AUTHORITY: Implementing Section 4.02 and authorized by Section 4.01(11) and 4.02 of the Illinois Act on the Aging [20 ILCS 105].

SOURCE: Emergency rules adopted at 4 Ill. Reg. 1, p. 67, effective December 20, 1979, for a maximum of 150 days; adopted at 4 Ill. Reg. 17, p. 151, effective April 25, 1980; amended at 4 Ill. Reg. 43, p. 86, effective October 15, 1980; emergency amendment at 5 Ill. Reg. 1900, effective February 18, 1981, for a maximum of 150 days; amended at 5 Ill. Reg. 12090, effective October 26, 1981; emergency amendment at 6 Ill. Reg. 8455, effective July 6, 1982, for a maximum of 150 days; amended at 6 Ill. Reg. 14953, effective December 1, 1982; amended at 7 Ill. Reg. 8697, effective July 20, 1983; codified at 8 Ill. Reg. 2633; amended at 9 Ill. Reg. 1739, effective January 29, 1985; amended at 9 Ill. Reg. 10208, effective July 1, 1985; emergency amendment at 9 Ill. Reg. 14011, effective August 29, 1985, for a maximum of 150 days; amended at 10 Ill. Reg. 5076, effective March 15, 1986; recodified at 12 Ill. Reg. 7980; amended at 13 Ill. Reg. 11193, effective July 1, 1989; emergency amendment at 13 Ill. Reg. 13638, effective August 18, 1989, for a maximum of 150 days; amended at 13 Ill. Reg. 17327, effective November 1, 1989; amended at 14 Ill. Reg. 1233, effective January 12, 1990; amended at 14 Ill. Reg. 10732, effective July 1, 1990; emergency amendment at 15 Ill. Reg. 2838, effective February 1, 1991, for a maximum of 150 days; amended at 15 Ill. Reg. 10351, effective July 1, 1991; emergency amendment at 15 Ill. Reg. 14593, effective October 1, 1991, for a maximum of 150 days; emergency amendment at 15 Ill. Reg. 17398, effective November 15, 1991, for a maximum of 150 days; emergency amendment suspended at 16 Ill. Reg. 1744; emergency amendment modified in response to a suspension by the Joint Committee on Administrative Rules and reinstated at 16 Ill. Reg. 2943; amended at 15 Ill. Reg. 18568, effective December 13, 1991; emergency amendment at 16 Ill. Reg. 2630, effective February 1, 1992, for a maximum of 150 days; emergency amendment at 16 Ill. Reg. 2901, effective February 6, 1992, to expire June 30, 1992; emergency amendment at 16 Ill. Reg. 4069, effective February 28, 1992, to expire June 30, 1992; amended at 16 Ill. Reg. 11403, effective June 30, 1992; emergency amendment at 16 Ill. Reg. 11625, effective July 1, 1992, for a maximum of 150 days; amended at 16 Ill. Reg. 11731, effective June 30, 1992; emergency rule added at 16 Ill. Reg. 12615, effective July 23, 1992, for a maximum of 150 days; modified at 16 Ill. Reg. 16680; amended at 16 Ill. Reg. 14565, effective September 8, 1992; amended at 16 Ill. Reg. 18767, effective November 27, 1992; amended at 17 Ill. Reg. 224, effective December 29, 1992; amended at 17 Ill. Reg. 6090, effective April 7, 1993; amended at 18 Ill. Reg. 609, effective February 1, 1994; emergency amendment at 18 Ill. Reg. 5348, effective March 22, 1994, for a maximum of 150 days; amended at 18 Ill. Reg. 13375, effective August 19, 1994; amended at 19 Ill. Reg. 9085, effective July 1, 1995; emergency amendment at 19 Ill. Reg. 10186, effective July 1, 1995, for a maximum of 150 days; emergency amendment at 19 Ill. Reg. 12693, effective August 25, 1995, for a maximum of 150 days; amended at 19 Ill. Reg. 16031, effective November 20, 1995; amended at 19 Ill. Reg. 16523, effective December 1, 1995; amended at 20 Ill. Reg. 1493, effective January 10, 1996; emergency amendment at 20 Ill. Reg. 5388, effective March 22, 1996, for a maximum of 150 days; amended at 20 Ill. Reg. 8995, effective July 1, 1996; amended at 20 Ill. Reg. 10597, effective August 1, 1996; amended at 21 Ill. Reg. 887, effective January 10, 1997; amended at 21 Ill. Reg. 6183, effective May 15, 1997; amended at 21 Ill. Reg. 12418, effective September 1, 1997; amended at 22 Ill. Reg. 3415, effective February 1, 1998; amended at 23 Ill. Reg. 2496, effective February 1, 1999; amended at 23 Ill. Reg. 5642, effective May 1, 1999; amended at 26 Ill. Reg. 9668, effective July 1, 2002; emergency amendment at 26 Ill. Reg. 10829, effective July 1, 2002, for a maximum of 150 days; amended at 26 Ill. Reg. 17358, effective November 25, 2002; emergency amendment at 28 Ill. Reg. 923, effective December 26, 2003, for a maximum of 150 days; amended at 28 Ill. Reg. 7611, effective May 21, 2004; emergency amendment at 30 Ill. Reg. 10117, effective June 1, 2006, for a maximum of 150 days; emergency amendment at 30 Ill. Reg. 11767, effective July 1, 2006, for a maximum of 150 days; amended at 30 Ill. Reg. 16281, effective September 29, 2006; amended at 30 Ill. Reg. 17756, effective October 26, 2006; amended at 32 Ill. Reg. 7588, effective May 5, 2008; emergency amendment at 32 Ill. Reg. 10940, effective July 1, 2008, for a maximum of 150 days; emergency expired November 27, 2008; amended at 32 Ill. Reg. 17929, effective November 10, 2008; amended at 32 Ill. Reg. 19912, effective December 12, 2008; amended at 33 Ill. Reg. 4830, effective March 23, 2009; amended at 34 Ill. Reg. 3448, effective March 8, 2010; emergency amendment at 34 Ill. Reg. 10854, effective July 15, 2010, for a maximum of 150 days; emergency expired December 11, 2010; emergency amendment at 34 Ill. Reg. 12224, effective August 4, 2010, for a maximum of 150 days; emergency expired December 31, 2010; amended at 35 Ill. Reg. 8919, effective June 2, 2011; emergency amendment at 35 Ill. Reg. 13936, effective July 28, 2011, for a maximum of 150 days; amended at 35 Ill. Reg. 20130, effective December 6, 2011; emergency amendment at 37 Ill. Reg. 11381, effective July 1, 2013, for a maximum of 150 days; emergency expired November 27, 2013; amended at 38 Ill. Reg. 5800, effective February 21, 2014; amended at 38 Ill. Reg. 14230, effective June 25, 2014; amended at 41 Ill. Reg. 15233, effective January 1, 2018; recodified at 42 Ill. Reg. 817; amended at 42 Ill. Reg. 20653, effective January 1, 2019; amended at 44 Ill. Reg. 2780, effective January 29, 2020; amended at 44 Ill. Reg. 5995, effective April 3, 2020; amended at 44 Ill. Reg. 8609, effective May 13, 2020; amended at 45 Ill. Reg. 13819, effective October 21, 2021; amended at 46 Ill. Reg. 12492, effective July 1, 2022; emergency amendment at 47 Ill. Reg. 7115, effective May 10, 2023, for a maximum of 150 days; emergency expired October 6, 2023; emergency amendment at 47 Ill. Reg. 15675, effective October 18, 2023, for a maximum of 150 days; amended at 48 Ill. Reg. 1129, effective January 3, 2024.

SUBPART A: GENERAL PROGRAM PROVISIONS

 

Section 240.100  Community Care Program

 

The statutory authority for this rule is vested in the Illinois Act on the Aging, as amended. The costs of Community Care Program services provided to all eligible participants who are also enrolled in Medical Assistance Programs administered by the Illinois Department of Healthcare and Family Services (HFS) will be submitted for Federal Financial Participation under provisions of a waiver granted to the State of Illinois relevant to Title XIX of the Social Security Act (Section 1915) (42 USC 1396). The costs of Community Care Program services provided to all other eligible participants will be borne by appropriations set within the State's budget process.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.110  Department Prerogative

 

Other programs or demonstration/research projects may be funded by the Department on a pilot basis.  These other programs or demonstration/research projects shall be funded for purposes of providing alternatives to nursing facility care; permitting equal access to Community Care Program services; evaluating the impact of the program on sustaining participants in the community and other funding opportunities for the Department; or for other purposes designated by the Department in the best interest of the Community Care Program and funding opportunities for the Department and other human service agencies through federal and State grant-making activity and waiver applications on behalf of the State of Illinois under Title XIX of the Social Security Act.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.120  Services Provided

 

a)         The Community Care Program (CCP) provides necessary services designed to prevent premature and unnecessary nursing facility care of participants determined eligible to receive those services.

 

b)         Services provided through the CCP are:  in-home care, adult day service, emergency home response, automated medication dispenser, information and referral, care coordination, and services made available through special demonstration/research projects.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.130  Maintenance of Effort

 

Services made available through the Community Care Program shall not supplant the same type of services which are available through other funded sources but shall be utilized for purposes of complementation and coordination of all services available to eligible participants.  Therefore, participants are not permitted to be enrolled in another Home and Community-Based Service (HCBS) Waiver.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.140  Program Limitations

 

The execution of all activities related to the Community Care Program, as specified in this Part, shall be subject to resources made available to the program through the appropriation process of the State of Illinois.

 

Section 240.150  Department Headquarters Location

 

The main address for the Department is:

 

Illinois Department on Aging

One Natural Resources Way, #100

Springfield IL 62702-1271

 

(Source:  Added at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.160  Definitions

 

"Adequate person-centered plan of care" means a person-centered plan of care that provides the minimum services needed to protect the health, safety and welfare of a participant.

 

"Adjusted rate" means a rate other than the established fixed rate of reimbursement.

 

"Administrative corrections" means allowable revisions to a proposal permitted and/or performed by the Department in cases of apparent clerical mistakes and in cases where the participant/Department has reason to believe a mistake may have been made and verification from the participant has been provided.  These actions shall be taken prior to award.

 

"Administrative costs" means those allowable costs related to the management and organizational maintenance of the provider.

 

"Adverse action" means the denial of CCP service; a reduction in dollars in the monthly cost of care according to the Participant Agreement – Person-Centered Plan of Care; a change in service type that could increase the participant's incurred monthly expense for care prior to July 1, 2010; or the termination from CCP service.

 

"Allegations" means unsubstantiated accusations or statements.

 

"Allowable costs" means those cost categories, as delineated in Section 240.2050, which will be considered in setting a fixed rate.

 

"Allowable maximums" means the highest authorized allocation available for services per month based upon Determination of Need assessment tool scores or the corollary scores on any successor assessment tool authorized by the Department to determine need for long term services and supports.

 

"AMD" means automated medication dispenser.

 

"Appellant" means the participant/authorized representative initiating an appeal as a result of Department action or inaction.

 

"Assistance with task" means giving aid or support in the performance of a task.

 

"Assistive device" means crutches, walker, wheel chair, hearing aid, etc.

 

"Authorized representative" means an agent designated, verbally or in writing, by the participant to be his/her representative, or the participant's legal guardian.  In the event that a participant  is unable to physically write his/her signature, the CCU may sign for the participant at the participant's verbal request.

 

"Authorized representative of the provider" means an owner, officer, or employee of the provider agency who has the authority to commit the agency to a financial and/or contractual responsibility.

 

"Authorized provider" means a provider who holds a valid contract with the Department to provide Community Care Program (CCP) services.

 

"Available resources" means assistance provided to a participant by family/friends, church, community, etc.

 

"Best interest" means the determined needs of the participant population are being met.

 

"Burial merchandise" means gravesites, crypts, mausoleums, urns, caskets, vaults, grave markers or other repositories for the remains of deceased persons, shrouds, etc.

 

"Calendar year" means from January 1 through December 31.

 

"Capable person" means a person who is qualified to perform the functions required.

 

"Care Coordinator" means a trained individual who is employed to assess needs, conduct eligibility screenings, and perform care coordination services and care coordination functions under the Community Care Program.

 

"CCP" means Community Care Program.

 

"CCU" means Care Coordination Unit.

 

"CCU in good standing" (See:  Contractor in good standing)

 

"Choices for Care" means a CCP program under which CCUs conduct prescreening or postscreening assessments to determine eligibility of participants age 60 and over for nursing facility placement, supportive living program placement, or the choice of community-based services. Screenings may be conducted in a hospital, nursing facility, supportive living program, or in the community depending on the circumstances.

 

"Close-out review" means a review performed at the close of the period of time allowed for correction of findings of non-compliance to determine if those corrections have been made and that the newly drawn review sample of participant/provider files reflects on-going compliance.

 

"Closed caseload" means a caseload restricted to those participants already receiving service and refers only to individual providers; no new participants shall be accepted and current participants who discontinue service for any reason will not be reinstated into this caseload.

 

"Community-based services" means services provided in an integrated setting in a participant's community.

 

"Comparable human service program" means a program that offers services that are similar to CCP services (e.g., home health aide, maid service).

 

"Compliance" means adherence to the CCP rules, policy and procedures and the contract with the Department, and all applicable federal, State and local laws/rules/ordinances.

 

"Components" means specified parts of the service as defined in the applicable Section.

 

"Confused and disoriented" means unable to clearly and accurately differentiate as to time, person and/or place.

 

"Continuous eligibility" means that the participant has met eligibility requirements each time a subsequent redetermination was administered.

 

"Contractor in good standing" means a CCP contractor who is currently in compliance or within the permitted time frame allotted for remedy to come into compliance with the Department's rules and contract.

 

"Control date" means a starting point for purposes of calculating a time frame; the count begins the next work or calendar day.

 

"Cost report" means a report of all categorized allowable costs to a provider that are directly associated with services purchased by the Department for its participants in categories as defined in Section 240.2050. The provider shall use the Direct Service Worker Cost Certification and the Detailed Cost Certification forms.

 

"Critical event" means any actual or alleged incident or situation that creates a significant risk of substantial or serious harm to the physical or mental health, safety or well-being of a participant. There are 3 subcategories that will be reported to the Department:

 

"Critical Incidents" include anticipated death, unanticipated death, hospitalization, medication error, serious injury, missing person, emergency department visit, property damage, nursing facility placement, fall (with injury), fall (without injury), special circumstance, criminal activity, and law enforcement interaction;

 

"Service Improvement Program Complaints" or "SIPs" is a complaint based reporting process with the purpose of identifying and resolving problematic issues related to the provision of home and community based services (HCBS); and

 

"Request for Change of Status" occurs anytime the condition of a CCP participant changes or there is a change in circumstances that affect the ability of the family and/or caregiver to safely provide support and assistance.

 

"Daily census maximum" means the total square footage of adult day service participant-allotted space divided by 40 sq. ft. equals the daily maximum number of participants that may be served in the adult day service facility.

 

"Department" means the Illinois Department on Aging.

 

"Director" means the Director of the Illinois Department on Aging.

 

"Discontinuance" means the cessation of CCP services provided to a participant for non-payment of incurred expense for care prior to July 1, 2010.

 

"Documentation" means tangible documents or supporting references or records used to record participant contact, determine eligibility or substantiate adherence to rules.

 

"Documenting" means making written entries on the Case Record Recording Sheet regarding contact with a participant; and/or the viewing or receiving of a document to be placed in participant /worker files to substantiate adherence to rules.

 

"DON" means the Determination of Need, which is a component of the comprehensive assessment tool, or any successor assessment tool authorized by the Department, used to determine CCP eligibility under this Part.

 

"Emergency" means a sudden unexpected occurrence demanding immediate action (e.g., participant illness, illness/death of a member of the participant's family).

 

"Emergency home response service" or "EHRS" means a 24-hour emergency communication link to assistance outside the participant's home based on the participant's health and safety needs and mobility limitations.  This service is provided by a 2-way voice communication system consisting of a base unit and an activation device worn by the participant that will automatically link the participant to a professionally staffed support center.  The support center assesses the situation and directs an appropriate response whenever this system is engaged by a participant.

 

"Errands" means performance of services outside the home such as essential shopping, picking up medications, and essential business needs as indicated in the person-centered plan of care.

 

"Escort" means accompanying those participants who are dependent on personal physical assistance to enable them to reach and use community resources in order to ensure their access to local services and to allow them to maintain independent living as required by the person-centered plan of care.

 

"Essential" means basic, indispensable or necessary.

 

"Exit conference" means the meeting at the Illinois Department on Aging between representatives of the Department and the Director, or his/her designee, and of the reviewed agency to resolve the agency's objection to the findings of the Compliance Review Report. These conferences shall be called when the findings indicate evidence of serious participant-related concerns (e.g., Type I findings).

 

"Face-to-face" means direct communication while physically in the presence of another person or persons.

 

"Face-to-face review" means an informal review (see Section 240.425) conducted in the appeal process by the Department in the home of an appellant with the participant (and appellant, if appellant is other than the participant) present. (A hearing is conducted by a Hearing Officer – see Section 240.450.)

 

"FUTA" means the Federal Unemployment Tax Act.

 

"Fiscally sound agency" means a CCU or provider that has on file at the Department documentation that supports that the CCU or provider has adequate financial resources to perform the terms of the contract (e.g., a line of credit from a financial institution).

 

"Fraudulent information" means purposely erroneous or untruthful information.

 

"Geographic area" means a physical area (e.g., county) of the State within which a contractor is authorized to provide services to Community Care Program participants.

 

"Historical costs" means the total allowable costs incurred for all programs the provider provided for the previous reporting year, which are presented via certified report by the provider.

 

"Home maintenance and repairs" means those non-routine tasks, excluding any work requiring a ladder or requiring specialized skills on the part of the worker, necessary to maintain a safe and healthful environment for the participant as required by the person-centered plan of care (e.g., defrosting the refrigerator; cleaning the oven; dusting walls and woodwork; cleaning closets, cupboards and insides of windows; changing filters on and cleaning humidifiers; replacing light bulbs; clearing hazards from outside steps and sidewalks if transportation and/or escort is required by the person-centered plan of care).

 

"Imminent" means likely to occur (e.g., injury or nursing facility care).

 

"Incomplete proposal" means the written offer to the Request for Proposal (e.g., attachments, appendices) that fails to include all requirements as stated in the Request for Proposal.

 

"Incurred monthly expense" means the participant's share of the cost of care for CCP services provided during a previous monthly period prior to July 1, 2010.

 

"Informal review" means the act of determining the facts relating to an appeal in an informal manner by the Department (see Section 240.425).

 

"Informality" means an irregularity that is a matter of form or variation from the exact requirement of the Request for Proposal, the correction or waiver of which would not be prejudicial to other applicants (e.g., failure to return number of copies of signed proposals as required by the Request for Proposal).

 

"In-home services" means services provided in the participant's residence with the participant present or on behalf of the participant (e.g., homecare aide).

 

"Intermediate Care Facility" or "ICF" means a facility that provides basic nursing care and other restorative services under periodic medical direction.  Many of these services may require skill in administration. ICFs are for residents who have long term illnesses or disabilities that may have reached a relatively stable plateau.

 

"Licensed Practical Nurse" or "LPN" means a nurse who has graduated from a formally approved program of practical nursing education and has been licensed by the appropriate State authority.

 

"Mandated time period" means the time frame required by pertinent rule.

 

"M.D." means medical doctor who is registered in the State of Illinois.

 

"Memorandum of Understanding" means a written document, executed by the participant/authorized representative, CCU representative and provider representative in which all parties agree to cooperate and in which activities are specified that must be fulfilled by each party.

 

"Observing participant's functioning" means watching for any change in the participant's needs that could indicate that a redetermination of eligibility and/or a revision in the CCP Participant Agreement – Person-Centered Plan of Care is necessary (e.g., participant is experiencing increasing difficulty in walking; participant is becoming increasingly confused and disoriented; participant's family member is no longer available to prepare meals for the participant).

 

"Occupancy costs" means the costs of depreciation, amortization of leasehold improvements, rent, property taxes, interest and other related costs.

 

"On-Notice" means the Department sanction imposed on a provider or CCU requiring that provider or CCU to bring specified services or requirements into compliance.

 

"Parent organization" means an entity to which the contractual party is a subsidiary.

 

"Participant" means a person who made a request for services, receives services, or is appealing benefits decisions under the Community Care Program.

 

"Performance of task" means to carry out an action, function or process.

 

"Period of stay" means period of time during which implementation of a contract action is temporarily delayed.

 

"Person-centered planning" means that service planning for participants in the Persons who are Elderly Waiver shall be developed through a person-centered planning process that addresses health and long-term services and supports (paid and unpaid) needs in a manner that reflects participant personal preferences, choices and goals.  The person-centered planning process is directed by the participant and may include an authorized representative that the participant has freely chosen to contribute to the process.  The planning process, and the resulting person-centered plan of care, will assist the participant in achieving personally defined outcomes in the most integrated community setting, including the assurance of their health, safety and welfare.

 

"Planning and Service Area" or "PSA" means a designated geographic area.

 

"Post-screening" means screening performed after a participant has entered a nursing facility due to an emergency situation or oversight without prescreening.

 

"Potentially" means having the capability of occurring, but not yet in existence (e.g., deterioration in the participant's condition).

 

"Program support costs" means those allowable costs not included as direct service or administrative costs.

 

"Proposal" means the written offer made by an applicant in response to Department Request for Proposal.

 

"Provider Agreement" means purchase of service agreement.

 

"Provider community experience" means documentation of having provided service within the community in which the provider has applied to provide CCP services.

 

"Provider in good standing" (See:  Contractor in good standing)

 

"Providers" means those service providers with whom the Department does business through contracts on a reimbursement basis for units of service delivery to specified participants.

 

"Reasonable" means using and showing reason or sound judgement, sensible, not excessive.

 

"Reasonable and diligent effort" means perseverance on the part of the participant/client in his/her attempt to dispose of the asset (e.g., as evidenced by copies of the advertisement for the sale of the asset).

 

"Registered Nurse" or "RN" means a nurse who has graduated from a formal program of nursing education and has been licensed by the appropriate state authority.

 

"Reinstatement" means the resumption of services, within an established time frame, at the same level provided prior to a suspension/discontinuance of the services.

 

"Related parties" means any other entities having a legal or contractual relationship with the contractual party.

 

"Request for Proposal" or "RFP" means a form of invitation to bid that the Department uses to obtain care coordination services and demonstration/research projects under the CCP.  The RFP explains the purpose of the invitation to bid, outlines the scope of the work and solicits proposals from provider agencies for the funding of services undertaken by the Department.

 

"Responsible person" means a capable person who does not appear to be disoriented or confused and is presumed to be acting in the best interest of another individual.

 

"Risk mitigation" means the process in which events or experiences that place the health, welfare and safety of program participants in jeopardy are evaluated in terms of nature, frequency and circumstance with the intent of providing services and supports aimed at reducing risk and the likelihood of its reoccurrence.

 

"Rotation plan" means a Department approved plan for the equitable distribution of participants to providers (used only if participant does not indicate a choice of providers).

 

"Routine procedures" means procedures performed in a hospital that result in no perceptible change in the participant's physical/mental health needs (e.g., tests, blood work-ups, x-rays, dialysis).

 

"Service area" means any area in which a provider has been awarded a contract to provide CCP services.

