MHSS shall provide face to face activities, instruction, interventions, and goal directed trainings that are designed to restore functioning and that are defined in the Individual Service Plan (ISP) in order to be reimbursed by Medicaid. MHSS shall include goal directed training in the following areas: (i) functional skills and appropriate behavior related to the individual’s health and safety; instrumental activities of daily living, and use of community resources; (ii) assistance with medication management; and (iii) monitoring health, nutrition, and physical condition with goals towards self-monitoring and self-regulation of all of these activities.
Individuals qualifying for MHS 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.
The individual shall have:
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 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.
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;
(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. 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 treatment provider shall be sufficient to meet this requirement. Family member statements shall not suffice to meet this requirement.
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.
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/her license to prescribe medications indicates that anti-psychotic, mood stabilizing, or antidepressant medications are medically contraindicated for the individual