N.Y. Comp. Codes R. & Regs. tit. 18 § 505.21

Current through Register Vol. 46, No. 45, November 2, 2024

Section 505.21 - Long term home health care programs; AIDS home care programs

(a) Definitions.

(1) Long term home health care program (LTHHCP) means a coordinated plan of care and services provided at home to invalid, infirm or disabled persons who are medically eligible for placement for an extended period of time in a hospital or residential health care facility (RHCF) if the LTHHCP were unavailable. Such program can be provided in the person's home, including an adult care facility other than a shelter for adults, or in the home of a responsible relative or other responsible adult.

(2)

(i) AIDS home care program (AHCP) means a coordinated plan of care and services provided at home to persons who are medically eligible for placement in a hospital or an RHCF and who are diagnosed by a physician as having acquired immune deficiency syndrome (AIDS) or human immunodeficiency virus (HIV)-related illness as defined by the AIDS Institute of the State Department of Health. Such definitions are contained in directives issued by the department from time to time.

(ii) An AHCP can be provided only by a LTHHCP provider specifically authorized under article 36 of the Public Health Law to provide an AHCP as a discrete part of the LTHHCP.

(iii) An AHCP can be provided in the person's home, which includes an adult care facility specifically approved to admit or retain residents for such program, the home of a responsible relative or other responsible adult, or in other residential settings as approved by the Commissioner of Health in conjunction with the Commissioner of Social Services.

(3) Government funds means funds provided under the provisions of title 11 of article 5 of the Social Services Law (medical assistance to needy persons).

(b) Assessment and authorization.

(1)

(i) If a LTHHCP, as defined under article 36 of the Public Health Law, is provided in the social services district for which he or she has authority, the local social services official, before he or she authorizes care in an RHCF, must notify the person in writing of the availability of the LTHHCP.

(ii) If an AHCP, as defined under article 36 of the Public Health Law, is provided in the social services district for which he or she has authority, the local social services official, before authorizing RHCF care, home health services, or personal care services for a person with AIDS, must notify the person in writing of the availability of the AHCP. If the person desires to remain and is deemed by his or her physician able to remain in his or her own home if the necessary services are provided, such person or his or her representative must so inform the local social services official, who must authorize an assessment under the provisions of section 3616 of the Public Health Law and paragraph (2) of this subdivision. If the results of the assessment indicate that the person can receive the appropriate level of care at home, the official must prepare for that person a plan for the provision of services comparable to services that would be rendered in a hospital or an RHCF, as appropriate for the person. In developing such plan, the official must consult with those persons performing the assessment and must assure that such plan is appropriate to the person's needs and will result in an efficient use of services.

(2) If a person who has been assessed in accordance with section 505.9(b) of this Part by a LTHHCP or an AHCP, a physician or discharge planner or, at the option of the social services district, another certified home health agency, as needing care in an RHCF or a hospital, desires to remain and is deemed by his or her physician able to remain in his/her own home or the home of a responsible relative or other responsible adult or an adult care facility, other than a shelter for adults, if the necessary services are provided and, for purposes of an adult care facility, the person meets the admission and continued stay criteria for such facility, the social services district must authorize a home assessment of the appropriateness of LTHHCP or AHCP services. The assessment must include, in addition to the physician's recommendation, an evaluation of the social and environmental needs of the person. The assessment will serve as a basis for the development of an appropriate plan of care for the person.

(i) If the person is in a hospital or an RHCF, the home assessment must be performed by the person's physician, the discharge coordinator of the hospital or RHCF referring the person, a representative of the social services district, and a representative of the LTHHCP or AHCP that will provide services to the person.

(ii) If the person is in his/her own home, the home assessment must be authorized by the social services district and must be performed by the person's physician, a representative of the social services district, and a representative of the LTHHCP or AHCP that will provide services to the person.

(iii) The assessment must be completed prior to or within 30 days after the provision of services begins. Payment for services provided prior to the completion of the assessment may be made only if it is determined, based upon such assessment, that the person qualifies for such services.

(iv) If the person is in an adult care facility, the home assessment must be performed by representatives of the LTHHCP or AHCP and the social services district in consultation with the operator of the adult care facility.

(v) Persons provided LTHHCP or AHCP services in adult care facilities must meet the admission and continued stay criteria for such facilities.

(vi) For persons requesting LTHHCP or AHCP services in adult care facilities, assessments must be completed prior to the provision of services.

(vii) Services provided by the LTHHCP or AHCP must not duplicate or replace those which the adult care facility is required by law or regulation to provide.

(viii) The commissioner must prescribe the forms on which the assessment will be made.

(3) If there is disagreement among the persons performing the assessment, or questions regarding the coordinated plan of care, or problems in implementing the plan of care, the issues must be reviewed and resolved by a physician designated by the Commissioner of Health.

(4) At the time of the initial assessment, and at the time of each subsequent assessment performed for a LTHHCP, or more often if the person's needs require it, the social services district must establish a monthly budget in accordance with which payment will be authorized. The social services district must provide the operator of the adult care facility with a copy of the completed assessment, the plan of care and the monthly budget.

