N.Y. Comp. Codes R. & Regs. tit. 14 § 599.4

Current through Register Vol. 46, No. 39, September 25, 2024

Section 599.4 - Definitions

(a) For purposes of this Part:

(1)After hours means before 8 a.m., 6 p.m. or later, or during weekends.

(2)Ambulatory Patient Groups (APGs) means a defined group of outpatient procedures, encounters or ancillary services grouped for payment purposes. The groupings are based on the intensity of the services provided and the medical procedures performed.

(3)Base rate means the numeric value that shall be multiplied by the weight for a given service to determine the Medicaid fee for a service.

(4)Clinical services contract means a written agreement between the governing authority of an existing or proposed provider of services and another organization separate from the provider of services for the purpose of obtaining some of the clinical services or some of the clinical staff necessary to operate the program in compliance with requirements for an operating certificate.

(5)Clinical staff means staff members who provide services directly to individuals, including professional staff, non-licensed professional staff, paraprofessional staff, and student interns.

(6)Clinician means a person who is a member of the professional staff, or non-licensed professional staff.

(7)Collateral means a person who is a member of the individual's family or household, or other person who regularly interacts with the individual and is directly affected by or has the capability of affecting their condition, and is identified in the treatment plan as having a role in treatment and/or is necessary for participation in the evaluation and assessment of the individual prior to admission. A group composed of collaterals of more than one individual may be gathered together for purposes of goal-oriented problem solving, assessment of treatment strategies and provision of practical skills for assisting the individual in the management of their illness.

(8)Commissioner means the Commissioner of the New York State Office of Mental Health.

(9)Community education means activities designed to increase community awareness of the manifestations of mental illness and emotional disturbance and the benefits of early identification and treatment.

(10)Counseling means the provision of assistance and guidance in resolving personal, social, or psychological problems and difficulties

(11)Current Procedural Terminology (CPT) means codes used in a coding system for health care procedures as defined in the publication Current Procedural Terminology which is published by the American Medical Association (AMA).

(12)Designated mental illness means a disruption of cognitive, emotional, or behavioral functioning, which can be classified and diagnosed using the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), or the International Classification of Diseases (ICD), other than:

(i) substance use disorders in the absence of other mental health conditions defined in the DSM or ICD;

(ii) Neurodevelopmental disorders in the absence of other mental health conditions defined in the DSM or ICD except Attention-Deficit/Hyperactivity Disorder and Tic Disorders;

(iii) major neurocognitive disorder, traumatic brain injury, or mental disorders due to another medical condition; or

(iv) V-Codes . Other conditions that may be a focus of clinical attention (commonly described with Z codes), except Parent-Child Relational Problem (V61.20/Z62.820) for children.

(13)Diagnostic and treatment center, for the purposes of this Part, means an outpatient program licensed as a diagnostic and treatment center pursuant to article 28 of the Public Health Law which provides more than 10,000 mental health visits annually, or for which mental health visits comprise over 30 percent of the annual visits. A program providing fewer than 2,000 total visits annually shall not be required to be licensed by the Office.

(14)Director of Community Services shall mean the director of community services for the mentally disabled appointed pursuant to Mental Hygiene Law.

(15)Evidence-based treatment means an intervention for which there is consistent scientific evidence demonstrating improved outcomes.

(16)Healthcare common procedure coding system (HCPCS codes) means a comprehensive, standardized coding and classification system for health services and products.

(17)Homebound individuals means people who have been determined by a licensed clinician to have a physical and/or mental illness that prevents them from leaving their residence to access mental health services or for whom a physician determines that leaving the residence to access mental health services would be detrimental to their health or mental health.

(18)Hospital-based Mental Health Outpatient Treatment and Rehabilitative Service Programs means a mental health program which is operated by a psychiatric hospital or a general hospital and is licensed under Article 28 of the Public Health Law and Article 31 of the Mental Hygiene Law, or is licensed solely under Article 28 of the Public Health Law and provides more than 10,000 mental health visits annually, or for which mental health visits comprise over 30 percent of the annual visits. A Mental Health Outpatient Treatment and Rehabilitative Service program licensed solely under Article 28 which provides fewer than 2,000 total visits annually shall not be required to be licensed by the Office.

(19)Injectable psychotropic medication administration with or without monitoring and education means the process of preparing and administering the injection of intramuscular psychotropic medications. With monitoring and education it includes individual education related to the use of the medication, as necessary.

(20)Linkage with primary care means activities designed to promote coordination, continuity and efficiency of mental health services and primary care services received by the individual.

