Converting Bed Hold to Occupancy Factor

Illinois Department of Human Services 

Information Bulletin

Division of Developmental Disabilities 

DD.21.026 FINAL

NOTE: This Information Bulletin only applies to 60D (24-Hour and Host Family) CILA providers.

Purpose:

Guidehouse, as part of the rate study, recommended the Division replace its current bed hold policy with an occupancy factor. Administratively, bed hold requires additional steps for tracking and ensuring these are properly identified and billed along with normal per diem reimbursement amounts. Financially, these days are not billable to Medicaid and must be covered entirely by State funds. By eliminating bed holds and using occupancy rate factors to account for the costs to providers associated with reserved bed capacity, the Division can include these expenses as indirect costs submitted for FFP, offsetting costs borne entirely by State funds.

As a result of this recommendation the Division will be including a 5% Occupancy Factor in all 24-Hour and Host Family CILA rates. The Occupancy Factor is paid for every day a person is billed as "Present". Providers will still be required to report individual absences. The Bed Hold Extension request process will no longer exist for 60D CILA clients.

Note: Providers cannot restrict individual's activities outside of the residential setting based on the implementation of the occupancy factor. Individuals must continue to be encouraged and supported to go overnight on family and friend visits.

Setting the Occupancy Factor:

Guidehouse made some general assumptions in the development of waiver service rate methodologies which include Staff Wages, Employment Related Expenses (ERE), Productivity Factors, Occupancy and Absences, Supervision, Administrative Expenses and Program Support Expenses. For residential services, Guidehouse also included Program Costs, Room and Board Costs, Transportation Costs and Administration Costs as part of the rate methodology.

In order to cover a provider's projected cost, the rate includes an occupancy factor to incorporate revenue lost to absences into the rate for expected billed units. A rate that includes an occupancy factor is more responsive to the actual relationship between provider revenue and costs.

The reimbursement for 24-Hour and Host Family CILA supports are paid on a per-diem basis for days the person is served. Likewise, providers are not paid for non-attendance days. The CILA Rate Methodology for 24-Hour and Host Family CILA supports assume a customer is receiving services from the CILA provider 19 hours per day, Monday through Friday, and up to 24 hours per day on weekends, 13 holidays and 10 other days the person may not attend a day program. The annual funding is averaged for an equal per-diem rate paid to the CILA provider regardless of what day of the week the CILA supports are delivered. Community Day Services (CDS), Supported Employment and/or Enhanced Residential (At-Home Day) account for the other 5 hours of the day during the week.

The Division conducted a review of the utilization of bed hold days for Fiscal Years (FYs) 19 and 20. In both FYs, the total program percentage of bed hold usage was 3.7%. The Division increased the total per diem by 5% as the Occupancy Factor, which is higher than the reported past usage. This means that every individual's individual per-diem rate will increase 5% to offset the potential days they may be away.

Billing Process:

Definitions:

Absence: When an individual is absent from the residential setting from midnight to midnight (24 hours). If the individual is present for part of the day, they would not be considered absent for billing purposes.

Absence Codes:

  • Absence Code "A" (Absent) - this code is to be used when the person is out of the home and the reason for the absence doesn't fit any of the other Absence Code definitions (midnight to midnight).
  • Absence Code "C" (Convalescent Care) - this code is to be used when a person is in a nursing facility for the entire day (midnight to midnight).
  • Absence Code "F" (Family or Friends home visit or vacation) - this code is to be used when a person is out of the home with family or friends on a home visit for the entire day (midnight to midnight). This code should also be used when the person is on vacation for the entire day (midnight to midnight).
  • Absence Code "H" (Hospitalization) - this code is to be used when a person is in the hospital for the entire day (midnight to midnight).
  • Absence Code "I" (Incarceration) - this code is to be used when a person is confined to jail or imprisonment for the entire day (midnight to midnight).
  • Absence Code "S" (State Operated Facility or Short-Term Stabilization Home) - this code is to be used when a person is in a State Operated Developmental Center or a Short-Term Stabilization Home for the entire day (midnight to midnight).

Process:

When an individual is present at the residential setting the service provider should report the individual as present with a "P" bill code.

