Consumer Eligibility, Enrollment and Benefit Status

Illinois Department of Human Services, Division of Mental Health FY11 Consumer Eligibility, Enrollment and Benefit Status (pdf)

1. Eligibility Groups

Individuals eligible for DHS/DMH funding of their mental health services may fall into one of the following categories:

1. Eligibility Group 1: Individuals who are Medicaid Eligible and in need of mental health services for a mental disorder or suspected mental disorder;
2. Eligibility Group 2: Individuals who are not Medicaid eligible but are in need of mental health services as indicated by their diagnosis, functioning level or treatment history meeting the criteria for the Non-Medicaid Target Population (see below);
3. Eligibility Group 3: Individuals who are not Medicaid eligible but are in need of mental health services as indicated by their diagnosis, treatment history and age meeting the criteria for the Non-Medicaid First Presentation of Psychosis Population (see below);
4. Eligibility Group 4: Individuals who are not Medicaid eligible but are in need of mental health services as indicated by their diagnosis and functioning level meeting the criteria for the Non-Medicaid Eligible Population (see below).

The provision of information through the enrollment/registration of an individual with DHS/DMH establishes which Eligibility Group the individual is qualified for, and an individual's eligibility group determines what services DHS/DMH will pay for and, in the case of non-Medicaid eligible individuals, up to what limits. In addition, an individual's household income and size determines the amount of the DHS/DMH rate for a mental health service that will be paid for by DHS/DMH.

Individuals who do not meet the criteria for one of the eligibility groups above, or who are not eligible for Medicaid and whose household income is 400% or greater than the Federal Poverty Guidelines are ineligible for payment by DHS/DMH for their mental health services.

2. Criteria for Eligibility Groups

a. Eligibility Group 1: Medicaid Eligible Criteria

To be eligible for this group an individual must:

• be in need of mental health services for a mental disorder or suspected mental disorder,
• have a qualifying diagnosis as listed in the DHS/DMH Rule 132 Diagnosis Codes List (at: http://www.dhs.state.il.us/page.aspx?item=32632)
• not be enrolled in the Illinois Healthcare and Family Services' Integrated Care Program,
• be enrolled/registered with DHS/DMH, and
• be currently eligible under the state's Medicaid program.

Community mental health service agencies will need to document the need for mental health services, and they can determine an individual's eligibility status under the state's Medicaid program by requesting this information from the individual. In addition, providers have access to a system to obtain this eligibility information. The Illinois Department of Healthcare and Family Services maintains a web-based system (the "MEDI System") that permits determination of an individual's current public benefit status, including their Medicaid eligibility status. This web-site and instructions for its use can be found at: http://www.myhfs.illinois.gov/.

b. Eligibility Group 2: Non-Medicaid Target Population Criteria

Note: Diagnosis codes listed here are currently under review for updates to meet the most recent versions of the DSM and ICD diagnostic manuals.

This eligibility group is aimed at applying state funding for mental health services for an individual with limited resources who is either: (a) an adult experiencing a serious mental illness, or (b) a child with a serious emotional disturbance.

To be eligible for this group an individual must:

• be in need of mental health services for a mental disorder,
• be enrolled/registered with DHS/DMH, including entry of the individual's Recipient Identification Number (RIN) and household income and size, and
• meet the following diagnostic, functioning level and treatment history criteria:

FOR ADULTS:
Target Population: Serious Mental Illness (SMI) for DHS/DMH funded MH services

Age: Must be 18 years of age or older

Individuals with serious mental illness are adults whose emotional or behavioral functioning is so impaired as to interfere with their capacity to remain in the community without supportive treatment. The mental impairment is severe and persistent and may result in a limitation of their capacities for primary activities of daily living, interpersonal relationships, homemaking, self-care, employment or recreation. The mental impairment may limit their ability to seek or receive local, state or federal assistance such as housing, medical and dental care, rehabilitation services, income assistance and food stamps, or protective services.

Must meet I + (II or III):

1. Diagnoses:

   The client must have one of the following diagnoses that meets DSM-IV criteria and which is the focus of the treatment being provided:

   • Schizophrenia (295.xx)
   • Schizophreniform Disorder (295.4)
   • Schizo-affective Disorder (295.7)
   • Delusional Disorder (297.1)
   • Shared Psychotic Disorder (297.3)
   • Brief Psychotic Disorder (298.8)
   • Psychotic Disorder NOS (298.9)
   • Bipolar Disorders (296.0x, 296.4x, 296.5x, 296.6x, 296.7, 296.80, 296.89, 296.90)
   • Cyclothymic Disorder (301.13)
   • Major Depression (296.2x, 296.3x)
   • Obsessive-Compulsive Disorder (300.30)
   • Anorexia Nervosa (307.1)
   • BulimiaNervosa (307.51)
2. Treatment History (Treatment history covers the client's lifetime treatment and is restricted to treatment for the DSM IV diagnosis specified in Section I.) To qualify under this section, the client must meet at least ONE of the criteria below:
   1. Continuous treatment of 6 months or more, including treatment during adolescence, in one, or a combination of, the following modalities: inpatient treatment, day treatment or partial hospitalization.
   2. Six months continuous residence in residential programming (e.g., long-term care facility or assisted, supported or supervised residential programs)
   3. Two or more admissions of any duration to inpatient treatment, day treatment, partial hospitalization or residential programming within a 12-month period.
   4. A history of using the following outpatient services over a 1 year period, either continuously or intermittently: psychotropic medication management, case management, outreach and engagement services.
   5. Previous treatment in an outpatient modality, and a history of at least one mental health psychiatric hospitalization.
3. Functional Criteria (Functional criteria has been purposely narrowed to descriptors of the most serious levels of functional impairment and are not intended to reflect the full range of possible impairment.)
   1. To qualify under this section, the client must meet at least TWO of the criteria, A1 through A7, or B1 as a result of the DSM-IV diagnosis specified in Section I. The client:
      1. Has a serious impairment in social, occupational or school functioning.
      2. Is unemployed or working only part-time due to mental illness and not for reasons of physical disability or some other role responsibility (e.g., student or primary caregiver for dependent family member); is employed in a sheltered setting or supportive work situation, or has markedly limited work skills.
      3. Requires help to seek public financial assistance for out-of-hospital maintenance (e.g., Medicaid, SSI, SSDI, other indicators).
      4. Does not seek appropriate supportive community services, e.g. recreational, educational or vocational support services, without assistance.
      5. Lacks supportive social systems in the community (e.g., no intimate or confiding relationship with anyone in their personal life, no close friends or group affiliations, is highly transient or has inability to co-exist within family setting).
      6. Requires assistance in basic life and survival skills (must be reminded to take medication, must have transportation to mental health clinic and other supportive services, needs assistance in self-care, household management, food preparation or money management, etc., is homeless or at risk of becoming homeless).
      7. Exhibits inappropriate or dangerous social behavior which results in demand for intervention by the mental health and/or judicial/legal system.
   2. The client does not currently meet the functional criteria listed above, however, the client:
      1. is currently receiving treatment, has a history within the past 5 years of functional impairment meeting TWO of the functional criteria listed above which persisted for at least 1 months, and there is documentation supporting the professional judgement that regression in functional impairment would occur without continuing treatment.