(21)Local governmental unit (LGU) means the unit of local government authorized in accordance with Article 41 of the Mental Hygiene Law to provide and plan for local or unified services.

(22)Modifiers means payment adjustments made to Medicaid fees for specific reasons such as billing for services in languages other than English and services delivered after hours.

(23)Office means the New York State Office of Mental Health.

(24)Mental Health Outpatient Treatment and Rehabilitative Service Program means a program licensed as a Mental Health Outpatient Treatment and Rehabilitative Service program under Article 31 of the Mental Hygiene Law.

(25)Off-site Location means a location at which services are delivered. Locations including but not limited to the community, or the individual's place of residence. The location in which the service is provided is determined by the individual's needs and goals documented in the individual's record.

(26)Peer group is a billing term that means a grouping of providers sharing similar features such as geography or auspice.

(27)Preadmission status means the status of an individual who is being evaluated to determine whether they are appropriate for admission to the Mental Health Outpatient Treatment and Rehabilitative Service program.

(28)Preadmission visit means visits provided prior to admission to a Mental Health Outpatient Treatment and Rehabilitative Service program.

(29)Primary clinician is the clinician responsible for the development and implementation of the treatment plan.

(30)Provider of service means the entity which is responsible for the operation of a program. Such entity may be an individual, partnership, association or corporation. For purposes of this Part, unless otherwise noted, the term also applies to a psychiatric center or institute operated by the Office of Mental Health.

(31)Quality improvement means a systematic and ongoing process for measuring and assessing the performance of a Mental Health Outpatient Treatment and Rehabilitative Service program and for conducting initiatives and taking action to improve safety, effectiveness, timeliness, person centeredness or other aspects of services.

(32)Satellite means a physically separate site to a certified Mental Health Outpatient T reatment and Rehabilitative Service program, which provides either a full or partial array of outpatient services on a regularly and routinely scheduled basis (full or part time).

(33)Serious emotional disturbance means a child or adolescent has a designated mental illness diagnosis according to the most current Diagnostic and Statistical Manual of Mental Disorders (DSM) and has experienced functional limitations due to emotional disturbance over the past 12 months on a continuous or intermittent basis. The functional limitations must be moderate in at least two of the following areas or severe in at least one of the following areas:

(i) ability to care for self (e.g., personal hygiene; obtaining and eating food; dressing; avoiding injuries); or

(ii) family life (e.g., capacity to live in a family or family like environment; relationships with parents or substitute parents, siblings and other relatives; behavior in family setting); or

(iii) social relationships (e.g., establishing and maintaining friendships; interpersonal interactions with peers, neighbors and other adults; social skills; compliance with social norms; play and appropriate use of leisure time); or

(iv) self-direction/self-control (e.g., ability to sustain focused attention for a long enough period of time to permit completion of age-appropriate tasks; behavioral self-control; appropriate judgment and value systems; decision-making ability); or

(v) ability to learn (e.g., school achievement and attendance; receptive and expressive language; relationships with teachers; behavior in school).

(34)Specialty Mental Health Outpatient Treatment and Rehabilitative Service means a program designated by the Commissioner as specializing in the provision of services to children who have a designated mental illness diagnosis and an impairment in functioning due to serious emotional disturbance.

(35)Supplemental payment means payments in addition to the service fee amount.

(36)Visit means an interaction consisting of one or more procedures occurring between a n individual and/or collateral and the clinic al staff on a given day.

(37)Weight means a numeric value that reflects the relative expected average resource utilization for each service as compared to the expected average resource utilization for all other services.

(b)Staffing Definitions

(1)Certified Peer Specialists, Credentialed Family Peer Advocates, and Credentialed Youth Peer Advocates are qualified by personal experience and will be certified or provisionally certified.

(i)Certified Peer Specialists will:

(a) Identify as being actively in recovery from a mental health condition or major life disruption and self-disclose one's mental health recovery journey; and

(b) Possess a certification from or are provisionally certified as a Certified Peer Specialist by an OMH-approved Certified Peer Specialist certification program.

(ii)Credentialed Family Peer Advocates (FPA) will:

(a) Demonstrate lived experience as a parent or primary caregiver who has navigated multiple child-serving systems on behalf of their child(ren) with social, emotional, developmental, health and/or behavioral healthcare needs;

(b)Possess a credential from or are provisionally credentialed as a Family Peer Advocate by an OMH-approved Family Peer Advocate credentialing program;

(iii)Credentialed Youth Peer Advocate will:

(a) Demonstrate "lived experience" as a person with first-hand experience with mental health and/or co-occurring behavioral health challenges in juvenile justice, special education, and/or foster care settings who is able to assist in supporting young people attain resiliency/recovery and wellness; and

(b) Possess a valid credential from or are provisionally certified as a Youth Peer Advocate by an OMH-approved Youth Peer Advocate credentialing program.

