N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 86-11.3

Current through Register Vol. 46, No. 45, November 2, 2024

Section 86-11.3 - Rates for providers of ICF/DD services

(a) There shall be one provider-wide rate for each provider, except that rates for ICF/DD services provided to individuals identified as specialized populations by OPWDD shall be determined under section 86-11.9 of this Subpart. Adjustments may be made to the rate resulting from any final audit findings or reviews.

(b) Rates shall be computed on the basis of a full 12 month base year CFR, adjusted in accordance with the methodology as provided in this section. The rate shall include operating cost components, and capital cost components as identified in applicable subdivisions. Such base year may be updated periodically, as determined by the department.

(c)Components of rates for ICF/DD services.

(1) The operating component shall be based on allowable costs identified in the consolidated fiscal reports. The operating component shall be inclusive of the following components:

(i)Regional average direct care wage, which shall mean the quotient of base year salaried direct care dollars for each provider in a Department of Health region, aggregated for all such providers in such region, for all residential habilitation-supervised IRA, residential habilitation-supportive IRA, day habilitation services and ICF/DD, divided by base year salaried direct care hours for each provider in a Department of Health region, aggregated for all such providers in such region, for all residential habilitation-supervised IRA, residential habilitation- supportive IRA, day habilitation services and ICF/DD services.

(ii)Regional average employee-related component, which shall mean the sum of vacation leave accruals and total fringe benefits for the base year for each provider of a Department of Health region, aggregated for all such providers in such region, such sum to be divided by base year salaried direct care dollars for each provider of a Department of Health region, aggregated for all such providers in such region, and then multiplied by the applicable regional average direct care wage as determined by subparagraph (i) of this paragraph.

(iii)Regional average program support component, which shall mean the sum of transportation related-participant staff travel, participant incidentals, expensed adaptive equipment, sub-contract raw materials, participant wages-non-contract, participant wages-contract, participant fringe benefits, staff development, supplies and materials-non-household, other-OTPS, lease/rental vehicle, depreciation-vehicle, interest-vehicle, other-equipment, other than to/from transportation allocation, salaried support dollars (excluding housekeeping and maintenance staff) and salaried program administration dollars for the base year for each provider of a Department of Health region, aggregated by all such providers in such region. Such sum shall be divided by the total base year salaried direct care dollars of all providers in a Department of Health region, and then multiplied by the applicable regional average direct care wage as determined pursuant to subparagraph (i) of this paragraph.

(iv)Regional average direct care hourly rate-excluding general and administrative, which shall mean the sum of the applicable regional average direct care wage as determined pursuant to subparagraph (i) of this paragraph, the applicable regional average employee-related component as determined pursuant to subparagraph (ii) of this paragraph, and applicable regional average program support component as determined pursuant to subparagraph (iii) of this paragraph.

(v)Regional average general and administrative component, which shall mean the sum of the insurance-general and agency administration allocation for the base year for each provider in a Department of Health region, aggregated for all such providers in such region, divided by (the sum of total program/site costs and other than to/from transportation allocation, less the sum of food, repairs and maintenance, utilities, expensed equipment, household supplies, telephone, lease/rental equipment, depreciation equipment, total property-provider paid, housekeeping and maintenance staff, salaried clinical dollars, and contracted clinical dollars for the base year for each provider of a Department of Health region, aggregated for all providers in such region). The regional average direct care hourly rate-exclusive of general and administrative costs, as determined pursuant to subparagraph (iv) of this paragraph, shall then be divided by (one minus the applicable regional average general and administrative quotient), from which the applicable regional average direct care wage hourly rate-excluding general and administrative, as computed in subparagraph (iv) of this paragraph shall be subtracted.

(vi)Regional average direct care hourly rate, which shall mean the sum of the applicable regional average direct care wage, as determined pursuant to subparagraph (i) of this paragraph, the applicable regional average employee-related component as determined pursuant to subparagraph (ii) of this paragraph, the applicable regional average program support component as determined pursuant to subparagraph (iii) of this paragraph, and the applicable regional general and administrative component computed in subparagraph (v) of this paragraph.

(vii)Provider average direct care wage, which shall mean the quotient of base year salaried direct care dollars divided by the base year salaried direct care hours of a provider.

