N.Y. Comp. Codes R. & Regs. tit. 14 § 671.7

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

Section 671.7 - Reimbursement and fiscal reporting for providers of service

(a) Effective July 1, 2014:

(1) reimbursement for residential habilitation services provided in non-state operated IRAs and CRs shall be in accordance with the provisions of Subpart 641-1 of this Title. Subpart 641-1 supersedes the provisions of subdivision (b) of this section for reimbursement of residential habilitation services provided in non-state operated supervised and supportive IRAs and CRs on or after July 1, 2014;

(2) the unit of service for residential habilitation services provided in non-state operated supervised IRAs and CRs shall be a daily unit of service. The requirements of this paragraph supersede the provisions of paragraph (b)(3)(ii) of this section for residential habilitation services provided in non-state operated supervised IRAs and CRs on or after July 1, 2014;

(3) residential habilitation services in non-state operated supervised CRs shall be provided and documented in accordance with subparagraphs 635-10.5(b)(11)(i) and (12)(i)-(ii) of this Title; and

(4) residential habilitation services in non-state operated supportive CRs shall be provided and documented in accordance with paragraph 635-10.5(b)(10) and subparagraphs (11)(iv)-(v) of this Title.

(b)Price setting.

(1) Applicability.

Price setting for community residential habilitation services and room and board in supervised and supportive community residences (for purposes of this section, community residence refers to supervised and supportive community residences only) certified in accordance with Part 686 of this Title and the requirements of this Part.

(2) Price periods.

(i) For facilities in Region I (as defined in section 635-4.1 of this Title) or for those facilities which are designated or have elected to report as Region I facilities, the price period is a 12 month period which begins on July 1st and ends on June 30th.

(ii) For facilities in Regions II and III (as defined in section 635-4.1 of this Title) or for those facilities which are designated or have elected to report as either Region II or Region III facilities, the price period is a 12 month period which begins on January 1st and ends on December 31st.

(3) Effective January 1, 2010, Supervised Community Residences Reimbursement--supervised IRA price.

(i) Effective January 1, 2010 the calculation of reimbursement for supervised community residences shall be consolidated with the calculation of reimbursement for supervised IRAs, if any, as follows:

(a) For each provider, the total annual allowable residential habilitation, and room, board and protective oversight costs exclusive of property in effect on December 31, 2009 for all supervised community residences shall be combined with the total annual allowable residential habilitation, and room, board and protective oversight costs exclusive of property in effect on December 31, 2009 for all supervised IRAs, if any, in order to establish annual aggregate gross reimbursable operating costs.

(b) The result in clause (a) of this subparagraph shall be increased by any trend factor effective on January 1, 2010 and applicable to community residences in accordance with provisions of paragraph (8) of this subdivision.

(c) The total annual capital reimbursement level supdated pursuant to paragraph (7) of this subdivision for January 1, 2010 for all supervised community residences and pursuant to section 686.13(k)(1)(vi) of this Title for January 1, 2010 for all supervised IRAs, if any, shall be combined into an aggregate annual amount and added to the result in clause (b) of this subparagraph.

(d) The result in clause (c) of this subparagraph shall be reduced by the reimbursement offsets described in paragraphs (9) and (10) of this subdivision which have been adjusted to an annual amount based on billing periods and certified capacities in effect on January 1, 2010.

(e) The result in clause (d) of this subparagraph shall be divided by 12 and then divided by the total certified capacities of these sites less any certified temporary use bed(s) to determine the uniform monthly supervised IRA price that shall be used to reimburse supervised community residence and supervised IRA facilities. This combined price will be referred to as the IRA price.

(ii) Countable service days.

(a) The full month supervised IRA price shall be paid for services provided to an individual who meets the enrollment requirement in subparagraph (5)(i) of this subdivision and who receives face-to-face residential habilitation services in accordance with the individual's ISP (individualized service plan) and community residential habilitation plan on four separate days of the 22 days of the enrollment requirement. These are known as countable service days.

(b) One-half of the full month supervised IRA price shall be paid for services provided to an individual who meets the enrollment requirement in subparagraph (5)(ii) of this subdivision and who receives face-to-face residential habilitation services in accordance with the individual's ISP and community residential habilitation plan on two separate days of the 11 days of the enrollment requirement. These are known as countable service days.

(c) Compliance. For the period from January 1, 2010 through August 1, 2010, a supervised community residence will be considered to have met the requirements in this subdivision for countable service days for a full month supervised IRA price if appropriately supervised staff members of the community residence have delivered at least four documented community residential habilitative services to an individual and that individual was enrolled for at least 22 days in the calendar month.

(d) Compliance. For the period from January 1, 2010 through August 1, 2010, a supervised community residence will be considered to have met the requirements in this subdivision for countable service days for a half month supervised IRA price if appropriately supervised staff members of the community residence have delivered at least two documented community residential habilitative services to an individual and that individual was enrolled for at least 11 days in the calendar month.

