TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER d: MEDICAL PROGRAMS
PART 140 MEDICAL PAYMENT
SECTION 140.453 COMMUNITY-BASED MENTAL HEALTH SERVICE DEFINITIONS AND PROFESSIONAL QUALIFICATIONS


 

Section 140.453 Community-based Mental Health Service Definitions and Professional Qualifications

 

a) Inter-Departmental Collaboration and Administration. The Department of Human Services-Division of Mental Health (DHS-DMH) and the Department of Children and Family Services (DCFS), pursuant to an executed interagency agreement, shall ensure the administration and coordination of mental health services.

 

b) Community-based Mental Health Professional Qualifications. All individuals qualified under this Section to provide services shall only provide the services listed in this Section within their scope of practice, as defined or by federal or state law, regulation or policy.

 

1) All professional definitions provided in this subsection (b) are only applicable to services detailed in this Section.

 

2) Independent Practitioner (IP). An IP, as defined by Section 140.452(a)(3), may receive direct reimbursement for services pursuant to Section 140.452(e). All other credentialed staff detailed in this Section must be employees of a Community Mental Health Center or Behavioral Health Clinic that may qualify for reimbursement for the services provided.

 

3) Licensed Practitioner of the Healing Arts (LPHA). An LPHA is defined as:

 

A) A physician who holds a valid license in the state of practice and is legally authorized under state law or rule to practice medicine in all its branches, so long as that practice is not in conflict with the Medical Practice Act of l987;

 

B) An advanced practice nurse with psychiatric specialty that holds a valid license in the state of practice and is legally authorized under state law or rule to practice as an advanced practice nurse, so long as that practice is not in conflict with the Illinois Nurse Practice Act or the Medical Practice Act of 1987;

 

C) A clinical psychologist who holds a valid license in the state of practice and is legally authorized under state law or rule to practice as a clinical psychologist, so long as that practice is not in conflict with the Clinical Psychologist Licensing Act;

 

D) A licensed clinical professional counselor possessing a master's degree who holds a valid license in the state of practice and is legally authorized under state law or rule to practice as a licensed clinical professional counselor, so long as that practice is not in conflict with the Professional Counselor and Clinical Professional Counselor Licensing Act [225 ILCS 107];

 

E) A marriage and family therapist who holds a valid license in the state of practice and is legally authorized under state law or rule to practice as a marriage and family therapist, so long as that practice is not in conflict with the Marriage and Family Therapist Licensing Act [225 ILCS 55];

 

F) A clinical social worker possessing a master's or doctoral degree who holds a valid license in the state of practice and is legally authorized under state law or rule to practice as a social worker, so long as that practice is not in conflict with the Clinical Social Work and Social Work Practice Act.

 

4) Qualified Mental Health Professional (QMHP). A QMHP is defined as one of the following:

 

A) Any individual identified as an LPHA in subsection (b)(3);

 

B) A registered nurse who holds a valid license in the state of practice, is legally authorized under state law or rule to practice as a registered nurse, so long as that practice is not in conflict with the Illinois Nurse Practice Act, and has training in mental health services or one year of clinical experience, under supervision, in treating problems related to mental illness, or specialized training in the treatment of children and adolescents.

 

C) An occupational therapist who holds a valid license in the state of practice and is legally authorized under state law or rule to practice as an occupational therapist, so long as that practice is not in conflict with the Illinois Occupational Therapy Practice Act [225 ILCS 75] with at least one year of clinical experience in a mental health setting. In the event the state of practice does not provide a legal authority for licensure, the individual must meet the requirements of 42 CFR 484.4 for an occupational therapist.

 

D) An individual possessing a master's or doctoral degree in counseling and guidance, rehabilitation counseling, social work, psychology, pastoral counseling, family therapy, or a related field and has:

 

i) Successfully completed 1,000 hours of practicum and/or internship under clinical and educational supervision; or

 

ii) One year of documented clinical experience under the supervision of a QMHP.

