Occupancy Factor and Medical Absence Payment

Illinois Department of Human Services

Division of Developmental Disabilities

DD.25.006

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

Purpose:

This Information Bulletin (IB) replaces IB DD.21.026. Beginning January 1, 2022, the Division replaced the former bed hold policies and payments with an Occupancy Factor as a part of the Guidehouse Rate Study recommendations. Beginning January 1, 2025, the Division is modifying the Occupancy Factor by adding additional payments for Medical Absences using some Absence Codes. Policy governing Occupancy Factor as stated in DD.21.026 was effective January 2, 2022 - December 31, 2024. This information bulletin includes additional information to address Medical Absence Payments required in state statute (210 ILCS 135/13.3) beginning January 1, 2025.

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 claimable for Federal Financial Participation (FFP) 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 customers.

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.

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 (HF 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 HF 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.

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 (SODC) or a Short-Term Stabilization Home for the entire day (midnight to midnight).

Medical Absence: A situation in which a resident is temporarily absent from a community-integrated living arrangement to receive medical treatment or for other reasons that have been recommended by third-party medical personnel, including, but not limited to, hospitalizations, placements in short-term stabilization homes or State-operated facilities, stays in nursing facilities, rehabilitation in long-term care facilities, or other absences for legitimate medical reasons. Medical Absence Codes Include any combination of Absence Code "C", Absence Code "H", and Absence Code "S".

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 considered.
      • 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.
  • During the effective period of the original implementation of the Occupancy Factor (January 1, 2022, through December 31, 2024), there were 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, including monitoring its impact on providers and updating Absence Codes, as needed.
  • 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.
  • An individual's termination date is their last day present in the CILA. If an individual terminates with "paid" Absence Code days after their last day present, the payment system will recoup any paid Absence Code days after the individual's termination date.
  • The individual's last day reported present will be their day of termination and the last day paid for the individual.

Adding Payments for Medical Absences Days beyond the Occupancy Factor:

  • Beginning January 1, 2025, the Division is incorporating the payment of up to 20 cumulative days in a State Fiscal Year (SFY) for Medical Absences which include Absence Codes: C, H, and S, as defined above, for 24 Hour and Host Family CILA in addition to the 18 days already funded through the Occupancy Factor.
  • The State Fiscal Year (SFY) is defined as beginning July 1, CCYY and ending June 30, CCYY.
  • In SFY 2025 and with this change going into effect January 1, 2025, the SFY for 2025 is defined as January 1, 2025, through June 30, 2025. Therefore, any Absence Codes between July 1, 2024, through December 31, 2024, cannot be counted or credited toward this change.
  • The "counters" for recording days reported with Absence Codes automatically reset at the beginning of the next SFY (July 1).
  • The first 18 days reported with the Absence Codes C, F, H, I, or S, in a SFY are counted as part of the Occupancy Factor.
  • Any day reported with the Absence Code A is excluded from all counted days.
  • After any Absence code has been billed for 18 days in the SFY, a Medical Absence code can be billed for the next 20 days in the SFY. The provider will be paid their per diem rate (daily rate minus offsets) for those Medical Absences.
  • The payment system has been programmed to count and pay up to 20 days in a SFY (after the 18 days of Occupancy Factor have been used) with reported Absence Codes C, H, or S.
  • For the Medical Absence payment process, paid days with appropriate Medical Absence Codes are paid at the individual's normal per-diem CILA rate after an applicable Third-Party Liability (TPL) payment is deducted from the Top-Line Rate.
  • Billed Occupancy Factor and Medical Absence code days are accumulated on a cumulative basis. Medical Absence code days are counted accordingly to pay up to 20 days in a SFY.
  • After the individual has been absent for the 18 days of Occupancy Factor and they've been absent for 20 days of Medical Absence, no further payments will be issued within the current SFY for any additional absence codes.
  • Since they are already included in the Occupancy Factor calculation, reported Absence Codes A, F, or I are not paid through this process under any circumstances.
  • MOBIUS Reports have been modified to inform providers of unpaid and paid days reported with applicable Absence Codes.
  • It is each CILA agency's responsibility to track and account for all paid and unpaid days reported with Absence Codes for each individual whom they serve.

If you have any questions regarding Occupancy Factor and Medical Absence Payment Information Bulletin, please email DHS.DDDComments@illinois.gov.

Effective Dates:

  • Occupancy Factor: January 1, 2022
  • Federal CMS Waiver Amendment Approval: December 19, 2024
  • Medical Absence Payments: January 1, 2025