New York Codes, Rules and Regulations
Title 18 - DEPARTMENT OF SOCIAL SERVICES
Chapter II - Regulations of the Department of Social Services
Subchapter E - Medical Care
Article 3 - Policies and Standards Governing Provision of Medical and Dental Care
Part 505 - Charges For Professional Health Services
Section 505.20 - Alternate care
Universal Citation: 18 NY Comp Codes Rules and Regs ยง 505.20
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Patients who no longer need hospital or skilled nursing facility care shall be discharged promptly and, for hospital patients, shall be discharged in accordance with the Department of Health's hospital discharge planning requirements contained in section 405.22(j) of Title 10 NYCRR.
(b) Facility responsibility.
(1) When a patient's condition
is such that continued care in a hospital or skilled nursing facility is
necessary pending placement in an alternate lower medical level of care,
continuing payment may be authorized following certification by the patient's
physician and a determination of coverability by the Commissioner of Health or
his or her other designee, pursuant to Department of Health regulation Part 85
that skilled nursing or health-related facility services are medically
necessary, are being provided, and are not otherwise available. When medically
feasible, nonmedical institutional placement in the community or other
community placement shall be arranged.
(2) As soon as the patient's physician has
indicated need for alternate medical care placement and the anticipated date
the patient will be ready for discharge to such care, the hospital or skilled
nursing facility shall inform the social services district, if required by such
district, and other agencies that can most appropriately be expected to arrange
for the provision of alternate care services, of the patient's medical needs
that must be satisfied in accordance with the physician's recommendations.
Failure by the hospital or skilled nursing facility to notify the local
district, if required by such district, or other appropriate agencies prior to
or within 24 hours of the patient's assignment to alternate care status shall
result in denial of payment for care rendered on or after that date. Verbal
notification by the hospital or skilled nursing facility shall be promptly
confirmed in writing to the local district, if required by the
district.
(3)
(i) The hospital or skilled nursing facility,
through its staff members responsible for discharge planning and, as necessary,
in coordination with the responsible local social services district, shall act
promptly to effect arrangements for alternate care.
(ii) The hospital or skilled nursing facility
shall make weekly admission contacts with at least three facilities providing
the appropriate level of care in its discharge community, defined as a 50-mile
radius around the facility. These contacts must be rotated weekly among all
available facilities in the referring facility's discharge community. The
contacts shall be documented.
(iii)
Except as otherwise provided in this subparagraph, the hospital or skilled
nursing facility shall have admission documentation for each patient awaiting
placement on file with at least five facilities in its discharge community. A
skilled nursing facility may restrict the number of facilities having a
patient's admission documentation on file to fewer than five under the
conditions set forth in 10 NYCRR Part 85 governing continuing stay reviews in
residential health care facilities. A hospital may restrict the number of
facilities having a patient's admission documentation on file to one facility
when there are other hospital patients receiving medical assistance and
awaiting alternate care placement; and
(a) the
patient, within the next 10 days, will either be placed in another facility or
discharged to the community; or
(b)
the patient has requested priority for readmission to the medical facility
where the patient resided prior to hospitalization, as provided for under
section 360.20 of this Title.
(iv) The local social services district may
direct that a hospitalized patient be placed outside the referring hospital's
discharge community when the hospital has been unsuccessful in locating an
alternate level of care bed within its discharge community within 60 days of
the day the patient was placed in alternate care status. A decision to seek
such placement shall be made only when the patient's local professional medical
director:
(a) determines that the patient's
needs cannot be met by facilities located within the hospital's discharge
community or that the patient's condition is such that a continued hospital
stay is medically contraindicated; and
(b) recommends such placement, based on his
or her review of available documentation concerning the patient's medical and
psychosocial needs.
(4) The hospital or skilled nursing facility
shall assess the patient's medical condition and alternate medical care
placement needs prior to or within 24 hours of the patient's assignment to
alternate care status. To determine the alternate care level to which the
patient shall be assigned, the hospital or skilled nursing facility shall apply
either the patient assessment standards promulgated by the Department of Health
(DOH) or a DOH-approved equivalent. Each patient assessment shall be reviewed
and updated periodically during the patient's alternate level of care stay
according to the continuing stay review intervals specified by DOH. A copy of
each such assessment form shall be forwarded to the local district, if required
by the district.
(5) No payment for
hospital or skilled nursing facility care for an eligible person pending
alternate medical care placement shall be made if:
(i) the requirements contained in paragraphs
(1) through (4) of this subdivision are not met;
(ii) the requesting hospital or skilled
nursing facility has an alternate care facility attached to it or affiliated
with it and such an alternate care facility has an appropriate alternate
medical care vacancy;
(iii) an
appropriate alternate medical care vacancy exists within a 50-mile radius of
the requesting facility or beyond this radius for a hospital patient whom the
local social services district has directed the hospital to place beyond the
hospital's discharge community pursuant to subparagraph (3)(iv) of this
subdivision; or
(iv) the requesting
hospital or skilled nursing facility has failed to secure other available
third-party reimbursement for the care of the patient for that period of time
the patient was awaiting alternate care placement.
(6) When the utilization review committee
determines that medical assistance payments should be discontinued because the
recipient has refused an appropriate alternate care placement, it shall send
written notification of its action to the recipient or the recipient's
representative or appropriate relative, and the local social services district.
The notice shall comply with the requirements of section 360.33 of this Title.
The notice and the action taken thereon shall be consistent with Federal and
State utilization review requirements and the recipient shall be notified of
his or her right to request a fair hearing as provided for in Part 358 of this
Title.
(7) Medical assistance
payments for patients needing alternate care placement shall be available only
for patients whose initial admission to the hospital or skilled nursing
facility was both medically necessary and appropriate. Medical assistance
payments for patients needing alternate care placement shall not be available
for patients whose initial admission was not both medically necessary and
appropriate, but was made because an appropriate placement at a lower level of
care was unavailable at the time of admission to the referring
facility.
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