Title: Section 86-12.1 - Utilization limits on OPWDD licensed clinics

86-12.1 Utilization limits on OPWDD licensed clinics

For periods on and after April 1, 2011 Medicaid reimbursement rates for clinics licensed by the Office for People With Developmental Disabilities (“OPWDD”) shall be subject to the following:

(a) Definitions: As used in this section:

(i) “Clinic” shall mean a clinic treatment facility licensed by OPWDD pursuant to 14 NYCRR Part 679.

(ii) “Clinic visit”. For services provided by a clinic for the period on and after April 1, 2011 through June 30, 2011, “clinic visit” shall have the same meaning such term has in 14 NYCRR Part 679 as in effect for such period, and for services provided by a clinic for the period on and after July 1, 2011, “clinic visit” shall have the same meaning such term has in 14 NYCRR Part 679 as in effect for such period.

(iii) "Monthly utilization threshold" shall be a monthly utilization standard defined in terms of an average monthly visit per patient served, as established by OPWDD based on peer norms.

(iv) “Reimbursement rate”. For the period from April 1, 2011 through June 30, 2011, “reimbursement rate” shall mean the applicable fee as set forth in 14 NYCRR Part 679 as in effect for such period, and for any period on and after July 1, 2011, “reimbursement rate” shall mean the rate established in accordance with 14 NYCRR Part 679 for such period or periods.

(v) "Utilization review period" shall mean the 2009 calendar year.

(b) Service categories and corresponding monthly utilization thresholds are:

(i) Nutrition/dietetics: 2.08

(ii) Speech language pathology: 4.33

(iii) Occupational therapy: 4.08

(iv) Physical therapy: 5.25

(v) Rehabilitation counseling: 3.25

(vi) Individual psychotherapy: 3.08

(vii) Group psychotherapy: 3.17

(c) For each service category identified in subdivision (b) of this section, OPWDD will annually calculate a monthly utilization rate for each clinic based on paid Medicaid claims for services rendered during the utilization review period. Service categories shall be identified by the procedure codes and clinician identifiers submitted on paid Medicaid claims. Visits associated with patients who received fewer than four visits within a service category shall be excluded from monthly utilization rate calculations. For utilization review periods beginning prior to July 1, 2011, OPWDD will use only the initial procedure code reported on the claim to calculate monthly utilization rates.

(d) When a clinic's calculated monthly utilization rate exceeds the monthly utilization threshold, OPWDD will calculate "excess visits" based on the following formula:

Excess Visits = (Clinic monthly utilization rate - Threshold Value) * Recipient Months

(e) OPWDD will sum a clinic's excess visits across all service categories. OPWDD will calculate excess visits as a percentage of total paid visits during the utilization review period. The reimbursement rates of clinics with excess visits shall be reduced by a uniform percentage in accordance with the following:

(f) For the period April 1, 2011 through March 31, 2012, OPWDD may waive the reimbursement rate reductions in this section in accordance with the provisions of section 26 of part H of chapter 59 of the laws of 2011, provided, however, that the waiver shall be subject to retroactive revocation upon a determination by OPWDD, in consultation with the Department, that the clinic has not complied with the terms of such waiver.

(g) The issuance of waivers as described in subdivision (f) of this section shall be subject to the following:

(i) In order to receive a waiver a clinic must submit to OPWDD a request for a waiver and a utilization reduction plan. OPWDD’s decision on the waiver shall be based on whether the clinic’s utilization reduction plan shows a reduction in the clinic’s planned state fiscal year 2011-2012 Medicaid visits by an amount equal to the paid visits in excess of the utilization thresholds and whether the clinic is operating in conformance with all applicable statutes, rules and regulations. For purposes of this section, a clinic's planned state fiscal year 2011-2012 visits cannot exceed its paid Medicaid visits in calendar year 2010.

(ii) OPWDD will compare the actual paid and planned state fiscal year 2011-2012 visits for each clinic granted a waiver. If a clinic fails to achieve the reduction in utilization in accordance with its utilization reduction plan, OPWDD will revoke the waiver and reduce the clinic’s reimbursement rates for state fiscal year 2011-12 as computed in accordance with the provisions of subdivisions (a) through (e) of this section, provided, however, that such reduction computation shall incorporate and reflect any utilization reduction that the clinic did achieve while operating under the waiver.