Section 1200.10  Purpose and Description

 

a)         General Program

 

1)         The University of Illinois is designated under the Specialized Care for Children Act to receive, administer, and hold in its own treasury federal and State funds and aid, including the Maternal and Child Health Services Block Grant (Title V of the Social Security Act (42 USC 701 et seq.), in relation to the administration of the Division of Specialized Care for Children. 

 

2)         DSCC administers a program of care coordination services and financial assistance, a component of which is diagnostic services, for children with physical disabilities or conditions that may lead to physical disabilities who meet eligibility criteria as set forth in this Part. 

 

3)         The objectives of the DSCC Program are as follows:

 

A)        To provide or pay for services to determine whether children meet the medical eligibility criteria necessary to qualify for the DSCC Program;

 

B)        To provide and promote family-centered, community-based, culturally competent coordinated care for eligible children and to facilitate the development of community-based systems of services for children and their families;

 

C)        To provide financial assistance for covered supports and services rendered to eligible children; and

 

D)        To make efforts to coordinate benefits for eligible children with other State or federally funded programs, including but not limited to, Title XIX and Title XXI of the Social Security Act, activities funded by the U.S. Departments of Agriculture and Education, health block grants, and categorical health programs. 

 

4)         The DSCC Program is not an entitlement and shall not be construed to create an entitlement. Eligibility and DSCC Program benefits are provided subject to the annual maximum dollar amounts set for each recipient child, budgetary limitations (see Section 1200.150(e)), and annual appropriations to the State and federal programs through which DSCC is funded. Any requirement imposed under this Part and any implementation of this Part shall cease in the event continued receipt of funds requires an amendment to this Part, federal or State funds for implementation of this Part are not available, or annual maximum dollar amounts for the recipient child are exceeded. 

 

b)         Supplemental Security Income – Disabled Children's Program

 

1)         DSCC administers the Supplemental Security Income-Disabled Children's Program (SSI-DCP) in accordance with section 1615c of the Social Security Act, Subchapter XVI (42 USC 1382d(a)(2)) to the extent provided in this subsection (b).

 

2)         Children are evaluated as eligible for the SSI-DCP by the U.S. Social Security Administration and the Illinois Department of Human Services-Division of Rehabilitation Services. Children deemed eligible (SSI-DCP children) are referred to DSCC for disposition.

 

3)         SSI-DCP children who meet the eligibility in this Part shall be eligible for DSCC Program benefits in accordance with this Part. SSI-DCP children who do not meet the eligibility criteria for the DSCC Program may be referred by DSCC to other programs, services, or institutions that may provide assistance.

 

c)         University of Illinois Policies and Procedures

As part of the University of Illinois, DSCC shall abide by all applicable University of Illinois policies and procedures.

 

Section 1200.20  Definitions

                                   

                        "Act" means the Specialized Care for Children Act [110 ILCS 345].

 

                        "Applicant Child" means the individual seeking DSCC Program benefits. 

 

"Associated Health Impairment" means a health impairment that, in isolation, would not be considered a medically eligible condition, but the treatment of which is medically necessary to successfully treat a medically eligible condition, excluding malignancy and chronic vegetative states.

 

"Care Coordination Services" means services paid for or provided by DSCC to promote the effective and efficient organization and utilization of resources to assure access to necessary comprehensive services for children eligible under this Part and their families.

 

"Chronic" means a condition that is expected to be long lasting or to be lifelong.

 

"Covered Supports and Services" means those benefits for which financial assistance is available under Section 1200.120.

 

"DSCC" or "Division" means the Division of Specialized Care for Children.

 

"DSCC Program" or "Program" means the program of care coordination services and financial assistance, a component of which is diagnostic services, for children with physical disabilities or who suffer from conditions that may lead to physical disabilities who meet eligibility criteria as set forth in this Part.

 

"Day" means calendar day, except when an action to be taken is scheduled to occur on a Saturday, Sunday or a State of Illinois holiday, in which case the legally responsible adult, designated representative, or DSCC has until the end of the next State business day to take the action.

 

"Designated Representative" means a person authorized by the LRA to act on his or her behalf.

 

"Diagnostic Services" means services provided or paid for by DSCC without regard to eligibility for financial assistance that are medically necessary to determine whether an applicant or recipient child meets the medical eligibility criteria of Section 1200.110. Diagnostic services are a component of care coordination services and financial assistance and no separate application is required. Diagnostic services are further described in Section 1200.90.

 

"Director" means the Executive Director of DSCC.

 

"Financial Assistance" means DSCC payment to a provider or other eligible persons for covered supports and services rendered to an applicant or recipient child. 

 

"Good Cause Shown" means a sufficient justification determined in the sole discretion of the Director or designee for failure to meet a requirement of this Part.  The availability of good cause shown is limited as further specified in this Part.  Good cause shown includes, but is not limited to, family emergencies, family death, demonstrated delays caused by the U.S. Postal Service, demonstrated delays or failures in electronic systems, or failure of a third party (e.g., medical provider) to submit necessary information to determine whether a child meets medical eligibility criteria.  

 

"Legally Responsible Adult" or "LRA" means:

 

if the applicant or recipient child is non-emancipated, a person with legal authority to act on behalf of and legally required to financially provide for the applicant or recipient child; or

 

an applicant or recipient child who is emancipated under State law to act on his or her own behalf.

 

"Medically Eligible Condition" means a medical condition that serves as one of the criteria that renders the applicant or recipient child eligible for DSCC Program benefits as detailed in Section 1200.110.

