Coordination of Community Support and Services for Enrollees in HCBS Waivers and Long-term Care Residential Coordination of Services Form

Applicable products • State of Illinois Model Contract Policy: Blue Cross and Blue Shield of Illinois promotes the integration of care coordination with pharmacy, behavior and physical health, social work services and community resources to ensure a range of services and support to promote the well-being and safety of members. Purpose: This guideline is designed to assist providers by directing them to evidence-based guidelines and governmental references that will enable them to ensure the safety and well-being of our members. Home and community-based services support enrolled members and their caregivers with person- centered services based on their plan of care. Services may aid the members and their caregivers with activities of daily living, such as bathing, dressing and food preparation. Enrollees in the HCBS program may have physical or mental illness, developmental disabilities, cognitive disabilities and chronic conditions. Regulatory requirements and references • State of Illinois Model Contract: 5.21.3.2; 5.22.3; Attachment XI (Quality Assurance) 1.1.1.1; 1.1.9.; 1.1.9.12; 1.1.9.16; Attachment 12: Utilization Review/ Peer Review 1.1.2.3.2; Attachment XXI: Required Minimum Standards of Care 3. Covered Services Guideline: This guideline is based on recommendations from the Centers for Medicare & Medicaid Services. Individualized plan of care: We use data from member health risk assessments to develop an individualized plan of care for each member. Members, caregivers, care coordinators and interdisciplinary care team participants develop short-and long-term goals for the individualized plan of care. An interdisciplinary care team made up of cross-functional representatives completes an initial evaluation of the diagnoses and procedures that place enrollees at risk of health-related complications. Through the interdisciplinary care team and medical management system, we may create an individualized plan of care specific to the unique needs and expectations of the member and family, if appropriate. The questionnaires are based on and supported by the approved clinical practice guidelines. Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Shield Association 2025-2026 Coordination of Community Support and Services for Enrollees in Home and Community
Based Waivers and Long-term Care Residential Coordination of Services

HCBS waivers: We may offer a combination of standard medical and non-medical community services to move individuals from institutional settings into their homes and community. Illinois HCBS waivers may be granted in the following situations: • Aging waiver – For individuals 60 years and older who live in the community • Individuals with disabilities waiver – For individuals who have a physical disability and are between the ages of 19 and 59 • HIV/AIDS waiver – For individuals who have been diagnosed with HIV or AIDS • Individuals with brain injury waiver – For individuals with an injury to the brain • Supportive living facilities – For individuals who need assistance with the activities of daily living but do not need the care of a nursing facility Covered services: Covered services eligible for benefits are in accordance with the terms of the Medicaid program. BCBSIL may offer additional benefits and services. Members may qualify for an HCBS waiver, supportive living facility or long-term care benefits. Eligibility for these benefits or waivers is determined solely by the state of Illinois and is usually done through the determination of need assessment tool. Based on the member’s determination of need score, the state will determine whether the member is eligible for a waiver service or benefits to reside in a supportive living facility or long-term care facility. The table below is an outline of services available under an HCBS waiver. Service Waiver Elderly Disability HIV/AIDS Brain Injury Adult Day Service √ √ √ √ Adult Day Service Transportation √ √ √ √ Environmental Modification √ √ √ Supported Employment √ Home Health Aide √ √ √ Nursing, Intermittent √ √ √ Nursing, Skilled √ √ √ Occupational Therapy √ √ √ Personal Assistant √ √ √ Physical Therapy √ √ √ Speech Therapy √ √ √ Prevocational Services √ Day Habilitation √ Homemaker √ √ √ √ Home Delivered Meals √ √ √ Emergency Home Response System √ √ √ √ Respite √ √ √ Adaptive Equipment √ √ √ Behavioral Services √ For additional information on HCBS waiver member services, contact our care coordination department at 855-334-4780.

Additional resources from the Agency for Healthcare Research and Quality • Long-term Care • Long-term Care Resources Physician responsibility for care: Providers are solely responsible for the provision of all health care services to members of Blue Cross Community Health PlansSM, and all decisions regarding member treatment and care are the sole responsibility of the provider. Such decisions are not directed or controlled by BCBSIL. BCBSIL’s decision about whether any medical service or supply is a covered benefit under the member’s benefit plan are benefit decisions only and are not the provisions of medical care. It is the provider’s responsibility to discuss all treatment options with the member, regardless of whether such treatment is a covered benefit under the member’s benefit plan. Providers and subcontractors are encouraged to cooperate and communicate with other service providers who serve members. Providers are required to provide services to members in the same manner and quality as those services that are provided to other patients who are not members. 255232.0126