Section 131.10  Purpose

 

This Part establishes criteria for payment of certain mental health and related services that are provided to children enrolled in the Screening, Assessment and Support Services (SASS) Program.

 

Section 131.20  Definitions

 

For the purposes of this Part, the following terms are defined:

 

"CARES" – Crisis and referral entry services.  The agent under contract with HFS, DCFS, or DHS to perform certain administrative functions on the State agency's behalf.

 

"CMHS" –  Community mental health services.

 

"DCFS" – The Illinois Department of Children and Family Services.

 

"DHS" – The Illinois Department of Human Services.

 

"DHS-DMH" – The Illinois Department of Human Services/Division of Mental Health.

 

"HFS" – The Illinois Department of Healthcare and Family Services.

 

"SASS" – Screening, assessment and support services.

 

"SASS agent" –  A provider of CMHS, under contract with HFS, DCFS or DHS to screen children in psychiatric crisis who are believed to be in need of admission to an inpatient facility.

 

"SASS period" – A 90-day period beginning with the date that the SASS agent begins initial screening of a child in psychiatric crisis.  The period may be extended beyond 90 days if it has been determined to be clinically necessary to do so by DCFS (for children for whom DCFS is legally responsible) or DHS (for any other child).

 

(Source:  Amended at 31 Ill. Reg. 10635, effective July 13, 2007)

 

Section 131.30  Eligibility

 

A child eligible for services provided under this Part is:

 

a)         An individual for whom DCFS is legally responsible;

 

b)         An individual under 21 years of age who is enrolled, pursuant to 89 Ill. Adm. Code 118, 120, 123 or 125, in one of the medical programs administered by HFS, except that any child who is enrolled in a managed care organization is not eligible; or

 

c)         Subject to funding that is appropriated and available to DHS-DMH for the SASS program, an individual who is under 18 years of age and who meets one of the  following criteria:

 

1)         An individual who, following submission of a completed application, does not qualify under subsection (b);

 

2)         An individual who meets criteria for the DHS-DMH target population (see Appendix A) and requires intensive community-based services in the SASS program, has no other means of payment as determined by DHS-DMH, and is seeking public payment for services covered under this Part; or

 

3)         An individual whose family is unable, unwilling, or refuses to apply for medical assistance (e.g., the family may not be able to comply with the requirement to gather the necessary information required to file an application for Medicaid or All Kids due to medical reasons, such as impending surgery or long term medical illness, or the family refuses to comply because family members are undocumented), or if the SASS agent, hospital or community mental health provider finds it impossible to assist the family in applying, may be permitted an exception to this requirement only in these instances.  A request for an exception may be made by contacting DHS-DMH.  A hospital or community mental health provider may report that it finds it impossible to assist the family in applying only if the family refuses to apply due to incapacitating medical or psychiatric illness reasons, or because family members are undocumented.

 

(Source:  Amended at 31 Ill. Reg. 10635, effective July 13, 2007)

 

Section 131.40  Screening Requirement

 

a)         Children in psychiatric crisis who are believed to be in need of admission to an inpatient psychiatric facility and for whom public payment for the admission may be sought must be referred to CARES.

 

b)         If determined to be appropriate, CARES shall refer the child to a SASS agent.

 

c)         The SASS agent shall screen and assess the mental health needs of the child.

 

Section 131.50  Program Services

 

a)         Community Mental Health Services

 

1)         Children, as a result of the mental health screening required under Section 131.40, for whom it has been determined by a SASS agent that appropriate alternative resources are available in the community shall be referred to those services by the SASS agent.  Community mental health services (CMHS) shall be reimbursed by HFS, DCFS or DHS only under the following conditions:

 

A)        The CMHS provider is enrolled with the HFS to participate in the Illinois medical assistance program and meets the requirements for certification and payment under 59 Ill. Adm. Code 132.

 

B)        The CMHS provider is one of the following:

 

i)          The SASS agent to which responsibility for managing the child’s care was assigned by CARES.

 

ii)         Another CMHS provider that, through CARES, is authorized to provide CMHS to children.

 

C)        The service is provided in accordance with the plan of care developed by the SASS agent.

 

D)        The service is provided during the SASS period.

 

E)        The patient was a child at the time of screening and met eligibility requirements specified in Section 131.30(c).

 

2)         Payment shall be made utilizing rates of reimbursement established under 59 Ill. Adm. Code 132.

 

b)         Pharmacy Services

 

1)        DHS shall pay for certain prescribed drugs dispensed to a child who meets DHS eligibility requirements in Section 131.30(c).  Pharmacy services, other than those provided by an inpatient psychiatric facility, shall be reimbursed only under the following conditions:

 

A)        The pharmacy provider is enrolled with HFS to participate in the Illinois medical assistance program.

