Section 86-5.9 - Determining patient eligibility

86-5.9 Determining patient eligibility.

(a) At the time of the initial assessment, and at the time of each subsequent assessment performed for a long-term home health care program, or more often if the person's need requires it, the local social services district shall establish a monthly budget in accordance with which payment shall be authorized.

(1) The budget shall include all of the services to be provided in accordance with the coordinated health plan of care by the long-term home health care program.

(2) Total monthly expenditures made for a long-term home health care program for an individual who is the sole member of his/her household in the program shall not exceed a maximum of 75 percent of the average monthly rates payable for nursing home services or health-related services in an intermediate care facility in the social services district, whichever is the appropriate level for the individual. Total monthly expenditures made for a long-term home health care program for two members of the same household shall not exceed a maximum of 75 percent of the average monthly rates payable for both members of the household for nursing home services or health-related services in an intermediate care facility in the social services district, whichever is the appropriate level for each person.

(3) When the monthly budget prepared for an individual 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 nursing home services or health-related services, a "credit" may be accrued in behalf of the individual. If a continuing assessment of the individual's needs demonstrates that he/she requires increased services, the local social services department may authorize any amount accrued during the previous 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 nursing home services or health-related services, "credit" may be accrued in behalf of the household. If a continuing assessment of the household's needs demonstrates that he/she/they require increased services, the local social services department may authorize any amount accrued during the previous 12 months over the 75-percent maximum.

(4) When the monthly budget prepared for an individual or a household is for an amount less than 75 percent of monthly rates payable for nursing home services or health-related services, and the continuing assessment of the person's needs demonstrates that he/she/they require 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 nursing home services or health-related services, the long-term home health care program may provide such services without prior approval of the local department of social services.

(5) If an assessment of the person's or household's needs demonstrates that he/she/they require 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.

(b) If a joint assessment by the local social services district and the provider of services indicates that the maximum expenditure permitted under paragraph (4) of this subdivision is not sufficient to provide long-term home health care program (LTHHCP) services to individuals with special needs, social services officials may authorize maximum monthly expenditures for such individuals, not to exceed 100 percent of the average skilled nursing or health-related facility rate established for that district (see 367-c(3-a) of the Social Services Law). 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 previous 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.

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

(ii) who has one or more of the following conditions: a mental disability (see section 1.03 of the Mental Hygiene Law), acquired immune deficiency syndrome, or dementias, including Alzheimer's disease.

(2) 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.

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

(4) The social services official must seek approval for authorization to serve additional persons with special needs by submitting to the State Commissioner of Social Services a written request which demonstrates that the provisions of this paragraph have

(i) met the needs of individuals who could not otherwise be served through the LTHHCP;

(ii) diverted clients from residential health care facility admission; or

(iii) permitted the admission of clients on alternate care status into the LTHHCP.

(c) The provisions of this section shall not apply to patients diagnosed with Acquired Immune Deficiency Syndrome as defined by ICD-9 codes 042, 043 and 044 if such patient is receiving services through a designated AHCP.
 

Effective Date: 
Monday, November 6, 1989
Doc Status: 
Complete