Comment on New Adult Waiver

The time frame is short, comments due by January 20, 2012. See Reta’s request and draft below.

The Arc is working on their comments now.

Tony

Application for 1915(c) HCBS Adult Waiver Draft IL.26.03.00 – Jul 01, 2012
 
Please find attached an initial draft of the renewal application for the Adult DD Waiver.  We emphasize that this is just an initial draft and currently under review by management staff.  We invite you to be critical of it and submit your comments to us at DHS.DDDComments@illinois.gov. 
 
The current Waiver expires on 6/30/12.  CMS regulations require that we submit the renewal 90 days prior to that date.  It is the State’s goal, however, to submit the renewal as early as possible in order to provide for additional time to respond to anticipated  questions posed by CMS.  Given these time frames, we are asking you to review the initial draft concurrently with management staff and as we work with the Medicaid agency (HFS) to finalize the application.
 
This first draft attempts to produce the current waiver in the new template required by CMS.  It incorporates the Performance Measures developed over the last year or so as part of the renewals of the two Children’s Waivers.  Please note that in some sections where the template discusses changes, the responses are addressing changes since the Waiver was last renewed five years ago.  (For example, the reference on the first page about increasing the frequency of review activity reflects changes from five years ago—we are not proposing increases from what we are now doing.)  We are currently working on the following items:
 

• Remediation language – samples of this can be found at the end of many of the major Appendices.   We have been receiving technical assistance from the National Quality Contractor, and they have recommended some changes in this area.
• Appendix J—this section will be updated to reflect new numbers for the first Waiver year as a result of the Ligas settlement.
• Priority Population Criteria—this is being reviewed for changes now that the Ligas Implementation Plan has been finalized.

 
The application is entered into a web portal designed for CMS.  The template and our content is downloaded here for you.  It may take some time to load.  In addition, if you see boxes with arrows, you may need to click on those arrows to read the full content.  Please not the document below is in excess of 180 pages.
 
 
 
Application for a §1915(c) Home and Community-Based Services Waiver

PURPOSE OF THE HCBS WAIVER PROGRAM

The Medicaid Home and Community-Based Services (HCBS) waiver program is authorized in §1915(c) of the Social Security Act. The program permits a State to furnish an array of home and community-based services that assist Medicaid beneficiaries to live in the community and avoid institutionalization. The State has broad discretion to design its waiver program to address the needs of the waiver’s target population. Waiver services complement and/or supplement the services that are available to participants through the Medicaid State plan and other federal, state and local public programs as well as the supports that families and communities provide.
The Centers for Medicare & Medicaid Services (CMS) recognizes that the design and operational features of a waiver program will vary depending on the specific needs of the target population, the resources available to the State, service delivery system structure, State goals and objectives, and other factors. A State has the latitude to design a waiver program that is cost-effective and employs a variety of service delivery approaches, including participant direction of services.
Request for a Renewal to a §1915(c) Home and Community-Based Services Waiver

1. Major Changes

Describe any significant changes to the approved waiver that are being made in this renewal application:
Character Count:out of 12000
Highlights of proposed changes include: In the renewal submission, Illinois is proposing new quality improvement strategies with specific performance measures that are described in each corresponding appendix. There are proposed changes in oversight strategies to increase the frequency of review activity. As a result of instituting new measures for ongoing oversight and monitoring of this waiver, which generate a steady stream of performance data, the OA and MA will be in an improved position to detect the impact of system design changes and to assess and compare performance over time and across systems. Many of the new performance measures have already been implemented as described in the Adult Waiver evidentiary report submitted to CMS as part of the waiver review process. Program capacity is also being increased as part of the renewal request. A settlement was reached in the Ligas v. Illinois case and the State has developed a plan to comply with the Court order.
Application for a §1915(c) Home and Community-Based Services Waiver

1. Request Information (1 of 3)

1. The Stateof Illinoisrequests approval for a Medicaid home and community-based services (HCBS) waiver under the authority of §1915(c) of the Social Security Act (the Act).
2. Program Title (optional – this title will be used to locate this waiver in the finder):

HCBS Waiver for Adults with Developmental Disabilities

1. Type of Request: renewal

Requested Approval Period: (For new waivers requesting five year approval periods, the waiver must serve individuals who are dually eligible for Medicaid and Medicare.)

[ ] Migration Waiver– this is an existing approved waiver
[X] Renewal of Waiver:
Provide the information about the original waiverbeing renewed
Base Waiver Number: 0350
Amendment Number
(if applicable):0350.R02.01
Effective Date:(mm/dd/yy)07/01/07
Draft ID: IL.26.03.00
Renewal Number: 03

1. Type of Waiver(select only one):

[Regular Waiver /]

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

07/01/12

1. Request Information (2 of 3)

1. Level(s) of Care. This waiver is requested in order to provide home and community-based waiver services to individuals who, but for the provision of such services, would require the following level(s) of care, the costs of which would be reimbursed under the approved Medicaid State plan (check each that applies):

[ ] Hospital
Select applicable level of care
( ) Hospital as defined in 42 CFR §440.10
If applicable, specify whether the State additionally limits the waiver to subcategories of the hospital level of care:
Character Count:out of 6000
( ) Inpatient psychiatric facility for individuals age 21 and under as provided in42 CFR §440.160
(X) not selected
[ ] Nursing Facility
Select applicable level of care
( ) Nursing Facility As defined in 42 CFR §440.40 and 42 CFR §440.155
If applicable, specify whether the State additionally limits the waiver to subcategories of the nursing facility level of care:
Character Count:out of 6000
( ) Institution for Mental Disease for persons with mental illnesses aged 65 and older as provided in 42 CFR §440.140
(X) not selected
[X] Intermediate Care Facility for the Mentally Retarded (ICF/MR) (as defined in 42 CFR §440.150)
If applicable, specify whether the State additionally limits the waiver to subcategories of the ICF/MR level of care:
Character Count:out of 6000
Not applicable.

1. Request Information (3 of 3)

1. Concurrent Operation with Other Programs. This waiver operates concurrently with another program (or programs) approved under the following authorities

Select one:
(X) Not applicable
( ) Applicable
Check the applicable authority or authorities:
[ ] Services furnished under the provisions of §1915(a)(1)(a) of the Act and described in Appendix I
[ ] Waiver(s) authorized under §1915(b) of the Act.
Specify the §1915(b) waiver program and indicate whether a §1915(b) waiver application has been submitted or previously approved:
Character Count:out of 6000
Specify the §1915(b) authorities under which this program operates (check each that applies):
[ ] §1915(b)(1) (mandated enrollment to managed care)
[ ] §1915(b)(2) (central broker)
[ ] §1915(b)(3) (employ cost savings to furnish additional services)
[ ] §1915(b)(4) (selective contracting/limit number of providers)
[ ] A program operated under §1932(a) of the Act.
Specify the nature of the State Plan benefit and indicate whether the State Plan Amendment has been submitted or previously approved:
Character Count:out of 6000
[ ] A program authorized under §1915(i) of the Act.
[ ] A program authorized under §1915(j) of the Act.
[ ] A program authorized under §1115 of the Act.
Specify the program:
Character Count:out of 6000
[ ] Not applicable
( ) not selected

1. Dual Eligiblity for Medicaid and Medicare.

Check if applicable:
[ ] This waiver provides services for individuals who are eligible for both Medicare and Medicaid.

2. Brief Waiver Description

Brief Waiver Description. In one page or less, briefly describe the purpose of the waiver, including its goals, objectives, organizational structure (e.g., the roles of state, local and other entities), and service delivery methods.
Character Count:out of 6000
The Adult Developmental Disabilities Waiver provides supports to eligible adults with developmental disabilities ages 18 and older. The supports provided are designed to prevent or delay out-of-home residential services for participants or to provide residential services in the least restrictive community setting for participants who would otherwise need ICF/MR level of care. The Waiver affords participants the choice between participant direction and employer authority and more traditional service delivery, or a combination of the two options. The number of participants served each year is based on available State appropriation levels. Participants who choose home-based supports may select from a menu of services based on their individual needs within an overall monthly services cost maximum. Typical services chosen by participants may include day programs as well as direct services provided by common law employees or by employees of direct service agencies. Participants also have a variety of therapies and other services available to them. Residential services participants are provided with residential services and supports from the qualified provider of their choice. These participants may also select day programs and have a variety of therapies and other services available to them. All participants receive assistance in directing service delivery options from Individual Service and Support Advocates (ISSA) employed by Independent Service Coordination (ISC) entities under contract with the Operating Agency. Participants who choose to hire common law employees receive assistance from a Financial Management Service (FMS) entity. Independent Service Coordination (ISC) entities under contract with the Operating Agency serve as the local point of access for adults with developmental disabilities. In cooperation with the Medicaid Agency (MA), the Division of Developmental Disabilities within the Illinois Department of Human Services (OA) operates the Adult Developmental Disabilities Waiver.

3. Components of the Waiver Request

The waiver application consists of the following components.Note: Item 3-E must be completed.

1. Waiver Administration and Operation.Appendix A specifies the administrative and operational structure of this waiver.
2. Participant Access and Eligibility.Appendix B specifies the target group(s) of individuals who are served in this waiver, the number of participants that the State expects to serve during each year that the waiver is in effect, applicable Medicaid eligibility and post-eligibility (if applicable) requirements, and procedures for the evaluation and reevaluation of level of care.
3. Participant Services.Appendix C specifies the home and community-based waiver services that are furnished through the waiver, including applicable limitations on such services.
4. Participant-Centered Service Planning and Delivery.Appendix D specifies the procedures and methods that the State uses to develop, implement and monitor the participant-centered service plan (of care).
5. Participant-Direction of Services. When the State provides for participant direction of services, Appendix Especifies the participant direction opportunities that are offered in the waiver and the supports that are available to participants who direct their services. (Select one):

(X) Yes. This waiver provides participant direction opportunities. Appendix E is required.
( ) No. This waiver does not provide participant direction opportunities. Appendix E is not required.
( ) not selected

1. Participant Rights.Appendix F specifies how the State informs participants of their Medicaid Fair Hearing rights and other procedures to address participant grievances and complaints.
2. Participant Safeguards.Appendix G describes the safeguards that the State has established to assure the health and welfare of waiver participants in specified areas.
3. Quality Improvement Strategy.Appendix H contains the Quality Improvement Strategy for this waiver.
4. Financial Accountability.Appendix I describes the methods by which the State makes payments for waiver services, ensures the integrity of these payments, and complies with applicable federal requirements concerning payments and federal financial participation.
5. Cost-Neutrality Demonstration.Appendix J contains the State’s demonstration that the waiver is cost-neutral.

