Fw: Arc and Comment on New Adult Waiver Draft

[Guest guest]

Arc and Comment on New Adult Waiver DraftFYI

Ellen

Ellen Garber Bronfeld

egskb@...

Arc and Comment on New Adult Waiver Draft

Director Casey and his team are asking for comments on the new

Adult Waiver. The Waiver drives how we provide supports and services to

individuals with intellectual and other developmental disabilities so it is

critical that the new waiver give individuals and families the flexibility they

need to have a real life of full choices. Is this email not displaying

correctly?

View it in your browser.

Dear Ellen,

The time frame is short, comments due by January 20,

2012. See Reta's request and draft below.

The Arc is working on their comments now.

Tony

Application for 1915© HCBS Adult Waiver Draft

IL.26.03.00 - Jul 01, 2012

Please find attached an initial draft of the renewal

application for the Adult DD Waiver. We emphasize that this is just an initial

draft and currently under review by management staff. We invite you to be

critical of it and submit your comments to us at DHS.DDDComments@....

The current Waiver expires on 6/30/12. CMS regulations

require that we submit the renewal 90 days prior to that date. It is the

State’s goal, however, to submit the renewal as early as possible in order to

provide for additional time to respond to anticipated questions posed by CMS.

Given these time frames, we are asking you to review the initial draft

concurrently with management staff and as we work with the Medicaid agency (HFS)

to finalize the application.

This first draft attempts to produce the current waiver

in the new template required by CMS. It incorporates the Performance Measures

developed over the last year or so as part of the renewals of the two

Children’s Waivers. Please note that in some sections where the template

discusses changes, the responses are addressing changes since the Waiver was

last renewed five years ago. (For example, the reference on the first page

about increasing the frequency of review activity reflects changes from five

years ago—we are not proposing increases from what we are now doing.) We are

currently working on the following items:

a.. Remediation language – samples of this can be

found at the end of many of the major Appendices. We have been receiving

technical assistance from the National Quality Contractor, and they have

recommended some changes in this area.

b.. Appendix J—this section will be updated to

reflect new numbers for the first Waiver year as a result of the Ligas

settlement.

c.. Priority Population Criteria—this is being

reviewed for changes now that the Ligas Implementation Plan has been finalized.

The application is entered into a web portal designed

for CMS. The template and our content is downloaded here for you. It may take

some time to load. In addition, if you see boxes with arrows, you may need to

click on those arrows to read the full content. Please not the document below

is in excess of 180 pages.

Application for a §1915© Home and Community-Based

Services Waiver

PURPOSE OF THE HCBS WAIVER PROGRAM

The Medicaid Home and Community-Based Services (HCBS)

waiver program is authorized in §1915© of the Social Security Act. The

program permits a State to furnish an array of home and community-based services

that assist Medicaid beneficiaries to live in the community and avoid

institutionalization. The State has broad discretion to design its waiver

program to address the needs of the waiver’s target population. Waiver

services complement and/or supplement the services that are available to

participants through the Medicaid State plan and other federal, state and local

public programs as well as the supports that families and communities provide.

The Centers for Medicare & Medicaid Services (CMS)

recognizes that the design and operational features of a waiver program will

vary depending on the specific needs of the target population, the resources

available to the State, service delivery system structure, State goals and

objectives, and other factors. A State has the latitude to design a waiver

program that is cost-effective and employs a variety of service delivery

approaches, including participant direction of services.

Request for a Renewal to a §1915© Home and

Community-Based Services Waiver

1. Major Changes

Describe any significant changes to the approved waiver

that are being made in this renewal application:

Character Count:out of 12000

Highlights of proposed changes include: In the renewal

submission, Illinois is proposing new quality improvement strategies with

specific performance measures that are described in each corresponding appendix.

There are proposed changes in oversight strategies to increase the frequency of

review activity. As a result of instituting new measures for ongoing oversight

and monitoring of this waiver, which generate a steady stream of performance

data, the OA and MA will be in an improved position to detect the impact of

system design changes and to assess and compare performance over time and across

systems. Many of the new performance measures have already been implemented as

described in the Adult Waiver evidentiary report submitted to CMS as part of the

waiver review process. Program capacity is also being increased as part of the

renewal request. A settlement was reached in the Ligas v. Illinois case and the

State has developed a plan to comply with the Court order.

Application for a §1915© Home and Community-Based

Services Waiver

1. Request Information (1 of 3)

1.. The Stateof Illinoisrequests approval for a

Medicaid home and community-based services (HCBS) waiver under the authority of

§1915© of the Social Security Act (the Act).

2.. Program Title (optional - this title will be used

to locate this waiver in the finder):

HCBS Waiver for Adults with Developmental Disabilities

1.. Type of Request: renewal

Requested Approval Period: (For new waivers requesting

five year approval periods, the waiver must serve individuals who are dually

eligible for Medicaid and Medicare.)

( )3 years (X)5 years

[ ] Migration Waiver- this is an existing approved

waiver

[X] Renewal of Waiver:

Provide the information about the original waiverbeing

renewed

Base Waiver Number: 0350

Amendment Number

(if applicable):0350.R02.01

Effective Date:(mm/dd/yy)07/01/07

Draft ID: IL.26.03.00

Renewal Number: 03

1.. Type of Waiver(select only one):

[Regular Waiver \/]

1.. Proposed Effective Date:(mm/dd/yy)

07/01/12

1. Request Information (2 of 3)

1.. Level(s) of Care. This waiver is requested in

order to provide home and community-based waiver services to individuals who,

but for the provision of such services, would require the following level(s) of

care, the costs of which would be reimbursed under the approved Medicaid State

plan (check each that applies):

[ ] Hospital

Select applicable level of care

( ) Hospital as defined in 42 CFR §440.10

If applicable, specify whether the State additionally

limits the waiver to subcategories of the hospital level of care:

Character Count:out of 6000

( ) Inpatient psychiatric facility for individuals age

21 and under as provided in42 CFR §440.160

(X) not selected

[ ] Nursing Facility

Select applicable level of care

( ) Nursing Facility As defined in 42 CFR §440.40 and

42 CFR §440.155

If applicable, specify whether the State additionally

limits the waiver to subcategories of the nursing facility level of care:

Character Count:out of 6000

( ) Institution for Mental Disease for persons with

mental illnesses aged 65 and older as provided in 42 CFR §440.140

(X) not selected

[X] Intermediate Care Facility for the Mentally Retarded

(ICF/MR) (as defined in 42 CFR §440.150)

If applicable, specify whether the State additionally

limits the waiver to subcategories of the ICF/MR level of care:

Character Count:out of 6000

Not applicable.

1. Request Information (3 of 3)

1.. Concurrent Operation with Other Programs. This

waiver operates concurrently with another program (or programs) approved under

the following authorities

Select one:

(X) Not applicable

( ) Applicable

Check the applicable authority or authorities:

[ ] Services furnished under the provisions of

§1915(a)(1)(a) of the Act and described in Appendix I

[ ] Waiver(s) authorized under §1915( of the Act.

Specify the §1915( waiver program and indicate

whether a §1915( waiver application has been submitted or previously

approved:

Character Count:out of 6000

Specify the §1915( authorities under which this

program operates (check each that applies):

[ ] §1915((1) (mandated enrollment to managed care)

[ ] §1915((2) (central broker)

[ ] §1915((3) (employ cost savings to furnish

additional services)

[ ] §1915((4) (selective contracting/limit number of

providers)

[ ] A program operated under §1932(a) of the Act.

Specify the nature of the State Plan benefit and

indicate whether the State Plan Amendment has been submitted or previously

approved:

Character Count:out of 6000

[ ] A program authorized under §1915(i) of the Act.

[ ] A program authorized under §1915(j) of the Act.

[ ] A program authorized under §1115 of the Act.

Specify the program:

Character Count:out of 6000

[ ] Not applicable

( ) not selected

1.. Dual Eligiblity for Medicaid and Medicare.

Check if applicable:

[ ] This waiver provides services for individuals who

are eligible for both Medicare and Medicaid.

2. Brief Waiver Description

Brief Waiver Description. In one page or less, briefly

describe the purpose of the waiver, including its goals, objectives,

organizational structure (e.g., the roles of state, local and other entities),

and service delivery methods.

Character Count:out of 6000

The Adult Developmental Disabilities Waiver provides

supports to eligible adults with developmental disabilities ages 18 and older.

The supports provided are designed to prevent or delay out-of-home residential

services for participants or to provide residential services in the least

restrictive community setting for participants who would otherwise need ICF/MR

level of care. The Waiver affords participants the choice between participant

direction and employer authority and more traditional service delivery, or a

combination of the two options. The number of participants served each year is

based on available State appropriation levels. Participants who choose

home-based supports may select from a menu of services based on their individual

needs within an overall monthly services cost maximum. Typical services chosen

by participants may include day programs as well as direct services provided by

common law employees or by employees of direct service agencies. Participants

also have a variety of therapies and other services available to them.

Residential services participants are provided with residential services and

supports from the qualified provider of their choice. These participants may

also select day programs and have a variety of therapies and other services

available to them. All participants receive assistance in directing service

delivery options from Individual Service and Support Advocates (ISSA) employed

by Independent Service Coordination (ISC) entities under contract with the

Operating Agency. Participants who choose to hire common law employees receive

assistance from a Financial Management Service (FMS) entity. Independent Service

Coordination (ISC) entities under contract with the Operating Agency serve as

the local point of access for adults with developmental disabilities. In

cooperation with the Medicaid Agency (MA), the Division of Developmental

Disabilities within the Illinois Department of Human Services (OA) operates the

Adult Developmental Disabilities Waiver.

3. Components of the Waiver Request

The waiver application consists of the following

components.Note: Item 3-E must be completed.

1.. Waiver Administration and Operation.Appendix A

specifies the administrative and operational structure of this waiver.

2.. Participant Access and Eligibility.Appendix B

specifies the target group(s) of individuals who are served in this waiver, the

number of participants that the State expects to serve during each year that the

waiver is in effect, applicable Medicaid eligibility and post-eligibility (if

applicable) requirements, and procedures for the evaluation and reevaluation of

level of care.

3.. Participant Services.Appendix C specifies the home

and community-based waiver services that are furnished through the waiver,

including applicable limitations on such services.

4.. Participant-Centered Service Planning and

Delivery.Appendix D specifies the procedures and methods that the State uses to

develop, implement and monitor the participant-centered service plan (of care).

5.. Participant-Direction of Services. When the State

provides for participant direction of services, Appendix Especifies the

participant direction opportunities that are offered in the waiver and the

supports that are available to participants who direct their services. (Select

one):

(X) Yes. This waiver provides participant direction

opportunities. Appendix E is required.

( ) No. This waiver does not provide participant

direction opportunities. Appendix E is not required.

( ) not selected

1.. Participant Rights.Appendix F specifies how the

State informs participants of their Medicaid Fair Hearing rights and other

procedures to address participant grievances and complaints.

2.. Participant Safeguards.Appendix G describes the

safeguards that the State has established to assure the health and welfare of

waiver participants in specified areas.

3.. Quality Improvement Strategy.Appendix H contains

the Quality Improvement Strategy for this waiver.

4.. Financial Accountability.Appendix I describes the

methods by which the State makes payments for waiver services, ensures the

integrity of these payments, and complies with applicable federal requirements

concerning payments and federal financial participation.

5.. Cost-Neutrality Demonstration.Appendix J contains

the State's demonstration that the waiver is cost-neutral.

4. Waiver(s) Requested

1.. Comparability.The State requests a waiver of the

requirements contained in §1902(a)(10)( of the Act in order to provide the

services specified in Appendix C that are not otherwise available under the

approved Medicaid State plan to individuals who: (a) require the level(s) of

care specified in Item 1.F and ( meet the target group criteria specified in

Appendix B.

2.. Income and Resources for the Medically

Needy.Indicate whether the State requests a waiver of §1902(a)(10)©(i)(III)

of the Act in order to use institutional income and resource rules for the

medically needy (select one):

( ) Not Applicable

(X) No

( ) Yes

( ) not selected

1.. Statewideness.Indicate whether the State requests

a waiver of the statewideness requirements in §1902(a)(1) of the Act (select

one):

(X)No

( )Yes

1.. If yes, specify the waiver of statewideness that

is requested (check each that applies):

2.. [ ] Geographic Limitation. A waiver of

statewideness is requested in order to furnish services under this waiver only

to individuals who reside in the following geographic areas or political

subdivisions of the State.

3.. Specify the areas to which this waiver applies

and, as applicable, the phase-in schedule of the waiver by geographic area:

4.. Character Count:out of 6000

5.. [ ] Limited Implementation of

Participant-Direction. A waiver of statewideness is requested in order to make

participant-direction of services as specified in Appendix E available only to

individuals who reside in the following geographic areas or political

subdivisions of the State. Participants who reside in these areas may elect to

direct their services as provided by the State or receive comparable services

through the service delivery methods that are in effect elsewhere in the State.

6.. Specify the areas of the State affected by this

waiver and, as applicable, the phase-in schedule of the waiver by geographic

area:

7.. Character Count:out of 6000

5. Assurances

In accordance with 42 CFR §441.302, the State provides

the following assurances to CMS:

1.. Health & Welfare:The State assures that necessary

safeguards have been taken to protect the health and welfare of persons

receiving services under this waiver. These safeguards include:

2.. As specified in Appendix C, adequate standards for

all types of providers that provide services under this waiver;

3.. Assurance that the standards of any State

licensure or certification requirements specified in Appendix C are met for

services or for individuals furnishing services that are provided under the

waiver. The State assures that these requirements are met on the date that the

services are furnished; and,

4.. Assurance that all facilities subject to §1616(e)

of the Act where home and community-based waiver services are provided comply

with the applicable State standards for board and care facilities as specified

in Appendix C.

5.. Financial Accountability.The State assures

financial accountability for funds expended for home and community-based

services and maintains and makes available to the Department of Health and Human

Services (including the Office of the Inspector General), the Comptroller

General, or other designees, appropriate financial records documenting the cost

of services provided under the waiver. Methods of financial accountability are

specified in Appendix I.

6.. Evaluation of Need:The State assures that it

provides for an initial evaluation (and periodic reevaluations, at least

annually) of the need for a level of care specified for this waiver, when there

is a reasonable indication that an individual might need such services in the

near future (one month or less) but for the receipt of home and community based

services under this waiver. The procedures for evaluation and reevaluation of

level of care are specified in Appendix B.

7.. Choice of Alternatives: The State assures that

when an individual is determined to be likely to require the level of care

specified for this waiver and is in a target group specified in Appendix B, the

individual (or, legal representative, if applicable) is:

8.. Informed of any feasible alternatives under the

waiver; and,

9.. Given the choice of either institutional or home

and community based waiver services. Appendix B specifies the procedures that

the State employs to ensure that individuals are informed of feasible

alternatives under the waiver and given the choice of institutional or home and

community-based waiver services.

10.. Average Per Capita Expenditures:The State assures

that, for any year that the waiver is in effect, the average per capita

expenditures under the waiver will not exceed 100 percent of the average per

capita expenditures that would have been made under the Medicaid State plan for

the level(s) of care specified for this waiver had the waiver not been granted.

Cost-neutrality is demonstrated in Appendix J.

11.. Actual Total Expenditures:The State assures that

the actual total expenditures for home and community-based waiver and other

Medicaid services and its claim for FFP in expenditures for the services

provided to individuals under the waiver will not, in any year of the waiver

period, exceed 100 percent of the amount that would be incurred in the absence

of the waiver by the State's Medicaid program for these individuals in the

institutional setting(s) specified for this waiver.

12.. Institutionalization Absent Waiver:The State

assures that, absent the waiver, individuals served in the waiver would receive

the appropriate type of Medicaid-funded institutional care for the level of care

specified for this waiver.

13.. Reporting:The State assures that annually it will

provide CMS with information concerning the impact of the waiver on the type,

amount and cost of services provided under the Medicaid State plan and on the

health and welfare of waiver participants. This information will be consistent

with a data collection plan designed by CMS.

14.. Habilitation Services.The State assures that

prevocational, educational, or supported employment services, or a combination

of these services, if provided as habilitation services under the waiver are:

(1) not otherwise available to the individual through a local educational agency

under the Individuals with Disabilities Education Act (IDEA) or the

Rehabilitation Act of 1973; and, (2) furnished as part of expanded habilitation

services.

15.. Services for Individuals with Chronic Mental

Illness.The State assures that federal financial participation (FFP) will not be

claimed in expenditures for waiver services including, but not limited to, day

treatment or partial hospitalization, psychosocial rehabilitation services, and

clinic services provided as home and community-based services to individuals

with chronic mental illnesses if these individuals, in the absence of a waiver,

would be placed in an IMD and are: (1) age 22 to 64; (2) age 65 and older and

the State has not included the optional Medicaid benefit cited in 42 CFR

§440.140; or (3) age 21 and under and the State has not included the optional

Medicaid benefit cited in 42 CFR § 440.160.

6. Additional Requirements

Note: Item 6-I must be completed.

1.. Service Plan. In accordance with 42 CFR

§441.301((1)(i), a participant-centered service plan (of care) is developed

for each participant employing the procedures specified in Appendix D. All

waiver services are furnished pursuant to the service plan. The service plan

describes: (a) the waiver services that are furnished to the participant, their

projected frequency and the type of provider that furnishes each service and (

the other services (regardless of funding source, including State plan services)

and informal supports that complement waiver services in meeting the needs of

the participant. The service plan is subject to the approval of the Medicaid

agency. Federal financial participation (FFP) is not claimed for waiver services

furnished prior to the development of the service plan or for services that are

not included in the service plan.

2.. Inpatients. In accordance with 42 CFR

§441.301((1) (ii), waiver services are not furnished to individuals who are

in-patients of a hospital, nursing facility or ICF/MR.

3.. Room and Board. In accordance with 42 CFR

§441.310(a)(2), FFP is not claimed for the cost of room and board except when:

(a) provided as part of respite services in a facility approved by the State

that is not a private residence or ( claimed as a portion of the rent and food

that may be reasonably attributed to an unrelated caregiver who resides in the

same household as the participant, as provided in Appendix I.

4.. Access to Services. The State does not limit or

restrict participant access to waiver services except as provided in Appendix C.

5.. Free Choice of Provider. In accordance with 42 CFR

§431.151, a participant may select any willing and qualified provider to

furnish waiver services included in the service plan unless the State has

received approval to limit the number of providers under the provisions of

§1915( or another provision of the Act.

6.. FFP Limitation. In accordance with 42 CFR §433

Subpart D, FFP is not claimed for services when another third-party (e.g.,

another third party health insurer or other federal or state program) is legally

liable and responsible for the provision and payment of the service. FFP also

may not be claimed for services that are available without charge, or as free

care to the community. Services will not be considered to be without charge, or

free care, when (1) the provider establishes a fee schedule for each service

available and (2) collects insurance information from all those served

(Medicaid, and non-Medicaid), and bills other legally liable third party

insurers. Alternatively, if a provider certifies that a particular legally

liable third party insurer does not pay for the service(s), the provider may not

generate further bills for that insurer for that annual period.

7.. Fair Hearing:The State provides the opportunity to

request a Fair Hearing under 42 CFR §431 Subpart E, to individuals: (a) who are

not given the choice of home and community- based waiver services as an

alternative to institutional level of care specified for this waiver; ( who

are denied the service(s) of their choice or the provider(s) of their choice; or

© whose services are denied, suspended, reduced or terminated. Appendix F

specifies the State's procedures to provide individuals the opportunity to

request a Fair Hearing, including providing notice of action as required in 42

CFR §431.210.

8.. Quality Improvement. The State operates a formal,

comprehensive system to ensure that the waiver meets the assurances and other

requirements contained in this application. Through an ongoing process of

discovery, remediation and improvement, the State assures the health and welfare

of participants by monitoring: (a) level of care determinations; ( individual

plans and services delivery; © provider qualifications; (d) participant health

and welfare; (e) financial oversight and (f) administrative oversight of the

waiver. The State further assures that all problems identified through its

discovery processes are addressed in an appropriate and timely manner,

consistent with the severity and nature of the problem. During the period that

the waiver is in effect, the State will implement the Quality Improvement

Strategy specified in Appendix H.

9.. Public Input. Describe how the State secures

public input into the development of the waiver:

Character Count:out of 6000

The State gathered public input for this Waiver

application from the Statewide Advisory Council (SAC) on Developmental

Disabilities, local network advisory councils, the Waiver Ad-Hoc Committee, and

a series of focus groups on the Strategic Plan arranged by the Waiver Operating

Agency. On an ongoing basis, the SAC meets once each quarter. It is comprised of

a direct consumer, a family member, and a provider elected from each of the

local network advisory councils across the state; a representative from the

Center for Capacity Building on Minorities with Disabilities Research at the

University of Illinois at Chicago; a representative from the federally-funded

Illinois Council on Developmental Disabilities; a representative from Equip for

Equality, the State’s protection and advocacy organization; and a director

from one of the State-Operated Developmental Centers in Illinois. Medicaid

Agency staff routinely attend. All members are welcome to provide individual

comments as well as viewpoints from their respective affiliations to the SAC.

Meetings are also well attended by the public. A segment of each meeting is

devoted to giving audience or network advisory council members the opportunity

to address the SAC on a topic of their choosing relating to developmental

disabilities. When the SAC needs detailed input on complex matters, ad-hoc

committees are formed as needed. Ad-Hoc committees have a broad spectrum of

membership that typically includes consumers, family members, providers, trade

group members, and other advocates. As ad-hoc committees develop their reports

and recommendations, updates of their meetings and drafts of their work are

distributed at the SAC. Comments from SAC members are routinely sought and

incorporated into the finished committee products. Such an ad-hoc committee was

created to assist the State in the development of this application. The

multi-year DDD Strategic Plan was developed with extensive inputs received from

direct consumers and families at over 30 statewide focus group meetings held

across the state. The information gathered in the focus groups provided valuable

insights into the wide-ranging array of service preferences. The focus group

dialogues had significant influences on the development of the Adult

Developmental Disabilities Waiver.

1.. Notice to Tribal Governments. The State assures

that it has notified in writing all federally-recognized Tribal Governments that

maintain a primary office and/or majority population within the State of the

State's intent to submit a Medicaid waiver request or renewal request to CMS at

least 60 days before the anticipated submission date is provided by Presidential

Executive Order 13175 of November 6, 2000. Evidence of the applicable notice is

available through the Medicaid Agency.

2.. Limited English Proficient Persons. The State

assures that it provides meaningful access to waiver services by Limited English

Proficient persons in accordance with: (a) Presidential Executive Order 13166 of

August 11, 2000 (65 FR 50121) and ( Department of Health and Human Services

" Guidance to Federal Financial Assistance Recipients Regarding Title VI

Prohibition Against National Origin Discrimination Affecting Limited English

Proficient Persons " (68 FR 47311 - August 8, 2003). Appendix B describes how the

State assures meaningful access to waiver services by Limited English Proficient

persons.

7. Contact Person(s)

1.. The Medicaid agency representative with whom CMS

should communicate regarding the waiver is:

Last Name: Roehrs

First Name:

Title: Bureau Chief

Agency: Department of Healthcare and Family

Services

Address: Bureau of Interagency Coordination

Address 2: 201 South Grand Avenue East, 3rd Floor

City: Springfield

State: Illinois

Zip: 62763

Phone: (217) 557-1863 Ext: [ ] [ ] TTY

Fax: (217) 557-8604

E-mail: .Roehrs@...

1.. If applicable, the State operating agency

representative with whom CMS should communicate regarding the waiver is:

Last Name: Hoskin

First Name: Reta

Title: Acting Director

Agency: Department of Human Services

Address: Division of Developmental Disabilities

Address 2: 319 E. Madison, Suite 3M

City: Springfield

State: Illinois

Zip: 62701

Phone: (217) 782-9421 Ext: [ ] [ ] TTY

Fax: (217) 558-2799

E-mail: Reta.Hoskin@...

8. Authorizing Signature

This document, together with Appendices A through J,

constitutes the State's request for a waiver under §1915© of the Social

Security Act. The State assures that all materials referenced in this waiver

application (including standards, licensure and certification requirements) are

readily available in print or electronic form upon request to CMS through the

Medicaid agency or, if applicable, from the operating agency specified in

Appendix A. Any proposed changes to the waiver will be submitted by the Medicaid

agency to CMS in the form of waiver amendments.

Upon approval by CMS, the waiver application serves as

the State's authority to provide home and community-based waiver services to the

specified target groups. The State attests that it will abide by all provisions

of the approved waiver and will continuously operate the waiver in accordance

with the assurances specified in Section 5 and the additional requirements

specified in Section 6 of the request.

Signature: [ ]

State Medicaid Director or Designee

Submission Date: [ ]

Last Name: Eagleson

First Name: Theresa

Title: Medicaid Director

Agency: Department of Healthcare and Family

Services

Address: Division of Medical Programs

Address 2: 201 South Grand Avenue East, 3rd Floor

City: Springfield

State: Illinois

Zip: 62763

Phone: (217) 782-2570

Fax: (217) 782-5672

E-mail: Theresa.Eagleson@...

Attachment #1: Transition Plan

Specify the transition plan for the waiver:

Character Count:out of 12000

Not applicable.

Additional Needed Information (Optional)

Provide additional needed information for the waiver

(optional):

Character Count:out of 60000

Appendix A: Waiver Administration and Operation

1.. State Line of Authority for Waiver

Operation.Specify the state line of authority for the operation of the waiver

(select one):

( ) The waiver is operated by the State Medicaid agency.

Specify the Medicaid agency division/unit that has line

authority for the operation of the waiver program (select one):

( ) The Medical Assistance Unit.

Specify the unit name:(Do not complete item A-2)

( ) Another division/unit within the State Medicaid

agency that is separate from the Medical Assistance Unit.

Specify the division/unit name. This includes

administrations/divisions under the umbrella agency that has been identified as

the Single State Medicaid Agency.(Complete item A-2-a).

(X) not selected

(X) The waiver is operated by a separate agency of the

State that is not a division/unit of the Medicaid agency.

Specify the division/unit name:Illinois Department of

Human Services (DHS), Division of Developmental Disabilities

In accordance with 42 CFR §431.10, the Medicaid agency

exercises administrative discretion in the administration and supervision of the

waiver and issues policies, rules and regulations related to the waiver. The

interagency agreement or memorandum of understanding that sets forth the

authority and arrangements for this policy is available through the Medicaid

agency to CMS upon request. (Complete item A-2-.

( ) not selected

Appendix A: Waiver Administration and Operation

1.. Oversight of Performance.

1.. Medicaid Director Oversight of Performance When

the Waiver is Operated by another Division/Unit within the State Medicaid

Agency. When the waiver is operated by another division/administration within

the umbrella agency designated as the Single State Medicaid Agency. Specify (a)

the functions performed by that division/administration (i.e., the Developmental

Disabilities Administration within the Single State Medicaid Agency), ( the

document utilized to outline the roles and responsibilities related to waiver

operation, and © the methods that are employed by the designated State

Medicaid Director (in some instances, the head of umbrella agency) in the

oversight of these activities:

As indicated in section 1 of this appendix, the waiver

is not operated by another division/unit within the State Medicaid agency. Thus

this section does not need to be completed.

Character Count:out of 12000

1.. Medicaid Agency Oversight of Operating Agency

Performance. When the waiver is not operated by the Medicaid agency, specify the

functions that are expressly delegated through a memorandum of understanding

(MOU) or other written document, and indicate the frequency of review and update

for that document. Specify the methods that the Medicaid agency uses to ensure

that the operating agency performs its assigned waiver operational and

administrative functions in accordance with waiver requirements. Also specify

the frequency of Medicaid agency assessment of operating agency performance:

Character Count:out of 12000

The Department of Healthcare and Family Services (HFS),

Illinois’ Medicaid Agency, conducts the following activities: •The Medicaid

Agency reviews and approves all changes to Medicaid policies, rules and

regulations prior to implementation. •The Medicaid Agency conducts all waiver

appeal hearings and issues final administrative decisions, providing the

independent hearing officer for all appeal hearings. The MA conducts all waiver

appeal hearings using trained hearing officers and does not delegate this

function to the OA. •The Medicaid Agency reviews and approves changes to the

Operating Agency’s payment rate methodologies. •The Medicaid Agency conducts

program monitoring by participating jointly with the Operating Agency in select

reviews of a representative sample of participants, and by using performance

measures and sampling described in Appendix A. •The Medicaid Agency conducts

fiscal monitoring by conducting validation reviews from the Operating Agency

post-payment reviews of a representative sample of participants, and by using

performance measures and sampling described in Appendix A. •Staff from the

Medicaid Agency are members of the Quality Management Committee (QMC). The

committee is responsible for the overall coordination of quality management

activities. Current members of the QMC include key staff from both the MA and

the OA. This includes representatives from the MA Bureau of Interagency

Coordination and the OA's Bureau of Quality Management, and the OA's Bureau of

Program Development and Medicaid Administration. The committee is charged with

reviewing data for the waiver performance measures, tracking the findings, and

discussing strategies for remediation, both individual and systemic, based on

the evidence presented. •Staff from the Medicaid Agency attends meetings of

the Operating Agency’s Statewide Advisory Council on Developmental

Disabilities, with which all major initiatives and policy issues are discussed.

The MA is not a formal member of the Statewide Advisory Council on DD but

voluntarily participates as a way to keep informed of issues impacting

individuals with DD being discussed by the council. The Statewide Advisory

Council is not a policy-making body, but is advisory in nature and addresses all

developmental disability issues including those services funded by Medicaid and

those funded by other State sources. Medicaid Agency staff attempt to attend all

Statewide Advisory Council meetings; however attendance is optional. Should an

absence be necessary, a meeting summary is provided by the OA. •The Medicaid

Agency participates with the Operating Agency in training and informational

sessions.

Appendix A: Waiver Administration and Operation

1.. Use of Contracted Entities.Specify whether

contracted entities perform waiver operational and administrative functions on

behalf of the Medicaid agency and/or the operating agency (if applicable)

(select one):

(X) Yes. Contracted entities perform waiver operational

and administrative functions on behalf of the Medicaid agency and/or operating

agency (if applicable).

Specify the types of contracted entities and briefly

describe the functions that they perform. Complete Items A-5 and A-6.:

Character Count:out of 6000

Under contract with the Operating Agency, private

entities complete eligibility determinations, as well as independent service

coordination and monitoring functions. These functions are done by Qualified

Mental Retardation Professionals (QMRPs) known as Qualified Support

Professionals (QSPs) in Illinois. In addition, the Operating Agency, at times,

uses contracted vendors, selected in accordance with the State's procurement

policies, to assist with functions related to consultation and technical

assistance for establishing provider qualifications and establishing rate

methodologies.

( ) No. Contracted entities do not perform waiver

operational and administrative functions on behalf of the Medicaid agency and/or

the operating agency (if applicable).

( ) not selected

Appendix A: Waiver Administration and Operation

1.. Role of Local/Regional Non-State Entities.Indicate

whether local or regional non-state entities perform waiver operational and

administrative functions and, if so, specify the type of entity (Select One):

( ) not selected

(X) Not applicable

( ) Applicable - Local/regional non-state agencies

perform waiver operational and administrative functions.

Check each that applies:

[ ] Local/Regional non-state public agenciesperform

waiver operational and administrative functions at the local or regional level.

There is an interagency agreement or memorandum of understandingbetween the

State and these agencies that sets forth responsibilities and performance

requirements for these agencies that is available through the Medicaid agency.

Specify the nature of these agencies and complete items

A-5 and A-6:

Character Count:out of 6000

[ ] Local/Regional non-governmental non-state

entitiesconduct waiver operational and administrative functions at the local or

regional level. There is a contract between the Medicaid agency and/or the

operating agency (when authorized by the Medicaid agency) and each

local/regional non-state entity that sets forth the responsibilities and

performance requirements of the local/regional entity. The contract(s)under

which private entities conduct waiver operational functions are available to CMS

upon request through the Medicaid agency or the operating agency (if

applicable).

Specify the nature of these entities and complete items

A-5 and A-6:

Character Count:out of 6000

[ ] Not applicable- Local/regional non-state agencies do

not perform waiver operational and administrative functions.

Appendix A: Waiver Administration and Operation

1.. Responsibility for Assessment of Performance of

Contracted and/or Local/Regional Non-State Entities. Specify the state agency or

agencies responsible for assessing the performance of contracted and/or

local/regional non-state entities in conducting waiver operational and

administrative functions:

Character Count:out of 6000

The Department of Human Services, the Operating Agency,

assesses the performance of the contracted entities.

Appendix A: Waiver Administration and Operation

1.. Assessment Methods and Frequency. Describe the

methods that are used to assess the performance of contracted and/or

local/regional non-state entities to ensure that they perform assigned waiver

operational and administrative functions in accordance with waiver requirements.

Also specify how frequently the performance of contracted and/or local/regional

non-state entities is assessed:

Character Count:out of 6000

The Operating Agency reviews and approves contracted

entities on an annual basis to ensure they are conforming to established

standards. Operating Agency staff conduct annual on-site surveys that focus on

compliance with the requirements of the Agency’s screening manual and ISSA

Guidelines, as well as contractual requirements. The survey protocol includes

staff qualifications and training, 24-hour accessibility for emergencies, a

review of the pre-admission screening process (documentation of required

assessments, eligibility determinations, informed choice and selection of

services, and conflict of interest), and review of the Individual Service and

Support Advocacy process (documentation of required visits, participation in

support plan development and approval, and annual re-determinations of

eligibility). Agencies are notified in writing of any deficiencies and are

required to submit a plan of correction, including timeframes, if the agency

scores less than 90% on their overall performance. Operating Agency staff review

the plan of correction and, if acceptable, approve it. Summary reports of the

reviews are shared with and discussed by the State’s Waiver Quality Management

Committee, which includes both Medicaid and the Operating Agency staff, during

its quarterly meetings.

Appendix A: Waiver Administration and Operation

1.. Distribution of Waiver Operational and

Administrative Functions.In the following table, specify the entity or entities

that have responsibility for conducting each of the waiver operational and

administrative functions listed (check each that applies):

In accordance with 42 CFR §431.10, when the Medicaid

agency does not directly conduct a function, it supervises the performance of

the function and establishes and/or approves policies that affect the

function.All functions not performed directly by the Medicaid agency must be

delegated in writing and monitored by the Medicaid Agency. Note: More than one

box may be checked per item. Ensure that Medicaid is checked when the Single

State Medicaid Agency (1) conducts the function directly; (2) supervises the

delegated function; and/or (3) establishes and/or approves policies related to

the function.

Function Medicaid Agency Other State Operating

Agency Contracted Entity

75137Participant waiver enrollment [X] [X] [X]

75138Waiver enrollment managed against approved

limits [X] [X] [ ]

75139Waiver expenditures managed against approved

levels [X] [X] [ ]

75140Level of care evaluation [X] [X] [X]

75141Review of Participant service plans [X] [X]

[X]

75142Prior authorization of waiver services [X]

[X] [X]

75143Utilization management [X] [X] [ ]

75144Qualified provider enrollment [X] [X] [ ]

75145Execution of Medicaid provider agreements [X]

[X] [X]

75146Establishment of a statewide rate methodology

[X] [X] [ ]

75147Rules, policies, procedures and information

development governing the waiver program [X] [X] [ ]

75148Quality assurance and quality improvement

activities [X] [X] [X]

Appendix A: Waiver Administration and Operation

Quality Improvement: Administrative Authority of the

Single State Medicaid Agency

As a distinct component of the State’s quality

improvement strategy, provide information in the following fields to detail the

State’s methods for discovery and remediation.

1.. Methods for Discovery: Administrative Authority

The Medicaid Agency retains ultimate administrative

authority and responsibility for the operation of the waiver program by

exercising oversight of the performance of waiver functions by other state and

local/regional non-state agencies (if appropriate) and contracted entities.

1.. Performance Measures

For each performance measure/indicator the State will

use to assess compliance with the statutory assurance complete the following.

Where possible, include numerator/denominator. Each performance measure must be

specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the

aggregated data that will enable the State to analyze and assess progress toward

the performance measure. In this section provide information on the method by

which each source of data is analyzed statistically/deductively or inductively,

how themes are identified or conclusions drawn, and how recommendations are

formulated, where appropriate.

Performance Measure:

Number and percent of reports submitted to the MA

with evidence of timely remediation in the areas of pre-admission screening and

waiver enrollment. Numerator: Number of reports on pre-admission screening and

waiver enrollment submitted to Waiver QMC. Denominator: Number of reports due.

Data Source(Select one):

Reports to State Medicaid Agency on delegated

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [X] 100%

Review

[X] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of semi-annual fiscal reports

generated by the MA where waiver enrollment, utilization and expenditures meet

estimated levels in the approved waiver. Numerator: Number of semi-annual fiscal

reports submitted to the Waiver QMC. Denominator: Number of required reports.

Data Source(Select one):

Other

If 'Other' is selected, specify:

MA MMIS

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[X] State Medicaid Agency [ ] Weekly [X] 100%

Review

[ ] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [ ] Annually [ ] Stratified

Describe Group:

[ ] Continuously and Ongoing [ ] Other

Specify:

[X] Other

Specify:

Semi-Annually

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [ ] Annually

[ ] Continuously and Ongoing

[X] Other

Specify:

Semi-Annually

Performance Measure:

Number and percent of reports submitted to the MA

with evidence of timely remediation in the area of level of care. Numerator:

Number of reports on level of care determinations submitted to the Waiver QMC.

Denominator: Number of required reports.

Data Source(Select one):

Reports to State Medicaid Agency on delegated

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [X] 100%

Review

[X] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of reports submitted to the MA

with evidence of timely remediation in the area of service plans. Numerator:

Number of reports on service plans submitted to the Waiver QMC. Denominator:

Number of required reports on service plans.

Data Source(Select one):

Reports to State Medicaid Agency on delegated

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [X] 100%

Review

[X] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of reports submitted to the MA

with evidence of timely remediation in the area of provider qualifications.

Numerator: Number of reports on provider qualifications submitted to the Waiver

QMC. Denominator: Number of required reports.

Data Source(Select one):

Reports to State Medicaid Agency on delegated

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [X] 100%

Review

[X] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of waiver providers with a

Medicaid provider agreement on file at the MA. Numerator: Number of waiver

providers with agreements on file with the MA. Denominator: Total number of

waiver providers.

Data Source(Select one):

Other

If 'Other' is selected, specify:

MA MMIS

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[X] State Medicaid Agency [ ] Weekly [X] 100%

Review

[ ] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of rate methodology changes

submitted to the MA for approval and submitted for Public Notice prior to

implementation by OA. Numerator: Number of rate changes submitted to the MA

prior to implementation by the OA. Denominator: Total number of rate methodology

changes adopted.

Data Source(Select one):

Reports to State Medicaid Agency on delegated

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [X] 100%

Review

[X] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of waiver program policies

submitted to the MA prior to OA dissemination and implementation. Numerator:

Number of waiver policies submitted to the MA prior to dissemination.

Denominator: Total number of waiver policy changes implemented.

Data Source(Select one):

Reports to State Medicaid Agency on delegated

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[X] State Medicaid Agency [ ] Weekly [X] 100%

Review

[X] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of requests for services

subject to prior authorization that are decided in a timely manner. Numerator:

Number of services subject to prior approval decided in a timely manner.

Denominator: Total number of requests submitted.

Data Source(Select one):

Program logs

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [X] 100%

Review

[X] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of quality reviews conducted as

compared to the number specified in the approved waiver. Numerator: Number of

ISP reviews conducted. Denominator: Number of participants in the annual sample.

Data Source(Select one):

Record reviews, on-site

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [X] 100%

Review

[X] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

1.. If applicable, in the textbox below provide any

necessary additional information on the strategies employed by the State to

discover/identify problems/issues within the waiver program, including frequency

and parties responsible.

Character Count:out of 6000

The OA conducts site visits based on a representative

sample of participants in the waiver. A planned schedule of all on-site reviews

is provided to the MA at the beginning of each waiver year. Joint reviews will

be conducted by the MA and OA. The MA will participate in select reviews, as

possible.

1.. Methods for Remediation/Fixing Individual Problems

1.. Describe the State’s method for addressing

individual problems as they are discovered. Include information regarding

responsible parties and GENERAL methods for problem correction. In addition,

provide information on the methods used by the State to document these items.

Character Count:out of 6000

The OA is responsible for timely remediation of issues

found during their monitoring. This includes assuring that individual issues are

resolved. The OA provides quarterly summary reports of their activities to the

Medicaid agency. The Medicaid Agency reviews the quarterly reports and

determines the appropriate follow-up. General remediation activities may

include, recommending that the OA clarify policy, retrain staff, provide

technical assistance, void claims, increase monitoring, conduct focused reviews

with the MA, or develop a plan of correction.

1.. Remediation Data Aggregation

Remediation-related Data Aggregation and Analysis

(including trend identification)

Responsible Party (check each that applies):

Frequency of data aggregation and analysis (check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [ ] Annually

[X] Continuously and Ongoing

[ ] Other

Specify:

1.. Timelines

When the State does not have all elements of the Quality

Improvement Strategy in place, provide timelines to design methods for discovery

and remediation related to the assurance of Administrative Authority that are

currently non-operational.

(X) No

( ) Yes

( ) not selected

Please provide a detailed strategy for assuring

Administrative Authority, the specific timeline for implementing identified

strategies, and the parties responsible for its operation.

