High Fidelity Wraparound Eligibility

Medicaid eligible children and adolescents ages 3 up to 21 who meet specific Medicaid eligibility criteria include the following:  

•  Youth with a primary mental health or substance use disorder diagnosis (as defined by the DSM-5, or any subsequent editions of this reference material) may also have a co-occurring diagnosis of intellectual and developmental disability.  

OR  

• Have a primary I/DD diagnosis as defined by DSM-5, or any subsequent editions of this reference material, along with a co-occurring diagnosis of mental health or substance use disorder.  

AND  

• Based on the current comprehensive clinical assessment (completed within the past year) that includes the use of CALOCUS or CANS, functional impairment is demonstrated, indicating the need for this level of service. Less intensive services were considered or previously attempted but found to be inappropriate or ineffective.  

AND  

• Youth’s symptoms and behaviors are unmanageable at home, school, or in other community settings without specialized support due to the deterioration of the beneficiary’s mental health or substance use disorder condition. This situation places them at imminent risk of out-of-home residential care, necessitating intensive, coordinated clinical interventions and potential need for PRTF or other long-term out-of-home placements.  

AND  

• Youth require coordination between two or more youth-serving agencies, including both medical and non-medical providers, to effectively access substance use disorder support and youth mental health services.