(i) For persons who neither reside in adult care facilities nor receive AHCP services:

(a) The budget must include all of the services to be provided in accordance with the coordinated plan of health care by the LTHHCP.

(b) Total monthly expenditures made for a LTHHCP for a person who is the sole member of his/her household in the program must not exceed a maximum of 75 percent of the average monthly rates payable for RHCF services in the social services district. Total monthly expenditures made for a LTHHCP for two members of the same household must not exceed a maximum of 75 percent of the average monthly rates payable for both members of the household for RHCF services in the social services district.

(c) When the monthly budget prepared for a person 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 RHCF services, a "credit" may be accrued on behalf of the person. If a continuing assessment of the person's needs demonstrates that he/she requires increased services, the social services district may authorize any amount accrued during the past 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 RHCF services, a "credit" may be accrued on behalf of the household. If a continuing assessment of the household's needs demonstrates that the household requires increased services, the social services district may authorize any amount accrued during the past 12 months over the 75-percent maximum.

(d) When the monthly budget prepared for a person or a household is for an amount less than 75 percent of monthly rates payable for RHCF services, and the continuing assessment of the person's or household's needs demonstrates that the person or household requires 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 RHCF services, the LTHHCP may provide such services without prior approval of the social services district.

(e) If an assessment of the person's or household's needs demonstrates that the person or household requires 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.

(ii) For persons residing in adult care facilities but not receiving AHCP services:

(a) The budget must include all of the services to be provided in accordance with the coordinated plan of health care by the LTHHCP.

(b) Total monthly expenditures made for LTHHCP services provided to a person residing in an adult care facility must not exceed a maximum of 50 percent of the average monthly rates payable for RHCF services in the social services district.

(c) When the monthly budget prepared for a person residing in an adult care facility is for an amount less than 50 percent of the average of the monthly rates for RHCF services, a "credit" may be accrued on behalf of the person. If a continuing assessment of the person's needs demonstrates that he/she requires increased services, the social services district may authorize the expenditure of any amount accrued during the past 12 months provided that such amount, when added to the amount previously expended, does not exceed the 50 percent maximum.

(d) When the monthly budget prepared for a person residing in an adult care facility is less than 50 percent of the monthly rates payable for RHCF services, and the continuing assessment of the person's needs demonstrates that he/she requires increased services in an amount less than 10 percent of the prepared monthly budget, but totaling no more than 50 percent of the monthly rates payable for RHCF services, the LTHHCP may provide such services without prior approval of the local social services district.

(e) If an assessment of the needs of an adult care facility resident demonstrates that services are required, the payment for which would exceed the monthly maximum specified in clause (b) of this subparagraph, but it can be reasonably anticipated that total expenditures for required services for such person will not exceed such maximum calculated over a one-year period, the social services official may authorize payment for such services.

(iii) For persons receiving AHCP services, total monthly expenditures for such services are not subject to the requirements of subparagraph (4)(i) or (ii) of this subdivision.

(5) If a joint assessment by the social services district and the provider of services under this paragraph indicates that the maximum expenditure permitted under paragraph (4) of this subdivision is not sufficient to provide LTHHCP services to persons with special needs, social services officials may authorize, pursuant to the provisions of section 367-c(3-a) of the Social Services Law, maximum monthly expenditures for such persons, not to exceed 100 percent of the average RHCF rate established for that district. In addition, if a continuing assessment of a person with special needs demonstrates that he/she requires increased services, a social services official may authorize the expenditure of any amount which has accrued under this section during the past 12 months as a result of the expenditures for a person participating in the LTHHCP not having exceeded such maximum. If an assessment of a person with special needs demonstrates that he/she requires increased services, the payment for which would exceed such monthly maximum, the social services official may authorize payment for such services if it can reasonably be anticipated that the total expenditures for the required services for such a person will not exceed the maximum calculated over a one-year period.

(i) As used in this subdivision, the term person with special needs means a person for whom a plan of care has been developed pursuant to subdivision 2 of section 367-c of the Social Services Law:

(a) who needs care including but not limited to respiratory therapy, tube feeding, decubitus care or insulin therapy which cannot be appropriately provided by a provider of personal care services as defined in section 505.14(d) of this Part; or

(b) who has one or more of the following conditions: a mental disability as defined in section 1.03 of the Mental Hygiene Law, acquired immune deficiency syndrome, or dementia, including Alzheimer's disease.

(ii) The number of persons with special needs for whom a social services official may authorize payment for services pursuant to this paragraph is limited to 25 percent of the total number of LTHHCP clients which a social services district is authorized to serve; provided that in any district containing a city having a population of one million or more, such limit is 15 percent.

(iii) In the event that a district reaches the limitation specified in this subparagraph, the social services official may, upon approval by the commissioner, authorize payment for services pursuant to this subdivision for additional persons with special needs.

