TITLE 89: SOCIAL SERVICES
CHAPTER IV: DEPARTMENT OF HUMAN SERVICES
SUBCHAPTER d: MEDICAL PROGRAMS
PART 144 DEVELOPMENTAL DISABILITIES SERVICES
SECTION 144.275 REIMBURSEMENT FOR PROGRAM (ACTIVE TREATMENT) COSTS IN RESIDENTIAL FACILITIES FOR CLIENTS WITH DEVELOPMENTAL DISABILITIES


 

Section 144.275 Reimbursement for Program (Active Treatment) Costs in Residential Facilities for Clients with Developmental Disabilities

 

Residential facilities, including distinct parts of facilities, for clients with developmental disabilities (ICF/MR certification with licensure for ICF/DD, ICF/DD-16, SLC, and ICF/MR-SNF/PED license), excluding State-operated facilities for individuals with developmental disabilities, will be reimbursed for an active treatment program for each client. Facility program reimbursement levels will be derived by the Department from the following four determinants which in combination will result in a total facility program per diem amount. These four determinants will be determined according to information provided in the most recent Inspection of Care (IOC) conducted by Department of Public Health survey staff. This IOC information must be validated by the survey staff prior to utilization for payment purposes. The new reimbursement level will be effective on the first day of the quarter following a facility's IOC. Where dollar, wage, or salary amounts are used, these shall be inflated to the fiscal year for which reimbursement will be made.

 

a) Minimum Staffing

 

1) Direct Services Facilities must be in compliance with the Health Care Financing Administration's (HCFA) (42 CFR 483.430 (1996)) minimum average daily staffing standards relative to client population according to each individual's overall level of functioning:

 

Overall Level of Functioning

FTE* Staff:Client Ratio

Mild

1:5

Moderate

1:2.5

Severe or Profound

1:2

 

*FTE = Full Time Equivalent

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), will 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 must be administered by a psychologist who is registered in Illinois under the Clinical Psychologist Licensing Act (Illinois Department of Professional Regulation); and

 

ii) an assessment of adaptive behaviors using a nationally 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 will be utilized by at least one Qualified Mental Retardation Professional (QMRP) to evaluate each client's functional skills and adaptive behaviors.

 

B) 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 Section 144.Table D and Section 144.Table E of this Part.

 

C) The amount for Direct Services for these staffing ratios shall be obtained by:

 

i) determining the number of clients within each overall level of functioning; 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), to obtain a total annual Direct Service cost; and dividing this total by 365 days and then by the number of clients to obtain the amount for Direct Services per client per day. For example, if a facility serves 40 clients in the mild level of functioning, 30 clients in the moderate level of functioning, and 30 clients in the severe/profound level of functioning, the number of FTE Direct Services staff will be (40 divided by 5) + (30 divided by 2.5) + (30 divided by 2) = 35. If the aide hourly wage is $5.00, the total annual cost will be 35 x $5 x 2080 = $364,000. The amount for FTE Direct Services per client per day will then be $364,000 divided by 365 divided by 100 = $9.97.

 

ii) In ICF/DD-16 facilities, the foregoing calculation is modified such that in step two of subsection (a)(1)(C)(i) of this Section, the facility may receive an amount for up to an additional .5 FTE. Direct Service is determined by multiplying .5 FTE by the proportion found by the ratio of the number of Medicaid eligible clients in the severe/profound level of functioning divided by the total number of eligible clients.

 

2) Licensed Nurses Facilities must be in compliance with HCFA (42 CFR 483.460 (1996)) and Illinois Department of Public Health (IDPH) (77 Ill. Adm. Code 350.1230) staffing standards relative to facility type.