When an individual is absent for the entire day (midnight to midnight) the residential provider should report the appropriate Absence Code for the individual.

  • Example: an individual is at home with their mother and father from Friday at 3 pm to Sunday at 5 pm. The provider would bill "P" for Friday and Sunday and "F" for Saturday.
  • Example: an individual goes to the hospital on Tuesday at 2 am. They return to their CILA on Saturday at 5 pm. The agency would bill "P" for Tuesday and Saturday. They would bill "H" for Wednesday, Thursday and Friday.

A residential provider should not bill "P" if the individual is temporarily visiting a residential setting but is residing elsewhere.

  • Example: an individual is at home with their mother and father from Friday at 3 pm to Sunday at 5 pm. They come back to the residential setting to pick up medications or for a couple hours to attend a birthday party on Saturday but then return to the parent's home. The provider would bill "P" for Friday and Sunday and "F" for Saturday.

When an individual is returning to the CILA from an extended absence, the CILA provider should bill "P" only when the CILA staff are providing care and there's an intent for the individual to remain at the CILA going forward.

  • Note: if an individual returns to the CILA from an extended absence due to a hospital stay, and then the individual must return to the hospital in the same day because their health quickly declined, the CILA provider can bill "P" as long as the intent was for the individual to remain at the CILA before their health declined and they needed to return to the hospital.
  • Example: an individual returns to the CILA from an extended absence due to a convalescent stay on Monday at 5pm. They return to the hospital at 11pm that night as their health quickly declined. The provider would bill "P" for Monday despite returning to the hospital because the intent was for the individual to remain at the CILA before their health declined and they needed to return to the hospital.

If an individual is absent from the residential site (for a vacation, outing, etc.) and the CILA provider is providing staff and a service to the individual for the same amount of service they would be providing at the CILA site, the provider can bill "P". If, however, the individual is at an overnight camp, for instance, and the camp staff is providing the service and CILA staff visit to check on them, they should not bill "P".

Further Notes on Occupancy Factors

  • The occupancy factor of 5% translates to 18.5 days absent from the CILA per year. This means that each individual receives an additional 5% on their funding to account for the assumption they will not be present at the CILA 18.5 days per year.
  • When reviewing the impact of any individual absence from a 24 Hour or Host Family CILA the CILA agency should consider the following:
    • How many absences others who reside in the home had over the course of the year.
      • For example: You have a 4 person CILA. The occupancy factor calculates 4 individuals each get 18.5 days away from the CILA for a total of 74 days. If 1 person is gone for 60 days but none of the others miss a day, the CILA agency is still on the positive side of the occupancy factor.
    • The lifetime of the person at the CILA needs to be considered too. This consideration will become more realized over the long term.
      • For example: A person has resided at the CILA for 3 years thus accumulating 55.5 total days of occupancy factor (18.5 days x 3 years). They're absent 2 days each the first 2 years thus giving them 51.5 days for an extended absence the third year before the CILA is on the negative side of the occupancy factor.
    • Finally, the overall organizational impact should also be taken into account.
      • For example: the CILA agency serves 100 people which equates to 1,850 total days of occupancy factor (18.5 days x 100 people). If 5 individuals use 90 days (450 days), 10 individuals use 50 days (500 days), 20 individuals are never absent (0 days), 35 individuals use 10 days (350 days) and 30 individuals use 18 days (540 days) the CILA agency is still on the positive side of the occupancy factor.
  • At this time, there are no exceptions to the occupancy factor to include long term hospitalizations, placements in Short Term Stabilization Homes, rehabilitation stays in long term care facilities, etc. The Division will review the occupancy factor from time to time to determine if the 5% continues to be an appropriate occupancy factor.
  • A provider's decision to issue discharge to an individual who has had excessive absences in a fiscal year is a decision only the provider can make. The individual, however, must be afforded appeal rights. The division suggests that a provider consider the total absences at the residential setting and the entire time the individual has resided at the CILA site and with the agency.

If you have any questions regarding these changes, please feel free to reach out to Derek Hedges at Derek.Hedges@Illinois.gov.

Effective Date:

January 1, 2022