SubPart 86-4 - Free-standing Ambulatory Care Facilities

Effective Date: 
Wednesday, June 14, 2017
Doc Status: 
Complete
Statutory Authority: 
Public Health Law, Sections 2803(2), 2807

Section 86-4.1 - Definitions

Section 86-4.1 Definitions. As used in this Subpart:

(a) Facility shall mean all free-standing ambulatory care facilities, diagnostic and/or treatment centers and clinics that are subject to article 28 of the Public Health Law, provided that such facility has been established by the Public Health Council and possesses a valid operating certificate issued by the Commissioner of Health. Rates of reimbursement for hospital-based facilities shall be governed by Subpart 86-1 of this Part.

(b) Free-standing ambulatory care facility, diagnostic and/or treatment center and clinic shall mean a medical facility with one or more organized health services not part of an inpatient hospital facility or vocational rehabilitation center, which is primarily engaged in providing services to out-of-hospital or ambulatory patients by or under the supervision of a physician or dentist, for the prevention, diagnosis or treatment of human disease, pain, injury, deformity or physical condition.

(c) Commissioner shall mean the New York State Commissioner of Health.

(d) Department shall mean the New York State Department of Health.

(e) Bureau shall mean the Bureau of Ambulatory Care Reimbursement in the department.

(f) Article 43 corporation shall mean a corporation organized and operating pursuant to article 43 of the Insurance Law.
 

Doc Status: 
Complete

Section 86-4.2 - Facility rates

86-4.2 Facility rates.

(a) Computation of rates of payment for facility services by government agencies and article 43 corporations shall be governed by the provisions of this Subpart.

(b) Each article 43 corporation shall submit a proposed reimbursement formula not inconsistent with the rules set forth in this Subpart, for approval by the commissioner, no later than 90 days prior to the effective date of rates of payment unless otherwise specified by the commissioner. In order to facilitate the exchange of information necessary for development of the reimbursement formula and rates, each article 43 corporation may confer with any facility, group or association of facilities prior as well as subsequent to submission of its proposed reimbursement formula and rates. The commissioner may require a report of any such contacts, when it is reasonably necessary to the discharge of his or her responsibilities under this Subpart.
 

Doc Status: 
Complete

Section 86-4.3 - Recording and reporting of financial and statistical data

86-4.3 Recording and reporting of financial and statistical data.

(a) Effective for all fiscal years beginning on or after January 1, 1975 treatment centers and/or diagnostic centers shall use the accrual basis of accounting except where an alternate basis is mandated by law. For fiscal years beginning on or after January 1, 1986 treatment centers and/or diagnostic centers shall submit to the New York State Department of Health a certified Ambulatory Health Care Facility-1 form (AHCF-1) no later than April 30th of each year or a later due date if specified in the annual report form transmittal.

(1) Investments, other than donations, shall be reported on the balance sheet of the AHCF-1 at cost. However, the notes to the financial statements shall describe the assets and indicate the quoted market value and cost for each category of investment.

(2) Fixed assets, other than donations, shall be reported on the balance sheet of the AHCF-1 at cost.

(b) Each facility shall complete and file with the department and/or its agent annual financial and statistical report forms supplied by the department and/or his agent. Each facility shall also file a copy of the audited financial statements for the facility, covering the same period as the annual report. Information contained in such filings shall be used by the department to establish rates of payment.

(c) Facilities shall submit to the commissioner separate financial and statistical data for each service and procedure for which rates are established.

(d) Effective on and after January 1, 1995, all diagnostic and/or treatment centers including satellite clinics covered under the same licensure and excluding diagnostic and/or treatment centers operated by New York City or by the New York City Health and Hospitals Corporation shall maintain all books and records utilized for cost reporting and reimbursement purposes on a calendar-year basis.

(e) Financial and statistical report forms shall be completed in accordance with generally accepted accounting principles as applied to medical facilities, unless the report instructions authorize specific variation from such principles.

(f) The financial and statistical reports required by this Subpart shall be submitted to the department and/or its agent no later than 120 days after the close of the fiscal year or a later due date if specified in the annual report form transmittal. A single thirty (30) day extension of time for filing reports may be granted by the commissioner only if a request for extension is received prior to the due date of the report and only if the facility justifies that the reports cannot be filed by the due date for reasons beyond the control of the facility.

(g) Reserved.

(h) In the event a facility fails to file the required financial and statistical reports on or before the due date or extended due date, or fails to comply with the provisions of section 86-4.4 of this Subpart, the commissioner shall reduce the facility's current rate paid by state governmental agencies by two percent beginning the first day of the calendar month following the original due date of the required reports and continuing until the last day of the month in which the required reports are filed.
 

Effective Date: 
Friday, July 26, 1996
Doc Status: 
Complete

Section 86-4.4 - Certification of reports

86-4.4 Certification of reports.

(a) All financial and statistical reports shall be certified by an independent licensed public accountant or an independent certified public accountant on forms prescribed and provided by the Department. A copy of the audited financial statements shall accompany the financial and statistical reports. Where the required financial and statistical report data are incorporated into the audited financial statements of a larger entity, the independent licensed public accountant or the independent certified public accountant shall provide the information necessary to reconcile the cost report presentation to the financial statements in detail. An accountant shall not be independent if: (1) any family relationship, including a relationship by marriage, exists between any accountant, member or employee of the accounting firm and the owner, operator or administrator of the facility; (2) any business relationship other than one related to accounting services exists between any accountant, member, or employee of the accounting firm and the owner, operator or administrator of the facility; (3) any accountant, member, or employee of the accounting firm is responsible for the books and records of the facility; or (4) any accountant, member, or employee of the accounting firm is a member of the board of directors, officer or employee of the facility.

(b) The requirements of subdivision (a) of this section shall not apply to facilities operated by units of government of the State of New York whose total operating costs are less than $100,000.

(c) All financial and statistical reports shall be certified by the operator of a proprietary facility, an officer of a voluntary facility or the public official responsible for the operation of a public facility, on forms prescribed and provided by the department.
 

Effective Date: 
Wednesday, July 31, 1991
Doc Status: 
Complete

Section 86-4.5 - Correction and supplementation of reports

86-4.5 Correction and supplementation of reports.

(a) In the event that any information or data which a facility has submitted to the department for use in establishing rates is found by the facility to be incorrect or incomplete for any reason, the facility shall submit corrected and complete information or data to the Department within 30 days of such finding and prior to certification of the rate.

(b) If the financial and statistical reports required by this Subpart are determined by the department or its agent to be incomplete or incorrect, the facility shall provide additional or corrected data within 30 days from the date of receipt of notice of the determination. Should the facility fail to file corrected or additional data within that period or by a later date specified by the Commissioner, the provisions of subdivision (h) of section 86-4.3 of this Subpart shall apply.

(c) All corrected or completed data or information must meet the certification requirements of section 86-4.4 of this Subpart.

(d) Specific additional data related to the rate setting process may be requested by the commissioner. The commissioner shall supply each facility with a preliminary listing of the data that will be required prior to the start of each rate period. Such data shall be submitted by the facility within 30 days from the date of receipt of a request for such information or by a later date specified by the Commissioner. Failure to submit the additional data shall result in the application of the provisions of subdivision (h) of section 86-4.3, unless the facility documents that the requested data does not exist or cannot reasonably be produced.
 

Effective Date: 
Thursday, February 25, 1993
Doc Status: 
Complete

Section 86-4.6 - Audits

86-4.6 Audits.

(a) All fiscal and statistical records and reports shall be subject to audit, which must commence no later than six years from the date of filing or the date when due, whichever is later. There shall be no limitation in situations involving possible fraud or where the facility or its agent prevents the Department of Health or the Department of Social Services from performing an audit. Notification by either department to the facility of the department's intent to audit shall toll the six-year period.

(b) All underlying books, records and documentation which form the basis for fiscal and statistical reports filed by the facility with the department, shall be kept and maintained by the facility for not less than six years from the date of filing or the date upon which the fiscal and statistical records were to be filed, whichever date is later. Any rate of payment certified or approved by the commissioner prior to audit shall represent a provisional rate until an audit is performed and completed, at which time such rate or adjusted rate shall represent the audit rate.

(c) Rate revisions resulting from audits shall be retroactive to the audited rate period or periods. Any resulting overpayments or underpayments shall be corrected by retroactive adjustment of the provisional rate paid, based upon the period audited.

(d) The commissioner may promulgate rate revisions based upon audits completed by the department or other State agencies. Unless otherwise indicated, such audits shall not be considered final and shall not preclude conduct of a complete audit by the Department of Health, Department of Social Services or their agents.
 

Effective Date: 
Wednesday, March 11, 1992
Doc Status: 
Complete

Section 86-4.7 - Title XVIII (Medicare) certification

86-4.7 Title XVIII (Medicare) certification. Any facility eligible for Title XVIII (Medicare) certification providing services to patients insured under Title XIX which is not, or ceases to be, a Title XVIII provider of care shall have its current reimbursement rate reduced by 10 percent. This rate reduction may remain in effect until the first day of the month following certification of such a provider by the Title XVIII program. Such rate reductions shall be in addition to any revision of rates based on audit exceptions.

Effective Date: 
Wednesday, July 31, 1991
Doc Status: 
Complete

Section 86-4.8 Reserved

Effective Date: 
Tuesday, February 19, 1980

Section 86-4.9 - Units of service

86-4.9 Units of service. (a) The unit of service used to establish rates of payment shall be the threshold visit, except for dialysis, abortion, sterilization services and free-standing ambulatory surgery, for which rates of payment shall be established for each procedure. For methadone maintenance treatment services, the rate of payment shall be established on a fixed weekly basis per recipient.
(b) A threshold visit, including all part-time clinic visits, shall occur each time a patient crosses the threshold of a facility to receive medical care without regard to the number of services provided during that visit. Only one threshold visit per patient per day shall be allowable for reimbursement purposes, except for transfusion services to hemophiliacs, in which case each transfusion visit shall constitute an allowable threshold visit.
(c) The following shall not constitute threshold visits within the meaning of subdivisions (a) and (b) of this section:

(1) visits solely for the purpose of receiving ordered ambulatory services;

(2) visits solely for the purpose of receiving pharmacy services;

(3) visits solely for the purpose of receiving nutrition services;

(4) visits solely for the purpose of receiving respiratory therapy;

(5) visits solely for the purpose of receiving recreation therapy;

(6) visits solely for the purpose of receiving medical social services, except for clinical social worker psychotherapy services as defined in subdivision (g) of this section;

(7) visits solely for the purpose of receiving group services, except for clinical group psychotherapy services in accordance with the provisions of subdivision (h) of this section;

(8) offsite services, defined as medical services provided by a facility's clinic staff at locations other than those operated by and under the licensure of the facility, or visits related to the provision of such offsite services, except in accordance with the provisions of subdivision (i) of this section.
(d) A procedure shall include the total service, including the initial visit, preparatory visits, the actual procedure and follow-up visits related to the procedure. All visits related to a procedure, regardless of number, shall be part of one procedure and shall not be reported as a threshold visit.
(e) Rates for separate components of a procedure may be established when patients are unable to utilize all of the services covered by a procedure rate. No separate component rates shall be established unless the facility includes in its annual financial and statistical reports the statistical and cost apportionments necessary to determine the component rates.
(f) Ordered ambulatory services may be covered and reimbursed on a fee-for-service basis in accordance with the State medical fee schedule. Ordered ambulatory services are specific services provided to nonregistered clinic patients at the facility, upon the order and referral of a physician, physician's assistant, dentist or podiatrist who is not employed by or under contract with the clinic, to test, diagnose or treat the patient. Ordered ambulatory services include laboratory services, diagnostic radiology services, pharmacy services, ultrasound services, rehabilitation therapy, diagnostic services and psychological evaluation services.
(g) For purposes of this section clinical social worker psychotherapy services are defined as individual psychotherapy services provided in a Federally Qualified Health Center, by a licensed clinical social worker or by a licensed master social worker who is working in a clinic under qualifying supervision in pursuit of licensed clinical social worker status by the New York State Education Department.

(h) Clinical group psychotherapy services provided in a Federally Qualified Health Center (FQHC), are defined as services performed by a clinician qualified as in subdivision (g) of this section, or by a licensed psychiatrist or psychologist to groups of patients ranging in size from two to eight patients. Clinical group psychotherapy shall not include case management services. Reimbursement for these services shall be made on the basis of a FQHC group rate which will be calculated by the Department for this specific purpose, payable for each individual up to the limits set forth herein, using elements of the Resource Based Relative Value System (RBRVS) promulgated by the Centers For Medicare And Medicaid Services (CMS), and approved by the State Division of Budget.

(i) Federally Qualified Health Centers will be reimbursed for the provision of offsite primary care services to existing FQHC patients in need of professional services available at the FQHC, but, due to the individual's medical condition, is unable to receive the services on the premises of the center.

(1) FQHC offsite services must:

(i) consist of services normally rendered at the FQHC site.

(ii) be rendered to an FQHC patient with a pre-existing relationship with the FQHC (i.e., the patient was previously registered as a patient with the FQHC) in order to allow the FQHC to render continuous care when their patient is too ill to receive on-site services, and only to patients expected to recover and return to become an on-site patient again. Off-site services may not be billed for patients whose health status is expected to permanently preclude return to on-site status.

(iii) be rendered only for the duration of the limiting illness, with the intent that the patient return to regular treatment as an on-site patient as soon as their medical condition allows.

