Section 141.101  Incorporation by Reference

 

a)         The following materials are incorporated by reference in this Part:

 

DSM-5 – Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (2022), American Psychiatric Association, 1000 Wilson Blvd., Suite 1825, Arlington, VA 22209-3901

 

ICD-10-CM – International Classification of Diseases, 10th Revision, Clinical Modification, World Health Organization, 20 Avenue Apia, 1211 Geneva 27, Switzerland

 

b)         Any rules of an agency of the United States or of a nationally recognized organization or association that are incorporated by reference in this Part are incorporated as of the date specified, and do not include any later amendments or editions.

 

Section 141.110  Definitions

 

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

 

"Behavioral Health Clinic" or "BHC" – An entity certified by the Department, or its agent, pursuant to 89 Ill. Adm. Code 140.499 and enrolled with the Department as a medical provider pursuant to 89 Ill. Adm. Code 140.

 

"Care Coordinator" – An individual who works with participants, providers, and members of an interdisciplinary team to coordinate care needs for the participant, ensuring that plans of care are implemented and that participants receive medically necessary services and supports.

 

"Caregiver" – An individual over the age of 18 who has significant responsibility for the direct care, protection, and supervision of a minor or an adult with a diagnosed disability or other chronic condition.

 

"Child and Family Team" or "CFT" – A group of individuals responsible for the development, implementation, and monitoring of a unified strengths-based service plan that engages and involves the participant and family.

 

"Community Mental Health Center" or "CMHC" – An entity certified by the Department, or its agent, pursuant to 59 Ill. Adm. Code 132 and enrolled with the Department as a medical provider pursuant to 89 Ill. Adm. Code 140.

 

"CPR" – The emergency procedure of cardiopulmonary resuscitation.

 

"Days" – Refers to calendar days unless otherwise stated.

 

"Department" – The Department of Healthcare and Family Services or its agents.

 

"Diagnostic and Statistical Manual of Mental Disorders" or "DSM" – The manual published by the American Psychiatric Association, and incorporated by reference in Section 141.101, that establishes standard criteria for the classification of mental disorders.

 

"Family" – An individual's biological family, adoptive family, guardian and/or authorized caregiver, as appropriate to each individual's age, developmental needs and guardianship status.

 

"High-Fidelity Wraparound" – An evidence-based process of individualized care planning for participants and their families that proceeds through four phases and is guided by the fidelity standards maintained by the National Wraparound Initiative (https://nwi.pdx.edu/).

 

"Home and Community-Based Services" or "HCBS" – Refers to a variety of person-centered medical and social services delivered in the home and in community settings to address the needs of individuals with functional limitations who require assistance.

 

"Integrated Assessment and Treatment Plan" or "IATP" – The service defined at 89 Ill. Adm. Code 140.453(d)(1).

 

"International Classification of Diseases" or "ICD" – A standard diagnostic tool for the identification, treatment and management of illness and disease maintained by the World Health Organization, and incorporated by reference in Section 141.101.

 

"Legal Guardian" – The court-appointed guardian of the person and/or estate under the Probate Act of 1975 [755 ILCS 5].

 

"Licensed Practitioner of the Healing Arts" or "LPHA" – An individual who meets the qualifications outlined at 89 Ill. Adm. Code 140.453(b)(3).

 

"Mental Health Professional" or "MHP" – An individual who meets the qualifications outlined at 89 Ill. Adm. Code 140.453(b)(5).

 

"Participant" – An individual determined eligible for services pursuant to this Part. Participant also includes the eligible individual's parent, legal guardian, or authorized representative, when applicable, for matters such as notice and decisions about the participant's care.

 

"Qualified Mental Health Professional" or "QMHP" – An individual who meets the qualifications outlined at 89 Ill. Adm. Code 140.453(b)(4).

 

"Readiness Review" – The process by which the Department, or its designee, assesses a provider's preparedness to render services consistent with the Department's established policies and procedures.

 

"Rehabilitative Services Associate" or "RSA" – An individual who meets the qualifications outlined at 89 Ill. Adm. Code 140.453(b)(6).

 

"Service Area" – The geographic region of the State in which a provider is designated as the entity responsible for delivering services to participants, as outlined in this Part.

