Sec. 10.09.93.07. Medical Eligibility

A. General Requirements.

(1) An admission to a chronic hospital is medically necessary for a participant whose:

(a) Medical condition is not stabilized subsequent to a course of treatment at an acute hospital, or whose deteriorating medical condition resulted in a readmission to an acute hospital from a nursing facility or community setting; and

(b) Service and care needs require active and continuing medical treatment at an intensity and frequency not provided in a nursing facility, as defined in COMAR 10.09.10.01B, such as:

(i) 24-hour availability of a physician, physician assistant, or nurse practitioner, and associated nursing staff; and

(ii) Active and continuing medical treatment by a physician at least three times per week as documented in the medical record, physician orders, and physician progress notes.

(2) An admission to a chronic hospital is medically necessary for a participant who:

(a) Requires rehabilitation services of a lesser intensity or frequency than the acute inpatient rehabilitation services provided in a special rehabilitation hospital; and

(b) May have comorbidities or a level of medical complexity that preclude admission to a special rehabilitation hospital.

(3) A participant who may not be able to fully participate in a chronic hospital rehabilitation program may be admitted for a brief trial period of inpatient care after review by the Department or its designee and approval by the Program. If no progress on rehabilitative goals occurs, the participant shall be discharged to a lower level of care.

B. Medical Criteria for Brain Injury Community Integration Programs. In order to be preauthorized by the Program for services in a brain injury community integration program, a participant:

(1) Shall have a primary diagnosis of brain injury;

(2) Shall be at low risk of potential medical instability;

(3) May not require acute inpatient physical rehabilitation services;

(4) Shall require an intensive neuro-behavioral or neuro-cognitive rehabilitation program at a chronic level of care as described in §A of this regulation in order to:

(a) Address pervasive and persisting maladaptive behaviors, or behavioral health risk factors, that preclude a safe discharge to the community or to a less restrictive setting; and

(b) Relearn basic living and adaptive skills;

(5) Shall have potential for achievement of specific functional outcomes with the potential of improving functional ability so that discharge to a less restrictive setting is a reasonable goal;

(6) Shall need rehabilitative programming, which may include:

(a) Recreation therapy;

(b) Speech language pathology;

(c) Occupational therapy;

(d) Physical therapy; and

(e) Neuro-psychology;

(7) Shall require at least two contacts daily within the rehabilitative programming that address the neuro-behavioral or neuro-cognitive needs of the participant;

(8) Shall require active and continued clinical treatment by a physician who is experienced in neuro-rehabilitation and in psychopharmacology for a minimum of three contacts per week;

(9) Shall require a structured and integrated environment of care that provides on-going behavioral programming designed to reduce maladaptive behaviors that are reinforced by clinical support and administrative staff;

(10) Shall make progress toward the achievement of specified functional outcomes; and

(11) Shall have the ability to participate in the required number of therapy sessions.