89 Ill. Adm. Code 144.275
Reimbursement for Program (Active Treatment) Costs in Residential Facilities for Clients with Developmental Disabilities
Section 144
Section 144.275
Reimbursement for Program (Active Treatment) Costs in Residential Facilities
for Clients with Developmental Disabilities
Residential facilities,
including distinct parts of facilities, for clients with developmental
disabilities (ICF/MR certification with licensure for ICF/DD, ICF/DD-16, SLC,
and ICF/MR-SNF/PED license), excluding State-operated facilities for
individuals with developmental disabilities, will be reimbursed for an active
treatment program for each client. Facility program reimbursement levels will
be derived by the Department from the following four determinants which in
combination will result in a total facility program per diem amount. These
four determinants will be determined according to information provided in the
most recent Inspection of Care (IOC) conducted by Department of Public Health
survey staff. This IOC information must be validated by the survey staff prior
to utilization for payment purposes. The new reimbursement level will be
effective on the first day of the quarter following a facility's IOC. Where
dollar, wage, or salary amounts are used, these shall be inflated to the fiscal
year for which reimbursement will be made.
a) Minimum Staffing
1) Direct Services – Facilities must be in compliance with the
Health Care Financing Administration's (HCFA) (42 CFR 483.430 (1996)) minimum
average daily staffing standards relative to client population according to
each individual's overall level of functioning:
Overall Level of Functioning
FTE* Staff:Client Ratio
Mild
1:5
Moderate
1:2.5
Severe or
Profound
1:2
*FTE = Full Time Equivalent
A) Determination of levels of functioning of clients with mental
retardation and related conditions, in accordance with the definition of the
American Association of Mental Retardation (Mental Retardation refers to
significantly subaverage general intellectual functioning existing concurrently
with deficits in adaptive behavior and manifested during the developmental
period), will include both:
i) an assessment of intellectual functioning as measured by a
standardized, full scale, individual intelligence test such as the Stanford
Binet and WAIS-R. Such an assessment must be administered by a psychologist
who is registered in Illinois under the Clinical Psychologist Licensing Act
(Illinois Department of Professional Regulation); and
ii) an assessment of adaptive behaviors using a nationally
standardized, Department approved assessment instrument, such as the Scales of
Independent Behavior (SIB) or the Inventory For Client and Agency Planning
(ICAP). Such an assessment instrument will be utilized by at least one
Qualified Mental Retardation Professional (QMRP) to evaluate each client's
functional skills and adaptive behaviors.
B) The final determination of each client's overall level of
functioning employs both the assessment of intellectual functioning and the
assessment of adaptive behaviors, and will be made according to the criteria
set forth in Section 144.Table D and Section 144.Table E of this Part.
C) The amount for Direct Services for these staffing ratios shall
be obtained by:
i) determining the number of clients within each overall level
of functioning; dividing each number by the client component of the staff:
client ratio; summing these quotients; multiplying the sum by the aide hourly
wage factor, and then by 2080 (52 weeks times 40 hours per week), to obtain a
total annual Direct Service cost; and dividing this total by 365 days and then
by the number of clients to obtain the amount for Direct Services per client
per day. For example, if a facility serves 40 clients in the mild level of
functioning, 30 clients in the moderate level of functioning, and 30 clients in
the severe/profound level of functioning, the number of FTE Direct Services
staff will be (40 divided by 5) + (30 divided by 2.5) + (30 divided by 2) = 35.
If the aide hourly wage is $5.00, the total annual cost will be 35 x $5 x 2080
= $364,000. The amount for FTE Direct Services per client per day will then be
$364,000 divided by 365 divided by 100 = $9.97.
ii) In ICF/DD-16 facilities, the foregoing calculation is
modified such that in step two of subsection (a)(1)(C)(i) of this Section, the
facility may receive an amount for up to an additional .5 FTE. Direct Service
is determined by multiplying .5 FTE by the proportion found by the ratio of the
number of Medicaid eligible clients in the severe/profound level of functioning
divided by the total number of eligible clients.
2) Licensed Nurses – Facilities must be in compliance with HCFA
(42 CFR 483.460 (1996)) and Illinois Department of Public Health (IDPH) (77
Ill. Adm. Code 350.1230) staffing standards relative to facility type.
