SubPart 86-11 - Rate Setting for Non-State Providers: Intermediate Care Facilities for Persons with Developmental Disabilities

Effective Date: 
Wednesday, June 13, 2018
Doc Status: 
Complete
Statutory Authority: 
Social Services Law, Section 363-a and Public Health Law, Section 201(1)(v)

Section 86-11.1 - Applicability

86-11.1 Applicability.

On and after November first, two thousand fourteen, rates of reimbursement for intermediate care facilities for persons with developmental disabilities (ICF/DD) services, other than those provided by the Office for People with Developmental Disabilities, shall be determined in accordance with this Subpart.

Effective Date: 
Wednesday, April 22, 2015
Doc Status: 
Complete

Section 86-11.2 - Definitions

86-11.2 Definitions. As used in this Subpart, the following terms shall have the following meanings:

(a) Allowable costs. Costs that are allowable under 14 NYCRR Subpart 635-6 or 14 NYCRR section 681.14(f).

(b) Base year. The consolidated fiscal report period from which the initial period rate will be calculated. Such period shall be January first, two thousand eleven through December thirty-first, two thousand eleven for providers reporting on a calendar year basis and July first, two thousand ten through June thirtieth, two thousand eleven for providers reporting on a fiscal year basis.

(c) Base operating rate. Reimbursement amount calculated by dividing annual reimbursement by applicable annual units of service, both in effect on June thirtieth, two thousand fourteen.

(d) Budget neutrality adjustment. Factor applied to adjust the proposed amount so that it is equivalent to the base amount of dollars.

(e) Capital cost. Costs that are related to the acquisition, lease, construction and/or long-term use of land, buildings and fixed equipment, leasehold improvements and vehicles.

(f) Department of Health (DOH) Regions. Regions as defined by the Department, assigned to providers based upon the geographic location of the provider’s headquarters as reported on the consolidated fiscal report. Such regions are as follows:

(1) Downstate: 5 boroughs of New York City, Nassau, Suffolk and Westchester;

(2) Hudson Valley: Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster;

(3) Upstate Metro: Albany, Erie, Fulton, Genesee, Madison, Monroe, Montgomery, Niagara, Onondaga, Orleans, Rensselaer, Saratoga, Schenectady, Warren, Washington, Wyoming;

(4) Upstate Non-Metro: Any counties not listed in subparagraphs (1), (2) or (3) of this paragraph.

(g) Depreciation. The allowable cost based on historical costs and useful life of buildings, fixed equipment, capital improvements and/or acquisition of real property. The useful life shall be based on “The Estimated Useful life of Depreciable Hospital Assets (2008 edition).”

(h) Facility. The site or physical building where ICF/DD services are provided.

(i) Financing expenditures. Interest expense and fees charged for financing of costs related to the purchase/acquisition, alteration, construction, rehabilitation and/or renovation of real property.

(j) Individual. Person receiving ICF/DD services.

(k) ICF/DD. An intermediate care facility for persons with developmental disabilities, as such term is used in 14 NYCRR Part 681.

(l) Initial period. July first, two thousand fourteen through June thirtieth, two thousand fifteen.

(m) Lease/rental and ancillary payments. A provider’s annual rental payments for real property and ancillary outlays associated with the property such as utilities and maintenance.

(n) Provider - an individual, corporation, partnership or other organization to which OPWDD has issued an operating certificate pursuant to Article 16 of the Mental Hygiene Law to operate an ICF/DD, and for which the NYS Department of Health has issued a Medicaid provider agreement.

(o) Rate sheet capacity. The certified capacity of the ICF/DDs operated by a provider.

(p) Reimbursable cost. The final allowable costs of the rate year after all audit and/or adjustments are made.

(q) Start-up costs. Those costs associated with the opening of a new facility or program. Start-up costs include pre-operational rent, utilities, staffing, staff training, advertising for staff, travel, security services, furniture, equipment and supplies.

(r) Target rate. The final rate in effect at the end of the transition period for each provider.

Effective Date: 
Wednesday, April 22, 2015
Doc Status: 
Complete

Section 86-11.3 - Rates for providers of ICF/DD services

86-11.3 Rates for providers of ICF/DD services.