 

"Skilled Nursing Facility" or "SNF" means a group care facility licensed by the Illinois Department of Public Health that provides skilled nursing care, continuous skilled nursing observations, restorative nursing and other services under professional direction with frequent medical supervision.  SNFs are provided for patients who need the type of care and treatment required during the post-acute phase of illness or during reoccurrences of symptoms in long-term illness (89 Ill. Adm. Code 101.20).

 

"Special diet" means a dietary restriction based upon the health and safety needs of the participant and prescribed by a physician (e.g., sodium free, fat, protein, diabetic, etc.); whereas a modified diet relates to a diet containing easy to chew foods.  A modified diet may be part of a specialized diet.

 

"State fiscal year" means from July 1 through June 30.

 

"Supportive Living Program" or "SLP" means the program that provides an affordable assisted living model offering limited personal and health services integrated within apartment-style housing.  The SLP operates under the authority of a 1915(c) Home and Community Based Services (HCBS) Waiver.  The SLP serves persons who would otherwise need nursing facility (NF) care, but whose individual needs can be met by the SLP.  HFS is the operating agency for the SLP Waiver.

 

"Suspension" means the temporary cessation of the provision of Community Care Program services provided to a participant.

 

"Suspension of referrals" means closed intake of new participants to a specific contractor.

 

"Termination" means the permanent cessation of the provision of Community Care Program services and eligibility of services.

 

"Threat" means the existence of circumstances that indicate the intent of an individual or group to destroy the property of or to injure or punish another individual or group, or the display of a weapon at an adult day services center or home.

 

"Too highly impaired participant" means a participant who needs 24 hour a day care, for whom CCP cannot develop a person-centered plan of care to protect his/her physical, mental and environmental needs and who does not have sufficient outside support from family, friends, church et. al., to provide for those needs (as determined by Part B – Unmet Need for Care – of the Community Care Program –  Determination of Need).  (Refer to Section 240.715.)

 

"Unallowable costs" means those costs that will not be considered in determining the fixed rate or in meeting the required minimum direct service expenditure.

 

"Unit of service" means a measured length of service, such as an hour, a day, a visit, a one-way trip, or some other measurable service component that will enable the Department to determine the amount of service provided individually or in aggregate to or on behalf of a participant.

 

"Validation of provider community experience" means the documentation of letters from community agencies attesting to experience with the provider within the community.

 

"Validity of participant billing" means the accuracy of the billing and documentation for participant services.

 

"Work days" means Monday through Friday at a minimum, excluding provider designated holidays.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

SUBPART B: SERVICE DEFINITIONS

 

Section 240.210  In-home Service

 

In-home service is defined as general non-medical support by supervised homecare aides who have received specialized training in the provision of in-home services.  The purpose of providing in-home service is to maintain, strengthen and safeguard the functioning of participants in their own homes in accordance with the authorized person-centered plan of care.

 

a)         Specific service components of in-home service shall include the following:

 

1)         Teaching/performing of meal planning and preparation; light housekeeping tasks (e.g., making and changing beds, dusting, washing dishes, vacuuming, cleaning floors, keeping the kitchen and bathroom clean and laundering the participant's linens and clothing); shopping skills/tasks; and home maintenance and repairs.

 

2)         Performing/assisting with essential shopping/errands may include handling the participant's money (proper accounting to the participant of money handled and provision of receipts are required).  These tasks shall be:

 

A)        performed as specifically required by the person-centered plan of care; and

 

B)        monitored by the homecare supervisor.

 

3)         Assisting with self-administered medication, which shall be limited to:

 

A)        reminding the participant to take his/her medications;

 

B)        reading instructions for utilization;

 

C)        uncapping medication containers; and

 

D)        providing the proper liquid and utensil with which to take medications.

 

4)         Assisting with following a written special diet plan and reinforcement of diet maintenance (can only be provided under the direction of a physician as required by the person-centered plan of care).

 

5)         Observing participant's functioning and condition and reporting to the supervisor, as outlined by the person-centered plan of care.

 

6)         Performing/assisting with personal care tasks that are not medical in nature, such as the examples set forth at 77 Ill. Adm. Code 245.40(c) (e.g., shaving, hair shampooing, drying and combing, bathing and sponge bath, shower bath or tub bath, toileting, dressing, nail care, respiratory services (as authorized by 20 ILCS 105/4.02(5)(F)), brushing and cleaning teeth or dentures and preparation of appropriate supplies, positioning/transferring participant, and assisting participant with exercise/range of motion), as defined by the person-centered plan of care.

 

7)         Escort/transportation to medical facilities, or for essential errands/shopping, or for essential participant business with or on behalf of the participant, as defined by the person-centered plan of care. This escort/transportation service may be provided directly by the homecare aide, directly by the provider, by the provider through contract, or by public transportation.

 

8)         Identifying and reporting critical events, including critical incidents, service improvement program complaints, and requests for change of status in the Department's automated reporting system. Completing initial critical event reports will occur within 7 days after the date the event occurred or was identified to have occurred. Assisting CCUs in their efforts to safeguard participant health, safety and welfare by demonstrating a willingness to collaborate, discuss and resolve issues that likely place a participant at increased risk for experiencing future critical events. Supporting CCU risk mitigation efforts by demonstrating a willingness to communicate about necessary adjustments to a participant's care plan in response to a critical event.

 

b)         Unit of Service

 

1)         One unit of in-home service is one hour of direct service provided to the participant in the participant's home, while providing transportation/escort, or while running errands and/or shopping on behalf of the participant.

 

2)         For services that the provider was unable to provide due to either the participant's absence without prior provider notification or refusal to admit the worker into the home to provide service (see Section 240.350), one unit of documented in-home service per occurrence will be reimbursed to the provider at a maximum of 2 units per participant per State fiscal year.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.230  Adult Day Service (ADS)

 

Adult day service is the direct care and supervision of adults aged 60 and over in a community-based setting for the purpose of providing personal attention and promoting social, physical and emotional well-being in a structured setting. These services shall be provided pursuant to an ADS Addendum to the participant's person-centered plan of care.

 

a)         Required Service Components

 

1)         Assessment of the participant's strengths and needs and development of an individual written person-centered plan of care for each participant that establishes specific participant goals for all service components to be provided or arranged for by the service provider.

 

A)        The individual ADS Addendum will be developed  by the adult day service team consisting of participant/authorized representative, Program Coordinator/Director and Program Nurse, and may include other staff at the option of the program Coordinator/Director.

 

B)        The participant, caregiver and other service providers will have the opportunity to contribute to the development, implementation and evaluation of the individualized ADS Addendum.

 

C)        The individualized ADS Addendum is to be established not later than the fourth week of service.

 

D)        The individualized ADS Addendum shall address the needs identified by the CCU, as described in the comprehensive assessment.

 

E)        The individualized ADS Addendum to the person-centered plan of care shall address the need identified by the service provider's staff and participant/authorized representative/caregiver during the individualized ADS Addendum process.

           

F)         Reassessing the participant's needs and reevaluating the appropriateness of the individualized person-centered plan of care shall be done as needed, but at least annually.

 

2)         A balance of purposeful activities to meet the participant's interrelated needs and interests (social, intellectual, cultural, economic, emotional, physical and spiritual) designed to improve or maintain the optimal functioning of the participant.

 

A)        Activity programming shall take into consideration participant differences in age, health status, sensory deficits, lifestyle, ethnicity, religious affiliation, values, experiences, needs, interests and abilities by providing for a variety of types and levels of involvement.

 

B)        Time for rest and relaxation shall be provided as needed or prescribed.

 

C)        Activity opportunities shall be available whenever the service provider's facility is in operation and participants are in attendance.

 

D)        A monthly calendar of activities shall be prepared and posted in a visible place.

 

E)        Opportunities to participate in other activities outside of the ADS shall be provided.  The setting will be integrated in, and support access to, the greater community.

 

3)         Assistance with or supervision of activities of daily living (e.g., walking, eating, toileting and personal care), as needed.

 

4)         Provision of health-related services appropriate to the participant's needs as identified in the provider's assessment and/or physician's orders, including health monitoring, nursing intervention on a moderate or intermittent basis for medical conditions and functional limitations, medication monitoring, medication administration or supervision of self-administration, and coordination of health services.

 

5)         Provision of a daily meal that meets the Dietary Guidelines for Americans, 2015-2020, 8^th edition, published by the Secretary of Health and Human Services and the Secretary of Agriculture; and that provides each participant a minimum of 33.5% of the Dietary Reference Intakes (DRI) as established by the Food and Nutrition Board of the Institute of Medicine of the National Academy of Sciences. Supplementary nutritious snacks shall also be provided. Special diets shall be provided as directed by the participant's physician.

 

6)         Agency provision or arrangement for transportation, with at least one vehicle physically accessible, to enable participants to receive adult day service at the adult day service provider's site and participate in sponsored outings.

 

7)         Provision of emergency care as appropriate in accordance with established adult day service provider policies and Section 240.1510.

 

8)         Identifying and reporting critical events including critical incidents, service improvement program complaints, and requests for change of status in the Department's automated reporting system. Completing initial critical event reports will occur within 7 days after the date the event occurred or was identified to have occurred.  Assisting CCUs in their efforts to safeguard participant health, safety and welfare by demonstrating a willingness to collaborate, discuss and resolve issues that likely place a participant at increased risk for experiencing future critical events.  Supporting CCU risk mitigation efforts by demonstrating a willingness to communicate about necessary adjustments to a participant's person-centered plan of care or ADS Addendum in response to a critical event.

 

b)         Ancillary Service Components

 

1)         Ancillary services, including physical, occupational, speech and creative arts therapies may be provided by site staff or through contractual arrangements when needed by participants.  If provided, ancillary services shall be within the framework of the individualized person-centered plan of care and ADS Addendum and shall be in accordance with professional practice standards and applicable State and federal regulations.

 

2)         Skilled nursing services, including, but not limited to, catheter installation, irrigations and care, dressings, enemas, oxygen therapy, suction/posturing, ostomy care and restorative nursing such as bladder retraining.  (All these procedures/interventions require physician orders and shall be administered by a Registered Nurse or a Licensed Practical Nurse, in accordance with the Illinois Nursing Act [225 ILCS 65].)

 

3)         Shopping assistance.

 

4)         Escort to medical and social services.

AGENCY NOTE:  Reimbursement for costs of ancillary services is not included in the unit rate paid by the Department and will not be paid by the Department.

 

c)         Unit of Service

 

1)         One unit of adult day service is defined as one direct participant contact hour (excluding transportation time) provided to a participant.  A direct participant contact hour is defined as 60 consecutive minutes of active programming, i.e., providing one or a combination of the service components listed in subsections (a)(2) through (7).

 

2)         One unit of documented adult day service transportation, provided by the adult day service provider, is defined as a one-way trip per participant to or from the adult day service provider's site and the participant's home. No more than two units of transportation shall be provided per participant in a 24-hour period, and shall not include trips to a physician, shopping, or other miscellaneous trips.

 

3)         For services (including transportation, if specified in the individualized ADS Addendum) which the provider was unable to provide due to the participant's absence without prior notification (see Section 240.350), the provider shall be reimbursed as follows:

 

A)        Two and one half units of documented adult day service per occurrence to a maximum of 5 units per participant per State fiscal year.

 

B)        One unit of documented adult day service transportation, provided by the adult day service provider, per occurrence to a maximum of 2 units per participant per State fiscal year.

 

4)         Refer to Section 240.1950 for further information regarding reimbursement.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.235  Emergency Home Response Service

 

a)         Service Definition

Emergency home response service (EHRS) is defined as a 24-hour emergency communication link to assistance outside the participant's home based on the participant's health and safety needs and mobility limitations.  This service is provided by a 2‑way voice communication system consisting of a base unit and an activation device worn by the participant that will automatically link the participant to a professionally staffed support center.  The support center assesses the situation and directs an appropriate response whenever this system is engaged by a participant.  The purpose of providing EHRS is to improve the independence and safety of participants in their own homes in accordance with the authorized person-centered plan of care, and thereby help reduce the need for nursing facility care.

 

b)         Specific components of EHRS shall include the following:

 

1)         provide a base unit and, when necessary, adaptive activation devices, together with all connectors, parts and equipment necessary for installation, that can be used in a home by up to 2 participants with hearing, mobility and/or visual impairments.

 

A)        Wireless adaptive activation devices (e.g., sip and puff, rocking lever switch) must be available when a participant cannot physically activate the call button.

 

B)        The system must be useable by visually and hearing impaired participants through visual and audible indications of alarm activation.

 

C)        Adaptive activation devices shall be provided at no extra cost to the participant;

 

2)         deliver the activation device to the participant and install the base unit, including connection of a seizure line jack, into a functioning telephone system in the participant's home within 15 calendar days after the date of referral.  This service shall not be subcontracted and shall be completed by trained employees identified by picture ID with an ID number that can be verified by the participant;

 

3)         train the participant and his or her designated emergency responders on the proper use of the base unit and activation device at the time of installation.  The training must include:

 

A)        demonstration of use and maintenance of EHRS equipment;

 

B)        explanation of the EHRS provider's services and response protocol;

 

C)        information on the general care of the base unit and activation device;       

 

D)        instruction about the monthly testing of the base unit and how to transmit the test results to the support center; and

 

E)        providing the participant with easy to understand written instructions in the use of EHRS devices, including how to report a malfunction of the equipment.  These instructions shall also be available in Braille or tape recorded to meet the participant's  needs;

 

4)         assist the participant in selecting and designating up to 3 local emergency responders, which must be updated by the EHRS provider at least every 6 months.  Each responder shall receive both verbal and written instructions from the provider;

 

5)         obtain participant's/authorized representative's signature to document that the EHRS unit was delivered and installed and that instructions and demonstration were given and understood.  A copy of this receipt must be sent to the CCU;

 

6)         own and operate a support center to provide live monitoring on a continuous basis, direct an appropriate response whenever the EHRS system is activated, and provide necessary technical support for fault conditions, including a language line that provides interpreter service for at least 140 languages and communication facilitated by a teletypewriter (TTY) communication device for the deaf, as appropriate;

 

7)         own and operate a back-up support center that provides all components specified in subsection (b)(6) and operates on a separate power grid;

 

8)         maintain adequate local staffing levels of qualified personnel to service necessary administrative activities, installation, in-home training, signal monitoring, technical support and repair requests in a timely manner.  A provider agency must have a written training program for personnel and be able to demonstrate staff qualifications;

 

9)         in the event of a malfunction, repair or replace the base unit or activation device within 24 hours after receiving the malfunction report;

 

10)         alert the participant when electric power to the base unit has been interrupted (e.g., unplugged) and the unit is operating on a standby power source;

 

11)         notify the CCU within 1 business day after activation of the base unit and work with the appropriate care coordination supervisor to resolve service complaints from the participant or emergency responder;

 

12)         notify the CCU immediately if EHRS services cannot be initiated or must be terminated; and

 

13)        maintain records in accordance with Section 240.1542 relating to participant referral and service statistics, including equipment delivery; device activation; participant and responder training; signal monitoring and test transmission activity; equipment malfunction, repair and replacement; power interruption alerts; and notification of the CCUs, plus billing and payment information, and personnel matters.

 

c)         Units of Service

 

1)         One unit of installation service is the one-time fee to the provider agency for the activity associated with the installation of the base unit in the participant's home.

 

2)         One unit of monthly service is the fixed unit rate of reimbursement, per month, for the provider agency activity associated with providing EHRS to each participant.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.237  Automated Medication Dispenser Service

 

a)         Service Description

 

1)         AMD service is defined as a portable, mechanical system for individual use that can be programmed to dispense or alert the participant to take non-liquid oral medications through auditory, visual or voice reminders; to provide notification of a missed medication dose; and to provide 24-hour technical assistance for the AMD service in the participant's residence.  The service may include medication specific directions or reminders to take other types of medications such as liquid medications or injections based on individual need.  The AMD unit is connected to a Department approved support center through a telephone line or wireless/cellular connection in the participant's residence. 

 

2)         The purpose of the service is to provide eligible participants with medication reminders to foster timely and safe administration of a medication schedule, thereby promoting independence and safety of all participants in their own residence, as well as reducing the need for nursing home care. 

 

3)         The authorization to receive this service is determined by the care coordinator through a screening process set forth in Section 240.741, which requires the participant/authorized representative to designate an assisting party to manage the AMD unit and medications as set forth in Section 240.741.

 

4)         The Department does not perform medication management, oversight or handling of the participant's medications.

 

5)         Provision of this service is contingent upon it continuing to be an approved service under the HCBS Waiver for Persons Who are Elderly.

 

b)         Specific components of AMD service must include, at a minimum, the following:

 

1)         an AMD unit installed in the participant's residence with all connectors, parts and equipment necessary for installation, and adaptations for operation by individuals who have functional, hearing or visual impairments, or who exhibit language barriers.

 

2)         delivery of the AMD unit to the participant and installation of the unit within 48 hours after the referral when the participant is at imminent risk of institutionalization and within 15 calendar days from the date of the referral in all other instances. 

 

A)        This timeline can be extended if requested by the participant/authorized representative/assisting party. 

 

B)        This service shall not be subcontracted and shall be provided by trained employees who will identify themselves by picture identification that can be verified by the participant/authorized representative/assisting party.

 

C)        Delivery and installation of the AMD unit may include coordination of emergency home response service (see Section 240.235) for a participant. 

 

D)        Provider shall make every effort to schedule and conduct the installation when the participant, authorized representative (if applicable), and assisting party are present.  Documentation of such efforts shall be provided to the Department upon request.

 

3)         training for the participant/authorized representative and assisting party on the proper use of the AMD system at the time of installation and subsequently when needed.  The training will include:

 

A)        demonstration of the use, including any adaptations for operation, general care, and maintenance of the unit/equipment;

 

B)        explanation of the AMD provider's services and notification processes;

 

C)        instruction on any testing or monitoring used to assure the proper functioning of the AMD unit/equipment, including how to report any malfunctions; and

 

D)        providing the participant/authorized representative/assisting party with easy to understand written instructions in the use, general care and maintenance of the AMD unit/equipment.  These instructions will be available in options such as non-English languages, large print, Braille, and audible recordings to meet the participant's needs.

 

4)         ensuring the participant/authorized representative reviews their assisting party designation at least every 6 months.  Any changes in this designation must be sent to the CCU within 5 calendar days after the date of execution of the assisting party change.  If there is a change in designation, the AMD provider must complete new training as required under subsection (b)(3) within 7 calendar days after the date of execution of the assisting party change.

 

5)         both:

 

A)        obtaining the signature of the participant/authorized representative to verify that:

 

i)          the AMD unit/equipment was delivered and installed; and

 

ii)         instructions and demonstration were given and understood by the participant/authorized representative; and. 

 

B)        providing to the CCU and the participant/authorized representative a copy of the verification, to be kept on file at the CCU.

 

6)         maintaining adequate local staffing levels of qualified personnel to conduct and provide necessary administrative activities, installation, in-home training, unit/equipment monitoring, technical support, AMD unit programming, and repair requests in a timely manner.  An AMD provider must have a written training program for personnel and be able to demonstrate that its staff members are qualified and have passed background checks.

 

7)         repairing or replacing the AMD unit/equipment within 24 hours after receiving a malfunction report.  This timeline will be extended if requested by the participant/authorized representative/assisting party.

 

8)         alerts to the participant/authorized representative and assisting party when electric power to the AMD unit has been interrupted (e.g., unplugged) and the unit is operating on a standby power source.

 

9)         notification to the CCU within 1 business day after installation of the AMD unit and working with the appropriate care coordinator to resolve service complaints from the participant/authorized representative/assisting party.

 

10)        notification to the CCU within 2 calendar days if the AMD service cannot be initiated or must be terminated.

 

11)        maintaining records in accordance with Section 240.1544 relating to participant referral and service statistics, including unit/equipment delivery; unit installation and programming; participant/authorized representative and assisting party training; missed medication notifications and dispositions; other AMD unit/equipment monitoring and test transmission activity; unit/equipment malfunction, repair and replacement; power interruption alerts; notifications to the CCUs; billing and payment information; and personnel qualifications, training and background checks.

 

12)        making available participant reports on missed medication doses, power and battery status, and other reporting features on an ongoing basis to the participant/authorized representative, assisting party and care coordinators via a privacy-protected and secure website or other modality.

 

13)        providing access to individual and aggregate reports and AMD system performance measures on an ongoing basis to authorized persons through a privacy-protected and secure website or other modality.

 

14)        providing ad hoc reports to the Department upon request.

 

c)         Units of Service

 

1)         One unit of installation service is the one-time fee to the AMD provider for the activity associated with the installation of the AMD unit/equipment in the participant's residence and training of the participant/authorized representative and assisting party.

 

2)         One unit of monthly service is the fixed unit rate of reimbursement, per month, for the provider agency activity associated with providing the AMD service to each participant.

 

(Source:  Amended at 44 Ill. Reg. 2780, effective January 29, 2020)

 

Section 240.240  Information and Referral

 

Information and Referral service is defined as assistance to participants to enable them to gain access to appropriate services and to receive services.

 

a)         Service components of information and referral include:

 

1)         A brief assessment of the participant's needs to facilitate appropriate referral to and follow-up with community resources;

 

2)         Assisting participants in applying for benefits provided by federal, state and local agencies;

 

3)         Follow-up to ensure that participant was linked to community-based services and supports;

 

4)         Information and referral may also encompass program-related public information efforts.

 

b)         Unit of Service

            One unit of Information and Referral service is 1 incoming telephone call received by the professional information and referral staff.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.250  Demonstration/Research Projects

 

a)         Demonstration/research projects are defined as services designated to test or demonstrate, as specified in Section 240.110, effective service delivery to participants 60 years of age and older to prevent/reduce the incidence of premature or inappropriate nursing facility care. These projects are study programs testing the feasibility of new types of services, service delivery methods or service components which, as a result of the demonstration/research, will be considered for incorporation in the CCP.

 

b)         Unit of Service

A unit of service for a demonstration/research project shall be as stated in each contract/grant executed.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.260  Care Coordination Service

 

Care coordination service is defined as the provision of a comprehensive needs assessment and service coordination by CCUs to assist an older person to gain access to and receive needed services. The participant/authorized representative is provided the opportunity to lead the person-centered planning process.

 

a)         Service Components

Specific components of care coordination service include the following:

 

1)         Review of all inquiries to determine if a request for CCP services is desired, and maintenance of a referral request log.

 

2)         Distribution and assistance with completion of CCP applications for charitable, private, and public benefits provided by federal, State and local agencies, including assistance with the initial application and redetermination for Medicaid benefits.

 

3)         Performance of determinations/redeterminations of eligibility, including a comprehensive needs assessment, the development of a person-centered plan of care and authorization/referral of CCP services.

 

4)         Completion of a minimum of 1 face-to-face contact with the participant in between initial assessment and annual reassessment.  The face-to-face visit is to occur between 4 and 8 months after the last determination or redetermination of eligibility.

 

5)         Reporting of critical events includes critical incidents, service improvement program complaints, and requests for change of status in the Department's automated reporting system. Completing initial critical event reports will occur within 7 days after the date the event occurred or was identified to have occurred.  All critical event reports will be closed to reflect mandatory follow-up with CCP participants within 60 days after the date the event occurred or was identified to have occurred. Critical event report closure will occur through completion of the 60-day review summary housed in the Department's automated reporting system.