Character Count:out of 6000

Appendix B: Participant Access and Eligibility

B-1: Specification of the Waiver Target Group(s)

1.. Target Group(s).Under the waiver of Section

1902(a)(10)( of the Act, the State limits waiver services to a group or

subgroups of individuals. Please see the instruction manual for specifics

regarding age limits. In accordance with 42 CFR §441.301((6), select one

waiver target group, check each of the subgroups in the selected target group

that may receive services under the waiver, and specify the minimum and maximum

(if any) age of individuals served in each subgroup:

Target Group Included Target SubGroup Minimum Age

Maximum Age

Maximum Age Limit No Maximum Age Limit

( ) Aged or Disabled, or Both - General

[ ] Aged [ ] [ ] [ ]

[ ] Disabled (Physical) [ ] [

]

[ ] Disabled (Other) [ ] [ ]

( ) Aged or Disabled, or Both - Specific

Recognized Subgroups

[ ] Brain Injury [ ] [ ] [ ]

[ ] HIV/AIDS [ ] [ ] [ ]

[ ] Medically Fragile [ ] [ ]

[ ]

[ ] Technology Dependent [ ] [

] [ ]

(X) Mental Retardation or Developmental

Disability, or Both

[X] Autism 18 [ ] [X]

[X] Developmental Disability 18 [ ] [X]

[X] Mental Retardation 18 [ ] [X]

( ) Mental Illness

[ ] Mental Illness [ ] [ ]

[ ] Serious Emotional Disturbance [ ] [

]

( ) not selected

1.. Additional Criteria. The State further specifies

its target group(s) as follows:

Character Count:out of 12000

Participants must be assessed as eligible for ICF/MR

level of care, must reside within the State of Illinois, must need active

treatment, and not be in need of nursing assessment, monitoring, intervention,

and supervision of their condition or needs on a 24-hour basis. The number of

individuals served each year will be based on available appropriations. New

enrollees will be selected from the Prioritization of Urgency of Need For

Services (PUNS) database, a database maintained by the Operating Agency of

individuals potentially in need of state-funded DD services within the next five

years. The selection criteria will provide for selection of individuals on

several bases, including urgency of need, length of time on the database, and

randomness.

1.. Transition of Individuals Affected by Maximum Age

Limitation. When there is a maximum age limit that applies to individuals who

may be served in the waiver, describe the transition planning procedures that

are undertaken on behalf of participants affected by the age limit (select one):

(X)Not applicable. There is no maximum age limit

( )The following transition planning procedures

are employed for participants who will reach the waiver's maximum age limit.

1.. Specify:

2.. Character Count:out of 12000

Appendix B: Participant Access and Eligibility

B-2: Individual Cost Limit (1 of 2)

1.. Individual Cost Limit.The following individual

cost limit applies when determining whether to deny home and community-based

services or entrance to the waiver to an otherwise eligible individual (select

one) Please note that a State may have only ONE individual cost limit for the

purposes of determining eligibility for the waiver:

( ) No Cost Limit. The State does not apply an

individual cost limit. Do not complete Item B-2-b or item B-2-c.

( ) Cost Limit in Excess of Institutional Costs. The

State refuses entrance to the waiver to any otherwise eligible individual when

the State reasonably expects that the cost of the home and community-based

services furnished to that individual would exceed the cost of a level of care

specified for the waiver up to an amount specified by the State. Complete Items

B-2-b and B-2-c.

The limit specified by the State is(select one)

( ) A level higher than 100% of the institutional

average.

Specify the percentage:[ ]

( ) Other

Specify:

Character Count:out of 6000

(X) not selected

( ) Institutional Cost Limit. Pursuant to 42 CFR

441.301(a)(3), the State refuses entrance to the waiver to any otherwise

eligible individual when the State reasonably expects that the cost of the home

and community-based services furnished to that individual would exceed 100% of

the cost of the level of care specified for the waiver. Complete Items B-2-b and

B-2-c.

(X) Cost Limit Lower Than Institutional Costs. The State

refuses entrance to the waiver to any otherwise qualified individual when the

State reasonably expects that the cost of home and community-based services

furnished to that individual would exceed the following amount specified by the

State that is less than the cost of a level of care specified for the waiver.

Specify the basis of the limit, including evidence that

the limit is sufficient to assure the health and welfare of waiver participants.

Complete Items B-2-b and B-2-c.

Character Count:out of 6000

For participants requesting home-based supports, total

costs are limited based on State statute (405 ILCS 80). The cost limit was

developed in 1990 with input from advocates and family members. Since

implementation, the cost limit has been updated based on annual cost of living

adjustments as prescribed by law. This limit does not apply to residential

services. The statutory monthly cost limit for waiver participants who receive

home-based supports and are in special education is two times the Supplemental

Security Income (SSI) amount for an adult living alone (SSI amount is currently

$674 for calendar year 2011). The statutory monthly cost limit for all other

waiver participants in home-based supports is three times the SSI amount. These

cost limits apply only to participants in the home-based supports option. Within

the statutory limits, the participant, Service Facilitator, and other members of

the team develop an individual service plan to meet the participant’s needs.

If the primary unpaid caregiver is temporarily unable to provide necessary

services that may endanger the participant’s health and welfare, the

participant will be considered for temporary crises services.

Participant-directed home-based supports are available to individuals living in

a home owned or leased by the participant or the participant’s family member.

Participant-directed home-based supports are not intended to meet all of the

needs of the participant being served. In combination with natural unpaid

supports, generic community resources, and Medicaid State Plan services,

home-based supports assist in meeting the needs of the participant. Current

State appropriations provide funding at the level specified in the State statute

for adults receiving this Waiver service option. If the health and welfare of

the participant cannot be assured on a long-term basis within the cost limit of

participant-directed home-based supports in combination with other natural

supports and community resources, the participant will be considered for other

service options within the Waiver, including residential habilitation.

The cost limit specified by the State is(select one):

(X) The following dollar amount:

Specify dollar amount:24264

The dollar amount(select one)

(X) Is adjusted each year that the waiver is in effect

by applying the following formula:

Specify the formula:

Character Count:out of 6000

The cost limit for participant-directed home-based

supports is based on the support plan of the participant, but in no case may it

be more than three hundred percent of the monthly federal Supplemental Security

Income (SSI) payment for an individual living alone. Federal SSI payments are

indexed to the cost of living. The Waiver home-based supports cost limit is

adjusted annually at the start of each calendar year based on cost of living

changes in the federal SSI payment levels.

( ) May be adjusted during the period the waiver is in

effect. The State will submit a waiver amendment to CMS to adjust the dollar

amount.

( ) not selected

( ) The following percentage that is less than 100% of

the institutional average:

Specify percent:[ ]

( ) Other:

Specify:

Character Count:out of 6000

( ) not selected

( ) not selected

Appendix B: Participant Access and Eligibility

B-2: Individual Cost Limit (2 of 2)

1.. Method of Implementation of the Individual Cost

Limit.When an individual cost limit is specified in Item B-2-a, specify the

procedures that are followed to determine in advance of waiver entrance that the

individual's health and welfare can be assured within the cost limit:

Character Count:out of 12000

Participant-directed home-based supports provided to

eligible participants who typically reside with family members are intended to

supplement the natural supports available from family members and significant

others, other community resources and Medicaid State Plan services. If the

health and welfare of the participant cannot be assured within the cost limit of

home-based supports in combination with other resources, the participant will be

considered for other appropriate adult waiver services that are not subject to

this cost limitation. Participants are notified of the opportunity to request a

fair hearing if enrollment is denied.

1.. Participant Safeguards.When the State specifies an

individual cost limit in Item B-2-a and there is a change in the participant's

condition or circumstances post-entrance to the waiver that requires the

provision of services in an amount that exceeds the cost limit in order to

assure the participant's health and welfare, the State has established the

following safeguards to avoid an adverse impact on the participant (check each

that applies):

[ ] The participant is referred to another waiver that

can accommodate the individual's needs.

[X] Additional services in excess of the individual cost

limit may be authorized.

Specify the procedures for authorizing additional

services, including the amount that may be authorized:

Character Count:out of 12000

Temporary Assistance services up to an additional $4000

per episode may be authorized for family emergencies subject to prior approval

by the Operating Agency. Temporary Assistance services are in excess of the

individual cost limit for home-based supports.

[X] Other safeguard(s)

Specify:

Character Count:out of 12000

Alternate adult waiver service options are offered to

address the needs of the participant. Service options are discussed with the

participant and guardian, as appropriate, to determine what alternate waiver

services are preferred. In addition, participants may be referred to other

Waivers to address the participant's needs, to other appropriate adult services

and/or the DHS Office of Inspector General.

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (1 of 4)

1.. Unduplicated Number of Participants.The following

table specifies the maximum number of unduplicated participants who are served

in each year that the waiver is in effect. The State will submit a waiver

amendment to CMS to modify the number of participants specified for any year(s),

including when a modification is necessary due to legislative appropriation or

another reason. The number of unduplicated participants specified in this table

is basis for the cost-neutrality calculations in Appendix J:

Table: B-3-a

Waiver Year Unduplicated Number of Participants

Year 1 17600

Year 2 17600

Year 3 17600

Year 4 17600

Year 5 17600

1.. Limitation on the Number of Participants Served at

Any Point in Time.Consistent with the unduplicated number of participants

specified in Item B-3-a, the State may limit to a lesser number the number of

participants who will be served at any point in time during a waiver year.

Indicate whether the State limits the number of participants in this way:

(select one):

( )The State does not limit the number of

participants that it serves at any point in time during a waiver year.

(X)The State limits the number of participants

that it serves at any point in time during a waiver year.

1.. The limit that applies to each year of the waiver

period is specified in the following table:

Table: B-3-b

Waiver Year Maximum Number of Participants Served

At Any Point During the Year

Year 1 17300

Year 2 17300

Year 3 17300

Year 4 17300

Year 5 17300

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (2 of 4)

1.. Reserved Waiver Capacity.The State may reserve a

portion of the participant capacity of the waiver for specified purposes (e.g.,

provide for the community transition of institutionalized persons or furnish

waiver services to individuals experiencing a crisis) subject to CMS review and

approval. The State (select one):

(X)Not applicable. The state does not reserve

capacity.

( )The State reserves capacity for the following

purpose(s).

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (3 of 4)

1.. Scheduled Phase-In or Phase-Out.Within a waiver

year, the State may make the number of participants who are served subject to a

phase-in or phase-out schedule (select one):

(X)The waiver is not subject to a phase-in or a

phase-out schedule.

( )The waiver is subject to a phase-in or

phase-out schedule that is included in Attachment #1 to Appendix B-3. This

schedule constitutes an intra-year limitation on the number of participants who

are served in the waiver.

1.. Allocation of Waiver Capacity.

Select one:

(X)Waiver capacity is allocated/managed on a

statewide basis.

( )Waiver capacity is allocated to local/regional

non-state entities.

Specify: (a) the entities to which waiver capacity is

allocated; ( the methodology that is used to allocate capacity and how often

the methodology is reevaluated; and, © policies for the reallocation of unused

capacity among local/regional non-state entities:

Character Count:out of 12000

1.. Selection of Entrants to the Waiver.Specify the

policies that apply to the selection of individuals for entrance to the waiver:

Character Count:out of 12000

Individuals potentially in need of these services are

enrolled in the State’s Prioritization of Urgency of Need for Services (PUNS)

database by one of the contracted entities serving as access points. This

database records demographic and clinical information regarding the individual

and his/ her circumstances, services currently received, and services needed. As

appropriations are available, individuals are selected for authorization for

Waiver services via an automated process that focuses on the individual’s

needs and the family’s circumstances (where applicable). Entrance to the

Waiver for Adults with Developmental Disabilities of otherwise eligible

applicants is deferred via this process until capacity becomes available as a

result of turnover or the appropriation of additional funding by the

legislature. The intake assessment tool and corresponding PUNS manual is

available on the Operating Agency's website. The number of individuals served

each year will be based on available appropriations. New enrollees will be

selected from the Prioritization of Urgency of Need For Services (PUNS)

database, a database maintained by the Operating Agency of individuals

potentially in need of state-funded DD services within the next five years. The

selection criteria will provide for selection of individuals on several basis,

including urgency of need, length of time on the database, and randomness.

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served - Attachment #1 (4 of

4)

Answers provided in Appendix B-3-d indicate that you do

not need to complete this section.

Appendix B: Participant Access and Eligibility

B-4: Eligibility Groups Served in the Waiver

1..

1.. State Classification.The State is a (select

one):

( ) §1634 State

( ) SSI Criteria State

(X) 209( State

( ) not selected

1.. Trust State.

Indicate whether the State is a Trust State

(select one):

(X) No

( ) Yes

( ) Unknown

1.. Medicaid Eligibility Groups Served in the

Waiver.Individuals who receive services under this waiver are eligible under the

following eligibility groups contained in the State plan. The State applies all

applicable federal financial participation limits under the plan. Check all that

apply:

Eligibility Groups Served in the Waiver (excluding the

special home and community-based waiver group under 42 CFR §435.217)

[ ] Low income families with children as provided in

§1931 of the Act

[ ] SSI recipients

[X] Aged, blind or disabled in 209( states who are

eligible under 42 CFR §435.121

[X] Optional State supplement recipients

[X] Optional categorically needy aged and/or disabled

individuals who have income at:

Select one:

(X) 100% of the Federal poverty level (FPL)

( ) % of FPL, which is lower than 100% of FPL.

Specify percentage:[ ]

( ) not selected

[ ] Working individuals with disabilities who buy into

Medicaid (BBA working disabled group as provided in §1902(a)(10)(A)(ii)(XIII))

of the Act)

[X] Working individuals with disabilities who buy into

Medicaid (TWWIIA Basic Coverage Group as provided in §1902(a)(10)(A)(ii)(XV) of

the Act)

[ ] Working individuals with disabilities who buy into

Medicaid (TWWIIA Medical Improvement Coverage Group as provided in

§1902(a)(10)(A)(ii)(XVI) of the Act)

[ ] Disabled individuals age 18 or younger who would

require an institutional level of care (TEFRA 134 eligibility group as provided

in §1902(e)(3) of the Act)

[ ] Medically needy

[X] Medically needy in 209( States (42 CFR §435.330)

[ ] Medically needy in 1634 States and SSI Criteria

States (42 CFR §435.320, §435.322 and §435.324)

[ ] Other specified groups (include only

statutory/regulatory reference to reflect the additional groups in the State

plan that may receive services under this waiver)

Specify:

Character Count:out of 6000

Special home and community-based waiver group under 42

CFR §435.217)Note: When the special home and community-based waiver group under

42 CFR §435.217 is included, Appendix B-5 must be completed

(X) No. The State does not furnish waiver services to

individuals in the special home and community-based waiver group under 42 CFR

§435.217.Appendix B-5 is not submitted.

( ) Yes. The State furnishes waiver services to

individuals in the special home and community-based waiver group under 42 CFR

§435.217.

( ) not selected

Select one and complete Appendix B-5.

( ) All individuals in the special home and

community-based waiver group under 42 CFR §435.217

( ) Only the following groups of individuals in the

special home and community-based waiver group under 42 CFR §435.217

(X) not selected

Check each that applies:

[ ] A special income level equal to:

Select one:

( ) 300% of the SSI Federal Benefit Rate (FBR)

( ) A percentage of FBR, which is lower than 300% (42

CFR §435.236)

Specify percentage: [ ]

( ) A dollar amount which is lower than 300%.

Specify dollar amount: [ ]

(X) not selected

[ ] Aged, blind and disabled individuals who meet

requirements that are more restrictive than the SSI program (42 CFR §435.121)

[ ] Medically needy without spenddown in States which

also provide Medicaid to recipients of SSI (42 CFR §435.320, §435.322 and

§435.324)

[ ] Medically needy without spend down in 209( States

(42 CFR §435.330)

[ ] Aged and disabled individuals who have income at:

Select one:

( ) 100% of FPL

( ) % of FPL, which is lower than 100%.

Specify percentage amount:[ ]

(X) not selected

[ ] Other specified groups (include only

statutory/regulatory reference to reflect the additional groups in the State

plan that may receive services under this waiver)

Specify:

Character Count:out of 6000

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (1 of 4)

In accordance with 42 CFR §441.303(e), Appendix B-5

must be completed when the State furnishes waiver services to individuals in the

special home and community-based waiver group under 42 CFR §435.217, as

indicated in Appendix B-4. Post-eligibility applies only to the 42 CFR §435.217

group. A State that uses spousal impoverishment rules under §1924 of the Act to

determine the eligibility of individuals with a community spouse may elect to

use spousal post-eligibility rules under §1924 of the Act to protect a personal

needs allowance for a participant with a community spouse.

1.. Use of Spousal Impoverishment Rules.Indicate

whether spousal impoverishment rules are used to determine eligibility for the

special home and community-based waiver group under 42 CFR §435.217 (select

one):

Answers provided in Appendix B-4 indicate that you do

not need to submit Appendix B-5 and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (2 of 4)

1.. Regular Post-Eligibility Treatment of Income: SSI

State.

Answers provided in Appendix B-4 indicate that you do

not need to submit Appendix B-5 and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (3 of 4)

1.. Regular Post-Eligibility Treatment of Income:

209( State.

Answers provided in Appendix B-4 indicate that you do

not need to submit Appendix B-5 and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (4 of 4)

1.. Post-Eligibility Treatment of Income Using Spousal

Impoverishment Rules

The State uses the post-eligibility rules of §1924(d)

of the Act (spousal impoverishment protection) to determine the contribution of

a participant with a community spouse toward the cost of home and

community-based care if it determines the individual's eligibility under §1924

of the Act. There is deducted from the participant’s monthly income a personal

needs allowance (as specified below), a community spouse's allowance and a

family allowance as specified in the State Medicaid Plan.. The State must also

protect amounts for incurred expenses for medical or remedial care (as specified

below).

Answers provided in Appendix B-4 indicate that you do

not need to submit Appendix B-5 and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

B-6: Evaluation/Reevaluation of Level of Care

As specified in 42 CFR §441.302©, the State provides

for an evaluation (and periodic reevaluations) of the need for the level(s) of

care specified for this waiver, when there is a reasonable indication that an

individual may need such services in the near future (one month or less), but

for the availability of home and community-based waiver services.

1.. Reasonable Indication of Need for Services.In

order for an individual to be determined to need waiver services, an individual

must require: (a) the provision of at least one waiver service, as documented in

the service plan, and ( the provision of waiver services at least monthly or,

if the need for services is less than monthly, the participant requires regular

monthly monitoring which must be documented in the service plan. Specify the

State's policies concerning the reasonable indication of the need for services:

2.. Minimum number of services.

The minimum number of waiver services (one or more) that

an individual must require in order to be determined to need waiver services

is:1

1.. Frequency of services. The State requires (select

one):

(X) The provision of waiver services at least monthly

( ) Monthly monitoring of the individual when services

are furnished on a less than monthly basis

If the State also requires a minimum frequency for the

provision of waiver services other than monthly (e.g., quarterly), specify the

frequency:

Character Count:out of 4000

( ) not selected

1.. Responsibility for Performing Evaluations and

Reevaluations.Level of care evaluations and reevaluations are performed (select

one):

( ) Directly by the Medicaid agency

( ) By the operating agency specified in Appendix A

( ) By an entity under contract with the Medicaid

agency.

Specify the entity:

Character Count:out of 4000

(X) Other

Specify:

Character Count:out of 4000

Level of care evaluations and re-evaluations are

performed by local entities under contract with the Operating Agency.

( ) not selected

1.. Qualifications of Individuals Performing Initial

Evaluation:Per 42 CFR §441.303©(1), specify the educational/professional

qualifications of individuals who perform the initial evaluation of level of

care for waiver applicants:

Character Count:out of 6000

Persons making the initial evaluations must be Qualified

Mental Retardation Professionals (QMRPs) as defined in Federal ICFMR

regulations. In Illinois, QMRPs are referred to as Qualified Support

Professionals (QSPs).

1.. Level of Care Criteria.Fully specify the level of

care criteria that are used to evaluate and reevaluate whether an individual

needs services through the waiver and that serve as the basis of the State's

level of care instrument/tool. Specify the level of care instrument/tool that is

employed. State laws, regulations, and policies concerning level of care

criteria and the level of care instrument/tool are available to CMS upon request

through the Medicaid agency or the operating agency (if applicable), including

the instrument/tool utilized.

Character Count:out of 12000

Required assessments and level of care criteria are

described fully in the Operating Agency’s screening manual for developmental

disabilities, which is used by all individuals conducting waiver screening. The

manual is available on the Operating Agency's website. Chapter 200 of the manual

describes the required assessments and qualifications for professionals

conducting the assessments. In brief, the following assessments of waiver

applicants are required to make an initial waiver level of care determination:

For applicants with mental retardation: • Valid psychological evaluation by a

qualified professional that documents diagnosis, cognitive and functional

limitations and age of onset. For applicants with cerebral palsy or epilepsy, or

a related condition: • Physical examination and medical history that documents

the diagnosis. For applicants with Autism: • Psychiatric evaluation by a

licensed psychiatrist and a psychosocial assessment. For all applicants: •

Inventory of Client and Agency Planning (ICAP). • Medical review consisting of

a physical examination by a qualified professional, medical history and

medication review. • Other assessments as needed to determine service needs.

Illinois uses the same process for determining Waiver eligibility as it does for

ICF/MR eligibility. For ongoing re-determination of Waiver level of care, a

current ICAP is required.

1.. Level of Care Instrument(s).Per 42 CFR

§441.303©(2), indicate whether the instrument/tool used to evaluate level of

care for the waiver differs from the instrument/tool used to evaluate

institutional level of care (select one):

(X) The same instrument is used in determining the level

of care for the waiver and for institutional care under the State Plan.

( ) A different instrument is used to determine the

level of care for the waiver than for institutional care under the State plan.

Describe how and why this instrument differs from the

form used to evaluate institutional level of care and explain how the outcome of

the determination is reliable, valid, and fully comparable.

Character Count:out of 12000

( ) not selected

1.. Process for Level of Care

Evaluation/Reevaluation:Per 42 CFR §441.303©(1), describe the process for

evaluating waiver applicants for their need for the level of care under the

waiver. If the reevaluation process differs from the evaluation process,

describe the differences:

Character Count:out of 12000

The Operating Agency contracts with entities that employ

QMRPs to complete the evaluations and reevaluations. As part of the initial

level of care determination process, staff of the contracted agencies are

responsible for performing or arranging for necessary assessments and collecting

other needed information to determine level of care. A qualified mental

retardation professional (QMRP) reviews assessment results and other available

information against the level of care criteria and guidance in the screening

manual for developmental disabilities. The QMRP uses the totality of the

information available and best clinical judgment in making the determination.

Assessment information and level of care determinations are documented on forms

specified by the Operating Agency. Level of care determinations are transmitted

electronically to the Operating Agency. The re-determination process is

essentially the same, except the ongoing level of care determination is based on

a current ICAP, individual assessments and other information from the service

planning process in conjunction with personal knowledge of the participant.

Level of care re-determinations are documented on a form specified by the

Operating Agency and are transmitted electronically to the Operating Agency.

1.. Reevaluation Schedule.Per 42 CFR §441.303©(4),

reevaluations of the level of care required by a participant are conducted no

less frequently than annually according to the following schedule (select one):

( ) Every three months

( ) Every six months

(X) Every twelve months

( ) Other schedule

Specify the other schedule:

Character Count:out of 4000

( ) not selected

1.. Qualifications of Individuals Who Perform

Reevaluations.Specify the qualifications of individuals who perform

reevaluations (select one):

(X) The qualifications of individuals who perform

reevaluations are the same as individuals who perform initial evaluations.

( ) The qualifications are different.

Specify the qualifications:

Character Count:out of 6000

( ) not selected

1.. Procedures to Ensure Timely Reevaluations.Per 42

CFR §441.303©(4), specify the procedures that the State employs to ensure

timely reevaluations of level of care (specify):

Character Count:out of 6000

The Operating Agency has an edit in the computerized

payment system to ensure reevaluations are conducted yearly. The edit requires

the contracted entity to enter the reevaluation date. If that date is more than

one year old, the edit will not allow payments to be made to the entity. On-site

reviews are done annually by the OA to ensure that documentation exists and

coincides with the reevaluation date entered in the payment system. The payment

edit has been found effective in providing an incentive for the contracted

entities to complete annual Waiver reevaluations in a timely manner.

1.. Maintenance of Evaluation/Reevaluation Records.Per

42 CFR §441.303©(3), the State assures that written and/or electronically

retrievable documentation of all evaluations and reevaluations are maintained

for a minimum period of 3 years as required in 45 CFR §92.42. Specify the

location(s) where records of evaluations and reevaluations of level of care are

maintained:

Character Count:out of 6000

Evaluation and reevaluation forms are kept by contracted

entities for the mandatory three years or more. Results are maintained

electronically by the Operating Agency for three or more years.

Appendix B: Evaluation/Reevaluation of Level of Care

Quality Improvement: Level of Care

As a distinct component of the State’s quality

improvement strategy, provide information in the following fields to detail the

State’s methods for discovery and remediation.

1.. Methods for Discovery: Level of Care

Assurance/Sub-assurances

1.. Sub-Assurances:

2.. Sub-assurance: An evaluation for LOC is provided

to all applicants for whom there is reasonable indication that services may be

needed in the future.

Performance Measures

For each performance measure/indicator the State will

use to assess compliance with the statutory assurance complete the following.

Where possible, include numerator/denominator. Each performance measure must be

specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the

aggregated data that will enable the State to analyze and assess progress toward

the performance measure. In this section provide information on the method by

which each source of data is analyzed statistically/deductively or inductively,

how themes are identified or conclusions drawn, and how recommendations are

formulated, where appropriate.

Performance Measure:

Number and percent of new waiver participants who

had a level of care assessment indicating need for ICF/MR level of care prior to

receipt of services. Numerator: Number of new waiver participants with a LOC

assessment indicating need for ICF/MR prior to receipt of services. Denominator:

All new waiver participants.

Data Source(Select one):

Other

If 'Other' is selected, specify:

OA MIS report of all new participants and date

of LOC assessment.

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [X] 100%

Review

[X] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

1.. Sub-assurance: The levels of care of enrolled

participants are reevaluated at least annually or as specified in the approved

waiver.

Performance Measures

For each performance measure/indicator the State will

use to assess compliance with the statutory assurance complete the following.

Where possible, include numerator/denominator. Each performance measure must be

specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the

aggregated data that will enable the State to analyze and assess progress toward

the performance measure. In this section provide information on the method by

which each source of data is analyzed statistically/deductively or inductively,

how themes are identified or conclusions drawn, and how recommendations are

formulated, where appropriate.

Performance Measure:

Number and percent of waiver participants reviewed

where the participant was reassessed through the annual redetermination process

of waiver eligibility within 12 months of their initial LOC evaluation or within

12 months of their last annual LOC re-evaluation. N: Re-assessments completed

within 12 months. D: Total number of participants due for waiver re-assessment.

Data Source(Select one):

Other

If 'Other' is selected, specify:

OA MIS automated reporting system

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [X] 100%

Review

[X] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

1.. Sub-assurance: The processes and instruments

described in the approved waiver are applied appropriately and according to the

approved description to determine participant level of care.

Performance Measures

For each performance measure/indicator the State will

use to assess compliance with the statutory assurance complete the following.

Where possible, include numerator/denominator. Each performance measure must be

specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the

aggregated data that will enable the State to analyze and assess progress toward

the performance measure. In this section provide information on the method by

which each source of data is analyzed statistically/deductively or inductively,

how themes are identified or conclusions drawn, and how recommendations are

formulated, where appropriate.

Performance Measure:

Number and percent of waiver participants' LOC

initial determination/re-determination forms/instruments reviewed that are

completed as required by the state. Numerator: Number of LOC

determinations/redeterminations completed as required by the state. Denominator:

Total number of LOC determinations reviewed.

Data Source(Select one):

Record reviews, on-site

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[X] State Medicaid Agency [ ] Weekly [ ] 100%

Review

[X] Operating Agency [ ] Monthly [X] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [X]

Representative Sample

Confidence Interval =

5%

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of LOC determinations reviewed

that were completed accurately. Numerator: Number of LOC determinations that

were accurately completed. Denominator: Number of LOC determinations reviewed.

Data Source(Select one):

Other

If 'Other' is selected, specify:

OA Review committee reporting database

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[X] State Medicaid Agency [ ] Weekly [ ] 100%

Review

[X] Operating Agency [ ] Monthly [X] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [X]

Representative Sample

Confidence Interval =

5%

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

1.. If applicable, in the textbox below provide any

necessary additional information on the strategies employed by the State to

discover/identify problems/issues within the waiver program, including frequency

and parties responsible.

Character Count:out of 6000

1.. Methods for Remediation/Fixing Individual Problems

1.. Describe the State’s method for addressing

individual problems as they are discovered. Include information regarding

responsible parties and GENERAL methods for problem correction. In addition,

provide information on the methods used by the State to document these items.

Character Count:out of 6000

The OA reviews the issues and identifies the most

appropriate response. General responses may include work with participants and

their providers, retraining staff, voiding claims, technical assistance,

increased monitoring, revising service plans, and requiring plans of correction.

The OA is responsible for seeing that individual issues are resolved. The OA

provides quarterly reports of these activities to the MA. Staff of the two State

agencies review the reports on a quarterly basis.

1.. Remediation Data Aggregation

Remediation-related Data Aggregation and Analysis

(including trend identification)

Responsible Party (check each that applies):

Frequency of data aggregation and analysis (check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

1.. Timelines

When the State does not have all elements of the Quality

Improvement Strategy in place, provide timelines to design methods for discovery

and remediation related to the assurance of Level of Care that are currently

non-operational.

(X) No

( ) Yes

( ) not selected

Please provide a detailed strategy for assuring Level of

Care, the specific timeline for implementing identified strategies, and the

parties responsible for its operation.

Character Count:out of 6000

Appendix B: Participant Access and Eligibility

B-7: Freedom of Choice

Freedom of Choice.As provided in 42 CFR §441.302(d),

when an individual is determined to be likely to require a level of care for

this waiver, the individual or his or her legal representative is:

1.. informed of any feasible alternatives under the

waiver; and

2.. given the choice of either institutional or home

and community-based services.

3.. Procedures.Specify the State's procedures for

informing eligible individuals (or their legal representatives) of the feasible

alternatives available under the waiver and allowing these individuals to choose

either institutional or waiver services. Identify the form(s) that are employed

to document freedom of choice. The form or forms are available to CMS upon

request through the Medicaid agency or the operating agency (if applicable).

Character Count:out of 12000

The QMRP/QSPs employed by the Operating Agency’s

contracted entities inform individuals, and/or their legal guardians, about

their options during the level of care determination process. The QMRP presents

the individual/legal representative with all service options, including both

Waiver and ICF/MR services that the individual is eligible to receive,

regardless of availability, in sufficient detail so they are able to make

informed choices. If the individual/legal representative does not speak English,

has limited proficiency or is non-verbal, the QMRP makes an accommodation.

Acceptable accommodations may include use of staff with secondary language

skills, translation services, oral assistance and communication devices. The

QMRP/QSP provides the individual/legal representative with additional

information and materials on the service options they choose to pursue and

arranges for and facilitates conversations with potential service providers

including visits to the potential providers as indicated. The IL 462-1238 form,

Choice of Supports and Services, specifically documents the decision to choose

Waiver services as an alternative to ICF/MR services at this time. This form

also states that choice of supports and services may be changed in the future

and is signed by the individual/legal representative. The form is also available

in Spanish (IL 462-1238S).

1.. Maintenance of Forms.Per 45 CFR §92.42, written

copies or electronically retrievable facsimiles of Freedom of Choice forms are

maintained for a minimum of three years. Specify the locations where copies of

these forms are maintained.

Character Count:out of 4000

Copies of the IL 462-1238 forms are available in English

and Spanish and are maintained by the contracted entity.

Appendix B: Participant Access and Eligibility

B-8: Access to Services by Limited English Proficiency

Persons

Access to Services by Limited English Proficient

Persons.Specify the methods that the State uses to provide meaningful access to

the waiver by Limited English Proficient persons in accordance with the

Department of Health and Human Services " Guidance to Federal Financial

Assistance Recipients Regarding Title VI Prohibition Against National Origin

Discrimination Affecting Limited English Proficient Persons " (68 FR 47311 -

August 8, 2003):

Character Count:out of 12000

The local ISC entities under contract with the Operating

Agency that serve as access points are integrated in their communities and on a

daily basis interact with a wide variety of individuals of varying backgrounds,

cultures, and languages. The entities have resources available to communicate

effectively with participants of limited English proficiency in their community,

including bilingual staff as needed, interpreters, translated forms, etc. The

Operating Agency has a website, www.dd.Illinois.gov, and a toll-free number,

1-888-DDPLANS, specifically designed for families’ use in learning more about

Illinois’ DD service system and in contacting their local entity for

assistance with accessing services. Each of these information points is

available in both Spanish and English. In addition, brochures and flyers are

available in other languages including: Arabic, Bosnian, Chinese, Hindi, Khner,

Korean, Polish, Russian, Urdu and Vietnamese.

Appendix C: Participant Services

C-1: Summary of Services Covered (1 of 2)

1.. Waiver Services Summary. List the services that

are furnished under the waiver in the following table. If case management is not

a service under the waiver, complete items C-1-b and C-1-c:

Service Type Service

75263Statutory Service Adult Day Care

75267Statutory Service Developmental Training

75265Statutory Service Residential Habilitation

75270Statutory Service Supported Employment

77381Extended State Plan Service Occupational

Therapy (Extended Medicaid State Plan)

77379Extended State Plan Service Physical Therapy

(Extended Medicaid State Plan)

77386Extended State Plan Service Speech Therapy

(Extended Medicaid State Plan)

77388Supports for Participant Direction Service

Facilitation

77312Other Service Adaptive Equipment

77314Other Service Assistive Technology

77369Other Service Behavior Intervention and

Treatment

77371Other Service Behavioral Services

(Psychotherapy and Counseling)

77316Other Service Emergency Home Response

Services (EHRS)

76310Other Service Home Accessibility

Modifications

76315Other Service Non-Medical Transportation

75273Other Service Personal Support

77374Other Service Skilled Nursing

77376Other Service Temporary Assistance (formerly

called Crisis Services)

77318Other Service Training and Counseling

Services for Unpaid Caregivers

76313Other Service Vehicle Modification

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in

the specification are readily available to CMS upon request through the Medicaid

agency or the operating agency (if applicable).

Service Type:

[statutory Service \/]

Service:

[Adult Day Health \/]

Alternate Service Title (if any):

Adult Day Care

Complete this part for a renewal application or a

new waiver that replaces an existing waiver. Select one :

(X)Service is included in approved waiver. There

is no change in service specifications.

( )Service is included in approved waiver. The

service specifications have been modified.

( )Service is not included in the approved

waiver.

Service Definition(Scope):

Services generally furnished four or more hours

per day on a regularly scheduled basis, for one or more days per week, or as

specified in the support plan, in a non-institutional, community-based setting,

encompassing both health and social services needed to ensure the optimal

functioning of the participant. Meals provided as part of these services shall

not constitute a " full nutritional regimen " (three meals per day).

Transportation between the participant's place of residence and the adult day

health (adult day care) center will be provided as a component of adult day

health services. The cost of this transportation is included in the rate paid to

providers of adult day health services.

Specify applicable (if any) limits on the amount,

frequency, or duration of this service:

Adult day care is typically available to

participants who are aged 60 and older. Participants who are not yet 60 may also

be served if day habilitation or employment services are determined by the

support planning team not to be appropriate because the participant is medically

fragile. For participants who choose home-based supports, this service is

included in the participant’s monthly cost maximum. See Appendix C-4. Services

are subject to prior approval by the Operating Agency. The annual rate is spread

over a State fiscal year maximum of 1,100 hours for any combination of day

programs. Payment during any month is limited to a maximum of 115 hours for any

combination of day programs.

Service Delivery Method (check each that applies):

[ ] Participant-directed as specified in Appendix

E

[X] Provider managed

Specify whether the service may be provided by

(check each that applies):

[ ] Legally Responsible Person

[ ] Relative

[ ] Legal Guardian

Provider Specifications:

Provider Category Provider Type Title

75264Agency Community-Based Agencies

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Adult Day Care

Provider Category:

[Agency \/]

Provider Type:

Community-Based Agencies

Provider Qualifications

License (specify):

89 Ill. Adm. Code 240

Certificate (specify):

Other Standard (specify):

59 Ill. Adm. Code 120 Contract with Department

on Aging Contract requirements

Verification of Provider Qualifications

Entity Responsible for Verification:

Department on Aging - Surveys are conducted once

per contracting period (six years), with additional surveys conducted as

necessary due to complaints or deficiencies. Waiver Operating Agency

(DHS-Verification of contract with the Department on Aging upon enrollment and

annually thereafter.

Frequency of Verification:

Department on Aging - Surveys are conducted once

per contracting period (six years), with additional surveys conducted as

necessary due to complaints or deficiencies. Waiver Operating Agency (DHS) -

Verification of contract with the Department on Aging upon enrollment and

annually thereafter.

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in

the specification are readily available to CMS upon request through the Medicaid

agency or the operating agency (if applicable).

Service Type:

[statutory Service \/]

Service:

[Day Habilitation \/]

Alternate Service Title (if any):

Developmental Training

Complete this part for a renewal application or a

new waiver that replaces an existing waiver. Select one :

(X)Service is included in approved waiver. There

is no change in service specifications.

( )Service is included in approved waiver. The

service specifications have been modified.

( )Service is not included in the approved

waiver.

Service Definition(Scope):

Assistance with acquisition, retention, or

improvement in self-help, socialization and adaptive skills that takes place in

a non-residential setting, separate from the participant’s private residence

or other residential living arrangement. Activities and environments are

designed to foster the acquisition of skills, appropriate behavior, greater

independence, and personal choice. Services are furnished four or more hours per

day on a regularly scheduled basis for one or more days per week or as specified

in the participant’s support plan. Meals provided as part of these services

shall not constitute a " full nutritional regimen " (three meals per day). Day

habilitation services focus on enabling the participant to attain or maintain

his or her maximum functional level and shall be coordinated with any physical,

occupational, or speech therapies in the support plan. In addition, day

habilitation services may serve to reinforce skills or lessons taught in other

settings. Developmental Training also includes a range of adaptive skills in the

areas of motor development, attention span, safety, problem solving,

quantitative skills, and capacity for individual living. Developmental training

also enhances a participant's ability to engage in productive work activities

through a focus on such habilitative goals as compliance, attendance, and task

completion. Developmental Training may also include training and supports

designed to maintain skills and functioning and to prevent or slow regression.

Developmental Training includes the reduction of maladaptive behaviors through

positive behavioral supports and other methods. Developmental Training does not

include the following: _ Special education and related services (as defined in

Section 601 (16) and (17) of the Individuals with Disabilities Education Act)

which otherwise are available to the participant through a local education

agency: _ Vocational rehabilitation services which otherwise are available to

the participant through a program funded under Section 110 of the Rehabilitation

Act of 1973. To foster community integration and learning in natural

environments, Developmental Training may be furnished in a variety of

community-based environments where persons without disabilities are present, as

well as in sites specifically certified for Developmental Training. Such

community-based Developmental Training programs include purposeful and

meaningful activities that are designed to improve, maintain, or prevent the

loss of independence, skills and functions enabling each participant to access

and participate in relationships, activities and functions of community life.

Activities may consist of job exploration activities (not paid employment) or

volunteer work, recreation, educational experiences in natural community

settings, maintaining family contacts and purposeful activities and services

where persons without disabilities are present. Developmental Training (DT)

includes transportation between the residence and other community locations

where DT occurs. Transportation is provided and billed as an integral part of

Developmental Training. Training and assistance in transportation usage are

provided as needed.

Specify applicable (if any) limits on the amount,

frequency, or duration of this service:

For participants who choose home-based supports,

this service is included in the participant’s monthly cost limit. See Appendix

C-4. The annual rate is spread over a State fiscal year maximum of 1,100 hours

for any combination of day programs. Monthly payment is limited to a maximum of

115 hours for any combination of day programs.

Service Delivery Method (check each that applies):

[ ] Participant-directed as specified in Appendix

E

[X] Provider managed

Specify whether the service may be provided by

(check each that applies):

[ ] Legally Responsible Person

[ ] Relative

[ ] Legal Guardian

Provider Specifications:

Provider Category Provider Type Title

75268Agency Community-Based Agencies

75269Agency Special Recreation Associations

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Developmental Training

Provider Category:

[Agency \/]

Provider Type:

Community-Based Agencies

Provider Qualifications

License (specify):

Certificate (specify):

59 Ill. Adm. Code 119 (Developmental Training)

Other Standard (specify):

59 Ill. Adm. Code 50 59 Ill. Adm. Code 120

Contract requirements

Verification of Provider Qualifications

Entity Responsible for Verification:

Waiver Operating Agency (DHS)

Frequency of Verification:

Annual certification survey

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Developmental Training

Provider Category:

[Agency \/]

Provider Type:

Special Recreation Associations

Provider Qualifications

License (specify):

Certificate (specify):

59 Ill. Adm. Code 119

Other Standard (specify):

59 Ill. Adm. Code 50 59 Ill. Adm. Code 120

Contract requirements

Verification of Provider Qualifications

Entity Responsible for Verification:

Waiver Operating Agency (DHS)

Frequency of Verification:

Annual certification survey

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in

the specification are readily available to CMS upon request through the Medicaid

agency or the operating agency (if applicable).

Service Type:

[statutory Service \/]

Service:

[Residential Habilitation \/]

Alternate Service Title (if any):

Residential Habilitation

Complete this part for a renewal application or a

new waiver that replaces an existing waiver. Select one :

(X)Service is included in approved waiver. There

is no change in service specifications.

