a) Inpatient Psychiatric Services
1) Payment for inpatient hospital psychiatric
services shall be made only to:
A) A hospital
that is a general hospital, as defined in Section
148.25(b),
with a functional unit, as defined in Section
148.25(c)(1),
that specializes in, and is enrolled with the Department to provide,
psychiatric services; or
B) A
hospital, as defined in Section
148.25(b),
that holds a valid license as, and is enrolled with the Department as, a
psychiatric hospital, as defined in Section
148.25(d)(1).
2) Inpatient psychiatric services
are those services provided to patients who are in need of short-term acute
inpatient hospitalization for active treatment of an emotional or mental
disorder.
3) Federal Medicaid
regulations preclude payment for patients over 20 or under 65 years of age in
any Institution for Mental Diseases (IMD). Therefore, psychiatric hospitals may
not receive reimbursement for services provided to patients over the age of 20
and under the age of 65. In the case of a patient receiving psychiatric
services immediately preceding his or her 21
st
birthday, psychiatric services shall be reimbursable by the Department until
the earliest of the following:
A) The date the
patient no longer requires the services.
B) The date the patient reaches 22 years of
age.
4) A psychiatric
hospital must be accredited by TJC or another Health and Human Services
Approved Accreditation Organization to provide services to program participants
under 21 years of age or be Medicare certified to provide services to program
participants 65 years of age and older. Distinct part psychiatric units and
psychiatric hospitals located in Illinois, or within 100 miles of Illinois,
must execute an agreement with an Illinois Department of Human Services (DHS)
operated mental health center (State-operated facility) for coordination of
services including, but not limited to, crisis screening and discharge planning
to ensure linkage to aftercare services with private practitioners or community
mental health services, as described in subsection (a)(5).
5) Coordination of Care - Purpose. The
Coordination of Care Agreement shall set forth an agreement between the
State-operated facility and the hospital for the coordination of services,
including but not limited to crisis screening and discharge planning to ensure
efficient use of inpatient care. The agreement shall also set forth the manner
in which linkage to aftercare services with community mental health agencies or
private practitioners shall be carried out.
6) Coordination of Care - General Provisions.
The general provisions of the Coordination of Care Agreement described in
subsection (a)(5) are as follows:
A) The
hospital shall agree, on a continuing basis, to comply with applicable
licensing standards as contained in State laws or regulations and shall
maintain accreditation by TJC or another Health and Human Services Approved
Accreditation Organization.
B) The
provider shall comply with Title VI of the Civil Rights Act of 1964 and the
Rehabilitation Act of 1973 and regulations promulgated under those Acts
prohibit discrimination on the grounds of sex, race, color, national origin or
handicap.
C) The provider shall
comply with the following applicable federal, State and local statutes
pertaining to equal employment opportunity,
affirmative action, and other
related requirements:
42 USCA 2000e,
29 USCA 203 et seq. and 775 ILCS
25.
D) The Coordination of Care
Agreement shall remain in effect until amended by mutual consent or cancelled
in writing by either party having given 30 days prior notification.
7) Coordination of Care - Special
Requirements. The hospital shall:
A) Provide
on its premises, the facilities, staff, and programs for the diagnosis,
admission, and treatment of persons who may require inpatient care or
assessment of mental status, mental illness, emotional disability, and other
psychiatric problems.
B) Notify the
community mental health agency that serves the geographic area from which the
recipient originated to allow the agency to prescreen the case prior to
referring the individual to the designated State-operated facility. The
community mental health agency's resources and other appropriate community
alternatives shall be considered prior to making a referral to the
State-operated facility for admission.
C) Complete any forms necessary and
consistent with the Mental Health and Developmental Disabilities Code in the
event of a referral for involuntary or judicial admission.
D) Notify the community mental health agency
or private practitioner of the date and time of discharge and invite their
participation in the discharge planning process.
E) Refer to the State-operated facility only
those individuals for whom less restrictive alternatives are documented not to
be appropriate at the time based on a clinical determination by the community
mental health agency, a private practitioner (if applicable), or the
hospital.
F) Notify the
State-operated facility prior to planned transfer of an individual and transfer
the individual at such time as to assure arrival of the person prior to 11 a.m.
Monday through Friday. In unusual situations, transfers may be made at other
times after prior discussion between the hospital and the State-operated
facility. The individual will only be transported to the State-operated
facility when, based on a clinical determination, he or she is medically stable
as determined by the transferring physician. A copy of the transfer summary
from the hospital must accompany the recipient at the time of admission to the
State-operated facility.