 

6)         Availability to receive inquiries and requests for services and supports, by telephone or in person, and respond to those inquiries and requests.

 

7)         Choices for Care prescreenings and postscreenings (see Section 240.1010).

 

8)         Department of Healthcare and Family Services (HFS) OBRA-1 (Level I ID Screen).

 

9)         Provide referrals to other needed services.

 

10)        Implementation of services and participant transfers.

 

11)        Authorization of all actions related to the disposition of CCP services as required by  this Part.

 

b)         Comprehensive Assessments

 

1)         A comprehensive assessment is required when a participant needs services to remain living independently in the community or is at imminent risk of nursing facility placement.

 

2)         A comprehensive assessment is not warranted when a participant only requires a referral to services (e.g., providing contact information for a vendor).

 

3)         Conditions triggering a comprehensive assessment may include, but are not limited to:

 

A)        multiple or complex health problems which are often chronic in nature, and may affect the ability of the participant to live independently, such as musculoskeletal disorders, strokes, heart disorders, or mental health issues (e.g., Alzheimer's disease, major depression, or organic brain syndrome).

 

B)        lack of sufficient formal or informal supports; or

 

C)        sudden and permanent loss of a primary caregiver.

 

4)         The Care Coordinator will appropriately complete the comprehensive assessment tool authorized by the Department, or any successor assessment tool, used to determine need for community-based or long-term services and supports, that is relevant to the participant in a manner consistent with the responsibilities set forth under Section 240.1420.

 

c)         Goals of Care

 

1)         Each participant/authorized representative is provided the opportunity to lead the person-centered planning process where possible.  The participant's authorized representative should have a participatory role, as needed and defined by the participant, unless State law confers decision-making authority to the legal representative.

 

2)         If a participant's Goals of Care cannot be developed to create an adequate person-centered plan of care, the Care Coordinator is required to discuss the risks associated with the preferences and selections made regarding one or more specific goals by the participant/authorized representative and suggest any alternative options and/or referrals that might be available to mitigate risk.

 

3)         Each participant will be advised by the Care Coordinator of his/her right to accept or refuse some or all offered services developed in participants' Goals of Care.

 

d)         Reassessments

 

1)         A reassessment will be conducted face-to-face on at least an annual basis to determine if the participant remains eligible for the program or if changes in the participant's services under the person-centered plan of care are needed and/or the Goals of Care need to be revised.

 

2)         A reassessment will also be conducted when requested by a participant/authorized representative or when a participant may have experienced a change in his/her needs.

 

3)         The participant/authorized representative develops his/her own revised Goals of Care with input from the Care Coordinator consistent with the responsibilities set forth in Section 240.1420.

 

e)         Unit of Service

Several different types of assessments constitute a care coordination unit of service for which reimbursement is made.

 

1)         Completion of 1 initial eligibility determination for CCP services constitutes 1 unit.

 

2)         Completion of 1 required continuous eligibility redetermination of CCP eligibility constitutes 1 unit.  A redetermination shall be completed at least annually.

 

3)         Completion of either 1 face-to-face prescreening or postscreen of a participant constitutes 1 unit.

 

4)         Completion of 1 HFS Interagency Certification of Screening Results form constitutes 1 unit.

 

5)         Availability to receive participant inquiries and requests, by telephone or in person, and to respond to those inquiries and requests for each active participant per month constitutes 1 unit.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.270  Alternative Provider

 

a)         An alternative provider is defined as an individual or an agency selected by the participant, assisted by the CCU and authorized by the Department to provide CCP services to a participant only if the following criteria are met:

 

1)         a contractual provider has failed to provide the services as required by the person-centered plan of care; and

 

2)         there is no contractual provider available to provide the services as required by the person-centered plan of care.

 

b)         Alternative providers may be supervised by the participant or agency providing the services, as required by the person-centered plan of care.  The service components and hours of service to be provided, as required by the person-centered plan of care, shall conform to the service components as defined in Section 240.210.

 

c)         The appropriate CCU shall be responsible for monitoring of alternative provider services.

 

d)         An alternative provider shall be authorized by the Department prior to provision of services to the participant.

 

e)         Unit of Service

 

1)         One unit of alternative in-home service is 1 hour of direct service provided to the participant while in the participant's home, while providing transportation/escort to the participant to medical facilities, or while performing essential errands/shopping or conducting essential participant business with or on behalf of the participant.

 

2)         For services that the provider was unable to provide due to either the participant's absence without prior provider notification or refusal to admit the worker into the home to provide service (see Section 240.350), 1 unit of documented in-home service per occurrence will be reimbursed to the alternative in-home provider to a maximum of 2 units per participant per State fiscal year.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.280  Individual Provider (Repealed)

                                                                                                                                   

(Source:  Repealed at 42 Ill. Reg. 20653, effective January 1, 2019)

SUBPART C: RIGHTS AND RESPONSIBILITIES

 

Section 240.300  Participant Rights and Responsibilities

 

The Department will administer CCP to assure certain rights to participants in accordance with the Home Care Participant Bill of Rights (see 20 ILCS 2405/17.1 and 320 ILCS 42/40) and the Medicaid Recipient Bill of Rights (see 305 ILCS 5/11-28).  In addition, the Department will assure that participants receive an explanation of their rights and responsibilities.  A copy of the rights and responsibilities shall be provided in written format to all participants during the initial visit for determination of eligibility or upon request by the participant.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.310  Right to Request Services

 

Any participant desiring to request CCP services shall have the right to request those services and to receive a written decision relative to that request.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.320  Nondiscrimination

 

a)         No eligible participant with a disability or protected person under other federal and State civil rights laws who requests/receives services may be discriminated against under CCP. 

 

b)         A participant/authorized representative may file a discrimination complaint with a vendor, a CCU, the Department, or other federal or State agency with jurisdiction over civil rights laws (see 4 Ill. Adm. Code 1725).

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.330  Freedom of Choice

 

a)         A participant has the right to request and, if eligible, to receive available CCP services.  A participant may choose at any time not to receive services for which eligibility has been determined.

 

b)         A participant/authorized representative shall be informed of, and have the right to choose from, choices regarding available services, supports and vendors in the participant's CCU service area:

 

1)         at the time of initial determination of eligibility or subsequent redetermination of the participant; or

 

2)         at the time of determination of presumptive eligibility for interim services; or

 

3)         at any time the participant/authorized representative requests a change of providers/vendors; or

 

4)         at the time of a Department-initiated total or partial caseload transfer.

 

c)         The person-centered planning process includes a method for the participant/authorized representative to request updates to the person-centered plan of care.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.340  Confidentiality/Safeguarding of Case Information

 

a)         For protection purposes, any information about a participant's case is confidential and may be used only for purposes directly related to the administration of the CCP.  Information that is considered to be included in the administration of the program is as follows:

 

1)         Establishing a participant's initial/continuing eligibility, preventing duplicate coverage under another Home and Community-Based Service (HCBS) Waiver, and providing assistance in transitioning to other programs in appropriate instances.

 

2)         Establishing the extent of a participant's: assets and income; determination of need under CCP; and other benefits. This includes recovery of payments and investigating allegations of fraud or other abuse of publicly funded benefits. This information may be shared in a secure manner by and among the Department and the Social Security Administration, the Department of Employment Security, HFS, the Department of Human Services, the Department of Revenue, the Secretary of State, the U.S. Department of Veterans Affairs, and any other governmental entity only to the extent that there is no conflict with any federal or State law or regulation.

 

3)         Finding and linking needed services and resources available to an eligible participant, including information about new laws or changes in public benefit programs.

 

4)         Assuring the health, safety, and welfare of the participant, including reporting alleged or suspected abuse, neglect, financial exploitation, or self-neglect, assisting with investigations conducted under the Adult Protective Services Program, and making referrals to the State/Regional Long Term Care Ombudsman Programs.

 

5)         Collecting data for the Department's demonstration/research projects.

 

6)         Compliance with legal proceedings in response to valid court or administrative agency orders.

 

7)         Directing and planning programming to transform long-term services and supports in Illinois and to maximize Federal Financial Participation in State expenditures under Medical Assistance Programs.

 

b)         Use of information for commercial, personal, political or other purposes not specified in this Section is specifically prohibited. Information about a participant's case under the CCP is exempt from disclosure under the Freedom of Information Act [5 ILCS 140].

 

c)         The Department, CCUs and vendors shall inform all agencies and governmental departments to whom information is furnished that this material is confidential and must be so considered by the agency or governmental department.

 

d)         Any information received from other agencies or persons, which includes the express statement that the information is not to be released to the participant/authorized representative or to any other person or agency under any circumstances, is prohibited from release as case information.  Requests for this information shall be referred to the originator of the restricted information.

 

e)         If any information about a participant or document contained in the participant's case file is to be used for any purpose other than the administration of CCP, the CCU or the vendor shall obtain a Release of Information form signed by the participant /authorized representative. The Release of Information form shall be placed in the participant's case record.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.350  Participant/Authorized Representative Cooperation

 

Participants/authorized representatives shall cooperate with the representatives of the Department/CCUs/providers in determinations of eligibility, redeterminations, other necessary or required face-to-face visits, or provision of CCP services.

 

a)         Failure to cooperate in the actions specified below shall be considered non-cooperative and shall be cause for suspension.

 

1)         A participant/authorized representative shall notify the office of the provider at least 1 day in advance when the participant will not be present in his/her home to receive scheduled services.

 

A)        If the participant's absence from his/her home on a day services are scheduled is due to an emergency, the participant/authorized representative shall advise the office of the provider as quickly as possible and it will not be considered non-cooperative.

 

B)        The provider shall document the absences of the participant without prior notification (except any absence caused by an emergency) and shall be reimbursed by the Department for 2 such absences (see Section 240.210).

 

C)        Two such documented absences within a State fiscal year shall be cause for suspension of the participant's services pending termination.  The provider has the option of not reporting non-cooperative absences; however, if the second non-cooperative absence is reported with request for reimbursement, suspension procedures shall be implemented.

 

D)        The provider shall verbally advise the CCU on the same day, if possible, but not later than the next work day after the date of the second non-cooperative absence.  A written report including, at a minimum, the names of the participant and the worker, and the dates of the first and second non-cooperative absence, shall be submitted by the provider to the CCU within 2 work days after the date of the second non-cooperative absence. The written report may be submitted in person or through mail, facsimile or electronic means.

 

E)        Upon receipt of verbal notification of the second documented non-cooperative absence within a State fiscal year, the CCU shall suspend the participant's services as required in Section 240.930.  The date of suspension shall be the date that the second non-cooperative absence occurred.

 

2)         A participant/authorized representative shall notify the office of an adult day service provider at least 1 day in advance when the participant will not be attending the adult day service site or will not be in need of transportation to or from the adult day service site, as scheduled and required by the person-centered plan of care.

 

A)        If the participant's absence from the adult day service site or refusal to accept transportation to the adult day service site is due to an emergency, the participant/authorized representative shall advise the office of the provider as quickly as possible and it will not be considered non-cooperative.

 

B)        The provider shall document the participant's absence or refusal to accept transportation without prior notification thereof (except any absence caused by an emergency) and shall be reimbursed by the Department for 2 such absences or refusals (refer to Section 240.230).

 

C)        Two such documented absences or refusals within a State fiscal year shall be cause for suspension of the participant's services pending termination.  The provider has the option of not reporting non-cooperative absences; however, if the second non-cooperative absence is reported with request for reimbursement, suspension procedures shall be implemented.

 

D)        The provider shall verbally advise the CCU on the same day, if possible, but not later than the next work day after the date of the second non-cooperative absence or refusal.  A written report including, at a minimum, the names of the participant and the worker and the dates of the first and second non-cooperative absence or refusal, shall be mailed by the provider to the CCU within 2 work days after the date of the second non-cooperative absence or refusal. The written report may be submitted in person or through mail, facsimile or electronic means.

 

E)        Upon receipt of verbal notification of the second documented non-cooperative absence or refusal within a State fiscal year, the CCU shall suspend the participant's adult day service (including transportation if specified in the person-centered plan of care) as required in Section 240.930.  The date of suspension shall be the date that the second non-cooperative absence or refusal occurred.

 

3)         A participant/authorized representative shall not refuse to allow the provider into the participant's home to provide services.

 

A)        The provider shall document the refusal to allow services to be provided and shall be reimbursed by the Department for 2 such refusals (see Section 240.210).

 

B)        Two such documented refusals within a State fiscal year shall be cause for suspension of the participant's services pending termination.  The provider shall verbally advise the CCU on the same day, if possible, but not later than the next work day after the date of the second refusal. A written report including, at a minimum, the names of the participant and the worker and the dates of the first and second refusal, shall be mailed by the provider to the CCU within 2 work days after the date of the second refusal. The written report may be submitted in person or through mail, facsimile or electronic means.

 

C)        Upon receipt of verbal notification of the second documented refusal within a State fiscal year, the CCU shall suspend the participant's services as required in Section 240.930.  The date of suspension shall be the date that the second refusal to allow service occurred.

 

4)         A participant/authorized representative shall not interfere with provision of the services specified in the person-centered plan of care, either in the participant's home or in any adult day service site.

 

A)        The provider shall document the interference with provision of the services specified in the person-centered plan of care.

 

B)        Two such documented instances of interference within a State fiscal year shall be cause for suspension of the participant's services pending termination.  The provider shall verbally advise the CCU on the same day, if possible, but not later than the next work day after the date of the second occurrence.  A written report including, at a minimum, the names of the participant and the worker and the dates of the first and second occurrence, shall be submitted by the provider to the CCU within 2 work days after the date of the second occurrence. The written report may be submitted in person or through mail, facsimile or electronic means.

 

C)        Upon receipt of verbal notification of the second documented occurrence of interference within a State fiscal year, the CCU shall suspend the participant's services as required in Section 240.930.  The date of suspension shall be the date of the second occurrence of interference occurrence.

 

5)         A participant /authorized representative or any family member/friend/acquaintance of the participant/authorized representative shall not threaten or act abusively (e.g., physical, verbal, sexual) or display a weapon (e.g., gun, knife) against any representative of the Department, CCU or provider who is present in the participant's home or at an adult day service site.  The participant/authorized representative shall be responsible for any animal present in the home of the participant and shall prevent the animal from physically harming a representative of the Department/CCU/provider.

 

A)        If the threat or abuse takes place in a participant's home, the party who has been threatened or abused shall leave the premises immediately and verbally advise the CCU on the same day, if possible, but not later than the next work day.

 

B)        If the threat or abuse takes place in an adult day service site, the family/authorized representative shall be advised immediately and the CCU shall verbally be advised on the same day, if possible, but not later than the next work day.

 

C)        A written report including, at a minimum, the name of the participant and the in-home worker/adult day service site worker, and the date and details of the threat or abuse, shall be submitted by the provider to the CCU within 2 work days after the date that the threat or abuse occurred. The written report may be submitted in person or through mail, facsimile or electronic means.

 

D)        Upon receipt of verbal notification of threat or abuse, the CCU shall, on the same day, if possible, but not later than the next work day:

 

i)         suspend a participant's services in the participant's home and/or at an adult day service site, as required in Section 240.930; or

 

ii)        suspend a participant's determination of eligibility process as required in Section 240.930.

 

E)        The date of suspension shall be the date that the threat or abuse occurred.

 

6)         A participant/authorized representative and/or any family member/friend/acquaintance of the participant/authorized representative will be responsible for damages to or loss of the AMD equipment or Emergency Home Response base unit or activation devices unless a law enforcement report of theft or intentional damage has been filed.

 

A)        The provider will document the damages/loss of the equipment.

 

B)        One documented occurrence of intentional damages/loss of equipment will be cause for suspension of the participant's services, pending termination.  The provider shall verbally advise the CCU on the same day, if possible, but not later than the next work day after the date of the occurrence.  A written report, including, at a minimum, the names of the participant and the worker and the date of the occurrence, will be submitted by the provider to the CCU within 2 work days after the date of the occurrence.  The written report may be submitted in person or through mail, facsimile or electronic means.

 

C)        Upon receipt of verbal notification of the documented occurrence of intentional damages or loss of equipment within a State fiscal year, the CCU will suspend the participant's services as required in Section 240.930.  The date of suspension will be the date of the occurrence of damages to or loss of equipment.

 

7)         The CCU shall notify the participant/authorized representative and the provider of the suspension in accordance with Section 240.930(c) and (d).

 

8)         The CCU shall develop a memorandum of understanding between the participant/authorized representative of the CCU and the provider, in accordance with Section 240.930(e).

 

9)         Upon the execution of the memorandum of understanding, the participant's services or the participant's determination of eligibility process, as appropriate, shall be reinstated in accordance with Section 240.930(f).

 

10)          Failure to sign a memorandum of understanding shall be grounds for termination or denial, as appropriate.

 

11)          If, following reinstatement, the requirements of the memorandum of understanding have not been adhered to by the participant/authorized representative, the request for services shall be denied or services shall be terminated, as appropriate.

 

12)          Notification of denial or termination shall be in accordance with Section 240.910 or 240.945, as appropriate.

 

b)         Failure to cooperate in the actions specified in this subsection (b) shall be considered non-cooperation and shall be cause for denial of a request for services or termination of service, as appropriate.

 

1)         A participant/authorized representative or any family member/friend/acquaintance of the participant/authorized representative shall not inflict physical injury upon any representative of the Department, CCU or provider, either in the participant's home or while the participant is attending an adult day service site.

 

A)        If the infliction of physical injury takes place in the participant's home, the injured party shall leave the premises immediately and verbally advise the CCU on the same day, if possible, but not later than the next work day.

 

B)        If the infliction of physical injury takes place in an adult day service site, the family/authorized representative shall be advised immediately and the participant shall be removed immediately.  The CCU shall verbally be advised on the same day, if possible, but not later than the next work day.

 

C)        A written report including, at a minimum, the names of the participant and the worker/adult day service site worker, and the date and details of the infliction of physical injury, shall be mailed by the provider to the CCU within 2 work days after the date that the physical injury was inflicted. The written report may be submitted in person or through mail, facsimile or electronic means.

 

D)        Upon receipt of verbal notification of physical injury the CCU shall, on the same day, if possible, but not later than the next work day:

 

i)          institute immediate denial of a request for services or termination of services.  The effective date of denial or termination shall be the date that the infliction of physical injury occurred;

 

ii)         verbally notify the participant/authorized representative of the denial or termination.  Written notification shall be sent by certified mail to the participant/authorized representative, and by regular mail to the provider within 5 calendar days after the date of the verbal notification; and

 

iii)        verbally notify the Department of the denial or termination followed by a written report within 5 calendar days after the date of the verbal notification.

 

2)         Participants/authorized representatives shall provide assistance in securing documentation and/or factual information to be utilized in the determination of initial and continuing eligibility for CCP services, as well as the type, level and amount of services to be provided.  Refusal to provide the specified assistance needed shall be cause for denial of a request for service or termination of a participant's services as appropriate.

 

3)         Participants/authorized representatives shall provide a mailing address, including sufficient information to enable the Department/CCU/provider to locate the participant/authorized representative (i.e., the name, address and telephone number of a contact through whom the participant may be located; it may be necessary to provide directions to the participant's home).  Refusal to provide the specified assistance needed shall be cause for denial of a request for service or termination of a participant's services as appropriate.

 

4)         Notification of denial or termination shall be in accordance with Section 240.910 or 240.945, except as specified in subsection (b)(1)(D).

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.360  Reporting Changes

 

It shall be the responsibility of the participant/authorized representative to report changes in circumstances (including household composition, change of address, change in level of services needed, and enrollment status in the Medical Assistance Program) that might affect eligibility for CCP within 30 calendar days after the effective date of the change.  Benefit changes at the federal level that affect a group of participants (such as increases in Social Security payment, etc.) need not be reported by the participant/authorized representative.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.370  Voluntary Repayment

 

Any participant who is receiving or has received services through CCP may voluntarily repay to the State of Illinois any amount up to the total cost expended by the State in providing Community Care services to the participant.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

SUBPART D: APPEALS

 

Section 240.400  Appeals and Fair Hearings

 

a)         Any participant who requests or receives CCP services of any kind has the right to appeal a decision, action or inaction of the Department, a CCU or a provider.  If the decision, action or inaction is based on automatic, non-discretionary changes in eligibility, rates or benefits required by federal or State statute or regulation, that adversely affect some or all participants, the appeal will be automatically denied and the participant will not be afforded a hearing.  The participant/authorized representative shall be informed by the CCU of his/her right to appeal at the time the participant/authorized representative is notified of the action taken. The participant shall be given an explanation of the right to appeal at the time of the initial home visit at which the action is taken and upon request.  A copy of the rights and responsibilities of participants who request services under  CCP and an explanation of the right to appeal shall be provided in written format during the initial home visit for determination of eligibility and upon request.

 

b)         It shall be the responsibility of each participant/authorized representative to advise the Department of his/her intent to appeal.

 

c)         The effective date of the appeal is the date a participant/authorized representative indicates to the Department the intent to appeal either by telephone or in writing.

 

d)         If the Department is advised of the intent to appeal either by letter or by telephone, the Department shall, within 2 work days, send to the appellant a Notice of Appeal to Department on Aging form to be completed and signed by the appellant/authorized representative.

 

e)         The written notice of appeal must be filed with the Department on a Notice of Appeal to Department on Aging form and shall be completed and executed by the appellant/authorized representative and returned to the Department.

 

f)         The executed Notice of Appeal to Department on Aging form must be submitted to the Department at its main office in Springfield.

 

g)         No later than 10 work days after the date of receipt of Notice of Appeal to Department on Aging form, the Department shall send written acknowledgment of receipt to the appellant/authorized representative and to all other parties to the appeal.

 

h)         The written Notice of Appeal to Department on Aging shall include the following:

 

1)         the name, address and telephone number of the participant  filing the appeal, or on whose behalf the appeal is filed; and

 

2)         the name, address and telephone number of the authorized representative, if any, filing the appeal on behalf of the participant;

 

3)         the specific action being appealed, including the date of notice advising the participant/authorized representative of the action appealed and the effective date of that action; and

 

4)         the name of the CCU, as indicated on the notice of the action being appealed.

 

i)          CCUs are to provide a copy of any notice of adverse action to any participant's authorized representative, if the participant has earned 10 points on the Mini-Mental State Examination (MMSE).  A single notice to a residence will suffice if the authorized representative is a family member living with the appellant.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.405  Representation

 

a)         The appellant may represent him/herself and/or may authorize legal counsel, a relative, a friend or other spokesperson to represent him/her.

 

b)         Written authorization is not required unless the appellant is not present at the hearing and:

 

1)         the representative is an employee, agent or representative of a hospital; or

 

2)         the representative is an employee, agent or representative of a group care facility; or

 

3)         the representative is a provider of Community Care services or an employee of an Area Agency on Aging; or

 

4)         the Hearing Officer, in his/her judgment, has reason to question the representative's authority to serve as a representative.

 

c)         A legal guardian or other appointed representative may represent a participant as authorized by a court of law.  The Department may request identification and other verification; however, a statement signed by the participant is not required.

