14 CRR-NY 599.13NY-CRR
14 CRR-NY 599.13
14 CRR-NY 599.13
599.13 Medical assistance clinic reimbursement system.
(a) Reimbursement for clinic treatment procedures will be fee based.
(b) A weight for each clinic procedure shall be established by the office which reflects the relative anticipated resource utilization for such procedure. For some procedures, fees shall be enhanced pursuant to section 599.14 of this Part through the use of billing modifiers for such things as procedures delivered after hours, services provided in languages other than English, and services of a minimum duration of 15 continuous minutes delivered by a physician or nurse practitioner in psychiatry.
(c) Providers will be categorized into peer groups pursuant to this section. The office will establish a base fee for reimbursement for each peer group. Such fee shall be reduced by 25 percent during the period in which any such provider retains an operating certificate with a duration of less than six months as a result of having been determined to be deficient in meeting applicable standards and requirements, pursuant to this Part.
(d) Peer group specific base fees may be adjusted as applicable by the office. Provider specific fee adjustments may be made to reflect pay for performance enhancements, penalties resulting from the office inspection and certification process, or for other reasons described in the regulations of the office.
(e) Payments for procedures will be determined by multiplying the assigned weight for the appropriate procedure code set forth at 10 NYCRR Part 86 by the base fee, and adjusting such fee for modifiers and discounts, as appropriate. When a modifier or discount is expressed as a percentage, it will adjust the payment by its percentage of the procedure weight. When more than one procedure applies to a visit, the highest value procedure shall be paid at its full fee value.
(1) Payments for additional procedures related to the visit will be discounted by 10 percent.
(2) Payments will be reduced by 25 percent for any visit in excess of 30, excluding crisis visits, off-site visits, complex care management, and any services that are counted as health services, provided during a state fiscal year to any individual who is 21 years of age or older on the first day of such fiscal year, and 50 percent for any visit in excess of 50, excluding crisis visits, off-site visits, complex care management, and any services counted as health services, provided during such fiscal year to any recipient, for fiscal years commencing on or after April 1, 2011, except that effective January 1, 2015, this reduction in payment will not apply to court-mandated services.
(f) The office will annually review procedure weights, modifier values, peer groupings and the base fees for each of the peer groupings, and will update them as needed. Any changes will be published in the State Register and posted on the office’s website.
(g) The office will establish and make public a list of weights associated with all CPT and HCPCS procedure codes which can be used to bill specific mental health clinic procedures through medical assistance. The office will update this list as needed.
(h) Providers licensed solely under article 31 of the Mental Hygiene Law shall be classified by the following peer groups. During the transition to the reimbursement methodology established in this Part, the fee paid to new clinics, or clinics commencing service in a new county, shall be equal to that of the lowest blended rate in the appropriate peer group.
(1) Upstate. All non-local governmental unit operated mental health clinics operating solely under an Office of Mental Health operating certificate and located in the following counties shall be considered to be included in the upstate peer group: Albany, Allegany, Broome, Cattaraugus, Cayuga, Chautauqua, Chemung, Chenango, Clinton, Columbia, Cortland, Delaware, Erie, Essex, Franklin, Fulton, Genesee, Greene, Hamilton, Herkimer, Jefferson, Lewis, Livingston, Madison, Monroe, Montgomery, Niagara, Oneida, Onondaga, Ontario, Orleans, Oswego, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Schuyler, Seneca, St. Lawrence, Steuben, Sullivan, Tioga, Tompkins, Ulster, Warren, Washington, Wayne, Wyoming, and Yates counties.
(2) Downstate. All non-local governmental unit operated mental health clinics operating solely under an Office of Mental Health operating certificate and located in the following counties shall be considered to be included in the downstate peer group: Bronx, Kings, New York, Queens, Richmond, Nassau, Suffolk, Dutchess, Orange, Putnam, Rockland and Westchester Counties.
(3) Local governmental unit-operated. All mental health clinics operated by a local governmental unit which are operating solely under an operating certificate from the office.
(4) State-operated. All hospital-based mental health clinics operated by the office.
(i) Hospital-based providers licensed under article 28 of the Public Health Law and article 31 of the Mental Hygiene Law shall be classified by the following peer groups. The base rates will be calculated pursuant to 10 NYCRR Part 86.
(1) Upstate hospital – all hospital-based mental health clinics in Albany, Allegheny, Broome, Cattaraugus, Cayuga, Chautauqua, Chemung, Chenango, Clinton, Columbia, Cortland, Delaware, Erie, Essex, Franklin, Fulton, Genesee, Greene, Hamilton, Herkimer, Jefferson, Lewis, Livingston, Madison, Monroe, Montgomery, Niagara, Oneida, Onondaga, Ontario, Orleans, Oswego, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Schuyler, Seneca, St. Lawrence, Steuben, Sullivan, Tioga, Tompkins, Ulster, Warren and Washington, Wayne, Wyoming, and Yates Counties.