( )Service is included in approved waiver. The

service specifications have been modified.

( )Service is not included in the approved

waiver.

Service Definition(Scope):

Residential habilitation means individually

tailored supports that assist with the acquisition, retention, or improvement in

skills related to living in the community. These supports include case

management, adaptive skill development, assistance with activities of daily

living, community inclusion, transportation, adult educational supports, social

and leisure skill development, that assist the participant to reside in the most

integrated setting appropriate to his/her needs. Residential habilitation also

includes personal support and protective oversight and supervision. Payment is

not made for the cost of room and board. Included in the cost not covered are

building maintenance, upkeep and improvement (other than such costs for

modification or adaptations to a facility required to assure the health and

safety of residents, or to meet the requirements of the applicable life safety

code). Payment is not made, directly or indirectly, to members of the

participant's immediate family. Residential Habilitation includes the reduction

of maladaptive behaviors through positive behavioral supports and other methods.

In addition, residential habilitation may include necessary nursing assessment,

direction and monitoring by a registered professional nurse, and support

services and assistance by a registered professional nurse or a licensed

practical nurse to ensure the participant’s health and welfare. These include

monitoring of health status, medication monitoring, and administration of

injections or suctioning. It also includes administration and/or oversight of

the administration of oral and topical medications consistent with the Illinois

Nursing and Advanced Practice Nursing Act (225 ILSC 65) and the Mental Health

and Developmental Disabilities Administrative Act. Nursing services are

considered an integral part of residential habilitation services. Meeting the

routine nursing needs of participants receiving 24-hour residential services is

the responsibility of the residential service provider who must employ or

contract with a professional nurse to perform their professional duties

including the oversight and training of direct support staff. Nursing supports

are part-time and limited; 24-hour nursing supports, similar to those provided

in a nursing facility (NF) or Intermediate Care Facility for individuals with

Developmental Disabilities (ICF/DD), are not available to participants in the

Waiver. These services are in addition to any Medicaid State Plan nursing

services for which the participant may qualify.

Specify applicable (if any) limits on the amount,

frequency, or duration of this service:

Residential Habilitation services are available to

participants who require this intensity of service based on their identified

needs. Factors involved in the assessment of the need for this service include

the urgency of the situation (e.g., the unexpected loss of a caregiver) and the

individual’s health and welfare concerns (e.g., an abusive or neglectful

situation). To ensure criteria are fairly applied to all initial applicants and

to those whose circumstances may change once they are enrolled in the Waiver,

the Operating Agency staff convene an internal committee to review each request

from a statewide perspective. This service will not be duplicative of other

services in the Waiver. For example, non-medical transportation is an integral

component of residential habilitation services.

Service Delivery Method (check each that applies):

[ ] Participant-directed as specified in Appendix

E

[X] Provider managed

Specify whether the service may be provided by

(check each that applies):

[ ] Legally Responsible Person

[ ] Relative

[ ] Legal Guardian

Provider Specifications:

Provider Category Provider Type Title

77467Agency Community-Based Agencies (CILA)

75266Agency Community-Based agencies (CLF)

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Residential Habilitation

Provider Category:

[Agency \/]

Provider Type:

Community-Based Agencies (CILA)

Provider Qualifications

License (specify):

59 Ill. Adm. Code 115 (Community Integrated

Living Arrangements - CILA)

Certificate (specify):

Other Standard (specify):

59 Ill. Adm. Code 50 59 Ill. Adm. Code 120 59

Ill. Adm. Code 116

Verification of Provider Qualifications

Entity Responsible for Verification:

Waiver Operating Agency (DHS)

Frequency of Verification:

Full licensure surveys are conducted at least

every three years, with focused surveys conducted more frequently if serious

deficiencies are identified.

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Residential Habilitation

Provider Category:

[Agency \/]

Provider Type:

Community-Based agencies (CLF)

Provider Qualifications

License (specify):

77 Ill. Adm. Code 370 (Community Living

Facilities - CLF)

Certificate (specify):

Other Standard (specify):

Contract requirements

Verification of Provider Qualifications

Entity Responsible for Verification:

Department of Public Health

Frequency of Verification:

Annual surveys and ongoing complaint

investigations

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in

the specification are readily available to CMS upon request through the Medicaid

agency or the operating agency (if applicable).

Service Type:

[statutory Service \/]

Service:

[supported Employment \/]

Alternate Service Title (if any):

Supported Employment

Complete this part for a renewal application or a

new waiver that replaces an existing waiver. Select one :

(X)Service is included in approved waiver. There

is no change in service specifications.

( )Service is included in approved waiver. The

service specifications have been modified.

( )Service is not included in the approved

waiver.

Service Definition(Scope):

Supported employment services consist of

intensive, ongoing supports that enable participants, for whom competitive

employment at or above the minimum wage is unlikely absent the provision of

supports, and who, because of their disabilities, need supports, to perform in a

regular work setting. Supported employment may include assisting the participant

to locate a job or develop a job on behalf of the participant. Supported

employment is conducted in a variety of settings; particularly work sites where

persons without disabilities are employed. Supported employment includes

activities needed to sustain paid work by participants, including supervision

and training. When supported employment services are provided at a work site

where persons without disabilities are employed, payment is made only for the

adaptations, supervision and training required by participants receiving waiver

services as a result of their disabilities but does not include payment for the

supervisory activities rendered as a normal part of the business setting.

Documentation is maintained in the file of each participant receiving this

service that the service is not available under a program funded under section

110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities

Education Act (20 U.S.C. 1401 et seq.). Federal financial participation is not

claimed for incentive payments, subsidies, or unrelated vocational training

expenses such as the following: 1. Incentive payments made to an employer to

encourage or subsidize the employer's participation in a supported employment

program. 2. Payments that are passed through to users of supported employment

programs. 3. Payments for training that are not directly related to a

participant's supported employment program. Supported employment may be provided

in integrated and competitive work settings in a business or industry that

primarily employs people without disabilities. Supported employment does not

include sheltered work or other similar types of vocational services furnished

in specialized facilities. Supported employment may include services and

supports that assist the participant in achieving self-employment through the

operation of a business. However, Medicaid funds may not be used to defray the

expenses associated with starting up or operating a business. Such assistance

may include: (a) aiding the participant to identify potential business

opportunities; ( assistance in the development of a business plan, including

potential sources of business financing and other assistance in developing and

launching a business; © identification of the supports that are necessary in

order for the participant to operate the business; and (d) the ongoing

assistance, counseling and guidance once the business has been launched.

Transportation will be provided between the participant's place of residence and

the employment site or between habilitation sites (in cases where the

participant receives waiver services in more than one place) as a component of

supported employment services. The cost of this transportation is included in

the rate paid to providers of supported employment services.

Specify applicable (if any) limits on the amount,

frequency, or duration of this service:

For participants who choose home-based supports,

this service is included in the participant’s monthly cost limit. See Appendix

C-4. SEP services are subject to prior approval by the Operating Agency. The

annual rate is spread over 1,100 hours for any combination of day programs.

Payment during any month is limited to 115 hours for any combination of day

programs.

Service Delivery Method (check each that applies):

[ ] Participant-directed as specified in Appendix

E

[X] Provider managed

Specify whether the service may be provided by

(check each that applies):

[ ] Legally Responsible Person

[ ] Relative

[ ] Legal Guardian

Provider Specifications:

Provider Category Provider Type Title

75271Agency Community-Based Agencies

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Statutory Service

Service Name: Supported Employment

Provider Category:

[Agency \/]

Provider Type:

Community-Based Agencies

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

59 Ill. Adm. Code 50 59 Ill. Adm. Code 120

Contract requirements

Verification of Provider Qualifications

Entity Responsible for Verification:

Waiver Operating Agency (DHS)

Frequency of Verification:

Annual certification surveys

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in

the specification are readily available to CMS upon request through the Medicaid

agency or the operating agency (if applicable).

Service Type:

[Extended State Plan Service \/]

Service Title:

Occupational Therapy (Extended Medicaid State

Plan)

Complete this part for a renewal application or a

new waiver that replaces an existing waiver. Select one :

(X)Service is included in approved waiver. There

is no change in service specifications.

( )Service is included in approved waiver. The

service specifications have been modified.

( )Service is not included in the approved

waiver.

Service Definition(Scope):

Occupational Therapy services under the waiver

differ in nature and scope from occupational therapy services in the Medicaid

State Plan. The provider qualifications specified in the Medicaid State Plan

apply. Waiver Occupational Therapy focuses on the long-term habilitative needs

of the participant, rather than short-term acute restorative needs. Restorative

services are covered under the Medicaid State Plan.

Specify applicable (if any) limits on the amount,

frequency, or duration of this service:

For participants who choose home-based supports,

this service is included in the participant’s monthly cost limit. See Appendix

C-4. There is a State fiscal year maximum of 26 hours, unless additional

documentation supports the need for additional hours (up to 52 hours). Services

are subject to prior approval by the Operating Agency.

Service Delivery Method (check each that applies):

[X] Participant-directed as specified in Appendix

E

[X] Provider managed

Specify whether the service may be provided by

(check each that applies):

[ ] Legally Responsible Person

[ ] Relative

[ ] Legal Guardian

Provider Specifications:

Provider Category Provider Type Title

77382Individual Occupational Therapist

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Extended State Plan Service

Service Name: Occupational Therapy (Extended

Medicaid State Plan)

Provider Category:

[individual \/]

Provider Type:

Occupational Therapist

Provider Qualifications

License (specify):

225 ILCS 75/1 et seq. 68 Ill. Adm. Code 1315

Certificate (specify):

Other Standard (specify):

Occupational Therapist may directly supervise a

Certified Occupational Therapist Assistant

Verification of Provider Qualifications

Entity Responsible for Verification:

Operating Agency (DHS)- Upon enrollment Medicaid

Agency (HFS)- Monthly verification of continuation of licensure

Frequency of Verification:

Operating Agency (DHS)- Upon enrollment Medicaid

Agency (HFS)- Monthly verification of continuation of licensure

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in

the specification are readily available to CMS upon request through the Medicaid

agency or the operating agency (if applicable).

Service Type:

[Extended State Plan Service \/]

Service Title:

Physical Therapy (Extended Medicaid State Plan)

Complete this part for a renewal application or a

new waiver that replaces an existing waiver. Select one :

(X)Service is included in approved waiver. There

is no change in service specifications.

( )Service is included in approved waiver. The

service specifications have been modified.

( )Service is not included in the approved

waiver.

Service Definition(Scope):

Physical Therapy services under the waiver differ

in nature and scope from physical therapy services in the Medicaid State Plan.

The provider qualifications specified in the Medicaid State Plan apply. Waiver

Physical Therapy focuses on the long-term habilitative needs of the participant,

rather than short-term acute restorative needs. Restorative services are covered

under the Medicaid State Plan.

Specify applicable (if any) limits on the amount,

frequency, or duration of this service:

For participants who choose home-based supports,

this service is included in the participant’s monthly cost limit. See Appendix

C-4. There is a State fiscal year maximum of 26 hours, unless additional

documentation supports the need for additional hours (up to 52 hours). Services

are subject to prior approval by the Operating Agency. Provider Specifications

Service Delivery Method (check each that applies):

[X] Participant-directed as specified in Appendix

E

[X] Provider managed

Specify whether the service may be provided by

(check each that applies):

[ ] Legally Responsible Person

[ ] Relative

[ ] Legal Guardian

Provider Specifications:

Provider Category Provider Type Title

77380Individual Physical Therapist

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Extended State Plan Service

Service Name: Physical Therapy (Extended

Medicaid State Plan)

Provider Category:

[individual \/]

Provider Type:

Physical Therapist

Provider Qualifications

License (specify):

225 ILCS 90/1 et seq. 68 Ill. Adm. Code 1340

Certificate (specify):

Other Standard (specify):

Physical Therapist may directly supervise a

certified physical therapist assistant.

Verification of Provider Qualifications

Entity Responsible for Verification:

Operating Agency (DHS) - Upon enrollment

Medicaid Agency (HFS) - Monthly verification of continuation of licensure

Frequency of Verification:

Operating Agency (DHS) - Upon enrollment

Medicaid Agency (HFS) - Monthly verification of continuation of licensure

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in

the specification are readily available to CMS upon request through the Medicaid

agency or the operating agency (if applicable).

Service Type:

[Extended State Plan Service \/]

Service Title:

Speech Therapy (Extended Medicaid State Plan)

Complete this part for a renewal application or a

new waiver that replaces an existing waiver. Select one :

(X)Service is included in approved waiver. There

is no change in service specifications.

( )Service is included in approved waiver. The

service specifications have been modified.

( )Service is not included in the approved

waiver.

Service Definition(Scope):

Speech Therapy services under the waiver differ in

nature and scope from speech therapy services in the Medicaid State Plan. The

provider qualifications specified in the Medicaid State Plan apply. Waiver

Speech Therapy focuses on the long-term habilitative needs of the participant,

rather than short-term acute restorative needs. Restorative services are covered

under the Medicaid State Plan.

Specify applicable (if any) limits on the amount,

frequency, or duration of this service:

For participants who choose home-based supports,

this service is included in the participant’s monthly cost limit. See Appendix

C-4. There is a State fiscal year maximum of 26 hours, unless additional

documentation supports the need for additional hours (up to 52 hours. Services

are subject to prior approval by the Operating Agency.

Service Delivery Method (check each that applies):

[X] Participant-directed as specified in Appendix

E

[X] Provider managed

Specify whether the service may be provided by

(check each that applies):

[ ] Legally Responsible Person

[ ] Relative

[ ] Legal Guardian

Provider Specifications:

Provider Category Provider Type Title

77387Individual Speech/Language Pathologist

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Extended State Plan Service

Service Name: Speech Therapy (Extended Medicaid

State Plan)

Provider Category:

[individual \/]

Provider Type:

Speech/Language Pathologist

Provider Qualifications

License (specify):

225 ILCS 110/1 et seq. 68 Ill. Adm. Code 1465

Certificate (specify):

Other Standard (specify):

Verification of Provider Qualifications

Entity Responsible for Verification:

Operating Agency (DHS)- Upon enrollment Medicaid

Agency (HFS)- Monthly verification of continuation of licensure

Frequency of Verification:

Operating Agency (DHS)- Upon enrollment Medicaid

Agency (HFS)- Monthly verification of continuation of licensure

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in

the specification are readily available to CMS upon request through the Medicaid

agency or the operating agency (if applicable).

Service Type:

[supports for Participant Direction \/]

The waiver provides for participant direction of

services as specified in Appendix E. Indicate whether the waiver includes the

following supports or other supports for participant direction.

Support for Participant Direction:

[information and Assistance in Support of

Participant Direction \/]

Alternate Service Title (if any):

Service Facilitation

Complete this part for a renewal application or a

new waiver that replaces an existing waiver. Select one :

(X)Service is included in approved waiver. There

is no change in service specifications.

( )Service is included in approved waiver. The

service specifications have been modified.

( )Service is not included in the approved

waiver.

Service Definition(Scope):

Service Facilitation includes services that assist

participants in gaining access to needed Waiver and other State plan services,

as well as medical, social, educational and other services, regardless of the

funding source for the services. The Service Facilitator assists the participant

and guardian if one has been appointed in designing an array of habilitation and

support services to meet the participant’s needs. The Service Facilitator

assists the participant and guardian to convene a support planning team, or may

convene the team as directed by the participant or guardian. In addition to the

participant, guardian (if applicable), family members and/or other individuals

important to the participant, Service Facilitator, and Individual Service and

Support Advocate (ISSA), the team may include other professionals and service

providers as needed. Based on assessment information and discussion among the

participant, guardian, family and other members of the support planning team,

the Service Facilitator writes/ updates the participant-centered support plan at

least annually or more often if needed. The Service Facilitator assists the

participant and guardian in choosing services and service providers as needed.

The Service Facilitator is responsible for ongoing monitoring of the provision

of services included in the participant’s support plan and for ensuring

participant health and welfare. The Service Facilitator is responsible for

ensuring the completion of Service Agreements between the participant and

service providers and monitoring the expenditure of funds according to the

individual budget, support plan and Service Agreements. The Service Facilitator

also assists the participant in determining individual providers of services,

such as Personal Support, Non-Medical Transportation and Behavior Intervention

and Treatment, are competent to provide the specific services the participant is

receiving.

Specify applicable (if any) limits on the amount,

frequency, or duration of this service:

This service will not be duplicative of other

services in the Waiver. For example, case management/care coordination services

are a component of residential services. This service is included in the

participant’s monthly cost limit. See Appendix C-4. No specific service

maximum. The support plan/Service Agreement must set aside at least two hours

per month to allow for routine required administrative activities.

Service Delivery Method (check each that applies):

[ ] Participant-directed as specified in Appendix

E

[X] Provider managed

Specify whether the service may be provided by

(check each that applies):

[ ] Legally Responsible Person

[ ] Relative

[ ] Legal Guardian

Provider Specifications:

Provider Category Provider Type Title

77389Agency Community-based agencies

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Supports for Participant Direction

Service Name: Service Facilitation

Provider Category:

[Agency \/]

Provider Type:

Community-based agencies

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Entity under contract with the Operating Agency

that does not also provide Individual Service and Support Advocacy. Services

must be provided personally by a professional defined in federal regulations as

a Qualified Mental Retardation Professional, known in Illinois as a Qualified

Support Professional (QSP).

Verification of Provider Qualifications

Entity Responsible for Verification:

Waiver Operating Agency (DHS)

Frequency of Verification:

Annual reviews

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in

the specification are readily available to CMS upon request through the Medicaid

agency or the operating agency (if applicable).

Service Type:

[Other Service \/]

As provided in 42 CFR §440.180((9), the State

requests the authority to provide the following additional service not specified

in statute.

Service Title:

Adaptive Equipment

Complete this part for a renewal application or a

new waiver that replaces an existing waiver. Select one :

(X)Service is included in approved waiver. There

is no change in service specifications.

( )Service is included in approved waiver. The

service specifications have been modified.

( )Service is not included in the approved

waiver.

Service Definition(Scope):

Adaptive equipment, as specified in the plan of

care, includes (a) devices, controls, or appliances that enable participants to

increase their ability to perform activities of daily living; ( devices,

controls or appliances that enable participants to perceive, control, access or

communicate with the environment in which they live; © such other durable

equipment not available under the State plan that is necessary to address

participant functional limitations; and (d) necessary initial training from the

vendor to use the adaptive equipment. Items reimbursed with Waiver funds do not

include any medical equipment and supplies furnished under the State plan and

exclude those items that are not of direct remedial benefit to the participant.

All items shall meet applicable standards of manufacture, design and

installation. All purchased items shall be the property of the participant or

the participant’s family. The cost of the service may include training the

participant or caregivers in the operation and/or maintenance of the equipment.

The cost of the service may include the performance of assessments to identify

the type of equipment needed by the participant.

Specify applicable (if any) limits on the amount,

frequency, or duration of this service:

For participants who choose home-based , this

service is not included in the participant’s monthly cost limit. There is a

$15,000 maximum per participant per five-year period for any combination of

adaptive equipment, assistive technology, home modifications and vehicle

modifications. See Appendix C-4. This service is subject to prior approval by

the Operating Agency.

Service Delivery Method (check each that applies):

[X] Participant-directed as specified in Appendix

E

[X] Provider managed

Specify whether the service may be provided by

(check each that applies):

[ ] Legally Responsible Person

[ ] Relative

[ ] Legal Guardian

Provider Specifications:

Provider Category Provider Type Title

77313Agency Equipment Vendors

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Adaptive Equipment

Provider Category:

[Agency \/]

Provider Type:

Equipment Vendors

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Enrolled vendor approved by the Service

Facilitator and participant/guardian

Verification of Provider Qualifications

Entity Responsible for Verification:

Financial Management Service entity or Operating

Agency

Frequency of Verification:

Upon enrollment

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in

the specification are readily available to CMS upon request through the Medicaid

agency or the operating agency (if applicable).

Service Type:

[Other Service \/]

As provided in 42 CFR §440.180((9), the State

requests the authority to provide the following additional service not specified

in statute.

Service Title:

Assistive Technology

Complete this part for a renewal application or a

new waiver that replaces an existing waiver. Select one :

(X)Service is included in approved waiver. There

is no change in service specifications.

( )Service is included in approved waiver. The

service specifications have been modified.

( )Service is not included in the approved

waiver.

Service Definition(Scope):

Assistive technology device is an item, piece of

equipment, or product system, whether acquired commercially, modified, or

customized, that is used to increase, maintain, or improve functional

capabilities of participants. Assistive technology service is a service that

directly assists a participant in the selection, acquisition, or use of an

assistive technology device. Assistive technology includes: 1. the evaluation of

the assistive technology needs of a participant, including a functional

evaluation of the impact of the provision of appropriate assistive technology

and appropriate services to the participant in the customary environment of the

participant. 2. Services consisting of purchasing, leasing, or otherwise

providing for the acquisition of assistive technology devices for participants.

3. Services consisting of selecting, designing, fitting, customizing, adapting,

applying, maintaining, repairing, or replacing assistive technology devices. 4.

Coordination and use of necessary therapies, interventions, or services with

assistive technology devices, such as therapies, interventions, or services

associated with other services in the support plan. 5. Training or technical

assistance for the participant, or, where appropriate, the family members,

guardians, advocates, or authorized representatives of the participant. 6.

Training or technical assistance for professionals or other persons who provide

services to, employ, or are otherwise substantially involved in the major life

functions of participants. Items reimbursed with Waiver funds do not include any

assistive technology furnished by the school program or by the Medicaid State

Plan and exclude those items that are not of direct remedial benefit to the

participant. All items shall meet applicable standards of manufacture, design

and installation. All purchased items shall be the property of the participant

or the participant’s family. The cost of the service may include training the

participant or caregivers in the operation and/or maintenance of the equipment.

The cost of the service may include the performance of assessments to identify

the type of equipment needed by the participant. The Waiver will not cover

assistive technology that is covered through the State plan.

Specify applicable (if any) limits on the amount,

frequency, or duration of this service:

For participants who choose home-based supports,

this service is not included in the participant’s monthly cost limit. There is

a $15,000 maximum per participant per five-year period for any combination of

adaptive equipment, assistive technology, home modifications, and vehicle

modifications. See Appendix C-4. This service is subject to prior approval by

the Operating Agency.

Service Delivery Method (check each that applies):

[X] Participant-directed as specified in Appendix

E

[X] Provider managed

Specify whether the service may be provided by

(check each that applies):

[ ] Legally Responsible Person

[ ] Relative

[ ] Legal Guardian

Provider Specifications:

Provider Category Provider Type Title

77315Agency Equipment vendor

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Assistive Technology

Provider Category:

[Agency \/]

Provider Type:

Equipment vendor

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Enrolled vendor approved by the waiver case

manager/Service Facilitator and participant/guardian

Verification of Provider Qualifications

Entity Responsible for Verification:

Operating Agency

Frequency of Verification:

Upon enrollment

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in

the specification are readily available to CMS upon request through the Medicaid

agency or the operating agency (if applicable).

Service Type:

[Other Service \/]

As provided in 42 CFR §440.180((9), the State

requests the authority to provide the following additional service not specified

in statute.

Service Title:

Behavior Intervention and Treatment

Complete this part for a renewal application or a

new waiver that replaces an existing waiver. Select one :

(X)Service is included in approved waiver. There

is no change in service specifications.

( )Service is included in approved waiver. The

service specifications have been modified.

( )Service is not included in the approved

waiver.

Service Definition(Scope):

Behavior intervention and treatment includes a

variety of individualized, behaviorally-based treatment models consistent with

best practice and research on effectiveness that are directly related to the

participant’s therapeutic goals. Interventions include, but are not limited

to: Applied Behavior Analysis, Relationship Development Intervention (RDI), and

Floor Time. These services are designed to assist participants to develop or

enhance skills with social value, lessen behavioral excesses and improve

communication skills. Key elements are: • Approach is tailored to address the

specific behavioral needs of the participant; • Targeted skills are broken

down into small attainable tasks; • Direct support staff and informal

caregiver training is a key component so that skills can be generalized and

communication promoted; • Services must be directly related to the

participant’s therapeutic goals contained in the support plan; and • Success

is closely monitored with detailed data collection. A behavior consultant

assesses the participant, including analysis of the presenting behavior and its

antecedents and consequences, and develops written behavior strategies based

upon the participant’s individual needs. The strategies are a component of the

participant-centered support plan and must be approved by the participant,

guardian if one has been appointed, responsible QMRP/Service Facilitator,

Individual Service and Support Advocate and the other members of the planning

team. Trained team members implement the planned behavior services. The behavior

consultant monitors progress on at least a monthly basis and more frequently if

needed to address issues with the participant’s outcomes. A progress report is

prepared by the behavior consultant and sent to the support planning team every

six months. This progress report is available to State staff upon request to

evaluate the efficacy of the treatment. The behavior consultant supervises

implementation of the behavior plan. This includes training of the direct

support staff and unpaid informal caregivers to ensure that they apply the

interventions properly, understand the specific services and outcomes for the

participant being served, and know the procedures for regularly reporting

participant progress. Services are provided by professionals working closely

with the participant’s direct support staff and unpaid informal caregivers in

the participant’s home and other natural environments. Direct support staff

and unpaid informal caregivers of participants receiving intensive behavior

treatment are vital members of the behavior team. They must be involved in the

initial training session to initiate services, and must remain involved with the

behavior consultant so that they are able to carry through and reinforce the

behaviors being worked on.

Specify applicable (if any) limits on the amount,

frequency, or duration of this service:

For participants who choose home-based supports,

this service is included in the participant’s monthly cost limit. See Appendix

C-4. There is a State fiscal year maximum of 66 hours.

Service Delivery Method (check each that applies):

[X] Participant-directed as specified in Appendix

E

[X] Provider managed

Specify whether the service may be provided by

(check each that applies):

[ ] Legally Responsible Person

[ ] Relative

[ ] Legal Guardian

Provider Specifications:

Provider Category Provider Type Title

77370Individual Behavior Consultant

111384Agency

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Behavior Intervention and

Treatment

Provider Category:

[individual \/]

Provider Type:

Behavior Consultant

Provider Qualifications

License (specify):

225 ILCS 15/1 et. Seq. 68 Ill. Adm. Code 1400

Certificate (specify):

Other Standard (specify):

Clinical psychologist Masters level professional

who is certified as a Behavior Analyst by the Behavior Analyst Certification

Board (bacb.com) Bachelor’s level professional who is certified as an

Associate Behavior Analyst by the Behavior Analyst Certification Board

(bacb.com) Professional who is certified to provide Relationship Development

Assessment. Information is at rdiconnect.com. Professional with a Bachelor’s

Degree in a human service field and who has completed at least 1,500 hours of

training or supervised experience in the application of behaviorally-based

therapy models consistent with best practice and research on individuals with

Autism Spectrum Disorder.

Verification of Provider Qualifications

Entity Responsible for Verification:

Operating Agency (DHS)- Upon enrollment and

annual verification of national certification Medicaid Agency (HFS) - Annual

check for continuation of licensure for clinical psychologists.

Frequency of Verification:

Operating Agency (DHS)- Upon enrollment and

annual verification of national certification Medicaid Agency (HFS) - Annual

check for continuation of licensure for clinical psychologists.

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Behavior Intervention and

Treatment

Provider Category:

[Agency \/]

Provider Type:

Provider Qualifications

License (specify):

225 ILCS 15/1 et. Seq. 68 Ill. Adm. Code 1400

Certificate (specify):

Board certified behavior analyst (at:

www.bacb.com)

Other Standard (specify):

1. Licensed Clinical psychologist 2. Masters

level professional who is certified as a Behavioral Analyst by the Behavior

Analyst Certification Board (see above) 3. Bachelor's level professional who is

certified as an Associate Behavior Analyst by the bacb (see above) 4.

Professional who is certified to provide Relationship Development Assessment

(information at: www.rdiconnect.com) 5. Early Intervention Specialist whith a

Developmental Therapy credential or equivalent experience and training 6.

Professional with a Bachelor's Degree in a human service field and who has

completed at least 1,500 hours of training or supervised experience in the

application of behaviorally-based therapy models consistent with best practice

and research on effectiveness for individuals with Autism Spectrum Disorder

Verification of Provider Qualifications

Entity Responsible for Verification:

Operating Agency (DHS)

Frequency of Verification:

Upon enrollment and annual verification of

national certification by the OA (DHS)

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in

the specification are readily available to CMS upon request through the Medicaid

agency or the operating agency (if applicable).

Service Type:

[Other Service \/]

As provided in 42 CFR §440.180((9), the State

requests the authority to provide the following additional service not specified

in statute.

Service Title:

Behavioral Services (Psychotherapy and Counseling)

Complete this part for a renewal application or a

new waiver that replaces an existing waiver. Select one :

(X)Service is included in approved waiver. There

is no change in service specifications.

( )Service is included in approved waiver. The

service specifications have been modified.

( )Service is not included in the approved

waiver.

Service Definition(Scope):

Psychotherapy is a treatment approach that focuses

on a goal of ameliorating or reducing the symptoms of emotional, cognitive or

behavioral disorder and promoting positive emotional, cognitive and behavioral

development. Counseling is a treatment approach that uses relationship skills to

promote the participant’s abilities to deal with daily living issues

associated with their cognitive or behavioral problems using a variety of

supportive and re-educative techniques.

Specify applicable (if any) limits on the amount,

frequency, or duration of this service:

For participants who choose home-based supports,

this service is included in the participant’s monthly cost limit. See Appendix

C-4. There is a State fiscal year maximum of 60 hours for any combination of

psychotherapy and counseling services.

Service Delivery Method (check each that applies):

[X] Participant-directed as specified in Appendix

E

[X] Provider managed

Specify whether the service may be provided by

(check each that applies):

[ ] Legally Responsible Person

[ ] Relative

[ ] Legal Guardian

Provider Specifications:

Provider Category Provider Type Title

77372Individual Licensed Psychotherapists

77373Individual Licensed Counselors

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Behavioral Services (Psychotherapy

and Counseling)

Provider Category:

[individual \/]

Provider Type:

Licensed Psychotherapists

Provider Qualifications

License (specify):

225 ILCS 15/1 et. Seq. 68 Ill. Adm. Code 1400

225 ILCS 20/1 et seq. 68 Ill. Adm. Code 1470 225 ILCS 55/1 et seq. 68 Ill. Adm.

Code 1283 225 ILCS 107/1 et seq. 68 Ill. Adm. Code 1375

Certificate (specify):

Other Standard (specify):

Clinical Psychologist Clinical Social Worker

Marriage/Family Therapist Clinical Professional Counselor

Verification of Provider Qualifications

Entity Responsible for Verification:

Operating Agency (DHS) - Upon enrollment and

annual verification of continuation of licensure Medicaid Agency (HFS) - Annual

check for continuation of licensure for licensed professionals

Frequency of Verification:

Operating Agency (DHS) - Upon enrollment and

annual verification of continuation of licensure Medicaid Agency (HFS) - Annual

check for continuation of licensure for licensed professionals

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Behavioral Services (Psychotherapy

and Counseling)

Provider Category:

[individual \/]

Provider Type:

Licensed Counselors

Provider Qualifications

License (specify):

All licensure categories for psychotherapists,

plus: 225 ILCS 20/1 et seq. 68 Ill Adm. Code 1470 225 ILCS 107/1 et seq. 68 Ill.

Adm. Code 1375

Certificate (specify):

Other Standard (specify):

Social Worker Professional Counselor

Verification of Provider Qualifications

Entity Responsible for Verification:

Operating Agency (DHS) - Upon enrollment and

annual verification of continuation of licensure Medicaid Agency (HFS) - Annual

check for continuation of licensure for licensed professionals

Frequency of Verification:

Operating Agency (DHS) - Upon enrollment and

annual verification of continuation of licensure Medicaid Agency (HFS) - Annual

check for continuation of licensure for licensed professionals

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in

the specification are readily available to CMS upon request through the Medicaid

agency or the operating agency (if applicable).

Service Type:

[Other Service \/]

As provided in 42 CFR §440.180((9), the State

requests the authority to provide the following additional service not specified

in statute.

Service Title:

Emergency Home Response Services (EHRS)

Complete this part for a renewal application or a

new waiver that replaces an existing waiver. Select one :

(X)Service is included in approved waiver. There

is no change in service specifications.

( )Service is included in approved waiver. The

service specifications have been modified.

( )Service is not included in the approved

waiver.

Service Definition(Scope):

EHRS is defined as a 24-hour emergency

communication link to assistance outside the participant’s home for

individuals based on health and safety needs and mobility limitations. This

service is provided by a two-way voice communication system consisting of a base

unit and an activation device worn by the participant that will automatically

link the individual to a professionally staffed support center. Whenever the

system is engaged by a participant, the support center assesses the situation

and directs an appropriate response. The purpose of providing EHRS is to improve

the independence and safety of participants in their own homes in accordance

with the authorized plan of care, and thereby help reduce the need for

institutional care or out-of-home placement in a more restrictive setting.

Specify applicable (if any) limits on the amount,

frequency, or duration of this service:

This service will not be duplicative of other

services in the waiver. For example, routine supervision and emergency response

are an integral component of residential services. EHRS are limited to

participants who live alone, or who are alone for significant parts of the day,

and have no regular caregiver for extended periods of time, and who would

otherwise require extensive routine supervision. For participants who choose

home-based supports, this service is included in the participant’s monthly

cost limit. See Appendix C-4. No specific service maximum. Provider

Specifications

Service Delivery Method (check each that applies):

[X] Participant-directed as specified in Appendix

E

[ ] Provider managed

Specify whether the service may be provided by

(check each that applies):

[ ] Legally Responsible Person

[ ] Relative

[ ] Legal Guardian

Provider Specifications:

Provider Category Provider Type Title

77317Agency Certified vendor

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Emergency Home Response Services

(EHRS)

Provider Category:

[Agency \/]

Provider Type:

Certified vendor

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Certified by the Department on Aging to provide

this service or approved by the Department of Human Services with a current

written rate agreement.

Verification of Provider Qualifications

Entity Responsible for Verification:

Department on Aging Operating Agency (DHS)

Division of Rehabilitation Services Operating Agency (DHS)

Frequency of Verification:

Initial Certification and recertification no

less frequently than every three years Initial approval and re-approval every

three years with annual written rate agreements Verification of certification or

approval upon enrollment and annual certification/approval

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in

the specification are readily available to CMS upon request through the Medicaid

agency or the operating agency (if applicable).

Service Type:

[Other Service \/]

As provided in 42 CFR §440.180((9), the State

requests the authority to provide the following additional service not specified

in statute.

Service Title:

Home Accessibility Modifications

Complete this part for a renewal application or a

new waiver that replaces an existing waiver. Select one :

(X)Service is included in approved waiver. There

is no change in service specifications.

( )Service is included in approved waiver. The

service specifications have been modified.

( )Service is not included in the approved

waiver.

Service Definition(Scope):

Those physical adaptations to the private

residence of the participant or the participant’s family, required by the

participant's support plan, that are necessary to ensure the health, welfare and

safety of the participant or that enable the participant to function with

greater independence in the home. Such adaptations include the installation of

ramps and grab-bars, widening of doorways, modification of bathroom facilities,

or the installation of specialized electric and plumbing systems that are

necessary to accommodate the adaptive equipment that are necessary for the

welfare of the participant. Excluded are those adaptations or improvements to

the home that are of general utility, such as carpeting, roof repair, central

air conditioning, and are not of direct remedial benefit to the participant.

Adaptations that add to the total square footage of the home are excluded from

this benefit. Seasonal items such as swimming pools and related equipment are

excluded. All services shall be provided in accordance with applicable State or

local building codes. This service is subject to prior approval by the Operating

Agency.

Specify applicable (if any) limits on the amount,

frequency, or duration of this service:

This service is not included in the

participant’s monthly cost limit/individual budget. There is a $15,000 maximum

per participant per five-year period for any combination of adaptive equipment,

assistive technology, home modifications and vehicle modifications. Within the

five-year maximum, there is also a $5,000 maximum per address for permanent home

modifications for rented homes. See Appendix C-4.

Service Delivery Method (check each that applies):

[X] Participant-directed as specified in Appendix

E

[X] Provider managed

Specify whether the service may be provided by

(check each that applies):

[ ] Legally Responsible Person

[ ] Relative

[ ] Legal Guardian

Provider Specifications:

Provider Category Provider Type Title

76311Individual Independent Contractor

76312Agency Construction Companies

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Home Accessibility Modifications

Provider Category:

[individual \/]

Provider Type:

Independent Contractor

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Enrolled vendor approved by the Service

Facilitator and participant/guardian

Verification of Provider Qualifications

Entity Responsible for Verification:

Financial Management Service entity or Operating

Agency

Frequency of Verification:

Upon enrollment

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Home Accessibility Modifications

Provider Category:

[Agency \/]

Provider Type:

Construction Companies

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Enrolled vendor approved by the Service

Facilitator and participant/guardian.

Verification of Provider Qualifications

Entity Responsible for Verification:

Financial Management Service entity or Operating

Agency

Frequency of Verification:

Upon enrollment

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in

the specification are readily available to CMS upon request through the Medicaid

agency or the operating agency (if applicable).

Service Type:

[Other Service \/]

As provided in 42 CFR §440.180((9), the State

requests the authority to provide the following additional service not specified

in statute.

Service Title:

Non-Medical Transportation

Complete this part for a renewal application or a

new waiver that replaces an existing waiver. Select one :

(X)Service is included in approved waiver. There

is no change in service specifications.

( )Service is included in approved waiver. The

service specifications have been modified.

( )Service is not included in the approved

waiver.

Service Definition(Scope):

Non-Medical Transportation is a service offered in

order to enable waiver participants to gain access to waiver and other community

services, activities and resources, as specified by the support plan. This

service is offered in addition to medical transportation required under the Code

of Federal Regulations (42 CFR §431.53) and transportation services under the

Medicaid State Plan, defined in the Code of Federal Regulations at 42 CFR

§440.170(a) (if applicable), and does not replace them. Transportation services

under the Waiver are offered in accordance with the participant’s support

plan. Whenever possible, family, neighbors, friends, or community agencies that

can provide this service without charge are utilized. Excluded is transportation

to and from covered Medicaid State Plan services. Also excluded is

transportation to and from day program services.

Specify applicable (if any) limits on the amount,

frequency, or duration of this service:

For participants who choose home-based supports,

this service is included in the participant’s monthly cost limit. See Appendix

C-4. This service will not be duplicative of other services in the Waiver. For

example, non-medical transportation is an integral component of residential and

day services. No more than $500 of the monthly cost limit may be used for

non-medical transportation services.

Service Delivery Method (check each that applies):

[X] Participant-directed as specified in Appendix

E

[ ] Provider managed

Specify whether the service may be provided by

(check each that applies):

[X] Legally Responsible Person

[ ] Relative

[ ] Legal Guardian

Provider Specifications:

Provider Category Provider Type Title

77309Individual Community-based agencies

76316Individual Individual rs

77311Individual Special Recreation Associations

77310Individual Public and private carriers

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Non-Medical Transportation

Provider Category:

[individual \/]

Provider Type:

Community-based agencies

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Drivers must have appropriate state licenses and

proof of insurance

Verification of Provider Qualifications

Entity Responsible for Verification:

Waiver Operating Agency (DHS)

Frequency of Verification:

Upon enrollment

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Non-Medical Transportation

Provider Category:

[individual \/]

Provider Type:

Individual rs

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Drivers must have appropriate state licenses and

proof of insurance

Verification of Provider Qualifications

Entity Responsible for Verification:

Financial Management Service entity

Frequency of Verification:

Upon enrollment

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Non-Medical Transportation

Provider Category:

[individual \/]

Provider Type:

Special Recreation Associations

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Drivers must have appropriate state licenses and

proof of insurance

Verification of Provider Qualifications

Entity Responsible for Verification:

Waiver Operating Agency (DHS)

Frequency of Verification:

Upon enrollment

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Non-Medical Transportation

Provider Category:

[individual \/]

Provider Type:

Public and private carriers

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Drivers must have appropriate state licenses and

proof of insurance

Verification of Provider Qualifications

Entity Responsible for Verification:

Financial Management Service entity

Frequency of Verification:

Upon enrollment

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in

the specification are readily available to CMS upon request through the Medicaid

agency or the operating agency (if applicable).

Service Type:

[Other Service \/]

As provided in 42 CFR §440.180((9), the State

requests the authority to provide the following additional service not specified

in statute.

Service Title:

Personal Support

Complete this part for a renewal application or a

new waiver that replaces an existing waiver. Select one :

(X)Service is included in approved waiver. There

is no change in service specifications.

( )Service is included in approved waiver. The

service specifications have been modified.

( )Service is not included in the approved

waiver.

Service Definition(Scope):

Personal Support includes: • Teaching adaptive

skills to assist the participant to reach personal goals; • Personal

assistance in activities of daily living; • Services provided on a short-term

basis because of the absence, incapacity or need for relief of those persons who

normally provide care (typically referred to as respite). Supports are typically

provided in such areas as eating, bathing, dressing, personal hygiene, community

integration, meal preparation (excluding the cost of the meals), transportation

and other activities of daily living. Supports may be provided to assist the

participant to perform such tasks as light housework, laundry, grocery shopping,

using the telephone, and medication management, which are essential to the

health and welfare of the participant, rather than for the participant’s

family. Supports may be provided to develop skills in money management or skills

necessary to self-advocate, exercise civil rights and exercise control and

responsibility over other support services. Such assistance also may include the

supervision of participants as provided in the support plan. Personal Support

may include an extension of behavioral and therapy services. Extension of

services means activities by the Personal Support worker that assist the

participant to implement a behavioral, occupational therapy, physical therapy,

or speech therapy plan to the extent permitted by state law and as prescribed in

the support plan. Implementation activities include assistance with exercise

routines, range of motion, reading the therapist’s directions, helping the

participant remember and follow the steps of the plan or hands-on assistance. It

does not include the actual service the professional therapist provides.

