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 505.35 - Assisted living programs
Universal Citation: 18 NY Comp Codes Rules and Regs ยง 505.35
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Purpose and scope. This section sets forth requirements governing the provision of, and payment for, assisted living program services to recipients of medical assistance (MA).
(b) Policy. If an MA recipient is eligible for and can be served appropriately and more cost-effectively through the provision of assisted living program services and such services are available, assisted living program services should be used to achieve the maximum reduction in the recipient's need for home health services or other long term care services.
(c) Definitions.
(1) Assisted living program means an entity,
as defined in section
485.2(s)
and section
494.2(a)
of this Title, which has been approved to operate as an assisted living program
in accordance with section
485.6(n)
of this Title and is operated in accordance with Parts 485, 486, 487, 488 and
494 of this Title.
(2) Unless
otherwise defined, all terms have the meanings set forth in Part 494 of this
Title.
(d) Scope of services.
(1) An assisted living program must
provide, or arrange to have provided, to its residents the services specified
under section
494.5 of this
Title. Those services are subject to reimbursement by the MA program in
accordance with the provisions of subdivision (h) of this section.
(2) All services must be provided in
accordance with the recipient's plan of care based upon the recipient's initial
assessment and periodic reassessments as required under section
494.4
of this Title.
(3) When a
reassessment indicates that assisted living program services are no longer
appropriate, services must continue to be provided in accordance with the
recipient's plan of care based upon the recipient's prior assessment, as
required under section
494.4
of this Title, until alternative placement arrangements can be made.
(e) Eligibility. To be eligible to receive assisted living program services, an MA recipient must meet the admission and retention standards specified in section 494.4 of this Title.
(f) Contracts. The assisted living program must have a contract with the social services district in which the assisted living program is operating, in accordance with section 494.4(h) of this Title.
(g) Case management.
(1) The contract executed between the
assisted living program and the social services district in which the program
is operating must provide that the program will assume all responsibility for
case management of the residents.
(2) The assisted living program must provide
case management services to MA recipients who are receiving assisted living
program services. The assisted living program must comply with the case
management requirements specified in section
494.6(b)
of this Title and must:
(i) receive referrals
for assisted living program services and provide information about such
services to MA recipients referred to the assisted living program;
(ii) refer an assisted living program
applicant who the program reasonably expects may be eligible for MA to the
social services district in which the program is located for an MA eligibility
determination;
(iii) permit access
by an MA recipient to his or her case records maintained by the assisted living
program;
(iv) establish linkages to
services provided by other community agencies, provide information about these
services to MA recipients and establish criteria for referring MA recipients to
these services;
(v) to the maximum
extent possible, achieve economic efficiencies, including, but not limited to
using, shared aides consistent with the assisted living program's staffing
standards; and
(vi) arrange for the
reduction or discontinuance of an MA recipient's services when the assisted
living program reassesses the recipient and determines that the recipient's
assisted living program services must be reduced or discontinued.
(h) Payment for assisted living program services.
(1) The MA
program will pay an assisted living program for services provided to eligible
MA recipients who are assisted living program residents at a capitated rate of
payment established in accordance with the regulations of the Department of
Health, based upon assessments of the recipients conducted pursuant to section
494.4
of this Title. Such capitated rate of payment is payment in full for the
following MA services provided to MA recipients:
(i) adult day health care provided in a
program approved by the Department of Health;
(ii) home health aide services;
(iii) medical supplies and equipment not
requiring prior approval pursuant to this Title;
(iv) nursing services;
(v) personal care services;
(vi) personal emergency response services;
and
(vii) physical therapy, speech
therapy, and occupational therapy;
(2) Before an assisted living program may
begin providing services for which payment will be made under the MA program to
an MA recipient, the program must complete, or arrange for the completion of,
the assessments and the other preadmission documentation specified in section
494.4
of this Title.
(3) In accordance
with section
494.4(h)
of this Title, a copy of the assessments for any MA recipient determined
appropriate to participate in the assisted living program must be transmitted
to the social services district which is financially responsible for the MA
recipient. Within 10 working days of receipt of the assessment from the
assisted living program, the social services district must review the
assessment and take one of the following actions:
(i) agree with the assisted living program's
assessment and arrange for the authorization of the appropriate payment for
care for 45 days; or
(ii) conduct
its own assessment and based upon the findings of that assessment, agree with
the assisted living program's assessment, and arrange for the authorization of
the appropriate payment for 45 days; or
(iii) conduct its own assessment and based
upon the findings of that assessment, disagree with the assisted living
program's assessment and forward both assessments to the local professional
director, or designee, for review and final determination of the appropriate
payment, which determination must be made within five working days of receipt
of the request.
(4)
Reassessments for assisted living program services must be conducted, in
accordance with the requirements of section
494.4
of this Title, no later than 45 days after a recipient's admission to the
assisted living program and as frequently as required to respond to changes in
the recipient's condition, but no less frequently than once every six months,
in order for an assisted living program to continue to provide services to an
eligible MA recipient. The district must review every reassessment that is
transmitted by the assisted living program for reauthorization of payment by
the MA program.
(5) Within 10
working days of receipt of the request for reauthorization of payment for
assisted living program services by the assisted living program, the district
must:
(i) agree with the assisted living
program's reassessment and arrange for the authorization of payment for care
for six months; or
(ii) conduct its
own reassessment and based upon the findings of that reassessment, agree with
the assisted living program's reassessment, and arrange for the authorization
of payment for six months; or
(iii)
conduct its own reassessment and, based upon the findings of that reassessment,
disagree with the assisted living program's reassessment and forward to the
local professional director, or designee, both reassessments for review and
final determination of the appropriate payment, which determination must be
made within five working days of receipt of the request.
(6) An MA recipient's assisted living program
services must not be discontinued solely because the costs of the recipient's
care exceed the amount of the capitated payment rate.
(7) The MA program will not make payments for
assisted living program services provided to an MA recipient while the
recipient is receiving residential health care facility services or in-patient
hospital services.
(i) District of fiscal responsibility. The social services district fiscally responsible for furnishing MA is the district in which the ALP resident resided immediately prior to his or her admission to the ALP if the resident was not a recipient of MA at the time of his or her admission, or the district responsible for furnishing MA to the ALP resident immediately prior to his or her admission to the ALP if the resident was a recipient of MA at the time of his or her admission.
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