I. Clinical Eligibility Determination
The Division of Substance Abuse and Mental Health (DSAMH) LTC system serves adults (age 18 years and older) with severe and persistent behavioral health disorders who meet disability, duration of illness and diagnostic criteria. The LTC System provides services for: individuals enrolled in Medicaid; individuals with dual eligibility of Medicaid and Medicare; individuals with Medicare only coverage; individuals without insurance coverage; and those with limited insurance coverage.
Clinical eligibility for and enrollment into the DSAMH Long Term Care (LTC) system will be determined by the DSAMH Eligibility and Enrollment Unit (EEU). The EEU will process all applications for enrollment into the DSAMH LTC System.
Clinical Eligibility Criteria for Enrollment into the DSAMH LTC System
- are age 18 years and older; and
- are U.S. citizens or have a legal resident alien status; and
- are residents of the State of Delaware; and
- present a history of having received intensive behavioral health treatment in one or more community or institutional programs including: Delaware Psychiatric Center; DSAMH Continuous Treatment Team programs; group homes, and long-term residential substance abuse treatment facilities; and/or
- present a history of having had multiple alcohol and other drug detoxification admissions and/or multiple intensive substance abuse treatment episodes.
Special eligibility determinations will be made for adults with developmental disabilities/mental retardation who have a severe and persistent behavioral health disorder and are in the upper mild range of mental retardation (317.0).
All individuals meeting the clinical eligibility criteria will be enrolled in the DSAMH LTC system.
Eligible Mental Illness Diagnoses
| BIPOLAR D/O Dx | CODE |
|---|---|
| Bipolar and related disorder due to another medical condition, With manic features | F06.33 |
| Bipolar and related disorder due to another medical condition, With manic- or hypomanic-like episodes | F06.33 |
| Bipolar and related disorder due to another medical condition, With mixed features | F06.34 |
| Bipolar I disorder, Current or most recent episode depressed | |
| Bipolar I disorder, Current or most recent episode depressed, In full remission | F31.76 |
| Bipolar I disorder, Current or most recent episode depressed, In partial remission | F31.75 |
| Bipolar I disorder, Current or most recent episode depressed, Mild | F31.31 |
| Bipolar I disorder, Current or most recent episode depressed, Moderate | F31.32 |
| Bipolar I disorder, Current or most recent episode depressed, Severe | F31.4 |
| Bipolar I disorder, Current or most recent episode depressed, Unspecified | F31.9 |
| Bipolar I disorder, Current or most recent episode depressed, With psychotic features | F31.5 |
| Bipolar I disorder, Current or most recent episode hypomanic | F31.0 |
| Bipolar I disorder, Current or most recent episode hypomanic, In full remission | F31.74 |
| Bipolar I disorder, Current or most recent episode hypomanic, In partial remission | F31.73 |
| Bipolar I disorder, Current or most recent episode hypomanic, Unspecified | F31.9 |
| Bipolar I disorder, Current or most recent episode manic | |
| Bipolar I disorder, Current or most recent episode manic, In full remission | F31.74 |
| Bipolar I disorder, Current or most recent episode manic, In partial remission | F31.73 |
| Bipolar I disorder, Current or most recent episode manic, Mild | F31.11 |
| Bipolar I disorder, Current or most recent episode manic, Moderate | F31.12 |
| Bipolar I disorder, Current or most recent episode manic, Severe | F31.13 |
| Bipolar I disorder, Current or most recent episode manic, Unspecified | F31.9 |
| Bipolar I disorder, Current or most recent episode manic, With psychotic features | F31.2 |
| Bipolar I disorder, Current or most recent episode unspecified | F31.9 |
| Bipolar II disorder | F31.81 |
| SCHIZOPHRENIA and OTHER PSYCHOTIC D/O | CODE |
|---|---|
| Schizoaffective disorder, Bipolar type | F25.0 |
| Schizoaffective disorder, Depressive type | F25.1 |
| Schizoid personality disorder | F60.1 |
| Schizophrenia | F20.9 |
| Schizophreniform disorder | F20.81 |
| MOOD DISORDERS | CODE |
|---|---|
| Major depressive disorder, Recurrent episode, In full remission | F33.42 |
| Major depressive disorder, Recurrent episode, In partial remission | F33.41 |
| Major depressive disorder, Recurrent episode, Mild | F33.0 |
| Major depressive disorder, Recurrent episode, Moderate | F33.1 |
| Major depressive disorder, Recurrent episode, Severe | F33.2 |