Personal Support is not intended to include professional services, home cleaning

services, or other community services used by the general public. Some

professional services are covered elsewhere under the home-based supports

option. Personal Support may be provided in the participant's home and may

include supports necessary to participate in other community activities outside

the home. The need for Personal Support and the scope of the needed services

must be documented in the participant-centered support plan. The amount of

Personal Support must be specified in the support plan/Service Agreement.

Specify applicable (if any) limits on the amount,

frequency, or duration of this service:

Personal Support will not be duplicative of other

services in the Waiver, i.e., residential habilitation, day habilitation, etc.,

since Personal Support services are already included in those services. For

participants who chose home-based supports, this service is included in the

participant’s monthly cost limit. See Appendix C-4. For participants still

enrolled in school, no Personal Support services may be delivered during the

typical school day relative to the age of the participant or during times when

educational services are being provided.

Service Delivery Method (check each that applies):

[X] Participant-directed as specified in Appendix

E

[X] Provider managed

Specify whether the service may be provided by

(check each that applies):

[ ] Legally Responsible Person

[X] Relative

[X] Legal Guardian

Provider Specifications:

Provider Category Provider Type Title

75331Individual Personal Support Worker

75274Agency Community-Based Agencies and Special

Recreation Associations

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Personal Support

Provider Category:

[individual \/]

Provider Type:

Personal Support Worker

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Aged 18 or older, and is deemed by the

participant or guardian to be qualified and competent to meet the

participant’s needs and carry out responsibilities assigned via the support

plan. Workers hired on or after July 1, 2007, must have passed criminal

background and Health Care Worker Registry checks prior to employment.

Verification of Provider Qualifications

Entity Responsible for Verification:

Financial Management Service (FMS) entity - Upon

enrollment Waiver Operating Agency (DHS)- Utilization reviews of a sample

thereafter

Frequency of Verification:

Financial Management Service (FMS) entity - Upon

enrollment Waiver Operating Agency (DHS)- Utilization reviews of a sample

thereafter

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Personal Support

Provider Category:

[Agency \/]

Provider Type:

Community-Based Agencies and Special Recreation

Associations

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

The Agency must be under contract with the

Operating Agency. Per these contracts, employees must complete Operating

Agency-approved direct support personnel training and pass competency-based

training assessments (40 hours of classroom and 80 hours of on-the-job training)

and be certified as direct support personnel. All employees must have passed

criminal background and Health Care Worker Registry checks prior to employment.

Verification of Provider Qualifications

Entity Responsible for Verification:

Waiver Operating Agency (DHS)

Frequency of Verification:

Annual

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in

the specification are readily available to CMS upon request through the Medicaid

agency or the operating agency (if applicable).

Service Type:

[Other Service \/]

As provided in 42 CFR §440.180((9), the State

requests the authority to provide the following additional service not specified

in statute.

Service Title:

Skilled Nursing

Complete this part for a renewal application or a

new waiver that replaces an existing waiver. Select one :

(X)Service is included in approved waiver. There

is no change in service specifications.

( )Service is included in approved waiver. The

service specifications have been modified.

( )Service is not included in the approved

waiver.

Service Definition(Scope):

Services listed in the participant-centered

support plan that are within the scope of the State's Nurse Practice Act and are

provided by a registered professional nurse, or licensed practical nurse under

the supervision of a registered nurse, licensed to practice in the State. These

services are in addition to any Medicaid State Plan nursing services for which

the participant may qualify.

Specify applicable (if any) limits on the amount,

frequency, or duration of this service:

This service will not be duplicative of other

services in the Waiver. For example, nursing services beyond those covered in

the State Plan, are a component of residential services For participants who

choose home-based supports, this service is included in the participant’s

monthly cost limit. See Appendix C-4. There is a State fiscal year maximum of

365 hours of service by a registered nurse and 365 hours of service by a

licensed practical nurse.

Service Delivery Method (check each that applies):

[X] Participant-directed as specified in Appendix

E

[ ] Provider managed

Specify whether the service may be provided by

(check each that applies):

[ ] Legally Responsible Person

[ ] Relative

[ ] Legal Guardian

Provider Specifications:

Provider Category Provider Type Title

77375Individual Registered Nurse; or Licensed

Practical Nurse, under supervision by a registered nurse

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Skilled Nursing

Provider Category:

[individual \/]

Provider Type:

Registered Nurse; or Licensed Practical Nurse,

under supervision by a registered nurse

Provider Qualifications

License (specify):

225 ILCS 65/1 et seq. 68 Ill. Adm. Code 1300

Certificate (specify):

Other Standard (specify):

Verification of Provider Qualifications

Entity Responsible for Verification:

Operating Agency (DHS) - Upon enrollment and

annual verification of continuation of license Medicaid Agency (HFS) - Monthly

check for continuation of licensure for licensed professionals

Frequency of Verification:

Operating Agency (DHS) - Upon enrollment and

annual verification of continuation of license Medicaid Agency (HFS) - Monthly

check for continuation of licensure for licensed professionals

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in

the specification are readily available to CMS upon request through the Medicaid

agency or the operating agency (if applicable).

Service Type:

[Other Service \/]

As provided in 42 CFR §440.180((9), the State

requests the authority to provide the following additional service not specified

in statute.

Service Title:

Temporary Assistance (formerly called Crisis

Services)

Complete this part for a renewal application or a

new waiver that replaces an existing waiver. Select one :

(X)Service is included in approved waiver. There

is no change in service specifications.

( )Service is included in approved waiver. The

service specifications have been modified.

( )Service is not included in the approved

waiver.

Service Definition(Scope):

Temporary Assistance (formerly called Crisis

Services) services are provided on an emergency temporary basis because of the

absence or incapacity of the persons who normally provide unpaid care. Absence

or incapacity of the primary caregiver(s) must be due to a temporary cause, such

as hospitalization, illness, injury, or other emergency situation. Temporary

Assistance services are not available for caregiver absences for vacations,

educational or employment-related reasons, or other non-emergency reasons. The

definition of Temporary Assistance services includes the same activities,

requirements and responsibilities as Personal Support. The participant, legal

representative, the service provider and the support planning team may set

mutually acceptable rates for Temporary Assistance services.

Specify applicable (if any) limits on the amount,

frequency, or duration of this service:

The rates must be specified in the Service

Agreements and are subject to review and approval by the Operating Agency on

either a targeted or a random sample basis. This service will not be duplicative

of other services in the Waiver. For example, Temporary Assistance services are

a component of residential services. This service is not included in the

participant’s monthly home-based services cost maximum. Temporary Assistance

services may not exceed $2,000 in any single month and may not be authorized for

more than two consecutive months or 60 consecutive days. For young adults

between age 18 and 22 who attend school, Temporary Assistance services may not

be delivered during the typical school day relative to the age of the

participant or during times when educational services are being provided. This

service is subject to prior approval by the Operating Agency.

Service Delivery Method (check each that applies):

[X] Participant-directed as specified in Appendix

E

[X] Provider managed

Specify whether the service may be provided by

(check each that applies):

[ ] Legally Responsible Person

[ ] Relative

[ ] Legal Guardian

Provider Specifications:

Provider Category Provider Type Title

77378Agency Community-Based Agencies and Special

Recreation Associations

77377Individual Crisis Services Worker

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Temporary Assistance (formerly

called Crisis Services)

Provider Category:

[Agency \/]

Provider Type:

Community-Based Agencies and Special Recreation

Associations

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

The Agency must be under contract with the

Operating Agency. Per these contracts, employees must complete DHS-approved

direct support personnel training and pass competency-based training assessments

(40 hours of classroom and 80 hours of on-the-job training) and be certified as

direct support personnel. All employees must have had criminal background and

Health Care Worker Registry checks completed prior to employment.

Verification of Provider Qualifications

Entity Responsible for Verification:

Community-Based Agency- Waiver Operating Agency

(DHS)- Annual Waiver Operating Agency (DHS)- Waiver Operating Agency (DHS) -

Annual

Frequency of Verification:

Community-Based Agency- Waiver Operating Agency

(DHS)- Annual Waiver Operating Agency (DHS)- Waiver Operating Agency (DHS) -

Annual

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Temporary Assistance (formerly

called Crisis Services)

Provider Category:

[individual \/]

Provider Type:

Crisis Services Worker

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Aged 18 or older, has a high school diploma or

GED, and is deemed by the guardian or family to be qualified and competent to

meet the participant’s needs and carry out responsibilities assigned via the

support plan. Crisis Services workers hired on or after July 1, 2007, must have

passed criminal background and Health Care Worker Registry checks prior to

employment.

Verification of Provider Qualifications

Entity Responsible for Verification:

Financial Management Service entity - Upon

enrollment Waiver Operating Agency (DHS) - Utilization reviews conducted of a

sample thereafter

Frequency of Verification:

Financial Management Service entity - Upon

enrollment Waiver Operating Agency (DHS) - Utilization reviews conducted of a

sample thereafter

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in

the specification are readily available to CMS upon request through the Medicaid

agency or the operating agency (if applicable).

Service Type:

[Other Service \/]

As provided in 42 CFR §440.180((9), the State

requests the authority to provide the following additional service not specified

in statute.

Service Title:

Training and Counseling Services for Unpaid

Caregivers

Complete this part for a renewal application or a

new waiver that replaces an existing waiver. Select one :

(X)Service is included in approved waiver. There

is no change in service specifications.

( )Service is included in approved waiver. The

service specifications have been modified.

( )Service is not included in the approved

waiver.

Service Definition(Scope):

Training and counseling services for individuals

who provide unpaid support, training, companionship or supervision to

participants. For purposes of this service, individual is defined as any person,

family member, neighbor, friend, companion, or co-worker who provides

uncompensated care, training, guidance, companionship or support to a

participant served in the waiver. This service may not be provided in order to

train paid caregivers or school personnel. Training includes instruction about

treatment regimens and other services included in the support plan, use of

equipment specified in the support plan, and includes updates as necessary to

safely maintain the participant at home. Counseling must be aimed at assisting

the unpaid caregiver in meeting the needs of the participant. All training for

individuals who provide unpaid support to the participant must be included in

the participant’s support plan. Caregivers who are compensated for direct

services under this Waiver may not receive services under this service title.

Training furnished to individuals who provide uncompensated care and support to

the participant must be directly related to their role in supporting the

participant in areas specified in the support plan. Counseling similarly must be

aimed at assisting unpaid individuals who support the participant to understand

and address participant needs.

Specify applicable (if any) limits on the amount,

frequency, or duration of this service:

This service will not be duplicative of other

services in the Waiver. For example, residential services include training and

supports for care givers, all of whom are paid. For participants who choose

home-based supports, this service is included in the participant’s monthly

cost limit. See Appendix C-4. No specific service maximum.

Service Delivery Method (check each that applies):

[X] Participant-directed as specified in Appendix

E

[ ] Provider managed

Specify whether the service may be provided by

(check each that applies):

[ ] Legally Responsible Person

[ ] Relative

[ ] Legal Guardian

Provider Specifications:

Provider Category Provider Type Title

77320Agency Specialized Training providers

77319Individual Licensed counselors

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Training and Counseling Services

for Unpaid Caregivers

Provider Category:

[Agency \/]

Provider Type:

Specialized Training providers

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Training programs, workshops or events deemed

qualified by the participant/guardian and approved by the Service Facilitator.

Examples include CPR instruction, first aid, and programs on disability-specific

topics such as epilepsy, autism, etc.

Verification of Provider Qualifications

Entity Responsible for Verification:

Operating Agency (DHS) or Financial Management

Service entity

Frequency of Verification:

Upon enrollment

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Training and Counseling Services

for Unpaid Caregivers

Provider Category:

[individual \/]

Provider Type:

Licensed counselors

Provider Qualifications

License (specify):

225 ILCS 15/1 et. seq. 68 Ill. Adm. Code 1400

225 ILCS 20/1 et seq. 68 Ill. Adm. Code 1470 225 ILCS 55/1 et seq. 68 Ill. Adm.

Code 1283 225 ILCS 107/1 et seq. 68 Ill. Adm. Code 1375 225 ILCS 20/1 et seq. 68

Ill Adm. Code 1470 225 ILCS 107/1 et seq. 68 Ill. Adm. Code 1375

Certificate (specify):

Other Standard (specify):

Verification of Provider Qualifications

Entity Responsible for Verification:

Waiver Operating Agency (DHS)

Frequency of Verification:

Upon enrollment Annual check for continuation of

licensure.

Appendix C: Participant Services

C-1/C-3: Service Specification

State laws, regulations and policies referenced in

the specification are readily available to CMS upon request through the Medicaid

agency or the operating agency (if applicable).

Service Type:

[Other Service \/]

As provided in 42 CFR §440.180((9), the State

requests the authority to provide the following additional service not specified

in statute.

Service Title:

Vehicle Modification

Complete this part for a renewal application or a

new waiver that replaces an existing waiver. Select one :

(X)Service is included in approved waiver. There

is no change in service specifications.

( )Service is included in approved waiver. The

service specifications have been modified.

( )Service is not included in the approved

waiver.

Service Definition(Scope):

Vehicle Modifications are adaptations or

alterations to an automobile or van that is the participant’s primary means of

transportation in order to accommodate the special needs of the participant.

Vehicle adaptations are specified by the support plan as necessary to enable the

participant to integrate more fully into the community and to ensure the health,

welfare and safety of the participant. The following are specifically excluded:

1. Adaptations or improvements to the vehicle that are of general utility, and

are not of direct remedial benefit to the participant; 2. Purchase or lease of a

vehicle; and 3. Regularly scheduled upkeep and maintenance of a vehicle except

upkeep and maintenance of the modifications. The vehicle that is adapted must be

owned by the participant, a family member with whom the participant lives or has

consistent and on-going contact, or a non-relative who provides primary

long-term support to the participant and is not a paid provider of such

services.

Specify applicable (if any) limits on the amount,

frequency, or duration of this service:

This service will not be duplicative of other

services in the waiver. For example, vehicle modifications are within the

transportation component of residential services and day habilitation services.

For participants who choose home-based supports, this service is not included in

the participant’s monthly cost limit. There is a $15,000 maximum per

participant per five-year period for any combination of adaptive equipment,

assistive technology, home modifications, and vehicle modifications. See

Appendix C-4. This service requires prior approval by the Operating Agency.

Service Delivery Method (check each that applies):

[X] Participant-directed as specified in Appendix

E

[ ] Provider managed

Specify whether the service may be provided by

(check each that applies):

[ ] Legally Responsible Person

[ ] Relative

[ ] Legal Guardian

Provider Specifications:

Provider Category Provider Type Title

76314Agency Equipment Vendor and Installer

Appendix C: Participant Services

C-1/C-3: Provider Specifications for Service

Service Type: Other Service

Service Name: Vehicle Modification

Provider Category:

[Agency \/]

Provider Type:

Equipment Vendor and Installer

Provider Qualifications

License (specify):

Certificate (specify):

Other Standard (specify):

Enrolled vendor approved by the Service

Facilitator and the participant/guardian

Verification of Provider Qualifications

Entity Responsible for Verification:

Financial Management Service entity or Operating

Agency

Frequency of Verification:

Upon enrollment

Appendix C: Participant Services

C-1: Summary of Services Covered (2 of 2)

1.. Provision of Case Management Services to Waiver

Participants. Indicate how case management is furnished to waiver participants

(select one):

( ) not selected

( ) Not applicable - Case management is not furnished as

a distinct activity to waiver participants.

(X) Applicable - Case management is furnished as a

distinct activity to waiver participants.

Check each that applies:

[X] As a waiver service defined in Appendix C-3. Do not

complete item C-1-c.

[ ] As a Medicaid State plan service under §1915(i) of

the Act (HCBS as a State Plan Option). Complete item C-1-c.

[ ] As a Medicaid State plan service under §1915(g)(1)

of the Act (Targeted Case Management). Complete item C-1-c.

[X] As an administrative activity. Complete item C-1-c.

NOTE: Pursuant to CMS-2237-IFC this selection is no longer available for 1915©

waivers.

[ ] Not applicable - Case management is not furnished as

a distinct activity to waiver participants. Do not complete item C-1-c.

( ) None of the above apply - Case management is

furnished as a waiver service (Do not complete item C-1-c).

1.. Delivery of Case Management Services.Specify the

entity or entities that conduct case management functions on behalf of waiver

participants:

Character Count:out of 4000

In addition to residential habilitation and service

facilitator services, which provide many components of case management services,

each waiver participant receives Individual Service and Support Advocacy (ISSA)

services from the local independent service coordination (ISC) entity under

contract with the Operating Agency. ISSAs are Qualified Mental Retardation

Professional (QMRP) staff (known as Qualified Support Professionals/QSPs in

Illinois), who are responsible for the annual re-determinations of level of

care, participate in the support planning process, approve all

participant-centered support plans, advocate on behalf of the participant and

family, visit with the participant at least four times per year to ensure health

and welfare and that needs are being met, and alert the Operating Agency about

issues that require additional monitoring and technical assistance. The maximum

for ISSA is 25 hours per state fiscal year, unless written approval is granted

for additional hours. This administrative service is required for all waiver

participants. For individuals who exercise participant direction as part of

home-based supports, the local service facilitator, also a QMRP(QSP in

Illinois), provides information and assistance in support of participant

direction. Service facilitation is a separate waiver service and participants

have the choice of providers. Other aspects of case management services are

provided by QMRPs/QSPs who are employees of direct service providers, including

residential habilitation providers. The case management functions performed

include coordination of multiple services and/or among multiple service

providers and linking waiver participants to other Federal, state and local

programs. Some components of case management, including development and/or

review of service plans, monitoring the implementation of service plans and

participant health and welfare, addressing problems in service provision, and

responding to participant crises, are provided under both the administrative and

case management services. We believe this is appropriate because the parties

conducting the administrative functions are independent of direct services

providers and play a role in the State's monitoring efforts. Direct case

managers must be involved in these issues too in order to ensure appropriate

service delivery.

Appendix C: Participant Services

C-2: General Service Specifications (1 of 3)

1.. Criminal History and/or Background

Investigations.Specify the State's policies concerning the conduct of criminal

history and/or background investigations of individuals who provide waiver

services (select one):

( )No. Criminal history and/or background

investigations are not required.

(X)Yes. Criminal history and/or background

investigations are required.

1.. Specify: (a) the types of positions (e.g.,

personal assistants, attendants) for which such investigations must be

conducted; ( the scope of such investigations (e.g., state, national); and,

© the process for ensuring that mandatory investigations have been conducted.

State laws, regulations and policies referenced in this description are

available to CMS upon request through the Medicaid or the operating agency (if

applicable):

2.. Character Count:out of 12000

3.. Criminal background checks with the Illinois State

Police are required for direct service staff hired by agencies providing

residential services, Developmental Training, Adult Day Care, Supported

Employment, Service Facilitation, Personal Support, or Individual Service and

Support Advocacy. These agencies may not knowingly hire or retain any person in

a full-time, part-time or contractual direct service position if that person has

been convicted of committing or attempting to commit one or more of the offenses

in the Illinois Health Care Worker Background Check Act (225 ILCS 64/25), unless

the person obtains a waiver of the conviction. For individual providers hired as

common law employees on or after July 1, 2007, the Financial Management Service

(FMS) entity/entities under contract with the OA, is required to obtain criminal

background checks and not enroll or retain independent personal support workers

(common law employees or domestic employees) if the person has been convicted as

described above. The FMS vendor obtains the criminal background check on behalf

of all participants who hire independent personal support workers. The results

are kept on file with the FMS vendor. Periodically, the OA and MA review

providers and FMS entities for compliance with this requirement.

4.. Abuse Registry Screening.Specify whether the State

requires the screening of individuals who provide waiver services through a

State-maintained abuse registry (select one):

( )No. The State does not conduct abuse registry

screening.

(X)Yes. The State maintains an abuse registry and

requires the screening of individuals through this registry.

1.. Specify: (a) the entity (entities) responsible for

maintaining the abuse registry; ( the types of positions for which abuse

registry screenings must be conducted; and, © the process for ensuring that

mandatory screenings have been conducted. State laws, regulations and policies

referenced in this description are available to CMS upon request through the

Medicaid agency or the operating agency (if applicable):

2.. Character Count:out of 12000

3.. By statute, the Illinois Department of Public

Health maintains an adult abuse and neglect registry. The registry is called the

Healthcare Worker Registry (formerly known as the Nurse Aide Registry). The

state law governing the Health Care Worker’s Registry is the Abused and

Neglected Long Term Care Facility Residents Reporting Act (210 ILCS 30). By

statute, the Illinois Department of Children and Family Services (DCFS)

maintains a child abuse and neglect registry. The registry is called the Child

Abuse and Neglect Tracking System, or CANTS. The state law governing the State

Central Register (DCFS CANTS) is the Abused and Neglected Child Reporting Act

(325 ILCS 5/1). Waiver providers are required by the OA to complete registry

checks on all employees. Employees cannot be hired if they fail the registry

checks. The results of the registry checks are documented by the provider.

Abuse/neglect screenings are required for all domestic employees hired on or

after July 1, 2007, who provide personal support or temporary assistance

services. Such individuals may not be employed in any capacity until the

employer has checked the individual against the Ill. Dept. of Public Health,

Health Care Worker Registry and the Ill. Dept. of Children and Family Services

Registry. The FMS entities conduct the registry checks for all personal support

workers employed directly by the participant or their representative.

Abuse/Neglect screenings are required for all individuals providing residential

habilitation, day habilitation (called Developmental Training), Supported

Employment, Service Facilitation, Personal Support or Individual Service and

Support Advocacy (ISSA) services. Such individuals may not be employed in any

capacity until the employer has checked the individual against: • The Illinois

Department of Public Health (IDPH) Health Care Worker Registry, and • The

Illinois Department of Children and Family Services (DCFS) State Central

Register (Children's Abuse and Neglect Tracking System - CANTS). If either

database reports substantiated or indicated findings of physical or sexual abuse

or egregious neglect, the person may not be employed. The OA and the MA review

providers and FMS entities for compliance with this requirement.

Appendix C: Participant Services

C-2: General Service Specifications (2 of 3)

1.. Services in Facilities Subject to §1616(e) of the

Social Security Act. Select one:

( )No. Home and community-based services under

this waiver are not provided in facilities subject to §1616(e) of the Act.

(X)Yes. Home and community-based services are

provided in facilities subject to §1616(e) of the Act. The standards that apply

to each type of facility where waiver services are provided are available to CMS

upon request through the Medicaid agency or the operating agency (if

applicable).

1.. Types of Facilities Subject to §1616(e).Complete

the following table for each type of facility subject to §1616(e) of the Act:

Facility Type

Community-Integrated Living Arrangement

Community -Based agencies (CLF)

1.. Larger Facilities: In the case of residential

facilities subject to §1616(e) that serve four or more individuals unrelated to

the proprietor, describe how a home and community character is maintained in

these settings.

Character Count:out of 12000

Community integration is a fundamental goal and

component of the support plan for all participants in the Waiver, regardless of

the size of the living arrangement. Every participant has an independent

Individual Service and Support Advocate (ISSA), part of whose role it is to

ensure availability of supports to encourage individual choices about

participating in specialized and generic activities outside the home and within

their home communities, developing and maintaining meaningful relationships with

friends and family, and participating in organizations and general community

life. The Operating Agency monitors support plans and ISSA visiting notes to

ensure that community integration is supported. Licensure standards are in place

to ensure participants may maintain personal possessions, visit with friends in

the community and be given the opportunity to develop social relationships and

pursue hobbies and personal interests through participation in neighborhood,

school and other community and other group activities. Residential habilitation

settings are integrated into their home communities. They are located to promote

easy access to stores, religious institutions, services, and activities in the

community, by foot, public transportation, or car. Consistent with each

participant’s service plan, the residential habilitation settings offer a

home-like environment, family-style meals and personal privacy.

Appendix C: Participant Services

C-2: Facility Specifications

Facility Type:

Community-Integrated Living Arrangement

Waiver Service(s) Provided in Facility:

Waiver Service Provided in Facility

77445Adaptive Equipment [X]

77446Skilled Nursing [ ]

77447Personal Support [ ]

77448Behavior Intervention and Treatment [X]

77449Occupational Therapy (Extended Medicaid

State Plan) [X]

77450Residential Habilitation [X]

77451Service Facilitation [ ]

77452Adult Day Care [X]

77453Non-Medical Transportation [ ]

77454Emergency Home Response Services (EHRS) [ ]

77455Supported Employment [X]

77456Assistive Technology [X]

77457Developmental Training [X]

77458Behavioral Services (Psychotherapy and

Counseling) [X]

77459Training and Counseling Services for Unpaid

Caregivers [ ]

77460Speech Therapy (Extended Medicaid State

Plan) [X]

77461Temporary Assistance (formerly called

Crisis Services) [ ]

77462Vehicle Modification [ ]

77463Physical Therapy (Extended Medicaid State

Plan) [X]

77464Home Accessibility Modifications [X]

Facility Capacity Limit:

8

Scope of Facility Sandards.For this facility type,

please specify whether the State's standards address the following topics (check

each that applies):

Scope of State Facility Standards

Standard Topic Addressed

Admission policies [X]

Physical environment [X]

Sanitation [X]

Safety [X]

Staff : resident ratios [ ]

Staff training and qualifications [X]

Staff supervision [X]

Resident rights [X]

Medication administration [X]

Use of restrictive interventions [X]

Incident reporting [X]

Provision of or arrangement for necessary health

services [X]

When facility standards do not address one or more

of the topics listed, explain why the standard is not included or is not

relevant to the facility type or population. Explain how the health and welfare

of participants is assured in the standard area(s) not addressed:

Staff-to-resident ratios Standards for residential

services do not specify staff-to-resident ratios. Instead, the standards employ

an outcome-oriented approach to ensure sufficient staff is available to meet the

needs of participants. Specifically, the CILA standards require that providers

ensure that the number, organization, and qualifications of staff meet the

training, care, support, health, safety, and evacuation needs of the

participants served by the provider. The CLF standards require that the provider

ensure that sufficient staff in numbers and qualifications is on duty all hours

of each day to provide services that meet the total needs of the residents.

Appendix C: Participant Services

C-2: Facility Specifications

Facility Type:

Community -Based agencies (CLF)

Waiver Service(s) Provided in Facility:

Waiver Service Provided in Facility

77489Adaptive Equipment [X]

77470Skilled Nursing [ ]

77471Personal Support [ ]

77472Behavior Intervention and Treatment [X]

77493Occupational Therapy (Extended Medicaid

State Plan) [X]

77474Residential Habilitation [X]

77475Service Facilitation [ ]

77496Adult Day Care [X]

77497Non-Medical Transportation [ ]

77498Emergency Home Response Services (EHRS) [ ]

77499Supported Employment [X]

77500Assistive Technology [X]

77481Developmental Training [X]

77482Behavioral Services (Psychotherapy and

Counseling) [X]

77483Training and Counseling Services for Unpaid

Caregivers [ ]

77504Speech Therapy (Extended Medicaid State

Plan) [X]

77505Temporary Assistance (formerly called

Crisis Services) [ ]

77506Vehicle Modification [ ]

77507Physical Therapy (Extended Medicaid State

Plan) [X]

77488Home Accessibility Modifications [X]

Facility Capacity Limit:

16

Scope of Facility Sandards.For this facility type,

please specify whether the State's standards address the following topics (check

each that applies):

Scope of State Facility Standards

Standard Topic Addressed

Admission policies [X]

Physical environment [X]

Sanitation [X]

Safety [X]

Staff : resident ratios [ ]

Staff training and qualifications [X]

Staff supervision [X]

Resident rights [X]

Medication administration [X]

Use of restrictive interventions [X]

Incident reporting [X]

Provision of or arrangement for necessary health

services [X]

When facility standards do not address one or more

of the topics listed, explain why the standard is not included or is not

relevant to the facility type or population. Explain how the health and welfare

of participants is assured in the standard area(s) not addressed:

Staff-to-resident ratios Standards for residential

services do not specify staff-to-resident ratios. Instead, the standards employ

an outcome-oriented approach to ensure sufficient staff is available to meet the

needs of participants. Specifically, the CILA standards require that providers

ensure that the number, organization, and qualifications of staff meet the

training, care, support, health, safety, and evacuation needs of the

participants served by the provider. The CLF standards require that the provider

ensure that sufficient staff in numbers and qualifications is on duty all hours

of each day to provide services that meet the total needs of the residents.

Appendix C: Participant Services

C-2: General Service Specifications (3 of 3)

1.. Provision of Personal Care or Similar Services by

Legally Responsible Individuals.A legally responsible individual is any person

who has a duty under State law to care for another person and typically

includes: (a) the parent (biological or adoptive) of a minor child or the

guardian of a minor child who must provide care to the child or ( a spouse of

a waiver participant. Except at the option of the State and under extraordinary

circumstances specified by the State, payment may not be made to a legally

responsible individual for the provision of personal care or similar services

that the legally responsible individual would ordinarily perform or be

responsible to perform on behalf of a waiver participant. Select one:

(X) No. The State does not make payment to legally

responsible individuals for furnishing personal care or similar services.

( ) Yes. The State makes payment to legally responsible

individuals for furnishing personal care or similar services when they are

qualified to provide the services.

Specify: (a) the legally responsible individuals who may

be paid to furnish such services and the services they may provide; ( State

policies that specify the circumstances when payment may be authorized for the

provision of extraordinary careby a legally responsible individual and how the

State ensures that the provision of services by a legally responsible individual

is in the best interest of the participant; and, © the controls that are

employed to ensure that payments are made only for services rendered. Also,

specify in Appendix C-1/C-3 the personal care or similar services for which

payment may be made to legally responsible individuals under the State policies

specified here.

Character Count:out of 12000

( ) not selected

1.. Other State Policies Concerning Payment for Waiver

Services Furnished by Relatives/Legal Guardians.Specify State policies

concerning making payment to relatives/legal guardians for the provision of

waiver services over and above the policies addressed in Item C-2-d. Select one:

( ) The State does not make payment to relatives/legal

guardians for furnishing waiver services.

( ) The State makes payment to relatives/legal guardians

under specific circumstances and only when the relative/guardian is qualified to

furnish services.

Specify the specific circumstances under which payment

is made, the types of relatives/legal guardians to whom payment may be made, and

the services for which payment may be made. Specify the controls that are

employed to ensure that payments are made only for services rendered. Also,

specify in Appendix C-1/C-3 each waiver service for which payment may be made to

relatives/legal guardians.

Character Count:out of 12000

(X) Relatives/legal guardians may be paid for providing

waiver services whenever the relative/legal guardian is qualified to provide

services as specified in Appendix C-1/C-3.

Specify the controls that are employed to ensure that

payments are made only for services rendered.

Character Count:out of 12000

Payment for Waiver services may be made to any relative

and/or legal guardian who meets the requirements to provide the service, except

for legally responsible relatives as defined in Section C-2(d) above (spouses).

Parents, other close relatives, and legal guardians may not provide host family

services (i.e., foster care and other shared living arrangements) under

residential habilitation services. This prohibition is specified in Illinois

Administrative Code, available upon request from either the Medicaid or

Operating Agency. Personal support, temporary assistance and non-medical

transportation are the only services that may be provided by a relative. The

services may be provided by relatives as long as they meet the same provider

qualifications and pass the required background checks as any other domestic

employee providing personal support or any other non-medical transportation

service provider. The participant-centered support plan governs the services to

be provided. For participants who exercise employer authority, the Financial

Management Service (FMS) entity receives time sheets detailing the date and time

of services delivered. The FMS entity conducts routine quality assurance

activities. The OA through it's representative sample, reviews personal support,

temporary assistance and non-medical transportation, regardless of the provider

relationship.

( ) Other policy.

Specify:

Character Count:out of 12000

( ) not selected

1.. Open Enrollment of Providers.Specify the processes

that are employed to assure that all willing and qualified providers have the

opportunity to enroll as waiver service providers as provided in 42 CFR

§431.51:

Character Count:out of 12000

As part of the participant-centered planning process,

participants in the Developmental Disabilities Adult Waiver and their guardian,

if one has been appointed, together with the Service Facilitator or responsible

QSP/QMRP, Individual Service and Support Advocate (ISSA), and other members of

the support planning team, are responsible for selecting needed services and

service providers. Participant-directed services allow participants or guardian

(as applicable), who choose to exercise employer authority to hire common law

employees (called domestic employees) with support from the Financial Management

Service (FMS) entity. Information regarding provider qualifications and program

guidelines is continuously available on the Operating Agency’s website. The

State does not impose barriers to the free choice of willing and qualified

providers. The Operating Agency (DHS) reviews and approves service providers for

participation in the Adult Developmental Disabilities Waiver based on the

provider qualifications specified in the Waiver. The State Medicaid Agency

enrolls all willing and qualified providers that are chosen by participants or

guardian, if one is appointed, in the Developmental Disabilities Adult Waiver.

Appendix C: Participant Services

Quality Improvement: Qualified Providers

As a distinct component of the State’s quality

improvement strategy, provide information in the following fields to detail the

State’s methods for discovery and remediation.

1.. Methods for Discovery: Qualified Providers

1.. Sub-Assurances:

2.. Sub-Assurance: The State verifies that providers

initially and continually meet required licensure and/or certification standards

and adhere to other standards prior to their furnishing waiver services.

Performance Measures

For each performance measure/indicator the State will

use to assess compliance with the statutory assurance complete the following.

Where possible, include numerator/denominator. Each performance measure must be

specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the

aggregated data that will enable the State to analyze and assess progress toward

the performance measure. In this section provide information on the method by

which each source of data is analyzed statistically/deductively or inductively,

how themes are identified or conclusions drawn, and how recommendations are

formulated, where appropriate.

Performance Measure:

Number and percent of licensed or certified

providers who meet initial licensure/certification standards. (Note: this covers

licensed residential habilitation providers, certified day habilitation

providers and licensed clinicians.) N: Number of newly enrolled providers who

meet initial standards. D: Total number of newly enrolled providers.

Data Source(Select one):

Other

If 'Other' is selected, specify:

OA MIS automated reports and licensure and

certification information

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [X] 100%

Review

[X] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of licensed or certified

providers who continue to meet licensure/certification standards on an ongoing

basis. (Note: covers the same providers as listed above.) N: Number of providers

who continue to meet standards. D: Total number of enrolled providers.

Data Source(Select one):

Other

If 'Other' is selected, specify:

MA reviews all licensed clinicians. OA will

merge MA data for reporting purposes.

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [X] 100%

Review

[X] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

1.. Sub-Assurance: The State monitors

non-licensed/non-certified providers to assure adherence to waiver requirements.

For each performance measure/indicator the State will

use to assess compliance with the statutory assurance complete the following.

Where possible, include numerator/denominator. Each performance measure must be

specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the

aggregated data that will enable the State to analyze and assess progress toward

the performance measure. In this section provide information on the method by

which each source of data is analyzed statistically/deductively or inductively,

how themes are identified or conclusions drawn, and how recommendations are

formulated, where appropriate.

Performance Measure:

The number and percent of

non-licensed/non-certified providers reviewed, by provider type, who meet

initial provider qualifications. (Note: Covers non-licensed behavioral

therapists, transportation providers, supported employment providers, etc.) N:

Number of providers who meet initial qualifications. D: Total number of newly

enrolled providers.

Data Source(Select one):

Other

If 'Other' is selected, specify:

OA MIS automated reports

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [X] 100%

Review

[X] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

The number and percent of

non-licensed/non-certified providers reviewed, by provider type, who continue to

meet the waiver provider qualifications. (Note: Covers same providers as listed

above.) N: Number of providers who continue to meet qualifications. D: Total

number of enrolled non-licensed providers.

Data Source(Select one):

Other

If 'Other' is selected, specify:

OA MIS automated reports

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[X] State Medicaid Agency [ ] Weekly [X] 100%

Review

[X] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of independent personal support

providers (domestic employees) screened by FMS vendors (on behalf of waiver

participants who self-direct and exercise employer authority) who passed initial

background and registry checks and thus were deemed eligible for hire. N: Number

of domestic employees who passed initial checks. D: Total number of domestic

employees hired.

Data Source(Select one):

Other

If 'Other' is selected, specify:

FMS vendor reports

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [X] 100%

Review

[X] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

1.. Sub-Assurance: The State implements its policies

and procedures for verifying that provider training is conducted in accordance

with state requirements and the approved waiver.

For each performance measure/indicator the State will

use to assess compliance with the statutory assurance complete the following.

Where possible, include numerator/denominator. Each performance measure must be

specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the

aggregated data that will enable the State to analyze and assess progress toward

the performance measure. In this section provide information on the method by

which each source of data is analyzed statistically/deductively or inductively,

how themes are identified or conclusions drawn, and how recommendations are

formulated, where appropriate.

Performance Measure:

Number and percent of providers reviewed, by

provider type, who meet waiver provider training requirements. Numerator: Number

of providers who met training requirements. Denominator: Total number of

providers subject to training requirements.

Data Source(Select one):

Training verification records

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [ ] 100%

Review

[X] Operating Agency [ ] Monthly [X] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[ ] Continuously and Ongoing [X] Other

Specify:

Provider training compliance will be reviewed

over the course of 5 years.

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

1.. If applicable, in the textbox below provide any

necessary additional information on the strategies employed by the State to

discover/identify problems/issues within the waiver program, including frequency

and parties responsible.

Character Count:out of 6000

1.. Methods for Remediation/Fixing Individual Problems

1.. Describe the State’s method for addressing

individual problems as they are discovered. Include information regarding

responsible parties and GENERAL methods for problem correction. In addition,

provide information on the methods used by the State to document these items.

Character Count:out of 6000

The OA reviews the findings and identifies the most

appropriate response. General responses may include working with participants

and their providers, retraining staff, voiding claims, technical assistance,

increased monitoring, revising service plans, and requiring plans of correction.

The OA is responsible for seeing that individual issues are resolved. The OA

provides quarterly reports of these activities to the MA. Staff of the two State

agencies review the reports on a quarterly basis.

1.. Remediation Data Aggregation

Remediation-related Data Aggregation and Analysis

(including trend identification)

Responsible Party (check each that applies):

Frequency of data aggregation and analysis (check each that applies):

[ ] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

1.. Timelines

When the State does not have all elements of the Quality

Improvement Strategy in place, provide timelines to design methods for discovery

and remediation related to the assurance of Qualified Providers that are

currently non-operational.

(X) No

( ) Yes

( ) not selected

Please provide a detailed strategy for assuring

Qualified Providers, the specific timeline for implementing identified

strategies, and the parties responsible for its operation.

Character Count:out of 6000

Appendix C: Participant Services

C-3: Waiver Services Specifications

Section C-3 'Service Specifications' is incorporated

into Section C-1 'Waiver Services.'

Appendix C: Participant Services

C-4: Additional Limits on Amount of Waiver Services

1.. Additional Limits on Amount of Waiver

Services.Indicate whether the waiver employs any of the following additional

limits on the amount of waiver services (select one).

( ) not selected

( ) Not applicable - The State does not impose a limit

on the amount of waiver services except as provided in Appendix C-3.

(X) Applicable - The State imposes additional limits on

the amount of waiver services.

When a limit is employed, specify: (a) the waiver

services to which the limit applies; ( the basis of the limit, including its

basis in historical expenditure/utilization patterns and, as applicable, the

processes and methodologies that are used to determine the amount of the limit

to which a participant's services are subject; © how the limit will be

adjusted over the course of the waiver period; (d) provisions for adjusting or

making exceptions to the limit based on participant health and welfare needs or

other factors specified by the state; (e) the safeguards that are in effect when

the amount of the limit is insufficient to meet a participant's needs; (f) how

participants are notified of the amount of the limit. (check each that applies)

[X] Limit(s) on Set(s) of Services.There is a limit on

the maximum dollar amount of waiver services that is authorized for one or more

sets of services offered under the waiver.

Furnish the information specified above.

Character Count:out of 24000

In addition to the information contained in the OA's DDD

Waiver Manual, each participant receives an initial award letter that contains

service limits. The service limits are discussed verbally during the annual

service planning process. The waiver case manager or service facilitator and the

ISSA review service limits with the participant and guardian, if applicable. The

written service plan is signed by the participant, or his or her guardian (if

one has been appointed), the waiver case manager/service facilitator and the

ISSA. Maximum for Modifications and Tangible Items There is a $15,000 maximum

per participant per five-year period for any combination of adaptive equipment,

assistive technology, and minor home and vehicle modifications. Within the

five-year maximum, there is also a $5,000 maximum per address for permanent home

modifications for rented homes. Individual program limits were combined to allow

participants greater flexibility within the tangible item budget to meet their

unique needs. Participants are informed of their right to request a fair

hearing, in the event any requests are denied. Participants are notified of the

limits in the OA's Waiver manual. Waiver case managers or service facilitators

and ISSA assist participants in understanding and managing the limits. Temporary

Assistance services may not exceed $2,000 in a single month and may not be

authorized for more than two consecutive months or 60 consecutive days. Under

certain circumstances, the OA can provide verbal approval within 24 hours of

receipt of a request for Temporary Assistance services. Services can begin upon

verbal approval. The Independent Service and Support Advocate (ISSA) or

home-based supports Service Facilitator will submit a written request for prior

authorization for Temporary Assistance services on behalf of the individual. The

OA will respond in writing to the request within 30 calendar days. However, when

an unplanned need occurs, Temporary Assistance services will begin upon receipt

of verbal approval from the OA. The OA will provide verbal approval ASAP but no

later than 24 hours of receipt of request, in thoses cases of unplanned need.