(4) Effective January 1, 2010, Supportive Community Residences Reimbursement-- supportive IRA price.

(i) Effective January 1, 2010 the calculation of reimbursement for supportive community residences shall be consolidated with the calculation of reimbursement for supportive IRAs, if any, as follows:

(a) For each provider, the total annual allowable residential habilitation, and room, board and protective oversight costs exclusive of property in effect on December 31, 2009 for all supportive community residences shall be combined with the total allowable residential habilitation, and room, board and protective oversight costs exclusive of property in effect on December 31, 2009 for all supportive IRAs, if any, in order to establish annual aggregate gross reimbursable operating costs.

(c) The total annual capital reimbursement level supdated pursuant to paragraph (7) of this subdivision for January 1, 2010 for all supportive community residences and pursuant to section 686.13(k)(1)(vi) of this Title for January 1, 2010 for all supportive IRAs, if any, shall be combined into an aggregate annual amount and added to the result in clause (b) of this subparagraph.

(e) The result in clause (d) of this subparagraph shall be divided by 12 and then divided by the total certified capacities of these sites less any certified temporary use bed(s) to determine the uniform monthly supportive IRA price that shall be used to reimburse supportive community residence and supportive IRA facilities. This combined price will be referred to as the supportive IRA price.

(ii) Countable service days.

(a) The full month supportive IRA price shall be paid for services provided to an individual who meets the enrollment requirement in subparagraph (5)(i) of this subdivision and who receives face-to-face residential habilitation services in accordance with the individual's ISP and community residential habilitation plan on four separate days of the 22 days of the enrollment requirement. No more than two services may be counted in a week. Services provided on these four days must be initiated, delivered, or concluded at the site. These are known as countable service days.

(b) One-half of the full month supportive IRA price shall be paid for services provided to an individual who meets the enrollment requirement in subparagraph (5)(ii) of this subdivision and who receives face-to-face residential habilitation services in accordance with the individual's ISP and community residential habilitation plan on two separate days of the 11 days of the enrollment requirement. No more than one service may be counted in a week. Services provided on these two days must be initiated, delivered, or concluded at the site. These are known as countable service days.

(5) Enrollment requirement for individuals enrolled in a supervised or supportive community residence.

(i) For the provider to be paid a full month supervised IRA price, the individual must be enrolled in the provider's supervised community residence program for a minimum of 22 days in the calendar month; to be paid a full month supportive IRA price, the individual must be enrolled in the provider's supportive community residence program for a minimum of 22 days in the calendar month.

(ii) For the provider to be paid a one-half month supervised IRA price, the individual must be enrolled in the provider's supervised community residence program for a minimum of 11 days in the calendar month; to be paid a one-half month supportive price, the individual must be enrolled in the provider's supportive community residence program for a minimum of 11 days in the calendar month.

(6) Standards for countable service days.

(i) In computing the countable service days, the provider cannot include days that the individual is in a hospital, nursing home, ICF/DD or other certified, licensed or government funded residential setting.

(ii) The day the individual is admitted or discharged from one of the other residential settings listed in subparagraph (i) of this paragraph may be a countable service day if, on that day, community residence staff deliver residential habilitation services to the individual at the community residence.

(iii) For supervised community residences only: in determining countable service days the provider may include days when an individual is away from the community residence, for purposes such as vacations and visits with family or friends, only when staff from the individual's community residence deliver and document services to that individual that are similar in scope, frequency and duration to the residential habilitation services typically delivered to the individual at the community residence.

(iv) The provisions of this paragraph notwithstanding, days when all individuals of the community residence are relocated due to an emergency or other conditions which necessitate relocation for the health and safety of those individuals may be considered as countable if:

(a) the relocation is reported to and approved by OPWDD; and

(b) staff regularly assigned to the community residence continue to deliver and document residential habilitation services that are similar in scope, frequency and duration to those typically delivered to the individuals at the certified site.

(v) Services provided on countable service days must be documented. On any countable service day there must be documentation of at least one residential habilitation service delivered to the person by community residence staff on that day.

(7) The capital component of the community residence price shall be equal to the amount of total allowable annual property, fixed equipment, and start-up costs pursuant to section 686.13(b)(3) and Subpart 635-6 of this Title divided by 12 and then divided by the total certified capacities of these sites less any certified temporary use bed(s). At the onset of each price period, OPWDD shall review the capital component for allowable material changes and if said changes conform to the requirements of section 686.13(b)(3) and Subpart 635-6 of this Title, the capital component shall be revised to reflect said changes.

(8) Total reimbursable costs derived through the application of the methodologies described in this subdivision shall be trended as follows:

(i) For providers reporting as Region I providers in operation on June 30th, the appropriate trend factor shall be applied to the allowable operating costs, exclusive of property, used to establish the price in effect on June 30th. That trend factor is 2.08 percent to trend June 30, 2010 costs to 2010-2011. Retention of the proceeds attributable to the application of the trend factor increase shall be contingent upon the provider reporting the use of the funds in the form and format specified by the commissioner.

