OMH-49-09-00004-P Medical Assistance Payments for Community Rehabilitation Services Within Residential Programs for Adults, Children & Adolescents

12/9/09 N.Y. St. Reg. OMH-49-09-00004-P

NEW YORK STATE REGISTER

VOLUME XXXI, ISSUE 49

December 09, 2009

RULE MAKING ACTIVITIES

OFFICE OF MENTAL HEALTH

PROPOSED RULE MAKING

NO HEARING(S) SCHEDULED

 

I.D No. OMH-49-09-00004-P

Medical Assistance Payments for Community Rehabilitation Services Within Residential Programs for Adults, Children & Adolescents

PURSUANT TO THE PROVISIONS OF THE State Administrative Procedure Act, NOTICE is hereby given of the following proposed rule:

Proposed Action:

This is a consensus rule making to amend Part 593 of Title 14 NYCRR.

Statutory authority:

Mental Hygiene Law, sections 7.09 and 31.04; and Social Services Law, sections 364 and 364-a

Subject:

Medical Assistance Payments for Community Rehabilitation Services within Residential Programs for Adults, Children & Adolescents.

Purpose:

To clarify the intent of the regulation regarding service authorization and treatment planning and make technical corrections.

Text of proposed rule:

1. Subdivision (b) of Section 593.2 of Title 14 NYCRR is amended to read as follows:

(b) Sections 364 and 364-a of the Social Services Law give the Office of Mental Health 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 [Social Services] Health.

2. Subdivision (a) of Section 593.3 of Title 14 NYCRR is amended to read as follows:

(a) This Part applies to any provider of service, licensed pursuant to [Part 586,] Part 594[,] or Part 595 of this Title, which proposes to operate a residential program for adults with mental illness and/or children or adolescents with serious emotional disturbance.

3. Subdivision (b) of Section 593.5 of Title 14 NYCRR is amended to read as follows:

(b) Reimbursement shall be made only for community rehabilitation services provided to individuals who have been authorized in writing [by a physician] as set forth in section 593.6 to receive community rehabilitation services provided by a licensed residential program. Such individuals must have a severe and persistent mental illness or, for children and adolescents, serious emotional disturbance, as defined by the [commissioner] Commissioner in the Office of Mental Health's Annual Statewide Comprehensive Plan for Mental Health Services developed pursuant to Section 5.07 of the Mental Hygiene Law. Community rehabilitation services are delineated in section 593.4(b) and (c) of this Part.

4. Subdivisions (a), (b) and (d) of Section 593.6 of Title 14 NYCRR are amended to read as follows:

(a) In order to receive reimbursement for the provision of community rehabilitation services to an individual, the provider of service must ensure that the individual has been authorized in writing by a physician, prior to or upon admission, to receive services as provided by the program. The written authorization must be retained as a part of the individual's case record. [Individuals whom are residing in a program governed by this Part on April 1, 1992 and have been receiving such services in accordance with an approved service plan, must receive a physician's authorization by July 1, 1992, which shall be considered to be effective April 1, 1992.] The physician's authorization must:

(1) be based upon appropriate clinical information and assessment of the individual. The initial authorization must include a face-to-face assessment;

(2) delineate the maximum duration of the authorization to receive such services; and

(3) specify that the individual is in need of community rehabilitation services as defined in section 593.4(b) of this Part.

(b) Service authorizations which are renewed must be signed by a physician, physician assistant, or nurse practitioner in psychiatry. [Physician's] Service authorizations must be renewed as follows:

(1) every six months for individuals residing within congregate residences and residential programs for children and adolescents. The reauthorization for a child or adolescent must include a face-to-face contact with the physician, physician assistant or nurse practitioner in psychiatry who signs and renews the service authorization;

(2) every 12 months for individuals residing within an apartment program; and

(3) upon transfer to a different category of adult program (i.e., congregate to apartment or apartment to congregate). The authorization renewal must, in the case of a transfer from congregate to apartment, occur upon the expiration date of the current authorization or, in the case of a transfer from apartment to congregate, within six months of admission to the new program or the expiration of the current authorization, whichever comes first.

(d) Such plan shall be developed by the staff of the program, resident and any collateral identified for participation in planning, as appropriate. The service plan must be reviewed and signed by a qualified mental health staff person. The service plan must be a mutually agreed upon course of action which, at a minimum, identifies the following:

(1) statement of service goals and objectives;

(2) identification of the community restorative services to be provided;

(3) proposed time periods; [and]

(4) efforts to coordinate services with other providers[.], as appropriate; and

(5) signature of the resident, documenting his or her participation, or any collateral, as appropriate, in planning and approval of the plan. Reasons for non-participation and/or non-approval by the resident shall be documented in the service plan.

5. Subdivision (g) of Section 593.6 of Title 14 NYCRR is repealed.

6. Subdivisions (a) and (b) of Section 593.7 are amended to read as follows:

(a) In order to receive reimbursement for the provision of community rehabilitation services, each individual must have a service plan which documents the delivery of appropriate community rehabilitation services which have been authorized by a physician, or reauthorized pursuant to subdivision (b) of section 593.6 of this Part.

