Navigating the Public Behavioral Health System with a Serious Mental Illness Designation
What is a Serious Mental Illness (SMI)?
A Serious Mental Illness means persons who as a result of a mental disorder as defined in section 36-501 exhibit emotional or behavioral functioning that is so impaired as to interfere substantially with their capacity to remain in the community without supportive treatment or services of a long-term or indefinite duration. In these persons mental disability is severe and persistent, resulting in a long-term limitation of their functional capacities for primary activities of daily living such as interpersonal relationships, homemaking, self-care, employment and recreation.
How To Receive a Serious MentaI Illness (SMI) Designation
See the Serious Mental Illness Determination Process document for information on the SMI determination process and the SMI Benefits document to learn about additional support and services available to individuals with an SMI designation.
Getting Connected and What to Expect
After an individual receives an SMI designation, they are notified in writing about how to receive services through the AHCCCS Complete Care Regional Behavioral Health Agreement (ACC-RBHA). The ACC-RBHA is the health plan contracted with AHCCCS to coordinate behavioral health service delivery to members living with an SMI in each geographic area of the state.
Each person’s situation is unique. Some individuals with an SMI designation are eligible for Medicaid, while others are not. If you or your loved one is not eligible for AHCCCS (this is called Non-Title XIX SMI), you may still be able to use behavioral health services through grant funds. To learn more about available services, see the Non-Title XIX SMI flier.
Getting Started with Services
One way to start receiving services is to enroll in an integrated clinic (also called a health home). The clinic will start with an intake process to develop an individual service plan (ISP) that considers the unique needs, strengths, culture, diversity and goals of each individual. Every member has a voice and choice in where to receive services.
An SMI designation allows an individual to receive increased access to a variety of behavioral health services and supports which may include:
- An Individual Service Plan (ISP) which outlines the services an individual receives. The ISP is created with the individual’s full participation, and may require the treatment team to take steps to meet unique recovery needs. The individual can use their ISP to make sure that they get the services that they want, need, and are entitled to. Learn more about the Individual Service Plan,
- An Assertive Community Treatment (ACT) Team is a community-based team of specialists who provide customized support,
- SMI Housing is supportive housing for individuals with an SMI determination, when available, or
- Case Manager assigned to coordinate needed services.
Know Your Rights as an Individual with an SMI designation
A person with an SMI designation has specific civil rights that are protected by administrative codes, including but not limited to the following:
- Office of Human Rights (OHR) Advocate or Designated Representative protects the rights of the members during Service Planning; Inpatient Treatment Discharge Planning; the SMI grievance or investigation process; and the SMI appeal process. The advocate or designated representatives are only assigned to SMI individuals who meet Special Assistance criteria. However, OHR is a resource for technical assistance for all SMI individuals. Contact the Office of Human Rights at 1-800-421-2142 or via email at OHRts@azahcccs.gov.
- SMI Grievance process available under the Arizona Administrative Code* (A.A.C R9-21-400). SMI grievances are complaints filed by an individual with a SMI designation or other concerned individual alleging a violation of an SMI member’s rights or a condition requiring an investigation. Learn more in this document about the SMI Complaint, Grievance, and Appeals Process.
- SMI Appeals process is used to request a review of a denial of any covered services. Learn more in the SMI Complaint, Grievance, and Appeals Process document. Issues that can be appealed include, but are not limited to:
- The reduction, suspension, or termination of a service the member was receiving (i.e., content of Individual Service Plan (ISP) or discharge plan, denial of a service, fees assessed to the individual or the denial of a fee waiver, and/or the result of a grievance or request for investigation),
- The failure to provide timely services,
- The failure to act within timeframes for resolving an appeal or complaint, and/or
- The denial of a request for services outside of the provider network when services are not available within the provider network.
- Inpatient Treatment and Discharge Plan (ITDP) is a written plan for services for an individual, prepared and carried out by the member and inpatient facility. The ITDP must be consistent with an individual’s needs, strengths, goals, and preferences for services. When done correctly,with an individual’s fullest participation, the ITDP will help members get the services they need to help with recovery. Learn more in the Your Rights While You Are Inpatient document.
For definitions of contract language see the AHCCCS Contract and Policy Dictionary.
- Q1: Where can I find more information on SMI member rights?
- Q2: How do you request an SMI Determination?
- Q3: What is the Grievance and Appeal System?
- Q4: What if I do not agree with my SMI determination?
- Q5: Does an SMI designation prevent me from enlisting in the military?
- Q6: How long does the SMI designation last?
- Q7: How are Medicare and Medicaid behavioral health benefits coordinated for a Non-Title 19 ACC-RBHA individual who is not eligible for full Medicaid (Title 19) benefits, but is eligible for Medicare?
Q1: Where can I find more information on SMI member rights?
For more information on SMI members and their rights, please see:
Q2: How do you request an SMI Determination?
The AHCCCS determining entity will complete the evaluation for the SMI determination. AHCCCS contracts with a single statewide entity that reviews eligibility and makes a determination of whether an individual meets the functional and diagnostic criteria for the SMI designation. A member may request an initial SMI determination assessment at any time. An SMI determination assessment may be repeated every six months. More information on requesting an SMI determination.
Q3: What is the Grievance and Appeal System?
A process for member grievances and appeals including Serious Mental Illness (SMI) grievances and appeals and also provider claim disputes. The Grievance and Appeal system provides access to the State fair hearing process. For more information on this process, please see How to File an Appeal.
Q4: What if I do not agree with my SMI determination?
You do have the right to appeal the decision of the SMI determination. To learn more about the appeal process please see the Appeals Process for Individuals with an SMI Designation document.
Q5: Does an SMI designation prevent me from enlisting in the military?
All military applicants are required to disclose a full medical history including a mental health history. To learn more, please refer to Department of Defense (DoD) Instruction 6130.03, Volume 1 Medical Standards for Military Service: Appointment, Enlistment, or Induction Section 5.28 for a comprehensive list of disqualifying mental health conditions and factors. A person who is found to have a disqualifying mental health condition may seek a medical enlistment waiver. However, obtaining a waiver is not automatic and approval is determined on a case-by-case basis. 32 CFR § 66.7(a)(1).
Q6: Does an SMI designation prevent me from enlisting in the military?
An SMI designation lasts until a person is reassessed and determined to no longer meet criteria. Learn more about SMI Decertification.
Q7: How are Medicare and Medicaid behavioral health benefits coordinated for a Non-Title 19 ACC-RBHA individual who is not eligible for full Medicaid (Title 19) benefits, but is eligible for Medicare?
Eligibility differs for both Medicaid and Medicare. Medicaid recipients can contact their provider to learn about available services. Non-Title XIX Medicaid members can contact the Clinical Teams, RBHA, or TRBHA for any grants or options available for any services.
For a Non-Title XIX ACC-RBHA member with Medicare benefits, Medicare is the primary payer for inpatient and outpatient Medicare-covered behavioral health services. Medicare-covered behavioral health services that exceed Medicare’s coverage limits, and non-covered Medicare services, may be covered by the Non-Title XIX ACC-RBHA plan. Work with your providers or your ACC-RBHA or TRBHA clinical care team (case manager) to coordinate your covered behavioral health services and arrange for any additional available financial assistance. See also AHCCCS AMPM Policy 320-T2: Non-Title XIX/XXI Services and Funding (Excluding Block Grants and Discretionary Grants).
The CMS Medicare & Your Mental Health Benefits booklet provides an overview of Medicare’s covered behavioral health services.