Title: Section 86-1.13 - Certified home health agency rates
86-1.13 Certified home health agency rates
(a) Effective January 1, 1988 reported costs and statistics for a facility's annual fiscal period ending two years prior to the rate period, trended pursuant to section 86-1.58 of this Subpart, shall be used in computing Medicaid rates for care provided by community-based home health agencies. No amount may be included in a rate that is in excess of the agency charges or in excess of 110 percent of the weighted average cost of all community-based agencies in their group. For hospital-based home health agencies, no amount may be included in a rate that is in excess of 110 percent of the weighted average cost of community-based agencies in their area.
(b) The Commissioner shall establish separate payment rates for home care nursing services provided by Certified Home Health Agencies (CHHAs) and Long Term Home Health Care Programs (LTHHCPs) to patients diagnosed with Acquired Immune Deficiency Syndrome (AIDS) as defined by ICD-9 codes 042, 043 and 044. Such rates shall be regional service prices increased by a case mix adjustment factor to reflect the additional resource utilization needed in home care treatment of AIDS patients in excess of resource utilization needed for an average mix of home care patients.
(1) Regional nursing service prices shall be computed based upon average nursing costs per visit calculated by aggregating the base year allowable costs and statistics reported by community based certified home health agencies located within each of four regions, provided however, that effective with rate periods commencing January 1, 1990, the calculation of regional nursing service prices pursuant to this paragraph shall also incorporate base year allowable costs and statistics for LTHHCPs. The regions shall be New York City Region which is comprised of New York, Kings, Queens, Richmond, Bronx, Westchester, Rockland and Putnam Counties; Nassau-Suffolk Region which is comprised of Nassau and Suffolk Counties; Rural Region which is comprised of all Non-Standard Metropolitan Statistical Area counties; All other Metropolitan Region which is comprised of all counties not included in the other regions.
(2) For agencies in the All Other Metropolitan Region group only, the base price will be adjusted by Wage Index Factors. Wage Index Factors shall be calculated for and applied to each of the Standard Metropolitan Statistical Areas (SMSA) within the All Other Metropolitan Region. The SMSA's are:
(vi) Glens Falls;
(vii) Niagara Falls;
(viii) Orange County
The Wage Index Factor shall be determined by weighting the Registered Nurse, Licensed Practical Nurse and Nurse's Aide salary categories based upon the proportion of skilled and Aide visits. The labor portion of the base price shall be multiplied by the respective wage index factor for each of the eleven SMSA's in the All Other Metropolitan Region group.
(3) The base regional service prices computed in accordance with this subdivision shall be increased by a trend factor developed in accordance with section 86-1.58 of this Subpart.
(4) The trended regional nursing service prices shall be increased by an AIDS case mix adjustment factor of 1.2988 to arrive at regional nursing service rates for home care services provided by CHHAs and LTHHCPs to patient diagnosed with AIDS.
(5) Adjustments to regional nursing service prices established by this subdivision shall be limited to annual adjustments made pursuant to paragraphs (1) and (3) of subdivision (b) of this section.
(c) The department shall establish a cap on reimbursable base year administrative and general costs equal to 30% of total reimbursable base year operational costs of a provider of services, excluding a provider of services reimbursed on an initial budget basis, and a new provider, excluding changes in ownership or changes in name, who begins operations in the year prior to the year which is used as a base year in determining rates of payment. The cap on administrative and general costs shall be applied after the application of the weighted average cost of all community-based agencies in their group or area, described in this section.
VOLUME A-2 (Title 10)