High Medical/High Personal Care Needs of Individuals with Developmental Disabilities

TITLE 89: SOCIAL SERVICES CHAPTER IV: DEPARTMENT OF HUMAN SERVICES SUBCHAPTER d: MEDICAL PROGRAMS PART 144 DEVELOPMENTAL DISABILITIES SERVICES SECTION 144.102 HIGH MEDICAL/HIGH PERSONAL CARE NEEDS OF INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES Section 144.102  High Medical/High Personal Care Needs of Individuals with Developmental Disabilities a)         For services provided on or after July 1, 2010, daily rates for qualifying ICFs/MR shall have their own reimbursement rates adjusted pursuant to this Section. b)         Qualifying Criteria In order to receive rate adjustments under this Section, facilities must meet the following criteria: 1)         Be a licensed ICF/MR, as defined in 77 Ill. Adm. Code 350, with more than 16 licensed beds and is not: A)        An SNF/PED, as defined in 77 Ill. Adm. Code 390; or B)        A campus facility, as defined under 89 Ill. Adm. Code 140.583. 2)         For the immediately preceding month, as documented in the remittance advice report, have: A)        An occupancy level of at least 93 percent of licensed ICFDD bed capacity; and B)        At least 93 percent of the ICFDD residents eligible for, and enrolled in, medical assistance under 89 Ill. Adm. Code 120. 3)         Based on the most recently conducted annual inspection of care survey, at least 50 percent of the residents of the facility must qualify as Medical Level III. c)         Adjustment Methodology The program and support components of the per diem rate for qualifying facilities shall be replaced with the adjusted program and support components, determined as follows: 1)         Adjustment Factor The adjustment factor for a facility shall be the product of the difference between the Medical Level III percentage and 50 percent and: A)        For facilities with a Medical Level III percentage less than 80 percent − 3.9; or B)        For all other facilities – 5.0. 2)         Adjusted Program Component The adjusted program component shall equal the product of the following: A)        The program component of the per diem rate, as determined under Section 144.275; and B)        The sum of 1.000 plus the adjustment factor for the facility, as determined in subsection (c)(1). 3)         Adjusted Support Component The adjusted support component shall equal the SNF/PED ceiling for the geographic area in which the facility is located. 4)         Subsequent Adjustments A)        Adjusted program and support components shall be redetermined when: i)          Changes to the program or support rate components are required in accordance with 89 Ill. Adm. Code 153; and ii)         The percentage of the residents who are classified as Medical Level III changes as a result of the facility's annual inspection of care survey.  The adjusted program component shall be recalculated and effective the first day of the month following the Medical Level III determinations. B)        All high medical/high personal care rates for residents classified as Medical Level III will be reviewed and updated for changes in the facility population at least once annually upon issuance of respective facility Inspection of Care surveys.