N.Y. Comp. Codes R. & Regs. tit. 18 § 505.34

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

Section 505.34 - Chronic care management demonstration programs

(a) Definitions.

(1) A chronic care management demonstration program (program) is a program authorized by chapter 653 of the Laws of 1984, chapter 832 of the Laws of 1987 or chapter 530 of the Laws of 1988 that tests cost-effective methods of coordinating the arrangement and provision of services to persons who require chronic or long-term care and determines whether such a program can effectively meet these persons' needs.

(2) Multi-disciplinary team is a group comprising one or more physicians, nurses, social workers, therapists, home health aides, nutritionists or such other health care professionals as determined necessary by the program, that assesses a person's eligibility for program enrollment and provides case management services to program enrollees.

(b) Contracts. A program may operate and receive medical assistance (MA) payments only if it has entered into a contract with the department. With the advice and consent of the Department of Health, the department may contract with a program sponsored by Beth Abraham Hospital, Bronx, NY, or with a program sponsored by a not-for-profit corporation affiliated with such hospital. With the advice and consent of the Department of Health and the Monroe County Department of Social Services, the department may contract with a program sponsored by Rochester Health Care, Inc. and with programs sponsored by other providers licensed or certified pursuant to article 28, 36, or 44 of the Public Health Law to provide services in Monroe County.

(c) Eligibility criteria.

(1) Except as provided in paragraph (2) of this subdivision, a person is eligible to enroll in a program if he or she meets the following criteria:

(i) is at least 55 years old or such age as may be specified in the contract required by subdivision (b) of this section;

(ii) is eligible for MA or, as may be specified in the contract required by subdivision (b) of this section, is eligible for MA and Medicare, and such person's MA eligibility is determined, where applicable, in accordance with the rules for the treatment of income and resources of institutionalized spouses specified in Part 360 of this Title;

(iii) resides in the program's service area;

(iv) is assessed by the program's multi-disciplinary team as being medically eligible for a residential health care facility (RHCF) level of care and such assessment has been confirmed by the department or, at the department's direction, the social services district in which the program is located;

(v) is assessed by the program as capable, as of the time of enrollment, of remaining in his or her home in the community without jeopardizing his or her health or safety or the health or safety of others; and

(vi) executes an enrollee agreement and an appropriate form which authorizes the release of medical and financial information to the program.

(2) A person is not eligible to enroll in a program if the program determines that:

(i) the person suffers from a severe and acute psychiatric disorder or from severe mental confusion, either of which presents a danger to the person or to others;

(ii) social, physical, or environmental factors would prevent the person from receiving effective care from the program or would present a danger to the person or to others;

(iii) the person, his or her family, if appropriate, and the program do not agree upon an appropriate plan of care; or

(iv) the person is a hospital in-patient or an RHCF resident on the date that otherwise would be his or her effective date of enrollment in the program, provided that the person may reapply to the program after he or she is discharged from the hospital or RHCF.

(d) Enrollment.

(1) A person may be referred to the program by a discharge planner of an RHCF, a general hospital or another entity or by any other referral source. The program's multi-disciplinary team must assess whether a person who seeks enrollment in the program is medically eligible for an RHCF level of care and meets the program's other eligibility criteria. When the program's multi-disciplinary team assesses the person to be medically eligible for the program, it must refer its assessment findings to the department or, at the department's direction, the social services district in which the program is located, for confirmation that the person is medically eligible for an RHCF level of care.

(2) The program must notify the person whether he or she has been accepted for or denied enrollment in the program. The notice must be on a form approved by the department.

(3) A person who has been denied enrollment in the program may request the program to review the denial of enrollment through the program's grievance process. If the person remains dissatisfied at the conclusion of the program's grievance process, he or she may appeal the program's denial of enrollment to the department through the appeals process set forth in subdivision (i) of this section.

(4) A person's enrollment in a program is voluntary. If an otherwise eligible person declines to enroll in the program, the program must refer the person to other appropriate services, which may include the entity that initially referred the person to the program.

(e) Program responsibilities.

(1) Generally. The program must coordinate all activities relating to an enrollee's medical care including providing, or arranging for the provision of, management and administrative support services required by paragraph (2) of this subdivision; case management services required by paragraph (3) of this subdivision; and such services listed in paragraph (4) of this subdivision as are required by an enrollee's plan of care.

