Inpatient Psychiatric Hospitals and Psychiatric Residential Treatment Facilities
The following words and terms, when used in Sections OAC 317:30-5-96.3 through 317:30-5-96.7 of the OHCA Rules, shall have the following meaning, unless the context clearly indicates otherwise:
"Allowable costs" means costs necessary for the efficient delivery of patient care.
"Ancillary Services" means the services for which charges are customarily made in addition to routine services. Ancillary services include, but are not limited to, physical therapy, speech therapy, laboratory, radiology and prescription drugs.
"Border Status" means a placement in a state that does not border Oklahoma but agrees to the same terms and conditions of instate or border facilities.
"Community-Based extended" means a PRTF that provides an extended environment for individuals who have completed a more intense treatment program and are preparing for full transition into the community, but who are not yet ready for independent living due to unresolved clinical issues, or unmet needs for personal, social, or vocational skills, that is furnished in a large campus residential setting.
"Community-Based, transitional" means a PRTF that furnishes structured, therapeutic treatment services in the context of a family-like, small multiple resident home environment of 16 beds or less.
"Developmentally disabled child" means a child with deficits in adaptive behavior originating during the developmental period. This condition may exist concurrently with a significantly sub-average general intellectual functioning.
"Eating Disorders Programs" means acute or intensive residential behavioral, psychiatric and medical services provided in a discreet unit to individuals experiencing an eating disorder.
"Free-standing" means an entity that is not integrated with any other entity as a main provider, a department of a provider, remote location of a hospital, satellite facility, or a provider-based entity.
"Professional services" means services of a physician, psychologist or dentist legally authorized to practice medicine and/or surgery by the state in which the function is performed.
"Provider-Based PRTF" means a PRTF that is part of a larger general medical surgical main hospital, and the PRTF is treated as "provider based" under 42 CFR 413.65 and operates under the same license as the main hospital.
"Public" means a hospital or PRTF owned or operated by the state.
"Routine Services" means services that are considered routine in the freestanding PRTF setting. Routine services include, but are not limited to:
(A) room and board;
(B) treatment program components;
(C) psychiatric treatment;
(D) professional consultation;
(E) medical management;
(F) crisis intervention;
(H) rehabilitative services;
(I) case management;
(J) interpreter services (if applicable);
(K) routine health care for individuals in good physical health; and
(L) laboratory services for a substance abuse/detoxification program.
"Specialty treatment program/specialty unit" means acute or intensive residential behavioral, psychiatric and medical services that provide care to a population with a special need or issues such as developmentally disabled, mentally retarded, autistic/Asperger's, eating disorders, sexual offenders, or reactive attachment disorders. These patients require a higher level of care and staffing ratio than a standard PRTF and typically have multiple problems.
"Sub-Acute Services" means a planned regimen of 24-hour professionally directed evaluation, care, and treatment for individuals. Care is delivered by an interdisciplinary team to individuals whose sub-acute neurological and emotional/behavioral problems are sufficiently severe to require 24-hour care. However, the full resources of an acute care general hospital or medically managed inpatient treatment is not necessary. An example of subacute care is services to children with pervasive developmental disabilities including autism, hearing impaired and dually diagnosed individuals with mental retardation and behavioral problems.
"Treatment Program Components" means therapies, activities of daily living and rehabilitative services furnished by physician/psychologist or other licensed mental health professionals.
"Usual and customary charges" refers to the uniform charges listed in a provider's established charge schedule which is in effect and applied consistently to most patients and recognized for program reimbursement. To be considered "customary" for Medicaid reimbursement, a provider's charges for like services must be imposed on most patients regardless of the type of patient treated or the party responsible for payment of such services.
317:30-5-96.3.Methods of payment
(a) Reimbursement. Covered inpatient psychiatric and/or substance abuse services rendered on or after October 1, 2005, will be reimbursed using one of the following methodologies:
(1) Diagnosis Related Group (DRG);
(2) cost based; or
(3) a predetermined per diem payment.
(b) Acute Level of Care.
(1) Psychiatric units within general medical surgical hospitals and Critical Access hospitals. Payment will be made utilizing a DRG methodology. [See OAC 317:30-5-41(1)(B)];
(2) Freestanding Psychiatric Hospitals and Psychiatric Units within Rehabilitation Hospitals. A predetermined statewide per diem payment will be made. Rates vary for public and private providers.
(c) Psychiatric Residential Treatment Facility (PRTF).
(1) Instate Levels of Service.
(A) Community-Based, extended. A pre-determined all-inclusive per diem payment will be made for routine, ancillary and professional services.
(B) Community-Based, transitional. A pre-determined per diem payment will be made for routine services. All other services are separately billable.
(C) Freestanding, Private. A predetermined all-inclusive per diem payment will be made for routine, ancillary and professional services.
(D) Freestanding, Public. Facilities will be reimbursed using either the statewide or facility specific interim rates and settled to total allowable costs as determined by analyses of the cost reports (Form CMS 2552) filed with the OHCA.
(E) Provider based. A predetermined all-inclusive per diem payment will be made for routine, ancillary and professional services.
(2) Out-of-state services.
(A) Border and "border status" placements. Facilities are reimbursed in the same manner as in-state PRTFs.
(B) Out-of-state placements. In the event comparable services cannot be purchased from an Oklahoma facility and the current payment levels are insufficient to obtain access for the member, the OHCA may negotiate a predetermined, all-inclusive per diem rate for specialty programs/units and/or subacute services. An incremental payment adjustment may be made for 1:1 staffing (if clinically appropriate and prior authorized). Payment may be up to, but no greater, than usual and customary charges.