Current through Register Vol. 48, No. 38, September 20, 2024
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:
|
Overall Level of Functioning
|
FTE*Staff: Client Ratio
|
|
Mild
|
1:10
|
|
Moderate
|
1:8
|
|
Severe-Profound
|
1:5
|
|
*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), 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.