4. Waiver(s) Requested

1. Comparability.The State requests a waiver of the requirements contained in §1902(a)(10)(B) of the Act in order to provide the services specified in Appendix C that are not otherwise available under the approved Medicaid State plan to individuals who: (a) require the level(s) of care specified in Item 1.F and (b) meet the target group criteria specified in Appendix B.
2. Income and Resources for the Medically Needy.Indicate whether the State requests a waiver of §1902(a)(10)(C)(i)(III) of the Act in order to use institutional income and resource rules for the medically needy (select one):

( ) Not Applicable
(X) No
( ) Yes
( ) not selected

1. Statewideness.Indicate whether the State requests a waiver of the statewideness requirements in §1902(a)(1) of the Act (select one):

1. If yes, specify the waiver of statewideness that is requested (check each that applies):
2. [ ] Geographic Limitation. A waiver of statewideness is requested in order to furnish services under this waiver only to individuals who reside in the following geographic areas or political subdivisions of the State.
3. Specify the areas to which this waiver applies and, as applicable, the phase-in schedule of the waiver by geographic area:
4. Character Count:out of 6000
5. [ ] Limited Implementation of Participant-Direction. A waiver of statewideness is requested in order to make participant-direction of services as specified in Appendix E available only to individuals who reside in the following geographic areas or political subdivisions of the State. Participants who reside in these areas may elect to direct their services as provided by the State or receive comparable services through the service delivery methods that are in effect elsewhere in the State.
6. Specify the areas of the State affected by this waiver and, as applicable, the phase-in schedule of the waiver by geographic area:
7. Character Count:out of 6000

5. Assurances

In accordance with 42 CFR §441.302, the State provides the following assurances to CMS:

1. Health & Welfare:The State assures that necessary safeguards have been taken to protect the health and welfare of persons receiving services under this waiver. These safeguards include:
2. As specified in Appendix C, adequate standards for all types of providers that provide services under this waiver;
3. Assurance that the standards of any State licensure or certification requirements specified in Appendix C are met for services or for individuals furnishing services that are provided under the waiver. The State assures that these requirements are met on the date that the services are furnished; and,
4. Assurance that all facilities subject to §1616(e) of the Act where home and community-based waiver services are provided comply with the applicable State standards for board and care facilities as specified in Appendix C.
5. Financial Accountability.The State assures financial accountability for funds expended for home and community-based services and maintains and makes available to the Department of Health and Human Services (including the Office of the Inspector General), the Comptroller General, or other designees, appropriate financial records documenting the cost of services provided under the waiver. Methods of financial accountability are specified in Appendix I.
6. Evaluation of Need:The State assures that it provides for an initial evaluation (and periodic reevaluations, at least annually) of the need for a level of care specified for this waiver, when there is a reasonable indication that an individual might need such services in the near future (one month or less) but for the receipt of home and community based services under this waiver. The procedures for evaluation and reevaluation of level of care are specified in Appendix B.
7. Choice of Alternatives: The State assures that when an individual is determined to be likely to require the level of care specified for this waiver and is in a target group specified in Appendix B, the individual (or, legal representative, if applicable) is:
8. Informed of any feasible alternatives under the waiver; and,
9. Given the choice of either institutional or home and community based waiver services. Appendix B specifies the procedures that the State employs to ensure that individuals are informed of feasible alternatives under the waiver and given the choice of institutional or home and community-based waiver services.
10. Average Per Capita Expenditures:The State assures that, for any year that the waiver is in effect, the average per capita expenditures under the waiver will not exceed 100 percent of the average per capita expenditures that would have been made under the Medicaid State plan for the level(s) of care specified for this waiver had the waiver not been granted. Cost-neutrality is demonstrated in Appendix J.
11. Actual Total Expenditures:The State assures that the actual total expenditures for home and community-based waiver and other Medicaid services and its claim for FFP in expenditures for the services provided to individuals under the waiver will not, in any year of the waiver period, exceed 100 percent of the amount that would be incurred in the absence of the waiver by the State’s Medicaid program for these individuals in the institutional setting(s) specified for this waiver.
12. Institutionalization Absent Waiver:The State assures that, absent the waiver, individuals served in the waiver would receive the appropriate type of Medicaid-funded institutional care for the level of care specified for this waiver.
13. Reporting:The State assures that annually it will provide CMS with information concerning the impact of the waiver on the type, amount and cost of services provided under the Medicaid State plan and on the health and welfare of waiver participants. This information will be consistent with a data collection plan designed by CMS.
14. Habilitation Services.The State assures that prevocational, educational, or supported employment services, or a combination of these services, if provided as habilitation services under the waiver are: (1) not otherwise available to the individual through a local educational agency under the Individuals with Disabilities Education Act (IDEA) or the Rehabilitation Act of 1973; and, (2) furnished as part of expanded habilitation services.
15. Services for Individuals with Chronic Mental Illness.The State assures that federal financial participation (FFP) will not be claimed in expenditures for waiver services including, but not limited to, day treatment or partial hospitalization, psychosocial rehabilitation services, and clinic services provided as home and community-based services to individuals with chronic mental illnesses if these individuals, in the absence of a waiver, would be placed in an IMD and are: (1) age 22 to 64; (2) age 65 and older and the State has not included the optional Medicaid benefit cited in 42 CFR §440.140; or (3) age 21 and under and the State has not included the optional Medicaid benefit cited in 42 CFR § 440.160.

6. Additional Requirements

Note: Item 6-I must be completed.

1. Service Plan. In accordance with 42 CFR §441.301(b)(1)(i), a participant-centered service plan (of care) is developed for each participant employing the procedures specified in Appendix D. All waiver services are furnished pursuant to the service plan. The service plan describes: (a) the waiver services that are furnished to the participant, their projected frequency and the type of provider that furnishes each service and (b) the other services (regardless of funding source, including State plan services) and informal supports that complement waiver services in meeting the needs of the participant. The service plan is subject to the approval of the Medicaid agency. Federal financial participation (FFP) is not claimed for waiver services furnished prior to the development of the service plan or for services that are not included in the service plan.
2. Inpatients. In accordance with 42 CFR §441.301(b)(1) (ii), waiver services are not furnished to individuals who are in-patients of a hospital, nursing facility or ICF/MR.
3. Room and Board. In accordance with 42 CFR §441.310(a)(2), FFP is not claimed for the cost of room and board except when: (a) provided as part of respite services in a facility approved by the State that is not a private residence or (b) claimed as a portion of the rent and food that may be reasonably attributed to an unrelated caregiver who resides in the same household as the participant, as provided in Appendix I.
4. Access to Services. The State does not limit or restrict participant access to waiver services except as provided in Appendix C.
5. Free Choice of Provider. In accordance with 42 CFR §431.151, a participant may select any willing and qualified provider to furnish waiver services included in the service plan unless the State has received approval to limit the number of providers under the provisions of §1915(b) or another provision of the Act.
6. FFP Limitation. In accordance with 42 CFR §433 Subpart D, FFP is not claimed for services when another third-party (e.g., another third party health insurer or other federal or state program) is legally liable and responsible for the provision and payment of the service. FFP also may not be claimed for services that are available without charge, or as free care to the community. Services will not be considered to be without charge, or free care, when (1) the provider establishes a fee schedule for each service available and (2) collects insurance information from all those served (Medicaid, and non-Medicaid), and bills other legally liable third party insurers. Alternatively, if a provider certifies that a particular legally liable third party insurer does not pay for the service(s), the provider may not generate further bills for that insurer for that annual period.
7. Fair Hearing:The State provides the opportunity to request a Fair Hearing under 42 CFR §431 Subpart E, to individuals: (a) who are not given the choice of home and community- based waiver services as an alternative to institutional level of care specified for this waiver; (b) who are denied the service(s) of their choice or the provider(s) of their choice; or (c) whose services are denied, suspended, reduced or terminated. Appendix F specifies the State’s procedures to provide individuals the opportunity to request a Fair Hearing, including providing notice of action as required in 42 CFR §431.210.
8. Quality Improvement. The State operates a formal, comprehensive system to ensure that the waiver meets the assurances and other requirements contained in this application. Through an ongoing process of discovery, remediation and improvement, the State assures the health and welfare of participants by monitoring: (a) level of care determinations; (b) individual plans and services delivery; (c) provider qualifications; (d) participant health and welfare; (e) financial oversight and (f) administrative oversight of the waiver. The State further assures that all problems identified through its discovery processes are addressed in an appropriate and timely manner, consistent with the severity and nature of the problem. During the period that the waiver is in effect, the State will implement the Quality Improvement Strategy specified in Appendix H.
9. Public Input. Describe how the State secures public input into the development of the waiver:

Character Count:out of 6000
The State gathered public input for this Waiver application from the Statewide Advisory Council (SAC) on Developmental Disabilities, local network advisory councils, the Waiver Ad-Hoc Committee, and a series of focus groups on the Strategic Plan arranged by the Waiver Operating Agency. On an ongoing basis, the SAC meets once each quarter. It is comprised of a direct consumer, a family member, and a provider elected from each of the local network advisory councils across the state; a representative from the Center for Capacity Building on Minorities with Disabilities Research at the University of Illinois at Chicago; a representative from the federally-funded Illinois Council on Developmental Disabilities; a representative from Equip for Equality, the State’s protection and advocacy organization; and a director from one of the State-Operated Developmental Centers in Illinois. Medicaid Agency staff routinely attend. All members are welcome to provide individual comments as well as viewpoints from their respective affiliations to the SAC. Meetings are also well attended by the public. A segment of each meeting is devoted to giving audience or network advisory council members the opportunity to address the SAC on a topic of their choosing relating to developmental disabilities. When the SAC needs detailed input on complex matters, ad-hoc committees are formed as needed. Ad-Hoc committees have a broad spectrum of membership that typically includes consumers, family members, providers, trade group members, and other advocates. As ad-hoc committees develop their reports and recommendations, updates of their meetings and drafts of their work are distributed at the SAC. Comments from SAC members are routinely sought and incorporated into the finished committee products. Such an ad-hoc committee was created to assist the State in the development of this application. The multi-year DDD Strategic Plan was developed with extensive inputs received from direct consumers and families at over 30 statewide focus group meetings held across the state. The information gathered in the focus groups provided valuable insights into the wide-ranging array of service preferences. The focus group dialogues had significant influences on the development of the Adult Developmental Disabilities Waiver.

1. Notice to Tribal Governments. The State assures that it has notified in writing all federally-recognized Tribal Governments that maintain a primary office and/or majority population within the State of the State’s intent to submit a Medicaid waiver request or renewal request to CMS at least 60 days before the anticipated submission date is provided by Presidential Executive Order 13175 of November 6, 2000. Evidence of the applicable notice is available through the Medicaid Agency.
2. Limited English Proficient Persons. The State assures that it provides meaningful access to waiver services by Limited English Proficient persons in accordance with: (a) Presidential Executive Order 13166 of August 11, 2000 (65 FR 50121) and (b) Department of Health and Human Services “Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons” (68 FR 47311 – August 8, 2003). Appendix B describes how the State assures meaningful access to waiver services by Limited English Proficient persons.

7. Contact Person(s)

1. The Medicaid agency representative with whom CMS should communicate regarding the waiver is:

1. If applicable, the State operating agency representative with whom CMS should communicate regarding the waiver is:

8. Authorizing Signature

This document, together with Appendices A through J, constitutes the State’s request for a waiver under §1915(c) of the Social Security Act. The State assures that all materials referenced in this waiver application (including standards, licensure and certification requirements) are readily available in print or electronic form upon request to CMS through the Medicaid agency or, if applicable, from the operating agency specified in Appendix A. Any proposed changes to the waiver will be submitted by the Medicaid agency to CMS in the form of waiver amendments.
Upon approval by CMS, the waiver application serves as the State’s authority to provide home and community-based waiver services to the specified target groups. The State attests that it will abide by all provisions of the approved waiver and will continuously operate the waiver in accordance with the assurances specified in Section 5 and the additional requirements specified in Section 6 of the request.

Attachment #1: Transition Plan

Specify the transition plan for the waiver:
Character Count:out of 12000
Not applicable.

