expenses are subtracted from earned income. The amount subtracted must not exceed the participant’s monthly earnings.(7-1-24)
02.No Duplication for Blind Work Expenses. Expenses, subtracted under the IRWE disregard, cannot be subtracted again under this disregard.(7-1-24)
IDAPA 16.03.05.546 Plan to Achieve Self-Support (pass)
A blind or disabled participant, with an approved PASS, must have income and resources disregarded. Conditions for this disregard are listed below.(7-1-24)
01.Under Age Sixty-Five. The participant must be under sixty-five (65), or receive AABD for the blind or disabled during the month of their sixty-fifth birthday.(7-1-24)
02.Approved PASS. A participant receiving SSI must have a PASS approved by SSA. A participant not receiving SSI must have a PASS approved by the Department.(7-1-24)
03.Income Necessary for Self-Support. The income and resources disregarded under the PASS must be necessary for the participant to achieve self-support.(7-1-24)
IDAPA 16.03.05.547 Pass Approved by Department
A PASS approved by the Department must be in writing, and contain all the following items:(7-1-24)
01.Occupational Objective. The PASS must have a specific occupational objective.(7-1-24)
02.Specific Goals. The PASS must have specific goals for using the disregarded income and resources to achieve self-support.(7-1-24)
03.Time Limit. The PASS must show a specific target date to achieve the goal. An approved PASS is limited to an initial period of eighteen (18) months. Extensions may be granted if needed.(7-1-24)
a.The first extension period lasts up to eighteen (18) months.(7-1-24)
b.A second eighteen (18) month extension period can be granted.(7-1-24)
c.A final extension, up to twelve (12) months can be granted. The PASS can be extended a total of forty-eight (48) months, when the original PASS goal required extensive education or vocational training.(7-1-24)
04.No Duplication of Disregards. An item disregarded as an IRWE or under the blindness exception cannot be disregarded under the PASS.(7-1-24)
05.Resource Limitation. The PASS disregard must not be used for resources, unless the resources cause the participant to be ineligible without the PASS disregard.(7-1-24)
06.Disregard of Resources. The PASS must list the participant’s resources. The PASS must list any resources the participant will receive under the plan, and show how the resources will be used toward the occupational goal. The PASS must list goal-related items or activities requiring savings or purchases and the amounts the participant plans to save or spend, and list resources disregarded under the plan. The PASS must show resources disregarded under the plan can be identified separate from the participant’s other resources.(7-1-24)
IDAPA 16.03.05.548 (Reserved)
IDAPA 16.03.05.600 Department Notice Responsibility
The participant must be notified of changes in eligibility or AABD cash amount. The notice must give the effective date, the reason for the action, the rule that supports the action, and appeal rights. See 42 CFR 435.917.(7-1-24)
IDAPA 16.03.05.601 Advance Notice Responsibility
When a reported change results in closure or decreas e, the participant must be notified at least ten (10) calendar days before the effective date of the action.(7-1-24)
IDAPA 16.03.05.602 Advance Notice Not Required
Advance notice is not required when a condition listed below exists. The participant must be notified by the date of the action.( 7-1-24)
01.The Department has Proof of the Participant’s Death.(7-1-24)
02.Participant Requests Closure in Writing.(7-1-24)
03.Participant in Institution. The participant is admitted or committed to an institution. Further payments to the participant do not qualify for federal financial participation under the State Plan.(7-1-24)
04.Nursing Care. The participant is placed in a nursing facility or an ICF/IID.(7-1-24)
05.Participant Address Unknown. The participant’s whereabouts are unknown. Department mail is returned with no forwarding address.(7-1-24)
06.Participant is Approved for Aid in Another State.(7-1-24)
07.Eligible One Month. The participant is eligible for aid only during the calendar month of their application for aid.(7-1-24)
08.Non-Citizen With Emergency. The participant is an illegal or legal non-citizen whose Medicaid eligibility ends the day their emergency medical condition stops.(7-1-24)
09.Retroactive Medicaid. The participant’s Medicaid eligibility is for a prior period.(7-1-24)
10.Special Allowance. A special allowance granted for a specific period is stopped.(7-1-24)
11.Patient Liability or Participant Participation Changes.(7-1-24)
12.Participant’s Level of Care Changes.(7-1-24)
IDAPA 16.03.05.603 (Reserved)
IDAPA 16.03.05.604 Participant Determined Ssi Eligible After Appeal
If the SSA finds a participant is blind or disabled, based on an appeal of an SSA decision, the participant meets the disability requirements for AABD cash and related Medicaid on the effective date determined by SSA. AABD cash payments are effective no earlier than the month SSA issues the favorable decision for SSI payments.(7-1-24)
IDAPA 16.03.05.605 Reporting Requirements
The participant must report changes in circumstances verbally or in writing, by the tenth of the month following the mo nth in which the change occurred. The participant must show good cause for not reporting changes. If failure to report a change results in an overpayment, the overpayment must be recovered.(7-1-24)
IDAPA 16.03.05.606 Required Proof
The participant must prove continuing eligibility for aid when a chang e could affect eligibility, and is allowed ten (10) calendar days to provide requested proof. The case is closed if the participant does not provide proof within ten (10) days and does not have good cause for not providing proof.(7-1-24)
IDAPA 16.03.05.607 Changes Affecting Eligibility
OR AABD CASH AMOUNT.
If a participant reports a change that results in an increase, AABD cash is increased effective the month of report. If a participant reports a change that results in a decrease, AABD cash is decreased or ended effective the first month after proper notice.(7-1-24)
IDAPA 16.03.05.608 Aabd Cash Underpayment
If the Department is at fault for issuing a payment less than the participant should have receive d, the Department will issue a supplemental payment for the difference.(7-1-24)
IDAPA 16.03.05.609 Aabd Cash Overpayment
If the participant is paid more AABD cash than they are eligible for, the Department must collect the overpayment.
The Department must notify the participant of the right to a hearing, the method for repayment, and the need for a repayment interview.(7-1-24)
IDAPA 16.03.05.610 Offset of Overpayment and Underpayment
When an underpayment is computed, any o verpayment for that month is subtracted from the underpayment. When an overpayment is computed, any underpayment for the month is subtracted.(7-1-24)
IDAPA 16.03.05.611 (Reserved)
IDAPA 16.03.05.617 Hearing Request
A participant may request a hearing to contest a Department decision. The participant must make the request within nin ety (90) days of the date the Department mailed the notice of decision. Hearings will be conducted according to IDAPA 62.01.01, “Idaho Rules of Administrative Procedure,” and Office of Administrative Hearings General Order No. 1.(7-1-24)
IDAPA 16.03.05.618 Continued Benefits Pending a Hearing Decision
The participant may continue to receive benefits upon reques t, pending the hearing decision. The Department must receive the participant’s request for continued benefits before the effective date of the Department’s action stated in the notice of decision. An applicant cannot receive continued benefits when appealing a denial for failure to provide citizenship and identity verification after the expiration of a reasonable opportunity period.(7-1-24)
01.Amount of Assistance. The Department will continue the participant's assistance at the current month's level while the hearing decision is pending, unless another change affecting assistance occurs.(7-1-24)
02.Continued Eligibility. The participant must continue to meet all eligibility requirements not related to the hearing issue.(7-1-24)
03.Overpayment. When the hearing decision is in the Department's favor, the participant must repay assistance received while the hearing decision was pending.(7-1-24)
IDAPA 16.03.05.619 (Reserved)
IDAPA 16.03.05.620 Medicaid Overpayment
If the participant receives Medicaid services during a month they are not eligible, the Department must collect the overpayment. If too little patient liability or participant participation is computed, the Department must collect the overpayment. The participant must be notified of the overpayment.(7-1-24)
IDAPA 16.03.05.621 Changes in Patient Liability
01.Increase in Patient Liability. If the patient liability is increased for the current or a past month, the Department will collect the patient liability directly from the participant.(7-1-24)
02.Decrease in Patient Liability. If the patient liability is decreased for a current or past month, the funds will be paid to the provider and the provider must reimburse the participant for the portion of the costs the participant paid more than their patient liability.(7-1-24)
IDAPA 16.03.05.622 (Reserved)
IDAPA 16.03.05.623 Eligibility Redetermination
An eligibility redetermination is completed at leas t once every year and when a change affecting eligibility occurs.
IDAPA 16.03.05.624 (Reserved)
IDAPA 16.03.05.650 Cooperation with the Quality Control Process
When the Department or federal government selects a case for review in the quality control process, the participant must cooperate in the review of the case. Benefits must be stopped, following advance notice, when a participant is unwilling to take part in the quality control process. If the participant reapplies for benefits, they must fully cooperate with the quality control process before the application can be approved.(7-1-24)
IDAPA 16.03.05.651 (Reserved)
IDAPA 16.03.05.700 Medicaid Eligibility
A participant must meet the eligibility requirements for at least one (1) Medicaid coverage group to be eligible for Medicaid benefits. Income and circumstances in the current month are used for eligibility for the current month.
Resources are counted as of the first moment of the month.(7-1-24)
IDAPA 16.03.05.701 Medicaid Application
An adult participant, a legal guardian, or a rep resentative of the participant must sign the application. The participant must submit the application to the Department. A Medicaid application may be made for a deceased person. (7-1-24)
IDAPA 16.03.05.702 Medical Support Cooperation
Medical support rights are assigned to the Department by signature on the application. The participant must cooperate with the Department to secure medical support and payments to be eligible for Medicaid. The participant must cooperate on behalf of themself and any participant for whom they can legally assign rights. A participant who cannot legally assign their own rights must not be denied Medicaid if the legally responsible person does not cooperate.
IDAPA 16.03.05.703 Child Support Cooperation
The participant must cooperate to identify and locate th e noncustodial parent, establish paternity, and establish, modify, and enforce a child medical support order to be eligible for Medicaid. This includes support payments received directly from the noncustodial parent. The cooperation requirement is waived for poverty level pregnant women exempt from cooperating in establishing paternity and obtaining medical support from, or derived from, the father of a child born out of wedlock. A participant who cannot legally assign their own rights must not be denied Medicaid if the legally responsible person does not cooperate.(7-1-24)
IDAPA 16.03.05.704 Cooperation Defined
Cooperation includes providing all information to identify and locate the noncustodial parent. Cooperation for Medicaid includes identifying other liable third-party payers.(7-1-24)
01.Name of Noncustodial Parent. The participant must provide the first and last name of the noncustodial parent.(7-1-24)
02.Information About Noncustodial Parent. The participant must also provide at least two (2) pieces of information, about the noncustodial parent, listed below:(7-1-24)
a.Birth Date.(7-1-24)
b.SSN.(7-1-24)
c.Current address.(7-1-24)
d.Current phone number.(7-1-24)
e.Current employer.(7-1-24)
f.Make, model, and license number of any motor vehicle owned by the noncustodial parent. (7-1-24)
g.Names, phone numbers, and addresses of the parents of the noncustodial parent.(7-1-24)
IDAPA 16.03.05.705 Good Cause for Not Cooperating in Secu
RING MEDICAL AND CHILD SUPPORT.
The participant may claim good cause for failure to cooperate in securi ng medical and child support for themself or a minor child. Good cause is limited to the following:(7-1-24)
01.Rape or Incest. There is proof the child was conceived because of incest or rape.(7-1-24)
02.Physical or Emotional Harm. There is proof the child’s non-custodial parent may inflict physical or emotional harm to the participant, the child, the custodial parent, or the caretaker relative. There is proof another person may inflict physical or emotional harm to an AABD-related participant if the participant cooperates in securing medical and child support.(7-1-24)
03.Minimum Information Cannot Be Provided. Substantial and credible proof is provided indicating the participant cannot provide the minimum information regarding the non-custodial parent.(7-1-24)
IDAPA 16.03.05.706 Closure After Review of Good Cause Request
If the participant claims good cause for not cooperating, but the Department determines there is not good cause, the participant must be given the opportunity to withdraw the application or have their Medicaid closed.(7-1-24)
IDAPA 16.03.05.707 Application Requirements for Potential Medical Coverage
01.Group Health Plan Enrollment Requirement. Each participant must apply for and enroll in a cost-effective employer group health plan as a condition of eligibility for Medicaid. Medicaid coverage must not be denied, delayed, or stopped pending the start of a participant's group health insurance coverage. A child entitled to enroll in a group health plan must not be denied Medicaid coverage solely because their caretaker fails to apply for the child's enrollment.(7-1-24)
02.Medicare Enrollment Requirement. Each participant who may be eligible for Medicare must apply for all parts of Medicare parts A, B, and D for which they are likely to be eligible, as a condition of eligibility for Medicaid.(7-1-24)
IDAPA 16.03.05.708 Medicaid Qualifying Trust Payments
For Medicaid Qualifying Trusts established before August 11, 1993, the maximum payment permitted to be made to a participant from the trust must be counted for Medicaid eligibility. The maximum is counted whether or not the trustee actually distributes payments.(7-1-24)
IDAPA 16.03.05.709 Medicaid Eligibility for Aabd Participant
A participant eligible for AABD cash is eligible for Medicaid, unless they are in an ineligible institution, receive excess payment from a Medicaid Qualifying Trust, or have an irrevocable trust that is not exempt.(7-1-24)
IDAPA 16.03.05.710 (Reserved)
IDAPA 16.03.05.720 Long-Term Care Resident and Medicaid
A resident of a long-term care facility must meet the AABD eligibility criteria to be eligible for Medicaid. A longterm care facility is a nursing facility or an ICF/IID. The need for long-term care is determined using IDAPA
01.Resources of Resident. The resident’s resource limit is two thousand dollars ($2,000). Resources of a married person in long-term care are computed using Federal Spousal Impoverishment rules. Under the SSI method, spouses can use the three thousand dollar ($3,000) couple resource limit if more advantageous. The couple must have lived in the nursing home, in the same room, for six (6) months.(7-1-24)
02.Medicaid Income Limit of Long-Term Care Resident Thirty Days or More. The monthly income limit for a long-term care facility resident is three (3) times the federal SSI benefit for a single person. To qualify for this income limit, the participant must be, or be likely to remain, in long-term care at least thirty (30) consecutive days.(7-1-24)
03.Medicaid Income Limit of Long-Term Care Resident Less Than Thirty Days. The monthly income limit, for the resident of a long-term care facility for less than thirty (30) consecutive days, is the AABD income limit for the participant’s living situation before long-term care. Living situations before long-term care do not include hospital stays.(7-1-24)
04.Income Not Counted. The income listed in Subsections 720.04.a. through 720.04.e. of this rule is not counted to compute Medicaid eligibility for a long-term care facility resident. This income is counted in determining participation in the cost of long-term care.(7-1-24)
a.Income excluded or disregarded in determining eligibility for AABD cash is not counted. (7-1-24)
b.The September 1972 RSDI increase is not counted.(7-1-24)
c.Any VA Aid and Attendance allowance, including any increment that is the result of a VA Unusual Medical Expense allowance, is not counted. These allowances are not counted for patient liability, unless the veteran lives in a state-operated veterans' home.(7-1-24)
d.RSDI benefit increases from cost-of-living adjustments (COLA) after April 1977 are not counted if they made the participant lose SSI or AABD cash. The COLA increases after SSI or AABD cash stopped are not counted.(7-1-24)
e.Income paid into an income trust exempt from counting for Medicaid eligibility under Subsection 872.02 of these rules is used for patient liability. Income paid to the trust and not used for patient liability is subject to the asset transfer penalty.(7-1-24)
05.Medicaid Participant Residing in a Skilled Nursing Facility. When a Medicaid participant who is a resident of a skilled nursing facility and meets that level of care as evidenced by the PAARR defined in IDAPA 16.03.26, “Medicaid Plan Benefits,” the resident is determined to be disabled for the duration of their residency in the skilled nursing facility.(7-1-24)
IDAPA 16.03.05.721 Qualified Long-Term Care Partnership Policy
Participants who have received, or are entitled to receive, benefits under a Qualified Long-Term Care Partnership policy issued in Idaho after November 1, 2006, will have certain resources disregarded as described below. (7-1-24)
01.Value of the Participant's Resources. The total dollar amount of the insurance benefits paid out for a policy holder of a Qualified Long-Term Care Partnership policy is disregarded in calculating the value of the participant's resources for long-term care Medicaid eligibility. The amount that is disregarded is determined on the effective date of an initial application approval for long-term care Medicaid benefits.(7-1-24)
02.Resource Disregard Excluded from Estate Recovery. The amount of the resources disregarded from a Qualified Long-Term Care Partnership policy under Subsection 721.01 of this rule, is deducted from the assets of the estate for Medicaid estate recovery.(7-1-24)
IDAPA 16.03.05.722 Patient Liability
Patient liability is the participant’s income counted toward the cos t of long-term care. Patient liability begins the month after the first full calendar month the patient is receiving benefits in a long-term care facility.(7-1-24)
IDAPA 16.03.05.723 Patient Liability for Person with No Community Spouse
For a participant with no community spouse, patient liability is computed as described below.(7-1-24)
Income of Participants in Long-Term Care. For a single participant, or participant whose spouse is also in long-term care and chooses the SSI method of calculating the amount of income and resources, the patient liability is their total income less the deductions in Subsection 723.03 of this rule.(7-1-24)
02.Community Property Income of Long-Term Care Participant with Long-Term Care Spouse.
Patient liability income for a participant, whose spouse is also in long-term care, choosing the community property method, is one-half (1/2) their share of the couple’s community income, plus their own separate income. The deductions under Subsection 723.03 of this rule are subtracted from their income.(7-1-24)
03.Income of Participant in Facility. A participant residing in the long-term care facility at least one (1) full calendar month, beginning with their most recent admission, must have the deductions in below subtracted from their income, after the AABD exclusions are subtracted from the income. Total monthly income includes income paid into an income (Miller) trust that month. The income deductions must be subtracted in the order listed.
Remaining income is patient liability.(7-1-24)
a.AABD Income Exclusions. Income excluded in determining eligibility for AABD cash is subtracted.(7-1-24)
b.Aid and Attendance and UME Allowances. VA Aid and Attendance allowance and Unusual Medical Expense (UME) allowance for a veteran or surviving spouse is subtracted, unless the veteran lives in a state operated veterans' home.(7-1-24)
c.SSI Payment Two (2) Months. The SSI payment for a participant entitled to receive SSI at their athome rate for up to two (2) months is subtracted, while temporarily in a long-term care facility.(7-1-24)
d.AABD Payment. The AABD payment, and income used to compute the AABD payment, for a participant paid continued AABD payments up to three (3) months in long-term care is subtracted.(7-1-24)
e.First Ninety ($90) Dollars of VA Pension. The first ninety ($90) dollars of a VA pension for a veteran in a private long-term care facility or a State Veterans Nursing Home is subtracted.(7-1-24)
f.Personal Needs. Forty dollars ($40) is subtracted for the participant’s personal needs. For a veteran or surviving spouse in a private long-term care facility or a State Veterans Nursing Home the first ninety ($90) dollars of VA pension substitutes for the forty dollar ($40) personal needs deduction.(7-1-24)
g.Employed and Sheltered Workshop Activity Personal Needs. For an employed participant or participant engaged in sheltered workshop or work activity center activities, the lower of the personal needs deduction of two hundred dollars ($200) or their gross earned income is subtracted. The participant's total personal needs allowance must not exceed two hundred and thirty dollars ($230). For a veteran or surviving spouse with sheltered workshop or earned income, and a protected VA pension, the total must not exceed two hundred dollars ($200). This is a deduction only. No actual payment can be made to provide for personal needs.(7-1-24)
h.Home Maintenance. Two hundred and twelve dollars ($212) is subtracted for home maintenance cost if the participant had an independent living situation, before their admission for long-term care. Their physician must certify in writing the participant is likely to return home within six (6) months, after the month of admission to a long-term care facility. This is a deduction only. No actual payment can be made to maintain the participant’s home.
i.Maintenance Need. A maintenance need deduction for a family member living in the long-term care participant’s home is subtracted. A family member is claimed, or could be claimed, as a dependent on the Federal Income Tax return of the long-term care participant. The family member must be a minor or dependent child, dependent parent, or dependent sibling of the long-term care participant. The maintenance need deduction is the AFDC payment standard for the dependents, computed according to the AFDC State Plan in effect before July 16, 1996.(7-1-24)
j.Medicare and Health Insurance Premiums. Expenses for Medicare and other health insurance premiums, and deductibles or coinsurance charges are subtracted, and not subject to payment by a third party.
Deduction of Medicare Part B premiums is limited to the first two (2) months of Medicaid eligibility. Medicare Part B premiums must not be subtracted, if the participant got SSI or AABD cash the month prior to the month for which patient liability is being computed.(7-1-24)
k.Mandatory Income Taxes. Taxes mandatorily withheld from unearned income for income tax purposes are subtracted. To qualify for deduction of mandatory taxes, the tax must be withheld from income before the participant receives the income.(7-1-24)
l.Guardian Fees. Court-ordered guardianship fees of the lesser of ten percent (10%) of the monthly benefit handled by the guardian, or twenty-five dollars ($25) are subtracted. Where the guardian and trustee is the same person, the total deduction for guardian and trust fees must not exceed twenty-five dollars ($25) monthly.
m.Trust Fees. Up to twenty-five dollars ($25) monthly paid to the trustee for administering the participant’s trust is subtracted.(7-1-24) n.
Impairment-Related Work Expenses (IR WE). IRWEs for an employed participant who is blind or disabled under AABD criteria are subtracted. IRWEs are purchased or rented items and services that are purchased or rented to perform work. The items must be needed because of the participant’s impairment. The actual monthly expense of the impairment-related items is subtracted. Expenses must not be averaged.(7-1-24)
o.Income Garnished for Child Support. Income garnished for child support to the extent the expense is not already accounted for in computing the maintenance need standard is subtracted.(7-1-24)
p.Incurred Medical Expenses. Amounts for certain limited medical or remedial care expenses that have current balances owed and are deemed medically necessary as defined in IDAPA 16.03.26, “Medicaid Plan Benefits,” are subtracted. Current medical expenses that are not covered by the Idaho Medicaid Plan, or by a third party, may be deducted from the base participation amount.(7-1-24)
q.Pre-existing Medical Expenses. Amounts for medical and remedial care expenses incurred within the three (3) months prior to the month of application are subtracted. The deductions for medical and remedial care expenses are limited to those medically necessary expenses incurred by the participant for the participant’s care.
These deductions are limited to the amount of liability owed by the participant, and if applicable, after any third-party insurance has been applied. The deduction for medical and remedial care expenses that were incurred as the result of imposition of a transfer of assets penalty period is limited to zero.(7-1-24)
IDAPA 16.03.05.724 Income Ownership of Participant with Community Spouse
Income ownership of a long-term care participant with a comm unity spouse is determined before patient liability is computed. The participant’s income ownership is counted as shown below.(7-1-24)
01.Income Paid in the Name of Spouse. Income paid solely in the name of a spouse, and not paid from a trust, is the separate income of the spouse.(7-1-24)
02.Payment in Name of Both Spouses. Income paid in the names of both the long-term care participant and the community spouse is divided evenly between each spouse.(7-1-24)
03.Payment in Name of Spouse or Spouses and Another Person. Income paid in the names of the participant and/or the community spouse and another person is counted as available to each spouse, in proportion to the spouse’s ownership. If payment is made to both spouses, and no proportion of ownership is specified, one-half of the income is counted to each spouse.(7-1-24)
04.Payment of Aid and Attendance. In the case of VA Aid and Attendance Allowance paid in the veteran’s name, with an increment for the veteran’s spouse, the increment is counted to the veteran.(7-1-24)
IDAPA 16.03.05.725 Patient Liability for Participant with Community Spouse
For a participant with a community spouse, pa tient liability is computed as described in Subsection 723.03 of these rules with the addition of the following steps for Community Spouse Allowance (CSA):(7-1-24)
01.Shelter Adjustment. The Department will add the current Food Stamp Program Standard Utility Allowance to the community spouse’s shelter costs. Shelter costs include rent, mortgage principal and interest, homeowner’s taxes, insurance, and condominium or cooperative maintenance charges. The Standard Utility Allowance must be reduced by the value of any utilities included in maintenance charges for a condominium or cooperative. The Department will subtract the Shelter Standard from the shelter and utilities. The Shelter Standard is thirty percent (30%) of one hundred fifty percent (150%) of one-twelfth (1/12) of the income official poverty line defined by the federal Office of Management and Budget (OMB) for a family of two (2) persons. The Shelter Adjustment is the positive balance remaining.(7-1-24)
02.Community Spouse Need Standard (CSNS). The Department will add the Shelter Adjustment to the minimum CSNS. The minimum CSNS equals one hundred fifty percent (150%) of one-twelfth (1/12) of the income official poverty line defined by the OMB for a family unit of two (2) members. The minimum CSNS is revised annually in July. The total CSNS may not exceed the maximum CSNS. The maximum CSNS is computed by multiplying one thousand five hundred dollars ($1,500) by the percentage increase in the consumer price index for all urban consumers (all items, US city average) between September 1988 and the September before the current calendar year. The maximum CSNS is revised annually in January.(7-1-24)
03.Community Spouse Allowance (CSA). The Department will subtract the community spouse’s gross income from the CSNS. The community spouse’s income includes income produced by their resources. The Department will round any remaining cents to the next higher dollar. Any positive balance remaining is the CSA. The CSA is subtracted as actually paid to the community spouse, up to the computed maximum. A larger spouse support amount must be used as the CSA, if court-ordered. The CSA ordered by a court is not subject to the CSA limit.
IDAPA 16.03.05.726 Personal Needs Supplement
(PNS).
A nursing home participant may receive a PNS to bring their gross income up to forty dollars ($40). Gross income is income after exclusions and before disregards, and includes money withheld to recover an AABD overpayment. The PNS is the difference between the participant's gross income and forty dollars ($40). If not in an even dollar amount, the PNS is rounded up to the next dollar. The participant's income including the PNS must not exceed forty dollars ($40).(7-1-24)
IDAPA 16.03.05.727 Fair Hearing on Csa Decision
Either spouse may ask for a fair hearing to show the com munity spouse needs a higher CSA. The hearing officer must consider if, due to unusual conditions, using the computed CSA causes significant financial hardship for the community spouse. If the fair hearing decision finds the community spouse needs more income than the CSA, the CSA must include the additional income.(7-1-24)
IDAPA 16.03.05.728 (Reserved)
IDAPA 16.03.05.731 Medicaid Eligibility of Married Persons
There are three (3) methods for Medicaid eligibility of an aged, blind, or disabled married person: (1) the SSI method, (2) the Community Property (CP) method, and (3) the Federal Spousal Impoverishment (FSI) method. The FSI method takes precedence. If the participant is not subject to the FSI method, the CP or SSI methods can be used.
IDAPA 16.03.05.732 Choosing Fsi, Ssi, or Cp Resource Counting Method
Table 732 is used to determine the resource counting method for a married person. If an HCBS participant with a spouse at home is not eligible using the FSI method, resources are computed using the SSI/CP method.
TABLE 732 - CHOOSING FSI, SSI, OR CP RESOURCE COUNTING METHOD
HOME BEFORE
AT HOME NO
HCBS
HCBS BEFORE
(2) IN NURSING
BEFORE
SSI/CPSSI/CPSSI/CPSSI/CPSSI/CP
(2) IN NURSING
AFTER
(2) AT HOME
SSI/CPFSISSI/CPSSI/CPFSI
(2) AT HOME
SSI/CPSSI/CPSSI/CPSSI/CPSSI/CP
(2) AT HOME
WITH HCBS ON
OR AFTER
IDAPA 16.03.05.733 Choosing Fsi, Ssi, or Cp Income Counting Method
Table 733 is used to determine the incom e counting method for a married person. If a participant subject to the FSI method is not eligible using FSI, income is computed using the SSI/CP method.
IDAPA 16.03.05.734 Choosing Fsi, Ssi, or Cp Patient Liability or Participation Method
Table 734 is used to determine the patient liability or participant participation method for a married participant in long-term care or receiving HCBS.
TABLE 733 - CHOOSING FSI, SSI, OR CP INCOME COUNTING METHOD
HOME BEFORE
BEFORE 9/30/89
(2) IN NURSING
(2) IN NURSING
(2) AT HOME
FSIFSISSI/CPFSIFSI
(2) AT HOME
(2) AT HOME
WITH HCBS ON
OR AFTER
TABLE 734 - PATIENT LIABILITY OR PARTICIPATION METHOD
SPOUSE ONE IN
NURSING HOME
BEFORE
SPOUSE ONE IN
NURSING HOME
ON OR AFTER 9/ 30/89
BEFORE 9/30/89
HOME WITH HCBS
ON OR AFTER 9/ 30/89
IDAPA 16.03.05.735 Federal Spousal Impoverishment (fsi) Method of Counting Income and
RESOURCES OF A COUPLE.
The FSI method must be used to compute income and resources of a married participant who requires long-term care as defined in Section 010 of these rules, and who has a community spouse. The participant must have entered longterm care on or after September 30, 1989. Terms used in the FSI method are listed below.(7-1-24)
01.Long-Term Care Spouse. Must be in a medical institution or nursing facility, or be an HCBS participant, for thirty (30) consecutive days, or appear likely to meet the thirty (30) days requirement.(7-1-24)
02.Community Spouse. The spouse of the long-term care participant. A community spouse is not in long-term care and is not an HCBS participant.(7-1-24)
03.Continuous Period of Long-Term Care. A period of residence either in a medical institution with nursing facility services, or at home with HCBS. A continuous period of long-term care is also a combination of institution and personal care services likely to last at least thirty (30) consecutive days. Absence from the institution, or a lapse in HCBS eligibility of thirty (30) consecutive days breaks continuity. The thirty (30) consecutive days of long-term care must not begin on a day the participant is hospitalized. If the participant is hospitalized after the first day of the thirty (30) consecutive days, the hospital stay does not interrupt the thirty (30) consecutive days. (7-1-24)
04.Start of Continuous Period of Long-Term Care. The first month of long-term care or HCBS.
05.Nursing Facility Services. Services at the nursing facility level or the ICF/IID level provided in a medical institution.(7-1-24)
IDAPA 16.03.05.736 Assessment Date and Counting Fsi Resources
SPOUSE TWO
SPOUSE TWO IN
NURSING
AT HOME
FSIFSIN/AFSIFSI
AFTER
TABLE 734 - PATIENT LIABILITY OR PARTICIPATION METHOD
The assessment date is the start date of the first continuous period of long-term care. The Department does a one-time assessment to determine the value of the couple’s community and separate resources as of the date of the first continuous period of long-term care. The resource assessment is done at the request of either spouse, after one (1) spouse is in long-term care or meets the level of care for HCBS, whether or not the couple has applied for Medicaid.
State laws relating to community property or the division of marital property are not applied in determining the FSI total combined resources of the couple.(7-1-24)
IDAPA 16.03.05.737 Treatment of Resources for Assessment
The resource rules used in determining eligibility for AABD cash and Medicaid are also used in determining the couple's total combined resources for the FSI resource assessment with the following exceptions:(7-1-24)
01.Resources for Sale. Excess resources offered for sale, are not excluded from the couple’s total combined resources for the FSI resource assessment.(7-1-24)
02.Jointly Owned Real Property. Jointly owned real property that is not the principal residence of the participant is not excluded if the community spouse is the joint owner.(7-1-24)
03.Long-term Care Partnership Policy. Resources excluded because of a participant’s qualified long-term care policy are not excluded for the FSI resource assessment.(7-1-24)
04.Excluded Home. As defined in 42 USC 1396r-5(c)(5), an excluded home placed in trust retains its exclusion for purposes of the resource assessment.(7-1-24)
IDAPA 16.03.05.738 One-Half Spousal Share
The spousal share is one-half (1/2) of the couple’s total combined resources on the assessment date. The spousal share does not change, even if the participant leaves long-term care and then enters long-term care again. The Department must inform the couple of the resources counted in the assessment and the value assigned. The couple must sign the assessment form under penalty of perjury. The signature requirement may be waived for the long-term care spouse if they or their representative says they are unable to sign the resources assessment. A copy of the assessment form must be provided to each spouse when eligibility is determined or when either spouse requests an assessment prior to application.(7-1-24)
IDAPA 16.03.05.739 (Reserved)
IDAPA 16.03.05.742 Community Spouse Resource Allowance
The CSRA protects resources for the community spouse. The CSRA is determined by subtracting the greater of the minimum resource allowance or the spousal share from the couple’s total combined resources as of the first day of the application month. The deduction must not be more than the maximum resource allowance at the time eligibility is determined.(7-1-24)
IDAPA 16.03.05.743 Resource Allowance Limits
The maximum resource allowance is computed by multiplying sixty thousand dollars ($60,000) by the percentage increase in the consumer price index for all urban consumers (all items, US city average) between September 1988 and the September before the current calendar year. The minimum resource allowance is computed by multiplying twelve thousand dollars ($12,000) by the percentage increase in the consumer price index for all urban consumers (all items, US city average) between September 1988 and the September before the current calendar year. If the result is not an even one hundred dollar ($100) amount, the Department will round up to the next one hundred dollars ($100).
The couple’s resources exceeding the CSRA are counted for the long-term care spouse.(7-1-24)
IDAPA 16.03.05.744 Income Counted First for Csra Revision
Income is determined prior to determining resources. If th e couple’s income is more than the minimum CSNS, the CSRA cannot be increased. If the community spouse has less income than the minimum CSNS, the CSRA may be increased as provided in Section 745 of these rules. Couple income is the community spouse’s gross income plus the long-term care spouse’s income. The long-term care spouse’s income is their gross income less the AABD cash income exclusions and their patient liability income deductions, but not the CSA deduction.(7-1-24)
IDAPA 16.03.05.745 Upward Revision of Csra
If the community spouse’s income, including income from their CSA and income-producing resources in their CSRA, is less than the minimum CSNS, the CSRA may be increased. The CSRA is increased by enough resources transferred from the long-term care spouse to raise the community spouse’s income to the minimum CSNS Resources included in the transfer are presumed to produce income at the treasury rate, whether or not the resources produce income. If the community spouse shows they are making reasonable use of their income and resources to generate income, the Department may waive the treasury rate requirement. Actual income produced by the resources transferred to the community spouse is used to compute the CSA. A higher CSA can be requested under Section 727 of these rules. If the transferred resources produce more than the treasury rate, the actual income produced is used to determine the additional resources that can be transferred to the community spouse in the CSRA. The long-term care spouse must transfer the resources to the community spouse, or the CSRA is not revised.(7-1-24)
IDAPA 16.03.05.746 Resource Transfer Allowance (rta)
The RTA is computed by subtracting the community spouse’s resources at the time of application from the CSRA.
The community spouse must own less than the CSRA to get an RTA. The long-term care spouse may transfer the RTA to the community spouse without an asset transfer penalty. If the institutional spouse transfers more than the RTA, the amount of the couple’s resources over the CSRA counts as the institutional spouse’s resources. After the month, a long-term care spouse is determined Medicaid-eligible under FSI, resources of the community spouse are not considered available to them while they remain in long-term care.(7-1-24)
IDAPA 16.03.05.747 Protected Period for Rta Transfer
The long-term care spouse has sixty (60) days, from the date their application is approved, to transfer their ownership of the RTA resources to the community spouse. The long-term care spouse must state, in writing, their intent to transfer the RTA resources to the community spouse within the protected period before they can be Medicaid-eligible.
Resources not transferred within the sixty (60) day protected period are available to the long-term care spouse, effective the day they entered the facility.(7-1-24)
IDAPA 16.03.05.748 Extension for Rta Transfer
The protected period can be extended beyond sixty (60) days, if necessary, because of the participant’s circumstances.
IDAPA 16.03.05.749 Resource Eligibility for Community Spouse
When the community spouse is a Medicaid part icipant, the spouse’s resources are counted using Medicaid rules. The FSI rules apply only to the long-term care spouse. For the month the couple stopped living together, resources of the community spouse available for their Medicaid eligibility are the resources owned by the couple.(7-1-24)
IDAPA 16.03.05.750 Income Eligibility for Community Spouse
When the community spouse is a Medicaid participant, the spouse’s income is counted using Medicaid rules. The FSI rules apply only to the long-term care spouse. The community spouse may choose between the SSI and CP methods for determining income for Medicaid eligibility.(7-1-24)
IDAPA 16.03.05.751 Change in Circumstances
The FSI method of calculating income and res ources stops the first full calendar month after a change in circumstances resulting in a couple no longer having a community spouse and a long-term care spouse.(7-1-24)
IDAPA 16.03.05.752 Notice and Hearing
The Department must tell the participant about the CSA, the family member allowance, the CSRA and how it was com puted, and the RTA. Any hearing requested about the CSRA or the RTA must be held within thirty (30) days of the date of the request for hearing.(7-1-24)
IDAPA 16.03.05.753 (Reserved)
IDAPA 16.03.05.761 Choice of Ssi or Cp Methods
A married participant, not using FSI, m ust be furnished a written explanation of SSI and CP income and resource counting methods. The couple chooses the most useful method, based on their circumstances. The same method must be used for both spouses.(7-1-24)
IDAPA 16.03.05.762 Ssi Method of Counting Income and Resources of a Couple
The SSI method is the same method used to count income and resources for AABD cash. Income and resources of the participant and spouse are counted as mutually available. This method must be used for months either spouse gets SSI or AABD cash, or an SSI and/or AABD application is filed and approved. This method must be used for Medicaid eligibility, and liability for the cost of long-term care, whether or not one (1) or both spouses apply for Medicaid. For long-term care, the couple’s income and resources are mutually available when one (1) or both spouses apply during the month they separated, because one (1) or both left their mutual home to enter a long-term care facility.(7-1-24)
IDAPA 16.03.05.763 Community Property (cp) Method of Counting Income and Resources of a
COUPLE.
A married participant in long-term care, whose spouse is not in the community, can use the CP method. A married participant using the FSI method, but not income-eligible using FSI, may choose the CP method for income eligibility. The CP method must not be used for the FSI participant’s resource eligibility or patient liability. (7-1-24)
IDAPA 16.03.05.764 Cp Method
The CP method gives each spouse an equal one-half (1/2) share of the couple’s community income and resources .
Each spouse also has their own separate income and resources. Whether the spouses live together or, if not living together, the length of time they have lived apart, does not change the way income and resources are counted. A spouse’s property includes income, personal property, and real property. The income and resources of a married couple acquired during the marriage are presumed to be community property of the couple. The couple can give evidence to rebut the presumption that property acquired during the marriage is community property.(7-1-24)
IDAPA 16.03.05.765 Transfer of Rights to Future Income Not Valid
An agreement between spouses, transferring or assigning rights to future income from one (1) spouse to the other, is not valid for eligibility for Medicaid.(7-1-24)
IDAPA 16.03.05.766 Cp Method Need Standard
The participant is budgeted as a single person if their spouse is no t a Medicaid applicant, is not living with them, or was not living with them on the first day of the month. The participant and spouse are budgeted as a couple if they both apply and live together, or if they were living together on the first day of the month.(7-1-24)
IDAPA 16.03.05.767 Cp Method Resource Limit
The participant’s resource limit is two thousand dollars ($2,00 0) if their spouse is not a Medicaid applicant, is not living with them, or was not living with them on the first day of the month. The participant and spouse have a resource limit of three thousand dollars ($3,000) if they both apply and live together, or if they were living together on the first day of the month.(7-1-24)
IDAPA 16.03.05.768 Cp Method Income Disregards
The participant gets the twenty dollar ($20) standard disregard if their spouse is not a Medicaid applicant, is not living with them, or was not living with them on the first day of the month. If the participant has earned income, they get the sixty-five dollar plus one-half ($65 + 1/2) of the remainder earned income disregard. The participant and spouse get the standard disregard on their combined unearned income if they both apply, and live together, or if they were living together on the first day of the month. If either spouse has earned income, they get the earned income disregard from their combined earned income.(7-1-24)
IDAPA 16.03.05.769 (Reserved)
IDAPA 16.03.05.777 Eligible Ssi Recipient
An SSI recipient, or an individual who would be SSI eligible i f they applied, is eligible for Medicaid if they meet any of the conditions below.(7-1-24)
01.Receives SSI. Gets SSI payments, even if eligibility is based on presumptive disability or presumptive blindness.(7-1-24)
02.Conditionally Eligible for SSI. Based on an agreement to dispose of excess resources.(7-1-24)
03.Eligible Spouse. Has their SSI payments combined with their spouse’s SSI payments.(7-1-24)
IDAPA 16.03.05.778 Ineligible Ssi Recipient
An SSI recipient is not eligible for Medicaid if they meet any of the conditions below.(7-1-24)
01.Medicaid Qualifying Trust. Has excess income from a Medicaid Qualifying Trust, created and funded before August 11, 1993.(7-1-24)
02.Noncooperation. Fails to cooperate in establishing paternity or securing support.(7-1-24)
03.Is in an Ineligible Institution.(7-1-24)
04.Trust. Has a trust that makes them ineligible for Medicaid.(7-1-24)
IDAPA 16.03.05.779 Psychiatric Facility Resident
A resident of a long-term care psychiatric medical fa cility is eligible for Medicaid if they are age sixty-five (65) or older. They must meet all the requirements of a long-term care resident.(7-1-24)
IDAPA 16.03.05.780 (Reserved)
IDAPA 16.03.05.781 Rsdi Recipient Entitled to Cola Disregard
A participant receiving RSDI is eligible for Medicaid if they became and remain ineligible for SSI payments as of April 2011, or for AABD cash or SSI payments from May 1977 through March 2011. The participant must still be entitled to AABD cash or SSI, except for a COLA in RSDI benefits. All RSDI COLAs received by the participant, and any person whose income and resources are counted in determining the participant’s eligibility, are disregarded for Medicaid.(7-1-24)
IDAPA 16.03.05.782 Medicaid Benefits Under Section 1619(b) of the Social Security Act
A participant may be eligible for Medicaid under Section 1619(b) of the Social Security Act either under federal or state criteria, depending on their circumstances.(7-1-24)
01.Federally Qualified Under SSA Section 1619(b). An SSI recipient with a disability, previously eligible for SSI cash, who, because of earnings from employment, no longer meets the financial eligibility requirements for SSI cash, is eligible for Medicaid. SSA determines the qualification for eligibility under Section 1619(b).(7-1-24)
02.State-Only Qualified Under SSA Section 1619(b). An AABD cash participant with a disability, who, because of earnings from employment, no longer meets the financial eligibility requirements for AABD cash, may be eligible for Medicaid. The Department determines eligibility for State-only Section 1619(b) Medicaid. Stateonly Section 1619(b) Medicaid is authorized under Section 1905(q) of the Social Security Act.(7-1-24)
a.A participant must meet all the following requirements to be eligible for State-only 1619(b)
Medicaid. The participant:(7-1-24)
i.Received AABD cash in the month prior to the first month of their eligibility under this rule.
ii.Is under age sixty-five (65).(7-1-24)
iii.Continues to have a disability.(7-1-24)
iv.Must depend on Medicaid coverage to continue working. An individual depends on Medicaid coverage if they:(7-1-24)
(1)Used Medicaid coverage within the past twelve (12) months;(7-1-24)
(2)Expect to use Medicaid coverage in the next twelve (12) months; or(7-1-24)
(3)Would be unable to pay unexpected medical bills in the next twelve (12) months without Medicaid coverage.(7-1-24)
v.Is not able to afford medical insurance equivalent to Medicaid, including attendant care. The participant meets this requirement if their earnings are under the limit referred to in Subsection 782.02.a.vii. of this rule.(7-1-24)
vi.Continues to meet all the non-disability eligibility requirements in these rules.(7-1-24)
vii.Has annual gross earned income less than the current calendar year's charted threshold for Idaho as developed by SSA for federal qualification for Section 1619(b) Medicaid. The charted threshold for Idaho is SI 02302.200 Charted Threshold Amounts, incorporated by reference in Subsection 002.04.(7-1-24)
b.State-only Section 1619(b) Medicaid ends when the participant meets one (1) of the following criteria. The participant:(7-1-24)
i.Is no longer eligible for AABD cash for a reason other than excess earned income;(7-1-24)
ii.Has gross earned income equal to or more than the current calendar year's annual earnings threshold for Idaho developed by the SSA for federal Section 1619(b) Medicaid;(7-1-24)
iii.Is age sixty-five (65) or older; or(7-1-24)
iv.Regains eligibility for AABD cash.(7-1-24)
IDAPA 16.03.05.783 Appeal of Ssa Decision - Applicant Determined Ssi Eligible After Appeal
An applicant denied Medicaid, because they do not meet SSI eligibility or RSDI disability requirements, can appeal the SSA denial with SSA. They can get Medicaid, if found eligible for SSI or Social Security disability because of their appeal. The effective date for Medicaid is the first day of the month that the Medicaid application was denied, by SSA. The participant’s eligibility for backdated Medicaid coverage must be determined.(7-1-24)
IDAPA 16.03.05.784 Appeal of Ssa Decision and Continued Medicaid
A Medicaid participant, denied RSDI or SSI because they are not disabled, can continue to get Medicaid if they appeal the SSA decision. The appeal must be filed within sixty (60) days of the SSA decision. If the final administrative decision rules against the participant’s appeal, Medicaid benefits must end. Medicaid benefits paid during the appeal are not an overpayment.(7-1-24)
IDAPA 16.03.05.785 Certain Disabled Children
A disabled child, not eligible for Medicaid outside a medical institution, is eligible for Medicaid if they meet the conditions below.(7-1-24)
01.Age. Is under nineteen (19) years old.(7-1-24)
02.AABD Criteria. Meets the AABD blindness or disability criteria.(7-1-24)
03.AABD Resource Limit. Meets the AABD single person resource limit.(7-1-24)
04.Income Limit. Has monthly income not exceeding three (3) times the federal SSI benefit payable monthly to a single person.(7-1-24)
05.Eligible for Long-Term Care. Meets the medical conditions for long-term care in IDAPA
06.Appropriate Care. Is appropriately cared for outside a medical institution, under a physician’s plan of care.(7-1-24)
07.Cost of Care. Can be cared for cost effectively outside a medical institution. The estimated cost of caring for the child must not exceed the cost of the child’s care in a hospital, nursing facility, or ICF/IID.(7-1-24)
08.Share of Cost. The financially responsible adult of a certain disabled child, who has family income above one hundred fifty percent (150%) of the federal poverty guidelines, is required to share in the cost of the child’s Medicaid benefits pursuant to the Idaho Medicaid State Plan and Section 56-2203, Idaho Code.(7-1-24)
IDAPA 16.03.05.786 (Reserved)
IDAPA 16.03.05.787 Home and Community Based Services (hcbs)
An aged, blind, or disabled participant, who is not income eligible for SSI or AABD cash, in their own home or community setting, is eligible for Medicaid if they meet the conditions below and meets all requirements in one (1) of the waiver Sections 788 through 789 of these rules.(7-1-24)
01.Resource Limit. Meets the AABD single person resource limit.(7-1-24)
02.Income Limit. Income of the participant must not exceed three (3) times the federal SSI monthly benefit for a single person. A married participant living at home with their spouse who is not an HCBS participant, may choose between the SSI, CP, and FSI methods. If their spouse is also an HCBS participant or lives in a nursing home, the couple may choose between the SSI and CP methods.(7-1-24)
03.Maintained in the Community. The applicant must be able to be maintained safely and effectively in their own home or in the community with the waiver services.(7-1-24)
04.Cost of Care. The cost of the participant's care must be cost effective as provided in IDAPA
05.Waiver Services Needed. The participant must need and receive, or be likely to need and receive, waiver services for thirty (30) consecutive days. The participant is ineligible when there is a break in need for, or receipt of, waiver services for thirty (30) consecutive days.(7-1-24)
06.Effective Date. Waiver services are effective the first day the participant is likely to need and receive waiver services. Medicaid begins the first day of the month in which the first day of approved waiver services are received.(7-1-24)
07.Annual Limit. The Department limits the number of participants approved for waiver services each year. A participant who applies for waiver services after the annual limit is reached, must be denied waiver services.(7-1-24)
IDAPA 16.03.05.788 Aged and Disabled (a&d) Waiver
To be eligible for the Aged and Disabled ( A&D) Waiver the participant must:(7-1-24)
01.Age Eighteen Through Sixty-Four. Be eighteen (18) through sixty-four (64) years old and meet the disability criteria, as provided in Section 156 of these rules, and need nursing facility level of care under IDAPA 16.03.26, “Medicaid Plan Benefits”; or(7-1-24)
02.Age Sixty-Five or Older. Be age sixty-five (65) or older and need nursing facility level of care under IDAPA 16.03.26, “Medicaid Plan Benefits.”(7-1-24)
IDAPA 16.03.05.789 Developmentally Disabled (dd) Waiver
To be eligible, the participant must be at leas t eighteen (18) years of age and need the level of care provided by an ICF/IID under IDAPA 16.03.26, “Medicaid Plan Benefits.”(7-1-24)
IDAPA 16.03.05.790 (Reserved)
IDAPA 16.03.05.799 Medicaid for Workers with Disabilities
An individual is eligible to participate in the Medicaid for Workers with Disabilities coverage group if the individual meets the requirements below.(7-1-24)
01.Non-Financial Requirements. An individual must:(7-1-24)
a.Be at least sixteen (16) but less than sixty-five (65) years of age;(7-1-24)
b.Meet the Medicaid residency requirement under Section 100 of these rules;(7-1-24)
c.Meet the citizenship requirements under 42 CFR 435.406, Citizenship and Non-citizen Eligibility;
d.Meet the SSN requirements under Section 10 3of these rules; and(7-1-24)
e.Meet the child support cooperation requirements under Sections 703 through 706 of these rules.
02.Disability. An individual must meet the medical definition for having a disability or blindness used by the SSA for Social Security Disability Insurance (SSDI) and SSI benefits.(7-1-24)
03.Employment. An individual must be employed which may include self-employment. Proof of employment must be provided to the Department. Hourly wage or hours worked will not be used to determine employment.(7-1-24)
04.Countable Resources. Cannot exceed ten thousand dollars ($10,000) for an individual or fifteen thousand dollars ($15,000) for a couple. When calculating resources, the following items will be excluded: (7-1-24)
a.Any resources excluded under Section 210 and Sections 222 through 299 of these rules;(7-1-24)
b.A second vehicle as described in Section 222 of these rules;(7-1-24)
c.Life insurance policies;(7-1-24)
d.Retirement accounts; and(7-1-24)
e.Exempt trusts as described in Section 872 of these rules.(7-1-24)
05.Countable Income. Is calculated using exclusions and disregards as described in Sections 300 through 547 of these rules. The countable income for:(7-1-24)
a.An individual cannot exceed five hundred percent (500%) of the current federal poverty guideline for a household of one (1).(7-1-24)
b.A couple cannot exceed five hundred percent (500%) of the current federal poverty guideline for a household of two (2).(7-1-24)
06.Earned Income Test. Gross income is the total of earned and unearned income before exclusions or disregards. Each individual’s gross earned income must be at least fifteen percent (15%) of their total gross income to qualify.(7-1-24)
07.Cost-Sharing. A participant in the Medicaid for Workers with Disabilities coverage group may be required to cost-share; the costs are determined under the provisions of the Idaho Medicaid State Plan.(7-1-24)
IDAPA 16.03.05.800 (Reserved)
IDAPA 16.03.05.802 Woman Diagnosed with Breast or Cervical Cancer
A woman not otherwise eligible for Medicaid and meeting the cond itions in Subsections 802.01 through 802.06 of this rule is eligible for Medicaid for the duration of her cancer treatment. Medicaid income and resource limits do not apply to this coverage group.(7-1-24)
01.Diagnosis. The participant is diagnosed with breast or cervical cancer through the CDC's National Breast and Cervical Cancer Early Detection Program.(7-1-24)
02.Age. The participant is under age sixty-five (65).(7-1-24)
03.Creditable Health Insurance. The participant is uninsured or, if insured, the plan does not cover her type of cancer.(7-1-24)
04.Non-Financial Eligibility. The participant meets the Medicaid non-financial eligibility requirements in Sections 100 through 108 and Sections 166 and 167 of these rules.(7-1-24)
05.Medical Support Cooperation. The participant meets the medical support cooperation requirement in Sections 702 through 706 of these rules.(7-1-24)
06.Group Health Plan Enrollment. The participant meets the requirement to enroll in available costeffective employer group health insurance.(7-1-24)
07.Presumptive Eligibility. The Department can presume the participant is eligible for Medicaid, before a formal Medicaid eligibility determination is made. A clinic authorized to screen for breast or cervical cancer by the National Breast and Cervical Cancer Early Detection Program makes the presumptive eligibility determination. The clinic tells the participant how to complete the formal Medicaid determination process. The Medicaid notice and hearing rights do not apply to presumptive eligibility. No overpayment occurs if the formal Medicaid determination finds the participant is not eligible.(7-1-24)
08.End of Treatment. The Department determines the end of treatment date under IDAPA 16.03.26, “Medicaid Plan Benefits.”(7-1-24)
IDAPA 16.03.05.803 (Reserved)
IDAPA 16.03.05.806 Disabled Adult Child
A participant age eighteen (18) or older is eligible for Medicaid if they received SSI or AABD cash based on blindness or a disability which began before they reached age twenty-two (22), and becomes ineligible for and remains ineligible for AABD cash or SSI because their disabled child RSDI benefit started or increased July 1, 1987, or later.(7-1-24)
01.RSDI Benefits Disregarded for Disabled Adult Child. If the participant became ineligible because they began receiving a disabled child benefit on or after July 1, 1987, the benefit amount and any later increases are disregarded.(7-1-24)
02.RSDI Increase Disregarded for Disabled Adult Child. If the participant became ineligible because their disabled child benefit increased on or after July 1, 1987, the increase and any later increases are disregarded.(7-1-24)
IDAPA 16.03.05.807 (Reserved)
IDAPA 16.03.05.808 Early Widows and Widowers Beginning January 1, 1991
A participant who meets the conditions below is considered an SSI recipient for Medicaid.(7-1-24)
Age. The participant, age fifty (50) to age sixty four and one-half (64-1/2), began receiving early widows or widowers Social Security benefits.(7-1-24)
02.Lost SSI or AABD. The participant lost SSI or AABD cash because they began receiving early widows or widowers Social Security benefits.(7-1-24)
03.Received SSI or AABD. The participant received SSI or AABD cash in the month, before the month, they became ineligible because they began receiving early widows or widowers Social Security benefits.
04.Widows or Widowers Benefits. The participant would still be eligible for SSI or AABD cash if their Social Security early widows or widowers benefits were not counted as income.(7-1-24)
05.No “Part A” Insurance. The participant is not entitled to Medicare Part A hospital insurance.
06.Applied On or After January 1, 1991. The participant’s Medicaid application was filed, or pending, on or after January 1, 1991.(7-1-24)
IDAPA 16.03.05.809 (Reserved)
IDAPA 16.03.05.810 Qualified Medicare Beneficiary (qmb)
A person meeting all requirements below is eligible for QM B, which pays Medicare premiums, coinsurance, and deductibles.(7-1-24)
01.Medicare Part A. The participant must be entitled to hospital insurance under Part A of Medicare at the time of their application.(7-1-24)
02.Nonfinancial Requirements. The participant must meet the Medicaid residence, citizenship, support cooperation, and SSN requirements.(7-1-24)
03.Income. Monthly income must not exceed one hundred percent (100%) of the Federal Poverty Guidelines (FPG). The single person income limit is the poverty line for a family of one (1) person. The couple income limit is the poverty line for a family of two (2) persons. The annual Social Security cost of living increase is disregarded from income, until the month after the month the annual FPG revision is published. AABD cash is not counted as income. The income exclusions and disregards used for AABD are used for QMB.(7-1-24)
04.Dependent Income. Income of the dependent child, parent, or sibling is not counted.(7-1-24)
05.QMB Dependent Family Member Disregard. A dependent family member is a minor child, adult child meeting SSA disability criteria, parent or sibling of the participant or spouse living with the participant. The family member is or could be claimed on the federal tax return of the participant or spouse. A participant with a dependent family member has an income disregard based on family size. The spouse is included in family size, whether or not the spouse is also participant. The disregard is based on the official poverty line income as defined by the OMB. The disregard is the difference between the poverty line for one (1) person, or two (2) persons if the participant has a spouse, and the poverty line for the family size including the participant, spouse, and dependent.
06.Resource Limit. The resource limit is equal to the amount defined under 42 USC 1396d(p)(1)(C).
The resource exclusions used for AABD are used for QMB.(7-1-24)
07.Effective Dates. The effective date of QMB coverage is no earlier than the first day of the month after the approval month. A QMB participant is not entitled to backdated Medicaid.(7-1-24)
IDAPA 16.03.05.811 Specified Low Income Med
ICARE BENEFICIARY (SLMB).
A person meeting all requirements below is eligible for SLM B. Medicaid pays the Medicare Part B premiums for a SLMB. The income and resource exclusions and disregards used for AABD are used for SLMB.(7-1-24)
01.Other Medicaid. The SLMB may be eligible for other Medicaid.(7-1-24)
02.Medicare Part A. The SLMB must be entitled to hospital insurance under Part A of Medicare at the time of their application.(7-1-24)
03.Nonfinancial Requirements. The SLMB must meet the Medicaid eligibility requirements of residence, citizenship, support cooperation, and SSN.(7-1-24)
04.Income. The annual Social Security cost of living increase is disregarded from income, until the month after the month the annual FPG revision is published. The single person limit is based on a family of one (1).
The couple limit is based on a family of two (2). The monthly income limit is up to one hundred twenty percent (120%) of the FPG.(7-1-24)
05.Resource Limit. The resource limit is equal to the amount defined under 42 USC 1396d(p)(1)(C).
The resource exclusions used for AABD are used for SLMB.(7-1-24)
06.Effective Dates. SLMB coverage begins on the first day of the application month, which may be backdated up to three (3) calendar months before the application month.(7-1-24)
IDAPA 16.03.05.812 Qualified Individual (qi)
A person meeting all requirements below is eligible for QI. M edicaid pays the Medicare Part B premiums for a QI.
The income and resource exclusions and disregards used for AABD are used for QI.(7-1-24)
01.Other Medicaid. The QI cannot be eligible for any other type of Medicaid.(7-1-24)
02.Medicare Part A. The QI must be entitled to hospital insurance under Part A of Medicare at the time of their application.(7-1-24)
03.Nonfinancial Requirements. The QI must meet the Medicaid eligibility requirements of residence, citizenship, support cooperation, and SSN.(7-1-24)
04.Income. The annual Social Security cost of living increase is disregarded from income, until the month after the month the annual FPG revision is published. The single person limit is based on a family of one (1).
The couple limit is based on a family of two (2). The monthly income limit is up to one hundred thirty-five percent (135%) of the FPG.(7-1-24)
05.Resource Limit. The resource limit is equal to the amount defined under 42 USC 1396d(p)(1)(C).
The resource exclusions used for AABD are used for SLMB.(7-1-24)
06.Coverage Limits. There is an annual limit on participants served based on availability of federal funds. New applications are denied when the annual limit is reached.(7-1-24)
07.Effective Dates. QI coverage begins on the first day of the application month, which may be backdated up to three (3) calendar months before the application month.(7-1-24)
IDAPA 16.03.05.813 Qualified Disabled and Working Individual (qdwi)
A person meeting all requirements below is eligible for QDWI. The person must not be eligible for any other type of Medicai d. A QDWI is eligible only for Medicaid payment of their Medicare Part A premium.(7-1-24)
01.Age and Disability. The participant must be a disabled worker under age sixty-five (65). (7-1-24)
02.Nonfinancial Requirements. The participant must meet the Medicaid eligibility requirements of residence, citizenship, support cooperation and SSN.(7-1-24)
03.Section 1818A Medicare. SSA determined the participant meets the conditions of Section 1818A of the Social Security Act.(7-1-24)
04.Income. Monthly income must not exceed two hundred percent (200%) of the one (1) person official poverty line defined by the OMB.(7-1-24)
05.Resource Limit. The resource limit is equal to the amount defined under 42 USC 1396d(s). The resource exclusions used for AABD are used for QDWI.(7-1-24)
IDAPA 16.03.05.814 Sponsored Legal Non-Citizen
All income and resources of a legal non-citi zen’s sponsor are deemed for Medicaid eligibility if the sponsor has signed an I-864 affidavit of support.(7-1-24)
IDAPA 16.03.05.815 Child Subject to Deeming
Income and resources of a child’s stepp arent are not deemed to the child in determining their Medicaid eligibility.
IDAPA 16.03.05.816 Fugitive Felon or Probation or Parole Violator
A person denied SSI or AABD cash because of the prohibition against payment to fugitive felons and probation and parole violators is not disqualified from Medicaid.(7-1-24)
IDAPA 16.03.05.817 (Reserved)
IDAPA 16.03.05.831 Asset Transfer Resulting in Penalty
Starting August 11, 1993, the participant is subject to a penalty if they transfer their income or resources for less than fair market value. The asset transfer penalty applies to Medicaid services received October 1, 1993 and later.
Excluded resources, other than the home and associated property, are not subject to the asset transfer penalty. Asset transfers subject to penalty under these rules may be voided and set aside by court action as provided in Section 56- 218, Idaho Code. The asset transfer penalty applies to a Medicaid participant in long-term care or HCBS. A participant in long-term care is a patient in a nursing facility or a patient in a medical institution, requiring and receiving the level of care provided in a nursing facility.(7-1-24)
01.Rebuttable Presumption. Unless a transfer meets the requirements of Section 841 of these rules, it is presumed that the transfer was made for the purpose of qualifying for Medicaid. The asset transfer penalty is applied unless the participant shows that the asset transfer would not have affected their eligibility for Medicaid, or the transfer was made for another purpose than qualifying for Medicaid.(7-1-24)
02.Contract for Services Provided by a Relative. A contract for personal services to be furnished to the participant by a relative is presumed to be made for the purpose of qualifying for Medicaid. The asset transfer penalty applies unless the participant shows that:(7-1-24)
a.A written contract for personal services was signed before services were delivered. The contract must require that payment be made after services are rendered. The contract must be dated, and the signatures notarized. Either party must be able to terminate the contract; and(7-1-24)
b.The contract must be signed by the participant or a legally authorized representative through a power of attorney, legal guardianship, or conservatorship. A representative who signs the contract must not be the provider of the personal care services under the contract; and(7-1-24)
c.Compensation for services rendered must be comparable to rates paid in the open market. (7-1-24)
03.Transfer of Income or Resources. Transfer of income or resources includes reducing or eliminating the participant’s ownership or control of the asset.(7-1-24)
04.Transfer of Income or Resources by a Spouse. A transfer by the participant’s spouse of either spouse’s income or resources, before eligibility is established, subjects the participant to the asset transfer penalty.
After the participant’s eligibility is established, a transfer by the spouse of the spouse’s own income or resources does not subject the participant to the asset transfer penalty.(7-1-24)
05.Transfer of Certain Notes and Loans. Funds used to purchase a promissory note, loan, or mortgage are considered a transferred asset which subjects the participant to a period of ineligibility. The amount of the asset transfer of such note, loan, or mortgage is the outstanding balance due on the date of the Medicaid application, unless the note, loan, or mortgage meets the following:(7-1-24)
a.Has a repayment term that is actuarially sound;(7-1-24)
b.Provides for payments to be made in equal amounts during the term of the loan with no deferral and no balloon payments; and(7-1-24)
c.Prohibits the cancellation of the balance upon the death of the lender.(7-1-24)
IDAPA 16.03.05.832 Medicaid Penalty for Asset Transfers
The asset transfer penalty is restrict ed Medicaid coverage.(7-1-24)
01.Restricted Coverage. Means Medicaid will not participate in the cost of nursing facility services or in a level of care in a medical institution equal to nursing facility services. The penalty for a person receiving PCS or community services under the HCBS waiver is ineligibility.(7-1-24)
02.Notice and Exemption. The participant must be notified in writing, at least ten (10) days before an asset transfer penalty is imposed.(7-1-24)
IDAPA 16.03.05.833 Asset Transfer Look-Back Period
The asset transfer penalty applies to any transfer for les s than fair market value made during a period preceding or following a request for long-term care services. Any asset transferred, regardless of type, is subject to a look-back period of sixty (60) months. The look-back period is counted from the date of the application for long-term care or HCBS services or the date of the transfer, whichever is later in time.(7-1-24)
IDAPA 16.03.05.834 Period of Restricted Coverage for Asset Transfers
The period of restricted coverage is the number of months computed by dividing the net uncompensated value of the transferred asset by the statewide average cost of nursing facilit y services to private patients. The cost is computed for the time of the participant’s most recent request for Medicaid. If the spouse becomes eligible for long-term care Medicaid, the rest of the period of restricted coverage is divided between the participant and spouse.(7-1-24)
IDAPA 16.03.05.835 Applying the Penalty Period of Restricted Coverage
Restricted coverage continues until the pa rticipant or spouse recovers all the assets, receives fair market value at the time of the transfer for all assets, or the period of restricted coverage ends. The penalty continues whether or not the participant is in long-term care. For assets transferred, the penalty period begins running the first day of the month after the month the transfer took place or was discovered to have taken place, or the date the individual would have been eligible for long-term care services or HCBS, if not for the transfer, whichever date is later in time. The value of all asset transfers made during the look-back period is accumulated for the purpose of calculating the penalty. If an additional transfer is discovered after the penalty has been served, a new penalty period begins the month following timely notice of closure of benefits. When a penalty period ends after the first day of the month, eligibility for longterm care services begins the day after the penalty period ends.(7-1-24)
IDAPA 16.03.05.836 Multiple Penalty Periods Applied Consecutively
A penalty period is computed for each transfer. One (1) penalty period must expire before the next begins.(7-1-24)
IDAPA 16.03.05.837 Life Estate as Asset Transfer
01.Transfer of a Remainder Interest. When a life estate in real property is retained by an individual, and a remainder interest in the property is transferred during the look-back period for less than the fair market value of the remainder interest transferred, the value of the uncompensated remainder is subject to the asset transfer penalty as described in Sections 831 through 835 of these rules. To compute the value of the life estate remainder, multiply the fair market value of the real property at the time of transfer by the remainder factor for the participant’s age at the time of transfer listed in the following table:
TABLE 837.01 - REMAINDER TABLE
AgeRemainderAgeRemainderAgeRemainderAgeRemainder 0.0281228.0393856.2099484.63002 1.0101229.0418757.2206985.64641 2.0098330.0445758.2317886.66236
02.Transfer of a Life Estate. When a life estate in real property is transferred by an individual during the look-back period for less than fair market value, the value of the life estate is subject to the asset transfer penalty as described in Sections 831 and 835 of these rules. To compute the value of the life estate, multiply the fair market value of the real property at the time of transfer by the life estate factor for the participant’s age at the time of transfer listed in the following table: 3.0099231.0474659.2432587.67738 4.0101932.0505860.2550988.69141 5.0106233.0539261.2673389.70474 6.0111634.0575062.2799890.71779 7.0117835.0613263.2930491.73045 8.0125236.0654064.3064892.74229 9.0133737.0697465.3203093.75308 10.0143538.0743366.3344994.76272 11.0154739.0791767.3490295.77113 12.0167140.0842968.3639096.77819 13.0180241.0897069.3791497.78450 14.0193442.0954370.3947898.79000 15.0206343.1014571.4108699.795 16.0218544.1077972.42739100.80025 17.0230045.1144273.44429101.80468 18.0241046.1213774.46138102.80946 19.0252047.1286375.47851103.81563 20.0263548.1362676.49559104.82144 21.0275549.1442277.51258105.83038 22.0288050.1525778.52951106.84512 23.0301451.1612679.54643107.86591 24.0315952.1703180.56341108.89932 25.0332253.1797281.58033109.95455 26.0350554.1894682.59705 27.0371055.1995483.61358 TABLE 837.01 - REMAINDER TABLE AgeRemainderAgeRemainderAgeRemainderAgeRemainder
IDAPA 16.03.05.838 Annuity as Asset Transfer
Except as provided in this rule, when assets are used to purchase an annuity during the look-back period, it is an asset transfer presumed to be made for the purpose of qualifying for Medicaid. To rebut this presumption, the participant must provide proof that clearly establishes the annuity was not purchased to make the participant eligible for Medicaid or avoid recovery from the estate following death. Proof is met if the participant shows the annuity meets TABLE 837.02 - LIFE ESTATE TABLE AgeLife EstateAgeLife EstateAgeLife EstateAgeLife Estate 0.9718828.9606256.7900684.36998 1.9898829.9581357.7739185.35359 2.9901730.9554358.7682286.33764 3.9900831.9525459.7567587.32262 4.9898132.9494260.7449188.30859 5.9893833.9460861.7326789.29526 6.9888434.9425062.7200290.28221 7.9882235.9386863.7069691.26955 8.9874836.9346064.6935292.25771 9.9866337.93026656797093.24692 10.9856538.9256766.6655194.23728 11.9845339.9208367.6509895.22887 12.9835940.9157168.6361 096.22181 13.9819841.9103069.6208697.21550 14.9806642.9045770.6052298.21000 15.9793743.8985571.5891499.20486 16.9781544.8922172.57261100.19975 17.9770045.8855873.55571101.19532 18.9759046.8786374.53862102.19054 19.9748047.8713775.52149103.18437 20.9736548.8637476.50441104.17856 21.9742549.8557877.48742105.16962 22.9712050.8374378.47049106.15488 23.9698651.8367479.45357107.13409 24.9684152.8296980.43659108.10068 25.9667853.8202 881.41967109.04545 26.9649554.8105482.40295 27.9629055.8004683.38642 the requirements Subsections 838.02 through 838.05 of this rule.(7-1-24)
01.Revocable Annuity. Is an annuity that can be assigned. The surrender amount of a revocable annuity is a countable resource.(7-1-24)
02.Irrevocable Annuity. The purchase price of an irrevocable, non-assignable annuity is treated as an asset transfer, unless the requirements of Subsections 838.03 through 838.05 of this rule are met.(7-1-24)
03.Irrevocable Annuity Life Expectancy Test. The participant’s life expectancy, as shown in the Social Security Actuarial - Period Life Table (2020), must equal or exceed the term of the annuity. Using the Table, compare the face value of the annuity to the participant’s life expectancy at the purchase time. The annuity meets the life expectancy test if the participant’s life expectancy equals or exceeds the term of the annuity. If the exact age is not in the Table, use the next lower age. See https://www.ssa.gov/oact/STATS/table4c6.html.(7-1-24)
04.State Named as Beneficiary. The purchase of an annuity is treated as an asset transfer unless the State of Idaho, Medicaid Estate Recovery is named as:(7-1-24)
a.The remainder beneficiary in the first position for at least the total amount of medical assistance paid on behalf of the institutionalized individual under this title; or(7-1-24)
b.The remainder beneficiary in the second position after the community spouse or minor or disabled child and is named in the first position if the community spouse or a representative of the minor or disabled child disposes of any remainder for less than fair market value.(7-1-24)
05.Equal Payment Test. The annuity must provide for payments in equal amounts during the term of the annuity with no deferral and no balloon payments made.(7-1-24)
06.Permitted Annuity. The purchase of an annuity is not treated as an asset transfer if the annuity meets any of the descriptions in Sections 408(b), or 408(q), Internal Revenue Code; or is purchased with proceeds from an account or trust described in Sections 408(a), 408(c), or 408(p), Internal Revenue Code, or is a simplified employee pension as described in Section 408(k), Internal Revenue Code, or is a Roth IRA described in Section 408A, Internal Revenue Code.(7-1-24)
IDAPA 16.03.05.839 Trusts as Asset Transfers
A trust established wholly or partly from the participant’s assets is an asset transfer. Assets transferred to a trust on or after August 11, 1993 are subject to the asset transfer penalty, regardless of when the trust was established. If the trust includes assets of another person, the asset transfer penalty applies to the participant’s share of the trust.(7-1-24)
IDAPA 16.03.05.840 Transfer of Jointly Owned Asset
Transfer of an asset owned jointly by th e participant and another person is considered a transfer by the participant.
The participant’s share of the asset is used to compute the penalty. If the participant and their spouse are joint owners of the transferred asset, the couple’s combined ownership is used to compute the penalty. If the spouse becomes eligible for long-term care Medicaid, the rest of the period of restricted coverage is divided between the participant and spouse.(7-1-24)
IDAPA 16.03.05.841 Penalty Exceptions for Asset Transfers
A participant is not subject to the asset transfer penalty for t aking any action described in Subsections 841.01 through 841.15 of this rule.(7-1-24)
01.Home to Spouse. The asset transferred was a home. Title to the home was transferred to the spouse.(7-1-24)
02.Home to Minor Child or Disabled Adult Child. The asset transferred was a home. Title to the home was transferred to the child of the participant or spouse. The child must be under age twenty-one (21) or blind or totally disabled under Social Security and SSI rules in 20 CFR Part 416.(7-1-24)
03.Home to Brother or Sister. The asset transferred was a home. Title to the home was transferred to a sibling of the participant or spouse. The sibling must have an equity interest in the transferred home and reside in that home for at least one (1) year immediately before the month the participant starts long-term care.(7-1-24)
04.Home to Adult Child. The asset transferred was a home. Title to the home was transferred to a child of the participant or spouse, other than a child under the age of twenty-one (21). The child must reside in that home for at least two (2) years immediately before the month the participant started long-term care. The adult child must prove they provided nursing facility level medical care to the participant which permitted them to live at home rather than enter long-term care. The child must not have received payment from Medicaid for home and communitybased services provided to the participant.(7-1-24)
05.Benefit of Spouse. The assets were transferred to the participant’s spouse or to another person for the sole benefit of the spouse.(7-1-24)
06.Transfer From Spouse. The assets were transferred from the participant’s spouse to another person for the sole benefit of the participant’s spouse.(7-1-24)
07.Transfer to Child. The assets were transferred to the participant’s child, or to a trust established solely for the benefit of the participant’s child. The child must be blind or totally disabled under Social Security and SSI rules in 20 CFR Part 416. The child may be any age.(7-1-24)
08.Intent to Get Fair Market Value. The participant or spouse proves they intended to dispose of the assets at fair market value or for other adequate consideration.(7-1-24)
09.Assets Returned. All assets transferred for less than fair market value have been returned to the participant.(7-1-24)
10.Medicaid Qualification Not the Intent. The participant or spouse proves the assets were transferred exclusively for a purpose other than to qualify for Medicaid or to avoid recovery.(7-1-24)
11.Undue Hardship. The participant, their representative, or the facility in which they reside may request the hardship waiver. The hardship waiver must be requested in writing within ten (10) days of the date of the asset transfer penalty notice. Undue hardship exists if any of the conditions below apply.(7-1-24)
a.The participant proves they are not able to pay for their nursing facility services or their waiver services by any means.(7-1-24)
b.The participant proves that they have made reasonable efforts, consistent with their physical and financial ability, to recover the transferred asset. The participant must fully cooperate with the State of Idaho in efforts to recover the transferred asset and, upon request, must assign their rights to recover the asset to the State of Idaho.(7-1-24)
c.The participant proves they did not knowingly transfer the asset.(7-1-24)
d.The participant proves they would be deprived of food, clothing, shelter, or other necessities of life if the asset transfer penalty is imposed and they assign their rights to recover the asset to the State of Idaho. (7-1-24)
12.Exception to Fair Market Value. The amount received is adequate, even if not fair market value.
This exception must meet one (1) of the conditions below.(7-1-24)
a.A forced sale was done under reasonable circumstances.(7-1-24)
b.Little or no market demand exists for the type of asset transferred and the lack of market demand was not created by a voluntary act of the participant to qualify for assistance or to avoid recovery.(7-1-24)
c.The asset was transferred to settle a legal debt approximately equal to the fair market value of the transferred asset.(7-1-24)
13.No Benefit to Participant. The participant received no benefit from the asset. This exception must meet one (1) of the conditions below.(7-1-24)
a.The participant or spouse held title to the property only as a trustee for another person and had no beneficial interest in the property.(7-1-24)
b.The transfer was done to clear title to property. The participant or spouse had no beneficial interest in the property. The defect in the title was not created to transfer assets to qualify for assistance or avoid recovery.
14.Fraud Victim. The asset was transferred because the participant or spouse was the victim of fraud, misrepresentation, or coercion. The participant or spouse must take all possible steps to recover the assets or property, or its equivalent in damages and assign recovery rights to the State of Idaho.(7-1-24)
15.Transfer to Trust of Disabled Person. The assets were transferred to a trust established solely for the benefit of an individual under sixty-five (65) years of age who is disabled. (7-1-24)
IDAPA 16.03.05.842 (Reserved)
IDAPA 16.03.05.871 Treatment of Trusts
This trust treatment rule applies to all Medicaid participants. This rules applies to trusts established with the participant’s assets on August 11, 1993, or later, and to amounts placed in trusts on or after August 11, 1993. This rule does not apply to an irrevocable trust if the participant meets the undue hardship exemption in Subsection 841.11 of these rules. Assets transferred to a trust are subject to the asset transfer penalty. This rule does not apply to a trust created with assets other than those of the individual, including a trust established by a will.(7-1-24)
01.Revocable Trust. Is treated as listed below. A revocable burial trust is not a trust for the purposes of Subsection 871.01 of this rule.(7-1-24)
a.The body (corpus) of a revocable trust is a resource.(7-1-24)
b.Payments from the trust to or for the participant are income.(7-1-24)
c.Any other payments from the trust are an asset transfer, triggering an asset transfer penalty period.
d.Under 42 USC 1396p(e)(5), the home and adjoining property loses its exclusion for eligibility purposes when transferred to a revocable trust, unless the participant or spouse is the sole beneficiary of the trust. The home is excluded again if removed from the trust. The exclusion restarts the month following the month the home was removed from the trust.(7-1-24)
02.Irrevocable Trust. Is treated as listed below.(7-1-24)
a.The part of the body of an irrevocable trust, from which corpus or income payments could be made to or for the participant, is a resource.(7-1-24)
b.Payments made to or for the participant are income.(7-1-24)
c.Payments from the trust for any other reason are asset transfers, triggering the asset transfer penalty.(7-1-24)
d.Any part of the trust from which payment cannot be made to, or for the benefit of the participant under any circumstances, is an asset transfer.(7-1-24)
e.The effective date of the transfer is the date the trust was established, or the date payments to the participant were foreclosed.(7-1-24)
f.The value of the trust, for calculating the transfer penalty, includes any payments made from that portion of the trust after the date the trust was established, or payments were foreclosed.(7-1-24)
g.An irrevocable burial trust is not subject to treatment under Subsection 871.02 of this rule, unless funds in the trust can be paid for a purpose other than the participant’s funeral and related expenses. The trust can provide that funds not needed for the participant’s funeral expenses are available to reimburse Medicaid, or to go to the participant’s estate.(7-1-24)
IDAPA 16.03.05.872 Exempt Trusts
A trust, created or funded on or after Augu st 11, 1993, is exempt from trust treatment and not subject to the asset transfer penalty if it meets a condition below.(7-1-24)
01.Trust for Disabled Person. To be exempt, a trust for a disabled person must meet all the conditions below.(7-1-24)
a.The trust contains the assets of a person under age sixty-five (65).(7-1-24)
b.The person is blind or totally disabled under the Social Security and SSI rules in 20 CFR Part 416.
c.The trust is established for the person’s benefit by their parent, grandparent, legal guardian, or a court.(7-1-24)
d.The trust is irrevocable.(7-1-24)
e.The trust is exempt until the person reaches age sixty-five (65). After the person reaches age sixtyfive (65), additions or augmentations are not exempt from trust treatment.(7-1-24)
f.Upon the person’s death, the amount not distributed by the trust must first be paid to the State of
02.Income Trust. To be exempt, an income trust must meet all the conditions below.(7-1-24)
a.The trust is established for the sole benefit of a person who would be eligible for Medicaid in longterm care, or eligible for HCBS except for excess income.(7-1-24)
b.Any income, placed directly into an income trust in the same calendar month in which received by the recipient, is not considered income to the individual for determining long-term care Medicaid eligibility. Money paid into the trust is income for patient liability or participant participation.(7-1-24)
c.The trust is irrevocable. The trust document may include a clause allowing the trust to be revoked if the participant leaves the nursing facility or HCBS for a reason other than death, and is no longer eligible for Medicaid because of excess income, if Medicaid is reimbursed up to the amount Medicaid has paid on the person's behalf.(7-1-24)
d.Income transferred to the trust must be used to pay patient liability or participant participation. If income is not used to pay allowable expenses, it is subject to the asset transfer penalty, unless one (1) of the following exceptions applies.(7-1-24)
i.Benefit of the spouse in Subsection 841.05 of these rules;(7-1-24)
ii.Transfer from the spouse in Subsection 841.06 of these rules; or(7-1-24)
iii.Undue hardship in Subsection 841.11 of these rules.(7-1-24)
e.Upon the person’s death, the amount not distributed by the trust must first be paid to the State of
03.Trust Managed by Non-Profit Association for Disabled Person. To be exempt, a trust managed by non-profit association for a disabled person must meet all the conditions below.(7-1-24)
a.The trust is established and managed by a nonprofit association. The nonprofit association must not be the participant, their parent, or grandparent.(7-1-24)
b.The trust contains the assets of a disabled person. The person must be blind or totally disabled under Social Security and SSI rules in 20 CFR Part 416.(7-1-24)
c.Accounts in the trust are established only for the benefit of disabled persons. An account can be established by the disabled person, their parent, grandparent, legal guardian, or a court. A separate account must be maintained for each beneficiary of the trust. For purposes of investment and management, the trust may pool the funds in the accounts.(7-1-24)
d.The trust is irrevocable.(7-1-24)
e.Upon the person’s death, the amount not distributed by the trust must first be paid to the State of
IDAPA 16.03.05.873 Payments from an Exempt Trust for Disabled Person or Pooled Trust
Cash payments from an exempt trust for a disabled person or a pooled trust must be treated as described below.
01.Cash Payments from Exempt Trust. For a disabled person are income in the month received.
02.Cash Payments from Pooled Trust. Are made directly to the participant are income in the month received.(7-1-24)
03.Payments for the Participant’s Food or Shelter. Are income in the month paid. The payments for food or shelter are valued at one-third (1/3) of the AABD budgeted needs for the participant’s living arrangement.
04.Payments Not Made to Participant. Payments from the exempt trust not made to, or on behalf of, the participant are an asset transfer.(7-1-24)
IDAPA 16.03.05.874 (Reserved)
IDAPA 16.03.05.915 Medicaid Redetermination
Medicaid eligibility is redetermine d each year. The redetermination for AABD cash is the Medicaid redetermination for participants receiving both programs.(7-1-24)
IDAPA 16.03.05.916 (Reserved)
16.04.18 Childrens Agencies and Residential Licensing
IDAPA 16.04.18.000 Legal Authority
Sections 39-1207, 39-1208, 39-1209, 39-1210, 39-1213, 56-1003, and 56-1005(8), Idaho Code, and Tittle 56, Chapter 27, Idaho Code, authorizes the Department and the Board of Health and Welfare to adopt and enforce rules for licensing these organizations.(7-1-24)
IDAPA 16.04.18.001 (Reserved)
IDAPA 16.04.18.009 Background Check Requirements
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Compliance. Background checks are required for individuals licensed under these rules and must comply with IDAPA 16.05.06, “Criminal History and Background Checks,” except for those individuals under Subsection 009.03 of this rule.(7-1-24)
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Individuals Subject to Background Check Requirements. The following individuals must receive a clearance under IDAPA 16.05.06, “Criminal History and Background Checks:”(7-1-24)
a.Adoptive parents and any other adult residing in the home at any time during the adoption process.
(7-1-24)
b.Children's Agencies;(7-1-24)
i.Chief Administrator;(7-1-24)
ii.Case Manager Supervisor;(7-1-24)
iii.Case Manager;(7-1-24)
iv.Support Staff; and(7-1-24)
v.Contractors and volunteers that have unsupervised time with children.(7-1-24)
c.Children's Residential Care Facilities:(7-1-24)
i.Owners;(7-1-24)
ii.Chief Administrator;(7-1-24)
iii.Medical Professional;(7-1-24)
iv.Licensed Treatment Professional;(7-1-24)
v.Case Manager Supervisor;(7-1-24)
vi.Case Manager;(7-1-24)
vii.Support Staff;(7-1-24)
viii. Direct Care Staff Supervisor;(7-1-24)
ix.Direct Care Staff;(7-1-24)
x.Teacher; and(7-1-24)
xi.Contractors and volunteers that have unsupervised time with children.(7-1-24)
d.Children's Therapeutic Outdoor Programs:(7-1-24)
i.Owners;(7-1-24)
ii.Chief Administrator;(7-1-24)
iii.Field Director;(7-1-24)
iv.Licensed Treatment Professional;(7-1-24)
v.Senior Field Staff;(7-1-24)
vi.Field Staff;(7-1-24)
vii.Intern;(7-1-24)
viii. Support Staff; and(7-1-24)
ix.Contractors and volunteers that have unsupervised time with children.(7-1-24)
- Exception to Clearance Requirement. Children's residential care facilities have discretion whether to require a clearance for any individual covered in Subsection 009.02 of this rule who has duties or performs tasks that do not involve contact with a child or their personal belongings.(7-1-24)
IDAPA 16.04.18.010 Definitions a Through M
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Chief Administrator. The duly authorized representative or designee of an organization responsible for day-to-day operations, management, and compliance with these rules and Title 39, Chapter 12, Idaho Code.(4-6-23)
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Child. Under Title 39, Chapter 12, Idaho Code, a “child” is an individual less than eighteen (18) years old, synonymous minor.(7-1-24)
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Child Care. The care, control, supervision, or maintenance of a child for twenty-four (24) hours a day provided as an alternative to parental care.(4-6-23)
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Children's Agency. A business for the placement of children in foster homes or for adoption and who does not provide child care as part of that business. A children's agency includes those providing home studies, post-placement supervision, post-finalization services, and other domestic and international adoptive services under Title 39, Chapter 1202(4), Idaho Code. A children's agency does not include an Idaho certified adoption specialist.
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Children's Camp. A program of child care at a location away from the child's home that is primarily recreational and includes the overnight accommodation of the child and is not intended to provide treatment, therapy, or rehabilitation for the child.(4-6-23)
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Children's Residential Care Facility. A children's institution as defined in Section 39-1202(6), Idaho Code, but excluding foster homes, children's therapeutic outdoor programs, accredited residential schools, and children's camps if the camps provide child care for less than nine (9) consecutive weeks in any one (1) year period.
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Children's Therapeutic Outdoor Program. A program that provides child care designed to provide behavioral, substance abuse, or mental health services to children in an outdoor setting. Also known as “outdoor program.”(4-6-23)
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Department. The Idaho Department of Health and Welfare, the Department Director, or designee.
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Direct Care Staff. An employee who has direct personal interaction with children in the supervision of child care.(4-6-23)
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Disrupted Placement. When a child is discharged by the organization based on the child's behaviors, or when a child is removed from an adoptive placement before the adoption is finalized.(4-6-23)
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Governmental Unit. The State of Idaho, any county, municipality, or other political subdivision, or any department, division, board, or other agency thereof.(4-6-23)
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Intercountry Adoption. The placement of a child from one (1) country to another for the purpose of adoption.(4-6-23)
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Mechanical Restraint. Devices used to restrict a person’s free movement.(4-6-23)
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Medical Professional. Person who received a degree in nursing or medicine and is licensed as a nurse, licensed nurse practitioner, physician's assistant, or medical doctor.(4-6-23)
IDAPA 16.04.18.011 Definitions N Through Z
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Nonaccredited Residential School. A residential school for any number of children that is not certified or accredited pursuant to Section 39-1207, Idaho Code, or has lost accreditation and is subject to the jurisdiction of the Department as a children's residential care facility pursuant to Section 39-1210, Idaho Code, unless and until accreditation is certified by the Idaho Department of Education.(4-6-23)
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Operator. An individual who operates or maintains within Idaho a children's residential care facility, children's agency, or outdoor program.(4-6-23)
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Organization. A children's agency, a children's residential care facility, or an outdoor program.
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Person. Any individual, association, partnership, corporation, or any group thereof.(4-6-23)
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Physical Restraint Intervention. Any intervention utilized to control the range and motion of an individual, including an escort, to assist a child in moving from one location to another.(4-6-23)
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Placement. The activities and arrangements related to finding a suitable home or facility for a child.(4-6-23)
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Plan of Correction. The detailed procedures developed between the Department and an organization required to bring the organization into compliance.(4-6-23)
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Residential School. A residential facility for children that provides services substantially comparable to those provided in nonresidential public schools where the primary purpose is the education and academic pursuits of the students. All additional provisions of Section 39-1202(23), Idaho Code, also apply in defining “Residential School”.(4-6-23)
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Seclusion. A room within a facility designed to temporarily isolate an individual to gain emotional or physical control by means of structure and minimal stimulation.(4-6-23)
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Staff-Child Ratio. The maximum number of children allowed under the care and supervision of one (1) staff.(4-6-23)
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Substance Abuse Treatment Facility. A licensed children’s residential care facility participating in the public Substance use Disorder (SUD) system specializing in providing programs of treatment for children whose primary problem is alcohol or drug abuse, under Section 39-302(5), Idaho Code. Private pay children's residential care facilities must utilize licensed professionals under Section 39-302(16), Idaho Code, to provide specialized treatment for children whose primary problem is alcohol or drug abuse.(4-6-23)
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Supervision. Monitoring a child based on their individual needs to provide for their safety and protection.(4-6-23)
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Support Staff. Any employee of an organization that provides food service, transportation service, maintenance service, housekeeping service, or administrative support.(7-1-24)
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Time-Out. Separation of a child from an activity as a means of behavior management. (4-6-23)
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Training. Instruction related to child care that increases knowledge, skill, and abilities. (4-6-23)
IDAPA 16.04.18.012 (Reserved)
LICENSING AND CERTIFICATION
Sections 100 – 199
IDAPA 16.04.18.100 Licensing
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Knowledge of Standards. The operator is responsible for knowing and always complying with the rules regulating the license. The operator is responsible for ensuring that staff are familiar with the rules governing their organization.(4-6-23)
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Voluntary Closure. The operator must notify the Department of any voluntary closure prior to the closure date.(4-6-23)
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Voluntary Withdrawal of License. The Department will withdraw the license of an organization that has not provided services in the last licensed year.(4-6-23)
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Operating Without a License. If children are found in an unlicensed organization, the Department will refer to law enforcement or Child Protective Services if it has been determined that an immediate threat to the children's health and safety exists;(4-6-23)
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Exceptions and Exemptions. Under Sections 39-1206 and 39-1211, Idaho Code, these rules do not apply to:(4-6-23)
a.The occasional or irregular care of a neighbor's, relative's or friend's child or children by a person not ordinarily engaged in child care; or(4-6-23)
b.Children's camps that only provide child care for any one (1) child for less than nine (9) consecutive weeks in any one (1) year period. A children's camp that provides child care for any one (1) child for more than nine (9) consecutive weeks in any one (1) year period constitutes a children's residential care facility and is subject to these rules. A children's camp that also constitutes a residential school must be governed as a residential school.(4-6-23)
IDAPA 16.04.18.101 Applications for License
A license application must be submitted to the Department using the Department-approved process and include applicant’s completed background clearance. All organizations must comply with applicable Idaho state, city, and county ordinances.(4-6-23)
IDAPA 16.04.18.102 Disposition of Applications
After receipt of a completed application that addresses each requirement for the organization, the Department will review the materials for compliance with these rules and will act on the application within thirty (30) days after receipt of the completed application.(4-6-23)
- Application Approval. A license will be issued to any organization in compliance with these rules.
The license is issued under the terms specified in the licensing survey and will be sent to the applicant.(4-6-23)
- License. A license will be issued to any organization in compliance with these rules and will specify the terms of licensure, such as:(4-6-23)
a.Capacity, age range, and gender;(4-6-23)
b.Specific services under the approved program description; and(4-6-23)
c.Effective up to twelve (12) months from the date of issuance unless suspended or revoked earlier.
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Variance. A license will be issued to an organization that has been approved for a variance through the Department-approved process, under Section 67-5230, Idaho Code. Variances must be approved annually.
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Provisional License. A provisional license may be issued to an organization when a licensing standard is not met but can be expected to be corrected within six (6) months of issuing the provisional license, provided this does not endanger the health, safety, and well-being of any child in care or who may come into care during the period of the provisional license. A provisional license will be issued according to Section 39-1216, Idaho Code.(7-1-24)
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Denial of Application. If an application is denied, notification will be sent to the applicant stating the basis for such denial.(4-6-23)
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Incomplete Application Process. Failure of the applicant to progress in the application process will result in a denial of the application.(7-1-24)
IDAPA 16.04.18.103 Restrictions on Applicability and Nontransfer
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Issued License. A license applies only to the organization and premises designated. Each license is issued in the name of the organization, or governmental unit identified on the application and only to an address of the organization stated in the application and approved program description for the period and services specified. Any change in terms, such as capacity, ages, or gender served, approved program description services, management, or address renders the license null and void.(4-6-23)
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Nontransferable. A license is nontransferable from one (1) individual to another, from one (1) business entity or governmental unit to another, or from one (1) location to another.(4-6-23)
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Change in Ownership, Operator, Terms, or Location. When these changes occur, the organization must submit a change application. The new owner or operator must obtain a license before starting operations.(4-6-23)
IDAPA 16.04.18.104 Mandatory Visitations
Under Section 39-1217, Idaho Code, the Department must visit and be given access to the premises of each organization as often as deemed necessary by the Department to assure compliance with these rules at intervals not to exceed twelve (12) months.(4-6-23)
IDAPA 16.04.18.105 License Renewal
Under Section 39-1215, Idaho Code, a renewal application must be submitted through a Department-approved process, no less than sixty (60) days before the expiration date of the license. When renewal applications are properly made, the existing license will, unless revoked, remain in force until the Department has completed an annual survey.
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Full Survey. An organization will receive a full survey upon initial licensure and annually thereafter.(4-6-23)
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Focused Survey. An organization may receive a focused annual survey if the organization meets the following:(4-6-23)
a.Has been licensed for three (3) consecutive years;(4-6-23)
b.Has received five (5) or fewer total deficiencies during the most recent annual survey and any midyear statement of deficiencies; and(4-6-23)
c.Has no criminal history, medication, child health record, dental, or repeat deficiencies in the last three (3) annual surveys or mid-year statement of deficiencies.(4-6-23)
IDAPA 16.04.18.106 Complaint Investigation
The Department will investigate complaints and has the discretion to decide which methods and tasks of investigation to employ. Onsite investigations can be unannounced and without prior notice.(7-1-24)
IDAPA 16.04.18.107 Suspension or Revocation for Infractions
A license may be suspended for a violation of these rules. Suspension may lead to revocation if the operator fails to satisfy the Department that the violation has been corrected to assure compliance.(4-6-23)
IDAPA 16.04.18.108 Nonrenewal, Denial, Revocation, or Suspension of License
If, upon investigation, it is found that an applicant or operator has failed or refused to comply with the provisions of the Child Care Licensing Reform Act, Title 39, Chapter 12, Idaho Code, or with these rules, or with any provision of the license, the Department may deny, suspend, revoke, or not renew a license. The Department may also deny, suspend, revoke, or deny renewal of a license for any organization when the following is determined:(7-1-24)
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Criminal Conviction or Relevant Record. Anyone providing direct care or working onsite under these rules is denied background clearance or refuses to comply with requirements in IDAPA 16.05.06, “Criminal History and Background Checks.”(4-6-23)
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Other Misconduct. The applicant, operator, or the chief administrator:(4-6-23)
a.Fails to furnish any data, statistics, records, or information requested by the Department without good cause or provides false information.(4-6-23)
b.Has been found guilty of, or is under investigation for, fraud, deceit, misrepresentation, or dishonesty with the operation of the organization.(4-6-23)
c.Has been found guilty of, or is under investigation for, the commission of any felony. (4-6-23)
d.Has knowingly permitted, aided, or abetted the commission of any illegal act.(4-6-23)
- Transfer of Children. May occur under the following circumstances:(4-6-23)
a.Any condition that endangers the health or safety of any resident or child.(4-6-23)
b.An organization is not in substantial compliance with, or has repeat violations of, these rules.
c.An organization has made little or no progress in correcting deficiencies within thirty (30) days from the date the Department accepted a plan of correction.(4-6-23)
d.An organization has knowingly misrepresented or omitted information on the application or other documents pertinent to obtaining a license.(4-6-23)
e.Refusal to allow Department full access to the organization’s grounds, facilities, and records.
f.An organization has violated the terms or conditions of a provisional license.(4-6-23)
IDAPA 16.04.18.109 Enforcement Remedy – Ban on Admissions
The Department may summarily ban admissions, in whole or in part, pending satisfactory correction of all deficiencies. Bans remain in effect until the Department determines that the organization has achieved compliance with all program requirements, or until a substitute remedy is imposed.(4-6-23)
IDAPA 16.04.18.110 Effect of Previous Revocation or Denial of a License
An organization cannot apply and the Department will not accept an application from any person, corporation, or partnership, including any owner with a ten percent (10%) or more interest, who has had a license denied or revoked, until five (5) years has elapsed from the date of denial, revocation, or conclusion of a final appeal, whichever occurred last.(4-6-23)
IDAPA 16.04.18.111 (Reserved)
CHILDREN'S AGENCIES, CHILDREN'S RESIDENTIAL CARE FACILITIES,
AND OUTDOOR PROGRAMS
Sections 200 – 299
IDAPA 16.04.18.200 General Standards for Organizations
These organizations must have policies and procedures addressing the licensing standards in Sections 200 - 299 of these rules.(4-6-23)
IDAPA 16.04.18.201 Access by Department-Authorized Agents
The Department must be provided access to the grounds, facilities, and records for determining compliance with applicable rules and investigation of complaints against the organization.(4-6-23)
IDAPA 16.04.18.202 Notification to the Department
An organization must notify the Department no later than the next business day of the following:(4-6-23)
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Change in Chief Administrator.(4-6-23)
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Employee Investigated for Child Abuse or Neglect.(4-6-23)
IDAPA 16.04.18.203 Notification
An organization must notify the Department by close of the next business day using the Department-approved process and immediately notify the parent, guardian, or placing children's agency for the following:(4-6-23)
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Fire. A fire that requires the services of a fire company or when children are relocated. (4-6-23)
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Hospitalized Child. Any illness, injury, or behavioral health crisis that requires admittance to a hospital.(4-6-23)
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Law Enforcement Authorities. When a child is detained, arrested, or charged by law enforcement authorities.(4-6-23)
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Suicide Attempt. A child’s attempt to commit suicide that requires an external emergency response or emergency room visit.(4-6-23)
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Missing or Runaway Child. When a child is missing or has eloped and is not within the child's supervision needs.(4-6-23)
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Death of a Child. If sudden death, or if the death occurs because of a crime or accident, the appropriate law enforcement agency must be contacted immediately.(4-6-23)
IDAPA 16.04.18.204 Registration
The organization must be registered with the Idaho Secretary of State.(4-6-23)
IDAPA 16.04.18.205 Organizational Chart
An organization must have an organizational chart identifying the job positions, individuals in each position, and the lines of authority within the organization.(4-6-23)
IDAPA 16.04.18.206 Insurance Coverage
An organization must maintain copies of current motor vehicle, comprehensive general liability, and professional liability insurance.(4-6-23)
IDAPA 16.04.18.207 Quality of Services
An organization must carry out its licensed programs in an environment that is safe, accessible, and appropriate for the needs of those served and with regard for the rights and protections of those persons receiving services. (4-6-23)
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Assess Compliance. The organization's administration must conduct and document a quality assurance review for compliance with these rules annually.(4-6-23)
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Corrective Action for Noncompliance. For each noncompliance, within thirty (30) days of notification by the Department, the organization must have developed and implemented a plan approved by the Department to correct each item within six (6) months.(4-6-23)
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Expeditious Correction. The Department may require a more expeditious correction when it determines there is a health and safety risk to children. The corrective action must be completed within twenty-four (24) hours of discovery of the noncompliance by the Department.(4-6-23)
IDAPA 16.04.18.208 Confidentiality and Privacy
An organization must have and follow processes governing access to, use of, and release of information about a person served that include the organization’s publicity, social media, research, and Health Insurance Portability and Accountability Act (HIPAA) practices.(4-6-23)
IDAPA 16.04.18.209 Program Description
An organization must have and follow a program description of the services and fees the organization charges including those provided by the organization or arranged through other sources. This information must be available to the public. The description must include criteria governing eligibility for service, age, specific characteristics, and treatment needs of children served, accommodation of cultural sensitivity, and the geographic area served. (4-6-23)
IDAPA 16.04.18.210 Sufficient Financial Resources
An organization must have sufficient financial resources to implement and deliver its programs. Initially and annually, organizations must develop and implement a financial plan to carry out its programs, to ensure that children receive safe and appropriate care and needed services, and to ensure licensing requirements are met.(4-6-23)
IDAPA 16.04.18.211 Human Resources Needed
An organization must:(4-6-23)
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Human Resources. Determine, organize, and deploy the human resources needed to provide services subject to these rules and to promote optimum outcomes for persons served.(4-6-23)
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Staff. Have an adequate number of qualified administrative staff, supervisor(s), case manager(s), direct care staff, and other staff to perform the prescribed functions required by these rules to provide for the needs, safety, protection, and supervision of children served.(4-6-23)
IDAPA 16.04.18.212 Chief Administrator Responsibilities
An organization must designate a person to function as the chief administrator to manage the organization including the overall day-to-day responsibilities. The chief administrator must adopt and implement lines of responsibility that ensure the proper and effective supervision and monitoring of employees and volunteers. There must be a written plan for the delegation of authority in the absence of the chief administrator.(4-6-23)
IDAPA 16.04.18.213 Chief Administrator Qualifications
- Qualifications. All organizations must employ a full-time chief administrator. At the time of appointment, the chief administrator must have two (2) years experience working with children and three (3) years experience in staff supervision and administration, and one (1) of the following:(4-6-23)
a.A Bachelor’s degree in a relevant discipline;(4-6-23)
b.The completion of a career development program which includes work related experience, training, or college credits that provide a level of achievement equivalent to the Bachelor's degree.(4-6-23)
- Outdoor Program. Additional Chief Administrator qualifications for an outdoor program are found in Section 502 of these rules.(4-6-23)
IDAPA 16.04.18.214 Case Manager Supervisor
The organization must employ a case manager supervisor when the organization employs eight (8) or more full-time case managers. A case manager supervisor is not allowed to supervise their own work and must not supervise more than eight (8) full-time case managers.(4-6-23)
IDAPA 16.04.18.215 Case Manager Supervisor Qualifications
A case manager supervisor must possess one (1) of the following:(4-6-23)
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Master's Degree. A Master's degree from an accredited college or university in a behavioral science or related field, and have demonstrated experience of not less than three (3) years working with families or children in a social service setting and two (2) years in staff supervision.(4-6-23)
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Bachelor's Degree. A Bachelor's degree from an accredited college or university in a behavioral science or related field, and have demonstrated experience of not less than four (4) years working with families or children in a social service setting and two (2) years in staff supervision.(4-6-23)
IDAPA 16.04.18.216 Case Manager
Except for nonaccredited residential schools, an organization must employ one (1) case manager who is not allowed to supervise their own work.(4-6-23)
IDAPA 16.04.18.217 Case Manager Qualifications
The organization must hire a case manager that possesses one (1) of the following:(4-6-23)
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Social Work Licensure. Licensed by the state of Idaho under Title 54, Chapter 32, Idaho Code, and IDAPA 24.14.01, “Rules of the State Board of Social Work Examiners.”(4-6-23)
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Bachelor’s Degree. A Bachelor's degree in a behavioral science, or a related field; and have the
a.For children's residential care facilities, the case manager must have at least one (1) year of fulltime work experience with children in a social service setting.(4-6-23)
b.For children’s agencies, the case manager must have at least one (1) year of full-time work experience in foster care or adoption services.(4-6-23)
- Five Years Full-Time Work Experience. Except for a children's agency, at least five (5) years of full-time work experience with children in a social service setting.(4-6-23)
IDAPA 16.04.18.218 Case Manager Responsibilities
- Children's Agencies.(4-6-23)
a.The responsibilities of a case manager employed or contracted by a children's agency to perform work within their scope that may include child assessment, service plan development, child placement, foster or adoptive home assessment, and supportive services for children and families.(4-6-23)
b.At the discretion of the supervisor, a case manager may be assigned a caseload of:(4-6-23)
i.Twenty (20) families with an adoption placement, or active child foster care; or(4-6-23)
ii.Forty (40) adoptive families being studied or awaiting an adoptive placement or foster home certification cases, or a proportionate combination of these families.(4-6-23)
- Children's Residential Care Facilities and Outdoor Programs.(4-6-23)
a.The responsibilities of a case manager employed or contracted by a children's residential care facility or outdoor program to perform work within their scope that may include assessment, writing the service plan, supervision, and support. The case manager must be available during normal business hours to provide onsite support.(4-6-23)
b.There must be at least one (1) case manager for every twenty (20) children.(4-6-23)
IDAPA 16.04.18.219 Staff Recruitment, Hiring, Supervision, Training, Evaluation, Promotion,
AND DISCIPLINE.
An organization must have processes governing recruitment, screening, hiring, supervision, training, evaluation, promotion, and discipline of employees and volunteers. An organization must employ persons and use volunteers who have an understanding and respect for children and their needs, the child's family and culture, are able to provide services to unrelated children and the problems they present, and are capable of performing activities related to their job. An organization must have the following:(4-6-23)
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Job Descriptions. Every position needs to identify and follow necessary qualifications, including education, experience, training, duties, and lines of authority. A designated employee of the organization must supervise a volunteer and be included in that individual's job description.(4-6-23)
-
Personnel Records. Every employee and volunteer needs a personnel record that contains the
a.Employment application or resume;(4-6-23)
b.Name, date of birth, current address, and phone number;(4-6-23)
c.Documents verifying education, certification, and license when the person fills a position requiring a minimum level of education, applicable certification, or license;(4-6-23)
d.Three (3) verified references from persons who are unrelated to the employee or volunteer. For a job applicant who has worked for an organization that provides care or services to children, one (1) of the references must be from a prior child care provider for whom the employee or volunteer worked;(4-6-23)
e.Verified documentation of a complete background check under IDAPA 16.05.06, “Criminal History and Background Checks”;(4-6-23)
f.Verification by the employee or volunteer of receipt of the organization's behavior management policy;(4-6-23)
g.Copy of the current job description, date they began their current job, and verification that the employee has been provided a copy of their current job description;(4-6-23)
h.The date the person was hired;(4-6-23)
i.For staff and volunteers who transport children, a copy of a valid driver's license. If they use their own vehicle to transport children, the record must include proof that the vehicle is properly insured.(4-6-23)
j.Performance evaluation within a probationary period and annual performance evaluations thereafter; and(4-6-23)
k.Documentation of any disciplinary actions.(4-6-23)
IDAPA 16.04.18.220 Orientation
An organization must document that each new employee, contractor, and volunteer participates in an orientation within the first week of employment that includes the following:(4-6-23)
-
Organization. The purpose of the organization.(4-6-23)
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Job Function. The policies and procedures of the organization as they relate to their job function.
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Job Responsibilities. The employee's, contractor's, or volunteer's role and responsibilities.
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Reporting Requirement for Child Abuse, Neglect, and Abandonment.(4-6-23)
IDAPA 16.04.18.221 Training
An organization must document that each new and current employee, volunteer, or contractor whose job function significantly changes, and whose primary role requires interaction with children, receive the following trainings before working independently. Volunteers and contractors who provide occasional services, or are always supervised, or both, are exempt from the training requirements:(4-6-23)
-
Specific Instruction in Job Responsibilities.(4-6-23)
-
Policies and Procedures.(4-6-23)
-
Child Safety.(4-6-23)
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CPR and First Aid. Employees, volunteers, and contractors who work independently with children need certification in cardiopulmonary resuscitation (CPR) and first aid appropriate to the age of the children served within ninety (90) days after employment and maintain the certification during their employment. (4-6-23)
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Job Shadowing. Employees are to receive job shadowing applicable to their daily responsibilities.
IDAPA 16.04.18.222 Initial and Annual Training
An organization must document that each new employee, volunteer, or contractor receive the following trainings prior to working independently and annually thereafter. Volunteers and contractors who provide occasional services or are always supervised, or both, are exempt from the training requirements:(4-6-23)
-
Child Abuse, Neglect, or Abandonment Identification.(4-6-23)
-
Emergency Procedures.(4-6-23)
-
Child Development Appropriate to Population Served.(4-6-23)
-
Cultural Sensitivity and Diversity.(4-6-23)
-
Behavior Management and Mental Health Issues Appropriate to Population Served. (4-6-23)
IDAPA 16.04.18.223 Permanent Register
The organization must maintain a permanent register of all children admitted into care that includes each child's full name, gender, date of birth, parents or guardian and their addresses, who placed the child, the date of placement, date of discharge, and to whom the child was discharged.(4-6-23)
IDAPA 16.04.18.224 Maintenance of Records
An organization must have and follow processes for the maintenance and security of records, that include: (4-6-23)
-
Record Storage. Ensuring electronic or hard copies of records are stored in a secure manner.
-
Record Confidentiality. Ensuring confidentiality and prevention of unauthorized access to records.(4-6-23)
-
Organization of Record. Requiring records be maintained in a uniform and organized manner.
-
Record Storage for Closed Organizations. Before an organization ceases operations, it must provide for the storage of all records mandated to be maintained by rules.(4-6-23)
IDAPA 16.04.18.225 Record Retention
All organization records must be maintained for at least five (5) years after the case is closed or services ended.
Except for home study only services, adoption agencies must permanently retain the records for an adopted child and adoptive parent.(4-6-23)
IDAPA 16.04.18.226 Icpc Compliance
Organizations must comply with the Interstate Compact on the Placement of Children (ICPC) on the state ICPC website: http://icpcstatepages.org.(4-6-23)
IDAPA 16.04.18.227 Reporting of Child Abuse, Neglect, and Abandonment
All suspected incidents of child abuse, neglect, or abandonment must be reported immediately to child protection services or law enforcement under Section 16-1605, Idaho Code. The chief administrator must ensure the safety and protection of children when the allegation is against an organization's staff, volunteer, or contractor. The chief administrator must initiate a thorough investigation of all reported incidents, submit an administrative summary of the investigation to the Department, and administer appropriate disciplinary action.(4-6-23)
IDAPA 16.04.18.228 Authorizations Required
Written authorization must be obtained from the parent, guardian, or court of jurisdiction to obtain and provide routine medical care, emergency medical and surgical care, and mental health care for the child.(4-6-23)
IDAPA 16.04.18.229 Health Services
The organization must assure appropriate health care is provided as follows:(4-6-23)
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Physical Exam. The organization will provide documentation of a physical exam within the last year by a licensed physician. If a child has not received a physical exam within the last year, it must be done within thirty (30) days of admission and annually thereafter. For a child under two (2) years old physical exams will be scheduled as determined by a licensed physician.(4-6-23)
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Immunizations. Documentation of current immunizations or exemptions for immunizations will be maintained according to Section 39-4802, Idaho Code, within thirty (30) days of admission.(4-6-23)
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Timely Medical Care. The organization will obtain or provide timely medical care for the treatment of injuries and illnesses, and will carry out corrective measures and treatment as ordered by the medical professional.(4-6-23)
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Required Documentation. Documentation will be maintained of all medical treatment provided, applicable medical insurance provider(s), policy numbers, and who holds the policy.(4-6-23)
IDAPA 16.04.18.230 Dental Services
Organizations must ensure and document the child has had a dental exam within the last nine (9) months or a dental exam within three (3) months of admission. An annual dental exam and necessary dental treatment, including prophylaxis, extraction, repair and restoration will be provided as ordered by the dentist. Dental care will be provided for a child under the age of three (3) when the child's dental needs indicate.(4-6-23)
IDAPA 16.04.18.231 Physical Restraint Intervention
An organization must have processes governing the appropriate use of physical restraint intervention strategies which follow a nationally recognized program. Physical restraint intervention strategies must:(4-6-23)
-
Protection. Be used only when a child's behavior could physically harm themselves or others, or to prevent the destruction of property, when the child fails to respond to nonphysical behavior management interventions.(4-6-23)
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Intervention Time Guidelines. Be used only until the child has regained control, not exceed fifteen (15) consecutive minutes, and include documentation of attempts made to release the child from the restraint.
-
Intervention Training Requirements. Be used only by employees or volunteers documented to have been specifically trained in its use and authorized to apply such strategies.(4-6-23)
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Conditions Limiting Restraint Use. Prohibit the application of a physical restraint intervention if a child has a documented physical condition that would contraindicate its use unless a medical professional has previously and specifically authorized its use in writing. Documentation will be maintained in the child's record.
-
Intervention Documentation. Require documentation of the behavior that required physical restraint intervention, the specific attempts to deescalate the situation before using physical restraint, the length of time the physical restraint was applied which includes documentation of the time started and completed, and the debriefing completed with the staff and child involved in the physical restraint.(4-6-23)
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Subsequent Review. Whenever physical intervention is used on a child more than two (2) times in one (1) week, require a review and appropriate action taken by the organization.(4-6-23)
IDAPA 16.04.18.232 Prohibited Restraints
The following restraints are prohibited:(4-6-23)
-
Mechanical, Chemical, and Alternative Forms.(4-6-23)
-
Transporting Children Using Restraints.(4-6-23)
-
Prone Restraints.(4-6-23)
IDAPA 16.04.18.233 Grievance Policy
An organization’s grievance policy must be in simple and clear language, require prompt investigation of the grievance by a person who can be objective, and provide at least one (1) level of appeal. The policy must be signed by the parent and guardian, if applicable, and the person receiving services. The policy will be shared in a manner appropriate to the person's age and their ability to understand, and requires monitoring to ensure there is no retaliation against the person who files a grievance.(4-6-23)
IDAPA 16.04.18.234 Suicide Prevention Plan
An organization must develop and follow a written suicide prevention plan that addresses the needs of the population the organization serves.(4-6-23)
IDAPA 16.04.18.235 Clothing
An organization must ensure each child has sufficient clean, properly fitting clothing, appropriate for the child's age, individual needs, program, and season.(4-6-23)
IDAPA 16.04.18.236 Education Policy
Except for an outdoor program, children of school age, under state law, must be enrolled in an appropriate school program within five (5) school days after a child’s placement or the organization must document why the child was unable to enroll.(4-6-23)
IDAPA 16.04.18.237 Personal Possessions, Allowance, and Money Policy
An organization must have and follow a personal possessions, allowance, and money policy that includes: (4-6-23)
-
Financial Accounting. Payment of, and accounting for, any allowance, social security benefits, and other financial benefits to a child.(4-6-23)
-
Child's Personal Possessions.(4-6-23)
a.Documented accounting for a child's personal possessions, clothing with which the child came into care, and items which were obtained while in care, and documented return of all inventoried items to the child, parent, or guardian at discharge, except illegal contraband and other items prohibited by the organization.(4-6-23)
b.At the time of inventory and when the items are returned, the organization must obtain the signature of the parent, guardian, or child who can understand the purpose of the inventory. In the event of a child’s elopement, clothing and other personal belongings must be secured until the child returns or other arrangements are made.
IDAPA 16.04.18.238 Emergency Policies
An organization must have emergency processes that ensure a caregiver has and follows the organization's procedures for the following emergencies:(4-6-23)
-
Fire.(4-6-23)
-
Natural Disaster.(4-6-23)
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Serious Accident or Injury.(4-6-23)
-
Medical.(4-6-23)
-
Missing Child.(4-6-23)
-
Power Outage.(4-6-23)
-
Bomb Threat.(4-6-23)
-
Severe Weather.(4-6-23)
-
Hostage Taking.(4-6-23)
-
Active Shooter.(4-6-23)
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Other Dangers Unique to the Location of an Organization.(4-6-23)
IDAPA 16.04.18.239 (Reserved)
CHILDREN'S AGENCY LICENSING FOSTER HOMES
Sections 300 – 350
IDAPA 16.04.18.300 Policies
A children's agency that licenses foster homes must have policies that comply with IDAPA 16.06.02, and may require that additional foster care rules be met if the agency deems appropriate.(7-1-25)
IDAPA 16.04.18.301 (Reserved)
IDAPA 16.04.18.304 Placement Agreement
The agency must use a placement agreement, signed by the foster parents and the agency before placing a child in a foster home, that identifies the responsibilities of the agency including supervision, support services for the foster family, and the responsibilities of the foster family. The foster family must be informed of and agree to follow the agency’s policies and procedures. An agency must review annually the agreement with the foster family and, when needed, develop a new agreement. The organization must provide the foster family with a copy of the signed current placement agreement and maintain a copy in the foster home record.(4-6-23)
IDAPA 16.04.18.305 Children's Agency Supervision of Child
An agency must develop a plan of supervisory visits with a child in foster care consistent with the child's service plan.
The child's record must contain documentation that the agency case manager personally visited the foster child at least once each month with at least one-half (1/2) of the visits occurring in the foster home. An agency may reduce the number of the agency's case manager visits with a child to once every ninety (90) days if there is documentation and justification in the service plan that a child's placement in a foster home is a long-term planned placement.
