TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER d: MEDICAL PROGRAMS
PART 140 MEDICAL PAYMENT
SECTION 140.648 DETERMINATION OF THE AMOUNT OF REIMBURSEMENT FOR DEVELOPMENTAL TRAINING (DT) PROGRAMS
Section 140.648 Determination of the Amount of Reimbursement for Developmental Training (DT) Programs
a) A DT program which is certified by the Department of Mental Health and Developmental Disabilities (DMHDD), shall be reimbursed for active treatment services delivered on or after January 1, 1990, to eligible participants.
b) The total rate shall be comprised of a Program Component and an Agency Component. Reimbursement levels for the Program Component shall be derived from four determinants which, in combination, shall result in the total Program per diem amount. The four determinants will be reviewed and validated according to information provided in the most recent Inspection of Care (IOC) conducted by Department surveillance staff in a long term care (LTC) facility (nursing facility or ICF/MR). Where dollar, wage or salary amounts are used, respective amounts shall be inflated to the fiscal year for which reimbursement shall be made.
c) Program Component. The four determinants which result in the total Program Component per diem are:
1) Direct Services – DT agencies shall be in compliance with the Health Care Financing Administration's (HCFA) minimum average daily staffing standards (42 CFR 442.430 (1990)) relative to client population according to each individual's overall leval of functioning. In order to meet and exceed the staffing standards set by HCFA and to assure adequate reimbursement for the delivery of active treatment service, the Department shall base reimbursement for direct service staff at the following per shift ratios:
A) Determination of levels of functioning of clients with mental retardation and related conditions, in accordance with the definition of the American Association of Mental Retardation (mental retardation refers to significantly subaverage general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period), shall include both:
i) an assessment of intellectual functioning as measured by a standardized, full scale, individual intelligence test such as the Stanford Binet and WAIS-R. Such an assessment shall be administered by a psychologist who is registered in Illinois under the Illinois Psychological Act (Illinois Department of Professional Regulation); and
ii) an assessment of adaptive behaviors using a national standardized, Department approved assessment instrument, such as the Scales of Independent Behavior (SIB), or the Inventory for Client and Agency Planning (ICAP). Such an assessment instrument shall be utilized by at least one Qualified Mental Retardation Professional (QMRP) (89 Ill. Adm. Code 144.275(b)(1) and 42 CFR 483.430 (1989) to evaluate each client's functional skills and adaptive behaviors. The Scales of Independent Behavior and the Inventory for Client and Agency Planning are published by, and available from, DLM Teaching Resources, 1 DLM Park, Allen, Texas 75002 (1-800-527-4747). The 1986 edition is incorporated and no later amendments or editions are included.
iii) The final determination of each client's overall level of functioning employs both the assessment of intellectual functioning and the assessment of adaptive behaviors, and will be made according to the criteria set forth in 89 Ill. Adm. Code 144.Table D and 144.Table E.
B) Reimbursement for direct services is calculated by: determining the number of clients within each level of mental retardation; dividing each number by the client component of the staff: client ratio; summing these quotients; multiplying the sum by the aide hourly wage factor and then by 2080 (52 weeks times 40 hours per week); then multiply by 1.08 (vacation and sick time factor) to obtain a total annual direct service cost; and dividing this total by the annual client days to obtain the amount for direct services per client per day. For the calculation method and an example, see 89 Ill. Adm. Code 144.275(a)(1)(C)(i)
2) Qualified Mental Retardation Professional – The supervisor of active treatment services in the developmental training environmental is the QMRP. To determine the reimbursement amount for QMRP supervisory staff, assume that a full-time QMRP is required for every 30 individuals who are certified for ICF/MR services. Reimbursement for QMRP services is calculated as follows: the number of QMRPs shall be obtained by dividing the number of clients in the DT program by 30; the obtained number of QMRPs is multiplied by the hourly wage factor and then by 2080 (52 weeks times 40 hours per week); and then multiply by 1.08 (vacation and sick time factor); the product is divided by the annual client days.