(a) There shall be one provider-wide rate for each provider, except that rates for ICF/DD services provided to individuals identified as specialized populations by OPWDD shall be determined under section 11.9 this Subpart. Adjustments may be made to the rate resulting from any final audit findings or reviews.

(b) Rates shall be computed on the basis of a full twelve month base year CFR, adjusted in accordance with the methodology as provided in this section. The rate shall include operating cost components, and capital cost components as identified in applicable subdivisions. Such base year may be updated periodically, as determined by the Department.

(c) Components of rates for ICF/DD services

(1) The operating component shall be based on allowable costs identified in the consolidated fiscal reports. The operating component shall be inclusive of the following components:

(i) Regional average direct care wage, which shall mean the quotient of base year salaried direct care dollars for each provider in a DOH region, aggregated for all such providers in such region, for all residential habilitation-supervised IRA, residential habilitation-supportive IRA, day habilitation services and ICF/DD, divided by base year salaried direct care hours for each provider in a DOH region, aggregated for all such providers in such region, for all residential habilitation-supervised IRA, residential habilitation-supportive IRA, day habilitation services and ICF/DD services.

(ii) Regional average employee-related component, which shall mean the sum of vacation leave accruals and total fringe benefits for the base year for each provider of a DOH region, aggregated for all such providers in such region, such sum to be divided by base year salaried direct care dollars for each provider of a DOH region, aggregated for all such providers in such region, and then multiplied by the applicable regional average direct care wage as determined by subparagraph (i) of this paragraph.

(iii) Regional average program support component, which shall mean the sum of transportation related-participant staff travel, participant incidentals, expensed adaptive equipment, sub-contract raw materials, participant wages-non-contract, participant wages-contract, participant fringe benefits, staff development, supplies and materials-non-household, other-OTPS, lease/rental vehicle, depreciation-vehicle, interest-vehicle, other-equipment, other than to/from transportation allocation, salaried support dollars (excluding housekeeping and maintenance staff) and salaried program administration dollars for the base year for each provider of a DOH region, aggregated by all such providers in such region. Such sum shall be divided by the total base year salaried direct care dollars of all providers in a DOH region, and then multiplied by the applicable regional average direct care wage as determined pursuant to subparagraph (i) of this paragraph.

(iv) Regional average direct care hourly rate-excluding general and administrative, which shall mean the sum of the applicable regional average direct care wage as determined pursuant to subparagraph (i) of this paragraph, the applicable regional average employee-related component as determined pursuant to subparagraph (ii) of this paragraph, and applicable regional average program support component as determined pursuant to subparagraph (iii) of this paragraph.

(v) Regional average general and administrative component, which shall mean the sum of the insurance-general and agency administration allocation for the base year for each provider in a DOH region, aggregated for all such providers in such region, divided by (the sum of total program/site costs and other than to/from transportation allocation, less the sum of food, repairs and maintenance, utilities, expensed equipment, household supplies, telephone, lease/rental equipment, depreciation equipment, total property-provider paid, housekeeping and maintenance staff, salaried clinical dollars, and contracted clinical dollars for the base year for each provider of a DOH region, aggregated for all providers in such region). The regional average direct care hourly rate-exclusive of general and administrative costs, as determined pursuant to subparagraph (iv) of this paragraph, shall then be divided by (one minus the applicable regional average general and administrative quotient), from which the applicable regional average direct care wage hourly rate-excluding general and administrative, as computed in subparagraph (iv) of this paragraph shall be subtracted.

(vi) Regional average direct care hourly rate, which shall mean the sum of the applicable regional average direct care wage, as determined pursuant to subparagraph (i) of this paragraph, the applicable regional average employee-related component as determined pursuant to subparagraph (ii) of this paragraph, the applicable regional average program support component as determined pursuant to subparagraph (iii) of this paragraph, and the applicable regional general and administrative component computed in subparagraph (v) of this paragraph.

(vii) Provider average direct care wage, which shall mean the quotient of base year salaried direct care dollars divided by the base year salaried direct care hours of a provider.

(viii) Provider average employee-related component, which shall mean the sum of vacation leave accruals and fringe benefits for the base year for each provider, divided by base year salaried direct care dollars of a provider, such quotient to be multiplied by the provider average direct care wage as computed in subparagraph (vii) of this paragraph.

