VI. Provider Requirements

Applicable Rules and Standards

Both federal and state rules and regulations governing Medicaid programs apply to services funded under the Medicaid Home and Community-Based Services (HCBS) Waivers. The table below provides the major rules for implementing Medicaid-funded home and community-based services.

Rules for Implementing Medicaid-Funded Homes and Community-Based Services

Additional Provider Standards

General Waiver Provider Requirements

1. Informing Individuals of Rights

   1. Notification of General Waiver Rights

      The responsible case manager or Service Facilitator must ensure and document that the participant and legal representative have received a complete explanation of their rights and responsibilities at the time of service initiation and upon request.

      The service provider agency providing case management/Service Facilitation must maintain documentation of the notifications in the individual record. Documentation in the service provider's individual file that the Pre-Admission Screening/Individual Service and Support Advocacy (PAS/ISSA) agency has provided explanation of rights and responsibilities to individuals at service initiation as part of the Pre-Admission Screening process (PAS) is acceptable. The responsible case manager or Service Facilitator may use the Rights of Individuals (IL462-1201) form or an equivalent signed notification form as long as it includes all the rights contained on the IL462-1201.

   2. Notification of Waiver Appeal Rights

      The waiver right to appeal applies to eligibility determinations, as well as to denial, suspension, reduction or termination of covered waiver services.

      The Pre-Admission Screening/Individual Service and Support Advocacy (PAS/ISSA) agency and responsible case manager/Service Facilitator must ensure and document that the individual and guardian have received an explanation of the rights and processes of appeal when waiver services are first initiated, upon request and as part of any notice of eligibility or service denial, suspension, reduction or termination. Documentation in the service provider agency's individual file that the PAS/ISSA agency has provided notification of appeal rights to the individual is acceptable.

      Providers may use the Notice of Individual's Right to Appeal  (IL462-1202) form, or an equivalent signed notice as long as it includes all rights to appeal, including the right to appeal to the HFS, to document in the individual record at the service provider agency that specific waiver appeal rights have been explained to the individual and guardian.

   3. Notice of Action

      The PAS/ISSA agency must provide the individual applying for or receiving waiver-funded services, and guardian if one has been appointed, a written notice of any determination or redetermination that the individual is not or is no longer waiver eligible. The responsible case manager/Service Facilitator must also provide the individual or guardian a written notice of any termination, exclusion, reduction or suspension of waiver services. Documentation that the notice of action has been sent must be maintained in the individual record.

      Additional information about the required contents of the notice of action, process for making an appeal, grounds for appeal, time limits, circumstances when services must be continued pending the outcome of the appeal, and the Department of Healthcare and Family Services appeal process are contained in the waiver rule (59 Ill. Adm. Code 120.100 and 120.110).

2. Confidentiality Requirements

   The responsible case manager/Service Facilitator must ensure and document that the individual or legal representative has been informed of confidentiality rights and has granted permission to release personal and program information for administrative purposes. The Release of Information form, or an equivalent release may be used to document this permission. This release covers release of individual information, billing and claiming information and information needed for quality assurance monitoring, audits and waiver claims monitoring, as determined by DHS. 

   The release form must:

   • Be signed by the participant or by the participant's legal representative, if one has been legally appointed.
   • Have both a signature date and a specific termination date.
   • Have a termination date that is no more than five years from the signature date.
   • Be renewed so that there is always a current, valid release.

   If a service provider must disclose confidential information for special purposes other than those directly related to waiver administration, the service provider must obtain specific prior permission from the participant or legal representative. The provider must also inform the persons to whom the provider furnishes the information that this material is confidential, is subject to the provisions of the Mental Health and Developmental Disabilities Confidentiality Act and if applicable, the federal Health Insurance Portability and Accountability Act, and must be protected from further disclosure.

   The service provider agency must maintain the current Release of Information in the individual record, and other releases if applicable.

3. Termination/Changes in Services

   Termination of waiver service authorizations requires Division of Developmental Disabilities approval and the decision is subject to waiver appeal rights. See Section VI.B for more information about appeal rights. Providers must inform individuals and guardians of their appeal rights and obtain Network staff approval prior to terminating waiver services to an individual. Providers must submit the Service Termination Approval Request (STAR) to the PAS/ISSA agency when requesting termination of service authorizations.

   The PAS/ISSA agency reviews and signs its approval of the termination and submits the STAR to the Division for approval.

   Applicable program rules contain criteria for termination of a covered waiver service to an individual.

   Additional criteria are:

   1. The individual was issued an award but did not initiate services with the timeframe specified in the award.
   2. The individual is being transferred to other waiver or non-waiver services, such as residential services, and the individual, guardian and the provider of other services have agreed upon the transfer. The Department may initiate or may request the PAS/ISSA agency to initiate a Service Termination Approval Request (STAR), if necessary, to terminate the waiver services no longer being received.
   3. The individual, guardian or family submits false information or engages in activity that results in misuse of funds.
   4. The individual, guardian or family fails to cooperate with necessary home visits by the responsible case manager or Service Facilitator or by ISSA or other state-approved monitors.
   5. The individual has not used waiver services for nine consecutive months. This requirement may be waived for extenuating circumstances and Division of Developmental Disabilities staff have approved an extension.
   6. The individual is no longer living in Illinois.

