TITLE 89: SOCIAL SERVICES
CHAPTER III: DEPARTMENT OF CHILDREN AND FAMILY SERVICES
SUBCHAPTER c: FISCAL ADMINISTRATION
PART 356
RATE SETTING
SECTION 356.1 PURPOSE (RENUMBERED)
Section 356.1 Purpose
(Renumbered)
(Source: Section 356.1 renumbered to Section 356.10 at 20 Ill. Reg.
14390, effective November 1, 1996)
 | TITLE 89: SOCIAL SERVICES
CHAPTER III: DEPARTMENT OF CHILDREN AND FAMILY SERVICES
SUBCHAPTER c: FISCAL ADMINISTRATION
PART 356
RATE SETTING
SECTION 356.2 DEFINITIONS (RENUMBERED)
Section 356.2 Definitions
(Renumbered)
(Source: Section 356.2 renumbered to Section 356.20 at 20 Ill. Reg.
14390, effective November 1, 1996)
| TITLE 89: SOCIAL SERVICES
CHAPTER III: DEPARTMENT OF CHILDREN AND FAMILY SERVICES
SUBCHAPTER c: FISCAL ADMINISTRATION
PART 356
RATE SETTING
SECTION 356.3 TYPES OF REIMBURSEMENT MADE BY THE DEPARTMENT (RENUMBERED)
Section 356.3 Types of
Reimbursement Made by the Department (Renumbered)
(Source: Section 356.3 renumbered to Section 356.30 at 20 Ill. Reg.
14390, effective November 1, 1996)
| TITLE 89: SOCIAL SERVICES
CHAPTER III: DEPARTMENT OF CHILDREN AND FAMILY SERVICES
SUBCHAPTER c: FISCAL ADMINISTRATION
PART 356
RATE SETTING
SECTION 356.4 COST INFORMATION REQUIREMENTS OF PROVIDERS (RENUMBERED)
Section 356.4 Cost
Information Requirements of Providers (Renumbered)
(Source: Section 356.4 renumbered to Section 356.40 at 20 Ill. Reg.
14390, effective November 1, 1996)
| TITLE 89: SOCIAL SERVICES
CHAPTER III: DEPARTMENT OF CHILDREN AND FAMILY SERVICES
SUBCHAPTER c: FISCAL ADMINISTRATION
PART 356
RATE SETTING
SECTION 356.5 DETERMINING RATE REIMBURSEMENT LEVELS (RENUMBERED)
Section 356.5 Determining
Rate Reimbursement Levels (Renumbered)
(Source: Section 356.5 renumbered to Section 356.50 at 20 Ill. Reg.
14390, effective November 1, 1996)
| TITLE 89: SOCIAL SERVICES
CHAPTER III: DEPARTMENT OF CHILDREN AND FAMILY SERVICES
SUBCHAPTER c: FISCAL ADMINISTRATION
PART 356
RATE SETTING
SECTION 356.6 DISALLOWABLE COSTS AND REDUCED REIMBURSEMENT (RENUMBERED)
Section 356.6 Disallowable
Costs and Reduced Reimbursement (Renumbered)
(Source: Section 356.6 renumbered to Section 356.60 at 20 Ill. Reg.
14390, effective November 1, 1996)
| TITLE 89: SOCIAL SERVICES
CHAPTER III: DEPARTMENT OF CHILDREN AND FAMILY SERVICES
SUBCHAPTER c: FISCAL ADMINISTRATION
PART 356
RATE SETTING
SECTION 356.7 NOTICE AND APPEAL OF PROVIDER RATES (RENUMBERED)
Section 356.7 Notice and
Appeal of Provider Rates (Renumbered)
(Source: Section 356.7 renumbered to Section 356.70 at 20 Ill. Reg.
14390, effective November 1, 1996)
| TITLE 89: SOCIAL SERVICES
CHAPTER III: DEPARTMENT OF CHILDREN AND FAMILY SERVICES
SUBCHAPTER c: FISCAL ADMINISTRATION
PART 356
RATE SETTING
SECTION 356.10 PURPOSE
Section 356.10 Purpose
The Department's requirements
for determining purchased care rate reimbursements are described in these
rules. Also described are certain reporting requirements, audit requirements,
allowable costs, disallowable costs, cost standards, profit factors, and the
relationship between units of service provided and reimbursement rates.
