TITLE 59: MENTAL HEALTH
CHAPTER IV: DEPARTMENT OF HUMAN SERVICES
PART 132 MEDICAID COMMUNITY MENTAL HEALTH SERVICES PROGRAM
SECTION 132.25 DEFINITIONS
Section 132.25 Definitions
For the purposes of this Part, the following terms are defined:
Accessibility Compliance with all appropriate provisions of the Americans With Disabilities Act (ADA) (42 USC 12101), as amended, and section 504 of the Rehabilitation Act of 1973 (29 USC 794). No otherwise qualified disabled individual solely by reason of a disability, shall be excluded from participation in, be denied the benefits of or be subjected to discrimination in programs, services or activities sponsored by the Provider. The Provider shall make reasonable modifications in policies, practices or procedures when the modifications are necessary to avoid discrimination on the basis of disability, unless it can demonstrate that making the modifications would fundamentally alter the nature of the services, program or activity. The Provider shall communicate this policy to all visitors, recipients of services, potential recipients of services, and employees. This includes the extent to which a Provider has adapted sites where services are provided to render its physical building elements, parking lot, entry, egress, restrooms, circulation paths, telecommunications and technology accessible to persons with disabilities in accordance with the ADA, section 504, and the most recent standards identified in the Illinois Accessibility Code (71 Ill. Adm. Code 400) and/or ADA Accessibility Guidelines, whichever standard is more stringent, as well as the Provider's reasonable modification for the delivery of services to otherwise eligible Clients for whom a site is inaccessible.
Activity Action taken on behalf of Clients to facilitate receipt of services.
Admission Note − A written report of an initial assessment and treatment plan that initiates Part 132 services for Clients who are admitted to a specialized substitute care living arrangement or for the Client who does not have a completed mental health assessment and is admitted to Assertive Community Treatment (ACT) services or a residential facility designated by the Public Payer for the purpose of stabilizing a crisis.
Adult − An individual who is 18 years of age or older or a person who is emancipated pursuant to the Emancipation of Mature Minors Act [750 ILCS 30].
Applicant − An entity that seeks certification to provide Medicaid community mental health services under this Part.
Assertive Community Treatment or ACT An intensive integrated rehabilitative crisis, treatment and rehabilitative support service for adults (18 years of age and older) provided by an interdisciplinary team to individuals with serious and persistent mental illness or co-occurring mental health and alcohol/substance abuse disorders. The service is intended to promote symptom stability and appropriate use of psychotropic medication, as well as restore personal care, community living and social skills. ACT is further defined in Section 132.150(h).
Certification Certificate A document by the Certifying State Agency that indicates that a stated Provider is certified to provide specific Part 132 services at specified sites.
Certified Family Partnership Professional or CFPP An individual who is certified and in good standing as a Family Partnership Professional by the Illinois Certification Board, doing business as (dba) the Illinois Alcohol and Other Drug Abuse Professional Certification Association, Inc. (IAODAPCA).
Certified Recovery Support Specialist or CRSS − An individual who is certified and in good standing as a Recovery Support Specialist by the Illinois Certification Board, dba IAODAPCA.
Certifying State Agency − Departments responsible for determining and monitoring compliance with this Part: Department of Healthcare and Family Services, Department of Human Services or Department of Children and Family Services.
CGAS − The Children's Global Assessment Scale as published in the Archives of General Psychiatry, Volume 40, November 1983, pp. 1228-1231.
Client − An individual who is Medicaid-eligible and is receiving Medicaid community mental health services.
Clinical Experience Work or volunteer or internship experience providing mental health services or supports supervised by a Mental Health Professional level professional.
CMMS − Centers for Medicare and Medicaid Services. A federal agency within the U.S. Department of Health and Human Services with responsibility for Medicare, Medicaid, State Children's Health Insurance (SCHIP), Health Insurance Portability and Accountability Act (HIPAA), and Clinical Laboratory Improvement Amendments (CLIA).
Collateral − A person with a relationship to a Client and who is important in the treatment or recovery goals of the Client or who is a resource to assist the Client in meeting treatment or recovery goals.
