Current through Register Vol. 48, No. 52, December 27, 2024
a)
The Individual, parents, guardian, or the Individual's representative may
appeal the following actions:
1) Refusal of
the Division or ISC agency to accept a request for Waiver program
enrollment.
2) Failure of the
Division or ISC agency to act on a request for services within the mandated
time period.
3) Denial of a
requested Waiver service by the Division or ISC agency (i.e., Individual in
Home-Based Supports and is now requesting Assistive Technology).
4) Denial of clinical eligibility by the
Division or an ISC agency.
5)
Suspension, termination, or reduction of services by the Division or a provider
agency.
b) The desire to
appeal any action listed under subsection (a) shall be communicated to the ISC
within 10 working days after the date the Individual or guardian receives the
notice of action from the provider. The communication shall be followed by a
written request to appeal signed by the Individual, parent, guardian, or
Individual's representative.
c)
Within 45 days after receiving notification to appeal, the ISC must:
1) Gather the following:
A) The written request to appeal signed by
the Individual, parent, guardian, or Individual's representative.
B) A complete appeal checklist.
C) A complete Documentation for Medicaid
Waiver Appeals form (IL444-0171) and supporting documents as indicated in the
form.
D) Documents from the
provider agency to support its decision to suspend, terminate, or reduce
services.
E) Any additional
documentation relevant to the appeal.
2) Submit the documents pursuant to
subsections (c)(1)(A) through (E) to DDD's Appeals Unit by:
A) Secure email. Emails should be directed to
DHS.DDDAppeals@illinois.gov;
B) Fax
to 217-558-2799 Attn: Appeals Unit supervisor; or
C) Mail to:
DHS/DDD - Program Development
Attn: Appeals Unit Supervisor
600 East Ash Street Building 400,
3rd Floor South
Springfield, IL 62703
d) Within 30 working days after the appeal
and supporting documents indicated in subsection (c)(1) are received, DDD shall
conduct an informal review of the appealed action listed in subsection (a) and
either uphold or not uphold the appealed action. The Individual, parent,
guardian, or Individual's representative (if any), and the service providers
shall be notified in writing of DDD's decision within 10 working days after the
informal review is complete. The written notification shall include:
1) A clear statement of the action to be
taken;
2) A clear statement of the
reason for the action;
3) A
specific policy reference which supports such action; and
4) A complete statement of the Individual's
right to continue the appeal and have an Administrative Hearing with HFS. When
DDD's Informal Review decision does not support the Individual's appeal, the
Individual, parent, guardian, the Individual's representative, and provider, if
applicable, will be notified that the appeal will continue to HFS for an
Administrative Hearing.
e) When DDD's informal review decision does
not support the Individual's appeal, within 10 working days after the decision,
DDD shall forward the appeal and all documents reviewed to HFS for an
administrative hearing to be scheduled by HFS.
f) The hearing shall be conducted by an
impartial hearing officer appointed by HFS.
g) The hearing may be held by
telephone.
h) HFS' hearing rules
for assistance appeals, as set forth at 89 Ill. Adm. Code 104, shall apply,
except that subsection (d) shall apply rather than any similar HFS
rule.
i) Following the hearing, the
Director of HFS shall issue a final administrative decision in accordance with
89 Ill. Adm. Code 104.70. Copies of the decision
shall be mailed to the Individual, guardian, parent, the Individual's
representative (if any), the provider, and the Supervisor of DDD's Appeals
Unit.
j) The receipt of the appeal
shall stay the decision pending the final administrative decision or the
withdrawal of the appeal. If the decision being appealed is regarding
suspension, termination, or reduction of services, services shall not be
suspended, terminated, or reduced until the appeal is resolved, except as
described below.
1) Services may be
suspended, terminated, or reduced before the final administrative decision
when:
A) The physical safety or health of the
Individual or others is in extreme risk of harm; or
B) Appropriate medical services are not
available at the provider agency thereby jeopardizing the health of the
Individual; and
C) The ISC agency
has:
i) Reviewed the Individual's record and
clinical information;
ii) Reviewed
the actions, including the supports implemented, of the provider;
iii) Discussed the current situation and
alternatives available with the Individual and guardian;
iv) Determined that a delay in termination,
suspension, or reduction in services would put the safety of the Individual or
others in extreme risk of harm and has documented that fact in the Individual's
record; and
v) Consulted with the
Division of Developmental Disabilities.
2) If the conditions of subsection (j)(1) are
met, services to the Individual may be terminated, suspended, or reduced and
the notice of action shall be given in accordance with Section
120.70(h) as
soon as possible, but in no case later than 48 hours before the termination,
suspension, or reduction in services.
3) The provider shall continue to provide
services until the appeal is resolved except as described in subsection
(j)(l).
4) If the conditions of
subsections (j)(l)(A) or (B) exist, the Individual (if possible), the guardian,
the ISC agency, and a Department representative will work together to secure
alternative services. The provider agency (including the QIDP) shall work
cooperatively with the Individual, the guardian, the ISC agency and the
Department in effort to secure and transition Individuals to alternative
services. This includes, but is not limited to, supplying records and other
documents, supplying the Individual's personal items, and conferencing with
prospective agencies regarding the Individual's care.