 

"Provider" means a person, firm, corporation, association, agency, institution or other legal entity that provides covered supports and services to an applicant or recipient child and meets the requirements of Section 1200.150.

 

"Recipient Child" means the individual who has been determined eligible to receive DSCC Program benefits.

 

"Receipt by DSCC" means the date DSCC acknowledges taking possession of information or forms (e.g., completed application) by means of an electronic or manual stamp.

 

"Receipt by an LRA" means the date the LRA acknowledges taking possession of information or forms (e.g., Notice of Determination) or 10 days after the date of the information or forms, whichever is later.

 

Section 1200.30  Application Process: General

 

a)         General

 

1)         An application shall be submitted by an LRA.

 

2)         An application is a signed request for DSCC Program benefits in a form approved by DSCC that has been completed to the best of the LRA's knowledge and belief.

 

3)         Applications are available at DSCC offices or online at http://dscc.uic.

edu/how-we-help/how-to-apply/.

 

4)         An LRA may apply for Program benefits using any of the following methods:

 

A)        Submitting an application at a DSCC office in person;

 

B)        Sending an application to a DSCC office via mail (U.S. Postal Service or private third party carrier);

 

C)        For care coordination service, online at http://dscc.uic.edu/how-we-help/how-to-apply/; or

 

D)        Additional methods that DSCC may establish.

 

5)         Applications shall be completed in accordance with instructions given by DSCC in any form approved by DSCC.

 

6)         A list of DSCC offices is available at http://dscc.uic.edu/find-an-office/.

 

7)         The LRA may be assisted by DSCC or by an individual of the LRA's choice in completing an application.

 

b)         Reapplication

When an application is not accepted or not processed, or when a recipient child has been terminated from the Program and when DSCC Program benefits are still desired, the LRA must reapply by submitting a new application in compliance with this Part. The LRA may reapply at any time.

 

c)         Good Cause Shown

DSCC may waive the requirements of this Section for good cause shown. 

 

Section 1200.40  Applications for Care Coordination Services and Financial Assistance

 

a)         Applications for care coordination services

 

1)         Applications for care coordination services shall include, at a minimum:

 

A)        The name, age, address and telephone number of the applicant child;

 

B)        The name, address and telephone number of the LRA;

 

C)        The LRA's signature; and

 

D)        Information necessary to determine medical eligibility or provide or arrange for diagnostic services as described in Sections 1200.90 and 1200.110.

 

2)         Completed Applications for Care Coordination Services

Applications for care coordination services shall be considered completed on the business day the requirements of subsections (a)(1) and (d) are met.

 

b)         Applications for Financial Assistance

 

1)         Applications for financial assistance shall include, at a minimum:

 

A)        The name, age, address and telephone number of the applicant child;

 

B)        The name, address and telephone number of the LRA;

 

C)        The LRA's signature;

 

D)        Information necessary to determine medical eligibility or provide or arrange for diagnostic services as further described in Sections 1200.90 and 1200.110; and

 

E)        Information necessary to determine financial eligibility as further described in Section 1200.80.

 

2)         Completed Application for Financial Assistance

Applications for financial assistance shall be considered completed on the business date the requirements of subsections (b)(1) and (d) are met.

 

c)         Diagnostic Services

No separate application is required for diagnostic services. Diagnostic services may be provided as part of the eligibility process for care coordination services or financial assistance.

 

d)         Supplemental Information

 

1)         After an application meeting the requirements of subsection (a)(1) or (b)(1) is received by DSCC, supplemental information, including interviews and Reimbursement Agreements (for financial assistance applications), may be requested by DSCC to establish eligibility. 

 

2)         The LRA shall submit the supplemental information no later than 45 days after the dated DSCC written notice or the date specified in that written notice, whichever is later. 

 

3)         Failure to submit the supplemental information within the required time frame shall cause the application to be deemed incomplete under subsection (e). 

 

e)         Incomplete Applications

 

1)         Applications that do not meet the requirements of subsections (a), (b) and (d) shall be considered incomplete and will not be accepted or processed. 

 

2)         Notice

 

A)        If DSCC does not accept or process an application for any reason set forth in this Section, DSCC shall use reasonable efforts to identify the LRA who initiated the application and inform the LRA of:

 

i)          The reason that DSCC did not process or did not accept the application; and

 

ii)         The action or actions required to accept or process the application.

 

B)        Notices sent pursuant to this subsection (e)(2) will not be required to comply with Section 1200.180.

 

3)         The LRA does not have any appeal rights for notices sent under this subsection (e).

 

f)         Good Cause Shown

DSCC may waive the requirements of this Section for good cause shown. 

 

Section 1200.50  General Responsibilities of Individuals Receiving DSCC Program Benefits

 

a)         The LRA and provider shall truthfully and factually supply all information and shall not in any way falsify or cause the falsification of documents necessary to determine eligibility for and provision of DSCC Program benefits.

 

b)         The LRA shall promptly report any change in contact information.

 

c)         The LRA shall consent to release of, or verification of, medical and financial information needed to determine eligibility.

 

d)         The LRA shall promptly report, within 30 days, any changes that may affect eligibility for DSCC Program benefits, including but not limited to changes in medical insurance that results in coverage for covered supports and services or diagnostic services for which DSCC has been providing financial assistance and is the payer of last resort. 

 

e)         The LRA must make maximum use of third party payments available for the applicant or recipient child, including but not limited to enrolling in State and federally funded healthcare programs such as Medicaid, CHIP, All Kids and Medicare; enrolling in private healthcare insurance; and, in the sole discretion of the Director or designee, utilizing private funds available to the applicant or recipient child.

