Presentation & Selection of Service Options
1000.10 Purpose of the DDPAS-10
The purpose of this chapter is to provide guidance on the determination of eligibility for services of the individual assessed; the presentation, choice, and referral process (including notice of the right to appeal); and the necessary documentation on the DDPAS-10 for these processes. The DDPAS-10 provides a summary of the determinations by the PAS agency, the notice of the right to appeal, and documentation of the referral and choice process.
During the presentation and selection of service options for eligible individuals, the PAS agency will ensure that individuals have the opportunities to choose from an array of appropriate service options that foster the development of functional skills, independence, and community integration, and that promote physical health and the development of relationships with family and friends.
1000.15 Individuals Determined Not To Be Eligible For Services
For individuals who are determined not to have a developmental disability (mental retardation or a related condition) or who are determined not to require active treatment for a developmental disability, the appropriate information must be entered on the DDPAS-2, the DDPAS-5, and the DDPAS-10. The DDPAS-10 must be furnished to the individual and legal guardian as a notice of the determination and the notice of the right to appeal.
Agencies must provide to the individual or to the guardian an oral explanation of the agency's final determination and the right to appeal. This explanation must be provided in person, by telephone, or email if the individual and legal guardian requests that medium. The individual and legal guardian must have the opportunity to ask questions and receive answers.
1000.20 Presentation and Selection of Service Categories
- The PAS agency will schedule meetings with the individual or legal guardian to discuss the results of the assessments and the final PAS determinations.
- The presentation and selection meetings must always occur at the convenience of the individual and legal guardian. These meetings may occur in face-to-face meetings, by telephone, or by email if the individual and legal guardian requests and is provided the opportunity to receive answers to questions.
- Only those persons the individual and legal guardian has specifically invited to the meeting will participate.
- The PAS agency will accommodate the individual and legal guardian who does not speak English or speak verbally. The PAS agency will ensure that basic communication equipment and translators are available to those who need them.
- During the meeting, the PAS agency will present determinations regarding whether the individual has a developmental disability (mental retardation or a related condition). If so, the PAS agency will present determinations regarding whether the individual needs 24-hour nursing care and whether the individual needs active treatment for the developmental disability.
These determinations must be substantiated by thorough and complete assessments and must be documented on the appropriate DDPAS forms. If requested, the PAS agency will provide the individual or legal guardian with a copy of all relevant assessments and PAS documents.
- Based on these determinations, the PAS agency will discuss with the individual and legal guardian all the potential service options for which the individual is found to be eligible, according to results of the current PAS.
- The PAS agency will present the individual and legal guardian with all service options that the individual is eligible to receive, regardless of availability.
- The PAS agency may not make recommendations regarding where services and supports must be provided, or by which providers.
- The PAS agency must explain in sufficient detail the service options that the individual is eligible to receive, so that the individual and legal guardian are able to make informed choices.
- The PAS agency must provide the individual and legal guardian with additional information and materials on the service options and facilitate their visits to potential service providers. Site visits may occur during the evening and weekend hours so the individual and legal guardian may meet others in the program and observe activities. The DDPAS-10 will document the referrals made on behalf of the individual, the responses from providers, and the visits and meetings that occur between the individual and legal guardian and prospective providers of services.
- In the event that an individual or legal guardian requires additional time to make a decision, the PAS agency must make periodic contact with the individual and legal guardian to determine if a decision has been reached and if additional information is needed to make a decision.
- The PAS agency's records for the individual must include thorough and complete documentation to substantiate the determinations.
- A copy of the DDPAS-10 must be maintained in the individual's file at the PAS agency's office.
- In the event that an individual and legal guardian, who has court-appointed authority in these matters, want different service options, the legal guardian's decision will supersede the individual's, unless the court intervenes. (Note that guardianship can be, and often is, limited to specific areas). The legal guardian's decision will be considered final, unless the court intervenes.
- An individual who is not under guardianship has the right to make the decision regarding future service options. The individual's decision will be considered binding.
- The signature of the individual or legal guardian represents that the PAS agency has explained each service option and the right to appeal to him/her and that the individual or legal guardian understands all options and the right to appeal.