(2) Downstate hospital – all hospital-based mental health clinics in Bronx, Kings, New York, Queens, Richmond, Nassau, Suffolk, Dutchess, Orange, Putnam, Rockland and Westchester Counties.
(3) The fee paid to new clinics, or clinics commencing service in a new county, shall be calculated pursuant 10 NYCRR section 86-8.6.
(j) Diagnostic and treatment center (D&TC) providers licensed under article 28 of the Public Health Law and article 31 of the Mental Hygiene Law shall be classified by the following peer groups. The base rates will be calculated pursuant to this Part. During the transition to the reimbursement methodology established in this Part, the fee paid to new clinics, or clinics commencing service in a new county, shall be equal to that of the lowest blended rate in the appropriate peer group.
(1) Upstate D&TC – all diagnostic and treatment centers in Albany, Allegheny, Broome, Cattaraugus, Cayuga, Chautauqua, Chemung, Chenango, Clinton, Columbia, Cortland, Delaware, Erie, Essex, Franklin, Fulton, Genesee, Greene, Hamilton, Herkimer, Jefferson, Lewis, Livingston, Madison, Monroe, Montgomery, Niagara, Oneida, Onondaga, Ontario, Orleans, Oswego, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Schuyler, Seneca, St. Lawrence, Steuben, Sullivan, Tioga, Tompkins, Ulster, Warren and Washington, Wayne, Wyoming, and Yates Counties.
(2) Downstate D&TC – all diagnostic and treatment centers in Bronx, Kings, New York, Queens, Richmond, Nassau, Suffolk, Dutchess, Orange, Putnam, Rockland and Westchester Counties.
(k) D&TCs and hospitals – where a corporation operates a hospital and a D&TC, the office will determine the primary relationship between the mental health clinic and the hospital or D&TC and assign the clinic to the appropriate peer group.
(l) Supplemental payments.
(1) Provider peer group base fees paid pursuant to this section shall be supplemented as appropriate for individual providers participating in the Office of Mental Health quality improvement initiative, or other performance initiatives developed by the office.
(i) In order to be enrolled in such quality improvement initiative or other Office of Mental Health performance-based payment system, the program shall execute an agreement with the office under which the provider agrees to participate in such initiative, and undertake such measures as shall be developed by the office.
(ii) Any program eligible to receive supplemental medical assistance reimbursement for participation in a quality improvement initiative, which fails at any time to meet the requirements set forth in the agreement, shall have its quality improvement supplement to its peer group base fee suspended until such time as the program meets such requirements, as determined by the office.
(2) Payments pursuant to this section shall be supplemented for providers participating in the community support program, pursuant to section 588.14 of this Title.
(m) System transition.
During the transition, the procedures indicated in the table following as full procedures shall be reimbursed at the full payment described in subdivision (e) of this section, subject to the discount for multiple procedures related to a visit. For all other procedures, there will be a transition to full procedure based reimbursement. During the transition, payment for such procedures will consist of a blended payment comprised of a legacy portion of the fees established under Part 588 and Part 592 of this Title and the procedure payment established under this Part. For such procedures, the blended payment will be calculated as follows:
(1) For providers licensed solely under article 31 of the Mental Hygiene Law and all mental health clinics licensed by the office located in diagnostic and treatment centers:
(i) The office will identify the amount of base medical assistance paid to the clinic pursuant to Part 588 of this Title for services delivered by the clinic for the period July 1, 2008 through June 30, 2009.
(ii) For clinics possessing an operating certificate with a duration of six months or more, the office will identify the volume of visits with supplemental payments pursuant to Part 592 of this Title for services delivered by the clinic for the period July 1, 2008 through June 30, 2009. Providers who had an operating certificate with a duration of less than six months during the period July 1, 2008 through June 30, 2009, will be considered to have had an operating certificate with a duration of six months or more during this period for the purposes of this calculation. For all providers, the calculation of the total supplemental payment shall utilize the supplemental rate in effect June 30, 2009, or rates made effective subsequent to June 30, 2009, and prior to the effective date of this Part which result from provider appeals or are made pursuant to applicable regulations.
(iii) For each provider, the office will divide the sum of the reimbursement from subparagraphs (i) and (ii) of this paragraph by the number of Medicaid visits associated with the relevant provider. The result will be the legacy component of the fee.