Community Support Service or CS Service Mental health rehabilitation services and supports for children, adolescents, families and adults necessary to assist clients in achieving rehabilitative, resiliency and recovery goals. The service consists of therapeutic interventions that facilitate illness self-management, skill building, identification and use of natural supports, and use of community resources. CS services help clients develop and practice skills in their home and community. CS service is further defined in Section 132.150(e).
Community Support Residential Service or CSR Service Mental health rehabilitation services and supports for children, adolescents and adults necessary to assist individuals in achieving rehabilitative, resiliency and identification and use of adaptive and compensatory strategies, identification and use of natural supports, and use of community resources for individuals who reside in sites designated by the Public Payer. CSR service is further defined in Section 132.150(f).
Community Support Team Service or CST Service Mental health rehabilitation services and supports available 24 hours per day and 7 days per week for children, adolescents, families and adults to decrease hospitalization and crisis episodes and to increase community functioning in order for the client to achieve rehabilitative, resiliency and recovery goals. The service consists of interventions delivered by a team that facilitates illness self-management, skill building, identification and use of adaptive and compensatory skills, identification and use of natural supports, and use of community resources. CST service is further defined in Section 132.150(g).
Confidentiality Act − The Mental Health and Developmental Disabilities Confidentiality Act [740 ILCS 110].
Contract − For purposes of this Part, a written agreement between the applicant/Provider and a Public Payer.
Co-occurring − Co-existing mental health and substance use disorders or developmental disabilities. Individuals eligible to receive services under this Part must have a diagnosis of mental illness.
Credential Designation of LPHA, QMHP, MHP, RSA or professional designation as included in this Part.
Crisis Intervention Services Interventions to stabilize a Client in a psychiatric crisis to avoid more restrictive levels of treatment and that have the goal of immediate symptom reduction, stabilization and restoration to a previous level of role functioning. A crisis is defined as a deterioration in the level of role functioning of the Client within the past 7 days or an increase in acute symptomatology. Crisis intervention services are further defined in Section 132.150(b).
Day − A calendar day unless otherwise indicated.
DCFS − The Illinois Department of Children and Family Services.
DHS − The Illinois Department of Human Services.
DSM-IV − The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (1994) or DSM-IV-TR (2000), American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825, Arlington, Virginia 22209-3901.
Enrollment − The official enrollment of a Provider in the medical assistance program by HFS on determination of compliance with 89 Ill. Adm. Code 140.11.
Family − A basic unit or constellation of one or more adults and children, foster or adoptive parents and children, and private individual guardians.
Focus Review A follow-up review done to assure implementation of an accepted Plan of Correction. A focus review looks at the violations found during a full review and addressed in a required Plan of Correction to assure implementation of the Plan of Correction.
GAF − The Global Assessment of Functioning Scale contained in the DSM-IV.
Guardian − The court-appointed guardian or conservator of the person under the Probate Act of 1975 [755 ILCS 5] or a temporary custodian or guardian of the person of a child appointed by an Illinois juvenile court or a legally-appointed guardian or custodian or other party granted legal care, custody and control over a minor child by a juvenile court of competent jurisdiction located in another state whose jurisdiction has been extended into Illinois via the child's legally authorized placement in accordance with the applicable interstate compact. (See the Juvenile Court Act of 1987 [705 ILCS 405] and the Interstate Compact on the Placement of Children [45 ILCS 15].)
Healthy Kids Screen A mental health screening done as part of an HFS Healthy Kids periodic screening (89 Ill. Adm. Code 140.485).
HFS − The Illinois Department of Healthcare and Family Services.
HIPAA − The Health Insurance Portability and Accountability Act (42 USC 1320 et seq.) (45 CFR 160 and 164 (2003)).
HITECH Health Information Technology for Economic and Clinical Health (HITECH) Act, Title XIII of Division A and Title IV of Division B of the American Recovery and Reinvestment Act of 2009 (ARRA), P.L. 111-5 (Feb. 17, 2009).
ICD-9-CM − International Classification of Diseases, 9th Revision, Clinical Modification (Centers for Medicare and Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244-1850 (2008)).
