Current through Register Vol. 48, No. 38, September 20, 2024
a)
Definitions
For the purposes of this Section, the following terms are
defined:
"Actual payments." The absolute amount of Medicaid payments
received by a provider from the Department, per written agreement, for the
delivery of Medicaid-reimbursable services during the fee year.
"Applicable provider" or "provider." A community agency from
which the Department purchases services through payments that are matched by
federal funds under Medicaid and that the Department has determined to be
subject to the provider participation fee.
"Days." Calendar days, unless otherwise specified.
"Department." The Department of Human Services.
"Fee." A fee that each applicable provider shall submit to the
community mental health and developmental disabilities services provider
participation fee trust fund.
"Fee year." The fiscal year beginning July 1 and ending June 30
for which the fee amount applies.
"Fund." The community mental health and developmental
disabilities services provider participation fee trust fund comprising the fees
submitted by applicable providers, the interest accrued on the fees, and the
related federal Medicaid matching funds.
"Medicaid." Medical assistance issued by the Illinois
Department of Public Aid, under the provisions of Title XIX of the Social
Security Act ( 42 USCA 1396(1998)), for eligible recipients, including Aid to
the Aged, Blind and Disabled (AABD), Temporary Assistance to Needy Families
(TANF), Medical Assistance No Grant (MANG), and Refugee Repatriate Program
(RRP) recipients as well as Title XIX eligible Department of Children and
Family Services (DCFS) wards.
"Medicaid payments." Payments made by the Department for
services covered under Medicaid for which the State receives federal matching
funds.
"Medicaid reimbursed services." A service provided by a
provider under an agreement with the Department for which the State receives
reimbursement from the Medicaid program and which is subject to the fee
process.
"Projected payments." The estimated amount of Medicaid payments
to be received by a provider from the Department, per written agreement, for
the delivery of Medicaid-reimbursable services during the fee year.
b) Fees
1) Calculation of projected fees
Each year the Department shall calculate a fee which shall be
paid by applicable providers. The fee amounts due to the fund by applicable
providers shall be based on the projected amount of Medicaid payments to be
made by the Department to the provider for the year taking into
consideration:
A) The unit rates for
services;
B) The units of service
billed by the assessed provider for the year prior to the fee year;
and
C) Any other factors which will
influence a change in the number of units of service to be billed during the
fee year.
2)
Differential fee collection schedule
A) The
Department shall establish a differential fee collection schedule for any
provider whose projected Medicaid payments during the current fee year exceeds
the actual Medicaid payments for the year prior to the fee year by more than 20
percent.
B) The Department shall
establish a differential fee collection schedule for such providers which
reflects the increasing payments for the current fee year.
C) The differential fee collection schedules
for these providers will require lesser fee submittals during the first quarter
with gradually increasing fee submittals according to the providers' projected
growth in Medicaid receipts.
3) Adjustment of inaccurate projections
A) If the Department determines that any fee
amount assessed a provider was incorrect, the Department will correct the fee
error.
i) The Department will issue a revised
fee amount for the quarter.
ii) The
Department will adjust the fee amounts due for subsequent quarters of the fee
year.
B) The Department
shall monitor quarterly the ratio of actual to projected total gross payments
for those assessed providers whose estimated increase in gross total payment
for the fee year is expected to exceed 20 percent.
i) When the accumulated actual fees due to
the fund by the assessed provider differ by more than 10 percent from the
accumulated projected fees, the Department shall issue a revised fee amount for
the immediate calendar quarter and a revised collection schedule for the
remainder of the fee year. When this occurs, the provider shall submit the
revised fee amount within 30 days after the date of postmark on the
Department's written notification of the change.
ii) When the accumulated actual fees due to
the fund by an assessed provider are less than the accumulated projected fee
amounts, the Department shall return to the provider the appropriate share of
overpaid fees.
4) Calculation of provider participation fees
The Department shall multiply the projected Medicaid payments
for services which it has determined to be subject to the provider
participation fee for the fee year of individual providers by any amount not
greater than 15 percent to determine the fee amount owed to the fund.
5) Notification of fee due date
The Department shall notify each assessed provider, in writing,
of the amount of the fee 30 days prior to the required fee due date. The
Department may modify the notification timeframes and extend the required fee
due date for good cause shown.
6) Provider submission of fees
A) Each provider shall submit the specified
fee in equal quarterly amounts on or before the first business day of each
calendar quarter.
