N.Y. Comp. Codes R. & Regs. tit. 14 § 680.12

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

Section 680.12 - Rate setting and financial reporting

(a) For the purposes of this section the following definitions shall apply:

(1)Specialty hospital or facility shall mean that program and site for which OPWDD has issued an operating certificate, pursuant to Mental Hygiene Law article 16, to operate as a specialty hospital, and for which the New York State Department of Social Services has issued a Medicaid provider agreement.

(2)Provider shall mean the individual, corporation, partnership or other organization to which the OPWDD has issued an operating certificate, pursuant to Mental Hygiene Law, article 16, to operate a specialty hospital, and to which the New York State Department of Social Services has issued a Medicaid provider agreement for such facility.

(3)Alternate care determined individual or ACD individual shall mean an individual who has been determined not to require specialty hospital care after completion of an independent utilization review, pursuant to section 680.9 of this Part.

(4)A newly certified facility shall mean a facility which has been in operation less than two years and has not yet submitted a cost report which covers a full 12 months of operation for any rate period January 1st to December 31st or any other 12-month period designated by the commissioner according to section 680.12(b)(1)(ii) (b) of this Part.

(5)Actual cost shall mean the costs that were audited and stepped-down by OPWDD or its agent for the specialty hospital and which are taken from the financial reports filed annually in accordance with section 680.12(b)(1)(ii) of this Part and which cover a full 12-month period of operation beginning 24 months prior to the effective date of the rate period in question. For the rate period from June 10, 1988 to December 31, 1988, as stated in section 680.12(d)(3) of this Part, the actual costs defined in the preceding sentence shall be taken from the annual financial information filed by the provider for the calendar year 1985 with Blue Cross/Blue Shield of Greater New York.

(6)Budget costs shall man the financial information submitted by a provider in accordance with section 680.12(b)(1)(i) of this Part.

(7)Reimbursable costs shall mean those actual or budget costs which are determined, based on a line item review/desk audit process by OPWDD or Blue Cross/Blue Shield of Greater New York, to be allowable in accordance with section 680.12(d)(8) of this Part.

(8)Operating costs shall mean a facility's costs, other than capital costs or start-up costs, which include personal service costs, administrative and general services costs, and other than personal service (OTPS) costs.

(i) Personal service costs include costs such as salaries, fringe benefits and accrued vacation costs for employees of the specialty hospital; and costs of persons performing services under contract to the specialty hospital. Services refers to the provisions of routine and ancillary care of individuals admitted to the specialty hospital in accordance with the provisions of this Part.

(ii) Administrative and general service costs refer to departments, divisions or other units which are operated for the benefit of the specialty hospital as a whole, and includes activities such as management, housekeeping, laundry, dietary services and operation and maintenance of grounds and physical plant.

(iii) OTPS costs include, but are not limited to, the costs of items such as food, minor equipment, supplies and materials, travel, medications and utilities.

(9)Capital costs shall mean property costs subject to the limitations contained in this section, Subpart 635-6 of this Title and Medicare principles of reimbursement, except that costs of ownership of real property shall not include principal or provider equity.

(b) Reporting requirements.

(1) Financial reports shall include the following:

(i) Budget reports.

(a) Each provider intending to operate a specialty hospital shall include budget reports in its application to receive an operating certificate.

(b) The budget report shall cover a 12-month period from January 1st to December 31st unless another time frame is specified by the commissioner.

(c) If a facility has undergone a change in its site specific certified capacity, the commissioner may, at his discretion, request the provider to submit a budget report subject to requirements listed in sections 680.12(b)(1)(i) (b) and 680.12(b)(3)(ii) of this Part.

(ii) Financial and statistical reports.

(a) Each provider that operates a specialty hospital certified by OPWDD shall, on an annual basis, complete and file with the OPWDD and/or Blue Cross/Blue Shield of Greater New York, annual financial reports and related statistical information in the form and format supplied by OPWDD and/or Blue Cross/Blue Shield of Greater New York.

(b) Such report shall cover a 12-month period from January 1st to December 31st, unless another time frame is specified by the commissioner.

(c) Each such report shall be forwarded so that it is received no later than 120 days after the last day of the period which it covers, except as stated in section 680.12(4)(i) and (ii) of this Part.

(d) If a facility has undergone a change in its site specific certified capacity, the commissioner may, at his discretion, request the facility to submit the incremental/decremental cost data associated with the capacity change. Such data shall comply with the requirements of section 680.12(b)(3)(i) of this Part.

