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Rule 132 Medicaid Community Mental Health Service Program
Application to the Individual Care Grant Program Seth Harkins, Ed.D. Director, ICG Program Department of Human Services Division of Mental Health Lee Ann Reinert, LCSW Clinical Policy Manager Department of Human Services Division of Mental Health Presented March 31, 2009
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Agenda Understand the purpose and vision of Rule 132
Understand the requirements of Rule 132 Understand the Individual Care Grant (ICG) services covered by Rule 132 Questions Presented March 31, 2009
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Illinois Rule 132 As the state mental health authority, the Department of Human Services, Division of Mental Health (DHS/DMH) uses Rule 132 to govern optional mental health Medicaid benefits in Illinois. Presented March 31, 2009
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Underlying Vision of Recovery and Resilience
Recovery refers to the process in which persons are able to live, work, learn, and participate fully in their communities. For some individuals, recovery is the ability to live a fulfilling and productive life despite a disability. For others, recovery implies the reduction or complete remission of symptoms. Science has shown that having hope plays an integral role in an individual’s recovery. Presented March 31, 2009
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Underlying Vision of Recovery and Resilience (cont)
Resilience means the personal and community qualities that enable us to rebound from adversity, trauma, tragedy, threats, or other stresses – and to go on with life with a sense of mastery, competence, and hope. Presented March 31, 2009
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Underlying Vision of Recovery and Resilience (cont)
We now understand from research that resilience is fostered by a positive childhood and includes positive individual traits, such as optimism, good problem-solving skills, and treatments. Closely-knit communities and neighborhoods are also resilient, providing supports for their members. Presented March 31, 2009
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Rule 132 Requirements Certification Process Recertification
In order to bill for Rule 132, providers must be certified by the DHS Bureau of Accreditation, Licensure and Certification Covered in previous trainings Call Cathy Cumpston at for certification questions Recertification Presented March 31, 2009
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Rule 132 Requirements Role Definitions and Supervision Clinical Record
Licensed Practitioner of the Healing Arts (LPHA) Qualified Mental Health Professional (QMHP) Mental Health Professional (MHP) Rehabilitative Services Associate (RSA) Clinical Record Utilization Review Post Payment Review Presented March 31, 2009
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ICG services billable under Rule 132
Group A – Evaluation and Planning Group B – Mental Health Services Group C – Non-Medicaid Services State of Illinois Community Mental Health Services Service Definition and Reimbursement Guide Presented March 31, 2009
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Evaluation and Planning
Group A Services Evaluation and Planning Presented March 31, 2009
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Mental Health Assessment
A formal process of gathering information Results in treatment recommendations Diagnosis of mental illness not required prior to beginning process Completed within 30 days of start of treatment Presented March 31, 2009
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Mental Health Assessment (Cont)
MHP may participate Requires at least one face to face contact with QMHP and signature Requires review and signature by LPHA Required elements listed within the Rule Updated annually by QMHP who has at least one face to face contact Presented March 31, 2009
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Treatment plan development, review and modification
Services Crosswalk: 50M Care Coordination For treatment provider Presented March 31, 2009
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Treatment plan development, review and modification
Process resulting in a written Individual Treatment Plan Developed with active participation by individual being served and parent/guardian Based on MHA and any additional evaluations Prescribes treatment recommended Presented March 31, 2009
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Treatment plan development, review, and modification
Completed within 45 days of completion of MHA MHP may participate, QMHP responsible for process and must sign plan LPHA must review Date of LPHA’s signature is considered effective date of the ITP Presented March 31, 2009
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Treatment plan development, review, and modification
Required elements are listed in the Rule Must include definitive 5-axis diagnosis. Record must document plan for any diagnostic questions remaining at the time of ITP development. Must be reviewed no less than every 6 months Presented March 31, 2009
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Treatment plan development, review, and modification
Shall include Continuity of care planning with parent/guardian, Estimated transition/discharge date Goals for continuing care Signatures Under 12: parent or guardian Over 12, under 18: Individual served and parent/guardian Over 18/emancipated minor: individual served Over 18, adjudicated legally incapable: individual served and legal guardian Presented March 31, 2009
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Psychological evaluation
Must be medically necessary Must be conducted within 90 days of the ITP Must utilize nationally standardized psychological assessment instruments Must result in written report including formulation of problems, tentative diagnosis, recommendations for treatment/services Presented March 31, 2009
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Mental Health Services
Group B Services Mental Health Services Presented March 31, 2009
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Mental Health Services
Following MHA (or Admission Note in certain circumstances) Consistent with ITP (or Admission Note in certain circumstances) Face to face, video conference, telephone contact Presented March 31, 2009
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Mental Health Services (cont)
Provided to: Individuals Families of individuals Groups of individual consumers For the primary benefit and well-being of the individual Related to an assessed need and goal on the ITP Presented March 31, 2009
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Mental Health Services (cont)
Services may be provided on-site or off-site, as indicated by the specific service Presented March 31, 2009
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Crisis Intervention Services
Activities to stabilize an individual in psychiatric crisis Goal of immediate symptom reduction, stabilization, and restoration to a previous level of role functioning May be provided by MHP with immediate access to QMHP Presented March 31, 2009
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Crisis Intervention Services
Services Crosswalk – 87M Therapeutic Stabilization One of an array of Rule 132 services Service must be provided and documented in accordance with definition and rule requirements Presented March 31, 2009
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Psychotropic Medication Services
Psychotropic Medication Administration Psychotropic Medication Monitoring Psychotropic Medication Training Presented March 31, 2009
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Psychotropic Medication Services
Psychotropic medication administration Time spent preparing the individual and the medication for administration Administering psychotropic medication Observing the client for possible adverse reactions Returning medication to proper storage Minimum staff: LPN under RN supervision Presented March 31, 2009