(ix) Provider average program support component, which shall mean the sum of transportation related-participant, staff travel, participant incidentals, expensed adaptive equipment, sub-contract raw materials, participant wages-non-contract, participant wages-contract, participant fringe benefits, staff development, supplies and materials-non-household, other-OTPS, lease/rental vehicle, depreciation-vehicle, interest-vehicle, other-equipment, other than to/from transportation allocation, salaried support dollars (excluding housekeeping and maintenance staff) and salaried program administration dollars for the base year for a provider. Such sum shall be divided by the base year salaried direct care dollars of such provider and such quotient shall be multiplied by the provider average direct care wage as computed in subparagraph (vii) of this paragraph.

(x) Provider average direct care hourly rate-excluding general and administrative, which shall mean the sum of the provider average direct care wage as determined pursuant to subparagraph (vii) of this paragraph, the provider average employee-related component as determined pursuant to subparagraph (viii) of this paragraph, and the provider average program support component as determined pursuant to subparagraph (ix) of this paragraph for each provider.

(xi) Provider average general and administrative component, which shall mean the sum of insurance-general and agency administration allocation for the base year for a provider, such sum to be divided by (the sum of total program/site costs and other than to/from transportation allocation less the sum of food, repairs and maintenance, utilities, expensed equipment, household supplies, telephone, lease/rental equipment, depreciation equipment, insurance – property and casualty, total property-provider paid, housekeeping and maintenance staff, salaried clinical dollars, and contracted clinical dollars for a provider) for the base year. The provider average direct care hourly rate-excluding general and administrative, as computed in subparagraph (x) of this paragraph, shall then be divided by (one minus the applicable provider average general and administrative quotient), from which the provider average direct care wage hourly rate-excluding general and administrative, as computed in subparagraph (x) of this paragraph, shall be subtracted.

(xii) Provider average direct care hourly rate, which shall mean the sum of the provider average direct care wage, as determined pursuant to subparagraph (vii) of this paragraph, the provider average employee-related component as determined pursuant to subparagraph (viii) of this paragraph, the provider average program support component as determined pursuant to subparagraph (ix) of this paragraph, and the provider average general and administrative component as determined pursuant to subparagraph (xi) of this paragraph.

(xiii) Provider direct care hours, which shall mean the sum of base year salaried direct care hours and base year contracted direct care hours, such sum to be divided by the rate sheet capacities for the base year. Such quotient to be multiplied by rate sheet capacities for the initial period.

(xiv) Regional average clinical hourly wage, which shall mean the quotient of base year salaried clinical dollars for each provider of a DOH region, aggregated for all such providers in such region, divided by base year salaried clinical hours for each provider of a DOH region, aggregated for all such providers in such region.

(xv) Provider average clinical hourly wage, which shall mean the quotient of base year salaried clinical dollars of a provider divided by base year salaried clinical hours of such provider.

(xvi) Provider salaried clinical hours, which shall mean the quotient of base year salaried clinical hours of a provider, divided by the rate sheet capacities for the base year, such quotient to be multiplied by the rate sheet capacities for the initial period for such provider.

(xvii) Regional average contracted clinical hourly wage, which shall mean the quotient of contracted clinical dollars divided by the base year contracted clinical hours for each provider of a DOH region, aggregated for all such providers in such region.

(xviii) Provider contracted clinical hours, which shall mean the quotient of a provider’s contracted clinical hours for the base year divided by the rate sheet capacities for the base year, such quotient to be multiplied by rate sheet capacities for the initial period.

(xix) Provider direct care hourly rate-adjusted for wage equalization factor, which shall mean the sum of the provider average direct care hourly rate, as determined pursuant to subparagraph (xii) of this paragraph multiplied by seventy-five hundredths and the applicable regional average direct care hourly rate, as determined pursuant to subparagraph (vi) of this paragraph multiplied by twenty-five hundredths.

(xx) Provider clinical hourly wage – adjusted for wage equalization factor, which shall mean the sum of the provider average clinical hourly wage, as determined pursuant to subparagraph (xv) of this paragraph, multiplied by seventy-five hundredths and the applicable regional average clinical hourly wage, as computed in subparagraph (xiv) of this paragraph multiplied by twenty-five hundredths.

