14 CRR-NY 841.12NY-CRR
14 CRR-NY 841.12
14 CRR-NY 841.12
841.12 Medical assistance payments for residential rehabilitation services for youth.
(a) Definitions.
For the purposes of this section:
(1) Eligible residential rehabilitation services for youth provider shall mean a residential rehabilitation services for youth provider that has been certified by the office to provide services pursuant to Part 817 of this Title.
(2) Allowable costs shall mean those costs incurred by an eligible residential rehabilitation services for youth provider which are eligible for payment by government agencies in accordance with title 11 of article 5 of the Social Services Law. To be allowable, costs must be reasonable and necessary for efficient provision of chemical dependence services, related to patient care, recurring, and approved by the commissioner.
(3) Patient day shall mean the unit of measure denoting lodging provided and services rendered to one patient between the census-taking hours on two successive days. A patient day is counted on the day of admission but not on the day of discharge. When a patient is admitted and discharged on the same day, this period shall be counted as one patient day.
(4) Billable day shall mean a patient day during which services are provided that conform to the requirements of Part 817 of this Title.
(5) Allowable days shall mean the total patient days provided by an eligible residential rehabilitation services for youth provider; and shall be calculated pursuant to paragraph (e)(2) of this section.
(6) Fee period shall be the calendar year.
(7) Base year shall mean the period from which fiscal and patient data are utilized to calculate rates of payment for the fee period.
(8) Fee cycle shall mean either one fee period or more than one consecutive fee periods. Such fee or fees shall be derived from a common base year.
(9) New eligible residential rehabilitation provider shall mean an eligible residential rehabilitation services for youth provider, as defined in paragraph (1) of this subdivision, for which relevant historical chemical dependence service costs are not available.
(10) Service operating fee shall mean fees calculated pursuant to subdivision (b) of this section as payment in full for operating expenses as required by Part 817 of this Title. Such fee shall not include the capital or admission review team add-ons.
(11) Capital add-on shall mean a provider-specific cost-based per diem calculated pursuant to subdivision (c) of this section and also section 841.14 of this Part to address allowable and approved real property, equipment and start-up costs not included in paragraph (10) or (12) of this subdivision.
(12) Admission review team (ART) add-on shall mean a per diem calculated pursuant to subdivision (d) of this section, and established to address the cost of the admission review team required by section 817.3 of this Title.
(b) Calculation of service operating fees.
Service operating fees for residential rehabilitation services for youth provided pursuant to Part 817 of this Title shall be developed by the office using a cost model based on the requirements of Part 817 of this Title. The cost model shall contain personal service and non-personal service costs. The cost model shall recognize cost differentials between the upstate and down-state regions of the State and also cost differentials between providers with differing service capacities. The service operating fee and any relevant add-ons to the fee shall be deemed to be inclusive of all service delivery costs and shall be considered payment in full to the residential rehabilitation services for youth provider for all non-capital costs related to delivery of services provided pursuant to Part 817 of this Title.
(1) For purposes of this section, the upstate and downstate geographic regions are defined as follows:
(i) The downstate region includes New York City and the counties of Nassau, Suffolk, Westchester, Rockland and Putnam. New York City includes the counties of New York, Bronx, Kings, Queens, and Richmond.
(ii) The upstate region includes all other counties in New York State.
(2) Within each geographic region, service operating fees shall be developed based on differing service capacities. The applicable fee level for a given residential rehabilitation services for youth facility shall be determined based on the geographic location of the facility, pursuant to paragraph (1) of this subdivision, and the residential rehabilitation services for youth provider's total statewide certified residential rehabilitation services for youth capacity.
(3) The service operating fees for each fee cycle, as defined in paragraph (a)(10) of this section, shall be developed by using base year patient and fiscal data. The base year fee calculation shall then be trended, using the Congressional Budget Office's Consumer Price Index for all Urban Consumers, to the first day of the fee cycle. The personal service component of the service operating fees shall be calculated by the office using the staffing requirements of Part 817 of this Title in conjunction with the applicable U.S. Department of Labor's Employment and Wage Estimates, as adapted by the office to coincide with the staffing position titles of Part 817 of this Title and the geographic regions defined in paragraph (1) of this subdivision. The fringe benefits, non-personal service and administrative components of the service operating fees shall be calculated by the office using fringe benefit, non-personal service and administrative fiscal data for providers operating residential rehabilitation services for youth.