8) Coordination of Care - Special
Requirements of the State-Operated Facility. The State-operated facility shall:
A) Admit individuals who have been screened
as defined in the Coordination of Care Agreement and are appropriate for
admission consistent with the provisions of the Mental Health and Developmental
Disabilities Code.
B) Evaluate
individuals for whom the hospital has executed a Petition and Certificate for
involuntary/judicial admission consistent with the Mental Health and
Developmental Disabilities Code.
C)
Consider for admission voluntary individuals for whom less restrictive
alternatives are documented not to be appropriate at the time, based on a
clinical determination by the community mental health agency, private
practitioner (if applicable), the hospital, or the State-operated
facility.
9)
Coordination of Care - Special Requirements for the Children's Mental Health
Screening, Assessment and Support Services (SASS) Program. For individuals
under 21 years of age, all inpatient admissions must be authorized through the
SASS Program. The hospital shall:
A) Prior to
admission, contact the Crisis and Referral Entry Service (CARES), the
Department's Statewide centralized intake and referral point for a mental
health screening and assessment of the patient, pursuant to 59 Ill. Adm. Code
131.40;
B) For admissions authorized through a SASS
screening, involve the SASS provider in the patient's treatment plan during the
inpatient stay and in the development of a discharge plan in order to
facilitate linkage to appropriate aftercare resources.
10) A participating hospital not enrolled for
inpatient psychiatric services may provide psychiatric care as a general
inpatient service only on an emergency basis for a maximum period of 72 hours
or in cases in which the psychiatric services are secondary to the services for
which the period of hospitalization is approved.
b) Inpatient Rehabilitation Services
1) Payment for inpatient rehabilitation
services shall be made only to a general hospital, as defined in Section
148.25(b),
with a functional unit of the hospital, as defined in Section
148.25(c)(2),
which specializes in, and is enrolled with the Department to provide, physical
rehabilitation services or a hospital, as defined in Section
148.25(d)(2),
which holds a valid license as, and is enrolled with the Department as, a
physical rehabilitation hospital.
2) The primary reason for hospitalization is
to provide a structured program of comprehensive rehabilitation services,
furnished by specialists, to the patient with a major handicap for the purpose
of habilitating or restoring the person to a realistic maximum level of
functioning.
3) For payment to be
made, a rehabilitation facility, which includes a distinct part unit as
described in Section
148.25(c)(2),
must be certified for participation under the Medicare Program and must be
licensed and/or certified by DPH to provide comprehensive physical
rehabilitation services. Out-of-state hospitals that specialize in physical
rehabilitation services must be licensed or certified to provide comprehensive
physical rehabilitation services by the authorized licensing agency in the
state in which the hospital is located.
4) A rehabilitation facility must meet the
following criteria:
A) Have a full-time (at
least 35 hours per week) director of rehabilitation; a participating general
hospital with a functional rehabilitation unit must have a part-time (at least
20 hours per week) director of rehabilitation.
B) Have an organized medical staff.
C) Have available consultants qualified to
perform services in appropriate specialties.
D) Have adequate space and equipment to
provide comprehensive diagnostic and treatment services.
E) Maintain records of diagnosis, treatment
progress (notations must be made at regular intervals) and functional
results.
F) Submit reports as
required by the Department.
5) A rehabilitation facility must provide, or
have a contractual arrangement with an appropriate entity or agency to provide,
the following minimal services:
A) Full-time
nursing services under the supervision of a registered nurse formally trained
in rehabilitation nursing.
B)
Full-time physical therapy and occupational therapy services.
C) Social casework services as an integral
part of the rehabilitation program.
6) A rehabilitation facility must have
available the following minimal services:
A)
Psychological evaluation services.
B) Prosthetic and orthotic
services.
C) Vocational
counseling.
D) Speech
therapy.
E) Clinical laboratory and
x-ray services.
F) Pharmacy
services.
7) The
director of rehabilitation must meet the following criteria:
A) Provide services to the hospital and its
patients as specified in subsection (b)(4).
B) Be a doctor of medicine or
osteopathy.
C) Be licensed under
State law to practice medicine or surgery.
D) Must have, after completing a one-year
hospital internship, at least two years of training or experience in the
medical management of inpatients requiring rehabilitation services.
8) Personnel of the rehabilitation
facility must meet the following minimum standards:
A) Physicians shall have unlimited licenses
to practice medicine and surgery in the state in which they practice.
Consultants shall be Board Qualified or Board Certified in their
specialty.
B) Physical therapists
shall be licensed by the Illinois Department of Financial and Professional
Regulation or comparable licensing agency in the state in which the facility is
located.
