TITLE 89: SOCIAL SERVICES
CHAPTER II: DEPARTMENT ON AGING
PART 240 COMMUNITY CARE PROGRAM
SECTION 240.1520 PROVIDER RESPONSIBILITIES
Section 240.1520 Provider Responsibilities
a) CCP services shall be purchased only from providers certified by the Department to provide those services.
b) Providers shall carry general liability insurance in the single limit minimum amount of $1,000,000 per occurrence, $3,000,000 in the aggregate.
c) Providers shall also carry the following insurance coverages:
1) worker's compensation for direct service staff;
2) volunteer protection equivalent to employees' coverage, including coverage for volunteer drivers/escorts; and
3) motor vehicle liability, uninsured motorist and medical payments, if agency staff transport clients in agency vehicles, or proof of minimum motor vehicle liability, uninsured motorist and medical payments, if agency staff transport clients in the staffs' own vehicles.
d) The policies or current letters documenting all provider agency insurance coverage and policies or current letters documenting staff coverage specified in subsection (b) or (c) shall be available to the Department upon request.
e) All providers of CCP services must comply with all applicable local, State and federal statutes, rules and regulations.
f) A provider shall provide services to all CCP clients referred by the Case Coordination Unit (CCU), with the following exceptions:
1) The Plan of Care is determined to be inappropriate in the professional judgement of the provider.
A) The provider shall immediately notify the CCU of the provider's assessment and evaluation of the situation.
B) The provider and the CCU shall work together to determine if a Plan of Care that adequately meets the client's needs can be developed.
C) In the event the provider and the CCU cannot reach an agreement, the Department shall be contacted and shall determine the final resolution.
2) The provider is unable to accept all CCP referrals.
A) The provider shall request a cap on the number of clients to be served (service cap), in writing, to the Department.
B) The Department will not approve a service cap for a provider that is the only provider of in-home service in the service area or when it is not in the best interest of the program.
C) Upon approval of the request, the provider assumes responsibility for managing intake to maintain the cap.
g) Any temporary change or deviation from the Plan of Care must be documented by the provider in the client's file. A provider shall not deviate from the client's Plan of Care without receipt of verbal (followed up, within 2 working days, with written instruction to be placed in the client's file) or written instruction from the Department or the CCU, except in cases of emergency, client refusal of service or client failure to be home to receive service.
h) It shall be the responsibility of the provider to advise the CCU of any change in the client's physical/mental/environmental needs that the provider, through the direct service worker/supervisor, has observed, when the change would affect the client's eligibility or service level or would necessitate a change in the Plan of Care.
i) All providers shall reply to requests by a client, by telephone or in writing, within 15 calendar days from the date of the request. The request and the response shall be documented in the client's file.
j) Providers shall electronically submit a Vendor Request for Payment (VRFP) that shall be received by the Department no later than the 15th day of the month following the month in which services were provided. The VRFP shall state the number of units of service provided to each identified client during the service month.
1) Service Provided Prior to July 1, 2010:
Reimbursement to the provider by the Department will be adjusted by calculating and deducting the client's incurred expense for care based upon the fixed fee share rate. Providers shall bill the Department for service rendered to clients in increments of full or one-half units only.
2) Service Provided On and After July 1, 2010:
Providers shall be reimbursed by the Department for the entire rate for each unit of service. There is no longer a deduction for the client's incurred expense for care. Providers shall bill the Department for service rendered to clients in increments of quarter units.
k) Client Incurred Expenses for Service Provided Prior to July 1, 2010
1) The provider shall be responsible for the collection from the client of the client incurred expense for care provided to the client in the following manner:
A) The billing shall be based, for each client, upon the units of service provided and the fixed fee share rate for the client's incurred expense for care as described in Section 240.870.
B) The provider must bill the client within 60 calendar days after the month in which the service was rendered.
C) A provider who fails to bill the client within 60 calendar days shall forfeit the right to collect the incurred expense for care. The client shall not be required to pay the expense and client services shall not be discontinued for failure to pay.