(iv) be an individual medical service rendered to an FQHC patient by a physician, physician assistant, midwife or nurse practitioner.

(v) not be rendered in a nursing facility or long term care facility, to any patient expected to remain a patient in that facility or at that level of care.

(vi) not be billed in conjunction with any other professional fee for that service, or on the same day as a threshold visit.

(2) Reimbursement for these services shall be made on the basis of an FQHC offsite professional rate, which will be calculated by the Department using elements of the Resource Based Relative Value System (RBRVS) promulgated by the Centers For Medicare And Medicaid Services (CMS) and approved by the State Division of Budget.

Effective Date: 
Wednesday, March 25, 2009
Doc Status: 
Complete

Section 86-4.10 - Minimum utilization standards

86-4.10 Minimum utilization standards.

(a) For the purpose of determining the number of threshold visits to be used in the computation of basic rates, the commissioner shall establish minimum utilization standards as provided in this section. Such standards shall be based upon an assessment of visits per full-time equivalent for health care personnel. A full-time equivalent (FTE) shall be based upon a 35-40 hour week.

(b) For the comprehensive primary care facilities, threshold visits shall be imputed at:

(1) 3,500 visits per year per FTE for the services of physicians and physician specialists;

(2) 3,000 visits per year per FTE for the services of dentists;

(3) 2,100 visits per year per FTE for the services of other health care providers such as physician's assistants, licensed midwives, nurse practitioners and dental hygienists;

(4) 2,100 visits per year per FTE for the services of therapists, such as speech, occupational and physical therapists;

(5) 1,500 visits per year per FTE for the services of mental health counselors.

Effective Date: 
Wednesday, January 23, 2002
Doc Status: 
Complete

Section 86-4.11 - Computation of basic rate for facilities other than licensed free-standing ambulatory surgery centers

86-4.11 Computation of basic rate for facilities other than licensed free-standing ambulatory surgery centers.

(a) Rates of payment for facilities other than licensed free-standing ambulatory surgery centers shall be established on a prospective basis and shall be computed on the basis of allowable fiscal and statistical data submitted by the facility for the fiscal year ended at least 15 months prior to the year for which rates are being set. Unless otherwise specified in this Subpart, the computed rates shall be all-inclusive, taking into consideration total allowable costs and total billable patient visits or procedures.

(b) Rates will be determined by applying ceiling limitations to allowable operating costs, applying the trend factor to the result, adding reimbursable capital costs, and dividing the sum by the total number of visits or procedures. In the case of proprietary facilities, a return on investment shall be added to reimbursable costs.

(c) Certification by the commissioner of reimbursement rates of payment by governmental agencies for the period April 1, 1993 through March 31, 1994 shall be extended six months, through September 30, 1994, by applying the applicable trend factors. Rates of payment shall then be for the fiscal-year period October 1st through September 30th. Approval by the commissioner of reimbursement rates for article 43 corporations shall be for the periods specified in the reimbursement formula approved by the Commissioner of Health.
 

Effective Date: 
Wednesday, July 13, 1994
Doc Status: 
Complete

Section 86-4.12 - Allowance for diagnostic and/or treatment centers providing a disproportionate share of bad debt and charity care

86-4.12 Allowance for diagnostic and/or treatment centers providing a disproportionate share of bad debt and charity care.

(a) Basic rates of payment by governmental agencies for voluntary non-profit or publicly sponsored diagnostic and/or treatment centers which provide a comprehensive range of primary health care services and can demonstrate losses as a result of providing a disproportionate share of bad debt and charity care shall include a bad debt and charity care allowance. In addition, a diagnostic and/or treatment center which is approved as a preferred primary care center may be eligible for a supplemental allowance. The supplemental allowance shall be based on losses associated with the delivery of bad debt and charity care incurred by a preferred primary care provider to the extent such losses exceed any losses associated with the delivery of bad debt and charity care incurred for 1993 or if later, the year immediately preceding the year in which the diagnostic and/or treatment center is first designated as a preferred primary care provider.

(b) The provisions of this section shall apply to rates of payment for rate periods during the period July 1, 1990 through March 31, 1991; April 1, 1991 through March 31, 1992, April 1, 1992 through March 31, 1993 and April 1, 1993 through September 30, 1994 and for each fiscal year period commencing on October first thereafter for the distribution of the bad debt and charity care allowance, and to rates of payment during the period January 1, 1994 through March 31, 1994 and each fiscal year period commencing on April 1st thereafter for preferred primary care providers who are eligible to receive a receive a supplemental allowance.

(c) Eligibility shall be limited to voluntary non-profit and publicly sponsored diagnostic and/or treatment centers for the initial distribution of the bad debt and charity care allowance and to diagnostic and/or treatment centers designated as preferred primary care providers for the supplemental allowance which meet the following criteria:

(1) the facility must demonstrate that it is licensed to provide primary medical care, must primarily provide a comprehensive range of primary care and related support services;

(2) the facility must be able to demonstrate on forms prescribed by the commissioner that a minimum of fifteen percent of total clinic threshold visits reported for the base year were eligible visits as defined in subdivision (e)(2) of this section;

(3) the facility must be able to demonstrate that it has made reasonable efforts to maintain financial support from community and public funding sources;

(4) the facility must be able to demonstrate that it has made reasonable efforts to collect payments for services from third-party insurance payors, governmental payors and self-paying patients;

(5) the facility must receive an all-inclusive cost-based Medicaid reimbursement rate in accordance with section 86-4.11 of this Title;

(6) the facility must have no petition for bankruptcy filed under either Chapter 7 or Chapter 11 of Title 11 of the U.S. Code. The commissioner may waive this criteria if the facility demonstrates that it is financially viable or a potentially financially viable organization with a comprehensive plan to maintain fiscal integrity.

(d) An annual aggregate amount set forth in statute (see Public Health Law 2807(2)(f)) shall be allocated and distributed to publicly sponsored and voluntary non-profit diagnostic and/or treatment centers.

(e) Allowances shall be established on a prospective basis and shall be computed on the basis of allowable fiscal and statistical data submitted by the facility for the fiscal year ended at least fifteen months prior to the year for which allowances are being set. The bad debt and charity care allowance shall be paid as an addition to the facility's rate of payment. The amount to be paid will be calculated by dividing each eligible facility's bad debt and charity care loss by base year Medicaid threshold visits.

(1) Eligible losses will be calculated by applying a facility's Medicaid rate of payment for the rate period for which the allowance is being determined, to identified base year eligible visits or units of service.

(2) An eligible visit shall be defined as the unit of service upon which Title XIX payment is based provided, however, to an individual who after a reasonable period of time appears to be unable to pay all or a portion of the payment due for the service, except for those portions of the payment due which are covered by a government agency, insurer or third- party payor, including payment made directly to the diagnostic and/or treatment center and indemnity or similar payment.

(3) All payments received in the base year directly for eligible visits, government and entitlement revenues obtained for the purpose of subsidizing the diagnostic and/or treatment center's general operating expenses and any supplemental allowance received by a diagnostic and/or treatment center designated as a preferred primary care provider shall be offset against eligible costs to arrive at an eligible loss under this section. (4) An annual amount of loss coverage will be calculated by applying eligible losses against the following nominal loss coverage formula:

Percent of eligible bad debt and charity care clinic visits to Percent of nominal total visits loss coverage

up to 15% 50%

15% to 30% 75%

30% plus 100%

The nominal loss coverage percentages may be increased to not more than one hundred percent for voluntary non-profit or publicly sponsored diagnostic and/or treatment centers if the sum of the nominal payments for all eligible voluntary non-profit or public diagnostic and/or treatment centers is less than the amounts allocated for non-public or public agencies.

(5) Separate coverage ratios shall be established for voluntary non-profit and publicly sponsored diagnostic and/or treatment centers in order to make the allocation described in subdivision (d) of this section. These coverage ratios will consist of the aggregate nominal losses for voluntary non-profit and publicly sponsored diagnostic and/or treatment centers, divided into non-public and publicly sponsored disproportionate share allocations, as appropriate. These coverage ratios shall be applied to each voluntary non-profit or publicly sponsored diagnostic and/or treatment center's annual amount of bad debt and charity care loss coverage to determine the level of bad debt and charity case losses to be incorporated into each facility's Medicaid rate of payment.

(6) The department may make periodic prospective adjustments to an eligible facility's Medicaid payment to ensure that each facility receives the full amount of the allowance for which it is eligible. In no instance shall a diagnostic and/or treatment center receive an allowance which in the aggregate exceeds the maximum amount for which it is eligible under this section. In no event shall a facility receive an allowance in an amount exceeding the facility's need for financing losses associated with the delivery of bad debt and charity care.

(f)(1) Eligible facilities shall submit to the department a supplement to the cost report used for Title XIX (Medicaid) reimbursement. This supplement shall be provided by the department and must be returned to the department within 45 days from the date it is received by facilities for the 1990 and 1991 rate years and thereafter shall be returned to the department with the cost report used for purposes of Title XIX reimbursement. The supplement shall include but not be limited to the number of eligible visits or units of service, the costs of eligible services, patient and third-party revenues associated with the eligible services, government and entitlement revenues and Article 2 and Article 6 Local Assistance funding associated with charity care as part of its annual reporting process.

(2) Eligible facilities shall collect and report actual threshold visits and revenues associated with the provision of bad debt and charity care services to their patient population. All reported data will be subject to audit. The allowance may be revised based upon audit findings.

(3) Facilities shall provide assurances that they will make and shall document upon request, the reasonable efforts made to maintain financial support from community and public funding sources and to collect payments from third-party payors, governmental payors and self-pay patients.

(4) The commissioner may retroactively reduce a facility's allowance if it is determined that actions or decisions by a facility's management have caused a significant reduction for the rate period in the delivery of comprehensive primary health care services to bad debt and charity care patients.
 

Effective Date: 
Wednesday, July 13, 1994
Doc Status: 
Complete

Section 86-4.13 - Groupings

86-4.13 Groupings.

(a) For the purpose of establishing reimbursable operating costs, facilities shall be compared on the basis of the following general criteria:

(1) similarity of services; and

(2) regional economic factors.

(b) Comparisons using similarity of services shall be based on the following:

(1) Comprehensive primary medical care services shall mean those health care services organized to provide basic medical care to the general population without regard to patient category or characteristics such as health status, diagnosis, age or sex. Such primary medical care services shall be provided by staff sufficient in number and capable of delivering comprehensive primary medical care services. A facility providing comprehensive primary medical care services as its principal mission shall be categorized as a comprehensive primary medical care facility.

(2) Limited primary medical care services shall mean those health care services organized to provide basic medical care to a population of individuals with a specific medical condition or dysfunction. Such primary medical care services focus on the medical care needs of this population that are incidental to, interrelated with or a consequence of the specific primary medical diagnosis/disease process. When limited primary medical care services are not the principal mission of a facility, the facility providing limited primary medical care services shall be categorized based on the services, as defined in this section, which it provides as its principal mission and shall not be categorized as a comprehensive primary medical care facility.

(3) Family planning services shall mean those services organized to provide reproductive and/or gynecological related health care services to men and women of reproductive age. A facility providing family planning services as its principal mission shall be categorized as a family planning facility.

(4) Abortion services shall mean those services related to the termination of pregnancy including services associated with verification of the pregnancy, abortion counseling services and post-procedure examinations. Sterilization procedures done as outpatient surgery shall be included in this category as well. A facility providing abortion services as its principal mission shall be categorized as an abortion facility.

(5) Developmentally disabled services shall mean those services organized to provide ongoing/long-term rehabilitation therapy services to individuals with developmentally related physical disabilities. A facility providing developmentally disabled services as its principal mission shall be categorized as a developmentally disabled services facility.

(6) Rehabilitation therapy services shall mean those services organized to provide episodic or short-term restorative therapy services to individuals physically disabled from causes that are predominantly other than developmentally related. A facility providing such rehabilitation therapy services as its principal mission shall be categorized as a rehabilitation therapy facility.

(7) Speech and hearing services shall mean speech/language pathology and audiology services. A facility providing speech and hearing services as its principal mission shall be categorized as a speech and hearing facility.

(8) Dental services shall mean those services organized to provide basic dental care to the general population. A facility providing dental services as its principal mission shall be categorized as a dental facility.

(9) Dialysis services shall mean hemodialysis, peritoneal dialysis and home dialysis services provided to patients with chronic renal disease. A facility providing dialysis services as its principal mission shall be categorized as a dialysis facility.

(10) Optometric services shall mean optometry and services related to eye and vision care. A facility providing optometric services as its principal mission shall be categorized as an optometric facility.

(11) Methadone maintenance treatment services shall mean drug detoxification and drug dependency counseling and rehabilitation services which include chemical management of the patient with methadone. A facility providing methadone maintenance treatment services as its principal mission and certified by the Office of Alcohol and Substance Abuse Services shall be categorized as a methadone maintenance treatment program (MMTP) facility.

(12) Drug free services shall mean drug dependency counseling and rehabilitation services, including incidental and interrelated medical care services, provided in a drug free environment. A facility providing drug free services as its principal mission shall be categorized as a drug free facility.

(13) Child health services shall mean acute, episodic, preventive and well child care services, including immunizations, provided to the pediatric population. A facility providing child health services as its principal mission shall be categorized as a child health facility. (14) A county sponsored facility which does not provide comprehensive primary medical care services but provides health care services such as dental, well child care, immunizations, TB services, STD services, and prenatal and/or other reproductive related health care services shall be categorized as a county sponsored multi-service facility.