(xxi) Provider reimbursement from direct care hourly rate, which shall mean the product of the calculated direct care hours, as determined pursuant to subparagraph (xiii) of this paragraph, and the provider direct care hourly rate-adjusted for wage equalization factor, as computed in subparagraph (xix) of this paragraph.

(xxii) Provider reimbursement from clinical hourly wage, which shall mean the product of the provider salaried clinical hours, as determined pursuant to subparagraph (xvi) of this paragraph and the provider clinical hourly wage- adjusted for wage equalization factor, as determined pursuant to subparagraph (xx) of this paragraph.

(xxiii) Provider reimbursement from contracted clinical hourly wage, which shall mean the product of the provider contracted clinical hours, as determined pursuant to subparagraph (xviii) of this paragraph and the applicable regional average contracted clinical hourly wage, as determined pursuant to subparagraph (xvii) of this paragraph.

(xxiv) Provider facility reimbursement, which shall mean the sum of food, repairs and maintenance, utilities, expensed equipment, household supplies, telephone, lease/rental equipment, depreciation equipment, insurance – property and casualty, housekeeping and maintenance staff, and program administration property the base year for a provider and such sum to be divided by provider rate sheet capacities for the base year. Such sum to be multiplied by rate sheet capacities for the initial period.

(xxv) Provider operating revenue, which shall mean the sum of provider reimbursement from direct care hourly rate, as determined pursuant to subparagraph (xxi) of this paragraph, the provider reimbursement from clinical hourly wage, as determined pursuant to subparagraph (xxii) of this paragraph, the provider reimbursement from contracted clinical hourly wage, as determined pursuant to subparagraph (xxiii) of this paragraph, and the provider facility reimbursement, as determined pursuant to subparagraph (xxiv) of this paragraph.

(xxvi) Statewide budget neutrality adjustment factor for operating dollars, which shall mean the quotient of all provider rate sheets in effect on June thirtieth, two thousand fourteen, divided by provider operating revenue, as determined pursuant to subparagraph (xxv) of this paragraph, for all providers.

(xxvii) Total provider operating revenue- adjusted, which shall mean the product of the provider operating revenue, as determined pursuant to subparagraph (xxv) of this paragraph and the statewide budget neutrality adjustment factor for operating dollars, as determined pursuant to subparagraph (xxvi) of this paragraph.

The final daily operating rate shall be determined by dividing the total provider operating revenue- adjusted, as determined by subparagraph (xxvii) of this paragraph, by the applicable provider rate sheet capacity for the initial period and such quotient to be further divided by three hundred sixty-five.

(2) Alternative operating component. For providers that did not submit a cost report or submitted a cost report that was incomplete for the base year, the final daily operating rate shall be a regional daily operating rate. This rate shall be the sum of:

(i) The product of the applicable regional average direct care hourly rate, as determined pursuant to subparagraph (vi) of paragraph (1) of this subdivision and the applicable regional average direct care hours, which shall mean the quotient of salaried and base year contracted direct care hours for each provider of a DOH region, aggregated for all such providers in such region, divided by the rate sheet capacities, pro-rated for partial year sites for the base year for each provider of a DOH region, aggregated for all such providers in such region; and

(ii) the product of the applicable regional average clinical hourly wage, as determined pursuant to subparagraph (xiv) of paragraph (1) of this subdivision and the applicable regional average clinical hours, which shall mean the quotient of salaried and base year contracted clinical hours for each provider of a DOH region, aggregated for all such providers in such region, divided by the rate sheet capacities, pro-rated for partial year sites for the base year for each provider of a DOH region, aggregated for all such providers in such region; and

(iii) the applicable regional average facility revenue, which shall mean the quotient of the sum of food, repairs and maintenance, utilities, expensed equipment, household supplies, telephone, lease/rental equipment, depreciation, insurance – property and casualty, housekeeping and maintenance staff, and program administration property for the base year divided by the rate sheet capacities, pro-rated for partial year sites for the base year for each provider of a DOH region, aggregated for all such providers in such region; and

Such sum shall then be multiplied by the statewide budget neutrality adjustment factor for operating dollars, as determined pursuant to subparagraph (xxvii) of paragraph (1) of this subdivision.