(2) Management and administrative support services. The program must provide, or arrange for the provision of, the following management and administrative support services:

(i) organizing a network of licensed or certified providers sufficient to provide the services listed in paragraph (4) of this subdivision, which may include a long-term home health care program, a diagnostic and treatment center, and other appropriate providers, and contracting with such providers to furnish medical and health-related services to enrollees;

(ii) submitting providers' payment claims to the appropriate payors and preparing necessary financial reports;

(iii) maintaining referral, enrollment, and disenrollment records;

(iv) monitoring enrollee utilization rates;

(v) establishing and maintaining an enrollee grievance process;

(vi) submitting to the department all enrollment and marketing materials for its review and approval;

(vii) educating the community regarding the program;

(viii) developing and maintaining, in cooperation with the department and the Department of Health, a system for gathering and reporting information necessary to evaluate the program;

(ix) developing and maintaining a quality assurance plan;

(x) providing documentation and such other information to the department as the department may require to determine a person's appeal to the department from the program's denial of enrollment, denial of disenrollment for good cause, or proposed involuntary disenrollment; and

(xi) furnishing such other management and administrative support services as the program and the department may agree to in the contract required by subdivision (b) of this section.

(3) Case management. The program's physicians, nurses, social workers, therapists, home health aides, nutritionists or other professionals must participate in multi-disciplinary teams that provide case management services to all enrollees when the program determines that the participation of such professionals in such teams is appropriate. Case management services include the following services and such other services as the contract required by subdivision (b) of this section may require:

(i) conducting initial assessments of each person's health and social status when he or she is enrolled in the program and conducting reassessments every three months and more frequently when necessary to address changes in the enrollee's health or social status;

(ii) developing and implementing an initial plan of care for each person when he or she is enrolled in the program and a new plan of care every three months or more frequently when necessary. The plan of care must be based on the assessment or reassessment required by subparagraph (i) of this paragraph and must specify the types of services the enrollee requires, the medical necessity for the services, and the frequency at which the services must be provided; and

(iii) monitoring each enrollee's progress to evaluate whether the services for which the enrollee has been authorized continue to be medically necessary and provided in accordance with the enrollee's plan of care.

(4) Services.

(i) The program must provide, or arrange for the provision of, such of the services set forth herein as are medically necessary and required by the contract required by subdivision (b) of this section and by the enrollee's plan of care. These services are defined in accordance with appendix VI-A of the Program for All Inclusive Care for the Elderly (PACE) Protocol. Appendix VI-A of the PACE Protocol is published by the Health Care Financing Administration, Office of Research and Demonstrations, Division of Research and Demonstration Systems Support, P.O. Box 11972, Baltimore, MD 21207-0972. Copies are available for public use and inspection at the Department of Social Services, 40 North Pearl St., Albany, NY 12243.

(a) acute hospital services, including in-patient and out-patient hospital services;

(b) adult day health care;

(c) ambulance services;

(d) audiology services;

(e) dental services;

(f) dietary services;

(g) durable medical equipment;

(h) in-home services;

(i) laboratory services;

(j) medical specialty services;

(k) medications;

(l) nursing facility services;

(m) nursing services;

(n) occupational, physical, and speech therapy services;

(o) personal care services;

(p) primary care services; and

(q) such other services as are specified in the contract required by subdivision (b) of this section or in appendix VI-A of the PACE Protocol.

(ii) The program must not directly provide any service for which a license or certificate under article 28, 36, 40, or any other article of the Public Health Law is required unless the program is licensed or certified to provide such service. The program must verify that all persons or entities with which it contracts to provide such services are appropriately licensed or certified pursuant to the Public Health Law.

(f) Payment. The contract required by subdivision (b) of this section must specify the capitated payment methodology and rate under which the department will pay the program for services provided to enrollees. In approving such methodology and rate, the department must be satisfied that the program is cost-effective when compared to the cost of services that would otherwise have been provided to program enrollees.

(g) Disenrollment for good cause.

(1) A person who has been enrolled in a program sponsored by Beth Abraham Hospital, or by a not-for-profit corporation affiliated with such hospital, for 180 or fewer days may disenroll from the program for any reason. A person who has been enrolled in such a program for more than 180 days may disenroll only for good cause, as defined in paragraph (2) of this subdivision. A person who is enrolled in a program sponsored by Rochester Health Care, Inc. or in a program sponsored by other licensed providers may disenroll at any time without cause.

(2) Good cause for disenrollment means:

(i) the program failed to furnish accessible, appropriate, and high quality medical care, services, or supplies to which the enrollee is entitled under the terms of the contract required by subdivision (b) of this section or the enrollee agreement, including, but not limited to the following:

(a) failure to arrange in-patient or out-patient care, consultations with specialists, or laboratory and radiological services when reasonably necessary;

(b) failure to coordinate and interpret any consultation findings with emphasis on continuity of medical care;

(c) failure to arrange for consultation appointments;

(d) failure to arrange for services at locations geographically accessible to the enrollee;

(e) failure to arrange for services with qualified licensed or certified providers; or

(f) failure to appropriately coordinate the enrollee' overall medical care, including periodic examinations, immunizations, and diagnosis and treatment of illness or injury; or

(ii) the program and the enrollee agree that disenrollment would be in the enrollee's best interests.

