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  HLT-42-10-00004-E Ambulatory Patient Groups (APGs) Payment Methodology  

  • 10/20/10 N.Y. St. Reg. HLT-42-10-00004-E
    NEW YORK STATE REGISTER
    VOLUME XXXII, ISSUE 42
    October 20, 2010
    RULE MAKING ACTIVITIES
    DEPARTMENT OF HEALTH
    EMERGENCY RULE MAKING
     
    I.D No. HLT-42-10-00004-E
    Filing No. 1011
    Filing Date. Sept. 29, 2010
    Effective Date. Sept. 29, 2010
    Ambulatory Patient Groups (APGs) Payment Methodology
    PURSUANT TO THE PROVISIONS OF THE State Administrative Procedure Act, NOTICE is hereby given of the following action:
    Action taken:
    Amendment of Subpart 86-8 of Title 10 NYCRR.
    Statutory authority:
    Public Health Law, section 2807(2-a)(e)
    Finding of necessity for emergency rule:
    Preservation of public health and public safety.
    Specific reasons underlying the finding of necessity:
    It is necessary to issue the proposed regulation on an emergency basis in order to meet the regulatory requirement found within the regulation itself to update the Ambulatory Patient Group (APG) weights at least once a year. To meet that requirement, the weights needed to be revised and published in the regulation for January 2010 and updated thereafter. Additionally, the regulation needs to reflect the many software changes made to the APG payment software, known as the APG grouper-pricer, which is a sub-component of the eMedNY Medicaid payment system. These changes include revised lists of payable and non-payable APGs, a new list of APGs that are not eligible for a capital add-on, and a list of APGs that are not subject to having their payment “blended” with provider-specific historical payment amounts. Finally, a brand new payment software enhancement, which allows payment on a procedure code-specific basis rather than an APG basis, needs to be reflected in the regulation.
    There is a compelling interest in enacting these amendments immediately in order to secure federal approval of associated Medicaid State Plan amendments and assure there are no delays in implementation of these provisions. APGs represent the cornerstone to health care reform. Their continued refinement is necessary to assure access to preventive services for all Medicaid recipients.
    Subject:
    Ambulatory Patient Groups (APGs) Payment Methodology.
    Purpose:
    To refine the APG payment methodology.
    Substance of emergency rule:
    The amendments to Part 86 of Title 10 (Health) NYCRR are required to update the Ambulatory Patient Groups (APGs) methodology, implemented on December 1, 2008, which governs reimbursement for certain ambulatory care fee-for-service (FFS) Medicaid services. APGs group procedures and medical visits that share similar characteristics and resource utilization patterns so as to pay for services based on relative intensity.
    86-8.1 - Scope
    The proposed amendments to section 86-8.1 of Title 10 (Health) NYCRR add a new subdivision (a) paragraph (6) to establish new rates of payment for ambulatory care services for hospital -based mental hygiene services for the following categories of facilities: mental retardation clinics, mental health clinics, alcoholism and drug abuse clinics, and methadone clinics.
    86-8.2 - Definitions
    The proposed amendments to section 86-8.2 of Title 10 (Health) NYCRR amend subdivision (q) to revise the definition of peer group so that it may include facility licensure and add a new subdivision (v) that defines a patient-specific peer group consisting of those persons designated as mentally retarded, developmentally disabled, or suffering from traumatic brain injury.
    86-8.7 - APGs and relative weights
    The proposed revision to section 86-8.7 of Title 10 (Health) NYCRR repeals all of section 86-8.7 effective July 1, 2010 and replaces it with a new section 86-8.7 that includes revised APG weights and procedure-based weights, adds two new procedures and procedure-based weights for D9248 Sedation (non-iv) and T1013 Sign Lang/Oral Interpretation.
    86-8.8 - Base rates
    The proposed revision to section 86-8.8 of Title 10 (Health) NYCRR amends subdivision (a) and subdivision (b) to establish base rates for a new MR/DD/TBI peer group effective July 1, 2010. Additionally, the proposed revision adds a new subdivision (f) that establishes a licensure-specific, provider-specific methodology for calculating blend rates for hospitals operating under the Mental Hygiene Law and establishes a schedule for implementation of the new blend rates.
