Common use of Service Agency Clause in Contracts

Service Agency. Qualify to provide the service. All Family Training must be included in the Enrollee Care Plan. Service DoA DHS-DRS HFS Persons who are Elderly Persons with Disabilities Persons with HIV/AIDS Persons with Brain Injury Supportive Living Facility Definition Standards HFS Fee-For-Service Service Limits Specialized Medical Equipment and Supplies x x x Specialized medical equipment and supplies to include devices, controls, or appliances, specified in the Enrollee Care Plan, which enable individuals to increase their abilities to perform activities of daily living, or to perceive, control, or communicate with the environment in which they live. This service also includes items necessary for life support, ancillary supplies, and equipment necessary to the proper functioning of such items, and durable and non-durable medical equipment not available under the Medicaid State Plan. All items shall meet applicable standards of manufacture, design, and installation. DRS:68 Il. Adm. Code 1253 Pharmacies 225.ILCS.85 Medical Supplies 225.ILCS.51 DSCC: 225.ILCS.51 If not licensed under 225 ILCS 51, must be accredited by the Joint Commission on Accreditation of Healthcare Organizations, or other accrediting organization. Meet DSCC Home Medical Equipment (HME) requirements for the HCBS Waiver. A Medicaid enrolled pharmacy or durable medical equipment provider that provides items not available from a DSCC approved HME provider, (such as specialformula). Items reimbursed with HCBS Waiver funds shall be in addition to any medical equipment and supplies furnished under the State Plan and shall exclude those items, which are not of direct medical or remedial benefit to the individual. DSCC:Medical supplies, equipment, and appliances are provided only on the prescription of the primary care Provider as specified in the Enrollee Care Plan. Behavioral Services (MA and PhD) x Behavioral Services provide remedial therapies to decrease maladaptive behaviors and/or to enhance the cognitive functioning of the recipient. These services are designed to assist Enrollees in managing their behavior and cognitive functioning and to enhance their capacity for independent living. Speech Therapist 225 ILCS 110/ Social Worker 225 ILCS 20/ Clinical Psychologist 225 ILCS 15/ Licensed Counselor 225 ILCS 107/ 89 IL Admin Code 686.1100 The amount, duration, and scope of services are based on the DON assessment conducted by the case manager and the service cost maximum determined by the DON score. The services are based on a clinical recommendation and are not covered under the State Plan. Service DoA DHS-DRS HFS Persons who are Elderly Persons with Disabilities Persons with HIV/AIDS Persons with Brain Injury Supportive Living Facility Definition Standards HFS Fee-For-Service Service Limits Assisted Living x The Supportive Living Program serves as an alternative to Nursing Facility (NF) placement, providing an option for seniors sixty-five (65) years of age or older and persons with physical disabilities between twenty-two (22) and sixty-four (64) years of age who require assistance with activities of daily living, but not the full medical model available through a Nursing Facility. Enrollees reside in their own private apartments with kitchen or kitchenette, private bath, individual heating and cooling system, and lockable entrance. Supportive Living Facilities (SLFs) are required to meet the scheduled and unscheduled needs of Residents twenty-four (24) hours a day. Supportive Living Facilities 89 Il. Adm.Code 146 SupPart B SLFs are reimbursed through a global rate, which includes the following Covered Services: • nursing services • Personal Care • medication administration, oversight, and assistance in self-administration • laundry • housekeeping • maintenance • social and recreational programming • ancillary services • twenty-four (24)–hour response/security staff • health promotion and exercise • Emergency call system • daily checks • Quality Assurance Plan • management of resident funds, if applicable