 

A) An ICF/MR (ICF/DD, SLC, SNF/PED but excluding ICF/DD-16) licensed for a population of 90 or fewer clients, none of whom require services under Levels II and III of Specialized Care-Health and Sensory Disabilities (Section 144.150(c) and (d)), will be reimbursed for a minimum of 4.8 FTE nurses. A facility with only such a population which has a licensed capacity greater than 90 clients will be reimbursed for additional FTE nurses according to the following Table:

 

Licensed Capacity, Client Type

 

FTE Nurse:Client Ratio

 

 

 

Greater than 90 clients with no Specialized Care Health and Sensory Disabilities needs under Level II and III

 

1:18.7

 

B) An ICF/MR (ICF/DD, SLC, SNF/PED but excluding ICF/DD-16) licensed for a population of 30 or fewer clients, all of whom require services under Level(s) II and/or III of Specialized Care Health and Sensory Disabilities will be reimbursed for a minimum of 4.8 FTE nurses. A facility with only such a population which has a licensed capacity greater than 30 clients will be reimbursed for additional FTE nurses according to the following Table:

 

Licensed Capacity, Client Type

 

FTE Nurse:Client Ratio

 

 

 

Greater than 30 clients requiring Specialized Care Health and Sensory Disabilities under Level(s) II and III

 

1:6.25

AGENCY NOTE: The Omnibus Reconciliation Act of 1987 (P.L. 100-203) requirements prohibit the admission of individuals with a primary diagnosis of mental retardation into non-ICF/MR facilities. Therefore, SNF/PED facilities which meet ICF/MR certification requirements must be certified ICF/MR in order to comply with federal law when admitting individuals with mental retardation. Facilities which undergo certification conversion to ICF/MR will retain State licensure for skilled care (SNF/PED).

 

C) An ICF/MR (ICF/DD, SLC, SNF/PED but excluding ICF/DD-16) which has a licensed capacity of 30 clients or more, some of whom require services under Level(s) II and/or III of Specialized Care Health and Sensory Disabilities, and some of whom do not require such services, will be reimbursed for a minimum of 4.8 FTE nurses for non Specialized Care individuals plus additional FTE nurses, up to a maximum of a 1:6.25 ratio, according to the following Table:

 

Client Type

 

FTE Nurse:Client Ratio

 

 

 

Client requiring Specialized Care Health and Sensory Disabilities under Level(s) II and/or III

 

1:6.25

 

For example, for a facility with a licensed capacity of 42 clients, 15 of whom require services under Level(s) II and/or III, and 27 of whom do not require such services, the number of FTE nurses will be (15 divided by 6.25 = 2.40) + (27 divided by 18.75 = 1.44, however, reimbursement will be calculated at the minimum of 4.8) = 7.2. Utilizing the maximum client ratio allowed, the facility will be reimbursed for 6.72 FTE nurses (42 divided by 6.25 = 6.72).

 

D) Licensed nurses are not required in an ICF/DD-16 if none of the clients require a physician's medical care plan of treatment.

 

i) An ICF/DD-16 which has eight or fewer clients with medical care plans of treatment but who do not require services under Specialized Care Health and Sensory Disabilities, Level(s) II and/or III, will be reimbursed for .5 FTE nurse. A facility with nine or more such clients will be reimbursed for one FTE nurse.

 

ii) An ICF/DD-16 with clients requiring medical care plans of treatment and additional medical services under Specialized Care Health and Sensory Disabilities, Level(s) II and/or III, will be reimbursed according to the method in subsection (a)(2)(D)(i) of this Section, plus additional reimbursement for licensed nurses using an FTE nurse: client ratio of 1:6.25 up to a maximum of the 1:6.25 ratio.

 

E) The licensed nurse component is computed similarly to the method in subsection (a)(1)(C) of this Section. To determine the amount for Licensed Nurses, the number of FTE nurses required for each facility type and/or for clients receiving services under Specialized Care Health and Sensory Disabilities, Level(s) II and/or III, shall be obtained according to subsections (a)(2)(A), (B), (C) and (D) of this Section. This number is multiplied by the hourly nurse wage factor and then by 2080 (52 weeks x 40 hours). The product is divided by 365 and then by the number of clients.

 

3) The total reimbursement amount for Minimum Staffing is the sum of the amount for Direct Staff plus the amount for Licensed Nurses.

 

b) Active Treatment

 

1) Qualified Mental Retardation Professional (QMRP) a person who has at least one year of experience working directly with persons with mental retardation or other developmental disabilities, and is one of the following:

 

A) A doctor of medicine or osteopathy.

