Illinois Administrative Code
Title 89 - SOCIAL SERVICES
Part 140 - MEDICAL PAYMENT
Subpart E - GROUP CARE
Section 140.569 - Clients With Exceptional Care Needs
Universal Citation: 89 IL Admin Code ยง 140.569
Current through Register Vol. 48, No. 38, September 20, 2024
a) Exceptional Care Program
1) Effective January 1, 2007, exceptional
care services shall be covered under the MDS-based reimbursement methodology as
described in 89 Ill. Adm. Code 147.Table A. As long as the nursing facility's
case mix, as determined by total minutes from 89 Ill. Adm. Code 147.Table A,
does not decrease in excess of five percent when compared to the case mix as of
June 30, 2006, exceptional care reimbursement shall be converted to a per diem
computed as the sum of all exceptional care daily payments less the residential
rate made to the facility on June 30, 2006 divided by the total number of
residents that are paid nursing and exceptional care rates as of June 30, 2006.
No new residents will be accepted into the Exceptional Care Program after
December 31, 2006. All facility exceptional care contracts will be terminated
December 31, 2006. The provisions of this Section governing the Exceptional
Care Program remain in place through December 31, 2006.
2) Pursuant to Section 5-5.8a of the Illinois
Public Aid Code [305 ILCS 5/5-5.8a] ,
the Department may make payments for exceptional care services to nursing
facilities ("providers") that meet licensure and certification requirements as
may be prescribed by the Department of Public Health and are enrolled in and
meet participation requirements of the Medical Assistance Program pursuant to
Sections
140.11
and
140.12.
3) Exceptional medical care is defined as the
level of care with extraordinary costs related to services which may include
physician, nurse, ancillary specialist services, and medical equipment and/or
supplies that have been determined to be a medical necessity. This shall apply
to Medicaid patients who are being discharged from the hospital or other
setting where Medicaid reimbursement is at a rate higher than the exceptional
care rate for related services or to persons who are in need of exceptional
care services who would otherwise be in an alternative setting at a higher cost
to the Department and Medicaid eligible residents transitioning from Medicare
to Medicaid while in the nursing facility. This includes but is not limited to
head-injured persons, ventilator dependent persons or persons with
HIV/AIDS.
4) The Department shall
negotiate rates with facilities requesting payment for exceptional care
services (see Section 5-5.8a of the Public Aid Code [305 ILCS 5/5-5.8a]). In
determining the rates of payment, the Department shall consider data collected
from exceptional care providers during fiscal year 1994, any intervening rate
adjustments (including any updates for inflation) and the average cost of each
service category for the geographic area in which the facility is located.
After approval of negotiated rates, the Department shall annually update a
facility's rates for inflation.
b) Exceptional Care Requirements
The Department may enter into agreements with providers for the provision of exceptional care services only if the provider agrees to the following terms:
1) The provider will
maintain separate records regarding costs related to the care of the
exceptional care residents.
2) The
provider must demonstrate the capacity and capability to provide exceptional
care as documented by Department of Public Health and Department of Healthcare
and Family Services records, including, but not limited to, being free of
finalized Department of Public Health findings (exhaustion of appeals process
with deficiencies remaining) after January 1, 1997, that the provider has
deficiencies related to substandard quality of care during the period of time
since the last standard certification survey or imposition of a conditional
license.
3) The provider must
maintain and provide documentation demonstrating:
A) Adherence to staffing requirements as set
out in subsection (c) of this Section;
B) Adherence to staff training requirements
as set out in subsection (d) of this Section;
C) Validity of written agreements as required
in subsection (e) of this Section;
D) Presence of emergency policy and
procedures as set out in subsection (f) of this Section;
E) Medical condition of the resident;
and
F) Care, treatments and
services provided to the resident.
4) The provider must have and maintain
physical plant adaptations to accommodate the necessary equipment, such as an
emergency electrical backup system.
c) Exceptional Care Staffing Requirements
Staffing requirements for providers of exceptional care include:
1) A minimum of one RN on
duty on the day shift, seven days per week (as required by the Department of
Public Health in 77 Ill. Adm. Code
300.1240
or
250.910(e) and
(f)(1) as appropriate). Additional RN staff
may be determined necessary by the Department of Healthcare and Family
Services, based on the Department's review of the exceptional care services
needs;
2) A minimum of the required
number of LPN staff (as required by the Department of Public Health in 77 Ill.
Adm. Code
300.1230 and
300.1240
or
250.910(e) and
(f)(1) as appropriate), on duty, with an RN
on call, if not on duty on the evening and night shifts, seven days per week;
and
3) For those providers of
complex respiratory or ventilator services under the exceptional care program,
a certified respiratory therapy technician or registered respiratory therapist,
on staff or on contract with the provider.
d) Training Requirements for Providers of Exceptional Care for Ventilator Dependent Residents
1) At least one of the full-time professional
nursing staff members must have successfully completed a course in the care of
ventilator dependent individuals and the use of ventilators, conducted and
documented by a certified respiratory therapy technician or registered
respiratory therapist or a qualified registered nurse who has at least one year
experience in the care of ventilator dependent persons.