IDAPA 16.04.18.306 Complaint Investigation Process
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Initiation of Complaint Investigation. When a complaint is received that relates to possible foster parent noncompliance with IDAPA 16.06.02, an agency must initiate a complaint investigation as soon as is indicated, based on seriousness of the allegation received, and no later than seven (7) calendar days after receipt of the allegation.(7-1-25)
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Agency Report. Upon completion of the investigation, an agency must prepare a written report that includes:(4-6-23)
a.The specific allegations;(4-6-23)
b.Findings of fact, based on the investigation;(4-6-23)
c.Conclusions regarding noncompliance with IDAPA 16.06.02;(7-1-25)
d.Any changes in the agency’s decision regarding placement specifications, based on the investigation’s findings; and(4-6-23)
e.Recommendations regarding licensing action and any required corrective action.(4-6-23)
IDAPA 16.04.18.307 Records Management
An agency must maintain the following records:(4-6-23)
-
Foster Home Record Contents. All documents pertaining to licensing of the home, any complaint investigation reports, and placement agreements between a foster parent and the agency.(4-6-23)
-
Placement Record. A complete record identifying all children placed in the foster home and removed from the home, including:(4-6-23)
a.Full name, age, gender, and race of the child;(4-6-23)
b.Date of the placement;(4-6-23)
c.Date and reasons for a foster child's departure from the foster home; and(4-6-23)
d.Any corrective action plans.(4-6-23)
IDAPA 16.04.18.308 Content of Child's Record
At the time of a child's placement, the person admitting the child must document in the child's record their physical and emotional state at the time of placement. An organization must document the following at the time of placement, and if not available at the time of an emergency placement, then within seven (7) days:(4-6-23)
-
Child's Full Name.(4-6-23)
-
Date of Birth.(4-6-23)
-
Gender.(4-6-23)
-
Height, Weight, Hair and Eye Colors, Race, and Identifying Marks.(4-6-23)
-
Last Known Address and with Whom Child Lived.(4-6-23)
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Last School Attended. Include previous grade level, current grade level, and scholastic performance.(4-6-23)
-
Parental Information. Include full names, marital status, and addresses unless parental rights are terminated.(4-6-23)
-
Guardian's Name and Address.(4-6-23)
-
Date of Admission.(4-6-23)
-
Name of Who Placed Child.(4-6-23)
-
Nature of Child's Problems. Include the reason for being served.(4-6-23)
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Documentation of Authority to Accept and Care for Child.(4-6-23)
-
Child’s Evaluations. Include the child's physical, social, and emotional development, and any special problems and needs they have, including medical, surgical, and dental care needs.(4-6-23)
-
Reports. Include psychological tests, psychiatric examinations, and follow-up treatment if obtained.(4-6-23)
-
Communications. Include records of the child's contacts with their family.(4-6-23)
IDAPA 16.04.18.309 Service Plans
An organization must develop and follow a written service plan that includes the following:(4-6-23)
- Initial Service Plan. To be developed and recorded in the child's record within thirty (30) days after admission and must:(4-6-23)
a.Identify the needs of the child and family, provide goals, and a time frame to achieve the goals;
b.Establish and document criteria for discharge;(4-6-23)
c.Demonstrate the service plan was developed with participation of the child's parent, guardian, or legal custodian, and the child. A child may be excluded from participation in development of the service plan if they are under nine (9) years old or incapable of understanding the purpose of the planned services; and(4-6-23)
d.Identify the persons responsible for coordinating and implementing the child's and family's 02. Updated Service Plan. To be updated every ninety (90) days and:(4-6-23)
a.Document progress towards achieving the goals in the service plan; and(4-6-23)
b.Demonstrate the service plan was developed with participation of the child's parent, guardian, or legal custodian, and the child. A child may be excluded from participation in development of the service plan if they are under nine (9) years old or incapable of understanding the purpose of the planned services.(4-6-23)
IDAPA 16.04.18.310 Discharge Summary
A discharge summary must be written within seven (7) days of discharge that includes:(4-6-23)
-
Date of and Reason for Discharge.(4-6-23)
-
Physical, Emotional, Medical, and Educational Needs of Child.(4-6-23)
-
Recommendations for Treatment.(4-6-23)
-
Documentation of Disrupted Placements, Assessed Causes, and Any Corrections. (4-6-23)
311 – 350.(RESERVED)
CHILDREN'S AGENCIES PROVIDING ADOPTION SERVICES
Sections 351 – 399
IDAPA 16.04.18.351 Pre-Adoptive Home
A home that has an approved adoption home study in which a child is placed for the purpose of adoption is not subject to foster home rules.(4-6-23)
IDAPA 16.04.18.352 Adoption Services – Nonprofit Status
An agency must provide documentation that it is incorporated as a nonprofit corporation.(4-6-23)
IDAPA 16.04.18.353 Policies and Procedures
An agency must have and follow policies and procedures for the adoption services it provides or facilitates including services for children, birth parents, adoptive applicants and parents, post-placement services, and post-finalization
IDAPA 16.04.18.354 Children Awaiting Adoptive Placement
For children under the supervision of the agency awaiting adoptive placement in a licensed foster home, there must be a documented review every month for an infant one (1) year old or younger, and every three (3) months for a child over one (1) year old, to determine actions necessary to locate an adoptive placement for the child.(4-6-23)
IDAPA 16.04.18.355 Services for Child's Birth Parents
An agency that accepts custody of a child from a birth parent(s) must provide services for the parent(s) either directly or through cooperative arrangements. The agency must ensure that the legal rights of the birth parent(s) are protected including checking the putative father registry and release of records, under Title 16, Chapter 15, Idaho Code, and Title 16, Chapter 20, Idaho Code, “Termination of Parental Rights and Adoptions.” The agency will respect the expressed desires of either or both birth parents to provide for continuity of identity of the child's religious, cultural, racial, linguistic, and ethnic background, provided the desired request does not deny or delay placement for adoption under the Multi-ethnic Placement Act (MEPA), P.L. 103-382 and P.L. 104-188, 42 USC, Section 622, and provided such considerations are legal.(4-6-23)
IDAPA 16.04.18.356 Financial Assistance to Birth Parent
Under Section 18-1511, Idaho Code, documentation of financial assistance to the birth parent is maintained in the file.(4-6-23)
IDAPA 16.04.18.357 Services for Adoptive Applicants
An agency must provide the following to its adoptive applicants:(4-6-23)
-
Suitability Criteria. Information about specific criteria by which the agency determines suitability as adoptive parents and areas the agency assesses to determine the ability of the adoptive applicants to meet the needs of an adopted child.(4-6-23)
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Selections and Services for a Specific Child. Procedures for selection of adoptive applicants to meet the needs of a specific child and, where indicated, assistance in obtaining resources and services to meet the continuing needs of the child.(4-6-23)
-
Legal Assessment. Procedures for assuring that a child placed is legally free for adoption, or an explanation that the placement is a legal-risk placement and any efforts made to free the child for adoption. (4-6-23)
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Preparation for Placement. Procedures for preparing an applicant for parenting and placement of a child.(4-6-23)
-
Counseling. Offer or arrange counseling for prospective adoptive parents including assistance in understanding a child's religion, culture, ethnic, or linguistic background and the impact of leaving familiar ties and surroundings, including attachment issues and living in an institution, as appropriate to the age of the child. (4-6-23)
-
Termination of Services. Procedures for termination of services for an applicant found to be unsuited for adoptive parenthood or for an applicant found suited to adopt but for whom a child cannot be found.
-
Financial. Provide a clear delineation of fees, charges, and other considerations for adoption services that include:(4-6-23)
a.Specific charges for expenses and services provided within the agency;(4-6-23)
b.Chronological itemization of fees for expenses and services provided by other identified sources;
c.Identification of the charges that are refundable and nonrefundable; and (4-6-23)
d.The manner and timing of payments.(4-6-23)
IDAPA 16.04.18.358 Payment Limitations in Adoption
An agency must prohibit the actual or promised payment or other material consideration to any party directly or indirectly involved in the administration of an adoption service, whether acting as an employee or independent contractor, except for the performance of routine professional duties necessary to complete the adoption process.
IDAPA 16.04.18.359 Prohibition of Contributions in Adoptions
An agency must not accept contributions from adoptive applicants or from persons acting on the applicant's behalf during the period of application or before an adoption has been finalized, nor accept a commitment to make a contribution after an adoptive placement.(4-6-23)
IDAPA 16.04.18.360 Prohibition of Staff Home Study
An agency must not do an adoption home study for its own staff, board member, or person with whom the agency contracts to provide services for the agency.(4-6-23)
IDAPA 16.04.18.361 Out-of-State Home Study
An agency may accept a home study from another out-of-state agency, with the following conditions:(4-6-23)
-
Out-of-State Approval. The out-of-state agency or individual is licensed or approved by a court in their state to provide adoptive home studies.(4-6-23)
-
Verification. The Idaho agency verifies licensure by receipt of a copy of the license or court approval.(4-6-23)
-
Agreement. There is a documented agreement of the terms of services between agencies. (4-6-23)
-
Documented Review of Home Study. The Idaho agency must document a review of the home study.(4-6-23)
IDAPA 16.04.18.362 Family Home Study, Application Process, and Content
An agency must complete or obtain a home study and application before approving the home for the placement of a child.(4-6-23)
- Required Information. The home study must meet the requirements outlined in IDAPA 16.06.01 and include the following:(7-1-25)
a.When there is a change in persons residing in the home, the applicant must notify the agency of the change by the next working day, and the new adult member must complete a background check;(4-6-23)
b.Social Security Number;(4-6-23)
c.Description of individuals and family dynamics with each member of the household;(4-6-23)
d.Documentation of any current or past family problems, including mental illness, substance abuse, addiction, and medical conditions;(4-6-23)
e.Special needs of the applicant's children and a description of how they will adjust to a new member of the household;(4-6-23)
f.Demonstrated understanding of the care that must be provided to the children served by the agency or express a willingness to learn how to provide that care;(4-6-23)
g.The applicant has adequate time to provide care and supervision for children;(4-6-23)
h.Demonstration of a home life that gives children the emotional stability they need. No marital or personal problems may exist within the family that would result in undue emotional strain in the home or be harmful to the interest of children placed in the home;(4-6-23)
i.Applicant's experience with other support agencies or resources in their communities and their comfort level in seeking help from services outside the family;(4-6-23)
j.Applicant's awareness of the potential for the child to have identity issues and loss regarding separation from birth parents;(4-6-23)
k.Applicant's ability to accept a child's background and help the child cope with their past; (4-6-23)
l.Applicant’s understanding that the child will have questions about birth parents and other relatives; and(7-1-25)
m.How the household will fulfill their transportation needs.(4-6-23)
-
Pre-Adoptive Parent to Inform Agency of Changes. The pre-adoptive parent is responsible to keep the agency that completed the home study informed of changes in the family's circumstances, or of any subsequent decision against adoption.(4-6-23)
-
Adoptive Placement Agreement. A home study is valid for the purposes of new adoptive placement for a period of one (1) year following the date of completion. Upon completion of an adoptive placement agreement, a home study remains valid for a period of two (2) years from the home study date of completion for the purpose of finalizing the adoption of the child(ren) for whom the adoptive placement agreement was written.
IDAPA 16.04.18.363 Safety Requirements
The property, structure, premises, and furnishings of an adoptive home must be constructed and maintained in good repair, in a clean condition, free from safety hazards and dangerous machinery and equipment. Areas and equipment that present a hazard to children must not be accessible by children. The safety requirements must be consistent with IDAPA 16.06.02, and may require that additional safety rules be met if the agency deems appropriate.(7-1-25)
IDAPA 16.04.18.364 (Reserved)
IDAPA 16.04.18.372 Trainings for Adoptive Applicants
The agency must provide or arrange the following training specific to the needs of the adoptive child and family, and maintain training records:(4-6-23)
-
Orientation. Orientation describes the agency’s adoption process and procedures, the availability of children for adoption, explains policies and procedures regarding adoptive placement, the kinds of children available, and the nature of the home study.(4-6-23)
-
Initial Training. Each applicant will complete not less than ten (10) hours of training prior to the placement of a child.(4-6-23)
-
Specific Training. The agency will provide or arrange specific training related to the culture and race of the child who is of a different culture or race from the adoptive parents.(4-6-23)
IDAPA 16.04.18.373 Services for Adoptive Parents
An agency must provide or arrange for the following services to adoptive parents served by the agency: (4-6-23)
-
Disclosure of Non-Identifying Child Information. Disclosure of all non-identifying information known to the agency about the child, the child's birth parents, and the circumstances leading to the decision to place for adoption.(4-6-23)
-
Post-Placement Services. Post-placement services related to support for the family and supervision of the placement.(4-6-23)
-
Provision of Resources. Provision of resources, or for the arrangement thereof, to ensure a safe, stable, and suitable placement for the child and the family, including information regarding the federal adoption assistance program.(4-6-23)
-
Adoption Finalization Assistance.(4-6-23)
a.Help in finalizing the legal adoption. The agency must obtain a copy of the final order of adoption.
b.Upon request, the agency, either directly or by referral to a resource, will assist the family with any identified problems associated with the adoption.(4-6-23)
IDAPA 16.04.18.374 Selection of an Adoptive Placement
An agency must consider the following factors in selecting adoptive parents for a child:(4-6-23)
-
Child's Needs. The physical, emotional, medical, and educational needs.(4-6-23)
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Continued Contact. The child's needs for continued contact with the birth parent(s) and other persons significant to the child.(4-6-23)
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Racial, Ethnic, and Cultural Considerations. Under the Multiethnic Placement Act (MEPA), P.L. 103-382 and P.L. 104-188, 42 USC, Section 622, the child's racial, ethnic, cultural identity, heritage, and background may only be considered if a written assessment indicates that such consideration is in the best interest of the child.(4-6-23)
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Authorized Placement on Approved Recommendations. The agency must require authorization by a chief administrator or case manager supervisor after the recommendations of approval are given by a case manager. The approval or denial must be documented in the case record.(4-6-23)
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Placement. An agency will place a child with agency-approved adoptive parents consistent with the recommendations specified in the home study and the needs of the child.(4-6-23)
IDAPA 16.04.18.375 Adoptive Child Information
An agency must provide adoptive parents with the following before the placement of a child:(4-6-23)
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Name. Child's name as permitted by law or disclosure agreement.(4-6-23)
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Date, Time, and Location of Birth. For children, up to two (2) years old, include the hospital, city, state, and country of birth.(4-6-23)
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Racial, Ethnic, and Religious Considerations.(4-6-23)
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Medical Records. Include physical and mental health records and special needs.(4-6-23)
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Family of Origin. Description of the child's family of origin, including age and gender of each family member, their relationship to the child, medical and mental health history, and social and education history of each member of the family.(4-6-23)
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Circumstances of the Placement. Description of the circumstances necessitating placement.
-
Preparation for Placement. Child's preparation for placement and attitude towards adoption.
-
Other Information. Any other information to enable the adoptive parent to provide a stable, safe, and healthy environment for the child.(4-6-23)
IDAPA 16.04.18.376 Post-Placement
An agency case manager must provide post-placement supervision to the adoptive family at the family's home at least thirty (30) days post-placement, then once every three (3) months before the final order of adoption. Supervisory reports must include:(4-6-23)
-
Documentation of Adjustment. Assessment and documentation of the child's and adoptive family's adjustment and, where indicated, plans to assist the child and family. This includes physical, emotional, medical, and educational needs of the child.(4-6-23)
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Medical Care Documentation. All medical care received during the supervisory period. (4-6-23)
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Assessment Results. Informing the adoptive parents of the results of the agency's assessment of the placement at the conclusion of each supervisory contact.(4-6-23)
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Disrupted Placement. Documentation of disrupted placements, assessed causes, and any corrections.(4-6-23)
IDAPA 16.04.18.377 (Reserved)
IDAPA 16.04.18.381 Intercountry Adoption Services
An agency providing intercountry adoption services must include in its program description of intercountry adoptive placement services that it provides services either directly or through collaboration with other agencies or individuals with proper credentials. When an adoption agency provides intercountry adoption services for a Hague accredited agency, they will have an Exempt Provider Agreement and copy of the agency's license or Hague accreditation.
IDAPA 16.04.18.382 Legal Requirements
A children's agency that arranges an intercountry adoption must:(4-6-23)
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Agreement. Maintain a file and provide for review to prospective adoptive families an Englishtranslated copy of any agreement that exists between a foreign government and the agency.(4-6-23)
-
Adoptive Home Standards. Receive an approval letter from United States Citizenship and Immigration Services (USCIS).(4-6-23)
-
United States Placement. Follow USCIS procedures to ensure that the child is or will be authorized to enter and reside permanently in the United States.(4-6-23)
-
Citizenship. Inform families about how to obtain citizenship for a foreign-born adopted child.
-
Child's Legal Status. Acquire documentation that, at referral, the child is legally free for intercountry adoption.(4-6-23)
IDAPA 16.04.18.383 (Reserved)
CHILDREN'S RESIDENTIAL CARE FACILITIES AND OUTDOOR PROGRAM
Sections 400 – 407
IDAPA 16.04.18.400 Intake Policy
An organization must have and follow an intake policy that sets the criteria for admitting children for care or services and keeps with the organization's purpose and services provided. Except for an emergency placement, the intake policy must include a requirement that sufficient information on each child admitted for care or services is obtained to determine that the child can be appropriately served by the organization. An emergency placement policy requires that the information needed to determine the appropriateness of continuing the placement or services is obtained within seven (7) days admission of placement.(4-6-23)
IDAPA 16.04.18.401 Content of Child's Record
Except for nonaccredited residential schools at the time of a child's placement, the person admitting the child must document in the child's record the child's physical and emotional state. At the time of placement, and if not available at the time of an emergency placement then within seven (7) days, an organization must document complete biographical and identifying information on each child admitted into care. The record must contain the following:
-
Child's Full Name.(4-6-23)
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Date of Birth.(4-6-23)
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Gender.(4-6-23)
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Height, Weight, Hair and Eye Colors, Race, and Identifying Marks.(4-6-23)
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Last Known Address and with Whom Child Lived.(4-6-23)
-
Last School Attended. Previous grade level, current grade level, and scholastic performance.
-
Parental Information. Full names, marital status, and addresses unless parental rights are terminated.(4-6-23)
-
Guardian's Name and Address.(4-6-23)
-
Date of Admission.(4-6-23)
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Name of Who Placed Child.(4-6-23)
-
Child's Primary Diagnosis.(4-6-23)
-
Nature of Child's Problems. Reason for being served.(4-6-23)
-
Documentation of Authority to Accept and Care for Child.(4-6-23)
-
Child's Evaluations. Child's physical, social, and emotional development, and any special problems and needs they have, including medical, surgical, and dental care needs.(4-6-23)
-
Medications. List of all medications the child is taking at time of admission.(4-6-23)
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Reports. Psychological tests, psychiatric examinations, and follow-up treatment if obtained.
IDAPA 16.04.18.402 Visitation Policy
An organization must have and follow a visitation policy that includes the following:(4-6-23)
-
Encourage Visits. The policy will encourage visits between a child and family members and others significant to the child except when visitation is contraindicated and is documented in the child's record. (4-6-23)
-
Visitation Log. The policy will maintain a visitation log for each child in residential care which includes the name of the person visiting and the date and time of the visit.(4-6-23)
IDAPA 16.04.18.403 Correspondence Policy
An organization must have and follow a correspondence policy. The organization will keep records of the child’s contacts with their family. The policy will specify the conditions under which the organization restricts the receipt of correspondence to or from a child and requires that the child and parent or guardian be informed of the restriction, the reason for the restriction, and that the restriction is documented in the child's record. The policy must prohibit staff from reading children's correspondence except where there is a legitimate documented reason to do so. When staff read a child's correspondence, the child must be present. Packages may be inspected.(4-6-23)
IDAPA 16.04.18.404 Religious and Cultural Policy
An organization must have and follow a policy regarding religious participation, religious training, cultural heritage, and cultural practices of children. Upon placement of any child, the child's parents or guardians will receive a copy of this policy and acknowledge receipt with their signature and date.(4-6-23)
IDAPA 16.04.18.405 Pregnant Minor
-
Pregnant Minor Protection. A pregnant minor may not sign a statement committing to any definitive plan prior to the birth of her child and must not be subject to coercion to release her child before or after the birth of her child.(4-6-23)
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Obstetrical Exam. An obstetrical exam is required and to be completed within ten (10) days of entering care.(4-6-23)
-
Licensed Hospital Delivery. Infant delivery must be in a hospital licensed by the state of Idaho; and(4-6-23)
-
Prenatal and Postnatal Care. A pregnant minor must be provided educational information on prenatal and postnatal care as appropriate.(4-6-23)
IDAPA 16.04.18.406 Continued Care
Continued care is authorized under the Idaho Child Care Licensing Reform Act Sections 39-1202 and 39-1213, Idaho Code, for individuals eighteen (18) to twenty-one (21) years old. Individuals who are in the care of a licensed residential care facility prior to turning eighteen (18) years old may remain in the program for up to ninety (90) days after their eighteenth birthday, or up to the age of twenty-one (21) if necessary to complete a treatment program or school educational program currently attended by the individual.(4-6-23)
IDAPA 16.04.18.407 Documentation Requirements for Continued Care
Prior to accepting an individual into continued care the following is required:(4-6-23)
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Voluntary Agreement. A voluntary agreement to remain in the program signed by the person turning eighteen (18), or a copy of a court order authorizing continued placement after the individual's eighteenth birthday.(4-6-23)
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Assessment for Others’ Safety. An assessment to assure that an individual does not jeopardize the health, safety, and well-being of the children in care of the organization.(4-6-23)
-
Additional Continued Care Plans. A plan that prohibits individuals from sharing a bedroom or other sleeping rooms with a child.(4-6-23)
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Documentation of Care Prior to Eighteenth Birthday. Documentation verifying the individual was in the care of the organization prior to their eighteenth birthday.(4-6-23)
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Documentation of Need for Continued Care. Documentation verifying the individual needs to remain to complete treatment, education, or other similar needs.(4-6-23)
CHILDREN'S RESIDENTIAL CARE FACILITIES
Sections 408 – 465
IDAPA 16.04.18.408 Direct Care Staff Supervisor Qualifications
A direct care staff supervisor, at the time of appointment, must possess one (1) of the following:(4-6-23)
-
Bachelor's Degree. A Bachelor's degree from an accredited college and one (1) year of full-time experience in a children's residential care facility.(4-6-23)
-
Associate's Degree. An Associate's degree or a minimum of forty-eight (48) credit hours from an accredited college and two (2) years of full-time experience in a children's residential care facility.(4-6-23)
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Experience. A high school diploma or equivalent and three (3) years of full-time experience in a children's residential care facility.(4-6-23)
IDAPA 16.04.18.409 Direct Care Staff Qualifications
Direct care staff must be at least nineteen (19) years old at the time of appointment and possess a high school diploma or equivalent.(4-6-23)
IDAPA 16.04.18.410 Required Staff Ratios
Except for nonaccredited residential schools, there must be staff ratio policies with the following requirements:
-
Supervisor-Staff Ratio. At least one (1) direct care staff supervisor for every twenty (20) direct care staff or less.(4-6-23)
-
Staff-Child Ratio - Daytime. One (1) direct care staff to every eight (8) children when children are awake and present, unless the presenting problems of the children are such that a ratio of one (1) to eight (8) is not sufficient to provide for the safety and treatment needs. In that case, the ratio of direct care staff to children must be increased to ensure the safety and treatment needs are met.(4-6-23)
-
Staff-Child Ratio - Sleeping Hours. One (1) awake direct care staff to twenty (20) children or less during the children's normal sleeping hours. Each individual building that houses the children's sleeping rooms must meet this ratio. If the presenting problems of the children are such that a ratio of one (1) to twenty (20) is not sufficient to provide for the safety and treatment needs, then the ratio of direct care staff to children must be increased to ensure the safety and treatment needs are met.(4-6-23)
-
Medical Emergency. One (1) staff on duty who is certified to provide cardiopulmonary resuscitation (CPR) and first aid for the age of the children.(4-6-23)
-
Emergency Staff Access. When only one (1) direct care worker is on duty, an additional staff will be available within ten (10) minutes or if assistance from first responders is available within ten (10) minutes, an additional staff will be available within thirty (30) minutes to assist with an emergency.(4-6-23)
IDAPA 16.04.18.411 Service Plans
Except for nonaccredited residential schools, an organization must develop and follow written service plans for a child admitted into care.(4-6-23)
- Initial Service Plan. Must be developed and recorded in the child's record within thirty (30) days after admission with the following:(4-6-23)
a.Identify the needs of the child and family, and provide goals and a time frame to achieve the goals;
b.Services the organization will provide to assure the safety, health, permanency, and well-being of the child;(4-6-23)
c.Criteria for discharge and projected discharge date;(4-6-23)
d.Demonstrate the service plan was developed with participation of the child's parent, guardian, or legal custodian, and the child. A child may be excluded from participation if they are under nine (9) years old or incapable of understanding the purpose of the planned services; and(4-6-23)
e.Identify the persons responsible for coordinating and implementing the child's and family's 02. Updated Service Plan. Must be updated every ninety (90) days and:(4-6-23)
a.Document services the organization will provide to assure the safety, health, permanency, and wellbeing of the child;(4-6-23)
b.Document progress towards achieving the goals in the service plan;(4-6-23)
c.Demonstrate the service plan was developed with participation of the child's parent, guardian, or legal custodian, and the child. A child may be excluded from participation if they are under nine (9) years old or incapable of understanding the purpose of the planned services.(4-6-23)
- Placements Less Than Thirty Days. A service plan for placements less than thirty (30) days must document the following upon admission:(4-6-23)
a.The immediate needs of the child; and(4-6-23)
b.Services the organization will provide to assure the safety, health, and well-being of the child.
IDAPA 16.04.18.412 Discharge Summary
Except for nonaccredited residential schools, a discharge summary must be written within seven (7) days of discharge and must include:(4-6-23)
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Date of and Reason for Discharge.(4-6-23)
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Physical, Emotional, Medical, and Educational Needs of Child.(4-6-23)
-
Recommendations for Treatment.(4-6-23)
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Documentation of Disrupted Placements, Assessed Causes, and Any Corrections. (4-6-23)
IDAPA 16.04.18.413 Compliance with Applicable Laws
An organization must comply with the applicable Idaho state and local zoning, fire, health, construction laws, ordinances, and regulations. The applicant must complete the following at the time of initial application: (4-6-23)
-
Sanitation Inspection. Obtain a sanitation inspection and report from the applicable Public Health District;(4-6-23)
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Fire Inspection. Obtain a fire safety inspection and report from the office of the Idaho State Fire Marshall, or local fire department;(4-6-23)
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Corrective Action and Fees. Correct all deficiencies noted in the sanitation and fire reports.
Document that the applicant has passed the inspections and paid any outstanding fees; and(4-6-23)
- Building, Planning and Zoning. Provide documentation demonstrating the facility meets the planning and zoning requirements of the applicable local laws, ordinances, and regulations and is in compliance with IDAPA 24.39.30, “Rules of Building Safety (Building Code Rules).”(4-6-23)
IDAPA 16.04.18.414 Building Requirements
An organization must meet the following:(4-6-23)
-
Access to Community Resources. Have access to school facilities, hospitals, recreational, and other community resources.(4-6-23)
-
Occupancy Restrictions. House only the number of persons for which it is rated, given its type of construction and size.(4-6-23)
-
Location Restrictions. Not be located within three hundred (300) feet of an aboveground storage tank containing flammable liquids or gases used in connection with a bulk plant, marine terminal, aircraft refueling, or bottling plant of a liquefied gas installation, or similar hazard.(4-6-23)
IDAPA 16.04.18.415 National Electrical Code Compliance
A building used to house children must comply with the National Electrical Code under IDAPA 24.39.10, “Rules of the Idaho Electrical Board.”(4-6-23)
IDAPA 16.04.18.416 Fire Safety Requirements
A building that houses children must be inspected by a state certified fire inspector before being occupied and on an annual basis thereafter for compliance with the applicable International Fire Code, under Section 41-253, Idaho Code. A copy of the inspection must be maintained at the facility with the following requirements:(4-6-23)
-
Fire Extinguishers. Each building used to house children is to have a minimum of one (1) 2-A- 10BC extinguisher per floor, and if there is a kitchen on the floor, a fire extinguisher is to be in or immediately adjacent to the kitchen. Each fire extinguisher is to be inspected annually by a fire extinguisher service agency.
-
Smoke Detectors. There must be one (1) smoke detector on each floor of the facility, approved by a nationally recognized testing laboratory, and installed and maintained as recommended by the manufacturer. Fire alarm systems, fire suppression/sprinkler systems, and kitchen hoods must be maintained as required by the stateadopted International Fire Code and inspected annually.(4-6-23)
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Carbon Monoxide Detector. There must be one (1) carbon monoxide detector on each floor of the facility that is approved by a nationally recognized testing laboratory and installed and maintained as recommended by the manufacturer. A facility that does not have equipment that produces carbon monoxide or does not have an attached garage is exempt from this requirement.(4-6-23)
IDAPA 16.04.18.417 Emergency Procedures
An organization must have and follow policies and procedures governing the handling of emergencies which include evacuation plans, telephone numbers for contacting ambulances, medical personnel, fire departments, hospitals, poison control centers, police, location and use of first aid kits, and roster with telephone numbers of staff to be contacted, and other emergency services as appropriate.(4-6-23)
IDAPA 16.04.18.418 Fire Drills
Fire drills must be conducted and recorded monthly, with each work shift participating in a drill once every three (3) months. Emergency evacuation routes must be posted in conspicuous locations on each floor of a building housing children. Where a fire alarm system is provided, evacuation drills must be initiated by activating the fire alarm system.(4-6-23)
IDAPA 16.04.18.419 Record Keeping
Records must be maintained of required fire drills and include the following:(4-6-23)
-
Identity of Person Conducting the Drill.(4-6-23)
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Date and Time of Drill.(4-6-23)
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Notification Method Used.(4-6-23)
-
Staff Members on Duty and Participating.(4-6-23)
-
Number of Occupants Evacuated.(4-6-23)
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Problems Encountered.(4-6-23)
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Weather Conditions During Evacuation.(4-6-23)
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Time Required to Complete Evacuation.(4-6-23)
IDAPA 16.04.18.420 Public Health District Inspection
The facility must provide documentation of an initial and annual inspection and approval by the applicable Public Health District before a license will be issued:(4-6-23)
-
Inspection Copy. A copy of the inspection must be maintained.(4-6-23)
-
Food Permit. A copy of the food permit must be posted. The facility must comply with IDAPA 16.02.19, “Idaho Food Code.”(4-6-23)
IDAPA 16.04.18.421 Drinking Water Systems
The facility must comply with IDAPA 58.01.08, “Idaho Rules for Public Drinking Water Systems.”(4-6-23)
IDAPA 16.04.18.422 Insect and Rodent Control
The facility must effectively prevent insects, rodents, and other pests from entering or infesting the facility. (4-6-23)
IDAPA 16.04.18.423 Buildings, Grounds, Furnishings, and Equipment
Buildings used to house children must be furnished with comfortable furniture, in good repair and appropriate to the age, size, and capabilities of the children. When an organization uses video monitoring systems, they must assure privacy of the children.(4-6-23)
IDAPA 16.04.18.424 Maintenance
Buildings, grounds, furnishings, and equipment must be kept clean, free of clutter, and in good repair.(4-6-23)
IDAPA 16.04.18.425 Equipment Storage
All facility cleaning equipment must be stored separate from the kitchen, from food preparation, service, and storage areas. Kitchen and bathroom sinks must not be used for cleaning mops, emptying mop buckets, or for any other purpose not connected with food preparation, or personal hygiene.(4-6-23)
IDAPA 16.04.18.426 Service Sink
A building housing more than twelve (12) persons must have a service sink used for general maintenance purposes such as floor mopping and not used for food preparation, dishwashing, or personal hygiene.(4-6-23)
IDAPA 16.04.18.427 Building’s Hazardous Materials or Toxins
Buildings used to house children must be free from hazardous materials and toxins. The organization must provide and maintain the following:(4-6-23)
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Radon Gas. Upon initial licensing, provide documentation of testing for radon gas. Buildings constructed prior to 1990 must provide documentation of asbestos or lead paint testing.(4-6-23)
-
Hazardous Material. Maintain documentation at the facility confirming any hazardous material or toxin have been removed or do not pose a threat to the children served. Hazardous materials and toxins are not limited to lead paint, asbestos, and radon.(4-6-23)
IDAPA 16.04.18.428 Lighting
All rooms used by children must be appropriately lighted for safety and comfort.(4-6-23)
IDAPA 16.04.18.429 Heating
Heating and ventilation equipment must be properly installed, inspected annually, and kept in good repair. Portable fuel burning and wood-burning heating appliances are prohibited. Portable electric heaters must not be used in sleeping rooms. Local fire officials must approve portable heaters used in other areas.(4-6-23)
IDAPA 16.04.18.430 Bathroom Facilities
A building used to house children must have adequate, clean, and easily accessible bathroom facilities and the following ratios are required:(4-6-23)
-
Toilets. One (1) per every ten (10) individuals.(4-6-23)
-
Bathtub or Shower. One (1) for every eight (8) individuals.(4-6-23)
-
Sink. One (1) for every ten (10) individuals, unless IDAPA 24.39.30, “Rules of Building Safety (Building Code Rules),” requires more for the type of building and its use.(4-6-23)
-
Multi-Stall Bathrooms. There must be separate use of bathroom facilities for boys and girls over six (6) years old. Staff must not use a multi-stall bathroom when children are present in the bathroom.(4-6-23)
IDAPA 16.04.18.431 Sleeping Rooms
Sleeping rooms in a building used to house children must meet the following:(4-6-23)
- Size. Space requirements are as follows:(4-6-23)
a.Seventy (70) square feet in a single occupancy room, exclusive of closet space.(4-6-23)
b.Forty-five (45) square feet per occupant in a multiple occupancy room, exclusive of closet space.
c.Existing multiple occupancy sleeping rooms may be approved relative to square feet per occupant until the room is remodeled or the building is extensively remodeled.(4-6-23)
d.Three (3) feet between the sides of beds when situated side by side, and two (2) feet at the end of the beds, when situated end to end. Beds may be placed against a wall.(4-6-23)
- Window Space. There must be sufficient window space for adequate natural light and ventilation.
Emergency egress or rescue windows must comply with IDAPA 24.39.30, “Rules of Building Safety (Building Code Rules).”(4-6-23)
- Restrictions. A child over the age of one (1) cannot share a sleeping room with an adult. A sleeping room must not be in a stairway, hallway, unfinished attic, unfinished basement, or in a separate building apart from staff supervision. There must be separate rooms for male and female children. Except for adult restrictions, sleeping room arrangements may be determined by the facility’s professionals to best meet the needs of the children.
Sleeping rooms must be near adult supervision.(4-6-23)
IDAPA 16.04.18.432 Beds
Each child must have their own bed that has substantial support, and is age and size appropriate. Each bed must have a comfortable, clean mattress that complies with the Consumer Product Safety Commission standard for mattresses, cpsc.gov. Each child must have seasonally appropriate bedding. The bed must be equipped with railings when used for children under two (2) years old. Over-and-under bunk beds must not be used for children under eight (8) years old. Cribs must meet Consumer Product Safety Commission, Crib Safety Tips available at: https://www.cpsc.gov/ Business--Manufacturing/Business-Education/FAQ?p=3019&tid%5b3028%5d=3028.(4-6-23)
IDAPA 16.04.18.433 Storage of Poisonous and Toxic Materials
Materials that are poisonous or toxic, or both, must be stored under lock and key and distinctly labeled as poisonous, toxic, and stored so as not to contaminate food and not to be a hazard to children.(4-6-23)
IDAPA 16.04.18.434 Flammable Liquids
Flammable liquids, including gasoline, propane, and kerosene, must be stored only in appropriate containers and kept separate from any building that houses children.(4-6-23)
IDAPA 16.04.18.435 Firearms
Firearms are prohibited in a children's residential care facility.(4-6-23)
IDAPA 16.04.18.436 Sufficient Recreational Space
Sufficient indoor and outdoor recreational space is needed so children can participate in a wide range of physical and individual activities.(4-6-23)
IDAPA 16.04.18.437 General Safety Provisions
The following conditions must be met:(4-6-23)
-
Reasonable Precautions. Prevent children from having unauthorized access to machinery, tools, irrigation ditches, and hazardous materials.(4-6-23)
-
Balconies, Ramps, and Stairways. Provide substantial railings as per IDAPA 24.39.30, “Rules of Building Safety (Building Code Rules).”(4-6-23)
-
Stairway Protection. Where an organization provides care to children under three (3) years old, stairways will be protected to prevent children from falling down the stairs.(4-6-23)
-
Hazard Area Restrictions. Depending on the age and functioning level of children and the type of hazard, an outdoor hazard area will be restricted to prevent easy access.(4-6-23)
-
Outdoor Activity Equipment. Equipment will be maintained in a safe condition free of sharp, loose, or pointed parts and anchored to the ground unless it is portable by design. The areas around and under high climbing equipment, swings, slides, and other similar equipment will be cushioned with material that absorbs falls.
Sand, woodchips, rubber mulch, or rubber mats commercially produced for this purpose are permitted.(4-6-23)
IDAPA 16.04.18.438 Diapering and Sanitation
A diaper-changing area must be separate from food preparation and serving areas and be easily accessible to a handwashing sink. The area must have nonabsorbent and washable surfaces, and be disinfected between uses by different children or protected by a disposable covering discarded after each use.(4-6-23)
IDAPA 16.04.18.439 Secured Facilities
Locked facilities are not allowed. Secured facilities using door delay security devices that prevent immediate egress must be approved by the local fire chief, cannot exceed fifteen (15) seconds, and comply with IDAPA 24.39.30, “Rules of Building Safety (Building Code Rules).” If the fire alarm is activated, the door must open immediately. The following conditions are required for secured facilities:(4-6-23)
-
Prohibit Use as Detention. Facilities will not be used for detention of children who are determined to be delinquent or who require secure custody pending court adjudication, court disposition, execution of a court order, or after commitment;(4-6-23)
-
Purpose. The secure facility is for the benefit, treatment, and safety of the child; and(4-6-23)
-
Egress. Prevention of egress will not be used as punishment or for facilitating supervision for staff convenience.(4-6-23)
IDAPA 16.04.18.440 Education Program
Excluding children in a licensed non-accredited residential school, each child of school age must attend either an accredited onsite school, accredited online school, Idaho public school, or charter school that is approved by the Idaho State Board of Education. Organizations may also assist children in continuing education through their home school district, if available. When the education program is provided directly by the organization, the following must be met:(4-6-23)
-
Teacher Ratio. At least one (1) Idaho certified teacher must be provided for every twenty (20) children or less.(4-6-23)
-
Teacher Qualifications. Teachers must possess a current Idaho certification.(4-6-23)
-
Minimum Hours. The school must provide education that meets the number of school days and clock hours as are required under Section 33-512, Idaho Code.(4-6-23)
IDAPA 16.04.18.441 Work
Children may be given a nonvocational work assignment as a constructive experience under child labor laws, which are age-appropriate and within the child's capabilities. The primary purpose of work must not be to substitute for paid labor.(4-6-23)
IDAPA 16.04.18.442 Recreation, Physical Exercise, and Leisure Time Activities
An organization must have a policy giving children the opportunity for daily participation in recreation, physical exercise, and leisure time activities and document the activities offered. Participation must be encouraged but not forced.(4-6-23)
IDAPA 16.04.18.443 Sleep
An organization must have and follow policies and procedures giving each child the opportunity for at least eight (8) hours of uninterrupted rest at night and more time if the service plan or health needs of the child require. (4-6-23)
IDAPA 16.04.18.444 Swimming Pool, Pond, or Other Body of Water for Use by Children
An above-ground or in-ground swimming pool, hot tub, pond, or other body of water on the premises of an organization for use by children must comply with Section 56-1003(3)(d), Idaho Code, and with applicable federal, state, county, and municipal laws, regulations, and ordinances regarding swimming pool construction, sanitation, water quality standards, water temperature, recreational bathing, and life-saving.(4-6-23)
-
Staff with Lifesaving or Lifeguard Certificate. The facility must maintain at least one (1) staff who has a valid lifesaving or lifeguard certificate issued by a nationally recognized organization. This certified staff must always be on duty when children are in the water.(4-6-23)
-
Repair and Safeguards. The facility must maintain the pools, hot tubs, ponds, and other bodies of water on its property in good repair, clean condition, and free from safety hazards and dangerous machinery and equipment. Areas and equipment that are hazardous to children must not be accessible by children. The following safeguards must be provided:(4-6-23)
a.The area surrounding a body of water for use by children will be secured by a fence and locked in a manner that prevents access by children, or have a secured protective covering that will prevent access by a child.
b.Pool or hot tub covers will be completely removed when in use;(4-6-23)
c.When the pool or hot tub cover is in place, the cover will be free from standing water; (4-6-23)
d.Covers will always be secured when the pool or hot tub is not in use;(4-6-23)
e.A reaching pole with a hook and a ring buoy will be accessible;(4-6-23)
f.Exterior ladders on above-ground pools will be removed when the pool is not in use; and (4-6-23)
g.A child who does not know how to swim will use an approved, appropriately fitting, lifesaving personal flotation device.(4-6-23)
- Safety for Children Five (5) Years and Under.(4-6-23)
a.Any organization that cares for children five (5) years old and under, and chooses to prevent access to a body of water by fencing must provide the following:(4-6-23)
i.The fence will be at least four (4) feet high with no vertical opening more than four (4) inches wide, be designed so that a young child cannot climb or squeeze under or through the fence, and surround all sides of the pool or pond;(4-6-23)
ii.The gate will be self-closing and have a self-latching mechanism in proper working order out of the reach of young children;(4-6-23)
iii.If a building forms one (1) side of the barrier for the pool, doors that provide unrestricted access to the pool will have alarms that produce an audible sound when the doors are opened; and(4-6-23)
iv.Furniture or other large objects will not be left near the fence enabling a child to climb on the furniture and gain access to the pool.(4-6-23)
b.Children must be under the direct supervision of an adult while using any body of water including a wading pool.(4-6-23)
c.Toys that attract young children to the pool area must be kept picked up and away from the pool area when not in use.(4-6-23)
IDAPA 16.04.18.445 Irrigation Canals, Rivers, Ponds, or Similar Bodies of Water for a Child
UNDER EIGHT YEARS.
An organization caring for a child eight (8) years and under, or a child who is physically or developmentally vulnerable, whose property adjoins an irrigation canal, river, pond, or similar body of water must have fencing that prevents access to the body of water by the child.(4-6-23)
-
Staff Training. The facility must maintain at least one (1) staff who has a valid lifesaving, swift water rescue, or lifeguard certificate issued by a nationally recognized organization for the type of water adjacent to or on the property, and this person must be on duty when any children are using the water for any purpose. (4-6-23)
-
Use of Rescue Equipment. All staff must be trained on the location and use of the water rescue equipment.(4-6-23)
-
Safety Equipment. Appropriate water rescue equipment must be maintained in an accessible area.
-
Fencing for Child Eight (8) Years and Under. The fence must be at least four (4) feet high with no vertical opening more than four (4) inches wide, and designed so that a young child cannot climb or squeeze under or through the fence.(4-6-23)
IDAPA 16.04.18.446 Irrigation Canals, Rivers, Ponds or Similar Bodies of Water for Child
OVER EIGHT YEARS.
When deciding whether a child over eight (8) years who is not developmentally, mentally, or physically disabled should have access to ponds, rivers, or other bodies of water on or adjacent to the facility, the facility must consider or provide the following:(4-6-23)
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Distance. The distance of the body of water from the closest facility structure.(4-6-23)
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Depth of the Water.(4-6-23)
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Water Flow.(4-6-23)
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Water Safety and Hazard Instruction to Child.(4-6-23)
-
Assessment of Child’s Swimming Ability.(4-6-23)
-
Documentation of Required Level of Child Supervision.(4-6-23)
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Signed Acknowledgment of Instruction. The child and their parent or guardian must provide a signed and dated acknowledgment of receipt of instruction and water safety and hazard information.(4-6-23)
IDAPA 16.04.18.447 Supervision of Recreational Activity
Staff conducting or supervising a recreational activity must have knowledge of and enforce appropriate safety techniques for the recreational activity and do the following:(4-6-23)
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Instruction. Instruct each participant in the appropriate safety procedures.(4-6-23)
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Safety Equipment. Ensure that each participant uses adequate and appropriate safety equipment for the activity and the child's ability.(4-6-23)
-
Rescue Equipment. Ensure that there is proper rescue equipment available and easily accessible.
-
Cardiopulmonary Resuscitation (CPR) and First Aid. Ensure that at least one (1) staff has current CPR and first aid certification appropriate to the age of the children.(4-6-23)
-
Staff Coverage. Ensure that there is adequate staff for the activity and children involved. (4-6-23)
IDAPA 16.04.18.448 Child's Health Record
There must be a health record for each child, available to appropriate staff for emergency use and to provide for the child's routine care. The record must contain the following:(4-6-23)
-
Initial Health Screening and History Including Allergies.(4-6-23)
-
Child's Medical Provider's Name, Address, and Phone Number.(4-6-23)
IDAPA 16.04.18.449 Medication
An organization must have and follow policies and procedures on the storage and administration, or assistance with medication, and comply with IDAPA 24.34.01, “Rules of the Idaho Board of Nursing.” The policies must address the 01. Medication Storage. Require that prescription and over-the-counter medication be stored under lock and key and the keys are safeguarded from children. For medications taken on field outings, storage of medication must be in the possession of staff who is qualified to administer or assist with medications. The medication must be in the original pharmacy-dispensed container, or in an original over-the-counter container, or placed in a unit container by a medical professional.(4-6-23)
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Administration and Assistance. Require that staff who administer or assist with self administration of medications be trained by a medical professional.(4-6-23)
-
Psychotropic Medication. Prohibit the administration of psychotropic medications:(4-6-23)
a.Unless a medical professional determines that the medication is clinically indicated; and (4-6-23)
b.For disciplinary purposes, for the convenience of staff, or as a substitute for appropriate treatment 04. Medication Changes. Document medications prescribed for the child while in care including the date prescribed and the prescribing physician. Prescribed medications must not be stopped or changed without consulting with a medical professional. Documentation of the consultation must include:(4-6-23)
a.Names of the child, the medical professional, and staff consulting with the medical professional;
b.Date of the consultation;(4-6-23)
c.Specific details of the change to include dosage, administration time, and instructions; and(4-6-23)
d.Reasons for the change.(4-6-23)
- Documentation for Prescription Medication. Document all prescription medication issued by a medical professional's order to include dosage to be given, and the following:(4-6-23)
c.The amount of dosage given and whether the child did not take the medication; and(4-6-23)
d.The person who administered or assisted in self-administration of the medication.(4-6-23)
- Documentation for Nonprescription Medication. Document all over-the-counter medication and the following:(4-6-23)
c.The amount of dosage given and whether the child did not take the medication;(4-6-23)
d.The person who administered or assisted in self-administration of the medication;(4-6-23)
e.The reason the medication was given. Over-the-counter medication will only be given according to the package instructions unless there is a child-specific valid order by a medical professional stating the medication is to be used for reasons other than those stated on the packaging; and(4-6-23)
f.The effects of the medication.(4-6-23)
- Disposal of Unused Medication. Dispose of all unused and expired medication so they are not available to children.(4-6-23)
IDAPA 16.04.18.450 Universal Precautions
Universal precautions must be taken for spills of body fluids such as blood, blood containing body fluids, eye discharge, feces, body tissue discharge, nasal discharge, saliva, urine, vomit, contaminated material, and diapers, which must be disposed of in a plastic bag that is secured with a tie. The disinfectant solution used to clean up body fluids must be a commercially prepared spill kit or a disinfectant solution. The person doing the cleaning and disinfecting must wear nonporous disposable gloves. Mops and other cleaning devices and fluids used to clean up body fluid spills must be disinfected, properly dried, and stored. Syringes must be disposed of under Occupational Safety and Health Act (OSHA) standards and not to be accessible to children.(4-6-23)
IDAPA 16.04.18.451 First Aid Kit
A first aid kit must be readily available and contain materials sufficient to meet a child's medical needs until other medical treatment is obtained. The contents, location, and use of first aid kits must be reviewed annually with all staff. The content of the kits must be inventoried and restocked as needed.(4-6-23)
IDAPA 16.04.18.452 Nutrition
Children must be provided daily three (3) nutritionally balanced meals in appropriate intervals and in amounts appropriate to their size and age. A licensed nutrition or dietitian professional must approve menus annually. The current menu must be readily available, and any change or substitution noted on the menu. Menus must be maintained on file for sixty (60) days. Accommodations must be made to a child with special medical or religious dietary needs.
IDAPA 16.04.18.453 Animals and Pets
Program animals must be free from disease and cared for in a safe and clean manner. Visiting and program dogs will be vaccinated against rabies with documentation kept on file.(4-6-23)
IDAPA 16.04.18.454 Tobacco Products, Alcohol, and Illegal Drugs
Use of tobacco, nicotine, vaping products, alcohol, and illegal drugs is prohibited by children, staff, volunteers, visitors, or contractors in any building used to house children, in the presence of children, or in vehicles used to transport children.(4-6-23)
IDAPA 16.04.18.455 Transporting Children
- Vehicle. Transportation of children must be in a vehicle that is:(4-6-23)
a.Properly registered;(4-6-23)
b.Covered by insurance for personal injury and liability;(4-6-23)
c.Driven by a person with a valid driver's license for the type of vehicle;(4-6-23)
d.Maintained in a clean and safe condition with documentation of maintenance;(4-6-23)
e.Equipped with a red triangular reflector device for use in emergency;(4-6-23)
f.Equipped with a first aid kit; and(4-6-23)
g.Equipped with a fire extinguisher that is properly secured and not readily available to children.
- Proper Seating of Children and Adults.(4-6-23)
a.A child must ride in an age-appropriate vehicle restraint seat according to Title 49, Chapter 6, Idaho Code, properly secured, or if the child is large enough, in a vehicle-manufactured seat, and properly use the passenger restraint device. All vehicle restraints and car seats must meet the Idaho Department of Transportation recommendations, be maintained in good operating condition, and not be expired.(4-6-23)
b.Adults riding in the vehicle must occupy a manufactured seat and use the passenger restraint device.(4-6-23)
IDAPA 16.04.18.456 Contraband
An organization must define prohibited contraband in a policy. Contraband found in the possession of children must be confiscated and secured. Local law enforcement must be notified if illegal contraband is confiscated. The organization will dispose of all contraband not confiscated by law enforcement and notice of such requirement will be provided in the organization’s contraband policy.(4-6-23)
IDAPA 16.04.18.457 Searches
If an organization conducts searches of children or the facility, it must have and follow policies and procedures.
Searches must be completed in the least intrusive manner possible for the type of search being conducted. All contraband will be disposed of under the contraband policy. The policies and procedures require the following:
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Training. Staff conducting any type of search must be trained on organization policy and procedures related to searches with documentation of training.(4-6-23)
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Pat Down Searches. Pat down searches of children may only be conducted to discourage the introduction of contraband into the facility, or to promote the safety of staff and other children. Pat down searches must be conducted as follows:(4-6-23)
a.The search is conducted in the presence of at least two (2) staff members;(4-6-23)
b.The child is told they are about to be searched;(4-6-23)
c.The child removes all outer clothing and empty all pockets;(4-6-23)
d.The staff pats the clothing of the child using only enough contact to conduct an appropriate search;
e.If the staff detects anything unusual, the child is asked to identify the item and appropriate steps taken to remove the item for inspection;(4-6-23)
f.If the child refuses to comply, the chief administrator is notified immediately and is responsible to resolve the matter; and(4-6-23)
g.All searches of children are documented in writing.(4-6-23)
- Strip and Body Cavity Searches are Prohibited.(4-6-23)
IDAPA 16.04.18.458 Behavior Management and Discipline Policy
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Documentation. An organization must explain the policy to the child considering their age and level of understanding. The parents or guardians and child will sign the policy acknowledging receipt.(4-6-23)
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Behavior Management. An organization must have and follow a behavior management and discipline policy for children that identifies appropriate and specific methods and ensures that these methods are positive and consistent. Individualized behavior management must be based on an assessment of the child's needs, stage of development, and behavior to promote self-control, self-direction, self-esteem, and an acceptable pattern of social behavior appropriate to the child’s age and development level. The policy must include the concept and application of least-restrictive effective treatment and positive reinforcements and prohibit the following: (4-6-23)
a.Physical force, except for physical restraint intervention;(4-6-23)
b.Any kind of punishment inflicted on the body, including spanking, hitting, slapping, spitting, kicking, shaking, pulling hair, pinching skin, twisting an arm or leg in a way that would cause pain or injury, kneeling or sitting on the chest, placing a choke hold, bending back a finger, and shoving or pushing a child into the wall, floor, or other stationary object;(4-6-23)
c.Cruel and unusual physical exercise, including forcing the child to take an uncomfortable position;
d.Verbal abuse, ridicule, humiliation, profanity, and other forms of degradation directed at a child or a child's family;(4-6-23)
e.Confinement in an area except an area approved by the Department for confinement of a child as provided under these rules;(4-6-23)
f.Withholding of necessary food, clothing, bedding, rest, toilet use, bathing facilities, and entrance to the facility;(4-6-23)
g.Denial of visits or communication with the child's family, except as specified in the child's service plan or court order;(4-6-23)
h.Denial of necessary educational, medical, counseling, and social services;(4-6-23)
i.Disciplining a group of children or another child for the actions of one (1) child, unless the organization's policies and procedures for group behavior management and discipline are based on a nationally recognized peer group treatment model and clearly prescribe the circumstances and safeguards under which group discipline is allowed, and the discipline is supervised directly by staff;(4-6-23)
j.The placing of anything in or on a child's mouth;(4-6-23)
k.A physical work assignment that produces unreasonable discomfort;(4-6-23)
l.Requiring cold showers or otherwise using water as a form of behavior management; (4-6-23)
m.Requiring an individual to remain silent for long periods for the purpose of behavior management;
n.Extensive withholding of emotional response or stimulation;(4-6-23)
o.Exploitation which includes, but is not limited to:(4-6-23)
i.Using a child's property without their consent or using a child's property in a way that is contrary to their best interests, such as expending a child's funds for the benefit of another; or(4-6-23)
ii.Accepting gifts in exchange for preferential treatment of a child or in exchange for services that the facility is already obliged to provide to the child.(4-6-23)
p.Failure to provide adequate supervision, including situations where the facility's employee or volunteer is asleep or ill on the job, or is impaired due to the use of alcohol or drugs; and(4-6-23)
q.Failure to provide care and treatment as prescribed by the child's services, program, or service plan.
IDAPA 16.04.18.459 Time-Out
An organization must have and follow policies and procedures governing the appropriate use of staff directed timeout as follows:(4-6-23)
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Use. Time-out is only used when a child's behavior is disruptive to the child's ability to learn, to participate appropriately, or to function appropriately with other children or the activity.(4-6-23)
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Children Under Six Years. For children under six (6) years old, the period for time-out is not to exceed one (1) minute for each year of the child's age and is used as a supplement to, but not a substitute for, other developmentally appropriate positive methods of behavior management.(4-6-23)
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Children Six Years or Older. For children six (6) years old and older the time duration cannot exceed sixty (60) consecutive minutes.(4-6-23)
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Prohibited Locations. The time-out cannot be in a closet, bathroom, unfinished basement, or attic, and cannot be in a locked area or box.(4-6-23)
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Documentation. A description in sufficient detail to provide a clear understanding of the incident that resulted in the child being placed in time-out, and the staff's attempts to help the child avoid time-out. (4-6-23)
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Observations. A staff is designated to be responsible for visually observing the child at random intervals not to exceed fifteen (15) minutes.(4-6-23)
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Reintroduction to the Group. The child is reintroduced to the group in a sensitive and nonpunitive manner as soon as control is regained.(4-6-23)
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Review. If there are more than ten (10) time-outs for a child in a twenty-four (24) hour period, a review is conducted to determine the suitability of the child remaining in the facility, whether modifications to the child's service plan are warranted, or whether staff need additional training in alternative therapeutic behavior management techniques and appropriate action taken is based on the findings of the review.(4-6-23)
IDAPA 16.04.18.460 Seclusion
Seclusion rooms must be equipped with break-resistant windows, and a mirror or camera that allows for full observation of the room. Rooms used for seclusion must be inspected and approved by a fire inspector annually. If an organization uses seclusion there must be policies and procedures, which include:(4-6-23)
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Seclusion. Seclusion will not be used as punishment or to substitute for other developmentally appropriate positive methods of behavior management. Seclusion may only be used as a means of intervention when the child's behavior is so violent or disruptive that it presents a high risk of physical or emotional harm to self or others, and less restrictive and less punitive interventions have been applied without success.(4-6-23)
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Time Needed. Seclusion must be used only for the time needed to change the behavior compelling
it.(4-6-23)
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Seclusion Duration. For children under six (6) years old, the period is not to exceed one (1) minute for each year of the child's age and is used as a supplement to, not a substitute for, other developmentally appropriate positive methods of behavior management. For children six (6) years old and older the time duration cannot exceed sixty (60) consecutive minutes.(4-6-23)
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Restrictions on Seclusion. Seclusion must not be in a box, closet, bathroom, unfinished basement, or attic. Except for a licensing-approved bedroom, a seclusion room cannot be used as a sleeping room, and temporary beds or mattresses in these areas are not allowed.(4-6-23)
-
Staff Supervision. A staff is designated to be responsible for visually observing the child at random intervals, which are not to exceed fifteen (15) minutes throughout the period of seclusion, and must be recorded in a log.(4-6-23)
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Supervisory Approval. Supervisory approval is required when the total seclusion time for one (1) child exceeds three (3) hours in a twenty-four (24) hour period, or more than four (4) separate seclusion incidents in a twenty-four (24) hour period.(4-6-23)
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Documentation. Each seclusion must be documented in writing and include the child's name, a description in sufficient details of the incident that resulted in the child being placed in seclusion, staff's attempts to help the child avoid seclusion, the date, start and end time of the seclusion, and the staff assigning the seclusion.
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Reintroduction. The child is reintroduced to the group in a sensitive and nonpunitive manner as soon as they can participate appropriately.(4-6-23)
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Review. If there are more than five (5) seclusions for a child in a twenty-four (24) hour period, there must be a documented review. The review is to determine whether modifications to the child's service plan are warranted or whether staff needs additional training in alternative therapeutic behavior management techniques or disciplinary action. Appropriate action must be taken based on the findings of the review.(4-6-23)
IDAPA 16.04.18.461 (Reserved)
NONACCREDITED CHILDREN'S RESIDENTIAL SCHOOLS
Sections 466 – 499
IDAPA 16.04.18.466 Staff Ratios Required
Nonaccredited children's residential schools must have at least one (1) staff member on duty and one (1) on-call and available within (10) minutes for every twenty-five (25) children or less. During normal sleeping hours, children in each sleeping room will be under close supervision and within easy call of a staff member.(4-6-23)
IDAPA 16.04.18.467 Child's Record
The school must maintain a record on each child with the following:(4-6-23)
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Child's Full Name.(4-6-23)
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Birth Date.(4-6-23)
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Gender.(4-6-23)
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Height, Weight, Hair and Eye Colors, Race, and Identifying Marks.(4-6-23)
-
Name, Address and Phone Number of Responsible Parent, Guardian, or Legal Custodian.
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Documentation of Authority to Accept and Care for Child.(4-6-23)
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Medical Care Authorizations.(4-6-23)
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School Reports Including Grades and Adjustment.(4-6-23)
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Reason for Referral or Placement.(4-6-23)
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Special Considerations and Needs.(4-6-23)
IDAPA 16.04.18.468 (Reserved)
OUTDOOR PROGRAMS
Sections 500 – 599
IDAPA 16.04.18.500 Base Camp Requirements
- Base Camp. An outdoor program must have a base camp or field office in Idaho, hereafter referred to as a “base camp.” A base camp must:(4-6-23)
a.Be staffed and monitored twenty-four (24) hours a day when there are children in the base camp or on expeditions;(4-6-23)
b.Have current staff personnel files;(4-6-23)
c.Have a current list of the names of staff and children in each field group;(4-6-23)
d.Have a master map of all activity areas used by the program;(4-6-23)
e.Have copies of each group's expeditionary route with its schedule and itinerary;(4-6-23)
f.Maintain current logs of all communications with each field group away from the base camp; and
g.Have an emergency response plan developed by the organization and updated annually. (4-6-23)
- Proof of Compliance. An outdoor program that operates in Idaho must comply with federal, state, and local regulations and maintain proof of compliance at the base camp.(4-6-23)
IDAPA 16.04.18.501 High Adventure Requirements
- High Adventure Activities Include the Following:(4-6-23)
a.Target sports;(4-6-23)
b.Aquatics;(4-6-23)
c.Hiking;(4-6-23)
d.Adventure challenge courses;(4-6-23)
e.Climbing and rappelling;(4-6-23)
f.Winter camping;(4-6-23)
g.Soloing;(4-6-23)
h.Spelunking;(4-6-23)
i.Expeditioning;(4-6-23)
j.Swimming in a river, stream, lake, or pond;(4-6-23)
k.Whitewater activities; and(4-6-23)
l.Animal-related activities.(4-6-23)
- High Adventure Activity Policies and Procedures. For the high adventure activities and for any activity identified by the outdoor program or the Department as a high adventure activity, there must be a policies and procedures to be followed that includes:(4-6-23)
a.Training, experience, and qualifications for leader and staff;(4-6-23)
b.Specific staff-to-participant ratios appropriate to the activity;(4-6-23)
c.Classification and limitations for each child's participation;(4-6-23)
d.Arrangement, maintenance, and inspection of the activity area;(4-6-23)
e.Appropriate equipment and the inspection and maintenance of the equipment; and(4-6-23)
f.Safety precautions to reduce the possibility of an accident or injury.(4-6-23)
- High Adventure Activities Leader. An activity leader who conducts high adventure activities must be at least twenty-one (21) years old and have documented training and experience in conducting the activity.
IDAPA 16.04.18.502 Staff Qualifications for Outdoor Programs
Staff, interns, and volunteers must complete a background check as required by IDAPA 16.05.06, “Criminal History and Background Checks.” Outdoor programs must have the following staff:(4-6-23)
- Chief Administrator. An outdoor program must have a chief administrator who is primarily responsible for ensuring that the program complies with applicable licensing rules and that staff are familiar with all program policies and procedures. The chief administrator may also function as the field director. In addition to qualifications in Section 213 of these rules, the chief administrator must also:(4-6-23)
a.Be at least twenty-five (25) years old; and(4-6-23)
b.Have a minimum of thirty (30) semester hours or forty-five (45) quarter hours in recreational therapy or related experience, or one (1) year of outdoor youth program field experience.(4-6-23)
- Field Director. An outdoor program must have a field director who is primarily responsible for the quality of the field activities, coordinates field operation, supervises direct care staff, and manages the field office.
The field director is responsible for compliance with applicable licensing rules and ensures that staff are familiar with all program policies and procedures, and must:(4-6-23)
a.Be at least twenty-five (25) years old;(4-6-23)
b.Have at least thirty (30) semester hours or forty-five (45) quarter hours in recreational therapy or related experience, or one (1) year of outdoor youth program field experience;(4-6-23)
c.Have at least forty (40) twenty-four (24) hour field days of program experience or equivalent experience in outdoor programs documented in their personnel file; and(4-6-23)
d.Be certified to provide CPR and first aid.(4-6-23)
- Senior Field Staff. An outdoor program must have a senior field staff working directly with each group of program participants, and must:(4-6-23)
a.Be at least twenty-one (21) years old;(4-6-23)
b.Have an associate degree or high school diploma or equivalent and thirty (30) semester hours or forty-five (45) quarter hours of education and training, or comparable experience and training, in a field related to recreation and adventure activities;(4-6-23)
c.Have forty (40) twenty-four (24) hour field days of program experience or equivalent experience in outdoor programs documented in their personnel file; and(4-6-23)
d.Be certified to provide CPR and first aid.(4-6-23)
- Field Staff. Must:(4-6-23)
a.Be at least twenty-one (21) years old;(4-6-23)
b.Have a high school diploma or equivalent; and(4-6-23)
c.Be certified to provide CPR and first aid.(4-6-23)
- Multidisciplinary Team. An outdoor program must have a multidisciplinary staff or program consultants who have knowledge of the physical and emotional demands of the program and are available to program participants upon the recommendation of the field director or senior field staff. The team must consist of: (4-6-23)
a.A licensed physician; and(4-6-23)
b.A licensed treatment professional including either a licensed psychologist, certified social worker, marriage and family counselor, or professional counselor.(4-6-23)
- Each Intern. Must:(4-6-23)
a.Be in a learning program to meet personal educational goals;(4-6-23)
b.Be at least eighteen (18) years old;(4-6-23)
c.Have a high school diploma or its equivalent; and(4-6-23)
d.Be under the supervision of a licensed therapist if they are in a clinical internship pursuing a professional degree or license.(4-6-23)
- Each Volunteer. Must:(4-6-23)
a.Be at least eighteen (18) years old; and(4-6-23)
b.Be under the direct, constant supervision of qualified staff.(4-6-23)
- Staff Health Requirements.(4-6-23)
a.Prior to engaging in any field activities with children, staff, interns, and volunteers must have a written statement from a licensed physician, physician's assistant, or nurse practitioner verifying they are physically fit to perform the duties of the job.(4-6-23)
b.A new, written physician's statement must be obtained every three (3) years. The medical professional who provides the written statement must be given a form to use that clearly describes the physical demands for the job and the environmental conditions the person being evaluated is required to work in. (4-6-23)
c.The outdoor program must review the form and maintain it in the individual's personnel file.
IDAPA 16.04.18.503 Skills and Training
Skills and training for each staff, intern, and volunteer must be documented and kept on file at the base camp.
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Skills. Each staff, intern, and volunteer must demonstrate specific skills, prior to assuming field supervision. The skill assessment procedures must be approved, and results of the assessment documented. (4-6-23)
-
Training. Chief administrator, field director, senior field staff, field staff, volunteers, and interns must have trainings that address deficiencies identified in the skills assessment. The curriculum will include:(4-6-23)
a.Four (4) days of practicum field training;(4-6-23)
b.Supervision of program participants;(4-6-23)
c.Water, food, shelter procurement, preparation, and conservation;(4-6-23)
d.Low-impact wilderness expedition and environmental conservation skills and procedures; (4-6-23)
e.Child management including containment control, safety, conflict resolution, and behavior management;(4-6-23)
f.Instruction in safety procedures and safe equipment use of fuel, fire, and life protection; (4-6-23)
g.Sanitation procedures related to food, water, and waste;(4-6-23)
h.Special instruction for individuals who conduct and supervise high adventure activities; (4-6-23)
i.Wilderness medicine, including health issues related to acclimation, exposure to the environment, and environmental elements;(4-6-23)
j.First aid kit contents and use;(4-6-23)
k.Navigation skills including map and compass use, and Global Positioning System (GPS); (4-6-23)
l.Local environmental precautions, including terrain, weather, insects, poisonous plants, wildlife, and proper response to adverse situations;(4-6-23)
m.Report writing, including development and maintenance of logs and journals;(4-6-23)
n.Federal, state, and local regulations including the Department, Idaho State Department of Fish and Game, Idaho Outfitters and Guides, and state and federal land use agencies; and(4-6-23)
o.Ongoing training for direct care staff to upgrade their skills, including mandatory training to maintain skills, certifications, and licenses.(4-6-23)
IDAPA 16.04.18.504 Staff Ratios and Group Size
-
Staff Ratio. Each group of children must have one (1) staff for every four (4) children. Where there are four (4) children or less there must be at least two (2) staff.(4-6-23)
-
Interns and Volunteers. Interns and volunteers must never be counted in the staff ratio and never have sole responsibility to supervise the child.(4-6-23)
IDAPA 16.04.18.505 Alcohol or Controlled Substances Prohibited
Staff, interns, and volunteers engaging in field activities with children are prohibited from using alcohol or controlled substances, or any other substance that impairs their ability to function and ensure the health and safety of the children in the program.(4-6-23)
IDAPA 16.04.18.506 (Reserved)
IDAPA 16.04.18.515 Assessments
-
Preadmission Assessment. Preadmission assessments must be done for each child by a qualified treatment professional familiar with the outdoor program prior to enrollment. This must include a review of the child's social and psychological history.(4-6-23)
-
Subsequent Assessments. Subsequent assessments must be done before the child leaves for the field portion away from the main base of operations. The assessment must include:(4-6-23)
a.An interview with the child by the senior field staff assigned to the child's field experience; and
b.A review of the child's health history and physical examination by a medically trained field staff assigned to the child's field experience.(4-6-23)
- Psychological Problems. For a child with a history of psychological problems, a psychological evaluation must be obtained and reviewed by the multidisciplinary team prior to the child's entrance into the field portion.(4-6-23)
IDAPA 16.04.18.516 Physical Examination
A child must have a physical examination within thirty (30) days prior to entrance into the outdoor program.(4-6-23)
- Physical Examination Requirements. The result of the physical exam must be recorded on a standard form provided by the outdoor program. The form must clearly document the type and extent of physical activity in which the child will be engaged and completed by a licensed physician, physician's assistant, or nurse practitioner, who signs the form, and includes:(4-6-23)
a.A urinalysis;(4-6-23)
b.A pregnancy test for each female participant;(4-6-23)
c.A physical assessment to determine fitness given the climate and temperature in which the child will be participating, and the child's age, weight, and physical condition; and(4-6-23)
d.A determination whether detoxification is indicated prior to entrance into the field portion of the program.(4-6-23)
-
Prior Physical Examination. A physical examination of a child who is coming into an outdoor program directly from a children's residential care facility is acceptable provided the physical examination is current, occurred prior to entrance into the field, and meets the criteria in Subsection 516.01.(4-6-23)
-
Medical Special Needs. If a child is currently taking or has been taking prescribed medication within the past six (6) months prior to placement, a notation must be made on the physical examination form by the medical professional approves the child's participation in an outdoor, high impact environment. The physical examination will include a description of any possible special needs due to the use of medication in said environment.
-
Physical Examination Availability. The physical examination form must be maintained at the base camp and a copy carried by staff in a waterproof container when the child is away from the base camp. The physical examination form must be maintained in a manner that assures the confidentiality of all medical and identifying information.(4-6-23)
IDAPA 16.04.18.517 Service Plans
An outdoor program must develop and follow a written service plan for a child admitted.(4-6-23)
- Initial Service Plan. Must be developed and recorded in the child's record within thirty (30) days after admission with the following:(4-6-23)
a.Identify the needs of the child and family, and provide goals and a time frame to achieve the goals;
b.Services the organization will provide to assure the safety, health, and wellbeing of the child;
c.Criteria for discharge and projected discharge date;(4-6-23)
d.Demonstrate the service plan was developed with participation of the child's parent, guardian, or legal custodian, and the child. A child may be excluded from participation if they are incapable of understanding the purpose of the planned services; and(4-6-23)
e.Identify the persons responsible for coordinating and implementing the child's and family's 02. Updated Service Plan. A service plan must be updated every ninety (90) days and must: (4-6-23)
a.Document services the organization will provide to assure the safety, health, and wellbeing of the child;(4-6-23)
b.Document progress towards achieving the goals in the service plan;(4-6-23)
c.Demonstrate the service plan was developed with participation of the child's parent, guardian, or legal custodian, and the child. A child may be excluded from participation if they are incapable of understanding the purpose of the planned services.(4-6-23)
IDAPA 16.04.18.518 Discharge Summary
A discharge summary must be written within seven (7) days of discharge, and include:(4-6-23)
-
Date of and Reason for Discharge.(4-6-23)
-
Physical, Emotional, Medical, and Educational Needs of Child.(4-6-23)
-
Recommendations for Treatment.(4-6-23)
-
Documentation of Disrupted Placements, Assessed Causes, and Any Corrections. (4-6-23)
IDAPA 16.04.18.519 Continued Care
Continued care is permitted under the Idaho Child Care Licensing Reform Act, Sections 39-1202 and 39-1213, Idaho Code, for individuals eighteen (18) to twenty-one (21) years old. Individuals who are in the care of a licensed outdoor program prior to turning eighteen (18) years old may remain in the program for up to ninety (90) days after their eighteenth birthday, or up to the age of twenty-one (21) if necessary to complete a treatment program or school educational program currently attended by the individual.(4-6-23)
IDAPA 16.04.18.520 Documentation Requirements for Continued Care
Prior to accepting an individual into continued care the following is required:(4-6-23)
-
Voluntary Agreement. A voluntary agreement to remain in the program signed by the person turning eighteen (18), or a copy of a court order authorizing continued placement after the individual's eighteenth birthday.(4-6-23)
-
Assessment for Others Safety. An assessment to assure that an individual does not jeopardize the health, safety, and well-being of the children in care of the organization.(4-6-23)
-
Additional Continued Care Plans. A plan that prohibits individuals from sharing a bedroom or other sleeping rooms with a child.(4-6-23)
-
Documentation of Care Prior to Eighteenth Birthday. Documentation verifying the individual was in the care of the organization prior to their eighteenth birthday.(4-6-23)
-
Documentation of Need for Continued Care. Documentation verifying the individual needs to remain to complete treatment, education, or other similar needs.(4-6-23)
IDAPA 16.04.18.521 Age Requirements
-
Age. A child must be at least eleven (11) years old and less than eighteen (18) years old unless the individual qualifies for continued care.(4-6-23)
-
Grouping. A licensed treatment professional familiar with the outdoor program must determine whether children eleven (11) years old through thirteen (13) years old are to be placed in a younger program group or in an older program group. The decision must be based upon the child's needs and level of maturity, both physical and mental. The basis for the decision must be documented in the child's record.(4-6-23)
IDAPA 16.04.18.522 Expeditions
Expeditions include any excursion taking children away from the base camp.(4-6-23)
-
Description. There must be an approved written description of the expedition. The expedition must not expose children to unreasonable risk.(4-6-23)
-
Group Size. The number of expedition participants must not exceed fifteen (15) children. (4-6-23)
-
Wilderness First Responder (WFR). At least one (1) staff member per expedition group must have a current WFR Certificate.(4-6-23)
-
Global Positioning System (GPS). Each expedition group must be equipped with a GPS system.
-
Staff Briefing. Staff must be briefed prior to any expedition. The briefing must include: (4-6-23)
a.The expedition route, terrain, time schedule, weather forecast, and any potential hazards; (4-6-23)
b.Any procedures unique to that expedition; and(4-6-23)
c.Participant backgrounds and any potential problems.(4-6-23)
-
Expedition Evaluations. Each expedition must be evaluated once during a calendar week, either in person by a field director or as detailed in the organization's approved policies and procedures. If the expedition is longer than three (3) weeks, onsite visits by a field director must occur every three (3) weeks.(4-6-23)
-
Staff Debriefing. Staff must be debriefed after an expedition.(4-6-23)
-
Participant Debriefing. Children must be debriefed after an expedition. The debriefing must include a written summary of the child's participation and progress and be retained in the child's record. (4-6-23)
-
Expedition Summary. Results of the evaluation of the conditions of the children, interactions of children and staff, briefings, debriefings, and compliance with program policies and procedures must be summarized and documented.(4-6-23)
IDAPA 16.04.18.523 Safety
Each outdoor program must have appropriate safety procedures and equipment.(4-6-23)
-
Environmental Hazards. Each program participant must have instruction on environmental hazards and precautions.(4-6-23)
-
First Aid Kit. There must be a first aid kit with sufficient supplies. The first aid kit must: (4-6-23)
a.Meet the standards of an appropriate national organization for the activity being conducted and the location and environment being used;(4-6-23)
b.Be reviewed with new staff for contents and use;(4-6-23)
c.Be reviewed at least annually with all staff for contents and use; and(4-6-23)
d.Be inventoried after each expedition and restocked as needed.(4-6-23)
IDAPA 16.04.18.524 Communications
-
Support System. There must be multiple reliable communication systems.(4-6-23)
-
Requirements. There must be daily communication between each field group and the base camp unless alternative arrangements have been made and documented in a communications log maintained at the base camp. Absence of communication must never exceed seventy-two (72) hours.(4-6-23)
-
Emergencies. The base camp support personnel must have immediate access to emergency telephone numbers, contact personnel, and procedures for an emergency evacuation or field incident requiring emergency medical support.(4-6-23)
IDAPA 16.04.18.525 Emergency Plan
An outdoor program must have and follow a written emergency plan and procedures for evacuations, disasters, medical emergencies, hostage situations, casualties, and missing children.(4-6-23)
- Plan Must Include:(4-6-23)
a.Designation of authority and staff assignments;(4-6-23)
b.Transportation and relocation of program participants when necessary;(4-6-23)
c.Instruction to all participants on how to respond to an emergency;(4-6-23)
d.Notification regarding the nature of the emergency and an accounting for each participant's location and status;(4-6-23)
e.Supervision of program participants after an evacuation or a relocation; and(4-6-23)
f.Arrangements for medical care and notification of a child's physician and identified parent or guardian.(4-6-23)
- Emergency Drills Must Be Conducted and Recorded Annually.(4-6-23)
IDAPA 16.04.18.526 Expedition and Hiking Limit Requirements
-
Physical Capability. Hiking must not exceed the physical capability of the weakest member of the group.(4-6-23)
-
Maximum Temperature. There must be no hiking when the temperature is above ninety-five (95) degrees Fahrenheit.(4-6-23)
-
Inability or Refusal to Hike. When a child cannot or refuses to hike, the group cannot continue hiking unless it is necessary for safety reasons, and a contingency plan, based on approved policies and procedures, must be used. The contingency plan must ensure there is staff coverage for each group, if the group is split, and that communication between the groups is maintained.(4-6-23)
-
Maps and Itinerary. Copies of map routes and anticipated schedules, including arrival and departure times, must be maintained by the field staff and base camp when a group is away from the base camp.
-
Acclimation to Environment. Staff must closely monitor children for acclimation to the temperature, climate, altitude, environment, and situation.(4-6-23)
-
Log. There must be a common written log that is signed and dated by the participating staff immediately following an expedition. The log must contain information on health problems, accidents, injuries, medications used, behavioral problems, and unusual occurrences and be recorded with any corrections initialed and dated.(4-6-23)
IDAPA 16.04.18.527 Water Requirements
- Water. Children must have access to potable water while hiking and the program must: (4-6-23)
a.Provide each child with six (6) quarts of potable water a day, unless a child's weight exceeds one hundred fifty (150) pounds, then one (1) additional quart of potable water will be provided for every twenty-five (25) pounds of body weight over one hundred fifty (150) pounds; and(4-6-23)
b.Encourage each child to consume at least three (3) quarts of potable water per day.(4-6-23)
-
Water for Cooling. When the temperature is eighty (80) degrees Fahrenheit or higher, adequate water must be available for coating each child's body for the purpose of cooling when needed.(4-6-23)
-
Water Caches. When water caches are used, each water cache must be placed at predetermined sites prior to the day the group leaves the camp. Field staff must verify the water cache locations before the group leaves the base camp each day.(4-6-23)
-
Aerial Water Drops. An expedition group must not depend on aerial drops for its water supply and be used only in an emergency.(4-6-23)
-
Water From a Natural Source. Water from a natural source used for drinking or cooking must be treated to eliminate health hazards.(4-6-23)
-
Electrolyte Replacement. Each group must have a supply of electrolyte replacement, with quantities to be determined by group size and environmental conditions.(4-6-23)
IDAPA 16.04.18.528 Nutritional and Sanitary Requirements
-
Menu. There must be a written menu approved annually by a professional nutritionist or dietitian with knowledge of program activity levels and environmental factors. The menu will list the necessary or recommended food supplies and caloric intake for each group. The current menu must be available, and any change or substitution noted on the menu. Menus must be maintained on file for sixty (60) days.(4-6-23)
-
Food. Each child must be provided enough food and calories based on the approved menu that includes fresh fruit and vegetables at least twice a week.(4-6-23)
-
Special Needs. The menu must take into consideration a child's special nutritional needs, including food allergies or religious restrictions.(4-6-23)
-
Fasting. There must be no imposed food fasting.(4-6-23)
-
Cleansing of Hands. Soap and water, or other methods to disinfect hands, is provided and encouraged after each latrine use. Cleansing of hands is required prior to food preparation.(4-6-23)
IDAPA 16.04.18.529 (Reserved)
IDAPA 16.04.18.530 Health Care Requirements
-
First Aid. First aid treatment will be provided in as prompt a manner as the location and circumstances allow.(4-6-23)
-
Administration and Assistance. Staff who administer or assist with self-administration of medications will be trained by a medical professional.(4-6-23)
-
Documentation. Complaints or reports by a child of illness and injuries will be recorded in the daily log along with any treatment provided.(4-6-23)
-
Negative Consequences. There will be no negative consequences imposed on a child for reporting an injury or illness, or for requesting to see a health care professional.(4-6-23)
-
Daily Physical Assessment. Children's hydration, skin condition, extremities, and general physical condition will be evaluated and recorded by field staff in the daily log.(4-6-23)
-
Weekly Physical Assessment. At least every seven (7) days, each child's physical condition will be assessed by a WFR, an EMT, or a medical professional. The results of the assessment will be recorded in the daily log and include:(4-6-23)
a.Blood pressure;(4-6-23)
b.Heart rate;(4-6-23)
c.Condition of extremities and skin;(4-6-23)
d.Hydration level;(4-6-23)
e.Allergies, if any;(4-6-23)
f.General physical condition; and(4-6-23)
g.Provision of appropriate medical treatment if needed.(4-6-23)
IDAPA 16.04.18.531 Medication
An outdoor program must have and follow policies and procedures on the storage and administration, or assistance with medication, and comply with IDAPA 24.34.01, “Rules of the Idaho Board of Nursing.” The policies must address the following:(4-6-23)
-
Medication Storage. Prescription and over-the-counter medication will be stored under lock and key and safeguarded from children. For medications taken on field outings, all medication will be in the possession of a staff member qualified to administer or assist with medications. The medication must be in the original pharmacydispensed container, in original over-the-counter container, or placed in a unit container by a medical professional.
-
Administration and Assistance. Staff who administer or assist with self-administration of medications will be trained by a medical professional.(4-6-23)
-
Psychotropic Medication. Prohibit the administration of psychotropic medications:(4-6-23)
a.Unless a medical professional determines that the medication is clinically indicated; and (4-6-23)
b.For disciplinary purposes, for the convenience of staff, or as a substitute for appropriate treatment 04. Documentation for Prescription Medication. Document all prescription medication issued by a medical professional's order to include dosage to be given, and the following:(4-6-23)
c.The dosage given and whether the child did not take the medication; and(4-6-23)
d.The person who administered or assisted in self-administration of the medication.(4-6-23)
- Documentation for Nonprescription Medication. Documentation for all over-the-counter medication must include:(4-6-23)
c.The dosage given whether the child did not take the medication;(4-6-23)
d.The person who administered or assisted in self-administration of the medication;(4-6-23)
e.The reason the medication was given. Over-the-counter medication will only be given according to the package instructions unless there is a child-specific valid order by a medical professional stating the medication is to be used for reasons other than those stated on the packaging; and(4-6-23)
f.The effects of the medication.(4-6-23)
- Medication Changes. Document medications prescribed for the child while in care including the date prescribed and the prescribing physician. Prescribed medications must not be stopped or changed without consulting with a medical professional. Documentation of the consultation must include:(4-6-23)
a.Name of the child, the medical professional, and staff consulting with the medical professional;
b.Date of the consultation;(4-6-23)
c.Specific details of the change including dosage, administration time, and instructions; and (4-6-23)
d.Reasons for the change.(4-6-23)
- Disposal of Unused Medication. Dispose of all unused and expired medication so they are not available to children.(4-6-23)
IDAPA 16.04.18.532 Participant Clothing, Equipment, and Supplies
Each program participant must have clothing, equipment, and supplies appropriate for the types of activities and for the weather conditions likely to be encountered.(4-6-23)
- Clothing, Equipment, and Supplies Requirements:(4-6-23)
a.Sunscreen;(4-6-23)
b.Insect repellent;(4-6-23)
c.A commercially available backpack or the materials to construct a safe backpack or bedroll;
d.Personal hygiene items necessary for cleansing;(4-6-23)
e.Appropriate feminine hygiene supplies;(4-6-23)
f.Wool blankets or an appropriate sleeping bag and a tarp or poncho when the average nighttime temperature is expected to be forty (40) degrees Fahrenheit or higher;(4-6-23)
g.Shelter, appropriate sleeping bag, and ground pad when the average nighttime temperature is expected to be thirty-nine (39) degrees Fahrenheit or lower;(4-6-23)
h.Clothing appropriate for temperature changes generally expected for the area;(4-6-23)
i.For each child, a clean change of clothing at least once a week or an opportunity to wash their clothes at least once a week; and(4-6-23)
j.For each child, clean undergarments and a means to clean their body at least twice a week.
Additional clean undergarments may be needed for health or sanitary reasons.(4-6-23)
- Denial of Clothing, Equipment, and Supplies. Appropriate clothing, equipment, and supplies must not be removed, denied, or made unavailable for any reason.(4-6-23)
IDAPA 16.04.18.533 Contraband
An outdoor program must define prohibited contraband in a policy.(4-6-23)
-
Confiscation. Contraband found in the possession of children must be confiscated and secured in a location inaccessible to children.(4-6-23)
-
Law Enforcement Notification. Local law enforcement must be notified when illegal contraband is confiscated.(4-6-23)
-
Disposal. The outdoor program will dispose of all contraband not confiscated by law enforcement, under the program's contraband policy. When contraband is disposed of, this must be witnessed by at least one (1) other staff member and the disposal documented in the child's record.(4-6-23)
IDAPA 16.04.18.534 Searches
If an outdoor program conducts searches of children, it must have and follow policies and procedures. Searches must be completed in the least intrusive manner possible for the type of search being conducted. All searches must be documented, including the reasons for the search, the persons conducting the search, and any results. The policies and procedures must include:(4-6-23)
- Pat Down Searches. May only be conducted to discourage the introduction of contraband or to promote the safety of staff and other children. Pat down searches must be conducted as follows:(4-6-23)
a.The search is conducted in the presence of at least two (2) staff members;(4-6-23)
b.The child will be told they are about to be searched;(4-6-23)
c.The child will remove all outer clothing and empty all pockets;(4-6-23)
d.The staff will pat the clothing of the child using only enough contact to conduct an appropriate search;(4-6-23)
e.If the staff detects anything unusual, the child will be asked to identify the item and appropriate steps taken to remove the item for inspection; and(4-6-23)
f.If the child refuses to comply, the chief administrator must be notified immediately and is responsible for resolving the matter.(4-6-23)
-
Searches. All searches of children must be documented in writing.(4-6-23)
-
Training. Staff conducting any type of search must be trained on organization policy and procedures related to searches with documentation of training.(4-6-23)
-
Strip and Body Cavity Searches are Prohibited.(4-6-23)
IDAPA 16.04.18.535 Behavior Management and Discipline Policy
An outdoor program must have and follow a behavioral management and discipline policy that identifies appropriate methods of behavioral management and ensures that any discipline is positive and consistent. Individual behavioral management must be based on an assessment of the child's needs, behavior, and stage of development with the goal of promoting self-control, self-direction, self-esteem, and an acceptable pattern of social behavior appropriate to the age and development level of the child. An organization must explain the policy to the child’s age and development level. The parents or guardians and child will sign the policy acknowledging receipt. The policy must include the concept and application of least-restrictive effective treatment and positive reinforcement and prohibits the following:
-
Physical Force. Except for physical restraint intervention;(4-6-23)
-
Punishment. Any kind of punishment inflicted on the body, including spanking, hitting, slapping, spitting, kicking, shaking, pulling hair, pinching skin, twisting an arm or leg in a way that would cause pain or injury, kneeling or sitting on the chest, placing a choke hold, bending back a finger, and shoving or pushing a child into a stationary object;(4-6-23)
-
Covering of the Mouth. The placement of anything in or over a child's mouth;(4-6-23)
-
Excessive Physical Demands. Cruel physical exercise, prolonged positions, or work assignments that produce unreasonable discomfort;(4-6-23)
-
Verbal Abuse. Ridicule, humiliation, profanity, and other forms of degradation directed at a child or a child's family;(4-6-23)
-
Restraints and Seclusion. Locked seclusion, mechanical restraints, and alternative forms of restraints;(4-6-23)
-
Withholding of Items. Withholding of necessary food, clothing, shelter, bedding, rest, medical care, and toilet use;(4-6-23)
-
Denials. Denial of visits or communication with the child's family except as specified in the child's plan or court order;(4-6-23)
-
Group Discipline. Disciplining a group of children or another child for the actions of one (1) child, unless the organization's policies and procedures for group behavior management and discipline are based on a nationally recognized peer group treatment model and clearly prescribe the circumstances and safeguards under which group discipline is allowed, and the discipline is supervised directly by staff;(4-6-23)
-
Behavioral Management Using Water. Requiring cold showers or otherwise using water as a form of behavior management;(4-6-23)
-
Extensive Periods of Silence. Demanding an individual to remain silent for long periods for the purpose of behavior management;(4-6-23)
-
Extensive Withholding of Emotional Response or Stimulation.(4-6-23)
-
Exploitation. Includes the following:(4-6-23)
a.Using a child's property without their consent or using a child's property in a way that is contrary to their best interests, such as expending a child's funds for the benefit of another; and(4-6-23)
b.Accepting gifts in exchange for preferential treatment of a child or in exchange for services that the organization is already obliged to provide to the child.(4-6-23)
-
Failure to Provide Adequate Supervision. Includes situations where the organization's employee or volunteer is asleep or ill on the job, or is impaired due to the use of alcohol or drugs;(4-6-23)
-
Failure to Provide Care and Treatment. As prescribed by the child's services, program, or service plan.(4-6-23)
IDAPA 16.04.18.536 Time-Out
An outdoor program must have and follow policies and procedures governing the appropriate use of time-out that includes the following:(4-6-23)
-
Use. Time-out is only used when a child's behavior is disruptive to the child's ability to learn, to participate appropriately, or to function appropriately with other children or the activity.(4-6-23)
-
Duration. Time duration cannot exceed sixty (60) consecutive minutes.(4-6-23)
-
Observation. A staff is designated to be responsible for visually observing the child at random intervals at least every fifteen (15) minutes.(4-6-23)
-
Documentation. A written description maintained in the child's file in sufficient detail to provide a clear understanding of the incident or behavior that resulted in the child being placed in time-out, staff's attempts to help the child avoid time-out, and observations by staff.(4-6-23)
-
Reintroduction to the Group. The child is reintroduced to the group in a sensitive and nonpunitive manner as soon as control is regained.(4-6-23)
-
Review. If there are more than ten (10) time-outs for a child in a twenty-four (24) hour period, a review is conducted to determine the suitability of the child remaining in the program, and whether staff needs additional training in alternative therapeutic behavior management techniques. Appropriate action must be taken based on the findings of the review.(4-6-23)
IDAPA 16.04.18.537 Work
Children may be given a nonvocational work assignment as a constructive experience, in compliance with child labor laws, that is age appropriate and within the child's capabilities. The primary purpose of work must not be to substitute for paid labor.(4-6-23)
IDAPA 16.04.18.538 Animals and Pets
Program animals must be free from disease and cared for in a safe and clean manner. Visiting and program dogs will be vaccinated against rabies and documentation kept on file.(4-6-23)
IDAPA 16.04.18.539 Transporting Children
- Vehicle. Transportation of children must be in a vehicle that is:(4-6-23)
a.Properly registered;(4-6-23)
b.Insured for personal injury and liability;(4-6-23)
c.Driven by a person with a valid driver's license for the type of vehicle;(4-6-23)
d.Maintained in a safe condition with documented maintenance;(4-6-23)
e.Equipped with a red triangle reflector device for use in an emergency;(4-6-23)
f.Equipped with a first aid kit; and(4-6-23)
g.Equipped with a fire extinguisher that is properly secured and not readily available to children.
- Proper Seating of Children and Adults. The driver and all passengers must ride in a vehiclemanufactured seat and properly use a passenger restraint device.(4-6-23)
IDAPA 16.04.18.540 Firearms
Firearms are prohibited in outdoor programs.(4-6-23)
IDAPA 16.04.18.541 (Reserved)
SOLO EXPERIENCES IN OUTDOOR PROGRAMS
Sections 551 – 559
IDAPA 16.04.18.551 Solo Experiences in Outdoor Programs
If an outdoor program conducts a solo component for children, they must have and follow policies and procedures.
Every outdoor program that includes a solo component will include a written description of the solo component in the program description.(4-6-23)
IDAPA 16.04.18.552 Plan
There must be a plan for the solo component, and an individual solo plan for each child. The plans must be documented and approved to ensure that the children are not exposed to unreasonable risks. The plans must include:
-
Individual Solo Plan. The goals, methods, techniques to be used, and time frames will be listed for each participant and each individual plan will be reviewed with the child and signed and dated by the child and the designated staff member.(4-6-23)
-
Ability. There will be consideration of the maturity level, health, physical ability, and emotional state of the child.(4-6-23)
-
Preparation. The child will be instructed on the solo experience, including expectations, restrictions, communication, environment, and emergency procedures.(4-6-23)
-
Backup Plan. There will be documented instructions for a backup plan in case the child's plan does not work.(4-6-23)
-
Responsible Staff. A designated staff member will be responsible for coordination and implementation of the plan.(4-6-23)
IDAPA 16.04.18.553 Solo Sites
Staff must be familiar with the site chosen to conduct solos. The following requirements apply:(4-6-23)
-
Pre-Site Investigation. A pre-site investigation will be conducted and mapped prior to the solo experience. The site will be checked at the time the child is placed to assure that no changes in the environment have taken place since the pre-site investigation that may put the child at risk.(4-6-23)
-
Hazardous Conditions. Any hazardous conditions, including terrain, are to be considered prior to selecting a solo site, considering the age, physical, developmental, and psychological issues of the children in the solo experience.(4-6-23)
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Mapping and Site Coordinates. The selected site will be mapped and the site coordinates will be recorded. The map and the site coordinates will be maintained at the solo site and communicated to the base camp prior to leaving for the solo component.(4-6-23)
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Supplies. Arrangements will be made prior to the solo experience for medication, food, and water drop-offs if needed.(4-6-23)
IDAPA 16.04.18.554 Supervision
Plans for supervision must be in place during the solo experience, and require:(4-6-23)
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Assigned Staff. The assignment of a specific staff member to be responsible for supervising each solo participant.(4-6-23)
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Observation. A predetermined procedure for observation that always ensures the child’s health, safety, and wellbeing, that includes:(4-6-23)
a.Placing children at a distance from each other and the central staff site to allow for appropriate supervision and emergency communication;(4-6-23)
b.Placing children requiring special attention closer to the central staff site;(4-6-23)
c.Clearly defining physical boundaries and any other restrictions;(4-6-23)
d.Instructing children to not participate in potentially dangerous activities;(4-6-23)
e.Notification and check-in systems;(4-6-23)
f.Visual checks; and(4-6-23)
g.Checking the participant's emotional and physical condition daily.(4-6-23)
IDAPA 16.04.18.555 Emergency Procedures
In addition to the requirements under Section 525 of these rules, solo emergency plans must include:(4-6-23)
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Instruction. Instructing participants on the safety and emergency procedures, including evacuation routes.(4-6-23)
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Communication. Providing each participant with signaling capabilities, including a whistle, for emergency notification.(4-6-23)
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Participant Response. Instructing participants on how to respond if the emergency notification system is put into use, including each participant’s requirement to check into the central staff site.(4-6-23)
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Check-In. Provide a check-in system should an emergency occur that includes notification to the base camp and an accounting of each participant's whereabouts and safety.(4-6-23)
IDAPA 16.04.18.556 (Reserved)
STATIONARY OUTDOOR PROGRAMS
Sections 560 – 562
IDAPA 16.04.18.560 Stationary Outdoor Programs
An outdoor program that maintains a designated location for the housing of children is considered stationary and must be subject to additional fire, health, and safety standards.(4-6-23)
IDAPA 16.04.18.561 Fire Safety Requirements
A stationary outdoor camp must be inspected by a state certified fire inspector before being occupied and annually thereafter, with a copy of the inspection maintained. The inspection requires:(4-6-23)
- Fire Extinguishers. One (1) 2-A-10BC type fire extinguisher must be in each of the following locations:(4-6-23)
a.On each floor in any building that houses children;(4-6-23)
b.In any room where cooking or heating occurs;(4-6-23)
c.In a group of tents within a seventy-five (75) foot travel distance; and(4-6-23)
d.Each fire extinguisher will be inspected annually by a fire extinguisher service agency. (4-6-23)
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Smoke Detectors. A smoke detector will be in buildings where children sleep.(4-6-23)
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Escape Routes. At least two (2) escape routes from buildings where children sleep.(4-6-23)
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Flammable Liquids. Flammable liquids will not be used to start fires, be stored in structures that house children, or be stored near ignition sources. If generators are used, they will only be refueled by staff when the generator is not running and is cool to the touch.(4-6-23)
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Electrical. Wiring will be properly attached and fused to prevent overloads.(4-6-23)
IDAPA 16.04.18.562 Health Safety Requirements
A stationary outdoor camp must be inspected by the applicable Public Health District before being occupied and annually thereafter with a copy of the inspection maintained. The inspection requires:(4-6-23)
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Food. Food is stored, prepared, and served in a manner that is protected from contamination.
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Water Supply. The water supply will be from a source that is accepted by the local health authority under IDAPA 58.01.08, “Idaho Rules for Public Drinking Water Systems,” at the time of application and for annual renewal of such licenses.(4-6-23)
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Sewage Disposal. Sewage will be disposed of through a public system, or in absence of a public system, in a manner approved by the local health authority under IDAPA 58.01.03, “Individual/Subsurface Sewage Disposal Rules.”(4-6-23)
IDAPA 16.04.18.563 (Reserved)
16.03.22 Residential Assisted Living Facilities
IDAPA 16.03.22.000 Legal Authority
The Idaho Board of Health and Welfare is authorized under Sections 39-3305 and 39-3358, Idaho Code, to adopt and enforce rules to protect the health, safety, and individual rights for residents in residential assisted living facilities.
IDAPA 16.03.22.001 Scope
These rules set standards for providing services that maintain a safe and healthy environment for residential assisted living facilities. .(7-1-26)
IDAPA 16.03.22.002 (Reserved)
IDAPA 16.03.22.009 Criminal History and Background Check Requirements
01.Criminal History and Background Check.
A residential assisted living facility must complete a criminal history and background check on employees and contractors, who have direct resident access to residents in the residential assisted living facility. The Department check conducted under IDAPA 16.05.06, “Criminal History and Background Checks,” satisfies this requirement.(7-1-26)
a.If a disqualifying crime as described in IDAPA 16.05.06, “Criminal History and Background Checks,” is disclosed, the individual must not have direct resident access to any resident.(3-15-22)
b.The individual is only allowed to work under another employee who has a cleared criminal history and background check while waiting for results. The unlicensed employee may not have one-to-one contact with a resident or access their personal belongings without the supervision of a cleared employee. (7-1-26)
IDAPA 16.03.22.010 Definitions and Abbreviations
01.Advance Directive.
A written instruction, such as a living will or durable power of attorney for health care, recognized under state law, whether statutory or as recognized by the courts of the State, related to the provision of medical care when the individual is unable to communicate.(3-15-22)
02.Behavior Plan. A person-centered document outlining strategies to address and modify a specific behavior, developed based on a functional assessment that identifies the underlying cause of the behavior, and includes proactive steps to prevent the behavior, teach alternate appropriate behaviors, and provide reinforcement for positive interactions.(7-1-26)
03.Call System. A signaling system whereby a resident can contact staff directly from their sleeping room, toilet room, and bathing area. The call system cannot be configured in such a way as to breach a resident’s right to privacy at the facility, including in the resident’s living quarters, in common areas, during medical treatments, while receiving other services, in written and telephonic communications, or in visits with family, friends, advocates, and resident groups.(7-1-26)
04.Cognitive Impairment. When a person experiences loss of short or long-term memory, orientation to person, place, or time, safety awareness, or loses the ability to make decisions that affect everyday life. (3-15-22)
05.Complaint Investigation. A survey to investigate the validity of allegations of noncompliance with applicable state requirements. Allegations will be investigated by the Licensing Agency as described in Section 39-3355, Idaho Code.(3-15-22)
06.Criminal Offense. Any crime as defined in Section 18-111, Idaho Code, 18 U.S.C. Section 4B1.2(a), and 18 U.S.C. Sections 1001 through 1027.(3-15-22)
07.Dementia. A chronic deterioration of intellectual function and other cognitive skills severe enough to interfere with the ability to perform activities of daily living.(3-15-22)
08.Developmental Disability. A developmental disability, as defined in Section 66-402, Idaho Code, means a chronic disability of a person which appears before twenty-two (22) years of age.(7-1-26)
09.Direct Resident Access. In-person access with any resident who resides at the facility, or any access to the residents' personal belongings or information.(3-15-22)
10.Elopement. When a resident who is cognitively, physically, mentally, emotionally, or chemically impaired, physically leaves the facility property or the secured unit or yard without personnel's knowledge. (7-1-26)
11.Hourly Adult Care. Nonresident daily services and supervision provided by a facility to individuals who are in need of supervision outside of their personal residence(s) for a portion of the day.(3-15-22)
12.Incident. An event that can cause a resident injury.(3-15-22)
13.Legal Guardian or Conservator. A court-appointed individual designated to manage the affairs or finances of another person who has been found to be incapable of handling their own affairs.(3-15-22)
14.Maladaptive Behavior. Any behavior that infringes on any resident's rights, or presents a danger to the resident or others..(7-1-26)
15.Medication. Any substance used to treat a disease, condition, or symptom, which may be taken orally, injected, or used externally, and is available through prescription or over-the-counter.(3-15-22)
16.Medication Administration. The process where a prescribed medication is given by a licensed nurse to a resident.(7-1-26)
17.Medication Assistance. The process whereby a non-licensed care provider is delegated tasks by a licensed nurse, to aid a person who cannot independently self-administer medications.(7-1-26)
18.Mental Disorders. Health conditions that are characterized by alterations in thinking, mood, behavior, or some combination thereof, that are all mediated by the brain and associated with distress or impaired functioning.(3-15-22)
19.Mental Illness. Refers collectively to all diagnosable mental disorders.(3-15-22)
20.Nursing Assessment. Information gathered related to a resident's health or medical status that has been reviewed, signed, and dated by a licensed nurse.(7-1-26)
21.Outside Services. Services provided to a resident by someone that is not a member of facility personnel.(3-15-22)
22.Owner. Any person or entity having legal ownership of the facility as an operating business, regardless of who owns the real property.(3-15-22)
23.Personnel. Paid individuals assigned the responsibility of providing care, supervision, and services to the facility and its residents. In this chapter of rules, “personnel” and “staff” are synonymous.(3-15-22)
24.Portable Heating Device. Any device designed to provide heat on a temporary basis that is not designed as part of a building's heating system, is not permanently affixed to the building, and, if electrical, is not hardwired to the building's electrical service. This does not include the use of therapeutic devices such as heating pads, heated mattress pads, and electric blankets, which require a physician or authorized provider’s order. (3-15-22)
25.PRN. Indicates that a medication or treatment prescribed by a medical professional to an individual may be given as needed.(3-15-22)
26.Provisional License. A license which may be issued to a facility not in compliance with the rules pending the satisfactory correction of all deficiencies.(3-15-22)
27.Publicly Funded Program.
Any program funded in whole, or in part, by an appropriation of the U.S. Congress, the Idaho Legislature, or other governmental body.(3-15-22)
28.Punishment. The use of an adverse consequence with a resident, the administration of any noxious or unpleasant stimulus, or deprivation of a resident's rights or freedom.(3-15-22)
29.Relative. A person related by birth, adoption, or marriage.(3-15-22)
30.Repeat Deficiency. A deficiency found on a licensure survey, complaint investigation, or followup survey that was also found on the previous survey.(3-15-22)
31.Reportable Incident. A situation when a facility is required to report information to the Residential Assisted Living Facilities Program, including:(3-15-22)
a.Any resident injury of significant or suspicious nature (i.e., an injury that includes severe bruising, fingerprint bruises, laceration(s) larger than a minor skin tear, sprains, or fractured bones);(3-15-22)
b.Resident elopement of any duration;(3-15-22)
c.Any significant injury resulting from a resident-to-resident incident;(7-1-26)
d.An incident that results in the resident's need for assessment or treatment at a hospital; or (7-1-26)
e.An incident that results in the resident's death.(3-15-22)
32.Scope. The frequency or extent of the occurrence of a deficiency in a facility.(3-15-22)
33.Self-Administration of Medication. The act of a resident taking a single dose of their own medication from a properly labeled container and placing it internally in, or externally on, their own body as a result of an order by an authorized provider.(3-15-22)
34.Survey. A review conducted by a surveyor to determine compliance with statutes and rules.
35.Surveyor. A person authorized by the Department to conduct surveys or complaint investigations to determine compliance with statutes and rules.(3-15-22)
36.Therapeutic Diet. A diet ordered by a physician or authorized provider, including a licensed registered dietician, as part of treatment for a clinical condition or disease.(7-1-26)
37.Toxic Chemical. A substance that is hazardous to health if inhaled, ingested, or absorbed through skin.(3-15-22)
38.Traumatic Brain Injury (TBI). An acquired injury to the brain caused by an external physical force, resulting in total or partial functional disability or psychosocial impairment. The term applies to open or closed-head injuries resulting in impairments in one (1) or more areas.(3-15-22)
39.Unlicensed Assistive Personnel (UAP). Staff, with or without formal credentials, employed to perform nursing care services under the direction and supervision of licensed nurses.(3-15-22)
40.Variance. Permission by the Department to do something contrary to rule.(3-15-22)
IDAPA 16.03.22.011 (Reserved)
IDAPA 16.03.22.050 Variances
The Licensing Agency may grant a variance to a rule provided th e written requests meet the requirements under Title 67 Chapter 52, Idaho Code.(7-1-26)
01.Temporary Variance. A temporary variance may be granted for a specific resident or situation.
02.Continuing A Variance. The Licensing Agency reviews the appropriateness of continuing a variance during the survey process.(7-1-26)
03.Revocation of Variance. The Licensing Agency may revoke a variance if circumstances identify a risk to resident health and safety.(7-1-26)
IDAPA 16.03.22.051 (Reserved)
IDAPA 16.03.22.100 Licensing Requirements
01.Issuance of License.
A license will be issued to any organization upon completing an application demonstrating compliance with these rules.(7-1-26)
02.Distinctive Business Name. Every facility must use a distinctive name, which is registered with the Idaho Secretary of State. The facility will notify the Department within thirty (30) calendar days of a registered name change.(7-1-26)
03.Display of Facility License. The current facility license must be posted in the facility and clearly visible to the general public.(3-15-22)
04.Licensee Responsibility. The licensee of the facility is responsible for the operation of the residential assisted living facility.(7-1-26)
IDAPA 16.03.22.101 (Reserved)
IDAPA 16.03.22.110 Facility License Application
01.License Application. License application forms are available online at the Licensing Agency’s website at http://assistedliving.dhw.idaho.gov. The applicant must provide the following information:(3-15-22)
a.A copy of the Certificate of Assumed Business Name from the Idaho Secretary of State; (3-15-22)
b.A complete set of printed operational policies and procedures;(3-15-22)
c.A copy of the Purchase Agreement, Lease Agreement, or Deed;(7-1-26)
d.A detailed floor plan of the facility, including measurements of all rooms, or a copy of architectural drawings; and(7-1-26)
e.The following must be obtained:(7-1-26)
i.Occupancy permit that the facility is located in a lawfully constituted fire district or affirmation that a lawfully constituted fire authority will respond to a fire at the facility;(7-1-26)
ii.Occupancy permit that all wiring in the facility complies with current electrical codes;(7-1-26)
iii.Occupancy permit or evidence that the facility meets local zoning codes for occupancy and local fire official documenting that the facility meets local fire codes for occupancy.(7-1-26)
02.Written Request for Building Evaluation. The applicant submits a request in writing to the Licensing Agency for a building evaluation. It must include the physical address of the building, the name, telephone number of the person who is to receive the building evaluation report, and be accompanied by a five hundred dollar ($500) initial building evaluation fee.(7-1-26)
03.Identification of the Licensed Administrator. The applicant must provide a copy of the administrator's license and criminal history background check.(7-1-26)
IDAPA 16.03.22.111 (Reserved)
IDAPA 16.03.22.115 Expiration and Renewal of License
01.Application for License Renewal.
The facility must submit to the Licensing Agency an annual report and application for renewal of a license at least thirty (30) days prior to the expiration of the existing license.
02.Existing License. The existing license, unless suspended, surrendered, or revoked, remains in force and effect until the Licensing Agency has acted upon the application renewal, when such application for renewal has been filed.(3-15-22)
IDAPA 16.03.22.116 (Reserved)
IDAPA 16.03.22.126 Effect of Enforcement Action Against a License
The Department will not review an application of an applicant who has an action, either current or in process, against a license held by the applicant in Idaho.(7-1-26)
IDAPA 16.03.22.127 Frequency of Inspections
01.No Core Issues. Facilit ies without core issue deficiencies during two (2) consecutive licensure surveys, will be inspected at least every thirty-six (36) months. For facilities with core issue deficiencies, surveys will be conducted at the discretion of the Licensing Agency, at least every fifteen (15) months.(7-1-26)
02.Complaint Investigations. Complaint investigations will occur based on the severity of the complaint.(7-1-26)
03.Correction of Non-Core Issues. The facility must correct non-core issues within thirty (30) calendar days of the exit conference. If the facility is unable to meet this timeframe, they must inform the Department within thirty (30) calendar days of the exit conference.(7-1-26)
IDAPA 16.03.22.128 (Reserved)
IDAPA 16.03.22.151 Activity Requirements
Each facility must develop and implement a written activ ity policy that encourages, and promotes residents to participate in planned, recreational, and other activities.(7-1-26)
IDAPA 16.03.22.152 Admission Requirements
01.Admissions Policies. Each facility must develop and implement written admission policies and procedures, which must include:(3-15-22)
a.The purpose, quantity, and characteristics of available services;(3-15-22)
b.Criteria for addressing admission, discharge, and transfer of residents to, from, or within the facility.(7-1-26)
02.Acceptable Admissions. Policies for admitting residents to the facility must include:(7-1-26)
a.The facility has the capability, capacity, and services to provide appropriate care;(3-15-22)
b.The resident does not require a type of service for which the facility is not licensed to provide or which the facility does not provide or arrange for; and(3-15-22)
c.The facility has the personnel, appropriate in numbers and with appropriate knowledge and skills to provide such services.(3-15-22)
IDAPA 16.03.22.153 Financial Requirements
Each facility must develop and implement financial policies and procedures that include:(3-15-22)
01.Resident Funds. A policy specifying how the facility will manage resident funds.(7-1-26)
02.Safeguarding of Funds. Specify how residents' funds will be managed and safeguarded and be in compliance with Section 39-3316, Idaho Code. If the facility does manage resident funds, policies must address the
a.The facility cannot require a resident to purchase goods or services from the facility, other than items specified in the admission agreement and facility policies;(3-15-22)
b.Each transaction must include copies of receipts.(7-1-26)
03.Funds at Discharge. When a resident permanently leaves the facility, the facility can only retain room and board funds prorated to the last day of the thirty (30) day notice. Per the admissions agreement, the facility may charge a fee for the repair of damages or cleaning the room. All remaining funds are the property of the resident.
IDAPA 16.03.22.154 Resident Safety Requirements
The facility must develop a written, dated set of policies and procedures that are specific to the populations served in the facility and are available to all staff at all times to direct and ensure compliance with these rules. The facility must develop and implement policies and procedures to address the following:(7-1-26)
01.Response to Accidents, Incidents, or Allegations of Abuse, Neglect, or Exploitation of Residents. This includes how accidents, incidents, or allegations of abuse, neglect, and exploitation are identified, documented, reported, investigated, and followed-up with interventions to prevent re-occurrence and ensure protection.(7-1-26)
02.Response to Emergencies. Staff responsibilities in emergency situations, including:(7-1-26)
a.Medical and psychiatric emergencies;(3-15-22)
b.Resident absence;(3-15-22)
c.Criminal situations; and(3-15-22)
d.Presence of law enforcement officials at the facility.(3-15-22)
03.Notification of Changes to Resident Health or Mental Status. Staff responsibilities and notification requirements for any changes in residents’ health or mental status.(7-1-26)
04.Provided Care and Services by Staff. Staff responsibilities when providing care and services to residents in the following areas:(7-1-26)
a.Activities of daily living;(3-15-22)
b.Dietary and eating, including when a resident refuses to eat or follow a prescribed diet; (3-15-22)
c.Dignity;(3-15-22)
d.Ensuring each individual’s rights;(3-15-22)
e.Medication assistance;(3-15-22)
f.Provision of privacy;(3-15-22)
g.Social activities;(3-15-22)
h.Supervision;(3-15-22)
i.Supporting resident independence; and(3-15-22)
j.Telephone access.(3-15-22)
05.Behavior Management for Residents. The facility must have policies and procedures to ensure staff are trained and complete timely assessment, plan development, and documentation as described in Section 330 of these rules.(3-15-22)
06.Facility Operations, Inspections, Maintenance, and Testing. Plans and procedures for the operation, periodic inspection, and testing of the physical plant, which includes utilities, fire safety, and plant maintenance for all areas of the facility’s campus.(3-15-22)
07.Hazardous Materials. The handling of hazardous materials.(3-15-22)
08.Mechanical Equipment. The handling of potentially dangerous mechanical equipment. (3-15-22)
09.Smoking Requirements. The facility must develop and implement written rules governing smoking. Smoking policies must be available to staff, residents, and visiting public and must ensure:(7-1-26)
a.Smoking is prohibited in areas where combustible supplies or materials, flammable liquids, gases, or oxidizers are in use or stored.(7-1-26)
b.Smoking in bed is prohibited.(7-1-26)
c.Unsupervised smoking by residents classified as not mentally or physically responsible, sedated by medication, or taking oxygen is prohibited.(7-1-26)
d.If smoking is permitted, there must be designated smoking areas which are clearly marked.
Designated smoking areas must have non-combustible disposal receptacles.(7-1-26)
IDAPA 16.03.22.155 Emergency Preparedness Requirements
Each facility must develop and implement an emer gency preparedness plan in the event of fire, explosion, natural disaster, or other emergency.(7-1-26)
01.Relocation Agreements. Each facility must have a current written agreement developed between the facility and two (2) separate locations to which residents would be relocated in the event the building is evacuated and cannot be reoccupied.(7-1-26)
02.Written Procedures. The facility must have written procedures outlining steps to be taken in the event of an emergency including:(3-15-22)
a.Each person's responsibilities;(3-15-22)
b.Where and how residents are to be evacuated; and(3-15-22)
c.Notification of emergency agencies.(3-15-22)
IDAPA 16.03.22.156 Hourly Adult Care Requirements
Facilities offering hourly adult care must develop and impl ement written policies and procedures which include the following:(3-15-22)
01.Services Offered. A description of hourly adult care services, including transportation services (if offered), meals, medical assistance, activities, supervision, and documentation requirements.(7-1-26)
02.Hourly Adult Care. The facility must keep record of names, dates, and description of services provided.(7-1-26)
03.Staffing. Staffing must be based on the needs of the entire facility, including those receiving hourly adult care and residents. Hourly adult care may be provided to as many individuals as possible without disrupting the day-to-day operations and normal activities of the facility.(3-15-22)
04.Accommodations. The facility must provide accommodations appropriate to the time frame for those receiving hourly adult care.(7-1-26)
IDAPA 16.03.22.157 (Reserved)
IDAPA 16.03.22.216 Requirements for Resident Admissions
01.Pre-Admission. Prior to admission, each resident must be assessed by the facility to ensure the resident is appropriate for placement in their residential assisted living facility. The assessment must include the
a.Documentation of level of assistance required for activities of daily living including bathing, dressing, toileting, grooming, eating, communicating and the use of adaptive equipment;(7-1-26)
b.Pre-admission nursing assessment;(7-1-26)
c.Documentation of any maladaptive behaviors including history, intensity, duration, and frequency, including potential contributing factors and mitigation efforts; and(7-1-26)
d.Documentation of the need for related outside services, including service type, name and frequency.(7-1-26)
02.Written Agreement. Prior to, or on the day of admission, the facility and each resident or the resident's legal guardian or conservator must enter into a written admission agreement.
The admission agreement will provide a complete reflection of the facility’s charges, commitments agreed to by each party, and the services to be provided by the facility. The agreement must include the following:(7-1-26)
a.Identify staffing patterns and qualifications of staff on duty during a normal day.(7-1-26)
b.Identify the facility's and resident's roles and responsibilities relating to assistance with medications including the reporting of missed medications or those taken on a PRN basis.(7-1-26)
c.Identify who is responsible for the resident's personal funds.(7-1-26)
d.Identify responsibility for protection and disposition of all valuables belonging to the resident and provision for the return of the resident's valuables if the resident leaves the facility.(7-1-26)
e.Identify conditions under which emergency transfers will be made as provided in Section 152 of these rules.(7-1-26)
f.Provide a description of the facility’s billing practices, notices, and procedures for payments and refunds. The following procedures must be included:(7-1-26)
i.Arrangement for payments;(3-15-22)
ii.Under what circumstances and time frame a partial month's resident fees are to be refunded when a resident no longer resides in the facility; and(3-15-22)
iii.Written notice to vacate the facility must be given thirty (30) calendar days prior to transfer or discharge on the part of either party, except in the case of the resident's emergency discharge or death. The facility may charge up to fifteen (15) days prorated rent from the date of the resident’s emergency discharge or death. The agreement must disclose any charges that will result when a resident fails to provide a thirty (30) day written notice.
g.Specify permission for the facility to transfer information from the resident's records to any facility to which the resident transfers.(7-1-26)
h.Specify resident responsibilities.(7-1-26)
i.Specify any restriction on choice of care or service providers, such as home health agency, hospice agency, or personal care services.(7-1-26)
j.Identify written documentation of the resident's preference regarding the formulation of an advance directive in accordance with Idaho state law. When a resident has an advance directive, a copy must be immediately available for staff and emergency personnel.(7-1-26)
k.Provide the methods by which a resident may contest charges or rate increases including contacting the ombudsman for the elderly.(7-1-26)
l.Disclose the conditions under which the resident can remain in the facility if payment for the resident shifts to a publicly funded program.(7-1-26)
m.Include a copy of the facility's smoking policy.(7-1-26)
IDAPA 16.03.22.217 Requirements for Termination of Admission Agreement
01.Notification. Before a facility discharges a resident, the facility must notify the resident or their representative in writing and their representative of the discharge and the cause.(7-1-26)
02.Facility Responsibility During Resident Discharge. The facility is responsible to assist the resident with transfer by providing a list of skilled nursing facilities, other residential assisted living facilities, and certified family homes that may meet the needs of the resident.(7-1-26)
03.Written Notice of Discharge. The written notice of discharge must include the following:
a.The specific reason for the discharge;(3-15-22)
b.The effective date of the discharge;(3-15-22)
c.A statement informing the resident of their appeal rights including timelines and methods; (7-1-26)
d.The name, address, and telephone number of the local ombudsman;(3-15-22)
e.The name, address, and telephone number of Disability Rights Idaho;(3-15-22)
f.If the resident fails to pay fees to the facility during the discharge appeal process, the resident's appeal of the involuntary discharge becomes null and void and the discharge notice applies; and(7-1-26)
g.When the notice does not contain all the above required information, the notice is void and must be reissued.(3-15-22)
04.Resident's Appeal of Involuntary Discharge. A resident may appeal all discharges, with the exception of an involuntary discharge in the case of nonpayment or emergency conditions that require the resident to be transferred to protect the resident or other residents in the facility from harm.(7-1-26)
05.Receipt of Appeal. The Department must receive the appeal request within thirty (30) calendar days of receipt of written notice of discharge.(7-1-26)
IDAPA 16.03.22.218 (Reserved)
IDAPA 16.03.22.250 Requirements for Building Construction and Physical Standards
01.Construction Changes.