Additional Needed Information (Optional)

Provide additional needed information for the waiver (optional):
Character Count:out of 60000

Appendix A: Waiver Administration and Operation

1. State Line of Authority for Waiver Operation.Specify the state line of authority for the operation of the waiver (select one):

( ) The waiver is operated by the State Medicaid agency.
Specify the Medicaid agency division/unit that has line authority for the operation of the waiver program (select one):
( ) The Medical Assistance Unit.
Specify the unit name:(Do not complete item A-2)
( ) Another division/unit within the State Medicaid agency that is separate from the Medical Assistance Unit.
Specify the division/unit name. This includes administrations/divisions under the umbrella agency that has been identified as the Single State Medicaid Agency.(Complete item A-2-a).
(X) not selected
(X) The waiver is operated by a separate agency of the State that is not a division/unit of the Medicaid agency.
Specify the division/unit name:Illinois Department of Human Services (DHS), Division of Developmental Disabilities
In accordance with 42 CFR §431.10, the Medicaid agency exercises administrative discretion in the administration and supervision of the waiver and issues policies, rules and regulations related to the waiver. The interagency agreement or memorandum of understanding that sets forth the authority and arrangements for this policy is available through the Medicaid agency to CMS upon request. (Complete item A-2-b).
( ) not selected

Appendix A: Waiver Administration and Operation

1. Oversight of Performance.
   1. Medicaid Director Oversight of Performance When the Waiver is Operated by another Division/Unit within the State Medicaid Agency. When the waiver is operated by another division/administration within the umbrella agency designated as the Single State Medicaid Agency. Specify (a) the functions performed by that division/administration (i.e., the Developmental Disabilities Administration within the Single State Medicaid Agency), (b) the document utilized to outline the roles and responsibilities related to waiver operation, and (c) the methods that are employed by the designated State Medicaid Director (in some instances, the head of umbrella agency) in the oversight of these activities:

As indicated in section 1 of this appendix, the waiver is not operated by another division/unit within the State Medicaid agency. Thus this section does not need to be completed.
Character Count:out of 12000

1. Medicaid Agency Oversight of Operating Agency Performance. When the waiver is not operated by the Medicaid agency, specify the functions that are expressly delegated through a memorandum of understanding (MOU) or other written document, and indicate the frequency of review and update for that document. Specify the methods that the Medicaid agency uses to ensure that the operating agency performs its assigned waiver operational and administrative functions in accordance with waiver requirements. Also specify the frequency of Medicaid agency assessment of operating agency performance:

Character Count:out of 12000
The Department of Healthcare and Family Services (HFS), Illinois’ Medicaid Agency, conducts the following activities: •The Medicaid Agency reviews and approves all changes to Medicaid policies, rules and regulations prior to implementation. •The Medicaid Agency conducts all waiver appeal hearings and issues final administrative decisions, providing the independent hearing officer for all appeal hearings. The MA conducts all waiver appeal hearings using trained hearing officers and does not delegate this function to the OA. •The Medicaid Agency reviews and approves changes to the Operating Agency’s payment rate methodologies. •The Medicaid Agency conducts program monitoring by participating jointly with the Operating Agency in select reviews of a representative sample of participants, and by using performance measures and sampling described in Appendix A. •The Medicaid Agency conducts fiscal monitoring by conducting validation reviews from the Operating Agency post-payment reviews of a representative sample of participants, and by using performance measures and sampling described in Appendix A. •Staff from the Medicaid Agency are members of the Quality Management Committee (QMC). The committee is responsible for the overall coordination of quality management activities. Current members of the QMC include key staff from both the MA and the OA. This includes representatives from the MA Bureau of Interagency Coordination and the OA’s Bureau of Quality Management, and the OA’s Bureau of Program Development and Medicaid Administration. The committee is charged with reviewing data for the waiver performance measures, tracking the findings, and discussing strategies for remediation, both individual and systemic, based on the evidence presented. •Staff from the Medicaid Agency attends meetings of the Operating Agency’s Statewide Advisory Council on Developmental Disabilities, with which all major initiatives and policy issues are discussed. The MA is not a formal member of the Statewide Advisory Council on DD but voluntarily participates as a way to keep informed of issues impacting individuals with DD being discussed by the council. The Statewide Advisory Council is not a policy-making body, but is advisory in nature and addresses all developmental disability issues including those services funded by Medicaid and those funded by other State sources. Medicaid Agency staff attempt to attend all Statewide Advisory Council meetings; however attendance is optional. Should an absence be necessary, a meeting summary is provided by the OA. •The Medicaid Agency participates with the Operating Agency in training and informational sessions.

Appendix A: Waiver Administration and Operation

1. Use of Contracted Entities.Specify whether contracted entities perform waiver operational and administrative functions on behalf of the Medicaid agency and/or the operating agency (if applicable) (select one):

(X) Yes. Contracted entities perform waiver operational and administrative functions on behalf of the Medicaid agency and/or operating agency (if applicable).
Specify the types of contracted entities and briefly describe the functions that they perform. Complete Items A-5 and A-6.:
Character Count:out of 6000
Under contract with the Operating Agency, private entities complete eligibility determinations, as well as independent service coordination and monitoring functions. These functions are done by Qualified Mental Retardation Professionals (QMRPs) known as Qualified Support Professionals (QSPs) in Illinois. In addition, the Operating Agency, at times, uses contracted vendors, selected in accordance with the State’s procurement policies, to assist with functions related to consultation and technical assistance for establishing provider qualifications and establishing rate methodologies.
( ) No. Contracted entities do not perform waiver operational and administrative functions on behalf of the Medicaid agency and/or the operating agency (if applicable).
( ) not selected

Appendix A: Waiver Administration and Operation

1. Role of Local/Regional Non-State Entities.Indicate whether local or regional non-state entities perform waiver operational and administrative functions and, if so, specify the type of entity (Select One):

( ) not selected
(X) Not applicable
( ) Applicable – Local/regional non-state agencies perform waiver operational and administrative functions.
Check each that applies:
[ ] Local/Regional non-state public agenciesperform waiver operational and administrative functions at the local or regional level. There is an interagency agreement or memorandum of understandingbetween the State and these agencies that sets forth responsibilities and performance requirements for these agencies that is available through the Medicaid agency.
Specify the nature of these agencies and complete items A-5 and A-6:
Character Count:out of 6000
[ ] Local/Regional non-governmental non-state entitiesconduct waiver operational and administrative functions at the local or regional level. There is a contract between the Medicaid agency and/or the operating agency (when authorized by the Medicaid agency) and each local/regional non-state entity that sets forth the responsibilities and performance requirements of the local/regional entity. The contract(s)under which private entities conduct waiver operational functions are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
Specify the nature of these entities and complete items A-5 and A-6:
Character Count:out of 6000
[ ] Not applicable– Local/regional non-state agencies do not perform waiver operational and administrative functions.

Appendix A: Waiver Administration and Operation

1. Responsibility for Assessment of Performance of Contracted and/or Local/Regional Non-State Entities. Specify the state agency or agencies responsible for assessing the performance of contracted and/or local/regional non-state entities in conducting waiver operational and administrative functions:

Character Count:out of 6000
The Department of Human Services, the Operating Agency, assesses the performance of the contracted entities.

Appendix A: Waiver Administration and Operation

1. Assessment Methods and Frequency. Describe the methods that are used to assess the performance of contracted and/or local/regional non-state entities to ensure that they perform assigned waiver operational and administrative functions in accordance with waiver requirements. Also specify how frequently the performance of contracted and/or local/regional non-state entities is assessed:

Character Count:out of 6000
The Operating Agency reviews and approves contracted entities on an annual basis to ensure they are conforming to established standards. Operating Agency staff conduct annual on-site surveys that focus on compliance with the requirements of the Agency’s screening manual and ISSA Guidelines, as well as contractual requirements. The survey protocol includes staff qualifications and training, 24-hour accessibility for emergencies, a review of the pre-admission screening process (documentation of required assessments, eligibility determinations, informed choice and selection of services, and conflict of interest), and review of the Individual Service and Support Advocacy process (documentation of required visits, participation in support plan development and approval, and annual re-determinations of eligibility). Agencies are notified in writing of any deficiencies and are required to submit a plan of correction, including timeframes, if the agency scores less than 90% on their overall performance. Operating Agency staff review the plan of correction and, if acceptable, approve it. Summary reports of the reviews are shared with and discussed by the State’s Waiver Quality Management Committee, which includes both Medicaid and the Operating Agency staff, during its quarterly meetings.

Appendix A: Waiver Administration and Operation

1. Distribution of Waiver Operational and Administrative Functions.In the following table, specify the entity or entities that have responsibility for conducting each of the waiver operational and administrative functions listed (check each that applies):

In accordance with 42 CFR §431.10, when the Medicaid agency does not directly conduct a function, it supervises the performance of the function and establishes and/or approves policies that affect the function.All functions not performed directly by the Medicaid agency must be delegated in writing and monitored by the Medicaid Agency. Note: More than one box may be checked per item. Ensure that Medicaid is checked when the Single State Medicaid Agency (1) conducts the function directly; (2) supervises the delegated function; and/or (3) establishes and/or approves policies related to the function.

Appendix A: Waiver Administration and Operation

Quality Improvement: Administrative Authority of the Single State Medicaid Agency

As a distinct component of the State’s quality improvement strategy, provide information in the following fields to detail the State’s methods for discovery and remediation.

1. Methods for Discovery: Administrative Authority

The Medicaid Agency retains ultimate administrative authority and responsibility for the operation of the waiver program by exercising oversight of the performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities.

1. Performance Measures

For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

1. If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.

Character Count:out of 6000
The OA conducts site visits based on a representative sample of participants in the waiver. A planned schedule of all on-site reviews is provided to the MA at the beginning of each waiver year. Joint reviews will be conducted by the MA and OA. The MA will participate in select reviews, as possible.

1. Methods for Remediation/Fixing Individual Problems
   1. Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.

Character Count:out of 6000
The OA is responsible for timely remediation of issues found during their monitoring. This includes assuring that individual issues are resolved. The OA provides quarterly summary reports of their activities to the Medicaid agency. The Medicaid Agency reviews the quarterly reports and determines the appropriate follow-up. General remediation activities may include, recommending that the OA clarify policy, retrain staff, provide technical assistance, void claims, increase monitoring, conduct focused reviews with the MA, or develop a plan of correction.

1. Remediation Data Aggregation

Remediation-related Data Aggregation and Analysis (including trend identification)

1. Timelines

When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Administrative Authority that are currently non-operational.
(X) No
( ) Yes
( ) not selected
Please provide a detailed strategy for assuring Administrative Authority, the specific timeline for implementing identified strategies, and the parties responsible for its operation.
Character Count:out of 6000

Appendix B: Participant Access and Eligibility

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

1. Target Group(s).Under the waiver of Section 1902(a)(10)(B) of the Act, the State limits waiver services to a group or subgroups of individuals. Please see the instruction manual for specifics regarding age limits. In accordance with 42 CFR §441.301(b)(6), select one waiver target group, check each of the subgroups in the selected target group that may receive services under the waiver, and specify the minimum and maximum (if any) age of individuals served in each subgroup:

1. Additional Criteria. The State further specifies its target group(s) as follows:

Character Count:out of 12000
Participants must be assessed as eligible for ICF/MR level of care, must reside within the State of Illinois, must need active treatment, and not be in need of nursing assessment, monitoring, intervention, and supervision of their condition or needs on a 24-hour basis. The number of individuals served each year will be based on available appropriations. New enrollees will be selected from the Prioritization of Urgency of Need For Services (PUNS) database, a database maintained by the Operating Agency of individuals potentially in need of state-funded DD services within the next five years. The selection criteria will provide for selection of individuals on several bases, including urgency of need, length of time on the database, and randomness.