(ii) For providers reporting as Region II or Region III providers in operation on December 31st, the appropriate trend factor shall be applied to the allowable operating costs, exclusive of property, used to establish the price in effect on December 31st except that for calendar year 2010, the initial price exclusive of property in effect on January 1, 2010 shall be trended. From February 1, 2010 to December 31, 2010, facilities shall be reimbursed operating costs that result in a full annual trend factor of 2.08 percent for the calendar year price period. The trend factor in effect for the price period ending December 31, 2010 shall be deemed to be the 2.08 percent full annual trend. Retention of the proceeds attributable to the application of the trend factor increase shall be contingent upon the provider reporting the use of the funds in the form and format specified by the commissioner.

(9) The price as computed in accordance with this subdivision shall be offset by rent as determined in accordance with section 686.13(c) of this Title. For community residences, the rent allowance shall be the SSI per diem level as follows:

(i)	NYC, Suffolk, Nassau, Westchester Counties	$25.38 per day
Rest of State	$24.39 per day
(ii)	For calendar year 1994: NYC and Nassau, Suffolk, and Westchester Counties	$25.68 per day
Rest of State	$24.69 per day
(iii)	For calendar year 1995: NYC and Nassau, Suffolk, and Westchester Counties	$25.97 per day
Rest of State	$24.99 per day
(iv)	For calendar year 1996: NYC and Nassau, Suffolk, and Westchester Counties	$26.27 per day
Rest of State	$25.28 per day
(v)	For calendar year 1997: NYC and Nassau, Suffolk, and Westchester Counties	$26.63 per day
Rest of State	$25.64 per day
(vi)	For calendar year 1998: NYC and Nassau, Suffolk, and Westchester Counties	$26.89 per day
Rest of State	$25.91 per day
(vii)	For calendar year 1999: NYC and Nassau, Suffolk, and Westchester Counties	$27.06 per day
Rest of State	$26.07 per day
(viii)	For calendar year 2000: NYC and Nassau, Rockland, Suffolk, and Westchester Counties	$27.28 per day
Rest of State	$26.30 per day
(ix)	For calendar year 2001: NYC and Nassau, Rockland, Suffolk, and Westchester Counties	$27.81 per day
Rest of State	$26.82 per day
(x)	For calendar year 2002: NYC and Nassau, Rockland, Suffolk, and Westchester Counties	$28.60 per day
Rest of State	$27.60 per day
(xi)	For calendar year 2003: NYC and Nassau, Rockland, Suffolk, and Westchester Counties	$28.76 per day
Rest of State	$27.76 per day
(xii)	For calendar year 2004: NYC and Nassau, Rockland, Suffolk, and Westchester Counties	$29.07 per day
Rest of State	$28.07 per day
(xiii)	For calendar year 2005: NYC and Nassau, Rockland, Suffolk, and Westchester Counties	$29.47 per day
Rest of State	$28.47 per day
(xiv)	For calendar year 2006: NYC and Nassau, Rockland, Suffolk, and Westchester Counties	$30.10 per day
Rest of State	$29.10
(xv)	For calendar year 2007: NYC and Nassau, Rockland, Suffolk, and Westchester Counties	$30.63 per day
Rest of State	$29.63
(xvi)	For calendar year 2008: NYC and Nassau, Rockland, Suffolk, and Westchester Counties	$31.00 per day
Rest of State	$30.00 per day
(xvii)	For calendar year 2009: NYC and Nassau, Rockland, Suffolk, and Westchester Counties	$31.97 per day
Rest of State	$30.97 per day
(xviii)	Effective January 1, 2010: NYC and Nassau, Rockland, Suffolk, and Westchester Counties	$31.97 per day
Rest of State	$30.97 per day
(xix)	Effective January 1, 2012: NYC and Nassau, Rockland, Suffolk, and Westchester Counties	$32.60 per day
Rest of State	$31.60 per day
(xx)	Effective January 1, 2013: NYC, Nassau, Rockland, Suffolk, and Westchester Counties	$32.90 per day
Rest of State	$31.90 per day
(xxi)	Effective January 1, 2014: NYC, Nassau, Rockland, Suffolk, and Westchester Counties	$33.20 per day
Rest of State	$32.20 per day
(xxii)	Effective January 1, 2015: NYC, Nassau, Rockland, Suffolk, and Westchester Counties	$1,005 per month
Rest of State	$975 per month

The commissioner may make adjustments to the offset based on the actual contribution of the persons in residence. The agency must request this adjustment in writing to the commissioner. This request must be made within one year of the close of the price period in question.

(10) The price as computed in accordance with this subdivision for a community residence of 16 or fewer beds shall be offset as follows:

(i) Supervised community residences:

(a) Effective January 1, 2010, the offset shall be $1,404 (or a prorated portion thereof for facilities which opened after April, 2009) and beginning January 1, 2010, $156 per month.

(b) Effective October 1, 2010, the offset shall be $200 per month.

