[Federal Register Volume 60, Number 44 (Tuesday, March 7, 1995)]
[Rules and Regulations]
[Pages 12419-12438]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-5375]
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DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
RIN 0720-AA23
Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS); Mental Health Services
agency: Office of the Secretary, DoD.
action: Final rule.
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summary: This final rule is to reform CHAMPUS quality of care standards
and reimbursement methods for inpatient mental health services. The
rule updates existing standards for residential treatment centers
(RTCs) and establishes new standards for approval as CHAMPUS-authorized
providers for substance use disorder rehabilitation facilities (SUDRFs)
and partial hospitalization programs (PHPs); implements recommendations
of the Comptroller General of the United States that DoD establish
cost-based reimbursement methods for psychiatric hospitals and
residential treatment facilities; adopts another Comptroller General
recommendation that DoD remove the current incentive for the use of
inpatient mental health care; and eliminates payments to residential
treatment centers for days in which the patient is on a leave of
absence.
dates: This rule is effective April 6, 1995, except amendments to
Sec. 199.4 which are effective October 1, 1995.
addresses: Office of the Civilian Health and Medical Program of the
Uniformed Services (OCHAMPUS), Office of Program Development; Aurora,
Colorado 80045-6900.
for further information contact: CAPT Deborah Kamin, NC, USN, Office of
the Assistant Secretary of Defense (Health Affairs), (703) 697-8975.
Questions regarding payment of specific claims should be addressed
to the appropriate CHAMPUS contractor.
supplementary information: Provisions of this rule apply to the CHAMPVA
(Civilian Health and Medical Program of the Department of Veterans
Affairs) in the same manner as they apply to CHAMPUS.
I. Introduction
Quality assurance and cost effectiveness of mental health care
services under CHAMPUS continue to be major reform issues for the
Defense Department and Congress. In recent years, a series of DoD
initiatives, legislative and regulatory actions, and Congressional
hearings have spotlighted both progress made and the need for more
improvement.
Two recent Comptroller General Reports are indicative of the
importance of these issues and the need for reform. The first of these,
``Defense Health Care: Additional Improvements Needed in CHAMPUS's
Mental Health Program,'' GAO/HRD-93-34, May 1993, stated that, although
DoD has taken actions to improve the program ``several problems
persist.'' The Report (hereafter referred to as ``GAO Report #1'')
elaborated:
For example, reviews of medical records have identified numerous
instances of poor medical record documentation, potentially
inappropriate admissions, excessive hospital stays, and poor-quality
care. Also, inspections of RTCs [Residential Treatment Centers]
continue to reveal significant health and safety problems, and
corrective actions often take many months.
Moreover, DoD * * * pays considerably higher rates for
comparable services than do other public programs.
GAO Report #1, p. 2. The Report referenced the General Accounting
Office's 1991 Congressional testimony regarding CHAMPUS mental health
care and inspections of residential treatment facilities conducted for
DoD since then:
Inspections conducted since our 1991 testimony have identified
some of the same problems we described then: unlicensed and
unqualified staff, inappropriate use of seclusion and medication,
inadequate staff-to-patient ratios, and inadequate documentation of
treatment.
The principal conclusions of this Report were: (1) ``Standards,
which include termination for noncompliance, should be specified and
termination proceedings, time frames, and reinspection provisions * * *
should be adopted;'' and (2) because ``DoD reimburses psychiatric
hospitals and RTCs at higher rates than do other government payers, it
should modify its payment system to more closely resemble other
programs such as Medicare.'' GAO Report #1, p. 9.
A second recent Comptroller General Report, ``Psychiatric Fraud and
Abuse: Increased Scrutiny of Hospital Stays Is Needed to Lessen Federal
Health Program Vulnerability,'' GAO/HRD-93-92, September 1993, also
called for improvements in the CHAMPUS mental health program. The
Report (hereafter referred to as GAO Report #2) said:
Investigations to date have revealed that federal health
programs have been subject to fraudulent and abusive psychiatric
hospital [[Page 12420]] practices, but apparently to a lesser extent
than private insurers * * *
Some federal control weaknesses do exist which have resulted in
unnecessary hospital admissions, excessive stays, and sometimes
inadequate quality of care * * *
DOD has also identified numerous instances of quality problems
and unnecessary hospital admissions.
GAO Report #2, pp. 9-10.
These two recent Comptroller General Reports, as well as a
substantial body of other documentation, highlight the need for a very
active quality assurance program. As discussed further below, two
primary issues are presented. First, there is a need for clear,
specific standards for psychiatric facilities on staff qualifications,
clinical practices, and all other aspects directly impacting the
quality of care. These standards are needed for residential treatment
facilities, substance use disorder rehabilitation facilities, and
partial hospitalization programs. These standards will help bring those
facilities, a minority in the industry, that have been unwilling or
unable to comply with necessary requirements, up to an appropriate
standard of care.
The second key issue is reimbursement rates. As documented by the
Comptroller General, CHAMPUS needs to discontinue payment rates based
on historical billed charges and establish payment rates based on the
actual costs of providing the services.
This final rule puts into place as part of the CHAMPUS regulation
comprehensive quality of care certification standards for residential
treatment facilities, substance abuse rehabilitation facilities, and
partial hospitalization programs. It also modifies current payment
methodologies, which will result in rates approximating the costs of
providing services in psychiatric hospitals and moving toward cost
levels for residential treatment facilities. In addition, the rule
addresses several other issues, addressed below.
II. Provisions of Rule to Reform Certification Standards for Mental
Health Care Facilities
The Comptroller General's call for stronger management by CHAMPUS
to assure quality of care in the mental health programs was based
partially on a review of serious abuses on the part of some providers.
The GAO presented audit findings identifying program weaknesses. Texas,
which is one of four states which account for more than half of CHAMPUS
mental health hospital costs, surfaced in recent audits as number one
in CHAMPUS mental health expenditures. Of particular concern are
practices described during 1991 hearings conducted before the Texas
state senate and summarized in GAO Report #2. In over 80 hours of
testimony, 175 witnesses--some beneficiaries of federal programs--
brought forth allegations which included exorbitant charges for care
never rendered; kickbacks for patient referrals; restraint of voluntary
patients against their will; discharge of patients upon exhaustion of
benefits, regardless of their condition; and isolation of family from
patients, including withholding of visitation and mail/telephone
privileges. While privately insured patients are the most common target
of unethical practices, increasing benefit limits and payment controls
by private third party payers may place federal programs at increased
risk for fraudulent practices. GAO auditors point out that, because
CHAMPUS reimburses mental health at rates higher than other federal
programs, it may be particularly vulnerable to the minority of
unethical providers seeking additional revenue sources.
In recent years, the Department has worked to strengthen oversight
and monitoring of mental health programs, particularly with respect to
treatment of children and adolescents. Through the contract with HMS,
and other efforts, CHAMPUS has paid much more attention to care in
RTCs. In [insert 30 days after date of publication] of 1992, Health
Management Strategies International (HMS) expressed specific concerns
about several of the CHAMPUS-authorized residential treatment centers.
Numerous quality of care issues surfaced during on-site facility visits
to residential treatment centers where CHAMPUS beneficiaries were
receiving care.
Here are several examples:
--Staff qualifications were deficient. In some cases, patient treatment
was not being directed by qualified psychiatrists. At one facility,
psychiatry residents were acting as facility medical directors. In some
facilities, one psychiatrist may be responsible for as many as 90
children and their families, seriously limiting professional time
available for individual attention. In some RTCs, group therapy was
being conducted by child care workers with high school diplomas.
--Several facilities failed to individualize treatment plans. At one
facility all treatment plans were the same, regardless of history,
needs or problems. Similarly, some facilities were discovered to focus
on one type of treatment to the exclusion of all other approaches. This
was true regardless of whether or not patients responded to this type
of treatment.
--In several facilities, registered nurses were not available on a
full-time basis. For example, at one facility children were ordering
their own medications ``as needed'' and medications were dispensed--
without further evaluation--by untrained child care workers. In one
instance a child who developed tardive dyskinesia (a motion disorder
resulting from medication) was described by a child care worker as
having a ``nervous tic.''
--There was evidence of excessive use of restraints and seclusion as
methods of behavioral management. Examples including placing children
as young as three or four in restraint and seclusion. In one facility,
seclusion was used 146 times in one month. The practice of zipping
children into so-called ``body bags'' was employed by several
facilities. Use of a body bag, which leaves an opening only for the
head, carries risk of overheating to the point of lethal hyperthermia.
One facility policy governing this practice did not require physician
evaluation of the patient for 72 to 96 hours after the event.
--Certain RTCs employed unnecessary strip searches and other intrusive
acts. Searches involve adult authority figures for forcing children
between the ages of four and 18 to remove all clothing and submit to
cavity searches. Cavity searches involve finger probes to the mouth,
vagina, and rectum. Some facilities were requiring such searches
whenever the patient returned from a pass or having a visitor. In many
cases, children subjected to such searches were victims of abuse and,
for some, these methods of search re-enact the original trauma.
These HMS case findings pointed out shortcomings in practices in
some RTCs that can be addressed through improved standards. Although
standards for residential treatment centers exist, they have evolved
over time from attempts to address individual issues with incremental
change. Further, existing CHAMPUS standards for residential treatment
centers were written as supplements to standards employed by the Joint
Commission on Accreditation of Hospital Organizations (JCAHO). In
recent years, the JCAHO has moved toward a more general set of facility
standards, with less specific reference to unique requirements of
medical specialties. The result has been that CHAMPUS standards--which
were not [[Page 12421]] intended to stand alone--do not address the
full spectrum of requirements and expectations for mental health
facilities and providers.
Originally drafted in the late 1970s, CHAMPUS standards for RTCs
have undergone multiple revisions to ensure they reflect currently
accepted clinical practice. This rule incorporates revisions necessary
to update existing standards. With shorter lengths of stay in acute
care facilities, mental health patients are reaching residential
treatment centers at earlier--and less stable--stages of treatment.
Similar to trends in other medical specialties, the growing intensity
of illness among inpatients has dictated a need for higher standards of
care and increasing levels of professional supervision and treatment.
Current CHAMPUS standards for RTCs must be updated to reflect more
clearly professional skill levels and intervention strategies employed
in today's mental health environment. Based on a clear record of
problems among some institutional mental health providers and the
shortcomings of current standards, DoD has developed a comprehensive,
unified set of standards for residential treatment centers, partial
hospitalization programs and substance use disorder rehabilitation
facilities. This rule updates existing standards to reflect current
mental health practices, account for policy shifts in the JCAHO, and
communicate clearly CHAMPUS policy with regard to quality and scope of
care provided to its beneficiaries.
The standards will work to prevent recurrence of abuses such as
those discussed by defining more completely and specifically quality
indicators which will be used to judge care rendered in these
facilities. Among areas addressed by the standards are:
Qualifications and authority of clinical director. Standards
require the clinical director of any RTC to have completed appropriate
training and have at least five years' experience in treating children
and adolescents. In addition to oversight of all clinical care
provided, standards for RTCs, substance abuse rehabilitation facilities
and partial hospitalization programs outline specific requirements for
clinical director participation in program development, peer review,
quality monitoring and improvement and coordination with the governing
body.
Adequate staffing with qualified professionals. Standards require
written staffing plans. Specific information is provided concerning
requirements for staffing levels and professional qualifications 24
hours per day, seven days per week (or, in the case of partial
hospitalization programs, during all hours of operation). Standards
require that all clinical care provided under clinical supervision is
the responsibility of a licensed or certified mental health
professional. Additionally, there must be evidence to show that
ultimate authority for management of the medical aspects of care is
vested in a physician.
Patient rights and limitations on use of seclusion and restraint.
Standards require provisions for protection of all individual patient
rights, including civil rights, provided for under federal law and the
laws of the state where the residential treatment center is located.
Specific requirements address privacy, personal freedoms, contact with
families and environmental safety. Detailed guidelines for use,
supervision and medical monitoring of behavior management--including
use of seclusion and retraint--are also provided.
Implementation of individualized treatment plans addressing each
patient's needs. Responsibility of development, supervision,
implementation and assessment of written, individualized and
interdisciplinary treatment plans is assigned to a qualified mental
health professional. Treatment goals must be communicated to the
family, must undergo regular review and must include specific,
measurable and observable criteria for discharge.
Comprehensive evaluation system to guide an ongoing quality
improvement program. Standards provide detailed expectations with
respect to evaluation systems by which quality, efficiency,
appropriateness and effectiveness of care, treatments, and services are
provided. The evaluation system must involve all disciplines, services,
and programs of the facility, including administrative and support
activities. Responsibility for development and implementation of
quality assurance and quality improvement programs rests with the
clinical director and must support overall facility and philosophical
assumptions and values.
The standards are designed to foster interdisciplinary
communication and patient protection through involvement and oversight
of the Governing Body, Chief Executive Officer, Clinical Director, and
Professional Staff with respect to administrative, utilization review,
and clinical activities. DoD has also strengthened standards for
substance abuse treatment programs in a manner similar to residential
treatment centers. For partial hospitalization, these standards occur
as part of implementation of this new benefit, which became effective
September 29, 1993.
This rule incorporates basic requirements governing CHAMPUS
approval of facilities providing mental health services as residential
treatment centers, as partial hospitalization providers, and substance
use disorder rehabilitation facilities. More detailed definition of
these basic standards have been issued under the authority of this
regulation. It should be noted that only the requirements included in
this final regulation have, by themselves, the force and effect of law.