1. Transition of Individuals Affected by Maximum Age Limitation. When there is a maximum age limit that applies to individuals who may be served in the waiver, describe the transition planning procedures that are undertaken on behalf of participants affected by the age limit (select one):

1. Specify:
2. Character Count:out of 12000

Appendix B: Participant Access and Eligibility

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

1. Individual Cost Limit.The following individual cost limit applies when determining whether to deny home and community-based services or entrance to the waiver to an otherwise eligible individual (select one) Please note that a State may have only ONE individual cost limit for the purposes of determining eligibility for the waiver:

( ) No Cost Limit. The State does not apply an individual cost limit. Do not complete Item B-2-b or item B-2-c.
( ) Cost Limit in Excess of Institutional Costs. The State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed the cost of a level of care specified for the waiver up to an amount specified by the State. Complete Items B-2-b and B-2-c.
The limit specified by the State is(select one)
( ) A level higher than 100% of the institutional average.
Specify the percentage:[          ]
( ) Other
Specify:
Character Count:out of 6000
(X) not selected
( ) Institutional Cost Limit. Pursuant to 42 CFR 441.301(a)(3), the State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed 100% of the cost of the level of care specified for the waiver. Complete Items B-2-b and B-2-c.
(X) Cost Limit Lower Than Institutional Costs. The State refuses entrance to the waiver to any otherwise qualified individual when the State reasonably expects that the cost of home and community-based services furnished to that individual would exceed the following amount specified by the State that is less than the cost of a level of care specified for the waiver.
Specify the basis of the limit, including evidence that the limit is sufficient to assure the health and welfare of waiver participants. Complete Items B-2-b and B-2-c.
Character Count:out of 6000
For participants requesting home-based supports, total costs are limited based on State statute (405 ILCS 80). The cost limit was developed in 1990 with input from advocates and family members. Since implementation, the cost limit has been updated based on annual cost of living adjustments as prescribed by law. This limit does not apply to residential services. The statutory monthly cost limit for waiver participants who receive home-based supports and are in special education is two times the Supplemental Security Income (SSI) amount for an adult living alone (SSI amount is currently $674 for calendar year 2011). The statutory monthly cost limit for all other waiver participants in home-based supports is three times the SSI amount. These cost limits apply only to participants in the home-based supports option. Within the statutory limits, the participant, Service Facilitator, and other members of the team develop an individual service plan to meet the participant’s needs. If the primary unpaid caregiver is temporarily unable to provide necessary services that may endanger the participant’s health and welfare, the participant will be considered for temporary crises services. Participant-directed home-based supports are available to individuals living in a home owned or leased by the participant or the participant’s family member. Participant-directed home-based supports are not intended to meet all of the needs of the participant being served. In combination with natural unpaid supports, generic community resources, and Medicaid State Plan services, home-based supports assist in meeting the needs of the participant. Current State appropriations provide funding at the level specified in the State statute for adults receiving this Waiver service option. If the health and welfare of the participant cannot be assured on a long-term basis within the cost limit of participant-directed home-based supports in combination with other natural supports and community resources, the participant will be considered for other service options within the Waiver, including residential habilitation.
The cost limit specified by the State is(select one):
(X) The following dollar amount:
Specify dollar amount:24264
The dollar amount(select one)
(X) Is adjusted each year that the waiver is in effect by applying the following formula:
Specify the formula:
Character Count:out of 6000
The cost limit for participant-directed home-based supports is based on the support plan of the participant, but in no case may it be more than three hundred percent of the monthly federal Supplemental Security Income (SSI) payment for an individual living alone. Federal SSI payments are indexed to the cost of living. The Waiver home-based supports cost limit is adjusted annually at the start of each calendar year based on cost of living changes in the federal SSI payment levels.
( ) May be adjusted during the period the waiver is in effect. The State will submit a waiver amendment to CMS to adjust the dollar amount.
( ) not selected
( ) The following percentage that is less than 100% of the institutional average:
Specify percent:[          ]
( ) Other:
Specify:
Character Count:out of 6000
( ) not selected
( ) not selected

Appendix B: Participant Access and Eligibility

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

1. Method of Implementation of the Individual Cost Limit.When an individual cost limit is specified in Item B-2-a, specify the procedures that are followed to determine in advance of waiver entrance that the individual’s health and welfare can be assured within the cost limit:

Character Count:out of 12000
Participant-directed home-based supports provided to eligible participants who typically reside with family members are intended to supplement the natural supports available from family members and significant others, other community resources and Medicaid State Plan services. If the health and welfare of the participant cannot be assured within the cost limit of home-based supports in combination with other resources, the participant will be considered for other appropriate adult waiver services that are not subject to this cost limitation. Participants are notified of the opportunity to request a fair hearing if enrollment is denied.

1. Participant Safeguards.When the State specifies an individual cost limit in Item B-2-a and there is a change in the participant’s condition or circumstances post-entrance to the waiver that requires the provision of services in an amount that exceeds the cost limit in order to assure the participant’s health and welfare, the State has established the following safeguards to avoid an adverse impact on the participant (check each that applies):

[ ] The participant is referred to another waiver that can accommodate the individual’s needs.
[X] Additional services in excess of the individual cost limit may be authorized.
Specify the procedures for authorizing additional services, including the amount that may be authorized:
Character Count:out of 12000
Temporary Assistance services up to an additional $4000 per episode may be authorized for family emergencies subject to prior approval by the Operating Agency. Temporary Assistance services are in excess of the individual cost limit for home-based supports.
[X] Other safeguard(s)
Specify:
Character Count:out of 12000
Alternate adult waiver service options are offered to address the needs of the participant. Service options are discussed with the participant and guardian, as appropriate, to determine what alternate waiver services are preferred. In addition, participants may be referred to other Waivers to address the participant’s needs, to other appropriate adult services and/or the DHS Office of Inspector General.

Appendix B: Participant Access and Eligibility

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

1. Unduplicated Number of Participants.The following table specifies the maximum number of unduplicated participants who are served in each year that the waiver is in effect. The State will submit a waiver amendment to CMS to modify the number of participants specified for any year(s), including when a modification is necessary due to legislative appropriation or another reason. The number of unduplicated participants specified in this table is basis for the cost-neutrality calculations in Appendix J:

1. Limitation on the Number of Participants Served at Any Point in Time.Consistent with the unduplicated number of participants specified in Item B-3-a, the State may limit to a lesser number the number of participants who will be served at any point in time during a waiver year. Indicate whether the State limits the number of participants in this way: (select one):

1. The limit that applies to each year of the waiver period is specified in the following table:

Appendix B: Participant Access and Eligibility

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

1. Reserved Waiver Capacity.The State may reserve a portion of the participant capacity of the waiver for specified purposes (e.g., provide for the community transition of institutionalized persons or furnish waiver services to individuals experiencing a crisis) subject to CMS review and approval. The State (select one):

Appendix B: Participant Access and Eligibility

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

1. Scheduled Phase-In or Phase-Out.Within a waiver year, the State may make the number of participants who are served subject to a phase-in or phase-out schedule (select one):

1. Allocation of Waiver Capacity.

Select one:

Specify: (a) the entities to which waiver capacity is allocated; (b) the methodology that is used to allocate capacity and how often the methodology is reevaluated; and, (c) policies for the reallocation of unused capacity among local/regional non-state entities:
Character Count:out of 12000

1. Selection of Entrants to the Waiver.Specify the policies that apply to the selection of individuals for entrance to the waiver:

Character Count:out of 12000
Individuals potentially in need of these services are enrolled in the State’s Prioritization of Urgency of Need for Services (PUNS) database by one of the contracted entities serving as access points. This database records demographic and clinical information regarding the individual and his/ her circumstances, services currently received, and services needed. As appropriations are available, individuals are selected for authorization for Waiver services via an automated process that focuses on the individual’s needs and the family’s circumstances (where applicable). Entrance to the Waiver for Adults with Developmental Disabilities of otherwise eligible applicants is deferred via this process until capacity becomes available as a result of turnover or the appropriation of additional funding by the legislature. The intake assessment tool and corresponding PUNS manual is available on the Operating Agency’s website. The number of individuals served each year will be based on available appropriations. New enrollees will be selected from the Prioritization of Urgency of Need For Services (PUNS) database, a database maintained by the Operating Agency of individuals potentially in need of state-funded DD services within the next five years. The selection criteria will provide for selection of individuals on several basis, including urgency of need, length of time on the database, and randomness.

Appendix B: Participant Access and Eligibility

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

Answers provided in Appendix B-3-d indicate that you do not need to complete this section.

Appendix B: Participant Access and Eligibility

B-4: Eligibility Groups Served in the Waiver

1.  
   1. State Classification.The State is a (select one):

( ) §1634 State
( ) SSI Criteria State
(X) 209(b) State
( ) not selected

1. Miller Trust State.

Indicate whether the State is a Miller Trust State (select one):
(X) No
( ) Yes
( ) Unknown

1. Medicaid Eligibility Groups Served in the Waiver.Individuals who receive services under this waiver are eligible under the following eligibility groups contained in the State plan. The State applies all applicable federal financial participation limits under the plan. Check all that apply:

Eligibility Groups Served in the Waiver (excluding the special home and community-based waiver group under 42 CFR §435.217)
[ ] Low income families with children as provided in §1931 of the Act
[ ] SSI recipients
[X] Aged, blind or disabled in 209(b) states who are eligible under 42 CFR §435.121
[X] Optional State supplement recipients
[X] Optional categorically needy aged and/or disabled individuals who have income at:
Select one:
(X) 100% of the Federal poverty level (FPL)
( ) % of FPL, which is lower than 100% of FPL.
Specify percentage:[          ]
( ) not selected
[ ] Working individuals with disabilities who buy into Medicaid (BBA working disabled group as provided in §1902(a)(10)(A)(ii)(XIII)) of the Act)
[X] Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in §1902(a)(10)(A)(ii)(XV) of the Act)
[ ] Working individuals with disabilities who buy into Medicaid (TWWIIA Medical Improvement Coverage Group as provided in §1902(a)(10)(A)(ii)(XVI) of the Act)
[ ] Disabled individuals age 18 or younger who would require an institutional level of care (TEFRA 134 eligibility group as provided in §1902(e)(3) of the Act)
[ ] Medically needy
[X] Medically needy in 209(b) States (42 CFR §435.330)
[ ] Medically needy in 1634 States and SSI Criteria States (42 CFR §435.320, §435.322 and §435.324)
[ ] Other specified groups (include only statutory/regulatory reference to reflect the additional groups in the State plan that may receive services under this waiver)
Specify:
Character Count:out of 6000
Special home and community-based waiver group under 42 CFR §435.217)Note: When the special home and community-based waiver group under 42 CFR §435.217 is included, Appendix B-5 must be completed
(X) No. The State does not furnish waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217.Appendix B-5 is not submitted.
( ) Yes. The State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217.
( ) not selected
Select one and complete Appendix B-5.
( ) All individuals in the special home and community-based waiver group under 42 CFR §435.217
( ) Only the following groups of individuals in the special home and community-based waiver group under 42 CFR §435.217
(X) not selected
Check each that applies:
[ ] A special income level equal to:
Select one:
( ) 300% of the SSI Federal Benefit Rate (FBR)
( ) A percentage of FBR, which is lower than 300% (42 CFR §435.236)
Specify percentage: [          ]
( ) A dollar amount which is lower than 300%.
Specify dollar amount: [          ]
(X) not selected
[ ] Aged, blind and disabled individuals who meet requirements that are more restrictive than the SSI program (42 CFR §435.121)
[ ] Medically needy without spenddown in States which also provide Medicaid to recipients of SSI (42 CFR §435.320, §435.322 and §435.324)
[ ] Medically needy without spend down in 209(b) States (42 CFR §435.330)
[ ] Aged and disabled individuals who have income at:
Select one:
( ) 100% of FPL
( ) % of FPL, which is lower than 100%.
Specify percentage amount:[          ]
(X) not selected
[ ] Other specified groups (include only statutory/regulatory reference to reflect the additional groups in the State plan that may receive services under this waiver)
Specify:
Character Count:out of 6000

Appendix B: Participant Access and Eligibility

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

In accordance with 42 CFR §441.303(e), Appendix B-5 must be completed when the State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217, as indicated in Appendix B-4. Post-eligibility applies only to the 42 CFR §435.217 group. A State that uses spousal impoverishment rules under §1924 of the Act to determine the eligibility of individuals with a community spouse may elect to use spousal post-eligibility rules under §1924 of the Act to protect a personal needs allowance for a participant with a community spouse.