(c) Effective January 1, 2014, the offset shall be $189 per month.

(d) The total amount received by a provider for the calendar year 2014 will also include the amount that the provider would have received if the offset for the period November 1, 2013 to December 31, 2013 had been $189 per month per individual instead of $200 per month per individual.

(e) Effective January 1, 2015, the offset shall be $194 per month.

(f) Effective January 1, 2018 through December 31, 2018, the offset shall be $191.50 per month. Effective January 1, 2019, the offset shall be $192 per month.

(ii) For supportive community residences the offset shall be $1,134 (or a prorated portion thereof for facilities which opened after April, 2009) and beginning January 1, 2010, $126 per month. Beginning January 1, 2018 through December 31, 2018 the offset shall be $161 per month. Ef- fective January 1, 2019, the offset shall be $154 per month.

(11) Effective October 1, 2010, for providers in all regions there shall be an efficiency adjustment applied to the IRA price for residential habilitation services provided in supervised IRAs and supervised community residences.

(i) There shall be three components of the efficiency adjustment as follows:

(a) Non-personal services (NPS). Providers which demonstrate a level of NPS at or above the benchmark described in subclause (2) of this clause shall be subject to a reduction in the supervised IRA price.

(1) For the purposes of this efficiency adjustment, NPS includes site other than personal services (OTPS), transportation, and expensed equipment contained in the supervised IRA price. NPS does not include personal services, contracted personal services, fringe benefits, total program administration, total agency administration, health care adjustments (HCA), capital costs and State paid items.

(2) The benchmark is predicated on the value of all NPS contained in a community residence provider's supervised IRA price in effect on June 30, 2008 for Region I reporting providers and on December 31, 2007 for Region II and Region III reporting providers. This value is expressed as a percentage of the total operating costs including transportation and HCA but exclusive of capitalized property contained in a provider's supervised IRA price on the respective date. Alternatively, for community residence providers which did not operate supervised IRAs at these times, the NPS costs and the total operating costs shall be extracted from the CFR filed for the period ending either on December 31, 2007 or June 30, 2008 as appropriate in order to calculate a comparable value. The percentages for each provider offering residential habilitation services are ranked ordinally. OPWDD has established the benchmark at the 15th percentile. All providers below the 15th percentile in the ordinal ranking are exempt from the NPS reduction.

(3) For all providers ranked at or above the benchmark, the reduction shall be applied to NPS operating costs contained in the supervised IRA price in effect on October 1, 2010.

(4) The percentage reduction shall be 18 percent.

(b) Administration. Providers which demonstrate a level of administration contained in the supervised IRA price at or above the benchmark described in subclause (2) of this clause shall be subject to a reduction in the supervised IRA price.

(1) For the purposes of this efficiency adjustment administration includes total program administration and total agency administration contained in a provider's supervised IRA price. Both total program administration and total agency administration include components representing personal services, administrative contracted services, administrative OTPS and administrative fringe benefits.

(2) The benchmark is predicated on the combined value of total program administration and total agency administration contained in a community residence provider's supervised IRA price in effect on June 30, 2008 for Region I reporting providers and on December 31, 2007 for Region II and Region III reporting providers. This value is expressed as a percentage of the total operating costs including transportation and HCA but exclusive of capitalized property contained in a provider's supervised IRA price on the respective date. Alternatively, for community residence providers which did not operate supervised IRAs at these times, the administrative costs and the total operating costs shall be extracted from the CFR filed for the period ending either on December 31, 2007 or June 30, 2008 as appropriate in order to calculate a comparable value. The percentages for each provider offering residential habilitation services are ranked ordinally. OPWDD has established the benchmark at the 15th percentile. All providers below the 15th percentile in the ordinal ranking are exempt from the administration reduction.

(3) For all providers ranked at or above the benchmark, the reduction shall be applied to total program administration and total agency administration operating costs contained in the supervised IRA price in effect on October 1, 2010.

(4) The percentage reduction shall be five percent.

(c) Residual adjustment. For providers subject to either one or both of the reductions described in clauses(a) and (b) of this subparagraph, a residual adjustment shall be implemented as described in subclauses (1) and (2) of this clause. The residual adjustment shall confine the aggregate effect of this efficiency adjustment and an offset factor of $44 per unit of service to a range between a minimum of 1.5 percent and a maximum of 3.5 percent of the total supervised IRA price on October 1, 2010.

(1) For providers which would realize a reduction in the total supervised IRA price less than 1.5 percent after combining the effects of clauses (a) and (b) of this subparagraph and $44 per unit of service, the total efficiency adjustment shall be increased to 1.5 percent of the total supervised IRA price in effect on October 1, 2010.

(2) For providers which would realize a reduction in the total supervised IRA price greater than 3.5 percent after combining the effects clauses (a) and (b) of this subparagraph and $44 per unit of service, the total efficiency adjustment shall be held to 3.5 percent of the total supervised IRA price in effect on October 1, 2010.