 

5) Mental Health Professional (MHP)

 

A) An MHP is defined as one of the following:

 

i) Any individual identified as a QMHP in subsection (b)(4); or

 

ii) An individual meeting the following qualifications, delivering services under the supervision of a QMHP:

 

An individual possessing 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;

 

An individual possessing a bachelor's degree in any field, other than those identified in subsection (b)(4)(D), with two years of documented clinical experience in a mental health setting under the supervision of a QMHP;

 

A practical nurse who holds a valid license in the state of practice and is legally authorized under state law or rule to practice as a practical nurse, so long as that practice is not in conflict with the Illinois Nurse Practice Act;

 

An individual possessing a certificate of psychiatric rehabilitation from a DHS-approved program, plus a high school diploma or GED, plus two years' documented experience in providing mental health services;

 

A recovery support specialist with a current certification from the Illinois Alcohol and Other Drug Abuse Professional Certification Association, Inc.;

 

A family partnership professional with current certification from the Illinois Alcohol and Other Drug Abuse Professional Certification Association, Inc.;

 

An occupational therapy assistant with at least one year of experience in a mental health setting that holds a valid license in the state of practice and is legally authorized under state law or rule to practice as an occupational therapist assistant, so long as that practice is not in conflict with the Illinois Occupational Therapy Practice Act. In the event the state of practice does not provide a legal authority for licensure, the individual must meet the requirements of 42 CFR 484.4 for an occupational therapist; or

 

An individual with a high school diploma or GED and a minimum of five years documented clinical experience in mental health or human services.

 

An individual who has completed a behavioral health technician or other psychiatric training certification through the Medical Education and Training Campus in Fort Sam Houston, Texas, with one year documented clinical experience in a mental health setting under supervision of a QMHP.

 

B) Any individual designated as an MHP prior to July 1, 2011 shall retain that designation throughout the continual course of his/her employment. In the event that the individual leaves the current employer, the designation is no longer valid.

 

6) Rehabilitative Services Associate (RSA). An RSA is defined as one of the following:

 

A) Any individual identified as a QMHP in subsection (b)(4); or

 

B) An individual meeting the following qualifications, delivering services under the supervision of a QMHP:

 

i) Any individual identified as an MHP in subsection (b)(5); or

 

ii) Any individual who is 21 years of age and demonstrates all of the following:

 

Skill in the delivery of rehabilitative services to adults or children;

 

The ability to work within a provider agency's structure and accept supervision; and

 

The ability to work constructively with individuals receiving services, other providers of service, and the community.

 

c) Service Reimbursements. The services detailed in subsections (d) and (e) may be eligible for reimbursement pursuant to the Department's published fee schedule when the services are:

 

1) Recommended by an LPHA or IP, operating within his/her scope of practice. Unless otherwise noted in this Section, the term services "recommended by an LPHA or IP" shall mean:

 

A) The services of Integrated Assessment and Treatment Planning performed by an LPHA or IP to determine an individual's potential clinical need for services; or

 

B) Those services identified by the LPHA or IP following the completion of an Integrated Assessment and Treatment Plan;

 

2) Provided to an individual for the maximum reduction of mental disability and restoration to the best possible functional level in accordance with 42 CFR 440.130. A mental disability, for the purposes of receiving services under this Section is established as follows:

 

A) The identification of a diagnosis, a functional impairment, and treatment recommendations by the LPHA or IP following the completion of the Integrated Assessment and Treatment Plan; or

 

B) For children under age 21 who do not meet the criteria listed in subsection (c)(2)(A), the identification of more than one documented criterion for a mental disorder listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a documented impact on the child's functioning in more than one life domain, and treatment recommendations by the LPHA or IP following the completion of the Integrated Assessment and Treatment Plan;

 

3) Provided consistent with any service limitations, utilization controls, and prior authorizations established by the Department. All prior authorizations for the services detailed in this Section shall be completed by the Department or its approved agent; and

 

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

 

d) Medicaid Rehabilitation Option (MRO). The following services are established as qualified mental health services under section 1905(a)(13)(C) of the Social Security Act (42 USC 1396d(19)).