Service Agency. Qualify to provide the service. All Family Training must be included in the Enrollee Care Plan. Service DoA DHS-DRS DSCC HFS Persons who are Elderly Persons with Disabilities Persons with HIV/AIDS Persons with Brain Injury Children who are Medically Fragile/ Technology- Dependent Supportive Living Facility Definition Standards HFS Fee-For-Service Service Limits Specialized Medical Equipment and Supplies x x x x Specialized medical equipment and supplies to include devices, controls, or appliances, specified in the Enrollee Care Plan, which enable individuals to increase their abilities to perform activities of daily living, or to perceive, control, or communicate with the environment in which they live. This service also includes items necessary for life support, ancillary supplies, and equipment necessary to the proper functioning of such items, and durable and non-durable medical equipment not available under the Medicaid State Plan. All items shall meet applicable standards of manufacture, design, and installation. DRS:68 Il. Adm. Code 1253 Pharmacies 225.ILCS.85 Medical Supplies 225.ILCS.51 DSCC: 225.ILCS.51 If not licensed under 225 ILCS 51, must be accredited by the Joint Commission on Accreditation of Healthcare Organizations, or other accrediting organization. Meet DSCC Home Medical Equipment (HME) requirements for the HCBS Waiver. A Medicaid enrolled pharmacy or durable medical equipment provider that provides items not available from a DSCC approved HME provider, (such as specialformulaspecial formula). Items reimbursed with HCBS Waiver funds shall be in addition to any medical equipment and supplies furnished under the State Plan and shall exclude those items, which are not of direct medical or remedial benefit to the individual. DSCC:Medical supplies, equipment, and appliances are provided only on the prescription of the primary care Provider as specified in the Enrollee Care Plan. Service DoA DHS-DRS DSCC HFS Persons who are Elderly Persons with Disabilities Persons with HIV/AIDS Persons with Brain Injury Children who are Medically Fragile/ Technology- Dependent Supportive Living Facility Definition Standards HFS Fee-For-Service Service Limits Behavioral Services (MA and PhD) x Behavioral Services provide remedial therapies to decrease maladaptive behaviors and/or to enhance the cognitive functioning of the recipient. These services are designed to assist Enrollees in managing their behavior and cognitive functioning and to enhance their capacity for independent living. Speech Therapist 225 ILCS 110/ Social Worker 225 ILCS 20/ Clinical Psychologist 225 ILCS 15/ Licensed Counselor 225 ILCS 107/ 89 IL Admin Code 686.1100 The amount, duration, and scope of services are based on the DON assessment conducted by the case manager and the service cost maximum determined by the DON score. The services are based on a clinical recommendation and are not covered under the State Plan. Service DoA DHS-DRS HFS Persons who are Elderly Persons with Disabilities Persons with HIV/AIDS Persons with Brain Injury Supportive Living Facility Definition Standards HFS Fee-For-Service Service Limits Assisted Living x The Supportive Living Program serves as an alternative to Nursing Facility (NF) placement, providing an option for seniors sixty-five (65) years of age or older and persons with physical disabilities between twenty-two (22) and sixty-four (64) years of age who require assistance with activities of daily living, but not the full medical model available through a Nursing Facility. Enrollees reside in their own private apartments with kitchen or kitchenette, private bath, individual heating and cooling system, and lockable entrance. Supportive Living Facilities (SLFs) are required to meet the scheduled and unscheduled needs of Residents twenty-four (24) hours a day. Supportive Living Facilities 89 Facilities89 Il. Adm.Code 146 SupPart B SLFs are reimbursed through a global rate, which includes the following Covered Services: • nursing services • Personal Care • medication administration, oversight, and assistance in self-administration • laundry • housekeeping • maintenance • social and recreational programming • ancillary services • twenty-four (24)–hour response/security staff • health promotion and exercise • Emergency call system • daily checks • Quality Assurance Plan • management of resident funds, if applicableapplicable MLTSS COVERED SERVICES Category of service Definition MLTSS coverage 001 Physician Services EXCLUDED 002 Dental Services EXCLUDED 003 Optometric Services EXCLUDED 004 Podiatric Services EXCLUDED 005 Chiropractic Services EXCLUDED 006 Physicians Psychiatric Services EXCLUDED 007 Development Therapy, Orientation and Mobility Services (Waivers) EXCLUDED 008 DSCC Counseling/Fragile Children EXCLUDED 009 DCFS Rehab Option Services EXCLUDED 010 Nursing service EXCLUDED 011 Physical Therapy Services EXCLUDED 012 Occupational Therapy Services EXCLUDED 013 Speech Therapy/Pathology Services EXCLUDED 014 Audiology Services EXCLUDED 