Revise the schedule of clinic fees using a new base year.
Text of proposed rule:
Delete 14 NYCRR Subdivision 679.6(j).
Add new Subdivision 679.6(j) as follows:
Section 679.6 Fee setting and financial reporting.
Subdivision 679.6(j)
(j) Fee setting.
(1) Effective March 1, 2009, for clinic treatment facilities which filed a 2004 or 2004/2005 certified cost report:
(i) Those certified Part 679 clinic treatment facilities which submitted a 2004 or 2004/2005 certified cost report with data yielding an adjusted operating cost per adjusted visit of less than or equal to $95.41 shall be reimbursed in accordance with Schedule A as set forth at subparagraph (5)(i) of this subdivision.
(ii) Those certified Part 679 clinic treatment facilities which submitted a 2004 or 2004/2005 certified cost report with data yielding an adjusted operating cost per adjusted visit of more than $95.41 shall be reimbursed in accordance with Schedule B as set forth at subparagraph (5)(ii) of this subdivision.
(iii) OMRDD shall determine the actual operating cost per adjusted visit by dividing total actual costs exclusive of property from either the 1/1/2004 12/31/2004 or 7/1/2004 6/30/2005 submitted and certified cost report, as applicable, by adjusted visits for the same period of time. OMRDD shall determine adjusted visits by weighting the annual utilization as reported by the provider for billing purposes by the relative proportion of all visits to total full clinic visits. The provider specific monetary effects of participation in fiscal year COLAs effective on October 1, 2006, June 1, 2007 and August 1, 2008 and Health Care Enhancements I, II, and III subsequent to the base year through October 1, 2008 shall be factored into the unit cost along with an efficiency adjustment (see subparagraph [j][1][iv]) to yield the adjusted operating cost per adjusted visit.
(iv) OMRDD shall establish allowable administrative costs. OMRDD shall allow administrative expense to the extent that the percentage of administrative costs to total operating and administrative costs in the 2004 or 2004/2005 cost reports does not exceed percentages similarly computed from the specific providers' HCBS Waiver services historical cost reports.
(2) Effective March 1, 2009, clinic treatment facilities which did not submit a 2004 or 2004/2005 certified cost report and which were certified before October 1, 2008 shall be reimbursed in accordance with Schedule A as set forth at subparagraph (5)(i) of this subdivision.
(3) Effective March 1, 2009, for clinic treatment facilities initially certified by OMRDD as Part 679 clinic treatment facilities on or after October 1, 2008:
(i) OMRDD shall use for fee setting purposes budget information and units of service submitted by the provider in its application to receive an operating certificate provided they have been accepted and approved by the Commissioner. The approved projected units of service shall be delineated in terms of numbers of full clinic visits, brief clinic visits, comprehensive diagnostic and evaluation visits, and group clinic visits. OMRDD shall approve budgeted costs based on whether they are necessary and appropriate to deliver services in accordance with this Part.
(ii) OMRDD shall determine projected adjusted visits for fee setting purposes by weighting the approved projected utilization by the relative proportion of all visits to full clinic visits.
(iii) OMRDD shall determine the allowable administrative component of budgeted costs. OMRDD shall compare the approved budgeted administrative costs as a percentage of total approved budgeted operating and administrative costs exclusive of property to the regional average percentage computed similarly and derived from regional providers' historical data. The percent of allowable administrative expense shall not exceed the applicable regional historical percentage.
(iv) Further, in order to effectively compare approved budgeted costs to the 2008 standard used for Part 679 clinic treatment facilities certified before October 1, 2008, any increases or decreases established for clinic treatment facilities on or after October 1, 2008 will be assumed to be incorporated in budgeted costs. OMRDD shall factor such increases or decreases out of allowable budgeted operating costs for the determination of adjusted budgeted cost per projected adjusted visit relative to $95.41.
(v) For clinic treatment facilities with approved budgets showing projected expenditures for the allowable operating costs exclusive of property, that when adjusted are less than or equal to $95.41 per projected adjusted visit, the fees for reimbursable services shall be pursuant to Schedule A (see subparagraph [5][i] of this subdivision).
(vi) For clinic treatment facilities with approved budgets showing projected expenditures for the allowable operating costs exclusive of property that when adjusted are more than $95.41 per projected adjusted visit, the fees for reimbursable services shall be pursuant to Schedule B (see subparagraph [5][ii] of this subdivision).
(4) The following types of clinic visits, regardless of where provided, delivered in accordance with this Part and the restrictions set forth at section 679.5 of this Part may be claimed for reimbursement:
(i) full clinic visit (including collateral and intake visits);
(ii) comprehensive diagnostic and evaluation visit;
(iii) group clinic visit; or
(iv) brief clinic visit.
