N.Y. Comp. Codes R. & Regs. tit. 14 § 593.7

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

Section 593.7 - Reimbursement standards

(a) In order to receive reimbursement for the provision of community rehabilitation services, each individual must have a service plan which documents the delivery of appropriate community rehabilitation services which have been authorized by a physician, or reauthorized pursuant to section 593.6(b) of this Part.

(b) Reimbursement will be based upon monthly and half-monthly rates. Such rates shall be paid based upon a minimum number of face-to-face contacts between an eligible resident of a program and a staff person of an approved provider of community rehabilitation services, subject to the following provisions:

(1) A full monthly rate will be paid for services provided to an eligible resident in residence for at least 21 days in a calendar month, who has received at least four contacts with a staff person of the program. For a teaching family home program, a youth shall have received at least 11 contacts, at least three of which must be provided by authorized program staff other than the teaching parents. At least four different community rehabilitative services must have been provided.

(2) A half monthly rate will be paid for services provided to an eligible resident in residence for at least 11 days in a calendar month, who has received at least two contacts with a staff person of the program. For a teaching family home program, a youth shall have received at least six contacts, at least two of which must be provided by authorized program staff other than the teaching parents. At least two different community rehabilitation services must have been provided.

(3) Only one contact can be counted each day and such contact shall be at least 15 minutes in duration.

(4) For reimbursement purposes, a contact shall involve the performance of at least one of the services indicated in the resident's current service plan.

(5) A reimbursable contact may occur at or away from the program, except that a reimbursable contact may not occur at the site of a licensed mental health outpatient program as such programs are described in Part 587 of this Title, nor when the otherwise eligible resident is an inpatient of any hospital for any reason or temporarily residing in any other licensed residential facility.

(6) Reimbursement for contacts provided under this program shall not be limited in any way by reimbursement for visits under any outpatient program licensed by the Office of Mental Health on the same day or reimbursement for visits provided by any comprehensive Medicaid case management program approved by the Office of Mental Health.

(c) The rates for each approved residential program for adults and community residence programs for children shall be established by the Office of Mental Health, subject to the approval of the Director of the Budget, pursuant to the following criteria:

(1) Providers of rehabilitation services shall be assigned an individual provider monthly rate based upon their cumulative approved costs for all sites divided by the maximum capacity for their sites divided by 12 months, divided by the specific utilization factor established by the Office of Mental Health for beds in adult congregate programs, adult apartment programs or for children's residential services programs. Rates for a half month service shall be 50 percent of the monthly rate. The rate calculated under this methodology will be reduced by $4 for a full month and $2 for a half month rate to account for payment pursuant to subdivision (d) of this section. All rates subject to the approval of the Division of Budget.

(2) All rates for providers in New York City calculated pursuant to paragraph (1) of this subdivision will be effective through May 31st of each year. All rates for providers in the rest of the State shall be effective through November 30th. The commissioner may authorize changes to rates to correct errors in the original calculation of the rate or to reflect changes in approved costs.

(3) The rate methodology for rehabilitation services provided in residential programs operated by the Office of Mental Health shall be the same as for other licensed providers except that there shall be one statewide rate which shall be the lower of the calculated rate or the highest rate approved for other providers. The rate shall be promulgated on the same schedule as for providers outside New York City.

(d) In addition to the rates allowed in paragraph (c)(1) of this section, a provider may receive an additional rate of $1 for each allowable service which is provided, as delineated in section 593.4(b) or (c) of this Part. No one service however may be reimbursed more than once each month and no more than four may be reimbursed accompanying a full month reimbursement nor more than two accompanying a half month's reimbursement.

(e) In addition to the rates allowed in paragraph (1) of subdivision (c) of this section, for services provided on or after April 1, 2014, a provider shall receive the equivalent of an additional 30 percent rate add-on for up to two years for community rehabilitation services provided to adults who were discharged directly from a State psychiatric center or nursing home to a congregate residence. A provider shall receive the equivalent of an additional 15 percent rate add-on for up to three years for community rehabilitation services provided to adults who were discharged directly from a State psychiatric center or nursing home to an apartment residence.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 593.7

Amended, New York State Register December 31, 2014/Volume XXXVI, Issue 52, eff.12/31/2014