Ill. Admin. Code tit. 89, § 140.646 - Reimbursement for Developmental Training (DT) Services for Individuals with Developmental Disabilities Who Reside in Long Term Care (ICF and SNF) and Residential (ICF/MR) Facilities

a) Residential providers are responsible for ensuring the provision of a continuous program of active treatment services for each resident (42 CFR 483.410(d) and 42 CFR 483.440). The Department (DPA) will reimburse SNF, ICF and ICF/MR facilities (including ICF/MR-15 Specialized Living Centers (SLC), and ICF/MR-SNF/PED) through a separate component of the per diem for DT services provided to residents who have developmental disabilities. Such individuals would be identified as needing DT by the facility's interdisciplinary team. The facilities may contract for these services from community providers whose programs are certified by the Department of Mental Health and Developmental Disabilities (DMHDD) or may provide their own (DT) if the DT Program is certified by the (DMHDD) and conducted by staff of the DT program. The DT program is defined as the distinct part of a long term care or residential facility, and/or independent business entity certified by DMHDD to provide DT services.

b) Billing by the facility and payment by the Department for each month of active treatment services provided by the facility includes DT services.

c) Timely Billing Flow-Through for DT Services

1) Claims for reimbursement for DT services must be received by the Department no later than the close of business on the 16^th day of the month following the previous month of DT services. If the 16^th day of the month falls on a weekend, billing must be received by the Department no later than the close of business of the Friday before that weekend.

2) If the billing for DT services is not received by the Department as specified in subsection (c)(1) above, a hold will be placed on the processing of the facility's claims for reimbursement and subsequent payment for services. The hold on processing of facility billing and payment for services will be lifted once the DT billing has been received.

3) The turnaround of DT attendance records from the DT provider to the facility must also be timely. These records are utilized by the facility to complete billing forms for DT services. DT attendance records should be received by the facility by the 7^th day of the month following the previous month of DT services. The facility must notify the Department five (5) working days before the 16^th day of the month if the attendance records regarding DT services have not been returned to the facility. When DT billing is late due to a delay by the DT agency in submitting attendance records, no hold will be placed on facility billings or payments.

d) Timely Payment Flow-Through for DT Services

1) The facility must flow-through payments to the DT agency for DT services no later than ten (10) working days after facility receipt of the payment from the Department, unless the facility itself operates the DT program. The expected time frame for the DT agency to receive its flow-through payment is twenty (20) calendar days (5 days in the mail from the Department to the facility, no more than 10 days to issue payment, and 5 days in the mail from the facility to the DT agency). Facilities may incur penalties under Sections 140.16 and 140.17 for violations of this requirement.

2) When the Department is notified that reimbursement for DT services has not been received by the DT agency within the specified time frame, Department staff will contact the residential provider and request a copy of the cancelled check which was issued for DT services. If the facility is unable to demonstrate to the Department that the DT payment has been received by the DT agency, the Department will take the actions provided in subsection (d)(3) below.

3) If the DT payment has not been received by the DT agency within twenty (20) calendar days following Department release of the payment to the facility, a hold will be placed on the processing of facility billing and payment for facility services. The hold on facility billing and payment will be lifted when the DT agency has received the outstanding payment for services.

e) Change of Ownership/Operator

1) Billing and payment for DT services must be processed and either paid in full or incurred as a debt whenever there is a change in ownership or licensed operator of a Medicaid funded residential facility. The transaction to change a licensed operator or transfer ownership must include a recognition of all debts of unprocessed and/or unpaid billings.

2) The Department will not enter into a provider agreement with a residential provider unless:

A) payment is made in full for all DT services by the previous owner/operator; or

B) the amount is incurred as a debt to be paid in full by the new owner/operator within forty-five (45) calendar days after becoming the new owner/operator when the Department has paid the facility in full prior to the change in ownership or licensed operator for all DT services provided under the previous owner; or

C) the amount is incurred as a debt to be paid in full by the new owner/operator within ten (10) working days after facility receipt of the payment from the Department, when such payment reaches the facility on or after the effective date of the change in ownership or licensed operator.

3) If the new owner/operator does not pay the full amount due the DT agency by the end of the forty-five (45) day period as specified in subsection (e)(2)(B) above, or by the end of the ten (10) day period as specified in subsection (e)(2)(C) above, a hold on the reimbursements will be implemented. The hold on facility billings and payment will be lifted after the DT agency has been paid in full for the indebted amount.

f) Providers of DT program services will be responsible for providing any required transportation between the program and the facility. Reimbursement for transportation costs is included in the DT program monthly rate as established in Section 140.648. The DT Program contracting with a long term care or residential facility may not elect to discontinue the provision of transportation.

g) The term Mentally Retarded and related conditions, as used in rules contained in Sections 140.646 - 140.652 refers to individuals meeting the definition of Mental Retardation or related conditions as described in 42 CFR 435.1009(1989).

h) The term "facility" which is used in rules contained in Sections 140.646 - 140.652 is understood to refer to long term care facilities (ICF and SNF) and residential facilities (ICF/MR, including ICF/MR-15 and SLC, and ICF/MR-SNF/PED).

i) Persons with developmental disabilities who are residents of facilities, and whose public school special education services have been terminated, are deemed eligible for DT services.

j) DT programs shall be subject to review as part of the Department's evaluation of recipient care under its utilization and medical reviews of long term care and residential facilities (Section 140.512).

k) Payment may be approved for DT services, during a DT participant's hospitalization, for a period not to exceed 10 days. Such payments:

1) are limited to individuals who will be returning to the same facility,

2) are a daily rate at 75% of the individual's current DT per diem rate.

Notes

Ill. Admin. Code tit. 89, § 140.646

Amended at 16 Ill. Reg. 1877, effective January 24, 1992