N.Y. Comp. Codes R. & Regs. Tit. 14 §§ 635-12.1

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

Section 635-12.1 - Definitions

As used in this Subpart:

(a)Full Medicaid coverage means the type of coverage under the Medicaid program that pays for the services requested or received.

(b)HCBS waiver means the home and community based services waiver in effect from October 1, 2009 through September 30, 2014 for individuals with developmental disabilities granted by the United States Department of Health and Human services to New York State pursuant to section 1915(c) of the Social Security Act, and any subsequent renewals of such waiver.

(c)Liable party means any party other than a governmental entity who is legally liable to pay for services pursuant to section 43.03 of the Mental Hygiene Law or any other applicable provision of law.

(d)Maintain full Medicaid coverage means taking all steps necessary to continue to receive full Medicaid coverage, including, but not limited to, spending down income or resources to meet the Medicaid eligibility level under section 366 (2)(a) of the Social Services Law.

(e)Notice date means:

(1) March 15, 2009 for ICF/DD services; the following HCBS waiver residential habilitation services: community (in a community residence), IRA, and family care; and HCBS waiver day habilitation services; or

(2) May 15, 2010 for Medicaid service coordination; day treatment services; the following HCBS waiver services: at home residential habilitation services, prevocational services, supported employment services, and respite services; and blended services and comprehensive services.

(f)Payment start date means:

(1) April 15, 2009 for ICF/DD services; the following HCBS waiver residential habilitation services: community (in a community residence), IRA, and family care; and HCBS waiver day habilitation services; or

(2) June 15, 2010 for Medicaid service coordination; day treatment services; the following HCBS waiver services: at home residential habilitation services, prevocational services, supported employment services, and respite services; and blended services and comprehensive services.

(g)Preexisting compliance date means:

(1) February 15, 2009 for ICF/DD services; the following HCBS waiver residential habilitation services: community (in a community residence), IRA, and family care; and HCBS waiver day habilitation services; or

(2) March 15, 2010 for Medicaid service coordination; day treatment services; the following HCBS waiver services: at home residential habilitation services, prevocational services, support employment services, and respite services; and blended services and comprehensive services.

(h)Preexisting services.

(1) For ICD/DD services; the following HCBS waiver residential habilitation services: community (in a community residence), IRA, and family care; and HCBS waiver day habilitation services, preexisting services means:

(i) services which an individual was receiving from a provider on a regular basis as of February 15, 2009 and receives from the same provider after February 15, 2009; and

(ii) residential habilitation services in an individualized residential alternative (IRA) which converted from a community residence after February 15, 2009, if the individual resided in the community residence on February 15, 2009; and

(iii) services which an individual was receiving on a regular basis as of February 15, 2009, and receives from a different provider after February 15, 2009 where the individual's receipt of the services from the different provider is the result of one provider assuming operation or control of the other provider's operations and programs, or is the result of a merger or consolidation of providers;

(iv) residential habilitation and/or group day habilitation which is received by an individual who formerly received community habilitation phase II in the following circumstances:

(a) the individual received residential habilitation and/or group day habilitation prior to the receipt of community habilitation phase II and the services were preexisting services; and

(b) after the individual stopped receiving community habilitation phase II, he or she resumed receipt of the residential habilitation and/or day habilitation services which were formerly provided; and

(c) the residential habilitation and/or day habilitation services would have been preexisting services except for the intervening receipt of community habilitation phase II.

(2) For Medicaid service coordination; day treatment services; the following HCBS waiver services: at home residential habilitation services, hourly community habilitation services, prevocational services, supported employment services, respite services; and blended services and comprehensive services, preexisting services means:

(i) services which an individual was receiving from a provider on a regular basis as of March 15, 2010 and receives from the same provider after March 15, 2010; and

(ii) services which an individual was receiving on a regular basis as of March 15, 2010, and receives from a different provider after March 15, 2010, where the individual's receipt of the services from the different provider is the result of one provider assuming operation or control of the other provider's operations and programs, or is the result of a merger or consolidation of providers; and

(iii) HCBS waiver respite services which converted after March 15, 2010 from respite services funded as a type of family support services if:

(a) the individual received the respite services funded as a type of family support services on a regular basis as of March 15, 2010 and continued to receive the services on a regular basis from the same provider until the conversion date; and

(b) the HCBS waiver respite services are delivered by the same provider; and

(iv) hourly community habilitation services which converted on November 1, 2010 from at home residential habilitation services if:

(a) the individual received the at home residential habilitation services on a regular basis as of March 15, 2010 and continued to receive the services on a regular basis from the same provider through November 1, 2010; and

(b) the hourly community habilitation services are delivered by the same provider.

(i)Provider means an individual, corporation, partnership or other organization to which OPWDD has issued an operating certificate, authorization or funding to provide services. Provider shall not mean OPWDD or any developmental disabilities services office.

(j)Services means ICF/DD services (Intermediate Care Facilities for Persons with Developmental Disabilities, see Part 681 of this Title), Medicaid service coordination, day treatment services, and the following HCBS waiver services: residential habilitation services (community [in a community residence], IRA, family care, and at home), hourly community habilitation services, day habilitation services, prevocational services, supported employment services, respite services, and community habilitation phase II services. Blended services, which are a combination of day habilitation, prevocational services and/or supported employment services, and comprehensive services, which are a combination of IRA residential habilitation services and day habilitation, are also considered services. A limited exception to the applicability of certain sections of this Subpart has been made in the case of some individuals who are applying for or receiving supported employment services or respite services (see section 635-12.12 of this Subpart).

N.Y. Comp. Codes R. & Regs. Tit. 14 §§ 635-12.1

Amended New York State Register July 1, 2015/Volume XXXVII, Issue 26, eff. 7/1/2015

Amended New York State Register October 28, 2015/Volume XXXVII, Issue 43, eff. 11/1/2015

Amended New York State Register April 20, 2016/Volume XXXVIII, Issue 16, eff. 4/20/2016

Amended New York State Register September 21, 2016/Volume XXXVIII, Issue 38, eff. 9/21/2016