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 and 43.02; Social Services Law, sections 364(3) and 364-a(1)
Subject:
Personalized Recovery Oriented Services (PROS).
Purpose:
Provide enhancements to individuals transitioning to more independent community living; reimburse providers for enhanced services.
Text of proposed rule:
1. A new subdivision (an) is added to section 512.4 of Title 14 NYCRR to read as follows:
(an) Target population member means an individual who has received long-term supports and services for at least six (6) months while living in an adult home, nursing home, or as an inpatient in a State psychiatric center, and is currently living in a more independent, integrated community setting. An individual shall be a member of the target population for the purposes of this Part for no longer than 12 consecutive calendar months following discharge from one of the identified settings.
2. A new section 512.20 is added to Title 14 NYCRR to read as follows:
§ 512.20 Target population.
(a) Individuals who are members of the target population as defined in Section 512.4 must meet the standard eligibility criteria for enrollment in PROS as defined in Section 512.7 of this Part.
(b) In addition to the other provisions of this Part, effective April 1, 2014, the following provisions shall apply to PROS providers that are providing services to members of the target population.
(1) Reimbursement for individuals in the target population who are in continuous pre-admission status is limited to four consecutive months, whether or not the individual is ultimately admitted to the program. Programs will be reimbursed for pre-admission services for the target population at the existing pre-admission rate plus 25 percent.
(2) Medicaid may reimburse the Intensive Rehabilitation component add-on for up to 50 percent of a provider’s total number of monthly base rate bills submitted annually. IR services provided to the target population shall not count toward the 50 percent limitation for Medicaid reimbursement.
(3) The following CRS services will offer an enhanced reimbursement when delivered off site, on separate days, to individuals in the target population:
(i) Basic skills living training;
(ii) Benefits and financial management;
(iii) Community living exploration;
(iv) Information and education regarding self help; and
(v) Wellness self management.
(4) If two or three of the identified CRS services are delivered off site to individuals in the target population in a calendar month, programs will be reimbursed at the base rate plus $135 (upstate) or $150 (downstate). If four or more of the identified CRS services are delivered off site to individuals in the target population in a calendar month, programs will be reimbursed at the base rate plus $270 (upstate) or $300 (downstate).
Text of proposed rule and any required statements and analyses may be obtained from:
Sue Watson, NYS Office of Mental Health, 44 Holland Avenue, Albany, NY 12229, (518) 474-1331, email: Sue.Watson@omh.ny.gov
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 OMH 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 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 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 OMH regarding Medicaid reimbursed programs. The rule making furthers the Legislative intent under Article 7 by ensuring that the OMH 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: Personalized Recovery-Oriented Services (PROS) is a comprehensive rehabilitation program that offers a range of services used to achieve a desired life role and overcome identified mental health barriers. Recently, the Centers for Medicare and Medicaid Services awarded New York State a “State Balancing Incentive Payment Program Grant” under Section 10202 of the Affordable Care Act. The Balancing Incentive Program (BIP) provides a financial incentive to stimulate greater access to non-institutionally based long-term services and supports. Under this proposal, during the grant period OMH would use BIP funding to provide the financial support needed to help transition individuals identified in the proposed regulation as members of the target population to live in more integrated and independent settings in the community. These individuals, who have received long-term supports and services for at least six months while living in an adult home, nursing home, or State psychiatric center, have been identified by the State as priority populations for integration into community settings.
The PROS model allows unlimited pre-admission services to enable prospective participants to make an informed decision to enroll in the program. Currently, PROS programs receive one rate for pre-admission services in a given month regardless of the number of contacts and use of staff resources. It is anticipated that more staff resources will be required when dealing with individuals from the target population as compared to other prospective PROS participants. This proposed rule increases the current pre-admission rate by 25 percent for the target population.
Existing regulations allow PROS programs to bill a maximum of two consecutive months for the pre-admission rate. This proposal increases the maximum to four consecutive months for pre-admission for the target population since target population members may require more engagement and education efforts in order to make an informed decision to enroll in PROS.
The Intensive Rehabilitation (IR) component of PROS is designed to help an individual pursue, attain and maintain a desired life role goal, and basic skill development is available through the Community Rehabilitation & Support (CRS) component. The target population, having resided in the identified settings for some time, may need intensive skill development in order to function at a healthy and optimal level. Skill development is most effective in natural settings that allow teaching and practice of specific skills.
Although almost all PROS services are allowed to be provided off-site in the community, current reimbursement rates do not support the additional expense of certain services to be delivered in the community. This proposed rule allows programs to receive higher reimbursement for delivering one or more of the following Community Rehabilitation and Support (CRS) services to the target population in the community: Basic Living Skills, Benefits and Financial Management, Community Living Exploration, Information and Education Regarding Self Help and Wellness Self- Management. Lastly, the proposed rule includes Medicaid fee changes paid to PROS providers of services effective April 1, 2014.
4. Costs:
(a) Cost to State government: BIP funds are 100 percent federal dollars and will be used to support increases in the pre-admission rate and enhanced, off site CRS payment. BIP funds are projected to be available through September, 2015. OMH has committed to continue to financially support serving the target population in PROS beyond the BIP end date, but does not anticipate that a significant percentage of the target population will transition from the identified settings after this period.
(b) Cost to local government: These regulatory amendments are not expected to result in any additional costs to local government.
(c) Cost to regulated parties: These regulatory amendments are not expected to result in any additional costs to regulated parties.
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 rule making should not result in an increase in 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 serve to provide enhancements to assist individuals in their transition to more independent community living following an extended period in an adult home, nursing home, or State psychiatric center, and serve to reimburse PROS providers for these enhanced services, 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 serve to provide the financial support needed to help transition individuals to more integrated and independent settings in the community following an extended period in an adult home, nursing home, or State psychiatric center. As there will be no adverse economic impact on small businesses or local governments as a result of these amendments, a regulatory flexibility analysis is not submitted with this notice.
Rural Area Flexibility Analysis
The amendments to 14 NYCRR Part 512 serve to provide the financial support needed to help transition individuals to more integrated and independent settings in the community following an extended period in an adult home, nursing home, or State psychiatric center. The proposed rule will not impose any adverse economic impact on 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 it is evident from the subject matter that there will be no adverse impact on jobs and employment opportunities as a result of these amendments. The amendments to 14 NYCRR Part 512 serve to provide the financial support needed to help transition individuals to more integrated and independent settings in the community following an extended period in an adult home, nursing home, or State psychiatric center.