3) Specialized Care – An amount shall be paid for clients who are in need of Specialized Care for Behavior Development Programs and/or Health and Sensory Disabilities. Complete descriptions of Specialized Care are found in Sections 144.125 and 144.150. Identification and validation of an individual's need for either or both categories of Specialized Care will be made during the annual IOC of the LTC facility where the individual resides.
A) In each category of Specialized Care, there are three levels of services. The service level for each client meeting the criteria of more than one service level in a category of Specialized Care shall be determined according to the one level which shall result in the greatest reimbursement amount. Reimbursement for the three levels is determined on the basis of:
i) Level I – .50 hours of Direct Service per service day.
ii) Level II – 1.0 hours of Direct Service per service day.
iii) Level III – 2.0 hours of Direct Service per service day. Reimbursement for clients who qualify for Level III in the category of Health and Sensory Disabilities is also made for 3.0 hours of licensed nurse time, at a ratio of 1:30 per service day.
B) The reimbursement amount for Specialized Care is determined according to the calculation method in subsection (c)(1)(B) above.
4) Related Program Costs – These costs include program materials, equipment, consultants and similar items necessary for the individual's DT program. The amount paid per client per day is determined as follows: Add the amounts calculated for Direct Services, QMRP and Specialized Care, and multiply this sum by the Developmental Training Regional Adjuster. The Regional Adjuster for DT programs in Health Service Areas (HSA) 6, 7 and 8 is 1.2; for all other HSAs, the Regional Adjuster is 1.0. The product is then multiplied by .10.
5) Total Program Component Per Diem – The total Program Component rate shall be the sum of the amounts for the four determinants (see subsection (c)(1), (2), (3) and (4)).
d) Agency Component
The Agency Component per diem will be a flat rate for costs of capital, support and transportation. Transportation is the conveyance of clients from the LTC facility to the DT site, and is the responsibility of the provider of the DT program services. For clients who have special transportation needs, such as vehicles modified for wheel chairs and positioning equipment, an upward adjustment shall be made to the Agency Component per diem. Clients who require special transportation are identified according to their Specialized Care service levels, which are verified during the IOCs of their residences (LTC facilities).
e) Total Per Diem Rate
1) The total per diem for each client is the sum of the Program Component, subsection (c)(5) above and the Agency Component, subsection (d) above.
2) The per diem rate for a DT program, based on IOC information, is the mean of per diems for eligible and enrolled clients.
f) The DT program may appeal for redetermination of the monthly rate established by the Department within 30 days after receiving notification of the rate by submitting an application to the IDPA. If a LTC facility initiates such an appeal without the concurrence of the affected DT program, the appeal will not be honored. The application must identify the basis for the appeal and provide all necessary documentation to explain and justify the basis.
g) The Department shall make an advance payment for DT services to a LTC facility that contracts for such services with a certified DT Program. The amount of the advance payment shall be equal to the unadjusted reimbursement the facility would receive for two months of service for the number of clients enrolled in DT. The LTC facility shall use this advance payment to provide advance payment to the DT program serving its recipients in accordance with Section 140.646(b). Facilities eligible to receive an advance payment must contract with a certified DT program which meets one of the following criteria:
1) The DT agency is a newly certified program, or
2) The DT agency experiences a significant increase in enrollment which results in:
A) a 20% client enrollment within one month, or
B) increased costs due to the need for a new setting.
3) The LTC facility shall submit a written request for a two-month advance payment to the Bureau of Developmental Disability Services. The letter shall state the reason for the advance, the clients involved (include the Public Aid ID numbers), and the DT rate of each client. The Department shall begin recovering the payment three months after the advance is issued. The recoupment shall be made in six equal installments via credit applied to the following six months of service. In the event that the facility terminates its contract for DT services before the last month of recoupment, the Department shall recover the entire amount of the advance payment in the month of contract termination, from facility claims processed by the Department. If the amount of such claims is insufficient for recovery of the advance payment balance due, or if such claims have been processed by the Department's payment system prior to contract termination, the advance payment balance shall become immediately due upon contract termination, payable by check to the Illinois Department of Public Aid.
(Source: Amended at 17 Ill. Reg. 7004, effective May 17, 1993)