AUTHORITY: Implements Section 7.1 of the Mental Health and Developmental Disabilities Administrative Act [20 ILCS 1705] and the Custody Relinquishment Prevention Act [20 ILCS 540].

SOURCE: Adopted at 42 Ill. Reg. 8258, effective May 4, 2018.

SUBPART A: INDIVIDUAL CARE GRANT – FAMILY SUPPORT PROGRAM

 

Section 139.100  Purpose

 

The Department shall administer the Individual Care Grant program, hereinafter named the Family Support Program (FSP), transferred to it by Section 5-5.23 of the Public Aid Code [305 ILCS 5].  The purpose of the FSP is to provide family support services designed to strengthen family stability and promote care in the community for qualifying youth with severe emotional disturbance.  The FSP provides a coordinated system of community-based and residential services that vary in scope and intensity based upon availability of providers and the particular needs of the youth and families.

 

Section 139.105  Incorporation by Reference

 

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

 

American Psychiatric Association

1000 Wilson Blvd., Suite 1825, Arlington VA 22209-3901

 

DSM-5 – Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition (2013)

 

World Health Organization

20 Avenue Apia, 1211 Geneva 27, Switzerland

 

ICD-10-CM – International Classification of Diseases, 10^th Revision, Clinical Modification

 

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 139.110  Definitions

 

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

 

"Bed Hold" – An approved absence from a residential treatment setting that the Department funds to ensure the individual receiving services retains the bed upon return to the facility.

 

"Community-based Services" – Behavioral health services provided to eligible individuals in the home, school or other natural settings.

 

"Crisis and Referral Entry Service" or "CARES" – Illinois' single point of entry into mobile crisis response services for children that accepts telephonic crisis referrals for children experiencing a mental health crisis and determines the most appropriate program or resource, State-funded or other, to link the referent and child to services.

 

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

 

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

 

"Department" or "HFS" – 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 139.105, that establishes standard criteria for the classification of mental disorders.

 

"Domain" – Area of functioning, interaction or other daily life activity assessed to determine the presence and severity of illness or impairment related to a behavioral health condition.

 

"FSP" – The Family Support Program established by Section 7.1 of the Mental Health and Developmental Disabilities Administrative Act [20 ILCS 1705/7.1] and administered by the Department pursuant to Section 5-5.23 of the Public Aid Code and this Part.

 

"FSP Youth" – An individual determined eligible for and participating in the FSP.

 

"Hospital or Similar Treatment Facility" – For the purpose of the Specialized Family Support Program established in a manner consistent with the Custody Relinquishment Prevention Act [20 ILCS 540], an entity licensed by the Illinois Department of Public Health as a hospital operating as either:

 

a free-standing psychiatric facility; or

 

a community hospital with a psychiatric distinct part unit.

 

"IDPH" – The Illinois Department of Public Health.

 

"Interagency Clinical Team" or "ICT" – The interagency clinical team established by intergovernmental agreement between the Department and the Illinois Departments of: Children and Family Services (DCFS), Human Services (DHS), Juvenile Justice (DJJ) and Public Health (DPH), and the Illinois State Board of Education (ISBE), as required by the Custody Relinquishment Prevention Act [20 ILCS 540].

 

"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 139.105.

 

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

 

"Mobile Crisis Response" – Short-term, crisis intervention and stabilization services provided to individuals presenting in a behavioral health crisis, as authorized by the CARES Line.

 

"Parent or Legal Guardian" – A parent, biological or adoptive, or a short-term legal guardian, or an individual appointed as legal guardian by the court.  A governmental agency, social service agency, or any employee thereof, appointed by a court as legal guardian or custodian is not considered a parent or legal guardian for the purposes of this Part.

 

"Public Aid Code" or "Code" – 305 ILCS 5.

 

"Peer Review Organization/Quality Improvement Organization" or "PRO/QIO" – A group of health quality experts, clinicians and consumers organized to improve the quality of care as permitted at 42 USC 1396a(d).  Details regarding the HFS PRO/QIO can be found at:  https://www.illinois.gov/hfs/MedicalProviders/

proqio/Pages/default.aspx.  

 

"Residential Treatment" – A live-in treatment facility providing intensive therapeutic intervention in a congregate setting for individuals with the most severe mental, emotional and behavioral disorders that cannot be treated or stabilized in a community setting.

 

"SFSP" – The Specialized Family Support Program established by Subpart B of this Part.

 

"SFSP Youth" – A youth at risk of custody relinquishment, referred to CARES, and determined eligible for the Specialized Family Support Program.

 

"Transition Bed Services" – Short-term, time-limited, out-of-home transitional services provided only at the time of a youth's admission to the SFSP, upon leaving the hospital or similar treatment facility, in order to provide necessary stabilization services to participating families.

 

"Youth" – Individuals under the age of 18.

 

"Youth at Risk of Custody Relinquishment" – A youth whose parents or legal guardians refuse to take the youth home from a hospital or similar treatment facility because the parents or legal guardians have a reasonable belief that the youth will harm himself or herself or other family members upon the youth's return home, and there is no evidence of abuse or neglect.

 

Section 139.115  Family Support Program Requirements

 

The following criteria must be met in order to be eligible for FSP Services:

 

a)         The parent or legal guardian of the individual seeking services must demonstrate and maintain residence in Illinois as defined in Section 2-10 of the Illinois Public Aid Code;

 

b)         The individual seeking services must be under the age of 18 at the time of application to be considered for enrollment in the FSP. 