For all new construction, changes of occupancy, modifications, additions, or renovations to existing buildings, the facility must submit construction drawings with specifications to the licensing authority for review and approval prior to any work being started. All new construction and conversions must install audible and visual notification devices for fire alarm systems in all common areas and resident rooms no matter the size of facility.(3-15-22)
02.Plans and Specifications.Plans must be prepared, signed, stamped, and dated by an architect or engineer licensed in the state of Idaho and submitted to the Department after approval of local authorities.(7-1-26)
03.Approval. All buildings, additions, and renovations are subject to approval by the Licensing Agency and must meet applicable requirements.(3-15-22)
04.Toilets and Bathrooms. Each facility must provide:(3-15-22)
a.A toilet and bathroom for resident use so arranged that it is not necessary for an individual to pass through another resident's room to reach the toilet or bath;(3-15-22)
b.Solid walls or partitions to separate each toilet and bathroom from all adjoining rooms; (3-15-22)
c.Mechanical ventilation to the outside from all inside toilets and bathrooms not provided with an operable exterior window;(3-15-22)
d.Adequate number of bathrooms to meet the needs of the residents admitted to the facility; (7-1-26)
05.Accessibility for Persons with Mobility and Sensory Impairments. For residents who have mobility or sensory impairments, the facility must provide a physical environment which meets the needs of the person for independent mobility and use of appliances, bathroom facilities, and living areas. New construction must meet the requirements of the Americans with Disabilities Act Accessibility Guidelines (ADAAG). Existing facilities must comply, to the maximum extent feasible.(7-1-26)
06.Plumbing. The temperature of hot water at plumbing fixtures used by residents must be between one hundred five degrees Fahrenheit (105°F) and one hundred twenty degrees Fahrenheit (120°F).(7-1-26)
07.Heating, Ventilation, and Air-Conditioning (HVAC). Equipment must be furnished, installed, and maintained to meet all requirements of current state and local mechanical, electrical, and construction codes. An HVAC system must be capable of maintaining a minimum temperature of seventy degrees Fahrenheit (70°F) and a maximum temperature of seventy-eight degrees Fahrenheit (78°F) during the day, and a minimum of sixty-two degrees Fahrenheit (62°F) and a maximum temperature of seventy-five degrees Fahrenheit (75°F) during the night.
Wood stoves, gas fireplaces, or solid burning fireplaces are not permitted as the sole source of heat, and the thermostat for the primary source of heat must be remotely located away from any of these sources.(7-1-26)
a.Portable heating devices of any kind are prohibited in resident sleeping areas;(7-1-26)
b.All fireplaces must provide a safety barrier that is tip resistant and ensures resident safety; (7-1-26)
c.Boilers, hot water heaters, and unfired pressure vessels must be equipped with automatic pressure relief valves;(3-15-22)
d.Fire and smoke dampers must be inspected, serviced, and cleaned once every four (4) years by a person professionally engaged in the business of servicing these devices or systems. A copy of these results must be kept in the facility.(3-15-22)
08.Dining, Recreation, Shower, Bathing, and Living Space. The total area set aside for these purposes must be no less than thirty (30) square feet per licensed bed. A hall or entry cannot be included as living or recreation space.(3-15-22)
09.Resident Sleeping Rooms. The facility must ensure that:(3-15-22)
a.Not more than two (2) residents can be housed in any multi-bed sleeping room;(7-1-26)
b.Square footage requirements for resident sleeping rooms must provide for not less than one hundred (100) square feet of floor space per resident in a single-bed sleeping room and not less than eighty (80) square feet of floor space per resident in a multi-bed sleeping room. For facilities constructed after January 1, 2021, square footage requirements for resident sleeping rooms must provide at least one hundred (100) square feet of floor space per resident for both single-bed and multi-bed sleeping rooms.(3-15-22)
c.The operable windowsill height must not exceed forty-four (44) inches above the floor in existing buildings being;(7-1-26)
d.Window screens must be provided on operable windows; and(7-1-26)
e.Closet space in each resident sleeping room must provide at least four (4) usable square feet per resident. Common closets used by two (2) or more residents must have substantial dividers for separation of each resident's clothing. All closets must be equipped with doors. Free-standing closets are deducted from the square footage of the sleeping room.(3-15-22)
10.Secure Environment. If the facility accepts and retains residents who have cognitive impairment and have a history of elopement or attempted elopement, the facility must provide an interior environment and exterior yard that is secure and safe. The secured environment and security provided must be evaluated and adjusted as necessary to meet the needs of all residents.(7-1-26)
11.Call System. The facility must have a call system available for each resident and maintain the resident’s right to privacy, including in the resident’s living quarters and common areas, during medical treatment, and other services, and in written and telephonic communications, or in visits with family, friends, advocates, and resident groups. The call system cannot be a substitute for supervision.(7-1-26)
IDAPA 16.03.22.251 (Reserved)
IDAPA 16.03.22.260 Requirements for Environmental Sanitation
01.Water Supply.
Water supply must be from an approved private, public, or municipal water supply.
a.Water from a private supply must have water samples submitted annually to either a private accredited laboratory or to the Public Health District Laboratory for bacteriological examination. The Department may require more frequent examinations if warranted.(7-1-26)
02.Garbage and Refuse Disposal. Garbage and refuse disposal must be provided to ensure that:
a.The premises and all buildings must be kept free from the accumulation of weeds, trash, and rubbish;(3-15-22)
b.Material not directly related to the maintenance and operation of the facility must not be stored on the premises; and(7-1-26)
c.Garbage containers must be maintained in a sanitary manner. Sufficient containers must be afforded to hold all garbage and refuse which accumulates between periods of removal from the facility.(7-1-26)
03.Insect and Rodent Control. A pest control program must effectively prevent insects, rodents, and other pests from entrance to, or infestation of, the facility.(7-1-26)
04.Linen and Laundry Facilities and Services.(3-15-22)
a.The facility must have linen suitable to the proper care and comfort of residents; and(7-1-26)
b.Not thread-bare, torn, or stained;(7-1-26)
c.Handled, processed, and stored in an appropriate manner that prevents contamination;(7-1-26)
d.Situated in an area separate and apart from where food is stored, prepared, or served;(7-1-26)
e.Soiled linen and clothing must be properly handled to prevent contamination. Clean linen and clothing received from a laundry service must be stored in a proper manner to prevent contamination; and(7-1-26)
f.Residents' and personnel’s personal laundry must be collected, transported, sorted, washed, and dried in a sanitary manner and cannot be washed with general linens (e.g., towels and sheets).(3-15-22)
05.Housekeeping and Maintenance Services. Housekeeping, maintenance personnel, and equipment must be provided to maintain the interior and exterior of the facility in a clean, safe, and orderly manner. Prior to occupancy of any sleeping room by a new resident, the room must be thoroughly cleaned including the bed, bedding, and furnishings.(3-15-22)
06.Toxic Chemicals. All toxic chemicals must be properly labeled. Toxic chemicals cannot be stored where food is stored, prepared, or served, where medications are stored, and where residents with cognitive impairment have access.(3-15-22)
IDAPA 16.03.22.261 (Reserved)
IDAPA 16.03.22.305 Requirements for the Licensed Nursing Assessment
For each resident the licensed nurse must assess, document, date and sign, the following:(7-1-26)
01.Pre-Admission Assessment. A review of the resident’s health and medical status including identification of medical and care needs.(7-1-26)
02.Quarterly Nursing Assessments. The facility nurse must visit the facility at least once every ninety (90) days to conduct quarterly assessments. The assessments must include:(7-1-26)
a.Review of the residents’ health and medical status, including any changes in medical or physical status; and(7-1-26)
b.Recommendations for changes needed to the NSA to meet the residents’ needs.(7-1-26)
03.Change in Resident Health Status. Physical assessment, identifying symptoms of illness, or changes in mental or physical health status.(7-1-26)
04.Recommendations. Notify the administrator regarding any medical changes requiring amendments to the NSA. Notify the physician or authorized provider of medical changes.(7-1-26)
05.Self-Administered Medication. Residents must be assessed prior to self-administering medications and every ninety (90) days thereafter.(7-1-26)
IDAPA 16.03.22.306 (Reserved)
IDAPA 16.03.22.310 Requirements for Medications and Treatments
Facility policies and procedures must specify how medications will be handled.(3-15-22)
01.Medication Distribution. The facility must ensure.(7-1-26)
a.All medications must be kept in a locked area such as a locked box or room;(3-15-22)
b.Poisons, toxic chemicals, and cleaning agents must not be stored with medications;(3-15-22)
c.Biologicals and other medications requiring cold storage must be maintained per manufacturer’s guidelines and the temperature monitored and documented weekly;(7-1-26)
d.Each prescription medication must be given to the resident directly from the medi-set, blister pack, or medication container;(3-15-22)
e.Each resident must be observed taking the medication; and(3-15-22)
f.Medications and treatments must be provided per physician or authorized provider orders. (7-1-26)
02.Discontinued and Expired Prescriptions. Discontinued or outdated medications and treatments must be removed from the resident's medication supply and cannot accumulate at the facility for longer than thirty (30) days. The unused medication must be disposed of properly. The facility must document the following: (7-1-26)
a.A description of the drug, including the amount;(3-15-22)
b.Name of the resident for whom the medication is prescribed;(3-15-22)
c.The method and date of disposal; and(7-1-26)
d.Signatures of responsible facility personnel and witness.(3-15-22)
03.Controlled Substances. The facility must track all controlled substances entering the facility, including the amount received, the date, a daily count, reconciliation of the number given or disposed, and the number remaining.(3-15-22)
04.Behavior Modifying Medication.(7-1-26)
a.Psychotropic or behavior modifying medication intervention must not be the first resort to address behaviors. The facility must attempt non-drug interventions to assist and redirect the resident’s behavior.(3-15-22)
b.The facility must document residents’ response to the medications including demonstrated behaviors and any side effects that impacted the residents’ health or safety.(7-1-26)
c.The facility must provide behavior updates to the physician or authorized provider when requested.
IDAPA 16.03.22.311 (Reserved)
IDAPA 16.03.22.320 Negotiated Service Agreement (nsa) Requirements
An interim plan must be developed and used while the NSA is being completed.(7-1-26)
IDAPA 16.03.22.321 (Reserved)
IDAPA 16.03.22.330 Requirements for Facility Records
The facility must develop policies and procedures in accordance with Sections 39-3316, Idaho Code, for a minimum of three (3) years.(7-1-26)
01.Paper Records. All paper records must be recorded legibly in ink.(3-15-22)
02.Record Confidentiality. The facility must comply with the Health Insurance Portability and Accountability Act (HIPAA).(7-1-26)
03.Resident Care Records. Each resident must have an individual care record. Entries must be documented during each shift and completed by the person providing the care, including the date, time, name, and title of the person making the entry.(7-1-26)
a.The plan of care must be available to staff at all times and include:(7-1-26)
i.A copy of written, signed, and dated medication and treatment orders;(7-1-26)
ii.Treatments, wound care, assistance with medications, and any delegated nursing tasks. PRN medication use (if applicable), including the reason for taking the medication and the efficacy;(7-1-26)
iii.Documentation when the resident refuses care or services or the resident missed taking prescribed medication including the reason;(7-1-26)
iv.Notification to the facility nurse of changes in the resident's physical or mental condition;
v.Nursing assessments;(7-1-26)
vi.The results of any physician or authorized provider visits, including phone calls to providers including the reason and outcome;(7-1-26)
vii.Copies of all signed and dated care plans prepared by outside service agencies;(3-15-22) viii.Notes regarding outside services and care provided to the resident, such as home health, hospice, or physical therapy;(3-15-22)
ix.Unusual events such as incidents, accidents, or altercations, and the facility's response; and
x.Documentation the physician, authorized, and legal representative provider has been contacted when a resident consistently refuses medical treatment or physician orders.(7-1-26)
04.Behavior Documentation. For residents who exhibit maladaptive behaviors, the facility must maintain documentation of the following:(7-1-26)
a.An assessment of maladaptive behaviors.(7-1-26)
b.A behavior plan that includes interventions;(7-1-26)
i.Interventions must be the least restrictive possible and must include the date and time of each maladaptive behavior, a description of the behavior, the interventions implemented and the effectiveness of each intervention.(7-1-26)
05.Discharge Records. Resident discharge documentation must include:(3-15-22)
a.A copy of the written notice of discharge if applicable;(7-1-26)
b.The date and the location where the resident was discharged; and(7-1-26)
c.The disposition of the resident's belongings.(3-15-22)
06.Additional Resident Records. The facility must also maintain the following for each resident:
a.A record of all resident personal property with a value of more than fifty dollars ($50); and
b.A record of complaints or grievances including the date received, the investigation and the outcome.(7-1-26)
07.Resident Admission and Discharge Register. The facility must maintain an admission and discharge register listing the name of each resident, the date admitted, and the date discharged.(7-1-26)
08.Dietary Records. The facility must maintain on-site a minimum of three (3) months of dietary records including:(7-1-26)
a.Planned, substitution, and therapeutic menus that have been approved and signed by a licensed registered dietitian.(7-1-26)
09.Water Supply. Laboratory reports documenting the bacteriological examination of a private water supply.(7-1-26)
10.Personnel Records. A record for each employee must be maintained and available, which includes the following:(3-15-22)
a.The employee's name, address, phone number, and date of hire;(3-15-22)
b.A job description that includes the purpose, responsibilities, duties, and authority;(3-15-22)
c.A copy of a valid license for nursing staff;(7-1-26)
d.Signed and dated record of all required staff training;(7-1-26)
e.Copies of CPR and first aid certifications;(3-15-22)
f.Evidence of medication training;(7-1-26)
g.Criminal history and background check results;(7-1-26)
h.Documentation by the licensed nurse of delegation to unlicensed staff;(7-1-26)
i.A signed and dated record identifying any administrator or manager designees; and(7-1-26)
j.Records of contracts with outside service providers and contract staff.(7-1-26)
11.As Worked Schedules. Work records indicating direct care staff names and shifts worked.
12.Fire and Life Safety Records. The administrator must ensure the facility's records for fire and life safety are maintained. The facility must maintain on file:(3-15-22)
a.The results of fire detection, alarm inspections, maintenance, and test results including:(7-1-26)
i.The results of the annual inspection and tests; and(3-15-22)
ii.Smoke detector sensitivity testing results.(3-15-22)
b.The results of any sprinkler system inspections, maintenance, and tests;(7-1-26)
c.Monthly examination of portable fire extinguishers, including initials and date and documenting the following:(7-1-26)
i.Each extinguisher seal or tamper indicator is not broken;(3-15-22)
ii.Each extinguisher has not been physically damaged;(3-15-22)
iii.Each extinguisher gauge shows a charged condition; and(3-15-22)
IDAPA 16.03.22.331 (Reserved)
IDAPA 16.03.22.335 Requirements for Infection Control
The facility must develop policies and p rocedures consistent with recognized standards that control and prevent infections for both staff and residents.(7-1-26)
01.Staff with an Infectious Disease. Staff with an infectious disease must not work until the infectious stage no longer exists or must be reassigned to a work area where contact with others is not expected and likelihood of transmission of infection is absent.(3-15-22)
- Standard Precautions. Standard precautions for infection prevention must be in accordance with the Centers for Disease Control and Prevention (CDC) guidelines.(7-1-26)
03.Reporting of Individual with an Infectious Disease. Facilities must report any cases of resident or staff illness consistent with the diseases listed in IDAPA 16.02.10, “Idaho Reportable Diseases.” The facility must follow guidance from local health districts.(7-1-26)
IDAPA 16.03.22.336 (Reserved)
IDAPA 16.03.22.405 Additional Fire and Life Safety Standards for All Buildings and
FACILITIES.
01.Medical Gases. Handling, use, and storage of medical gas must be according to local fire code standards.(7-1-26)
02.Natural or Man-Made Hazards. When natural or man-made hazards are present on the facility property or border the facility property, suitable fences, guards, railing, or a combination must be installed to provide protection for the residents.(3-15-22)
03.Telephone. The facility must have a telephone on the premises available for staff use in the event of an emergency. Emergency telephone numbers must be posted near the telephone.(3-15-22)
04.Prohibited Applications. The following are prohibited uses of a Relocatable Power Tap. (7-1-26)
a.Medical equipment;(7-1-26)
b.Daisy chain or plugging one (1) plug strip into a second plug strip;(7-1-26)
c.Appliances;(7-1-26)
d.As a convenience, in lieu of permanent installed receptacles; and(7-1-26)
e.Extend through walls, ceilings, floors, under doors or floor coverings, or be subject to environmental or physical damage.(7-1-26)
IDAPA 16.03.22.406 (Reserved)
IDAPA 16.03.22.410 Requirements for Emergency Actions and Fire Drills
Fire drills must be conducted quarterly and at least one per shift per year and include date and time of drill including personnel and residents involved.(7-1-26)
01.Report of Fire. Any fire or fire incident occurring within the facility must be reported to the Department within fifteen (15) days of the occurrence. A fire incident is considered any activation of the building's fire alarm system other than a false alarm, during testing of the fire alarm system, or during a fire drill.(7-1-26)
02.Fire Watch. Where a required fire alarm system or fire sprinkler system is out of service for more than four (4) hours in a twenty-four (24) hour period, the local jurisdiction must be notified, and the building evacuated, or an approved and documented fire watch provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.(7-1-26)
IDAPA 16.03.22.411 (Reserved)
IDAPA 16.03.22.430 Requirements for Furnishings, Equipment, and Supplies
Each facility must provide:( 7-1-26)
01.Common Shared Furnishings. Common areas must be furnished with appropriate reading lamps, tables, chairs, or sofas that are clean, safe, and in good repair.(7-1-26)
02.Resident Sleeping Room Furnishings. All facility provided furnishings such as a dresser, or bed, must be in good repair, clean, and safe. Resident beds shall be at least thirty-six (36) inches wide.(7-1-26)
03.Resident Telephone Privacy. The facility must have at least one (1) telephone that is accessible to all residents, and provide local calls at no additional cost. The telephone must be placed in such a manner as to provide the resident privacy while using the telephone.(3-15-22)
04.Basic Services. Basic services and personal supplies must be provided in accordance with the admission agreement.(7-1-26)
IDAPA 16.03.22.431 (Reserved)
IDAPA 16.03.22.450 Requirements for Food and Nutritional Care Services
The facility food services must meet the standards in IDAPA 16.02.19, “Idaho Food Code.”(7-1-26)
IDAPA 16.03.22.451 Menu and Diet Planning
01.Menu. Must be plann ed approved, signed, and dated by a licensed registered dietitian.(7-1-26)
a.Menus will provide a sufficient variety of foods in adequate amounts at each meal;(3-15-22)
b.The weekly menu must be posted in a facility common area; and(7-1-26)
c.The facility must serve the planned menu. If substitutions are made, the menu must be modified to reflect the substitutions.(3-15-22)
02.Therapeutic Diets. Therapeutic menus must be planned, approved, signed, and dated by a licensed registered dietitian.(7-1-26)
IDAPA 16.03.22.452 (Reserved)
IDAPA 16.03.22.455 Food Supply
The facility must maintain a seven (7) day supply of nonperishable foods and a two (2) day supply of perishable fo ods. The facility's kitchen must have the types and amounts of food to be served readily available to meet all planned menus during that time.(3-15-22)
IDAPA 16.03.22.456 (Reserved)
IDAPA 16.03.22.460 Food Preparation and Service
01.Food Preparation. Foods must be prepared by methods that conserve nutritional value, flavor, and appearance.(3-15-22)
02.Frequency. Meals must be served at least three (3) times per day at regular intervals with snacks and fluids offered between meals.(7-1-26)
03.Disposable Items. The facility will not use single-use items except in unusual circumstances for a short period of time or for special events.(3-15-22)
IDAPA 16.03.22.461 (Reserved)
IDAPA 16.03.22.600 Requirements for Staffing Standards
The facility must develop policies and procedures for s taffing to ensure adequate care is provided to residents which include:(7-1-26)
01.On-Duty Staff Up and Awake During Residents' Sleeping Hours.Staff must be up and awake, and immediately available in the facility during resident sleeping hours.(7-1-26)
02.Detached Buildings or Units. Facilities with detached buildings or units must have at least one (1) staff present and available in each building when residents are present.(7-1-26)
03.Cardio-Pulmonary Resuscitation (CPR) and First Aid Certification. Provide for at least one (1) direct care staff with certification in first aid and CPR in the facility at all times. Facilities with multiple buildings or units will have at least one (1) direct care staff with certification in first aid and CPR in each building or each unit at all times.(7-1-26)
IDAPA 16.03.22.601 (Reserved)
IDAPA 16.03.22.625 Orientation Training Requirements
Staff must complete orientation training specific to their job description as described in Section 39-3324, Idaho Code, within thirty (30) days of hire. Prior to working alone staff must have completed the orientation training requirements.(7-1-26)
01.Number of Hours of Training. A minimum of sixteen (16) hours of job-related orientation training must be completed prior to providing unsupervised personal assistance to residents. The means and methods of training are at the facility’s discretion.(7-1-26)
02.Content for Training. Orientation training must include the following:(3-15-22)
a.Resident rights;(3-15-22)
b.Reporting and documentation requirements for allegations of abuse, neglect, and exploitation;
c.Relevant policies and procedures; and(7-1-26)
d.Training must be specific and appropriate to the population served.(7-1-26)
IDAPA 16.03.22.626 (Reserved)
IDAPA 16.03.22.640 Continued Training Requirements
Each employee must receive a minimum of eight (8) hours of job-related continued training per year.(3-15-22)
IDAPA 16.03.22.641 Additional Training Related to Changes
When policies or procedures are added, modified, or deleted, the date of the change must be specified on the policy and staff training must be updated.(7-1-26)
IDAPA 16.03.22.642 (Reserved)
IDAPA 16.03.22.645 Assistance with Medications
01.Training Requirements. Prio r to assisting residents with medications, staff must complete the
a.A medication assistance course offered by one (1) of Idaho’s community colleges or a curriculum approved by the Department. This training is in addition to the curriculum minimum orientation requirements.
b.Staff training on documentation requirements and how to respond when a resident refuses or misses a medication, receives an incorrect medication, or when medication is unavailable or missing.(3-15-22)
02.Delegation. The facility nurse must delegate and document assistance with medications and other nursing tasks. Each medication assistant must be delegated individually, including skill demonstration, prior to assisting with medications or nursing tasks, and any time the licensed nurse changes.(3-15-22)
IDAPA 16.03.22.646 (Reserved)
IDAPA 16.03.22.900 Enforcement Actions
Enforcement actions, as descri bed in these rules and Sections 39-3357 and 39-3358, Idaho Code, are actions the Department can impose upon a facility. The Department will consider a facility's compliance history, and the number, scope, and severity of the deficiencies when initiating or extending an enforcement action. The Department can impose any of the enforcement actions, independently or in conjunction with others.(7-1-26)
IDAPA 16.03.22.901 Enforcement Action
If the Department determined non-complia nce with these rules immediately jeopardizes the health or safety of residents the Department may take action in accordance with Section 39-3358, Idaho Code.(7-1-26)
IDAPA 16.03.22.902 (Reserved)
IDAPA 16.03.22.910 Enforcement Action of a Consultant
A consultant may be required when an acceptable plan of correctio n has not been submitted, or if the Department identifies repeat deficient practice(s) in the facility. The consultant is required to submit periodic reports to the Licensing Agency.(7-1-26)
IDAPA 16.03.22.911 (Reserved)
IDAPA 16.03.22.920 Enforcement Action of Limit on Admissions
01.Reasons for Limit on Admissions.
The Department may limit admissions for the following reasons:(3-15-22)
a.The facility is inadequately staffed or the staff is inadequately trained to handle more residents;
b.The facility otherwise lacks the resources necessary to support the needs of more residents;
c.The Department identifies repeat core issues during any follow-up survey; or(7-1-26)
d.An acceptable plan of correction is not submitted as described in Section 39-3352, Idaho Code.
02.Notification of Limit on Admissions. Limits or bans on admissions will remain in effect until the Department determines the facility has achieved substantial compliance with requirements or receives written evidence and statements from the outside consultant that the facility is in compliance.(7-1-26)
IDAPA 16.03.22.921 (Reserved)
IDAPA 16.03.22.925 Enforcement Action of Civil Monetary Penalties
01.Civil Monetary Penalties. M ay be imposed when it is determined a facility is operating without a license, has repeat non-core deficiencies that place residents at significant risk for potential harm, or the facility fails to comply with conditions of the provisional license. Actual harm to a resident or residents does not need to occur. A single act, omission, or incident will not give rise to imposition of multiple penalties, even though such act, omission, or incident may violate more than one (1) rule.(7-1-26)
02.Assessment Amount for Civil Monetary Penalty. Civil monetary penalties are assessed at ten dollars ($10) for each day the facility is or was out of compliance per deficiency, multiplied by the total number of occupied licensed beds.(7-1-26)
a.In any ninety (90) day period, the penalty amounts may not exceed the limits shown in the following table:
03.Notice of Civil Monetary Penalties and Appeal Rights. The Department will give written notice informing the facility of the amount of the penalty, the basis for its assessment and the facility's appeal rights.
04.Payment of Penalties. The facility must pay the full amount of the penalty within thirty (30) calendar days from the date the notice is received, unless the facility requests an administrative review. The civil monetary penalty determined through administrative review must be paid within thirty (30) calendar days of the dated administrative review decision, unless the facility requests an administrative hearing. The amount of the civil monetary penalty determined through an administrative hearing must be paid within thirty (30) calendar days of the dated hearing decision unless the facility files a petition for judicial review. Interest accrues on all unpaid penalties at the legal rate of interest for judgments. Such interest accruement will begin one (1) calendar day after the date of the initial assessment of the penalty.(7-1-26)
05.Failure to Pay. Failure of a facility to pay the entire penalty, together with any interest, is cause for revocation of the license or the amount will be withheld from Medicaid payments to the facility.(3-15-22)
IDAPA 16.03.22.926 (Reserved)
IDAPA 16.03.22.930 Enforcement Action of Temporary Management
Limits on Accruing Civil Monetary Amount Number of Occupied Beds in Facility Repeat Deficiency 3-4 Beds$2 ,880 5-50 Beds$6,400 51-100 Beds$10,800 101-150 Beds$17,600 151 or More Beds$29,200
01.Need for Temporary Management. The Department may impose, and appoint the use of temporary management in situations where it is determined there is immediate jeopardy to the health and safety of the residents, such as:(7-1-26)
a.To ensure the safe relocation of residents due to a facility closure; or(7-1-26)
b.A temporary manager is necessary to bring the facility back into substantial compliance pending improvements to bring the facility into compliance with program requirements.(7-1-26)
02.Powers and Duties of the Temporary Manager. The temporary manager will have the authority to direct and oversee the day-to-day operations of the facility including the enforcement of policies and procedures and ensuring the facility is in compliance with these rules.(7-1-26)
03.Responsibility for Payment of the Temporary Manager. All compensation and per diem costs of the temporary manager must be paid by the licensee.(3-15-22)
IDAPA 16.03.22.931 (Reserved)
IDAPA 16.03.22.935 Enforcement Action of a Provisional License
A provisional license may be issued when a facility has one (1) or more core issues, when non-core issues have not been corrected, have become repeat deficiencies, or an acceptable plan of correction is not submitted as described in these rules. The provisional license will state the conditions the facility must follow to continue to operate. (3-15-22)
IDAPA 16.03.22.936 (Reserved)
16.06.03 Daycare Licensing
IDAPA 16.06.03.000 Legal Authority
Sections 39-1107, 39-1111, 56-1003, 56-1005(8), and 56-1007, Idaho Code, and Tittle 56, Chapter 27, Idaho Code, authorize the Department and the Board to adopt and enforce rules for licensing daycare centers, group daycare facilities, and family daycare homes.(7-1-24)
IDAPA 16.06.03.001 Incorporation by Reference
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Occupational Safety Health Act (OSHA). A copy of OSHA may be obtained at the Idaho Industrial Commission, 317 Main Street., P.O. Box 83720, Boise, Idaho, 83720-0041 or at https://www.osha.gov/ sites/default/files/publications/OSHA2001.pdf.(7-1-24)
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Crib Safety – Full Size Baby Cribs. Crib Safety. Consumer Product Safety Commission, Compliance information for full size cribs can be found at https://www.cpsc.gov/Business--Manufacturing/Business- Education/FAQ?p=3019&tid%5b3028%5d=3028.(7-1-24)
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Crib Safety -- Non-Full-Size Baby Cribs. Crib Safety. Consumer Product Safety Commission, Compliance information for non-full size cribs can be found at https://www.cpsc.gov/Business--Manufacturing/ Business-Education/FAQ?p=3019&tid%5b3029%5d=3029.(7-1-24)
IDAPA 16.06.03.002 (Reserved)
IDAPA 16.06.03.009 Background Check Requirements
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Compliance. Department enhanced background checks are required for individuals licensed under these rules and must comply with IDAPA 16.05.06, “Criminal History and Background Checks.”(7-1-24)
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Background Check Requirements. Each owner, operator, or applicant seeking licensure for a daycare facility must submit evidence that the following individuals successfully completed and received a clearance for a Department enhanced background check, at least every five (5) years, under Sections 39-1105 and 39-1113, Idaho Code:(7-1-24)
a.Owners, operators, and staff;(7-1-24)
b.All other individuals thirteen (13) years old or older who have unsupervised direct contact with children; or(7-1-24)
c.All other individuals thirteen (13) years old or older who are in the household or regularly on the premises.(7-1-24)
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Family Daycare Homes. Under Section 39-1114, Idaho Code, any person providing daycare for four (4) or more children in a family daycare home is required to comply with Sections 39- 1105 and 39-1113, Idaho Code.(7-1-24)
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Background Check Frequency. The Department can require a background check at any time on any individual who is an owner, operator, staff, household member of a daycare facility, and all other individuals who are thirteen (13) years old or older who have unsupervised direct contact with children or who are regularly on the premises.(7-1-24)
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Juvenile Justice Records. The enhanced background check for individuals under eighteen (18) years, must include a check of the juvenile justice records, as authorized by the minor and their parent or guardian.
Records must be checked for each jurisdiction in which the individual has resided since becoming thirteen (13) through eighteen (18) years old. Each owner, operator, or applicant is responsible for requesting a check of the juvenile justice record, the associated costs of these records, and submitting them to the Department for review. A check of the juvenile justice records must include the following:(7-1-24)
a.Juvenile justice records of adjudication of the magistrate division of the district court; (7-1-24)
b.County probation services; and(7-1-24)
c.Department records.(7-1-24)
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Cost of Background Check and Juvenile Justice Records. Each individual who requests and obtains a Department background check is responsible for the cost of the background check and check of juvenile justice records.(7-1-24)
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Private Schools and Private Kindergartens. Under Section 39-1105, Idaho Code, any person who owns, operates, or is employed by a private school for educational purposes for children four (4) through six (6) years old or a private kindergarten must comply with Sections 39-1105 and 39-1113, Idaho Code.(7-1-24)
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Reporting Convictions. Following completion of a background check and clearance, additional criminal convictions, and juvenile justice adjudications for disqualifying crimes under Section 39-1113, Idaho Code, must be self-disclosed by the individual to the owner or operator of a daycare facility. The owner or operator must report these additional convictions and adjudications to the Department within five (5) days of learning of the conviction or adjudication.(7-1-24)
IDAPA 16.06.03.010 (Reserved)
IDAPA 16.06.03.121 Application for Daycare License or Renewal
Any individual applying for licensure as a daycare facility must be at least eighteen (18) years old, apply, and provide information required by the Department under this rule, to include:(7-1-24)
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Completed Licensing Application.(7-1-24)
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Licensing Fee. The applicant must pay the appropriate licensing fee prior to the issuance of a daycare license.(7-1-24)
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Inspection Reports. The following reports must be submitted to the Department with the application that prove the facility or proposed facility meets:(7-1-24)
a.Building code under IDAPA 24.39.30, “Rules of Building Safety (Building Code Rules),” where required;(7-1-24)
b.Electrical code under IDAPA 24.39.10, “Rules of the Idaho Electrical Board,” where required;
c.Fire code under Section 41-253, Idaho Code, where required; and(7-1-24)
d.Local planning and zoning requirements. All daycare facilities must comply with applicable city and county ordinances.(7-1-24)
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Proof of Insurance. The applicant must provide proof of current fire and liability insurance coverage for the daycare facility.(7-1-24)
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Background Clearance. Evidence that the applicant and all individuals required to have a background check have received a clearance from the Department.(7-1-24)
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Statement to Comply. As part of the application, the applicant must thoroughly read and review these rules and agree that they are prepared to comply with all provisions. Providers must also certify that they will not harm, shake, or abuse children, and that children in their care will not experience maltreatment under 45 CFR 98.41.(7-1-24)
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Statement Disclosing Revocation or Disciplinary Actions. A written statement that discloses any revocation or other disciplinary action taken or in the process of being taken against the applicant as a daycare provider in any jurisdiction, or a statement from the applicant stating they have never been involved in any such action.(7-1-24)
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Other Information as Requested. The applicant must provide other information that may be requested by the Department for the proper administration and enforcement of these rules.(7-1-24)
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Health and Safety Inspection. The Department will order a health and safety inspection of the daycare facility once the application for licensure is complete and the licensing fee has been paid.(7-1-24)
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Additional Requirements for License Renewal. A daycare license must be renewed every two (2) years. The daycare operator must submit to the Department the renewal application, fee, and all required documentation in this rule at least forty-five (45) days prior to the expiration of the current daycare license. (7-1-24)
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Relicense. When a renewal application has been completed correctly, the existing license will, unless officially revoked, remain in force until the Department has acted on the application for renewal. (7-1-24)
IDAPA 16.06.03.122 (Reserved)
IDAPA 16.06.03.123 Disposition of Applications
The Department will initiate action on each completed application within thirty (30) days after receipt that addresses each requirement for the specific type of daycare license. Upon receipt of a completed application, the Department will review the materials for compliance with these rules.(7-1-24)
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Termination of Application Process. Failure of the applicant to cooperate with the Department in the application process may result in the termination of the application process. Failure to cooperate means that the information requested is not provided within ninety (90) days, or not provided in the form requested by the Department, or both.(7-1-24)
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Denial of Application. If an application is denied, a signed letter will be sent directly to the applicant by registered or certified mail, advising the applicant of the denial and stating the basis for such denial. An applicant whose application has been denied may not reapply until after one (1) year has elapsed from the date on the denial of application.(7-1-24)
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Failure to Complete Application Process. Failure of the applicant to complete the application process within six (6) months of the original date of application will result in a denial of the application. (7-1-24)
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Denial of Licensure. If the Department determines the applicant is not in compliance with these rules and further determines not to issue a daycare license, the Department will, within thirty (30) days from the date the completed application is submitted, issue a letter of denial of licensure stating the basis for the denial. (7-1-24)
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Incomplete Application. The Department is not required to take any action on an application until the application is complete.(7-1-24)
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Notification of License Renewal. The Department will notify the licensed daycare operator at least ninety (90) days prior to expiration of the license.(7-1-24)
IDAPA 16.06.03.124 (Reserved)
IDAPA 16.06.03.150 Restrictions on Applicability and Nontransfer
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Issued License. A license applies only to the daycare facility licensed by the Department, or the person and premises designated. Each license is issued in the business name or individual name, and only to the specified address identified on the application of the facility. A license issued in the name of a daycare facility licensed by the Department applies only to the period and services specified in the license.(7-1-24)
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Return of License. The operator must immediately return their license to the Department under any of the following circumstances:(7-1-24)
a.Changes of management or address;(7-1-24)
b.Upon suspension or revocation of the license; or(7-1-24)
c.Upon voluntary discontinuation of service.(7-1-24)
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Nontransferable. A license is nontransferable or assignable from one (1) individual to another, from one (1) business entity or governmental unit to another, or from one (1) location to another.(7-1-24)
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Change in Ownership or Location. When there is a change in ownership or location, the daycare facility must reapply for a license. A license must be obtained before starting operations.(7-1-24)
IDAPA 16.06.03.151 (Reserved)
IDAPA 16.06.03.200 Staff and Other Record Requirements
Each owner or operator of a daycare facility must maintain a current list covering the previous twelve-month period of all staff and other individuals thirteen (13) years old or older who have unsupervised direct contact with children, or are regularly on the premises. The record must contain the following:(7-1-24)
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Legal Name.(7-1-24)
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Proof of Age.(7-1-24)
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Phone Number.(7-1-24)
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Training Records.(7-1-24)
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Verification of Background Check Clearance.(7-1-24)
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Results of Juvenile Justice Records.(7-1-24)
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Verification of Pediatric Rescue Breathing, Infant-Child CPR, and Pediatric First Aid Certification from a Certified Instructor.(7-1-24)
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Times, Dates, and Records of Hours on the Premises Each Day.(7-1-24)
IDAPA 16.06.03.201 Child Record Requirements
Each owner or operator of a daycare facility must maintain records for each child in attendance covering the previous twelve-month period. The record must contain the following:(7-1-24)
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Child's Full Name.(7-1-24)
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Date of Birth.(7-1-24)
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Parent or Guardian's Name, Address, and Contact Information.(7-1-24)
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Emergency Contact Information.(7-1-24)
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Child's Health Information.(7-1-24)
a.Immunization record or waiver of exemption form or statement;(7-1-24)
b.Any medical conditions or allergies that could affect the care of the child; and(7-1-24)
c.Medications the child is taking or may be allergic to.(7-1-24)
- Times, Dates, and Record of Attendance Each Day. Sign-in/out records, electronic or manual, including the signature of a parent or guardian.(7-1-24)
IDAPA 16.06.03.202 (Reserved)
IDAPA 16.06.03.360 Fire Safety Standards
Each daycare facility must comply with the following.(7-1-24)
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Inspections. Must be completed by the local fire official or designee. For a daycare located outside of the area of authority under Section 39-1109, Idaho Code, the Department can designate an approved inspector for daycare licensing purposes only.(7-1-24)
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Daycare Fire Inspection Fees. Are payable to the local fire department or fire district official.
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Unobstructed Exits. Required exits must be located in such a way that an unobstructed path outside the building is provided to a public way or area of refuge.(7-1-24)
a.Exit doors must open from the inside without the use of a key or any special knowledge or effort.
b.There must be at least two (2) exits located a distance apart of not less than one-half (1/2) the diagonal dimension of the building or portion used for daycare, but not to exceed seventy-five (75) feet. An exception may be made for the following:(7-1-24)
i.The distance between exits may be extended to ninety (90) feet if the building is totally protected throughout with smoke detectors; or(7-1-24)
ii.The distance between exits may be increased to one hundred ten (110) feet if the building is equipped with an automatic fire sprinkler system.(7-1-24)
c.The required dimensions of exits must not be less than thirty-two (32) inches of clear exit width and not be less than six (6) feet, eight (8) inches in height. An exception for sliding patio doors will be accepted as a required second exit in a family daycare home and group daycare facility only.(7-1-24)
d.Sleeping room exits must be provided with at least one (1) emergency egress window having at least a single net clear opening of five point seven (5.7) square feet, minimum height twenty-four (24) inches, minimum width twenty (20) inches, and maximum finished sill height not over forty-four (44) inches.(7-1-24)
i.Approved egress windows from sleeping areas must be operable from the inside without the use of separate tools.(7-1-24)
ii.In lieu of egress windows, an approved exit door is acceptable.(7-1-24)
iii.An approved piece of furniture or platform, if anchored in place, may be approved to sit in front of a window if the sill height is over forty-four (44) inches.(7-1-24)
e.Where children are located on a story below the level of exit discharge (basement), there must be at least two (2) exits, one (1) of which must open directly to the outside. More than one (1) exit from the basement opening directly to the outside may be required, depending on the structure of the building, to ensure the safety of the occupants.(7-1-24)
f.Where children are located on a story above the level of exit discharge, there must be two (2) exits, one (1) of which must open directly to the outside and comply with building codes.(7-1-24)
IDAPA 16.06.03.361 Facility Capacity and Determining Occupant Load
Occupant load is determined by the local fire official or designee.(7-1-24)
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Area for Daycare Use Only. The local fire official or designee will only use those areas used for daycare purposes when determining the occupant load.(7-1-24)
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Facilities with an Occupancy Load of Fifty or More. Must meet the requirements in Section 360 of these rules and this rule.(7-1-24)
a.Exit doors must swing in the direction of egress.(7-1-24)
b.Exit doors from rooms, if provided with a latch, must have panic hardware installed.(7-1-24)
- Exit Signs. Must be installed at required exit doorways and wherever else necessary to clearly indicate the direction of egress.(7-1-24)
IDAPA 16.06.03.362 Fire Extinguishers and Safety Requirements
Each daycare facility must comply with the following fire extinguisher and safety requirements as applicable for size and type of facility.(7-1-24)
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Portable Fire Extinguisher. There must be an approved portable fire extinguisher (minimum 2A- 10BC) mounted securely in a visible location not to exceed five (5) feet from the floor to the top of the extinguisher and not more than seventy five (75) feet travel distance to an extinguisher and maintained properly.(7-1-24)
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Kitchen Area. An approved fire extinguisher must be present, or a hood-type fire suppression system be installed in the kitchen area.(7-1-24)
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Fire Extinguishers. Approved fire extinguishers must be maintained properly.(7-1-24)
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Facilities Over Three Thousand Square Feet. Each daycare facility over three thousand (3,000) square feet is required to have additional fire extinguishers as approved by the local fire official or designee. (7-1-24)
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Fire Alarm System. Each daycare facility with over fifty (50) children, must have an approved fire alarm system installed.(7-1-24)
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Smoke Detectors. Must be installed and maintained in the following locations:(7-1-24)
a.On the ceiling, wall outside, or each separate sleeping area in the immediate vicinity of bedrooms;
b.In each room used for sleeping purposes; and(7-1-24)
c.In each story within a facility including basements.(7-1-24)
d.If there is a basement, there must be a smoke detector installed in the basement having a stairway which opens from the basement into the facility. Such detector must be connected to a sounding device or other detector to provide an alarm that is audible in the sleeping area.(7-1-24)
- Automatic Sprinkler Systems. Must be provided in all daycare facilities greater than twenty thousand (20,000) square feet in area or when the number of children under the age of eighteen (18) months exceeds one hundred (100).(7-1-24)
IDAPA 16.06.03.363 Fire Safety and Evacuation Plans
Each daycare facility must have an approved fire safety and evacuation plan prepared that includes the following:
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Evacuation. Procedures and policies for accounting for staff and children after an evacuation is completed.(7-1-24)
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Evacuation Plan and Assembly Point for Children and Staff.(7-1-24)
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Locations of Facility Exits.(7-1-24)
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Evacuation Routes.(7-1-24)
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Location of Fire Alarms.(7-1-24)
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Location of Fire Extinguishers.(7-1-24)
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Annual Review. Fire safety and evacuation plans must be reviewed or updated annually and available in the facility for reference and review.(7-1-24)
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Fire and Emergency Evacuation Drills. Must be conducted on a routine schedule at least two (2) times each year and all staff and children must participate.(7-1-24)
IDAPA 16.06.03.364 (Reserved)
IDAPA 16.06.03.380 Health Standards
Each daycare facility licensed by the Department, must comply with the following. Health inspections must be conducted annually by a qualified inspector designated by the Department and will be unannounced.(7-1-24)
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Food. Must be from an approved source under IDAPA 16.02.19, “Idaho Food Code.” Food must not be served past expiration or “use by” date.(7-1-24)
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Food Preparation. Food for use in daycare facilities must be prepared and served in a sanitary manner with sanitized utensils and on surfaces that have been cleaned, rinsed, and sanitized prior to use to prevent cross-contamination.(7-1-24)
a.Frozen food must be thawed in the refrigerator, under cold running water, or as part of the cooking process and cooked to proper temperatures under IDAPA 16.02.19, “Idaho Food Code.”(7-1-24)
b.Individuals preparing food must use proper hand-washing techniques, minimize bare hand contact with food, and wear clean clothes.(7-1-24)
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Food Temperatures. Potentially hazardous foods must be kept refrigerated at forty-one degrees Fahrenheit (41°F) or below, held hot at one hundred thirty-five degrees Fahrenheit (135°F) or more, and reheated or cooled at safe temperatures under IDAPA 16.02.19, “Idaho Food Code.” Refrigerators must be equipped with an accurate thermometer.(7-1-24)
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Food Storage. All food that is served in daycare facilities must be stored in such a manner that protects it from potential contamination. There must be no evidence of pests present in the daycare facility. (7-1-24)
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Food Contact Surfaces. Must be kept clean and sanitized, including counters, serving tables, high chair trays, and cutting boards.(7-1-24)
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Dishwashing Sanitizing. Dishes, glasses, utensils, silverware, and all other objects used for food preparation and eating must be sanitized using appropriate sanitizing procedures.(7-1-24)
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Utensil Storage. Clean utensils must be stored on clean shelves or drawers and not subject to recontamination, and sharp knives and other sharp objects be kept out of reach of children.(7-1-24)
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Garbage. Must be kept covered or inaccessible to children.(7-1-24)
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Hand Washing. Children and facility staff must be provided with individual or disposable towels for hand drying, and the hand washing area be equipped with soap and warm and cold running water.(7-1-24)
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Diaper Changing. Must be conducted in such a manner as to prevent the spread of communicable diseases, be separate from food preparation and serving areas, and have easy access to a hand washing sink. (7-1-24)
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Sleeping Areas. Children sleeping at the facility must have separate cots, mats, or beds and blankets.(7-1-24)
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Safe Sleep. Providers must place newborn infants up to twelve (12) months old in a safe sleep environment. Safe sleep practices include alone, on their backs, and in a Consumer Product Safety Commission (CPSC) certified sleep space.(7-1-24)
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Restrooms, Water Supply, and Sewage. All daycare facilities must have restrooms.(7-1-24)
a.Each facility must have at least one (1) flushable toilet and one (1) hand washing sink with warm and cold water per restroom.(7-1-24)
b.Plumbing and bathroom fixtures must be in good condition.(7-1-24)
c.All daycare facilities and homes must comply with IDAPA 24.39.30, “Rules of Building Safety (Building Code Rules).”(7-1-24)
- Water Supply. The facility's water supply must meet one (1) of the following requirements:
a.Be from a public water system that is maintained under IDAPA 58.01.08, “Idaho Rules for Public Drinking Water Systems,” at the time of initial or renewal application; or(7-1-24)
b.Be from a private source, such as well or spring, be tested annually for bacteria and nitrate, and be approved by the Department.(7-1-24)
c.Water used for consumption at a daycare facility is from an acceptable source. Temporary use of bottled water or boiled water may be allowed for a period specified by the Department.(7-1-24)
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Sewage Disposal. Facility sewage must be disposed of through a public system, or in the absence of a public system, in a manner approved by the local health authority under IDAPA 58.01.03 “Individual/Subsurface Sewage Disposal Rules.”(7-1-24)
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Alcohol and Illegal Drugs. Must not be used by providers, owners, operators, staff, volunteers, children, or visitors at daycare facilities, in the presence of children during hours of operation, or in vehicles while transporting children.(7-1-24)
a.Any individual under the influence of alcohol or drugs is not permitted at or in the daycare facility.
b.Illegal drugs are prohibited by law and therefore are not allowed on the premises of any licensed daycare facility at any time.(7-1-24)
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Smoke-Free Environment. Children must be afforded a smoke-free environment during all daycare hours, whether indoors or outdoors. While children are in care, the operator and all staff must ensure that no smoking or other tobacco use occurs within the facility, in outdoor areas, or in vehicles when children are present.
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Transportation. Provider that transports a child(ren) will possess a valid driver's license, be insured under Idaho Law, and abide by all traffic laws including the requirement that all children are in proper safety restraints while being transported under Section 49-672, Idaho Code, and Section 49-673, Idaho Code. Vehicles used to transport children will be properly maintained and in good working condition.(7-1-24)
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Disaster and Emergency Planning. Providers must have documented plans for emergencies resulting from a natural disaster, or human-caused event that include:(7-1-24)
a.Procedures for evacuation, relocation, shelter-in-place, lock-down, communication and reunification with families, continuity of operations, and accommodation of infants and toddlers and children with disabilities or chronic medical conditions.(7-1-24)
b.Procedures for staff and volunteer emergency preparedness training and practice drills. (7-1-24)
c.Guidelines for the continuation of daycare services in the period following the emergency or disaster.(7-1-24)
d.Procedures for the prevention of and response to emergencies due to food and allergic reactions.
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Medication. No person can administer any medication to a child without it first being authorized by a parent or caretaker. All medications, refrigerated or unrefrigerated, must be in a locked box or otherwise in inaccessible to children.(7-1-24)
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Adequate Heat, Light, and Ventilation. A daycare facility must have adequate heat, light and ventilation. Windows and doors must be screened if used for ventilation.(7-1-24)
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Immunizations. Daycare operators must comply with requirements under IDAPA 16.02.11, “Immunization Requirements for Licensed Daycare Facility Attendees.”(7-1-24)
IDAPA 16.06.03.381 Miscellaneous Safety Requirements
Each daycare facility licensed by the Department must comply with the following:(7-1-24)
- Telephone. An operable telephone or cell phone must always be available in the facility with the following conditions:(7-1-24)
a.The telephone number used must be made available to parents and guardians.(7-1-24)
b.Emergency phone numbers to include 911, an adult emergency substitute operator, and the address and phone number of the facility must be posted by the telephone or in a location that is easily and always visible.
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Heat-Producing Equipment. A furnace, fireplace, wood-burning stove, water heater, and other flame or heat-producing equipment must be installed and maintained as recommended by the manufacturer and protected on all surfaces by screens or other means.(7-1-24)
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Portable Heating Devices. Must be limited and approved for use and location by the Fire Inspector prior to use within a facility and will not be used during sleeping hours.(7-1-24)
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Storage of Weapons, Firearms, and Ammunition. Firearms or other weapons stored at a daycare facility must be kept in a locked cabinet, gun safe, or other container that is inaccessible to children, while children are in attendance. Keys to these containers must also be inaccessible to children.(7-1-24)
a.Ammunition must be stored in a locked container separate from firearms.(7-1-24)
b.Matches, lighters, and any other means of starting fires must be kept away from and out of the reach of children.(7-1-24)
c.Other weapons that could cause harm must be stored out of reach of children.(7-1-24)
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Animals and Pets. Any pet or animal present at the facility, indoors or outdoors, must be in good health, show no evidence of carrying disease, and be a friendly companion of the children. The operator must maintain the animal's vaccinations and vaccination records which will be made available to the Department upon request.(7-1-24)
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Hazardous Materials. Cleaning materials, flammable liquids, detergents, aerosol cans, pesticides, and other poisonous and toxic materials must be kept in their original containers and in a place inaccessible to children. They must be used in such a way that will not contaminate play surfaces, food, food preparation areas, or constitute a hazard to the children. Biocontaminants must be disposed of appropriately.(7-1-24)
IDAPA 16.06.03.382 (Reserved)
IDAPA 16.06.03.400 Buildings, Grounds, Furnishings, and Equipment
Each daycare facility licensed by the Department must comply with the following:(7-1-24)
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Appliances and Electrical Cords. All appliances, lamp cords, exposed light sockets, and electrical outlets will be protected to prevent electrocution.(7-1-24)
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Balconies and Stairways. Balconies and stairways accessible to children will have substantial railings as required by IDAPA 24.39.30, “Rules of Building Safety (Building Code Rules).(7-1-24)
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Stairway Protection. Where an operator cares for children less than three (3) years old, stairways will be protected to prevent child access to stairs.(7-1-24)
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Hazardous Area Restrictions. Based on the age and functioning level of children in care and the type of hazard and the area surrounding the hazard, the area will be restricted to prevent easy access to the hazard.
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Fueled Equipment. Fueled equipment including motorcycles, mopeds, lawncare equipment, and portable cooking equipment. This equipment will not be stored or repaired in areas where children are present.
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Water Hazards. Above and below ground pools, hot tubs, ponds, and other bodies of water that are on the daycare facility premises must provide the following safeguards:(7-1-24)
a.The area surrounding the body of water must be fenced and locked in a manner that prevents access by children and meets the following(7-1-24)
i.The fence will be at least four (4) feet high with no vertical opening more than four (4) inches wide and designed so that a young child cannot climb or squeeze under or through the fence. The fence will surround all sides of the pool and have a self-closing gate that has a self-latching mechanism in proper working order that is out of the reach of young children.(7-1-24)
ii.If the house forms one (1) side of the barrier for the pool, all doors that provide unrestricted access to the pool will have alarms that produce an audible sound when the door is opened.(7-1-24)
b.Furniture or other large objects will not be left near the fence in a manner that would enable a child to climb on the furniture or other large object and gain access to the pool. If the area surrounding a pool, hot tub, pond, or other body of water is not fenced and locked, there will be a secured protective covering that prevents access by a child.(7-1-24)
c.Wading pools and buckets will be empty when not in use.(7-1-24)
d.Children will be under direct supervision of adult staff who are certified in pediatric CPR and pediatric first aid while using a bathtub, pool, hot tub, pond, or other body of water.(7-1-24)
e.A minimum of a four (4) foot high fence that prevents access from the daycare facility premises if the daycare premises are adjacent to a body of water.(7-1-24)
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Indoor Play Areas and Toys. The indoor play areas will be clean, have age-appropriate toys, and be free from accumulation of dirt, rubbish, or other health hazards.(7-1-24)
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Outdoor Play Areas and Toys. Any outdoor play area must be maintained free from hazards such as wells, machinery, and animal waste.(7-1-24)
a.If any part of the play area is adjacent to a busy roadway, drainage or irrigation ditch, stream, large holes, or other hazardous areas, the play area will be enclosed with a fence in good repair that is at least four (4) feet high without any holes or spaces greater than four (4) inches in diameter.(7-1-24)
b.Outdoor equipment, such as climbing apparatus, slides, and swings will be anchored firmly and placed in a safe location and according to the manufacturer's instructions.(7-1-24)
c.Outdoor play areas will be designed so that all parts are always visible and easily supervised by staff.(7-1-24)
d.Toys, play equipment, and any other equipment used by the children will be of substantial construction and free from rough edges and sharp corners. Unguarded ladders on slides will be kept in good repair and well-maintained.(7-1-24)
e.Toys and objects with a diameter of less than one (1) inch (two point five (2.5) centimeters), objects with removable parts that have a diameter of less than one (1) inch (two point five (2.5) centimeters), plastic bags, styrofoam objects, and balloons will not be accessible to children ages three (3) and under, or children who are known to place such objects in their mouths.(7-1-24)
IDAPA 16.06.03.401 (Reserved)
IDAPA 16.06.03.420 Continued Compliance, Reporting Changes, and Critical Incidents
Each daycare owner or operator must always comply with the fire, safety, and health requirements under these rules and the following:(7-1-24)
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Department Access. The owner, operator, or staff of a daycare facility must allow the Department access to the premises and records for reinspection at any time during the licensing period.(7-1-24)
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Posting Information. A daycare must post the Department's contact information and the statewide number to file daycare complaints.(7-1-24)
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Reporting Changes. The owner, operator, or staff of a daycare facility notifies the Department of any changes that affect the terms of licensure or could affect the health, well-being, or safety of children. (7-1-24)
-
Critical Incidents. A daycare operator must report any of the following to the Department within twenty-four (24) hours:(7-1-24)
a.Any injury that requires hospitalization of a child.(7-1-24)
b.Death or near death of a child in care.(7-1-24)
c.When a child is missing from a daycare facility.(7-1-24)
d.Any arrests, citations, withheld judgments, or criminal convictions of disqualifying crimes under Section 39-1113, Idaho Code, of an operator or any individual regularly on the premises of the facility and provide documentation that the individual is not working with children or is not on the premises.(7-1-24)
IDAPA 16.06.03.421 (Reserved)
16.02.27 Idaho Radiation Control Rules
IDAPA 16.02.27.000 Legal Authority
This chapter is adopted under the legal authority of Section s 56-1003, 56-1007, 56-1041, 56-1043, 56-1044, and 56- 1046, Idaho Code.(7-1-26)
IDAPA 16.02.27.001 Scope
To define licensure, education, quality assurance, and safety requirements for X-ray machines.(7-1-26)
IDAPA 16.02.27.002 Definitions
01.Department.
The Idaho Department of Health and Welfare.(7-1-26)
02.Qualified Expert. An individual who meets nationally recognized radiation safety standards and has specific training in shielding design and X-ray safety.(7-1-26)
03.Radiation Safety Program. A documented program that ensures compliance with radiation protection standards, including safety procedures, training and quality control.(7-1-26)
IDAPA 16.02.27.003 License Requirements and Application
01.Federal Facilities.
All X-ray machines except those owned and operated at federal facilities or exempted under Section 56-1046(4), Idaho Code, must be licensed with the Department.(7-1-26)
02.License Application. Facilities must complete a license application approved by the Department.
03.Insurance and Financial Responsibility. Applicants must provide documentation of adequate insurance coverage and financial responsibility to ensure compliance with safety standards and regulatory obligations.(7-1-26)
IDAPA 16.02.27.004 License Renewal and Fees
01.License Renewal. X-ray licensees must comply with the renewal cycles and fees as determined in the following table:
02.Licensing Fee Due Dates and Late Penalties. Fees are due within thirty (30) calendar days of the renewal date. A late fee of fifty ($50) will be assessed at thirty-one (31) days past the renewal date. If the fees are not paid by day ninety-one (91) past the renewal date, licensure will be terminated.(7-1-26)
03.Radiation Safety Program Flat Fee. A facility or group of facilities under one administrative control that has a full-time in-house radiation safety program that includes X-ray machines, may pay a flat annual facility fee of one thousand dollars ($1,000) instead of the base and per tube fees. Facilities must submit annual documentation of their quality assurance and quality control program for review by the Department.(7-1-26)
04.Recognition of Other Licenses. The Department will recognize out-of-state or federally licensed X-ray machines until the next required renewal cycle, when such licenses meet equivalent safety and operational standards to minimize duplicative licensing requirements. Facilities with federal or out-of-state licenses must register with the Department within thirty (30) days.(7-1-26)
X-Ray Renewal Cycle and Facility Fees Facility TypeRenewal CycleBase FeePer Tube Fee Hospital, Clinic, Medical Practice2 Years$50$25 Dental, Chiropractic, Podiatric, Veterinary Practice 4 Years$50$25 Industrial, research, academic/ educational, or security 10 Years$50$25
IDAPA 16.02.27.005 X-Ray Shielding Plan Approval
Facilities housing X-ray machines must have a qualified expert conduct a site-specific shielding plan. A copy of this plan, including the floor plan and site-specific shielding calculations, must be submitted to the Department within thirty (30) days before conducting imaging procedures on patients.(7-1-26)
IDAPA 16.02.27.006 On-Site Inspection
Qualified representatives of the Department are authorized to ins pect the premises and operations of all licensed Xray facilities to determine the adequacy of their shielding, quality control, quality assurance, safety, training, and other X-ray control programs. Department representatives will issue a written inspection report of findings, list items requiring a response, and specify the response timeframes required to maintain licensure.(7-1-26)
IDAPA 16.02.27.007 X-Ray Machine Quality Control and Quality Assurance
01.Quality Control. Licensed facilities must follow all X-ray machine manufacturer’s required quality control procedures. Quality control records must be available for review by the Department and retained for at least two (2) license renewal cycles.(7-1-26)
02.Quality Assurance. Licensed facilities must have a written quality assurance plan documenting how quality control records are reviewed, safety procedures are followed, and X-ray machine operators are appropriately trained.(7-1-26)
IDAPA 16.02.27.008 X-Ray Machine Performance Standards
01.Radiation Output. X -ray machines must have a consistent radiation output within specified limits.
02.Image Quality. The machines must produce high-quality images with sufficient contrast, resolution, and minimal noise.(7-1-26)
03.Safety Features. X-ray machines must include the following safety features:(7-1-26)
a.Beam Lighting Devices: to restrict the X-ray beam to the area of interest and reduce patient exposure;(7-1-26)
b.Warning Lights and Signals: to indicate when the machine is in operation; and(7-1-26)
c.Interlocks: to prevent accidental exposure by ensuring that the X-ray beam is only activated when the machine is properly configured.(7-1-26)
04.Maintenance and Calibration. Regular maintenance and calibration of X-ray machines are required to ensure they operate within specified performance standards.(7-1-26)
05.Compliance. X-ray machines used for human imaging must comply with (a) or (b) and must comply with (c):(7-1-26)
a.U.S. Food and Drug Administration (FDA): FDA regulations on radiation-emitting products.
b.International Electrotechnical Commission (IEC): IEC standards for medical electrical equipment.
c.Documentation of compliance should be maintained for two (2) license renewal periods and be made available for inspection by regulatory authorities.(7-1-26)
IDAPA 16.02.27.009 X-Ray Facility and Operator Training Requirements
01.Facility Requirements. Licensed facilities must:(7-1-26)
a.Post notice standards for protection against radiation in the facility;(7-1-26)
b.Keep radiation exposure as low as is practical;(7-1-26)
c.Provide written, site-specific, emergency procedures;(7-1-26)
d.Provide written, site-specific, safety procedures as they apply to each machine;(7-1-26)
e.Provide written, site-specific, operating procedures as they apply to each machine;(7-1-26)
f.Provide and document staff training; and(7-1-26)
g.Ensure personnel wear monitoring devices, if applicable.(7-1-26)
02.Operator Training Requirements. No individual will be permitted to operate an X-ray machine until they have completed training and proven competency in radiation safety topics. Licensed facilities must retain written training records for each X-ray machine operator. Training records for current and former X-ray operators must be made available upon request. Training records must be retained for a minimum of two (2) license renewal cycles. X-ray operator training must include the following topics:(7-1-26)
a.Fundamental of radiation safety;(7-1-26)
b.Characteristics of gamma and X-radiation;(7-1-26)
c.Units of radiation dose (millirem);(7-1-26)
d.Bioeffects of excessive exposure to radiation;(7-1-26)
e.Levels of radiation emitted from X-ray machines;(7-1-26)
f.Methods of controlling radiation dose including working time, distance, and shielding;(7-1-26)
g.State and federal radiation protection standards;(7-1-26)
h.Proper use of site-specific radiation survey instruments;(7-1-26)
i.Use of personnel monitoring equipment;(7-1-26)
j.Proper use of site-specific X-ray machines; and(7-1-26)
k.Site-specific operating and emergency procedures.(7-1-26)
IDAPA 16.02.27.010 License Modification, Suspension, or Revocation
The Department may modify, suspend, or revoke an X-ray license if materially false statements are made by the licensee on the application, for failure to respond to inspection findings in a timely manner, or if the Department finds that the X-ray producing device is used in a fashion that endangers patients, facility staff, or the public.(7-1-26)
IDAPA 16.02.27.011 (Reserved)
16.03.08 Federal Welfare Programs
IDAPA 16.03.08.000 Legal Authority
Section 56-202, Idaho Code, the Low-Income Home Energy Assistance Act of 1981, 42 U.S.C Sections 8621 to 8629, and 45 CFR Parts 260 - 265.(7-1-26)
IDAPA 16.03.08.001 Scope
These rules provide standards for the adm inistration of the Temporary Assistance for Needy Families (TANF) program and the Low-Income Home Energy Assistance Program (LIHEAP). These rules do not apply to the Emergency Assistance for Families in Idaho program.(7-1-26)
IDAPA 16.03.08.002 (Reserved)
TANF PROGRAM
(Sections 100–199)
IDAPA 16.03.08.100 Tanf Eligibility
To be eligible for TANF, individuals must care for a dependent child or be pregnant and meet these requirements:
( 7-1-26)
01.Application. Submit a signed application;(7-1-26)
02.Residency. Individuals must reside in Idaho (absence allowed for up to one hundred and eighty (180) days), intend to remain, and not claim residency in another state;(7-1-26)
03.Household Unit. Only one (1) TANF cash benefit is allowed in the same month for the household unit; and(7-1-26)
04.Other Benefits. Households eligible for TANF may not also receive Aid to the Aged, Blind, and Disabled (AABD) cash or Foster Care payments.(7-1-26)
IDAPA 16.03.08.101 Mandatory Tanf Household Members
A household must include:( 7-1-26)
01.Dependent Children. Children under the age of eighteen (18) who reside with a parent or caretaker relative, including siblings and half siblings, living in the same home.(7-1-26)
02.Parents. Individuals who have an eligible child living with them.(7-1-26)
03.Pregnant Woman. At least in the third trimester before the baby is due and is unable to work due to medical reasons.(7-1-26)
04.Spouses. A married spouse living in the home.(7-1-26)
05.Caretaker Relative. An adult family member (other than the parent) who is responsible for a dependent child.(7-1-26)
IDAPA 16.03.08.102 Income and Resources
01.Income Determination. Eli gibility and benefit amounts are based on countable income and resources including those of ineligible household members as determined by the Department.(7-1-26)
02.Caretaker Income. When a caretaker relative is applying solely for a relative child, only the child’s income is counted.(7-1-26)
IDAPA 16.03.08.103 Cooperation Responsibility
The parent, or caretaker relative included in the grant, must cooperate with the Department to identify and locate any non-custodial parent, establish paternity, and establish, modify and enforce the child support order, unless good cause exists.(7-1-26)
IDAPA 16.03.08.104 Good Cause for Not Cooperating
Good cause for not cooperating with Child Support Services (CSS) are limited to:(7-1-26)
01.Rape or Incest. Proof is provided that the child was conceived as a result of rape or incest.
02.Physical or Emotional Harm. Proof is provided that the non-custodial parent may inflict physical or emotional harm to the children, the custodial parent, or the caretaker relative.(7-1-26)
03.Minimum Information Cannot be Provided. Substantial and credible proof is provided indicating the participant cannot provide the minimum information regarding the non-custodial parent.(7-1-26)
IDAPA 16.03.08.105 (Reserved)
IDAPA 16.03.08.111 Substance Abuse Screening and Testing Notice at Application
The Department will provide notice of substance abuse screening and possible testing to each TANF applicant.
01.Screening Requirement. The Department conducts substance abuse screening as a condition of receiving TANF cash assistance.(7-1-26)
02.Testing Requirement. The Department conducts substance abuse testing as a condition for receiving TANF cash assistance, if screening indicates the applicant is engaged in, or at high risk of, substance abuse.
03.Treatment Requirement. Participants must enter a substance abuse treatment program and cooperate with treatment, if screening, assessment or testing shows them in need of substance abuse treatment.
IDAPA 16.03.08.112 Individual Responsibility Plan (irp)
01.Individual Responsibility Plan.
An Individual Responsibility Plan (IRP) must be negotiated and signed by the mandatory adult household members as defined in these rules, with all application activities completed before eligibility can be approved. The household must continue to comply with ongoing IRP requirements to remain eligible.(7-1-26)
02.Modifications. If the participant cannot meet an IRP condition, the participant must notify the Department. The IRP may be renegotiated or modified when conditions change.(7-1-26)
IDAPA 16.03.08.113 Intentional Program Violations (ipv)
If an individual commits IPV the Department will take all reas onable steps to recover the overpayment from the responsible individual.(7-1-26)
IDAPA 16.03.08.114 Sanctions for Non-Compliance
01.Applicant Voluntary Quit.
An adult household member who quits a twenty-plus (20+) hour/week job within sixty (60) days of application without good cause results in ninety (90) days of ineligibility.(7-1-26)
02.Striking. If any adult household member is on strike, the entire household is ineligible.(7-1-26)
03.Work Activity Noncompliance. Failure to meet work activity requirements in the IRC, without good cause, counts as an occurrence. Penalties are based on the number of occurrences as follows:(7-1-26)
a.First Occurrence. The household is ineligible for one (1) month or until compliance, whichever is longer.(7-1-26)
b.Second Occurrence. The household is ineligible for three (3) months or until compliance, whichever is longer.(7-1-26)
c.Third Occurrence. The household permanently is ineligible.(7-1-26)
04.Work Activity Penalties. Work activity penalties are applied as follows:(7-1-26)
a.Individual Penalty. Penalties for individuals count towards an individual’s total number of sanctions. Any household an individual resides in during the period is subject to the penalty period.(7-1-26)
b.Child Work Activity Penalty. A fifty-dollar ($50) penalty per month, per child sixteen (16) years of age or older, will be subtracted from the household grant if they do not meet work activity requirements while living in the household.(7-1-26)
c.School Attendance Penalty. A fifty dollar ($50) monthly deduction per child applies if school-age children fail to attend school, unless participating in IRP-approved work activities.(7-1-26)
05.Paternity. If the grant is reduced by fifty percent (50%) for failure to establish paternity within twelve (12) months, child support penalties apply first before school or work penalties.(7-1-26)
06.IRP Noncompliance. Failing to meet IRP requirements without good cause will result in applicable penalties.(7-1-26)
IDAPA 16.03.08.115 Overpayment
In the event of an overpayment the parti cipant will be notified of the overpayment including details on the recovery process, hearing rights, repayment methods, and the need to schedule a repayment interview.(7-1-26)
IDAPA 16.03.08.116 (Reserved)
LIHEAP
(Sections 200–299)
IDAPA 16.03.08.200 Liheap Eligibility
To be eligible for LIHEAP, households must meet the following requirements:(7-1-26) 01.
Application. Submit a signed application or have active Supplemental Nutrition Assistance Program (SNAP) benefits in the current LIHEAP season (October to September);(7-1-26)
02.Citizenship. Meet citizenship eligibility requirements;(7-1-26)
03.Income. Meet income eligibility requirements;(7-1-26)
04.Residency. Reside in Idaho;(7-1-26)
05.Verifications. Provide requested verifications;(7-1-26)
06.Benefits. Only one (1) LIHEAP regular assistance benefit and one (1) LIHEAP Crisis benefit per LIHEAP season;(7-1-26)
07.Responsibility. A household member is responsible for home energy costs and incur the costs either directly or as a designated portion of their rent; and(7-1-26)
08.Federal Income. Households in which one (1) or more individuals are receiving Supplemental Security Income (SSI) under Title XVI of the Social Security Act, SNAP, or means tested Veterans Affairs (VA) benefits are eligible for LIHEAP.(7-1-26)
IDAPA 16.03.08.201 Mandatory Liheap Household Members
All individuals or groups of individuals who are living together as one economic unit for whom residential energy is customarily purchased in common or who make designated payments for energy as a portion of rent.(7-1-26)
IDAPA 16.03.08.202 Income
Gross income is counted for all household members, includ ing income from ineligible household members, as determined by the Department.(7-1-26)
IDAPA 16.03.08.203 Overpayments
In the event of an overpayment, the part icipant will be notified of the overpayment, including details on the recovery process, hearing rights, and repayment methods.(7-1-26)
IDAPA 16.03.08.204 Recoupment of Overpayment
The Department will take all reasonable steps to recover th e overpayment from the responsible individual who provided intentionally false or misleading information to obtain program eligibility.(7-1-26)
IDAPA 16.03.08.205 Provisions Contingent Upon Federal Funding
This program is contingent upon availability and receipt of funds appropriated through federal legislation. When federal funds are not available, these provisions or any part therein are considered dormant; there may be no advance notice of termination or reduction of benefits. If additional funds are available, a supplemental payment may be made at the discretion of the Administrator.(7-1-26)
IDAPA 16.03.08.206 (Reserved)
16.06.12 Idaho Child Care Program
IDAPA 16.06.12.000 Legal Authority
Under Section 56-202, Idaho Code, the Director of the Department of Health and Welfare is authorized to promulgate, adopt, and enforce rules for the administration of public assistance programs.(3-17-22)
IDAPA 16.06.12.001 Title and Scope
-
Title. These rules are titled IDAPA 16.06.12, “Idaho Child Care Program (ICCP).” (3-17-22)
-
Scope. These rules provide the requirements for determining participant and provider eligibility for the Idaho Child Care Program (ICCP) and issuing child care benefit payments.(3-17-22)
IDAPA 16.06.12.002 (Reserved)
IDAPA 16.06.12.008 Audit, Investigation and Enforcement
In addition to any actions specified in these rules, the Department may audit, investigate and take enforcement action under the provisions of IDAPA 16.05.07, “Investigation and Enforcement of Fraud, Abuse or Misconduct.”
IDAPA 16.06.12.009 Criminal History and Background Check Requirements
-
Compliance with Department Criminal History and Background Check. Criminal history and background checks are required for ICCP providers. Providers who are required to have a criminal history check must comply with IDAPA 16.05.06, “Criminal History and Background Checks.”(3-17-22)
-
ICCP Provider is Approved. The ICCP provider must have completed a criminal history and background check, and received a clearance, prior to becoming an ICCP provider.(3-17-22)
-
Availability to Work or Provide Service.(3-17-22)
a.Those individuals licensed or certified by the Department are not available to provide services or receive licensure or certification until the criminal history and background check is completed and a clearance issued by the Department.(3-17-22)
b.Individuals living in the home who have direct contact with children are allowed contact after the criminal history application and self-disclosure is completed as provided in Tittle 56, Chapter 27, Idaho Code, except when they have disclosed a disqualifying crime listed in IDAPA 16.05.06, “Criminal History and Background Checks.”(3-17-22)
- Applicants, Providers, and Other Individuals Subject to Criminal History Check Requirements. The following applicants, providers, and other individuals listed below must submit evidence to the Department that the following individuals have successfully completed and received a Department criminal history and background check clearance:(3-17-22)
a.All child care centers, group, family, relative, and in-home providers, including owners, operators, and staff, who have direct contact with children;(3-17-22)
b.All individuals thirteen (13) years of age or older who have direct contact with children; and
c.All individuals thirteen (13) years of age or older who are regularly on the premises. (3-17-22)
-
Renewal of Criminal History and Background Check Requirement. Applicants, providers, employees, volunteers, and individuals thirteen (13) years of age or older who have direct contact with or provide care to children eligible for ICCP benefits must comply with these requirements and receive a clearance as provided in IDAPA 16.05.06, “Criminal History and Background Checks,” every five (5) years.(3-17-22)
-
Criminal History and Background Check at Any Time. The Department can require a criminal history and background check at any time on any individual providing child care to an ICCP eligible child. (3-17-22)
-
Additional Criminal Convictions. Once an individual has received a criminal history clearance, any additional criminal convictions must be reported by the child care provider to the Department when the provider learns of the conviction.(3-17-22)
IDAPA 16.06.12.010 Definitions and Abbreviations -- a Through L
The following definitions and abbreviations apply to this chapter:(3-17-22)
-
AABD. Aid to the Aged, Blind, and Disabled.(3-17-22)
-
Abuse or Abusive. Provider practices that are inconsistent with sound fiscal, business, or child care practices and result in an unnecessary cost to the Idaho Child Care Program, in reimbursement that is not necessary, or that fail to meet professional recognized standards for child care, or result in physical harm, pain, or mental anguish to children.(3-17-22)
-
Child. Any person under age eighteen (18) who is under the care of a parent, relative, or someone acting in loco parentis.(3-17-22)
-
Child Care. Care, control, supervision, or maintenance of a child provided for compensation by an individual, other than a parent, for less than twenty-four (24) hours in a day.(3-17-22)
-
Claim. Any request or demand for payment, or document submitted to initiate payment, for items or services provided under the Idaho Child Care Program.(3-17-22)
-
Department. The Idaho Department of Health and Welfare or its designee.(3-17-22)
-
Earned Income. Income received by a person as wages, tips, or self-employment income before deductions for taxes or any other purposes.(3-17-22)
-
Employment. A job paying wages or salary at federal or state minimum wage, whichever is applicable, including work paid by commission or in-kind compensation. Full or part-time participation in a VISTA or AmeriCorps program is also employment.(3-17-22)
-
Foster Care. The twenty-four (24) hour substitute care of children in the legal custody of the state of Idaho provided in a state licensed foster home by persons who may or may not be related to a child. Foster care is provided in lieu of parental care and is arranged through a private or public agency.(3-17-22)
-
Foster Child. A child in the legal custody of the state of Idaho placed for twenty-four (24) hour substitute care by a private or public agency.(3-17-22)
-
Foster Home. The private home of an individual or family licensed under the state of Idaho and providing twenty-four (24) hour substitute care to six (6) or fewer children.(3-17-22)
-
Fraud or Fraudulent. An intentional deception or misrepresentation made by a person with knowledge that the deception could result in some unauthorized benefit to himself or some other person. (3-17-22)
-
Good Cause. The conduct of a reasonably prudent person in the same or similar circumstances, unless otherwise defined in these rules.(3-17-22)
-
In Loco Parentis. Acting “in loco parentis” means a person who acts in place of a parent, assuming care and custody of a child by legal guardianship.(3-17-22)
-
Intentional Program Violation (IPV). An intentional false or misleading action, omission, or statement made in order to qualify as a provider or recipient in the Idaho Child Care program or to receive program benefits or reimbursement.(3-17-22)
-
Job Training and Education Program. A program designed to provide job training or education.
Programs may include high school, junior college, community college, college or university, general equivalency diploma (GED), technical school, and vocational programs. To qualify as a Job Training and Education Program, the program must prepare the trainee for employment.(3-17-22)
-
Infant/Toddler. A child less than forty-eight (48) months of age.(3-17-22)
-
Incapacitated Parent. A parent who is determined by a licensed practitioner of the healing arts to be unfit, incapable, or significantly limited in their ability to provide adequate care for their child or ward. (3-17-22)
-
Knowingly, Known, or With Knowledge. With respect to information or an action about which a person has actual knowledge of the information or action; acts in deliberate ignorance of the truth or falsity of the information or the correctness or incorrectness of the action; or acts in reckless disregard of the truth or falsity of the information or the correctness or incorrectness of the action.(3-17-22)
-
Legal Guardian. A court-appointed individual who acts as the primary caretaker of a child or minor.(3-17-22)
-
Licensed Practitioner of the Healing Arts. A licensed physician, physician assistant, nurse practitioner, or clinical nurse specialist.(3-17-22)
IDAPA 16.06.12.011 Definitions and Abbreviations -- M Through Z
The following definitions and abbreviations apply to this chapter of rules:(3-17-22)
-
Managing Employee. A general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an organization or entity.(3-17-22)
-
Minor Parent. A parent under the age of eighteen (18).(3-17-22)
-
Non-Recurring Lump Sum Income. Income received by a family in a single payment, not expected to be available to the family again.(3-17-22)
-
Parent. A person responsible for a child because of birth, adoption, marriage, legal guardianship, foster care; or a person acting in loco parentis.(3-17-22)
-
Preventive Services. Services needed to reduce or eliminate the need for protective intervention.
Preventive services permit families to participate in activities designed to reduce or eliminate the need for out-ofhome placement of a child by the Department.(3-17-22)
-
Prospective Income. Income a family expects to receive within a given time. This can be earned or unearned income.(3-17-22)
-
Provider. An individual, organization, agency, or other entity providing child care. (3-17-22)
-
Relative Provider. Grandparent, great-grandparent, aunt, uncle, or adult sibling by blood or current marriage who provides child care.(3-17-22)
-
SSI. Supplemental Security Income.(3-17-22)
-
Special Needs. Any child with physical, mental, emotional, behavioral disabilities, or developmental delays identified on an Individual Education Plan (IEP) or an Individualized Family Service Plan (IFSP).(3-17-22)
-
State Median Income (SMI). State Median Income Estimates in the Code of Federal Regulations are available on the U.S. Government Publishing Office website at https://www.gpo.gov/fdsys.(3-17-22)
-
TAFI. Temporary Assistance for Families in Idaho.(3-17-22)
-
Unearned Income. Unearned income includes retirement, interest child support, and any income received from a source other than employment or self-employment.(3-17-22)
IDAPA 16.06.12.012 (Reserved)
APPLICATION REQUIREMENTS
(Sections 050-069)
IDAPA 16.06.12.050 Iccp Application for Benefits
A family applying for child care benefits must submit a completed and signed application to the Department.
-
Application Received. The Department will date stamp the application on the day the application is received. The applicant has thirty (30) days from the date the application is received by the Department to complete the application process by providing all required verifications.(3-17-22)
-
New Application Required. A new application is required if all requested verification is not provided within thirty (30) days from the date the application was received by the Department. The time limit can be extended by the Department for events beyond the Department’s control.(3-17-22)
-
Notification. The Department will act on applications for child care benefits within thirty (30) days of receipt. The applicant will be notified in writing of the approval or denial of the application and of the applicant’s right to appeal.(3-17-22)
IDAPA 16.06.12.051 Signatures
An individual who is applying for benefits, receiving benefits, or providing additional information as required by this chapter, may do so with the depiction of the individual's name either handwritten, electronic, or recorded telephonically. Such signature serves as intention to execute or adopt the sound, symbol, or process for the purpose of signing the related record.(3-17-22)
IDAPA 16.06.12.052 (Reserved)
FINANCIAL CRITERIA FOR ICCP ELIGIBILITY
(Sections 070-099)
IDAPA 16.06.12.070 Income Limits
To be eligible for child care assistance, a family's countable income must meet the following using the published Federal Poverty Guidelines (FPG) available on the U.S. Health and Human Services website at http://aspe.hhs.gov/ poverty.(4-6-23)
-
Income at Application. When applying, a family's income cannot exceed one hundred seventyfive percent(175%) of FPG for a family of the same size.(4-6-23)
-
Income During Eligibility Period. During the eligibility period, when a family's countable income exceeds eighty-five percent (85%) of the State Median Income (SMI) for a family of the same size, the family becomes ineligible for child care assistance.(3-17-22)
-
Income at Redetermination. At redetermination, if a family's income exceeds one hundred seventy-five percent (175%) of FPG for a family of the same size, the family may be eligible to receive a graduated phase out of child care assistance.(4-6-23)
IDAPA 16.06.12.071 Countable Income
All gross earned and unearned income is counted in determining eligibility and the child care benefit amount, unless specifically excluded under Section 072 of these rules.(3-17-22)
IDAPA 16.06.12.072 Excluded Income
The following sources of income are not counted as family income.(3-17-22)
-
Earned Income of a Dependent Child. Income earned by a dependent child under age eighteen (18) is not counted, unless the child is a parent who is seeking or receiving child care benefits.(3-17-22)
-
Income Received for Person Not Residing With the Family. Income received on behalf of a person who is not living in the home.(3-17-22)
-
Educational Funds. All educational funds including grants, scholarships, an AmeriCorps Education Award, and federal and state work-study income.(3-17-22)
-
Assistance. Assistance to meet a specific need from other organizations and agencies. (3-17-22)
-
Lump Sum Income. Non-recurring lump sum income is excluded.(3-17-22)
-
Loans. A loan is money received that is to be repaid.(3-17-22)
-
TAFI and AABD Benefits.(3-17-22)
-
Foster Care Payments.(3-17-22)
-
AmeriCorps/VISTA Volunteers. Living allowances, wages and stipends paid to AmeriCorps or VISTA volunteers under 42 U.C.S. 5044, P.L. 93-113, Title IV, Section 404(g) are excluded as income. (3-17-22)
-
Income Tax Refunds and Earned Income Tax Credits. Income tax refunds and earned income tax credits are excluded as income.(3-17-22)
-
Travel Reimbursements. Reimbursements from employers for work-related travel. (3-17-22)
-
Tribal Income. Income received from a tribe for any purpose other than direct wages. (3-17-22)
-
Foster Parents’ Income. Income of licensed foster parents is excluded when determining eligibility for a foster child. Income is counted when determining eligibility for the foster parent's own child(ren).
-
Adoption Assistance. Adoption assistance payments are excluded from income.(3-17-22)
-
Temporary Census Income. All wages paid by the Census Bureau for temporary employment related to U.S. Census activities are excluded for a time period not to exceed six (6) months during the regularly scheduled ten-year U.S. Census.(3-17-22)
-
Office of Refugee Resettlement Assistance.(3-17-22)
-
Workforce Investment Act (WIA) Benefits or Workforce Innovation and Opportunity Act (WIOA) Benefits.(3-17-22)
IDAPA 16.06.12.073 Income Deductions
Court-ordered child support payments made by a parent who receives child care benefits are deducted from income when determining eligibility. The actual amount paid and the amount of the legal obligation for child support must be verified.(3-17-22)
IDAPA 16.06.12.074 Averaging Self-Employment Income
- Annual Self-Employment Income. When self-employment income is considered annual support by the household, the Department averages the self-employment income over a twelve-month (12) period, even if:
a.The income is received over a shorter period of time than twelve (12) months; and (3-17-22)
b.The household receives income from other sources in addition to self-employment. (3-17-22)
- Seasonal Self-Employment Income. A seasonally self-employed individual receives income from self-employment during part of the year. When self-employment income is considered seasonal, the Department averages self-employment income for only the part of the year the income is intended to cover.(3-17-22)
IDAPA 16.06.12.075 Calculation of Self-Employment Income
The Department calculates self-employment income by adding monthly income to capital gains and subtracting a deduction for expenses as determined in Subsection 075.03 of this rule.(3-17-22)
-
How Monthly Income is Determined. If no income fluctuations are expected, the average monthly income amount is projected for the certification period. If past income does not reflect expected future income, a proportionate adjustment is made to the expected monthly income.(3-17-22)
-
Capital Gains Income. Capital gains include profit from the sale or transfer of capital assets used in self-employment. The Department calculates capital gains using the federal income tax method. If the household expects to receive any capital gains income from self-employment assets during the certification period, this amount is added to the monthly income as determined in Subsection 075.01 of this rule to determine the gross monthly income.(3-17-22)
-
Self-Employment Expense Deduction. The Department uses the standard self-employment deduction in Subsection 075.03.a. of this rule, unless the applicant claims that their actual allowable expenses exceed the standard deduction and provides proof of the expenses described in Subsection 075.03.b. of this rule. (3-17-22)
a.The self-employment standard deduction is determined by subtracting fifty percent (50%) of the gross monthly self-employment income as determined in Subsections 075.01 and 075.02 of this rule; or (3-17-22)
b.The self-employment actual expense deduction is determined by subtracting the actual allowable expenses from the gross monthly self-employment income. The following items are not allowable expenses and may not be subtracted from the gross monthly self-employment income:(3-17-22)
i.Net losses from previous tax years;(3-17-22)
ii. Federal, state, and local income taxes;(3-17-22)
iii. Money set aside for retirement;(3-17-22)
iv. Work-related personal expenses such as transportation to and from work; and(3-17-22)
v.Depreciation.(3-17-22)
IDAPA 16.06.12.076 Projecting Monthly Income
Income is projected for each month. Past income may be used to project future income. Changes expected during the certification period will be considered. Criteria for projecting monthly income is listed below:(3-17-22)
-
Income Already Received. Count income already received by the household during the month. If the actual amount of income from any pay period is known, use the actual pay period amounts to determine the total month's income. Convert the actual income to a monthly amount if a full month's income has been received or is expected to be received. If no changes are expected, use the known actual pay period amounts for the past thirty (30) days to project future income.(3-17-22)
-
Anticipated Income. Count income the household and the Department believe the household will get during the remainder of the certification period. If the income has not changed and no changes are anticipated, use the income received in the past thirty (30) days as one indicator of anticipated income. If changes in income have occurred or are anticipated, past income cannot be used as an indicator of anticipated income. If income changes and income received in the past thirty (30) days does not reflect anticipated income, the Department can use the household income received over a longer period to anticipate income. If income changes seasonally, the Department can use the household income from the last season, comparable to the certification period, to anticipate income.
a.Full Month's Income. If income will be received for all regular pay dates in the month, it is considered a full month of income.(3-17-22)
b.If income will not be received for all regular pay dates in the month, it is not considered a full month of income and it is not converted.(3-17-22)
c.Income Paid on Salary. Income received on salary, rather than an hourly wage, is counted at the expected monthly salary rate.(3-17-22)
d.Income Paid at Hourly Rate. Compute anticipated income paid on an hourly basis by multiplying the hourly pay by the expected number of hours the client will work in the pay period. Convert the pay period amount to a monthly amount.(3-17-22)
e.Fluctuating Income. When income fluctuates each pay period and the rate of pay remains the same, average the income from the past thirty (30) days to determine the average pay period amount. Convert the average pay period amount to a monthly amount.(3-17-22)
IDAPA 16.06.12.077 Converting Income to a Monthly Amount
If a full month's income is expected, but is received on other than a monthly basis, convert the income to a monthly amount using one of the formulas below:(3-17-22)
-
Weekly Amount. Multiply weekly amounts by four point three (4.3).(3-17-22)
-
Bi-Weekly Amount. Multiply bi-weekly amounts by two point one five (2.15).(3-17-22)
-
Semi-Monthly Amount. Multiply semi-monthly amounts by two (2).(3-17-22)
-
Monthly Amount. Use the exact monthly income if it is expected for each month of the certification period.(3-17-22)
IDAPA 16.06.12.078 Asset Cap
A family must not be in possession of assets exceeding one million dollars ($1,000,000).(3-17-22)
IDAPA 16.06.12.079 (Reserved)
NON-FINANCIAL CRITERIA
(Sections 100-199)
IDAPA 16.06.12.100 (Reserved)
IDAPA 16.06.12.101 Parental Choice of Child Care Provider
Eligible parents may choose among the following types of child care providers available under ICCP: (3-17-22)
-
Child Care Center. A child care center cares for thirteen (13) or more children.(3-17-22)
-
Group Child Care. Group child care is for seven (7) to twelve (12) children.(3-17-22)
-
Family Child Care. Family child care is for six (6) or fewer children.(3-17-22)
-
Relative Child Care. Relative child care is for six (6) or fewer related children.(3-17-22)
-
In-Home Child Care. In-home child care is provided by a relative or non-relative in the home of the child. Eligibility for in-home child care is determined in accordance with Section 400 of these rules. (3-17-22)
IDAPA 16.06.12.102 Residency
The family must live in the state of Idaho, and have no immediate intention of leaving.(3-17-22)
IDAPA 16.06.12.103 Cooperation in Establishment of Paternity and Obtaining Support
A natural or adoptive parent, or other individual who lives with and exercises parental control over a minor child who has an absent parent, must cooperate in establishing paternity for the child and obtaining child support at application and redetermination.(4-6-23)
-
Providing All Information. “Cooperation” includes providing all information to identify and locate the non-custodial parent, unless good cause for non-cooperation exists.(3-17-22)
-
Established Case for Custodial Parent. After Child Support Services (CSS) has established a case for a custodial parent, all child support payments must be sent directly to CSS. If the custodial parent receives child support directly from the non-custodial parent, the custodial parent must forward the payment to CSS for receipting.(4-6-23)
-
Failure to Cooperate.(3-17-22)
a.This includes failure to complete the non-custodial or alleged parent information or filiation affidavit as requested, failure to sign the limited power of attorney, or evidence of failure to cooperate provided by CSS.(4-6-23)
b.When a parent or individual fails to cooperate the family is not eligible to participate in the Idaho Child Care Program.(4-6-23)
- Cooperation Exemptions. The parent or individual will not be required to provide information about the non-custodial or alleged parent or otherwise cooperate in establishing paternity or obtaining support if good cause for not cooperating exists. Good cause for failure to cooperate must be provided.(4-6-23)
a.Good cause for failure to cooperate in obtaining support is:(3-17-22)
i.Proof the child was conceived because of incest or forcible rape;(4-6-23)
ii. Proof the non-custodial parent may inflict physical or emotional harm to the children, the custodial parent, or individual exercising parental control. This must be supported by medical evidence, police reports, or as a last resort, an affidavit from a knowledgeable source; and(4-6-23)
iii. Substantial and credible proof is provided indicating the custodial parent cannot provide the minimum information regarding the non-custodial parent.(3-17-22)
b.A parent or individual claiming good cause for failure to cooperate must submit a notarized statement to the Department identifying the child for whom the exemption is claimed and the reasons for the good cause claim.(4-6-23)
c.The cooperation requirement will be waived if good cause exists. No further action will be taken to establish paternity or obtain support. If good cause does not exist, the parent will be notified that they are not eligible to receive ICCP benefits, until child support cooperation has been obtained.(4-6-23)
IDAPA 16.06.12.104 Family Composition
A family is a group of individuals living in a common residence, whose combined income is considered in determining eligibility and the child care benefit amount. No individual may be considered a member of more than one (1) family in the same month. The following individuals are included in determining the family composition:
-
Married Parents. Married parents living together in a common residence, includes biological, adoptive, step-parent, guardian, and foster parent.(3-17-22)
-
Unmarried Parents. Unmarried parents who live in the same home and who have a child in common living with them.(3-17-22)
-
Dependents. Individuals who are dependents of a parent, guardian, or caretaker relative and living in the home at the primary residence.(3-17-22)
-
Minor Parent. A minor parent and child are considered a separate family when they apply for child care benefits, even if they live with other relatives.(3-17-22)
-
Individual Acting In Loco Parentis. An individual acting in loco parentis who is eligible to apply for child care benefits, and the child’s natural or adoptive parents are not living in the home.(3-17-22)
-
Citizenship or Alien Status Requirement. Family members who are not citizens or living lawfully in the United States will not be counted in the family size. The income of those non-counted family members will be counted when determining the household’s income according to Sections 070 through 099 of these rules.
IDAPA 16.06.12.105 Eligible Child
A family can only receive child care benefits for eligible children. A child is eligible for child care benefits under the following conditions:(3-17-22)
- Immunizations Requirements. A child must be immunized in accordance with Chapter 11, Title 39 , Idaho Code. Child care benefits can continue during a reasonable period necessary for the child to be immunized.
Parents must provide evidence that the child has been immunized unless the child is attending school. (3-17-22)
- Citizenship or Alien Status Requirement. A child must be one (1) of the following: (3-17-22)
a.A citizen;(3-17-22)
b.Living lawfully in the United States.(3-17-22)
- Child's Age Requirement. A child must be under thirteen (13) years of age to be eligible for child care benefits, unless they meet one (1) or more of the following criteria:(3-17-22)
a.A child is eligible for child care benefits until the month of their nineteenth birthday if they are physically or mentally incapable of self-care, as verified by a licensed mental health professional or licensed practitioner of the healing arts.(3-17-22)
b.A child may be eligible for child care benefits until the month of their nineteenth birthday if a court order, probation order, child protection, or mental health case plan requires constant supervision.(3-17-22)
- Child Custody. A child may move from one (1) parent's home to the other parent's home on a regular basis. The child may be a member of either household, but not both households. If the parents cannot agree on the child's household for the child care benefit, the child is included in the household with primary custody. Primary custody is determined by where the child is expected to spend fifty-one percent (51%) or more of the nights during a benefit period. When only one (1) parent applies for ICCP benefits, the child may be included in that parent's household even though they do not have primary physical custody of the child.(3-17-22)
IDAPA 16.06.12.106 Incapacitated Parent
An incapacitated parent, unable to adequately care for the children in a two (2) parent family, is not required to have any qualifying activities as listed under Section 200 of these rules, as long as the other parent is participating in qualifying activities. A single parent family in which the parent is incapacitated is not eligible for ICCP. A parent with a disability does not automatically qualify as an incapacitated parent.(3-17-22)
IDAPA 16.06.12.107 (Reserved)
QUALIFYING ACTIVITIES
(Sections 200-299)
IDAPA 16.06.12.200 Qualifying Activities for Child Care Benefits
To be eligible for child care benefits, each parent included in the household must need child care because they are engaged in one (1) of the qualifying activities listed in Subsections 200.01 through 200.05 of this rule. (3-17-22)
-
Employment. The parent is currently employed.(3-17-22)
-
Self-Employment. The parent is currently self-employed in a business that is a sole proprietorship.
A sole proprietorship is a business owned by one (1) person. Restrictions apply for self-employment as follows:
a.For the first twelve (12) months of self-employment benefits, actual activity hours are used.
b.At month thirteen (13), the number of activity hours will be limited. To calculate the activity hours, the net monthly self-employment income is divided by the current federal minimum wage. The qualifying activity hours are the lesser of the calculated activity hours or actual activity hours.(3-17-22)
- Training or Education. The parent is attending an accredited education or training program. The following restrictions apply to training or education activities:(3-17-22)
a.On-line classes cannot be counted as a qualifying activity for child care.(3-17-22)
b.Persons who are attending post-baccalaureate classes with no other qualifying activity, do not qualify for child care benefits.(3-17-22)
c.More than forty-eight (48) months of post-secondary education has been used as a qualifying activity.(3-17-22)
-
Preventive Services. The parent is receiving preventive services as defined in Section 011 of these rules. The Department will verify the continued need for preventive services at least every three (3) months.
-
Personal Responsibility Contract (PRC) or Other Negotiated Agreement. The parent is completing Personal Responsibility Contract (PRC) or other self-sufficiency activities negotiated between the Department and the parent.(3-17-22)
IDAPA 16.06.12.201 Projecting Qualifying Activity Hours
-
Activity Hours. Activity hours are projected for each month to determine if payment is made on a full-time or part-time basis. Past activity hours may be used to project future activity hours if the employer and number of hours worked are the same and are expected to remain the same throughout the certification period. Hours for each qualifying activity must be projected individually and converted to a monthly amount.(3-17-22)
-
Weekly Hours. Multiply weekly amounts by four point three (4.3).(3-17-22)
-
Bi-weekly Hours. Multiplying bi-weekly amounts by two point one five (2.15).(3-17-22)
-
Semi-Monthly Hours. Multiplying semi-monthly amounts by two (2).(3-17-22)
-
Monthly Hours. Use the exact monthly hours if it is expected for each month of the certification period.(3-17-22)
IDAPA 16.06.12.202 Cessation of Qualifying Activities
An eligible family who loses or ceases its qualifying activity, may continue to receive assistance for up to three (3) months to engage in a job search and resume work, or resume attendance at a job training or educational program.
IDAPA 16.06.12.203 (Reserved)
IDAPA 16.06.12.400 Requirements for in-Home Care Under Iccp
Parents must contact the Department to request approval of in-home child care. Only parents who have qualified activities outside their home will be considered for in-home care approval. The Department limits the approval of all in-home child care under ICCP to the following circumstances:(3-17-22)
-
Three or More Children in the Home. There are three (3) or more ICCP eligible children in the home who are not in school at any time during the day and require child care.(3-17-22)
-
Fewer Than Three Children in the Home. If there are fewer than three (3) children in the home who are eligible for ICCP and require child care, in-home care will be approved by the Department only when one (1) of the following special circumstances are met:(3-17-22)
a.Parents' qualifying activity occurs during times when out-of-home care is not available. If child care is needed during any period when out-of home care is not available, in-home care will be approved for the entire time care is needed. A family is not expected to change between out-of-home and in-home care.(3-17-22)
b.The family lives in an area where out-of-home care is not available.(3-17-22)
c.A child has a verified illness or disability that would place the child or other children in an out-ofhome facility at risk.(3-17-22)
IDAPA 16.06.12.401 In-Home Care Health and Safety Requirements
Annually each in-home care provider is responsible to ensure that health and safety requirements are met for children being cared for in the children’s own home, as defined in Section 802 of these rules.(3-17-22)
IDAPA 16.06.12.402 (Reserved)
PAYMENT INFORMATION
(Sections 500-599)
IDAPA 16.06.12.500 Allowable Child Care Costs
Care provided to an eligible child by an eligible child care provider is payable subject to the following conditions:
-
Payment for Employment, Training, Education, or Preventive Service Hours. Child care must be reasonably related to the hours of the parent's qualifying activities.(3-17-22)
-
One-Time Registration Fees. One-time fees for registering a child in a child care facility are payable above the local market rate, if the fee is charged to all who enroll in the facility. Reimbursement can not exceed two hundred fifty dollars ($250) and must be usual and customary rates charged to all families. Registration fees are separate from local market rates.(3-17-22)
IDAPA 16.06.12.501 Non-Allowable Child Care Costs
Care provided to an eligible child is not payable under the following conditions:(3-17-22)
-
Family Member or Guardian Providing Child Care. A parent, step-parent, or guardian will not be paid for providing child care to their own child or ward.(3-17-22)
-
Provider Living at Same Address as Child. ICCP will not pay for in-home child care if the provider lives at the same address as the child.(3-17-22)
-
School Tuition, Academic Credit, or Tutoring. ICCP payments will not be made for school tuition, academic credit, or tutoring for school age children; this includes:(3-17-22)
a.Any services provided to such students during the regular school day, including kindergarten;
b.Any services for which such students receive academic credit toward graduation; or (3-17-22)
c.Any instructional services which supplant or duplicate the academic program of any public or private school.(3-17-22)
IDAPA 16.06.12.502 Amount of Payment
Child care payments will be based on Subsections 502.01 through 502.04 of this rule.(3-17-22)
- Payment Rate. Payment will be based on the lower of the provider’s usual and customary rates or the Local Market Rate (LMR).(3-17-22)
a.The local market rates for child care are the maximum monthly amounts that ICCP will pay for any given category of child care in a geographic area designated by the Department. The local market rates for child care are established based on a comprehensive survey of child care providers. Using information gathered in the survey, including the age of child, the type of child care, and the designated area where the provider does business, a local market rate is specified for each category of child care. The rate survey is conducted triennially.(3-17-22)
b.Payment rates will be determined by the location of the child care facility.(3-17-22)
c.If the child care facility is not in Idaho, the local market rate will be the rate where the family lives.
-
Usual and Customary Rates. Rates charged by the child care provider must not exceed the usual and customary rates charged for child care to persons not entitled to receive benefits under ICCP.(3-17-22)
-
In-Home Care. Parents are responsible to pay persons providing care in the child’s home the minimum wage, as required by the Fair Labor Standards Act (29 U.S.C. 206a) and other applicable state and federal requirements.(3-17-22)
-
Payments. Payments will be issued directly to eligible providers.(3-17-22)
IDAPA 16.06.12.503 Copayments
Eligible families, except TAFI families participating in non-employment TAFI activities and guardians of foster children, must pay part of their child care costs.(4-6-23)
-
Provider Responsibility. Providers are responsible for ensuring families pay the determined child care costs and must not waive these costs.(4-6-23)
-
Family Payment. Family income and activity for the month of the child care will determine the family share of child care costs. The payment made by the Department will be the allowable local market rate or billed costs, whichever is lower, less the co-payment.(4-6-23)
IDAPA 16.06.12.504 Student Co-Payment Requirements
- Post-Secondary Student.(3-17-22)
a.A post-secondary student who works less than ten (10) hours per week will be required to pay a copayment.(3-17-22)
b.A post-secondary student who works ten (10) hours or more per week will have a co-payment based on family income.(3-17-22)
- High School or GED Student. A student who is in high school, or who is taking GED courses will have a co-payment based on family income.(3-17-22)
IDAPA 16.06.12.505 Interim Child Care Payment
If child care arrangements would otherwise be lost, child care may be paid when a child temporarily stops attending child care for no longer than (1) calendar month and plans to return.(3-17-22)
IDAPA 16.06.12.506 (Reserved)
CHANGE REPORTING REQUIREMENTS FOR THOSE RECEIVING CHILD CARE BENEFITS
(Sections 600 - 699)
IDAPA 16.06.12.600 Change Reporting Requirements
A family who receives child care benefits must report the following permanent changes by the tenth day of the month following the month in which the change occurred.(3-17-22)
-
Change in Permanent Address.(3-17-22)
-
Change in Household Composition.(3-17-22)
-
Change in Income. When the household's total gross income for family of the same size exceeds any of the following:(3-17-22)
a.One hundred and thirty percent (130%) of the Federal Poverty Guidelines (FPG);(3-17-22)
b.Eighty-five percent (85%) of the State Median Income (SMI); or(3-17-22)
c.The graduated phase-out income limit as defined in the Idaho Child Care State Plan. (3-17-22)
- Change in Child Care Provider.(3-17-22)
IDAPA 16.06.12.601 (Reserved)
IDAPA 16.06.12.602 Redetermination of Eligibility for Child Care Benefits
-
Redetermination. The Department will redetermine eligibility for child care benefits at least every twelve (12) months.(3-17-22)
-
Graduated Phase Out. At redetermination, if a household's income exceeds one hundred seventyfive percent (175%) of FPG for a family of the same size eligible children may receive a graduated phase out benefit that is limited to twelve (12) months following the completion of a redetermination under the Idaho Child Care State Plan.(4-6-23)
IDAPA 16.06.12.603 (Reserved)
PAYMENT ADJUSTMENTS AND PENALTIES
(Sections 700-704)
IDAPA 16.06.12.700 Underpayment of Child Care Benefits
When the Department has underpaid a family's child care benefits, a supplemental payment will be made. (3-17-22)
IDAPA 16.06.12.701 Recoupment of Overpayments
The Department may recoup or recover the amount paid for child care services from a provider or a parent. Interest will accrue on these overpayments at the statutory rate set under Section 28-22-104, Idaho Code, from the date of the final determination of the amount owed for services. Interest will not accrue on overpayments made due to Department error. An overpayment due to family, agency, or provider error, IPV or fraud must be recovered in full. A parent or provider may negotiate a repayment schedule with the Department.(3-17-22)
IDAPA 16.06.12.702 Intentional Program Violations (ipv)
An IPV is an intentionally false or misleading action or statement as identified below in Subsections 702.01 through 702.08 of this rule. An IPV is established when a family member or the child care provider admits the IPV in writing and waives the right to an administrative hearing, or when determined by an administrative hearing, a court decision, or through deferred adjudication. Deferred adjudication exists when the court defers a determination of guilt because the accused family member or child care provider meets the terms of a court order or an agreement with the prosecutor.(3-17-22)
-
False Statement. An individual makes a false statement to the Department, either orally or in writing, in order to participate in the Idaho Child Care Program.(3-17-22)
-
Misleading Statement. An individual makes a misleading statement to the Department, either orally or in writing, to participate in the Idaho Child Care Program.(3-17-22)
-
Misrepresentation of Fact. An individual misrepresents one (1) or more facts to the Department, either orally or in writing, to participate in the Idaho Child Care Program.(3-17-22)
-
Concealing Fact. An individual conceals or withholds one (1) or more facts to participate in the Idaho Child Care Program.(3-17-22)
-
Non-Compliance With Rules and Regulations. An individual fails repeatedly or substantially to comply with this chapter of rules.(3-17-22)
-
Violation of Provider Agreement. An individual knowingly violates any term of their provider agreement.(3-17-22)
-
Failure to Meet Qualifications. A provider fails to meet the qualifications specifically required by this chapter of rules or by any applicable licensing board.(3-17-22)
IDAPA 16.06.12.703 Penalties for an Ipv
When the Department determines an IPV was committed, the party who committed the IPV loses eligibility for ICCP.
If an individual has committed an IPV, the entire family is ineligible for child care benefits. If a child care provider has committed an IPV, the provider is ineligible to receive payments. The period of ineligibility for each offense, for both participants and providers, is as follows:(3-17-22)
-
First Offense. Twelve (12) months, for the first IPV or fraud offense, or the length of time specified by the court.(3-17-22)
-
Second Offense. Twenty-four (24) months for the second IPV or fraud offense, or the length of time specified by the court.(3-17-22)
-
Third Offense. Permanent ineligibility for the third or subsequent IPV or fraud offense, or the length of time specified by the court.(3-17-22)
IDAPA 16.06.12.704 Denial of Payment
The Department may deny payment for the reasons described in Subsections 704.01 through 704.05 of this rule.
-
Services Not Provided. Any or all claims for child care services it determines were not provided.
-
Services Not Documented. Child care services not documented by the provider as required in Subsection 810.01 of these rules.(3-17-22)
-
Contrary to Rules or Provider Agreement. Child care services provided contrary to these rules or the provider agreement.(3-17-22)
-
Failure to Provide Immediate Access to Records. The Department may deny payment when the provider does not allow immediate access to records as provided in Subsection 810.02 of these rules. (3-17-22)
-
Paying for Attendance. Payment will be denied if an eligible provider pays directly or indirectly, overtly or covertly, for a child to attend the provider’s child care facility.(3-17-22)
IDAPA 16.06.12.705 Funding Restrictions
If a funding shortfall is projected, the Department may reduce child care benefits to ensure that ICCP operates within its financial resources.(3-17-22)
IDAPA 16.06.12.706 (Reserved)
ENFORCEMENT REMEDIES
(Sections 750-799)
IDAPA 16.06.12.750 Termination of Provider Status
Under Section 56-209h, Idaho Code, the Department may terminate the provider agreement of, or otherwise deny provider status for a period up to five (5) years from the date the Department's action becomes final to any individual or entity providing ICCP.(3-17-22)
-
Submits an Incorrect Claim. Submits a claim with knowledge that the claim is incorrect.
-
Fraudulent Claim. Submits a fraudulent claim.(3-17-22)
-
Knowingly Makes a False Statement. Knowingly makes a false statement or representation of material facts in any document required to be maintained or submitted to the Department.(3-17-22)
-
Immediate Access to Documentation. Fails to provide, upon written request by the Department, immediate access to documentation required to be maintained.(3-17-22)
-
Non-Compliance With Rules and Regulations. Fails repeatedly or substantially to comply with the rules and regulations governing Idaho child care payments.(3-17-22)
-
Violation of Material Term or Condition. Knowingly violates any material term or condition of the provider agreement.(3-17-22)
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Failure to Repay. Has failed to repay, or was a managing employee or had an ownership or control interest in any entity that has failed to repay, any overpayments or claims previously found to have been obtained contrary to statute, rule, regulation, or provider agreement.(3-17-22)
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Fraudulent or Abusive Conduct. Has been found, or was a managing employee in any entity which has been found, to have engaged in fraudulent conduct or abusive conduct.(3-17-22)
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Failure to Meet Qualifications. Fails to meet the qualifications specifically required by rule or by any applicable licensing entity.(3-17-22)
IDAPA 16.06.12.751 Refusal to Enter Into an Agreement
The Department may refuse to enter into a provider agreement for the reasons described in Subsections 751.01 through 751.06 of this rule.(3-17-22)
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Convicted of a Felony. The provider has been convicted of a felony or is under investigation for the commission of a felony.(3-17-22)
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Committed an Offense or Act Not in Best Interest of Child Care Participants. The provider has committed an offense or act which the Department determines is inconsistent with the best interests of ICCP participants.(3-17-22)
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Failed to Repay. The provider has failed to repay the Department monies which had been previously determined to have been owed to the Department.(3-17-22)
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Investigation Pending. The provider has a pending investigation for program fraud or abuse.
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Terminated Provider Agreement. The provider was the managing employee, officer, owner, or spouse, partner, or relative of an owner of an entity, whose provider agreement was terminated under Section 750 of these rules.(3-17-22)
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Excluded Individuals. The provider has a current exclusion from participation in federal programs by the Office of Inspector General List of Excluded Individuals and Entities.(3-17-22)
IDAPA 16.06.12.752 Provider Notification
When the Department determines actions defined in Sections 701 through 705, 750, and 751 of these rules are appropriate, it will send written notice of the decision to the provider or person. The notice will state the basis for the action, the length of the action, the effect of the action on that person's ability to provide services under state and federal programs, and the person's appeal rights.(3-17-22)
IDAPA 16.06.12.753 Notice to State Licensing Authorities
The Department will promptly notify all appropriate licensing authorities having responsibility for licensing of a Department action, and the facts and circumstances of that action. The Department may request certain actions be taken and that the Department be informed of actions taken.(3-17-22)
IDAPA 16.06.12.754 (Reserved)
PROVIDER ELIGIBILITY
(Sections 800-808)
IDAPA 16.06.12.800 Child Care Provider Licensing
All providers of child care who receive a Department subsidy must be licensed or must comply with: applicable State Daycare licensing requirements in Title 39, Chapter 11, Idaho Code; these rules; local licensing ordinances; or tribal ordinances. If both state requirements and ordinances apply to a provider, the provider must comply with the stricter requirement. A provider operating outside Idaho must comply with the licensing laws of their state or locality.
IDAPA 16.06.12.801 Health and Safety Training
All child care providers must complete a series of health and safety trainings during an orientation period of not more than ninety (90) days, in addition to ongoing annual training that address each of the following topics: (3-17-22)
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Infectious Diseases. The prevention and control of infectious diseases (including immunization).
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Sudden Infant Death Syndrome. The prevention of sudden infant death syndrome and use of safe sleeping practices.(3-17-22)
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Medication. The administration of medication, consistent with standards for parental consent.
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Allergic Reactions. The prevention of and response to emergencies due to food and allergic reactions.(3-17-22)
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Environmental Safety. Building and physical premises safety, including identification of and protection from hazards, bodies of water, and vehicular traffic.(3-17-22)
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Child Abuse Prevention. Prevention of shaken baby syndrome, abusive head trauma, child maltreatment, and recognition and reporting of child abuse and neglect.(3-17-22)
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Emergency Preparedness. Emergency preparedness and response planning for emergencies resulting from a natural disaster, or a man-caused event.(3-17-22)
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Hazardous Substances. Proper handling, storage, and disposal of medicines, cleaning supplies, and other hazardous substances, including biocontaminants.(3-17-22)
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Transportation. Appropriate precautions in transporting children, including the use of child safety restraints and seat belts.(3-17-22)
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Child Development. Address major domains such as cognitive, social, emotional, physical development, and approaches to learning.(3-17-22)
IDAPA 16.06.12.802 Health and Safety Requirements
All providers must comply with the health and safety requirements under this rule. All providers must agree to an annual, unannounced health and safety inspection, except for in-home child care under Section 401 of these rules.
Compliance with these standards does not exempt a provider from complying with stricter health and safety standards under state law, tribal law, local ordinance, or other applicable law.(4-6-23)
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Age of Provider. All child care providers providing services must be eighteen (18) years old or older. Persons sixteen (16) or seventeen (17) years old may provide child care if they have direct, on-site supervision from a licensed child care provider who is at least eighteen (18) years old.(3-17-22)
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Sanitary Food Preparation. Food for use in child care facilities must be prepared and served in a sanitary manner. Utensils and food preparation surfaces must be cleaned and sanitized before using to prevent contamination.(3-17-22)
-
Food Storage. All food served in child care facilities must be stored to protect it from potential contamination.(3-17-22)
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Hazardous Substances. Medicines, cleaning supplies, and other hazardous substances must be handled safely and stored out of the reach of children. Biocontaminants must be disposed of appropriately. (3-17-22)
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Emergency Communication. A telephone or some type of emergency communication system is required.(3-17-22)
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Smoke Detectors, Fire Extinguishers, and Exits. A properly installed and operational smoke detector must be on the premises where child care occurs. Adequate fire extinguishers and fire exits must be available on the premises.(3-17-22)
-
Hand Washing. Each provider must wash their hands with soap and water at regular intervals, including before feeding, after diapering or assisting children with toileting, after nose wiping, and after administering first aid.(4-6-23)
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CPR/First Aid. All providers must have current certification in pediatric rescue breathing (CPR) and pediatric first aid treatment from a certified instructor.(3-17-22)
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Health of Provider. Each provider must certify that they do not have a communicable disease or any physical or psychological condition that might pose a threat to the safety of a child in their care.(4-6-23)
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Child Abuse. Providers must report suspected child abuse to the appropriate authority. (3-17-22)
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Transportation. Providers who transport children as part of their child care operations must operate safely and legally, using child safety restraints and seat belts as required by state and local statutes. (3-17-22)
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Disaster and Emergency Planning. Providers must have documented plans for emergencies resulting from a natural disaster, or man-caused event that include:(4-6-23)
a.Procedures for evacuation, relocation, shelter-in-place, lock-down, communication and reunification with families, continuity of operations, and accommodation of infants and toddlers and children with disabilities or chronic medical conditions.(4-6-23)
b.Procedures for staff and volunteer emergency preparedness training and practice drills. (3-17-22)
c.Guidelines for the continuation of child care services in the period following the emergency or disaster.(3-17-22)
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Environmental Safety. Building and physical premises must be safe, including identification of and protection from hazards that can cause bodily injury including electrical hazards, bodies of water, and vehicular traffic.(3-17-22)
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Safe Sleep. Providers must place newborn infants to twelve (12) months in a safe sleep environment. Safe sleep practices include alone, on their backs, and in a Consumer Product Safety Commission (CPSC) certified crib.(4-6-23)
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Behavior Management and Discipline. Methods of behavior management and discipline for children must be positive, consistent, and based on each child's needs, stage of development, and behavior. Discipline is to promote self-control, self-esteem, and independence. Providers must certify that they will not harm, shake, or abuse children, and that children in their care will not experience maltreatment under 45 CFR 98.41.(4-6-23)
IDAPA 16.06.12.803 Child Care Provider Training Requirements
Each child care provider must receive and ensure that each staff member who provides child care receives and completes twelve (12) hours of ongoing training every twelve (12) months after the staff member's date of hire.
