New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 86 - Reporting and Rate Certifications for Facilities › Subpart 86-5 - Long-term Home Health Care Programs › Section 86-5.9 - Determining patient eligibility

Current through Register Vol. 46, No. 28, July 10, 2024
(a) At the time of the initial assessment,
					 and at the time of each subsequent assessment performed for a long-term home
					 health care program, or more often if the person's need requires it, the local
					 social services district shall establish a monthly budget in accordance with
					 which payment shall be authorized.
(1) The
					 budget shall include all of the services to be provided in accordance with the
					 coordinated health plan of care by the long-term home health care
					 program.
(2) Total monthly
					 expenditures made for a long-term home health care program for an individual
					 who is the sole member of his/her household in the program shall not exceed a
					 maximum of 75 percent of the average monthly rates payable for nursing home
					 services or health-related services in an intermediate care facility in the
					 social services district, whichever is the appropriate level for the
					 individual. Total monthly expenditures made for a long-term home health care
					 program for two members of the same household shall not exceed a maximum of 75
					 percent of the average monthly rates payable for both members of the household
					 for nursing home services or health-related services in an intermediate care
					 facility in the social services district, whichever is the appropriate level
					 for each person.
(3) When the
					 monthly budget prepared for an individual 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 nursing home services or health-related services, a "credit" may be
					 accrued in behalf of the individual. If a continuing assessment of the
					 individual's needs demonstrates that he/she requires increased services, the
					 local social services department may authorize any amount accrued during the
					 previous 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 nursing home services or health-related
					 services, "credit" may be accrued in behalf of the household. If a continuing
					 assessment of the household's needs demonstrates that he/she/they require
					 increased services, the local social services department may authorize any
					 amount accrued during the previous 12 months over the 75 percent
					 maximum.
(4) When the monthly
					 budget prepared for an individual or a household is for an amount less than 75
					 percent of monthly rates payable for nursing home services or health-related
					 services, and the continuing assessment of the person's needs demonstrates that
					 he/she/they require 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 nursing home services or health-related services, the
					 long-term home health care program may provide such services without prior
					 approval of the local department of social services.
(5) If an assessment of the person's or
					 household's needs demonstrates that he/she/they require 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.