    86-8.9 - Diagnostic coding and rate computation
    The proposed revision to section 86-8.9 of Title 10 (Health) NYCRR amends subdivision (e) to remove APG 322 Medication Administration and Observation from the list of no blend APGs.
    86-8.10 - Exclusions from payment
    The proposed revision to section 86-8.10 of Title 10 (Health) NYCRR amends subdivisions (h) and (i) to remove APG 312 Full Day Partial Hospitalization for mental Illness, APG 320 Case Management - Treatment Plan Development - Mental Health or Substance Abuse, and 427 Biofeedback and Other Training from the never pay APG list and removes APG 414 Level I Immunization and Allergy Immunotherapy, APG 415 Level II Immunization and APG 416 Level III Immunization, and APG 280 Vascular Radiology Except Venography of Extremity from the if stand alone do not pay list and adds APG 448 After Hours Services to the if stand alone do not pay list.
    86-8.13 - Out of state providers
    The proposed revision to section 86-8.13 of Title 10 (Health) NYCRR amends subdivision (a) paragraph (1) to correct the spelling of Middlesex.
    This notice is intended
    to serve only as a notice of emergency adoption. This agency intends to adopt this emergency rule as a permanent rule and will publish a notice of proposed rule making in the State Register at some future date. The emergency rule will expire December 27, 2010.
    Text of rule and any required statements and analyses may be obtained from:
    Katherine Ceroalo, DOH, Bureau of House Counsel, Reg. Affairs Unit, Room 2438, ESP Tower Building, Albany, NY 12237, (518) 473-7488, email: regsqna@health.state.ny.us
    Regulatory Impact Statement
    Statutory Authority:
    Authority for the promulgation of these regulations is contained in section 2807(2-a)(e) of the Public Health Law, section 79(u) of part C of chapter 58 of the laws of 2008 and section 129(l) of part C of chapter 58 of the laws of 2009, which authorize the Commissioner of Health to adopt and amend rules and regulations, subject to the approval of the State Director of the Budget, establishing an Ambulatory Patient Groups methodology for determining Medicaid rates of payment for diagnostic and treatment center services, free-standing ambulatory surgery services and general hospital outpatient clinics, emergency departments and ambulatory surgery services.
    Legislative Objective:
    The Legislature's mandate is to convert, where appropriate, Medicaid reimbursement of ambulatory care services to a system that pays differential amounts based on the resources required for each patient visit, as determined through APGs.
    Needs and Benefits:
    The proposed regulations are in conformance with statutory amendments to provisions of Public Health Law section 2807(2-a), which mandated implementation of a new ambulatory care reimbursement methodology based on APGs. This reimbursement methodology provides greater reimbursement for high intensity services and relatively less reimbursement for low intensity services. It also allows for greater payment homogeneity for comparable services across all ambulatory care settings (i.e., Outpatient Department, Ambulatory Surgery, Emergency Department, and Diagnostic and Treatment Centers). By linking payments to the specific array of services rendered, APGs will make Medicaid reimbursement more transparent. APGs provide strong fiscal incentives for health care providers to improve the quality of, and access to, preventive and primary care services.
    COSTS:
    Costs for the Implementation of, and Continuing Compliance with this Regulation to the Regulated Entity:
    There will be no additional costs to providers as a result of these amendments.
    Costs to Local Governments:
    There will be no additional costs to local governments as a result of these amendments.
    Costs to State Governments:
    There will be no additional costs to NYS as a result of these amendments. All expenditures under this regulation are fully budgeted in the SFY 2009-10 and 2010-11 enacted budgets.
    Costs to the Department of Health:
    There will be no additional costs to the Department of Health as a result of these amendments.
    Local Government Mandates:
    There are no local government mandates.
    Paperwork:
    There is no additional paperwork required of providers as a result of these amendments.
    Duplication:
    This regulation does not duplicate other state or federal regulations.