(viii)Provider average employee-related component, which shall mean the sum of vacation leave accruals and fringe benefits for the base year for each provider, divided by base year salaried direct care dollars of a provider, such quotient to be multiplied by the provider average direct care wage as computed in subparagraph (vii) of this paragraph.

(ix)Provider average program support component, which shall mean the sum of transportation related-participant, staff travel, participant incidentals, expensed adaptive equipment, sub-contract raw materials, participant wages-non-contract, participant wages-contract, participant fringe benefits, staff development, supplies and materials-non-household, other-OTPS, lease/rental vehicle, depreciation-vehicle, interest-vehicle, other-equipment, other than to/from transportation allocation, salaried support dollars (excluding housekeeping and maintenance staff) and salaried program administration dollars for the base year for a provider. Such sum shall be divided by the base year salaried direct care dollars of such provider and such quotient shall be multiplied by the provider average direct care wage as computed in subparagraph (vii) of this paragraph.

(x)Provider average direct care hourly rate-excluding general and administrative, which shall mean the sum of the provider average direct care wage as determined pursuant to subparagraph (vii) of this paragraph, the provider average employee-related component as determined pursuant to subparagraph (viii) of this paragraph, and the provider average program support component as determined pursuant to subparagraph (ix) of this paragraph for each provider.

(xi)Provider average general and administrative component, which shall mean the sum of insurance-general and agency administration allocation for the base year for a provider, such sum to be divided by (the sum of total program/site costs and other than to/from transportation allocation less the sum of food, repairs and maintenance, utilities, expensed equipment, household supplies, telephone, lease/rental equipment, depreciation equipment, insurance "" property and casualty, total property-provider paid, housekeeping and maintenance staff, salaried clinical dollars, and contracted clinical dollars for a provider) for the base year. The provider average direct care hourly rate-excluding general and administrative, as computed in subparagraph (x) of this paragraph, shall then be divided by (one minus the applicable provider average general and administrative quotient), from which the provider average direct care wage hourly rate-excluding general and administrative, as computed in subparagraph (x) of this paragraph, shall be subtracted.

(xii)Provider average direct care hourly rate, which shall mean the sum of the provider average direct care wage, as determined pursuant to subparagraph (vii) of this paragraph, the provider average employee-related component as determined pursuant to subparagraph (viii) of this paragraph, the provider average program support component as determined pursuant to subparagraph (ix) of this paragraph, and the provider average general and administrative component as determined pursuant to subparagraph (xi) of this paragraph.

(xiii)Provider direct care hours, which shall mean the sum of base year salaried direct care hours and base year contracted direct care hours, such sum to be divided by the rate sheet capacities for the base year. Such quotient to be multiplied by rate sheet capacities for the initial period.

(xiv)Regional average clinical hourly wage, which shall mean the quotient of base year salaried clinical dollars for each provider of a Department of Health region, aggregated for all such providers in such region, divided by base year salaried clinical hours for each provider of a Department of Health region, aggregated for all such providers in such region.

(xv)Provider average clinical hourly wage, which shall mean the quotient of base year salaried clinical dollars of a provider divided by base year salaried clinical hours of such provider.

(xvi)Provider salaried clinical hours, which shall mean the quotient of base year salaried clinical hours of a provider, divided by the rate sheet capacities for the base year, such quotient to be multiplied by the rate sheet capacities for the initial period for such provider.

(xvii)Regional average contracted clinical hourly wage, which shall mean the quotient of contracted clinical dollars divided by the base year contracted clinical hours for each provider of a Department of Health region, aggregated for all such providers in such region.

(xviii)Provider contracted clinical hours, which shall mean the quotient of a provider's contracted clinical hours for the base year divided by the rate sheet capacities for the base year, such quotient to be multiplied by rate sheet capacities for the initial period.

(xix)Provider direct care hourly rate- adjusted for wage equalization factor, which shall mean the sum of the provider average direct care hourly rate, as determined pursuant to subparagraph (xii) of this paragraph multiplied by 0.75 and the applicable regional average direct care hourly rate, as determined pursuant to subparagraph (vi) of this paragraph multiplied by 0.25.