2) All staff caring for ventilator dependent
residents must have documented inservice training in ventilator care prior to
providing such care. Inservice training must be conducted at least annually by
a certified respiratory therapy technician or registered respiratory therapist
or a qualified registered nurse who has at least one year experience in the
care of ventilator dependent persons. Inservice training documentation shall
include name and qualification of the inservice director, duration of
presentation, content of presentation and signature and position description of
all participants.
e) Exceptional Care Agreement Requirements
The provider must have a valid written agreement with:
1) A medical equipment and supply provider
which must include a service contract for ventilator equipment when accepting
ventilator dependent residents;
2)
A local emergency transportation provider;
3) A local hospital capable of providing the
necessary care for equipment dependent residents, when appropriate;
and
4) A certified respiratory
therapy technician or registered respiratory therapist (unless a respiratory
therapist is on staff within the facility), when accepting ventilator dependent
residents or residents requiring respiratory therapy services.
f) Exceptional Care Emergency Policy and Procedures Requirements
The provider must have specific written policies and procedures addressing emergency needs for residents requiring exceptional care.
g) Accessibility to Records
The provider must make accessible to HFS and/or IDPH all provider, resident and other records necessary to determine that the needs of the resident are being met and to determine the appropriateness of exceptional care services.
h) Provider Approval Process
1) A provider shall notify
the Department, in writing, of its interest in participating in the Exceptional
Care Program.
2) If approved by the
Department, a written exceptional care agreement with the provider shall be
executed. Such agreements are separate and distinct from the provider
agreements specified in Section
140.11(a)(6)
and are not subject to the provisions regarding notice and right to hearing in
the event of termination specified in 89 Ill. Adm. Code
104.208
and
104.210.
3) Providers desiring to discontinue
providing exceptional care shall notify the Department, in writing, at least 60
days prior to the date of termination. Payment for exceptional care residents
already residing in facilities which notify the Department that they wish to
discontinue providing exceptional care services will remain at the previous
exceptional care rate as long as the resident meets exceptional care criteria
and as long as all related criteria are met by the provider as determined by
the Department's utilization review (see Monitoring, subsections (k)(2) and (3)
of this Section) or the resident is discharged.
4) It is the responsibility of the provider
to effect appropriate discharge planning for exceptional care residents when
terminating services for exceptional care. The Department agrees to assist
providers with any information available regarding appropriate placement
settings.
5) The Department may
terminate a provider's agreement, for any reason, upon 60 days written notice
to the provider. Reasons for which the Department may terminate an agreement
include, but are not limited to, Department of Public Health findings that the
provider has deficiencies related to substandard quality of care or imposition
of a conditional license.
i) Determining Eligibility for Exceptional Care Payment
1) A person being discharged from
a hospital or those who are in another setting must be approved by an
authorized Department representative prior to placement in a facility to be
eligible for exceptional care payment.
2) In order for a person to be approved for
exceptional care reimbursement, the cost of the person's care must be at least
50% more than the proposed admitting provider's Medicaid per diem rate
(capital, support and nursing components). Eligible items that may be used in
computing the cost of the resident's care include nursing services costs,
therapy services costs, and medical equipment and supply costs. Computations
for determining cost of care shall be based upon costs for services, medical
equipment and supplies for the proposed admitting provider as determined by the
Department.
j) Provision for Hospital Patients for which a Long Term Care Placement is Unavailable
In the event placement for a patient in need of exceptional care services or skilled nursing services cannot be located, the Department shall approve payment to the hospital in which the patient is receiving services at a rate not to exceed the average Statewide long term care provider per diem for the level of services provided.
k) Monitoring
1) All utilization controls applied to
exceptional care by the Department in accordance with the approved plan for
medical services under the Illinois Public Aid Code [305 ILCS
5/5-2] , and Title XIX of the Federal Social Security
Act (
42 USC
1396 a) shall continue to apply to
exceptional care provided under the Exceptional Care Program described in the
Health Finance Reform Act [20 ILCS 2215/3-5 ].
2) The Department shall provide for a program
of delegated utilization review and quality assurance. The Department may
contract with Medical Peer Review organizations to provide utilization review
and quality assurance.
3) The
Department shall review exceptional care residents' utilization of services
every 90 days. A review may be waived by the Department if one or more previous
assessments show that a resident's condition has stabilized. However, two
consecutive reviews shall not be waived. Department staff will maintain contact
with the long term care provider regarding the resident's condition during the
time period any assessment is waived.
4) In the event that it is determined that
the resident is no longer in need of or receiving exceptional care services,
the Department shall discontinue the exceptional care payment rate for the
resident and reduce the rate of payment to the provider to the provider's
standard Medicaid per diem rate.
Disclaimer: These regulations may not be the most recent version. Illinois may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
