Illinois Administrative Code › Title 50 - INSURANCE › Part 2035 - MEDICAL NECESSITY CRITERIA FOR SERIOUS MENTAL ILLNESSES FOR INDIVIDUALS UNDER THE AGE OF 26 › Section 2035.20 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
"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.