Section 505.20 - Alternate care.

505.20 Alternate care. (a) Patients who no longer need hospital or skilled nursing facility care shall be discharged promptly and, for hospital patients, shall be discharged in accordance with the Department of Health's hospital discharge planning requirements contained in section 405.22(j) of Title 10 NYCRR.

(b) Facility responsibility. (1) When a patient's condition is such that continued care in a hospital or skilled nursing facility is necessary pending placement in an alternate lower medical level of care, continuing payment may be authorized following certification by the patient's physician and a determination of coverability by the Commissioner of Health or his or her other designee, pursuant to Department of Health regulation Part 85 that skilled nursing or health-related facility services are medically necessary, are being provided, and are not otherwise available. When medically feasible, nonmedical institutional placement in the community or other community placement shall be arranged.

(2) As soon as the patient's physician has indicated need for alternate medical care placement and the anticipated date the patient will be ready for discharge to such care, the hospital or skilled nursing facility shall inform the social services district, if required by such district, and other agencies that can most appropriately be expected to arrange for the provision of alternate care services, of the patient's medical needs that must be satisfied in accordance with the physician's recommendations. Failure by the hospital or skilled nursing facility to notify the local district, if required by such district, or other appropriate agencies prior to or within 24 hours of the patient's assignment to alternate care status shall result in denial of payment for care rendered on or after that date. Verbal notification by the hospital or skilled nursing facility shall be promptly confirmed in writing to the local district, if required by the district.

(3) (i) The hospital or skilled nursing facility, through its staff members responsible for discharge planning and, as necessary, in coordination with the responsible local social services district, shall act promptly to effect arrangements for alternate care.

(ii) The hospital or skilled nursing facility shall make weekly admission contracts with at least three facilities providing the appropriate level of care in its discharge community, defined as a 50-mile radius around the facility. These contracts must be rotated weekly among all available facilities in the referring facility's discharge community. The contracts shall be documented.

(iii) Except as otherwise provided in this subparagraph, the hospital or skilled nursing facility shall have admission documentation for each patient awaiting placement on file with at least five facilities in its discharge community. A skilled nursing facility may restrict the number of facilities having a patient's admission documentation on file to fewer than five under the conditions set forth in 10 NYCRR Part 85 governing continuing stay reviews in residential health care facilities. A hospital may restrict the number of facilities having a patient's admission documentation on file to one facility when there are other hospital patients receiving medical assistance and awaiting alternate care placement; and

(a) the patient, within the next 10 days, will either be placed in another facility or discharged to the community; or

(b) the patient has requested priority for readmission to the medical facility where the patient resided prior to hospitalization, as provided for under section 360.20 of this Title.

(iv) The local social services district may direct that a hospitalized patient be placed outside the referring hospital's discharge community when the hospital has been unsuccessful in locating an alternate level of care bed within its discharge community within 60 days of the day the patient was placed in alternate care status. A decision to seek such placement shall be made only when the patient's local professional medical director:

(a) determines that the patient's needs cannot be met by facilities located within the hospital's discharge community or that the patient's condition is such that a continued hospital stay is medically contraindicated; and

(b) recommends such placement, based on his or her review of available documentation concerning the patient's medical and psychosocial needs.

(4) The hospital or skilled nursing facility shall assess the patient's medical condition and alternate medical care placement needs prior to or within 24 hours of the patient's assignment to alternate care status. To determine the alternate care level to which the patient shall be assigned, the hospital or skilled nursing facility shall apply either the patient assessment standards promulgated by the Department of Health (DOH) or a DOH-approved equivalent. Each patient assessment shall be reviewed and updated periodically during the patient's alternate level of care stay according to the continuing stay review intervals specified by DOH. A copy of each such assessment form shall be forwarded to the local district, if required by the district.

(5) No payment for hospital or skilled nursing facility care for an eligible person pending alternate medical care placement shall be made if:

(i) the requirements contained in paragraphs (1) through (4) of this subdivision are not met;

(ii) the requesting hospital or skilled nursing facility has an alternate care facility attached to it or affiliated with it and such an alternate care facility has an appropriate alternate medical care vacancy;

(iii) an appropriate alternate medical care vacancy exists within a 50-mile radius of the requesting facility or beyond this radius for a hospital patient whom the local social services district has directed the hospital to place beyond the hospital's discharge community pursuant to subparagraph (3)(iv) of this subdivision; or

(iv) the requesting hospital or skilled nursing facility has failed to secure other available third-party reimbursement for the care of the patient for that period of time the patient was awaiting alternate care placement.

(6) When the utilization review committee determines that medical assistance payments should be discontinued because the recipient has refused an appropriate alternate care placement, it shall send written notification of its action to the recipient or the recipient's representative or appropriate relative, and the local social services district. The notice shall comply with the requirements of section 360.33 of this Title. The notice and the action taken thereon shall be consistent with Federal and State utilization review requirements and the recipient shall be notified of his or her right to request a fair hearing as provided for in Part 358 of this Title.

(7) Medical assistance payments for patients needing alternate care placement shall be available only for patients whose initial admission to the hospital or skilled nursing facility was both medically necessary and appropriate. Medical assistance payments for patients needing alternate care placement shall not be available for patients whose initial admission was not both medically necessary and appropriate, but was made because an appropriate placement at a lower level of care was unavailable at the time of admission to the referring facility.

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