Intervention A deliberate interaction between staff and one or more Clients or a Client's collateral for the purpose of alleviating the Client's symptoms of mental illness and improving the Client's level of functioning.
ITP − Individual treatment plan.
Level of Role Functioning − Refers to the Client's abilities in critical areas such as vocational, educational, independent living, self-care, and social and family relationships. To assess the severity of the impairment in role functioning, scales approved for use include, but are not limited to, the GAF Scale or the CGAS Scale.
Licensed Clinician − An individual who is either a licensed practitioner of the healing arts (LPHA); a licensed social worker (LSW) possessing at least a master's degree in social work and licensed under the Clinical Social Work and Social Work Practice Act [225 ILCS 20] with specialized training in mental health services or with at least two years experience in mental health services; a licensed professional counselor (LPC) possessing at least a master's degree and licensed under the Professional Counselor and Clinical Professional Counselor Licensing Act [225 ILCS 107] with specialized training in mental health services or with at least two years experience in mental health services; a registered nurse (RN) licensed under the Nurse Practice Act [225 ILCS 65] with at least one year of clinical experience in a mental health setting or who possesses a master's degree in psychiatric nursing; or an occupational therapist (OT) licensed under the Illinois Occupational Therapy Practice Act [225 ILCS 75] with at least one year of clinical experience in a mental health setting.
Licensed Practitioner of the Healing Arts or LPHA − An Illinois licensed health care practitioner who, within the scope of State law, has the ability to independently make a clinical assessment, certify a diagnosis and recommend treatment for persons with a mental illness and who is one of the following: a physician; an advanced practice nurse with psychiatric specialty licensed under the Nurse Practice Act [225 ILCS 65]; a clinical psychologist licensed under the Clinical Psychologist Licensing Act [225 ILCS 15]; a licensed clinical social worker (LCSW) licensed under the Clinical Social Work and Social Work Practice Act [225 ILCS 20]; a licensed clinical professional counselor (LCPC) licensed under the Professional Counselor and Clinical Professional Counselor Licensing Act [225 ILCS 107]; or a licensed marriage and family therapist (LMFT) licensed under the Marriage and Family Therapist Licensing Act [225 ILCS 55] and 68 Ill. Adm. Code 1283.
Medicaid − Medical assistance authorized by HFS under the provisions of the Illinois Public Aid Code [305 ILCS 5/Art. V], the Children's Health Insurance Program Act [215 ILCS 106] and Titles XIX and XXI of the Social Security Act (42 USCA 1396 and 1397aa).
Medical Necessity or Medically Necessary − An LPHA has determined through assessment that a Client has a diagnosis of mental illness or serious emotional disorder as defined in the ICD-9-CM or DSM-IV that has resulted in a significant impairment in the Client's level of functioning in at least one major life functional area and needs one or more mental health services that are identified in the Mental Health Assessment and ITP to stabilize the Client's functioning, or to restore or rehabilitate the Client to a maximum level of life functioning. For Clients under the age of 21, medical necessity or medically necessary may additionally mean that the Client has more than one documented criteria of a mental illness or serious emotional disorder as listed in the DSM-IV that is likely to impact the Client's level of role functioning across critical life areas and needs a Medicaid reimbursable Part 132 mental health service recommended by the completion of an approved Healthy Kids screen by a physician or the completion of a Mental Health Assessment and included in an ITP that could not have been omitted without adversely affecting the Client's level of functioning.
Mental Health Assessment or MHA A Mental Health Assessment required by Section 132.148(a) to assess the need for Part 132 services.
Mental Health Intensive Outpatient Services Scheduled group therapeutic sessions made available for at least 4 hours per day, 5 days per week. Mental health intensive outpatient services are further defined in Section 132.150(j).