 

Section 141.115  Participant Rights and Responsibilities

 

Participants shall receive an explanation of their rights and responsibilities.  A copy of the rights and responsibilities shall be provided in written format to all participants during the initiation of service planning or upon request by the participant.

 

a)         Participants have the right to request and to receive the services identified under this Part, as medically necessary.

 

b)         Participants may choose at any time not to receive any or all the services for which eligibility has been determined.

 

c)         Participants shall be informed of and shall have the right to choose from the available, medically necessary HCBS services, supports, and providers, as described in this Part.

 

d)         Participants have the right, and will be informed of the process, to request updates to their service plan.

 

e)         Participants have the right to request a copy of their assessment and their service plan.

 

f)         Participants shall be responsible for providing any information, documentation or paperwork required by the Department to appropriately assess and provide services to the participant.

 

g)         The participant is required to notify the Department or its designee of any changes in circumstances that might impact service eligibility or communication with the participant including, but not limited to, change of contact information, change in service needs or participant availability, change of enrollment status in the Medical Assistance Program, or changes to the participant's legally responsible parent, guardian, representative or agent, within 30 calendar days after the effective date of the change.

 

h)         Participants and their parents or legal guardians, are required to actively participate in the participant's care throughout the course of treatment.  This includes responding to requests for additional information from the Department or its designee, participating in the assessment and service planning process, and communicating with selected service providers.  Participants that do not actively participate in treatment for a period exceeding 90 days may be disenrolled from services.

 

Section 141.200  Participant Eligibility Requirements

 

To be determined eligible for the Children's Mental Health Home and Community Based Services (CMH-HCBS), the individual seeking services must meet all the following criteria:

 

a)         Demonstrate and maintain residence in Illinois as defined in Section 2-10 of the Illinois Public Aid Code (305 ILCS 5/2-10);

 

b)         Be eligible for comprehensive medical benefits under Illinois Medical Assistance Program pursuant to Article V of the Illinois Public Aid Code (305 ILCS 5);

 

c)         Be under the age of 21;

 

d)         Demonstrate a Severe Emotional Disturbance (SED), as defined in 89 Ill. Adm. Code 139.115(e)(1), or have been diagnosed with a Severe and Persistent Mental Illness (SPMI), based on the DSM-5; and

 

e)         Demonstrate a degree of emotional and mental disturbance which substantially interferes with, or substantially limits, the individual's ability to function in the family, school, or community setting.

 

Section 141.205  Eligibility Determination Process

 

a)         The Department will implement a standardized, assessment-based process for identifying individuals eligible to receive CMH-HCBS that includes the following:

 

1)         An individual seeking community-based mental health services must first have an Integrated Assessment and Treatment Plan (IATP) completed by a qualified provider of their choice. IATP providers shall be required to upload IATP data into the Department's statewide IATP data system.

 

2)         The Department shall apply a standardized stratification methodology against IATP data to identify individuals who meet the eligibility criteria outlined in Section 141.200. The stratification methodology shall:

 

A)        Utilize information from the individual's IATP to determine whether the individual meets the criteria outlined in Sections 141.200(d) and 141.200(e); and

 

B)        Be published and maintained on the Department's website.

 

b)         Individuals seeking CMH-HCBS, or their parent, legal guardian, or authorized representative as appropriate, may also submit a request for an eligibility determination along with a copy of the individual's completed IATP to the Department or its designee.

 

1)         The Department or its designee will review complete requests for eligibility determination based upon the criteria found in Section 141.200 to determine whether the request is approved or denied within 30 days after the date the completed request for eligibility determination is received by the Department.

 

2)         The Department shall issue a written notice of disposition of the request for eligibility determination, consistent with 89 Ill. Adm. Code 102.70.

 

c)         The Department shall issue written notice to individuals or their parent, legal guardian or authorized representative, when applicable, regarding the individual's eligibility to receive CMH-HCBS within 15 days after the individual is determined eligible.

 

d)         Individuals determined eligible for CMH-HCBS shall be authorized to receive services for a period of 6 calendar months beginning on the first day of the calendar month following the eligibility determination.