(Source: Renumbered from Section 356.1 at 20 Ill. Reg. 14390, effective
November 1, 1996)
| TITLE 89: SOCIAL SERVICES
CHAPTER III: DEPARTMENT OF CHILDREN AND FAMILY SERVICES
SUBCHAPTER c: FISCAL ADMINISTRATION
PART 356
RATE SETTING
SECTION 356.20 DEFINITIONS
Section 356.20 Definitions
"Administrative cost" means those costs related to
the management and organizational maintenance of the purchase of care provider
such as program administration, postage, and clerical support.
"Allowable costs" means those reasonable costs, as
defined in this Section, that will be considered for reimbursement. Prior to
the final rate determination, allowable costs are subject to revenue offset and
application of reasonable cost standards if applicable, as specified in Section
356.50.
"Cost report" means a report of all costs incurred
and revenue earned by a provider that are directly associated with services
purchased by the Department for its clients.
"Department" or "DCFS" means the
Department of Children and Family Services.
"Disallowable costs" means those costs that will
not be considered for reimbursement.
"Fiscal year" means July 1 through June 30.
"For-profit agencies" means those agencies that are
registered as for-profit by the Secretary of State and recognized as for-profit
entities by the Internal Revenue Service.
"Fringe benefits" means those provider costs not
paid as salaries but incurred by agencies directly for the benefit of their
employees. Fringe benefits include, but are not limited to employee health and
retirement benefits, payroll taxes, worker's compensation insurance and
unemployment compensation insurance. Liability insurance and malpractice
insurance are not considered fringe benefits because the provider itself
receives substantial benefits and protections from incurring those costs.
"Historical costs" means the total expenditure
incurred for all programs the purchase of care provider provided for the
previous State fiscal year that are presented via certified audit.
"Ownership costs" means the costs of maintenance,
utilities, property and building insurance, depreciation, amortization of
leasehold improvements, rent, property taxes, interest and other related costs.
"Preoperating expenses" are those operating
expenses that are incurred in making preparation for rendering client care
before the first client is admitted (e.g., costs based upon the amount of time
an executive director spends on developing a new program prior to the
initiation of program services, staff salaries paid during training prior to
the initiation of program services, etc.).
"Purchase of care providers" means those service
providers with whom the Department of Children and Family Services (Department)
does business through contracts on a reimbursable basis for units of service
delivered to specific clients.
"Reasonable costs" means those costs incurred by
purchase of care providers that are determined to be necessary and appropriate
in accordance with Section 356.50.
"Reimbursement rates" are rate levels used by the
Department to reimburse for institutional and group home care; foster care; day
care center and home care; adoption, counseling and homemaker service; and
others as required for contracting purposes. These services are further
defined in 89 Ill. Adm. Code 302 (Services Delivered by the Department of
Children and Family Services).
"Revenues to be offset" means funding provided by a
governmental unit via a grant mechanism that is not clearly linked to the
provision of service to any one particular client. The Department will wholly
or partially discount such funding in determining the providers' reimbursable
costs.
"Support costs" means food and dietary, laundry,
housekeeping, and other related costs.
"Total agency costs" means the total expenditure
incurred for all programs the purchase of care provider provides during a State
fiscal year.
"Unit of service" means a measured length of time,
such as an hour or a day or some other measurable service component, that will
enable the Department to determine the amount of service provided individually
or in aggregate to clients.
(Source: Amended at 29 Ill.
Reg. 8696, effective June 8, 2005)
| TITLE 89: SOCIAL SERVICES
CHAPTER III: DEPARTMENT OF CHILDREN AND FAMILY SERVICES
SUBCHAPTER c: FISCAL ADMINISTRATION
PART 356
RATE SETTING
SECTION 356.30 TYPES OF REIMBURSEMENT MADE BY THE DEPARTMENT
Section 356.30 Types of
Reimbursement Made by the Department
a) The Department will reimburse providers through payments made
according to standard reimbursement levels and through reimbursement levels
which are specifically negotiated through contract. The Department shall notify
the provider in writing of the reimbursement rate.
b) Reimbursement according to rate reimbursement levels.
