New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter V - Medical Facilities › Subchapter B - Hospital Establishment › Part 670 - Determination Of Public Need For Medical Facility Establishment › Section 670.3 - Residential health care facilities

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Notwithstanding the provisions of
				  subdivisions (a), (b) and (c) of section
				  670.1 of this Part, the factors,
				  methodology and procedures to be used by the Public Health Council for
				  determining the public need for residential health care facility beds shall
				  include, but not be limited to, the substantive criteria, methodology and
				  procedure set forth in section
				  709.3 of this Chapter and the
				  provisions of subdivision (c) of this section.
(b) Any application for establishment wherein
				  a determination of public need is made pursuant to this section, shall be
				  subject to the provisions of subdivision (d) of section
				  670.1 of this Part.
(c)
(1) In
				  determining the need for residential health care facilities, beds and services,
				  consideration shall be given to the needs of persons who receive or are
				  eligible to receive medical assistance benefits at the time of admission to a
				  facility pursuant to title XIX of the Federal Social Security Act and title 11
				  of article 5 of the Social Services Law, hereafter referred to as Medicaid
				  patients, and the extent to which the applicant serves or proposes to serve
				  such persons, as reflected by factors including, but not necessarily limited
				  to, the applicant's admissions policies and practices. An application by an
				  applicant that is or will be a provider that participates in the medical
				  assistance (Medicaid) program shall not be approved unless the applicant agrees
				  to comply with the requirements of this subdivision. An applicant that, at the
				  time of consideration of its application by the Public Health Council, proposes
				  not to participate in the Medicaid program may be approved, provided all other
				  review criteria have been met, upon the condition that if, in the future, it
				  does participate in the Medicaid program, it would comply fully with the
				  requirements of this subdivision.
(2) To ensure that the needs of Medicaid
				  patients in an applicant's service area are met and that such patients have
				  adequate access to appropriate residential health care facilities, beds and
				  services, applicants shall be required to accept and admit at least a
				  reasonable percentage of Medicaid patients as determined pursuant to this
				  subdivision. Such reasonable percentage of Medicaid patient admissions, also
				  referred to herein as the Medicaid patient admissions standard, shall be equal
				  to 75 percent of the annual percentage of all residential health care facility
				  admissions, in the long-term care planning area in which the applicant facility
				  is located, that are Medicaid patients. The calculation of such planning area
				  percentage shall not include admissions to residential health care facilities
				  that have an average length of stay of 30 days or less. If there are four or
				  fewer residential health care facilities in a planning area, the applicable
				  Medicaid patient admissions standard for such planning area shall be equal to
				  75 percent of the planning area annual percentage of all residential health
				  care facility admissions that are Medicaid patients or 75 percent of the annual
				  percentage of all residential health care facility admissions, in the health
				  systems agency area in which the facility is located, that are Medicaid
				  patients, whichever is less. In calculating such percentages, the department
				  will use the most current admissions data which have been received and analyzed
				  by the department. An applicant will be required to make appropriate
				  adjustments in its admissions policies and practices so that the proportion of
				  its own annual Medicaid patient admissions is at least equal to 75 percent of
				  the planning area percentage or health systems agency area percentage,
				  whichever is applicable.
(3) The
				  proportion of an applicant's admissions that must be Medicaid patients, as
				  calculated under paragraph (2) of this subdivision, may be increased or
				  decreased based on the following factors:
(i)
				  the number of individuals within the planning area currently awaiting placement
				  to a residential health care facility and the proportion of total individuals
				  awaiting such placement that are Medicaid patients, provided that patients
				  awaiting placement include, but need not be limited to, alternate level of care
				  patients in general hospitals;
(ii)
				  the proportion of the facility's total patient days that are Medicaid patient
				  days and the length of time that the facility's patients who are admitted as
				  private paying patients remain such before becoming Medicaid
				  eligible;
(iii) the proportion of
				  the facility's admissions who are Medicare patients or patients whose services
				  are paid for under provisions of the Federal Veterans' Benefit Law;
(iv) the facility's patient case mix based on
				  the intensity of care required by the facility's patients or the extent to
				  which the facility provides services to patients with unique or specialized
				  needs; and
(v) the financial impact
				  on the facility due to an increase in Medicaid patient admissions.
(4)
(i) An applicant shall submit a written plan,
				  subject to the approval of the department, for reaching the Medicaid patient
				  admissions standard required by this subdivision. The plan shall provide for
				  reaching the standard within no longer than a two-year period and the facility
				  shall give preference, as necessary, to Medicaid patients in order to reach the
				  admissions standard within the prescribed time period.
(ii) Once the Medicaid patient admissions
				  standard is reached, the facility shall not reduce its proportion of Medicaid
				  patient admissions so as to go below the standard unless and until the
				  applicant, in writing, requests the approval of the department to adjust the
				  standard and the department's written approval is obtained. In reviewing
				  requests to adjust a facility's Medicaid patient admissions standard, the
				  department shall consider factors which may include, but need not be limited
				  to, those factors set forth in paragraphs (2) and (3) of this
				  subdivision.
(iii) After a
				  facility's initial Medicaid patient admissions standard has been reached, the
				  department may increase such facility's Medicaid patient admissions standard,
				  based on the criteria set forth in this subdivision, if the percentage of
				  Medicaid patients admitted by residential health care facilities in the
				  facility's planning area or health systems agency area, as appropriate,
				  increases due to factors other than an increase in Medicaid patient admissions
				  by the applicant.
(5)
(i) Subject to the provisions of subparagraph
				  (ii) of this paragraph, after the phase-in period provided for in paragraph (4)
				  of this subdivision, a facility shall be prohibited from failing, refusing or
				  neglecting to accept or admit a Medicaid patient for whom it is otherwise able
				  to provide care, regardless of whether the level of reimbursement received for
				  such patient is less than the rate the facility charges private pay patients,
				  unless the facility has reached and is maintaining compliance with the Medicaid
				  patient admissions standard imposed by this subdivision. Compliance with the
				  requirements of this subdivision shall be determined on the basis of a
				  facility's total annual admissions, so that a facility may exercise its
				  discretion in determining when during a year it will admit a sufficient number
				  of Medicaid patients to maintain its Medicaid patient admissions
				  standard.
(ii) A facility may be
				  exempt from the requirement of admitting a Medicaid patient in order to meet or
				  maintain its Medicaid patient admissions standard if it can demonstrate in
				  writing to the satisfaction of the commissioner that the Medicaid patient was
				  denied admission solely in order to admit another patient who had a greater
				  need of residential health care facility services, as determined by the
				  intensity of care anticipated to be required by such patient, and that there
				  was only one bed available in the facility at the time of the admission
				  decision to accommodate a new admission. Facilities shall not be required to
				  obtain prior department approval in order to accept a non-Medicaid patient in
				  place of a Medicaid patient pursuant to this subparagraph, but shall maintain
				  sufficient documentation including, but not necessarily limited to, a copy of
				  the patient review instrument for the patient admitted and the Medicaid patient
				  denied admission in order to justify the admission decision. Copies of such
				  documentation shall be provided to the department upon request.