PRIOR APPROVAL FOR CARE AND SERVICES

Section 85.37 - Time limits within which determinations shall be made

PRIOR APPROVAL FOR CARE AND SERVICES

85.37 Time limits within which determinations shall be made. (a) All decisions on requests for prior approval must be made and all required notices shall be sent by the New York State Department of Health to the requesting provider and, where required, to the medical assistance patient-recipient, within 21 calendar days of receipt of such requests by the New York State Department of Health; except that in cases where prior approval requests for dental care are received in area offices outside the five boroughs of New York City and a clinic examination is necessary, the required notices above shall be transmitted within 30 calendar days of receipt of such requests by the respective upstate area office.

(b) In the event prior approval requests must be returned to the requesting provider for submission of additional information, the calendar day limit in subdivision (a) of this section will be tolled from the day the request is returned to the provider until the day the request plus additional information is returned to the New York State Department of Health.

(c) In the event the prior approval request and the requested additional information from the provider is received on a Thursday or Friday which occurs after the 19th calendar day referenced in subdivision (b) of this section, two additional working days may be added to the 21-calendar day limit specified in subdivision (a) of this section.

(d) If a determination is not made and transmitted in accordance with provisions in subdivisions (a)-(c) of this section, the New York State Department of Health shall, within two working days from the expiration of the time limits set forth in subdivisions (a)-(c) of this section, notify the requesting provider and patient-recipient of such fact and of the patient's-recipient's right to request a fair hearing to determine whether the prior approval request should be approved.
 

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Section 85.38 - Child/Teen Health Plan

85.38 Child/Teen Health Plan (also known as Child Health Assurance Program).

A free-standing diagnostic and treatment center which participates in the Medicaid program shall submit billings with the appropriate specialty codes which accurately reflect all health services provided to children eligible for the Child/Teen Health Plan (also known as Child Health Assurance Program) as defined in 18 NYCRR section 501.1(a) in order to assure maximum utilization of such services.
 

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Section 85.39 - RESERVED

RESERVED

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Section 85.40 REPEALED

Effective Date: 
Wednesday, March 2, 2011

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

Section 85.42 - Catastrophic health care expense program

85.42 Catastrophic health care expense program.

(a) The Expanded Health Care Coverage Act of 1988 (Chapter 703 of the Laws of 1988) establishes, under the jurisdiction of the New York State Department of Social Services, the Catastrophic Health Care Expense Program (CHCEP). The Department of Social Services will permit authorized counties to make available assistance with cost sharing to eligible county individuals and families for the purpose of assisting such individuals and families with catastrophic health care expenses. The CHCEP program requires participants eligible for cost sharing to receive such assistance in accordance with a schedule that sets forth the cost sharing shares between the participant and the program.

(b) The following schedule entitled "Cost Sharing Proportional Schedule" shall be used by the New York State Department of Social Services in determining a beneficiary's fiscal responsibility for catastrophic health care expenses covered under the CHCEP assistance with cost sharing program:
Cost Sharing Proportional Schedule

Category of Service Recipient Cost Share Responsibility

Hospital Emergency Room 75 percent

Selected Optional Services 50 percent

Podiatry

Clinical Psychology

Optometry/Eye Care Services

Transportation

Inpatient Hospitalization 30 percent

Physician, Dental & Clinic Services, 25 percent

Health Maintenance Organization, Home

Health Care

(freestanding and hospital-based)

including ordered diagnostic and

treatment services:

Pharmacy

Durable Medical Equipment

Laboratory

Radiology

Referred Ambulatory

Audiology (Hearing Aid)

Ambulatory Surgery and Outpatient Surgery 15 percent

Effective Date: 
Wednesday, May 2, 1990
Doc Status: 
Complete

Section 85.43 - Nurse Practitioner Services

85.43 Nurse Practitioner Services

(a) Definitions. (1) "Nurse practitioner" means a person who is licensed and currently registered as a registered professional nurse in New York State and who is certified as a nurse practitioner by the Department of Education (See 6910 of the Education Law and 8 NYCRR sections 64.5 and 64.6.)

