N.Y. Comp. Codes R. & Regs. tit. 10 § 85.5

Current through Register Vol. 46, No. 50, December 11, 2024

Section 85.5 - Limitation on hospital stay

(a) To be a covered benefit under medical assistance for the needy as provided in section 365-a(2)(b) of the Social Services Law, any hospital stay beyond 20 days per spell of illness, except for rehabilitation care as hereinafter provided, during which all or any part of the cost of such care, services and supplies are claimed as items of medical assistance shall require a prior determination of coverability by a person designated by the Commissioner of Health. Any hospital stay for care under an established plan for rehabilitation of physical disability in a rehabilitation hospital or rehabilitation unit, beyond 40 days shall require such prior determination of coverability. A written request for such determination shall be made by the patient's physician. Such request shall include evidence documented in the patient's medical record showing that in order to preserve life or to prevent substantial risk of continuing disability, an additional period of care is required of such complexity or intensity that it can be provided only in a hospital. Care of such complexity or intensity shall include, but not be limited to:

(1) severe burns requiring continued therapy in a burns unit.

(2) continuing cardiovascular, renal or pulmonary decompensation requiring care in a coronary care unit, intensive care unit, pulmonary care unit or other acute care setting in the hospital.

(3) central nervous system damage with threatened or impaired consciousness.

(4) persistent fever or serious infection.

(5) persistent hemorrhage or threat of recurrent hemorrhage.

(6) life threatening conditions including malignancy when chemotherapy, radiotherapy or other therapy can be provided and monitored effectively only in a hospital.

(7) conditions requiring physical rehabilitation under an established rehabilitation plan when such treatment can be carried out only in a hospital setting.

(b) Such request for determination of coverability for continued care shall be made before the 20th but not before the 16th day of stay. The determination of coverability shall be for an additional period not to exceed 10 days after the 20th day of stay. Determination of coverability shall be made for additional periods of stay not to exceed 10 days each pursuant to written requests submitted as aforesaid prior to expiration of the last period for which there has been a determination of coverability.

(c) In the case of care under an established plan for rehabilitation of physical disability referred to in subdivision (a) of this section, the request for extended coverability determination shall be made before the 40th but not before the 36th day of stay, and determination of coverability shall not exceed 20 days for the initial additonal period of stay and for any additional period thereafter.

(d) Spell of illness, for the purpose of this section, shall begin on the first day of hospital care and shall end 60 days following discharge from the hospital inpatient service. Except in case of emergency or urgency, readmission during said 60- day period shall be subject to the prior approval of the commissioner's designee upon a showing of necessity to preserve life or to prevent substantial risk of disability.

(e) A determination of coverability may be granted by a designated physician or non-physician under the supervision of a physician. A determination of noncoverability shall be made only by a designated physician. Notice of determination shall be given to the patient's physician, the hospital administrator, and if there is a determination of noncoverability to the patient. A written record of determinations made of such coverability or noncoverability shall be entered in the hospital records and made available for review.

(f) The patient's physician or hospital administrator may, within three days of the date of such notification, appeal such determination of noncoverability in writing to the physician or physicians designated by the Commissioner of Health for such purpose. Notification of decision on appeal shall be given to the patient's physician, the hospital administrator and the patient. If there is a determination of noncoverability or such determination of noncoverability is affirmed on appeal, any inpatient hospital care, services or supplies provided during the additional period of stay requested shall not be a covered benefit under medical assistance for the needy.

N.Y. Comp. Codes R. & Regs. Tit. 10 § 85.5