(2)Licensed Practitioner of the Healing Arts (LPHA). Licensed practitioner of the healing arts (LPHA) means the following professional staff:

(i) nurse practitioner;

(ii) physician;

(iii) physician assistant;

(iv) psychiatric nurse practitioner;

(v) psychiatrist;

(vi) psychologist;

(vii) registered nurse;

(viii) licensed clinical social worker (LCSW); and

(ix) licensed master social worker (LMSW) if supervised by an LCSW, licensed psychologist, or psychiatrist employed by the agency.

(x) licensed mental health counselors (LMHC);

(xi) licensed marriage and family therapists (LMFT);

(xii) licensed psychoanalysts; and

(xiii) licensed creative arts therapists (LCAT).

(3)Limited permit means that the New York State Education Department has determined that permit holders have met all requirements for licensure except those relating to the professional licensing final examination, and that pending licensure limited permit holders are functioning under proper supervision as outlined in the New York State Education Department law governing each of the professions.

(4)Paraprofessional staff are individuals qualified by formal or informal training and professional experience in a mental health field or treatment setting and who are supervised by professional staff. Paraprofessional staff are at least 18 years of age and have a bachelor's degree, which may be substituted for a high school diploma or equivalent and 1-3 years of relevant experience working with individuals with serious mental illness or substance use disorders.

(5)Professional staff means practitioners possessing a license or a limited permit from the New York State Education Department who are qualified by credentials, training, and experience to provide direct services related to the treatment of mental illness and shall include the following:

(i)Creative arts therapist is an individual who is currently licensed as a creative arts therapist by the New York State Education Department or possesses a creative arts therapist permit from the New York State Education Department.

(ii)Licensed practical nurse is an individual who is currently licensed as a licensed practical nurse by the New York State Education Department or possesses a licensed practical nurse permit from the New York State Education Department.

(iii)Psychoanalyst is an individual who is currently licensed as a psychoanalyst by the New York State Education Department or possesses a permit from the New York State Education Department.

(iv)Psychologist is an individual who is currently licensed as a psychologist by the New York State Education Department or possesses a permit from the New York State Education Department.

(v)Marriage and family therapist is an individual who is currently licensed as a marriage and family therapist by the New York State Education Department or possesses a permit from the New York State Education Department.

(vi)Mental health counselor is an individual who is currently licensed as a mental health counselor by the New York State Education Department or possesses a permit from the New York State Education Department.

(vii)Nurse practitioner is an individual who is currently certified as a nurse practitioner by the New York State Education Department or possesses a permit from the New York State Education Department.

(viii)Nurse practitioner in psychiatry is an individual who is currently certified as a nurse practitioner with an approved specialty area of psychiatry (NPP) by the New York State Education Department or possesses a permit from the New York State Education Department.

(ix)Physician is an individual who is currently licensed as a physician by the New York State Education Department or possesses a permit from the New York State Education Department.

(x)Physician assistant is an individual who is currently licensed or possesses a permit to practice as a physician assistant issued by the New York State Education Department.

(xi)Psychiatrist is an individual who is currently licensed or possesses a permit to practice medicine in New York State.

(xii)Registered Professional Nurse is an individual who is currently licensed as a registered professional nurse by the New York State Education Department or possesses a permit from the New York State Education Department.

(xiii)Social worker is an individual who is either currently licensed as a licensed master social worker or as a licensed clinical social worker by the New York State Education Department, or possesses a permit from the New York State Education Department to practice and use the title of either licensed master social worker or licensed clinical social worker.

(c)Service Component Definitions

(1)Assessment/Screening means services to identify an individual's needs, strengths and service needs, through evaluation and information gathering of an individual's current psychiatric, physical and behavioral health condition(s) and history for the purpose of establishing a diagnosis and determining appropriate services to meet their needs. Assessments include health screenings and physicals to determine the need for and referral to additional physical health services. Assessments also include interactions with an individual's collateral supports to obtain necessary information for the benefit of the treatment planning for the individual.

(2)Complex care management means time-limited interventions to restore functioning and address the symptoms of mental illness, including skill-building to help individuals identify solutions to problems that threaten recovery and care coordination services to help individuals connect with medical or other remedial services.

