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, evidence- informed or evidence-based therapeutic techniques based on applied behavior analysis principles used to result in positive 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) IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 005 Page 16 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 screening 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) IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 006 Page 17 27. Evidence-Informed Interventions. Interventions that use elements or components of evidence- based techniques and are delivered by a qualified individual, who are not certified or credentialed in an EBM. (7-1-26) 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)