(2) For hospital-based providers licensed under both article 28 of the Public Health Law and article 31 of the Mental Hygiene Law, the blended payment promulgated by the office, in consultation with the Department of Health, shall be determined as follows:
(i) The office will identify the amount of base medical assistance paid to the clinic pursuant to Part 588 of this Title for services delivered by the clinic for the period July 1, 2008 through June 30, 2009.
(ii) For clinics possessing an operating certificate with a duration of six months or more, the office will identify the volume of visits with supplemental payments pursuant to Part 592 of this Title for services delivered by the clinic for the period July 1, 2008 through June 30, 2009. Providers who had an operating certificate with a duration of less than six months, during the period July 1, 2008 through June 30, 2009, will be considered to have had an operating certificate with a duration of six months or more during this period for the purposes of this calculation. For all providers, the calculation of the total supplemental payment shall utilize the supplemental rate in effect June 30, 2009, or rates made effective subsequent to June 30, 2009, and prior to the effective date of this Part which result from provider appeals or are made pursuant to applicable regulations.
(iii) For each provider, the sum of the amounts calculated pursuant to subparagraphs (i) and (ii) of this paragraph shall be included in the calculation of the rates utilizing the methodology set forth at 10 NYCRR Part 86.
(3) During the transition, procedures will be reimbursed as a blended rate or full procedure code based rate pursuant to the following table:
| Blend | Full Procedure Code | Office of Mental Health Service Name |
| X | Complex Care Management | |
| X | Crisis Intervention Service - Brief | |
| X | Crisis Intervention Service - Complex | |
| X | Crisis Intervention Service - Per Diem | |
| X | Developmental and Psychological Testing | |
| X | Injectable Psychotropic Medication Administration - No Time Limit | |
| X | Injectable Psychotropic Medication Administration with Monitoring and Education - Minimum of 15 Minutes | |
| X | Psychotropic Medication Treatment - Minimum of 15 Minutes | |
| X | Initial Mental Health Assessment, Diagnostic Interview, and Treatment Plan Development | |
| X | Psychiatric Assessment - Minimum of 30 Minutes | |
| X | Psychiatric Assessment - Minimum of 45 Minutes | |
| X | Individual Psychotherapy - Minimum of 30 Minutes | |
| X | Individual Psychotherapy - Minimum of 45 Minutes | |
| X | Group and Multifamily/Collateral Group Psychotherapy - Minimum of 60 Minutes | |
| X | Family Therapy/Collateral w/o patient - Minimum of 30 minutes | |
| X | Family Therapy/Collateral with patient - Minimum of 60 minutes |
(4) For providers licensed solely under article 31 of the Mental Hygiene Law and mental health clinics licensed by the office located in diagnostic and treatment centers for procedures paid as a blend, there will be a transition to a full procedure code based reimbursement system as follows:
(i) Year 1. Providers will receive 75 percent of the legacy payment amount and 25 percent of the calculated value of the procedure-related fee established in this section.
(ii) Year 2. Providers will receive 50 percent of the legacy payment amount and 50 percent of the calculated value of the procedure related fee established in this section.
(iii) Year 3. Providers will receive 25 percent of the legacy payment amount and 75 percent of the calculated value of the procedure related fee established in this section.
(iv) Year 4. Providers will receive 100 percent of the procedure fee payment.
(v) When more than one procedure is delivered during a visit, the applicable discount will not be applied to the blend component of the payment.
(5) For hospital-based providers licensed under both article 28 of the Public Health Law and article 31 of the Mental Hygiene Law, the transition to full procedure code reimbursement will be consistent with the transition schedule described in 10 NYCRR Part 86.
(6) During the transition, upon the request and subject to the approval of the Director of Community Services, the provider shall furnish the Director of Community Services and the office with a transition plan describing the level and type of services not funded by medical assistance that will be provided to the community. The component of the legacy payment associated with Part 592 of this Title shall be contingent upon the provider’s compliance with such plan. For providers operated by a county, the component of the legacy payment associated with Part 592 of this Title will be contingent upon compliance with such a transition plan that has been approved by the office.
(7) For hospital-based programs licensed under article 31 of the Mental Hygiene Law and operated by corporations operating programs licensed under article 28 of the Public Health Law, an additional capital payment per visit shall be determined by dividing all allowable capital costs for all article 31 licensed programs operated by that corporation after deducting any exclusions, by the sum of the total number of visits to all of the article 31 licensed programs operated by that corporation.
14 CRR-NY 599.13
Current through August 15, 2021
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IMPORTANT NOTE REGARDING CONTENT CURRENCY: The "Current through" date indicated immediately above is the date of the most recently produced official NYCRR supplement covering this rule section. For later updates to this section, if any, please: consult editions of the NYS Register published after this date; or contact the NYS Department of State Division of Administrative Rules at [email protected]. See Help for additional information on the currency of this unofficial version of NYS Rules.