Medicaid Eligibility Criteria for In-Home Services

Medical Necessity Criteria for IIH

Youth receiving IIH Services must have the functional capability to understand and benefit from the required activities and counseling of this service.  These services are rehabilitative and are intended to improve the youth’s functioning.  It is unlikely that youth with severe cognitive and developmental delays/impairments would clinically benefit and meet the service eligibility criteria.

Prior to the start of services, a valid Comprehensive Needs Assessment, as defined earlier in this chapter, shall be conducted by the LMHP, LMHP-S, LMHP-R, or LMHP-RP, documenting the youth’s diagnosis and describing how service needs can best be met through intervention provided typically but not solely in the youth’s residence. The Comprehensive Needs Assessment describes how the youth’s clinical needs put the youth at risk of out-of-home placement.

Youth shall meet all of the following criteria including Diagnostic, At Risk, Level of Care and Family Involvement to qualify for IIH services.

1. Diagnostic Criteria

Youth qualifying for this service shall demonstrate a clinical necessity for the service arising from mental, behavioral or emotional illness which results in significant functional impairments in major life activities.  The diagnosis must be the primary clinical issue addressed by services and must support the mental, behavioral or emotional illness attributed to the recent significant functional impairments in major life activities.

2. At Risk Criteria

The impairments experienced by the member are to such a degree that they shall meet at least two of the criteria below, on a continuing or intermittent basis, for being at risk of out of home placement as defined in definitions section. 

a. Have difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or out-of-home placement as defined in the definition section of this manual because of conflicts with family or community;  and/or

b. Exhibit such inappropriate behavior that documented, repeated interventions by the mental health, social services, or judicial system are or have been necessary resulting in being at risk for out of home placement;  and/or

c. Exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior resulting in being at risk for out of home placement.

3. Level of Care:

The impairments experienced by the member are to such a degree that they shall meet one of the criteria below:

1. When services that are far more intensive than outpatient clinic care are required to stabilize the youth in the family situation, or

2. When the youth’s residence as the setting for services is more likely to be successful than a clinic.

4. Family Involvement:

At least one parent/legal guardian or responsible adult with whom the youth is living shall be willing to participate in the intensive in-home services with the goal of keeping the youth with the family.  In the instance of this service, a responsible adult shall be an adult who lives in the same household with the child and is responsible for engaging in counseling and service-related activities to benefit the youth.​