Idaho Admin. Code r. 16.03.09.701

Current through September 2, 2024

Section 16.03.09.701 - INPATIENT BEHAVIORAL HEALTH SERVICES: PARTICIPANT ELIGIBILITY

01.Inpatient Psychiatric Hospital Services. Participants are eligible who have a diagnosis from the current DSM with substantial impairment in thought, mood, perception, or behavior. A court-ordered admission or physician's emergency certificate alone does not justify Medicaid reimbursement for these services. Medical necessity must be demonstrated for admission or extended stay by meeting the severity of illness and intensity of service criteria as found in Subsections 701.03 and 701.04 of this rule. Services may be provided in:

a. A freestanding psychiatric hospital;

b. A hospital psychiatric unit; and

c. Subject to federal approval, an institution for mental diseases.

02.Inpatient Substance Use Disorder Services. Participants are eligible when medical necessity is demonstrated by meeting the severity of illness and intensity of service criteria as found in Subsections 701.03 and 701.04 of this rule. A court-ordered admission or physician's emergency certificate alone does not justify Medicaid reimbursement for these services.

03.Severity of Illness Criteria. Both severity of illness and intensity of services criteria must be met for admission to an IMD or psychiatric unit of a general hospital.

a. Severity of illness criteria. The participant must meet one (1) of the following criteria related to the severity of their psychiatric illness:

i. Is currently dangerous to self as indicated by at least one (1) of the following:

(1) Has actually made an attempt to take their own life in the last seventy-two (72) hours (details of the attempt must be documented); or

(2) Has demonstrated self-mutilative behavior within the past seventy-two (72) hours (details of the behavior must be documented); or

(3) Has a clear plan to seriously harm himself, overt suicidal intent, and lethal means available to follow the plan (this information can be from the participant or a reliable source and details of the participant's plan must be documented); or

(4) The participant has a current plan, specific intent, or recurrent thoughts to seriously harm himself or others, and is at significant risk of making an attempt without immediate intervention; or

ii. Participant is actively violent or aggressive and exhibits homicidal ideation or other symptoms that indicate they are a probable danger to others as indicated by one (1) of the following:

(1) The participant has engaged in, or threatened, behavior harmful or potentially harmful to others or caused serious damage to property that would pose a serious threat of injury or harm to others within the last twenty-four (24) hours (description of the behavior and extent of injury or damage must be documented, as well as the time the behavior occurred relative to the present); or

(2) The participant has made threats to kill or seriously injure others or to cause serious damage to property that would pose a threat of injury or harm to others and has effective means to carry out the threats (details of threats must be documented); or

(3) A mental health professional has information from the participant or a reliable source that the participant has a current plan, specific intent, or recurrent thoughts to seriously harm others or property and is at significant risk of making the attempt without immediate intervention (details must be documented); or

iii. Participant is gravely impaired as indicated by at least one (1) of the following criteria:

(1) The participant has such limited functioning that their physical safety and well being are in jeopardy due to their inability for basic self-care, judgment, and decision making (details of the functional limitations must be documented); or

(2) The acute onset of psychosis or severe thought disorganization or clinical deterioration has rendered the participant unmanageable and unable to cooperate in non-hospital treatment (details of the participant's behaviors must be documented); or

(3) There is a need for treatment, evaluation, or complex diagnostic testing where the participant's level of functioning or communication precludes assessment or treatment, or both, in a non-hospital based setting, and may require close supervision of medication or behavior or both.

(4) The participant is undergoing severe or medically complicated withdrawal from alcohol, opioids, stimulants, or sedatives.

04.Intensity of Service Criteria. The participant must meet all of the following criteria related to the intensity of services needed for treatment.

a. Documentation that ambulatory care resources available in the community do not meet the treatment needs of the participant; and

b. The services provided can reasonably be expected to improve the participant's condition or prevent further regression so that inpatient services will no longer be needed; and

c. Treatment of the participant's condition requires services on an inpatient basis, including twenty-four (24) hour nursing observation.

d. Exceptions. The requirement to meet intensity of service criteria may be waived for first-time admissions if severity of illness is met and the physician is unable to make a diagnosis or treatment decision while the participant is in their current living situation. The waiver of the intensity of services requirement can be for no longer than forty-eight (48) hours and is not waivable for repeat hospitalizations.

05.Exclusions. If a participant meets one (1) or more of the following criteria, Medicaid reimbursement will be denied:

a. The participant is unable to actively participate in an outpatient treatment program solely because of a major medical condition, surgical illness or injury; or

b. The participant has a primary diagnosis of being intellectually disabled and the primary treatment need is related to the intellectual disability.

Idaho Admin. Code r. 16.03.09.701

Effective March 17, 2022