(3) Day program services component. There shall be a day program services component for individuals who participate in either in-house day programming or day services, which shall equal the sum of the in-house day programming amount from the provider rate sheet in effect on June thirtieth, two thousand and fourteen, plus the product of the units of service for the day services providers as was used in the calculation of the rate in effect on June thirtieth, two thousand and fourteen and the day service provider’s rate in effect on July first, two thousand and fourteen.

(4) Capital component.

(i) For Capital Assets Approved on or after July first, two thousand fourteen. OPWDD regulations under 14 NYCRR Subpart 635-6 establish standards and criteria for calculating provider reimbursement for the acquisition and lease of real property assets which require approval by the office for people with developmental disabilities. The regulations also address associated depreciation and related financing expenses. The rate will include costs for actual straight line depreciation, interest expense, financing expenses, and lease cost.

In no case will the total capital reimbursement associated with the capital asset exceed the total acquisition cost, renovation and financing cost associated with a capital asset. The asset life for building acquisitions shall be twenty-five years.

(ii) For Capital Assets Approved Prior to July first, two thousand fourteen. The State will identify each asset by provider, and provide a schedule of these assets identifying: total actual cost, reimbursable cost determined by the prior approval, total financing cost, allowable depreciation and allowable interest for the remaining useful life as determined by the prior approval, and the allowable reimbursement for each year of the remaining useful lives.

In no case will the total reimbursable depreciation or principal amortization and total interest associated with the capital asset exceed the total acquisition cost, renovation and financing cost associated with a capital asset.

(iii) Notification to Providers. 14 NYCRR Subpart 635-6 contains the criteria and standards associated with capital costs and reimbursement. Each provider will receive a schedule of “prior approved assets” that is being used to establish the real property capital component of the provider’s reimbursement rate.

(iv) Initial rate for capital assets approved on or after July first, two thousand fourteen. The rate shall include the approved appraised costs of an acquisition or fair market value of a lease, and estimated costs for renovations, interest, soft costs and start-up expenses. Such costs shall be included in the rate as of the date of certification of the site, continuing until such time as actual costs are submitted to the State. Estimated costs shall be submitted in lieu of actual costs for a period no greater than two years. If actual costs are not submitted to the State within two years from the date of site certification, the amount of capital costs included in the rate shall be zero for each period in which actual costs are not submitted. The Department may retroactively adjust the capital component.

(v) Cost verified rates for capital assets approved on or after July first, two thousand fourteen. The provider shall submit to the State supporting documentation of actual costs. Actual costs shall be verified by the State reviewing the supporting documentation of such costs. A provider submitting such actual costs shall certify that the reimbursement requested reflects allowable capital costs and that such costs were actually expended by such provider. Under no circumstances shall the amount included in the rate under this subparagraph exceed the amount authorized in the approval process. Capital costs shall be depreciated over a twenty-five year period for acquisition of properties or amortized over the life of the lease for leased sites. Capital improvements shall be depreciated over the life of the asset. The amortization of interest shall not exceed the life of the loan taken. Amortization or depreciation shall begin upon certification by the provider of such costs. Start-up costs may be amortized over a one year period beginning with site certification. If actual costs are not submitted to the State within two years from the date of site certification, the amount of capital costs included in the rate shall be zero for each period in which actual costs are not submitted.

(vi) Capital reimbursement reconciliation schedule. Beginning with the cost reporting period ending December thirty-first, two thousand fourteen, each provider shall submit to OPWDD, as part of the annual cost report, a capital reimbursement reconciliation schedule.

This schedule will specifically identify the differences, by capital reimbursement item, between the amounts reported on the certified cost report, and the reimbursable items, including depreciation, interest and lease cost from the schedule of approved reimbursable capital costs.

The provider’s independent auditor will apply procedures to verify the accuracy and completeness of the capital reimbursement reconciliation schedule.

The Department will retroactively adjust capital reimbursement based on the actual cost verification process as described in subparagraph (iv) of this paragraph.

Effective Date: 
Wednesday, April 22, 2015
Doc Status: 
Complete

Section 86-11.4 - Assessment

86-11.4 Assessment.

Rates shall include the assessment described in section 43.04 of the Mental Hygiene Law.