 

f)         Maximum insurance benefits must be used.  The LRA is responsible for and shall cause any other responsible individuals to comply with insurance contract provisions required to maximize the level of insurance benefits.

 

g)         The LRA must sign a Reimbursement Agreement for the total amount of financial assistance provided by DSCC whenever monies are recovered or can be recovered arising from any claim, demand, or cause of action relating to the medical condition of the applicant or recipient child from sources including but not limited to a lawsuit judgment, settlement of a lawsuit, settlement in anticipation of litigation, or insurance recovery or settlement.  At the request of DSCC, the LRA shall cause any other individual with authority over the monies, including the attorney retained to represent the LRA, applicant child or recipient child, to also sign the Reimbursement Agreement.

 

h)         Failure to meet any requirements of this Part may result in a complete or partial ineligibility determination, termination, or suspension in DSCC Program benefits.  DSCC will notify the LRA of these determinations through a Notice of Determination in accordance with Section 1200.180.

 

i)          DSCC may, in its sole discretion, pursue any actions necessary against all liable persons, including but not limited to LRAs, for any payments made by DSCC that were inappropriate.

 

Section 1200.60  Effective Dates of Coverage

 

a)         Care Coordination Services

Care coordination services may be provided or paid for on the date of receipt of a completed application under Section 1200.40(a)(2).

 

b)         Financial Assistance

DSCC may provide financial assistance on the date of DSCC's receipt of a completed application under Section 1200.40(b)(2) and retroactively for up to 90 days prior to the date of DSCC's receipt of a completed application. 

 

c)         Diagnostic Services

DSCC may provide or pay for diagnostic services on the date of DSCC's receipt of a completed application under Section 1200.40(a)(2) or (b)(2) and may pay retroactively for up to 90 days prior to the date of DSCC's receipt of a completed application. 

 

d)         Reapplication

When reapplication to the DSCC Program is necessary, effective dates of coverage shall be determined pursuant to DSCC's receipt of the resubmitted completed application. For example, financial assistance may be provided on the date of DSCC's receipt of the resubmitted completed application and retroactively for up to 90 days prior to the date of DSCC's receipt of the resubmitted completed application.

 

e)         Effective Dates for Amendments to this Part

Amendments to this Part shall be effective for dates of service on and after July 1, 2018. A recipient child eligible for care coordination services as of June 30, 2018 who fails to meet the medical eligibility criteria of Section 1200.70(a)(2) as of July 1, 2018 shall remain eligible for care coordination Services without a break in coverage only if the recipient child continues to meet the nonmedical eligibility criteria of Section 1200.70(a)(1) and (a)(3) as of July 1, 2018. Recipient children eligible for financial assistance prior to July 1, 2018 shall remain eligible for financial assistance until redetermination under Section 1200.80(f).

 

Section 1200.70  Care Coordination Services Eligibility and Standards

 

a)         Care coordination services are services paid for or provided by DSCC to promote the effective and efficient organization and utilization of resources to assure access to necessary comprehensive services for children eligible under this Part and their families. Care coordination services may be covered by DSCC for an applicant or recipient child where the applicant or recipient child:

 

1)         Is under 21 years of age;

 

2)         Meets or is suspected of meeting the medical eligibility criteria in Section 1200.110; and

 

3)         Is a resident of Illinois as set forth in Section 1200.100.

 

b)         Diagnostic services may be provided in accordance with Section 1200.90 only if the criteria of subsection (a)(1) and (a)(3) are met.

 

c)         There is no financial eligibility criteria for care coordination services.

 

d)         Eligibility for care coordination services shall be reconsidered every 18 months and whenever a change occurs that impacts medical eligibility.

 

e)         Eligibility for care coordination services shall end when the requirements of this Section are no longer met, except as provided in Section 1200.170.

 

Section 1200.80  Financial Assistance Eligibility and Standards

 

a)         DSCC may pay a provider or other eligible persons for covered supports and services rendered to an applicant or recipient child. The LRA may qualify for financial assistance when the criteria of this subsection (a) are met.

 

1)         The applicant or recipient child:

 

A)        Is under 21 years of age;

 

B)        Meets or is suspected of meeting the medical eligibility criteria in Section 1200.110;

 

C)        Is a resident of Illinois as set forth in Section 1200.100; and

 

D)        Is a U.S. citizen or lawfully admitted to the United States.

If neither of these requirements are met, the LRA must be a U.S. citizen or lawfully admitted to the United States.

 

2)         If the applicant or recipient child is not the LRA, the LRA must be a resident of Illinois as set forth in Section 1200.100.

 

3)         The applicant or recipient child:

 

A)        Is eligible for a medical assistance program under the Illinois Public Aid Code [305 ILCS 5], the Covering All Kids Health Insurance Act (All Kids) [215 ILCS 170], or the Children's Health Insurance Program Act (CHIP) [215 ILCS 106];

 

B)        Meets the financial requirements of Medicaid, All Kids or CHIP but is not eligible for coverage based on the nonfinancial criteria; or

 

C)        The LRA has a household income at or below 325% federal poverty level (FPL) as outlined in https://aspe.hhs.gov/poverty-guidelines.

 

b)         Diagnostic services may be provided without regard to the financial eligibility criteria of subsection (a)(3) in accordance with Section 1200.90 and only when the criteria of subsections (a)(1)(A), (a)(1)(C), (a)(1)(D) and (a)(2) are met.

 

c)         When more than one child in a family qualifies for financial assistance, DSCC may give each eligible child the same period of eligibility.

 

d)         DSCC shall only provide financial assistance for covered supports and services as set forth in Section 1200.120.

