10A NCAC 22O .0112       PSYCHIATRIC ADMISSION CRITERIA/MEDICAID BENEFICIARIES UNDER AGE 21

Medicaid criteria for the admission of those persons under age 21 to psychiatric hospitals or psychiatric units of general hospitals is limited herein.  To be approved for admission, the patient must meet criteria in Items (1), (2) and (3) of this Rule as follows:

(1)           Client meets criteria for one or more DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ‑‑ a manual whose purpose is to provide clear descriptions of diagnostic categories in order to enable clinicians and investigators to diagnose, communicate about, study, and treat various mental disorders) diagnoses. This manual is hereby incorporated by reference including subsequent amendments and editions.  Copies may be obtained from the American Psychiatric Association 1400 K Street, NW Washington, DC 2000 tel: 1-800-368-5777 at a cost of fifty-four dollars and ninety-five cents ($54.95) (hard cover); forty-two dollars and ninety-five cents ($42.95) (soft cover); five dollars ($5.00) s. and h.  The manual is available for inspection at the Division of Medical Assistance 1985 Umstead Dr., Raleigh, NC; and

(2)           At least one of the following criteria:

(a)           Client is presently a danger to self (e.g., engages in self‑injurious behavior, has a significant suicide potential, or is acutely manic).  This usually would be indicated by one of the following:

(i)            Client has made a suicide attempt or serious gesture (e.g., overdose, hanging, jumping from or placing self in front of moving vehicle, self‑inflicted gunshot wound), or is threatening same with likelihood of acting on the threat, and there is an absence of supervision or structure to prevent suicide of the client who has made an attempt, serious gesture or threat.

(ii)           Client manifests a significant depression, including current contemplation of suicide or suicidal ideation, and there is an absence of supervision or structure to prevent suicide.

(iii)          Client has a history of affective disorder:

(A)          with mood which has fluctuated to the manic phase, or

(B)          has destabilized due to stressors or non‑compliance with treatment.

(iv)          Client is exhibiting self‑injurious behavior (cutting on self, burning self) or is threatening same with likelihood of acting on the threat; or

(b)           Client engages in actively violent, aggressive or disruptive behavior or client exhibits homicidal ideation or other symptoms which indicate he is a probable danger to others.  This usually would be indicated by one of the following:

(i)            Client whose evaluation and treatment cannot be carried out safely or effectively in other settings due to impulsivity, impaired judgment, severe oppositionalism, running away, severely disruptive behaviors at home or school, self‑defeating and self‑endangering activities, antisocial activity, and other behaviors which may occur in the context of a dysfunctional family and may also include physical, psychological, or sexual abuse.

(ii)           Client exhibits serious aggressive, assaultive, or sadistic behavior that is harmful to others (e.g., assaults with or without weapons, provocations of fights, gross aggressive over‑reactivity to minor irritants, harming animals) or is threatening same with likelihood of acting on the threat.  This behavior should be attributable to the client's specific DSM‑IV diagnosis and can be treated only in a hospital setting; or

(c)           Acute onset of psychosis or severe thought disorganization or clinical deterioration in condition of chronic psychosis rendering the client unmanageable and unable to cooperate in treatment.  This usually would be indicated by the following:  Client has recent onset or aggravated psychotic symptoms (e.g., disorganized or illogical thinking, hallucinations, bizarre behavior, paranoia, delusions, incongruous speech, severely impaired judgment) and is resisting treatment or is in need of assessment in a safe and therapeutic setting; or

(d)           Presence of medication needs, or a medical process or condition which is life‑threatening (e.g., toxic drug level) or which requires the acute care setting for its treatment.  This usually would be indicated by one of the following:

(i)            Proposed treatments require close medical observation and monitoring to include, but not limited to, close monitoring for adverse medication effects, capacity for rapid response to adverse effects, and use of medications in clients with concomitant serious medical problems.

(ii)           Client has a severe eating disorder or substance abuse disorder which requires 24‑hour‑a‑day medical observation, supervision, and intervention.

(iii)          Client has Axis I or Axis II diagnosis, with a complicating or interacting Axis III diagnosis, the combination of which requires psychiatric hospitalization in keeping with any one of these criteria, and with the Axis III diagnosis treatable in a psychiatric setting (e.g., diabetes, malignancy, cystic fibrosis); or

(e)           Need for medication therapy or complex diagnostic evaluation where the client's level of functioning precludes cooperation with the treatment regimen, including forced administration of medication.  This usually would be indicated by one of the following:

(i)            Client whose diagnosis and clinical picture is unclear and who requires 24 hour clinical observation and assessment by a multi‑disciplinary hospital psychiatric team to establish the diagnosis and treatment recommendations.

(ii)           Client is involved in the legal system (e.g., in a detention or training school facility) and manifests psychiatric symptoms (e.g., psychosis, depression, suicide attempts or gestures) and requires a comprehensive assessment in a hospital setting to clarify the diagnosis and treatment needs; and

(3)           To meet the federal requirement at 42 CFR 441. 152, all of the following must apply:

(a)           Ambulatory care resources available in the community do not meet the treatment needs of the recipient.

(b)           Proper treatment of the recipient's psychiatric condition requires services on an inpatient basis under the direction of a physician.

(c)           The services can reasonably be expected to improve the recipient's condition or prevent further regression so that services will no longer be needed.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 441, Subpart D; 42 C.F.R. 441.151;

Eff. October 1, 1993;

Amended Eff. February 1, 1996.