VIII. Requirements for Agencies Providing Waiver Activities and Services

A. Applicable Rules and Standards

Both federal and state rules and regulations governing Medicaid programs apply to services/activities 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 and activities.

Rules for Implementing Medicaid-Funded Home and Community-Based Services and Activities

Rule Number	Title	Adult Waiver	Children's Support Waiver	Children's Residential Waiver
89 Ill Adm. Code 140.11 and 140.12	Providers must be enrolled in and eligible to participate in the Illinois Medical Assistance Program	X	X	X
Rule 50 59 Ill. Adm. Code 50	Office of Inspector General (OIG): Investigations of Alleged Abuse or Neglect and Deaths in State-Operated and Community Agency Facilities	x	x	x
Rule 115 59 Ill. Adm. Code 115	Community Integrated Living Arrangements (CILA)	x
Rule 116 59 Ill. Adm. Code 116	Administration of Medication in Community Settings	x		x
Rule 119 59 Ill. Adm. Code 119	Community Day Services (formerly known as Developmental Training)	x
Rule 120 59 Ill. Adm. Code 120	Medicaid Home and Community-Based Services/activities Waiver Program for Individuals with Developmental Disabilities	x	x	x
Rule 240 89 Ill. Adm. Code 240	Community Care Program: governs adult day care providers	x
Rule 370 77 Ill. Adm. Code 370	Community Living Facilities (CLF)	x
Rule 401 (PDF)	Licensing Standards for Child Welfare Agencies			x
Rule 403 (PDF)	Licensing Standards for Group Homes			x
Rule 384 (PDF)	Behavior Treatment in Residential Child Care Facilities			x
Rule 331 (PDF)	Unusual Incidents			x
Rule 385 (PDF)	Background Checks			x
325 ILCS 5	The Abused and Neglected Child Reporting Act (ANCRA) sets forth the requirements for reporting and responding to situations of abuse and neglect against children under the age of 18		x	x
225 ILCS 46/25	Health Care Worker Background Check Act	x	x	x
Rule 104 89 Ill. Adm. Code 104 (PDF)	Practice in Administrative Hearings	x	x	x
210 UKCS 30/6.2	The Abused and Neglected Long Term Care Facilities Reporting Act. The implementing rules are found at 59 Ill. Adm. Code 50 (for incidents that occur on-site at a developmental disabilities-funded community agency) and 59 Ill. Adm. Code 51 (for incidents that occur in private homes or in non-licensed community homes).	x	x	x
320 ILCS 20	Illinois Elder Abuse and Neglect Act. Adult Day Care providers must be in compliance with these provisions.	x	x	x
405 ILCS 5 (PDF)	Mental Health and Developmental Disabilities Code. Prohibits providers from using the following interventions: seclusion (time-out in a locked room); withholding food or drink; electric shock stimuli; punishment or discipline.	x	x	x
740 ILCS 110 (PDF)	Mental Health and Developmental Disabilities Confidentiality Act	x	x	x

B. Additional Agency Standards

Agency Type	Standard
All Agency Types	Meet Medicaid waiver provider enrollment requirements
Adult residential and day programs Child Group Home Agencies ISC Agencies Personal Support Provider Agencies	Follow the Uniform Grants Agreements (UGA) requirements.
Licensed Professionals	Comply with Department of Financial and Professional Regulation applicable regulations.
Medicaid Waiver Enrolled Providers	Ensure entities and individuals who are excluded from participation in the Illinois Medicaid program do not serve as an employee, administrator, operator, or in any other capacity. HFS maintains a list of terminated or suspended providers and barred entities and individuals.

C. General Waiver Provider Requirements

Informing Individuals of Rights
1. Notification of General Waiver Rights
  The ISC must ensure and document the individual and/or guardian, if applicable, have received a complete explanation of their rights and responsibilities at the time-of-service initiation and upon request. The provider agency must maintain documentation of the notifications in the individual record. The ISC may use the Rights of Individuals (PDF) (IL462-1201 Form) or an equivalent signed notification form as along as it includes all the rights contained on the IL462-1201. At this link, you can find an accessible version of the Rights of Individuals in Medicaid Home and Community-Based Services Developmental Disability Waivers(PDF).
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 Independent Service Coordination agency must ensure the individual and/or guardian, if applicable, 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 Independent Service Coordinator (ISC) has provided notification of appeal rights to the individual is acceptable.
  Providers may use the Notice of Individual's Right to Appeal (PDF) (IL462-1202 Form), or an equivalent document in the individual record at the service provider agency that documents specific waiver appeal rights have been explained to the individual and/or guardian, if applicable.
3. Notice of Action
  The ISC must provide the individual applying for or receiving waiver-funded services and/or guardian, if applicable, a written notice of any determination or redetermination that the individual is not or is no longer waiver eligible. The responsible ISC must also provide the individual and/or guardian, if applicable, with a written notice of any termination, exclusion, reduction or suspension of waiver services. Documentation 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.
Confidentiality Requirements
The responsible ISC and service providers, as applicable, must ensure and document the individual and/or guardian, if applicable, has been informed of confidentiality rights and has granted permission to release personal and program information for administrative purposes. The Release of Information (PDF) (IL462-1214 Form), or an equivalent release, may be used to document this permission. This release covers the 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:
1. Be signed by the individual and/or guardian, if applicable.
2. Have both a signature date and a specific termination date that is no more than five years from the signature date.
3. Be renewed so 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 individual and/or guardian, if applicable. 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 (PDF), if applicable, the federal Health Insurance Portability and Accountability Act (PDF) , and must be protected from further disclosure.

The service provider agency must maintain the current Release of Information (PDF) (IL462-1214 Form) in the individual record and other releases, if applicable.