 

e)         Payment shall only be made on behalf of applicant or recipient children to providers or other eligible persons who meet the requirements of this Part.

 

f)         Eligibility for financial assistance shall be redetermined annually and whenever a change occurs that impacts the eligibility criteria of subsections (a)(1) and (a)(2). Changes to subsection (a)(3) shall not be a cause to initiate a redetermination outside the annual redetermination process. 

 

g)         Except as provided in Section 1200.170, eligibility for financial assistance shall end:

 

A)        When the requirements of subsections (a)(1) and (a)(2) are no longer met; or

 

B)        When the requirements of subsection (a)(3) are not met as part of the annual redetermination process. 

 

Section 1200.90  Diagnostic Services

 

a)         Diagnostic services are services provided or paid for by DSCC without regard to financial eligibility that are medically necessary to determine whether an applicant or recipient child meets the medical eligibility criteria of Section 1200.110. Diagnostic services are a component of care coordination services and financial assistance and no separate application is required.

 

b)         Whenever eligibility or ineligibility is established based upon existing information or an interview with the LRA, applicant or recipient child, which may occur when a diagnosis has already been established, DSCC shall not be required to cover diagnostic services.

 

c)         Diagnostic services shall be provided on an outpatient basis unless inpatient services are medically necessary to complete the diagnostic evaluation as approved in the sole discretion of the Director or designee.

 

Section 1200.100  Resident of Illinois

 

a)         Definition

Resident of Illinois means:

 

1)         Any person "living in the State of Illinois" with the intent to remain in the State indefinitely.  The term "living in the State of Illinois" shall be limited to all persons whose primary domicile is located within the State. Intent to remain indefinitely is established through a showing that a person has significant contacts with the State of Illinois, which may be evidenced by maintaining a bank account in the State, registering to vote in the State, paying Illinois income taxes, obtaining permanent employment within the State, owning real estate within the State, possessing an Illinois driver's license, Secretary of State identification, or similar permits, or any other similar documentation;

 

2)         Any person who is present in the State of Illinois for the purpose of performing migrant agricultural labor and who evidences a pattern of regularly returning to the State to perform that work or who expresses an intention to establish a pattern of regularly returning to the State to perform that work.  Migrant agricultural labor is defined as agricultural work of a seasonal or temporary nature that requires the worker to be away from his or her permanent place of residence to perform the work more than overnight; or

 

3)         Any person who is an active duty member of the U.S. military and on official military assignment within the State of Illinois, whether or not he or she maintains residence in another state, or any person who is an active duty member of the U.S. military on official military assignment in another state or country who pays Illinois income taxes.

 

b)         LRA Illinois Residency for Financial Assistance 

When the LRA is no longer a resident of Illinois and the LRA is not the recipient child, financial assistance may be provided to the recipient child not to exceed 12 months from the date of the change of the LRA's residency status if:

 

1)         The LRA was a resident of Illinois when the recipient child became eligible; and

 

2)         The recipient child remains a resident of Illinois and one of the following applies:

 

A)        An active DSCC supported treatment plan for the recipient child's medically eligible condition was in progress at the time the LRA lost residency status;

 

B)        Discontinuation of treatment would result in probable harm to the recipient child or there is an adverse outcome of treatment, as determined in the sole discretion of the Director or designee; or

 

C)        Legal action is in progress that will establish legal guardianship of the recipient child with a person or agency located in Illinois.

 

c)         Self-Attestation

If documentation cannot be provided to substantiate the requirements of subsections (a)(1) and (a)(2), these requirements may be substantiated by the LRA's attestation. No further information, including documentation, shall be required from the LRA. The attestation shall be signed by the LRA and one witness.

 

Section 1200.110  Medical Eligibility

 

a)         General

In order to be eligible for DSCC Program benefits:

 

1)         An applicant child shall be suspected of having, and a recipient child shall have, one or more of the medically eligible conditions set forth in subsection (c);

 

2)         The medically eligible condition shall:

 

A)        be chronic;

 

B)        involve a physical limitation or restriction; or

 

C)        necessitate long-term highly specialized medical care;

 

3)         The recipient child shall have an active plan of care for the medical treatment of the medically eligible condition from a provider that shall be periodically updated by the provider; and

 

4)         If care coordination services are sought, the applicant or recipient child must benefit from care coordination services.

 

b)         Medical Reports 

 

1)         Medical eligibility is determined following a review of medical reports, including current plans of care from a provider of the applicant or recipient child.

 

2)         If there is insufficient information to determine medical eligibility, DSCC may provide or pay for diagnostic services as set forth in Section 1200.90.

 

c)         Medically Eligible Conditions

 

1)         "Blood Disorders" means both inherited and acquired hematologic conditions that are chronic and require management by a specialist.  Primary hematologic malignancies (i.e., leukemias) are excluded. 

 

2)         "Cardiovascular Impairments" means impairments that primarily affect the heart and/or the larger blood vessels that are chronic and require management by a specialist.

 

3)         "Craniofacial and External Body Impairments" means significant defects affecting the skin and/or its underlying structures and defects of the mucosa and/or its underlying structures of the internal parts that may affect breathing, speech and eating, are chronic, and require management by a specialist. Internal parts include the oral and nasal structures with their extension into the mouth, pharynx, larynx, major bronchi, and esophageal structures. Defects of dentition and occlusion associated with severe oro-craniofacial structural deformities, or that are causative to impairment of intelligible speech and/or difficulty chewing food, are included.

 

4)         "Eye Impairments" means those that affect the eye and/or eye muscles, excluding isolated refractive errors, that lead to or cause a significant risk of loss of vision, are chronic, and require management by a specialist. 

