Definition of Serious Mental Illness for Health Home Eligibility

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In New York State, Medicaid recipients who are determined to have Serious Mental Illness (SMI) are eligible for participation in Health Homes. The designation of SMI allows health home services to be delivered to people with mental illness who have difficulty functioning successfully in their relationship, jobs, schools, and other life roles within their chosen community.

According to the DSM 5, a mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.1

For the purposes of Health Home eligibility, SMI is determined by both a diagnosis of mental illness and an impairment that impacts social, vocational, and psychological functioning. While SMI meets the Health Home single qualifying condition eligibility criteria, the functional criteria will determine Health Home service appropriateness criteria.

To be considered an individual with a serious mental illness, a person must have at least one of the diagnoses set forth in Section 1 and at least one of the functional impairments set forth in Section 2 resulting from such diagnosis.

Section 1. Qualifying DSM 5/ICD 10 diagnoses:

A DSM-5 diagnosis is usually applied to the individual's current presentation; previous diagnoses from which the individual has recovered should be clearly noted as such.

Specifiers indicating course (e.g., in partial remission, in full remission) may be listed after the diagnosis and are indicated in a number of criteria sets. Where available, severity specifiers are provided to guide clinicians in rating the intensity, frequency, duration, symptom count, or other severity indicator of a disorder. Severity specifiers are indicated by the instruction "Specify current severity" in the criteria set and include disorder-specific definitions. Descriptive features specifiers have also been provided in the criteria set and convey additional information that can inform treatment planning (e.g., obsessive-compulsive disorder, with poor insight). Not all disorders include course, severity, and/or descriptive features specifiers.2

Psychotic Disorders: F21, F22, F23, F20.81, F20.9, F25.0, F25.1, F06.2, F06.0, F06.1, F28, F29

Bipolar Disorders: F31.11, F31.12, F31.14, F31.2, F31.73, F31.74, F31.9, F31.0, F31.31, F31.32, F31.4, F31.5, F31.75, F31.76, F31.9, F31.81, F34.0, F06.33, F06.34, F31.89

Obsessive-Compulsive Disorders: F42

Depression: F34.8, F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.9, F33.0, F33.1, F33.2, F233.3, F33.41, F33.42, F33.9, F34.1, N94.3, F06.31, F06.32, F06.34, F32.8, F32.9, F34, F32.08

Anxiety Disorders: F41.9, F41.0, F41.1, F44.81, F40.0, F43.10

Personality Disorders: F60.0, F60.1, F60.3, F60.04, F60.5, F60.6, F60.9, F60.81, F21

Section 2. Extended impairment in functioning:

A recipient is determined to meet one or more of the criteria listed below as a result of their qualifying diagnosis:

  1. Marked difficulties in self-care such as personal hygiene, diet, clothing, avoiding injuries, securing health care, or complying with medical advice; or
  2. Marked restrictions of activities of daily living such as maintaining a residence, getting and maintaining a job, attending school, using transportation, day-to-day money management, or accessing community service; or
  3. Marked difficulties in maintaining social functioning such as establishing and maintaining social relationships, interpersonal interactions with primary partners, children and other family members, friends, or neighbors, social skills, compliance with social norms, or appropriate use of leisure time; or
  4. Frequent deficiencies of concentration, persistence, or pace resulting in failure to complete tasks in a timely manner in work, home, or school setting. Individuals may exhibit limitations in these areas when they repeatedly are unable to complete simple tasks within an established time period, make frequent errors in task, or require assistance in the completion of tasks.


1. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (5th ed.) (Arlington: VA, 2013) 20. 1
2. American Psychiatric Association 22 2