Waiver/Home Care Provider Forms
| Application Forms |
What is the Illinois Waiver for Children who are Medically Fragile, Technology Dependent (sometimes referred to as the Home Care Program)?
This program helps families care for children (birth up to age 21) who are medically fragile and technology dependent. The program offers care coordination and services to support the family in providing care for their child at home. In-home nursing services are available based on the medical needs of the child or youth. The Division of Specialized Care for Children (DSCC) operates this program on behalf of the Illinois Department of Healthcare and Family Services (HFS). The services are offered through a federal 1915(c) Home and Community-Based Services waiver. A waiver is a program that provides services that allow individuals with unique needs to remain in their own home or live in a community setting rather than in an institution, such as a nursing facility or hospital.
Who does the Waiver/Home Care Program help?
Any Illinois child:
- From birth to age 21;
- Who needs long term intensive and highly technical nursing care, case management, known as care coordination, and other support services to be safely cared for at home; and
- Who meets the medical and financial eligibility requirements for the waiver program.
What are the eligibility requirements?
- The child or youth meets the medical criteria, as determined by their health condition and technology needs, as evaluated by professionals (a minimum score of 50 on level of care screening assessment).
- The family is willing and able to care for the child in their home to the fullest extent possible.
- The family is able to safely care for the child in the family's home.
- A determination is made that without the in-home support services provided through the waiver program, the child would be at risk to be in an institution.
- The estimated cost of the in-home support services is not greater than the cost of the institutional level of care appropriate to the child's medical need.
- The child meets Medicaid financial income requirements, when parental income is not considered. Families do have to make application to Medicaid.
What services can be provided to help my child live at home?
When needed by your child and after approval by the Illinois Department of Healthcare and Family Services (HFS), the following services are available for children enrolled in the waiver:
- All Medical services available under the Illinois Medicaid program such as hospitalizations, doctor visits, and medications, unless the services are covered by the child’s insurance.
- Services include shift nursing care in the home, provided by registered nurses, licensed practical nurses and certified nurse’s aide from an approved nursing agency. The number of hours provided per week is determined by the assessment of the child's medical and nursing care needs.
- Medical equipment and supplies prescribed by the child's physician.
- Minor home modifications needed to provide access, accommodate needed medical equipment, or to assure the child's safe access and safety in the home.
- Family training that includes instruction about treatments and use of equipment as well as Cardiopulmonary Resuscitation (CPR).
- Respite (nursing) care in the child's home or in a designated community-setting to periodically relieve the family of care-giving responsibilities.
- Medically supervised day care offering technological support and nursing care provided in a licensed medical day care setting. (Currently there are no licensed providers in Illinois.)
- Placement maintenance counseling providing short-term, issue-specific family or individual counseling for the purpose of maintaining the child in the home placement.
- Nurse training to provide child specific training for the in-home nurses in the use of new or unique equipment or special needs of the child.
When will I know if my child is eligible?
Once the family has completed and returned the DSCC application for the Waiver/Home Care Program, the DSCC care coordinator works with the family to gather the medical, home, and community information needed for HFS to determine eligibility. The waiver application, which contains a detailed description of the child's medical condition and needs, is submitted to HFS for approval. The application process can usually be completed within a few weeks, but may be delayed for a number of reasons.
What must I do after the home care plan is approved?
Once the application is approved, DSCC care coordinators will help the family implement the plan. DSCC will assist the family to arrange for home modification and equipment and supply delivery, as needed, facilitate other medical or waiver services, and notify the nursing agency chosen by the family. The care coordinator will meet with the family at regular intervals to ensure the plan is working, to discuss the family's satisfaction with services, and to review the family and child’s needs. The child's plan will be reviewed and updated on a regular basis for continued approval.
How do I apply?
Print the following application forms and mail them to the DSCC office in your area. You can locate the office in your area from our website.
You can fill-in and print completed forms from our web site, print blank
forms and complete them manually, or contact a DSCC Regional Office to
receive them by regular mail. Instructions
are available to explain how to complete pdf forms on-line. The Adobe
Reader, available free from the Adobe
web site, is needed to view and print these PDF files.
Note: Adobe Reader does not allow you to save completed forms to disk;
the ability to save completed forms is available commercially with the
Adobe Acrobat product suite.
| General Application |
Or you can call your nearest DSCC office and request application forms. You will be asked to provide financial and health care information about your child and family. These forms are needed to begin the waiver application process.
Home Care Provider Forms Online
- Price Estimate for Medical
Equipment & Supplies (53.33)
Home medical equipment providers approved for the waiver/home care program must complete this form annually, and whenever major changes in the child's equipment & supplies occur. The estimated cost of prescribed equipment and supplies must be submitted to ensure the child's medical plan of care remains cost effective. Providers can electronically complete this form and submit it, via fax, to the regional office coordinating the child's care. Or, the form can printed and completed manually.
- Guidelines for Nurses Working in Home Care (53.80)
Nursing Agencies are required to ensure that all nursing staff have read and comply with these guidelines for nurses working in home care.
- Guidelines for Nursing Agencies Working with the Illinois Home and Community Based Services (HCBS) Waiver for Medically Fragile, Technology Dependent Children (53.84)
This document has been prepared specifically for the nursing supervisors of a Nursing Agency who has been approved by DSCC for participation in the HCBS Waiver Program and should be shared with any agency personnel. It outlines the role of DSCC, the role of the Nursing Agency and common issues in Home Care as well as the requirements for Nursing Agencies and billing for nursing services.
- Nursing Supervisory Summary Form
The Nursing Supervisory Summary Form (55.08), or a similar form containing the same information, is required from the nursing agencies every 60 days. This information is provided to the Department of Healthcare and Family Services. It is available in 2 formats:
- Microsoft Word
- PDF (The Adobe
Acrobat Reader, available free from the Adobe web site, is needed to view and print PDF files. )
- Microsoft Word
- Home Nursing Services Weekly Billing Form
Nursing Agencies can fill-in and print completed forms from our web site, print blank forms and complete them manually, or contact the DSCC Call Center toll-free at 877-791-5170 to receive them by regular mail. The Home Nursing Services Weekly Billing Form (55.12) is available in 2 formats:
- Microsoft Word
- PDF (The Adobe Acrobat Reader, available free from the Adobe web site, is needed to view and print PDF files.)
This form includes expanded general billing instructions.
- Microsoft Word
Instructions are
available to explain how to complete PDF forms on-line.
Note: Acrobat Reader does not allow you to save completed forms to disk; the
ability to save completed forms is available commercially with the Adobe Acrobat
3.0 (or later) product suite.