(5) Payment schedules.
(i)
Schedule A
Operating Component
Total
of Fee
Fee
Full clinic visit
$ 94.81
$100.97
Comprehensive diagnostic and
$284.43
$302.91
evaluation visit
Group clinic visit
$31.61
$33.66
Brief clinic visit
$47.41
$50.49
(ii)
Schedule B
Operating Component
Total
of Fee
Fee
Full clinic visit
$110.17
$116.33
Comprehensive diagnostic and
$330.51
$348.99
evaluation visit
Group clinic visit
$36.72
$38.78
Brief clinic visit
$55.09
$58.17
Text of proposed rule and any required statements and analyses may be obtained from:
Barbara Brundage, Director, Regulatory Affairs Unit, OMRDD, 44 Holland Avenue, Albany, New York 12229, (518) 474-1830, email: barbara.brundage@omr.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.
Additional matter required by statute:
Pursuant to the requirements of SEQRA and 14 NYCRR Part 602, OMRDD has on file a Negative Declaration with respect to this Action. OMRDD has determined that the action described herein will have no effect on the environment, and an E.I.S. is not needed.
Regulatory Impact Statement
1. Statutory Authority -
a. The New York State Office of Mental Retardation and Developmental Disabilities' (OMRDD) responsibility to assure and encourage the development of programs and services in the area of care, treatment, rehabilitation, education and training of persons with mental retardation and developmental disabilities, is stated in the New York Mental Hygiene Law Section 13.07.
b. OMRDD's authority to adopt rules and regulations necessary and proper to implement any matter under its jurisdiction is stated in the New York State Mental Hygiene Law Section 13.09(b).
c. Section 43.02 of the Mental Hygiene Law grants the commissioner the authority to establish rates and fees for payment under the Medicaid program for facilities licensed by OMRDD and it requires the commissioner to adopt rules and regulations to effectuate Section 43.02.
2. Legislative Objectives -
These amendments further the legislative objectives embodied in the sections 13.07, 13.09(b), and 43.02 of the Mental Hygiene Law. The promulgation of these amendments will maintain the financial stability of clinic services certified by OMRDD.
3. Needs and Benefits -
In establishing a schedule of fees for Article 16 clinics (Part 679 clinic treatment facilities), OMRDD examines providers' costs of providing clinic services during a particular year, called the "base year." In time, particularly with fluctuations in the economy, those base year values lose their relevance and become outdated. The last base year OMRDD used was 1990 for upstate providers and 1989/1990 for downstate providers.
In addition, the existing regulations treat monetary increments to fees effective after the base year, such as cost of living adjustments and health care enhancements, as add-ons to the existing fee schedules. With every add-on, there are those providers which participate and those providers which do not, precipitating a doubling of the number of applicable fee schedules.
The new schedule of fees addresses more current costs by using a new base year of 2004 for upstate providers and 2004/2005 for downstate providers. It appropriately reassigns provider payment to a fee schedule which reflects the relative changes in a provider's costs from the 1990 or 1989/90 base year. Moreover, because the new fees incorporate all the add-ons since the previous base year, this regulation eliminates the multitude of schedules and the confusion they engendered.
Finally, this regulation is consistent with the Department of Health's overall restructuring of New York's health care system to strengthen primary and preventative care. This restructuring includes reforming certification so the appropriate State agency has the lead authority for oversight, and so that rules are clear to providers and do not impede coordinated care for patients with co-morbidities. As part of this reform, approximately 22 clinics currently certified and paid by the Department of Health as Diagnostic and Treatment Centers ("Article 28 clinics") will be certified as Article 16 clinics and reimbursed through the payment methodology established by this regulation.
The Department of Health's restructuring also includes transitioning funding from inpatient to outpatient services to support quality care in outpatient settings and address the problem of avoidable hospitalizations. Part of this transition is a new rate setting methodology, called Ambulatory Patient Groups or APGs, under which the amount paid for a visit varies depending on the intensity of the services provided during the visit. The Diagnostic and Treatment Centers are scheduled for APG phase in effective March 1, 2009. OMRDD considers the revision of the Article 16 clinic fee schedule interim until such time as OMRDD restructures its clinic service platform to move to an APG reimbursement system in collaboration with the Department of Health. This interim measure is a step in the process which ultimately aims to attain Medicaid reimbursement that is consistent with the reimbursement for similar services provided by other State agencies.