A) An ICF/MR (ICF/DD, SLC, SNF/PED but excluding ICF/DD-16)
licensed for a population of 90 or fewer clients, none of whom require services
under Levels II and III of Specialized Care-Health and Sensory Disabilities
(Section 144.150(c) and (d)), will be reimbursed for a minimum of 4.8 FTE
nurses. A facility with only such a population which has a licensed capacity
greater than 90 clients will be reimbursed for additional FTE nurses according
to the following Table:
Licensed Capacity, Client Type
FTE Nurse:Client Ratio
Greater than 90 clients with
no Specialized Care – Health and Sensory Disabilities needs under Level II
and III
1:18.7
B) An ICF/MR (ICF/DD, SLC, SNF/PED but excluding ICF/DD-16)
licensed for a population of 30 or fewer clients, all of whom require services
under Level(s) II and/or III of Specialized Care – Health and Sensory
Disabilities will be reimbursed for a minimum of 4.8 FTE nurses. A facility
with only such a population which has a licensed capacity greater than 30
clients will be reimbursed for additional FTE nurses according to the following
Table:
Licensed Capacity, Client Type
FTE Nurse:Client Ratio
Greater than 30 clients
requiring Specialized Care – Health and Sensory Disabilities under Level(s)
II and III
1:6.25
AGENCY NOTE: The Omnibus Reconciliation Act of 1987 (P.L.
100-203) requirements prohibit the admission of individuals with a primary diagnosis
of mental retardation into non-ICF/MR facilities. Therefore, SNF/PED facilities
which meet ICF/MR certification requirements must be certified ICF/MR in order
to comply with federal law when admitting individuals with mental retardation.
Facilities which undergo certification conversion to ICF/MR will retain State
licensure for skilled care (SNF/PED).
C) An ICF/MR (ICF/DD, SLC, SNF/PED but excluding ICF/DD-16) which
has a licensed capacity of 30 clients or more, some of whom require services
under Level(s) II and/or III of Specialized Care – Health and Sensory
Disabilities, and some of whom do not require such services, will be reimbursed
for a minimum of 4.8 FTE nurses for non Specialized Care individuals plus
additional FTE nurses, up to a maximum of a 1:6.25 ratio, according to the
following Table:
Client Type
FTE Nurse:Client Ratio
Client requiring Specialized
Care – Health and Sensory Disabilities under Level(s) II and/or III
1:6.25
For example, for a facility with a licensed capacity of 42
clients, 15 of whom require services under Level(s) II and/or III, and 27 of
whom do not require such services, the number of FTE nurses will be (15 divided
by 6.25 = 2.40) + (27 divided by 18.75 = 1.44, however, reimbursement will be
calculated at the minimum of 4.8) = 7.2. Utilizing the maximum client ratio
allowed, the facility will be reimbursed for 6.72 FTE nurses (42 divided by
6.25 = 6.72).
D) Licensed nurses are not required in an ICF/DD-16 if none of the
clients require a physician's medical care plan of treatment.
i) An ICF/DD-16 which has eight or fewer clients with medical
care plans of treatment but who do not require services under Specialized Care –
Health and Sensory Disabilities, Level(s) II and/or III, will be reimbursed for
.5 FTE nurse. A facility with nine or more such clients will be reimbursed for
one FTE nurse.
ii) An ICF/DD-16 with clients requiring medical care plans of
treatment and additional medical services under Specialized Care – Health and
Sensory Disabilities, Level(s) II and/or III, will be reimbursed according to
the method in subsection (a)(2)(D)(i) of this Section, plus additional
reimbursement for licensed nurses using an FTE nurse: client ratio of 1:6.25 up
to a maximum of the 1:6.25 ratio.
E) The licensed nurse component is computed similarly to the
method in subsection (a)(1)(C) of this Section. To determine the amount for
Licensed Nurses, the number of FTE nurses required for each facility type and/or
for clients receiving services under Specialized Care – Health and Sensory
Disabilities, Level(s) II and/or III, shall be obtained according to
subsections (a)(2)(A), (B), (C) and (D) of this Section. This number is
multiplied by the hourly nurse wage factor and then by 2080 (52 weeks x 40
hours). The product is divided by 365 and then by the number of clients.
