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

Effective Date

12/28/1992

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.

Volume

VOLUME A-2 (Title 10)

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