N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 86-2.9

Current through Register Vol. 46, No. 45, November 2, 2024

Section 86-2.9 - Adult day health care in residential health care facilities

(a) Except as specifically identified in subdivision (g), rates for residential health care facility services for adult day health care registrants shall be computed on the basis of the allowable costs, as reported by the residential health care facility, and the total number of visits by adult day health care registrants, as defined in Part 425 of this Title, for which services were delivered pursuant to Article 6 of Subchapter A of Chapter V of this Title subject to the maximum daily rate provided for in this section.

(b) For adult day health care programs without adequate cost experience, rates will be computed based upon annual budgeted allowable costs, as submitted by the residential health care facility and the total estimated annual number of visits by adult day health care registrants, as defined in Part 425 of this Title, for which services were delivered pursuant to Article 6 of Subchapter A of Chapter V of this Title subject to the maximum daily rate provided for in this section.

(c) Allowable costs shall include, but are not limited to, the following:

(1) applicable salary and nonsalary operating costs;

(2) cost of transportation; and

(3) appropriate portion of capital costs, allocated according to instructions accompanying the RHCF-4 report.

(i) Notwithstanding any provision to the contrary, effective January 1, 2015, for leases originating prior to December 31, 2018 and being renewed beyond such date, residential health care facilities that lease property from a non-related organization in order to operate an adult day health care program consistent with this section shall receive reimbursement from the department related to the cost of such lease. In the event that there is no historic cost, the department shall reimburse such adult day health care program for the lesser of the aggregate lease costs reported to the department during calendar year 2013, or the amount actually paid to the lessor for such lease in the calendar year two years prior to the claim for reimbursement pursuant to this subdivision, provided that such reimbursement shall not exceed any applicable maximum daily rate as provided for in this section. If the lease reported for that year does not span the calendar year, the first twelve months of the lease shall constitute the amount paid for such lease in a calendar year for the calculation above.

(ii) Beginning January 1, 2019, any residential health care facility that seeks to be reimbursed for costs related to newly leased property from a non-related organization in order to operate an adult day health care program consistent with this section shall, prior to entering into the lease, demonstrate to the satisfaction of the commissioner that: the adult day health care program meets a public need; such program would enable participants to remain in the community, in the least restrictive setting, and avoid institutionalization; and the leased property is the most cost effective option for the facility to operate the adult day health care program. Upon determination that the proposed or existing program satisfactorily meets each of these requirements, the commissioner may grant reimbursement for the lease payment. In the event that no historic cost is available, such adult day health care program will receive the lesser of the lease cost reported during the calendar year 2013 or the actual lease payment for the first twelve months of operation, regardless of any subsequent changes or renewals to such lease or ownership of the facility operations or the leased premises, provided that such reimbursement shall not exceed any applicable maximum daily rate as provided for in this section. If the lease reported for that year does not span the calendar year, the first twelve months of the lease shall constitute the amount paid for such lease in a calendar year for the calculation above.

(d) The maximum daily rate, excluding the allowable costs of transportation, for services provided to a registrant in a 24-hour period as described in Part 425 of this Title shall be 75 percent of the sponsoring facility's former skilled nursing facility rate in effect on January 1, 1990, with the operating component trended forward to the rate year by the sponsoring facility's trend factor.

(e) Notwithstanding subdivision (d) of this section or any other regulations to the contrary, for the period July 1, 1992 to March 31, 1993 and annual periods beginning April 1st, thereafter, the maximum daily rate, excluding the allowable costs of transportation, for services provided to a registrant in a 24-hour period as described in Part 425 of this Title shall be 65 percent of the sponsoring facility's former skilled nursing facility rate in effect on January 1, 1990 with the operating component trended forward to the rate year by the sponsoring facility's trend factor. The provisions of this subdivision shall be contingent upon extension of section 1 of chapter 41 of the Laws of 1992, or upon the enactment of permanent statutory authority.

(f) For facilities without a skilled nursing facility rate, computed in accordance with section 86-2.10 or 86-2.15 of this Subpart, in effect on January 1, 1990, a weighted average rate for each region listed in Appendix 13-A of this Title shall be used as the proxy for the facility's January 1, 1990 skilled nursing facility rate in determining the maximum daily rate for such facilities as set forth in subdivisions (d) and (e) of this section. The weighted average rate for each region shall be equal to the statewide weighted average 1990 skilled nursing facility rate with the statewide average direct component and indirect component of the rate adjusted respectively by the regional direct and indirect input price adjustment factors described in section 86-2.10 of this Subpart. The statewide weighted average rate shall be computed by multiplying each residential health care facility's 1990 skilled nursing facility rate times its 1990 skilled nursing facility patient days, summing the result statewide, and dividing by the statewide total 1990 skilled nursing facility patient days. The 1990 rate used in computing the statewide weighted average rate shall be the latest 1990 rate in effect on July 1, 1992 for the former skilled nursing level of care which is contained in the rate which has been certified by the commissioner pursuant to section 2807 (3) of the Public Health Law.

(g) Effective April 1, 1994 and thereafter, reimbursement for adult day health care services that are provided to registrants with acquired immune deficiency syndrome (AIDS) and other human immunodeficiency virus (HIV) related illnesses and, effective April 1, 2017, that are provided to registrants who are otherwise considered at the discretion of the commissioner to be part of a high-need population that, regardless of their HIV status, would benefit from receiving these adult day health care services shall be established pursuant to this subdivision. The services to be provided to such registrants shall be the same as those listed in Part 759 of this Title. Reimbursement to a residential health care facility shall be established as follows:

(1) The rate of payment shall consist of a single price per visit to include the operating component, transportation, and the capital cost component of the rate. Payment shall be based upon a per visit rate of $160 with not more than one reimbursable visit per 24-hour period per registrant.

(2) To be eligible to receive reimbursement pursuant to this section, a residential health care facility must be certified by the department pursuant to Part 710 of this Title to provide adult day health care services for AIDS/HIV registrants and, effective April 1, 2017, other high-need registrants.

(3) The price established pursuant to this section shall be full reimbursement for the following:

(i) physician services, nursing services, and other related professional expenses directly incurred by the licensed residential health care facility;

(ii) administrative personnel, business office, data processing, recordkeeping, housekeeping, food services, transportation, plant operation and maintenance and other related facility overhead expenses;

(iii) all other services described in Article 6 of this Title appropriate to the level of general medical care required by the patient;

(iv) all medical supplies, immunizations, and drugs directly related to the provisions of services except for those drugs used to treat AIDS patients for which fee-for-service reimbursement is available as determined by the Department of Social Services.

N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 86-2.9

Amended New York State Register June 14, 2017/Volume XXXIX, Issue 24, eff. 6/14/2017

Amended New York State Register September 29, 2021/Volume XLIII, Issue 39, eff. 9/29/2021