TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER b: ASSISTANCE PROGRAMS
PART 120 MEDICAL ASSISTANCE PROGRAMS
SECTION 120.530 HOME AND COMMUNITY BASED SERVICES WAIVERS FOR MEDICALLY FRAGILE, TECHNOLOGY DEPENDENT, DISABLED PERSONS
Section 120.530 Home and Community Based Services Waivers for Medically Fragile, Technology Dependent, Disabled Persons
a) The Department shall administer a home and community-based service (HCBS) waiver program as set forth in Sections 5-2(7) and 5-2.05(a) of the Public Aid Code [305 ILCS 5] and pursuant to Section 1915(c) of the Social Security Act (42 USC 1396n(c)) for disabled persons who are medically fragile and technology dependent.
b) A determination must be made that, except for the provision of in-home care, these individuals would require the level of care provided in a hospital or a skilled nursing facility.
c) The Division of Specialized Care for Children (DSCC) shall perform operational functions under the HCBS waiver program pursuant to an interagency agreement with the Department.
d) In addition to being eligible for all of the services set forth in 89 Ill. Adm. Code 140.3, individuals covered under the HCBS waiver are eligible for the following waiver services:
1) Respite care;
2) Environmental modifications;
3) Special medical supplies and equipment;
4) Medically supervised day care;
5) Family and nurse training; and
6) Maintenance counseling.
e) The Department shall determine eligibility. An individual meeting the following criteria shall qualify:
l) The individual is younger than 21 years of age or was a waiver participant the day before turning 21 years of age;
2) The individual is disabled as defined in Section 120.314;
3) The individual scores a minimum of 50 points on the level of care screening described in subsection (h);
4) The estimated cost of the individual's in-home care to be paid by the State shall not be greater than the institutional level of care appropriate to the individual's medical needs (hospital or skilled nursing facility), as determined by the Department:
A) if the appropriate comparable institutional level of care for a ventilator dependent individual is a hospital, the greater of:
i) 125 percent of the Statewide average per diem expenditure for hospital care for the previous fiscal year; or
ii) 100 percent of the average per diem expenditure provided in the hospital from which the individual was placed; or
B) if the appropriate comparable institutional level of care for a non-ventilator dependent individual is a hospital, 125 percent of the Statewide average per diem expenditure for hospital care in the previous fiscal year; or
C) if the appropriate comparable institutional level of care for the individual is a skilled nursing facility:
i) the per diem rate of the geographically closest skilled nursing facility meeting the individual's medical needs; or
ii) if the individual requires exceptional care services the per diem rate will be a blended rate based on the private pay rate for the geographically closest skilled nursing facility meeting the individual's medical needs and the Statewide average rate for medical assistance clients requiring a similar level of care;
5) For children under 21 years of age, the individual would be eligible for Medicaid if his or her responsible relative's income and resources were excluded from consideration; and
6) A written plan of care has been developed and approved pursuant to subsection (f).
f) Plan of Care
1) The Department shall determine the home and community-based services based on a written plan of care developed in consultation with the individual's family or guardian, attending physician and DSCC care coordinator.
2) At a minimum, the plan of care shall identify an appropriate primary residence, describe the medical and other services to be furnished, the frequency of the services, the type of provider required to render the service and a description of the family's or guardian's active participation, to the fullest extent possible, as caregivers in meeting the individual's medical needs.
3) The Department may, in its discretion, approve a cost-effective alternative to services in the plan of care, as long as the alternative services meet the medical needs of the individual.
4) When determining the hours of care necessary to maintain the individual at home, consideration shall be given to the availability of other services, including direct care provided by nonpaid caregivers, such as, but not limited to, the individual's family or guardian, that can reasonably be expected to meet the medical needs of the individual.
5) The Department will review the individual's plan of care to determine continued eligibility for participation in the waiver on the following schedule:
A) During the first 18 months of participation in the waiver, a review will be performed every six months.
B) After the first 18 months, a review will be performed every six months and, depending upon the individual's medical condition, the plan of care may be approved for a period not to exceed 12 months.
C) Based on the results of the Department's review, a new plan of care may be developed if warranted by a change in the individual's need for medical services or a change in the individual's home environment.
g) Eligibility Denials or Terminations
1) An individual shall not be determined eligible for coverage under the waiver if:
A) The individual requires institutionalization solely because of a severe mental or developmental impairment.
B) The individual does not meet the minimum score required under subsection (e)(3).
2) Termination of coverage under the waiver shall be initiated upon the occurrence of any of the following events:
A) Failure of a family or guardian to cooperate with the Department, DSCC, or service providers in implementing a plan of care, if the Department determines that, as a result of that noncooperation, a plan of care cannot be implemented or the health and well being of the individual could be jeopardized.
B) Upon renewal for continued participation in the waiver, the individual does not meet the minimum score required under subsection (e)(3).
C) The individual does not require at least one of the services described under subsection (d).
3) A transition period of no more than 60 days, during which the individual will continue to receive services through the waiver, will be provided on terminations resulting from subsections (g)(2)(B) and (C).
h) DSCC shall perform a level of care screening for the waiver as follows:
1) The level of care screening will be performed using a Department approved screening tool.
2) The level of care screening will be performed as follows:
A) On all new requests for admission to the waiver;
B) On all renewals for continued participation in the waiver; and
C) Whenever there is a significant change in the participant's status or care needs.
3) The level of care screening will consist of the following elements:
A) Technology needs will be screened to determine the risk of disability or death if the technology is lost, as well as the degree of skill for assessment and judgment needed to operate the technology; and
B) Medical fragility will be screened to determine the frequency and need for skilled care.
(Source: Amended at 41 Ill. Reg. 3279, effective March 8, 2017)