N.J. Admin. Code § 10:52-1.16

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:52-1.16 - Utilization control: inpatient psychiatric services for beneficiaries under 21 years of age in private psychiatric hospitals

(a) This section specifies the unique requirements for certification of the need for inpatient psychiatric services provided to beneficiaries under 21 years of age in private psychiatric hospitals. In accordance with Section 1905(a)16 and (h) of the Social Security Act, a team, consisting of physicians and other qualified personnel, shall determine that inpatient services are necessary and can reasonably be expected to improve the beneficiary's condition. This section also includes general requirements; certification of the need for services, which involves "active treatment" as defined in (c) below; requirements for the team certifying the need for services; and requirement for an individual plan of care. These requirements do not apply to an admission to a psychiatric unit of a general hospital. See 10:52-1.15 for requirements on utilization control in an acute care general hospital.

(b) This rule applies only to inpatient psychiatric services in an approved private psychiatric hospital for the treatment of children and youths before NJ FamilyCare-Children's Program beneficiaries reach age 19 and before the Medicaid beneficiary reaches age 21 or, if the Medicaid beneficiary was receiving the services immediately before he reached age 21, before the earlier of the following:

1. The date the beneficiary no longer requires the services; or

2. The date the beneficiary reaches age 22. (See 42 CFR 441.151) .

(c) The following words and terms, when used in this chapter, shall have the following meanings unless the context clearly indicates otherwise.

1. "Active treatment" means implementation of a professionally developed and supervised plan of care, as described in (f) below, that is:

i. Developed and implemented no later than 14 days after admission; and,

ii. Designed to achieve the beneficiary's discharge from inpatient status at the earliest possible time.

2. "Independent team" means a team that is not associated with the facility; for example, none of the members of the team has an employment or consultant relationship with the admitting facility. The independent team shall include a physician who has competence in diagnosis and treatment of mental illness, preferably child psychiatry and who has knowledge of the individual's clinical condition and situation.

3. "Interdisciplinary team," as described in Federal regulations in 42 CFR 441.156, is comprised of those employed by, or those who provide services to, Medicaid/NJ FamilyCare beneficiaries in the facility or program, and include, at a minimum, either a Board-eligible or Board-certified psychiatrist; or a physician and a clinical psychologist who has a doctoral degree; or a physician with specialized training and experience in the diagnosis and treatment of mental diseases, and a psychologist who has a Master's degree in clinical psychology or who has been certified by the State psychological association; and one of the following:

i. A psychiatric social worker;

ii. A registered nurse with specialized training or one year's experience in treating mentally ill individuals;

iii. A psychologist who has a Master's degree in clinical psychology or who has been certified by the State or by the State psychological association; or,

iv. An occupational therapist who is licensed by the State in which the individual is practicing, if applicable, and who has specialized training or one year experience in treating mentally ill individuals.

4. "Plan of care" means a written plan developed for each beneficiary to improve the beneficiary's condition to the extent that the beneficiary no longer needs inpatient care.

(d) Certification of the need for services (see 42 CFR 441.152) shall be made by a team, either independent or interdisciplinary, as specified in (e) below, and shall include the following statements: The team shall certify that:

1. Ambulatory care resources available in the community do not meet the treatment needs of the beneficiary;

2. Proper treatment of the beneficiary's psychiatric condition requires services on an inpatient basis under the direction of a physician; and

3. Services can reasonably be expected to improve the beneficiary's condition or prevent further regression so that inpatient services would no longer be needed.

(e) The certification of the need for services, as stated in (d) above, shall be made by teams, in accordance with Federal regulations, 42 CFR 441.153 and specified as follows:

1. Certification for the admission of an individual who is a beneficiary when admitted to a facility or program shall be made by an independent team, as described in (c) above.

2. Certification for an inpatient applying for Medicaid/NJ FamilyCare while in the facility or program shall be made by an interdisciplinary team responsible for the plan of care and as described in (c) above.

3. Certification of an emergency admission of a beneficiary shall be made by the interdisciplinary team responsible for the plan of care, in accordance with Federal regulation, 42 CFR 441.156, and as described in (f)1 below.

(f) Within 14 days of admission to a private psychiatric hospital, or before authorization for payment, the attending physician or staff physician must establish a written plan of care for each applicant or beneficiary to improve the beneficiary's condition to the extent that inpatient care no longer is necessary, in accordance with (e) above. (See 42 CFR 456.180 and 456.181.)

1. The plan of care shall:

i. Be based on a diagnostic evaluation that includes examination of the medical, psychological, social, behavioral and developmental aspects of the beneficiary's clinical condition and situation and reflects the beneficiary's need for inpatient psychiatric care;

ii. Be developed by a team of professionals as described in (g) below in consultation with the beneficiary, the beneficiary's parents, legal guardians or others in whose care he or she will be released after discharge;

iii. State treatment objectives;

iv. Prescribe an integrated program of therapies, activities and experiences designed to meet the beneficiary's treatment objectives; and

v. Include, at an appropriate time, post discharge plans and coordination of inpatient services with the partial discharge plan and related community services to ensure continuity of care with the beneficiary's family, school, and community upon discharge.

2. The plan shall be reviewed every 30 days by the team to:

i. Determine that services being provided are or were required on an inpatient basis; and,

ii. Recommend changes in the plan as indicated by the beneficiary's overall adjustments as an inpatient.

(g) Functions of the interdisciplinary team developing the individual plan of care are as follows:

1. The individual plan of care as described under 42 CFR 441.155, shall be developed by an interdisciplinary team of physicians and other personnel who are employed by, or provide services to, patients in the psychiatric hospital.

2. Based on education and experience, preferably including competence in child psychiatry, the team shall be capable of the following:

i. Assessing the beneficiary's immediate and long-range therapeutic needs, developmental priorities and personal strengths and liabilities;

ii. Assessing the potential resources of the beneficiary's family;

iii. Setting treatment objectives; and,

iv. Prescribing therapeutic modalities to achieve the plan's objectives.

N.J. Admin. Code § 10:52-1.16

Amended by 50 N.J.R. 1261(a), effective 5/21/2018