Medicaid Medical Necessity Eligibility Criteria

Intensive-In Home Counseling

1. 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 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. 

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

or 

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

3. 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. 

Mental Health Skill-Building

1. 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 within the past year.

2. The individual shall require individualized goal directed training in order to acquire or maintain self-regulation of basic living skills.

3. 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

4. The individual shall have had a prescription for antipsychotic, mood stabilizing, or antidepressant medications within the 12 months prior to the Comprehensive Needs Assessment.

Individuals 18-20 years shall meet all of the above medical necessity criteria and;

The individual shall not be in a supervised setting. 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. a

Functional Family Therapy

1. The youth must be under the age of 21. 

2. The initial assessment completed provides evidence of symptoms and functional impairment that the youth has met criteria for disruptive behavior, mood, substance use or trauma and stressor-related disorders. 

3. Within the past 30 calendar days, the youth has demonstrated behaviors that puts the youth at risk of out of home placement:

4. The youth’s successful reintegration or maintenance in the community is dependent upon an integrated and coordinated treatment approach that involves intensive family/caregiver partnership through the FFT model. Participation in an alternative community-based service would not provide the same opportunities for effective intervention for the youth’s problem behaviors. 

5. There is a family member or other committed caregiver available to participate in this intensive service. 

6. Arrangements for supervision at home/community are adequate to ensure a reasonable degree of safety and a safety plan has been established or will be quickly established by the FFT program as clinically indicated. a

Outpatient Counseling (Individual and/or Family

1. Requires treatment in order to sustain behavioral or emotional gains or to restore cognitive functional levels that have been impaired.

2. Exhibits deficits in peer relations, dealing with authority; is hyperactive; has poor impulse control; is clinically depressed or demonstrates other dysfunctional clinical symptoms having an adverse impact on attention and concentration, ability to learn, or ability to participate in employment, educational, or social activities.

3. Is at risk for developing or requires treatment for maladaptive coping strategies.

4. Presents a reduction in individual adaptive and coping mechanisms or demonstrates extreme increase in personal distress.

Strategic Therapy Associates, Inc.          1.800.716.3534          108 Duncraig Dr., Lynchburg, VA  24502

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