 

d)         Any action or inaction by the appellant's representative is considered action or inaction by the appellant.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.410  When the Appeal May Be Filed

 

a)         The right to appeal must be exercised within 60 calendar days after the date the notice of the action being appealed was sent to the participant advising the action being taken by the CCU, such as:

 

1)         the date the notice was sent by a CCU of a decision on a request for a determination of eligibility for CCP services;

 

2)         the date the notice was sent by a CCU or the Department of a reduction or termination of CCP services, except for instances involving automatic, non-discretionary changes in eligibility, rates or benefits required by federal or State statute or regulation; or

 

3)         the date the notice was sent by a CCU or the Department of denial of a request or other action that aggrieves the participant, when that denial or action was other than an eligibility determination or a decision to reduce or terminate services.

 

b)         If a notice of appeal is filed after the 60 calendar day time period, the right to appeal is not affected.  However, the final administrative decision of the Department will not be favorable to the appellant if it is determined that the 60 calendar day time period applies to the situation and has expired.

 

c)         The 60 calendar day time limitation does not apply when:

 

1)         a CCU or the Department fails to send the required written notification of the action taken that is being appealed;

 

2)         a CCU or the Department fails to allow 15 calendar days from the date of the notice to the effective date of the action appealed;

 

3)         a CCU, provider or the Department fails to take any action on a specific request made by a participant within 15 calendar days after the date of request as required in Section 240.1520;

 

4)         a CCU, provider or the Department denies a request without informing the participant in writing within 15 calendar days after the date of request, as required in Section 240.1520;

 

5)         a CCU or provider failed to advise the participant/authorized representative of the right to appeal; or

 

6)         a CCU or provider has violated CCP rules.

 

d)         If a participant/authorized representative advised the Department by telephone of his/her intent to appeal and subsequently files a written appeal with the Department, the date of the documented telephoned intent shall be the date of filing of the appeal.

 

e)         If the intent to appeal by or on behalf of a participant is filed within 10 calendar days after the date of the notice of adverse action (see to Section 240.160) and is followed by a written appeal as requested by the Department, CCP services shall be continued at the level in effect prior to the notice of adverse action until the final decision in the appeal is reached, except for instances involving automatic, non-discretionary changes in eligibility, rates or benefits required by federal or State statute or regulation.  The participant/authorized representative and all other interested parties to the appeal shall be notified in writing by the Department of the continuation of the participant's services at the previous level. If the Department determines that the health, safety or welfare of the provider/direct service worker will be jeopardized if service is continued (see Section 240.350), the participant's right to continued service may be denied until the appeal decision is reached.

 

f)         Services shall not be continued during the appeal process for a participant receiving interim services.  Those participants receiving interim services have not received full eligibility for the CCP and are only presumed eligible until a full determination of eligibility has been completed.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.415  What May be Appealed

 

The following actions of CCUs, providers or the Department may be appealed:

 

a)         Refusal to accept a referral for CCP services.

 

b)         Failure to act upon a referral form within the mandated time period, unless delayed in any manner by the participant/authorized representative in the determination of eligibility process.

 

c)         A decision to deny CCP services.

 

d)         Failure to advise prescreened participants/authorized representatives that they have a choice of:

 

1)         nursing facility care, if eligible;

 

2)         supported living program provider care, if eligible;

 

3)         receiving in-home or community-based services, if eligible; or

 

4)         declining any of these options.

 

e)         A decision to reduce, terminate or in any way change CCP services or how those services are provided.  If the decision to reduce, terminate or in any way change CCP services is based on automatic, non-discretionary changes in eligibility, rates or benefits required by federal or State statute or regulation, which adversely affects some or all participants, the appeal will be automatically denied and the participant affected will not be afforded a hearing.

 

f)         A decision to deny a request for redetermination.

 

g)         Failure to make a decision or take appropriate action on any request made by a participant within 15 calendar days after the date of the request.

           

h)         A decision by a CCU to uphold a provider decision with which the participant/authorized representative does not agree.

 

i)          Failure to advise the participant/authorized representative of his/her right to choose a Department authorized provider in the service area of the participant to provide the services required by the person-centered plan of care.

 

j)          Failure of a CCU to advise a participant/authorized representative of any of his/her rights under CCP.

 

k)         Failure of a CCU or provider to comply with CCP rules in this Part and 89 Ill. Adm. Code 220.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.420  Group Appeals

 

The Department may consolidate a number of participant appeals for the purpose of conducting a single group informal review and subsequent hearing. The consolidation must be based upon the Department's determination that all of the appeals involve the same complaint, and the only issue in question is one of State or federal law or policy.  Consideration shall be given to the geographic proximity and the physical condition of the appellants.  Each appellant has the option of withdrawing from the group and presenting their appeal individually.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.425  Informal Review

 

When an appeal is received by the Department, the Department shall proceed to conduct an informal review of the action or inaction serving as the basis of the appeal.

 

a)         The purpose of an informal review shall be to determine the facts in the appealed action or inaction.

 

b)         If the basis for the appeal involves the functioning of the participant in his/her environment or if the Department is unable to arrive at a decision based upon the facts presented, the Department or it's designated agent may conduct a face-to-face review in the participant's home.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.430  Informal Review Findings

 

a)         Within 60 calendar days after the date of receipt of the Notice of Appeal to Department on Aging form, the Department shall conduct an informal review and issue an Appeal Findings Notice that may be delayed pending an extension of time caused by the appellant.

 

b)         The Appeal Findings Notice shall clearly state the facts determined and decision of the Department based upon the informal review. Copies shall be sent to all parties to the appeal.

 

1)         If the appeal is upheld, based upon the Department decision resulting from the informal review, the appeal file shall be closed.

 

2)         If the original action is modified, based upon the Department decision resulting from the informal review, the appeal shall automatically proceed to hearing unless the appellant/authorized representative withdraws the hearing request in writing.

 

3)         If the appeal is denied, based upon the Department decision resulting from the informal review, the appeal shall automatically proceed to hearing unless the appellant/authorized representative withdraws the hearing request in writing.

 

c)         CCUs are to provide a copy of any notice of adverse action to a participant's authorized representative, if the participant has earned 10 points on the Mini-Mental State Examination (MMSE).  If the authorized representative is a family member residing with the participant, the single notice to the participant will suffice.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.435  Withdrawing an Appeal

 

a)         The appellant/authorized representative, may withdraw the appeal at any time prior to or during the appeal process.  The withdrawal may be submitted in writing or by telephone.

 

b)         The Department shall acknowledge the withdrawal of appeal and advise the appellant/authorized representative that the appeal is formally closed, in writing, by certified mail, return receipt requested.

 

c)         The Department shall furnish copies of the acknowledgment of withdrawal to all interested parties to the appeal.

 

(Source:  Amended at 16 Ill. Reg. 11731, effective June 30, 1992)

 

Section 240.436  Cancelling an Appeal

 

a)         The Department may cancel an appeal at any time during the appeal process for any of the following:

 

1)         Appellant's death;

 

2)         Appellant never received a notice of adverse action from the Department;

 

3)         Appellant is not a CCP participant ;

 

4)         Appellant moves out of State;

 

5)         Appellant's appeal is upheld by the Department;

 

6)         Appellant/ authorized representative does not submit a Notice of Appeal to the Department within 60 calendar days after the date the notice of adverse action was sent;

 

7)         Appeal is not related to any CCP services; and/or

 

8)         Appeal is filed by an unauthorized representative.

 

b)         The Department shall advise the appellant/authorized representative that the appeal is cancelled and formally closed, in writing, by certified mail, return receipt requested.

 

c)         If the appellant/authorized representative does not agree with the reason for cancellation, the appellant/authorized representative must notify the Department, in writing, within 10 work days after receipt of the Notice of Cancellation.

 

d)         If the appellant/authorized representative notifies the Department, in writing, within 10 work days after receipt of the Notice of Cancellation, the Department shall reinstate the appeal and continue the appeal process.

 

e)         The Department shall furnish copies of the Notice of Cancellation to all interested parties to the appeal.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.440  Examining Department Records

 

Before or during the appeal hearing, if requested, the Department shall permit the appellant/appellant's authorized representative to examine all portions of the case record and any other documents to be used at the hearing.  Department records may be examined only in the presence of a Department employee.  Copies of case material shall be provided by the Department upon request of the appellant/appellant's authorized representative.  A charge of ten (10) cents per sheet shall be made for each copy provided.

 

(Source:  Added at 7 Ill. Reg. 8697, effective July 20, 1983)

 

Section 240.445  Hearing Officer

 

All hearings will be conducted by an impartial Hearing Officer authorized by the Director of the Department to conduct the hearing.

 

(Source:  Amended at 13 Ill. Reg. 11193, effective July 1, 1989)

 

Section 240.450  The Hearing

 

The hearing will be informal but the rules of evidence and privilege as applied in civil cases in the circuit courts of this State shall be followed.  Evidence not admissible under those rules of evidence may be admitted, however, (except where precluded by statute) if it is of a type commonly relied upon by reasonably prudent men in the conduct of their affairs.  (Illinois Administrative Procedure Act [5 ILCS 100/10-10 through 10-40]) The proceedings will be recorded.  The appellant may present the case or have an authorized representative present it, and may bring witnesses to the hearing.  The appellant/authorized representative shall have the opportunity before and during the hearing to examine material the Department plans to have available, which must include:

 

a)         Statement of Facts; and

 

b)         Pertinent case information, including all documents to be used at the hearing.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.451  Conduct of Hearing

 

The hearing may be conducted with some or all parties, including the hearing officer, present at different locations connected with each other by telephone.

 

(Source:  Added at 16 Ill. Reg. 18767, effective November 27, 1992)

 

Section 240.455  Continuance of the Hearing

 

a)         During the hearing, the appellant/authorized representative may request a continuance from the Hearing Officer.  The continuance shall be granted if:

 

1)         the appellant needs additional information;

 

2)         a necessary witness is absent;

 

3)         the appellant is ill;

 

4)         the appellant's authorized representative is unavailable; or

 

5)         for any other reason that necessitates a continuance in order for the appellant to present the appeal.

 

b)         The appeal shall be continued to the next available docket opening, if acceptable to the appellant.

 

c)         If the continuance is allowed, the ninety (90) calendar day time limitation of the appeal process shall be extended by the number of calendar days of the allowed continuance.

 

(Source:  Amended at 13 Ill. Reg. 11193, effective July 1, 1989)

 

Section 240.460  Postponement

 

a)         A hearing shall be postponed for a reasonable period if:

 

1)         the appellant needs additional information;

 

2)         a necessary witness is absent;

 

3)         the appellant is ill;

 

4)         the appellant's authorized representative is unavailable; or

 

5)         for any other reason that necessitates a postponement in order for the appellant to present the appeal.

 

b)         The appellant/authorized representative may request a postponement, which shall be in writing to the Hearing Officer before the scheduled hearing date.  A verbal request may be made when the hearing is convened.

 

c)         The appeal shall be continued to the next available docket opening, if acceptable to the appellant.

 

d)         If the request is approved, the Hearing Officer will send the appellant/authorized representative and all interested parties to the appeal a letter (with the original appeal number) rescheduling the hearing.  If the postponement is denied, the appellant/authorized representative will be notified in writing as well as all parties to the appeal. If the delay is allowed, the ninety (90) calendar day time limitation of the appeal process is extended by the number of calendar days of allowed delays and all parties to the appeal will be notified in writing.

 

(Source:  Amended at 13 Ill. Reg. 11193, effective July 1, 1989)

 

Section 240.465  Dismissal Due to Non-Appearance

 

a)         If neither the appellant nor the appellant's authorized representative appears at the time and place designated for the hearing, and a postponement has not been requested in writing, the appeal is considered abandoned and is dismissed.

 

b)         The refusal by the appellant/authorized representative to proceed with the hearing is considered a non-appearance.  The appeal is considered abandoned and is dismissed.

 

c)         Dismissal of an appeal is a final administrative decision.  The Department will make any planned change in services, which had been delayed pending the outcome of the appeal, immediately upon receipt of written notification from the Hearing Officer and will notify all parties to the appeal in writing.

 

d)         The Department will send a written notice to the appellant/authorized representative and all parties to the appeal advising that the appeal has been dismissed for non-appearance.

 

(Source:  Amended at 13 Ill. Reg. 11193, effective July 1, 1989)

 

Section 240.470  Rescheduling the Appeal Hearing

 

a)         Within 10 calendar days after the date of the dismissal notice, the appellant/authorized representative may submit a written request to reschedule the appeal hearing.  The written request to reschedule the appeal hearing must be sent to the Hearing Section as shown on the Dismissal Notice issued by the Hearing Officer.  The dismissal will be vacated if good cause can be shown for the non-appearance that led to the dismissal.  Good cause is defined as:

 

1)         Death in the family;

 

2)         Personal injury or illness that reasonably prohibits the appellant from attending the hearing; or

 

3)         Sudden and unexpected emergencies.

 

b)         If the appeal hearing is rescheduled, a Hearing Officer will send a letter rescheduling the hearing to the appellant/authorized representative with copies to all parties to the appeal.  The Department shall restore any benefits due the participant that were terminated or reduced as a result of the dismissal, shall send a letter so advising to the appellant/authorized representative, and shall send copies of the letter to all parties to the appeal.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.475  Recommendations of Hearing Officer

 

The hearing officer shall certify the entire record of the hearing to the Director of the Department and shall recommend a decision on each issue in the hearing.  The hearing officer shall not render a final decision relevant to any issue in the hearing.

 

(Source:  Added at 7 Ill. Reg. 8697, effective July 20, 1983)

 

Section 240.480  The Appeal Decision

 

a)         The decision resulting from the appeal shall be made in writing no later than 90 calendar days after the close of the hearing record.  The appellant/authorized representative and all other parties to the appeal shall be notified by sending to them a copy of the decision by U.S. mail. The decision shall be made by applying Department rules to the particular case situation.  Appeals shall be considered on a case-by-case basis.

 

b)         The final adminstrative decision shall be issued by the Director of the Department and it shall either:

 

1)         uphold or modify the Hearing Officer's recommendation in the appeal;

 

2)         not uphold the Hearing Officer's recommendation; or

 

3)         determine a lack of Department jurisdiction.

 

c)         The decision shall instruct the vendor/CCU/Department to take corrective action as appropriate.  In the event that the participant who is a party to the appeal purchased services not provided by the vendor during the period in which the appeal was conducted, the Department will reimburse the participant under the following conditions:

 

1)         the decision rendered by the Department is in favor of the participant in whose behalf the appeal was taken; and

 

2)         the appeal was based upon the denial of a request for services.

 

d)         Payment shall be authorized only for the level, type and amount of services for which payment would have been made through CCP during the same time period.  Payment shall not exceed the amount that would have been paid through CCP for the same services.

 

e)         The decision resulting from the appeal and the recorded transcript shall become a part of the record of the appeal.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.485  Reviewing the Official Report of the Hearing

 

At any time within 5 years after the date of the release of the Department's final administrative decision, the appellant/authorized representative may review the official report of the hearing.  The official report, including documents presented at the proceedings, findings of fact, and findings of law, will be made available by the Department on Aging upon request.  The Springfield office of the Department is the only location where the official report of the hearing may be reviewed.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

SUBPART E: REQUEST FOR SERVICES

 

Section 240.510  Participant Agreement for Community Care Program

 

If an individual is determined eligible for CCP, he/she or an authorized representative shall sign a written Participant Agreement and Consent Form to request services.

 

a)         Any participant requesting CCP services orally or in writing, shall be contacted by the CCU  within 5 calendar days after the date of the inquiry/request.

 

b)         The signed Participant Agreement and Consent Form will accompany an appropriately completed person-centered comprehensive assessment.

 

c)         The participant/authorized representative shall be informed in writing of eligibility requirements to receive services under CCP and of the participant's right to appeal under this Part.

 

d)         When a participant has a legally appointed guardian, the guardian shall sign the Participant Agreement and Consent Form – Person-Centered Plan of Care.  A legally appointed guardian may serve as the "guardian of the person" and/or "guardian of the estate". One legally appointed guardian may serve as guardian of the person while a second legally appointed guardian may serve as guardian of the estate. If 2 different persons are appointed guardian for an individual, one of the person and one of the estate, the guardian of the person determines which one is to sign the Participant Agreement and Consent Form.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.520  Who May Make Application (Repealed)

                                               

(Source:  Repealed at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.530  Date of Application (Repealed)

 

(Source:  Repealed at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.540  Statement to be Included on Participant Agreement and Consent Form

 

The following statement shall be included on the Participant Agreement and Consent Form:

 

NOTICE

 

I understand that a decision regarding my eligibility for Community Care services must be made within 30 calendar days after the date of this completed form. I must be notified in writing of the decision within 15 calendar days after it is made, and I will receive services, if I am eligible, within 15 calendar days after the notice of eligibility is mailed to me.  However, any delay I cause in failing to provide information requested by the Department on Aging will extend these time limits.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.550  Person-Centered Planning Process

 

A person-centered plan of care will be developed in collaboration with the participant who is eligible for services using a person-centered planning process with the CCU.

 

a)         The person-centered planning process will ensure:

 

1)         the opportunity for the participant/authorized representative to lead and direct the planning process, whenever possible, and to select other persons to participate in decision-making;

 

2)         the scheduling of timely meetings that occur at times and locations convenient to the participant/authorized representative, preferably in the participant's place of residence to assess the participant's environment to ensure the development of a person-centered plan of care that considers the participant's safety;

 

3)         the provision of necessary information and support to enable the participant/authorized representative to make informed choices and decisions;

 

4)         the inclusion of strategies for solving disagreements within the planning process, including clear guidelines for conflicts of interest on the part of all who participate in decision-making;

 

5)         the protection of the rights of the participant/authorized representative to choose available services, supports and providers/vendors; and

 

6)         the sharing of contact information for the CCU/Care Coordinator so the participant/authorized representative can request a redetermination of eligibility, additional or new services, or other updates and changes to the person-centered plan of care.

 

b)         The CCU will provide all information and support in a culturally-sensitive manner to ensure that the participant/authorized representative is able to make informed choices and decisions, including appropriate available options for limited English-proficient persons and/or those with a disability. 

 

c)         The CCU will provide a copy of the final person-centered plan of care and any subsequent revisions to the participant/authorized representative and any other person identified as being responsible for monitoring or implementing the plan, including the providers/vendors.

 

d)         The CCU will monitor the participant to prevent unnecessary or inappropriate care.

 

e)         Review of the Person-Centered Plan of Care

 

1)         The CCU will review and revise a person-centered plan of care:

 

A)        at least every 12 months following an assessment/reassessment of functional needs;

 

B)        when a participant's personal circumstances or functional needs change significantly; and

 

C)        at the request of a participant/authorized representative.

 

2)         The CCU will document its periodic review of the participant and any information that is collected under the measures being used to evaluate the effectiveness of the services and supports based on the described needs and related conditions of the participant.

 

3)         Revisions will be supported by a specific assessed functional need of the participant and a written justification included in the revised person-centered plan of care, indicating that the use of the previously identified adherence interventions and risk strategies were unsuccessful before changing services, supports and/or providers/vendors.  Changes will be scaled as appropriate first using the least intrusive options.  

 

4)         The CCU shall document that positive interventions and supports were used prior to any modification and that less intrusive methods were tried but were unsuccessful.

 

(Source:  Added at 42 Ill. Reg. 20653, effective January 1, 2019)

SUBPART F: ELIGIBILITY FOR COMMUNITY CARE PROGRAM SERVICES

 

Section 240.600  Eligibility Requirements

 

For purposes of being determined eligible to receive Community Care Program services, requirements of eligibility specified in Sections 240.710 through 240.875 must be satisfied.

 

(Source:  Amended at 13 Ill. Reg. 11193, effective July 1, 1989)

 

Section 240.610  Establishing Initial Eligibility

 

a)         Once a participant/authorized representative has contacted the CCU, establishing initial eligibility is the joint responsibility of the participant/authorized representative and the CCU.

 

b)         It is the responsibility of the participant/authorized representative to provide the factual information necessary to establish eligibility.  Should the participant/authorized representative be unable to do so, CCU staff, with the consent of the participant/authorized representative, shall assist in obtaining this information.

 

c)         If the participant/authorized representative refuses to give consent, and information needed for eligibility determination is, therefore, unavailable, the request for services shall be denied.

 

d)         If a home visit, as required by Section 240.620, is made at the address provided by the participant/authorized representative and the participant cannot be located, the request for services shall be denied.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.620  Home Visit

 

a)         Determinations and redeterminations of need for CCP services shall be administered during a visit to the home of the participant, except when conducted in the prescreening process or when a CCP participant has been hospitalized or placed in any type of institution and will be discharged to the community in less than 60 calendar days.

 

b)         A home visit shall be conducted, and a redetermination of need administered in the participant's home, within 15 calendar days after a participant's discharge from a hospital or other institution.

 

c)         A home visit shall not be required in the conduct of determinations or redeterminations of need following hospitalization for routine procedures, as defined in Section 240.160.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.630  Determination of Eligibility

 

a)         A determination of eligibility is an examination of each participant's circumstances to determine the functional need for receipt of CCP, nursing facility, or supported living program provider services.  This determination shall consist of analyzing, evaluating and documenting, when necessary, current, full and complete information obtained from the face-to-face comprehensive assessment of the participant in his/her place of residence.

 

b)         The assessment shall include the comprehensive assessment tool and all required CCP forms authorized by the Department, or any successor assessment tool and forms used to determine the need for long-term services and supports.

 

c)         A participant's request/services may be denied or terminated when eligibility criteria are not met, as required by Sections 240.710 through 240.875.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.640  Eligibility Decision

 

A decision regarding the participant's initial eligibility or ineligibility to receive CCP services shall be made within 30 calendar days after the date of receipt by the Department or its CCU of a completed referral form for CCP services, unless delayed by the participant/authorized representative. (See Section 240.660.)

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.650  Continuous Eligibility

 

Eligibility shall be continuous throughout the participant's participation in CCP.  Continuous eligibility is validated through the redetermination process specified in Section 240.655, except for instances involving an automatic, non-discretionary change in eligibility, rates or benefits by federal or State statute or regulation. A redetermination of eligibility shall be conducted at least once annually or as requested, and as required by Section 240.655.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.655  Redeterminations Process

 

Redetermination of CCP shall be conducted by the CCU at least annually; whenever requested by the participant/authorized representative; or whenever the participant may have experienced a change in his/her needs that indicates the need for a redetermination to assure continued eligibility (see Section 240.630).

 

a)         A decision on the redetermination shall be made within 30 calendar days after the date the redetermination process begins, except as extended by the Department.

 

b)         Redeterminations conducted at the request of the participant/authorized representative or whenever the participant may have experienced a change in needs shall be accomplished and a decision rendered within 30 calendar days after the date of the request for redetermination, except as extended by the Department.

 

c)         The 30 calendar day time limit for completion of a redetermination of a participant's eligibility shall be extended by any delay caused by the participant/authorized representative.

 

1)         Participant delay is defined as the number of calendar days a redetermination of eligibility is delayed because of the participant's/authorized representative's failure to provide documentation supporting his/her eligibility or otherwise cooperate as set out in Section 240.350.

 

2)         In the event that a participant's eligibility cannot be determined due to the participant's/authorized representative's failure to provide documentation within 30 calendar days after the date it is verbally requested by the CCU, the CCU shall extend the time limit for an additional 60 calendar days, after which services shall be terminated if documentation is not provided.

 

d)         The participant shall maintain eligibility and services shall continue to be provided throughout the redetermination process unless the participant/authorized representative delays the process beyond the additional 60 calendar days specified in subsection (c)(2).

 

e)         Written notification to the participant/authorized representative shall be made as required by Section 240.945.

