IX. Provider Enrollments and Qualifications

A. Waiver Provider Enrollment Overview

All waiver agencies, individual providers and companies such as construction companies, 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 personal support workers, behavior analysts, and licensed professionals 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 Region 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 F/EA, 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 Department of Healthcare and Family Services works with DFPR to assure 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 the licensure or registration has expired, the provider is disenrolled and the individual is assisted to find other service providers.

  1. 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 provider agency and ISC staff. Direct support workers are trained using a curriculum developed by the State or by using a comparable curriculum approved by the State.

  1. 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 the 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 are continuously available on the DHS website. Information specific to Child Group Homes is continuously available on the Department of Children and Family Services website.

  1. General Provider Enrollment Requirements

Agencies who provide adult residential and day services within the Waiver, ISSA, Child Group Home services, Self-Directed Assistance and Personal Support services must enroll in the IMPACT system as an eligible Medicaid provider. Some Waiver providers must meet specific requirements and qualifications in addition to general enrollment requirements. Please see Becoming a New Developmental Disabilities Provider on the Department of Human Services website to access general and specific requirements and qualifications for enrollment.

B. Criteria for Provider Termination

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

  1. The provider violates any of the terms and conditions of participation in the HFS Waiver Program Provider Agreement (HFS-1413A) PDF.
  2. 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.
  3. The provider is terminated or suspended by the HFS pursuant to 89 Ill. Adm. Code 104 and 140.
  4. The provider submits false, duplicate or fraudulent bills.
  5. The provider fails to notify DHS promptly of overpayments of which the provider becomes aware or fails to reimburse the State promptly for any overpayment.
  6. The provider does not maintain adequate documentation of actual service delivery to support bills submitted.

For those providers required to sign a contract with 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 individuals may choose to terminate services from a particular provider at any time regardless of the cause above.

  1. Termination/Changes in Services

Termination of waiver service authorizations requires Division of Developmental Disabilities approval, and the decision is subject to waiver appeal rights. Providers must inform individuals and/or guardians, if applicable, of their appeal rights and obtain Region staff approval prior to terminating waiver services to an individual. Providers must submit the Service Termination Approval Request (IL462-2028)(PDF) (STAR) to the PAS/ISSA agency when requesting termination of service authorizations.

The Independent Service Coordinator (ISC) reviews and signs its approval of the termination and submits the STAR form 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 within the timeframe specified in the award.
  2. The individual, guardian, if applicable, and/or family submits false information or engages in activity which results in misuse of funds.
  3. The individual, guardian, if applicable, and/or family fails to cooperate with necessary home visits by the ISC or other state-approved monitors.
  4. 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.
  5. The individual is no longer living in Illinois.

If an individual changes the type of waiver service or changes residential providers, the Service Termination Approval Request (IL462-2028)(PDF)) is submitted to the Independent Service Coordinator.

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 (STAR) is not necessary to change day program, home-based support, SDA agency, or therapy provider.

C. Individual's Service Termination

  1. Provider requests for service termination of waiver services to an individual can be recommended by the provider only if there is documentation the basis for termination is in accordance with program rules.

In such situations, termination of services can be recommended only after consultation with the individual, guardian, if applicable, and/or other persons from the individual's support network as the individual and/or guardian, if applicable, chooses and in compliance with appeal rights requirements specified in the waiver Rule 120 59 Ill. Adm. Code 120.

  1. Termination of waiver services to an individual can occur only if:
    1. The ISC has been consulted and concurs. In the event conflicts arise that cannot be resolved among the parties involved, the provider or the ISC shall make a referral to the Department for technical assistance.
    2. The individual and/or guardian, if applicable, has waived or exhausted his or her appeal rights.

If the above criteria are met, the service provider completes and submits a Service Termination Approval Request (IL462-2028)(PDF)) and must submit the STAR form to the ISC.