- The signature of the PAS QIDP represents that the service options and the right to appeal process contained in the DDPAS-10 have been explained to the individual or legal guardian and that the QIDP believes that the individual or legal guardian understands the service options and right to appeal process. A signature by anyone other than the PAS QIDP is invalid.
- If the individual is eligible for Home and Community-Based Services waiver programs, the PAS QIDP must also assist the individual/guardian in completing Choice of Supports and Services (IL462-1238) form.
1000.30 Eligibility Criteria for Service Options
The following represents the eligibility criteria for various service options available throughout Illinois. The PAS agency is only authorized to present to the individual or legal guardian the service options that the individual is eligible to receive. If an individual does not meet the eligibility criteria for a given service, the PAS agency will not present that option to the individual or legal guardian.
If a desired service is not available in a geographic area of the individual's or guardian's choice, the PAS agency shall assist the individual or guardian in working with the providers in that geographic area to develop such services, where feasible, and will inform the individual or guardian of providers in geographic areas that are secondarily preferred, working collaboratively with other PAS agencies in other service areas, as necessary.
Nursing Facility (ICF/SNF) Admission Criteria
- An individual with a developmental disability is appropriate for admission to a nursing facility (ICF/SNF) only if the individual:
- Requires 24-hour nursing care
- Does not need active treatment for a developmental disability, has chosen to retire from active treatment (see Chapter 900 of this manual), or has a categorical need for nursing facility level of care, as described in Section 400.40 of this manual.
- Is not a danger to self or others (as defined in Chapter 1000.40-4 )
- If a person is seeking admission to a nursing facility and will pay for nursing facility services through the use of private funds, the individual can be admitted regardless of the determinations by PAS regarding the need for a nursing facility level of care and the need for active treatment. In such cases, the PAS agency must inform the individual that the individual may proceed with the admission, but must also inform the individual regarding his or her eligibility status under Medicaid.
ICF/DD Admission Criteria
An individual with a developmental disability is appropriate for admission to an ICF/DD if the individual:
- Needs active treatment for a developmental disability
- May or may not require 24 hour nursing care
- Is not a danger to self or others (as defined in Chapter 1000.40-4).
SNF/PED Admission Criteria
An individual is appropriate for admission to a Long-Term Care Facility for individuals under age 22 (commonly known as a Skilled Nursing Facility for Pediatric Residents or SNF/PED) certified as an Intermediate Care Facility for Individuals with Mental Retardation if he or she:
- Is under the age of 22 at the time of admission to the facility, except when the facility's interdisciplinary team has determined that either initial or continued services in the facility are appropriate because of the person's physical and mental functioning status and that the facility has the service resources to meet the needs of the resident.
- Needs 24-hour nursing care.
- Needs active treatment for a developmental disability.
- The facility interdisciplinary team determines that placement shall not constitute a serious danger to the other residents.
Criteria for SODC Admission
- An individual with a developmental disability is appropriate for admission to a State-Operated Developmental Center (SODC) if he/she:
- Needs active treatment for a developmental disability.
- Is determined by the PAS agency to be a danger to self or others. An individual is considered to be a danger to self or others if he or she:
- Needs constant supervision for maladaptive behaviors. An individual is determined to need constant supervision for maladaptive behaviors if his or her recent history (within the past six months) of behavior patterns indicates that there is serious threat to the health or safety of the individual or others related to any of the following behaviors: serious assault or aggression toward others; serious self-injurious behavior; arson or attempted arson; or sexual misconduct.
- Requires inpatient treatment for acute psychiatric care.
- Should the PAS agency determine that an individual requires SODC level of care, the PAS agency must contact the Division of Developmental Disabilities (DDD) Region Facilitator to seek authorization for such an admission. The PAS agency must be prepared to describe all alternative support services attempted without success. The initial steps in the Clinical and Administrative Review Team (CART) process will usually be a necessary preliminary to SODC consideration.
- An admission to an SODC setting should be considered temporary. Once the individual's maladaptive behaviors are stable, the PAS agency must be prepared to link the individual to appropriate community services.
Criteria For Medicaid Waiver Settings (e.g., CILA, Home-Based Support Services, etc.)
An individual is eligible for the above-named Medicaid waiver settings if the person:
- Needs active treatment for a developmental disability.
- Does not require 24-hour nursing care.