Additional detail in the more lengthy standards are extensions of the
regulation. They establish the agency's interpretations of the
regulation and will serve as guidelines for compliance with the
regulatory requirements. The complete standards are available to the
public from the Office of CHAMPUS. These more lengthy standards are
finalized coincident with issuance of this final regulation.
III. Provisions of Rule to Reform Payment Methods for Mental Health
Care Facilities
This rule implements payment reforms in keeping with the
Comptroller General's recommendations regarding payment reform for
mental health care facilities. The Comptroller General's findings
regarding current CHAMPUS payment rates are especially noteworthy.
According to the report: ``Our work indicates that DoD pays psychiatric
facilities considerably more than other government programs do for
comparable services.'' GAO Report #1, p.6. The Comptroller General very
accurately summarized the background of the current CHAMPUS payment
methods for psychiatric hospitals and RTCs:
Although the current CHAMPUS system of per diem reimbursements
has helped limit program cost increases for inpatient mental health,
the per diem rates were based on providers' billed charges, not
their costs. The rates were based on billing data from a period when
providers' charges were not subject to controls and had just
increased significantly. Before 1989 when no upper limit on rates
existed, hospitals, and RTCs essentially set their own CHAMPUS
payment rates. Before the per diem calculations, hospitals and RTC
rates increased significantly. For example, average daily charges
per CHAMPUS inpatient day rose by 17 percent from fiscal years 1987
to 1988. One RTC boosted its daily charges from an average of $331
in fiscal year 1987 to $531 in June 1988--a 60% increase.
GAO Report #1, pp 6-7.
Because CHAMPUS payments are based on historical billed charges,
they substantially exceed the facilities' actual [[Page 12422]] costs
and Medicare reimbursement rates. Based on an analysis of payments to a
number of high CHAMPUS volume psychiatric hospitals, the Comptroller
General concluded ``The hospitals made large profits, on average, on
CHAMPUS patients.'' GAO Report #1, p. 7.
A similar pattern emerges on payment rates for RTCs. Using fiscal
year 1991 data, the Comptroller General compared CHAMPUS payments to
state-authorized daily rates for a number of RTCs in Florida and
Virginia, and found that the average daily CHAMPUS rate was 36 percent
more than the average state rate. RTC cost data were available for
three RTCs in Texas, the state with the highest total CHAMPUS RTC
costs. These data showed ``an average profit margin of 27 percent.''
Id., p. 8. The Comptroller General also stated that the index factor
used to annually update CHAMPUS RTC per diems, the consumer price index
for urban medical services (CPI-U), results in excessive increases. The
GAO Report says the hospital market basket index factor that CHAMPUS
and Medicare use for hospital payments ``would be more appropriate than
the CPI-U because it reflects increases in the amounts hospitals pay
for goods and services'' rather than ``increases in charges by health
practitioners and facilities.'' Id.
The problem of excessive payments also involves substance use
disorder rehabilitation facilities, which continue to be paid by
CHAMPUS billed charges. According to the Comptroller General:
These facilities set their own fees and can increase them
freely--without controls over their charges. Some of the facilities
are paid more on a daily basis than are psychiatric hospitals. Id.
Based on these findings, the Comptroller General recommended
that the Secretary of Defense:
Establish a system of reimbursing psychiatric facilities, RTCs,
and specialized treatment facilities based on a cost-based system
similar to Medicare, adjusted appropriately for differences in
beneficiary demographics, rather than the present per diem or billed
charges system.
Id., p. 10.
Under the proposed rule, CHAMPUS payments to specialty psychiatric
hospitals and units and residential treatment facilities would have
gradually transitioned from the present system of per diem rates based
on historical billed charges to a new system of per diem rates based on
detailed facility cost reports. Comments from providers and the
professional community pointed out the significant administrative
complexity and costs associated with payments based on cost reporting.
They proposed alternatives premised on adjustments to the current
system. We have been persuaded by these comments and have made
adjustments to current payment structures which, although not based on
detailed facility cost reports, move CHAMPUS reimbursement rates
significantly closer to the costs of delivering care in mental health
facilities. This rule is based on the legal authority of 10 USC
1079(j)(2) which authorizes CHAMPUS to adopt payment methods for
institutional providers similar to those applicable to Medicare. Under
the final rule, CHAMPUS payments to specialty psychiatric hospitals and
units will remain at FY95 rates for a two-year period beginning in
FY96. Additionally, effective [insert 30 days after date of
publication], the cap on per diem rates for these hospitals and units
will be reduced from the current 80th percentile to the 70th percentile
of all CHAMPUS base year charges in high volume hospitals. In FY98,
payments will again be updated using the Medicare update factor for
hospitals and units exempt from the Medicare Prospective Payment
System.
With respect to RTCs, the rule makes similar adjustments to current
payment methodologies. Per diem rates will remain at FY95 rates during
fiscal years 1996 and 1997 and will be subject to a cap set at the 70th
percentile of all CHAMPUS RTC per diem rates. RTCs with FY95 payment
rates below the 30th percentile of all RTC CHAMPUS per diem rates will
be exempt from the two year freeze in rates, instead continuing the
current methodology for annual updates, up to the 30th percentile rate.
Beginning in FY 1998, payment updates for all RTCs will be based on the
Medicare update factor used for hospitals and units exempt from
Medicare's Prospective Payment System.
We estimate that payment methodologies under this rule will lead to
aggregate expenditures which approximate average costs in psychiatric
hospitals and units. While cost data are not generally available for
RTCs, we estimate that under this rule, aggregate expenditures for RTC
care will move closer to the level of average facility costs. We expect
that over the next two years, we will obtain more data on actual RTC
costs that will facilitate an assessment of whether additional
regulatory changes should be considered.
With respect to substance use disorder rehabilitation facilities,
this rule includes services provided by these facilities under the
CHAMPUS DRG-based payment system. Currently, most substance use
disorder rehabilitation services reimbursed by CHAMPUS are provided by
facilities covered by the CHAMPUS DRG system or mental health per diem
system. Only a small portion are provided by facilities that continue
to be paid on the basis of billed charges. Under Medicare, these
facilities are covered by the Medicare Prospective Payment System.
Based on these factors, we believe inclusion of services provided by
substance use disorder rehabilitation facilities should be included
with the similar services already covered by the CHAMPUS DRG-based
payment system. Partial hospitalization for substance use disorder
rehabilitation will be reimbursed in the same manner as psychiatric
partial hospitalization programs and the rates will be frozen at the
FY95 level for fiscal years 1996 and 1997.
The payment system changes appear at the proposed revisions to
section 199.14.
IV. Other Provisions of Rule
A. Therapeutic Leave of Absence Days
Currently, DoD pays RTCs for days a patient is away from the
facility on an approved therapeutic leave of absence. The payment
amount is 100% of the normal per diem for the first three days and 75%
for additional days. It is our view that current rates are not
justified by any costs to the facility. In addition, we are aware of no
other public payer that pays for leave days. Therefore, for care
provided on or after July 1, 1995, this rule eliminates payment for
days in which patients are on leave from the residential treatment
center. We received a number of comments objecting to this on the
grounds that therapeutic leave of absence are an important part of
therapy, and should be recognized in reimbursement for services. We
agree that therapeutic leaves are an important component in the
patient's overall treatment plan. However, because payment rates to
RTCs under this rule will probably remain above average costs, we
believe they will be sufficient to cover facility costs associated with
reserving space for the patient's return. This change applies only to
RTCs; in psychiatric hospitals, substance use disorder rehabilitation
facilities and partial hospitalization programs, leave days are not
reimbursed by CHAMPUS.
B. Reversing Incentive for Inpatient Care
Another of the recommendations of the Comptroller General was to
``reverse the financial incentives to use inpatient care by introducing
larger copayments for CHAMPUS inpatient care.'' GAO
[[Page 12423]] Report #1, p. 10. This recommendation was based on the
Comptroller General's conclusion that there is a ``bias toward patients
receiving inpatient rather than outpatient care'' because inpatient
care is less expensive for dependents of active duty members than
outpatient care. Id., p. 8-9. These beneficiaries currently pay
approximately $10.00 per day or $25 per admission, whichever is
greater, for inpatient care. For outpatient care, dependents of active
duty members pay a $150 deductible (subject to a $300 family limit) and
20 percent of the allowable payment for individual professional
services. Consequently, as a general matter, there is a financial
incentive for beneficiaries to seek services on an inpatient, rather
than an outpatient basis. Under 10 U.S.C. section 1079(i)(2), DoD has
authority to establish mental health copayment requirements different
from those for other CHAMPUS services.
This rule establishes a per day copayment of $20 for dependents of
active duty beneficiaries. This is based on the fact that an outpatient
mental health visit is generally approximately $100, meaning that the
copayment would be $20. Thus, an inpatient day would have a roughly
equal beneficiary copayment as an outpatient visit (excluding the
deductible). One commenter objected to this proposal. Based on DoD
experience in delivery of mental health services, information collected
during utilization management reviews, and reports from the GAO, our
observation is that inpatient mental health services remain vulnerable
to over utilization. We believe this modest increase in inpatient cost
share addresses the Comptroller General's recommendation, without
impairing access to care or imposing hardship on beneficiaries. (With
respect to avoidance of hardship, we note that the catastrophic cap for
active duty dependents is $1000 per family per year.) To ensure
adequate notice of providers and beneficiaries we have established an
effective date of October 1, 1995 for the copayment requirements as
stated above.
C. Equalization of Alcoholism and Drug Abuse Benefit Provisions
The frequent coexistence of alcohol and other chemical dependency
or abuse suggests existing differences in benefit structures for
treatment of alcohol and drug abuse should be eliminated. Effective for
admissions on or after October 1, 1995, this rule includes treatment
for both alcohol and drug dependency/abuse under a broad benefit
package designed to include treatment of all substance use disorders.
IV. Additional Discussion of Public Comments
The proposed rule was published in the Federal Register June 29,
1994 (59 FR Page 33465). We received 23 comment letters, all of which
were from providers and provider associations. Many of the comments
were quite similar in wording and content. Some were very detailed and
provided helpful insight and analysis. We thank those who provided
input on this important issue. Significant items raised by commenters
and our analysis of the comments are summarized below.
1. GAO Recommendations are Based Upon Outdated Information. We
received a significant number of comments regarding our reliance on GAO
reports for developing components of the proposed rule. Findings and
recommendations provided in GAO reports relied to some extent on
information gathered prior to realization of impact from several DoD
quality, cost and utilization management initiatives.
Response. Although substantial progress has been made as a result
of earlier DoD efforts, ongoing utilization reviews and facility
inspections continue to reveal departures from minimum CHAMPUS health
and safety standards. Additionally, in many areas CHAMPUS continues to
reimburse mental health services at significantly higher rates than
many other third party payers. While the GAO analysis does not reflect
the specific impact of recent initiatives, we believe the themes which
emerged from their two reports remain current.
2. Specificity of Standards. Several commenters asserted that
standards in the proposed rule were stated too broadly, leaving
excessive room for interpretation and significant doubt as to the exact
CHAMPUS requirements. Examples included the absence of stated
requirements for specific staff-to-patient ratios and specific numbers
for professional staffing. A similar comment was that terms like
``essentially stabilized'' and ``reasonable and observable'' treatment
goals should be better defined. Commenters pointed out that specific
standards which provide explicit requirements for all aspects of
facility certification should be published for public review and
comment prior to their application in the certification process.
Response. A more detailed set of standards which provide the
agency's interpretation of standards contained in the rule are
available from OCHAMPUS. These were made available for public review
concurrent with publication of the proposed rule. The more detailed set
of standards does not include specific requirements with respect to
professional staff mix and staff-to-patient ratios because these will
vary depending upon the characteristics of each facility. Consistent
with regulatory standards in the rule and further described in the
supplemental set available from OCHAMPUS, facilities should develop
staffing patterns which reflect the characteristics and special needs
of the population served, the patient census, and acuity/intensity of
services required. With respect to specific definitions of terms, the
unique requirements brought by each patient to the treatment setting
necessarily require individual assessments, and professional judgment
as to required level of care for the presenting symptoms or dysfunction
and progress being made in addressing the patient's specific needs. As
such, we do not think it appropriate to establish a fixed list of
criteria which must be applied to all patients.
3. Requirement for Physician Medical Directors. Physician
professional associations agreed with a requirement for physician
medical directors, but associations representing non-physician mental
health professionals objected to this. Several commenters recommended
that current non-physician medical directors who are serving
successfully should be exempt from this requirement.
Response. We have reconsidered the provisions in the proposed rule
regarding physician oversight of all clinical services and agree that
some of the language may have had the effect of unduly restricting the
scope of practice for some providers, particularly doctoral level
psychologists. We are also aware that widely recognized accrediting
bodies, as well as several states, permit independent practice and
hospital admitting privileges for certain non-physician providers. We
have made revisions to language contained in the proposed rule to
assure our standards are consistent with those of the Joint Commission
on Accreditation of Hospital Organizations (JCAHO) and in keeping with
changing practice patterns in the mental health community. Because
treatment of mental health patients often includes pharmacologic
intervention and evaluation and treatment for related or co-existing
medical problems, physician management for these components of therapy
is still required. We require medical management of patients to be
under the supervision of a physician medical director. However, we also
agree that oversight of the spectrum of clinical services provided in a
program [[Page 12424]] may be accomplished by doctoral level
psychologists. We have added language which allows clinical directors
to be physicians or, where permitted by law and by the facility,
doctoral level psychologists who meet CHAMPUS requirements for
individual professional providers.