   If an individual changes the type of waiver service or changes residential provider, the current provider must submit the Service Termination Approval Request, before the newly requested services can be approved and authorized. For example, for an individual leaving home-based supports (HBS) and moving to CILA, the home-based support services must be terminated officially before CILA services can be authorized and paid.

   Submitting a Service Termination Approval Request is not necessary to change day program, home-based support service facilitation agency or therapy provider.

4. Assistance with Participant Benefits

   1. Medicaid Enrollment

      The PAS/ISSA agency and responsible case manager/Service Facilitator should assist the applicant, guardian or family in completing the forms and compiling the necessary documentation and background information, including the verification of income and assets, to apply for Medicaid and to maintain continuous Medicaid enrollment. The application may either be brought in or mailed to the local DHS Family Community Resource Center (FCRC) office, formerly known as the DPA/DHS local office.

   2. Redetermination of Medicaid Eligibility

      The FCRC caseworker conducts redeterminations of Medicaid eligibility annually or as necessary. Responsible case managers or Service Facilitators and individuals are responsible for ensuring that enrollment is reauthorized in a timely manner. Providers may not be paid for covered waiver services during time periods when the individual's Medicaid enrollment lapses.

      If necessary, providers are also responsible for completing Notice of DHS Community-Based Services  form to document for the DHS FCRC caseworker that the individual initially meets or continues to meet his/her Medicaid spend down obligation.

      For individuals who have spenddown obligations, DHS has developed a file transfer process to document a waiver participant's continuing spenddown met status. In most situations, this file transfer takes the place of the Notice of DHS Community-Based Services (HFS-2653) after the first few months of service. The provider is responsible for completing the HFS-2653 in situations when the automated process does not have necessary information.

   3. Redetermination of Waiver Programmatic Eligibility

      The Medicaid waiver requires an annual redetermination of individual waiver eligibility by the Individual Service and Support Advocate (ISSA), who is a Qualified Intellectual Disability Professional (QIDP) and is independent of the providers of direct services. The redetermination must include a review of all eligibility factors. The purpose of the review is to verify continued eligibility for the Medicaid waivers and to establish continuing need for an ICF/DD level of service.

      The ISSA must document results of the annual redetermination with the Redetermination of Medicaid Adult Waiver Eligibility form. This completed form must be maintained in the Independent Service Coordination agency files, subject to periodic review.

      The ISSA must also enter the annual waiver programmatic eligibility (active treatment) determination and date in the Reporting of Community Services (ROCS) software and transmit it to DHS in a timely manner. DHS will reject payment for ISSA services unless an annual re-determination has been transmitted within the past 12 months.

      The Individual Service and Support Advocacy (ISSA) Guidelines contain specific guidance on these requirements and process.

   4. Food Stamps

      The DHS Family Community Resource Center (FCRC) determines Food Stamp eligibility. The responsible case manager or Service Facilitator should assist the applicant, guardian or family in completing the forms and compiling the necessary documentation and background information, including the verification of income, assets, shelter and medical costs, to apply for Food Stamps and to maintain Food Stamp eligibility.

   5. Notifying DHS of Changes in Participant Status

      The responsible case manager or Service Facilitator must notify the DHS Division of DD and the DHS Family Community Resource Center (FCRC) of the following changes in the individual's status:

      • Change of address: Address changes are done on the client data in ROCS and by telephone/mail to the FCRC.
      • Change in Social Security (SSI/SSDI) benefits or other earned or unearned income:
        • Benefits and income changes must be done on the client income screen in ROCS and by telephone/mail to the FCRC, no later than five calendar days after the change.
        • DHS requires that SSI (SSDI) benefits received by individuals receiving residential services be applied toward the residential costs. Individuals may retain a monthly personal allowance.
      • Death: Notification of death must be done on the Service Termination Approval Request form, on the ROCS client data screen in ROCS and by telephone/mail to the FCRC, no later than five calendar days after the change. Deaths must also be reported to the Office of the Inspector General according to their requirements.

      The responsible case manager or Service Facilitator must also notify the local Social Security Office of changes in address or earned income, of placement into or from a long-term care facility, including Intermediate Care Facility for Developmental Disabilities (ICFDD), state-operated facility and nursing facility, or death. Notification for individuals who receive Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) benefits must be made as soon as possible to facilitate necessary updates or adjustments in the amount of the SSI or SSDI benefit.

      The Notice of DHS Community-Based Services (HFS 2653 form), may be used to notify the local DHS FCRC of changes in the costs of services, types of services or termination of services that affect the amount that may be applied toward the spenddown obligation. Notification of these changes must be made no later than five calendar days after the change.