8/12/15 N.Y. St. Reg. HLT-31-14-00002-A
PURSUANT TO THE PROVISIONS OF THE State Administrative Procedure Act, NOTICE is hereby given of the following action:
Action taken:
Addition of Subpart 86-12 to Title 10 NYCRR.
Statutory authority:
L. of 2011, ch. 59, part H, sections 26 and 111(a)
Subject:
Outpatient Services Licensed Under the Mental Hygiene Law.
Purpose:
Creates methodology for adjusting provider reimbursement in OPWDD, OHM and OASAS certified clinics based on annual patient visits.
Text or summary was published
in the August 6, 2014 issue of the Register, I.D. No. HLT-31-14-00002-P.
Final rule as compared with last published rule:
No changes.
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.ny.govAssessment of Public Comment
The Department received one set of comments during the public comment period from the New York City Department of Health and Mental Hygiene (“NYCDOHMN”).
Comment: The Department should consider a “phased in” approach to soften the fiscal impact on providers.
Response: As indicated in the regulatory impact statement, the intent of the utilization threshold procedure is to “discourage excessive and inappropriate utilization of services”. In accordance with social services law 365-a, Medicaid covers medically necessary care and services. Reimbursement of excessive services or those that represent inappropriate utilization would be inconsistent with statute. Therefore, a “phased in” implementation approach would not be appropriate.
Comment: Provider billing systems will need to be revised to accommodate the new utilization threshold payment guidelines. Providers will need time to revise their systems so that they are not financially at risk of having claims denied.
Response: Providers will not be required to revise their Medicaid billing systems for the utilization thresholds. Providers should submit claims as they normally do. Utilization threshold limits will be applied through post payment claim edits.
Comment: For purposes of utilization thresholds, complex care management should be disregarded when computing the number of visits to an OMH-licensed clinic.
Response: Case/care management is exempt from the utilization threshold visit calculation.
