PURSUANT TO THE PROVISIONS OF THE State Administrative Procedure Act, NOTICE is hereby given of the following proposed rule:
Proposed Action:
Amendment of Part 512 of Title 14 NYCRR.
Statutory authority:
Mental Hygiene Law, sections 7.09, 31.04, 43.02; Social Services Law, sections 364-(3) and 364-a(1)
Subject:
Personalized Recovery-Oriented Services (PROS).
Purpose:
To modify PROS registration, documentation and program standards, and include the methodology for calculating capital add-on.
Substance of proposed rule (Full text is posted at the following State website:www.omh.state.ny.us):
This rule will amend Part 512 of Title 14 NYCRR, which established the licensed program category for Personalized Recovery-Oriented Services (PROS) programs. The complete text of the rulemaking is available at www.omh.state.ny.us.
OVERVIEW
The purpose of a PROS program is to assist individuals in their recovery from the disabling effects of mental illness through the coordinated delivery of a customized array of rehabilitation, treatment and support services. Such services are available both in traditional program settings and in off-site locations where individuals live, learn, work and socialize. Providers are expected to create a therapeutic environment which fosters awareness, hopefulness and motivation for recovery while supporting a harm reduction philosophy.
The PROS regulations adopted in February, 2008, included a stringent registration process, rigorous documentation requirements, and specific programmatic decisions reflecting current clinical practice. Since adoption of the 2008 PROS regulations, OMH has received valuable information through evaluation of operational PROS programs and feedback from PROS providers. Therefore, changes within the PROS regulations are necessary in order to provide an updated, improved mental health delivery system. An overview of the revisions is provided below.
REVISIONS REGARDING REGISTRATION SYSTEM
OMH developed and implemented a PROS registration system that would alert PROS providers and other service providers of potential unauthorized co-enrollment issues. While the PROS registration process accomplished its goal of administering co-enrollment edits via an electronic pre-billing process, it proved to be a complex and costly process for both providers and OMH. Therefore, OMH, in conjunction with the New York State Department of Health, has modified the EMedNY system and the OMH registration system, creating a "real-time" registration process. This change will eliminate certain registration and documentation requirements, thus reducing cost to both PROS providers and to OMH.
REVISIONS REGARDING DOCUMENTATION
When the PROS regulations were adopted, modifications were made which increased the documentation requirements related to reimbursement. OMH has since determined that these requirements resulted in a difficult record keeping process which could reduce the efficient operation of a mental health program. The unfunded operational cost of the documentation requirements created clinical and financial strains on PROS providers. The amended regulations modify the PROS documentation requirements in a manner that is consistent with the requirements of other outpatient programs.
REVISIONS REGARDING GROUP SIZE
In many instances, PROS services are provided in a group format. Current regulations state ratios for groups within Community Rehabilitation and Support (CRS) to be 12 recipients to one staff person and, for Intensive Rehabilitation (IR), eight recipients to one staff person. Providers have the flexibility, on occasion, to include up to 15 individuals in CRS groups and 10 individuals in IR groups. However, the existing regulations limit providers, in these cases, to bill for only 12 individuals in CRS groups and eight individuals in the IR groups. Currently, if more than 15 individuals attend a CRS group or 10 individuals attend an IR group, the regulations do not permit billing for any member of the group. The amended regulations remove the provision that disallows payment for all group members when groups exceed 15 for CRS and 10 for IR. The ratios will be maintained in regulation but will be handled as a certification/clinical practice issue.
REVISIONS REGARDING ONGOING REHABILITATION AND SUPPORT
Ongoing rehabilitation and support (ORS) is a service which is designed to provide ongoing counseling, mentoring, advocacy and support for the purpose of sustaining an individual's role in competitive, integrated employment. Current regulations state that providers may only bill the ORS component add-on for individuals who work in an integrated competitive job for a minimum of 15 hours per week. However, provider feedback indicates that individuals are frequently working 10 hours or more per week, but not the necessary 15 hour minimum. OMH has amended the regulations to reflect a change from 15 hours to 10 hours per week for the minimum required for ORS services.
REVISIONS REGARDING CAPITAL ADD-ON FOR HOSPITAL-BASED PROS
Under the existing regulations, certain hospital-based providers may receive an add-on to their monthly case payment that reflects their capital costs. However, the current regulations do not include the methodology for calculating such add-on funding. The regulations have been modified to include such methodology.
REVISIONS REGARDING COLA
A cost of living adjustment, which increased monthly base rates, as well as rates for intensive rehabilitation and ongoing rehabilitation and support services, was established effective April 1, 2008. That COLA is consistent with the enacted 2008-2009 State Budget and is reflected in this rulemaking.