 

c)         The individual seeking services must not be under the legal guardianship or in the legal custody of any unit of federal, State or local government;

 

d)         The parent or legal guardian of the individual seeking services must agree to meet the responsibilities detailed in Section 139.120 and comply with Department policies regarding applying for services; and

 

e)         The individual seeking services must:

 

1)         Demonstrate a severe emotional disturbance (SED) by meeting the following criteria:

 

A)        Have a primary mental health diagnosis from the current DSM or corresponding International Classification of Diseases (ICD) that was identified prior to the individual's 18^th birthday.  For the purposes of demonstrating an SED, the following diagnoses and diagnostic factors shall be excluded as acceptable qualifying primary mental health diagnoses: Adjustment Disorders, Intellectual/Developmental Disabilities, Learning Disabilities, Other Factors that May be the Focus of Clinical Attention from the DSM, and Supplementary Classification of Factors Influencing Health Status and Contact with Health Services from the ICD;

 

B)        In the absence of treatment or other supports, the individual's degree of emotional and mental disturbance consistently prevents him or her from functioning in at least two of the following domains: age appropriate self-care, family life, education, community living, or peer relationships;

 

C)        For individuals under age 6, the individual demonstrates pronounced emotional or behavioral symptoms, including, but not limited to: severe social withdrawal, symptoms of attachment disorder, or aggressive behavior in more than one domain;

 

D)        The illness, symptoms and functional impairment identified in subsections (e)(1)(A) through (C) have been present for at least six months.

 

2)         Demonstrate a severity of need indicating that the individual's clinical needs are not being addressed through actively participating in traditional out-patient mental health services;

 

3)         Demonstrate sufficient cognitive capacity to respond to psychiatric treatment and intervention;

 

4)         Demonstrate an illness presentation consistent with that of a chronic condition, including a history of illness and treatment such that the current presentation is not the result of an acute episode; and

 

5)         Demonstrate behavior or symptoms that are likely to respond to the treatment services available in the FSP.

 

Section 139.120  Family Support Program Parent or Legal Guardian Responsibilities

 

a)         In order for an individual seeking services to participate in the FSP, the parent or legal guardian of the individual must agree to:

 

1)         Actively participate in the FSP youth's care throughout the course of treatment;

 

2)         Be primarily responsible for financial obligations associated with participation in the program (e.g., transportation, any necessary equipment, and other fees incurred not included in the services covered by the Department);

 

3)         Assist in identifying and coordinating funding of services from all available sources, including insurance coverage;

 

4)         Assist in the completion of all applications for public assistance programs, including Medical Assistance, supplemental security income (SSI), Social Security benefits (SSA), and other programs as appropriate;

 

5)         Complete and submit such forms and documents as may be required by the Department;

 

6)         In the event the FSP youth requires treatment in a residential setting pursuant to Section 139.305:

 

A)        Notify the Department of all assets and sources of public financial support of the FSP youth.

 

B)        Make available all sources of public financial support for the FSP youth, including but not limited to SSA and SSI (see 42 USC 1381), to be applied to the costs of residential care, to the extent provided by law;

 

C)        Coordinate all educational functions, processes and funding with the FSP youth's home school district and to ensure compliance with the compulsory education attendance requirements found in Section 26-1 of the School Code [105 ILCS 5].  Parents or legal guardians electing to educate their child in a private education setting or through homeschooling shall be responsible for coordinating all matters with their home school district and be responsible for all financial costs related to education, consistent with Illinois statute and ISBE regulations;

 

D)        Participate in and cooperate with the residential facility's requirements for the FSP youth's care, treatment and discharge to the community;

 

E)        Supply the usual and customary costs of parenthood or legal guardianship, including: clothing, medical, dental, personal allowance, incidentals and transportation costs to and from residential treatment; and

 

F)         Accept the FSP youth back into the home or be solely responsible for establishing residence for the FSP youth upon discharge from residential treatment.

 

b)         The parent or legal guardian must notify the Department of any changes:

 

1)         In the financial income or assets of the parent or legal guardian and FSP youth;

 

2)         In the level of financial support from public sources for the parent or legal guardian and FSP youth;

 

3)         In any health care coverage for the FSP youth;

 

4)         Of address for the parent or legal guardian; and

 

5)         Of legal guardianship or legal custody of the FSP youth.

 

Section 139.125  Application Process and Requirements

 

a)         A parent or legal guardian may obtain an application packet electronically from the Department.

 

b)         All completed application materials may be submitted by the parent or legal guardian to the Department.  The Department's designated provider of mobile crisis response services for children shall assist the parent or legal guardian in obtaining, completing and submitting the application, as requested by the parent or legal guardian.

 

c)         An application is complete and ready for determination when it minimally contains the following:

 

1)         A complete program application;

 

2)         A copy of the youth's birth certificate and proof of Social Security number; and

 

3)         A copy of the court order or documentation defining custody or non-parental guardianship, if appropriate.

 

Section 139.130  Application Determination Process

 

a)         The Department's PRO/QIO will review complete applications based upon the criteria found in Sections 139.115 and 139.120 to determine whether an application is approved or denied within 30 days after the date the Department receives the application.

 

b)         The Department will identify incomplete applications within 30 days after the date the Department receives the application. 

 

1)         Notification of incomplete applications will be made to the parent or legal guardian.  In the event the FSP application was submitted by the Department's designated provider of mobile crisis response services for children, notification of an incomplete application shall be made to the provider to assist families in providing any missing application materials.

