Okla. Admin. Code § 317:30-5-241.9

Current through Vol. 42, No. 4, November 1, 2024

Section 317:30-5-241.9 - Partial hospitalization program (PHP) - Children/Adolescent

(a)Definition. Partial hospitalization is an intermediary, stabilizing step for children and adolescents who have had inpatient psychiatric hospitalization prior to returning to school and community supports or as a less restrictive alternative when inpatient treatment may not be indicated. PHP services are:

(1) Reasonable and necessary for the diagnosis or active treatment of the member's condition; and

(2) Reasonably expected to improve the member's condition and functional level and to prevent relapse or hospitalization.

(b)Eligibility criteria. This service must be prior authorized by OHCA or its designated agent, and individuals must meet ongoing medical necessity criteria. Treatment is time limited, and length of participation is based on the individual's needs.

(c)Eligible providers. Provider agencies for PHP must be accredited to provide partial hospitalization services by The Joint Commission (TJC), the Commission on Accreditation of Rehabilitation Facilities (CARF), the Accreditation Commission for Health Care (ACHC) or The Council on Accreditation (COA) for partial hospitalization and enrolled in SoonerCare. Staff providing these services are employees or contractors of the enrolled agency. The agency is responsible for ensuring that all services are provided by properly credentialed clinicians.

(d)Qualified practitioners. Program services are overseen by a psychiatrist. The number of professionals and paraprofessionals required on the clinical team is dependent on the size of the program. The clinical team includes the following required professionals:

(1) A licensed physician, physician's assistant, or advanced practice registered nurse [any of whom meet the requirements of an LBHP as described at OAC 317:30-5-240.3(a)] ;

(2) Registered nurse; and

(3) One (1) or more LBHPs or licensure candidates listed in OAC 317:30-5-240.3(a) and (b).

(4) The clinical team may also include a certified behavioral health case manager.

(e)Service components. PHP includes the following services:

(1) Assessment, diagnostic and service plan services for mental illness and/or substance use disorders provided by LBHPs or licensure candidates;

(2) Individual/group/family (primary purpose is treatment of the member's condition) psychotherapies provided by LBHPs or licensure candidates;

(3) Substance use disorder specific services are provided by LBHPs or licensure candidates qualified to provide these services;

(4) Drugs and biologicals furnished for therapeutic purposes;

(5) Family counseling, the primary purpose of which is treatment of the member's condition;

(6) Behavioral health rehabilitation services to the extent the activities are closely and clearly related to the member's care and treatment, provided by a certified behavioral health case manager II, certified alcohol and drug counselor (CADC), LBHP, or licensure candidate who meets the professional requirements listed in OAC 317:30-5-240.3; and

(7) Care coordination of behavioral health services provided by certified behavioral health case managers.

(f)Limitations. Services are subject to the following:

(1) Children under age six (6) are not eligible for behavioral health rehabilitation services unless a prior authorization for children ages four (4) and five (5) has been granted by OHCA or its designated agent based on a finding of medical necessity.

(2) Services must be offered at a minimum of three (3) hours per day, five (5) days per week.

(3) Therapeutic services are limited to four (4) billable hours per day.

(4) Group size is limited to a maximum of eight (8) individuals as clinically appropriate given diagnostic and developmental functioning.

(5) Occupational, physical and speech therapy will be provided by the Independent School District (ISD). Academic instruction, meals, and transportation are not covered.

(6) PHP services cannot be billed in conjunction with the following:

(A) Children's psychosocial rehabilitation services;

(B) Residential services [psychiatric residential treatment facility (PRTF) or residential behavior management services (RBMS)];

(C) Targeted case management (TCM);

(D) Individual, family, or group therapy;

(E) Mobile crisis intervention within the PHP setting;

(F) Peer-to-peer services;

(G) Certified Community Behavioral Health (CCBH) services;

(H) Day treatment;

(I) Multi-systemic therapy (MST);

(J) Program of Assertive Community Treatment (PACT) [Applicable for individuals eighteen (18) to twenty-one (21) years of age].

(g)Service requirements. This service includes:

(1) Therapeutic services that include the following:

(A) Psychiatrist/physician face-to-face visit two (2) times per month; and

(B) Crisis management services available twenty-four (24) hours a day, seven (7) days a week.

(2) Psychotherapies that are provided at a minimum of four (4) hours per week and include the following:

(A) Individual therapy - a minimum of one (1) session per week;

(B) Family therapy - a minimum of one (1) session per week; and

(C) Group therapy - a minimum of two (2) sessions per week.

(3) Interchangeable services that include the following:

(A) Behavioral health case management (face-to-face);

(B) Behavioral health rehabilitation services/alcohol and other drug abuse education, except for children under age six (6), unless a prior authorization has been granted for children ages four (4) and five (5);

(C) Medication training and support; and

(D) Expressive therapy.

(h)Documentation requirements. Documentation needs to specify active involvement of the member's family, caretakers, or significant others involved in the individual's treatment. A nursing health assessment must be completed within twenty-four (24) hours of admission. A physical examination and medical history must be coordinated with the primary care physician. Service plan updates are required every three (3) months or more frequently based on clinical need. Records must be documented according to OAC 317:30-5-248.

(i)Staffing requirements. Staffing must consist of the following:

(1) A registered nurse (RN) trained and competent in the delivery of behavioral health services as evidenced by education and/or experience that is available on-site during program hours to provide necessary nursing care and/or psychiatric nursing care [one (1) RN at a minimum can be backed up by a licensed practical nurse (LPN) but an RN must always be on site]. Nursing staff administers medications, follows up with families on medication compliance, and completes restraint assessments;

(2) Medical director must be a licensed psychiatrist;

(3) A psychiatrist/physician must be available twenty-four (24) hours a day, seven (7) days a week.

(4) One (1) or more LBHPs or licensure candidates listed in OAC 317:30-5-240.3(a) and (b).

(j)Reimbursement. PHP services are reimbursed pursuant to the methodology described in the Oklahoma Medicaid State Plan. PHP reimbursement is all-inclusive of the service components, except for the following:

(A) Physician services;

(B) Medications;

(C) Psychological testing by a licensed psychologist.

Okla. Admin. Code § 317:30-5-241.9

Adopted by Oklahoma Register, Volume 39, Issue 24, September 1, 2022, eff. 9/12/2022