Title: Section 505.35 - Assisted living programs.

505.35 Assisted living programs. (a) Purpose and scope. This section sets forth requirements governing the provision of, and payment for, assisted living program services to recipients of Medical Assistance (MA).

(b) Policy. If an MA recipient is eligible for and can be served appropriately and more cost-effectively through the provision of assisted living program services and such services are available, assisted living program services should be used to achieve the maximum reduction in the recipient's need for home health services or other long-term care services.

(c) Definitions. (1) Assisted living program means an entity, as defined in section 485.2(s) and section 494.2(a) of this Title, which has been approved to operate as an assisted living program in accordance with section 485.6(n) of this Title and is operated in accordance with Parts 485, 486, 487, 488 and 494 of this Title.

(2) Unless otherwise defined, all terms have the meanings set forth in Part 494 of this Title.

(d) Scope of services. (1) An assisted living program must provide, or arrange to have provided, to its residents the services specified under section 494.5 of this Title. Those services are subject to reimbursement by the MA program in accordance with the provisions of subdivision (h) of this section.

(2) All services must be provided in accordance with the recipient's plan of care based upon the recipient's initial assessment and periodic reassessments as required under section 494.4 of this Title.

(3) When a reassessment indicates that assisted living program services are no longer appropriate, services must continue to be provided in accordance with the recipient's plan of care based upon the recipient's prior assessment, as required under section 494.4 of this Title, until alternative placement arrangements can be made.

(e) Eligibility. To be eligible to receive assisted living program services, an MA recipient must meet the admission and retention standards specified in section 494.4 of this Title.

(f) Contracts. The assisted living program must have a contract with the social services district in which the assisted living program is operating, in accordance with section 494.4(h) of this Title.

(g) Case management. (1) The contract executed between the assisted living program and the social services district in which the program is operating must provide that the program will assume all responsibility for case management of the residents.

(2) The assisted living program must provide case management services to MA recipients who are receiving assisted living program services. The assisted living program must comply with the case management requirements specified in section 494.6(b) of this Title and must:

(i) receive referrals for assisted living program services and provide information about such services to MA recipients referred to the assisted living program;

(ii) refer an assisted living program applicant who the program reasonably expects may be eligible for MA to the social services district in which the program is located for an MA eligibility determination;

(iii) permit access by an MA recipient to his or her case records maintained by the assisted living program;

(iv) establish linkages to services provided by other community agencies, provide information about these services to MA recipients and establish criteria for referring MA recipients to these services;

(v) to the maximum extent possible, achieve economic efficiencies, including, but not limited to using, shared aides consistent with the assisted living program's staffing standards; and

(vi) arrange for the reduction or discontinuance of an MA recipient's services when the assisted living program reassesses the recipient and determines that the recipient's assisted living program services must be reduced or discontinued.

(h) Payment for assisted living program services. (1) The MA program will pay an assisted living program for services provided to eligible MA recipients who are assisted living program residents at a capitated rate of payment established in accordance with the regulations of the Department of Health, based upon assessments of the recipients conducted pursuant to section 494.4 of this Title. Such capitated rate of payment is payment in full for the following MA services provided to MA recipients:

(i) adult day health care provided in a program approved by the Department of Health;

(ii) home health aide services;

(iii) medical supplies and equipment not requiring prior approval pursuant to this Title;

(iv) nursing services;

(v) personal care services;

(vi) personal emergency response services; and

(vii) physical therapy, speech therapy, and occupational therapy.

(2) Before an assisted living program may begin providing services for which payment will be made under the MA program to an MA recipient, the program must complete, or arrange for the completion of, the assessments and the other pre-admission documentation specified in section 494.4 of this Title.

(3) In accordance with section 494.4(h) of this Title, a copy of the assessments for any MA recipient determined appropriate to participate in the assisted living program must be transmitted to the social services district which is financially responsible for the MA recipient. Within 10 working days of receipt of the assessment from the assisted living program, the social services district must review the assessment and take one of the following actions:

(i) agree with the assisted living program's assessment and arrange for the authorization of the appropriate payment for care for 45 days; or

(ii) conduct its own assessment and based upon the findings of that assessment, agree with the assisted living program's assessment, and arrange for the authorization of the appropriate payment for 45 days; or

(iii) conduct its own assessment and based upon the findings of that assessment, disagree with the assisted living program's assessment and forward both assessments to the local professional director, or designee, for review and final determination of the appropriate payment, which determination must be made within five working days of receipt of the request.

(4) Reassessments for assisted living program services must be conducted, in accordance with the requirements of section 494.4 of this Title, no later than 45 days after a recipient's admission to the assisted living program and as frequently as required to respond to changes in the recipient's condition, but no less frequently than once every six months, in order for an assisted living program to continue to provide services to an eligible MA recipient. The district must review every reassessment that is transmitted by the assisted living program for reauthorization of payment by the MA program.

(5) Within 10 working days of receipt of the request for reauthorization of payment for assisted living program services by the assisted living program, the district must:

(i) agree with the assisted living program's reassessment and arrange for the authorization of payment for care for six months; or

(ii) conduct its own reassessment and based upon the findings of that reassessment, agree with the assisted living program's reassessment, and arrange for the authorization of payment for six months; or

(iii) conduct its own reassessment and, based upon the findings of that reassessment, disagree with the assisted living program's reassessment and forward to the local professional director, or designee, both reassessments for review and final determination of the appropriate payment, which determination must be made within five working days of receipt of the request.

(6) An MA recipient's assisted living program services must not be discontinued solely because the costs of the recipient's care exceed the amount of the capitated payment rate.

(7) The MA program will not make payments for assisted living program services provided to an MA recipient while the recipient is receiving residential health care facility services or in-patient hospital services.

(i) District of fiscal responsibility. The social services district fiscally responsible for furnishing MA is the district in which the ALP resident resided immediately prior to his or her admission to the ALP if the resident was not a recipient of MA at the time of his or her admission, or the district responsible for furnishing MA to the ALP resident immediately prior to his or her admission to the ALP if the resident was a recipient of MA at the time of his or her admission.