(b) Scope of Care. (1) "Nurse practitioners" shall be authorized to provide health care services to eligible medical assistance recipients which fall within the scope of practice for certified nurse practitioners as determined by the Department of Education (See section 6902 of the Education Law and 8 NYCRR sections 52.12, 64.5 and 64.6.)

(c) Medicaid Enrollment. (1) In order for a nurse practitioner to provide health care services to eligible medical assistance recipients, he/she must enroll with the Department of Social Services.

(2) The licensed physician in collaboration with the nurse practitioner must also enroll with the Department of Social Services.

(3) As a condition of enrollment, the nurse practitioner and the collaborating physician must agree to make their practice agreements and protocols available for inspection by staff of the Department of Social Services (DSS).
 

Effective Date: 
Wednesday, May 30, 1990
Doc Status: 
Complete

Section 85.44 - Minimum Standards Preferred Primary Care Providers (PPCP)

85.44 Minimum Standards Preferred Primary Care Providers (PPCP).

(a) Purpose. The purpose of these regulations is to establish minimum standards to qualify as a Preferred Primary Care Provider (PPCP). Preferred primary care is a comprehensive range of services aimed at improving access to and availability of comprehensive primary health care to Medicaid eligible and medically indigent persons and persons in underserved areas and assuring that minimum standards of care and services will be upheld.

(b) Eligibility.

(1) Eligibility is extended to providers of comprehensive primary care services licensed under Article 28 of the Public Health Law:

(i) Licensed diagnostic and treatment centers which primarily provide a comprehensive range of primary medical services, or

(ii) Hospital-based outpatient departments.

(2) Providers included in PPCP shall have an approved provider agreement with the Department of Health and in addition shall meet minimum standards pursuant to this section and the goals and performance standards developed by the program and accepted by the Department. In the event the provider fails to abide by the provisions of the provider agreement, the Commissioner shall require prompt corrective action, impose sanctions or revoke the provider agreement as the facts may warrant.

(3) The facility shall participate in the Child/Teen Health Program.

(c) General requirements.

(1) Continuity of care. Continuity of care shall be assured by:

(i) assigning the same primary care practitioner, or team of such practitioners, who assume the principal responsibility for the care of each patient and follow the patient on each health care encounter;

(ii) provision of a tracking and referral system to document care given to the patient when patient is sent to an emergency service, hospital, or other provider of health care services. Facility staff shall assist the patient with arrangements or make arrangements for the patients for off-site services, facilitate receipt of those services, monitor reports of results of off site services, and integrate results into patient records;

(iii) provision for follow-up of missed appointments via telephone, outreach worker visit, letter or telegram that is appropriate to the urgency of the patient's need; and

(iv) approved hospitals making specialty services available to hospital and diagnostic and treatment center-based PPCPs and to practitioners enrolled in the Preferred Physician and Children Program in their service area.

(2) PPCPs shall enroll eligible children and their families in the Child Health Insurance Program and accept such reimbursement for primary care services of the facility.

(3) Scheduling of appointments and hours of operation.

(i) Operational hours of the facility shall be at least 5 days per week for 40 hours during weekdays with an additional 8 hours during evenings or weekends. Alternate scheduling of hours may be established to meet the needs of patients upon written approval of the Commissioner.

(ii) Patients shall have prompt access via telephone to a clinical staff member on a 24 hours basis for health care emergency problems.

(iii) Service scheduling shall accommodate personal appointments, walk-in patients and referrals.

(iv) Appointment scheduling shall allow ample time to include physical examinations, treatments and patient teaching.

(v) Appointments for non-urgent visits for current patients of the program shall be available in no more than two weeks from the time of a request, 90 percent of the time. Appointments for non-urgent visits by new patients shall be available in no more than four weeks from the time of request. Patients shall be triaged to assure that urgent and emergency care patients which can be managed by the facility receive medical care in a timely manner.