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Training Contents. Training must be related to continuing education in child development, teaching and curriculum, health and safety, and business practices. Pediatric rescue breathing (CPR) and pediatric first aid treatment training will not count towards the required twelve (12) hours of annual training.(3-17-22)
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Documented Training. It is the responsibility of the child care provider to ensure that each staff member who provides child care has completed twelve (12) hours of training each year. The training must be documented in the staff member's record.(3-17-22)
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Staff Training Records. Each child care provider is responsible for maintaining documentation of staff's training and must produce this documentation when the provider agreement is renewed annually. (3-17-22)
IDAPA 16.06.12.804 Child Care Provider Agreement
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Compliance. All providers must sign and comply with a provider agreement.(3-17-22)
-
Provide Direct Care. Except for Child Care Centers described in Subsection 101.01 of these rules, the individual who signs the provider agreement must provide the majority of direct care to the children in that child care facility.(3-17-22)
IDAPA 16.06.12.805 Criminal History and Background Check Requirement
Applicants, providers, employees, volunteers, and all other individuals age thirteen (13) or older who have direct contact with or provide care to children eligible for ICCP benefits must comply with the requirements and receive clearance as provided in IDAPA 16.05.06, “Criminal History and Background Checks,” every five (5) years.
IDAPA 16.06.12.806 Purview of Child Protective Act or Juvenile Justice Reform Act
Providers must certify that they are not, through stipulation or adjudication, under the purview of the Child Protective Act, Section 16-1600, Idaho Code, or the Juvenile Corrections Act, Section 20-501 through 20-547, Idaho Code. Any person who has a substantiated child protection complaint cannot be a provider.(3-17-22)
IDAPA 16.06.12.807 Parent or Caretaker Access to Child Care Premises
Providers serving families who receive a child care subsidy must allow parents or caretakers unlimited access to their children and to persons giving care, except that access to children will not be required if prohibited by court order.
IDAPA 16.06.12.808 Reporting Requirements for Providers
A child care provider must report any of the following changes within ten (10) days:(3-17-22)
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Change in Provider Charges. The provider changes any rate for child care services. (3-17-22)
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Child Stops Attending Care. A child covered under ICCP stops attending child care, or is taken to another child care provider.(3-17-22)
-
Change of Provider Address. The provider changes the location where child care is provided.
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Change in Who Lives in Home. An individual who provides child care in their home must report when any other person moves into the home.(3-17-22)
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Intent Not to Renew License. The provider intends not to renew their license, or other required certifications.(3-17-22)
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Death or Serious Injury. Providers must report when a child sustains a serious injury or dies while at the location of, or as a result of participating in child care.(3-17-22)
IDAPA 16.06.12.809 Consumer Education Information
The Department will make public by electronic means, in an easily accessible format:(3-17-22)
-
Monitoring and Inspection Reports. The results of all child care monitoring and inspection reports.(3-17-22)
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Substantiated Complaints. Substantiated complaints about failure to comply with child care laws, rules, and policies, that include information on the date of such an inspection, and where applicable, information on corrective action taken.(3-17-22)
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Death and Serious Injury. The total number of deaths, serious injuries, and instances of substantiated child abuse that occurred in child care settings each year.(3-17-22)
IDAPA 16.06.12.810 Documentation of Services and Access to Records
- Documentation of Services. Providers must generate documentation at the time of service sufficient to support the reimbursement for child care services. Documentation must be legible and retained for a period of three (3) years from the date the child care was provided. Documentation to support child care services includes:(3-17-22)
a.Records of attendance, including signatures of a parent or guardian;(3-17-22)
b.Immunization records, conditional admittance form, or exemption form according to IDAPA 16.02.11, “Immunization Requirements for Licensed Daycare Facility Attendees.”(3-17-22)
c.Billing records and receipts;(3-17-22)
d.Policies regarding sign-in procedures, and others as applicable; and(3-17-22)
e.Sign-in records, electronic or manual, or the Child and Adult Food Care Program records.
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Immediate Access to Records. Providers must grant to the Department and its agents, immediate access to records for review and copying during normal business hours. These records are defined in Subsection 810.01 of this rule.(3-17-22)
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Copying Records. The Department and its authorized agents may copy any record as defined in Subsection 810.01 of this rule. The Department may request in writing to have copies of records supplied by the provider. The requested copies must be furnished within twenty (20) working days after the date of the written request, unless an extension of time is granted by the Department for good cause. Failure to timely provide requested copies will be a refusal to provide access to records.(3-17-22)
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Removal of Records From Provider's Premises. The Department and its authorized agents may remove from the provider's premises copies of any records defined in Subsection 810.01 of this rule. (3-17-22)
IDAPA 16.06.12.811 (Reserved)
16.06.02 Foster Care Licensing
IDAPA 16.06.02.000 Legal Authority
Sections 39-1211, 39-1213, 56-1003, and 56-1005(8)Idaho Code, and Tittle 56, Chapter 27, Idaho Code,. (7-1-26)
IDAPA 16.06.02.001 (Reserved)
IDAPA 16.06.02.010 Definitions
The terms listed in this section apply to this chapter. Terms not defined below are defined in Title 39, Chapter 12, and IDAPA 16.06.01.(7-1-26)
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Caregiver. A foster parent with whom a child in foster care has been placed or a designated official for a child care institution in which a child in foster care has been placed.(7-1-25)
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Child. Includes individuals age eighteen (18) to twenty-three (23) who are ordered into or voluntarily entered Extended Foster Care through the Department.(7-1-26)
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Department. The Idaho Department of Health and Welfare or its authorized representatives.
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Foster Home. Includes both foster homes and relative foster homes as set forth in Idaho Code.
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Foster Parent. Licensed person(s) residing in a private home under their direct control. (7-1-26)
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Household Member. Any person, other than a foster child, who resides in, or on the property of, a foster home. (7-1-25)
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Medical Professionals. Persons who have received a degree in nursing or medicine and are licensed as a registered nurse, nurse practitioner, physician’s assistant, or medical doctor.(7-1-25)
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Noncompliance. Violation of, or inability to meet, the requirements of these rules or terms of licensure. (7-1-25)
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Plan of Correction. The detailed procedures and activities developed between the Department and caregiver required to bring a foster family into conformity with these rules. (7-1-25)
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Restraint. Physical interventions to control the range and motion of a child.(7-1-25)
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Supervision. Being within sight and normal hearing range of a child being cared for. (7-1-26)
IDAPA 16.06.02.011 (Reserved)
IDAPA 16.06.02.102 Disposition of Applications
The Department will expeditiously initiate action on each completed application within one (1) business day after receipt that addresses each requirement for the specific type of home. (7-1-25)
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Approval of Application. The Department will issue a license to any foster home complying with these rules. (7-1-25)
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Regular License. The Department will issue a regular license to any foster home complying with these rules and will specify the terms of licensure. (7-1-26)
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Kin-specific License. A license for kin to become foster parents through a separate and expedited path. To qualify, applicants must:(7-1-26)
a.Have a relationship with a foster child as described in Idaho law;(7-1-26)
b.Receive a background check clearance in accordance with this chapter; and(7-1-26)
c.Complete an abbreviated kin caregiver assessment focused solely on determining kin family’s ability to meet the child(ren)’s needs and how the Department can support the needs of kin and the child(ren).
(7-1-26)
- Limited License. May be issued for the care of a specific child in a home which may not meet the requirements for a license, provided: (7-1-25)
a.The child is already in the home and has formed strong emotional ties with the foster parents; and
b.It can be shown that the child's continued placement in the home would be more conducive to their welfare than removal to another home. (7-1-25)
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Denial of Application. If an application is denied, a signed letter will be sent to the applicant by registered or certified mail, advising the applicant of the denial and stating the basis for such denial. An applicant whose application has been denied may not reapply until one (1) year after the date of denial. (7-1-26)
-
Failure to Complete Application Process. An application will be deemed vacated if the application process is not completed within six (6) months of the original date of application. (7-1-26)
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Facilitating Applications.(7-1-25)
a.The Department may, within its appropriation, cover reasonable expenses to ensure homes meet the requirements of these rules.(7-1-26)
b.The Department will establish procedures to fast-track applications from candidates who have a successful track record of serving as a foster home in other states.(7-1-25)
- Reactivating an Idaho License. If less than twelve (12) months has elapsed from the last licensed foster home visit required by Section 39-1217, Idaho Code, the Department may fast-track reactivating the license if the prior licensee:(7-1-25)
a.Relinquished the license in good standing; and(7-1-25)
b.Attests to maintaining conformity with the standards established by the Department. (7-1-25)
IDAPA 16.06.02.103 Restrictions on Applicability and Nontransfer
A license is nontransferable and applies only to the foster home or the person and premises designated. Each license is issued in the individual’s name, and to the address on the application. A license issued in the name of a foster parent applies to the period and services specified in the license. Any change in address renders the license null and void. (7-1-26)
IDAPA 16.06.02.104 (Reserved)
IDAPA 16.06.02.105 Revisit and Relicense
Revisit and relicense studies will document how the foster home continues to meet licensing standards. A renewal application must be submitted to the Department prior to the expiration of the existing license. Unless revoked, the existing license will remain effective until the Department has acted on the renewal application. (7-1-26)
IDAPA 16.06.02.106 Complaints
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Investigation. The Department will investigate complaints regarding foster homes. The investigation may include further contact with the complainant, scheduled or unannounced visits to the foster home, collateral contacts including interviews with the victim, parents or guardian, consultants, children in care, other persons who may have knowledge of the complaint, and inspections by fire or health officials. (7-1-25)
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Informed of Action. If an initial preliminary investigation indicates that a more complete investigation must be made, the foster parents will be informed of the investigation, and any action to be taken, including referral for civil or criminal action. (7-1-25)
IDAPA 16.06.02.107 Suspension for Circumstances Beyond Control of Foster Parent
When circumstances occur over which the foster parent has no control including illness, epidemics, fire, flood, or contamination, which temporarily place the operation of the foster home out of compliance with these rules, the license must be suspended until the nonconformity is remedied. (7-1-25)
IDAPA 16.06.02.108 Suspension or Revocation and Transfer of Children
-
Suspension. The Department may summarily suspend a foster care license.(7-1-26)
-
Revocation. The Department may revoke the license of a foster home when the Department determines the home is not in compliance and in the following circumstances:(7-1-26)
a.Any condition that endangers the health or safety of any child.(7-1-26)
b.A foster home is not in substantial compliance with these rules.(7-1-26)
c.A foster home has made little or no progress in correcting deficiencies within thirty (30) days from the date the Department accepted a plan of correction.(7-1-26)
d.Repeat violation of these rules or Idaho Law.(7-1-26)
e.Knowingly misrepresented or omitted information on the application or other documents pertinent to obtaining a license.(7-1-26)
f.Refusal to allow Department representatives full access to the foster home and its grounds, facilities, and records.(7-1-26) g,Violating any of the terms of a provisional license.(7-1-26)
h.The Department concludes that an adult in the foster home fails to live a law-abiding lifestyle and by a preponderance of the evidence determines the adult has committed a prior offense set forth in IDAPA 16.06.02.201.05.(7-1-26)
i.The Department may revoke a license even when:(7-1-26)
(1) The adult received an order under Section 20-525A, Idaho Code, or other equivalent law; a withheld judgment; an order under Section 19-2604, Idaho Code, or other equivalent law; or the record has been sealed.(7-1-26)
(2) Law enforcement did not investigate, charges were never filed, where charges were dismissed, or where a person was acquitted.(7-1-26)
ii. Before the Department revokes a license pursuant to this subsection, the Department shall notify the licensee of its intent to revoke the license pursuant to law and give the licensee an opportunity to provide pertinent information about the offense, later good conduct, or treatment before the license is revoked.(7-1-26)
iii. A clearance from the background check unit does not preclude the revocation of a license under this subsection.(7-1-26)
IDAPA 16.06.02.109 (Reserved)
IDAPA 16.06.02.111 Effect of Previous Revocation or Denial of a License
An organization cannot apply and the Department will not accept an application from any person, corporation, or partnership, including any owner with a ten percent (10%) or more interest, who has had a license denied or revoked, until five (5) years has elapsed from the date of denial, revocation, or conclusion of a final appeal, whichever occurred last. (7-1-25)
IDAPA 16.06.02.112 (Reserved)
IDAPA 16.06.02.200 Licensing Provisions Related to the Indian Child Welfare Act
These rules do not supersede the licensing authority of Indian tribes under the Indian Child Welfare Act, P.L. 95-608, 25 USC, Sections 1901 – 1963. (7-1-25)
IDAPA 16.06.02.201 Foster Parent Qualifications and Suitability
An applicant for licensure as a foster parent must meet the following: (7-1-25)
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Age. Be eighteen (18) years old or older.(7-1-25)
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Communication. Be able to communicate with the child, the children’s agency, and health care and other service providers.(7-1-25)
-
Income and Resources. Have a defined and sufficient source of income and be capable of managing that income to meet the needs of the foster family without relying on the payment made for the care of a foster child. (7-1-25)
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Literacy. At least one (1) adult caretaker in the home must have functional literacy. (7-1-26)
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Law-Abiding Lifestyle. Not have committed a prior offense described in IDAPA 16.05.06.210.01.
However, the Department may in its discretion deny a license if the applicant has committed a prior offense described in IDAPA 16.05.06.210.02 or 16.05.06.210.03. The commission of any prior offense is proven by a preponderance of the evidence and by the underlying facts and circumstances.(7-1-26)
IDAPA 16.06.02.202 Background Checks
All applicants for a foster care license and other adult members of the household must comply with IDAPA 16.05.06 and the following: (7-1-26)
-
Change in Household Membership. By the next working day after another adult begins residing in a foster home, a foster parent must notify the children's agency of the change in household membership and assure that the new adult household member will complete a background check within fifteen (15) days of residence in the foster home. (7-1-25)
-
Foster Parent’s Child Turns Eighteen. A foster parent’s child who turns eighteen (18) and lives continuously in the home is not required to have a background check except as specified in this rule. (7-1-25)
a.After turning eighteen (18) years old, if the foster parent’s adult child no longer lives in the foster parent’s home and subsequently resumes living in the foster home, they will be considered an adult household member and must complete a background check within fifteen (15) days from the date they became an adult household member. (7-1-25)
b.If the adult child leaves the foster home for the purpose of higher education or military service, and periodically returns to the home for less than ninety (90) days, they are not considered to be an adult household member and are not required to complete a background check. While in the home, they cannot have any unsupervised direct care responsibilities for any foster children in the home. Should they remain in the foster home for more than ninety (90) days, they will immediately be considered an adult household member and must complete a background check within fifteen (15) days from the date they became an adult household member. (7-1-25)
c.If the adult child continues to live in their parent’s foster home or on the same property, they must complete a background check within fifteen (15) days of turning twenty-one (21), This requirement is not necessary if the adult child has completed a background check between the ages of eighteen (18) and twenty-one (21). (7-1-25)
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Background Check at Any Time. The Department retains the authority to require a background check at any time on individuals who are residing in a foster home or on the foster parent’s property. (7-1-25)
-
Emergency Placement of Children. An emergency occurs when a child enters or experiences an unplanned placement change in foster care. The Department may request that a criminal justice agency perform a Federal Interstate Identification Index name-based criminal history record check of each adult residing in the home.
This refers to those limited instances when placing a child in the home of relatives or kin, as a result of a sudden unavailability of the child's parent or caretaker.(7-1-25)
a.All adult household members will submit fingerprints to the Department's Background Check Unit within ten (10) calendar days and follow requirements outlined in IDAPA 16.05.06. The Department forwards the fingerprints to the State Central Record Repository for submission to the FBI within fifteen (15) calendar days from the date the name search was conducted. The Department's background check unit will positively identify the individual that is being considered to receive the child in an emergency situation as their fingerprints are submitted.
(7-1-26)
b.When placement of a child in a home is denied as a result of the Department review of the namebased criminal history record check of any adult household member, all adults must still comply with Subsection 202.04.a. of this rule and IDAPA 16.05.06.(7-1-26)
c.The child will be removed from the home immediately if any adult household member fails to provide written permission to perform a federal criminal history record check, submit fingerprints, or any adult household member is denied a Department background check clearance.(7-1-25)
- Exceptions to Background Checks. Background checks are optional for certain youth in foster care who reach the age of eighteen (18) but are less than twenty-one (21) years of age and continue to reside in the same licensed foster home.(7-1-25)
IDAPA 16.06.02.203 Initial and Ongoing Evaluation
An applicant must participate in the process and tasks to complete an initial evaluation for foster care licensure.
- Applicant Participation. The applicant must do all the following:(7-1-25)
a.Cooperate with and allow the children's agency to determine compliance with these rules to conduct an initial foster home study; (7-1-25)
b.Inform the children's agency if the applicant is currently licensed or has been previously licensed as a foster parent or the applicant has been involved in the care and supervision of children or adults; (7-1-25)
c.All household members must disclose current mental health and/or substance abuse issues.
d.All household members must provide information on their physical and mental health history, including any history of drug or alcohol abuse or treatment.(7-1-25)
e.Provide two (2) satisfactory references, one (1) of which may be from a person related to the applicant(s). An applicant will provide additional references upon the request of the children's agency. (7-1-25)
- Disclosure of Information and Assurances. An applicant must provide the children's agency with the following or any additional information the children's agency deems necessary to complete the initial family home study: (7-1-25)
a.Names, including maiden or other names used, and ages of the applicant(s);(7-1-25)
b.Social Security Number;(7-1-25)
c.Education;(7-1-25)
d.Verification of marriages and divorces;(7-1-25)
e.Religious and cultural practices of the applicant including their willingness and ability to accommodate or provide care to a foster child of a different race, religion, or culture; (7-1-25)
f.Statement of income and financial resources and the family's management of these resources;
g.Reasons for applying to be a foster parent;(7-1-25)
h.Report any prior arrest, investigation, or other official action regarding a sexual offense or impropriety.(7-1-25)
i.Provide and abide by the following written assurances:(7-1-25)
i.Applicants will not use any illegal substances, abuse alcohol by consuming it in excess amounts, or abuse legal prescription and/or nonprescription drugs by consuming them in excess amounts or using them contrary to as indicated.(7-1-25)
ii. Applicants and their guests will not smoke in the foster family home, in any vehicle used to transport the child, or in the presence of the child in foster care.(7-1-25)
- Home Study. The applicant must complete an agency home study, which is a written comprehensive family assessment to include the following elements:(7-1-25)
a.At least one scheduled on-site visit to assess the home to ensure that it meets the standards set forth in these rules;(7-1-25)
b.At least one scheduled in-home interview for each household member to observe family functioning and assess the family’s capacity to meet the needs of a child or children in foster care;(7-1-25)
c.The Department has discretion on whether to interview or observe each household member based on his or her age and development.(7-1-25)
IDAPA 16.06.02.204 Subsequent Evaluations
A foster parent must comply with the following: (7-1-25)
-
Reasonable Access. A foster parent will allow the children's agency reasonable access to the foster home, including interviewing each foster parent, each foster child, and any household member to determine compliance with these rules, for child supervision purposes, and to conduct a relicense study. (7-1-25)
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Update Information. Provide all changes to the information in the initial evaluation and subsequent evaluations. (7-1-25)
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Family Functioning. Provide information on changes in family functioning and interrelationships. (7-1-25)
-
Other Circumstances. Provide the children's agency with any information regarding circumstances within the family that may adversely impact the foster child. (7-1-25)
-
Plan of Correction. Cooperate with the children's agency in developing and carrying out a written plan required to correct any rule noncompliance identified by any evaluation conducted by the children's agency.
IDAPA 16.06.02.205 Foster Parent Duties
A foster parent must do the following: (7-1-25)
-
Case Plan Implementation. Cooperate with, and assist the children's agency with implementation of the case plan for children and their families. (7-1-25)
-
Reporting Progress and Problems. Promptly and fully disclose to the children's agency information concerning a child's progress and problems. (7-1-25)
-
Termination of Placement. Provide notification to the children's agency of the need for a child to be moved from the foster home not less than fourteen (14) days before the move, except when a delay would jeopardize the child's care or safety, or the safety of members of the foster family. (7-1-25)
IDAPA 16.06.02.206 (Reserved)
IDAPA 16.06.02.239 Transportation
Applicants must ensure that the child(ren) always has reliable, legal and safe transportation. Reliable transportation includes a properly maintained vehicle or access to reliable public transportation; legal transportation includes having a valid driving license, insurance and registration; and safe transportation includes safety restraints as appropriate for the child. (7-1-26)
IDAPA 16.06.02.240 (Reserved)
IDAPA 16.06.02.242 Child Placement Requirements
A foster family may mutually accept the placement of children into the home within the terms of the foster home license and the children's agency placement agreement. The following provisions will be considered for determining placement: (7-1-25)
- Determining Factors. The number and the age group of children placed in a foster home will be determined by the following: (7-1-25)
a.The accessibility, accommodations, and the space in the home;(7-1-25)
b.The interest of the foster family; and(7-1-25)
c.The experience, training, or skill of the foster family.(7-1-25)
-
Maximum Number of Children. Except as specified, the maximum number of children in care at any time, including the foster family's own children, or daycare children, will be limited to not more than six (6) children. (7-1-25)
-
Children Under Two Years Old. Except as specified in Subsection 242.04 of this rule, the maximum number of children under two (2) years old, including those of the foster family, will be limited to two (2) children or less. (7-1-25)
-
Special Circumstances Regarding Maximum Numbers of Children. The maximum number of children in care at any time may be extended in order: (7-1-26)
a.To allow siblings to remain together;(7-1-25)
b.To allow a child who has an established, meaningful relationship with the family to remain with the family; (7-1-25)
c.To allow a family with special training or skills to provide care for a child who has a severe disability; or(7-1-25)
d.To allow a parenting youth in foster care to remain with the child of the parenting youth. (7-1-25)
- Continued Care. A foster child who reaches the age of eighteen (18) may continue in foster care placement until the age of twenty-three (23) if the safety, health, and well-being of other foster children residing in the home is not jeopardized. (7-1-26)
IDAPA 16.06.02.243 Interagency Placement of Children
A foster family must only accept for placement children referred from the children's agency that licenses the foster home. A foster family may accept for placement a foster child from another children's agency only if that children's agency and the foster family have received prior approval for the placement of a child from the children's agency that licensed the home. (7-1-25)
IDAPA 16.06.02.244 Substitute Care Placement and Children's Agency Notification
A foster parent must: (7-1-25)
-
Substitute Care. Place a child in substitute care only with the prior knowledge and consent of the children's agency; and (7-1-25)
-
Notification to Agency. Notify the children's agency before the beginning of any planned absence that requires substitute care of a child for a period of twenty-four (24) hours or more. (7-1-25)
IDAPA 16.06.02.245 (Reserved)
IDAPA 16.06.02.246 Behavior Management and Discipline
Methods of behavior management and discipline for children must be positive and consistent. These methods must be based on each child's needs, stage of development, and behavior. (7-1-26)
- Prohibitions. The following types of punishment of a foster child are prohibited:(7-1-25)
a.Physical force or any kind of punishment inflicted on the body, including spanking;(7-1-25)
b.Cruel and unusual physical exercise or forcing a child to take an uncomfortable position; (7-1-25)
c.Use of excessive physical labor with no benefit other than for punishment;(7-1-25)
d.Mechanical, medical, or chemical restraint;(7-1-25)
e.Locking a child in a room or area of the home;(7-1-25)
f.Denying necessary food, clothing, bedding, rest, toilet use, bathing facilities, or entrance to the foster home; (7-1-25)
g.Mental or emotional cruelty;(7-1-25)
h.Verbal abuse, ridicule, humiliation, profanity, threats, or other forms of degradation directed at a child or a child's family; (7-1-25)
i.Threats of removal from the foster home;(7-1-25)
j.Denial of visits or communication with a child's family unless authorized by a children's agency in its service plan for the child and family; and (7-1-25)
k.Denial of necessary educational, medical, counseling, or social services.(7-1-25)
-
Restraint. A foster parent who has received specific training in the use of child restraint may use reasonable restraint methods, approved by the children's agency, to prevent a child from harming themselves, other persons or property, or to allow a child to gain control of themselves. (7-1-25)
-
Authority. The authority for the discipline of a foster child must not be delegated by a foster parent to other members of the household. (7-1-25)
-
Agency Consultation. A foster parent must consult with the children's agency prior to using any behavior management or discipline technique that exceeds the scope of these rules. (7-1-25)
IDAPA 16.06.02.247 Medical and Dental Care
-
Health Care Services. A foster parent must follow and carry out the health or dental care plan for a child as directed by a medical professional. (7-1-25)
-
Child Injury and Illness. Follow the children's agency approved policies for medical care of a child. (7-1-26)
-
Dispensing of Medications. Provide prescription medication strictly as directed by a medical professional. (7-1-26)
IDAPA 16.06.02.248 (Reserved)
IDAPA 16.06.02.254 Religious and Cultural Practices
A foster parent must provide a child in care with opportunity for spiritual development and cultural practices according to the wishes of the child and the child's parent or tribe. (7-1-25)
IDAPA 16.06.02.255 (Reserved)
IDAPA 16.06.02.257 Reasonable and Prudent Parent Standard
A caregiver must follow the reasonable and prudent parent standard.(7-1-25)
- Reasonable and Prudent Parent Standard Defined. “Age or developmentally appropriate” means the following:(7-1-25)
a.Activities or items that are generally accepted as suitable for children of the same chronological age or level of maturity or that are determined to be developmentally appropriate for a child, based on the development of cognitive, emotional, physical, and behavioral capacities that are typical for an age or age group; and(7-1-25)
b.In the case of a specific child, activities or items that are suitable for the child based on the developmental stages attained by the child with respect to the cognitive, emotional, physical, and behavioral capacities of the child.(7-1-25)
c.The foster parents will seek approval from the children’s agency before altering a child’s physical appearance including haircuts, body piercing, and tattooing.(7-1-25)
IDAPA 16.06.02.258 (Reserved)
IDAPA 16.06.02.270 Record Management and Reporting Requirements
A foster parent must maintain a record for each child in the home that will include all written material provided to the foster home by the children's agency and additional information gathered by the foster parent that includes the following: (7-1-25)
-
Personal Data. The child's name, sex, date of birth, religion, race, and tribe, if applicable; (7-1-25)
-
Any Known History of Abuse and Neglect of the Child.(7-1-25)
-
Any Known Emotional and Psychological Needs of the Child. (7-1-25)
-
Any Information Known about the Child’s Health.(7-1-25)
-
Any Known Behavioral Problems of the Child.(7-1-25)
IDAPA 16.06.02.271 Reporting Foster Home Changes
A foster parent must report to the children's agency any significant change in the foster home by the next working day from the time a foster parent becomes aware of a change, including the following: (7-1-25)
-
Serious Illness Including Physical or Mental Health, Injury, or Death of a Foster Parent or Household Member. (7-1-25)
-
Arrests, Citations, Withheld Judgments, or Criminal Convictions of a Foster Parent or Household Member. (7-1-25)
-
Initiation of Court-Ordered Parole or Probation of a Foster Parent or Household Member.
-
Admission or Release From Facilities. Admission to, or release from, a correctional facility, a hospital, or an institution for the treatment of an emotional, mental health, or substance abuse issue of a foster parent or household member. (7-1-25)
-
Change of Employment Status of a Foster Parent.(7-1-25)
-
Counseling, Treatment, or Therapy. Counseling or other methods of therapeutic treatment on an outpatient basis for an emotional, mental, or substance abuse issue of a foster parent or household member. (7-1-25)
-
Change of Residence. A foster parent will inform the children's agency of any planned change in residence and apply for licensure at the new address not less than two (2) weeks prior to a change in residence.
-
Household Members. Inform the children's agency of changes in household members including minor children.(7-1-25)
-
Additional Licensing Application. A foster parent will notify the children's agency within five (5) days after filing an application for a certified family home, daycare, or group daycare license.(7-1-25)
IDAPA 16.06.02.272 Confidentiality
A foster parent must maintain the confidentiality of any information and records regarding a foster child and the child's parents and relatives. A foster parent will release information about the foster child only to persons authorized by the children's agency responsible for the foster child. Foster parents will follow the Department's policies for the use of social media and posting of pictures of children in foster care. (7-1-25)
IDAPA 16.06.02.273 Critical Incident Notification
The foster parent must immediately notify the responsible children's agency of any of the following incidents:
-
Death. Death or near death of a child in care.(7-1-25)
-
Suicide. Suicidal ideation, threats, or attempts to commit suicide by the foster child. (7-1-25)
-
Missing. When a foster child is missing from a foster home.(7-1-25)
-
Illness. Any illness or injury that requires medical treatment of hospitalization of a foster child.
-
Law Enforcement Authorities. A foster child's detainment, arrest, or other involvement with law enforcement authorities. (7-1-25)
-
Removal of Child. Attempted removal or removal of a foster child from the foster home by any person who is not authorized by the children's agency. (7-1-25)
IDAPA 16.06.02.274 (Reserved)
16.03.01 Eligibility for Health Care Assistance for Families and Children
IDAPA 16.03.01.000 Legal Authority
Sections 56-202, 56-203, 56-209, 56-239, 56-250, 56-253, 56-255, 56-256 and 56-257, Idaho Code, authorize the Departm ent to adopt and enforce rules for the administration of Title XIX of the Social Security Act (Medicaid), and Title XXI of the Social Security Act.(7-1-24)
IDAPA 16.03.01.001 Written Interpretations
The Department has written statements that pertain to the i nterpretation of, or documentation of compliance with, these rules. The documents are available for public inspection and copying at cost at the Department or at any of its Regional Offices.(7-1-24)
IDAPA 16.03.01.002 (Reserved)
IDAPA 16.03.01.010 Definitions (a Through L)
01.Advanced Payment of Premium Tax Credit.
Payment of federal tax credits specified in 26 USC Part 36B (as added by Section 1401 of the Affordable Care Act) which are provided on an advance basis to an eligible individual enrolled in a Qualified Health Plan (QHP) through an exchange under Sections 1402 and 1412 of the Affordable Care Act.(7-1-24)
02.Adult. Any individual who has passed the month of their nineteenth birthday.(7-1-24)
03.Affordable Care Act. The Patient Protection and Affordable Care Act of 2010 (Pub. L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (P L 111-152).(7-1-24)
04.Applicant. A person applying for public assistance from the Department, including individuals referred to the Department from a Health Insurance Exchange or Marketplace.(7-1-24)
05.Application. An application for benefits including an Application for Assistance (AFA) or other application recognized by the Department, including referrals from a Health Insurance Exchange or Marketplace.
06.Application Date. The date the Application for Assistance (AFA) is received by the Department or by the Health Insurance Exchange or Marketplace electronically, telephonically, in person, or the date the application is postmarked, if mailed.(7-1-24)
07.Caretaker Relative. A relative of a child by full- or half-blood, adoption, or marriage with whom the child is living and who assumes primary responsibility for the child's care. A caretaker relative includes a child’s natural, adoptive, or step-parents, grandparents, siblings, aunt, uncle, niece, nephew, or cousin.(7-1-24)
08.Child. Any individual from birth through the end of the month of their nineteenth birthday.
09.Citizen. A person having status as a “national of the United States” defined in 8 USC 1101(a)(22)that includes both citizens of the United States and non-citizen nationals of the United States.(7-1-24)
10.Cost-Sharing. A participant payment for a portion of Medicaid service costs such as deductibles, co-insurance, or co-payment amounts.(7-1-24)
11.Creditable Health Insurance. Coverage that provides benefits for inpatient and outpatient hospital services and physicians' medical and surgical services. Creditable coverage excludes liability, limited scope dental, vision, specified disease, or other supplemental-type benefits.(7-1-24)
12.Department. The Idaho Department of Health and Welfare or its designee.(7-1-24)
13.Federal Poverty Guidelines (FPG). Issued annually by the Department of Health and Human Services (HHS).TheFPG are available on the U.S. Health and Human Services website at http://aspe.hhs.gov/poverty.
14.Health Assessment. An examination performed by a primary care provider in order to determine the appropriate health plan for a Medicaid-eligible individual.(7-1-24)
15.Health Care Assistance (HCA). Health coverage that includes Medicaid coverage under Title XIX or Title XXI and private health insurance plans purchased with a Premium Tax Credit described in Subsection 010.01 of this rule granted by the Department for persons or families within Idaho.(7-1-24)
16.Health Insurance Premium Program (HIPP). The Premium Assistance program in which Title XIX and Title XXI participants may participate.(7-1-24)
17.Health Plan. A set of health services paid for by Idaho Medicaid, or health insurance coverage obtained through the Health Insurance Exchange or Marketplace.(7-1-24)
18.Health Questionnaire. A tool used to assist Department staff in determining the correct Health Plan for the Medicaid applicant.(7-1-24)
19.Internal Revenue Code. The federal tax law used to determine eligibility under Title 26 USC for individual income and self-employment income.(7-1-24)
20.Internal Revenue Service (IRS). The US government agency in charge of tax laws. These laws are used to determine income eligibility. The IRS website is at http://www.irs.gov.(7-1-24)
21.Insurance Affordability Programs. Include Title XIX, Title XXI, and all insurance programs available in the Health Insurance Exchange or Marketplace.(7-1-24)
22.Lawfully Present. An individual who is a qualified non-citizen under Section 221 of these rules.
IDAPA 16.03.01.011 Definitions (m Through Z)
01.MAGI-Based Income. Incom e calculated using the same financial methodologies used by the IRS to determine modified adjusted gross income (MAGI) for federal tax filers, with the following exceptions: (7-1-24)
a.Educational income under Section 382 of these rules;(7-1-24)
b.Indian monies excluded by federal law are not included in MAGI-based income;(7-1-24)
c.Lump sum income is counted only in the month received under Section 384 of these rules; and
d.For Medicaid applicants, MAGI-based income is calculated based on income received in the month of application. (7-1-24)
02.Medicaid. Idaho’s Medical Assistance Program administered by the Department and funded with federal and state funds under Title XIX of the Social Security Act that provides medical care for eligible individuals.
03.Modified Adjusted Gross Income (MAGI). Adjusted Gross Income as defined by the IRS, plus certain tax-exempt income.(7-1-24)
04.Newborn Deemed Eligible. A child born to a woman who is eligible for and receiving medical assistance on the date of the child’s birth, including during a month of retroactive eligibility for the mother. A child born under these conditions is eligible for Medicaid for the first year of their life.(7-1-24)
05.Non-Citizen. Same as “alien” under Section 101(a)(3) of the Immigration and Nationality Act (INA) (8 USC 1101 (a)(3)), and includes any individual who is not a citizen or national of the United States. (7-1-24)
06.Parent. For a household with a MAGI-based eligibility determination a parent can be:(7-1-24)
a.Natural;(7-1-24)
b.Biological;(7-1-24)
c.Adoptive; or(7-1-24)
d.Stepparent.(7-1-24)
07.Participant. An individual who is eligible for, and enrolled in, a Health Care Assistance program.
08.Qualified Hospital. Has a Memorandum of Understanding (MOU) with the Department, participates as a provider under the Medicaid State Plan, may assist individuals in completing and submitting applications for health coverage, and has not been disqualified from doing presumptive eligibility determinations.
09.Qualified Non-Citizen. Same as “qualified alien” under 8 USC164(b) and (c).(7-1-24)
10.Reasonable Opportunity Period. A period allowed for an individual to provide requested proof of citizenship or identity. A reasonable opportunity period extends for ninety (90) days beginning on the 5th day after the notice requesting the proof has been mailed to the applicant. This period may be extended if the Department determines that the individual is making a good faith effort to obtain necessary documentation.(7-1-24)
11.Sibling. For household with MAGI-based eligibility determination, a natural or biological, adopted, half- or stepsibling.(7-1-24)
12.Tax Dependent. A person, who is a related child, or other qualifying relative or person, under federal IRS standards for whom another individual can claim a deduction for a personal exemption when filing a federal income tax for a taxable year.(7-1-24)
13.Third-Party. Includes a person, institution, corporation, public or private agency that is liable to pay all or part of the medical cost of injury, disease, or disability of a medical assistance participant.(7-1-24)
14.Title XIX of the Social Security Act. Also known as Medicaid, is a medical benefits program jointly financed by the federal and state governments and administered by the States. This program pays for medical assistance for certain individuals and families with low income, and for some program types, limited resources.
15.Title XXI of the Social Security Act. Also known as the Children's Health Insurance Program (CHIP), is a federal and state partnership similar to Medicaid that expands health insurance to targeted, low-income children.(7-1-24)
IDAPA 16.03.01.012 (Reserved)
APPLICATION REQUIREMENTS
(Sections 100-199)
IDAPA 16.03.01.100 Participant Rights
The participant has rights protected by federal and state l aws and Department rules. The Department will inform participants of the following rights during the application process and eligibility reviews.(7-1-24)
01.Right to Apply. Any person has the right to apply for any Health Care Assistance program.
Applications may be submitted by paper, electronically, fax, or telephonically. Application information must be in a form or format provided by the Department.(7-1-24)
02.Right to Hearing. Any participant can request a hearing to contest a Department decision under IDAPA 62.01.01, “Idaho Rules of Administrative Procedure,” and Office of Administrative Hearings General Order No. 1.(7-1-24)
03.Right to Request Reinstatement of Benefits. Any participant has the right to request reinstatement of benefits until a hearing decision is made if the request for the reinstatement is made before the effective date of the action taken on the notice of decision. Reinstatement pending a hearing decision is not provided if an application is denied because an individual did not provide citizenship or identity documentation during a reasonable opportunity period allowed by the Department.(7-1-24)
IDAPA 16.03.01.101 (Reserved)
IDAPA 16.03.01.111 Signatures
An individual who is applying for benefits, receiv ing benefits, or providing additional information as required by these rules, may do so with the depiction of the individual's name either handwritten, electronic, or recorded telephonically. Such signature serves as intention to execute or adopt the sound, symbol, or process for the purpose of signing the related record.(7-1-24)
IDAPA 16.03.01.112 (Reserved)
IDAPA 16.03.01.130 Application Time Limits
Each application will be processed as clos e to real time as practicable, but not longer than forty-five (45) days, from the date of application, unless prevented by events beyond the Department’s control.(7-1-24)
IDAPA 16.03.01.131 (Reserved)
IDAPA 16.03.01.140 Eligibility Effective Dates
Title XIX and Title XXI coverage begins the first day of the app lication month. Coverage for a newborn is effective the date of birth.(7-1-24)
IDAPA 16.03.01.141 (Reserved)
IDAPA 16.03.01.150 Retroactive Medical Assistance Eligibility
Title XIX and Title XXI can begin up to three (3) calendar months before the application month if the participant is eligible during the prior period. Coverage is provided if services that can be paid by Medicaid were received in the prior period. (7-1-24)
IDAPA 16.03.01.151 (Reserved)
NON-FINANCIAL REQUIREMENTS
(Sections 200-299)
IDAPA 16.03.01.200 Non-Financial Criteria for Determ
INING ELIGIBILITY.
Non-financial criteria are conditions of elig ibility, other than income, that must be met before Health Care Assistance can be authorized.(7-1-24)
IDAPA 16.03.01.201 (Reserved)
IDAPA 16.03.01.210 Residency
The participant must live in Idaho and have no immediate intention of leaving, including an individual who has entered the state to look for work, or who has no permanent, fixed address.(7-1-24)
IDAPA 16.03.01.211 (Reserved)
IDAPA 16.03.01.220 U.s. Citizenship Verification
01.Citizenship Verified.
Citizenship must be verified through electronic means when available. If an electronic verification is not immediately obtainable, the Department may request documentation from the applicant.
The Department will not deny the application for health coverage until the applicant has had a reasonable opportunity period to obtain and provide the necessary proof of US citizenship.(7-1-24)
02.Benefits During Reasonable Opportunity Period. Benefits are provided during the reasonable opportunity period that is provided to allow the applicant time to obtain and provide documentation to verify U.S. citizenship. No overpayment exists for the reasonable opportunity period if the applicant does not provide necessary documentation during the reasonable opportunity period so that the application results in denial.(7-1-24)
IDAPA 16.03.01.221 U.s. Citizenship and Qualified Non-Citizen Requirements
Any individual who participates in Medicaid benefits must provide proof of US citizenship unless they have oth erwise met the requirements under 42 CFR 435.406 Citizenship and Non-Citizen Eligibility.(7-1-24)
IDAPA 16.03.01.222 (Reserved)
IDAPA 16.03.01.250 Emergency Medical Condition
An individual who meets eligibility criteria for a category of as sistance but does not meet US citizenship requirements or eligible non-citizen requirements may receive medical assistance under a Title XIX or Title XXI coverage group as follows:(7-1-24)
01.Emergency Medical Conditions. An individual not meeting the US citizenship requirement may receive medical services necessary to treat an emergency medical condition, including labor and delivery. Emergency medical conditions have acute symptoms of severity, including severe pain.(7-1-24)
02.Determination of Emergency Medical Conditions. The Department determines if a condition meets criteria of an emergency medical condition. (7-1-24)
03.Limitation on Medical Assistance. Medical assistance is limited to the period established for the emergency medical condition.(7-1-24)
04.Documentation Waived. For undocumented individuals with emergency medical conditions, the Social Security Number (SSN) requirement is waived because an SSN cannot be issued. Individuals must be otherwise eligible for Title XIX or XXI.(7-1-24)
IDAPA 16.03.01.251 Sponsor Deeming
Income of a legal non-citizen’s sponsor and the sponsor’s spouse are counted in determining eligibility.(7-1-24)
IDAPA 16.03.01.252 Sponsor Responsibility
Section 213 of the Immigration and Naturalization Act req uires that a sponsor signing Form I-864, Affidavit of Support, reimburse the Department for Health Care Assistance benefits paid for a sponsored, qualified non-citizen.
IDAPA 16.03.01.253 (Reserved)
IDAPA 16.03.01.270 Social Security Number (ssn) Requirement
01.SSN Required.
An applicant must provide their SSN, or proof they have applied for an SSN, to the Department before approval of eligibility. If the applicant has more than one (1) SSN, all numbers must be provided.
a.The SSN must be verified by the Social Security Administration (SSA) electronically. When an SSN is unverified, the applicant is not eligible for Health Care Assistance. (7-1-24)
b.The Department will notify the applicant in writing if eligibility is being denied or lost for failure to meet the SSN requirement.(7-1-24)
02.Application for SSN. The applicant must apply for an SSN, or a duplicate SSN when they cannot provide their SSN to the Department. If the SSN has been applied for, but not issued by the SSA, the Department cannot deny, delay, or stop benefits. The Department will help an applicant with required documentation when the applicant applies for an SSN.(7-1-24)
03.Failure to Apply for SSN. The applicant may be granted good cause for failure to apply for an SSN if they have a well-established religious objection to applying for an SSN. A well-established religious objection means the applicant:(7-1-24)
a.Is a member of a recognized religious sect or division of the sect; and(7-1-24)
b.Adheres to the tenets or teachings of the sect, or division of the sect, and for that reason is conscientiously opposed to applying for or using a national identification number.(7-1-24)
04.SSN Requirement Waived. An applicant may have the SSN requirement waived when they are:
a.Only eligible for emergency medical services under Section 250 of these rules; or(7-1-24)
b.A newborn deemed eligible child under Section 530 of these rules.(7-1-24)
IDAPA 16.03.01.271 (Reserved)
IDAPA 16.03.01.280 Group Health Plan Enrollment
Title XIX and Title XXI participants must apply for and enroll in a cost-effective group health plan if one is available.
A cost-effective health plan is one which has premiums and co-payments at a lower cost than Medicaid would pay for full medical services. Medicaid will pay premiums and other co-payments for plans the Department finds costeffective.(7-1-24)
IDAPA 16.03.01.281 Medical Exception for Inmates
An inmate can receive Medicaid while they are an inpatient in a medical facility, and must meet all Medicaid eligibility requirements.(7-1-24)
IDAPA 16.03.01.282 (Reserved)
IDAPA 16.03.01.290 Assignment of Rights to Medical Support and Third-Party Liability
Under Sections 56-203B and 56-209b(3), Idaho Code, medical support rights are assigned to the Department by signature on the application for assistance. The participant must cooperate to secure medical support from any liable third-party. The cooperation requirement may be waived if the participant has good cause for not cooperating.
IDAPA 16.03.01.291 Medical Support Cooperation
A Medicaid participant responsible for assignin g their rights to medical support must cooperate to identify and locate the noncustodial parent, establish paternity, and establish, modify, and enforce a medical support order.(7-1-24)
01.Cooperation Defined. Cooperation includes providing all information to identify and locate the non-custodial parent and identify other liable third party-payers. The participant must provide the first and last name of the non-custodial parent, and at least two (2) of the following pieces of information about the non-custodial parent:
a.Birth-date;(7-1-24)
b.SSN;(7-1-24)
c.Current address;(7-1-24)
d.Current phone number;(7-1-24)
e.Current employer;(7-1-24)
f.Make, model, and license number of any motor vehicle owned by the non-custodial parent; or
g.Names, phone numbers, and addresses of the parents of the non-custodial parent.(7-1-24)
02.Good Cause Defined. The participant may claim good cause for failure to cooperate in securing medical support for a minor child. Good cause is limited to the following:(7-1-24)
a.Proof the child was conceived because of incest or rape;(7-1-24)
b.Proof the child’s non-custodial parent may inflict physical or emotional harm to the participant, the child, the custodial parent, or the caretaker relative;(7-1-24)
c.A credible explanation is provided showing the participant cannot provide the minimum information regarding the non-custodial parent; or(7-1-24)
d.A participant who has good cause for not cooperating under Subsection 291.03.b of this rule.
03.Conditions for Non-Denial of Medicaid. Medicaid cannot be denied for individuals who meet one (1) of the following conditions:(7-1-24)
a.A child or unmarried minor child who cannot legally assign their rights to medical support; or
b.A pregnant woman whose income is at or below the FPG, and who does not cooperate in establishing paternity and obtaining medical support from, or derived from, the father of the unborn child.(7-1-24)
IDAPA 16.03.01.292 (Reserved)
IDAPA 16.03.01.296 Cooperation with the Quality Control Process
When the Department or federal government selects a case for review in the quality control process, the participant must cooperate in the review of the case.(7-1-24)
IDAPA 16.03.01.297 (Reserved)
FINANCIAL REQUIREMENTS
(Sections 300-344)
IDAPA 16.03.01.300 Household Composition and Financial Responsibility
Household composition and financial responsibility are divided into two (2) categories: tax-filing and non-tax filing hou seholds.(7-1-24)
IDAPA 16.03.01.301 Tax Filing Household
01.Taxpayers. For an individual filing a federal tax return for the taxable year in which an initial determination or redetermination of eligibility is made, and who is not claimed as a tax dependent by another taxpayer, the tax filing household consists of the taxpayer, the taxpayer’s spouse, and the taxpayer’s tax dependents.
02.Individuals Claimed as a Tax-Dependent. For an individual who is claimed as a tax dependent by another taxpayer, the tax filing household is the household of the taxpayer claiming such individual as a tax dependent, except when tax dependents meeting any of the following criteria will be treated as non-filers under Section 302 of these rules. Individuals:(7-1-24)
a.Claimed as a tax dependent by an individual other than a spouse or custodial parent;(7-1-24)
b.Under age nineteen (19) living with both parents, if the parents are not married, or married filing separately; and(7-1-24)
c.Under age nineteen (19) claimed as a tax dependent by a parent residing outside of the applicant household.(7-1-24)
03.Married Couples. For married couples living together, each spouse is included in the household of the other spouse, regardless of whether a joint federal tax return is filed, if one (1) spouse is claimed as a tax dependent by the other spouse, or if each filed separately.(7-1-24)
IDAPA 16.03.01.302 Non-Tax Filing Household
01.Individuals Not Filing a Tax Return and No t Claimed as a Tax Dependent. For an individual who does not expect to file a federal tax return and is not claimed as a tax dependent by a tax filer, or meets one (1) of the exceptions in this rule, the household consists of the individual and, if living with the individual the following:
a.The individual’s spouse;(7-1-24)
b.The individual’s natural, adopted, and stepchildren under age nineteen (19); or(7-1-24)
c.If individuals are under age nineteen (19), the individual’s natural, adopted, and step parents and natural, adoptive, and step siblings under age nineteen (19).(7-1-24)
02.Married Couples. Married couples living together will be included in the household of the other spouse.(7-1-24)
IDAPA 16.03.01.303 (Reserved)
INCOME
(Sections 345-394)
IDAPA 16.03.01.345 Household Income
The sum of calculated MAGI-based income of every individual whose income must be included in the household budget minus a standard disregard in the amount of five percent (5%) of federal poverty guidelines by family size, if the disregard is used to establish eligibility.(7-1-24)
IDAPA 16.03.01.346 Determining Income Eligibility
Financial eligibility for Medicaid applicants will be based on calculated monthly household income and household size. Eligibility for Health Care Assistance is determined by comparing the individual's calculated income against the income limit.(7-1-24)
IDAPA 16.03.01.347 Earned Income
Earned income is derived from labor or active participation in a business. Earned income includes taxable wages, tips, salary, commissions, bonuses, self-employment, and any other type of income defined as earnings by the Internal Revenue Service (IRS). Earned income is counted as income when it is received, or would have been received, except for the decision of the participant to postpone receipt. Earnings over a period of time and paid at one (1) time, such as the sale of farm crops, livestock, or poultry are annualized, and IRS-allowable self-employment expenses deducted.(7-1-24)
IDAPA 16.03.01.348 Dependent Child’s Earned Income
A dependent child’s earned income is excl uded, unless the child is required to file a tax return based on his own income.(7-1-24)
IDAPA 16.03.01.349 (Reserved)
IDAPA 16.03.01.350 In-Kind Income
An individual who receives a service, ben efit, or durable goods instead of wages is earning in-kind income. In-kind income is excluded.(7-1-24)
IDAPA 16.03.01.351 Self-Employment Earned Income
Income from self-employment is treated as earned income. Calculated self-employment income is the taxable selfemployment income after gross receipts and the IRS allowable costs of producing the self-employment income, when the self-employment is expected to continue under Title 26, U.S.C. (7-1-24)
IDAPA 16.03.01.352 (Reserved)
IDAPA 16.03.01.370 Unearned Income
Unearned income is any income the individual receives that is not gained through employment. Unearned income is not excluded income if it is taxable.(7-1-24)
IDAPA 16.03.01.371 (Reserved)
IDAPA 16.03.01.384 Lump Sum Income
A non-recurring lump sum payment is income in the month the lump sum is received. Lump sum income is a retroactive monthly benefit or a windfall payment. The lump sum may be earned or unearned income that is paid in a single sum. Lump sum income includes retirement, survivors, and disability insurance (RSDI), severance pay, disability insurance, and lottery winnings.(7-1-24)
IDAPA 16.03.01.385 (Reserved)
IDAPA 16.03.01.388 Dependent Child's Unearned Income
A child's unearned income is countable towards their household’s eligibility, only when the child must file a tax ret urn based on their own income.(7-1-24)
IDAPA 16.03.01.389 (Reserved)
DISREGARDS
(Section 395-399)
IDAPA 16.03.01.395 Income Disregards
A standard disregard in the amount of five percent (5%) of federal poverty guidelines by family size is applied to the calculated income of an individual in those situations whe re the application of the disregard is necessary in order for the individual to be eligible for the highest income limit health care coverage for which they may be eligible.
IDAPA 16.03.01.396 (Reserved)
HEALTH COVERAGE FOR ADULTS
(Sections 400-499)
IDAPA 16.03.01.400 Medicaid for Adults
Medicaid is available for the following adults:(7-1-24) 01.
Parent, Caretaker Relative, or a Pregnant Woman. The individual who:(7-1-24)
a.Is a parent, caretaker relative, or a pregnant woman in the household budget unit.(7-1-24)
b.Is responsible for an eligible dependent child, which includes the unborn child of a pregnant woman.(7-1-24)
c.Lives in the same household with the eligible dependent child.(7-1-24)
02.Adults Under Age 65. The individual must:(7-1-24)
a.Be age nineteen (19) or older and under age sixty-five (65);(7-1-24)
b.Not entitled to or enrolled in Medicare Part A or Part B; and(7-1-24)
c.Not otherwise eligible for any other coverage under the State Plan.(7-1-24)
03.MAGI Income Eligibility. For any of the eligibility groups under Subsections 400.01 and 02, the individual must meet all income requirements of the Medicaid program for eligibility determined under MAGI methodologies identified in Sections 300 through 303, and 411 of these rules. Eligibility is based on:(7-1-24)
a.The number of members included in the household budget unit;(7-1-24)
b.All countable income for the household budget unit; and(7-1-24)
c.Eligible individuals will have income calculated using their MAGI. Individuals with MAGI not greater than one hundred thirty-three per cent (133%) after applying a five per cent (5%) disregard to income are eligible to receive Medicaid in this rule.(7-1-24)
04.Member of More Than One Budget Unit. No person may receive benefits in more than one (1) budget unit during the same month.(7-1-24)
05.More Than One Medicaid Budget Unit in Home. If there is more than one (1) Medicaid budget unit in a home, each budget unit is considered a separate unit.(7-1-24)
IDAPA 16.03.01.401 (Reserved)
IDAPA 16.03.01.411 Income Limits for Parents and Caretaker Relatives
The income limits are based on the number of household budg et unit members. Parents and caretaker relatives, whose MAGI-based income does not exceed the guidelines listed in the table below for their household size, meet the income limit for parent and caretaker relative Medicaid.
IDAPA 16.03.01.412 (Reserved)
TABLE 411 INCOME LIMITS
Number of Household Members Income Limit 1$233 2$289 3$365 4$439 5$515 6$590 7$666 8$741 9$816 10$982 Over 10 PersonsAdd $75 Each
IDAPA 16.03.01.419 Transitional Medicaid for Parent Caretaker Adults
Participants who no longer qualify for Medicaid due to an increase in earned income or working hours are eligible for an add itional twelve (12) months of Medicaid. Participants must have been eligible for Medicaid during at least three (3) of the six (6) months immediately preceding the month in which the participant became ineligible.(7-1-24)
IDAPA 16.03.01.420 Extended Medicaid for Spousal Parent Caretaker Support Increase
Participants are eligible for four (4) cal endar months of Extended Medicaid if an increase in the participant’s spousal support causes them to exceed the income limit for their household budget unit size. The participant must have received Medicaid in Idaho in at least three (3) of the six (6) months before the month the participant became income ineligible.(7-1-24)
IDAPA 16.03.01.421 Pregnant Woman Ineligible Because of Excess Income
A pregnant woman who receives Health Care Assistance and becomes ineligible beca use of an increase in income will continue to receive coverage through the end of the month in which the sixtieth day of her postpartum period falls.(7-1-24)
IDAPA 16.03.01.422 (Reserved)
HEALTH COVERAGE FOR CHILDREN
(Sections 520-529)
IDAPA 16.03.01.520 Financial Eligibility
Children are eligible for Health Care Assistance when th e household's total MAGI-based income minus a standard disregard in the amount of five percent (5%) of FPG by family size is less than or equal to the applicable income limit for the age of the child.(7-1-24)
01.Title XIX Income Limit. For children age zero (0) to six (6), Title XIX income limit is one hundred forty-two percent (142%) of the FPG for the household size. For children age six (6) through age eighteen (18) the income limit is one hundred thirty three percent (133%) of the FPG for the household size. (7-1-24)
02.Title XXI Income Limit. For children age zero (0) to six (6), Title XXI income limit is between one hundred forty-two percent (142%) and one hundred eighty-five percent (185%) of the FPG for the household size. For children ages six (6) through eighteen (18) the income limit is between one hundred thirty-three percent (133%) and one hundred eighty five percent (185%) of the FPG for the household size.(7-1-24)
03.Disregard Applied. A standard disregard in the amount of five percent (5%) of FPG by family size is applied to the calculated income used to establish the child’s eligibility when applying the disregard is necessary for the child to be financially eligible.(7-1-24)
IDAPA 16.03.01.521 Household Size and Financial Responsibility
Household size and financial responsibility for health coverag e for children is determined using the methodology under Section 300 of these rules.(7-1-24)
IDAPA 16.03.01.522 (Reserved)
IDAPA 16.03.01.523 Access to or Coverage Under Other Health Plans
A child is ineligible for coverage under the CHIP plan if they have access to or are enrolled in other health coverage plans as described below:(7-1-24)
01.Covered by Creditable Health Insurance. The child is covered by creditable health insurance at the time of application.(7-1-24)
02.Child is Eligible under Idaho’s Title XIX State Plan.(7-1-24)
03.Idaho State Employee Benefit Plan. The child is eligible to receive health insurance benefits under Idaho’s State employee benefit plan.(7-1-24)
IDAPA 16.03.01.524 Continuous Health Care Assistance Eligibility for Children Under Age
NINETEEN.
Children under age nineteen (19), who are found eligible for healt h coverage in an initial determination or at renewal, remain eligible for a period of twelve (12) months. The twelve (12) month continuous eligibility period does not apply if, for any reason, eligibility was determined incorrectly.(7-1-24)
01.Reasons Continuous Eligibility Ends.(7-1-24)
a.The child is no longer an Idaho resident;(7-1-24)
b.The child dies;(7-1-24)
c.The participant requests closure; or(7-1-24)
d.The child turns nineteen (19) years old under Subsection 010.05 of these rules.(7-1-24)
02.Reasons Children are not Eligible for Continuous Eligibility.(7-1-24)
a.A child is approved for emergency medical services; or(7-1-24)
b.A child is approved for pregnancy-related services.(7-1-24)
IDAPA 16.03.01.525 Former Foster Child
An individual who is between the age of eighteen (18) and twenty-six (26), who was in foster care and became ineligible for Medicaid as a foster child due to age, may receive Medicaid coverage until their twenty-sixth birthday.
There are no financial eligibility criteria. The only non-financial criteria are the receipt of foster care services and age.
IDAPA 16.03.01.526 (Reserved)
SPECIAL CIRCUMSTANCES FOR CHILDREN
(Sections 530-549)
IDAPA 16.03.01.530 Newborn Child Deemed
ELIGIBLE FOR MEDICAID.
A child is deemed eligible for Medicaid for their first year of life when the following exists.(7-1-24)
01.Mother Filing an Application. The child is born to a mother who files an application for medical assistance. (7-1-24)
02.Mother Is Eligible for Medicaid. The mother is eligible for Medicaid in the newborn’s birth month, including a month of retroactive coverage. This includes a mother who qualifies for coverage only for the delivery because of her alien status.(7-1-24)
IDAPA 16.03.01.531 Minor Parent Living with Parents
A minor parent is a child under the age of eighteen (18) who is pregnant or has a child. Minor parents who live with their parents may be eligible for Health Care Assistance for themselves and their children. The minor parent’s eligibility is determined under Section 300 of these rules related to tax filing households.(7-1-24)
IDAPA 16.03.01.532 Resident of an Eligible Institution
A resident of an eligible institution must meet all non-finan cial and financial criteria of Title XIX, Title XXI, or any other applicable program.(7-1-24)
IDAPA 16.03.01.533 Children with Special Circumstances and Medicaid
Children who receive foster care or are in adoptive placements are eligible for Medicaid. The children must meet non-financial criteria and the financial requirements described for the children's coverage group.(7-1-24)
IDAPA 16.03.01.534 (Reserved)
IDAPA 16.03.01.535 Title Iv-E Foster Care Child
A child may be eligible for Medicaid under the Title IV-E foster care program if they meet the eligibility requirements in IDAPA 16.06.01, “Child and Family Services,” Section 425.(7-1-24)
IDAPA 16.03.01.536 (Reserved)
IDAPA 16.03.01.540 Youth Empowerment Services (yes) Program Children
01.Payments for Children Under Eighteen (18)
Years Old with SED. Under Section 56-254(2), Idaho Code, the Department will make payments for medical assistance for a child under eighteen (18) years old with serious emotional disturbance (SED), as defined in Section 16-2403, Idaho Code, and verified by an independent assessment:(7-1-24)
a.Whose family income does not exceed three hundred percent (300%) of the FPG as determined using MAGI-based eligibility standards; or(7-1-24)
b.Who meets other Title XIX Medicaid eligibility standards under the rules of the Department.
02.Youth Empowerment Services (YES) Benefits. Applicants whose family income is equal to or less than three hundred percent (300%) of the FPG for children zero (0) to eighteen (18) years old and who meet the non-financial eligibility criteria in Sections 200 through 299 of these rules may receive the following benefits:
a.YES State Plan option services and supports under IDAPA 16.03.26, “Medicaid Plan Benefits,”
Sections 640 through 649; and(7-1-24)
b.Additional covered services under IDAPA 16.03.26, “Medicaid Plan Benefits.”(7-1-24)
03.Additional Eligibility Criteria and Program Requirements for YES. Additional eligibility criteria and program requirements applicable to the YES State Plan option are under IDAPA 16.03.26, “Medicaid Plan Benefits.”(7-1-24)
IDAPA 16.03.01.541 (Reserved)
IDAPA 16.03.01.545 Presumptive Eligibility for Children and Adults
Presumptive eligibility determination for qualifying medical coverage groups can only be provided by a qualified hospi tal defined in Section 011 of these rules.(7-1-24)
01.Presumptive Eligibility Decisions. Decisions of presumptive eligibility can be made for individuals who meet program requirements for MAGI-based Medicaid coverage.(7-1-24)
02.Presumptive Eligibility Determination. Presumptive eligibility determinations are made by a qualified hospital when an individual receiving medical services is not covered by health care insurance and the financial assessment by hospital staff indicates the individual is eligible for Medicaid coverage in Idaho. This determination is made by hospital staff through an online presumptive application process:(7-1-24)
a.Prior to completion of a full Medicaid application; and(7-1-24)
b.Prior to a determination being made by the Department on the full application.(7-1-24)
03.Presumptive Eligibility Period. The presumptive eligibility period begins on the date the presumptive application is filed online and ends with the earlier of the following:(7-1-24)
a.The date the full eligibility determination is completed by the Department; or(7-1-24)
b.The end of the month after the month the qualified hospital completed the presumptive eligibility determination.(7-1-24)
IDAPA 16.03.01.546 Qualified Hospital Presumptive Eligibility Processes
A qualified hospital must have a Memorandum of Understanding (MOU) with the Department and follow all standards and processes agreed to in the MOU.(7-1-24)
01.Acceptance of Application. The qualified hospital accepts the request for services in the same manner as all applications for assistance are accepted.(7-1-24)
02.Standards and Processes. The presumptive eligibility determination must be based on standards and processes provided by the Department.(7-1-24)
03.Assistance to Applicant. The qualified hospital must assist the applicant in completing the Department's application process.(7-1-24)
04.Qualified Hospital Staff. Only qualified hospital staff who are trained in presumptive eligibility standards can make a presumptive eligibility determination.(7-1-24)
05.Notice to Applicant. The qualified hospital or the Department will provide notice to the applicant within two (2) business days on the presumptive eligibility determination.(7-1-24)
06.Notice and Hearing Rights. Presumptive eligibility decisions are not appealable and do not have hearing rights under the Title XIX Medicaid program.(7-1-24)
07.Number of Presumptive Eligibility Periods Allowed. Only one (1) presumptive eligibility period is allowed per applicant in any twelve (12) month period.(7-1-24)
IDAPA 16.03.01.547 (Reserved)
CASE MAINTENANCE REQUIREMENTS
(Sections 600-701)
IDAPA 16.03.01.600 Annual Eligibility Renewal
Participants must have an annual eligibility review of all eligibility factors. Exceptions to the annual eligibility ren ewal are listed in Section 601 of these rules. (7-1-24)
01.Continuing Eligibility. Is determined using available electronic verification sources without participant contact, unless information:(7-1-24)
a.Is not available;(7-1-24)
b.Sources provide conflicting information; or(7-1-24)
c.Is inconsistent with information provided by the participant.(7-1-24)
02.Inconsistency Impacts Eligibility. When inconsistency exists from electronic verification sources that impact participant eligibility, information must be verified by the participant. The Department provides the participant a document that displays household information currently being used to establish eligibility and asks the participant to verify correctness, and if not correct to provide updated information.(7-1-24)
IDAPA 16.03.01.601 Exceptions to Annual Renewal
A participant who receives Title XIX or T itle XXI through time-limited coverage does not require an annual renewal when the following exists.(7-1-24)
01.Extended Medicaid. A participant who receives extended Medicaid is eligible under Section 420 of these rules.(7-1-24)
02.Pregnant Woman. A pregnant woman of any age is eligible for the Pregnant Woman coverage if she meets all the non-financial and financial criteria of the coverage group. Coverage includes services as described in IDAPA 16.03.26, “Medicaid Plan Benefits.” The Pregnant Woman medical assistance coverage extends through the sixty (60) day postpartum period if she applied for medical assistance while pregnant and was receiving medical assistance when the child was born. An individual who applies for Pregnant Woman medical assistance after the child is born is not eligible for the sixty-day (60) postpartum period.(7-1-24)
03.Newborn Child of Medicaid-Eligible Mother. A participant receiving Medicaid as the newborn child of a Medicaid-eligible mother is eligible under Section 530 of these rules.(7-1-24)
IDAPA 16.03.01.602 (Reserved)
IDAPA 16.03.01.610 Reporting Requirements
Changes in family circumstances must be reported to the Department by the tenth of the month following the month in wh ich the change occurred. Report of changes may be made verbally, in writing, through personal contact, telephone, fax, electronic mail, or mail.(7-1-24)
IDAPA 16.03.01.611 Types of Changes That Must Be Reported
Changes in circumstances the participant m ust report are the following:(7-1-24)
01.Name or Address. A name change for any participant or a change of address or location. (7-1-24)
02.Household Composition. Changes in family composition if a parent or relative caretaker receives Medicaid.(7-1-24)
03.Marital Status. Marriages or divorces of any family member if a parent or relative caretaker receives Medicaid.(7-1-24)
04.New SSN. SSN is newly assigned to a Medicaid Health Care Assistance program participant.
05.Health Insurance Coverage. Enrollment or disenrollment of a participant in a health insurance plan.(7-1-24)
06.End of Pregnancy. Pregnant participants must report when pregnancy ends.(7-1-24)
07.Earned Income. Changes in the amount or source of earned income if a parent or relative caretaker receives Title XIX benefits.(7-1-24)
08.Unearned Income. Changes in the amount or source of unearned income if a parent or relative caretaker receives Title XIX benefits.(7-1-24)
09.Support Income. Changes in the amount of spousal support received by an adult household member.(7-1-24)
10.Disability. A family member who becomes disabled or is no longer disabled if a parent or relative caretaker receives Title XIX benefits.(7-1-24)
IDAPA 16.03.01.612 (Reserved)
IDAPA 16.03.01.620 Notice of Changes in Eligibility
The Department will notify the participant of changes in their Health Care Assistance. The notice must give the effective date, the reason for the action, the rule that supports the action, and appeal rights.(7-1-24)
IDAPA 16.03.01.621 Notice of Change of Plan
The Department can switch a participant from the Medicaid Basic Plan to the Medicaid Enhanced Plan within the same month. Advance notice must be given to the participant when there is a decrease in their benefits and they will be switched from the Enhanced Plan to the Basic Plan.(7-1-24)
IDAPA 16.03.01.622 Advance Notice Responsibility
The Department must notify the participant at least ten (10) calendar days before the effective date when a reported change results in Health Care Assistance closure.(7-1-24)
IDAPA 16.03.01.623 Advance Notice Not Required
Advance notice is not required when a condition under this rule exists. The participant will be notified no later than the dat e of the action.(7-1-24)
01.The Department has Proof of the Participant’s Death.(7-1-24)
02.The Participant Requests Closure in Writing.(7-1-24)
03.Participant in Institution. The participant is admitted or committed to an institution. Further payments to the participant do not qualify for federal financial participation under the State Plan.(7-1-24)
04.Nursing Care. The participant is placed in a nursing facility or Intermediate Care Facility for Persons with Intellectual Disabilities (ICF/IID).(7-1-24)
05.The Participant’s Address is Unknown.(7-1-24)
06.The Participant is Approved for Medical Assistance in Another State.(7-1-24)
07.Eligible One Month. The participant is eligible for aid only during the calendar month of their application for aid.(7-1-24)
08.Retroactive Medicaid. The participant’s Title XIX or Title XXI eligibility is for a prior period.
IDAPA 16.03.01.624 (Reserved)
IDAPA 16.03.01.700 Overpayments
Health Care Assistance overpayments occur when a participant receives benefits during a month they were not eligible.(7-1-24)
IDAPA 16.03.01.701 Recovery of Overpayments
All Health Care Assistance overpayments are subject to recovery. Overpa yments are recovered by direct payment from the participant.(7-1-24)
01.Notice of Overpayment. The participant must be informed of the Health Care Assistance overpayment and appeal rights.(7-1-24)
02.Notice of Recovery. The participant must be informed when their Health Care Assistance overpayment is fully recovered.(7-1-24)
IDAPA 16.03.01.702 (Reserved)
16.03.19 Certified Family Homes
IDAPA 16.03.19.000 Legal Authority
Sections 56-1005 and 39-3505, Idaho Code, authorize the Idaho Board of Health and Welfare to adopt and enforce rules and standards for Certified Family Homes. Sections 56-264 and 56-1007, Idaho Code, authorize the Department to adopt and develop application and certification criteria, and to charge and collect application and certification fees.
Under Sections 56-1002, 56-1003, 56-1004, 56-1005, and 56-1009, Idaho Code, and Tittle 56, Chapter 27, Idaho Code, the Department and the Board of Health and Welfare have prescribed powers and duties to provide for the administration and enforcement of Department programs and rules.(3-28-23)
IDAPA 16.03.19.001 Scope and Exceptions
-
Scope. These rules set the administrative requirements for care providers who are paid to care for an adult living in the care provider’s home, when the adult is elderly or has a developmental disability, mental illness, or physical disability, and needs personal assistance.(3-28-23)
-
Exceptions. These rules do not apply to the following:(3-28-23)
a.Individuals who provide only housing, meals, transportation, housekeeping, or recreational and social activities.(3-28-23)
b.Health facilities defined by Title 39, Chapter 13, Idaho Code.(3-28-23)
c.Residential assisted living facilities defined by Title 39, Chapter 33, Idaho Code.(3-28-23)
d.Any arrangement for care in a relative’s home that is not compensated through a publicly funded program.(3-28-23)
e.Homes approved by the Department of Veterans Affairs as a “medical foster home” described in 38 CFR Part 17 and Sections 39-3502 and 39-3512, Idaho Code. Care providers who provide care to both veterans and non-veterans living in a “medical foster home” are not exempt from these rules.(3-28-23)
- State Certification to Supersede Local Regulation. These rules supersede any program of any political subdivision of the state that certifies or sets standards for certified family homes. These rules do not supersede any other local regulations.(3-28-23)
IDAPA 16.03.19.002 Incorporation by Reference
The Americans with Disabilities Act Accessibility Guidelines, 28 CFR Part 36 - 2010 ADA Standards for Accessible Design, is incorporated by reference. The website is http://www.ada.gov/2010ADAstandards_index.htm. (3-28-23)
IDAPA 16.03.19.003 (Reserved)
IDAPA 16.03.19.009 Criminal History and Background Check Requirements
-
Background Check Clearance. The provider, staff, substitute caregivers, and all adults living in the home, except for residents, are required to complete a background check and receive a clearance affiliated with the certified family home program (i.e., Agency ID 1104) under IDAPA 16.05.06, “Criminal History and Background Checks.”.(3-28-23)
-
When Certification Can Be Granted. Prior to certification, all adults living in the home, except for residents, must complete the background check and receive a clearance.(3-28-23)
-
New Adults in the Home After Certification. An adult who plans to live in the home must, prior to moving, complete a self-declaration form, be fingerprinted, and not have any designated crimes under IDAPA 16.05.06, “Criminal History and Background Checks.”(3-28-23)
-
Visitors. No unsupervised contact with residents unless the visitor first clears a background check.
-
Minor Child Turning Eighteen. A minor child turning eighteen (18) and living in the home must complete a self-declaration form, be fingerprinted, and not have any designated crimes under IDAPA 16.05.06, “Criminal History and Background Checks,” within thirty (30) days following the month of their eighteenth birthday.
-
Substitute Caregivers and Staff. Any staff or substitute caregiver must complete a selfdeclaration form, be fingerprinted, and not have any designated crimes under IDAPA 16.05.06, “Criminal History and Background Checks,” prior to any unsupervised contact with the resident.(3-28-23)
-
Renewal of Clearance. The Department can require a new background check at any time.
Renewed clearance from the Department must also be obtained as follows:(3-28-23)
a.Every five (5) years through the first fifteen (15) consecutive years, except as noted below, then every ten (10) years;(3-28-23)
b.For adults continuously affiliated (i.e., holding the certificate, living in, or providing substitute care) for at least five (5) years with an existing CFH in operation on or before July 1, 2015, who renewed their clearance after July 1, 2020, a second renewal is needed during the fifth year after the previous clearance, then every ten (10) years; or(3-28-23)
c.For adults continuously affiliated for at least fifteen (15) years with an existing CFH in operation on or before July 1, 2005, who received clearance after July 1, 2020, a renewed clearance is needed every ten (10) years.(3-28-23)
IDAPA 16.03.19.010 Definitions and Abbreviations
The following definitions apply, in addition to the terms defined under Section 39-3502, Idaho Code: (3-28-23)
-
Alternate Caregiver. A CFH provider approved by the Department to care for a resident from another CFH for up to thirty (30) consecutive days when the original provider is temporarily absent or unable to care for the resident.(3-28-23)
-
Certificate. A permit issued by the Department to operate a CFH.(3-28-23)
-
Certified Family Home (CFH). Hereafter referred to as “CFH” or “the home.”(3-28-23)
-
Certified Family Home (CFH) Requirements. The requirements under which CFHs must operate are these rules and the provisions of Title 39, Chapter 35, Idaho Code.(3-28-23)
-
Critical Incident. Any actual or alleged event or situation that creates a significant risk of substantial or serious harm to the physical or mental health, safety, or well-being of a resident.(3-28-23)
-
Healthcare Professional. An individual licensed to provide healthcare within their respective discipline and scope of practice.(3-28-23)
-
Immediate Jeopardy. An immediate or substantial danger to a resident.(3-28-23)
-
Incident. An actual or alleged event or situation that impacts or has the potential to impact the resident's health or safety, but does not rise to the level of a critical incident.(3-28-23)
-
Incidental Supervision. Supervision of the resident by a provider-approved, responsible adult not including care services such as medication management, personal assistance, managing resident funds, etc. (3-28-23)
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Instrumental Activities of Daily Living. The performance of secondary level activities that enable a person to live independently in the community, including preparing meals, accessing transportation, shopping, laundry, money management, housework, medication management, using tools and technology, and other associated tasks.(3-28-23)
-
Level of Care. A categorical assessment of the resident's functional ability in any given activity of daily living, instrumental activity of daily living or self-preservation, and the degree of care required in that area to sustain the resident in a daily living environment.(3-28-23)
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Plan of Service. The generic term used in these rules to refer to the Negotiated Service Agreement, Personal Care Plan, Plan of Care, Individual Support Plan, Support and Spending Plan, or any other comprehensive service plan.(3-28-23)
-
Primary Residence. A person’s place of permanent domicile or residence, to which the person intends to return after any temporary absence. The residence in which a person stays for at least thirty (30) days in any consecutive sixty (60) day period.(3-28-23)
-
PRN (Pro Re Nata). An abbreviation meaning “when necessary,” allowing prescribed medication or treatment to be given as needed.(3-28-23)
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Relative. A person related by birth, adoption, or marriage to the third degree, including spouses, parents, children, siblings, grandparents, grandchildren, aunts, uncles, nephews, nieces, great-grandparents, greatgrandchildren, great-aunts, great-uncles, and first cousins.(3-28-23)
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Staff. The provider, or a person retained by the provider to assist with maintaining the home and caring for residents. A full-time staff works at least forty (40) hours per week for the CFH.(3-28-23)
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Variance. A temporary exception not exceeding twelve (12) months issued by the Department to a CFH allowing noncompliance with a specific requirement of these rules when the provider shows good cause for the exception and the variance does not endanger any resident’s health or safety.(3-28-23)
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Visitor. A guest of a household member who is temporarily visiting the home for thirty (30) consecutive days or less.(3-28-23)
-
Vulnerable Adult. A person eighteen (18) years of age or older who seems unable to protect themself from abuse, neglect, or exploitation due to the effects of advancing age, mental illness, developmental or physical disability, or other chronic health condition.(3-28-23)
-
Waiver. A permanent exception issued by the Department to a CFH allowing noncompliance with a specific requirement of these rules when the provider shows good cause for the exception and the waiver does not endanger any resident’s health or safety.(3-28-23)
IDAPA 16.03.19.012 (Reserved)
IDAPA 16.03.19.100 Certification Requirements
An individual is required to obtain certification to operate a CFH under Section 39-3512, Idaho Code. (3-28-23)
- Certification Limitations. The Department cannot certify or maintain the certification of any individual who:(3-28-23)
a.Charges room or board to any person who is not a resident, full-time staff, or a relative under these rules. A variance may be granted by the Department under Section 39-3505(3), Idaho Code.(3-28-23)
b.Holds a current license for a children’s foster home, unless a variance is granted by the Department under Section 39-3505(4), Idaho Code.(3-28-23)
c.Is appointed, is a relative of, or resides in the home with the legal guardian of the resident, except if any of the aforementioned is a relative of the resident. A variance may be granted by the Department when it is determined the guardianship is in the best interest of the resident.(3-28-23)
d.Is absent from the CFH for more than thirty (30) consecutive days when the home has an admitted
e.Has a primary residence somewhere other than the CFH.(3-28-23)
- Certification Study. Following receipt of an acceptable application and other required documents, the Department will begin a certification study within thirty (30) days. The certification study will serve as the basis for issuing a certificate. The study will include the following:(3-28-23)
a.A review of all material submitted;(3-28-23)
b.A home inspection;(3-28-23)
c.An interview with the applicant;(3-28-23)
d.An interview with the applicant’s relatives or other household members, when deemed necessary;
e.A review of the care needs of other household members to evaluate the ability of the applicant to meet the needs of the resident;(3-28-23)
f.A medical or psychological examination of the applicant or staff, when the Department determines it is necessary, including a statement from a healthcare professional that the individual has the ability to adequately care for the resident and ensure a safe living environment; (3-28-23)
g.Proof that the applicant or their spouse has a legal right to occupy the home and has control of the premises (e.g., a lease, deed, or mortgage for the property); and(3-28-23)
h.Other information necessary to verify that the home complies with these rules.(3-28-23)
- Provider Training Requirements. As a condition of initial certification, the applicant must receive training in the following areas:(3-28-23)
a.Resident rights;(3-28-23)
b.Certification in first aid and adult Cardio-Pulmonary Resuscitation (CPR) which must be kept current and include hands-on skills training;(3-28-23)
c.Emergency procedures;(3-28-23)
d.Fire safety, including use and maintenance of fire extinguishers, smoke detectors, and carbon monoxide detectors;(3-28-23)
e.Unless a licensed practical nurse, registered nurse, physician’s assistant, or medical doctor, completion of a Department-approved medications course through an Idaho technical college; and (3-28-23)
f.Complaint investigation and inspection procedures.(3-28-23)
IDAPA 16.03.19.101 Application for Certification
The applicant must apply for certification on Department forms and submit the following to the Department:
-
Completed Application Signed by Applicant.(3-28-23)
-
Statement to Comply. A written statement that the applicant has thoroughly read and reviewed all CFH requirements, and is prepared to comply.(3-28-23)
-
Statement Disclosing Revocation or Disciplinary Actions. A written statement disclosing any past, current, or pending revocation, or other disciplinary action, against the applicant as a care provider in any jurisdiction.(3-28-23)
-
Electrical Inspection. A written statement from a licensed electrician or the local/state electrical inspector within the past twelve (12) months indicating that all electrical installations in the home comply with applicable local code and are in good working order.(3-28-23)
-
Plumbing Inspection. A written statement from a licensed plumber within the last twelve (12) months that the water supply and sewage disposal system in the home are in good working order.(3-28-23)
-
Heating and Air Conditioning Inspection. A written statement within the last twelve (12) months by a person licensed to service heating and cooling systems that these systems in the applicant's home are in good operating condition.(3-28-23)
-
Proof of Insurance. Proof of homeowner's or renter's insurance on the applicant’s home. For continued certification, the provider must ensure that insurance is kept current.(3-28-23)
-
List of Individuals Living in the Home. A list of all individuals living in the home at the time of application and their relationship to the applicant.(3-28-23)
-
Other Information as Requested. Other information that may be requested by the Department for the proper administration and enforcement of the CFH requirements.(3-28-23)
IDAPA 16.03.19.102 Termination of Application
- Failure to Cooperate. Failure of the applicant to cooperate with the Department in the application process will result in the termination of the application. Failure to cooperate means the applicant does not submit in the form requested or within a reasonable timeframe as determined by the Department:(3-28-23)
a.Information under Section 101 of these rules; or(3-28-23)
b.Payment of the application fee under Section 109 of these rules.(3-28-23)
- Reapplication. An applicant whose application has been terminated may reapply for certification.
IDAPA 16.03.19.103 (Reserved)
IDAPA 16.03.19.109 Application and Certification Fees
- Application Fee. An applicant is required to pay the Department a non-refundable application fee of one hundred fifty ($150) dollars for each of the following:(3-28-23)
a.As part of the initial application to become a CFH care provider;(3-28-23)
b.As part of any reapplication after the initial application is terminated, withdrawn, or the CFH closed; or(3-28-23)
c.When the home will be operated by a new care provider.(3-28-23)
- Certification Fees. The provider is required to pay to the Department a certification fee of twentyfive ($25) dollars per month while certified. This amount is billed to the provider every three (3) months, and is due and payable within thirty (30) days of the invoice date.(3-28-23)
a.Failure of the provider to pay certification fees when due may cause the Department to take enforcement action under Section 913 of these rules.(3-28-23)
b.Monthly certification fees paid in advance for the CFH will be refunded when the provider operates the home for less than fifteen (15) days during any given month for which payment was received by the Department.
An advance payment refund may be issued when the provider voluntarily closes the home as provided in Section 114 of these rules, or involuntarily closes the home due to an enforcement remedy imposed by the Department. (3-28-23)
IDAPA 16.03.19.110 Issuance of Certificate
The Department will issue a certificate when certification requirements are met. Each certificate must be available at the home upon request.(3-28-23)
-
Full Certificate. The Department will issue a full certificate upon a finding that the CFH is compliant with CFH requirements. A full certificate is effective for no more than twelve (12) months from the issue date.(3-28-23)
-
Temporary Certificate. The Department may issue a temporary certificate to allow time for the provider to meet all certification requirements without a lapse in certification when the provider plans to relocate to a residence within the state and continue operation of a CFH. A temporary certificate is effective for no more than sixty (60) days from the issue date.(3-28-23)
a.At least thirty (30) days prior to moving into a new residence, the provider must notify the certifying agent for the region in which the new home will be located. Prior to moving into the new residence, the provider must submit to the certifying agent the following:(3-28-23)
i.A completed application form under Section 101 of these rules;(3-28-23)
ii. Copies of all inspection reports for the new residence under Section 101 of these rules; and iii. Other information requested by the Department to ensure the new residence is appropriate for use as a CFH and safe for occupation.(3-28-23)
b.The Department will issue a temporary certificate upon review and approval of the information required under Subsection 110.02 of this rule.(3-28-23)
c.The provider must coordinate with the certifying agent an inspection of the new residence to occur prior to the expiration of the temporary certificate and be prepared to demonstrate compliance with CFH requirements during the home inspection.(3-28-23)
d.The Department will issue a full certificate as described in Subsection 110.01 of this rule when it determines that the home complies with CFH requirements.(3-28-23)
IDAPA 16.03.19.111 Renewal of Certificate
-
Home Inspection. A home inspection by a certifying agent is required the year after the initial certification study and at least every twenty-four (24) months thereafter. The home inspection will consist of the elements of the certification study under Section 100 of these rules.(3-28-23)
-
Desk Review. When the Department determines a home inspection is not required to renew the certificate, the Department may conduct a desk review by written notification to the provider. The provider must submit copies of the following documentation to the certifying agent at least thirty (30) days prior to the expiration of the certificate:(3-28-23)
a. Current first aid and adult CPR certifications;(3-28-23)
b. Private well water testing report, as applicable;(3-28-23)
c.Updated septic system inspection or pumping report, as applicable, when the previous inspection is older than five (5) years;(3-28-23)
d. Annual fire extinguisher inspection reports, or sales receipts for fire extinguishers that comply with Section 600 of these rules that are less than twelve (12) months old;(3-28-23)
e.Logs of smoke and carbon monoxide detector tests and battery replacement, fire extinguisher examinations, and emergency plan reviews;(3-28-23)
f.Emergency drill summaries or recordings;(3-28-23)
g. Training logs;(3-28-23)
h.Proof of current homeowner’s or renter’s insurance;(3-28-23)
i.Requests for renewed exceptions that meet the requirements in Sections 120 through 140 of these rules as applicable; and(3-28-23)
j.Other information as requested by the Department.(3-28-23)
IDAPA 16.03.19.112 Denial of Application for Certificate
- Causes For Denial. Causes for denial of an application for issuance of a certificate, besides those under Section 39-3523, Idaho Code, include the following:(3-28-23)
a.The applicant or provider has willfully misrepresented or omitted information on the application or other submitted documents;(3-28-23)
b.A required background check results in an Unconditional Denial;(3-28-23)
c.The applicant or provider has been denied or has had revoked any child care (including foster home) or health facility license, residential assisted living facility license, or CFH certificate;(3-28-23)
d.The applicant or provider has been found to have operated a health facility, residential assisted living facility, or CFH without a license or certificate;(3-28-23)
e.A court has ordered that the applicant or provider must not operate a health facility, residential assisted living facility, or CFH;(3-28-23)
f.The applicant or provider is directly under the control or influence of any person who is described in Subsection 112.01 of this rule.(3-28-23)
- Notice of Denial. Immediately upon denial of an application, the Department will provide notice by certified mail or by personal service, including the reason(s) for the denial and instructions regarding appealing the decision.(3-28-23)
IDAPA 16.03.19.113 Operating Without a Certificate
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Operating Without Certificate. A person found to be operating as a CFH as described under Section 39-3512, Idaho Code, without first obtaining a certificate may be referred for criminal prosecution under Section 39-3528, Idaho Code. (3-28-23)
-
Placement or Transfer of Resident. Upon discovery of such a person described in Subsection 113.01 of this rule, the Department may transfer residents to the appropriate placements when: (3-28-23)
a.There is an immediate threat to any resident's health and safety; or(3-28-23)
b.The individual operating the home does not cooperate with the Department to apply for certification, meet certification standards, and obtain a valid certificate.(3-28-23)
IDAPA 16.03.19.114 Voluntary Closure
When choosing to voluntarily close a CFH, the provider must give written notice at least thirty (30) days in advance to the residents, or the residents’ representatives when applicable, and the certifying agent in the region where the home is located. The notification must include the following:(3-28-23)
-
Date of Notification.(3-28-23)
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Provider’s Certificate. A copy of the certificate, or information from the certificate that includes:
a.The provider's name; and(3-28-23)
b.Address of the home; or(3-28-23)
c.Certificate number.(3-28-23)
-
Closure Date. The written notice must include the planned closure date. The Department will not refund or prorate prepaid certification fees on retroactive closures.(3-28-23)
-
Discharge Plans. If applicable, discharge plans for current residents must accompany the written notice to the certifying agent.(3-28-23)
IDAPA 16.03.19.115 Required Ongoing Training
The provider must document a minimum of eight (8) hours per year of ongoing, relevant training.(3-28-23)
-
Initial Provider Training. The initial provider training required in Section 100 of these rules satisfies the eight (8) hour training requirement for the first year of certification.(3-28-23)
-
Content of Training. Relevant training includes any topic that maintains or expands caregiving skills or safety practices in the home, such as topics of supervision, services, and care to vulnerable adults. (3-28-23)
a.At least half of the required ongoing training hours each year must be devoted to the specific conditions, diagnoses and needs of admitted residents, when residents are admitted.(3-28-23)
b.The remaining hours may be devoted to general topics related to caregiving, health, or safety.
- Documentation of Training. The provider must document ongoing training to include the following:(3-28-23)
a.Topic or title of the training with a brief description;(3-28-23)
b.Source of training, including the name of the instructor or author;(3-28-23)
c.Number of hours the provider received instruction;(3-28-23)
d.Whether the training was resident-specific or a general topic; and(3-28-23)
e.Date of the training.(3-28-23)
IDAPA 16.03.19.116 (Reserved)
IDAPA 16.03.19.120 Exceptions
The Department may grant an individual provider an exception to a specific standard in these rules under Section 39- 3554, Idaho Code. Such an exception may be in the form of a permanent waiver or a temporary variance effective for up to twelve (12) months.(3-28-23)
- Written Request. The provider must submit a written request for an exception to the regional certifying agent where the home is located prior to any planned noncompliance with any rule under these rules. The appropriateness of granting an exception is determined by the Department. The request must include the following:
a.Reference to the Section of these rules for which the exception is requested;(3-28-23)
b.Reasons that show good cause for granting the exception, including any extenuating circumstances and any compensating factors or conditions that may have bearing on the exception, such as additional floor space or additional staffing; and(3-28-23)
c.A signed statement from the provider that assures resident health and safety will not be jeopardized if the exception is granted, including an agreement to implement any special conditions the Department may require.
-
Special Conditions. When granting an exception, the Department may require the provider to meet special conditions while the exception is in effect to ensure the health and safety of residents.(3-28-23)
-
Variance Renewal. To renew a variance, the provider must submit a written request to the regional certifying agent where the home is located at least thirty (30) days prior to expiration of the variance. The request for renewal must include the information required in Subsection 120.01 of this rule. The appropriateness of renewing a variance is determined by the Department.(3-28-23)
-
Exception Not Transferable. An exception granted under Sections 120 through 140 of these rules is not transferable to any other provider, home, or resident.(3-28-23)
IDAPA 16.03.19.121 Revoking an Exception
- Causes for Revocation. The Department may revoke any exception granted under Sections 120 through 140 of these rules when:(3-28-23)
a.The provider has not met the special conditions associated with granting the exception; (3-28-23)
b.Conditions within the home have changed such that an exception is no longer prudent; or(3-28-23)
c.The health and safety of residents have otherwise been compromised.(3-28-23)
-
Written Notice. The Department will provide written notice to the provider when an exception is revoked, including the reason for the revocation.(3-28-23)
-
Time Frame to Comply. When there is a threat to the health or safety of any person, the provider must immediately upon notification comply with the rule for which the exception is revoked. When no such threat exists, compliance must occur within thirty (30) days of notification.(3-28-23)
IDAPA 16.03.19.122 (Reserved)
IDAPA 16.03.19.130 Nursing Facility Level of Care Variance
-
Request for Variance. A CFH may care for one (1) resident who requires nursing facility level of care as defined in Section 39-1301(b), Idaho Code, without obtaining a variance. A provider seeking to care for two (2) or more residents who require nursing facility level of care must request a variance in writing from the Department as required in Section 120 of these rules.(3-28-23)
-
Conditions for Variance. The Department may issue a written variance permitting the arrangement when:(3-28-23)
a.Each of the residents or their representative provides a written statement to the Department requesting the arrangement;(3-28-23)
b.Each of the residents or their representative making the request is competent, informed, and has not been coerced; and(3-28-23)
c.The Department finds the arrangement safe and effective.(3-28-23)
IDAPA 16.03.19.131 (Reserved)
IDAPA 16.03.19.140 Variance to the Two Resident Limit
A CFH may admit or retain a maximum of two (2) residents without first obtaining a variance from the Department.
Exceeding that limit requires a variance from the Department.(3-28-23)
-
Application for Variance. The provider must apply on forms provided by the Department for a variance to the two (2) resident limit to care for three (3) or four (4) residents on a per resident basis prior to any new admissions. The application must be submitted to the certifying agent where the home is located. The Department determines the appropriateness of granting the variance.(3-28-23)
-
Criteria for Determination. The Department will determine if safe and appropriate care can be provided based on residents’ needs. The Department will consider the following factors in making its determination:
a.Each current or prospective resident's physical, mental, and behavioral status and history;(3-28-23)
b.The household composition including the number of adults, children, and other family members requiring care and their care needs from the provider;(3-28-23)
c.The training, education, and experience of the provider to meet each resident's needs; (3-28-23)
d.Potential barriers that might limit egress from and ingress to the home;(3-28-23)
e.The number and qualifications of staff to meet the needs of residents and others requiring care in the home;(3-28-23)
f.The desires of the prospective and current residents or their representatives, including approval of roommate, if applicable;(3-28-23)
g.The individual and collective hours of care needed by the residents; and(3-28-23)
h.The physical layout of the home and the square footage available to meet the space requirements of all persons living in the home.(3-28-23)
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Other Employment. A provider who is granted a variance to admit three (3) or four (4) residents must not have other gainful employment outside the home unless staff are immediately able to consult with the provider about resident needs as they arise.(3-28-23)
-
Additional Training. A provider who is granted a variance to admit three (3) or four (4) residents must obtain additional training to meet the needs of the residents as follows:(3-28-23)
a.A provider who cares for three (3) residents must obtain a total of twelve (12) hours per year of ongoing relevant training under Section 115 of these rules.(3-28-23)
b.A provider who cares for four (4) residents must obtain a total of sixteen (16) hours per year of ongoing relevant training under Section 115 of these rules. (3-28-23)
c.When caring for three (3) or four (4) residents for only part of the year, additional training hours above those hours required in Section 115 of these rules are prorated by month. A resident is counted towards the home’s resident census when the admission agreement is in effect for fifteen (15) days or more during the month. The following table shows the additional prorated training requirements to be added to the base training hours:
- Reassessment of Variance. A variance to care for more than two (2) residents must be reassessed at least annually and when either of the following occurs:(3-28-23)
a.Each time the provider applies to the Department for approval of a prospective third or fourth resident admission; or(3-28-23)
b.When there is a significant change in any of the factors specified in Subsection 140.02 of this rule.
-
Annual Home Inspection. A CFH with a variance to care for more than two (2) residents must have a home inspection by a certifying agent at least annually.(3-28-23)
-
Shared Sleeping Rooms. In addition to the requirements in Section 700 of these rules, the provider must not house more than two (2) residents in any one (1) sleeping room.(3-28-23)
-
Fire Drill Frequency. A provider who is granted a variance to admit three (3) or four (4) residents must conduct fire drills as described in Section 600 of these rules, except the frequency of the fire drills must be at least monthly.(3-28-23)
IDAPA 16.03.19.141 (Reserved)
IDAPA 16.03.19.150 Inspections of Homes
The Department will inspect each CFH at least every twenty-four (24) months, calculated from the first month of the most recent certification. Inspections may occur more frequently as the Department deems necessary. That determination may consider the results of previous inspections, history of compliance with rules, and complaints.
-
Notice of Inspection. All inspections, except for the initial certification study, may be made unannounced and without prior notice.(3-28-23)
-
Inspection by Certifying Agent. The Department may use the services of any qualified person or organization, either public or private, to examine and inspect any home requesting certification. The inspector has the authority to have full access to the home and the authority to:(3-28-23)
Months3 Residents4 Residents 120 minutes40 minutes 240 minutes1 hour and 20 minutes 31 hour2 hours 41 hour and 20 minutes2 hours and 40 minutes 51 hour and 40 minutes3 hours and 20 minutes 62 hours4 hours 72 hours and 20 minutes4 hours and 40 minutes 82 hours and 40 minutes5 hours and 20 minutes 93 hours6 hours 103 hours and 20 minutes6 hours and 40 minutes 113 hours and 40 minutes7 hours and 20 minutes
a.Examine quality of care and service delivery;(3-28-23)
b.Examine home records, resident records, and any records or documents pertaining to any financial transactions between residents and the home, including resident accounts;(3-28-23)
c.Examine the physical premises, including the condition of the home, grounds and equipment, food service, water supply, sanitation, maintenance, and housekeeping practices; (3-28-23)
d.Examine any other areas necessary to determine compliance with the CFH requirements;(3-28-23)
e.Interview the provider, any adults living in the home, the resident and the resident's relatives, substitute caregivers, persons who provide incidental supervision, and any other person who is familiar with the home or its operation. Interviews are conducted privately unless otherwise specified by the person being interviewed or that person’s legal guardian, except when the legal guardian is an alleged perpetrator in an allegation being investigated in connection with the interview; and(3-28-23)
f.Inspect the entire home, including the personal living quarters of household members, to check for inappropriate storage of combustibles, faulty wiring, or other conditions that may have a direct impact on the operation of the home. The provider, staff, substitute caregiver, or any other adult living in the home may accompany the certifying agent.(3-28-23)
IDAPA 16.03.19.151 Violations
When an investigation or inspection finds violations of the CFH requirements, the Department will notify the provider in writing within thirty (30) days of the completed inspection or investigation.(3-28-23)
-
Technical Assistance. When the Department determines a violation does not pose a health or safety risk to residents or is not otherwise a core issue, and the non-compliant practice was due to the provider’s misunderstanding of a standard, the Department may give technical assistance to the provider under Section 39-3527, Idaho Code. When given written notice of technical assistance, the provider must correct the violation within thirty (30) days of the notice.(3-28-23)
-
Statement of Deficiencies. When the Department determines a formal citation is necessary to enforce compliance with a standard, the Department may issue the provider a statement of deficiencies. The statement of deficiencies will include the findings of the investigation or inspection and any rules or statutes the home was found to have violated.(3-28-23)
-
Plan of Correction. When a statement of deficiencies is issued, the provider must develop a plan of correction and submit it to the Department for review and approval.(3-28-23)
a.Depending on the severity of the deficiency, the provider may be given up to fourteen (14) calendar days to submit a written plan of correction to the regional certifying agent where the home is located. (3-28-23)
b.An acceptable plan of correction includes:(3-28-23)
i.How each deficiency was corrected or how it will be corrected;(3-28-23)
ii. What steps have been taken to assure that the deficiency does not reoccur;(3-28-23)
iii. Acceptable time frames for correction of the deficiency not to exceed thirty (30) days from the date of the Department’s written notice; and(3-28-23)
iv. Signature of the provider or written acknowledgment that the provider agrees to implement the plan of correction.(3-28-23)
c.Follow-up inspections may be conducted to determine whether corrections to deficiencies have been made according to the Department-approved plan of correction.(3-28-23)
- Disclosure of Deficiencies. A statement of deficiencies, if issued, for each inspection or investigation of a current provider, including the approved plan of correction, will be made available to the public upon written request to the Department under Title 74, Chapter 1, Idaho Code.(3-28-23)
IDAPA 16.03.19.152 (Reserved)
IDAPA 16.03.19.160 Investigations
- Complaints.(3-28-23)
a.Any person who believes that staff have committed a violation of the CFH requirements may report a complaint to the Department.(3-28-23)
b.In addition to its own investigation, the Department will also refer any complaint alleging abuse, neglect, or exploitation of a vulnerable adult to adult protective services according to Section 39-5303, Idaho Code, for potential criminal investigation.(3-28-23)
-
Critical Incidents. The Department will investigate or cause to be investigated any reported critical incident that indicates a possible violation of CFH requirements.(3-28-23)
-
Investigation Method. The nature of the alleged violation will determine the method used to investigate the report. Interviews will be conducted according to Subsection 150.02.e. of these rules. Onsite investigations at the home can be unannounced and without prior notice.(3-28-23)
-
Written Report. Within thirty (30) days following completion of an investigation, the Department will provide a written report, including findings of the investigation, to the provider and any named complainant, if applicable.(3-28-23)
-
Public Disclosure. The Department will not publicly disclose information or findings from an investigation so as to identify the complainant except as permitted under Section 74-105(16), Idaho Code, or individual residents except in an administrative or judicial proceeding.(3-28-23)
IDAPA 16.03.19.161 (Reserved)
IDAPA 16.03.19.170 Minimum Standards of Care
The provider must adequately care for each resident as follows:(3-28-23)
-
Plan of Service. Ensure services are provided to meet the terms of the resident's plan of service as described in Section 250 of these rules.(3-28-23)
-
Supervision. Ensure the resident receives appropriate and adequate supervision under the resident's plan of service while in the care of CFH staff.(3-28-23)
-
Daily Living Activities. Ensure assistance is provided to the resident at the level of care indicated on the resident’s plan of service in the areas of activities of daily living and instrumental activities of daily living.
-
Medication Management. Ensure assistance and monitoring of medications is provided as described in Sections 400 through 402 of these rules, as applicable.(3-28-23)
-
Emergency Services. Ensure immediate and appropriate interventions on behalf of the resident are provided in response to an emergency, including the following:(3-28-23)
a.Developing emergency plans as described in Section 600 of these rules and executing those plans when necessary;(3-28-23)
b.Evacuating the resident from the home;(3-28-23)
c.Providing first aid to the resident when seriously injured;(3-28-23)
d.Administering CPR to the resident unless the resident has an order not to resuscitate; and(3-28-23)
e.Contacting 9-1-1 for first responder services when necessary for the protection of the resident.
- Supportive Services. Coordinate paid services for the resident outside the home, including:
a.Medical appointments;(3-28-23)
b.Dental appointments;(3-28-23)
c.Other services in the community as identified in the plan of service or reasonably requested by the resident; and(3-28-23)
d.Arrange transportation to and from the service location.(3-28-23)
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Resident Rights. Protect the resident's rights as listed under Section 200 of these rules and Section 39-3516, Idaho Code.(3-28-23)
-
Safe Living Environment. Provide a physical living environment that complies with Sections 500 through 710 of these rules.(3-28-23)
IDAPA 16.03.19.171 (Reserved)
IDAPA 16.03.19.174 Activities and Community Integration
Section 39-3501, Idaho Code, requires that a CFH provide a homelike, family-styled living environment with a focus on integrated community living. The provider must offer the following:(3-28-23)
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Activities. As reasonably reflecting the interests of the resident, recreational activities, participation in social functions, and daily activities.(3-28-23)
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Transportation. Arrangement of transportation to and from community, recreational, and religious activities within twenty-five (25) miles of the home when requested by the resident at least twenty-four (24) hours in advance.(3-28-23)
IDAPA 16.03.19.175 Room and Board
The home must provide room, utilities, and three (3) daily meals to the resident. The following are included in the charge for room and board: (3-28-23)
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Sleeping Room. A sleeping room meeting the requirements of Section 700 of these rules, and, when requested by the resident, equipped with a dresser and chair in good repair.(3-28-23)
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Bed. A bed that is at least thirty-six (36) inches wide. Roll-away type beds, cots, folding beds, or double bunks must not be used unless requested by the resident. A clean and comfortable mattress, bedspread, sheets and pillow cases, and pillow that are standard for the size of the bed must also be included. The bed, bedding, and mattress must be kept in good repair.(3-28-23)
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Monitoring or Communication System. A monitoring or communication system, when necessary due to the size or design of the home, or the needs of the resident. The provider must hold a written agreement with the resident or resident's representative prior to using a monitoring system that may violate the resident's right to privacy.(3-28-23)
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Secure Storage. On request, a lockable storage cabinet or drawer for personal items for each 05. Bathroom. Access to bathing and toilet facilities meeting the requirements of Section 700 of these 06. Common Areas. Access to common living areas, including:(3-28-23)
a.A living room or family room that contains adequate lighting for activities, side or coffee tables, comfortable chairs or sofas, and basic television:(3-28-23)
b.A dining area containing a table and chairs; and(3-28-23)
c.A kitchen with a sink, oven, refrigerator, and counter space.(3-28-23)
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Supplies. Bath and hand towels, wash cloths, a reasonable supply of soap, shampoo, toilet paper, and facial tissue, and first aid supplies.(3-28-23)
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Housekeeping Service. Housekeeping and maintenance meeting the requirements in Section 500 of these rules, including laundry services.(3-28-23)
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Water. Potable water meeting the requirements of Section 500 of these rules.(3-28-23)
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Sewer. A sewage disposal system meeting the requirements of Section 500 of these rules.
-
Trash. Disposal of garbage meeting the requirements of Section 500 of these rules. (3-28-23)
-
Heating and Cooling. Sufficient heating and cooling meeting the requirements of Section 700 of these rules.(3-28-23)
-
Electricity. Sufficient electricity to power common household and personal devices. (3-28-23)
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Telecommunication. Access to a telephone or cell phone with unlimited local calls throughout the day, including night hours, meeting the requirements of Section 600 of these rules.(3-28-23)
-
Meals. Breakfast, lunch, and dinner offered each day.(3-28-23)
a.Food must be prepared in a safe and sanitary method that conserves nutritional value, flavor, and appearance when prepared by the provider or other member of the household.(3-28-23)
b.Meals offered by the home must meet the dietary requirements or restrictions of the resident when so ordered by a healthcare professional.(3-28-23)
c.Food must be handled and stored safely.(3-28-23)
IDAPA 16.03.19.176 (Reserved)
IDAPA 16.03.19.180 Hourly Adult Care
Hourly adult care (adult day health) may be offered in a CFH when the provider implements a policy and procedure including:(3-28-23)
-
Medicaid Provider Agreement. Each element under the Medicaid Provider Agreement Additional Terms - Adult Day Care (Adult Day Health).(3-28-23)
-
Records. Maintenance of legible records identifying:(3-28-23)
a.The rate charged by the provider for hourly adult care services if the participant is private pay;
b.On a per day basis, when hourly adult care services were provided in the home, the name of each participant and resident who received services, their times of arrival to and departure from the home and the names of staff who provided services and their arrival and departure times.(3-28-23)
- Fire and Life Safety.(3-28-23)
a.Review of emergency preparedness plans under Section 600 of these rules with the individual who completed the enrollment contract and provision of a written copy of the plans to that individual; and (3-28-23)
b.Conduct of emergency drills under Section 600 of these rules, except that the frequency of the drills must be at least monthly.(3-28-23)
IDAPA 16.03.19.181 (Reserved)
IDAPA 16.03.19.200 Resident Rights Policy
The provider must possess and implement a written policy designed to protect and promote resident rights. In addition to the rights under Section 39-3516, Idaho Code, the resident rights policy must include the following:
-
Monitoring Correspondence. The right to send and receive mail unopened, either by postal service, electronically, or by other means, unless the resident's plan of service specifically calls for the provider to monitor the correspondence to protect the resident from abuse or exploitation.(3-28-23)
-
Image. The right to control staff’s use of pictures and videos containing the resident’s image.
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Crime-Free Living Environment. The right to a living environment free of illicit drug use or possession, and other criminal activities.(3-28-23)
-
Freedom From Discrimination. The right to be free from discrimination on the basis of race, color, national origin, sex, religion, age, disability, or veteran status;(3-28-23)
-
Freedom of Choice. The right to be free from intimidation, manipulation, and coercion. (3-28-23)
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Basic Needs Allowance. For each resident whose care is publicly funded, in whole or in part, the right to retain, for personal use, the CFH basic allowance established by IDAPA 16.03.05. “Eligibility for Aid to the Aged, Blind, and Disabled,” Section 513. The provider’s total monthly charges to a resident receiving public assistance must be limited to ensure the resident retains at least the basic needs allowance.(3-28-23)
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Resident Funds and Property. The right to manage personal funds and use personal property, including access to the home. (3-28-23)
a.The resident has the right to retain and use personal property in their own living area. The provider must ensure, however, the storage and use of these items by the resident does not present a fire or life safety hazard.
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Access to Records, Medications, and Treatments. The right for the resident's healthcare professionals to have reasonable access to the resident's records, medications, and treatments subject to the resident's permission.(3-28-23)
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Freedom From Exploitation. The right to be free from exploitation. (3-28-23)
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Written Response to Grievance. The right to a written response to any expressed grievance describing how the provider resolved or attempted to resolve the grievance.(3-28-23)
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Advance Notice. The right to receive written advance notice at least thirty (30) calendar days prior to non-emergency transfer or discharge unless the transfer or discharge is for a reason under Section 261 of these 12. Personal Records. The right to access personal records, including those under Section 270 of these 13. Activities. The right to participate in social, religious, and community activities.(3-28-23)
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Other CFHs. The right to review a list of other CFHs that may be available in case of transfer.
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File Complaints. The right to file a complaint with the Department under Section 160 of these 16. Care of a Personal Nature. The right to refuse routine care of a personal nature from any person whom the resident is uncomfortable receiving such care.(3-28-23)
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Formulate Advance Directives. The right to be informed, in writing, regarding the formulation of advance directives under Title 39, Chapter 45, Idaho Code.(3-28-23)
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Other Rights. The right to exercise any other rights established by law.(3-28-23)
IDAPA 16.03.19.201 Notice of Resident Rights
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Resident Rights Notice. At the time of admission to the home, the provider must inform the resident or their representative, verbally and in writing, of the home’s resident rights policy and supply the resident or their representative a copy of the policy. (3-28-23)
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Annual Review of Resident Rights. The provider must review the resident rights policy with the resident or their representative at least annually.(3-28-23)
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Documentation of Review. The provider must keep a log of each review of the resident rights policy in the resident's record. The log must include dated signatures from the provider and the resident or the resident's representative acknowledging the review.(3-28-23)
IDAPA 16.03.19.202 (Reserved)
IDAPA 16.03.19.210 Reporting Requirements
The provider must report the following to the regional certifying agent where the home is located or appropriate agency or individual:(3-28-23)
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Serious Physical Injury or Death. The provider must report to the appropriate law enforcement agency within four (4) hours when there is reasonable cause to believe that abuse, neglect, or sexual assault has resulted in death or serious physical injury jeopardizing the life, health, or safety of a resident under Section 39-5303, Idaho Code.(3-28-23)
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Abuse, Neglect, or Exploitation. When the provider has reasonable cause to believe that a vulnerable adult is being or has been abused, neglected, or exploited, the provider must immediately report this information to the Idaho Commission on Aging or its Area Agencies on Aging, under Section 39-5303, Idaho Code.
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Critical Incidents. The provider must notify the certifying agent when a critical incident affects the health or safety of the resident or leads to a change in the resident's condition, including serious illness, accident, elopement, death, or adult protective services or law enforcement contact and investigation. Reporting requirements are as follows:(3-28-23)
a.Within twenty-four (24) hours of the resident's death or disappearance; and(3-28-23)
b.Within three (3) business days following:(3-28-23)
i.Contact from adult protective services or law enforcement in conjunction with an investigation;
ii. A visit to an urgent care clinic or emergency room; or(3-28-23)
iii. Admission to a hospital.(3-28-23)
- Report of Fire. A written report of each fire incident occurring within the home, for which a fire extinguisher was discharged or 9-1-1 was contacted, must be submitted to the certifying agent within three (3) business days of the occurrence. The report must include:(3-28-23)
a.Date of the incident;(3-28-23)
b.Origin of the fire;(3-28-23)
c.Extent of damage; (3-28-23)
d.How and by whom the fire was extinguished; and(3-28-23)
e.Injuries or deaths, if any.(3-28-23)
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Additional Criminal Convictions. The provider must immediately report to the certifying agent any additional criminal convictions for themselves, staff, any other adult living in the home, or a substitute caregiver.
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Notice of Investigations. The provider must immediately report to the certifying agent when the provider, staff, any other adult living in the home, or a substitute caregiver is charged with or under investigation by law enforcement, adult protection services, or child protection services for:(3-28-23)
a.Abuse, neglect, or exploitation of any vulnerable adult or child;(3-28-23)
b.Other criminal conduct; or(3-28-23)
c.When an adult protection or child protection complaint is substantiated.(3-28-23)
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Funds Managed by the Provider for a Deceased Resident. For resident funds managed under Section 275 of these rules, upon the death of the resident, the provider must convey the resident’s remaining funds, with a final accounting of those funds, to the individual administering the resident’s estate within thirty (30) days.
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Discharge of a Resident. The provider must immediately notify the certifying agent upon the discharge of any resident from the home.(3-28-23)
IDAPA 16.03.19.211 (Reserved)
IDAPA 16.03.19.225 Uniform Assessment Requirements
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State Responsibility for Publicly Funded Residents. The Department will assess residents accessing services through a publicly funded program according to uniform criteria developed for that program.
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Provider Responsibility for Private-Pay Residents. The provider will develop, identify, assess, or direct a uniform needs assessment of each private-pay resident. The uniform needs assessment must be: (3-28-23)
a.Completed no later than fourteen (14) calendar days after admission; and(3-28-23)
b.Reviewed when there is a change in condition, or every twelve (12) months, whichever occurs first.
- Core Elements. The assessment of a private-pay resident must be based on the following:
a.Identification and background information;(3-28-23)
b.Medical diagnosis;(3-28-23)
c.Medical and health needs;(3-28-23)
d.Prescription medications including routes of administration, and any treatments or special diets, if applicable;(3-28-23)
e.Historical and current behavior patterns;(3-28-23)
f.Cognitive function;(3-28-23)
g.Psychosocial and physical needs of the resident;(3-28-23)
h.Functional status; and(3-28-23)
i.Assessed level of care.(3-28-23)
- Results of Assessment. The results of the assessment for both publicly funded and private-pay residents are used to evaluate the provider’s ability to meet the resident's needs, and to evaluate whether any special training, licenses, or certificates may be required to care for certain residents.(3-28-23)
IDAPA 16.03.19.226 (Reserved)
IDAPA 16.03.19.250 Plan of Service
The provider must ensure each resident has a plan of service. The plan must identify the resident, describe the services to be offered, and describe how the services will be delivered.(3-28-23)
- Core Elements. A resident's plan of service must be based on the resident's:(3-28-23)
a.Assessment;(3-28-23)
b.Service needs for activities of daily living;(3-28-23)
c.Need for limited nursing services;(3-28-23)
d.Need for medication assistance;(3-28-23)
e.Frequency of needed services;(3-28-23)
f.Level of care;(3-28-23)
g.Habilitation and training needs;(3-28-23)
h.Behavioral management needs, including identification of situations that trigger dangerous, unlawful, or otherwise problematic behavior, plans to prevent such situations, and coping procedures if triggered;
i.Healthcare professional’s orders;(3-28-23)
j.Admission records;(3-28-23)
k.Supportive services;(3-28-23)
l.Desires and choices, to the greatest extent possible;(3-28-23)
m.Need for supervision, including the degree;(3-28-23)
n.Transfer and discharge needs; and(3-28-23)
o.Other identified needs.(3-28-23)
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Signature and Approval. The provider and the resident or the resident’s representative must sign and date the plan of service upon its completion, within fourteen (14) days of the resident's admission. (3-28-23)
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Developing the Plan. The provider will consult the resident and other individuals identified by the resident in developing the plan of service. Professional staff must be involved in developing the plan if required by another program.(3-28-23)
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Copy of the Plan. Signed copies of the plan of service must be placed in the resident's file and given to the resident or the resident’s representative, if applicable, no later than fourteen (14) days after admission.
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Changes to the Plan. A record must be made of any changes to the plan. When changes to the plan are made, the resident or resident's representative and the provider must sign and date the updated plan. (3-28-23)
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Frequency of Review. The plan of service must be reviewed when the resident experiences a significant change in condition, or at least every twelve (12) months, whichever occurs first.(3-28-23)
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Date of Regular Review. The date of the next regularly scheduled review must be documented in the plan of service.(3-28-23)
IDAPA 16.03.19.251 (Reserved)
IDAPA 16.03.19.260 Admissions
The provider must only admit or retain residents in the home under Section 39-3507, Idaho Code.(3-28-23)
- Department Review. The provider must obtain approval from the Department for each admission prior to the prospective resident moving into the home. The following must be provided to the regional certifying agent where the home is located:(3-28-23)
a.Name, gender, and date of birth of the prospective resident;(3-28-23)
b.The contemplated date of admittance of the prospective resident into the home;(3-28-23)
c.The prospective resident's history and physical from the resident’s healthcare professional, conducted within the previous twelve (12) month period and reflecting the resident’s current health status. If the resident is private-pay, the documentation must include a statement from the resident's healthcare professional indicating that the resident is appropriate for CFH care;(3-28-23)
d.A list of the prospective resident's current medications and treatments from their healthcare professional;(3-28-23)
e.Contact information for the prospective resident's healthcare professionals;(3-28-23)
f.Contact information for the prospective resident's representative, if applicable;(3-28-23)
g.The prospective resident's plan of service from another healthcare setting, or any such plan of service conducted for the resident within the previous six (6) months, if one exists, when the resident transfers to the home from another healthcare setting; and(3-28-23)
h.Other information requested by the Department relevant to the appropriateness of the admission and the provider's ability to provide adequate care.(3-28-23)
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Notification. Within five (5) business days of receipt of the documents under Subsection 260.01 of this rule, the Department will notify the provider whether the proposed admission is approved or denied. When verbal notification is given, the Department will provide follow-up written communication to the provider stating the approval or denial within ten (10) business days.(3-28-23)
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Emergency Admission. The provider may not accept an emergency admission without prior approval from the Department except under the following conditions:(3-28-23)
a.The provider may make a conditional admission when the provider reasonably believes the CFH has the ability to provide adequate care to the resident and the request for an emergency placement occurs after normal business hours and the provider is unable to contact the Department for prior approval. The provider must notify the resident or the resident’s representative that the admission is conditional upon Department approval.
b.The provider must notify the regional certifying agent where the home is located by the next business day when a conditional emergency admission is made.(3-28-23)
c.The provider must follow the regular admission process under Subsection 260.01 of this rule within two (2) business days of making a conditional emergency admission. The Department may deny the placement and require the provider to immediately transfer the resident when the Department has reasonable cause to believe the provider lacks the ability to provide adequate care to the resident.(3-28-23)
- Admission Agreement. At the time of admission to the CFH, the provider and the resident or resident's representative, if applicable, must enter into an admission agreement. The agreement must be in writing and be signed and dated by both parties. The agreement must, in itself or by reference to the resident's plan of service, include provisions addressing at least the following:(3-28-23)
a.Whether or not the resident intends to assume responsibility for self-administering medication;
b.Steps the provider will take in the event the resident is not able to carry out self-preservation (e.g., performance of life-saving measures, contacting 9-1-1, honoring an order not to resuscitate, etc.);(3-28-23)
c.Whether or not the provider will accept responsibility for managing the resident's funds; (3-28-23)
d.How a partial month's refund will be managed;(3-28-23)
e.Arrangements for the return of the resident’s belongings should the resident leave the home;
f.Amount of liability coverage provided by the homeowner's or renter's insurance policy and whether the insurance policy covers the resident's personal belongings;(3-28-23)
g.A requirement of written notice on the part of the provider, resident, or resident's representative of at least thirty (30) calendar days prior to termination of the admission agreement, when the termination is not for a situation under Subsection 261.01.b. of these rules;(3-28-23)
h.Conditions under which an emergency temporary placement will be made consistent with Subsection 261.02 of these rules;(3-28-23)
i.Consent or denial for the provider to supply pertinent information from the resident's record to the resident's healthcare professionals or, in case of transfer, current or prospective care setting;(3-28-23)
j.Responsibility of the provider to obtain consent for medical procedures from the resident’s legal guardian or power of attorney for healthcare if the resident is unable to make medical decisions;(3-28-23)
k.Resident responsibilities as appropriate that do not conflict with the CFH requirements; (3-28-23)
l.Amount the provider will charge the resident for room and board on a monthly basis, and a separately listed amount for any monthly care charges for which the resident is responsible; (3-28-23)
m.A requirement of written notice to the resident or resident's representative of at least thirty (30) calendar days before the provider implements changes to charges under Subsection 260.04.l. of this rule; (3-28-23)
n.Protections that address eviction processes and appeals comparable to those provided under Idaho landlord tenant law. The admission agreement must either:(3-28-23)
i.Adopt the eviction and appeal processes under Title 6, Chapter 3, Idaho Code; or(3-28-23)
ii. Adopt the eviction and appeal processes as described in the version of the admission agreement provided by the Department; and (3-28-23)
o.Additional conditions as agreed upon by both parties but consistent with the CFH requirements.
