N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 86-10.2

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

Section 86-10.2 - Definitions

As used in this Subpart, the following terms shall have the following meanings:

(a) Allowable capital costs. Capital costs that are allowable under 14 NYCRR Subpart 635-6.

(b) Allowable operating costs. In the case of residential habilitation services, operating costs that are allowable under 14 NYCRR paragraph 635-10.4 (b)(1) and subdivision 686.13(b); in the case of day habilitation services, operating costs that are allowable under 14 NYCRR paragraph 635-10.4(b)(2).

(c) Acuity factor. Factor developed through a regression analysis utilizing components of Developmental Disabilities Profile-2 (DDP-2) scores, average residential bed size, Willowbrook class indicators and historical utilization data to predict direct care hours needed to serve individuals. Factors are available on the Department's website: http://www.health.ny.gov/health_care/medicaid/rates/mental_hygiene/

(d) Allowable Agency Administration. For Non-State Government and Voluntary Providers, from the CFR for the base year, divide the Agency Administration Allocation (from CFR1 Line 65) by the Total Operating Costs (from CFR1 Line 64) to determine the agency administration percentage.

(e) Authorized Rate Period Units, or Authorized Units. Units approved by OPWDD Budget Office to deliver Day Habilitation Services. OPWDD Budget Office adjusts the units based on addition or subtraction of individuals as well as addition or subtraction of sites. These units are tracked on an ongoing basis and reported to DOH on a semi-annual basis (January and July). Based on the unit update the operating portion of the final target rate will not change. The capital portion will be adjusted by the change in units, which will change the overall Day Habilitation rate.

(f) Base Period CFR, or Base Year CFR. The Consolidated Fiscal Report (CFR) used to update methodologies.

(g) Budget Neutrality Adjustment. Factor applied to the end of the methodology, by service, to ensure the total annual target reimbursement is equivalent to the total annual base reimbursement. The factors can be found on the Department's website at http://www.health.ny.gov/health_care/medicaid/rates/mental_hygiene/

(h) Capital Costs. Allowable costs that are related to the acquisition, lease and/or long-term use of land, buildings and construction equipment, leasehold improvements and vehicles.

(i) Community residence. A facility operated as a community residence under 14 NYCRR Part 686, including an individualized residential alternative.

(j) Consolidated Fiscal Report (CFR). The reporting tool utilized by all government and nongovernment providers to communicate annual costs incurred as a result of operating OPWDD programs and services, along with related patient utilization and staffing statistics. The CFR is the report and associated instructions as of April 1, 2013, identified by the New York State Education Department, and found at: http://www.oms.nysed.gov/rsu/Manuals_Forms/

(k) Day habilitation services. Day habilitation services provided under the home and communitybased services waiver operated by OPWDD and pursuant to 14 NYCRR Subpart 635-10.

(l) Department of Health (DOH) regions. Regions as defined by the Department, assigned to providers based upon the geographic location of the provider's headquarters as reported on the consolidated fiscal report. Such regions are as follows:

(1) Downstate: five boroughs of New York City, Nassau, Suffolk, Westchester;

(2) Hudson Valley: Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster;

(3) Upstate Metro: Albany, Erie, Fulton, Genesee, Madison, Monroe, Montgomery, Niagara, Onondaga, Orleans, Rensselaer, Saratoga, Schenectady, Warren, Washington, Wyoming;

(4) Upstate Non-Metro: Any counties not listed in paragraph (1), (2) or (3) of this subdivision.

(m) Depreciation. The allowable cost based on historical costs and useful life of buildings, equipment, capital improvements and/or acquisition of real property. The useful life shall be based on "The Estimated Useful Life of Depreciable Hospital Assets (2008 edition)" except that the useful life for day habilitation buildings will be 25 years. The depreciation method used shall be straight-line method.

(n) Developmental Disabilities Profile (DDP-2). The document titled Developmental Disabilities Profile (DDP-2) dated 10/16 and issued by OPWDD. This document, the Developmental Disabilities Profile (DDP-2) User's Guide and another document titled Scoring the DDP are available during business hours and by appointment at the following locations:

(1) the Department of State, Division of Administrative Rules, One Commerce Plaza, 99 Washington Avenue, Albany NY 12231-0001;

(2) OPWDD, Attention Public Access Officer, 44 Holland Avenue, Albany, NY 12229.

(o) E-Score factor. Factor derived from analysis of evacuation scores to adjust staffing needs necessary to address health and safety needs.

(p) Evacuation score (E-Score). The score for a supervised community residence that is certified under chapter 32 or 33 of the Residential Board and Care Occupancies of the NFPA 101 Life Safety Code (2000 edition) that is provided to the Department by OPWDD once a year. The Escore is described in the NFPA 101A Guide on Alternative Approaches to Life Safety, 2001 edition. The Life Safety Code and Guide on Alternative Approaches to Life Safety are available from the National Fire Protection Association, One Batterymarch Park, Quincy, MA 021697471; or is available during business hours and by appointment at the following locations:

(1) the Department of State, Division of Administrative Rules, One Commerce Plaza, 99 Washington Avenue, Albany, NY 12231-0001;

(2) OPWDD, Attention Public Access Officer, 44 Holland Avenue, Albany, NY 12229.

(q) Facility. The site or physical building where actual services are provided.