(b) Reimbursement will be based upon monthly and half-monthly rates. Such rates shall be paid based upon a minimum number of face-to-face contacts between an eligible resident or a program and a staff person of an approved provider of community rehabilitation services, subject to the following provisions:

(1) A full monthly rate will be paid for services provided to an eligible resident in residence for at least 21 days in a calendar month, who has received at least four contacts with a staff person of the program. For a family-based treatment program or a teaching family home program, a youth shall have received at least 11 contacts, at least three of which must be provided by authorized program staff other than the professional family or teaching parents. At least four different community rehabilitative services must have been provided.

(2) A half monthly rate will be paid for services provided to an eligible resident in residence for at least 11 days in a calendar month who has received at least two contacts with a staff person of the program. For a family-based treatment program or a teaching family home program, a youth shall have received at least six contacts, at least two of which must be provided by authorized program staff other than the professional family or teaching parents. At least two different community rehabilitation services must have been provided.

(3) Only one contact can be counted each day and each contact shall be at least 15 minutes in duration.

(4) For reimbursement purposes, a contact shall involve the performance of at least one of the services indicated in the resident's current service plan.

(5) A reimbursable contact may occur at or away from the program, except that a reimbursable contact may not occur at the site of a licensed mental health outpatient program as such programs are described in [Parts 585 and] Part 587 of this Title, nor when the otherwise eligible resident is an inpatient of any hospital for any reason or temporarily residing in any other licensed residential facility.

(6) Reimbursement for contacts provided under this program shall not be limited in any way by reimbursement for visits under any outpatient program licensed by the Office of Mental Health on the same day or reimbursement for visits provided by any comprehensive Medicaid case management program approved by the Office of Mental Health.

7. Subdivision (g) of Section 593.8 of Title 14 NYCRR is amended to read as follows:

(g) Notwithstanding the provisions of this section, if a provider of service seeks reimbursement in excess of the limits imposed in section 593.7 of this Part, the provider shall be presumed to have violated the provisions of this Part, whereupon the Office of Mental Health shall notify the Department of [Social Services] Health in order that the Department of [Social Services] Health may exercise its authority to recover such overpayment as may have occurred.

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, [phone], email: [e-mail]

Data, views or arguments may be submitted to:

Same as above.

Public comment will be received until:

45 days after publication of this notice.

Consensus Rule Making Determination

This rulemaking is filed as a Consensus rule on the grounds that its purpose is to make technical corrections and is non-controversial. No person is likely to object to this rulemaking since it merely clarifies the intent of the regulation regarding service authorization and reauthorization, and treatment planning requirements. In addition, the rulemaking makes technical corrections regarding a State agency which is no longer in existence and removes references to Parts in Title 14 NYCRR that have been repealed.

The rulemaking provides flexibility by removing restrictive language regarding the need for a quarterly written summary for physician authorization. When the original regulations regarding service authorization were written, the intent was that there would be communication, collaboration and consistency with regard to the need for, and progress of, an individual's treatment. The physician's authorization prescribes the provision of community rehabilitation services for a set period of time. The initial and renewal authorizations are based on need, which is formulated and confirmed by the presentation of clinical information and assessment of the individual. The initial authorization includes a face-to-face assessment, and the renewal authorization is based on the summary of progress that a resident has achieved. The summary of progress can be obtained by a written document, face-to-face consultation, or case review that occurs prior to the authorization. The physician is required to sign and document his license number on the Physician Authorization Form, which acts as a prescription for service. The intent of the physician receiving a summary of information is to familiarize himself with the case and ongoing treatment as the treating physician. The physician also has the opportunity to obtain status information in his/her treatment/clinical sessions. This exceeds the minimum expectations of the regulation as the consumer is an active patient of the physician.

Since the time that this regulation was originally drafted, the use of physician assistants and nurse practitioners in psychiatry has greatly increased. In recognition of their scope of practice, the Office of Mental Health has determined that renewal authorizations can be prepared by a physician, a physician assistant and a nurse practitioner in psychiatry.

The rulemaking also corrects an inaccurate reference to the Department of Social Services, a State agency which is no longer in existence, and clarifies that the correct agency is the Department of Health. In addition, it removes references to Parts no longer in effect within Title 14 NYCRR.

As this rulemaking serves to only make technical corrections and clarify the agency's original intent regarding service authorizations, it is correctly filed as a consensus rulemaking.

Statutory Authority: Sections 7.09 and 31.04 of the Mental Hygiene Law grant the Commissioner of the Office of Mental Health the power and responsibility to adopt regulations that are necessary and proper to implement matters under his jurisdiction. Sections 364 and 364-a of the Social Services Law give the Office of Mental Health the 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.

Job Impact Statement

A Job Impact Statement is not submitted with this notice because it merely clarifies the intent of the regulations regarding service authorization and treatment planning requirements, and makes technical corrections. There will be no adverse impact on jobs and employment opportunities as a result of this rulemaking.