N.Y. Comp. Codes R. & Regs. tit. 18 § 505.4

Current through Register Vol. 46, No. 51, December 18, 2024

Section 505.4 - Hospital services

(a) Definition. Inpatient hospital care shall include, except as otherwise specified, the care, treatment, maintenance and nursing services as may be required on an inpatient basis and certified to be covered by the Commissioner of Health or his designee under the regulations of the State Department of Health.

(b) Exclusions.

(1) Care, treatment, maintenance and nursing services for individuals admitted to a general hospital on Friday or Saturday shall be deemed to include only those inpatient days beginning with and following the Sunday after such date of such admission unless such periods of time are determined to be covered benefits pursuant to Part 85 of Department of Health's regulations or are rendered by general hospitals determined by the Commissioner of Health to be rendering full service on a seven-day-a-week basis.

(2) Care, treatment, maintenance and nursing services for uncomplicated procedures which may be performed on an outpatient basis in accordance with regulations issued by the Commissioner of Health, unless the Commissioner of Health or his designee determines that the medical condition of the individual patient requires that the procedure be performed on an in-patient basis.

(c) Effective May 1, 1992, payment for in-patient hospital services furnished to a recipient who is eligible for medical assistance (MA) solely as a result of being eligible for or in receipt of home relief (HR) and who is at least 21 years of age but under the age of 65 will be made only for a total of 32 days in any consecutive 127-month period unless such services are provided to the recipient through enrollment in a program which receives full capitation payments. No hospital providing in-patient services to a recipient may discharge the recipient solely because the maximum number of reimbursable in-patient service days has been received.

(d) Where care may be provided.

(1) Instate hospital care.

(i) Inpatient hospital service shall be provided in a public, incorporated (nonprofit) or proprietary hospital which is in possession of a valid operating certificate issued in accordance with the provisions of article 28 of the Public Health Law.

(ii) In addition, such hospital shall be qualified to participate under title XVIII of the Federal Social Security Act or be determined currently to meet the requirements for such participation and shall have in effect a hospital utilization review plan applicable to all patients who receive medical assistance; provided, however, emergency hospital services may be provided in a hospital which does not currently meet such requirements when such services are necessary to prevent the death or serious impairment of the health of the individual and which, because of the threat to the life or health of the individual, necessitate the use of the most accessible hospital available which is equipped to furnish such services.

(2) Hospital care under the medical assistance program also includes:

(i) care for the mentally ill and those with tuberculosis who are 65 years of age or over and who are in public institutions primarily or exclusively for the treatment of mental illness or tuberculosis, respectively;

(ii) care for the mentally retarded in nursing homes or health-related facilities, including such facilities for the mentally retarded exclusively; or in the nursing home or health-related facility sections of institutions for the mentally retarded;

(iii) care for the mentally ill individuals under 21 years of age in any institution or facility operated primarily or exclusively for the mentally ill when such institution or facility is operated by the State Department of Mental Hygiene or is currently certified by that department and accredited as a psychiatric hospital by the Joint Commission on Accreditation of Hospitals; when inpatient services involve active treatment which meet standards of Federal regulations; and when a team consisting of physicians and other personnel qualified to make determinations with respect to mental health conditions has determined inpatient care as necessary and that care can reasonably be expected to improve the condition to the extent that eventually such services will no longer be necessary. In the case of a person who during the course of hospitalization attains the age of 21, such services may continue until he reaches the age of 22;

(iv) care for individuals 65 of years age or over in hospitals primarily or exclusively for the care of the mentally ill, which are certified by the State Department of Mental Hygiene and accredited by the Joint Commission on Accreditation of Hospitals and meet standards prescribed by applicable Federal regulations. The extent of medical assistance coverage of such care shall be limited to supplementation of the available Medicare benefits by payment of the deductible and coinsurance liabilities of that program; and

(v) hospital care for mentally disabled persons under the medical assistance program shall not include care in institutions or facilities primarily or exclusively for treatment of mental disabilities except as provided for in this paragraph.

(e) Out-of-state hospital care.

(1) When hospital inpatient services are provided in a hospital located outside New York State, such hospital shall be in compliance with applicable licensing or approval requirements established by the officially designated standard setting authority in the state where the care was received.

(2) In addition, such hospital shall be qualified to participate under title XVIII of the Federal Social Security Act or be determined currently to meet the requirements for such participation and shall have in effect a hospital utilization review plan applicable to all patients who receive medical assistance; provided however, emergency hospital services may be provided in a hospital which does not currently meet such requirements when such services are necessary to prevent the death or serious impairment of the health of the individual and which because of the threat to the life or health of the individual necessitate the use of the most accessible hospital available which is equipped to furnish such services.

(f) Hospital's required notification of admission. Hospitals shall notify the appropriate public welfare official, if required by such official, of the admission of any person who presents a medical assistance identification card or other appropriate evidence indicating he has been determined to be eligible for medical assistance, within five days of such admission, Saturdays, Sundays and legal holidays excluded, so that the public welfare official may prepare to take the steps necessary for the payment of the hospital's charges for the care of such person.

(g) Authorization for inpatient hospital care.

(1) The identification card issued to persons eligible for medical assistance shall constitute authorization for necessary inpatient hospital care in facilities operated in compliance with applicable law and meeting appropriate standards therefor, subject to the requirements and limitations included in this Subchapter.

(2)

(i) Certification by a physician of the patient's need for inpatient hospital services shall be obtained upon admission, or if later, upon application for medical assistance.

(ii) Recertification by a physician of the need for continued inpatient hospital care shall be made as required by the Commissioner of Health on or before the 60th day of the patient's inpatient hospital stay.

(iii) The documentation and information required by Department of Health regulation 405.24(c) shall satisfy the requirement of subparagraphs (i) and (ii) of this paragraph.

(iv) Certification by the Commissioner of Health or his designee that care, services and supplies are covered benefits shall be required for all inpatient hospital care in accordance with Part 85 of the Health Department regulations.

(3) A review of the necessity of admission and continued stay and other reviews shall be conducted in accordance with applicable regulations of the State Department of Health.

(4) In addition to the certifications, recertifications and reviews required by paragraph (2) of this subdivision and section 505.20 of this Part, the attending physician and hospital shall provide the Commissioner of Health or his designee on a timely basis, documentation to support the necessity and appropriateness of the patient's admission, continued stay and/or need for surgery pursuant to Part 85 of the Department of Health regulations.

(5) A plan of care for each medical assistance patient shall be established and periodically evaluated by a physician and shall be maintained by the hospital. The documentation and information required by regulations of the State Department of Health shall satisfy the plan of care requirement.

(6) Hospital claims submitted for payment on discharge of the patient shall be in accordance with section 540.6 of this Subchapter and shall not be processed for payment unless supported by a form signed by a responsible member of the hospital staff and containing such information as the department may require, including a statement confirming certifications required by this subdivision and section 505.20 of this Part were executed as needed and are available for review in the hospital.

(7) The hospital utilization review committee shall, in addition to the reviews required by paragraph (5) of this subdivision, conduct medical care evaluation studies of care provided to Medicaid patients in accordance with Medicare requirements and other reviews required by the State Commissioner of Health.

(8) In the event that a local social services district processes a discharge claim for payment which is not supported by the form required in paragraph (6) of this subdivision, such payment by the local social services district shall be subject to disallowance.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 505.4