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

Clinical Eligibility Exclusions

IDD	CODE
Intellectual disability (intellectual developmental disorder), Moderate	F71
Intellectual disability (intellectual developmental disorder), Profound	F73
Intellectual disability (intellectual developmental disorder), Severe	F72

DSAMH LTC services will not be available for:

• Adults with DSM-V diagnoses not listed as eligible.Adults with the following DSM-V 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-V 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.

In cases where DSAMH determines that a consumer/client does not meet eligibility criteria and denies enrollment into DSAMH’s LTC system, the denial will be made by an EEU physician. The EEU will issue a denial letter to the referring organization and the consumer/client; the denial letter will include an explanation for the denial and recommendations for more effective services or additional follow-up behavioral health care service provision by the referring organization.

If the provider or the consumer/client chooses to appeal the decision, a written appeal must be filed with the DSAMH Deputy Director or designee within five (5) working days of the notification of determination. DSAMH will issue a response to an appeal within five (5) working days of receiving it. An enrollment denial upheld on appeal is subject to a second level appeal. For Medicaid enrolled consumers/clients, the second level appeal will be heard by the Division of Social Services.

When the EEU makes a positive determination of eligibility, the consumer/client will be enrolled in the DSAMH LTC System within seven (7) working days of the date of written notification to the referring organization and the consumer of eligibility determination. For Medicaid recipients, the EEU will indicate the “SPI Flag” in the Medicaid Management Information System (MMIS) on the consumer’s enrollment date. The EEU will also enter each consumer in the DSAMH EEU Client Tracking System and will establish a re-determination date in the System.

EEU will coordinate with the enrollee and his/her current behavioral health services provider to effect a transfer of care to a DSAMH Long Term Care Primary Service Provider (PSP). Enrolled consumers whose DSHP behavioral health provider is also a DSAMH Long Term Care provider will have the choice of remaining with his/her current provider. Consumers who are not engaged with a behavioral health provider at the time of enrollment, or those whose provider is not funded by DSAMH, will be referred to a DSAMH Long Term Care provider. In either case, the EEU will link the consumer to a Primary Service Provider. The EEU will identify the PSP based on the consumer’s residence and will confirm the PSP’s available service capacity through the Long Term Care Service Inventory which it maintains. Consumers’ preferences regarding providers will be taken into account in this process. The EEU will not refer to a PSP which has no available service openings.

In coordinating the transfer of care, EEU staff will meet as needed to identify specific provider(s) to whom each consumer is to be referred. A designated EEU staff member will be assigned to each consumer and will call the identified provider to refer the consumer and will confirm the provider’s tentative acceptance of each consumer within one (1) working day of written eligibility determination contained in the notification letter to the referring organization and consumer. After receiving this confirmation of the provider’s tentative acceptance of the consumer, the EEU will fax the consumer’s Enrollment Application Form to the provider. The EEU will also fax the Unit’s Eligibility Determination Summary to the identified provider, if the provider had not already received the Summary during the eligibility notification process. The EEU will also notify the referring organization as to the consumer’s new primary behavioral health provider. If the provider to whom the EEU has referred the consumer believes that they are unable to appropriately serve the consumer, the provider will call the designated EEU staff member with this information. If the EEU agrees with the provider’s determination, they will identify another Long Term Care provider to serve the consumer.

The provider must make concerted efforts to locate the consumer and must arrange for an initial scheduled contact which will occur within five (5) days after the provider has accepted the consumer. The provider then completes the referral process by submitting the CRF to DSAMH within twenty four (24) hours of this first scheduled contact. Providers must call the designated EEU staff member on the day they contact the consumer to confirm this contact. If a provider has not called to confirm contact with the consumer, the designated EEU staff member will call that provider to determine the consumer’s status. If the provider has not located the consumer, the provider will outline the outreach and engagement activities they intend to undertake to effect linkage with the consumer. EEU staff will then follow up with the provider in ten (10) working days to determine whether linkage has occurred. If linkage has occurred, treatment will continue; if it hasn’t, the EEU will notify the referring organization that service linkage has not occurred and will enroll the client on an ‘inactive status’. The provider must make ongoing efforts to locate the consumer and make weekly progress reports to the designated EEU staff member . The client’s status will be re-evaluated at ninety (90) days.

If, during the outreach process, a consumer indicates that he/she does not want to receive services from the identified provider, that provider will call the designated EEU staff person with this information. The EEU staff and the provider will review the engagement activities which were undertaken and determine whether the consumer will be referred to another provider, or to another level of service.

Authorization of Substance Abuse Services

Providers accepting consumers enrolled in the LTC System must request service authorization as required by current Division policy. For LTC consumers, the Screening and Evaluation Team may accept the ASI that is submitted as part of the Enrollment Application Form and use it to confirm appropriate placement.

Authorization of Mental Health Services

The Division’s current system for authorization of Continuous Treatment Team and group home services will continue.