B) Due dates for
provider submission of quarterly fee payments shall be January 2, April 1, July
1, and October 1, or, if these dates are on weekends or holidays, the first
business day immediately following.
7) Delayed fee collection schedules
A) The Secretary of the Department is
authorized to establish delayed fee collection schedules for providers that are
unable to make timely payments due to financial difficulties.
B) Delayed fee collection schedules shall be
granted only under extraordinary circumstances to qualified providers that meet
all of the requirements in subsections (b)(7)(C) and (D).
C) Denial of an application to borrow
provider participation fee funds from a financial institution or other lending
entity.
D) A signed written
agreement with the Department specifying the terms and conditions of the
delayed fee collection schedule, which shall contain the following provisions:
i) Specific reason(s) for the establishment
of the delayed fee collection schedule;
ii) Specific dates on which submission of the
fees will be received by the Department and the amount of the fees which will
be received on each specified date described;
iii) The interest that shall be due from the
provider as a result of the establishment of the delayed fee collection
schedule;
iv) A certification
stating that, should the provider entity be sold, the new owners shall be made
aware of the liability and shall assume responsibility for repaying the debt to
the Department in accordance with the original agreement;
v) A certification stating that all
information forwarded to the Department in support of the establishment of the
delayed fee collection schedule request is true and accurate to the best of the
signatory's knowledge; and
vi) Such
other terms and conditions that may be required by the Department.
E) In order to receive
consideration for delayed fee collection schedules, providers shall forward
their requests in writing (telefax requests are acceptable) to the Department.
Requests must be received within five working days after the date of the
Department's notification of the provider participation fee due for the subject
quarter. All telefax requests must be followed-up with original written
requests. All requests shall include:
i) An
explanation of the circumstances creating the need for the delayed fee
collection schedule;
ii) Supportive
documentation to substantiate the emergency nature of the request and risk of
irreparable harm to the provider's clients;
iii) Specification of the arrangements being
requested by the provider.
F) The Department shall notify the provider,
in writing, of its decision with regard to the request for the establishment of
a delayed fee collection schedule. An agreement shall be issued to the provider
for all approved requests. The agreement shall be signed by the provider's
administrator, owner, chief executive officer, or other authorized
representative and must be received by the Department before the first
scheduled fee submittal date listed in the delayed fee collection schedule.
i) The Department shall waive the penalties
for delinquent and/or deficient fee submittal upon the approval of the
provider's request for establishment of a delayed fee collection schedule. When
a provider's request for establishment of a delayed fee collection schedule is
approved and the Department receives the signed agreement in accordance with
this subsection, such penalties shall be permanently waived for the subject
quarter unless the provider reneges on the conditions of the agreement. When
the provider reneges on the conditions of the agreement, the agreement shall be
considered null and void and such penalties shall be fully
reinstated.
ii) The delayed fee
collection schedule shall include interest at a rate not to exceed the State's
borrowing rate. The applicable interest rate shall be identified in the
agreement described in subsection (b)(7)(E).
iii) When a provider has requested and
received Department approval for a delayed fee collection schedule, the
provider shall not receive approval for subsequent delayed fee collection
schedules until such time as the terms and conditions of any current delayed
fee collection agreement has been satisfied. The waiver of penalties described
in subsection (b)(7)(F)(i) shall not apply to a provider that has not satisfied
the terms and conditions of any current delayed fee collection
agreement.
8)
Penalty for delinquent or deficient fees
Any provider that fails to submit the fee when due, or submits
less than the full amount due, shall be assessed a penalty of 10 percent of the
delinquency or deficiency for each month, or fraction thereof, computed on the
full amount of the delinquency or deficiency, which includes any penalty
accrued and not paid, from the time the fee was due.
9) Notification to comptroller
A) The Secretary may take action to notify
the Office of the Comptroller to collect any amount of monies owed by the
provider to the fund.
B) The
Secretary may take action against providers failing to submit any delinquent or
deficient fee or penalty including:
i)
Suspension of payments;
ii)
Cancellation of the provider contract or agreement; and
iii) Refusal to issue, extend, or reinstate
the provider contract or agreement.
c) Local government funds certification
Providers may use local government funds as a source to meet
their obligated, quarterly assessed fee amount in part or in whole.
1) If local government funds are used, the
provider shall certify the planned spending of these local funds for the
specified services in lieu of actual cash payment to the fund by providing a
statement from each local government funder stating the intent of that funder
to contribute the applicable portion of the fee amount, signed by the
chairperson of the local government funder taxing authority.
