NEW YORK STATE DEPARTMENT OF HEALTH CERTIFIED MEDICAL RESPITE PROGRAM

Guidance on Medicaid Waiver-Funded Services

  • Guidance is also available in Portable Document Format (PDF)

In January 2024, the Department of Health (Department) adopted new regulations at 10 NYCRR Part 1007 that define certification and operating standards for medical respite programs. The Department also received federal approval for an amendment to New York State's Medicaid section 1115 demonstration waiver. As part of a larger strategy to improve health equity in New York State, the waiver provides for the establishment of regional Social Care Networks (SCNs) that will contract with social care service providers to deliver social care services to eligible Medicaid managed care members. Medical respite, also known as recuperative care, is one of several health-related social needs (HRSN) services funded under the terms of the waiver.

  • This guidance document applies only to medical respite stays that are paid for by a SCN using Medicaid section 1115 demonstration waiver funds (that is, "Medicaid waiver-funded" medical respite stays).
  • Medicaid waiver-funded medical respite stays are subject to all requirements identified in:
    • This guidance document;
    • 10 NYCRR Part 1007;
    • SCN Operations Manual; and
    • Any other medical respite guidance issued by the Department.
  • This guidance document will be updated frequently to reflect changes in policy and guidance related to the overall Medicaid 1115 demonstration waiver and the SCNs.

SOCIAL CARE NETWORK AS PAYOR

The SCN will be the payor for Medicaid waiver-funded medical respite services. To receive Medicaid waiver-funded reimbursement for services, the medical respite program must:

  • Obtain certification from the Department in accordance with 10 NYCRR Part 1007 and any related guidance issued by the Department.
  • Contract with the regional SCN to provide medical respite services.
  • Comply with SCN decisions regarding recipient eligibility and allowable length of stay.
    • Note that the medical respite program has primary responsibility for determining the recipient's length of stay; however, the SCN will review and approve or reject this recommendation.

RECIPIENT ELIGIBILITY

To be eligible for Medicaid waiver-funded medical respite services, a recipient must:

  • Meet all criteria established in 10 NYCRR §1007.2 and §1007.7 and in the Department's
    Guidance on Referrals, Assessments, and Service Plans;
  • Be an enrolled Medicaid managed care member;
  • Be screened using the Accountable Health Communities Social Needs Screening Tool and qualify to receive Enhanced Health-Related Social Needs services (Enhanced HRSN services), as defined in the SCN Operations Manual; and
  • Meet the clinical and social risk criteria for medical respite services as defined in the SCN Operations Manual and authorized by the SCN.

REFERRAL PATHWAY

Typically, the referring provider will refer an eligible member to the appropriate regional SCN, and the SCN will then refer the member to a specific medical respite program.

Hospitals and providers that are both contracted with the SCN and screening members using the Accountable Health Communities Social Needs Screening Tool may also refer members directly to a specific medical respite program.

LIMITS ON LENGTH OF STAY

Under the terms of the waiver:

  • Post-hospitalization care is limited to 90 days total per each 12-month period.
  • Pre-procedure care is limited to a clinically appropriate amount of time as determined by a medical professional and is typically brief in duration. Pre-procedure care is limited to 30 days total per each 12-month period.
  • An eligible individual may be admitted to medical respite care multiple times over a 12-month period, as long as:
    • Each admission is clinically appropriate;
    • The individual still meets all criteria listed under "Recipient Eligibility," above; and
    • The individual's stay in medical respite does not exceed the time limits specified above (that is, 90 days for post-hospitalization care or 30 days for pre-procedure care).
  • In all cases, the 12-month period will be assessed on a rolling basis, not by calendar year.

Nothing in the regulations or guidance precludes another entity (such as a managed care organization, a hospital system, local government, charitable organization, etc.) from paying for a recipient to reside in the medical respite program for additional days beyond the maximum Medicaid waiver reimbursable stay.

DISCHARGE COMPLAINTS

A medical respite recipient has the right to submit a discharge complaint if they believe that:

  • The medical respite program did not provide adequate advance written notice of discharge; or
  • The discharge reason is wrong.

The recipient may submit a discharge complaint to their medical respite program, Social Care Network, Managed Care Organization, and/or any other payors funding the recipient’s medical respite stay. The medical respite program must help the recipient submit a discharge complaint if asked. See pages 6 through 7 of the Department’s Guidance on Discharge Planning for a complete description of recipient rights and medical respite program obligations related to discharge complaints.