Section 505.25 - Ambulatory care for recipients with mental illness.

505.25 Ambulatory care for recipients with mental illness. (a) Definitions.

(1) For the purposes of the Medical Assistance Program, ambulatory care for eligible recipients with mental illness means any arrangement or therapeutic environment for the delivery of medical care, health care, or services meeting the criteria set forth in sections 7.09, 7.15 and 31.04 and article 43 of the Mental Hygiene Law, as implemented by appropriate sections of 14 NYCRR Parts 579 and 585.

(2) All definitions specified in Parts 579 and 585 of 14 NYCRR apply to this section.

(b) Description of Medicaid-covered programs for ambulatory care for mental illness when currently certified by a valid operating certificate. (1) Clinic treatment programs provide a comprehensive array of services for mentally ill persons and collaterals, usually during visits of less than three hours. The frequency of visits, the duration of treatment, and the extent of services provided during a visit or during the course of treatment are variable, depending upon the identified needs of the patient. A clinic treatment program shall provide, but need not be limited to the following services:

(i) assessment and treatment planning services;

(ii) verbal therapies;

(iii) medication therapy;

(iv) crisis services; and

(v) case management services.

(2) Day treatment programs provide a comprehensive array of services for mentally ill persons and collaterals through the use of supervised, planned services and extensive patient-staff interaction. In general, the duration of a visit exceeds three hours, visits occur with regular frequency usually declining over the course of treatment, and more than one service is provided during a visit. Except for patients under the age of 18, the program is designed for patients who are expected to need day treatment services for a limited period. The average length of stay is expected to be six months or less. A day treatment program shall provide, but need not be limited to the following services:

(i) assessment and treatment planning services;

(ii) verbal therapies;

(iii) medication therapy;

(iv) crisis services;

(v) case management services;

(vi) social training;

(vii) task and skill training; and

(viii) socialization activities.

(3) Continuing treatment programs provide a comprehensive array of services for mentally ill persons and collaterals on a relatively longterm basis in a therapeutic environment through the use of supervised, planned services for the purpose of maintaining the patient in the community. In general, the duration of a visit exceeds three hours, visits occur with a regular frequency determined by the patient's condition, and more than one service is provided during a visit. The program is designed primarily for patients at least 18 years of age who are expected to require services for an extended period of time, usually exceeding six months. A continuing treatment program shall provide, but need not be limited to the following services:

(i) assessment and treatment planning services;

(ii) verbal therapies;

(iii) medication therapy;

(iv) crisis services;

(v) case management services;

(vi) social training;

(vii) task and skill training; and

(viii) socialization activities.

(c) Where programs for ambulatory care for mental illness shall be delivered.

(1) Programs for ambulatory care for mental illness shall be provided in a facility which is certified under article 31 of the Mental Hygiene Law and located in free-standing facilities, the outpatient departments of acute care hospitals, diagnostic and treatment centers, the outpatient departments of private or public psychiatric hospitals, or in county-sponsored community mental health facilities.

(2) Services may be delivered to a recipient in his home only when home visits are a component of the individual's service plan, prepared under the supervision of a physician and subject to periodic review and evaluation, in accordance with 14 NYCRR Parts 579 and 585.

(3) Crises services which are appropriately documented may be delivered in any setting and regardless of another reimbursable service delivered on the same date.

(d) Standards which shall be met by programs in order to bill under the Medical Assistance Program. (1) All programs must meet the standards set forth by 14 NYCRR Parts 579 and 585, as revised on April 1, 1991, by the addition of 14 NYCRR Parts 587 and 588.

(2) All services shall be delivered in accordance with a written individual treatment plan.

(3) All programs shall be authorized by a valid operating certificate issued to the faculty by the Office of Mental Health.

(4) Each facility, regardless of sponsorship, providing outpatient programs for the mentally ill shall establish a utilization review plan that is acceptable to the Office of Mental Health.

(5) All occasions of services billed as clinic visits shall reflect face-to-face interaction between recipient and appropriate personnel.

(e) Services coverable under the Medical Assistance Program. (1) Services required for ambulatory care for mental illness when certified by a physician to be medically necessary and appropriate, are covered services under the Medical Assistance Program.

(2) Except for crisis services, no more than one visit for mental health services per patient per day is reimbursable regardless of the number of mental health services provided or the number of mental health programs in which the recipient participates.

(3) Any service provided by a clinic, day or continuing treatment program to an eligible individual at a setting other than those listed in subdivision (c) of this section shall have the location identified in the treatment plan along with the justification of the need for such off-site services except in annotated emergency conditions.

(4) Collateral (as defined in 14 NYCRR 585.4(a)(3)) services may be provided to assist in the gathering of information for diagnosis and evaluation, to assure appropriate planning of care for the recipient, to ameliorate those factors of the home environment which interfere with treatment goals of the therapeutic setting, and to enhance the therapeutic environment by treatment continuation in the home. Such services shall be physician-approved and subject to utilization review procedures. An occasion of collateral service shall be billed against the primary patient's Medicaid identification card, and may occur on the same date as another service provided to the primary patient.

