CurrentNew York State Department of HealthPolicy N/A

Out-of-State Skilled Nursing Facilities Policy Guidelines

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This policy governs New York Medicaid prior approval, admission, continued stay, renewal, reporting, quality-of-care, and Medicare coordination requirements for members receiving care in out-of-state skilled nursing facilities.

Policy Summary

PayerNew York State Department of Health

PolicyOut-of-State Skilled Nursing Facilities Policy Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApril 1, 2026

Next Review DateN/A

Key ActionObtain NYSDOH prior approval before admission to and for continued services at an out-of-state skilled nursing facility for NYS Medicaid members requiring high-level or custodial-level care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

365 daysMaximum initial authorization period

300 milesIn-state search radius

14 daysDenial recency limit

Prior approvalGeneral admission requirement

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CurrentNew York State Department of HealthPolicy N/A

Out-of-State Skilled Nursing Facilities 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

PolicyOut-of-State Skilled Nursing Facilities Policy Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApril 1, 2026

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

365 daysMaximum initial authorization period

300 milesIn-state search radius

14 daysDenial recency limit

Prior approvalGeneral admission requirement

Census reporting frequency

Not requiredMedicare-primary exception

Out-of-State SNF Coverage Requirements

Initial out-of-state SNF admission

NYS Medicaid payment for out-of-state SNF care is available only when NYSDOH prior approval requirements are met, subject to stated exceptions.

ALL of the following

The member requires high-level or custodial-level skilled nursing facility care.
The referring practitioner and proposed out-of-state skilled nursing facility are enrolled in NYS Medicaid.
ONE of
- The member has been denied admission by all in-state skilled nursing facilities within 300 miles of the member's residence.
- For a pediatric member under 21 years old, the member has been denied admission by all Medicaid-enrolled pediatric facilities in New York State.
All submitted denials were issued within the last 14 days; facility nonresponses and requests for additional information do not count as denials.
ONE of
- The member will be temporarily absent from New York State and residents of the member's district customarily obtain care at the proposed facility.
- Another documented policy basis for the out-of-state placement is accepted by NYSDOH.

Prior approval exceptions

Prior approval is not required in the following situations.

ONE of

The care is short-term rehabilitation in an out-of-state skilled nursing facility.
Medicare is the primary payor and the care or services are Medicare-approved.

Renewal of out-of-state SNF services

Continued out-of-state SNF care after the initial approval period requires a new request and renewal documentation.

ALL of the following

The initial 365-day approval period has ended.
The out-of-state skilled nursing facility contacts the member's county of residence for necessary updates to the principal provider file.
The out-of-state skilled nursing facility submits a new prior approval request through ePACES and provides a completed Renewal Request form for OOS SNF.

Authorization Parameters

Initial Authorization

Maximum initial authorization periodUp to 365 days

In-State Placement Search

Required in-state facility searchAll in-state skilled nursing facilities within 300 miles of the member's residence

Denial Documentation

Maximum age of facility denialsWithin the last 14 days

Pediatric Eligibility

Pediatric member threshold

Required Provider Actions

Prior Authorization

Obtain prior approval

Obtain NYSDOH prior approval before admitting a NYS Medicaid member requiring high-level or custodial-level care to an out-of-state skilled nursing facility and for continued services. Payment will not be made unless the admission has been approved through a prior approval request.

Note

Apply prior approval exceptions

Prior approval is not required when the care is short-term rehabilitation in an out-of-state skilled nursing facility or when Medicare is the primary payor.

Documentation Required

Document in-state placement efforts

Key Terms

Out-of-State Skilled Nursing Facility (OOS SNF)

FacilityA skilled nursing facility located outside New York State.

Prior Approval

General requirementNYSDOH approval is required for admission to and continued services at an out-of-state skilled nursing facility.

Short-term rehabilitation exceptionPrior approval is not required for short-term rehabilitation in an out-of-state skilled nursing facility.

Medicare exceptionPrior approval is not required when Medicare is the primary payor.

Admission Assessment Requirements

Policy Summary

PayerNew York State Department of Health

PolicyOut-of-State Skilled Nursing Facilities Policy Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApril 1, 2026

Next Review DateN/A

SourceLink

On This Page

Before requesting out-of-state placement, obtain denials from all in-state SNFs within 300 miles of the member’s residence. For members under 21, obtain denials from all Medicaid-enrolled pediatric facilities in New York State; denials must be dated within the last 14 days, and nonresponses or requests for additional information do not qualify.

Prior Authorization

Meet authorization conditions

An out-of-state SNF admission may be authorized for up to 365 days only when the member will be temporarily absent from New York State and residents of the member’s district customarily obtain care at the proposed facility, in addition to meeting the applicable denial requirements.

Documentation Required

Submit initial admission request

Complete the Request for Prior Approval - Initial Admission to an Out-of-State Skilled Nursing Facility form and submit it with all in-state facility denials. Fax requests to (518) 402-3253 or email them to FFSOOS@health.ny.gov; requests submitted by the proposed out-of-state facility rather than the member’s case manager or discharge planner will not be accepted.

Prior Authorization

Verify Medicaid enrollment

Ensure that both the referring practitioner and the proposed out-of-state facility are enrolled in NYS Medicaid before submitting the admission request.

Documentation Required

Complete admission assessments

For every out-of-state SNF admission or transfer, the discharge planner or case manager must complete the H/C PRI (DOH-694) and PASRR/SCREEN (DOH-695). If high-level SNF care is recommended, complete a Level 1 Evaluation and continue the federal PASRR process when serious mental illness or intellectual disability is identified.

Prior Authorization

Renew authorization

After the initial 365-day approval, the out-of-state facility must contact the member’s county of residence for necessary updates to the principal provider file. The facility must also submit a new prior approval request through ePACES and provide a completed Renewal Request form for OOS SNF.

Documentation Required

Submit monthly census

At the end of each calendar month, every approved out-of-state SNF must submit a current census listing members’ names, Medicaid numbers, and coverage types, along with a list of Medicaid members who were discharged or expired.

Billing Rule

Coordinate with Medicare

Follow Medicare rules for care and services provided to Medicaid members whose primary coverage is Medicare. Medicare-approved care and services for Medicare-primary Medicaid members do not require NYS Medicaid prior approval.

For every out-of-state skilled nursing facility admission or transfer, the discharge planner or case manager must complete the H/C PRI (DOH-694) and PASRR/SCREEN (DOH-695).

Level 1 EvaluationA Level 1 Evaluation must be completed when the screener recommends high-level skilled nursing facility care.

Continuing PASRR processIf serious mental illness or intellectual disability is identified, continue the PASRR process as defined in federal regulations.