104 CMR 29.04 - Application for DMH Services; Domicile, Clinical Criteria and Determination of Need
(1)
Application for DMH Services.
(a) An application for DMH services for an
individual shall be submitted to the DMH Area Office where the individual or,
in the case of a minor, where his or her legally authorized representative
resides.
(b) An application may be
submitted by:
1. An individual or his or her
legally authorized representative. An individual may be assisted by another
person in completing the application.
2. A facility or program on behalf of an
individual:
a. if the facility or program
submitting the application has obtained authorization from the individual or
his or her legally authorized representative to do so; or
b. if the facility or program believes an
individual lacks the capacity to apply for services, and has filed a petition
with the Probate and Family Court for guardianship for the
individual.
(c)
An application shall include the following:
1.
a completed application form;
2.
supporting documentation of psychiatric evaluations and clinical records, and
place of domicile that are available to the individual. The individual or his
or her legally authorized representative may be asked to authorize the
Department to obtain additional information which it deems necessary to support
the application.
(d) The
Department may, in its discretion, require a personal interview and/or a
clinical evaluation of the individual to gather additional information to
support the application.
(e) An
application shall be considered complete when the Department has received the
completed application form and such additional information which it deems
necessary to support the application.
(f) Time frame for actions to be taken on an
application:
1. Within five business days of
receipt of an application form, the Area Director or designee shall review the
application to determine whether additional information is required, and shall
notify the applicant that the application has been received and request any
additional information identified.
2. Within 20 business days of
receipt of an application form, the Area Director or designee shall determine
whether the application is complete, and if any additional information
requested has not been received, and shall so notify the applicant or take
other appropriate steps to obtain such information.
3. Within 20 business days of receipt of the
completed application, including any additional information requested by the
Department, the Area Director or designee shall determine whether the
individual meets clinical criteria set forth in 104 CMR 29.04(3).
4. During the pendency of an application, the
Area Director or designee shall actively engage the applicant in completing the
application process, including provision of any additional information. Such
engagement may include provision of critical need case management pursuant to
104 CMR 29.05(3)
or other short term services that do not
require full service authorization pursuant to 104 CMR 29.04(1)(i)
a. If within 90 days of receipt of the
application, any additional information, personal interviews and/or clinical
evaluations have not been received or completed, the Area Director or designee
may make a determination on the application based upon such information as is
then available.
b. If at the end of
such 90-day period the Area Director or designee determines that there is
insufficient information upon which to make a determination, but the applicant
and/or his or her family is engaged in the application process, the Area
Director or designee shall extend the 90-day period for a reasonable length of
time in order to complete the process.
c. If at the end of such 90-day period, or
extension thereof, the Area Director or designee determines that there is
insufficient information upon which to make a determination and the applicant
and/or his or her family is not engaged in the application process, and if
despite active attempts to engage the applicant, the applicant refuses to
provide such additional information or to participate in a personal interview
and/or clinical evaluation, the application may be deemed withdrawn.
5. Within 20 business days of an
individual being determined to meet clinical criteria for DMH services as set
forth in 104 CMR 29.04(3), the Area Director or designee shall determine
whether the individual needs DMH services as set forth in 104 CMR 29.04(4).
The Area Director or designee may extend the time periods within 104 CMR 29.04(1)(f) for good cause.
(g) The Department may redetermine whether a
client continues to meet the criteria for DMH Services pursuant to 104 CMR
29.04(3) and (4) annually; when a client's circumstances have changed; or when
information becomes available that may affect the Department's decision
regarding service authorization.
(h) If during the application process the
Area Director or designee determines that the individual is in need of short
term services, in addition to active engagement as provided in 104 CMR
29.04(1)(f)4, including critical need case management, the Area Director or
designee may authorize such services. During this period, the individual's
application shall be considered "pending". Provision of such services does not
indicate whether an application will be approved, and shall not be subject to
appeal pursuant to
104 CMR
29.16.
(i) The Department may develop services that,
in the Department's sole discretion, may be authorized without requiring an
applicant to submit a full application or to meet the clinical and service need
requirements as provided in 104 CMR 29.04.
1.
Requests for and approval of such services shall be based on criteria
determined by the Department to be applicable to such services.
2. An individual who receives such services
shall not be considered a DMH client for purposes of
104 CMR
29.00; provided however, a provider of such services
may be required by contract to comply with service planning provisions of
104 CMR
29.00.
(2)
Domicile. The
following factors shall be used in determining whether an individual is
domiciled within Massachusetts:
(a) An
individual will be determined to be domiciled within Massachusetts if he or
she:
1. lives within Massachusetts with the
intention to remain a resident of Massachusetts permanently or for an
indefinite period; or
2. is a minor
whose parent(s) or legal guardian lives within Massachusetts with the intention
to remain a resident of Massachusetts permanently or for an indefinite
period.