4. Admitting Privileges for Non-physician Providers. A number of
commenters objected to proposed language which limited admitting
privileges to physicians. They argued that such limitations on certain
non-physician mental health professionals, for example, master's level
clinical social workers, were unnecessarily restrictive and counter to
legislative and industry trends toward an expanded scope of practice
for these providers.
Response. We are aware of these changes and agree that, where
permitted by law and by the facility, individuals who meet the CHAMPUS
definition of individual professional mental health provider should be
allowed to refer patients for admission. We have included language in
the final rule which reflects this position.
5. Qualifications for CEOs. We received a number of comments
suggesting that upgraded CEO requirements should not apply to
individuals who, although they do not meet these standards, are
currently serving in that capacity successfully.
Response. We believe the proposed standards for CEOs are
appropriate, given the level and scope of responsibility attached to
this position. However, we have included language which makes CEO
qualification standards effective October 1, 1997. This should provide
sufficient time for CEOs currently serving to undertake appropriate
education and/or training to meet increased requirements.
5. Upgraded Standards are Costly and May Limit Treatment Options
for CHAMPUS Beneficiaries. A number of commenters suggested that
standards in the proposed rule were costly to implement. They argued
that the increased cost of doing business, in addition to potential
reductions in reimbursement caused by the rule's payment reforms, may
cause some providers to drop participation in CHAMPUS programs.
Commenters viewed this as a particular problem for providers with
limited CHAMPUS volume and those in rural areas. Some commenters argued
that treatment methods not relying upon a medical model should be
expanded, rather than changed to conform.
Response. Standards in this final rule are based upon accepted
standards of practice, requirements of the Joint Commission on
Accreditation of Healthcare Organizations, and input from Department
consultants and the provider community. Although we have made
significant progress in addressing quality issues raised by GAO's study
and highlighted in various forms, rapidly evolving practice patterns
and treatment settings require CHAMPUS standards which reflect the
character and pace of these changes. We believe these updated standards
are necessary minimums which ensure CHAMPUS beneficiaries receive high
quality care by appropriately trained professionals and staff. We
believe the cost of upgraded standards will be accommodated within
projected reimbursement rates. Facilities unable or unwilling to comply
with these standards are not in a position to provide a proper standard
of care.
6. Implementation of Seclusion and Restraint. We received a large
number of comments objecting to standards which restricted
implementation of seclusion and restraint to qualified mental health
professionals. Additionally, the proposed rule excluded seclusion and
restraint as behavior management devices in substance use disorder
rehabilitation facilities. Commenters argued that these restrictions
were unworkable, that they may pose safety issues when professional
staff are not immediately available, and that facility staff are
trained to use these techniques for behavior management.
Response. Seclusion and restraint imply a severity of dysfunction
and need for treatment beyond the scope of care settings addressed in
this rule. If seclusion and/or restraint is frequently required for
behavior management in RTCs, PHPs, or SUDRFs, this suggests patients
who require a more intense level of care. Facilities should evaluate
policies and practices to determine their effectiveness in identifying
patients who have not been assigned to the appropriate level of care.
All facility staff should be trained in temporary holds which provide
immediate intervention for safety of the patient and others. Also,
facilities should have clear emergency response procedures which define
appropriate intervention in crisis situations.
With the exception of brief physical holds and time outs, use of
seclusion and restraint is excluded in SUDRFs, as patients who require
this level of intervention are not appropriate to this treatment
setting. The use of time out or physical holds should be infrequent,
since behavior routinely requiring this type of intervention suggests a
need for care at a higher level of intensity. We do agree that proposed
rule language may have restricted appropriate response to emergency
situations. We have added clarifying language which requires a
qualified mental health professional to be responsible for
implementation of seclusion and restraint, but allows actual
implementation by facility staff under supervision of the responsible
provider.
7. Inclusion of Spiritual and Skills Assessments. A number of
commenters questioned inclusion of new requirements for spiritual and
skills assessments in the proposed standards and requested more
detailed description of this requirement.
Response. Spiritual assessments are part of a comprehensive,
multidisciplinary assessment which should address the full range of a
patient's clinical needs, including the impact of religious, ethnic and
cultural influences upon the patient or family. Spiritual assessments,
which occur in the context of obtaining a social history, are not new
to the CHAMPUS standards and are included specifically in standards of
other widely recognized accrediting bodies. A skills assessment is an
important component of patient evaluation and includes activities of
daily living, perceptual-motor skills, sensory integration factors,
cognitive skills, communication skills, social interaction skills,
creative abilities, vocational skills, and the impact of physical
limitations. Activity services related to this assessment should be
part of the therapeutic plan and should be supervised by a qualified
mental health professional.
8. Requirement for Clinical Formulation. Several commenters
questioned the need for clinical formulation in addition to development
of a treatment plan. Additionally, several comments pointed out the
standards allowed less time for completion of a treatment plan (10
days) than for development of the clinical formulation (14 days) which
forms the basis of the treatment plan.
Response. The clinical formulation summarizes significant clinical
interpretations from each of the multidisciplinary assessments, forming
the basis for development of a master treatment plan. Interrelating
findings from all assessments, the clinical formulation should clearly
describe problems to be addressed in the treatment plan and indicate
appropriate focus for the treatment strategies. We view this as a
necessary, and not redundant, part of the process for developing a plan
of care responsive to the unique requirements of each patient. We agree
the proposed time requirements were not consistent with
[[Page 12425]] this logic and have modified language accordingly.
Treatment plans must be completed within 10 days; clinical
formulations no longer have a specific deadline, but must be completed
prior to development of the interdisciplinary treatment plan.
9. Family Therapy. A large number of commenters raised the issue of
logistical problems which present difficulty in accomplishing family
therapy for CHAMPUS beneficiaries. An example frequently used was the
deployment of military members which caused geographic separations. The
argument was made that CHAMPUS should be more flexible regarding this
requirement.
Response. Family therapy is not a new requirement for CHAMPUS
beneficiaries. Geographical distance is not considered a reason to
exclude the family from a treatment plan. For patients separated from
their families by deployment or for other reasons, CHAMPUS allows
geographically distant family therapy. If one or both parents reside a
minimum of 250 miles from the RTC, the RTC has the flexibility to
arrange for therapy with parents at the distant locality. If family
therapy is clinically contraindicated, rationale for this conclusion
must be documented in the patient's record.
10. Annual Facility Evaluation. We received several comments
arguing that a service specific annual evaluation was overly burdensome
to facilities and ``unheard of'' outside academic settings.
Response. The proposed rule identified this requirement in the
context of facility development of a strategic plan which contains
specific goals and objectives for each program component or service and
patient population served. Sound business practices would suggest
regular organizational assessments to identify progress toward
established performance and fiscal goals and objectives. The
Department, as well as other accrediting agencies, expect governing
bodies, through their CEOs, to provide sufficient resources to achieve
the organization's missions, goals, philosophy and objectives. Without
a clear idea of resource allocation and performance across the range of
services provided, it is unclear how facilities would evaluate
outcomes, or the need for change. We do not agree that this is overly
burdensome and find it surprising that such reviews would be limited
only to academic settings.
11. Education Hours in Partial Hospitalization Programs. The
proposed rule does not count educational hours towards total hours for
``full day'' partial hospitalization programs. Several commenters
argued that, by not including time spent in school, those hours,
combined with the required six hours for a full day partial program,
result in an excessively long day for patients.
Response. Patients who meet the criteria for admission to partial
hospitalization programs do not require a professionally managed milieu
twenty-four hours a day, as do individuals in residential treatment
programs. Therefore, we find it reasonable to expect that school hours
may be accommodated separately from the hours spent in therapy and
other treatment activities. Determinations as to school hours vs. time
spent in treatment or other activities should be considered as part of
an overall assessment of the patient's needs and addressed in an
individualized treatment plan.
12. Benefit Limitations. One provider association objected to
CHAMPUS limits on treatment of substance use disorders, stating that
these limits do not consider the chronic nature of this problem.
Response. Compared to many third party payers, CHAMPUS provides one
of the more generous benefits for treatment of substance use disorders.
We do recognize the chronic as well as individual nature of these
problems and, consistent with that, provide an allowance for waivers of
benefit limits when continued treatment is justified.
13. Burden and Expense Associated With Cost Based Reimbursement.
The overwhelming majority of comments on the proposed cost based
reimbursement system argued that the cost and administrative burden
associated with these changes, for both the Department and providers,
far exceeded any benefit to the government. A number of commenters
pointed out that the GAO reports which provided impetus for payment
reform were based on outdated information which did not reflect the
results of earlier initiatives. Commenters suggested that, if DoD is
required to implement additional cost containment measures, these could
be accomplished more efficiently through adjustments to existing
payment mechanisms.
Response. After full consideration of comments from the provider
community, as well as our continuing analysis of costs associated with
implementation of a cost based system for mental health, we agree that
implementation of the proposed system is not appropriate at this time.
Although cost containment and utilization management programs have
achieved program savings, we agree with GAO conclusion that additional
improvements are needed. While the GAO report may not reflect the full
measure of cost and quality improvements achieved by earlier efforts,
continuing program reviews and findings gathered through utilization
management programs suggest CHAMPUS mental health programs require
additional controls.
In keeping with comments from the industry and our own analysis,
additional cost containment in CHAMPUS mental health programs will be
accomplished through adjustments to current reimbursement mechanisms.
For specialty psychiatric hospitals and units, payment will be held at
FY95 rates for two years, beginning in FY96 and extending through FY97.
Additionally, April 6, 1995, payment will be capped at a rate not to
exceed the 70th percentile of payment rates in all high volume CHAMPUS
psychiatric hospitals. We estimate that these adjustments will result
in CHAMPUS payments at the level of average aggregate costs for
psychiatric hospitals and units, thereby addressing concerns expressed
by the GAO.
The general lack of availability with respect to RTC cost
information presented some difficulties in our attempt to analyze
impact of payment reforms for this community. In measures similar to
those for psychiatric hospitals, RTC payment rates for facilities at or
above the 30th percentile of all CHAMPUS RTC payment rates in FY95 will
be held constant, with no additional update through fiscal years FY96
and FY97. Additionally, effective April 6, 1995, payments will be
capped at level not to exceed the 70th percentile of all RTC rates
nationally. For those RTCs paid at levels below the 30th percentile of
national CHAMPUS RTC rates, payments will be updated by the lesser of
the CPI-U for medical care or the amount that brings the rate up to the
30th percentile level. The update factor for payments beginning in FY98
will be the Medicare update factor for hospitals and units exempt from
the Medicare prospective payment system. In order to determine the
effectiveness of RTC cost containment measures established in this
final rule, the Department will continue to explore avenues for
obtaining accurate cost data for RTC services.
V. Rulemaking Procedures
This rule is a significant regulatory action as determined by the
Office of Management and Budget. Also, we certify that this rule will
not significantly affect a large number of [[Page 12426]] small
entities within the meaning of the Regulatory Flexibility Act.
This rule does not impose new information collection requirements.
List of Subjects in 32 CFR Part 199
Claims, handicapped, health insurance, and military personnel.
Accordingly, 32 CFR part 199 is amended as follows:
PART 199--[AMENDED]
1. The authority citation for part 199 is revised to read as
follows:
Authority: 5 U.S.C. 301; 10 U.S.C. chapter 55.
2. Section 199.4 is amended by revising the heading of paragraph
(e)(4), paragraph (e)(4) introductory text, (e)(4)(i), (e)(4)(ii),
(e)(4)(iv), and the introductory text of paragraph (f)(2)(ii), and by
adding new paragraphs (e)(4)(v), and (f)(2)(ii)(D), as follows:
Sec. 199.4 Basic program benefits.
* * * * *
(e) * * *
* * * * *
(4) Treatment of substance use disorders. Emergency and inpatient
hospital care for complications of alcohol and drug abuse or dependency
and detoxification are covered as for any other medical condition.
Specific coverage for the treatment of substance use disorders includes
detoxification, rehabilitation, and outpatient care provided in
authorized substance use disorder rehabilitation facilities.
(i) Emergency and inpatient hospital services. Emergency and
inpatient hospital services are covered when medically necessary for
the active medical treatment of the acute phases of substance abuse
withdrawal (detoxification), for stabilization, and for treatment of
medical complications of substance use disorders. Emergency and
inpatient hospital services are considered medically necessary only
when the patient's condition is such that the personnel and facilities
of a hospital are required. Stays provided for substance use disorder
rehabilitation in a hospital-based rehabilitation facility are covered,
subject to the provisions of paragraph (e)(4)(ii) of this section.
Inpatient hospital services also are subject to the provisions
regarding the limit on inpatient mental health services.
(ii) Authorized substance use disorder treatment. Only those
services provided by CHAMPUS-authorized institutional providers are
covered. Such a provider must be either an authorized hospital, or an
organized substance use disorder treatment program in an authorized
free-standing or hospital-based substance use disorder rehabilitation
facility. Covered services consist of any or all of the services listed
below. A qualified mental health provider (physicians, clinical
psychologists, clinical social workers, psychiatric nurse specialists)
(see paragraph (c)(3)(ix) of this section) shall prescribe the
particular level of treatment. Each CHAMPUS beneficiary is entitled to
three substance use disorder treatment benefit periods in his or her
lifetime, unless this limit is waived pursuant to paragraph (e)(4)(v)
of this section. (A benefit period begins with the first date of
covered treatment and ends 365 days later, regardless of the total
services actually used within the benefit period. Unused benefits
cannot be carried over to subsequent benefit periods. Emergency and
inpatient hospital services (as described in paragraph (e)(4)(i) of
this section) do not constitute substance abuse treatment for purposes
of establishing the beginning of a benefit period.)
