section .0100 – Reserved for future codification

Link to law: http://reports.oah.state.nc.us/ncac/title 10a - health and human services/chapter 25 - medical assistance provided/subchapter c/subchapter c rules.html
Published: 2015

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subchapter 25C – behavioral health/substance abuse

 

section .0100 – Reserved for future codification

 

10a ncac 25c .0101       reserved for future codification

section .0200 – mental health center

services

 

10A NCAC 25C .0201       MENTAL HEALTH CENTER SERVICES

(a)  Psychiatric testing at a mental health center shall be

covered only when the center has individualized treatment plans and goals for

the patient.  Payment shall be made only if the testing is medically necessary.

(b)  Mental health centers providing active treatment for

psychiatric or medical illness occurring in the mentally retarded shall be

covered for such treatment.

(c)  There must be a current diagnosis, treatment plan, and

specific goals for each patient.  The visit must be medically necessary.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54;

42 C.F.R. 440.70;

Eff. February 1, 1976;

Amended Eff. September 30, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. January 1, 1984; December 1, 1981;

Transferred from 10A NCAC 22O .0107 Eff. May 1, 2012.

 

section .0300 – inpatient psychiatric hospital services

 

10A NCAC 25C .0301       INPATIENT PSYCHIATRIC HOSPITAL SERVICES

Inpatient psychiatric hospital services are covered in

private psychiatric hospitals for services provided in beds licensed as

inpatient psychiatric or substance abuse hospital beds and in State mental

hospitals, for recipients under age 21, for recipients defined in 42 CFR

441.151 (c), and for recipients over age 65 as defined in Social Security Act

1905 (a) and (h) and 1861 (f). The admitting hospital is responsible for

obtaining certification for person under age 21 in accordance with Subpart D of

42 CFR 441.  Admission to all out of state psychiatric hospitals including

those enrolled as border psychiatric hospitals are subject to prior approval

for necessity to go out of state.  Admissions to psychiatric hospitals enrolled

as border hospitals are limited to cases where it is the general practice for

recipients in a particular locality to use medical resources in the other

State.  Services in out of state hospitals are provided only to the same extent

and under the same conditions as medical services provided in North Carolina.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. February 1, 1991;

Transferred from 10A NCAC 22O .0111 Eff. May 1, 2012.

 

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.