1) The Department shall adopt the rates promulgated by another
state agency where that agency is the primary purchaser of service. This shall
include hospitals, nursing homes, community living facilities, day care
providers and individual medical care providers.
2) The Department shall calculate standard rates in accordance
with Section 5a of the Children and Family Services Act [20 ILCS 505/5a]. This
calculation will consider the minimum wage law, U.S. Department of Agriculture
cost statistics, the age of the children to be served, the nature of the
children's service needs, the experience and background of the individual
provider, and the type of service provided. Reimbursement rates for these
providers are set by the Department utilizing market surveys and independent
cost analyses in order to arrive at a reasonable cost for specific units of
service unless otherwise specified in this Part. Services for which the
Department shall calculate standard rates include, but are not limited to,
agency foster care and agency adoption services.
3) The Department shall calculate individual program rates for
child care institutions, group homes, independent living arrangements and
maternity centers subject to the provisions of Section 356.50.
c) Reimbursement according to negotiated contracts.
Agencies that
provide services which reflect a significant variance in the type of service
and type of client are reimbursed according to reasonable cost standards as
established by the Department's approved rate methodology. See Section 356.50.
(Source: Amended at 24 Ill. Reg. 7692, effective June 1, 2000)
| TITLE 89: SOCIAL SERVICES
CHAPTER III: DEPARTMENT OF CHILDREN AND FAMILY SERVICES
SUBCHAPTER c: FISCAL ADMINISTRATION
PART 356
RATE SETTING
SECTION 356.40 COST INFORMATION REQUIREMENTS OF PROVIDERS
Section 356.40 Cost
Information Requirements of Providers
a) Cost Reporting – Except as otherwise provided by this
subsection, all providers shall annually file a certified cost report on a
schedule provided by the Department. The time period covered by the cost
report shall correspond to the Department's fiscal year unless otherwise
approved by the Department. The Department may designate cost reports filed by
the provider with other State agencies as suitable for fulfilling this
requirement when those reports provide all of the information needed by the
Department in a clear and usable way. Any provider that completes an audit in
accordance with 89 Ill. Adm. Code 357.120 (Purchase of Service Fiscal Reports
and Records) shall bind the DCFS cost report required by this subsection within
that audit. Day care providers are exempt from all audit and cost reporting
requirements unless they are involved in the cost based rate negotiations
authorized under Section 356.30(a) of this Part. Providers involved in those
rate negotiations shall file the cost report on the Department schedule, as
described in this subsection, and, if required to file an OMB Circular A–133
audit, a copy of that audit with the cost report bound within the audit.
b) Accrual Accounting – The provider shall use the accrual basis
of accounting when reporting financial data.
c) Audits – Providers shall cooperate in any audits undertaken to
verify the truth, accuracy, and completeness of reported costs, in accordance
with 89 Ill. Adm. Code 434 (Audits, Reviews, and Investigations).
d) Total Costs and Revenue – Providers must report all costs of
service and must disclose their total costs and revenue. Supporting
documentation will be required to verify the costs allocated to each of the
various services the Department purchases and to the sum of other services the agency
provides. The reported total cost and revenue must be certified by a licensed
public accountant.
e) Historical Costs – Historical costs will be established when
the provider has operated one or more years and independent auditors concur
with the reported total costs. New providers who have not established their
historical costs shall be permitted to submit budgeted information for the
first fiscal reporting period. However, no rate increases shall be authorized
for the next fiscal year until audited historical costs are available. When
the rate increase is authorized based on historical costs, it will coincide
with the effective date of the contract if the audit is received in accordance
with contractual requirements.
f) Other Information Required – As a condition of contract
issuance or renewal, the Department will request and receive promptly any other
financial information, reasonably related to rate determination, needed to
determine the provider's costs. For determining State Fiscal Year 2000 rates,
this may include submission of program budgets. (See Section 356.50(f).)
(Source: Amended at 29 Ill.
