CMH-HCBS Provider Requirements

TITLE 89: SOCIAL SERVICES CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES SUBCHAPTER d: MEDICAL PROGRAMS PART 141 SOCIAL SERVICE FOR NON-WAIVER HOME AND COMMUNITY BASED SERVICES SECTION 141.240 CMH-HCBS PROVIDER REQUIREMENTS Section 141.240  CMH-HCBS Provider Requirements a)         Care Coordination and Support Organizations (CCSO).  Providers approved to provide CCS services shall be referred to as CCSOs.  CCSOs must: 1)         Obtain and maintain CCS program approval pursuant to Section 141.240(b). 2)         Provide cost reporting information upon request to the Department in a manner and format specified by the Department. 3)         Not provide other non-waiver HCBS services defined in this Part, unless the Department has determined the provider is the sole provider willing and qualified to provide such services within the provider's Service Area and that the provider has established sufficient separations and independence between its direct service delivery and CCS services to ensure that conflict of interest standards are met. 4)         Maintain, or establish prior to the delivery of any CCS services, Medicaid Rehabilitation Option (MRO) Crisis Services Program Approval pursuant to 89 Ill. Adm. Code 140.Table N.(c)(4). 5)         Provide the Department with a minimum of 90 days written notice in the instance that the provider is unable or unwilling to continue providing services. b)         Program Approvals 1)         Care Coordination and Support (CCS) Program Approval A)        Program Approval Process i)          Providers seeking program approval as a CCSO shall complete and submit the Department's CCSO Provider Application. The Department will accept and review CCSO Provider Applications during established application timeframes, according to a standardized schedule maintained and published on the Department's website at pathways.illinois.gov. ii)         Applicants determined to be approved as a CCSO must pass a Readiness Review, to be conducted by the Department or its designee, prior to delivering CCS services. The Readiness Review shall examine a provider's readiness to deliver CCS services, including a review of policies, procedures, training materials, staffing levels, and other documents necessary to verify a provider's readiness to begin accepting referrals for CCS services. The Department may, at its sole discretion, elect to perform any or all components of the Readiness Review on-site. iii)        Approved CCSOs shall be subject to ongoing quality and fidelity monitoring activities and reviews. iv)        Deficiencies identified as part of the Readiness Review process or as part of the Department's quality or fidelity monitoring reviews shall be communicated in writing to the provider. Providers shall be given no less than 30 days to correct or ameliorate deficiencies identified by the Department or its designee. B)        Service Delivery. The provider must attest annually to meeting the standards detailed in this subsection. The provider shall demonstrate compliance with the following requirements through policy, procedures, staffing detail, aggregated service detail, and/or client record documentation: i)          CCS services are to be available 24 hours a day, each day of the year, and shall minimally adhere to the Department's crisis response protocols and timeframes when delivering crisis response services. ii)         The provider must have sufficient office space to deliver CCS services consistent with the requirements outlined in this Part. iii)        CCS services are to be delivered to all referred individuals within the Service Area on a no-decline basis. iv)        The provider must coordinate service delivery with the participant's primary care provider, behavioral health care providers, other community and supportive services providers, and/or managed care entity, as appropriate. v)         CCS services are to be delivered consistent with the values, principles, and processes of Wrapround and in accordance with the fidelity standards published on the Department's website at pathways.illinois.gov. vi)        CCS services are to be provided during times and at locations that reasonably accommodate the participant and family's service and treatment needs. C)        Staffing Requirements i)          CCSOs shall ensure that CCS services are delivered by staff who are not: •           Related by blood or marriage to the participant, or any paid caregiver of the participant; •           Financially responsible for the participant; or •           Empowered to make financial or health-related decisions on behalf of the participant. ii)         Staff delivering CCS services shall meet the credentials detailed in Section 141.220(a). iii)        Supervisors of Care Coordinators must: •           Maintain an average ratio of one supervisor to no more than eight (1:8) staff members, with no more than 10 staff members assigned to one supervisor at a time; •           Minimally meet the qualifications of a QMHP; and •           Complete the Department's required training and certification processes as outlined at pathways.illinois.gov. iv)        CCSOs shall employ at least one full time Clinical Manager who meets the qualifications of an LPHA and who is responsible for overseeing CCS services. 2)         Intensive Home-Based (IHB) Services Program Approval A)        Providers seeking program approval to provide IHB services shall be approved pursuant to the program approval process outlined in 89 Ill. Adm. Code 140.Table N(b), except that program approval and subsequent re-approval reviews shall be conducted every two years and shall be conducted to determine compliance with Section 141.220(e) and the IHB requirements outlined in this subsection. B)        Service Delivery.  The provider must attest annually to IHB services meeting the standards detailed in this subsection. Additionally, the provider shall demonstrate compliance with the following requirements through policy, procedures, staffing detail, aggregated service detail and/or client record documentation. i)          Providers of IHB services must deliver services in the participant's natural setting, based upon the preferences of the participant and family, with an emphasis on services occurring in the home setting to the extent possible. ii)         Providers of IHB services must provide IHB services during times that are convenient to the participant and family and that accommodate the participant's service and treatment needs, including evenings and weekends as needed. iii)        For participants receiving CCS services, the IHB provider shall collaborate with the participant's CCSO, including maintaining monthly contact with the participant's designated Care Coordinator and participating in the participant's CFT meetings, as appropriate. iv)        In the instance a participant receiving IHB experiences a crisis event, the IHB provider shall make efforts to be available for consultation to the participant, family, and the responding crisis worker as applicable. v)         Providers of IHB services must ensure that multiple contacts are made with the participant and family per week, with as many contacts as possible occurring face-to-face, based upon the participant and family's needs and preferences. 3)         Providers delivering IHB services must maintain an IHB team lead meeting the qualifications of an LPHA. 4)         Provider-Based Utilization Management. The provider shall establish an IHB service review process that adheres to the following: A)        The team delivering IHB services shall meet weekly to review the treatment progress of participants receiving IHB services. B)        The IHB team lead shall review the participant's IATP and IHB clinical intervention plan monthly to ensure ongoing necessity for service delivery. The IHB team lead shall: i)          Review each participant's progress in service; and ii)         Identify any necessary changes in IHB services, including a recommendation for transition to less intensive services, consistent with the participant's IATP. Recommendations for changes in the frequency, duration, or scope of IHB services shall be shared with the participant's designated care coordinator and CFT, when applicable.