II. Participant Eligibility & Waiver Program Enrollment

Individuals applying for waiver services must first qualify for and be enrolled in the Illinois Medicaid program. This section provides information on how providers can confirm an individual's Medicaid eligibility and then provides information about participant enrollment in the waiver programs.

Confirming Participant Medicaid Eligibility

  1. Department of Healthcare and Family Services (HFS) Toll-Free Provider Hotline

    Enrolled service providers and PAS/ISSA agencies may call the HFS Provider hotline during state working hours to verify an individual's Medicaid enrollment. Providers may make up to six inquiries per call. The toll-free number is 1-800-842-1461.  When using the automated system, callers must:

    1. Enter their Medicaid provider identification number. The identification number is generally the 9-digit Federal Employer Identification Number (FEIN) or Social Security Number (SSN) followed by:
      • 100 for Adult Waiver
      • 400 for Children's Support Waiver
      • 700 for Children's Residential Waiver

        (e.g., 123456789100 (FEIN/SSN + 100)).

    2. Enter the individual's Medicaid Recipient Identification Number (RIN) and the month of service for which they need eligibility information.

      Callers who do not know the individual's RIN may talk with a Provider hotline staff member. To confirm eligibility when speaking with a staff member, callers must provide the individual's name, birth date and SSN.

  2. HFS Provider Web Site

    HFS maintains a website, Medical Electronic Data Interchange (MEDI), on which registered users (service providers) may verify an individual's Medicaid eligibility status. The website contains information on how to use the system. First time users should:

    • Click on Getting Started and/or MEDI/IEC training to learn about MEDI, system requirements and user information.
    • Register using your Illinois driver's license number.
    • Click on login after registering and provide the requested information, including your Medicaid provider ID (see above).

    After this one-time registration, users may use MEDI  to verify individual Medicaid enrollment.  Waiver providers cannot use the MEDI system to submit claims or to access remittance advices.

    Note:  The message "Eligible for DHS social services," means the individual is not enrolled in Medicaid. Some individuals have been assigned a Recipient ID Number (RIN) without being enrolled in Medicaid. PAS/ISSA staff, case managers, and Service Facilitators should make every effort to enroll these people in Medicaid.

  3. Medicaid HCBS Waiver Clinical Eligibility Criteria

    A DHS-designated Pre-Admission Screening/Individual Service and Support Advocacy (PAS/ISSA) agency screens applicants for Medicaid HCBS waiver-funded services clinical eligibility and offers an informed choice of services. Please see the Pre-Admission Screening Agency (PAS) Manual.  This manual contains guidance for PAS agencies on clinical eligibility determinations.

    Clinical eligibility criteria, also known as level of care or level of service criteria, for Medicaid HCBS Waiver funding are presented in Table 1. As part of the waiver eligibility determination process, individuals must be evaluated to determine level of service needs.

    Persons within the PAS agencies completing initial level of service evaluations and re-evaluations must be Qualified Intellectual Disabiilty Professionals (QIDP) as defined in Federal ICF/MR Regulations. The QIDPs:

    • Must inform participants and/or their legal representatives, about their options during the level of service determination process.
    • The QIDP presents participants/legal representatives with all service options, including both Waiver and ICF/DD services that the participant is eligible to receive, regardless of availability, in sufficient detail so they are able to make informed choices.
    • QIDPs must accommodate participants/legal representatives who have limited English proficiency or who do not speak verbally.
    • The QIDP is not permitted to make recommendations regarding where services and supports should be provided, or by which provider.
    • The QIDP provides the participants/legal representatives with additional information and materials on the service options they choose to pursue and arranges for and facilitates conversations with potential service providers.
    • For each individual determined eligible for the waiver, the QIDP must complete  Choice of Supports and Services (IL462-1238). This form specifically documents the participant's/legal guardian's decision to choose waiver services as an alternative to ICF/DD services. This form also states that choice of supports and services may be changed in the future and must be signed by the participant/legal representative.
  4. Special Medicaid Eligibility for Children in the Children's Waivers

    Children who are determined clinically eligible for either of the Children's Waivers who are under the age of 19 can apply for Medicaid under special eligibility rules that can waive family income for families who would not otherwise qualify for Medicaid benefits for their child, based on the parent's income.

    The PAS agency that determines clinical eligibility for the Children's Waivers can assist families to apply for Medicaid for their child. For children found clinically eligible for the waivers and for whom funding is authorized, PAS agencies will follow special procedures to help the family apply for Medicaid benefits. This will ensure that the child's Medicaid application is given special handling. Please contact the PAS agency in your area for more information about the Children's Waiver Medicaid application process.

