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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 53 Pa.B. 6142 (September 30, 2023).

55 Pa. Code § 5221.12. Consumer eligibility.

§ 5221.12. Consumer eligibility.

 (a)  Persons eligible for intensive case management are:

   (1)  Adults, 18 years of age or older, who have a serious and persistent mental illness. A person shall be considered to have a serious and persistent mental illness when two of the following criteria are met:

     (i)   Diagnosis—Schizophrenia or chronic major mood disorder (diagnosis codes 295 and 296 in the DSM III-R).

     (ii)   Treatment history—One of the following:

       (A)   Admission to State mental hospitals totaling 60 days within the past 2 years.

       (B)   Two admissions to community inpatient psychiatric units totaling 20 or more days within the past 2 years.

       (C)   Five or more face-to-face encounters with emergency services personnel within the past 2 years.

       (D)   Three or more years of continuous attendance in a community mental health service, at least one unit of service per quarter.

       (E)   History of sporadic course of treatment as evidenced by at least three missed appointments within the past 6 months, inability to or unwillingness to maintain medication regimen or involuntary committment to outpatient treatment.

     (iii)   Functioning level. One of the following:

       (A)   Global Assessment of Functioning Scale (DSM-III-R, pages 12, and 20) ratings of 40 and below.

       (B)   A rating of 60 and below if the person is 35 years of age or younger or has a history of aggressive or violent behaviors.

   (2)  Adults who were receiving intensive case management services as children and were reviewed by the provider and approved by the county administrator as needing intensive case management services beyond the date of transition from child to adult.

   (3)  Children who are mentally ill or emotionally disturbed and who meet one of the criteria described as follows:

     (i)   Children, 6 years of age or younger, who are enrolled in, or require, early intervention services under section 671 of the Education of the Handicapped Act (20 U.S.C.A. §  1400).

     (ii)   Children who, with their families, are receiving services from three or more publicly funded programs such as, Medical Assistance, Aid to Families with Dependent Children and Special Education.

     (iii)   Children who are returning from State mental hospitals, community inpatient units or other out-of-home placements, including foster homes and juvenile court placements.

     (iv)   Children who are recommended as needing mental health services by a local interagency team which shall include county agency representatives.

   (4)  Families of eligible children who are receiving intensive case management services.

 (b)  Exceptions. An adult or child receiving, or who needs to receive, mental health services but who does not meet the requirements of this section is eligible for intensive case management upon review and recommendation by the county administrator and written approval by the Department’s area office of mental health.

 (c)  Termination. Intensive case management may be terminated for one of the following reasons:

   (1)  Determination by the consumer or the parent of a child receiving the service that intensive case management is no longer needed or wanted.

   (2)  Determination by the intensive case manager in consultation with his supervisor or the director of intensive case management, and with written concurrence by the county administrator that intensive case management is no longer necessary or appropriate for the adult or child receiving the services.

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