(b) There shall
be a presumption that the following individuals are not domiciled in
Massachusetts:
1. Individuals who reside in a
home, group living environment, residential school, or other setting subject to
licensure or regulation by Massachusetts, which residence was arranged or is
being funded by another State, including any agency or political subdivision
thereof and any entity under contract with the other State for such
purposes;
2. Persons who reside in
a home, group living environment, residential school, or other setting subject
to licensure or regulation by Massachusetts, which residence were arranged by a
parent, guardian, or family member who is not domiciled in Massachusetts, and
was not so domiciled at the time of the person's placement.
(c) An individual whose
application for services is denied based on a determination that the individual
is not domiciled within Massachusetts shall be so notified and shall be
informed that such determination may be appealed in accordance with
104 CMR
29.16.
(3)
Clinical Criteria for DMH
Services.
(a)
Adult
Services. To meet the clinical criteria to receive DMH services,
individuals 22 years of age or older, must have a serious, and persistent
mental illness that, except as provided in 104 CMR 29.04(3)(c), meets the
criteria for the following qualifying diagnostic categories specified within
the current edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM):
1. Schizophrenia
Spectrum and other Psychotic Disorders;
2. Bipolar and Depressive
Disorders;
3. Anxiety
Disorders;
4. Dissociative
Disorders;
5. Feeding and Eating
Disorders;
6. Borderline
Personality Disorder;
7.
Obsessive-compulsive and Related Disorders;
8. Trauma and Stressor Related Disorders; and
which mental illness is the primary cause of functional impairment that substantially interferes with or limits the individual's performance of one or more major life activities, and is expected to do so in the succeeding year.
(b)
Child and Youth
Services. To meet the clinical criteria to receive DMH services,
individuals younger than 22 years old at the time of application, must have a
serious emotional disturbance that, except as provided in 104 CMR
29.04(3)(c)(2), meets diagnostic criteria for a diagnosis specified within the
current edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM), which is the primary cause of functional impairment
that substantially interferes with or limits the individual's performance of
one or more major life activities, and is expected to do so in the succeeding
year.
(c)
Non-qualifying Disorders.
1. The following diagnoses do not qualify as
the primary cause of functional impairment for the purpose of adult service
authorization:
a. Under Bipolar and Depressive
Disorders: Persistent Depressive Disorder (Dysthymia), Disruptive Mood
Dysregulation Disorder and Premenstrual Dysphoric Disorder;
b. Under Anxiety Disorders: Separation
Anxiety Disorder and Selective Mutism;
c. Under Feeding and Eating Disorders: Binge
Eating DO;
d. Under Obsessive
Compulsive and Related Disorders: Hoarding DO;
e. Under Trauma and Stressor Related
Disorders: Adjustment Disorders;
f.
Other diagnoses identified in interpretive guidelines that may be issued by the
Department.
2. The
following diagnoses do not qualify as the primary cause of functional
impairment for the purpose of service authorization for any individual of any
age:
a. Neurodevelopmental
Disorders;
b. Neurocognitive
Disorders;
c. Mental Disorders Due
to a Another Medical Condition (e.g., traumatic brain
injury);
d.
Substance-related/Induced and Addictive Disorders;
e. Disruptive, Impulse Control and Conduct
Disorders; or
f. Other diagnoses
identified in interpretive guidelines that may be issued by the
Department.
(d)
Individuals 18 through 21 Years of Age at the Time of
Application: For transition planning purposes, the determination
of whether an individual who is 18 through 21 years of age at the time of
application meets clinical criteria for youth pursuant to 104 CMR 29.04(3)(b)
shall include a consideration of whether the individual is likely to meet the
clinical criteria for adults pursuant to 104 CMR 29.04(3)(a).
1. If it appears that the individual is
likely to meet clinical criteria for adults pursuant to 104 CMR 29.04(3)(a),
then the determination of need conducted pursuant to 104 CMR 29.04(4) shall
include consideration of services the individual may need after his or her
22nd birthday.
2. If it appears that the individual meets
clinical criteria for youth pursuant to 104 CMR 29.04(3)(b), but is not likely
to meet clinical criteria for adults pursuant to 104 CMR 29.04(3)(a), then the
determination of need conducted pursuant to 104 CMR 29.04(4) shall include
planning for, and consideration of, transitional services and support that may
be offered to assist the individual in his or her transition out of DMH
services.
(e) No later
than 12 months before his or her 22nd birthday, a
youth who was determined to meet clinical criteria pursuant to 104 CMR
29.04(3)(b), and is enrolled in a DMH service shall be referred for
determination of whether the youth meets clinical criteria under 104 CMR
29.04(3)(a).
1. If the youth is determined to
meet clinical criteria under 104 CMR 29.04(3)(a), he or she shall continue to
receive the DMH service previously authorized until such time as his or her
service needs are reviewed in accordance with 104 CMR 29.04(4) and it is
determined that his or her service needs have changed.