    For young adults determined eligible for the Children's Waiver, the PAS agency will assist the individual to apply for Medicaid benefits as an adult through the local DHS office. Please contact PAS for more information about the Medicaid application for young adults.

  5. Waiver Clinical Eligibility Criteria

    1. Waiver for Adults with Developmental Disabilities

      1. Individuals must be aged eighteen or older.
      2. Individuals must be a resident of Illinois living in Illinois.
      3. Individuals must be enrolled in Medicaid in Illinois.
      4. Individuals must have a developmental disability, either mental retardation or a related condition.
      5. Individuals must be determined disabled according to the provisions of Title II of the Social Security Act, Federal Old-Age, Survivors and Disability Insurance Benefits (42 U.S.C. 421). 
      6. Individuals must be assessed as eligible for Intermediate Care Facility for people with Mental Retardation (ICF/MR) level of care/level of service:

        • Manifested mental retardation before the age of 18, as described in 42 Code of Federal Regulations Chapter IV [10-1-96 edition], Section 483.102(b)(3), or manifested a related condition before the age of 22, as defined in 42 Code of Federal Regulations, Section 435.1009.
        • If a related condition, have substantial functional deficits in three out of six major life areas.
        • Have been determined to need active treatment for the developmental disability, as defined in 42 Code of Federal Regulations Chapter IV [10-1-96 Edition], Section 483.440 [a].

        See the Pre-Admission Screening (PAS) Manual for more complete information regarding these definitions and level of service requirements.

      7. Individuals must not be in need of nursing assessment, monitoring, intervention, and supervision of their condition or needs on a 24-hour basis.
      8. Individuals must not be receiving services in a nursing facility, skilled nursing facility, Intermediate Care Facility for people with Developmental Disabilities (ICF/DD), state-operated facility, skilled nursing facility for pediatrics, hospice facility, sheltered care facility, assisted living facility or hospital. If receiving services in a long term care facility or hospital, be prepared to move to an appropriate setting prior to receiving developmental disability (DD) waiver-funded services.
      9. Individuals must not be receiving services funded through another Medicaid waiver program at the time DD waiver-funded services are authorized.

        This includes the Division of Rehabilitation Services Home Services Program, the Department on Aging Community Care Program, the University of Illinois Division of Specialized Care for Children Technology-Dependent/Medically-Fragile Children's Waiver Program, and the Supportive Living Facility Program (SLF).

        If receiving other waiver services, the participant must terminate the other waiver services and choose the Adult Waiver prior to, and as a condition of, receiving DD waiver services.

      10. The number of individuals served each year will be based on available appropriations. New enrollees will be selected from the Prioritization of Urgency of Need For Services (PUNS) database, a database maintained by the Division of Developmental Disabilities of individuals potentially in need of state-funded DD services within the next five years. The selection criteria will provide for selection of individuals on several bases, including urgency of need, length of time on the database, and randomness.
    2. Children's Support Waiver

      1. Individuals must be between the ages of three and 21.
      2. Individuals must reside at home with their families.
      3. Individuals must be a resident of Illinois living in Illinois.
      4. Individuals must be enrolled in Medicaid in Illinois.
      5. Individuals must have mental retardation or a related condition.
      6. Individuals must be assessed as eligible for ICF/MR level of service: 
        • If a related condition, have substantial functional deficits in three out of six major life areas. 
        • Have been determined to need active treatment for the developmental disability.

          See the PAS Manual for detailed information about level of care/level of service requirements.

      7. Individual must not be a ward of the State.
      8. Individual must not be in need of nursing assessment, monitoring, intervention, and supervision of their condition or needs on a 24-hour basis.
      9. Individual must not be receiving services in a long-term care facility or hospital. If receiving services in a long-term care facility or hospital, be prepared to move to an appropriate setting prior to receiving Developmental Disability waiver-funded services.
      10. Not be receiving services funded through another Medicaid waiver program at the time Developmental Disability waiver-funded services are authorized. This includes the Division of Rehabilitation Services Home Services Program and the University of Illinois, Division of Specialized Care for Children Technology-Dependent/Medically Fragile Children's Waiver Program.

        If receiving other waiver services, the participant must terminate the other waiver services and choose the Children's Support Waiver prior to and as a condition of receiving developmental disabilities waiver services.

        The number of individuals served each year will be based on available appropriations. New enrollees will be selected from the Prioritization of Urgency of Need For Services (PUNS) database, a database maintained by the Division of Developmental Disabilities of individuals potentially in need of state-funded developmental disability services within the next five years. The selection criteria will provide for selection of individuals on several bases, including urgency of need, length of time on the database, and randomness.