 

Section 141.210 Authorization Process for CMH-HCBS

 

a)         Individuals determined eligible for CMH-HCBS shall be authorized to receive services as detailed in Section 141.220 for a period of 6 calendar months beginning on the first day of the calendar month following the eligibility determination or redetermination.

 

b)         The Department will conduct a redetermination of eligibility utilizing the stratification methodology outlined in Section 141.205(a)(2) prior to the end of the participant's 6-month eligibility period.

 

1)         In order to conduct a redetermination of eligibility, a completed full re-assessment of the individual's IATP must be uploaded to the statewide IATP data portal at least 45 days prior to the end of the participant's 6-month eligibility period.

 

2)         The Department or its agent shall notify participants in the instance a re-assessment of the individual's IATP has not been completed at least 45 days prior to the end of the participant's 6-month eligibility period.

 

c)         Determinations that the individual no longer meets the CMH-HCBS eligibility requirements in Section 141.200 shall be issued in writing to the participant, consistent with 89 Ill. Adm. Code 102.70.

 

Section 141.215  Service Reimbursement

 

a)         The CMH-HCBS services detailed in Section 141.220 shall be eligible for reimbursement pursuant to the Department's published fee schedule when the services are rendered by a provider approved by the Department and are:

 

1)         Recommended by a Licensed Practitioner of the Healing Arts (LPHA) in consultation with the participant's Child and Family Team (CFT), as applicable, on the participant's IATP;

 

2)         Provided to a participant for the maximum reduction of mental disability and restoration to the best possible functional level;

 

3)         Provided consistent with any service limitations, utilization controls, and prior authorizations established by the Department pursuant to 89 Ill. Adm. Code 140.40 or as detailed in this Part; and

 

4)         Provided for the direct benefit of the participant, which may include support provided to immediate caregivers of the eligible participant.

 

b)         Reimbursement for CMH-HCBS services shall not:

 

1)         Be made for services provided to a participant at the same time as another service that is the same in nature and scope as the CMH-HCBS service, regardless of payer or program source, including Federal, state, local, and private entities;

 

2)         Include special education and related services defined in the Individuals with Disabilities Education Improvement Act of 2004 (20 U.S.C. 1400 et seq.) that otherwise are available to the participant through a local education agency, or vocational rehabilitation services that otherwise are available to the individual through a program funded under section 110 of the federal Rehabilitation Act of 1973 (29 U.S.C. 701 et seq.); and

 

3)         Be made to relatives, legally responsible individuals, or legal guardians rendering services to the participant.

 

Section 141.220  CMH-HCBS Services

 

Individuals determined eligible for CMH-HCBS shall be eligible to receive the services listed within this section, as medically necessary.

 

a)         Care Coordination and Support (CCS). CCS is an evidence-informed, structured approach to care coordination that adheres to required procedures for participant and family engagement, individualized care planning, identifying and utilizing strengths and natural supports while monitoring progress and fidelity to the required process.  CCS includes a broad set of activities designed to assess, plan, and monitor the service needs of the participant and family and includes, but is not limited to: engagement and outreach; organization and facilitation of a CFT; review and update of the individual's IATP; Crisis Assessment, Safety and Prevention Planning, and Response (CASPR); coordination and consultation with providers and formal and informal supports involved in the participant's care; and, referral, linkage, and follow-up.

 

1)         CCS shall be provided at two intensity levels – CCS: High-Fidelity Wraparound (CCSW) and CCS: Intensive (CCSI).

 

A)        Care Coordination and Support: High-Fidelity Wraparound (CCSW). CCSW shall be delivered in accordance with the evidence-based practice of High-Fidelity Wraparound.  CCSW Care Coordinators shall not exceed an average Care Coordinator to participant caseload of 1:10, with no more than 12 participants on a caseload at one time. CCSW shall include facilitation of at least one CFT meeting a minimum of every 30 days, or more often as appropriate to each participant's needs, as well as frequent in-person and phone contacts.

 

B)        Care Coordination and Support: Intensive (CCSI).  CCSI shall be delivered in accordance with the principles of High-Fidelity Wraparound.  CCSI Care Coordinators shall not exceed an average Care Coordinator to participant caseload of 1:25, with no more than 30 participants on a caseload at one time. CCSI shall include facilitation of at least one CFT meeting a minimum of every 60 days, or more often as appropriate to each participant's needs, as well as frequent in-person and phone contacts.

