65E-11.004. Clinical Guidelines for Referral

(1) Every child referred to the Behavioral Health Network shall be screened as a first step in determining the child’s eligibility for services. If the screening indicates the child has the potential to meet the Behavioral Health Network clinical eligibility criteria described in this section, an assessment shall be conducted.

(2) A child shall be considered eligible for behavioral health services from the Behavioral Health Network when the child is determined to be Title XXI eligible for the Florida KidCare Program, be at least five (5) years of age and not yet nineteen (19) years of age, and

(a) The child requires a level of care not available in the other KidCare programs and care is in excess of the benchmark behavioral health benefit package as described in Chapter 409, F.S.; and,

(b) The child is expected to show improvement or achieve stability as a direct result of the services to be rendered under the benefit package specified in Rule 65E-11.003, F.A.C.; and,

(c) At the time of assessment, the child requires no more than 30 days of residential treatment; and,

(d) The child’s family indicates a willingness to participate in the goals and objectives outlined in the child’s treatment plan; and,

(e) The child meets one of the following clinical eligibility criteria described below as determined by the Lead Agency or their designee for making clinical eligibility determinations:

1. The child has a DSM-IV Axis I clinical classification of mental disorders or substance-related disorders,

2. A child diagnosed with Attention-Deficit/Hyper Activity Disorder as the primary DSM-IV-R Axis I diagnosis does not qualify for Behavioral Health Network services; and,

3. The child demonstrates a significant level of functional impairment as measured by the Children’s Global Assessment Scale (C-GAS), with a score of fifty or below.

(3) Disenrollment Criteria. A child shall be considered disenrolled from the Behavioral Health Network at midnight of the last day of the current enrollment month if one of the following occurs:

(a) The parent has neglected to pay the premium;

(b) The child turns 19 years old;

(c) The child becomes Medicaid eligible or obtains other insurance coverage;

(d) The child moves out of state;

(e) The child is placed in residential treatment exceeding thirty days;

(f) The child becomes an inmate of a public institution, or

(g) The child no longer meets the Behavioral Health Network’s treatability or clinical eligibility criteria.

(4) When determining or reviewing a child's eligibility under the program, the applicant shall be provided with notice of changes in eligibility. When a transition from the Behavioral Health Network to another program is appropriate, the Behavioral Health Liaison shall notify the Children’s Medical Services case manager in writing and shall ensure the affected family is afforded a transition which promotes continuity of behavioral health care coverage.

(5) The department shall be the final authority on all admissions, transfers, and discharges of children into and from the Behavioral Health Network and retains the right to override any decision of a Lead Agency with regard to a child’s admission, transfer, and discharge.

(6) In the case of any dispute between the department and a Lead Agency, an enrolled child shall remain in the Behavioral Health Network and continue to receive care at the expense of the Lead Agency for the duration of the resolution of the dispute.

Rulemaking Authority 409.8135(6) FS. Law Implemented 409.8135 FS. History–New 1-17-01, Amended 8-31-03.