(4) From time to time, at the discretion of the office, the service operating fees may be revised or updated. This process of revising or updating service operating fees may be based on the following:
(i) the application of an annual trend factor to the service operating fee. Such trend factor shall be based on the Congressional Budget Office's Consumer Price Index for all Urban Consumers and shall apply to all components of the service operating fee, but shall not apply to the capital or admission review team add-ons to the service operating fee;
(ii) the establishment of a new base year and fee cycle;
(iii) a change in the number of service operating fees and/or the upper and lower service capacities applicable to a service operating fee within a geographic region; or
(iv) programmatic changes or cost variations which are determined by the office to warrant a revision or update to the service operating fees.
(c) Capital add-on.
(1) To be considered as allowable, capital costs must be both reasonable and necessary to patient care under Part 817 of this Title. Allowable capital costs shall be determined and reimbursed by the office in accordance with the requirements of section 841.14 of this Part. Allowable patient days shall be determined in accordance with paragraph (e)(2) of this section.
(2) The capital add-on to the service operating fee shall be calculated for each fee period on a provider-specific basis by dividing the provider's allowable capital costs for that fee period by the allowable patient days for that fee period.
(3) Interest on current working capital shall be treated and reported as an administrative operating expense and as such is not considered an allowable capital cost.
(4) The capital add-on may be adjusted on a retroactive or prospective basis to more accurately reflect the actual or anticipated capital cost. At the discretion of the office, when the capital add-on is adjusted retroactively actual patient days for the fee period of the adjustment may be used instead of allowable patient days.
(d) Admission review team (ART) add-on.
(1) The admission review team add-on shall be calculated by dividing the annual cost of the review team or teams by the aggregate of the annual Medicaid units of service for Medicaid eligible Residential Rehabilitation Services for Youth (RRSY) patients. The admission review team add-on may be calculated either prospectively or retroactively.
(i) When the admission review team add-on is calculated prospectively it shall be based on the estimated cost of the admission review team and the estimated aggregate of the annual Medicaid units of service for Medicaid eligible RRSY patients.
(ii) When the admission review team add-on is calculated retroactively it shall be based on the actual cost of the admission review team and the actual aggregate of the annual Medicaid units of service for Medicaid eligible RRSY patients.
(2) Admission review team costs may include consultants under contract to the office, staff employed by the office, and associated non-personal service costs. The calculated admission review team add-on shall be identical for all residential rehabilitation services for youth providers.
(3) All expenditures for the admission review team shall be the responsibility of the office. The admission review team add-on shall be recouped in its entirety from each residential rehabilitation services for youth provider to reimburse the office for admission review team expenditures.
(4) The admission review team add-on may be adjusted either prospectively or retroactively to more accurately reflect the actual or anticipated cost of the admission review team.
(e) Fees and add-ons.
(1) Service operating fees shall be calculated as described in subdivision (b) of this section.
(2) Calculation of allowable patient days. For the purposes of determining rates of payment for capital costs, allowable patient days for eligible residential rehabilitation services for youth providers shall be computed using the higher of allowable days in the base year or 90 percent of possible days based upon annualized certified bed capacity.
(3) If the office determines that sufficient allowable expense exists, capital and admission review team add-ons shall be calculated and added to the service operating per diem fee. Capital and admission review team add-ons to the service operating fee shall be calculated as defined in subdivisions (c) and (d) of this section.
(4) Per diem fee add-ons established under this section shall be effective for a 12-month period beginning January 1st and ending December 31st.
(5) At the discretion of the office, per diem fee add-ons may be calculated from approved budgeted cost or approved actual cost.
(6) Fees and add-ons established under this section shall be provisional pending the completion of an audit in accordance with section 841.13 of this Part.
(f) Exceeding certified capacity.
The other provisions of this section notwithstanding, if the office determines that an eligible residential rehabilitation services for youth provider or a new eligible residential rehabilitation services for youth provider has violated regulations of the office by exceeding certified capacity, the commissioner may, at his or her discretion, adjust retroactively any fees or fee add-ons certified under this section to reflect the allowable costs and actual patient days incurred by the eligible residential rehabilitation services for youth provider for rendering such services. Such revised fees or fee add-ons may be applied retroactively, shall be calculated according to the methodology set forth in this section, and shall become effective upon approval by the Division of the Budget.
(g) New eligible residential rehabilitation services for youth providers.
(1) Each new eligible residential rehabilitation services for youth provider shall prepare and submit to the commissioner a budgeted cost report in accordance with the requirements of section 841.5(b)(1), (c)(1), (2), (e) and (f) of this Part. Such report shall:
(i) include a detailed projection of revenues and a line item expense budget with regard to staffing and non-personal service costs, including capital costs;
(ii) include a detailed staffing plan;
(iii) include a projected month by month bed utilization by program;
(iv) cover a 12-month period; and
(v) be completed and submitted at least 180 days prior to the beginning of the rate year for which a rate is being requested.