 

B)        The service is provided in accordance with the plan of care developed by the SASS agent.

 

C)        The service was provided during the SASS period.

 

D)        The patient was a child at the time of screening.

 

E)        The prescribed drug has been determined by DHS/DMH as appropriate for the treatment of serious emotional disturbance or mental illness or related symptoms.

 

2)         Payment shall be made utilizing rates of reimbursement established under the provisions of 89 Ill. Adm. Code 140.444 and 140.445.

 

c)         Transportation Services

 

1)         DHS shall pay for certain emergency and non-emergency transportation services provided to a child who meets DHS eligibility criteria specified in Section 131.30(c).  Transportation services, other than those provided by an inpatient psychiatric facility, shall be reimbursed only under the following conditions:

 

A)        The transportation provider is enrolled with HFS to participate in the Illinois medical assistance program.

 

B)        The transportation is in support of the plan of care developed by the SASS agent and is to or from a source of medical care covered under this Part.

 

C)        The service was provided during the SASS period.

 

D)        The patient was a child at the time of screening.

 

2)         Payment shall be made utilizing rates of reimbursement established under 89 Ill. Adm. Code 140.492 and 140.493.

 

d)         Inpatient Psychiatric Services

 

1)         DHS shall pay for certain inpatient psychiatric services provided to a child who meets DHS eligibility criteria specified in Section 131.30(c).  Inpatient psychiatric services, other than those provided by an inpatient psychiatric facility operated by DHS, shall be reimbursed only under the following conditions:

 

A)        The inpatient facility is enrolled with HFS to participate in the Illinois medical assistance program and meets the special requirements for inpatient psychiatric services found at 89 Ill. Adm. Code 148.40(a).

 

B)        Prior to admission, the individual shall be screened by a SASS agent to determine the appropriateness of an inpatient admission and the availability of alternative treatment resources in the community.

 

C)        The admission is approved by DHS or its agent.

 

D)        Prior to discharge, the SASS agent participated in the development of the discharge plan.

 

E)        The date of admission was during the SASS period.

 

F)         The patient was a child at the time of admission.

 

2)         Payment shall be made utilizing rates of reimbursement established for the  medical assistance program under 89 Ill. Adm. Code 148.270 and 89 Ill. Adm. Code 152.200, subject to utilization review or pre- or post-payment reviews, as applicable.

 

e)          Psychiatric Physician Services

                         A child eligible for psychiatric physician services must be currently enrolled in a SASS program and must meet the requirements under Section 131.30(c)(1) and (2).

 

1)         Physician services shall be reimbursed only under the following conditions:

 

A)        The physician is enrolled with HFS to participate in the Illinois Medical Assistance Program.

 

B)        The service is one of the following:

 

i)         Psychiatric diagnostic interview examination inpatient and outpatient by a SASS staff psychiatrist;

 

ii)        Electroconvulsive therapy (includes necessary monitoring), single and multiple seizures per day.  Electroconvulsive therapy must have prior approval from DHS;

 

iii)       Individual psychotherapy, insight oriented behavior modifying and/or supportive that is approximately 20-80 minutes face to face with the patient with medical evaluation and management services provided in a hospital inpatient setting only, during an inpatient psychiatric stay; or

 

iv)       Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, approximately 20-80 minutes face to face with the patient with medical evaluation and management services.

 

C)        The service was provided during the SASS period.

 

D)        The patient was a child at the time of screening.

 

2)          Payment shall be made utilizing rates of reimbursement established under the provisions of 89 Ill. Adm. Code 140.410 through 140.414.

 

(Source:  Amended at 31 Ill. Reg. 10635, effective July 13, 2007)

 

Section 131.60  Billing for Services

 

All program services described in this Part are provided and billed to HFS in accordance with that agency's policies as found in the HFS Handbook for Providers of Medical Services (found at www.hfs.illinois.gov/ handbooks/), including any necessary prior authorization for the service.

 

(Source:  Amended at 31 Ill. Reg. 10635, effective July 13, 2007)

 

Section 131.70  Accountability

 

a)         All payments made under this Part are subject to post-payment review and audit pursuant to the applicable rules under which the rates of reimbursement were established (see 89 Ill. Adm. Code 140.30, 140.410 through 140.414, 140.444, 140.455, 140.492, 140.493; 89 Ill. Adm. Code 148.270; and 89 Ill. Adm. Code 152.200).

 

b)         HFS, DHS and DCFS shall implement a systematic process to assess the accessibility, effectiveness, and quality of services provided under this Part.

