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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 §3.8019Admission Criteria for Intensive Outpatient Rehabilitation/Treatment Service

(a) An intensive outpatient rehabilitation/treatment service is defined as one consisting of at least 10 hours per week for four to 12 weeks, but less than 24 hours per day.

(b) An individual is considered eligible for treatment in an outpatient service when the individual meets the conditions of paragraph (3) of this subsection, as well as the conditions of paragraph (1) or (2) of this subsection.

  (1) 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) Concerning diagnosis of alcohol/drug abuse, the individual must meet the criteria for the definition of chemical substance abuse, as detailed in either the most current revision of the international classification of diseases, or the most current revision of the diagnostic and statistical manual for professional practitioners.

  (3) Concerning factors for admission to an intensive outpatient rehabilitation/treatment service, the patient must have met the diagnostic criteria for chemical dependency under paragraph (1) of this subsection or for abuse under paragraph (2) of this subsection, and must meet the conditions of all four of the subparagraphs (A)-(D) of this paragraph.

    (A) Category 1: medical functioning. The patient must meet the following criterion: the patient is not bed-confined or has no medical complications that would hamper the patient's participation in the outpatient service.

    (B) Category 2: family, social, academic dysfunction. The patient must meet the criteria of 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 has no primary or social support system to assist with immediate recovery, but has the social skills to obtain such a support system or to become involved in a self-help fellowship.

    (C) Category 3: emotional/behavioral status. The patient must meet the criteria under all three 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 the patient expresses an interest to work toward rehabilitation/treatment goals.

    (D) Category 4: recent chemical substance use. The patient must meet the following criterion: the patient's chemical substance use is excessive and maladaptive.


Source Note: The provisions of this §3.8019 adopted to be effective August 28, 1991, 16 TexReg 4403; amended to be effective February 14, 1999, 24 TexReg 713

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