(c) Regional economic factors shall be defined to mean significant differences in labor cost experienced by facilities that are due to their geographic location and which impact on the delivery of patient care services.

(d) For the purpose of comparison, when there are fewer than three facilities defining a particular category of service as their principal mission, the facilities will be treated as ungrouped until such time as there are at least two other similar facilities.
 

Effective Date: 
Thursday, April 1, 1993
Doc Status: 
Complete

Section 86-4.14 - Ceilings on payments

86-4.14 Ceilings on payments.

(a) Reimbursement rate ceilings for the administrative cost center, the patient transportation cost center and for comparable patient care cost centers shall be established for facilities. Comparable patient care cost centers shall include, but not be limited to, the following:

(1) ancillary services cost center (clinical laboratory, pharmacy and diagnostic radiology services);

(2) medical services cost center;

(3) dental services cost center; and

(4) therapy services cost centers.

For a facility which provides limited primary medical care services as defined in section 86-4.13(b)(2) of this Subpart, the administrative and patient care costs incurred by the facility to provide such limited primary medical care services shall be excluded from the costs used to determine the ceilings for the facility's peer group. Reimbursement specific to limited primary medical care services will be established for the facility. The ceilings on costs related to limited primary medical care services will be determined based on the cost experience of facilities which provide limited primary medical care services.

(b) The ceilings shall be established prior to the addition of the trend factor and after the exclusion of desk-audit disallowances and capital costs from total reported costs. The costs of facilities with costs less than 75 percent or over 125 percent of the group average will be raised or lowered to fall within the 75-percent to 125-percent limits.

(c) Ceilings for each cost center shall be computed at 105 percent of the adjusted weighted average base year costs of the facilities in the cost center group.

(d) For the purpose of grouping facilities to establish cost center group ceilings, comprehensive primary medical care facilities will be grouped taking into consideration geographical differences such as upstate/downstate regions and urban/rural locations; family planning facilities will be grouped taking into consideration upstate/downstate regions; all other facilities will be grouped on a statewide basis. If upstate/downstate regions and/or urban/rural locations have not already been taken into account, the ceilings for facilities grouped in accordance with Subpart 86-4.13(b) will be adjusted by wage adjustment factors to recognize differences due to regional economic factors.

(e) The wage adjustment factor will be established by the commissioner based on examination of the salary and employee health and welfare cost experience of the facilities grouped in accordance with section 86-4.13(b) and the methodology described in section 86-1.54(j)(2). The wage adjustment factors will be updated on an annual basis upon then current and available data.

(f) Ceilings for operating costs of ungrouped facilities shall be established at the lower of reported base-year operating costs trended to the rate period or the operating cost component of the existing published rate trended forward by a one-year trend factor.

(g) A change in a facility's group or a revision in cost after ceilings have been established shall not cause a recalculation of ceilings for other facilities in the original or new groups, unless the change was occasioned by an error by the department.
 

Effective Date: 
Thursday, April 1, 1993
Doc Status: 
Complete

Section 86-4.15 - Calculation of trend factor

86-4.15 Calculation of trend factor.

(a) The commissioner shall establish trend factors to project increases in allowable operating costs during the effective period of the reimbursement rate.

(b) To determine trend factors, the elements of facilities' costs shall be weighted based upon data for salaries, employee health and welfare expense, nonpayroll administrative and general expense, nonpayroll household and maintenance expense, and nonpayroll professional care expense. Each weight shall be adjusted by one or more price indices. Included among these indices are elements of the United States Department of Labor consumer and producer price indices and special indices developed by the commissioner for this purpose.

(c) The projected trend factors shall be updated on an annual basis, based upon then current and available data. The commissioner shall adjust subsequent trend factors based upon such update.
 

Effective Date: 
Wednesday, July 31, 1991
Doc Status: 
Complete

Section 86-4.16 - Revisions in certified rates

86-4.16 Revisions in certified rates.

(a) The commissioner shall consider only those applications for prospective revisions of certified or approved rates which are in writing and which address one or more of the issues set forth in this section.

(b) Errors, whether mathematical or clerical, made by the department or an article 43 corporation in the rate calculation process or in the development of group ceilings, and errors, whether mathematical or clerical or otherwise, in data submitted by a facility, when the revised data submitted meet the same certification requirements as the original data, may be the basis for an application for prospective revision of a certified or approved rate. Such errors may include, but shall not be limited to, the following areas related to the development of reimbursable costs:

(1) funding of depreciation, capital costs, patient visits/procedure; and

(2) nonallowable costs, such as revenue recoveries. Applications pursuant to this subdivision must be submitted within 120 days of receipt of the applicable title XIX or article 43 corporation program initial rate computation sheet. Any modified rate certified or approved pursuant to this paragraph shall be effective the first day of the rate period. If not commenced within 120 days of receipt of the commissioner's initial rate computation sheet, a rate appeal pursuant to this subdivision may be initiated at time of audit of the base-year cost figures upon or prior to receipt of the notice of program reimbursement. Such rate appeals shall be recognized only to the extent that they are based upon mathematical or clerical errors in cost and/or statistical data originally submitted by the facility, or revisions initiated by a third-party fiscal intermediary or, in the case of a governmental facility, by the sponsor government, or mathematical or clerical errors made by the Department of Health. Such notice of appeal must be presented in writing prior to or at the exit conference for such audits.

(c) Documented increases in the overall operating costs of a facility resulting from the implementation of additional or expanded programs, staff or services specifically mandated for the facility by the commissioner may be the basis for an application for prospective revision of a certified or approved rate. An appeal may be submitted pursuant to this subdivision at any time throughout the rate period, or within 60 days after the end of the rate period. Any modified rate certified or approved pursuant to this subdivision shall be effective on the date additional staff not reflected in the base year is hired by the facility.

(d) Documented increases in overall operating costs of a facility resulting from capital renovation, expansion, replacement or the inclusion of new programs, staff or services approved by the commissioner through the certificate of need (CON) process may be the basis for an application for revision of a certified rate, provided, however, that such CON approval shall not be required with regard to such applications for rate revisions which are submitted by federally qualified health centers or rural health centers which are exempt from such CON approval pursuant to section 2807-z of the Public Health Law. To receive consideration for reimbursement of such costs in the current rate year, a facility shall submit, at the time of appeal or as requested by the commissioner, detailed staffing documentation, proposed budgets and financial data, anticipated utilization expressed in terms of threshold visits and/or procedures and, where relevant, the final certified costs of construction approved by the department. An appeal may be submitted pursuant to this paragraph at any time throughout the rate period. Any modified rate certified or approved pursuant to this paragraph shall be effective on the date the new service or program is implemented or, in the case of capital renovation, expansion or replacement, on the date the project is completed and in use.

(e) Upon receipt of actual cost data for appeals pursuant to subdivisions (c)and (d) of this section, the modified rate based on projections will be retroactively revised to reflect actually incurred costs held to operating cost ceiling limitations and utilization standards set forth in this Subpart.

(f) Appeals pursuant to subdivision (c) or (d) of this section for subsequent rate periods must be submitted for each subsequent period within 120 days of receipt of the commissioner's initial rate computation sheet for that year.

(g) Appeals to adjustments made as a result of audits conducted by the Department of Health may be the basis for an application for rate revision. The specific items of appeal and any material documentation necessary to support provider's position must be submitted within 30 days of the receipt of the audit.
 

Effective Date: 
Wednesday, February 19, 2014
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Section 86-4.17 - Appeal process

86-4.17 Appeal process.

(a) An application by a facility for review of a certified or approved rate pursuant to section 86-4.16 of this Subpart shall be submitted to the bureau for staff review and shall set forth the basis for the appeal and the issues of fact. Documentation shall accompany the application, where appropriate, and the department may request such additional documentation as is necessary for determination of the issues. The affirmation or revision of the rate based upon such staff review shall be final unless, within 30 days of its receipt, a hearing before a rate review officer is requested by registered or certified mail. The request shall contain a statement of the factual issues to be resolved. The facility may submit memoranda on legal issues which it deems relevant to the appeal.

(b) Where the rate review officer determines that there is no factual issue, the request for a hearing shall be denied and the facility shall be notified of such determination. No administrative appeal shall be available from this determination. Where the rate review officer determines that there is a factual issue, a notice of hearing shall be issued establishing the date, time and place of the hearing and setting forth the factual issues as determined by such officer. The hearing shall be held in conformity with the provisions of section 12-a of the Public Health Law and the State Administrative Procedure Act.

(c) The recommendation of the rate review officer shall be submitted to the Commissioner of Health for final approval or disapproval and recertification of the rate where appropriate.

(d) In reviewing appeals for revisions to certified or approved rates, the commissioner may refuse to accept or consider an appeal from a facility:

(1) which is providing an unacceptable level of care as determined after review by the State Hospital Review and Planning Council;

(2) which is operated by management determined by the department to be providing an unacceptable level of care in one of its facilities as determined after review by the State Hospital Review and Planning Council;

(3) where it has been determined by the commissioner that the operation is being conducted by a person or persons not properly established in accordance with the Public Health Law; or

(4) where a fine or penalty has been imposed on the facility and such fine or penalty has not been paid.

(e) If an appeal or application by a facility affects only the facility's article 43 rate, the facility must appeal or make application to the article 43 corporation for a change or revision in its article 43 rate within the time periods set forth in this Subpart. If the article 43 corporation recommends that such appeal or application be granted, it shall forward such recommendation to the commissioner for determination. If the article 43 corporation denies such appeal or application, the facility may, within 30 days after receipt of the denial, appeal such determination to the commissioner. The basis upon which a facility may appeal or make application for a change or revision in its article 43 rate shall be the same as the basis for an appeal or application set forth in this Subpart.

(f) If an appeal or application by a facility for a change or revision in its rate of reimbursement paid by government agencies and determined pursuant to this Subpart also affects the facility's approved article 43 rate, the facility shall forward a copy of its appeal or application to the article 43 corporation at the same time the facility submits the appeal or application to the commissioner. The article 43 corporation shall forward any recommendation for a determination of such appeal or application to the commissioner. Upon the commissioner's determination, the article 43 corporation shall send a copy of such determination to the facility.
 

Effective Date: 
Friday, July 26, 1996
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Section 86-4.18 Reserved

Effective Date: 
Tuesday, February 19, 1980

Section 86-4.19 - Rates for facilities without adequate cost experience

86-4.19 Rates for facilities without adequate cost experience.

(a) A facility shall be deemed to be without adequate cost experience when fiscal and statistical data necessary for setting a rate are unavailable through no fault of the operator or his or her agents, and due to circumstances beyond his or her control, or in the instance of a newly licensed facility or in the instance of a new service for which certificate of need (CON) approval has been received as required by law. The rates certified for a facility without adequate cost experience shall be determined on the basis of:

(1) the rates established for comparable services or facilities in the geographic area;

(2) reasonable and complete cost projections based on estimated costs and statistics contained in a proposed annual budget for the new service or newly licensed facility, reviewed for adequacy and reasonableness of the proposed operation including but not limited to utilization, as compared to standards established in Section 86-4.10 of this Subpart, staffing, and salaries;

(3) actual allowable expenditures and statistics for prior or subsequent cost reporting periods; and/or

(4) existing ceilings.

(b) Rates for new services or facilities established pursuant to this section shall be retroactively adjusted using actual costs and statistics for the first full fiscal period of operation of the new facility or service.

(c) Notwithstanding the above, rates of payment for licensed free-standing ambulatory surgery centers shall be determined pursuant to section 86-4.40 of this Subpart.

(d) All rates of reimbursement certified pursuant to this section, exclusive of those for licensed free-standing ambulatory surgery centers, shall be subject to audit. After audit, the facility rate shall be revised based upon actual allowable costs incurred during the rate period, consistent with the provisions of this Subpart.
 

Effective Date: 
Wednesday, July 31, 1991
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Section 86-4.20 - Capital cost reimbursement

86-4.20 Capital cost reimbursement. The capital cost of a facility for purposes of determining and certifying the capital cost component of a rate shall be determined and computed in accordance with the provisions of sections 86-4.23 through 86-4.26 of this Subpart, and shall be certified and audited as actually having been expended. Capital costs shall not be trended or held to operating cost ceilings pursuant to sections 86-4.15 and 86-4.14, respectively.

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Section 86-4.21 - Allowable costs

86-4.21 Allowable costs.

(a) To be considered as allowable in determining reimbursement rates, costs must be actual, reasonable and properly chargeable to necessary patient care. Except as otherwise provided in this Part, or in accordance with specific determination by the commissioner, allowable costs shall be determined by the application of the principles of reimbursement developed for determining payments under the title XVIII (Medicare) program.

(b) Allowable costs shall not include costs for services that have not been approved by the commissioner.

(c) Allowable costs shall include a monetary value assigned to services provided under contract by religious orders and to services rendered by an owner and operator of a facility or an operator's relatives in accordance with section 86-4.27 of this Subpart.

(d) Allowable costs may not include amounts in excess of reasonable or maximum title XVIII (Medicare) costs or in excess of customary charges to the general public. This provision shall not apply to services furnished by public providers free of charge or at a nominal fee. Allowable costs shall not include any amount for bad debts.

(e) Allowable costs shall not include expenses or portions of expenses reported by individual facilities which are determined by the commissioner not to be reasonably related to the efficient production of service because of either the nature or amount of the particular item.