1. Use of Spousal Impoverishment Rules.Indicate whether spousal impoverishment rules are used to determine eligibility for the special home and community-based waiver group under 42 CFR §435.217 (select one):

Answers provided in Appendix B-4 indicate that you do not need to submit Appendix B-5 and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

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

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

Answers provided in Appendix B-4 indicate that you do not need to submit Appendix B-5 and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

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

1. Regular Post-Eligibility Treatment of Income: 209(B) State.

Answers provided in Appendix B-4 indicate that you do not need to submit Appendix B-5 and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

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

1. Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules

The State uses the post-eligibility rules of §1924(d) of the Act (spousal impoverishment protection) to determine the contribution of a participant with a community spouse toward the cost of home and community-based care if it determines the individual’s eligibility under §1924 of the Act. There is deducted from the participant’s monthly income a personal needs allowance (as specified below), a community spouse’s allowance and a family allowance as specified in the State Medicaid Plan.. The State must also protect amounts for incurred expenses for medical or remedial care (as specified below).
Answers provided in Appendix B-4 indicate that you do not need to submit Appendix B-5 and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

B-6: Evaluation/Reevaluation of Level of Care

As specified in 42 CFR §441.302(c), the State provides for an evaluation (and periodic reevaluations) of the need for the level(s) of care specified for this waiver, when there is a reasonable indication that an individual may need such services in the near future (one month or less), but for the availability of home and community-based waiver services.

1. Reasonable Indication of Need for Services.In order for an individual to be determined to need waiver services, an individual must require: (a) the provision of at least one waiver service, as documented in the service plan, and (b) the provision of waiver services at least monthly or, if the need for services is less than monthly, the participant requires regular monthly monitoring which must be documented in the service plan. Specify the State’s policies concerning the reasonable indication of the need for services:
2. Minimum number of services.

The minimum number of waiver services (one or more) that an individual must require in order to be determined to need waiver services is:1

1. Frequency of services. The State requires (select one):

(X) The provision of waiver services at least monthly
( ) Monthly monitoring of the individual when services are furnished on a less than monthly basis
If the State also requires a minimum frequency for the provision of waiver services other than monthly (e.g., quarterly), specify the frequency:
Character Count:out of 4000
( ) not selected

1. Responsibility for Performing Evaluations and Reevaluations.Level of care evaluations and reevaluations are performed (select one):

( ) Directly by the Medicaid agency
( ) By the operating agency specified in Appendix A
( ) By an entity under contract with the Medicaid agency.
Specify the entity:
Character Count:out of 4000
(X) Other
Specify:
Character Count:out of 4000
Level of care evaluations and re-evaluations are performed by local entities under contract with the Operating Agency.
( ) not selected

1. Qualifications of Individuals Performing Initial Evaluation:Per 42 CFR §441.303(c)(1), specify the educational/professional qualifications of individuals who perform the initial evaluation of level of care for waiver applicants:

Character Count:out of 6000
Persons making the initial evaluations must be Qualified Mental Retardation Professionals (QMRPs) as defined in Federal ICFMR regulations. In Illinois, QMRPs are referred to as Qualified Support Professionals (QSPs).

1. Level of Care Criteria.Fully specify the level of care criteria that are used to evaluate and reevaluate whether an individual needs services through the waiver and that serve as the basis of the State’s level of care instrument/tool. Specify the level of care instrument/tool that is employed. State laws, regulations, and policies concerning level of care criteria and the level of care instrument/tool are available to CMS upon request through the Medicaid agency or the operating agency (if applicable), including the instrument/tool utilized.

Character Count:out of 12000
Required assessments and level of care criteria are described fully in the Operating Agency’s screening manual for developmental disabilities, which is used by all individuals conducting waiver screening. The manual is available on the Operating Agency’s website. Chapter 200 of the manual describes the required assessments and qualifications for professionals conducting the assessments. In brief, the following assessments of waiver applicants are required to make an initial waiver level of care determination: For applicants with mental retardation: • Valid psychological evaluation by a qualified professional that documents diagnosis, cognitive and functional limitations and age of onset. For applicants with cerebral palsy or epilepsy, or a related condition: • Physical examination and medical history that documents the diagnosis. For applicants with Autism: • Psychiatric evaluation by a licensed psychiatrist and a psychosocial assessment. For all applicants: • Inventory of Client and Agency Planning (ICAP). • Medical review consisting of a physical examination by a qualified professional, medical history and medication review. • Other assessments as needed to determine service needs. Illinois uses the same process for determining Waiver eligibility as it does for ICF/MR eligibility. For ongoing re-determination of Waiver level of care, a current ICAP is required.

1. Level of Care Instrument(s).Per 42 CFR §441.303(c)(2), indicate whether the instrument/tool used to evaluate level of care for the waiver differs from the instrument/tool used to evaluate institutional level of care (select one):

(X) The same instrument is used in determining the level of care for the waiver and for institutional care under the State Plan.
( ) A different instrument is used to determine the level of care for the waiver than for institutional care under the State plan.
Describe how and why this instrument differs from the form used to evaluate institutional level of care and explain how the outcome of the determination is reliable, valid, and fully comparable.
Character Count:out of 12000
( ) not selected

1. Process for Level of Care Evaluation/Reevaluation:Per 42 CFR §441.303(c)(1), describe the process for evaluating waiver applicants for their need for the level of care under the waiver. If the reevaluation process differs from the evaluation process, describe the differences:

Character Count:out of 12000
The Operating Agency contracts with entities that employ QMRPs to complete the evaluations and reevaluations. As part of the initial level of care determination process, staff of the contracted agencies are responsible for performing or arranging for necessary assessments and collecting other needed information to determine level of care. A qualified mental retardation professional (QMRP) reviews assessment results and other available information against the level of care criteria and guidance in the screening manual for developmental disabilities. The QMRP uses the totality of the information available and best clinical judgment in making the determination. Assessment information and level of care determinations are documented on forms specified by the Operating Agency. Level of care determinations are transmitted electronically to the Operating Agency. The re-determination process is essentially the same, except the ongoing level of care determination is based on a current ICAP, individual assessments and other information from the service planning process in conjunction with personal knowledge of the participant. Level of care re-determinations are documented on a form specified by the Operating Agency and are transmitted electronically to the Operating Agency.

1. Reevaluation Schedule.Per 42 CFR §441.303(c)(4), reevaluations of the level of care required by a participant are conducted no less frequently than annually according to the following schedule (select one):

( ) Every three months
( ) Every six months
(X) Every twelve months
( ) Other schedule
Specify the other schedule:
Character Count:out of 4000
( ) not selected

1. Qualifications of Individuals Who Perform Reevaluations.Specify the qualifications of individuals who perform reevaluations (select one):

(X) The qualifications of individuals who perform reevaluations are the same as individuals who perform initial evaluations.
( ) The qualifications are different.
Specify the qualifications:
Character Count:out of 6000
( ) not selected

1. Procedures to Ensure Timely Reevaluations.Per 42 CFR §441.303(c)(4), specify the procedures that the State employs to ensure timely reevaluations of level of care (specify):

Character Count:out of 6000
The Operating Agency has an edit in the computerized payment system to ensure reevaluations are conducted yearly. The edit requires the contracted entity to enter the reevaluation date. If that date is more than one year old, the edit will not allow payments to be made to the entity. On-site reviews are done annually by the OA to ensure that documentation exists and coincides with the reevaluation date entered in the payment system. The payment edit has been found effective in providing an incentive for the contracted entities to complete annual Waiver reevaluations in a timely manner.

1. Maintenance of Evaluation/Reevaluation Records.Per 42 CFR §441.303(c)(3), the State assures that written and/or electronically retrievable documentation of all evaluations and reevaluations are maintained for a minimum period of 3 years as required in 45 CFR §92.42. Specify the location(s) where records of evaluations and reevaluations of level of care are maintained:

Character Count:out of 6000
Evaluation and reevaluation forms are kept by contracted entities for the mandatory three years or more. Results are maintained electronically by the Operating Agency for three or more years.

Appendix B: Evaluation/Reevaluation of Level of Care

Quality Improvement: Level of Care

As a distinct component of the State’s quality improvement strategy, provide information in the following fields to detail the State’s methods for discovery and remediation.

1. Methods for Discovery: Level of Care Assurance/Sub-assurances
   1. Sub-Assurances:
2. Sub-assurance: An evaluation for LOC is provided to all applicants for whom there is reasonable indication that services may be needed in the future.

Performance Measures
For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

1. Sub-assurance: The levels of care of enrolled participants are reevaluated at least annually or as specified in the approved waiver.

Performance Measures
For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

1. Sub-assurance: The processes and instruments described in the approved waiver are applied appropriately and according to the approved description to determine participant level of care.

Performance Measures
For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

1. If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.

Character Count:out of 6000

1. Methods for Remediation/Fixing Individual Problems
   1. Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.

Character Count:out of 6000
The OA reviews the issues and identifies the most appropriate response. General responses may include work with participants and their providers, retraining staff, voiding claims, technical assistance, increased monitoring, revising service plans, and requiring plans of correction. The OA is responsible for seeing that individual issues are resolved. The OA provides quarterly reports of these activities to the MA. Staff of the two State agencies review the reports on a quarterly basis.

1. Remediation Data Aggregation

Remediation-related Data Aggregation and Analysis (including trend identification)

1. Timelines

When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Level of Care that are currently non-operational.
(X) No
( ) Yes
( ) not selected
Please provide a detailed strategy for assuring Level of Care, the specific timeline for implementing identified strategies, and the parties responsible for its operation.
Character Count:out of 6000

Appendix B: Participant Access and Eligibility

B-7: Freedom of Choice

Freedom of Choice.As provided in 42 CFR §441.302(d), when an individual is determined to be likely to require a level of care for this waiver, the individual or his or her legal representative is:

1. informed of any feasible alternatives under the waiver; and
2. given the choice of either institutional or home and community-based services.
3. Procedures.Specify the State’s procedures for informing eligible individuals (or their legal representatives) of the feasible alternatives available under the waiver and allowing these individuals to choose either institutional or waiver services. Identify the form(s) that are employed to document freedom of choice. The form or forms are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Character Count:out of 12000
The QMRP/QSPs employed by the Operating Agency’s contracted entities inform individuals, and/or their legal guardians, about their options during the level of care determination process. The QMRP presents the individual/legal representative with all service options, including both Waiver and ICF/MR services that the individual is eligible to receive, regardless of availability, in sufficient detail so they are able to make informed choices. If the individual/legal representative does not speak English, has limited proficiency or is non-verbal, the QMRP makes an accommodation. Acceptable accommodations may include use of staff with secondary language skills, translation services, oral assistance and communication devices. The QMRP/QSP provides the individual/legal representative with additional information and materials on the service options they choose to pursue and arranges for and facilitates conversations with potential service providers including visits to the potential providers as indicated. The IL 462-1238 form, Choice of Supports and Services, specifically documents the decision to choose Waiver services as an alternative to ICF/MR services at this time. This form also states that choice of supports and services may be changed in the future and is signed by the individual/legal representative. The form is also available in Spanish (IL 462-1238S).

