N.Y. Comp. Codes R. & Regs. tit. 18 § 505.9

Current through Register Vol. 46, No. 50, December 11, 2024

Section 505.9 - Residential health care

(a)Qualifications for participation.

(1) In-state nursing facility care. Nursing care must be provided only in a nursing facility, as defined in the regulations of the Department of Health, which:

(i) holds a current operating certificate issued by the Department of Health;

(ii) qualifies as, or has an application pending to become, a provider in the Medicare program pursuant to title XVIII of the Federal Social Security Act, unless the nursing facility provides care solely to pediatric patients;

(iii) meets the Federal requirements for a "nursing facility" under title XIX of the Federal Social Security Act; and

(iv) has a current effective provider agreement with the Department of Social Services.

(2) Out-of-state nursing facility care. When nursing facility care is provided to a medical assistance recipient in a nursing facility located outside New York State, such nursing facility must:

(i) comply with applicable licensing or approval requirements established by the officially designated standard-setting authority in the state where the care was received;

(ii) qualify as, or have an application pending to become, a provider in the Medicare program pursuant to title XVIII of the Federal Social Security Act, unless the nursing facility provides care solely to pediatric patients;

(iii) meet the Federal requirements for a "nursing facility" under title XIX of the Federal Social Security Act; and

(iv) have a current provider agreement with the officially designated standard-setting authorities of the state in which the facility is located.

(3) Out-of-state facilities lacking title XVIII certification. Medical assistance payments are available solely for those recipients admitted to and retained in nursing facility beds certified for participation in title XVIII of the Federal Social Security Act.

(4) In-state intermediate facility care for the mentally retarded. In-state intermediate facility care for the mentally retarded must be provided only in intermediate care facilities for the mentally retarded that:

(i) have valid operating licenses issued by the Office of Mental Retardation and Developmental Disabilities (OMRDD) under article 31 of the Mental Hygiene Law;

(ii) have valid provider agreements with the Department of Social Services; and

(iii) have been certified as intermediate care facilities for the mentally retarded by the OMRDD.

(5) Out-of-state intermediate facility care for the mentally retarded. When intermediate facility care for the mentally retarded is provided to MA recipients in intermediate care facilities for the mentally retarded located in other states, payment must be made only for care provided by out-of-state facilities that:

(i) comply with applicable licensing requirements established by the officially designated standard-setting authorities of the states in which the facilities are located;

(ii) have valid provider agreements with the officially designated standard-setting authorities of the states in which the facilities are located; and

(iii) are certified as intermediate care facilities for the mentally retarded by the officially designated standard-setting authorities of the states in which the facilities are located.

(b)Prior approval and prior authorization of level of care.

(1) Prior approval of level of care.

(i) Prior approval of level of care when required by the Commissioner of the Department of Health, or his or her designee, is required before services provided in a nursing facility (NF) or intermediate care facility for the mentally retarded (ICF/MR) can be reimbursed under the MA program.

(ii) Prior approval of level of care will be granted in accordance with patient assessment criteria and standards promulgated or approved by the Commissioner of the Department of Health or his or her designee.

(iii) Reviews of medical necessity must be made in accordance with standards promulgated or approved by the Commissioner of Health or his or her designee.

(2) Prior authorization.

Prior authorization by a local social services official for care in an NF or ICF/MR is required pursuant to Part 504 of this Title. In no case can prior authorization exceed the maximum eligibility period permitted by regulations of the Department of Social Services. Failure by an NF or ICF/MR to comply with the requirements of this subdivision may result in retroactive denial of authorization by the local social services official. In addition, if the Commissioner of Health, or his or her designee, determines that a recipient received a level of care that was not medically necessary, authorization will be retroactively rescinded.

(c)Maximum reimbursable rate.

The maximum reimbursable rate for payments made for nursing facility care provided in a nursing facility located in the State of New York will be at the rate approved by the Director of the Budget.

(d)Reserved bed days.