(f) Allowable costs shall not include costs which principally afford diversion, entertainment or amusement to facility owners, operators or employees.

(g) Allowable costs shall not include any interest charged or penalty imposed by governmental agencies or courts, or the costs of policies obtained solely to insure against the imposition of such penalties.

(h) Allowable costs shall not include the direct or indirect costs of advertising (except help-wanted ads), public relations and promotion. Reasonable direct and indirect costs of outreach services designed to attract patients in need of medical services shall be allowable.

(i) Allowable costs shall not include costs or contributions or other payments to political parties, candidates or organizations.

(j) Allowable costs shall include only that portion of the dues paid to any professional association which has been determined by the commissioner to be allocable to expenditures other than for public relations, advertising and political contributions.

(k) Allowable costs shall not include any element of cost determined by the commissioner to have been created by the sale of a facility.

(l) Allowable costs shall include the cost of services incurred by the facility's staff to provide offsite services to registered patients of the facility. Allowable costs shall not include the cost of offsite services provided to nonregistered patients or the cost of services provided through arrangements with other facilities. When the cost of such services cannot be established, income from such services shall be used to adjust allowable costs.

(m) Allowable costs shall include the cost of National Health Service Corps personnel, based upon the liability incurred by the facility for the report period, not actual expenditures for the personnel during the report period.

(n) Allowable costs shall not include the cost of ordered ambulatory services. When the cost of such services cannot be determined, income from the services may be used to adjust allowable costs.

(o) Allowable costs may include certain costs not normally covered under Medicare (title XVIII of the Social Security Act), including but not limited to the cost of dental services, patient transportation, prescription drugs, eyeglasses, prosthetic or orthotic devices, podiatry services.

(p) Allowable costs shall not include the costs of education services, including special classroom programs for preschool and school-age children unable to attend public schools, unless such services are medically necessary.

(q) Allowable costs shall include the costs of recreational services rendered in accordance with a physician's plan of treatment. The costs of recreational services that provide leisure activities shall not be allowable.

(r) Allowable costs shall not include costs related to inpatient services rendered by hospitals or services related to living accommodations in a residential treatment program.

(s) All research costs shall be excluded from allowable costs. Research shall include those studies and projects which have as their purpose the enlargement of general knowledge and understanding, are experimental in nature and hold no prospect of immediate benefit to the facility or its patients.

(t) The costs of educational activities for employees, less tuition paid or reimbursed by other than the facility and supporting tuition or related grants, shall be allowable, provided such activities are directly related to patient care services.

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Section 86-4.22 - Recoveries of expense

86-4.22 Recoveries of expense. Operating costs shall be reduced by the cost of services and activities which are not properly chargeable to patient care. In the event that the commissioner determines that it is not practical to establish the costs of such services and activities, the income derived from them may be substituted for their costs. The activities and services covered by this provision include, but are not limited to:

(a) drugs and supplies sold to other than facility patients;

(b) telephone and telegraph services for which a charge is made;

(c) discount on purchases;

(d) sale of scrap;

(e) employee cafeterias;

(f) vending machines;

(g) operation of parking facilities for community convenience;

(h) lease of office and other space to concessionaires; and

(i) sale of silver from X-ray films.
 

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Section 86-4.23 - Depreciation

86-4.23 Depreciation.

(a) Allowable depreciation shall be limited to those assets which are used for purposes of providing or supporting direct patient care. Reported depreciation based on historical cost is recognized as a proper element of cost. Useful lives for assets purchased after 1991 shall be the higher of the reported useful life or those useful lives from the Estimated Useful Lives of Depreciable Hospital Assets, 1988 edition, American Hospital Association, consistent with title XVIII provisions. Useful lives for assets purchased prior to 1991 shall be determined by use of the 1983 edition. Copies of these publications are available from the American Hospital Association, 840 North Lake Shore Drive, Chicago, IL 60611, and copies are available for inspection and copying at the offices of the Records Access Officer of the Department of Health, Corning Tower Building, Empire State Plaza, Albany, NY 12237.

(b) In the computation of rates for voluntary facilities, depreciation shall be included on a straight-line method on plant and nonmovable equipment. Depreciation on movable equipment may be computed on a straight-line method or accelerated under a double declining balance or sum-of-the-years' digits method.

(1) Voluntary facilities shall fund depreciation unless the commissioner determines, upon application by the facility and after inviting written comments from interested parties, that a waiver of the requirement for funding is necessary and in the public interest. Funding shall mean the transfer of monies to the funded accounts. Board-designated funds and the accrual of liabilities to the funded depreciation accounts shall not be recognized as funding of depreciation. Deposits to the funded depreciation accounts must remain in such accounts for six months or more to be considered as valid funding transactions unless expended for the purposes for which the account was funded.

(2) Funding for plant and fixed equipment shall mean that the transfer of monies to the funded accounts shall occur by the end of the fiscal period in which the depreciation is recorded.

(3) Depreciation on major movable equipment shall be funded in the year revenue is received from the reimbursement of each expense and in the amount included in reimbursement for that year.

(4) Such funds may be used only for capital expenditures with approval as required for the amortization of capital indebtedness.

(c) In the computation of rates for public facilities, depreciation shall be included on a straight-line method on plant and nonmovable equipment. Depreciation on movable equipment may be computed on a straight-line method or accelerated under a double declining balance or sum-of-the-years' digits method.

(d) In the computation of reimbursement rates for proprietary facilities, depreciation shall be computed on a straight-line basis on plant and nonmovable equipment. Depreciation on movable equipment may be computed on a straight-line method or accelerated under a double declining balance or sum-of-the-years' digits method.

(e) Facilities financed by mortgage loans pursuant to the Hospital Mortgage Loan Construction Law shall conform to the requirements of this Subpart. In lieu of depreciation and interest, on the loan-financed portion of the facilities, the commissioner shall allow level debt service on the mortgage loan, together with such required fixed charges, sinking funds and reserves as may be determined by the commissioner as necessary to assure repayment of the mortgage indebtedness.

(f) Article 43 corporations may elect to include in their reimbursement rates depreciation computed by a method other than that used in subdivisions (b), (c) and (d) of this section, subject to approval of the commissioner.

(g) An amount for rent will be reimbursed as capital cost in lieu of depreciation, provided the following conditions are met:

(1) if required, the lease is reviewed and approved by the department;

(2) the applicant has no interest, direct or indirect, beneficial or of record, in the ownership of the building or any overlease;

(3) the rental per square foot, in the judgment of the department, is the same as or is comparable to other rentals in the building in which the facility is to be located, and the rental per square foot is comparable to the rental of similar space in other comparable buildings in the area when such comparisons can be made; and

(4) the rent, if the lease is a sublease, is the same as or less than rent in comparable leases in the geographic area.
 

Effective Date: 
Wednesday, July 31, 1991
Doc Status: 
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Section 86-4.24 - Interest

86-4.24 Interest.

(a) Necessary interest on both current and capital indebtedness is an allowable cost for all facilities.

(b) To be considered an allowable cost, interest must be incurred to satisfy a financial need, and at a rate not in excess of what a prudent borrower would have to pay in the money market at the time the loan was made. The interest must be paid to a lender not related through control, ownership, affiliation or personal relationship to the borrower. Financial need for capital indebtedness relating to a specific project shall exist when all available restricted funds designated for capital acquisition of that type have been considered for equity purposes.

(c) Interest expense shall be reduced by investment income with the exception of income from funded depreciation, qualified pension funds, trusteed malpractice insurance funds or in instances where income from gifts or grants is restricted by donors. Interest on funds borrowed from a donor-restricted fund or funded depreciation is an allowable expense. Investment income shall be defined as the aggregate net amount realized from dividends, interest, rental income, interest earned on temporary investment of withholding taxes, as well as all gains and losses. If the aggregate net amount realized is a loss, the loss is not allowable. Investment income shall reduce interest expense allowed for reimbursement as follows:

(1) for all medical facilities, investment income shall first be used to reduce operating interest expense for that year;

(2) any remaining amount of investment income, after application of paragraph (1), shall be used to reduce capital interest expense reimbursed that year for medical facilities; and

(3) any remaining amount of investment income after application of paragraph (2) shall not be considered in the determination of allowable costs.

(d) Interest on current indebtedness shall be treated and reported as an operating, administrative expense and shall be held to operating cost ceilings.

(e) Interest on capital indebtedness shall be an allowable cost if the debt generating the interest is approved by the commissioner, and incurred for authorized purposes, and if the principal of the debt does not exceed either the amount approved by the commissioner or the cost of the authorized purposes. Capital indebtedness shall mean all debt obligations of a facility that are:

(1) evidenced by a mortgage note or bond and secured by a mortgage on the land, building or nonmovable equipment, a note payable secured by the nonmovable equipment of a facility, or a capital lease;

(2) incurred for the purpose of financing the acquisition, construction or renovation of land, building or nonmovable equipment; and

(3) found by the commissioner to be reasonable, necessary and in the public interest with respect to the facility; or

(4) incurred for the purpose of advance refunding or debt. Gains and losses resulting from the advanced refunding of debt shall be treated and reported as a deferred charge or asset. This deferred charge or asset shall be amortized on a straight-line basis over the period of the scheduled maturity date of the debt being refunded.

(f) Interest related to refinancing indebtedness shall be considered an allowable cost only to the extent that it is payable with respect to an amount equal to the unpaid principal of the indebtedness then being refinanced. However, interest incurred on refinanced debt in excess of the previously unpaid balance of the refinanced indebtedness will be allowable upon demonstration by the operator to the commissioner that such refinancing will result in a debt service savings over the life of the indebtedness.

(g) Where a public finance authority has established a mortgage rate of interest such that sufficient cash flows exist to retire the mortgage prior to the stated maturity, the amount of the mortgage to be forgiven, at the time of such forgiveness, shall be capitalized as a deferred asset and amortized over the remaining mortgage life, as a reduction to the facility's capital expense.

(h) Voluntary facilities shall report mortgage obligations financed by public finance authorities for their benefit and which they are responsible to repay, as liabilities in the general fund when such mortgage obligations are incurred.
 

Effective Date: 
Thursday, September 10, 1992
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Section 86-4.25 - Return on investment

86-4.25 Return on investment.

(a) In computing the allowable costs of a proprietary facility, there shall be included an allowance for a reasonable return on the average equity capital representing the owner's investment for the provisions of patient care. The percentage to be used in computing the allowance shall be a rate determined annually by the commissioner to be reasonably related to the then current money market.

(b) Equity capital is the net worth of the provider adjusted for those assets and liabilities which are not related to the provision of patient care. Equity capital consists of the provider's investment in plant, property and equipment, net of depreciation and noncurrent debt related to the investment or deposited funds, and net working capital for necessary and proper operation of patient care activities.
 

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Section 86-4.26 - Sales, leases and realty transactions

86-4.26 Sales, leases and realty transactions.

(a) If a facility is sold or leased or is the subject of any other realty transaction before a rate for the facility has been determined and certified by the commissioner, the capital cost component of such rate shall be determined in accordance with the provisions of sections 86-4.20, 86-4.23, 86-4.24 and 86-4.25 of this Subpart.

(b) If a facility is sold or leased or is the subject of any other realty transaction after a rate for the facility has been determined and certified by the commissioner, the capital cost component of such rate shall continue with the same force and effect as if such sale, lease or other realty transaction had not occurred. This subdivision shall not be construed as limiting the powers and rights of the commissioner to change rate computations based upon previous error, deceit or any other misrepresentation or misstatement that has let the commissioner to determine and certify a rate which he would otherwise not have determined or certified. Further, this subdivision shall not be construed as limiting the powers and rights of the commissioner to reduce rates when one or more of the original property right aspects related to a facility is terminated.

(c) If a facility enters into a sale and leaseback agreement with a nonrelated purchaser involving plant facilities or equipment prior to October 23, 1992 the incurred rental specified in the agreement shall be included in allowable costs if the following conditions are met:

(1) the rental charges are reasonable based on consideration of rental charges of comparable equipment and market conditions in the area; the type, expected life, condition and value of the equipment rented and other provisions of the rental agreements;

(2) adequate alternate equipment which would serve the purpose are not or were not available at lower cost; and

(3) the leasing was based on economic and technical considerations.

(4) If all these conditions were not met, the rental charge cannot exceed the amount which the facility would have included in reimbursable costs had it retained legal title to the equipment, such as interest, taxes, depreciation, insurance and maintenance costs.

(5) If a facility enters into a sale and leaseback agreement with a nonrelated purchaser involving land, the incurred rental costs associated with the land are not includable in allowable costs.

(d) An arms length lease purchase agreement with a nonrelated lessor involving plant facilities or equipment entered into on or after October 23, 1992 which meets any one of the four following conditions, establishes the lease as a virtual purchase.

(1) The lease transfers title of the facilities or equipment to the lessee during the lease term.

(2) The lease contains a bargain purchase option.

(3) The lease term is at least 75 percent of the useful life of the facilities or equipment. This provision is not applicable if the lease begins in the last 25 percent of the useful life of the facilities or equipment.

(4) The present value of the minimum lease payments (payments to be made during the lease term including bargain purchase option, guaranteed residual value and penalties for failure to renew) equals at least 90 percent of the fair market value of the leased property. This provision is not applicable if the lease begins in the last 25 percent of the useful life of the facilities or equipment. Present value is computed using the lessee's incremental borrowing rate, unless the interest rate implicit in the lease is known and is less than the lessee's incremental borrowing rate, in which case the interest rate implicit in the lease is used.

