Section 145.10  General Provisions

a)         This Section is promulgated to establish a demonstration project for nursing facilities that primarily serve persons with severe mental illness.  The Department intends to evaluate the results of the demonstration project at the end of three years.  General applicability of the provisions of this Subpart will depend upon the findings of the evaluation.  It is the Department's intent to make the project a standard category of service after reviewing the results of the evaluation.  Section 1905(a)(16) and Section 1905(a)(27)(b) of the Social Security Act provide that federal financial participation (FFP) is not available for medical assistance under Title XIX for services provided to any individual who is under 65 years of age and who is a resident in an institution for mental diseases (IMD) unless the payment is for inpatient psychiatric services for individuals under 21 years of age.  In some Illinois nursing facilities, a very high proportion of residents are not elderly and have a severe mental illness.  The purpose of the demonstration project is to allow nursing facilities to specialize in the treatment of persons with severe mental illness and focus their resources on providing psychiatric rehabilitation services rather than on meeting requirements designed primarily for elderly and medically impaired residents.  The demonstration project will focus upon evaluating standards and payment methods specific to the needs of facilities specializing in serving persons with mental illness.  The facilities in the demonstration project will serve as sites for examining service models appropriate for the mentally ill population in a long term care setting.  They will also serve as sites for comparing costs for the numbers and credentials of staff appropriate for the physically, medically ill population.  The cost information evaluated from the demonstration project will be used by the Department to develop a payment rule for services provided by a nursing facility to residents who have a serious mental illness as required by 305 ILCS 5/5-5.5(d).  The demonstration project shall be in effect until June 30, 2007.  The Department shall evaluate the demonstration project and report to the Illinois General Assembly regarding its findings and recommendations by December 31, 2004.

b)         For the purposes of this Part, "severe mental illness" is defined as the presence of a major disorder as classified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1400 K Street NW, Washington, DC 20005 (Fourth Printing, 1998, no later amendments or editions included)), excluding alcohol and substance abuse, Alzheimer's disease, and other forms of dementia based upon organic or physical disorders.  A severe mental illness is determined by all of the following three areas:

1)         Diagnoses that constitute a severe mental illness are:

A)        Schizophrenia,

B)        Delusional disorder,

C)        Schizo-affective disorder,

D)        Psychotic disorder not otherwise specified,

E)         Bipolar disorder I – mixed, manic, and depressed,

F)         Bipolar disorder II,

G)        Cyclothymic disorder,

H)        Bipolar disorder not otherwise specified,

I)          Major Depression, recurrent,

J)         Psychotic disorder, not otherwise specified.

2)         In addition, the individual must be 18 years of age or older and be substantially functionally limited by mental illness in at least two of the following areas:

A)        Self-maintenance,

B)        Social functioning,

C)        Community living activities,

D)        Work related skills.

3)         Finally, the disability must be of an extended duration, expected to be present for at least a year, that results in a substantial limitation in major life activities.  These individuals will typically also have one of the following characteristics:

A)        Have experienced two or more psychiatric hospitalizations;

B)        Receive Social Security Income (SSI) or Social Security Disability Income (SSDI) due to mental illness or have been deemed eligible for it.

c)         In order to be eligible to enter the demonstration project, a nursing facility must meet each of the following criteria:

1)         Ninety percent or more of the residents have a diagnosis of severe mental illness;

2)         No more than 15 percent of the residents are 65 years of age or older;

3)         None of the residents has a primary diagnosis of moderate, severe, or profound mental retardation;

4)         None of the residents requires medical or nursing care at a level higher than the intermediate nursing care light level of care as defined in 77 Ill. Adm. Code  300.1230(n); and

5)         The facility must be in good standing with the Departments of Healthcare and Family Services and Public Health.

d)         Nursing facilities that meet the criteria set forth in subsection (c) of this Section may apply to the Department to be considered for participation in the demonstration project.  In selecting facilities for the demonstration project, the Department shall consider other factors beyond the criteria in subsection (c) of this Section such as, but not limited to, the facility's history of compliance with all applicable State and federal standards and the effect of lost federal funds associated with withdrawal from certification.  The Department will enter into provider agreements with those facilities selected for the demonstration project.  No more than 12 facilities shall be admitted to the demonstration project.

e)         Nursing facilities participating in the demonstration project must comply with the standards set forth in 77 Ill. Adm. Code 300.6000 through 300.6095.  Based on a finding of noncompliance by the Department of Public Health on the part of a nursing facility participating in the demonstration project with any requirement set forth in 77 Ill. Adm. Code 300.6000 through 300.6095, the Department may impose sanctions as set forth in 89 Ill. Adm. Code 147.301 after notice to the facility.

f)          Notwithstanding any other provisions contained in the Administrative Code requiring certification of nursing facilities, nursing facilities participating in the demonstration project are not required to be certified for Title XIX participation in order to enroll for participation in the Medical Assistance Program or to receive payment for services.

g)         The Department shall not pay for any new admissions to the nursing facilities participating in the demonstration project of residents who:

1)         Are age 60 years or older;

2)         Do not have a severe mental illness as determined by the State's mental health pre-admission screening program; or

3)         Require medical or nursing care at a level higher than the intermediate nursing care light level of care as defined in 77 Ill. Adm. Code 300.1230(n).

h)         The Departments of Healthcare and Family Services and Public Health, and the Department of Human Services-Division of Mental Health, shall have the right of entry and inspection of any nursing facilities participating in the demonstration project to determine success and utility of the demonstration project.

i)          The Department shall provide technical assistance to nursing facilities participating in the demonstration project to assist them in meeting the standards set forth in 77 Ill. Adm. Code 300.6000 through 300.6095.

(Source:  Amended at 29 Ill. Reg. 18906, effective November 4, 2005)