Medicaid Certification/Enrollment/Recertification

Section 2090 Section 2090.30  Medicaid Certification/Enrollment/Recertification a)         Providers may be certified and recertified by the Department as set forth  herein and may enroll for participation in the Illinois Medical Assistance Program as provided in 89 Ill. Adm. Code 148.340(d).  Application for Medicaid certification and enrollment for alcoholism and other drug abuse treatment service providers may be made by providers who are: 1)         Currently licensed by the Department under the provisions of 77 Ill. Adm. Code 2060 for alcoholism and other drug abuse treatment services described in 77 Ill. Adm. Code 2060. 2)         Currently licensed by the Illinois Department of Public Health as  a hospital pursuant to 77 Ill. Adm. Code 250 for the treatment services described in 77 Ill. Adm. Code 250. b)         Medicaid Certification 1)         Applications for certification may be obtained in person or by writing to: Illinois Department of Human Services 100 W. Randolph, Suite 5-600 Chicago, Illinois  60601 Attention:  Division of Licensing and Certification 2)         Applicants for new certification will be accepted from programs or parent organizations of such programs which have been licensed as specified in this Section for at least two years. Applicants shall demonstrate two years of experience in providing quality substance abuse services of the kind for which certification is being requested and for the type of population which will be served. 3)         Applicants shall submit documentation of the following: A)        evidence of the need within the community for the type of services to be provided by the program for which certification is sought; B)        description of the organization that will be operating the program; C)        fiscal solvency of the organization; D)        description of the physical facilities to be utilized by the program; E)        description of the program and the clientele it serves; F)         projection of the total number of Medicaid clients to be served each month, the average length of stay anticipated, and the estimated average per person cost of treatment; G)        schedule of the specific dates, times and places services will be provided; H)        number and type of people served during the previous two years in the program for which certification is sought and a description of the people served (demographics, gender, drug of choice, Medicaid eligibility, income level, etc.); I)         name, address and professional qualifications of the program's Medical Director; J)         name and qualifications of each individual who will be staffing the program and a description of that individual's responsibilities with respect to the program; K)        copies of written referral agreements with other social service systems and primary medical care  service systems within the applicant's area; L)        copies of linkage agreements with other substance abuse treatment programs within the applicant's area implemented to assure availability of all levels of care as required in 77 Ill. Adm. Code 2060; M)       documentation of the program's quality assurance system and utilization review policy as applied to the program's clinical standards which have been used for the previous two years, with a copy of the two most recent utilization review reports; and N)        measurable outcome evaluation process used for the past two years and statistics on the program's client outcomes. 4)         Applicants shall submit evidence that they are in compliance with all applicable Department audit requirements as specified in 89 Ill. Adm. Code 507. 5)         Applications which are missing significant components or which have inadequate information shall be returned to the applicant with a statement specifying the missing or inadequate information. Completed applications may be resubmitted.  Applications which are missing less significant components may be held by the Department and the applicant notified in writing of the missing information.  The applicant may submit only the missing components.  The Department shall hold such incomplete applications no more than 30 calendar days. 6)         Certification is site-specific and services are to be provided on-site, unless they are provided in accordance with the off-site service provisions as set forth in 77 Ill. Adm. Code 2060.203. 7)         Sites providing 24 hours of services to clients and having more than 16 beds shall not be certified for Medicaid enrollment for other than adolescent residential rehabilitation services. 8)         In order to receive certification for a site having 16 beds or less, a program must meet the following criteria: A)        be a free-standing program of 16 or fewer beds; or B)        be within a larger facility, as a distinct unit of 16 beds or less, which: i)          is licensed; ii)         is physically separate from other certified and licensed programs (for example, separated by floors, wings, or other building sections); iii)        provides a level of care significantly different in clinical content from other certified and licensed programs (for example, adult versus adolescent care, women versus men, hearing impaired versus non-impaired); iv)        has a separate cost center (budgeting, accounting, etc.); v)         has separate staffing; and vi)        has separate operating policies and procedures. 9)         Prior to certification, the Department shall conduct an on-site inspection. 