The Kentucky Department for Medicaid Services funds mental health and mental retardation services, in conjunction with the Department of Mental Health/Mental Retardation Services, operates several inpatient facilities which provide psychiatric, rehabilitative, and nursing care services to its clients. These program s provide acute, inpatient psychiatric care for adults who are mentally ill.
Inpatient psychiatric hospital services must involve active treatment which is reasonably expected to improve the patient's condition or prevent further regression, so that eventually such services will no longer be necessary.
Periodic medical and social evaluations should determine at what point a patient's progress has reached the stage where his/her needs can be met appropriately outside the institution.
Federal regulations emphasize "active treatment" as one of the necessary elements of inpatient services. Active treatment is defined as the implementation of a professionally developed individual plan of care which sets forth treatment objectives and therapies enabling the individual's functioning to improve to the point that institutional care is no longer necessary.
Limitations of Service
- Admissions for diagnostic purposes are covered only if the diagnostic procedures cannot be performed on an outpatient basis.
- Patients may be permitted home visits; however, this must be clearly documented on billing statements as payment cannot be made for these days.
- Private accommodations will be reimbursed only if medically necessary and so ordered by the attending physician.
- The physician's orders for and description of reasons for private accommodations must be maintained in the recipient's medical records. If a private room is the only room available, payment will be made until another room becomes available. If all rooms on a particular floor or unit are private rooms, payment will be made.
Federal regulations instruct that recipients may remain in a mental hospital only so long as there is a certified psychiatric need or such hospitalization can be expected to benefit them by effecting clinical recovery or significant symptomatic improvement.
The following may be used as general guidelines in determining whether a recipient meets the criteria for mental hospital benefits:
- Patients with functional psychoses without significant concurrent illness for whom general hospital care or outpatient care is not feasible.
- Patients who require brief periods of protection from the consequences of their behavior during episodes of acute disturbance or depression (suicide, homicide, refusal to eat, etc.).
- Patients with acute or chronic psychiatric illness who require 24 hour care for diagnostic evaluation and psychiatric treatment.
- Patients with chronic mental illness who require protection and management, as well as treatment during periods of disruptive behavior requiring regular and frequent attendance of a physician.
- Patients with severe organic brain disease whose usual behavior is unresponsive to medication, and is too disturbing to be managed at home or in another facility, such as physically aggressive patient or person dangerous to himself.
- Patients who during episodes of agitation or restlessness produced by a stress situation may require brief mental hospital treatment.
The following care needs do not meet the criteria for mental hospital care:
- Persons with major medical problems and minor symptoms, or for whom pmatric consultation might be utilized rather than mental hospital admission.
- Persons with inconsequential lapses of memory and mild disorientation as a result of chronic brain syndrome, who are more effectively treated or managed in their own homes, long term care facility, etc., and for whom a mental hospital has little to offer and may even aggravate their confusion.
- Patients who need only adequate living accommodations, economic aid, or social support services.
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