PBHS Service Eligibility
Eligibility criteria may differ depending on the type of service.
Basic eligibility criteria for access to the Public Behavioral Health System are:
- The individual has a mental health disorder as defined in DSM IV TR
- Individual is a Medicaid recipient
- Individual is ‘dually eligible’ for Medicare but remains in the Medicaid fee-for-service system
- Individual is Medicaid ineligible and because of psychiatric and financial need may be eligible to have the cost of mental health services (in whole or in part) subsidized by the State and/or local funds.
- Psychiatric inpatient care
- Psychiatric day treatment (partial hospitalization)
- Residential Treatment
- Outpatient mental health clinic
- Individual mental health practitioner services
- Psychiatric Rehabilitation
- Residential Rehabilitation
- Mobile Treatment Services
- Supported Living Services
- Supported Employment and vocational services
- Case Management Services
- Residential Crisis Services
The adult Medicaid population is eligible for all services within the ‘benefits package’ if they meet medical necessity criteria for that level of service. The Medicaid-ineligible individuals are eligible for all services, except inpatient and emergency rooms services, if funding is available, the individual meets medical necessity criteria for that level of service, and the individual meets any specific eligibility requirements such as:
Has received services in the PBHS within two years, or is homeless, or
Has Social Security Disability Insurance “SSDI” due to psychiatric impairment, or
Has been incarcerated within the last 3 years, or
Is on conditional release from a Maryland State hospital, or,
Has been discharged from a Maryland psychiatric hospital within the last 3 months.
Maryland’s Public Behavioral Health System remains a consumer-focused, recovery-oriented system of care. Both at the policy and program level, consumers and families play an essential role in defining Maryland’s Public Behavioral Health System (PBHS). Consumers and families are assisted and encouraged to become advocates in their recovery and in mental health systems transformation. In collaboration with many mental health advocacy and support organizations, and through the leadership and guidance of BHA’s Office of Consumer Affairs, many exciting consumer-run programs and initiatives are developing and expanding, such as peer-support groups and self-directed care projects. Anyone that wishes to learn more about these programs and/ortraining programs that offer CEUs which can be applied towards an individual's Certified Peer Recovery Specialist credential should contact BHA’s Office of Consumer Affairs at 410-402-8447.
The Behavioral Health Administration values consumer choice. Consumers’ wishes and needs drive the referral process in obtaining a provider of service. The consumer’s preference and consumer’s needs are carefully balanced in selecting a provider within the PBHS.
Consumer preferences can be identified in the following areas:
- Provider location
- Transportation to provider office
- Provider office hours
- Gender of provider
- Culture and communication
Consumer needs are identified in at least the following areas:
- Child or adolescent
- Deaf or hard of hearing
Consumers and or families members can contact Optum (the Administrative Services Agency for the PBHS) for information on services within the PBHS and or getting a referral for a provider.
Advocacy and Support Organizations
Maryland’s Public Behavioral Health System (PBHS) continues to value the support and partnership with its advocacy and support organizations. Through their efforts, many successes have been accomplished in diminishing the stigma surrounding mental illness, protecting and preserving the rights of individuals with mental illness, improving access to services and improving the coordination of care through building a recovery-based model of care. Individuals with mental illness and families of individuals with mental illness can contact these organizations for resource information and support in helping them recover.
If you or your provider does not agree with an Value Options decision about your care, you may file an appeal. The appeal process can include three levels of review. Care Managers must ask the opinion of a physician advisor before care can be denied and must offer an alternate plan to the services being requested. The following file can provide specific details on how to file an appeal/grievance.
A complaint is an expression of dissatisfaction with some aspect of the Public Behavioral Health System. The appeal/grievance process and filing a complaint is not the same. If you wish to file a complaint, please contact your local Core Service Agency and/or the Behavioral Health Administration’s Office of Consumer Affairs Office for assistance.