(5) All reimbursable billings shall only be for a documented, definable medical service of face-to-face professional exchange between provider and client, or collateral, in accordance with goals stated in the treatment plan.

(f) Noncovered services under the Medical Assistance Program. (1) Only covered services which are actually delivered to eligible recipients shall be reimbursed.

(2) The cost of routine physicians' services are included in facilities' rate or fee and shall not be billed separately.

(3) Educational services or patient education programs are not coverable, except that services may be utilized to meet the duration of visit requirements specified in subparagraph (h)(2)(ii) of this section.

(4) Sheltered workshop services are not coverable.

(5) Telephone contacts are not reimbursable.

(g) Payment. (1) Payment for ambulatory care to Medicaid recipients with mental illness in facilities licensed or operated by the Office of Mental Health shall be at rates or fees certified by the Commissioner of Mental Health and approved by the State Director of the Budget, except that payment for ambulatory mental health care provided in an outpatient department of an acute care hospital licensed pursuant to article 28 of the Public Health Law shall be at rates or fees certified by the Commissioner of the State Department of Health and approved by the State Director of the Budget.

(2) Payment for services to collaterals of Medicaid recipients shall be made in accordance with regulations of the Office of Mental Health and this department.

(3) Payment for ambulatory care to Medicaid recipients with mental illness who are in a residential health care facility shall not be made by the Department of Social Services. Payment shall be made to the provider of mental health services by the residential health care facility.

(4) Medications administered or dispensed in conjunction with ambulatory care programs are included in the rate or fee of the facility. A visit to monitor medication shall be paid as a brief clinic visit if on a date different from another service.

(h) Reimbursement. (1) State reimbursement shall be available for expenditures made in accordance with the provisions of this section and when the following conditions are met:

(i) documentation by a physician that treatment is appropriate and necessary;

(ii) documentation that at least one Medicaid reimbursable service has been delivered for each billable occasion of service;

(iii) services are provided by staff designated as appropriate by regulations of the Office of Mental Health;

(iv) except for crisis services, the location of service is documented in the recipient's record and off-site service is justified; and

(v) utilization review policies and procedures, acceptable to the Office of Mental Health, are operative.

(2) State reimbursement shall be available, at fees approved by the New York State Director of the Budget, for ambulatory care for eligible recipients with mental illness when billed according to the following structure:

(i) Clinic treatment programs. (a) A clinic treatment visit of at least 30 minutes shall be billed as a clinic visit.

(b) A clinic treatment visit, lasting at least 15 minutes but less than 30 minutes, shall be billed as a brief clinic visit.

(c) A clinic treatment visit, where only group therapy is provided and lasting at least 50 minutes, shall be billed as a clinic group visit.

(ii) Day treatment programs. (a) A day treatment visit, lasting at least five hours, shall be billed as a full-day treatment visit.

(b) A day treatment visit, lasting at least three hours but less than five hours, shall be billed as a half-day treatment visit.

(c) A day treatment visit, lasting for at least one hour but less than three hours, shall be billed as a brief day treatment visit. Such visits shall be clinically justified, documented, and used primarily to enable the recipient to participate in the program for longer periods of time.

(iii) Continuing treatment programs. (a) A continuing treatment visit, lasting at least five hours, shall be billed as a full continuing treatment visit.

(b) A continuing treatment visit, lasting at least three hours but less than five hours, shall be billed as a half continuing treatment visit.

(c) A continuing treatment visit, lasting for at least one hour but less than three hours, shall be billed as a brief continuing treatment visit. Such visits shall be clinically justified, documented, and used primarily to enable the recipient to participate in the program for longer periods of time.

(iv) No more than three visits per patient for assessment and treatment planning services shall be reimbursable for the period prior to each admission to the program.

(v) Consultations with collaterals, lasting at least 30 minutes, shall be billed as a collateral consultation.

(i) Fee schedule. Program Visits Duration Fee

(1) Clinic treatment: Regular at least 30 minutes $40

Brief at least 15 minutes 20 Group at least 50 minutes 14 Collateral at least 30 minutes 14 Home at least 30 minutes 40

(2) Day treatment: Full day at least 5 hours $36

Half day at least 3 hours but

less than 5 hours 18

Brief day at least 1 hour but

less than 3 hours 12

Collateral at least 30 minutes 12 Home at least 30 minutes 36

(3) Continuing treatment: Full day at least 5 hours 36

Half day at least 3 hours but

less than 5 hours 18

Brief day at least one hour but

less than 3 hours 12

Collateral at least 30 minutes 12 Home at least 30 minutes 36

(4) The effective date of this schedule shall be August 1, 1982.

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