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 505.21 - Long term home health care programs; AIDS home care programs
Universal Citation: 18 NY Comp Codes Rules and Regs ยง 505.21
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Definitions.
(1) Long term home health care program
(LTHHCP) means a coordinated plan of care and services provided at home to
invalid, infirm or disabled persons who are medically eligible for placement
for an extended period of time in a hospital or residential health care
facility (RHCF) if the LTHHCP were unavailable. Such program can be provided in
the person's home, including an adult care facility other than a shelter for
adults, or in the home of a responsible relative or other responsible
adult.
(2)
(i) AIDS home care program (AHCP) means a
coordinated plan of care and services provided at home to persons who are
medically eligible for placement in a hospital or an RHCF and who are diagnosed
by a physician as having acquired immune deficiency syndrome (AIDS) or human
immunodeficiency virus (HIV)-related illness as defined by the AIDS Institute
of the State Department of Health. Such definitions are contained in directives
issued by the department from time to time.
(ii) An AHCP can be provided only by a LTHHCP
provider specifically authorized under article 36 of the Public Health Law to
provide an AHCP as a discrete part of the LTHHCP.
(iii) An AHCP can be provided in the person's
home, which includes an adult care facility specifically approved to admit or
retain residents for such program, the home of a responsible relative or other
responsible adult, or in other residential settings as approved by the
Commissioner of Health in conjunction with the Commissioner of Social
Services.
(3) Government
funds means funds provided under the provisions of title 11 of article 5 of the
Social Services Law (medical assistance to needy persons).
(b) Assessment and authorization.
(1)
(i) If
a LTHHCP, as defined under article 36 of the Public Health Law, is provided in
the social services district for which he or she has authority, the local
social services official, before he or she authorizes care in an RHCF, must
notify the person in writing of the availability of the LTHHCP.
(ii) If an AHCP, as defined under article 36
of the Public Health Law, is provided in the social services district for which
he or she has authority, the local social services official, before authorizing
RHCF care, home health services, or personal care services for a person with
AIDS, must notify the person in writing of the availability of the AHCP. If the
person desires to remain and is deemed by his or her physician able to remain
in his or her own home if the necessary services are provided, such person or
his or her representative must so inform the local social services official,
who must authorize an assessment under the provisions of section 3616 of the Public Health Law and paragraph
(2) of this subdivision. If the results of the assessment indicate that the
person can receive the appropriate level of care at home, the official must
prepare for that person a plan for the provision of services comparable to
services that would be rendered in a hospital or an RHCF, as appropriate for
the person. In developing such plan, the official must consult with those
persons performing the assessment and must assure that such plan is appropriate
to the person's needs and will result in an efficient use of
services.
(2) If a
person who has been assessed in accordance with section
505.9(b)
of this Part by a LTHHCP or an AHCP, a physician or discharge planner or, at
the option of the social services district, another certified home health
agency, as needing care in an RHCF or a hospital, desires to remain and is
deemed by his or her physician able to remain in his/her own home or the home
of a responsible relative or other responsible adult or an adult care facility,
other than a shelter for adults, if the necessary services are provided and,
for purposes of an adult care facility, the person meets the admission and
continued stay criteria for such facility, the social services district must
authorize a home assessment of the appropriateness of LTHHCP or AHCP services.
The assessment must include, in addition to the physician's recommendation, an
evaluation of the social and environmental needs of the person. The assessment
will serve as a basis for the development of an appropriate plan of care for
the person.
(i) If the person is in a
hospital or an RHCF, the home assessment must be performed by the person's
physician, the discharge coordinator of the hospital or RHCF referring the
person, a representative of the social services district, and a representative
of the LTHHCP or AHCP that will provide services to the person.
(ii) If the person is in his/her own home,
the home assessment must be authorized by the social services district and must
be performed by the person's physician, a representative of the social services
district, and a representative of the LTHHCP or AHCP that will provide services
to the person.
(iii) The assessment
must be completed prior to or within 30 days after the provision of services
begins. Payment for services provided prior to the completion of the assessment
may be made only if it is determined, based upon such assessment, that the
person qualifies for such services.
