104 CMR, § 29.04

Current through Register 1533, October 25, 2024

Section 29.04 - Application for DMH Services; Domicile, Clinical Criteria and Determination of Need; Services Provided Pursuant to a PASRR Evaluation and Determination

Except as provided in 104 CMR 29.04(6) for individuals determined to have a serious mental illness as a result of a PASRR Level II evaluation, 104 CMR 29.04 shall apply to all individuals for whom an application for DMH services is submitted.

(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 the minor's legally authorized representative, resides.

(b) An application may be submitted by:

1. An individual or the individual's 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 the individual's 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 the individual's 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. If it appears that the applicant is not domiciled within Massachusetts, as provided in 104 CMR 29.04(2), the Area Director or designee shall deny the application and shall so notify the applicant pursuant to 104 CMR 29.04(2)(c).

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 the applicant's 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 the applicant's 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).

6. 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.

3. An individual receiving services pursuant to 104 CMR 29.04(1)(i) may, in addition, apply for and be authorized for services pursuant to 104 CMR 29.03.

4. Denial of a request for services pursuant to 104 CMR 29.04(1)(i) shall not be subject to appeal pursuant to 104 CMR 29.16.

(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 the individual:

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 the individual's 22^nd 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 the individual's transition out of DMH services.

(e) No later than 12 months before the individual's 22^nd 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), the individual shall continue to receive the DMH service previously authorized until such time as the individual's service needs are reviewed in accordance with 104 CMR 29.04(4) and it is determined that the individual's 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 the individual's 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 the individual's 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 the individual's 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 the individual's legally authorized representative of other community services that may be available to meet the individual's needs.

If after reasonable efforts, neither the individual nor the individual's 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 the applicant's legally authorized representative to review the individual's request for services and the individual's 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 the individual's 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 the individual's 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 the individual's 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 the individual's legally authorized representative indicates that the individual no longer needs or wants DMH services, a notice will be sent to the individual and the individual's legally authorized representative that the application is considered withdrawn.

(d) If after reasonable efforts, neither the individual nor the individual's legally authorized representative can be located, the application will be deemed withdrawn; provided however, if the applicant reapplies for services within 12 months of the applicant's application being deemed withdrawn, the applicant 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 the individual's 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 the individual's 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 the individual's legally authorized representative of other community services that may be available to meet the individual's service needs.

(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, the individual 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).

(6)Services Provided Pursuant to a PASRR Evaluation and Determination. The provisions of 104 CMR 29.04(6) shall apply to individuals who are subject to a PASSR evaluation as a result of a referral for or admission to a nursing facility.

(a)Level II Evaluation and Determination. An individual who is determined by the Department to have a serious mental illness as the result of a PASRR Level II evaluation shall:

1. be deemed to meet the domicile requirements of 104 CMR 29.04(2).

2. be deemed to meet the clinical criteria for DMH services as set forth in 104 CMR 29.04(3).

3. be determined to need any Specialized Services identified in the applicable PASRR Level II evaluation, and if such service is a DMH service, shall be authorized to receive such service.

4.Additional Services: When the applicable PASRR Level II evaluation recommends additional services that may facilitate a diversion or discharge from a nursing facility, DMH shall:

a. authorize transition case management services.

b. determine whether such recommended services are DMH services;

c. determine the individual's need for such services in accordance with 104 CMR 29.04(4);

d. authorize such services in accordance with 104 CMR 29.04(5); provided, however, that if DMH does not have the capacity to provide the needed service, transition case management shall remain engaged with the individual to assist in identifying other services that may be appropriate or until the needed service is available; and

e. support the individual in obtaining recommended services that are needed and which DMH does not provide.

(b) Determinations regarding provision of services made pursuant to 104 CMR 29.04(6)(a)4 shall be subject to appeal in accordance with 104 CMR 29.16.

(c) No application for DMH services shall be required for the provision of services pursuant to 104 CMR 29.04(6); provided, however, that DMH shall provide the individual with required information and notices, as provided in 104 CMR 29.03(3), and may require additional information from the individual and authorization for the communication of personal health information between previous health care providers and providers of such services.

(d) Upon diversion or discharge from a nursing facility of an individual with serious mental illness, determinations regarding clinical criteria, need for services and service authorizations made in accordance with 104 CMR 29.04(6) shall remain in effect, subject to the provisions of 104 CMR 29.00; provided, however, that except as provided in 104 CMR 29.15, no such individual shall be discharged from DMH services without the approval of the applicable Area Director and Area Medical Director.