Effective Date: 
Wednesday, April 22, 2015
Doc Status: 
Complete

Section 86-11.5 - Reporting requirements.

86-11.5. Reporting requirements.

(a) Providers shall report costs and maintain financial and statistical records in accordance with 14 NYCRR Subpart 635-4.

(b) Generally Accepted Accounting Principles (GAAP). The completion of the financial and statistical report forms shall be in accordance with generally accepted accounting principles as applied to the provider unless the reporting instructions authorized specific variation in such principles. The State shall identify provider cost and providers shall submit cost data in accordance with generally accepted accounting principles (GAAP).

Effective Date: 
Wednesday, April 22, 2015
Doc Status: 
Complete

Section 86-11.6 - Trend Factor, Increases to Compensation and Other Adjustments

86-11.6 Trend Factor, Increases to Compensation and Other Adjustments.

(a) Trend Factor. For years in which the Department does not update the base year, subject to the approval of the Director of Budget, the Department may use a compounded trend factor to bring base year costs forward to the appropriate rate period. The trend factor shall be taken from applicable years from consumer and producer price indices, including, but not limited to the Medical Care Services Index; U.S. city average, by expenditure category and commodity and service group for the period April to April of each year.

(b) Increases to Compensation.

(1) Applicability. On or after January 1, 2015, rates of reimbursement for providers that operate eligible programs as defined in this section will be revised to incorporate funding for compensation increases to their direct support professional employees. Such rate increases will be effective January 1, 2015. The compensation increase funding will be included in the provider's rate issued for January 1, 2015 or in a subsequent rate with the inclusion of funding in the amount necessary to achieve the same funding impact as if the rate had been issued on January 1, 2015. The compensation increase funding will be inclusive of associated fringe benefits.

(2) Definitions. As used in this section, the following terms shall have the following meanings:

(i) Direct support professionals are those defined as Direct Care and Support per Consolidated Fiscal Report (CFR) Appendix R and reported on the CFR under the Position Title code identifiers of 100 or 200. Contracted staff salary information will not be utilized.

(ii) Clinical staff are those defined as Clinical per CFR Appendix R and reported on the CFR under the Position Title code identifier of 300. Contracted staff salary information will not be utilized.

(iii) Eligible rate based programs shall mean Intermediate Care Facility for Persons with Developmental Disabilities (ICFs/DD).

(3) Increases for Eligible Rate Based Programs.

(i) January 1, 2015 Increase. Rates for eligible rate based programs will be revised to incorporate funding for compensation increases to direct support professional employees. Such rate increases will be effective January  1, 2015. The compensation increase funding will be included in the provider’s rate issued for January  1, 2015, or in a subsequent rate with the inclusion of funding in the amount necessary to achieve the same funding impact as if the rate had been issued on January 1, 2015. The compensation increase funding will be inclusive of associated fringe benefits.

(ii) April 1, 2015 Increase. In addition to the compensation funding effective January 1, 2015, providers that operate ICFs/DD will receive a compensation increase targeted to direct support professional and clinical employees to be effective April 1, 2015. The compensation increase funding will be inclusive of associated fringe benefits. The April 1, 2015 direct support professionals compensation funding will be compounded on the amount which was calculated for the January 1, 2015 compensation increase and will be an augmentation to the January 1, 2015 increase.

(iii) Calculations. The basis for the calculation of provider and regional direct care, support and clinical salary averages and associated fringe benefit percentages will be the data in providers’ CFRs for July 1, 2010 through June 30, 2011 for providers reporting on a fiscal year basis or January 1, 2011 through December 31, 2011 for providers reporting on a calendar year basis.

(a) The January 1, 2015 and April 1, 2015 Direct Support Professionals compensation increase funding formula will be as follows:

(1) The annual impact of a two percent increase to 2010-11 or 2011 salaried direct care dollars, salaried support dollars and associated fringe benefits will be calculated.

(2) The annual impact of the two percent increase for salaried direct care dollars, salaried support dollars and associated fringe will be added to the appropriate operating components in the rate methodology. This will result in a recalculation of provider and regional average direct care wages, provider and regional average employee-related components, provider and regional average program support components, and provider and regional average direct care hourly rates.