 

5)         "Gastrointestinal Impairments" means disabling conditions affecting the esophagus, stomach or intestines that are chronic and require management by a specialist. 

 

6)         "Hearing Impairments" means loss of hearing or deafness of at least 30 decibels (dB) in two frequencies (500, 1000, 2000, 4000 and 8000 Hz) or a 35 dB loss in one speech frequency (500, 1000 and 2000 Hz) involving one or both ears, as determined by audiometric testing that are chronic and require otological intervention and management by a specialist.

 

7)         "Inborn Errors of Metabolism" means those newborn conditions leading to severe neurological, mental and/or physical deterioration that are chronic and require management by a specialist.

 

8)         "Nervous System Impairments" means those impairments that affect the brain, spinal cord or peripheral nerves, that present as persistent or recurring loss of function but not cognitive or emotional disability, and that are chronic and require management by a specialist. 

 

9)         "Orthopedic Impairments" means those that affect bone, joint or muscle and that are chronic and require management by a specialist. 

 

10)        "Pulmonary Impairments" means chronic disabling conditions affecting the lungs or breathing, such as cystic fibrosis or chronic lung disease, that are chronic and require management by a specialist.  Asthma, as an isolated condition, is excluded. 

 

11)        "Urogenital Impairments" means organic impairments that affect the kidney, ureter, bladder, urethra and/or ano-genital structures and that are chronic and require management by a specialist.  Urinary tract infections and isolated ureteral urinary reflux are excluded unless associated with a persistent structural defect.

 

Section 1200.120  Financial Assistance for Covered Supports and Services

 

a)         When the financial assistance criteria of Section 1200.80 are met, DSCC may provide financial assistance for the following:

 

1)         Consultative services.

 

2)         Continuing outpatient supervision of the medically eligible condition and associated health impairments, including office or clinic visits.

 

3)         Hospitalization and inpatient medical and/or surgical treatment, including special rehabilitation services. Provided, however, that procedures, tests or services shall not be performed on an inpatient basis if, under medical professional standards they are usually and customarily performed in outpatient facilities, unless determined to be medically indicated by the Director or designee based on the recommendation of the recipient or applicant child's treating physician.

 

4)         Home based care intended to prevent continued hospitalization, excluding continuing care nursing, life support systems, or high technology equipment and related supplies.  The care is limited to training of parents and/or community healthcare providers; provision of medically necessary recommended equipment and supplies; and periodic visiting nurse and/or related health personnel supervision. 

 

5)         Assistive appliances; mechanical, structural or electrical equipment intended to support, replace or augment a dysfunctioning or nonfunctioning part of the body, such as braces, prosthetic limbs, hearing aids, wheelchairs, related adaptive devices; and special supplies determined medically necessary to accomplish rehabilitation or habilitation goals.  Excluded are fixed architectural modifications of the dwelling and property related thereto in which the Recipient or Applicant Child resides.  External ramps and/or mechanical lifts needed to provide the Recipient or Applicant Child access to the dwelling are not excluded.

 

6)         Speech, physical and occupational therapy.

 

7)         Nutrition evaluation and guidance and provision of special dietary substances upon medical recommendation, except those dietary substances available through programs of public or private agencies established for those purposes.

 

8)         Specialized dental care, such as orthodontia, prosthodontia, or oral surgery as required to further the treatment plan of a recipient or applicant child with severe oro-craniofacial deformities (e.g., cleft lip and/or cleft palate) or severe congenital malformation of the teeth (e.g., anodontia or dentinogenesis imperfecta).  Routine preventive or restorative dentistry is not provided except for recipient or applicant children for whom this service is a specific recommendation to be integrated into an authorized orthodontic or prosthodontic plan.

 

9)         Arrangements for home follow-up services by public health and/or related rehabilitative or habilitative services personnel.

 

10)         Prescriptive drugs.

 

11)         Genetic evaluation and family counseling.

 

12)         Psychological and psychiatric evaluation.

 

13)         Medically necessary supports and services for the treatment of associated health impairments.

 

14)         Transportation, lodging, meals and parking costs for the LRA, applicant or recipient child, and any additional caretaker whose presence is medically required to provide care for the applicant or recipient child:

 

A)        When necessary to make recommended supports and services accessible;

 

B)        When no other sources are available for this purpose; and

 

C)        By the most economically appropriate method and at a cost not exceeding limitations set forth in the Reimbursement Schedule of the Travel Regulation Council (80 Ill. Adm. Code 3000.Appendix A).  DSCC will prescribe the form and procedure families must follow in order to verify and be reimbursed for expenses. When circumstances so dictate to meet the healthcare needs of the applicant or recipient child, the Director or designee shall authorize payments in excess of the amount stated in this subsection (a)(14)(C).

 

b)         The supports and services described in this Section shall only be covered when:

 

1)         Rendered by providers who meet the requirements of Sections 1200.50 and 1200.150;

 

2)         For payment (e.g., copayments, deductibles) made on behalf of an applicant or recipient child to other eligible persons such as an LRA, the applicable requirements of this Part must be met, including but not limited to Sections 1200.50 and 1200.150.

 

3)         Authorized pursuant to Section 1200.140;

 

4)         Except for diagnostic services, they are part of a treatment plan that has defined treatment objectives and goals for medical supports and services;

 

5)         DSCC is the payer of last resort as outlined in Section 1200.150;

 

6)         Funds are available as outlined in Sections 1200.10 and 1200.150;

 

7)         Medically necessary for medical supports and services or diagnostic services; and

 

8)         For nonmedical supports or services related to the medically eligible condition or associated health impairment.