 

B) A registered nurse.

 

C) An individual who holds at least a bachelor's degree in one of the following professional categories: Occupational Therapist; Physical Therapist; Psychologist. Master's Degree: Social Worker; Recreation Specialist; Registered Dietitian; and Human Services, including but not limited to Sociology, Special Education, Rehabilitation Counseling, and Psychology. (42 CFR 483.430 (1996))

 

D) The amount for QMRPs assumes that a full-time QMRP is required for every 15 clients. The number of QMRPs shall be obtained by dividing the number of clients in the facility by 15. The obtained number of QMRPs is multiplied by the hourly wage factor and then by 2080. The product is divided by 365 and then by the number of clients to arrive at an amount per client per day.

 

2) Interdisciplinary Team (IDT)

 

A) The amount for services rendered by the IDT assumes that each client requires one day of IDT services per year. This amount is computed to be $1.82 per client per day.

 

B) Interdisciplinary Team A team which represents the professions, disciplines, or service areas that are relevant to identifying the client's needs and designing programs that meet the client's needs. Appropriate facility staff must participate in interdisciplinary team meetings. Participation by other agencies serving the client is required (see the Department of Public Aid's rule at 89 Ill. Adm. Code 140.647). Participation by the client, his or her parent (if the client is a minor), or the client's legal guardian is required unless the participation is unobtainable or inappropriate. (42 CFR 483.440 (1996))

 

3) Additional Direct Service Staff (ADSS)

 

A) The amount for ADSS assumes an FTE staff:client ratio of 1:7.5. The total number of clients is divided by 7.5 and a per diem amount is obtained according to the method described in subsection (a)(1)(B) of this Section. In SLC facilities, the foregoing calculation is modified so that the overall level of functioning is distributed proportionately across each living unit (16-18 clients) in step one of the calculation. If dividing the number of clients results in a fraction, it is rounded up to the next whole number in proportion to the number of clients in the severe/profound level of functioning. The total FTE is obtained by summing the calculation results from each living unit.

 

B) Additional Direct Services Staff Staff which is in addition to HCFA's minimum average daily staffing standards (subsection (a)(1) of this Section), and for which the Department will provide reimbursement to ensure the delivery of active treatment. Examples of ADSS include, but are not limited to, staff who provide activity services, dietetic aides, and music therapists.

 

4) The total reimbursement amount for Active Treatment is the sum of the amounts for QMRP, IDT and ADSS.

 

c) Specialized Care

An additional amount shall be paid for clients meeting the requirements for services under Specialized Care. Detailed descriptions of services under Specialized Care are found in Section 144.125 Specialized Care Behavior Development Programs, and Section 144.150, Specialized Care Health and Sensory Disabilities. The service Level for each client meeting the criteria of more than one Level under Specialized Care shall be determined according to his/her disability or functional deficit which represents the most intense need for services under Specialized Care, and results in the greatest reimbursement.

 

1) Specialized Care Behavior Development Programs

Behavior development programs are related to maladaptive behaviors which occur with high frequency and/or great severity, and are instituted for the reduction of maladaptive behaviors and/or the increase of adaptive behaviors. The behavior development program shall demonstrate the need for and use of a more intensive staffing pattern (direct care staff) than the regular pattern which is reimbursed for under subsection (a)(1) of this Section. The service Level for a client who meets the requirements for services under Specialized Care - Behavior Development Programs will be identified and validated during the most recent IOC.

 

A) Level I .5 hours FTE Direct Service per day. More intense program services are provided for behaviors which occur with high frequency but moderate severity, such as verbal abuse one or more times per four hours which is hostile in tone and content.

 

B) Level II 1.0 hours FTE Direct Service per day. More intense program services are provided for behaviors which occur with high frequency and are aggressive or destructive, such as purposeful attacks of others which may result in minimal injuries, one or more times per day.

 

C) Level III 2.0 hours FTE Direct Service per day. More intense program services are provided for behaviors which occur with very high frequency such as hyperactivity one or more times per minute, or occur with high frequency and are seriously aggressive, assaultive or destructive and which may result in serious injury.