 

f)         Any change in services shall be initiated within 15 calendar days after the date the written notice is mailed to the participant/authorized representative, as required by Section 240.945.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.660  Extension of Time Limit

 

The 30 calendar day time limit for completion of a determination of a participant's eligibility may be extended by any delay caused by the participant.

 

a)         Participant delay is defined as the number of calendar days a determination of eligibility is delayed because of the participant's/authorized representative's failure to provide documentation supporting his/her eligibility.

 

b)         In the event that a participant's eligibility cannot be determined due to the participant's/authorized representative's failure to provide documentation within 90 calendar days after the date of receipt of the completed referral form, the request for services shall be denied.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

SUBPART G: NON-FINANCIAL REQUIREMENTS

 

Section 240.710  Age

 

To be eligible to receive CCP services, a participant shall be at least 60 years of age. A participant's/authorized representative's statement regarding age shall be accepted unless the information is contradictory, not specific, or otherwise questionable.  In these cases, the participant/authorized representative is responsible for providing documentation of age to supplement the statement.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.715  Determination of Need

 

a)         To be eligible to receive CCP services, a participant shall exhibit a need for nursing facility, supportive living program, or home and community-based services.  The Determination of Need assessment tool or any successor assessment tool authorized by the Department specifies the factors that together, determine the participant's need for long term care or home and community-based services.

 

b)         The need for long term care is based upon the determined need for a continuum of in-home and community-based services to prevent inappropriate or premature placement in a nursing facility.

 

c)         The extent and degree of a participant's need for long term care shall be determined on the basis of impaired cognitive and functional status as well as the available physical/environmental supports provided to the participant by family, friends or others in the community.

 

d)         The Determination of Need assessment tool consists of 2 parts:

 

1)         The Mini-Mental State Examination (Folstein, Folstein and McHugh, 1975, no later editions or amendments included) measures cognitive functioning of the participant.

 

A)        The participant who receives a score of 21 or higher shall be considered cognitively intact and zero points shall be added to the Part A, Level of Impairment, score on the Determination of Need assessment tool.

 

B)        The participant who receives a score of 20 or less or who has been diagnosed by a physician or psychiatrist as having dementia, Alzheimer's disease, or organic brain syndrome shall be considered cognitively impaired and 10 points shall be added to the Part A, Level of Impairment, score on the Determination of Need assessment tool.

 

C)        Ten additional points shall be added to the Part A, Level of Impairment, score on the Determination of Need assessment tool for the participant who meets the following 3 criteria:

 

i)          Participant has been adjudicated disabled or incompetent by a Probate Court judge or judge assigned to render a decision on such matters in a court of competent jurisdiction; 

 

ii)         a physician or psychiatrist licensed by the State of Illinois has certified that, in his/her professional judgement, the participant suffers from Alzheimer's disease, organic brain syndrome, or dementia; and

 

iii)        a physician or psychiatrist licensed by the State of Illinois has certified that, in his/her professional judgement, the participant requires 24-hour home and community-based services to remain in the home.

 

2)         The Determination of Need assessment tool measures the participant's ability to perform the following activities of daily living (ADLs) and instrumental activities of daily living (IADLs):

 

A)        Activities of Daily Living

 

i)          Eating

 

ii)         Bathing

 

iii)        Grooming

 

iv)        Dressing

 

v)         Transferring

 

vi)        Incontinence

 

B)        Instrumental Activities of Daily Living

 

i)          Preparing meals

 

ii)         Being alone

 

iii)        Telephoning

 

iv)        Managing money

 

v)         Routine health

 

vi)        Special health

 

vii)       Outside home

 

viii)      Laundry

 

ix)        Housework

 

e)         The Determination of Need assessment scale includes the 6 ADLs and 9 IADLs identified. Each function is scored in 2 parts:  Part A – Level of Impairment, and Part B – Unmet Need for Care.

 

1)         Part A − Level of Impairment, of the Determination of Need assessment tool measures the ability of the participant to perform each ADL and IADL function.  A scoring range of zero through 3 indicates the degree of impairment of the participant in the performance of ADLs and IADLs.

 

A)        A score of zero for any function indicates that the participant performs or can perform all essential components of the activity, with or without an existing assistive device, such that:

 

i)          no significant impairment of function remains;

 

ii)         activity is not required by the participant  (routine health and special health only);

 

iii)        the participant may benefit from but does not require supervision or physical assistance.

 

B)        A score of 1 for any function indicates that the participant performs or can perform most essential components of the activity, with or without an existing assistive device, but some impairment of function remains such that the participant requires some supervision or physical assistance to accomplish some or all components of the activity.  This includes the participant who:

 

i)          experiences minor, intermittent fatigue in performing the activity;

 

ii)         takes longer time to accomplish than an unimpaired person requires; or

 

iii)        must perform the activity more frequently than an unimpaired person.

 

C)        A score of 2 for any function indicates that the participant cannot perform most of the essential components of the activity, even with an existing assistive device, and requires a great deal of assistance or supervision to accomplish the activity.  This includes the participant who:

 

i)          experiences frequent fatigue in performing the activity;

 

ii)         takes an excessive amount of time to perform the activity; or

 

iii)        must perform the activity much more frequently than an unimpaired person.

 

D)        A score of 3 for any function indicates that the participant cannot perform the activity and requires someone to perform the task, although the participant may be able to assist in small ways, or requires constant supervision.

 

2)         Part B, Unmet Need for Care, of the Determination of Need assessment tool measures the need of the participant for assistance/performance/supervision for each ADL and IADL function that is not being met by non-CCP resources in the community (e.g., family, friends, local services).

 

A)        A score of zero for any function indicates that there is no impairment, or that the participant's need for assistance is met to the extent that the participant is at no risk to health or safety if additional assistance is not acquired, or that additional assistance will not benefit the participant, or that the participant's needs are being met by non-CCP resources and, therefore, the participant has no need for assistance.

 

B)        A score of 1 for any function indicates that the participant's need for assistance is met most of the time, but the participant's health and safety are at minimal risk if additional assistance is not acquired.

 

C)        A score of 2 for any function indicates that the participant's need for assistance is not met most of the time, and the participant's health and safety are at moderate risk if additional assistance is not acquired.

 

D)        A score of 3 for any function indicates that the participant's need for assistance is rarely, or never, met and the participant's health and safety are at severe risk, which would require acute medical intervention, if additional assistance is not acquired.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.727  Minimum Score Requirements

 

Participants determined eligible to receive CCP services shall have their need for nursing facility care or home and community-based services established by receipt of a minimum score of 29 points on the DON, 15 of which must be scored on Total Impairment, which includes Part A and the MMSE (see Section 240.715).

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.728  Maximum Payment Levels for Person-Centered Plans of Care Including In-home Service

 

Maximum monthly service dollars are calculated according to the participant's total DON score and approved person-centered plan of care for in-home service or other combination of options, excluding adult day service.  These maximum monthly service dollars will be adjusted by the Department to be consistent with any future unit rate adjustments for CCP providers.

 

DON SCORE	SERVICE MAXIMUM LEVEL (Effective on and after January 1, 2022)
29	$    627
30	701
31	777
32	852
33	926
34	1,002
35	1,077
36	1,150
37	1,226
38	1,301
39	1,375
40	1,451
41	1,526
42	1,599
43	1,676
44	1,750
45	1,827
46	1,899
47	1,975
48	2,051
49	2,123
50	2,200
51	2,275
52	2,350
53	2,424
54	2,496
55	2,573
56	2,648
57	2,725
58	2,797
59	2,874
60	2,949
61	3,022
62	3,098
63	3,174
64	3,247
65	3,322
66	3,399
67	3,471
68	3,547
69	3,622
70	3,696
71	3,772
72	3,847
73	3,920
74	3,997
75	4,071
76	4,147
77	4,221
78	4,296
79	4,372
80	4,444
81	4,521
82	4,596
83	4,671
84	4,745
85	4,822
86	4,895
87	4,969
88	5,046
89	5,118
90	5,195
91	5,270
92	5,343
93	5,419
94	5,495
95	5,568
96	5,643
97	5,720
98	5,792
99	5,868
100	5,944

 

(Source:  Amended at 46 Ill. Reg. 12492, effective July 1, 2022)

 

Section 240.729  Maximum Payment Levels for Person-Centered Plans of Care Including Adult Day Service

 

Maximum monthly service dollars are calculated according to the participant's total DON score and approved person-centered plan of care for adult day service or other combination of options including adult day service. These maximum monthly service dollars will be adjusted by the Department to be consistent with any future unit rate adjustments for CCP providers.

 

DON SCORE	SERVICE MAXIMUM LEVEL (Effective on and after January 1, 2022)
29	$  1,284
30	1,493
31	1,717
32	1,937
33	2,161
34	2,382
35	2,518
36	2,652
37	2,786
38	2,920
39	3,055
40	3,191
41	3,325
42	3,460
43	3,595
44	3,729
45	3,865
46	4,000
47	4,135
48	4,268
49	4,403
50	4,538
51	4,673
52	4,809
53	4,941
54	5,076
55	5,212
56	5,344
57	5,481
58	5,615
59	5,750
60	5,884
61	6,019
62	6,154
63	6,287
64	6,424
65	6,557
66	6,693
67	6,830
68	6,961
69	7,098
70	7,233
71	7,367
72	7,502
73	7,637
74	7,771
75	7,905
76	8,041
77	8,175
78	8,311
79	8,445
80	8,578
81	8,714
82	8,849
83	8,983
84	9,118
85	9,254
86	9,386
87	9,522
88	9,656
89	9,789
90	9,926
91	10,059
92	10,196
93	10,332
94	10,463
95	10,600
96	10,735
97	10,870
98	11,004
99	11,138
100	11,273

 

(Source:  Amended at 46 Ill. Reg. 12492, effective July 1, 2022)

 

Section 240.730  Person-Centered Plan of Care

 

a)         A person-centered plan of care will be developed using the person-centered planning process in accordance with Section 240.550. 

 

b)         The person-centered plan of care, and any subsequent revisions, shall be written in plain language and shall reflect the participant's goals, preferences and desired outcomes, indicating services and supports important to the participant, based upon the functional needs identified by the comprehensive assessment, including:

 

1)         a description of the conditions that directly correspond to the assessed functional needs, including:

 

A)        the strengths and preferences of the individual, and resources available to him/her;

 

B)        the clinical and support needs as identified through a comprehensive assessment of functional needs;

 

C)        paid and unpaid services and supports that will assist the participant to achieve identified goals, and natural supports and vendors available to meet those needs;

 

D)        risk factors and measures in place to minimize harm, including possible interventions that may be used if aid is necessary for adherence to program requirements, and the customized strategies and back-up plans to minimize any risk factors for the individual;

 

E)        identification of the Care Coordinator and other individuals/vendors responsible for monitoring the person-centered plan of care;

 

F)         any measures that will be used to support how to evaluate the effectiveness of the services and supports; and

 

G)        the time limits for periodic reviews to determine if services and supports are still appropriate, need to be modified, or can be terminated.

 

2)         a summary of the alternatives and settings considered by the participant/authorized representative and his/her final selections of services, supports and providers/vendors as reinforcement that the right of freedom of choice may be exercised.

 

A)        The CCU will list all providers or programs in the service area and document the available options discussed with the participant/authorized representative. 

 

B)        The CCU will also afford the participant/authorized representative an opportunity to visit all of the adult day facilities in his/her service area before finalizing any selections.

 

3)         an acknowledgement of informed consent by the participant/authorized representative.

 

c)         Services are to be offered to each participant who meets the minimum required scores on the DON; who meets all other eligibility requirements; for whom an adequate person-centered plan of care has been developed; and whose service costs are within the allowable maximums. Care coordinators and participants/authorized representatives shall develop the person-centered plan of care in the best interest of the participant/authorized representatives, based on services selected by the participants/authorized representatives from among those available in the community.  Maximum monthly service dollars are only available to fund services provided through the CCP.

 

d)         If a person-centered plan of care cannot be developed that adequately meets the participant's needs within the allowable maximums for cost of service, CCP services shall be denied or services terminated, as appropriate to the case.

 

e)         Each participant/authorized representative must be advised by the CCU of his/her right to refuse the offered services, to choose to enter a long-term care facility or to choose neither.

           

f)         The allowable monthly cost for services provided to an eligible participant and paid for through the CCP cannot exceed the maximum monthly cost as determined by the score attained on the CCP DON that is determined by the CCU based on current, full and complete information on the specific needs of the participant.  A person-centered plan of care shall be based upon the number of days in a month.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.735  Supplemental Information

 

The CCP determination of eligibility shall be supplemented by any collateral casework information (e.g., medical statement from attending Physician, Nurse Practitioner, Registered Nurse or Christian Science Practitioner, and documentation of family support) deemed necessary by the Department.  Supplemental casework information will be included in the case notes.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.740  Assessment of Need

 

a)         The CCP comprehensive assessment tool and determination of need for CCP services shall be administered by CCU care coordinators or Department personnel who are technically competent persons certified by the Department to conduct the comprehensive assessment and determinations of need.

 

b)         The certification shall result from the successful completion of training, which includes, but is not limited to, the following topics.

 

1)         financial eligibility determination (see Sections 240.800 through 240.875);

 

2)         administration of the DON (see Section 240.715);

 

3)         person-centered plan of care development and implementation;

 

4)         performance of Choices for Care screenings (see Section 240.1010); and

 

5)         form utilization and flow.

 

c)         Scoring of the CCP DON shall be accomplished without regard to the capability of CCP vendors to totally meet the determined needs of the participant.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.741  Prerequisites for Automated Medication Dispenser Service

 

a)         Authorization for the AMD service is determined based on a participant's need for the service, including the participant's medication, medical, cognitive and physical needs that indicate the potential to benefit from the AMD service.

 

b)         To be authorized for the service, the participant must:

 

1)         meet all of the following criteria:

 

A)        eligibility for CCP services;

 

B)        take 1 or more medications that necessitate the medications be taken at a set schedule to avoid complications;

 

C)        have the potential to benefit from the service, understand the need to take medications, respond to alerts to take medication and is physically able to take medication independently from the AMD unit;

 

D)        designate an assisting party to assist with the AMD unit and medications; and

 

E)        commit to using the AMD unit appropriately; and

 

2)         exhibit at least 1 of the following issues or diagnoses:

 

A)        a history of non-adherence to treatment, medication or therapy regimens;

 

B)        resides alone or lacks assistance from others to assist with regular medication administration;

 

C)        impaired motor function that causes difficulty in handling medication receptacles and small pills;

 

D)        attempts at using less costly alternatives (e.g., pill reminders, medication organizers with alarms and telephone reminders/prompts) have failed;

 

E)        recent transition from a more restrictive care setting, such as a hospital or nursing facility;

 

F)         has a diagnosis of cognitive impairment;

 

G)        has a diagnosis of diabetes;

 

H)        has a diagnosis of congestive heart failure;

 

I)         has a diagnosis of hypertension;

 

J)         has a diagnosis of depression/mental illness; or

 

K)        has a diagnosis of cancer.

 

c)         Other criteria may be developed by the Department to assist in determining what is the most appropriate AMD system to meet the participant's needs.

 

d)         The participant/authorized representative and/or the assisting party shall complete documentation acknowledging that the AMD was installed.  Whenever possible, the assisting party should be present during the AMD installation.

 

e)         The assisting party must complete documentation requested by the Department agreeing that he/she/they will be responsible for:

 

1)         administration and oversight of the participant's medications;

 

2)         manually filling or arranging for another person, who could be the participant, to fill the AMD unit in accordance with prescribing instructions;

 

3)         working with the AMD provider to program the dispenser for the initial medication schedule and subsequent changes;  

 

4)         using best efforts to ensure no illegal substances are placed in the AMD unit;

 

5)         serving as a point of contact for the AMD provider and taking reasonable and necessary actions based on any notifications of missed medication doses and other system issues;

 

6)         receiving and understanding the instructions and demonstration given by the AMD provider for the AMD equipment;

 

7)         understanding how to access reports about the unit and medication regimen and contacting the AMD provider when medication schedules are changed; and

 

8)         providing reasonable advance notice to the AMD provider, CCU, and participant/authorized representative if unable to continue acting as the assisting party.

 

f)         A participant/authorized representative will be responsible for damages to or loss of the AMD equipment unless a law enforcement report of theft has been filed.

 

1)         The provider will document the damages/loss of equipment.

 

2)         One documented occurrence of damages/loss of equipment may be cause for suspension of the participant's AMD services pending termination, in accordance with the Participant Agreement.  The provider will verbally advise the CCU on the same day, if possible, but not later than the next work day after the date of the occurrence.  A written report, including, at a minimum, the names of the participant and the worker and the date of the occurrence, will be submitted by the provider to the CCU within 2 work days after the date of the occurrence.  The written report may be submitted in person or through mail, facsimile or electronic means.

 

3)         Upon receipt of the written report documenting the occurrence of damages/loss of equipment, the CCU may suspend the participant's AMD services in accordance with Section 240.930.  The date of suspension may be the date of the occurrence of damages to or loss of equipment.

 

g)         Whenever an assisting party can no longer meet the obligations set out in subsection (e), it is the responsibility of the participant/authorized representative to identify a new assisting party and cooperate with arrangements for that individual to be trained by the AMD provider.  Notification of the change shall be communicated to the AMD provider and the CCU before the change is made.

 

h)         An assisting party cannot be an individual or entity providing other services under CCP, such as an in-home service provider.

 

i)          Failure to have a current assisting party designation may result in the participant's termination from the AMD service, in accordance with Section 240.930.

 

(Source:  Amended at 44 Ill. Reg. 2780, effective January 29, 2020)

 

Section 240.750  Citizenship

 

To be eligible for CCP, a participant must be either a U.S. citizen or a noncitizen within the specific categories and subject to the restrictions set forth at 89 Ill. Adm. Code 120.310.

                                   

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.755  Residence

 

a)         To be eligible for CCP, a participant must be a resident of the State of Illinois as defined in Section 2-10 of the Public Aid Code [305 ILCS 5].

 

b)         Only those persons who are legally admitted to the U.S. can be found to be residents of the State of Illinois. The residency of a participant is based on 1 of the following factors:

 

1)         A participant whose residence is located in Illinois, butwhose U.S. Post Office address indicates a state other than Illinois (i.e., a participant residing near the State line), is a resident of Illinois;

 

2)         An individual currently living in Illinois and receiving a State Supplementary Payment (as defined in 42 CFR 435.4), Mandatory State Supplement or Optional State Supplement from a different state, is not a resident of Illinois for purposes of CCP eligibility;

 

3)         A participant who is incapable of stating his/her intent to remain in Illinois is a resident of Illinois if he/she currently lives in Illinois.

 

c)         Illinois cannot deny eligibility to a participant who, although currently residing in Illinois, has not lived in this State for a specific period of time.  An Illinois resident who is temporarily absent from the State retains Illinois residency if the individual intends to return to Illinois when the reason for the absence is accomplished.  If an individual remains outside of Illinois for a continuous period of more than 12 months, he/she will provide evidence (e.g., a copy of his/her most recent State Income Tax return) documenting that the absence was not due to an intent to change his/her residency.

 

d)         Illinois cannot deny eligibility to a participant who is temporarily absent from Illinois and plans to return when the purpose of his/her absence has been completed unless the absence will exceed 60 calendar days or unless the other state has determined that the participant is a resident of that state.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.760  Social Security Number

 

a)         To be eligible for CCP, each participant must furnish a Social Security Number (SSN).  If more than 1 SSN has been used by a participant, then all SSNs are to be furnished.

 

b)         If any CCP participant does not have an SSN, the Department or CCU shall assist him/her in making the application.

 

c)         CCP services will not be denied, delayed or discontinued pending the issuance or validation of an SSN if the participant has applied for the SSN.

 

d)         Participants who refuse to furnish an SSN, and/or apply for an SSN when requested, are ineligible for CCP.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

SUBPART H: FINANCIAL REQUIREMENTS

 

Section 240.800  Financial Factors

 

a)         All CCP participants/authorized representatives are required to provide information, relative to the value and types of assets owned, requested to determine eligibility for services under CCP based on enrollment in a medical assistance program administered by HFS.

 

b)         All participants/authorized representatives are required to provide information, relative to the amount and source of all income, requested to determine eligibility for services under CCP based on enrollment in a medical assistance program administered by HFS.

 

c)         To determine whether a participant is presumptively eligible for enrollment to receive interim services under Sections 240.865 and 240.1020, CCUs will determine assets and income in accordance with the requirements set forth by HFS at 89 Ill. Adm. Code 120 (Medical Assistance Programs).

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.810  Assets

 

a)         To be eligible to receive CCP services, a participant shall not own interest in non-exempt assets having a combined value in excess of $17,500, if:

 

1)         unmarried; or

 

2)         married and:

 

A)        spouse is receiving CCP services;

 

B)        spouse is in a nursing facility;

 

C)        spouse does not reside on a permanent basis with, and does not receive support from or give support to, theparticipant;

 

D)        spouse is abandoned; or

 

E)        spouse is potentially abusing the participant.

 

EXCEPTION:  A participant, who is married and the spouse does not receive CCP services, shall not own interest in non-exempt assets having a total value in excess of the asset disregard amount allowed by HFS for Medicaid in a pre-paid burial plan or life insurance policy + burial merchandise. Non-exempt assets having value over the asset disregard amount up to the amount allowed by the Community Spouse Asset Allowance, as adopted by HFS at 89 Ill. Adm. Code 120.379(d), must be transferred to or for the sole benefit of the community spouse.  If the couple owns assets that exceed the asset disregard and prevention of spousal impoverishment amounts allowed by statute, the excess (up to the amount of non-exempt assets allowed after transfer, and/or up to the amount of countable monthly income allowed after diversion) shall be designated as a spend down, to be spent before Medicaid enrollment is established.

 

b)         The value of non-exempt assets shall be considered in determining eligibility for CCP.

 

c)         All assets not specifically exempt are non-exempt.

 

d)         When a participant's non-exempt assets are greater than the allowable disregard as specified in subsection (a), consideration of non-liquid assets may be deferred as follows:

 

1)         real property may be deferred from consideration for 6 months;

 

2)         the participant shall sign an agreement to dispose of the real property in excess of the allowable disregard within 6 months after the date of the agreement; and

 

3)         the 6-month period for disposition may be extended an additional 6 months if the participant fails to dispose of the asset (through no fault of his/her own) despite reasonable and diligent effort.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.815  Exempt Assets

 

a)         Exempt Assets

 

1)         Homestead property.

 

2)         Clothing and personal effects.

 

3)         Household furnishings.

 

4)         Business or farming equipment used for the production of income.

 

5)         Motor vehicles except those primarily used for recreational purposes.

 

6)         Group life insurance held as a condition of employment or provided by employer.

 

7)         The principal of a trust fund only when the instrument establishing the trust specifically states the principal cannot be impaired.

 

8)         One of the following:

 

A)        a prepaid burial plan with a total value of up to the amounts specified in 89 Ill. Adm. Code 120.381(c) and (d) if burial merchandise is not specified.  If burial merchandise is specified in the burial plan, that merchandise shall be exempt.  Any excess of the allowed amounts in value for burial services shall be considered non-exempt; or

 

B)        life insurance policy with a total face or cash value of the amount specified in 89 Ill. Adm. Code 120.381(a)(5) or less.  When both cash and face value exceed this amount, apply the excess cash value over this amount toward the non-exempt assets.