Mental Health Professional or MHP − An individual who provides services under the supervision of a Qualified Mental Health Professional and who possesses: a bachelor's degree in counseling and guidance, rehabilitation counseling, social work, education, vocational counseling, psychology, pastoral counseling, family therapy, or related human service field; a bachelor's degree in any other field with two years of supervised clinical experience in a mental health setting; a practical nurse license under the Nurse Practice Act [225 ILCS 65]; a certificate of psychiatric rehabilitation from a DHS-approved program plus a high school diploma or GED plus 2 years experience in providing mental health services; a recovery support specialist certified from, and in good standing with, the Illinois Alcohol and Other Drug Abuse Professional Certification Association, Inc.; a family partnership professional certificate from and in good standing with the Illinois Alcohol and Other Drug Abuse Professional Certification Association, Inc.; an occupational therapy assistant licensed under the Illinois Occupational Therapy Practice Act [225 ILCS 75] with at least one year of experience in a mental health setting; or a minimum of a high school diploma or GED and 5 years supervised clinical experience in mental health or human services. A supervised internship in a mental health setting counts toward the experience in providing mental health services. Any individual meeting the minimum credentials for an LPHA or QMHP under this Part is deemed to also meet the credentialing requirements of an MHP. Any individual employed as an MHP prior to July 1, 2013 may continue to be so designated unless employment changes.
Mental Health Setting A location, public or private, in a group or individual practice, in a mental health center, hospital or clinic where services intended to reduce symptoms of mental illness are provided to persons with mental illness.
Mental Illness − A mental or emotional disorder diagnosis contained in the DSM-IV or ICD-9-CM or, for Clients under age 21, symptoms of mental illness that are likely to impact the Client's level of role function across critical life areas, authorized by the Public Payer funding the services under this Part and the condition that will be the main focus of treatment for services under this Part. Mental illness does not include organic disorders such as dementia and those associated with known or unknown physical conditions such as hallucinosis, amnestic disorder and delirium; psychoactive substance induced organic mental disorders; and mental retardation or psychoactive substance use disorders.
Natural Setting − A setting where an individual who has not been diagnosed with a mental illness typically spends time, including home, school, work, churches, community centers, libraries, parks, recreation centers, etc. These sites are not licensed, certified or accredited as a treatment setting nor typically identified as treatment sites.
Natural Support Persons identified by the Client who are not paid to provide support, e.g., family, friends, pastor.
Notice of Deficiencies A written document that specifies the standards within this Part with which the Provider is not compliant.
Notice of Non-certification A written document that notifies the applicant or Provider that the Certifying State Agency is not issuing a Certificate of Certification.
Notice of Suspension from Billing The report generated under Section 132.42(f) following a post-payment review that details the findings for the review when less than 50% of the billings have been found to be substantiated.
Notice of Unsubstantiated Billings The report generated under Section 132.42(c) following a post-payment review that details the findings of the review.
Off-site − Locations other than those considered on-site.
On-site − Location that is a certified Provider site as described in Section 132.90 and the surrounding Provider owned, leased or controlled property and buildings and adjacent parking areas. Additionally, any service that is provided via telephone or video or that is provided to a Client in a staff person's office in a certified site is considered on-site.
One Year Experience − A period of time consisting of at least 1,500 work hours.
Original Signature A signature affixed to any document that is made by the person to whom the signature belongs, either in ink or via electronic means compliant with Section 132.85(f).
Part 132 Services − The community mental health services described in this Part.
Physician − A physician licensed under the Medical Practice Act of 1987 [225 ILCS 60] to practice medicine in all its branches.
Plan of Correction Plan submitted in response to findings from the Certifying State Agency of non-compliance resulting from a certification or post-payment review that specifies actions the Provider or applicant will take to come into compliance with this Part by correcting the cited violations. The Plan of Correction will include the time frame for compliance and how ongoing compliance will be monitored and assured.
Provider − An organization certified to provide Medicaid community mental health services in accordance with this Part that is a sole proprietorship, partnership, limited liability corporation, unit of local government, or corporation, public or private, either for profit or not for profit.
Psychosocial Rehabilitation Service or PSR Service Facility-based rehabilitative skill-building services for adults age 18 and older with serious mental illness or co-occurring psychiatric disabilities and addictions. The PSR interventions focus on identification and use of recovery tools and skill building to facilitate independent living and adaptation, problem solving and coping skills development. PSR service is further defined in Section 132.150(i).
Psychotropic Medication Medication whose use for antipsychotic, antidepressant, antimanic, antianxiety, behavioral modification or behavioral management purposes is listed in the AMA Drug Evaluations or Physician's Desk Reference, or that is administered for any of these purposes.
