Medicaid eligible individuals with a suspected diagnosis of Intellectual Disability defined as significantly sub-average general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental phase, prior to age 22 years, or a related disability as defined as a severe, chronic condition found to be closely related to Intellectual Disability and meet the six following conditions:

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•It is manifested before 22 years of age for Intellectual Disability and related disabilities.

•It is likely to continue indefinitely;

•It results in substantial functional limitations in 3 or  more of the following areas of major life activities: Self Care, Understanding and use of language, learning, mobility, self-direction, and capacity for independent living;

•The person’s needs are such that supervision is necessary due to impaired judgment, limited capabilities, behavior problems, abusiveness, assaultive behavior or because drug effects/medical monitoring; and

•The person is in need of services directed toward acquiring skills to function as independently as possible or the prevention or regression or loss of current optimal functional status.

•Specific symptoms or disturbances make the member unable to access behavioral health, medical, educational, social, developmental or other supportive services required.

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South Carolina Medicaid eligible children under the age of 21 years old that meet specific needs based criteria and are “at risk” due to one of the following:

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•At high risk for medical compromise due to one of the following conditions:

o Failure to take advantage of necessary health care services;

o Noncompliance with their prescribed medical regime;

o An inability to coordinate multiple medical, social, and other services due to the existence of an unstable medical condition in need of stabilization;

o An inability to understand medical directions because of comprehension barriers;

•Absence of a community support system to assist in appropriate follow-up care at home;

•Offending or victimization;

•A victim of abuse, neglect, or violence;

•Medical complexity that requires frequent care planning;

•Diagnosis of or suspected diagnosis of a developmental delay or a diagnosed physical or mental condition that has a high probability of resulting in developmental delay and/or intellectual disability and are less than age 6

•Children who at any time during the past year have a diagnosable mental, behavioral or diagnostic criterion that meets the coding and definition criteria specified in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM);

•Specific symptoms or disturbances make the member unable to access behavioral health, medical, educational, social, developmental or other supportive services required.

Medicaid-eligible adults with serious and persistent mental illness must meet the following criteria:

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•   Medicaid eligible individuals age 21 and older who have a major mental disorder included in the current edition of the Diagnostic and Statistical Manual of Mental Disorders classification under schizophrenia disorders, major affective disorders, severe personality disorders, psychotic disorders, and delusional (paranoid) disorders or a diagnosis of a mental disorder and at least one hospitalization within the past 12 months for treatment of a mental disorder.

•  Specific symptoms or disturbances make the member unable to access behavioral health, medical, educational, social, developmental or other supportive services required.

Medicaid eligible pregnant women who are at risk for medical compromise due to one of the following:

•Failure to take advantage of necessary prenatal care or services, or
•Noncompliance with their prescribed medical regime, or
•Inability to coordinate multiple medical, social or other services due to the existence of an unstable medical condition in need of stabilization
•An inability to understand medical directions because of comprehension barriers and

oIs expecting her first live birth and has never parented a child, or
oHas previously been pregnant, but experienced a stillbirth, miscarriage, or had an abortion, or
oHas previously parented her child but her parental rights were terminated, or
oHas delivered a child, but the child died within the first 24 months of life, or
oHas parented a child but there is an age gap of 15 or more years since the last delivery.

 NOTE:: 

The At Risk Infant is eligible for case management under this population to the second birthday;


Medicaid eligible individuals who are at risk of substance abuse, dependency or addiction or diagnosed with a substance disorder, psychoactive substance dependency, or induced organic mental disorders as defined in the current edition of the Diagnostic and Statistical Manual or Medicaid eligible individuals who received treatment in an intensive alcohol and drug abuse treatment program or chemical dependence hospital.
 

Specific symptoms or disturbances make the member unable to access behavioral health, medical, educational, social, developmental or other supportive services required.

“At Risk” of substance abuse, dependency or addition:
In order to meet criteria for this target population, the individual should have identified at least two (2) risk factors, one of which involves active substance use in any of the three (3) domains. Risk factors should be identified and addressed throughout the assessment. Severity on the American Society of Addiction Medicine (ASAM) dimensions should be reflected in documentation. The Case Management Plan (CMP) should be directly linked the assessment findings and the risk factors should be addressed in the goals/objectives.

Alcohol and Other Drug (AOD) Risk Factors by domains:

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Individual:

•Early (pre-adolescent) and adult with persistent problem behaviors:

•Risk taking, high sensation seeking behaviors (in adolescents, consider developmental stages)

•Antisocial behavior

•AOD use that does not meet diagnostic criteria (in adolescents, includes experimental use; in adults, increased use when stressed or self-medicating due to other symptoms/problems)

Family:

•Low perception of harm (increases likelihood of initiating use)

•Perception of parental/sibling acceptance/approval of substance abuse (strong predictor of adolescent substance abuse; linked to alcohol initiation during family gatherings)

•Lack of mutual attachment & nurturing by parents/caregivers with a family history of alcoholism

•Chaotic home environment with substance use in home

Peers/School/Community:

•Associating with substance using peers

•Drinking in social settings or having peers who do

•Accessibility to AOD

•Availability of AOD

•Misperceptions about extent and acceptability of drug abusing behavior

•Beliefs that drug abuse is generally tolerated

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Medicaid eligible individuals who have been diagnosed with a genetic disorder, have preliminary laboratory tests showing evidence of a disorder or individuals who have a family member with an illness which is associated with a genetic disorder. The individual must be referred by the doctor of the individual who has been diagnosed with an illness, which is caused by a genetic disorder.

Specific symptoms or disturbances make the member unable to access behavioral health, medical, educational, social, developmental or other supportive services required.

Medicaid eligible individuals who are suspected of having a traumatic brain injury, spinal cord injury or both or a similar disability not associated with the process of a progressive, degenerative illness, dementia, or a neurological disorder related to aging, regardless of the age of onset. The individual has substantial functional limitations and:

•Has urgent circumstances affecting his or her health or functional status; and
•Is dependent on others to provide or assist with critical health needs, basic activities of daily living or requires daily monitoring or supervision in order to avoid institutionalization.
•Specific symptoms or disturbances make the member unable to access behavioral health, medical, educational, social, developmental or other supportive services required.

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Medicaid eligible non-institutionalized individuals between the ages 0 to 64 year diagnosed as legally blind, visually impaired, deaf, hard of hearing or multi-handicapped by a qualified specialist in the area of vision or hearing.
Specific symptoms or disturbances make the member unable to access behavioral health, medical, educational, social, developmental or other supportive services required.

Coverage is limited to Medicaid eligible individuals in need of services and who meet all the following criteria:

•Individuals who are 18 years of age or older
•Individuals who lack formal or informal resources to address their mental and physical needs
•Individuals who have at least two functional dependencies or one functional dependency and a cognitive impairment
•Individuals who require MTCM assistance to obtain needed services
•Individuals who are at risk for institutionalization

Specific symptoms or disturbances make the member unable to access behavioral health, medical, educational, social, developmental or other supportive services required.