Reg. 8696, effective June 8, 2005)
| TITLE 89: SOCIAL SERVICES
CHAPTER III: DEPARTMENT OF CHILDREN AND FAMILY SERVICES
SUBCHAPTER c: FISCAL ADMINISTRATION
PART 356
RATE SETTING
SECTION 356.50 DETERMINING RATE REIMBURSEMENT LEVELS
Section 356.50 Determining
Rate Reimbursement Levels
This Section applies to those
situations where the Department promulgates standard or individual rates
identified in Section 356.30(b)(2) and (3).
a) Forms – Financial reporting forms shall be used in
establishing rates of reimbursement, regardless of the type of service
provided.
b) For-Profit Agencies – Contracts with for-profit agencies must
clearly identify any profit factor that must directly correspond to units of
services provided. Profit will be categorized as an administrative cost and
will be limited to 9% of the total contract amount. Profit will also be
included in calculating the overall administrative cost standard.
c) Reasonable Cost Standards – Reasonable cost standards shall be
applied to certain categories of costs except that program and transportation
costs may be exempted if warranted by the special needs of the clientele. The
reasonable cost standards establish reimbursement ceilings for categories of
costs. The standards are derived from the median costs of all agencies providing
similar services. Fringe benefits above 25% of salaries shall not be
reimbursed by the Department. Administrative costs may not exceed 20% of the
costs for other services. Reimbursement may exceed the reasonable cost
standards if a higher rate is negotiated as a result of a rate appeal or rate
enhancement that clearly demonstrates that costs in excess of the standards are
the result of a necessary level of resources purchased in a prudent manner.
However, administrative costs may not exceed 20% of the costs of other
services.
d) Revenues to be Offset – Revenues to be offset shall include
grants, other non-purchase-of-service revenue from other governmental agencies,
revenues from the school lunch program, and revenues from local education
agencies. All revenues to be offset shall be reported by the provider. These
revenues will be considered as part of the resources available to the provider
in determining reasonable costs. The Department will not reimburse a provider
for the proportion of services or administrative charges that have been paid,
wholly, or in part, by such revenues.
e) Units of Service and Provider Capacity – Reimbursement rates
shall be determined on the basis of actual units of service provided or the
median utilization for all agencies providing similar services, whichever is
greater. However, significant deviations from the utilization level may be
used in rate-setting if unusual circumstances beyond the control of the
provider directly caused a significant change in occupancy rates.
f) Special Provisions for Calculating Individual Rate
Reimbursement including Child Care Institutions, Group Homes, Maternity
Centers, and Shelter Programs – For State Fiscal Year 2000 (from July 1, 1999
through June 30, 2000), the rates for all child care institutions, group homes,
maternity centers, independent living, specialized foster care, treatment
foster care and shelter programs will be calculated as outlined in this Section
except that programs that would receive reductions will be held harmless at
State Fiscal Year 1999 levels if both Fiscal Year 1998 cost reports and a
program budget for State Fiscal Year 2000 are submitted within 30 days after
notice to the program. If a program fails to submit a cost report within the
30-day period, the rate will be adjusted to 80% of the applicable State Fiscal
Year 1999 rate. If a program files a cost report but not a budget, the rate
will not be held harmless and will be adjusted downward based on the rate
calculation methodology, but in no instance shall the rate be less than 80% of
the program's State Fiscal year 1999 rate. This rate adjustment for State
Fiscal Year 2000 applies regardless of the other provisions of this Part.
1) The Department will conduct a joint rate calculation with the
Illinois Department of Human Services.
2) Reimbursement rates shall be determined on the basis of actual
units of service provided, or the median utilization level for all similar
providers, whichever is greater. The maximum utilization level that will be
used to determine reimbursement rates shall be 98% of licensed or approved
program capacity. For the purpose of establishing the median utilization
level, residential programs will be grouped into two categories:
A) Child Care Institutions and Group Homes; and
B) Maternity Homes and approved Shelter programs.
3) The reasonable cost standards for support and ownership costs
shall be 120% of the median costs of all similar providers. Providers shall be
deemed dissimilar, and subject to an adjusted cost standard if one or more of
the following conditions has occurred on or after July 1, 1983:
A) the provider has built an entirely new building used directly
by clients of the program,
B) the provider has renovated a building used directly by program
clients and the annual depreciation and/or interest costs are $20,000 or more,
or
C) the provider has entered a first-time lease for a building used
directly by program clients.
4) These costs shall be demonstrated by an annual audit cost
report and accompanying notes as prescribed by 89 Ill. Adm. Code 357.120
(Purchase of Service Fiscal Reports and Records). The reasonable cost
standards shall include a geographic differential factor to reflect the
differences in costs due to geographic location when such cost differentials
exist. The existence of such differentials is determined by measurement of the
audited costs reported by providers and the application of generally accepted
statistical tests to these costs. Any geographic differential factor that results
from these tests is included in the Department's rate notices sent to
providers.