3) The total reimbursement amount for Minimum Staffing is the sum
of the amount for Direct Staff plus the amount for Licensed Nurses.
b) Active Treatment
1) Qualified Mental Retardation Professional (QMRP) – a person
who has at least one year of experience working directly with persons with
mental retardation or other developmental disabilities, and is one of the
following:
A) A doctor of medicine or osteopathy.
B) A registered nurse.
C) An individual who holds at least a bachelor's degree in one of
the following professional categories: Occupational Therapist; Physical
Therapist; Psychologist. Master's Degree: Social Worker; Recreation Specialist;
Registered Dietitian; and Human Services, including but not limited to
Sociology, Special Education, Rehabilitation Counseling, and Psychology. (42
CFR 483.430 (1996))
D) The amount for QMRPs assumes that a full-time QMRP is required
for every 15 clients. The number of QMRPs shall be obtained by dividing the
number of clients in the facility by 15. The obtained number of QMRPs is
multiplied by the hourly wage factor and then by 2080. The product is divided
by 365 and then by the number of clients to arrive at an amount per client per
day.
2) Interdisciplinary Team (IDT)
A) The amount for services rendered by the IDT assumes that each
client requires one day of IDT services per year. This amount is computed to be
$1.82 per client per day.
B) Interdisciplinary Team – A team which represents the professions,
disciplines, or service areas that are relevant to identifying the client's
needs and designing programs that meet the client's needs. Appropriate facility
staff must participate in interdisciplinary team meetings. Participation by
other agencies serving the client is required (see the Department of Public
Aid's rule at 89 Ill. Adm. Code 140.647). Participation by the client, his or
her parent (if the client is a minor), or the client's legal guardian is
required unless the participation is unobtainable or inappropriate. (42 CFR
483.440 (1996))
3) Additional Direct Service Staff (ADSS)
A) The amount for ADSS assumes an FTE staff:client ratio of
1:7.5. The total number of clients is divided by 7.5 and a per diem amount is
obtained according to the method described in subsection (a)(1)(B) of this
Section. In SLC facilities, the foregoing calculation is modified so that the
overall level of functioning is distributed proportionately across each living
unit (16-18 clients) in step one of the calculation. If dividing the number of
clients results in a fraction, it is rounded up to the next whole number in
proportion to the number of clients in the severe/profound level of
functioning. The total FTE is obtained by summing the calculation results from
each living unit.
B) Additional Direct Services Staff – Staff which is in addition
to HCFA's minimum average daily staffing standards (subsection (a)(1) of this
Section), and for which the Department will provide reimbursement to ensure the
delivery of active treatment. Examples of ADSS include, but are not limited to,
staff who provide activity services, dietetic aides, and music therapists.
4) The total reimbursement amount for Active Treatment is the sum
of the amounts for QMRP, IDT and ADSS.
c) Specialized Care
An additional amount shall be paid for clients meeting the
requirements for services under Specialized Care. Detailed descriptions of
services under Specialized Care are found in Section 144.125 Specialized Care –
Behavior Development Programs, and Section 144.150, Specialized Care – Health
and Sensory Disabilities. The service Level for each client meeting the
criteria of more than one Level under Specialized Care shall be determined
according to his/her disability or functional deficit which represents the most
intense need for services under Specialized Care, and results in the greatest
reimbursement.
1) Specialized Care – Behavior Development Programs
Behavior development programs are related to maladaptive
behaviors which occur with high frequency and/or great severity, and are
instituted for the reduction of maladaptive behaviors and/or the increase of
adaptive behaviors. The behavior development program shall demonstrate the need
for and use of a more intensive staffing pattern (direct care staff) than the
regular pattern which is reimbursed for under subsection (a)(1) of this
Section. The service Level for a client who meets the requirements for services
under Specialized Care - Behavior Development Programs will be identified and
validated during the most recent IOC.
A) Level I – .5 hours FTE Direct Service per day. More intense
program services are provided for behaviors which occur with high frequency but
moderate severity, such as verbal abuse one or more times per four hours which
is hostile in tone and content.
B) Level II – 1.0 hours FTE Direct Service per day. More intense
program services are provided for behaviors which occur with high frequency and
are aggressive or destructive, such as purposeful attacks of others which may
result in minimal injuries, one or more times per day.
