AUTHORITY: Sections 5-5.5 and 12-13 of the Illinois Public Aid Code [305 ILCS 5/5-5.5 and 12-13]

SOURCE: Adopted at 26 Ill. Reg. 3081, effective February 15, 2002; emergency amendment at 29 Ill. Reg. 10259, effective July 1, 2005, for a maximum of 150 days; amended at 29 Ill. Reg. 18906, effective November 4, 2005; amended at 38 Ill. Reg. 23759, effective December 2, 2014.

SUBPART A: DEMONSTRATION PROJECT FOR MENTAL HEALTH SERVICES IN NURSING FACILITIES

 

Section 145.10  General Provisions (Repealed)

 

(Source:  Repealed at 38 Ill. Reg. 23759, effective December 2, 2014)

SUBPART B: INSTITUTION FOR MENTAL DISEASES PROVISIONS FOR NURSING FACILITIES

 

Section 145.20  General Provisions

 

Sections 1905(a)(16) and 1905(a)(27)(B) of the Social Security Act provide that federal financial participation (FFP) is not available for any medical assistance under Title XIX for services provided to any individual who is older than 21 years of age and under 65 years of age and who is a patient in an IMD.  The purpose of this Subpart B is to set forth the process by which the Department shall identify nursing facilities that are IMDs or that are at risk of becoming IMDs, the preventive measures to be taken to avoid classification of a nursing facility as an IMD, and the actions to be taken if a facility is identified as an IMD.

 

Section 145.30  Definitions

 

For purposes of this Part, the following terms shall be defined as follows:

 

"IMD" means a nursing facility that is considered to be an Institution for Mental Diseases (IMD) under Section 1905(i) of the Social Security Act (42 USC 1396d(i)). Federal regulations provide that:  An IMD is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.  An IMD has an overall character of a facility established and maintained primarily for the care and treatment of individuals with mental diseases.  An institution for the mentally retarded (ICF/MR) is not an IMD (see 42 CFR 435.1009).

 

"Class I IMD" means a nursing facility determined to be an IMD during the initial review conducted pursuant to Section 145.40.

 

"Class II IMD" means a nursing facility determined to be an IMD in a subsequent review conducted pursuant to Section 145.50.

 

"IMD Guidelines" means the Guidelines in Section 4390 of the CMMS State Medicaid Manual relating to Institutions for Mental Diseases (Centers for Medicare and Medicaid Services, 7500 Security Boulevard, Baltimore MD 21244-1850 (1994, no later amendments or editions included)). Criteria used in determining whether the overall character of a facility is that of an IMD include whether the current need for institutionalization for more than 50 percent of all the patients in the facility results from mental diseases and whether the facility specializes in providing psychiatric/psychological care and treatment.

 

"Mental Disease" means mental disease or mental illness as defined in the IMD Guidelines.  Mental disease includes those diseases listed as mental disorders in the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) until implementation of the International Classification of Diseases, 10^th Revision, Clinical Modification (ICD-10-CM) and its classifications for mental disorders, with the exception of mental retardation, senility and organic brain syndrome.

 

"Current need for nursing facility care results from mental disease" means that a review of the resident's diagnoses, the character and nature of his or her problems, functional status, and his or her care needs indicates that the resident's need for nursing facility care results from his or her mental disease and not a physical or medical reason.

 

(Source:  Amended at 38 Ill. Reg. 23759, effective December 2, 2014)

 

Section 145.40  Initial IMD Review, Determination and Classification of Facilities

 

a)         An initial review of data on nursing facility residents in enrolled nursing facilities shall be conducted by the Department.  The initial data review shall be based on Minimum Data Set data electronically submitted to the Department on nursing facility residents who are residents of the facility as of March 1, 2001. Based on the review, a determination shall be made of the number of residents whose current need for nursing facility care results from mental disease.  The facility's total resident census shall be determined by the Department at the time of the data review.

 

b)         The percentage of residents whose current need for nursing facility care results from mental disease will be determined by dividing the number of the residents whose current need for nursing facility care results from mental disease, identified in the data review in subsection (a) of this Section, by the total resident census.

 

c)         If the initial data review of a facility indicates that further information is needed in order to determine whether the current need for nursing facility care for more than 50 percent of all residents in the facility results from mental diseases, the Department may contact the facility or make an on-site visit to obtain additional information.  The Department will verify the resident count and make a determination of the facility's IMD status based on the IMD Guidelines.

 

d)         If a facility is determined to be an IMD during the initial review and determination, the Department shall notify the facility that it has been identified as a Class I IMD nursing facility.

 

e)         A facility that is classified as a Class I IMD nursing facility in accordance with the review and determination process in this Section shall receive the Class I IMD per diem reimbursement rate as stipulated in Section 145.80(a).

 

f)         A change in ownership or operator shall not change or otherwise affect the designation of a facility as an IMD under this Section.

