CurrentNew York State Department of HealthPolicy N/A

Limited Licensed Home Care Service Agency Manual Policy Guidelines

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This manual governs Medicaid participation, referral, assessment, prior authorization, reauthorization, payment, and service definitions for Limited Licensed Home Care Service Agencies serving eligible residents of adult homes and enriched housing programs.

Policy Summary

PayerNew York State Department of Health

PolicyLimited Licensed Home Care Service Agency Manual Policy Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProvide LLHCSA services only after the district has determined that the agency can appropriately and cost-effectively meet the resident's need and has issued prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsMaximum standard prior-authorization period

30 daysAssessment completion period after physician order

6 monthsMinimum reassessment frequency

8 weeksIllustrative time-limited authorization

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CurrentNew York State Department of HealthPolicy N/A

Limited Licensed Home Care Service Agency Manual Policy Guidelines

Customize your policy alerts

Sign up for all New York State Department of Health policy alerts

Know when New York State Department of Health releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerNew York State Department of Health

PolicyLimited Licensed Home Care Service Agency Manual Policy Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProvide LLHCSA services only after the district has determined that the agency can appropriately and cost-effectively meet the resident's need and has issued prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsMaximum standard prior-authorization period

30 daysAssessment completion period after physician order

6 monthsMinimum reassessment frequency

8 weeksIllustrative time-limited authorization

5+Minimum population in facility definitions

LLHCSA Eligibility, Assessment, and Authorization

LLHCSA Service Eligibility and Payment

LLHCSA services are covered for Medicaid-eligible residents of qualifying Adult Homes (AHs) or Enriched Housing Programs (EHPs) when the service need is assessed and authorized by the local department of social services (LDSS), the LLHCSA is the appropriate and cost-effective provider, and all payment and setting requirements are met.

ALL of the following

Agency and resident eligibility
- The provider is a Limited Licensed Home Care Service Agency (LLHCSA), meaning a Department of Health-certified operator of an Adult Home or Enriched Housing Program that is also DOH-licensed to provide services solely to its eligible residents.
- The recipient is Medicaid-eligible and resides in the AH or EHP served by the LLHCSA.
The resident requires one or more covered LLHCSA services
- Personal Care Services (PCS), including related nursing supervision, when the services are not the responsibility of the facility.
- Application of sterile dressings, including related skilled nursing tasks, when the facility is not otherwise responsible for providing the service.
- Administration of subcutaneous and/or intramuscular medication injections by a registered professional nurse employed by the LLHCSA.
The resident has been assessed by the LDSS and determined appropriate for the requested LLHCSA service based on the assessed need and nurse assessor's assessment and care plan.
The LDSS determines that the LLHCSA can appropriately and cost-effectively meet the resident's medical need.
The requested services are prior authorized by the district through the prior authorization system and authorized on eMedNY before they are rendered.
The services are provided while the recipient is residing in the AH or EHP and is not receiving residential health care facility services or inpatient hospital services and is not otherwise absent from the facility.

Authorization Periods and Timing Requirements

Prior Authorization Period

Standard maximumSix months

ExceptionAnnual prior authorizations may be used when the LDSS has DOH approval

Applies toLLHCSA home care services prior authorized by the district

Reassessment Interval

Minimum intervalAt least every six months

Annual exceptionAnnual authorizations may be used when the LDSS has DOH approval

PurposeReassess the individual's continued appropriateness for LLHCSA home care services

Operational and Billing Responsibilities

Documentation Required

Maintain complete Medicaid records

Maintain financial and health records sufficient to fully disclose the services, care, and supplies provided to Medicaid recipients. Furnish information regarding any payment claimed to an authorized official upon request from the Department of Health or the local department of social services.

Prior Authorization

Refer residents for service assessment

When an eligible adult home or enriched housing program resident may need covered services, send a referral to the local department of social services where the LLHCSA is located. The referral may include a copy of a district-approved physician’s order.

Personal care services
Application of sterile dressings
Subcutaneous or intramuscular medication injections

Program and Service Definitions

Adult Home

Facility typeAn adult care facility established and operated to provide long-term residential care

ResidentsFive or more adults unrelated to the operator

Services providedRoom, board, housekeeping, personal care, and supervision

Enriched Housing Program

Resident populationFive or more adults, primarily persons age 65 or older

SettingA community-integrated setting resembling independent housing units

Services provided

Policy Summary

PayerNew York State Department of Health

PolicyLimited Licensed Home Care Service Agency Manual Policy Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProvide LLHCSA services only after the district has determined that the agency can appropriately and cost-effectively meet the resident's need and has issued prior authorization.

SourceLink

On This Page

Assessment Completion

Completion periodWithin 30 days after receipt of the physician's order

Required assessmentsSocial assessment, nursing assessment, and assessment of efficiencies

Responsible entityThe local department of social services must complete or arrange for completion of the assessments

Time-Limited Authorization Example

Illustrative authorizationEight weeks

When usedWhen the recipient's condition is expected to improve over a period of weeks

Follow-upReassess the patient's continued need before authorizing additional services

Prior Authorization

Obtain prior authorization before providing services

Provide LLHCSA services only after the district determines that the agency can appropriately and cost-effectively meet the resident’s medical need and prior authorizes the required home care services. Unless the LDSS has DOH approval for annual prior authorizations, six months is the maximum authorization period.

Billing Rule

Follow payment and billing restrictions

Bill only for services prior authorized by the district and rendered by the LLHCSA. Medicaid payment is unavailable when the recipient is receiving residential health care facility services or inpatient hospital services, or is otherwise absent from the facility.

Services included in the Medicaid rate cannot be billed separately.
This includes covered personal care services and certain nursing services for medication administration or sterile dressing application when the facility is not otherwise responsible for providing them.

Prior Authorization

Respond to reassessment decisions

Cooperate with reassessment and resulting authorization decisions. Following reassessment, the LDSS may reauthorize, deny, discontinue, increase, or decrease services; when the recipient’s condition changes, a new assessment should be conducted by the nurse assessor and forwarded to the LDSS in a timely manner.

Continued appropriateness is reassessed at least every six months, or annually when DOH has approved annual authorizations.
A time-limited authorization, such as eight weeks, may be used when improvement is expected over several weeks.

Prior Authorization

Implement condition-based authorization adjustments

When an authorization combines sterile dressing changes with personal care services and/or subcutaneous or intramuscular injections, accept an adjusted nursing-services authorization when the sterile-dressing task is no longer indicated; a complete new assessment is not required for that adjustment. If the condition requiring sterile dressing changes deteriorates and increased services are needed, a complete reassessment must be completed.

The LDSS must send the adjusted authorization to the LLHCSA and notify the Medicaid recipient that services were decreased because the nursing task is no longer required.
Do not impose a separate charge for services included in the Medicaid rate.

The program provides or arranges room and provides board, housekeeping, personal care, and supervision

Limited Licensed Home Care Service Agency

OperatorA Department of Health-certified operator of an adult home or enriched housing program

LicensureAlso licensed by the Department of Health as a limited licensed home care service agency

Eligible recipientsProvides services solely to its eligible residents

Covered functionsPersonal care services, including nursing supervision; application of sterile dressings; and intramuscular and subcutaneous injections by a registered professional nurse

Covered LLHCSA Services

Personal carePersonal care services, including related nursing supervision

Dressing careApplication of sterile dressings

Medication administrationAdministration of subcutaneous and intramuscular medications