(1) The department will pay the medical institutions listed in paragraph (3) of this subdivision to reserve a bed for an MA recipient temporarily hospitalized or on leave of absence from the institution for one or more reserved bed days; however, the department will not pay to reserve an NF bed for a recipient 21 years of age or older who is temporarily hospitalized unless such recipient is receiving hospice services within the NF. A reserved bed day is a day for which the department pays a medical institution to reserve an MA recipient's bed while he or she is temporarily hospitalized or on leave of absence from the institution. The recipient must be absent from the institution overnight for the day to be considered a reserved bed day. A recipient is considered to be absent overnight when he or she is absent later than the time at which the institution normally conducts its patient census. The day the recipient departs for temporary hospitalization or the leave of absence begins is counted as a reserved bed day. The day the recipient returns is not counted as a reserved bed day.

(2) Payments necessary to reserve an NF bed for an MA recipient under 21 years of age who is temporarily hospitalized or on leave of absence, as permitted by this section, will be made at the reserved bed rate established for the facility by the Commissioner of the Department of Health and approved by the Director of the Budget. Payments necessary to reserve a NF bed for an MA recipient 21 years of age or older, as permitted by this section, shall be made at 95 percent of the Medicaid rate otherwise payable to the facility with regard to such days of care in the case of a leave of absence, and at 50 percent of the Medicaid rate otherwise payable to the facility with regard to such days of care in the case of the temporary hospitalization of a recipient receiving hospice services within the facility. Payments to reserve a bed in any other medical facility listed in paragraph (3) of this subdivision, as permitted by this section, will be at the full rate established for the facility.

(3) Medical institutions which may receive payments for reserved bed days are:

(i) an NF;

(ii) an ICF/MR;

(iii) a specialty hospital as defined in 14 NYCRR Part 680;

(iv) a psychiatric facility, including a residential treatment facility for children and youth (RTF);

(v) a rehabilitation facility;

(vi) a psychiatric or rehabilitation unit of a general hospital; or

(vii) a hospice for individuals residing in NFs who are in receipt of hospice services.

(4) General rules regarding payment for reserved bed days.

(i) Payment for reserved bed days will be made in accordance with paragraphs (1) and (2) of this subdivision.

(ii) Payment for bed reservations that are terminated will be from the date the recipient was admitted to the hospital through the date the hospital notified the institution of the circumstances that resulted in the termination.

(iii) No payment will be made for periods when recipients are absent from the institution as a direct result of a labor dispute in the institution.

(iv) No payment will be made for reserved bed days when a recipient's primary third-party resource is Medicare unless the recipient has been a patient in an NF for at least 30 days immediately before the hospitalization which resulted in the recipient's current Medicare coverage.

(v) NFs, ICFs/MR, specialty hospitals and RTFs must indicate on billing claims that authorization to claim reimbursement for reserved bed days has been obtained when necessary according to paragraph (7) of this subdivision.

(5) Length of stay and vacancy rate requirements.

(i) Applicability to NFs, ICF/MRs and specialty hospitals. The department will pay an institution for a recipient's reserved bed days when:

(a) the recipient has been a patient in the institution for at least 30 days since the date of his or her initial admission; and

(b) the part of the institution to which the recipient will return has a vacancy rate of no more than five percent on the first day the recipient is hospitalized or on leave of absence. When computing vacancy rates, an institution must disregard beds that have been reserved for other patients/residents. ICFs/MR with more than 30 beds are exempt from this vacancy rate requirement.

(ii) Applicability to RTFs. The department will pay an RTF for a recipient's reserved bed days when:

(a) the recipient has been institutionalized for at least 15 consecutive days. The appropriate regional office of the Office of Mental Health (OMH) may waive this length- of-stay requirement for a recipient temporarily hospitalized for emergency psychiatric or medical care; and

(b) the part of the RTF to which the recipient will return has a vacancy rate of not more than five percent or two vacant beds, whichever is greater, on the first day the recipient is hospitalized or on leave of absence. When computing a vacancy rate, the RTF must disregard beds that have been reserved for other patients.