| Major depressive disorder, Recurrent episode, Unspecified | F33.9 |
| Major depressive disorder, Recurrent episode, With psychotic features | F33.3 |
| Major depressive disorder, Single episode | |
| Major depressive disorder, Single episode, In full remission | F32.5 |
| Major depressive disorder, Single episode, In partial remission | F32.4 |
| Major depressive disorder, Single episode, Mild | F32.0 |
| Major depressive disorder, Single episode, Moderate | F32.1 |
| Major depressive disorder, Single episode, Severe | F32.2 |
| Major depressive disorder, Single episode, Unspecified | F32.9 |
| Major depressive disorder, Single episode, With psychotic features | F32.3 |
| PERSONALITY DISORDERS | CODE |
|---|---|
| Borderline personality disorder | F60.3 |
| Paranoid personality disorder | F60.0 |
| Schizotypal personality disorder | F21 |
| SUBSTANCE DEPENDENCE Dx | CODE |
|---|---|
| Alcohol use disorder, Mild | F10.10 |
| Alcohol use disorder, Moderate | F10.20 |
| Alcohol use disorder, Severe | F10.20 |
| Cocaine use disorder, Mild | F14.10 |
| Cocaine use disorder, Moderate | F14.20 |
| Cocaine use disorder, Severe | F14.20 |
| Opioid use disorder, Mild | F11.10 |
| Opioid use disorder, Moderate | F11.20 |
| Opioid use disorder, Severe | F11.20 |
| Phencyclidine use disorder, Mild | F16.10 |
| Phencyclidine use disorder, Moderate | F16.20 |
| Phencyclidine use disorder, Severe | F16.20 |
| IDD | CODE |
|---|---|
| Intellectual disability (intellectual developmental disorder), Moderate | F71 |
| Intellectual disability (intellectual developmental disorder), Profound | F73 |
| Intellectual disability (intellectual developmental disorder), Severe | F72 |
Clinical Eligibility Exclusions
DSAMH LTC services will not be available for:
- Adults with DSM-IV diagnoses not listed as eligible.Adults with the following DSM-IV developmental disabilities/mental retardation diagnoses: 318.0 (Moderate Mental Retardation); 318.1 (Severe Mental Retardation); 318.2 (Profound Mental Retardation); and 319.0 (Mental Retardation, Severity Unspecified); and
- Adults with DSM-IV diagnoses not listed as eligible.
Requests for a clinical eligibility determination should be submitted on a consumer’s/client’s behalf by any Managed Care Organization (MCO) participating in the Diamond State Health Plan (DSHP) or by a behavioral health provider currently treating the consumer/client. The referral process will remain the same for all organizations submitting a request for a clinical eligibility determination and enrollment. The documentation for a clinical eligibility determination is independent from the financial eligibility determination for Medicaid, Medicare and other third party insurance liability. Financial eligibility determination for Medicaid will be performed by the DHSS/Division of Social Services (DSS).
The requesting MCO or behavioral health organization must provide full documentation regarding medical necessity when applying for a consumer’s/client’s clinical eligibility determination for and enrollment in the DSAMH LTC system. This will include full documentation regarding the consumer’s/client’s utilization of behavioral health services prior to the request for clinical eligibility determination.
The requesting organization must complete the Enrollment Application Form and submit it to the Director of the EEU. The requesting organization will ensure that all information needed to make a timely decision for a clinical eligibility determination will be provided to the EEU. In addition to submitting the Enrollment Application Form, the requesting organization must designate a Clinical Liaison to serve as a point of contact regarding issues of referral.
The EEU will review the referral packet for completeness and quality. Incomplete packets will be returned to the referring organization for completion within one (1) working day of DSAMH’s receipt of the incomplete application.
Upon receipt of a complete referral packet, the EEU will evaluate the clinical documentation provided, complete an Eligibility Determination Review and make a determination as to the consumer’s/client’s eligibility for the DSAMH LTC system within one (1) working days of receipt of the complete application.
The EEU will provide written notification to the referring organization and the consumer/client of the results of its eligibility determination within one (1) working days of the review’s completion. Notification to the referring organization will include a copy of the Eligibility Determination Summary.