IDAPA 16.03.19.261 Discharge or Transfer
- Termination of Admission Agreement. The admission agreement must only be terminated under the following conditions:(3-28-23)
a.The provider or the resident, or the resident's representative, if applicable, provides the other party at least thirty (30) calendar days' prior written notice; or(3-28-23)
b.A three (3) day written notice may be given by the provider to the resident or the resident's representative, if applicable, when any of the following occur, subject to the appeal process under Subsection 260.04.n. of these rules: (3-28-23)
i.Nonpayment of the resident's bill identified in Subsection 260.04.l. of these rules;(3-28-23)
ii. The resident violates any written conditions of the admission agreement (e.g., no smoking, no pets, etc.); or(3-28-23)
iii. The resident engages in the unlawful delivery, production, or use of a controlled substance on the premises of the home.(3-28-23)
- Emergency Temporary Placement. The admission agreement will remain in force and effect, excluding the provider's responsibility for care and the charge to the resident for such care under Subsection 260.04.l. of these rules, while the resident is temporarily transferred from the home to another care setting on an emergency basis unless either party terminates the agreement under Subsection 261.01 of this rule. An emergency temporary placement must only occur when:(3-28-23)
a.The resident's mental or physical condition deteriorates to a level requiring evaluation or services that cannot be met by the provider or reasonably accommodated by the home; or(3-28-23)
b.Emergency conditions require such transfer to protect the resident, other residents, the provider, or other individuals living in the home from harm.(3-28-23)
- Return of Resident’s Possessions. The provider must document the return of the resident’s personal possessions to the resident or resident's representative as arranged in the admission agreement according to Subsection 260.04.e. of these rules, and must:(3-28-23)
a.Return immediately upon discharge:(3-28-23)
i.All personal funds belonging to the resident; and(3-28-23)
ii. Any medication, supplement, or treatment belonging to the resident;(3-28-23)
b.Return within three (3) business days:(3-28-23)
i.If the provider was deemed to be managing the resident's funds under Subsection 275.02 of these rules, a copy of the final accounting of the resident’s funds;(3-28-23)
ii. All belongings listed on the resident’s belongings inventory; and(3-28-23)
iii. Any other items belonging solely to the resident, including personal documents.(3-28-23)
IDAPA 16.03.19.262 (Reserved)
IDAPA 16.03.19.270 Resident Records
The provider must maintain legible records for each resident admitted to the home as follows.(3-28-23)
-
Updated Records. Records maintained by the CFH must be updated, as necessary, to reflect accurate information as changes occur.(3-28-23)
-
Maintenance of Records. The provider must ensure records are maintained and available for inspection in the home as follows:(3-28-23)
a.Admission records for two (2) years from the date of the resident’s discharge from the home; and
b.Ongoing records for two (2) years from the date of the record.(3-28-23)
- Admission Records. The following records pertaining to the resident must be completed or collected as part of the initial admission process and continuing retention of the resident’s records thereafter:
a.A form containing general resident information including:(3-28-23)
i.Full legal name;(3-28-23)
ii. Primary residence, if other than the CFH;(3-28-23)
iii. Marital status and sex;(3-28-23)
iv. Date of birth;(3-28-23)
v.The name, address, and telephone number of an individual identified by the resident or the resident’s representative who should be contacted in an emergency or upon death of the resident;(3-28-23)
vi.The resident's healthcare professionals and their contact information, and the contact information for any other supportive service used by the resident;(3-28-23)
vii. Social information including social history, hobbies, and interests;(3-28-23)
viii. Information about any specific health problems that may be useful in a medical emergency; and ix. Any other health-related, emergency, or pertinent information that the resident requests the provider to keep on record.(3-28-23)
b.Results of the resident’s history and physical examination performed by a healthcare professional conducted no earlier than twelve (12) months prior to admission;(3-28-23)
c.A list of all medications, treatments, and special diets prescribed by a healthcare professional;
d.The written admission agreement under Section 260 of these rules;(3-28-23)
e.A log of the resident rights policy review under Section 201 of these rules;(3-28-23)
f.The assessment under Section 225 of these rules;(3-28-23)
g.The plan of service under Section 250 of these rules;(3-28-23)
h.An inventory of the resident's belongings that may consist of photographs or a written descriptive list. The resident or the resident’s representative may inventory any personal possession they so choose and expect returned upon the resident's transfer or discharge from the home. The belongings inventory may be updated at any time but must be reviewed at least annually;(3-28-23)
i.If the resident has a representative, a copy of the document giving the representative legal authority to act on behalf of the resident, including guardianship or power of attorney for healthcare decisions; and (3-28-23)
j.A copy of any care plan that is prepared for the resident by an outside service provider. (3-28-23)
- Ongoing Records. The following records must be completed or collected by the provider for ongoing services to the resident:(3-28-23)
a.Any incident or accident occurring while the resident is living in the home and the staff’s response, including refusal of any prescription medication. If the incident or accident occurs while the resident is receiving supportive services, the provider must obtain a written report of the event from the service provider;(3-28-23)
b.The provider's written response to any grievance under Section 200 of these rules;(3-28-23)
c.Notes or logs from the licensed nurse, home health agency, physical therapist, or any other service providers, documenting the services provided to the resident at each visit to the home;(3-28-23)
d.Documentation of changes in the resident’s physical, behavioral, or mental status, and the staff’s response, including usage of any PRN medication; (3-28-23)
e.When the provider is deemed to be managing the resident's funds, financial accounting records for such funds as described in Section 275 of these rules; and(3-28-23)
f.Medication records as described in Sections 400 through 402 of these rules, as applicable.
IDAPA 16.03.19.271 (Reserved)
IDAPA 16.03.19.275 Resident Funds and Financial Records
- Resident Funds Policy. Each provider must possess and implement a policy and procedure describing how the resident's funds will be managed including the following:(3-28-23)
a.When the resident moves out from the home under any circumstances except those under Section 912 of these rules, the provider will:(3-28-23)
i.Only retain prepaid room and board funds prorated to the last day of the notice period terminating the admissions agreement as specified in the agreement, or upon the resident moving from the home, whichever is later; (3-28-23)
ii. Immediately return all remaining resident funds to the resident or to the resident’s representative as specified in the admission agreement under Section 260 of these rules; and(3-28-23)
iii. Only use the resident’s funds for that resident’s expenses until a new payee is appointed. (3-28-23)
b.Prohibit personal loans to the resident from the provider, provider's relatives, and other household members unless the loan is from a relative of the resident. When such a loan is made, the provider must: (3-28-23)
i.Ensure the terms of the loan are described in a written contract signed and dated by the resident or resident's representative;(3-28-23)
ii. Maintain a copy of the loan contract in the resident's record; and(3-28-23)
iii. Immediately update documentation of repayments towards the loan.(3-28-23)
- Managing Resident Funds. When the resident's funds are turned over to the provider or staff for any purpose other than payment for services allowed under CFH requirements, or if the provider, provider’s relative, staff, or an individual living in the home acts as the resident’s payee, the provider is deemed to be managing the resident's funds. The provider who manages a resident’s funds must:(3-28-23)
a.Establish a separate account at a financial institution for each resident to which resident income and use of the resident's funds may be accounted and reconciled by means of a financial statement;(3-28-23)
b.Prohibit commingling of the resident's funds with the funds of any other person, including borrowing funds from the resident;(3-28-23)
c.Upon request, notify the resident or the resident’s representative the current amount of the resident’s funds available for their use;(3-28-23)
d.Charge the resident the amount agreed upon in the admission agreement under Section 260 of these rules for CFH services on a monthly basis;(3-28-23)
e.Maintain separate accounting records, including bank statements, cash ledgers with a running balance of cash on-hand, and receipts for any purchases in excess of ten dollars ($10) for each resident for whom the provider manages funds;(3-28-23)
f.Restore funds to the resident if the provider cannot produce proper accounting records of resident’s funds or property under Subsection 275.02.e. of this rule. Restitution of these funds to the resident is a condition for continued operation of the CFH;(3-28-23)
g.Not require the resident to purchase goods or services from or for the home other than those under Section 260 of these rules; and(3-28-23)
h.Provide the resident, the resident’s legal guardian, representative with financial power of attorney, or conservator access to the resident's funds.(3-28-23)
IDAPA 16.03.19.276 (Reserved)
IDAPA 16.03.19.300 Short-Term Care and Supervision
When the provider is temporarily unavailable to provide care or supervision to the resident, the provider may designate another adult to provide care and supervision, or only supervision to the resident. The provider must assure that this short-term arrangement meets the needs of the resident and protects the resident from harm. (3-28-23)
- Alternate Care. Means services to the resident at another CFH. An alternate caregiver operating the other CFH ensures care and supervision are provided to the resident under the resident's original plan of service and admission agreement. The following applies to an alternate care placement:(3-28-23)
a.The Department must approve an alternate care placement using the process under Section 260 of these rules. The alternate caregiver must:(3-28-23)
i. Not exceed the number of residents for which the home is certified to provide care; (3-28-23)
ii. Comply with Section 140 of these rules when the resident receiving alternate care will be the third or fourth resident in the alternate caregiver's home; and (3-28-23)
iii. Comply with Section 130 of these rules when the resident receiving alternate care requires nursing facility level of care and any other resident in the alternate caregiver's home requires nursing facility level of care.
b.Upon approval from the Department, alternate care may be provided for up to thirty (30) consecutive days.(3-28-23)
c.The provider must give or arrange for resident-specific training to the alternate caregiver prior to alternate care, including supplying copies of the resident's current assessment, plan of service, and admission agreement.(3-28-23)
- Substitute Care. Means services to the resident in the same CFH where the resident holds an admission agreement during the regular provider's absence. A substitute caregiver must be an adult designated by the provider to provide care and supervision to the resident in the provider's CFH. The following apply to the designation of a substitute caregiver:(3-28-23)
a.The provider is responsible to give or arrange for resident-specific training to the substitute caregiver prior to substitute care, including reviewing copies of each resident's current assessment, plan of service, and admission agreement.(3-28-23)
b.Staffing levels in the home must be maintained at the same level as when the provider is available to provide care and supervision.(3-28-23)
c.Substitute care can be provided for up to thirty (30) consecutive days.(3-28-23)
d.The substitute caregiver must have the following qualifications:(3-28-23)
i.Current certification in first aid and adult Cardio-Pulmonary Resuscitation (CPR) that meets the standards under Section 100 of these rules;(3-28-23)
ii. A cleared background check under Section 009 of these rules; and(3-28-23)
iii. Completion of a medications training under Section 100 of these rules.(3-28-23)
- Incidental Supervision. Means a brief reprieve for the provider from direct care responsibilities.
An individual providing incidental supervision is approved by the provider to supervise the resident only. (3-28-23)
a.Incidental supervision must not include resident care.(3-28-23)
b.Incidental supervision may be provided for up to ten (10) hours per week for no more than six (6) consecutive hours, so long as the resident does not require care.(3-28-23)
IDAPA 16.03.19.301 (Reserved)
IDAPA 16.03.19.400 Medication Policy
The provider must possess and implement written medication policies and procedures that describe in detail how staff will ensure appropriate assistance with and handling of and safeguarding of medications. These policies and procedures must be maintained in the home and include the following:(3-28-23)
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Following Orders. Assistance given by staff will only be as directed by the resident’s healthcare professionals.(3-28-23)
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Evidence of Orders. Evidence of each resident’s orders will be maintained in the home, regardless of whether the resident is able to self-administer, and may consist of the following:(3-28-23)
a.Written prescriptions from the healthcare professional for the medication, including the dosage;
b.Medisets or sealed blister medication cards filled and appropriately labeled by a pharmacist or licensed nurse with the names of the medications, dosages, times to be taken, routes of administration, and any special instructions;(3-28-23)
c.An original prescription bottle labeled by a pharmacist describing the order and instructions for use; or(3-28-23)
d.If the medication, supplement, or treatment is without a prescription, it will be listed among overthe-counter medications approved by the resident’s healthcare professional as indicated by a signed statement. Overthe-counter medications will be given as directed on the packaging.(3-28-23)
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Alteration of Orders. Staff will not alter dosage, discontinue or add medications, including overthe-counter medications and supplements, or discontinue, alter, or add treatments or special diets without first consulting the resident’s prescribing healthcare professional and obtaining an order for the change as required under Subsection 400.02 of this rule.(3-28-23)
-
Allergies. The provider will list any known food or drug allergies for each resident and take precautions to guard against the resident ingesting such allergens.(3-28-23)
-
Training. Each staff assisting with resident medications will have successfully completed a medication training under Section 100 of these rules. Additionally:(3-28-23)
a.Each resident’s orders will be reviewed by each staff assisting residents with medications prior to offering assistance; and(3-28-23)
b.Written instructions will be in place that outline who to notify if any of the following occur:
i.Doses are not taken;(3-28-23)
ii. Overdoses occur; or(3-28-23)
iii. Side effects are observed.(3-28-23)
c.The provider will ensure any staff assisting with medications has reviewed each resident’s known allergies and takes precautions against the resident ingesting such allergens.(3-28-23)
-
Consumer Medication Information. The provider will keep on file in the resident’s record the consumer medication information handout for each current prescription medication.(3-28-23)
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Self-Administration. When the provider cares for a resident who self-administers medications, staff will follow Section 401 of these rules.(3-28-23)
-
Assistance with Medication. When the provider cares for a resident who needs assistance with medications, the provider must follow Section 402 of these rules.(3-28-23)
IDAPA 16.03.19.401 Self-Administration of Medication
Prior to giving the resident responsibility for administering medications without assistance, the provider must ensure the following:(3-28-23)
- Approval. The provider has obtained written approval from the resident’s healthcare professional stating that the resident is capable of safe self-administration; otherwise, staff will comply with Section 402 of these 02. Evaluation. The resident’s record includes documentation that the resident’s healthcare professional has evaluated the resident’s ability to safely self-administer medication. The evaluation must include verification of the following:(3-28-23)
a.The resident understands the purpose of each medication;(3-28-23)
b.The resident is oriented to time and place and knows the appropriate dosage and times to take the medication;(3-28-23)
c.The resident understands the expected effects, adverse reactions, or side effects, and knows what actions to take in case of an emergency; and(3-28-23)
d.The resident can take the medication without assistance or reminders from staff.(3-28-23)
- Change in Condition. Should the condition of the resident change such that it brings into question the resident’s ability to safely continue self-administration of medications, the provider will arrange for a reevaluation of the resident to self-administer under Subsection 401.02 of this rule. Until the resident's healthcare professional provides written approval for the resident to resume self-administration, staff will comply with Section 402 of these 04. Safeguarding Medication. The provider must ensure that the medications of a resident who selfadministers are safeguarded, including providing a lockable storage cabinet or drawer to the resident under Section 175 of these rules. The resident is allowed to maintain personal medications under the resident’s own control and possession.(3-28-23)
IDAPA 16.03.19.402 Assistance with Medication
The provider must offer assistance with medications to residents who need assistance. Prior to staff assisting residents with medication, the provider must ensure the following conditions are in place:(3-28-23)
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Condition of the Resident. The resident’s health condition is stable.(3-28-23)
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Nursing Assessment. The resident’s health status does not require nursing assessment before receiving the medication nor nursing assessment of the therapeutic or side effects after the medication is taken, unless the staff assisting with medications is a healthcare professional operating within the scope of their license. (3-28-23)
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Containers. The medication is in the original pharmacy-dispensed container with its proper label and directions or in an original over-the-counter container or in a Mediset, blister pack, or similar organizational system. When a Mediset, blister pack, or similar system is used, staff will comply with the following. (3-28-23)
a.The system contains easily identifiable dates and times for medication dispensing;(3-28-23)
b.The system is filled according to the schedule ordered by the resident’s healthcare professional for each medication;(3-28-23)
c.Unless filled by a pharmacy or a licensed nurse, the system is filled not more than seven (7) days prior to the scheduled medication dispensing date;(3-28-23)
d.Staff only dispense the specific medication scheduled for dispensing and assist within twenty (20) minutes before or after the specified time;(3-28-23)
e.The original medication container with its proper label is maintained in the home until the medication it contained is completely used or refused by the resident; and(3-28-23)
f.Any medication scheduled for dispensing that the resident refuses or that is otherwise missed is immediately removed from the system and disposed of at the earliest opportunity under Subsection 402.07 of this rule.(3-28-23)
- Safeguarding Medications. Staff take adequate precautions to safeguard the medications of each resident for whom they provide assistance. Safeguarding consists of the following:(3-28-23)
a.Storing each resident’s medications in an area or container designated only for that particular resident including a label with the resident’s name, except for medications that must be refrigerated or over-thecounter medications;(3-28-23)
b.Keeping the designated area or container for the resident’s medications under lock and key when either of the following apply:(3-28-23)
i.The resident’s medications include a controlled substance; or(3-28-23)
ii. Any member of the household has drug-seeking behaviors.(3-28-23)
c.Ensuring each resident’s designated medication area or container is clean and kept free of contamination, including disposal of loose pills at the earliest opportunity under Subsection 402.07 of this rule;
d.Dispensing only one (1) resident’s set of medications from its designated area or container at one (1) time to mitigate medication errors; and(3-28-23)
e.On at least a monthly basis, the provider conducts and documents an inventory of narcotic medications and reconciles the actual amount on-hand with the expected amount on-hand. When a discrepancy occurs between the expected and actual amounts, the provider will:(3-28-23)
i.Investigate the cause of the discrepancy; and(3-28-23)
ii. Write a summary report of the investigation and keep the report in the resident’s record. (3-28-23)
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Scope of Practice. Only a healthcare professional working within the scope of their license may administer medications or practice other nursing functions. Practice of such functions must comply with IDAPA 24.34.01, “Rules of the Idaho Board of Nursing.”(3-28-23)
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Documentation of Assistance. Documentation of assistance with medications is maintained in the home. Such documentation:(3-28-23)
a.Is logged concurrent with the time of assistance; and(3-28-23)
b.Contains at least the following information:(3-28-23)
i.The name of the resident receiving the medication;(3-28-23)
ii. The name of the medication given;(3-28-23)
iii. The dosage of the medication given; and(3-28-23)
iv. The time and date the medication was given.(3-28-23)
- Disposal of Medication. Medication that has been discontinued as ordered by the resident's healthcare professional, has expired, or should otherwise be disposed of under this rule is disposed of by the provider within thirty (30) days of the order, expiration date, or as otherwise described in this rule. A written record of all disposal of drugs will be maintained in the home and include:(3-28-23)
a.The name of the medication;(3-28-23)
b.The amount of the medication, including the number of pills at each dosage, if applicable;
c.The name of the resident for whom the medication was prescribed;(3-28-23)
d.The reason for disposal;(3-28-23)
e.The date on which the medication was disposed;(3-28-23)
f.The method of disposal; and(3-28-23)
g.A signed statement from the provider and a credible witness confirming the disposal of the medication.(3-28-23)
IDAPA 16.03.19.403 (Reserved)
IDAPA 16.03.19.500 Environmental Sanitation Standards
The provider is responsible for disease prevention and maintenance of sanitary conditions in the home and must ensure:(3-28-23)
- Water Supply. The water supply for the home is adequate, safe, and sanitary by obtaining and keeping in the home evidence of the following:(3-28-23)
a.The home uses a public or municipal water supply or a Department-approved private water supply;
b.If water is from a private supply, water samples are submitted to an accredited laboratory and show an absence of bacterial contamination at least annually, or more frequently if deemed necessary by the Department; and(3-28-23)
c.The home always has adequate water pressure to meet sanitary requirements.(3-28-23)
- Sewage Disposal. The sewage disposal system is approved and maintained by obtaining and keeping in the home evidence of the following:(3-28-23)
a.All sewage and liquid wastes are discharged, collected, treated, and disposed of in a manner approved by the local municipality or the Department. The Department may require the provider to obtain a statement from the area health district indicating that the sewage disposal system meets local requirements. The statement, if required, must be kept on file at the home.(3-28-23)
b.For homes with nonmunicipal sewage disposal, the septic tank has been pumped within the last five (5) years or the system is otherwise in good working condition.(3-28-23)
- Garbage and Refuse Disposal. Garbage and refuse disposal is provided by or at the home at least biweekly and the garbage containers are:(3-28-23)
a.Constructed of durable materials and provided with tight-fitting lids;(3-28-23)
b.Maintained in good repair and do not leak or absorb liquids; and(3-28-23)
c.Sufficient in number to hold under lid all garbage and refuse that accumulates between periods of removal from the premises such that storage areas are free of excess refuse and debris.(3-28-23)
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Insect and Rodent Control. The home is maintained free from infestations of insects, rodents, and other pests by using a control program based on the pest involved when an infestation appears.(3-28-23)
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Yard. The yard surrounding the home is safe and maintained.(3-28-23)
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Laundry. A washing machine and dryer are readily available for the proper and sanitary washing of linen and other washable goods and laundry services are offered:(3-28-23)
a.On at least a weekly basis; or(3-28-23)
b.When soiled linens or clothing create a noticeable odor.(3-28-23)
- Housekeeping and Maintenance. Sufficient housekeeping and maintenance are provided to maintain the interior and exterior of the home in a clean, safe, and orderly manner including compliance with the following:(3-28-23)
a.Resident sleeping rooms are cleaned on at least a weekly basis as described in the resident’s plan of service and thoroughly cleaned immediately after the discharge of the previous resident using the room; and
b.Deodorizers are not used to cover odors caused by poor housekeeping or unsanitary conditions.
IDAPA 16.03.19.501 (Reserved)
IDAPA 16.03.19.600 Fire and Life Safety Standards
Each home must meet the requirements of this rule and all other applicable requirements of local and state codes concerning fire and life safety.(3-28-23)
- General Requirements. The provider must ensure that:(3-28-23)
a.The home is structurally sound and equipped and maintained to assure the safety of residents.
b.When natural or man-made hazards are present, suitable fences, guards, or railings are in place to protect the resident according to the resident’s needs as documented in the plan of service.(3-28-23)
c.The exterior and interior of the home are kept free from the accumulation of weeds, trash, debris, rubbish, and clutter.(3-28-23)
- Fire and Life Safety Requirements. The provider must ensure that:(3-28-23)
a.Smoke detectors are installed in sleeping rooms, hallways, on each level of the home, and as recommended by the local fire district.(3-28-23)
b.Carbon monoxide (CO) detectors are installed as recommended by the Department when:
i.The home is equipped with gas or other fuel-burning appliances or devices; or(3-28-23)
ii. An enclosed garage is attached to the home.(3-28-23)
c.Unvented combustion devices of any kind are prohibited from use inside the home. (3-28-23)
d.Any locks installed on exit doors can always be easily opened from the inside without the use of keys or any special knowledge.(3-28-23)
e.Electric portable heating devices are only used under the following conditions:(3-28-23)
i.The unit is maintained in good working order and without obvious damage or fraying of the cord;
ii. Remain unplugged until in operation, and then plugged directly into a wall outlet and not a surge protector, power strip, or extension cord;(3-28-23)
iii. The user complies with safety labels, which remain on the unit;(3-28-23)
iv. The unit is equipped with automatic shut-off protection when tipped over; and(3-28-23)
v.The unit is operated under direct supervision and at least thirty-six (36) inches away from combustibles (e.g., furnishings, bedding, and blankets), pets, and people.(3-28-23)
f.Each resident’s sleeping room has at least one (1) door or window that can be easily opened from the inside and leads directly to the outside. If a window is used as a means of egress/ingress, the following conditions are met:(3-28-23)
i.The window sill height is not more than forty-four (44) inches above the finished floor; (3-28-23)
ii. The window opening is at least twenty (20) inches in width and twenty-four (24) inches in height; and(3-28-23)
iii. If the sleeping room is in a below-ground basement, the window opens into a window well through which the resident can easily exit.(3-28-23)
g.Flammable or highly combustible materials are stored safely. Necessary precautions are taken to protect the resident from obtaining flammable materials as appropriate for the resident’s functional and cognitive ability.(3-28-23)
h.Boilers, hot water heaters, and unfired pressure vessels are equipped with automatic pressure relief valves.(3-28-23)
i.A two and a half (2.5) pound or larger dry chemical multipurpose A:B:C type portable fire extinguisher is immediately accessible without obstructions in a designated location, subject to Department approval, on each level of the home.(3-28-23)
j.Electrical installations and equipment comply with IDAPA 24.39.10, “Rules of the Idaho Electrical Board,” or authorized local jurisdiction.(3-28-23)
k.Fuel-fired heating devices are approved by the local heating/venting/air conditioning (HVAC) board.(3-28-23)
l.Exits are free from obstruction.(3-28-23)
m.Paths of travel to exits and all exit doorways are at least twenty-eight (28) inches wide. (3-28-23)
n.The door into each bathroom and sleeping room, if equipped with a lock, can be unlocked from either side to allow access to the room in case of an emergency.(3-28-23)
o.Cleaners, pesticides, and other toxic chemicals or materials are:(3-28-23)
i.Only used according to the manufacturer's instructions; and(3-28-23)
ii. Stored with necessary precautions to protect the resident as appropriate for the resident’s functional and cognitive ability.(3-28-23)
- Smoking. Smoking is a fire hazard. The provider may choose to allow or not allow smoking in the home or on the property. If the provider chooses to allow smoking, the provider must reduce the risk of fire by prohibiting smoking:(3-28-23)
a.In any area where flammable liquids, gases, or oxidizers are in use or stored;(3-28-23)
b.In bed; and(3-28-23)
c.By the resident without supervision unless unsupervised smoking is specifically allowed in the resident’s plan of service.(3-28-23)
- Emergency Preparedness Plan. The provider must develop and implement a written emergency preparedness plan. The provider must review the plan with the resident, or the resident’s representative, at admission and at least every twelve (12) months thereafter. The plan must address the following:(3-28-23)
a.Evacuation of the home in the event of a house fire, including:(3-28-23)
i.A floor plan depicting at least two (2) escape routes from each room, excluding bathrooms and the laundry room;(3-28-23)
ii. A designated meeting area indicated on the floor plan where all household members will congregate upon evacuation of the home; and(3-28-23)
iii. Identification of the person responsible to take a head-count at the designated meeting area and relay information to firefighters regarding the probable whereabouts in the home of missing individuals. (3-28-23)
b.Emergency situations in which people are confined to the home for a period of at least seventy-two (72) hours and considering adequate food, water, and medications during that time;(3-28-23)
c.Complying with mandatory evacuation orders from the area, including prearranged plans to shelter within the local community and in a town outside the local community, and considering the necessary supplies that will be kept in a state of readiness for quick evacuation; and(3-28-23)
d.Procedures for any situation in which the provider is incapacitated and unable to provide services.
- Emergency Drills. The provider must ensure staff conduct emergency drills, at least half of which over a year are fire drills, at least every three (3) months as follows:(3-28-23)
a.Those persons capable of participating in a fire drill reach a point of safety outside the home within three (3) minutes from the start of the drill.(3-28-23)
b.Residents who are medically unable to exit unassisted are exempt from physical participation in a fire drill if the provider has an effective evacuation plan for such residents and staff discuss the plan with the resident immediately prior to the drill;(3-28-23)
c.Documentation of the drill is kept in the home, which may consist of a video recording or a written summary, to include the following:(3-28-23)
i.The date and time of the drill;(3-28-23)
ii. The purpose of the drill;(3-28-23)
iii. If a fire drill, the length of time for all persons who participated in the drill to reach a point of safety outside the home;(3-28-23)
iv. The name or likeness of each person who participated in the drill; and(3-28-23)
v.Any problems encountered during the drill or deviations from the home’s emergency plans, and how the provider will overcome the problem or improve performance in future drills.(3-28-23)
- Maintenance of Equipment. The provider must ensure that all equipment in the home is properly maintained by:(3-28-23)
a.Testing smoke and carbon monoxide detectors at least monthly and keeping a written record of the test results on file in the home.(3-28-23)
b.If the smoke or carbon monoxide detector has replaceable batteries, replacing the batteries at least every twelve (12) months or as indicated by a low battery, whichever occurs first.(3-28-23)
c.Replacing each smoke or carbon monoxide detector at the end of its useful life as indicated by the manufacturer, which date is to be labeled on the unit.(3-28-23)
d. Replacing or servicing the portable fire extinguishers through a professional servicing company every twelve (12) months or when the quarterly examination reveals issues with the extinguisher under Subsection 600.06.e. of this rule, whichever occurs first.(3-28-23)
e.Examining all portable fire extinguishers at least every three (3) months as indicated by initials and date on a log, to determine that:(3-28-23)
i.The extinguisher is in its designated location;(3-28-23)
ii. Seals or tamper indicators are not broken, and the safety pin is in place;(3-28-23)
iii. The extinguisher has not been physically damaged;(3-28-23)
iv. The extinguisher does not have any obvious defects, such as leaks;(3-28-23)
v.The nozzle is unobstructed and intact; and(3-28-23)
vi. Chemicals are prevented from settling and clumping by repeatedly tipping the extinguisher upside down and right-side up.(3-28-23)
f.When the home has wood-burning or pellet stoves, arranging for professional cleaning of the chimneys at least annually by a person in the business of chimney sweeping, and keeping the records on file in the home.(3-28-23)
g.Maintaining functional and dependable telephone or cell phone service and hardware. Additionally, ensuring that the following numbers are either programmed into the telephone or cell phone, or alternatively, such numbers are posted in the home:(3-28-23)
i.General emergency numbers including 9-1-1, poison control, adult protective services, and the suicide hotline; and(3-28-23)
ii. Emergency contacts for each resident.(3-28-23)
IDAPA 16.03.19.601 (Reserved)
IDAPA 16.03.19.700 Home Construction and Physical Home Standards
- General Requirements. Any residence used as a CFH must be suitable for that use. CFHs must only be located in buildings intended for residential use.(3-28-23)
a.Remodeling or additions to the home must be consistent with residential use of the property and must comply with local building standards and IDAPA 24.39.30, “Rules of Building Safety (Building Code Rules),” including obtaining building permits as required by the local jurisdiction.(3-28-23)
b.All homes are subject to Department approval.(3-28-23)
- Toilet Facilities and Bathrooms. The home must contain:(3-28-23)
a.A bathroom equipped with at least one (1) flush toilet, one (1) tub or shower, and one (1) sink with a mirror;(3-28-23)
b.Toilet and shower or bathing facilities separated from all rooms by solid walls or partitions;
c.A window that is easily opened to the outside, or forced ventilation to the outside, in each room containing a toilet, shower, or bath;(3-28-23)
d.All tubs, showers, and sinks connected to hot and cold running water; and(3-28-23)
e.Without passing through another person’s sleeping room, access to toilet and bathing facilities designated for the resident’s use.(3-28-23)
- Accessibility for Residents with Physical and Sensory Impairments. A provider choosing to provide services to a resident who has difficulty with mobility or who has sensory impairments must ensure the physical environment maximizes the resident’s independent mobility and use of appliances, bathroom facilities, and living areas. The home must be equipped with necessary accommodations that meet the “American With Disabilities Act Accessibility Guidelines--Standards for Accessible Design (SFAD),” under Section 002 of these rules and as described below according to the individual resident’s needs:(3-28-23)
a.A ramp that complies with Section 405 of the SFAD. Elevators or lifts that comply with Sections 409 and 410, respectively, may be utilized in place of a ramp;(3-28-23)
b.Doorways large enough to allow easy passage of a wheelchair and that comply with Subsection 404.2.3 of the SFAD;(3-28-23)
c.Toilet and bathing facilities that comply with Sections 603 and 604 of the SFAD;(3-28-23)
d.Sinks that comply with Section 606 of the SFAD;(3-28-23)
e.Grab bars in resident toilet facilities and bathrooms that comply with Section 609 of the SFAD;
f.Bathtubs or shower stalls that comply with Sections 607 and 608 of the SFAD, respectively;
g.Non-retractable faucet handles that comply with Subsection 309.4 of the SFAD. Self-closing valves are not allowed;(3-28-23)
h.Suitable handrails on both sides of all stairways leading into and out of the home that comply with Section 505 of the SFAD; and(3-28-23)
i.Smoke and carbon monoxide detectors that comply with Section 702 of the SFAD. (3-28-23)
-
Storage Areas. Adequate storage space must be provided in the home.(3-28-23)
-
Lighting. Adequate lighting must be provided in all resident sleeping rooms and any other rooms accessed by the resident.(3-28-23)
-
Ventilation. The home must be well-ventilated and the provider must take precautions to prevent offensive odors.(3-28-23)
-
Heating and Cooling. The temperature in the home must be maintained between sixty-five degrees Fahrenheit (65°F) and eighty degrees Fahrenheit (80°F) when residents or adult hourly care participants are at home.
Thermostats must be located away from stoves, fireplaces, and furnaces.(3-28-23)
-
Plumbing. All plumbing in the home must be in good working order and comply with local and state codes. All plumbing fixtures must be maintained in good repair.(3-28-23)
-
Resident Sleeping Rooms. The provider must ensure each sleeping room occupied by a resident is:
a.Not an attic, stairway, hall, or any other space commonly used for other than bedroom purposes.
b.Not in a below-ground basement or a room located on the second story or higher unless the following conditions are met:(3-28-23)
i.The resident is able to independently recognize an emergency and self-evacuate from the sleeping room without physical assistance or verbal cueing as assessed and indicated in the resident’s plan of service; or ii. The sleeping room of a responsible and able-bodied individual living in the home is located on the same level with the resident’s sleeping room; and(3-28-23)
iii. The level of the home on which the resident’s sleeping room is located has floors, ceilings, and walls that are finished to the same degree as the rest of the home.(3-28-23)
c.Separated by walls running from floor to ceiling and has a solid door.(3-28-23)
d.Not also the provider’s sleeping room unless there is medical necessity to share the room. A relative of the provider must not share the resident’s sleeping room unless the individual is also a relative of the
e.Covered by a ceiling with a height of at least seven feet, six inches (7’6”) at its lowest point.
f.Equipped with a closet that is:(3-28-23)
i.If shared, fairly and substantially divided such that each resident’s space is clearly distinct.
ii. Equipped with a door if the resident so chooses.(3-28-23)
g.At least one hundred (100) square feet for a one (1) person sleeping room and at least one hundred and sixty (160) square feet for a two (2) person sleeping room. Free-standing closet space must be deducted from the square footage in the sleeping room.(3-28-23)
IDAPA 16.03.19.701 Manufactured and Modular Homes
- Approved Homes. A residential modular or manufactured building approved by the Idaho Division of Building Safety (DBS) or U.S. Department of Housing and Urban Development (HUD) may be approved for use as a CFH when the home meets the following:(3-28-23)
a.The manufactured or modular home meets the HUD or DBS requirements under state and federal regulations as of the date of manufacture; and(3-28-23)
b.The manufactured or modular home meets the adopted standards and requirements of the local jurisdiction in which the home is located.(3-28-23)
- Prohibited Homes. The following types of manufactured homes will not be approved by the Department for use as a CFH:(3-28-23)
a.Recreational vehicles, including fifth wheel trailers, truck campers, and commercial coaches;
b.Manufactured or modular tiny houses with 400 square feet or less of floor space, excluding lofts;
c.Tent-like structures, including yurts; and(3-28-23)
d.Manufactured or modular homes not approved by DBS or HUD or with unregulated or unapproved modifications or additions.(3-28-23)
IDAPA 16.03.19.702 (Reserved)
IDAPA 16.03.19.710 Site Requirements
The provider must ensure home and real property comply with the following:(3-28-23)
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Fire District. The home is located in a lawfully constituted fire district or the provider holds an agreement with the nearest fire district that the fire department will respond when not responding to other calls within their district.(3-28-23)
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Accessible Road. The home is always served by an all-weather road kept open to motor vehicles all year.(3-28-23)
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Emergency Medical Services. The home is accessible to emergency medical services. (3-28-23)
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Accessible to Services. The home is accessible to necessary social, medical, and rehabilitation services.(3-28-23)
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House Number. The house number is prominently displayed and plainly visible from the street.
IDAPA 16.03.19.711 (Reserved)
IDAPA 16.03.19.900 Emergency Powers of the Director
When an emergency endangers the life or safety of a resident, the Director may summarily suspend or revoke any CFH certificate. As soon thereafter as practical, the Director will provide an opportunity for a hearing under IDAPA 62.01.01, “Idaho Rules of Administrative Procedure,” and Office of Administrative Hearings General Order No. 1.
IDAPA 16.03.19.901 Enforcement Process
If the Department finds that the provider does not meet, or did not meet, a rule or statute governing CFHs, it may impose a remedy, independently or in conjunction with others, subject to these rules for notice and appeal. (3-28-23)
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Determination of Remedy. In determining which enforcement remedy(s) to impose, if any, the Department will consider the provider’s compliance history, complaints, and the number, scope, and severity of the deficiencies. Subject to these considerations, the Department may impose any of the remedies listed under Sections 909 through 915 of these rules.(3-28-23)
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Notice of Enforcement Remedy. The Department will give the provider written notice of any enforcement remedy it imposes. The notice will be mailed immediately by certified mail or delivered by personal service upon the Department’s decision. The notice will include the decision, the reason for the Department’s decision, and how the provider may appeal the decision under IDAPA 62.01.01, “Idaho Rules of Administrative Procedure,” and Office of Administrative Hearings General Order No. 1.(3-28-23)
IDAPA 16.03.19.902 Failure to Comply
The Department may impose any of the enforcement remedies under Sections 909 through 913 of these rules when it determines any of the following conditions exist:(3-28-23)
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Out of Compliance. The provider has not complied with any part of the CFH requirements within thirty (30) days of being notified by the Department in writing that the CFH is out of compliance with that requirement.(3-28-23)
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Lack of Progress. The provider has made little or no progress in correcting deficiencies within thirty (30) days from the date the Department accepted the provider’s plan of correction.(3-28-23)
IDAPA 16.03.19.903 Repeated Noncompliance
When the Department determines that a provider has repeated noncompliance with any of the CFH requirements, it may impose any of the enforcement remedies under Sections 909 through 913 of these rules.(3-28-23)
IDAPA 16.03.19.904 (Reserved)
IDAPA 16.03.19.909 Enforcement Remedy of Provisional Certification
When the Department finds that the provider is unable or unwilling to meet a CFH requirement because of conditions that are not anticipated to continue beyond six (6) months and do not jeopardize the health or safety of the residents, the Department may impose provisional certification upon the provider.(3-28-23)
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Conditions of Provisional Certification. The Department, at its discretion, may impose conditions upon the provider in conjunction with provisional certification, which conditions will be included with the notice of provisional certification, if so imposed. Conditions are imposed to ensure the provider achieves compliance with the CFH requirements and to aid the Department in monitoring the provider’s performance during the provisional certification period.(3-28-23)
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Certification or Revocation. The Department, upon review of the provider’s performance during the provisional certification period, may issue a full certificate to the provider when the Department finds that the provider has achieved compliance with the CFH requirements, or revoke the provider’s certificate if the provider failed to comply.(3-28-23)
IDAPA 16.03.19.910 Enforcement Remedy of Ban on All Admissions
All admissions to the home are banned pending satisfactory correction of all deficiencies. The ban remains in effect until the Department determines that the provider has achieved full compliance with all CFH requirements or until a substitute remedy is imposed.(3-28-23)
IDAPA 16.03.19.911 Enforcement Remedy of Ban on Admissions of Resident with Specific
DIAGNOSIS.
Any admission to the home of a prospective resident with a specific diagnosis may be banned when the Department has determined the provider lacks the skill or ability to provide adequate care to such a resident under Section 170 of these rules.(3-28-23)
IDAPA 16.03.19.912 Enforcement Remedy of Summary Suspension and Transfer of Resident
The Department may summarily suspend the provider’s certificate and transfer the resident when convinced by a preponderance of the evidence that the resident’s health and safety are in immediate jeopardy. In such a transfer, the provider must:(3-28-23)
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Return Resident's Possessions. Comply with Subsection 261.03 of these rules; and (3-28-23)
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Refund Prepaid Charges. Refund to the resident a prorated amount restoring prepaid charges for room, board, and care for the month within fourteen (14) calendar days of the Department’s notice of summary suspension.(3-28-23)
IDAPA 16.03.19.913 Enforcement Remedy of Revocation of Certificate
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Revocation of the Certificate. The Department may institute a revocation action when persuaded by a preponderance of the evidence that the provider is not in compliance with the CFH requirements. (3-28-23)
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Additional Causes for Revocation. The Department may also revoke any certificate for any of the following causes:(3-28-23)
a.The provider willfully misrepresented or omitted any of the following:(3-28-23)
i.Information pertaining to the continuing certification of the CFH; or(3-28-23)
ii. Information pertaining to an investigation that obstructs the certifying agent's collection of evidence.(3-28-23)
b.When persuaded by a preponderance of the evidence that conditions exist endangering the health or safety of any resident;(3-28-23)
c.An act adversely affecting the welfare of any resident is being or has been permitted, aided, performed, or abetted by the provider or staff. Such acts may include neglect, physical, mental, or sexual abuse, and exploitation;(3-28-23)
d.The provider has demonstrated or exhibited a lack of sound judgment essential to the operation and management of a CFH;(3-28-23)
e.The provider has violated any condition of a provisional certificate in effect upon the CFH;
f.The provider has been cited with one (1) or more core issue deficiencies;(3-28-23)
g.An accumulation of minor violations that, when taken as a whole, constitute inadequate care;
h.Repeat violations of any of the CFH requirements;(3-28-23)
i.The provider lacks the ability to properly care for the resident, as required by the CFH requirements, or as directed by the Department;(3-28-23)
j.The provider refuses to allow any certifying agent or other representative of the Department or protection and advocacy agency representative full access to the home, records, or the residents according to their respective authority to access such;(3-28-23)
k.The provider fails to pay the certification fee under Section 109 of these rules.(3-28-23)
IDAPA 16.03.19.914 (Reserved)
IDAPA 16.03.19.915 Transfer of Resident
The Department may require transfer of a resident from a CFH to an alternative placement on the following grounds:
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Violation of Laws or Rules. As a result of a violation of a provision of the CFH requirements, the provider is unable or unwilling to provide an adequate level of meals, lodging, personal assistance, or supervision to the resident; or(3-28-23)
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Violation of Resident’s Rights. As a result of a violation of the resident’s rights under Section 39- 3516, Idaho Code, or Section 200 of these rules.(3-28-23)
IDAPA 16.03.19.916 (Reserved)
IDAPA 16.03.19.950 Right to Sell
Nothing contained in these rules limits the right of any homeowner to sell, lease, mortgage, or close any CFH under applicable laws.(3-28-23)
IDAPA 16.03.19.951 (Reserved)
16.06.01 Child and Family Services
IDAPA 16.06.01.000 Legal Authority
These rules are established to govern the statewide provision of services associated with child protection, foster care, and adoption under the following statutes: Sections 16-1601, 16-1629, 16-1623, 16-2001, 16-2102, 16-2406, 16- 2423, and 16-2433, 39-1209 through 1211, 39-5603, 39-7501, 56-202(b), 56-204A, 56-204B, 56-803, 56-1003, 56- 1004, and 56-1007, Idaho Code, and Tittle 56, Chapter 27, Idaho Code.(7-1-25)
IDAPA 16.06.01.001 Scope
- Scope. These rules are established to govern the statewide provision of:(3-15-22)
a.Services associated with child protection, alternate care, and adoption; and(3-15-22)
b.As resources are available, services aimed at preventing child abuse, neglect, and abandonment.
IDAPA 16.06.01.002 (Reserved)
IDAPA 16.06.01.009 Criminal History and Background Check Requirements
- Compliance With Department Criminal History and Background Check. All current Department employees, applicants, transfers, reinstated former employees, student interns, contract employees, Certified Adoption Professionals, volunteers, and others assigned to programs that involve direct contact with children or vulnerable adults as described in Section 39-5302, Idaho Code, must comply with the provisions in IDAPA 16.05.06, “Criminal History and Background Checks.”(3-15-22)
IDAPA 16.06.01.010 Definitions and Abbreviations a Through E
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Adoption Services. Protective services through which a child is provided with a permanent home, under new legal parentage, including transfer of the mutual rights and responsibilities that prevail in the parent-child relationship.(3-15-22)
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Alternate Care. Temporary living arrangements, when necessary for a child to leave their own home, through a variety of foster care, respite care, residential treatment, and institutional resources, under the protections established in P.L. 96-272, the federal “Adoption Assistance and Child Welfare Act of 1980” as amended by Public Law 105-89, the Adoption and Safe Families Act of 1997 (ASFA), Title 16, Chapter 16, Idaho Code, and the Indian Child Welfare Act (ICWA), 25 U.S.C. Sections 1901-1963.(7-1-25)
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Child’s Plan. A federally required component of the family case plan for a child in alternate care.
The child’s plan contains elements related to reasonable efforts, the family's plan, the child's alternate care provider, compelling reasons for not terminating parental rights, Indian status, education, medical, and other information important to the day-to-day care of the child.(7-1-25)
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Board. The Idaho State Board of Health and Welfare.(3-15-22)
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Case Management. A change-oriented service to families that ensures and coordinates ongoing assessment, family case planning, treatment, permanency, planning, child safety, advocacy, documentation, and timely closure of a case.(7-1-25)
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Child and Family Services (CFS). Those programs and services provided to families and children, administered by the department in accordance with these rules.(7-1-25)
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Child Protective Services. Services provided in response to potential, alleged, or actual abuse, neglect, or abandonment of individuals under the age of eighteen (18) in accordance with the provisions Title 16, Chapter 16, Idaho Code.(7-1-25)
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Compact Administrator. The individual designated to coordinate interstate transfers of persons requiring special services in accordance with the provisions of Title 16, Chapter 19, Idaho Code; Title 16, Chapter 21, Idaho Code; or Title 39, Chapter 75, Idaho Code.(7-1-25)
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Daycare. Care and supervision provided for compensation during part of a twenty-four (24) hour day, for a child or children not related by blood or marriage to the person or persons providing the care, in a place other than the child’s or children’s own home or homes.(7-1-25)
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Deprivation. One of the factors used in determining Aid to Families with Dependent Children -- Foster Care (AFDC-FC) eligibility for children in foster care. Deprivation is a lack of, or interruption in, the maintenance, physical care, and parental guidance a child ordinarily receives from one (1) or both parents. A child is deprived by the continued absence of a parent, incapacity of a parent, death of a parent, unemployment or underemployment of the principal wage earner parent.(3-15-22)
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Director. The Director of the Idaho Department of Health and Welfare or their designee. (3-15-22)
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Extended Family Member of an Indian Child. As defined by the law; or custom of the Indian child’s tribe or, in the absence of such law or custom, a person who has reached the age of eighteen (18) and who is the Indian child’s grandparent, aunt or uncle, brother or sister, brother-in-law or sister-in-law, niece or nephew, first or second cousin, or stepparent.(7-1-25)
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Extended Foster Care. A court order or voluntary case extending foster care placement services and authority for individuals between the ages of eighteen (18) and twenty-one (21) years to help such person achieve a successful transition to adulthood, providing they were in the custody of the department until their eighteenth birthday and must meet the criteria set forth in 42 25 U.S.C. 675(8)(B)(iv).(7-1-25)
IDAPA 16.06.01.011 Definitions and Abbreviations F Through K
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Family. Parent(s), legal guardian(s), related individuals including birth or adoptive immediate family members, extended family members and significant other individuals, who are included in the family plan.
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Family Assessment. An ongoing process based on information gained through a series of meetings with a family to gain mutual understanding of strengths and resources that can support them in creating long-term solutions related to identified safety threats and needs to support family integrity, unity, and the ability to care for their children.(7-1-25)
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Family Case Record. Compilation of all documentation relating to a family, including legal documents, identifying information, and evaluations.(7-1-25)
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Case Plan. A document developed with the family, to guide the provision of services. The plan identifies who does what, when, how, and why and incorporates specific plans for case participants. If the family includes an Indian child, or child’s tribe, tribal elders or leaders are consulted early in the plan development.(7-1-25)
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Family Services Worker. Case carrying personnel working in regional Child and Family Services Programs.(7-1-24)
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Field Office. A Department of Health and Welfare service delivery site.(3-15-22)
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Independent Living Services. Provided to eligible foster or former foster youth, ages fourteen (14) to twenty-three (23), designed to support a successful transition to adulthood.(7-1-25)
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Indian. Any person who is a member of an Indian tribe or who is an Alaska Native and a member of a Regional Corporation as defined in 43 U.S.C. 1606.(3-15-22)
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Indian Child. Any unmarried person who is under the age of eighteen (18) and is either: (7-1-25)
a.A member of an Indian tribe; or(3-15-22)
b.Eligible for membership in an Indian tribe and is the biological child of a member of an Indian tribe.(7-1-25)
- Indian Child's Tribe.(3-15-22)
a.The Indian tribe in which an Indian child is a member or eligible for membership, or (3-15-22)
b.In the case of an Indian child who is a member of or eligible for membership in more than one (1) tribe, the Indian tribe with which the Indian child has the more significant contacts.(3-15-22)
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Indian Tribe. Any Indian Tribe, band, nation, or other organized group or community of Indians recognized as eligible for the services provided to Indians by the Secretary because of their status as Indians, including any Alaska Native village as defined in 43 U.S.C. 1602(c).(3-15-22)
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Interstate Compact on the Placement of Children (ICPC). Interstate Compact on the Placement of Children (ICPC) in Title 16, Chapter 21, Idaho Code, ensures that the jurisdictional, administrative, and human rights obligations of interstate placement or transfers of children are protected.(3-15-22)
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Kin. Individuals who do not meet the definition of relative in Section 16-1602, Idaho Code, who have a significant, family-like relationship with a child. Kin may include extended family members, godparents, close family friends, clergy, teachers, and members of an Indian child’s tribe, and foster parents who have a significant relationship with the child for at least six (6) months.(7-1-25)
IDAPA 16.06.01.012 Definitions and Abbreviations L Through R
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Legal Guardianship. A judicially-created relationship, in accordance with Title 15, Chapter 5, Part 2, Idaho Code, including one made by a tribal court, between a child and a relative or non-relative. (3-15-22)
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Parent. A person who, by birth or through adoption, is considered legally responsible for a child.
The term “legal guardian” is not included in the definition of parent.(3-15-22)
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Permanency Planning. The identification of programs, services, and activities designed to establish permanent home and family relationships for children.(7-1-25)
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Relative. A child’s child’s grandparent, great grandparent, aunt, great aunt, uncle, great uncle, brother-in-law, sister-in-law, first cousin, sibling and half sibling by blood, marriage, or adoption.(7-1-25)
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Relative Guardian. A relative who is appointed a child’s legal guardian in accordance with Title 15, Chapter 5, Part 2, Idaho Code, including a guardianship established by a tribal court.(3-15-22)
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Reservation. Indian country as defined in 18 U.S. Code Section 1151 and any lands, not covered under such section, title to which is held by the United States in trust for the benefit of any Indian tribe or individual or held by any Indian tribe or individual subject to a restriction by the United States against alienation. (7-1-25)
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Respite Care. Short term, temporary care of a child by a licensed or agency-approved caregiver different from their usual caregiver. Respite care ranges from one (1) partial day up to fourteen (14) consecutive days.
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Responsible Party. A department social worker, clinician, family services worker, or services provider who maintains responsibility and authority for case planning and case management.(7-1-25)
IDAPA 16.06.01.013 Definitions and Abbreviations S Through Z
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Safety Assessment. A process and standardized tool for contact between a family services worker and a family to objectively determine if safety threats, or immediate service needs exist that require further Child and Family Services response.(3-15-22)
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Safety Plan. Plan developed by the department and a family that assures the immediate safety of a child.(7-1-25)
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Sibling. One (1) of two (2) or more persons who shares the same biological or adoptive mother or father, or both. Siblings may be full-siblings or half-siblings. Siblings include those children who would be considered a sibling if not for the disruption in parental rights due to termination of parental rights or the death of a parent.(3-15-22)
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Tribal Court. A court with jurisdiction over child-custody proceedings and which is either a Court of Indian Offenses, a court established and operated under the code or custom of an Indian tribe, or any other administrative body of a tribe vested with authority over child custody proceedings.(7-1-25)
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Voluntary Services Agreement. A written and executed agreement between the department and parents or legal guardians regarding the provision of voluntary foster care placement of a child and includes areas of concern, desired results, and task responsibility.(7-1-25)
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Withholding of Medically Indicated Treatment. Withholding of medically indicated treatment as defined by 42 U.S.C. 5106g(a)(5).(7-1-25)
IDAPA 16.06.01.014 (Reserved)
GENERAL REQUIREMENTS AND SERVICES
(Sections 020-239)
IDAPA 16.06.01.020 General Requirements Applicable to All Child and Family Services
PROGRAMS.
- Initiating Child and Family Services. Child and Family Services are initiated upon referral for services that the program is legally mandated to provide or after completion of a written request for services. Efforts will be made to identify any Indian children in the family and all possible tribes in which a child may be a member or eligible for membership.(7-1-25)
a.A screening is conducted to determine service needs and safety threats that can be addressed through Child and Family Services.(7-1-25)
b.Upon referral or application for services, the family services worker must inform the family that:
i.They have the right to accept or reject services offered by the department, except those services imposed by law or by a court order;(7-1-25)
ii. Fees may be charged for certain services, and that the parent(s) has the financial responsibility for the child in care;(7-1-25)
iii. They have the right to pursue an administrative appeal of any decision of Child and Family Services relating to them, including any decision not to provide services or to discontinue services; the department’s failure to act upon a referral or request for services within thirty (30) days; or a decision to remove a child from an alternate care placement unless court-ordered or court-authorized.(7-1-25)
- Individual Authorized to Request Voluntary Services. Requests for voluntary services must be made by a parent or an authorized representative.(7-1-25)
IDAPA 16.06.01.021 (Reserved)
IDAPA 16.06.01.030 Core Child and Family Services
In addition to other services included in this chapter, the following state and federally mandated core services are provided to eligible youth and/or families through the Child and Family Services Program:(7-1-25)
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Assessment and Safety/Case Planning Services. A family assessment in which the safety threats to the child, and the family's concerns, strengths, and resources are identified. Assessment results inform the development and implementation of the case plan.(7-1-25)
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Prevention Services. Evidence-based services that support children and families and are designed to reduce the risk of child abuse, neglect, or abandonment.(4-6-23)
a.These services are provided in the Family First Prevention Services Act (Public Law 115-123) under the categories of mental health, substance use prevention and treatment, and in-home parent skill-based programs and services. Additional services can be implemented through community education, and partnerships with other community agencies such as schools and courts.(4-6-23)
b.The Department sets the maximum hourly or flat rates for Prevention Services covered by Title IV- E federal funding and are based on the cost for services. When services are provided by private providers, payment must be made according to a contract authorized by the Child and Family Services Program Manager, based on the cost for services to be provided. Current information about services and rates can be obtained from Child and Family Services website.(4-6-23)
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Alternate Care (Placement) Services. Temporary living arrangements outside of the family home for minors who are placed in the care or custody of the department under Title 16, Chapter 16, Idaho Code. The department arranges and finances, in full or in part, out-of-home placements.(7-1-25)
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Interstate Compact on Out-of-State Placements. Where necessary to encourage all possible positive contacts between a child in alternate care with relatives, kin, and extended family, placement with families outside the state of Idaho will be considered. The department may contract with a residential facility out-of-state if it best serves the needs of the child. Placement will be coordinated with the respective interstate compact administrator according to the provisions of Title 16, Chapter 21, Idaho Code.(7-1-25)
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Independent Living. Services, including assessment and planning, provided to eligible youth and young adults to promote self-reliance and successful transition to adulthood.(7-1-25)
a.Eligibility - Current foster youth or young adults will:(7-1-25)
i.Be fourteen (14) to twenty-one (21) years of age;(3-15-22)
ii. Currently be under department or tribal care and placement authority established by a court order or voluntary agreement with the youth’s family, or be under a voluntary agreement for continued care if the youth is between eighteen (18) and twenty-one (21) years of age; and(7-1-25)
b.Eligibility - Youth or young adults formally in foster care will:(7-1-25)
i.Be (23) years of age; and(7-1-25)
ii. Have been under department or tribal care and placement authority established by a court order or voluntary agreement with the youth’s family, or under a voluntary agreement for continued care after the youth has reached eighteen (18) years of age; and(7-1-25)
iii. Have been placed in foster care or similar eligible setting for a minimum of ninety (90) days total after reaching sixteen (16) years of age or have aged out of foster care; or(3-15-22)
iv. Be eighteen (18) to twenty-three (23) years of age, provide verification of meeting the Independent Living eligibility criteria in another state, and currently be a resident of Idaho.(3-15-22)
c.Eligibility Limit. Once established as in Subsection 030.09.b. in this rule, a youth’s eligibility is maintained up to their twenty-third birthday, regardless of whether they continue to be the responsibility of the Department, tribe, or be in foster care.(3-15-22)
- Adoption Services. Services designed to promote and support the permanency of children in foster care through adoption. This involves the legal and permanent transfer of parental rights and responsibilities to the family assessed as the most suitable to meet the needs of the individual child.(7-1-25)
IDAPA 16.06.01.031 (Reserved)
IDAPA 16.06.01.050 Protections and Safeguards for Children and Families
- Reasonable Efforts. Services offered or provided to a family intended to prevent or eliminate the need for removal of the child from the family, to reunify a child with their family, and to finalize a permanent plan.
The following efforts must be made and specifically documented by the Department in reports to the court. The court will make the determination of whether or not the Department's efforts were reasonable.(3-15-22)
a.Efforts to prevent or eliminate the need for a child to be removed from their home; (3-15-22)
b.Efforts to return a child home are not required due to a judicial determination of aggravated circumstances; and(3-15-22)
c.Efforts to finalize a permanent plan, so that each child in the Department's care will have a family with whom the child can have a safe and permanent home.(3-15-22)
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Active Efforts. Efforts beyond reasonable efforts required under ICWA to provide remedial services and rehabilitative programs designed to prevent the breakup of an Indian family, or to reunify an Indian family. Active efforts must include contacts and work with an Indian child’s tribe.(7-1-25)
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Compliance with the Indian Child Welfare Act of 1978.(7-1-25)
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Legal Requirements for Indian Children. When there is reason to believe that a child is an Indian child, notice of the pending proceeding must be sent according to the notice provisions specified in Section 051 of these rules. Notice must also include notice of the tribe’s right to intervene; their right to twenty (20) days additional time to prepare for the proceeding; the right to appointment of counsel if the parent(s) or Indian custodian(s) is indigent; and the right to examine all documents filed with the court upon which placement may be based. (3-15-22)
05.Visitation for Child’s Parent(s) or Legal Guardian(s). The department should determine the scope, duration, and manner of visitation that best promotes the best interest of the child and ensures that visitation does not impair the physical or mental health of a child. In-person visitation arrangements between a child and a parent who has been substantiated at a Level One or Two by the department for one of the following: sexual abuse, sexual exploitation, or physical abuse will not be granted unless it is in the best interest of the child and the child’s physical and/or mental health will not be impaired. If in-person visitation is granted, it will only occur under the following conditions:(7-1-25)
a.Approved by a program manager, after consultation with the child’s guardian ad litem, where applicable, who concludes that in-person visitation is in the best interest of the child and that the child’s physical and/ or mental health will not be impaired;(7-1-25)
b.Under conditions set forth by the program manager. Conditions of supervised visitation will include the following:(7-1-25)
i.The parent will not be left alone with the child for any reason, including restroom breaks; (7-1-25)
ii. For sexual abuse and exploitation cases, the parent will not allow the child to sit on his or her lap;
iii. The parent will not be allowed to engage in secret conversations or other communication that cannot be monitored in real time;(7-1-25)
c.The best interest decision and visit conditions are documented and explained in writing. (7-1-25)
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Notification of Change in Visitation. Notification to the child's parent(s) or legal guardian(s) if there is to be a change in their visitation schedule with their child or ward in foster care.(7-1-25)
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Qualified Expert Witness-(QEW) under ICWA. The testimony of an expert witness is required at the hearing in which an Indian child is placed in state custody, typically the adjudicatory, and at the hearing for termination of parental rights. A QEW must be qualified to testify regarding whether the child’s continued custody by the parent or Indian custodian is likely to result in serious emotional or physical damage to the child and should be qualified to testify as to the prevailing social and cultural standards of the Indian child’s Tribe. The department, the court, or any party may request the assistance of the Indian child’s Tribe or the Bureau of Indian Affairs office serving the Indian child’s Tribe in locating persons qualified to serve as expert witnesses. A QEW in order of preference is:
a.A member of the Indian child’s Tribe;(7-1-25)
b.A member of the Tribe of the Indian child’s parent;(7-1-25)
c.A descendant of the Indian child’s Tribe;(7-1-25)
d.A member of a tribe recognized as sharing the same ethnicity, language, territory, traditions, or customs as the child’s tribe;(7-1-25)
e.A member of any federally recognized tribe;(7-1-25)
f.An individual not meeting the definitions in (a) through (e) who is designated by the child’s Tribe as qualified to testify to the prevailing social and cultural standards of the Indian child’s Tribe.(7-1-25)
g.The family services worker regularly assigned to the Indian child may not serve as a QEW in proceedings concerning the child.(7-1-25)
- Compliance with Requirements of the Multiethnic Placement Act of 1994 (MEPA) as Amended by the Interethnic Placement (IEPA) of 1996.(7-1-25)
a.Nothing in MEPA/IEP is to be construed to affect the application of the Indian Child Welfare Act of 1978.(3-15-22)
- Family Decision-Making and Plan Development.(3-15-22)
a.A case plan will be completed within thirty (30) days of the date the case was opened. (7-1-25)
b.Families will be given ample opportunity to participate in the identification of areas of concern, their strengths, and developing service goals and tasks. The family plan and any changes to it must be signed and dated by the family. If the family refuses to sign the plan, the reason for their refusal will be documented on the plan.
c.Plans are to be reviewed with the family no less frequently than once every three (3) months. When there are major changes to the plan including a change in the long term goal, the family plan must be renegotiated by the department and the family as well as signed by the family. A new plan must be negotiated at least annually.
- Compelling Reasons. Reasons why the parental rights of a parent of a child in the department's care and custody should not be terminated when the child has been in the custody of the department for fifteen (15) out of the most recent twenty-two (22) months.(7-1-25)
a.These reasons must be documented in the Alternate Care Plan, in a report to the court, and the court must make a determination if the reasons are sufficiently compelling.(3-15-22)
b.A compelling reason must be documented when a child's plan for permanency is not adoption, guardianship, or return home.(3-15-22)
c.When compelling reasons are not appropriate, the petition for termination of parental rights must be filed by the end of the child's fifteenth month in foster care.(3-15-22)
- Permanency Preferences. The following preferences will be considered in the order listed below when recommending and making permanency decisions:(7-1-25)
a.Return home if safe to do so;(3-15-22)
b.Adoption or legal guardianship by a relative or kin;(3-15-22)
c.Adoption or legal guardianship by non-relative;(3-15-22)
d.Another planned permanent living arrangement such as long-term foster care.(3-15-22)
IDAPA 16.06.01.051 Notice Requirements for Icwa
- Notice of Pending Proceedings -- Who is Notified. When there is reason to believe that a child is an Indian child, the initial and any subsequent Notice of Pending Proceedings must be sent to the Indian child’s parent(s), custodian(s), and tribe. Notices of Pending Proceedings must be sent to the ICWA Designated Agent for the child’s tribe via Registered Mail, Return Receipt Requested. All Notices of Pending Proceedings must be received by the child’s parent(s), Indian custodian(s) and tribe at least 10 (ten) days before the proceeding is scheduled to occur.
Returned receipts are to be kept in the child’s file and made available for review by the court.(3-15-22)
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Rights Under a Notice of Pending Proceedings. Notices of Pending Proceedings must also include notice of the tribe’s right to intervene; their right to twenty (20) additional days to prepare for the proceedings; the right to appointment of counsel if the parent(s) or Indian custodian(s) are indigent; and the right to examine all documents filed with the court upon which placement may be based.(3-15-22)
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Notice of Pending Proceedings--When Identity or Location of Parent(s), Indian Custodian(s), or Tribe is Unknown. If the identity or location of the parent(s) or Indian custodian(s) or the tribe is unknown, the Notice of Pending Proceedings must be sent to the Secretary of the Interior by certified mail with a return receipt requested at the following address: Department of the Interior, Bureau of Indian Services, Division of Human Services, Code 450, Mail Stop, 1849 C Street N.W., Washington, D.C. 20240.(3-15-22)
IDAPA 16.06.01.052 (Reserved)
IDAPA 16.06.01.060 Family Case Records
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Electronic and Physical Files. The department will maintain an electronic file and a physical file containing information on each family receiving services. The physical file will contain non-electronic documentation such as originals or original copies of all court orders, birth certificates, social security cards, and assessment information that is original outside the department.(7-1-25)
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Storage of Records. All physical family case records must be stored in a secure file storage area, away from public access and retained not less than five (5) years after the case is closed, after which they may be destroyed.(3-15-22)
a.Exception for Adoption Records. Complete family case records involving adoptive placements must be forwarded to the department’s central adoption unit for permanent storage.(7-1-25)
b.Exception for Case Records Involving an Indian Child. A case record involving an Indian child must be available at any time at the request of an Indian child’s tribe or the Secretary of the Interior.(3-15-22)
IDAPA 16.06.01.061 (Reserved)
ALTERNATE (OUT-OF-HOME) CARE
(Sections 400-424)
IDAPA 16.06.01.400 Authority for Alternate Care Services
Upon approval of the regional Child and Family Services Program Manager or their designee, the department may provide or purchase alternative care under the following conditions:(7-1-25)
- Department Custody. When the child is in the legal custody or guardianship of the department; or 02. Voluntary Placement. Agreement with the parent(s) or legal guardian(s) after the parent(s) or legal guardian(s) request assistance from the agency due to circumstances that interfere with their ability to meet the needs of or they are no longer able to maintain a child in their home and it is in the best interest of the child for an out of home placement with case planning services to address the family situation. Young adults who exited foster care at age 18, who are not yet 21, may also enter a voluntary placement under extended foster care.(7-1-25)
a.A case plan and an out-of-home placement agreement must be developed between the Department and the family. The case plan will identify areas of concern, goals, desired results, time frames, tasks and task responsibilities. The out-of-home placement agreement will include the terms for reimbursement of costs with any necessary justification for deviation from Child Support guidelines.(7-1-25)
b.A voluntary agreement for out-of-home placement entered into between the department and the parent(s) or legal guardian(s) of a minor child that specifies the legal obligations of all parties and may be revoked at any time by the child's parent(s) or legal guardian(s) and the child must be returned to the parent or legal guardian unless a court determines that the return of the child would be contrary to the child’s best interest.(7-1-25)
c.A contract between the department and the service provider, if applicable, must also be in effect.
d.When seeking federal funding the department will comply with the Social Security Act section 472.
e.Indian child. Where any parent or Indian custodian voluntarily consents to a foster care placement, such consent shall not be valid unless executed in writing and recorded before a judge of a court of competent jurisdiction and accompanied by the presiding judge’s certificate that the terms and consequences of the consent were fully explained in detail and were fully understood by the parent or Indian custodian. The court shall also certify that either the parent or Indian custodian fully understood the explanation in English or that it was interpreted into a language that the parent or Indian custodian fully understood. Any consent given prior to, or within ten days after, birth of the Indian child shall not be valid. Any parent or Indian custodian may withdraw consent to a foster care placement under State law at any time and, upon such withdrawal, the child shall be returned to the parent or Indian custodian unless a court determines that the return of the child would be contrary to the child’s best interest. (7-1-25)
IDAPA 16.06.01.401 Considerations for Placement in Alternate Care
The department will make timely and ongoing efforts to identify and notify, both verbally and in writing individuals identified below of the potential imminent placement and the requirements for consideration as a placement resource.
The department will comply with 16-1629(11), Idaho Code, to make reasonable efforts to place the child in the least restrictive environment to the child consistent with the best interest and special needs of the child and follow placement priority:(7-1-25)
- Family Assessment. Relatives and non-relatives must comply with IDAPA 16.06.02 as a condition of licensed placement.(7-1-25)
IDAPA 16.06.01.402 Involuntary Placement of Indian Children
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Involuntary. Placement of an Indian child in foster care must be based upon clear and convincing evidence, including information from a qualified expert witness that active efforts were made to prevent the Indian child’s placement or are preventing reunification.(7-1-25)
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Notice. Notice to the child’s Tribe will be made as stated in Subsection 05.01 of these rules.
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Accepted. An Indian child accepted for foster care or proadoptive placement shall be placed in the least restrictive setting which most approximates a family and in which his special needs, if any, may be met. The child shall also be placed within reasonable proximity to his or her home, taking into account any special needs of the child.(7-1-25)
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Placement. In any foster care or preadoptive placement of an Indian child where the child’s Tribe has not established a different order of preference, preference must be given, in descending order, as listed below, to the placement of the child with:(7-1-25)
a.Extended Family. A member of the Indian child’s extended family;(3-15-22)
b.Foster Home Approved by Tribe. A foster home licensed approved, as specified by the Indian child’s tribe;(7-1-25)
c.Licensed Indian Foster Home. An Indian foster home licensed or approved by an authorized non- Indian licensing authority; or(3-15-22)
d.Indian Institution. An institution for children approved by an Indian tribe or operated by an Indian organization which has a program suitable to meet the child’s needs.(7-1-25)
IDAPA 16.06.01.403 Date a Child Entered Foster Care
A child is considered to have entered foster care on the date the child is actually removed from their home. All foster care benefits and eligibility determinations must be based on this date. However for the purpose of funding the department will follow requirements included in the Social Security Act Section 475.(7-1-25)
IDAPA 16.06.01.404 Foster Care Goal
It is the goal of the Department that not more than twenty-five percent (25%) of foster youth will be in foster care longer than twenty-four (24) months. The Department will monitor this goal annually.(3-15-22)
IDAPA 16.06.01.405 Alternate Care Case Management
Case management must continue while the child is in alternate care and must ensure the following:(3-15-22)
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Preparation Provided to the Placement. Preparing a child for placement in alternate care is the joint responsibility of the child’s family, the child (when appropriate), the family services worker, and the alternate care provider.(7-1-25)
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Information for Alternate Care Provider. The Department and the family have informed the alternate care provider of their roles and responsibilities in meeting the needs of the child including:(3-15-22)
a.Any medical, health and dental needs of the child including the names and address of the child’s health and educational providers, a record of the child’s immunizations, the child’s current medications, the child’s known medical problems, and any other pertinent health information concerning the child;(3-15-22)
b.The name of the child’s doctor;(3-15-22)
c.The child’s current functioning and behaviors;(3-15-22)
d.A copy of the child's portion of the case plan including any visitation arrangements; (7-1-25)
e.The case history of the child, including the reason the child came into foster care, the child’s legal status, and the permanency goal for the child;(3-15-22)
f.A history of the child’s previous placements and reasons for placement changes, excluding information that identifies or reveals the location of any previous alternate care providers without their consent;
g.The child’s cultural and racial identity;(3-15-22)
h.Any educational, developmental, or special needs of the child;(3-15-22)
i.The child’s interest and talents;(3-15-22)
j.The child’s attachment to current caretakers;(3-15-22)
k.The individualized and unique needs of the child;(3-15-22)
l.Procedures to follow in case of emergency; and(3-15-22)
m.Any additional information, that may be required by the terms of the contract with the alternate care provider.(3-15-22)
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Consent for Medical Care. Whenever possible the parent(s) or legal guardian(s) should sign for medical, dental, or mental health appointments. The department will follow Section 16-1602(29), Idaho Code, when parent(s) or legal guardian(s) are unavailable and Section 16-1627, Idaho Code, when authorization for emergency medical treatment is needed.(7-1-25)
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Contact with Child. The family, the family services worker, and the alternate care provider will establish a schedule for frequent and regular visits with the child by the family and by the family services worker or designee.(7-1-25)
a.Face-to-face contact with a child by the assigned family services worker must occur at least monthly or more frequently depending on the needs of the child or the provider, or both, and the stability of the placement. Face-to-face contact may be made in settings other than where the child resides as long as contact between the assigned family services worker and the child occurs where the child resides a minimum of once every sixty (60) days.(7-1-24)
b.The department will assess for possible abuse, neglect, or abandonment of children in alternate care.(7-1-25)
c.Frequent and regular contact between the child and parents and other family members will be encouraged and facilitated unless it is specifically determined not to be in the best interest of the child. Such contact will be face-to-face if possible, with this contact augmented by telephone calls, written correspondence, pictures, and the use of video and other technology as may be relevant and available.(3-15-22)
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Discharge Planning. Planning for discharge from alternate care are developed with all concerned parties. Discharge planning will be initiated at the time of placement and completed prior to the child’s return home or to the community.(3-15-22)
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Transition Planning. Planning for discharge from alternate care into a permanent placement are developed with all concerned parties. Discharge planning will be initiated at the time of placement and completed prior to the child’s return home or to the community.(3-15-22)
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Financial and Support Services. As part of the discharge planning, Departmental resources are coordinated to expedite access to Department financial and medical assistance and community support services.
IDAPA 16.06.01.406 (Reserved)
IDAPA 16.06.01.422 Alternate Care Planning
The elements of alternate care planning for the family and the child are mandated by the provisions of Sections 471(a)(16), 475(1), and 475(5)(A) and (D) of the Social Security Act and Section 16-1621, Idaho Code. (7-1-25)
IDAPA 16.06.01.423 (Reserved)
ELIGIBILITY AND FUNDING INFORMATION
(Sections 425-441)
IDAPA 16.06.01.425 Title Iv-E Eligibility
The state will claim Title IV-E funding for foster care placement costs as allowed within the Social Security Act, sections 421, 422, 423, 424, 428, 471, 472, 473, 474, and section 475 (Effective February 9, 2018). Claims for Title IV-E maintenance may begin as early as the first day of placement in the month in which all initial Title IV-E eligibility factors are met.(7-1-25)
IDAPA 16.06.01.426 (Reserved)
IDAPA 16.06.01.428 Custody and Placement
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Interstate Placements. In interstate placements, a child may be placed with an approved unlicensed relative when delaying the placement would be harmful to the child’s well-being. In those cases, a subsequent request for foster care licensure will be made through the Interstate Compact on the Placement of Children.(7-1-25)
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Intrastate Placements That Become Interstate Placements. If a foster care placement that was initially intrastate becomes an interstate placement because the family with whom the child is placed relocates to another state, a request for foster care licensure will be made through the Interstate Compact on the Placement of Children immediately upon the decision to move the child.(7-1-25)
IDAPA 16.06.01.429 (Reserved)
IDAPA 16.06.01.430 Ongoing Eligibility
To continue eligibility for Title IV-E, the department will complete an annual redetermination to assure that the court has determined that the department has made reasonable efforts to finalize a permanency plan for the child within twelve (12) months of the date the child is considered to have entered foster care and at least once every twelve (12) months thereafter while the child is in foster care.(7-1-25)
IDAPA 16.06.01.431 (Reserved)
IDAPA 16.06.01.432 Medicaid Eligibility for Child in Foster Care
For Title XIX Medicaid eligibility for a foster child, please refer to IDAPA 16.03.01,.(7-1-25)
IDAPA 16.06.01.433 Income, Benefits and Savings of Children in Foster Care
FACS will apply for income or benefits including social security, tribal benefits, or estates of deceased parents. The payee will be DHW-FACS-CWFT.(7-1-25)
IDAPA 16.06.01.434 Forwarding of Benefits
Child Support Services will be notified when a child goes on a trial home visit and be provided the name and address of the responsible party to discontinue accrual of child support owed to the state.(7-1-25)
- Return to Foster Care. If the child returns to foster care, the Department’s Child Support Unit must be notified immediately of the correct payee.(3-15-22)
IDAPA 16.06.01.435 (Reserved)
IDAPA 16.06.01.436 Parental Financial Support for Children in Alternate Care
When a child enters care if there is a child support order already in effect for that child, the child support funds will be redirected to the department to contribute to the cost of the child’s care. If there is no child support order already in effect, a new child support case will not automatically be opened. The department may initiate a child support case for a child in care, in its discretion, if the department concludes that doing so is in the best interest of the child. This provision does not limit the authority of the department to initiate or otherwise litigate child support on other grounds.
IDAPA 16.06.01.437 Accounting and Reporting
The Department’s Division of Family and Community Services, Child Welfare Funding Team must account for the receipt of funds and develop reports showing how much money has been received and how it has been utilized.
IDAPA 16.06.01.438 Support Agreement for Voluntary Placements
If the placement is voluntary, the parent(s) must sign an agreement that specifies the amount of support to be paid, when it is to be paid to the payee, and the address to which it is to be paid.(3-15-22)
IDAPA 16.06.01.439 (Reserved)
IDAPA 16.06.01.440 Insurance Coverage
The parent(s) or legal guardian(s) must inform the Department of all insurance policies covering the child, including names of carriers, and policy or subscriber numbers. If medical, health, and dental insurance coverage are available for the child, the parent(s) must acquire and maintain such insurance.(3-15-22)
IDAPA 16.06.01.441 Referral to Child Support Services
The Department will refer the parent(s) to the Bureau of Child Support Services for support payment arrangements.
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Assignment of Child Support. The Department through the Bureau of Child Support Services will secure assignment of any support due to the child while in alternate care. Social Security and Supplemental Security Income benefits are specifically aimed at meeting the child’s needs and therefore will follow the child in placement and the Department must request to be named payee for all funds for placements extending over thirty (30) days.
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Collection of Child Support. The Department must take action to collect any child support ordered in a divorce or custody decree.(7-1-25)
MEDICAL AND DENTAL FOR CHILDREN IN OUT-OF-HOME CARE
(Sections 442-479)
IDAPA 16.06.01.442 Medicaid for Children in Alternate Care
Every child placed in alternate care will receive a medical card each month.(3-15-22)
IDAPA 16.06.01.443 Epsdt Screening
Children in alternate care will receive the Early Periodic Screening, Diagnosis and Treatment (EPSDT) services allowable under Medicaid. Those children already receiving Medicaid at the time of placement will be screened within thirty (30) days after placement. Children not receiving Medicaid at the time of placement will receive a screening within thirty (30) days from the date Medicaid eligibility is established.(3-15-22)
IDAPA 16.06.01.444 Medical Emergencies
In case of serious illness, the alternate care provider must notify the child’s doctor and the Department immediately.
The parent(s) or legal guardian(s) or the court in an emergency, or the Department if it is the guardian of the child, have the authority to consent to major medical care or hospitalization.(3-15-22)
IDAPA 16.06.01.445 Dental Care
Each child age three (3) who is placed in alternate care must receive a dental examination as soon as possible after placement, but not later than ninety (90) days, and thereafter according to a schedule prescribed by the dentist.
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Costs Paid by Medicaid. If dental care not included in the state medical assistance program is recommended, a request for payment must be submitted to the state Medicaid dental contractor.(7-1-25)
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Emergencies. For children in shelter care, emergency dental services will be provided for and paid for by the Department, if there are no other financial resources available.(3-15-22)
IDAPA 16.06.01.446 Costs of Prescription Drugs
The Department will purchase prescribed drugs, at the Medicaid rate, for a child in alternate care through participating pharmacists, in excess of the Medicaid monthly maximum.(3-15-22)
IDAPA 16.06.01.447 Medical Examination Upon Entering Alternate Care
Within thirty (30) days of entering alternate care, each child will receive a medical examination to assess the child's health status, and thereafter according to a schedule prescribed by the child's physician or other health care professional.(3-15-22)
IDAPA 16.06.01.448 (Reserved)
IDAPA 16.06.01.451 Drivers’ Training, Drivers’ Licenses, and Permits for Children in
ALTERNATE CARE.
No Department employee or foster parent is allowed to sign for any foster child’s driver’s license or permit without written authorization from the Child and Family Services Program Manager. Any Department employee or foster parent signing for a foster child’s driver’s license or permit without the approval of the Child and Family Services Program Manager assumes full personal responsibility and liability for any driving related damages that may be assessed against the child. Those damages will not be covered by the Department’s insurance.(3-15-22)
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Payments by Department. Subject to existing appropriations, the Department may make payments for driver’s training, driver’s license, and permits for a child in the Department’s legal custody when driver’s training or obtaining a driver’s license or permit is part of the child’s Independent Living Plan. In addition, subject to existing appropriations, the Department may reimburse a foster parent, licensed by the Department, for the cost of procuring owner’s or operator’s insurance listing a child residing in their home as a named insured with respect to the operation of a motor vehicle subject to the limits exclusive of interest and costs with respect to each motor vehicle as provided in Section 49-117, Idaho Code.(3-15-22)
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Payment by Parent(s) or Legal Guardian(s). The parent(s) or legal guardian(s) of children in foster care may authorize drivers’ training, provide payment and sign for drivers’ licenses and permits. (3-15-22)
IDAPA 16.06.01.452 (Reserved)
LICENSURE AND REIMBURSEMENT OF ALTERNATE CARE PROVIDERS
(Sections 480-549)
IDAPA 16.06.01.480 Alternate Care Licensure
All private homes and facilities providing care for children under these rules must be licensed in accordance with IDAPA 16.06.02, “Foster Care Licensing,” unless foster care placement of an Indian child is made with a foster home licensed or approved by the Indian child’s tribe, or an institution for children approved by an Indian tribe or operated by an Indian organization.(7-1-25)
IDAPA 16.06.01.481 Facilities Operated by the State
Facilities operated by the State and providing care for children under these rules must meet the standards for Children’s Residential Care Facilities in IDAPA 16.04.18.(7-1-25)
IDAPA 16.06.01.482 Payment to Family Alternate Care Providers
The rates for alternate care providers are proposed by Child and Family Services to the Joint Finance and Appropriations Committee (JFAC) when the annual review of reimbursements rates indicates that the amount is not sufficient to support foster parents in meeting the needs of children and young adults in extended foster care. Current rates as approved by JFAC are posted on the Child and Family Services website and will include the following:
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Shelter Care. Reimbursement rate for placement of children requiring emergency alternate care for a maximum of thirty (30) days.(7-1-25)
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Room and Board. Reimbursement rates for placement of children in relative or non-relative foster care by age.(7-1-25)
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Additional Reimbursement. Based upon an ongoing assessment of the child's circumstances that necessitate special rates as well as the foster parent’s ability, activities, and involvement in addressing those special needs.(7-1-25)
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Gifts. Additional payments to support gifts for children in foster care at Christmas and the child’s birthday.(7-1-25)
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Crisis Level of Need. The director or designee may approve enhanced rates for foster parents when there are insufficient foster homes available to meet the needs of children needing placement including sibling groups.(7-1-25)
IDAPA 16.06.01.483 Reimbursement in the Home of a Relative
Relatives licensed as a foster family must be afforded the opportunity to receive foster care reimbursement for any child(ren) placed in their home through the Department. A relative foster family may choose not to accept a foster care reimbursement and apply for a TAFI grant or provide for the child’s care using their own financial resources.
IDAPA 16.06.01.484 Additional Financial Support to Family Alternate Care Providers
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Clothing. Costs for clothing will be paid, based upon the Department’s determination of each child’s needs. All clothing purchased for a child in alternate care becomes the property of the child.(7-1-25)
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School Fees. School fees due upon enrollment will be paid directly to the school or to the alternate care providers, based upon the Department’s determination of the child’s needs.(7-1-25)
IDAPA 16.06.01.485 Treatment Foster Care
A family home setting in which treatment foster parents provide twenty-four (24) hour room and board as well as therapeutic services and a high level of supervision. Services provided in treatment foster care are at a more intense level than provided in foster care and at a lower level than provided in residential care. Services may include the following: participation in the development and implementation of the child’s treatment plan, behavior modification, community supports, crisis intervention, documentation of services and the child’s behavior, participation as a member of a multi-disciplinary team, and transportation. Placement into a treatment foster home for children in the custody of the department under the purview of the Child Protective Act, is based on the documented needs of the child, the inability of less restrictive settings to meet the child’s needs, and the clinical judgment of the department.
- Qualifications. Prior to being considered for designation and reimbursement as a treatment foster parent, each prospective treatment foster parent must accomplish the following:(3-15-22)
a.Meet all foster family licensure requirements as set forth in IDAPA 16.06.02, Foster Care Licensing;(7-1-25)
b.Complete department-approved treatment foster care initial training; and(7-1-25)
c.Provide a minimum of two (2) references in addition to those provided to be licensed to provide foster care. The additional references must be from individuals who have worked with the prospective treatment foster parent. The additional references must verify that the prospective treatment foster parent has:(3-15-22)
i.Training related to, or experience working with, children or youth with mental illness or behavior disorders; and(3-15-22)
ii. Demonstrated cooperation and a positive working relationship with families and providers of child welfare or mental health services.(3-15-22)
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Continuing Education. Following designation as a treatment foster home, each treatment foster home parent must complete fourteen (14) hours of additional training per year as specified in an agreement developed between the treatment foster parents and the department.(7-1-25)
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Availability. At least one (1) treatment foster parent, in each treatment family home, must be available twenty-four (24) hours a day, seven (7) days a week to respond to the needs of the foster child. (3-15-22)
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Payment. The department will pay treatment foster parents up to one thousand eight hundred ($1,800) dollars per month, per child, which includes the monthly payment rate posted on the Child and Family Services website. The payment will be made to treatment foster parents in accordance with a contract with the Department.(7-1-25)
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Payment to Contractors. The department may also provide treatment foster care through a contract with an agency that is a private provider of treatment foster care. The department will specify the rate of payment in the contract with the agency.(7-1-25)
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Treatment Plan. The treatment foster parent(s) must implement the portions of the department or Children’s Agency-approved treatment plan for which they are designated as responsible, for each child in their care.
IDAPA 16.06.01.486 Other Alternative Care
Foster care for children who generally require more structured services and activities than found in a family setting.
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Referral. Any referral of a child to a other alternative care-setting where the department will make full or partial payment must have prior authorization by the Child and Family Services Program Manager or designee.
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Placement. Determined by the documented mental, medical or behavioral health needs of each child and the ability of other alternate care provider to meet those needs.(7-1-25)
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Payment. Payment will be in accordance with the contract authorized by the regional director or division administrator, based on the needs of the children being placed and the services to be provided. (7-1-25)
IDAPA 16.06.01.487 (Reserved)
CHILD PROTECTION SERVICES
(Sections 550-639)
550 -- 551. (RESERVED)
IDAPA 16.06.01.552 Reporting System
The department maintains a system for receiving and responding to reports or complaints on a twenty four (24) hour per day, seven (7) day per week basis statewide.(7-1-25)
IDAPA 16.06.01.553 Assigning Reports for Safety Assessment
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Child Reports. The Department will assign all reports of possible abuse, neglect, or abandonment of children for safety assessment, unless there is insufficient information to indicate assignment is necessary.
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Infant Reports. To ensure the protection of infants in health care facilities throughout the state and who have been in continuously hospitalized since birth, who were born extremely prematurely, or who have a longterm disability, the department will assign reports of instances of withholding of medically indicated treatment from disabled infants with life-threatening conditions in accordance with the department’s response priorities. (7-1-25)
IDAPA 16.06.01.554 Response Priorities
The Department will use the following priorities for responding to allegations of abuse, neglect, or abandonment. If a variance is necessary from these response priorities, it will be documented in the family’s case file with a description of action taken, and will be reviewed and signed by the Child and Family Services Supervisor.(7-1-25)
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Priority I. The department will respond immediately if a child is in immediate danger involving a life-threatening or emergency situation and for cases of sexual abuse when a child may have contact with the alleged perpetrator. Law enforcement will be notified and requested to assist. Every attempt will be made to coordinate the department’s assessment with law enforcement’s investigation. The child will be seen by a family services worker, law enforcement, and medical personnel if applicable, immediately unless written regional protocol agreements direct otherwise. All allegations of physical abuse of a child through the age of six (6) or with profound developmental disabilities will be considered Priority I unless there is reason to believe that the child is not in immediate danger.(7-1-25)
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Priority II. A child is not in immediate danger but allegations of abuse, or neglect are clearly defined in the referral. The child will be seen by the family services worker within forty-eight hours (48) of the department’s receipt of the referral. Law enforcement must be notified within twenty-four (24) hours of receipt of all Priority II referrals.(7-1-25)
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Priority III. A child may be in a vulnerable situation because of services needs which, if left unmet, may result in harm, or a child is without parental care for safety, health and well-being. A family services worker must respond within three (3) calendar days and the child will be seen by the worker within five (5) calendar days of the department’s receipt of the referral.(7-1-25)
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Notification of the Person Who Made the Referral. The department must notify the person who made the child protection referral of the receipt of the referral within five (5) days, unless notification is declined.
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Disclosure of Information to Professionals. The Department has the discretion to disclose, on a need-to-know basis, minimally necessary information to individuals who are professionally involved in the ongoing care of the child who is the subject of a report of abuse, neglect, or abandonment. This includes information that the professional needs to know in order to fulfill their role in maintaining the child's safety and well-being. This provision applies to:(7-1-25)
a.Physicians, residents on a hospital staff, interns, and nurses;(3-15-22)
b.School teachers, school staff, and day care personnel; and(3-15-22)
c.Mental health professionals, including psychologists, counselors, marriage and family therapists, and social workers.(3-15-22)
IDAPA 16.06.01.555 Supervisory Review - Certain Priority I and Ii Cases
In all Priority I and II cases where the alleged victim of abuse, neglect, or abandonment is six (6) years old or younger, review by a supervisor or team of all case documentation and facts will be conducted within forty-eight (48) hours of initiation of the safety assessment. Such review will be documented in the file with the signature of the supervisor or team leader, time and date, whether additional safety-related issues will be pursued and by whom, and any planning for initiation of services.(7-1-25)
IDAPA 16.06.01.556 Reports Involving Indian Children
Possible abuse, neglect, or abandonment of a child who is known or believed to be Indian will be reported to appropriate tribal authorities immediately. If the reported incident occurs off a reservation, the department will perform the investigation. The department will also investigate incidents reported on a reservation if requested to do so by appropriate authorities of the tribe. A record of any response will be maintained in the case record and written documentation will be provided to the appropriate tribal authorities.(7-1-25)
IDAPA 16.06.01.557 Reports Involving Military Families
The department will comply with notice requirements pertaining to child abuse or neglect in which the person having care of the child is a member of the armed forces (or the spouse of the member) as required by 10 USC 1787.
IDAPA 16.06.01.558 (Reserved)
IDAPA 16.06.01.559 Child Protection Safety and Comprehensive Assessments
The department’s safety and comprehensive assessments will be conducted in a standardized format and utilize statewide assessment and multi-disciplinary team protocols.(7-1-25)
- Assessment of a Child. The family services worker will complete an assessment of every child of concern. When the child is interviewed as part of a safety and comprehensive assessment, the interview of a child concerning a child protection report will be conducted:(7-1-25)
a.In a manner that protects all children involved from undergoing any unnecessary traumatic experience;(7-1-25)
b.By a professional with specialized training in using techniques that consider the natural communication modes and developmental stages of children; and(3-15-22)
c.In a neutral, non-threatening environment, if available.(7-1-25)
- Assessment of the Family. The family services worker conducting the interview will: (7-1-25)
a.Immediately notify the parent(s) or legal guardian(s) of the purpose and nature of the assessment.
b.Provide at the initial contact the name and work phone numbers of the family services worker and their supervisor to ensure the family has a contact for questions and concerns that may arise following the visit;
c.Inquire if the family is Indian, or has Indian heritage, for the purposes of ICWA;(3-15-22)
d.Interview siblings who are identified as being at risk; and(3-15-22)
e.Not divulge the name of the person making the report of child abuse or neglect.(3-15-22)
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Collateral Interviews. Any assessment of an abuse or neglect report will include at minimum one (1) collateral interview with a person who is familiar with the circumstances of the child(ren) involved. Collateral interviews will be conducted with discretion and preferably with the parent(s)’ or legal guardian(s)’ permission.
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Completion of a Comprehensive Assessment. A Safety Assessment will be completed on each referral assigned for assessment of abuse or neglect, or both. When safety threats are identified in the safety assessment and the case remains open for services.(7-1-25)
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Notification of the Person Who Made the Referral. The department must notify the person who made the child protection referral when the safety assessment has been completed.(7-1-25)
IDAPA 16.06.01.560 Disposition of Child Protection Reports
Within five (5) days following completion of safety assessments, the department will determine whether the reports are substantiated or unsubstantiated. All persons who are identified as a caretaker will be notified of the disposition of the assessment as it pertains to them.(7-1-25)
- Substantiated. Child abuse, neglect, or abandonment reports are substantiated by one (1) or more of the following:(3-15-22)
a.Witnessed by a family services worker, as defined in Section 011 of these rules;(3-15-22)
b.A court determines, in an adjudicatory hearing, that a child comes within the jurisdiction of Title 16, Chapter 16, Idaho Code;(7-1-25)
c.A confession by the alleged offender;(7-1-25)
d.Corroborated by physical or medical evidence; or(3-15-22)
e.Established by evidence that it is more likely than not that abuse, neglect, or abandonment occurred.(3-15-22)
- Unsubstantiated. Child abuse, neglect, or abandonment reports are unsubstantiated when they are not found to be substantiated under Subsection 560.01 of this rule due to:(7-1-25)
a.Insufficient evidence; or(3-15-22)
b.An erroneous report.(3-15-22)
IDAPA 16.06.01.561 Child Protection Central Registry
In compliance with P.L. 109-248, July 27, 2006, the Child Protection Central Registry was established under the authority of Section 16-1629(3), Idaho Code. The Child Protection Central Registry provisions in this chapter of rules apply to safety assessments conducted by the department after October 1, 2007.(7-1-25)
IDAPA 16.06.01.562 Confidentiality of the Child Protection Central Registry and Requests
TO CHECK THE REGISTRY.
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Confidentiality of Child Protection Central Registry. The names on the Child Protection Central Registry are confidential and may only be released with the written consent of the individual on whom a criminal history and background check is being conducted, unless otherwise required by federal or state law. No information is released regarding the severity or type of child abuse, neglect, or abandonment.(3-15-22)
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Child Protection Central Registry Check Fee. The fee for requesting a name-based check of the Child Protection Central Registry is twenty ($20) dollars. The request must be accompanied with a signed written consent by the individual whose name is being checked.(3-15-22)
IDAPA 16.06.01.563 Levels of Risk on the Child Protection Central Registry
When an incident of abuse, neglect, or abandonment has been substantiated, a level of risk is assigned to the incident.
- Child Protection Level One. Names of individuals for whom an incident of abuse, neglect, or abandonment has been substantiated for any of the following will remain permanently on the Child Protection Central Registry at Level One.(7-1-25)
a.Sexual Abuse as defined in Sections 16-1602(1)(b) or 18-1506, Idaho Code;(7-1-25)
b.Sexual Exploitation as defined in Sections 18-1507 or 18-1507A, Idaho Code;(7-1-25)
c.Abuse as described in Section 16-1602(1)(a), Idaho Code, that causes life-threatening, disabling, or disfiguring injury or damage;(7-1-25)
d.Neglect as described in Section 16-1602(31), Idaho Code, that results in life-threatening, disabling, or disfiguring injury or damage;(3-15-22)
e.Abandonment as described in Section 16-1602(2), Idaho Code, that results in life-threatening, disabling, or disfiguring injury or damage;(3-15-22)
f.Death of a child as a result of abuse, neglect, or abandonment;(7-1-25)
g.Torture of a child as described in Section 18-4001, Idaho Code;(3-15-22)
h.Aggravated Circumstances as described in Section 16-1602(6), Idaho Code; or(3-15-22)
i.Occurrence of two (2) or more separate, substantiated incidents of abuse, neglect, or abandonment, listed under Subsection 563.02 of this rule.(7-1-25)
- Child Protection Level Two. An individual with a Level Two designation will remain on the Child Protection Central Registry for a minimum of ten (10) years. After the end of the ten-year (10) period, an individual may petition the department to request their name be removed from the Child Protection Central Registry in accordance with Section 566 of these rules. Names of individuals for whom an incident of abuse, neglect, or abandonment has been substantiated for any of the following will be given the designation of Level Two. (7-1-25)
a.Prenatal use of any controlled substance as defined under Section 37-2701(e), Idaho Code, except as prescribed by a medical professional;(3-15-22)
b.Administering or knowingly allowing a child to absorb or ingest one (1) or more controlled substances as defined under Section 37-2701(e), Idaho Code, except in the amount prescribed for the child by a medical professional;(3-15-22)
c.Child exposed to:(3-15-22)
i.Drug paraphernalia, as defined in Section 37-2701(o), Idaho Code;(7-1-25)
ii. Manufacture of controlled substances, as defined under Section 37-2701(e), Idaho Code, and Section 37-2701(t), Idaho Code; or(7-1-25)
iii. Chemical components used in the manufacture of controlled substances, as defined under Section 37-2701(e), Idaho Code.(3-15-22)
d.Abuse as described in Section 16-1602(1)(a), Idaho Code, that results in neither disabling nor disfiguring injury or damage, but requires medical treatment as recommended by a medical provider;(7-1-25)
e.Abandonment as described in Section 16-1602(2), Idaho Code, that results in neither disabling nor disfiguring injury or damage, but requires medical treatment as recommended by a medical provider:(7-1-25)
f.Neglect as described in Section 16-1602(31), Idaho Code, that results in neither disabling nor disfiguring injury or damage, but requires medical treatment as recommended by a medical professional; (7-1-25)
g.The restraint or confinement of a child that poses a substantial risk of causing life-threatening, disabling, or disfiguring injury or damage;(3-15-22)
h.Medical neglect as described in Section 16-1602(31), Idaho Code, that poses a substantial risk of resulting in life-threatening, disabling, or disfiguring injury or damage;(3-15-22)
i.Malnutrition as established by medical evidence; or(3-15-22)
j.Occurrence of two (2) or more separate, substantiated incidents of abuse, neglect, or abandonment, listed under Subsection 563.03 of this rule.(7-1-25)
- Child Protection Level Three. An individual with a Level Three designation will remain on the Child Protection Central Registry for a minimum of five (5) years. After the end of the five-year (5) period, an individual may petition the department to request their name be removed from the Child Protection Central Registry in accordance with Section 566 of these rules. Names of individuals for whom an incident of abuse, neglect, or abandonment has been substantiated for any of the following are given the designation of Level Three. (7-1-25)
a.Lack of supervision;(3-15-22)
b.Failure to protect from abuse, neglect, or abandonment as described in Section 16-1602, Idaho Code;(3-15-22)
c.Failure to discharge parental responsibilities described under Section 16-1602(31)(b), Idaho Code;
d.Abuse as described in Section 16-1602(1)(a), Idaho Code, that causes minor injuries or damage that does not require medical treatment;(7-1-25)
e.Neglect as described in Section 16-1602(31), Idaho Code, that causes minor injuries or damage that does not require medical treatment.(7-1-25)
IDAPA 16.06.01.564 Notification of a Substantiated Incident of Abuse, Neglect, or
ABANDONMENT, AND RELATED ADMINISTRATIVE REVIEW AND CONTESTED CASE APPEAL
RIGHTS.
- Notification of Substantiated Incident. Prior to placement on the Child Protection Central Registry, the department will notify by certified mail, return receipt requested, each individual for whom an incident of abuse, neglect, or abandonment has been substantiated. The individual has twenty-eight (28) days from the date on the notification to file a request for an administrative review. Failure to request a review will result in the individual’s name being entered on the Child Protection Central Registry without further right for appeal. The department’s written notice will state:(7-1-25)
a.The risk level assigned to the incident;(3-15-22)
b.The basis for the department’s decision;(7-1-25)
c.The individual’s right to request an administrative review by the department’s Family and Community Services (FACS) Division Administrator of the department’s decision; and(7-1-25)
d.The department’s contact information.(7-1-25)
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Administrative Review Requested. If the individual requests an administrative review by the FACS Division Administrator within twenty-eight (28) days from the date on the notification, the appeal process will begin. The individual will receive redacted documents regarding the incident that is being appealed. The individual will have fourteen (14) days to submit additional documentation. At the end of the fourteen-day period, the incident will be reviewed by the FACS Division Administrator and a decision will be rendered to either affirm, reverse, or modify, the decision to substantiate the incident of abuse, neglect, or abandonment. The Department will notify the individual of the FACS Division Administrator’s decision by mail. If the administrative review affirms or modifies the decision to substantiate, failure to timely request a contested case appeal will result in the individual’s name being entered on the Child Protection Central Registry without further right for appeal.(7-1-25)
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Reversal of Decision to Substantiate. When the FACS Division Administrator completes the administrative review and reverses the decision to substantiate the incident of abuse, neglect, or abandonment, then no further action is required by the individual. The individual’s name will not be placed on the Child Protection Central Registry.(7-1-25)
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Contested Case Appeal. When the FACS Division Administrator completes the administrative review and affirms the decision to substantiate the incident of abuse, neglect, or abandonment, the individual will be notified by mail that the individual has twenty-eight (28) days to continue the appeal process and will be informed of:
a.The basis for the department’s decision;(7-1-25)
b.The procedures for filing a contested case appeal;(7-1-25)
c.The procedures for filing a petition for removal from the Child Protection Central Registry after the applicable minimum time has passed under Section 566 of these rules;(7-1-25)
d.The department's contact information; and(7-1-25)
e.That failure to respond at any point in the appeal process will end the appeal process and the individual’s name will automatically be entered on the Child Protection Central Registry without further notice or right to appeal.(7-1-25)
- Child Protection Central Registry. Following a decision by the hearing officer to affirm the decision to substantiate, an individual’s name will be placed on the Child Protection Central Registry. (7-1-25)
IDAPA 16.06.01.565 (Reserved)
IDAPA 16.06.01.566 Petition for Removal of an Individual’s Name from the Child Protection
CENTRAL REGISTRY.
Any individual whose name is on the Child Protection Central Registry and whose required minimum time on the registry has elapsed, may petition the Department to remove their name from the Registry. If not previously assigned a risk level, the petitioner will be assigned a child protection risk level in accordance with the criteria under Section 563 of these rules. An individual whose name appears with a Level One designation on the Child Protection Central Registry is not eligible to petition for removal.(7-1-25)
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Petition for Removal From the Child Protection Central Registry. Any individual whose name appears on the Child Protection Central Registry with a designation of either Level Two or Level Three, may petition to have their name removed from the Child Protection Central Registry after the minimum period of time has elapsed for the applicable level. The petition must include a written statement from the petitioner to the department's FACS Division Administrator requesting that the petitioner's name be removed from the Child Protection Central Registry.
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Criteria for Granting Petition for Removal From the Child Protection Central Registry. The petition for removal from the Child Protection Central Registry will be granted if:(3-15-22)
a.There are no additional substantiated reports on the Child Protection Central Registry or that of other states in which the petitioner has resided since the last substantiated report of abuse, neglect, or abandonment in Idaho; and(3-15-22)
b.There are no convictions, adjudications, or withheld judgments for any of the crimes listed under Subsection 566.03 of this rule:(3-15-22)
i.On Idaho’s central repository of criminal history records as established and maintained by the Idaho State Police under Title 67, Chapter 30, Idaho Code; or(3-15-22)
ii. On the criminal history repository of other states in which the petitioner has resided since the last substantiated report of abuse, neglect, or abandonment in Idaho.(3-15-22)
- Criminal History Checks. It is the responsibility of the petitioner to request, pay for, and obtain the criminal history checks and submit them to the department.(7-1-25)
a.The department will not remove a petitioner from the Child Protection Central Registry when the petitioner’s criminal history and background check reveals a conviction for a disqualifying crime under IDAPA 16.05.06, “Criminal History & Background Checks”, Section 210, except the department may remove a petitioner from the Child Protection Central Registry where the conviction arose from the same events for which the person was placed on the registry.(7-1-25)
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Granting or Denying Removal From the Child Protection Central Registry. The department will issue a letter granting or denying removal of the petitioner’s name from the Child Protection Central Registry within twenty-eight (28) days of receipt of the petition.(7-1-25)
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Appeal of a Denial of Removal From the Child Protection Central Registry. The individual may appeal the denial of removal of their name from the Child Protection Central Registry.(7-1-25)
IDAPA 16.06.01.567 “Safe Haven” Exemption for Parents of Certain Abandoned Infants
No disposition will be made on the parent(s) and no information will be entered into the Child Protection Central Registry when a parent(s) relinquishes their infant within the first thirty (30) days of life to a “Safe Haven” according to Title 39, Chapter 82, Idaho Code.(7-1-25)
IDAPA 16.06.01.568 Court-Ordered Child Protection Safety Assessment
When, in any divorce proceeding or upon request for modification of a divorce decree, an allegation of child abuse or child sexual abuse is made, implicating either party, the court may order that an investigation/safety assessment be conducted by the department. Court orders for preliminary child protective safety assessment and for any subsequent assessment the court may deem necessary will be served on the department supervisor for child protection services in the field office in which the court has geographical jurisdiction. The child protection supervisor must immediately initiate the safety assessment and consult with the court promptly if there are any obstacles preventing its completion.
Immediately upon completing the report, the department must make a written report to the court.(7-1-25)
IDAPA 16.06.01.569 Petition Under the Child Protective Act
If any incident of child abuse, neglect, or abandonment is substantiated through a safety assessment, or during the provision of services, and cannot be resolved through informal processes or voluntary agreement that is adequate for protection of the child, the department will request the prosecuting attorney to file a Child Protective Act petition.
IDAPA 16.06.01.570 (Reserved)
IDAPA 16.06.01.571 Child Custody Investigations for the District Court
Where no other community resources are available and when ordered by the district courts, the department will, for a fee of thirty-five dollars ($35) per hour, conduct safety assessments that will provide information to assist the court.
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Requests From Private Attorney. If a parent’s attorney requests a safety assessment, and a report of findings regarding the fitness of a parent, the attorney must be advised that such service is provided on behalf of a child but not on behalf of a litigant, and that any such assessment and report would be provided to the court pursuant to a court order.(7-1-25)
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Conduct of the Assessment. In conducting the assessment, the family services worker must explain to the family the purpose for which the information is being obtained. If the judge intends to treat the report as evidence, the family must be informed that any information they provide will be brought out at the court hearing. If the family refuses to give information to the family services worker, the department has no authority to require cooperation. However, the judge may issue an order directing the family to provide information to the family services worker for the purpose of making a report to the court.(7-1-25)
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Report to Court. The family services worker will provide a report only to the Magistrate judge who ordered the assessment, and must use the department’s standardized format. The report must describe what was observed about the home conditions and the care of the child(ren).(7-1-25)
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Department Clients. If the family is or has been a client of the Department, disclosure of information must comply with IDAPA 16.05.01, “Use and Disclosure of department Records.”(7-1-25)
IDAPA 16.06.01.572 (Reserved)
ADOPTION SERVICES
(Sections 700-710)
IDAPA 16.06.01.700 Adoption Services Policy
Where reasonable efforts to reunite or preserve a family are unsuccessful, or where relinquishment is requested by the parent(s), the department will consider whether termination of parental rights is in the best interests of the child. The department must make every effort to place any child legally free for adoption in an appropriate adoptive home. Each child will be placed with an adoptive family who can support the racial, ethnic or cultural identity of the child, and is able to cope with any forms of discrimination the child may experience.(7-1-25)
IDAPA 16.06.01.701 Services to Be Provided in Adoptions
In addition to the services provided under these rules, the department provides the following:(7-1-25)
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Pre-Placement Child/Family Assessment. An assessment of the child’s history, needs as an individual and as part of a family.(7-1-25)
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Preparation for Placement. Assistance to the child in addressing grief and loss due to separation from their parents and with the transition to an adoptive placement.(7-1-25)
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Technical Assistance. Assistance in completing the legal adoption, including compliance with the Indian Child Welfare Act.(3-15-22)
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Post Adoption Services. Post adoption services are provided within available resources. Children with negotiated adoption assistance agreements from any state, are eligible for any services available to Idaho children. International adoptees residing in Idaho are also eligible for any services available to Idaho children under the Inter-Country Adoption of 2000 (P.L.106-279). Children with IV-E or state adoption assistance agreements are eligible for Medicaid in Idaho. A referral from an Interstate Compact on Adoption and Medical Assistance member state serves as formal application for services in Idaho. Applications for Medicaid are made through the Department in accordance with IDAPA 16.03.01, “Eligibility for Health Care Assistance for Families and Children.” (7-1-25)
IDAPA 16.06.01.702 (Reserved)
IDAPA 16.06.01.710 Family History
If the child’s permanency goal is termination of parental rights and adoption, the following information will be obtained and placed in the child's permanent adoption record:(7-1-25)
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Informational Forms. Background forms regarding the birth mother, birth father, and child including demographic, medical, social, and genetic information.(7-1-25)
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Hospital Records. Child’s birth records.(7-1-25)
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Evaluations/Assessments. Any evaluations and assessments completed on child.(7-1-25)
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Current Picture. Current picture of child.(3-15-22)
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Narrative Social History. Social history that addresses:(7-1-25)
a.Family dynamics and history;(3-15-22)
b.Child’s current functioning and behaviors;(3-15-22)
c.Interests, talents, abilities, strengths;(3-15-22)
d.Child’s cultural and racial identity needs.(7-1-25)
e.Child’s life story, including placement moves and reasons;(7-1-25)
f.Child’s attachments to current caretakers, siblings and other significant connections; (7-1-25)
g.Medical, developmental and educational needs;(3-15-22)
h.Child’s past experiences, and trauma;(7-1-25)
i.Indian child’s ancestry including membership or eligibility for membership in, and social and cultural connections to the parent’s tribe, including names and addresses of extended family;(7-1-25)
j.Individualized recommendations regarding each child’s need for permanency; and (3-15-22)
k.Reasons for requesting termination of parental rights.(3-15-22)
TERMINATION OF PARENT-CHILD RELATIONSHIP
(Sections 711-749)
IDAPA 16.06.01.711 (Reserved)
IDAPA 16.06.01.714 Voluntary Termination
Parent(s) requesting placement of a newborn child are referred to Idaho’s licensed private adoption agencies.
Parent(s) requesting placement of a newborn Indian child are referred to tribal social services agencies. (7-1-25)
IDAPA 16.06.01.715 (Reserved)
IDAPA 16.06.01.719 Investigation
An investigation and report under the Termination of Parent and Child Relationship Act may be completed by an authorized agency, certified adoption professional or the department. In addition to the factors set forth in Section 16- 2008(2), Idaho Code, completed reports will include:(7-1-25)
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Description of Investigation. The allegations contained in the petition;(7-1-25)
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The Process of the Assessment and Investigation;(7-1-25)
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Child-Related Factors. The child’s circumstances, including:(7-1-25)
a.Current functioning and behaviors;(7-1-25)
b.Medical, educational and developmental needs;(7-1-25)
c.History and past experiences;(7-1-25)
d.Identity needs;(7-1-25)
e.Interests and talents;(7-1-25)
f.Attachments to current caretakers and any absent parent;(7-1-25)
g.Current living situation;(7-1-25)
- Documentation. Documentation of compliance with the Indian Child Welfare Act, including identification of whether the child or parent is Indian and if so:(7-1-25)
a.Notification of the pending proceedings to the parent(s) or Indian custodian(s) and the Indian child’s tribe, or the Secretary of the Interior if their identity or location is unknown;(7-1-25)
b.Notification of the right of the parent(s) or Indian custodian(s) and the Indian child’s tribe to intervene in the proceeding and their right to be granted up to twenty (20) additional days to prepare for the proceeding;(7-1-25)
c.Evidence, including identity and qualifications of expert witnesses, that continued custody of the child by the parent(s) or Indian custodian(s) is likely to result in serious emotional or physical damage to the child;
- Circumstances. The circumstances of the parent(s) whose rights are being terminated including:
a.Present circumstances, history, and condition;(7-1-25)
b.Desires regarding plans for the child;(7-1-25)
c.Reasonable efforts made by the petitioner(s) to locate an absent parent(s) and provisions of notification to an unmarried father of the paternity registration requirement under Section 16-1513, Idaho Code;
d.Contact with the parent(s) of a minor parent, unless lack of contact is explained; and (7-1-25)
e.The advertisement of any parent with a disability of their right to provide information regarding the manner in which the use of adaptive equipment or supportive services will enable the parent to carry out the responsibilities of parenting the child;(7-1-25)
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Facts. Other facts which may be pertinent to the parent and child relationship and this particular case; i.e., compliance with Interstate Compact Placement on Children; and(7-1-25)
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Recommendation. A recommendation and reasons as to whether or not the termination of the parent and child relationship should be granted.(7-1-25)
IDAPA 16.06.01.720 (Reserved)
BECOMING AN ADOPTIVE PARENT
(Sections 750-850)
IDAPA 16.06.01.750 Application to Be Adoptive Parent(s)
An applicant must participate in the process and tasks to complete an adoptive home study.(7-1-25)
- Initial Application. Each adoptive applicant must:(3-15-22)
a.Cooperate with and allow the department, or certified adoption professional, to determine compliance with these rules to conduct an adoption home study;(7-1-25)
b.Inform the department, or certified adoption professional, if the applicant has previously applied to become a foster or adoptive parent, is currently licensed as a foster parent, or has been involved in the care and supervision of children or adults;(7-1-25)
c.Provide a medical statement for each applicant, signed by a qualified medical professional, within the twelve (12) months period prior to application for adoption, indicating the applicant is in such physical and mental health so as to not adversely affect either the health or quality of care of the adopted child;(3-15-22)
d.Provide the name of, and a signed release to obtain the following information about, each member of the household:(3-15-22)
i.Admission to, or release from, a facility, hospital, or institution for the treatment of an emotional, intellectual, or substance abuse issue;(3-15-22)
ii. Outpatient counseling, treatment, or therapy for an emotional, intellectual, or substance abuse issue.(3-15-22)
e.Provide three (3) satisfactory references, one (1) of which may be from a person related to the applicant. Each applicant must provide additional references upon the request of the department or certified adoption professional;(7-1-25)
f.All applicants for adoption and other adult members of the household must comply with the provisions in IDAPA 16.05.06, “Criminal History and Background Checks” and IDAPA 16.06.02, “Foster Care Licensing,” Section 202.(7-1-25)
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Psychological Evaluation. An evaluation by a psychologist or a psychiatrist can be required when an applicant has received or is currently receiving treatment for psychological problems or mental illness or when the family services worker, or certified adoption professional, in consultation with their supervisor, determines that there appear to be emotional problems in the family that merit further evaluation.(7-1-25)
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Orientation of Potential Applicants. Initial meetings with individual families or groups of applicants, must be scheduled promptly to explain policies and procedures regarding adoptive placement, the kinds of children available, and the nature of the home study.(7-1-25)
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Denial of Application. Following an initial interview, an applicant who does not appear to meet the requirements at the time of initial application may be denied a full home study. The family will be advised why they were ineligible for a full home study and notice provided to the applicant of their right to appeal this decision.
Upon resolution of the factors leading to the denial, the applicant may again file an application and receive a home study.(7-1-25)
- Application for Subsequent Adoptions. Following the finalization of an adoption, a family may apply to be considered for another placement.(3-15-22)
a.Parents who have finalized an adoption and wish to reapply must complete an adoption application and financial statement, complete a Background Check, and submit medical reports and three (3) personal references.