 

2)         CCS services must be delivered:

 

A)        Consistent with the evidence-informed best practices as approved by the Department;

 

B)        By Community Mental Health Center (CMHC) or Behavioral Health Clinic (BHC) that has been approved as a Care Coordination and Support Organization (CCSO) pursuant to Section 141.240(b);

 

C)        By staff who minimally meet the qualification of an MHP and complete the Department's approved training and certification process as detailed at pathways.illinois.gov;

 

D)        On an individual basis;

 

E)        At a service location and setting deemed appropriate for reimbursement, as detailed in the Department's published fee schedule; and

 

F)         By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in 89 Ill. Adm. Code 140.6(m) and 140.403.

 

b)         Family Peer Support. Family Peer Support is a structured, strengths-based, individualized service provided to a parent, legal guardian or primary caregiver of a participant with behavioral health needs. Family Peer Support services are directed toward the well-being and benefit of the participant and are designed to enhance the caregiver's capacity to understand the participant's behavioral health needs, to support the participant in the home and community, and to advocate for services and supports for the participant and family.  Family Peer Support must be provided:

 

1)         By a CMHC or BHC;

 

2)         On an individual basis;

 

3)         At a service location and setting deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

 

4)         By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in 89 Ill. Adm. Code 140.6(m) and 140.403; and

 

5)         By staff who meet the following requirements:

 

A)        Meet the qualifications of a Rehabilitative Services Associate (RSA);

 

B)        Have individual lived experience or experience as a caregiver of a child with special needs, preferably behavioral health needs;

 

C)        Have experience navigating any of the child-serving systems;

 

D)        Have experience supporting, educating and advocating for family members who are involved with the child-serving systems;

 

E)        Have access to supervision and clinical consultation provided by a Qualified Mental Health Professional (QMHP) or LPHA who actively participates in ongoing training and coaching specific to Family Peer Support as required by the Department and as outlined at pathways.illinois.gov; and

 

F)         Have completed the Department's approved Family Peer Support training process and actively participate in ongoing training and coaching by the Department or its designee as outlined at pathways.illinois.gov.

 

c)         Respite. Respite is a time-limited, individualized, supervised service that provides families scheduled relief to help prevent stressful situations, including avoiding a crisis or escalation within the home.  Services shall be provided in the home and in locations within the participant's community with the intent of providing both participant and caregiver supportive time apart to reduce stress and increase the likelihood of the participant remaining safely at home and in the community.  Respite is a supportive service and is to be provided as an adjunct to other behavioral health therapeutic services the participant and family receives.

 

1)         Respite services must be provided:

 

A)        By a CMHC or BHC;

 

B)        On an individual or group basis.  Group services shall not exceed a 3:1 participant to staff ratio;

 

C)        In a home or other community setting deemed appropriate for reimbursement, as detailed in the Department's published fee schedule.  Respite services shall not be provided in an institutional setting or residential treatment facility;

 

D)        Face-to-face; and

 

E)        By staff who minimally meet the qualifications of an RSA, maintain CPR certification, and have access to a QMHP or LPHA for clinical consultation, as needed.

 

2)         Respite services may be subject to prior authorization, pursuant to 89 Ill. Adm. Code 140.40.

 

d)         Therapeutic Mentoring. Therapeutic Mentoring is a structured, strengths-developing, individualized service provided to a participant who requires support in recognizing, displaying, and using pro-social behavior in the home and community setting.  Therapeutic Mentoring is designed to assist the participant by improving their ability to navigate various social contexts, observe and practice appropriate behaviors and key interpersonal skills that build confidence, assist with emotional stability, demonstrate empathy, and enhance positive communication of personal needs without escalating into crisis.  Therapeutic Mentoring must be provided:

 

1)         By a CMHC or BHC;

 

2)         On an individual basis;

 

3)         At a service location and setting deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

 

4)         By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in 89 Ill. Adm. Code 140.6(m) and 140.403; and

 

5)         By staff who minimally meet the qualifications of a RSA, have access to a QMHP or LPHA for clinical consultation, as needed, and who have completed the Department's approved Therapeutic Mentoring training process as outlined at pathways.illinois.gov.

