State of Illinois
Department of Human Services
Instructions For Application for 60D CILA Support Services
An Application for 60D CILA Support Services must be completed prior to the determination of an individual CILA rate. All information
on the application is required and must be completed entirely and accurately. If any questions on the application are left blank the
application may be determined “incomplete” and returned to the local PAS/ISC/ISSA agency. A CILA Award Letter cannot be issued until
the CILA rate is established.
A CILA provider agency must receive a signed CILA Award Letter or a Pre-Award Letter (PAL) prior to initiating any services for which
reimbursement will be sought from the Department of Human Services (DHS). DHS will not reimburse services delivered before the
“Earliest Effective Date” specified in the CILA Award Letter.
Individuals applying for CILA services must be eligible for waiver services according to the DHS' Home and Community-Based Services
Waiver and the individual must meet the funding criteria. Upon issuance of a CILA award letter, the individual is eligible for waiver
services.
Individual Information
1.
Name of individual - Enter the LAST and FIRST name of the individual. It is important that the name appear exactly as it will be
entered in the Community Reimbursement Sub-System (CRS) and Medicaid system. Differences in spelling, or using a nickname in the
CILA Rate Model and a proper name in the CRS or Medicaid system causes errors and may result in program authorization, rate change,
and other payment-related problems.
2.
Social Security Number - Enter the nine digit Social Security Number (SSN) of the individual. It is important that the SSN be
reported exactly as it will be entered into the CRS and Medicaid system. Do not enter “999-99-9999” if the Social Security Number is not
known. A copy of the individual's Social Security Card or SSA print screen is a required attachment.
3.
Recipient Identification Number (RIN) - Enter the nine-digit (RIN) of the individual. It is important that the RIN be reported
exactly as it will be entered into the CRS and Medicaid system. Do not enter “99999999” if the Recipient Identification Number is
unknown. A CURRENT copy of the individual's Medicaid card or HFS print screen is a required attachment.
4.
Date of Birth - Enter the month, day, and year of the individual's date of birth. Use MM/DD/YYYY format.
5.
Gender - Enter the designation for "Male" or "Female".
6.
Is the individual ambulatory (walks independently or with assistive devices)? - If the individual uses a
wheelchair for mobility or cannot ambulate with physical assistance or assistive devices, mark “No.” If the individual is able
to walk, does not use a wheelchair, or is able to ambulate with the use of assistive devices, mark “Yes.” The answer to #6
should be consistent with the information concerning ambulation in the individual's ICAP.
7.
ICAP or SIBR Summary Score - Enter the two-digit ICAP or SIBR Summary Score.
8.
ICAP or SIBR Maladaptive Behavioral Index Score - Enter the two-digit ICAP or SIBR Score.
9.
Date of Evaluation of ICAP or SIBR Summary - Enter the date of ICAP or SIBR evaluation completed. NOTE:
The ICAP or SIBR must have been completed within the past year. A copy of the ICAP or SIBR Summary is required.
CILA Provider Information
10.
Provider Agency Name - Print the name of the CILA agency that will be providing the CILA supports.
11.
Provider Agency DHS ID Number - Enter the four-digit DHS provider ID number, e.g., 0104 or 1912.
IL462-4425Instructions (R-9-12) Instructions for Application for 60D CILA Support Services
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State of Illinois
Department of Human Services
Instructions For Application for 60D CILA Support Services
12.
Address of the CILA site where the individual will be living - Enter the address, apartment number, etc., of the
CILA where the applicant will be living. It is important to keep the addresses of individuals living in CILA up-to-date.
Discrepancies in the CILA Site Capacity result in processing delays for CILA funding requests and your agency will be
contacted for a “Residential Site Capacity Review”. Residential Site Capacity Reviews can result in retroactive rate
adjustments.
13.
County where the CILA home is located - Enter the name of the county or the address provided in #12.. Do not
enter the county of the home office of the CILA provider.
14.
Total residential capacity of the CILA site in which the individual will be living - Enter the number of individuals
the agency anticipates to live in the CILA home at full capacity.
15.