 

2)         Incomplete applications must be complete within 30 days after the date of the notice of incomplete application.

 

3)         If an application is not completed within the 30 day period and all missing materials remitted to the Department within that time, the application shall not be reviewed.

 

c)         The Department will issue written notice to the parent or legal guardian stating whether the application was approved, denied or not reviewed due to being incomplete.  Notification of applications that are denied or not reviewed due to being incomplete shall include notice of the right to appeal and instructions on how to pursue appeal as provided in Section 139.600.

 

d)         An application that is denied or determined to be incomplete does not prohibit reapplying for the FSP.

 

Section 139.135  Authorization Process for Family Support Program Participation

 

a)         Youth determined eligible for the FSP shall be authorized to receive services as detailed in Section 139.140, for an initial period of 180 days.

 

b)         Within the last 30 days of an FSP youth's initial or subsequent 180-day authorization to receive FSP services, a Continued Enrollment Authorization Request may be submitted to the Department.

 

1)         The Continued Enrollment Authorization process shall review the FSP youth's:

 

A)        Progress in treatment;

 

B)        Updated Assessment and Treatment Plan;

 

C)        Other updated clinical documentation, as available;

 

D)        The FSP youth's overall clinical presentation to determine whether the FSP youth continues to meet the requirements detailed in Section 139.115; and

 

E)        For FSP youth that are 18 years of age or older but have not reached 21 years of age at the time of Continued Enrollment Authorization:

 

            i)          Active school attendance by the individual; and

 

ii)         Whether the individual has not graduated high school, achieved high school graduation equivalency, or otherwise qualified for high school graduation pursuant to Section 27-22 of the School Code.

 

2)         Determinations that the FSP youth continues to meet the eligibility criteria in Sections 139.115 and 139.135 shall result in an additional authorization for participation in the FSP for a period of 180 days.

 

3)         Determinations that the FSP youth no longer meets the FSP eligibility criteria in Sections 139.115 and 139.135 may be resubmitted for reconsideration.  Reconsideration shall be completed by staff unfamiliar with the original review.  Notice of determination that the FSP youth no longer meets the FSP eligibility criteria in Section 139.115 or fails to meet the criteria in Section 139.135 shall be issued in writing to the parent or legal guardian, along with notice of the right to appeal and instructions on how to pursue an appeal (see Section 139.600).

 

Section 139.140  Family Support Program Services

 

a)         An approved application, regardless of a youth's primary source of insurance (e.g., private insurance, Medicaid, etc.), shall result in the FSP youth being eligible to receive FSP services that include, but are not limited to, service planning, case management and service coordination with other providers, as needed, and:

 

1)         Community-based mental health services, such as:

 

A)        Medically necessary mental health services eligible for reimbursement under the Illinois Medical Assistance Program; and

 

B)        Family support services (see Section 139.300); or

 

2)         Residential treatment subject to prior authorization and continued stay review (see Section 139.500(b), (c) and (d)).

 

b)         When available and determined to be clinically appropriate by clinical staff involved in the youth's treatment process, the use of services qualifying for federal financial participation shall be prioritized over similar services funded by State-only funds in accordance with Section 5-5.23(b) of the Code.

 

c)         The Department shall not be responsible for funding tuition or any other educational costs for youth participating in the FSP.

 

Section 139.145  Family Support Program Service Planning

 

a)         When a youth is determined eligible for the FSP, the Department's designated provider of mobile crisis response services for children will assist the FSP youth and parent or legal guardian in the completion of an FSP Plan.

 

b)         The FSP Plan shall include the development of a crisis safety plan, education on the usage of CARES, and development and review of the FSP youth's service recommendations in the assessment and treatment plan.

 

c)         The FSP youth and all necessary stakeholders, as determined by the FSP youth and parent or legal guardian, shall be included in the FSP planning process as determined to be clinically appropriate by the FSP coordinator.

 

d)         The FSP Plan must include:

 

1)         The presentation, diagnosis, and treatment needs of the FSP youth;

 

2)         Recommended services to address the treatment needs of the FSP youth; and

 

3)         A clinical summary in support of recommended services.

 

e)         The FSP Plan shall be updated and reviewed at least monthly with the parent or legal guardian of FSP youth to ensure effectiveness.

 

f)         In the event the FSP youth is eligible for residential treatment, the Department's designated provider of mobile crisis response services for children shall update the FSP Plan in coordination with the residential facility and the parent or legal guardian.

 

Section 139.150  Family Support Program Discharge

 

a)         An FSP youth may be discharged from the FSP in any of the following circumstances:

 

1)         The FSP youth is determined, pursuant to Section 139.135(b), to no longer be appropriate for the FSP;

 

2)         The FSP youth reaches the age of 21;

 

3)         The parent or legal guardian is no longer an Illinois resident, consistent with Section 139.115(a);

 

4)         Failure of the parent or legal guardian to comply with any of the requirements found in Section 139.120;

 

5)         Legal guardianship or legal custody of the FSP youth is ordered by a court to a State or federal agency, except for the Illinois Office of State Guardian (OSG);

 

6)         The FSP youth does not receive FSP services for any period of 90 consecutive days or more; or

 

7)         The parent or legal guardian, or FSP youth age 18 or older, requests the discharge of the FSP youth.

 

b)         Notice of discharge from the FSP shall be issued to the parent or legal guardian for FSP youth below the age of 18, and to adult FSP youth age 18 and older or the adult FSP youth's legal guardian as applicable, along with notice of the right to appeal and instructions on how to pursue an appeal (see Section 139.600).