FOR CHILDREN:
Target Population: Serious Emotional Disturbance (SED) for DHS/DMH funded MH services

Age: Birth through 17 years of age

Individuals determined on the basis of a mental health assessment to have a serious emotional disturbance and display serious cognitive, emotional, and behavioral dysfunctions.

Must meet I + (II or III):

1. Diagnoses:

   One of the following DSM-IV diagnoses which is the focus of the treatment being provided:

   • Attention Deficit/Hyperactivity Disorders (314.00,314.01, 314.9)
   • Schizophrenia (295.xx)
   • Schizophreniform Disorder (295.4)
   • Schizo-Affective Disorder (295.7)
   • Delusional Disorder (297.1)
   • Shared Psychotic Disorder (297.3)
   • Brief Psychotic Disorder (298.8)
   • Psychotic Disorder NOS (298.9)
   • Bipolar Disorders (296.0x, 296.4x, 296.5x, 296.6x, 296.7, 296.80, 296.89, 296.90)
   • Cyclothymic Disorder (301.13)
   • Major Depression (296.2x, 296.3x)
   • Panic Disorder with or without Agoraphobia (300.01, 300.21)
   • Obsessive-Compulsive Disorder (300.30)
   • Anorexia Nervosa (307.1)
   • Bulimia Nervosa (307.51)
   • Post Traumatic Stress Disorder (309.81)
   • Intermittent Explosive Disorder (312.34)
   • Tourette's Disorder (307.23)
2. Treatment History (Treatment history cover's the client's lifetime treatment and is restricted to treatment for a DSM IV diagnosis specified in Section I.)

   The youth must meet at least ONE of the criteria below:

   1. Continuous treatment of 6 months or more in one, or a combination of, the following: inpatient treatment; day treatment; or partial hospitalization.
   2. Six months continuous residence in a residential treatment center. 
   3. Two or more admissions of any duration to inpatient treatment, day treatment, partial hospitalization or residential treatment programming within a 12 month period.
   4. A history of using the following outpatient services over a 1 year period, either continuously or intermittently: psychotropic medication management, case management or SASS/intensive community based services. 
   5. Previous treatment in an outpatient modality and a history of at least one mental health psychiatric hospitalization.
3. Functional Criteria (Functional criteria has been purposely narrowed to descriptors of the most serious levels of functional impairment and are not intended to reflect the full range of possible impairments.)

   The youth must meet criteria for functional impairment in TWO of the following areas. The functional impairment must: 1) be the result of the mental health problems for which the child is or will be receiving care and 2) expected to persist in the absence of treatment.

   1. Functioning in self care - Impairment in age-appropriate self care skills is manifested by a person's consistent inability to take care of personal grooming, hygiene, clothes and meeting of nutritional needs.
   2. Functioning in community - Impairment in community functioning is manifested by a consistent lack of age appropriate behavioral controls, decision-making, judgment and value systems which results in potential involvement or involvement the juvenile justice system.
   3. Functioning in social relationships - Impairment of social relationships is manifested by the consistent inability to develop and maintain satisfactory relationships with peers and adults.
   4. Functioning in the family - Impairment in family functioning is manifested by a pattern of
      1. disregard for safety and welfare of self or others, e.g., fire setting, serious and chronic destructiveness,
      2. significantly disruptive behavior exemplified by repeated and/or unprovoked violence to siblings and/or parents, or 
      3. inability to conform to reasonable limitations and expectations. The degree of impairment requires intensive (i.e. beyond age appropriate) supervision by parent/caregiver and may result in removal from the family or its equivalent.
   5. Functioning at school - Impairment in functioning at school is manifested by the inability to pursue educational goals in a normal time frame - e.g. consistently failing grades, repeated truancy, expulsion, property damage or violence towards others --that cannot be remediated by a classroom setting (whether traditional or specialized).

c. Eligibility Group 3: Non-Medicaid First Presentation of Psychosis Criteria

This eligibility group is aimed at applying state funding for mental health services for an individual with limited resources who is an adult that is presenting to the mental health service system for the first time as experiencing a serious mental illness.

To be eligible for this group an individual must:

• be in need of mental health services for a mental disorder,
• be enrolled/registered with DHS/DMH, including entry of the individual's Recipient Identification Number (RIN) and household income and size, and
• meet the following age, diagnostic and treatment history criteria (must meet all of these criteria):
  1. Between the ages 18 up until age 41 at the time of the first presentation for mental health services;
  2. Diagnosed with one or more of the following psychiatric diagnoses by a psychiatrist:
     1. 295.00 Schizophrenic Disorder, Simple Type
     2. 295.05 Schizophrenia, Simple Type, in Remission
     3. 295.10 Schizophrenia Disorganized Type
     4. 295.20 Schizophrenia, Catatonic Type
     5. 295.25 Schizophrenia, Catatonic Type, in Remission
     6. 295.30 Schizophrenia, Paranoid Type
     7. 295.40 Schizophreniform Disorder, Acute Schizophrenic Episode
     8. 295.70 Schizoaffective Disorder
     9. 295.90 Schizophrenia, Undifferentiated Type
     10. 296.04 Bipolar I Disorder, Single Manic Episode, Severe with Psychotic Features
     11. 296.44 Bipolar I Disorder, Most Recent Episode Manic, Severe with Psychotic Features
     12. 296.54 Bipolar I Disorder, Most Recent Episode Depressed, Severe with Psychotic Features
     13. 296.64 Bipolar I Disorder, Most Recent Episode Mixed, Severe with Psychotic Features
  3. Minimal or no prior mental health treatment, as evidenced by the individual not having been prescribed more than 16 weeks of antipsychotic medications;
  4. No history of autism, pervasive developmental disorder, mental retardation, or organic brain issues (trauma, tumor, etc.) requiring ongoing primary services for any of these problems.