(ii) New sites. To the extent that a provider is subject to this efficiency adjustment, a corresponding correction to approved budgeted costs for new sites shall be made so that the percentage offsets in effect before inclusion of the new site18 percent NPS, 5 percent administration and any residual adjustment theretoshall be preserved when the new site's budgeted costs are included in the calculation of the supervised IRA price.

(iii) For purposes of requesting a price adjustment, the effects of this efficiency adjustment resulting from the NPS and administrative reductions as described in clauses (i)(a) and (b) of this paragraph as well as any subsequent residual adjustment thereto per clause (i)(c) of this paragraph shall not be construed as a basis for loss. In processing a price adjustment, any revised price will be offset by the monetary effects of the NPS and administrative reductions including the residual adjustment thereto, if any.

(iv) The commissioner at his or her discretion may waive all or a portion of the NPS reduction as described in clause (i)(a) of this paragraph and/or the administrative reduction as described in clause (i)(b) of this paragraph for a provider upon the provider demonstrating that the imposition the reduction(s) would jeopardize the continued operation of the IRA(s) and/or community residence(s).

(12) Effective July 1,2011, supportive IRA prices shall be revised to reflect a two percent reduction to the operating components of the price in effect on June 30, 2011. For the purposes of a vacancy price adjustment, the effects of this reduction shall not be construed as a basis for loss.

(13) Effective July 1,2011, pursuant to section 635-10.5(b)(18)(iv) of this Title, providers shall be subject to the supervised IRA price reductions except for those providers specifically excluded by the exemptions described in that subparagraph.

(14) The price determined through the application of this subdivision may be appealed. Such appeal shall be pursuant to section 686.13(i) of this Title, except that the determination following such first level appeal process shall be the commissioner's final decision.

(15) The prices determined in accordance with this subdivision shall not be considered final unless approved by the director of the Division of the Budget.

(c)Employee healthcare enhancement (HCE).

(1) Providers are eligible to have additional funding included in their rate if they submitted a completed 2005 OPWDD survey on health care benefits for all full-and part-time employees.

(2) Based on a survey of providers, OPWDD determined a benchmark of health care benefits offered to employees by providers. In September 2005, OPWDD notified those providers if their health care benefits were at, above, or below the benchmark.

(3) Providers whose employee health care benefits are below the benchmark may apply to OPWDD for additional funding to be effective January 1, 2006 as follows:

(i) For providers which reported on the survey that no health care benefits are offered, OPWDD determined an allocation for each provider based on the total number of employees reported multiplied by $2,500, except that if there are any employees who were reported on the survey and to whom the provider chooses not to offer this funding, the allocation based on the total number of employees reported will be reduced by the number of excluded employees reported multiplied by $2,500. These funds must be used to establish employee health care benefits or to reduce employee out-of-pocket health-related expenses.

(ii) For providers which reported on the survey that employee health care benefits are offered to some or all employees, OPWDD determined an allocation for each provider based on the total number of employees reported multiplied by $325, except that if there are any employees who were reported on the survey and to whom the provider chooses not to offer this funding, the allocation based on the total number of employees reported will be reduced by the number of excluded employees reported multiplied by $325. These funds must be used to enhance employee health care benefits or to reduce employee out-of-pocket health- related expenses.

(4) Effective January 1, 2006, providers may receive additional funding that would have been received during the period of April 1, 2004 through December 31, 2005 if the funding described in paragraph (3) of this subdivision had been paid. Providers whose employee health care benefits are below the benchmark may apply to OPWDD for additional funding as follows:

(i) For providers which reported on the survey that no employee health care benefits are offered, no additional funding for the period of April 1, 2004 through December 31, 2005 is available.

(ii) For providers which reported on the survey that employee health care benefits are offered to some or all employees, OPWDD determined an allocation for each provider based on the total number of employees reported multiplied by $325, except that if there are any employees who were reported on the survey and to whom the provider chooses not to offer this funding, the allocation based on the total number of employees reported will be reduced by the number of excluded employees reported multiplied by $325. The annual allocation of $325 will be adjusted for the 21-month period of April 1, 2004 through December 31, 2005. These funds must be used to reimburse health care expenses paid by employees.

(5) In order to receive an allocation described in paragraph (3) or (4) of this subdivision, the provider must send to OPWDD a completed written application submitted in the form and format specified by the commissioner.

(6) Funding is contingent upon OPWDD's approval of the application. OPWDD will base its decision on whether the application is complete; whether it complies with the requirements of this subdivision; and whether the application recognizes the provider's lowest paid employees. OPWDD may request additional information and/or documentation as needed before approving the application.

(7) Payment of the allocation described in paragraph (3) or (4) of this subdivision shall be subject to the provider submitting a resolution by its governing body that funds received will be used to implement the plans described in the provider's approved application. To receive the allocation, the provider must submit the resolution and the commission may approve it.

(8) A rate revised by OPWDD pursuant to this subdivision shall not be considered final unless and until approved by the State Division of the Budget.

