PART 679 DETERMINATION OF NEED (DON) AND RESULTING SERVICE COST MAXIMUMS (SCMs) : Sections Listing

TITLE 89: SOCIAL SERVICES
CHAPTER IV: DEPARTMENT OF HUMAN SERVICES
SUBCHAPTER d: HOME SERVICES PROGRAM
PART 679 DETERMINATION OF NEED (DON) AND RESULTING SERVICE COST MAXIMUMS (SCMs)

AUTHORITY: Implementing Section 3 of the Disabled Persons Rehabilitation Act [20 ILCS 2405/3].

SOURCE: Adopted at 19 Ill. Reg. 5062, effective March 21, 1995; amended at 20 Ill. Reg. 6303, effective April 18, 1996; amended at 21 Ill. Reg. 2674, effective February 7, 1997; recodified from the Department of Rehabilitation Services to the Department of Human Services at 21 Ill. Reg. 9325; emergency amendment at 22 Ill. Reg. 2328, effective January 12, 1998, for a maximum of 150 days; amended at 22 Ill. Reg. 10445, effective May 29, 1998; emergency amendment at 22 Ill. Reg. 16031, effective August 14, 1998, for a maximum of 150 days; emergency expired on January 11, 1999; amended at 23 Ill. Reg. 1615, effective January 20, 1999; amended at 23 Ill. Reg. 7492, effective June 17, 1999; emergency amendment at 23 Ill. Reg. 10526, effective August 10, 1999, for a maximum of 150 days; amended at 24 Ill. Reg. 285, effective December 23, 1999; amended at 24 Ill. Reg. 6563, effective May 1, 2000; emergency amendment at 24 Ill. Reg. 9966, effective July 1, 2000, for a maximum of 150 days; amended at 24 Ill. Reg. 17126, effective November 3, 2000; emergency amendment at 27 Ill. Reg. 17428, effective November 6, 2003, for a maximum of 150 days; emergency expired April 3, 2004; amended at 28 Ill. Reg. 7056, effective April 30, 2004; emergency amendment at 28 Ill. Reg. 15178, effective November 8, 2004, for a maximum of 150 days; emergency expired April 6, 2005; amended at 31 Ill. Reg. 422, effective December 29, 2006; amended at 31 Ill. Reg. 11332, effective July 18, 2007; amended at 43 Ill. Reg. 2117, effective January 24, 2019.

 

Section 679.10  General Provisions

 

a)         The DON, pursuant to 89 Ill. Adm. Code 676.30(d), is the assessment tool used to determine an individual's non-financial eligibility for HSP services based on the individual's impairment in the completion of the activities of daily living (ADLs) (Part A) and the individual's need for care that is not met by existing family and other resources (Part B). This assessment is made to determine whether or not the individual is at imminent risk of institutionalization, and therefore eligible for placement in a hospital/nursing facility and/or services through HSP.

 

b)         If the individual receives at least the minimum DON score to be considered eligible for institutional placement or HSP services (see 89 Ill. Adm. Code 682), the DON score relates to a specific Service Cost Maximum (SCM) that may be expended on services for an individual who chooses HSP services as an option to institutionalization (see Section 679.50).

 

Section 679.20  Composition of the DON

 

The DON is comprised of three sections which are:

 

a)         the Mini-Mental Status Examination section, as developed by the University of Illinois-Chicago, School of Public Health, which is used to determine the individual's cognitive functioning, and therefore the ability of the individual to adequately respond to the DON questions about his or her functioning capacity in the completion of the DON. Home Service Program staff may choose to not administer the MMSE if interaction with the customer, during the interview to gather demographic information, reveals no cognitive problems. The Mini-Mental Status Examination section shall not be administered to individuals who:

 

1)         are 12 years of age or younger;

 

2)         manifest, or have been diagnosed with, mental retardation or a related condition that results in impairment of a person's general intellectual functioning; or

 

3)         manifest adaptive behavior and require services similar to an individual with mental retardation.

 

b)         Part A which measures the individual's need for care in the completion of ADLs; and

 

c)         Part B which measures the individual's unmet need for care in the completion of ADLs.

 

(Source:  Amended at 24 Ill. Reg. 6563, effective May 1, 2000)

 

Section 679.30  Scoring of the DON Except for Respite Cases

 

a)         An individual receiving a 14 or more on the Mini-Mental Status Examination shall receive "zero" points towards his/her column A score. An individual receiving less than 14 points shall receive an additional "10" points added to his/her column A score for the determination of eligibility and a SCM.

 

b)         The remaining two sections of the DON measure the individual's ability to complete the ADLs. The ADLs are specifically:  eating, bathing, grooming, dressing, transferring, incontinence care, preparing meals, being alone, telephoning, managing money, routine health care tasks (or those health care tasks not requiring specialized training), specialized health care tasks (or those requiring assistance from trained medical practitioners), necessary travel outside the home, laundry, and housework.

 

1)         Part A of the DON measures the individual's need for assistance in the completion of each of the ADLs on the following rating scale.

 

A)        None ("0" points) – the individual can perform all essential components of the ADL with or without an existing assistive device;

 

B)        Minimal ("1" point) – the individual can perform most of the ADL, with or without an existing assistive device, but requires some supervision and/or assistance to ensure the task is fully completed;

 

C)        Moderate ("2" points) – the individual requires a great deal of supervision and/or assistance, with or without existing assistive devices, in the completion of the essential components of the task; and

 

D)        Severe ("3" points) – the individual cannot perform any of the essential components of the task, with or without existing assistive devices and requires constant supervision and/or assistance.

