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 505.9 - Residential health care
Universal Citation: 18 NY Comp Codes Rules and Regs ยง 505.9
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Qualifications for participation.
(1) In-state nursing facility care. Nursing
care must be provided only in a nursing facility, as defined in the regulations
of the Department of Health, which:
(i) holds
a current operating certificate issued by the Department of Health;
(ii) qualifies as, or has an application
pending to become, a provider in the Medicare program pursuant to title XVIII
of the Federal Social Security Act, unless the nursing facility provides care
solely to pediatric patients;
(iii)
meets the Federal requirements for a "nursing facility" under title XIX of the
Federal Social Security Act; and
(iv) has a current effective provider
agreement with the Department of Social Services.
(2) Out-of-state nursing facility care. When
nursing facility care is provided to a medical assistance recipient in a
nursing facility located outside New York State, such nursing facility must:
(i) comply with applicable licensing or
approval requirements established by the officially designated standard-setting
authority in the state where the care was received;
(ii) qualify as, or have an application
pending to become, a provider in the Medicare program pursuant to title XVIII
of the Federal Social Security Act, unless the nursing facility provides care
solely to pediatric patients;
(iii)
meet the Federal requirements for a "nursing facility" under title XIX of the
Federal Social Security Act; and
(iv) have a current provider agreement with
the officially designated standard-setting authorities of the state in which
the facility is located.
(3) Out-of-state facilities lacking title
XVIII certification. Medical assistance payments are available solely for those
recipients admitted to and retained in nursing facility beds certified for
participation in title XVIII of the Federal Social Security Act.
(4) In-state intermediate facility care for
the mentally retarded. In-state intermediate facility care for the mentally
retarded must be provided only in intermediate care facilities for the mentally
retarded that:
(i) have valid operating
licenses issued by the Office of Mental Retardation and Developmental
Disabilities (OMRDD) under article 31 of the Mental Hygiene Law;
(ii) have valid provider agreements with the
Department of Social Services; and
(iii) have been certified as intermediate
care facilities for the mentally retarded by the OMRDD.
(5) Out-of-state intermediate facility care
for the mentally retarded. When intermediate facility care for the mentally
retarded is provided to MA recipients in intermediate care facilities for the
mentally retarded located in other states, payment must be made only for care
provided by out-of-state facilities that:
(i)
comply with applicable licensing requirements established by the officially
designated standard-setting authorities of the states in which the facilities
are located;
(ii) have valid
provider agreements with the officially designated standard-setting authorities
of the states in which the facilities are located; and
(iii) are certified as intermediate care
facilities for the mentally retarded by the officially designated
standard-setting authorities of the states in which the facilities are
located.
(b) Prior approval and prior authorization of level of care.
(1) Prior approval of level of care.
(i) Prior approval of level of care when
required by the Commissioner of the Department of Health, or his or her
designee, is required before services provided in a nursing facility (NF) or
intermediate care facility for the mentally retarded (ICF/MR) can be reimbursed
under the MA program.
(ii) Prior
approval of level of care will be granted in accordance with patient assessment
criteria and standards promulgated or approved by the Commissioner of the
Department of Health or his or her designee.
(iii) Reviews of medical necessity must be
made in accordance with standards promulgated or approved by the Commissioner
of Health or his or her designee.
(2) Prior authorization.
Prior authorization by a local social services official for care in an NF or ICF/MR is required pursuant to Part 504 of this Title. In no case can prior authorization exceed the maximum eligibility period permitted by regulations of the Department of Social Services. Failure by an NF or ICF/MR to comply with the requirements of this subdivision may result in retroactive denial of authorization by the local social services official. In addition, if the Commissioner of Health, or his or her designee, determines that a recipient received a level of care that was not medically necessary, authorization will be retroactively rescinded.
(c) Maximum reimbursable rate.
The maximum reimbursable rate for payments made for nursing facility care provided in a nursing facility located in the State of New York will be at the rate approved by the Director of the Budget.
(d) Reserved bed days.