C) Level III – 2.0 hours FTE Direct Service per day. More intense
program services are provided for behaviors which occur with very high
frequency such as hyperactivity one or more times per minute, or occur with
high frequency and are seriously aggressive, assaultive or destructive and
which may result in serious injury.
2) Specialized Care – Health and Sensory Disabilities
Specialized services for health and sensory disabilities
refer to care which some clients must receive in order to attain physical
health and development.
A) Definitions
i) Ambulatory – The client is capable of walking without
assistance or the aid of adaptive equipment or devices.
ii) Mobile Nonambulatory – The client is capable of locomotion
with mobility assistance such as adaptive equipment or devices.
iii) Nonmobile – The client is not capable of locomotion even with
mobility assistance.
B) Level I – .5 hours FTE Direct Service per day. The client is ambulatory,
mobile nonambulatory, or has the potential to become mobile nonambulatory, and
requires services to compensate for a sensory deficit (auditory or visual), or
services enabling him or her to be mobile (physical disabilities).
i) Sensory deficits – visual. The client's vision is 20/200 or
less in the better eye with the greatest possible correction (Section 2 of the
Blind Persons Operating Vending Machines Act [20 ILCS 2420/2]).
ii) Sensory deficits – auditory. The client has a hearing impairment
of at least 55 decibels in the better ear, unaided.
iii) Physical disabilities means physical impairments which result
in functional deficits requiring the client to receive training in the use of a
device or devices, to achieve some level of independent mobility.
C) Level II – 1.0 hours FTE Direct Service per day. The client is
nonmobile or mobile nonambulatory, requires mobility assistance, and requires
services to meet high personal care needs. The client may also have
significant daily medical needs and/or dual sensory deficits (visual and
auditory).
i) Mobility assistance means assistance in transferring from a
bed to an alternative position device, and assistance with movement/mobility
around the facility.
ii) High personal care means one or more of the following:
assistance with bathing, clothing, grooming and hygiene, eating and continence;
position changes at two hour intervals, or as specified in the individual
program plan; range of motion twice a day, or as specified in the individual
program plan.
iii) Daily medical need means daily insulin injections, drug
(insulin) monitoring, and/or ostomy care for a jejunostomy, ileostomy or
colostomy.
iv) Dual sensory deficits means both an auditory disability and a
visual disability.
AGENCY NOTE: A client who meets the criteria for Level II
services is eligible for the FTE nurse:client ratio according to subsections
(a)(2)(B), (C) and (D) of this Section.
D) Level III – 2.0 hours FTE Direct Service per day. The client is
typically nonmobile or mobile nonambulatory, but may be ambulatory, and
requires services to meet high medical needs. High medical needs mean one or
more of the following:
i) daily intermittent catheterization;
ii) care for wounds including stage III and IV decubitus ulcers,
deep wounds, infected wounds, extensive burns, or extensive lesions requiring
treatment in the form of medications, dressings, whirlpool, ultraviolet light
and/or irrigations;
iii) respiratory care including tracheotomy care, positive
pressure breathing treatments, aerosol therapy, postural drainage and
percussion, vibration and/or suctioning;
iv) feeding via nasogastric tube, or prolonged oral feeding; and
v) intensive physical habilitation due to a functional deficit as
determined by physical or psychological causes.
AGENCY NOTE: A client who meets the criteria for Level III
services is eligible for the FTE nurse:client ratio according to subsections
(a)(2)(B), (C) and (D) of this Section.
3) The total reimbursement amount for Specialized Care shall be
the sum of the amounts determined under subsections (c)(1) and (2) of this
Section, pro-rated over the number of eligible clients identified in the most
recent facility reimbursement survey. For example, if the hourly wage is
$5.00, assume a facility with ten residents, two of whom meet the criteria for
Specialized Care – Health and Sensory Disabilities Level II, subsection
(c)(2)(C) of this Section, with no daily medical needs or sensory deficits, and
eight of whom do not meet Specialized Care criteria. The facility will receive
an amount of $.81 per client per day (two hours x 1.14 (FTE adjustment factor)
divided by eight hours/day = .285 staff; then .285 x (2080 hours/year divided
by 365 days/year); then divide by ten clients and multiply by $5.00 to obtain
$0.81).
d) Related Costs
1) An amount per client per day will be paid for other program
costs, including program – related supplies, consultants and other items
necessary for the delivery of active treatment to clients in accordance with
their individual program plans.