(A) Rehabilitative care. Rehabilitative care in a authorized
hospital or substance use disorder rehabilitative facility, whether
free-standing or hospital-based, is covered on either a residential or
partial care (day or night program) basis. Coverage during a single
benefit period is limited to no more than inpatient stay (exclusive of
stays classified in DRG 433) in hospitals subject to CHAMPUS DRG-based
payment system or 21 days in a DRG-exempt facility for rehabilitation
care, unless the limit is waived pursuant to paragraph (e)(4)(v) of
this section. If the patient is medically in need of chemical
detoxification, but does not require the personnel or facilities of a
general hospital setting, detoxification services are covered in
addition to the rehabilitative care, but in a DRG-exempt facility
detoxification services are limited to 7 days unless the limit is
waived pursuant to paragraph (e)(4)(v) of this section. The medical
necessity for the detoxification must be documented. Any detoxification
services provided by the substance use disorder rehabilitation facility
must be under general medical supervision.
(B) Outpatient care. Outpatient treatment provided by an approved
substance use disorder rehabilitation facility, whether free-standing
or hospital-based, is covered for up to 60 visits in a benefit period,
unless the limit is waived pursuant to paragraph (e)(4)(v) of this
section.
(C) Family therapy. Family therapy provided by an approved
substance use disorder rehabilitation facility, whether free-standing
or hospital-based, is covered for up to 15 visits in a benefit period,
unless the limit is waived pursuant to paragraph (e)(4)(v) of this
section.
* * * * *
(iv) Confidentialty. Release of any patient identifying
information, including that required to adjudicate a claim, must comply
with the provisions of section 544 of the Public Health Service Act, as
amended, (42 U.S.C. 290dd-3), which governs the release of medical and
other information from the records of patients undergoing treatment of
substance abuse. If the patient refuses to authorize the release of
medical records which are, in the opinion of the Director, OCHAMPUS, or
a designee, necessary to determine benefits on a claim for treatment of
substance abuse the claim will be denied.
(v) Waiver of benefit limits. The specific benefit limits set forth
in paragraphs (e)(4)(ii) of this section may be waived by the Director,
OCHAMPUS in special cases based on a determination that all of the
following criteria are met:
(A) Active treatment has taken place during the period of the
benefit limit and substantial progress has been made according to the
plan of treatment.
(B) Further progress has been delayed due to the complexity of the
illness.
(C) Specific evidence has been presented to explain the factors
that interfered with further treatment progress during the period of
the benefit limit.
(D) The waiver request includes specific time frames and a specific
plan of treatment which will complete the course of treatment.
* * * * *
(f) * * *
(2) * * *
(ii) Inpatient cost-sharing. Except in the case of mental health
services (see paragraph (f)(2)(ii)(D) of this section), dependents of
active duty members of the Uniformed Services or their sponsors are
responsible for the payment of the first $25 of the allowable
institutional costs incurred with each covered inpatient admission to a
hospital or other authorized institutional provider (refer to
Sec. 199.6), or the amount the beneficiary or sponsor would have been
charged had the inpatient care been provided in a Uniformed Service
hospital, whichever is greater.
* * * * *
(D) Inpatient cost-sharing for mental health services. For care
provided on or after October 1, 1995, the inpatient cost-sharing for
mental health services is $20 per day for each day of the inpatient
admission. This $20 per day cost [[Page 12427]] sharing amount applies
to admissions to any hospital for mental health services, any
residential treatment facility, any substance abuse rehabilitation
facility, and any partial hospitalization program providing mental
health or substance use disorder rehabilitation services.
* * * * *
3. Section 199.6 is amended by revising paragraphs (b)(4)(vii) and
(b)(4)(xii), by removing paragraph (b)(4)(x)(B)(3), and by adding a new
paragraph (b)(4)(xiv) to read as follows:
Sec. 199.6 Authorized providers.
* * * * *
(b) Institutional providers. * * *
* * * * *
(4) Categories of institutional providers. * * *
* * * * *
(vii) Residential treatment centers. This paragraph (b)(4)(vii)
establishes standards and requirements for residential treatment
centers (RTCs).
(A) Organization and administration.
(1) Definition. A Residential Treatment Center (RTC) is a facility
or a distinct part of a facility that provides to beneficiaries under
21 years of age a medically supervised, interdisciplinary program of
mental health treatment. An RTC is appropriate for patients whose
predominant symptom presentation is essentially stabilized, although
not resolved, and who have persistent dysfunction in major life areas.
The extent and pervasiveness of the patient's problems require a
protected and highly structured therapeutic environment. Residential
treatment is differentiated from:
(i) Acute psychiatric care, which requires medical treatment and
24-hour availability of a full range of diagnostic and therapeutic
services to establish and implement an effective plan of care which
will reverse life-threatening and/or severely incapacitating symptoms;
(ii) Partial hospitalization, which provides a less than 24-hour-
per-day, seven-day-per-week treatment program for patients who continue
to exhibit psychiatric problems but can function with support in some
of the major life areas;
(iii) A group home, which is a professionally directed living
arrangement with the availability of psychiatric consultation and
treatment for patients with significant family dysfunction and/or
chronic but stable psychiatric disturbances;
(iv) Therapeutic school, which is an educational program
supplemented by psychological and psychiatric services;
(v) Facilities that treat patients with a primary diagnosis of
chemical abuse or dependence; and
(vi) Facilities providing care for patients with a primary
diagnosis of mental retardation or developmental disability.
(2) Eligibility.
(i) Every RTC must be certified pursuant to CHAMPUS certification
standards. Such standards shall incorporate the basic standards set
forth in paragraphs (b)(4)(vii) (A) through (D) of this section, and
shall include such additional elaborative criteria and standards as the
Director, OCHAMPUS determines are necessary to implement the basic
standards.
(ii) To be eligible for CHAMPUS certification, the facility is
required to be licensed and fully operational for six months (with a
minimum average daily census of 30 percent of total bed capacity) and
operate in substantial compliance with state and federal regulations.
(iii) The facility is currently accredited by the Joint Commission
on Accreditation of Healthcare Organizations (JCAHO) under the current
edition of the Manual for Mental Health, Chemical Dependency, and
Mental Retardation/Developmental Disabilities Services which is
available from JCAHO, P.O. Box 75751, Chicago, IL 60675.
(iv) The facility has a written participation agreement with
OCHAMPUS. The RTC is not a CHAMPUS-authorized provider and CHAMPUS
benefits are not paid for services provided until the date upon which a
participation agreement is signed by the Director, OCHAMPUS.
(3) Governing body.
(i) The RTC shall have a governing body which is responsible for
the policies, bylaws, and activities of the facility. If the RTC is
owned by a partnership or single owner, the partners or single owner
are regarded as the governing body. The facility will provide an up-to-
date list of names, addresses, telephone numbers and titles of the
members of the governing body.
(ii) The governing body ensures appropriate and adequate services
for all patients and oversees continuing development and improvement of
care. Where business relationships exist between the governing body and
facility, appropriate conflict-of-interest policies are in place.
(iii) Board members are fully informed about facility services and
the governing body conducts annual review of its performance in meeting
purposes, responsibilities, goals and objectives.
(4) Chief executive officer. The chief executive officer, appointed
by and subject to the direction of the governing body, shall assume
overall administrative responsibility for the operation of the facility
according to governing body policies. The chief executive officer shall
have five years' administrative experience in the field of mental
health. On October 1, 1997, the CEO shall possess a degree in business
administration, public health, hospital administration, nursing, social
work, or psychology, or meeting similar educational requirements as
prescribed by the Director, OCHAMPUS.
(5) Clinical Director. The clinical director, appointed by the
governing body, shall be a psychiatrist or doctoral level psychologist
who meets applicable CHAMPUS requirements for individual professional
providers and is licensed to practice in the state where the
residential treatment center is located. The clinical director shall
possess requisite education and experience, credentials applicable
under state practice and licensing laws appropriate to the professional
discipline, and a minimum of five years' clinical experience in the
treatment of children and adolescents. The clinical director shall be
responsible for planning, development, implementation, and monitoring
of all clinical activities.
(6) Medical director. The medical director, appointed by the
governing body, shall be licensed to practice medicine in the state
where the residential treatment center is located and shall possess
requisite education and experience, including graduation from an
accredited school of medicine or osteopathy, an approved residency in
psychiatry and a minimum of five years clinical experience in the
treatment of children and adolescents. The Medical Director shall be
responsible for the planning, development, implementation, and
monitoring of all activities relating to medical treatment of patients.
If qualified, the Medical Director may also serve as Clinical Director.
(7) Medical or professional staff organization. The governing body
shall establish a medical or professional staff organization to assure
effective implementation of clinical privileging, professional conduct
rules, and other activities directly affecting patient care.
(8) Personnel policies and records. The RTC shall maintain written
personnel policies, updated job descriptions and personnel records to
assure the selection of qualified personnel and successful job
performance of those personnel.
(9) Staff development. The facility shall provide appropriate
training and development programs for administrative, professional
support, and direct care staff. [[Page 12428]]
(10) Fiscal accountability. The RTC shall assure fiscal
accountability to applicable government authorities and patients.
(11) Designated teaching facilities. Students, residents, interns
or fellows providing direct clinical care are under the supervision of
a qualified staff member approved by an accredited university. The
teaching program is approved by the Director, OCHAMPUS.
(12) Emergency reports and records. The facility notifies OCHAMPUS
of any serious occurrence involving CHAMPUS beneficiaries.
(B) Treatment services.
(1) Staff composition.
(i) The RTC shall follow written plans which assure that medical
and clinical patient needs will be appropriately addressed 24 hours a
day, seven days a week by a sufficient number of fully qualified
(including license, registration or certification requirements,
educational attainment, and professional experience) health care
professionals and support staff in the respective disciplines.
Clinicians providing individual, group, and family therapy meet CHAMPUS
requirements as qualified mental health providers and operate within
the scope of their licenses. The ultimate authority for planning,
development, implementation, and monitoring of all clinical activities
is vested in a psychiatrist or doctoral level psychologist. The
management of medical care is vested in a physician.
(ii) The RTC shall ensure adequate coverage by fully qualified
staff during all hours of operation, including physician availability,
other professional staff coverage, and support staff in the respective
disciplines.
(2) Staff qualifications. The RTC will have a sufficient number of
qualified mental health providers, administrative, and support staff to
address patients' clinical needs and to coordinate the services
provided. RTCs which employ individuals with master's or doctoral level
degrees in a mental health discipline who do not meet the licensure,
certification and experience requirements for a qualified mental health
provider but are actively working toward licensure or certification,
may provide services within the all-inclusive per diem rate, provided
the individual works under the clinical supervision of a fully
qualified mental health provider employed by the RTC. All other program
services shall be provided by trained, licensed staff.
(3) Patient rights.
(i) The RTC shall provide adequate protection for all patient
rights, including rights provided by law, privacy, personnel rights,
safety, confidentiality, informed consent, grievances, and personal
dignity.
(ii) The facility has a written policy regarding patient abuse and
neglect.
(iii) Facility marketing and advertising meets professional
standards.
(4) Behavioral management. The RTC shall adhere to a comprehensive,
written plan of behavioral management, developed by the clinical
director and the medical or professional staff and approved by the
governing body, including strictly limited procedures to assure that
the restraint or seclusion are used only in extraordinary
circumstances, are carefully monitored, and are fully documented. Only
trained and clinically privileged RNs or qualified mental health
professionals may be responsible for the implementation of seclusion
and restraint procedures in an emergency situation.
(5) Admission process. The RTC shall maintain written policies and
procedures to ensure that, prior to an admission, a determination is
made, and approved pursuant to CHAMPUS preauthorization requirements,
that the admission is medically and/or psychologically necessary and
the program is appropriate to meet the patient's needs. Medical and/or
psychological necessity determinations shall be rendered by qualified
mental health professionals who meet CHAMPUS requirements for
individual professional providers and who are permitted by law and by
the facility to refer patients for admission.
(6) Assessments. The professional staff of the RTC shall complete a
current multidisciplinary assessment which includes, but is not limited
to physical, psychological, developmental, family, educational, social,
spiritual and skills assessment of each patient admitted. Unless
otherwise specified, all required clinical assessments are completed
prior to development of the multidisciplinary treatment plan.
(7) Clinical formulation. A qualified mental health professional of
the RTC will complete a clinical formulation on all patients. The
clinical formulation will be reviewed and approved by the responsible
individual professional provider and will incorporate significant
findings from each of the multidisciplinary assessments. It will
provide the basis for development of an interdisciplinary treatment
plan.
(8) Treatment planning. A qualified mental health professional
shall be responsible for the development, supervision, implementation,
and assessment of a written, individualized, interdisciplinary plan of
treatment, which shall be completed within 10 days of admission and
shall include individual, measurable, and observable goals for
incremental progress and discharge. A preliminary treatment plan is
completed within 24 hours of admission and includes at least an
admission note and orders written by the admitting mental health
professional. The master treatment plan is reviewed and revised at
least every 30 days, or when major changes occur in treatment.
(9) Discharge and transition planning. The RTC shall maintain a
transition planning process to address adequately the anticipated needs
of the patient prior to the time of discharge. The planning involves
determining necessary modifications in the treatment plan, facilitating
the termination of treatment, and identifying resources to maintain
therapeutic stability following discharge.