One (1) reference may be from a person related to the applicant. When requested by the department or certified adoption professional, an applicant must provide additional references.(7-1-25)
b.The prospective adoptive family will assist in amending the original adoption study to include information concerning the acceptance and adjustment of the child previously placed in the home and their request for another placement.(3-15-22)
c.Prospective adoptive parent(s) applying for subsequent adoption with an agency with whom they have maintained a foster care license since their previous adoption may have the requirement for a new Background Check, medical reports and personal references waived by the agency.(7-1-25)
IDAPA 16.06.01.751 (Reserved)
IDAPA 16.06.01.762 Completing the Adoption Home Study
The initial home study is completed prior to placement of any child for adoption in that home.(3-15-22)
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Interviews. Family assessment interviews as well as individual interviews are held with the prospective adoptive parent(s).(7-1-25)
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Content. Adoption home studies for foster care, special needs, independent, relative, and stepparent adoptions must include an assessment of the following:(3-15-22)
a.Names, including maiden or other names used by the applicant(s);(3-15-22)
b.Legal verification that the person(s) adopting is at least fifteen (15) years older than the child, or twenty-five (25) years of age or older, except in cases where the adopting person is a spouse of the child’s parent, must be accomplished by viewing:(7-1-25)
i.A certified copy of the birth certificate filed with the Bureau of Vital Statistics; or(3-15-22)
ii. One (1) of the following documents for which a birth certificate was presumably required prior to its issuance: armed services or other governmental identification, including a valid Idaho driver’s license, passport, visa, alien identification cards, or naturalization papers.(7-1-25)
iii. If verifying documentation is not available, the report must indicate the date and place of birth and reason for lack of verification.(3-15-22)
c.Verification the family has resided and maintained a dwelling within the State of Idaho for at least six (6) consecutive months prior to the filing of the petition;(7-1-25)
d.Adequacy of the family’s house, property, and neighborhood for the purpose of providing adoptive care as determined by on-site observations;(3-15-22)
e.Educational background of the applicant(s);(3-15-22)
f.A statement of employment, family income, and financial resources, including access to health and life insurance and the family’s management of these resources;(3-15-22)
g.Current and historical mental illness, drug or alcohol abuse, and medical conditions and how they may impact the adoptive parent(s) ability to care for an adopted child;(3-15-22)
h.Previous criminal convictions and history of child abuse and neglect;(3-15-22)
i.Family history, including childhood experience and the applicant(s) parents’ methods of discipline and problem-solving;(3-15-22)
j.Verification of marriages and divorces;(3-15-22)
k.Names, ages, and addresses of all biological and adopted children currently residing inside or outside the home. Information regarding the current adjustment and special needs of the applicant(s) children;
l.The religious and cultural practices of the family, including their interest and ability to parent and support a child’s knowledge of and involvement in that child’s cultural, racial, ethnic, and religious background different than their own;(7-1-25)
m.For an Indian child, the study will determine the prevailing social and cultural standards of the Indian community in which the parent(s) or extended family resides or maintains social and cultural ties; (7-1-25)
n.Individual and family functioning including inter-relationships with each member of the household and the family’s ability to help a child integrate into the family;(3-15-22)
o.Activities, interests, and hobbies;(3-15-22)
p.Child care and parenting skills, including historical and current methods of discipline used in the home;(3-15-22)
q.Reasons for applying for adoption;(3-15-22)
r.Prior and current experiences with adoption, understanding of adoption, and ability to form relationships and bond with a specific child or general description of children;(7-1-25)
s.Attitudes toward adoption by immediate and extended members of the family and other persons who reside in the home;(3-15-22)
t.Specifications of the child preferred by the family that include the number of children, age, gender, race, ethnic background, social, emotional, and educational characteristics. The family’s ability to accept the behavior and personality of a specific child (if known) or general description of children and their ability to meet the child’s particular educational, developmental, and psychological needs;(3-15-22)
u.Emotional stability and maturity in dealing with the needs, challenges, and related issues associated with the placement of a child into the applicant(s) home;(3-15-22)
v.Attitude about an adopted child’s birth family including:(7-1-25)
i.Ability to accept a child’s background and help the child cope with their past; and(7-1-25)
ii. Willingness to work with the child’s family or tribe;(7-1-25)
w.Training needs of the applicant(s); and(3-15-22)
x.A recommendation regarding the family’s ability to provide adoptive care to a specific child (if known) or general description of children.(3-15-22)
IDAPA 16.06.01.763 Pre-Adoptive Parent Responsibilities
The pre-adoptive parent is responsible to keep the department, agency or certified adoption professional that completed the home study informed of any changes in the family’s circumstances, or of any subsequent decision against adoption.(7-1-25)
IDAPA 16.06.01.764 Adoption Home Study
An adoption home study is valid for the purposes of new adoptive placement for a period of one (1) year following the date of completion. Upon completion of an adoptive placement agreement, an adoption home study remains valid for a period of two (2) years from the date of completion for the purpose of finalizing the adoption of the child(ren) for whom the adoptive placement agreement was written.(3-15-22)
IDAPA 16.06.01.765 (Reserved)
IDAPA 16.06.01.770 Closure of Adoption Home Studies
Upon pre-adoptive placement of a child or children in the home, the adoption home study closes for the placement of an additional child or children for the purpose of adoption until a home study update is completed.(7-1-25)
IDAPA 16.06.01.771 Adoption Home Study Update
An adoption home study must be updated on an annual basis to remain valid for new adoptive placements. Adoption home study updates must include the following:(7-1-25)
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Initial Adoption Home Study and Subsequent Home Study Updates. All changes to the information contained in the initial Adoption Home Study and any subsequent Adoption Home Study Updates.
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Family Functioning and Inter-Relationships. Information on any changes in family Functioning and inter relationships.(7-1-25)
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Circumstances Adversely Impacting Child Placed for Adoption. Information regarding circumstances within the family that may adversely impact a child placed for adoption.(7-1-25)
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A Home Study Update Completed for the Purpose of Adoptive Placement of an Additional Child or Children in the Home. A home study update completed for the purpose of adoptive placement of an additional child or children in the home where a child or children are already placed for adoption and that adoption has not yet finalized must include agreement for the placement of the additional child or children by the individual or agency responsible for the placement of the initial child or children, and the individual or agency responsible for the additional child or children.(3-15-22)
IDAPA 16.06.01.772 (Reserved)
IDAPA 16.06.01.790 Foster Parent Adoptions
The procedure and requirements are the same for all adoptive applicants. Licensed foster parents with a current home study recommending them for both foster care and adoption do not need an adoption specific home study to adopt a child matching the characteristics of a child or children for whom they are approved or recommended for placement.
They are eligible to be considered for adoption as part of the home study process completed to provide foster care.
These requirements include compliance with the Indian Child Welfare Act, the Multi-Ethnic Placement Act of 1994 and the Interethnic Adoption Provisions of 1996.(7-1-25)
IDAPA 16.06.01.791 (Reserved)
IDAPA 16.06.01.833 Placement Supervision -- Transfer from Out of State Private Agency
When a prospective adoptive parent(s) moves to Idaho, with a child who has been placed with them by a private agency in their former state of residency, supervision services are provided through one of Idaho’s private, licensed adoption agencies, or a certified adoption professional.(7-1-25)
IDAPA 16.06.01.834 (Reserved)
THE ADOPTIVE PLACEMENT
(Sections 860-888)
IDAPA 16.06.01.860 Placement of the Child
The adoptive placement of a child in the custody or legal guardianship of the department will be selected using a committee process of no less than three (3) individuals and be approved by a regional program manager. (7-1-25)
- Factors Considered in Determining Adoptive Placements.(7-1-25)
a.For an Indian child, Indian Child Welfare Act (1978) placement preferences must be followed:
i.A member of the child’s extended family;(7-1-25)
ii. Other members of the Indian child’s tribe;(7-1-25)
iii. Other Indian families.(7-1-25)
b.The primary factor in determining adoptive placement is the prospective family’s ability to protect and promote the best interests of the child to be placed in their home.(7-1-25)
c.The ability to meet the cultural and racial needs of the child does not necessitate the family have the same culture or race of the child.(7-1-25)
- Disclosure. Full background information and the child’s history must be discussed with the prospective adoptive parent(s) prior to pre-adoptive placement. The disclosure of background information is confirmed at the time of placement by a written acknowledgment signed by the family services worker and prospective adoptive family. A copy of this statement must be provided to the adoptive family and one (1) copy is kept in the child’s permanent record.(7-1-25)
IDAPA 16.06.01.861 Procedures Following Adoptive Placement
A period of support and supervision lasting at least six (6) months must be completed following the adoptive placement prior to the finalization of the adoption. In situations where a foster family has a significant relationship with a child and the child has been placed in their home for at least the last six (6) months, the supervisory period may be reduced to a minimum of three (3) months. Scheduled visits to the home will be made at least monthly during this period to assist the child and the family in their adjustment.(7-1-25)
IDAPA 16.06.01.862 Progress Reports
Reports documenting the progress of the child’s placement will be prepared at least every thirty (30) days. Reports include the family services worker’s or certified adoption professional’s findings based on their observation of each child and prospective adoptive parent(s) with an emphasis on:(7-1-25)
- Initial and Subsequent Reports.(7-1-25)
a.Special needs and/or circumstances of each child;(7-1-25)
b.Services planned or provided to each child and the family;(7-1-25)
c.General appearance and adjustment of each child during the report period;(7-1-25)
d.Adjustment of each child to school and/or daycare;(7-1-25)
e.Health and developmental progress, and medical practitioner information for each child; (3-15-22)
f.Acceptance of each child for coverage on the family’s medical insurance, when coverage begins, and whether there will be any limitations, exclusions, or both;(7-1-25)
g.Each family member’s adjustment to adoptive placement;(7-1-25)
h.Adoption assistance negotiation;(3-15-22)
i.Changes in family situation or circumstances; and(7-1-25)
j.Areas of concern during the report period as addressed by each child and the adoptive parent(s); and(3-15-22)
IDAPA 16.06.01.863 Investigation of Petition to Adopt and Report to the Court
Written reports of investigation regarding allegations stated in petitions filed under Section 16-1506, Idaho Code, are filed at the same time as the prospective adoptive family’s adoption home study. The investigation and report may be completed by the department, licensed adoption agency, or certified adoption professional supervising the adoptive placement. Caution is exercised discussing identifying information to avoid revealing information in the petition while attempting to secure the necessary facts for the report. If there is reason to believe the child may be an Indian child and the child’s tribe or the Secretary of the Interior has not received written Notice of Pending Proceedings, the worker must inform the court, the attorney for the petitioner(s) and the independent agency of the need to comply with the Indian Child Welfare Act. The report to the court must address the following:(7-1-25)
- Legal Availability of the Child. The family services worker or certified adoption professional will interview the family and any other person(s) having knowledge in the matter, review all documentary evidence presented by the petitioner(s), and record the information and source of the information, noting any discrepancies.
Such documentary evidence must include the following:(7-1-25)
a.Birth certificate of the child;(7-1-25)
b.Consent(s) of the child's parent(s) to terminate their parental rights, termination decrees for any parent(s) whose parental rights have been terminated involuntarily by the court, and documentation of marriage and divorce;(7-1-25)
c.Termination decrees for any parent(s) whose parental rights have been terminated involuntarily by the court;(7-1-25)
d.Documentation of marriage and divorce;(7-1-25)
e.If the child is an Indian child, a copy of the Notice of Pending Proceedings for Termination of Parental Rights, and the return receipts showing that the notice was received by the Indian child’s parent(s) or Indian custodian(s), and the child’s tribe;(3-15-22)
f.Consent to adoption has been secured for all persons from whom it is required, including a legal guardian(s), to make the child legally available for adoption;(3-15-22)
g.Death certificate of a deceased parent;(7-1-25)
h.Verification from the Bureau of Vital Statistics of the registry of any putative father; and (3-15-22)
i.The Interstate Compact on the Placement of Children Form 100-A, for a child born outside of the state of Idaho, to determine if required state authorizations have been given, or if the Compact does not apply.
- Needs of the Child. History of the child and the child’s birth family including:(7-1-25)
a.Information about the child's previous adoptive family and the circumstances of the disruption if the child was previously adopted;(7-1-25)
b.Detailed description of the circumstances that brought about the placement with the prospective adoptive family;(7-1-25)
c.Social, medical, and genetic history forms must be completed, made available to the prospective adoptive family, and submitted to the court, showing reasonably known or available medical and genetic information regarding both birth parents and the child, as well as reasonably known or available providers of medical care and services to birth parents and child; and(7-1-25)
d.The appropriateness of the prospective adoptive family for the particular child or children who are the subject of the petition including any alleged relative or stepparent relationship between the child and the prospective adoptive parent(s) specifying any documentary evidence of that relationship.(7-1-25)
- Evaluation and Recommendation. A brief summary of data presented in prior sections and the adoption home study, supporting the recommendation regarding the adoption.(7-1-25)
IDAPA 16.06.01.864 (Reserved)
IDAPA 16.06.01.870 Removal of a Child from a Prospective Adoptive Home
The final decision to remove a child from a prospective adoptive home will be made by the Department as the legal guardian of the child.(7-1-25)
IDAPA 16.06.01.871 (Reserved)
IDAPA 16.06.01.881 Closure of Case
A certified copy of the final order of adoption and a copy of the executed consent to adoption are necessary to close the adoption file and initiate the child’s adoption assistance benefits.(7-1-25)
IDAPA 16.06.01.882 Records of Placement
Upon finalization of the adoption, the complete record from the local field office, regarding the child and family will be permanently stored.(7-1-25)
IDAPA 16.06.01.883 (Reserved)
IDAPA 16.06.01.884 Opening Sealed Adoption Records
In addition to the exceptions noted in Section 16-1511, Idaho Code, sealed adoption proceedings may be opened in the following circumstances according to the Indian Child Welfare Act:(7-1-25)
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Motion of an Indian Individual. Upon motion of an Indian individual who has reached the age of eighteen (18) and was the subject of an adoption, the court must provide tribal affiliation, if any, of the individual’s biological parent(s) and other information necessary to protect any rights flowing from the individual’s tribal relationship.(3-15-22)
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Request From the Secretary of the Interior or the Indian Child's Tribe. Upon request of the Secretary of the Interior or the Indian child’s tribe, evidence of efforts to comply with the Indian Child Welfare Act must be made available to the parties requesting such information.(3-15-22)
IDAPA 16.06.01.885 (Reserved)
CERTIFIED ADOPTION PROFESSIONAL
(Sections 889-899)
IDAPA 16.06.01.889 Certified Adoption Professional Requirements
An applicant requesting to become a Certified Adoption Professional must meet the following criteria: (3-15-22)
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College Degree. A minimum of a bachelor's degree in a field deemed related to adoptions by the Department's Child and Family Services Program, such as social work, psychology, family counseling or other related behavioral science;(3-15-22)
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Adoption Training. A minimum of twenty (20) hours of training in adoption services within the last four (4) years;(7-1-25)
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Background Clearance. Complete a background check in accordance with IDAPA 16.05.06, “Criminal History and Background Checks,” and receive a clearance;(7-1-25)
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License. A current license to practice social work in the state of Idaho;(3-15-22)
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Experience. A minimum of two (2) years of experience as a paid full-time employee providing adoption services with a licensed private or public children’s agency;(7-1-25)
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References. Three (3) satisfactory references, one (1) of which must be from a previous employer for whom the applicant worked providing adoption services;(3-15-22)
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Insurance. Verification of malpractice insurance that will provide coverage for the applicant’s work as a certified adoption professional; and(3-15-22)
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Application Fee. An application fee of one hundred dollars ($100) to be reimbursed, less a twentyfive dollar ($25) processing fee, in the event the application is denied.(3-15-22)
IDAPA 16.06.01.890 Terms of Certification for Adoption Professionals
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Certification. Certification for adoption professionals is completed through the Division of Family and Community Services. Certifications are effective for a period of two (2) years.(7-1-25)
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Types of Certification. Certified adoption professionals may provide any, some, or all of the following services:(7-1-25)
a.Adoption home studies for families seeking domestic infant adoption.(3-15-22)
b.Adoption home studies for families seeking domestic special needs adoption.(3-15-22)
c.Adoption home studies for families seeking step-parent or relative adoption.(3-15-22)
d.Court ordered investigations for termination of parental rights for domestic private or independent adoptions.(3-15-22)
e.Court reports for domestic private or independent adoptions.(3-15-22)
f.Supervision of adoptive placements for domestic private or independent adoptions. (3-15-22)
- Limits of Certification. Certified adoption professionals may not provide the following services:
a.Birth parent education or counseling.(3-15-22)
b.Services related to international adoption.(3-15-22)
- Recertification. Certified adoption professionals must apply for renewal of their certificate every two (2) years and must provide the following:(3-15-22)
a.Documentation of ten (10) hours of adoption training taken during the previous two (2) years;
b.Verification of malpractice insurance;(3-15-22)
c.A satisfactory recommendation from the Division of Family and Community Services designee responsible for the review of the certified adoption professional’s work; and(7-1-25)
d.A certification fee of one hundred dollars ($100) to be reimbursed, less a twenty-five dollar ($25) processing fee, in the event the recertification is denied.(3-15-22)
- Lapse of Certification. If a certified adoption professional does not apply for recertification within two (2) years in accordance with Subsection 890.04 of this rule, this will result in a lapse of certification. Any lapse in certification will require completion of a new certified adoption professional application, documentation of ten (10) hours of adoption training during the two (2) years previous to this new application, and a new background check.
a.If the individual applying for certification has received a background check clearance in accordance with IDAPA 16.05.06 “Criminal History and Background Checks within three (3) years of the date of this application and has not lived outside the state of Idaho since their last background check, all of the following must be conducted and no disqualifying crimes or appearance on a registry found:(7-1-25)
i.A name-based background check by the Idaho State Police;(3-15-22)
ii. A check of the Idaho Child Protection Central Registry;(3-15-22)
iii. A check of the Idaho Adult Protection Registry; and(3-15-22)
iv. A check of the Idaho Sexual Offender Registry.(3-15-22)
b.If the individual has lived outside the state of Idaho for any amount of time during the three (3) years since the previous background check clearance, a new Department criminal history and background check clearance is required.(7-1-25)
- Denial of Recertification. The department may choose not to recertify a certified adoption professional. Notification of denial will be made by certified mail. The notice will state the specific grounds for denial of recertification. This decision may be appealed within twenty-eight (28) days of receipt of notification under the provisions in IDAPA 62.01.01, “Idaho Rules of Administrative Procedure,” and Office of Administrative Hearings General Order No. 1. Grounds for denial of recertification are one (1) or more of the following: (7-1-25)
a.Substandard quality of work following the development of a quality improvement plan; (3-15-22)
b.Failure to gain ten (10) additional hours of adoption continuing education required for recertification;(7-1-25)
c.A demonstrated pattern of negligence or incompetence in performing the duties of a certified adoption professional.(3-15-22)
d.Failure to maintain malpractice insurance; or(7-1-25)
e.Failure to maintain a license to practice social work in the state of Idaho. This requirement does not apply to a certified adoption professional who has maintained their initial certification that occurred prior to July 1, 2012.(3-15-22)
- Decertification. A certified adoption professional can be decertified by the department at any time during a two (2) year period of certification. Notification of decertification will be made by the department by certified mail. The notice will state the specific grounds for decertification. This decision may be appealed within twenty-eight (28) days of receipt of notification under the provisions in IDAPA 62.01.01, “Idaho Rules of Administrative Procedure,” and Office of Administrative Hearings General Order No. 1. Grounds for decertification are one (1) or more of the following:(7-1-25)
a.Conviction for a felony;(3-15-22)
b.Negligence in carrying out the duties of a certified adoption professional;(3-15-22)
c.Misrepresentation of facts regarding their qualifications or the qualifications of a prospective adoptive family to adopt, or both;(3-15-22)
d.Failure to obtain departmental review and approval of home studies court reports, and/or placement supervision reports, or both, on more than one (1) occasion;(7-1-25)
e.Failure to maintain malpractice insurance;(3-15-22)
f.Suspension or loss of a license to practice social work in Idaho; or(3-15-22)
g.Practice as a certified adoption professional outside the scope of the certification.(3-15-22)
IDAPA 16.06.01.891 Certified Adoption Professional Client Relationship
A certified adoption professional may not assume a legal relationship with any child for whom they have been contracted to perform services and may not provide services for anyone with whom they have had a personal or professional relationship during the previous two (2) years.(3-15-22)
IDAPA 16.06.01.892 Minimum Standards for Service
A certified adoption professional must meet the following service requirements:(3-15-22)
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Description of Services Available. A written description of services will be provided to families by the certified adoption professional before any work is completed. The description of services must include information regarding Department oversight of the certified adoption professional and any limitations related to the use of the completed home study;(3-15-22)
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Education. Provision of, or referral to, educational resources to adoptive applicants requesting non-relative adoption;(3-15-22)
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Content. Standards for home studies, home study updates, court reports, and supervisory reports must, at a minimum, meet the standards for adoption services established in these rules;(7-1-25)
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Release of Information. A written release of information that gives consent to the exchange of information between the certified adoption professional and Child and Family Services must be obtained from a family that receives services from a certified adoption professional; and(3-15-22)
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Disclosure of Non-Identifying Information. When providing adoption supervision or adoption finalization court report services, the certified adoption professional must provide disclosure of all known nonidentifying information about the child, the child’s birth parents, and the circumstances leading to the decision to place the child for adoption.(3-15-22)
IDAPA 16.06.01.893 Records of the Certified Adoption Professional
Records of the home studies, court reports, and supervisory reports provided by the certified adoption professional must be made available to the Division of Family and Community Services designee two (2) weeks prior to the required court filing date. The designee will be responsible for monitoring of quality of the services provided.
IDAPA 16.06.01.894 Fees Charged by the Department
Monitoring fees will accompany the submission of each report and be paid directly to the Department through the Division of Family and Community Services as follows:
IDAPA 16.06.01.895 Department Responsibility to Certified Adoption Professional
The Division of Family and Community Services is responsible for:(3-15-22)
a.Reviewing and responding to submitted reports within five (5) business days;(3-15-22)
b.Initiation of corrective action plans when the documentation of a certified adoption professional is determined to be incorrect or substandard; and(3-15-22)
c.Dissemination of information to certified adoption professionals that may impact provided services.(3-15-22)
IDAPA 16.06.01.896 (Reserved)
ADOPTION AND GUARDIANSHIP ASSISTANCE
(Sections 900-999)
IDAPA 16.06.01.900 Conditions for Adoption Assistance
The purpose of the adoption assistance program is to encourage the legal adoption of children with special needs who would not be able to have the security of a permanent home without support payments. Applications are made through the Division of Family and Community Services, for a determination of eligibility. Eligibility is determined solely on the child’s need. No means test may be applied to the adoptive family’s income or resources. Once an application for adoption assistance is submitted to the Division of Family and Community Services, the Division will respond with a determination of the child’s eligibility within forty-five (45) days.(7-1-25)
- Special Needs Criteria. The definition of special needs includes the following factors: (3-15-22)
a.The child cannot or should not be returned to the home of the parents as evidenced by an order from a court of competent jurisdiction terminating parents rights or its equivalent; and(3-15-22)
b.The child has a physical, mental, emotional, or medical disability, or is at risk of developing such disability based on the child’s experience of documented physical, emotional, or sexual abuse, or neglect; or
c.The child’s age makes it difficult to find an adoptive home; or(3-15-22)
Table 894 - Qualified Individuals Home Study or Court Report$50 Supervision Report or Home Study Update $30
d.The child is being placed for adoption with at least one (1) sibling; and(3-15-22)
e.Reasonable but unsuccessful effort to place the child with special needs without a subsidy must be made, except in cases where it is not in the best interests of the child due to their significant emotional ties with the foster parent(s) or relative(s) who are willing to adopt the child.(7-1-25)
IDAPA 16.06.01.901 (Reserved)
IDAPA 16.06.01.908 Title Iv-E Adoption Assistance
The department will remain in compliance with the requirements and benefits for federally funded adoption assistance benefits per the Social Security Act, most recently updates by the Family First Prevention Services Act of 2018 (P.L. 115-123).(7-1-25)
IDAPA 16.06.01.909 State Funded Adoption Assistance
Children in state custody who meet the special needs criteria found in Subsection 900.01 of these rules and do not qualify for Title IV-E adoption assistance found at Section 908 in these rules, may be eligible for state-funded adoption assistance benefits. If the child is determined ineligible for Title IV-E adoption assistance, the application will be evaluated for a state-funded subsidy.(7-1-25)
IDAPA 16.06.01.910 Types and Amounts of Assistance
The needs of the child and the family, including any other children in the family, will be considered in determining the amount and type of support to be provided. Assistance may include the following:(3-15-22)
- Nonrecurring Adoption Reimbursement. Payment for certain one-time expenses necessary to finalize the adoption may be paid when a family adopts a special needs child. The child's eligibility must be determined and the contract for reimbursement must be fully executed prior to the finalization of the adoption. The reimbursement is paid only after the adoption finalizes.(3-15-22)
a.The expenses are defined as reasonable and necessary adoption fees, court costs, attorney fees, and other expenses that are directly related to the legal adoption finalization and which are not incurred in violation of state or federal law. These expenses cannot be reimbursed if they are paid for the adoptive parents by other sources such as an employer.(7-1-25)
b.Documentation of expenses must be submitted.(3-15-22)
c.Costs are reimbursable up to two thousand dollars ($2,000) per child and are entered on adoption assistance program agreement.(7-1-25)
d.Children for whom the adoption has been finalized without a negotiated nonrecurring expenses reimbursement agreement are not eligible to apply for these benefits.(7-1-25)
- Monthly Cash Payment. A monthly cash payment may be established to assist the adoptive family in meeting the additional expenses of the child’s special needs. The amount of the payment must be negotiated with the family by the family services worker and based on the family's circumstances and what additional resources are needed to incorporate the child into the adoptive family.(7-1-25)
a.The amount must not exceed the rate for family foster care, which would be made if the child were in a family foster home in Idaho.(7-1-25)
b.Payments received for treatment foster care, gifts, clothing, and school fees are not considered part of the family foster care rate.(3-15-22)
c.For children who are currently eligible for Personal Care Services (PCS), the treatment foster care rate of up to a maximum of one thousand dollars ($1,000) per month may be used in negotiating the adoption assistance upon prior approval of the Department's Family and Community Services (FACS) Division Administrator.
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Title XIX -- Medicaid Coverage. Any child with special needs who has an adoption assistance agreement in effect is eligible for medical coverage.(7-1-25)
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Title XX -- Social Services. Any child with special needs who has an adoption assistance agreement is also eligible for state-authorized Title XX - Federal Social Services Block Grant funded services.
IDAPA 16.06.01.911 Adoption Assistance Program Agreement
A written agreement must be negotiated and fully executed between the department and adopting family prior to the finalization of adoption and implementation of benefits.(7-1-25)
- Agreement Specifications. The agreement specifies the following:(3-15-22)
a.The type and amount of assistance to be provided;(3-15-22)
b.An annual review of each agreement will be conducted by the department to evaluate the need for continued monthly cash payment and the amount of the payment;(7-1-25)
c.The type and amount of assistance may be adjusted only with the concurrence of the adoptive parent(s) based upon changes in the needs of the child or changes in the circumstances of the adoptive family;
d.The adoptive parent(s) are required to inform the department of any circumstances that would make them ineligible for adoption assistance payments, or eligible for adoption assistance payments in a different amount.
- Termination of Adoption Assistance. Adoption assistance benefits are terminated if: (7-1-25)
a.The adoptive parent(s) no longer have legal responsibility for the child;(7-1-25)
b.The child is no longer receiving any financial support from the parents, or(7-1-25)
c.The child has reached the age of eighteen (18) years if the adoption was finalized prior to the child's sixteenth (16) birthday or twenty-one (21) years if finalized after the child's sixteenth (16) birthday regardless of the child's educational status.(7-1-25)
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Suspension of Adoption Assistance. Adoption assistance monthly cash payments will be suspended if the child is placed in foster care in any state. Benefits will be reinstated upon the child’s reunification with the adoptive parent(s).(7-1-25)
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Adoption Assistance Follows the Child. If the adoptive parents are located in a state other than Idaho, or move out of Idaho with the child, the adoption assistance payments initiated by Idaho will continue for the child. Referral for Medicaid or other state medical insurance and social service benefits will be forwarded to the new state of residence through the Interstate Compact on Adoption and Medical Assistance. Children receiving a state funded adoption subsidy, may not be eligible for Medicaid in a state other than Idaho.(7-1-25)
IDAPA 16.06.01.912 (Reserved)
IDAPA 16.06.01.920 Administrate Review for Adoption Assistance
Adoptive parents have twenty-eight (28) days from the date of the department’s notification of Title IV-E adoption assistance eligibility determination or change in adoption assistance benefits to request an administrative review.
Notification will be made by mail of their right to appeal and procedures for filing an appeal.(7-1-25)
- Request for Reconsideration. Adoptive parents who were not informed of adoption assistance benefits prior to the finalization of their child’s adoption may submit an application to the department prior to the eighteenth birthday of the adopted child.(7-1-25)
a.Eligibility is determined based on the eligibility factors for a special needs child that were in effect at the time of the child’s adoption.(7-1-25)
b.If the eligibility determination finds a child was eligible for benefits at that time of the child’s adoption, and an agreement was not signed prior to the finalization, the department is required to deny benefits to the child, since no contract was in effect at the time of the adoption finalization.(7-1-25)
c.The adoptive parent(s) may request an administrative hearing for Title IV-E adoption assistance eligibility determination.(7-1-25)
i.The determinations to be made at and administrative review hearing is whether extenuating circumstances exist or whether the family was wrongly denied eligibility, or both.(7-1-25)
ii. A favorable ruling from a fair hearing officer is required for the department to change Title IV-E eligibility and provide adoption assistance based on extenuating circumstances.(7-1-25)
IDAPA 16.06.01.921 Retroactive Adoption Assistance Benefits
The department may negotiate retroactive adoption assistance benefits for a maximum of twenty-four (24) months from the date of adoption assistance application, identified in Section 920.01 of these rules.(7-1-25)
IDAPA 16.06.01.922 Conditions for Guardianship Assistance
The purpose of the guardianship assistance program is to encourage legal permanency of children with special needs who would not be able to have the security of a permanent home without support payments. Applications are made through the Division of Family and Community Services for a determination of eligibility. Eligibility is determined solely on the child’s need. No means test may be applied to the income or resource of the prospective legal guardian(s). The following conditions must be met for a child to be eligible for guardianship assistance. (7-1-25)
-
Assessment of Suitability. The suitability of an individual to become a legal guardian for a specific child or sibling group will be determined through a home study.(7-1-25)
-
Eligibility for Guardianship Assistance. Guardianship assistance will be determined for each child placed in the legal custody of the department prior to the finalization of the guardianship. Eligibility is based on the child’s needs. No means test may be applied to the prospective legal guardian family’s income or resources in a determination of eligibility. The child will first be considered for eligibility for a federally-funded subsidy. Should the child be found ineligible for a federally-funded subsidy, the child will be considered for a state-funded subsidy.
-
Guardianship and Foster Care Licensure. To receive guardianship assistance, a potential legal guardian must be licensed or approved to provide foster care.(7-1-25)
IDAPA 16.06.01.923 Title Iv-E Guardianship Assistance
In addition to Sections 922 and 926-928 of these rules, the department will comply with the requirements and benefits of the Title IV-E Guardianship Assistance Program in the Social Security Act, made available by the Fostering Connections to Success and Increasing Adoptions Act of 2008 (P.L. 110-351).(7-1-25)
IDAPA 16.06.01.924 State-Funded Guardianship Assistance
- A Child Is Eligible For State-funded Guardianship Assistance If The Department Determines The Child Meets The Requirements In Section 922 Of These Rules In Addition To The Following: (7-1-25)
a.The child meets the special needs criteria in Subsection 900.01 of these rules;(7-1-25)
b.The child’s parents have had their parental rights legally terminated or are deceased; and (7-1-25)
c.There is documentation of unsuccessful efforts to place the child for adoption.(7-1-25)
IDAPA 16.06.01.925 Types and Amounts of Guardianship Assistance
-
Nonrecurring Expenses. The department will reimburse the cost, up to two thousand dollars ($2,000) of nonrecurring expenses associated with obtaining legal guardianship of a child eligible for Title IV-E or state-funded guardianship assistance. Financial assistance for legal fees may be provided regardless of the legal guardian’s state of residence.(7-1-25)
-
Monthly Cash Payment. The cash payment for Title IV-E or state-funded guardianship assistance may not exceed the published foster care rate a child would receive if living in family foster care in Idaho. Monthly cash payments are prospective only. There will be no retroactive benefits or payments.(7-1-25)
-
Title XIX Medicaid.(7-1-25)
a.A child eligible for Title IV-E guardianship assistance is eligible for Medicaid in the state where the child resides.(7-1-25)
b.A child eligible for state-funded guardianship assistance living in Idaho is eligible for Medicaid benefits. If the legal guardian moves to another state, they will be required to apply for Medicaid for the child in the new state of residency.(7-1-25)
IDAPA 16.06.01.926 Guardianship Assistance Program Agreements
The department and the prospective legal guardian(s) must enter into a written agreement prior to the finalization of the guardianship. The department will provide the prospective legal guardian(s) with a copy of the agreement.
- Agreement Specifications. All guardianship assistance agreements will specify the following:
a.The amount and manner in which the guardianship assistance payment will be provided to the prospective legal guardian;(7-1-25)
b.The manner in which the payment may be adjusted periodically in consultation with the legal guardian, based on the circumstances of the legal guardian and the needs of the child;(7-1-25)
c.Any additional services and assistance for which the child and the legal guardian will be eligible under the agreement;(7-1-25)
d.The procedure by which the legal guardian may apply for additional services;(7-1-25)
e.A statement that the agreement will remain in effect without regard to the state of residency of the legal guardian;(7-1-25)
f.The procedure by which the department will make a mandatory annual evaluation of the need for continued assistance and the amount of the assistance; and(7-1-25)
- Termination of Guardianship Assistance. Guardianship assistance benefits and cash payments are automatically terminated when:(7-1-25)
a.A court terminates the legal guardianship or removes the legal guardian;(7-1-25)
b.The child no longer resides in the home of the legal guardian, and the legal guardian no longer provides financial support for the child;(7-1-25)
c.The child has reached the age of eighteen (18) years if the guardianship was finalized prior to the child's sixteenth (16) birthday or twenty-one (21) years if finalized after the child's sixteenth (16) birthday, regardless of the child's educational status or physical or developmental delays; or(7-1-25)
d.The child marries, dies, or enters the military.(7-1-25)
- Suspension of Guardianship Assistance. Guardianship assistance monthly cash payments will be suspended if the child is placed in foster care in any state. Benefits will be reinstated upon the child’s reunification with the legal guardian(s).(7-1-25)
IDAPA 16.06.01.927 Administrative Review for Guardianship Assistance
The prospective legal guardian has twenty-eight (28) days from the date of the department’s notification of the guardianship assistance determination, to request an administrative review. The determination will be reviewed by the FACS Division Administrator, and a decision will be rendered to either affirm, reverse, or modify, the decision.
The department will notify the individual, by mail, of the FACS Division Administrator’s decision, of their right to appeal, and procedures for filing an appeal.(7-1-25)
IDAPA 16.06.01.928 (Reserved)
16.05.07 The Investigation and Enforcement of Fraud, Abuse, and Misconduct
IDAPA 16.05.07.000 Legal Authority
Sections 56-202(b), 56-203(1), 56-203(2), 56-209, 56-209h, 56-227 , 56-227A through D, 56-1001, and 56-1003, Idaho Code, authorize the Director to adopt rules regarding fraud, abuse, and misconduct of public assistance programs.(3-17-22)
IDAPA 16.05.07.001 Scope
These rules protect the integrity of the pu blic assistance programs by identifying instances of fraud, abuse, and other misconduct by providers and their employees, participants, and by providing that appropriate action is taken to correct the problem. Nothing contained within this chapter will limit the Department from taking any other action authorized by law, including seeking damages under Section 56-227B, Idaho Code.(3-17-22)
IDAPA 16.05.07.002 Written Interpretations
This agency has written statements which pertain to the interpretation of the rules of this chapter, or to the documentation of compliance with the rules of this chapter. The document is available for public inspection and copying at cost in the main office of this agency.(3-17-22)
IDAPA 16.05.07.003 Administrative Appeals
Appeals and proceedings for any Department actions are governed by IDAPA 62. 01.01, “Idaho Rules of Administrative Procedure,” and Office of Administrative Hearings General Order No. 1. An appeal does not stay the action of the Department.(3-17-22)
IDAPA 16.05.07.004 (Reserved)
IDAPA 16.05.07.010 Definitions
For purposes of this chapter of rules, the following terms apply.(3-17-22) 01.
Abuse or Abusive. Provider practices that are inconsistent with sound fiscal, business, child care, or medical practices, and result in an unnecessary cost to a public assistance program, in reimbursement for services that are not medically necessary, or that fail to meet professionally recognized standards for health care, or in physical harm, pain, or mental anguish to a medical assistance recipient.(3-17-22)
02.Access to Documentation and Records. To review and copy records at the time a written request is made during normal business hours. Documentation includes all materials as described in Section 101 of these rules.(3-17-22)
03.Claim. Any request or demand for payment, or document submitted to initiate payment, for items or services provided under a public assistance program, whether under a contract or otherwise.(3-17-22)
04.Conviction. An individual or entity is considered to have been convicted of a criminal offense:
a.When a judgment of conviction has been entered against the individual or entity by a federal, state, or local court, regardless of whether there is an appeal pending or whether the judgment of conviction or other record relating to criminal conduct has been expunged;(3-17-22)
b.When there has been a finding of guilt against the individual or entity by a federal, state, or local court;(3-17-22)
c.When a plea of guilty or nolo contendere by the individual or entity has been accepted by a federal, state, or local court; or(3-17-22)
d.When the individual or entity has entered into participation in a first offender, deferred adjudication, or other arrangement or program where judgment of conviction has been withheld.(3-17-22)
05.Department. The Idaho Department of Health and Welfare, its authorized agent or designee.
06.Director. The Director of the Idaho Department of Health and Welfare or the Director’s designee.
07.Exclusion. A specific person or provider will be precluded from directly or indirectly providing services and receiving reimbursement under Medicaid.(3-17-22)
08.Fraud or Fraudulent. An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.(3-17-22)
09.Knowingly, Known, or with Knowledge. A person, with respect to information or an action, who:
a.Has actual knowledge of the information or an action;(3-17-22)
b.Acts in deliberate ignorance of the truth or falsity of the information or the correctness or incorrectness of the action; or(3-17-22)
c.Acts in reckless disregard of the truth or falsity of the information or the correctness or incorrectness of the action.(3-17-22)
10.Managing Employee. A general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency.(3-17-22)
11.Medicaid. Idaho's Medical Assistance Program.(3-17-22)
12.Medical Assistance. Payments for part or all of the cost of services funded by Titles XIX or XXI of the federal Social Security Act, as amended.(3-17-22)
13.Misconduct. Wrongful, improper, or unlawful conduct related to public assistance rules and programs, including violations of rules, statutes, provider agreements and terms, provider handbooks, and any instructions contained in provider information releases or other program notices.(3-17-22)
14.Participant. An individual or recipient who is eligible and enrolled in any public assistance program.(3-17-22)
15.Person. An individual, trust or estate, partnership, corporation, professional association or corporation, or other entity, public or private.(3-17-22)
16.Program. Any public assistance program, including the Medicaid program and Idaho’s State Plan, or any parts thereof.(3-17-22)
17.Provider. An individual, organization, agency, or other entity providing items or services under a public assistance program.(3-17-22)
18.Provider Agreement. A written agreement between the Department and a provider or group of providers of supplies or services. This agreement contains any terms or conditions deemed appropriate by the Department.(3-17-22)
19.Public Assistance Program. Assistance for which provision is made in any federal or state law existing, or hereafter enacted, by the state of Idaho or the congress of the United States by which payments are made from the federal government to the state in aid, or in respect to payment by the state for welfare purposes to any category of needy person, and any other program of assistance for which provision for federal or state funds for aid may from time to time be made.(3-17-22)
20.Recoup and Recoupment. The collection of funds for the purpose of recovering overpayments made to providers for items or services the Department has determined should not have been paid. The recoupment may occur through the collection of future claims paid or other means.(3-17-22)
21.Sanction. Any abatement or corrective action taken by the Department which is appealable under Section 003 of these rules.(3-17-22)
22.State Plan. The contract between the state and federal government under 42 U.S.C. Section 1396a(a).(3-17-22)
IDAPA 16.05.07.011 (Reserved)
IDAPA 16.05.07.020 Department Actions
When an instance of fraud, abuse, or other misconduct is identified, the Department will take action to correct the problem as provided in this rule. Such corrective action may include: denial of payment, recoupment, payment suspension, provider agreement suspension, termination of provider agreement, imposition of civil monetary penalties, exclusion, participant lock-in, referral for prosecution, or referral to state licensing boards.(3-17-22)
IDAPA 16.05.07.021 (Reserved)
IDAPA 16.05.07.100 Investigation and Audits
Investigation and audits of provider fraud, abuse, or m isconduct conducted by the Department’s Bureau of Compliance or its successor are governed under these rules.(3-17-22)
01.Investigation Methods. Under Sections 56-209h(2) and 56-227(5), Idaho Code, the Department will investigate and identify potential instances of fraud, abuse, or other misconduct by any person related to or involved in public assistance programs administered by the Department. Methods may include:(3-17-22)
a.Review of computerized reports;(3-17-22)
b.Referrals to or from other agencies, health care providers, or persons;(3-17-22)
c.Conducting audits, interviews, and pre-payment and post-payment reviews;(3-17-22)
d.Probability sampling and extrapolation; and(3-17-22)
e.Issuing subpoenas to compel testimony or the production of records.(3-17-22)
02.Probability Sampling. Probability sampling will be done in conformance with generally accepted statistical standards and procedures. “Probability sampling” means the standard statistical methodology in which a sample is selected based on the theory of probability, a mathematical theory used to study the occurrence of random events.(3-17-22)
03.Extrapolation. Whenever the results of a probability sample are used to extrapolate the amount to be recovered, the demand for recovery will be accompanied by a clear description of the universe from which the sample was drawn, the sample size and method used to select the sample, the formulas and calculation procedures used to determine the amount to be recovered, and the confidence level used to calculate the precision of the extrapolated overpayment. “Extrapolation” means the methodology whereby an unknown value can be estimated by projecting the results of a probability sample to the universe from which the sample was drawn with a calculated margin of error.(3-17-22)
IDAPA 16.05.07.101 Documentation of Services and Access to Records
01.Documentation of Services. Pro viders must generate documentation at the time of service sufficient to support each claim or service, and as required by rule, statute, or contract. Documentation must: (3-17- 22)
a.Be legible and consistent with professionally recognized standards; and(3-17-22)
b.Be retained for a period of five (5) years from the date the item or service was provided. (3-17-22)
02.List Of Records. Documentation to support claims for services may include medical records, treatment plans, medical necessity justification, assessments, appointment sheets, patient accounts, financial records or other records regardless of its form or media.(3-17-22)
03.Immediate Access To Records. Providers must grant to the Department, the U.S. Department of Health and Human Services and its agents, immediate access to records for review and copying during normal business hours. These records are listed in Subsection 101.02 of this rule.(3-17-22)
04.Copying Records. The Department may copy any record listed in Subsection 101.02 of this rule.
a.They may request in writing to have copies of records supplied by the provider.(3-17-22)
b.The requested copies must be furnished within twenty (20) working days after the date of the written request, unless an extension of time is granted by the Department for good cause.(3-17-22)
c.Failure to timely provide requested copies will be a refusal to provide access to records.
05.Removal of Records From Provider’s Premises. The Department may remove from the provider’s premises copies of any records listed in Subsection 101.02 of this rule.(3-17-22)
IDAPA 16.05.07.102 (Reserved)
IDAPA 16.05.07.200 Denial of Payment
The following are reasons the Department may deny payment.(3-17-22) 01.
Billed Services Not Provided or Not Medically Necessary. The Department may deny payment for any and all claims it determines are for items or services:(3-17-22)
a.Not provided or not found by the Department to be medically necessary.(3-17-22)
b.Not documented to be provided or medically necessary.(3-17-22)
c.Not provided under professionally recognized standards of health care.(3-17-22)
d.Provided as a result of a prohibited physician referral under 42 CFR Part 411, Subpart J. (3-17-22)
02.Contrary to Rules or Provider Agreement. The Department may deny payment when services billed are contrary to Department rules or the provider agreement.(3-17-22)
03.Failure to Provide Immediate Access to Records. The Department may deny payment when the provider does not allow immediate access to records as listed in Section 101 of these rules.(3-17-22)
IDAPA 16.05.07.201 (Reserved)
IDAPA 16.05.07.205 Recoupment
The Department may recoup the amount paid for items or services listed in Section 200 of these rules. If recoupment is impracticable, the Department may pursue any available legal remedies it may have. Interest will accrue on overpayments at the statutory rate set forth in Section 28-22-104, Idaho Code, from the date of the final determination of the amount owed for items or services until the date of recovery.(3-17-22)
IDAPA 16.05.07.206 (Reserved)
IDAPA 16.05.07.210 Suspension of Payments Pending Investigation
The Department may suspend public-assistance payments in whole or part in a suspected case of fraud or abuse pending investigation and conclusion of legal proceedings related to the provider’s alleged fraud or abuse.
When payments have been suspended under this rule, the Department will provide for a hearing within thirty (30) days of receipt of any timely filed notice of appeal.(3-17-22)
01.Basis for Suspension of Payments. When the Department through reliable evidence suspects fraud or abuse, or when a provider fails to provide immediate access to records, public-assistance payments may be withheld or suspended.(3-17-22)
02.Notice of Suspension of Payments. The Department may withhold public-assistance payments without first notifying the provider of its intention to do so when the Department is suspending payments of a Medicaid provider. The Department will send written notice within five (5) days of taking such action under 42 CFR 455.23(b). All other public assistance providers will be notified prior to the suspension of payments.
03.Duration of Suspension of Payments. The withholding of payment actions under this rule will be temporary and will not continue after:(3-17-22)
a.The Department or the prosecuting authorities determine there is insufficient evidence of fraud or willful misrepresentation by the provider; or(3-17-22)
b.Legal proceedings related to the provider’s alleged fraud or abuse are completed.(3-17-22)
IDAPA 16.05.07.211 (Reserved)
IDAPA 16.05.07.220 Provider Agreement Suspension
In the event the Department identifies a suspected case of fraud or abuse, it may summ arily suspend the provider agreement when necessary to prevent or avoid immediate danger to the public health or safety. This provider agreement suspension temporarily bars the provider from participation in the medical assistance program, pending investigation and Department action. The Department will notify the provider of the suspension. The suspension is effective immediately upon written, electronic, or oral notification. When a provider agreement is suspended under this rule, the Department will provide for a hearing within thirty (30) days of receipt of any timely filed notice of appeal(3-17-22)
IDAPA 16.05.07.221 (Reserved)
IDAPA 16.05.07.230 Termination of Provider Status
Under Section 56-209h, Idaho Code, the Department may terminate the provider agreement or otherwise deny provider status for a period of up to five (5) years from the date the Department’s action becomes final.(3-17-22)
IDAPA 16.05.07.231 (Reserved)
IDAPA 16.05.07.235 Civil Monetary Penalties
Under Section 56-209h, Idaho Code, the Department may assess civil monetary penalties against a provider, any of ficer, director, owner, and managing employee for conduct identified in Idaho Code 56-209h(6)(a) through (i).
IDAPA 16.05.07.236 Civil Monetary Penalty Percentages
The Department will determine the percentage of each penalty b y the type of conduct, the frequency, and knowledge of the conduct. When more than one (1) type of conduct described in Idaho Code 56-209h(6)(a) through (i) is found per line item, the penalty percentage will be based on the most significant conduct.(3-17-22)
01.Conduct Resulting in No Overpayment. The Department determines civil monetary penalties to be assessed for the following types of conduct violations that did not result in an overpayment.(3-17-22)
a.Participant Fees. The provider collected or attempted to collect fees from participants that the provider was not entitled to collect. Violations for this type of conduct will result in a ten percent (10%) penalty.
b.Minor Rule Violations. Services were provided and properly paid but violated rule, policy, or provider agreement. Minor rule violations will result in a ten percent (10%) penalty. Minor rule violations may
i.Incorrect date spanning;(3-17-22)
ii.Failure to list required provider credentials; or(3-17-22)
iii.Failure to obtain required client signatures.(3-17-22)
c.Significant Rule Violations. Services were provided but violated rule, policy, or provider agreement. Significant rule violations will result in a fifteen percent (15%) penalty. Significant rule violations may
i.Incomplete physician referrals; or(3-17-22)
ii.Failure to maintain documentation once valid Healthy Connections referral is obtained. (3-17-22)
02.Conduct Resulting in Overpayment. The Department determines the civil monetary penalties to be assessed for the following types of conduct violations resulting in overpayment. Civil monetary penalties will not be assessed when a provider self-reports an overpayment and the Department receives the report prior to the initiation of a Department audit.(3-17-22)
a.Significant Rule Violations. Services were provided but violated rule, policy, or provider agreement. Significant rule violations will result in a fifteen percent (15%) penalty. Significant rule violations may
i.Billing more services than allowed;(3-17-22)
ii.Billing non-physician services as physician services;(3-17-22)
iii.Billing incorrect codes (such as Physician’s Current Procedural Terminology (CPT), diagnosis, revenue, etc.) or modifiers; or(3-17-22)
iv.Inadequate documentation to support services billed.(3-17-22)
b.Significant Rule Violations Related to Participant Care. Services were provided but violated rule, policy, or provider agreement related to participant care. Significant rule violations related to participant care will result in a twenty percent (20%) penalty. Significant rule violations may include:(3-17-22)
i.Failure to obtain required Healthy Connections referrals or failure to list required core elements, such as the start and end dates on the referral;(3-17-22)
ii.No required physician or practitioner signatures;(3-17-22)
iii.No orders or inadequate orders, assessments, plans or evaluations prior to delivery of service or items;(3-17-22)
iv.Services or items provided by unqualified staff;(3-17-22)
v.Services or items provided by excluded individual; or(3-17-22)
vi.Services or items not covered by program.(3-17-22)
c.Significant Rule Violations for No Service or Refusal of Immediate Access to Documentation.
Services were not provided, were not documented, or refusal to provide immediate access to documentation upon written request as required in Section 56-209h(6)(e), Idaho Code, of these rules. Violations will result in a twenty-five percent (25%) penalty. Significant rule violations may include:(3-17-22)
i.Billing and receiving payment multiple times for the same service or item;(3-17-22)
ii.No documentation;(3-17-22)
iii.Cloned documentation;(3-17-22)
iv.Service not provided;(3-17-22)
v.More units billed than provided;(3-17-22)
vi.Billing laboratory services provided by independent laboratory, unless an exception applies, such as an independent laboratory that can bill for a reference laboratory; or(3-17-22)
vii.Missing required pre-authorization.(3-17-22)
03.Penalty Enhancements.(3-17-22)
a.Error Rates. The Department determines which error rate applies by comparing the number of violations to the number of similar line items audited, or to all audited line items. Penalty percentages identified in Subsections 236.01 and 236.02 of this rule may be increased by:(3-17-22)
i. Five percent (5%) when the error percentage of audited services is greater than twenty-five percent (25%); and(3-17-22)
ii.Ten percent (10%) when the error percentage of audited services is greater than thirty-five percent (35%).(3-17-22)
b.Fraudulently or Knowingly. When the Department determines the conduct was committed fraudulently or knowingly as defined in Section 010 of these rules, the penalty percentages may be increased by fifteen percent (15%).(3-17-22)
IDAPA 16.05.07.237 Civil Monetary Penalties for Criminal History Background Check
VIOLATIONS.
Under Section 56-209h(8)(b), Idaho Code, the Department may assess civi l monetary penalties against a provider, any officer, director, owner, or managing employee for failing to perform required background checks or failing to meet required time lines for completion of background checks as required by rule.(3-17-22)
IDAPA 16.05.07.238 (Reserved)
IDAPA 16.05.07.240 Mandatory Exclusions from the Medicaid Program
The Department will exclude from the Medicaid program any provider, entity, or person that:(3-17-22)
01.Conviction of a Criminal Offense. Has been convicted of a criminal offense related to the delivery of an item or service under a federal or any state health care program, including the performance of management or administrative services relating to the delivery of items or services under any such program.
02.Conviction of a Criminal Offense Related to Patient Neglect or Abuse. Has been convicted, under federal or state law, of a criminal offense related to the neglect or abuse of a patient, in connection with the delivery of a health care item or service, including any offense that the Department concludes entailed, or resulted in, neglect or abuse of patients. The conviction need not relate to a patient who is a program beneficiary.(3-17-22)
03.Other Exclusions. Is identified by the Centers for Medicare and Medicaid Services (CMS) as having been excluded by another state, the Office of Inspector General or any person CMS directs the Department to exclude.(3-17-22)
IDAPA 16.05.07.241 (Reserved)
IDAPA 16.05.07.245 Terms of Mandatory Exclusions from the Medicaid Program
Mandatory exclusions from the Medicaid program imposed under Section 240 of these rules, will be for not less than ten (10) years. The exclusion may exceed ten (10) years if aggravating factors are present. In the case of any mandatory exclusion of any person, if the individual has been convicted on two (2) or more previous occasions of one (1) or more offenses for which an exclusion may be effected under this rule, the period of exclusion will be permanent.(3-17-22)
IDAPA 16.05.07.246 (Reserved)
IDAPA 16.05.07.250 Permissive Exclusions from the Medicaid Program
The Department may exclude any person or entity from the Medicaid program for a period of not less than one (1) year:(3 -17-22)
01.Endangerment of Health or Safety of a Patient. Where there has been a finding by a governmental agency against such person or entity of endangering the health or safety of a patient, or of patient abuse, neglect, or exploitation.(3-17-22)
02.Failure to Disclose or Make Available Records. That has failed or refused to disclose, make available, or provide immediate access to the Department, or any licensing board, any records maintained by the provider or required of the provider to be maintained, which the Department deems relevant to determining the appropriateness of payment.(3-17-22)
03.Other Exclusions. For any reason for which the Secretary of Health and Human Services, or their designee, could exclude an individual or entity.(3-17-22)
IDAPA 16.05.07.251 (Reserved)
IDAPA 16.05.07.260 Aggravating Factors
For purposes of lengthening the period of mandatory exclusions and permissive exclusions from the Medicaid program, the following factors may be considered. This is not intended to be an exhaustive list of factors which may be considered:(3-17-22)
01.Financial Loss. The acts resulted in financial loss to the program of one thousand five hundred dollars ($1,500) or more. The entire amount of financial loss to such program will be considered, including any amounts resulting from similar acts not adjudicated, regardless of whether full or partial restitution has been made to the program.(3-17-22)
02.Time Acts Were Committed. The acts were committed over a period of one (1) year or more.
03.Adverse Impact. The acts had a significant adverse physical, mental, or financial impact on one (1) or more program participants or other individuals.(3-17-22)
04.Length of Sentence. The length of any sentence imposed by the court related to the same act.
05.Prior Record. The excluded person has a prior criminal, civil, or administrative sanction record.
IDAPA 16.05.07.261 Reinstatement After Exclusion from Medicaid Program
An individual or entity who has been excluded from the Medicaid Program is not automatically reinstated at the end of the exclusion period. An individual or entity excluded by the Department must submit a written application for reinstatement to the Department. An applicant excluded by the Department must receive written notice of reinstatement from the Department before reinstatement is complete.(3-17-22)
01.Conditions for Reinstatement. To be reinstated, the applicant must meet the following criteria:
a.Not be currently excluded from the Medicaid program by the federal government or by any state Medicaid agency;(3-17-22)
b.Not have a currently terminated Medicaid provider number by any state Medicaid agency;
c.Has all debts to the Department paid in full;(3-17-22)
d.Not be the subject of any civil, criminal, or state licensing authority investigation;(3-17-22)
e.Has not been convicted of any crime during the exclusion period;(3-17-22)
f.Has all the required, valid licensure and credentials necessary to provide services;(3-17-22)
g.Has met and continues to meet all terms and conditions of any court-ordered probation;
h.Did not work in any capacity as an employee or contractor for any individual or entity receiving Medicaid funds during the applicant’s exclusion period; and(3-17-22)
i.Did not submit claims or cause claims to be submitted for Medicaid reimbursement for services or supplies provided, ordered, or prescribed by an excluded individual or entity during the applicant’s exclusion period.
02.Applying for Reinstatement. An individual or entity may not begin the process of reinstatement earlier than one hundred twenty (120) days before the end of the exclusion period specified in the exclusion notice.
The Department will not consider a premature application. An applicant that appears on the federal or any state exclusion list may apply for reinstatement, but consideration of the application will not start until after the excluding agency has reinstated the individual or entity. (3-17-22)
03.Request for Reinstatement. An excluded individual or entity must request an application form in writing from the Department and specifically request reinstatement. The request for reinstatement must include:
a.The applicant’s name, address, and phone number; and(3-17-22)
b.Copies of any required license, credentials, and provider number, if they exist.(3-17-22)
04.Complete Application for Reinstatement. The applicant must complete the reinstatement application form and return the fully executed and notarized form to the Department. (3-17-22)
05.Department Decision. The Department will issue a written decision to grant or deny a request for reinstatement.(3-17-22)
06.Reinstatement Denied. When an application for reinstatement is denied, the applicant is ineligible to reapply for one (1) year from the date the decision of denial becomes final.(3-17-22)
IDAPA 16.05.07.262 (Reserved)
IDAPA 16.05.07.265 Refusal to Enter Into an Agreement
The Department may refuse to enter into a provider agreement for the reasons described in this rule.(3-17-22)
01.Convicted of a Felony. The provider has been convicted of a felony under federal or state law.
02.Committed an Offense or Act Not in Best Interest of Medicaid Participants. The provider has committed an offense or act which the Department determines is inconsistent with the best interests of Medicaid participants.(3-17-22)
03.Failed to Repay. The provider has failed to repay the Department monies which had been previously determined to have been owed to the Department.(3-17-22)
04.Investigation Pending. The provider has a pending investigation for program fraud or abuse.
05.Terminated Provider Agreement. The provider was the managing employee, officer, or owner of an entity whose provider agreement was terminated under Section 230 of these rules.(3-17-22)
IDAPA 16.05.07.266 (Reserved)
IDAPA 16.05.07.270 Miscellaneous Corrective Actions
The Department may take lesser action to investigate, monitor and correct suspected instances of fraud, abuse, over utilization, and other misconduct as provided in this rule.(3-17-22)
01.Issuance of a Warning. Issuance of a warning letter describing the nature of suspected violations, and requesting an explanation of the problem and a warning that additional action may be taken if the action is not justified or discontinued.(3-17-22)
02.Review. Prepayment review of all or selected claims submitted by the provider with notice that claims failing to meet written guidelines will be denied.(3-17-22)
03.Referral. Referral to state licensing boards for review of quality of care and professional and ethical conduct.(3-17-22)
IDAPA 16.05.07.271 (Reserved)
IDAPA 16.05.07.275 Disclosure of Certain Persons
Prior to entering into or renewing a pro vider agreement, or at any time upon written request by the Department, a provider must disclose to the Department the identity of any person described under 42 CFR 1001.1001. The Department may refuse to enter into or renew an agreement with any provider associated with any person so described. The Department may also refuse to enter into, or terminate, a provider agreement if it determines that the provider did not fully and accurately make any disclosure required under these rules.(3-17-22)
IDAPA 16.05.07.276 (Reserved)
IDAPA 16.05.07.280 Provider Notification
When the Department determines actions defined in Sections 2 00 through 250 of these rules are appropriate, it will send written notice of the decision to the provider or person. The notice will state the basis for, and the length and effect of the action on that person’s ability to provide services under state and federal programs, and the person’s appeal rights.(3-17-22)
IDAPA 16.05.07.281 (Reserved)
IDAPA 16.05.07.285 Notice to State Licensing Authorities
The Department will promptly notify all appropriate licensing authorities having responsibility for licensing or certification of a Department action, and the facts and circumstances of that action. The Department may request certain action be taken and that it be informed of actions taken.(3-17-22)
IDAPA 16.05.07.286 (Reserved)
IDAPA 16.05.07.290 Public Notice
The Department will give notice of the action taken and the effectiv e date to the public, appropriate beneficiaries, and may give notice as appropriate to related providers, the Quality Improvement Organization (QIO), institutional providers, professional organizations, contractors, other health insurance payors, and other agencies or Departmental divisions.(3-17-22)
IDAPA 16.05.07.291 (Reserved)
IDAPA 16.05.07.300 Department of Health and Human Services
The Department will notify the Office of Inspector General within fifteen (15) days after a final action in which a person has been excluded, convicted of a criminal offense related to participation in the delivery of health care items or services under the Medicaid program, or reinstated from a prior exclusion.(3-17-22)
IDAPA 16.05.07.301 (Reserved)
16.03.04 Idaho Food Stamp Program
IDAPA 16.03.04.000 Legal Authority
Sections 56-202, 56-203, and 56-209, Idaho Code, authorizes the Department to enter into contracts and agreements with the federal government and to engage in rulemaking for the administration and management of public assistance or welfare services.(7-1-24)
IDAPA 16.03.04.001 (Reserved)
IDAPA 16.03.04.008 Audit, Investigation and Enforcement
The Department may audit, investigate and take enforcement action under these rules and the provisions of IDAPA 16.05.07, “Investigation and Enforcement of Fraud, Abuse or Misconduct.”(7-1-24)
IDAPA 16.03.04.009 (Reserved)
IDAPA 16.03.04.010 Definitions a Through D
01.Adequate Notice. Notice a household must receive on or before the first day of the month an action by the Department is effective.(7-1-24)
02.Administrative Error Claim. A claim resulting from an overissuance caused by the Department’s action or failure to act.(7-1-24)
03.Aid to the Aged, Blind and Disabled (AABD). Cash, excluding in-kind assistance, financed by federal, state, or local government and provided to cover living expenses or other basic needs.(7-1-24)
04.Application for Participation. The application form filed by the head of the household or authorized representative.(7-1-24)
05.Authorized Representative. A person designated by the household to act on behalf of the household to apply for, or receive and use Food Stamps.(7-1-24)
06.Battered Women and Children's Shelter. A shelter for battered women and children which is a public or private nonprofit residential facility.(7-1-24)
07.Boarder. An individual paying a reasonable amount for meals and lodging.(7-1-24)
08.Boarding House. A licensed commercial enterprise offering meals and lodging for payment to make a profit.(7-1-24)
09.Broad-Based Categorical Eligibility. If a participant meets the eligibility requirements found in 7 CFR Section 273.2(j)(2) and also all other Food Stamp eligibility criteria, then the participant is eligible for Food Stamps. Participants who are eligible under this definition are also subject to resource, gross, and net income eligibility standards.(7-1-24)
10.Categorical Eligibility. If all household members receive or are authorized to receive monthly cash payment through TAFI, AABD, or SSI, the household is categorically eligible. Categorically eligible households are exempt from resource, gross, and net income eligibility standards.(7-1-24)
11.Certification Period. The period for which a household is certified to receive Food Stamp benefits. The month of application counts as the first month of certification.(7-1-24)
12.Contact (Six-Month). A recertification that waives the interview requirement, allowing for written contact and verification of the participant’s circumstances in lieu of the interview.(7-1-24)
13.Claim Determination. The action taken by the Department establishing the household’s liability for repayment when an overissuance of Food Stamps occurs.(7-1-24)
14.Department. The Idaho Department of Health and Welfare.(7-1-24)
15.Disqualified Household Members. Individuals required to be excluded from participation in the Food Stamp Program are Disqualified Household Members.(7-1-24)
IDAPA 16.03.04.011 Definitions E Through L
01.Electronic Benefit Transfer (EBT).
A method of issuing Food Stamps to an eligible household.
02.Eligible Foods. Any food or food product for human consumption excluding alcohol, tobacco, and hot food products ready for immediate consumption. Eligible foods also include garden seeds and plants to grow food for human consumption.(7-1-24)
03.Eligible Household. A household living in Idaho and meeting the eligibility criteria in these rules.
04.Exempt. A household member who is not required to register for, or participate in, the JSAP program is exempt. A household member who is not required to register for work is exempt.(7-1-24)
05.Extended Certification Household (EC). A household in which all members are elderly or disabled, and no one has earned income.(7-1-24)
06.Fair Hearing. A fair hearing in an appeal of a Department decision.(7-1-24)
07.Federal Fiscal Year (FFY). The period from October 1 to September 30.(7-1-24)
08.Field Office. A Department service delivery site.(7-1-24)
09.Food and Nutrition Service (FNS). The federal entity under the US Department of Agriculture (USDA) that administers the Food Stamp program.(7-1-24)
10.Group Living Arrangement. A public or private nonprofit residential setting serving no more than sixteen (16) residents. The residents are blind or disabled and receiving benefits under Title II or XVI of the Social Security Act, certified by the Department under Section 1616(e) of the Social Security Act, or under standards determined by the Secretary of USDA to be comparable to Section 1616(e) of the Social Security Act.(7-1-24)
11.Homeless Person. A person:(7-1-24)
a.Who has no fixed or regular nighttime residence.(7-1-24)
b.Whose primary nighttime residence is a temporary accommodation for not more than ninety (90) days in the home of another individual or household.(7-1-24)
c.Whose primary nighttime residence is a temporary residence in a supervised public or private shelter providing temporary residence for homeless persons.(7-1-24)
d.Whose primary nighttime residence is a temporary residence in an institution which provides temporary residence for people who are being transferred to another institution.(7-1-24)
e.Whose primary nighttime residence is a temporary residence in a public or private place which is not designed or customarily used as sleeping quarters for people.(7-1-24)
12.Homeless Meal Provider. A public or private nonprofit establishment or a profit-making restaurant that provides meals to homeless people. The establishment or restaurant must be approved by the Department and authorized as a retail food store by FNS.(7-1-24)
13.Identification Card. The card identifying the bearer as eligible to receive and use Food Stamps.
14.Inadvertent Household Error Claim (IHE). A claim resulting from an overissuance, caused by the household’s misunderstanding or unintended error.(7-1-24)
15.Income and Eligibility Verification System (IEVS). A system of information acquisition and exchange for income and eligibility verification which meets Section 1137 of the Social Security Act requirements.
16.Institution of Higher Education. Any institution that normally requires a high school diploma or equivalency certificate for enrollment. These institutions include colleges, universities, and business, vocational, technical, or trade schools at the post-secondary level.(7-1-24)
17.Institution of Post-Secondary Education. Educational institutions normally requiring a high school diploma or equivalency certificate for enrollment or admits persons beyond the age of compulsory school attendance. The institution must be legally authorized by the state and provide a program of training to prepare students for gainful employment.(7-1-24)
18.Legal Noncitizen. A qualified alien under 8 USC Section 1641(b).(7-1-24)
19.Limited Utility Allowance (LUA). Utility deduction given to a food stamp household that has a cost for more than one (1) utility. This includes electricity and fuel for purposes other than heating or cooling, water, sewage, well and septic tank installation and maintenance, telephone, and garbage or trash collection.(7-1-24)
IDAPA 16.03.04.012 Definitions M Through Z
01.Migrant Farmworker Household. Has a member who travels from community to community to do agricultural work.(7-1-24)
02.Minimum Utility Allowance (MUA). Utility deduction given to a food stamp household that has a cost for one (1) utility that is not heating, cooling, or telephone.(7-1-24)
03.Nonexempt. A household member who must register for work and participate in the JSAP program.(7-1-24)
04.Nonprofit Meal Delivery Service. A political subdivision or a private nonprofit organization that prepares and delivers meals and is authorized to accept Food Stamps.(7-1-24)
05.Overissuance. The amount Food Stamps issued exceeds the Food Stamps a household was eligible to receive.(7-1-24)
06.Parental Control. Means that an adult household member has a minor in the household who is dependent financially or otherwise on the adult. Minors living with children of their own are not under parental control.(7-1-24)
07.Participant. A person who receives Food Stamp benefits.(7-1-24)
08.Program. The Food Stamp Program created under the Food Stamp Act and administered in Idaho by the Department.(7-1-24)
09.Recertification. A recertification is a process for determining ongoing eligibility for Food Stamps.
10.Retail Food Store. For Food Stamp purposes means:(7-1-24)
a.An establishment, or recognized department of an establishment, or a house-to-house food trade route, whose food sales volume is more than fifty percent (50%) staple food items for home preparation and consumption.(7-1-24)
b.Public or private communal dining facilities and meal delivery services.(7-1-24)
c.Private nonprofit drug addict or alcohol treatment and rehabilitation programs.(7-1-24)
d.Public or private nonprofit group living arrangements.(7-1-24)
e.Public or private nonprofit shelters for battered women and children.(7-1-24)
f.Private nonprofit cooperative food purchasing ventures, including those whose members pay for food prior to the receipt of the food.(7-1-24)
g.A farmers’ market.(7-1-24)
h.An approved public or private nonprofit establishment that feeds homeless persons. The establishment must be approved by FNS.(7-1-24)
11.Sanction. A penalty period when an individual is ineligible for Food Stamps.(7-1-24)
12.Seasonal Farmworker Household. Has a member who does agricultural work of a seasonal or other temporary nature.(7-1-24)
13.Self-Employment. The process of actively earning income directly from one's own business, trade, or profession. To be considered self-employed, a person is responsible for obtaining or providing a service or product that generates, or is expected to generate, income.(7-1-24)
14.Spouse. Persons who are legally married under Idaho law.(7-1-24)
15.Standard Utility Allowance (SUA). Utility deduction given to a food stamp household that has a cost for heating or cooling.(7-1-24)
16.State. Any of the fifty (50) States, the District of Columbia, Puerto Rico, Guam, Northern Mariana Islands, and Virgin Islands of the United States.(7-1-24)
17.Student. An individual between the ages of eighteen (18) and fifty (50), physically and intellectually fit, and enrolled at least half-time in an institution of higher education. An institution of higher education usually requires a high school or general equivalency diploma for enrollment. This includes colleges, universities, and vocational or technical schools at the post-secondary school level.(7-1-24)
18.Substance Use Disorder Treatment Program. Any drug or alcohol rehabilitation program conducted by a private nonprofit organization or institution or a publicly operated community mental health center under Part B of Title XIX of the Public Health Service Act (42 USC 300x, et seq.). Indian reservation-based centers may qualify if FNS requirements are met and the program is funded by the National Institute on Alcohol Abuse under Public Law 91-616 or was transferred to Indian Health Service funding.(7-1-24)
19.Supplemental Security Income (SSI). Monthly cash payments under Title XVI of the Social Security Act. Payments include state or federally administered supplements.(7-1-24)
20.Systematic Alien Verification for Entitlements (SAVE). The federal automated system that provides immigration status needed to determine an applicant's eligibility for many public benefits, including Food Stamps.(7-1-24)
21.Telephone Utility Allowance (TUA). Utility deduction given to a Food Stamp household that has a cost for telephone services and no other utilities.(7-1-24)
22.Timely Notice. Notice that is mailed electronically, at least ten (10) days before the effective date of an action taken by the Department.(7-1-24)
23.Tribal General Assistance. Cash , excluding in-kind assistance, financed by federal, state, or local government and provided to cover living expenses or other basic needs.(7-1-24)
24.Verification. Third party data or documents used to prove the accuracy of information used to make an eligibility determination.(7-1-24)
25.Verified Upon Receipt. Information received from certain authorized automated system matches that are considered automatically verified unless questionable.(7-1-24)
26.Written Notice. Correspondence that is generated by any method including handwritten, typed, or electronic, delivered to the customer by hand, U.S. Mail, professional delivery service, or by any electronic means.
The terms “notice” and “written notice” are used interchangeably.(7-1-24)
IDAPA 16.03.04.013 Abbreviations a Through G
01.AABD.
Aid to the Aged, Blind, and Disabled.(7-1-24)
02.ABAWD. Able-bodied adults without dependents.(7-1-24)
03.AE. Administrative Error.(7-1-24)
04.AFA. Application for Assistance.(7-1-24)
05.CSS. Bureau of Child Support Services.(7-1-24)
06.DHW. Department of Health and Welfare in Idaho.(7-1-24)
07.EBT. Electronic Benefit Transfer.(7-1-24)
08.EWS. Enhanced Work Services.(7-1-24)
09.FNS. Food and Nutrition Service of the USDA.(7-1-24)
10.FFY. Federal fiscal year.(7-1-24)
11.FPG. Federal Poverty Guideline(s).(7-1-24)
12.FQC. Federal Quality Control.(7-1-24)
13.HUD. US Department of Housing and Urban Development.(7-1-24)
IDAPA 16.03.04.014 Abbreviations I Through Z
01.IHE. Inad vertent household error.(7-1-24)
02.IPV. Intentional program violation.(7-1-24)
03.IRS. Internal Revenue Service.(7-1-24)
04.JSAP. Job Search Assistance Program.(7-1-24)
05.LUA. Limited utility allowance.(7-1-24)
06.MUA. Minimum utility allowance.(7-1-24)
07.PA. Public Assistance.(7-1-24)
08.RSDI. Retirement, Survivors, Disability Insurance received from SSA.(7-1-24)
09.SAVE. Systematic Alien Verification for Entitlements.(7-1-24)
10.SDX. State Data Exchange.(7-1-24)
11.SQC. State Quality Control.(7-1-24)
12.SUA. Standard utility allowance.(7-1-24)
13.SSA. Social Security Administration.(7-1-24)
14.SSI. Federal Supplemental Security Income Program for the aged, blind, or disabled.(7-1-24)
15.SSN. Social Security Number.(7-1-24)
16.TAFI. Temporary Assistance for Families in Idaho.(7-1-24)
17.TOP. Treasury Offset Program.(7-1-24)
18.TUA. Telephone Utility Allowance.(7-1-24)
19.UI. Unemployment Insurance.(7-1-24)
20.USDA. U S Department of Agriculture.(7-1-24)
21.VA. Veterans Administration.(7-1-24)
22.WIOA. Workforce Innovation and Opportunity Act.(7-1-24)
IDAPA 16.03.04.015 (Reserved)
IDAPA 16.03.04.099 Signatures
An individual who is applying for benefits, receiving benefits, or providing additional information as required in these rules, may do so with the representation of the individual's name either handwritten, electronic, or recorded telephonically. Such signature serves as intention to execute or adopt the sound, symbol, or process for the purpose of signing the related record. (7-1-24)
IDAPA 16.03.04.100 Application
To apply for Food Stamps, the household or an authorized representati ve must complete and file an application with the Department, complete an interview, and verify information. There is no age requirement for applicants.
Applicants may bring anyone to the interview. The Department will act on all applications and will grant Food Stamps to eligible households back to the date of application.(7-1-24)
IDAPA 16.03.04.101 Application Forms
Households can file an application the firs t day they contact the Department. The Department will have AFA forms readily available to households and will provide an AFA to any person making a request. Requests for the application can be made by telephone, in person, or by another person. The Department will mail or give the AFA to the person on the day requested.(7-1-24)
IDAPA 16.03.04.102 (Reserved)
IDAPA 16.03.04.103 Filing an Application
The AFA must contain the applicant’s name, address, signature, and application date. A household can file for Food Stamps by turning in page one of the AFA to the Food Stamp office. This protects the application date. If the household is eligible, Food Stamps for the first month will be prorated from the application date. The AFA can be submitted at the field office by the household or authorized representative. The AFA can be submitted by mail, fax, or email.(7-1-24)
IDAPA 16.03.04.104 (Reserved)
IDAPA 16.03.04.106 Determination of When a New Application for Assistance (afa) Is
REQUIRED.
The Department must follow the procedure outlined in 7 CFR 273.2(g) and (h) in determining when a food stamp hou sehold is required to fill out a new AFA.(7-1-24)
IDAPA 16.03.04.107 (Reserved)
IDAPA 16.03.04.113 Household Cooperation
The household must cooperate with the Department. The application must be denied if the household refuses to cooperate. Refusal to cooperate includes failing to act without a sound and timely excuse. Giving false information on purpose is failure to cooperate. If an application is denied or Food Stamps are stopped for refusal to cooperate, the household may reapply. The household is not eligible until it cooperates with the Department.(7-1-24)
IDAPA 16.03.04.114 Application Withdrawal
Households can withdraw their applic ation any time before the eligibility decision. The Department will document the case record with the withdrawal reason. The Department will tell the household of the right to reapply.(7-1-24)
IDAPA 16.03.04.115 Authorized Representative
The household can choose a nonhousehold member to act as an authorized representative. The household can design ate in writing another responsible household member or a responsible adult outside the household as an authorized representative. An adult employee of an authorized substance use disorder treatment and rehabilitation center, or an authorized group living arrangement center, may act as an authorized representative for the household.
Conditions for an authorized representative are:(7-1-24)
01.Designating Authorized Representative. Households may designate an authorized representative to act on behalf of a household to apply for, receive, or use food stamps. The authorized representative should be aware of household circumstances.(7-1-24)
02.Persons Who Cannot Be an Authorized Representative. Persons with a conflict of interest may not act as an authorized representative without the Department’s written approval. The field office supervisor must determine if no one else is available and give written approval. Persons with a conflict of interest are listed below:
a.Retailers allowed to accept Food Stamps.(7-1-24)
b.Department employees involved in the certification or issuance process.(7-1-24)
c.A person disqualified for IPV during the penalty period, unless they are the only adult household member and no one else is available.(7-1-24)
d.Homeless meal providers.(7-1-24)
03.Department Responsibilities. The Department will:(7-1-24)
a.Make sure authorized representatives are properly selected.(7-1-24)
b.Record the representative’s name in the case record.(7-1-24)
c.Inform the household it will be liable for any overissuance resulting from wrong information given by the representative.(7-1-24)
d.Make sure the household freely requested the representative.(7-1-24)
04.Authorized Representative Removed. The Department may remove an authorized representative for up to one (1) year if the person knowingly gives false information, or improperly uses the Food Stamps. This provision does not apply to substance use disorder centers and group homes. Written notice must be sent to the household and the authorized representative thirty (30) days before the penalty begins. The notice must list: (7-1-24)
a.The proposed action.(7-1-24)
b.The reason for the action.(7-1-24)
c.The right to a fair hearing.(7-1-24)
d.The name and telephone number to contact for more information.(7-1-24)
05.Authorized Representatives for Substance Use Disorder Treatment Centers and Group Homes. Substance use disorder treatment centers and the heads of group living arrangements that act as authorized representatives for their residents, and which intentionally misrepresent households’ circumstances, may be prosecuted under applicable federal and state statutes for their acts.(7-1-24)
IDAPA 16.03.04.116 (Reserved)
IDAPA 16.03.04.120 Household Interviews
The Department must conduct an interview with the applican t, a member of the household, or the authorized representative. Interviews must be conducted either face-to-face or via telephone The frequency of the interview must be as follows:(7-1-24)
01.Twenty-Four Months. At least once every twenty-four (24) months for households certified for twenty-four (24) months.(7-1-24)
02.Twelve Months. Every twelve (12) months for all other households.(7-1-24)
IDAPA 16.03.04.121 (Reserved)
IDAPA 16.03.04.133 Verification
The Department must have verification to support the benefit determination. The Department must give the applicant hous ehold a clear written statement of the proof to bring to the interview. The statement will indicate the Department will help the household get proof, if needed. The Department must give the household ten (10) calendar days from the request date to provide proof. Proof can be provided in person, by mail, or by electronic interfaces. If the proof supplied is questionable, the Department can require further proof. The Department will notify the household of any other steps necessary to complete the application process.(7-1-24)
IDAPA 16.03.04.134 (Reserved)
IDAPA 16.03.04.135 Sources of Verification
The following sources of verification must be considered:(7-1-24)
Written Confirmation. A primary source of proof is written confirmation of circumstances.
Written proof includes driver’s licenses, work or school identification, birth certificates, wage stubs, award letters, court orders, divorce decrees, separation agreements, insurance policies, rent receipts, and utility bills. Acceptable proof is not limited to a single document. Proof can be obtained from the household or other sources. Secondary sources of proof must be used to verify a household’s circumstances if the primary source cannot be obtained or does not prove eligibility or benefit level.(7-1-24)
02.Collateral Contact. An oral confirmation of a household’s circumstances by a person outside of the household. The collateral contact may be made either in-person or over the telephone.(7-1-24)
03.Automated System Data. Information that is obtained through interfacing with other government agency computer systems or authorized systems.(7-1-24)
IDAPA 16.03.04.136 (Reserved)
IDAPA 16.03.04.137 Proof for Questionable Information
Prior to the certification, a six-month or twelve-month contact, or recertification of the household, the Department must verify all questionable information regarding eligibility and benefit level. Proof is required when details are not consistent with information received by the Department. Proof may be obtained either verbally or in writing.(7-1-24)
IDAPA 16.03.04.138 Providing Proof to Support Application Statements
The household has primary responsibility to provide proof sup porting its statements on the application and to resolve any questionable information. The Department must assist the household in obtaining proof. Households may supply proof in person, or by mail, facsimile, or other electronic interfaces. The Department will not require the household to present proof in person.(7-1-24)
IDAPA 16.03.04.139 (Reserved)
IDAPA 16.03.04.142 Processing Standards
The Department will determine Food Stamp eligibility within thirty (30) days of the application date. The application date is the day the AFA is received and date stamped by the field office. The application date for a person released from a public institution is the release date if the person applied for Food Stamps before their release. The AFA must contain at least the applicant’s name and address and be signed by a responsible household member or representative.
IDAPA 16.03.04.143 (Reserved)
IDAPA 16.03.04.146 Denial of Food Stamp Application
The Department will deny the Food Stamp application under conditions listed below and send the household notice of deni
al.(7-1-24)
01.Household Ineligible. The Department will deny the application for ineligible households as soon as possible, but not later than thirty (30) calendar days following the application date.(7-1-24)
02.Household Fails to Appear for Interview. If the household fails to appear for an interview, and fails to contact the Department, the application will be denied thirty (30) calendar days after the application date.
03.Household Does Not Provide Proof After Interview. If the household did not provide requested proof after an interview or later request, the Department will deny the application ten (10) calendar days after the request for proof.(7-1-24)
IDAPA 16.03.04.147 Delays in Processing
The Department must follow the procedure outlined in 7 CFR 273.2(h) in determining the appropriate action to take on fo od stamp benefits when there are delays in completing the application process.(7-1-24)
IDAPA 16.03.04.148 (Reserved)
IDAPA 16.03.04.155 Expedited Service Eligibility
Applicants must be screened to determine if the household is entitled to expedited service. The household must meet one (1) of the expedited service criteria below. The household must have provided proof postponed by the last expedited service or have been certified under the normal standards since the last expedited service.(7-1-24)
01.Low Income and Resources. To receive expedited services, the household’s monthly countable gross income must be less than one hundred fifty dollars ($150) and the household’s liquid resources must not exceed one hundred dollars ($100).(7-1-24)
02.Destitute. To receive destitute expedited services, the household must be a destitute migrant or seasonal farmworker household. The household’s liquid resources must not exceed one hundred dollars ($100).
03.Income Less Than Rent and Utilities. The household’s combined monthly gross income and liquid resources are less than their monthly rent or mortgage, and utilities cost.(7-1-24)
IDAPA 16.03.04.156 Time Limits for Expedited Food Stamps
Time limits for acting on expedited Food Stamp applications
01.Seven Day Limit for Food Stamps. For households entitled to expedited service, the Department will provide Food Stamps to the household within seven (7) days of the application date.(7-1-24)
02.Seven Days After Discovery. If not discovered at initial screening, the Department will provide expedited services to an expedite-eligible household within seven (7) days, which begins the day after the Department finds the household is entitled to expedited service.(7-1-24)
03.Seven Days for Waived Interview. The Department will provide expedited services within seven (7) days of the application date for households entitled to an office interview waiver. Seven (7) days is counted from the application date.(7-1-24)
IDAPA 16.03.04.157 Expedited Food Stamp Work Registration
The applicant must complete work registration unles s they are exempt or have a representative register them. Other non- exempt household members must register if the registration can be done in seven (7) days.(7-1-24)
IDAPA 16.03.04.158 Expedited Verification
The Department will verify the applicant’s identity through readi ly available proof or a collateral contact. Proof may include identification such as a driver’s license, birth certificate, or voter registration card. The Department will try to get proof so that benefits can be issued within seven (7) days of the application date. Expedited Food Stamps must not be delayed beyond seven (7) days for proof other than identity. Other proof can be postponed to issue expedited Food Stamps.(7-1-24)
IDAPA 16.03.04.159 (Reserved)
IDAPA 16.03.04.160 Expedited Certification
If all required proof is provided for expedited certification, a normal certification period is assi gned. Certification based on application date, household type, and proof is listed below:(7-1-24)
01.Non-migrant Household Applying from the First Through the Fifteenth of the Month.
a.For a non-migrant household applying from the first through the fifteenth of the month, if proof of eligibility factors is postponed, assign a normal certification period; the Department will issue the first month’s benefits. The Department will not issue the second month’s benefits until the postponed proof is received.(7-1-24)
b.When proof is postponed, the household has thirty (30) days from the application date to provide the proof. The household must be given timely and adequate notice that no further benefits will be issued until proof is completed. If the proof results in changes in the household’s Food Stamps, the Department will act on the changes without advance notice.(7-1-24)
c.If postponed proof is provided before the second month, the Department will process an issuance for the first working day of the second month. If proof is provided in the second month, the Department will issue benefits within seven (7) calendar days from the date the proof is received. If postponed proof is not provided within thirty (30) days from the application date, the Department will close the case.(7-1-24)
02.Non-migrant Household Applying from the Sixteenth Through the End of the Month.
a.For a non-migrant household applying from the sixteenth to the end of the month, if proof of eligibility factors is postponed, the Department will assign a normal certification period, and issue the first- and second-month’s benefits within the expedited time frame.(7-1-24)
b.When proof is postponed, the household has thirty (30) days from the application date to complete the proof. The household must be given timely and adequate notice that no further benefits will be issued until proof is completed. If the proof results in changes in the household’s Food Stamps, the Department will act on the changes without advance notice.(7-1-24)
c.If postponed proof is provided within thirty (30) days, the Department will process an issuance for the first working day of the third month. If postponed proof is not provided within thirty (30) days from the application date, the Department will close the case.(7-1-24)
03.Migrant Household Applying from the First Through the Fifteenth of the Month.(7-1-24)
a.For a migrant household applying from the first (1st) through the fifteenth (15th) of the month, if proof of eligibility factors is postponed, the Department will assign a normal certification period, and issue the first month’s benefits.(7-1-24)
b.When proof is postponed, the household has thirty (30) days from the application date to complete in-state proof. The household has sixty (60) days from the application date to complete out-of-state proof. The household must be given adequate and timely notice no further benefits will be issued until the postponed proof is completed. Before the second month’s benefits are issued, the household must provide all in-state postponed proofs.
Before the third month’s benefits are issued, the household must provide all out-of-state postponed proof. If the proofs result in changes in the household’s Food Stamps, the Department will act on these changes, without providing advance notice.(7-1-24)
c.Migrants are entitled to postponed out-of-state proof only once each season. If postponed in-state proof is provided before the second month, the Department will process an issuance for the first working day of the second month. If postponed out-of-state proof is provided before the third month, the Department will process a regular issuance for the third month. If postponed out-of-state proof is provided in the third month, the Department will issue benefits within seven (7) calendar days from the date proof is received. If postponed in-state proof is not provided within thirty (30) days from the application date, the Department will close the case. If postponed out-ofstate proof is not provided within sixty (60) days from the application date, the Department will close the case.
04.Migrant Household Applying from the Sixteenth Through the End of the Month.(7-1-24)
a.For a migrant household applying from the Sixteenth to the end of the month, if proof of eligibility factors is postponed, the Department will assign a normal certification period, and issue the first- and second-months’ benefits within the expedited time frame.(7-1-24)
b.When proof is postponed, the household has thirty (30) days from the application date to provide in-state proof. The household has sixty (60) days from the application date to provide out-of-state proof. The household must be given adequate and timely notice no further benefits will be issued until the postponed proof is completed. Before the third month’s benefits are issued, the household must provide all in-state and out-of-state postp oned proofs. If the proofs result in changes in the household’s Food Stamps, the Department will act on these changes without providing advance notice.(7-1-24)
c.Migrants are entitled to postponed out-of-state proof only once each season. If postponed proof is provided before the third month, the Department will process a regular issuance for the third month. If postponed outof-state proof is provided in the third month, the Department will issue benefits within seven (7) calendar days from the date proof is received. If postponed in-state proof is not provided within thirty (30) days from the application date, the Department will close the case. If postponed out-of-state proof is not provided within sixty (60) days from the application date, the Department will close the case.(7-1-24)
05.Reapplying Household. When a household granted postponed proof at the last expedited certification reapplies, it must provide the postponed proof before it is again eligible for expedited certification. The Department does not require postponed proof if the household was certified under normal standards since the last expedited certification.(7-1-24)
IDAPA 16.03.04.161 No Limit to Expedited Certifications
There is no limit to the number of times a household can receive expedited certification.(7-1-24)
IDAPA 16.03.04.162 Expedited Services for D
ESTITUTE HOUSEHOLDS.
Migrant or seasonal farmworker households meeting destitute conditions below can get expedited services. The rules for destitute households apply at initial application, the six-month or twelve-month contact, and recertification, but only for the first month of each contact or certification period.(7-1-24)
01.Terminated Source of Income. When the household’s only income for the application month was received before the application date and was from a terminated source the Department will consider the household destitute. Terminated income is income received monthly or more often, no longer received from the same source the rest of the application month, or the next month or income received less often than monthly and not expected in the month the next regular payment is normally due.(7-1-24)
02.New Income in Application Month. When only new income is expected in the application month, the household is considered destitute. Only twenty-five dollars ($25), or less, of new income can be received in the ten (10) days after the application date. Income is new if twenty-five dollars ($25), or less, is received during the thirty (30) days before the application date. New income was received less often than monthly, was not received in the last normal payment interval, or was twenty-five dollars ($25) or less.(7-1-24)
03.Terminated Income and New Income in Application Month. Destitute households can get terminated income before the application date and new income before and after the application date. New income must not be received for ten (10) days after application and not exceed twenty-five dollars ($25). The household must get no other income in the application month.(7-1-24)
04.Application Month. For the application month, the Department will count only income received between the first day of the month and the application date, and will not count income from a new source expected after the application date.(7-1-24)
IDAPA 16.03.04.163 Special Consideration of Income for Destitute Households
Special consideration of in come for destitute households is listed below. The rules for destitute households apply at initial application, a six-month or twelve-month contact, and recertification, but only for the first month of each contact or certification period.(7-1-24)
01.Travel Advances. For destitute eligibility and benefit level, travel advances:(7-1-24)
a.Rom employers for travel costs to a new employment location are excluded.(7-1-24)
b.Against future wages are counted as income, but not a new source of income.(7-1-24)
02.Household Member Changes Job. A person changing jobs with the same employer is still getting income from the same source. A migrant’s income source is the grower, not the crew chief. When a migrant moves with a crew chief from one (1) grower to another, the income from the first grower is ended. The income from the next grower is new income.(7-1-24)
03.Recertification or Six-Month or Twelve-Month Contact. The Department will disregard income from the new source for the first month of the new certification period if more than twenty-five dollars ($25) will not be received by the tenth calendar day after the normal issuance.(7-1-24)
IDAPA 16.03.04.164 Denial of Expedited Service
The Department will deny expedited service if the household does not meet expedite criteria or fails to cooperate in the application process. Failure to cooperate includes missing a scheduled expedited service appointment. The Department will still process the application under standard methods.(7-1-24)
IDAPA 16.03.04.165 Contesting Denied Expedited Service
The Department will offer an agency conference to a household contesting denial of expedited services. The Department will tell households they can request an agency conference; the conference will not delay or replace a fair hearing. Migrant farmworker households and households planning to move are entitled to expedited fair hearings.
IDAPA 16.03.04.166 (Reserved)
IDAPA 16.03.04.178 Categorically Eligible Households
Households with all members meeting one (1) of the criteria below are categorically eligible for Food Stamps. The Department will not compute resource eligibility, gross or net income limits, social security number information, sponsored alien information, and residency. Categorically eligible households must meet all other Food Stamp eligibility criteria, and have the same rights as other households.(7-1-24)
01.Cash Benefits. All household members are approved for or already receive TAFI, AABD, or SSI cash benefits.(7-1-24)
02.Benefits Recouped. All household members have AABD or SSI benefits being recouped. (7-1-24)
03.Grant Less Than Ten Dollars. All household members not receiving TAFI, AABD, or SSI because their grant is less than ten dollars ($10).(7-1-24)
IDAPA 16.03.04.179 Households Not Categorically Eligible
The households listed below are not categorical ly eligible for Food Stamps.(7-1-24)
01.IPV. Households are not categorically eligible, if any household member is disqualified for a Food Stamp IPV.(7-1-24)
02.Work Requirements. Households are not categorically eligible, if any household member fails to comply with the Food Stamp work requirements.(7-1-24)
03.Ineligible Legal Non-Citizen or Student. Households are not categorically eligible if any member is an ineligible legal non-citizen or ineligible student.(7-1-24)
04.Nonexempt Institution. Households are not categorically eligible if any member is a person living in a nonexempt institution.(7-1-24)
IDAPA 16.03.04.180 Categorical Eligibility Ends
Categorical eligibility ends when the household member i s no longer eligible for TAFI, AABD, or SSI. If the household is still eligible under Food Stamp rules, the household will continue to receive Food Stamps. If categorical eligibility ends and household income or resources exceed the Food Stamp limits, the household is no longer eligible for Food Stamps. Food Stamps will stop after timely advance notice.(7-1-24)
IDAPA 16.03.04.181 Broad -Based Categorically E
LIGIBLE HOUSEHOLD EXCEPTIONS.
If a household contains any of the following members, the household is not eligible under Broad-Based Categorical Eligibility.(7-1-24)
01.IPV. Any household member is disqualified for an IPV.(7-1-24)
02.Drug-Related Felony. Any household member is ineligible because of a drug-related felony.
03.Strike. Any household member is on strike.(7-1-24)
04.Transferred Resources. Any household member transferred resources to qualify for benefits.
05.Refusal to Cooperate. Any household member refused to cooperate in providing information that is needed to determine initial or ongoing eligibility.(7-1-24)
IDAPA 16.03.04.182 Verification for Tafi or Aabd Households
To determine eligibility for Food Stamps in TAFI or AA BD households, the Department will use TAFI or AABD proof.(7-1-24)
IDAPA 16.03.04.183 Time Limits for Categorically Eligible Households
The Food Stamp application must not be delayed or denied because of a delayed public assistance decision. (7-1-24)
IDAPA 16.03.04.184 (Reserved)
IDAPA 16.03.04.195 Disaster Certification
When allowed by FNS, under Section 302(a) of the Disaster Relief Act of 1974, the Department can certify households affected by a natural disaster. If the Secretary of USDA declares a disaster area, the Department will follow disaster instructions issued by the USDA.(7-1-24)
IDAPA 16.03.04.196 (Reserved)
IDAPA 16.03.04.200 Nonfinancial Criteria
Nonfinancial criteria are identification, residency , Social Security Number, citizenship, and work requirements.
Households must meet these nonfinancial criteria to be eligible for Food Stamps.(7-1-24)
IDAPA 16.03.04.201 Identification
The person making application for Food Stamps, including an authorized representative, must prove identity. Proof includes a driver’s license, school identification, wage stubs, and birth certificates. The Department will accept other reasonable proof of identity.(7-1-24)
IDAPA 16.03.04.202 Residency
A household must live in Idaho when applying for Food Stamps. A person can get Food Stamps as a member of only one (1 ) household a month.(7-1-24)
01.Place of Residency. An eligible Food Stamp household is not required to live in a permanent dwelling or have a fixed mailing address. There is no residence duration requirement.(7-1-24)
02.Vacationing Persons Not Residents. Persons in Idaho for vacation only are not residents for Food Stamp eligibility. Vacation is the period a household spends away from their usual activity, work, or home for travel, rest, or recreation.(7-1-24)
03.Different Physical and Mailing Addresses. The physical and mailing addresses of a Food Stamp household can be different. If the mailing address is not the household’s physical address, the household must provide proof of the physical address.(7-1-24)
IDAPA 16.03.04.203 Social Security Number (ssn) Requirement
01.Expectations. Before certification, households must provide the Department the SSN, or proof of application for SSN, for each household member. If a household member has more than one (1) SSN, they must provide all SSNs. Each SSN must be verified by the SSA. A household member with an unverified SSN is not eligible for Food Stamp benefits. The ineligible person’s income and resources must be counted in the Food Stamp budget. If benefits are reduced or ended, because one (1) or more persons fail to meet the SSN requirement, the household must be notified in writing.(7-1-24)
02.Good Cause for Not Applying for SSN. If a household member can show good cause why an SSN application was not completed in a timely manner, an extension must be granted to allow them to receive Food Stamp benefits for one (1) month in addition to the month of application. Good cause for failure to apply must be shown monthly for such a household member to continue to participate.(7-1-24)
IDAPA 16.03.04.204 Citizenship and Qualified Non-Citizen
REQUIREMENTS.
To be eligible for Food Stamps, an individual must meet the requirements under 7 CFR 273.4, “Citizenship and alien status.”(7-1-24)
IDAPA 16.03.04.205 Written Declaration of Citizenship or Immigration Status
To get Food Stamps, one (1) adult household member must certi fy by signing a statement, under penalty of perjury, regarding the citizenship and immigration status of household members applying for benefits.(7-1-24)
IDAPA 16.03.04.206 Proof of Proper Immigration Status
01.Expectations.
Households are required to submit documents to verify the immigration status of the legal non-citizen applicants.(7-1-24)
02.Failure to Provide Legal Non-Citizen Documents. If a household says it is unable or unwilling to provide legal non-citizen status documents for a legal non-citizen household member, the legal non-citizen member must be classified as an ineligible legal non-citizen.(7-1-24)
IDAPA 16.03.04.207 Non-Citizen Eligibility Pending Verification
When an application is delayed after the Department has subm itted a request to a federal agency for proof of eligible alien status, the Department must certify the person applying as eligible for Food Stamps pending the results of the investigation. The certification can last up to six (6) months from the date of the original request for proof. (7-1-24)
IDAPA 16.03.04.208 (Reserved)
IDAPA 16.03.04.212 Food Stamp Households
A Food Stamp household is composed of a person, or group of persons, applying for or getting Food Stamps. The composition of Food Stamp households is listed below:(7-1-24)
01.A Person Living Alone.(7-1-24)
02.Living with Others Preparing Separate Meals. Person(s) living with others, but customarily purchasing food and preparing meals separately from the others.(7-1-24)
03.Living with Others with Furnished Meals. Person(s) living with others and being furnished both meals and lodging. The person(s) pays less than the thrifty food plan.(7-1-24)
04.Living Together Preparing Common Meals. A group of persons who live, purchase food, and customarily prepare meals together for home consumption.(7-1-24)
05.Women Living in Shelter. Women, or women with their children, temporarily residing in a shelter for battered women and children.(7-1-24)
06.Living in Substance Use Disorder Treatment Center. Person living in a publicly operated community health center or in a private nonprofit center for substance use disorder treatment and rehabilitation.
07.Resident of Group Living Center. Person residing in a group living arrangement center certified by the Department.(7-1-24)
IDAPA 16.03.04.213 Separate Food Stamp Household Composition
FOR RELATED MEMBERS.
One (1) of the conditions below must be met for related persons living together to be separate Food Stamp households.(7-1-24)
01.Children Age Twenty-Two and Older Living With Parents. Can be separate Food Stamp households. The households must purchase and prepare their food separately.(7-1-24)
02.Households Must Prepare Food Together Because of Age and Disability. Households that must purchase and prepare food together because one (1) household contains a person sixty (60) years old or older unable to purchase and prepare meals because of a disability, can be separate Food Stamp households. The spouse of the disabled person must be considered a member of that person’s household. These households must meet the following conditions:(7-1-24)
a.The disability must be permanent under the Social Security Act or a nondisease-related, severe permanent disability.(7-1-24)
b.The income of the household, which does not contain the person unable to purchase and prepare meals separately, must not exceed one hundred sixty-five percent (165%) of the net monthly income limit for the household size. To count income for the one hundred sixty-five percent (165%) net monthly income standard, exclude the income of the disabled person and their spouse.(7-1-24)
c.Count all available income to the household not containing the disabled person. Compare the net monthly income eligibility standard for that size household.(7-1-24)
IDAPA 16.03.04.214 Child Custody
For a child under eighteen (18) years old, the parent with primary physical custody is eligible to receive Food Stamp benefits for that child. If both parents request food stamp benefits for the child, primary custody is determined by where the child is expected to spend fifty-one percent (51%) or more of the nights during a certification period. When only one (1) parent applies for food stamp benefits, the child may be included in that parent's household even though they do not have primary physical custody of the child.(7-1-24)
IDAPA 16.03.04.215 Persons Not Eligible for Separate Food St
AMP HOUSEHOLD STATUS.
Persons listed below cannot be separate Food Stamp household s. For Food Stamps, they are part of the household where they live.(7-1-24)
01.Spouses.(7-1-24)
02.Parents and Children Together. Children under age twenty-two (22), living together with their parents. Parents and children living together include natural, adopted, or stepchildren.(7-1-24)
03.Child Under Age Eighteen Under Parental Control. A child under age eighteen (18) and under parental control of an adult household member, unless the child is a foster child.(7-1-24)
IDAPA 16.03.04.216 Elderly or Disabled Food St
AMP HOUSEHOLD MEMBERS.
To be counted as an elderly or disabled Food Stamp household member, the person must meet one (1) of the llowing:(7-1-24)
01.Age Sixty or Older.(7-1-24)
02.Entitled to SSI Benefits. This includes SSI presumptive disability payments, SSI emergency advance payments, or special SSI status.(7-1-24)
03.Entitled to Social Security Payments Based on Disability or Blindness (RSDI).(7-1-24)
04.State Supplement. Entitled to state or federally funded State supplement payments to the SSI program such as AABD.(7-1-24)
05.Entitled to Medicaid Based on SSI-Related Disability or Blindness.(7-1-24)
06.Disability Retirement. Entitled to federal or state funded-disability retirement benefits because of a disability considered permanent by SSA.(7-1-24)
07.Disabled Veteran. A veteran with a service- or nonservice-connected disability rated or paid as total.(7-1-24)
08.Veteran Needing Aid and Attendance. A veteran considered in need of regular aid and attendance or permanently housebound under USC Title 38.(7-1-24)
09.Veteran's Surviving Spouse. In need of aid and attendance or permanently housebound. (7-1-24)
10.Veteran's Surviving Child. Permanently incapable of self-support under USC Title 38.(7-1-24)
11.Veteran's Survivor Entitled. A veteran’s surviving spouse or child entitled to receive payment for a service-connected death under USC Title 38. The veteran’s surviving spouse or child must be permanently disabled under Section 221(i) of the Social Security Act. A veteran’s surviving spouse or child entitled to pension benefits for a nonservice death under USC Title 38. The veteran’s surviving spouse or child must be permanently disabled under Section 221(i) of the Social Security Act. “Entitled” refers to veterans, surviving spouses, and children receiving pay or benefits, or who have been approved for payments, but are not yet receiving them.(7-1-24)
12.Railroad Retirement and Medicare. Entitled to an annuity payment under Section 2(a)(1)(iv) of the Railroad Retirement Act of 1974 and determined eligible for Medicare by the Railroad Retirement Board.
13.Railroad Retirement and Disability. Entitled to an annuity payment under Section 2(a)(1)(v) of the Railroad Retirement Act of 1974 and is determined disabled by the Board under SSI criteria.(7-1-24)
IDAPA 16.03.04.217 Nonhousehold Members
Nonhousehold members are persons not counted in determining Food Stamp household size. Their income and resources do not count toward the Food Stamp household. Nonhousehold members may be eligible as a separate household and are listed below:(7-1-24)
01.Roomers. A person who pays for lodging, but not meals.(7-1-24)
02.Live-In Attendants. A person living with a household to provide medical, housekeeping, child care, or other similar services.(7-1-24)
03.Ineligible Students. A person between the ages of eighteen (18) and fifty (50), physically and intellectually fit, enrolled at least half-time in an institution of higher education, and not meeting Food Stamp eligibility requirements for students.(7-1-24)
04.Residents of Institutions. A resident of an institution is an ineligible household member because the institution provides the resident over fifty percent (50%) of three (3) meals daily, as part of the normal services.
The institution is not allowed to accept Food Stamps.(7-1-24)
IDAPA 16.03.04.218 Persons Disqualified as Food
STAMP HOUSEHOLD MEMBERS.
Persons disqualified as Food Stamp household members mu st not participate in the Food Stamp program.
Disqualified household members include, but are not limited to, sanctioned individuals, fleeing felons, and ineligible non-citizens. Treatment of disqualified household members is described under 7 CFR 273.11(c).(7-1-24)
IDAPA 16.03.04.219 Circumstances Under Which Food Stamp Participation Is Prohibited
01.Prohibition from Receiving Food Stamp Benefits. An individual is prohibited from receiving Food Stamp benefits at the time of application if they:(7-1-24)
a.Receive tribal commodities;(7-1-24)
b.Are incarcerated;(7-1-24)
c.Are in an institution;(7-1-24)
d.Are in foster care and the foster parents are receiving a cash benefit for providing care and maintenance for the child;(7-1-24)
e.Receive Food Stamp benefits in another household;(7-1-24)
f.Are deceased; or(7-1-24)
g.Receive cash benefits in a TAFI Caretaker Relative household.(7-1-24)
02.Prohibited Participation During the Certification Period. If the Department learns of prohibited participation during the certification period, it will act to end benefits for that individual.(7-1-24)
IDAPA 16.03.04.220 (Reserved)
IDAPA 16.03.04.226 Job Search Assistance Program (jsap)
01.JSAP Status.
All household members, unless exempt, must participate in JSAP, including members who are on strike and members who are not migrants in the job stream. The Department determines the JSAP status of a participant at certification, a six-month or twelve-month contact, recertification, and when household changes occur.(7-1-24)
02.JSAP Information. The Department will explain the JSAP requirement, rights, responsibilities, and the result of failure to comply.(7-1-24)
IDAPA 16.03.04.227 Exemptions from Jsap
01.Parents or Caretakers Responsible for the Care of a Child Under Six Years Old.
If the child becomes six (6) during the certification period, the parent or caretaker must register for JSAP at the next scheduled six-month or twelve-month contact or recertification, unless exempt for another reason.(7-1-24)
02.Parents and Caretakers of an Incapacitated Person. A parent or caretaker responsible for the care of a person incapacitated due to illness or disability is exempt from JSAP.(7-1-24)
03.Persons Who Are Incapacitated. A person physically or intellectually unfit for employment is exempt from JSAP.(7-1-24)
04.Students Enrolled Half-Time. A student eighteen (18) years or older is exempt from JSAP if they:
a.Are enrolled at least half-time in any institution of higher learning and if they meet the definition of an eligible student in Section 282 of these rules; or(7-1-24)
b.Are enrolled at least half-time in any other recognized school or training program.(7-1-24)
c.Remain enrolled during normal periods of class attendance, vacation, and recess. If they graduate, enroll less than half-time, are suspended or expelled, drop out, or do not intend to register for the next normal school term (excluding summer), they must register for work at the next scheduled six-month or twelve-month contact or recertification.(7-1-24)
05.SSI Applicants. Are exempt from JSAP until SSI eligibility is determined.(7-1-24)
06.Persons Who Are Employed or Self-Employed. Are exempt from JSAP if they are:(7-1-24)
a.Working at least thirty (30) hours per week;(7-1-24)
b.Receiving earnings equal to the federal minimum wage multiplied by thirty (30) hours; or (7-1-24)
c.A migrant or seasonal farm worker under contract or agreement to begin employment within thirty (30) days.(7-1-24)
07.Persons in Treatment for a Substance Use Disorder. A regular participant in a substance use disorder treatment and rehabilitation program is exempt from JSAP.(7-1-24)
08.Unemployment Insurance (UI) Applicant/Recipient. A person receiving UI is exempt from JSAP. A person applying for, but not receiving UI, is exempt from JSAP if they are required to register for work with the Department of Commerce and Labor as part of the UI application process.(7-1-24)
09.Children Under Age Sixteen. Are exempt from JSAP. A child who turns sixteen (16) within a certification period must register for JSAP at the six-month or twelve-month contact or recertification, unless exempt for another reason.(7-1-24)
10.Persons Age Sixteen or Seventeen. Are exempt from JSAP if they are attending school at least half-time, or are enrolled in an employment and training program, including GED, at least half-time.(7-1-24)
11.Participants Age Sixty or Older. Are exempt from JSAP.(7-1-24)
12.Pregnant Women. In their third trimester are exempt from JSAP.(7-1-24)
IDAPA 16.03.04.228 Deferrals from Jsap for Household Members Participating in Tafi
Deferrals from JSAP for household members participati ng in the TAFI program are listed below.(7-1-24)
01.Reasonable Distance. Appropriate child care is not available within a reasonable distance from the participant’s home or work site.(7-1-24)
02.Relative Child Care. Informal child care by relatives or others is not available or is unsuitable.
03.Child Care Not Available. Appropriate and affordable child care is not available.(7-1-24)
IDAPA 16.03.04.229 Participants Losing Jsap Exempt Status
If an exempt household member becomes mandatory, the Department must notify the participant of JSAP requirements.(7-1-24)
IDAPA 16.03.04.230 (Reserved)
IDAPA 16.03.04.236 Good Cause
A mandatory participant may get a deferral from JSAP requirements, if the Department determines a valid reason exists.(7-1-24)
IDAPA 16.03.04.237 Sanctions for Failure to Comply with Jsap
WORK PROGRAM REQUIREMENTS.
When a JSAP participant fails or refuses to comply with work program req uirements without good cause, sanctions listed below must be applied. In determining which sanction to impose, sanctions previously imposed for voluntary quit or reduction in work hours under Section 271 of these rules must be considered.(7-1-24)
01.Noncomplying Household Member. The participant who commits the work program violation is excluded as a household member when determining the Food Stamp allotment. The person cannot receive Food Stamps, but their income and resources are counted in the Food Stamp computation for the household. The person must serve a minimum sanction period plus take corrective action to become eligible for Food Stamps again. If the sanctioned household member becomes exempt from JSAP requirements, the Department will end the sanction.
a.First work program violation. A minimum sanction period of one (1) month is imposed.(7-1-24)
b.Second work program violation. A minimum sanction period of three (3) months is imposed.
c.Third and subsequent work program violations. A minimum sanction period of six (6) months is imposed.(7-1-24)
02.Joins Another Household. If a sanctioned household member leaves the original household and joins another Food Stamp household, treat the sanctioned member as an excluded household member. The person cannot receive Food Stamps, but their income and resources are counted in the Food Stamp computation for the household. The person is excluded for the rest of the sanction period and until corrective actions are taken. (7-1-24)
03.Closure Reason. The household must be informed of the reason for the closure.(7-1-24)
04.Sanction Notice. The household must be informed of the proposed sanction period.(7-1-24)
05.Sanction Start. The household must be informed the sanction will begin the first month after timely notice.(7-1-24)
06.Actions to End Sanction. The household must be informed of the actions the household can take to end the sanction.(7-1-24)
07.Fair Hearing. The household must be informed of the right to a fair hearing.(7-1-24)
IDAPA 16.03.04.238 Notice of Sanctions for Failure to Comply with Jsap
A Notice of Decision is sent when a participant fails to com ply with JSAP requirements. The Notice of Decision must contain data listed below. If the member complies before the effective date of the action, the sanction does not take effect. The Notice of Decision must:(7-1-24)
01.Include the Proposed Sanction Period.(7-1-24)
02.Include the Reason for Sanction.(7-1-24)
03.Include the Actions the Sanctioned Person Takes to End Sanction.(7-1-24)
04.Tell the Household of its Right to Fair Hearing.(7-1-24)
IDAPA 16.03.04.239 Right to Appeal Sanction
The participant has the right to appeal the decision to sanct ion. The participant may contest a decision of mandatory status or a denial, reduction, or termination of benefits, due to failure to comply with JSAP. Appeals are conducted under IDAPA 62.01.01, “Idaho Rules of Administrative Procedure,” and Office of Administrative Hearings General Order No. 1. The Department will notify JSAP of the fair hearing.(7-1-24)
IDAPA 16.03.04.240 Jsap Sanction Begins
The sanction period begins the first month after the Notice of Decision unless a fair hearing is requested.(7-1-24)
IDAPA 16.03.04.241 Ending Sanctions for Failure to Comply with Jsap
Household members sanctioned for not complying with JSAP are ineligible until a condition listed below is met.
( 7-1-24)
01.Fair Hearing Reversal. Sanction ends if a fair hearing reverses the sanction.(7-1-24)
02.Sanctioned Member Becomes Exempt. Sanction ends if the sanctioned member becomes exempt from JSAP.(7-1-24)
03.Member Complies With JSAP. Sanction ends if the member, who refused to comply with a JSAP requirement, complies. The member must complete corrective action and serve the minimum sanction period.
IDAPA 16.03.04.242 Corrective Action for Work Programs
A mandatory participant can requalify for Food Stamps after a sancti on by becoming exempt from work requirements, or serving the sanction period and correcting noncompliance with JSAP.(7-1-24)
IDAPA 16.03.04.243 (Reserved)
IDAPA 16.03.04.251 Able-Bodied Adults Without Dependents (abawd) Work Requirement
To participate in the Food Stamp program, a person must meet one (1) of the following. A person who does not meet one (1) of these con ditions may not participate in the Food Stamp program as a member of any household for more than three (3) full months (consecutive or otherwise) in a fixed thirty-six (36) month period.(7-1-24)
01.Work at Least Eighty Hours per Month. The person must work at least eighty (80) hours per month. The definition of work is any combination of:(7-1-24)
a.Work in exchange for money.(7-1-24)
b.Work in exchange for goods or services, known as “in-kind” work.(7-1-24)
c.Unpaid work, with a public or private non-profit agency.(7-1-24)
02.Participate in JSAP or Another Work Program. The person must participate in and comply with the requirements of the JSAP program (other than job search or job readiness activities), the WIOA program, a program under Section 236 of the Trade Act of 1974, or another work program recognized by the Department. The person must participate for at least eighty (80) hours per month.(7-1-24)
03.Combination of Work and Work Programs. The person must work and participate in a work program. Participation in work and work programs must total at least eighty (80) hours per month.(7-1-24)
04.Participate in Work Opportunities. The person must participate in and comply with the requirements of a Work Opportunities program.(7-1-24)
05.Residents of High Unemployment Areas. ABAWDs residing in a county identified by the Department as having high unemployment or lack of jobs may not be subject to the three (3) month limitation of benefits. ABAWDs residing in these counties are subject to JSAP work requirement.(7-1-24)
IDAPA 16.03.04.252 Proof Required for Abawds
The Department requires proof of comp liance with the ABAWD requirements. If there is evidence the ABAWD got Food Stamps in another state, the Department will get proof of the number of countable months from that state, before certification. A written or verbal statement from the other state agency of countable months is acceptable proof.(7-1-24)
IDAPA 16.03.04.253 Abawd Good Cause
The work requirement is met if an ABAWD would have worked at least eighty (80) hours per month but missed work r good cause. The absence from work must be temporary. The ABAWD must keep the job. Circumstances beyond control of the ABAWD are the basis of good cause. These include illness, illness of a household member requiring the presence of the ABAWD, household emergency, and lack of transportation.(7-1-24)
IDAPA 16.03.04.254 Reporting Abawd Changes
ABAWDs must report within the first ten (10) days of the mon th following the date of change if total work or work program hours drop below eighty (80) hours per month.(7-1-24)
IDAPA 16.03.04.255 Regaining Eligibility
ABAWDs whose three (3) month eligibility expires may regain eligibility for Food Stamps. During any thirty (30) consecut ive days, the person must meet one (1) of the work requirements below. The Department will prorate Food Stamp benefits from the date the person regains eligibility. ABAWDs must continue to meet the work requirement to get Food Stamps or meet conditions for the three (3) additional months. There is no limit on the number of times an ABAWD may regain and maintain eligibility by meeting the work requirement.(7-1-24)
01.Work Eighty Hours. The person must work eighty (80) or more hours per month.(7-1-24)
02.Participate in JSAP. The person must participate in and comply with the requirements of the JSAP program (other than job search or job search training), the WIOA program, or a program under Section 236 of the Trade Act of 1974 for eighty (80) or more hours per month.(7-1-24)
IDAPA 16.03.04.256 Three Additional Months of Food Stamps After Regaining Eligibility
A person who regained eligibility under Section 255 of these rules, but is no longer fulfilling the ABAWD work req uirements in Section 251 of these rules through no fault of their own, may get Food Stamps for an additional three (3) consecutive months. For an applicant, the three (3) consecutive months begin the first full month of benefits. For a participant, the three (3) consecutive months begin the month following the month the participant no longer meets the work requirements. A person is eligible for the additional three (3) consecutive months only once in a thirty-six (36) month period.(7-1-24)
IDAPA 16.03.04.257 Persons Not Considered Abawd
Persons meeting any of the following are not considered ABAWD.(7-1-24)
01.Age. Persons under eighteen (18) and fifty-three (53) years old or older. Beginning October 1, 2024, the age limit increases to fifty-five (55).(7-1-24)
02.Disability. Persons medically certified as physically or intellectually unfit for employment. A person is medically certified as physically or intellectually unfit for employment if:(7-1-24)
a.Receiving temporary or permanent disability benefits issued by a government or private source.
b.Obviously intellectually or physically unfit for employment, as determined by the Department.
c.The person has a statement from a physician, physician's assistant, nurse, nurse practitioner, designated representative of the physician's office, licensed or certified psychologist, a social worker, or any other medical personnel the Department determines appropriate, verifying physical or intellectual unfitness for employment.(7-1-24)
03.All Persons Residing in a Household Where a Household Member Is Under Age Eighteen.
04.Pregnant Persons.(7-1-24)
05.A homeless individual, as defined under 7 CFR 271.2.(7-1-24)
06.A veteran who served in the US Armed Forces and was discharged or released from service, regardless of the reason for discharge or release.(7-1-24)
07.An individual who was eighteen (18) years old or older (at a state agency’s option), who at the time aged out of foster care program and who is under twenty-five (25) years old.(7-1-24)
IDAPA 16.03.04.258 Food Stamps Issued to Ineligible Abawd
If benefits are paid to an ABAWD in error, the months count against the three- (3) month time limit until repaid.