 

C)        Burial spaces intended for use of the participant and grave markers shall be exempt (see 89 Ill. Adm. Code 120.381(b)).

 

9)         The value of the allotment under the Supplemental Nutrition Assistance Program (SNAP) Act of 2008 (7 USC 2017(b)).

 

10)         The value of the U.S. Department of Agriculture donated foods (surplus commodities).

 

11)         The value of supplemental food assistance received under the Child Nutrition Act of 1966 as amended (42 USC 1780(b)) and the special food service program for children under the National School Lunch Act, as amended (42 USC 1760).

 

12)         Assets protected by purchase of a certified long-term care insurance policy that meets State standards [320 ILCS 35/25(a)(1) through (5)].

 

b)         In addition to the exempt assets listed in subsection (a), the following assets are exempt.  These assets remain exempt only so long as they can be identified by a separate account.

 

1)         Any benefits received under Title III, Part C, Nutrition Program for the Elderly, of the Older Americans Act of 1965, as amended (42 USC 3030(e) and (f)).

 

2)         Any payment received under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (42 USC  4636).

 

3)         Any funds distributed per capita to or held in trust for members of any Indian tribe under P.L. 92-254, P.L. 93-134 or P.L. 97-458 (25 USC  1407).

 

4)         Tax-exempt portions of payments made pursuant to the Alaska Native Claims Settlement Act (43 USC  1626).

 

5)         Experimental Housing Allowance Program payments made under Annual Contributions Contracts entered into prior to January 1, 1975, under Section 23 of the U.S. Housing Act of 1937, as amended (42 USC  1437 (f)).

 

6)         Effective October 17, 1975, receipts distributed to certain Indian tribal members for marginal land held by the United States government.

 

7)         Payments to volunteers under the 1973 Domestic Volunteer Service Act (42 USC  5044, Section 4951).  These include:

 

A)        Vista Volunteers;

 

B)        Volunteers serving as senior health aides, senior companions, foster grandparents, or persons serving in the National Senior Volunteer Corps (NSVC).

 

8)         Any grant or loan to any undergraduate student for educational purposes made or insured under any program administered by the Secretary of Education.

 

9)         Supplemental Security Income (SSI) lump sum payments.

 

10)         Income received under Section 4(c) of the Senior Citizens and Persons with Disabilities Property Tax Relief Act [320 ILCS 25].  This includes both the benefits commonly known as the "circuit breaker" and the "additional grants".

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.820  Asset Transfers

 

a)         The following transactions are considered transfers of assets:

 

1)         when a participant buys, sells or gives away real or personal property; or

 

2)         if the participant changes the way real or personal property is held.

 

b)         Transfers of assets that are exempt at the time of transfer do not affect eligibility.

 

c)         Transfers of non-exempt assets completed within 60  months before the date of request for CCP services  shall be considered in determining eligibility.  If a fair market value was not received, the value of the transferred asset shall be considered toward non-exempt assets and any excess amount shall be considered available to meet service costs unless it is proven that the participant did not transfer the property to qualify for or increase the need for CCP.

 

1)         If real property was transferred, fair market value is to be determined by use of statements from reputable realtors or other community members recognized as knowledgeable of property value (e.g., bankers, tax assessors, auctioneers).

 

2)         If personal property was transferred, fair market value is to be determined by use of a statement from an institution having knowledge of the property at the time of the transfer, or from an individual who has specific knowledge of the transfer and/or the value of the asset at the time of the transfer.

 

3)         Factors to be considered when determining whether a transfer of property was made to qualify for or increase the need for CCP include but are not limited to:

 

A)        the participant's physical and mental condition at the time of transfer;

 

B)        the participant's financial situation at the time of transfer;

 

C)        the participant's need for services at the time of transfer;

 

D)        changes in the participant's living arrangements at the time of transfer; and

 

E)        how soon after the transfer the participant applied for services.

 

d)         If after consideration of these factors the participant is ineligible, the period of ineligibility begins at the date of request for services for participants and the date of termination for participants.  The period of ineligibility lasts from the initial date for as long as the asset would meet the cost of CCP services if it were available to the participant, but in no case shall it last longer than 60 months after the date of transfer.

 

e)         A participant determined ineligible under subsection (d) may become eligible if the following occurs:

 

1)         the property is reconveyed to the participant; or

 

2)         an adequate consideration is paid to the participant.

 

f)         It shall be the responsibility of a participant to report all property transfers to the CCU within 5 days after the date of the transaction.

 

g)         If an unreported transfer of property was made by a participant within 60 months prior to the date of request for services or was made after the submission of the request for services but before CCP services were authorized, and services to which the participant was not entitled were received as a result of the failure to report the transfer, services shall be terminated.

 

h)         Involuntary transfers do not affect eligibility.

 

i)          When the property transfer was made to obtain support or care, and the terms of the agreement are being met, only those needs not included in the agreement may be met through CCP.

 

j)          Transfers because of separation, divorce or other settlement shall not affect eligibility if:

 

1)         they are court ordered; or

 

2)         if there is no court order and the participant and his/her spouse divide the property in half.

 

k)         Transfers from an individual bank account to a joint bank account do not affect eligibility if the participant retains access to the money and the money continues to be used for the participant's needs.

 

l)          Income tax refunds are available assets.  If the refund is based on a joint income tax return, one-half of the refund is to be considered as belonging to the participant.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.825  Income

 

a)         Documentation of all currently available income that is not specified as exempt shall be provided during the participant's determination/redetermination of eligibility for CCP.

           

b)         In accordance with provisions of 89 Ill. Adm. Code 120.379, a participant whose spouse (i.e., community spouse) is not receiving CCP services may divert income to his/her spouse so that the spouse may have exempt income up to the amount exempted by HFS (see 89 Ill. Adm. Code 120.379(e)) for a community spouse. 

           

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.830  Unearned Income Exemptions

 

Unearned income is all income other than that received in the form of salary or wages for services performed as an employee or profits from self-employment.

 

a)         The following unearned income shall be exempt from consideration in determining eligibility:

 

1)         Any allotment under SNAP (7 USC 2017(b));

 

2)         The value of the U.S. Department of Agriculture donated foods (surplus commodities);

 

3)         Any payment received under the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (42 USC 4636);

 

4)         Any per capita judgment funds paid under Public Law 92-254 to members of the Blackfeet Tribe of the Blackfeet Indian Reservation, Montana and Gros Ventre Tribe of the Fort Belknap Reservation, Montana (25 USC 1264);

 

5)         Any benefits received under Title III, Nutrition Program for the elderly, of the Older Americans Act of 1965, as amended (42 USC 3030(e));

 

6)         Any compensation provided to individual volunteers under the Retired Senior Volunteer Program (42 USC 5001) and the Foster Grandparent Program (42 USC 5011) and Older Americans Community Service Programs (42 USC 3056) established under Title II of the Domestic Volunteer Service Act, as amended (42 USC 5001 through 5023);

 

7)         Income in an amount not greater than the current amount allowed received by a beneficiary of life insurance which is expended on the funeral and burial of the insured;

 

8)         Income received under Section 4(c) of the Senior Citizens and Persons with Disabilities Property Tax Relief Act.  This includes both the benefits commonly known as the "circuit breaker" and "additional grants";

 

9)         Payments to volunteers under the 1973 Domestic Volunteer Service Act (48 USC 5044(q)).  These include:

 

A)        Vista Volunteers;

 

B)        volunteers serving as senior health aides, senior companions, or foster grandparents;

 

C)        persons serving in the Service Corps of Retired Executives (SCORE) or the Active Corps of Executives (ACE);

 

10)         Social Security death benefits expended on a funeral/burial;

 

11)         The value of home produce that is used for personal consumption;

 

12)         The value of supplemental food assistance received under the Child Nutrition Act of 1966, as amended, (42 USC 1780(b)) and the special food service program for children under the National School Lunch Act, as amended (42 USC 1760);

 

13)         Any payments distributed per capita or held in trust for members of any Indian tribe under Public Law 92-254, 93-134 or 94-450 (25 USC 1407);

 

14)         Tax exempt portions of payments made pursuant to the Alaska Native Claims Settlement Act (43 USC 1626);

 

15)         Experimental Housing Allowance Program payments made under Annual Contributions Contracts entered into prior to January 1, 1975 under Section 23 of the U.S. Housing Act of 1937, as amended (42 USC 1437(f));

 

16)         That portion of an educational benefit that is actually used for items such as tuition, books, fees, equipment or transportation, necessary for school attendance:

 

A)        Veterans Educational Assistance –  

Income from educational benefits paid to a veteran or to a dependent of a veteran shall be exempt only to the extent that it is applied toward educational expenses;

 

B)        Social Security Administration (SSA) Benefits –

Income received as a SSA benefit paid to or for an individual and conditioned upon the individual's regular attendance in a school, college or university, or a course of vocational or technical learning, shall be exempt to the extent that it is applied toward educational expenses;

 

C)        Loan and Grants –  

Income from educational loans and grants obtained and used under conditions that prevent their use for current living costs shall be exempt;

 

17)         Income from educational loans and grants made or insured under any program administered by the Secretary of Education is totally exempt whether the grant is paid directly to the schools or to the student. These loans and grants include the National Direct Student Loans, Basic Educational Opportunity Grants, Supplementary Educational Opportunity Grant, Work Study Grant, and the Guaranteed Loan Program;

 

18)         The following incentive allowances:

 

A)        National Training Services Grant –

Incentive payments which the Department of Rehabilitation Services authorizes to be paid for a maximum of 2 years to disabled persons receiving categorical public assistance and enrolled in the National Training Service Project;

 

B)        Jobs Training Partnership Act (JTPA) –

Needs based payments (e.g., transportation); case assistance (e.g., uniforms and lunches); compensations in lieu of wages; and allowances received under JTPA are exempt.

 

b)         Unearned Income In-Kind

 

1)         Unearned income in-kind is payment made by a person other than a member of a participant's family on behalf of or in the name of a member of the participant's family (e.g., payment of CCP incurred expense for care, medical bills, etc.).

 

2)         Unearned income in-kind shall be exempt.

 

3)         When the participant's family shares a dwelling unit with another family or individuals, the exchange of cash for purposes of satisfying payment of shelter related obligations shall not constitute an income in-kind payment and shall not be considered available to the person who receives and disburses the shelter-related payment.

 

c)         Earmarked Income

 

1)         Earmarked income is income restricted for the use of a specified participant by court order or by legal stipulation of a contributor.

 

2)         Earmarked income shall be considered as income of the specified participant only.

 

d)         Lump Sum Payments

 

1)         Lump sum payments shall be considered available for the eligibility period in which it is received and are not exempt.

 

2)         Supplemental Security Income (SSI) lump sum payments are exempt income. SSI lump sum payments that are kept separately and are not combined with other monies remain exempt.

 

e)         Protected Income

SSI is protected income and not considered available to be applied toward the incurred expense for CCP services of anyone other than the SSI recipient.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.835  Earned Income

 

Earned income is remuneration acquired through the receipt of salaries or wages for services performed as an employee or profits from an activity in which the participant is self-employed.  Income received as payment for jury duty or serving as an election judge is considered earned income.  This includes any payments for mileage, meals, etc.

 

a)         Exempt Earned Income

The first $20.00 of gross monthly earned income plus one-half of the next $60.00 shall be exempt.  Additionally, the following recognized expenses of employment shall be exempt:

 

1)         Withholding taxes (federal and state)

 

2)         Social Security tax

 

3)         Transportation costs.  If the participant's own car is the means of transportation, the mileage reimbursement rate paid by the State of Illinois per mile shall be allowed as transportation expense.

 

4)         Lunch supplementation

 

A)        If carried from home, 15 cents per working day to a maximum of $3.00 per month.

 

B)        If purchased at work, 45 cents per working day to a maximum of $9.00 per month.

 

5)         Special tools and uniforms required by employment

 

6)         The following expenses ONLY if mandatory as a condition of employment:

 

A)        Union dues

 

B)        Group life insurance premiums

 

C)        Group health insurance premiums

 

D)        Retirement plan withholding

 

b)         Earned Income from Work/Study/Training Programs

 

1)         Income from the Job Training Partnership Act (JTPA) shall be considered earned income.

 

2)         Income from college work-study is considered exempt income.

 

c)         Earned Income from Self-Employment

 

1)         Income realized from self-employment shall be considered earned income.

 

2)         Accurate and complete records shall be kept on all monies received and spent through self-employment.  If the participant fails or refuses to maintain complete (i.e., adequate to complete federal income tax return) business records, the participant shall be ineligible.

 

3)         Business expenses shall be documented.  The participant shall have full responsibility for proof of any business expense.  No deduction shall be allowed for depreciation/obsolescence/similar losses (e.g., theft, breakage) in the operation of the business.

 

4)         Gross income from the business shall be turned back into the business only to replace stock actually sold.

 

5)         The net income shall be the gross remaining after the replacement of stock and business expenses and the appropriate employment expenses, as specified in subsection (a), have been deducted. The earned income exemption, if applicable, shall be computed on the net income.

 

d)         Income from Rental Property

 

1)         Income a participant receives from rental property he/she owns shall be considered earned income if the participant is actively engaged in the management of the property.  The activity is to be determined by the participant's declaration or by viewing a management agreement.

 

2)         When determining net income, the reasonable and necessary rental expenses the participant incurs in the production of income may be deducted from the gross income.  Reasonable and necessary rental expenses include repairs, taxes, insurance, mortgage payments and utilities if the landlord pays them.

 

3)         If a participant is responsible for cleaning a room and providing clean linens, the income he/she receives shall be considered earned income from a roomer rather than earned income from rental property.

 

4)         After deduction of rental expenses (which determines net rental income), the appropriate earned income exemption/employment expenses, as specified in subsection (a), shall be deducted from net rental income to determine net income.

 

5)         The appropriate earned income exemption shall be deducted from gross rental income (after deducting expenses) to determine net income.

 

e)         Earned Income In-Kind

 

1)         Earned income in-kind is remuneration received in a form other than cash for services performed.  That remuneration shall include, but is not limited to:  housing, food (except meals provided while working), satisfaction of a debt, or a service provided by the employer for the employee.

 

2)         Earned income in-kind shall be exempt.

 

f)         Income from Earned Income Credit

Earned Income Credit payments received as a part of an income tax refund are considered earned income when received as:

 

1)         an advance payment; or

 

2)         part or all of an income tax refund.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.840  Potential Retirement, Disability and Other Benefits

 

a)         Participants are required to apply for all financial benefits for which they may qualify and to avail themselves of those benefits at the earliest possible date.

 

b)         The CCU is responsible for making participant referrals to the appropriate agency or resources when it appears that financial benefits may be available.

 

c)         Potential benefits may include, but are not limited to the following:

 

1)         Social Security Benefits

 

2)         Railroad Retirement Benefits

 

3)         Veterans' Benefits

 

4)         Servicemen's Dependents Allowances

 

5)         Unemployment Compensation Benefits, Supplementary Unemployment Assistance

 

6)         Worker's Compensation Benefits

 

7)         Black Lung Disease Benefits

 

8)         Benefits from private industry, professional groups, labor unions and other organizations.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.845  Family

 

For purposes of this Subpart, family means the participant, his/her spouse or partner in a civil union if residing in the same household, and any persons declared by the participant and spouse or civil union partner, if applicable, as dependents for federal income tax purposes.  Any income received by any family member shall be considered family income.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.850  Monthly Average Income

 

Income to be received on a monthly basis during the twelve (12) month period is to be added to the total amount of income received during the previous twelve (12) months from irregular (other than monthly) sources:  e.g., farm, interest and/or dividend income.  The total amount of income thus determined is to be divided by twelve (12) to arrive at the monthly average.

 

Section 240.855  Applicant/Client Expense for Care (Repealed)

                                                           

(Source:  Repealed at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.860  Change in Income

 

It is the responsibility of a participant/authorized representative to inform the CCU/Department of any change in the participant's income. Change in income shall be reported at the time of determination or redetermination of eligibility or within 30 calendar days after the date of the change, whichever is sooner.  The participant/authorized representative shall provide written documentation when available. (See Section 240.360.) Failure to notify the CCU/Department of a change in income may result in reimbursement to the Department or termination.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.865  Application For Medical Assistance (Medicaid)

 

Participants/authorized representatives will be required to apply for and, if financially eligible, enroll in medical assistance under Article V of the Illinois Public Aid Code as a condition of eligibility for (CCP). 

 

a)         The Care Coordinator shall, when needed:

 

1)         provide the participant/authorized representative with a copy of the mail-in medical assistance application and/or the web portal address for the online application, as appropriate;

 

2)         assist the participant/authorized representative with completing the application; and

 

3)         submit the application at the web portal address or to the participant's local Department of Human Services (DHS) office.

 

b)         Completing an application for medical assistance includes, but is not limited to, obtaining, completing and submitting a medical assistance application, together with any required supporting documentation.

 

c)         Services shall be provided to participants by the Department during the period in which a medical assistance application is pending.

 

d)         Although participants/authorized representatives must agree to apply for and, if financially eligible, enroll in medical assistance, participants are not required to meet the eligibility criteria for medical assistance under Article V of the Illinois Public Aid Code to receive services under CCP.

 

(Source:  Amended at 48 Ill. Reg. 1129, effective January 3, 2024)

 

Section 240.870  Determination of Applicant/Client Monthly Expense for Care (Repealed)  

                                                                                                                                   

(Source:  Repealed at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.875  Participant Responsibility

                                                 

If a participant desires services in addition to those authorized by CCP, the participant shall be responsible for full payment for those additional services.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

SUBPART I: DISPOSITION OF DETERMINATION

 

Section 240.905  Prohibition of Institutionalized Individuals From Receiving Community Care Program Services

 

a)         CCP services shall not be provided to:

 

1)         any participant who is eligible for those services while an in-patient of any institution that is subject to licensure as required by the Illinois Nursing Home Care Act [210 ILCS 45].

 

2)         any individual residing in a public institution (see 42 CFR 435.1009).

 

3)         any individual confined or detained in any local or State penal or correctional institution or by a federal law enforcement agency.

 

b)         A resident of a private institution who has a contract with the institution providing total needs throughout life is ineligible for this program, as no needs remain to be met.

 

c)         A resident of a private institution (other than those who have purchased life care contracts) is ineligible for this program when he/she has purchased care and maintenance to provide for all his/her needs in the institution and the amount paid has not been wholly consumed for care.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.910  Written Notification

 

Each participant requesting CCP services shall receive written notification of eligibility or ineligibility to receive CCP services.

 

a)         Written notification shall be sent to the participant/authorized representative within 15 calendar days after the date of the completed determination of eligibility.

 

b)         The written notification shall contain the following statement:

 

NOTICE

 

If you have been found eligible for Community Care services, you should begin receiving services within 15 calendar days after the date of this Notice. If a homecare aide has not come to help you within 15 calendar days, you can hire your own homecare aide (including a friend or relative) to provide the amount and type of Community Care services specified in this Notice.  The Department on Aging will pay the homecare aide you have hired to the extent authorized by the CCP Participant Agreement.  Payment shall continue until the Department's approved provider initiates provision of Community Care services to you.

 

c)         If it is necessary for the participant/authorized representative to hire his/her own homecare aide due to the failure of the authorized provider to provide CCP services within 15 calendar days, the temporary services and payment for those services shall terminate immediately upon initiation of service provided by a CCP approved provider. (See Section 240.1580(c).)

 

d)         If a participant is determined ineligible and request for CCP services is denied, the written notification shall be sent to the participant/authorized representative by certified mail, return receipt requested, or given to the participant/authorized representative personally, in which case the participant/authorized representative shall provide a signed and dated receipt for the notice. The notice shall clearly state the reason for the denial and shall advise the participant/authorized representative of his/her right to appeal the decision.  (See Section 240.400.)

 

e)         If a participant is denied because of death, the notice may be sent by regular mail.

 

f)         The date of the written notice of eligibility or ineligibility shall be the same date as the date of mailing.  The provider shall be notified on the same date of mailing as the participant.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.915  Service Provision

 

If a participant is determined eligible for CCP, services shall be provided in accordance with the person-centered plan of care within 15 calendar days after the date of the notification of eligibility, as required by Section 240.910, unless delayed by the participant/authorized representative.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.920  Reasons for Denial

 

Denial of CCP eligibility shall be based upon 1 or more of the reasons identified in this Section:

 

a)         Participant is less than 60 years of age at the time of the determination of eligibility.

 

b)         Participant is not in need of CCP services:  scored less than 29 total points/less than 15 points on Part A, Level of Impairment, of the DON.

 

c)         Participant/legal guardian/authorized representative refuses to sign the Participant Agreement – Person-Centered Plan of Care.

 

d)         Participant/authorized representative does not agree with the person-centered plan of care/hours of service and an agreement could not be reached during the person-centered planning process.

 

e)         Participant is deceased.

 

f)         Participant has been institutionalized or is not otherwise available for services for more than 60 calendar days after the date of referral.

 

g)         Participant/authorized representative voluntarily withdraws a request.

 

h)         Participant cannot be located to determine eligibility for or to provide CCP services.

 

i)          Participant/authorized representative has not provided reasonable documentation supporting eligibility as required by the Department or its CCU within 90 calendar days after the date of receipt of referral.

 

j)          Participant/authorized representative has not cooperated with the Department/CCU/vendor as required and as specified by Section 240.350.

 

k)         Participant does not meet citizenship requirements.

 

l)          Participant does not meet residency requirements.

 

m)        The CCU determines that an adequate person-centered plan of care cannot be developed that adequately meets the participant's determined needs under Section 240.715.

 

n)         The total value of participant's non-exempt assets is in excess of $17,500.

 

o)         Eligibility could not be established for a participant who was receiving interim services based upon presumptive eligibility as required by Sections 240.1020 and 240.865.

 

p)         Participant/authorized representative provided fraudulent information.

 

q)         Participant whose request for CCP services was previously denied or whose services were terminated for non-cooperation as set forth in Section 240.350 shall be denied services upon a subsequent request for services, unless the situation or condition that led to the memorandum of understanding (see Section 240.350) has been permanently resolved.

           

r)          Participant/authorized representative refuses to sign the Participant Agreement and Consent Form in accordance with Section 240.330

           

s)         Participant/authorized representative has transferred non-exempt assets or failed to report a transfer within the past 60 months for the purpose of obtaining CCP services.

 

t)          Participant/authorized representative has not reported or refused to provide documentation of changes in circumstances that have occurred prior to eligibility determination as required by Section 240.360.

 

u)         Participant/authorized representative refuses to apply for and, if eligible, enroll in medical assistance under Article V of the Illinois Public Aid Code as required by Section 240.865.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.925  Frequency of Redeterminations (Renumbered)

 

(Source:  Section 240.925 renumbered to Section 240.655 at 13 Ill. Reg. 11193, effective July 1, 1989)

 

Section 240.930  Suspension of Services

 

a)         CCP services may be suspended by a CCU when a participant has not cooperated with the vendor in the provision of services as set forth in Section 240.350. Services shall be reinstated when the participant has met and continues to meet the requirements in the memorandum of understanding (MOU) (see  Section 240.350).

 

b)         The vendor shall notify the CCU of the need for suspension in accordance with Section 240.350.

 

c)         Upon receipt of the vendor's verbal request for suspension, the CCU shall immediately, but not later than the next work day, verbally advise the participant of the suspension and the date of the suspension of services. This date shall be the date the vendor left or was unable to render service.