 

1) Integrated Assessment and Treatment Planning (IATP). IATP is the formal process of information gathering and review that utilizes a standardized assessment and service planning tool in order to: identify a client's integrated healthcare needs and strengths across all domains; recommend services needed to ameliorate a client's condition and improve well-being; and develop, review, and update an individualized treatment plan.

 

A) The IATP shall:

 

i) Be completed once every 180 days;

 

ii) Only be reimbursed upon utilization of a Department approved assessment and service planning instrument as published on the Department's website;

 

iii) Be reviewed, approved and signed by an LPHA;

 

iv) Be provided to the client, or the client's parent or guardian, upon completion or revision.

 

B) The IATP service is also inclusive of the following functions:

 

i) Clinical assessment activities, performed by, or under the supervision of, an LPHA using a nationally standardized assessment instrument resulting in a written report or documented outcome that includes the identification of a clinical issue or tentative diagnosis to assist in the completion of IATP;

 

ii) Diagnostic assessment activities, only when provided consistent with the Clinical Psychologist Licensing Act [225 ILCS 15] and using a nationally standardized psychological assessment instrument, resulting in a written report that includes the identification of issues, tentative diagnosis, and recommendations for treatment or services; and

 

iii) The completion of the Level of Care Utilization System (LOCUS) screen, or its successor instrument.

 

C) IATP may be provided:

 

i) By Community Mental Health Centers, Behavioral Health Clinics, or Independent Practitioners;

 

ii) At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

 

iii) On an individual basis;

 

iv) By an MHP, QMHP, LPHA; and

 

v) By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in Sections 140.6(n) and 140.403.

 

2) General MRO Services

 

A) Community Support Services. Community Support Services shall consist of therapeutic interventions that facilitate illness self-management, identification and use of natural supports, and skill building.

 

i) Community Support Services includes: engaging the individual to have input into his/her service delivery and recovery process; development of relapse prevention strategies and plans; assistance in development of functional, interpersonal and community coping skills (including adaptation to home, school, family and work environments); and skill-building related to symptom self-monitoring. Community Support Services may include an evidence-informed approach to skills training.

 

ii) Community Support Services may only be provided:

 

By a Community Mental Health Center or Behavioral Health Clinic;

 

At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

 

In an individual or group modality;

 

By an RSA, MHP, QMHP, LPHA; and

 

By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in Sections 140.6(n) and 140.403.

 

B) Intensive Outpatient (IO) Services. Intensive Outpatient Services are scheduled group therapeutic sessions made available for at least four hours per day, five days per week, for individuals at risk of, or with a history of, psychiatric hospitalization.

 

i) IO Services may only be provided:

 

By a Community Mental Health Center or Behavioral Health Clinic;

 

Through programs approved pursuant to Table N;

 

At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

 

By a QMHP;

 

In a group modality; and

 

On a face-to-face basis.

 

ii) IO services may be subject to prior authorization, pursuant to Section 140.40.

 

C) Medication Administration. Medication Administration consists of preparing the individual and the medication for administration and observing the individual for possible adverse reactions. Medication Administration services may only be provided:

 

i) By a Community Mental Health Center or Behavioral Health Clinic;

 

ii) At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

 

iii) On an individual basis;

 

iv) By face-to-face contact; and

 

v) By staff that hold a valid license in the state of practice and are legally authorized under state law or rule to administer medication, so long as that practice is not in conflict with the Illinois Nurse Practice Act or the Medical Practice Act of 1987 (e.g., a physician, a psychiatrist, advanced practice nurse, registered nurse or a practical nurse).