(iii) Applicability to psychiatric facilities and psychiatric units of general hospitals. The department will pay a facility for a recipient's reserved bed days when the recipient has been institutionalized for at least 15 consecutive days. There is no vacancy rate requirement for these psychiatric facilities or units.

(iv) Applicability to rehabilitation facilities or rehabilitation units of general hospitals. The department will pay a facility for a recipient's reserved bed days when the recipient has been institutionalized for at least 30 consecutive days. There is no vacancy rate requirement for rehabilitation facilities or units.

(6) Reserving beds for recipients who are temporarily hospitalized. ICFs/MR, RTFs and specialty hospitals, as a condition of participation in the MA program, must make, extend and terminate bed reservations for MA recipients who are temporarily absent from such institutions for hospitalization as provided in subparagraphs (i) through (iv) of this paragraph. NFs must, as a condition of participation in the MA program, make, extend and terminate bed reservations for MA recipients who are either under 21 years of age, or receiving hospice services within the facility and temporarily absent from such institutions for hospitalization as provided in subparagraphs (i) through (iv) of this paragraph.

(i) Reserving a recipient's bed. The institution must reserve a recipient's bed when the recipient is hospitalized and expected to return to the institution in 15 or fewer days, subject to the limitations set forth in this paragraph. Unless medically contraindicated, the institution must reserve the same bed and room the recipient occupied before being hospitalized. When an institution reserves a recipient's bed, it must notify the hospital by telephone and in writing, according to department instructions, that:

(a) the recipient's bed has been reserved;

(b) the hospital discharge planning coordinator must notify the institution by telephone of any changes in the recipient's condition during the period that the recipient's bed is reserved; and

(c) the hospital discharge planning coordinator must notify the institution of the recipient's planned discharge date by the morning of the fourth day of hospital care. The hospital discharge planning coordinator must also notify the institution by telephone if the recipient's planned discharge date must be adjusted after the third and before the 16th day of hospital care because his or her condition has changed or additional medical information has become available. The hospital discharge planning coordinator must confirm in writing all bed reservation telephone communications.

(ii) When a recipient's bed will not be reserved. Under certain circumstances a recipient's bed will not be reserved. The institution must notify the hospital where the recipient is admitted that it is not reserving the recipient's bed. The institution must make appropriate notes on the recipient's transfer records or telephone the hospital within 24 hours after the recipient has been admitted if the recipient's bed will not be reserved. The institution also must document its decision not to reserve the bed. If a bed is not reserved, the recipient must be given priority in readmission to the institution over persons referred to the institution for their first admissions. An NF, ICF/MR, RTF or specialty hospital cannot reserve a recipient's bed when:

(a) it is clear when the recipient is hospitalized that he or she will not return to the institution within 15 days or fewer;

(b) after hospitalization, the recipient will need a level of care the institution does not provide; or

(c) the recipient does not want to return to the institution.

(iii) Extending bed reservation. An NF, ICF/MR, RTF or specialty hospital must extend the bed reservation of a hospitalized recipient under the following circumstances:

(a) if an extension will permit the recipient to return to the institution within 20 days of his or her admission to the hospital, the bed reservation must be extended up to five days beyond the 15-day limit; or

(b) if an extension will permit a recipient hospitalized for acute psychiatric care to return to the RTF within 30 days of his or her admission to the hospital, the RTF must extend the recipient's reservation up to 15 days beyond the 15-day limit.

(iv) Terminating bed reservations.

(a) An NF, ICF/MR, RTF and specialty hospital must terminate a recipient's bed reservation when:

(1) the planned discharge date determined by the hospital by the morning of the fourth day of hospital care is more than 15 days from the day the recipient was admitted; or

(2) the hospital adjusted the recipient's planned discharge date between the morning of the fourth day of hospital care and the 16th day of hospital care and the new discharge date will not permit the recipient to return to the institution within 20 days of the hospital admission date, except as provided in clause (b) of this subparagraph.