(10) Clinical documentation. Clinical records shall be maintained
on each patient to plan care and treatment and provide ongoing
evaluation of the patient's progress. All care is documented and each
clinical record contains at least the following: demographic data,
consent forms, pertinent legal documents, all treatment plans and
patient assessments, consultation and laboratory reports, physician
orders, progress notes, and a discharge summary. All documentation will
adhere to applicable provisions of the JCAHO and requirements set forth
in Sec. 199.7(b)(3). An appropriately qualified records administrator
or technician will supervise and maintain the quality of the records.
These requirements are in addition to other records requirements of
this Part, and documentation requirements of the Joint Commission on
Accreditation of Healthcare Organizations.
(11) Progress notes. RTC's shall document the course of treatment
for patients and families using progress notes which provide
information to review, analyze, and modify the treatment plans.
Progress notes are legible, contemporaneous, sequential, signed and
dated and adhere to applicable provisions of the Manual of Mental
Health, Chemical Dependency, and Mental Retardation/Development
Disabilities Services and requirements set forth in Sec. 199.7(b)(3).
(12) Therapeutic services.
(i) Individual, group, and family psychotherapy are provided to all
patients, consistent with each patient's treatment plan, by qualified
mental health providers.
(ii) A range of therapeutic activities, directed and staffed by
qualified [[Page 12429]] personnel, are offered to help patients meet
the goals of the treatment plan.
(iii) Therapeutic educational services are provided or arranged
that are appropriate to the patients educational and therapeutic needs.
(13) Ancillary services. A full range of ancillary services is
provided. Emergency services include policies and procedures for
handling emergencies with qualified personnel and written agreements
with each facility providing the service. Other ancillary services
include physical health, pharmacy and dietary services.
(C) Standards for physical plant and environment.
(1) Physical environment. The buildings and grounds of the RTC
shall be maintained so as to avoid health and safety hazards, be
supportive of the services provided to patients, and promote patient
comfort, dignity, privacy, personal hygiene, and personal safety.
(2) Physical plant safety. The RTC shall be of permanent
construction and maintained in a manner that protects the lives and
ensures the physical safety of patients, staff, and visitors, including
conformity with all applicable building, fire, health, and safety
codes.
(3) Disaster planning. The RTC shall maintain and rehearse written
plan for taking care of casualities and handling other consequences
arising from internal and external disasters.
(D) Standards for evaluation system.
(1) Quality assessment and improvement. The RTC shall develop and
implement a comprehensive quality assurance and quality improvement
program that monitors the quality, efficiency, appropriateness, and
effectiveness of the care, treatments, and services it provides for
patients and their families, primarily utilizing explicit clinical
indicators to evaluate all functions of the RTC and contribute to an
ongoing process of program improvement. The clinical director is
responsible for developing and implementing quality assessment and
improvement activities throughout the facility.
(2) Utilization review. The RTC shall implement a utilization
review process, pursuant to a written plan approved by the professional
staff, the administration, and the governing body, that assesses the
appropriateness of admission, continued stay, and timeliness of
discharge as part of an effort to provide quality patient care in a
cost-effective manner. Findings of the utilization review process are
used as a basis for revising the plan of operation, including a review
of staff qualifications and staff composition.
(3) Patient records review. The RTC shall implement a process,
including monthly reviews of a representative sample of patient
records, to determine the completeness and accuracy of the patient
records and the timeliness and pertinence of record entries,
particularly with regard to regular recording of progress/non-progress
in treatment.
(4) Drug utilization review. The RTC shall implement a
comprehensive process for the monitoring and evaluating of the
prophylactic, therapeutic, and empiric use of drugs to assure that
medications are provided appropriately, safely, and effectively.
(5) Risk management. The RTC shall implement a comprehensive risk
management program, fully coordinated with other aspects of the quality
assurance and quality improvement program, to prevent and control risks
to patients and staff and costs associated with clinical aspects of
patient care and safety.
(6) Infection control. The RTC shall implement a comprehensive
system for the surveillance, prevention, control, and reporting of
infections acquired or brought into the facility.
(7) Safety. The RTC shall implement an effective program to assure
a safe environment for patients, staff, and visitors, including an
incident report system, a continuous safety surveillance system, and an
active multidisciplinary safety committee.
(8) Facility evaluation. The RTC annually evaluates accomplishment
of the goals and objectives of each clinical program and service of the
RTC and reports findings and recommendations to the governing body.
(E) Participation agreement requirements. In addition to other
requirements set forth in paragraph (b)(4)(vii), of this section in
order for the services of an RTC to be authorized, the RTC shall have
entered into a Participation Agreement with OCHAMPUS. The period of a
participation agreement shall be specified in the agreement, and will
generally be for not more than five years. Participation agreements
entered into prior April 6, 1995 must be renewed not later than October
1, 1995. In addition to review of a facility's application and
supporting documentation, an on-site inspection by OCHAMPUS authorized
personnel may be required prior to signing a Participation Agreement.
Retroactive approval is not given. In addition, the Participation
Agreement shall include provisions that the RTC shall, at a minimum:
(1) Render residential treatment center impatient services to
eligible CHAMPUS beneficiaries in need of such services, in accordance
with the participation agreement and CHAMPUS regulation;
(2) Accept payment for its services based upon the methodology
provided in Sec. 199.14(f) or such other method as determined by the
Director, OCHAMPUS;
(3) Accept the CHAMPUS all-inclusive per diem rate as payment in
full and collect from the CHAMPUS beneficiary or the family of the
CHAMPUS beneficiary only those amounts that represent the beneficiary's
liability, as defined in section 199.4, and charges for services and
supplies that are not a benefit of CHAMPUS;
(4) Make all reasonable efforts acceptable to the Director,
OCHAMPUS, to collect those amounts, which represents the beneficiary's
liability, as defined in Sec. 199.4;
(5) Comply with the provisions of Sec. 199.8, and submit claims
first to all health insurance coverage to which the beneficiary is
entitled that is primary to CHAMPUS;
(6) Submit claims for services provided to CHAMPUS beneficiaries at
least 30 days (except to the extent a delay is necessitated by efforts
to first collect from other health insurance). If claims are not
submitted at least every 30 days, the RTC agrees not to bill the
beneficiary or the beneficiary's family for any amounts disallowed by
CHAMPUS;
(7) Certify that:
(i) It is and will remain in compliance with the provisions of
paragraph (b)(4)(vii) of this section establishing standards for
Residential Treatment Centers;
(ii) It has conducted a self assessment of the facility's
compliance with the CHAMPUS Standards for Residential Treatment Centers
Serving Children and Adolescents with Mental Disorders, as issued by
the Director, OCHAMPUS and notified the Director, OCHAMPUS of any
matter regarding which the facility is not in compliance with such
standards; and
(iii) It will maintain compliance with the CHAMPUS Standards for
Residential Treatment Centers Serving Children and Adolescents with
Mental Disorders, as issued by the Director, OCHAMPUS, except for any
such standards regarding which the facility notifies the Director,
OCHAMPUS that it is not in compliance.
(8) Designate an individual who will act as liaison for CHAMPUS
inquiries. The RTC shall inform OCHAMPUS in writing of the designated
individual;
(9) Furnish OCHAMPUS, as requested by OCHAMPUS, with cost data
certified [[Page 12430]] by an independent accounting firm or other
agency as authorized by the Director, OCHAMPUS;
(10) Comply with all requirements of this section applicable to
institutional providers generally concerning preauthorization,
concurrent care review, claims processing, beneficiary liability,
double coverage, utilization and quality review and other matters;
(11) Grant the Director, OCHAMPUS, or designee, the right to
conduct quality assurance audits or accounting audits with full access
to patients and records (including records relating to patients who are
not CHAMPUS beneficiaries) to determine the quality and cost-
effectiveness of care rendered. The audits may be conducted on a
scheduled or unscheduled (unannounced) basis. This right to audit/
review includes, but is not limited to:
(i) Examination of fiscal and all other records of the RTC which
would confirm compliance with the participation agreement and
designation as an authorized CHAMPUS RTC provider;
(ii) Conducting such audits of RTC records including clinical,
financial, and census records, as may be necessary to determine the
nature of the services being provided, and the basis for charges and
claims against the United States for services provided CHAMPUS
beneficiaries;
(iii) Examining reports of evaluations and inspections conducted by
federal, state and local government, and private agencies and
organizations;
(iv) Conducting on-site inspections of the facilities of the RTC
and interviewing employees, members of the staff, contractors, board
members, volunteers, and patients, as required;
(v) Audits conducted by the United States General Accounting
Office.
(F) Other requirements applicable to RTCs.
(1) Even though an RTC may qualify as a CHAMPUS-authorized provider
and may have entered into a participation agreement with CHAMPUS,
payment by CHAMPUS for particular services provided is contingent upon
the RTC also meeting all conditions set forth in section 199.4
especially all requirements of paragraph (b)(4) of that section.
(2) The RTC shall provide inpatient services to CHAMPUS
beneficiaries in the same manner it provides inpatient services to all
other patients. The RTC may not discriminate against CHAMPUS
beneficiaries in any manner, including admission practices, placement
in special or separate wings or rooms, or provisions of special or
limited treatment.
(3) The RTC shall assure that all certifications and information
provided to the Director, OCHAMPUS incident to the process of obtaining
and retaining authorized provider status is accurate and that it has no
material errors or omissions. In the case of any misrepresentations,
whether by inaccurate information being provided or material facts
withheld, authorized status will be denied or terminated, and the RTC
will be ineligible for consideration for authorized provider status for
a two year period.
* * * * *
(xii) Psychiatric partial hospitalization programs. Paragraph
(b)(4)(xii) of this section establishes standards and requirements for
psychiatric partial hospitalization programs.
(A) Organization and administration.
(1) Definition. Partial hospitalization is defined as a time-
limited, ambulatory, active treatment program that offers
therapeutically intensive, coordinated, and structured clinical
services within a stable therapeutic milieu. Partial hospitalization
programs serve patients who exhibit psychiatric symptoms, disturbances
of conduct, and decompensating conditions affecting mental health.
(2) Eligibility.
(i) Every psychiatric partial hospitalization program must be
certified pursuant to CHAMPUS certification standards. Such standards
shall incorporate the basic standards set forth in paragraphs
(b)(4)(xii) (A) through (D) of this section, and shall include such
additional elaborative criteria and standards as the Director, OCHAMPUS
determines are necessary to implement the basic standards. Each
psychiatric partial hospitalization program must be either a distinct
part of an otherwise authorized institutional provider or a
freestanding program.
(ii) To be eligible for CHAMPUS certification, the facility is
required to be licensed and fully operational for a period of at least
six months (with a minimum patient census of at least 30 percent of bed
capacity) and operate in substantial compliance with state and federal
regulations.
(iii) The facility is currently accredited by the Joint Commission
on Accreditation of Healthcare Organizations under the current edition
of the Accreditation Manual for Mental Health, Chemical Dependency, and
Mental Retardation/Developmental Disabilities Services.
(iv) The facility has a written participation agreement with
OCHAMPUS. On October 1, 1995, the PHP is not a CHAMPUS-authorized
provider and CHAMPUS benefits are not paid for services provided until
the date upon which a participation agreement is signed by the
Director, OCHAMPUS. Partial hospitalization is capable of providing an
interdisciplinary program of medical and therapeutic services a minimum
of three hours per day, five days per week, and may include full- or
half-day, evening, and weekend treatment programs.
(3) Governing body.
(i) The PHP shall have a governing body which is responsible for
the policies, bylaws, and activities of the facilities. If the PHP is
owned by a partnership or single owner, the partners or single owner
are regarded as the governing body. The facility will provide an up-to-
date list of names, addresses, telephone numbers, and titles of the
members of the governing body.
(ii) The governing body ensures appropriate and adequate services
for all patients and oversees continuing development and improvement of
care. Where business relationships exist between the governing body and
facility, appropriate conflict-of-interest policies are in place.
(iii) Board members are fully informed about facility services and
the governing body conducts annual review of its performance in meeting
purposes, responsibilities, goals and objectives.
(4) Chief executive officer. The Chief Executive Officer, appointed
by and subject to the direction of the governing body, shall assume
overall administrative responsibility for the operation of the facility
according to governing body policies. The chief executive officer shall
have five years' administrative experience in the field of mental
health. On October 1, 1997, the CEO shall possess a degree in business
administration, public health, hospital administration, nursing, social
work, or psychology, or meet similar educational requirements as
prescribed by the Director, OCHAMPUS.
(5) Clinical Director. The clinical director, appointed by the
governing body, shall be a psychiatrist or doctoral level psychologist
who meets applicable CHAMPUS requirements for individual professional
providers and is licensed to practice in the state where the PHP is
located. The clinical director shall possess requisite education and
experience, credentials applicable under state practice and licensing
laws appropriate to the professional discipline, and a minimum of five
years' clinical experience in the treatment of mental disorders
specific to the ages and [[Page 12431]] disabilities of the patients
served. The clinical director shall be responsible for planning,
development, implementation, and monitoring of all clinical activities.
(6) Medical director. The medical director, appointed by the
governing body, shall be licensed to practice medicine in the state
where the residential treatment center is located and shall possess
requisite education and experience, including graduation from an
accredited school of medicine or osteopathy, an approved residency in
psychiatry and a minimum of five years clinical experience in the
treatment of mental disorders specific to the ages and disabilities of
the patients served. The Medical Director shall be responsible for the
planning, development, implementation, and monitoring of all activities
relating to medical treatment of patients. If qualified, the Medical
Director may also serve as Clinical Director.
(7) Medical or professional staff organization. The governing body
shall establish a medical or professional staff organization to assure
effective implementation of clinical privileging, professional conduct
rules, and other activities directly affecting patient care.
(8) Personnel policies and records. The PHP shall maintain written
personnel policies, updated job descriptions, personnel records to
assure the selection of qualified personnel and successful job
performance of those personnel.