2) Providers shall not require clients to pay a greater share of the cost of services prescribed in the Plan of Care than required by the Client Agreement.
3) If a client requests additional service from the provider other than that allowed by the Client Agreement, the Department will not be billed for those additional units of service.
4) Providers may accept partial or full payment from a third party for a client's incurred expense. However, the liability for the proportionate share, if third party payment is not received, remains with the client as indicated by the expense for care agreement executed by the client and included as an integral part of the Client Agreement.
5) Providers have the option of not billing a client for the incurred expense for care. The client must be notified in advance if billing resumes.
6) Providers shall respond verbally or in writing to the client on any question presented to the provider, either verbally or in writing, regarding the validity of a billing. If the question is not resolved to the satisfaction of the client, the provider shall advise the client of his/her right to appeal the question, and the provider shall assist the client in filing an appeal if requested or needed. The provider shall also advise the client that non-payment shall result in discontinuance of CCP services. Providers may not discontinue services until authorized to do so by the CCU (refer to Section 240.935 of this Part).
7) The provider shall advise the CCU of any failure by a client to pay a monthly bill rendered by the provider for services provided to the client for more than 30 calendar days from the date of the initial monthly billing. The provider may request the CCU to discontinue service to the client in default as stated above (refer to Sections 240.875 and 240.935 of this Part).
8) If the client makes payment to the provider for incurred monthly expense that has already been reimbursed to the provider by the Department, the provider shall reimburse the Department within 30 calendar days from the date of receipt of payment from the client.
l) Providers shall provide the Department with an annual audit report to be completed by an independent Certified Public Accountant and in accordance with 74 Ill. Adm. Code 420.Subpart D. The audit report shall be filed at the offices of the Illinois Department on Aging, 421 East Capitol Avenue, #100, Springfield, Illinois 62701-1789, within 6 months from the date of the close of the provider's business fiscal year.
m) Providers must accept all correspondence from the Department. Failure to do so may lead to contract action (refer to Section 240.1665).
1) Providers must maintain records for administration, audit, budgeting, evaluation, operation and planning efforts by the Department in offering CCP services, including:
A) records of all CCP referrals to the provider, including the disposition of each referral;
B) client records, which shall include, but are not limited to, applicable forms as required by the Department;
C) administrative records, including:
i) data used by the Department to provide information to the public;
ii) service utilization;
iii) complaint resolution; and
iv) billing and payment information, plus the underlying documentation to support the units of service submitted to the Department for reimbursement.
2) These records shall be available at all times to the Department, the Illinois Department of Healthcare and Family Service (HFS), the U.S. Department of Health and Human Services (HHS), and/or any designees, and shall be maintained for a period of at least 6 years from the termination date of the Provider Agreement. Any records being maintained under this subsection (n) by a provider who ceases to provide the agreed services shall be transmitted in accordance with Subpart K.
o) Providers must notify the Department within 7 days after any change in agency information (e.g., acquisition, assignment, consolidation, merger, sale of assets, transfer, etc.) or contact information (e.g., address, telephone, fax, email address, contact person, authorized representative, etc.).
1) Providers must notify the Department at least 30 days in advance of any relocation of their administrative office.
2) Providers must submit documentation of changes in provider name, corporate structure and/or Federal Employer Identification Number to the Office of General Counsel. This documentation shall be reviewed to determine if an assignment of the Provider Agreement has occurred (see Section 240.1607(k)).
p) Providers must conduct criminal background checks, as required by the Illinois Healthcare Worker Background Check Act [225 ILCS 46], and check the HHS exclusion database and the HFS Office of Inspector General database on all agency staff and all regularly scheduled volunteers having access to financial information or one-on-one contact with CCP clients.
1) Provider agencies shall comply with the requirements of the Health Care Worker Background Check Act.
2) Staff refusing to submit to a background check shall not have contact with CCP clients in any capacity.
(Source: Amended at 35 Ill. Reg. 8919, effective June 2, 2011)