(d) Employee healthcare enhancement II.

(1) Effective January 1, 2007 providers may be eligible to receive funding for the healthcare enhancement II (HCE II). Providers must use these funds to establish or enhance employee health care benefits or to reduce employee out of pocket health care expenses.

(2) In order to receive funding described in this subdivision the provider must have sent to OPWDD a completed written application by July 31, 2006, unless this deadline was extended by the commissioner.

(3) Funding is contingent upon OPWDD's approval of the application. OPWDD shall decide whether to approve the application based on whether the application is complete; whether it complies with the requirements of this subdivision; and whether the application recognizes the provider's lowest paid employees. OPWDD may request additional information and/or documentation, or revisions to an application, before approving the application.

(4) Funding for HCE II is available at either $2,500 per employee or $425 per employee, as follows:

(i) The annual allocation at the $2,500 level is determined by OPWDD based on the total number of employees included in the provider's approved HCE II application multiplied by $2,500. Funding at the $2,500 level is available to providers which:

(a) submitted an application for HCE II funding at the $2,500 level; and

(b) do not offer health care benefits; and

(c) were insufficiently funded for health care, as determined by OPWDD. Affected providers were notified by OPWDD of this determination.

(ii) The annual allocation at the $425 level is determined by OPWDD based on the total number of employees included in the provider's approved HCE II application multiplied by $425. Funding at the $425 level is available to providers which:

(a) offer healthcare benefits to some or all employees and submitted an application for HCE II funding at the $425 level; or

(b) applied for HCE II funding at the $2,500 level but received funding at the $2,500 per employee level pursuant to subdivision (c) of this section; or

(c) submitted an application at the $2,500 level but have sufficient funding for health care, as determined by OPWDD. Affected providers were notified by OPWDD of this determination.

(5) The application submitted to OPWDD shall include plans for the expenditure of the HCE II allocation in conformance with this subdivision. Such HCE II plans shall assure that all employees included in the application are entitled to some benefit from HCE II, although the value per employee may be lesser or greater than $2,500 or $425 per employee. Higher paid employees whose earnings exceed a salary cap established by the provider maybe excluded from receipt of any HCE II funds if these funds are reallocated to lower paid staff.

(6) A provide approved to receive HCE II funding pursuant to subparagraph (4)(ii) of this subdivision shall receive an amount that would have been paid if the HCE II initiative had been implemented April 1, 2006.

(7) Payment of the HCE II funding shall be subject to the provider submitting a resolution by its governing body that funds received shall be used to implement the plans described in the provider's approved application. To receive the allocation the provider must submit the resolution and the commissioner must approve it.

(8) A rate revised by OPWDD pursuant to this subdivision shall not be considered final unless and until approved by the State Division of the Budget.

(e)Employee healthcare enhancement III.

(1) Effective January 1, 2008 providers may be eligible to receive funding for the healthcare enhancement III (HCE III) included in their fee.

(2) Funding. Based on a survey of providers' historical data as of January 1, 2005, OPWDD determined a benchmark of health care benefits offered to employees by providers. Prior to September 30, 2007, OPWDD notified those providers which OPWDD deemed eligible for HCE III funding at the benchmark level. Providers deemed eligible for HCE III funding below the benchmark level were mailed applications with instructions.

(i) Providers deemed eligible for HCE III funding at the benchmark level shall receive an amount equaling 1.0 percent of the operating costs exclusive of any HCE III component contained in the fee in effect on January 1,2008 net of any funding provided pursuant to subparagraph (iii) of this paragraph. Providers which also operate programs and services eligible for the 3.0 percent funding level increase under this Chapter may not receive this 1.0 percent funding level increase unless they have declined the 3.0 percent funding level increase in the eligible programs and services. Providers which receive this 1.0 percent funding level increase may not apply for employee health care funding described in subparagraph (ii) of this paragraph.

(ii) Providers deemed eligible for HCE III funding below the benchmark level may apply to OPWDD to receive an amount equaling 1.0 percent of the operating costs exclusive of any HCE III component contained in the fee in effect on January 1, 2008 net of any funding provided pursuant to subparagraph (iii) of this paragraph.

(a) Providers shall use these funds to establish or enhance employee health care benefits and/or to reduce employee out-of-pocket health care expenses and/or to offset the portion of premium increases paid by the provider which exceeds the portion of the trend factor or COLA applicable to those premium increases. Providers shall assure that benefits resulting from this additional funding recognize their lower paid employees.

(b) In order to receive the funding described in this subparagraph, the provider must have sent to OPWDD a completed application and attestation received or postmarked by October 1, 2007, unless the deadline was extended by the commissioner. In the application and attestation, the provider must have indicated its intended use of the funds; agreed to obtain a resolution by December 31, 2007 from its governing body authorizing such use; and agreed to maintain on file the resolution as well as records detailing the distribution of HCE III funds.