 

D) Medication Monitoring. Medication Monitoring includes observation, evaluation and discussion of target symptoms responses, adverse effects, laboratory results, tardive dyskinesia screens, and new target symptoms or medications. Medication Monitoring services may only be provided:

 

i) By a Community Mental Health Center or Behavioral Health Clinic;

 

ii) At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

 

iii) On an individual basis;

 

iv) By an RSA, MHP, QMHP or LPHA, as designated in writing to provide the service by staff that hold a valid license in the state of practice and are legally authorized under state law to prescribe medication pursuant to the Illinois Nurse Practice Act or the Medical Practice Act of 1987; and

 

v) By video or face-to-face contact, notwithstanding the restriction on services provided via phone in Sections 140.6(n) and 140.403. Phone consultation is allowed only when a client is experiencing adverse symptoms and phone consultation with another professional is necessary.

 

E) Medication Training. Medication Training includes training individuals on self-administration and safeguarding of medication and communication with other professionals, family or caregivers on medication issues. Medication Training services may only be provided:

 

i) By a Community Mental Health Center or Behavioral Health Clinic;

 

ii) At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

 

iii) In an individual or group modality;

 

iv) By video or face-to-face contact; and

 

v) By an RSA, MHP, QMHP or LPHA, as designated in writing to provide the service by staff that hold a valid license in the state of practice and are legally authorized under state law to prescribe medication pursuant to the Illinois Nurse Practice Act or the Medical Practice Act of 1987.

 

F) Psychosocial Rehabilitation (PSR). PSR shall be rehabilitative therapy for individuals designed to increase abilities and resources necessary for community living, socialization, work and recovery. Core activities include cognitive-behavioral interventions, problem solving, interventions to reduce or ameliorate symptoms of a co-occurring disorder and other rehabilitative interventions. PSR is provided in an organized program through individual and group interventions. The focus of treatment interventions includes capacity building to facilitate independent living and adaptation, problem solving and coping skills development.

 

i) PSR services may only be provided:

 

On-site at a Community Mental Health Center;

 

Through a program that is approved pursuant to Table N;

 

In an individual or group modality. The staffing ratio for groups shall not exceed one full-time equivalent staff to 15 individuals;

 

By an RSA, MHP, QMHP and LPHA; and

 

By face-to-face contact.

 

ii) PSR may be subject to prior authorization, pursuant to Section 140.40.

 

G) Therapy/Counseling. Therapy/Counseling is a treatment modality that uses interventions based on psychotherapy theory and techniques to promote emotional, cognitive, behavioral or psychological changes. Therapy/Counseling Services may be provided:

 

i) By a Community Mental Health Center, Behavioral Health Clinic, or Independent Practitioner;

 

ii) At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

 

iii) In an individual, group or family modality;

 

iv) By an MHP, QMHP and LPHA; and

 

v) By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in Sections 140.6(n) and 140.403.

 

3) MRO Mental Health Crisis Services

 

A) Crisis Services. Crisis Services are short-term, time-limited interventions that may be provided prior to, or without, an established IATP.

 

i) Crisis Intervention. Crisis Intervention is short-term intervention for clients who, in the course of treatment or intervention, appear to need immediate intensive intervention to achieve crisis symptom reduction and stabilization. Crisis Intervention shall be provided:

 

By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in Section 140.6(n) and 140.403; and

 

By a QMHP, LPHA or MHP with immediate access to a QMHP.

 

ii) Mobile Crisis Response (MCR). MCR is a mobile, responding to the location of the client, intervention seeking to achieve crisis symptom reduction, stabilization, and restoration of the client to a previous level of functioning, establishing support for the client's caregivers when applicable, mitigating the crisis event. MCR activities are tailored to the needs of the client, require face-to-face crisis screening, and may include: short-term intervention; crisis safety planning; brief counseling; consultation with other qualified providers to assist with the client's specific crisis; referral and linkage to community services; and, in the event that the client cannot be stabilized in the community, facilitation of a safe transition to a higher level of care. MCR shall be provided:

 

By a provider certified by the Department to provide MRO Crisis Services pursuant to Table N;

 

On a face-to-face basis;

 

By a crisis team trained in crisis de-escalation techniques, led by a QMHP, LPHA or MHP with immediate access to a QMHP and at least one other individual meeting any of the qualifications detailed in subsection (b); and

 

Utilizing a Department approved crisis screening instrument available on the Department's website.