Subsequent written approval is issued to the participant, Service Facilitator

and ISSA by the OA.

[X] Prospective Individual Budget Amount.There is a

limit on the maximum dollar amount of waiver services authorized for each

specific participant.

Furnish the information specified above.

Character Count:out of 24000

The annual supports budget limits are based on the

Illinois Home-Based Support Services Law for Mentally Disabled Adults [405 ILCS

80]. The limits are indexed to Social Security benefit levels and are adjusted

each January when Social Security benefits are adjusted for cost of living

increases. These statutory budget limits were set through a public legislative

process that included opportunities for public comment by advocates and

individuals with mental disabilities and their families. The total amount of

Waiver services provided in any month is determined by the support plan of the

participant within the program maximums. The annual support plan is developed by

the waiver case manager (Service Facilitator), with input from the ISSA and

other team members, and is based on assessments of the participant’s needs.

Written notices of changes to limits are sent to all participants/guardians,

Financial Management Service entities, Service Facilitation providers and

Individual Service and Support Advocacy (ISSA) entities by the OA. We expect

that the monthly support services budget limits, currently $2,022 for calendar

year 2011 (or $1,348 if between the ages of 18 and 22 and still attending

school), together with natural supports, general community resources,

school-based services (for young adult participants still attending school), and

Medicaid State plan services will be sufficient to meet the participant’s

needs.

[ ] Budget Limits by Level of Support.Based on an

assessment process and/or other factors, participants are assigned to funding

levels that are limits on the maximum dollar amount of waiver services.

Furnish the information specified above.

Character Count:out of 24000

[ ] Other Type of Limit.The State employs another type

of limit.

Describe the limit and furnish the information specified

above.

Character Count:out of 24000

[ ] Not applicable.The State does not impose a limit on

the amount of waiver services except as provided in Appendix C-3.

Appendix D: Participant-Centered Planning and Service

Delivery

D-1: Service Plan Development (1 of 8)

State Participant-Centered Service Plan Title:Sometimes

referred to as Individual Service Plan or Support Plan

1.. Responsibility for Service Plan Development.Per 42

CFR §441.301((2), specify who is responsible for the development of the

service plan and the qualifications of these individuals (select each that

applies):

[ ] Registered nurse, licensed to practice in the State

[ ] Licensed practical or vocational nurse, acting

within the scope of practice under State law

[ ] Licensed physician (M.D. or D.O)

[ ] Case Manager(qualifications specified in Appendix

C-1/C-3)

[ ] Case Manager(qualifications not specified in

Appendix C-1/C-3).

Specify qualifications:

Character Count:out of 6000

[ ] Social Worker.

Specify qualifications:

Character Count:out of 6000

[X] Other

Specify the individuals and their qualifications:

Character Count:out of 6000

For the participant-directed home-based supports, the

Service Facilitator, who is QMRP/QSP, is responsible. For those receiving

residential habilitation services, the QMRP employed by the licensed provider,

is responsible for service plan development. Waiver case manager for residential

habilitation providers and Service Facilitator qualifications are specified in

Appendix C-1.

Appendix D: Participant-Centered Planning and Service

Delivery

D-1: Service Plan Development (2 of 8)

1.. Service Plan Development Safeguards.Select one:

( )Entities and/or individuals that have

responsibility for service plan development may not provide other direct waiver

services to the participant.

(X)Entities and/or individuals that have

responsibility for service plan development may provide other direct waiver

services to the participant.

1.. The State has established the following safeguards

to ensure that service plan development is conducted in the best interests of

the participant. Specify:

2.. Character Count:out of 6000

3.. In addition to the waiver case manager/Service

facilitator who is a QMRP/QSP employed by a direct service provider, all Waiver

participants hav an Individual Service and Support Advocate (ISSA) who is a

QMRP/QSP employed by an independent service coordination (ISC) entity under

contract with the Operating Agency. The ISSA participates in and approves the

participant-directed support plan. The ISSA also conducts quarterly visits to

the individual to ensure that services in the plan are being fully implemented

and are meeting the participants’ needs.

Appendix D: Participant-Centered Planning and Service

Delivery

D-1: Service Plan Development (3 of 8)

1.. Supporting the Participant in Service Plan

Development.Specify: (a) the supports and information that are made available to

the participant (and/or family or legal representative, as appropriate) to

direct and be actively engaged in the service plan development process and (

the participant's authority to determine who is included in the process.

Character Count:out of 12000

For all Waiver participants, participant-centered

support plans are developed by QMRP/QSPs, who work as part of a team that

includes the participant being served, the participant’s legal guardian (if

one has been appointed), the participant’s Individual Service and Support

Advocate (ISSA), other individuals from the participant’s support network as

the participant or guardian chooses, and professional consultants as deemed

necessary by the provider. The written plan may be produced in other formats,

such as pictures, DVD, etc., to accommodate specific needs of the participant,

team, or provider; however, the plan must exist in written format. ISSAs are

directed to contact the participant and guardian, if one has been appointed,

prior to any support planning meetings to identify areas of concern, answer

questions, and generally prepare for the meeting. The participant or guardian

(if one has been appointed), responsible waiver case manager or Service

Facilitator, and the ISSA must approve the support plan, in writing.

Appendix D: Participant-Centered Planning and Service

Delivery

D-1: Service Plan Development (4 of 8)

1.. Service Plan Development Process.In four pages or

less, describe the process that is used to develop the participant-centered

service plan, including: (a) who develops the plan, who participates in the

process, and the timing of the plan; ( the types of assessments that are

conducted to support the service plan development process, including securing

information about participant needs, preferences and goals, and health status;

© how the participant is informed of the services that are available under the

waiver; (d) how the plan development process ensures that the service plan

addresses participant goals, needs (including health care needs), and

preferences; (e) how waiver and other services are coordinated; (f) how the plan

development process provides for the assignment of responsibilities to implement

and monitor the plan; and, (g) how and when the plan is updated, including when

the participant's needs change. State laws, regulations, and policies cited that

affect the service plan development process are available to CMS upon request

through the Medicaid agency or the operating agency (if applicable):

Character Count:out of 24000

Plan Development and Modification Within 30 days after

the initiation of services, the responsible waiver case manager/Service

Facilitator/QMRP/QSP shall prepare a written participant-centered support plan

for each participant only after consultation with the following: •

Face-to-face consultation with the participant; • Consultation with the

participant’s legal guardian, if one has been appointed; • Other individuals

from the participant’s support network (including family members) as the

participant or guardian chooses; • The participant’s ISSA; and •

Professional consultants as deemed necessary. The written plan may be produced

in other formats, such as pictures, DVD, etc., to accommodate specific needs of

the participant, team, or provider; however, the plan must exist in written

format. The support plan shall: • Contain a description of the participant’s

preferences; • List and describe the necessary activities, training,

materials, equipment, assistive technology, and services that are needed to

assist the participant; • Describe how opportunities of choice will be

provided, including specifying means for the following: -supporting the

participant or guardian, if one has been appointed, to indicate preferences

among options presented, by whatever communication methods necessary; -providing

the necessary support and training for the participant to be able to indicate

preferences, including a description of any training and support needed to fully

participate in the planning process and other choice making; and -assisting the

participant or guardian to understand the negative consequences of choices that

may involve risk; • Prioritize and structure the delivery of services toward

the goal of achieving the participant’s or guardian’s preferences; •

Provide for supports for the participant to access generic resources and

Medicaid State Plan services; and • Contribute to the continuous movement of

the participant toward the achievement of the participant’s or guardian’s

preferences. The support plan shall: • Be dated; • Be approved in writing by

the participant or guardian, if one has been appointed. Requirements for

approval from or consultation with the participant’s guardian shall be

considered to have been complied with if the provider documents that it has

taken reasonable measures to obtain this approval or consultation and that the

participant’s guardian has failed to respond; • Be approved in writing by

the responsible waiver case manager/Service Facilitator/QMRP/QSP; and • Be

approved, in writing, by the participant’s ISSA. The ISSA shall approve only

those plans that meet the requirements established in the Waiver. If the ISSA

determines that the proposed plan does not meet these requirements, the ISSA

shall work with the participant or guardian, if applicable, and provider(s) to

ensure the proposed plan is modified as necessary. In the event that conflicts

arise that cannot be resolved among the parties involved, the ISSA or

responsible waiver case manager/Service Facilitator shall make a referral to the

Operating Agency for technical assistance. The responsible waiver case

manager/Service Facilitator shall regularly review and revise the plan by

following the same procedures as set out above, whenever necessary, to reflect

any of the following: • Changes in the participant’s needs and preferences;

• Achievement of goals or skills outlined within the plan; or • Any

determination made that any service being provided is unresponsive. In

developing, modifying, and evaluating the effectiveness of the plan, the

responsible waiver case manager/Service Facilitator shall include assessments

made by professionals and shall: • Include consideration of the expressed

opinions of the participant or guardian, as applicable, and other individuals

from the participant’s support network; and • Account for the following: (i)

the financial limitations of the participant, the provider, and funding sources;

(ii) the supports and training needed, offered, and accepted by the participant;

(iii) the participant’s medical status, (iv) the participant’s ability to

communicate his or her needs and preferences, and (v) matters identified in

Section e below in accordance with imminent danger. • Next best options may be

considered as responsive if the participant or guardian, as applicable, cannot

specifically have what is preferred due to limitations identified. All plans

must be updated at least annually.

Appendix D: Participant-Centered Planning and Service

Delivery

D-1: Service Plan Development (5 of 8)

1.. Risk Assessment and Mitigation.Specify how

potential risks to the participant are assessed during the service plan

development process and how strategies to mitigate risk are incorporated into

the service plan, subject to participant needs and preferences. In addition,

describe how the service plan development process addresses backup plans and the

arrangements that are used for backup.

Character Count:out of 12000

For all Waiver participants, the responsible waiver case

manager/Service Facilitator and ISSA must address during the planning process

with the participant and guardian (if one has been appointed) the negative

consequences of choices that may involve risk and document the issues concerned

and the decisions made. They will describe, when it is necessary to do so, to

the participant and the participant’s support network, how the preferences

might be limited because of imminent significant danger to the participant’s

health, safety, or welfare based on the following: • The participant or

guardian’s, if one has been appointed, history of decision-making and ability

to learn from the natural negative consequences of poor decision-making; • The

possible long and short-term consequences that might result to the participant

if the participant makes a poor decision; • The possible long and short-term

effects that might result to the participant if the provider limits or prohibits

the participant or guardian from making a choice; and • The safeguards

available to protect the participant’s safety and rights in each context of

choices. Backup plans are developed, if it is determined to be necessary, as

part of the plan development process. If the participant is receiving services

from an agency, the agency is required to provide back-up personnel as needed.

When the participant is exercising employer authority, the back-up plan is

specific to the participant's needs and may include family, other social service

agencies, etc. This waiver provides support services to adults of all ages, some

of who live at home with other family members. As part of the service planning

process, the participant or guardian, if one has been appointed, can make

arrangements with multiple providers who can be contacted as needed. A back-up

plan is necessary when the absence of the service presents a risk to the health,

welfare and/or safety of the participant. The planning team evaluates the need

and type of back-up plan taking into consideration natural supports and

available waiver services. Participants residing with family members can enter

into agreements with providers that can provide services in an emergency

situation or provide staff substitutes when regular staff cannot work assigned

hours.

Appendix D: Participant-Centered Planning and Service

Delivery

D-1: Service Plan Development (6 of 8)

1.. Informed Choice of Providers.Describe how

participants are assisted in obtaining information about and selecting from

among qualified providers of the waiver services in the service plan.

Character Count:out of 6000

A list of providers, by provider type, is available on

the OA's website. A written list of providers is available upon request.

Participants are supported by the Independent Service Coordination (ISC) entity

under contract with the Operating Agency. Once the individual or guardian

expresses an interest in or selects the type(s) of services he or she wishes to

receive, the ISC informs the individual or guardian of providers offering that

type of service in the desired geographic area. ISCs will make referrals to

those providers selected by the individual/guardian. These referrals must be

documented on the DDPAS-10 form. The ISC ensures linkage with potential

providers, and may, at the participant's request, participate in discussions or

visits with providers. A copy of the DDPAS-10 form is maintained in the

individual's file at the ISC entity's office.

Appendix D: Participant-Centered Planning and Service

Delivery

D-1: Service Plan Development (7 of 8)

1.. Process for Making Service Plan Subject to the

Approval of the Medicaid Agency.Describe the process by which the service plan

is made subject to the approval of the Medicaid agency in accordance with 42 CFR

§441.301((1)(i):

Character Count:out of 6000

Annually OA staff review the adequacy of support plans

through a representative sample during on-site reviews. The MA participates in

select reviews. The reviews consist of record reviews, interviews with

participants and staff, and observations. Data from these reviews are aggregated

by the OA and shared with the MA staff as part of the Quality Management

Committee activity. This committee meets quarterly. In addition, the Medicaid

Agency conducts sample reviews of service plans to ensure they are developed in

accordance with Waiver requirements.

Appendix D: Participant-Centered Planning and Service

Delivery

D-1: Service Plan Development (8 of 8)

1.. Service Plan Review and Update.The service plan is

subject to at least annual periodic review and update to assess the

appropriateness and adequacy of the services as participant needs change.

Specify the minimum schedule for the review and update of the service plan:

( )Every three months or more frequently when

necessary

( )Every six months or more frequently when

necessary

(X)Every twelve months or more frequently when

necessary

( )Other schedule

1.. Specify the other schedule:

2.. Character Count:out of 6000

3.. Maintenance of Service Plan Forms.Written copies

or electronic facsimiles of service plans are maintained for a minimum period of

3 years as required by 45 CFR §92.42. Service plans are maintained by the

following (check each that applies):

[ ] Medicaid agency

[ ] Operating agency

[ ] Case manager

[X] Other

Specify:

Character Count:out of 4000

Responsible waiver case manager or Service Facilitator

(for participant-directed support services) and ISSA, employed by an Independent

Service Coordination (ISC) entity under contract with the OA.

Appendix D: Participant-Centered Planning and Service

Delivery

D-2: Service Plan Implementation and Monitoring

1.. Service Plan Implementation and

Monitoring.Specify: (a) the entity (entities) responsible for monitoring the

implementation of the service plan and participant health and welfare; ( the

monitoring and follow-up method(s) that are used; and, © the frequency with

which monitoring is performed.

Character Count:out of 24000

The waiver case manager/Service Facilitator is

responsible for implementing the service plan and ensuring the ongoing health

and welfare of the participant. They are to have face-to-face contact with the

participant at least six times per year, one visit every two months. The ISSA,

who is independent of direct service provision, is responsible for monitoring

the implementation of the service plan and ensuring the health and welfare of

the participant. The ISSA must visit at least quarterly with each participant in

the Waiver. The OA monitors the waiver case management and ISSA activity through

a representative sample of participants on a continuous, ongoing basis. Data is

collected and analyzed as specified under the Quality Improvement sections in

Appendices D and G on an ongoing, continuous basis. Summary reports are shared

with the MA quarterly and discussed during quarterly Quality Management

Committee meetings. When problems are identified, they are documented and

remediation efforts are initiated by the OA. Remediation efforts may include

revising service plans, increased monitoring, technical assistance, plans of

correction, and voidance of claims. The support plan is reviewed

1.. Monitoring Safeguards.Select one:

( )Entities and/or individuals that have

responsibility to monitor service plan implementation and participant health and

welfare may not provide other direct waiver services to the participant.

(X)Entities and/or individuals that have

responsibility to monitor service plan implementation and participant health and

welfare may provide other direct waiver services to the participant

1.. The State has established the following safeguards

to ensure that monitoring is conducted in the best interests of the participant.

Specify:

2.. Character Count:out of 24000

3.. In addition to routine monitoring by the

responsible waiver case manager or Service Facilitator, the Individual Services

and Support Advocacy (ISSA) entity, an Independent Service Coordination (ISC)

entity under contract with the Operating Agency, continually (at least quarterly

or more often if necessary) monitors the implementation of the plan and works

cooperatively with the service providers, participant, and guardian (if one is

appointed) to resolve any concerns. In the event that issues cannot be resolved,

the provider or the ISSA shall make a referral to the Operating Agency for

technical assistance.

Appendix D: Participant-Centered Planning and Service

Delivery

Quality Improvement: Service Plan

As a distinct component of the State’s quality

improvement strategy, provide information in the following fields to detail the

State’s methods for discovery and remediation.

1.. Methods for Discovery: Service Plan

Assurance/Sub-assurances

1.. Sub-Assurances:

2.. Sub-assurance: Service plans address all

participants’ assessed needs (including health and safety risk factors) and

personal goals, either by the provision of waiver services or through other

means.

Performance Measures

For each performance measure/indicator the State will

use to assess compliance with the statutory assurance complete the following.

Where possible, include numerator/denominator. Each performance measure must be

specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the

aggregated data that will enable the State to analyze and assess progress toward

the performance measure. In this section provide information on the method by

which each source of data is analyzed statistically/deductively or inductively,

how themes are identified or conclusions drawn, and how recommendations are

formulated, where appropriate.

Performance Measure:

Number and percent of the participant plans of

care reviewed that address all participant needs identified by the assessment.

Numerator: Participant plans that addressed all identified needs. Denominator:

All sample ISPs reviewed.

Data Source(Select one):

Record reviews, on-site

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[X] State Medicaid Agency [ ] Weekly [ ] 100%

Review

[X] Operating Agency [ ] Monthly [X] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [X]

Representative Sample

Confidence Interval =

5%

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of satisfaction survey

respondents sampled who report they receive services to address their needs.

Numerator: Number of respondents who reported they received services to address

their needs. Denominator: Total respondents sampled.

Data Source(Select one):

Analyzed collected data (including surveys,

focus group, interviews, etc)

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [ ] 100%

Review

[X] Operating Agency [ ] Monthly [X] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [X]

Representative Sample

Confidence Interval =

5%

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of participants reviewed whose

service plan have strategies to address all health and safety risks indicated in

the assessment. Numerator: Number of ISPs with strategies to address all

identified health and safety risks. Denominator: Total ISPs sampled with an

assessed health and/or safety risk.

Data Source(Select one):

Record reviews, on-site

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[X] State Medicaid Agency [ ] Weekly [ ] 100%

Review

[X] Operating Agency [ ] Monthly [X] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [X]

Representative Sample

Confidence Interval =

5%

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

1.. Sub-assurance: The State monitors service plan

development in accordance with its policies and procedures.

Performance Measures

For each performance measure/indicator the State will

use to assess compliance with the statutory assurance complete the following.

Where possible, include numerator/denominator. Each performance measure must be

specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the

aggregated data that will enable the State to analyze and assess progress toward

the performance measure. In this section provide information on the method by

which each source of data is analyzed statistically/deductively or inductively,

how themes are identified or conclusions drawn, and how recommendations are

formulated, where appropriate.

Performance Measure:

Number and percent of ISP's that were developed in

accordance with state requirements. Numerator: Number of ISPs that were

developed in accordance with state requirements. Denominator: Number of ISPs

reviewed.

Data Source(Select one):

Record reviews, on-site

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[X] State Medicaid Agency [ ] Weekly [ ] 100%

Review

[X] Operating Agency [ ] Monthly [X] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [X]

Representative Sample

Confidence Interval =

5%

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

1.. Sub-assurance: Service plans are updated/revised

at least annually or when warranted by changes in the waiver participant’s

needs.

Performance Measures

For each performance measure/indicator the State will

use to assess compliance with the statutory assurance complete the following.

Where possible, include numerator/denominator. Each performance measure must be

specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the

aggregated data that will enable the State to analyze and assess progress toward

the performance measure. In this section provide information on the method by

which each source of data is analyzed statistically/deductively or inductively,

how themes are identified or conclusions drawn, and how recommendations are

formulated, where appropriate.

Performance Measure:

Number and percent of waiver participants reviewed

whose Individual Service Plan (ISP) was updated/revised when their needs

changed. Numerator: Number of ISPs that were revised when the participant's

needs changed. Denominator: All participants in the sample whose needs changed.

Data Source(Select one):

Record reviews, on-site

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[X] State Medicaid Agency [ ] Weekly [ ] 100%

Review

[X] Operating Agency [ ] Monthly [X] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [X]

Representative Sample

Confidence Interval =

5%

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

1.. Sub-assurance: Services are delivered in

accordance with the service plan, including the type, scope, amount, duration

and frequency specified in the service plan.

Performance Measures

For each performance measure/indicator the State will

use to assess compliance with the statutory assurance complete the following.

Where possible, include numerator/denominator. Each performance measure must be

specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the

aggregated data that will enable the State to analyze and assess progress toward

the performance measure. In this section provide information on the method by

which each source of data is analyzed statistically/deductively or inductively,

how themes are identified or conclusions drawn, and how recommendations are

formulated, where appropriate.

Performance Measure:

Number and percent of satisfaction survey

respondents sampled who reported the receipt of all services listed in the

service plan. Numerator: Number of respondents who reported receipt of all

services in their ISP. Denominator: Total number of survey respondents.

Data Source(Select one):

Analyzed collected data (including surveys,

focus group, interviews, etc)

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [ ] 100%

Review

[X] Operating Agency [ ] Monthly [X] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [X]

Representative Sample

Confidence Interval =

5%

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of participants reviewed who

received four quarterly visits from the ISC entity under contract with the OA to

monitor that services are being delivered in accordance with the services in the

plan of care. N: Number of participants who received 4 quarterly ISSA visits. D:

Number of participants in sample.

Data Source(Select one):

Record reviews, on-site

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[X] State Medicaid Agency [ ] Weekly [ ] 100%

Review

[X] Operating Agency [ ] Monthly [X] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of participants reviewed who

received the services in the scope, amount, duration and frequency as specified

in their ISP. Numerator: Number of participants who received services as

specified in their ISP. Denominator: Number of participant ISPs in sample.

Data Source(Select one):

Record reviews, on-site

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[X] State Medicaid Agency [ ] Weekly [ ] 100%

Review

[X] Operating Agency [ ] Monthly [X] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [X]

Representative Sample

Confidence Interval =

5%

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

1.. Sub-assurance: Participants are afforded choice:

Between waiver services and institutional care; and between/among waiver

services and providers.

Performance Measures

For each performance measure/indicator the State will

use to assess compliance with the statutory assurance complete the following.

Where possible, include numerator/denominator. Each performance measure must be

specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the

aggregated data that will enable the State to analyze and assess progress toward

the performance measure. In this section provide information on the method by

which each source of data is analyzed statistically/deductively or inductively,

how themes are identified or conclusions drawn, and how recommendations are

formulated, where appropriate.

Performance Measure:

Number and percent of waiver participant records

reviewed with an appropriately completed and signed freedom of choice form that

specified choice was offered between waiver services and institutional care at

the time of enrollment. N: Number of participant records reviewed with choice

form. D: Number of records in sample.

Data Source(Select one):

Record reviews, on-site

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[X] State Medicaid Agency [ ] Weekly [ ] 100%

Review

[X] Operating Agency [ ] Monthly [X] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [X]

Representative Sample

Confidence Interval =

5%

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of records reviewed that

document participants were informed at least annually of the right to choose

their providers (subject to provider qualifications). Numerator: Number of

participant records reviewed documenting annual right to choose providers.

Denominator: Number of sample records reviewed.

Data Source(Select one):

Record reviews, on-site

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[X] State Medicaid Agency [ ] Weekly [ ] 100%

Review

[X] Operating Agency [ ] Monthly [X] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [X]

Representative Sample

Confidence Interval =

5%

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of participants reviewed who

were offered choice between/among waiver services (for which there has been a

determination of need). Numerator: Number of participants reviewed who were

offered choice. Denominator: Number of participants reviewed.

Data Source(Select one):

Record reviews, on-site

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[X] State Medicaid Agency [ ] Weekly [ ] 100%

Review

[X] Operating Agency [ ] Monthly [X] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [X]

Representative Sample

Confidence Interval =

5%

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

1.. If applicable, in the textbox below provide any

necessary additional information on the strategies employed by the State to

discover/identify problems/issues within the waiver program, including frequency

and parties responsible.

Character Count:out of 6000

1.. Methods for Remediation/Fixing Individual Problems

1.. Describe the State’s method for addressing

individual problems as they are discovered. Include information regarding

responsible parties and GENERAL methods for problem correction. In addition,

provide information on the methods used by the State to document these items.

Character Count:out of 6000

The OA reviews the data findings and identifies the most

appropriate response. General responses may include work with participants and

their providers, retraining staff, voiding claims, technical assistance,

increased monitoring, revising service plans, and requiring plans of correction.

The OA is responsible for seeing that these individual issues are resolved. The

OA provides quarterly reports of these activities to the MA. Staff of the two

State agencies review the reports on a quarterly basis.

1.. Remediation Data Aggregation

Remediation-related Data Aggregation and Analysis

(including trend identification)

Responsible Party (check each that applies):

Frequency of data aggregation and analysis (check each that applies):

[ ] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

1.. Timelines

When the State does not have all elements of the Quality

Improvement Strategy in place, provide timelines to design methods for discovery

and remediation related to the assurance of Service Plans that are currently

non-operational.

(X) No

( ) Yes

( ) not selected

Please provide a detailed strategy for assuring Service

Plans, the specific timeline for implementing identified strategies, and the

parties responsible for its operation.

Character Count:out of 6000

Appendix E: Participant Direction of Services

Applicability(from Application Section 3, Components of

the Waiver Request):

(X) Yes. This waiver provides participant direction

opportunities. Complete the remainder of the Appendix.

( ) No. This waiver does not provide participant

direction opportunities. Do not complete the remainder of the Appendix.

( ) not selected

CMS urges states to afford all waiver participants the

opportunity to direct their services. Participant direction of services includes

the participant exercising decision-making authority over workers who provide

services, a participant-managed budget or both. CMS will confer the Independence

Plus designation when the waiver evidences a strong commitment to participant

direction.

Indicate whether Independence Plus designation is

requested(select one):

( ) Yes. The State requests that this waiver be

considered for Independence Plus designation.

(X) No. Independence Plus designation is not requested.

( ) not selected

Appendix E: Participant Direction of Services

E-1: Overview (1 of 13)

1.. Description of Participant Direction.In no more

than two pages, provide an overview of the opportunities for participant

direction in the waiver, including: (a) the nature of the opportunities afforded

to participants; ( how participants may take advantage of these opportunities;

© the entities that support individuals who direct their services and the

supports that they provide; and, (d) other relevant information about the

waiver's approach to participant direction.

Character Count:out of 12000

The waiver uses a participant-centered planning approach

directly involving the participant and the participant’s guardian, if one has

been appointed, as members of the support planning team along with the waiver

case manager or Service Facilitator, direct service providers, Individual

Service and Support Advocate (ISSA) and any other persons important to the

participant (including family members where chosen by the participant). For

individuals receiving home-based supports, the Waiver is designed to give

participants the budget authority to direct some or all of their services within

established cost limits. In addition, participants have the option of using

employer authority to hire and fire independent providers (domestic employees)

if they desire. FMS vendors assist participants who opt to use the employer

authority. During the initial support planning process, the participant and/or

the guardian, if one has been appointed, will receive information about

participant-directed services and supports. Information will be presented in

both written and other formats to ensure the participant understands the

participant-directed options and can make an informed choice. Information is

provided about decision-making budget authority up to the approved cost limits.

Specific information is provided about the roles and responsibilities of the

participant or legal representative and the Financial Management Service vendors

available as part of the employer authority option. Guidelines for participants

hiring personal support workers in the participant’s home are available from

the OA when the employer authority option is desired. The State conducted a

Request for Proposal (RFP) process to select Financial Management Service (FMS)

vendor(s). The Operating Agency developed the RFP for the FMS Vendor

(Fiscal/Employer Agent) pursuant to Section 3504 of the IRS Code, IRS Revenue

Procedure 70-6 and Proposed Notice 2003-70 and Operating Agency rules and

regulations. Qualifications included a financially stable company with at least

one year of experience in providing Vendor Fiscal/Employer Agent services

directly to individual participants enrolled in self-directed programs similar

to the Illinois Waiver program. The Operating Agency contracts with two FMS

vendors statewide. The “per member per month†(PMPM) fee, determined through

the RFP process – a competitive bid process – and subsequently negotiated by

the State and the successful vendors, is claimed as an administrative expense

under the Waiver. The participant’s choice of the type of supports is

documented as part of the participant-centered support plan. Service Agreements

are completed for each provider selected by the participant. Participants

selecting participant-directed services home-based supports are assisted by the

local Service Facilitator, the Individual Service and Support Advocate (ISSA)

and the Financial Management Service (FMS) entity. The team members are

available to assist the participant and/or legal representative to understand

and fulfill their responsibilities. If at any time the participant voluntarily

decides he/she no longer wants to exercise the employer authority to hire and

fire independent providers, the participant can request agency-based services

and supports. This change is documented in the support plan. The plan would be

revised to reflect the change in service delivery and any other changes required

as a result of the participant or legal representative’s decision to change to

no longer use the employer authority and instead receive agency-based services

and supports. If an investigation determines that the participant, guardian or

participant’s representative committed fraud regarding employer authority

program funds, the participant may be involuntarily restricted from the employer

authority option. This determination by the State is subject to appeal to the

Medicaid Agency. The outcome of the appeal process is final. In this event,

agency-based services would be made available and documented in the support

plan.

Appendix E: Participant Direction of Services

E-1: Overview (2 of 13)

1.. Participant Direction Opportunities.Specify the

participant direction opportunities that are available in the waiver. Select

one:

( ) Participant: Employer Authority. As specified in

Appendix E-2, Item a, the participant (or the participant's representative) has

decision-making authority over workers who provide waiver services. The

participant may function as the common law employer or the co-employer of

workers. Supports and protections are available for participants who exercise

this authority.

( ) Participant: Budget Authority. As specified in

Appendix E-2, Item b, the participant (or the participant's representative) has

decision-making authority over a budget for waiver services. Supports and

protections are available for participants who have authority over a budget.

(X) Both Authorities. The waiver provides for both

participant direction opportunities as specified in Appendix E-2. Supports and

protections are available for participants who exercise these authorities.

( ) not selected

1.. Availability of Participant Direction by Type of

Living Arrangement.Check each that applies:

[X] Participant direction opportunities are available to

participants who live in their own private residence or the home of a family

member.

[ ] Participant direction opportunities are available to

individuals who reside in other living arrangements where services (regardless

of funding source) are furnished to fewer than four persons unrelated to the

proprietor.

[ ] The participant direction opportunities are

available to persons in the following other living arrangements

Specify these living arrangements:

Character Count:out of 4000

Appendix E: Participant Direction of Services

E-1: Overview (3 of 13)

1.. Election of Participant Direction.Election of

participant direction is subject to the following policy (select one):

( )Waiver is designed to support only individuals

who want to direct their services.

(X)The waiver is designed to afford every

participant (or the participants representative) the opportunity to elect to

direct waiver services. Alternate service delivery methods are available for

participants who decide not to direct their services.

( )The waiver is designed to offer participants

(or their representatives) the opportunity to direct some or all of their

services, subject to the following criteria specified by the State. Alternate

service delivery methods are available for participants who decide not to direct

their services or do not meet the criteria.

1.. Specify the criteria

2.. Character Count:out of 18000

Appendix E: Participant Direction of Services

E-1: Overview (4 of 13)

1.. Information Furnished to Participant. Specify: (a)

the information about participant direction opportunities (e.g., the benefits of

participant direction, participant responsibilities, and potential liabilities)

that is provided to the participant (or the participant's representative) to

inform decision-making concerning the election of participant direction; ( the

entity or entities responsible for furnishing this information; and, © how and

when this information is provided on a timely basis.

Character Count:out of 12000

During the level of care evaluation process, the local

ISC entities under contract with the Operating Agency provide information about

participant-directed opportunities and assist participants and their families in

making informed choices from among Waiver services. Information is available for

participants and guardians that include guidelines for selecting personal

support workers as domestic employees, information on Financial Management

Service (FMS) entities, rights and responsibilities, and other requirements of

the Waiver. The waiver case manager/Service Facilitator provides information to

all participants when waiver services are initiated. The waiver case manager and

the ISSA assist the participant to understand the service options available

under the waiver. The information is reviewed with participants annually as part

of the support planning process.

Appendix E: Participant Direction of Services

E-1: Overview (5 of 13)

1.. Participant Direction by a Representative. Specify

the State's policy concerning the direction of waiver services by a

representative (select one):

( )The State does not provide for the direction of

waiver services by a representative.

(X)The State provides for the direction of waiver

services by representatives.

1.. Specify the representatives who may direct waiver

services: (check each that applies):

2.. [X] Waiver services may be directed by a legal

representative of the participant.

3.. [ ] Waiver services may be directed by a non-legal

representative freely chosen by an adult participant.

4.. Specify the policies that apply regarding the

direction of waiver services by participant-appointed representatives, including

safeguards to ensure that the representative functions in the best interest of

the participant:

5.. Character Count:out of 12000

Appendix E: Participant Direction of Services

E-1: Overview (6 of 13)

1.. Participant-Directed Services. Specify the

participant direction opportunity (or opportunities) available for each waiver

service that is specified as participant-directed in Appendix C-1/C-3.

Participant-Directed Waiver Service Employer

Authority Budget Authority

77312Adaptive Equipment [X] [X]

77374Skilled Nursing [ ] [X]

75273Personal Support [X] [X]

77369Behavior Intervention and Treatment [ ] [X]

77381Occupational Therapy (Extended Medicaid State

Plan) [ ] [X]

76315Non-Medical Transportation [X] [X]

77316Emergency Home Response Services (EHRS) [ ]

[X]

77314Assistive Technology [X] [X]

77371Behavioral Services (Psychotherapy and

Counseling) [ ] [X]

77318Training and Counseling Services for Unpaid

Caregivers [X] [X]

77386Speech Therapy (Extended Medicaid State Plan)

[ ] [X]

77376Temporary Assistance (formerly called Crisis

Services) [X] [X]

76313Vehicle Modification [X] [X]

77379Physical Therapy (Extended Medicaid State

Plan) [ ] [X]

76310Home Accessibility Modifications [X] [X]

Appendix E: Participant Direction of Services

E-1: Overview (7 of 13)

1.. Financial Management Services.Except in certain

circumstances, financial management services are mandatory and integral to

participant direction. A governmental entity and/or another third-party entity

must perform necessary financial transactions on behalf of the waiver

participant. Select one:

(X) Yes. Financial Management Services are furnished

through a third party entity. (Complete item E-1-i).

Specify whether governmental and/or private entities

furnish these services. Check each that applies:

[ ] Governmental entities

[X] Private entities

( ) No. Financial Management Services are not furnished.

Standard Medicaid payment mechanisms are used. Do not complete Item E-1-i.

( ) not selected

Appendix E: Participant Direction of Services

E-1: Overview (8 of 13)

1.. Provision of Financial Management

Services.Financial management services (FMS) may be furnished as a waiver

service or as an administrative activity. Select one:

( ) FMS are covered as the waiver service specified in

Appendix C1/C3

The waiver service entitled:

(X) FMS are provided as an administrative activity.

( ) not selected

Provide the following information

1.. Types of Entities: Specify the types of entities

that furnish FMS and the method of procuring these services:

Character Count:out of 12000

One or more Financial Management Service FMS) vendor is

selected through a competitive Request for Proposal (RFP) process. The criteria

used in selecting the vendor included: • Financial stability, with at least

one year of experience in providing employer agent services to participants in

similar participant-directed options. • Ability to perform all functions in

accordance with Federal, State and Department regulations and requirements. •

Ability to perform all functions directly without the use of a sub-agent. •

Ability to verify, process and pay invoices for goods and services approved in

the participant’s support plan in accordance with Operating Agency

requirements. • Ability to prepare and maintain a comprehensive FMS policy and

procedure manual that reflects all tasks performed, Illinois-specific labor, tax

and workers’ compensation insurance requirements, as well as requirements of

the Waiver. • An internal quality management plan that demonstrates sufficient

internal controls to monitor FMS performance.

1.. Payment for FMS. Specify how FMS entities are

compensated for the administrative activities that they perform:

Character Count:out of 12000

The fee for each FMS vendor is established through a

competitive bid process. The FMS vendor(s) will be compensated based on a per

member per month (PMPM) negotiated fee for each participant who uses FMS

services.

1.. Scope of FMS.Specify the scope of the supports

that FMS entities provide (check each that applies):

Supports furnished when the participant is the employer

of direct support workers:

[X] Assists participant in verifying support worker

citizenship status

[X] Collects and processes timesheets of support workers

[X] Processes payroll, withholding, filing and payment

of applicable federal, state and local employment-related taxes and insurance

[X] Other

Specify:

Character Count:out of 12000

Assist with performing required background checks, abuse

and neglect registry checks and any other screening and verify personal support

worker qualifications.

Supports furnished when the participant exercises budget

authority:

[X] Maintains a separate account for each participant's

participant-directed budget

[X] Tracks and reports participant funds, disbursements

and the balance of participant funds

[ ] Processes and pays invoices for goods and services

approved in the service plan

[X] Provide participant with periodic reports of

expenditures and the status of the participant-directed budget

[ ] Other services and supports

Specify:

Character Count:out of 12000

Additional functions/activities:

[ ] Executes and holds Medicaid provider agreements as

authorized under a written agreement with the Medicaid agency

[X] Receives and disburses funds for the payment of

participant-directed services under an agreement with the Medicaid agency or

operating agency

[X] Provides other entities specified by the State with

periodic reports of expenditures and the status of the participant-directed

budget

[ ] Other

Specify:

Character Count:out of 12000

1.. Oversight of FMS Entities. Specify the methods

that are employed to: (a) monitor and assess the performance of FMS entities,

including ensuring the integrity of the financial transactions that they

perform; ( the entity (or entities) responsible for this monitoring; and, ©

how frequently performance is assessed.

Character Count:out of 12000

The FMS vendor(s) must have internal monitoring

procedures and processes to ensure contract performance compliance. The State

reserves the right to monitor and track vendor(s) performance over the course of

the contract. The State will monitor the vendor(s) based on the performance

measures approved in the waiver and any other contractual requirements. The

vendor(s) agrees to provide all of the data specified by the State for service

payment and claiming purposes. The vendor(s) agrees to cooperate with the State

on monitoring and tracking activities which may require the vendor to submit

requested progress reports, allow unannounced inspections of its facilities,

participate in scheduled meetings and provide management reports as requested by

the State. The Operating Agency will review performance on an annual basis and

share the results of these reviews with the Quality Management Committee.

Appendix E: Participant Direction of Services

E-1: Overview (9 of 13)

1.. Information and Assistance in Support of

Participant Direction.In addition to financial management services, participant

direction is facilitated when information and assistance are available to

support participants in managing their services. These supports may be furnished

by one or more entities, provided that there is no duplication. Specify the

payment authority (or authorities) under which these supports are furnished and,

where required, provide the additional information requested (check each that

applies):

[ ] Case Management Activity. Information and assistance

in support of participant direction are furnished as an element of Medicaid case

management services.

Specify in detail the information and assistance that

are furnished through case management for each participant direction opportunity

under the waiver:

Character Count:out of 6000

[X] Waiver Service Coverage. Information and assistance

in support of participant direction are provided through the following waiver

service coverage(s) specified in Appendix C-1/C-3 (check each that applies):

Participant-Directed Waiver Service Information

and Assistance Provided through this Waiver Service Coverage

77312Adaptive Equipment [ ]

77374Skilled Nursing [ ]

75273Personal Support [ ]

77369Behavior Intervention and Treatment [ ]

77381Occupational Therapy (Extended Medicaid State

Plan) [ ]

75265Residential Habilitation [ ]

77388Service Facilitation [X]

75263Adult Day Care [ ]

76315Non-Medical Transportation [ ]

77316Emergency Home Response Services (EHRS) [ ]

75270Supported Employment [ ]

77314Assistive Technology [ ]

75267Developmental Training [ ]

77371Behavioral Services (Psychotherapy and

Counseling) [ ]

77318Training and Counseling Services for Unpaid

Caregivers [ ]

77386Speech Therapy (Extended Medicaid State Plan)

[ ]

77376Temporary Assistance (formerly called Crisis

Services) [ ]

76313Vehicle Modification [ ]

77379Physical Therapy (Extended Medicaid State

Plan) [ ]

76310Home Accessibility Modifications [ ]

[X] Administrative Activity. Information and assistance

in support of participant direction are furnished as an administrative activity.

Specify (a) the types of entities that furnish these

supports; ( how the supports are procured and compensated; © describe in

detail the supports that are furnished for each participant direction

opportunity under the waiver; (d) the methods and frequency of assessing the

performance of the entities that furnish these supports; and, (e) the entity or

entities responsible for assessing performance:

Character Count:out of 12000

Individual Service and Support Advocates (ISSA) employed

by ISC entities, under contract with the Operating Agency, are compensated on a

fee-for-service basis at a statewide hourly rate. ISSA entities were selected

through a request-for-proposal (RFP) process. ISSA staff participates in the

development of the participant-centered support plan and approve the final plan,

as well as monitor its implementation and the general health and well being of

the participant. ISSA entities are surveyed annually by the Operating Agency.

One or more Financial Management Service (FMS) entity/entities, under contract

with the Operating Agency and selected through a request for proposal (RFP)

process, provides fiscal/employer agent (F/EA) services. The FMS entity/entities

is compensated on a per member per month basis. The Operating Agency reviews the

performance of the FMS entity on an annual basis.

Appendix E: Participant Direction of Services

E-1: Overview (10 of 13)

1.. Independent Advocacy(select one).

