N.Y. Comp. Codes R. & Regs. tit. 14 § 679.8

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

Section 679.8 - Reimbursement methodology

(a)Definitions.

Definitions pertaining to the ambulatory patient croup classification and reimbursement methodology can be found in 10 NYCRR section 86-8.2. Additional definitions are as follows:

(1) Coding improvement factor. A numeric value which OPWDD may use to adjust for more complete and accurate coding for visits upon implementation of the APG reimbursement system.

(2) Evaluation and management (E&M) services. Services and/or consultations as designated by CPT provided by a physician, nurse practitioner or an appropriately supervised physician assistant.

(b) Ambulatory patient groups (APG).

For services provided on or after July 1, 2011, the operating component of rates shall be reimbursed using a methodology that is prospective and is based upon the APG classification and reimbursement system as described in 10 NYCRR sections 86-8.2, 86-8.7, 86-8.9(a), 86-8.10 and 86-8.11(b).

(c)Operating component.

The operating component of the rates is the product of the peer group base rate times the procedure's allowed relative APG weight or the final APG weight for each APG on a claim.

(1) The base rates.

There shall be a separate base rate for each peer group. OPWDD's three peer groups and base rates are as follows:

(i) Peer Group A. Except for clinics described in subparagraph (iii) of this paragraph, Peer Group A shall be comprised of clinic treatment facilities that have the certified main clinic site located in New York City or Long Island, i.e., the counties of New York, Bronx, Kings, Queens, Richmond, Nassau and Suffolk. The base rate for Peer Group A is $180.95.

(ii) Peer Group B. Except for clinics described in subparagraph (iii) of this paragraph, Peer Group B shall be comprised of clinic treatment facilities that have the certified main clinic site located in a county other than those identified in subparagraph (i) of this paragraph. The base rate for Peer Group B is $186.99.

(iii) Peer Group C. Clinic treatment facilities that are affiliated with and serve two major hospital systems and have the following Federal designations as of July 1, 2011:

(a) University Center for Excellence in Developmental Disabilities (UCEDD) by the United States Department of Health and Human Services' Administration on Developmental Disabilities (ADD); and

(b) National Institutes for Health's (NIH's) Eunice Kennedy Shriver National Institute of Child Health and Human Development Intellectual and Developmental Disability Research Center (IDDRC); and

(c) Maternal and Child Health Bureau (MCHB), Health Resources and Services Agency of the United States Public Health Service, Leadership Education in Neurodevelopmental and Related Disabilities (LEND) training program.

The base rate for Peer Group C is $270.50.

(2) APGs and APG relative weights are listed in 10 NYCRR section 86-8.7.

(d)Capital cost component.

If a visit includes a service which maps to an APG which allows a capital add-on, there shall be a capital add-on to the operating component of the APG payment for the visit.

(1) The capital cost component shall be a fixed amount equal to the capital cost component of the clinic's regular visit fee in effect on June 30, 2011.

(2) Beginning July 1, 2012, OPWDD shall subject the capital cost component to an annual review for certain clinic treatment facilities.

(i) Clinics specifically subject to review are those which:

(a) had operating certificates for a diagnostic and treatment center issued by the NYS DOH pursuant to article 28 of the Public Health Law; and

(b) transferred long term therapeutic and clinical habilitative services on or after April 1, 2009 to an operating certificate for a clinic treatment facility issued by OPWDD pursuant to article 16 of the Mental Hygiene Law; and

(c) received funding of the property component in an amount equal to the previously approved article 28 DOH diagnostic and treatment center property component.

(ii) OPWDD's review shall consist of a comparison of the capital cost reimbursement in effect at the time of its review to the clinic's actual capital expenditures as reflected in its annual financial report submitted for the period two years prior to the period subject to revision.

(iii) For those clinics reviewed pursuant to this paragraph, the capital cost component shall be the lesser of:

(a) the most recent reimbursement; or

(b) the greater of:

(1) the actual capital expenditures; or

(2) the amount reimbursed to clinic treatment facilities certified by OPWDD which do not meet the criteria specified in subparagraph (i) of this paragraph.

(e) Clinic services not paid based upon the APG classification and reimbursement system are described in 10 NYCRR section 86-8.10 Exclusions from payment.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 679.8

Amended New York State Register March 30, 2016/Volume XXXVIII, Issue 13, eff.4/1/2016

Amended New York State Register April 20, 2016/Volume XXXVIII, Issue 16, eff.4/20/2016

Amended New York State Register September 21, 2016/Volume XXXVIII, Issue 38, eff. 9/21/2016