(3) The provider direct care hourly rate – adjusted for wage equalization factor will be recalculated to utilize the provider average direct care hourly rate and regional average direct care hourly rate, as calculated in subparagraph (2) of this paragraph.

(4) An identification will be made of the dollar difference between the provider direct care hourly rate – adjusted for wage equalization factor, which is in the rate in effect on December 31, 2014, and the provider direct care hourly rate – adjusted for wage equalization factor, as calculated in subparagraph (3) of this paragraph.

(5) The rate difference identified in subparagraph (4) of this paragraph will be multiplied by the calculated direct care hours in the rate in effect on December 31, 2014 to calculate the additional funding generated by the direct care compensation adjustment.

(6) The rate add-on for the compensation increase shall be determined by dividing the additional funding, as calculated in subparagraph (5) of this paragraph by the rate sheet units in effect on January 1, 2015.

(b) The April 1, 2015 Clinical compensation increase funding formula will be as follows:

(1) The annual impact of a two percent increase to 2010-11 or 2011 salaried clinical dollars and associated fringe benefits will be calculated.

(2) The annual impact of the two percent increase for salaried clinical dollars and associated fringe will be added to the appropriate operating components in the rate methodology. This will result in a recalculation of provider and regional average employee-related components, provider and regional average clinical hourly wages.

(3) The provider clinical hourly wage – adjusted for wage equalization factor will be recalculated to utilize the provider average clinical hourly wage and regional average clinical hourly wage, as calculated in subparagraph (2) of this paragraph.

(4) An identification will be made of the dollar difference between the provider clinical hourly wage – adjusted for wage equalization factor, which is in the rate in effect on December 31, 2014, and the provider clinical hourly wage – adjusted for wage equalization factor, as calculated in subparagraph (3) of this paragraph.

(5) The rate difference identified in subparagraph (4) of this paragraph will be multiplied by the provider salaried clinical hours in the rate in effect on December 31, 2014 to calculate the additional funding generated by the clinical compensation adjustment.

(6) The rate add-on for the compensation increase shall be determined by dividing the additional funding, as calculated in subparagraph (5) of this paragraph by the rate sheet units in effect on January 1, 2015.

(c) Occupancy Adjustment

(1) Definitions.  As used in this section, the following terms shall have the following meanings:

(i) Occupancy Adjustment  – An  adjustment to the calculated daily rate of a Provider operating an ICF/DD to account for days when Medicaid billing cannot occur because an individual has passed away or has moved to another site.

(2) For the initial rate period beginning July 1, 2014 and thereafter, providers will receive an occupancy adjustment to the operating component of their rate for vacancy days.  The occupancy adjustment percentage is calculated by dividing the agency’s rate period service days by one-hundred percent of the agency’s certified capacity.  The certified capacity is calculated taking into account capacity changes throughout the year, multiplied by one-hundred percent of the year’s days.  This adjustment will begin on July 1, 2016 and be recalculated on an annual basis based on the previous year’s experience.  The occupancy adjustment calculation will be agency specific and will be the higher of the agency’s actual occupancy percentage or at 95% occupancy. The occupancy percentage will be used to adjust the operating component of the rate for the rate year.

 

Effective Date: 
Wednesday, June 13, 2018
Doc Status: 
Complete

Section 86-11.7 - Transition to new methodology

86-11.7. Transition to new methodology.

The reimbursement methodology described in this subpart will be phased-in over a three-year period, with a year for purposes of the transition period meaning a twelve-month period from July first to the following June thirtieth, and with full implementation in the beginning of the fourth year. During this transition period, the base operating rate will transition to the target rate as determined by the reimbursement methodology described in this subpart, according to the phase-in schedule outlined below. The base operating rate will remain fixed and the target rate, as determined by the reimbursement methodology in this subpart, will be updated to reflect rebasing of cost data, trend factors and/or other appropriate adjustments.

 

 

Transition Year

Base operating rate

Target rate

Year One (July 1, 2014 – June 30, 2015)

75%

25%

Year Two (July 1, 2015 – June 30, 2016)

50%

50%

Year Three (July 1, 2016 - June 30, 2017)

25%

75%

Year Four (July 1, 2017 – June 30, 2018)

0%

100%

 

 

 

 

 

 

 

 

 

 

Effective Date: 
Wednesday, April 22, 2015
Doc Status: 
Complete

Section 86-11.8 - Rate corrections

86-11.8. Rate corrections

(a) Arithmetic or calculation errors will be adjusted accordingly in instances that would result in an annual change of $5,000 or more in a provider’s annual reimbursement for ICFs/DD.