    3. Children's Residential Waiver

      1. Individuals must be between the ages of three and 21.
      2. Individual must be a resident of Illinois living in Illinois. 
      3. Individual must be enrolled in Medicaid in Illinois.
      4. Individual must have mental retardation or a related condition.
      5. Individual must be assessed as eligible for ICF/MR level of service:
        • If a related condition, have substantial functional deficits in three out of six major life areas.
        • Have been determined to need active treatment for the developmental disability.

          See the PAS Manual for detailed information about level of care/level of service requirements.

      6. Individual must be in need of children's residential waiver supports.
      7. Individual must not be a ward of the State.
      8. Individual must not be in need of nursing assessment, monitoring, intervention and supervision of their condition or needs on a 24-hour basis.
      9. Individual must not be receiving services in a long-term care facility or hospital. If receiving services in a long-term care facility or hospital, be prepared to move to an appropriate setting prior to receiving DD waiver-funded services.
      10. Not be receiving services funded through another Medicaid waiver program at the time DD waiver-funded services are authorized. This includes the Division of Rehabilitation Services Home Services Program and the University of Illinois Division of Specialized Care for Children Technology-Dependent/Medically Fragile Children's Waiver Program.

        If receiving other waiver services, the participant must terminate the other waiver services and choose the Children's Residential Waiver prior to and as a condition of receiving DD waiver services.

        The number of individuals served each year will be based on available appropriations. New enrollees will be selected from the Prioritization of Urgency of Need For Services (PUNS) database, a database maintained by the Division of Developmental Disabilities of individuals potentially in need of state-funded DD services within the next five years. The selection criteria will provide for selection of individuals on several bases, including urgency of need, length of time on the database and randomness.

  6. Priority HCBS Waiver Enrollment Criteria - Adult Waiver Program

    For residential services, the State gives priority within available waiver capacity to eligible persons according to the following priority population criteria, in priority order, beginning with the most critical need:

    • Individuals who are in crisis situations (e.g., including but not limited to, persons who have lost their caregivers or persons who are in abusive or neglectful situations). 
    • Individuals who are wards of the Department of Children and Family Services and are approaching the age of 18 and individuals who are aging out of children's residential services funded by the Division of Developmental Disabilities. 
    • Individuals who reside in state-operated developmental centers. 
    • Bogard class members, i.e., certain individuals with developmental disabilities who currently reside or previously resided in a nursing facility. 
    • Individuals with mental retardation who reside in state-operated mental health hospitals. 
    • Individuals with aging caregivers 
    • Individuals who reside in private ICF/DDs

    For support services, the Division gives priority within available waiver capacity to eligible persons who have been identified as individuals who are not receiving any support services from the Division or the Division of Rehabilitation Services (except vocational rehabilitation services). Within this population, if requests exceed available capacity, the Division will prioritize: 

    • Individuals whose primary caregiver is age 60 or older, but is not yet in crisis.
    • Individuals who have exited special education within the last five years.
    • Individuals who are living with only one caregiver.
  7. Notification to Providers of Waiver Participant Eligibility

    Sharing of assessment information is essential to the development of a timely and appropriate individual service plan. Sharing of other documentation of PAS actions and determinations is necessary to ensure that participants are made aware of their rights and that all providers are informed about each participant's status. The PAS/ISSA agency must send the following information to the responsible case manager or Service Facilitator when the Waiver Program clinical eligibility determination process is complete and services are being initiated:

    1. Copies of all paper DDPAS forms.
    2. A print-screen of the Presentation and Selection of Service Options (DHS DDPAS 10).
    3. For adults, the Inventory for Client and Agency Planning (ICAP) summary information.
    4. Psychological and other assessments relevant to the service planning process.
    5. Documentation of notification of appeal and other rights, as applicable.
    6. Documentation of informed choice of ICF/DD or waiver services form, Choice of Supports and Services.
  8. Participant Service Termination

    1. Provider requests for service termination of waiver services to an individual can be recommended by the provider only if there is documentation that the basis for termination is in accordance with program rules.

      In such situations, termination of services can be recommended only after consultation with the individual, individual's guardian, and other persons from the individual's support network as the individual or the guardian chooses and in compliance with appeal rights requirements specified in the waiver rule (59 Ill. Adm. Code 120). 

    2. Termination of waiver services to an individual can occur only if:
      1. The ISSA has been consulted and concurs. In the event conflicts arise that cannot be resolved among the parties involved, the provider or the ISSA shall make a referral to the Department for technical assistance.
      2. The individual or guardian has waived or exhausted his or her appeal rights.
    3. If the above criteria are met, the service provider completes a Service Termination Approval Request (STAR) form and sends it to the PAS/ISSA agency for signature.  The PAS/ISSA agency sends this form to the DDD Network staff for approval.