015 Sitter Services EXCLUDED 016 Home Health Aides EXCLUDED 017 Anesthesia Services EXCLUDED 018 Midwife Services EXCLUDED 019 Genetic Counseling EXCLUDED 020 Inpatient Hospital Services (General) EXCLUDED 021 Inpatient Hospital Services (Psychiatric) EXCLUDED 022 Inpatient Hospital Services (Physical Rehabilitation) EXCLUDED 023 Inpatient Hospital Services (ESRD) EXCLUDED 024 Outpatient Services (General) EXCLUDED 025 Outpatient Services (ESRD) EXCLUDED 026 General Clinic Services EXCLUDED 027 Psychiatric Clinic Services (Type 'A') EXCLUDED 028 Psychiatric Clinic Services (Type 'B') EXCLUDED 029 Clinic Services (Physical Rehabilitation) EXCLUDED 030 Healthy Kids Services EXCLUDED 031 Early Intervention Services EXCLUDED 032 Environmental modifications (waiver) EXCLUDED 033 Mental Health Clinic Option Services EXCLUDED 034 Mental Health Rehab Option Services COVERED SERVICE 035 Alcohol and Substance Abuse Rehab. Services COVERED SERVICE 036 Juvenile Rehabilitation EXCLUDED 037 Skilled Care - Hospital Residing EXCLUDED 038 Exceptional Care COVERED SERVICE 039 DD/MI Non-Acute Care - Hospital Residing EXCLUDED 040 Pharmacy Services (Drug and OTC) EXCLUDED 041 Medical equipment/prosthetic devices EXCLUDED 042 Family planning service EXCLUDED 043 Clinical Laboratory Services EXCLUDED 044 Portable X-Ray Services EXCLUDED 045 Optical Supplies EXCLUDED 046 Psychiatric Drugs EXCLUDED 047 Targeted case management service (mental health) COVERED SERVICE 048 Medical Supplies EXCLUDED 049 DCFS Targeted Case Management Services EXCLUDED 050 Emergency Ambulance Transportation EXCLUDED 051 Non-Emergency Ambulance Transportation COVERED SERVICE 052 Medicare Transportation COVERED SERVICE 053 Taxicab Services COVERED SERVICE 054 Service Car COVERED SERVICE 055 Auto transportation (private) COVERED SERVICE 056 Other Transportation COVERED SERVICE 057 Nurse Practitioners Services EXCLUDED 058 Social work service COVERED SERVICE 059 Psychologist service COVERED SERVICE 060 Home Care EXCLUDED 061 General Inpatient EXCLUDED 062 Continuous Care Nursing EXCLUDED 063 Respite Care EXCLUDED 064 Other Behavioral Health Services COVERED SERVICE 065 LTC Full Medicare Coverage EXCLUDED 066 Home Health Services EXCLUDED 067 All Kids application agent (valid on provider file only) EXCLUDED 068 Targeted case management service (early intervention) EXCLUDED 069 Subacute Care Program EXCLUDED 070 LTC - Skilled COVERED SERVICE 071 LTC - Intermediate COVERED SERVICE 072 LTC--NF skilled (partial Medicare coverage) EXCLUDED 073 LTC--ICF/MR EXCLUDED 074 LTC--ICF/MR skilled pediatric EXCLUDED 075 LTC - MI Recipient age 22-64 EXCLUDED 076 LTC - Specialized Living Center - Intermediate MR EXCLUDED 077 SOPF--MI recipient over 64 years of age EXCLUDED 078 SOPF--MI recipient under 22 years of age EXCLUDED 079 SOPF--MI recipient non-matchable EXCLUDED 080 Rehabilitation option service (special LEA service) EXCLUDED 081 Capitation Services EXCLUDED 082 LTC--Developmental training (level I) EXCLUDED 083 LTC--Developmental training (level II) EXCLUDED 084 LTC--Developmental training (level III) EXCLUDED 085 LTC - Recipient 22-64 in IMD not MI or MR COVERED SERVICE 086 LTC SLF Dementia Care COVERED SERVICE 087 LTC - Supportive Living Facility (Waivers) COVERED SERVICE 088 Licensed Clinical Professional Counselor (LCPC) COVERED SERVICE 089 LTC - MR Recipient - Inappropriately Placed EXCLUDED 090 Case Management EXCLUDED 091 Homemaker COVERED SERVICE 092 Agency Providers RN, LPN, CNA and Therapies COVERED SERVICE 093 Individual Providers PA, RN, LPN, CNA and Therapies COVERED SERVICE 094 Adult Day Health COVERED SERVICE 095 Habilitation Services COVERED SERVICE 096 Respite Care COVERED SERVICE 097 Other HCFA Approved Services COVERED SERVICE 098 Electronic Home Response/EHR Installation (MARS), MPE Certification (Provider) COVERED SERVICE 099 Transplants EXCLUDED 100 Genetic counseling EXCLUDED 102 Fluoride varnish EXCLUDED ATTACHMENT II: CONTRACTING AREAS AND POTENTIAL ENROLLEES Contracting Areas There are nineteen (19) Urban Areas in Illinois and eighty-three (83) Rural Areas. Urban Area counties are highlighted in bold below. Statewide: Adams, Alexander, Bond, Boone, Brown, Bureau, Calhoun, Carroll, Cass, Champaign, Christian, Clark, Clay, Clinton, Coles, Cook, Crawford, Cumberland, DeKalb, XxXxxx, Xxxxxxx, Dupage, Edgar, Edwards, Effingham, Fayette, Ford, Franklin, Fulton, Gallatin, Greene, Grundy, Hamilton, Hancock, Hardin, Xxxxxxxxx, Xxxxx, Iroquois, Xxxxxxx, Xxxxxx, Xxxxxxxxx, Jersey, Xx