ACT Eligibility Requirements

To qualify for this service, individuals must the following criteria: 

1. The individual must be 18 years or older (as required by Early and Periodic Screening, Diagnostic and Treatment (EPSDT), youth below age 18 may receive ACT if medically necessary); 

2. The individual must have a documented DSM diagnosis that is consistent 

with a serious and persistent mental illness, including but not limited to, the following DSM categories: Schizophrenia Spectrum and Other Psychotic Disorders; and, Bipolar and Related Disorders. Individuals with diagnoses that fall outside of these categories may be eligible depending on the level of associated long-term disability; in these cases, a Physician letter justifying this exception should accompany the service authorization request. 

3. The individual has significant functional impairment as demonstrated by at least one of the following: 

• Significant difficulty in consistent performance of the range of routine daily tasks required for basic adult functioning in the community (for example, caring for personal business affairs; obtaining medical, legal, and housing services; recognizing and avoiding common dangers or hazards to self and possessions; meeting nutritional needs; attending to personal hygiene); 
• Significant difficulty maintaining consistent employment at a self- sustaining level; or
• Significant difficulty consistently carrying out the head-of- household responsibilities (such as meal preparation, household tasks, budgeting, or child-care tasks and responsibilities); or 
• Significant difficulty maintaining a safe living situation (for example, repeated evictions or loss of housing or utilities). 

4. The individual has high service needs as indicated by one or more of the following:

•  High use of acute psychiatric hospital as defined by multiple admissions within the past two years; 
• At least one recent long-term stay of 30 days or more in an acute psychiatric hospital inpatient setting within the last two years; 
• High use of behavioral health crisis services as defined by more than four interventions in the last 12 months; 
• Intractable (persistent or recurrent) severe mental health disorder symptoms (affective, psychotic, suicidal, etc.); 
• Co-occurring mental health and substance use disorder of significant duration (more than six months); 
• High risk or recent history of criminal justice involvement (such as arrest, incarceration, probation)as a result of the individual’s mental health disorder symptoms;