 

e)         Intensive Home-Based (IHB) Services. IHB services are strengths-based, family-driven, focused services provided directly to participants and their caregivers in home and community settings to:  improve participant and family functioning; improve the family's ability to provide effective support to the participant; and promote healthy family functioning.  Interventions are designed to enhance and improve the family's capacity to maintain the participant within the home and community, and to prevent the participant's admission to an inpatient hospital or other out-of-home treatment setting.

 

1)         IHB services consist of two components: Intensive Home-Based Clinical (IHBC) and Intensive Home-Based Support (IHBS).

 

A)        IHBC are therapeutic services driven by an evidence-informed clinical intervention plan that is focused on symptom reduction. IHBC services may be provided by staff who minimally meet the qualifications of a QMHP and have completed the Department approved training and certification process in family therapy and evidence-based practice as outlined at pathways.illinois.gov.

 

B)        IHBS are adjunct services that may only be provided in conjunction with IHBC services.  The goal of IHBS is to support the participant and family in implementing the therapeutic interventions, skills development, and behavioral techniques outlined in the IHBC clinical intervention plan.  IHBS services must be provided under the clinical direction of the clinician delivering IHBC services.  IHBS services may be provided by staff who minimally meet the qualifications of an MHP, have two years of experience working with children and families, and have completed the Department approved training and certification process in family therapy and evidence-based practice as outlined at pathways.illinois.gov.

 

2)         IHB services require the active participation of at least one adult family member who resides in the same home as the participant or who shares in caregiving responsibility for the participant.

 

3)         IHB services must be delivered:

 

A)        By a CMHC or BHC with an IHB Program Approval pursuant to Section 141.240(b)(2);

 

B)        Consistent with HFS-approved evidence-based practice guidelines and fidelity requirements as outlined at pathways.illinois.gov;

 

C)        By a team overseen by a full-time LPHA;

 

D)        On an individual or family basis;

 

E)        By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in 89 Ill. Adm. Code 140.6(m) and 140.403; and

 

F)         At a service location and setting deemed appropriate for reimbursement, as detailed in the Department's published fee schedule.

 

f)         Therapeutic Support Services (TSS). TSS are adjunct therapeutic modalities not otherwise covered under the Illinois Medical Assistance Program that support individualized goals as part of the participant's service plan.  TSS are designed to help participants find a form of expression beyond words or traditional therapies to reduce anxiety, aggression, and other clinical issues while enhancing service engagement through direct activity and stimulation.  TSS includes the following interventions:  art therapy, dance/movement therapy, equine-assisted therapy, horticultural therapy, music therapy, and drama therapy.

 

1)         TSS shall be subject to standards for utilization and prior authorization as follows:

 

A)        Prior authorization by the Department or its designee shall be required;

 

B)        TSS shall not exceed $3,000 per State fiscal year per participant;

 

C)        The specific TSS interventions must be documented as a recommended service by the authorizing LPHA, in collaboration with the CFT, on the participant's IATP and must be directly tied to supporting the achievement of one or more goals on the service plan; and

 

2)         TSS may only be provided by an individual qualified in the specific intervention being delivered, consistent with the following:

 

A)        Individuals delivering art therapy must be credentialed by the Art Therapy Credentials Board (https://www.atcb.org/);

 

B)        Individuals delivering dance/movement therapy must be credentialed or board certified by the American Dance Therapy Association (https://www.adta.org/);

 

C)        Individuals delivering equine-assisted therapy must have a certification or credential in equine-assisted therapy from a recognized national or international non-profit association;

 

D)        Individuals delivering horticultural therapy must maintain a professional registration with the American Horticultural Therapy Association (https://ahta.memberclicks.net/);

 

E)        Individuals delivering music therapy must be certified by the Certification Board for Music Therapists (https://www.cbmt.org/); and

 

F)         Individuals delivering drama therapy must be credentialed by the North American Drama Therapy Association (https://www.nadta.org/).

