N.Y. Comp. Codes R. & Regs. Tit. 10 § 85.41 - Approval of residential health care facility (rhcf) admission and continued stay
(a) For purposes
of this section:
(1) An RHCF shall mean any
health care provider with an operating certificate as a skilled nursing
facility (SNF) or health related facility (HRF) issued by the
department.
(2) Level of care
approval shall mean a determination that the care and services furnished by an
RHCF are necessary and adequate to meet a patient's clinical needs.
(3) Commissioner's designee shall mean:
(i) an RHCF utilization review agent, as
specified in Section
416.9 or
421.13 of this Title; or,
(ii) an
agency of local government which has a written Memorandum of Understanding
(MOU) with the commissioner for making Medicaid payment determinations with
respect to RHCF admission and/or continued stay.
(b) Approval by the commissioner
or the commissioner's designee, is required for Medicaid reimbursement (see
title 11 of article 5 of the Social Services Law) of care and services provided
in an RHCF.
(c) Level of care
approval shall be granted by the commissioner or the commissioner's designee in
accordance with patient assessment criteria and standards contained in sections
400.12,
400.13,
and
86-2.30(i)
of this Title.
(d)
(1) The commissioner may at his/her sole
discretion terminate the designee status of any agency of local government or
RHCF utilization review agent on 30 days advance written notice to the
designee. Reasons for termination may include, but shall not be limited to,
decisions by the commissioner's designee which are not in substantial
compliance with the patient assessment criteria and standards specified in
section
400.12,
400.13,
and
86-2.30(i)
of this Title.
(2) For agencies of
local government, reasons for termination shall also include failure to comply
with the terms and standards specified in any written MOU between the
commissioner and the local government agency which prescribes the conditions
for commissioner's designee status.
(e) For RHCFs, the scope of commissioner's
designee authority shall be limited to patients seeking admission to, or
continued stay in, the particular facility. Designee status shall be further
limited to those individuals who have established or are in the process of
establishing Medicaid eligibility (see title 11 of article 5 of the Social
Services Law).
(f)
(1) For agencies of local government, the
scope of commissioner's designee authority shall be limited to admission and
continued stay review determinations with respect to patients who have
established or are in the process of establishing Medicaid eligibility (see
title 11 of article 5 of the Social Services Law) who are seeking admission or
continued stay in New York State RHCFs within 50 miles of the patient's
residence or within 50 miles of the medical facility in which the individual is
currently a patient if no current legal residence exists.
(2) For all other patients, level of care
approval shall be made by the commissioner.
(g) When the commissioner terminates pursuant
to this section the level of care approval function of any RHCF or agency of
local government, the commissioner shall assume responsibility for placement
and/or continued stay review determinations.
Notes
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