(iv) If the person is in an adult care
facility, the home assessment must be performed by representatives of the
LTHHCP or AHCP and the social services district in consultation with the
operator of the adult care facility.
(v) Persons provided LTHHCP or AHCP services
in adult care facilities must meet the admission and continued stay criteria
for such facilities.
(vi) For
persons requesting LTHHCP or AHCP services in adult care facilities,
assessments must be completed prior to the provision of services.
(vii) Services provided by the LTHHCP or AHCP
must not duplicate or replace those which the adult care facility is required
by law or regulation to provide.
(viii) The commissioner must prescribe the
forms on which the assessment will be made.
(3) If there is disagreement among the
persons performing the assessment, or questions regarding the coordinated plan
of care, or problems in implementing the plan of care, the issues must be
reviewed and resolved by a physician designated by the Commissioner of
Health.
(4) At the time of the
initial assessment, and at the time of each subsequent assessment performed for
a LTHHCP, or more often if the person's needs require it, the social services
district must establish a monthly budget in accordance with which payment will
be authorized. The social services district must provide the operator of the
adult care facility with a copy of the completed assessment, the plan of care
and the monthly budget.
(i) For persons who
neither reside in adult care facilities nor receive AHCP services:
(a) The budget must include all of the
services to be provided in accordance with the coordinated plan of health care
by the LTHHCP.
(b) Total monthly
expenditures made for a LTHHCP for a person who is the sole member of his/her
household in the program must not exceed a maximum of 75 percent of the average
monthly rates payable for RHCF services in the social services district. Total
monthly expenditures made for a LTHHCP for two members of the same household
must not exceed a maximum of 75 percent of the average monthly rates payable
for both members of the household for RHCF services in the social services
district.
(c) When the monthly
budget prepared for a person who is the sole member of his/her household in the
program is for an amount less than 75 percent of monthly rates payable for RHCF
services, a "credit" may be accrued on behalf of the person. If a continuing
assessment of the person's needs demonstrates that he/she requires increased
services, the social services district may authorize any amount accrued during
the past 12 months over the 75-percent maximum. When the monthly budget
prepared for two members of the same household is for an amount less than 75
percent of monthly rates payable for RHCF services, a "credit" may be accrued
on behalf of the household. If a continuing assessment of the household's needs
demonstrates that the household requires increased services, the social
services district may authorize any amount accrued during the past 12 months
over the 75-percent maximum.
(d)
When the monthly budget prepared for a person or a household is for an amount
less than 75 percent of monthly rates payable for RHCF services, and the
continuing assessment of the person's or household's needs demonstrates that
the person or household requires increased services in an amount less than 10
percent of the prepared monthly budget, but totaling no more than 75 percent of
the monthly rates payable for RHCF services, the LTHHCP may provide such
services without prior approval of the social services district.
(e) If an assessment of the person's or
household's needs demonstrates that the person or household requires services,
the payment for which would exceed such monthly maximum, but it can be
reasonably anticipated that total expenditures for required services for such
person or household will not exceed such maximum calculated over a one-year
period, the social services official may authorize payment for such
services.
(ii) For
persons residing in adult care facilities but not receiving AHCP services:
(a) The budget must include all of the
services to be provided in accordance with the coordinated plan of health care
by the LTHHCP.
(b) Total monthly
expenditures made for LTHHCP services provided to a person residing in an adult
care facility must not exceed a maximum of 50 percent of the average monthly
rates payable for RHCF services in the social services district.
(c) When the monthly budget prepared for a
person residing in an adult care facility is for an amount less than 50 percent
of the average of the monthly rates for RHCF services, a "credit" may be
accrued on behalf of the person. If a continuing assessment of the person's
needs demonstrates that he/she requires increased services, the social services
district may authorize the expenditure of any amount accrued during the past 12
months provided that such amount, when added to the amount previously expended,
does not exceed the 50 percent maximum.