( 7-1-24)
IDAPA 16.03.04.259 Strikes
Households must be denied Food Stamps if a member is unemployed because of a strike, unless the household was eligible for or getting Food Stamps the day before the strike.(7-1-24)
IDAPA 16.03.04.260 Government Employees Dismissed for Strike
State, federal, and local government employees dismissed because of joining in a strike against the governmental entity have voluntarily quit a job without good cause.(7-1-24)
IDAPA 16.03.04.261 Voluntary Job Quit
An employed household member who voluntarily quits a job without good cause is not eligible for Food Stamps. The Department is required to make a voluntary job quit determination when it learns that any employed household member has quit their job and any of the following circumstances apply.(7-1-24)
01.Voluntary Job Quit Timeframes. The Department must make a voluntary job quit determination:
a.For any applicant who quits their job within sixty (60) days of the application date.(7-1-24)
b.For any new household member who quits their job within the sixty (60) days prior to entering the household.(7-1-24)
c.For any recipient who quits their job at any time during the certification period.(7-1-24)
02.Job Definition for Voluntary Job Quit. The Department must make a voluntary job quit determination for any household member who is not exempt from work registration for any reason other than employment if:(7-1-24)
a.They quit a job of at least thirty (30) hours a week; or(7-1-24)
b.Their weekly earnings from the job they quit are equivalent to the federal minimum wage multiplied by thirty (30) hours.(7-1-24)
IDAPA 16.03.04.262 Voluntary Reduction in Work Hours
An employed household member who voluntarily reduces hours of work without good cause is not eligible for Food St amps. The Department is required to make a reduction in work hours determination when it learns that any employed household member has voluntarily reduced their work hours and any of the following circumstances apply.
01.Voluntary Work Reduction Timeframe. The Department must make a reduction in work hours determination if the hours of work were voluntarily reduced by a(n):(7-1-24)
a.Applicant, within sixty (60) days of the application date.(7-1-24)
b.New household member, within the sixty (60) days prior to entering the household.(7-1-24)
c.Recipient, at any time during the certification period.(7-1-24)
02.What Counts as a Significant Voluntary Work Reduction. For any household member's eligibility for Food Stamps to be affected, the Department must determine that:(7-1-24)
a.Prior to the voluntary reduction in hours, the job was at least thirty (30) hours a week; and (7-1-24)
b.The hours of work have been voluntarily reduced to less than thirty (30) hours per week without good cause.(7-1-24)
IDAPA 16.03.04.263 (Reserved)
IDAPA 16.03.04.265 Situations Not Considered Voluntary Job Quit or Reduction of Work
Situations not counted as a voluntary job quit or reduct ion of work hours are listed below:(7-1-24)
01.The Person Ends Self-Employment.(7-1-24)
02.Employer Demands Resignation and Person Resigns.(7-1-24)
03.Laid Off From New Job. A person quits a job, secures new employment at comparable salary or hours, and then is laid off or loses the new job through no fault of their own.(7-1-24)
IDAPA 16.03.04.266 Household Member Leaves During a Penalty Period
When the household member who committed a voluntary quit or reduction in hours penalty leaves the household, the penalty follows the household member who caused it. If the household member who committed the penalty joins another household, they are ineligible for the balance of the penalty period unless they meet the conditions stated in Subsection 275.01 of these rules.(7-1-24)
IDAPA 16.03.04.267 Good Cause for Voluntarily Quitting a Job or Reducing Work Hours
If a household member voluntarily quits a job, the Departmen t will determine if the quit was for good cause. All facts and circumstances submitted by the household and the employer must be considered. Good cause reasons are listed in 7 CFR 273.7(i)(3).(7-1-24)
IDAPA 16.03.04.268 Proof of Job Quit or Reduction of Work Hours
Verification from the household is required if the household’s jo b quit or reduction of work hours is questionable.
When proof of the voluntary quit cannot be obtained, the household must not be denied Food Stamps. If a household member refuses, without good cause, to provide enough information to determine voluntary quit or work reduction, a penalty must be imposed.(7-1-24)
IDAPA 16.03.04.269 (Reserved)
IDAPA 16.03.04.270 Penalty for Applicant Quitting a Job or Reducing Work Hours
If the Department determines a voluntary quit or reductio n of work hours was not for good cause, the member who quit is not eligible for a ninety (90) day penalty period. The penalty period begins the date the household member quit. The applicant household must be told the job quit and work reduction penalty information listed below:
01.Denial Reason. The household must be informed of the reason for the Food Stamp denial for the member.(7-1-24)
02.Sanction Period. The household must be informed of the proposed voluntary quit or work reduction sanction period.(7-1-24)
03.Fair Hearing. The household must be informed of the right to a fair hearing.(7-1-24)
04.Right to Reapply. The household must be informed of the right to reapply after the ninety (90) day penalty period.(7-1-24)
IDAPA 16.03.04.271 Penalty for Recipient Quitting
A JOB OR REDUCING WORK HOURS.
If the Department determines a member of the household vol untarily quit a job or reduced work hours, the penalty listed in Subsection 271.01 of this rule must be imposed. Food Stamps must be reduced, beginning the first month after timely notice. The household must be told the information listed in this rule within ten (10) calendar days of the voluntary quit or reduction in work ruling. When determining the sanction to impose, previous sanctions for noncompliance with JSAP and work registration requirements as described in Section 237 of these rules must be considered. Previous sanctions for recipient voluntary quit or work reduction must also be considered. If the sanctioned household member becomes exempt from JSAP requirements, the Department will end the sanction. The voluntary quit sanction does not end if the sanctioned household member becomes exempt due to application or receipt of Unemployment Insurance.(7-1-24)
01.Non-Complying Household Member. The participant who commits the work program violation is excluded as a household member when determining the Food Stamp allotment. The person cannot receive Food Stamps, but their income and resources are counted in the Food Stamp computation for the household. The person must serve a minimum sanction period plus take corrective action to become eligible for Food Stamps again.
Corrective action includes: returning to work, increasing work hours to meet the work exemption, or completing required activities with JSAP.(7-1-24)
a.First work program violation. A minimum sanction period of one (1) month is imposed.(7-1-24)
b.Second work program violation. A minimum sanction period of three (3) months is imposed.
c.Third and subsequent work program violation. A minimum sanction period of six (6) months is imposed.(7-1-24)
02.Joins Another Household. If a sanctioned household member leaves the original household and joins another Food Stamp household, the Department will treat the sanctioned member as an excluded household member. The person cannot receive Food Stamps, but their income and resources are counted in the Food Stamp computation for the other household. The person is excluded for the rest of the sanction and until corrective actions are taken.(7-1-24)
03.Closure Reason. The household must be informed of the reason for the closure.(7-1-24)
04.Sanction Notice. The household must be informed of the proposed sanction period.(7-1-24)
05.Sanction Start. The household must be informed the sanction will begin the first month after timely notice.(7-1-24)
06.Actions to End Sanction. The household must be informed of the actions the household can take to end the sanction.(7-1-24)
07.Fair Hearing. The household must be informed of the right to a fair hearing.(7-1-24)
IDAPA 16.03.04.272 Participant Voluntary Quit or Reduction of Work Hours
If it is discovered a household member voluntarily quit a job or reduced work hours without good cause during the certification period the Department must provide the individual with a notice of adverse action within ten (10) days after the determination of a quit or reduction in work effort. The individual will be disqualified according to the minimum mandatory sanction schedule under Subsection 271.01 of these rules.(7-1-24)
IDAPA 16.03.04.273 (Reserved)
IDAPA 16.03.04.275 Ending Voluntary Quit Work Program Penalties
Eligibility may be reestablished before the end of the penalty period for an otherwise eligible household member when they meet the conditions in Subsection 275.01 of this rule. Eligibility may be reestablished after a voluntary quit or work reduction penalty period has elapsed for an otherwise eligible household member when they meet a condition in Subsection 275.02 of this rule.(7-1-24)
01.Ending Voluntary Quit or Reduction Penalty Before the End of the Penalty Period. If the sanctioned household member becomes exempt from JSAP requirements, their eligibility for Food Stamps may be reestablished. The voluntary quit penalty does not end if the sanctioned household member becomes exempt due to application or receipt of Unemployment Insurance.(7-1-24)
02.Ending Voluntary Quit or Reduction Penalty After Penalty Period.(7-1-24)
a.If the sanctioned household member gets a new job comparable in salary or hours to the job they quit, their eligibility for Food Stamps may be reestablished. A comparable job may entail fewer hours or a lower net salary than the job which was quit. To be comparable, the hours for the new job cannot be less than thirty (30) hours per week and the salary or earnings for the new job cannot be less than federal minimum wage multiplied by thirty (30) hours per week.(7-1-24)
b.If the sanctioned household member’s hours of work are restored to more than thirty (30) hours per week before reduction, their eligibility for Food Stamps may be reestablished.(7-1-24)
c.A sanctioned household member can requalify for Food Stamps after serving the minimum sanction period and completing corrective action. The participant must contact the Department and request an opportunity to correct the sanction.(7-1-24)
IDAPA 16.03.04.276 Failure to Comply with a Requirement of Another Means - Tested
PROGRAM.
Food Stamps must not increase when a failure to co mply causes other means-tested benefits to decrease. Benefits from means-tested programs like TAFI may decrease due to failure to comply with a program requirement. Food Stamp benefits must not increase because of this income loss. If a reduction in benefits from another means-tested program occurs, the Department will verify the reason for the reduction. If the reason for the reduction cannot be verified, the Department will document the case record to reflect the good faith effort to verify the information.
IDAPA 16.03.04.277 Penalty for Failure to Comply with a Requirement of Another Means -
TESTED PROGRAM.
To prevent an increase in Food Stamp ben efits, penalties will be applied to a Food Stamp case for failure to comply with a requirement of another means-tested program such as TAFI. When a Food Stamp recipient fails to comply with a requirement of the TAFI program, the Department will count that portion of the benefit decrease attributed to the TAFI penalty. Conditions for ending the penalty are listed below.(7-1-24)
01.Time-Limited TAFI Penalty. If the TAFI penalty is time-limited, the Department will end the Food Stamp penalty when the TAFI penalty is ended.(7-1-24)
02.Lifetime TAFI Penalty. If the TAFI penalty is a lifetime penalty, apply the Food Stamp penalty for a length of time to match the remaining months of TAFI eligibility for the household. The Department will end the Food Stamp penalty if the household subsequently reapplies for TAFI and is denied for a reason other than the noncompliance that caused the TAFI penalty.(7-1-24)
03.Member Who Caused the TAFI Penalty Leaves the Household. The Department will end the Food Stamp penalty when the member who caused the TAFI penalty leaves the household.(7-1-24)
IDAPA 16.03.04.278 Cooperation in Establishment of Paternity and Obtaining Support
A natural or adoptive parent or other individual living with and exercis ing parental control over a minor child who has an absent parent must cooperate in establishing paternity for the child and obtaining support for the child.
IDAPA 16.03.04.279 Failure to Cooperate
When a parent or individual fails to cooperate in establishing paternity and obtaining support, they are not eligible to particip ate in the Food Stamp Program.(7-1-24)
IDAPA 16.03.04.280 Exemptions from the Cooperation Requirement
The parent or individual will not be required to provide informat ion about the absent or alleged parent or otherwise cooperate in establishing paternity or obtaining support if good cause for not cooperating exists. Good cause for failure to cooperate in obtaining support is listed below:(7-1-24)
01.Rape or Incest. Proof the child was conceived because of incest or forcible rape.(7-1-24)
02.Physical or Emotional Harm. Proof the absent parent may inflict physical or emotional harm to the children, the participant, or individual exercising parental control. This must be supported by medical evidence, police reports, or as a last resort, an affidavit from a knowledgeable source.(7-1-24)
03.Minimum Information Cannot be Provided. Substantial and credible proof is provided indicating the participant cannot provide the minimum information regarding the non-custodial parent.(7-1-24)
IDAPA 16.03.04.281 (Reserved)
IDAPA 16.03.04.283 Student Enrollment
A student is considered enrolled in an institution of higher education if participating in a regular curriculum there.
Enrollment status of a student begins the first day of the school term for the institution of higher education. The enrollment continues through normal periods of class attendance, vacation, and recess. Enrollment stops if the student graduates, is suspended or expelled, drops out, or does not intend to register for the next normal school term. Summer school terms are not normal school terms.(7-1-24)
IDAPA 16.03.04.284 Determining Student Eligibility
To be eligible for Food Stamps, a student must meet at least one (1) of the following:(7-1-24)
Employment. The student:(7-1-24)
a.Is employed a minimum of eighty (80) hours per month and is paid for such employment; or
b.Is self-employed a minimum of eighty (80) hours per month; and(7-1-24)
c.Must earn at least the federal minimum wage times eighty (80) hours.(7-1-24)
02.Work Study Program. The student is in a state or federally financed work study program during the regular school year. The student exemption begins the month the school term begins, or the month the work study is approved, whichever is later. The exemption continues until the end of the month the school term ends, or it becomes known the student has refused an assignment. The student work study exemption stops when there are breaks of a full calendar month or longer between terms, without approved work study. The exemption only applies to months the student is approved for work study.(7-1-24)
03.Caring for Dependent Child. The student is:(7-1-24)
a.Responsible for the care of a dependent household member under the age of six (6).(7-1-24)
b.Responsible for the care of a dependent household member who has reached the age of six (6), but is under age twelve (12) when the state agency has determined that adequate child care is not available to enable the student to attend class and comply with the eighty (80) hour work requirement.(7-1-24)
c.A single parent enrolled in an institution of higher education on a full-time basis, as determined by the institution, and be responsible for the care of a dependent child under age twelve (12).(7-1-24)
04.TAFI Participant. The student gets cash benefits from the TAFI program.(7-1-24)
05.Training. The student is assigned to or placed in an institution of higher education through, or complying with, the following programs: WIOA, JOBS, JSAP, a program under Section 236 of the Trade Act of 1974, or a program for employment and training operated by a state or local government.(7-1-24)
IDAPA 16.03.04.285 Ineligibility of Fugitive Felons and Probation and Parole Violators
Individuals who are fleeing to avoid prosecution or custody for a crime, or an attempt to commit a crime, classified as a felony (or in the state of New Jersey, a high misdemeanor), or who are violating a condition of probation or parole under a federal or state law, cannot be considered eligible household members.(7-1-24)
IDAPA 16.03.04.286 Effective Date of Ineligibility
The effective date of disqualification for Food Stamps is the month following the date the Department has docu mented evidence the individual is fleeing or violating parole/probation.(7-1-24)
IDAPA 16.03.04.287 Ineligibility for a Felony Conviction
FOR POSSESSION, USE, OR DISTRIBUTION
OF A CONTROLLED SUBSTANCE.
Individuals convicted under federal or state law of a felony involving the possession, use, or distribution of a controlled subs tance can receive Food Stamps when they comply with the terms of a withheld judgment, probation, or parole. Controlled substance felons who are not complying with the terms of a withheld judgment, probation, or parole are not eligible for Food Stamps.(7-1-24)
IDAPA 16.03.04.288 (Reserved)
IDAPA 16.03.04.300 Resources Defined
Resources include, but are not limited to, cash, bank accounts, stocks, bonds, personal property, and real property. A household must have the right, authority, or power to change the resource to cash for the resource to be counted. The household must have the legal right to use the resource for support and maintenance for the resource to be counted.
IDAPA 16.03.04.301 Determining Resources
The resources of all household members are count ed unless the resource is excluded.(7-1-24)
IDAPA 16.03.04.302 (Reserved)
IDAPA 16.03.04.305 Resource Limit
The Food Stamp resource limit is five thousand dollars ($5,00 0) for Broad-Based Categorically Eligible households.
Households that do not meet the requirements for Broad-Based Categorical Eligibility are subject to resource limits published by the FNS.(7-1-24)
IDAPA 16.03.04.306 (Reserved)
IDAPA 16.03.04.308 Equity Value of Resources
Equity value is the current market value of a resource, minus any encumbrance. The current market value is the price the resource is expected to sell for, on the open market, in the geographic area involved. An encumbrance is a legally binding debt against property. The encumbrance on the property does not prevent the property owner from selling to a third party.(7-1-24)
IDAPA 16.03.04.309 Liquid Resources
All liquid resources are counted, unless excluded. Liquid resources are lis ted below and can be easily converted to cash.(7-1-24)
01.Cash on Hand.(7-1-24)
02.All Bank and Credit Union Accounts.(7-1-24)
03.Lump Sum Payments. Such as insurance, SSI, retirement, and income tax refund.(7-1-24)
04.Trusts. Unrestricted trust accounts and any available amounts from restricted trust accounts.
05.Stocks, less Fees for Transfer and Penalty for Early Sale.(7-1-24)
06.Savings Bonds, Treasury Bonds, Commercial Bonds at Current Market Value.(7-1-24)
07.Savings Certificates or Certificates of Deposit. Issued by banks, credit unions, or other financial concerns, less the penalty for early withdrawal.(7-1-24)
IDAPA 16.03.04.310 Nonliquid Resources
Countable nonliquid resources are resources not easily converted to cash and are listed below.(7-1-24)
01.Real Property. Equity value of real property (land and buildings, including mobile homes) unless specifically excluded. Property may be excluded if the property is:(7-1-24)
a.Used as a home.(7-1-24)
b.Income-producing, and the income is consistent with the property’s fair market value.(7-1-24)
c.Essential to employment or self-employment.(7-1-24)
d.Used in connection with an excluded vehicle.(7-1-24)
02.Vehicles. Licensed and unlicensed automobiles, trucks, vans, motorcycles, self-propelled motor homes, snowmobiles, boats, aircraft, all-terrain vehicles, and mopeds.(7-1-24)
03.Personal Property. Personal property not otherwise excluded. Personal property includes trailers pulled by another means or campers placed on the bed of a truck or pickup.(7-1-24)
IDAPA 16.03.04.311 Factors Making Property a Resource
Property of any kind, including cash, can be a resource and must meet all criteria listed below:(7-1-24)
01.Ownership Interest. A participant must have ownership interest in property for it to be counted as a resource. Property is not a resource if the participant does not own all or part of the property.(7-1-24)
02.Legal Right to Spend or Convert Property. A participant must have a legal right to spend or convert property to cash. Physical possession of property is not needed if the owner has the legal ability to spend or convert the property to cash.(7-1-24)
03.Legal Ability to Use for Support and Maintenance. Property is not a resource if it cannot legally be used for the owner’s support and maintenance.(7-1-24)
IDAPA 16.03.04.312 (Reserved)
IDAPA 16.03.04.314 Jointly Owned Resources
A resource owned jointly by members of two (2) or more households is counted in its entirety for each household, unless the household proves the resource is not available. If the household shows it has access to only a portion of a resource, that portion of the resource is counted.(7-1-24)
IDAPA 16.03.04.315 Jointly Owned Resources Excluded
A jointly owned resource is excluded, if the household shows it can not sell or divide the resource without consent of the other owner, and the other owner will not sell or divide the resource. A jointly owned resource is excluded, if owned by a resident in a shelter for battered women and children and access to the resource requires agreement of a joint owner living in the former household. A vehicle, jointly owned by a household member and a person not living in the household, may be excluded. The household member must not have possession of the vehicle. The household member must not be able to sell the vehicle.(7-1-24)
IDAPA 16.03.04.316 (Reserved)
IDAPA 16.03.04.323 Lump Sum Resources
Nonrecurring lump sum payments are considered a resource in the month received, unless excluded under these rules.
A household is not required to report changes in resources during a certification period. Some lump sum payments
01.Retroactive Payments.(7-1-24)
a.Social Security.(7-1-24)
b.SSI.(7-1-24)
c.Public Assistance.(7-1-24)
d.Railroad Retirement Benefits.(7-1-24)
e.Unemployment Compensation Benefits.(7-1-24)
f.Child Support.(7-1-24)
02.Insurance Settlements.(7-1-24)
03.Income Tax Refunds, Rebates, or Credits.(7-1-24)
04.Property Payments. Lump sum payments and contract payments from sale of property are counted as income.(7-1-24)
05.Security Deposits. Refunds of security deposits on rental property or utilities.(7-1-24)
06.Disability Pension. Annual adjustment payments in VA disability pensions.(7-1-24)
07.Vacation Pay. Vacation pay, withdrawn in one (1) lump sum by a terminated employee.(7-1-24)
08.Military Reenlistment Bonuses.(7-1-24)
09.Job Corps Readjustment Pay.(7-1-24)
10.Severance Pay. Paid in one (1) lump sum to a former employee.(7-1-24)
11.TAFI One-Time Cash Diversion Payment.(7-1-24)
IDAPA 16.03.04.324 (Reserved)
IDAPA 16.03.04.334 Vehicles
The value of any vehicle that is primarily for recreational use counts toward the household’s resource limit. All other vehicles in the household will have their values counted as provided in 7 CFR 273.(7-1-24)
IDAPA 16.03.04.335 (Reserved)
IDAPA 16.03.04.351 Excluded Resources
Some resources do not count against the limit because they are excluded. Resources excluded by federal law are also excluded for Food Stamps. Exclusions from resources are under Sections 352 through 382 of these rules.(7-1-24)
IDAPA 16.03.04.352 Household Goods Excluded
Household goods are items of personal property normally found in the home. The items must be used for mai ntenance, use, and occupancy of the home. Household goods include, but are not limited to, furniture, appliances, television sets, carpets, and utensils for cooking and eating.(7-1-24)
IDAPA 16.03.04.353 Personal Effects Excluded
Personal effects are items worn or carried by a participant, o r items having an intimate relation to the participant.
They include, but are not limited to, clothing, jewelry, personal care items, and prosthetic devices. Personal effects include items for education or recreation, such as books, musical instruments, or hobby materials.(7-1-24)
IDAPA 16.03.04.354 Home and Lot Excluded
The home and surrounding land and buildings not separated b y property owned by others, are excluded as a resource.
A public road or right of way that separates any plot from the home will not affect the exclusion. The home may be a house, trailer, or vehicle.(7-1-24)
01.Unoccupied Home Exclusion. A temporarily unoccupied home is excluded if the household members intend to return. The household members must be absent because of employment, training for future employment, illness, or the home must be temporarily uninhabitable from casualty or natural disaster.(7-1-24)
02.Building Lot Exclusion. The following are excluded as a resource:(7-1-24)
a.A lot where a household is building a permanent home(7-1-24)
b.A lot where a household intends to build a permanent home; and(7-1-24)
c.A lot and partly completed home(7-1-24)
d.The household can only have one (1) home and lot excluded. The household cannot own a home and lot and have a building lot exclusion for another property.(7-1-24)
IDAPA 16.03.04.355 Life Insurance Excluded as a Resource
The cash surrender value of life insurance policies is excluded as a resource.(7-1-24)
IDAPA 16.03.04.356 Burial Space or Plot and Funeral Agreement Exclusions
Burial spaces or plots and funeral agreements are excluded from resources as listed below.(7-1-24)
01.Burial Space or Plot Exclusion. One (1) burial space or plot, for each household member, from resources. The value of the burial space or plot does not affect this exclusion.(7-1-24)
02.Funeral Agreement Exclusion. Up to the equity value of one (1) bona fide funeral agreement, for each household member, from resources.(7-1-24)
IDAPA 16.03.04.357 Pension Plans or Funds Excluded as a Resource
The cash value of any funds in a plan, contract, or account, under Sections 401 (a), 403(a), 403(b), 408, 408A, 457(b), and 501(c) of the Internal Revenue Code of 1986. and the value of funds in a Federal Thrift Savings Plan Account under 5 U.S.C. 8439 are excluded as a resource. This exclusion includes any current or future tax preferred retirement accounts approved under federal or state law.(7-1-24)
IDAPA 16.03.04.358 Income-Producing Property Excluded
Property that annually produces income consistent with its fair market value is excluded as a resource. Real property, not used as a home, is excluded as a resource if it produces income consistent with its fair market value. This exclusion includes land and buildings. Annual income is consistent with the property’s fair market value when consistent with area market trends.(7-1-24)
IDAPA 16.03.04.359 Livestock Excluded
Livestock includes cows, pigs, sheep, llamas, and horses.
Farm animals kept for food are excluded.(7-1-24)
IDAPA 16.03.04.360 Property Used for Self-Suppor
T EXCLUDED.
Property essential to the employment or self-employment of a household member, such as tools of a trade or the farm land and machinery of a farmer, is excluded as a resource. Essential work-related equipment of an ineligible legal non-citizen or disqualified person is excluded as a resource. Self-support property is excluded during employment and temporary periods of unemployment. For a household member engaged in farming, property essential to selfemployment continues to be excluded for one (1) year from the date the household member ends self-employment from farming.(7-1-24)
IDAPA 16.03.04.361 Property Used with Excluded
VEHICLE.
Portions of real or personal property are e xcluded as a resource if used in connection with an excluded vehicle. The vehicle must be used to produce income or be necessary for transporting a physically disabled household member.
IDAPA 16.03.04.362 Salable Item Without Significant Return Excluded
Resources that cannot be sold fo r a significant return are excluded. “Significant return” means any return, after estimating costs of sale or disposition, and taking into account the ownership interest of the household, is more than one thousand five hundred dollars ($1,500).(7-1-24)
IDAPA 16.03.04.363 Hud Family Self-Sufficiency (fss) Escrow Account
Escrow accounts and the interest earned on an escrow account esta blished by HUD for families participating in the FSS Program under Section 544 of the National Affordable Housing Act, are excluded as a resource when determining eligibility for food stamps. The federal exclusion for the funds in this program and other similar type escrow funds are only excluded while the funds are still in the escrow account or being used for a HUD approved purpose. Participants in the FSS program may withdraw funds from the escrow account before completing the program, with permission from the public housing authority, but only for purposes related to the goal of the FSS contract, such as completion of higher education, job training, or to meet start-up expenses involved in creation of a small business.(7-1-24)
IDAPA 16.03.04.364 Educational Accounts Excluded as a Resource
The cash value of any funds in a qualified tuition program under Sectio n 529 of the Internal Revenue Code of 1986, or in a Coverdell education savings account under Section 530 of the Internal Revenue Code, are excluded as resources.(7-1-24)
IDAPA 16.03.04.365 Individual Development Account Excluded as a Resource
The cash value of an Individual Developm ent Account (IDA) under Section 56-1101(5), Idaho Code, is excluded as a resource.(7-1-24)
IDAPA 16.03.04.366 (Reserved)
IDAPA 16.03.04.373 Government Payments Excluded
Government payments for the restoration of a home damaged in a disas ter are excluded as a resource. The household must be subject to legal sanction if the funds are not used as intended.(7-1-24)
IDAPA 16.03.04.374 Excluded Inaccessible Resources
The cash value of resources not legally avail able to the household is excluded as a resource. The household must provide proof resources are not available.(7-1-24)
IDAPA 16.03.04.375 Frozen or Secured Accounts Excluded
Frozen bank accounts used as security for a loan or due to bankruptcy proceedings are excluded as resources.
IDAPA 16.03.04.376 Real Property Excluded If Attempt to Sell
Real property is excluded as a resource if the household is making a good faith effort to sell it at a reasonable price.
The Department will verify the property is for sale and the household has not refused a reasonable offer.(7-1-24)
IDAPA 16.03.04.377 Trust Funds Excluded
Trust funds are excluded if all conditions listed below are met:(7-1-24)
Trust Irrevocable or Not Changeable by Household. The household must be unable to revoke the trust agreement or change the name of the beneficiary during the certification period.(7-1-24)
02.Trust Unlikely to End During Certification. The trust arrangement must be unlikely to end during the certification period.(7-1-24)
03.Trustee Independent from Household Control. The trustee of the fund is either a court, institution, corporation, or organization not under the direction or ownership of a household member, or a courtappointed person who has court-imposed limits placed on the use of funds.(7-1-24)
04.Trust Not Under Control of Household-Directed Business. The trust investments do not directly involve or help any business or corporation under the control, direction, or influence of a household member.
05.Origin and Use of Trust. The funds held in an irrevocable trust are:(7-1-24)
a.Set up from the household’s own funds. The trustee uses the funds only to make investments for the trust, or to pay education or medical expenses of the beneficiary; or(7-1-24)
b.Set up from nonhousehold funds by a nonhousehold member.(7-1-24)
IDAPA 16.03.04.378 Installment Contracts Excluded
An installment contract for the sale of land and buildings is excluded as a resource. The purchase price must be consistent with the property’s fair market value. The contract or agreement must produce income consistent with the property’s fair market value. Income is consistent with the property’s fair market value when consistent with area market trends. The actual property sold under an excluded installment contract is excluded as a resource. Property held as security for the fulfillment of an excluded installment contract is excluded as a resource.(7-1-24)
IDAPA 16.03.04.379 Treatment of Excluded Resources
An excluded resource kept in a separate account is excluded for an unlimited period. If an excluded resource is combined with countable resources, the resource is not counted for six (6) months from the date the funds are combined. After six (6) months, the total combined resources are counted.(7-1-24)
IDAPA 16.03.04.380 (Reserved)
IDAPA 16.03.04.381 Nonliquid Resources with Liens Excluded
A nonliquid resource, with a lien placed against it, is exclud ed. The lien must result from a business loan. The lien agreement must forbid the household to sell the resource.(7-1-24)
IDAPA 16.03.04.382 (Reserved)
IDAPA 16.03.04.383 Excluded Resource Changes to Counted Resource
Resource value increases when a participant replaces an excluded resource with a counted resource.
IDAPA 16.03.04.384 (Reserved)
IDAPA 16.03.04.386 Transfer of Resources
Households that knowingly transfer resources for the purpose of qualifying or attempting to qualify for Food Stamps benefits are disqualified from participation in the program for up to one (1) year from the date of the discovery of the transfer.(7-1-24)
IDAPA 16.03.04.387 Transfer of Resource Not Counted
FOR DISQUALIFICATION.
A transferred resource is not counted for disqu alification, under the conditions below:(7-1-24)
01.Three Months Before Application. The transfer of a resource was more than three (3) months before the date of Food Stamp application.(7-1-24)
02.Resources Less Than Limit. The transfer, when added to the other countable resources, does not exceed the resource limit.(7-1-24)
03.Transfer at Fair Market Value. The sale or trade of a resource, made at or near the fair market value, is not counted.(7-1-24)
04.Transfer Between Household Members. A resource transferred between members of the same household, including ineligible legal non-citizens or disqualified persons whose resources are considered available to the household, is not counted.(7-1-24)
05.Transfer for Reasons Other Than Food Stamps. A resource transferred for reasons other than trying to qualify for Food Stamps is not counted.(7-1-24)
IDAPA 16.03.04.388 Disqualification for Transferring Resources
The Department will base the disqualification period on the amount the transferred resource exceeds the resource limit, when added to other countable resources. Disqualification periods are listed in Table 388. The disqualification period begins in the first month of application or recertification.
Amount in Excess of the Resource LimitMonths of Disqualification $0 - 249.991 $250 - 999.993
IDAPA 16.03.04.389 (Reserved)
IDAPA 16.03.04.400 Income
All household income is counted in the Food Stamp budget unless excluded under these rules. Income can be earned or unearned.(7-1-24)
IDAPA 16.03.04.401 Earned Income
Earned income includes, but is not limited to the following.(7-1-24)
Wages or Salary. Wages and salaries of an employee, advances, tips, commissions, meals, and military pay are earned income. Garnishments from wages are earned income.(7-1-24)
02.Self-Employment Income. Income from self-employment, including capital gains, is earned income. Rental property is self-employment income if a household member manages the property an average of twenty (20) or more hours per week. Payment from a roomer or boarder is self-employment income.(7-1-24)
03.Training Allowances. From programs such as Vocational Rehabilitation.(7-1-24)
04.Payments Under Title I. Such as VISTA and University Year for Action under P.L. 93-113.
05.On-the-Job Training Programs. WIOA income includes monies paid by WIOA or the employer.
Income from WIOA on-the-job training programs is earned income, unless paid to a household member under age nineteen (19). The household member under age nineteen (19) must be under the control of another household member.(7-1-24)
06.Basic Allowance for Housing (BAH). An Armed Services housing allowance.(7-1-24)
IDAPA 16.03.04.402 Unearned Income
Unearned income includes, but is not limited to the following:(7-1-24)
01.Public Assistance (PA). Payments from SSI, TAFI, AABD, GA, or other Public programs.
02.Retirement Income. Payments from annuities, pensions, and retirement.(7-1-24)
03.Strike Benefits.(7-1-24)
04.Veteran's Benefits.(7-1-24)
05.Disability Income.(7-1-24)
06.Workers' Compensation.(7-1-24)
07.Unemployment Insurance.(7-1-24)
08.Contributions.(7-1-24) $1,000 - 2999.996 $3,000 - 4,999.999 $5,000 or more12 Amount in Excess of the Resource LimitMonths of Disqualification
09.Rental Property Income. Minus the cost of doing business, if a household member is not managing the property at least twenty (20) hours per week.(7-1-24)
10.Support Payments. Includes child support payments.(7-1-24)
11.Alimony.(7-1-24)
12.Educational Benefits Unless Excluded.(7-1-24)
13.Regular Payments from a Government Source. Payments or allowances a household receives that are funded from a government source.(7-1-24)
14.Dividends, Interest, and Royalties.(7-1-24)
15.Contract Income From the Sale of Property.(7-1-24)
16.Funds From Trusts. Monies withdrawn from trusts exempt as a resource. Dividends paid or dividends that could be paid from trusts exempt as a resource.(7-1-24)
17.Recurring Lump Sum Payments.(7-1-24)
18.Cash Prizes, Gifts, and Lottery Winnings.(7-1-24)
19.Diverted Support or Alimony. Child support or alimony payments diverted by the provider to a third party to pay a household expense.(7-1-24)
20.Agent Orange Payments. Payments made under the Agent Orange Act of 1991 and disbursed by the US Treasury.(7-1-24)
21.Garnishments.(7-1-24)
22.Tribal Gaming Income. The participant can choose to count the income in the month received, or prorate the income over the period it is intended to cover.(7-1-24)
23.Other Monetary Benefits Not Otherwise Counted or Excluded.(7-1-24)
IDAPA 16.03.04.403 (Reserved)
IDAPA 16.03.04.405 Excluded Income
Income excluded when computing Food Stamp eligibility is listed below:(7-1-24)
Money Withheld. Money withheld voluntarily or involuntarily, from an assistance payment, earned income, or other income source, to repay an overpayment from that income source.(7-1-24)
02.Child Support Payments. Child support payments received by TAFI recipients that are withheld by the state.(7-1-24)
03.Earnings of Household Member Under Age Eighteen Attending School. The member must be under parental control of another household member and attending elementary or secondary school. In this rule, a student is someone who attends elementary or secondary school, or who attends GED or home-school classes that are recognized, operated, or supervised by the school district. This exclusion applies during semester and summer vacations if enrollment will resume after the break. If the earnings of the child and other household members cannot be differentiated, the Department will prorate equally among the working members and exclude the child’s share.
04.Educational Income. Includes grants, scholarships, fellowships, work study, educational loans on which payment is deferred, and veterans’ educational benefits. To be excluded, education benefits must meet requirements under 7 CFR 273.9(c)(3).(7-1-24)
05.Infrequent or Irregular Income. If it does not exceed thirty dollars ($30) total in a three (3) month period.(7-1-24)
06.Cash Donations. Based on need and received from one (1) or more private nonprofit charitable organizations. The donations must not exceed three hundred dollars ($300) in a calendar quarter of an FFY. (7-1-24)
07.Income in Kind. Any gain or benefit, such as meals, garden produce, clothing, or shelter, not paid in money.(7-1-24)
08.Vendor Payments. Payment made on behalf of a household by a person or organization outside of the household directly to either the household’s creditors or to a person or organization providing a service to the household.(7-1-24)
09.Third Party Payments. Payment by a third party on behalf of a household using funds that are not owed to the household.(7-1-24)
10.Loans. Money received that is to be repaid(7-1-24)
11.Money for Third Party Care. Money received and used for the care and maintenance of a third party who is not in the household. If a single payment is for both household members and nonhousehold members, the identifiable portion of the payment for nonhousehold members is excluded. If a single payment is for both household members and nonhousehold members, the Department will exclude the lesser of:(7-1-24)
a.The prorated share of the nonhousehold members if the portion cannot be identified.(7-1-24)
b.The amount used for the care and maintenance of the nonhousehold members.(7-1-24)
12.Reimbursements. For past or future expenses not exceeding actual costs. Payments must not represent a gain or benefit, be used for the purpose intended, and be for other than normal living expenses. Excluded reimbursements are not limited to:(7-1-24)
a.Travel, per diem, and uniforms for job or training.(7-1-24)
b.Out-of-pocket expenses of volunteer workers.(7-1-24)
c.Medical and dependent care expenses.(7-1-24)
d.Pay for services provided by Title XX of the Social Security Act.(7-1-24)
e.Repayment of loans made by the household from their personal property limit. The repayment must not exceed the amount of the loan.(7-1-24)
f.Work-related and dependent care expenses paid by the JSAP program.(7-1-24)
g.Transitional child care payments.(7-1-24)
h.Child care payments under the Child Care and Dependent Block Grant Act of 1990.(7-1-24)
13.Federal Earned Income Tax Credit (EITC).(7-1-24)
14.Work Study. Work Study income received while attending post-secondary school.(7-1-24)
15.HUD FSS Escrow Account. The federal exclusion for these funds is only excluded while the funds are in the escrow account or being used for a HUD-approved purpose. See Section 363 of these rules for further clarification.(7-1-24)
16.Temporary Census Earnings. Wages earned for temporary employment related to US Census activities during the regularly scheduled ten (10) year US Census.(7-1-24)
17.Income Excluded by Federal Law.(7-1-24)
IDAPA 16.03.04.406 (Reserved)
IDAPA 16.03.04.407 Income and Eligibility Verification System (ievs)
Income must be verified with the IEVS system for all households applying for or getting Food Stamps and for disqu alified members with income counted toward the household Food Stamp benefits.(7-1-24)
IDAPA 16.03.04.408 (Reserved)
IDAPA 16.03.04.409 Use of Ievs Information for Applicant Households
IEVS data must be used to compute eligibility and benefits if IEVS data is received before the application is processed. IEVS data on applicant households must be used as soon as possible, even if the applicant household was approved before the IEVS data was received. Action on applications must not be delayed pending receipt of IEVS data. If IEVS data requiring further proof is received before application approval the proof must be obtained and resolved before approving the application. If an applicant household cannot provide an SSN at application, IEVS data must be used as soon as possible after the SSN is known. IEVS data must be used for all household members, eligible, excluded or disqualified.(7-1-24)
IDAPA 16.03.04.410 (Reserved)
IDAPA 16.03.04.411 Verified Upon Receipt Ievs Data
The IEVS data listed below is considered verified upon receipt, unless it is questionable:(7-1-24)
01.Benefit Data Exchange (BENDEX). BENDEX Social Security retirement and disability income data.(7-1-24)
02.State Data Exchange (SDX). Benefit and eligibility data from SSA under Titles II and XVI of the Social Security Act accessed through the SDX.(7-1-24)
03.TAFI.(7-1-24)
04.AABD.(7-1-24)
05.Medicaid. The Federally aided program for medical care (Title XIX, Social Security Act). (7-1-24)
IDAPA 16.03.04.412 Unverified Ievs Data
The IEVS data listed below is considered unverified:
01.IRS Reported Unearned Income. Data from IRS, including any unreported assets producing income.(7-1-24)
02.Wage File. Data from Department of Commerce and Labor or its counterpart in another state.
Wage data from Beneficiary Earning Exchange Record (BEER).(7-1-24)
03.Self-Employment Earnings. Data from BEER.(7-1-24)
04.Income Information the Department Deems Questionable.(7-1-24)
IDAPA 16.03.04.413 (Reserved)
IDAPA 16.03.04.428 Calculation of Self-Employment Income
Self-employment is generally considered annual or seasonal.
The Department will add all gross self-employment income, either actual or anticipated, and capital gains and exclude the costs of producing the self-employment income and divide the remaining amount of self-employment income by the number of months over which the income will be averaged. This amount is the monthly self-employment income.(7-1-24)
01.Self-Employment Expense Deduction.The Department will use a standard fifty percent (50%) self-employment deduction unless the applicant claims the actual allowable expenses exceed the standard deduction and provides proof of the expenses.(7-1-24)
02.Allowable Costs of Producing Self-Employment Income. Costs of labor, stock, raw material, seed and fertilizer, payments on the principal of the purchase price of income-producing real estate and capital assets, equipment, machinery, and other durable goods, interest paid to purchase income-producing property, insurance premium, and taxes paid on income-producing property.(7-1-24)
03.Costs Not Allowable. Net losses from previous periods, federal, state, and local income taxes, money set aside for retirement, work-related personal expenses (such as transportation to and from work), depreciation, amount that exceeds the payment a household receives from a boarder for lodging and meals, net losses from previous periods, and federal, state, and local income taxes.(7-1-24)
IDAPA 16.03.04.429 Self-Employed Farmer
To be considered a self-employed farmer, a person must receive, or expect to receive, an annual gross income of one thousand dollars ($1,000) or more earned from farming activities. If a farmer’s cost of producing self-employment income results in a loss, the Department subtracts the loss from other countable income in the household under 7 CFR 273.11(a)(2)(ii)(A) and (B).(7-1-24)
IDAPA 16.03.04.430 (Reserved)
IDAPA 16.03.04.501 Initial Changes in Food Stamp Case
The Department will act on changes in household circumstances fo und during the application or the initial interview.
01.Food Stamp Issuance Changes. The Department will make changes to the household’s Food Stamp issuance when it is required to act on a change.(7-1-24)
02.Change Before Certification. If a household reports a change in household circumstances before certification, the Department will include the reported information in determining Food Stamp eligibility and amount.
03.Change After Certification. If a household reports a change after the initial Food Stamp benefit has been paid, the Department must act on the change as required by policy for acting on changes within a certification period. Notice of the change must be given to the Food Stamp household.(7-1-24)
IDAPA 16.03.04.502 Earned Income When a Household Mem
BER TURNS AGE EIGHTEEN.
When a child attending elementary or secondary school turns age eighteen (18), the Department will not count earned income received or expected by that person until the next six-month or twelve-month contact, or recertification.
IDAPA 16.03.04.503 (Reserved)
IDAPA 16.03.04.508 Projecting Monthly Income
Income is projected for each month. Past income may be used to project future income. Changes expected during the certification period must be considered. Criteria for projecting monthly income is listed below:(7-1-24)
01.Income Already Received. The Department will count income already received by the household during the month. If the actual amount of income from any pay period is known, use the actual pay period amounts to determine the total month’s income. The Department will convert the actual income to a monthly amount if a full month’s income has been received or is expected to be received.(7-1-24)
02.Anticipated Income. The Department will count income that the household and the Department anticipate the household will get during the remainder of the certification period. If the exact income amount is uncertain or unknown, that portion must not be counted. If the date of receipt of income cannot be anticipated for the month of the eligibility determination, that portion must not be counted. If the income has not changed and no changes are anticipated, the Department will use the income received in the past thirty (30) days as one (1) indicator of anticipated income. If changes in income have occurred or are anticipated, past income cannot be used as an indicator of anticipated income. If income changes and income received in the past thirty (30) days do not reflect anticipated income, the Department can use the household income received over a longer period to anticipate income.
If income changes seasonally, the Department can use the household income from the last season, comparable to the certification period, to anticipate income.(7-1-24)
IDAPA 16.03.04.509 Types of Income to Be Averaged
Types of income to be averaged are listed below. Income fo r a destitute migrant or seasonal farm worker household is not averaged.(7-1-24)
01.Self-Employment Income.(7-1-24)
02.Contract Income. Income over the period of the contract, if not received on an hourly or piecework basis. Households with averaged contract income include school employees, share croppers, and farmers.
These households do not include migrants or seasonal farm workers.(7-1-24)
03.Income Received Less Often Than Monthly. When receipt of income is less often than monthly, the anticipated income can be averaged over the period intended to cover to determine the average monthly income.
04.Child Support Income. Can be averaged to make a valid projection for ongoing income. (7-1-24)
IDAPA 16.03.04.510 (Reserved)
IDAPA 16.03.04.512 Special Cases for Counting Income
Special cases for coun ting income are listed below:(7-1-24)
01.Wages Held at the Request of Employee. Income in the month the wages would have been paid by the employer.(7-1-24)
02.Garnishments Held by Employer. Income in the month the wages would have been paid.
03.Wages Held by Employer, Other Than Garnishment and Employee Request. Even if in violation of law, are not counted as income.(7-1-24)
04.Advances on Wages. Count as income if the household reasonably expects the advance to be paid.
05.Varying Payment Cycles. Households getting unearned or earned income on a recurring monthly or semi-monthly basis do not have varying income merely because mailing or payment cycles cause additional payments to be received in a month. The income is counted for the month it is intended.(7-1-24)
06.Nonrecurring Lump Sum Payments and Capital Gains. Nonrecurring lump sum payments must not be counted as income, but are counted as a resource starting in the month received. Nonrecurring lump sum payments include capital gains from the sale or transfer of securities, real estate, or other real property held as an investment for a set period. The capital gains are income only if the assets were used in self-employment.(7-1-24)
IDAPA 16.03.04.513 (Reserved)
IDAPA 16.03.04.532 Gross Income Limit
Households exceeding the gross income limit for the househo ld size are not eligible unless they are categorically eligible or have an elderly or disabled member. A household with an elderly or disabled household member is exempt from the gross income limit.(7-1-24)
IDAPA 16.03.04.533 Household Eligibility and Benefit Level
A household’s eligibility and benefit level is calculated u nder 7 CFR 273.10, except as indicated below. The deductions in this rule are subtracted from non-excluded income.(7-1-24)
01.Standard Deductions. Are determined by federal law.(7-1-24)
02.Earned Income Deduction. Is twenty percent (20%) of gross earned income.(7-1-24)
03.Homeless Shelter Deduction. Is established by FNS.(7-1-24)
04.Excess Medical Deduction. Excess medical expense is nonreimbursed medical expense of more than thirty-five dollars ($35) per household per month. The household member must be either age sixty (60) or older or disabled to get this expense deduction. Special diets are not deductible. For allowable medical expenses, see Section 535 of these rules.(7-1-24)
05.Dependent Care Expense Deduction. Is for monthly dependent care expenses. The dependent care may be needed for children or adults.(7-1-24)
06.Child Support Expense Deduction. Is the legally obligated child support and arrearage the household pays, or expects to pay, to or for a non-household member.(7-1-24)
07.Excess Shelter Expense Deduction. Excess shelter expense is the monthly shelter cost over fifty percent (50%) of the household’s income after all other deductions, and is not deducted if the household has received the homeless shelter deduction. For allowable shelter expenses, see Section 542 of these rules.(7-1-24)
IDAPA 16.03.04.534 Averaging Infrequent, Fluctuating, or
ONE-TIME ONLY EXPENSES.
Infrequent, fluctuating, or one-time only expenses for medical, child support, shelter, or child care may be averaged.
IDAPA 16.03.04.535 Medical Expenses
Elderly or disabled household members that incur medical expenses over thirty-five dollars ($35) per month are allowed a Standard Medical Expense (SME) deduction. Eligible households must verify monthly medical expenses of more than thirty-five dollars ($35) at initial application. Households with medical expenses that exceed the monthly SME may either verify the minimum amount to receive the SME or request and verify excess costs to receive an actual expense deduction at application and recertification. The household must provide proof of the incurred or anticipated cost before a deduction is allowed.(7-1-24)
IDAPA 16.03.04.536 Dependent Care Expenses
The care of a dependent must be necessary to maintain emplo yment, conduct job search, or attend school or training.
The dependent care expenses must be deducted from income.(7-1-24)
IDAPA 16.03.04.537 Dependent Care Restrictions
The following types of dependent care cannot be deducted:(7-1-24)
Care by Household Member. If the care is provided by another household member.(7-1-24)
02.In-Kind Payment. Such as food or exchanges for shelter.(7-1-24)
03.Vendor Payment.(7-1-24)
04.Spouse Can Give Care. If the spouse in the home is physically capable of the dependent care and is not working, seeking work, or registered for work.(7-1-24)
05.Dependent Care. If paid or reimbursed under a federal child care program.(7-1-24)
IDAPA 16.03.04.538 Child Support Expenses
Child support expense may be deducted for a household paying or expecting to pay legally obligated child support to or for a person living outside the household. The child support expense deducted must reflect the child support the household pays or expects to pay during the certification period, rather than the obligated amount.(7-1-24)
IDAPA 16.03.04.539 (Reserved)
IDAPA 16.03.04.542 Costs Allowed for Shelter Deduction
Shelter costs are current charges for the sh elter occupied by the household and include costs for the home temporarily not occupied because of employment or training away from home or illness.(7-1-24)
IDAPA 16.03.04.543 Utility Allowances
The shelter deduction is computed using one (1) of four (4) utility allowances: SUA, LUA, MUA, or TUA. Utility allowances are not prorated.(7-1-24)
01.Standard Utility Allowance (SUA).(7-1-24)
a.The household must have a primary heating or cooling cost to qualify for SUA. The heating or cooling costs must be separate from rent or mortgage payments.(7-1-24)
b.Households are limited to one (1) SUA.(7-1-24)
02.Limited Utility Allowance (LUA). The household must be billed for more than one (1) utility that is not for heating or cooling.(7-1-24)
03.Minimum Utility Allowance (MUA). The household must be billed for one (1) utility that is not for heating, cooling, or telephone service.(7-1-24)
04.Telephone Utility Allowance (TUA). The household must be billed for telephone service and have no other verified utility expenses.(7-1-24)
IDAPA 16.03.04.544 (Reserved)
IDAPA 16.03.04.547 Costs Not Allowed for the Shelter Deduction
The costs listed below are not allowed in computing the shelter deduction.(7-1-24)
01.Fees for a One-Time Utility Deposit.(7-1-24)
02.Damage or Advance Deposits on Rentals.(7-1-24)
03.Payments Made to Pay Past Due Rent.(7-1-24)
04.Cost to Cut the Household’s Own Wood for Heating.(7-1-24)
05.Furniture Rental Fees.(7-1-24)
06.Insurance on Furniture or Personal Belongings.(7-1-24)
07.Vehicle Not Used as Residence. Payments or gasoline costs on vehicles used only for recreation.
08.Repairs Not Paid by Household. Costs for repairing or replacing shelter paid by private or public agencies, insurance companies, or any other source.(7-1-24)
09.Shelter Not Paid by Household but Paid by a Vendor or Employer.(7-1-24)
10.Utility Costs Paid by HUD or FmHA Negative Utility Payment.(7-1-24)
IDAPA 16.03.04.548 Computing the Shelter Deduction
The shelter deduction is computed as listed below:(7-1-24)
If Household has Elderly or Disabled Member. The Department will deduct the monthly shelter cost exceeding fifty percent (50%) of the household’s income after all other deductions.(7-1-24)
02.If Household has No Elderly or Disabled Member. The Department will deduct the excess of fifty percent (50%) of the household’s income, after all other deductions, up to the maximum limit under Title 7 USC Section 2014.(7-1-24)
IDAPA 16.03.04.549 Net Income Limit Test
Categorically eligible households do not have to meet the net income limit. All other households, including those with an elderly or disabled household member, must not exceed the net income limit to be eligible for Food Stamps.
IDAPA 16.03.04.550 Determination of Food St
AMP BENEFIT.
The Food Stamp benefit is computed under 7 CFR 273.9 and 273.10.(7-1-24)
IDAPA 16.03.04.551 Rounding Food Stamp Payment
Income and deductions are not rounded in determining gro ss or net income. Only the final Food Stamp amount is rounded.(7-1-24)
IDAPA 16.03.04.552 (Reserved)
IDAPA 16.03.04.562 Prorating Initial Month's Benefits
Prorating is based on a thirty (30) day calendar month. Benefits are prorated from the application date to the end of the month.(7-1-24)
IDAPA 16.03.04.563 Food Stamp Prorating Formula
The prorated Food Stamp amount is determined under 7 CFR 2 73.10(a)(1)(iii)(B). If the amount for the initial month is less than ten dollars ($10), benefits must not be issued.(7-1-24)
IDAPA 16.03.04.564 Benefits After the Initial Month
After the initial month, benefits must b e issued as described below.(7-1-24)
01.All Eligible One and Two Person Households. Receive a minimum allotment equal to eight percent (8%) of the maximum one (1) person allotment.(7-1-24)
02.All Eligible Three or More Person Households. When the calculation of benefits would yield a zero benefit, the Department will deny the household’s application on the grounds that its net income exceeds the level at which benefits are issued.(7-1-24)
03.Not Categorically Eligible. All households, except categorically eligible households, must be denied if the household’s net income exceeds the level at which benefits are issued.(7-1-24)
IDAPA 16.03.04.565 (Reserved)
IDAPA 16.03.04.573 Acting on Household Composition Changes
Changes in household composition are not required to be reported. If a household does report a change in household composition, the Department will act on the change using options under 7 CFR 273.12(c).(7-1-24)
IDAPA 16.03.04.574 (Reserved)
IDAPA 16.03.04.575 Household Composition Changes for Student
Ineligible students are defined as nonhous ehold members. When a student’s status changes, the change is treated as a new person entering or leaving the Food Stamp household.(7-1-24)
IDAPA 16.03.04.576 (Reserved)
IDAPA 16.03.04.588 Notice of Decision to Households
The Department must send the household a written notice as soon as Food Stamps are approved or denied. The household must get the notice no later than thirty (30) days after the application date.(7-1-24)
IDAPA 16.03.04.589 (Reserved)
IDAPA 16.03.04.601 Reporting Requirements and Responsibilities
Changes may be reported by phone, mail, other electronic interfaces, or in person to the Department. Households must report when:(7-1-24)
01.Household’s Total Gross Income Exceeds One Hundred Thirty Percent (130%) of FPG for the Household Size.(7-1-24)
02.There is a Decrease in the Household’s ABAWD Hours to Less Than Eighty (80) Hours Per Month.(7-1-24)
03.There are Substantial Lottery Winnings. Defined as equal to or greater than the financial resource limit for elderly or disabled households not subject to the Broad-Based Categorical Eligibility (BBCE) resource limit.(7-1-24)
IDAPA 16.03.04.602 (Reserved)
IDAPA 16.03.04.603 Person Outside Household Fails to Provide Proof -- Changes
Food Stamps cannot be closed solely because a person outside the household fails to provide requested proof. The Department will attempt to get another source of proof if a person outside the household does not provide requested proof. Disqualified household members are not persons outside the household.(7-1-24)
IDAPA 16.03.04.604 (Reserved)
IDAPA 16.03.04.611 Time Frames for Reporting Changes in Household Circumstances
Households reporting required changes to the Department must do so by the tenth day of the month following the mo nth in which the change occurred. If Food Stamps are over-issued because a household fails to report required changes, a claim determination must be prepared. A person can be disqualified for failure to report a change if they commit an IPV.(7-1-24)
IDAPA 16.03.04.612 (Reserved)
IDAPA 16.03.04.613 Changes on Which the Department Must Act
The Department must follow the procedures for acting on reported changes under 7 CFR 273.12.(7-1-24)
614 -- 616.(RESERVED)
IDAPA 16.03.04.617 Increases in Food Stamp Benefits
01.Household Reports a Change. If a ho usehold reports a change that results in an increase in Food Stamps and the proof cannot be obtained through interfaces or data brokers, the Department must allow the household ten (10) days to provide proof.(7-1-24)
02.Failure to Provide Proof of Change. If the household fails to provide proof of a change that would increase the benefit level, the Food Stamp benefit remains at the amount already established.(7-1-24)
03.Proof Provided Within Ten Days. If the household provides proof within ten (10) days of reporting the change, the Department will increase the Food Stamp benefits beginning the month immediately following the month in which the change was reported. For changes reported after the 20th of the month, a supplement is issued for the next month no later than the 10th of the next month. If the change is reported and verified after the final date to adjust Food Stamp benefits for the following month in the Department’s automated eligibility system, the change to the Food Stamp benefits must be made by the following month, even if a supplement must be issued.(7-1-24)
04.Proof Not Provided Within Ten Days. If the household fails to provide proof within ten (10) days of reporting the change, but provides proof later, benefits are increased the month after the proof of the change is provided.(7-1-24)
IDAPA 16.03.04.618 Decreases in Food Stamp Benefits
If the Department acts on a change that results in a decrease in Food Stamp benefits, the Department must give timely notice, if required. The notice must explain the reason for the action.(7-1-24)
619 -- 620.(RESERVED)
IDAPA 16.03.04.621 Tafi or Aabd Household Reporting Changes
If a change in the AABD or TAFI grant results in a change in the household's Food Stamp benefits, the Department must count the new grant amount, regardless of whether the Food Stamps increase or decrease. If a change requires a reduction or ending of TAFI or AABD and Food Stamp benefits, the Department will issue a Notice of Decision for both programs. If the household makes a timely request for a fair hearing and continued benefits, Food Stamp benefits continue pending the hearing. The household must reapply if certification expires before the hearing is complete.(7-1-24)
IDAPA 16.03.04.622 Change Ends Tafi or Aabd Income
Food Stamp benefits will be closed only if there is a change on which the Department is required to act. If TAFI or AABD ends and the household remains Food Stamp eligible, the Department must advise the household of any applicable work registration requirements.(7-1-24)
IDAPA 16.03.04.623 Failure to Take Required Action
If the Department is unable to make a change in Food Stamp eligibility or issuance and an overissuance results, the Department will collect the overpayment. If the Department fails to act on a change that increases household benefits, the Department will restore lost benefits.(7-1-24)
IDAPA 16.03.04.624 (Reserved)
IDAPA 16.03.04.629 Notice of Lowering or Ending Benefits
Households must be sent a Notice of Decision when Food Stamps are ended or reduced unless notice is not required under these rules.(7-1-24)
IDAPA 16.03.04.630 Adequate Notice
Adequate notice is a written statement telling the household the acti on the Department is taking. The notice must tell the reasons for the action and advise the household of the right to a hearing. All notices must be adequate. If Food Stamps are reduced, the household must receive the notice on or before the first day of the month the action is effective.(7-1-24)
IDAPA 16.03.04.631 Timely Notice
Timely notice must be mailed at least ten (10) days before the ef fective date of the action.(7-1-24)
IDAPA 16.03.04.632 Timely Notice Not Required
Timely notice is not required when the conditions listed belo w are met. Adequate notice must be given.(7-1-24)
01.Statement of Household. The Department gets a clear, written, signed statement from the household. Food Stamps can be ended or reduced from the facts given in the household statement.(7-1-24)
02.Food Stamps Reduced After Closure Notice. The household is sent a notice of closure because it did not provide requested proof. The household provides the proof before the first day of the month of closure. If the proof results in reduced Food Stamps, the reduced benefits are issued.(7-1-24)
03.Food Stamps Closed or Reduced Because of IPV Penalty. The Department must impose the IPV penalty the first of the month after the month it gives written notice to the participant.(7-1-24)
IDAPA 16.03.04.633 Notice of Changes Not Required
Notice to individual Food Stamp households is not required w hen the conditions under Subsection 633.01 in this rule are met. Mass notice must be given in some situations under Subsection 633.02 in this rule:(7-1-24)
01.Waiver by the Household. A household member or authorized representative provides a written statement requesting closure. The person gives information causing reduction or an end to benefits and states, in writing, they know adverse action will be taken. The person acknowledges in writing continuation of benefits is waived if a fair hearing is requested.(7-1-24)
02.Mass Changes. Include changes:(7-1-24)
a.In the income limit tables.(7-1-24)
b.In the issuance tables.(7-1-24)
c.In Social Security benefits.(7-1-24)
d.In SSI payments.(7-1-24)
e.In TAFI or AABD grants.(7-1-24)
f.Caused by a reduction, suspension, or cancellation of Food Stamps ordered by the Secretary of USDA.(7-1-24)
g.When the Department performs mass changes, it notifies Food Stamp households of the mass change by one (1) of the following methods:(7-1-24)
i.Media notices.(7-1-24)
ii.Posters in the Food Stamp offices and issuance locations.(7-1-24)
iii.A general notice mailed to households.(7-1-24)
03.Mass Changes in TAFI or AABD. When a mass change to TAFI or AABD causes a Food Stamp change, the Department will use the following criteria:(7-1-24)
a.If the Department has thirty (30) days advance notice of the TAFI or AABD mass change, Food Stamps must be adjusted the same month as the change.(7-1-24)
b.If the Department does not have advance notice, Food Stamp benefits must be changed no later than the month after the TAFI or AABD mass change.(7-1-24)
c.Ten (10) day advance notice to Food Stamp households is not required. Adequate notice must be sent to Food Stamp households.(7-1-24)
d.If a household requests a fair hearing because of an issue other than mass change, the Department will continue Food Stamps.(7-1-24)
04.Notice of Death. Notice is not required when the Department learns of the death of all household members.(7-1-24)
05.Completion of Restored Benefits. Notice is not required when an increased allotment, due to restored benefits, ends. The household must have been notified in writing when the increase would end.(7-1-24)
06.Joint Public Assistance and Food Stamp Applications. Notice is not required if the household jointly applies for TAFI or AABD and Food Stamps and gets Food Stamps pending TAFI or AABD approval. The household must be notified at certification that Food Stamps will be reduced upon TAFI or AABD approval. (7-1-24)
07.Converting From Repayment to Benefit Reduction. Notice is not required if a household with an IHE or IPV claim fails to repay under the repayment schedule. An allotment reduction is enforced.(7-1-24)
08.Households Receiving Expedited Service. Notice is not required if all the following conditions are met:(7-1-24)
a.The applicant received expedited services.(7-1-24)
b.Proof was postponed.(7-1-24)
c.A regular certification period was assigned.(7-1-24)
d.Written notice, stating future Food Stamps depend on postponed proof, was given at approval.
09.Residents of a Substance Use Disorder Treatment Center or a Group Living Arrangement Center. Notice is not required when the Department ends Food Stamps to residents of a substance use disorder treatment center or group living arrangement center if:(7-1-24)
a.The Department revokes the center’s certification.(7-1-24)
b.FNS disqualifies the center as a retailer.(7-1-24)
IDAPA 16.03.04.634 Verbal Request for End of Food Stamps
If a household makes a verbal request for closure, the Departm ent will end the benefits, and notify the household with a ten (10) day advance Notice of Decision.(7-1-24)
IDAPA 16.03.04.635 (Reserved)
IDAPA 16.03.04.639 Continuation of Benefits Pending a Hearing
The household retains the right to continued benefits when the househ old requests a fair hearing within the ten (10) day notice period. The household must request this continuation of Food Stamps. If certification has not expired, Food Stamps can continue at the former level. Benefits must be continued within five (5) working days of the household’s request for a fair hearing.(7-1-24)
IDAPA 16.03.04.640 (Reserved)
IDAPA 16.03.04.641 Reducing or Ending Benefits Before Hearing Decision
Benefits may be ended or reduced before the hearing decision, if any of the following is met:(7-1-24)
01.Appeal of Federal Law. The hearing official states, in writing, the sole issue being appealed is one of federal law, regulation, or policy.(7-1-24)
02.Food Stamp Issuance Changes. Food Stamp eligibility or benefit level changes occur before the hearing decision and a new hearing is not requested.(7-1-24)
03.Food Stamp Certification Period Expires.(7-1-24)
04.Mass Change Occurs Before the Hearing Decision.(7-1-24)
IDAPA 16.03.04.642 (Reserved)
IDAPA 16.03.04.644 Expiration of Certification Period
Household eligibility ends when the certi fication period expires.(7-1-24)
IDAPA 16.03.04.645 Recertification Process
The Department must follow the recertification procedures under 7 CFR 273.14.(7-1-24)
IDAPA 16.03.04.646 Notice of Decision for Timely Recertification
A Notice of Decision must be sent to households that reapply for Food Stamps.
To receive Food Stamps with no break in issuance, households must complete a six-month or twelve-month contact or recertification before the fifteenth day of the last month of certification or six-month or twelve-month contact period. If the household applies before the fifteenth day of the month, the Department will notify the household of eligibility or denial by the end of the current certification period.(7-1-24)
IDAPA 16.03.04.647 (Reserved)
IDAPA 16.03.04.650 Restoration of Lost Benefits
Lost benefits must be restored. The Department may find Food Stamps have been incorrectly denied, ended, or underissued to an eligible household. The Department may learn of lost benefits from case reviews, Quality Control reviews, or other sources. Benefits are restored when caused by a Department error, when a fair hearing is reversed, or an IPV disqualification is reversed. The Department will restore benefits to eligible and previously eligible households and to households who have moved out of state. The Department will restore benefits for SSA joint processing errors.(7-1-24)
IDAPA 16.03.04.651 Time Frames for Restoration of Benefits
Benefits must not be restored if lost more than twelve (12) months before notification or discovery.(7-1-24)
01.Lost Benefits Reported by Household. Are restored when the Department learns of lost benefits reported by the household, a person outside the household, or by another agency. Twelve (12) months are counted from the month the Department is notified of the lost benefits.(7-1-24)
02.Lost Benefits Discovered by Department. Are restored when the Department discovers lost benefits during the course of business. Twelve (12) months are counted from the month the Department discovers the benefits were lost.(7-1-24)
03.Lost Benefits From Fair Hearing. Are restored to a household that requests a fair hearing and the decision is in the household’s favor. Twelve (12) months are counted from the effective date of the adverse action causing the fair hearing.(7-1-24)
IDAPA 16.03.04.652 (Reserved)
IDAPA 16.03.04.656 Replacing Food Destroyed by a Disaster
Conditions and procedures for replacing food destroyed by a disaster are listed below. The food must have been purchased with Food Stamps.(7-1-24)
01.Food Destroyed in a Disaster. The actual value of loss, not to exceed one (1) month’s allotment, can be replaced. The food bought with Food Stamps must have been destroyed in a disaster. The disaster may involve only the household, such as a house fire, or a larger scope, such as a flood. There is no limit on the number of times food destroyed in a disaster may be replaced.(7-1-24)
02.Replacement Time Limit for Disaster Loss. The Department must provide either disaster Food Stamps or replacement Food Stamps, but not both, within ten (10) days of the reported loss, if:(7-1-24)
a.The household reports the disaster within ten (10) days of the incident.(7-1-24)
b.The disaster is verified by collateral contact, an organization such as the Fire Department or Red Cross, or by home visit.(7-1-24)
IDAPA 16.03.04.657 (Reserved)
IDAPA 16.03.04.675 Ipv, Ihe, and Ae Food Stamp Claims
An overissuance exists when the amount of Food Stamps issued exceeds th e Food Stamps a household is eligible to receive. The Department must establish a claim against the household, to recover the value of Food Stamps overissued or misused. The types of Food Stamp claims are listed below.(7-1-24)
01.Intentional Program Violation (IPV) Claim. A overissuance caused by an intentional, knowing, and willful program violation.(7-1-24)
02.Inadvertent Household Error (IHE) Claims. An error, without intent to cause an overissuance, which results in a Food Stamp overissuance. Causes of IHE claims are:(7-1-24)
a.Failure to give information. A household, without intent to cause an overissuance, fails to give correct or complete information.(7-1-24)
b.Failure to report change that was required to be reported. A household, without intent to cause an overissuance, fails to report changes or to report at all.(7-1-24)
c.Failure to comply. A household, without intent to cause an overissuance, fails to comply due to language barrier, educational level, or not understanding written or verbal instructions.(7-1-24)
d.Pending IPV. An IHE claim occurs between the time of an IPV referral and the IPV decision.
03.Agency Error Claim (AE). A claim that results from an overissuance caused by a Department action or a failure to act.(7-1-24)
IDAPA 16.03.04.676 Persons Liable for Food Stamp Claims
The persons listed below are responsible for paying a claim.(7-1-24)
Adult Household Members. Adult members of the household at the time of the overissuance or trafficking are liable. They are individually and jointly liable, whether residing in the household where the claim arose, or in any other household.(7-1-24)
02.Sponsor of an Alien. The sponsor of an alien household member if the sponsor is at fault for the claim.(7-1-24)
03.Person Connected to the Household. A person connected to the household, such as an authorized representative, who trafficks or causes an overissuance or trafficking.(7-1-24)
IDAPA 16.03.04.677 Computing Food Stamp Claims
The Department computes Food Stamp clai ms as described below.(7-1-24)
01.Claims Not Related to Trafficking. The Department computes claims not related to trafficking back to a minimum of twelve (12) months before it became aware of the overissuance. The Department does not compute these claims back more than six (6) years. For an IPV claim, the Department computes back to the month the first IPV occurred. The Department continues to compute back a minimum of twelve (12) months before the first IPV. The Department does not compute IPV claims back more than six (6) years before the first IPV.(7-1-24)
02.Trafficking-Related Claims. Are the value of the trafficked Food Stamps as determined by:
a.The individual’s admission.(7-1-24)
b.Adjudication.(7-1-24)
c.The documentation forming the basis for the trafficking determination.(7-1-24)
IDAPA 16.03.04.678 (Reserved)
IDAPA 16.03.04.692 Determining Delinquent Claims
The Department determines if a claim is delinquent using the following.(7-1-24)
Claim Not Paid by Due Date. Is delinquent if there is not a satisfactory payment arrangement. The claim remains delinquent until paid in full, a satisfactory repayment agreement is negotiated, or allotment reduction is invoked.(7-1-24)
02.Payment Arrangement Not Followed. The claim is delinquent if a payment arrangement is established, but scheduled payment is not made by the due date. The claim remains delinquent until paid in full, allotment reduction is invoked, or the Department agrees to resume or renegotiate the repayment schedule. (7-1-24)
03.Previous Claim. A claim is not delinquent if another claim for the same household is being paid through an installment agreement or allotment reduction. The Department begins collection on the new claim after the first claim is settled.(7-1-24)
04.Collection Coordinated Through Court. A claim is not delinquent if the Department is unable to determine delinquency status because collection is coordinated through the court system.(7-1-24)
05.Claim Awaiting Hearing Decision. Is not delinquent. If later, the hearing officer affirms a claim does exist against the household, the Department notifies the household.(7-1-24)
IDAPA 16.03.04.693 (Reserved)
IDAPA 16.03.04.694 Collecting Claims
The Department collects payment for claims using the methods listed below.(7-1-24)
01.Allotment Reduction. The Department reduces the Food Stamp allotment to collect the claim.
a.For an IPV claim, the allotment reduction limit is the greater of twenty dollars ($20) per month or twenty percent (20%) of the household's monthly allotment.(7-1-24)
b.For an IHE or AE claim, the allotment reduction limit is the greater of ten dollars ($10) per month or ten percent (10%) of the household's monthly allotment. The household can agree to a higher amount.(7-1-24)
c.The Department does not reduce the initial month's Food Stamps unless the household agrees to this reduction.(7-1-24)
02.Household Repays the Claim from its EBT Account.(7-1-24)
03.Payment by Cash, Check, or Money Order.(7-1-24)
04.Household Performing Public Service. Payment by public service as ordered by a court, specifically as payment of a claim.(7-1-24)
05.Collection by Treasury Offset Program (TOP). The Department submits claims delinquent for one hundred and eighty (180) days, or more, for collection through TOP.(7-1-24)
IDAPA 16.03.04.695 Top Notices
The Department will provide the household with a notice of intent to collect via Treasury offset. The notice must inform the household of the right to request a Department review of the intended collection action. The Department must receive the request for review within sixty (60) days of the notice of intent to collect. The notice of review determination must inform the household of the right to request that FNS review the Department’s decision. The notice must include instructions for requesting a review by FNS and the address of the FNS regional office. (7-1-24)
IDAPA 16.03.04.696 Effects of Top on the Food Stamp Household
When a claim is referred to TOP, any eligible federal pay ment owed to the household may be intercepted and applied to the claim to reduce the debt. The household may be required to pay collection or processing fees charged by the federal government to intercept the payment.(7-1-24)
IDAPA 16.03.04.697 Removing a Claim from Top
The Department removes a claim from TOP under the conditions listed below.(7-1-24)
Instructed by FNS or Treasury.(7-1-24)
02.Household Undergoing Allotment Reduction.(7-1-24)
03.Claim Is Paid in Full.(7-1-24)
04.Claim Is Satisfied Through a Hearing, Termination, Compromise, or Other Means. (7-1-24)
05.Household Arranges to Resume Payments.(7-1-24)
IDAPA 16.03.04.698 Intentional Program Violation (ipv)
An IPV includes the actions listed below. The participant must intentionally, knowingly, and willfully commit a program vio lation.(7-1-24)
01.False Statement. A person makes a false statement to the Department, either orally or in writing, to get Food Stamps.(7-1-24)
02.Misleading Statement. A person makes a misleading statement to the Department, either orally or in writing, to get Food Stamps.(7-1-24)
03.Misrepresenting. A person misrepresents facts to the Department, either orally or in writing, to get Food Stamps.(7-1-24)
04.Concealing. A person conceals or withholds facts to get Food Stamps.(7-1-24)
05.Violation of Regulations. A person commits any act violating the Food Stamp Act, federal regulations, or state Food Stamp regulations. The violation may relate to use, presentation, transfer, acquisition, receipt, or possession of Food Stamps.(7-1-24)
06.Trafficking in Food Stamps. Means any of the following:(7-1-24)
a.The buying, selling, stealing, or otherwise effecting an exchange of food stamp benefits issued and accessed via EBT cards, card numbers, and personal identification numbers (PINs), or by manual voucher and signature, for cash or consideration other than eligible food, either directly, indirectly, in complicity or collusion with others, or acting alone;(7-1-24)
b.Attempting to buy, sell, steal, or otherwise affect an exchange of food stamp benefits issued and accessed via EBT cards, card numbers, and PINs, or by manual voucher and signatures, for cash or consideration other than eligible food, either directly, indirectly, in complicity or collusion with others, or acting alone;(7-1-24)
c.The exchange of firearms, ammunition, explosives, or controlled substances, defined under Section 802 of Title 21, USC, for food stamp benefits;(7-1-24)
d.Purchasing a product with food stamp benefits that has a container requiring a return deposit with the intent of obtaining cash by discarding the product and returning the container for the deposit amount, intentionally discarding the product, and intentionally returning the container for the deposit amount;(7-1-24)
e.Purchasing a product with food stamp benefits with the intent of obtaining cash or consideration other than eligible food by reselling the product, and subsequently intentionally reselling the product purchased with food stamp benefits in exchange for cash or consideration other than eligible food; or(7-1-24)
f.Intentionally purchasing products originally purchased with food stamp benefits in exchange for cash or consideration other than eligible food.(7-1-24)
IDAPA 16.03.04.699 Establishing an Intentional Program Violation (ipv)
The Department establishes an IPV by th e actions listed below.(7-1-24)
01.Waiver. The participant signs a waiver to a disqualification hearing.(7-1-24)
02.Hearing. An administrative disqualification hearing determines an IPV.(7-1-24)
03.Judgment. A court judgment determines an IPV.(7-1-24)
IDAPA 16.03.04.700 Administrative Responsibility for Establishing Ipv
The Department must investigate and refer cases for an IPV determination. If there is enough recorded evidence to establish an IPV, the Department must take the actions listed below:(7-1-24)
01.Act to Collect. The Department must act to collect overissuances. The Department must set up IHE overissuance claims when a suspected IPV claim is not pursued under administrative or prosecution procedures.
02.Obtain Administrative Disqualification. The Department pursues administrative disqualification when:(7-1-24)
a.The case facts do not warrant civil or criminal prosecution.(7-1-24)
b.The case referred for prosecution was declined.(7-1-24)
c.The case was referred for prosecution and no action was taken in a reasonable time.(7-1-24)
d.The case was referred for prosecution, but the case was withdrawn by the Department.(7-1-24)
03.Do Not Obtain Administrative Disqualification. The Department must not pursue an administrative disqualification in cases:(7-1-24)
a.Being referred for prosecution.(7-1-24)
b.After any prosecutor action against the accused if the case issues are the same or related circumstances.(7-1-24)
IDAPA 16.03.04.701 Penalties for an Ipv
IPV persons are ineligible for Food Stamps for twelve (12) months for the first violation, for twenty-four (24) months r the second violation, and permanently for the third violation. The Department will disqualify only the person(s) who committed the IPV. The Department will notify the person in writing of the disqualification penalty. The penalty continues without interruption until completed, regardless of the eligibility of the disqualified person. An IPV penalty can be imposed even if no overissuance claim exists.(7-1-24)
01.Administrative Disqualification Hearings. The disqualification begins no later than the first day of the second month following the date the person gets written notice of the disqualification.(7-1-24)
02.Waivers. The disqualification begins the first day of the month following the date the person gets the written notice of disqualification.(7-1-24)
03.Court Decisions. The disqualification begins on the date imposed by the court (to start the beginning of the following month) or, if no date is specified, within forty-five (45) days of the date the disqualification was ordered, beginning the first day of the month.(7-1-24)
IDAPA 16.03.04.702 Penalties for Ipv Trafficking
IPV persons are ineligible for Food Stamps for two (2) years for the first finding by a court the recipient purchased illegal drugs with Food Stamps, are permanently ineligible for Food Stamps for a second finding by the court the recipient purchased illegal drugs with Food Stamps, and are permanently ineligible for Food Stamps for a first finding by a court the recipient purchased firearms, ammunition, or explosives with Food Stamps. A person convicted of trafficking in Food Stamp benefits of five hundred dollars ($500) or more is permanently disqualified from the Food Stamp program.(7-1-24)
IDAPA 16.03.04.703 Penalties for Ipv Receipt of Multiple Benefits
A person found making a fraudulent statement or representation abo ut identity or residence to get multiple benefits is ineligible for Food Stamps for ten (10) years for the first and second offenses and permanently for the third offense.
IDAPA 16.03.04.704 (Reserved)
IDAPA 16.03.04.715 Waived Hearings
Persons accused of an IPV may waive their right to an administrative disqualification hearing by completing and signing a Waiver of Disqualification Hearing. If the reviewers determine a waiver is proper, each household member suspected of IPV must be mailed or given a Waiver of Disqualification Hearing.(7-1-24)
IDAPA 16.03.04.716 Disqualification After Waived Hearing
Persons waiving their right to an IPV administrative disqual ification hearing must have penalties imposed. (7-1-24)
IDAPA 16.03.04.717 Court Referrals
Procedures for court referrals
01.Referred Cases. The Department may refer persons to law enforcement or county prosecutor who are suspected of getting or receiving Food Stamps by committing an IPV, or persons suspected of committing an IPV.
02.Impose Court Penalties. The Department must disqualify a person found guilty of IPV by a court for the length of time specified by the court. The disqualified member’s household will remain responsible for the overissuance, resulting from the disqualified member’s IPV, regardless of the household’s eligibility. If the court fails to specify a period, the Department will use the IPV penalty periods under Section 701 of these rules unless they are contrary to the court order.(7-1-24)
IDAPA 16.03.04.718 Deferred Adjudication
Deferred Adjudication is an out-of-c ourt settlement between the accused IPV member and the prosecutor. Terms of the settlement are listed below:(7-1-24)
01.Deferred Judgment Conditions. Guilt is not decided by the court because the accused person has met the terms of a court order or an agreement with the prosecutor.(7-1-24)
02.Agreement with Prosecutor. If the Department has an agreement with the prosecutor, the prosecutor may defer adjudication. The prosecutor must agree to give advance written notice to the member stating the consequences of consenting to disqualification.(7-1-24)
03.Notice to Food Stamp Member. If the prosecutor decides deferred adjudication is fitting, the household member suspected of IPV must be mailed or presented with a Deferred Adjudication Disqualification Consent Agreement.(7-1-24)
04.Disqualification Period. The period of disqualification must begin within forty-five (45) days of the date the member signed the Deferred Adjudication Disqualification Consent Agreement. The period of disqualification must begin as agreed upon with the prosecutor. Once a disqualification penalty is imposed against a member, the period continues uninterrupted regardless of the household’s eligibility. The disqualified member’s household continues to be responsible for overissuance repayment resulting from the disqualified member’s IPV regardless of the household’s eligibility.(7-1-24)
05.Notice of Disqualification. The Department must provide a completed Notice of Disqualification before the disqualification to the disqualified member and remaining household members. The Department must provide a Demand Letter for Overissuance and Repayment Agreement.(7-1-24)
IDAPA 16.03.04.719 (Reserved)
IDAPA 16.03.04.720 Claims Discharged by Bankruptcy
The Department will act for FNS in bankruptcy proceedings agains t households owing claims. The Department may file proofs of claims, objections to discharge, exceptions, petitions, and any other documents, motions, or objectives FNS might have filed.(7-1-24)
IDAPA 16.03.04.721 (Reserved)
IDAPA 16.03.04.722 Interstate Claims Collection
Idaho is responsible for initiating and continuing collection action on any Food Stamp recipient claim regardless of whet her the household remains in Idaho.(7-1-24)
IDAPA 16.03.04.723 (Reserved)
IDAPA 16.03.04.728 Food Stamp Reduction, Suspension, or Cancellation
Food Stamps for all Food Stamp households must be reduced su spended, or cancelled, if ordered by the USDA Secretary to comply with Section 18 of the Food Stamp Act of 1977. Reduced Food Stamps are computed using the thrifty food plan amounts and are reduced by a percentage defined by FNS. Food Stamp reduction, suspension, and cancellation rules are described below:(7-1-24)
01.Reducing Food Stamps. FNS will notify the Department of the effective date of reduction and of the thrifty food plan reduction percentage. The Department must:(7-1-24)
a.Act immediately to carry out the reduction.(7-1-24)
b.Guarantee one (1) and two (2) person households a minimum benefit of equal to eight percent (8%) of the maximum one (1) person allotment unless the reduction is ninety percent (90%) or more of total projected monthly benefits.(7-1-24)
02.Restoring Lost Benefits. Households whose Food Stamps are reduced or cancelled under this rule are not entitled to restoration of benefits. Reductions or cancellations of Food Stamps may be ordered restored by the USDA Secretary.(7-1-24)
03.Suspension or Cancellation. If a suspension or cancellation is in effect, no Food Stamps are to be issued to the applicant.(7-1-24)
04.Hearings. Any household whose allotment was reduced, suspended, or cancelled under this rule can request a fair hearing.(7-1-24)
IDAPA 16.03.04.729 (Reserved)
IDAPA 16.03.04.751 Boarders
Rules for Food Stamp boarders are listed below:(7-1-24)
Boarder Included with Food Stamp Household. Boarders may be included in the Food Stamp household providing board. The Food Stamp household must request the boarder be included. The household must be otherwise eligible.(7-1-24)
02.Foster Children and Foster Adults. Foster children and foster adults are boarders. Foster care payments and guardianship payments are not income for Food Stamps if the foster child and adult do not get Food Stamps as part of the household. If the household requests the foster child and adult be included in the Food Stamp household, foster care payments and guardianship payments are counted.(7-1-24)
03.Certified Family Home (CFH). CFH residents are considered boarders and may be included in the CFH providers household.(7-1-24)
04.Meal Compensation. Boarder status must be given to persons paying a reasonable monthly amount for meals.(7-1-24)
a.Payments for more than two (2) meals a day must equal or exceed the thrifty food plan for the boarder household size.(7-1-24)
b.Payments for two (2) meals or less per day must equal or exceed two-thirds (2/3) of the thrifty food plan for the boarder household size.(7-1-24)
05.Nonboarder Status. A person paying less than a reasonable amount for meals is a member of the household providing board.(7-1-24)
06.Income from Boarders. If the boarder is not a Food Stamp household member:(7-1-24)
a.The meals and lodging payment is self-employment income for the Food Stamp household.
b.The boarder’s income and resources are not counted for the Food Stamp household.(7-1-24)
IDAPA 16.03.04.752 Strikers
Households with strikers are not eligible to get Food Stamps unless the household was eligible the day before the strike.(7-1-24)
IDAPA 16.03.04.753 Sponsored Legal Non-Citizens
Sponsored legal non-citizens are lawfully admitted for permanent United States residence. A sponsor executes an I- 864 affidavit of support on behalf of legal non-citizen. The income and resources of the sponsor will be deemed until the legal non-citizen becomes a naturalized citizen or until they have worked forty (40) qualifying quarters of coverage under Title II of the Social Security Act, or the sponsor dies. A qualifying quarter includes a quarter worked by the legal non-citizen’s parent while the legal non-citizen was under eighteen (18) and a quarter worked by the legal non-citizen’s spouse during marriage if the legal non-citizen remains married to the spouse or the spouse is deceased.
Any quarter after January 1, 1997, in which a legal non-citizen received any federal means-tested benefit is not counted as a qualifying quarter.(7-1-24)
IDAPA 16.03.04.754 Deeming Income and Resources to
SPONSORED LEGAL NON-CITIZEN.
Income and resources of the sponsor are deemed available to the legal non -citizen. If the sponsor lives with their spouse, the spouse’s income and resources are also deemed available to the legal non-citizen. The income and resources are deemed, even if the sponsor and spouse were married after the sponsor signed the sponsorship agreement. The Department counts income and resources deemed to the legal non-citizen toward Food Stamp eligibility and issuance level of the legal non-citizen’s household.(7-1-24)
01.Battered Legal Non-Citizen Whose Sponsor Signed an Affidavit of Support. For sponsor deeming, a battered legal non-citizen includes the non-citizen and the child of the non-citizen. The non-citizen or child must be battered in the US by a spouse, parent, or member of the family in the same household. The non-citizen must not participate in, or acquiesce to, the battering of the child.(7-1-24)
a.A battered legal non-citizen whose sponsor signed an affidavit of support is exempt from the sponsor deeming requirement for one (1) year if the need for Food Stamps is connected to the battery and the legal non-citizen no longer lives with the batterer.(7-1-24)
b.The exemption from the sponsor deeming requirement can exceed more than one (1) year if the legal non-citizen demonstrates the battery has been recognized in an order of a judge or by the INS and the need for Food Stamps is connected to the battery.(7-1-24)
02.Indigent Legal Non-Citizen Whose Sponsor Signed an Affidavit of Support. A non-citizen is indigent if the household income does not exceed one-hundred thirty percent (130%) of the poverty income guideline (gross income limit) for the household size.(7-1-24)
a.For an indigent non-citizen, the Department counts the non-citizen’s own income and the cash or in-kind income and resources provided by the sponsor and spouse who signed an affidavit of support.(7-1-24)
b.A legal non-citizen that satisfies the indigent exemption criteria is exempt from deeming for twelve (12) months. The exemption can be renewed for additional twelve-month periods.(7-1-24)
c.If a legal non-citizen is granted an indigence exemption, the Department must provide written notification to the Statistics Branch of the INS on an annual basis. Required information includes written notice of the determination, the sponsored legal non-citizen’s name, and the sponsor’s name.(7-1-24)
d.A legal non-citizen can elect to decline the indigent exemption to avoid sponsor liability and notification to the INS.(7-1-24)
e.If the legal non-citizen declines the indigent exemption, the household is subject to sponsored deeming.(7-1-24)
IDAPA 16.03.04.755 (Reserved)
IDAPA 16.03.04.757 Sponsored Legal Non-Citizen's Responsibility
The legal non-citizen and their spouse are responsible for getting the sponsor to cooperate with the Department in determi ning Food Stamp eligibility. The legal non-citizen and their spouse are responsible for providing the information and proof to determine the income and resources of the sponsor and sponsor’s spouse. The legal noncitizen and their spouse are responsible for providing information and proof to determine if the sponsor sponsors other legal non-citizens and how many.(7-1-24)
IDAPA 16.03.04.758 (Reserved)
IDAPA 16.03.04.761 Collecting Claims Against Sponsors Who Signed an I-864 Affidavit of
SUPPORT ON OR AFTER DECEMBER 19, 1997.
Claims may be collected against a sponsor who signed an I-864 af fidavit of support on or after December 19, 1997, and is found to have provided false statements or withheld information.(7-1-24)
IDAPA 16.03.04.762 Collecting Claims Against Sponsored Legal
NON-CITIZENS.
Claims may be collected against sponsored legal non-citizens with a sponsor who signed an I-864 affidavit of support on or after December 19, 1997. Action may be taken to collect by submitting an IHE or IPV.(7-1-24)
IDAPA 16.03.04.763 Reimbursement for Benefits Received
A sponsor who signed an affidavit on or after December 19, 1997, mus t reimburse the Department for the amount of Food Stamps received by the sponsored legal non-citizen if false information is provided or information is withheld.
At the time of application for a sponsored legal non-citizen, the legal non-citizen’s sponsor must be notified that he will be required to reimburse the Department for the entire amount of Food Stamps received by the sponsored legal non-citizen.(7-1-24)
IDAPA 16.03.04.764 (Reserved)
IDAPA 16.03.04.791 Resident of an Institution
A resident of an institution is not eligible for Food Stamps unless the resident meets one (1) of the requirements listed below. A person is a resident of an institution if the institution provides over fifty percent (50%) of the person’s meals as a part of normal services. Residents must be otherwise Food Stamp eligible.(7-1-24)
01.Resident Under Housing Act. The resident is in federally subsidized housing for the elderly, under Section 202 of the Housing Act or 236 of the National Housing Act.(7-1-24)
02.Person with Substance Use Disorder. The resident is a person with a substance use disorder living and taking part in a treatment and rehabilitation program.(7-1-24)
03.Blind or Disabled. The person is a disabled or blind resident of a group living arrangement.
04.Battered Woman and Child(ren). The resident is a woman or a woman and her child(ren), temporarily living in a shelter for battered women and children.(7-1-24)
a.The woman is a separate household from other shelter residents for Food Stamps.(7-1-24)
b.The woman and her children are a separate household from other shelter residents for Food Stamps.
05.Homeless Person. The resident is a person living in a public or private nonprofit shelter for homeless persons.(7-1-24)
IDAPA 16.03.04.792 Prerelease Applicants from Public Institutions
Residents of public institutions who apply for prerelease program SSI may apply for Food Stamps before their release from public institutions. The application date is the date the person is released from the institution. Eligibility is based on the best estimate of a household’s circumstances for the release month and the month after. Eligibility and Food Stamp amount are based on income and resources. Food Stamps for the initial month are prorated from the date the person is released from the institution to the end of the calendar month.(7-1-24)
IDAPA 16.03.04.793 Substance Use Disorder Treatment Centers
01.Center Provides Certification List. Each month, each center must give the field office a list of current participant residents. The list’s accuracy must be certified in writing by the center manager or designee. The Department must conduct random on-site visits to assure list accuracy. If the list is not accurate, or the Department fails to act on the change, the Department may transfer the Food Stamp amount from the center’s account to the household’s Food Stamp account, for the months the household was not living in the center.(7-1-24)
02.Center Misusing Food Stamps. The Department must promptly notify FNS if it believes a center is misusing Food Stamps. The Department must not act before FNS takes action against the center.(7-1-24)
IDAPA 16.03.04.794 Treatment Center Responsibilities
Each treatment center must follow Food Stamp appl ication standards, except for:(7-1-24)
01.Return Food Stamps.(7-1-24)
a.The center must return to the Department all issue documents and Food Stamps not given to a departing resident.(7-1-24)
b.Food Stamps must be returned to the Department if the participant left before the sixteenth of the month and the center was unable to give them the Food Stamps.(7-1-24)
c.Food Stamps must be returned to the Department if they were left over for a resident who left on or after the sixteenth of the month.(7-1-24)
02.Give Food Stamps to Departing Participant.(7-1-24)
a.The center must give the departing participant the ID card and any unredeemed Food Stamps.
b.The center must give the participant a full month’s Food Stamps if they have been issued, but none have been spent on behalf of the participant.(7-1-24)
c.The center must give the departing participant one-half (1/2) of the monthly Food Stamps if the participant leaves before the sixteenth of the month and a portion of the Food Stamps have been spent on behalf of the participant.(7-1-24)
d.If the participant leaves the center on or after the sixteenth, and Food Stamps were issued and used, the center is not required to give Food Stamps to the participant.(7-1-24)
03.Food Stamp Misuse. The center must be disqualified if it is administratively or judicially found the center misappropriated or used Food Stamps for purchases not contributing to a certified participant’s meals.
04.FNS Disqualifies Center. If FNS disqualifies a center as a retailer, the Department must close residents’ cases. Individual notice of adverse action is not required.(7-1-24)
IDAPA 16.03.04.795 Residents of Group Living Arrangements
Disabled or blind residents of public or private non-profit group living arrangements, serving no more than sixteen (16) residents, may get Food Stamps. Residents get Food Stamps under the same standards as other households.
Group living arrangements rules are listed below:(7-1-24)
01.FNS-Authorized Retailer or Department Certified. The center must be an FNS-authorized retailer or be certified by the Department as a non-profit group living center. Center status must comply with Section 1616(e) of the Social Security Act or comparable standards of the Secretary of USDA.(7-1-24)
02.Application Option. Residents may apply on their own, as a group, or through an authorized representative employed and designated by the center. Residents may apply through an authorized representative of the resident’s choice.(7-1-24)
03.Residents Apply on Their Own Behalf. A person or a group of residents making up a household can apply on their own behalf. The center must determine the resident is physically and intellectually capable of handling their own affairs. If the resident is eligible, the center does not act as the authorized representative. The resident or group is responsible for reporting any changes affecting eligibility or benefit level. The resident is responsible for overissuances.(7-1-24)
04.Certification. Residents of a center applying through the center’s authorized representative must be certified as a one (1) person household. Residents of a center applying on their own behalf must be certified according to household size.(7-1-24)
05.Residents Are Exempt From Work Registration.(7-1-24)
06.Residents Are Entitled to Notices of Adverse Action. If a group living arrangement center loses its authorization or certification, notice is not required.(7-1-24)
07.Using Food Stamps. The Food Stamps may be used by the resident, a group of residents, or by the center to purchase food for the resident. The center may accept Food Stamps as payment for meals. If residents purchase or prepare food for home consumption, the center must ensure each resident’s Food Stamps are used for meals intended for that resident.(7-1-24)
IDAPA 16.03.04.796 Shelters for Battered Women and Children
The Department must determine if the shelter for battered w omen and children is a public or private non-profit residential facility. The Department must determine if the shelter serves only battered women and their children. If the facility serves other persons, the Department must determine if a portion of the facility is set aside to serve only battered women and children. Shelters having FNS authorization to redeem Food Stamps on a wholesale basis meet the shelter definition. Battered women and children shelter rules are listed below:(7-1-24)
01.Food Stamp Eligibility. Women and children who recently left a household containing a person who abused them may get Food Stamps, even if the household they left was getting Food Stamps. Shelter residents may apply for and get separate Food Stamps only once in a month. The original Food Stamp certification must have included the person who subjected them to abuse. The resident household must meet eligibility criteria for income, resources, and expenses.(7-1-24)
02.Income, Resources, and Expenses of the Household Are Counted. Income, resources, and expenses of their former household, containing the person who subjected them to abuse, are not counted. Jointly held resources are inaccessible if the resources are jointly owned by the shelter resident and members of the abusive household. Jointly held resources are inaccessible if the shelter residents’ access to the resource is dependent on the agreement of the joint owner still living in the former household. Room payments to the shelter are shelter expenses.
03.Food Stamps for Former Household. The Department must take prompt action to correct the former household’s eligibility and allotment. The Department must issue a ten (10) day advance notice of adverse action.(7-1-24)
IDAPA 16.03.04.797 (Reserved)
IDAPA 16.03.04.816 Purchase of Prepared Meals
Persons listed below may purchase prepared meals with their Food Stamps at sites authorized to accept Food Stamps .
01.Older Persons Eating at Communal Dining Facility. Persons sixty (60) or older and their spouses, or persons who receive SSI and their spouses, can use Food Stamps to buy meals made for them at communal dining facilities authorized to accept Food Stamps.(7-1-24)
02.Persons Unable to Prepare Meals Getting Meal Delivery Service. A person sixty (60) years of age or over, and a spouse, can elect to use Food Stamps to purchase meals from a nonprofit meal delivery service. A housebound, physically handicapped, or otherwise disabled person, unable to adequately prepare all meals, and a spouse, can elect to use Food Stamps to purchase meals from a nonprofit meal delivery service.(7-1-24)
03.Resident Center. A resident of a residential treatment center for substance use disorders can use Food Stamps at the center. The person must be enrolled in a treatment and rehabilitation program operated by a nonprofit organization or institution.(7-1-24)
04.Battered Women and Children. A resident of a shelter for battered women and children can use Food Stamps to purchase meals prepared by the shelter.(7-1-24)
05.Homeless. A homeless Food Stamp participant can use Food Stamps to buy meals prepared by a homeless meal provider.(7-1-24)
IDAPA 16.03.04.817 (Reserved)
IDAPA 16.03.04.850 Food Stamp Household Rights
The Food Stamp household has rights protected by federal and state laws and Department rules.
The Department must inform participants of their rights during the application process and eligibility reviews. Food Stamp rights are listed below:(7-1-24)
01.Application. The right to get an application on the date requested.(7-1-24)
02.Application Registered. The right to have the signed application accepted right away.(7-1-24)
03.Representative. The right to have an authorized representative if the applicant cannot get to the Food Stamp office. The authorized representative must have knowledge of the applicant’s situation.(7-1-24)
04.Thirty Day Processing. The right to have the application processed and Food Stamps issued within thirty (30) days.(7-1-24)
05.Notification. The right to be told in writing of:(7-1-24)
a.The reasons for the Department’s action if the application is rejected.(7-1-24)
b.The reasons for the Department’s action if Food Stamps are reduced or stopped.(7-1-24)
06.Fair Hearing. The right to request a fair hearing about the Department’s decision. The right to request a fair hearing if the household feels discrimination has taken place in any way. Food Stamp fair hearings must be requested within ninety (90) days from the day notice is mailed. In certain situations, Food Stamps may continue if a fair hearing is requested.(7-1-24)
IDAPA 16.03.04.851 (Reserved)
IDAPA 16.03.04.852 Food Stamp Household Responsibilities
The Food Stamp household must provide correct and complete information so the Department can make accurate elig ibility and benefit decisions. The responsibilities of the Food Stamp household are listed below:(7-1-24)
01.Provide Information. The Food Stamp household must provide information to determine Food stamp eligibility. This includes, but is not limited to, all information about household income, work, and housing cost.
02.Quality Control. The Food Stamp household must cooperate with Quality Control if the case is selected for review.(7-1-24)
IDAPA 16.03.04.853 Department Informing Responsibilities
The Department must inform the Food Stamp household of what is expected of the household in the eligibility determi nation process and advise the household of the information listed below:(7-1-24)
01.Households Rights and Responsibilities.(7-1-24)
02.Eligibility Factors That Must be Met and Proven.(7-1-24)
03.Consequences for Failure to Provide Proof of Eligibility Factors.(7-1-24)
04.Alternate Methods to Prove Eligibility When Household is Unable to Provide Proof. (7-1-24)
05.Methods the Department Uses to Prove Eligibility When Household is Unable to Provide Proof.(7-1-24)
06.Social Security Numbers the Department Will Use to Get Wage, Income, and Employment Information.(7-1-24)
IDAPA 16.03.04.854 Department Will Document Eligibility Decisions
The Department will document eligibility, ineligibility, and Food Stamp issuance in the case record. The Department must record enough detail to support the Food Stamp determination.(7-1-24)
IDAPA 16.03.04.855 (Reserved)
IDAPA 16.03.04.861 No Discrimination in Food Stamp Program
The Department must not allow human rights discrimination in the Food Stamp Program. The Department will adm inister the Food Stamp program so no applicant or recipient in Idaho is discriminated for or against due to race, color, gender, or age. The Department will administer the Food Stamp program so no applicant or recipient in Idaho is discriminated for or against, due to political or religious belief or affiliation, national origin, handicap, or disability.
IDAPA 16.03.04.862 Public Notice for No Discrimination
The Department will inform the public via the application form that the Food Stamp Program is conducted without discrim ination. The Department must display the USDA poster “And Justice for All” in all field offices. The application form must inform the public the Food Stamp Program is conducted without discrimination.(7-1-24)
IDAPA 16.03.04.863 (Reserved)
IDAPA 16.03.04.864 Discrimination Complaint Procedure
Any person can file a discrimination complaint. The person may use the Department’s complaint procedure. The person may file a complaint directly to FNS, to the Department, or both. The field office must explain both procedures orally or in writing.(7-1-24)
IDAPA 16.03.04.865 Disclosure of Information
The Department will make available to any federal, state, or local l aw enforcement officer the address, SSN, and (if available) photograph of a Food Stamp recipient. The officer must furnish the recipient’s name and provide the Department the federally required evidence the person is fleeing to avoid prosecution, custody, or confinement for a felony, violating a condition of parole or probation, or has information necessary for the officer to conduct an official duty related to a felony or parole violation.(7-1-24)
IDAPA 16.03.04.866 Availability of Public Information
Rules, state plans of operation, procedures, handbooks, manuals, and instructions used to certify households must be available to the public. These materials must be available for public examination during regular office hours and workdays. See 7 CFR 272.1(d).(7-1-24)
IDAPA 16.03.04.867 Food Stamp Information Requirements
Federal regulations and procedures in FNS notices and po licy memos must be available for examination by the public. State plans of operation must be available for examination by the public. Examination may take place during office hours at Department headquarters. Handbooks must be available for examination upon request at each field office. The Department must provide information about Food Stamps through mass media, posters, fliers, pamphlets, and face-to-face contacts. Minimum requirements are listed below:(7-1-24)
01.Rights and Responsibilities. Households must be informed of Food Stamp program rights and responsibilities.(7-1-24)
02.Bilingual Information. All program information must be available in Spanish.(7-1-24)
IDAPA 16.03.04.868 (Reserved)
IDAPA 16.03.04.872 Program Transfer During Certification Period
Households changing from Food Stamps to Food Distribu tion Program on Indian Reservations (FDPIR) must end their participation the last day of the month they choose to change programs.(7-1-24)
IDAPA 16.03.04.873 (Reserved)
IDAPA 16.03.04.879 Review of Case File
The participant or their representative can review their case file under IDAPA 16.05.01, “Use and Disclosure of Department Records.”(7-1-24)
IDAPA 16.03.04.880 (Reserved)
IDAPA 16.03.04.883 Refusal to Cooperate with Quality Control Reviews
The Department is required to conduct monthly random quality control reviews of food stamp cases, denials of food stamp applications, and issuance amounts. If a household is selected and refuses to cooperate in a quality control review, it is not eligible for food stamp benefits.(7-1-24)
01.Advance Notice to End Food Stamps. The Department must send the household advance notice to end Food Stamps. The notice must list the reason for the proposed action, the right to a hearing, the right to schedule a conference or to continue the review.(7-1-24)
02.Food Stamp Eligibility During Quality Control Review Period, After Refusal to Cooperate.
The household is not eligible for Food Stamps during the Quality Control review period until it cooperates with the review.(7-1-24)
IDAPA 16.03.04.884 (Reserved)
16.03.21 Developmental Disabilities Agencies (DDA), Residential Habilitation Agencies, and Adult Residential Care Facilities
IDAPA 16.03.21.000 Legal Authority
Section 39-4605, Idaho Code, authorizes the Idaho Board of Health and Welfare to adopt rules and standards of cert ification for Developmental Disabilities Agencies, Residential Habilitation Agencies, and Adult Residential Care Facilities, to promote the health and safety of participants. These entities will be referred to as an organization for this rule chapter.(7-1-26)
IDAPA 16.03.21.001 Scope
These rules govern developmental disabili ties agencies, residential rehabilitation agencies, and adult residential care facilities.(7-1-26)
IDAPA 16.03.21.002 (Reserved)
IDAPA 16.03.21.009 Criminal History and Background Check Requirements
01.Verification of Compliance.
The organization must verify that all employees, subcontractors, agents of the organization, and volunteers have complied with IDAPA 16.05.06, “Criminal History and Background Checks.”(7-1-26)
IDAPA 16.03.21.010 Definitions – a Through Z
For the purposes of this chapter of rules, the following terms apply.(3-17-22) 01.
Abuse. The non-accidental act of sexual, physical, verbal, or mental mistreatment, or injury of a participant through the action or inaction of another individual.(7-1-26)
02.Adult Residential Care Facility. A facility that provides any service or group of services which provide care to the developmentally disabled on an inpatient or residential basis.(7-1-26)
03.Advocate. An authorized or designated representative of a program or organization operating under federal or state mandate to represent the interests of developmentally disabled, mentally ill, or elderly participants.(7-1-26)
04.Communicable Disease. A disease that may be transmitted from one (1) person or animal to another person either by direct contact or through an intermediate host, vector, inanimate object, or other means that may result in infection, illness, disability, or death.(3-17-22)
05.Deficiency. A determination of non-compliance with a specific rule or part of rule.(3-17-22)
06.Department. The Idaho Department of Health and Welfare.(3-17-22)
07.Developmental Disability Agency (DDA). A business entity that meets the definition of a developmental disabilities facility provided in Section 39-4604(3), Idaho Code, that is certified by the Department to provide services to eligible individuals.(7-1-26)
08.Exploitation. An action that may include, but is not limited to, the unjust or improper use of a vulnerable participant’s financial power of attorney, funds, property, or resources by another person for profit or advantage.(7-1-26)
09.Health Care Professional. An individual licensed to provide health care within their respective discipline and scope of practice.(3-17-22)
10.Immediate Jeopardy. A level of non-compliance with one (1) or more requirements in this chapter that has caused, or is likely to cause, serious injury, harm, impairment, or death to a participant that requires an immediate response.(7-1-26)
11.Maladaptive Behavior. Any behavior that significantly interferes with participant care or presents a danger to self or others.(7-1-26)
12.Medication. Any substance or drug used to treat a disease, condition, or symptoms that may be taken orally, injected, or used externally, and is available through prescription or over the counter.(7-1-26)
13.Neglect. The failure to provide food, clothing, shelter, or medical care reasonably necessary to sustain the life and health of a vulnerable adult as defined in Section 18-1505, Idaho Code.(7-1-26)
14.Participant. An individual receiving services through a DDA, Residential Habilitation Agency or Adult Residential Care Facility.(7-1-26)
15.Residential Habilitation. Services consisting of an integrated array of individually tailored services and supports furnished to an eligible participant that are designed to assist them to reside successfully in their own home. Services include personal care services, and skill training. Individuals who provide residential habilitation services must be employed by a residential habilitation agency.(7-1-26)
16.Physical Restraint. Any manual hold or mechanical device that the participant cannot remove easily, and which restricts the free movement of or normal functioning of any portions of a participant’s body.
17.Plan of Service. An initial plan, annual plan, or addendum that identifies all services offered .(7-1-26)
18.Repeat Deficiency. The Department has found an organization is out of compliance with a rule and received a citation on two (2) consecutive surveys.(7-1-26)
19.Substantial Compliance. A level of compliance that has not or will not cause significant injury that requires medical attention to a participant.(7-1-26)
20.Survey. A review conducted by the Department to determine compliance with statutes and rules.
21.Time Out. A separate unlocked room or location, that is supervised, that is used to remove a participant from an activity that may be triggering or reinforcing maladaptive behavior.(7-1-26)
IDAPA 16.03.21.011 (Reserved)
IDAPA 16.03.21.100 Certification Requirements for Dda, Residential Habilitation Agencies,
AND ADULT RESIDENTIAL CARE FACILITIES.
01.Application for Initi al Certification. Certification will be issued to any organization upon completing an application demonstrating compliance with these rules(7-1-26)
02.Content of Application for Certification. The application must include:(7-1-26)
a.Business names of the organization as filed with the Secretary of State;(7-1-26)
b.Organizational chart or plan for staffing;(7-1-26)
c.The following Policies and Procedures;(7-1-26)
i.Staff and volunteer qualifications including, roles, responsibilities and organization expectations;
ii.Staff training that is specific and appropriate to the population served;(7-1-26)
iii.Infection prevention measures to mitigate the spread of communicable diseases;(7-1-26)
iv.General health care services including assessment and treatment of acute and chronic complaints or situations.(7-1-26)
v.Transportation safety, including the organization’s preventive maintenance program, inspection intervals, insurance coverage, and licensed driver requirements for organization owned vehicles, and a policy for staff owned vehicles, if applicable;(7-1-26)
vi.The organization must ensure the participant and the guardian, if applicable, has been informed of how to file a grievance. The organization must respond to the grievance within fourteen (14) days or less;(7-1-26)
vii.Medication standards;(7-1-26) viii.Behavior Management, including approved interventions to manage inappropriate or maladaptive behaviors, and restraints if applicable;(7-1-26)
ix.Reporting incidents of abuse, neglect and exploitation including notifying the proper authorities;
x.Incident Reports for all events that occur during service delivery that interfere with the participants’ safety or ability to participate;(7-1-26)
xi.Termination of services that ensures the safety of the participant and notifies all relevant parties;
xii.The organization will only accept and retain participants for whom the organization has the appropriate staff and skills to provide the services; and(7-1-26) xiii.Each organization must ensure the rights provided under Section 66-412, Idaho Code, and will ensure the participant’s privacy and confidentially, promote independence in the community and allow participants to refuse services.(7-1-26)
d.DDA center and Adult Residential Care Facilities must include the following:(7-1-26) i.“Americans with Disabilities Act Accessibility Guidelines,” under 28 CFR Part 36, Appendix checklist, local fire safety inspection, and Certificate of Occupancy; and;(7-1-26)
ii.Policies and procedures for responding to fire, emergencies, including emergency evacuation plans.
03.Denial of an Application. The Department may deny any application for the following reasons;
a.The applicant is not in substantial compliance with these rules;(7-1-26)
b.The applicant has willfully misrepresented or omitted information on the application; or(7-1-26)
c.The administrator or owner of an organization whose certification has been revoked within the last five (5) years.(7-1-26)
04.Certificate. The Department will issue an initial six (6) month certificate when it is determined the organization is in substantial compliance. Following the initial or a provisional certificate the Department will issue a one year (1-year) certificate, or as needed to determine compliance with rules. A three (3) year certificate is issued when it is determined the organization is in substantial compliance.(7-1-26)
a.Application of renewal. An organization must apply to renew its certificate no less than sixty (60) days before the expiration date.(7-1-26)
b.Expiration. Expiration of a certificate without a timely request for renewal rescinds the organization’s certificate.(7-1-26)
c.DDA Center and Adult Residential Care Facility, the certificate must be posted and visible to the public.(7-1-26)
05.Survey and Investigations.(7-1-26)
a.Investigation Survey. The Department will investigate complaints of alleged rule violations.
Complainant information is kept confidential.(7-1-26)
b.Method of Investigation. The Department will determine the method used to investigate the complaint.(7-1-26)
c.Notification to Complainant. The Department will provide a written response to the complainant upon completion of the investigation.(7-1-26)
d.Licensing and Certification will conduct survey and investigation at specified intervals to determine compliance with this chapter of rules and Title 66, Chapter 4, Idaho Code and Section 39-4605, Idaho Code.(7-1-26)
06.Notification To the Department.(7-1-26)
a.The Department must be notified when the organization's owner, administrator, service area, or address changes; and(7-1-26)
b.New ownership, certificates are not transferable.(7-1-26)
IDAPA 16.03.21.101 (Reserved)
IDAPA 16.03.21.117 Organizations Approved Through National Accreditation
Organizations that are accredited are require d to produce the following records to renew a certificate:(7-1-26)
01.The Current Accreditation Verification or Report.(3-17-22)
02.Criminal History Background Check Requirements.(7-1-26)
03.Staff Records.(7-1-26)
IDAPA 16.03.21.118 (Reserved)
GENERAL ORGANIZATION QUALIFICATIONS AND REQUIREMENTS
Sections 300-399
IDAPA 16.03.21.300 General Staffing Requirements
The organization must have a qualified administrator, supervisor and direct service provider (DSP) to meet the needs of participants served. The organization administrator and supervisor can be the same individual if the organization can meet requirements of each duty.(7-1-26)
01.Administrator Qualifications and Duties. The administrator must have two (2) years of supervisory experience with the population served. On a temporary basis, an administrator may delegate administrative functions on their behalf. The administrator or their designee is responsible for the overall operations of the organization, including compliance with these rules.(7-1-26)
02.Supervisor Duties. Complete or obtain the plan of service, supervise DSP, including at least quarterly supervision, and coordinate other service providers to ensure continuity of service delivery.(7-1-26)
03.DSP Duties. Perform tasks as assigned under the direction of a supervisor. Tasks may not be assigned that require specific certification or licensure.(3-17-22)
04.Parent or Legal Guardian of Participant. A DDA may not hire the parent or legal guardian of a participant to provide services to the parent’s or legal guardian's child.(3-17-22)
IDAPA 16.03.21.301 Organization Record Requirements
01.Accessibility of Records.
An organization’s records must be available to the Department, with or without prior notification.(7-1-26)
02.General Record Requirements. The organization must maintain accurate, current, and complete records for a minimum of five (5) years.(7-1-26)
03.Staff Records. Records must contain the following:(7-1-26)
a.Name, address, phone number, date of hire and termination, if applicable;(7-1-26)
b.Documentation supporting qualifications to carry out assigned duties;(3-17-22)
c.Current driver’s license and automobile liability insurance for staff who transport participants;
04.Participant Records.Records must contain the following:(7-1-26)
a.Documentation of type and duration of services delivered, including the date, time, and name of person providing the service;(7-1-26)
b.Name, address, phone number, and contact information of guardian (if applicable) or emergency contact;(7-1-26)
c.General health information including specific dietary or medical needs, and health care providers;
d.Signed notification of participant rights, grievance procedures, and contact information for protection and advocacy services that is clear and understandable; and;(7-1-26)
e.Plan of service and incident reports.(7-1-26)
IDAPA 16.03.21.302 Training Requirements
The organization must document all staff training, including th e date, description of training, and name of the person conducting the training. Staff must be trained on the following:(7-1-26)
01.Initial and Annual Training. Prior to working with participants and annually thereafter, staff must complete:(7-1-26)
a.Safety training on natural disasters;(7-1-26)
b.Abuse, neglect, and exploitation training covering definitions and reporting requirements;
c.Organization’s policy and procedures;(7-1-26)
d.Participant's rights, advocacy resources, and confidentiality; and(3-17-22)
e.Behavior intervention strategies and techniques including appropriate responses to maladaptive behaviors;(7-1-26)
f.For DDA centers and Adult Residential Care Facility services, fire safety training, fire drills, and emergency evacuation plans.(7-1-26)
02.CPR and First Aid Training. Staff must be certified in CPR and first aid prior to working alone with participants and ongoing thereafter.(7-1-26)
03.Participant Specific Training. Prior to delivering services, DSPs must be trained on the specific needs of the participant including medical, or health requirements, and the use of assistive devices if applicable;
04.Ongoing Training. DSPs must be trained when there are changes that impact services or supports including:(7-1-26)
a.Participant’s plan of service and corresponding implementation plans, as applicable; and (3-17-22)
b.Participant’s physical, medical, and behavioral status.(3-17-22)
IDAPA 16.03.21.303 (Reserved)
IDAPA 16.03.21.404 Organization Reporting
01.Reporting Requirements.The or ganization will follow Sections 39-5303 and 16-1605, Idaho Code when there are allegations of abuse, neglect, or exploitation. The organization will protect the participant from the possibility of abuse during services while the investigation is in progress. The organization will document their investigation of all alleged violations.(7-1-26)
02.Reporting Incidents to the Department. The organization must notify the Division of Licensing and Certification by the close of the next business day of the following incidents that occur to the participant during service hours:(7-1-26)
a.Death;(3-17-22)
b.Hospitalization;(3-17-22)
c.Participant’s arrest or incarceration; or(3-17-22)
d.When staff actions result in a report to protective or legal authorities.(3-17-22)
IDAPA 16.03.21.405 Medication
Each organization must ensure appropriate handling and safegu arding of medications. Staff assisting participants with medications must complete the assistance with medications training course available through a Departmentapproved training.(7-1-26)
01.Handling of Participant's Medication. The organization must:(7-1-26)
a.Maintain the medication in the original pharmacy-dispensed container, over-the- counter container, or placed in a unit container (by a licensed nurse or pharmacy staff) appropriately labeled with the name of the medication, dosage, time to be taken, route of administration, and any special instructions;(7-1-26)
b.Medication and treatment must be provided per the health care professional’s orders. DDAs and residential habilitation agencies may use Medi sets filled and labeled by pharmacy staff or licensed nurse can serve as written evidence of the order; and(7-1-26)
c.The organization must store medications under the proper conditions and according to manufacturer’s recommendations.(7-1-26)
d.Discontinued or outdated medications must be removed from the participant’s medication supply within thirty (30) calendar days.(7-1-26)
02.Self-Administration of Medication. A participant can self-administer medication when there is written approval from a health care professional supporting the participant is capable of completing this task safely.
03.Assistance with Medication. Staff must follow policy and procedures for assisting participants with medications, and the following conditions must be in place:(7-1-26)
a.The participant's health condition is stable; and(7-1-26)
b.The participant's health status does not require nursing assessment before receiving the medication or nursing assessment of the therapeutic or side effects after the medication is taken;(3-17-22)
04.Medication Record. Record must contain the following:(7-1-26)
a.Name of the participant;(3-17-22)
b.Name and dosage of the medication given;(3-17-22)
c.Time and date the medication was given;(3-17-22)
d.Initials of individual assisting with medication that can be verified with matching signature;
e.Documentation of medication errors, including missed doses, incorrect doses, or adverse side effects;(7-1-26)
f.Documentation that a health care professional was contacted for adverse events; and(7-1-26)
g.Documentation of corrective action for adverse events or incidents of repeated medication errors.
05.Disposal of Medications. Documentation of disposal or destruction of medications consistent with procedures outlined in the assistance with medication training course.(7-1-26)
IDAPA 16.03.21.406 (Reserved)
QUALITY ASSURANCE, BEHAVIOR MANAGEMENT, AND SPECIFIC PROGRAM REQUIREMENTS
Sections 500-599
IDAPA 16.03.21.500 Requirements for an Organization’s Quality Assurance Program
Each organization must develop and implement a quality assuran ce program that improves the quality of services, identifies non-compliance or safety issues including corrective measures and timeframes. This review must include;
01.Participant Records. Assess for accurate content and effectiveness of service delivery;(7-1-26)
02.Staff Records. Assess that staff have the necessary skills and training to provide adequate service delivery; and(7-1-26)
03.Policies and Procedures. Review to ensure content meets the needs of participants served.