SUBPART B: INDIVIDUAL CARE GRANT: SPECIALIZED FAMILY SUPPORT PROGRAM

 

Section 139.200  Purpose

 

Pursuant to the Custody Relinquishment Prevention Act, the purpose of the Specialized Family Support Program (SFSP), is to identify and respond to youth at risk of custody relinquishment and their families.  The SFSP connects those youth and their families with the most appropriate clinical services, while focusing on returning the youth to the home and family by delivering treatment and support services in the least restrictive setting.

 

Section 139.205  Specialized Family Support Program Requirements

 

a)         The following criteria must be met in order for a youth to be enrolled in the SFSP:

 

1)         The youth's parent or legal guardian must demonstrate and maintain residence in Illinois as defined in Section 2-10 of the Illinois Public Aid Code.

 

2)         The youth must be under the age of 18 at the time of SFSP enrollment.

 

3)         The youth must not be under the legal guardianship or in the legal custody of any unit of federal, State or local government.

 

4)         At the time of SFSP enrollment:

 

A)        The youth must be admitted to a hospital or similar treatment facility for the primary purpose of psychiatric treatment and be determined clinically appropriate for discharge in accordance with facility policy;

 

B)        The youth's parent or legal guardian refuses to take the youth home from the hospital or similar treatment facility because the parent or legal guardian has a reasonable belief that the youth will harm himself or herself or other family members upon returning home.

 

5)         The parent or legal guardian and youth have been referred and accepted for SFSP enrollment pursuant to Section 139.215.

 

Section 139.210  Specialized Family Support Program Parent or Legal Guardian Responsibilities

 

a)         In order for a youth to participate in the SFSP, the youth's parent or legal guardian must agree to:

 

1)         Meet the requirements of Section 139.120;

 

2)         Accept and allow the SFSP youth to remain in the home or be solely responsible for establishing a safe alternative residence for the SFSP youth upon enrollment into the program;

 

3)         Assist in the collection of medical, educational and other records and completion of all applications for treatment programs, as appropriate;

 

4)         Initiate and coordinate all necessary educational processes with the youth's home educational district to meet the youth's educational and treatment needs; and

 

5)         Consent to program participation and sign the SFSP Parent Agreement.

 

b)         The parent or legal guardian's failure to comply with any component of Section 139.120 or this Section at any time during participation in the SFSP may result in discharge pursuant to Section 139.225.

 

Section 139.215  Specialized Family Support Program Referral Requirements

 

Referred youth shall be accepted for enrollment into the SFSP upon completion of the following requirements:

 

a)         The parent or legal guardian and youth have been reported to the DCFS Child Abuse Hotline as a youth at risk of custody relinquishment;

 

b)         Existing crisis systems, such as the DHS Comprehensive, Community Based Youth Services (CCBYS) Program, have been unable to stabilize the family crisis, reunite the family, and eliminate the potential of custody relinquishment;

 

c)         DCFS has determined that there is no evidence of abuse or neglect with respect to the report to the DCFS Child Abuse Hotline;

 

d)         A referral to the Crisis and Referral Entry Service (CARES) Line has been made directly from DCFS personnel or individuals designated by DCFS and approved by the Department; and

 

e)         The CARES Line has determined that the youth and the parent or legal guardian meet the criteria required in Section 139.205(a).

 

Section 139.220  Specialized Family Support Program Components

 

a)         SFSP youth will be enrolled in the SFSP for 90 days.

 

b)         During enrollment in the SFSP, the SFSP youth shall be:

 

1)         Assessed to determine his or her behavioral health needs;

 

2)         Assigned a local SFSP coordinator from one of the Department's designated providers of mobile crisis response services for children to coordinate treatment for the SFSP youth;

 

3)         Eligible to receive services consistent with Section 139.140(a)(1) and (2).

 

c)         Upon initial enrollment in the SFSP, the SFSP youth may be eligible for transition bed services (Section 139.310).

 

d)         During the SFSP youth's enrollment, the Department's designated provider of mobile crisis response services for children shall:

 

1)         Work collaboratively with other Illinois crisis systems to stabilize the SFSP youth and family and develop the SFSP youth's crisis safety plan;

 

2)         Work with the SFSP youth and parent or legal guardian to assess the SFSP youth's behavioral health needs and provide treatment recommendations to the Department;

 

3)         Assist the SFSP youth and parent or legal guardian in applying for all State-funded behavioral health programs that the provider has identified as clinically appropriate for the youth; and

 

4)         Provide the Department, prior to the SFSP youth's completion of participation with the SFSP, an SFSP Assessment Report that includes:

 

A)        A mental health assessment;

 

B)        A psychiatric report;

 

C)        An overview of insurance and other public benefits available to fund treatment for the SFSP youth;

 

D)        A listing of any additional assessments completed regarding the SFSP youth and their outcomes;

 

E)        A copy of the SFSP youth's Individual Education Plan (IEP) or similar documentation outlining services or accommodations provided to the SFSP youth by his or her home school district, as applicable;

 

F)         Treatment and service recommendations that the SFSP coordinator has determined are clinically appropriate for the SFSP youth and family; and

 

G)        A clinical review and signature by a Licensed Practitioner of the Healing Arts (LPHA).

 

e)         The SFSP youth's Assessment Report shall be provided to the Interagency Clinical Team (ICT) pursuant to the Custody Relinquishment Prevention Act that will be responsible for connecting the SFSP youth with treatment and services subsequent to participation in the SFSP as recommended in the SFSP Assessment Report.  The Department will work collaboratively with the ICT and other State agencies to assist the ICT in connecting SFSP youth with SFSP Assessment Report recommended services.