(e) If a lease is established as a virtual purchase under subdivision (d) of this section, the rental charge is includable in capital-related costs to the extent that it does not exceed the amount that the provider would have included in capital-related costs if it had legal title to the asset (the cost of ownership). The cost of ownership shall be limited to depreciation and interest. Further, the amounts to be included in capital-related costs are determined as follows:

(1) The difference between the amount of rent paid and the amount of rent allowed as capital-related costs is considered a deferred charge and is capitalized as part of the historical cost of the asset when the asset is purchased.

(2) If an asset is returned to the owner instead of being purchased, the deferred charge may be included in capital-related costs in the year the asset is returned.

(3) If the term of the lease is extended for an additional period of time at a reduced lease cost and the option to purchase still exists, the deferred charge may be included in capital-related costs to the extent of increasing the reduced rental to an amount not in excess of the cost of ownership. (4) If the term of the lease is extended for an additional period of time at a reduced lease cost and the option to purchase no longer exists, the deferred charge may be included in capital-related costs to the extent of increasing the reduced rental to a fair rental value.

(5) If the lessee becomes the owner of the leased asset (either by operation of the lease or by other means), the amount considered as depreciation for the purpose of having computed the limitation on rental charges under subdivision (e) of this section, must be used in calculating the limitation on adjustments for the purpose of determining any gain or loss upon disposal of an asset.

(6) In the aggregate, the amount of rental or lease costs included in capital-related costs may not exceed the amount of the costs of ownership that the provider could have included in capital-related costs had the provider legal title to the asset.

(f) If a facility enters into a sale and leaseback agreement involving plant facilities or equipment on or after October 23, 1992, the amounts to be included in capital-related costs both on an annual basis and over the useful life of the asset shall not exceed the costs of ownership, which shall be limited to depreciation and interest, and shall be determined as follows:

(1) If the annual rental or lease cost in the early years of the lease are less than the annual costs of ownership, but in the later years of the lease the annual rental or lease costs are more than the annual costs of ownership, in the years that the annual rental or lease costs are more than the annual costs of ownership, the facility may include in capital-related costs annually the actual amount of rental or lease costs, except that in any given year, the amount included in capital related costs is limited to an amount which would not cause the aggregate rental or lease costs included up to that year in capital-related costs to exceed the costs of ownership that would have been included in capital-related costs up to that year if the provider had retained legal title to the asset.

(2) If the annual rental or lease costs in the early years of the lease exceed the annual costs of ownership, which shall be limited to depreciation and interest, but in the later years of the lease the annual rental or lease costs are less than the annual costs of ownership, the facility may carry forward amounts of rental or lease costs that were not included in capital-related costs in the early years of the lease due to the costs of ownership limitation, and include these amounts in capital-related costs in the years of the lease when the annual rental or lease costs are less than the annual costs of ownership, provided, however, in any given year the amount of actual annual rental or lease costs plus the amount carried forward to that year may not exceed the amount of the costs of ownership for that year.

(3) In the aggregate, the amount of rental or lease costs included in capital-related costs may not exceed the amount of the costs of ownership that the provider could have included in capital-related costs if the provider had retained legal title to the asset.

(4) If a facility enters into a sale and leaseback agreement involving land, the incurred rental for the cost of land is not includable in allowable costs.
 

Effective Date: 
Monday, October 25, 1993
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Section 86-4.27 - Compensation of operators and relatives of operators

86-4.27 Compensation of operators and relatives of operators.

(a) Reasonable compensation for operators or relatives of operators for required services actually performed shall be considered an allowable cost. The amount to be allowed shall be equal to the amount normally required to be paid for the same service provided by a nonrelated employee, as determined by the commissioner. Compensation shall not be included in the rate computation for any services which the operator or relative of the operator is not authorized to perform under New York State law and regulation.

(b) In determining a reasonable level of compensation for operators or relatives of operators, the commissioner may consider the quality of care provided to patients by the facility during the year in question.
 

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Section 86-4.28 - Related organizations

86-4.28 Related organizations.

(a) A related organization shall be defined as any entity which controls the facility or which the facility controls, either directly or indirectly, or an organization or institution whose actions or policies the facility has the power, directly or indirectly, to significantly influence or direct, or a special purpose organization or where an association of material interest exists in an entity which supplies goods and/or services to the facility, or any entity which is controlled directly or indirectly by the immediate family of the operator. Immediate family shall include each parent, child, spouse, brother, sister, first cousin, aunt and uncle, whether such relationship arises by reason of birth, marriage or adoption. A special purpose organization shall be defined as an organization which is established to conduct certain of the facility's patient-care-related or non-patient-care-related activities. The special purpose organization shall be considered to be related if:

(1) the facility controls the special purpose organization through contracts or other legal documents that allow direct authority over the organization's activities, management and policies; or

(2) the facility is, for all practical purposes, the sole beneficiary of the special organization's activities. The facility shall be considered the special purpose organization's sole beneficiary if one or more of the three following circumstances exist:

(i) a special purpose organization has solicited funds in the name of and with the expressed or implied approval of the facility, and substantially all the funds solicited by the organization were intended by the contributor or were otherwise required to be transferred to the facility or used at its discretion or direction;

(ii) the facility has transferred some of its resources to a special purpose organization, substantially all of whose resources are held for the benefit of the facility; or

(iii) the facility has assigned certain of its functions (such as the operation of a dormitory) to a special purpose organization that is operating primarily for the benefit of the facility.

(b) The costs of goods and/or services furnished to a facility by a related organization shall be included in the computation of the basic rate at the lower of the cost to the related organization or the market price of comparable goods and/or services available in the facility's region within the course of normal business operations.
 

Effective Date: 
Wednesday, March 11, 1992
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Section 86-4.29 Reserved

Section 86-4.30 Reserved

Section 86-4.31 - Termination of service

86-4.31 Termination of service.

The bureau shall be notified within 30 days of the deletion of any previously offered service or if services are withheld from patients paid for by any government agency. Such notification shall include a statement indicating the date of the deletion or withholding of the service and the cost impact of such action on the facility. Rates shall be adjusted to reflect the deletion or withholding of a service. Should the facility fail to provide timely notice to the bureau and receive overpayments, penalties and rate reduction in the manner provided in sections 86-4.3 and 86-4.6 of this Subpart shall apply.
 

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Section 86-4.32 Reserved

Section 86-4.33 Reserved

Section 86-4.34 - Pilot reimbursement projects

86-4.34 Pilot reimbursement projects.

(a) The commissioner may waive the requirements of this Subpart to effect the development of additional knowledge and experience in different types of reimbursement mechanisms, contingent upon the approval of the United States Department of Health and Human Services where necessary.

(b) Individual facilities or groups of facilities shall enter into such ventures with the understanding that the reimbursement received over the life of the projects shall be as defined in the experiment contract.
 

Doc Status: 
Complete

Section 86-4.35 - Computation of basic rates for clinic services provided to Acquired Immune Deficiency Syndrome (AIDS) and Human Immunodeficiency Virus (HIV) sero-positive patients by freestanding ambulatory care facilities and hospital clinic outpatient

86-4.35 Computation of basic rates for clinic services provided to Acquired Immune Deficiency Syndrome (AIDS) and Human Immunodeficiency Virus (HIV) sero-positive patients by freestanding ambulatory care facilities and hospital clinic outpatient services.

(a) For payments made pursuant to this section and pursuant to section 86-1.11(h) of this Part, for ambulatory services to AIDS patients, HIV- positive patients, and patients seeking verification of HIV infection, reimbursement shall be based upon a single payment schedule with a discrete price for each of the five clinic services set forth in subdivision (c) of this section.

(b) To be eligible to receive reimbursement pursuant to this section, facilities must be licensed pursuant to Article 28 of the Public Health Law and certified to provide general medical services and complete a written signed agreement with the commissioner to provide these discrete services. Facilities interested in establishing such agreements must submit in writing the required documentation in a manner acceptable to the commissioner. Such agreement shall describe the Medicaid patients who will be eligible for reimbursement under this section and shall establish the documentation and services required for patient assignment to each of the five clinic services.

(c) The five clinic services for which reimbursement shall be available according to the prices as established by this section are as follows:

(1) HIV Counseling and Testing Visits - This visit shall mean the provision of pre-test HIV counseling in a medical setting as performed in compliance with Article 27-f of the State Public Health Law. This visit shall also include laboratory testing necessary to determining whether a person has HIV disease. This visit shall also mean the provision of post-test HIV counseling in a medical setting as performed in compliance with the confidentiality provisions of Article 27-f of the State Public Health Law for those individuals whose test results are positive. This visit is available for the purpose of informing these individuals of their test results and providing supportive counseling for those HIV zero positive persons experiencing adverse psychological responses to their serostatus.

(2) Post-test Counseling Visit - This visit shall mean the provision of post-test HIV counseling in a medical setting as performed in compliance with the confidentiality provisions of Article 27-f of the State Public Health Law for those persons whose test results are negative. This visit is available for the purpose of informing these individuals of their results and counseling them on preventive measures.

(3) Initial Comprehensive HIV Medical Evaluation Visit - This visit shall mean a comprehensive medical history and physical examination, and laboratory testing necessary for the evaluation of HIV disease and related conditions. The evaluation shall be complete enough to: establish the state of HIV illness, diagnose active opportunistic infections and tumors, identify appropriate prophylactic therapies to prevent future opportunistic infections, initiate indicated anti-HIV therapy, and identify significant psycho-social problems to be addressed in the care plan.

(4) Drug and Immunotherapy Visits for HIV Infected Patients - This visit shall mean to those HIV-related treatments that require active health care supervision during the treatment visit and/or extensive amount of provider monitoring following the treatment.

(5) Monitoring Visit for Asymptomatic HIV Disease - This visit shall mean the clinical and laboratory evaluation necessary to monitor the status of HIV disease to indicate the appropriate stage to initiate active drug treatment for HIV or prophylactic treatment for opportunistic infections.

(d) The prices established pursuant to this section shall provide full reimbursement for the following:

(1) physician services, nursing services, technician services, and other related professional expenses directly incurred by the licensed facility;

(2) space occupancy and plant overhead costs;

(3) administrative personnel, business office, data processing, recordkeeping, housekeeping, and other related facility overhead expenses;

(4) all ancillary services including laboratory tests and diagnostic x-ray services where specified in the treatment regimes and as detailed in the agreement pursuant to subdivision (b) of this section; and

(5) all medical supplies, immunizations, and drugs directly related to the provision of the services except for those drugs used to treat AIDS patients for which fee for service reimbursement is available under section 7.0 of the Medicaid Ordered Ambulatory Services Fee Schedule as contained in the Medicaid Management Information Systems (MMIS) Clinic Services Provider Manual (revised October, 1988). Copies of the schedule may be obtained from the New York State Department of Social Services and are available for inspection and copying at the Department of Health, Records Access Office, 22nd floor, Corning Tower Building, Governor Nelson A. Rockefeller Empire State Plaza, Albany, New York 12237-0042. (e) The price for each service shall be adjusted for regional differences in wage levels, space occupancy and facility overhead costs.

(f) The commissioner shall establish trend factors to project increases in the base year prices during the effective period of the reimbursement rates. The trend factors shall be developed using available price indices including elements of the United States Department of Labor consumer and producer price indices and special price indices developed by the commissioner for this purpose. The projected trend factors shall be updated on an annual basis, based upon current and available data.

(g) At the discretion of the commissioner, health services may be added or deleted from the visits contained in subdivision (c) of this section. The commissioner shall notify participating providers of such changes at least 60 days before such changes shall be effective and the agreements as outlined in subdivision (b) of this section shall be modified to encompass any such changes.

(h) Payment for any other clinic services which are not covered pursuant to subdivision (c) of this section shall be reimbursed as follows:

(1) for facilities with a cost-based all-inclusive clinic visit rate established pursuant to this Subpart or to Subpart 86-1, services shall be reimbursed at the all-inclusive clinic visit rate.

(2) for facilities without a cost-based all-inclusive rate, fee-for- service reimbursement is available under the Ordered Ambulatory Services Fee Schedule as referenced in paragraph (5) of subdivision (d) of this section for medical services ordered by the patient's attending physician.

(i) For financial reporting purposes and statistical reporting purposes, facilities which provide services pursuant to subdivision (c) of this section must comply as appropriate with the standards established for said reporting in sections 86-1.3 or 86-4.3 of this Part.
 

Effective Date: 
Wednesday, January 3, 1990

Section 86-4.36 REPEALED

Effective Date: 
Wednesday, March 2, 2011

Section 86-4.37 - Computation of basic rates of payment for services provided to Medicaid patients by preferred primary care providers

86-4.37 Computation of basic rates of payment for services provided to Medicaid patients by preferred primary care providers.

(a) For payments made pursuant to this section and pursuant to section 86-1.11(h)(4) of this Part, for ambulatory care services to Medicaid patients, reimbursement shall be based upon a uniform payment schedule with a discrete price set forth in subdivision (c) of this section.

(b) To be eligible to receive reimbursement pursuant to this section, facilities must be licensed pursuant to Article 28 of the Public Health Law, and certified to provide general medical services, and enter into a written agreement with the commissioner to provide the discrete services described in subdivision (c) of this section. These clinic services are defined on the basis of patient characteristics and provider services. Patient characteristics include age, sex and diagnoses. Provider services include diagnostic examinations, treatments, and ancillary services including significant diagnostic technologies. Diagnostic technologies are defined as: diagnostic nuclear medicine, diagnostic radiology, diagnostic ultrasound, cardiography, cardiac fluoroscopy, echocardiography, and neurological and neuromuscular procedures.