1. Maintenance of Forms.Per 45 CFR §92.42, written copies or electronically retrievable facsimiles of Freedom of Choice forms are maintained for a minimum of three years. Specify the locations where copies of these forms are maintained.

Character Count:out of 4000
Copies of the IL 462-1238 forms are available in English and Spanish and are maintained by the contracted entity.

Appendix B: Participant Access and Eligibility

B-8: Access to Services by Limited English Proficiency Persons

Access to Services by Limited English Proficient Persons.Specify the methods that the State uses to provide meaningful access to the waiver by Limited English Proficient persons in accordance with the Department of Health and Human Services “Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons” (68 FR 47311 – August 8, 2003):
Character Count:out of 12000
The local ISC entities under contract with the Operating Agency that serve as access points are integrated in their communities and on a daily basis interact with a wide variety of individuals of varying backgrounds, cultures, and languages. The entities have resources available to communicate effectively with participants of limited English proficiency in their community, including bilingual staff as needed, interpreters, translated forms, etc. The Operating Agency has a website, www.dd.Illinois.gov, and a toll-free number, 1-888-DDPLANS, specifically designed for families’ use in learning more about Illinois’ DD service system and in contacting their local entity for assistance with accessing services. Each of these information points is available in both Spanish and English. In addition, brochures and flyers are available in other languages including: Arabic, Bosnian, Chinese, Hindi, Khner, Korean, Polish, Russian, Urdu and Vietnamese.

Appendix C: Participant Services

C-1: Summary of Services Covered (1 of 2)

1. Waiver Services Summary. List the services that are furnished under the waiver in the following table. If case management is not a service under the waiver, complete items C-1-b and C-1-c:

Appendix C: Participant Services

C-1: Summary of Services Covered (2 of 2)

1. Provision of Case Management Services to Waiver Participants. Indicate how case management is furnished to waiver participants (select one):

( ) not selected
( ) Not applicable – Case management is not furnished as a distinct activity to waiver participants.
(X) Applicable – Case management is furnished as a distinct activity to waiver participants.
Check each that applies:
[X] As a waiver service defined in Appendix C-3. Do not complete item C-1-c.
[ ] As a Medicaid State plan service under §1915(i) of the Act (HCBS as a State Plan Option). Complete item C-1-c.
[ ] As a Medicaid State plan service under §1915(g)(1) of the Act (Targeted Case Management). Complete item C-1-c.
[X] As an administrative activity. Complete item C-1-c. NOTE: Pursuant to CMS-2237-IFC this selection is no longer available for 1915(c) waivers.
[ ] Not applicable – Case management is not furnished as a distinct activity to waiver participants. Do not complete item C-1-c.
( ) None of the above apply – Case management is furnished as a waiver service (Do not complete item C-1-c).

1. Delivery of Case Management Services.Specify the entity or entities that conduct case management functions on behalf of waiver participants:

Character Count:out of 4000
In addition to residential habilitation and service facilitator services, which provide many components of case management services, each waiver participant receives Individual Service and Support Advocacy (ISSA) services from the local independent service coordination (ISC) entity under contract with the Operating Agency. ISSAs are Qualified Mental Retardation Professional (QMRP) staff (known as Qualified Support Professionals/QSPs in Illinois), who are responsible for the annual re-determinations of level of care, participate in the support planning process, approve all participant-centered support plans, advocate on behalf of the participant and family, visit with the participant at least four times per year to ensure health and welfare and that needs are being met, and alert the Operating Agency about issues that require additional monitoring and technical assistance. The maximum for ISSA is 25 hours per state fiscal year, unless written approval is granted for additional hours. This administrative service is required for all waiver participants. For individuals who exercise participant direction as part of home-based supports, the local service facilitator, also a QMRP(QSP in Illinois), provides information and assistance in support of participant direction. Service facilitation is a separate waiver service and participants have the choice of providers. Other aspects of case management services are provided by QMRPs/QSPs who are employees of direct service providers, including residential habilitation providers. The case management functions performed include coordination of multiple services and/or among multiple service providers and linking waiver participants to other Federal, state and local programs. Some components of case management, including development and/or review of service plans, monitoring the implementation of service plans and participant health and welfare, addressing problems in service provision, and responding to participant crises, are provided under both the administrative and case management services. We believe this is appropriate because the parties conducting the administrative functions are independent of direct services providers and play a role in the State’s monitoring efforts. Direct case managers must be involved in these issues too in order to ensure appropriate service delivery.

Appendix C: Participant Services

C-2: General Service Specifications (1 of 3)

1. Criminal History and/or Background Investigations.Specify the State’s policies concerning the conduct of criminal history and/or background investigations of individuals who provide waiver services (select one):

1. Specify: (a) the types of positions (e.g., personal assistants, attendants) for which such investigations must be conducted; (b) the scope of such investigations (e.g., state, national); and, (c) the process for ensuring that mandatory investigations have been conducted. State laws, regulations and policies referenced in this description are available to CMS upon request through the Medicaid or the operating agency (if applicable):
2. Character Count:out of 12000
3. Criminal background checks with the Illinois State Police are required for direct service staff hired by agencies providing residential services, Developmental Training, Adult Day Care, Supported Employment, Service Facilitation, Personal Support, or Individual Service and Support Advocacy. These agencies may not knowingly hire or retain any person in a full-time, part-time or contractual direct service position if that person has been convicted of committing or attempting to commit one or more of the offenses in the Illinois Health Care Worker Background Check Act (225 ILCS 64/25), unless the person obtains a waiver of the conviction. For individual providers hired as common law employees on or after July 1, 2007, the Financial Management Service (FMS) entity/entities under contract with the OA, is required to obtain criminal background checks and not enroll or retain independent personal support workers (common law employees or domestic employees) if the person has been convicted as described above. The FMS vendor obtains the criminal background check on behalf of all participants who hire independent personal support workers. The results are kept on file with the FMS vendor. Periodically, the OA and MA review providers and FMS entities for compliance with this requirement.
4. Abuse Registry Screening.Specify whether the State requires the screening of individuals who provide waiver services through a State-maintained abuse registry (select one):

1. Specify: (a) the entity (entities) responsible for maintaining the abuse registry; (b) the types of positions for which abuse registry screenings must be conducted; and, (c) the process for ensuring that mandatory screenings have been conducted. State laws, regulations and policies referenced in this description are available to CMS upon request through the Medicaid agency or the operating agency (if applicable):
2. Character Count:out of 12000
3. By statute, the Illinois Department of Public Health maintains an adult abuse and neglect registry. The registry is called the Healthcare Worker Registry (formerly known as the Nurse Aide Registry). The state law governing the Health Care Worker’s Registry is the Abused and Neglected Long Term Care Facility Residents Reporting Act (210 ILCS 30). By statute, the Illinois Department of Children and Family Services (DCFS) maintains a child abuse and neglect registry. The registry is called the Child Abuse and Neglect Tracking System, or CANTS. The state law governing the State Central Register (DCFS CANTS) is the Abused and Neglected Child Reporting Act (325 ILCS 5/1). Waiver providers are required by the OA to complete registry checks on all employees. Employees cannot be hired if they fail the registry checks. The results of the registry checks are documented by the provider. Abuse/neglect screenings are required for all domestic employees hired on or after July 1, 2007, who provide personal support or temporary assistance services. Such individuals may not be employed in any capacity until the employer has checked the individual against the Ill. Dept. of Public Health, Health Care Worker Registry and the Ill. Dept. of Children and Family Services Registry. The FMS entities conduct the registry checks for all personal support workers employed directly by the participant or their representative. Abuse/Neglect screenings are required for all individuals providing residential habilitation, day habilitation (called Developmental Training), Supported Employment, Service Facilitation, Personal Support or Individual Service and Support Advocacy (ISSA) services. Such individuals may not be employed in any capacity until the employer has checked the individual against: • The Illinois Department of Public Health (IDPH) Health Care Worker Registry, and • The Illinois Department of Children and Family Services (DCFS) State Central Register (Children’s Abuse and Neglect Tracking System – CANTS). If either database reports substantiated or indicated findings of physical or sexual abuse or egregious neglect, the person may not be employed. The OA and the MA review providers and FMS entities for compliance with this requirement.

Appendix C: Participant Services

C-2: General Service Specifications (2 of 3)

1. Services in Facilities Subject to §1616(e) of the Social Security Act. Select one:

1. Types of Facilities Subject to §1616(e).Complete the following table for each type of facility subject to §1616(e) of the Act:

1. Larger Facilities: In the case of residential facilities subject to §1616(e) that serve four or more individuals unrelated to the proprietor, describe how a home and community character is maintained in these settings.

Character Count:out of 12000
Community integration is a fundamental goal and component of the support plan for all participants in the Waiver, regardless of the size of the living arrangement. Every participant has an independent Individual Service and Support Advocate (ISSA), part of whose role it is to ensure availability of supports to encourage individual choices about participating in specialized and generic activities outside the home and within their home communities, developing and maintaining meaningful relationships with friends and family, and participating in organizations and general community life. The Operating Agency monitors support plans and ISSA visiting notes to ensure that community integration is supported. Licensure standards are in place to ensure participants may maintain personal possessions, visit with friends in the community and be given the opportunity to develop social relationships and pursue hobbies and personal interests through participation in neighborhood, school and other community and other group activities. Residential habilitation settings are integrated into their home communities. They are located to promote easy access to stores, religious institutions, services, and activities in the community, by foot, public transportation, or car. Consistent with each participant’s service plan, the residential habilitation settings offer a home-like environment, family-style meals and personal privacy.