 

g)         Individual Supports and Services (ISS). ISS are habilitative activities, services and goods not otherwise covered under the Illinois Medical Assistance Program that serve as adjunct supports to the therapeutic interventions and supports for participants. ISS are intended to promote health, wellness and behavioral health stability through community stabilization and family stability.  ISS services may only be provided for the direct benefit of the participant.

 

1)         ISS includes the following categories of activities, services and goods:

 

A)        Physical wellness activities and goods that promote a healthy lifestyle through physical activity (i.e., sports club fees or gym memberships; bicycles, scooters, roller skates and related safety equipment) and nutrition education (i.e., cooking classes, non-credit nutrition courses);

 

B)        Special or therapeutic youth development programs offered by a community-based organization that serve individuals with disabilities who otherwise would not be able to successfully participate in traditional youth development programs.  These programs focus on developing social skills through youth development opportunities that are supported by staff with specialized training;

 

C)        Strengths-developing activities (i.e., music lessons, art lessons, therapeutic summer camp);

 

D)        Sensory items ordered by a licensed occupational therapist, speech-language pathologist, physical therapist, or Licensed Practitioner of the Healing Arts as defined in 89 Ill. Adm. Code 140.453(b)(3); and

 

E)        Parent education and training.

 

2)         ISS shall be subject to standards for utilization and prior authorization as follows:

 

A)        Prior authorization by the Department or its designees shall be required;

 

B)        ISS shall not exceed $1,500 per State fiscal year per participant; and

 

C)        The specific ISS interventions must be documented as a recommended service by the authorizing LPHA, in collaboration with the CFT, on the participant's IATP and must be directly tied to supporting the achievement of one or more goals on the service plan.

 

Section 141.230  Service Planning

 

a)         When an individual is determined eligible for CMH-HCBS, they shall be assigned to a designated Care Coordination and Support Organization (CCSO) to initiate service planning.  Participants shall have free choice of CCSO providers, including the ability to switch CCSO providers at any time.

 

b)         Child and Family Teams. CCSOs shall convene a CFT for each participant receiving CCS.  The CFT shall include the participant, the participant's primary caregiver and family members as appropriate, the CCSO, and should seek to include additional formal and informal supports involved in the participant and family's lives.

 

1)         The CFT shall meet on a regular basis, consistent with the Department's provider handbook for CCSOs available on the Department's website and pursuant to the requirements of CCS services outlined in Section 141.220(a). 

 

2)         Participants shall have full choice in determining the members of their CFT.

 

3)         The CFT, utilizing a consensus based process facilitated by the CCSO, shall support participants and families in achieving their identified goals through the ongoing identification of the participant and family's strengths and needs, the development of a strengths-based service plan, and regular review of the participant and family's progress towards meeting their goals.

 

c)         Strengths-Based Service Plans.  The CCSO shall work with participants, their family, and CFT members, as appropriate, to develop an individualized, strengths-based service plan that is based upon the participant's assessed needs and strengths and identified service preferences.

 

1)         The strengths-based service plan shall include:

 

A)        The presentation, diagnosis, and holistic strengths and needs of the participant;

 

B)        A crisis prevention and safety plan;

 

C)        Recommended services to address the needs of the participant and family; and

 

D)        A clinical summary in support of recommended services.

 

2)         The service plan shall be finalized and agreed to with the informed consent of the participant in writing, signed by all individuals and providers responsible for its implementation, and reviewed and authorized by an LPHA.

 

3)         Individuals receiving CCS services shall have their strengths-based service plans reviewed and updated, as necessary, consistent with the CFT meeting frequency outlined in Section 141.220(a).  Strengths-based service plans for participants receiving CMH-HCBS but not receiving CCS services shall be reviewed and updated no less frequently than every 180 days.

 

Section 141.240  CMH-HCBS Provider Requirements

 

a)         Care Coordination and Support Organizations (CCSO).  Providers approved to provide CCS services shall be referred to as CCSOs.  CCSOs must:

 

1)         Obtain and maintain CCS program approval pursuant to Section 141.240(b).

 

2)         Provide cost reporting information upon request to the Department in a manner and format specified by the Department.