(d) When the monthly budget prepared for a
person residing in an adult care facility is less than 50 percent of the
monthly rates payable for RHCF services, and the continuing assessment of the
person's needs demonstrates that he/she requires increased services in an
amount less than 10 percent of the prepared monthly budget, but totaling no
more than 50 percent of the monthly rates payable for RHCF services, the LTHHCP
may provide such services without prior approval of the local social services
district.
(e) If an assessment of
the needs of an adult care facility resident demonstrates that services are
required, the payment for which would exceed the monthly maximum specified in
clause (b) of this subparagraph, but it can be reasonably anticipated that
total expenditures for required services for such person will not exceed such
maximum calculated over a one-year period, the social services official may
authorize payment for such services.
(iii) For persons receiving AHCP services,
total monthly expenditures for such services are not subject to the
requirements of subparagraph (4)(i) or (ii) of this subdivision.
(5) If a joint assessment by the
social services district and the provider of services under this paragraph
indicates that the maximum expenditure permitted under paragraph (4) of this
subdivision is not sufficient to provide LTHHCP services to persons with
special needs, social services officials may authorize, pursuant to the
provisions of section 367-c (3-a) of the Social
Services Law, maximum monthly expenditures for such persons, not to exceed 100
percent of the average RHCF rate established for that district. In addition, if
a continuing assessment of a person with special needs demonstrates that he/she
requires increased services, a social services official may authorize the
expenditure of any amount which has accrued under this section during the past
12 months as a result of the expenditures for a person participating in the
LTHHCP not having exceeded such maximum. If an assessment of a person with
special needs demonstrates that he/she requires increased services, the payment
for which would exceed such monthly maximum, the social services official may
authorize payment for such services if it can reasonably be anticipated that
the total expenditures for the required services for such a person will not
exceed the maximum calculated over a one-year period.
(i) As used in this subdivision, the term
person with special needs means a person for whom a plan of care has been
developed pursuant to subdivision 2 of section 367-c of the Social Services Law:
(a) who needs care including but not limited
to respiratory therapy, tube feeding, decubitus care or insulin therapy which
cannot be appropriately provided by a provider of personal care services as
defined in section
505.14(d)
of this Part; or
(b) who has one or
more of the following conditions: a mental disability as defined in section 1.03 of the Mental Hygiene Law, acquired
immune deficiency syndrome, or dementia, including Alzheimer's
disease.
(ii) The number
of persons with special needs for whom a social services official may authorize
payment for services pursuant to this paragraph is limited to 25 percent of the
total number of LTHHCP clients which a social services district is authorized
to serve; provided that in any district containing a city having a population
of one million or more, such limit is 15 percent.
(iii) In the event that a district reaches
the limitation specified in this subparagraph, the social services official
may, upon approval by the commissioner, authorize payment for services pursuant
to this subdivision for additional persons with special needs.
(iv) The social services official must seek
approval for authorization to serve additional persons with special needs by
submitting a written request to the commissioner which demonstrates that the
provisions of this paragraph have (a) met the needs of individuals who could
not otherwise be served through the LTHHCP; (b) diverted clients from
residential health care facility admission; or (c) permitted the admission of
clients on alternate care status into the LTHHCP.
(v) Social services districts are responsible
for the retention of information deemed necessary by the department to evaluate
the effectiveness of raising the limitation on expenditures for the delivery of
long term home health care services, and for compliance with reporting
requirements established by the department.
(vi) The provisions of this paragraph remain
in effect until December 31, 1993.
(6) When a person who is in a hospital or an
RHCF is identified as being medically eligible for hospital or RHCF care, and
who desires to return to his/her own home and is deemed by his/her physician as
able to be cared for at home, an assessment must be completed, and
authorization for LTHHCP or AHCP services or notification that the person is
ineligible for such program must be timely made with respect to ensuring
continued Federal reimbursement.
(7) The social services district is
responsible for the general case management of the overall needs of the person.
Case management includes:
(i) facilitating
determination of financial eligibility for medical assistance;
(ii) involvement in the assessment and
reassessment of the social and environmental needs of the person;
(iii) preparation of the monthly budget for
persons other than those receiving AHCP services; and
(iv) coordination of LTHHCP or AHCP services
and other social services which may be required to keep the person in his/her
own home.