(X)No. Arrangements have not been made for

independent advocacy.

( )Yes. Independent advocacy is available to

participants who direct their services.

1.. Describe the nature of this independent advocacy

and how participants may access this advocacy:

2.. Character Count:out of 12000

Appendix E: Participant Direction of Services

E-1: Overview (11 of 13)

1.. Voluntary Termination of Participant

Direction.Describe how the State accommodates a participant who voluntarily

terminates participant direction in order to receive services through an

alternate service delivery method, including how the State assures continuity of

services and participant health and welfare during the transition from

participant direction:

Character Count:out of 12000

At any time upon request by the participant or guardian,

if one has been appointed, agency-directed services can be voluntarily initiated

and the participant-directed option can be terminated. Typically 30-day advance

written notice is given to the employee, however, this is not mandatory. The

participant would select a community agency to provide and direct Waiver

services. Any changes are discussed among those responsible for support planning

and are documented in the plan. All agreed changes are noted in the

participant’s support plan, as necessary. The ISSA works with service

providers, the waiver case manager/service facilitator and the Operating Agency

as necessary to ensure service continuity and health and welfare during the

transition.

Appendix E: Participant Direction of Services

E-1: Overview (12 of 13)

1.. Involuntary Termination of Participant

Direction.Specify the circumstances when the State will involuntarily terminate

the use of participant direction and require the participant to receive

provide-managed services instead, including how continuity of services and

participant health and welfare is assured during the transition.

Character Count:out of 12000

If at any time the MA or the OA determines that the

participant and/or his or her representative have committed fraud regarding

participant-directed program funds, the participant may be involuntarily

restricted from participant-directed services. This determination by the State

is subject to appeal to the MA. The outcome of the appeal process is final. In

this event, agency-directed services would be made available and documented in

the support plan. The ISSA works with the service providers, the waiver case

manager/service facilitator and the OA as necessary to ensure service continuity

and health and welfare during the transition.

Appendix E: Participant Direction of Services

E-1: Overview (13 of 13)

1.. Goals for Participant Direction.In the following

table, provide the State's goals for each year that the waiver is in effect for

the unduplicated number of waiver participants who are expected to elect each

applicable participant direction opportunity. Annually, the State will report to

CMS the number of participants who elect to direct their waiver services.

Table E-1-n

Employer Authority Only Budget Authority Only or

Budget Authority in Combination with Employer Authority

Waiver Year Number of Participants Number of

Participants

Year 1 [ ] 3800

Year 2 [ ] 3800

Year 3 [ ] 3800

Year 4 [ ] 3800

Year 5 [ ] 3800

Appendix E: Participant Direction of Services

E-2: Opportunities for Participant Direction (1 of 6)

1.. Participant - Employer AuthorityComplete when the

waiver offers the employer authority opportunity as indicated in Item E-1-b:

2.. Participant Employer Status.Specify the

participant's employer status under the waiver. Select one or both:

[ ] Participant/Co-Employer. The participant (or the

participant's representative) functions as the co-employer (managing employer)

of workers who provide waiver services. An agency is the common law employer of

participant-selected/recruited staff and performs necessary payroll and human

resources functions. Supports are available to assist the participant in

conducting employer-related functions.

Specify the types of agencies (a.k.a., agencies with

choice) that serve as co-employers of participant-selected staff:

Character Count:out of 6000

[X] Participant/Common Law Employer. The participant (or

the participant's representative) is the common law employer of workers who

provide waiver services. An IRS-Approved Fiscal/Employer Agent functions as the

participant's agent in performing payroll and other employer responsibilities

that are required by federal and state law. Supports are available to assist the

participant in conducting employer-related functions.

1.. Participant Decision Making Authority.The

participant (or the participant's representative) has decision making authority

over workers who provide waiver services. Select one or more decision making

authorities that participants exercise:

[X] Recruit staff

[ ] Refer staff to agency for hiring (co-employer)

[ ] Select staff from worker registry

[X] Hire staff common law employer

[X] Verify staff qualifications

[X] Obtain criminal history and/or background

investigation of staff

Specify how the costs of such investigations are

compensated:

Character Count:out of 4000

Cost of required background checks are paid through the

Financial Management Service (FMS) entity.

[X] Specify additional staff qualifications based on

participant needs and preferences so long as such qualifications are consistent

with the qualifications specified in Appendix C-1/C-3.

[X] Determine staff duties consistent with the service

specifications in Appendix C-1/C-3.

[X] Determine staff wages and benefits subject to State

limits

[X] Schedule staff

[X] Orient and instruct staff in duties

[X] Supervise staff

[X] Evaluate staff performance

[X] Verify time worked by staff and approve time sheets

[X] Discharge staff (common law employer)

[ ] Discharge staff from providing services

(co-employer)

[ ] Other

Specify:

Character Count:out of 4000

Appendix E: Participant Direction of Services

E-2: Opportunities for Participant-Direction (2 of 6)

1.. Participant - Budget AuthorityComplete when the

waiver offers the budget authority opportunity as indicated in Item E-1-b:

2.. Participant Decision Making Authority.When the

participant has budget authority, indicate the decision-making authority that

the participant may exercise over the budget. Select one or more:

[X] Reallocate funds among services included in the

budget

[X] Determine the amount paid for services within the

State's established limits

[X] Substitute service providers

[X] Schedule the provision of services

[X] Specify additional service provider qualifications

consistent with the qualifications specified in Appendix C-1/C-3

[X] Specify how services are provided, consistent with

the service specifications contained in Appendix C-1/C-3

[X] Identify service providers and refer for provider

enrollment

[ ] Authorize payment for waiver goods and services

[ ] Review and approve provider invoices for services

rendered

[ ] Other

Specify:

Character Count:out of 4000

Appendix E: Participant Direction of Services

E-2: Opportunities for Participant-Direction (3 of 6)

1.. Participant - Budget Authority

2.. Participant-Directed BudgetDescribe in detail the

method(s) that are used to establish the amount of the participant-directed

budget for waiver goods and services over which the participant has authority,

including how the method makes use of reliable cost estimating information and

is applied consistently to each participant. Information about these method(s)

must be made publicly available.

Character Count:out of 12000

Within the overall home-based supports cost limit, the

participant-centered support plan specifies the types of and amounts of covered

services needed by the participant. The maximum annual allocation is set by

State law. At the time the law was passed, public hearings were held regarding

its implementation. The annual allocation is indexed to the cost of living (as

required by law). Participants and the general public are made aware of the

program budget amount in a variety of ways. For example, the Waiver Manual is

available at the OA's website and contains this information. A Rate Table is

also posted on the OA's website (see below). In addition, ISSAs and Service

Facilitators assist individuals in understanding and working within the annual

and monthly allocations. Individuals may request a fair hearing of any denial or

reduction in services. The manual, Service Facilitators and ISSAs infrom them of

their rights to appeal. For some services, statewide rates apply, such as

Behavior Intervention and Treatment. For other services, the participant is

given the authority, with help from the local Service Facilitator, to negotiate

individual rates. A written Service Agreement is executed between each service

provider, the participant or his or her quardian and the local Service

Facilitator. The Service Agreement defines the terms of the services to be

provided including the effective date, the rate of payment, the maximum units of

service to be provided each month and the maximum monthly charge. A copy of the

Service Agreement for domestic employees is on file with the Financial

Management Service (FMS) entity. Bills submitted in excess of the monthly and

annual allocations are rejected for payment. This ensures that the combination

of services received is consistent with the support plan and does not exceed the

annual service cost limit. The Rate Table is updated when rate adjustments are

implemented, based on State appropriations.

Appendix E: Participant Direction of Services

E-2: Opportunities for Participant-Direction (4 of 6)

1.. Participant - Budget Authority

2.. Informing Participant of Budget Amount. Describe

how the State informs each participant of the amount of the participant-directed

budget and the procedures by which the participant may request an adjustment in

the budget amount.

Character Count:out of 12000

Upon being authorized for Waiver services, the

participant or guardian are informed in writing by the Operating Agency and in

person by the ISSA about the overall cost limit, participant-directed

opportunities, and budget authority. Once services have begun, the participant

and guardian are notified and kept informed of any adjustments to the overall

amount by the Operating Agency, Service Facilitator, and ISSA.

Appendix E: Participant Direction of Services

E-2: Opportunities for Participant-Direction (5 of 6)

1.. Participant - Budget Authority

2.. Participant Exercise of Budget Flexibility.Select

one:

( )Modifications to the participant directed

budget must be preceded by a change in the service plan.

(X)The participant has the authority to modify the

services included in the participant directed budget without prior approval.

1.. Specify how changes in the participant-directed

budget are documented, including updating the service plan. When prior review of

changes is required in certain circumstances, describe the circumstances and

specify the entity that reviews the proposed change:

1.. Character Count:out of 12000

2.. Participants and guardians may adjust

utilization within the monthly allocation without prior review or approval by

the State. Adjustments are made, with the assistance of the Service Facilitator,

via the use of Service Agreements with providers and by updating the support

plan. Changes in services are documented in the support plan and in revised

Service Agreements. Changes in Service Agreements where the participant

exercises employer authority must be shared with the Financial Management

Service (FMS) entity and ISSA for payment and monitoring purposes.

Appendix E: Participant Direction of Services

E-2: Opportunities for Participant-Direction (6 of 6)

1.. Participant - Budget Authority

2.. Expenditure Safeguards.Describe the safeguards

that have been established for the timely prevention of the premature depletion

of the participant-directed budget or to address potential service delivery

problems that may be associated with budget underutilization and the entity (or

entities) responsible for implementing these safeguards:

Character Count:out of 12000

Per statute, adult home-based supports spending is

limited on a monthly basis. Participants are encouraged by members of the

support planning team to allocate authorized services throughout the month to

avoid premature depletion of program funds. Service facilitators closely monitor

expenditures for services consistent with the support plan on a monthly basis.

Edits in the electronic billing system prevent over expenditures. Quarterly

visits by the ISSAs, made to monitor support plan implementation and the

participant's general health, safety and well being, identify and address issues

of concern, including the timely prevention of the premature depletion of the

participant-directed budget or potential service delivery problems.

Appendix F: Participant Rights

Appendix F-1: Opportunity to Request a Fair Hearing

The State provides an opportunity to request a Fair

Hearing under 42 CFR Part 431, Subpart E to individuals: (a) who are not given

the choice of home and community-based services as an alternative to the

institutional care specified in Item 1-F of the request; ( are denied the

service(s) of their choice or the provider(s) of their choice; or, © whose

services are denied, suspended, reduced or terminated. The State provides notice

of action as required in 42 CFR §431.210.

Procedures for Offering Opportunity to Request a Fair

Hearing.Describe how the individual (or his/her legal representative) is

informed of the opportunity to request a fair hearing under 42 CFR Part 431,

Subpart E. Specify the notice(s) that are used to offer individuals the

opportunity to request a Fair Hearing. State laws, regulations, policies and

notices referenced in the description are available to CMS upon request through

the operating or Medicaid agency.

Character Count:out of 12000

Notification The entities responsible for notifying an

applicant/participant of adverse actions are: • The waiver case

manager/Service Facilitator is responsible for informing participants of the

right to appeal upon Waiver enrollment. The Operating Agency has developed a

standard form, Notice of Individual Right to Appeal (DD-1202) for this purpose.

The standard form states: If an appeal request is received within 10 calendar

days after receipt of the notice of action, the decision in the notice shall be

stayed, pending the results of the appeal. Independent service coordination

(ISC) entities under contract with the OA are responsible for written

notification when there is: • Determination of ineligibility for Waiver

services. • Denial of choice of Waiver or institutional services. • Denial

of choice of Waiver services or providers. • The waiver case manager/Service

Facilitator are responsible for written notification when there is a denial,

reduction, suspension or termination of service by the provider. • OA and MA

staff are responsible for written notification when there is an adverse decision

in the fair hearing process. Written notifications contain information on the

continuation of services pending the results of the appeal process. Notices of

adverse actions and the opportunity to request a fair hearing are maintained by

the entity that was responsible for the notifications. Appeal Process

Participants and guardians, if appointed, are informed by the ISSA employed by

the ISC entities of appeal rights when Waiver services are begun, and also upon

notice of service denial, suspension, termination or reduction. Appeal rights

are also available at any time upon request. 89 Ill. Admin. Code 104 and 59 Ill.

Admin Code 120.110 describe the fair hearing request procedures in use for the

Adult Developmental Disability Waiver. If participants receive notice of adverse

action, they have ten working days to file an appeal. Once the appeal is filed,

the Operating Agency has 30 working days to conduct an informal review of the

appealed action. The informal review process can reverse, modify, or leave the

action unchanged. At the conclusion of the informal hearing, the participant and

the service provider, if applicable, will be notified in writing of the decision

within ten working days. The notice will include clear statements of the action

to be taken, the reason for the action, supporting policy references, and the

right to appeal the decision to the Medicaid Agency. The participant has ten

working days to appeal the informal review decision to the Medicaid Agency for

final administrative action. The request for an appeal to continue existing

services allows those services to continue until the hearing decision is reached

or unless the appeal is withdrawn. The Medicaid Agency appoints an impartial

hearing officer to conduct the hearing at the Medicaid Agency or Operating

Agency office nearest to the family’s home unless all parties agree to an

alternate location. The hearing officer may participate by video conference. The

Medicaid Agency notifies the participant as well as the Operating Agency. The

final administrative decision by the Medicaid Agency may be appealed to the

State Circuit Court.

Appendix F: Participant-Rights

Appendix F-2: Additional Dispute Resolution Process

1.. Availability of Additional Dispute Resolution

Process.Indicate whether the State operates another dispute resolution process

that offers participants the opportunity to appeal decisions that adversely

affect their services while preserving their right to a Fair Hearing. Select

one:

(X) No. This Appendix does not apply

( ) Yes. The State operates an additional dispute

resolution process

( ) not selected

1.. Description of Additional Dispute Resolution

Process.Describe the additional dispute resolution process, including: (a) the

State agency that operates the process; ( the nature of the process (i.e.,

procedures and timeframes), including the types of disputes addressed through

the process; and, © how the right to a Medicaid Fair Hearing is preserved when

a participant elects to make use of the process: State laws, regulations, and

policies referenced in the description are available to CMS upon request through

the operating or Medicaid agency.

Character Count:out of 12000

Appendix F: Participant-Rights

Appendix F-3: State Grievance/Complaint System

1.. Operation of Grievance/Complaint System.Select

one:

( ) No. This Appendix does not apply

(X) Yes. The State operates a grievance/complaint system

that affords participants the opportunity to register grievances or complaints

concerning the provision of services under this waiver

( ) not selected

1.. Operational Responsibility.Specify the State

agency that is responsible for the operation of the grievance/complaint system:

Character Count:out of 4000

The ISC entities, under contract with the OA, are

responsible for hearing and resolving local provider issues that arise at the

local providers. The OA is responsible for providing technical assistance when

the ISC entity cannot successfully resolve local issues. The FMS entity/entities

maintain a complaint log regarding payroll issues concerning domestic employees.

1.. Description of System.Describe the

grievance/complaint system, including: (a) the types of grievances/complaints

that participants may register; ( the process and timelines for addressing

grievances/complaints; and, © the mechanisms that are used to resolve

grievances/complaints. State laws, regulations, and policies referenced in the

description are available to CMS upon request through the Medicaid agency or the

operating agency (if applicable).

Character Count:out of 12000

Each participant enrolled in the Waiver meets with ISSA

staff a minimum of four times each year, approximately once per quarter. The

participant or guardian, if one is appointed, may at any time contact ISSA staff

to discuss unresolved issues or problems affecting the participant’s health

and welfare. ISSA staff will work with the waiver case manager/Service

Facilitator to resolve grievances/complaints, particularly those between the

participant and service providers. If the grievance continues, ISSA staff will

continue the process by involving agency staff of increasing authority, up to

and including the executive director of the case manager/service facilitator or

direct service agency. If the grievance cannot be resolved, ISSA staff may

contact Operating Agency staff for technical assistance or intervention. The

participant or guardian may contact OA staff to file a complaint at any time

during this process. Referrals are tracked on a referral database by the

Operating Agency. Participants are informed that filing a grievance or making a

complaint is not a prerequisite or substitute for a fair hearing.

Appendix G: Participant Safeguards

Appendix G-1: Response to Critical Events or Incidents

1.. Critical Event or Incident Reporting and

Management Process.Indicate whether the State operates Critical Event or

Incident Reporting and Management Process that enables the State to collect

information on sentinel events occurring in the waiver program.Select one:

( ) not selected

(X) Yes. The State operates a Critical Event or Incident

Reporting and Management Process (complete Items b through e)

( ) No. This Appendix does not apply (do not complete

Items b through e)

If the State does not operate a Critical Event or

Incident Reporting and Management Process, describe the process that the State

uses to elicit information on the health and welfare of individuals served

through the program.

Character Count:out of 12000

1.. State Critical Event or Incident Reporting

Requirements. Specify the types of critical events or incidents (including

alleged abuse, neglect and exploitation) that the State requires to be reported

for review and follow-up action by an appropriate authority, the individuals

and/or entities that are required to report such events and incidents and the

timelines for reporting. State laws, regulations, and policies that are

referenced are available to CMS upon request through the Medicaid agency or the

operating agency (if applicable).

Character Count:out of 24000

The Adults with Disabilities Domestic Abuse Intervention

Act (20 ILCS 2435) and the Abused and Neglected Long Term Care Facilities

Reporting Act (210 ILCS 30/6.2) set forth the requirements for prevention of

abuse and neglect for adults age 18 and older, as well as other individuals. The

implementing rules are found at 59 Ill. Adm. Code 50 (for incidents that occur

on-site at a developmental disabilities-funded community agency) and 59 Ill.

Adm. Code 51 (for incidents that occur in private homes or in non-licensed

community homes). Under both laws, the types of critical incidents that must be

reported include any allegation of physical or mental abuse, neglect or

financial exploitation committed by anyone against the waiver participant.

Unauthorized use of restraint, seclusion or restrictive interventions is

considered abuse and must be reported. Serious injuries that require treatment

by a physician or a nurse where abuse or neglect is suspected and medication

errors that have an adverse outcome must be reported. Serious injuries that

require treatment by a physician or a nurse must be included in a quarterly

quality assurance report to the OA. Deaths must be reported if the death

occurred while the individual was present in an agency program or if the death

occurs within 14 days of discharge, transfer or deflection from the agency

program. Deaths must be reported within 14 hours from the time the death was

first discovered or the reporter ws informed of the death (only four hours if

abuse or neglect is suspected). Mandated reporters under Rule 50 (agency sites)

include all Medicaid Agency and OA staff and all community agency employees

(including payroll employees, contractual employees, volunteers, and

subcontractors). Mandated reporters must report the allegation within four hours

of the time it was first discovered by the staff. Mandated reporters must report

allegations if they are told about abuse or neglect, if they witness it, or if

they suspect it. The DHS OIG Adults with Disabilities Abuse Project has

statutory authority to respond to allegations related to adults with

disabilities who reside in domestic situations. OIG has authority to

investigate, take emergency action, work with local law enforcement authorities,

obtain financial and medical records, and pursue guardianship. With the

individual's consent, substantiated cases are referred to the OA for development

of a service plan to meet identified needs. Anyone may make a report by calling

the OA's Office of Inspector General 24-hour hotline (800)843-6154 (voice and

TTY) or (800)447-6404.

1.. Participant Training and Education. Describe how

training and/or information is provided to participants (and/or families or

legal representatives, as appropriate) concerning protections from abuse,

neglect, and exploitation, including how participants (and/or families or legal

representatives, as appropriate) can notify appropriate authorities or entities

when the participant may have experienced abuse, neglect or exploitation.

Character Count:out of 12000

The participant and/or his or her guardian (if one has

been appointed) are informed by the waiver case manager/Service Facilitator

about protections from abuse, neglect, and exploitation. The information

provided includes the process for reporting allegations to the Operating

Agency’s Office of the Inspector General (OIG). Participants and guardians are

informed that anyone who suspects abuse, neglect or exploitation may report an

allegation. Information is presented both verbally and in writing, initially and

upon request. Incidents Reported to the Office of Inspector General The

Operating Agency (DHS) Office of the Inspector General (OIG), which is a

semi-independent entity that reports to both the Governor and the Secretary of

DHS, investigates alleged abuse, neglect and exploitation of adults with mental,

developmental, or physical disabilities in private homes and of adults with

mental or developmental disabilities in DHS-funded community agencies. Other

Incidents Reported to the Operating Agency (DHS) Quarterly, Community-Integrated

Living Arrangements (CILA) providers of residential habilitation are required to

report all medication errors to the Operating Agency. CILA and day habilitation

program providers are required to report serious injuries to the Operating

Agency quarterly. Reports are analyzed for patterns and trends and are shared

with the Quality Management Committee. Any medication error that results in an

adverse outcome is reported to the Operating Agency within seven working days.

All reports are reviewed, coordinated with OIG investigation, and followed up as

necessary to ensure that adequate safeguards are in place to prevent future

occurrences.

1.. Responsibility for Review of and Response to

Critical Events or Incidents. Specify the entity (or entities) that receives

reports of critical events or incidents specified in item G-1-a, the methods

that are employed to evaluate such reports, and the processes and time-frames

for responding to critical events or incidents, including conducting

investigations.

Character Count:out of 12000

The OA (DHS) Office of Inspector General (OIG), which is

a semi-independent entity that reports to both the Governor and the Secretary of

DHS, investigates alleged abuse, neglect and exploitation of adults with mental,

developmental, or physical disabilities in private homes and of adults with

mental or developmental disabilities in DHS-funded community agencies. The OA

Office of Inspector General Adults with Disabilities Abuse Project has statutory

authority to respond to allegations related to adults with disabilities between

the ages of 18 and 59 who reside in domestic situations. OIG has authority to

investigate, take emergency action, work with local law enforcement authorities,

obtain financial and medical records, and pursue guardianship. With the

individual's consent, substantiated cases are referred to the OA for follow-up.

The OIG shall initiate an assessment of all reports of alleged or suspected

abuse or neglect within 7 calendare days after the report is received. Reports

of abuse or neglect that indicated that the life or safety of an adult with

disabilities is in imminent danger shall be assessed within 24 hours after the

receipt of the report. Reports of exploitation shall be assessed within 30

calendar days after the report is received.

1.. Responsibility for Oversight of Critical Incidents

and Events. Identify the State agency (or agencies) responsible for overseeing

the reporting of and response to critical incidents or events that affect waiver

participants, how this oversight is conducted, and how frequently.

Character Count:out of 12000

Both the Medicaid Agency and the Operating Agency work

together through the Quality Management Committee, which meets quarterly, to

ensure appropriate oversight of critical incidents and events. The Operating

Agency maintains a tracking database of reported critical incidents requiring

review/investigation and follow-up activities. A report is produced quarterly

and is shared with the Quality Management Committee. Summary data and analytical

reports are reviewed and discussed.

Appendix G: Participant Safeguards

Appendix G-2: Safeguards Concerning Restraints and

Restrictive Interventions (1 of 2)

1.. Use of Restraints or Seclusion.(Select one):

(X) The State does not permit or prohibits the use of

restraints or seclusion

Specify the State agency (or agencies) responsible for

detecting the unauthorized use of restraints or seclusion and how this oversight

is conducted and its frequency:

Character Count:out of 12000

In addition to the safeguards outlined for use of

restrictive interventions below, the State has the following additional

safeguards specific to the use of restraints. The Mental Health and

Developmental Disabilities Code (405 ILCS 5/2-108) contains the following

requirements governing the use of restraints. Restraint may be used only as a

therapeutic measure to prevent a participant from causing physical harm to

himself or physical abuse to others. Restraint may only be applied by a person

who has been trained in the application of the particular type of restraint to

be utilized. In no event shall restraint be utilized to punish or discipline a

participant, nor is restraint to be used as a convenience for the staff. Except

for emergencies, restraint may be employed only upon the written order of a

physician, clinical psychologist, clinical social worker, or registered nurse

with supervisory responsibilities. No restraint shall be ordered unless the

physician, clinical psychologist, clinical social worker, or registered nurse

with supervisory responsibilities, after personally observing and examining the

participant, is clinically satisfied that the use of restraint is justified to

prevent the participant from causing physical harm to himself or others. In no

event may restraint continue for longer than two hours unless within that time

period a nurse with supervisory responsibilities or a physician confirms, in

writing, following a personal examination of the participant, that the restraint

does not pose an undue risk to the participant's health in light of the

participant's physical or medical condition. The order shall state the events

leading up to the need for restraint and the purposes for which restraint is

employed. The order shall also state the length of time restraint is to be

employed and the clinical justification for that length of time. No order for

restraint shall be valid for more than sixteen hours. If further restraint is

required, a new order must be obtained. In the event there is an emergency

requiring the immediate use of restraint, it may be ordered temporarily by a

qualified person only where a physician, clinical psychologist, clinical social

worker, or registered nurse with supervisory responsibilities is not immediately

available. In that event, an order by a nurse, clinical psychologist, clinical

social worker, or physician must be obtained as quickly as possible, and the

participant must be examined by a physician or supervisory nurse within two

hours after the initial employment of the emergency restraint. Whoever orders

restraint in emergency situations must document its necessity and place that

documentation in the participant's record. Emergencies are situations when

restraints are necessary to prevent the individual from causing physical harm to

self or others and appropriate authorizing personnel are not immediately

available. Emergencies, as all use of restraints, are reviewed by personnel who

may authorize use of restraints, the executive director and the Human Rights

Committee to ensure the appropriateness of the use of restraint in the emergency

situation. The person who orders restraint must inform the provider’s

executive director or his/her designee in writing of the use of restraint within

24 hours. The executive director must review all restraint orders daily and must

inquire into the reasons for the orders for restraint by any person who

routinely orders them. Restraint may be employed during all or part of one

24-hour period, the period commencing with the initial application of the

restraint. However, once restraint has been employed during one 24-hour period,

it may not be used again on the same participant during the next 48 hours

without the prior written authorization of the executive director. Restraint

must be employed in a humane and therapeutic manner and the person being

restrained must be observed by a qualified person as often as is clinically

appropriate but in no event less than once every fifteen minutes. The qualified

person must maintain a record of the observations. Specifically, unless there is

an immediate danger that the participant will physically harm himself or others,

restraint shall be loosely applied to permit freedom of movement. Further, the

participant must be permitted to have regular meals and toilet privileges free

from the restraint, except when freedom of action may result in physical harm to

the participant or others. Every provider agency that employs restraint must

provide training in the safe and humane application of each type of restraint

employed. The agency may not authorize the use of any type of restraint by an

employee who has not received training in the safe and humane application of

that type of restraint. Each agency in which restraint is used must maintain

records detailing which employees have been trained and are authorized to apply

restraint, the date of the training and the type of restraint that the employee

was trained to use. Whenever restraint is imposed upon any participant whose

primary mode of communication is sign language, the participant must be

permitted to have his hands free from restraint for brief periods each hour,

except when freedom may result in physical harm to the participant or others.

Whenever restraint is used, the participant must be advised of his right to have

any person of his choosing, including the Guardianship and Advocacy Commission

or the agency designated pursuant to the Protection and Advocacy for

Developmentally Disabled Persons Act notified of the restraint. A participant

who is under guardianship may request that any person of his choosing be

notified of the restraint whether or not the guardian approves of the notice.

( ) The use of restraints or seclusion is permitted

during the course of the delivery of waiver services. Complete Items G-2-a-i and

G-2-a-ii.

( ) not selected

1.. Safeguards Concerning the Use of Restraints or

Seclusion.Specify the safeguards that the State has established concerning the

use of each type of restraint (i.e., personal restraints, drugs used as

restraints, mechanical restraints or seclusion). State laws, regulations, and

policies that are referenced are available to CMS upon request through the

Medicaid agency or the operating agency (if applicable).

Character Count:out of 12000

1.. State Oversight Responsibility.Specify the State

agency (or agencies) responsible for overseeing the use of restraints or

seclusion and ensuring that State safeguards concerning their use are followed

and how such oversight is conducted and its frequency:

Character Count:out of 12000

Appendix G: Participant Safeguards

Appendix G-2: Safeguards Concerning Restraints and

Restrictive Interventions (2 of 2)

1.. Use of Restrictive Interventions.(Select one):

( ) The State does not permit or prohibits the use of

restrictive interventions

Specify the State agency (or agencies) responsible for

detecting the unauthorized use of restrictive interventions and how this

oversight is conducted and its frequency:

Character Count:out of 12000

(X) The use of restrictive interventions is permitted

during the course of the delivery of waiver servicesComplete Items G-2-b-i and

G-2-b-ii.

( ) not selected

1.. Safeguards Concerning the Use of Restrictive

Interventions. Specify the safeguards that the State has in effect concerning

the use of interventions that restrict participant movement, participant access

to other individuals, locations or activities, restrict participant rights or

employ aversive methods (not including restraints or seclusion) to modify

behavior. State laws, regulations, and policies referenced in the specification

are available to CMS upon request through the Medicaid agency or the operating

agency.

Character Count:out of 20000

In addition to the safeguards outlined for use of

restrictive interventions below, the State has the following additional

safeguards specific to the use of restraints. The Mental Health and

Developmental Disabilities Code (405 ILCS 5/2-108) contains the following

requirements governing the use of restraints. Restraint may be used only as a

therapeutic measure to prevent a participant from causing physical harm to

himself or physical abuse to others. Restraint may only be applied by a person

who has been trained in the application of the particular type of restraint to

be utilized. In no event shall restraint be utilized to punish or discipline a

participant, nor is restraint to be used as a convenience for the staff. Except

for emergencies, restraint may be employed only upon the written order of a

physician, clinical psychologist, clinical social worker, or registered nurse

with supervisory responsibilities. No restraint shall be ordered unless the

physician, clinical psychologist, clinical social worker, or registered nurse

with supervisory responsibilities, after personally observing and examining the

participant, is clinically satisfied that the use of restraint is justified to

prevent the participant from causing physical harm to himself or others. In no

event may restraint continue for longer than two hours unless within that time

period a nurse with supervisory responsibilities or a physician confirms, in

writing, following a personal examination of the participant, that the restraint

does not pose an undue risk to the participant's health in light of the

participant's physical or medical condition. The order shall state the events

leading up to the need for restraint and the purposes for which restraint is

employed. The order shall also state the length of time restraint is to be

employed and the clinical justification for that length of time. No order for

restraint shall be valid for more than sixteen hours. If further restraint is

required, a new order must be obtained. In the event there is an emergency

requiring the immediate use of restraint, it may be ordered temporarily by a

qualified person only where a physician, clinical psychologist, clinical social

worker, or registered nurse with supervisory responsibilities is not immediately

available. In that event, an order by a nurse, clinical psychologist, clinical

social worker, or physician must be obtained as quickly as possible, and the

participant must be examined by a physician or supervisory nurse within two

hours after the initial employment of the emergency restraint. Whoever orders

restraint in emergency situations must document its necessity and place that

documentation in the participant's record. Emergencies are situations when

restraints are necessary to prevent the individual from causing physical harm to

self or others and appropriate authorizing personnel are not immediately

available. Emergencies, as all use of restraints, are reviewed by personnel who

may authorize use of restraints, the executive director and the Human Rights

Committee to ensure the appropriateness of the use of restraint in the emergency

situation. The person who orders restraint must inform the provider’s

executive director or his/her designee in writing of the use of restraint within

24 hours. The executive director must review all restraint orders daily and must

inquire into the reasons for the orders for restraint by any person who

routinely orders them. Restraint may be employed during all or part of one

24-hour period, the period commencing with the initial application of the

restraint. However, once restraint has been employed during one 24-hour period,

it may not be used again on the same participant during the next 48 hours

without the prior written authorization of the executive director. Restraint

must be employed in a humane and therapeutic manner and the person being

restrained must be observed by a qualified person as often as is clinically

appropriate but in no event less than once every fifteen minutes. The qualified

person must maintain a record of the observations. Specifically, unless there is

an immediate danger that the participant will physically harm himself or others,

restraint shall be loosely applied to permit freedom of movement. Further, the

participant must be permitted to have regular meals and toilet privileges free

from the restraint, except when freedom of action may result in physical harm to

the participant or others. Every provider agency that employs restraint must

provide training in the safe and humane application of each type of restraint

employed. The agency may not authorize the use of any type of restraint by an

employee who has not received training in the safe and humane application of

that type of restraint. Each agency in which restraint is used must maintain

records detailing which employees have been trained and are authorized to apply

restraint, the date of the training and the type of restraint that the employee

was trained to use. Whenever restraint is imposed upon any participant whose

primary mode of communication is sign language, the participant must be

permitted to have his hands free from restraint for brief periods each hour,

except when freedom may result in physical harm to the participant or others.

Whenever restraint is used, the participant must be advised of his right to have

any person of his choosing, including the Guardianship and Advocacy Commission

or the agency designated pursuant to the Protection and Advocacy for

Developmentally Disabled Persons Act notified of the restraint. A participant

who is under guardianship may request that any person of his choosing be

notified of the restraint whether or not the guardian approves of the notice.

1.. State Oversight Responsibility.Specify the State

agency (or agencies) responsible for monitoring and overseeing the use of

restrictive interventions and how this oversight is conducted and its frequency:

Character Count:out of 20000

In addition to routine monitoring by the waiver case

manager/QMRP/Service Facilitator and the safeguards for restrictive

interventions (which include any use of restraints) outlined in Appendix G-2-c-i

below, the Individual Service and Support Advocacy (ISSA) provider, an

independent entity under contract with the Operating Agency, continually (at

least quarterly or more often if necessary) monitors the implementation of the

support plan, including the prohibition of restrictive interventions, and works

with the service providers, participant, and family to resolve any concerns.

Both the QMRP/Service Facilitator and the ISSA are mandated reporters of abuse

or neglect, including appropriate or inappropriate use of restraints. As a

component of annual surveys for agency compliance with provider standards, the

Operating Agency monitors for: • Any restriction of individual rights as

contained in the Mental Health and Developmental Disabilities Code. • The

required agency process for the periodic review of behavior intervention and

human rights issues. The Operating Agency conducts on-site quality assurance

reviews that include a review of any use of restrictive interventions to ensure

that requirements in the State’s Mental Health and Developmental Disabilities

Code, outlined above, have been met. Both the Medicaid Agency and the Operating

Agency work together through the Quality Management Committee to ensure

appropriate oversight of restraints. The oversight includes analysis of summary

reports to identify trends and patterns. The Quality Management Committee may

recommend additional focused reviews by the Operating Agency as necessary to

ensure compliance with these requirements, or may develop other strategies or

policy clarifications as necessary for improvement.

Appendix G: Participant Safeguards

Appendix G-3: Medication Management and Administration

(1 of 2)

This Appendix must be completed when waiver services are

furnished to participants who are served in licensed or unlicensed living

arrangements where a provider has round-the-clock responsibility for the health

and welfare of residents. The Appendix does not need to be completed when waiver

participants are served exclusively in their own personal residences or in the

home of a family member.

1.. Applicability.Select one:

( ) No. This Appendix is not applicable (do not complete

the remaining items)

(X) Yes. This Appendix applies (complete the remaining

items)

( ) not selected

1.. Medication Management and Follow-Up

2.. Responsibility.Specify the entity (or entities)

that have ongoing responsibility for monitoring participant medication regimens,

the methods for conducting monitoring, and the frequency of monitoring.

Character Count:out of 12000

Residential habilitation providers must have a

registered professional nurse, advanced practice nurse, physician licensed to

practice medicine in all of its branches, or physician assistant on duty or on

call at all times. At least quarterly this professional reviews medication

orders, medication labels and medication administration records to ensure that

medication labels, and medications administered match those ordered. A part of

this review may include review of the appropriateness and effectiveness of

medications. For participants receiving psychotropic medications, a screening

for and documentation of abnormal involuntary movements, including tardive

dyskinesia, is completed at least every six months by employees trained in

performing this type of assessment. Use of medications to modify or control

behaviors is considered to be a restrictive intervention. As such, it is also

subject to the provider requirements for oversight by a properly constituted

human rights committee as described in G-2. The OA has an administrative rule

that regulates the administration of medications in community settings. The rule

ensures the safety of individuals residing in community settings with 16 or

fewer beds. The OA and MA review team includes Registered Nurses. The team

reviews participant medication regimen and compliance with rules applicable to

medication management and administration. A representative sample of

participants is reviewed annually. Participant-specific issues are followed up

as part of the review process. The OA is responsible for oversight and follow-up

of medication management issues.

1.. Methods of State Oversight and Follow-Up.Describe:

(a) the method(s) that the State uses to ensure that participant medications are

managed appropriately, including: (a) the identification of potentially harmful

practices (e.g., the concurrent use of contraindicated medications); ( the

method(s) for following up on potentially harmful practices; and, © the State

agency (or agencies) that is responsible for follow-up and oversight.

Character Count:out of 12000

The Operating Agency is responsible for oversight and

follow-up of medication management issues. The OA conducts annual quality

assurance on-site reviews of a representative sample of waiver participants.

Registered nurses employed by the OA conduct annual desk reviews of psychotropic

medications for participants whose medications are funded by Medicaid.

Participant-specific issues are followed up as part of the review process.

Findings are summarized and reported to the Quality Management Committee.

Potentially harmful systemic medication management practices that are identified

in the course of these reviews are brought to the Quality Management Committee,

which includes key staff from the OA and MA. The Committee meets quarterly, for

discussion of appropriate systemic follow-up action.

Appendix G: Participant Safeguards

Appendix G-3: Medication Management and Administration

(2 of 2)

1.. Medication Administration by Waiver Providers

2.. Provider Administration of Medications.Select one:

( ) Not applicable. (do not complete the remaining

items)

(X) Waiver providers are responsible for the

administration of medications to waiver participants who cannot self-administer

and/or have responsibility to oversee participant self-administration of

medications. (complete the remaining items)

( ) not selected

1.. State Policy.Summarize the State policies that

apply to the administration of medications by waiver providers or waiver

provider responsibilities when participants self-administer medications,

including (if applicable) policies concerning medication administration by

non-medical waiver provider personnel. State laws, regulations, and policies

referenced in the specification are available to CMS upon request through the

Medicaid agency or the operating agency (if applicable).

Character Count:out of 12000

General Requirements When medications are provided or

employees of a waiver residential habilitation services provider supervise their

administration, the provider must ensure that such medications are provided and

their administration is supervised in accordance with the Illinois Nursing and

Advanced Practice Nursing Act (225 ILSC 65). Waiver residential habilitation

service providers may allow non-licensed direct support persons to administer

medications as long as the provider complies with the Administration of

Medication in Community Settings rule (59 Ill. Adm. Code 116). Day habilitation

providers may not allow non-licensed direct support persons to administer

medications. Waiver residential habilitation providers have ongoing

responsibility for monitoring participant medication regimens and ensuring

compliance with the Illinois Nursing and Advanced Practice Nursing Act (225 ILSC

65) and its implementing rule (59 Ill. Adm. Code 116). Providers must maintain

and implement written policies and procedures that include provisions describing

on-going supervision and monitoring of direct support staff who are authorized

to administer medications, annual review and any necessary retraining of

authorized direct support staff in the theory and practice of medication

administration, a systematic review of all medication errors, adverse drug

reactions, and incidents to identify contributing factors and plan corrective

action, recording and reporting of all instances of retraining and retesting for

failure to qualify as an authorized direct support staff. Rule 116 permits a

registered nurse who has successfully completed the Operating

Agency/DHS-approved nurse-trainer course for medication administration in the

community (6 hours) to authorize direct support personnel to administer

medication in residential sites. Authorized direct support personnel must be at

least eighteen, have completed high school or G.E.D., demonstrate functional

literacy, and have successfully completed required competency-based training and

assessment by the nurse-trainer. Training includes specifics related to the

participant, medication, dosages, etc. Direct support personnel are authorized

to administer only those specific medications to specific participants for which

they have successfully completed training and competency evaluations. Authorized

direct support personnel are re-evaluated by a nurse-trainer at least annually

to ensure competency to administer each medication to each participant. The

waiver residential provider must ensure and document the following: • A

physician must be responsible for the medical services provided to participants,

and the management of participants’ medications. • Only a competent medical

professional, that is, a physician licensed pursuant to the Medical Practice

Act, advanced practice nurse licensed pursuant to the Nursing and Advanced

Practice Nursing Act, and physician’s assistant licensed pursuant to Physician

Assistant’s Practice Act, may prescribe and monitor all prescription

medications. • All medications, including patent or proprietary medication,

e.g., cathartics, headache remedies, or vitamins, may be given only upon the

written order of a competent medical professional. Rubber stamp signatures are

not acceptable. All orders must be given as prescribed by the competent medical

professional and at the designated time. A registered professional nurse or

licensed practical nurse may take telephone orders. All orders must be

immediately signed by the nurse taking the order and placed in the

participant’s record. These orders must be countersigned or documented by

facsimile prescription by the competent medical professional within ten working

days. • An individual medication administration record (MAR) must be kept for

each participant for medication administered. It must contain at least the

following: -- the participant’s name; -- the name and dosage form of the drug;

-- the name of the prescribing physician, physician assistant, advanced practice

nurse, dentist, podiatrist, or certified optometrist; -- dose; -- frequency or

times of administration; -- route of administration; -- date and time given; --

most recent date of the order; -- allergies to medication; and -- special

considerations. The MAR for the current month must be kept with the medications

or in participant’s record. The MAR must be completed and initialed

immediately after the medication is administered. Each MAR must have a section

that contains the full signature and title of each person who initials it. All

changes in medication must be noted on the MAR by a nurse, physician, physician

assistant, dentist, podiatrist, or certified optometrist and shared with

administering staff prior to the next dose. Participant refusal to take

medication must be noted on the MAR and in the individual record. • For waiver

participants who are independently self-administering medications, no MAR is

required; however, the provider must track and document that the medications are

being taken by the participant. • A physician must provide the written order

for a waiver participant to self-administer medications or participate in a

self-administration of medication training program based on the results of the

participant’s evaluation. The order must become part of the individual record.