5) Historical costs, except depreciation, interest and
amortization of allowable pre-operating expenses shall be increased by inflation
adjustment factor to reflect the increases in costs caused by general
inflation. The maximum increase in a facility's reimbursement rate shall be
150% of the inflation adjustment factor for the most current year. The
percentage limitation shall be applied to the most recent rate unless that rate
declined due to a combination of both reduced utilization and reduced costs.
In such case, the next most recent rate shall be used to determine the
allowable maximum increase. This limitation will not be applied to cost
increases mandated by regulatory agencies or program changes approved by the
Department Director.
6) New programs not having historical costs shall have a rate set
via a process that begins with completion of a projected historical cost budget
in the same format used to set historical cost rates. The Regional Office
developing the contract shall negotiate costs based on a comparison of the
budget with levels of staffing generally needed for similar programs; with
prevailing wage rates; and with levels of supply, ownership, support and other
costs common to similar programs. The Department shall review the results and
shall engage in further negotiations when an examination of submitted data
determines an anomaly or disparity in the data in comparison to other data
submitted by other providers. A new start rate shall then be set using the
reasonable cost standards applying to the particular program under the terms of
this Part with one exception: To allow for the phase-in placement of clients,
the divisor applied to costs will be the greater of:
A) the number five percentage points lower than the median
utilization level applying to ongoing programs of the same type; or
B) the projected utilization agreed to by the Department and the provider.
g) The Department will adopt Day Care Rates developed by the
Illinois Department of Human Services for similar day care services.
(Source: Amended at 29 Ill.
Reg. 8696, effective June 8, 2005)
| TITLE 89: SOCIAL SERVICES
CHAPTER III: DEPARTMENT OF CHILDREN AND FAMILY SERVICES
SUBCHAPTER c: FISCAL ADMINISTRATION
PART 356
RATE SETTING
SECTION 356.60 DISALLOWABLE COSTS AND REDUCED REIMBURSEMENT
Section 356.60 Disallowable
Costs and Reduced Reimbursement
Certain costs shall not be
considered by the Department for reimbursement. Cost standards may be applied
to costs claimed to yield reasonable costs. Disallowable costs shall include:
a) expenses resulting from transactions with related parties
and/or parent organizations which are greater than the expense to the related
party;
b) non-straightline depreciation;
c) research items except as approved by the Department for
program evaluation;
d) bad debts;
e) special benefits to owners, including owner and key-man life
insurance;
f) compensation to non-working owners and officers;
g) discounts, rebates, allowances, and charity grants offered by
the agency;
h) entertainment expenses;
i) fund-raising;
j) revenue producing expenses;
k) legal fees for litigation with governmental agencies;
l) non-program related activities;
m) membership to national, state, or parent organizations;
n) awards and grants to individuals;
o) fines and penalties;
p) mortgage and loan principal payments;
q) contingency funds;
r) losses on other grants and contracts;
s) expenses relating to the development of bids or proposals;
t) housing of non-clients (does not prohibit the expense of
live-in staff);
u) severance pay;
v) federal and state income tax;
w) sales tax; and
x) other costs not reasonably related to services.
(Source: Renumbered from Section 356.6 at 20 Ill. Reg. 14390, effective
November 1, 1996)
| TITLE 89: SOCIAL SERVICES
CHAPTER III: DEPARTMENT OF CHILDREN AND FAMILY SERVICES
SUBCHAPTER c: FISCAL ADMINISTRATION
PART 356
RATE SETTING
SECTION 356.70 NOTICE AND APPEAL OF PROVIDER RATES
Section 356.70 Notice and
Appeal of Provider Rates
a) Provider Eligibility – Purchase of service providers for whom
the Department calculates individual rates (refer to Section 356.30(b)(3)) or
negotiates rates (refer to Section 356.30(c)) are eligible to appeal their
rates, subject to the provisions of this Section.