 

d)         Notification of the suspension of services shall be sent to the participant /authorized representative and the vendors by the CCU by regular mail within 5 calendar days after the verbal notification by the CCU to the participant.

 

e)         The CCU, in accordance with Section 240.350, shall obtain the signature of all parties to the MOU within 30 calendar days after the effective date of suspension.

 

f)         Upon execution of the MOU (see Section 240.160), reinstatement of service shall be authorized in writing by the CCU, to be effective on or before 15 calendar days after the date of the last signature on the MOU.  The written notice shall be provided to the participant and vendors by regular mail.

 

g)         Suspension of services may not be appealed because a suspension is not a final decision.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.935  Discontinuance of Services to Clients (Repealed)

                                                           

(Source:  Repealed at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.940  Penalty Payments

 

The Department shall pay $100 to each eligible participant to whom a Notice of Eligibility is not mailed within 45 calendar days after the date on which eligibility is determined, as defined in Section 240.510, by the Department or a CCU.  It shall be the responsibility of the participant/authorized representative to notify the Department in writing when this occurs.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.945  Notification

 

a)         Any participant whose CCP services are being changed in the following manner shall be advised of the change by written notice:  change of service type; reduced amount of service; or termination.

 

1)         The written notice shall be sent to a participant/authorized representative by certified mail, return receipt requested, or given personally, in which case the participant/authorized representative is to provide a signed and dated receipt for the notice, except for instances involving automatic, non-discretionary changes in eligibility, rates or benefits required by federal or State statute or regulation. In these instances, regular mail is acceptable. Also, in the event of the death of a participant, regular mail is acceptable for notification purposes.

 

2)         The notice shall clearly state the reason for the action being taken.

 

3)         The participant/authorized representative shall be notified of the action being taken no later than 15 calendar days after the date of assessment or redetermination and the action shall be effective no sooner than 15 calendar days after the date of the notice if the action is adverse to the participant (see Section 240.160 for a definition of adverse action). This time frame does not apply to termination as a result of the non-cooperative act specified in Section 240.350(b)(1).

 

4)         In instances involving an automatic, non-discretionary change in eligibility, rates or benefits required by federal or State statute or regulation, the participant/authorized representative will be notified of the action being taken at least 15 calendar days prior to the implementation by the CCU of the change affecting the participant.  The action will be effective no sooner than 15 calendar days after the date of notice if the action is adverse to the participant.

 

5)         In the event of a death, the termination shall be effective the date of the participant's death. The form shall be dated and mailed/hand-delivered upon the Department or the CCU being informed of the death.

 

b)         CCP services may be changed, reduced or terminated at the request of the participant/authorized representative and do not require the 15-calendar day notice period under the following circumstances:

 

1)         the participant/authorized representative provides the CCU with a signed statement that the change, reduction or termination is at his/her request;

 

2)         the CCU, participant/authorized representative and provider mutually agree to the initiation of the change, reduction or termination on the agreed upon date (which may be less than the required 15 calendar days after the date of the notice to the participant/authorized representative);

 

3)         a written notice is provided to the participant/authorized representative (either by certified mail, return receipt requested, or handed to the participant/authorized representative, with a receipt provided by the participant/authorized representative for the notice) prior to the initiation of the change or reduction.  The notice shall indicate the agreed upon effective date;

 

4)         rights of appeal shall not be denied to a participant/authorized representative who has requested a change or reduction in CCP services; and

 

5)         the CCU has documented all of the requirements of this subsection (b) and placed the participant's statement in the case record.

 

c)         When an assessment or reassessment for services requires an increase, or no change in service, the participant/authorized representative shall be notified in writing.  The notice shall be mailed by regular mail to the participant/authorized representative within 15 calendar days after the date of the assessment or reassessment.

 

d)         A copy of any notification mailed/hand-delivered to a participant/authorized representative shall be mailed/provided to the appropriate provider on the same date it is mailed/hand-delivered to the participant/authorized representative.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.950  Reasons for Termination

 

A participant shall be terminated from CCP for 1 or more of the reasons identified in this Section:

 

a)         participant is deceased;

 

b)         participant has been institutionalized or is otherwise not available for services for more than 60 calendar days;

 

c)         participant's condition has improved and there is no longer a need for CCP services as measured by the CCP DON to determine need for long-term services and supports;

 

d)         participant cannot be located;

 

e)         participant/authorized representative has requested termination of services;

 

f)         participant/authorized representative refuses transfer to a different vendor/CCU and the current vendor/CCU cannot provide services needed by the participant;

 

g)         participant/authorized representative has failed to cooperate with the Department/CCU/vendor as required and as specified in Section 240.350;

 

h)         participant no longer meets citizenship requirements;

 

i)          participant no longer meets residency requirements;

 

j)          the CCU determines that an adequate person-centered plan of care cannot be developed that meets the participant's determined needs under Section 240.715.

                       

k)         the total value of a participant's non-exempt assets has increased and exceeds $17,500;

 

l)          participant/authorized representative failed to report the transfer of non-exempt assets within the past 60 months for the purpose of obtaining CCP services;

           

m)        participant/authorized representative has failed to report or refused to provide documentation of changes in circumstances, as required by Section 240.360;

 

n)         participant/authorized representative refuses to sign a Participant Agreement – Person-centered Plan of Care;

 

o)         participant refuses to sign the Participant Agreement and Consent Form in accordance with Section 240.330; or

 

p)         Participant/authorized representative refuses to apply for and, if eligible, enroll in medical assistance under Article V of the Public Aid Code, as required by Section 240.865.

             

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.955  Reasons for Reduction or Change

 

Reasons for reduction in level or amount of services provided to a participant or change in type of services or any other change in service shall be based on current determination of eligibility.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

SUBPART J: SPECIAL SERVICES

 

Section 240.1010  Choices for Care Nursing Facility, Supportive Living Program, and Community-Based Screening

 

a)         Choices for Care nursing facility, supportive living program, and community-based prescreening is the assessment of the need of all participants age 60 and over, regardless of the payment source, prior to placement in a nursing facility (licensed under the Nursing Home Care Act; certified to participate in the Medicare program under Title XVIII of the Social Security Act (42 USC 301 et seq.), or certified to participate in the Medicaid program under Title XIX of the Social Security Act; placement in a supportive living program (Medicaid waiver)); or to determine if the participant/authorized representative chooses community-based services and supports. 

 

b)         Except as indicated in subsections (j) and (l), any participant seeking admission to a nursing facility or supportive living program must be screened to determine his/her need for nursing facility or supportive living program services pursuant to this Section.

 

c)         Prescreening shall be accomplished by completion of the DON, completion of the HFS Interagency Certification of Screening Results form, and completion of an HFS OBRA Level I Screen if the participant is determined appropriate for nursing facility or supportive living program placement.  In addition, the participant will receive a copy of:

 

1)         Notice of Privacy Practices brochure; and

 

2)         Your need to know about Adult Protective Services brochure.

                         

d)         In compliance with federal Preadmission Screening and Resident Review (PASRR) requirements, when CCUs completing the HFS OBRA Level I Screen determine there is a suspicion of and a reasonable basis to suspect mental illness and/or developmental disability, the CCU shall make the appropriate referral to contracted providers of DHS-Division of Mental Health or DHS-Division of Developmental Disabilities within 1 day to determine if an HFS OBRA Level II Screen is required. If it is determined that no further screening is required by the DHS contracted providers, the CCU shall complete the required forms. If further screening is required by the DHS contracted providers, that entity shall complete the required forms.

 

e)         The hospital shall notify the CCU at least 24 hours prior to discharge.

           

f)         CCUs will have the capacity to complete face-to-face prescreenings 7 days per week, at a minimum of 7 hours per day.  CCUs are not required to complete screens on federal holidays.

 

g)         Responsibility for prescreenings shall be vested in the CCUs. The CCU is responsible for ensuring that copies of the HFS Interagency Certification of Screening Results form and the HFS OBRA Level I Screen are sent to the appropriate nursing facility or supportive living program.

 

h)         The participant who is prescreened shall:

 

1)         be informed of all appropriate options, including nursing facility, supportive living program, in-home and community-based services; and

 

2)         be advised of his/her right to refuse nursing facility, supportive living program, in-home, community-based, or all services.

 

i)          Postscreening shall occur if a participant is admitted to a nursing facility or supportive living program without benefit of prescreening.

 

1)         Postscreening may occur for any of the following reasons:

 

A)        after nursing facility or supportive living program placement in an emergency situation when there is a pre-existing condition of need for a caregiver and the caregiver is no longer able to provide care. The CCU shall conduct prescreening within 2 calendar days after the date of the request for postscreening;

 

B)        for nursing facility or supportive living program admissions from a hospital emergency room or  outpatient services; or

 

C)        for nursing facility or supportive living program admissions for participants coming from out-of-state.

 

2)         The CCU shall conduct a postscreening within 2 calendar days after the date of the request for postscreening.

 

j)          Nursing facility prescreening does not apply to the following:

 

1)         Transfers from 1 nursing facility to another.

 

2)         Admissions to a continuing care retirement community with which the participant has a life care contract.

 

3)         Participants who are receiving or will be receiving hospice services.

 

4)         Returns to a nursing facility from a hospital.

 

5)         Admissions to a nursing facility from the community for respite care for a period of no more than 15 calendar days.

 

6)         Admissions to sheltered care facilities.

 

7)         Participants who resided in a nursing facility on June 30, 1996.

 

8)         Participants who resided in a nursing facility for a period of at least 60 calendar days who are returning to a nursing facility after an absence of not more than 60 calendar days.

 

k)         A prescreening or postscreening for supportive living program admissions is not required for:

 

1)         Hospice services;

 

2)         Caregiver respite services;

 

3)         Transfers from nursing facilities licensed under the Nursing Home Care Act and certified to participate in the Medicaid program or another supportive living program without a break in service. It is the admitting supportive living program's responsibility to ensure that a screening document is received from the transferring nursing facility or supportive living program; or

 

4)         Residents who were admitted to a supportive living program from a hospital to which they were transferred for the purpose of receiving care.

 

l)          Any participant who has been admitted to a nursing facility that operates under the Hospital Licensing Act [210 ILCS 85], or provider licensed under Section 35 of the Alternative Health Care Delivery Act [210 ILCS 3/35], whose actual length of stay in the facility exceeds 21 calendar days, shall be screened to determine the participant's need for continued services.

 

m)        Nursing facility conversion screening is the assessment of the appropriateness of in-home and community-based care for nursing facility residents age 60 and over who have applied for and been found eligible for Medicaid assistance.

 

1)         Conversion screens shall be initiated by a referral from HFS.

 

2)         Conversion screens shall be accomplished in accordance with Deinstitutionalization (see Section 240.1960(g)). A Deinstitutionalization assessment will be conducted within 60 days after the date of admittance to the nursing facility if the participant chooses to have follow-up by the CCU.

 

3)         Conversion screens shall include the option of CCP transitional services for those participants who are appropriate for in-home and community-based services.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.1020  Interim Services

 

Interim services are CCP services provided to participants age 60 and over on an interim basis, dependent upon the participant's presumptive eligibility and following prescreening of the participant.

 

a)         Presumptive eligibility shall be based upon the following criteria:

 

1)         A referral has been received from a participant age 60 or over, or from the participant's authorized representative, following prescreening.

 

2)         Notification has been received by the CCU from a hospital or from a participant/authorized representative or agency in the community that the participant is at imminent risk of nursing facility placement within 3 calendar days.

           

3)         The DON to determine need for long-term services and supports has been administered.

 

4)         The participant/authorized representative has provided declared information on all other CCP eligibility requirements.

 

5)         The participant/authorized representative has signed a Participant Agreement and Consent Form.

 

6)         After presumptive eligibility has been determined, the CCU shall notify the vendor within the next business day and services will start within 2 business days.

 

b)         When presumptive eligibility has been determined and interim services are approved in accordance with the person-centered plan of care, services shall be initiated by the vendor to the participant within 2 work days after the date of notification to the vendor of the participant's presumptive eligibility.

 

c)         A comprehensive assessment shall be administered in the residence of the participant by the CCU. 

 

1)         When the assessment is not conducted in the community, the CCU will make the follow-up home visit within 15 calendar days after the date of the participant's discharge.

 

2)         When the assessment is conducted in the community, the CCU will make the follow-up home visit within 30 calendar days after the date of the interim assessment.

 

3)         The formal determination of eligibility for CCP services shall be completed within 90 calendar days after the date of receipt of the referral.

 

d)         Interim services may continue up to a maximum of 90 calendar days after the date of referral, pending finalization of the formal determination of eligibility by the CCU. Services shall be denied at any time during the 90 calendar day interim service period:

 

1)         if evidence of ineligibility, based upon any eligibility requirement, is determined;

 

2)         if the participant/authorized representative fails to cooperate in the determination of eligibility process;

 

3)         as specified in Section 240.660, in the event that a participant's eligibility cannot be determined due to the participant's/authorized representative's failure to provide accurate and verifiable documentation regarding eligibility within 90 calendar days after the date of receipt of the referral; or

 

4)         if a person-centered plan of care cannot be developed that adequately meets the participant's determined needs (see Section 240.920(n)).

 

e)         Notification of eligibility or ineligibility shall be provided in writing.  If eligibility is denied, provision of interim services shall cease on the date of receipt by the vendor of the Participant Agreement – Person-Centered Plan of Care.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.1040  Intense Service Provision

 

Several CCP workers' services (not to exceed 4) may be utilized, on a 1-time basis only, to clean a new participant's home, thereby making it possible to maintain the health and safety of the participant. However, the total monthly service costs may not exceed the maximum monthly cost allowable as indicated on the participant agreement.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.1050  Temporary Service Increase

 

A participant who is currently receiving services under CCP may request a temporary service increase when he/she is at imminent risk of nursing facility care or has been hospitalized for not more than 60 calendar days.

 

a)         The CCU will conduct the DON to determine need for long-term services and supports within 2 calendar days after notification.

 

b)         The CCU will assist the participant/authorized representative with the completion of the Participant Agreement and Consent Form. The CCU shall verbally authorize a temporary increase in services if the need is indicated by the determination.  The CCU shall notify the vendor by telephone to reinstate services, giving the date of discharge and the temporary increase.

 

c)         Notification shall be given to the participant/authorized representative and the vendor immediately following completion of the required forms.  The notification shall be confirmed in writing. Both the verbal and written notification shall indicate the increase and the temporary nature of the increase.

 

d)         The CCU shall make a home visit to the participant for the purpose of redetermination of need to determine if the temporary increase should be continued or reduced.  (See Section 240.620(c).)

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

SUBPART K: TRANSFERS

 

Section 240.1110  Participant Transfer Request − Vendor to Vendor − No Change in Service

 

a)         The Department, a CCU or a participant/authorized representative may request a transfer for provision of CCP services from 1 vendor to another vendor, within the same service area, and without any change in service needs.  The transfer request may be initiated by verbally advising the CCU of the desired change in vendor.  The CCU shall verbally advise the participant of the vendor choices available.  The CCU shall complete a new Participant Agreement and Consent Form – Person-Centered Plan of Care, including choice of vendor based upon that verbal advice from the participant/authorized representative as to his/her selection.

 

b)         Reasons for the CCU to authorize a vendor to vendor transfer with no change in services provided may include:

 

1)         the needs of a participant are not being met by the current vendor; or

 

2)         the participant has exercised his/her right of freedom of choice and requested transfer.

 

c)         Within 5 work days after the date of receipt of a verbal request to effect a transfer, the CCU shall forward a new Participant Agreement and Consent Form and new CCP Participant Agreement to the participant/authorized representative for signature.

 

d)         Within 30 calendar days after the date of receipt of the signed Participant Agreement and Consent Form:

 

1)         the CCU shall:

 

A)        complete a person-centered plan of care establishing the effective date of transfer; and

 

B)        forward:

 

i)          the person-centered plan of care to the participant/authorized representative;

 

ii)         a copy of the Participant Agreement − Person-Centered Plan of Care to the receiving vendor on the same day the Participant Agreement − Person-Centered Plan of Care is sent to the participant; and

 

iii)        a copy of the Participant Agreement − Person-Centered Plan of Care to transferring vendor.

 

2)         upon receipt of the vendor's signature on the Participant Agreement – Plan of Care, the CCU shall place a copy of the executed Participant Agreement – Plan of Care in the CCU's participant file and a copy shall be forwarded to the participant/authorized representative.

 

e)         The effective date of the transfer shall be within 15 calendar days after the date of the Participant Agreement − Person-Centered Plan of Care and service shall be initiated by the receiving vendor without service interruption.

 

f)         If a delay in any of the time frames established in this Section is caused by the documented action or inaction of the participant/authorized representative, time frames shall be extended by the number of calendar days of the delay.

           

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.1120  Participant Transfer Request – Vendor to Vendor – With Change in Service

 

a)         A request for transfer of a CCP participant from 1 vendor to another vendor within the same service area that requires a change in the services provided shall be completed by the CCU following a redetermination of need.  The request may be initiated by the Department, CCU, the vendor, or the participant/authorized representative verbally or in writing to the CCU.  The CCU shall complete the redetermination of need, including obtaining a completed and signed Participant Agreement and Consent Form – Person-Centered Plan of Care from the participant/authorized representative, within 30 calendar days after the date of the request unless delayed by the participant/authorized representative.

 

b)         Reasons for a vendor to vendor transfer with a required change in service may include:

 

1)         a change in the participant's condition; and

 

2)         the vendor's inability to meet the service needs of the participant, as required by the person-centered plan of care.

 

c)         The CCU shall:

 

1)         no later than 15 calendar days after the date of redetermination, complete in accordance with Section 240.945 and forward:

 

A)        the Participant Agreement − Person-Centered Plan of Care to the participant/authorized representative;

 

B)        a copy of the Participant Agreement − Person-Centered Plan of Care, the CCP Participant Agreement to the receiving vendor on the same day the Participant Agreement − Person-Centered Plan of Care is sent to the participant/authorized representative;

 

C)        a copy of the Participant Agreement − Person-Centered Plan of Care to the transferring vendor.

 

2)         Upon receipt of the vendor's signature on the Participant Agreement – Person-centered Plan of Care, a copy of the executed Participant Agreement – Person-centered Plan of Care shall be placed in CCU's participant file and a copy shall be forwarded to the participant/authorized representative.

 

d)         The effective date of transfer shall be no later than 15 calendar days after the date of the Participant Agreement − Person-Centered Plan of Care and service shall be initiated by the receiving vendor without service interruption.

 

e)         If any delay in any of the time frames established in this Section is caused by the documented action or inaction of the participant/authorized representative, time frames shall be extended by the number of calendar days of delay.

           

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.1130  Participant Transfers – Care Coordination Unit to Care Coordination Unit

 

a)         A CCP participant may transfer from 1 CCU service area to another CCU service area with continuous eligibility pending a redetermination of eligibility by the receiving CCU.  The transfer may be requested by the Department, a CCU, or the participant/authorized representative verbally or in writing.

 

b)         A reason for transfer from CCU to CCU shall be a geographic change in the participant's residence.

 

c)         The effective date of transfer shall be within 15 calendar days after the date of the Participant Agreement − Person-Centered Plan of Care and services shall be initiated by the receiving vendor without service interruption.

 

d)         To implement the transfer, the transferring CCU, within 5 work days after the date of a request or notice of need to transfer, or 5 work days prior to the effective date of transfer, whichever provides the most notification to the receiving CCU, shall:

 

1)         notify the receiving CCU of the impending transfer and the desired date of transfer;

 

2)         forward to the receiving CCU the original case record of the transferring participant; and

 

3)         forward the Participant Agreement − Person-Centered Plan of Care to the participant/authorized representative and a copy to the transferring vendor.

                                   

e)         The receiving CCU shall:

 

1)         Upon receipt of the participant's case record, advise the participant/authorized representative as to the vendors in the CCU's area that are authorized, and appropriate, to provide the participant's service needs in accordance with the participant's person-centered plan of care.  The participant shall advise the CCU as to his/her selection and the CCU shall complete a new Participant Agreement and Consent Form − Person-Centered Plan of Care.

 

2)         Forward to the participant/authorized representative a new completed Participant Agreement and Consent Form – Person-Centered Plan of Care for signature.

 

3)         Upon receipt of the signed Participant Agreement and Consent Form – Person-Centered Plan of Care, establishing the effective date of the transfer.

 

4)         Forward:

 

A)        the Participant Agreement − Person-Centered Plan of Care to the participant/authorized representative;

 

B)        a copy of the Participant Agreement − Person-Centered Plan of Care and the old Participant Agreement – Person-Centered Plan of Care and a copy of the applicable pages of the comprehensive assessment to the receiving vendor on the same day the Participant Agreement − Person-Centered Plan of Care is sent to the participant/authorized representative.

 

5)         Upon receipt of the vendor's signature on the new Participant Agreement – Person-Centered Plan of Care, a copy of the executed Participant Agreement – Person-Centered Plan of Care is to be placed in CCU's participant file and a copy shall be forwarded to the participant/authorized representative.

 

f)         If any delay in any of the time frames established by this Section is caused by the documented action or inaction of the participant/authorized representative, time frames shall be extended by the number of days of delay.

 

g)         The receiving CCU shall perform an initial determination of eligibility of the participant and develop a new person-centered plan of care within 30 calendar days after the date of receipt of the case record.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.1140  Transfers of Pending Requests for Services

 

If a transfers of pending requests for services occur, the purpose of those transfers shall be to assure that the participants maintain their status and to assure that appropriate action will be completed as specified in Section 240.610.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.1150  Interagency Transfers

 

Participants from the DHS-Division of Rehabilitation Services (DHS-DORS) may transfer to the Department on Aging if in accordance with the interagency agreement executed between both Departments and if the participant meets eligibility requirements established by the Department on Aging for CCP.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.1160  Temporary Transfers – Care Coordination Unit to Care Coordination Unit

 

a)         A CCP participant/authorized representative may request a transfer from the participant's CCU service area to another CCU service area for a temporary period of time, not to exceed 31 calendar days, when the participant is temporarily residing with a relative, or other responsible individual, but intends to return to the participant's permanent residence.  When the temporary transfer exceeds 31 calendar days, the transfer is considered to be permanent (see Section 240.1130).

 

b)         The managing CCU shall retain primary responsibility for the participant and maintenance of the participant's original records.

 

c)         To implement the temporary transfer, the managing CCU, within 5 work days after the date of request or notice of need to transfer, shall:

 

1)         notify the temporary CCU of the impending transfer, the participant's name, temporary address and telephone number, the anticipated length of stay and the type and amount of CCP service to be provided, and whether the participant has an authorized representative;

 

2)         obtain from the temporary CCU, and provide to the participant/authorized representative, a list of authorized and appropriate vendors in the temporary CCU's service area;

 

3)         complete a Participant Agreement and Consent Form and obtain signatures from the participant/authorized representative;

 

4)         complete a new Participant Agreement – Person-Centered Plan of Care, obtain signatures and forward copies as appropriate;

 

5)         provide the temporary CCU with a copy of the Case Documentation for Determination of Need;

 

6)         prepare and forward a Participant Agreement − Person-centered Plan of Care;

 

7)         authorize the temporary vendor to receive payment for CCP services provided, beginning on the effective service date;

 

8)         provide the temporary vendor with information required for billing for CCP services provided to the participant.

