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TITLE 28INSURANCE
PART 1TEXAS DEPARTMENT OF INSURANCE
CHAPTER 3LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES
SUBCHAPTER HHSTANDARDS FOR REASONABLE COST CONTROL AND UTILIZATION REVIEW FOR CHEMICAL DEPENDENCY TREATMENT CENTERS
RULE §3.8011Admission Criteria for Inpatient Rehabilitation/Treatment (Hospital or 24-hour Residential) Services

An individual is considered eligible for admission to a residential rehabilitation/treatment service when the individual meets the required conditions of paragraphs (1) and (2) of this section.

  (1) Diagnosis. The diagnosis must meet the criteria for the definition of chemical dependence, as detailed in the most current revision of the international classification of diseases, or the most current revision of the diagnostic and statistical manual for professional practitioners, accompanied by evidence that some of the symptoms have persisted for at least one month or have occurred repeatedly over a longer period of time.

  (2) Other factors for admission to residential rehabilitation/treatment services. Once the diagnostic criteria for chemical dependency have been met, the patient must meet the conditions of each of the subparagraphs (A)-(D) of this paragraph, in order to be eligible for treatment provided in an adult residential rehabilitation/treatment service program. Once the diagnostic criteria for chemical dependency have been met, the patient must meet the conditions of each of the subparagraphs (A)-(F) of this paragraph in order to be eligible for treatment provided in an adolescent residential rehabilitation/treatment service program.

    (A) Category 1: medical functioning. The patient must meet the criteria in clauses (i) and (ii) of this subparagraph.

      (i) A documented medical assessment following admission (except in instances in which the patient is being referred from an inpatient service) indicates that the patient is medically stable and not in acute withdrawal.

      (ii) The patient is not bed-confined or has no medical complications that would hamper participation in the residential service.

    (B) Category 2: family, social, or academic dysfunction and logistic impairments. The patient must meet the criteria in at least one clause out of clauses (i)-(v) in this subparagraph.

      (i) The patient manifests severe social isolation or withdrawal from social contacts.

      (ii) The patient lives in an environment (social and interpersonal network) in which treatment is unlikely to succeed (e.g., a chaotic family dominated by interpersonal conflict which undermines patient's efforts to change).

      (iii) Patient's family and/or significant others are opposed to the patient's treatment efforts and are not willing to participate in the treatment process.

      (iv) Family members and/or significant other(s) living with the patient manifest current chemical dependence disorders, and are likely to undermine treatment.

      (v) Logistic impairments (e.g., distance from treatment facility, mobility limitations, etc.) preclude participation in a partial hospitalization or outpatient treatment service.

    (C) Category 3: emotional/behavioral status. The patient must meet the criteria in all three of the clauses (i)-(iii) of this subparagraph.

      (i) Patient is coherent, rational, and oriented for treatment.

      (ii) Mental state of the patient does not preclude the patient's ability to:

        (I) comprehend and understand the materials presented; and

        (II) participate in rehabilitation/treatment process.

      (iii) There is documentation that:

        (I) with continued treatment the patient will be able to improve and/or internalize the patient's motivation toward recovery within the recommended length of stay time frames (e.g., becoming less defensive, verbalizing, and working on alcohol and/or drug related issues, etc.);

        (II) interventions, treatment goals, and/or contracts are in place to help the patient deal with or confront the blocks to treatment (e.g., family intervention, employee counseling confrontation, etc.).

    (D) Category 4: recent chemical substance use. The patient must meet the criteria in at least one clause out of clauses (i) and (ii) of this subparagraph.

      (i) The patient's chemical substance use is excessive, and the patient has attempted to reduce or control it, but has been unable to do so (as long as chemical substances are available).

      (ii) Virtually all of the patient's daily activities revolve around obtaining, using, and/or recuperating from the effects of chemical substances and the patient requires a secured environment to control the patient's access to chemical substances.

    (E) Category 5: maturation level. The patient must meet the criteria in both clauses (i) and (ii) of this subparagraph.

      (i) The adolescent is assessed as manifesting physical maturation at least in middle adolescent range (i.e., post pubescent; not growth retarded).

      (ii) The history of the adolescent reflects cognitive development of at least 11 years of age.

    (F) Category 6: developmental status. The adolescent patient must display:

      (i) documented history of inability to function within the expected age norms despite normal cognitive and physical maturation (e.g., refusal to interact with family members, overt prostitution, felony, other criminal charges, etc.); and/or

      (ii) a recent history of moderate to severe conduct disorder, as defined in the Diagnostic and Statistical Manual, or impulsive disregard for social norms and rights of others; and/or

      (iii) documented difficulty in meeting developmental expectations in a major area of functioning (e.g., social, academic, or psychosexual) to an extent which interferes with the capacity to remain behaviorally stable.


Source Note: The provisions of this §3.8011 adopted to be effective August 28, 1991, 16 TexReg 4403.

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