N.Y. Comp. Codes R. & Regs. tit. 14 § 588.13

Current through Register Vol. 46, No. 45, November 2, 2024

Section 588.13 - Reimbursement for outpatient programs

(a) Reimbursement under the medical assistance program for outpatient programs licensed solely pursuant to article 31 of the Mental Hygiene Law and Part 587 of this Title which serve adults with a diagnosis of mental illness and children with a diagnosis of emotional disturbance shall be in accordance with the following fee schedule.

(1) Reimbursement under the medical assistance program for clinic treatment programs shall be in accordance with the following fee schedule. Such reimbursement shall be adjusted pursuant to subdivisions (i), (j) and (k) of this section.

(i) For programs operated in Bronx, Kings, New York, Queens, Richmond, Nassau, Suffolk, Putnam, Rockland and Westchester Counties:

Regular	at least 30 minutes	$71.94
Brief	at least 15 minutes	35.97
Group	at least 60 minutes	25.18
Collateral	at least 30 minutes	71.94
Group Collateral	at least 60 minutes	25.18
Crisis	at least 30 minutes	71.94

(ii) For programs operated in Allegany, Cattaraugus, Chautauqua, Chemung, Erie, Genesee, Livingston, Monroe, Niagara, Ontario, Orleans, Schuyler, Seneca, Steuben, Tioga, Tompkins, Wayne, Wyoming and Yates Counties:

Regular	at least 30 minutes	$64.75
Brief	at least 15 minutes	32.37
Group	at least 60 minutes	22.66
Collateral	at least 30 minutes	64.75
Group Collateral	at least 60 minutes	22.66
Crisis	at least 30 minutes	64.75

(iii) For programs operated in Broome, Cayuga, Chenango, Clinton, Cortland, Delaware, Essex, Franklin, Fulton, Hamilton, Herkimer, Jefferson, Lewis, Madison, Montgomery, Oneida, Onondaga, Oswego, Otsego, St. Lawrence, Albany, Columbia, Dutchess, Greene, Orange, Rensselaer, Saratoga, Schenectady, Schoharie, Sullivan, Ulster, Warren and Washington Counties:

Regular	at least 30 minutes	$63.55
Brief	at least 15 minutes	31.77
Group	at least 60 minutes	22.25
Collateral	at least 30 minutes	63.55
Group Collateral	at least 60 minutes	22.25
Crisis	at least 30 minutes	63.55

(2) The minimum duration of a group or group collateral visit at a school-based clinic program shall consist of the duration of a scheduled class period at the school in which the program is based, or 60 minutes, whichever is less.

(3) Reimbursement under the medical assistance program for non-State operated continuing day treatment programs licensed pursuant to article 31 of the Mental Hygiene Law and Part 587 of this Title for services provided on or after January 1, 2009, and prior to April 1, 2009, shall be in accordance with the following fee schedule.

(i) For programs operated in Bronx, Kings, New York, Queens, Richmond, Nassau, Suffolk, Putnam, Rockland and Westchester Counties:

Regular, collateral, group collateral, and crisis visits shall be reimbursed on the basis of service hours. The reimbursement for any service hour shall be based upon the cumulative number of service hours provided in a calendar month to an individual recipient. When the service hours of any single visit include more than one rate, the provider of service shall be reimbursed at the rate that applies to the first hour of such visit. The rates of reimbursement are as follows:

Service hour 1-50	$12.54 per service hour
Service hour 51-80	$8.97 per service hour
Service hour beyond 80	$6.61 per service hour

(ii) For programs operated in Allegany, Cattaraugus, Chautauqua, Chemung, Erie, Genesee, Livingston, Monroe, Niagara, Ontario, Orleans, Schuyler, Seneca, Steuben, Tompkins, Wayne, Wyoming and Yates Counties:

Service hour 1-50	$11.29 per service hour
Service hour 51-80	$8.97 per service hour
Service hour beyond 80	$6.61 per service hour

(iii) For programs operated in Broome, Cayuga, Chenango, Clinton, Cortland, Delaware, Essex, Franklin, Fulton, Hamilton, Herkimer, Jefferson, Lewis, Madison, Montgomery, Oneida, Onondaga, Oswego, Otsego, St. Lawrence, Tioga, Albany, Columbia, Dutchess, Greene, Orange, Rensselaer, Saratoga, Schenectady, Schoharie, Sullivan, Ulster, Warren and Washington Counties:

Regular, collateral, group collateral, and crisis visits shall be reimbursed on the basis of service hours. The reimbursement for any service hour shall be based upon the cumulative number of service hours provided in a calendar month to an individual recipient. When the service hours for any single visit include more than one rate, the provider of service shall be reimbursed at the rate that applies to the first hour of such visit. The rates of reimbursement are as follows:

Service hour 1-50	$11.08 per service hour
Service hour 51-80	$8.97 per service hour
Service hour beyond 80	$6.61 per service hour