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Psychotropic Medication Services
Psychotropic medication monitoring Monitoring and evaluating target symptom response Monitoring for adverse effects, including tardive dyskinesia screening Monitoring for new target symptoms or medication Staff must be designated in writing by a physician or advanced practice nurse Presented March 31, 2009
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Psychotropic Medication Services
Psychotropic medication training Training the individual or the individual’s family/guardian to Administer the individual’s medication Monitor levels and dosage Watch for side effects Staff must be designated in writing by a physician or advanced practice nurse Presented March 31, 2009
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Therapy/Counseling May be provided to Minimum Staff: MHP Individual
Group of 2 or more individuals A family Minimum Staff: MHP Presented March 31, 2009
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Therapy/Counseling (cont)
Examples Cognitive behavioral therapy Functional family therapy Motivational enhancement therapy Trauma counseling Anger management Sexual offender treatment Presented March 31, 2009
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Community Support Minimum staff: RSA
Community Support – Individual (CSI) Community Support – Group (CSG) Community Support – Residential (CSR) Minimum staff: RSA Presented March 31, 2009
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Community Support Location of service
CSI and CSG – at least 60% must be provided in natural settings CSR – must be billed as on-site For CSG, group size must not exceed 15 individuals Presented March 31, 2009
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Community Support Services and supports necessary to assist individuals in achieving rehabilitative, resiliency and recovery goals These services facilitate: Illness self-management Skill building Identification and use of natural supports Use of community resources Presented March 31, 2009
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Community Support – Individual/Group
Services Crosswalk – 87M Therapeutic Stabilization One of an array of Rule 132 services Service must be provided and documented in accordance with definition and rule requirements Presented March 31, 2009
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Examples of Community Support
Coordination and assistance with identification of individual strengths, resources, preferences and choices Assistance with the identification of existing natural supports for development of a natural support team, and in building such a team Assistance with the identification of risk factors related to relapse and development of relapse prevention plans and strategies Presented March 31, 2009
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Examples of Community Support
Support and promotion of self-advocacy and participation in decision making, treatment and treatment planning Support and consultation with individual/support system directed primarily to the well-being and benefit of the individual Presented March 31, 2009
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Examples of Community Support
Skill building in order to assist in development of functional, interpersonal, family, coping, and community living skills that are negatively impacted by the individual’s mental illness Presented March 31, 2009
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Community Support Is NOT:
Supervised Meals “Book-end Billing” General Milieu Time Presented March 31, 2009
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Case Management Services
Case management vs. Community support: Case management does for the client Community support teaches the client how to do for self Presented March 31, 2009
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Case Management Services
Mental Health Case Management Client Centered Consultation Transition Linkage and Aftercare Presented March 31, 2009
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Case Management – Mental Health
Assessment, planning, coordination and advocacy For individuals who Need multiple services Require assistance in gaining access and using services Identification and Investigation of available resources Presented March 31, 2009
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Case Management – Mental Health (cont)
Explaining options to the individual Linking the individual with appropriate resources Minimum staff: RSA Presented March 31, 2009
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Case Management – Mental Health
Services Crosswalk – 51M Application assistance for youth currently receiving DMH funded services with a Recipient Identification Number (RIN) Presented March 31, 2009
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Examples of Case Management – Mental Health
Helping individual access appropriate mental health services, including the ICG program Applying for public entitlements Locating housing Obtaining medical and dental care Obtaining other social, educational, vocational or recreational services Presented March 31, 2009
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Examples of Case Management – Mental Health
Assessing the need for service Identifying and investigating available resources Explaining options Assisting in application process Presented March 31, 2009
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Client Centered Consultation
An individual client-focused professional communication Between provider staff With staff of other agencies With other professionals or systems who are involved with providing services to a client Must be provided in conjunction with one or more Group B mental health services Minimum Staff: RSA Presented March 31, 2009
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Client Centered Consultation
Services Crosswalk: 50M Care Coordination For ICG/SASS worker – during youth’s residential stay (not at transition times) Presented March 31, 2009
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Examples of Client Centered Consultation
Face to face or telephone contacts (including scheduled meetings or conferences) between provider staff, staff of other agencies, and child-caring systems concerning the individual’s status Contacts with educational, legal or medical system Staffing with school personnel or other professionals involved in treatment Presented March 31, 2009
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Transition Linkage and Aftercare
Services are provided to assist in an effective transition in living arrangement consistent with the individual’s welfare and development Minimum staff: MHP Presented March 31, 2009
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Transition Linkage and Aftercare
Services Crosswalk – 50M Care Coordination For ICG/SASS worker, during transitional phases of residential placement Presented March 31, 2009
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Examples of Transition Linkage and Aftercare
Services provided to individuals being discharged from inpatient psychiatric care, transitioning to adult services, moving into or out of one placement to another placement or parent’s home Time spent planning with staff of current living arrangement or the receiving living arrangement Time spent locating client-specific placement resources, such as meetings and phone calls Presented March 31, 2009
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Psychosocial Rehabilitation
Facility-based rehabilitative skill-building services Individuals 18 or older Available at least 25 hours/week at least 4 days/week Adjunct service to community support Presented March 31, 2009
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Psychosocial Rehabilitation (cont.)