(2) Statistical reporting requirements for specialty hospitals shall include, but not be limited to, the following:

(i) Each provider shall submit with its annual financial report, statistical data relevant to program utilization and in the form and format supplied by OPWDD or its agent, Blue Cross/Blue Shield of Greater New York. Such data shall include a roster of individuals and their utilization review status for the financial reporting period in question, a listing of the actual number of service days for the specialty hospital and a listing by individual of the total number of days any individual was on alternate care determination status as defined in section 680.12(a)(3) of this Part. This data will correspond to the identical time period of the financial report.

(ii) Each provider shall, upon the request of OPWDD, submit statistical data relevant to the administration and operation of the program as determined by the commissioner. Such data shall be submitted within the time frames specified in the request.

(3) Requirements for certification of financial reports and related statistical information.

(i) Each provider shall complete the required financial reports in accordance with generally accepted accounting principles, unless other principles are specified by this Part or the Medicare Provider Reimbursement Manual, commonly referred to as HIM-15, published by the U.S. Department of Health and Human Services Health Care Financing Administration (HCFA). The HIM-15 document is available from:

Health Care Financing Administration

Division of Communication Services

Production and Distribution Branch

Room 577, East High Rise Building

6325 Security Boulevard

Baltimore, MD 21207

(ii) The Medicare Provider Reimbursement Manual may be reviewed in person during regular business hours at the:

(a) NYS Department of State, 99 Washington Avenue, Albany, NY 12231; or by appointment at the

(b) NYS Office for People With Developmental Disabilities, Office of Counsel, 44 Holland Avenue, Albany, NY 12229.

(iii) Financial reports information shall be certified for their compliance with section 680.12(b)(3)(i) of this Part the provider's executive director or officer and by an independent licensed public accountant or certified public accountant who is not on the staff of the provider, on the staff of a program operated by the provider, and who has no financial interest in the provider nor is a related party as defined in Subpart 635-99 of this Title; and include a statement of the findings and opinion of the certified public accountant or licensed public accountant.

(iv) Budget reports shall be certified for their fair representation of anticipated expenditures by the provider's executive director or officer.

(4) Failure to file required financial and statistical reports.

(i) The commissioner may grant an extension of time of up to 30 days for filing the required reports if OPWDD receives a written request for an extension from a provider, at least 15 days prior to the initial due date. Such request for extension shall document, in writing, that the provider cannot file the report by the due date for reasons beyond its control, and shall include an explanation of such reasons.

(ii) The commissioner may grant an additional extension of 30 days if the provider applies for an extension in accordance with the procedure stated in section 680.12(b)(4)(i) of this Part. The maximum allowable extension that may be granted will not exceed 60 days in total unless the commissioner, upon investigation, finds that failure to report is beyond the control of the provider and/or enforcement of the reporting time frame requirements would jeopardize the program's operation.

(iii) If a provider fails to file the required reports, on or before the due dates, taking into account any granted extensions, the commissioner may, at his or her discretion, reduce the specialty hospital's existing rate, exclusive of State-paid items, by five percent for a period beginning on the first day of the month following the due date of the required reports and continuing until the last day of the calendar month in which the required information is received.

(iv) In the event that the rate for a specific rate period cannot be developed so that it will be effective on the first day of the rate period, due to the facility's not submitting the required reports by the due date, the rate in existence on the last day of the rate period (i.e., the length of time as determined by the commissioner that an approved rate is valid) prior to the subject rate period, will be in effect until such time as OPWDD can develop a new rate. The rate in existence on the last day of the rate period may be reduced by five percent according to the provisions of section 680.12(b)(4)(iii) of this Part.

(v) When OPWDD develops a new rate for a specialty hospital for which a rate was paid in accordance with section 680.12(b)(4)(iv) of this Part, the rate developed will be effective on the first day of the first month following receipt of the required reports. The commissioner may, at his discretion and based on his finding that the factor(s) causing the delay has/have been corrected, make the rate retroactive to the beginning of the rate period in question if the provider makes such a request within 60 days subsequent to submission of the delinquent report.

(5) Requirements for the revision of financial reports shall include the following:

(i) In the event that OPWDD determines that the required financial report is incomplete, inaccurate, incorrect or otherwise unacceptable, the provider shall have 30 days from the date of its receipt of notification to submit revised financial reports or additional data. Such data or reports shall be certified by the provider's executive director or officer and an independent licensed public accountant or certified public accountant pursuant to the requirements stipulated in section 680.12(b)(3) of this Part.