(4) Reimbursement under the medical assistance program for non-state operated continuing day treatment programs licensed solely pursuant to article 31 of the Mental Hygiene Law, and Part 587 of this Title for services provided on or after April 1, 2015, shall be in accordance with the following fee schedule. The reimbursement for any regular visit shall be based upon the cumulative number of program hours provided in a calendar month to an individual recipient, excluding time spent in meals, adding two hours for each half-day visit and four hours for each full-day visit. Collateral, group collateral pre-admission and crisis visits will be reimbursed at the half-day rate for program hours 1-40 regardless of the cumulative total of hours for regular visits in that month. Collateral, group collateral, pre-admission and crisis visits shall not be included in the calculation of the cumulative total hours in the program for a recipient. When the program hours of any single visit include more than one rate, the provider of service shall be reimbursed at the rate that applies to the first hour of such visit. Regular visits shall be reimbursed on the basis of program attendance and service provision as set forth in section 588.7 of this Part. The rates of reimbursement are as follows:

(i) For programs operated in Bronx, Kings, New York, Queens, Richmond, Nassau, Suffolk, Putnam, Rockland and Westchester counties:

Program hours 1-40	$62.07 full day (4 hours)
Program hours 1-40	$31.04 half day (2 hours)
Program hours 41-64	$46.56 full day (4 hours)
Program hours 41-64	$23.28 half day (2 hours)
Program hours 65+	$34.30 full day (4 hours)
Program hours 65+	$17.16 half day (2 hours)
Collateral	$31.04
Group Collateral	$31.04
Crisis	$31.04
Pre-Admission	$31.04

Program hours 1-40	$55.92 full day (4 hours)
Program hours 1-40	$27.96 half day (2 hours)
Program hours 41-64	$46.60 full day (4 hours)
Program hours 41-64	$23.60 half day (2 hours)
Program hours 65+	$34.34 full day (4 hours)
Program hours 65+	$17.17 half day (2 hours)
Collateral	$27.96
Group Collateral	$27.96
Crisis	$27.96
Pre-Admission	$27.96

(iii) For programs operated in Broome, Cayuga, Chenango, Clinton, Cortland, Delaware, Essex, Franklin, Fulton, Hamilton, Herkimer, Jefferson, Lewis, Madison, Montgomery, Oneida, Onondaga, Oswego, Otsego, St. Lawrence, Tioga, Albany, Columbia, Dutchess, Greene, Orange, Rensselaer, Saratoga, Schenectady, Schoharie, Sullivan, Ulster, Warren and Washington counties:

Program hours 1-40	$54.92 full day (4 hours)
Program hours 1-40	$27.47 half day (2 hours)
Program hours 41-64	$46.63 full day (4 hours)
Program hours 41-64	$23.32 half day (2 hours)
Program hours 65+	$34.36 full day (4 hours)
Program hours 65+	$17.19 half day (2 hours)
Collateral	$27.47
Group Collateral	$27.47
Crisis	$27.47
Pre-Admission	$27.47

(b) Reimbursement under the medical assistance program for non-State operated continuing day treatment programs licensed pursuant to article 31 of the Mental Hygiene Law and operated by agencies licensed pursuant to article 28 of the Public Health Law, and Part 587 of this Title shall be in accordance with the following fee schedule:

(1) For services provided on or after April 1, 2015, the reimbursement for any regular visit shall be based upon the cumulative number of program hours provided in a calendar month for an individual recipient, excluding time spent in meals, adding two hours for each half-day visit and four hours for each full-day visit. Collateral, group-collateral, pre-admission and crisis visits will be reimbursed at the half-day rate for program hours 1-40 regardless of the cumulative total of hours for regular visits in that month. Collateral, group collateral, pre-admission and crisis visits shall not be included in the calculation of the cumulative total hours in the program for a recipient. When the program hours of any single visit include more than one rate, the provider of service shall be reimbursed at the rate that applies to the first hour of such visit. Regular visits shall be reimbursed on the basis of program attendance and program provision as set forth in section 588.7 of this Part. The rates of reimbursement are as follows:

Program hours 1-40	$62.16 full day (4 hours)
Program hours 1-40	$41.65 half day (2 hours)
Program hours 41+	$46.62 full day (4 hours)
Program hours 41+	$31.23 half day (2 hours)
Collateral	$41.65
Group Collateral	$41.65
Crisis	$41.65
Pre-Admission	$41.65

(2) For amounts paid under this subdivision:

(i) There shall be added an allowance for the cost of capital, which shall be determined by the application of the principles of cost-finding for the Medicare program. No capital expenditure for which approval by the office is required under the applicable provisions of the Mental Hygiene Law or Part 551 of this Title shall be included in allowable capital costs for purposes of rate computation unless such approval has been secured.

(ii) Allowable capital expenditures shall not include costs specifically excluded pursuant to section 2807-c of the Public Health Law.

(iii) The capital payment per visit for a provider's continuing day treatment programs shall be determined by dividing all allowable capital costs of the provider's licensed outpatient mental health clinic, day treatment, and continuing day treatment, after deducting any exclusions, by the sum of the total number of visits for such programs.