(c) Funding is contingent upon OPWDD's approval of the application and attestation. OPWDD shall decide whether to approve the application and attestation based on whether it is complete and conforms to the requirements of this subdivision. OPWDD may request additional information or documentation before approving the application and attestation.

(iii) A provider approved to receive HCE III funding pursuant to subparagraph (i) or (ii) of this paragraph shall receive an amount that would have been paid if the HCE III initiative had been implemented April 1, 2007.

(3) A fee revised by OPWDD pursuant to this subdivision shall not be considered final unless and until approved by the State Division of the Budget.

(f)Health care adjustments (HCA) IV and V.

(1) Effective November 1, 2009, providers may be eligible to receive funding for HCA IV and HCA V included in their fees.

(2) Benchmark providers and non-benchmark providers. Based on a survey of providers' historical data as of January 1, 2005, OPWDD determined a benchmark of health care related benefits offered to employees by providers. Prior to October 31, 2007, OPWDD notified those providers which OPWDD deemed eligible for HCE III funding at the benchmark level. Providers eligible for HCE III funding at the benchmark level are eligible for HCA IV and HCA V funding at the benchmark level. All other providers are eligible for HCA IV and HCA V funding below the benchmark level.

(3) Funding.

(i) Providers eligible for HCA IV and HCA V funding at the benchmark level.

(a) The HCA IV and HCA V funding levels for benchmark providers shall be 1.0 percent of the allowable operating costs used in establishing the provider specific fees. Each adjustment shall be applied sequentially to effect compounding of the adjustments.

(b) Providers which also operate programs and services eligible for the 3.0 percent funding level increase under this Chapter may not receive this 1.0 percent funding level increase unless they have declined the 3.0 percent funding level increase in the eligible programs and services. Providers which receive this 1.0 percent funding level increase may not apply for employee health care funding described in subparagraph (ii) of this paragraph.

(ii) Providers eligible for HCA IV and HCA V funding below the benchmark level may apply to OPWDD to receive this funding.

(a) The HCA IV and HCA V funding levels for non-benchmark providers shall be 1.0 percent of the allowable operating costs used in establishing the provider specific fees. Each adjustment shall be applied sequentially to effect compounding of the adjustments.

(c) In order to receive HCA IV and HCA V funds, the provider must have sent to OPWDD a completed application and attestation received or postmarked no later than September 11, 2009 unless the deadline was extended by the commissioner. In the application and attestation, the provider must have indicated its intended use of the funds; agreed to obtain a resolution by October 31, 2009 from its governing body authorizing such use; and agreed to maintain on file the resolution as well as records detailing the distribution of HCA IV and HCA V funds.

(d) Funding is contingent upon OPWDD's approval of the application and attestation based on whether it is complete and conforms to the requirements of this subdivision. OPWDD may request additional information or documentation before approving the application and attestation.

(4) Catch-up provisions. Effective November 1, 2009, benchmark providers which do not receive any HCA funding at the 3.0 percent level and non-benchmark providers with approved applications shall be eligible to receive additional funding for HCA IV in an amount that would have been received for the period of April 1, 2008 through October 31, 2009 if the 1.0 percent increment had been implemented on April 1, 2008. Effective November 1, 2009, benchmark providers which do not receive any HCA funding at the 3.0 percent level and non-benchmark providers with approved applications shall be eligible to receive additional funding for HCAV in an amount that would have been received for the period of April 1, 2009 through October 31, 2009 if the 1.0 percent increment had been implemented on April 1, 2009. Nothing in this paragraph shall entitle a provider to receive payment for services which have not been provided.

(5) Consolidation of HCE and HCA funds effective January 1, 2010.

(i) Effective January 1, 2010, the health care adjustments (HCE I through III and HCA IV and HCA V) included in the price shall be consolidated into a single discrete amount. For purposes of determining this amount, OPWDD shall combine the HCE I through III and HCA IV and HCA V components contained in the initial fee in effect on January 1, 2010. OPWDD shall use this fixed amount as the HCA payment for the fee periods beginning on or after January 1, 2010.

(ii) Effective January 1, 2010, with the consolidation of the health care adjustments, non-benchmark providers shall use HCE I, II and III funds first to either offset health care premium increases and/or to maintain benefits that were established and funded with previous HCE I, II and III receipts. Remaining funds shall be used to establish or enhance employee health care related benefits and/or to reduce employee out-of-pocket health care related expenses. Non-benchmark providers shall continue to use HCA IV and V funds first to offset health care premium increases. Remaining funds shall be used to establish or enhance employee health care related benefits and/or to reduce employee out-of-pocket health care related expenses. Health care enhancement/adjustment funds included in prices for services delivered on or after July 6, 2011 shall be used by non-benchmark providers for the purposes described in this subparagraph and/or for any other options that continue and/or enhance existing health care benefits and/or improve the recruitment and/or retention of the provider's lower paid employees. However, in using these funds accordingly, non-benchmark providers may establish which priorities serve the needs of such employees. Additionally, on July 6, 2011, health care enhancement/adjustment funding shall be included in the reimbursable cost category of fringe benefits in the price.