(ii) If the revised data referred to in section 680.12(b)(5)(i) of this Part are not received within 30 days of the provider's receipt of notification, the facility's existing rate may be reduced in accordance with section 680.12(b)(4)(iii) unless the commissioner has granted an extension pursuant to section 680.12(b)(4)(i) or (ii).

(iii) In the event the provider discovers that the financial reports it has submitted are incomplete, inaccurate or incorrect prior to receiving its new rate, the provider must notify OPWDD that such error exists. The provider will have 30 days from the date such notification is received by OPWDD to submit revised reports or additional data. Such data or report shall meet the certification requirements of the report being corrected. If the corrected data or report are received within a reasonable time before the issuance of the rate, OPWDD shall incorporate the corrected data or report into its computation of the rate without the provider having to file an appeal application. However, OPWDD will not accept the resubmission of a January 1-December 31, 2008 cost report subsequent to January 1, 2011 for the purposes of the calculation of the rate effective July 1, 2011 as described in clause (d)(5)(ii)(f) of this section.

(iv) If the revised data or report referred to in section 680.12(b)(5)(iii) of this Part are not received within the time periods set forth in section 680.12(b)(5)(iii), the facility's existing rate may be reduced in accordance with section 680.12(b)(4)(iii).

(c)Requirements of financial records.

(1) Each provider shall maintain financial records which reflect all expenditures made and revenues received for its operations.

(2) Each provider shall complete and file with the New York State Department of Health and/or its agent, annual financial and statistical report forms supplied by the New York State Department of Health and/or its agent.

(3) The financial records shall include separate accounts for each type of expense and revenue included on the annual budget or annual cost report. Such subaccounts and control accounts as are necessary for effective financial management may be established by the specialty hospital. A separate expense and revenue account shall be established to properly identify the expense and revenues directly and indirectly attributable to ACD individuals.

(4) All such financial records and any related records shall be subject to audit by the commissioner or his agent, the Office of the State Comptroller, the State Department of Social Services and by agencies of the Federal government as provided by law.

(d) Rates of payment made for specialty hospital services rendered to title XIX recipients shall be at the levels set forth in the approved New York Medicaid State Plan. The rates shall be contingent upon Federal financial participation (FPP) and approval.

(e)Audits.

(1) Each provider shall maintain the statistical and financial records which formed the basis of the reports submitted to the commissioner or his agent for six years from the date on which the reports were submitted or due, whichever is later.

(2) All such records shall be subject to audit for a period of six years from the date on which the reports were submitted or due to the commissioner or his agent, whichever is later.

(i) Field audits or desk audits shall be conducted by the commissioner or his agent or the Department of Social Services at a time and place and in a manner to be determined by the commissioner or the DSS.

(ii) The audits may be performed on any financial or statistical records required to be maintained.

(iii) Any finding of an above-described audit shall constitute grounds for recoupment at the discretion of the commissioner, provided that such audit finding relates to the allowable costs, and to the extent that, except as authorized in 18 NYCRR 517.16, the audit finding has been upheld in a decision after a hearing or a hearing has not been requested on such finding.

(iv) The six-year limitation shall not apply in situations in which fraud may be involved or where the provider or an agent thereof prevents or obstructs the commissioner from performing an audit pursuant to this section.

(3) All administrative review (including hearings) of audits conducted to determine allowable Medicaid expenses and offsetting revenues shall be in accordance with 18 NYCRR Part 517.

(4) All administrative review of audits which are conducted by OPWDD, and which are not described in paragraph (3) of this subdivision, shall be in accordance with the following:

(i) At the conclusion of the audit, the provider shall be afforded an opportunity to submit additional documentation to the commissioner. After the receipt and review of such additional documentation, a copy of the audit findings shall, within 120 days, be sent to the provider by certified mail, return receipt requested. In order to have the additional documentation considered, the provider must submit the documentation within the time specified.

(ii) The audit findings shall become final unless, within 30 days of receipt thereof, the provider requests an administrative review of the audit findings.

(iii) Request for administrative review of audit findings shall be sent to the commissioner by registered or certified mail.

(iv) Such requests shall contain a detailed statement of the provider's objections to the findings, along with copies of any documentation the facility wishes to submit.

(v) The provider shall be notified in writing of the determination of those items to which the provider objected, including a statement of the reasons therefor. The audit findings, as adjusted in accordance with the determination after administrative review, shall be final.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 680.12

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

Amended New York State Register June 16, 2021/Volume XLIII, Issue 24, eff. 6/16/2021