N.Y. Comp. Codes R. & Regs. tit. 14 § 671.4

Current through Register Vol. 46, No. 45, November 2, 2024

Section 671.4 - Eligibility requirements and authorization for service

(a) Principles of compliance.

(1) Eligible facility. In order to receive medical assistance or other OPWDD reimbursement for community residential habilitation services, the provider shall:

(i) be authorized pursuant to the requirements of section 671.2(d) of this Part; and

(ii) have retained, either through employment or contractual arrangement, sufficient qualified staff appropriate for the delivery of community residential habilitation services.

(2) Eligible persons are those persons who:

(i) have a diagnosis of developmental disability; and

(ii) are appropriately admitted (see glossary) to the community residence under whose auspice the community residential habilitation services are going to be delivered; and

(iii) have an authorization from a licensed physician indicating that for the period March 1, 1993 to September 12, 1993, rehabilitative services (as defined by Part 671 in effect at that time) are necessary to meet the person's medical, remedial or developmental needs; and

(iv) have an individualized, written plan of services (see glossary) setting forth the services to be provided, the activities, interventions, and therapies associated with such services, and the outcomes (see glossary) to be achieved; and

(v) meet the requirements for approval for participation in the home and community-based services waiver as set forth at Subpart 635-10.3(b)(1)-(4) of this Title:

(a) for the period from March 1, 1993 to when a level of care eligibility determination (see glossary) is completed, the pre-existing licensed physician's authorization for rehabilitation services as defined in this Part effective during this same period, shall be deemed equivalent to a physician's statement that the person is eligible for ICF/IID level of care;

(b) after September 13, 1993 all persons made eligible pursuant to clause (a) of this subparagraph shall have a formal ICF/IID level of care eligibility determination completed by the person's designated qualified intellectual disability professional (QIDP; see glossary) or other authorized party (see glossary) and signed by a licensed physician not later than March 13, 1994;

(c) persons who will be admitted to a community residence after September 13, 1993, shall have an ICF/IID level of care eligibility determination completed prior to admission and the initiation of services;

(d) said ICF/IID level of care eligibility determination shall be redone on an annual basis.

(3) In order to claim for Medicaid reimbursement for the provision of community residential habilitation services, the authorized provider shall ensure that the person is eligible for medical assistance. (Note: Persons who are not medical assistance eligible shall also receive appropriate and equivalent community residential habilitation services in accordance with their needs, but the source of reimbursement and method of claiming will be different.)

(4) In order to receive reimbursement for rehabilitative services to an eligible person for the period March 1, 1993 to September 12, 1993, the authorized provider must ensure that the person has been authorized in writing by a New York State licensed physician to receive such services. A New York State licensed physician's assistant or a nurse practitioner operating under the supervision of a licensed physician, and consistent with their scope of community practice, may, in lieu of the physician, sign the authorization form.

(5) Prior to September 13, 1993, the physician's authorization of services required pursuant to subparagraph (2)(iii) of this subdivision shall have:

(i) included a "face-to-face" contact (see glossary) with the person;

(ii) been based on a valid developmental disability diagnosis and shall have included consideration of any relevant information;

(iii) set forth the duration of the authorization to receive such services which, in any event, shall be no longer than one year from the effective start date for the authorization; and

(iv) been retained as either an original document or copy in the person's plan of services located with the authorized provider or wherever the person is receiving services.

(b)Standards of certification.

(1) OPWDD shall verify that those who are receiving community residential habilitation services from an authorized provider:

(i) have a diagnosis of developmental disability; and

(ii) have either a physician's authorization indicating that rehabilitative services are necessary to meet the person's medical, remedial or developmental needs or have an initial and annually redone ICF/IID level of care eligibility determination signed by a physician or, if the LCED is an annual renewal, it may be signed by a physician's assistant/nurse practitioner. For persons in residence as of September 13, 1993, said determination shall have been completed prior to March 14, 1994.

(2) OPWDD shall verify that those who are receiving community residential habilitation services, have an individual plan of services which identifies the services being received, the outcomes to be achieved, and the general expectations for when said outcomes are expected to be achieved.

(3) OPWDD shall verify that the plan(s) of services is being implemented as specified.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 671.4

Amended New York State Register October 28, 2015/Volume XXXVII, Issue 43, eff.11/1/2015

Amended New York State Register April 20, 2016/Volume XXXVIII, Issue 16, eff.4/20/2016

Amended New York State Register September 21, 2016/Volume XXXVIII, Issue 38, eff. 9/21/2016