Behavioral Health Eligibility Requirements

Eligibility Requirements

Medicare Eligibility:

Individual must be under the care of a physician.
The physician certifies and oversees plan of care.
Individual must be homebound. Homebound is defined as infrequent and taxing effort to leave home for short durations due to illness/injury, need for assistive devices, special transportation or the assistance of another person.
There is an identified need for reasonable and necessary skilled care in the place of residence/home. This can include: Intermittent and/or part-time skilled nursing care; Physical therapy; Speech therapy; Ongoing Occupational therapy
A face-to-face visit with a MD, APRN or PA is required for those with PPS Medicare.
Behavioral health or cognitively impaired individuals may be considered homebound.
If the illness is manifested in part by a refusal to leave home or is of such nature that it would not be considered safe to leave home unattended, even if they have no physical limitations. Potential examples include, but not limited to paranoid schizophrenia, panic disorder, dementia, agoraphobia, and psychosis.

Medicaid Eligibility:

Have a DSM V diagnostic condition or corresponding ICD 10 diagnosis.
Must be under the care of a physician.
Receiving services under a plan of care created and reviewed regularly by physician.
Primary request for services is for assistance with psychiatric medication management.
Individual can be adequatedly and safely maintained in the home: Has complex co-morbid issues resulting in diffculty attending community health treatment; Requires long term injectable medication and/or regular bloodwork to maintain stability on current medication regime
Without psychiatric nurse/home services member would be at high risk of requiring a higher level of care.
A face-to-face visit with a MD, APRN or PA is required.
Homebound status not required.