Feasibility of Expanding Self-Directed Services to People with Serious Mental Illness. 3.4. Exclusions from Coverage


SDC programs generally do not include coverage for mental health visits to emergency departments or for mental health crisis, inpatient, or residential treatment services. These services also are not ones that participants self-direct or write into their recovery plans. Instead, these services are covered either by Medicaid, Medicare or private insurance, or by public mental health authorities or hospitals under uncompensated care.

There are two main reasons why "acute care" services are excluded from SDC planning. First, individuals usually do not know what expenses they will have for these services before these services are needed, and any use of these services can result in high unanticipated health care expenses. Consequently, when planning a SDC budget, most individuals would not know what amount of money to allocate for use of these services, and they might not allocate enough to cover their expenses during the course of a year. Second, public mental health systems would not want to put individuals with SMI at risk for not obtaining mental health services during periods of crisis, when they are most in need of services and most at risk of harming themselves or others. Indeed, providing or paying for services needed by individuals with SMI during periods of acute exacerbation of mental health symptoms is a primary rationale for having a public mental health system.

Psychiatric medications are not covered in most SDC programs, and psychiatric medication use is often not written into participants' SDC recovery plans. There may be no benefit to making psychiatric medications part of the SDC planning process, and there could be risks. As pointed out by one key informant, SDC participants have the option to "fire" their psychiatrist if they are unsatisfied with the medications they are being prescribed or with the medication decision-making process. Moreover, if psychiatric medications are included in SDC planning, medication expenses may affect participants' choices among medications and their use of medications over time. Such an influence could have adverse consequences for participants, including a greater risk of crises and hospitalizations. Although SDC participants are not allocated monies specifically for medications, many participants have prescription drug coverage through their health insurance plans. Also, participants usually are allowed to use part of their individual budgets to pay for medication expenses not covered by insurance.

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