 

2) Specialized Care Health and Sensory Disabilities

Specialized services for health and sensory disabilities refer to care which some clients must receive in order to attain physical health and development.

 

A) Definitions

 

i) Ambulatory The client is capable of walking without assistance or the aid of adaptive equipment or devices.

 

ii) Mobile Nonambulatory The client is capable of locomotion with mobility assistance such as adaptive equipment or devices.

 

iii) Nonmobile The client is not capable of locomotion even with mobility assistance.

 

B) Level I .5 hours FTE Direct Service per day. The client is ambulatory, mobile nonambulatory, or has the potential to become mobile nonambulatory, and requires services to compensate for a sensory deficit (auditory or visual), or services enabling him or her to be mobile (physical disabilities).

 

i) Sensory deficits visual. The client's vision is 20/200 or less in the better eye with the greatest possible correction (Section 2 of the Blind Persons Operating Vending Machines Act [20 ILCS 2420/2]).

 

ii) Sensory deficits auditory. The client has a hearing impairment of at least 55 decibels in the better ear, unaided.

 

iii) Physical disabilities means physical impairments which result in functional deficits requiring the client to receive training in the use of a device or devices, to achieve some level of independent mobility.

 

C) Level II 1.0 hours FTE Direct Service per day. The client is nonmobile or mobile nonambulatory, requires mobility assistance, and requires services to meet high personal care needs. The client may also have significant daily medical needs and/or dual sensory deficits (visual and auditory).

 

i) Mobility assistance means assistance in transferring from a bed to an alternative position device, and assistance with movement/mobility around the facility.

 

ii) High personal care means one or more of the following: assistance with bathing, clothing, grooming and hygiene, eating and continence; position changes at two hour intervals, or as specified in the individual program plan; range of motion twice a day, or as specified in the individual program plan.

 

iii) Daily medical need means daily insulin injections, drug (insulin) monitoring, and/or ostomy care for a jejunostomy, ileostomy or colostomy.

 

iv) Dual sensory deficits means both an auditory disability and a visual disability.

 

AGENCY NOTE: A client who meets the criteria for Level II services is eligible for the FTE nurse:client ratio according to subsections (a)(2)(B), (C) and (D) of this Section.

 

D) Level III 2.0 hours FTE Direct Service per day. The client is typically nonmobile or mobile nonambulatory, but may be ambulatory, and requires services to meet high medical needs. High medical needs mean one or more of the following:

 

i) daily intermittent catheterization;

 

ii) care for wounds including stage III and IV decubitus ulcers, deep wounds, infected wounds, extensive burns, or extensive lesions requiring treatment in the form of medications, dressings, whirlpool, ultraviolet light and/or irrigations;

 

iii) respiratory care including tracheotomy care, positive pressure breathing treatments, aerosol therapy, postural drainage and percussion, vibration and/or suctioning;

 

iv) feeding via nasogastric tube, or prolonged oral feeding; and

 

v) intensive physical habilitation due to a functional deficit as determined by physical or psychological causes.

 

AGENCY NOTE: A client who meets the criteria for Level III services is eligible for the FTE nurse:client ratio according to subsections (a)(2)(B), (C) and (D) of this Section.

 

3) The total reimbursement amount for Specialized Care shall be the sum of the amounts determined under subsections (c)(1) and (2) of this Section, pro-rated over the number of eligible clients identified in the most recent facility reimbursement survey. For example, if the hourly wage is $5.00, assume a facility with ten residents, two of whom meet the criteria for Specialized Care Health and Sensory Disabilities Level II, subsection (c)(2)(C) of this Section, with no daily medical needs or sensory deficits, and eight of whom do not meet Specialized Care criteria. The facility will receive an amount of $.81 per client per day (two hours x 1.14 (FTE adjustment factor) divided by eight hours/day = .285 staff; then .285 x (2080 hours/year divided by 365 days/year); then divide by ten clients and multiply by $5.00 to obtain $0.81).