 

g)         A Class I IMD facility that no longer meets the definition of an IMD shall relinquish its Class I IMD classification and may not again be classified as a Class I IMD.

 

Section 145.50  Subsequent IMD Reviews, Determinations and Classifications

 

a)         Subsequent reviews of data on nursing facility residents in enrolled nursing facilities shall be conducted periodically using the Minimum Data Set data electronically submitted to the Department.

 

b)         The percentage of residents whose current need for nursing facility care results from mental disease will be determined by dividing the number of the residents whose current need for nursing facility care results from mental disease, identified in the data review in subsection (a) of this Section, by the total resident census. The facility's total resident census shall be determined by the Department at the time of the data review.

 

c)         If a subsequent data review indicates that further information is needed in order to determine whether the current need for nursing facility care for more than 50 percent of all residents in the facility results from mental diseases, the Department may contact the facility or make an on-site visit to obtain additional information. The Department will verify the resident count and make a determination of the facility's status based on the IMD Guidelines.

 

d)         Within 45 days after the on-site visit, the Department shall determine whether the facility is an IMD and notify the facility of its IMD status.

 

e)         A facility determined to be an IMD as the result of a subsequent data review and determination shall be classified as a Class II IMD nursing facility effective the first day of the quarter after the determination.   A change in ownership or operator shall not change or otherwise affect the designation of  a facility as an IMD under this Section.

 

f)         No facility may be classified as a Class I IMD nursing facility as a result of a subsequent review under this Section.

 

Section 145.60  Effect of Becoming a Class II IMD and Redetermination Reviews

 

a)         A facility that is classified as a Class II IMD nursing facility in accordance with the review and determination process in Section 145.50 shall receive the Class II IMD per diem reimbursement rate as stipulated in Section 145.80(b).

 

b)         The Class II IMD rate shall be effective on the first day of the quarter after the Department makes its determination that a facility is a Class II IMD.

 

c)         If requested by a Class II IMD nursing facility, the Department shall make a redetermination of a facility's status as an IMD by conducting a resident data review and on-site visit of the facility.

 

d)         If the Department determines that the facility is not an IMD as the result of a redetermination review, the facility shall be reclassified to non-IMD status effective the first day of the month following the redetermination review.

 

Section 145.70  Watch List of Nursing Facilities at Risk of Becoming IMDs

 

a)         If the initial, subsequent or any other Department data reviews indicate that the current need for nursing facility care for 40 percent or more of the residents residing in the facility results from mental disease, the Department shall notify the facility that it is at risk of becoming an IMD, advise the facility of the consequences of becoming an IMD, and place the facility on an "at risk" list. The Department may conduct an on-site review of an "at risk" facility at any time.

 

b)         The Department shall notify the State mental health authority when a facility is at risk of becoming an IMD.

 

Section 145.80  Reimbursement Rate for IMD Nursing Facility Classifications

 

a)         Reimbursement Rate for Class I IMD Nursing Facilities

            A facility classified under Section 145.40 shall have its per diem reimbursement rate for all residents set at the reimbursement rate that would otherwise be determined under the Department's administrative rules located at 89 Ill. Adm. Code 140, 147 and 153 for long term care services provided by nursing facilities that are not IMDs.

 

b)         Reimbursement Rate for Class II IMD Nursing Facilities

 

1)         A facility classified as a Class II IMD pursuant to Section 145.50 shall have its per diem reimbursement rate for residents who are 22 through 64 years of age set at one-half of the reimbursement rate that would otherwise be determined under Department rules for long term care services provided by nursing facilities that are not IMDs.

 

2)         The per diem reimbursement rate for residents 21 years of age or younger and residents 65 years of age or older shall be set at the reimbursement rate that would otherwise be determined under Department rules for long term care services provided by nursing facilities that are not IMDs.

 

Section 145.90  Reviews

 

a)         Upon notification that it has been determined to be a Class II IMD, either as the result of a subsequent review pursuant to Section 145.50 or a redetermination review pursuant to Section 145.60(c), a facility may request a review of the Department's determination.  Such a request must be submitted in writing and received by the Department within 30 days after the date of the Department's notice to the facility that it has been determined to be an IMD.  Such a request shall include a clear explanation and supporting documentation of the facility's basis for considering the Department's determination that it is an IMD to be in error. Department review shall be limited to the Department's:

 

1)         calculation of the percentage of persons whose mental disease is the reason for being in the facility; and

 

2)         determination of those residents who are counted in arriving at the number of persons whose mental disease is the reason for being in the facility and the number of residents who have a physical or medical reason for being in the facility.

 

b)         The Department shall complete its review and issue a final determination of a facility's request for review unless the Department in the course of its review determines that an on-site visit is needed.  Upon the request of the Department, a facility may submit further documentation to the Department in support of its request for review during the course of the Department's review.  Department review shall not delay implementation of a facility's reimbursement rate pursuant to Section 145.80(b).