1. Individuals qualifying for Mental Health Skill-building Services must demonstrate a clinical necessity for the service arising from a condition due to mental, behavioral, or Manual Title Community Mental Health Rehabilitative Services Chapter IV Page 52 Chapter Subject Covered Services and Limitations Page Revision Date 2/6/2018 emotional illness that results in significant functional impairments in major life activities. Services are provided to individuals who require individualized goal-directed training to achieve or maintain stability and independence in the community.
2. Individuals age 21 and over shall meet all of the following criteria in order to be eligible to receive mental health skill-building services:
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 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 and 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) 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 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.
D. The individual shall have had a prescription for antipsychotic, mood stabilizing, or antidepressant medications within the 12 months prior to the service specific provider intake date. 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 Manual Title Community Mental Health Rehabilitative Services Chapter IV Page 53 Chapter Subject Covered Services and Limitations Page Revision Date 2/6/2018 prescriber detailing the contraindication. This documentation shall be maintained in the individual’s mental health skill-building services 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, (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.
3. 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 mental health skill-building services and the following: 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 Mental Health Skill-building Services as long as the treatment for the substance abuse condition is intended to positively impact the mental health condition. The impact of the substance abuse condition on the mental health condition must be documented in the service specific provider intake, the ISP, and the progress notes.