(c) The seventy-one clinic services for which reimbursement shall be available at prices established pursuant to this section are:

(1) Diagnostic Investigation Exams NEC - This visit shall be for any patient for the purpose of diagnostic investigation of problems attendant to physical medicine nowhere else categorized. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures and shall include necessary laboratory tests and the use of diagnostic technologies, and any other services specified in the agreement referenced in subdivision (b) of this section. This visit shall only occur after a complete physical and history and shall include all other laboratory and diagnostic technology ancillaries that are required to complete the diagnostic investigation, This visit is not for the sole purpose of receiving an X-ray.

(2) Diagnostic Investigation with Nuclear Imaging - This visit shall be for patients requiring diagnostic nuclear imaging including contrast imaging in order to complete a diagnostic investigation. This visit shall only occur after a complete physical and history and shall include all other laboratory and diagnostic technology ancillaries that are required to complete the diagnostic investigation, and any other services specified in the agreement referenced in subdivision (b) of this section. This visit is not for the sole purpose of receiving diagnostic nuclear medicine.

(3) Diagnostic Investigation with Computerized Axial Tomography Imaging - This visit shall be for patients requiring a CAT scan in order to complete a diagnostic investigation. This visit shall only occur after a complete physical and history and shall include all other laboratory and diagnostic technology ancillaries that are required to complete the diagnostic investigation, and any other services specified in the agreement referenced in subdivision (b) of this section. This visit is not for the sole purpose of receiving a CAT scan.

(4) Diagnostic Investigation with Magnetic Resonance Imaging - This visit shall be for patients requiring a MRI in order to complete a diagnostic investigation. This visit shall only occur after a complete physical and history and shall include all other laboratory and diagnostic technology ancillaries that are required to complete the diagnostic investigation, and any other services specified in the agreement referenced in subdivision (b) of this section. This visit is not for the sole purpose of receiving an MRI.

(5) Management Exam NEC This visit shall be for any patient for the treatment of problems attendant to physical medicine nowhere else categorized. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(6) Medication Administration - This visit shall be for the sole purpose of administering drugs, injectables or renewal of a prescription with a concomitant brief provider assessment, and any other services specified in the agreement referenced in subdivision (b) of this section.

(7) Pediatric Annual Well Care Exam - This visit shall be for healthy children ages three years through seventeen years. This visit shall include a physical examination, developmental appraisal, nutritional assessment, hearing and vision screening, immunizations as indicated, selected laboratory tests such as hematocrit, blood counts, lead screening, TB Tine, urinalysis, VD for teenagers, on an appropriate schedule, and other services specified in the agreement referenced in subdivision (b) of this section.

(8) Adult Annual Well Care Exam - This visit shall be for generally healthy patients over seventeen years of age. This visit shall include an annual physical examination, health education, nutritional assessment, blood pressure, hearing and vision screening, selected ancillaries when appropriate, including standard laboratory tests, chest x-rays, mammograms, and any other services specified in the agreement referenced in subdivision (b) of this section.

(9) First Prenatal - Routine - This visit shall be for females with a confirmed diagnosis of a normal pregnancy for the purpose of initiating a prenatal care treatment regimen. This visit shall include a complete physical examination and history, nutritional counseling, health education, appropriate treatment measures including laboratory ancillaries and the use of key technologies, and any other services specified in the agreement referenced in subdivision (b) of this section.

(10) First Prenatal - Complicated - This visit shall be for females with a confirmed diagnosis of a complicated pregnancy for the purpose of initiating a prenatal care treatment regimen. This visit shall include a complete physical examination and history, nutritional counseling, health education, appropriate treatment measures including laboratory ancillaries and the use of key technologies, and any other services specified in the agreement referenced in subdivision (b) of this section.

(11) Prenatal Management Revisit - Complicated - This visit shall be for females with a confirmed pregnancy and complications primarily related to pregnancy. This visit shall be for the purpose of providing ongoing prenatal care including a limited physical examination, nutritional counseling, health education, appropriate treatment and diagnostic measures including laboratory ancillaries and the use of key technologies, and any other services specified in the agreement referenced in subdivision (b) of this section.

(12) Post Partum Management - Complicated - This visit shall be for females with a confirmed pregnancy and complications primarily related to pregnancy. This visit shall be for the purpose of providing post partum care including a limited physical examination, nutritional counseling, health education, appropriate treatment and diagnostic measures including laboratory ancillaries and the use of key technologies, and any other services specified in the agreement referenced in subdivision (b) of this section.

(13) Prenatal Revisit Well Care - Normal - This visit shall be for female patients with a confirmed normal pregnancy. This visit shall be for the purpose of providing ongoing routine or uncomplicated prenatal care including a limited physical examination, nutritional counseling, health education, appropriate treatment and diagnostic measures including laboratory ancillaries and the use of key technologies, and any other services specified in the agreement referenced in subdivision (b) of this section.

(14) Post Partum Management - Normal - This visit shall be for females of all ages for the purpose of providing postpartum care following a normal pregnancy and delivery. This visit shall be for the purpose of post partum care including a limited physical examination, nutritional counseling, health education, appropriate treatment and diagnostic measures including laboratory ancillaries and the use of key technologies, and any other services specified in the agreement referenced in subdivision (b) of this section.

(15) Neonatal and Congenital Diagnostic Investigation - This visit shall be for the purpose of investigation of problems of congenital disorders and newborns with medical conditions. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures including laboratory ancillaries and the use of diagnostic technologies, and other services specified in the agreement referenced in subdivision (b) of this section.

(16) Management of Neonatal and Congenital Problem - This visit shall be for the treatment of problems associated with congenital disorders and newborns with problems. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures including laboratory ancillaries, and other services specified in the agreement referenced in subdivision (b) of this section.

(17) Pediatric Well Care Exam - This visit shall be for healthy newborns and children under three years of age. This visit shall include a physical examination, developmental checks, health education for the parents as warranted, immunizations as indicated, selected laboratory tests and screening procedures such as PKU, sickle cell, lead, TB Tine, urinalysis, hematocrit, on an appropriate schedule, and other services specified in the agreement referenced in subdivision (b) of this section.

(18) Female Reproductive Diagnostic Investigation - This visit shall be for the purpose of investigating female reproductive problems. This visit shall include a physical examination and history with appropriate diagnostic and treatment measures including laboratory ancillaries and the use of diagnostic technologies, and any other services specified in the agreement referenced in subdivision (b) of this section.

(19) Management of Female Reproductive Problems - This visit shall be for the treatment of female reproductive problems. This visit shall include a physical examination and history with appropriate diagnostic and treatment measures including appropriate laboratory ancillaries, and any other services specified in the agreement referenced in subdivision (b) of this section.

(20) Annual Gynecological Examination - This visit shall be for an annual gynecological examination. This visit shall include a physical examination and history, health education, a full pelvic examination, pap smear, appropriate laboratory ancillaries and any other services specified in the agreement referenced in subdivision (b) of this section.

(21) Contraceptive Well Care Exam - This visit shall be for the purpose of providing contraceptives and family planning. This exam shall include a physical examination and history, health and family planning education, appropriate laboratory ancillaries and any other services specified in the agreement referenced in subdivision (b) of this section.

(22) Ear, Nose and Throat Diagnostic Investigation - Adult - This visit shall be for patients over seventeen years of age for the purpose of investigation of ear and nasopharynx problems. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures, and shall include necessary laboratory tests and the use of key diagnostic technologies, and any other services specified in the agreement referenced in subdivision (b) of this section.

(23) Ear, Nose and Throat Diagnostic Investigation - Pediatric - This visit shall be for children up to and including seventeen years of age for the purpose of investigation of ear and nasopharynx problems. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures, and shall include necessary laboratory tests and the use of key diagnostic technologies, and any other services specified in the agreement referenced in subdivision (b) of this section.

(24) Management of Ear, Nose and Throat Problems - Adult - This visit shall be for patients over seventeen years of age for the treatment of problems of the ear and nasopharynx. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(25) Management of Ear, Nose and Throat Problems - Pediatric - This visit shall be for children up to and including seventeen years of age for the treatment of problems of the ear and nasopharynx. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(26) Ophthalmological Services - This visit shall be for any patient for eye examinations and treatment of eye disorders. This visit shall include appropriate ophthalmological procedures as well as any laboratory ancillaries or diagnostic technologies required, and any other services specified in the agreement referenced in subdivision (b) of this section.

(27) Respiratory Diagnostic Investigation - Adult - This visit shall be for patients over seventeen years of age for the purpose of investigation of respiratory problems. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures, and shall include necessary laboratory tests and the use of key diagnostic technologies, and any other services specified in the agreement referenced in subdivision (b) of this section.

(28) Respiratory Diagnostic Investigation - Pediatric - This visit shall be for children up to and including seventeen years of age for the purpose of investigation of respiratory problems. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures, and shall include necessary laboratory tests and the use of key diagnostic technologies, and any other services specified in the agreement referenced in subdivision (b) of this section.

(29) Management of Respiratory Problems - Adult - This visit shall be for patients over seventeen years of age for the treatment of respiratory problems. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(30) Management of Respiratory Problems - Pediatric - This visit shall be for children up to an including seventeen years of age for the treatment of respiratory problems. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(31) Systemic Infection Diagnostic Investigation - This visit shall be for the purpose of investigation of systemic infections. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures, and shall include necessary laboratory tests and the use of key diagnostic technologies, and any other services specified in the agreement referenced in subdivision (b) of this section.

(32) Management of Systemic Infections - This visit shall be for the treatment of systemic infections. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(33) Gastrointestinal Diagnostic Investigation - This visit shall be for for the purpose of investigation of gastrointestinal problems. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures, and shall include necessary laboratory tests and the use of key diagnostic technologies, and any other services specified in the agreement referenced in subdivision (b) of this section.

(34) Management of Gastrointestinal Problems - Adult - This visit shall be for patients over seventeen years of age for the treatment of gastrointestinal problems. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(35) Management of Gastrointestinal Problems - Pediatric - This visit shall be for children up to and including seventeen years of age for the treatment of gastrointestinal problems. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(36) Hepatobiliary Diagnostic Investigation - This visit shall be for for the purpose of investigation of hepatobiliary problems. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures, and shall include necessary laboratory tests and the use of key diagnostic technologies, and any other services specified in the agreement referenced in subdivision (b) of this section.

(37) Management of Hepatobiliary Problems - This visit shall be for the treatment of hepatobiliary problems. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(38) Genito-Urological Diagonstic Investigation - This visit shall be for male patients for the purpose of investigation of genito-urological and reproductive problems. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures, and shall include necessary laboratory tests and the use of key diagnostic technologies, and any other services specified in the agreement referenced in subdivision (b) of this section.

(39) Management of Genito-Urological Problems - This visit shall be for male patients for the treatment of genito-urological problems. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(40) Cardiac Diagnostic Investigation - This visit shall be for the purpose of investigation of cardiac and circulatory problems. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures, and shall include necessary laboratory tests and the use of diagnostic technologies, and any other services specified in the agreement referenced in subdivision (b) of this section.

(41) Management of Cardiac Problems - This visit shall be for the treatment of cardiac and circulatory problems. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(42) Endocrinal Diagnostic Investigation - This visit shall be for the purpose of investigation of diabetes and other metabolic problems and diseases of the endocrine system and pancreas. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures, and shall include necessary laboratory tests and the use of key diagnostic technologies, and any other services specified in the agreement referenced in subdivision (b) of this section.

(43) Management of Other Endocrinal Problems - This visit shall be for the treatment of other metabolic problems and diseases of the endocrine system and pancreas, excluding diabetes. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(44) Management of Diabetes - Pediatric - This visit shall be for children up to and including seventeen years of age for the treatment of problems associated with diabetes. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(45) Management of Diabetes - Adult - This visit shall be for patients over seventeen years of age for the treatment of problems associated with diabetes. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(46) Skin and Soft Tissue Diagnostic Investigation - This visit shall be for the purpose of investigation of skin and soft tissue injuries and problems. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures, and shall include necessary laboratory tests and the use of diagnostic technologies, and any other services specified in the agreement referenced in subdivision (b) of this section.

(47) Inflammatory Muscular/Skeletal Diagnostic Investigation - This visit shall be for the purpose of investigation of muscular/skeletal problems including arthritis, rheumatism and other inflammatory/degenerative diseases of the joints and bones. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures, and shall include necessary laboratory tests and the use of diagnostic technologies, and any other services specified in the agreement referenced in subdivision (b) of this section.

(48) Other Muscular/Skeletal Diagnostic Investigation - This visit shall be for the purpose of investigation of other muscular/skeletal problems, excluding arthritis, rheumatism and other inflammatory/degenerative diseases of the joints and bones. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures, and shall include necessary laboratory tests and the use of key diagnostic technologies, and any other services specified in the agreement referenced in subdivision (b) of this section.

(49) Rehabilitation Therapy - This visit shall be for therapy and treatment planning for any patient with diagnosed physical disabilities requiring physical, rehabilitation or occupational services. This visit shall include the necessary laboratory ancillaries to manage the course of treatment, and any other services specified in the agreement referenced in subdivision (b) of this section.