 

iii) Crisis Stabilization. Crisis Stabilization services are available immediately following an MCR event and are designed to prevent additional behavioral health crises from occurring by providing strengths-based, individualized, direct supports on a one-on-one basis to clients in the home or community setting. Crisis Stabilization services shall be provided:

 

By a provider certified by the Department to provide MRO Crisis Services pursuant to Table N;

 

Upon demonstrated need for stabilizing supports as documented in the client's Crisis Safety Plan following the review, approval, and signature by an LPHA. The Crisis Safety Plan contains an identification of diagnosis, need or functional impairment; a treatment recommendation of Crisis Stabilization service accompanied by a recommendation for service amount, frequency and duration; and documentation of the entity responsible for service delivery;

 

On a face-to-face basis; and

 

By an MHP, with immediate access to a QMHP, trained in crisis intervention techniques.

 

4) Team-based MRO Services

 

A) Assertive Community Treatment (ACT) Services. ACT Services consist of integrated crisis, treatment and rehabilitative supports provided by an interdisciplinary team to individuals with serious and persistent mental illness or co-occurring mental health and substance use disorders. ACT Services are intended to promote symptom stability, management of co-morbid health conditions, and appropriate use of psychotropic medications, as well as to restore personal care, community living, work and social skills. ACT Services encompass counseling and therapy, medication management and monitoring, skill building, and crisis stabilization services. ACT Services focus on the restoration of functional skills (e.g., psychosocial, adaptive, self-care) to promote and maintain community living.

 

i) ACT Services shall be:

 

Provided only by Community Mental Health Centers;

 

At least one member of the team who is either a Certified Recovery Support Specialist (CRSS) or Certified Family Partnership Professional (CFPP), based upon the age of the clients served by the team. A person with lived experience may be included on a team that does not have a CRSS or CFPP if he/she obtains certification within 18 months after his/her date of hire; and

 

Available 24 hours per day, seven days a week, each week of the year.

 

ii) ACT Services may only be provided:

 

To eligible individuals age 18 or older;

 

At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

 

In an individual or group modality; and

 

By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in Sections 140.6(n) and 140.403.

 

iii) ACT Services may be subject to prior authorization, pursuant to Section 140.40.

 

iv) ACT Services shall be delivered by a team led by a full-time:

 

LPHA;

 

Licensed social worker (LSW) possessing at least a master's degree in social work, who holds a valid license in the state of practice and is legally authorized under that state's law or rule to practice as an LSW so long as that practice is not in conflict with the Clinical Social Work and Social Work Practice Act [225 ILCS 20] and who has specialized training in mental health services, or with at least two years experience in mental health services;

 

Licensed professional counselor possessing at least a master's degree, who holds a valid license in the state of practice and is legally authorized under that state's law or rule to practice as a licensed professional counselor so long as that practice is not in conflict with the Professional Counselor and Clinical Professional Counselor Licensing Act [225 ILCS 107] and who has specialized training in mental health services, or with at least two years experience in mental health services;

 

Registered nurse (RN) who holds a valid license in the state of practice and is legally authorized under that state's law or rule to practice as a RN, so long as that practice is not in conflict with the Nursing and Advanced Practice Nursing Act [225 ILCS 65], and who has at least one year of clinical experience in a mental health setting or a master's degree in psychiatric nursing; or

 

Occupational therapist (OT) who holds a valid license in the state of practice, is legally authorized under that state's law or rule to practice as an OT, so long as that practice is not in conflict with the Illinois Occupational Therapy Practice Act [225 ILCS 75] and who has at least one year of clinical experience in a mental health setting.