Text of proposed rule and any required statements and analyses may be obtained from:
Joyce Donohue, NYS Office of Mental Health, 44 Holland Avenue, Albany, NY 12229, (518) 474-1331, email: cocbjdd@omh.state.ny.us
Data, views or arguments may be submitted to:
Same as above.
Public comment will be received until:
45 days after publication of this notice.
Regulatory Impact Statement
1. Statutory authority: Subdivision (b) of Section 7.09 of the Mental Hygiene Law grants the Commissioner of the Office of Mental Health (OMH) the authority and responsibility to adopt regulations that are necessary and proper to implement matters under his or her jurisdiction.
Subdivision (a) of Section 31.04 of the Mental Hygiene Law empowers the Commissioner to issue regulations setting standards for licensed programs for the rendition of services for persons with mental illness.
Subdivision (a) of Section 43.02 of the Mental Hygiene Law provides that payments under the medical assistance program for services approved by the Office of Mental Health shall be at rates certified by the Commissioner of Mental Health and approved by the Director of the Budget. Subdivision (b) of Section 43.02 of the Mental Hygiene Law gives the Commissioner authority to request from operators of facilities licensed by the OMH such financial, statistical and program information as the Commissioner may determine to be necessary. Subdivision (c) of Section 43.02 of the Mental Hygiene Law gives the Commissioner of Mental Health authority to adopt rules and regulations relating to methodologies used in establishment of schedules of rates for services.
Sections 364(3) and 364-a(1) of the Social Services Law give OMH responsibility for establishing and maintaining standards for medical care and services in facilities under its jurisdiction, in accordance with cooperative arrangements with the Department of Health.
2. Legislative objectives: Articles 7, 31 and 43 of the Mental Hygiene Law reflect the Commissioner's authority to establish regulations regarding mental health programs and establish rates of payments for services under the Medical Assistance program. Sections 364 and 364-a of the Social Services Law reflect the role of the Office of Mental Health regarding Medicaid reimbursed programs. The rulemaking furthers the Legislative intent under Article 7 by ensuring that the Office of Mental Health fulfills its responsibility to assure the development of comprehensive plans, programs and services in the care, treatment, rehabilitation and training of persons with mental illness.
3. Needs and benefits: The Personalized Recovery-Oriented Services (PROS) initiative created a framework to assist individuals and providers in improving both the quality of care and outcomes for people with serious mental illness in New York State.
The PROS regulations adopted in February, 2008, included a stringent registration process, rigorous documentation requirements, and specific programmatic decisions reflecting current clinical practice. Since that time, OMH has received valuable information through the evaluation of operational PROS programs and feedback from PROS providers. The changes within the PROS regulations are necessary in order to provide an updated, improved mental health delivery system.
One issue that was needed to be addressed was the registration process. OMH had developed and implemented a PROS registration system, the intent of which was to alert PROS providers and other service providers of potential unauthorized co-enrollment issues. While the PROS registration process does accomplish its goal of administering co-enrollment edits via an electronic pre-billing process, it proved to be a complex and costly system for providers and OMH. In some cases, the registration system created delays in processing and limited payment for services within the lower pre-admission payment rate. For example, an individual may have received an entire month of PROS services, yet the provider was reimbursed at a level that did not cover the real costs of rendering those services because of the pre-admission payment rate.
It has become apparent that the three phases of PROS enrollment, each carrying a different set of documentation requirements, added greater complexity and costs to OMH and to PROS providers. In addition, OMH staff must be allocated to operate this system, which is difficult in this time of limited fiscal resources. As a result, OMH, in conjunction with the New York State Department of Health, has modified the EMedNY system and the registration system will be adjusted to serve as a "real-time registration." This change will eliminate certain registration and documentation requirements, thus reducing costs to both PROS providers and OMH.
Another area of concern was the documentation requirements within the regulations. When the PROS regulations were adopted, modifications were made which increased the documentation requirements related to reimbursement. OMH has since determined that these requirements resulted in a difficult recordkeeping process which could potentially be disruptive to the efficient operation of a mental health program. The unfunded operational cost of the documentation requirements created clinical and financial strains on PROS providers.
The amended regulations modify the PROS documentation requirements in a manner that is consistent with the requirements of other outpatient programs. Providers will collect information essential to prove medical necessity for services, provide a road map for an individual's participation in the program, and justify individual monthly PROS bills. The changes, however, will allow providers to complete these critical functions effectively and efficiently in a manner that improves clinical care and fiscal accountability. In addition, the changes will allow providers to develop approaches and documentation practices that fit the intent of their program and integrate with their current practice and electronic record keeping and billing systems.