• Medication training programs must be implemented and carried out only by a

registered professional nurse or a licensed practical nurse under the

supervision of a registered nurse and may not be carried out by direct support

staff or other unauthorized personnel. • A competent medical professional must

perform an examination of the participant prior to the initiation of

psychotropic medications or any medications to manage behavior. • Screening

for and documentation of abnormal involuntary movements, including tardive

dyskinesia, in participants receiving prescribed psychotropics for which this is

indicated as a possible side effect, must be completed at least every six months

by employees trained in performing this type of assessment. • A competent

medical professional must review the medications prescribed and must see the

participant at least annually, and every three months if psychotropic

medications, or any medications to manage behavior, have been prescribed.

Physician documentation within the individual record must include, but is not

limited to, the rationale for continuing current medications at current levels

and/or initiating new medications; and medication side effects. • A competent

medical professional must evaluate the ability of the participant to

self-administer medications. Ability to self-administer medication must be

reassessed at least annually. Participants must be evaluated using Department

approved screening and assessment tools, in accordance with 59 Ill. Adm. Code

116. • A psychiatrist must review psychotropic medications as needed, but at

least quarterly, and be available for consultation when psychotropic medications

have been prescribed. • When agencies supervise the self-administration of

medication training programs or administer the medications, medications must be

secured from unauthorized access and only a physician, pharmacist, registered or

licensed practical nurse or agency employee authorized to supervise the

self-administration of medication training program or administer medications may

have access to medications. A physician, pharmacist or registered professional

nurse must be available at all times to consult with trained, unlicensed direct

support employees administering medications or supervising a self-administration

of medications training program for persons with developmental disabilities. •

The qualified mental retardation professional must ensure employees, guardians,

and waiver participants have information on expected consequences, potential

benefits, and side effects of any prescribed medication. • All medications

must be labeled. • Participants who are able to self-administer medications

independently must have access to their medications. • Medications must be

stored safely and at appropriate temperatures. • Informed consent must be

obtained from the participant or guardian for all medical services and

medications arranged by the provider.

1.. Medication Error Reporting.Select one of the

following:

(X) Providers that are responsible for medication

administration are required to both record and report medication errors to a

State agency (or agencies).

Complete the following three items:

(a) Specify State agency (or agencies) to which errors

are reported:

Character Count:out of 12000

Waiver residential habilitation providers must report

all medication errors to the Operating Agency, the Department of Human Services

(DHS). Medication errors resulting in an adverse reaction are reported to the

DHS Office of Inspector General (OIG).

( Specify the types of medication errors that

providers are required to record:

Character Count:out of 12000

Waiver residential habilitation providers are required

to record all medication errors.

© Specify the types of medication errors that

providers must report to the State:

Character Count:out of 12000

Waiver residential habilitation providers are required

to report all medication errors quarterly in a summary report format. Any

medication error that results in an adverse outcome is to be reported to both

OIG and the Operating Agency. The waiver residential provider must report these

types of errors to OIG within four hours and to the Operating Agency within 7

working days.

( ) Providers responsible for medication administration

are required to record medication errors but make information about medication

errors available only when requested by the State.

Specify the types of medication errors that providers

are required to record:

Character Count:out of 12000

( ) not selected

1.. State Oversight Responsibility.Specify the State

agency (or agencies) responsible for monitoring the performance of waiver

providers in the administration of medications to waiver participants and how

monitoring is performed and its frequency.

Character Count:out of 12000

The Operating Agency is responsible for oversight and

follow-up of medication administration issues. These issues are reviewed as part

of residential licensure surveys that occur at least every three years and

during annual quality assurance site reviews of a representative sample of

waiver participants. Participant-specific issues are followed up as part of the

review process. Potentially harmful systemic medication management practices

that are identified in the course of these reviews are brought to the Quality

Management Committee, which includes the Medicaid Agency and meets quarterly,

for discussion of remediation and appropriate systemic follow-up action.

Appendix G: Participant Safeguards

Quality Improvement: Health and Welfare

As a distinct component of the State’s quality

improvement strategy, provide information in the following fields to detail the

State’s methods for discovery and remediation.

1.. Methods for Discovery: Health and Welfare

The State, on an ongoing basis, identifies, addresses

and seeks to prevent the occurrence of abuse, neglect and exploitation.

1.. Performance Measures

For each performance measure/indicator the State will

use to assess compliance with the statutory assurance complete the following.

Where possible, include numerator/denominator. Each performance measure must be

specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the

aggregated data that will enable the State to analyze and assess progress toward

the performance measure. In this section provide information on the method by

which each source of data is analyzed statistically/deductively or inductively,

how themes are identified or conclusions drawn, and how recommendations are

formulated, where appropriate.

Performance Measure:

The number and percent of participant records

reviewed that documented the participant (and/or family or legal guardian)

received information/education about how to report abuse, neglect, exploitation

and other critical incidents as specified in the approved waiver. N: Number of

records where participant received A/N information. D: Number of participants in

the sample.

Data Source(Select one):

Record reviews, on-site

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[X] State Medicaid Agency [ ] Weekly [ ] 100%

Review

[X] Operating Agency [ ] Monthly [X] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [X]

Representative Sample

Confidence Interval =

5%

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of participants for whom

critical incidents were identified and appropriate measures taken by the

provider. Numerator: Number of participants with at least one critical incident

reported where the provider took appropriate measures. Denominator: Number of

participants in the sample with at least one critical incident.

Data Source(Select one):

Record reviews, on-site

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[X] State Medicaid Agency [ ] Weekly [ ] 100%

Review

[X] Operating Agency [ ] Monthly [X] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [X] Other

Specify:

Within the representative sample, participants

with at least one incident

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of participants who received

the coordination and support to access health care services identified in their

service plan. Numerator: Number of participants who received support to access

healthcare services. Denominator: Number of participants in the sample with

health care services identified in their ISP.

Data Source(Select one):

Record reviews, on-site

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[X] State Medicaid Agency [ ] Weekly [ ] 100%

Review

[X] Operating Agency [ ] Monthly [X] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[ ] Continuously and Ongoing [X] Other

Specify:

Within the representative sample, those with

health care needs identified in the ISP

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

The number and percent of reportable deaths that

were reported within the required timelines. Numerator: Number of reportable

deaths reported within required timelines. Denominator: All reportable deaths.

Data Source(Select one):

Other

If 'Other' is selected, specify:

OA (DHS) Office of Inspector General (OIG) and

Medicaid eligibility file.

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [X] 100%

Review

[X] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

The number and percent of participants with

identified restrictive interventions where procedures were followed as specified

in the approved waiver. Numerator: Number of restrictive interventions that

followed required procedures. Denominator: Number of participants in the sample

with at least one restrictive intervention.

Data Source(Select one):

Record reviews, on-site

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [ ] 100%

Review

[X] Operating Agency [ ] Monthly [X] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [X] Other

Specify:

Within the representative sample, those with at

least one restrictive intervention

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[X] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of investigations with

substantiated findings and/or recommendations where the state adhered to the

follow-up methods specified in the approved waiver. Numerator: Number of

investigations with substantiated findings and/or recommendations where the

state adhered to required follow-up methods. Denominator: All investigations

with substantiated findings and/or recommendations.

Data Source(Select one):

Critical events and incident reports

If 'Other' is selected, specify:

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [X] 100%

Review

[X] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of written responses to abuse,

neglect and/or exploitation investigations that were received from the provider

within the required time frames. Numerator: Number of responses received within

required time frames. Denominator: All investigations requiring a written

response.

Data Source(Select one):

Other

If 'Other' is selected, specify:

OA OIG database

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [X] 100%

Review

[X] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

1.. If applicable, in the textbox below provide any

necessary additional information on the strategies employed by the State to

discover/identify problems/issues within the waiver program, including frequency

and parties responsible.

Character Count:out of 6000

1.. Methods for Remediation/Fixing Individual Problems

1.. Describe the State’s method for addressing

individual problems as they are discovered. Include information regarding

responsible parties and GENERAL methods for problem correction. In addition,

provide information on the methods used by the State to document these items.

Character Count:out of 6000

The OA reviews the data collected and identifies the

most appropriate response (remediation). General responses may include work with

participants and their providers, retraining staff, voiding claims, technical

assistance, increased monitoring, revising service plans, and requiring plans of

correction. The OA is responsible for seeing that these individual issues are

resolved. The OA provides quarterly reports of these activities to the MA. Staff

of the two State agencies review the reports on a quarterly basis.

1.. Remediation Data Aggregation

Remediation-related Data Aggregation and Analysis

(including trend identification)

Responsible Party (check each that applies):

Frequency of data aggregation and analysis (check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

1.. Timelines

When the State does not have all elements of the Quality

Improvement Strategy in place, provide timelines to design methods for discovery

and remediation related to the assurance of Health and Welfare that are

currently non-operational.

(X) No

( ) Yes

( ) not selected

Please provide a detailed strategy for assuring Health

and Welfare, the specific timeline for implementing identified strategies, and

the parties responsible for its operation.

Character Count:out of 6000

Appendix H: Quality Improvement Strategy (1 of 2)

Under §1915© of the Social Security Act and 42 CFR

§441.302, the approval of an HCBS waiver requires that CMS determine that the

State has made satisfactory assurances concerning the protection of participant

health and welfare, financial accountability and other elements of waiver

operations. Renewal of an existing waiver is contingent upon review by CMS and a

finding by CMS that the assurances have been met. By completing the HCBS waiver

application, the State specifies how it has designed the waiver’s critical

processes, structures and operational features in order to meet these

assurances.

a.. Quality Improvement is a critical operational

feature that an organization employs to continually determine whether it

operates in accordance with the approved design of its program, meets statutory

and regulatory assurances and requirements, achieves desired outcomes, and

identifies opportunities for improvement.

CMS recognizes that a state’s waiver Quality

Improvement Strategy may vary depending on the nature of the waiver target

population, the services offered, and the waiver’s relationship to other

public programs, and will extend beyond regulatory requirements. However, for

the purpose of this application, the State is expected to have, at the minimum,

systems in place to measure and improve its own performance in meeting six

specific waiver assurances and requirements.

It may be more efficient and effective for a Quality

Improvement Strategy to span multiple waivers and other long-term care services.

CMS recognizes the value of this approach and will ask the state to identify

other waiver programs and long-term care services that are addressed in the

Quality Improvement Strategy.

Quality Improvement Strategy: Minimum Components

The Quality Improvement Strategy that will be in effect

during the period of the approved waiver is described throughout the waiver in

the appendices corresponding to the statutory assurances and sub-assurances.

Other documents cited must be available to CMS upon request through the Medicaid

agency or the operating agency (if appropriate).

In the QMS discovery and remediation sections throughout

the application (located in Appendices A, B, C, D, G, and I) , a state spells

out:

a.. The evidence based discovery activities that will

be conducted for each of the six major waiver assurances;

b.. The remediation activities followed to correct

individual problems identified in the implementation of each of the assurances;

In Appendix H of the application, a State describes (1)

the system improvement activities followed in response to aggregated, analyzed

discovery and remediation information collected on each of the assurances; (2)

the correspondent roles/responsibilities of those conducting assessing and

prioritizing improving system corrections and improvements; and (3) the

processes the state will follow to continuously assess the effectiveness of the

QMS and revise it as necessary and appropriate.

If the State’s Quality Improvement Strategy is not

fully developed at the time the waiver application is submitted, the state may

provide a work plan to fully develop its Quality Improvement Strategy, including

the specific tasks the State plans to undertake during the period the waiver is

in effect, the major milestones associated with these tasks, and the entity (or

entities) responsible for the completion of these tasks.

When the Quality Improvement Strategy spans more than

one waiver and/or other types of long-term care services under the Medicaid

State plan, specify the control numbers for the other waiver programs and/or

identify the other long-term services that are addressed in the Quality

Improvement Strategy. In instances when the QMS spans more than one waiver, the

State must be able to stratify information that is related to each approved

waiver program.

Appendix H: Quality Improvement Strategy (2 of 2)

H-1: Systems Improvement

1.. System Improvements

2.. Describe the process(es) for trending,

prioritizing, and implementing system improvements (i.e., design changes)

prompted as a result of an analysis of discovery and remediation information.

Character Count:out of 12000

A representative sample is selected each year. Reviews

are scheduled and conducted throughout the year. Each performance measure in the

application specifies the frequency of data collection and data aggregation.

Data collection is continuous and ongoing throughout the year and individual

problems are remediated as they are identified. All data collected including the

timeliness of remediation activities is summarized quarterly and shared with the

Quality Management Committee which meets quarterly. The data is analyzed and

evaluated for trends on a quarterly and annual basis. As trends are identified,

proactive remediation is initiated. Annual reports are produced with trends

identified based on the full representative sample and/or 100% review of data.

Illinois has a quality management strategy based on the federal assurances in

the waiver. The elements of discovery, remediation and systems improvement are

key to the quality management design. The Medicaid Agency (MA) and the Operating

Agency (OA) meet quarterly for scheduled Quality Management Committee meetings

to discuss waiver oversight and monitoring, including measuring system

performance and making system improvements. Participants in this meeting include

Healthcare and Family Services (HFS) program and fiscal staff (the MA), and

Department of Human Services (the OA) program and fiscal staff, the Office of

Inspector General (OIG), and other key staff. Discovery activities are described

in other parts of the application. State staff conducts discovery activities and

review discovery information on an ongoing basis. For on-site and off-site

record reviews, discovery information is reviewed and discussed with the waiver

providers at the time of discovery. This information is assimilated and reviewed

by both the OA and MA. Findings are prioritized for remediation and improvement.

This occurs informally through discussion when issues are identified and more

formally through interagency meetings including the quarterly Quality Management

Committee meetings. The front line of the quality assurance system is the

Individual Service and Support Advocates (ISSAs), employed by Independent

Service Coordination (ISC) entities contracted by the OA. They visit each person

quarterly to check on their general health and well-being. The ISSAs use a

standard tool and protocol that includes such areas as physical environment,

individual rights, health, service plan implementation and behavioral supports.

A representative sample of the completed tools for each ISSA is reviewed on an

annual basis by the OA. The ISSAs must be independent of any direct care

providers and are charged with identifying issues and initiating problem

resolution as needed. In the event issues cannot be resolved at the local level,

the ISSA must refer the situation to the OA. The ISSAs are provided with a

standardized form for these referrals. The OA tracks such reports and follow up

activity in a central referral database. Summary and analytical reports are

completed and reviewed by the State’s Quality Management Committee for trend

identification and system improvement. Additional information on the complaint

referral process is included in Appendix G. Additional information regarding MA

oversight activities is provided below. The Adults with Developmental

Disabilities waiver quality management plan is part of an overall quality

management plan for the three 1915 © HCBS waivers operated by the DHS,

Division of Developmental Disabilities. The other waivers include the children's

support waiver, (waiver control number 064) and the children’s residential

waiver (waiver control number 0473). While some data may be collected during the

same onsite provider reviews, the sample for each waiver is independently

selected and collected for later trending and aggregation. The samples are drawn

separately and the results aggregated separately. The state's process for

discovery, remediation and implementing system improvement is discussed

following each federal assurance category below. 1. Level of Care (LOC)

Determination • The OA reviews all authorization requests for waiver services

to ensure that the applicant has been accurately determined eligible for an

ICFMR level of care by the independent service coordination (ISC) entities. •

The ISC entities are surveyed annually by the OA for contract compliance.

Surveyors record their findings on a standard tool. The data collected for each

of the contracted entities is compiled and summarized via an electronic report.

•The OA reviews LOC eligibility and timeliness of redeterminations for a

representative sample of participants during annual onsite and record reviews.

The MA participates in selected reviews as part of oversight activities. •

State staff reviews system performance at least annually through an analysis of

progress or regression in the scope of overall findings by ISC entity. • The

State’s Quality Management Committee reviews summary reports of survey

findings and recommends corrective action. Corrective action can include

retraining, technical assistance, contract changes, etc. 2. Service Plan •

Annually the OA reviews service plan development and implementation based on a

representative sample of participants to ensure individual support plans are

based on adequate assessments to address the participant’s needs and are

completed on a timely basis. The MA participates in select reviews as part of

oversight activities. • When support plan inadequacies are found, the OA takes

remedial actions and identifies the most appropriate response. General responses

may include work with participants and their providers, revising service plans,

retraining staff, voiding claims, technical assistance, increased monitoring,

and requiring a plan of correction. All individual findings are addressed by the

OA. Systemic actions may include policy or rule changes, clarifications,

technical assistance and training. • The ISSAs are participants in the

individual support planning team. When issues involving the support plan or

choice cannot be resolved locally the ISSA refers the issues to the OA for

technical assistance and follow-up actions as necessary. • The OA maintains a

database to track referrals and follow-up actions. •The MA and OA review that

participants were given informed choice of waiver services and service providers

for a random sample of participants during annual onsite and record reviews. •

Summary reports regarding support plans are reviewed by the Quality Management

Committee for identification of concerns, patterns and trends and for

development of suggestions for improvements. Selected reports are shared with

the Statewide Advisory Council. The QMC summarizes each meeting, maintains a log

of suggestions for improvement, and tracks the implementation of the

suggestions. 3. Qualified Providers • The OA monitors direct support

professional (DSP) training and QSP (QMRP) qualifications, initial training, and

continuing education requirements as part of the annual provider and ISC entity

reviews. • The Financial Management Services entity/entities under contract

with the OA verifies that non-licensed/non-certified providers who are hired

under the employer authority are qualified and have required background and

registry checks upon waiver enrollment. •The OA verifies provider

qualifications for other non-licensed non-certified providers (for example,

transportation providers) upon enrollment. Providers that do not meet

requirements are not enrolled. •The MA and OA review qualifications and

training during annual onsite and record reviews for providers. The MA

participates in select reviews as part of oversight activities. •Documentation

of provider qualifications is a component of the OA and MA review of the

Financial Management Services entity/entities for compliance with contractual

and waiver requirements. • Summary reports of provider qualification reviews

are reviewed by the State’s Quality Management Committee for identification of

concerns, patterns and trends and for development of suggestions for

improvements. Selected reports are shared with the Statewide Advisory Council.

4. Health and Welfare •The MA and OA review health and welfare provisions for

a representative sample of participants during annual onsite and record reviews.

The reviews include interviews with guardians and participants (as possible),

ISSAs and waiver case managers/service facilitators. • In response to

identified trends and emerging issues, the OA issues written communications on

health and safety policies and procedures. These notices are posted on the OA

website. • The OA provides training on issues where trends and patterns appear

to be systemic in nature. • Summary reports of health and welfare findings are

reviewed by the State’s Quality Management Committee for identification of

concerns, patterns and trends and for development of suggestions for

improvements. Selected reports are shared with the Statewide Advisory Council.

5. Administrative Authority •The MA works closely with the OA through an

interagency agreement. Activities are designed to assure the State meets the

statutory assurances of the 1915 © waiver and to verify that the OA is

fulfilling the obligations of the interagency agreement. •The OA has ongoing

communication with the MA through monitoring activities; testing and monitoring

claims; participation in training; discussion and approval of policy and system

changes; and approval of policy and rule changes through the MA Policy Review

System. •The MA makes the final administrative decision on all appeals. •The

OA conducts program monitoring of a representative sample of participants that

includes review of service providers, service coordination, Financial Management

Services vendors and claims. The MA participates in select reviews. •Staff

from the MA and OA participate in quarterly Quality Management Committee

meetings. Typical issues discussed include review findings and follow-up

activities, quality management planning, discussion of rules, training, and

policy and system changes. 6. Financial Accountability •Financial oversight of

claims is delegated to the OA to ensure that they are coded and paid in

accordance with the reimbursement methodology specified in the approved waiver.

•The OA conducts post payment reviews of claims based on the sampling

specified in Appendix 1. The OA reviews and analyzes rejected claims and other

error reports to determine if system changes are needed. •Based on findings,

the OA notifies the MA Fraud Unit as required to provide information about

potential fraud investigations. •The OA submits a quarterly report to the MA

with their findings and remediation activities. The MA conducts a validation

review based on the report to verify that the OA followed their post-payment

review procedures and that appropriate remediation activities were taken. •All

summary reports are shared with the MA and discussed within the Quality

Management Committee (QMC) where systemic issues are identified, and suggestions

for improvement are made. The QMC summarizes each meeting, maintains a log of

suggestions for improvement, and tracks the implementation of the suggestions.

1.. System Improvement Activities

Responsible Party (check each that applies):

Frequency of Monitoring and Analysis (check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [X] Quarterly

[ ] Quality Improvement Committee [X] Annually

[ ] Other

Specify: [ ] Other

Specify:

1.. System Design Changes

2.. Describe the process for monitoring and analyzing

the effectiveness of system design changes. Include a description of the various

roles and responsibilities involved in the processes for monitoring & assessing

system design changes. If applicable, include the State’s targeted standards

for systems improvement.

Character Count:out of 12000

The OA compiles results of all review activity to

identify trends and presents these findings with the MA. Based on identified

patterns of concerns, corrective action is initiated by the OA to address and

prevent similar problems with other providers. Such action is dependent on the

specific identified issue but may include revision of training requirements and

curricula, issuance of clarification memos, revision of contract language,

and/or modification of performance measures. Other types of actions include

voiding claims as a result of post payment reviews and changes to administrative

requirements. The Quality Management Committee meets quarterly to discuss

findings, trends and the effectiveness of system design changes in response to

identified issues. The QMC prioritizes system corrections and enhancements on an

ongoing basis. The QMC determines who is responsible for implementation of each

correction or enhancement and the time frames for completion. The QMC tracks

implementation and whether the changes had the desired effect and whether

further modifications are needed. At least annually, the QMC discusses issues

such as the need for waiver amendments including capacity changes, changes to

covered services, provider qualifications and other major design changes. Since

there are three waivers operated by the DHS, Division of Developmental

Disabilities, system design changes take into account all three waivers

(IL.0464, IL.0473, and IL.350.90). However, each waiver is analyzed separately.

Some design changes may be specific to one waiver or may involve multiple

waivers.

1.. Describe the process to periodically evaluate, as

appropriate, the Quality Improvement Strategy.

Character Count:out of 12000

The process to evaluate the State's Quality Improvement

Strategy (QIS) is conducted annually as part of the Quality Management Committee

activities. Key staff from the MA and OA are members of the QMC. A portion of

one meeting per year will be devoted to an overview of the previous year's

activities and whether changes are needed to the QMC procedures, membership and

scope. On a quarterly basis, key staff from the MA Bureau of Interagency

Coordination meet with key staff from the OA to review all Performance Measures

and remediation activities. Summarized evidentiary data are reveiwed, trends are

identified and additional remediation activities are developed and incorporated

into the Quality Improvement Strategy. Meeting summaries of the Quality

Management Committee track remediation activities and outcomes.

Appendix I: Financial Accountability

I-1: Financial Integrity and Accountability

Financial Integrity. Describe the methods that are

employed to ensure the integrity of payments that have been made for waiver

services, including: (a) requirements concerning the independent audit of

provider agencies; ( the financial audit program that the state conducts to

ensure the integrity of provider billings for Medicaid payment of waiver

services, including the methods, scope and frequency of audits; and, © the

agency (or agencies) responsible for conducting the financial audit program.

State laws, regulations, and policies referenced in the description are

available to CMS upon request through the Medicaid agency or the operating

agency (if applicable).

Character Count:out of 12000

Provider agencies that are under contract with the

Operating Agency and receive over $500,000 in Operating Agency funding are

required to have an independent audit of their financial statements on an annual

basis. If the Operating Agency performs rate calculations or expense and revenue

analysis, provider agencies are required to submit revenue and expense data by

program on a consolidated financial report form prescribed by the Operating

Agency, regardless of overall funding level. This independent audit is an

Operating Agency requirement and the Single Audit Act of 1984 (Act) and the

Single Audit Act Amendment of 1996 does not apply to this Waiver. Medicaid

payments received as reimbursement for providing services to Medicaid eligible

individuals are not considered Federal awards under the Act and therefore,

providers are exempt from Federal audit requirements for these payments.

Individual providers and businesses that are not under contract with the

Operating Agency are not required to have audits completed on their financial

information. However, the Operating Agency reserves the right to audit any

provider at any time. Copies of the audits and consolidated financial reports

are on file with the Operating Agency. The Operating Agency performs desk

reviews and a sample of on-site reviews of the independent audits on an annual

basis. The Medicaid and Operating Agencies work cooperatively to review rates

and provider claims. The MA delegates to the OA the financial oversight of

claims. The OA reivews 100% of claims verifying the following: 1) The individual

was eligible and enrolled in the waiver on the date of service, and, 2) The

rates were paid in accordance with the reimbursement methodology. In addition,

the OA selects a representative sample of claims and conducts post payment

reviews to verify whether the services were approved in the service plan. The OA

summarizes the post payment review data and provides quarterly reports to the MA

of their findings and any remediation activities (on an individual and systemic

basis). Remediation may include, recommending that the OA clarify policy,

retrain staff, provide technical assistance, void claims, increase monitoring,

conduct focused reviews with the MA, or develop plans of correction, as

appropriate. The MA performs a validation review based on the OA report to

verify that post payment review procedures were followed and appropriate

remediation actions taken. The MA's validation review includes an assessment and

review of the internal controls established by the OA. The MA assesses the

appropriateness of established controls and performs tests to provide reasonable

assurance that the established controls are followed. The MA uses the data

warehouse to verify that claiming errors were corrected by crediting CMS with

any applicable FFP. As a result of validation reviews, the MA works with the OA

to modify and strengthen internal controls as needed. The OA reviews rate

calculations anytime there is a significant change in the computerized

information management system. The results of all financial reviews are shared

between the two State agencies and discussed during the Quality Management

Committee meetings. In addition, results of some reviews may be shared with the

Statewide Advisory Council on Developmental Disabilities in order to obtain

input from stakeholders regarding corrective actions.

Appendix I: Financial Accountability

Quality Improvement: Financial Accountability

As a distinct component of the State’s quality

improvement strategy, provide information in the following fields to detail the

State’s methods for discovery and remediation.

1.. Methods for Discovery: Financial Accountability

State financial oversight exists to assure that claims

are coded and paid for in accordance with the reimbursement methodology

specified in the approved waiver.

1.. Performance Measures

For each performance measure/indicator the State will

use to assess compliance with the statutory assurance complete the following.

Where possible, include numerator/denominator. Each performance measure must be

specific to this waiver (i.e., data presented must be waiver specific).

For each performance measure, provide information on the

aggregated data that will enable the State to analyze and assess progress toward

the performance measure. In this section provide information on the method by

which each source of data is analyzed statistically/deductively or inductively,

how themes are identified or conclusions drawn, and how recommendations are

formulated, where appropriate.

Performance Measure:

Number and percent of waiver claims reviewed that

were submitted using the correct rate as specified in the waiver application.

Numerator: Number of claims with correct rate. Denominator: All claims.

Data Source(Select one):

Other

If 'Other' is selected, specify:

OA Comparison of claims with approved rates

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [X] 100%

Review

[X] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of waiver service claims that

were submitted for participants who were Medicaid waiver eligible on the date

that the service was delivered. Numerator: Number of claims reviewed that were

submitted for participants who were Medicaid eligible on the date the service

was provided. Denominator: All claims.

Data Source(Select one):

Other

If 'Other' is selected, specify:

OA MIS automated reports

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [X] 100%

Review

[X] Operating Agency [ ] Monthly [ ] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [ ]

Representative Sample

Confidence Interval =

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[X] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

Performance Measure:

Number and percent of reviewed waiver service

claims submitted for FFP that are specified in the participant's service plan.

Numerator: Number of claims reviewed that were specified in the ISP. Number of

claims in the sample.

Data Source(Select one):

Other

If 'Other' is selected, specify:

OA Comparison of claims with service plans in

sample

Responsible Party for data

collection/generation(check each that applies): Frequency of data

collection/generation(check each that applies): Sampling Approach(check each

that applies):

[ ] State Medicaid Agency [ ] Weekly [ ] 100%

Review

[X] Operating Agency [ ] Monthly [X] Less than

100% Review

[ ] Sub-State Entity [ ] Quarterly [X]

Representative Sample

Confidence Interval =

5%

[ ] Other

Specify: [X] Annually [ ] Stratified

Describe Group:

[ ] Continuously and Ongoing [ ] Other

Specify:

[ ] Other

Specify:

Data Aggregation and Analysis:

Responsible Party for data aggregation and

analysis (check each that applies): Frequency of data aggregation and analysis

(check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

1.. If applicable, in the textbox below provide any

necessary additional information on the strategies employed by the State to

discover/identify problems/issues within the waiver program, including frequency

and parties responsible.

Character Count:out of 6000

1.. Methods for Remediation/Fixing Individual Problems

1.. Describe the State’s method for addressing

individual problems as they are discovered. Include information regarding

responsible parties and GENERAL methods for problem correction. In addition,

provide information on the methods used by the State to document these items.

Character Count:out of 6000

The OA reviews the issues and identifies the most

appropriate response. General responses may include work with participants and

their providers, retraining staff, voiding claims, technical assistance,

increased monitoring, revising service plans, and requiring plans of correction.

The OA is responsible for seeing that these individual issues are resolved. The

OA provides summary reports of these activities to the MA. Staff of the two

State agencies review the reports on a quarterly basis.

1.. Remediation Data Aggregation

Remediation-related Data Aggregation and Analysis

(including trend identification)

Responsible Party (check each that applies):

Frequency of data aggregation and analysis (check each that applies):

[X] State Medicaid Agency [ ] Weekly

[X] Operating Agency [ ] Monthly

[ ] Sub-State Entity [ ] Quarterly

[ ] Other

Specify: [X] Annually

[ ] Continuously and Ongoing

[ ] Other

Specify:

1.. Timelines

When the State does not have all elements of the Quality

Improvement Strategy in place, provide timelines to design methods for discovery

and remediation related to the assurance of Financial Accountability that are

currently non-operational.

(X) No

( ) Yes

( ) not selected

Please provide a detailed strategy for assuring

Financial Accountability, the specific timeline for implementing identified

strategies, and the parties responsible for its operation.

Character Count:out of 6000

Appendix I: Financial Accountability

I-2: Rates, Billing and Claims (1 of 3)

1.. Rate Determination Methods. In two pages or less,

describe the methods that are employed to establish provider payment rates for

waiver services and the entity or entities that are responsible for rate

determination. Indicate any opportunity for public comment in the process. If

different methods are employed for various types of services, the description

may group services for which the same method is employed. State laws,

regulations, and policies referenced in the description are available upon

request to CMS through the Medicaid agency or the operating agency (if

applicable).

Character Count:out of 12000

Rate determination methods for each waiver service are

outlined below. Adult Day Care The Adult Day Care rate is based on the rate used

by the Illinois Department on Aging in their elderly waiver program, adjusted to

include a transportation factor based on the Department on Aging’s

transportation rate. Residential Habilitation Community-Integrated Living

Arrangement (CILA) rates are calculated using individualized model rate

methodologies since 1994. The models (24 hour, host family, intermittent and

family) fund components based on individual needs and the size of the home.

Rates are based on system-wide provider cost data where possible and proxy

values where necessary or appropriate. Rates have been subject to cost of living

adjustments when enacted. Community Living Facility and some CILA rates from

legacy programs are calculated based on past individual provider cost reports.

Rates are subject to cost of living adjustments when enacted and may be adjusted

based on rate appeals. Developmental Training The statewide standard claiming

rate is based on historical statewide grant-funded DT average allowable costs.

The rate is subject to cost of living adjustments when enacted. Rates may

include add-ons based on individual medical and behavioral needs, subject to

prior approval by the Operating Agency. Supported Employment The statewide

standard claiming rates were based on the historical statewide DT rate with

incentives to encourage Supported Employment programs generally and Supported

Employment in individual job settings specifically. The rates are subject to

cost of living adjustments when enacted. Personal Support/Temporary Assistance

Services Rates for Personal Support and Temporary Assistance are negotiated

between the participant, guardian (as applicable) or representatives and the

providers with assistance from the Service Facilitator. The negotiated rates

must be specified in the Service Agreement and are subject to review and

approval by the Operating Agency on either a targeted or sample basis. These

rates are not subject to cost of living adjustments. Home and Vehicle

Modifications, Adaptive Equipment and Assistive Technology Rates are usual and

customary. Payments are subject to prior approval by the Operating Agency. Two

bids are required for approval. There are per-participant five-year cost limits

and specific cost limits on rental housing governing the use of these services.

Non-medical Transportation Statewide mileage rates are set by the Operating

Agency. Per-trip rates are usual and customary charges. The rate is subject to

cost of living adjustments when enacted by the General Assembly and signed by

the Governor. Emergency Home Response Services The statewide rates for

installation and monthly basic service are adopted from the rates established in

October 2006 by the Department on Aging for their elderly waiver program.

Training and Counseling For Unpaid Care Givers The counseling rate is identical

to the standard statewide rate currently used in the adult DD waiver for

Individual Counseling services. This rate was based on available cost data for

licensed social workers on contract with traditional developmental disabilities

agencies. The rate is subject to cost of living adjustments when enacted.

Training and workshop rates are usual and customary charges. These rates are not

subject to cost of living adjustments. Behavior Intervention and Treatment There

are two rate levels for this service based on provider qualifications. The

higher rate is based on a weighted combination of Bureau of Labor Statistics

wage for licensed clinical psychologists, provider survey results and a

comparison to bargaining agreement wages for state employees. The lower rate is

set at 80% of the higher rate. Both rates are subject to cost of living

adjustments when enacted. Behavioral Services (Psychotherapy and Counseling) and

Nursing These rates are based on available cost data for clinical psychologists

and social workers on contract with traditional developmental disabilities

agencies. The rates are subject to cost of living adjustments when enacted.

Physical Therapy, Occupational Therapy, and Speech Therapy These rates are based

on rates for these services in the Medicaid State Plan, converted to an hourly

rate. Service Facilitation The Service Facilitation rate and the ISSA rate are

identical because both services are provided by QSP/QMRP staff. The rate is a

standard statewide hourly rate. The rate has been subject to cost of living

adjustments when enacted. General All rate methodologies are established by the

Operating Agency and reviewed and approved by the Medicaid Agency. The Medicaid

Agency solicits public comments by means of a public notice when changes in

methods and standards for establishing payment rates under the Waiver are

proposed. The notice is published in accordance with Federal requirements at 42

CFR 447.205, which prescribes the content and publication criteria for the

notice. Whenever rates change, a listing of all covered services and

corresponding rates is made available to families, Service Facilitators, ISSA

and providers. Copies of rate methodologies are on file with the Medicaid Agency

and the Operating Agency.

1.. Flow of Billings.Describe the flow of billings for

waiver services, specifying whether provider billings flow directly from

providers to the State's claims payment system or whether billings are routed

through other intermediary entities. If billings flow through other intermediary

entities, specify the entities:

Character Count:out of 6000

Provider Payment Waiver funding is appropriated to the

Operating Agency primarily from the State’s General Revenue Fund. The

Operating Agency maintains a computerized payment system that includes

authorization for each participant, payments to providers, units of service

delivered to each participant, and payment and claiming rates per unit of

service. The payment system contains edits to ensure that payments are made only

to providers that are properly enrolled for the services delivered and that

payment is made at the correct payment rate. There is a three-party Medicaid

Waiver provider agreement (HFS 1413A,R-2-01) between the provider, the Operating

Agency and the Medicaid Agency. This agreement contains language that the

provider voluntarily reassigns payment to the Operating Agency (DHS). If a

provider chooses not to assign payment to the Operating Agency, the provider

will sign the standard Medicaid provider agreement (HFS-1413). Payments for some

services, such as participant-directed personal support services where the

participant exercises employer authority, flow through the Financial Management

Service (FMS) entity and are paid and transmitted to the Operating Agency (DHS)

system for claims processing. Operating Agency Claims Processing Information

from the Operating Agency computerized payment system feeds into the

computerized claiming system that contains edits to ensure that the participant

has been determined to meet the ICF/MR level of care prior to the date of

service. The Operating Agency claiming system picks up the established claiming

rate and compares it with the actual payment rate; the lower of the two is the

amount claimed. Finally, the Operating Agency claiming system subtracts from the

Waiver claim the spenddown obligation of each participant, if any (available on

a monthly extract from the Medicaid Agency MMIS system). Medicaid Agency Claims

Processing The Operating Agency Waiver claiming data are transmitted to the

Medicaid Agency via a weekly computer tape exchange. The Waiver subsection of

the MMIS matches the participant against the recipient eligibility file to

ensure Medicaid eligibility on the date of service and matches the provider

against the provider enrollment file to ensure that the provider is enrolled as

a Waiver provider with the Medicaid Agency. The Waiver subsection includes edits

for Waiver claims that conflict with other Waiver and hospital, nursing home,

hospice facility, or ICF/MR claims and rejects Waiver claims that are

duplicative or incompatible. Federal matching funds are deposited into the

State’s General Revenue Fund.

Appendix I: Financial Accountability

I-2: Rates, Billing and Claims (2 of 3)

1.. Certifying Public Expenditures(select one):

(X)No. State or local government agencies do not

certify expenditures for waiver services.

( )Yes. State or local government agencies

directly expend funds for part or all of the cost of waiver services and certify

their State government expenditures (CPE) in lieu of billing that amount to

Medicaid.

1.. Select at least one:

2.. [ ] Certified Public Expenditures (CPE) of State

Public Agencies.

3.. Specify: (a) the State government agency or

agencies that certify public expenditures for waiver services; ( how it is

assured that the CPE is based on the total computable costs for waiver services;

and, © how the State verifies that the certified public expenditures are

eligible for Federal financial participation in accordance with 42 CFR

§433.51(.(Indicate source of revenue for CPEs in Item I-4-a.)

4.. Character Count:out of 6000

5.. [ ] Certified Public Expenditures (CPE) of Local

Government Agencies.

6.. Specify: (a) the local government agencies that

incur certified public expenditures for waiver services; ( how it is assured

that the CPE is based on total computable costs for waiver services; and, ©

how the State verifies that the certified public expenditures are eligible for

Federal financial participation in accordance with 42 CFR §433.51(. (Indicate

source of revenue for CPEs in Item I-4-b.)

7.. Character Count:out of 6000

Appendix I: Financial Accountability

I-2: Rates, Billing and Claims (3 of 3)

1.. Billing Validation Process.Describe the process

for validating provider billings to produce the claim for federal financial

participation, including the mechanism(s) to assure that all claims for payment

are made only: (a) when the individual was eligible for Medicaid waiver payment

on the date of service; ( when the service was included in the participant's

approved service plan; and, © the services were provided:

Character Count:out of 6000

Provider billings are validated by the Operating Agency

(DHS) to verify the effective date of each Waiver service authorized in the

participant’s support plan and the participant’s level of care eligibility.

Providers are required to certify billings are true and accurate. Provider

claimss are further validated by applying MMIS processing edits and by

conducting Operating Agency (DHS) post-payment financial reviews. See also

Appendix I-1 for additional information on post-payment reviews. Through

post-payment reviews, the Operating Agency, of either 100% of claims or based on

a representative sample basis, confirms that services were in accordance with

the support plan.

1.. Billing and Claims Record Maintenance

Requirement.Records documenting the audit trail of adjudicated claims (including

supporting documentation) are maintained by the Medicaid agency, the operating

agency (if applicable), and providers of waiver services for a minimum period of

3 years as required in 45 CFR §92.42.

Appendix I: Financial Accountability

I-3: Payment (1 of 7)

1.. Method of payments -- MMIS(select one):

( ) Payments for all waiver services are made through an

approved Medicaid Management Information System (MMIS).

( ) Payments for some, but not all, waiver services are

made through an approved MMIS.

Specify: (a) the waiver services that are not paid

through an approved MMIS; ( the process for making such payments and the

entity that processes payments; © and how an audit trail is maintained for all

state and federal funds expended outside the MMIS; and, (d) the basis for the

draw of federal funds and claiming of these expenditures on the CMS-64:

Character Count:out of 6000

(X) Payments for waiver services are not made through an

approved MMIS.

Specify: (a) the process by which payments are made and

the entity that processes payments; ( how and through which system(s) the

payments are processed; © how an audit trail is maintained for all state and

federal funds expended outside the MMIS; and, (d) the basis for the draw of

federal funds and claiming of these expenditures on the CMS-64:

Character Count:out of 6000

Under an interagency agreement with the Medicaid Agency,

the Operating Agency makes payments from a central computer system. On a weekly

basis, Waiver claims are edited and sent to the Medicaid Agency for Medicaid

claiming. The audit trail is established through State agency approved rates,

support plan authorization, documentation of service delivery, and computerized

payment and claiming systems cross-matched with the Medicaid Agency, MMIS

system. The OA performs a post payment review, based on a representative sample

of waiver claims. The post payment review looks at whether the services were

specified in the service plan. The OA reviews 100% of claims to determine the

following: 1) whether the individual was eligible on the date of services, and

2) whether the rates paid are in accordance with the reimbursement methodology.

The OA submits a quarterly report to the MA with their findings and remediation

activities. The MA conducts a validation review based on the report to verify

that the OA followed their post payment review procedures and verifies that

appropriate remediation actions were taken.

( ) Payments for waiver services are made by a managed

care entity or entities. The managed care entity is paid a monthly capitated

payment per eligible enrollee through an approved MMIS.

