10A NCAC 25C .0302. NC MEDICAID CRITERIA FOR CONTINUED ACUTE STAY IN AN INPATIENT PSYCHIATRIC FACILITY

The following criteria apply to individuals under the age of 21 in a psychiatric hospital or in a psychiatric unit of a general hospital, and to individuals aged 21 through 64 receiving treatment in a psychiatric unit of a general hospital.  These criteria shall be applied after the initial admission period of up to three days.  To qualify for Medicaid coverage for a continuation of an acute stay in an inpatient psychiatric facility a patient must meet each of the conditions specified in Items (1) through (4) of this Rule.  To qualify for Medicaid coverage for continued post-acute stay in an inpatient psychiatric facility a patient must meet all of the conditions specified in Item (5) of this Rule.

(1)           The patient has one of the following:

(a)           A current DSM-IV, Axis I diagnosis; or

(b)           A current DSM-IV, Axis II diagnosis and current symptoms/behaviors which are characterized by all of the following:

(i)            Symptoms/behaviors are likely to respond positively to acute inpatient treatment; and

(ii)           Symptoms/behaviors are not characteristic of patient's baseline functioning; and

(iii)          Presenting problems are an acute exacerbation of dysfunctional behavior patterns which are recurring and resistive to change.

(2)           Symptoms are not due solely to mental retardation.

(3)           The symptoms of the patient are characterized by:

(a)           At least one of the following:

(i)            Endangerment of self or others; or

(ii)           Behaviors which are grossly bizarre, disruptive, and provocative (e.g. feces smearing, disrobing, pulling out hair); or

(iii)          Related to repetitive behavior disorders which present at least five times in a 24-hour period; or

(iv)          Directly result in an inability to maintain age appropriate roles; and

(b)           The symptoms of the patient are characterized by a degree of intensity sufficient to require continual medical/nursing response, management, and monitoring.

(4)           The services provided in the facility can reasonably be expected to improve the patient's condition or prevent further regression so that treatment can be continued on a less intensive level of care, and proper treatment of the patient's psychiatric condition requires services on an inpatient basis under the direction of a physician.

(5)           In the event that not all of the requirements specified in Items (1) through (4) of this Rule are met, reimbursement may be provided for patients through the age of 17 for continued stay in an inpatient psychiatric facility at a post-acute level of care to be paid at the High Risk Intervention Residential High (HRI-R High) rate if the facility and program services are appropriate for the patient's treatment needs and provided that all of the following conditions are met:

(a)           The psychiatric facility has made a referral for case management and after care services to the area Mental Health, Developmental Disabilities, Substance Abuse (MH/DD/SA) program which serves the patient's county of eligibility.

(b)           The area MH/DD/SA program has found that no appropriate services exist or are accessible within a clinically acceptable waiting time to treat the patient in a community setting.

(c)           The area MH/DD/SA program has agreed that the patient has a history of sudden decompensation or measurable regression and experiences weakness in his or her environmental support system which are likely to trigger a decompensation or regression.  This history must be documented by the patient's attending physician.

(d)           The inpatient facility must have a contract to provide HRI-R, High with the area MH/DD/SA program which serves the patient's county of eligibility, or the area program's agent.  Psychiatric hospitals or psychiatric units in general hospitals are eligible to establish contract relationships with all non-Carolina Alternatives area MH/DD/SA programs or their agents in accordance with statutory procedures as defined in G.S. 122C-142.

(e)           The Child and Family Services Section of the Division of Mental Health, Developmental Disabilities, Substance Abuse Services shall approve the use of extended HRI-R, High, based on criteria in Sub-items (a)-(c) of this Item.

(f)            The area MH/DD/SA program shall approve the psychiatric facility for the provision of extended HRI-R High, receive claims from the inpatient facility, and provide reimbursement to the facility in accordance with the terms of its contract.

 

History Note:        Authority G.S. 108A-25(b); 108A-54; 42 C.F.R. 441, Subpart D;

Eff. January 1, 1998;

Temporary Amendment Eff. August 20, 1999;

Amended Eff. March l9, 2001;

Transferred from 10A NCAC 22O .0113 Eff. May 1, 2012.