(c) Effective April 1, 2015, reimbursement under the medical assistance program for day treatment programs serving children licensed solely pursuant to article 31 of the Mental Hygiene Law, and Part 587 of this Title shall be in accordance with the following fee schedule.

(1) For programs operated in Bronx, Kings, New York, Queens and Richmond Counties:

Full day	at least 5 hours	$98.36
Half day	at least 3 hours	49.19
Brief day	at least 1 hour	32.79
Collateral	at least 30 minutes	32.79
Home	at least 30 minutes	98.36
Crisis	at least 30 minutes	98.36
Preadmission - full day	at least 5 hours	98.36
Preadmission - half day	at least 3 hours	49.19

(2) For programs operated in other than Bronx, Kings, New York, Queens and Richmond Counties:

Full day	at least 5 hours	$95.08
Half day	at least 3 hours	47.54
Brief day	at least 1 hour	31.64
Collateral	at least 30 minutes	31.64
Home	at least 30 minutes	95.08
Crisis	at least 30 minutes	95.08
Preadmission - full day	at least 5 hours	95.08
Preadmission - half day	at least 3 hours	47.54

(d) Providers whose reimbursement under the medical assistance program for clinic, continuing day treatment, and/or day treatment has been supplemented in accordance with Part 592 of this Title will have this additional reimbursement limited in total to an amount established by the commissioner which shall be subject to the availability of appropriations in the Office of Mental Health's budget. Supplemental reimbursement received in excess of this threshold will be recovered in a succeeding year through the medical assistance recovery process authorized pursuant to section 368-c of the Social Services Law.

(e) Effective April 1, 2015, reimbursement under the medical assistance program for regular, collateral and crisis visits to all non-State operated partial hospitalization programs licensed pursuant to article 31 of the Mental Hygiene Law and Part 587 of this Title shall be in accordance with the following fee schedule:

(1) For programs located in Nassau and Suffolk Counties, the fee shall be $29.10 for each service hour.

(2) For programs located in New York City, the fee shall be $38.22 for each service hour.

(3) For programs located in the counties in the region of New York State designated by the Office of Mental Health as the Hudson River Region, the fee shall be $32.10 for each service hour.

(4) For programs located in the counties in the region of New York State designated by the Office of Mental Health as the Central Region, the fee shall be $22.12 for each service hour.

(5) For programs located in the counties in the region of New York State designated by the Office of Mental Health as the Western Region, the fee shall be $27.28 for each service hour.

(f) Effective April 1, 2015, reimbursement under the medical assistance program for on-site and off-site visits for all non-State operated intensive psychiatric rehabilitation treatment programs licensed pursuant to article 31 of the Mental Hygiene Law and Part 587 of this Title shall be at $24.97 for each service hour.

(g) The commissioner will only consider requests for revisions of rates calculated under the provisions of this section due to errors made by the Office of Mental Health in the calculation of the rates.

(1) A request for revision of a certified fee calculated in accordance with subdivision (a) of this section shall be sent to the commissioner by registered or certified mail and shall contain a detailed statement of the basis for the requested revision together with any documentation that the provider of service wishes to submit.

(2) A request for revision must be submitted within 120 days of receipt by the provider of service of the rate computation sheet.

(3) The provider of service shall be notified in writing of the commissioner's determination, including a statement of the reasons thereof.

(h) Clinic, continuing day treatment, and/or day treatment programs for which an operating certificate has been issued and which are not designated as Level I comprehensive outpatient programs pursuant to Part 592 of this Title may qualify to become Level II comprehensive outpatient programs under such Part, and shall comply with the applicable provisions of such Part.

(i) Clinic treatment programs for which an operating certificate has been issued shall receive an adjustment to the fee schedules set forth in paragraph (a)(1) of this section if they are enrolled in a continuous quality improvement initiative implemented by the commissioner. In order to be enrolled in such continuous quality improvement initiative, the program shall execute an agreement with the Office of Mental Health under which the provider agrees to participate in such initiative, and undertake such quality improvement measures as shall be developed by the commissioner.

(j) Any program eligible to receive supplemental medical assistance reimbursement pursuant to subdivision (i) of this section, and which fails at any time to meet the requirements set forth in the agreement executed pursuant to such subdivision, shall have its continuous quality improvement adjustment suspended until such time as the program meets such requirements, as determined by the commissioner.

(k) A clinic treatment program that has been approved by the Office of Mental Health to provide services to children and adolescents during evening and weekend hours shall receive a rate enhancement for regular or collateral clinic visits provided to recipients under the age of 18 years, when such services are provided during weekdays commencing 6 p.m. or later, or on a Saturday or Sunday, provided, however, that an enhanced rate shall only be paid for one visit provided for a recipient on any given day.

(l) Outpatient services operated by agencies licensed under article 28 of the Public Health Law which are also licensed pursuant to article 31 of the Mental Hygiene Law shall not be considered to be specialty services pursuant to section 2807(2)(g) of the Public Health Law.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 588.13

Amended, New York State Register October 8, 2014/Volume XXXVI, Issue 40, eff.10/8/2014

Amended New York State Register September 2, 2015/Volume XXXVII, Issue 35, eff.9/2/2015