(xx)Provider clinical hourly wage "" adjusted for wage equalization factor, which shall mean the sum of the provider average clinical hourly wage, as determined pursuant to subparagraph (xv) of this paragraph, multiplied by 0.75 and the applicable regional average clinical hourly wage, as computed in subparagraph (xiv) of this paragraph multiplied by 0.25.

(xxi)Provider reimbursement from direct care hourly rate, which shall mean the product of the calculated direct care hours, as determined pursuant to subparagraph (xiii) of this paragraph, and the provider direct care hourly rate-adjusted for wage equalization factor, as computed in subparagraph (xix) of this paragraph.

(xxii)Provider reimbursement from clinical hourly wage, which shall mean the product of the provider salaried clinical hours, as determined pursuant to subparagraph (xvi) of this paragraph and the provider clinical hourly wage- adjusted for wage equalization factor, as determined pursuant to subparagraph (xx) of this paragraph.

(xxiii)Provider reimbursement from contracted clinical hourly wage, which shall mean the product of the provider contracted clinical hours, as determined pursuant to subparagraph (xviii) of this paragraph and the applicable regional average contracted clinical hourly wage, as determined pursuant to subparagraph (xvii) of this paragraph.

(xxiv)Provider facility reimbursement, which shall mean the sum of food, repairs and maintenance, utilities, expensed equipment, household supplies, telephone, lease/rental equipment, depreciation equipment, insurance "" property and casualty, housekeeping and maintenance staff, and program administration property the base year for a provider and such sum to be divided by provider rate sheet capacities for the base year. Such sum to be multiplied by rate sheet capacities for the initial period.

(xxv)Provider operating revenue, which shall mean the sum of provider reimbursement from direct care hourly rate, as determined pursuant to subparagraph (xxi) of this paragraph, the provider reimbursement from clinical hourly wage, as determined pursuant to subparagraph (xxii) of this paragraph, the provider reimbursement from contracted clinical hourly wage, as determined pursuant to subparagraph (xxiii) of this paragraph, and the provider facility reimbursement, as determined pursuant to subparagraph (xxiv) of this paragraph.

(xxvi)Statewide budget neutrality adjustment factor for operating dollars, which shall mean the quotient of all provider rate sheets in effect on June 30, 2014, divided by provider operating revenue, as determined pursuant to subparagraph (xxv) of this paragraph, for all providers.

(xxvii)Total provider operating revenue- adjusted, which shall mean the product of the provider operating revenue, as determined pursuant to subparagraph (xxv) of this paragraph and the statewide budget neutrality adjustment factor for operating dollars, as determined pursuant to subparagraph (xxvi) of this paragraph.

The final daily operating rate shall be determined by dividing the total provider operating revenue-adjusted, as determined by subparagraph (xxvii) of this paragraph, by the applicable provider rate sheet capacity for the initial period and such quotient to be further divided by 365.

(2) Alternative operating component. For providers that did not submit a cost report or submitted a cost report that was incomplete for the base year, the final daily operating rate shall be a regional daily operating rate. This rate shall be the sum of:

(i) The product of the applicable regional average direct care hourly rate, as determined pursuant to subparagraph (1)(vi) of this subdivision and the applicable regional average direct care hours, which shall mean the quotient of salaried and base year contracted direct care hours for each provider of a Department of Health region, aggregated for all such providers in such region, divided by the rate sheet capacities, pro-rated for partial year sites for the base year for each provider of a Department of Health region, aggregated for all such providers in such region; and

(ii) the product of the applicable regional average clinical hourly wage, as determined pursuant to subparagraph (1)(xiv) of this subdivision and the applicable regional average clinical hours, which shall mean the quotient of salaried and base year contracted clinical hours for each provider of a Department of Health region, aggregated for all such providers in such region, divided by the rate sheet capacities, pro-rated for partial year sites for the base year for each provider of a Department of Health region, aggregated for all such providers in such region; and

(iii) the applicable regional average facility revenue, which shall mean the quotient of the sum of food, repairs and maintenance, utilities, expensed equipment, household supplies, telephone, lease/rental equipment, depreciation, insurance "" property and casualty, housekeeping and maintenance staff, and program administration property for the base year divided by the rate sheet capacities, pro-rated for partial year sites for the base year for each provider of a Department of Health region, aggregated for all such providers in such region; and

Such sum shall then be multiplied by the statewide budget neutrality adjustment factor for operating dollars, as determined pursuant to subparagraph (1)(xxvii) of this subdivision.

