305 ILCS 5/5-37

(305 ILCS 5/5-37)

Sec. 5-37. Billing mechanism for preventive mental health services delivered to children.

(a) The General Assembly finds:

(1) It is common for children to have mental health needs but to not have a full-blown diagnosis of a mental illness. Examples include, but are not limited to, children who have mild or emerging symptoms of a mental health condition (such as meeting some but not all the criteria for a diagnosis, including, but not limited to, symptoms of depression, attentional deficits, anxiety or prodromal symptoms of bipolar disorder or schizophrenia); cutting or engaging in other forms of self-harm; or experiencing violence or trauma).

(2) The federal requirement that Medicaid-covered children have access to Early and Periodic Screening, Diagnostic and Treatment services includes ensuring that Medicaid-covered children who have a mental health need but do not have a mental health diagnosis have access to treatment.

(3) The Department of Healthcare and Family Services' existing policy acknowledges this federal requirement by allowing for Medicaid billing for mental health services for children who have a need for services but who do not have a mental health diagnosis in Section 207.3.3 of the Community-Based Behavioral Services Provider Handbook. However, the current policy of the Department of Healthcare and Family Services requires clinicians to specify a diagnosis code and make a notation in the child's medical record that the service is preventive. This effectively requires the clinician to associate a diagnosis with the child and is a major barrier for services because many clinicians rightly are unwilling to document a mental health diagnosis in the medical record when a diagnosis is not medically appropriate.

(b) Consistent with the existing policy of the Department of Healthcare and Family Services and the federal Early and Periodic Screening, Diagnostic and Treatment requirement, within 3 months after the effective date of this amendatory Act of the 101st General Assembly, the Department of Healthcare and Family Services shall convene a working group that includes children's mental health providers to receive input on recommendations to develop a medically appropriate and practical solution that enables mental health providers and professionals to deliver and receive reimbursement for medically necessary mental health services provided to a Medicaid-eligible child under age 21 that has a mental health need but does not have a mental health diagnosis in order to prevent the development of a serious mental health condition. The working group shall ensure that the recommended solution works in practice and does not deter clinicians from delivering prevention and early treatment to children with mental health needs but who do not have a diagnosed mental illness. The Department of Healthcare and Family Services shall meet with this working group at least 4 times prior to finalizing the solution to enable and allow for mental health services for a child without a mental health diagnosis for purposes of prevention and early treatment when recommended by a licensed practitioner of the healing arts. If the Department of Healthcare and Family Services determines that an Illinois Title XIX State Plan amendment is necessary to implement this Section, the State Plan amendment shall be filed with the federal Centers for Medicare and Medicaid Services by no later than 12 months after the effective date of this amendatory Act of the 101st General Assembly. If rulemaking is required to implement this Section, the rule shall be filed by the Department of Healthcare and Family Services with the Joint Committee on Administrative Rules by no later than 12 months after the effective date of this amendatory Act of the 101st General Assembly, or if federal approval is required, within 6 months after federal approval. If federal approval is required but not granted, this Section shall become inoperative.

(Source: P.A. 101-461, eff. 1-1-20.)