An enrollee’s continued eligibility for the DSAMH LTC system will be monitored by the EEU. The EEU will analyze utilization patterns on an individual and aggregate basis for all enrollees and will identify enrollees whose utilization appear low given the individual’s identified clinical needs at enrollment. When the EEU has identified under-utilizing consumers, it will ask the provider to submit a Consumer Status Review so that the EEU can work with the provider to analyze reasons for low service utilization; evaluate the provider’s response to the consumer’s use of service; and determine additional outreach activities which may be required.

The EEU will conduct sample chart reviews to review enrollees’ clinical status, treatment, rehabilitation and support service needs and receipt of such services. All service utilization and provision will be assessed in terms of progressing toward recovery goals. The EEU will also review the “Days Lapse Report” to monitor consumers’ active service connection.

The EEU will notify the Primary Service Provider when it identifies consumers who have either not engaged in treatment or who appear to be withdrawing from treatment. When the EEU identifies an enrollee as potentially able to be disenrolled from the LTC system, it will conduct a clinical review with the Primary Service Provider to assess the individual’s self-care potential and recovery status.

TRANSFER OF CONSUMERS FROM ONE PROVIDER AGENCY TO ANOTHER AGENCY

When a consumer transfers to a care provider outside of the DSAMH system, clinicians and other professionals need to make a good faith effort to ensure a treatment plan will be written by the new provider and continuity of care will occur.

I. Transfer initiated by the system, i.e. EEU or Provider Agency

1. The first conversation about the pending transfer is between the Provider Agency and the Consumer, and should be held within the first 30 days after notification of intent to transfer. The EEU must be notified of the intent to transfer, unless it was initiated by the EEU.
2. Within the next 30 days, the Provider Agency schedules a meeting with the Consumer, their Advocate and/or the Office of Consumer Affairs, and relevant Agency personnel.
3. Following the meeting, it is the responsibility of the Provider Agency to contact the EEU within 3 business days, and discuss the outcome of the meeting.
4. Unless there is compelling evidence that the transfer should not occur, the EEU approves the transfer request.
5. Once the transfer is approved, within 5 business days, the Provider Agency must provide the Consumer with a written statement of intent to transfer, including information about how to appeal the decision.
6. Upon receipt of the intent to transfer statement, the Consumer has the right to appeal the decision. The appeal should be in writing and delivered to the Ombudsman of the Provider Agency within 30 days. The Provider Agency must submit the appeal to the DSAMH Deputy Director. The Deputy Director will make a decision about the transfer within 14 days. The decision is communicated to the Consumer, their Advocate and/or the Office of Consumer Affairs, the EEU, and the Provider Agency.
7. If the appeal is overruled, the Provider Agency, with the consumer, completes a transfer plan within 14 days that includes recommendations on treatment and support required to continue the Consumer’s recovery, including proposed treatment goals. Copies of this transfer plan are shared with the EEU, the Consumer and the Advocate.
8. If the appeal is upheld, the Provider Agency will meet with the consumer, their Advocate and/or the Office of Consumer Affairs to develop a cooperative plan of action.
9. If there is a waiting list for the new Provider Agency, the transferring consumer is placed at the end of the list while continuing to receive services through his/her current Provider Agency until an opening is available.
10. Prior to actual transfer, the Provider Agency completes and submits a written discharge summary to the EEU.
11. The EEU will notifies the receiving agency about the impending transfer and initiates sharing of documentation between providers (i.e., treatment plans, medication records, and other pertinent information required to promote successful transfer for the Consumer, including recommendations on treatment and support needs required to continue the Consumer’s recovery.)
12. Based on shared information, the new Provider Agency develops a draft initial treatment plan.
13. The new Provider Agency schedules a meeting with the Consumer and Advocate for intake, review, finalizing and signing of initial treatment plan.

II. Consumer has choice of service provider within relevant guidelines

1. Transfer initiated by the Consumer.
   • Guidelines:
     • The Consumer contacts the Office of Consumer Affairs or the Provider Agency to request a transfer to another agency.
     • If the request is made to the Provider Agency, that Agency will contact the Office of Consumer Affairs.
     • If the contact is made to the Office of Consumer Affairs, that Office contacts the ombudsman of the Provider Agency where the consumer receives services to advise them of the consumer’s wish to transfer.
     • In either case, that Provider Agency schedules a meeting with the consumer and his/her advocate to occur within 15 business days of the request. Unless the consumer has another advocate, the Office of Consumer Affairs as Advocate should be included in that meeting.
     • Following the meeting and within 3 business days, it is the responsibility of the Provider Agency to contact the EEU and discuss the outcome of the meeting.
     • Unless there is compelling evidence that the transfer should not occur, the EEU approves the transfer request.
     • Once approved, the Provider Agency must provide the Consumer with a written statement of intent to transfer, with information about how to appeal the action. In addition, the Provider Agency completes a transfer plan that includes recommendations on treatment and support required to continue the Consumer’s recovery, including proposed treatment goals. Copies of this transfer plan are shared with the EEU, the Consumer, and the Advocate.
     • If there is a waiting list for the new Provider Agency, the transferring consumer is placed at the end of the list while continuing to receive services through his current Provider Agency until an opening is available.
     • Prior to the actual transfer, the Provider Agency completes and submits a written discharge summary to the EEU.
     • The EEU will initiate sharing of documentation between Provider Agencies (i.e., treatment plans, medication records, and other pertinent information required to promote successful transfer for the Consumer, including recommendations on treatment and support needs required to continue the Consumer’s recovery).
     • Based on shared information, the new Provider Agency develops a draft initial treatment plan.
     • The new Provider Agency schedules a meeting with the Consumer and Advocate for intake, review, finalizing and signing of initial treatment plan.
     • The consumer may choose a new service provider no more than once every two years of service, unless the Provider Agency and/or the EEU determine that more frequent choice is in the Consumer’s best interest.