Program director must be at least QMHP Delivered by at least an RSA Staff to client ratio shall not exceed 1 to 15 Document each session of service Only billable for ICG-Community, age 18 and older Presented March 31, 2009
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Non-Medicaid Services
Group C Non-Medicaid Services Presented March 31, 2009
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Group C – Non-Medicaid Oral interpretation and sign language
Vocational Services – age 14 or older only Vocational Engagement Vocational Assessment Job finding supports Job retention supports Job leaving/termination supports Presented March 31, 2009
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Oral Interpretation and Sign Language
Service necessary to ensure provision of mental health services to individuals whose primary language is not English, or who have hearing impairment Need must be indicated on MHA Must be performed in conjunction with another medically necessary, billable service Presented March 31, 2009
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Vocational Engagement
Activities for a specific client to engage that client in making a decision to actively seek competitive employment or formal credit/certificate bearing education Goal for employment or preparation for employment must be on ITP Minimum staff: RSA Presented March 31, 2009
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Vocational Engagement Caveats
Does not include provider-based pre-vocational programs or educational programs that do not result in credentials recognized by an employer Activities related to employment that may be viewed in terms of the client’s broader rehabilitative or social functioning skills & are not job specific should be expressed in those terms and billed as Medicaid-covered services Presented March 31, 2009
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Vocational Assessment
Developing a vocational profile to guide individual choices in seeking and maintaining competitive employment Minimum staff: RSA Presented March 31, 2009
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Vocational Assessment
Vocational profile typically includes: Work history Interests Skills Strengths Education Impact of symptoms on ability to use strengths Job preferences Presented March 31, 2009
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Vocational Assessment
Client’s vocational goals should be integrated in the treatment plan Does not include pre-vocational work experiences or simulated/situational work experiences at the provider’s site Presented March 31, 2009
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Job Finding/Retention Supports
Activities for a specific individual, directed toward helping to find and procure a job/keep the job Provided under the following conditions: Placement based on consumer job preferences Competitive employment in integrated work settings Ongoing supports as needed Integration of supported employment services with other mental health services Presented March 31, 2009
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Job Finding/Retention Supports
At least 40% delivered in natural settings This does not include general job development Minimum staff: RSA Presented March 31, 2009
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Job Finding/Retention Supports
Interventions must be specific to work and the job Therapeutic supports to help individuals manage symptoms as they work toward achieving recovery goals should be distinguished from this service Presented March 31, 2009
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Job Leaving/Termination Supports
Activities for a specific individual, who is employed, directed toward helping them leave a job in good standing. May also be provided to help client see unplanned job loss as transitional, and a learning experience that will help with the next job. Presented March 31, 2009
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Job Leaving/Termination Supports
Provided to ensure that job loss is not seen as a reason to discontinue participation in supported employment Minimum staff: RSA Presented March 31, 2009
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Other ICG Billable Services
Overview of Material Covered in Previous Training Presented March 31, 2009
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Other ICG billable services
51M Application Assistance S9986 / W051M – Pseudo RIN Application Assistance For youth who are new to DMH system and do not have RINs 72M Child Support Services S9986 / W072M – ICG Child Support Services Will require authorization over $1575 per youth Presented March 31, 2009
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Other ICG billable services
97M Behavior Management S9986 / W097M – ICG Behavior Management Will require authorization over $3500 per youth 17M Group Home S9986 / W017M – ICG Services Group Home (Consumer Present) S9986 / W017B – ICG Services Group Home (Bed Hold) Presented March 31, 2009
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Other ICG billable services
19M Residential S9986 / W019M – ICG Services Residential (Consumer Present) S9986 / W019B – ICG Services Residential (Bed Hold) S9986 / W020M or W021M – Residential special unit #1 or #2 (Consumer Present) S9986 / W020B or W021B – Residential special unit #1 or #2 (Bed Hold) Presented March 31, 2009
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Questions Seth Harkins, Ed.D. Director, ICG Program Department of Human Services Division of Mental Health Lee Ann Reinert, LCSW Clinical Policy Manager Department of Human Services Division of Mental Health Cathy Cumpston, Chief Bureau of Accreditation, Licensure and Certification Presented March 31, 2009
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