IDAPA 16.03.21.501 (Reserved)
IDAPA 16.03.21.510 Managing Participant Behavior
The use of systematic interventions to manage inappropriate or maladaptive participant behaviors must follow facility policy and be incorporated into the participant’s individual service plan.(7-1-26)
01.Techniques to Manage Maladaptive Behavior. Interventions to manage behaviors must never be used:(7-1-26)
a.For disciplinary purposes;(3-17-22)
b.For the convenience or lack of staff; or(7-1-26)
c.As a substitute for an active treatment program or needed training.(7-1-26)
02.Physical Restraints and Time Out Requirements. Physical restraints and time out must be:
a.Used as an emergency measure when other lesser restrictive interventions have failed and there is substantial risk for harm to self or others; or(7-1-26)
b.Part of an integral service plan that is intended to lead to less restrictive means of managing or eliminating the behavior for which the restraint is applied.(7-1-26)
c.Utilized by staff that have been certified in a nationally recognized behavior management program approved by the Department.(7-1-26)
d.Used only until the participant has regained control.(7-1-26)
e.Documented in the participant record including date, time, duration, staff involved and description of behaviors.(7-1-26)
03.Written Informed Consent. If an organization uses physical restraints as part of their behavior management program, participants, and their legal guardian, if applicable, must provide written informed consent.
IDAPA 16.03.21.511 Standards for a Dda Center and Adult Residential Care Facility
01.Environment.
The facility must be designed and equipped to meet the needs of each participant including sufficient space, adaptive equipment, lighting, and noise control. Facilities providing residential care must provide participants with sleeping rooms including furnishings, such as a dresser and bed, and be safe and in good repair.(7-1-26)
02.Construction Changes. For changes of occupancy, modifications, additions, or renovations to existing buildings, the facility must submit certificate of occupancy to the Department for approval prior to admitting participants.(7-1-26)
03.Fire Safety Standards. Locations must maintain the following records:(7-1-26)
a.A copy of an annual local fire authority inspection including any necessary corrective actions;
b.Documentation of quarterly fire drills, including date, time, duration, names of participants and staff involved, and any resulting corrective action(s); and(7-1-26)
c.Documentation that at least two (2) times each year fire drills included a complete evacuation of the building.(7-1-26)
04.Environment Safety Standards.(7-1-26)
a.Provide fences, guards, or railings to protect participants on the premises where natural or manmade hazards are present;(7-1-26)
b.Portable heating devices must be approved by the local fire authority;(7-1-26)
c.Properly label and store all hazardous or toxic substances under lock and key;(7-1-26)
d.Maintain water temperatures in areas accessed by participants at one hundred twenty degrees Fahrenheit (120°F) or below;(7-1-26)
e.Have a telephone on the premises with emergency numbers available; and(7-1-26)
f.Evacuation plans must be posted throughout the center and indicate point of orientation, location of all fire extinguishers, location of all fire exits, and designated meeting area outside of the building.(7-1-26)
05.Food Safety and Nutrition.(7-1-26)
a.Adult residential care facilities must:(7-1-26)
i.Meet the standards in IDAPA 16.02.19. Compliance is verified through inspection by the local District Health Department.(7-1-26)
ii.Provide three (3) daily balanced meals in appropriate intervals.(7-1-26)
iii.Menu must be planned, approved, signed and dated by a registered dietician. Menus must be maintained on file for sixty (60) days and include any substitutions.(7-1-26)
iv.Accommodations must be made to a participant with special medical or religious dietary needs.
b. Refrigerators and freezers used to store participant foods will be maintained at or below forty-one degrees Fahrenheit (41°F), and ten degrees Fahrenheit (10°F) respectively; and(7-1-26)
c.When medicines requiring refrigeration are stored in a food refrigerator, medicines must be stored in a package and kept inside a covered, leak-proof container that is identified as a container for the storage of medicines.(7-1-26)
06.Housekeeping and Maintenance Services. The organization must meet the following:(7-1-26)
a.The center must be clean, safe, and kept in good repair;(7-1-26)
b.Ensure the building is free from infestations of insects, rodents, and other pests; and(7-1-26)
c.Maintain the temperature and humidity of the building within a normal comfort range by heating, air conditioning, or other means.(7-1-26)
IDAPA 16.03.21.512 Residential Habilitation Agencies Termination Procedures
01.Emergency Termination.
Emergency conditions warranting immediate termination of services include:(7-1-26)
a.A change in the participant’s condition resulting in an increased level of care beyond the scope of the organization’s ability to provide care for the participant; or(7-1-26)
b.Significant behavior concerns including physical aggression by the participant that puts the health and safety of the organization’s staff or other participants in jeopardy and behavior management techniques have failed to reduce the risk to staff or others.(7-1-26)
02.Termination with Notice. The organization must provide written notice of no less than thirty (30) days for termination, include a transition plan, and a copy of the organization grievance policy. A transition plan is an interim plan defining activities to facilitate the transition out of residential habilitation services.(7-1-26)
03.Termination with Agreement. Services may be terminated prior to thirty (30) days if both parties agree in writing.(7-1-26)
IDAPA 16.03.21.513 (Reserved)
RULE ENFORCEMENT PROCESS AND REMEDIES
Sections 600-699
IDAPA 16.03.21.600 Enforcement Process
The Department may impose an enforcement action when it determines an organization is not in compliance with these rules. The Department may monitor the organization on an as-needed basis, until it has been established the organization is in substantial compliance.(7-1-26)
01.Determination of Remedy. In determining which remedy to impose, the Department will consider the organization’s compliance history, change of ownership, the number of deficiencies, the scope and severity of the deficiencies, and the potential risk to participants. Subject to these considerations, any one or combination of the following remedies, is subject under these rules for notice and appeal:(7-1-26)
a.Require the organization to submit a plan of correction approved by the Department;(7-1-26)
b.Issue a provisional certificate;(7-1-26)
c.Ban new enrollment of participants;(7-1-26)
d.Summarily suspend the certificate and transfer participants; or(3-17-22)
e.Revoke the organization’s certificate.(7-1-26)
02.Immediate Jeopardy. If it is determined an organization’s non-compliance with these rules immediately jeopardizes the health or safety of a participant, the certificate may be summarily suspended.(7-1-26)
03.Repeat Deficiency. A Repeat deficiency may result in any of the remedies listed in this section.
04.Failure to Comply. The Department may impose one (1) or more of the remedies specified in this section if the organization has not returned to compliance within three (3) months of implementing a plan of correction.(7-1-26)
IDAPA 16.03.21.601 Revocation of Certificate
01.Revocation of the Organizations Certificate.
The Department may revoke a certificate when the organization is not in substantial compliance with the requirements.(7-1-26)
02.Causes for Revocation of the Certificate. The Department may revoke any organization’s certificate for any of the following causes:(7-1-26)
a.The certificate holder has willfully misrepresented or omitted information on the application for certification or other documents pertinent to obtaining a certificate;(3-17-22)
b.Conditions exist in the organization that endanger the health or safety of any participant; (7-1-26)
c.Any act adversely affecting the welfare of participants is being permitted, performed, or aided and abetted by the person(s) supervising the provision of services in the organization. Such acts include neglect, physical abuse, mental abuse, emotional abuse, violation of civil rights, or exploitation;(7-1-26)
d.The organization has failed to comply with any of the conditions of a provisional certificate;
e.The organization lacks adequate staff, as required by these rules or as directed by the Department, to properly care for the number and type of participants served at the organization; or(7-1-26)
f.The certificate holder refuses to allow the Department or protection and advocacy agencies full access to the organization environment, organization records, or the participants.(7-1-26)
IDAPA 16.03.21.602 Injunction to Prevent Operation Without Certificate
Notwithstanding the existence or pursuit of any other rem edy, the Department may in the manner provided by law, maintain an action in the name of the state for injunction or other process against any person or governmental unit to restrain or prevent the establishment, conduct, management, or operation of an organization without a certificate required under this chapter. For the purposes of these rules, a governmental unit is the state, or any county, municipality, or other political subdivision, or any department, division, board, or other organization thereof.
IDAPA 16.03.21.603 Waivers
Waivers to these rules may be granted through the Department -approved process under Section 67-5230, Idaho Code.
IDAPA 16.03.21.604 (Reserved)
16.02.08 Vital Statistics Rules
IDAPA 16.02.08.000 Legal Authority
Section 39-242, Idaho Code, authorizes the Board of Health and Welfare to adopt rules for Title 39, Chapter 2, Idaho Code, related to vital statistics.(3-15-22)
IDAPA 16.02.08.001 (Reserved)
IDAPA 16.02.08.050 Definitions
For the purposes of this chapter, the following definitions apply:(3-15-22) 01.
Attendant at Birth or Stillbirth. Any physician, midwife, or other person who assists in the delivery of a live born infant or stillborn fetus.(3-15-22)
02.Birth Out of Wedlock. A birth occurring when the mother was not married at the time of either conception or birth, or between conception and birth.(3-15-22)
03.Board. The Idaho Board of Health and Welfare.(3-15-22)
04.Confidential Registry. A file of all notices of putative fathers’ claims to paternity for their child(ren) born out of wedlock and intent to support such child(ren), that is established in the office of the State Registrar of Vital Statistics.(3-15-22)
05.Current Registration. The filing of a certificate less than one (1) year after the event occurs.
06.Delayed Registration. The filing of a certificate one (1) year or more after the event occurs.
07.Department. The Idaho Department of Health and Welfare.(3-15-22)
08.Director. The Director of the Idaho Department of Health and Welfare or their designee. (3-15-22)
09.Expedited Certified Copy. A certified copy of a vital record that has been given priority status for processing and issuance.(3-15-22)
10.Local Registrar. The local registration officer identified in Section 39-247, Idaho Code, appointed by the State Registrar of Vital Statistics to carry out duties incidental to the operation of the vital statistics system within a specified area.(3-15-22)
11.Mortician or Funeral Director. Any person who makes a business of disposing of dead bodies.
The term “mortician or person acting as such” refers to any person having charge of the burial, cremation, or other disposition of a dead body. This includes stillborn fetuses.(3-15-22)
12.Putative Father. The biological father of a child as identified by himself, the natural mother, an adoption agency, or a court.(3-15-22)
13.Relatives of Deceased Qualified Adult Adoptees. The adoptive parents or grandparents of the adult adoptee.(3-15-22)
14.Relatives of Deceased Qualified Birth Parents. The parents or grandparents of birth parents.
IDAPA 16.02.08.051 (Reserved)
IDAPA 16.02.08.100 Certificates, Records, and Forms
01.Official Nature of Forms.
Forms and reports may be prescribed and distributed by the State Registrar for reporting vital statistics. These forms and reports may be used only for official purposes.(3-15-22)
02.Requirements for Preparation of Certificates. Unless otherwise directed by the State Registrar, no certificate or record will be complete, correct, and acceptable for registration that:(3-15-22)
a.Has not been printed legibly in dark, unfading ink;(3-15-22)
b.Has signatures entered other than in dark, unfading ink;(3-15-22)
c.Does not have the certifier’s name typed or printed legibly under the certifier’s signature;(3-15-22)
d.Does not supply all items of information called for thereon or satisfactorily account for their omission;(3-15-22)
e.Contains alterations or erasures;(3-15-22)
f.Does not contain signatures as required;(3-15-22)
g.Is marked “copy” or “duplicate”;(3-15-22)
h.Is a copy;(3-15-22)
i.Is prepared on an improper form;(3-15-22)
j.Contains improper or inconsistent data;(3-15-22)
k.Contains an indefinite cause of death that denotes only symptoms of disease or conditions resulting from disease; and(3-15-22)
l.Is not prepared in conformity with statutes, regulations, or with instructions issued by the State Registrar.(3-15-22)
03.Certificates with Defects. Certificates with defects as cited in Subsection 100.02 of this rule may be withheld from certification until the defect is remedied by persons who have the knowledge and authority to do so.
04.Copies of Original Certificates.(3-15-22)
a.Copies from the original certificate will not be made or certified by any organization or person other than the State Registrar of Vital Statistics except as authorized by an agreement between the State Registrar and local registrar.(3-15-22)
b.If the State Registrar finds evidence that a certificate was registered through misrepresentation or fraud, the State Registrar has authority to withhold the issuance of a certified copy of such certificate until a determination of the facts has been made.(3-15-22)
IDAPA 16.02.08.101 (Reserved)
IDAPA 16.02.08.150 Local Registration
01.Determination.
The State Registrar will determine whether additional offices other than the Vital Statistics Bureau are needed to aid the administration of the vital statistics system.(3-15-22)
a.Such determination will be based on the most efficient and effective method to operate the vital statistics system.(3-15-22)
b.If the State Registrar determines that additional offices are necessary, such offices will be designated with the approval of the Director.(3-15-22)
c.In all cases, the employees of such offices are subject to the control of the State Registrar when they are performing functions relating to the vital statistics system. The State Registrar will determine the specific responsibilities and duties of each office.(3-15-22)
02.Local and Deputy Registrars. The State Registrar may contract for the services of qualified local registrars who will perform duties as assigned by the State Registrar. The State Registrar may summarily remove any local registrar for failing to perform their duties. The State Registrar may appoint deputy state registrars to fulfill duties on behalf of the State Registrar.(3-15-22)
IDAPA 16.02.08.151 (Reserved)
IDAPA 16.02.08.201 Completion and Correction of Certificates
01.Correction of Minor Errors on Certificates During the First Year.(3-15-22)
a.Except as otherwise provided in these rules, correction of obvious errors or transposition of letters in words of common knowledge, may be made by the State Registrar or an authorized agent within the first year after the date of the event either upon individual observation, query, or upon request of any person listed in Subsection 201.07.d. of this rule. The method of correction will be determined by the State Registrar, and is not subject to the requirements of Subsection 201.09 of this rule.(3-15-22)
b.When such minor corrections are made by the State Registrar, a notation as to the source of the information, together with the date the change was made and the initials of the authorized agent making the change must be made on the certificate in such a way as not to become a part of any certification issued. The certificate will not be marked as amended.(3-15-22)
02.Amendment of Registrant's Given Names or Surname on Birth Certificates Within the First Ye a r.(3-15-22)
a.Until the registrant’s first birthday, given names or surname may be amended upon written notarized request of:(3-15-22)
i.Both parents;(3-15-22)
ii.The mother in the case of a child born out of wedlock and the father's name is not shown on the certificate;(3-15-22)
iii.The father in the case of the death or incapacity of the mother;(3-15-22)
iv.The mother in the case of the death or incapacity of the father; or(3-15-22)
v.The legal guardian or agency having legal custody of the registrant.(3-15-22)
b.The certificate must be marked as amended.(3-15-22)
03.Amendment of Registrant's Given Name on Birth Certificate After the First Year.(3-15-22)
a.After one (1) year from the date of birth, the provisions of Subsection 201.07 of this rule must be followed to amend the given name if the name was entered in error at the time of the preparation of the birth certificate.(3-15-22)
b.A legal name change order from a court of competent jurisdiction must be submitted to change any part of a name after one (1) year unless there is verifiable documentation establishing the child legally assumed the desired name before the first birthday.(3-15-22)
04.Addition of Given Names on Birth Certificates.(3-15-22)
a.Until the registrant’s seventh birthday, given names, for a child whose birth was recorded without given names, may be added to the certificate upon written notarized request of:(3-15-22)
i.Both parents;(3-15-22)
ii.The mother in the case of a child born out of wedlock and the father's name is not shown on the certificate;(3-15-22)
iii.The father in the case of the death or incapacity of the mother;(3-15-22)
iv.The mother in the case of the death or incapacity of the father; or(3-15-22)
v.The legal guardian or agency having legal custody of the registrant.(3-15-22)
b.The certificate will be marked as amended.(3-15-22)
c.After the registrant’s seventh birthday, the provisions of Subsection 201.07 of this rule must be followed to add a given name.(3-15-22)
05.Acknowledgment of Paternity. When paternity has already been established on the certificate by a Voluntary Acknowledgment of Paternity affidavit, a court determination of paternity is required to change the father's information.(3-15-22)
06.All Other Amendments. Unless otherwise provided in these rules or in Section 39-250, Idaho Code, all other amendments to vital records must be supported by:(3-15-22)
a.A notarized affidavit setting forth:(3-15-22)
i.Information to identify the certificate;(3-15-22)
ii.The incorrect data as it is listed on the certificate; and(3-15-22)
iii.The correct data as it should appear.(3-15-22)
b.If one (1) year has elapsed since the date the event occurred, one (1) or more items of documentary evidence which support the alleged facts, and which were established at least five (5) years prior to the date of application for amendment or within seven (7) years of the date of the event.(3-15-22)
c.Any item of a medical nature can be amended only upon receipt of a notarized affidavit from the person certifying such item, except that queries originating in the vital statistics office and subsequently completed and signed by the certifier may be used to complete or modify the reported cause of death. The State Registrar may require documentary evidence to substantiate the requested amendment. Requests for amendments for which a funeral home, birth facility, or certifier provides verifiable documentation of a data entry error will not be marked amended.(3-15-22)
d.Applications to amend a specific vital record will be accepted as follows:(3-15-22)
i.An application to amend a birth certificate may only be made by one (1) or both of the parents, the legal guardian, the registrant if eighteen (18) years of age or older, or the individual responsible for filing the certificate.(3-15-22)
ii.An application to amend a death certificate may only be made by the informant, the next of kin, the funeral director or person acting as such who signed the death certificate, or the certifying physician or coroner.
iii.An application to amend a stillbirth or miscarriage certificate may only be made by one or both parents or the individuals responsible for filing the certificate.(3-15-22)
iv.An application to amend a marriage or divorce certificate may only be made by the custodian of the official record from which the certificate was prepared, either of the parties to the marriage or divorce, or the individual responsible for filing the certificate.(3-15-22)
e.The State Registrar will evaluate the evidence submitted in support of any amendment, or require additional documentation. The State Registrar’s decision and determination will be based upon serving the objectives of the vital statistics statutes and the best interests of the public. In the event the application is rejected or additional information is required, the State Registrar must advise the applicant of the reason for the action and the right to appeal pursuant to Section 39-250(5), Idaho Code.(3-15-22)
07.Amendment of the Same Item More Than Once. Once an item is amended on a vital record, that item can not be amended again except upon receipt of a court order from an Idaho court of competent jurisdiction.
08.Methods of Amending Certificates.(3-15-22)
a.Certificates of birth, death, stillbirth, miscarriage, marriage, and divorce may only be amended by the State Registrar as follows:(3-15-22)
i.Preparing a new certificate showing the correct information when the State Registrar deems that the nature of the amendment so requires. The new certificate may be prepared on the form used for registering current events at the time of amendment. Except as provided elsewhere in these rules, the item number of the entry that was amended must be identified on the new certificate. In every case, except as provided elsewhere in these rules or the Idaho Code, the new certificate must show the date the amendment was made and be given the same state file number as the existing certificate. Signatures appearing on the existing certificate must be typed on the new certificate.
ii.Completing the item in any case where the item was left blank on the existing certificate. (3-15-22)
iii.Drawing a single line through the item to be amended and inserting the correct data immediately above or to the side. The line drawn through the original entry must not obliterate such entry.(3-15-22)
iv.A birth certificate amended in accordance with the provisions of Section 39-250(4), Idaho Code, must be amended as prescribed in Subsection 201.09.a.iii. of this rule. The fact that the name was changed in accordance with a court order must be stated on the certificate.(3-15-22)
b.Unless prohibited by statute or rule, the date the amendment was made and the initials of the person making the change must be inserted on the face of the certificate and the certificate marked as amended.(3-15-22)
IDAPA 16.02.08.202 (Reserved)
IDAPA 16.02.08.251 Fees for Copies, Searches, and Other Services
01.Certified Copies.
The fee for the issuance of a certified copy of a death certificate is sixteen dollars ($16) per copy. This fee incorporates the additional one dollar ($1) coroner training and education fund fee under Section 39-252(2), Idaho Code. The fee for the issuance of a certified copy of any other vital record is sixteen dollars ($16) per copy.(4-6-23)
02.Searches. The fee for a search of the files for a record of any vital event when no record is found, no copy is made, or a special document search is requested, is sixteen dollars ($16).(3-15-22)
03.Verifications. Except for Idaho state agencies and public health districts, the fee for manual or written data verification from a certificate is ten dollars ($10).(3-15-22)
04.Statistical, Research, or Public Health Services. The State Registrar assesses the fee for statistical, research, or public health services. The costs are calculated based upon the costs of retrieving the data and the costs of compiling, organizing, and printing the data. Cost may be reduced on a prorated basis to reflect the number of expected requests for the same information or service.(4-6-23)
05.Fees for Other Services.(3-15-22)
a.The fee for filing a report, certificate, or decree of adoption is twenty dollars ($20).(3-15-22)
b.The fee for establishing a delayed certificate of any vital event is twenty-five dollars ($25).
c.For any vital event, the fee for establishing a new certificate due to a court order, a replacement certificate, or an amended certificate is twenty dollars ($20), except as specified under Subsection 251.05.f.ii. of this rule.(3-15-22)
d.A service fee may be established by the local registration area, in addition to the certified copy fee for each certified copy of a vital record.(3-15-22)
e.The fee for a copy of a certificate of any vital event provided upon written request to local, states other than Idaho, or federal government agencies under Section 39-270(b), Idaho Code, is sixteen dollars ($16) .(4-6-23)
f.Fees for correction of a certificate of any vital event.(3-15-22)
i.The fee for a replacement certified copy of a certificate of any vital event when the incorrect certified copy is returned for exchange within sixty (60) days of a correction of an error is five dollars ($5) per certified copy.(3-15-22)
ii.There is no charge for a correction of an error(s) on a certificate of any vital event when the required documentation is received within the first year after the date of the event.(3-15-22)
iii.The fee for correction of an error(s) on a certificate of any vital event, when the required documentation is received one (1) year or more after the date of the event, is twenty dollars ($20) per submitted correction request.(3-15-22)
g.Fees for priority processing or special handling.(3-15-22)
i.A service fee of ten dollars ($10) per certificate or document will be added for priority processing or special handling of a request for a certified copy or copies of a certificate of any vital event, a request for a disinterment permit, a request to file a registry form, or a request regarding another vital event related form or document, other than those under Subsection 251.05.g.ii. of this rule. This fee will be in addition to the current fee(s) for each certified copy, search, or filing requested, or any combination thereof. This fee is forfeited and a new service fee must be paid for priority processing or special handling in the event that the requester takes longer than ninety (90) days to respond to a request for additional information, or documentation, or both.(4-6-23)
ii.A service fee of twenty-five dollars ($25) per certificate will be added for priority processing to establish a new or amended certificate of any vital event due to a report, certificate or decree of adoption, delayed certificate filing, a court order, a paternity affidavit or rescission, a subsequent marriage affidavit or a correction of a certificate. This fee is in addition to the current fee(s) for the legal amendment processing or request for a certified copy or copies, or both. This fee is forfeited and a new legal amendment service fee must be paid for priority processing or special handling in the event that the requester takes longer than ninety (90) days to respond to a request for additional information or documentation or both.(4-6-23)
06.Waiver of Fee Requirement.(4-6-23)
a.Fees may be waived for Idaho state agency and public health district administrative use requests.
Statistical information prepared for public health planning purposes may be published and distributed without charge whenever the Director determines that the publication and distribution is in the public interest.(4-6-23)
b.The fee for a birth certificate may be waived for an individual applying for the Idaho Department of Transportation’s no-fee identification available to an individual who is experiencing homelessness. The applicant must have direct and tangible interest, provide a completed vital statistics certificate request form with required identification, and provide a photocopy of the completed verification of homelessness form established and required by the Idaho Department of Transportation. One (1) free birth certificate may be issued for a registrant under this waiver. Subsequent copies will be subject to normal fees.(4-6-23)
IDAPA 16.02.08.252 (Reserved)
IDAPA 16.02.08.300 Registration of Births
01.Certifier's Signature.
The certifier of the facts of birth according to Section 39-255, Idaho Code, must sign the birth certificate. No stamps or other types of facsimile signatures may be used. When a birth occurs in an institution, the signature of the certifier on the medical record of birth may satisfy the requirements of Section 39- 255(a), Idaho Code.(3-15-22)
02.Signature of the Informant. When a birth occurs in an institution and the institution maintains a worksheet signed by either parent (named on the birth certificate) as informant, and the worksheet is part of the medical record, the signature of the informant on the worksheet may satisfy the requirements of Section 39-255(c), Idaho Code.(3-15-22)
03.Out-of-Institution Births. The State Registrar may require additional evidence of the birth when the birth did not occur in an institution and was not attended by a person who regularly attends births. If acceptable documentary evidence is not received, the State Registrar will inform the parent(s) of their right to petition an Idaho court of competent jurisdiction for an order establishing the facts as set forth on the birth certificate.(3-15-22)
IDAPA 16.02.08.301 Registration of Foundlings
01.Form of Certificate.
A special foundling certificate must be filed for any infant of unknown parentage and include, as a minimum, the following items:(3-15-22)
a.The designated name;(3-15-22)
b.The estimated date of birth;(3-15-22)
c.The sex and race;(3-15-22)
d.The address where found;(3-15-22)
e.The name and address of the person or agency assuming custody;(3-15-22)
f.A short description of the circumstances surrounding the finding of the infant, including the date of the finding; and(3-15-22)
g.The signature of the informant and the date the certificate was signed.(3-15-22)
02.Responsibility for Filing. The person or authorized representative of the agency assuming custody of the infant must sign the certificate and file it within fifteen (15) days of the finding with the State Registrar.
IDAPA 16.02.08.302 (Reserved)
IDAPA 16.02.08.400 New Birth Certificates Following Marriage of Natural Parents
If the natural parents marry after the birth of a child born in this state, a new birth certificate will be prepared for the child by the State Registrar upon receipt of an affidavit of paternity signed by the natural parents of said child, together with a certified copy of the parents’ marriage record. When paternity has already been established on the certificate by a Voluntary Acknowledgment of Paternity affidavit, a court determination of paternity is required to change the father’s information.(3-15-22)
IDAPA 16.02.08.401 Adoption of Persons Born in Idaho
01.Examination of Adoptive Child Born in Idaho for Whom No Original Birth Certificate Can Be Located.(3-15-22)
a.The physician’s report of the physical examination of the adoptive child, conducted under Section 39-258, Idaho Code, must indicate the sex, the estimated age, the race, and the existence or absence of obvious congenital malformations or anomalies of the child.(3-15-22)
b.The State Registrar may require the adoptive parents to furnish a court order that identifies natural parents, date of birth, place of birth, and those facts found by the physician’s physical examination.(3-15-22)
02.Corrections on Adoptive Certificates.(3-15-22)
a.Minor corrections may be made within one (1) year after the establishment of the adoptive birth certificate in accordance with Subsection 201.01 of these rules.(3-15-22)
b.Name change amendments may be made by a court order amending the original adoption order or by a new order of a court, according to Subsection 201.09 of these rules.(3-15-22)
c.All other amendments (except the registrant’s name) will be made according to Subsections 201.07 through 201.09 of these rules.(3-15-22)
d.To protect the confidential nature of adoptive births, the State Registrar may elect not to mark the record amended when carrying out amendments under Section 401 of this rule, when the indication of amendment would not be in the best interest of the registrant.(3-15-22)
IDAPA 16.02.08.402 Registration System
FOR ADULT ADOPTEES.
01.Search for “the Other Birth Parent.” The State Registrar will not participate in the search for “the other birth parent.” The adoption service units of the Department may participate in such searches when requested to do so by a birth parent or the adult adoptee. Costs of the search will be provided by the birth parent or adult adoptee seeking the match. Such service costs will be set by the adoption service unit and are based upon the actual cost of the search and cost of notification of the registrant(s).(3-15-22)
02.Completion of Match. When dated evidence of a completed search is presented to the State Registrar and “the other birth parent” has not been found, then and only then will a match be completed as cited in Section 39-259A(e) and (f), Idaho Code.(3-15-22)
a.When one (1) of the birth parents cannot be found according to Section 39-259A(b)(3), Idaho Code, no information about the missing birth parent will be released to either registrant, except as provided for in Section 39-258(9)(b), Idaho Code.(4-6-23)
b.When one (1) birth parent is deceased, proof of death must be established by a certified copy of the death certificate or a verification of the fact of death from the Vital Statistics official of the state where death occurred. Such proof is the responsibility of the registered birth parent.(3-15-22)
03.Siblings of Adult Adoptee. When it appears that there is a match between siblings, the State Registrar may confirm the match from the sealed adoption record on file in the Vital Statistics Office and make appropriate notification to the siblings. However, if the birth parent(s) has not also voluntarily registered, no identifying information about the birth parent(s) will be provided to the adult adoptee or the sibling, except as provided for in Section 39-258(9)(b), Idaho Code, or where proof of death of the birth parent(s) is found.(4-6-23)
04.Notification. When it appears to the State Registrar that a match has occurred, the State Registrar will notify the registrants by certified mail of the opportunity to withdraw from the register prior to proceeding with full notification of the registrants. Such withdrawal must be made by written notarized request and be received by the State Registrar within thirty (30) days of the date of registrant’s receipt of notification from the State Registrar. Such withdrawal is exempt from the usual withdrawal fee.(3-15-22)
05.Registration Time. Birth parents or relatives of qualified birth parents may register at any time after an adoption has taken place, regardless of the adoptee’s age. Adoptees may register after they have reached their eighteenth birthday.(3-15-22)
06.Fees. An initial filing fee of ten dollars ($10) is paid by or on behalf of each registrant and must be submitted with the registration form. An update fee of ten dollars ($10) is charged whenever a registrant requests in writing a revision, update, or withdrawal of a previous registration.(3-15-22)
07.Release of Information. When it appears there is a match between registered adult siblings and no birth parent information has been registered, before release of identifying information to any registered adult sibling, the State Registrar will require proof from the registrant(s) of the identity and the relationship of the registrant to other registrants. At least two (2) documents providing such proof must be viewed and recorded by the State Registrar. (3-15-22)
IDAPA 16.02.08.403 (Reserved)
IDAPA 16.02.08.450 Registration of Deaths and Stillbirths
01.Acceptance of Incomplete Death Certificate. If all the information necess ary to complete a death certificate is not available within five (5) days after the date the death occurred, the person in charge of interment or removal of the body from the district in which the death occurred must file the certificate as prescribed by the State Registrar with all information that is available, provided that the medical certification of the cause of death has been signed by the person responsible for such certification. If the cause of death is unknown or undetermined, the cause of death must be shown as unknown or undetermined on the certificate. The person responsible for the medical certification of the cause of death must also sign the authorization for final disposition of the body. If the body is to be cremated, the coroner must also give additional authorization.(3-15-22)
a.A supplemental report providing the cause of death and any other requested information missing from the original certificate must be filed by the person responsible for medical certification of the cause of death with the State Registrar within thirty (30) days of the State Registrar's request for supplemental information, or as otherwise authorized by the State Registrar, by means provided or approved by the State Registrar.(3-15-22)
b.The State Registrar will make the information on the supplemental report(s) a part of the existing death certificate and will file the supplemental report(s) with the death certificate. The State Registrar will also mark the death certificate to show that supplemental information was added.(3-15-22)
02.Signatures Required on Death Certificates.(3-15-22)
a.The mortician, or person acting as such, must sign the death certificate. No stamps or other types of facsimile signatures may be used.(3-15-22)
b.The responsible person must sign the medical certification of the cause of death. Failure to do so will invalidate the record as a legal document. No stamps or other types of facsimile signatures may be used.
03.Signatures Required on Stillbirth Certificates.(3-15-22)
a.The mortician, or person acting as such, must sign the certificate. No stamps or other types of facsimile signatures may be used.(3-15-22)
b.When a hospital disposes of a stillborn fetus, in accordance with Section 39-268(3), Idaho Code, the hospital authority must complete and sign the certificate as mortician.(3-15-22)
c.The person responsible according to Section 39-260, Idaho Code, for the attendant or medical certification, must sign the certificate. No stamps or other types of facsimile signatures may be used.(3-15-22)
IDAPA 16.02.08.451 Induced Abortion Reporting Forms -- Compilations
01.Nature of Reports.
The completed forms submitted to the Vital Statistics Unit are statistical reports, not certificates. Copies of the reports will not be issued.(3-15-22)
02.Compilations. No compilations will be released for public use that identify the institution where the induced abortion was performed, the physician who performed the induced abortion procedure, or the person completing the report of induced abortion.(3-15-22)
IDAPA 16.02.08.452 (Reserved)
IDAPA 16.02.08.501 Marriage License Recording Fees
The county recorders will charge a recording fee of two dollars ($2) for each marriage certificate.(3-15-22)
IDAPA 16.02.08.502 (Reserved)
IDAPA 16.02.08.600 Divorce Certificate Filing Fee
Effective July 1, 1985, the Clerk of the Court will charge a fee of one dollar ($1) for each divorce certificate filed in accordance with Section 39-266, Idaho Code.(3-15-22)
IDAPA 16.02.08.601 (Reserved)
IDAPA 16.02.08.650 Late or Delayed Registration of Birth
01.Late Registration -- Fifteen Days to One Year.(3-15-22)
a.Birth certificates filed after fifteen (15) days, but within one (1) year from the date of birth, will be registered on the standard form of live birth certificate in the manner prescribed in Section 39-255, Idaho Code. Such certificate will not be marked as delayed.(3-15-22)
b.In any case where the certificate is signed by someone other than the attendant or person in charge of the institution where birth occurred, a notarized statement setting forth the reason must be attached to the certificate. The State Registrar may require additional evidence in support of the facts of birth.(3-15-22)
02.Form of Delayed Birth Certificate. All certificates registered one (1) year or more after the date of birth will be registered on a delayed birth certificate form.(3-15-22)
03.Who May Request the Registration of and Sign a Delayed Birth Certificate.(3-15-22)
a.Any person born in this state whose birth is not recorded in this state, or the parent, guardian, next of kin of that person, or older person acting for the registrant and having personal knowledge of the facts of birth, may request the registration of a delayed birth certificate, subject to these rules and instructions issued by the State Registrar.(3-15-22)
b.Each delayed birth certificate must be signed and sworn to before a notary public by the person whose birth is to be registered if such person is eighteen (18) years of age or older and is competent to sign and swear to the accuracy of the facts stated therein; otherwise, the certificate must be signed and sworn to by one (1) of the following in the indicated order of priority:(3-15-22)
i.One (1) of the parents of the registrant; or(3-15-22)
ii.The guardian of the registrant; or(3-15-22)
iii.The next of kin of the registrant; or(3-15-22)
iv.Any older person over eighteen (18) years of age having personal knowledge of the facts of birth.
04.Facts to be Established for a Delayed Registration of Birth. The minimum facts that must be established by documentary evidence are the following:(3-15-22)
a.The original full name of the registrant;(3-15-22)
b.The date of birth and place of birth;(3-15-22)
c.The full maiden name of the mother; and(3-15-22)
d.The full name of the father, unless the registrant was born out of wedlock, in which case the name of the father will not be entered on the delayed certificate except as provided in Sections 39-250, 39-255, or 39-257, Idaho Code, and rules adopted in accordance with these statutes.(3-15-22)
05.Delayed Registration Following a Legal Change of Status.(3-15-22)
a.When evidence is presented reflecting a legal change of status by adoption, legitimation, paternity determination, acknowledgment of paternity, or a court-ordered name change, a new delayed certificate may be established to reflect such change.(3-15-22)
b.In such cases changing legal status, when no birth certificate is found, the delayed certificate may be filed reflecting the information established by the legal change.(3-15-22)
06.Documentary Evidence -- Requirements.(3-15-22)
a.To be acceptable for filing, the name of the registrant and the date and place of birth entered on a delayed birth certificate must be supported by at least:(3-15-22)
i.Two (2) pieces of documentary evidence, only one (1) of which may be an affidavit of personal knowledge, if the record is filed within seven (7) years after the date of birth.(3-15-22)
ii.Three (3) pieces of documentary evidence, only one (1) of which may be an affidavit of personal knowledge, if the record is filed seven (7) years or more after the date of birth. One (1) document must be dated within seven (7) years after the date of birth.(3-15-22)
b.Facts of parentage must be supported by at least one (1) document. This document may be one (1) of the documents above other than an affidavit of personal knowledge.(3-15-22)
07.Documentary Evidence -- Acceptability.(3-15-22)
a.The State Registrar may establish a priority of best evidence.(3-15-22)
b.Documents presented, such as census, hospital, church, and school records, must be from independent sources and be in the form of the original record or a certified copy of the original or a notarized statement and copy from the custodian of the record or document.(3-15-22)
c.All documents submitted in evidence, other than an affidavit of personal knowledge, must have been established at least ten (10) years prior to the date of application or have been established prior to the applicant’s seventh birthday.(3-15-22)
d.An affidavit of personal knowledge, to be acceptable, must be made by a parent of the applicant or an older person other than a parent, who is over eighteen (18) years of age and be signed before a notary public. In all cases, the affiant must be at least ten (10) years older than the applicant and have personal knowledge of the facts of birth.(3 -15-22)
08.Abstraction of Documentary Evidence.(3-15-22)
a.The State Registrar, or a designated representative, will abstract on the delayed birth certificate a description of each document submitted to support the facts shown on the delayed birth certificate. This description will include:(3-15-22)
i.The title or description of the document;(3-15-22)
ii.The name and address of the affiant, if the document is an affidavit of personal knowledge, or of the custodian, if the document is an original or certified copy of a record or a notarized statement from the custodian;
iii.The date of the original filing of the document being abstracted; and(3-15-22)
iv.The information regarding the birth facts contained in the document.(3-15-22)
b.All documents submitted in support of the delayed birth registration will be returned to the applicant after review, provided, however, that the State Registrar may make and keep on file abstracts or photocopies of any such documents.(3-15-22)
09.Certification by the State Registrar. The State Registrar, or a designated representative, will by signature certify:(3-15-22)
a.That no prior birth certificate is on file for the person whose birth is to be recorded;(3-15-22)
b.That the State Registrar or a designated representative has reviewed the evidence submitted to establish the facts of birth; and(3-15-22)
c.That the abstract of the evidence appearing on the delayed birth certificate accurately reflects the nature and content of the documents.(3-15-22)
10.Dismissal After One Year. Applications for delayed certificates that have not been completed within one (1) year from the date of application may be dismissed at the discretion of the State Registrar. Upon dismissal, the State Registrar will so advise the applicant, and all documents submitted in support of such registration will be returned to the applicant.(3-15-22)
IDAPA 16.02.08.651 Late or Delayed Registration of Deaths
The registration of death after the time prescribed by statute or rule must be made on the standard death certificate form. (3-15-22)
01.Minimum Evidence Required.(3-15-22)
a.If the person responsible for the medical certification of death, according to Section 39-260, Idaho Code, and the attending mortician or person who acted as such are available and they do complete and sign the death certificate; and(3-15-22)
i.If the certificate is filed within one (1) year after the date of death or finding of the body, the death certificate may be completed without additional evidence and filed with the State Registrar; or(3-15-22)
ii.If the certificate is filed one (1) year or more after the date of death or finding of the body, the medical certifier and the mortician or person who acted as such must state in accompanying affidavits that the information on the certificate is based on records kept in their files.(3-15-22)
b.If either the medical certifier or the attending mortician, or person acting as such (or both), is unavailable, the certificate may be filed by the next of kin of the deceased and must be accompanied by:(3-15-22)
i.An affidavit of the person filing the certificate, swearing to the accuracy of the information on the certificate; and(3-15-22)
ii.Two (2) documents that identify the name of the deceased and the date and place of death.
02.Additional Evidence. In all cases, the State Registrar may require additional documentary evidence to prove the facts of death.(3-15-22)
03.Summary Statement. A summary statement of the evidence submitted in support of the delayed registration will be entered on the certificate, and the certificate will be marked as delayed.(3-15-22)
IDAPA 16.02.08.652 (Reserved)
IDAPA 16.02.08.700 Late and Delayed Registration of Marriage
01.Late Registration. Until one (1) year has elapsed from the date of the ceremony, marriage certificates will be accepted for filing by the State Registrar in accordance with Section 39-262, Idaho Code, and will not be marked as delayed.(3-15-22)
02.Delayed Registration. The registration of a marriage after one (1) year must be made on the regular marriage certificate form.(3-15-22)
a.The certificate must be filed with the county recorder where the marriage license was originally issued.(3-15-22)
b.To be acceptable for registration by the State Registrar, the delayed marriage certificate must be supported by a notarized statement from two (2) people other than the bride and groom who know that a marriage ceremony was performed and the date and place of the marriage ceremony. One (1) of these statements must be from an actual witness to the marriage ceremony.(3-15-22)
c.When the officiant is not available to sign the delayed marriage certificate, the delayed marriage certificate must be signed by an actual witness to the marriage ceremony, other than the bride and groom. (3-15-22)
03.Additional Evidence. In all cases, the State Registrar may require additional documentary evidence to prove the facts of marriage.(3-15-22)
04.Summary Statement. A summary statement of the evidence submitted in support of the delayed registration will be entered on the certificate, and the certificate will be marked as delayed.(3-15-22)
IDAPA 16.02.08.701 Late and Delayed Registration of Divorce
01.Late Registration. Until one (1) year has elapsed from the date of the divorce decree, divorce certificates will be accepted for filing by the State Registrar in accordance with Section 39-265, Idaho Code, and will not be marked as delayed.(3-15-22)
02.Delayed Registration. The registration of a divorce after one (1) year must be made on the regular divorce certificate form that is:(3-15-22)
a.Filed by the court directly with the State Registrar; and(3-15-22)
b.Accompanied by a certified copy of the final decree of divorce.(3-15-22)
03.Additional Evidence. In all cases, the State Registrar may require additional documentary evidence to prove the facts of divorce.(3-15-22)
04.Summary Statement. A summary statement of the evidence submitted in support of the delayed registration will be entered on the certificate, and the certificate will be marked as delayed.(3-15-22)
IDAPA 16.02.08.702 (Reserved)
IDAPA 16.02.08.800 Delayed Registration of Stillbirth and Miscarriage
The requirements for filing delayed stillbirth and miscarriage certificates are the same as those for a delayed death certificate, except that the Section on paternity is governed by Section 39-260, Idaho Code.(3-15-22)
IDAPA 16.02.08.801 (Reserved)
IDAPA 16.02.08.850 Removal of Dead Body or Fetus from Place of Death or Stillbirth
Before removing a dead body or fe tus from the place of death or stillbirth, the funeral director, or person acting as such, must, under Section 39-268, Idaho Code:(3-15-22)
01.Obtain Assurance That Death Is from Natural Causes. Obtain assurance from the attending physician, physician assistant, advanced practice registered nurse, or their designated associate, responsible for medical certification of the cause of death or stillbirth:(3-15-22)
a.That the death or stillbirth is from natural causes; and(3-15-22)
b.That the attending physician, physician assistant, advanced practice registered nurse, or their designated associate, will assume responsibility for certification of the cause of death or stillbirth; or(3-15-22)
02.Notify the Coroner. Notify the coroner when:(3-15-22)
a.The case falls within the jurisdiction of the coroner in accordance with Section 39-260, Idaho Code; or(3-15-22)
b.The death or stillbirth is due to natural causes; and(3-15-22)
i.There was no attending physician, physician assistant, or advanced practice registered nurse during the last illness; or(3-15-22)
ii.There was no physician, physician assistant, or advanced practice registered nurse in attendance at the stillbirth; or(3-15-22)
iii.When the attending physician, physician assistant, advanced practice registered nurse, or their designated associate, is not available or is physically incapable of providing assurance that the death or stillbirth is from natural causes or providing permission to remove the dead body or fetus from the place of death or stillbirth.
03.Receive Permission to Remove the Dead Body or Fetus. Receive permission to remove the dead body or fetus from the place of death or stillbirth from:(3-15-22)
a.The attending physician, physician assistant, advanced practice registered nurse, or their designated associate, if the death is from natural causes and all assurances in Subsection 850.01 of this rule have been met; or
b.The coroner, if the case falls within the jurisdiction of the coroner, in accordance with Section 39- 260, Idaho Code, or if the death or stillbirth is due to natural causes and one (1) of the conditions listed in Subsections 850.02.b.i. through 850.02.b.iii. of this rule has been met.(3-15-22)
IDAPA 16.02.08.851 Authorization for Disinterment and Reinterment
01.Disinterment and Reinterment of a Dead Body or Fetus. Upon receipt of a notarized application, or an order of a court of record of this state, the State Registrar will issue a permit for the disinterment and reinterment of a dead body or fetus. The permit will be issued only to the mortician who is identified on the application or order as the mortician in charge of the disinterment. The application for the permit must be signed by the applicant and the mortician in charge of the disinterment. The applicant for the permit must be either: (3-15-22)
a.The person or persons who have the highest authority under the provisions of Section 54-1142, Idaho Code; or(3-15-22)
b.A person authorized by Section 39-269, Idaho Code, to request a special disinterment for legal purposes, in which case the application must state facts showing that the ends of justice require disinterment.
02.Mass Disinterment and Reinterment. Upon receipt of a notarized application, or an order of a court of record of this state, the State Registrar may issue a single permit for the disinterment and reinterment of all remains included in a mass disinterment. The permit will be issued only to the mortician who is identified on the application or order as the mortician in charge of the disinterment. The application or order for the permit must identify the remains of each body to the extent possible and specify the place of disinterment and reinterment. The application for the permit must be signed by the applicant and the mortician in charge of the disinterment. The applicant for the permit must be either:(3-15-22)
a.The person or persons who have the highest authority under the provisions of Section 54-1142, Idaho Code, for each of the deceased; or(3-15-22)
b.A person authorized by Section 39-269, Idaho Code, to request a special disinterment for legal purposes, in which case the application must state facts showing that the ends of justice require disinterment.
03.Nature of Permit. The authorization issued in accordance with the statutes and rules governing disinterment is permission for disinterment, transportation and reinterment.(3-15-22)
IDAPA 16.02.08.852 (Reserved)
16.02.19 Idaho Food Code
IDAPA 16.02.19.000 Legal Authority
Sections 37-121 and 39-1603, Idaho Code, authorize the Board to adopt rules for the regulation of food establi shments to protect public health.(4-6-23)
IDAPA 16.02.19.001 Applicability
01.These Rules Apply to Food Establishments.
Food establishments under Section 39-1602, Idaho Code, must follow these rules. Those facilities include the following:(4-6-23)
a.Restaurants, catering facilities, taverns, kiosks, vending facilities, commissaries, cafeterias, mobile food facilities, and temporary food facilities;(4-6-23)
b.Schools, senior centers, hospitals, residential care and treatment facilities, nursing homes, correctional facilities, camps, food banks, and church facilities;(4-6-23)
c.Retail markets, meat, fish, delicatessen, bakeries, supermarkets, convenience stores, health food stores, and neighborhood markets; and (4-6-23)
d.Food, water and beverage processing and bottling facilities that manufacture, process, and distribute food, water, and beverages, and are not inspected for food safety by a federal agency.(4-6-23)
02.These Rules Do Not Apply to These Establishments Under Idaho Code.(4-6-23)
a.Agricultural markets as exempted in Section 39-1602, Idaho Code.(4-6-23)
b.Bed-and-breakfast operations that prepare and offer food for breakfast only to guests. The number of guest beds must not exceed ten (10) beds under Section 39-1602, Idaho Code.(4-6-23)
c.Day care facilities regulated by Sections 39-1101 through 39-1119, Idaho Code.(4-6-23)
d.Licensed outfitters and guides regulated by Sections 36-2101 through 36-2119, Idaho Code.
e.Low-risk food establishments, as exempted in Section 39-1602, Idaho Code, which offer only non- TCS foods.(4-6-23)
f.Farmers market vendors and roadside stands that only offer or sell non-TCS foods or cottage foods.
g.Non-profit charitable, fraternal, or benevolent organizations that do not prepare or serve food on a regular basis as exempted in Section 39-1602, Idaho Code. Food is not considered to be served on a regular basis if it is not served for more than five (5) consecutive days on no more than three (3) occasions per year for foods that are non-TCS. For all other food, it must not be served more than one (1) meal per week.(4-6-23)
h.Private homes where food is prepared or served for family consumption or receives catered or home-delivered food as exempted by Section 39-1602, Idaho Code.(4-6-23)
i.Cottage food operations, when the consumer is informed and must be provided contact information for the cottage food operations by a clearly legible label on the product packaging; or a clearly visible placard at the sales or service location that also states:(4-6-23)
i.The food was prepared in a home kitchen that is not subject to regulation and inspection by the regulatory authority; and(4-6-23)
ii.The food may contain allergens.(4-6-23)
03.How to Use This Chapter of Rules. These rules are modifications, additions, or deletions made to the federal publication incorporated by reference in Section 002 of these rules. To follow these rules the publication is required. Changes to those standards are listed in these rules by which section of the incorporated publication is being modified at the beginning of each Section of rule. Citations to the incorporated Food Code are in the format “xxxx.xx.”(4-6-23)
IDAPA 16.02.19.002 Incorporation by Reference
The Department adopted by reference the “Food Code, 2013 Recomme ndations of the United States Public Health Service Food and Drug Administration,” Publication PB2013-110462, hereafter referred to as the incorporated Food Code. A certified copy of this publication may be reviewed at the main office of the Department. It is also available online at http://www.fda.gov/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/ucm374275.htm. This publication is being adopted with modifications and additions as follows:(4-6-23)
01.Chapter 1, Purpose and Definitions. Additions and modifications have been made to this chapter.
See Sections 100 - 199 of these rules.(4-6-23)
02.Chapter 2, Management and Personnel. Modifications have been made to this chapter. See Sections 200 - 299 of these rules.(4-6-23)
03.Chapter 3, Food. Modifications have been made to this chapter. See Sections 300-399 of these rules.(4-6-23)
04.Chapter 4, Equipment, Utensils, and Linens. This chapter has been adopted with no modifications.(4-6-23)
05.Chapter 5, Water, Plumbing and Waste. This chapter has been adopted with no modifications.
06.Chapter 6, Physical Facilities. Modifications have been made to this chapter. See Sections 600- 699 of these rules.(4-6-23)
07.Chapter 7, Poisonous or Toxic Materials. Modifications have been made in this chapter. See Sections 700 - 799 of these rules.(4-6-23)
08.Chapter 8, Compliance and Enforcement. Modifications have been made in this chapter. See Sections 800-899 of these rules.(4-6-23)
09.Annexes 1 Through 7 Are Excluded. These sections have not been adopted.(4-6-23)
IDAPA 16.02.19.003 (Reserved)
IDAPA 16.02.19.050 Training and Informational Materials
Section 56-1007, Idaho Code, authorizes the Department to esta blish a reasonable charge for training and informational materials that are provided to the public.(4-6-23)
IDAPA 16.02.19.051 (Reserved)
IDAPA 16.02.19.100 Purposes and Definitions
Sections 100 through 199 of these rules will be used for modifications and additions to Chapter 1 of the incorporated
IDAPA 16.02.19.101 (Reserved)
IDAPA 16.02.19.110 Definitions and Abbreviations -- a Through K
The definitions under this Section are modifications or additions to the definitions provided in the incorporated Food Code.( 4-6-23)
01.Agricultural Market. Any venue where a fixed or mobile retail food establishment can engage in the sale of raw or fresh fruits, vegetables, and nuts in the shell. It may also include the sale of factory sealed non-TCS foods. Agricultural market means the same as “farmers market” or “roadside stand.”(4-6-23)
02.Board. The Idaho Board of Health and Welfare under Section 56-1005, Idaho Code.(4-6-23)
03.Consent Order. An enforceable agreement between the regulatory authority and the license holder to correct violations that caused the actions taken by the regulatory authority.(4-6-23)
04.Core Item. A provision in the incorporated Food Code that is not designated as a priority item or a priority foundation item and includes items that usually relate to general sanitation, operation controls, sanitation standard operating procedures (SSOPs), facilities or structures, equipment design, or general maintenance. (4-6-23)
05.Cottage Food Operation. When a person or business prepares or produces cottage food products in the home kitchen of that person's primary residence or other designated kitchen or location.(4-6-23)
06.Cottage Food Product. Non-TCS foods that are sold directly to a consumer. Examples include: baked goods, fruit jams, jellies, fruit pies, breads, cakes, pastries, cookies, candies, confections, dried fruits, dry herbs, seasonings and mixtures, cereals, trail mixes, granola, nuts, vinegar, popcorn and popcorn balls, and cotton candy.(4-6-23)
07.Department. The Idaho Department of Health and Welfare under Section 56-1002, Idaho Code, or its designee.(4-6-23)
08.Director. The Director of the Idaho Department of Health and Welfare under Section 56-1003, Idaho Code.(4-6-23)
09.Embargo. An action taken by the regulatory authority that places a food product or equipment used in food production on hold until a determination is made on the product's safety.(4-6-23)
10.Enforcement Inspection. An inspection conducted by the regulatory authority when compliance with these rules by a food establishment is lacking and violations remain uncorrected after the first follow-up inspection to a routine inspection.(4-6-23)
11.Farmers Market. Any fixed or mobile retail food establishment at which farmer producers sell agricultural products directly to the public. Farmers market means the same as “agricultural market” and “roadside stand.”(4-6-23)
12.Food Establishment. Modifications to Section 1-201.10 amend the definition of “food establishment” as follows:(4-6-23)
a.Delete Subparagraph 3(c) of the term “food establishment” in the incorporated Food Code;
b.Add Subparagraph 3(h) to the term “food establishment” to clarify that a cottage food operation is not a food establishment.(4-6-23)
13.Food Processing Plant. Modification to Section 1-201.10 amends the definition of “food processing plant” by deleting Subparagraph 2 of the term “food processing plant” in the incorporated Food Code.
14.Good Retail Practice. Preventive measures that include practices and procedures that effectively control the introduction of pathogens, chemicals, and physical objects into food.(4-6-23)
15.High-Risk Food E stablishment. Performs the following:(4-6-23)
a.Extensive handling of raw ingredients;(4-6-23)
b.Preparation processes that include the cooking, cooling, and reheating of TCS foods; or(4-6-23)
c.A variety of processes requiring hot and cold holding of TCS foods.(4-6-23)
IDAPA 16.02.19.111 Definitions and Abbreviations -- L Through Z
The definitions under this Section are modifications or additions to the definitions provided in the incorporated Food Code.( 4-6-23)
01.License. Is used in these rules the same as the term “permit” is used in the incorporated Food Code.
02.License Holder. Is used in these rules the same as the term “permit holder” is used in the incorporated Food Code.(4-6-23)
03.Low-Risk Food Establishment. Provides factory-sealed prepackaged non-TCS foods. The establishment may have limited preparation of non-TCS foods only.(4-6-23)
04.Medium-Risk Food Establishment. Includes the following:(4-6-23)
a.A limited menu of one (1) or two (2) items;(4-6-23)
b.Prepackaged raw ingredients cooked or prepared to order;(4-6-23)
c.Raw ingredients requiring minimal assembly;(4-6-23)
d.Most products are cooked or prepared and served immediately; or(4-6-23)
e.Hot and cold holding of TCS foods is restricted to minimal holding between preparation and service.(4-6-23)
05.Priority Item. A provision in the incorporated Food Code whose application contributes directly to the elimination, prevention, or reduction to an acceptable level, hazards associated with foodborne illness or injury, and there is no other provision that more directly controls the hazard. A priority item includes items with a quantifiable measure to show control of hazards such as cooking, reheating, cooling, handwashing, and is an item that is denoted in the incorporated Food Code with a superscript (P).(4-6-23)
06.Priority Foundation Item. A provision in the incorporated Food Code whose application supports, facilitates, or enables one (1) or more priority items. Priority foundation item includes an item that requires the purposeful incorporation of specific actions, equipment, or procedures by industry management to attain control of risk factors that contribute to foodborne illness or injury such as personnel training, infrastructure or necessary equipment, HACCP plans, documentation or record keeping, and labeling. A priority foundation item is an item that is denoted in the incorporated Food Code with a superscript (Pf).(4-6-23)
07.Regulatory Authority. The Department is the regulatory authority authorized to enforce compliance of these rules.(4-6-23)
a.The Department is responsible for preparing the rules, rule amendments, standards, policy statements, operational procedures, program assessments, and guidelines.(4-6-23)
b.The seven (7) Public Health Districts have been assigned and the Division of Licensing and Certification has been designated by the Director as the regulatory authority for the purpose of issuing licenses, collecting fees, conducting inspections, reviewing plans, determining compliance with the rules, investigating complaints and illnesses, examining food, embargoing food, and enforcing these rules.(4-6-23)
08.Risk Control Plan. A document describing the specific actions to be taken by the license holder to address and correct a continuing hazard or risk within the food establishment.(4-6-23)
09.Risk Factor Violation. Improper practices or procedures that are most frequently identified by epidemiologic investigation as a cause of foodborne illness or injury.(4-6-23)
10.Roadside Stand. Any fixed or mobile retail food establishment at which an individual farmer producer sells their own agricultural products directly to consumers. Roadside stand means the same as “agricultural market” and “farmers market.”(4-6-23)
11.TCS. Time/Temperature Control for Safety.(4-6-23)
IDAPA 16.02.19.112 (Reserved)
IDAPA 16.02.19.200 Management and Personnel
Sections 200 through 299 of these rules will be used for modifications and additions to Chapter 2 of the incorporated Food Code.(4-6-23)
IDAPA 16.02.19.201 Person in Charge
Modification to Section 2-101.11. The license holder will be the person in charge or will designate a person in charge and will ensure that a person in charge is present at the food establishment during all hours of food preparation and service.(4-6-23)
IDAPA 16.02.19.202 (Reserved)
IDAPA 16.02.19.210 Demonstration of Knowledge
Modification to Section 2-102.11. The person in charge of a food establishment may demonstrate knowledge on the risk s of foodborne illness or health hazards by one (1) of the following.(4-6-23)
01.No Priority Violations. Complying with the incorporated Food Code by not having any priority violations at the time of inspection;(4-6-23)
02.Approved Courses. Completion of the Idaho Food Safety Exam, or an equivalent course designed to meet the same training as the Idaho Food Safety Exam; or(4-6-23)
03.Certified Food Protection Manager. Being a certified food protection manager who has shown proficiency of required information through passing a test that is part of an accredited program.(4-6-23)
IDAPA 16.02.19.211 (Reserved)
IDAPA 16.02.19.300 Food
Sections 300 through 399 of these rules will be used for modifications and additions to Chapter 3 of the incorporated
IDAPA 16.02.19.301 (Reserved)
IDAPA 16.02.19.320 Meat and Poultry
01.Custom Meat. Meat that is processed for individual owner(s) by a custom butcher, under the custom exemption in 9 CFR 303.1, “Mandatory Meat Inspection Exemptions,” must be marked “Not For Sale” and may not be sold, served, or given away to any member of the public. This meat must be for the use in the household of such owner(s), their families, non-paying guest, and employees only.(4-6-23)
02.Poultry Exemption. Poultry that is exempt in 9 CFR 381.10, Subpart C, “Mandatory Poultry Products Inspection Exemptions” may be sold, served, or given away in Idaho, if it is processed in a licensed food processing facility and is labeled “Exempt from USDA Inspection per PL 492.”(4-6-23)
IDAPA 16.02.19.321 (Reserved)
IDAPA 16.02.19.325 Game Animals
Modification to Section 3-201.l7(A)(4), is made by deleting Section 3-201.17(A)(4) and replacing it with this rule.
01.Field Dressed Game Animals. Uninspected wild game animals and wild poultry may be customprocessed or prepared and served upon request by an individual having ownership of the animal. Except as allowed in Subsection 325.04 of this rule, uninspected wild game animals and wild poultry must be processed for or served to that owner and for the family or guests of that individual animal owner only.(4-6-23)
02.Processing Game Animals. Game animals and birds are to be completely separated from other food during storage, processing, preparation, and service with the use of separate equipment or areas or by scheduling and cleaning, providing there is compliance with the following:(4-6-23)
a.Slaughtering and cleaning of game animals or birds cannot be done in the food establishment, except for meat processing establishments with kill floors;(4-6-23)
b.Game animals and other animal carcasses are free of any visible dirt, filth, fecal matter, or hair before such carcasses enter the food establishment, except for meat processing establishments with kill floors; and
c.An identifying tag with the owner's name must be on each carcass or divided parts and packaged or wrapped parts; and(4-6-23)
d.Each carcass or divided parts and packaged or wrapped parts are marked or tagged with a “Not for sale” label. Except as allowed in Subsection 325.04 of this rule, these may not be sold, given away, or served to any members of the public.(4-6-23)
03.Uninspected Game Animals. Any uninspected game animals prepared and served in a food establishment may only be prepared and served at the request of the owner of the animals for the owner and invited family or friends at a private dinner. Except as allowed in Subsection 325.04 of this rule, these animals may not be served, sold, or given away to any members of the public.(4-6-23)
04.Donated Game Meat. Legally harvested game meat may be donated to a food bank or food pantry when the following conditions are met:(4-6-23)
a.The end recipient of the donated game meat signs an acknowledgment statement indicating that they are aware that the meat has been donated and that the meat itself is uninspected, wild-harvested game meat.
b.The game meat must have been processed by:(4-6-23)
i.A facility that is subject to inspection by the regulatory authority with jurisdiction over meat products;(4-6-23)
ii.The facility packages the game meat into portions that require no further processing or cutting by the food bank or food pantry.(4-6-23)
c.The meat is labeled by the processor with the following:(4-6-23)
i.Species identification;(4-6-23)
ii.The name and address of the meat processing facility; and(4-6-23)
iii.The words “Processed for Donation or Private Use” and “Cook to 165° F.”(4-6-23)
IDAPA 16.02.19.326 (Reserved)
IDAPA 16.02.19.355 Food Processing Plants
Food processing plants, establishments, canning factories, or operations must meet the requirements in Chapters 1 through 8 of the incorporated Food Code, and this rule.(4-6-23)
01.Thermal Processing of Low-Acid Foods. Low-acid food products processed using thermal methods for canning must meet the requirements of 21 CFR 113.(4-6-23)
02.Processing of Acidified Foods. Acidified food products must meet the requirements of 21 CFR
IDAPA 16.02.19.114 (4-6-23)
03.Bottled Water Processing. Bottled drinking water processed in Idaho must be from a licensed processing facility that meets the requirements of 21 CFR 129. Bottled drinking water must also meet the quality and monitoring requirements in 21 CFR 165.(4-6-23)
04.Approval of Process Methods. A variance by the regulatory authority must be approved and granted for specialized processing methods for products listed in Section 3-502.11.(4-6-23)
05.Labels. Proposed labels must be submitted to the regulatory authority for review and approval before printing.(4-6-23)
06.Testing. The license holder is responsible for chemical, microbiological, or extraneous material testing procedures to identify failures or food contamination of food products being processed or manufactured by the license holder.(4-6-23)
07.Quality Assurance Program. The license holder or their designee must develop and submit to the regulatory authority for review and approval a quality assurance program or HACCP plan that covers the food processing operation and includes the following:(4-6-23)
a.An organization chart identifying the person responsible for quality control operations;(4-6-23)
b.A process flow diagram outlining the processing steps from the receipt of the raw materials to the production and packaging of the finished product(s) or group of related products;(4-6-23)
c.A list of specific points in the process that are critical control points that have scheduled monitoring;(4-6-23)
d.Product codes that establish and identify the production date and batch;(4-6-23)
e.A manual covering sanitary maintenance of the facility and hygienic practices to be followed by the employees; and(4-6-23)
f.A records system allowing for review and evaluation of all operations including the quality assurance program results. These records must be kept for a period of time that exceeds the shelf life of the product by six (6) months or for two (2) years, whichever is less.(4-6-23)
IDAPA 16.02.19.356 (Reserved)
IDAPA 16.02.19.360 Advising Consumers of Health Risk of Raw or Undercooked Foods
Modification to Section 3-603.11.(4-6-23)
Consumption of Animal Foods That Are Raw, Undercooked, or Not Otherwise Processed to Eliminate Pathogens. Except as specified in Section 3-401.11(C) and Subparagraph 3-401.11(D)(3) and under Section 3-801.11(D), if an animal food such as beef, eggs, fish, lamb, milk, pork, poultry, or shellfish that is raw, undercooked or not otherwise processed to eliminate pathogens is offered in a ready-to-eat form as a deli, menu, vended, or other item, or as a raw ingredient in another ready-to-eat food, the license holder must inform the consumers of health risks.(4-6-23)
02.How to Inform Consumers of Health Risk. The license holder must use any effective means to inform consumers of potential health risks. Some effective ways that may be used to inform consumers are: brochures, deli case placards, signs or verbal warnings that state, “Consuming raw or undercooked meats, poultry, seafood, shellfish, or eggs may increase your risk of foodborne illness, especially if you have certain medical conditions.”(4-6-23)
IDAPA 16.02.19.361 (Reserved)
IDAPA 16.02.19.370 Adulterated or Misbranded Food
The regulatory authority may order the license holder or other p erson who has custody of misbranded food to destroy, denature, or recondition adulterated or misbranded food under Section 37-118, Idaho Code. See Section 851 of these rules for embargo, tagging, storage, and release of adulterated or misbranded food.(4-6-23)
IDAPA 16.02.19.371 (Reserved)
IDAPA 16.02.19.600 Physical Facilities
Sections 600 through 699 of these rules will be used for modifications and additions to Chapter 6 of the incorporated Food Code.(4-6-23)
IDAPA 16.02.19.601 (Reserved)
IDAPA 16.02.19.620 Private Homes and Living or Sleeping Quarters, Use Prohibition
Modifications to Section 6-202.111. Except for cottage food operations, a private home, a room used as living or sleeping quarters, or an area directly opening into a room used as living or sleeping quarters may not be used for conducting food establishment operations. Residential assisted living facilities designed to be a homelike environment, are exempted from Section 6-202.111.(4-6-23)
IDAPA 16.02.19.621 (Reserved)
IDAPA 16.02.19.700 Poisonous or Toxic Materials
Sections 700 through 799 of these rules will be used for modifications and additions to Chapter 7 of the incorporated
IDAPA 16.02.19.701 (Reserved)
IDAPA 16.02.19.720 Restriction and Storage of Medicines
Modifications to Section 7-207.11.(4-6-23)
Medicines Allowed in a Food Establishment. Only those medicines that are necessary for the health of employees, patients, or residents in a care facility are allowed in a food establishment. Subsection 720.01 of this rule does not apply to medicines that are stored or displayed for retail sale.(4-6-23)
02.Labeling of Medicines. Medicines that are in a food establishment for the employees, patients, or residents use must be labeled as specified under Section 7-101.11 and located to prevent the contamination of food, equipment, utensils, linens, and single-service and single-use articles.(4-6-23)
IDAPA 16.02.19.721 Refrigerated Storage of Medicines
Modification to Section 7-207.12. Medicines belonging to employees, patients, or residents in a care facility that require refrigeration may be stored in a food refrigerator using the following criteria:(4-6-23)
01.Medicines Stored in a Leak-Proof Container. Medicines must be stored in a package or container and kept inside a covered, leak-proof container that is identified as a container for the storage of medicines. (4-6-23)
02.Accessibility of Stored Medicines. Medicines will be stored to permit access to self-medicating patients or residents to their individual medication. Authorized staff in a care facility also have access to these medications.(4-6-23)
IDAPA 16.02.19.722 (Reserved)
IDAPA 16.02.19.800 Compliance and Enforcement
Sections 800 through 899 of these rules will be used for modifications and additions to Chapter 8 of the incorporated
IDAPA 16.02.19.801 (Reserved)
IDAPA 16.02.19.830 Application for a License
01.To Apply for a Food Establishment License.
To apply, the application and fee is submitted to the “regulatory authority” as defined in Section 111 of these rules.(4-6-23)
02.Food License Expiration. The license for an Idaho food establishment expires on December 31st of each year.(4-6-23)
03.Renewal of License. A renewal application and a license fee must be submitted to the regulatory authority by December 1st of each year for the next calendar year starting January 1st.(4-6-23)
04.Summary Suspension of License. A license may be immediately suspended under Section 831 of these rules. Reinstatement of a license after a summary suspension does not require a new application or fee unless the license is revoked.(4-6-23)
05.Revocation of License. When corrections have been made to a food establishment whose license has been revoked under Section 860 of these rules, a new application and fee must be submitted to the regulatory
06.License is Non-Transferable. A license is not transferable when ownership changes under Section 8-304.20 of the incorporated Food Code.(4-6-23)
IDAPA 16.02.19.831 Summary Suspension of License
The regulatory authority may summarily suspend a license to operate a food establishment when it determines an imminent health hazard exists.(4-6-23)
01.Reasons a Summary Suspension May Be Issued. When a food establishment does not follow the principles of food safety, a foodborne illness is found, or an environmental health hazard exists and public safety cannot be assured by the continued operation of the food establishment, a summary suspension may be issued. The following are some reasons the regulatory authority may determine a summary suspension is necessary:(4-6-23)
a.Inspection of the food establishment shows uncorrected priority violations;(4-6-23)
b.Examination of food shows the food is unsafe;(4-6-23)
c.Review of records shows that proper steps for food safety have not been met;(4-6-23)
d.An employee working with food is suspected of having a disease that is communicable through food; or(4-6-23)
e.An imminent health hazard exists.(4-6-23)
02.Prior Notification Is Not Required for a Summary Suspension. Upon providing a written notice of summary suspension to the license holder or person in charge, the regulatory authority may suspend a food establishment's license without prior warning, notice of hearing, or hearing.(4-6-23)
03.Written Notice of Summary Suspension. The regulatory authority must give the license holder or person in charge a written notice with the following information when suspending a license.(4-6-23)
a.The specific reasons or violations the summary suspension is issued for with reference to the specific section of the incorporated Food Code which is in violation;(4-6-23)
b.A statement notifying the food establishment its license is suspended and all food operations are to cease immediately;(4-6-23)
c.The name and address of the regulatory authority representative to whom a written request for reinspection can be made and who can certify the reasons for the suspension have been eliminated;(4-6-23)
d.A statement notifying the food establishment of its right to an informal hearing with the regulatory authority upon submission of a written request within fifteen (15) days of receiving the summary suspension notice;
e.A statement informing the food establishment that proceedings for revocation of its license will be initiated by the regulatory authority if violations are not corrected; and(4-6-23)
f.The right to appeal to the Department under Section 861 of these rules.(4-6-23)
04.Length of Summary Suspension. The suspension will remain in effect until the conditions cited in the notice of suspension no longer exist and their elimination has been confirmed by the regulatory authority during a re-inspection.(4-6-23)
05.Re-Inspection of Food Establishment. The regulatory authority will conduct a re-inspection of the food establishment within two (2) working days of receiving a written request stating the condition for the suspension no longer exists.(4-6-23)
06.Reinstatement of License. The regulatory authority will immediately reinstate the suspended license if the re-inspection determines the public health hazard no longer exists. The regulatory authority will provide a written notice of reinstatement to the license holder or person in charge.(4-6-23)
IDAPA 16.02.19.832 (Reserved)
IDAPA 16.02.19.840 Inspections and Correction of Violations
Modification to Section 8-401.10.(4-6-23)
Inspection Interval Section 8-401.10(A). Except as specified in Section 8-401.10(C), the regulatory authority must inspect a food establishment at least once every twelve (12) months.(4-6-23)
02.Section 8-401.10(B). This section has not been adopted.(4-6-23)
03.Section 8-401.10(C). This section is adopted as published.(4-6-23)
04.Section 8-405.11. This section is adopted with the following modifications:(4-6-23)
a.Delete Section 8-405.11(B)(1); and(4-6-23)
b.Amend Section 8-405-11(B)(2) to ten (10) calendar days after the inspection for the permit holder to correct priority or priority foundation items or HACCP plan deviations.(4-6-23)
IDAPA 16.02.19.841 Inspection Scores
The regulatory authority will provide the license holder an inspection report with a total score indicating the number of ri sk factor violations and the number of repeat risk factor violations added together. Repeat violations are those observed during the last inspection. The inspection report will also score the total number of good retail practice violations and the number of repeat good retail practice violations. These scores will be used to determine if a followup inspection or a written report of correction is needed to verify corrections have been made.(4-6-23)
01.Medium-Risk Food Establishment. If the risk factor violations exceed three (3), or good retail practice violations exceed six (6), an onsite follow-up inspection is required for verification of correction by the regulatory authority.(4-6-23)
02.High-Risk Food Establishment. If the risk factor violations exceed five (5), or good retail practice violations exceed eight (8), an onsite follow-up inspection is required for verification of correction by the regulatory
03.Written Violation Correction Report. A written violation correction report by the license holder may be provided to the regulatory authority if the total inspection score of the food establishment does not exceed those listed in Section 845 of these rules. The report must be mailed within five (5) days of the correction date identified on the inspection report.(4-6-23)
IDAPA 16.02.19.842 (Reserved)
IDAPA 16.02.19.845 Verification and Documentation of Correction
In addition to Section 8-405.20 of the incorporated Food C ode, the onsite follow-up inspection may not be required for verification of correction if the regulatory authority chooses to accept a written report of correction from the license holder.(4-6-23)
01.Written Report of Correction. The regulatory authority may choose to accept a written report of correction from the license holder stating that specific violations have been corrected. The license holder must submit this report to the regulatory authority within five (5) days after the correction date identified on the inspection report.
a.Medium-risk food establishment. If the risk factor violations do not exceed three (3), or the good retail practice violations do not exceed six (6), a follow-up inspection is not required for verification of correction.
b.High-risk food establishment. If the risk factor violations do not exceed five (5), or the good retail practice violations do not exceed eight (8), a follow-up inspection is not required for verification of correction.
02.Risk Control Plan. The regulatory authority may require the development of a risk control plan as verification of correction. The risk control plan must provide documentation on how the license holder will obtain long-term correction of priority violations that are repeated violations, including how control will be monitored and who will be responsible.(4-6-23)
IDAPA 16.02.19.846 (Reserved)
IDAPA 16.02.19.850 Enforcement Inspections
01.Follow-Up Inspection. If a fo llow-up inspection reveals that priority, priority foundation, or core violations identified on a previous inspection have not been corrected or still exist, an enforcement inspection may be made.(4-6-23)
02.Written Notice. The license holder will receive written notice on the inspection form of the specific date for an enforcement inspection. This date must be within fifteen (15) days of the current or follow-up inspection.(4-6-23)
03.Enforcement Inspections on Consent Order. When a compliance conference results in a consent order and includes a compliance schedule to correct violations without further regulatory action, all inspections by the regulatory authority to satisfy the compliance schedule will be considered enforcement inspections until the next annual inspection.(4-6-23)
04.Regulatory Action. If the violations have not been corrected by the date of the enforcement inspection, regulatory action will be initiated to revoke the license issued to the food establishment.(4-6-23)
IDAPA 16.02.19.851 Enforcement Procedures for Adulterated or Misbranded Food
The regulatory authority may order the license holder or oth er person who has custody of adulterated or misbranded food to destroy, denature, or recondition adulterated or misbranded food under Section 37-118, Idaho Code. The following procedures apply:(4-6-23)
01.Serving an Embargo Order. An embargo order must be served by one (1) of the following ways:
a.Delivered personally to the license holder or person in charge of the food establishment; or
b.Posted at a public entrance to the food establishment, provided a copy of the notice is sent by firstclass mail to the license holder or the person in charge of the embargoed food.(4-6-23)
02.The Embargo Order Is Effective When Served. The embargo order is effective at the time the notice is delivered to the license holder or person in charge, or when the notice is posted.(4-6-23)
03.Tagging Embargoed Food. The regulatory authority must securely place an official tag or label on food or containers identified as food subject to the hold order.(4-6-23)
04.Storage of Embargoed Food. The regulatory authority allows storage of food under conditions specified in the embargo order, unless storage is not possible without risk to the public health. The regulatory authority may order immediate destruction of the adulterated or misbranded food for public safety.(4-6-23)
05.Removal of Embargo Tag or Label. The removal of the embargo tag, label, or other identification from food under embargo must be done by the regulatory authority.(4-6-23)
06.Embargo Release. The issue of release and removal of the embargo tag, label, or other identification from the suspected food when it is not adulterated or misbranded must be done by the regulatory
IDAPA 16.02.19.852 (Reserved)
IDAPA 16.02.19.860 Revocation of License
The regulatory authority may revoke the license issued to a food establishment when the license holder fails to comply with these rules or the operation of the food establishment is a hazard to public health.(4-6-23)
01.Reasons a License May Be Revoked.(4-6-23)
a.The license holder violates any term or condition in Section 8-304.11 of the incorporated Food Code.(4-6-23)
b.Access to the facility is denied or obstructed by an employee, agent, contractor, or other representative during the performance of the regulatory authority's duties. It is not necessary for the regulatory authority to seek an inspection order to gain access as permitted in Section 8-402.40 of the incorporated Food Code, before proceeding with revocation.(4-6-23)
c.A public health hazard or priority violation remains uncorrected after being identified by the regulatory authority and an enforcement inspection confirms the violation or hazard still exists. See Section 850 of these rules on enforcement inspections.(4-6-23)
d.A core violation remains uncorrected after being identified by the regulatory authority and an enforcement inspection confirms the violation still exists. See Section 845 of these rules on verification and documentation of correction.(4-6-23)
e.Failure to comply with any consent order issued after a compliance conference. See Section 861 of these rules on compliance conference.(4-6-23)
f.Failure to comply with a regulatory authority's summary suspension order. See Section 831 of these rules on summary suspension of a license.(4-6-23)
g.Failure to comply with an embargo order. See Section 851 of these rules on adulterated or misbranded food.(4-6-23)
h.Failure to comply with a regulatory authority order issued when an employee is suspected of having a communicable disease. See Chapter 2 of the incorporated Food Code on employee health.(4-6-23)
02.Notice to Revoke a License. The regulatory authority must notify the license holder of the food establishment in writing of the intended revocation of the license. See Section 861 of these rules for appeal process.
The notice must include Subsections 860.02.a. through 860.02.c. of this rule:(4-6-23)
a.The specific reasons and Sections of the Idaho Food Code that are in violation and the cause for the revocation;(4-6-23)
b.The right of the license holder to request in writing a compliance conference with the regulatory authority within fifteen (15) days of the notice; and(4-6-23)
c.The right of the license holder to appeal in writing to the Department. See Subsection 861.02 of these rules.(4-6-23)
d.The following is sufficient notification of the license holder's appeal rights: “You have the right to request in writing a compliance conference with (name and address of designated health district official) within fifteen (15) days of the receipt of this notice. You may also appeal the revocation of your license to the Director by filing a written appeal with the Department as provided in IDAPA 16.05.03, “Contested Case Proceedings and Declaratory Rulings,” within fifteen (15) days of the receipt of this notice, or if a timely request is made for a compliance conference and the matter is not resolved by a consent order, within five (5) working days following the conclusion of the compliance conference.”(4-6-23)
03.Effective Date of Revocation. The revocation will be effective fifteen (15) days following the date of service of notice to the license holder, unless an appeal is filed or a timely request for a compliance conference is made. If a compliance conference is requested and the matter is not resolved by a consent order, the revocation will be effective five (5) working days following the end of the conference, unless an appeal is filed with the Director within that time. See Section 861 of these rules for compliance conference, consent order, and appeal process.
IDAPA 16.02.19.861 Appeal Process
A license holder may appeal a summary suspension, notice of revocation, other action, or failure to act by the reg ulatory authority that adversely affects the license holder. A summary suspension or other emergency order is not stayed during the appeal process.(4-6-23)
01.Compliance Conference. The license holder may request in writing a compliance conference with the regulatory authority within fifteen (15) days of receipt of the notice or action by the regulatory authority. If a timely request for a compliance conference is made, a compliance conference will be scheduled within twenty (20) days and conducted in an informal manner by the regulatory authority. At the compliance conference the license holder may explain the circumstances of the alleged violations and propose a resolution for the matter.(4-6-23)
a.If the compliance conference results in an agreement between the license holder and the regulatory authority to remedy circumstances giving rise to the action and to assure future compliance, the agreement must be put in written form and signed by both parties. This written agreement constitutes an enforceable consent order.
b.Unless otherwise specifically stated in the consent order, the agreement will be for the duration of the existing license only.(4-6-23)
02.Appeal to the Director. The license holder may appeal in writing to the Director within fifteen (15) days of receipt of the notice of action by the regulatory authority, or if a timely request for a compliance conference was made, within five (5) working days following the completion of the compliance conference. (4-6-23)
IDAPA 16.02.19.862 (Reserved)
IDAPA 16.02.19.890 Criminal and Civil Proceedings
The regulatory authority may choose to enfo rce the provisions of these rules and its administrative orders through the courts.(4-6-23)
01.Criminal Proceedings. Misdemeanor proceedings to enforce these rules, federal regulations, and the enabling statutes may be instituted as provided in Sections 37-117, 37-119, 37-2103, and 56-1008, Idaho Code.
These statutes provide for fines or terms of imprisonment that may be sought through the court of competent jurisdiction.(4-6-23)
02.Civil Proceedings. Civil enforcement actions may be commenced and prosecuted in the district court in the county where the alleged violation occurred under Sections 56-1009 and 56-1010, Idaho Code. The person who is alleged to have violated any statute, rule, federal regulation, license, or order may be charged in the court proceeding. This action may be brought to compel compliance with these rules, regulations, license, or order for relief or remedies authorized in these rules.(4-6-23)
03.Injunctive Relief. In addition to other remedies provided by law, Section 56-1009, Idaho Code, allows for a search warrant to gain access and injunctions to be issued in the name of the state against any person or entity to enjoin them from violating these rules, regulations, statutes, or administrative orders.(4-6-23)
IDAPA 16.02.19.891 (Reserved)
16.05.06 Criminal History and Background Checks
IDAPA 16.05.06.000 Legal Authority
Sections 56-202(b), 56-203(2), 56-204A, 56-1007, 39-1105, 39-1107, 39-1111, 39-1210(10), 39-1211(4), 39-3520, 39-5604, 39-9109, 66-404(7), 15-5-308(4), 15-5-311(5), and 15-5-316(5), Idaho Code, and Tittle 56, Chapter 27, Idaho Code, authorize the Department to conduct criminal history and background checks. US Public Law 92-544, authorizes the Department to submit fingerprints and receive responses from the Federal Bureau of Investigations for the processing of background checks. IRS Publication 1075 requires the Department to submit fingerprints and establish a personnel screening program for its employees who have access to the Federal Tax Information File as part of their duties. 42 USC Section 9858f requires the Department to check specific records for federal child care programs.(3-28-23)
IDAPA 16.05.06.001 Policy
The Department will conduct a fingerprint-based criminal history and background check on individuals who complete a criminal history application. The criminal history applicant is required to disclose any pertinent information regarding crimes or findings that would disqualify the individual from providing care or services to children or vulnerable adults. The Department may obtain information for these criminal history and background checks from the following sources:(3-28-23)
01.Federal Bureau of Investigation.(3-28-23)
02.Idaho State Police Bureau of Criminal Identification.(3-28-23)
03.Any state or federal Child Protection Registry.(3-28-23)
04.Any state or federal Adult Protection Registry.(3-28-23)
05.Any state Sexual Offender Registry.(3-28-23)
06.Office of Inspector General List of Excluded Individuals and Entities.(3-28-23)
07.Idaho Department of Transportation Driving Records.(3-28-23)
08.Nurse Aide Registry.(3-28-23)
09.Other states and jurisdictions records and findings.(3-28-23)
IDAPA 16.05.06.002 (Reserved)
IDAPA 16.05.06.010 Definitions
For the purposes of this chapter of rules, the following terms apply:(3-28-23)
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Agency. An administrative subdivision of government or an establishment engaged in doing business for another entity. This term is synonymous with the term “employer”.(3-28-23)
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Application. An individual’s request for a background check in which the individual discloses any convictions, pending charges, or child or adult protection findings, and authorizes the Department to obtain information from available databases and sources relating to the individual.(3-28-23)
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Background Check Unit. The Department’s Unit responsible for processing fingerprint-based background checks, and issuing clearances or denials according to these rules.(3-28-23)
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Clearance. A clearance is a document designated by the Department as the official result of a completed background check with no disqualifying crimes or relevant records found.(3-28-23)
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Conviction. An individual is considered to have been convicted of a criminal offense when:
a.A judgment of conviction, or an adjudication, has been entered against the individual by any federal, state, military, or local court;(3-28-23)
b.There is a finding of guilt against the individual by any federal, state, military, or local court;
c.A plea of guilty or nolo contendere by the individual has been accepted by any federal, state, military, or local court;(3-28-23)
d.An individual has entered into or participated in first offender, deferred adjudication, or another arrangement or program where judgment of conviction has been withheld. This includes when:(3-28-23)
i.An individual participates in a drug court; or(3-28-23)
ii. An individual participates in a mental health court.(3-28-23)
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Criminal History and Background Check. A criminal history and background check is a fingerprint-based check of an individual’s criminal record and other relevant records. Also referred to as “background check”.(3-28-23)
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Denial. A denial of clearance is issued by the Department when an individual has a relevant record or disqualifying crime under Sections 200 and 210 of these rules.(3-28-23)
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Department. The Idaho Department of Health and Welfare or its designee.(3-28-23)
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Direct Patient Access Employee. Any individual who has access to a patient or resident of a longterm care provider or facility whether through employment or contract, and who has duties or performs tasks that involve (or may involve) one-on-one (1:1) contact with a patient or resident or has access to their personal belongings. Volunteers are not considered a Direct Patient Access employee of a long-term care provider or facility unless volunteers are required to undergo a background check under the rules applicable to that specific type of facility or provider.(3-28-23)
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Disqualifying Crime. A disqualifying crime is a designated crime under Section 210 of these rules that results in the unconditional denial of an applicant.(3-28-23)
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Employer. An entity that hires people to work in exchange for compensation. This term is synonymous with the term “agency”.(3-28-23)
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Enhanced Clearance. A clearance issued by the Department that includes a search of child protection registries in states or jurisdictions in which an applicant resided during the preceding five (5) years.
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Relevant Record. A record that is found in a search of criminal records or registries checked by the Department under Tittle 56, Chapter 27, Idaho Code, and these rules.(3-28-23)
IDAPA 16.05.06.011 (Reserved)
IDAPA 16.05.06.050 Fees and Costs for Background Checks
The fee for a Department fingerprint-based background check is up to seventy dollars ($70) for an individual. The applicant is responsible for the cost of the background check. The Department may waive the fee for certain individuals. An applicant is responsible for any additional costs incurred by the Department paid to agencies, judicial, or law enforcement jurisdictions in other states. The Department will collect the additional funds to cover its costs.
IDAPA 16.05.06.051 (Reserved)
IDAPA 16.05.06.060 Agency Responsibilities
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Initial Registration. Agencies required to obtain Department background checks on individuals must register with the Department and receive an agency identification number before applications are processed or accessed.(3-28-23)
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Change in Name or Ownership. An agency or facility must:(3-28-23)
a.If acquired by another entity, the new ownership will register as a new agency and provide contact information to obtain a new agency identification number and website access within thirty (30) calendar days of acquisition. New ownership occurs when the agency obtains a new federal Employer Identification Number with the Internal Revenue Service.(3-28-23)
b.The previous ownership will settle any background check debt with the Department prior to the completion of the acquisition. The Department reserves the right to not acknowledge the transfer to the new ownership if the previous ownership background check debt is not settled.(3-28-23)
c.If there is a change in name or location, the agency will update their profile on the Department website with their new name, location, and contact information within thirty (30) calendar days of the change.
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Applicant Screening. The agency must screen applicant background check disclosures that are submitted to the Department website to determine the suitability of the applicant for employment or program participation. If an applicant discloses a disqualifying crime or offense, or discloses other information that would indicate a risk to the health and safety of children and vulnerable adults, a determination of suitability for employment or program participation should be made during the initial application review.(3-28-23)
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Time Frames For Compliance. The agency is responsible for ensuring the required time frames are met for completion and submission of the application and fingerprints to the Department as required in Section 150 of these rules.(3-28-23)
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Review Background Check Results. The agency is responsible for reviewing the results of the background check even if a clearance that resulted in no disqualifying crimes or offenses found is issued by the Department. The agency must complete this review within fourteen (14) calendar days of the clearance being accessible on the Department’s website.(3-28-23)
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Employment Determination. The Department does not make the final fitness determination for employment or program participation for the applicant. The agency will determine the ability or risk of the individual to provide care or services to children or vulnerable adults after reviewing the applicant’s background check results.
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Discovery of Criminal Convictions or Disqualifying Records After Clearance is Issued. After a clearance is issued, if the agency discovers that the applicant may no longer be eligible to hold a Department clearance due to the existence of either a conviction for a disqualifying offense, or a relevant record listed in these rules, the agency is required to report their discovery to the Background Check Unit. The Department may compel the applicant to be processed for a new background check under Subsection 195.04 of these rules if it deems it appropriate to do so.(3-28-23)
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Retention of Records. The agency will retain all applicant background check documentation as provided in Subsection 300.02 of these rules.(3-28-23)
IDAPA 16.05.06.061 (Reserved)
IDAPA 16.05.06.070 Noncompliance with These Rules
The Department will report an agency’s noncompliance with these rules to the applicable licensing or certification unit or appropriate program integrity unit.(3-28-23)
IDAPA 16.05.06.071 (Reserved)
IDAPA 16.05.06.100 Individuals Subject to a Background Check
The following are persons or classes of individuals who are required by statute, or Department rules, to complete a background check.(3-28-23)
Required ClassesIdaho Code and IDAPA Chapter(s)
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Adoptive Parent Applicants IDAPA 16.06.01, “Child and Family Services”
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Certified Family Homes Section 39-3520, Idaho Code IDAPA 16.03.19, “Certified Family Homes”
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Children’s Agency Facility StaffIDAPA 16.04.18, “Children’s Agencies and Residential Licensing”
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Children's Residential Care Facilities Section 39-1210, Idaho Code 05. Children's Therapeutic Outdoor Programs Section 39-1208, Idaho Code 06. Citizen Review Panel Members Public health district volunteers who must comply with Section 16-1647, Idaho Code, “Citizen Review Panels - Child Protection Legislative Review Panel”
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Contracted Non-Emergency Medical Transportation Providers IDAPA 16.03.09, “Medicaid Basic Plan Benefits”
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Court Appointed Guardians and Conservators Title 15, Chapter 5, Idaho Code, & Title 66, Chapter 4, Idaho Code.
Court required guardian and conservator background checks are not provided Department clearances under Subsection 180.01 of these rules 09. Designated Examiners and Dispositioners IDAPA 16.07.39, “Designated Examiners and Dispositioners”
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Developmental Disabilities Agencies IDAPA 16.03.21, “Developmental Disabilities Agencies” (DDA)
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Emergency Medical Services (EMS)
IDAPA 16.01.05, “Emergency Medical Services (EMS) -- Education, Instructor, and Examination Requirements”
IDAPA 16.01.07, “Emergency Medical Services (EMS) -- Personnel Licensing Requirements”
- High Risk Providers of Medicaid IDAPA 16.03.09, “Medicaid Basic Plan Benefits”
The Medicaid Provider Handbook 13. Home and Community-Based Services (HCBS)
IDAPA 16.04.17, “Residential Habilitation Agencies”
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Home Health AgenciesIDAPA 16.03.07, “Home Health Agencies”
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Idaho Behavioral Health Plan (IBHP)IDAPA 16.03.09, “Medicaid Basic Plan Benefits”
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Idaho Child Care Program (ICCP)IDAPA 16.06.12, “Idaho Child Care Program” (ICCP)
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Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)
IDAPA 16.03.11, “Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)”
- Licensed Foster Care Section 39-1211, Idaho Code 19. Licensed Day Care Sections 39-1105, 39-1113, and 39-1114, Idaho Code
IDAPA 16.05.06.101 Department Individuals Subject to a Background Check
The following Department employees, contractors, and volunteers are subject to background checks. (3-28-23)
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Employees, Contractors, and Volunteers. Employees, contractors, and volunteers providing direct care services or who have access to children or vulnerable adults under Section 39-5302(10), Idaho Code.
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Employees of Bureau of Compliance.(3-28-23)
a.Fraud Investigators;(3-28-23)
b.Utilization Review Analysts; and(3-28-23)
c.Background Check Unit staff.(3-28-23)
- Employees at State Institutions. All employees of the following state-funded institutions;
a.Southwest Idaho Treatment Center, Nampa, Idaho;(3-28-23)
b.State Hospital North, Orofino, Idaho;(3-28-23)
c.State Hospital South, Blackfoot, Idaho; and(3-28-23)
d.State Hospital West, Nampa, Idaho.(3-28-23)
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Emergency Medical Services (EMS) Employees. EMS communication specialists and managers.
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Other Employees. Other Department employees as determined by the Director.(3-28-23)
IDAPA 16.05.06.102 (Reserved)
IDAPA 16.05.06.120 Application for a Background Check
Individuals who are subject to a background check must submit their application on the Department website.
- Mental Health Services IDAPA 16.07.33, “Adult Mental Health Services”
IDAPA 16.07.37, “Children’s Mental Health Services”
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Personal Assistance AgenciesIDAPA 16.03.10, “Medicaid Enhanced Plan Benefits”
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Personal Care Service Providers Section 39-5604, Idaho Code 23. Residential Assisted Living FacilitiesIDAPA 16.03.22, “Residential Assisted Living Facilities”
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Service Coordinators and Paraprofessional Providers 25. Skilled Nursing FacilitiesIDAPA 16.03.02, “Skilled Nursing Facilities”
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Substance Use Disorders ServicesIDAPA 16.07.17, “Substance Use Disorders Services”
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Support Brokers and Community Support Workers IDAPA 16.03.13, “Consumer-Directed Services”
Required ClassesIdaho Code and IDAPA Chapter(s)
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Application Form. To request a background check, the applicant must apply on the Department website and provide all the information requested in the Department-provided forms. The individual's application authorizes the Department to obtain information and release it under applicable state and federal law. (3-28-23)
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Disclosures. The individual must disclose any conviction, pending charges or indictment for crimes, and furnish a description of the crime and the particulars on the application. The individual must also disclose any notice by a state or local agency of substantiated child or substantiated vulnerable adult abuse, neglect, exploitation, or abandonment complaint, and any other information as required.(3-28-23)
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Failure to Disclose Information.(3-28-23)
a.An applicant who falsifies or fails to disclose information on the application, may be subject to prosecution under Sections 18-3203, 18-5401, and 56-227A, Idaho Code.(3-28-23)
b.An applicant required to obtain a background check under Section 126 of these rules that knowingly makes a materially false statement in connection to their background check will receive an unconditional denial as provided in Section 200 of these rules.(3-28-23)
IDAPA 16.05.06.121 (Reserved)
IDAPA 16.05.06.125 Idaho Child Protection Central Registry Checks
The Department will provide the results of a check of the Idaho Child Protection Central Registry to any agency that requires it to comply with applicable federal, state, or local law. The Department will process those requests under this rule.(3-28-23)
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Request for an Idaho Child Protection Central Registry Check. A request for an Idaho Child Protection Central Registry check must be submitted on the Department form by mail, facsimile transmission, or email attachment.(3-28-23)
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Fee Amount. The fee for an Idaho Child Protection Central Registry check is twenty dollars ($20) for each subject checked.(3-28-23)
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Department Response. A response will be returned to the agency initiating the request for the check within fourteen (14) days of receipt of the request. The Department’s response will be limited to confirmation whether the subject is listed in the Registry. The requestor may contact the Department’s Division of Family and Community Services if additional information is needed.(3-28-23)
IDAPA 16.05.06.126 Applicants Receiving a Department Enhanced Clearance
The following classes of individuals are required to provide their previous residence information for the preceding five (5) years in their application for a background check. If the applicant’s previous background check included checks of out-of-state Central Child Protection Registries within the previous six (6) months, the applicant is not required to complete them again.(3-28-23)
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Adoptive Parent Applicants.(3-28-23)
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Behavioral Health Programs.(3-28-23)
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Certified Family Homes.(3-28-23)
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Children’s Agency Facility Staff.(3-28-23)
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Children’s Residential Care Facilities.(3-28-23)
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Children’s Therapeutic Outdoor Programs.(3-28-23)
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Citizen Review Panel Members.(3-28-23)
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Idaho Child Care Program (ICCP).(3-28-23)
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Licensed Foster Care.(3-28-23)
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Licensed Day Care.(3-28-23)
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Mental Health Services.(3-28-23)
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Substance Use Disorders Services.(3-28-23)
IDAPA 16.05.06.127 (Reserved)
IDAPA 16.05.06.140 Submission of Fingerprints
Ten (10) rolled fingerprints must be collected from the individual and submitted to the Department under Section 150 of these rules to process a background check request.(3-28-23)
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Department Fingerprinting Locations. The Department will collect the individual's fingerprints at designated locations listed on the Department’s website. The applicant may contact the Background Check Unit for additional guidance.(3-28-23)
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Submitting Fingerprints by Mail. Individuals who elect to have fingerprints collected by a local law enforcement agency or by the applicant’s agency must use a federal FD-258 Applicant fingerprint card. The fingerprint card must be completed using the instructions provided, signed, and mailed along with the applicable fee to the address indicated on the Department’s website. The applicant fingerprints and fees must be received by the Department in the time frame required in Section 150 of these rules.(3-28-23)
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Submission of Reprints. If an individual’s submitted fingerprints are deemed unreadable by the Department, Idaho State Police, or the FBI, the applicant must comply with a request for reprints from the Department within fifteen (15) calendar days from the date of the notice. Failure to comply with the request will result in the applicant being unavailable to provide services.(3-28-23)
IDAPA 16.05.06.141 (Reserved)
IDAPA 16.05.06.150 Time Frame for Submitting Fingerprints
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Time Frame. The applicant fingerprints must be received by the Department within twenty-one (21) days from the date of the application submission in the Department background check system whether the fingerprints are sent by mail or collected at a Department fingerprinting location. If the Department does not receive the applicant fingerprints within sixty (60) calendar days from the background check submission date on the Department website, the applicant must complete a new application.(3-28-23)
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No Extension of Time Frame. The Department will not extend the twenty-one (21) day time frame, unless the agency provides just cause. If the Department does not extend the time frame, the applicant must be removed from any situation where they can have direct access to a vulnerable person or their belongings. (3-28-23)
IDAPA 16.05.06.151 (Reserved)
IDAPA 16.05.06.160 Withdrawal of Application
An individual may withdraw their application for a background check at any time. An individual who withdraws their application cannot provide services, or receive licensure or certification. Fees paid for the cost of the background check are non-refundable once the fingerprints have been submitted by the Department to the Idaho State Police.
IDAPA 16.05.06.161 (Reserved)
IDAPA 16.05.06.170 Availability to Provide Services Pending Completion of the Background
CHECK.
An individual is available to provide services on the day the application is submitted on the Department website, has been reviewed by the agency, and while pending completion of the background check under this rule. The individual must have submitted their application and fingerprints in the time frame required in Section 150 of these rules to provide services.(3-28-23)
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Employees of Providers, Contractors, Bureau of Emergency Medical Services (EMS), or the Department. An individual is available to provide services on a provisional basis at the discretion of the agency or EMS Bureau if no disqualifying crimes or relevant records are disclosed on the application. The agency must review the application for any disqualifying crimes under Section 210 of these rules or other relevant records under Section 200 of these rules. The agency determines whether the applicant poses a health or safety risk to vulnerable clients before allowing the individual to provide services until a clearance or denial is issued by the Department. (3-28-23)
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Individuals Licensed or Certified by the Department. Individuals applying for licensure or certification by the Department are not available to provide services or receive licensure or certification until the background check is complete and a clearance is issued by the Department. The following are individuals required to have a clearance prior to providing services:(3-28-23)
a.Adoption or foster care applicants and adults in the home;(3-28-23)
b.Certification or licensure applicants;(3-28-23)
i.Certified family homes;(3-28-23)
ii. Licensed Emergency Medical Services applicants; and(3-28-23)
iii. Department-licensed child care providers.(3-28-23)
IDAPA 16.05.06.171 (Reserved)
IDAPA 16.05.06.180 Background Check Results
The Department will issue a clearance or denial once the background check is completed.(3-28-23)
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Results of Background Checks. The results can be accessed on the Department’s website.
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Findings for Court-Required Criminal History and Background Checks. Under Tittle 56, Chapter 27, Idaho Code,, the Department will provide findings of a court-ordered background check to individuals appointed by the court under Title 15, Chapter 5, or Title 66, Chapter 4, Idaho Code.(3-28-23)
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Department Employees That Have Access to the Internal Revenue Service Federal Tax Information File. Employees assigned to the Self-Reliance Division that access the Internal Revenue Service Federal Tax Information file as part of their duties will be processed for a background check by the Background Check Unit. The Self-Reliance Division will make a fitness determination based on its own policies. (3-28-23)
IDAPA 16.05.06.181 Application Status
An individual and their agency may check on the background check status and the individual’s availability to work on the Department website.(3-28-23)
IDAPA 16.05.06.182 (Reserved)
IDAPA 16.05.06.190 Background Check Clearance
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Clearance. A clearance is issued by the Department once all relevant records and findings have been reviewed and the Department has cleared the applicant. The clearance will be published on the Department’s website and is available for printing to the individual and their agency.(3-28-23)
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Clearance Types. An applicant required to pass a background check must receive a clearance as provided below:(3-28-23)
a.An enhanced clearance is required for each of the classes listed in Section 126 of these rules and requires searches from states and jurisdictions where the applicant has resided in the previous five (5) years. A relevant record on any child protection registry will result in a denial under Subsection 200.01 of these rules. An applicant who applies to work in any of these classes must receive or have an enhanced clearance.(3-28-23)
b.An applicant not listed in Section 126 of these rules will receive a clearance provided they do not disclose or have a relevant record under Subsections 200.01.a., 200.01.c., 200.01.d., 200.01.e., 200.01.f., or 200.01.g., or a disqualifying crime under Subsections 210.01, 210.02, or 210.03 of these rules.(3-28-23)
- Revocation of Clearance. A clearance may be revoked for the following:(3-28-23)
a.The individual fails to comply with the Department’s request to submit to a new background check under Subsection 195.04 of these rules.(3-28-23)
b.The individual completes a new background check and is found to have a criminal or relevant record that results in an inability to proceed action or in a denial under Sections 200 or 270 of these rules. (3-28-23)
c.The applicant withdraws their application from the background check process under Section 160 of these rules.(3-28-23)
d.The background check fees are not paid, or are insufficient to cover the costs of the background check.(3-28-23)
IDAPA 16.05.06.191 (Reserved)
IDAPA 16.05.06.195 Use of Previously Completed Background Checks
The agency is responsible for confirming that the applicant has received a clearance under Section 190 of these rules.
Once a clearance is issued by the Department, verifiable continuous employment of the applicant with the same agency eliminates the requirement for a new background check.(3-28-23)
- New Background Check. Any individual required to have a background check under these rules must complete a new application, including fingerprints when:(3-28-23)
a.An applicant is accepting employment with a new agency, and their last Department background check was completed more than three (3) years prior to their employment date; or(3-28-23)
b.An applicant is applying for licensure or certification with the Department. and their last Department background check was completed more than three (3) years prior to their employment date or licensure application date; or(3-28-23)
c.An applicant’s affiliation ends, is later re-affiliated to the same agency, and the applicant background check is older than three (3) years at the time of the re-affiliation.(3-28-23)
- Use of Background Check Within Three Years of Completion. Any agency may use a Department background check clearance obtained under these rules if:(3-28-23)
a.The individual has received a Department’s background check clearance within three (3) years from the date of employment;(3-28-23)
b.Prior to allowing the individual to provide services, the agency must affiliate itself to the individual’s clearance through the Department’s website by having the agency’s identification number added to the individual’s background check; and(3-28-23)
c.The agency completes a state-only background check of the individual through the Idaho State Police Bureau of Criminal Identification, and no disqualifying crimes are found.(3-28-23)
i.The action must be initiated by the agency within thirty (30) calendar days of obtaining access to the individual’s background check clearance issued by the Department; and(3-28-23)
ii. The agency must be able to provide proof of this action by maintaining a copy of the records required in Subsections 195.02.a and 195.02.c of these rules.(3-28-23)
d.An applicant’s affiliation ends, is later re-affiliated to the same agency, and the applicant background check was completed less than three (3) years from the time of the re-affiliation, the provisions of Subsections 195.02.b and 195.02.c of these rules apply.(3-28-23)
e.An agency not listed in Section 126 of these rules may use an individual’s Department clearance or enhanced clearance that was obtained within three (3) years from date of employment.(3-28-23)
f.An individual with a current clearance that is not Enhanced but is completed within three (3) years from date of employment, who seeks to affiliate themselves to a new agency identified in Section 126 of these rules, must apply for a new background check to obtain an Enhanced clearance. An agency or employer identified in Subsections 126.08 and 126.10 of these rules may not hire an employee with a clearance obtained prior to January 1, 2020, unless the Enhanced clearance complies with the requirements found in 42 USC Section 9858. (3-28-23)
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Agency Discretion. Any agency or employer, at its discretion, may require an individual to complete a Department background check at any time, even if the individual has received a background check clearance within three (3) years.(3-28-23)
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Department Discretion. The Department may require a background check of any individual covered under these rules at any time. Any individual required to complete a background check under these rules must be fingerprinted within fourteen (14) days from the date of notification by the Department.(3-28-23)
IDAPA 16.05.06.196 (Reserved)
IDAPA 16.05.06.200 Unconditional Denial
An individual who receives an unconditional denial is not available to provide services, have access, or be licensed or certified by the Department.(3-28-23)
- Reasons for an Unconditional Denial. Unconditional denials are issued for:(3-28-23)
a.Disqualifying crimes under Section 210 of these rules;(3-28-23)
b.A relevant record on any Child Protection Registry for the classes of individuals under Section 126 of these rules;(3-28-23)
c.A relevant record on the Idaho Child Protection Central Registry with a Level one (1) or Level two (2) designation for all other applicants covered by these rules;(3-28-23)
d.A relevant record on the Nurse Aide Registry;(3-28-23)
e.A relevant record on either the state or federal sex offender registries;(3-28-23)
f.A relevant record on the U. S. Health and Human Services, Office of the Inspector General List of Excluded Individuals and Entities (LEIE);(3-28-23)
g.A relevant record on the state Medicaid Exclusion List: or(3-28-23)
h.A materially false statement made knowingly in connection to the Department’s background check application for the classes of individuals under Section 126 of these rules will result in a five-year disqualification period for the applicant.(3-28-23)
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Issuance of an Unconditional Denial. The Department will issue an unconditional denial within fourteen (14) days of completion of a background check.(3-28-23)
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Challenge of Department's Unconditional Denial. An individual has twenty-eight (28) days from the date the unconditional denial is issued to challenge the Department's unconditional denial. The individual must submit the challenge in writing and provide court records or other information which demonstrates the Department's unconditional denial is incorrect. These documents must be filed with the Background Check Unit.(3-28-23)
a.If the individual challenges the Department's unconditional denial, the Department will review the court records, documents, and other information filed by the individual. The Department will issue a decision within thirty (30) days of the receipt of the challenge. The Department’s decision will be a final order under IDAPA 62.01.01, “Idaho Rules of Administrative Procedure,” and Office of Administrative Hearings General Order No. 1.
b.If the individual does not challenge the Department's unconditional denial within thirty (30) days, it becomes a final order of the Department under IDAPA 62.01.01, “Idaho Rules of Administrative Procedure,” and Office of Administrative Hearings General Order No. 1.(3-28-23)
- Appeal of an Unconditional Denial. Following a challenge of the Department’s unconditional denial, an individual may appeal the Department’s decision under IDAPA 62.01.01, “Idaho Rules of Administrative Procedure,” and Office of Administrative Hearings General Order No. 1. The request to appeal an unconditional denial does not stay the action of the Department.(3-28-23)
IDAPA 16.05.06.201 (Reserved)
IDAPA 16.05.06.210 Disqualifying Crimes Resulting in an Unconditional Denial
An individual is not available to provide direct care or services when the individual discloses or the background check reveals a conviction for a disqualifying crime on their record under this rule.(3-28-23)
- Disqualifying Crimes. The disqualifying crimes under this rule, or any substantially conforming foreign criminal violation, will result in an unconditional denial being issued.(3-28-23)
a.Crimes against vulnerable adults:(3-28-23)
i.Abuse, neglect, or exploitation of a vulnerable adult, as defined in Section 18-1505, Idaho Code;
ii. Abandoning a vulnerable adult, as defined in Section 18-1505A, Idaho Code;(3-28-23)
iii. Sexual abuse and exploitation of a vulnerable adult, as defined in Section 18-1505B, Idaho Code.
b.Aggravated, first-degree and second-degree arson, as defined in Sections 18-801 through 18-803, and 18-805, Idaho Code;(3-28-23)
c.Forcible sexual penetration by use of a foreign object, as defined in Section 18-6604, Idaho Code;
d.Hiring, employing, or using a minor to engage in certain acts, as defined in Section 18-1517A, Idaho Code;(3-28-23)
e.Human trafficking, as defined in Sections 18-8602 and 18-8603, Idaho Code;(3-28-23)
f.Incest, as defined in Section 18-6601, Idaho Code;(3-28-23)
g.Injury to a child, felony or misdemeanor, as defined in Section 18-1501, Idaho Code; (3-28-23)
h.Kidnapping, as defined in Sections 18-4501 through 18-4503, Idaho Code;(3-28-23)
i.Lewd conduct with a minor, as defined in Section 18-1508, Idaho Code;(3-28-23)
j.Mayhem, as defined in Section 18-5001, Idaho Code;(3-28-23)
k.Manslaughter:(3-28-23)
i.Voluntary manslaughter, as defined in Section 18-4006(1) Idaho Code;(3-28-23)
ii. Involuntary manslaughter, as defined in Section 18-4006(2), Idaho Code;(3-28-23)
iii. Felony vehicular manslaughter, as defined in Section 18-4006(3)(a) and (b), Idaho Code;(3-28-23)
l.Murder in any degree or assault with intent to commit murder, as defined in Sections 18-4001, 18- 4003, and 18-4015, Idaho Code;(3-28-23)
m.Poisoning, as defined in Sections 18-4014 and 18-5501, Idaho Code;(3-28-23)
n.Rape, as defined in Section 18-6101, Idaho Code;(3-28-23)
o.Robbery, as defined in Section 18-6501, Idaho Code;(3-28-23)
p.Felony stalking, as defined in Section 18-7905, Idaho Code;(3-28-23)
q.Sale or barter of a child, as defined in Section 18-1511, Idaho Code;(3-28-23)
r.Ritualized abuse of a child, as defined in Section 18-1506A, Idaho Code;(3-28-23)
s.Female Genital Mutilation, as defined in Section 18-1506B, Idaho Code;(3-28-23)
t.Sexual abuse or exploitation of a child, as defined in Sections 18-1506, Idaho Code; (3-28-23)
u.Felony sexual exploitation of a child, as defined in Section 18-1507, Idaho Code;(3-28-23)
v.Sexual battery of a minor child under sixteen (16) or seventeen (17) years of age, as defined in Section 18-1508A, Idaho Code;(3-28-23)
w.Video voyeurism, as defined in Section 18-6605, Idaho Code;(3-28-23)
x.Enticing of children, as defined in Sections 18-1509 and 18-1509A, Idaho Code;(3-28-23)
y.Inducing individuals under eighteen (18) years of age into prostitution or patronizing a prostitute, as defined in Sections 18-5609 and 18-5611, Idaho Code;(3-28-23)
z.Any felony punishable by death or life imprisonment;(3-28-23)
aa.Attempted strangulation, as defined in Section 18-923, Idaho Code;(3-28-23)
bb.Felony domestic violence, as defined in Section 18-918, Idaho Code;(3-28-23)
cc.Battery with intent to commit a serious felony, as defined in Section 18-911, Idaho Code;(3-28-23)
dd.Assault with intent to commit a serious felony, as defined in Section 18-909, Idaho Code; or
ee.Aggravated sexual battery, as defined in Section 18-925, Idaho Code; (3-28-23)
ff.Sexual abuse of an animal, as defined in Section 18-6602, Idaho Code;(3-28-23)
gg.Sexual abuse of human remains, as defined in Section 18-6603, Idaho Code; or(3-28-23)
hh.Attempt, conspiracy, accessory after the fact, or aiding and abetting, as defined in Sections 18-205, 18-304, 18-305, 18-306, 18-307, 18-1701, and 19-1430, Idaho Code, to commit any of the disqualifying designated crimes.(3-28-23)
- Disqualifying Five-Year Crimes. The Department will issue an unconditional denial for an individual who has been convicted of the following described crimes for five (5) years from the date of the conviction for the crimes listed in this rule, or any substantially conforming foreign criminal violation:(3-28-23)
a.Any felony not described in Subsection 210.01, or 210.03 of this rule;(3-28-23)
b.Misdemeanor domestic violence, as defined in Section 18-918, Idaho Code;(3-28-23)
c.Failure to report abuse, abandonment or neglect of a child, as defined in Section 16-1605, Idaho Code;(3-28-23)
d.Misdemeanor forgery of and fraudulent use of a financial transaction card, as defined in Sections 18-3123 through 18-3128, Idaho Code;(3-28-23)
e.Misdemeanor forgery and counterfeiting, as defined in Sections 18-3601 through 18-3620, Idaho Code;(3-28-23)
f.Misdemeanor identity theft, as defined in Section 18-3126, Idaho Code;(3-28-23)
g.Misdemeanor insurance fraud, as defined in Sections 41-293 and 41-294, Idaho Code; (3-28-23)
h.Public assistance fraud, as defined in Sections 56-227, 56-227A, 56-227D, 56-227E and 56-227F, Idaho Code;(3-28-23)
i.Sexual exploitation of a child by electronic means, felony or misdemeanor, as defined in Section 18-1507A, Idaho Code;(3-28-23)
j.Stalking in the second degree, as defined in Section 18-7906, Idaho Code;(3-28-23)
k.Misdemeanor vehicular manslaughter, as defined in Section 18-4006(3)(c), Idaho Code; (3-28-23)
l.Sexual exploitation by a medical care provider, as defined in Section 18-919, Idaho Code;
m.Sexual Battery, as defined in Section 18-924, Idaho Code;(3-28-23)
n.Operating a certified family home without certification, as defined in Section 39-3528, Idaho Code; or(3-28-23)
o.Attempt, conspiracy, accessory after the fact, or aiding and abetting, as defined in Sections 18-204, 18-205, 18-304, 18-306, 18-307, 18-1701, and 19-1430, Idaho Code, to commit any of the disqualifying five (5) year crimes.(3-28-23)
- Disqualifying Three-Year Crimes. The Department will issue an unconditional denial for an individual who has been convicted of the following described crimes for three (3) years from the date of the conviction for the crimes listed in this rule, or any substantially conforming foreign criminal violation: (3-28-23)
a.A controlled substance manufacture, delivery, or possession with intent to deliver or manufacture offense, as defined in Section 37-2732, Idaho Code, felony;(3-28-23)
b.A controlled substance paraphernalia offense, as defined in Section 37-2734B, Idaho Code, felony; or(3-28-23)
c.Operating a motor vehicle under the influence of alcohol, drugs, or any other intoxicating substance offense, as defined in Section 18-8004, Idaho Code, felony.(3-28-23)
- Underlying Facts and Circumstances. The Department may consider the underlying facts and circumstances of felony or misdemeanor conduct including a guilty plea or admission in determining whether or not to issue a clearance, regardless of whether or not the individual received one (1) of the following:(3-28-23)
a.A withheld judgment;(3-28-23)
b.A dismissal, suspension, deferral, commutation, or a plea agreement where probation or restitution was or was not required;(3-28-23)
c.An order under Section 19-2604, Idaho Code, or other equivalent state law; or(3-28-23)
d.A sealed record.(3-28-23)
IDAPA 16.05.06.211 (Reserved)
IDAPA 16.05.06.270 Criminal or Relevant Record - Action Pending
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Notice of Inability to Proceed. When the applicant is identified as having a pending criminal action for a crime or relevant record that may disqualify them from receiving a clearance for the background check, the Department may issue a notice of inability to proceed. (3-28-23)
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Availability to Provide Services. The applicant is not available to provide service when a notice of inability to proceed or denial is issued by the Department. Any previous clearance issued by the Department will be revoked as described in Section 190 of these rules.(3-28-23)
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Reconsideration of Action Pending. In the case of an inability to proceed status, the applicant can submit documentation that the matter has been resolved to the Department for reconsideration within one hundred and twenty (120) calendar days from the date of notice. When the Department receives this documentation, the Department will notify the applicant of the reconsideration and issue a clearance or denial. When the Department’s reconsideration results in a clearance after review, any previously revoked clearance will be restored as described in Section 190 of these rules.(3-28-23)
IDAPA 16.05.06.271 (Reserved)
IDAPA 16.05.06.300 Background Check Records
Background checks done under this chapter become the property of the Department and are held confidential.
- Release of Background Check Records. A copy of the background check as defined in Section 010 of these rules will be released:(3-28-23)
a.To the individual who has requested the background check and upon receipt of a written request to the Department, provided the individual releases the state from all liability;(3-28-23)
b.In response to a subpoena issued by a court of competent jurisdiction; or(3-28-23)
c.As otherwise required by law.(3-28-23)
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Department Retention of Records. The Department will preserve all applicant background check records for six (6) years.(3-28-23)
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Use and Dissemination Restrictions for FBI Criminal Identification Records. According to 28 CFR 50.12, the Department will:(3-28-23)
a.Notify the individual fingerprinted that the fingerprints will be used to check the criminal history records of the FBI;(3-28-23)
b.In determining the suitability for licensing or employment, provide the individual the opportunity to complete or challenge the accuracy of the information contained in the FBI identification record;(3-28-23)
c.Notify the individual that they have fifteen (15) days to correct or complete the FBI identification record or to decline to do so; and(3-28-23)
d.Advise the individual who wishes to correct the FBI identification record that procedures for changing, correcting, or updating are provided in 28 CFR 16.34.(3-28-23)
IDAPA 16.05.06.301 (Reserved)
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