Opinion ID: 2125986
Heading Depth: 1
Heading Rank: 2

Heading: Amount of Benefits

Text: The Hospital claims it is entitled to payments under HCI for the entire 20-day stay. The State, on the other hand, argues that the Hospital is entitled only to expenses incurred during the 72-hour detention. The Hospital's position is premised upon the section of HCI which provides that a qualified resident is eligible for assistance to pay for any part of the cost of care that is a direct consequence of the medical condition that necessitated the emergency care. Ind. Code § 12-5-6-2.1(a). Thus, the Hospital maintains that HCI coverage is not terminated upon the lapse of a patient's medical condition. Instead, HCI permits coverage for all medical costs that are a direct consequence of an initial emergency medical condition. The Hospital claims its position is further supported by Ind. Code § 12-5-6-12(b) which provides that HCI payments should conclude when the patient is medically stable and can safely be discharged. On the other hand, the State argues that once an HCI application is approved, benefits do not automatically continue until the patient is discharged; there is a limitation on the duration of services provided mandated by the legislature. Ind. Code § 12-5-6-12 provides: (a) The state department of public welfare shall, with the advice of its medical staff, the department of mental health, and other individuals selected by the administrator of the department, adopt rules under IC 4-22-2 to:       (2) establish limitations consistent with medical necessity on the duration of services to be provided;       To the extent possible, rules adopted under this section must be consistent with IC XX-X-X-XX.7(b). (b) The rules adopted under subsection (a) must include rules that will deny payment for services provided to a patient after the patient is medically stable and can safely be discharged. This statute was effective July 1, 1986. The regulation referred to in subsection (a) was subsequently promulgated by the state welfare department and provided: Financial assistance to eligible hospital patients shall be available, consistent with reasonable medical necessity, until such time as the patient is medically stable and can be safely discharged. Stable means the alleviation of the condition which prompted the hospitalization. 470 IAC 11.1-2-1(b), effective January 1, 1987. Thus, even though a patient may remain hospitalized and may benefit from continued therapy or counselling, HCI reimbursement is no longer available if the patient is medically stable. In addition, it is the Hospital's responsibility to fully document the patient's condition at the time of admission and throughout the course of the hospitalization so that the welfare department can determine the patient's eligibility for HCI benefits. Although the State concedes that a 72-hour detention is a situation in which HCI benefits should be provided for those who meet the non-medical eligibility requirements, the State argues that the Hospital has failed to meet its burden of establishing that Campbell was medically eligible for benefits beyond the 72-hour period. We agree. The Hospital claims that Campbell's condition was sufficiently serious throughout his stay because Campbell remained hospitalized for 20 days. The Hospital notes that Ind. Code § 16-14-9.1-7(b)(2) provides that 72-hour detentions can be extended if there is probable cause to believe the person is mentally ill and either dangerous or gravely disabled and requires continuing care and treatment. However, that section also requires that before a detention can be extended, certain reports must be submitted and hearings held. There is nothing in the record before us to indicate that these required reports were prepared or that the hearings took place. We cannot conclude, on the basis of the record before us, that proof of Campbell's continued stay in the hospital, without more, is sufficient evidence that his condition continued to be medically unstable as required under HCI. This question must also be decided on remand.