2) If the certification process is used, the
provider shall submit to the Department, by October 31 of the year following
the fee year, an annual audit statement from a certified public accounting firm
which demonstrates that the local government funds were spent for the intended
service and in the amounts required according to the fee amount.
3) Expenditure of funds on Medicaid Services
A) If the local government funds were not
spent for the Medicaid service as required:
i)
The provider shall submit to the State by October 31 of the year following the
fee year the amount of the fee which was not spent;
ii) A fine equal to 25 percent of the amount
of the fee not properly covered by the local government funds certification
process.
B) This payment
shall be submitted to the State Treasury by October 31 of the year following
the fee year.
d) Deposit of revenue
Deposits to the fund shall consist of:
1) Federal revenues received under Title XIX
of the Social Security Act as a result of the increased rates paid by the
Department to providers of Medicaid-reimbursable services;
2) The fees paid by providers of
Medicaid-reimbursable services under agreement with the Department which are
eligible for reimbursement from Medicaid and which are subject to the fee
process;
3) The interest earned on
the deposits to the fund; and
4)
The revenues generated from fines and penalties levied by the Department on
providers in accordance with subsection (c)(3).
e) Protection from reduction
1) The moneys in the fund shall be exempt
from any State budget reduction Acts.
2) The funds shall not be used to replace any
funds otherwise appropriated to the Medicaid program by the Illinois General
Assembly.
f)
Administration of contingency reserves
1)
Moneys paid from the fund shall be used first to:
A) Pay for the administrative expenses
incurred by the Department in performing the duties authorized by Section 18.1
of the Mental Health and Developmental Disabilities Administrative Act
[20 ILCS 1705/18.1
];
B) Pay any amounts reimbursable
to the federal government, which are required to be paid by State
warrant.
2)
Disbursements from the fund shall be by warrants drawn by the State Comptroller
upon receipt of vouchers duly executed and certified by the
Department.
3) The Department shall
establish a contingency reserve not to exceed three percent in any fee year of
the total amount of the revenues described in subsection (d).
g) Fund expenditures
The Department shall spend 100 percent of the moneys in the
fund during the fee year from which the monies were collected to reimburse
providers for the delivery of Medicaid services less:
1) The administrative expenses incurred in
performing the duties authorized by Section 18.1 of the Mental Health and
Developmental Disabilities Administrative Act; and
2) A maximum of three percent of the total
deposits made to the fund in any fee year for the contingency
reserve.
h) Provider
assurance
1) In the aggregate, providers under
contract with the Department to provide Medicaid reimbursable services that are
subject to the fee payment process are entitled to a return of 100 percent of
the fee amount paid during any fee year:
A)
Plus the federal funding portion;
B) Less the administration expenses incurred
by the Department in performing the activities authorized; and
C) Less the allowed three percent contingency
reserve.
2) No provider
shall receive back less than the amount required as a fee for any given fee
year.
i) Department
records
The Department shall maintain records showing the amount of
money paid by each provider into the fund and the amount of money that has been
paid from the fund to each provider for each fee year.
j) Annual audit
1) The Department shall conduct an annual
audit of the fund to determine that:
A)
Receipts were appropriate and accurate;
B) Disbursements were appropriate and
accurate;
C) Delayed fee collection
schedules were justified and approved;
D) Interest and penalties were properly
calculated and imposed;
E) Local
government funds were properly certified;
F) Contingency reserves were accurately
calculated;
G) Records were
appropriate, complete and correct.
2) Any errors or deficiencies identified as a
result of such audit shall be corrected on a timely basis.
k) Fee correction and recovery
If the Department's annual audit identifies erroneous fee or
reimbursable payment amounts, then it shall:
1) Correct the fee payment amount and any
related fine and notify the provider;
2) Correct the reimbursable payment amount to
the provider; or
3) Take the action
necessary to recover the required fee or reimbursed payment amount from the
provider.
l)
Applicability of provider participation fees
1) The Department shall determine which
services and which providers will be subject to the provider participation
fees.
2) The Department may choose
to terminate or revise its policies concerning the computation and/or
collection of provider participation fees if laws or regulations are
implemented affecting state financing of Medicaid services with mandatory
provider participation fees.
3) If
the Department terminates the collection of provider participation fees and a
positive balance remains in the fund, the Department shall expend the balance
as follows:
A) Refund to each provider any
portion of the annual fees the provider had submitted, but for which the
provider had not yet been reimbursed.
