Pa. Code 5221.12

Consumer eligibility

This regulation defines eligibility criteria for intensive case management (ICM) services under Pennsylvania's mental health system. Eligible consumers include adults with serious and persistent mental illness meeting specified diagnostic, treatment history, and functioning criteria; children who are mentally ill or emotionally disturbed meeting one of several enumerated criteria; families of eligible children; and adults who transitioned from child ICM services. The regulation also addresses exceptions requiring county administrator and state approval, and specifies conditions under which ICM services may be terminated.

55 Pa. Code § 5221.12 - Consumer eligibility 

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(a)
 Persons
 eligible for intensive case management are: 
 
(1)
 Adults, 18 years of age or older, who
 have a serious and persistent mental illness. A person shall be considered to
 have a serious and persistent mental illness when two of the following criteria
 are met:
(i)

Diagnosis
-Schizophrenia or chronic major mood disorder
 (diagnosis codes 295 and 296 in the DSM III-R).

(ii)

Treatment history
-One
 of the following:
(A)
 Admission to State
 mental hospitals totaling 60 days within the past 2 years.

(B)
 Two admissions to community inpatient
 psychiatric units totaling 20 or more days within the past 2 years.

(C)
 Five or more face-to-face encounters with
 emergency services personnel within the past 2 years.

(D)
 Three or more years of continuous
 attendance in a community mental health service, at least one unit of service
 per quarter.

(E)
 History of
 sporadic course of treatment as evidenced by at least three missed appointments
 within the past 6 months, inability to or unwillingness to maintain medication
 regimen or involuntary commitment to outpatient treatment.

(iii)

Functioning level
. One
 of the following:
(A)
 Global Assessment of
 Functioning Scale (DSM-III-R, pages 12, and 20) ratings of 40 and
 below.

(B)
 A rating of 60 and below
 if the person is 35 years of age or younger or has a history of aggressive or
 violent behaviors.

(2)
 Adults who were receiving intensive case
 management services as children and were reviewed by the provider and approved
 by the county administrator as needing intensive case management services
 beyond the date of transition from child to adult.

(3)
 Children who are mentally ill or
 emotionally disturbed and who meet one of the criteria described as follows: 
 
(i)
 Children, 6 years of age or younger, who
 are enrolled in, or require, early intervention services under section 671 of
 the Education of the Handicapped Act (20 U.S.C.A. §
 
1400
).

(ii)
 Children who, with their families, are
 receiving services from three or more publicly funded programs such as, Medical
 Assistance, Aid to Families with Dependent Children and Special Education.

(iii)
 Children who are returning
 from State mental hospitals, community inpatient units or other out-of-home
 placements, including foster homes and juvenile court placements.

(iv)
 Children who are recommended as needing
 mental health services by a local interagency team which shall include county
 agency representatives.

(4)
 Families of eligible children who are
 receiving intensive case management services.

(b)

Exceptions
. An adult or
 child receiving, or who needs to receive, mental health services but who does
 not meet the requirements of this section is eligible for intensive case
 management upon review and recommendation by the county administrator and
 written approval by the Department's area office of mental health.

(c)

Termination
. Intensive
 case management may be terminated for one of the following reasons: 
 
(1)
 Determination by the consumer or the
 parent of a child receiving the service that intensive case management is no
 longer needed or wanted.

(2)

 Determination by the intensive case manager in consultation with his supervisor
 or the director of intensive case management, and with written concurrence by
 the county administrator that intensive case management is no longer necessary
 or appropriate for the adult or child receiving the services.

Notes

55

 Pa. Code §
 
5221.12

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