Level of CILA support services provided at this CILA site - Indicate whether the 60D CILA Support Application is
being completed for a individual who will be receiving “24-Hour” CILA supports, or Foster Care / Host Family, “Intermittent”
CILA supports, or “Family” CILA supports.
*
24-Hour with Shift Staff - Where the individual owns or leases the setting or resides in an agency
controlled site and will receive 24-Hour supports. Staff do not reside at the CILA site.
*
24-Hour with Foster Care / Host Family - The individual lives in a site controlled by the individual,
the foster care family or agency, and will receive 24-Hour supports delivered by staff who reside at the CILA site, or
a combination of live-in and shift staff. A Prior Approval Request for Host Family Services form is also required.
*
“Family or Relative Intermittent” - Settings where the individual lives with their family, guardian, or other relative
and will receive less than 24-Hour supports from the CILA agency.
*
“Intermittent” Not With Family or Other Relative CILA - Settings where the individual lives independent of their
family or guardian and will receive less than 24-Hour supports.
16.
Is the Night Shift Staff allowed to sleep at any time? - If the night shift staff in “24HR Shift Staff” settings is allowed
to sleep at any time during their scheduled shift, mark “Yes.” For night shift staff who are required to be awake for the full
duration of their shift, mark “No.”
17.
Type of Intermittent / Family Support - For questions about training requirements of job classifications below,
contact DDD at (217) 782-9438.
*
Direct Support Person (DSP) - Enter number of hours of DSP supports to be provided on a weekly basis.
DSP's must complete the training requirements.
*
Supervisor - Enter number of hours of Supervisory staff supports provided on a weekly basis. Supervisory staff are
staff who provide management oversight of the day-to-day operation of Direct Support Personnel and other agency
staff.
*
Qualified Intellectual Disability Professional (QIDP) - Enter number of hours of staff supports provided on a weekly
basis. A QIDP provides programmatic oversight, service planning, and quality assurance activities.
*
Mileage for staff-related miles - Enter the number of staff-related miles on a weekly basis. NOTE: Mileage requested
should relate only to staff travel to and from the individual's home. Do not include mileage for other services or to and
from day programs.
IL462-4425Instructions (R-9-12) Instructions for Application for 60D CILA Support Services
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State of Illinois
Department of Human Services
Instructions For Application for 60D CILA Support Services
18.
List the names of all other individuals at, or moving to this site - List the names of the other individuals who either
are, or will be, living at the CILA home indicated. Indicate whether the individual is currently living in the home or intends to live
at this site. Also indicate whether they are currently receiving supports funded by DHS or other source such as private pay.
Please indicate the program code or program name for anyone funded by DHS.
(PAS/ISC/ISSA) Agency Information: The receiving PAS/ISC/ISSA agency will be specified in the individual's rate sheet
based on county and zip code of the CILA site where the individual will be served.
Rate Type Information
19.
Rate Type - Indicate the most appropriate rate type. If you are unsure of the appropriate response, please contact
your Region Facilitator or BTS Representative.
20.
Residence Location Prior to CILA Placement - Indicate the residence location prior to their move to CILA. NOTE:
For individuals currently receiving short-term supports such as emergency respite, please indicate their previous permanent
residence type.
Community-Based Residential Setting: If known, enter the type of the community-based resident location where the
applicant previously lived.
Alternative Day Program Supports
All alternative day program authorizations require prior approval from the Region Facilitator or BTS Representative.
Regular Work / Sheltered Employment (Program 38U) - A long-term employment program carried out in a sheltered work
environment. Authorization for Regular Work / Sheltered Employment must be pre-approved by the Division of Developmental
Disabilities. Use the Request for Alternative Day Program form (IL462-0285) along with the required documentation to request
billing authorization.
Supported Employment (Programs 39U, 36U, 39G, 36G) - All Supported Employment authorizations require a denial of
funding to be on record from the Division of Rehabilitation Services (DRS). Provider must first apply to have these supports
reimbursed by DRS. Upon receipt of the Alternative Day Program Request form (IL462-0285) along with the required DRS
denial for funding, DHS staff will "authorize" the individual for billing effective the date of the DRS denial in all Supported
Employment categories.
IL462-4425Instructions (R-9-12) Instructions for Application for 60D CILA Support Services
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