 

Section 1200.130  Supports and Services Not Covered

 

a)         DSCC will not provide financial assistance for the following:

 

1)         Organ transplants and related anti-rejection drugs.

 

2)         Surgery or other treatment that is primarily for cosmetic purposes.

 

3)         Research, experimental or investigational services, drugs and equipment, except as provided in subsection (b).

 

4)         Primary care services required to support general health unrelated to the medically eligible condition, including but not limited to routine well child and dental care, immunizations, nonspecialty infant formula, clothing and diapers.

 

5)         Routine medical and dental treatment.

 

6)         Treatment for acute childhood illnesses.

 

7)         Treatment related to trauma or short-term complications related to the trauma.

 

8)         Supports or services available without charge.

 

9)         Transitional care.

 

10)         Respite care.

 

11)         Unkept appointments, except for good cause shown.

 

12)         Nonmedically necessary items and services provided for the convenience of recipients and/or their families, except for good cause shown.

 

13)         Supports and services not specifically itemized in Section 1200.120.

 

b)       Research, Experimental or Investigational Services, Drugs and Equipment. The DSCC Director or designee shall determine whether services, drugs or equipment are, in fact, research, experimental or investigational based on the criteria set forth in this subsection (b).

 

1)         The affected services, drugs and equipment are medical or professional services, hospital services, drugs, devices or equipment that have not been recognized as having a proven habilitative or rehabilitative value as determined by the professional standards of the applicable medical or healthcare specialty groups, including but not limited to:

 

A)        equipment or appliances that do not have the approval of the Department of Health and Human Services, Food and Drug Administration or other appropriate federal agency (investigational new drugs and devices and investigational services and treatments shall not be deemed to have received federal approval);

 

B)        medical and/or other health related services, including drugs, food supplements, equipment or appliances not reported on, described or discussed in published and recognized professional journals that have an advisory board passing on their publications; and

 

C)        services, drugs, devices, equipment or appliances that have not been recognized by appropriate national professional organizations.

 

2)         If a provider wishes to utilize services, drugs or equipment that is possibly research, experimental or investigational, the provider must provide a written justification for doing so to the DSCC Director or designee who may approve in his/her sole discretion.  Other pertinent information from knowledgeable professional sources may be required. 

 

3)         If DSCC authorizes services, drugs or equipment later determined by DSCC as research, experimental or investigational and, if the provider has failed to notify DSCC in advance of the possible experimental, research or investigational nature, the provider may be obligated to refund any monies paid by DSCC or the LRA.

 

c)         As used in this Section, acute means an immediate associated consequence of infection, trauma, disease, toxicity or malignancy.

 

Section 1200.140  Authorization

 

a)         All covered supports and services and diagnostic services shall require a written prior authorization as a condition of DSCC financial assistance, except for the following:

 

1)         Outpatient appointments for specialty providers;

 

2)         Co-pays related to the medically eligible condition and associated health impairment;

 

3)         Deductibles related to the medically eligible condition and associated health impairment;

 

4)         Routine laboratory and diagnostic tests for management and monitoring of the medically eligible condition and associated health impairment; and

 

5)         Medical reports.

 

b)         Authorization shall be provided prior to receipt of the covered support or service and diagnostic service, except as allowed in subsection (c).

 

c)         DSCC may retroactively pay for covered supports and services and diagnostic services:

 

1)         For an applicant child, pursuant to Section 1200.60(b) and (c).

 

2)         For a recipient child, when DSCC is notified within 30 days after the rendering of the covered support and service or diagnostic service.  The 30 days may be waived for good cause shown.

 

d)         Authorizations shall minimally include, as applicable, the number of professional outpatient service visits approved, the time period of the authorization, and a description of the equipment or service to be provided, with medical justification. 

 

e)         Services, drugs or equipment that are duplicative of those authorized or exceed DSCC authorized limits shall not be covered.

 

f)         All hospitalizations and all equipment purchases are subject to separate authorizations for each occasion of the service.

 

g)         Supports or services provided that differ in any way from those approved are not guaranteed for payment.

 

Section 1200.150  Standards for Reimbursement for Providers and Other Eligible Persons

 

a)         In order to receive reimbursement by DSCC for covered supports and services and diagnostic services rendered to an applicant or recipient child, a provider shall:

 

1)         Hold a valid, appropriate license, certification, accreditation, or credentials required by the state where the covered support and service or diagnostic service is rendered; 

 

2)         Not be excluded from participation in Medicare, Medicaid or any other federal or State healthcare program;

 

3)         Meet any other requirements imposed as a condition of receiving Title V funds and comply with the requirements of applicable federal and State laws and not engage in practices prohibited by those laws; 

 

4)         Have a provider agreement on file with DSCC;

 

5)         Accept as payment in full the amounts paid by DSCC and not seek further payment from the LRA beyond copayments and deductibles when DSCC does not pay the copayments or deductibles;

 

6)         Furnish to DSCC or designee, in the form and manner requested by it, any information it requests regarding payments for covered supports and services or diagnostic services, including but not limited to dates of service, appropriate ICD diagnostic codes, current procedural terminology (CPT) codes, HCPCS National Level II codes, American Dental Association (ADA) codes, National Drug Codes (NDC) and as available, explanations of benefits from non-federally or non-State funded third party payers; 

 

7)         Notify DSCC in writing immediately when there is a change in meeting any requirement or information previously submitted by the provider;

 

8)         Comply with any audits by DSCC, State or federal government in connection with the DSCC Program; and 

 

9)         Comply with the applicable requirements of Section 1200.50.