 

Section 139.225  Specialized Family Support Program Discharge

 

At any time during SFSP enrollment that the parent or legal guardian no longer meets the applicable requirements of Section 139.210, the SFSP youth may:

 

a)         Be discharged from the SFSP.  The Department shall issue written notice of the discharge to the parent or legal guardian along with notice of the right to appeal and instructions on how to pursue appeal (see Section 139.600).

 

b)         Be referred to the DCFS Child Abuse Hotline for the purpose of reporting the programmatic discharge.

SUBPART C: COMMUNITY AND RESIDENTIAL SERVICES

 

Section 139.300  Family Support Services

 

a)         Family support services include the following:

 

1)         Therapeutic support services that are time-limited, therapeutic interventions, or mental health services, not otherwise reimbursed under the Illinois Medical Assistance Program, targeted to support and stabilize individuals receiving the service in their home or home-like setting.

 

2)         Individual support services are activities, services and goods that are intended to promote community stabilization and family stability, and support the treatment plan of the individual receiving services.

 

b)         The Department shall establish standards for utilization, prior authorization and funding for these services as follows:

 

1)         Family support services require prior authorization by the Department;

 

2)         Maximum annual financial limits per individual are:

 

A)        Therapeutic support services:  $3000; and

 

B)        Individual support services:  $1500.

 

Section 139.305  Family Support Program Residential Treatment

 

a)         Prior authorization is necessary to access residential treatment consistent with Section 139.500(b) and (c).

 

b)         Upon approval of prior authorization for residential treatment, the Department's designated provider of mobile crisis response services for children shall:

 

1)         Discuss the potential facilities available for the FSP youth's placement with the parent or legal guardian;

 

2)         Facilitate preparing and submitting referral packets and necessary consents to potential facilities; and

 

3)         Upon admission of the FSP youth to a residential facility, update the youth's FSP Plan, in coordination with the residential facility (Section 139.145).

 

c)         Admission and ongoing treatment of an FSP youth in a residential facility is based on the availability of treatment services and the availability of providers willing to meet the specific clinical needs of the FSP youth.  The Department shall make every reasonable effort to find and retain an appropriate facility willing to serve the FSP youth.

 

d)         The Department shall reimburse providers of family support program residential treatment services as follows:

 

1)         For State-funded services, pay the program or facility at the rate established by the Purchased Care Review Board (PCRB) as detailed in 89 Ill. Adm. Code 900. All PCRB rates and rate changes shall be applied by HFS with a prospective effective date, following the receipt of the PCRB Rate Change Letter from the provider and confirmation of the rate from the PCRB;

 

2)         For services that qualify for federal financial participation, the Department shall fund services consistent with the rate methodology established pursuant to section 1902(a)(13) of the Social Security Act (42 USC 1396a);

 

3)         The Department may negotiate special services and rates, as necessary, to facilitate behavioral health treatment for individuals:

 

A)        requiring residential treatment;

 

B)        requiring specialized residential services; or

 

C)        requiring supportive services upon transition home.

 

e)         Bed Holds

 

1)         The Department may reimburse a residential facility for bed hold days when the residential facility demonstrates that it is at or over 85% occupancy at the time of the bed hold and:

 

A)        Planned bed hold requests that exceed 3 consecutive days are included in the FSP youth's treatment plan; or

 

B)        Unplanned bed hold requests do not exceed 7 consecutive days.

 

2)         All reimbursement to FSP residential treatment providers for bed holds is subject to prior authorization or concurrent review by the Department (see Section 139.500(e)).

 

3)         An FSP youth's absence from a facility due to acute psychiatric hospitalization, involvement with the criminal justice system, or elopement from the facility for a full treatment day shall not qualify as an acceptable bed hold day and shall not be reimbursed.

 

f)         Transition from Residential Treatment

 

1)         The residential treatment facility shall begin the process of transition planning upon admission of the FSP youth, which includes coordination with the Department's designated provider of mobile crisis response services for children, the parent or legal guardian, and other providers and stakeholders, to ensure that all planning documents reflect a timely transition to least restrictive treatment settings.

 

A)        Within 45 days after admission, the residential treatment facility shall establish and maintain a monthly case staffing meeting to coordinate treatment with the Department's designated provider of mobile crisis response services for children, the parent or legal guardian, and other providers and stakeholders.

 

B)        Notification of monthly case staffing meetings shall be made to all participants 14 days in advance of the meeting date.

 

2)         An FSP youth may remain enrolled in the FSP and transition to community-based services from a residential facility, so long as he or she continues to meet the FSP requirements in Section 139.115.

 

g)         Discharge

FSP youth shall be discharged from a residential treatment facility in the following cases:

 

1)         Successful completion of treatment in a residential facility;

 

2)         Indication from the residential treatment facility that the facility is no longer willing or able to meet the clinical needs of the FSP youth;

 

3)         Request from the parent or legal guardian to discontinue services at the residential treatment facility;

 

4)         The FSP youth no longer meets the clinical criteria for residential treatment services (see Section 139.500(d)).  Upon determination that the FSP youth no longer meets the clinical criteria for residential treatment services, the residential facility shall facilitate discharge to home within 14 days beyond the FSP youth's last approved treatment day; or

 

5)         The FSP youth is discharged from the FSP pursuant to Section 139.150.