Revisions were also required to the billing processes for certain groups. In many instances, PROS services are provided in a group format. Current regulations state ratios for groups within Community Rehabilitation and Support (CRS) to be 12 recipients to one staff person and, for Intensive Rehabilitation (IR), eight recipients to one staff person. Providers have the flexibility to, on occasion, include up to 15 individuals in CRS groups and 10 individuals in IR groups. Under existing regulations, providers are limited in these cases to bill for only 12 individuals in CRS groups and eight individuals in IR groups. In addition, current regulations do not permit billing for any member of the group if more than 15 individuals (CRS) or 10 individuals (IR) are in attendance. The amended regulations remove the provision that disallows payment for all group members when groups exceed 15 for CRS and 10 for IR. The ratios will be maintained in regulation but will be handled as a certification/clinical practice issue.
Changes were also needed regarding ongoing rehabilitation and support (ORS) services. The ORS service is designed to provide ongoing counseling, mentoring, advocacy and support for the purpose of sustaining an individual's role in competitive, integrated employment. It is intended to assist individuals in managing symptoms and overcoming functional impairments as they integrated into a competitive workplace. The existing regulations state that providers may bill the ORS component add-on only for individuals who work in an integrated competitive job for a minimum of 15 hours per week. However, feedback from providers had indicated that individuals are frequently working 10 hours or more per week, but not the necessary 15-hour minimum. In an effort to be responsive to current practice, sensitive to the present economy, and respectful of the clinical benefit to individuals, the agency has amended the regulations to reflect a change from 15 hours to 10 hours per week for the minimum required for ORS services.
Modifications were also needed to include a methodology for calculating add-on funding. Under existing regulation, certain hospital-based providers may receive an add-on to their monthly case payment that reflects their capital costs. As the existing regulations do not provide such methodology, the amended regulations have been modified accordingly.
Lastly, a cost of living adjustment, which increased monthly base rates, as well as rates for intensive rehabilitation and ongoing rehabilitation and support services, was established effective April 1, 2008. That COLA is consistent with the enacted 2008-2009 State Budget and is reflected in this rulemaking.
4. Costs:
(a) Cost to regulated persons: The only potential costs to regulated persons would be for the expenditures incurred by the current 21 licensed PROS providers in making the necessary system changes to adapt their electronic medical records and billing systems to comport with the amended regulations. These costs should be offset by the savings that will be generated by the reduced staff time needed to meet the requirements under existing regulations. All new licensees will experience a savings in costs than would have otherwise occurred under the existing regulations.
(b) Cost to State and local government: None expected. Costs to the State may be lessened as a result of staff savings. Additional staff would have been necessary to operate the PROS enrollment system had the registration system not been modified.
5. Local government mandates: The regulation will not mandate any additional imposition of duties or responsibilities upon county, city, town, village, school or fire districts.
6. Paperwork: This rulemaking should not result in an increase in paperwork requirements. One of the goals of this rulemaking is to lessen the paperwork burden placed on providers, so ultimately it should result in less paperwork requirements.
7. Duplication: The regulatory amendment does not duplicate existing State or federal requirements.
8. Alternatives: The only alternative would have been to continue with the current PROS regulations in place. As the amendments reflect input from PROS providers and should ultimately result in an improved and more efficient mental health delivery system, that alternative was necessarily rejected.
9. Federal standards: The regulatory amendment does not exceed any minimum standards of the federal government for the same or similar subject areas.
10. Compliance schedule: The regulatory amendment will become effective upon adoption.
Regulatory Flexibility Analysis
The amendments to 14 NYCRR Part 512, Personalized Recovery-Oriented Services, specify new registration processes, documentation requirements and program standards; provide the methodology for calculating capital add-on funding associated with certain hospital providers; and indicate a cost of living adjustment which was effective 4/1/08. This rulemaking will not create an adverse economic impact upon small business or local governments; therefore, a regulatory flexibility analysis is not submitted with this notice.
Rural Area Flexibility Analysis
The amendments to 14 NYCRR Part 512, Personalized Recovery-Oriented Services, specify new registration processes, documentation requirements and programs standards; provide the methodology for calculating capital add-on funding associated with certain hospital providers; and include a cost of living adjustment, which was effective 4/1/08. This rulemaking will not impose any adverse economic impact upon rural areas; therefore, a Rural Area Flexibility Analysis is not submitted with this notice.
Job Impact Statement
A Job Impact Statement is not submitted with this notice because there will be no adverse impact on jobs and employment opportunities. The rulemaking merely serves to modify registration processes, documentation requirements, and program standards for Personalized Recovery-Oriented Services (PROS) programs. In addition, it provides the methodology for calculating capital add-on funding associated with certain hospitals, and includes a cost of living adjustment, which was effective 4/1/08.