(50) Management of Skin and Soft Tissue Problems - This visit shall be for the treatment of skin and soft tissue injuries and problems. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(51) Management of Poisoning - This visits shall be for the treatment of problems associated with poisoning. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(52) Management of Inflammatory Muscular/Skeletal Problems - This visit shall be for the treatment of muscular/skeletal problems including arthritis, rheumatism and other inflammatory/degenerative diseases of the joints and bones. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(53) Management of Other Muscular/Skeletal Problems - This visit shall be for the treatment of other muscular/skeletal problems, excluding arthritis, rheumatism and other inflammatory/degenerative diseases of the joints and bones. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(54) Oncological Diagnostic Investigation - This visit shall be for the purpose of investigation of malignancies, excluding benign tumors and malignancies of the skin. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures including laboratory ancillaries and the use of diagnostic technologies, and other services specified in the agreement referenced in subdivision (b) of this section.

(55) AIDS Diagnostic Investigation - This visit shall be for the purpose of investigation of the AIDS virus. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures including laboratory ancillaries and the use of diagnostic technologies, and other services specified in the agreement referenced in subdivision (b) of this section.

(56) Other Hematological Diagnostic Investigation - This visit shall be for the purpose of investigation of other myeloproliferative diseases of the blood and blood forming organs, and anemias. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures including laboratory ancillaries and the use of diagnostic technologies, and other services specified in the agreement referenced in subdivision (b) of this section.

(57) Therapeutic IV Push and Chemotherapy Injection - This visit shall be for therapy and treatment planning for any patient diagnosed with an oncological/hematological problem requiring a therapeutic regime, either IV push and/or chemotherapy injection to ameliorate symptoms, or reverse or cure malignancies, excluding benign tumors and malignancies of the skin, and myeloproliferative diseases of the blood and blood forming organs. Therapies will include IV push and chemotherapy injection. This visit shall include necessary laboratory ancillaries to manage the course of treatment, and any other services specified in the agreement references in subdivision (b) of this section.

(58) Therapeutic Infusions - This visit shall be for therapy and treatment planning for any patient diagnosed with an oncological/hematological problem requiring a therapeutic regime of infusions, including blood product transfusions to ameliorate symptoms, or reverse or cure malignancies, excluding benign tumors and malignancies of the skin, and myeloproliferative diseases of the blood and blood forming organs. Therapies will include infusions including transfusions of blood products. This visit shall include necessary laboratory ancillaries to manage the course of treatment, and any other services specified in the agreement references in subdivision (b) of this section.

(59) Therapeutic Radio Therapy - This visit shall be for therapy and treatment planning for any patient diagnosed with an oncological/hematological problem requiring a therapeutic regime of radio therapy to ameliorate symptoms, or reverse or cure malignancies, excluding benign tumors and malignancies of the skin, and myeloproliferative diseases of the blood and blood forming organs. Therapies will include radiation therapy or hyperthermia as an adjunct to radiation therapy. This visit shall include necessary laboratory ancillaries to manage the course of treatment, and any other services specified in the agreement references in subdivision (b) of this section.

(60) Oncological Management - This visit shall be for the management of patients currently undergoing a therapeutic regime to ameliorate symptoms, or reverse or cure malignancies, excluding benign tumors and malignancies of the skin, and myeloproliferative diseases of the blood and blood forming organs. Therapies will include IV push and chemotherapy injection, infusions including blood product transfusions, and radiation therapy or hyperthermia as an adjunct to radiation therapy, and other services specified in the agreement referenced in subdivision (b) of this section. Patients need not receive therapy every visit. When the patient does not receive therapy, the visit shall include observation of the therapy's effects and the use of laboratory ancillaries necessary for managing and assessing the course of therapy.

(61) Management of Anemias - Pediatric - This visit shall be for children up to and including seventeen years of age for the treatment of anemias. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures including laboratory ancillaries, and other services specified in the agreement referenced in subdivision (b) of this section.

(62) Management of Anemias - Adult - This visit shall be for patients over seventeen years of age for the treatment of anemias. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(63) Management of AIDS - Pediatric - This visit shall be for children up to and including seventeen years of age for the treatment of AIDS. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(64) Management of AIDS - Adult - This visit shall be for patients over seventeen years of age for the treatment of AIDS. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(65) Management of Other Hematological Problems - This visit shall be for the treatment of other myeloproliferative diseases of the blood and blood form organs. This visit shall include a physical examination and history with appropriate treatment and diagnostic laboratory tests, and any other services specified in the agreement referenced in subdivision (b) of this section.

(66) Neurological and Psycho/Social Diagnostic Investigation - This visit shall be for the purpose of investigation of problems related to the central nervous system, medical conditions attendant to mental illness, substance abuse, and social problems. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures including laboratory ancillaries and the use of diagnostic technologies, and other services specified in the agreement referenced in subdivision (b) of this section.

(67) Speech and Hearing Services - Adult - This visit shall be for patients over seventeen years of age for the purpose of an audiology examinations, and speech therapy and treatment planning, and any other services specified in the agreement referenced in subdivision (b) of this section.

(68) Speech and Hearing Services - Pediatrics - This visit shall be for children up to and including seventeen years of age for the purpose of an audiology examinations, and speech therapy and treatment planning, and any other services specified in the agreement referenced in subdivision (b) of this section.

(69) Neurological and Psycho/Social Management - This visits shall be for the treatment of problems associated with the central nervous system, medical problems attendant to mental illness, substance abuse, and social problems. This visit shall include a physical examination and history with appropriate treatment and diagnostic measures including laboratory ancillaries, and other services specified in the agreement referenced in subdivision (b) of this section.

(70) Counseling - This visit shall be for the primary purpose of providing supportive counseling, extended individual and family counseling, somatotherapy and health education to patients with diagnosed mental illness or substance abuse problems and any other service specified in the agreement referenced in subdivision (b) of this section. This visit shall not be for a medical work up although ancillaries necessary to monitor and provide treatment of the patient are included.

(71) Diagnostic Investigation of Vascular Systems - This visit shall be for patients requiring radiologic exams of cardiac vessels and other arterial and various radiologic procedures. This visit shall only occur after a complete physical and history and shall include all other laboratory and diagnostic technology ancillaries that are required to complete the diagnostic investigation, and any other services specified in the agreement referred in Subdivision (b) of this section. This visit is not for the sole purpose of receiving diagnostic radiologic procedures.

(d) The prices established pursuant to this section shall provide full reimbursement for the following:

(1) physician services, nursing services, therapist services, technician services, nutrition services, health education services, psychosocial services, care coordination services and other related professional expenses directly incurred by the licensed facility;

(2) space occupancy and plant overhead costs;

(3) all ancillary services including laboratory tests, diagnostic tests including professional interpretations, and as detailed in the agreement described in subdivision (b) of this section;

(4) all medical supplies, immunizations, and drugs directly related to the provision of the services as detailed in the agreement pursuant to subdivision (b) of this section; and

(5) administrative personnel, business office, data processing, recordkeeping, housekeeping, and other related facility overhead expenses.

(e) The price for each service shall be adjusted for regional differences in wage levels to reflect differences in labor costs for personnel providing direct patient care and clinic support staff.

(f) During the initial rate period of provider participation, reimbursement to preferred primary care providers shall be no less than that which would be received pursuant to sections 86-4.1 through 86-4.31 of this Subpart.

(g) The commissioner shall establish trend factors to project increases in the base year prices during the effective period of the reimbursement rates. The trend factors shall be developed using available price indices including elements of the United States Department of Labor consumer and producer price indices and special price indices developed by the commissioner for this purpose. The projected trend factors shall be updated on an annual basis, based upon current and available data.

(h) Any clinic services not covered in subdivision (c) of this section shall be reimbursed based on the provider's established cost-based all inclusive visit rate pursuant to this Subpart.

(i) In addition to complying with the requirements for recording and reporting financial and statistical data in sections 86-4.3, 86-4.4 and 86-4.5 of this Subpart, facilities designated as preferred primary care providers shall complete surveys of patient characteristics, treatment patterns, health care organization factors, costs associated with patient care, and other factors as undertaken from time to time by the commissioner.

(j)(1) An adjustment may be made to payments described in this section for diagnostic and treatment centers designated as preferred primary care providers to support the facility's efforts to meet the health care needs of the community. Activities for which such adjustment may be available include, but are not limited to, patient access after routine hours of operation; effective operation of patient management record systems and appointment systems; assurance of continuity of patient care with the same practitioner or team of practitioners; other essential support for the scope of practice undertaken by preferred primary care diagnostic and treatment centers; effective quality assurance, utilization management and patient care management systems; outreach, case management and community intervention consistent with the designation; and participation in comprehensive programs to provide substance and alcohol treatment services.

(2)(i) An adjustment may also be made to increase coverage of disproportionate share of bad debt and charity care losses of preferred primary care providers which acquired capital assets through financing from public authorities.

(ii) Such adjustment shall be based on the unrecovered capital costs associated with the disproportionate share of bad debt and charity care, which shall be calculated by applying the capital component of the facility's Medicaid rate of payment for the rate period for which the allowance is being determined, to identified eligible visits as defined in section 86-4.12.

(k) An adjustment shall be made to payments described in this section to cover the costs of primary medical malpractice insurance sufficient to meet the requirements of Section 91.1(a) of this Title for physicians employed by preferred primary care diagnostic and treatment centers.

Effective Date: 
Monday, December 28, 1992
Doc Status: 
Complete

Section 86-4.38 - Computation of basic rates of payment for services provided to Medicaid patients by specialty clinics

86-4.38 Computation of basic rates of payment for services provided to Medicaid patients by specialty clinics.

(a) Notwithstanding other provisions of this Subpart or Subpart 86-1, rates of reimbursement for specialty services, including but not limited to hemo and peritonial dialysis and outpatient rehabilitative services, shall be calculated in the manner described in section 86-4.37(a) through (h). Rates of reimbursement for methadone maintenance treatment services shall be calculated in the manner described in section 86-4.39. Rates of reimbursement for day health care services provided to patients with acquired immune deficiency syndrome (AIDS) and other human immunodeficiency virus (HIV) related illnesses by freestanding ambulatory care facilities shall be calculated in the manner described in section 86-4.41. Such payment levels will be made available to providers who document in writing and through site inspection or records review that they are, in fact, organized and providing specialty services.

(b) The criteria for recognition as a specialty service include but are not limited to: requirement for highly specialized staff, equipment or facilities; whether the facility presently provides the services to the population in need; whether the services may be provided safely and effectively on an outpatient basis; and whether the services are structured to address extensive and complex needs for patients with chronic or infectious medical conditions.

(c) In addition to complying with the requirements for recording and reporting financial and statistical data in sections 86-4.3, 86-4.4 and 86-4.5 of this Subpart, facilities shall complete surveys of patient characteristics, treatment patterns, health care organization factors, costs associated with patient care, and other factors as undertaken from time to time by the Commissioner.
 

Effective Date: 
Thursday, April 22, 1993
Doc Status: 
Complete

Section 86-4.39 - Computation of basic rates for methadone maintenance treatment services provided by freestanding ambulatory care facilities and hospital outpatient clinic services.

86-4.39 Computation of basic rates for methadone maintenance treatment services provided by freestanding ambulatory care facilities and hospital outpatient clinic services.

(a) For payments made pursuant to this section and pursuant to section 86-1.11(h)(5) of this Part, for methadone maintenance treatment services reimbursement shall be based upon a fixed weekly payment per recipient.

(b) To be eligible to receive reimbursement pursuant to this section, facilities must have an operating certificate issued pursuant to Part 401 of this Title, and be certified to provide outpatient methadone maintenance treatment services.

(c) The clinic services which shall be provided to be eligible for reimbursement according to the price as established by this section includes: urinalysis drug testing, dispensing of methadone, medical supervision and arranging for appropriate laboratory tests for the initial and annual physical examinations, preparation and monitoring of treatment plans, maintenance of patient medical histories, prescribing methadone dosage, counseling as prescribed in the patients' individual treatment plan, and maintenance of records.

(d) The weekly price established pursuant to this section shall be reimbursement for the following, as required by New York State Office of Alcoholism and Substance Abuse Services in 10 N.Y.C.R.R. Part 1040:

(1) physician services, nursing services, therapist services, technician services, nutrition services, health education services, psychosocial services, care coordination services and other related professional expenses directly incurred by the licensed facility;

(2) space occupancy and plant overhead costs;

(3) all ancillary procedures directly related to the provision of services with the exception of laboratory and diagnostic tests other than urinalysis testing;

(4) all medical supplies and drugs directly related to the provision of services; and

(5) administrative personnel, business office, data processing recordkeeping, housekeeping,and other related facility overhead expenses.

(e) The methadone maintenance treatment service weekly price shall be established using 1986 cost and statistical data for the factors listed in subdivision (d) of this section reported by diagnostic and treatment centers and hospital based outpatient programs. Weekly visit utilization shall be based upon the average daily census information compiled by the New York State Office of Alcoholism and Substance Abuse Services. The price shall be trended forward in accordance with subdivision (f) of this section in a manner consistent with the rate period of the facility's other basic services. After the price has been trended forward, the price shall be increased by adding the product of the estimated statewide number of urinalysis tests per week per patient multiplied by the current Medicaid reimbursement fee for urinalysis toxicology screening.

