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

Current through Register Vol. 46, No. 28, July 10, 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.