SUBCHAPTER 22O ‑ MEDICAL ASSISTANCE PROVIDED

 

SECTION .0100 ‑ GENERAL

 

10A NCAC 22O .0101 HOSPITAL INPATIENT

 

History Note: Authority G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.10;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. January 1, 1984;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

10A NCAC 22O .0102 HOSPITAL OUTPATIENT (Transferred to 10A NCAC 25M .0301)

 

10A NCAC 22O .0103 HOME HEALTH SERVICES (transferred to 10a ncac 25O .0201(a))

 

10A NCAC 22O .0104 LABORATORY AND X‑RAY SERVICES (Items (1)-(3) transferred to 10A NCAC 25P .0406 and Items (4)-(5) transferred to 10A NCAC 25U .0201))

 

10A NCAC 22O .0105 EYEGLASSES AND OPTOMETRIC SERVICES (transferred to 10A NCAC 25N .0301)

 

10A NCAC 22O .0106 CHIROPRACTIC SERVICES (Transferred to 10A NCAC 25P .0403)

 

10A NCAC 22O .0107 MENTAL HEALTH CENTER SERVICES (transferred to 10A NCAC 25C .0201)

 

10A NCAC 22O .0108 INTERMEDIATE CARE FACILITIES (transferred to 10A NCAC 25D .0201(a)-(b))

 

10A NCAC 22O .0109 HEARING AID SERVICES (TRANSFERRED TO 10A NCAC 25N .0201)

 

10A NCAC 22O .0110 AMBULANCE SERVICES (transferred to 10A ncac 25w .0201)

 

10A NCAC 22O .0111 INPATIENT PSYCHIATRIC HOSPITAL SERVICES (Transferred to 10A NCAC 25C .0301)

 

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.

 

10A NCAC 22O .0113 NC MEDICAID CRITERIA FOR CONTINUED ACUTE STAY IN AN INPATIENT PSYCHIATRIC FACILITY (Transferred to 10A NCAC 25C .0302)

 

10A NCAC 22O .0114 NORTH CAROLINA SPECIALTY HOSPITAL SERVICES (Transferred to 25M .0201(e))

 

10A NCAC 22O .0115 CLINIC SERVICES (transferred to 10A NCAC 25P .0402)

 

10a ncac 22o .0116 skilled nursing facility (transferred to 10a ncac 25m .0401(a)-(c))

 

10a NCAC 22O .0117 ABORTION (Transferred to 10A NCAC 25P .0405)

 

10A NCAC 22O .0118 PHARMACY SERVICES (transferred to 10A NCAc 25K .0201)

 

10A NCAC 22O .0119 OUT‑OF‑STATE SERVICES (transferred to 10A NCAc 25S .0201)

 

10A NCAC 22O .0120 PERSONAL CARE SERVICES (transferred to 10A NCAC 25O .0202(a)-(b))

 

10A NCAC 22O .0121 DURABLE MEDICAL EQUIPMENT

 

History Note: Authority G.S. 108A‑25(b); 42 C.F.R. 440.70(b)(3);

Eff. March 1, 1990;

Amended Eff. March 1, 1993;

Recodified from 10 NCAC 26B .0120 Eff. October 1, 1993;

Recodified from 10 NCAC 26B .0121 Eff. January 1, 1998;

Repealed Eff. September 1, 2005.

 

10A NCAC 22O .0122 PRIVATE DUTY NURSING (transferred to 10A NCAC 25O .0204)

 

10A NCAC 22O .0123 Case MGMT SVCS/Adults/Children AT-Risk/abuse/neglect/expoitation (transferred to 10a ncac 25f .0201)

 

10A NCAC 22O .0124 HIV CASE MANAGEMENT (Transferred to 10A NCAC 25F .0301)

 

10A NCAC 22O .0125 HOME INFUSION THERAPY (transferred to 10A NCAC 25O .0203)

 

SECTION .0200 ‑ DENTAL SERVICES

 

10A NCAC 22O .0201 DEFINITIONS (transferred to 10A NCAC 25H .0201)

 

10a NCAC 22O .0202 STANDARDS FOR PARTICIPATION (Transferred to 10A NCAC 25H .0203)

 

10a NCAC 22O .0203 ELIGIBILITY (Transferred to 10A NCAC 25H .0202)

 

10A NCAC 22O .0204 AMOUNT: DURATION: AND SCOPE OF SERVICES (Transferred to 10A NCAC 25H .0204)

 

10a NCAC 22O .0205 RESTRICTIONS AND PRIOR APPROVAL (Transferred to 10a NCAC 25H .0205)

 

10A NCAC 22O .0206 GUIDELINES ON SERVICES (Transferred to 10A NCAC 25H .0301)

 

10a NCAC 22O .0207 SPECIFIC GUIDELINES (Transferred to 10a NCAC 25H .0302)

 

10A NCAC 22O .0208 ANESTHESIA (Transferred to 10A NCAC 25H .0303)

 

10A NCAC 22O .0209 ANALGESIA (Transferred to 10A NCAC 25H .0304)

 

10A NCAC 22O .0210 DRUGS (Transferred to 10a NCAC 25H .0305)

 

10a NCAC 22O .0211 PRIOR APPROVAL (Transferred To 10A NCAC 25H .0206)

 

section .0300 Amount, duration, and scope of assistance

 

10A NCAC 22O .0301 MEDICAL SERVICES (Transferred to 10A NCAC 25A .0201)

 

section .0400 limitation of amount, duration, and scope of assistance

 

10A NCAC 22O .0401 INPATIENT HOSPITAL SERVICES (Paragraphs (a)-(d) Transferred to 10A NCAC 25M .0201 and paragraph (e) transferred to 10A NCAC 25P .0201))

 

10a NCAC 22O .0402 OUTPATIENT HOSPITAL SERVICES (transferred to 10A NCAC 25P .0301)

 

10A NCAC 22O .0403 SKILLED NURSING FACILITY SERVICES (transferred to 10A NCAC 25M .0401(d))

 

10A NCAC 22O .0404 PHYSICIAN SERVICES (transferred to 10A NCAC 25P .0401)

 

10A NCAC 22O .0405 PODIATRIST SERVICES (transferred to 10A NCAC 25P .0404)

 

10A NCAC 22O .0406 HOME HEALTH SERVICES (Transferred to 10A NCAC 25O .0201(b)-(e))

 

10A NCAC 22O .0407 PRESCRIBED DRUGS

 

History Note: Authority G.S. 108A‑25(b); 143B‑10; S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.120; 42 C.F.R. 440.230(d)

Eff. February 1, 1976

Amended Eff. October 1, 1977;

Readopted Eff. October 31, 1977

Amended Eff. May 1, 1990; August 1, 1983; April 1, 1982;

Repealed Eff. April 1, 2010.

 

10A NCAC 22O .0408 INTERMEDIATE CARE FACILITIES (transferred to 10A NCAC 25D .0201(c)-(j))

 

10A NCAC 22O .0409 Therapeutic Leave (Transferred to 10A NCAC 25m .0501)

 

10A ncac 22o .0410 personal care services (transferred to 10a ncac 25o .0202(c)-(e))