 

b)         DSCC shall be the payer of last resort for covered supports and services and diagnostic services. Payment shall not be made until insurance or any other third party payer has paid or rejected the claim.

 

1)         The provider or other person eligible to receive payment shall submit claims or invoices to any third party payers liable for payment prior to billing DSCC. 

 

2)         DSCC is not required to pursue third party liability payments from State or federally funded healthcare programs, including but not limited to Medicaid, All Kids, CHIP or Medicare.

 

3)         The Director or designee may waive the DSCC third party payer status if necessary to avoid undue suffering or to preserve life and good health and if immediate payment will cause DSCC funds to be utilized in the most efficient and effective fashion, all as determined based on usual and customary medical standards.

 

c)         Subject to all the limits on benefits contained in this Part, DSCC will pay the cost of care coordination services, covered supports and services, and diagnostic services above that reimbursed by a third party payer up to an established rate of payment.  When third party payments exceed the DSCC payment maximums, the bill shall be considered paid in full.

 

d)         In order to be eligible for payment consideration, an initial claim or bill, or a claim or bill resubmitted following prior rejection, must be received timely by DSCC, but no later than 18 months from the date when covered supports or services or diagnostic services are provided. Failure to comply with this subsection shall result in no payment by DSCC. DSCC shall have no liability for any payment of these late claims.  Providers who fail to comply with this subsection shall also not seek payment from the applicant child, recipient child, or LRA. The requirements of this subsection may be waived by the Director or designee for good cause shown.

 

e)         The DSCC Program is not an entitlement and shall not be construed as an entitlement. DSCC shall not be liable for any benefits, including those DSCC authorized prior to the unavailability of funds. A provider's rendering of goods and services in excess of the funds available may result in no payment by DSCC. (See Section 1200.10(a)(4).)  For recipient children, the Director or designee shall establish maximum dollar amounts for payment of covered supports and services and diagnostic services per State fiscal year (July 1 through June 30). The maximum dollar amount for each recipient child shall be based on how many recipient children receiving financial assistance are in the program and the amount of State and federal annual appropriations available, combined with other restraints on DSCC's resources. DSCC shall inform the LRA and any provider who may be affected of the limit that may result in no payment by DSCC. (See also Section 1200.10(a)(4).)

 

f)         DSCC may request providers to submit updated enrollment information.  Failure of a provider to submit this information within the requested time frames may result in the disenrollment of the provider from the DSCC Program. Disenrollment shall have no effect on the future eligibility of the Provider to participate and is intended only for purposes of DSCC's efficient administration. A disenrolled provider may reapply to the DSCC Program.

 

g)         Providers and other eligible persons who fail to meet the requirements of this Section shall not be eligible for payment by DSCC for care coordination services, covered supports and services, and diagnostic services.

 

Section 1200.160  Eligibility Redeterminations and Investigations

 

a)         Redeterminations

 

1)         DSCC shall send a notice to LRAs at least 60 days prior to the end of the period of eligibility that informs the LRA of the requirements for continued eligibility.

 

2)         If the requirements for continued eligibility are not fulfilled by the deadline established in the notice, a Notice of Determination advising of the cancellation shall be issued to the recipient child pursuant to the requirements of Section 1200.180. Coverage shall end on the last day of the eligibility period.

 

3)         A recipient child's eligibility may be reinstated without requiring a new application if the requirements for continued eligibility are fulfilled within 90 days following the last date of coverage.

 

b)         Investigations

 

1)         Eligibility may be reviewed based on information known, reported or discovered or failure to meet any requirements of this Part.

 

2)         If eligibility is reviewed, supplemental information, including interviews, may be requested by DSCC to determine continued eligibility. 

 

3)         The LRA shall submit the supplemental information no later than 45 days after the dated DSCC written notice or the date specified in the DSCC written notice, whichever is later. The requirements of this subsection (b)(3) may be waived for good cause shown. 

 

4)         Failure to submit the supplemental information within the required time frame may adversely impact eligibility for DSCC Program benefits.

 

5)         DSCC shall advise the LRA of any adverse eligibility determinations made pursuant to this subsection (b) in accordance with the Notice of Determination requirements of Section 1200.180.  

 

c)         Reapplication

Nothing in this Section shall prevent an LRA from reapplying for DSCC Program benefits at any time.

 

Section 1200.170  DSCC Program Benefits After Loss of Eligibility

 

a)         DSCC may provide care coordination services and financial assistance beyond the recipient child's eligibility ending date when necessary to complete a treatment plan developed before that time, for purposes of continuity of care, if cessation of treatment would cause an immediate threat to or damage the life or good health of the recipient child or would negate gains resulting from previous habilitative or rehabilitative efforts. 

 

b)         The determination in this Section shall be made in the sole discretion of the Director or designee.

 

c)         In no event shall the extension continue more than six months beyond the medical eligibility ending date of the recipient child.

 

d)         Diagnostic services shall not be an available benefit under this Section.

 

Section 1200.180  Notice of Determination and Communication Standards

 

a)         Notice of Determination

 

1)         Applicant Children

Unless the emergent nature of the applicant child's condition requires a decision in a more timely fashion, as determined in the sole discretion of the Director or designee, the Division shall send a written Notice of Determination notifying the LRA of the eligibility status of the applicant child within 30 days after the receipt of a completed application.   If the Notice of Determination involves an adverse eligibility determination, the notice shall specifically state the reasons and contain an explanation of the LRA's right to appeal under to Section 1200.190.  