2. If the youth is determined not to meet
clinical criteria under 104 CMR 29.04(3)(a), then the youth will be engaged in
planning and will be offered transitional services and support to assist in his
or her transition out of DMH services.
(f)
Result of Determination
Relative to Clinical Criteria.
1.
If an individual is found to meet the clinical criteria for DMH services as set
forth in 104 CMR 29.04(3), then the Area Director or designee shall determine
whether the individual needs DMH services as provided in 104 CMR
29.04(4).
2. If an individual does
not meet the clinical criteria set forth in 104 CMR 29.04(3), a notice denying
the application for DMH services will be sent to the individual and his or her
legally authorized representative and, if appropriate, to the facility or
program that submitted the application in accordance with 104 CMR 29.04(1)(b)2.
The notice shall:
a. set forth the reasons for
the denial;
b. inform the
individual and his or her legally authorized representative of the right to
appeal the denial of the application for DMH services based on clinical
criteria pursuant to
104 CMR
29.16(3); and
c. inform the individual and his or her
legally authorized representative of other community services that may be
available to meet his or her needs.
If after reasonable efforts, neither the individual nor his or her legally authorized representative can be located, the denial shall be noted in the individual's application file and no further action will be required.
(4)
Determination of Need for DMH
Services. The determination of whether an individual who has been
found to meet the clinical criteria for DMH services as set forth in 104 CMR
29.04(3), needs DMH services, will be based on the following:
(a) contact with the applicant and his or her
legally authorized representative to review the individual's request for
services and his or her current status;
(b) determination of whether the individual's
service needs, personal goals, and service preferences can be met by a DMH
service;
(c) assessment of the
individual's current resources, entitlements, and insurance that allow for
provision of appropriate services in the community; and
(d) assessment of the availability of
appropriate services from other public or private entities.
(5)
Result of
Determination of Need for DMH Services.
(a) If it is determined that the individual
needs DMH Services, and that there is existing capacity in an appropriate
service, the services will be authorized. The Area Director or designee will
notify the individual and his or her legally authorized representative and, if
appropriate, the facility or program which submitted the application on the
individual's behalf pursuant to 104 CMR 29.04(1)(b)2. The notice shall:
1. state that services have been
authorized;
2. state the DMH
services identified as needed; and
3. identify the service provider who will be
contacting the individual to engage in service planning and delivery.
(b) If it is determined that an
individual needs DMH services, but there is no capacity in such service(s), the
Area Director or designee will so notify the individual and his or her legally
authorized representative and, if appropriate, the facility or program which
submitted the application on the individual's behalf pursuant to 104 CMR
29.04(1)(b)2.
1. The Area Director or designee
will thereafter periodically contact the individual or his or her legally
authorized representative regarding the individual's status and continued need
for DMH service(s).
2. At such time
when the DMH service(s) becomes available, the individual will be offered a
referral to such service(s); provided however, that:
a. the Department may request updated
information to determine whether the individual still needs the particular DMH
service being offered;
b. if it has
been more than 12 months since the individual was determined to meet criteria
for DMH services pursuant to 104 CMR 29.04(3) and (4), the Area Director or
designee may refer to the individual for redetermination of whether the
individual continues to meet such criteria.
(c) If the individual or his or her legally
authorized representative indicates that the individual no longer needs or
wants DMH services, a notice will be sent to the individual and his or her
legally authorized representative that the application is considered
withdrawn.
(d) If after reasonable
efforts, neither the individual nor his or her legally authorized
representative can be located, the application will be deemed withdrawn;
provided however, if the applicant reapplies for services within 12 months of
his or her application being deemed withdrawn, he or she shall be presumed to
continue to meet the clinical criteria for DMH services; and provided further,
the Department may require updated information to conduct service
planning.
(e) If it is determined
that the individual does not need DMH services, the application will be denied
and the Area Director or designee will so notify the individual and his or her
legally authorized representative and, if appropriate, the facility or program
which submitted the application on the individual's behalf pursuant to 104 CMR
29.04(1)(b)2. The notice shall:
1. set forth
the reasons for the denial;
2.
inform the individual and his or her legally authorized representative of the
right to appeal the denial of the application for DMH services based on need
pursuant to
104 CMR
29.16(4); and
3. inform the individual and his or her
legally authorized representative of other community services that may be
available to meet his or her service needs.
If after reasonable efforts, neither the individual nor his or her legally authorized representative can be located, the denial shall be noted in the individual's application file and no further action will be required.
(f) If
an individual whose application was denied because of a determination that the
individual did not need DMH services reapplies due to a change in circumstances
within 12 months of such denial, he or she shall be presumed to continue to
meet the clinical criteria for DMH services; provided however, the Department
may require updated information to complete a determination of need pursuant to
104 CMR 29.04(4).
Notes
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