(1) The department will pay the
medical institutions listed in paragraph (3) of this subdivision to reserve a
bed for an MA recipient temporarily hospitalized or on leave of absence from
the institution for one or more reserved bed days; however, the department will
not pay to reserve an NF bed for a recipient 21 years of age or older who is
temporarily hospitalized unless such recipient is receiving hospice services
within the NF. A reserved bed day is a day for which the
department pays a medical institution to reserve an MA recipient's bed while he
or she is temporarily hospitalized or on leave of absence from the institution.
The recipient must be absent from the institution overnight for the day to be
considered a reserved bed day. A recipient is considered to be absent overnight
when he or she is absent later than the time at which the institution normally
conducts its patient census. The day the recipient departs for temporary
hospitalization or the leave of absence begins is counted as a reserved bed
day. The day the recipient returns is not counted as a reserved bed
day.
(2) Payments necessary to
reserve an NF bed for an MA recipient under 21 years of age who is temporarily
hospitalized or on leave of absence, as permitted by this section, will be made
at the reserved bed rate established for the facility by the Commissioner of
the Department of Health and approved by the Director of the Budget. Payments
necessary to reserve a NF bed for an MA recipient 21 years of age or older, as
permitted by this section, shall be made at 95 percent of the Medicaid rate
otherwise payable to the facility with regard to such days of care in the case
of a leave of absence, and at 50 percent of the Medicaid rate otherwise payable
to the facility with regard to such days of care in the case of the temporary
hospitalization of a recipient receiving hospice services within the facility.
Payments to reserve a bed in any other medical facility listed in paragraph (3)
of this subdivision, as permitted by this section, will be at the full rate
established for the facility.
(3)
Medical institutions which may receive payments for reserved bed days are:
(i) an NF;
(ii) an ICF/MR;
(iii) a specialty hospital as defined in 14
NYCRR Part 680;
(iv) a psychiatric
facility, including a residential treatment facility for children and youth
(RTF);
(v) a rehabilitation
facility;
(vi) a psychiatric or
rehabilitation unit of a general hospital; or
(vii) a hospice for individuals residing in
NFs who are in receipt of hospice services.
(4) General rules regarding payment for
reserved bed days.
(i) Payment for reserved
bed days will be made in accordance with paragraphs (1) and (2) of this
subdivision.
(ii) Payment for bed
reservations that are terminated will be from the date the recipient was
admitted to the hospital through the date the hospital notified the institution
of the circumstances that resulted in the termination.
(iii) No payment will be made for periods
when recipients are absent from the institution as a direct result of a labor
dispute in the institution.
(iv) No
payment will be made for reserved bed days when a recipient's primary
third-party resource is Medicare unless the recipient has been a patient in an
NF for at least 30 days immediately before the hospitalization which resulted
in the recipient's current Medicare coverage.
(v) NFs, ICFs/MR, specialty hospitals and
RTFs must indicate on billing claims that authorization to claim reimbursement
for reserved bed days has been obtained when necessary according to paragraph
(7) of this subdivision.
(5) Length of stay and vacancy rate
requirements.
(i) Applicability to NFs,
ICF/MRs and specialty hospitals. The department will pay an institution for a
recipient's reserved bed days when:
(a) the
recipient has been a patient in the institution for at least 30 days since the
date of his or her initial admission; and
(b) the part of the institution to which the
recipient will return has a vacancy rate of no more than five percent on the
first day the recipient is hospitalized or on leave of absence. When computing
vacancy rates, an institution must disregard beds that have been reserved for
other patients/residents. ICFs/MR with more than 30 beds are exempt from this
vacancy rate requirement.
(ii) Applicability to RTFs. The department
will pay an RTF for a recipient's reserved bed days when:
(a) the recipient has been institutionalized
for at least 15 consecutive days. The appropriate regional office of the Office
of Mental Health (OMH) may waive this length- of-stay requirement for a
recipient temporarily hospitalized for emergency psychiatric or medical care;
and
(b) the part of the RTF to
which the recipient will return has a vacancy rate of not more than five
percent or two vacant beds, whichever is greater, on the first day the
recipient is hospitalized or on leave of absence. When computing a vacancy
rate, the RTF must disregard beds that have been reserved for other
patients.