(4) Practitioner credentials.

(i) Staff physicians shall have training, experience and qualifications appropriate to the needs of their patients.

(ii) Specialists shall be board certified or admissible or shall have equivalent training and experience to qualify them to practice in the specialty area.

(iii) Sufficient other practitioners duly licensed and qualified to meet the primary medical care needs of patients shall be available to meet patient need.

(iv) A portion of the physician members of the medical staff sufficient to meet patient needs of the PPCP shall have admitting privileges in affiliate hospitals. The PPCP, and its physicians who are affiliated with a hospital and sending or admitting patients to the hospital from the PPCP, shall work to facilitate coordination of care and information transfer about PPCP patients between the inpatient and ambulatory care facilities. Alternatively, where diagnostic and treatment center-based physicians are not able to gain hospital inpatient admission privileges, the facility shall have hospital backup agreements which provide prompt hospital admission and discharge information to the PPCP. (5) The facility shall participate in local social service district managed care programs for Medicaid recipients when requested by the local district.

(d) Primary Care Services.

(1) Primary care services shall include the fields of internal medicine, obstetrics/gynecology, family practice and pediatrics.

(2) The facility shall provide, directly or by contract, diagnostic radiology, pharmacy and clinical laboratory services, in accordance with patient needs; make arrangements for and assure receipt of services; and ensure receipt of radiology and laboratory reports.

(3) Services the facility provides under contract shall comply with section 400.4 of this Title and contracts shall:

(i) be available for review and inspection by the Department of Health;

(ii) include assurances that the Department of Health has access to agent or agency sites and records to conduct on-site program compliance reviews; and

(iii) require that the subcontractors provide contracted care and services that meet the minimum standards established in this section and are provided in accordance with generally accepted standards of practice and patient care services.

(4) PPCP shall provide or arrange for, but not be limited to, the following preventive health services:

(i) hypertension control;

(ii) diabetes control;

(iii) immunization;

(iv) healthy lifestyles promotion;

(v) cervical, breast and colon cancer screening;

(vi) HIV screening and counseling;

(vii) family planning;

(viii) sexually transmissible disease services; and

(ix) prenatal care and services.

(5) The PPCP shall be organized, equipped and staffed for effective management of the following medical conditions in an ambulatory setting which are associated with excess inpatient hospital admissions:

(i) adult otitis media;

(ii) pediatric otitis media;

(iii) respiratory infection;

(iv) chronic obstructive pulmonary disease;

(v) adult pneumonia;

(vi) pediatric pneumonia;

(vii) adult bronchitis/asthma;

(viii) pediatric bronchitis/asthma;

(ix) heart conditions including angina and chest pain;

(x) cellulitis and differential diagnosis.

(6) Providers shall conduct a psychosocial assessment of each patient, to identify social, economic, psychological and emotional problems which present obstacles to health and treatment. When problems are identified the PPCP shall make referral, as appropriate to the patient needs, to the local Department of Social Services, community mental health resources, alcohol and substance abuse providers and support groups or social/psychological specialists.

(7) Nutrition promotion services. The provider shall establish and implement, directly or by referral, a program of nutrition screening and counseling which includes:

(i) individual nutrition risk assessment, including screening for specific nutritional risk conditions at the initial visit and continuing reassessment as needed;

(ii) professional nutrition counseling, monitoring and follow-up of all patients at nutritional risk;

(8) Records. The facility shall collect such information and make it available in such form as the Commissioner shall require.

(e) Quality Assurance. Preferred Primary Care Providers shall monitor provision of quality care through the facility quality assurance program through performance indicators. The program shall include but not be limited to the following activities in addition to the facility-wide activities of the quality assurance program:

(1) determining patient satisfaction with all components of services including those provided through contracts and by arrangement,

(2) determining and documenting the extent to which the PPCP reaches medically underserved populations in the facility services area, and

(3) determining the extent to which services of the facility are successful in managing, on an ambulatory care basis, patient medical conditions which are associated with excess hospital admissions.
 

