N.Y. Comp. Codes R. & Regs. tit. 14 § 841.7

Current through Register Vol. 46, No. 25, June 18, 2024

Section 841.7 - Medical assistance payments and utilization review for substance use disorder residential rehabilitation services for youth

(a) The provisions of this section are applicable to programs certified under Part 817.

(b) Rates of Payment.

(1) Rates will be calculated using a cost-based fee methodology inclusive of operating costs and capital reimbursement. There shall be no capital add-on to these fees, nor any separate Medicaid reimbursement for capital costs. There shall be no admission review team add-on.

(2) Fees will be established using a regression model based on the relationship between normalized cost and program capacity, recognizing both regional cost differentials and economies of scale. The calculated statewide fees based on program capacity, will then be adjusted using regional cost factors (based on the county in which the facility is located).

(3) Fees will be deemed to be inclusive of all service delivery costs and will be considered payment in full for fee-for-service Medicaid reimbursed services.

(4) Fee schedules used to determine rates will be posted on the Office website. Schedules used to determine fees include:

(i) Statewide OASAS Residential Rehabilitation Services for Youth (RRSY) fee chart based on bed size; and

(ii) Geographic region and regional cost factor chart.

(c) Bed size.

(1) For existing and new inpatient rehabilitation facilities, the bed size will be based on the certified capacity of the program site.

(2) If the certified bed size changes, the fee will be revised accordingly and will be effective on the date of the bed size change.

(3) Facilities with fewer than fourteen (14) certified beds will use the fourteen-bed fee. Facilities with sixty (60) or more certified beds will use the sixty-bed fee.

(4) Bed size is determined at certification and listed on the program operating certificate issued by the Office.

(d) Base year. The base year for new fee calculations will be the most recent, substantially complete Consolidated Fiscal Report period available at the time of the calculation.

(e) Certification for treatment, utilization review and control.

(1) For an individual who is a Medicaid recipient when admitted to the residential rehabilitation services for youth program, certification of services must be made by an independent team as defined in Part 817 of this Title.

(2) For individuals who apply for Medicaid after admission to the residential rehabilitation for youth program, or for emergency admissions, certification of services must be made by the multidisciplinary team as defined in Part 817 of this Title. This team must include a physician. Emergency admission certification must be made within 14 days after admission. Certification must be made at the time of admission or, if an individual applies for Medicaid while in the facility, at the time of application.

(3) The utilization review plan of an eligible residential rehabilitation services for youth provider shall include the following:

(i) provision for review of each Medicaid recipient's need for services furnished in accordance with the criteria of Part 817 of this Title;

(ii) provisions to ensure that utilization review of a Medicaid recipient's treatment plan and services shall be performed by a multidisciplinary team that includes a physician as defined in Part 817 of this Title;

(iii) procedures to be used by the committee to ensure that staff of the eligible residential rehabilitation services for youth provider take needed corrective action;

(iv) provisions to ensure that the patient's record includes all information required by Part 817 of this Title, as well as the name of the patient's physician, the dates of Medicaid application and authorization if made after admission, initial and subsequent continued stay review dates, the reasons and plan for continued stay if continued stay is necessary, and other supporting material found necessary and appropriate by the multidisciplinary team;

(v) specification of records and reports to be made by the utilization review group;

(vi) provisions for maintaining the confidentiality of the identities of patients in the records and reports of the utilization review group; and

(vii) written criteria to assess the need for continued stay which conform to the requirements of Part 817 of this Title.

(4) The group performing utilization review shall ensure that subsequent reviews for continued stay of a recipient in an eligible residential service for youth program are conducted no later than each thirty-day period following the initial continued stay review. The date assigned for each subsequent continued stay review shall be noted in the patient's record.

(5) Continued stay reviews shall be performed in accordance with the following:

(i) Review for continued stay shall be conducted by the multidisciplinary team defined in Part 817 of this Title.

(ii) The review shall be conducted on or before the review date assigned.

(iii) The multidisciplinary team shall review and evaluate the documentation referred to in this Part in relation to the criteria established in this Part.

(iv) If the multidisciplinary team finds that a recipient's continued stay is needed, the multidisciplinary team shall assign a new continued stay review date in accordance with paragraph (4) of this subdivision.

(v) Any decision of the multidisciplinary team that continued stay is unnecessary shall be provided in writing within two days to the director, the attending physician, the primary counselor, and the patient; and Medicaid billing shall cease as of the day of notification. However, any decision to discharge or retain the patient shall be made on clinical grounds independent of the utilization review group's determination.

(vi) A multidisciplinary team must certify that the services continue to be needed by each recipient.

(vii) If the multidisciplinary team finds that a continued stay is not needed, it shall notify the recipient's attending physician and primary counselor within one working day and provide them two working days to present their views before a final decision.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 841.7

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