GIS 15 MA/011: Reminder of Expedited Authorization Process for Medicaid Recipients with Immediate Need for Personal Care Services

To: Local District Commissioners, Medicaid Directors, Supervisors of Long Term Care Services, Managed Care Coordinators

From: Mark Kissinger, Director Division of Long Term Care

Subject: Reminder of Expedited Authorization Process for Medicaid Recipients with Immediate Need for Personal Care Services

Effective Date: Immediately

Contact Person: Bureau of Managed Long Term Care Staff
(518) 474-5888 or services@health.ny.gov

The purpose of this General Information System message is to remind local departments of social services of long-standing Department regulations that provide for an expedited authorization process for Medicaid recipients (i.e. persons who have been determined to be financially and otherwise eligible for Medicaid) who need personal care services immediately to protect their health or safety but the nursing assessment cannot be completed in five business days.

Personal Care Services Program regulations at 18 NYCRR Section 505.14(b)(5)(iv) have long provided as follows:

"(iv) When the patient needs Level I or Level II services immediately to protect his or her health or safety and the nursing assessment cannot be completed in five business days, the social services district may authorize the services based on the physician's order and the social assessment, provided that:
(a) the nursing assessment is obtained within 30 calendar days; and
(b) the recommendations of the nursing assessment are reviewed and changes are made in the authorization as required"

This expedited authorization process may be most appropriate for Medicaid recipients, whether located in the community or a nursing facility, who, in addition to being eligible for Medicaid:

  • 1. Are subject to mandatory enrollment in a managed long term care (MLTC) plan and whose enrollment in a MLTC plan, through no fault of the recipient, might not occur with reasonable promptness (i.e. by the 20th of the month); and
  • 2. Reside at home in the community, or are seeking to return to the community, have no informal caregivers who are able and willing to provide assistance with needed personal care services tasks, are not already receiving home care services from a home care services agency, and who have no third party insurance or Medicare to pay for needed assistance.

Questions regarding this information can be sent to the following address: services@health.ny.gov