d. Eligibility Group 4: Non-Medicaid Eligible Population Criteria

This eligibility group is aimed at applying state funding for mental health services for an individual with limited resources who is in need of mental health services for a mental disorder or suspected mental disorder as indicated by their mental health diagnosis and functioning level.

To be eligible for this group an individual must:

• be in need of mental health services for a mental disorder,
• be enrolled/registered with DHS/DMH, including entry of the individual's Recipient Identification Number (RIN) and household income and size, and
• meet the following diagnostic and functioning level criteria:

Age: Birth and older

Must have both I and II:

II. Impairment

Has significant impairment in an important area of life functioning as a result of the mental disorder identified in diagnostic criteria above and as indicated on the Global Level of Functioning (GAF) or Children's Global Assessment Scale (CGAS).

LISTING OF DSM IV DIAGNOSES AND ICD-9 CODES

DSM-IV CODES	DMHDD ELIGIBLE POPULATION -- 11/26/08
295.00	Schizophrenic Disorder, Simple type
295.01	Schizophrenia, Simple Type, Subchronic
295.02	Schizophrenia, Simple Type, Chronic
295.03	Schizophrenia, Simple Type, Subchronic with Acute Exacerbation
295.04	Schizophrenia, Simple Type, Chronic with Acute Exacerbation
295.05	Schizophrenia, Simple Type, In Remission
295.10	Schizophrenia, Disorganized Type
295.11	Schizophrenia, Disorganized Type, Subchronic
295.12	Schizophrenia, Disorganized Type, Chronic
295.13	Schizophrenia, Disorganized Type, Subchronic with Acute Exacerbation
295.14	Schizophrenia, Disorganized Type, Chronic with Acute Exacerbation
295.15	Schizophrenia, Disorganized Type, In Remission
295.20	Schizophrenia, Catatonic Type
295.21	Schizophrenia, Catatonic Type, Subchronic
295.22	Schizophrenia, Catatonic Type, Chronic
295.23	Schizophrenia, Catatonic Type, Subchronic with Acute Exacerbation
295.24	Schizophrenia, Catatonic Type, Chronic with Acute Exacerbation
295.25	Schizophrenia, Catatonic Type, In Remission
295.30	Schizophrenia, Paranoid Type
295.31	Schizophrenia, Paranoid Type, Subchronic
295.32	Schizophrenia, Paranoid Type, Chronic
295.33	Schizophrenia, Paranoid Type, Subchronic with Acute Exacerbation
295.34	Schizophrenia, Paranoid Type, Chronic with Acute Exacerbation
295.35	Schizophrenia, Paranoid Type, In Remission
295.40	Schizophreniform Disorder/Acute Schizophrenic Episode
295.41	Acute Schizophrenic Episode, Subchronic
295.42	Acute Schizophrenic Episode, Chronic
295.43	Acute Schizophrenic Episode, Subchronic With Acute Exacerbation
295.44	Acute Schizophrenic Episode, Chronic With Acute Exacerbation
295.45	Acute Schizophrenic Episode, In Remission
295.60	Schizophrenia, Residual Type
295.61	Schizophrenia, Residual Type. Subchronic
295.62	Schizophrenia, Residual Type. Chronic
295.63	Schizophrenia, Residual Type, Subchronic with Acute Exacerbation
295.64	Schizophrenia, Residual Type, Chronic with Acute Exacerbation
295.65	Schizophrenia, Residual Type, In Remission
295.70	Schizoaffective Disorder
295.71	Schizoaffective Disorder, Subchronic
295.72	Schizoaffective Disorder, Chronic
295.73	Schizoaffective Disorder, Subchronic With Acute Exacerbation
295.74	Schizoaffective Disorder, Chronic With Acute Exacerbation
295.75	Schizoaffective Disorder, In Remission
295.90	Schizophrenia, Undifferentiated Type
295.91	Schizophrenia, Undifferentiated Type, Subchronic
295.92	Schizophrenia, Undifferentiated Type, Chronic
295.93	Schizophrenia, Undifferentiated Type, Subchronic with Acute Exacerbation
295.94	Schizophrenia, Undifferentiated Type, Chronic with Acute Exacerbation
295.95	Schizophrenia, Undifferentiated Type, In Remission
296.00	Bipolar I Disorder, Single Manic Episode, Unspecified
296.01	Bipolar I Disorder, Single Manic Episode, Mild
296.02	Bipolar I Disorder, Single Manic Episode, Moderate
296.03	Bipolar I Disorder, Single Manic Episode, Severe Without Psychotic Features
296.04	Bipolar I Disorder, Single Manic Episode, Severe With Psychotic Features
296.05	Bipolar I Disorder, Single Manic Episode, In Partial Remission
296.06	Bipolar I Disorder, Single Manic Episode, In Full Remission
296.10	Manic Disorder, Recurrent Episode, Unspecified
296.11	Manic Disorder, Recurrent Episode, Mild
296.12	Manic Disorder, Recurrent Episode, Moderate
296.13	Manic Disorder, Recurrent Episode, Severe, Without Psychotic Features
296.14	Manic Disorder, Recurrent Episode, With Psychotic Features
296.15	Manic Disorder, Recurrent Episode, In Partial Remission
296.16	Manic Disorder, Recurrent Episode, In Full Remission
296.20	Major Depressive Disorder, Single Episode, Unspecified
296.21	Major Depressive Disorder, Single Episode, Mild
296.22	Major Depressive Disorder, Single Episode, Moderate
296.23	Major Depressive Disorder, Single Episode, Severe Without Psychotic Features
296.24	Major Depressive Disorder, Single Episode, Severe With Psychotic Features
296.25	Major Depressive Disorder, Single Episode, In Partial Remission
296.26	Major Depressive Disorder, Single Episode, In Full Remission
296.30	Major Depressive Disorder, Recurrent, Unspecified
296.31	Major Depressive Disorder, Recurrent, Mild
296.32	Major Depressive Disorder, Recurrent, Moderate
296.33	Major Depressive Disorder, Recurrent, Severe Without Psychotic Features
296.34	Major Depressive Disorder, Recurrent, Severe With Psychotic Features
296.35	Major Depressive Disorder, Recurrent, In Partial Remission
