N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 86-4.35

Current through Register Vol. 46, No. 51, December 18, 2024

Section 86-4.35 - Computation of basic rates for clinic services provided to acquired immune deficiency syndrome (aids) and human immunodeficiency virus (hiv) sero-positive patients by freestanding ambulatory care facilities and hospital clinic outpatient services

(a) For payments made pursuant to this section and pursuant to section 86- 1.11(h) of this Part, for ambulatory services to AIDS patients, HIV positive patients, and patients seeking verification of HIV infection, reimbursement shall be based upon a single payment schedule with a discrete price for each of the five clinic services set forth in subdivision (c) of this section.

(b) To be eligible to receive reimbursement pursuant to this section, facilities must be licensed pursuant to article 28 of the Public Health Law and certified to provide general medical services and complete a written signed agreement with the commissioner to provide these discrete services. Facilities interested in establishing such agreements must submit in writing the required documentation in a manner acceptable to the commissioner. Such agreement shall describe the Medicaid patients who will be eligible for reimbursement under this section and shall establish the documentation and services required for patient assignment to each of the five clinic services.

(c) The five clinic services for which reimbursement shall be available according to the prices as established by this section are as follows:

(1) HIV counseling and testing visits. This visit shall mean the provision of pre-test HIV counseling in a medical setting as performed in compliance with article 27-f of the State Public Health Law. This visit shall also include laboratory testing necessary to determine whether a person has HIV disease. This visit shall also mean the provision of post-test HIV counseling in a medical setting as performed in compliance with the confidentiality provisions of article 27-f of the State Public Health Law for those individuals whose test results are positive. This visit is available for the purpose of informing these individuals of their test results and providing supportive counseling for those HIV zero positive persons experiencing adverse psychological responses to their serostatus.

(2) Post-test counseling visit. This visit shall mean the provision of post-test HIV counseling in a medical setting as performed in compliance with the confidentiality provisions of article 27-f of the State Public Health Law for those persons whose test results are negative. This visit is available for the purpose of informing these individuals of their results and counseling them on preventive measures.

(3) Initial comprehensive HIV medical evaluation visit. This visit shall mean a comprehensive medical history and physical examination, and laboratory testing necessary for the evaluation of HIV disease and related conditions. The evaluation shall be complete enough to: establish the state of HIV illness, diagnose active opportunistic infections and tumors, identify appropriate prophylactic therapies to prevent future opportunistic infections, initiate indicated anti-HIV therapy, and identify significant psycho-social problems to be addressed in the care plan.

(4) Drug and immunotherapy visits for HIV infected patients. This visit shall mean to those HIV-related treatments that require active health care supervision during the treatment visit and/or extensive amount of provider monitoring following the treatment.

(5) Monitoring visit for asymptomatic HIV disease. This visit shall mean the clinical and laboratory evaluation necessary to monitor the status of HIV disease to indicate the appropriate stage to initiate active drug treatment for HIV or prophylactic treatment for opportunistic infections.

(d) The prices established pursuant to this section shall provide full reimbursement for the following:

(1) physician services, nursing services, technician services, and other related professional expenses directly incurred by the licensed facility;

(2) space occupancy and plant overhead costs;

(3) administrative personnel, business office, data processing, recordkeeping, housekeeping, and other related facility overhead expenses;

(4) all ancillary services including laboratory tests and diagnostic X-ray services where specified in the treatment regimes and as detailed in the agreement pursuant to subdivision (b) of this section; and

(5) all medical supplies, immunizations, and drugs directly related to the provision of the services except for those drugs used to treat AIDS patients for which fee for service reimbursement is available under section 7.0 of the Medicaid Ordered Ambulatory Services Fee Schedule as contained in the Medicaid Management Information Systems (MMIS) Clinic Services Provider Manual (revised October, 1988). Copies of the schedule may be obtained from the New York State Department of Social Services and are available for inspection and copying at the Department of Health, Records Access Office, 22nd Floor, Corning Tower Building, Governor Nelson A. Rockefeller Empire State Plaza, Albany, New York 12237-0042.

(e) The price for each service shall be adjusted for regional differences in wage levels, space occupancy and facility overhead costs.

(f) The commissioner shall establish trend factors to project increases in the base year prices during the effective period of the reimbursement rates. The trend factors shall be developed using available price indices including elements of the United States Department of Labor consumer and producer price indices and special price indices developed by the commissioner for this purpose. The projected trend factors shall be updated on an annual basis, based upon current and available data.

(g) At the discretion of the commissioner, health services may be added or deleted from the visits contained in subdivision (c) of this section. The commissioner shall notify participating providers of such changes at least 60 days before such changes shall be effective and the agreements as outlined in subdivision (b) of this section shall be modified to encompass any such changes.

(h) Payment for any other clinic services which are not covered pursuant to subdivision (c) of this section shall be reimbursed as follows:

(1) for facilities with a cost-based all inclusive clinic visit rate established pursuant to this Subpart or to Subpart 86-1, services shall be reimbursed at the all inclusive clinic visit rate.

(2) for facilities without a cost-based all-inclusive rate, fee for service reimbursement is available under the Ordered Ambulatory Services Fee Schedule as referenced in paragraph (d)(5) of of this section for medical services ordered by the patient's attending physician.

(i) For financial reporting purposes and statistical reporting purposes, facilities which provide services pursuant to subdivision (c) of this section must comply as appropriate with the standards established for said reporting in section 86-1.3 or 86-4.3 of this Part.

N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 86-4.35