N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 69-4.30

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

Section 69-4.30 - Computation of rates for early intervention services provided to infants and children ages birth to three years old and their families or caregivers

(a) The commissioner shall annually determine the rates for approved early intervention services and evaluations provided to eligible children, subject to the approval of the Director of the Budget. For payments made pursuant to this section for early intervention services to Medicaid patients, reimbursement shall be based upon a uniform payment schedule with discrete prices as set forth in subdivision (d) of this section. To be eligible to receive reimbursement pursuant to this section, providers must be approved to provide early intervention services pursuant to article 25 of the Public Health Law.

(b) For purposes of this section, a billable visit shall mean a face-to-face contact for the provision of authorized early intervention services between a provider of early intervention services and the individual(s) receiving such services, except for service coordination as described in paragraph (c)(3) of this section. Duration shall mean the time spent by a provider of early intervention services providing direct care or client contact. Activities such as case recording, training and conferences, supervisory conferences, team meetings and administrative work are not separately billable activities.

(c) Reimbursement shall be available at prices established pursuant to this section for the following early intervention program services:

(1)Screening as defined in section 69-4.1(an) of this Subpart and performed in accordance with section 69-4.8 of this Subpart. A provider shall submit one claim for a screening regardless of the number of visits required to perform and complete a screening. The Early Intervention Official shall approve any screenings provided to a child beyond the initial screening conducted in accordance with section 69-4.8 of this Subpart. Reimbursement shall not be provided for screenings performed after a child has been found eligible for early intervention services.

(2)Multidisciplinary evaluation as defined in section 69-4.1 (o) of this Subpart and performed in accordance with section 69-4.8 of this Subpart. Reimbursable evaluations shall include multidisciplinary evaluations and supplemental evaluations. A provider shall submit one claim for an evaluation (multidisciplinary or supplemental) regardless of the number of visits required to perform and complete the evaluation.

(i) A multidisciplinary evaluation shall include a developmental assessment, a review of pertinent records and a parent interview as specified in section 69-4.8 (e)(3)(ii) of this Subpart, and may include a family -directed assessment.

(a) A developmental assessment shall mean procedures conducted by qualified personnel with sufficient expertise in early childhood development who are trained in the use of professionally acceptable methods and procedures to evaluate each of the developmental domains: physical development, cognitive development, communication development, social or emotional development and adaptive development.

(b) A family-directed assessment shall mean a voluntary, family-directed assessment conducted by qualified personnel who are trained in the use of professionally acceptable methods and procedures to assist the family in identifying their concerns, priorities and resources related to the development of the child.

(ii)Supplemental evaluations shall include supplemental physician or non-physician evaluations and shall be provided upon the recommendation of the IFSP based on input from the team conducting the multidisciplinary evaluation and agreement of the child's parent. Supplemental evaluations provided must be required by and performed in accordance with the child's IFSP as specified in section 69-4.8 (l) of this Subpart.

(a)Supplemental physician evaluation shall mean an evaluation by a physician licensed pursuant to article 131 of the Education Law for the purpose of providing specific medical information regarding physical or mental conditions that may impact on the growth and development of the child and completing the required evaluation of the child's physical development as specified in section 69-4.8 (f)(3)(i) of this Subpart, or assessing specific needs in one or more of the developmental domains in accordance with section 69-4.8 (f) of this Subpart.

(b)Supplemental non-physician evaluation shall mean an additional evaluation for assessing the child's specific needs in one or more of the developmental domains in accordance with section 69-4.8 of this Subpart. Information obtained from this evaluation shall provide direction as to the specific early intervention services that may be required for the child for the IFSP team to determine whether the current team can address the concerns with the addition of another functional outcome or if additional services or specific interventions are required to meet the needs of the child. Supplemental non-physician evaluations may be conducted only by qualified personnel as defined in section 69-4.1(al) of this Subpart.

(c) A non-physician supplemental audiological evaluation may be performed for infants who have failed newborn hearing screening.

(iii)

(a) One multidisciplinary evaluation may be reimbursed within a 12 - month period without prior approval of the Early Intervention Official to develop and implement the initial IFSP. The Early Intervention Official shall assess the need for and, if appropriate, approve and notify the department of any additional multidisciplinary or supplemental evaluations provided to a child within a twelve - month period. If additional multidisciplinary or supplemental evaluations are necessary, such notice shall be provided on a monthly basis in a format provided by the department. Additional multidisciplinary or supplemental evaluations provided subsequent to the child's initial IFSP must be required by and performed in accordance with the IFSP as specified in section 69-4.8 (l) of this Subpart.