(9) Staff development. The facility shall provide appropriate
training and development programs for administrative, professional
support, and direct care staff.
(10) Fiscal accountability. The PHP shall assure fiscal
accountability to applicable government authorities and patients.
(11) Designated teaching facilities. Students, residents, interns,
or fellows providing direct clinical care are under the supervision of
a qualified staff member approved by an accredited university. The
teaching program is approved by the Director, OCHAMPUS.
(12) Emergency reports and records. The facility notifies OCHAMPUS
of any serious occurrence involving CHAMPUS beneficiaries.
(B) Treatment services.
(1) Staff composition.
(i) The PHP shall ensure that patient care needs will be
appropriately addressed during all hours of operation by a sufficient
number of fully qualified (including license, registration or
certification requirements, educational attainment, and professional
experience) health care professionals. Clinicians providing individual,
group, and family therapy meet CHAMPUS requirements as qualified mental
health providers, and operate within the scope of their licenses. The
ultimate authority for managing care is vested in a psychiatrist or
licensed doctor level psychologist. The management of medical care is
vested in a physician.
(ii) The PHP shall establish and follow written plans to assure
adequate staff coverage during all hours of operation, including
physician availability, other professional staff coverage, and support
staff in the respective disciplines.
(2) Staff qualifications. The PHP will have a sufficient number of
qualified mental health providers, administrative, and support staff to
address patients' clinical needs and to coordinate the services
provided. PHPs which employ individuals with master's or doctoral level
degrees in a mental health discipline who do not meet the licensure,
certification and experience requirements for a qualified mental health
provider but are actively working toward licensure or certification,
may provide services within the all-inclusive per diem rate, provided
the individual works under the clinical supervision of a fully
qualified mental health provider employed by the PHP. All other program
services shall be provided by trained, licensed staff.
(3) Patient rights.
(i) The PHP shall provide adequate protection for all patient
rights, including rights provided by law, privacy, personal rights,
safety, confidentiality, informed consent, grievances, and personal
dignity.
(ii) The facility has a written policy regarding patient abuse and
neglect.
(iii) Facility marketing and advertising meets professional
standards.
(4) Behavioral management. The PHP shall adhere to a comprehensive,
written plan of behavior management, developed by the clinical director
and the medical or professional staff and approved by the governing
body, including strictly limited procedures to assure that restraint or
seclusion are used only in extraordinary circumstances, are carefully
monitored, and are fully documented. Only trained and clinically
privileged RNs or qualified mental health professionals may be
responsible for implementation of seclusion and restraint procedures in
an emergency situation.
(5) Admission process. The PHP shall maintain written policies and
procedures to ensure that prior to an admission, a determination is
made, and approved pursuant to CHAMPUS preauthorization requirements,
that the admission is medically and/or psychologically necessary and
the program is appropriate to meet the patient's needs. Medical and/or
psychological necessity determinations shall be rendered by qualified
mental health professionals who meet CHAMPUS requirements for
individual professional providers and who are permitted by law and by
the facility to refer patients for admission.
(6) Assessments. The professional staff of the PHP shall complete a
multidisciplinary assessment which includes, but is not limited to
physical health, psychological health, physiological, developmental,
family, educational, spiritual, and skills assessment of each patient
admitted. Unless otherwise specified, all required clinical assessment
are completed prior to development of the interdisciplinary treatment
plan.
(7) Clinical formulation. A qualified mental health provider of the
PHP will complete a clinical formulation on all patients. The clinical
formulation will be reviewed and approved by the responsible individual
professional provider and will incorporate significant findings from
each of the multidisciplinary assessments. It will provide the basis
for development of an interdisciplinary treatment plan.
(8) Treatment planning. A qualified mental health professional with
admitting privileges shall be responsible for the development,
supervision, implementation, and assessment of a written,
individualized, interdisciplinary plan of treatment, which shall be
completed by the fifth day following admission to a full-day PHP, or by
the seventh day following admission to a half-day PHP, and shall
include measurable and observable goals for incremental progress and
discharge. The treatment plan shall undergo review at least every two
weeks, or when major changes occur in treatment.
(9) Discharge and transition planning. The PHP shall develop an
individualized transition plan which addresses anticipated needs of the
patient at discharge. The transition plan involves determining
necessary modifications in the treatment plan, facilitating the
termination of treatment, and identifying resources for maintaining
therapeutic stability following discharge.
(10) Clinical documentation. Clinical records shall be maintained
on each patient to plan care and treatment and provide ongoing
evaluation of the patient's progress. All care is documented and each
clinical record contains at least the following: demographic data,
consent forms, [[Page 12432]] pertinent legal documents, all treatment
plans and patient assessments, consultation and laboratory reports,
physician orders, progress notes, and a discharge summary. All
documentation will adhere to applicable provisions of the JCAHO and
requirements set forth in Sec. 199.7(b)(3). An appropriately qualified
records administrator or technician will supervise and maintain the
quality of the records. These requirements are in addition to other
records requirements of this Part, and documentation requirements of
the Joint Commission on Accreditation of Health Care Organization.
(11) Progress notes. PHPs shall document the course of treatment
for patients and families using progress notes which provide
information to review, analyze, and modify the treatment plans.
Progress notes are legible, contemporaneous, sequential, signed and
dated and adhere to applicable provisions of the Manual for Mental
Health, Chemical Dependency, and Mental Retardation/Developmental
Disabilities Services and requirements set forth in section
199.7(b)(3).
(12) Therapeutic services.
(i) Individual, group, and family therapy are provided to all
patients, consistent with each patient's treatment plan by qualified
mental health providers.
(ii) A range of therapeutic activities, directed and staffed by
qualified personnel, are offered to help patients meet the goals of the
treatment plan.
(iii) Educational services are provided or arranged that are
appropriate to the patient's needs.
(13) Ancillary services. A full range of ancillary services are
provided. Emergency services include policies and procedures for
handling emergencies with qualified personnel and written agreements
with each facility providing these services. Other ancillary services
include physical health, pharmacy and dietary services.
(C) Standards for physical plant and environment.
(1) Physical environment. The buildings and grounds of the PHP
shall be maintained so as to avoid health and safety hazards, be
supportive of the services provided to patients, and promote patient
comfort, dignity, privacy, personal hygiene, and personal safety.
(2) Physical plant safety. The PHP shall be of permanent
construction and maintained in a manner that protects the lives and
ensures the physical safety of patients, staff, and visitors, including
conformity with all applicable building, fire, health, and safety
codes.
(3) Disaster planning. The PHP shall maintain and rehearse written
plans for taking care of casualities and handling other consequences
arising from internal and external disasters.
(D) Standards for evaluation system.
(1) Quality assessment and improvement. The PHP shall develop and
implement a comprehensive quality assurance and quality improvement
program that monitors the quality, efficiency, appropriateness, and
effectiveness of care, treatments, and services the PHP provides for
patients and their families. Explicit clinical indicators shall be used
to be used to evaluate all functions of the PHP and contribute to an
ongoing process of program improvement. The clinical director is
responsible for developing and implementing quality assessment and
improvement activities throughout the facility.
(2) Utilization review. The PHP shall implement a utilization
review process, pursuant to a written plan approved by the professional
staff, the administration and the governing body, that assesses
distribution of services, clinical necessity of treatment,
appropriateness of admission, continued stay, and timeliness of
discharge, as part of an overall effort to provide quality patient care
in a cost-effective manner. Findings of the utilization review process
are used as a basis for revising the plan of operation, including a
review of staff qualifications and staff composition.
(3) Patient records. The PHP shall implement a process, including
regular monthly reviews of a representative sample of patient records,
to determine completeness, accuracy, timeliness of entries, appropriate
signatures, and pertinence of clinical entries. Conclusions,
recommendations, actions taken, and the results of actions are
monitored and reported.
(4) Drug utilization review. The PHP shall implement a
comprehensive process for the monitoring and evaluating of the
prophylactic, therapeutic, and empiric use of drugs to assure that
medications are provided appropriately, safely, and effectively.
(5) Risk management. The PHP shall implement a comprehensive risk
management program, fully coordinated with other aspects of the quality
assurance and quality improvement program, to prevent and control risks
to patients and staff, and to minimize costs associated with clinical
aspects of patient care and safety.
(6) Infection control. The PHP shall implement a comprehensive
system for the surveillance, prevention, control, and reporting of
infections acquired or brought into the facility.
(7) Safety. The PHP shall implement an effective program to assure
a safe environment for patients, staff, and visitors, including an
incident reporting system, disaster training and safety education, a
continuous safety surveillance system, and an active multidisciplinary
safety committee.
(8) Facility evaluation. The PHP annually evaluates accomplishment
of the goals and objectives of each clinical program component or
facility service of the PHP and reports findings and recommendations to
the governing body.
(E) Participation agreement requirements. In addition to other
requirements set forth in paragraph (b)(4)(xii) of this section, in
order for the services of a PHP to be authorized, the PHP shall have
entered into a Participation Agreement with OCHAMPUS. The period of a
Participation Agreement shall be specified in the agreement, and will
generally be for not more than five years. On October 1, 1995, the PHP
shall not be considered to be a CHAMPUS authorized provider and CHAMPUS
payments shall not be made for services provided by the PHP until the
date the participation agreement is signed by the Director, OCHAMPUS.
In addition to review of a facility's application and supporting
documentation, an on-site inspection by OCHAMPUS authorized personnel
may be required prior to signing a participation agreement. The
Participation Agreement shall include at least the following
requirements:
(1) Render partial hospitalization program services to eligible
CHAMPUS beneficiaries in need of such services, in accordance with the
participation agreement and CHAMPUS regulation.
(2) Accept payment for its services based upon the methodology
provided in section 199.14, or such other method as determined by the
Director, OCHAMPUS;
(3) Accept the CHAMPUS all-inclusive per diem rate as payment in
full and collect from the CHAMPUS beneficiary or the family of the
CHAMPUS beneficiary only those amounts that represent the beneficiary's
liability, as defined in Sec. 199.4, and charges for services and
supplies that are not a benefit of CHAMPUS;
(4) Make all reasonable efforts acceptable to the Director,
OCHAMPUS, to collect those amounts, which represent the beneficiary's
liability, as defined in Sec. 199.4;
(5) Comply with the provisions of Sec. 199.8, and submit claims
first to all health insurance coverage to which the beneficiary is
entitled that is primary to CHAMPUS; [[Page 12433]]
(6) Submit claims for services provided to CHAMPUS beneficiaries at
least every 30 days (except to the extent a delay is necessitated by
efforts to first collect from other health insurance). If claims are
not submitted at least every 30 days, the PHP agrees not to bill the
beneficiary or the beneficiary's family for any amounts disallowed by
CHAMPUS;
(7) Certify that:
(i) It is and will remain in compliance with the provisions of
paragraph (b)(4)(xii) of this section establishing standards for
psychiatric partial hospitalization programs;
(ii) It has conducted a self assessment of the facility's
compliance with the CHAMPUS Standards for Psychiatric Partial
Hospitalization Programs, as issued by the Director, OCHAMPUS, and
notified the Director, OCHAMPUS of any matter regarding which the
facility is not in compliance with such standards; and
(iii) It will maintain compliance with the CHAMPUS Standards for
Psychiatric Partial Hospitalization Programs, as issued by the
Director, OCHAMPUS, except for any such standards regarding which the
facility notifies the Director, OCHAMPUS that it is not in compliance.
(8) Designate an individual who will act as liaison for CHAMPUS
inquiries. The PHP shall inform OCHAMPUS in writing of the designated
individual;
(9) Furnish OCHAMPUS with cost data, as requested by OCHAMPUS,
certified by an independent accounting firm or other agency as
authorized by the Director, OCHAMPUS;
(10) Comply with all requirements of this section applicable to
institutional providers generally concerning preauthorization,
concurrent care review, claims processing, beneficiary liability,
double coverage, utilization and quality review and other matters;
(11) Grant the Director, OCHAMPUS, or designee, the right to
conduct quality assurance audits or accounting audits with full access
to patients and records (including records relating to patients who are
not CHAMPUS beneficiaries) to determine the quality and cost-
effectiveness of care rendered. The audits may be conducted on a
scheduled or unscheduled (unannounced) basis. This right to audit/
review includes, but is not limited to:
(i) Examination of fiscal and all other records of the PHP which
would confirm compliance with the participation agreement and
designation as an authorized CHAMPUS PHP provider;
(ii) Conducting such audits of PHP records including clinical,
financial, and census records, as may be necessary to determine the
nature of the services being provided, and the basis for charges and
claims against the United States for services provided CHAMPUS
beneficiaries;
(iii) Examining reports of evaluations and inspections conducted by
federal, state and local government, and private agencies and
organizations;
(iv) Conducting on-site inspections of the facilities of the PHP
and interreviewing employees, members of the staff, contractors, board
members, volunteers, and patients, as required;
(v) Audits conducted by the United States General Account Office.
(F) Other requirements applicable to PHPs.
(1) Even though a PHP may qualify as a CHAMPUS-authorized provider
and may have entered into a participation agreement with CHAMPUS,
payment by CHAMPUS for particular services provided is contingent upon
the PHP also meeting all conditions set forth in section 199.4 of this
part.
(2) The PHP shall provide patient services to CHAMPUS beneficiaries
in the same manner it provides inpatient services to all other
patients. The PHP may not discriminate against CHAMPUS beneficiaries in
any manner, including admission practices, placement in special or
separate wings or rooms, or provisions of special or limited treatment.