 

h)         Notice of Discharge

The residential facility shall provide written notice of discharge to the Department, the FSP youth, and the parent or legal guardian, as appropriate, at least 14 days prior to the date of discharge.  The notice shall include the right to appeal and instructions on how to pursue an appeal (see Section 139.600).

 

i)          Prohibition on Discharge from an Acute Care Setting

 

1)         The residential treatment provider shall not discharge any FSP youth while the FSP youth is receiving inpatient acute care services without the expressed written consent of the Department, if the FSP youth was receiving services at the residential treatment facility immediately preceding admission to an acute care hospital setting.

 

2)         The residential treatment provider shall coordinate the FSP youth's return to the residential treatment setting following acute care hospitalization.

 

Section 139.310  Specialized Family Support Program Transition Bed Services

 

a)         SFSP transition bed services will be provided to individuals enrolled in the SFSP, at the time of the SFSP youth's admission to the program and upon leaving the hospital or similar treatment facility.

 

b)         SFSP transition bed services are subject to prior authorization and shall not be authorized for any combination of periods or days to exceed 30 total days.

 

c)         In order for an SFSP youth to receive an initial 7 days of transition bed services upon admission to the SFSP, the following requirements must be met:

 

1)         The SFSP youth will enter transition bed services upon leaving the hospital or similar treatment facility;

 

2)         A suitable bed is available to accept the SFSP youth within the network of available SFSP transition beds;

 

3)         The Department's designated provider of mobile crisis response services for children determines that the SFSP youth can be stabilized through the application of community supports, but requires short-term use of  transition bed services;

 

4)         The SFSP youth's crisis safety plan indicates that the use of a transition bed will stabilize the SFSP youth's immediate behavioral health needs and is signed by an LPHA;

 

5)         The SFSP youth's parent or legal guardian is willing to accept the SFSP youth home or be solely responsible for establishing an alternative residence for the SFSP youth upon discharge from the transition bed; and

 

6)         The prior authorization has been approved for the SFSP youth to access the SFSP transition bed pursuant to Section 139.500(f)(1).

 

d)         Once an SFSP youth has completed the initial 7 days of transition bed services, the SFSP youth may receive additional periods of authorized days, not to exceed 30 total days of transition bed services, if the following requirements are met:

 

1)         Ongoing authorization of care is approved pursuant to Section 139.500(f)(2);

 

2)         The SFSP youth and the SFSP youth's parent or legal guardian continue to meet the ongoing SFSP eligibility requirements in Sections 139.205 and 139.210; and

 

3)         The SFSP youth's parent or legal guardian has identified a living arrangement for the SFSP youth upon discharge from the SFSP transition bed.

 

e)         The Department will reimburse providers of SFSP transition bed services as follows:

 

1)         For State-funded services, pay the program or facility at the rate established by the Purchased Care Review Board (PCRB) as detailed in  89 Ill. Adm. Code 900. All PCRB rates and rate changes shall be applied by HFS with a prospective effective date, following the receipt of the PCRB Rate Change Letter from the provider and confirmation of the rate from the PCRB; or

 

2)         For services that qualify for federal financial participation, the Department shall fund services consistent with the rate methodology established pursuant to section 1902(a)(13) of the Social Security Act (42 USC 1396a).

SUBPART D: PROVIDERS OF FAMILY SUPPORT SERVICES

 

Section 139.400  Family Support Program Residential Treatment Providers

 

a)         In order to participate in the FSP as a provider of residential treatment services, facilities must meet the following requirements:

 

1)         Be licensed or certified by DCFS, IDPH or HFS as:

 

A)        A child care institution;

 

B)        A group home;

 

C)        An independent living program;

 

D)        A specialty congregate care program or setting;

 

E)        A residential provider participating in the federal Medicaid program; or

 

F)         A non-Illinois entity meeting equivalent credentials as detailed in this subsection (a)(1) in the state in which the facility operates, as accepted by the Department;

 

2)         Establish and maintain enrollment with the Department as a medical provider pursuant to 89 Ill. Adm. Code 140;

 

3)         Comply with all Department handbooks and policies;

 

4)         Review all FSP referrals for admission solely upon clinical and treatment factors of the youth, absent of all educational factors;

 

5)         Upon acceptance of the FSP referral, arrange with the parent or legal guardian for access to, or the provision of, an appropriate educational program to meet the needs of the FSP youth, in compliance with the compulsory education attendance requirements in Section 26-1 of the School Code and this Part;

 

6)         Provide family support program residential treatment pursuant to Section 139.305;

 

7)         Be willing to negotiate additional services, as required by the Department, to meet the individualized needs of FSP youth and to develop any necessary specialized resources required to treat FSP youth;

 

8)         Provide active treatment to admitted FSP youth;

 

9)         Actively involve parents, legal guardians and other necessary stakeholders in the FSP youth's treatment, which includes notifying families of key treatment, educational and social events; and

 

10)         Provide follow-up care to FSP youth.

 

b)         Facilities denied or terminated from participation in the FSP as a provider of residential treatment services for failure to meet the requirements in this Section shall be provided written notice of the denial or termination and of the right to appeal (see Section 139.610).

 

Section 139.405  Specialized Family Support Program:  Transition Bed Services Providers

 

a)         Providers of SFSP transition bed services must meet the following requirements:

 

1)         Comply with Section 139.400, with the exception of Section 139.400(a)(5);

 

2)         Provide SFSP transition bed services pursuant to Section 139.310;

 

3)         Provide short-term crisis and transitional treatment to SFSP youth, not to exceed 30 days; and

 

4)         Comply with the Department's program requirements authorizing the crisis treatment of individuals seeking services.

