N.Y. Comp. Codes R. & Regs. tit. 10 § 85.7

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

Section 85.7 - Extension of 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 inpatient stay which exceeds the period of time determined to be a covered benefit under sections 85.1 through 85.6 of this Part and under this section but does not exceed a total of 20 days or, if for rehabilitation of physical disability as described in subdivision (a) of section 85.5 of this Part, a total of 40 days, shall be subject to a determination of extended coverability. Such determination shall be made by a person designated by the Commissioner of Health, shall be made prior to the expiration of the previously determined period of covered benefit and shall be for a specified period of time not to exceed applicable length of stay norms for comparable patients which have been authorized by the Commissioner of Health or the 20th day of stay, whichever is less. If the stay is for rehabilitation of physical disability as described in subdivision (a) of section 85.5 of this Part, such specified period of time shall not exceed the 40th day of stay. Determination of extended coverability shall be based upon existence of medical conditions which can be treated only by continued care on an inpatient hospital basis as documented in the patient's medical record.

(b) While making a determination of coverability, if the person designated by the Commissioner of Health determines that during a previously determined period of covered benefit, the care, supplies and services actually provided did not require provision on an inpatient hospital basis, the designated person may make a determination of noncoverability as to part or all of such previously determined period of covered benefit under medical assistance for the needy.

(c) A determination of benefit coverability under this section shall be made by a designated physician or nonphysician under a designated physician's supervision. A determination of noncoverability shall be made only by a designated physician. If such determination of noncoverability is made, any inpatient hospital care, supplies or services provided beyond the previously determined period of covered benefit shall not be a covered benefit under medical assistance for the needy.

(d) 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.

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

(f) Any hospital care, services or supplies covered as a benefit under this section shall be subject to length of stay limitations of section 85.5 of this Part.

N.Y. Comp. Codes R. & Regs. Tit. 10 § 85.7