(iii)
Applicability to psychiatric facilities and psychiatric units of general
hospitals. The department will pay a facility for a recipient's reserved bed
days when the recipient has been institutionalized for at least 15 consecutive
days. There is no vacancy rate requirement for these psychiatric facilities or
units.
(iv) Applicability to
rehabilitation facilities or rehabilitation units of general hospitals. The
department will pay a facility for a recipient's reserved bed days when the
recipient has been institutionalized for at least 30 consecutive days. There is
no vacancy rate requirement for rehabilitation facilities or units.
(6) Reserving beds for recipients
who are temporarily hospitalized. ICFs/MR, RTFs and specialty hospitals, as a
condition of participation in the MA program, must make, extend and terminate
bed reservations for MA recipients who are temporarily absent from such
institutions for hospitalization as provided in subparagraphs (i) through (iv)
of this paragraph. NFs must, as a condition of participation in the MA program,
make, extend and terminate bed reservations for MA recipients who are either
under 21 years of age, or receiving hospice services within the facility and
temporarily absent from such institutions for hospitalization as provided in
subparagraphs (i) through (iv) of this paragraph.
(i) Reserving a recipient's bed. The
institution must reserve a recipient's bed when the recipient is hospitalized
and expected to return to the institution in 15 or fewer days, subject to the
limitations set forth in this paragraph. Unless medically contraindicated, the
institution must reserve the same bed and room the recipient occupied before
being hospitalized. When an institution reserves a recipient's bed, it must
notify the hospital by telephone and in writing, according to department
instructions, that:
(a) the recipient's bed
has been reserved;
(b) the hospital
discharge planning coordinator must notify the institution by telephone of any
changes in the recipient's condition during the period that the recipient's bed
is reserved; and
(c) the hospital
discharge planning coordinator must notify the institution of the recipient's
planned discharge date by the morning of the fourth day of hospital care. The
hospital discharge planning coordinator must also notify the institution by
telephone if the recipient's planned discharge date must be adjusted after the
third and before the 16th day of hospital care because his or her condition has
changed or additional medical information has become available. The hospital
discharge planning coordinator must confirm in writing all bed reservation
telephone communications.
(ii) When a recipient's bed will not be
reserved. Under certain circumstances a recipient's bed will not be reserved.
The institution must notify the hospital where the recipient is admitted that
it is not reserving the recipient's bed. The institution must make appropriate
notes on the recipient's transfer records or telephone the hospital within 24
hours after the recipient has been admitted if the recipient's bed will not be
reserved. The institution also must document its decision not to reserve the
bed. If a bed is not reserved, the recipient must be given priority in
readmission to the institution over persons referred to the institution for
their first admissions. An NF, ICF/MR, RTF or specialty hospital cannot reserve
a recipient's bed when:
(a) it is clear when
the recipient is hospitalized that he or she will not return to the institution
within 15 days or fewer;
(b) after
hospitalization, the recipient will need a level of care the institution does
not provide; or
(c) the recipient
does not want to return to the institution.
(iii) Extending bed reservation. An NF,
ICF/MR, RTF or specialty hospital must extend the bed reservation of a
hospitalized recipient under the following circumstances:
(a) if an extension will permit the recipient
to return to the institution within 20 days of his or her admission to the
hospital, the bed reservation must be extended up to five days beyond the
15-day limit; or
(b) if an
extension will permit a recipient hospitalized for acute psychiatric care to
return to the RTF within 30 days of his or her admission to the hospital, the
RTF must extend the recipient's reservation up to 15 days beyond the 15-day
limit.
(iv) Terminating
bed reservations.
(a) An NF, ICF/MR, RTF and
specialty hospital must terminate a recipient's bed reservation when:
(1) the planned discharge date determined by
the hospital by the morning of the fourth day of hospital care is more than 15
days from the day the recipient was admitted; or
(2) the hospital adjusted the recipient's
planned discharge date between the morning of the fourth day of hospital care
and the 16th day of hospital care and the new discharge date will not permit
the recipient to return to the institution within 20 days of the hospital
admission date, except as provided in clause (b) of this
subparagraph.