    Alternatives:
    These regulations are in conformance with Public Health Law section 2807(2-a). Alternatives would require statutory amendments.
    Federal Standards:
    This amendment does not exceed any minimum standards of the federal government for the same or similar subject areas.
    Compliance Schedule:
    The proposed amendment will become effective upon filing with the Department of State.
    Regulatory Flexibility Analysis
    Effect on Small Business and Local Governments:
    For the purpose of this regulatory flexibility analysis, small businesses were considered to be general hospitals, diagnostic and treatment centers, and free-standing ambulatory surgery centers. Based on recent data extracted from providers' submitted cost reports, seven hospitals and 245 DTCs were identified as employing fewer than 100 employees.
    Compliance Requirements:
    No new reporting, record keeping or other compliance requirements are being imposed as a result of these rules.
    Professional Services:
    No new or additional professional services are required in order to comply with the proposed amendments.
    Economic and Technological Feasibility:
    Small businesses will be able to comply with the economic and technological aspects of this rule. The proposed amendments are intended to further reform the outpatient/ambulatory care fee-for-service Medicaid payment system, which is intended to benefit health care providers, including those with fewer than 100 employees.
    Compliance Costs:
    No initial capital costs will be imposed as a result of this rule, nor is there an annual cost of compliance.
    Minimizing Adverse Impact:
    The proposed amendments apply to certain services of general hospitals, diagnostic and treatment centers and freestanding ambulatory surgery centers. The Department of Health considered approaches specified in section 202-b(1) of the State Administrative Procedure Act in drafting the proposed amendments and rejected them as inappropriate given that this reimbursement system is mandated in statute.
    Small Business and Local Government Participation:
    Local governments and small businesses were given notice of these proposals by their inclusion in the SFY 2009-10 enacted budget and the Department's issuance in the State Register of federal public notices on February 25, 2009, June 10, 2009 and January 20, 2010.
    Rural Area Flexibility Analysis
    Effect on Rural Areas:
    Rural areas are defined as counties with a population less than 200,000 and, for counties with a population greater than 200,000, includes towns with population densities of 150 persons or less per square mile. The following 44 counties have a population less than 200,000:
    AlleganyHamiltonSchenectady
    CattaraugusHerkimerSchoharie
    CayugaJeffersonSchuyler
    ChautauquaLewisSeneca
    ChemungLivingstonSteuben
    ChenangoMadisonSullivan
    ClintonMontgomeryTioga
    ColumbiaOntarioTompkins
    CortlandOrleansUlster
    DelawareOswegoWarren
    EssexOtsegoWashington
    FranklinPutnamWayne
    FultonRensselaerWyoming
    GeneseeSt. LawrenceYates
    GreeneSaratoga
    The following 9 counties have certain townships with population densities of 150 persons or less per square mile:
    AlbanyErieOneida
    BroomeMonroeOnondaga
    DutchessNiagaraOrange
    Compliance Requirements:
    No new reporting, recordkeeping, or other compliance requirements are being imposed as a result of this proposal.
    Professional Services:
    No new additional professional services are required in order for providers in rural areas to comply with the proposed amendments.
    Compliance Costs:
    No initial capital costs will be imposed as a result of this rule, nor is there an annual cost of compliance.
    Minimizing Adverse Impact:
    The proposed amendments apply to certain services of general hospitals, diagnostic and treatment centers and freestanding ambulatory surgery centers. The Department of Health considered approaches specified in section 202-bb(2) of the State Administrative Procedure Act in drafting the proposed amendments and rejected them as inappropriate given that the reimbursement system is mandated in statute.
    Opportunity for Rural Area Participation:
    Local governments and small businesses were given notice of these proposals by their inclusion in the SFY 2009-10 enacted budget and the Department's issuance in the State Register of federal public notices on February 25, 2009, June 10, 2009 and January 20, 2010.
    Job Impact Statement
    A Job Impact Statement is not required pursuant to Section 201-a(2)(a) of the State Administrative Procedure Act. It is apparent, from the nature and purpose of the proposed regulations, that they will not have a substantial adverse impact on jobs or employment opportunities.
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