4. Costs -
a. There will be no additional cost to providers of clinic services to implement and comply with the amendments. Providers will bill Medicaid for clinic services in the same way they have always billed.
b. There will be additional costs to the state and federal governments as a result of this fee schedule amendment. The aggregate additional costs will be $4.2 million, which represents $2.1 million in federal funds and $2.1 million in state funds, of which OMRDD will be responsible for $1.0 million and the Department of Health $1.1 million.
c. There are no costs to local governments as a result of these specific amendments because Chapter 58 of the Laws of 2005 places a cap on the local share of Medicaid costs.
5. Paperwork -
There will be no additional paperwork required as a result of these amendments. Providers will bill Medicaid for clinic services in the same way they have always billed.
6. Local Government Mandates -
a. There are no new requirements imposed on local governments by this amendment.
7. Duplication -
a. The amendment does not duplicate any existing State or Federal requirement.
8. Alternatives -
a. The only alternative would be to maintain the current fee schedules which are outdated and confusing.
9. Federal Standards -
a. The amendment does not exceed any minimum standard of the federal government for the same or similar subject area.
10. Compliance Schedule -
a. OMRDD intends to finalize and file the proposed amendment within and according to the timeframes provided by the State Administrative Procedure Act. (SAPA).
Regulatory Flexibility Analysis
1. Types and number of small businesses and local governments rule applies -
a. These proposed regulatory amendments will apply to agencies which operate clinic services for persons with developmental disabilities. While most services are provided by voluntary agencies which employ more than 100 people overall, many of the facilities operated by these agencies at discrete sites employ fewer than 100 employees at each site, and each site (if viewed independently) would therefore be classified as a small business. Some smaller agencies which employ fewer than 100 employees would themselves be classified as small businesses. OMRDD estimates that approximately 36 clinic provider agencies would be affected by the proposed amendments.
b. Local governments do have a local share of the Medicaid costs for clinic services. However, there are no costs to local governments as a result of these amendments because Chapter 58 of the Laws of 2005 places a cap on the local share of Medicaid costs.
a. There will be no additional paperwork as indicated in the Regulatory Impact Statement. Providers will bill Medicaid for clinic services in the same way they have always billed.
3. Cost to implement and comply with this rule -
a. There will be no additional cost to providers of clinic services to implement and comply with the amendments. Providers will bill Medicaid for clinic services in the same way they have always billed.
b. There will be additional costs to the state and federal governments as a result of this fee schedule amendment. The aggregate will be $4.2 million, which represents $2.1 million in federal funds and $2.1 million in state funds, of which OMRDD will be responsible for $1.0 million and the Department of Health $1.1 million.
c. There are no costs to local governments as a result of these specific amendments because Chapter 58 of the Laws of 2005 places a cap on the local share of Medicaid costs.
4. Assessment of the economic and technological feasibility of compliance -
a. There is no new technology required by the rule.
5. How the rule is designed to minimize economic impact -
a. The amendments will allow OMRDD to reimburse providers of Article 16 clinic services at revised levels which addresses more current costs using a new base year of 2004 or 2004/2005 and eliminates the multitude of existing fee schedules. The revised clinic fee schedule will have positive impacts on small business providers of clinic services resulting from these reimbursements.
6. Small business and local government participation -
a. The Provider Council and Provider Associations have been made aware of the proposed regulations. The regulations were discussed at various meetings and presentations over the past several months. Both the Provider Council and Provider Associations have had the opportunity to comment during the pre-submission period. The Provider Council was set up years ago by the Commissioner to facilitate open communication and solicit input on various issues. The Provider Council has over 40 members representing various provider associations and provider agencies from across New York State.
Rural Area Flexibility Analysis
A Rural Area Flexibility Analysis for the proposed amendment is not being submitted because the amendment will not impose any adverse economic impact on rural areas or on reporting, record keeping or other compliance requirements on public or private entities in rural areas. The amendment creates a revised schedule of fees, which addresses more current costs using a new base year of 2004 or 2004/2005 and eliminates the multitude of existing fee schedules. The existing fee schedules were last set using a base year of 1990 or 1989/1990 which no longer accurately reflect current provider costs.
Job Impact Statement
A Job Impact Statement for the proposed amendment is not being submitted because it is apparent from the nature and purpose of the rule that it will not have a substantial adverse impact on jobs and/or employment opportunities. The rule creates a revised schedule of fees, which addresses more current costs using a new base year of 2004 or 2004/2005 and eliminates the multitude of existing fee schedules. The existing fee schedules were last set using a base year of 1990 or 1989/1990 which no longer accurately reflect current provider costs.