Appendix C: Participant Services

C-2: General Service Specifications (3 of 3)

1. Provision of Personal Care or Similar Services by Legally Responsible Individuals.A legally responsible individual is any person who has a duty under State law to care for another person and typically includes: (a) the parent (biological or adoptive) of a minor child or the guardian of a minor child who must provide care to the child or (b) a spouse of a waiver participant. Except at the option of the State and under extraordinary circumstances specified by the State, payment may not be made to a legally responsible individual for the provision of personal care or similar services that the legally responsible individual would ordinarily perform or be responsible to perform on behalf of a waiver participant. Select one:

(X) No. The State does not make payment to legally responsible individuals for furnishing personal care or similar services.
( ) Yes. The State makes payment to legally responsible individuals for furnishing personal care or similar services when they are qualified to provide the services.
Specify: (a) the legally responsible individuals who may be paid to furnish such services and the services they may provide; (b) State policies that specify the circumstances when payment may be authorized for the provision of extraordinary careby a legally responsible individual and how the State ensures that the provision of services by a legally responsible individual is in the best interest of the participant; and, (c) the controls that are employed to ensure that payments are made only for services rendered. Also, specify in Appendix C-1/C-3 the personal care or similar services for which payment may be made to legally responsible individuals under the State policies specified here.
Character Count:out of 12000
( ) not selected

1. Other State Policies Concerning Payment for Waiver Services Furnished by Relatives/Legal Guardians.Specify State policies concerning making payment to relatives/legal guardians for the provision of waiver services over and above the policies addressed in Item C-2-d. Select one:

( ) The State does not make payment to relatives/legal guardians for furnishing waiver services.
( ) The State makes payment to relatives/legal guardians under specific circumstances and only when the relative/guardian is qualified to furnish services.
Specify the specific circumstances under which payment is made, the types of relatives/legal guardians to whom payment may be made, and the services for which payment may be made. Specify the controls that are employed to ensure that payments are made only for services rendered. Also, specify in Appendix C-1/C-3 each waiver service for which payment may be made to relatives/legal guardians.
Character Count:out of 12000
(X) Relatives/legal guardians may be paid for providing waiver services whenever the relative/legal guardian is qualified to provide services as specified in Appendix C-1/C-3.
Specify the controls that are employed to ensure that payments are made only for services rendered.
Character Count:out of 12000
Payment for Waiver services may be made to any relative and/or legal guardian who meets the requirements to provide the service, except for legally responsible relatives as defined in Section C-2(d) above (spouses). Parents, other close relatives, and legal guardians may not provide host family services (i.e., foster care and other shared living arrangements) under residential habilitation services. This prohibition is specified in Illinois Administrative Code, available upon request from either the Medicaid or Operating Agency. Personal support, temporary assistance and non-medical transportation are the only services that may be provided by a relative. The services may be provided by relatives as long as they meet the same provider qualifications and pass the required background checks as any other domestic employee providing personal support or any other non-medical transportation service provider. The participant-centered support plan governs the services to be provided. For participants who exercise employer authority, the Financial Management Service (FMS) entity receives time sheets detailing the date and time of services delivered. The FMS entity conducts routine quality assurance activities. The OA through it’s representative sample, reviews personal support, temporary assistance and non-medical transportation, regardless of the provider relationship.
( ) Other policy.
Specify:
Character Count:out of 12000
( ) not selected

1. Open Enrollment of Providers.Specify the processes that are employed to assure that all willing and qualified providers have the opportunity to enroll as waiver service providers as provided in 42 CFR §431.51:

Character Count:out of 12000
As part of the participant-centered planning process, participants in the Developmental Disabilities Adult Waiver and their guardian, if one has been appointed, together with the Service Facilitator or responsible QSP/QMRP, Individual Service and Support Advocate (ISSA), and other members of the support planning team, are responsible for selecting needed services and service providers. Participant-directed services allow participants or guardian (as applicable), who choose to exercise employer authority to hire common law employees (called domestic employees) with support from the Financial Management Service (FMS) entity. Information regarding provider qualifications and program guidelines is continuously available on the Operating Agency’s website. The State does not impose barriers to the free choice of willing and qualified providers. The Operating Agency (DHS) reviews and approves service providers for participation in the Adult Developmental Disabilities Waiver based on the provider qualifications specified in the Waiver. The State Medicaid Agency enrolls all willing and qualified providers that are chosen by participants or guardian, if one is appointed, in the Developmental Disabilities Adult Waiver.

Appendix C: Participant Services

Quality Improvement: Qualified Providers

As a distinct component of the State’s quality improvement strategy, provide information in the following fields to detail the State’s methods for discovery and remediation.

1. Methods for Discovery: Qualified Providers
   1. Sub-Assurances:
2. Sub-Assurance: The State verifies that providers initially and continually meet required licensure and/or certification standards and adhere to other standards prior to their furnishing waiver services.

Performance Measures
For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

1. Sub-Assurance: The State monitors non-licensed/non-certified providers to assure adherence to waiver requirements.

For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

1. Sub-Assurance: The State implements its policies and procedures for verifying that provider training is conducted in accordance with state requirements and the approved waiver.

For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).
For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

1. If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.

Character Count:out of 6000

1. Methods for Remediation/Fixing Individual Problems
   1. Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.

Character Count:out of 6000
The OA reviews the findings and identifies the most appropriate response. General responses may include working with participants and their providers, retraining staff, voiding claims, technical assistance, increased monitoring, revising service plans, and requiring plans of correction. The OA is responsible for seeing that individual issues are resolved. The OA provides quarterly reports of these activities to the MA. Staff of the two State agencies review the reports on a quarterly basis.

1. Remediation Data Aggregation

Remediation-related Data Aggregation and Analysis (including trend identification)

1. Timelines

When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Qualified Providers that are currently non-operational.
(X) No
( ) Yes
( ) not selected
Please provide a detailed strategy for assuring Qualified Providers, the specific timeline for implementing identified strategies, and the parties responsible for its operation.
Character Count:out of 6000

Appendix C: Participant Services

C-3: Waiver Services Specifications

Section C-3 ‘Service Specifications’ is incorporated into Section C-1 ‘Waiver Services.’

Appendix C: Participant Services

C-4: Additional Limits on Amount of Waiver Services

1. Additional Limits on Amount of Waiver Services.Indicate whether the waiver employs any of the following additional limits on the amount of waiver services (select one).

( ) not selected
( ) Not applicable – The State does not impose a limit on the amount of waiver services except as provided in Appendix C-3.
(X) Applicable – The State imposes additional limits on the amount of waiver services.
When a limit is employed, specify: (a) the waiver services to which the limit applies; (b) the basis of the limit, including its basis in historical expenditure/utilization patterns and, as applicable, the processes and methodologies that are used to determine the amount of the limit to which a participant’s services are subject; (c) how the limit will be adjusted over the course of the waiver period; (d) provisions for adjusting or making exceptions to the limit based on participant health and welfare needs or other factors specified by the state; (e) the safeguards that are in effect when the amount of the limit is insufficient to meet a participant’s needs; (f) how participants are notified of the amount of the limit. (check each that applies)
[X] Limit(s) on Set(s) of Services.There is a limit on the maximum dollar amount of waiver services that is authorized for one or more sets of services offered under the waiver.
Furnish the information specified above.
Character Count:out of 24000
In addition to the information contained in the OA’s DDD Waiver Manual, each participant receives an initial award letter that contains service limits. The service limits are discussed verbally during the annual service planning process. The waiver case manager or service facilitator and the ISSA review service limits with the participant and guardian, if applicable. The written service plan is signed by the participant, or his or her guardian (if one has been appointed), the waiver case manager/service facilitator and the ISSA. Maximum for Modifications and Tangible Items There is a $15,000 maximum per participant per five-year period for any combination of adaptive equipment, assistive technology, and minor home and vehicle modifications. Within the five-year maximum, there is also a $5,000 maximum per address for permanent home modifications for rented homes. Individual program limits were combined to allow participants greater flexibility within the tangible item budget to meet their unique needs. Participants are informed of their right to request a fair hearing, in the event any requests are denied. Participants are notified of the limits in the OA’s Waiver manual. Waiver case managers or service facilitators and ISSA assist participants in understanding and managing the limits. Temporary Assistance services may not exceed $2,000 in a single month and may not be authorized for more than two consecutive months or 60 consecutive days. Under certain circumstances, the OA can provide verbal approval within 24 hours of receipt of a request for Temporary Assistance services. Services can begin upon verbal approval. The Independent Service and Support Advocate (ISSA) or home-based supports Service Facilitator will submit a written request for prior authorization for Temporary Assistance services on behalf of the individual. The OA will respond in writing to the request within 30 calendar days. However, when an unplanned need occurs, Temporary Assistance services will begin upon receipt of verbal approval from the OA. The OA will provide verbal approval ASAP but no later than 24 hours of receipt of request, in thoses cases of unplanned need. Subsequent written approval is issued to the participant, Service Facilitator and ISSA by the OA.
[X] Prospective Individual Budget Amount.There is a limit on the maximum dollar amount of waiver services authorized for each specific participant.
Furnish the information specified above.
Character Count:out of 24000
The annual supports budget limits are based on the Illinois Home-Based Support Services Law for Mentally Disabled Adults [405 ILCS 80]. The limits are indexed to Social Security benefit levels and are adjusted each January when Social Security benefits are adjusted for cost of living increases. These statutory budget limits were set through a public legislative process that included opportunities for public comment by advocates and individuals with mental disabilities and their families. The total amount of Waiver services provided in any month is determined by the support plan of the participant within the program maximums. The annual support plan is developed by the waiver case manager (Service Facilitator), with input from the ISSA and other team members, and is based on assessments of the participant’s needs. Written notices of changes to limits are sent to all participants/guardians, Financial Management Service entities, Service Facilitation providers and Individual Service and Support Advocacy (ISSA) entities by the OA. We expect that the monthly support services budget limits, currently $2,022 for calendar year 2011 (or $1,348 if between the ages of 18 and 22 and still attending school), together with natural supports, general community resources, school-based services (for young adult participants still attending school), and Medicaid State plan services will be sufficient to meet the participant’s needs.
[ ] Budget Limits by Level of Support.Based on an assessment process and/or other factors, participants are assigned to funding levels that are limits on the maximum dollar amount of waiver services.
Furnish the information specified above.
Character Count:out of 24000
[ ] Other Type of Limit.The State employs another type of limit.
Describe the limit and furnish the information specified above.
Character Count:out of 24000
[ ] Not applicable.The State does not impose a limit on the amount of waiver services except as provided in Appendix C-3.

Appendix D: Participant-Centered Planning and Service Delivery

D-1: Service Plan Development (1 of 8)

State Participant-Centered Service Plan Title:Sometimes referred to as Individual Service Plan or Support Plan

1. Responsibility for Service Plan Development.Per 42 CFR §441.301(b)(2), specify who is responsible for the development of the service plan and the qualifications of these individuals (select each that applies):

[ ] Registered nurse, licensed to practice in the State
[ ] Licensed practical or vocational nurse, acting within the scope of practice under State law
[ ] Licensed physician (M.D. or D.O)
[ ] Case Manager(qualifications specified in Appendix C-1/C-3)
[ ] Case Manager(qualifications not specified in Appendix C-1/C-3).
Specify qualifications:
Character Count:out of 6000
[ ] Social Worker.
Specify qualifications:
Character Count:out of 6000
[X] Other
Specify the individuals and their qualifications:
Character Count:out of 6000
For the participant-directed home-based supports, the Service Facilitator, who is QMRP/QSP, is responsible. For those receiving residential habilitation services, the QMRP employed by the licensed provider, is responsible for service plan development. Waiver case manager for residential habilitation providers and Service Facilitator qualifications are specified in Appendix C-1.

Appendix D: Participant-Centered Planning and Service Delivery

D-1: Service Plan Development (2 of 8)

1. Service Plan Development Safeguards.Select one:

1. The State has established the following safeguards to ensure that service plan development is conducted in the best interests of the participant. Specify:
2. Character Count:out of 6000
3. In addition to the waiver case manager/Service facilitator who is a QMRP/QSP employed by a direct service provider, all Waiver participants hav an Individual Service and Support Advocate (ISSA) who is a QMRP/QSP employed by an independent service coordination (ISC) entity under contract with the Operating Agency. The ISSA participates in and approves the participant-directed support plan. The ISSA also conducts quarterly visits to the individual to ensure that services in the plan are being fully implemented and are meeting the participants’ needs.