(f) The Commissioner shall establish trend factors to project increases in the price during the effective period of the reimbursement rates. The trend factors shall be developed using available price indices including elements of the United States Department of Labor consumer and producer price indices and special price indices developed by the Commissioner for this purpose. The projected trend factors shall be updated on an annual basis, based upon current and available data.

(g) The Commissioner, in consultation with the New York State Office of Alcoholism and Substance Abuse Services, may add or delete health services from the methadone maintenance treatment services contained in subdivision (c) of this section, if the Commissioner finds that the inclusion or deletion of such services is appropriate based upon commonly accepted medical standards, current scientific or medical literature, or the results of properly conducted medical or scientific research. The Commissioner shall notify participating providers of such changes at least 60 days before such changes shall be effective.

(h) When such an addition or deletion is made pursuant to subdivision (g) of this section, the price established pursuant to subdivision (e) of this section shall be adjusted based upon an estimate of the costs of such added or deleted services efficiently and economically provided by general hospitals or diagnostic and treatment services.

(i) For financial reporting purposes and statistical reporting purposes, facilities which provide services pursuant to subdivision (c) of this section must comply as appropriate with the standards established for said reporting in sections 86-1.3 or 86-4.3 of this Part.
 

Effective Date: 
Thursday, November 19, 1992
Doc Status: 
Complete

Section 86-4.40 - Computation of case-based rates of payment for licensed free-standing ambulatory surgery centers and hospital based ambulatory surgery services

86-4.40 Computation of case-based rates of payment for licensed free-standing ambulatory surgery centers and hospital-based ambulatory surgery services.

(a) Medicaid reimbursement for medically necessary ambulatory surgery services provided by licensed free-standing ambulatory surgical centers and hospital-based ambulatory surgery services shall be based upon a single payment schedule with a discrete price for each of the separate groupings of surgical procedures set forth in this section.

(b) Reimbursement for ambulatory surgery services shall be based upon the Products of Ambulatory Surgery (PAS) classification system as defined in subdivision (o) of this section. A base price shall be established for each of the payment groups defined in the PAS classification. All procedures within the same payment group shall be reimbursed at a single discrete price.

(c) Each base price shall be adjusted by a wage equalization factor and a space occupancy factor to reflect regional differences in the price of labor and space. The wage equalization factor shall be applied to the operating room and pre-operative and post-operative nursing personnel salary components of each base price.

(d) Prices established pursuant to subdivision (b) of this section shall provide full reimbursement for applicable:
(1) nursing services, technician services, and other related professional expenses directly incurred by the licensed facility;
(2) drugs, biologicals, surgical dressings, supplies, splints, appliances and equipment directly related to the provision of the surgical procedures;
(3) diagnostic or therapeutic items and services directly related to the provision of surgical procedures;
(4) materials for anesthesia;
(5) prosthetic and orthotic appliances provided during or integral to an ambulatory surgery procedure;
(6) administrative personnel, business office, data processing, recordkeeping, housekeeping and other related facility overhead expenses;
(7) space occupancy and plant overhead costs;
(8) costs associated with graduate medical education programs involved in the provision of ambulatory surgery services; and
(9) costs associated with hospital-based physicians, defined as salaried physicians, excluding interns and residents, engaged in direct provision of ambulatory surgical services can be included in a facility's payment rates upon appeal to the Department of Health. Such adjustments will be limited to the current schedule of surgical fees, as set forth in section 7.0 of the Medicaid Management Information System Provider Manual, Physicians (revised January, 1985). Copies of the Physicians Manual schedules may be obtained from the Department of Social Services, and are available for inspection and copying at the Department of Health Records Access Office, as indicated in subdivision (h) of this section.
(e) The commissioner shall establish trend factors to project increases in the base year prices during the effective period of the reimbursement rate. To determine trend factors, cost elements shall be weighted based upon data for salaries, employee health and welfare expenses, nonpayroll administrative and general expense, nonpayroll household and maintenance expense, and nonpayroll professional care expense. Each weight shall be adjusted by one or more price indices. Included among these indices are elements of the United States Department of Labor consumer and producer price indices and special indices developed by the commissioner for this purpose.
(f) The projected trend factors shall be updated on an annual basis, based upon then current and available data. The commissioner shall adjust annually subsequent trend factors based upon such update.
(g) Dental procedures included in subdivision (o) of this section performed at facilities for patients requiring the use of an operating room with anesthesia will continue to be paid at current cost-based rates.
(h) Reimbursement for physician services rendered in connection with the provision of ambulatory surgical services shall be in accordance with the Medicaid fee schedule set forth in Title 18 (Social Services) of the Official Compilation of Codes, Rules and Regulations of the State of New York at section 533.4 (18 NYCRR 533.4), as amended pursuant to chapter 904 of the Laws of 1984. Copies of the current schedule of fees, as set forth in section 7.0 of the Medicaid Management Information System Provider Manual, Physicians (revised January 1985), may be obtained from the Bureau of Program, Policy and Operations of the Division of Medical Assistance of the New York State Department of Social Services, 40 North Pearl Street, Albany, NY 12243. The current physicians' fee schedule is available for inspection and copying at the Department of Health, Records Access Office, 22nd Floor, Corning Tower Building, Governor Nelson A. Rockefeller Empire State Plaza, Albany, New York 12237-0042.
(i) Reimbursement for durable medical equipment subsequently required as a result of the provision of ambulatory surgical services shall be in accordance with section 4.2 of the Medicaid Management Information System (MMIS) Provider Manual, Durable Medical Equipment, Medical and Surgical Supplies, Prosthetic and Orthotic Appliances (revised March 1984). Copies of the current durable medical equipment schedules may be obtained from the New York State Department of Social Services, and are available for inspection and copying at the Department of Health, Records Access Office, as indicated in subdivision (h) of this section.
(j) Reimbursement for prosthetic and orthotic appliances subsequently required as a result of and necessitated by the provision of ambulatory surgical services shall be in accordance with Part 522 of Title 18 (Social Services) of the Official Compilation of Codes Rules and Regulations (18 NYCRR Part 522). Copies of current fee schedules for prosthetic and orthotic appliances, as contained in sections 4.6, 4.3 and 4.4, respectively, of the MMIS Provider Manual referenced in subdivision (g) of this section, may be obtained from the New York State Department of Social Services, and are available for inspection and copying at the Department of Health, Records Access Office, as indicated in subdivision (h) of this section.
(k) For any procedure which is not an ambulatory surgical procedure:
(1) facilities with a cost-based all-inclusive Medicaid clinic rate established pursuant to this Part or Subpart 86-1, shall be reimbursed at such rate; provided, however, that the provisions of subdivisions (h) through (j) of this section shall not apply and that the cost for services referred to in these subdivisions shall be considered fully reimbursed through payment of such clinic rate; and
(2) for facilities without a cost-based all-inclusive Medicaid clinic rate established pursuant to this Part or Subpart 86-1, facility costs shall be reimbursed in accordance with section 6.2.5 of the Medicaid Management Information System (MMIS) Clinic Provider Manual, Fees for Hospital-Based Referred Ambulatory Use of the Operating Room (revised December 1984). Copies of the schedule may be obtained from the New York State Department of Social Services, and are available for inspection and copying at the Department of Health, Records Access Office, as indicated in subdivision (h) of this section.
(l) Where multiple procedures are performed and they appear in more than one PAS group, payment pursuant to this section shall be based upon 100 percent of the group price for the highest priced procedure and 50 percent of the applicable group price for each additional procedure furnished in the same operative session.
(m) Reserved.
(n) Reserved.
(o) The following table represents the Products of Ambulatory Surgery (PAS) classification system for which reimbursement is available according to group and group price as established in this section. The Products of Ambulatory Surgery classification system, developed by the New York State Department of Health, classifies ambulatory surgery procedures based upon similarities in patient and resource use characteristics. The table includes the PAS classification and PAS name as follows:

 

 

PAS GROUP GROUP NAME
PAS GROUP 1 Nerve Repair
PAS GROUP 2 Eye Therapeutic
PAS GROUP 3 Eye Repair
PAS GROUP 4 Lens Remove/Replace
PAS GROUP 5 Eye Laser Therapeutic
PAS GROUP 6 Eye Muscle Repair
PAS GROUP 7 Ear Repair
PAS GROUP 8 Ear Therapeutic
PAS GROUP 9 Nasal/Paranasal Therapeutic
PAS GROUP 10 Rhino/Septo Plasty
PAS GROUP 11 Tonsil/Adenoid Therapeutic
PAS GROUP 12 Nasal/Tracheal Endoscope
PAS GROUP 13 Thoracic Diagnostic/Therapeutic
PAS GROUP 14 Vascular Diagnostic II
PAS GROUP 15 Vascular Repair
PAS GROUP 16 Vascular Diagnostic/Therapeutic
PAS GROUP 17 UpperGI Diagnostic/Therapeutic
PAS GROUP 18 LowerGI Diagnostic/Therapeutic
PAS GROUP 19 Rectal Diagnostic/Therapeutic
PAS GROUP 20 Hepatic Diagnostic/Therapeutic
PAS GROUP 21 Hepatic Endoscopy
PAS GROUP 22 Hernia Repair
PAS GROUP 23 Cystoscope
PAS GROUP 24 Urological Therapeutic
PAS GROUP 25 Lithotripsy
PAS GROUP 26 Male Genital Diagnostic
PAS GROUP 27 Genito-Urinary Repair
PAS GROUP 28 Male Genital Therapeutic
PAS GROUP 29 Laparoscopy
PAS GROUP 30 Oviduct Diagnostic/Therapeutic
PAS GROUP 31 Gyn Diagnostic/Therapeutic
PAS GROUP 32 Dilation and Curettage
PAS GROUP 33 Soft Tissue Repair
PAS GROUP 34 Bone Therapeutic
PAS GROUP 35 Arthroscopy
PAS GROUP 36 Bone Repair
PAS GROUP 37 Soft Tissue Therapy
PAS GROUP 38 Breast Diagnostic/Therapeutic
PAS GROUP 39 Breast Repair
PAS GROUP 40 Skin Diagnostic/Therapeutic
PAS GROUP 41 Skin Repair
PAS GROUP 42 Urological Diagnostic
PAS GROUP 43 Oral Surgery
PAS GROUP 44 STRB
PAS GROUP 45 Eye Implant/Therapeutic (HIV)

 

Effective Date: 
Tuesday, November 4, 1997
Doc Status: 
Complete

Section 86-4.41 - Computation of basic rates for day health care services provided by freestanding ambulatory care facilities to patients with acquired immune deficiency syndrome (AIDS) and other human immunodeficiency (HIV) related illnesses

86-4.41 Computation of basic rates for day health care services provided by freestanding ambulatory care facilities to patients with acquired immune deficiency syndrome (AIDS), other human immunodeficiency virus (HIV) related illnesses and other high-need populations that, regardless of their HIV status and in the discretion of the commissioner, would benefit from receiving adult day health care services.

Effective April 1, 1994 and thereafter, reimbursement for adult day health care services that are provided to registrants with acquired immune deficiency syndrome (AIDS), other human immunodeficiency virus (HIV) related illnesses and, effective April 1, 2017, that are provided to registrants who are otherwise considered at the discretion of the commissioner to be part of a high-need population that, regardless of their HIV status, would benefit from receiving these adult day health care services shall be established pursuant to this section.

(a) For payments made pursuant to this section for day health care services rendered to patients who have AIDS or HIV-related illness and other high-need registrants, reimbursement shall be a single price per visit, with not more than one reimbursable visit per day per patient. For 1993 an initial price shall be determined taking into consideration reasonable projections of necessary costs, and the costs and statistics contained in proposed annual budgets for this service as defined in section 759.1(d) of this Title, including, but not limited to, utilization, staffing and salaries. For subsequent rate periods the price established pursuant to this section shall be adjusted by the trend factor described in subdivision (e) of this section after considering the actual allowable expenditures and statistics for the year which ended 15 months prior to the rate period.

(b) To be eligible to receive reimbursement pursuant to this section, a freestanding ambulatory care facility must be certified to provide general medical services and day health care services for AIDS/HIV patients and, effective April 1, 2017, to other high-need registrants.

(c) The price established pursuant to this section shall be full reimbursement for the following:

(1) physician services, nursing services, and other related professional expenses directly incurred by the licensed facility, including the provision of triage or sick call services;

(2) space occupancy and plant overhead costs;

(3) administrative personnel, business office, data processing, recordkeeping, housekeeping, food services, transportation, and other related facility overhead expenses;

(4) all ancillary services described in section 759.8 of this Title and laboratory tests and diagnostic x-ray services appropriate to the level of primary medical care required by the patient;

(5) all medical supplies, immunizations, and drugs directly related to the provision of services.

(d) Components of the price may be adjusted for service capacity, urban or rural location, and for regional differences in wage levels, space occupancy, and facility overhead costs, by comparing anticipated utilization and costs with actual experiences. The downstate region shall be defined as the counties of Putnam, Rockland, Westchester, Bronx, Kings, New York, Queens, Richmond, Nassau, and Suffolk and the upstate region shall be defined as all remaining counties in the State.

(e) The commissioner shall establish trend factors to project increases in prices for the effective period of the reimbursement rates. The trend factors shall be developed using available price indices including elements of the United States Department of Labor consumer and producer price indices and special price indices developed by the Commissioner for this purpose. The projected trend factors shall be updated on an annual basis, based upon current and available data.

Effective Date: 
Wednesday, June 14, 2017
Doc Status: 
Complete