NURSING SERVICES PROVIDER IN ILLINOIS

DELIVERING MEDICALLY NECESSARY NURSING SUPPORT TO PROMOTE HEALTH, STABILITY, AND INDEPENDENCE

Nursing Services in Illinois provide skilled nursing care to individuals with complex medical needs who require assistance to manage chronic conditions, recover from illness or injury, and maintain their health while living in the community. These services are authorized under the Illinois Medicaid State Plan and Home and Community-Based Services (HCBS) Waiver programs to avoid unnecessary hospitalization and institutionalization.

​​​1. GOVERNING AGENCIES

Agency: Illinois Department of Healthcare and Family Services (HFS)

Role: Administers Medicaid State Plan and Waiver-funded Nursing Services, oversees provider enrollment, service authorization, and reimbursement

Agency: Illinois Department of Public Health (IDPH)

Role: Licenses Home Health Agencies and oversees nursing regulations related to quality, licensing, and public health compliance

Agency: Centers for Medicare & Medicaid Services (CMS)

Role: Provides federal oversight ensuring Medicaid- and Medicare-funded Nursing Services meet federal standards for quality, participant-centered care, and medical necessity

2. NURSING SERVICE OVERVIEW

Nursing Services provide hands-on, skilled medical care under the direction of a physician or authorized practitioner, supporting individuals in managing medical conditions safely at home or in community settings.

Approved providers may deliver:

• Comprehensive health assessments

• Administration of medications and injections

• Wound care and dressing changes

• IV therapy and enteral feeding management

• Chronic disease monitoring and management (e.g., diabetes, cardiac care)

• Tracheostomy care and ventilator management

• Catheter care and bowel program management

• Health education and training for participants and caregivers

• Coordination with healthcare providers to ensure integrated care

All services must be prescribed in a physician’s order, align with an Individualized Service Plan (ISP) or Plan of Care (POC), and meet Medicaid’s skilled care definition.

3. LICENSING & PROVIDER APPROVAL REQUIREMENTS

Prerequisites:

• Register business entity with the Illinois Secretary of State

• Obtain EIN from the IRS and NPI (Type 2)

• Obtain a Home Health Agency license through the Illinois Department of Public Health (if providing in-home nursing)

• Enroll as a Medicaid and/or Medicare provider through the Illinois Medicaid Provider Enrollment Portal (IMPACT system) and CMS PECOS

• Maintain professional and general liability insurance

• Develop comprehensive policies for skilled nursing services, participant protection, emergency response, infection control, and documentation

• Ensure all nursing staff meet licensing, credentialing, background checks, and continuing education requirements

4. ILLINOIS PROVIDER ENROLLMENT PROCESS

Initial Interest and Application:

• Submit Provider Enrollment Application through the IMPACT system for Medicaid Nursing Services (State Plan or Waiver)

• If billing Medicare, complete the PECOS Medicare Enrollment Application

Application and Documentation Submission:

• Submit Articles of Incorporation, proof of EIN/NPI, Home Health Agency license (if applicable), insurance certificates, clinical staffing credentials, and operational policies

Program Readiness Review:

• IDPH and/or HFS conduct surveys to evaluate nursing service protocols, clinical record systems, emergency procedures, and participant protections

Approval & Medicaid/Medicare Enrollment:

• Upon approval, providers are authorized to bill Medicaid and/or Medicare for Nursing Services using assigned codes (e.g., RN or LPN hourly units)

5. REQUIRED DOCUMENTATION

• Articles of Incorporation or Business License (Illinois Secretary of State)

• IRS EIN confirmation

• NPI confirmation

• IDPH Home Health Agency License (if required)

• Proof of professional and general liability insurance

• Nursing Services Policy & Procedure Manual including:

  • Participant intake, physician order management, and care planning procedures

  • Medication administration, skilled nursing task documentation, and critical incident response

  • Infection control, emergency preparedness, and fall prevention protocols

  • Participant rights, HIPAA confidentiality standards, and grievance procedures

  • Staff credentialing, background checks, training, and competency validation

  • Medicaid billing, clinical service tracking, and audit readiness documentation

6. STAFFING REQUIREMENTS

Role: Nursing Services Administrator / Clinical Supervisor

Requirements: Active Registered Nurse (RN) license in Illinois; experience in clinical supervision; background clearance

Role: Registered Nurses (RNs)

Requirements: Active Illinois RN license; CPR certification; clinical skills competency evaluations

Role: Licensed Practical Nurses (LPNs)

Requirements: Active Illinois LPN license; CPR certification; supervision by RN

All clinical staff must complete:

• HIPAA compliance and participant confidentiality training

• Abuse prevention, elder/dependent adult protections, and mandatory reporting training

• Infection control and emergency procedures training

• Annual clinical skills competency assessments and continuing professional education

7. MEDICAID WAIVER PROGRAMS AND STATE PLAN COVERAGE

Nursing Services are reimbursed through:

• Illinois Medicaid State Plan: For participants requiring intermittent or continuous skilled nursing services at home

• Adults with Developmental Disabilities Waiver

• Children and Young Adults with Developmental Disabilities Waiver

• Persons with Brain Injury (BI) Waiver

• Persons with Disabilities (PD) Waiver

• Children's Support Waiver (for private duty nursing needs)

Approved providers may deliver:

• Hourly skilled nursing (RN or LPN) services

• Intermittent skilled nursing visits for care plan management

• Specialized medical task support under physician orders

8. TIMELINE TO LAUNCH

Phase: Business Formation and Clinical Compliance Preparation

Timeline: 2–4 months

Phase: Staff Hiring, Credentialing, and Policy Development

Timeline: 3–5 months

Phase: IDPH Licensure Survey (if applicable) and IMPACT/PECOS Enrollment

Timeline: 3–6 months

Phase: Medicaid and Medicare Billing System Setup and Service Launch

Timeline: 30–60 days

9. CONTACT INFORMATION

Illinois Department of Public Health (IDPH) — Home Health and Nursing Services

Website: https://dph.illinois.gov/topics-services/health-care-regulation/home-health-agencies.html

Illinois Department of Healthcare and Family Services (HFS)

Website: https://www.hfs.illinois.gov/

Centers for Medicare & Medicaid Services (CMS)

Website: https://www.cms.gov/

WAIVER CONSULTING GROUP’S START-UP ASSISTANCE SERVICE — ILLINOIS NURSING SERVICES PROVIDER

WCG assists home health agencies, skilled nursing providers, and healthcare entrepreneurs in launching Medicaid- and Medicare-compliant Nursing Services across Illinois.

​​​​​​​​​​​​​​​​​​​Scope of Work:

• Business registration, Home Health Agency licensure application, and Medicaid/Medicare enrollment support

• Development of Nursing Services Policy & Procedure Manual

• Staff credentialing templates, care plan forms, and clinical documentation systems

• Medicaid and Medicare billing setup and claims management assistance

• Website, domain, and professional branding support

• Clinical compliance programs, including infection control and emergency preparedness templates

• Quality assurance program development and audit preparation tools

• Referral partnership development with hospitals, physicians, and community service agencies

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