 

c)         Hospitals and CMHS providers providing services under this Part will be required to participate and cooperate fully in any monitoring and quality improvement efforts undertaken by HFS, DCFS and/or DHS.

 

d)         DHS, DCFS and HFS reserve the right to ensure that appropriate standards of treatment and service delivery are maintained for any individual child or for the system, including on-site inspection and individual consultation.

 

(Source:  Amended at 31 Ill. Reg. 10635, effective July 13, 2007)

Section 131.APPENDIX A  DHS/DMH Target Population

 

The DHS/DMH target population, for purposes of this Part, consists of children 17 years of age or younger who meet the diagnoses criteria of subsection (a) and treatment history of subsection (b) or who meet the diagnoses criteria of subsection (a) and functional criteria of subsection (c).

 

a)         Diagnoses

 

One of the following DSM-IV diagnoses that is the focus of the treatment being provided:

 

1)         Attention Deficit/Hyperactivity Disorders (314.00, 314.01, 314.9)

 

2)         Schizophrenia (295.xx)

 

3)         Schizophreniform Disorder (295.4)

 

4)         Schizo-Affective Disorder (295.7)

 

5)         Delusional Disorder (297.1)

 

6)         Shared Psychotic Disorder (297.3)

 

7)         Brief Psychotic Disorder (298.8)

 

8)         Psychotic Disorder (298.5)

 

9)         Bipolar Disorders (296.0x, 296.4x, 296.5x, 296.6x, 296.7, 296.80, 296.89, 296.90)

 

10)         Cyclothymic Disorder (301.11)

 

11)         Major Depression (296.2x, 296.3x)

 

12)         Panic Disorder with or without Agoraphobia (300.01, 300.21)

 

13)         Obsessive-Compulsive Disorder (300.30)

 

14)         Anorexia Nervosa (307.1)

 

15)         Bulimia Nervosa (307.51)

 

16)         Post Traumatic Stress Disorder (309.81)

 

17)         Intermittent Explosive Disorder (312.34)

 

18)         Tourette’s Disorder (307.23)

 

b)         Treatment History

 

Treatment history covers the client’s lifetime treatment and is restricted to treatment for a DSM-IV diagnosis specified in subsection (a).

 

The youth must meet at least ONE of the following criteria:

 

1)         Continuous treatment of six months or more in one, or a combination of, the following:

 

A)        inpatient treatment;

 

B)        day treatment; or

 

C)        partial hospitalizations.

 

2)         Six months of continuous residence in a residential treatment center.

 

3)         Two or more admissions of any duration to inpatient treatment, day treatment, partial hospitalization or residential treatment programming within a 12 month period.

 

4)         A history of using the following outpatient services over a one year period, either continuously or intermittently:

 

A)        psychotropic medication management;

 

B)        case management; or

 

C)        SASS/intensive community-based services.

 

5)         Previous treatment in an outpatient modality and a history of at least one mental health psychiatric hospitalization.

 

c)                  Functional Criteria

 

Functional criteria has been purposely narrowed to descriptors of the most serious levels of functional impairment and are not intended to reflect the full range of possible impairments.

 

The functional impairment must be the result of the mental health problems for which the child is, or will be, receiving care and must be expected to persist in the absence of treatment.

 

The youth must meet criteria for functional impairment in TWO of the following areas:

 

1)         Functioning in self care – Impairment in age-appropriate self-care skills is manifested by a person’s consistent inability to take care of personal grooming, hygiene, clothing, and meeting of nutritional needs.

 

2)         Functioning in community – Impairment in community functioning is manifested by a consistent lack of age-appropriate behavioral controls, decision-making, judgment and value systems that results in potential involvement in the juvenile justice system.

 

3)         Functioning in social relationships – Impairment of social relationships is manifested by the consistent inability to develop and maintain satisfactory relationships with peers and adults.

 

4)         Functioning in the family –

 

A)        Impairment in family functioning is manifested by a pattern of:

 

i)          disregard for the safety and welfare of self or others, e.g., fire setting, serious and chronic disruptiveness;

 

ii)         significantly disruptive behavior exemplified by repeated and/or unprovoked violence to siblings and/or parents; or

 

iii)        inability to conform to reasonable limitations and expectations.

 

B)         The degree of impairment requires intensive (i.e., beyond age-appropriate) supervision by parent/caregiver and may result in removal from the family or its equivalent.

 

5)         Functioning at school – Impairment in functioning at school is manifested by the inability to pursue educational goals in a normal time frame, e.g., consistently failing grades, repeated truancy, expulsion, property damage, or violence toward others that cannot be remediated in a classroom setting (whether traditional or specialized).