(3) The program must notify the enrollee of its approval or denial of the enrollee's request to be disenrolled for good cause. The notice must be on a form approved by the department.

(4) An enrollee whose request for disenrollment for good cause has been denied may request the program to review the denial of his or her disenrollment request through the program's grievance process. If the enrollee remains dissatisfied at the conclusion of the program's grievance process, he or she may appeal the program's denial of his or her request for disenrollment for good cause to the department through the appeals process set forth in subdivision (i) of this section.

(h) Involuntary disenrollment.

(1) The program may involuntarily disenroll an enrollee if the program determines that:

(i) the enrollee moved out of the program's service area or left the program's service area for any reason for more than 30 consecutive days;

(ii) the enrollee failed to pay or make arrangements satisfactory to the program to pay any amount of excess income owed the program within 30 days after such amount is due provided that the program first made a reasonable effort in writing to collect such amount;

(iii) the enrollee has not complied with his or her plan of care or the enrollee, and the enrollee's family if appropriate, and the program do not continue to agree upon an appropriate plan of care;

(iv) the enrollee and his or her program primary care physician or multi-disciplinary team can no longer agree on the enrollee's plan of care;

(v) the enrollee provided the program with false information or otherwise deceived the program or engaged in fraudulent conduct with respect to any aspect of the program;

(vi) the enrollee, any of his or her family members, or others in the enrollee's home, have been abusive to any program personnel;

(vii) the enrollee is no longer eligible for MA or, as may be specified in the contract required by subdivision (b) of this section, is no longer eligible for MA and Medicare;

(viii) the enrollee knowingly failed to complete and submit any consent, release, assignment or other document reasonably requested by the program to obtain services or to ensure payment by Medicare, MA, or another third party;

(ix) the enrollee died;

(x) the program's authorization to provide or arrange for the provision of services or its contracts enabling it to offer services have terminated; or

(xi) the program or the program's contract with the department has terminated for any reason.

(2)

(i) The program must promptly notify an enrollee, other than an enrollee who has died, of its intention to disenroll the enrollee involuntarily. The notice must be on a form approved by the department.

(ii) The enrollee may request the program to review the proposed involuntary disenrollment through the program's grievance process. If the enrollee remains dissatisfied at the conclusion of the program's grievance process, he or she may appeal the program's proposed involuntary disenrollment to the department through the appeals process set forth in subdivision (i) of this section; however, an enrollee may not appeal the proposed involuntary disenrollment if the reason for the proposed involuntary disenrollment is that the program or the program's contract with the department has terminated for any reason. During the pendency of an enrollee's appeal to the department, the program must continue to provide the enrollee with such services as may be included in the enrollee's plan of care.

(i) Appeals to the department.

(1) This subdivision sets forth the appeals process by which the following persons may appeal final program grievance determinations to the department:

(i) a person who has been denied enrollment in the program;

(ii) a person whom the program proposes to disenroll involuntarily for a reason other than that the person has died or the program or the program's contract with the department has terminated for any reason; or

(iii) a person whom a program sponsored by Beth Abraham Hospital, or by a not-for-profit corporation affiliated with such hospital, determines to deny disenrollment for good cause.

(2) If a person described in paragraph (1) of this subdivision remains dissatisfied at the conclusion of the program's grievance process, he or she may file a written appeal with the department within 15 days after receiving the program's final written grievance determination. The person's written appeal must include the following information, which the program must assist the person to obtain, if necessary:

(i) the name and address of the person filing the appeal and the date of the program's final written grievance determination;

(ii) the date the person filed a grievance with the program;

(iii) a copy of the program's final written grievance determination;

(iv) if the appeal is from a denial of an enrollee's request for disenrollment for good cause, a description of the circumstances constituting good cause for disenrollment from the program; and

(v) a copy of the program's notice denying the person's request for enrollment or request for disenrollment for good cause or proposing to disenroll the person involuntarily.

(3) The program may prepare a written statement in support of the program's determination to deny the person's request to enroll in, or disenroll for good cause from, the program or in support of the program's determination to disenroll the person involuntarily.

(4) The department must decide appeals within 15 days after receipt and issue a written decision either affirming or reversing the program's determination. The department's decision must fully explain the reasons for the decision and the facts upon which the decision is based.

(5) An appeal to the department under this subdivision is not a fair hearing pursuant to Part 358 of this Title. The commissioner of the department will designate an appeals officer who must decide appeals from final program grievance determinations. A decision of the appeals officer may be appealed by the person or the program pursuant to article 78 of the Civil Practice Law and Rules.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 505.34