Describe how payments are made to the managed care

entity or entities:

Character Count:out of 6000

( ) not selected

Appendix I: Financial Accountability

I-3: Payment (2 of 7)

1.. Direct payment.In addition to providing that the

Medicaid agency makes payments directly to providers of waiver services,

payments for waiver services are made utilizing one or more of the following

arrangements (select at least one):

[ ] The Medicaid agency makes payments directly and does

not use a fiscal agent (comprehensive or limited) or a managed care entity or

entities.

[ ] The Medicaid agency pays providers through the same

fiscal agent used for the rest of the Medicaid program.

[X] The Medicaid agency pays providers of some or all

waiver services through the use of a limited fiscal agent.

Specify the limited fiscal agent, the waiver services

for which the limited fiscal agent makes payment, the functions that the limited

fiscal agent performs in paying waiver claims, and the methods by which the

Medicaid agency oversees the operations of the limited fiscal agent:

Character Count:out of 6000

Under an interagency agreement with the Medicaid Agency,

the Operating Agency or a Financial Management Service (FMS) entity, as

described in Appendix E, makes payments directly to providers of Waiver

services. The Operating Agency then sends claims via computer tape based on the

paid services electronically to the Medicaid Agency for further adjudication and

Federal Waiver reimbursement purposes.

[ ] Providers are paid by a managed care entity or

entities for services that are included in the State's contract with the entity.

Specify how providers are paid for the services (if any)

not included in the State's contract with managed care entities.

Character Count:out of 6000

Appendix I: Financial Accountability

I-3: Payment (3 of 7)

1.. Supplemental or Enhanced Payments.Section

1902(a)(30) requires that payments for services be consistent with efficiency,

economy, and quality of care. Section 1903(a)(1) provides for Federal financial

participation to States for expenditures for services under an approved State

plan/waiver. Specify whether supplemental or enhanced payments are made. Select

one:

(X)No. The State does not make supplemental or

enhanced payments for waiver services.

( )Yes. The State makes supplemental or enhanced

payments for waiver services.

1.. Describe: (a) the nature of the supplemental or

enhanced payments that are made and the waiver services for which these payments

are made; ( the types of providers to which such payments are made; © the

source of the non-Federal share of the supplemental or enhanced payment; and,

(d) whether providers eligible to receive the supplemental or enhanced payment

retain 100% of the total computable expenditure claimed by the State to CMS.

Upon request, the State will furnish CMS with detailed information about the

total amount of supplemental or enhanced payments to each provider type in the

waiver.

2.. Character Count:out of 6000

Appendix I: Financial Accountability

I-3: Payment (4 of 7)

1.. Payments to State or Local Government

Providers.Specify whether State or local government providers receive payment

for the provision of waiver services.

(X) No. State or local government providers do not

receive payment for waiver services. Do not complete Item I-3-e.

( ) Yes. State or local government providers receive

payment for waiver services. Complete Item I-3-e.

Specify the types of State or local government providers

that receive payment for waiver services and the services that the State or

local government providers furnish: Complete item I-3-e.

Character Count:out of 4000

( ) not selected

Appendix I: Financial Accountability

I-3: Payment (5 of 7)

1.. Amount of Payment to State or Local Government

Providers.

Specify whether any State or local government provider

receives payments (including regular and any supplemental payments) that in the

aggregate exceed its reasonable costs of providing waiver services and, if so,

whether and how the State recoups the excess and returns the Federal share of

the excess to CMS on the quarterly expenditure report. Select one:

Answers provided in Appendix I-3-d indicate that you do

not need to complete this section.

( )The amount paid to State or local government

providers is the same as the amount paid to private providers of the same

service.

( )The amount paid to State or local government

providers differs from the amount paid to private providers of the same service.

No public provider receives payments that in the aggregate exceed its reasonable

costs of providing waiver services.

( )The amount paid to State or local government

providers differs from the amount paid to private providers of the same service.

When a State or local government provider receives payments (including regular

and any supplemental payments) that in the aggregate exceed the cost of waiver

services, the State recoups the excess and returns the federal share of the

excess to CMS on the quarterly expenditure report.

Describe the recoupment process:

Character Count:out of 6000

Appendix I: Financial Accountability

I-3: Payment (6 of 7)

1.. Provider Retention of Payments.Section 1903(a)(1)

provides that Federal matching funds are only available for expenditures made by

states for services under the approved waiver. Select one:

(X) Providers receive and retain 100 percent of the

amount claimed to CMS for waiver services.

( ) Providers do not receive and retain 100 percent of

the amount claimed to CMS for waiver services.

Provide a full description of the billing, claims, or

payment processes that result in less than 100% reimbursement of providers.

Include: (a) the methodology for reduced or returned payments; ( a complete

listing of types of providers, the amount or percentage of payments that are

reduced or returned; and, © the disposition and use of the funds retained or

returned to the State (i.e., general fund, medical services account, etc.):

Character Count:out of 12000

( ) Providers are paid by a managed care entity (or

entities) that is paid a monthly capitated payment.

Specify whether the monthly capitated payment to managed

care entities is reduced or returned in part to the State.

Character Count:out of 12000

( ) not selected

Appendix I: Financial Accountability

I-3: Payment (7 of 7)

1.. Additional Payment Arrangements

2.. Voluntary Reassignment of Payments to a

Governmental Agency.Select one:

( )No. The State does not provide that providers

may voluntarily reassign their right to direct payments to a governmental

agency.

(X)Yes. Providers may voluntarily reassign their

right to direct payments to a governmental agency as provided in 42 CFR

§447.10(e).

1.. Specify the governmental agency (or agencies) to

which reassignment may be made.

1.. Character Count:out of 4000

2.. The Operating Agency (DHS)

2.. Organized Health Care Delivery System.Select one:

(X)No. The State does not employ Organized Health

Care Delivery System (OHCDS) arrangements under the provisions of 42 CFR

§447.10.

( )Yes. The waiver provides for the use of

Organized Health Care Delivery System arrangements under the provisions of 42

CFR §447.10.

1.. Specify the following: (a) the entities that are

designated as an OHCDS and how these entities qualify for designation as an

OHCDS; ( the procedures for direct provider enrollment when a provider does

not voluntarily agree to contract with a designated OHCDS; © the method(s) for

assuring that participants have free choice of qualified providers when an OHCDS

arrangement is employed, including the selection of providers not affiliated

with the OHCDS; (d) the method(s) for assuring that providers that furnish

services under contract with an OHCDS meet applicable provider qualifications

under the waiver; (e) how it is assured that OHCDS contracts with providers meet

applicable requirements; and, (f) how financial accountability is assured when

an OHCDS arrangement is used:

1.. Character Count:out of 18000

2.. Contracts with MCOs, PIHPs or PAHPs.Select one:

(X) The State does not contract with MCOs, PIHPs or

PAHPs for the provision of waiver services.

( ) The State contracts with a Managed Care

Organization(s) (MCOs) and/or prepaid inpatient health plan(s) (PIHP) or prepaid

ambulatory health plan(s) (PAHP) under the provisions of §1915(a)(1) of the Act

for the delivery of waiver and other services. Participants may voluntarily

elect to receive waiver and other services through such MCOs or prepaid health

plans. Contracts with these health plans are on file at the State Medicaid

agency.

Describe: (a) the MCOs and/or health plans that furnish

services under the provisions of §1915(a)(1); ( the geographic areas served

by these plans; © the waiver and other services furnished by these plans; and,

(d) how payments are made to the health plans.

Character Count:out of 18000

( ) This waiver is a part of a concurrent

§1915(b)/§1915© waiver. Participants are required to obtain waiver and other

services through a MCO and/or prepaid inpatient health plan (PIHP) or a prepaid

ambulatory health plan (PAHP). The §1915( waiver specifies the types of

health plans that are used and how payments to these plans are made.

( ) not selected

Appendix I: Financial Accountability

I-4: Non-Federal Matching Funds (1 of 3)

1.. State Level Source(s) of the Non-Federal Share of

Computable Waiver Costs.Specify the State source or sources of the non-federal

share of computable waiver costs. Select at least one:

[ ] Appropriation of State Tax Revenues to the State

Medicaid agency

[X] Appropriation of State Tax Revenues to a State

Agency other than the Medicaid Agency.

If the source of the non-federal share is appropriations

to another state agency (or agencies), specify: (a) the State entity or agency

receiving appropriated funds and ( the mechanism that is used to transfer the

funds to the Medicaid Agency or Fiscal Agent, such as an Intergovernmental

Transfer (IGT), including any matching arrangement, and/or, indicate if the

funds are directly expended by State agencies as CPEs, as indicated in Item

I-2-c:

Character Count:out of 6000

Funds are directly appropriated by the Illinois General

Assembly from the General Revenue Funds to the OA (DHS). The funds are not

transferred.

[ ] Other State Level Source(s) of Funds.

Specify: (a) the source and nature of funds; ( the

entity or agency that receives the funds; and, © the mechanism that is used to

transfer the funds to the Medicaid Agency or Fiscal Agent, such as an

Intergovernmental Transfer (IGT), including any matching arrangement, and/or,

indicate if funds are directly expended by State agencies as CPEs, as indicated

in Item I-2- c:

Character Count:out of 6000

Appendix I: Financial Accountability

I-4: Non-Federal Matching Funds (2 of 3)

1.. Local Government or Other Source(s) of the

Non-Federal Share of Computable Waiver Costs.Specify the source or sources of

the non-federal share of computable waiver costs that are not from state

sources. Select One:

(X) Not Applicable. There are no local government level

sources of funds utilized as the non-federal share.

( ) Applicable

Check each that applies:

[ ] Not Applicable. There are no non-State level sources

of funds for the non-federal share.

[ ] Appropriation of Local Government Revenues.

Specify: (a) the local government entity or entities

that have the authority to levy taxes or other revenues; ( the source(s) of

revenue; and, © the mechanism that is used to transfer the funds to the

Medicaid Agency or Fiscal Agent, such as an Intergovernmental Transfer (IGT),

including any matching arrangement (indicate any intervening entities in the

transfer process), and/or, indicate if funds are directly expended by local

government agencies as CPEs, as specified in Item I-2-c:

Character Count:out of 6000

[ ] Other Local Government Level Source(s) of Funds.

Specify: (a) the source of funds; ( the local

government entity or agency receiving funds; and, © the mechanism that is used

to transfer the funds to the State Medicaid Agency or Fiscal Agent, such as an

Intergovernmental Transfer (IGT), including any matching arrangement, and /or,

indicate if funds are directly expended by local government agencies as CPEs, as

specified in Item I-2- c:

Character Count:out of 6000

( ) not selected

Appendix I: Financial Accountability

I-4: Non-Federal Matching Funds (3 of 3)

1.. Information Concerning Certain Sources of

Funds.Indicate whether any of the funds listed in Items I-4-a or I-4-b that make

up the non-federal share of computable waiver costs come from the following

sources: (a) health care-related taxes or fees; ( provider-related donations;

and/or, © federal funds. Select one:

(X) None of the specified sources of funds contribute to

the non-federal share of computable waiver costs

( ) The following source(s) are used

Check each that applies:

[ ] None of the foregoing sources of funds contribute to

the non-federal share of computable waiver costs.

[ ] Health care-related taxes or fees

[ ] Provider-related donations

[ ] Federal funds

For each source of funds indicated above, describe the

source of the funds in detail:

Character Count:out of 6000

( ) not selected

Appendix I: Financial Accountability

I-5: Exclusion of Medicaid Payment for Room and Board

1.. Services Furnished in Residential Settings.Select

one:

( ) No services under this waiver are furnished in

residential settings other than the private residence of the individual.

(X) As specified in Appendix C, the State furnishes

waiver services in residential settings other than the personal home of the

individual.

( ) not selected

1.. Method for Excluding the Cost of Room and Board

Furnished in Residential Settings.The following describes the methodology that

the State uses to exclude Medicaid payment for room and board in residential

settings:

Character Count:out of 12000

The Operating Agency sets rates for a participant in a

residential habilitation setting based on a rate methodology that is comprised

of the following components: • Room and Board Component - reimburses community

providers for keeping a home in normal operation. • Program Component -

reimburses community providers for providing habilitation services and supports,

including training, protective oversight, supervision and other assistance to

participants with a developmental disability living in a residential setting.

• Transportation Component - reimburses community providers for providing

general transportation to and from community locations that are not day program

sites or places where Medicaid State Plan services are delivered. •

Administration Component - reimburses community providers for general staff

supervision and overhead related to the delivery of residential supports. •

Individual Supports Component - reimburses community providers for supports that

are specific to a participant’s needs that are not covered elsewhere. The

Operating Agency determines waiver claims for residential services based on the

Program, Transportation, Administration and Individual Supports components of

the rates. The Room and Board Component is excluded when calculating Waiver

claims.

Appendix I: Financial Accountability

I-6: Payment for Rent and Food Expenses of an Unrelated

Live-In Caregiver

Reimbursement for the Rent and Food Expenses of an

Unrelated Live-In Personal Caregiver.Select one:

(X)No. The State does not reimburse for the rent

and food expenses of an unrelated live-in personal caregiver who resides in the

same household as the participant.

( )Yes. Per 42 CFR §441.310(a)(2)(ii), the State

will claim FFP for the additional costs of rent and food that can be reasonably

attributed to an unrelated live-in personal caregiver who resides in the same

household as the waiver participant. The State describes its coverage of live-in

caregiver in Appendix C-3 and the costs attributable to rent and food for the

live-in caregiver are reflected separately in the computation of factor D (cost

of waiver services) in Appendix J. FFP for rent and food for a live-in caregiver

will not be claimed when the participant lives in the caregiver's home or in a

residence that is owned or leased by the provider of Medicaid services.

The following is an explanation of: (a) the method used

to apportion the additional costs of rent and food attributable to the unrelated

live-in personal caregiver that are incurred by the individual served on the

waiver and ( the method used to reimburse these costs:

Character Count:out of 6000

Appendix I: Financial Accountability

I-7: Participant Co-Payments for Waiver Services and

Other Cost Sharing (1 of 5)

1.. Co-Payment Requirements.Specify whether the State

imposes a co-payment or similar charge upon waiver participants for waiver

services. These charges are calculated per service and have the effect of

reducing the total computable claim for federal financial participation. Select

one:

(X) No. The State does not impose a co-payment or

similar charge upon participants for waiver services.

( ) Yes. The State imposes a co-payment or similar

charge upon participants for one or more waiver services.

1.. Co-Pay Arrangement.

Specify the types of co-pay arrangements that are

imposed on waiver participants (check each that applies):

Charges Associated with the Provision of Waiver

Services(if any are checked, complete Items I-7-a-ii through I-7-a-iv):

[ ] Nominal deductible

[ ] Coinsurance

[ ] Co-Payment

[ ] Other charge

Specify:

Character Count:out of 6000

( ) not selected

Appendix I: Financial Accountability

I-7: Participant Co-Payments for Waiver Services and

Other Cost Sharing (2 of 5)

1.. Co-Payment Requirements.

2.. Participants Subject to Co-pay Charges for Waiver

Services.

Answers provided in Appendix I-7-a indicate that you do

not need to complete this section.

Appendix I: Financial Accountability

I-7: Participant Co-Payments for Waiver Services and

Other Cost Sharing (3 of 5)

1.. Co-Payment Requirements.

2.. Amount of Co-Pay Charges for Waiver Services.

Answers provided in Appendix I-7-a indicate that you do

not need to complete this section.

Appendix I: Financial Accountability

I-7: Participant Co-Payments for Waiver Services and

Other Cost Sharing (4 of 5)

1.. Co-Payment Requirements.

2.. Cumulative Maximum Charges.

Answers provided in Appendix I-7-a indicate that you do

not need to complete this section.

Appendix I: Financial Accountability

I-7: Participant Co-Payments for Waiver Services and

Other Cost Sharing (5 of 5)

1.. Other State Requirement for Cost Sharing.Specify

whether the State imposes a premium, enrollment fee or similar cost sharing on

waiver participants. Select one:

(X)No. The State does not impose a premium,

enrollment fee, or similar cost-sharing arrangement on waiver participants.

( )Yes. The State imposes a premium, enrollment

fee or similar cost-sharing arrangement.

1.. Describe in detail the cost sharing arrangement,

including: (a) the type of cost sharing (e.g., premium, enrollment fee); ( the

amount of charge and how the amount of the charge is related to total gross

family income; © the groups of participants subject to cost-sharing and the

groups who are excluded; and, (d) the mechanisms for the collection of

cost-sharing and reporting the amount collected on the CMS 64:

2.. Character Count:out of 12000

Appendix J: Cost Neutrality Demonstration

J-1: Composite Overview and Demonstration of

Cost-Neutrality Formula

Composite Overview.Complete the fields in Cols. 3, 5 and

6 in the following table for each waiver year. The fields in Cols. 4, 7 and 8

are auto-calculated based on entries in Cols 3, 5, and 6. The fields in Col. 2

are auto-calculated using the Factor D data from the J-2d Estimate of Factor D

tables. Col. 2 fields will be populated ONLY when the Estimate of Factor D

tables in J-2d have been completed.

Level(s) of Care: ICF/MR

Col. 1 Col. 2 Col. 3 Col. 4 Col. 5 Col. 6 Col. 7

Col. 8

Year Factor D Factor D' Total: D+D' Factor G

Factor G' Total: G+G' Difference (Col 7 less Column4)

1 29714.00 3125.15 32839.15 84178.76 3449.03

87627.79 54788.64

2 25516.00 3113.79 28629.79 84372.41 3424.95

87797.36 59167.57

3 25516.00 3102.48 28618.48 84566.52 3401.04

87967.56 59349.08

4 25516.00 3091.20 28607.20 84761.07 3377.29

88138.36 59531.16

5 25516.00 3079.97 28595.97 84956.07 3353.72

88309.79 59713.82

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (1 of 9)

1.. Number Of Unduplicated Participants Served.Enter

the total number of unduplicated participants from Item B-3-a who will be served

each year that the waiver is in operation. When the waiver serves individuals

under more than one level of care, specify the number of unduplicated

participants for each level of care:

Table: J-2-a: Unduplicated Participants

Waiver Year Total Number Unduplicated Number of

Participants (from Item B-3-a) Distribution of Unduplicated Participants by

Level of Care (if applicable)

Level of Care:

ICF/MR

Year 1 17600 17600

Year 2 17600 17600

Year 3 17600 17600

Year 4 17600 17600

Year 5 17600 17600

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (2 of 9)

1.. Average Length of Stay.Describe the basis of the

estimate of the average length of stay on the waiver by participants in item

J-2-a.

Character Count:out of 6000

The average length of stay is estimated based on the

actual length of stay for current waiver participants for State Fiscal Years

2002 – 2006 (Waiver Years 5, and 1 through 4).

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (3 of 9)

1.. Derivation of Estimates for Each Factor.Provide a

narrative description for the derivation of the estimates of the following

factors.

1.. Factor D Derivation. The estimates of Factor D

for each waiver year are located in Item J-2-d. The basis for these estimates is

as follows:

Character Count:out of 12000

Total Waiver capacity and the estimated utilization of

each waiver service is estimated based on FY2006 and FY2007 year-to-date actual

Waiver enrollment and service utilization patterns and costs for each current

Waiver service. Operating Agency staff analyzed data from both the 372 initial

report for FY2006 and a database that contains information on paid Waiver

services. The database includes the number so users of each paid service and

number of units of each service received. For new services, estimated

utilization is based on anticipated utilization, rates and costs. Cost estimates

are based on current FY06 claiming rates (Waiver Year 4). There are no budgeted

rate increases in FY07 (Waiver Year 5). Estimates for future years do not

include potential rate increases at this time.

1.. Factor D' Derivation. The estimates of Factor D'

for each waiver year are included in Item J-1. The basis of these estimates is

as follows:

Character Count:out of 12000

Ancillary service data was pulled for those people with

a DD waiver provider for WY'08 - WY'12. Factor D Prime cost per capita is

estimated to decrease by -0.36% for WY'13 - WY'17. This percentage is based upon

the average historical percent change for WY'08 - WY'12 actual ancillary

expenditures for Developmentally Disabled Waiver recipients and carried forward

to WY'13 - WY'17.

1.. Factor G Derivation. The estimates of Factor G for

each waiver year are included in Item J-1. The basis of these estimates is as

follows:

Character Count:out of 12000

Factor G is based on historical ICF/MR data for ICF/MR

recipients of all ages for State Fiscal Years 2008 – 2012. Factor G estimated

for WY2013 – FY2017 is based on the historical percent changes trended forward

for all years. The average historical cost per capita decrease was 0.27%.

1.. Factor G' Derivation. The estimates of Factor G'

for each waiver year are included in Item J-1. The basis of these estimates is

as follows:

Character Count:out of 12000

Factor G’ is based on historical Medicaid ancillary

services for those individuals in an ICFMR setting for FY2008 – FY2012. Factor

G’ estimated for FY2008 to FY2012 is based upon historical percent changes

trended forward for all years. The average historical cost per capita increase

was 0.23%.

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (4 of 9)

Component management for waiver services. If the

service(s) below includes two or more discrete services that are reimbursed

separately, or is a bundled service, each component of the service must be

listed. Select “manage components†to add these components.

Waiver Services

Adult Day Care

Developmental Training

Residential Habilitation

Supported Employment

Occupational Therapy (Extended Medicaid State

Plan)

Physical Therapy (Extended Medicaid State Plan)

Speech Therapy (Extended Medicaid State Plan)

Service Facilitation

Adaptive Equipment

Assistive Technology

Behavior Intervention and Treatment

Behavioral Services (Psychotherapy and Counseling)

Emergency Home Response Services (EHRS)

Home Accessibility Modifications

Non-Medical Transportation

Personal Support

Skilled Nursing

Temporary Assistance (formerly called Crisis

Services)

Training and Counseling Services for Unpaid

Caregivers

Vehicle Modification

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (5 of 9)

1.. Estimate of Factor D.

i. Non-Concurrent Waiver. Complete the following table

for each waiver year. Enter data into the Unit, # Users, Avg. Units Per User,

and Avg. Cost/Unit fields for all the Waiver Service/Component items. Select

Save and Calculate to automatically calculate and populate the Component Costs

and Total Costs fields. All fields in this table must be completed in order to

populate the Factor D fields in the J-1 Composite Overview table.

Waiver Year: Year 1

Waiver Service/ Component Unit # Users Avg. Units

Per User Avg. Cost/ Unit Component Cost Total Cost

GRAND TOTAL: 522973400.00

Total Estimated Unduplicated Participants: 17600

Factor D (Divide total by number of

participants): 29714.00

Average Length of Stay on the Waiver: 335

Adult Day Care Total: 180000.00

Adult Day Care Hour 25 800.00 9.00 180000.00

Developmental Training Total:

133380000.00

Developmental Training Hour 13500 950.00 10.40

133380000.00

Residential Habilitation Total:

328032000.00

Residential Habilitation Day 9600 335.00 102.00

328032000.00

Supported Employment Total: 5497500.00

Supported Employment-Individual Hour 600 525.00

13.00 4095000.00

Supported Employment-Group Hour 300 425.00 11.00

1402500.00

Occupational Therapy (Extended Medicaid State

Plan) Total: 148000.00

Occupational Therapy (Extended Medicaid State

Plan) Hour 250 16.00 37.00 148000.00

Physical Therapy (Extended Medicaid State Plan)

Total: 83250.00

Physical Therapy (Extended Medicaid State Plan)

Hour 150 15.00 37.00 83250.00

Speech Therapy (Extended Medicaid State Plan)

Total: 29600.00

Speech Therapy (Extended Medicaid State Plan) Hour

200 4.00 37.00 29600.00

Service Facilitation Total: 4560000.00

Service Facilitation Hour 3800 30.00 40.00

4560000.00

Adaptive Equipment Total: 12500.00

Adaptive Equipment Per Item 25 1.00 500.00

12500.00

Assistive Technology Total: 2500.00

Assistive Technology Per Item 25 1.00 100.00

2500.00

Behavior Intervention and Treatment Total:

4550000.00

Behavior Intervention and Treatment Hour 3500

20.00 65.00 4550000.00

Behavioral Services (Psychotherapy and Counseling)

Total: 968600.00

Behavioral Services-Psychotherapy-Individual Hour

1000 17.00 37.00 629000.00

Behavioral Services-Psychotherapy-Group Hour 400

17.00 12.00 81600.00

Behavioral Services-Counseling-Individual Hour 600

12.00 30.00 216000.00

Behavioral Services-Counseling-Group Hour 350

12.00 10.00 42000.00

Emergency Home Response Services (EHRS) Total:

3000.00

Emergency Home Response Services (EHRS) Per Month

(1 X install) 10 10.00 30.00 3000.00

Home Accessibility Modifications Total:

780000.00

Home Accessibility Modifications Per Item 100 1.00

7800.00 780000.00

Non-Medical Transportation Total:

288000.00

Non-Medical Transportation Per Item 200 120.00

12.00 288000.00

Personal Support Total: 44100000.00

Personal Support Hour 3500 900.00 14.00

44100000.00

Skilled Nursing Total: 20150.00

Skilled Nursing Hour 10 65.00 31.00 20150.00

Temporary Assistance (formerly called Crisis

Services) Total: 100800.00

Temporary Assistance (formerly called Crisis

Services) Hour 20 360.00 14.00 100800.00

Training and Counseling Services for Unpaid

Caregivers Total: 12500.00

Counseling Services for Unpaid Caregivers Hour 25

10.00 30.00 7500.00

Training Services for Unpaid Caregivers Per Event

25 1.00 200.00 5000.00

Vehicle Modification Total: 225000.00

Vehicle Modification Per Item 25 1.00 9000.00

225000.00

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (6 of 9)

1.. Estimate of Factor D.

i. Non-Concurrent Waiver. Complete the following table

for each waiver year. Enter data into the Unit, # Users, Avg. Units Per User,

and Avg. Cost/Unit fields for all the Waiver Service/Component items. Select

Save and Calculate to automatically calculate and populate the Component Costs

and Total Costs fields. All fields in this table must be completed in order to

populate the Factor D fields in the J-1 Composite Overview table.

Waiver Year: Year 2

Waiver Service/ Component Unit # Users Avg. Units

Per User Avg. Cost/ Unit Component Cost Total Cost

GRAND TOTAL: 449089975.00

Total Estimated Unduplicated Participants: 17600

Factor D (Divide total by number of

participants): 25516.00

Average Length of Stay on the Waiver: 335

Adult Day Care Total: 180000.00

Adult Day Care Hour 25 800.00 9.00 180000.00

Developmental Training Total:

108300000.00

Developmental Training Hour 11400 950.00 10.00

108300000.00

Residential Habilitation Total:

297279000.00

Residential Habilitation Day 8700 335.00 102.00

297279000.00

Supported Employment Total: 4455000.00

Supported Employment-Individual Hour 550 525.00

13.00 3753750.00

Supported Employment-Group Hour 150 425.00 11.00

701250.00

Occupational Therapy (Extended Medicaid State

Plan) Total: 185000.00

Occupational Therapy (Extended Medicaid State

Plan) Hour 200 25.00 37.00 185000.00

Physical Therapy (Extended Medicaid State Plan)

Total: 92500.00

Physical Therapy (Extended Medicaid State Plan)

Hour 100 25.00 37.00 92500.00

Speech Therapy (Extended Medicaid State Plan)

Total: 92500.00

Speech Therapy (Extended Medicaid State Plan) Hour

100 25.00 37.00 92500.00

Service Facilitation Total: 3651375.00

Service Facilitation Hour 2675 35.00 39.00

3651375.00

Adaptive Equipment Total: 80000.00

Adaptive Equipment Per Item 25 1.00 3200.00

80000.00

Assistive Technology Total: 75000.00

Assistive Technology Per Item 25 1.00 3000.00

75000.00

Behavior Intervention and Treatment Total:

7117500.00

Behavior Intervention and Treatment Hour 1825

60.00 65.00 7117500.00

Behavioral Services (Psychotherapy and Counseling)

Total: 1110000.00

Behavioral Services-Psychotherapy-Individual Hour

700 25.00 37.00 647500.00

Behavioral Services-Psychotherapy-Group Hour 500

25.00 12.00 150000.00

Behavioral Services-Counseling-Individual Hour 350

25.00 30.00 262500.00

Behavioral Services-Counseling-Group Hour 200

25.00 10.00 50000.00

Emergency Home Response Services (EHRS) Total:

7500.00

Emergency Home Response Services (EHRS) Per Month

(1 X install) 25 10.00 30.00 7500.00

Home Accessibility Modifications Total:

585000.00

Home Accessibility Modifications Per Item 75 1.00

7800.00 585000.00

Non-Medical Transportation Total:

789600.00

Non-Medical Transportation Per Item 470 140.00

12.00 789600.00

Personal Support Total: 24453000.00

Personal Support Hour 2470 900.00 11.00

24453000.00

Skilled Nursing Total: 62000.00

Skilled Nursing Hour 25 80.00 31.00 62000.00

Temporary Assistance (formerly called Crisis

Services) Total: 198000.00

Temporary Assistance (formerly called Crisis

Services) Hour 50 360.00 11.00 198000.00

Training and Counseling Services for Unpaid

Caregivers Total: 37000.00

Counseling Services for Unpaid Caregivers Per

Event 25 36.00 30.00 27000.00

Training Services for Unpaid Caregivers Per Event

50 1.00 200.00 10000.00

Vehicle Modification Total: 340000.00

Vehicle Modification Per Item 25 1.00 13600.00

340000.00

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (7 of 9)

1.. Estimate of Factor D.

i. Non-Concurrent Waiver. Complete the following table

for each waiver year. Enter data into the Unit, # Users, Avg. Units Per User,

and Avg. Cost/Unit fields for all the Waiver Service/Component items. Select

Save and Calculate to automatically calculate and populate the Component Costs

and Total Costs fields. All fields in this table must be completed in order to

populate the Factor D fields in the J-1 Composite Overview table.

Waiver Year: Year 3

Waiver Service/ Component Unit # Users Avg. Units

Per User Avg. Cost/ Unit Component Cost Total Cost

GRAND TOTAL: 449089975.00

Total Estimated Unduplicated Participants: 17600

Factor D (Divide total by number of

participants): 25516.00

Average Length of Stay on the Waiver: 335

Adult Day Care Total: 180000.00

Adult Day Care Hour 25 800.00 9.00 180000.00

Developmental Training Total:

108300000.00

Developmental Training Hour 11400 950.00 10.00

108300000.00

Residential Habilitation Total:

297279000.00

Residential Habilitation Day 8700 335.00 102.00

297279000.00

Supported Employment Total: 4455000.00

Supported Employment-Individual Hour 550 525.00

13.00 3753750.00

Supported Employment-Group Hour 150 425.00 11.00

701250.00

Occupational Therapy (Extended Medicaid State

Plan) Total: 185000.00

Occupational Therapy (Extended Medicaid State

Plan) Hour 200 25.00 37.00 185000.00

Physical Therapy (Extended Medicaid State Plan)

Total: 92500.00

Physical Therapy (Extended Medicaid State Plan)

Hour 100 25.00 37.00 92500.00

Speech Therapy (Extended Medicaid State Plan)

Total: 92500.00

Speech Therapy (Extended Medicaid State Plan) Hour

100 25.00 37.00 92500.00

Service Facilitation Total: 3651375.00

Service Facilitation Hour 2675 35.00 39.00

3651375.00

Adaptive Equipment Total: 80000.00

Adaptive Equipment Per Item 25 1.00 3200.00

80000.00

Assistive Technology Total: 75000.00

Assistive Technology Per Item 25 1.00 3000.00

75000.00

Behavior Intervention and Treatment Total:

7117500.00

Behavior Intervention and Treatment Hour 1825

60.00 65.00 7117500.00

Behavioral Services (Psychotherapy and Counseling)

Total: 1110000.00

Behavioral Services-Psychotherapy-Individual Hour

700 25.00 37.00 647500.00

Behavioral Services-Psychotherapy-Group Hour 500

25.00 12.00 150000.00

Behavioral Services-Counseling-Individual Hour 350

25.00 30.00 262500.00

Behavioral Services-Counseling-Group Hour 200

25.00 10.00 50000.00

Emergency Home Response Services (EHRS) Total:

7500.00

Emergency Home Response Services (EHRS) Per Month

(1 X install) 25 10.00 30.00 7500.00

Home Accessibility Modifications Total:

585000.00

Home Accessibility Modifications Per Item 75 1.00

7800.00 585000.00

Non-Medical Transportation Total:

789600.00

Non-Medical Transportation Per Item 470 140.00

12.00 789600.00

Personal Support Total: 24453000.00

Personal Support Hour 2470 900.00 11.00

24453000.00

Skilled Nursing Total: 62000.00

Skilled Nursing Hour 25 80.00 31.00 62000.00

Temporary Assistance (formerly called Crisis

Services) Total: 198000.00

Temporary Assistance (formerly called Crisis

Services) Hour 50 360.00 11.00 198000.00

Training and Counseling Services for Unpaid

Caregivers Total: 37000.00

Counseling Services for Unpaid Caregivers Per

Event 25 36.00 30.00 27000.00

Training Services for Unpaid Caregivers Per Event

50 1.00 200.00 10000.00

Vehicle Modification Total: 340000.00

Vehicle Modification Per Item 25 1.00 13600.00

340000.00

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (8 of 9)

1.. Estimate of Factor D.

i. Non-Concurrent Waiver. Complete the following table

for each waiver year. Enter data into the Unit, # Users, Avg. Units Per User,

and Avg. Cost/Unit fields for all the Waiver Service/Component items. Select

Save and Calculate to automatically calculate and populate the Component Costs

and Total Costs fields. All fields in this table must be completed in order to

populate the Factor D fields in the J-1 Composite Overview table.

Waiver Year: Year 4

Waiver Service/ Component Unit # Users Avg. Units

Per User Avg. Cost/ Unit Component Cost Total Cost

GRAND TOTAL: 449089975.00

Total Estimated Unduplicated Participants: 17600

Factor D (Divide total by number of

participants): 25516.00

Average Length of Stay on the Waiver: 335

Adult Day Care Total: 180000.00

Adult Day Care Hour 25 800.00 9.00 180000.00

Developmental Training Total:

108300000.00

Developmental Training Hour 11400 950.00 10.00

108300000.00

Residential Habilitation Total:

297279000.00

Residential Habilitation Day 8700 335.00 102.00

297279000.00

Supported Employment Total: 4455000.00

Supported Employment-Individual Hour 550 525.00

13.00 3753750.00

Supported Employment-Group Hour 150 425.00 11.00

701250.00

Occupational Therapy (Extended Medicaid State

Plan) Total: 185000.00

Occupational Therapy (Extended Medicaid State

Plan) Hour 200 25.00 37.00 185000.00

Physical Therapy (Extended Medicaid State Plan)

Total: 92500.00

Physical Therapy (Extended Medicaid State Plan)

Hour 100 25.00 37.00 92500.00

Speech Therapy (Extended Medicaid State Plan)

Total: 92500.00

Speech Therapy (Extended Medicaid State Plan) Hour

100 25.00 37.00 92500.00

Service Facilitation Total: 3651375.00

Service Facilitation Hour 2675 35.00 39.00

3651375.00

Adaptive Equipment Total: 80000.00

Adaptive Equipment Per Item 25 1.00 3200.00

80000.00

Assistive Technology Total: 75000.00

Assistive Technology Per Item 25 1.00 3000.00

75000.00

Behavior Intervention and Treatment Total:

7117500.00

Behavior Intervention and Treatment Hour 1825

60.00 65.00 7117500.00

Behavioral Services (Psychotherapy and Counseling)

Total: 1110000.00

Behavioral Services-Psychotherapy-Individual Hour

700 25.00 37.00 647500.00

Behavioral Services-Psychotherapy-Group Hour 500

25.00 12.00 150000.00

Behavioral Services-Counseling-Individual Hour 350

25.00 30.00 262500.00

Behavioral Services-Counseling-Group Hour 200

25.00 10.00 50000.00

Emergency Home Response Services (EHRS) Total:

7500.00

Emergency Home Response Services (EHRS) Per Month

(1 X install) 25 10.00 30.00 7500.00

Home Accessibility Modifications Total:

585000.00

Home Accessibility Modifications Per Item 75 1.00

7800.00 585000.00

Non-Medical Transportation Total:

789600.00

Non-Medical Transportation Per Item 470 140.00

12.00 789600.00

Personal Support Total: 24453000.00

Personal Support Hour 2470 900.00 11.00

24453000.00

Skilled Nursing Total: 62000.00

Skilled Nursing Hour 25 80.00 31.00 62000.00

Temporary Assistance (formerly called Crisis

Services) Total: 198000.00

Temporary Assistance (formerly called Crisis

Services) Hour 50 360.00 11.00 198000.00

Training and Counseling Services for Unpaid

Caregivers Total: 37000.00

Counseling Services for Unpaid Caregivers Per

Event 25 36.00 30.00 27000.00

Training Services for Unpaid Caregivers Per Event

50 1.00 200.00 10000.00

Vehicle Modification Total: 340000.00

Vehicle Modification Per Item 25 1.00 13600.00

340000.00

Appendix J: Cost Neutrality Demonstration

J-2: Derivation of Estimates (9 of 9)

1.. Estimate of Factor D.

i. Non-Concurrent Waiver. Complete the following table

for each waiver year. Enter data into the Unit, # Users, Avg. Units Per User,

and Avg. Cost/Unit fields for all the Waiver Service/Component items. Select

Save and Calculate to automatically calculate and populate the Component Costs

and Total Costs fields. All fields in this table must be completed in order to

populate the Factor D fields in the J-1 Composite Overview table.

Waiver Year: Year 5

Waiver Service/ Component Unit # Users Avg. Units

Per User Avg. Cost/ Unit Component Cost Total Cost

GRAND TOTAL: 449089975.00

Total Estimated Unduplicated Participants: 17600

Factor D (Divide total by number of

participants): 25516.00

Average Length of Stay on the Waiver: 335

Adult Day Care Total: 180000.00

Adult Day Care Hour 25 800.00 9.00 180000.00

Developmental Training Total:

108300000.00

Developmental Training Hour 11400 950.00 10.00

108300000.00

Residential Habilitation Total:

297279000.00

Residential Habilitation Day 8700 335.00 102.00

297279000.00

Supported Employment Total: 4455000.00

Supported Employment-Individual Hour 550 525.00

13.00 3753750.00

Supported Employment-Group Hour 150 425.00 11.00

701250.00

Occupational Therapy (Extended Medicaid State

Plan) Total: 185000.00

Occupational Therapy (Extended Medicaid State

Plan) Hour 200 25.00 37.00 185000.00

Physical Therapy (Extended Medicaid State Plan)

Total: 92500.00

Physical Therapy (Extended Medicaid State Plan)

Hour 100 25.00 37.00 92500.00

Speech Therapy (Extended Medicaid State Plan)

Total: 92500.00

Speech Therapy (Extended Medicaid State Plan) Hour

100 25.00 37.00 92500.00

Service Facilitation Total: 3651375.00

Service Facilitation Hour 2675 35.00 39.00

3651375.00

Adaptive Equipment Total: 80000.00

Adaptive Equipment Per Item 25 1.00 3200.00

80000.00

Assistive Technology Total: 75000.00

Assistive Technology Per Item 25 1.00 3000.00

75000.00

Behavior Intervention and Treatment Total:

7117500.00

Behavior Intervention and Treatment Hour 1825

60.00 65.00 7117500.00

Behavioral Services (Psychotherapy and Counseling)

Total: 1110000.00

Behavioral Services-Psychotherapy-Individual Hour

700 25.00 37.00 647500.00

Behavioral Services-Psychotherapy-Group Hour 500

25.00 12.00 150000.00

Behavioral Services-Counseling-Individual Hour 350

25.00 30.00 262500.00

Behavioral Services-Counseling-Group Hour 200

25.00 10.00 50000.00

Emergency Home Response Services (EHRS) Total:

7500.00

Emergency Home Response Services (EHRS) Per Month

(1 X install) 25 10.00 30.00 7500.00

Home Accessibility Modifications Total:

585000.00

Home Accessibility Modifications Per Item 75 1.00

7800.00 585000.00

Non-Medical Transportation Total:

789600.00

Non-Medical Transportation Per Item 470 140.00

12.00 789600.00

Personal Support Total: 24453000.00

Personal Support Hour 2470 900.00 11.00

24453000.00

Skilled Nursing Total: 62000.00

Skilled Nursing Hour 25 80.00 31.00 62000.00

Temporary Assistance (formerly called Crisis

Services) Total: 198000.00

Temporary Assistance (formerly called Crisis

Services) Hour 50 360.00 11.00 198000.00

Training and Counseling Services for Unpaid

Caregivers Total: 37000.00

Counseling Services for Unpaid Caregivers Per

Event 25 36.00 30.00 27000.00

Training Services for Unpaid Caregivers Per Event

50 1.00 200.00 10000.00

Vehicle Modification Total: 340000.00

Vehicle Modification Per Item 25 1.00 13600.00

340000.00

.

Tony auski

Executive Director

The Arc of Illinois

20901 S. LaGrange Rd. Suite 209

fort, IL 60423

815-464-1832 (OFFICE)

708-828-0188 (CELL)

Tony@...

follow on Twitter | friend on Facebook | forward to a

friend

Copyright © 2011 The Arc of Illinois, All rights

reserved.

You are receiving this email because you are a member of

The Arc of Illinois.

Our mailing address is:

The Arc of Illinois

20901 S.LaGrange Rd.

Suite 209

fort, IL 60423

Add us to your address book

unsubscribe from this list | update subscription

preferences | view email in browser