Serious Mental Illness (SMI): What is it and what resources are available for families?

January 25, 2024

A Serious Mental Illness (SMI) designation can provide an adult with services and support to help improve their quality of life and their ability to live independently.

Diagnoses that could qualify for the SMI designation can include, but are not limited to, depression, schizophrenia, bipolar disorder, obsessive compulsive disorder, panic disorder, post-traumatic stress disorder (PTSD) and borderline personality disorder. For a comprehensive list of SMI qualifying diagnoses, refer to the Serious Mental Illness Determination form available at https://community.solari-inc.org/wp-content/uploads/2023/09/SMI-Determination-Form.pdf.

Individuals with an SMI designation may be eligible to receive services including specialized case management, additional counseling and treatment sessions, transportation to appointments per AHCCCS policy, and other resources such as supported employment and housing services. For example, insurance might limit the amount of counseling visits, but additional visits could be covered for some individuals with an SMI designation.

Any adult living in Arizona can apply for an evaluation of SMI designation regardless of their insurance status. The application process can be started when the individual is 17.5 years old.

SMI is a designation, not a diagnosis. Solari Crisis and Human Services (https://solari-inc.org) reviews all applications for SMI eligibility determinations in Arizona using the criteria set forth by the Arizona Health Care Cost Containment System (AHCCCS).

Individuals make their requests for SMI determination to their community provider if they currently have AHCCCS coverage, or through the Regional Behavioral Health Authority (RBHA) for the region they reside in if they are not covered by AHCCCS. Their provider must complete an assessment packet within seven days of the request and has one additional day to send it to Solari for review.

After receiving the packet, Solari has three business days to review and determine eligibility for SMI services. Individuals can choose to extend their eligibility determination period for 20 days if they feel additional information could be accessed to help with the decision.

Individuals can also agree to extend their determination process for 30 to 60 calendar days for an extended evaluation period. This could include a period of abstinence or reduced use of drugs and alcohol to help the reviewing behavioral health professional determine eligibility.

After receiving an eligibility packet, Solari will determine whether the individual is eligible for SMI services using the state’s guidelines. To be eligible for SMI services, the individual must have a qualifying diagnosis of mental illness as described in the AHCCCS Medical Policy Manual 320-P SMI Qualifying Diagnosis Section available at https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/300/320P.pdf.

The individual must also experience serious dysfunction as a result of that diagnosis – for example, they have challenges with everyday activities or interactions. These can include social, occupational and psychological functioning including how flexible the individual can be with different scenarios during a day. Functional impairment must have existed for most of the past 12 months, or for most of the past six months with expected continuation of at least six additional months. A person might also qualify for the SMI designation without this dysfunction if they are considered at risk or expected to deteriorate to this level of dysfunction without treatment and support.

Solari mails a Notice of Decision to the individual. If they are eligible, Solari notifies their provider and AHCCCS. If they are not eligible, individuals have two levels of appeal. First, they can participate in an informal conference with a different doctor than the one who gave their eligibility decision. The second level of appeal would be a hearing with an administrative law judge. Members are eligible for a new determination six months after the previous date of determination, regardless of whether they used the appeal and hearing process.

The SMI designation can provide an individual with additional choices for providers, said Lori Schectman, program specialist for Ending the Silence, a program for youth offered by National Alliance on Mental Illness (NAMI). Patients could also have different options for medication including injectable medication from their provider.

SERVICES FOR CHILDREN

Children under age 18 can also receive services through a Serious Emotional Disturbance (SED) designation. This is available to children who have diagnosable mental, behavioral or emotional conditions that substantially interfere with or limit their roles or functioning in family, school or community activities.

“If your child is struggling behaviorally and you feel like you can’t get support for them, an SED designation could be appropriate to help them get services,” said Kelly Carbello, social worker with Arizona Peer and Family Coalition.