 

2)         Part B of the DON measures the individual's unmet need for care in the completion of the ADLs on the following scale.

 

A)        None ("0" points) – the individual has no unmet need for care in that the individual needs no assistance in completion of the essential components of the task, or family and/or other resources already provide for this task;

 

B)        Minimal ("1" point) – the individual's need for assistance in the completion of the task is met at least 50% of the time, and, without periodic assistance, there is a risk to the individual's health and safety;

 

C)        Frequent ("2" points) – the individual's need for assistance in the completion of the task is met less than 50% of the time and, without assistance, there is moderate risk to the individual's health and safety; and

 

D)        Constant ("3" points) – the individual's need for assistance in the completion of the task is seldom (less than 10% of the time) or never met and, without assistance, there is extreme risk to the individual's health and safety.

 

c)         In administering the DON for children, the assessor should ensure the ratings given reflect limitations due to the individual's disability and not the individual's age and/or the additional burden placed on the caregiver.

 

1)         On Part A, determine if a child of the individual's age should be able to complete all or part of the task. If the inability to perform the task relates only to the individual's age, a score of "zero" should be given. Otherwise, score "1", "2", or "3" according to the individual's impairment level.

 

2)         On Part B, determine the additional burden placed on a caregiver providing the service. If, because of the individual's age, there is no increased burden, a score of "0" should be given. If there is an increased burden on the caregiver due to the individual's disability, score "1", "2", or "3" according to the increased level of burden in providing the task.

 

(Source:  Amended at 43 Ill. Reg. 2117, effective January 24, 2019)

 

Section 679.40  Scoring the DON for Respite Cases

 

In order to be eligible for respite services, the individual must receive 29 points in Part A of the DON, which includes the 10 points from the Mini-Mental Status Examination, as appropriate. No points are necessary in Part B as respite services are to provide relief to a caregiver who normally provides all care for an individual which is at no cost to DHS.

 

Section 679.50  Service Cost Maximums (SCMs)

 

a)         For each individual meeting the minimum required DON scores for eligibility (see 89 Ill. Adm. Code 682), there is a corresponding Service Cost Maximum (SCM) for his/her DON score which is the maximum amount that may be expended for services through HSP for an individual who chooses HSP services over institutionalization.  This amount directly corresponds to the amount the State would expect to pay for the nursing care component of institutionalization if the individual chose institutionalization.

 

b)         The monthly SCMs for individuals served under the HSP Disabled Individual Medicaid Waiver are:

 

DON Range

11/1/03 SCM

8/1/04 SCM

8/1/05 SCM

8/1/06 SCM

8/1/07 SCM

29-32

$1,154

$1,194

$1,249

$1,329

$1,488

33-40

$1,326

$1,371

$1,435

$1,527

$1,710

41-49

$1,475

$1,526

$1,597

$1,699

$1,902

50-59

$1,766

$1,827

$1,912

$2,034

$2,277

60-69

$2,076

$2,147

$2,247

$2,390

$2,677

70-79

$2,244

$2,322

$2,430

$2,585

$2,894

80-100

$2,412

$2,495

$2,612

$2,778

$3,111

 

c)         The monthly SCMs for individuals served under the HSP AIDS Medicaid Waiver are:

 

DON Range

11/1/03 SCM

8/1/04 SCM

8/1/05 SCM

8/1/06 SCM

8/1/07 SCM

29-32

$1,486

$1,538

$1,609

$1,712

$1,917

33-40

$2,228

$2,305

$2,412

$2,566

$2,873

41-49

$2,970

$3,073

$3,216

$3,421

$3,831

50-59

$3,714

$3,842

$4,021

$4,278

$4,790

60-69

$4,458

$4,611

$4,827

$5,134

$5,749

70-79

$5,198

$5,378

$5,628

$5,987

$6,704

80-100

$5,943

$6,148

$6,435

$6,845

$7,664

 

d)         The monthly SCMs for individuals served under the HSP Brain Injury Medicaid Waiver are:

 

DON Range

11/1/03 SCM

8/1/04 SCM

8/1/05 SCM

8/1/06 SCM

8/1/07 SCM

29-32

$1,286

$1,331

$1,393

$1,482

$1,659

33-40

$1,427

$1,476

$1,545

$1,644

$1,841

41-49

$1,586

$1,640

$1,717

$1,826

$2,045

50-59

$1,901

$1,966

$2,058

$2,189

$2,451

60-69

$2,234

$2,311

$2,419

$2,573

$2,881

70-79

$2,415

$2,499

$2,615

$2,782

$3,115

80-100

$2,597

$2,686

$2,811

$2,990

$3,349

             

e)         The SCM for an individual may be exceeded on a monthly basis to meet a temporary increase in need for services as long as the average monthly cost for services during the twelve month period does not exceed the SCM. Such an increase in services shall not last more than 3 months.

 

f)         The exceptional care rate (ECR) for individuals who cannot be served under an HSP waiver's SCM is established by the Department of Healthcare and Family Services (HFS) under 89 Ill. Adm. Code 140.569(i).  This rate is comparable to the assessed cost for institutionalization and shall not be exceeded.  To determine the exceptional care rate for an individual served under an HSP waiver program:

 

1)         the nearest approved exceptional care nursing facility to the individual's

home is identified;

 

2)         the exceptional care rate for that facility is requested from HFS; and

 

3)         the daily exceptional care rate is multiplied by 30.3 to establish a monthly

average.

 

(Source:  Amended at 31 Ill. Reg. 422, effective December 29, 2006)