Ill. Admin. Code tit. 59 § 131.50

Current through Register Vol. 48, No. 49, December 6, 2024

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.

Ill. Admin. Code tit. 59, § 131.50

Amended at 31 Ill. Reg. 10635, effective July 13, 2007