Medicaid Eligibility Criteria for Mental Health Skill Building

Individuals qualifying for MHSS must demonstrate a clinical necessity for the service arising from a condition due to 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:

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) 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 the 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.

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.

C. The individual shall have a prior history of any of the following: (i) psychiatric hospitalization; (ii) Community Stabilization, 23- hour Crisis Stabilization or Residential Crisis Stabilization Unit Services, (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 in order to be initially admitted to services, and not for subsequent authorizations of service. See the Documentation and Utilization Review section for additional information.

D. The individual shall have had a prescription for antipsychotic, mood stabilizing, or antidepressant medications within the 12 months prior to the Comprehensive Needs Assessment. If a physician or other 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. See the Documentation and Utilization Review section for additional information. Individuals 18-20 years shall meet all of the above medical necessity criteria listed in paragraphs 1 through 2 (A-D) in order to be eligible to receive MHSS and the following:

E. The individual shall not be in a supervised setting as described in §63.2-905.1 of the Code of Virginia. If the individual is transitioning into an independent living situation, services shall only be authorized for up to six months prior to the date of transition. Individuals eligible for this service may have a dual diagnosis of either mental illness and developmental disability or mental illness and substance use disorder. If an individual has co-occurring mental health and substance use disorders, integrated treatment for both disorders is allowed within MHSS as long as the treatment for the substance use disorder is intended to positively impact the mental health condition. The impact of the substance use disorder on the mental health condition must be documented in the Comprehensive Needs Assessment, the ISP, and the progress notes.