Appendix D: Participant-Centered Planning and Service Delivery

D-1: Service Plan Development (3 of 8)

1. Supporting the Participant in Service Plan Development.Specify: (a) the supports and information that are made available to the participant (and/or family or legal representative, as appropriate) to direct and be actively engaged in the service plan development process and (b) the participant’s authority to determine who is included in the process.

Character Count:out of 12000
For all Waiver participants, participant-centered support plans are developed by QMRP/QSPs, who work as part of a team that includes the participant being served, the participant’s legal guardian (if one has been appointed), the participant’s Individual Service and Support Advocate (ISSA), other individuals from the participant’s support network as the participant or guardian chooses, and professional consultants as deemed necessary by the provider. The written plan may be produced in other formats, such as pictures, DVD, etc., to accommodate specific needs of the participant, team, or provider; however, the plan must exist in written format. ISSAs are directed to contact the participant and guardian, if one has been appointed, prior to any support planning meetings to identify areas of concern, answer questions, and generally prepare for the meeting. The participant or guardian (if one has been appointed), responsible waiver case manager or Service Facilitator, and the ISSA must approve the support plan, in writing.

Appendix D: Participant-Centered Planning and Service Delivery

D-1: Service Plan Development (4 of 8)

1. Service Plan Development Process.In four pages or less, describe the process that is used to develop the participant-centered service plan, including: (a) who develops the plan, who participates in the process, and the timing of the plan; (b) the types of assessments that are conducted to support the service plan development process, including securing information about participant needs, preferences and goals, and health status; (c) how the participant is informed of the services that are available under the waiver; (d) how the plan development process ensures that the service plan addresses participant goals, needs (including health care needs), and preferences; (e) how waiver and other services are coordinated; (f) how the plan development process provides for the assignment of responsibilities to implement and monitor the plan; and, (g) how and when the plan is updated, including when the participant’s needs change. State laws, regulations, and policies cited that affect the service plan development process are available to CMS upon request through the Medicaid agency or the operating agency (if applicable):

Character Count:out of 24000
Plan Development and Modification Within 30 days after the initiation of services, the responsible waiver case manager/Service Facilitator/QMRP/QSP shall prepare a written participant-centered support plan for each participant only after consultation with the following: • Face-to-face consultation with the participant; • Consultation with the participant’s legal guardian, if one has been appointed; • Other individuals from the participant’s support network (including family members) as the participant or guardian chooses; • The participant’s ISSA; and • Professional consultants as deemed necessary. The written plan may be produced in other formats, such as pictures, DVD, etc., to accommodate specific needs of the participant, team, or provider; however, the plan must exist in written format. The support plan shall: • Contain a description of the participant’s preferences; • List and describe the necessary activities, training, materials, equipment, assistive technology, and services that are needed to assist the participant; • Describe how opportunities of choice will be provided, including specifying means for the following: -supporting the participant or guardian, if one has been appointed, to indicate preferences among options presented, by whatever communication methods necessary; -providing the necessary support and training for the participant to be able to indicate preferences, including a description of any training and support needed to fully participate in the planning process and other choice making; and -assisting the participant or guardian to understand the negative consequences of choices that may involve risk; • Prioritize and structure the delivery of services toward the goal of achieving the participant’s or guardian’s preferences; • Provide for supports for the participant to access generic resources and Medicaid State Plan services; and • Contribute to the continuous movement of the participant toward the achievement of the participant’s or guardian’s preferences. The support plan shall: • Be dated; • Be approved in writing by the participant or guardian, if one has been appointed. Requirements for approval from or consultation with the participant’s guardian shall be considered to have been complied with if the provider documents that it has taken reasonable measures to obtain this approval or consultation and that the participant’s guardian has failed to respond; • Be approved in writing by the responsible waiver case manager/Service Facilitator/QMRP/QSP; and • Be approved, in writing, by the participant’s ISSA. The ISSA shall approve only those plans that meet the requirements established in the Waiver. If the ISSA determines that the proposed plan does not meet these requirements, the ISSA shall work with the participant or guardian, if applicable, and provider(s) to ensure the proposed plan is modified as necessary. In the event that conflicts arise that cannot be resolved among the parties involved, the ISSA or responsible waiver case manager/Service Facilitator shall make a referral to the Operating Agency for technical assistance. The responsible waiver case manager/Service Facilitator shall regularly review and revise the plan by following the same procedures as set out above, whenever necessary, to reflect any of the following: • Changes in the participant’s needs and preferences; • Achievement of goals or skills outlined within the plan; or • Any determination made that any service being provided is unresponsive. In developing, modifying, and evaluating the effectiveness of the plan, the responsible waiver case manager/Service Facilitator shall include assessments made by professionals and shall: • Include consideration of the expressed opinions of the participant or guardian, as applicable, and other individuals from the participant’s support network; and • Account for the following: (i) the financial limitations of the participant, the provider, and funding sources; (ii) the supports and training needed, offered, and accepted by the participant; (iii) the participant’s medical status, (iv) the participant’s ability to communicate his or her needs and preferences, and (v) matters identified in Section e below in accordance with imminent danger. • Next best options may be considered as responsive if the participant or guardian, as applicable, cannot specifically have what is preferred due to limitations identified. All plans must be updated at least annually.

Appendix D: Participant-Centered Planning and Service Delivery

D-1: Service Plan Development (5 of 8)

1. Risk Assessment and Mitigation.Specify how potential risks to the participant are assessed during the service plan development process and how strategies to mitigate risk are incorporated into the service plan, subject to participant needs and preferences. In addition, describe how the service plan development process addresses backup plans and the arrangements that are used for backup.

Character Count:out of 12000
For all Waiver participants, the responsible waiver case manager/Service Facilitator and ISSA must address during the planning process with the participant and guardian (if one has been appointed) the negative consequences of choices that may involve risk and document the issues concerned and the decisions made. They will describe, when it is necessary to do so, to the participant and the participant’s support network, how the preferences might be limited because of imminent significant danger to the participant’s health, safety, or welfare based on the following: • The participant or guardian’s, if one has been appointed, history of decision-making and ability to learn from the natural negative consequences of poor decision-making; • The possible long and short-term consequences that might result to the participant if the participant makes a poor decision; • The possible long and short-term effects that might result to the participant if the provider limits or prohibits the participant or guardian from making a choice; and • The safeguards available to protect the participant’s safety and rights in each context of choices. Backup plans are developed, if it is determined to be necessary, as part of the plan development process. If the participant is receiving services from an agency, the agency is required to provide back-up personnel as needed. When the participant is exercising employer authority, the back-up plan is specific to the participant’s needs and may include family, other social service agencies, etc. This waiver provides support services to adults of all ages, some of who live at home with other family members. As part of the service planning process, the participant or guardian, if one has been appointed, can make arrangements with multiple providers who can be contacted as needed. A back-up plan is necessary when the absence of the service presents a risk to the health, welfare and/or safety of the participant. The planning team evaluates the need and type of back-up plan taking into consideration natural supports and available waiver services. Participants residing with family members can enter into agreements with providers that can provide services in an emergency situation or provide staff substitutes when regular staff cannot work assigned hours.

Appendix D: Participant-Centered Planning and Service Delivery

D-1: Service Plan Development (6 of 8)

1. Informed Choice of Providers.Describe how participants are assisted in obtaining information about and selecting from among qualified providers of the waiver services in the service plan.

Character Count:out of 6000
A list of providers, by provider type, is available on the OA’s website. A written list of providers is available upon request. Participants are supported by the Independent Service Coordination (ISC) entity under contract with the Operating Agency. Once the individual or guardian expresses an interest in or selects the type(s) of services he or she wishes to receive, the ISC informs the individual or guardian of providers offering that type of service in the desired geographic area. ISCs will make referrals to those providers selected by the individual/guardian. These referrals must be documented on the DDPAS-10 form. The ISC ensures linkage with potential providers, and may, at the participant’s request, participate in discussions or visits with providers. A copy of the DDPAS-10 form is maintained in the individual’s file at the ISC entity’s office.

Appendix D: Participant-Centered Planning and Service Delivery

D-1: Service Plan Development (7 of 8)

1. Process for Making Service Plan Subject to the Approval of the Medicaid Agency.Describe the process by which the service plan is made subject to the approval of the Medicaid agency in accordance with 42 CFR §441.301(b)(1)(i):

Character Count:out of 6000
Annually OA staff review the adequacy of support plans through a representative sample during on-site reviews. The MA participates in select reviews. The reviews consist of record reviews, interviews with participants and staff, and observations. Data from these reviews are aggregated by the OA and shared with the MA staff as part of the Quality Management Committee activity. This committee meets quarterly. In addition, the Medicaid Agency conducts sample reviews of service plans to ensure they are developed in accordance with Waiver requirements.

Appendix D: Participant-Centered Planning and Service Delivery

D-1: Service Plan Development (8 of 8)

1. Service Plan Review and Update.The service plan is subject to at least annual periodic review and update to assess the appropriateness and adequacy of the services as participant needs change. Specify the minimum schedule for the review and update of the service plan:

1. Specify the other schedule:
2. Character Count:out of 6000
3. Maintenance of Service Plan Forms.Written copies or electronic facsimiles of service plans are maintained for a minimum period of 3 years as required by 45 CFR §92.42. Service plans are maintained by the following (check each that applies):

[ ] Medicaid agency
[ ] Operating agency
[ ] Case manager
[X] Other
Specify:
Character Count:out of 4000
Responsible waiver case manager or Service Facilitator (for participant-directed support services) and ISSA, employed by an Independent Service Coordination (ISC) entity under contract with the OA.

Appendix D: Participant-Centered Planning and Service Delivery

D-2: Service Plan Implementation and Monitoring

1. Service Plan Implementation and Monitoring.Specify: (a) the entity (entities) responsible for monitoring the implementation of the service plan and participant health and welfare; (b) the monitoring and follow-up method(s) that are used; and, (c) the frequency with which monitoring is performed.

Character Count:out of 24000
The waiver case manager/Service Facilitator is responsible for implementing the service plan and ensuring the ongoing health and welfare of the participant. They are to have face-to-face contact with the participant at least six times per year, one visit every two months. The ISSA, who is independent of direct service provision, is responsible for monitoring the implementation of the service plan and ensuring the health and welfare of the participant. The ISSA must visit at least quarterly with each participant in the Waiver. The OA monitors the waiver case management and ISSA activity through a representative sample of participants on a continuous, ongoing basis. Data is collected and analyzed as specified under the Quality Improvement sections in Appendices D and G on an ongoing, continuous basis. Summary reports are shared with the MA quarterly and discussed during quarterly Quality Management Committee meetings. When problems are identified, they are documented and remediation efforts are initiated by the OA. Remediation efforts may include revising service plans, increased monitoring, technical assistance, plans of correction, and voidance of claims. The support plan is reviewed

1. Monitoring Safeguards.Select one:

1. The State has established the following safeguards to ensure that monitoring is conducted in the best interests of the participant. Specify:
2. Character Count:out of 24000
3. In addition to routine monitoring by the responsible waiver case manager or Service Facilitator, the Individual Services and Support Advocacy (ISSA) entity, an Independent Service Coordination (ISC) entity under contract with the Operating Agency, continually (at least quarterly or more often if necessary) monitors the implementation of the plan and works cooperatively with the service providers, participant, and guardian (if one is appointed) to resolve any concerns. In the event that issues cannot be resolved, the provider or the ISSA shall make a referral to the Operating Agency for technical assistance.