Caring for those with long-term challenges is a vital societal goal. This section contains information and resources for long-term care and services.
The Department of Healthcare and Family Services (HFS) is responsible for the Medicaid Long Term Care (LTC) program for approximately 55,000 eligible residents in 738 nursing facilities. The mission is to ensure that the LTC services for which the department pays are appropriate for and meet the needs of recipients, meet standards of quality, and are in compliance with federal and state regulations.
The department staff is responsible for developing policy in accordance with state and federal regulations, enrolling providers and ensuring that sanctions set by the Department of Public Health are implemented. Staff also work with billing issues to ensure that correct payment to providers is made by a system of ongoing pre- and post-payment review adjustments, as well as entering bed hold data, providing billing assistance and information to providers, resolving billing discrepancies and coordinating billing with the Department of Human Services local offices. The department is also responsible for determining whether nursing facilities meet the federal definition of an “Institution for Mental Diseases” for federal Medicaid claiming purposes.
The department field staff conducts onsite reviews at nursing facilities to validate Minimum Data Set (MDS) coding as it relates to reimbursement.
Long Term Care Direct Billing Project
Healthcare and Family Services (HFS) will be implementing a new billing process, following national billing standards, for all Long Term Care providers beginning October 1, 2016. Impacted providers include Nursing Facilities, Nursing Facilities eligible to be licensed as Specialized Mental Health Rehabilitation Facilities, Intermediate Care Facilities for Individuals with Intellectual and Developmental Disabilities, and Supportive Living Providers.
The billing process will follow the UB04 and 837I Implementation guidelines. Providers or their billing agents will be required to electronically submit monthly claims for dates of service beginning October 1, 2016, using the Health Insurance Portability and Accountability Act (HIPAA)-compliant 837I Institutional Health Care Claim. The monthly claim will be submitted via an X12 file transfer or direct data entry following the UB-04 format. Providers will be able to submit claims for consideration through the HFS Internet Electronic Claim (IEC) system which is accessible through the Medical Electronic Data Interchange (MEDI). HFS currently supports HIPAA version 005010XX223A2 for 837I claims in X12 format. Paper claims will not be accepted.
The billing system currently in place for providers to access and process claims will not change until the new billing process is fully implemented. Claims for dates of service prior to October 1, 2016 will continue to be generated and facilities must continue to meet all requirements of timely submittal through MEDI or EDI vendor. The requirement for providers to submit monthly billings for reimbursement purposes does not impact the reimbursement rates paid to providers. Providers will continue to be reimbursed in accordance with their Medicaid approved reimbursement methodology.
Questions regarding this process can be submitted to HFS.LTC@illinois.gov.
Supportive Living Program (SLP)
The Department of Healthcare and Family Services (HFS) oversees the Supportive Living Program (SLP), which provides a service-enriched housing option to those age 65 and older or individuals with disabilities, ages 22-64 years old. The aim of this program is preserving privacy and autonomy while emphasizing health and wellness for people who would otherwise need nursing home care. Supportive living facilities (SLFs) consist of apartments with kitchenettes and private bathrooms while providing services such as intermittent nursing, personal care, medication oversight, meals, housekeeping, laundry, and 24-hour security.
The Supportive Living Program is open to any provider who can meet application criteria (which include site control, zoning approval, marketing study, phase one environmental study, architectural drawings). A site can be certified when program requirements found at 89 Ill. Adm. Code Part 146 are met within 24 months of an approved application. Approval of the application is subject to various factors including, but not limited to, accuracy, completeness, geographic distribution and waiver limits. Department staff work with SLFs both before and after opening to ensure compliance with regulations, and are responsible for the SLP waiver monitoring functions.
Pathways to Community Living: Illinois’ Money Follows the Person (Pathways)
The Pathways to Community Living program in Illinois was developed under the Money Follows the Person (MFP) federal demonstration project. Authorized by the Deficit Reduction Act of 2006, and extended until September 2016 by the Affordable Care Act, MFP supports state long term care rebalancing by assisting eligible individuals to move from long-term care facilities (nursing homes) and Intermediate Care Facilities for Persons with Developmental Disabilities (ICF/DD) to community settings.
In Illinois, the Department of Healthcare and Family Services is the lead agency in this initiative, working in partnership with the Department of Human Services, the Department on Aging, and the Illinois Housing Development Authority. Under the Money Follows the Person federal demonstration grant, Illinois' Pathways to Community Living program provides individuals choices about where they can live, as well as assistance with community supports and services. Pathways is available to individuals currently residing in long-term care facilities (nursing homes) and Intermediate Care Facilities for Persons with Developmental Disabilities (ICF/DD) who are over age 65, or to individuals with physical disabilities, or developmental disabilities, or mental illness.