- Is not a danger to self or others (as defined in Chapter 1000.40-4).
- Meets the applicable selection criteria listed in section 1000.40 and 1000.45, for the specific service being requested.
- Funding capacity is available within the DDD Waiver.
1000.40 Clinical Eligibility and Eligibility for Funding
Clinical eligibility is determined according to various factors, as outlined in the previous sections of this Chapter.
Eligibility for funding is a separate matter and is established in the following ways:
- For nursing facility and for ICF/DD services, funding eligibility exists through the State Medicaid Plan for all clinically eligible individuals who are Medicaid eligible and who need these services.
- For DD waiver services, funding eligiblity is limited for both children and adults. The number of individuals served is based on the available appropriations. As appropriations are available, individuals are selected for authorization for waiver services from the Prioritization of Urgency of Need for Services (PUNS) database, a database of individuals potentially in need of State-funded developmental disability services within the next five years, maintained by the DHS, DDD. Enrollment on the PUNS database is facilitated by the local PAS agency.
Entrance to the DD Waiver of otherwise eligible applicants is deferred via this process until capacity becomes available as a result of turnover or the appropriation of additional funding by the legislature.
Selection from PUNS is via an automated process that focuses on the individual's needs and the family's circumstances (where applicable).
For adults, the criteria for selection from the PUNS database are based on the priority population criteria below (Section 1000.45). For children, the criteria for selection from PUNS include urgency of need, length of time on the database, and randomness.
1000.45 Priority Population Criteria-Adult Waiver Services
For clinically eligible adults who are seeking funding, the criteria for selection from the PUNS database, using the automated selection process as appropriations become available, are the priority population criteria below. PAS agencies must not submit requests for funding to DDD's central office unless the adult individual fits into one of the following categories for the type of services being requested.
For residential services (e.g., Community Integrated Living Arrangements), in the order of priority:
- Individuals who are in crisis situations (e.g., including, but not limited to, persons who have lost their care givers, persons who are in abusive or neglectful situations).
- Individuals who are wards of the Illinois Department of Children and Family Services and are approaching the age of 22 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 Centers.
- Individuals who reside in private ICFs/MR.
- Individuals with aging care givers.
For support services, (e.g., Home-Based Support Services), the adult individual must not be receiving any support services from DDD or the Division of Rehabilitation Services (except vocational rehabilitation services). Further, the adult individual must fit into one of the following circumstances:
- Individuals whose primary care giver 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 care giver.
If a PAS agency finds that an appropriate priority population criterion does not fit an individual requesting residential services or an individual requesting support services, the PAS agency must inform the individual and guardian in a letter that the PAS agency is not submitting a request for funding "because the individual does not meet priority population guidelines as directed by the Division of Developmental Disabilities."
The letter must also inform the individual and guardian regarding the appeal rights under the waiver, as described in Section 1000.80 Appeal Process. If the family is seeking residential services and if the person is eligible for ICF/DD services, that eligibility should be mentioned in the letter, with an offer to assist in referrals to ICFs/DD if the individual/guardian wishes.
If DDD denies a request for funding for waiver services submitted to it by a PAS agency because DDD believes that the individual does not fall into a priority population category, notice of this denial will be provided through the PAS agency, including information regarding the right to appeal, as described in Section 1000.80 Appeal Process.
1000.50 Presentation and Selection of Specific Providers
Once the individual or guardian expresses an interest in or selects the type of services he or she wishes to receive, the PAS agency must inform the individual and guardian of all providers offering that type of service in the desired geographic area.
PAS agencies will make referrals to those providers selected by the individual or family in order to arrange meetings and site visits. These referrals must be documented on the DDPAS-10. All information required in order for the individual and guardian to make an informed decision must be presented.
Times for visits must accommodate the individual's and guardian's needs and those of the agencies. Reasonable wishes of the individual and guardian for friends, family, and others to accompany them shall be respected. If possible, the individual and guardian may meet prospective house mates.
The PAS agency QIDP will accompany the individual and guardian on the visit.
If the individual and guardian requires additional time in order to make a decision, the PAS agency QIDP will periodically inquire regarding whether a decision has been made and whether additional information is needed.