(iv) The social services official must seek approval for authorization to serve additional persons with special needs by submitting a written request to the commissioner which demonstrates that the provisions of this paragraph have (a) met the needs of individuals who could not otherwise be served through the LTHHCP; (b) diverted clients from residential health care facility admission; or (c) permitted the admission of clients on alternate care status into the LTHHCP.

(v) Social services districts are responsible for the retention of information deemed necessary by the department to evaluate the effectiveness of raising the limitation on expenditures for the delivery of long term home health care services, and for compliance with reporting requirements established by the department.

(vi) The provisions of this paragraph remain in effect until December 31, 1993.

(6) When a person who is in a hospital or an RHCF is identified as being medically eligible for hospital or RHCF care, and who desires to return to his/her own home and is deemed by his/her physician as able to be cared for at home, an assessment must be completed, and authorization for LTHHCP or AHCP services or notification that the person is ineligible for such program must be timely made with respect to ensuring continued Federal reimbursement.

(7) The social services district is responsible for the general case management of the overall needs of the person. Case management includes:

(i) facilitating determination of financial eligibility for medical assistance;

(ii) involvement in the assessment and reassessment of the social and environmental needs of the person;

(iii) preparation of the monthly budget for persons other than those receiving AHCP services; and

(iv) coordination of LTHHCP or AHCP services and other social services which may be required to keep the person in his/her own home.

(8) No single authorization for LTHHCP or AHCP services may exceed four months.

(i) A reassessment must be performed at least every 120 days, and must include an evaluation of the medical, social and environmental needs of the person, and must include a representative of the LTHHCP or AHCP, a representative of the social services district, and a physician designated by the Commissioner of Health. If there is a change in the person's level of care, he/she must be notified in writing of such change.

(ii) If a change in the person's level of care occurs between assessment periods as recommended by the LTHHCP or AHCP, the social services district must be notified and a new assessment must be authorized.

(c) Requirements for provision of care.

(1) Home health aide services may be provided directly by a LTHHCP or by an AHCP, or through contract arrangements between the LTHHCP or AHCP and voluntary agencies or proprietary agencies.

(2) Personal care services may be provided directly by a LTHHCP or an AHCP, or through contract arrangements between the LTHHCP or AHCP and the social services district or voluntary or proprietary agencies.

(3) In addition to providing nursing services to the person receiving LTHHCP or AHCP services, the LTHHCP's or AHCP's registered professional nurse or professional therapist must also be assigned responsibility for the supervision of the person providing personal care services to evaluate the person's ability to carry out assigned duties, to relate well to persons receiving LTHHCP or AHCP services, and to work effectively as a member of a team of health workers. This supervision must be carried out during periodic visits to the home in accordance with policies and standards established by the Department of Health.

(4) Services of a registered professional nurse or professional therapist and supervision of persons providing personal care services may be carried out concurrently. The frequency of periodic visits must be determined by the coordinated plan of care, but in no case may they be less frequent than every 120 days.

(d) Payment.

(1) Payment for a LTHHCP or an AHCP must be at rates established for each service for each agency authorized to provide the program. Rates must be on a per-visit basis, or, in the case of home health aide services and personal care services, on an hourly basis.

(2)

(i) When personal care services are directly provided by a LTHHCP or an AHCP, or when they are provided through contract arrangements with an agency that does not have a rate negotiated with the social services district, the Department of Health will establish the rate of payment with the approval of the Department of Social Services and the Director of the Budget.

(ii) When personal care services are provided by a LTHHCP or an AHCP through contract arrangements with a social services district, computation of the budget must be based on the district's salary schedule, but no payment may be made to the LTHHCP or AHCP.

(iii) When personal care services are provided by a LTHHCP or an AHCP through contract arrangements with an agency that has a rate negotiated with the social services district, the LTHHCP or AHCP rate must be no higher than that locally negotiated rate.

(3) Payment for assessment for a LTHHCP or an AHCP:

(i) is included in the hospital rate for staff participation in discharge planning;

(ii) is included in the physician's visit fee if the physician is not on the hospital staff, and performs the initial assessment while the person is in the hospital;

(iii) is included in the physician's home visit fee when the initial assessment or reassessment is performed in the person's home;

(iv) is included in the physician's office visit fee when the initial assessment or reassessment is performed in a nonfacility-related physician's office; and

(v) is included in the clinic fee when the initial assessment or reassessment is performed in a clinic or outpatient department.

(4) LTHHCP or AHCP participation in initial assessment and reassessment must be included in the administrative costs of the program.

(5) No social services district may make payments pursuant to title XIX of the Federal Social Security Act for benefits available under title XVIII (Medicare) of such Act without documentation of the following:

(i) that the LTHHCP or AHCP has prepared written justification for not having made application for Medicare because of the person's apparent technical ineligibility; or

(ii) that application for Medicare benefits has been rejected by either the Health Care Financing Administration or its fiscal intermediary.

(6) No social services district may make payment for a person receiving LTHHCP or AHCP services while payments are being made for that person for inpatient care in an RHCF or a hospital.

(e) Reimbursement. State reimbursement shall be available for expenditures made in accord with the provisions of this section.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 505.21