10)         Based upon the on-site inspection and a review of the application for certification, the Department will certify the program if the Department determines that: A)        the applicant has proven that an unmet need for the services exists in the community the program will serve; B)        the organization operating the program is fiscally sound and responsible; C)        the program management is experienced in business and in the delivery of substance abuse services; D)        the program has sufficient written agreements with social, medical and other substance abuse service providers within its area to assure proper linkage of services to an individual; E)        the program has experience with the Medicaid eligible population it intends to serve; F)         the program has adequate physical facilities and adequate numbers of professional staff to provide the services; G)        the program conducts utilization review and has a quality improvement plan; and H)        the program has a measurable outcome evaluation process in place that provides measurable indicators of improvement by program participants. 11)         The Department shall notify the applicant in writing of its determination regarding certification. A)        Approval of Certification/Medicaid Enrollment If the Department certifies the program, it shall include the IDPA Medicaid enrollment forms with the letter of certification.  The applicant shall submit the completed enrollment forms along with a copy of the letter of certification to IDPA.  However, providers who have applied for hospital licensure for the first time and hold a provisional hospital license for treatment services are not eligible to apply for Medicaid enrollment for those treatment services. B)        Denial of Certification If the Department is not able to certify the program based on the criteria outlined in this Section, the Department shall notify the applicant in writing, describing those deficiencies that will result in a denial of the certification.  The applicant has 60 days after receipt of the notice to correct the deficiencies and supply the new information to the Department.  If the new information indicates that the program meets the criteria of this Part, the Department shall certify the applicant.  If the program continues to fail to meet the requirements of this Part, the Department shall deny the application for certification.  If certification is denied, the applicant may appeal the Department's decision and request a hearing pursuant to 89 Ill. Adm. Code 104: Subpart C (Medical Vendor Hearings). 12)         Certification shall be effective on the date of approval by the Department and shall remain in effect until the expiration of the provider's license as required in this Section or for three years for any provider not licensed by the Department.   Certification is also subject to any sanctions levied under Section 2090.100 of this Part.  After the effective date of certification, the provider may deliver services to Medicaid recipients that will be reimbursable after the applicant completes the IDPA Medicaid enrollment procedure. 13)         When and if a certified provider is no longer licensed as set forth in this Section (whether voluntarily or involuntarily) the certification shall be null and void.  Upon proof by the Department's licensing division that the license is no longer in effect, the Department shall notify the provider by certified mail that certification is null and void. 14)         Recertification A)        To be eligible for recertification, providers shall be in compliance with all Sections of 77 Ill. Adm. Code 2060 referenced in this Part. B)        To be eligible for recertification, providers who receive funding from the Department shall be in compliance with all applicable Department audit requirements specified in 89 Ill. Adm. Code 507. C)        Providers shall apply for recertification at least 90 days prior to the expiration of the provider license. D)        Providers shall submit a recertification application provided by the Department.  In addition, the provider shall submit copies of all utilization review (UR) reports and results of the program's measured outcome evaluations since the date of last inspection. E)        The Department shall review all documents and the results of the last licensure inspection and shall recertify the program if it complies with the requirements of the Alcoholism and Other Drug Abuse and Dependency Act and this Part. 15)         Denial of Recertification If the Department is not able to recertify the program based on its review and inspection, the Department shall notify the applicant in writing, describing those deficiencies that will result in a denial of the recertification.  The applicant has 30 days after receipt of the notice to correct the deficiencies and supply the new information to the Department.  If the new information indicates that the program meets the criteria of this Part, the Department shall recertify the program.  If the program continues to fail to meet the requirements of this Part, the Department shall deny the application for recertification and shall notify the applicant in writing, giving the reasons for the denial.  The provider may appeal the Department's decision and request a hearing pursuant to 89 Ill. Adm. Code 104: Subpart C (Medical Vendor Hearings).  Certification shall remain in effect pending the final decision on recertification unless the provider is sanctioned pursuant to Section 2090.100 of this Part.  When the denial of recertification is final, the provider shall arrange for transfer of all Medicaid clients of the program as appropriate.