CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2035 MEDICAL NECESSITY CRITERIA FOR SERIOUS MENTAL ILLNESSES FOR INDIVIDUALS UNDER THE AGE OF 26
SECTION 2035.20 DEFINITIONS
Section 2035.20 Definitions
"Assertive Community Treatment" or "ACT" means a bundle of health care services delivered through a multidisciplinary team of mental health professionals to individuals who are experiencing severe and persistent symptoms from a serious mental illness. These specialty services mitigate symptoms of the mental illness, support recovery, increase functioning and symptom management, and decrease hospitalizations and crisis episodes. Services are delivered in the office and in the person's natural environment to:
optimize engagement; and
promote wellness, self-management, resiliency, skill-building, and use of natural supports to prevent lifelong struggles with serious and persistent mental health symptoms.
"CALOCUS composite score" means a composite score assigned to an individual under age 18 that is derived by applying the standards contained in "CALOCUS: Child and Adolescent Level of Care Utilization System" (American Association for Community Psychiatry, PO Box 570218, Dallas TX 75357-0218) (Child and Adolescent Version 20) (July 2019) (no later editions or amendments included).
"Code" means the Illinois Insurance Code [215 ILCS 5].
"Community Support Team Treatment" or "CST Treatment" means a bundle of health care services delivered through a multidisciplinary team of mental health professionals to individuals experiencing moderate to severe symptoms from a serious mental illness. These specialty services mitigate symptoms of the mental illness, support recovery, increase functioning and symptom management, and decrease hospitalizations and crisis episodes. Services are delivered in the office and in the person's natural environment to:
optimize engagement; and
promote wellness, self-management, resiliency, skill-building, and use of natural supports to prevent lifelong struggles with serious and persistent mental health symptoms.
"Coordinated Specialty Care for First Episode Psychosis Treatment" or "CSC" means a bundle of health care services delivered through a multidisciplinary team of mental health professionals to individuals who are experiencing an episode of psychosis for the first time, as well as to their families. These specialty services mitigate symptoms of psychosis, support recovery, increase functioning and symptom management, and decrease hospitalizations and crisis episodes. Services are delivered in the office and in the person's natural environment to:
optimize engagement; and
promote wellness, self-management, resiliency, skill-building, and use of natural supports to prevent lifelong struggles with serious and persistent mental health symptoms.
"DSM" means the DSM-5 as modified by the DSM-5 Update: February 2020.
"DSM-5" means the "Diagnostic and Statistical Manual of Mental Disorders: DSM-5" (American Psychiatric Association, 800 Maine Ave, SW, Ste. 900, Washington DC 20024-2812) (5th ed.) (2013) (no later editions or amendments included).
"DSM-5 Update: February 2020" means the "Supplement to Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition" (American Psychiatric Association, 800 Maine Ave., SW, Ste. 900, Washington DC 20024-2812) (Feb. 2020) (no later editions or amendments included).
"Excepted benefits" has the meaning ascribed in the following federal regulations:
For individual health insurance coverage, 45 CFR 148.220; and
For group health insurance coverage, 45 CFR 146.145(b).
"HMO Act" means the Health Maintenance Organization Act [215 ILCS 125].
"Issuer" means a "health insurance issuer" as defined in Section 5 of the Illinois Health Insurance Portability and Accountability Act [215 ILCS 97].
"LOCUS composite score" means a composite score assigned to an individual of age 18 or older that is derived by applying the standards contained in "LOCUS: Level of Care Utilization System for Psychiatric and Addiction Services" (American Association for Community Psychiatry, PO Box 570218, Dallas TX 75357-0218) (Adult Version 20) (Dec. 2016) (no later editions or amendments included).
"Nonfederal governmental payor" means the State or any of its political subdivisions, or any agency or instrumentality of either, in relation to its establishment of a nonfederal governmental plan.
"Nonfederal governmental plan" has the meaning ascribed in Section 5 of the Health Insurance Portability and Accountability Act.
"Utilization review" has the meaning ascribed in Section 10 of the Managed Care Reform and Patient Rights Act [215 ILCS 134].
"Utilization review organization" has the meaning ascribed in 50 Ill. Adm. Code 4520.30.