 

d) Related Costs

 

1) An amount per client per day will be paid for other program costs, including program related supplies, consultants and other items necessary for the delivery of active treatment to clients in accordance with their individual program plans.

 

2) For each facility type, this amount will be determined as follows. Add the amounts determined for subsections (a), (b) and (c) of this Section, but excluding the amount for the IDT (subsection (b)(2) of this Section), and then multiply this sum by the factor determined by the Department for the facility's geographic area (see the Department of Public Aid's rule at 89 Ill. Adm. Code 140.Table B). The product plus the amount for the IDT (subsection (b)(2) of this Section), is then multiplied by a constant for the facility type, as follows:

 

Facility Type

 

Constant

ICF/DD

 

.10

SNF/PED or ICF/DD

(An ICF/DD with some clients requiring services under Level(s) II and/or III of Specialized Care Health and Sensory Disabilities)

 

.15

ICF/DD-16 and SLC

 

.20

 

3) An ICF/DD with some clients requiring services under Level(s) II and/or III of Specialized Care Health and Sensory Disabilities, and some clients not requiring such services will have the total related cost calculated according to the weighted sum of the number of clients requiring Level(s) II and/or III multiplied by .15, plus the number of clients not requiring such services multiplied by .10. For example, for a facility with a licensed capacity of 90 clients, 30 of whom require services under Level(s) II and/or III, and 60 of whom do not require such services, the total related cost will be calculated according to subsection (d)(2) of this Section for both groups of clients. (That is, subsections (a), (b) and (c) of this Section are summed, excluding the amount for the IDT, for clients requiring Level(s) II and/or III and for clients not requiring Level(s) II and/or III. Each sum is multiplied by the factor determined by the Department for the facility's geographic area, and the products are added to the amount for the IDT.) Each outcome is multiplied by the appropriate constant (the SNF/PED-ICF/DD constant of .15 or the ICF/DD constant of .10), and then by the number of clients in each group respectively. The two products are summed and then divided by the total number of clients.

 

4) An amount will also be paid for dental services which are in compliance with HCFA's regulations (42 CFR 483.460(e), (f) and (g) (1996)), for each client age 21 or more. This amount will be determined by adding the flat per diem of $.40 to the amount calculated according to subsection (d)(2) of this Section. This per diem will cover the costs of prophylaxis treatment up to once every six months, and periodontal services as needed for each eligible client.

 

5) An amount will also be paid for base nursing assessments, development and updating of nursing care plans, health risk information and planning. Tardive Dyskinesia (TD) screening, coordination and implementation of medical services, monitoring of medication effectiveness and side effects, and annual flu immunizations in ICF/DD-16s. A flat per diem of $.57 provides for 12 hours of licensed practical nurse time per person per year and one hour of registered professional nurse time per person per year.

 

6) An amount will also be paid for supervision of medication administration. The amount to be reimbursed is based upon a 1:12 ratio of registered professional nurse time at $19.44 per hour (including fringe benefits) to medication administration time. Medication administration time is based upon the number of medication episodes per day documented by each individual's Medication Administration Record (MAR) and the following:

 

A) Five Minute Episode Simple medication preparation, individual self-medication training, administration, and documentation, e.g., up to four medications at one time consisting of oral medications, topical medications, ear drops, creams, and/or lotions. Medications in this category may be simple pill administration or may require the pill be crushed and mixed with an edible binder such as applesauce or pudding. This episode type also includes monitoring a person for "cheeking" or spitting out medication.

 

B) Ten Minute Episode Advanced medication preparation, individual self-medication training, administration and documentation, e.g., glucose monitoring with set insulin injection, blood pressure and/or pulse checks required prior to medication administration, and/or five or more medications at one time.

 

C) Fifteen Minute Episode Complex medication preparation, individual self-medication training, administration and documentation, e.g., glucose monitoring with sliding scale insulin injections, injectable medications, rectal anti-convulsant medications, i.e., Diastat with monitoring.

 

e) Total Program Per Diem Total program per diem for each facility will be the sum of the amounts from subsections (a), (b), (c) and (d) of this Section.

 

(Source: Amended at 24 Ill. Reg. 13404, effective August 18, 2000)