(3) The PHP shall assure that all certifications and information
provided to the Director, OCHAMPUS incident to the process of obtaining
and retaining authorized provider status is accurate and that is has no
material errors or omissions. In the case of any misrepresentations,
whether by inaccurate information being provided or material facts
withheld, authorized provider status will be denied or terminated, and
the PHP will be ineligible for consideration for authorized provider
status for a two year period.
* * * * *
(xiv) Substance use disorder rehabilitation facilities. Paragraph
(b)(4)(xiv) of this section establishes standards and requirements for
substance use order rehabilitation facilities (SUDRF). This includes
both inpatient rehabilitation centers for the treatment of substance
use disorders and partial hospitalization centers for the treatment of
substance use disorders.
(A) Organization and administration.
(1) Definition of inpatient rehabilitation center. An inpatient
rehabilitation center is a facility, or distinct part of a facility,
that provides medically monitored, interdisciplinary addiction-focused
treatment to beneficiaries who have psychoactive substance use
disorders. Qualified health care professionals provide 24-hour, seven-
day-per-week, medically monitored assessment, treatment, and
evaluation. An inpatient rehabilitation center is appropriate for
patients whose addiction-related symptoms, or concomitant physical and
emotional/behavioral problems reflect persistent dysfunction in several
major life areas. Inpatient rehabilitation is differentiated from:
(i) Acute psychoactive substance use treatment and from treatment
of acute biomedical/emotional/behavioral problems; which problems are
either life-threatening and/or severely incapacitating and often occur
within the context of a discrete episode of addiction-related
biomedical or psychiatric dysfunction;
(ii) A partial hospitalization center, which serves patients who
exhibit emotional/behavioral dysfunction but who can function in the
community for defined periods of time with support in one or more of
the major life areas;
(iii) A group home, sober-living environment, halfway house, or
three-quarter way house;
(iv) Therapeutic schools, which are educational programs
supplemented by addiction-focused services;
(v) Facilities that treat patients with primary psychiatric
diagnoses other than psychoactive substance use or dependence; and
(vi) Facilities that care for patients with the primary diagnosis
of mental retardation or developmental disability.
(2) Definition of partial hospitalization center for the treatment
of substance use disorders. A partial hospitalization center for the
treatment of substance use disorders is an addiction-focused service
that provides active treatment to adolescents between the ages of 13
and 18 or adults aged 18 and over. Partial hospitalization is a generic
term for day, evening, or weekend programs that treat patients with
psychoactive substance use disorders according to a comprehensive,
individualized, integrated schedule of care. A partial hospitalization
center is organized, interdisciplinary, and medically monitored.
Partial hospitalization is appropriate for those whose addiction-
related symptoms or concomitant physical and emotional/behavioral
problems can be managed outside the hospital environment for defined
periods of time with support in one or more of the major life
areas. [[Page 12434]]
(3) Eligibility.
(i) Every inpatient rehabilitation center and partial
hospitalization center for the treatment of substance use disorders
must be certified pursuant to CHAMPUS certification standards. Such
standards shall incorporate the basic standards set forth in paragraphs
(b)(4)(xiv) (A) through (D) of this section, and shall include such
additional elaborative criteria and standards as the Director, OCHAMPUS
determines are necessary to implement the basic standards.
(ii) To be eligible for CHAMPUS certification, the SUDRF is
required to be licensed and fully operational (with a minimum patient
census of the lesser of: six patients or 30 percent of bed capacity)
for a period of at least six months and operate in substantial
compliance with state and federal regulations.
(iii) The SUDRF is currently accredited by the Joint Commission on
Accreditation of Healthcare Organizations under the Accreditation
Manual for Mental Health, Chemical Dependency, and Mental Retardation/
Developmental Disabilities Services, or by the Commission on
Accreditation of Rehabilitation Facilities as an alcoholism and other
drug dependency rehabilitation program under the Standards Manual for
Organizations Serving People with Disabilities, or other designated
standards approved by the Director, OCHAMPUS.
(iv) The SUDRF has a written participation agreement with OCHAMPUS.
On October 1, 1995, the SUDRF is not considered a CHAMPUS-authorized
provider, and CHAMPUS benefits are not paid for services provided until
the date upon which a participation agreement is signed by the
Director, OCHAMPUS.
(4) Governing body.
(i) The SUDRF shall have a governing body which is responsible for
the policies, bylaws, and activities of the facility. If the SUDRF is
owned by a partnership or single owner, the partners or single owner
are regarded as the governing body. The facility will provide an up-to-
date list of names, addresses, telephone numbers and titles of the
members of the governing body.
(ii) The governing body ensures appropriate and adequate services
for all patients and oversees continuing development and improvement of
care. Where business relationships exist between the governing body and
facility, appropriate conflict-of-interest policies are in place.
(iii) Board members are fully informed about facility services and
the governing body conducts annual reviews of its performance in
meeting purposes, responsibilities, goals and objectives.
(5) Chief executive officer. The chief executive officer, appointed
by and subject to the direction of the governing body, shall assume
overall administrative responsibility for the operation of the facility
according to governing body policies. The chief executive officer shall
have five years' administrative experience in the field of mental
health or addictions. On October 1, 1997 the CEO shall possess a degree
in business administration, public health, hospital administration,
nursing, social work, or psychology, or meet similar educational
requirements as prescribed by the Director, OCHAMPUS.
(6) Clinical Director. The clinical director, appointed by the
governing body, shall be a qualified psychiatrist or doctoral level
psychologist who meets applicable CHAMPUS requirements for individual
professional providers and is licensed to practice in the state where
the SUDRF is located. The clinical director shall possess requisite
education and experience, including credentials applicable under state
practice and licensing laws appropriate to the professional discipline.
The clinical director shall satisfy at least one of the following
requirements: certification by the American Society of Addiction
Medicine; one year or 1,000 hours of experience in the treatment of
psychoactive substance use disorders; or is a psychiatrist or doctoral
level psychologist with experience in the treatment of substance use
disorders. The clinical director shall be responsible for planning,
development, implementation, and monitoring of all clinical activities.
(7) Medical director. The medical director, appointed by the
governing body, shall be licensed to practice medicine in the state
where the center is located and shall possess requisite education
including graduation from an accredited school of medicine or
osteopathy. The medical director shall satisfy at least one of the
following requirements: certification by the American Society of
Addiction Medicine; one year or 1,000 hours of experience in the
treatment of psychoactive substance use disorders; or is a psychiatrist
with experience in the treatment of substance use disorders. The
medical director shall be responsible for the planning, development,
implementation, and monitoring of all activities relating to medical
treatment of patients. If qualified, the Medical Director may also
serve as Clinical Director.
(8) Medical or professional staff organization. The governing body
shall establish a medical or professional staff organization to assure
effective implementation of clinical privileging, professional conduct
rules, and other activities directly affecting patient care.
(9) Personnel policies and records. The SUDRF shall maintain
written personnel policies, updated job descriptions, personnel records
to assure the selection of qualified personnel and successful job
performance of those personnel.
(10) Staff development. The SUDRF shall provide appropriate
training and development programs for administrative, support, and
direct care staff.
(11) Fiscal accountability. The SUDRF shall assure fiscal
accountability to applicable government authorities and patients.
(12) Designated teaching facilities. Students, residents, interns,
or fellows providing direct clinical care are under the supervision of
a qualified staff member approved by an accredited university or
approved training program. The teaching program is approved by the
Director, OCHAMPUS.
(13) Emergency reports and records. The facility notifies OCHAMPUS
of any serious occurrence involving CHAMPUS beneficiaries.
(B) Treatment services.
(1) Staff composition.
(i) The SUDRF shall follow written plans which assure that medical
and clinical patient needs will be appropriately addressed during all
hours of operation by a sufficient number of fully qualified (including
license, registration or certification requirements, educational
attainment, and professional experience) health care professionals and
support staff in the respective disciplines. Clinicians providing
individual, group and family therapy meet CHAMPUS requirements as
qualified mental health providers and operate within the scope of their
licenses. The ultimate authority for planning, development,
implementation, and monitoring of all clinical activities is vested in
a psychiatrist or doctoral level clinical psychologist. The management
of medical care is vested in a physician.
(ii) The SUDRF shall establish and follow written plans to assure
adequate staff coverage during all hours of operation of the center,
including physician availability and other professional staff coverage
24 hours per day, seven days per week for an inpatient rehabilitation
center and during all hours of operation for a partial hospitalization
center. [[Page 12435]]
(2) Staff qualifications. Within the scope of its programs and
services, the SUDRF has a sufficient number of professional,
administrative, and support staff to address the medical and clinical
needs of patients and to coordinate the services provided. SUDRFs that
employ individuals with master's or doctoral level degrees in a mental
health discipline who do not meet the licensure, certification and
experience requirements for a qualified mental health provider but are
actively working toward licensure or certification, may provide
services within the DRG, provided the individual works under the
clinical supervision of a fully qualified mental health provider
employed by the SUDRF.
(3) Patient rights.
(i) The SUDRF shall provide adequate protection for all patient
rights, safety, confidentiality, informed consent, grievances, and
personal dignity.
(ii) The SUDRF has a written policy regarding patient abuse and
neglect.
(iii) SUDRF marketing and advertising meets professional standards.
(4) Behavioral management. When a SUDRF uses a behavioral
management program, the center shall adhere to a comprehensive, written
plan of behavioral management, developed by the clinical director and
the medical or professional staff and approved by the governing body.
It shall be based on positive reinforcement methods and, except for
infrequent use of temporary physical holds or time outs, does not
include the use of restraint or seclusion. Only trained and clinically
privileged RNs or qualified mental health professionals may be
responsible for the implementation of seclusion and restraint in an
emergency situation.
(5) Admission process. The SUDRF shall maintain written policies
and procedures to ensure that, prior to an admission, a determination
is made, and approved pursuant to CHAMPUS preauthorization
requirements, that the admission is medically and/or psychologically
necessary and the program is appropriate to meet the patient's needs.
Medical and/or psychological necessity determinations shall be rendered
by qualified mental health professionals who meet CHAMPUS requirements
for individual professional providers and who are permitted by law and
by the facility to refer patients for admission.
(6) Assessment. The professional staff of the SUDRF shall provide a
complete, multidisciplinary assessment of each patient which includes,
but is not limited to, medical history, physical health, nursing needs,
alcohol and drug history, emotional and behavioral factors, age-
appropriate social circumstances, psychological condition, education
status, and skills. Unless otherwise specified, all required clinical
assessments are completed prior to development of the multidisciplinary
treatment plan.
(7) Clinical formulation. A qualified mental health care
professional of the SUDRF will complete a clinical formulation on all
patients. The clinical formulation will be reviewed and approved by the
responsible individual professional provider and will incorporate
significant findings from each of the multidisciplinary assessments. It
will provide the basis for development of an interdisciplinary
treatment plan.
(8) Treatment planning. A qualified health care professional with
admitting privileges shall be responsible for the development,
supervision, implementation, and assessment of a written,
individualized, and interdisciplinary plan of treatment, which shall be
completed within 10 days of admission to an inpatient rehabilitation
center or by the fifth day following admission to full day partial
hospitalization center, and by the seventh day of treatment for half
day partial hospitalization. The treatment plan shall include
individual, measurable, and observable goals for incremental progress
towards the treatment plan objectives and goals and discharge. A
preliminary treatment plan is completed within 24 hours of admission
and includes at least a physician's admission note and orders. The
master treatment plan is regularly reviewed for effectiveness and
revised when major changes occur in treatment.
(9) Discharge and transition planning. The SUDRF shall maintain a
transition planning process to address adequately the anticipated needs
of the patient prior to the time of discharge.
(10) Clinical documentation. Clinical records shall be maintained
on each patient to plan care and treatment and provide ongoing
evaluation of the patient's progress. All care is documented and each
clinical record contains at least the following: demographic data,
consent forms, pertinent legal documents, all treatment plans and
patient assessments, consultation and laboratory reports, physician
orders, progress notes, and a discharge summary. All documentation will
adhere to applicable provisions of the JCAHO and requirements set forth
in Sec. 199.7(b)(3). An appropriately qualified records administrator
or technician will supervise and maintain the quality of the records.
These requirements are in addition to other records requirements of
this Part, and provisions of the JCAHO Manual for Mental Health,
Chemical Dependency, and Mental Retardation/Developmental Disabilities
Services.
(11) Progress notes. Timely and complete progress notes shall be
maintained to document the course of treatment for the patient and
family.
(12) Therapeutic services.
(i) Individual, group, and family psychotherapy and addiction
counseling services are provided to all patients, consistent with each
patient's treatment plan by qualified mental health providers.
(ii) A range of therapeutic activities, directed and staffed by
qualified personnel, are offered to help patients meet the goals of the
treatment plan.
(iii) Therapeutic educational services are provided or arranged
that are appropriate to the patient's educational and therapeutic
needs.
(13) Ancillary services. A full range of ancillary services is
provided. Emergency services include policies and procedures for
handling emergencies with qualified personnel and written agreements
with each facility providing the service. Other ancillary services
include physical health, pharmacy and dietary services.
(C) Standards for physical plant and environment.
(1) Physical environment. The buildings and grounds of the SUDRF
shall be maintained so as to avoid health and safety hazards, be
supportive of the services provided to patients, and promote patient
comfort, dignity, privacy, personal hygiene, and personal safety.
(2) Physical plant safety. The SUDRF shall be maintained in a
manner that protects the lives and ensures the physical safety of
patients, staff, and visitors, including conformity with all applicable
building, fire, health, and safety codes.
