Opinion ID: 2145100
Heading Depth: 1
Heading Rank: 6

Heading: qualifying care

Text: In the second assignment of error, Inner Harbour asserts the district court wrongly determined that although providing acute psychiatric care entitles the provider to reimbursement under the program, providing residential psychiatric care does not. A care facility seeking reimbursement from the department pursuant to state medical assistance program regulations has the burden to prove its entitlement thereto. Sunrise Country Manor v. Neb. Dept. of Soc. Servs., 246 Neb. 726, 523 N.W.2d 499 (1994). Under 471 Neb.Admin. Code, ch. 20, § 001.02 (1990), inpatient hospital psychiatric services are covered under the program only if such services are medically necessary. Inner Harbour correctly notes that ch. 20, § 001.02A, does not make acute care a requirement for reimbursement and that [t]he correct standard is active psychiatric care pursuant to 471 N.A.C. § 20-001.02.A. Brief for appellant at 14. Inner Harbour further contends that ch. 20, § 001.02, only requires that a patient receive active treatment, not acute care, and that the main distinction is between hospitals providing inpatient active care and those providing chronic or custodial care. Chapter 20, § 001.02A, defines active treatment as follows: 1. Treatment provided under a treatment plan.... 2. Reasonably expected to improve the client's medical condition or to determine a psychiatric diagnosis. The treatment must, at a minimum, be designed to reduce or control the client's psychiatric symptoms to facilitate the movement of the client to a less restrictive environment within a reasonable period of time. .... 3. Services supervised and evaluated by a psychiatrist. In Inner Harbour's view, the minor's care met the foregoing criteria. Inner Harbour also argues that the use of an acute care standard violates department regulations requiring that psychiatric care be provided by the least restrictive means. Chapter 20, § 001.02A(2), requires that inpatient active treatment must, at a minimum, be designed to ... facilitate the movement of the client to a less restrictive environment within a reasonable period of time. Also, 471 Neb.Admin. Code, ch. 10, § 010.11 (1988), requires that [i]npatient hospital care must be reasonable, medically necessary, and appropriate for the billed class of care. Furthermore, 471 Neb.Admin. Code, ch. 20, § 001 (1988), states: The [d]epartment[`s] philosophy is that all [inpatient hospital psychiatric] care provided to clients must be provided at the least restrictive and most appropriate level of care.... More restrictive levels of care will be used only when all other resources have been explored and have been deemed to be inappropriate. Inpatient hospital psychiatric services are medically necessary psychiatric services provided to an inpatient as defined in 471 NAC 10-001.02. While Inner Harbour argues that the minor received the same level of care in both the locked and the unlocked unit, Claytor's testimony is that if a patient in the wilderness setting required immediate medical attention, the patient would be returned to the locked unit. Thus, placing the minor in the unlocked wilderness unit is sufficient proof that she no longer needed 24-hour medical attention and daily visits from her physician. Neither is there any showing that the care in question met the requirement of ch. 20, § 001.02A(3), which states that [t]he client must be treated by a psychiatrist at least three times a week.... Moreover, although participation in the medical assistance program is voluntary, a state that chooses to participate must comply with federal statutory and regulatory requirements. Wilder v. Virginia Hospital Assn., 496 U.S. 498, 110 S.Ct. 2510, 110 L.Ed.2d 455 (1990); Alexander v. Choate, 469 U.S. 287, 105 S.Ct. 712, 83 L.Ed.2d 661 (1985); Harris v. McRae, 448 U.S. 297, 100 S.Ct. 2671, 65 L.Ed.2d 784 (1980). Furthermore, the Supremacy Clause compels compliance with federal law and regulations by participants in the medical assistance program. Elizabeth Blackwell Health Center for Women v. Knoll, 61 F.3d 170 (3d Cir. 1995), cert. denied ___ U.S. ___, 116 S.Ct. 816,133 L.Ed.2d 760 (1996). Under 42 U.S.C. § 1396d(a)(16) (1994), medical assistance includes payment for inpatient psychiatric hospital services for individuals under age 21, as defined in subsection (h) of this section. Section 1396d(h)(1)(A) states that inpatient psychiatric hospital services for individuals under age 21 includes only inpatient services which are provided in an institution (or distinct part thereof) which is a psychiatric hospital as defined in section 1395x(f) of this title or in another inpatient setting that the Secretary [of the U.S. Department of Health and Human Services] has specified in regulations. Also, ch. 20, § 001, requires that inpatient hospital psychiatric services must be provided by a hospital that meets the requirements for participation in the program for psychiatric hospitals. Those requirements are set out in 42 U.S.C. § 1395x(f) (1994), which states that [t]he term `psychiatric hospital' means an institution which ... satisfies the requirements of paragraphs (3) through (9) of subsection (e) of this section. Finally, § 1395x(e)(5) states that [t]he term `hospital' ... means an institution which ... provides 24-hour nursing service rendered or supervised by a registered professional nurse, and has a licensed practical nurse or registered professional nurse on duty at all times.... Thus, while the department's interpretation of the level of care required for reimbursement as acute is erroneous, as was the district court's adoption of the acute care standard, the regulations governing the medical assistance program nevertheless require that the psychiatric treatment be active. See ch. 20, § 001. Although the evidence would support a finding that the care in question constituted active treatment as defined in ch. 20, § 001, the foregoing statutes and regulations also make clear that only inpatient psychiatric services given those under age 21 in a facility which provides 24-hour nursing service qualify for payment under the program. The evidence does not establish that the care in question was provided in such a setting. Furthermore, 471 Neb.Admin. Code, ch. 20, § 001.01B(4)(b) (1988), provides that [t]he staffing pattern must ensure the availability of a registered professional nurse 24 hours each day.... The testimony does not establish that Inner Harbour's wilderness setting care meets that requirement. Consequently, there is no merit to the second assignment of error.