296.36	Major Depressive Disorder, Recurrent, In Full Remission
296.40	Bipolar I Disorder, Most Recent Episode Manic, Unspecified
296.40	Bipolar I Disorder, Most Recent Episode Hypomanic
296.41	Bipolar I Disorder, Most Recent Episode Manic, Mild
296.42	Bipolar I Disorder, Most Recent Episode Manic, Moderate
296.43	Bipolar I Disorder, Most Recent Episode Manic, Severe Without Psychotic Features
296.44	Bipolar I Disorder, Most Recent Episode Manic, Severe With Psychotic Features
296.45	Bipolar I Disorder, Most Recent Episode Manic, In Partial Remission
296.46	Bipolar I Disorder, Most Recent Episode Manic, In Full Remission
296.50	Bipolar I Disorder, Most Recent Episode Depressed, Unspecified
296.51	Bipolar I Disorder, Most Recent Episode Depressed, Mild
296.52	Bipolar I Disorder, Most Recent Episode Depressed, Moderate
296.53	Bipolar I Disorder, Most Recent Episode Depressed, Severe Without Psychotic Features
296.54	Bipolar I Disorder, Most Recent Episode Depressed, Severe With Psychotic Features
296.55	Bipolar I Disorder, Most Recent Episode Depressed, In Partial Remission
296.56	Bipolar I Disorder, Most Recent Episode Depressed, In Full Remission
296.60	Bipolar I Disorder, Most Recent Episode Mixed, Unspecified
296.61	Bipolar I Disorder, Most Recent Episode Mixed, Mild
296.62	Bipolar I Disorder, Most Recent Episode Mixed, Moderate
296.63	Bipolar I Disorder, Most Recent Episode Mixed, Severe Without Psychotic Features
296.64	Bipolar I Disorder, Most Recent Episode Mixed, Severe With Psychotic Features
296.65	Bipolar I Disorder, Most Recent Episode Mixed, In Partial Remission
296.66	Bipolar I Disorder, Most Recent Episode Mixed, In Full Remission
296.7	Bipolar I Disorder, Most Recent Episode Unspecified
296.80	Bipolar Disorder NOS
296.81	Atypical Manic Disorder
296.82	Atypical Depressive Disorder
296.89	Bipolar II Disorder
296.90	Mood Disorder NOS/Unspecified Affective Psychosis
296.99	Other Specified Affective Psychoses
297.0	Paranoid State, Simple
297.1	Delusional Disorder/Paranoia
297.2	Paraphrenia
297.3	Shared Psychotic Disorder/Shared Paranoid Disorder
297.8	Other Specified Paranoid States
297.9	Unspecified Paranoid State
298.0	Depressive Type Psychosis
298.1	Excitative Type Psychosis
298.2	Reactive Confusion
298.3	Acute Paranoid Reaction
298.4	Psychogenic Paranoid Psychosis
298.8	Brief Psychotic Disorder/ Other and Unspecified Reactive Psychosis
298.9	Psychotic Disorder NOS
300.00	Anxiety Disorder NOS
300.01	Panic Disorder Without Agoraphobia
300.02	Generalized Anxiety Disorder
300.09	Anxiety States, Other
300.10	Hysteria, Unspecified
300.11	Conversion Disorder
300.12	Dissociative Amnesia/Psychogenic Amnesia
300.13	Dissociative Fugue/Psychogenic Fugue
300.14	Dissociative Identity Disorder/Multiple Personality
300.15	Dissociative Disorder NOS
300.16	Factitious Disorder With Predominantly Psychological Signs and Symptoms
300.19	Factitious Disorder NOS/Other and Unspecified Factitious Illness
300.19	Factitious Disorder With Combined Psychological and Physical Signs and Symptoms/Other and Unspecified Factitious Illness
300.19	Factitious Disorder With Predominantly Physical Signs and Symptoms/Other and Unspecified Factitious Illness
300.20	Phobia, Unspecified
300.21	Panic Disorders with Agoraphobia
300.22	Agoraphobia Without History of Panic Disorder
300.23	Social Phobia
300.29	Specific Phobia/Other Isolated or Simple Phobias
300.3	Obsessive-Compulsive Disorder
300.4	Dysthymic Disorder/Neurotic Depression
300.5	Neurasthenia
300.6	Depersonalization Disorder
300.7	Body Dysmorphic Disorder/Hypochondriasis
300.81	Somatization Disorder
300.82	Somatoform Disorder NOS, Undifferentiated Somatoform Disorder
300.9	Unspecified Mental Disorder (non-psychotic)/Unspecified Neurotic Disorder
301.0	Paranoid Personality Disorder
301.10	Affective Personality Disorder, Unspecified
301.11	Chronic Hypomanic Personality Disorder
301.12	Chronic Depressive Personality Disorder
301.13	Cyclothymic Disorder
301.20	Schizoid Personality Disorder
301.21	Introverted Personality
301.22	Schizotypal Personality Disorder
301.3	Explosive Personality Disorder
301.4	Obsessive-Complusive Personality Disorder
301.50	Histrionic Personality Disorder
301.51	Chronic Factitious Illness With Physical Symptoms
301.59	Other Histrionic Personality Disorder
301.6	Dependent Personality Disorder
301.7	Antisocial Personality Disorder
301.81	Narcissistic Personality Disorder
301.82	Avoidant Personality Disorder
301.83	Borderline Personality Disorder
301.84	Passive-aggressive Personality
301.89	Personality Disorder, Other
301.9	Personality Disorder NOS
302.1	Zoophilia
302.2	Pedophilia
302.3	Transvestic Fetishism
302.4	Exhibitionism
302.50	Trans-sexualism, With Unspecified Sexual History
302.51	Trans-sexualism, With Asexual History
302.52	Trans-sexualism, With Homosexual History
302.53	Trans-sexualism, With Heterosexual History
302.6	Gender Identity Disorder NOS/Disorders of Psychosexual Identity
302.6	Gender Identity Disorder in Children/Disorders of Psychosexual Identity
302.70	Sexual Dysfunction NOS
302.71	Hypoactive Sexual Desire Disorder/Psychosexual Dysfunction With Inhibited Sexual Desire
302.72	Female Sexual Arousal Disorder/Psychosexual Dysfunction With Inhibited Sexual Excitement
302.72	Male Erectile Disorder/Psychosexual Dysfunction With Inhibited Sexual Excitement
302.73	Female Orgasmic Disorder/Psychosexual Dysfunction With Inhibited Female Orgasm
302.74	Male Orgasmic Disorder/Psychosexual Dysfunction With Inhibited Male Orgasm
302.75	Premature Ejaculation/Psychosexual Dysfunction with Premature Ejaculation
302.76	Dyspareunia [Not Due to a General Medical Condition]/Psychosexual Disorder With Functional Dysparenunia
302.79	Sexual Aversion Disorder/Psychosexual Dysfunction With Other Specified Psychosexual Dysfunctions
302.81	Fetishism
302.82	Voyeurism
302.83	Sexual Masochism
302.84	Sexual Sadism
302.85	Gender Identity Disorder in Adolescents or Adults
302.89	Frotteurism/Other Specified Psychosexual Disorder
302.9	Sexual Disorder NOS/Unspecified Psychosexual Disorder
302.9	Paraphilia NOS/Unspecified Psychosexual Disorder
306.51	Vaginismus [Not Due to a General Medical Condition]/Psychogenic Vaginismus
307.1	Anorexia Nervosa
307.20	Tic Disorder NOS
307.21	Transient Tic Disorder/Transiant Tic Disorder of Childhood
307.22	Chronic Motor or Vocal Tic Disorder
307.23	Tourette's Disorder
307.3	Stereotypic Movement Disorder/Stereotyped Repetitive Movements
307.40	Dyssomnia NOS/Parasomnia NOS
307.42	Insomnia Related To..[Indicate the Axis I or II Disorder]/Persistent Disorder of Initiating or Maintaining Sleep
307.42	Primary Insomnia/Persistent Disorder of Initiating or Maintaining Sleep
307.44	Primary Hypersomnia/Persistent Disorder of Initiating or Maintaining Wakefulness
307.44	Hypersomnia Related to..[Indicate the Axis I or II Disorder]/Persistent Disorder of Initiating or Maintaining Wakefulness
307.46	Sleep Terror Disorder/Somnambulism or Night Terrors
307.46	Sleepwalking Disorder/Somnambulism or Night Terrors
307.47	Dyssomnia NOS/Other Dysfunctions of Sleep Stages or Arousal from Sleep
307.47	Nightmare Disorder/Other Dysfunctions of Sleep Stages or Arousal from Sleep
307.47	Parasomnia NOS/Other Dysfunctions of Sleep Stages or Arousal from Sleep
307.50	Eating Disorder NOS
307.51	Bulimia Nervosa
307.52	Pica
307.53	Rumination Disorder/Psychogenic Rumination
307.54	Psychogenic Vomiting
307.59	Feeding Disorder of Infancy or Early Childhood
307.6	Enuresis (Not Due to General Medical Condition)
307.7	Encopresis, Without Constipation and Overflow Incontinence
308.0	Acute Reaction to Stress, Predominant Disturbance of Emotions
308.1	Acute Reaction to Stress, Predominant Disturbance of Consciousness
308.2	Acute Reaction to Stress, Predominant Psychomotor Dysfunction
308.3	Acute Stress Disorder/Other Acute Reactions to Stress
308.4	Mixed Disorders as Reaction to Stress
308.9	Acute Reaction to Stress, Unspecified
309.0	Adjustment Disorder With Depressed Mood/Brief Depressive Reaction
309.1	Prolonged Depressive Reaction
309.21	Separation Anxiety Disorder
309.24	Adjustment Disorder With Anxiety/Adjustment Reaction with Anxious Mood
309.28	Adjustment Disorder With Mixed Anxiety and Depressed Mood
309.29	Adjustment Reaction With Predominant Disturbance of Other Emotions, Other
309.3	Adjustment Disorder with Disturbance of Conduct
309.4	Adjustment Disorder with Mixed Disturbance of Emotions and Conduct
309.81	Posttraumatic Stress Disorder
309.9	Adjustment Disorder Unspecified
310.1	Personality Change Due to..(Indicate the General Medical Condition)/Organic Personality Syndrome
311	Depressive Disorder NOS
312.00	Undersocialized Conduct Disorder, Aggressive Type
312.01	Undersocialized Conduct Disorder, Aggressive Type, Mild
312.02	Undersocialized Conduct Disorder, Aggressive Type, Moderate
312.03	Undersocialized Conduct Disorder, Aggressive Type, Severe
312.10	Undersocialized Conduct Disorder, Unaggressive Type
312.11	Undersocialized Conduct Disorder, Unaggressive Type, Mild
312.12	Undersocialized Conduct Disorder, Unaggressive Type, Moderate
312.13	Undersocialized Conduct Disorder, Unaggressive Type, Severe
312.20	Socialized Conduct Disorder
312.21	Socialized Conduct Disorder, Mild
312.22	Socialized Conduct Disorder, Moderate
312.23	Socialized Conduct Disorder, Severe
312.30	Impulse-Control Disorder NOS
312.31	Pathological Gambling
312.32	Kleptomania
312.33	Pyromania
312.34	Intermittent Explosive Disorder
312.35	Isolated Explosive Disorder
312.39	Trichotillomania/Disorder of Impulse Control, Other
312.4	Mixed Disturbance of Conduct and Emotions
312.81	Conduct Disorder, Childhood-Onset Type
312.82	Conduct Disorder, Adolescent-Onset Type
312.89	Conduct Disorder, Unspecified Onset
312.9	Disruptive Behavior Disorder NOS/Unspecified Disturbance of Conduct
313.0	Overanxious Disorder
313.21	Shyness Disorder of Childhood
313.22	Introverted Disorder of Childhood
313.23	Selective Mutism/Elective Mutism
313.81	Oppositional Defiant Disorder
313.82	Identity Problem/Identity Disorder
313.89	Reactive Attachment Disorder of Infancy or Early Childhood/Other or Mixed Emotional Disturbances of Childhood or Adolescence, Other
313.9	Disorder of Infancy, Childhood or Adolescence NOS/Unspecified Emotional Disturbance of Childhood or Adolescence
314.00	Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type
314.01	Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type
314.01	Attention-Deficit/Hyperactivity Disorder, Combined Type
314.1	Hyperkinesis With Developmental Delay
314.2	Hyperkinetic Conduct Disorder
314.8	Other Specified Manifestations of Hyperkinetic Syndrome
314.9	Attention-Deficit/Hyperactivity Disorder NOS/Unspecified Hyperkinetic Syndrome
316	[Specified Psychological Factor] Affecting..[Ind. the Gen. Med. Cond.]/Psychic Factors Associated with Disease Classified Elsewhere
	Observation of suspected mental illness, other

NOTE: In a diagnosis where the DSMIV and ICD-9 Code is listed and different, the DSMIV diagnosis is listed prior to the "/".

3. Enrollment/Registration with DHS/DMH

In order for a community mental health service provider to receive payment from DHS/DMH for mental health services provided to an individual, it is essential that the individual be enrolled or registered with DHS/DMH. This enrollment/registration process supplies the information necessary to determine the individual's eligibility to receive services funded by DHS/DMH, and the services and amount of services they qualify for. It also is an important component of accountability for state funds and source of information necessary for effective management of a public mental health service system.

DHS/DMH expects the information provided in the enrollment/registration process to be complete and accurate. Failure to supply complete and correct information may lead to the individual being incorrectly determined as ineligible for funding of their services by DHS/DMH, or placed in the incorrect eligibility group.

A critical component of enrollment/registration of individual is entry of their correct State of Illinois Recipient Identification Number (RIN). If an individual does not have a RIN or cannot provide it, community mental health service agencies have access to a system to obtain this information. The Illinois Department of Human Services maintains a web-based system (the "e-RIN System") that permits determination of an individual's RIN or obtaining a RIN for an individual who does not yet have one. This web-site and instructions for its use can be found at: http://www.dhs.state.il.us/page.aspx?item=32574.

Instructions for the process of enrolling/registering an individual with DHS/DMH can be found at: http://www.illinoismentalhealthcollaborative.com/provider/prv_information.htm.

4. Service benefits for eligible consumers

1. Activities and services funded by capacity grants

   Individuals may be eligible for activities and services supported by capacity grant funding for those Providers funded for specific capacity grants according to the requirements of the grants.

2. Eligibility Group 1: Medicaid Eligible

   Individuals in this group are eligible to have all community mental health services funded by DHS/DMH paid for by DHS/DMH as long as these services are medically necessary.

3. Eligibility Group 2: Non-Medicaid Target Population

   For this Group DHS/DMH's aim is to fund core services essential for individuals with serious mental illness or emotional disturbance. Individuals in this group are not Medicaid eligible but can have the following services up to the limits indicated paid for by DHS/DMH in whole or in part dependent upon the individual's income group:

   DHS Act Code	CPT/ HCPCS	W Code	Modifier Order	Modifer Order (2)	Service	Service Limits
   10	H2011				Crisis intervention	None
   13	H2011		HK		Crisis intervention, state operated facility screening
   1A	H2011		HT		Crisis intervention--multiple staff
   01	H0031		AH		Mental health assessment (LCP)	Total of 16 units per individual per fiscal year.
   0M	H0031		HN		Mental health assessment (MHP)
   0Q	H0031		HO		Mental health assessment (QMHP, AM/MA)
   0C	H0032		HN		Treatment plan development, review, modification (MHP)	Total of 8 units per individual per fiscal year.
   0D	H0032		HO		Treatment plan development, review, modification (QMHP)
   5R	T1016		HM		Case management--mental health (RSA)	Total of 20 units per individual per fiscal year.
   5M	T1016		TF		Case management--mental health (MHP)
   5A	T1016		HN		Case management--transition linkage and aftercare (MHP)
   5B	T1016		HO		Case management--transition linkage and aftercare (QMHP)
   5C	T1016		HK	HN	Case management--mandated follow-up (MHP)
   5D	T1016		HK	HO	Case management- mandated follow-up (QMHP)
   5L	H0002		HE		Case management - LOCUS	Total of 3 events per individual per fiscal year.
   25	T1502				Psychotropic medication administration (LPN/RN)	Total of 12 events per individual per fiscal year.
   2D	T1502		SA		Psychotropic medication administration (APN)
   26	90862		52		Psychotropic medication monitoring (non-APN / non-MD)	Total of 8 units per individual per fiscal year.
   2E	90862		SA		Psychotropic medication monitoring (APN)	Total of 8 units per individual per fiscal year.
   2F	90862		UA		Psychotropic medication monitoring (MD/DO/DC)
   31	H0034		HN		Psychotropic medication training--Individual
   7A	T1013				Oral interpretation and sign language	Total of 100 units per individual per fiscal year.

4. Eligibility Group 3: Non-Medicaid First Presentation of Psychosis Population

   For this Group DHS/DMH's aim is to fund core services for adults first presenting to the mental health system with a serious mental illness in order to minimize the likelihood of further exacerbation of their mental disorder and deterioration in functioning. Individuals in this group are not Medicaid eligible but can have the following services up to the limits indicated paid for by DHS/DMH in whole or in part dependent upon the individual's income group:

   DHS Act Code	CPT/ HCPCS	W Code	Modifier Order	Modifier Order (2)	Service	Service Limits
   10	H2011				Crisis intervention	None
   13	H2011		HK		Crisis intervention, state operated facility screening
   1A	H2011		HT		Crisis intervention--multiple staff
   01	H0031		AH		Mental health assessment (LCP)	Total of 16 units per individual per fiscal year.
   0M	H0031		HN		Mental health assessment (MHP)
   0Q	H0031		HO		Mental health assessment (QMHP, AM/MA)
   0C	H0032		HN		Treatment plan development, review, modification (MHP)	Total of 8 units per individual per fiscal year.
   0D	H0032		HO		Treatment plan development, review, modification (QMHP)
   5R	T1016		HM		Case management--mental health (RSA)	Total of 20 units per individual per fiscal year.
   5M	T1016		TF		Case management--mental health (MHP)
   5A	T1016		HN		Case management--transition linkage and aftercare (MHP)
   5B	T1016		HO		Case management--transition linkage and aftercare (QMHP)
   5C	T1016		HK	HN	Case management--mandated follow-up (MHP)
   5D	T1016		HK	HO	Case management- mandated follow-up (QMHP)
   5L	H0002		HE		Case management - LOCUS	Total of 3 events per individual per fiscal year.
   25	T1502				Psychotropic medication administration (LPN/RN)	Total of 12 events per individual per fiscal year.
   2D	T1502		SA		Psychotropic medication administration (APN)
   26	90862		52		Psychotropic medication monitoring (non-APN / non-MD)	Total of 8 units per individual per fiscal year.
   2E	90862		SA		Psychotropic medication monitoring (APN)
   2F	90862		UA		Psychotropic medication monitoring (MD/DO/DC)
   31	H0034		HN		Psychotropic medication training--Individual	Total of 8 units per individual per fiscal year.
   7A	T1013				Oral interpretation and sign language	Total of 100 units per individual per fiscal year.

5. Eligibility Group 4: Non-Medicaid Eligible Population

   For this Group DHS/DMH's aim is to fund services sufficient for the individual to be assessed and determined to meet the criteria of another DHS/DMH eligibility group or referred to an alternative provider or resource for services and support. Individuals in this group are not Medicaid eligible but can have the following services up to the limits indicated paid for by DHS/DMH in whole or in part dependent upon the individual's income group:

   DHS Act Code	CPT/ HCPCS	W Code	Modifier Order	Service	Service Limits
   10	H2011			Crisis intervention	None
   13	H2011		HK	Crisis intervention, state operated facility screening
   1A	H2011		HT	Crisis intervention--multiple staff
   01	H0031		AH	Mental health assessment (LCP)	Total of 8 units per individual per fiscal year.
   0M	H0031		HN	Mental health assessment (MHP)
   0Q	H0031		HO	Mental health assessment (QMHP, AM/MA)
   7A	T1013			Oral interpretation and sign language	Total of 24 units per individual per fiscal year.

5. Criteria for determination of the amount of the DHS/DMH rate to be paid by DHS/DMH

1. Income Groups and DHS/DMH payment

   With limited state funding, DHS/DMH aims to support mental health services for individuals who are in need not only clinically, but also financially. To achieve this DHS/DMH has established household income groups based on the current Federal Poverty Guidelines or Levels (FPL). The table on the following page shows these income groups as indicated by an individual's household size and household monthly income.

   This table also shows that the amount of payment from DHS/DMH for a mental health service provided to an individual will be based on the individual's income group. That is, the amount or portion of the DHS/DMH rate for a mental health service that DHS/DMH will pay will be based on an individual's income group as determined by their household monthly income and size

   Income Ranges by Household Size and Multiples of the Federal Poverty Guidelines or Level (FPL) for FFY 2010

   Monthly Income Groups A through E

   Number of Persons in Household	Income Group A Under 200% FPL DHS/DMH pays 100% of the rate Range	Income Group B 200% FPL to greater than 250% FPL DHS/DMH pays 80% of the rate Range	Income Group C 250% FPL to greater than 300% FPL DHS/DMH pays 60% of the rate Range	Income Group D 300% FPL to greater than 350% FPL DHS/DMH pays 40% of the rate Range	Income Group E 350% to greater than 400% FPL DHS/DMH pays 20% of the rate Range
   1	$0 - $1,804	$1,805 - $2,255	$2,256 - $2,707	$2,708 - $3,158	$3,159 - $3,609
   2	$0 - $2,427	$2,428 - $3,034	$3,035 - $3,642	$3,643 - $4,249	$4,250 - $4,856
   3	$0 - $3,051	$3,052 - $3,814	$3,815 - $4,576	$4,577 - $5,339	$5,340 - $6,102
   4	$0 - $3,674	$3,675 - $4,593	$4,594 - $5,512	$5,513 - $6,430	$6,431 - $7,349
   5	$0 - $4,297	$4,298 - $5,372	$5,373 - $6,447	$6,448 - $7,521	$7,522 - $8,596
   6	$0 - $4,921	$4,922 - $6,151	$6,152 - $7,381	$7,382 - $8,612	$8,613 - $9,842
   7	$0 - $5,544	$5,545 - $6,930	$6,931 - $8,317	$8,318 - $9,703	$9,704 - $11,089
   8	$0 - $6,167	$6,168 - $7,709	$7,710 - $9,252	$9,253 - $10,794	$10,795 - $12,336
   9	$0 - $6,791	$6,792 - $8,489	$8,490 - $10,187	$10,188 - $11,884	$11,885 - $13,582
   10	$0 - $7,414	$7,415 - $9,268	$9,269 - $11,122	$11,123 - $12,975	$12,976 - $14,829
   11	$0 - $8,037	$8,038 - $10,047	$10,048 - $12,057	$12,058 - $14,066	$14,067 - $16,076
   12	$0 - $8,661	$8,662 - $10,826	$10,827 - $12,992	$12,993 - $15,157	$15,158 - $17,322
   13	$0 - $9,284	$9,285 - $11,605	$11,606 - $13,927	$13,928 - $16,248	$16,249 - $18,569
   14	$0 - $9,907	$9,908 - $12,384	$12,385 - $14,862	$14,863 - $17,339	$17,340 - $19,816
   15	$0 - $10,531	$10,532 - $13,164	$13,165 - $15,797	$15,798 - $18,430	$18,431 - $21,062
   16	$0 - $11,154	$11,155 - $13,943	$13,944 - $16,732	$16,733 - $19,520	$19,521 - $22,309
   17	$0 - $11,777	$11,778 - $14,722	$14,723 - $17,667	$17,668 - $20,611	$20,612 - $23,556
   18	$0 - $12,401	$12,402 - $15,501	$15,502 - $18,602	$18,603 - $21,702	$21,703 - $24,802
   19	$0 - $13,024	$13,025 - $16,280	$16,281 - $19,537	$19,538 - $22,793	$22,794 - $26,049
   20	$0 - $13,647	$13,648 - $17,060	$17,061 - $20,472	$20,473 - $23,884	$23,885 - $27,296

2. Determining and documenting an individual's income

   To confirm an individual's household income, the provider must communicate to the individual that in order to have the State of Illinois pay for all or part of the mental health services they receive, the individual must supply documentation of their household income. Acceptable examples of documentation of income are a copy of the most recently filed State or Federal Income Tax Return or any other document indicating the current status of household income (e.g., pay check stubs, W-2 forms, proof of unemployment). When a provider is unable to secure income verification from an individual and relies solely on the individual's verbal report, the provider must document this in the individual's clinical record or a separate financial record what attempts were made to secure such information and the reason for the absence of such documentation.

   Zero (0) is a possible and valid entry for household income, but not for household size.

   Documentation regarding an individual's household income and size is to be completed within thirty-days of the individual's first service event.

   Documentation from the individual supporting his or her household income level shall be kept in the individual's clinical record or a separate financial record. Providers are not required to submit such documentation to DHS/DMH but this information is subject to review. DHS/DMH anticipates that this documentation will be reviewed as part of the post-payment review process, and failure to maintain this documentation may result in disallowance of payments and payment recoupment for services to individuals not eligible for Medicaid.

3. Additional conditions of DHS/DMH payment for services: Individual co-pays and HIPAA requirements

   As a condition of DHS/DMH payment for mental health services for individuals in financial need, DHS/DMH requires that any co-payments from an individual for any service funded by DHS/DMH in whole or in part not exceed the total DHS/DMH rate when added to the amount paid by DHS/DMH; that is, the co-payment is not to exceed the difference between the full DHS/DMH rate for that service and the amount paid by DHS/DMH for the service. Beyond this requirement, DHS/DMH does not prescribe for providers a specific sliding fee scale or co-payment required of individuals receiving mental health services.

   It is also important that individuals receiving services funded by DHS/DMH are fully informed that not only is the State of Illinois, through DHS/DMH, paying for all or part of their mental health services, but that their private health information is being shared with the DHS/DMH. This is a federal regulation requirement under HIPAA. A sample form for this purpose, "Documentation of Consumer Choice to Receive DHS-Funded Services" is available at: http://www.dhs.state.il.us/page.aspx?item=49700

4. Exceptions for reporting an individual's household income

   There are three exceptions to the requirement for reporting an individual's household income that can be entered:

   1. Minors between the ages of 12 and 17 seeking outpatient therapy/counseling without the consent of their parents or guardian
       

      Per Illinois statute (405 ILCS 5/3-501) a minor between the ages of 12 and 17 can receive up to five sessions lasting no more than 45 minutes each of outpatient therapy/counseling (i.e., up to 15 units of this specific service) without the consent or knowledge of their parent or guardian. Providers wishing to submit claims to DHS/DMH for the provision of this service to an individual under these conditions will not have to report the individual's household income, but instead will enter the code for this condition as specified in the MIS Consumer Enrollment/Registration instructions (available at: http://www.illinoismentalhealthcollaborative.com/provider/prv_information.htm)

   2. Household medical debt

      An individual seeking mental health services may be part of a household with income above the 200% poverty level, but with a household combined debt for prior medical expenses (not covered by insurance or other third parties) that exceed 7.5% of the total gross household income. Providers wishing to submit claims to DHS/DMH for the provision of mental health services to an individual from a household with this debt level will enter the code for this condition as specified in the MIS Consumer Enrollment/Registration instructions (available at: http://www.illinoismentalhealthcollaborative.com/provider/prv_information.htm)

      When this code is entered, the individual's household income will not be used to determine the proportion of the DHS/DMH rate that will be paid to the provider.

   3. Other exceptions

      If the provider needs for DHS/DMH to pay for mental health services for an individual without that individual documenting or reporting their household income due to exceptional circumstances, the provider will not have to report the individual's household income, but instead will enter the code for this condition as specified in the MIS Consumer Enrollment/Registration instructions (available at: http://www.illinoismentalhealthcollaborative.com/provider/prv_information.htm).

      DMH expects that this exception will be used infrequently and not as a matter of course when registering individuals.

      For all three of the above exceptions, DHS/DMH will pay the full DHS/DMH rate for the mental health services provided under the exception.

      The provider must maintain documentation clearly supporting the exception in the individual's clinical record or a separate financial record. Providers are not required to submit such documentation to DHS/DMH but this information is subject to review. DHS/DMH anticipates that this documentation will be reviewed as part of the post-payment review process, and failure to maintain this documentation may result in disallowance of payments and recoupment.

5. Updating household size and income information

   DHS/DMH will apply the above requirements, including documentation requirements, for all registrations in FY11.

   For billings or claims submitted for an individual consumer, that individual consumer's enrollment/registration record must reflect their current household size and income and comply with the above requirements, including documentation requirements.

6. Required information for six-month updates for existing consumers

DHS/DMH requires that the following fields be updated at least every six months. The updating of these fields at six months intervals will ensure more accurate reporting of the consumer's status and eligibility determination.

• Income (Household and Client)
• Household Size
• Household Composition
• Education Level
• Military Status
• Employment Status
• Court/Forensic Treatment
• MH Residential Arrangement
• Justice System Involvement
• Diagnosis Information
• CGAS or GAF Score
• Client Functioning Children and Adolescent or Adult
• History of Illness Information