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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 §3.8015Admission Criteria for Partial Hospitalization Services

An individual is considered eligible for partial hospitalization admission when the individual meets the conditions of paragraphs (1) and (2) of this section.

  (1) Criteria for the definition of chemical dependence. 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 adult and/or adolescent partial hospitalization service. The individual has met the diagnostic criteria for chemical dependency in paragraph (1) of this section and must meet the conditions of all four subparagraphs (A)-(D) of this paragraph.

    (A) Category 1: medical functioning. All the conditions in clauses (i)-(iii) of this subparagraph must be met, as follows:

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

      (ii) the absence of any medical or physical complications that would hamper the patient's participation in the partial hospitalization program; and

      (iii) logistic impairments (e.g., distance from treatment facility, mobility limitations, etc.) that would preclude participation in an outpatient treatment service.

    (B) Category 2: family, social, academic dysfunction. The individual must meet the conditions in at least one clause out of clauses (i) and (ii) of this subparagraph.

      (i) Patient's social system and significant others are supportive of recovery to the extent that the patient can adhere to a treatment plan and treatment service schedules without substantial risk of reactivating the patient's addiction.

      (ii) Patient's family and/or significant others are willing to participate in the partial hospitalization program.

    (C) Category 3: emotional/behavioral status. The individual must meet the conditions of all three clauses of 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.); and

        (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 alcohol/drug chemical substance use. The individual must meet the conditions 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.


Source Note: The provisions of this §3.8015 adopted to be effective August 28, 1991, 16 TexReg 4403.

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