Page 279
MRG
UPDATED: JUNE 2010
705
OTHER ELIGIBILITY REQUIREMENTS PRESUMPTIVE ELIGIBILITY
NURSING FACILITY, HOSPICE OR HOME HEALTH CARE SERVICES
social services district is neither expected to or required to visit or converse with the applicant or hospital staff at this time to evaluate medical need. The evaluation is performed from the written material provided by the hospital to explain the care required.
The hospital submits medical documentation of the type of care required. The hospital may use the suggested Medical Documentation Transmittal Form (Attachment II to 97 ADM-10) to transmit this information to the local social services district. Documentation of the type of care required should be sufficiently detailed to enable a local social services district to evaluate the appropriateness of LTHHCP or CHHA services. In addition, documentation needs to be sufficiently detailed to enable the local social services district to determine cost effectiveness of CHHA services.
1. Home Care
If the applicant will be receiving the services of a CHHA, the local social services district multiplies the hourly or visit rate for each home health service by the number of hours or visits the patient requires per month. This monthly amount is then divided by 30 days to determine the average daily cost. Sixty five percent of the average daily cost is then compared to the hospital’s Medicaid alternate level of care rate to determine cost effectiveness.
No cost comparison is required for persons who will receive their care through a LTHHCP, since in order to participate in the LTHHCP the cost of care in that program must be less than the cost of care in a skilled nursing facility.
2. Nursing Facility and Hospice Services
If the applicant will be receiving nursing facility services, the local social services district compares 65 percent of the average regional Medicaid nursing facility rate with the appropriate (Upstate or New York City/Metro Region) Medicaid alternate level of care rate to determine cost effectiveness.