Section 86-5.3 - Patient assessment

86-5.3 Patient assessment.

(a) Long-term home health care program participation. The direct costs for patient assessments and reassessments to the LTHHCP shall be included in the administrative costs of the LTHHCP and shall be included in the program's conversion of its cost report to an hourly or visit cost basis. These costs shall be limited to LTHHCP staff participation in the patient assessment.

(b) The cost of hospital/RHCF staff participating in patient assessment and discharge planning is included in the Medicaid rate of the facility and may not be added to the costs of the long-term home health care program.

(c) The cost of staff of the local social services district may not be included in the cost of the patient assessment.

(d) Physician participation. (1) If the patient is in a hospital/RHCF and the physician is not on the staff of that facility, reimbursement for the physician's initial assessment is included in his visit fee in accordance with the Medicaid fee schedule.

(2) If the patient is in the community:

(i) and the assessment takes place in a clinic, reimbursement for the initial assessment is included in the clinic rate for medical or social care provided;

(ii) and the assessment takes place in the home, reimbursement for the initial assessment is included in the physician's home visit fee;

(iii) and the assessment takes place in the nonfacility-related physician's office, reimbursement for the initial assessment is included in the physician's office visit fee.

(e) Initial assessments for Medicaid patients shall be conducted only with authorization of the local social services district unless arrangements for patient admission have been made pursuant to section 3616 of the State Public Health Law.

(f) If an assessment of the person's needs demonstrates that he/she requires services the payment for which would exceed the monthly maximum, 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.

(g) If a change in the patient's level of care occurs between required patient assessment periods, the LTHHCP must formally notify the local social services district with justification for change. A new plan of care must be submitted in writing to the local social services district for their review and approval.

(h) If the patient requires unanticipated services but not a change of level of care between assessment periods, the program may provide such services if:

(1) the patient's budget is below the 75-percent ceiling and/or there are accrued savings and the costs of the needed services are equal to or less than 10 percent of the current budget for the services provided by the program; or

(2) the additional services exceed the 75-percent ceiling and there is not an accrued savings, providing that the additional cost does not exceed the patient's budget by more than 10 percent. This contingency provision may only be used when 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.
 

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