b) Notice in Filing of Appeal – Appeals of the rate reimbursement
determination shall be submitted in writing by the provider to the central
office manager responsible for the administration of reimbursement rates within
60 days after the written notice by the Department disclosing the provider
reimbursement rate. Notice shall be effective upon the date of mailing to the
provider's address. Appeals submitted more than 60 days after the notice will
not be considered by the Department.
c) Principles of Appeals Process – The appeals process is
designed to allow a provider to petition for an increase in its reimbursable
cost rate in response to mechanical or clerical errors and/or circumstances
which are beyond the control of the provider, which have an impact upon current
operating costs, and which were not included in the Department's determination
of the current allowable costs. In order to hear an appeal, the provider must
have a current signed contract.
d) Basis for Increase in Reimbursable Cost – Appeals submitted
for the following reasons must be received by the Department within 60 days
after reimbursable rate notice. Any change in rate, either positive or
negative, as a result of the appeal process will coincide with the effective
date of the amendment. Increases in reimbursable cost can be granted by the
Department for the following reasons and in the following categories:
1) Mechanical or clerical errors were committed by the
Department.
2) There has been a substantial decrease in external government
grants which the Department determines seriously limits the ability of the
agency to deliver required services to Department clients, to the extent that
such revenues were considered available when the Department approved the
reimbursable cost of the provider.
3) The Agency was able to document and justify that the
Department's treatment of its historical cost data resulted in an inequitable
application of the rate-setting process.
4) Mechanical or clerical errors were committed by the provider
on required cost reports and used by the Department in the calculation of
reimbursable costs.
e) Procedures for Filing Appeals – An appeal for an increase in
the reimbursable cost shall be submitted in writing to the central office
manager responsible for the administration of reimbursement rates with a copy
to the Lead Regional Administrator.
1) An appeal shall include but not be limited to:
A) Identification of the current approved reimbursable rate;
B) a clear, concise statement of the reasons for the appeal;
C) a detailed statement of financial, statistical and related
information in support of the appeal;
D) a citation to any statutory or regulatory requirement pertinent
to the appeal; and
E) certification under penalty of perjury by either the chief
executive officer or the financial officer of the provider that the application
and all the information reports, schedules, budgets, books and records
submitted are true, correct and accurate.
2) The Department will not accept or process an appeal which does
not meet the requirements of this Section. In addition, no appeal can be acted
upon unless the provider has a current signed contract.
3) Any documentation submitted in support of this appeal which is
subsequent to filing of the appeal, shall contain the same certification
described in subsection (e)(1)(E) above.
f) Review by the Central Office Manager Responsible for the
Administration of Reimbursement Rates
1) When a provider has filed an appeal, the central office
manager responsible for the administration of reimbursement rates shall
acknowledge in writing that an appeal has been received.
2) The central office manager responsible for the administration
of reimbursement rates will review each appeal for adequacy of documentation
and appropriateness of the request. If required for the analysis, the Lead
Regional Administrator shall provide his/her comments and recommendations
regarding the appeal within 15 days after receipt.
3) The central office manager responsible for the administration
of reimbursement rates may request a meeting at a reasonably convenient place
with representatives of the provider prior to submission of recommendations to
the Director of the Department. The purpose of such meetings shall include:
A) clarification, formulation, and simplification of issues;
B) resolution of matters in controversy;
C) exchange of documents and information;
D) stipulations of facts so as to avoid unnecessary presentation
before the Director of the Department;
E) identification of all documents which the provider or staff
intend to present to the Director; and
F) such other matters as may aid in the simplification of the
evidence and disposition of the issue.
4) Within 30 days after receipt by the central office manager
responsible for the administration of reimbursement rates, an appeal which has
complied with the principles and requirements of this Section, or within 15
days after the scheduled meeting between the central office manager responsible
for the administration of reimbursement rates and the provider, whichever is
later, the central office manager responsible for the administration of
reimbursement rates will make a recommendation to the Director or his designee
on this matter.
g) Final Decision of the Director – The decision of the Director
of the Department shall constitute final action on the appeal. Decision of the
Director shall be made within 60 days after receipt of the appeal by the
central office manager responsible for the administration of reimbursement
rates, except that, if the central office manager responsible for the
administration of reimbursement rates requests additional information, the
period shall be extended by the time taken in providing that information.
