RE: NYS 2023-2024 BUDGET-SUBPART B, AMENDMENTS TO INCLUDE CRISIS RESIDENCE FACILITIES

TO: METROPLUSHEALTH PARTICIPATING PROVIDERS – CRISIS RESIDENCE FACILITIES

Effective May 3, 2024, per the NYS 2023-2024 Budget – Subpart B, modification for previously existing coverage requirement related to hospitals have been amended to include Crisis Residence facilities. Coverage for sub-acute care in a crisis residence facility licensed or operated by the Office of Mental Health (OMH) shall not be subject to preauthorization.

The following amended provisions apply to MetroPlusHealth’s participating network of hospitals and crisis residence facilities in New York State that are licensed or operated by the OMH.

All inpatient care in a hospital and coverage for sub-acute care in a crisis residence facility licensed or operated by OMH may be reviewed retrospectively.

Please note, if care is denied retrospectively, the MMC members should not have any financial obligation to the facility for treatment.

Criteria

For Members under the age of 18 years:

• During the first 14 days of the inpatient admission, should also not be subject to concurrent utilization review, provided the facility:
• Notifies MetroPlusHealth of both the admission and the initial treatment plan within two business days of the admission
• Performs daily clinical review of the member
• Participates in periodic consultation with MetroPlusHealth to ensure that the facility is using the OMH approved evidence-based, and peer reviewed clinical review criteria used by MetroPlusHealth. This is to ensure that the inpatient care is medically necessary and appropriate for the age of the member.

For Members 18 years and older:  

• During the first 30 days of the inpatient or residential admission, should also not be subject to concurrent utilization review, provided the facility:
• Notifies MetroPlusHealth of both the admission and the initial treatment plan within two business days of the admission
• Performs daily clinical review of the member
• Participates in periodic consultation with MetroPlusHealth to ensure that the facility is using the OMH approved evidence-based, and peer reviewed clinical review criteria used by MetroPlusHealth. This is to ensure that the inpatient or residential care admission is medically necessary and appropriate for the age of the member.
• Concurrent reviews may be conducted during the first 30 days if,

• The member meets the clinical criteria designated by the OMH, or
• If the member is admitted to a hospital or facility which has been designated by the OMH for concurrent review, in consultation with the Department of Health (DOH) and the Department of Financial Services (DFS).

If you have any questions regarding this memo, please contact MetroPlusHealth at: [email protected].

> Download / Print this memo