Effective Date: 
Wednesday, September 18, 1991
Doc Status: 
Complete

Section 85.45 REPEALED

Effective Date: 
Wednesday, February 13, 2013

Section 85.46 RESERVED

Section 85.47 - Alternate level of care placement - Trial discharge

85.47 Alternate level of care placement - Trial discharge.

Trial discharges from an acute care hospital to a specialty rehabilitation hospital or a physical medicine and rehabilitation unit of a general hospital shall be in accordance with subdivision (a), (c) and (d) of this section. Trial discharges from an acute care hospital to mental health facilities licensed under Article 31 of the Mental Hygiene Law or to a residential health care facility, (RHCF), licensed under Article 28 of the Public Health Law shall be in accordance with subdivision (b), (c) and (d) of this section.

(a) Hospitals shall receive Medicaid reimbursement at the alternate level of care (ALC) rate as established by section 2807-c of the Public Health Law for patients readmitted to such acute care hospitals from a specialty rehabilitation hospital or physical medicine and rehabilitation unit of a general hospital pursuant to the following requirements:

(1) The initial admission to the acute care hospital complied with the requirements of 18 NYCRR 505.20(b)(7).

(2) The purpose of the trial discharge to the specialty rehabilitation hospital or physical medicine and rehabilitation unit of a general hospital was to evaluate the facility's ability to care for that patient.

(3) The patient's acute care hospital medical record and discharge plan fully documented the reason for the trial discharge as well as the possibility of readmission if the trial discharge was unsuccessful.

(4) The specialty rehabilitation hospital or physical medicine and rehabilitation unit of a general hospital determined, in writing, that the facility does not have the capability to meet the patient's assessed needs.

(5) The patient's readmission to the acute care hospital occurred within thirty (30) calendar days from the date of the original discharge to the receiving facility.

(b) Hospitals shall receive Medicaid reimbursement at the alternate level of care (ALC) rate for patients readmitted to such acute care hospitals from mental health facilities licensed under Article 31 of the Mental Hygiene Law or RHCFs licensed under Article 28 of the Public Health Law pursuant to the following requirements:

(1) The initial admission to the acute care hospital complied with the requirements of 18 NYCRR 505.20(b)(7).

(2) The patient who was discharged by the acute care facility to a nursing home or mental health facility for the purpose of a trial discharge had a documented history, as evidenced in the patient's hospital record, of alcohol or substance abuse, behavioral problems or psychiatric illness and is under treatment for one of these conditions.

(3) The purpose of the trial discharge to the mental health facility or RHCF was to evaluate the facility's ability to care for the patient.

(4) The patient's acute care hospital medical record and discharge plan fully documented the reason for the trial discharge as well as the possibility of readmission if the trial discharge was unsuccessful.

(5) The written evaluation by the mental health facility or the RHCF determined that the facility does not have the capability to meet the patient's assessed needs.

(6) The patient's readmission to the acute care hospital occurred within thirty (30) calendar days from the date of the original discharge to the RHCF or mental health facility except for RHCF residents who assert their rights under 415.3(h)(1)(iv) of this Title.

(c) The acute care hospital and the receiving facility shall establish, in writing, mutually acceptable arrangements for the implementation of the patient's trial discharge and possible return including but not limited to responsibility for transferring medical records, transportation of patient, education of patient's family regarding trial discharge process, and notification between facilities if the patient is to be returned to the acute care hospital.

(d) Nothing in this section shall be construed to limit in any manner, patients' or residents' rights as guaranteed to hospital, RHCF, and mental health facility patients and residents by applicable law or regulation.
 

Effective Date: 
Wednesday, August 12, 1992
Doc Status: 
Complete