Section 85.41 - Approval of Residential Health Care Facility (RHCF) admission and continued stay

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 thirty (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 sections 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 fifty (50) miles of the the patient's residence or within fifty (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.

Effective Date: 
Wednesday, January 24, 1990
Doc Status: 
Complete