(b) Certain evaluation and assessment procedures may be repeated if deemed necessary and appropriate by the Early Intervention Official in conjunction with the required annual evaluation of the child's IFSP or more frequently in accordance with section 69-4.8 (k) of this Subpart. If additional evaluation or assessment procedures are necessary, the Early Intervention Official shall approve up to one more multidisciplinary evaluation and two supplemental evaluations prior to the next annual IFSP. Such additional evaluations must be required by and performed in accordance with the child's IFSP as specified in section 69-4.8 (l) of this Subpart. Any additional evaluations within that period shall be based on the indicators specified in section 69-4.8 (k) and shall first be approved by the Early Intervention Official and the Commissioner of Health of the New York State Department of Health; in assessing the need for such additional evaluations, the Early Intervention Official and the Commissioner of Health shall ensure that such additional evaluations are required by and performed in accordance with the child's IFSP.

(3)Service coordination as defined in section 69-4.1(m)(2)(xii) of this Subpart. Service coordination shall be provided by appropriate qualified personnel, delivered in accordance with the child's IFSP, and billed in 15 minute units that reflect the time spent providing services in accordance with sections 69-4.6 and 69-4.7 of this Subpart, or billed under a capitation or other rate methodology as may be established by the Commissioner subject to the approval of the Director of the Budget and as specified in prior written notice provided by the Commissioner to Early Intervention Officials. Such written notice shall specify that any newly established rate methodology shall apply only to initial IFSPs and IFSP amendments made on or after the effective date of such written notice by the Commissioner. The rate methodology may be established on a per month, per week, and/or service component basis for providing service coordination services. When units of time are billed, the first unit shall reflect the initial five to fifteen minutes of service provided and each unit thereafter shall reflect up to an additional fifteen minutes of service provided. Except for child/family interviews to make assessments and plans, contacts for service coordination need not be face-to-face encounters; they may include contacts with service providers or a child's parent, caregiver, daycare worker or other similar collateral contacts, in fulfillment of the child's IFSP.

(4)Assistive technology as defined in section 69-4.1(m)(2)(ii) of this Subpart.

(5) Home and community-based individual/collateral visit. This shall mean the provision by appropriate qualified personnel of early intervention services to an eligible child and/or collateral services that are provided in the context of the parent/caregiver-child dyad to help the child reach their outcomes, as articulated in the child's IFSP. Home and community-based visits take place at the child's home or other natural setting in which children under three years of age are typically found (including day care centers, other than those located at the same premises as the early intervention provider, and family day care homes). Reimbursable home and community-based individual/collateral visits shall include basic and extended visits.

(i) A basic visit is a minimum of 30 minutes and less than one hour in duration. Up to three (3) such visits provided by appropriate qualified personnel within different disciplines per day may be billed for each eligible child as specified in an approved IFSP without prior approval of the Early Intervention Official.

(ii) An extended visit is one hour or more in duration. Up to three such visits provided by appropriate qualified personnel within different disciplines per day may be billed for each eligible child as specified in an approved IFSP without prior approval of the early intervention official.

(iii) Notwithstanding subparagraphs (i) and (ii) of this paragraph, no more than three basic and extended visits combined per day may be billed for each eligible child as specified in an approved IFSP without prior approval of the early intervention official.

(iv) A provider shall not bill for a basic and extended visit provided on the same day by appropriate qualified personnel within the same discipline without prior approval of the early intervention official.

(6) Office/facility-based individual/collateral visit. This shall mean the provision by appropriate qualified personnel of early intervention services to an eligible child and/or collateral services that are provided in the context of the parent/caregiver-child dyad to help the child reach his or her outcomes, as articulated in the child's IFSP. Office/facility-based visits take place at an approved early intervention provider's site (including day care centers located at the same premises as the early intervention provider). A basic office/facility-based visit is a minimum of 30 minutes and less than one hour in duration. Up to one (1) visit per discipline and no more than three (3) office/facility-based visits per day may be billed for each eligible child as specified in an approved IFSP without prior approval of the Early Intervention Official.