(b) An RTF
must terminate a recipient's bed reservation if the recipient was hospitalized
for acute psychiatric care, the recipient's planned discharge date was changed
between the morning of the fourth day and 16th day of hospital care and the new
discharge date will not permit the recipient to return to the institution
within 30 days of the hospital admission date.
(c) The hospital discharge coordinator must
provide the institution with appropriate documentation regarding circumstances
which caused the discharge date to be changed.
(7) Reserving beds for recipients who are on
leave of absence.
(i) A recipient is on leave
of absence when he or she is absent from the medical institution overnight to
visit friends or relatives or to participate in a medically acceptable
therapeutic or rehabilitative plan of care.
(ii) An NF, ICF/MR, RTF and specialty
hospital must, as a condition of participation in the MA program, reserve beds
as follows:
(a) Reserving the recipient's bed.
A medical institution must reserve a recipient's bed when his or her plan of
care provides for leaves of absence. Unless medically contraindicated, the
institution must reserve the same bed and room the recipient occupied before
the leave of absence. If a bed may not be reserved for a recipient under this
paragraph, the institution must give priority to the recipient's readmission,
over individuals referred for their first admissions.
(b) Prior authorization for payment of leave
of absence reserved bed days:
(1) is not
required for the first 18 of a recipient's reserved bed days during any
12-month period;
(2) is required if
a recipient's reserved bed days are more than 18 days in any 12-month period,
except for a recipient in an RTF, ICF/MR or specialty hospital. The medical
institution must request prior authorization from the recipient's social
services district's MA professional director. Prior authorization will be
granted only if the 18-day limit interferes with a physician's ability to
prescribe an appropriate therapeutic or rehabilitative plan for the recipient;
and
(3) is required for a
recipient's reserved bed days in an RTF which exceed 75 days in any 12-month
period or 4 days per single leave. The RTF must request prior authorization
from the appropriate regional office of the OMH for payment of the excess
reserved bed days. The request for prior authorization must be:
(i) supported by verification from a
physician;
(ii) consistent with the
RTF's written policy; and
(iii)
approved by the appropriate regional office of the OMH.
(c) An ICF/MR or a specialty
hospital may request payment without prior authorization for an unlimited
number of reserved bed days in any 12-month period.
(iii) For a recipient in a rehabilitation or
psychiatric facility other than an RTF, or in the psychiatric or rehabilitation
unit of a general hospital, the facility or unit must assure that leaves of
absence are consistent with the institution's written policy on the use of
leaves for therapy only, and limited to two days for any single leave, unless
the recipient's social services district's MA professional director has
approved an exception to this limitation prior to the leave.
(iv) Other payment standards for leave of
absence reserved bed days.
(a) When a
recipient incurs expenses, such as room and board, while on leave of absence,
and the institution's per diem rate already reimburses the institution for
these expenses, the institution must pay the cost. The recipient's social
services district must give prior approval for an exception to this
requirement. The social services district must ensure that costs included in
the institution's per diem rate are reconciled with the institution's claim for
payment of reserved bed days.
(b)
No payment for reserved bed days will be made if a recipient returns to the
institution from a leave of absence and is then discharged within 24 hours.
Prior approval by the recipient's social services district's MA professional
director, or for a recipient in an RTF, by the Commissioner of the OMH or his
or her designee, or, for recipients in ICFs/MR or specialty hospitals, by the
Commissioner of the OPWDD or his or her designee, must be obtained for an
exception to this provision.
(v) An NF may not reserve a bed under this
paragraph for a recipient who is temporarily receiving care in a
hospital.
(vi) A bed reservation
under this paragraph must be terminated when the institution is informed that
the recipient will not return from leave to the institution.
(vii) When a recipient has been a patient in
more than one medical institution within any 12-month period, the institution
where the recipient is currently a patient must determine the number of paid
leave of absence days in other institutions. Such institution must assure that
the recipient's total number of leave days during the previous 12-month period
does not exceed 18 days, unless prior authorization for extra days has been
received or the 180-day limit is inapplicable. When a recipient is transferred
to another inpatient institution, a copy of his or her absence register must be
included in the transfer records.