 

b)         Facilities denied or terminated from participation in the SFSP as a provider of transition bed services for failure to meet the requirements in this Section shall be provided written notice of the denial or termination and of the right to appeal (see Section 139.610).

SUBPART E: UTILIZATION CONTROLS

 

Section 139.500  Medical Necessity and Utilization Review of Services

 

a)         Utilization Review.  The Department shall utilize its designated PRO/QIO to review clinical services provided in a residential setting.  For services requiring prior authorization and ongoing continued stay authorization, payments to providers will only be made upon authorization of services. 

 

1)         Utilization review denials for clinical reasons shall be based upon physician review and determination.

 

2)         Utilization review may consist of, but shall not be limited to, certification of need, prior authorization, continued stay, pre-payment, post-payment, and all other clinical review activities required.

 

3)         Utilization review activities shall determine:

 

A)        Whether the services being requested are reasonable and medically necessary for the diagnosis and treatment of illness;

 

B)        The medical necessity, reasonableness and appropriateness of residential treatment requests for the individual seeking services that have demonstrated that community services are unable to meet his or her clinical needs;

 

C)        The completeness, adequacy and quality of residential treatment, when provided;

 

D)        Whether the quality of the services meets professionally recognized standards of health care; or

 

E)        Whether those services furnished or proposed to be furnished are:

 

i)          Consistent with the provisions of appropriate medical care; and

 

ii)         Being delivered in the most clinically appropriate and cost efficient manner as determined by the PRO/QIO.

 

b)         Certification of Need.  The Department shall require a Certification of Need prior to admission to designated residential treatment facilities.  A Certification of Need shall include:

 

1)         A screening by the Department's designated provider of mobile crisis response services for children to determine that community supports and treatment cannot meet the individual's needs in the community;

 

2)         A psychiatric evaluation and signed attestation from the individual's treating physician indicating the clinical justification for residential treatment.

 

A)        The psychiatric evaluation shall include: mental status examination and diagnosis; overview of illness and presentation, including functional impact; history of treatment, including medications, for at least the most recent 12 months; treatment goals for residential treatment and timespan for achieving those goals; and

 

B)        The signed attestation from the physician shall indicate that admission to a residential setting is required to meet the treatment needs of the individual seeking services; and

 

3)         The Department's agent shall have a physician concur, through the issuance of prior authorization, that the residential treatment at the facility being requested shall be sufficient to meet the clinical needs of the individual seeking services.

 

c)         Prior Authorization for Residential Treatment.  A prior authorization review shall be conducted prior to admission to a residential facility to determine if the request for residential treatment is clinically appropriate for the individual seeking residential care, given the individual's overall clinical presentation.

 

1)         Approved requests for residential treatment shall be issued an initial authorization of 60 days of treatment.

 

2)         Determinations resulting from the prior authorization review that residential treatment is not clinically appropriate may be resubmitted for a prior authorization reconsideration review or completed by a physician unfamiliar with the original review.

 

3)         Final determinations that residential treatment is not clinically appropriate for the individual seeking residential services shall be based upon physician review and clinical determination. Written notice of the determination shall be issued in writing to the individual seeking services, and parent or legal guardian, including notice of the right to appeal and how to pursue an appeal under Section 139.600.

 

d)         Continued Stay Review.  Continued stay review may be conducted during the last 10 days of any authorized treatment period to determine the ongoing clinical appropriateness for residential services.

 

1)         Continued stay reviews shall assess the ongoing needs of an individual seeking care, provision of active treatment by the provider, and the individual's active participation in treatment services.

 

2)         If approved pursuant to continued stay review, residential treatment shall be authorized for a continued treatment period of 30 days.

 

3)         Determinations resulting from the review that residential treatment is no longer clinically appropriate may be resubmitted for a continued stay reconsideration review completed by a physician unfamiliar with the original review.

 

4)         Final determinations that residential treatment is no longer clinically appropriate for the individual seeking residential services shall be based upon physician review and clinical determination. Written notice of the determination shall be issued in writing to the individual seeking services and the parent or legal guardian as appropriate, including notice of the right to appeal and how to pursue an appeal under Section 139.600.

 

e)         FSP Bed Holds

 

1)         Prior approval of planned bed hold requests that exceed 3 days in length shall be performed prior to the FSP youth's departure from the facility.

 

2)         Concurrent review of unplanned bed hold requests shall be performed on the first day of the FSP youth's absence from the facility.

 

3)         Bed hold requests shall be performed consistent with the criteria established in Section 139.305(e).

 

f)         SFSP Transition Beds

 

1)         Prior approval for SFSP transition beds shall be performed prior to admission.  Approved requests for SFSP transition beds shall be issued an initial authorization of 7 days.

 

2)         Continued stay review for SFSP transition beds may be performed within the last 3 days of an SFSP youth's treatment in an SFSP transition bed to seek continued crisis stabilization services.  An approved request for continued stay for SFSP transition beds shall be authorized for subsequent periods up to 7 days, not to exceed a total authorization of 30 consecutive days.

 

g)         Pre-payment Review.  The Department may require residential facilities to submit claims to the Department for pre-payment review and approval prior to rendering payment for services provided.

 

h)         Utilization Control.  Residential treatment facilities funded by the Department are subject to the utilization control requirements established in 42 CFR 456.  The Department or its designee shall provide 30 days written notice to residential providers of the establishment of all necessary utilization control efforts.  Written notice may include the publication of agency handbooks or other policy documents.