(7) Parent-child group visit. This shall mean the provision of early intervention services in a group composed of parent(s) or other designated caregivers and eligible children, and a minimum of one appropriate professional qualified to provide early intervention services at an early intervention provider's site or a community-based site (e.g., day care center or family day care). Up to one (1) visit per day may be billed for each eligible child as specified in an approved IFSP without prior approval of the Early Intervention Official.

(8) Group early intervention service visit. This shall mean the provision of physical therapy, occupational therapy, speech-language therapy, applied behavior analysis, or special instruction early intervention services by appropriate qualified personnel to eligible children in a group at an approved early intervention provider's site or at a day care facility duly licensed in New York State.

(i) Up to 120 minutes of group early intervention services per day may be billed for each eligible child as specified in an approved IFSP without prior approval of the Early Intervention Official. Any additional group sessions in the same day shall be approved by the Early Intervention Official.

(ii) A group early intervention service session shall be a minimum of 60 minutes and a maximum of 120 minutes in length and in accordance with the child's IFSP.

(iii) Groups shall consist of two to ten eligible children. Use of a one-to-one aide should be based on clinical appropriateness.

(iv) Groups shall be provided by, at a minimum, one approved and appropriately qualified early intervention provider and one assistant.

(v) Groups shall consist of children with similar IFSP outcomes and include appropriate therapeutic approaches.

(vi) Children participating in a group early intervention service shall not also receive individual services (including push-in/pull-out services) while the group is in session.

(vii) Session notes shall be provided for each child as an individual, not for the group as a whole, and shall include, at a minimum:

(a) eligible child's name;

(b) specific type of service provided;

(c) individual or group service;

(d) group size if applicable;

(e) setting in which the group service was rendered;

(f) date and time the service was rendered, including start and end times;

(g) brief description of the student's progress made by receiving the service during the session;

(h) name, title, signature, and credentials of the person furnishing the service; and

(i) signature and credentials of supervising clinician as appropriate, dated within 45 days of the date of service.

(9) Family/caregiver support group visit. This shall mean the provision of early intervention services by appropriate qualified personnel to a group of parents or other designated caregivers (such as foster parents, day care staff) and/or siblings of eligible children for the purposes of:

(i) enhancing their capacity to care for and/or enhance the development of the eligible child; and/or

(ii) provide support, education, and guidance to such individuals relative to the child's unique developmental needs. Up to two (2) visits per day may be billed for each eligible child as specified in an approved IFSP without prior approval of the Early Intervention Official (for example, one (1) for parents or other designated caregivers and one (1) for sibling(s) in a given day).

(10) ABA services. ABA services shall be billed as either basic or extended visits, as described in subdivision (c) paragraph (5) of this section, up to and in accordance with the hours of service as specified the child's IFSP.

(11) The Early Intervention Official shall approve and notify the department of any visits provided in addition to those described in paragraphs (5) through (11) of this subdivision as may be required by and provided in accordance with the child's IFSP. If such additional visits are necessary, such notice shall be provided on a monthly basis on forms provided by the Department.

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

(1) physician services, nursing services, therapist services, technician services, nutrition services, psychosocial services, service coordination, and other related professional and paraprofessional expenses directly incurred by the approved provider;

(2) space occupancy, except as provided in subdivision (f) of this section, and plant overhead costs;

(3) all supplies directly related to the provision of early intervention services, except as provided in subdivision (g) of this section; and

(4) administrative, personnel, business office, data processing, recordkeeping, housekeeping, and other related provider overhead expenses.

(e) The price for each service shall be adjusted for regional differences in wage levels to reflect differences in labor costs for personnel providing direct care and support staff and shall include consideration of absentee data and child to professional to paraprofessional ratios.

(f)Assistive technology devices.

Reimbursement for approved assistive technology devices shall be at reasonable and customary charges approved by the commissioner or his designee.

N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 69-4.30

Amended New York State Register November 30, 2016/Volume XXXVIII, Issue 48, eff. 11/30/2016

Amended New York State Register December 5, 2018/Volume XL, Issue 49, eff. 12/5/2018

Amended New York State Register November 13, 2019/Volume XLI, Issue 46, eff. 11/13/2019

Amended New York State Register February 14, 2024/Volume XLVI, Issue 7, eff. 2/14/2024