(8) Prior authorization for payment for
reserved bed days.
(i) Prior authorization for
payment of reserved bed days is not required when a recipient is hospitalized
for 15 or fewer days and returns immediately to the institution.
(ii) Prior authorization for payment of
reserved bed days is required when:
(a) a
recipient is hospitalized for 15 or fewer days and returns to an institution
which has been identified by the social services district, the Office of Health
Systems Management of the Department of Health, the OMRDD or the OMH as having
deviated from this subdivision's standards. The social services district must
require such institution to request prior authorization for payment;
or
(b) a recipient is hospitalized
for 15 or fewer days and does not return from the hospital immediately
following the time for which the bed was reserved; or
(c) a recipient, who based on available
medical information was expected to be hospitalized for 15 days or fewer, is
hospitalized for more than 15 days. If prior authorization is obtained, payment
will be made for the recipient's reserved bed days up to 20 days per hospital
stay, or up to 30 days per hospital stay for a recipient in an RTF who was
hospitalized for acute psychiatric care.
(iii) Prior authorization for payment must be
requested as follows:
(a) NFs must request
prior authorization from the recipient's social services district's MA
professional director. The social services district must approve or disapprove
in writing all or part of the request within five business days of its receipt.
Requests will be disapproved under the following circumstances:
(1) when the hospitalization is clearly
inappropriate, based on available medical documentation;
(2) when the recipient, at the time of
hospitalization, could not reasonably have been expected to return to the
institution within 15 or fewer days; or
(3) when the hospital changed the recipient's
planned discharge date between the morning of the fourth day of hospital care
and the 16th day of hospital care, and the new date would not permit the
recipient to return to the institution within 20 days of the date of hospital
admission, or the new date would not permit the recipient to return to the
institution within 30 days of hospital admission for a recipient in an RTF who
was hospitalized for acute psychiatric care. In this instance, prior
authorization will be granted from the date of admission up to and including
the date the institution was notified of the change in planned discharge
date.
(b) For ICFs/MR
and specialty hospitals, the social services district must accept a prior
authorization that has been approved by the Commissioner of the OMRDD or his or
her designee.
(c) For RTFs the
social services district must accept an authorization that has been approved by
the Commissioner of the OMH or his or her designee.
(iv) Special bed reservation limits may be
established on an individual case basis for a recipient in an ICF/MR, specialty
hospital or RTF when the recipient's hospital stay would be longer than
allowable limits. Such reservations must be approved by the State Commissioner
of Social Services.
(9)
Absence registers and other reports.
(i) Each
medical inpatient institution that is an MA provider must maintain an absence
register for each recipient who is absent after the institution's normal
census-taking hour.
(ii) Medical
institutions and agencies exercising prior approval authority must make
adequate records available to Federal and State auditors to verify the number
and nature of reservations authorized under this section.
(iii) Medical institutions must record
reserved bed days and overnight absences on any financial and statistical
reports that require patient day information.
(e) Required training of nurse aides.
(1) Policy.
Consistent with the regulations of the Department of Health (10 NYCRR Part 414), on and after January 1, 1990, residential health care facilities must use nurse aides who meet the following standards:
(i) if used on a full-time basis, nurse aides
must have completed a training and competency evaluation program or a
competency evaluation program approved by the Department of Health and have
been determined to be competent to provide nursing or nursing-related services
according to the Department of Health's regulations; and
(ii) if used on a temporary, per diem, leased
or any other basis, nurse aides must have completed a training and competency
evaluation program or a competency evaluation program approved by the
Department of Health.
(2) Employment, training and evaluation of
nurse aides.
(i) Residential health care
facilities must comply with the regulations of the Department of Health (10
NYCRR Part 414) regarding the employment, training and evaluation of nurse
aides.
(ii) Before a residential
health care facility employs a nurse aide, it must consult the State Nurse Aide
Registry to determine whether such registry contains the name of the nurse
aide.
(f) Payment for required training and competency evaluation of nurse aides.
(1) Policy.
