New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 85 - Medical Assistance Benefits › Limitation on Hospital Stay › Section 85.7 - Extension of hospital stay

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
					 To be a covered benefit under medical assistance for the needy as provided in
					 section 365-a (2)(b)  of the Social
					 Services Law, any inpatient stay which exceeds the period of time determined to
					 be a covered benefit under sections
					 85.1
					 through
					 85.6 
					 of this Part and under this section but does not exceed a total of 20 days or,
					 if for rehabilitation of physical disability as described in subdivision (a) of
					 section
					 85.5 
					 of this Part, a total of 40 days, shall be subject to a determination of
					 extended coverability. Such determination shall be made by a person designated
					 by the Commissioner of Health, shall be made prior to the expiration of the
					 previously determined period of covered benefit and shall be for a specified
					 period of time not to exceed applicable length of stay norms for comparable
					 patients which have been authorized by the Commissioner of Health or the 20th
					 day of stay, whichever is less. If the stay is for rehabilitation of physical
					 disability as described in subdivision (a) of section
					 85.5 
					 of this Part, such specified period of time shall not exceed the 40th day of
					 stay. Determination of extended coverability shall be based upon existence of
					 medical conditions which can be treated only by continued care on an inpatient
					 hospital basis as documented in the patient's medical record.
(b) While making a determination of
					 coverability, if the person designated by the Commissioner of Health determines
					 that during a previously determined period of covered benefit, the care,
					 supplies and services actually provided did not require provision on an
					 inpatient hospital basis, the designated person may make a determination of
					 noncoverability as to part or all of such previously determined period of
					 covered benefit under medical assistance for the needy.
(c) A determination of benefit coverability
					 under this section shall be made by a designated physician or nonphysician
					 under a designated physician's supervision. A determination of noncoverability
					 shall be made only by a designated physician. If such determination of
					 noncoverability is made, any inpatient hospital care, supplies or services
					 provided beyond the previously determined period of covered benefit shall not
					 be a covered benefit under medical assistance for the needy.
(d) Notice of determination shall be given to
					 the patient's physician, the hospital administrator and, if there is a
					 determination of noncoverability, to the patient.
(e) The patient's physician or hospital
					 administrator may, within three days of the date of such notification, appeal a
					 determination on noncoverability in writing to the physician or physicians
					 designated by the commissioner for such purpose. Notification of the decision
					 on appeal shall be given to the patient's physician, the hospital administrator
					 and the patient. If the determination of noncoverability is affirmed on appeal,
					 any inpatient hospital care, supplies, or services provided beyond the
					 previously determined period of covered benefit shall not be a covered benefit
					 under medical assistance for the needy.
(f) Any hospital care, services or supplies
					 covered as a benefit under this section shall be subject to length of stay
					 limitations of section
					 85.5 
					 of this Part.