(Source: Amended at 24 Ill. Reg. 7692, effective June 1, 2000)
| TITLE 89: SOCIAL SERVICES
CHAPTER III: DEPARTMENT OF CHILDREN AND FAMILY SERVICES
SUBCHAPTER c: FISCAL ADMINISTRATION
PART 356
RATE SETTING
SECTION 356.80 REIMBURSEMENT FOR PROGRAM ENHANCEMENTS
Section 356.80 Reimbursement
for Program Enhancements
a) Any change in rates due to program enhancements submitted for
the reasons cited below in relation to current cost impacts, either positive or
negative, as a result of the review process, will be reflected in a contract
amendment. Under no circumstances will the Department be responsible for
enhancements that were implemented outside of the following process.
1) The Department and the provider have reached mutual agreement
that substantive changes and/or enhancement of the current program are
necessary and/or desirable and have been approved by the Director;
2) It is necessary and/or desirable to adjust the licensed
capacity of a facility or program;
3) The Department required substantial program changes as a
result of mandated licensing requirements; and
4) State and federal regulatory requirements have generated a
substantial increase in reimbursable cost during the current contract year.
b) Procedures for Requesting a Program Enhancement
A request
shall be submitted in writing to the Administrator of the Region where the
program is located with a copy to the central office manager responsible for
the administration of reimbursement rates. If needed, the central office
manager responsible for the administration of reimbursement rates shall supply,
upon request, the name and mailing address of the Lead Regional Administrator.
The request shall include, but not be limited to:
1) The current approved reimbursable costs and the reimbursable
costs sought pursuant to the request;
2) A clear, concise statement of the reasons for the request;
3) A detailed statement of financial, statistical and related
information in support of the request that clearly indicates current outcomes
and the relationship between the additional costs submitted and the change of
circumstances or other reasons for the higher cost;
4) A citation to any statutory, regulatory, or contractual
requirement pertinent to the appeal;
5) Crucial elements that will be outlined and analyzed for every
program enhancement include but are not limited to:
A) Summary document or letter explaining the reason for the
request for a new rate;
B) Certified audit report for most recent provider prior fiscal
year;
C) Consolidated Financial Reports for most recent provider prior
fiscal year (reporting all programs);
D) The new rate being sought;
E) Data identifying the individual cost of each item for which
additional reimbursement is being sought;
F) Detailed explanation of why the petitioned costs cannot be
funded within the current rate;
G) Beginning date the costs are planned to occur;
H) Quantifiable programmatic outcomes occurring as a result of a
rate change;
I) Reporting activities that will be implemented to ensure
program outcomes occur at committed levels;
J) Quantification of past program performances for current and
preceding 2 fiscal years, including, where applicable:
i) Number of children successfully completing program treatment;
ii) Rate of children leaving without completion of treatment;
iii) Number of incidents of psychiatric hospitalizations;
iv) Number of runaways;
v) Number of incidences requiring police intervention; and
vi) Number of unusual incident reports;
K) Organization charts reflecting pre-request and post-request
funds for additional staffing;
6) Certification under penalty of perjury by either the chief
executive officer or the financial officer of the provider that the application
and all the information reports, schedules, budgets, books and records
submitted are true, correct and accurate.
c) Regional Review Process
1) Within 30 days after filing a request for enhancements with
associated cost increases, the regional contract administrator responsible for
administration of the contract shall acknowledge in writing that the request
has been received.
2) The responsible regional contract administrator will review
each request for adequacy of documentation and appropriateness of the request.
3) The responsible regional contract administrator may request a
meeting. The purposes of the meetings may include:
A) Clarification, formulation, and simplification of issues;
B) Resolution of matters in controversy;
C) Exchange of documents and information;
D) Stipulations of facts; and
E) Such other matters as may aid in the simplification of the
evidence and disposition of the issue.
d) The decision of the Director of the Department shall
constitute final action. Decision of the Director shall be made within 150 days
after the enhancement request.
e) Rate Setting for Approved Program Enhancements
A summary of
enhancements and costs approved by the Director of the Department shall be
forwarded to the central office manager responsible for the administration of
reimbursement rates. The central office manager responsible for the
administration of reimbursement rates will determine, based on standard
Department rate setting methodology, the change to the reimbursable unit costs.
(Source: Added at 24 Ill. Reg. 7692, effective June 1, 2000)
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