 

B) Community Support Team (CST). CST consists of mental health rehabilitation services and supports to decrease hospitalization and crisis episodes and to increase community functioning in order for the individual to achieve rehabilitative, resiliency and recovery goals. CST 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.

 

i) CST Services shall be:

 

Provided only by programs approved pursuant to Table N;

 

Delivered by a team led by a full-time QMHP; and

 

Available 24 hours per day, seven days a week, each week of the year.

 

ii) CST Services may only be provided:

 

By a Community Mental Health Center or Behavioral Health Clinic;

 

At all service locations and setting deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

 

On an individual basis;

 

By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in Sections 140.6(n) and 140.403.

 

iii) CST Services may be subject to prior authorization, pursuant to Section 140.40.

 

e) Targeted Case Management (TCM). The following services are established pursuant to section 1905(a)(19) of the Social Security Act (42 USC 1396d(a)(19)).

 

1) Types of TCM Services

 

A) Client-centered Consultation Case Management. Client-centered Consultation Case Management consists of client-specific professional communications among provider staff or between provider staff and staff of other providers who are involved with service provision to the individual. Professional communications include offering or obtaining a professional opinion regarding the individual's current functioning level or improving the individual's functioning level, discussing the individual's progress in treatment, adjusting the individual's current treatment, or addressing the individual's need for additional or alternative mental health services. Client-centered Consultation Case Management services may only be provided:

 

i) To eligible individuals receiving one or more services detailed in Section 140.453(d)(2) (General MRO Services);

 

ii) By a Community Mental Health Center or Behavioral Health Clinic;

 

iii) At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

 

iv) On an individual basis;

 

v) By an RSA, MHP, QMHP and LPHA; and

 

vi) By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in Sections 140.6(n) and 140.403.

 

B) Mental Health Case Management Services. Mental Health Case Management Services consist of: assessment, planning, coordination and advocacy services for individuals who need multiple services and require assistance in gaining access to and in using behavioral health, physical health, social, vocational, educational, housing, public income entitlements and other community services to assist the individual in the community. Mental Health Case Management Services may also include identifying and investigating available resources, explaining options to the individual, and linking the individual with necessary resources. Mental Health Case Management Services may be provided:

 

i) For 30 days prior to completion of the Integrated Assessment and Treatment Plan;

 

ii) By a Community Mental Health Center or Behavioral Health Clinic;

 

iii) At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

 

iv) On an individual basis;

 

v) By an RSA, MHP, QMHP and LPHA; and

 

vi) By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in Sections 140.6(n) and 140.403.

 

C) Transition Linkage and Aftercare Case Management Services shall be provided to assist in an effective transition in living arrangements, consistent with the individual's welfare and development. This includes discharge from institutional settings, transition to adult services, and assisting the individual or the individual's family or caretaker with the transition.

 

i) Transition, Linkage and Aftercare Limitation. The Department will not fund more than 40 hours of this service per State fiscal year for an eligible individual.

 

ii) Transition, Linkage and Aftercare may only be provided:

 

By a Community Mental Health Center or Behavioral Health Clinic;

 

At all service locations and settings deemed appropriate for reimbursement, as detailed in the Department's published fee schedule;

 

On an individual basis;

 

By an MHP, QMHP and LPHA; and

 

By video, phone or face-to-face contact, notwithstanding the restriction on services provided via phone in Sections 140.6(n) and 140.403.

 

iii) Transition Linkage and Aftercare Case Management Services may be subject to prior authorization, pursuant to Section 140.40.

 

2) Limitation on Targeted Case Management Services. The Department shall not fund more than 240 total hours of targeted case management services per State fiscal year per individual (not per provider).

 

(Source: Amended at 43 Ill. Reg. 6736, effective May 28, 2019)