(3)Crisis Intervention Services, including crisis response, and crisis planning means services including medication and verbal therapy designed to address and remediate acute distress and associated behaviors and rehabilitate individuals who are experiencing or who are at risk of experiencing acute mental health crises and to avoid the need for emergency or inpatient psychiatric hospital services. Crisis intervention services also include:

(i) Crisis response services, which are services to safely and respectfully de-escalate situations of acute distress or agitation which require immediate attention; and

(ii) Crisis planning services, which are rehabilitative skills training services to assist individuals to effectively avoid or respond to mental health crises by identifying triggers that risk their remaining in the community or that result in functional impairments. Services assist the individual or family members, or other collaterals as necessary for the benefit of the individual, with identifying a potential psychiatric or personal crisis, developing a crisis management or safety plan, or as appropriate, seeking other supports to restore stability and functioning.

(4)Developmental testing means diagnostic services including the administration, interpretation, and reporting of screening and assessment instruments for children and adolescents to assist in the determination of the child's developmental level for the purpose of facilitating the mental health diagnosis and treatment planning processes.

(5)Health monitoring means diagnostic and therapeutic services for preventive medicine counseling and risk factor reduction interventions. These interventions are intended to address conditions associated with increased risk of medical illness and early death, including but not limited to blood pressure, body mass index (BMI), diet and exercise, alcohol, tobacco and other drug use, sexual practices, injury prevention, dental health, diagnostic and laboratory test results available at the time of the encounter. These interventions are also intended to address issues related to social determinants of health including but not limited to food insecurity, housing instability, poverty, exposure to violence.

(i)Health physical means the physical evaluation of an individual, including an age and gender appropriate history, examination, and the ordering of laboratory/diagnostic procedures, as appropriate.

(ii)Health screening means the initial gathering and assessing of information concerning the individuals' medical history and current physical health status (including physical examination and determination of substance use) for purposes of informing an assessment and determination of its potential impact on an individual's mental health diagnosis and treatment, and the need for additional health services or referral.

(6)Neurobehavioral Status Examination is a clinical assessment of thinking, reasoning and judgment, including attention, language, memory, problem solving and visual spatial abilities and interpretation of the results for treatment planning.

(7)Peer and Family Peer Recovery Support Services means services for adults and children/youth, including age-appropriate psychoeducation, counseling, person-centered goal planning, modeling effective coping skills, and facilitating community connections and crisis support to reduce symptomology and restore functionality. Family Peer Recovery Support Services also include engagement, bridging support, parent skill development, and crisis support for families caring for a child who is experiencing social, emotional, medical, developmental, substance use and/or behavioral challenges in their home, school, placement, and/or community to promote recovery, self-advocacy, and the development of natural supports and community living skills.

(8)Psychiatric consultation means an evaluation of a recipient by a physician, nurse practitioner, or physician's assistant, including the preparation, evaluation, report or interaction between the practitioner and a referring practitioner for the purposes of diagnosis, integration of treatment and continuity of care.

(9)Psychological testing means a psychological evaluation, including psychological testing evaluation services and test administration and scoring, using standard assessment methods and instruments to assist in mental health assessment and the treatment planning processes.

(10)Psychotherapy means therapeutic services for the purpose of alleviating symptoms or dysfunction associated with an individual's mental health condition or emotional disturbance, reversing or changing maladaptive patterns of behavior, encouraging personal growth and development, and supporting the individual's capacity to develop or restore age-appropriate developmental milestones. Services include tobacco use disorder treatment services.

(11)Medication treatment means monitoring and evaluating target symptom response to treat the individual's mental illness and/or substance use disorder, ordering and reviewing diagnostic studies, writing prescriptions and consumer education as appropriate, preparing, administering and monitoring the injection of intramuscular medications.

(12)Screening, Brief Intervention and Referral to Treatment (SBIRT) is an evidence-based assessment, counseling, and referral services which provide:

(1) screening to identify individuals exhibiting or who are at risk of substance use-related problems;

(2) early intervention, including counseling and skills restoration services to modify risky consumption patterns and behaviors; and

(3) referral to appropriate services for individuals who need more extensive, specialized treatment to address such substance consumption patterns and behaviors.

(13)Treatment planning is an ongoing, collaborative and person-centered process directed by the individual in collaboration with the individual's family or other collaterals, as appropriate and approved by the individual and a licensed clinician, resulting in the development of treatment and rehabilitative goals, needs, preferences, capacities and desired outcomes for the provision of services.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 599.4

Amended, New York State Register December 17, 2014/Volume XXXVI, Issue 50, eff. 12/17/2014

Amended New York State Register November 23, 2022/Volume XLIV, Issue 47, eff. 11/23/2022