(b) In order to request a rate correction in accordance with subdivision (a) of this section, the provider must send to the Department of Health its request by certified mail, return receipt requested, within ninety days of the provider receiving the rate computation or within ninety days of the first day of the rate period in question, whichever is later.

Effective Date: 
Wednesday, April 22, 2015
Doc Status: 
Complete

Section 86-11.9 - Specialized template populations

86-11.9. Specialized template populations. Notwithstanding any other provisions of this Subpart, rates for individuals identified by OPWDD as qualifying for specialized template populations funding shall be as follows:

(a) For individuals initially identified as qualifying for specialized template populations funding between November 1, 2011 and March 31, 2014.

 

 

Residential – Specialized Level of Care

Region

Gross Annual Funding Allocation Per Individual – Operating Only

Downstate

 

$166,400

Upstate

 

$150,500

 

 

 

Residential – Highly Complex Level of Care

Region

Gross Annual Funding Allocation Per Individual – Operating Only

Downstate

 

$189,500

Upstate

 

$171,500

 

 

 

Residential – Auspice Change

Region

Gross Annual Funding Allocation Per Individual – Operating Only

Downstate

 

$136,500

Upstate

 

$123,500

 

 

 

Day Services – Specialized Level of Care

Region

Gross Annual Funding Allocation Per Individual – Operating Only

Downstate

 

$41,730

Upstate

 

$37,562

 

 

 

Day Services – Highly Complex Level of Care

Region

Gross Annual Funding Allocation Per Individual – Operating Only

Downstate

 

$46,433

Upstate

 

$43,063

 

 

(b) For individuals initially identified as qualifying for specialized template populations funding after March 31, 2014.

 

 

Residential – Highly Complex Level of Care

Region

Gross Annual Funding Allocation Per Individual – Operating Only

Downstate

 

$189,500

Upstate

 

$171,500

 

 

 

Residential – Auspice Change

Region

Gross Annual Funding Allocation Per Individual – Operating Only

Downstate

 

$136,500

Upstate

 

$123,500

 

 

 

Day Services – Highly Complex Level of Care

Region

Gross Annual Funding Allocation Per Individual – Operating Only

Downstate

 

$46,433

Upstate

 

$43,063

 

 

 

(c) January 1, 2015 Increase. The fees for specialized template populations funding will be revised to incorporate funding for compensation increases to direct support professional employees. Such fee increases will be effective January 1, 2015. The compensation increase funding will be included in the provider’s fee issued for January 1, 2015 or in a subsequent fee with the inclusion of funding in the amount necessary to achieve the same funding impact as if the fee had been issued on January 1, 2015. The compensation increase funding will be inclusive of associated fringe benefits.

(d) April 1, 2015 Increase. In addition to compensation funding effective January 1, 2015, the fees for specialized template population funding will revised to incorporate funding for a compensation increase to direct support professional and clinical employees to be effective April 1, 2015. The April 1, 2015 direct support compensation funding will be compounded on the amount which was calculated for the January 1, 2015 compensation increase and will be an augmentation to the January 1, 2015 increase.

(e) Calculations.

(1) The portion of the fee that is identified as direct care and support will be increased by 2% and multiplied by the fee sheet fringe benefit percentage to calculate the additional direct support compensation increases for January 1, 2015 and April 1, 2015.

(2) The portion of the fee that is identified as clinical will be increased by 2% and multiplied by the fee sheet fringe benefit percentage to calculate the additional clinical compensation increase for April 1, 2015.

Effective Date: 
Wednesday, June 13, 2018
Doc Status: 
Complete

Section 86-11.10 - Severability

86-11.10 Severability.

If any provision of this Subpart or its application to any person or circumstance is held to be invalid, the remainder of this Subpart and the application of that provision to other persons or circumstances will not be affected.

Effective Date: 
Wednesday, April 22, 2015
Doc Status: 
Complete