The EEU will establish a system for monitoring the anniversary dates for enrollees and will conduct redetermination reviews of all DSHP LTC enrollees on an annual basis.

As part of the re-determination process, the Primary Service Provider will be required to submit an abbreviated, updated Enrollment Application Form (“short form”) for review by the EEU. As a result of the re-determination review, the EEU will either confirm the enrollee’s continued eligibility or disenroll the individual from the DSAMH LTC system. If the consumer is determined to continue to be eligible for the DSAMH LTC system, the EEU will confirm this with the Primary Service Provider. If the consumer is to be disenrolled, the process in Section VIII. is followed.

In situations where the Primary Service Provider initiates the re-determination process, it will notify the EEU of consumers/clients enrolled in the DSAMH LTC system who are judged to no longer need long term behavioral health services due to improvement in their behavioral health status and their success in recovery. The primary service provider must submit a Request for Re-Determination and notify the consumer of this request; the Request for Re-Determination will include a certification that the consumer has been notified and wants to return to the basic benefit. The Request for Re- Determination will also describe why the client no longer needs LTC, as well as a summary of treatment plans (including recommendations for current treatment) and a description of the client’s ongoing self-care and relapse prevention plan. When the EEU receives this request, it will notify the enrollee of their right to dispute this recommendation and provide them with the procedures for doing so. If the consumer disputes the provider’s recommendation, the EEU will take this into consideration during its review. When the consumer is requesting a re-determination, the DSAMH Office of Consumer Affairs will assist the consumer in submitting the Consumer Request for Re-Determination.

The EEU will review the Request for Re-Determination and make a determination within five (5) working days as to whether the consumer will be disenrolled from the LTC System. The EEU will notify the Primary Service Provider and the consumer of the results of this determination within two (2) working days of the review’s completion. When the provider has requested disenrollment and the EEU determines that the consumer should continue to be enrolled, this decision is made with the concurrence of the EEU physician. The EEU will send the Eligibility Determination Summary to the Primary Service Provider.

If the EEU has determined that an individual is no longer in need of long term behavioral healthcare, the disenrollment decision will be made by an EEU physician. The EEU will issue a disenrollment letter which will include an explanation of the bases for disenrollment and will include the Eligibility Determination Summary with this letter. The primary service provider or the enrollee has the right to resubmit the disenrollment request within ten (10) working days or to appeal the decision. If the provider or the consumer chooses to appeal the decision, a written appeal must be filed with the DSAMH Deputy Director or designee within five (5) working days of the notification of determination. DSAMH will issue a response to appeals within five (5) working days; a disenrollment decision which is upheld is subject to a second level appeal.

For Medicaid enrolled consumers, the second level appeal will be heard by the Division of Social Services.

The EEU will assume primary responsibilities for administering the disenrollment process. Responsibilities will include: final approval of a change in service status; final authorization of disenrollment from the DSAMH LTC system; and the processing of disenrollment information to the Division of Social Services/Medicaid Office for Medicaid beneficiaries.

A program participant may be disenrolled from the DSAMH LTC system under the following circumstances:

• Improvement in behavioral health status, as indicated by a combination of the following:
  • a change in diagnosis and/or functioning no longer indicating a need for long term intensive service provision; evidence that the enrollee has not needed/utilized higher levels of care
  • stable medication history;
  • stable psychosocial factors as demonstrated by an assessment of functioning and quality of life scales; or
• Placement in a correctional facility (detainee or un-sentenced vs. sentenced); or
• Inpatient treatment in a nursing facility beyond a continuous sixty day period prior to the request for disenrollment; or
• Relocation to another state; or
• Death of participant.

In order to effect a disenrollment, the EEU will request that the primary service provider submit a DSAMH LTC Client Discharge Summary. The DSAMH LTC Discharge Summary will include: a summary of the enrollee’s treatment plans; medications; and other pertinent information required to promote the most successful transfer for the client. The Discharge Summary will provide recommendations on treatment and support required to continue the consumer’s recover, including the methods to be used for ongoing self-care and relapse prevention. As part of this process, the EEU will confirm the consumer’s Medicaid eligibility before referring a consumer back to the DSHP MCO or a treatment provider for the basic benefit and will change the SPI flag in the MMIS for Medicaid beneficiaries.

When management of the consumer’s behavioral health care is to be returned to a Medicaid DSHP MCO, the EEU will ensure that the Primary Service Provider coordinates with the consumer’s/client’s MCO to effect a clinically appropriate transition of care.