C) Occupational therapists
shall be licensed by the Illinois Department of Financial and Professional
Regulation or comparable licensing agency in the state in which the facility is
located.
D) Registered nurses and
licensed practical nurses shall be currently licensed by the Illinois
Department of Financial and Professional Regulation or comparable licensing
agency in the state in which the facility is located.
E) Social workers shall have completed two
years of graduate training leading to a Master's Degree in social work from an
accredited graduate school of social work.
F) Psychologists shall have a Master's Degree
in clinical psychology.
G)
Vocational counselors shall have a Master's Degree in Rehabilitation
Counseling, Psychology or Guidance from a school accredited by the North
Central Association or its equivalent.
H) An orthotist or prosthetist, certified by
the American Board of Certification in Orthotics and Prosthetics, shall
fabricate or supervise the fabrication of all limbs and braces.
c) End-Stage Renal
Disease Treatment (ESRDT) Services. The Department provides payment to
hospitals, as defined in Section
148.25(b),
for ESRDT services only when the hospital is Medicare certified for ESRDT and
services are provided as follows:
1)
Inpatient hospital care is provided for the evaluation and treatment of acute
renal disease.
2) Outpatient
chronic renal dialysis treatments are provided in the outpatient renal dialysis
department of the hospital, a satellite unit of the hospital that is
professionally associated with the center for medical direction and
supervision, or a free-standing chronic dialysis center certified by Medicare,
pursuant to 42 CFR
405, Subpart U (2013).
3) Home dialysis treatments are provided
through the outpatient renal dialysis department of the hospital, a satellite
unit of the hospital that is professionally associated with the center for
medical direction and supervision, in a patient's home, or through a
free-standing chronic dialysis center certified by Medicare, pursuant to 42 CFR
405, Subpart U (2013).
d) Hospital-Based Organized Clinic Services.
Hospital-based clinics, as described in Section
148.25(b)(4),
must meet the requirements of 89 Ill. Adm. Code
140.461(a).
The following two categories of hospital-based organized clinic services are
recognized in the Medical Assistance Program:
1) Psychiatric Clinic Services
A) Psychiatric Clinic Services (Type A). Type
A psychiatric clinic services are clinic service packages consisting of
diagnostic evaluation; individual, group and family therapy; medical control;
optional Electroconvulsive Therapy (ECT); and counseling, provided in the
hospital clinic setting.
B)
Psychiatric Clinic Services (Type B). Type B psychiatric clinic services are
active treatment programs in which the individual patient is participating in
no less than social, recreational, and task-oriented activities at least four
hours per day at a minimum of three half days of active treatment per week. The
duration of an individual patient's participation in this treatment program is
limited to six months in any 12 month period.
C) Approval. The Department and DHS are
responsible for approval and enrollment of community hospitals providing
psychiatric clinic services. In order to participate as a provider of
psychiatric clinic services, a hospital must have previously been enrolled with
the Department for the provision of inpatient psychiatric services on or after
June 1, 2002 or must be currently enrolled for the provision of inpatient
psychiatric services and execute a Psychiatric Clinic Services Type A and B
Enrollment Assurance with DHS and the Department, which assures that the
hospital is enrolled for the provision of inpatient psychiatric services and
meets the following requisites:
i) The
hospital must be accredited by, and be in good standing with, TJC or another
Health and Human Services Approved Accreditation Organization.
ii) The hospital must have executed a
Coordination of Care Agreement between the hospital and the designated DHS
State-operated facility serving the mentally ill in the appropriate geographic
area.
iii) The clinical staff of
the psychiatric clinic must collaborate with the mental health service network
to provide discharge, linkage and aftercare planning for recipients of
outpatient services.
iv) The
hospital must be enrolled to participate in Medicaid Program (Title XIX) and
must meet all conditions and requirements set forth by the
Department.
D) Duration
of Approval. The approval described in subsection (d)(1)(D) of this Section
shall be in effect for a period of two years from the date HFS approves the
psychiatric clinic's enrollment. The approval may be terminated by HFS or DHS
with cause upon 30 days written notice to the hospital. Accordingly, the
hospital must submit a 30 day written notification to HFS and DHS when
terminating delivery of psychiatric clinic services.
2) Physical Rehabilitation Clinic Services
Physical rehabilitation clinic services include the same
rehabilitative services provided to inpatients by hospitals enrolled to provide
the services described in Section
148.40(b).
Clinic services should be utilized when the patient's condition is such that it
does not necessitate inpatient care and adequate care and treatment can be
obtained on an outpatient basis through the hospital's specialized
clinic.