(b) An RTF must terminate a recipient's bed reservation if the recipient was hospitalized for acute psychiatric care, the recipient's planned discharge date was changed between the morning of the fourth day and 16th day of hospital care and the new discharge date will not permit the recipient to return to the institution within 30 days of the hospital admission date.

(c) The hospital discharge coordinator must provide the institution with appropriate documentation regarding circumstances which caused the discharge date to be changed.

(7) Reserving beds for recipients who are on leave of absence.

(i) A recipient is on leave of absence when he or she is absent from the medical institution overnight to visit friends or relatives or to participate in a medically acceptable therapeutic or rehabilitative plan of care.

(ii) An NF, ICF/MR, RTF and specialty hospital must, as a condition of participation in the MA program, reserve beds as follows:

(a) Reserving the recipient's bed. A medical institution must reserve a recipient's bed when his or her plan of care provides for leaves of absence. Unless medically contraindicated, the institution must reserve the same bed and room the recipient occupied before the leave of absence. If a bed may not be reserved for a recipient under this paragraph, the institution must give priority to the recipient's readmission, over individuals referred for their first admissions.

(b) Prior authorization for payment of leave of absence reserved bed days:

(1) is not required for the first 18 of a recipient's reserved bed days during any 12-month period;

(2) is required if a recipient's reserved bed days are more than 18 days in any 12-month period, except for a recipient in an RTF, ICF/MR or specialty hospital. The medical institution must request prior authorization from the recipient's social services district's MA professional director. Prior authorization will be granted only if the 18-day limit interferes with a physician's ability to prescribe an appropriate therapeutic or rehabilitative plan for the recipient; and

(3) is required for a recipient's reserved bed days in an RTF which exceed 75 days in any 12-month period or 4 days per single leave. The RTF must request prior authorization from the appropriate regional office of the OMH for payment of the excess reserved bed days. The request for prior authorization must be:

(i) supported by verification from a physician;

(ii) consistent with the RTF's written policy; and

(iii) approved by the appropriate regional office of the OMH.

(c) An ICF/MR or a specialty hospital may request payment without prior authorization for an unlimited number of reserved bed days in any 12-month period.

(iii) For a recipient in a rehabilitation or psychiatric facility other than an RTF, or in the psychiatric or rehabilitation unit of a general hospital, the facility or unit must assure that leaves of absence are consistent with the institution's written policy on the use of leaves for therapy only, and limited to two days for any single leave, unless the recipient's social services district's MA professional director has approved an exception to this limitation prior to the leave.

(iv) Other payment standards for leave of absence reserved bed days.

(a) When a recipient incurs expenses, such as room and board, while on leave of absence, and the institution's per diem rate already reimburses the institution for these expenses, the institution must pay the cost. The recipient's social services district must give prior approval for an exception to this requirement. The social services district must ensure that costs included in the institution's per diem rate are reconciled with the institution's claim for payment of reserved bed days.

(b) No payment for reserved bed days will be made if a recipient returns to the institution from a leave of absence and is then discharged within 24 hours. Prior approval by the recipient's social services district's MA professional director, or for a recipient in an RTF, by the Commissioner of the OMH or his or her designee, or, for recipients in ICFs/MR or specialty hospitals, by the Commissioner of the OPWDD or his or her designee, must be obtained for an exception to this provision.

(v) An NF may not reserve a bed under this paragraph for a recipient who is temporarily receiving care in a hospital.

(vi) A bed reservation under this paragraph must be terminated when the institution is informed that the recipient will not return from leave to the institution.

(vii) When a recipient has been a patient in more than one medical institution within any 12-month period, the institution where the recipient is currently a patient must determine the number of paid leave of absence days in other institutions. Such institution must assure that the recipient's total number of leave days during the previous 12-month period does not exceed 18 days, unless prior authorization for extra days has been received or the 180-day limit is inapplicable. When a recipient is transferred to another inpatient institution, a copy of his or her absence register must be included in the transfer records.

(8) Prior authorization for payment for reserved bed days.