(2) The service operating fee and admission review team add-on for each new eligible residential rehabilitation services for youth provider shall be calculated and reimbursed pursuant to the requirements of subdivisions (b) to (f) of this section. The capital add-on shall be approved, calculated and reimbursed pursuant to the requirements of subdivisions (c), (e) and (f) of this section and section 841.14 of this Part.
(3) Upon submission of the financial reports pursuant to this subdivision, the commissioner may adjust retroactively the new eligible residential rehabilitation services for youth provider's existing capital add-on to more accurately reflect the reported operating costs and patient days of the eligible residential rehabilitation services for youth provider.
(h) Approval of fees and fee add-ons.
Service operating fees and fee add-ons established in accordance with the provisions of this section or revised in accordance with the provisions of section 841.13 of this Part shall be calculated by the commissioner and shall be approved by the State Division of the Budget. An eligible residential rehabilitation services for youth provider shall receive written notice of a fee after such approval.
(i) Certification for treatment, utilization review and control.
(1) For an individual who is a Medicaid recipient when admitted to the residential rehabilitation services for youth program, certification of services must be made by an independent team as defined in Part 817 of this Title.
(2) For individuals who apply for Medicaid after admission to the residential rehabilitation for youth program, or for emergency admissions, certification of services must be made by the multidisciplinary team as defined in Part 817 of this Title. This team must include a physician. Emergency admission certification must be made within 14 days after admission. Certification must be made at the time of admission or, if an individual applies for Medicaid while in the facility, at the time of application.
(3) The utilization review plan of an eligible residential rehabilitation services for youth provider shall include the following:
(i) provisions for review of each Medicaid recipient's need for services furnished in accordance with the criteria of Part 817 of this Title;
(ii) provisions to ensure that utilization review of a Medicaid recipient's treatment plan and services shall be performed by a multidisciplinary team that includes a physician as defined in Part 817 of this Title;
(iii) procedures to be used by the committee to ensure that staff of the eligible residential rehabilitation services for youth provider take needed corrective action;
(iv) provisions to ensure that the patient's record includes all information required by Part 817 of this Title, as well as the name of the patient's physician, the dates of Medicaid application and authorization if made after admission, initial and subsequent continued stay review dates, the reasons and plan for continued stay if continued stay is necessary, and other supporting material found necessary and appropriate by the multidisciplinary team;
(v) specification of records and reports to be made by the utilization review group;
(vi) provisions for maintaining the confidentiality of the identities of patients in the records and reports of the utilization review group; and
(vii) written criteria to assess the need for continued stay which conform to the requirements of Part 817 of this Title.
(4) The group performing utilization review shall ensure that subsequent reviews for continued stay of a recipient in an eligible residential service for youth program are conducted no later than each 30-day period following the initial continued stay review. The date assigned for each subsequent continued stay review shall be noted in the patient's record.
(5) Continued stay reviews shall be performed in accordance with the following:
(i) Review for continued stay shall be conducted by the multidisciplinary team defined in Part 817 of this Title.
(ii) The review shall be conducted on or before the review date assigned.
(iii) The multidisciplinary team shall review and evaluate the documentation referred to in subparagraph (3)(iv) of this subdivision in relation to the criteria established in response to subparagraph (3)(vii) of this subdivision.
(iv) If the multidisciplinary team finds that a recipient's continued stay is needed, the multidisciplinary team shall assign a new continued stay review date in accordance with paragraph (4) of this subdivision.
(v) Any decision of the multidisciplinary team that continued stay is unnecessary shall be provided in writing within two days to the director, the attending physician, the primary counselor, and the patient; and Medicaid billing shall cease as of the day of notification. However, any decision to discharge or retain the patient shall be made on clinical grounds independent of the utilization review group's determination.
(vi) A multidisciplinary team must certify that the services continue to be needed by each recipient.
(vii) If the multidisciplinary team finds that a continued stay is not needed, it shall notify the recipient's attending physician and primary counselor within one working day and provide them two working days to present their views before a final decision.
14 CRR-NY 841.12
Current through May 31, 2021
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IMPORTANT NOTE REGARDING CONTENT CURRENCY: JULY 31, 2023, 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 Admisnistrative Rules at [email protected]. See Help for additional information on the currency of this unofficial version of the NYS Rules.