(3) Day program services component. There shall be a day program services component for individuals who participate in either in-house day programming or day services, which shall equal the sum of the in-house day programming amount from the provider rate sheet in effect on June 30, 2014 plus the product of the units of service for the day services providers as was used in the calculation of the rate in effect on June 30, 2014 and the day service provider's rate in effect on July 1, 2014.

(4) Capital component. Capital component.

(i) For capital assets approved on or after July 1, 2014. OPWDD regulations under 14 NYCRR Subpart 635-6 establish standards and criteria for calculating provider reimbursement for the acquisition and lease of real property assets which require approval by the Office for People with Developmental Disabilities. The regulations also address associated depreciation and related financing expenses. The rate will include costs for actual straight line depreciation, interest expense, financing expenses, and lease cost. In no case will the total capital reimbursement associated with the capital asset exceed the total acquisition cost, renovation and financing cost associated with a capital asset. The asset life for building acquisitions shall be 25 years.

(ii) For capital assets approved prior to July 1, 2014. The State will identify each asset by provider, and provide a schedule of these assets identifying: total actual cost, reimbursable cost determined by the prior approval, total financing cost, allowable depreciation and allowable interest for the remaining useful life as determined by the prior approval, and the allowable reimbursement for each year of the remaining useful lives. In no case will the total reimbursable depreciation or principal amortization and total interest associated with the capital asset exceed the total acquisition cost, renovation and financing cost associated with a capital asset.

(iii) Notification to providers. 14 NYCRR Subpart 635-6 contains the criteria and standards associated with capital costs and reimbursement. Each provider will receive a schedule of "prior approved assets" that is being used to establish the real property capital component of the provider's reimbursement rate.

(iv) Initial rate for capital assets approved on or after July 1, 2014. The rate shall include the approved appraised costs of an acquisition or fair market value of a lease, and estimated costs for renovations, interest, soft costs and start-up expenses. Such costs shall be included in the rate as of the date of certification of the site, continuing until such time as actual costs are submitted to the State. Estimated costs shall be submitted in lieu of actual costs for a period no greater than two years. If actual costs are not submitted to the State within two years from the date of site certification, the amount of capital costs included in the rate shall be zero for each period in which actual costs are not submitted. The department may retroactively adjust the capital component.

(v) Cost verified rates for capital assets approved on or after July 1, 2014. The provider shall submit to the State supporting documentation of actual costs. Actual costs shall be verified by the State reviewing the supporting documentation of such costs. A provider submitting such actual costs shall certify that the reimbursement requested reflects allowable capital costs and that such costs were actually expended by such provider. Under no circumstances shall the amount included in the rate under this subparagraph exceed the amount authorized in the approval process. Capital costs shall be depreciated over a 25 year period for acquisition of properties or amortized over the life of the lease for leased sites. Capital improvements shall be depreciated over the life of the asset. The amortization of interest shall not exceed the life of the loan taken. Amortization or depreciation shall begin upon certification by the provider of such costs. Start-up costs may be amortized over a one year period beginning with site certification. If actual costs are not submitted to the State within two years from the date of site certification, the amount of capital costs included in the rate shall be zero for each period in which actual costs are not submitted.

(vi) Capital reimbursement reconciliation schedule. Beginning with the cost reporting period ending December 31, 2014, each provider shall submit to OPWDD, as part of the annual cost report, a capital reimbursement reconciliation schedule. This schedule will specifically identify the differences, by capital reimbursement item, between the amounts reported on the certified cost report, and the reimbursable items, including depreciation, interest and lease cost from the schedule of approved reimbursable capital costs. The provider's independent auditor will apply procedures to verify the accuracy and completeness of the capital reimbursement reconciliation schedule. The department will retroactively adjust capital reimbursement based on the actual cost verification process as described in subparagraph (iv) of this paragraph.

N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 86-11.3

Adopted, New York State Register June 25, 2014/Volume XXXVI, Issue 25, eff. 6/25/2014

Amended New York State Register April 22, 2015/Volume XXXVII, Issue 16, eff. 4/22/2015