Home » 2011 Issues » June 29, 2011 » PDD-16-11-00014-A Reimbursement of Clinic Treatment Facilities ("Article 16 Clinics")
PDD-16-11-00014-A Reimbursement of Clinic Treatment Facilities ("Article 16 Clinics")
6/29/11 N.Y. St. Reg. PDD-16-11-00014-A
NEW YORK STATE REGISTER
VOLUME XXXIII, ISSUE 26
June 29, 2011
RULE MAKING ACTIVITIES
OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES
NOTICE OF ADOPTION
I.D No. PDD-16-11-00014-A
Filing No. 525
Filing Date. Jun. 14, 2011
Effective Date. Jul. 01, 2011
Reimbursement of Clinic Treatment Facilities ("Article 16 Clinics")
PURSUANT TO THE PROVISIONS OF THE State Administrative Procedure Act, NOTICE is hereby given of the following action:
Action taken:
Amendment of Part 679 of Title 14 NYCRR.
Statutory authority:
Mental Hygiene Law, sections 13.07, 13.09 and 43.02; L. 2009, ch. 58, section 21; and Public Health Law, section 2807(2-a)(e)
Subject:
Reimbursement of clinic treatment facilities ("Article 16 clinics").
Purpose:
To effect a new reimbursement methodology for clinic treatment facilities and to achieve consistency with other State agencies.
Substance of final rule:
The regulations change the reimbursement methodology for clinics certified or operated by OPWDD. The unit of service is a clinic visit. A clinic visit must include face-to-face service. However, associated observation is considered a face-to-face service. A clinic visit is all the clinical services provided for a person on a common date of service, except that a diagnostic and evaluation service conducted over more than one day is treated as one visit, and on-site and off-site clinic visits provided on the same day are treated as two separate visits.
Clinics assign ICD diagnostic codes and CPT/HCPCS procedure codes to all services and submit this information with claims for reimbursement. The methodology groups these codes to Ambulatory Patient Groups (APGs) based upon the intensity of the services provided, procedures performed, diagnoses, and resource utilization. Each APG is associated with a relative weight, and there are procedure-specific weights and associated weights. APGs, APG relative weights and procedure-specific and associated weights are listed in Department of Health regulations. APGs may package with a same-day medical visit. When multiple procedures group to the same APG, payment may be discounted.
Each clinic is assigned to a peer group. Peer Group A includes clinics that have the main clinic site in New York City or Long Island. Peer Group B includes clinics that have the main clinic site in any other county in the State. Peer Group C includes clinics that are affiliated with and serving two major hospital systems and that, as of July 1, 2011, are designated by the United States Department of Health and Human Services' Administration on Developmental Disabilities as a University Center for Excellence in Developmental Disabilities; are designated by the National Institutes for Health's Eunice Kennedy Shriver National Institute of Child Health and Human Development as an Intellectual and Developmental Disability Research Center, and are designated by the United States Public Health Service Health Resources and Services Administration Maternal and Child Health Bureau as a Leadership Education in Neurodevelopmental and Related Disabilities training program.
There is a base rate for each peer group. The operating component of the rate is the product of the base rate and the procedure's allowed relative APG weight or the final APG weight for each APG on a claim.
If a visit includes a service which maps to an APG which allows a capital add-on, there will be a capital add-on to the operating component of the APG payment for the visit. The capital component will equal the capital cost component of the clinic's regular visit fee in effect on June 30, 2011.
OPWDD will review the capital cost component beginning July 1, 2012 for clinics that were licensed by the Department of Health as diagnostic and treatment centers, transferred long term therapeutic and clinical habilitative services on or after April 1, 2009 to an OPWDD licensed clinic, and received capital funding equal to the diagnostic and treatment center property component. OPWDD will compare the capital cost reimbursement to the clinic's actual capital expenditures from the financial report for the period two years prior. The capital cost component will then be changed to the lesser of (1) the most recent reimbursement; or (2) the greater of actual capital expenditures or the amount reimbursed to OPWDD licensed clinics that are not having their capital component reviewed.
APG reimbursement is phased in using a blended payment. The blended payment is comprised of the clinic's provider specific average legacy fee, plus payment under the APG methodology, plus a capital cost component, if any. For the period beginning on July 1, 2011 and ending on June 30, 2012, the payment will be 75% of the provider specific average legacy fee and 25% of the APG fee; for the twelve months beginning July 1, 2012, the payment will be 50% of the provider specific average legacy fee and 50% of the APG fee; for the six months beginning July 1, 2013, the blend will be 25% of the provider specific average legacy fee and 75% of the APG fee. On and after January 1, 2014, fees will be entirely APG based.
OPWDD will determine the average legacy fee as follows. OPWDD will determine counts of paid visits for each clinic and visit type under the previous reimbursement methodology for service dates between April 1, 2009 and March 31, 2010. OPWDD may adjust this look-back period to accommodate instances where a clinic was not certified by OPWDD for the entire year. OPWDD will also determine each clinic's total operating payment by visit type by multiplying the count of paid visits for the visit type by the operating component of the fee in effect on June 30, 2011 for the same visit type. OPWDD may adjust these results to prevent a clinic from incurring a decrease or increase in Medicaid reimbursement disproportionate to that of the clinics within its peer group. OPWDD will then sum the total operating payments by visit type and then divide this amount by the clinic's total paid visits across all visit types. The result will be the average legacy fee for the provider.
Clinics that begin operation on or after July 1, 2011 will be reimbursed in accordance with the phase-in except that the average of the legacy fees for all clinics will be used in the payment calculation, instead of the clinic-specific average legacy fee.
Department of Health regulations list the clinic services that will not be paid using the APG classification and reimbursement system.
Final rule as compared with last published rule:
Nonsubstantial changes were made in sections 679.2(a)(3), 679.3(j), (p), 679.8(b), (c), (d), 679.9(a), (b), (c) and (e).
Text of rule and any required statements and analyses may be obtained from:
Barbara Brundage, Director, Regulatory Affairs Unit, OPWDD, 44 Holland Avenue, Albany, NY 12229, (518) 474-1830, email: barbara.brundage@opwdd.ny.gov
Additional matter required by statute:
Pursuant to the requirements of the State Environmental Quality Review Act, OPWDD, as lead agency, has determined that the action described herein will have no effect on the environment, and an E.I.S. is not needed.
Revised Regulatory Impact Statement, Revised Regulatory Flexibility Analysis, Revised Rural Area Flexibility Analysis and Revised Job Impact Statement
Minor changes were made to the proposed regulation to correct grammar, italicize “i.e.,” to move a misplaced bracket and to remove an extraneous “the.” Also, language was updated to replace references to “the effective date” or dates pegged to the effective date with the actual calendar dates.
These changes do not necessitate revisions to the previously published Regulatory Impact Statement, Regulatory Flexibility Analysis for Small Business and Local Governments, Rural Area Flexibility Analysis or Job Impact Statement.