(8) No single
authorization for LTHHCP or AHCP services may exceed four months.
(i) A reassessment must be performed at least
every 120 days, and must include an evaluation of the medical, social and
environmental needs of the person, and must include a representative of the
LTHHCP or AHCP, a representative of the social services district, and a
physician designated by the Commissioner of Health. If there is a change in the
person's level of care, he/she must be notified in writing of such
change.
(ii) If a change in the
person's level of care occurs between assessment periods as recommended by the
LTHHCP or AHCP, the social services district must be notified and a new
assessment must be authorized.
(c) Requirements for provision of care.
(1) Home health aide services may be provided
directly by a LTHHCP or by an AHCP, or through contract arrangements between
the LTHHCP or AHCP and voluntary agencies or proprietary agencies.
(2) Personal care services may be provided
directly by a LTHHCP or an AHCP, or through contract arrangements between the
LTHHCP or AHCP and the social services district or voluntary or proprietary
agencies.
(3) In addition to
providing nursing services to the person receiving LTHHCP or AHCP services, the
LTHHCP's or AHCP's registered professional nurse or professional therapist must
also be assigned responsibility for the supervision of the person providing
personal care services to evaluate the person's ability to carry out assigned
duties, to relate well to persons receiving LTHHCP or AHCP services, and to
work effectively as a member of a team of health workers. This supervision must
be carried out during periodic visits to the home in accordance with policies
and standards established by the Department of Health.
(4) Services of a registered professional
nurse or professional therapist and supervision of persons providing personal
care services may be carried out concurrently. The frequency of periodic visits
must be determined by the coordinated plan of care, but in no case may they be
less frequent than every 120 days.
(d) Payment.
(1) Payment for a LTHHCP or an AHCP must be
at rates established for each service for each agency authorized to provide the
program. Rates must be on a per-visit basis, or, in the case of home health
aide services and personal care services, on an hourly basis.
(2)
(i)
When personal care services are directly provided by a LTHHCP or an AHCP, or
when they are provided through contract arrangements with an agency that does
not have a rate negotiated with the social services district, the Department of
Health will establish the rate of payment with the approval of the Department
of Social Services and the Director of the Budget.
(ii) When personal care services are provided
by a LTHHCP or an AHCP through contract arrangements with a social services
district, computation of the budget must be based on the district's salary
schedule, but no payment may be made to the LTHHCP or AHCP.
(iii) When personal care services are
provided by a LTHHCP or an AHCP through contract arrangements with an agency
that has a rate negotiated with the social services district, the LTHHCP or
AHCP rate must be no higher than that locally negotiated rate.
(3) Payment for assessment for a
LTHHCP or an AHCP:
(i) is included in the
hospital rate for staff participation in discharge planning;
(ii) is included in the physician's visit fee
if the physician is not on the hospital staff, and performs the initial
assessment while the person is in the hospital;
(iii) is included in the physician's home
visit fee when the initial assessment or reassessment is performed in the
person's home;
(iv) is included in
the physician's office visit fee when the initial assessment or reassessment is
performed in a nonfacility-related physician's office; and
(v) is included in the clinic fee when the
initial assessment or reassessment is performed in a clinic or outpatient
department.
(4) LTHHCP
or AHCP participation in initial assessment and reassessment must be included
in the administrative costs of the program.
(5) No social services district may make
payments pursuant to title XIX of the Federal Social Security Act for benefits
available under title XVIII (Medicare) of such Act without documentation of the
following:
(i) that the LTHHCP or AHCP has
prepared written justification for not having made application for Medicare
because of the person's apparent technical ineligibility; or
(ii) that application for Medicare benefits
has been rejected by either the Health Care Financing Administration or its
fiscal intermediary.
(6)
No social services district may make payment for a person receiving LTHHCP or
AHCP services while payments are being made for that person for inpatient care
in an RHCF or a hospital.
(e) Reimbursement. State reimbursement shall be available for expenditures made in accord with the provisions of this section.
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