 

3)         Not provide other non-waiver HCBS services defined in this Part, unless the Department has determined the provider is the sole provider willing and qualified to provide such services within the provider's Service Area and that the provider has established sufficient separations and independence between its direct service delivery and CCS services to ensure that conflict of interest standards are met.

 

4)         Maintain, or establish prior to the delivery of any CCS services, Medicaid Rehabilitation Option (MRO) Crisis Services Program Approval pursuant to 89 Ill. Adm. Code 140.Table N.(c)(4).

 

5)         Provide the Department with a minimum of 90 days written notice in the instance that the provider is unable or unwilling to continue providing services.

 

b)         Program Approvals

 

1)         Care Coordination and Support (CCS) Program Approval

 

A)        Program Approval Process

 

i)          Providers seeking program approval as a CCSO shall complete and submit the Department's CCSO Provider Application. The Department will accept and review CCSO Provider Applications during established application timeframes, according to a standardized schedule maintained and published on the Department's website at pathways.illinois.gov.

 

ii)         Applicants determined to be approved as a CCSO must pass a Readiness Review, to be conducted by the Department or its designee, prior to delivering CCS services. The Readiness Review shall examine a provider's readiness to deliver CCS services, including a review of policies, procedures, training materials, staffing levels, and other documents necessary to verify a provider's readiness to begin accepting referrals for CCS services. The Department may, at its sole discretion, elect to perform any or all components of the Readiness Review on-site.

 

iii)        Approved CCSOs shall be subject to ongoing quality and fidelity monitoring activities and reviews.

 

iv)        Deficiencies identified as part of the Readiness Review process or as part of the Department's quality or fidelity monitoring reviews shall be communicated in writing to the provider. Providers shall be given no less than 30 days to correct or ameliorate deficiencies identified by the Department or its designee.

 

B)        Service Delivery. The provider must attest annually to meeting the standards detailed in this subsection. The provider shall demonstrate compliance with the following requirements through policy, procedures, staffing detail, aggregated service detail, and/or client record documentation:

 

i)          CCS services are to be available 24 hours a day, each day of the year, and shall minimally adhere to the Department's crisis response protocols and timeframes when delivering crisis response services.

 

ii)         The provider must have sufficient office space to deliver CCS services consistent with the requirements outlined in this Part.

 

iii)        CCS services are to be delivered to all referred individuals within the Service Area on a no-decline basis.

 

iv)        The provider must coordinate service delivery with the participant's primary care provider, behavioral health care providers, other community and supportive services providers, and/or managed care entity, as appropriate.

 

v)         CCS services are to be delivered consistent with the values, principles, and processes of Wrapround and in accordance with the fidelity standards published on the Department's website at pathways.illinois.gov.

 

vi)        CCS services are to be provided during times and at locations that reasonably accommodate the participant and family's service and treatment needs.

 

C)        Staffing Requirements

 

i)          CCSOs shall ensure that CCS services are delivered by staff who are not:

 

•           Related by blood or marriage to the participant, or any paid caregiver of the participant;

 

•           Financially responsible for the participant; or

 

 

•           Empowered to make financial or health-related decisions on behalf of the participant.

 

ii)         Staff delivering CCS services shall meet the credentials detailed in Section 141.220(a).

 

iii)        Supervisors of Care Coordinators must:

 

•           Maintain an average ratio of one supervisor to no more than eight (1:8) staff members, with no more than 10 staff members assigned to one supervisor at a time;

 

•           Minimally meet the qualifications of a QMHP; and

 

•           Complete the Department's required training and certification processes as outlined at pathways.illinois.gov.

 

iv)        CCSOs shall employ at least one full time Clinical Manager who meets the qualifications of an LPHA and who is responsible for overseeing CCS services.

 

2)         Intensive Home-Based (IHB) Services Program Approval

 

A)        Providers seeking program approval to provide IHB services shall be approved pursuant to the program approval process outlined in 89 Ill. Adm. Code 140.Table N(b), except that program approval and subsequent re-approval reviews shall be conducted every two years and shall be conducted to determine compliance with Section 141.220(e) and the IHB requirements outlined in this subsection.