The department will pay residential health care facilities for the training and competency evaluation of nurse aides as administrative costs under the medical assistance program. Payment will be limited to the actual costs which residential health care facilities incur, up to a maximum payment established by the department. The department will consult with the Department of Health when developing the maximum payment permitted under this subdivision.
(2)
Maximum payments for costs of training and competency evaluation of nurse
aides. In determining the amount of payment to be made to residential health
care facilities for the costs of training and competency evaluation of nurse
aides, actual costs claimed by such facilities will be subject to a maximum
payment for training and competency evaluation as follows:
(i) Training. A maximum payment established
by the department for each region listed in subdivision (g) of this section,
based upon regional variations in nurse aide training costs.
(ii) Competency evaluation. A total of $165
per individual for competency testing for up to three tests; or a maximum of
$25 for each individual who was employed as a nurse aide as of June 10, 1989,
and who has been deemed to have met the requirement of completing an approved
nurse aide training program and passing the competency evaluation examinations,
or for whom the requirement has been waived by the Department of
Health.
(3) Claims for
payment.
A residential health care facility must submit a voucher to the department detailing its actual expenditures for the training and competency evaluation of nurse aides not less than 30 days after the end of each calendar quarter. Each such voucher must include:
(i) the residential health care facility's
name and provider number;
(ii) the
times, dates and places of the training and/or evaluation;
(iii) the name and address of the approved
program that provided the training or evaluation;
(iv) the names and other individual
identifying information of employees who were trained or evaluated;
(v) the actual costs incurred for training
and evaluation; and
(vi) the
residential health care facility's regional code.
(4) Payment for costs of required training
and competency evaluation of nurse aides expended before July 1, 1990. The
department and the Department of Health will reconcile all payments for the
training and competency evaluation of nurse aides included in the residential
health care facilities' per diem medical assistance rates prior to July 1,
1990, with actual expenditures reported by facilities for that period in
accordance with the following procedure:
(i)
The Department of Health will provide reconciliation forms to all residential
health care facilities. Residential health care facilities must report on these
forms their actual costs incurred and expended before July 1, 1990, for
required training and competency evaluation of nurse aides. Residential health
care facilities must return completed forms to the Department of Health
certifying their actual costs for the period.
(ii) The department will consider the actual
costs reported to be administrative costs under the medical assistance program.
Payment for these costs will be limited to the actual, documented expenditures
by residential health care facilities, subject to the maximum payments
developed by the department. Payments which were included in the residential
health care facilities' per diem rates for such period for training and
evaluation will be deducted from reported costs. If reported costs exceed the
payments received as part of the residential health care facilities' rate,
facilities will be required to submit vouchers, as specified in paragraph (3)
of this subdivision, to claim any underpayments for the period. If the reported
costs are less than the payments received as part of the residential health
care facilities' rates, facilities' future medical assistance payments will be
offset to recover the overpayments.
(g) Regional ceiling:
| Region | Counties in Region |
Regional Caps |
| Albany | Albany, Columbia, Greene, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Fulton | $ 450 |
| Binghamton | Broome, Tioga | $ 450 |
| Erie | Cattaraugus, Chautauqua, Erie, Niagara, Orleans | $ 475 |
| Elmira | Chemung, Steuben, Schuyler | $ 558 |
| Glens Falls | Essex, Warren, Washington | $ 450 |
| Long Island | Nassau, Suffolk | $ 483 |
| Orange | Chenango, Delaware, Orange, Otsego, Sullivan, Ulster | $ 567 |
| New York City | Bronx, Kings, Queens, Richmond, New York | $ 450 |
| Poughkeepsie | Dutchess, Putnam | $450 |
| Rochester | Livingston, Monroe, Ontario, Wayne | $589 |
| Central Rural | Cayuga, Cortland, Seneca, Tompkins, Yates | $ 450 |
| Syracuse | Madison, Onondaga | $ 501 |
| Utica | Herkimer, Jefferson, Lewis, Oneida, Oswego | $ 450 |
| Westchester | Rockland, Westchester | $ 450 |
| Northern Rural | Clinton, Franklin, Hamilton, St. Lawrence | $ 450 |
| Western Rural | Allegany, Genesee, Wyoming | $ 450 |
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