 

1)         Denial of Payment as a Result of Utilization Review

 

A)        If the Department determines, as a result of utilization review, that a residential treatment facility has misrepresented admissions, length of stay, discharges or billing information, or has taken an action that results in the unnecessary admission or inappropriate discharge of a program participant, unnecessary multiple admissions of a program participant, unnecessary transfer of a program participant, or other inappropriate medical or other practices with respect to program participants or billing for services furnished to program participants, the Department may, as appropriate:

 

i)          Deny payment (in whole or in part) with respect to residential services provided; and

 

ii)         Require the residential facility to take action necessary to prevent or correct the inappropriate practice.

 

B)        When payment is denied by the Department under subsection (h)(1)(A)(i) as a result of prepayment review, an appeal of the review activity may be made to the PRO/QIO.  The PRO/QIO shall provide the final reconsideration within 30 days after the request of the provider, if that request is:

 

i)          The result of a medical necessity or appropriateness of care denial determination; and

 

ii)         Received within 60 days after receipt of the notice of denial.  The date of the notice of denial is counted as day one.

 

C)        When payment is denied by the Department under subsection (h)(1)(A)(i) as a result of a certification of need, prior authorization, concurrent or continued stay review, an expedited appeal of the review activity may be requested.

 

i)          The PRO/QIO shall provide a final expedited review within one business day after the request of the provider, if the request includes:

 

•           All necessary information to process the appeal of the review;

 

•           All relevant medical documents; and

 

•           The basis for seeking the appeal.

 

ii)         Failure of the provider to submit all needed information shall toll the time in which the final review shall be completed.  The results of the final review shall be communicated to the provider by telephone within one business day, and in writing within 3 business days, after the determination.

 

D)        A determination under subsection (h)(1), if it is related to a pattern of inappropriate admissions, length of stay and billing practices, may result in a referral to the HFS Office of Inspector General.

SUBPART F: APPEALS

 

Section 139.600  FSP and SFSP Recipient Appeals

 

For appeals by individuals or their authorized representatives regarding FSP or SFSP participation or services, the following shall apply:

 

a)         The HFS rules for Assistance Appeals (89 Ill. Adm. Code 104.Subpart A) shall apply to all appeals under this Section except that:

 

1)         Informal review of any appealable issue must be completed by the Department's Bureau of Behavioral Health pursuant to this Section before formal appeal of the issue may be requested by the Department's Bureau of Administrative Hearings (BAH); and

 

2)         Sections 89 Ill. Adm. Code 104.10, 104.11, 104.70(b), 104.70(d), 104.74, 104.75 and 104.80 shall not apply.

 

b)         The parent or legal guardian, FSP youth of legal majority, or authorized representative may appeal the following issues:

 

1)         Failure to take action on an application for a program or request for services;

 

2)         Denial of admission to a program or request for services;

 

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

 

4)         Termination of participation in a program, except that the expiration of the 90 day period of SFSP enrollment shall not be appealable.

 

c)         Individuals or their representatives seeking to appeal any of the issues in subsection (b) must first request informal review of the issue by the Department's Bureau of Behavioral Health before the issue may be appealed to the 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, except that transition bed services shall not be provided beyond a total of 30 days during any instance of participation in the SFSP.

 

d)         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.

 

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

 

2)         The Department shall notify the individual or authorized representative in writing of the result of the informal review.  The written notification shall:

 

A)        State the result of the informal review, including action to be taken, if any;

 

B)        State the reason and policy basis for the action; and

 

C)        Provide notice of the right to appeal and instructions on how to proceed with formal appeal through the BAH.

 

e)         The individual or authorized representative may appeal the result of the informal review by filing a written request for appeal with the BAH within 10 days after the date of the notice of the result of the informal review.  If the request for appeal is received by the BAH prior to the Department's intended action taking effect, the action shall be stayed until the appeal is resolved through final administrative decision or withdrawal of the appeal, except that transition bed services shall not be provided beyond a total of 30 days during any instance of participation in the SFSP.

 

f)         The final administrative decision shall be issued to the interested parties within 90 days after the date the appeal is filed with the BAH unless additional time is required for proper disposition of the appeal.

 

g)         Appropriate action implementing the final administrative decision shall be taken within 30 days after the date the final administrative decision is issued.

 

Section 139.610  FSP and SFSP Provider Appeals

 

For appeals regarding participation as a provider in the FSP and the SFSP, the following shall apply:

 

a)         The HFS rules for Medical Vendor Hearings (89 Ill. Adm. Code 104.Subpart C) shall apply to all appeals under this Section except that Sections 104.204, 104.205, 104.206, 104.207, 104.208, 104.210, 104.211, 104.213, 104.216, 104.217, 104.249, 104.260, 104.272, 104.273 and 104.274 shall not apply.

 

b)         A facility participating or seeking to participate as a provider in the FSP or SFSP may appeal the following:

 

1)         Denial or termination of participation in the FSP as a provider of residential treatment services (see Section 139.400); or

 

2)         Denial or termination of participation in the SFSP as a provider of transition bed services (see Section 139.405).

 

c)         The facility may appeal the Department's action by filing a written request for appeal with the HFS Medical Vendor Hearing Section within 10 days after the date of the notification of the denial or termination of participation as a provider in the program.

 

d)         The burden of proof in hearings conducted pursuant to this Section shall be on the appealing facility.