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 505.8 - Nursing service
Universal Citation: 18 NY Comp Codes Rules and Regs ยง 505.8
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Where nursing care may be provided. Nursing services, as medically needed, may be provided to a medical assistance recipient in the person's home and, with respect to a child receiving nursing services pursuant to an individualized education program or an interim or final individualized family services plan, also in a school, an approved pre-school or a natural environment, including home and community settings, where such child would otherwise be found.
(b) Who may provide nursing care.
(1) Nursing care to patients in New
York State shall be provided by a person possessing a license and current
registration from the New York State Education Department to practice as a
registered professional nurse or licensed practical nurse.
(2) Out-of-state nurses providing care to a
New York State Medical Assistance patient who is temporarily located outside
New York State, must be licensed and registered in the state in which they are
practicing.
(c) Nursing service in the home.
(1) For necessary
nursing service to be provided in the person's home, full and primary use shall
be made of the services of an approved home health agency, including a
hospital-based home health agency.
(2) Such service shall be provided on a per
visit basis and may include not only intermittent or part-time nursing service
for the patient but also instructions to members of the patient's family in
procedures necessary for the care of the patient.
(3) Service of a registered professional
nurse or of a licensed practical nurse on a private practitioner basis may be
provided to a patient in his own home only under the following circumstances:
(i) when there is no approved home health
agency available to provide the intermittent or part-time nursing services
needed by the patient;
(ii) when
the patient is in need of individual and continuous nursing care beyond that
available from an approved home health agency.
(d) Prior approval and prior authorization. Prior approval shall be required for nursing service provided in a person's home by a private practicing registered professional or licensed practical nurse, except that in an urgent situation the attending physician may order the service of such nurse for no more than two nursing days and immediately notify the Department of Health.
(e) Physician's written order required. All nursing services provided by a registered professional nurse or licensed professional nurse in a recipient's home, a school, an approved pre-school, or a natural environment, including home and community settings, where such child would otherwise be found, must be provided in accordance with the attending physician's written order and plan of treatment. In extraordinary circumstances and for valid reasons which must be documented, nursing services in the home may be initiated by a home health agency before the physician examines the recipient. A physician's written order is required for all such nursing services in excess of the initial two visits.
(f) Reimbursement.
(1) Reimbursement for nursing services
rendered by a registered professional nurse or licensed practical nurse on a
private practitioner basis shall be at fees not to exceed those established by
the Department of Health and approved by the State Budget Director. Nursing
services rendered by a registered professional nurse or licensed practical
nurse on a private practitioner basis in a hospital provided on dates between
July 1, 1977 and October 8, 1979 are non-reimbursable under the Medical
Assistance Program, except that a local social services official (or the MMIS
project director, if a county was listed in section
540.6
of this Subchapter at the time service was rendered) may determine to reimburse
services rendered after October 1, 1979, in accordance with this Part, if
written approval is obtained from the State Commissioner.
(2) Reimbursement shall not be allowed on a
fee paid to a legally responsible relative who provides nursing services in the
patient's home.
(3) Payment for
nursing services provided by an approved home health agency, including a
hospital-based home health agency, shall be at rates established by the State
Commissioner of Health pursuant to subdivision 7 of section 206 of the Public Health Law and
reimbursement for such expenditures shall be at such rates.
(4) Payment is available for nursing services
which are part of the development of, or furnished pursuant to, an
individualized education program and which are provided by a registered
professional nurse or licensed practical nurse employed by, or under contract
to, a school district, an approved pre-school, a county in the State or the
City of New York. Reimbursement for such services must be made in accordance
with the provider agreement.
(5)
Payment is available for nursing services which are part of the development of,
or furnished pursuant to, an interim or final individualized family services
plan and which are provided by a registered professional nurse or licensed
practical nurse employed by, or under contract to, an approved early
intervention program or a municipality in the State. Reimbursement for such
services must be made in accordance with the provider agreement.
(6) Effective January 1, 2007, payment for
nursing services provided to medically fragile children; and effective April 1,
2022, payment for nursing services provided to medically fragile adults; shall
be at an enhanced rate which exceeds the provider's nursing services payment
rate established by the Department of Health and approved by the State Budget
Director under this subdivision.