(6) Provider's distribution of HCA IV and HCA V funds is subject to audit to ensure conformity with the requirements of this subdivision and distribution of funds consistent with the provider's approved application.

(g) Health care adjustment (HCA) VI.

(1) Effective October 1, 2010, providers may be eligible to receive funding for HCA VI included in their prices.

(2) Benchmark providers and non-benchmark providers. Based on a survey of providers' historical data as of January 1, 2005, OPWDD determined a benchmark of healthcare related benefits offered to employees by providers. Prior to October 31, 2007, OPWDD notified those providers which OPWDD deemed eligible for health care enhancement (HCE) III funding at the benchmark level. These providers are "benchmark providers" and are eligible for HCA VI funding at the benchmark level. All other providers ("non benchmark providers") are eligible for HCA VI funding below the benchmark level.

(3) Funding.

(i) Providers eligible for HCA VI funding at the benchmark level.

(a) The HCA VI funding level for benchmark providers shall be 3.0 percent of the allowable operating costs used in establishing the provider specific price in effect on April 1, 2010.

(b) Alternatively, a provider eligible for HCA VI funding at the benchmark level shall receive a 1.0 percent funding increase in all its programs and services eligible under this Chapter if the provider notified OPWDD by August 13, 2010 in writing that it was declining the 3.0 percent funding level increase and electing instead to receive a 1.0 percent funding level increase in all its programs and services eligible under this Chapter.

(c) Providers eligible for funding at the benchmark level may not apply for HCA VI funding described in subparagraph (ii) of this paragraph.

(ii) Providers eligible for HCA VI funding below the benchmark level may apply to OPWDD to receive this funding.

(a) The HCA VI funding level for non-benchmark providers shall be 1.0 percent of the allowable operating costs used in establishing the provider specific price in effect on April 1, 2010.

(b) Providers shall use these funds first to offset health care premium increases. Remaining funds shall be used to establish or enhance employee health care related benefits and/or to reduce employee out-of-pocket health care related expenses. Health care adjustment funds included in prices for services delivered on or after July 6, 2011 shall be used by non-benchmark providers for the purposes described in this clause and/or for any other options that continue and/or enhance existing health care benefits and/or improve the recruitment and/or retention of the provider's lower paid employees. However, in using these funds accordingly, non-benchmark providers may establish which priorities serve the needs of such employees. Additionally, on July 6, 2011, health care adjustment funding shall be included in the reimbursable cost category of fringe benefits in the price.

(c) In order to receive the HCA VI funds, the provider must have sent to OPWDD a completed application and attestation received or postmarked no later than August 13, 2010 unless the deadline was extended by the commissioner. In the application and attestation, the provider must have indicated its intended use of the funds; agreed to obtain a resolution by September 30, 2010 from its governing body authorizing such use; and agreed to maintain on file the resolution as well as records detailing the distribution of HCA VI funds.

(4) Effective October 1, 2010, benchmark providers shall be eligible and non-benchmark providers with approved applications shall be eligible to receive additional funding for HCA VI in an amount that would have been received if the health care adjustment VI had been in effect for the period of April 1, 2010 through September 30, 2010. Nothing in this paragraph shall entitle a provider to receive payment for services which have not been provided.

(5) Providers' distribution of HCA VI funds is subject to audit to ensure conformity with the requirements of this subdivision and distribution of funds consistent with the provider's approved application.

(h) All fees, and any corrections to fees shall not be final, unless approved by the Director of the Division of the Budget.

(i)Reimbursement for persons eligible for medical assistance.

(1) In order to receive medical assistance reimbursement for community residential habilitation services, the facility must meet the requirements of section 671.1 of this Part, and:

(i) ensure that all the requirements of section 671.6 of this Part are satisfied; and

(ii) ensure that persons for whom medical assistance reimbursement is requested, are eligible for participation in the medical assistance program.

(2) Reimbursement shall be available only for community residential habilitation services identified in section 671.5 of this Part which are set forth in the written plans of services of the persons for whom reimbursement is claimed.

(j)Reimbursement for persons ineligible for medical assistance.

(1) In order to receive other reimbursement for community residential habilitation services, the facility must meet the requirements of Subpart 635-12 of this Title, and section 671.1(d) of this Part, and ensure that all the requirements of section 671.6 of this Part are satisfied.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 671.7

Amended, New York State Register March 26, 2014/Volume XXXVI, Issue 12, eff. 3/26/2014

Amended New York State Register March 25, 2015/Volume XXXVII, Issue 12, eff. 3/25/2015

Amended New York State Register October 28, 2015/Volume XXXVII, Issue 43, eff. 11/1/2015

Amended New York State Register April 20, 2016/Volume XXXVIII, Issue 16, eff. 4/20/2016

Amended New York State Register September 21, 2016/Volume XXXVIII, Issue 38, eff. 9/21/2016

Amended New York State Register March 28, 2018/Volume XL, Issue 13, eff. 3/28/2018