Services available to children with an SED designation include counseling, medication, inpatient behavioral health and wrap-around services. Parents can request an evaluation for the SED designation through their child’s healthcare provider, and Solari also determines eligibility for SED.
Parents who have questions about their child’s mental health, or their own mental health, can connect with their local NAMI chapter. “Parents are their child’s advocate,” Schectman said. “They need to understand and research what their child’s condition entails.” NAMI provides support groups, classes and advocacy for families.

Children who are SED eligible do not automatically qualify for the SMI designation when they become adults; they need to apply for SMI eligibility. Parents can apply for their child to receive the SED designation from birth to age 18. An SMI determination request can be submitted when a child turns 17.5. If they qualify, SMI services will begin upon their 18th birthday. Once an individual turns 18, the SMI request must come from the patient unless the parent or caregiver has guardianship.

HOW SERVICES WORK

Individuals who receive an SMI or SED designation and have private or no health insurance receive services through their region’s Regional Behavioral Health Authority (RBHA). This is also true of DDD members who do not receive services through the Arizona Long-Term Care System (ALTCS). Arizona is divided into three regions, each covered by a different RBHA.

DDD/ALTCS and SMI eligible members continue to receive services through their existing health plan, Mercy Care or United Healthcare Community Plan. They don’t need to change their health plans to their region’s RBHA plan to receive SMI benefits. They also won’t need to switch plans to a new area’s RHBA plan if they move to another county in Arizona.

Members who have both DDD/ALTCS and SMI services can request to combine these meetings, noted Summer Kamal, behavioral health coordinator with Mercy Care. This helps to ensure fewer meetings and helps keep the SMI and DDD teams on the same page with needed support.

SMI services are voluntary. Individuals who no longer desire to receive these services can choose not to but can keep their designation active by interacting with a provider at least once every six months. They can also ask their clinical team about being assessed for removal of the SMI designation. Because the SED designation is for children, parents can decide whether to request its removal.

COMMON MISCONCEPTIONS

Some parents believe that if their adult child receives an SMI designation, it will be easier to qualify for adult services through the Division of Developmental Disabilities (DDD) or for Supplemental Security Income (SSI) payments through Social Security.

“These are different entities,” said Dr. Korey Hawkins, manager of clinical eligibility with Solari. “Qualifying for one doesn’t mean it’ll be easier to qualify for another.”

Another common misunderstanding is that substance use will disqualify someone from receiving the SMI designation, but this is not the case. “The decision is based on if the individual has an SMI-qualifying diagnosis and functional impairment in one of the domains that is directly related to that SMI-qualifying diagnosis,” Hawkins said. “While an individual may have a comorbid substance-related diagnosis, if the forementioned is met, their substance use does not preclude them from meeting SMI criteria.”

Why would someone not want to obtain an SMI designation for themselves, or an SED designation for their child?

Some people might think that an SMI or SED designation could take away someone’s rights. “This is not true. Simply having a designation does not impact a person’s rights,” Hawkins said. “A person’s SMI or SED designation is considered protected health information. There are instances where a judge may rule to remove certain individual rights. However, this is not related to the determination process.”

The AHCCCS Office of Individual and Family Affairs (OIFA) promotes recovery and wellness among individuals with mental health and substance abuse challenges. All OIFA staff members have personal experience with mental illness, either from their own experience or by supporting someone through this journey.

OIFA administrator Susan Kennard has a family member with the SMI designation, and she said the services helped shape their treatment plan. Appropriate treatment helped the individual get closer to achieving personal goals.

Many professionals believe parents or individuals hesitate to pursue SMI or SED designations due to stigma still associated with mental illness. “We have a long way to go in how people perceive mental illness,” said CJ Loiselle, deputy assistant director for the AHCCCS Division of Grants and Innovation (DGI). “Treatment for mental illness is no different than treatment for any other illness. Chronic illnesses don’t have a stigma attached to them.”

For more information about pursuing an SMI or SED designation, contact your AHCCCS provider or your region’s RBHA.

ARIZONA REGIONAL BEHAVIORAL HEALTH AUTHORITIES (RHBAs):

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