 

B)        Service Delivery.  The provider must attest annually to IHB services meeting the standards detailed in this subsection. Additionally, the provider shall demonstrate compliance with the following requirements through policy, procedures, staffing detail, aggregated service detail and/or client record documentation.

 

i)          Providers of IHB services must deliver services in the participant's natural setting, based upon the preferences of the participant and family, with an emphasis on services occurring in the home setting to the extent possible.

 

ii)         Providers of IHB services must provide IHB services during times that are convenient to the participant and family and that accommodate the participant's service and treatment needs, including evenings and weekends as needed.

 

iii)        For participants receiving CCS services, the IHB provider shall collaborate with the participant's CCSO, including maintaining monthly contact with the participant's designated Care Coordinator and participating in the participant's CFT meetings, as appropriate.

 

iv)        In the instance a participant receiving IHB experiences a crisis event, the IHB provider shall make efforts to be available for consultation to the participant, family, and the responding crisis worker as applicable.

 

v)         Providers of IHB services must ensure that multiple contacts are made with the participant and family per week, with as many contacts as possible occurring face-to-face, based upon the participant and family's needs and preferences.

 

3)         Providers delivering IHB services must maintain an IHB team lead meeting the qualifications of an LPHA.

 

4)         Provider-Based Utilization Management. The provider shall establish an IHB service review process that adheres to the following:

 

A)        The team delivering IHB services shall meet weekly to review the treatment progress of participants receiving IHB services.

 

B)        The IHB team lead shall review the participant's IATP and IHB clinical intervention plan monthly to ensure ongoing necessity for service delivery. The IHB team lead shall:

 

i)          Review each participant's progress in service; and

 

ii)         Identify any necessary changes in IHB services, including a recommendation for transition to less intensive services, consistent with the participant's IATP. Recommendations for changes in the frequency, duration, or scope of IHB services shall be shared with the participant's designated care coordinator and CFT, when applicable.

 

Section 141.250  Participant Appeals

 

For appeals by individuals or their authorized representatives regarding CMH-HCBS participation or services, the following shall apply:

 

a)         The individual, parent or legal guardian, or authorized representative may appeal the following issues:

 

1)         Failure to take action on a request for eligibility determination or a request for services;

 

2)         Denial of a request for CMH-HCBS eligibility or a request for services;

 

3)         Any action by the Department to reduce, change, suspend or terminate any service; or

 

4)         Termination of eligibility for CMH-HCBS.

 

b)         The Department rules for Assistance Appeals (89 Ill. Adm. Code 104.Subpart A) shall apply to all appeals under this Section, except that informal review of a denial of a request for CMH-HCBS eligibility or termination of eligibility for CMH-HCBS must be completed by the Department's Bureau of Behavioral Health pursuant to this Section before formal appeal of the issue may be requested to the Department's Bureau of Administrative Hearings (BAH).

 

1)         Request for informal review must be submitted in writing to the Bureau of Behavioral Health within 20 days after the date of notice of the contested action and must clearly identify the issue or action for which informal review is sought.

 

2)         If the request for informal review is received by the Bureau of Behavioral Health prior to the Department's intended action taking effect, the action shall be stayed through the completion of the informal review and the subsequent 10 day period to formally appeal the outcome of the informal review to the BAH pursuant to 89 Ill. Adm. Code 102.81.

 

3)         The Bureau of Behavioral Health shall complete the informal review of the contested action within 30 days after receipt of the request and shall determine whether to maintain, reverse or modify the action, or take other action as necessary.

 

A)        The Department may request and review all materials pertaining to the informal review held by the Department's vendors, agents or providers.

 

B)        The Department shall provide written notification to the individual or authorized representative of the result of the informal review, consistent with 89 Ill. Adm. Code 102.70.

 

4)         The individual, parent or legal guardian, or authorized representative may appeal the outcome of the informal review to the BAH within 60 days after the date of notice of the outcome of the informal review, pursuant to 89 Ill. Adm. Code 102.82.

 

Section 141.260  Provider Appeals

 

Appeals regarding participation as a provider of CMH-HCBS services or the Department's decision regarding program approval, as outlined in this Part, shall be conducted pursuant to the process outlined in 89 Ill. Adm. Code 140.Table N(f).