(i) Medically
fragile children means children who are at risk of hospitalization or
institutionalization, but who are capable of being cared for at home if
provided with appropriate home care services, including but not limited to case
management services and continuous nursing services, and includes any children
under the age of 21 receiving continuous nursing services pursuant to this
section; medically fragile adults means adults who are at risk of
hospitalization or institutionalization, but who are capable of being cared for
at home if provided with appropriate home care services, including but not
limited to case management services and continuous nursing services, and
includes but is not limited to any individuals who previously qualified as a
medically fragile child but who no longer meet the age requirements.
(ii) The enhanced rate shall be determined by
applying thirty percent (30%) of the provider's approved rate in addition to
the rate otherwise payable under this subdivision, which increase is at least
equivalent to the reimbursement rate for the AIDS Home Care Program specified
in section
86-1.46(b) of
Title 10 of the Official Compilation of Codes, Rules and Regulations of the
State of New York. Licensed Home Care Services Agency (LHCSA) providers
receiving reimbursement at the enhanced rate shall use such amounts only to
recruit and retain nurses to ensure the delivery of nursing services to
medically fragile children and medically fragile adults.
(iii) The enhanced rate shall only be payable
upon submission of a certification by a nurse provider, on forms and procedures
prescribed by the Department, that he or she has satisfactory training and
experience to provide nursing services to medically fragile children and
medically fragile adults. A LHCSA provider shall make and submit such
certifications on behalf of nurses rendering services to children and adults
under this subdivision.
(7)
(i)
Fee-for-service reimbursement for provider directory participants.
(a) Effective October 1, 2020, the
Commissioner of Health shall, subject to the provisions of paragraph (f)(6) of
this section, and the provisions of paragraph (f)(7)(ii) of this section, and
subject to the availability of federal financial participation, annually
increase fees for the fee-for-service reimbursement of private duty nursing
services provided to medically fragile children by fee-for-service private duty
nursing services providers who enroll and participate in the provider directory
pursuant to paragraph (f)(7)(ii) of this section, over a period of three years,
commencing October 1, 2020, by one-third annual increments, until such fees for
reimbursement equal the final benchmark payment designed to ensure adequate
access to the service. In developing such benchmark, the Commissioner of Health
may utilize the average 2018 Medicaid managed care payments for reimbursement
of such private duty nursing services.
(b) Effective April 1, 2022, the Commissioner
of Health shall, subject to the provisions of paragraph (f)(6) of this section,
and the provisions of paragraph (f)(7)(ii) of this section, and subject to the
availability of federal financial participation, increase fees for the
fee-for-service reimbursement of private duty nursing services provided to
medically fragile adults by fee-for-service private duty nursing services
providers who enroll and participate in the provider directory pursuant to
paragraph (f)(7)(ii) of this section, so such fees for reimbursement equal the
benchmark payment designed to ensure adequate access to the service. In
developing such benchmark, the Commissioner of Health may utilize the average
2018 Medicaid managed care payments for reimbursement of such private duty
nursing services.
(ii)
Provider directory for fee-for-service private duty nursing services provided
to medically fragile children and medically fragile adults. The Commissioner of
Health shall establish a directory of qualified providers for the purpose of
promoting the availability and ensuring delivery of fee-for-service private
duty nursing services to medically fragile children and medically fragile
adults. Qualified providers enrolling in the directory shall ensure the
availability and delivery of such services to individuals in need of such
services, and shall receive increased reimbursement for such services pursuant
to paragraph f(7)(i)(a) and f(7)(i)(b) of this section. The directory shall
offer enrollment to all private duty nursing services providers to promote and
ensure the participation in the directory of all nursing services providers
available to serve medically fragile children and medically fragile
adults.
(g) Nurse-midwife services.
(1) Standards of
conformity. The provision of nurse-midwife services to a recipient in the
Medical Assistance Program shall be in conformity with the provisions of
section 85.36 of the Department of Health
regulations (10 NYCRR) in order to be a reimbursable service.
(2) Payment for nurse-midwife services.
(i) State reimbursement shall be available
for expenditures made in accordance with provisions of this section.
(ii) Payment and reimbursement under the
Medical Assistance Program for services provided by an independently practicing
nurse-midwife shall be in accordance with fees established by the State
Department of Health and approved by the State Director of the
Budget.
(iii) Services provided by
a nurse-midwife who is salaried by a medical facility that is reimbursed for
services on a cost-related basis shall not be reimbursed on a fee-for-service
basis if the cost for the nurse-midwife's salary is included in the facility's
cost-based rate.
(iv) Services
provided by nurse-midwives under this subdivision shall be eligible for payment
and State reimbursement effective January 1,
1984.
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