(i) Prior authorization for payment of reserved bed days is not required when a recipient is hospitalized for 15 or fewer days and returns immediately to the institution.

(ii) Prior authorization for payment of reserved bed days is required when:

(a) a recipient is hospitalized for 15 or fewer days and returns to an institution which has been identified by the social services district, the Office of Health Systems Management of the Department of Health, the OMRDD or the OMH as having deviated from this subdivision's standards. The social services district must require such institution to request prior authorization for payment; or

(b) a recipient is hospitalized for 15 or fewer days and does not return from the hospital immediately following the time for which the bed was reserved; or

(c) a recipient, who based on available medical information was expected to be hospitalized for 15 days or fewer, is hospitalized for more than 15 days. If prior authorization is obtained, payment will be made for the recipient's reserved bed days up to 20 days per hospital stay, or up to 30 days per hospital stay for a recipient in an RTF who was hospitalized for acute psychiatric care.

(iii) Prior authorization for payment must be requested as follows:

(a) NFs must request prior authorization from the recipient's social services district's MA professional director. The social services district must approve or disapprove in writing all or part of the request within five business days of its receipt. Requests will be disapproved under the following circumstances:

(1) when the hospitalization is clearly inappropriate, based on available medical documentation;

(2) when the recipient, at the time of hospitalization, could not reasonably have been expected to return to the institution within 15 or fewer days; or

(3) when the hospital changed the recipient's planned discharge date between the morning of the fourth day of hospital care and the 16th day of hospital care, and the new date would not permit the recipient to return to the institution within 20 days of the date of hospital admission, or the new date would not permit the recipient to return to the institution within 30 days of hospital admission for a recipient in an RTF who was hospitalized for acute psychiatric care. In this instance, prior authorization will be granted from the date of admission up to and including the date the institution was notified of the change in planned discharge date.

(b) For ICFs/MR and specialty hospitals, the social services district must accept a prior authorization that has been approved by the Commissioner of the OMRDD or his or her designee.

(c) For RTFs the social services district must accept an authorization that has been approved by the Commissioner of the OMH or his or her designee.

(iv) Special bed reservation limits may be established on an individual case basis for a recipient in an ICF/MR, specialty hospital or RTF when the recipient's hospital stay would be longer than allowable limits. Such reservations must be approved by the State Commissioner of Social Services.

(9) Absence registers and other reports.

(i) Each medical inpatient institution that is an MA provider must maintain an absence register for each recipient who is absent after the institution's normal census-taking hour.

(ii) Medical institutions and agencies exercising prior approval authority must make adequate records available to Federal and State auditors to verify the number and nature of reservations authorized under this section.

(iii) Medical institutions must record reserved bed days and overnight absences on any financial and statistical reports that require patient day information.

(e)Required training of nurse aides.

(1) Policy.

Consistent with the regulations of the Department of Health (10 NYCRR Part 414), on and after January 1, 1990, residential health care facilities must use nurse aides who meet the following standards:

(i) if used on a full-time basis, nurse aides must have completed a training and competency evaluation program or a competency evaluation program approved by the Department of Health and have been determined to be competent to provide nursing or nursing-related services according to the Department of Health's regulations; and

(ii) if used on a temporary, per diem, leased or any other basis, nurse aides must have completed a training and competency evaluation program or a competency evaluation program approved by the Department of Health.

(2) Employment, training and evaluation of nurse aides.

(i) Residential health care facilities must comply with the regulations of the Department of Health (10 NYCRR Part 414) regarding the employment, training and evaluation of nurse aides.

(ii) Before a residential health care facility employs a nurse aide, it must consult the State Nurse Aide Registry to determine whether such registry contains the name of the nurse aide.

(f)Payment for required training and competency evaluation of nurse aides.

(1) Policy.

The department will pay residential health care facilities for the training and competency evaluation of nurse aides as administrative costs under the medical assistance program. Payment will be limited to the actual costs which residential health care facilities incur, up to a maximum payment established by the department. The department will consult with the Department of Health when developing the maximum payment permitted under this subdivision.