 

2)         Recipient Children

DSCC shall send a Notice of Determination informing the LRA of any action DSCC intends to take that adversely affects eligibility of a recipient child.  The Notice of Determination shall specifically state the effective date and reasons for the proposed action, shall be sent at least 30 days prior to the effective date of the proposed action, and shall contain an explanation of the LRA's right to appeal under to Section 1200.190.

 

b)         Communication Standards

 

1)         In the sole discretion of DSCC, DSCC may deliver the Notice of Determination and any other communication in person, via mail (U.S. Postal Services or private carrier) to the last known address of the LRA, or electronically to the last known email or other electronic address of the LRA. 

 

2)         DSCC may use electronic means to communicate only if the individual to whom the Notice of Determination, request, or communication would be sent has agreed to receive written notices electronically.

 

Section 1200.190  Appeal Process

 

a)         General

The appeal processes set forth in this Section shall be informal in nature and not subject to the Administrative Review Law [735 ILCS 5/Art. III].

 

b)         Right to Meeting

 

1)         The LRA, or the designated representative, has a right to a meeting with DSCC with respect to any adverse eligibility determinations set forth in a Notice of Determination issued pursuant to Section 1200.180.

 

2)         The request must be made in writing and must identify the decision being questioned.

 

3)         The request must be made within 30 days after receipt of the Notice of Determination.

 

4)         DSCC shall contact the LRA, or the designated representative, within 10 days after receipt of the request, to schedule a meeting date, time and place.

 

5)         Within 10 days after the meeting, DSCC shall notify the LRA or the designated representative of the result of the meeting, the specific reasons for the decision, and any applicable effective dates of the decision (see Section 1200.180).  For adverse eligibility determinations, the notice shall also contain an explanation of the LRA's right to a conference pursuant to subsection (c).

 

6)         The Director shall not take part in this meeting or the resulting decision.

 

7)         Unless the meeting decision is appealed pursuant to subsection (c), the meeting decision is final.

 

c)         Right to Conference

 

1)         The LRA, or designated representative, has a right to appeal the subsection (b) meeting decision to the Director or designee in a conference with the Director or designee. 

 

2)         The request for a conference must be made in writing and must identify the specific meeting decision being appealed.

 

3)         The request must be made within 30 days after receipt of the subsection (b) meeting decision.

 

4)         DSCC shall contact the LRA or designated representative, within 10 days after receipt of the request, to schedule a conference date, time and place.

 

5)         The Director or designee shall consider the subsection (b) meeting decision, any written material presented at the subsection (b) meeting, any evidence presented at the conference, and any other information the Director or designee obtains through a third party report or investigation of the issues raised by the appeal.

 

6)         Within 10 days after the appeal conference, DSCC shall notify the LRA of the result of the appeal conference, the specific reasons for the decision, and any applicable effective dates of the decision (see Section 1200.180). For adverse eligibility determinations, the notice shall also contain an explanation that the decision is final and cannot be appealed.

 

7)         The conference decision rendered by the Director or designee is final.

 

d)         DSCC may deny or dismiss a meeting or conference if:

 

1)         The LRA or designated representative withdraws the request for the meeting or appeal conference in writing; or

 

2)         The LRA or designated representative fails without good cause shown to appear at the scheduled meeting or conference.

 

Section 1200.200  Appeal:  Procedural Rights, Available Benefits, and Effective Dates of Appeal Decision

 

a)         Procedural Rights at Appeals Meeting and Conference

The LRA or the designated representative has the following rights:  

 

1)         The right at any time to inspect and copy the contents of the applicant or recipient child's case file and any other documents used by DSCC in making its determination or proposing its action;

 

2)         The right to appear on his or her own behalf, to be advised, or to be accompanied by a relative, friend, lawyer or advocate;

 

3)         The right to present relevant information, witnesses and evidence in any form; and

 

4)         The right to ask questions of DSCC staff present.

 

b)         Benefits While Awaiting Appeal Decisions 

 

1)         Applicant Children

An LRA whose application for care coordination services or financial assistance is denied may appeal the denial but shall not receive any financial assistance, diagnostic services, or care coordination services on behalf of the applicant child while awaiting the final decision.

 

2)         Recipient Children

 

A)        Care Coordination Services

 

i)          If an appeal is initiated for care coordination services in accordance with Section 1200.190, the care coordination services shall continue, pending the final decision of the appeals process, unless the LRA or designated representative specifically requests that care coordination services not be continued.

 

ii)         Diagnostic services shall not be an available benefit.

 

B)        Financial Assistance

 

i)          If an appeal for financial assistance is initiated in accordance with Section 1200.190, DSCC payment shall be stayed pending the final decision of the appeal process.

 

ii)         If the recipient child is also receiving care coordination services, the care coordination services will not be affected.

 

c)         Effective Dates of DSCC Decisions

 

1)         Care Coordination Services

 

A)        Applicant Children

Care coordination services determined appropriate as a result of an appeal shall be effective as of the date of the final decision of the appeal process.

 

B)        Recipient Children

Care coordination services determined inappropriate as a result of an appeal shall be discontinued as of the date of the final decision of the appeal process.

 

2)         Financial Assistance

 

A)        Applicant Children

Financial assistance determined appropriate as a result of an appeal shall be effective from the date of the completed application.

 

B)        Recipient Children

Financial assistance determined appropriate as a result of an appeal of a specific covered support and service shall be rendered as soon as practicably possible from the date of the final decision of the appeal process.

 

3)         No Appeal

If an LRA does not initiate an appeal, the effective date shall be the date stated in the Notice of Determination issued under Section 1200.180.