N.Y. Comp. Codes R. & Regs. tit. 14 § 841.10

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

Section 841.10 - Medical assistance payments for substance use disorder outpatient programs

(a) Applicability. The provisions of this section are applicable to programs certified or co-certified to provide ambulatory care services provided by the following:

(1) substance use disorder outpatient clinics certified or co-certified pursuant to Part 822 of this Title;

(2) opioid treatment programs providing opioid full agonist treatment medications and certified under Part 822 of this Title;

(3) substance use disorder outpatient rehabilitation programs certified or co-certified pursuant to Part 822 of this Title; and

(4) substance use disorder medically supervised outpatient withdrawal and stabilization services certified under Section 816.8 of this Title; and

(5) integrated outpatient programs certified pursuant to Part 825.

Each program shall contain two peer groups, one upstate and one downstate.

(b) Billable services requirements and limitations must be delivered in accordance with the provisions of the Ambulatory Patient Groups (APG) Clinical and Medicaid Billing Guidance, as incorporated by reference in this Title (hereinafter referred to as the APG Manual), in effect at the time the service(s) was delivered.

(c) Definitions. All applicable definitions and rules covering standardized APG pricing logic for New York State's Medical Assistance program are found at Title 10 NYCRR Part 86-8.

(d) APGs and associated weights.

(1) APGs shall be subject to periodic revision; the most current listing shall be published in the APG Manual available on the Office website.

(2) The Department of Health, in consultation with the office, shall assign weights associated with all CPT and HCPCS procedure codes that can be used to bill under the APG methodology.

The office shall maintain and update a list of weights associated with APGs as published in the "APG Policy and Medicaid Billing Guidance" manual on the OASAS website. Such list may include APGs not specifically associated with addiction outpatient and opioid treatment services, but which may appropriately be billed by providers subject to this Part.

(e) Base Rates. Base rates for addiction outpatient services shall be developed by the Office, and subject to the approval of the Department of Health, in accordance with the following:

(1) Separate base rates shall be established for each peer group. Base rates shall reflect differing regional cost factors, variations in patient population and service delivery, available funding levels, and capital expenditures;

(2) Additional discrete base rates may be developed by the Office for such peer groups as may be established by regulation in this Part; and

(3) Base rates may be periodically adjusted to reflect changes in provider case mix, service costs and other factors as determined by the Office.

(4) All base rates established by the Office shall be published on the Office's website.

(f) System Updating. The following elements of the APG rate-setting system shall be reviewed at least annually, with all changes posted on the New York State Department of Health's website:

(1) The listing of reimbursable APGs and associated weights,

(2) The applicable International Statistical Classification of Diseases and Related Health Problems, as incorporated by reference in this Title (ICD),-10 codes, or subsequent ICD categorization, utilized in the APG software system,

(3) The Applicable CPT/HCPCS codes utilized in the APG software system; and

(4) The APG software system's grouping and pricing logic.

(g) Bundled payment for opioid treatment program (OTP) services.

(1) OASAS will establish regional weekly bundled payments for freestanding opioid treatment programs. Such payments will be available as an alternative to the reimbursement under the Ambulatory Patient Group (APG) fee methodology already in place for OTPs. Programs may bill any given week of OTP service for any given patient under either methodology (APGs or the bundled payment methodology), but not both. The initial bundled fees shall be effective March 16, 2020.

(2) For purposes of these bundled payments there will be two regions, downstate and upstate, with the regional assignment based on program location. The downstate region includes the following counties: New York, Kings, Queens, Richmond, Bronx, Nassau, Suffolk, Westchester, Rockland, Putnam, Dutchess and Orange. The upstate region includes all other counties in the State.

(3) The proposed bundled payments are based on service delivery that mirrors a subset of the Medicare OTP bundles in terms of both services and practitioners, as well as in terms of cost by practitioner for each service. Services covered by the bundled payment include: FDA-approved opioid agonist and antagonist treatment medications, dispensing and administering medications, substance use disorder counseling, individual and group therapy, toxicology testing, intake activities, and periodic assessments.

(4) Weekly fees shall be established in the following rate code classifications:

(i) Methadone Dispensing and/or Counseling - This code covers all of the services listed above for a patient being treated with Methadone.

(ii) Methadone Take Home - This code is billable when the patent has a supply of take-home medication in their possession for the week being billed. It cannot be billed for the same week as the dispensing and/or counseling code.

(iii) Buprenorphine Dispensing and/or Counseling - This code covers all of the services listed above for a patient being treated with Buprenorphine.

(iv) Buprenorphine Take Home - This code is billable when the patent has a supply of take-home medication in their possession for the week being billed. It cannot be billed for the same week as the dispensing and/or counseling code.

(5) The initial bundled payments, effective March 16, 2020, shall be calculated by using the unregionalized Medicare fees for the same services, meaning those fees shall not vary by region.

(6) Effective August 2, 2021 the fees shall be regionalized using the OASAS OTP regional factor of 1.1700 (Downstate relative to Upstate) for freestanding facilities. The regional factor shall be applied on a budget neutral basis assuming that the Downstate region would have 94.41% of the methadone bundle service volume based on a historical volume calculation by the Office. The medication take home fees shall continue to be identical to those used by Medicare, and, as with Medicare, not regionalized.

(7) The Office, may, at its discretion, periodically update the bundled fees using trends, actual cost, Medicare benchmarking, program modeling, or some combination of these techniques - subject to available funding, Federal approval, and NYS Division of the Budget approval.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 841.10

Amended New York State Register December 9, 2015/Volume XXXVII, Issue 49, eff. 11/20/2015

Adopted New York State Register January 26, 2022/Volume XLIV, Issue 04, eff. 1/26/2022