2) For each facility type, this amount will be determined as
follows. Add the amounts determined for subsections (a), (b) and (c) of this
Section, but excluding the amount for the IDT (subsection (b)(2) of this
Section), and then multiply this sum by the factor determined by the Department
for the facility's geographic area (see the Department of Public Aid's rule at
89 Ill. Adm. Code 140.Table B). The product plus the amount for the IDT
(subsection (b)(2) of this Section), is then multiplied by a constant for the
facility type, as follows:
Facility Type
Constant
ICF/DD
.10
SNF/PED or ICF/DD
(An ICF/DD
with some clients requiring services under Level(s) II and/or III of
Specialized Care – Health and Sensory Disabilities)
.15
ICF/DD-16 and SLC
.20
3) An ICF/DD with some clients requiring services under Level(s)
II and/or III of Specialized Care – Health and Sensory Disabilities, and some
clients not requiring such services will have the total related cost calculated
according to the weighted sum of the number of clients requiring Level(s) II
and/or III multiplied by .15, plus the number of clients not requiring such
services multiplied by .10. For example, for a facility with a licensed
capacity of 90 clients, 30 of whom require services under Level(s) II and/or
III, and 60 of whom do not require such services, the total related cost will
be calculated according to subsection (d)(2) of this Section for both groups of
clients. (That is, subsections (a), (b) and (c) of this Section are summed,
excluding the amount for the IDT, for clients requiring Level(s) II and/or III
and for clients not requiring Level(s) II and/or III. Each sum is multiplied
by the factor determined by the Department for the facility's geographic area,
and the products are added to the amount for the IDT.) Each outcome is
multiplied by the appropriate constant (the SNF/PED-ICF/DD constant of .15 or
the ICF/DD constant of .10), and then by the number of clients in each group
respectively. The two products are summed and then divided by the total number
of clients.
4) An amount will also be paid for dental services which are in
compliance with HCFA's regulations (42 CFR 483.460(e), (f) and (g) (1996)), for
each client age 21 or more. This amount will be determined by adding the flat
per diem of $.40 to the amount calculated according to subsection (d)(2) of
this Section. This per diem will cover the costs of prophylaxis treatment up
to once every six months, and periodontal services as needed for each eligible
client.
5) An amount will also be paid for base nursing assessments,
development and updating of nursing care plans, health risk information and
planning. Tardive Dyskinesia (TD) screening, coordination and implementation of
medical services, monitoring of medication effectiveness and side effects, and
annual flu immunizations in ICF/DD-16s. A flat per diem of $.57 provides for
12 hours of licensed practical nurse time per person per year and one hour of
registered professional nurse time per person per year.
6) An amount will also be paid for supervision of medication
administration. The amount to be reimbursed is based upon a 1:12 ratio of
registered professional nurse time at $19.44 per hour (including fringe
benefits) to medication administration time. Medication administration time is
based upon the number of medication episodes per day documented by each individual's
Medication Administration Record (MAR) and the following:
A) Five Minute Episode – Simple medication preparation, individual
self-medication training, administration, and documentation, e.g., up to four
medications at one time consisting of oral medications, topical medications,
ear drops, creams, and/or lotions. Medications in this category may be simple
pill administration or may require the pill be crushed and mixed with an edible
binder such as applesauce or pudding. This episode type also includes
monitoring a person for "cheeking" or spitting out medication.
B) Ten Minute Episode – Advanced medication preparation,
individual self-medication training, administration and documentation, e.g.,
glucose monitoring with set insulin injection, blood pressure and/or pulse
checks required prior to medication administration, and/or five or more
medications at one time.
C) Fifteen Minute Episode – Complex medication preparation,
individual self-medication training, administration and documentation, e.g.,
glucose monitoring with sliding scale insulin injections, injectable
medications, rectal anti-convulsant medications, i.e., Diastat with monitoring.
e) Total Program Per Diem – Total program per diem for each
facility will be the sum of the amounts from subsections (a), (b), (c) and (d)
of this Section.