Sec. 599.15. Indigent care

(a) The indigent care program for clinics has been established by New York State to offset a portion of the losses from uncompensated care experienced by diagnostic and treatment centers licensed by the New York State Department of Health and mental health clinics licensed by the office that are not also licensed by the New York State Department of Health and/or not directly operated by the office.

(b) Eligible mental health clinics, for purposes of this section, shall mean non-profit or county-sponsored clinics that can demonstrate losses from a disproportionate share of uncompensated care during a base period two years prior to the grant period; with the exception of the transition period to be established by the office in guidance. Non-profit mental health clinics meeting or exceeding profit margins and total net assets established pursuant to subdivision (k) of this section shall not be eligible for allocations pursuant to this section.

(c) Uncompensated care need, for purposes of this section, means the following, subject to limitations to be provided in guidance by the office:

(1) self pay, including partial pay or no pay visits;

(2) required or optional mental health clinic procedures provided but NOT covered under a clinic’s agreement with a third-party payer;

(3) unreimbursed clinic visits/procedures appropriately provided to an insured recipient by a clinic staff member not approved for payment by a third party payer in contract with the clinic; or

(4) unreimbursed clinic visits/procedures appropriately provided to an insured recipient by a clinic staff member when the procedure is not reimbursed by a third party payer not in contract with the clinic.

(d) To be eligible for an allocation of funds pursuant to this section, a mental health clinic must demonstrate that a minimum of five percent of total clinic visits reported during the applicable base year period meet the eligibility requirements for the pool. For clinics operated by an agency that operates more than one clinic, to be eligible for an allocation of funds pursuant to this section, the agency must demonstrate that a minimum of five percent of its total clinic visits meets these requirements. To be eligible, clinics must further demonstrate that they maintain a sliding fee scale for uninsured individuals.

(e) Documentation of uncompensated care need must be retained by the clinic and will be subject to an audit by the New York State Office of the Medicaid Inspector General or other party empowered to conduct such audits.

(f) Rules for the reporting of data on uncompensated care visits to the office will be established in guidance. Providers participating in the uncompensated care pool that do not submit annual data by dates to be established by the office will be excluded from the pool for that year.

(g) A mental health clinic qualifying for a distribution pursuant to this section shall provide assurances satisfactory to the Commissioners of Health and Mental Health that it shall undertake reasonable efforts to maintain financial support from community and public funding sources and reasonable efforts to collect payments for services from third-party insurance payers, governmental payers and self-paying patients.

(h) To be eligible for reimbursement pursuant to this section, claims must be consistent with the medical assistance billing standards set forth in this Part. Payments from the indigent care pool shall be made in accordance with the payment rules established by the office and the Department of Health.

(i) The allocations of funds to a mental health clinic may be reduced if the office determines that provider management actions or decisions have caused a significant reduction for the grant period in the delivery of mental health services to uncompensated care residents of the community.

(j) The value of uncompensated care payments will be established in guidance issued by the office.

(k) Except as provided in subdivisions (1) and (2) of this subdivision and excluding mental health clinics operated by hospitals licensed pursuant to article 28 of the Public Health Law, providers operating mental health clinics generating net profits from the clinic program in excess of 15 percent of total revenue and which report total net assets in excess of two times their total annual operating budget, as determined by the provider's submissions pursuant to section 599.6(o) of this Part, shall implement a provider-specific indigent care compliance plan approved by the office to serve individuals without creditable coverage or the ability to pay the provider's private pay or sliding fee scale, Such indigent care compliance plan shall include terms regarding the acceptance of referrals to serve such individuals from the office, local government unit, or community and remain in effect until the office determines that net profits and assets no longer exceed the levels established in this subdivision. A provider that fails to fully comply with this subsection may have limitations placed on its operating certificate or other sanctions imposed, in accordance with State law and regulations.

(1) Providers required to comply with this subsection may submit documentation to the office outside of the applicable consolidated fiscal report reporting period to demonstrate that net profits and assets no longer exceed the levels established in this subsection. Redeterminations regarding the applicability of this subsection prior to the submission of the next consolidated fiscal report shall be at the discretion of the office based on an assessment of the provider's overall financial situation and compliance with Part 513 of this Title.

(2) Non-profit providers that demonstrate losses from the operation of other OMH-licensed programs shall not be required to comply with this subdivision if such losses result in net profits of less than 15 percent of total revenue for all OMH licensed programs operated by the provider.