(3) Disaster planning. The SUDRF shall maintain and rehearse
written plans for taking care of casualties and handling other
consequences arising from internal or external disasters.
(D) Standards for evaluation system.
(1) Quality assessment and improvement. The SUDRF develop and
implement a comprehensive quality assurance and quality improvement
program that monitors the quality, efficiency, appropriateness, and
effectiveness of the care, treatments, and services it provides for
patients and their families, utilizing clinical indicators of
effectiveness to contribute to an ongoing process of program
improvement. The clinical director is [[Page 12436]] responsible for
developing and implementing quality assessment and improvement
activities throughout the facility.
(2) Utilization review. The SUDRF shall implement a utilization
review process, pursuant to a written plan approved by the professional
staff, the administration, and the governing body, that assesses the
appropriateness of admissions, continued stay, and timeliness of
discharge as part of an effort to provide quality patient care in a
cost-effective manner. Findings of the utilization review process are
used as a basis for revising the plan of operation, including a review
of staff qualifications and staff composition.
(3) Patient records review. The center shall implement a process,
including monthly reviews of a representative sample of patient
records, to determine the completeness and accuracy of the patient
records and the timeliness and pertinence of record entries,
particularly with regard to regular recording of progress/non-progress
in treatment plan.
(4) Drug utilization review. An inpatient rehabilitation center
and, when applicable, a partial hospitalization center, shall implement
a comprehensive process for the monitoring and evaluating of the
prophylactic, therapeutic, and empiric use of drugs to assure that
medications are provided appropriately, safely, and effectively.
(5) Risk management. The SUDRF shall implement a comprehensive risk
management program, fully coordinated with other aspects of the quality
assurance and quality improvement program, to prevent and control risks
to patients and staff and costs associated with clinical aspects of
patient care and safety.
(6) Infection control. The SUDRF shall implement a comprehensive
system for the surveillance, prevention, control, and reporting of
infections acquired or brought into the facility.
(7) Safety. The SUDRF shall implement an effective program to
assure a safe environment for patients, staff, and visitors.
(8) Facility evaluation. The SUDRF annually evaluates
accomplishment of the goals and objectives of each clinical program and
service of the SUDRF and reports findings and recommendations to the
governing body.
(E) Participation agreement requirements. In addition to other
requirements set forth in paragraph (b)(4)(xiv) of this section, in
order for the services of an inpatient rehabilitation center or partial
hospitalization center for the treatment of substance abuse disorders
to be authorized, the center shall have entered into a Participation
Agreement with OCHAMPUS. The period of a Participation Agreement shall
be specified in the agreement, and will generally be for not more than
five years. On October 1, 1995, the SUDRF shall not be considered to be
a CHAMPUS authorized provider and CHAMPUS payments shall not be made
for services provided by the SUDRF until the date the participation
agreement is signed by the Director, OCHAMPUS. In addition to review of
the SUDRFS application and supporting documentation, an on-site visit
by OCHAMPUS representatives may be part of the authorization process.
In addition, such a Participation Agreement may not be signed until an
SUDRF has been licensed and operational for at least six months. The
Participation Agreement shall include at least the following
requirements:
(1) Render applicable services to eligible CHAMPUS beneficiaries in
need of such services, in accordance with the participation agreement
and CHAMPUS regulation;
(2) Accept payment for its services based upon the methodology
provided in Sec. 199.14, or such other method as determined by the
Director, OCHAMPUS;
(3) Accept the CHAMPUS-determined rate as payment in full and
collect from the CHAMPUS beneficiary or the family of the CHAMPUS
beneficiary only those amounts that represent the beneficiary's
liability, as defined in Sec. 199.4, and charges for services and
supplies that are not a benefit of CHAMPUS;
(4) Make all reasonable efforts acceptable to the Director,
OCHAMPUS, to collect those amounts which represent the beneficiary's
liability, as defined in Sec. 199.4;
(5) Comply with the provisions of Sec. 199.8, and submit claims
first to all health insurance coverage to which the beneficiary is
entitled that is primary to CHAMPUS;
(6) Furnish OCHAMPUS with cost data, as requested by OCHAMPUS,
certified to by an independent accounting firm or other agency as
authorized by the Director, OCHAMPUS;
(7) Certify that:
(i) It is and will remain in compliance with the provisions of
paragraph (b)(4)(xiv) of the section establishing standards for
substance use disorder rehabilitation facilities;
(ii) It has conducted a self assessment of the SUDRF'S compliance
with the CHAMPUS Standards for Substance Use Disorder Rehabilitation
Facilities, as issued by the Director, OCHAMPUS, and notified the
Director, OCHAMPUS of any matter regarding which the facility is not in
compliance with such standards; and
(iii) It will maintain compliance with the CHAMPUS Standards for
Substance Use Disorder Rehabilitation Facilities, as issued by the
Director, OCHAMPUS, except for any such standards regarding which the
facility notifies the Director, OCHAMPUS that it is not in compliance.
(8) Grant the Director, OCHAMPUS, or designee, the right to conduct
quality assurance audits or accounting audits with full access to
patients and records (including records relating to patients who are
not CHAMPUS beneficiaries) to determine the quality and cost
effectiveness of care rendered. The audits may be conducted on a
scheduled or unscheduled (unannounced) basis. This right to audit/
review included, but is not limited to:
(i) Examination of fiscal and all other records of the center which
would confirm compliance with the participation agreement and
designation as an authorized CHAMPUS provider;
(ii) Conducting such audits of center records including clinical,
financial, and census records, as may be necessary to determine the
nature of the services being provided, and the basis for charges and
claims against the United States for services provided CHAMPUS
beneficiaries;
(iii) Examining reports of evaluations and inspection conducted by
federal, state and local government, and private agencies and
organizations;
(iv) Conducting on-site inspections of the facilities of the SUDRF
and interviewing employees, members of the staff, contractors, board
members, volunteers, and patients, as required.
(v) Audits conducted by the United States General Accounting
Office.
(F) Other requirements applicable to substance use disorder
rehabilitation facilities.
(1) Even though a SUDRF may qualify as a CHAMPUS-authorized
provider and may have entered into a participation agreement with
CHAMPUS, payment by CHAMPUS for particular services provided is
contingent upon the SUDRF also meeting all conditions set forth in
Sec. 199.4.
(2) The center shall provide inpatient services to CHAMPUS
beneficiaries in the same manner it provides services to all other
patients. The center may not discriminate against CHAMPUS beneficiaries
in any manner, including admission practices, placement in special or
separate wings or rooms, or [[Page 12437]] provisions of special or
limited treatment.
(3) The substance use disorder facility shall assure that all
certifications and information provided to the Director, OCHAMPUS
incident to the process of obtaining and retaining authorized provider
status is accurate and that it has no material errors or omissions. In
the case of any misrepresentations, whether by inaccurate information
being provided or material facts withheld, authorized provider status
will be denied or terminated, and the facility will be ineligible for
consideration for authorized provider status for a two year period.
* * * * *
4. Section 199.14 is amended by designating the current text of
paragraph (a)(2)(ii)(A) as paragraph (a)(2)(ii)(A)(1), revising
paragraphs (a)(2)(ii)(B) and (a)(2)(iv)(C), the heading of paragraph
(a)(2)(ix), paragraphs (a)(2)(ix)(A), (a)(2)(ix)(C), (f)(3), and
(f)(5), and by adding new paragraphs (a)(1)(ii)(F), (a)(2)(ii)(A)(2),
and (f)(6) as follows:
Sec. 199.14 Provider reimbursement methods.
(a) Hospitals. * * *
(1) CHAMPUS Diagnosis Related Group (DRG)-based payment system. * *
*
(ii) Applicability of the DRG system. * * *
(F) Substance Use Disorder Rehabilitation facilities.
With admissions on or after July 1, 1995, substance use disorder
rehabilitation facilities, authorized under Sec. 199.6(b)(4)(xiv), are
subject to the DRG-based payment system.
* * * * *
(2) CHAMPUS mental health per diem payment system.
* * * * *
(ii) Hospital-specific per diems for higher volume hospitals and
units. * * *
(A) Per diem amount. * * *
(2) In states that have implemented a payment system in connection
with which hospitals in that state have been exempted from the CHAMPUS
DRG-based payment system pursuant to paragraph (a)(1)(ii)(A) of this
section, psychiatric hospitals and units may have per diem amounts
established based on the payment system applicable to such hospitals
and units in the state. The per diem amount, however, may not exceed
the cap amount applicable to other higher volume hospitals.
(B) Cap.
(1) As it affects payment for care provided to patients prior to
April 6, 1995, the base period per diem amount may not exceed the 80th
percentile of the average daily charge weighted for all discharges
throughout the United States from all higher volume hospitals.
(2) Applicable to payments for care provided to patients on or
after April 6, 1996, the base period per diem amount may not exceed the
70th percentile of the average daily charge weighted for all discharges
throughout the United States from all higher volume hospitals. For this
purpose, base year charges shall be deemed to be charges during the
period of July 1, 1991 to June 30, 1992, adjusted to correspond to base
year (FY 1988) charges by the percentage change in average daily
charges for all higher volume hospitals and units between the period of
July 1, 1991 to June 30, 1992 and the base year.
* * * * *
(iv) Base period and update factors.
* * * * *
(C) Update factors.
(1) The hospital-specific per diems and the regional per diems
calculated for the base period pursuant to paragraphs (a)(2)(ii) of
this section shall remain in effect for federal fiscal year 1989; there
will be no additional update for fiscal year 1989.
(2) Except as provided in paragraph (a)(2)(iv)(C)(3) of this
section, for subsequent federal fiscal years, each per diem shall be
updated by the Medicare update factor for hospitals and units exempt
from the Medicare prospective payment system.
(3) As an exception to the update required by paragraph
(a)(2)(iv)(C)(2) of this section, all per diems in effect at the end of
fiscal year 1995 shall remain in effect, with no additional update,
throughout fiscal years 1996 and 1997. For fiscal year 1998 and
thereafter, the per diems in effect at the end of fiscal year 1997 will
be updated in accordance with paragraph (a)(2)(iv)(C)(2).
(4) Hospitals and units with hospital-specific rates will be
notified of their respective rates prior to the beginning of each
Federal fiscal year. New hospitals shall be notified at such time as
the hospital rate is determined. The actual amounts of each regional
per diem that will apply in any Federal fiscal year shall be published
in the Federal Register at approximately the start of that fiscal year.
* * * * *
(ix) Per diem payment for psychiatric and substance use disorder
rehabilitation partial hospitalization services.
(A) In general. Psychiatric and substance use disorder
rehabilitation partial hospitalization services authorized by
Sec. 199.4 (b)(10) and (e)(4) and provided by institutional providers
authorized under Sec. 199.6 (b)(4)(xii) and (b)(4)(xiv), are reimbursed
on the basis of prospectively determined, all-inclusive per diem rates.
The per diem payment amount must be accepted as payment in full for all
institutional services provided, including board, routine nursing
services, ancillary services (includes art, music, dance, occupational
and other such therapies), psychological testing and assessments,
overhead and any other services for which the customary practice among
similar providers is included as part of the institutional charges.
* * * * *
(C) Per diem rate. For any full day partial hospitalization program
(minimum of 6 hours), the maximum per diem payment amount is 40 percent
of the average inpatient per diem amount per case established under the
CHAMPUS mental health per diem reimbursement system for both high and
low volume psychiatric hospitals and units (as defined in
Sec. 199.14(a)(2)) for the fiscal year. A partial hospitalization
program of less than 6 hours (with a minimum of three hours) will be
paid a per diem rate of 75 percent of the rate for a full-day program.
* * * * *
(f) Reimbursement of Residential Treatment Centers.
* * * * *
(3) For care on or after April 6, 1995, the per diem amount may not
exceed a cap of the 70th percentile of all established Federal fiscal
year 1994 RTC rates nationally, weighted by total CHAMPUS days provided
at each rate during the first half of Federal fiscal year 1994, and
updated to FY95. For Federal fiscal years 1996 and 1997, the cap shall
remain unchanged. For Federal fiscal years after fiscal year 1997, the
cap shall be adjusted by the Medicare update factor for hospitals and
units exempt from the Medicare prospective payment system.
* * * * *
(5) Subject to the applicable RTC cap, adjustments to the RTC rates
may be made annually.
(i) For Federal fiscal years through 1995, the adjustment shall be
based on the Consumer Price Index-Urban (CPI-U) for medical care as
determined applicable by the Director, OCHAMPUS.
(ii) For purposes of rates for Federal fiscal years 1996 and 1997:
(A) for any RTC whose 1995 rate was at or above the thirtieth
percentile of all established Federal fiscal year 1995 RTC rates
normally, weighted by total CHAMPUS days provided at each rate during
the first half of Federal fiscal [[Page 12438]] year 1994, that rate
shall remain in effect, with no additional update, throughout fiscal
years 1996 and 1997; and
(B) For any RTC whose 1995 rate was below the 30th percentile level
determined under paragraph (f)(5)(ii)(A) of this section, the rate
shall be adjusted by the lesser of: the CPI-U for medical care, or the
amount that brings the rate up to that 30th percentile level.
(iii) For subsequent Federal fiscal years after fiscal year 1997,
RTC rates shall be updated by the Medicare update factor for hospitals
and units exempt from the Medicare prospective payment system.
(6) For care provided on or after July 1, 1995, CHAMPUS will not
pay for days in which the patient is absent on leave from the RTC. The
RTC must identify these days when claiming reimbursement.
Dated: March 1, 1995.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 95-5375 Filed 3-6-95; 8:45 am]
BILLING CODE 5000-04-M