(2) Maximum payments for costs of training and competency evaluation of nurse aides. In determining the amount of payment to be made to residential health care facilities for the costs of training and competency evaluation of nurse aides, actual costs claimed by such facilities will be subject to a maximum payment for training and competency evaluation as follows:

(i) Training. A maximum payment established by the department for each region listed in subdivision (g) of this section, based upon regional variations in nurse aide training costs.

(ii) Competency evaluation. A total of $165 per individual for competency testing for up to three tests; or a maximum of $25 for each individual who was employed as a nurse aide as of June 10, 1989, and who has been deemed to have met the requirement of completing an approved nurse aide training program and passing the competency evaluation examinations, or for whom the requirement has been waived by the Department of Health.

(3) Claims for payment.

A residential health care facility must submit a voucher to the department detailing its actual expenditures for the training and competency evaluation of nurse aides not less than 30 days after the end of each calendar quarter. Each such voucher must include:

(i) the residential health care facility's name and provider number;

(ii) the times, dates and places of the training and/or evaluation;

(iii) the name and address of the approved program that provided the training or evaluation;

(iv) the names and other individual identifying information of employees who were trained or evaluated;

(v) the actual costs incurred for training and evaluation; and

(vi) the residential health care facility's regional code.

(4) Payment for costs of required training and competency evaluation of nurse aides expended before July 1, 1990. The department and the Department of Health will reconcile all payments for the training and competency evaluation of nurse aides included in the residential health care facilities' per diem medical assistance rates prior to July 1, 1990, with actual expenditures reported by facilities for that period in accordance with the following procedure:

(i) The Department of Health will provide reconciliation forms to all residential health care facilities. Residential health care facilities must report on these forms their actual costs incurred and expended before July 1, 1990, for required training and competency evaluation of nurse aides. Residential health care facilities must return completed forms to the Department of Health certifying their actual costs for the period.

(ii) The department will consider the actual costs reported to be administrative costs under the medical assistance program. Payment for these costs will be limited to the actual, documented expenditures by residential health care facilities, subject to the maximum payments developed by the department. Payments which were included in the residential health care facilities' per diem rates for such period for training and evaluation will be deducted from reported costs. If reported costs exceed the payments received as part of the residential health care facilities' rate, facilities will be required to submit vouchers, as specified in paragraph (3) of this subdivision, to claim any underpayments for the period. If the reported costs are less than the payments received as part of the residential health care facilities' rates, facilities' future medical assistance payments will be offset to recover the overpayments.

(g)Regional ceiling:

Region	Counties in Region	Regional Caps
Albany	Albany, Columbia, Greene, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Fulton	$ 450
Binghamton	Broome, Tioga	$ 450
Erie	Cattaraugus, Chautauqua, Erie, Niagara, Orleans	$ 475
Elmira	Chemung, Steuben, Schuyler	$ 558
Glens Falls	Essex, Warren, Washington	$ 450
Long Island	Nassau, Suffolk	$ 483
Orange	Chenango, Delaware, Orange, Otsego, Sullivan, Ulster	$ 567
New York City	Bronx, Kings, Queens, Richmond, New York	$ 450
Poughkeepsie	Dutchess, Putnam	$450
Rochester	Livingston, Monroe, Ontario, Wayne	$589
Central Rural	Cayuga, Cortland, Seneca, Tompkins, Yates	$ 450
Syracuse	Madison, Onondaga	$ 501
Utica	Herkimer, Jefferson, Lewis, Oneida, Oswego	$ 450
Westchester	Rockland, Westchester	$ 450
Northern Rural	Clinton, Franklin, Hamilton, St. Lawrence	$ 450
Western Rural	Allegany, Genesee, Wyoming	$ 450

N.Y. Comp. Codes R. & Regs. Tit. 18 § 505.9

Amended New York State Register May 29, 2019/Volume XLI, Issue 22, eff. 5/29/2019