When a decision has been made and an agreement has been arrived at with a service provider, an initial Individual Service Plan (ISP) will be developed for the individual prior to the initiation of the new service arrangement. The ISP will be a collaborative effort involving the individual/guardian, the PAS QIDP, staff representatives from current and future providers, and any others requested by the individual and guardian.
1000.60 Four Weekly Follow-Up Visits
PAS agencies will perform weekly follow-up visits during the first four weeks after an individual has begun receiving services, for any services arranged as a part of the PAS process. Weekly visits will not be performed for individuals whom PAS agencies have found not eligible for DD services. Weekly visits will also not be performed for individuals for whom the PAS process was not completed, for example, for those who have moved and whose location cannot be identified by the PAS agency or for those who have not responded to the PAS agency during its attempt to complete PAS for the individual.
During the four weekly visits, the PAS agency will monitor the individual's health, safety, general well-being, and satisfaction with services. The PAS agency will monitor whether the individual is receiving the necessary services.
The agency will retain documentation of its visits in its files and will address problematic issues beyond the four weeks if necessary, referring to DDD's central office any problematic issues that do not respond to appropriate intervention at the agency level. For individuals receivig services outside the original PAS agency's service area, the receiving PAS agency shall perform the four weekly visits, unless by mutual agreement the original PAS agency retains this responsibility.
1000.70 Service Coordination After PAS
For individuals for whom the PAS results in services through the DD Home and Community-Based Services Waiver (DD Waiver), the original PAS agency will ensure that PAS information and appropriate service information will be transferred to the appropriate Individual Service and Supports Advocacy (ISSA) provider. ISSA services will provide service coordination functions for the individual until such time as the individual no longer receives DDD Waiver services.
For individuals with developmental disabilities for whom the PAS results in no DD services or results in DD services that are not part of the DD Home and Community- Based Services Waiver, no further ongoing service coordination will be provided, except that temporary needs for service coordination will be handled through Program 500 Independent Service Coordination. If needed, a new PAS may be performed at a later date.
Service coordination activities for members of the Bogard class will be conducted according to guidance from the Department of Human Services.
Individuals discharged from certain Long Term Care facilities will receive monitoring visits under Program 500 Independent Service Coordination in accordance with Discharge, Linkage, and Aftercare regulations.
1000.80 Appeal Process
Among the rights of appeal identified in Rule 120 (Medicaid Home and Community-Based Services Waiver Program for Individuals with developmental disabilities) and the DDD Waiver Manual (with updates) for individuals seeking or receiving DD waiver services, their parents, or their guardians are the following:
- The right to appeal denial of waiver eligibility.
- The right to appeal denial, suspension, reduction, or termination of services.
Individuals, their parents, and their guardians must be informed regarding their appeal rights when an appealable action has been taken. When the appealable action is taken by the PAS agency, the PAS agency must inform the individual, parents, and guardians regarding the basis for the PAS agency's action and inform them of their appeal rights.
When the appealable action is taken by DDD, the PAS agency must inform the individual, parents, and guardians regarding the basis for the action and inform them of their appeal rights.
The following language, or its equivalent, must be provided in the letter:
As your right under the Medicaid Home and Community-Based Services DD Adult Waiver program, the action described in this letter may be appealed. You may appeal this action by contacting your PAS Agency and they will assist you in submitting an appeal packet, along with a written statement from you and/your legal guardian indicating the reason for which you are appealing this action. If you wish to appeal, you and the PAS agency must submit your appealwithin 60 calendar days after you receive this letter to:
Illinois Department of Human Services
Division of Developmental Disabilities
319 E. Madison Street, Suite 3M
Springfield, IL 62701
For denials of eligibility by a PAS agency, the DDPAS-10 documents the PAS agency determination and shall be sent along with the letter from the individual, parent, or guardian. The individual, parent, or legal guardian may contact the DDD PAS agency for assistance in obtaining information about the appeal process. Administrative information on the appeal process is also available in Rule 120, Section 120.110 Appeals and Fair Hearings (59 Illinois Administrative Code 120.110).
1000.90 Reporting of Determinations To DHS
Once the determinations regarding the individual's need for 24-hour nursing and active treatment are completed, per the instructions in this manual, these determinations and the dates they were made must be reported to DDD's central office via the reporting of Community Reporting Services software (ROCS).