Current through Vol. 42, No. 1, September 16, 2024
(a)
Eligible
settings for inpatient psychiatric services. The following individuals
may receive SoonerCare-reimbursable inpatient psychiatric services in the
following eligible settings:
(1) Individuals
under twenty-one (21) years of age, in accordance with OAC
317:30-5-95.23, may receive
SoonerCare-reimbursable inpatient psychiatric services in a psychiatric unit of
a general hospital, a psychiatric hospital, or a PRTF; and may receive chemical
dependency detoxification/withdrawal management services in a psychiatric unit
of a general hospital or in a psychiatric hospital.
(2) Individuals ages twenty-one (21) and
older may receive SoonerCare-reimbursable inpatient psychiatric and/or chemical
dependency detoxification/withdrawal management services in a psychiatric unit
of a general hospital or in a psychiatric hospital.
(b)
Psychiatric hospitals and
psychiatric units of general hospitals. To be eligible for payment under
this Part, inpatient psychiatric programs must be provided to eligible
SoonerCare members in a hospital that:
(1) Is
a psychiatric hospital that:
(A) Successfully
underwent a State survey to determine whether the hospital meets the
requirements for participation in Medicare as a psychiatric hospital per
42 C.F.R. §
482.60; or
(B) Is accredited by a national organization
whose psychiatric accrediting program has been approved by CMS;
or
(2) Is a general
hospital with a psychiatric unit that:
(A)
Successfully underwent a State survey to determine whether the hospital meets
the requirements for participation in Medicare as a hospital as specified in 42
C.F.R. Part 482 ; or
(B) Is
accredited by a national accrediting organization whose accrediting program has
been approved by CMS; and
(3) Meets all applicable federal regulations,
including, but not limited to:
(A) Medicare
Conditions of Participation for Hospitals (42 C.F.R. Part 482), including
special provisions applying to psychiatric hospitals (42 C.F.R. §
482.60 -.62);
(B) Medicaid for Individuals Age 65 or over
in Institutions for Mental Diseases ( 42 C.F.R. Part 441 , Subpart
C);
(C) Inpatient Psychiatric
Services for Individuals under Age 21 in Psychiatric Facilities or Programs (42
C.F.R. Part 441, Subpart D); and/or
(D) Utilization Control [ 42 C.F.R. Part 456
, Subpart C (Utilization Control: Hospitals) or Subpart D (Utilization Control:
Mental Hospitals)]; and
(4) Is contracted with the OHCA;
and
(5) If located within Oklahoma
and serving members under eighteen (18) years of age, is appropriately licensed
by the Oklahoma Department of Human Services (OKDHS) as a residential child
care facility (10 O.S. §§ 401 to 402) that is providing services as a
residential treatment facility in accordance with OAC
340:110-3-168.
(6) If located out of state, services must be
provided within the licensure for each facility and scope of practice for each
provider and supervising or rendering practitioner for the state in which the
facility/provider is located. Services must be in compliance with the
state-specific statutes, rules and regulations of the applicable practice
act.
(c)
PRTF. Every PRTF must:
(1) Be
individually contracted with OHCA as a PRTF;
(2) Meet all of the state and federal
participation requirements for SoonerCare reimbursement, including, but not
limited to, 42 C.F.R. §
483.354, as well as all requirements in
42 C.F.R.
483 Subpart G governing the use of restraint
and seclusion;
(3) Be appropriately
licensed and/or certified:
(A) If an in-state
facility, by OKDHS as a residential child care facility (10 O.S. § 401 to
402) that is providing services as a residential treatment facility in
accordance with OAC
340:110-3-168; or
(B) If an out-of-state facility, by the
licensing or certifying authority of the state in which the facility does
business and must provide an attestation to OHCA that the PRTF is in compliance
with the condition of participation for restraint and seclusion, as is required
by federal law.
(4) Be
appropriately certified by the State Survey Agency, the Oklahoma State
Department of Health (OSDH) as meeting Medicare Conditions of Participation;
and
(5) Be accredited by TJC, the
Council on Accreditation of Rehabilitation Facilities (CARF), or the Council on
Accreditation (COA).
(d)
Required documents. The required documents for enrollment for each
participating provider can be downloaded from the OHCA's website.
Added at 17 Ok Reg
3469, eff 8-01-00 (emergency); Added at 18 Ok Reg 1130, eff 5-11-01; Amended at
19 Ok Reg 2138, eff 6-27-02; Amended at 23 Ok Reg 2508, eff 6-25-06; Amended at
24 Ok Reg 2880, eff 7-1-07 (emergency); Amended at 25 Ok Reg 1161, eff 5-25-08;
Amended at 27 Ok Reg 111, eff 10-2-09 (emergency); Amended at 27 Ok Reg 964,
eff 5-13-10; Amended at 27 Ok Reg 2737, eff 7-20-10 (emergency); Amended at 28
Ok Reg 1452, eff 6-25-11
