VII. Provider Enrollment and Qualifications

Waiver Provider Enrollment Overview

All waiver agencies, individual providers and companies such as construction and transportation companies and equipment vendors must be enrolled with the Department of Healthcare and Family Services (HFS) as Medicaid Waiver providers to provide services under the HCBS waiver programs and be screened against the federal Health and Human Services excluded provider database. All licensed professionals, behavior analysts and personal support domestic employees must be enrolled individually. All providers must be established as Developmental Disability providers with the Department of Human Services. Establishment requires transmission of provider data in ROCS or through the Fiscal Employer Agent (F/EA). Agencies providing services must work with Division Network staff to determine whether or not they require a formal Service Agreement or contract with the Department. 

Please see Becoming a New Developmental Disabilities Provider for more information.

HFS enrolls all willing and qualified providers. HFS and DHS or the Financial Management Services entity, as authorized under a written agreement with HFS (the Medicaid Agency), maintain the provider agreements.

  1. Licensed Professional Providers

    Division staff check all professional licensure or registration status upon waiver enrollment. The State's Department of Financial and Professional Regulation (DFPR) licenses or registers:

    • Speech/Language Pathologists
    • Occupational Therapists
    • Physical Therapists
    • Clinical Psychologists, Clinical Social Workers, Marriage/Family Therapists, Clinical Professional Counselors
    • Registered Nurses and Practical Nurses

    The Department of Healthcare and Family Services works with DFPR to assure that all licensed professionals are included in the database match between DFPR and the Medicaid Management Information System (MMIS) provider database. The database match is transmitted monthly between HFS and DFPR to verify ongoing provider licensure status. If the match finds that the licensure or registration has expired, the provider is disenrolled and the participant is assisted to find other service providers.

  2. Non-Licensed Providers and Agency Staff

    The State monitors non-licensed and approved providers such as personal support workers and behavior analysts through targeted desk reviews and on-site visits. The Division has specific training requirements for direct support workers who work for community agencies and ongoing continuing education requirements for Qualified Intellectual Disability Professionals (QIDPs), including case managers and Service Facilitators. Direct support workers are trained via a protocol developed by the State or via one approved by the State as comparable.

  3. Child Group Homes (Children's Residential Waiver only)

    The Department of Children and Family Services (DCFS), the State's child protective agency, licenses all community-based agencies providing Child Group Home services, based on regularly scheduled on-site surveys. In addition, DHS will monitor every two years that contractual requirements specified in the Child Group Home contract are met.

    In addition to the information provided in this manual, information regarding provider qualifications and program guidelines is continuously available on the DHS web site. Information specific to Child Group Homes is continuously available on the Department of Children and Family Services web site.

General Provider Enrollment Requirements

Agencies that provide adult residential and day services, ISSA services, Child Group Home services, Home-Based Support Services Service Facilitation and Personal Support must have a DHS contractual service agreement.  Please see Becoming a New Developmental Disability Provider on the Department of Human Services web site. 

Some waiver providers must meet specific requirements and qualifications in addition to general enrollment requirements. You may also find this information by looking at the Becoming a New Developmental Disability Provider web page for additional requirements and qualifications specific to providers by service type.

Criteria for Provider Termination

The HFS Waiver Program Provider Agreement (HFS-1413A) includes the criteria for provider termination from waiver program participation. Examples of criteria for provider termination are:

  • The provider violates any of the terms and conditions of participation in the HFS Waiver Program Provider Agreement (HFS-1413A).
  • The provider no longer meets the Medicaid waiver provider standards applicable for the service, for example, is no longer licensed by the Department of Financial and Professional Regulation or is no longer in compliance with licensure or contractual requirements.
  • The provider is terminated or suspended by the HFS pursuant to 89 Ill. Adm. Code 104 and 140.
  • The provider submits false, duplicate or fraudulent bills.
  • The provider fails to notify the DHS promptly of overpayments of which the provider becomes aware or fails to reimburse the State promptly for any overpayment.
  • The provider does not maintain adequate documentation of actual service delivery to support bills submitted.

For those providers required to sign a contract with the DHS, the DHS contract and contract attachments contain additional criteria for provider termination from program participation. Copies of the DHS contract and attachments are available on the DHS website.

Waiver participants may choose to terminate services from a particular provider at any time regardless of the cause above.