B) Expend whatever is required for any
outstanding costs related to the administration of the provider participation
fee initiative or to its termination.
C) Distribute any remaining balance among
contributing providers proportionally to each provider's contributions to the
fund during the 12-month period prior to termination.
m) Appeals procedure
1) Appealable decisions - A provider may
request a hearing on the following issues:
A)
The initial assessment or change in the amount of the required
payment;
B) An audit finding that a
provider is required to reimburse the Department for a fee or
payment.
2) Notice of
appeal rights - The Department shall inform the provider of the right to appeal
and the appeal procedure whenever the provider is notified of the initial
assessment or change in the amount of the required payment, or of an audit
finding that a provider is required to reimburse the Department for a fee or
payment.
3) Request for hearing - A
provider may appeal the Department's decision by requesting a hearing in
writing within 10 days after receipt of the decision. The request shall be sent
to:
Bureau of Administrative Hearings
Department of Human Services
100 South Grand Avenue East
Springfield IL 62762
4) Stay of proceedings - The request for an
appeal shall stay any proceedings or decision taken concerning the provider
until the resolution of the appeal.
5) Upon request of the provider at any time
prior to the scheduled hearing, the provider may request an informal conference
with the Division of Disability and Behavorial Health Services to determine the
facts and issues and to resolve any conflicts as amicably as
possible.
6) Hearing officer - The
hearing shall be conducted by a hearing officer appointed by the
Secretary.
7) Scheduling and notice
of hearings - Within 60 days after the receipt after the appeal, the hearing
officer shall schedule a hearing, to be held in the Department's central
offices or a place agreed to by the hearing officer, the Department staff
involved and the provider. The hearing officer shall send written notice of the
hearing to the provider via certified mail. The notice shall contain:
A) A statement of the nature of the
hearing;
B) A statement of the time
and place of the hearing;
C) A
statement of the right to be represented by an attorney at the provider's
expense.
8) Continuances
- The hearing officer may, upon good cause shown, grant a continuance requested
by the provider.
9) Conduct of
hearings
A) The hearing officer shall regulate
the course of the hearings; hold informal conferences for the purpose of
resolving the case; dispose of procedural issues; continue the hearing from
time to time when necessary; examine witnesses and rule upon the relevancy of
evidence.
B) At the hearing, the
provider and the Department may present written and oral evidence. The
Department shall have the burden of proving by substantial evidence that the
decision was made in accordance with the statutes and this Section. Upon
conclusion of the Department's presentation, the provider may present written
and oral evidence.
C) The common
law rules of evidence shall not be enforced in the hearing. The hearing officer
shall conduct the hearing in a manner that allows participants to present their
evidence fully and freely. Either party may ask questions of each other or any
witness, and the hearing officer may ask questions of either party or any
witness. Questions impeaching the witness' character or credentials shall be
improper.
D) The hearing shall be
taped or stenographically recorded. The tape or a copy of the transcript shall
be retained by the Department. If the provider appeals the hearing officer's
decision, a copy of the record shall be provided to the provider upon
request.
10) Standard of
review - In all appeals, the hearing officer shall decide whether there was
substantial evidence showing that the Department's decision was made in
accordance with statute and this Section.
11) Decision - Within 10 working days after
the hearing, the hearing officer shall issue a written decision that upholds,
modifies or reverses the Department's decision. The decision shall contain the
reasons for the hearing officer's action. The hearing officer shall mail copies
to the provider and the Department via certified mail. The decision shall be
accompanied by a letter that informs the provider of the right to appeal the
decision and state the procedure for requesting an appeal.
12) Appeal of the hearing officer's decision
A) The provider may request a review of the
hearing officer's decision by the Secretary or his or her designee no more than
20 days after the receipt of the hearing officer's decision.
B) Upon receipt of the request for review,
the Secretary or designee shall review the hearing officer's decision and
copies of all documents considered at the hearing. Within 20 working days after
receipt of the request for review, the Secretary or his or her designee shall
issue a decision upholding, modifying or reversing the hearing officer's
decision. The Secretary or his and her designee shall uphold the decision if he
or she determines that the decision was supported by substantial evidence.
Copies of the decision shall be sent to the provider, the Department and the
hearing officer.
C) The Secretary's
decision shall constitute a final administrative decision in accordance with
Section 3-101 of the Administrative Review Law [735 ILCS
5/3-101] .