Xxxxxxx, Johnson, Kane, Kankakee, Kendall, Knox, Lake, XxXxxxx, Xxxxxxxx, Lee, Livingston, Logan, Macon, Macoupin, Xxxxxxx, Xxxxxx, Marshall, Mason, Massac, McDonough, McHenry, McLean, Menard, Mercer, Monroe, Montgomery, Morgan, Moultrie, Ogle, Peoria, Perry, Piatt, Pike, Pope, Pulaski, Putnam, Randolph, Richland, Rock Island, Saline, Sangamon, Xxxxxxxx, Xxxxx, Xxxxxx, St. Clair, Stark, Stephenson, Tazewell, Union, Vermilion, Wabash, Xxxxxx, Xxxxxxxxxx, Xxxxx, White, Whiteside, Will, Xxxxxxxxxx, Winnebago, Woodford xxxx://xxx.xxxxx.xxx/files/Rural_Health_Clinic/Rural_urban_counties.pdf Potential Enrollees Potential Enrollees include: families and children eligible for Medicaid through Title XIX or Title XXI (Children’s Health Insurance Program); Affordable Care Act expansion Medicaid-eligible adults; Medicaid-eligible adults with disabilities who are not eligible for Medicare; Medicaid-eligible older adults who are not eligible for Medicare; Dual-Eligible Adults receiving long-term services and supports (LTSS) in an institutional care setting or through an HCBS waiver; Special Needs Children, defined as Medicaid-eligible enrollees under the age of 21 who are covered under Supplemental Security Income (SSI), a disability category of eligibility, or are receiving services from the Division of Specialized Care for Children (DSCC); and children formerly under the care of Department of Children and Family Services (DCFS) who have opted out of the DCFS-specific managed care program. Members excluded from the scope of this Contract are as follows: • Dual-Eligible Adults enrolled in MMAI; • Dual-Eligible Adults not receiving nursing facility or waiver services; • Participants who are American Indian/Alaskan Natives unless they voluntarily enroll in an MCO; • DCFS Youth in Care children; • Participants only eligible with a Spend-Down; • All Presumptive Eligibility categories; • Participants who are incarcerated in a county jail, Illinois Department of Corrections facility, or federal penal institution; • Participants in a State facility operated as a psychiatric hospital as a result of a forensic commitment; • Participants enrolled in partial/limited benefits programs; and, • Participants with comprehensive third-party insurance. ATTACHMENT III <Intentionally left blank for future use> Attachment IV Rate Sheet [PLAN NAME HERE] Rate Cell Regions Region 1 – Northwestern Illinois Region 2 – Central Illinois Region 3 – Southern Illinois Region 4 – Xxxx County Region 5 – Collar Counties Affordable Care Act (ACA) Expansion Adults Rates Effective January 1, 2018 through December 31, 2018 ACA Adults Region 1 Rate Region 2 Rate Region 3 Rate Region 4 Rate Region 5 Rate Female 19-24 Years Old Male 19-24 Years Old Female 25-34 Years Old Male 25-34 Years Old Female 35-44 Years Old Male 35-44 Years Old Female 45-54 Years Old Male 45-54 Years Old Female 55-64 Years Old Male 55-64 Years Old Non-Disabled Children and Adults (NDCA) Rates Effective January 1, 2018 through December 31, 2018 NDCA Region 1 Rate Region 2 Rate Region 3 Rate Region 4 Rate Region 5 Rate 0 thru 3 months 4 thru 23 months 2 thru 5 Years Old 6 thru 13 Years Old 14 thru 20 Years Old- Female 21thru 44 Years Old- Female 45+Years Old(Male&Female) Special Needs Children (SNC) Rates Effective January 1, 2018 through December 31, 2018 SNC Region 1 Rate Region 2 Rate Region 3 Rate Region 4 Rate Region 5 Rate Disabled Adults (DA) - Service Package I (SPI) Rates Effective January 1, 2018 through December 31, 2018 DA-SPI Region 1 Rate Region 2 Rate Region 3 Rate Region 4 Rate Region 5 Rate Community Residents HCBS DD Waiver ICFDD Nursing Facility HCBS Other Waivers State Operated Facility Disabled Adults (DA) – Service Package II (SPII) Rates Effective January 1, 2018 through December 31, 2018 DA-SPII - Blended Region 1 Rate Region 2 Rate Region 3 Rate Region 4 Rate Region 5 Rate Managed Long Term Services and Supports (MLTSS) Rates Effective January 1, 2018 through December 31, 2018 MLTSS Region 1 Rate Region 2 Rate Region 3 Rate Region 4 Rate Region 5 Rate 21 thru 64 Years Old 65+ Years Old State Only IMD* Rates Effective January 1, 2018 through December 31, 2018 State Only IMD Region 1 Rate Region 2 Rate Region 3 Rate Region 4 Rate Region 5 Rate ATTACHMENT V: STATE OF ILLINOIS DRUG-FREE WORKPLACE CERTIFICATION Contractor certifies that it will not engage in the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance in the performance of the Agreement. This business or corporation has twenty-five (25) or more employees, and Contractor certifies and agrees that it will provide a drug-free workplace by: