Consumer Eligibility, Enrollment/Registration, and Benefit Groups (FY15)


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 for which Eligibility Group the individual is qualified. In turn, an individual's eligibility group determines for what services DHS/DMH will pay, 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 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

  1. 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 must 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 web-based system maintained by the Illinois Department of Healthcare and Family Services (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/.
  2. Eligibility Group 2: Non-Medicaid Target Population Criteria
    Criteria for this eligibility group are aimed at applying state funding for mental health services for an individual with limited resources who is either: (a) an adult experiencing serious mental illnesses, or (b) a child with 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 1 + (II or III):
 
 I. Diagnoses(doc)

II. Treatment History , and III. Functional Criteria (doc) 

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):


 I. Diagnoses (doc)


II. 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:

___ A. Continuous treatment of 6 months or more in one, or a combination of, the following: inpatient treatment; day treatment; or partial hospitalization.

___ B. Six months continuous residence in a residential treatment center.

___ C. Two or more admissions of any duration to inpatient treatment, day treatment, partial hospitalization or residential treatment programming within a 12 month period.

___ D. 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.

___ E. Previous treatment in an outpatient modality and a history of at least one mental health psychiatric hospitalization.


III. 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.

Criteria for Functional Impairment (doc) 

  1. Eligibility Group 3: Non-Medicaid First Presentation of Psychosis Criteria
    Criteria for this eligibility group are 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.
  1. Eligibility Group 4: Non-Medicaid Eligible Population Criteria
    Criteria for this eligibility group are 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 (doc), Must have both I and II:


DSMIV CODES/ ICD-9-CM/ DMHDD ELIGIBLE POPULATION -- 11/26/08 (doc) 

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, the individual must 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 the use of their correct State of Illinois Recipient Identification Number (RIN) when registering the individual with DMH. 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 determined to be 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:
    Codes/ Modifier Order/Services/ Service Limits (doc) 
  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:
    Codes / Modifier Order/Service/ Service Limits (doc) 
  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:
    Codes/ Modifier Order/ Service/ Service Limits (doc) 

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 goal, the 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 2013 (doc)
  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 he/she 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). DHS/DMH does not require specific income documents. Providers should use their best judgment in obtaining documents that accurately represent household income and size. 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 where applicable, 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:
      • 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 FY13.
    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