(r) Final Average Rate. The final average rate is determined using the final rate year reimbursable cost divided by the final rate year total units of service regardless of payer.

(s) Financing expenditures. Interest expense and fees charged for financing of costs related to the purchase/acquisition, alteration, construction, rehabilitation and/or renovation of real property, vehicles, and equipment.

(t) Individual. Person receiving a residential or day habilitation service.

(u) Initial period. The first 12 months of the rate cycle.

(v) Lease/rental and ancillary payments. A facility's annual rental payments for real property and ancillary outlays associated with the property such as utilities and maintenance.

(w) Occupancy Adjustment. An adjustment to the calculated daily rate of a Voluntary Agency which provides Supervised Residential Habilitation to account for days when Medicaid billing cannot occur because an individual has passed away or has moved to another site.

(1) For the rate periods beginning July 1, 2019, Voluntary Providers receive an occupancy adjustment to the operating component of their rate for vacancy days. The occupancy adjustment percentage is calculated by dividing the sum of the agency's rate period reported retainer days, service days and the therapy days by 100% of the agency's certified capacity. The certified capacity is calculated taking into account capacity changes throughout the year, multiplied by 100% of the year's days. This adjustment will begin on July 1, 2019 and be recalculated on an annual basis based on the most current and complete twelve months of experience.

(2) For the period beginning May 1, 2021, the occupancy adjustment will be 0%.

(x) Operating costs. Provider costs related to the provision of day habilitation and residential habilitation services provided in a community residence and identified in such provider's cost reports. With the exception of live-in caregiver services, allowable operating costs shall not include the costs of board.

(y) Provider. An individual, corporation, partnership or other organization to which OPWDD has issued an operating certificate to operate a community residence, and for which the NYS Department of Health has issued a Medicaid provider agreement, or an individual, corporation, partnership or other organization to which OPWDD has issued an operating certificate or approval to operate a day habilitation program, and for which the Department has issued a Medicaid provider agreement.

(z) Rate. A reimbursement amount based on a computation using annual provider reimbursable cost divided by the applicable annual units of service.

(aa) Rate Period. The annual time period that rates are effective. For Voluntary Providers the time period is July 1st through June 30th.

(ab) Rate sheet capacity. The number of individuals for whom a provider is certified or approved by OPWDD to provide residential habilitation.

(ac) Rebasing. Updating cost data in the methodology, using an available and complete CFR.

(ad) Reimbursable cost. The final allowable costs of the rate year after all audit and/or adjustments are made.

(ae) Residential habilitation. Residential habilitation services provided in a community residence, under the home and community-based services waiver operated by OPWDD and pursuant to 14 NYCRR Subpart 635-10 and 14 NYCRR Part 671.

(af) Retainer days. Days of Medical leave or an associated day where any other institutional or in-patient Medicaid payment is made for providing services to the beneficiary. A provider is limited to being paid 14 Retainer days per rate year, multiplied by certified capacity. Effective on or after May 1, 2021, Retainer days will be reimbursed at a rate of 50 percent of the provider's established rate.

(ag) Room and board. Room means hotel or shelter type expenses including all property related costs such as rental or depreciation related to the purchase of real estate and furnishings; maintenance, utilities and related administrative services. Board means three meals a day or any other full nutritional regimen.

(ah) Service days. A day when paid Supervised IRA staff deliver residential habilitation to a person who is either present in the Supervised IRA or is absent from the IRA and receives residential habilitation services from paid Supervised IRA staff, and these services are of the same scope, frequency and duration as the services provided when the person is resident in the Supervised IRA.

(ai) Start-up costs. Those costs associated with the opening of a new program. Start-up costs include pre-operational rent, utilities, staffing, staff training, advertising for staff, travel, security services, furniture, equipment and supplies.

(aj) State supplement. Amount paid to a provider to cover room and board costs in excess of SSI and Supplemental Nutrition Assistance Program (SNAP) payments.

(ak) Target rate. The final rate in effect at the end of the transition period for each waiver service determined using the rate year final reimbursable cost for each respective provider for each respective service divided by the final total of actual units of service for all individuals, regardless of payor.

(al) Therapy Day. A therapy day is a day when the individual is away from the supervised residence and is not receiving services from paid Residential Habilitation staff and the absence is for the purpose of a visiting with family or friends, or a vacation. The therapy day must be described in the person's plan of care to be eligible for payment and the person may not receive another Medicaid-funded residential or in-patient service on that day. Effective May 1, 2021 or after, a provider is limited to being paid 96 therapy days per rate year per person. All therapy days will be reimbursed at a rate of 50 percent of the provider's established rate.

(am) Units of service. The unit of measure for the following waiver services shall be:

(1) residential habilitation provided in a supervised community residence--daily;

(2) residential habilitation provided in a supportive community residence--monthly;

(3) day habilitation--daily.

(an) Wage Equalization. The sum of the provider average direct care hourly rate multiplied by seventy-five hundredths from the base period CFR and the applicable regional average direct care hourly rate multiplied by twenty-five hundredths from the base period CFR.

N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 86-10.2

Adopted, New York State Register June 25, 2014/Volume XXXVI, Issue 25, eff. 6/25/2014

Amended New York State Register April 22, 2015/Volume XXXVII, Issue 16, eff. 4/22/2015

Amended New York State Register July 14, 2021/Volume XLIII, Issue 28, eff. 7/14/2021