Psychotropic Medication Administration Service Consists of preparing the Client and the medication for administration, administering psychotropic medications, observing the Client for possible adverse reactions, and returning the medication to proper storage. Psychotropic medication administration service is further defined in Section 132.150(c)(3).
Psychotropic Medication Monitoring Service Includes observation and evaluation of target symptom response, adverse effects, including tardive dyskinesia screens, and new target symptoms or medication. This may include discussing laboratory results with the Client. Psychotropic medication monitoring service is further defined in Section 132.150(c)(4).
Psychotropic Medication Training Service Includes training the Client or the Client's family or guardian to administer the Client's medication, to monitor proper levels and dosage, and to watch for side effects. Psychotropic medication training service is further defined in Section 132.150(c)(5).
Public Payer − A State agency or a unit of local government that is responsible for payment for services under this Part provided to a Client pursuant to a contract with the Provider.
Qualified Mental Health Professional or QMHP − One of the following:
A licensed social worker (LSW) possessing at least a master's degree in social work and licensed under the Clinical Social Work and Social Work Practice Act [225 ILCS 20] with specialized training in mental health services or with at least 2 years experience in mental health services;
A licensed professional counselor possessing at least a master's degree and licensed under the Professional Counselor and Clinical Professional Counselor Licensing Act [225 ILCS 107] with specialized training in mental health services or with at least two years experience in mental health services;
A registered nurse (RN) licensed under the Nurse Practice Act [225 ILCS 65] with at least one year of clinical experience in a mental health setting or who possesses a master's degree in psychiatric nursing;
An occupational therapist (OT) licensed under the Illinois Occupational Therapy Practice Act [225 ILCS 75] with at least one year of clinical experience in a mental health setting; or
An individual possessing at least a master's degree in counseling and guidance, rehabilitation counseling, social work, vocational counseling, psychology, pastoral counseling, or family therapy or related field, who has successfully completed a practicum or internship that included a minimum of 1,000 hours of supervised direct service in a mental health setting, or who has one year of clinical experience under the supervision of a QMHP.
Any individual meeting the minimum credentials for a LPHA under this part is deemed to also meet the credentialing requirements of a QMHP.
Rehabilitative Services Associate or RSA − An RSA must be at least 21 years of age, be a high school graduate or have a GED certificate, have demonstrated skills in the field of services to adults or children, have demonstrated the ability to work within the Provider's structure and accept supervision, and have demonstrated the ability to work constructively with Clients, treatment resources and the community. Any individual meeting the minimum credentials for an MHP, QMHP or LPHA under this Part is deemed to also meet the credentialing requirements of an RSA. Any individual employed as an RSA prior to July 1, 2013 may continue to be so designated unless employment changes.
Screening, Assessment and Support Services or SASS − A program of intensive mental health services provided by an agency certified to provide Part 132 services and under contract to provide screening, assessment and support services to children with a mental illness or emotional disorder who are at risk for psychiatric hospitalization.
Section 504 − Section 504 of the Rehabilitation Act of 1973 (29 USC 794).
Specialized Substitute Living Arrangement − A living arrangement providing services to a Client supervised by a Provider licensed under the Child Care Act of 1969 [225 ILCS 10] or any comparable Act in another state when the Provider is under contract to the State agency.
State Agency − Department of Healthcare and Family Services, Department of Human Services, or Department of Children and Family Services.
State Medicaid Agency The Illinois Department of Healthcare and Family Services.
Suspended Certificate A certificate that is temporarily inactive due to Certifying State Agency action.
Therapy/Counseling Service A treatment modality that uses interventions based on psychotherapy theory and techniques to promote emotional, cognitive, behavioral or psychological changes as identified in the ITP. Therapy/counseling service is further defined in Section 132.150(d).
Unit of Local Government − A county, municipal corporation, or other local government entity organized under the laws of the State of Illinois that, pursuant to an executed intergovernmental agreement with HFS, has agreed to pay for Medicaid community mental health services.
(Source: Amended at 38 Ill. Reg. 15550, effective July 1, 2014)