Eligibility
Eligibility Requirements
Medicaid Criteria and requirements :
In order to be eligible for Mental Health Skill-building Services, an individual must meet all of the following:
Medical Necessity Criteria
Individuals qualifying for MHSS must demonstrate a clinical necessity for the service arising from a condition due to a mental, behavioral, or emotional illness that results in significant functional impairments in major life activities.
Individuals age 21 and over shall meet all of the following criteria in order to be eligible to receive MHSS:
1. The Individual is diagnosed with Mental Illness
A. The individual shall have one of the following as a primary mental health diagnosis:
1) Schizophrenia or other psychotic disorder as set out in the DSM-5,
2) Major Depressive Disorder;
3) Recurrent Bipolar I or Bipolar II;
4) Any other serious mental health disorder that a physician has documented specific to the identified individual within the past year that includes all of the following:
(i) is a serious mental illness;
(ii) results in severe and recurrent disability;
(iii) produces functional limitations in thethe individual’s major life activities that are documented in the individual’s medical record, AND; (iv) the individual requires individualized training in order to achieve or maintain independent living in the community.
2. The individual needs skills training
B. The individual shall require individualized goal-directed training in order to acquire or maintain self-regulation of basic living skills such, as symptom management; adherence to psychiatric and physical health medication treatment plans; appropriate use of social skills and personal support system; skills to manage personal hygiene, food preparation, and the maintenance of personal adequate nutrition; money management; and use of community resources.
3.The individual have a prior history of psychiatric admission
C. The individual shall have a prior history of any of the following:
(i) psychiatric hospitalization;
(ii) either residential or non-residential crisis stabilization,
(iii) ICT or Program of Assertive Community Treatment (PACT) services;
(iv) placement in a psychiatric residential treatment facility as a result of decompensation related to the individual’s serious mental illness; or
(v) a temporary detention order (TDO) evaluation pursuant to the Code of Virginia §37.2-809(B). This criterion shall be met n order to be initially admitted to services, and not for subsequent authorizations of service. Discharge summaries from prior providers that clearly indicate
(i) the type of treatment provided,
(ii) the dates of the treatment previously provided, and
(iii) the name of the treatment provider shall be sufficient to meet this requirement. Family member statements shall not suffice to meet this requirement.
4. The Individual is on psychotropic medications
D. The individual shall have had a prescription for antipsychotic, mood stabilizing, or antidepressant medications within the 12 months prior to admission to MHSBS. If a physician or another practitioner who is authorized by his license to prescribe medications indicates that anti-psychotic, mood stabilizing, or antidepressant medications are medically contraindicated for the individual, the provider shall obtain medical records signed by the physician or other licensed prescriber detailing the contraindication. This documentation shall be maintained in the individual’s MHSS record, and the provider shall document and describe how the individual will be able to actively participate in and benefit from services without the assistance of medication. This criterion shall be met upon admission to services, and not for subsequent authorizations of service. Discharge summaries from prior providers that clearly indicate (i) the type of treatment provided, including psychiatric medication history, (ii) the dates of the treatment previously provided, and (iii) the name of the treatment provider shall be sufficient to meet this requirement. Family member statements shall not suffice to meet this requirement.