 

d)         The temporary vendor shall advise the temporary CCU of any needed adjustments in the participant's person-centered plan of care.

 

e)         The temporary CCU shall:

 

1)         if advised by the temporary vendor, make a home visit to the participant and identify possible needed changes;

 

2)         advise the managing CCU and the temporary vendor of any changes needed in the participant's person-centered plan of care;

 

3)         monitor the provision of services to the participant;

 

4)         advise the managing CCU of the date of the participant's expected return to his/her permanent residence.

 

f)         The participant/authorized representative shall advise the temporary CCU of the date of the participant's expected return to his/her permanent residence no later than 5 work days prior to the date of the participant's return.

 

g)         Upon the participant's return to his/her permanent residence, the managing CCU shall:

 

1)         terminate the authorization of the temporary vendor to receive payment for CCP services provided to the participant;

 

2)         reinstate authorization for the permanent vendor to receive payment for CCP services provided to the participant;

 

3)         notify the permanent vendor of the reinstatement and the first day that services shall be provided to the participant by the permanent vendor;

 

4)         prepare and forward a Participant Agreement − Person-Centered Plan of Care.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.1170  Caseload Transfer – Vendor to Vendor

 

a)         A caseload transfer shall occur when the serving vendor's contract for provision of CCP services has been terminated by either party to the contract.

 

b)         The Department shall notify the appropriate CCU of the impending transfer and the effective termination date, and forward a copy of each notification to the respective transferring and receiving vendors.

 

c)         The participant/authorized representative shall complete the Participant Agreement and Consent Form and forward it to the CCU by the date specified in the Department notice (no later than 15 calendar days after the date of mailing by the Department).

 

d)         Within 5 work days after the date specified by the Department in subsection (c), the CCU shall identify the receiving vendor for each participant in the caseload, using the completed Participant Agreement and Consent Form or the approved rotation plan, if a Participant Agreement and Consent Form has not been received.

 

e)         Upon adequate notification by the Department of the vendor's intent to terminate its contract, the CCU shall:

 

1)         advise the receiving vendor verbally of the impending transfer of the participants and the date that service must be initiated for each participant to prevent interruption of service;

 

2)         send written notification to the participants/authorized representatives giving the date of initiation of service by the receiving vendor; and

 

3)         send a new Participant Agreement – Person-Centered Plan of Care and applicable pages of the comprehensive assessment for each transferring participant to the appropriate receiving vendor.

 

f)         The time frame specified in subsection (e) does not apply when an emergency procurement action is required due to contract termination and to prevent interruption of participant services.

 

g)         The participant's/authorized representative's signature shall be obtained on the new Participant Agreement – Person-Centered Plan of Care and copies distributed as appropriate.

 

h)         The transfer of a caseload must be completed no later than the effective termination date of the contract.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.1180  Caseload Transfer – Care Coordination Unit to Care Coordination Unit

 

a)         A caseload transfer shall occur when the authorized CCU's contract for provision of CCP care coordination services has been terminated by either party to the contract.

 

b)         The transferring CCU shall:

 

1)         transfer each participant's original case record file to the receiving CCU no later than the termination date of transferring CCU's contract;

 

2)         the transferring CCU shall retain all records relating to requests for payment and receipt thereof and any documents peculiar to that agency.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

SUBPART L: ADMINISTRATIVE SERVICE CONTRACT

 

Section 240.1210  Administrative Service Contract

 

The Department shall designate, through purchase of service contracts, individuals/agencies to carry out administrative duties in support of the Community Care Program.  Specific responsibilities are delineated in the Administrative Service Contract.

 

(Source:  Amended at 13 Ill. Reg. 11193, effective July 1, 1989)

SUBPART M: CARE COORDINATION UNITS AND PROVIDERS

 

Section 240.1310  Standard Contractual Requirements for Care Coordination Units and Providers

 

a)         The contract shall be an agreement between the Department and the CCU or provider agency as evidence of the terms and conditions of the contract.  The terms and conditions shall, at a minimum, include the following:

 

1)         the contractual agreement between the Department and the CCU/provider may be terminated without cause by either party upon 60 calendar days written notice;

 

2)         the contractual agreement between the Department and the CCU/provider may be amended, with the mutual consent of both parties, at any time during the term of the contract; and

 

3)         all program and financial records, reports, and related information and documentation, including participant files, that are generated as a result of the agreement shall be considered the property of the Department.

 

b)         Upon written notification from the Department of a change in the fixed unit rates of reimbursement, the CCU/provider may exercise its 60 calendar day termination rights if the CCU/provider no longer wishes to provide service at the newly established fixed unit rates of reimbursement.

 

c)         CCUs and providers shall have sufficient personnel to ensure service to all CCP participants.

 

d)         At the time of application for award of contracts, CCUs and providers shall submit documentation specified by the Department to confirm the legal structure under which they are doing business.

 

e)         CCUs and providers may be units of State government, units of local government, for-profit or not-for-profit corporations, limited liability companies, sole proprietorships, partnerships or individuals.

 

1)         An agency of State government must submit a letter from the Director or head of the agency citing the statutory authority for the agency to enter into a contract to provide the proposed CCP service.

 

2)         A unit of local government must submit a copy of the resolution or ordinance duly passed by the governing body of the unit of government authorizing the execution of the contract.  The resolution or ordinance shall designate the individual authorized to execute the agreement in behalf of that unit of government.

 

3)         A partnership, individual or sole proprietorship must submit copies of "Certificate of Ownership of Business" issued by the County Clerks for the counties in which the applicant agency is proposing to provide service.

 

4)         A corporation or limited liability company must submit a "Certificate of Good Standing" from the Office of the Illinois Secretary of State certifying that the corporation has complied with the requirement to file an annual report and has paid required franchise taxes.

 

5)         A not-for-profit corporation shall submit:

 

A)        a "Certificate of Good Standing" from the Office of the Illinois Secretary of State certifying that the corporation has complied with the requirement to file an annual report; and

 

B)        a current letter from the Office of the Illinois Attorney General certifying that the corporation is in full compliance with or is exempt from the charitable trust laws of the State of Illinois.  Thereafter, a non-exempt provider shall provide a letter, certified by the provider's Board of Directors, to the Department upon request, stating that the provider remains in compliance or is exempt.

 

6)         A nongovernmental agency shall certify that:

 

A)        CCU/provider or any of its officers, agents or employees have not been convicted of bribery or attempting to bribe an officer or employee of the State of Illinois nor made an admission of guilt of such conduct which is a matter of record; and

 

B)        CCU/provider is not in arrears or not in default to the State of Illinois upon any debt or contract, and that it is not in default as to the surety, or otherwise, upon any obligation to the State of Illinois, and that it has not failed to perform faithfully any previous contract with the State of Illinois.

 

f)         CCUs and providers shall certify that their respective agency acknowledges and complies with the Illinois Human Rights Act [755 ILCS 5]; the Equal Employment Opportunity Act of 1974, as amended (Title VII of the U.S. Civil Rights Act of 1964, as amended (42 USC 2000e et seq.)); the Civil Rights Act of 1964, as amended (42 USC 2000d et seq.); section 504 of the Rehabilitation Act of 1973, as amended (29 USC 790 et seq.); and the Immigration Reform and Control Act of 1986 (8 USC 1101 et seq.).

 

g)         CCUs and providers shall certify to the Department that their respective agencies are fiscally sound, as defined in Section 240.160, or demonstrate the ability to obtain financial resources as required during the performance of their contract.

 

h)         Assignment by a CCU or provider of a contract awarded between the CCU or provider and the Department to any other organizations or entities shall result in the immediate termination of the CCU or provider contractual agreement.

 

i)          Failure by CCUs or providers to seek and obtain written Department approval prior to entering into subcontracts with other entities for the provision of CCPCCP services shall result in the immediate termination of the CCU or provider contractual agreement.

 

j)          The Department shall be immediately notified in the event of a merger/consolidation/sale of assets of a CCU or provider by the CCU or provider and provided with copies of all relevant supporting documents.

 

1)         Following review of the merger/consolidation/sale of assets documents by General Counsel, the Department will determine whether the merger/consolidation/sale of assets has resulted in an assignment of the contract (see subsection (h)).

 

2)         If the merger/consolidation/sale of assets has not resulted in an assignment, the Department retains the right to terminate the contract if performance of the contract by the new corporate structure is not in the best interests of the CCP, such as a merger or consolidation with an entity that has been subject to previous contract action by the Department or some other state or federal agency.

 

3)         Failure to notify the Department shall result in termination of the CCU or provider contract.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.1320  Vendor or Care Coordination Unit Fraud/Illegal or Criminal Acts

 

a)         Reporting of Illegal Acts

 

1)         Any entity involved in the administration of the CCP or in the provision of CCP services, upon receipt of any report of or evidence of an improper or unlawful act having been committed by their employees, for the purpose of illegally obtaining money or extorting payment for care, goods, services or supplies, shall immediately:

 

A)        inform the appropriate law enforcement authorities; and

 

B)        report to the Department, including any documentation which may have been obtained, regarding any alleged theft or missing items having value over $50.00 or such unlawful activities which result in a police report.

 

2)         Failure of a CCU or vendor to make a report to the appropriate law enforcement authorities and to the Department shall result in contract action as delineated in Section 240.1665 for vendors and Subpart N for CCUs.

 

b)         Department staff, designated by the Director, shall make an immediate investigation of the alleged improper or unlawful acts.  When the result of the Department's investigations produces evidence that indicates CCU/vendor improprieties or unlawful activities, the Department shall make an immediate report to the appropriate law enforcement authorities.

 

c)         Any entity or individual provider involved in the administration/provision of CCP services shall not bill the Department for more services than were provided to or on behalf of CCP participants.

 

1)         Anyone in receipt of information that the Department has been improperly billed for services shall report the incident to the Department and provide the Department with any report/documentation that may have been obtained.

 

2)         Department staff, designated by the Director, shall complete an immediate review of the report.

 

3)         If the Department determines that the allegations in the report are factual, based upon the above cited-review, the Department will advise the CCU or vendor in writing regarding what action shall be taken (e.g., no action, if in the best interests of the participant; suspension; termination). (See Sections 240.1399 and 240.1665 for vendors and Subpart N for CCUs.)

 

d)         Any entity or individual involved in the provision of CCP services shall cooperate with and provide assistance to the Department/law enforcement authorities in any investigation of any alleged illegal or criminal act. (See Section 240.1665 for vendors and Subpart N for CCUs.)

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.1399  Termination of a Vendor or Care Coordination Unit (CCU)

 

In the event conditions warrant termination of an Agreement or a Contract, termination shall be in accord with provisions in the Agreement or Contract.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

SUBPART N: CARE COORDINATION UNITS

 

Section 240.1400  Community Care Program Care Coordination

 

a)         A designated CCU, as outlined in 89 Ill. Adm. Code 220.600 through 220.675, shall be contracted with as a CCU by the Department for a specific geographic area by executing a contract for the provision of CCP care coordination services.

 

b)         All providers of CCP care coordination services shall meet all standards promulgated by the Department relating to the services provided, upon completion of the procurement as specified in 89 Ill. Adm. Code 220.610 through 220.675 All Department funded CCUs must adhere to the equal opportunity requirements of the Illinois Department of Human Rights and the contract executed between the CCU and the Department.

 

c)         Care coordination services shall be purchased only from providers determined capable and competent by the Department to provide those services, as described in 89 Ill. Adm. Code 220.600 through 220.675 once a procurement has occurred under 89 Ill. Adm. Code 220.610 through 220.675.

 

d)         CCU contracts with the Department to provide CCP care coordination services shall not be assigned.

 

e)         CCUs shall not subcontract for the direct provision of CCP care coordination services unless prior written approval has been obtained from the Department.

 

f)         A CCP provider may not serve as a CCU in the same contract service area except temporarily to provide for the orderly transition of duties while the Department seeks a replacement CCU or the Department seeks a replacement provider, as indicated in the particular case.  In no instance shall that arrangement exist for longer than a 3 month period.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.1410  Care Coordination Unit Administrative Minimum Standards

 

a)         A CCU must meet the Standard Contractual Requirements of Section 240.1310.

 

b)         A CCU shall be open for business at least 7 hours each weekday (Monday through Friday) and shall have and utilize an alternative method approved by the Department, and on file at the CCU, for receiving requests from participants on any weekdays (excluding holidays) when the CCU is not open for business.

 

c)         All program records, reports, and related information and documentation, including participant files, that are generated in support of the contract between the CCU and the Department shall be considered the property of the Department.

 

1)         The CCU shall submit, upon demand, or otherwise make available at the option of the Department, all such records, information and documentation to the Department/Department authorized designee.

 

2)         All the records, information and documentation shall be maintained by the CCU in accordance with provisions of 89 Ill. Adm. Code 220.100.

 

3)         All records, case notes or other information maintained on persons served under the contract shall be confidential and shall be protected by the CCU from unauthorized disclosure as required by 89 Ill. Adm. Code 220.100 and Section 240.340 of this Part.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.1420  Care Coordination Unit Responsibilities

 

CCUs, in the performance of their CCP contract, shall have the following responsibilities for purposes of care coordination:

 

a)         intake to address public inquiries regarding services and supports and making preliminary decisions regarding need for a home visit for a comprehensive assessment.

 

b)         Determine functional and financial eligibility for services, including:

 

1)         scheduling a face-to-face meeting between a certified Care Coordinator and a participant/authorized representative;

 

2)         utilizing the comprehensive assessment tool, or any successor assessment tool used to determine need for long-term services and supports authorized by the Department, including all addenda, to assess the participant's functional needs, cognitive, psychological, and social well-being, including but not limited to participant demographics, physical health history and assessment, behavioral health, medications, nutritional screening, caregiver, transportation, environment, financial, legal status, and person-centered goals of care, as well as other factors contributing to quality of life and the ability to live independently in the community;

 

3)         reporting alleged or suspected abuse, neglect, financial exploitation, or self-neglect; assisting with investigations conducted under the Adult Protective Services Program; and making referrals to the State/Regional Long Term Care Ombudsman Programs.

 

4)         identifying existing informal and formal support systems and the need for further evaluation by other disciplines, and/or services that would assist the participant in maintaining independent living and coordinating available resources to assist the participant/authorized representative to gain access to and receive needed services and supports, whether paid or unpaid, that will assist the participant to achieve identified goals, including distributing and assisting with completion of applications and forms required to access services identified in the goals of care; and

 

5)         maintaining relationships with DHS, HFS, managed care entities, physicians, hospital discharge personnel, and providers/vendors for the purpose of receiving input that may be beneficial to the CCU in exercising these responsibilities.

 

c)         full responsibility for the performance of CCP determinations/redeterminations of eligibility, including residents of nursing homes seeking to return to the community, and development of a Participant Agreement – Person-Centered Plan of Care for each CCP client.  (The Participant Agreement – Person-Centered Plan of Care can be revised only by the CCU.)  CCUs should maintain liaison with DHS, HFS, physicians, hospital discharge personnel, and providers/vendors for the purpose of receiving input that may be beneficial to the CCU in exercising these responsibilities.

 

d)         develop a Participant Agreement − Person-Centered Plan of Care for each participant receiving CCP services based on person-centered planning and freedom of choice in the selection of services, supports and vendors.

 

e)         monitor the person-centered plan of care, including the Goals of Care, to ensure that services/resources are being provided.

 

f)         implement transfer of a participant as required by Sections 240.1110 through 1180.

 

g)         send/hand deliver a person-centered plan of care to the participant/authorized representative as required by Sections 240.910 and 240.945.  Also send/hand-deliver to providers/vendors, on same day the CCU sends the form to the participant/authorized representative, the following:

 

1)         the applicable sections of the comprehensive assessment tool; and

 

2)         copy of the Participant Agreement − Person-Centered Plan of Care.           

 

h)         during the face-to-face/in-person visit and, upon subsequent request, advise participants/authorized representatives of all rights and responsibilities under the CCP and furnish each participant/authorized representative with a copy of those rights and responsibilities, including a copy of "Things You Need to Know" brochures and Home Care Participant Bill of Rights brochures.  Also provide a copy of the Request for Appeal form as promulgated by the Department and rendering assistance in filing the Request for Appeal form as requested or needed.

 

i)          arrange for the implementation of CCP services by CCP vendors in accordance with the person-centered – plan of care, and develop memoranda of understanding when needed to maintain service.  (See Section 240.350.)

 

j)          submit to HFS all requested records for issues under the Medical Assistance Program, and any other information or records for HFS to discharge its responsibilities as the Single State Agency under Title XIX of the Social Security Act.

 

k)         send notification to the participant/authorized representative as required by Section 240.910 if a participant is determined ineligible for CCP services and providing linkage to other indicated services (e.g., Older Americans Act (42 USC 3001 et seq.) services).

 

l)          advise the participant/authorized representative of his/her right to receive a penalty payment as specified in Section 240.940 if the notice of eligibility is not mailed within 45 calendar days after the date on which a completed request is received by the Department or CCU.

 

m)        inform and assist the participant in the exercise of his/her rights to obtain an alternative provider as specified in Section 240.270 if provision of CCP service is delayed beyond the required time frame.

 

n)         maintain a record of all participants receiving services under the CCP being served within the CCU's jurisdiction.

 

o)         address any request by participant/authorized representative/vendor relating to CCP services and respond verbally/in writing within 15 calendar days after the date of request and so document in the participant's file.

 

p)         document in the participant's file all contact, verbal or written, with or on behalf of participants/authorized representatives.

 

q)         monitor for critical event notifications coming from Adult Protective Services, Emergency Home Response, In-Home and Adult Day Service providers.  CCUs will respond to all critical event notifications by providing mandatory follow-up with CCP participants who have experienced a critical event. All critical event reports will be closed to reflect mandatory follow-up with CCP participants within 60 days after the date the event occurred or was identified to have occurred. CCUs will close critical event reports through completion of the 60-day review summary housed in the Department's automated reporting system.

 

r)          complete and submit CCP assessment billing data to the Department; review and correct rejects; and provide assistance to vendors with billing errors.

 

s)         provide, in a timely manner, copies of all participant documents requested by the Department for participant appeals or other Departmental matters.

 

t)          attend hearings on appeals affecting participants under the CCU's jurisdiction and testify as requested.  The CCU shall make available the appellant's case records at the hearing.

 

u)         conduct Choices for Care prescreening, postscreening, and Deinstitutionalization in accordance with Section 240.1010.

 

v)         conduct HFS OBRA-1 (Level I ID Screen).

 

w)        provide the Department with an annual financial audit report completed in accordance with Generally Accepted Audit Standards and Audit Guidelines issued by the Department.

 

1)         The financial audit report shall be filed within 6 months after the close of the CCU's business fiscal year.  The annual financial audit report must include, at a minimum, an income and expense statement and a balance sheet with the auditor's opinion and findings.

 

2)         The annual financial audit report shall be filed with the Illinois Department at its main office in Springfield.

 

x)         maintain all records and documentation as specified in this Part and applicable procedures.

 

y)         respond to correspondence as required in performing all specified responsibilities.

 

z)         obtain any necessary consent and cooperation for release of information when required to document case record material and to take subsequent indicated action.

 

aa)       develop and maintain resource listings for the geographic area served by the CCU, which will be shared with the Department upon request, to ensure that choices are presented to participants/authorized representatives in an objective manner that also allows for a rotation system for referrals to providers/vendors when the participant/authorized representative elects not to make a choice.

 

bb)       perform other activities as required by State or federal or local rules, regulations and ordinances as they relate to the CCP.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.1430  Care Coordinator Staff Positions, Qualifications and Responsibilities

 

a)         A CCU shall have specified staff to carry out the following functions:

 

1)         care coordination; and

 

2)         supervision of care coordinators.

 

b)         Care coordination supervisor qualifications shall be as specified in 89 Ill. Adm. Code 220.605(a)(2).

 

c)         Care coordination qualifications shall be as specified in 89 Ill. Adm. Code 220.605(b)(2).

 

d)         Care coordinator activities and responsibilities shall, at a minimum, include:

 

1)         administration of the DON;

 

2)         development of a Participant Agreement – Person-Centered Plan of Care;

 

3)         performance and/or approval of Choices for Care screening;

 

4)         performance of HFS OBRA-1 (Level I ID Screen);

 

5)         authorization of CCP services; and

 

6)         attendance at appeal hearings.

 

e)         Required activities that may be performed by a care coordinator or other CCU staff include:

 

1)         screening of inquiries;

 

2)         arranging for service implementation in accordance with each specific Participant Agreement – Person-Centered Plan of Care;

 

3)         completing required billing activities with the Department;

 

4)         reviewing and correcting required billing activities with the Department;

 

5)         assisting providers with Vendor Request for Payment (VRFP) rejects;

 

6)         timely provision of documents requested by the Department for participant appeals or other Departmental matters;

 

7)         implementing case transfers; and

 

8)         assisting with referral of participants to HFS for Medicaid application as requested.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

 

Section 240.1440  Training Requirements For Care Coordination Supervisors and Case Coordinators

 

CCUs in the performance of their CCP contracts, shall adhere to the following training requirements immediately upon adoption of this Section regardless of whether a procurement has occurred pursuant to 89 Ill. Adm. Code 220.610 through 220.675.

 

a)         Care Coordination Supervisors

 

1)         Either prior to or within 60 calendar days after the date of employment with the CCU, each care coordination supervisor shall successfully complete:

 

A)        Department sponsored CCP training on the DON eligibility determination, care planning, Choices for Care screening, and OBRA-1 (Level I ID Screen).

 

B)        Successful completion of this training shall be established by certification.

 

2)         Each care coordination supervisor shall meet the following in-service training requirements:

 

A)        Recertification of CCP training within the 18 month anniversary of each previous recertification (e.g., recertification in September, subsequent recertification no later than March of the second following year);

 

B)        18 hours of documented in-service training on aging related subjects within each calendar year.  For partial years of employment, training shall be prorated to equal 1.5 hours for each full month of employment.  Documented participation in in-house staff training and/or local, State, regional or national conferences on aging related subjects, and the recertification required in subsection (a)(2)(A), will qualify as in-service training on an hour-for-hour basis.

 

b)         Care Coordinators

 

1)         Prior to performing CCP eligibility determinations and developing person-centered plans of care, each case manager and each supervisor acting as a care coordinator shall successfully complete:

 

A)        Department sponsored CCP training on the DON, eligibility determination, care planning, Choices for Care screening and OBRA-1 (Level I ID Screen).

 

B)        Successful completion of this training shall be established by preliminary certification which shall expire 6 months from completion of training.

 

2)         Each care coordinator and each supervisor acting as a care coordinator manager shall meet the following training requirements:

 

A)        certification of CCP training within 6 months from the preliminary certification (e.g., preliminary training in January, full certification no later than July); and

 

B)        recertification of CCP training within the 18 month anniversary of each previous certification (e.g., full certification in April, subsequent recertification no later than October of the second following year); and

 

C)        18 hours of documented in-service training on aging related subjects within each calendar year.  For partial years of employment, training shall be prorated to equal 1.5 hours for each full month of employment. Documented participation in in-house staff training and/or local, State, regional or national conferences on aging related subjects, in addition to the certification required in subsection (b)(2)(A), will qualify as in-service training on an hour-for-hour basis.

 

(Source:  Amended at 42 Ill. Reg. 20653, effective January 1, 2019)

SUBPART O: PROVIDERS