Current through Register Vol. 47, No. 12, March 26, 2025
(a)
Physical medical rehabilitation inpatient services shall qualify for
reimbursement pursuant to section 2807-c(4)(e-2) of the Public Health Law for
periods on and after December 1, 2009, only if such services are provided in a
hospital specializing in such services or in a distinct unit within a general
hospital designated for such services and only if:
(1) such hospital or such unit qualified for
exempt unit status for purposes of reimbursement under the Federal Medicare
prospective payment system as of December 31, 2001; or
(2) on or before July 1, 2009, the hospital
submitted a written request to the department for exempt status providing
assurances acceptable to the department that the hospital or unit within the
hospital meets the exempt status criteria set forth in section
2807-c
(4)(e) of the Public Health Law for 2009 for
periods prior to December 1, 2009.
(i) For
periods on and after January 1, 2010, a hospital seeking exempt status for a
hospital or a distinct unit within the hospital not previously recognized by
the department as exempt for reimbursement purposes shall submit a written
request to the department for such exempt status and shall provide assurances
and supporting documentation acceptable to the department that the hospital or
unit meets qualifying exempt status criteria in effect at the time such written
request is submitted. Approval by the department of such exempt status shall,
for reimbursement purposes, be effective on the January 1st following such
approval, provided that the request for such exempt unit status was received at
least 120 days prior to such date.
(ii) For days of service occurring on and
after December 1, 2009, the operating component of rates of payment for
inpatient services, other than physician services, for facilities subject to
this subdivision shall be a per diem amount reflecting the facility's reported
2005 operating costs, excluding physician costs, as submitted to the department
prior to July 1, 2009, not including reported direct medical education costs
and physician costs, and held to a ceiling of 110 percent of the average of
such costs in the region in which the facility is located, as described in
subdivision (i) of this section. Such rates shall reflect trend adjustments in
accordance with the applicable provisions of section
2807-c
(10) of the Public Health Law.
(b) Chemical dependency
rehabilitation inpatient services shall qualify for reimbursement pursuant to
section 2807-c(4)(e-2) of the Public Health Law for periods on and after
December 1, 2009, only if such services are provided in a hospital specializing
in such services or in a distinct unit within a general hospital designated for
such services and only if:
(1) the services
provided in such hospital or unit are limited to chemical dependency
rehabilitation care and do not include chemical dependency related inpatient
detoxification and/or withdrawal services; or
(2) such hospital or unit is licensed to
provide such services pursuant to both the Public Health Law and the Mental
Hygiene Law and meets the applicable alcohol and/or substance abuse
rehabilitation standards set forth in regulations.
(i) Any such unit within a hospital must be
in a designated area and consist of designated beds providing only chemical
dependency rehabilitation inpatient services with adequate adjoining supporting
spaces and assigned personnel qualified by training and/or by experience to
provide such services and in accordance with any applicable criteria regarding
the provision of such services issued by the New York State Office of Alcohol
and Substance Abuse Services.
(ii)
For days of service occurring on and after December 1, 2009, the operating
component of rates of payment for inpatient services, other than physician
services, for facilities subject to this subdivision shall be a per diem amount
reflecting the facility's reported 2005 operating costs, excluding physician
costs, as submitted to the department prior to July 1, 2009, not including
reported direct medical education costs and physician costs, and held to a
ceiling of 110 percent of the average of such costs in the region in which the
facility is located, as described in subdivision (i) of this section. Such
rates shall reflect trend adjustments in accordance with the applicable
provisions of section
2807-c
(10) of the Public Health Law.
(c)
Critical
access hospitals.
(1) Rural hospitals
shall qualify for inpatient reimbursement as critical access hospitals pursuant
to section 2807-c(4)(e-2) of the Public Health Law for periods on and after
December 1, 2009, only if such hospitals are designated as critical access
hospitals in accordance with the provisions of title XVIII (Medicare) of the
Federal Social Security Act.
(2)
For days of service occurring on and after December 1, 2009, the operating
component of rates of payment for inpatient services, other than physician
services, for facilities subject to this subdivision shall be a per diem amount
reflecting the facility's reported 2005 operating costs, excluding physician
costs, as submitted to the department prior to July 1, 2009, and held to a
ceiling of 110 percent of the average of such costs for all such designated
hospitals statewide. Such rates shall reflect trend factor adjustments in
accordance with the applicable provisions of section
2807-c
(10) of the Public Health Law.
(d)
Cancer hospitals.
(1) Hospitals shall qualify for inpatient
reimbursement as cancer hospitals pursuant to section 2807-c(4)(e-2) of the
Public Health Law for periods on and after December 1, 2009, only if such
hospitals were, as of December 31, 2008, designated as comprehensive cancer
hospitals in accordance with the provisions of title XVIII (Medicare) of the
Federal Social Security Act.
(2)
For days of service occurring on and after December 1, 2009, the operating
component of rates of payment for inpatient services, other than physician
services, for facilities subject to this subdivision shall be a per diem amount
reflecting the facility's reported 2005 operating costs, excluding physician
costs, as submitted to the department prior to July 1, 2009. Such rates shall
reflect trend factor adjustments in accordance with the applicable provisions
of section
2807-c
(10) of the Public Health Law.
(e)
Specialty long term
acute care hospital.
(1) Hospitals
shall qualify for inpatient reimbursement as specialty long term acute care
hospitals pursuant to section 2807-c(4)(e-2) of the Public Health Law for
periods on and after December 1, 2009, only if such hospitals were, as of
December 31, 2008, designated as specialty long term acute care hospitals in
accordance with the provisions of title XVIII (Medicare) of the Federal Social
Security Act.
(2) For days of
service occurring on and after December 1, 2009, the operating component of
rates of payment for inpatient services, other than physician services, for
facilities subject to this subdivision shall be a per diem amount reflecting
the facility's reported 2005 operating costs, excluding physician costs, as
submitted to the department prior to July 1, 2009. Such rates shall reflect
trend factor adjustments in accordance with the applicable provisions of
section
2807-c
(10) of the Public Health Law.
(f)
Acute care children's
hospitals.
Hospitals shall qualify for inpatient and outpatient
reimbursement as acute care children's hospitals pursuant to section
2807-c(4)(e-2) of the Public Health Law for periods on and after December 1,
2009, only if:
(1) Such hospitals
were, as of December 31, 2008, designated as acute care children's hospitals in
accordance with the provisions of title XVIII (Medicare) of the Federal Social
Security Act; and
(2) Such
hospitals filed a discrete 2007 institutional cost report reflecting reported
Medicaid discharges of greater than 50 percent of total discharges.
(i) For days of service occurring on and
after December 1, 2009, the operating component of rates of payment for
inpatient services, other than physician services, for facilities subject to
this subdivision shall be a per diem amount reflecting the facility's reported
2007 operating costs, excluding physician costs, as submitted to the department
prior to July 1, 2009. Such rates shall reflect trend factor adjustments in
accordance with the applicable provisions of section
2807-c
(10) of the Public Health Law.
(g)
Substance
abuse detoxification inpatient services.
For patients discharged on and after December 1, 2008,
rates of payment for general hospitals which are certified by the Office of
Alcoholism and Substance Abuse Services (OASAS) to provide services to patients
determined to be in the diagnostic category of substance abuse (MDC 20, DRGs
743 through 751) will be made on a per diem basis. This includes inpatient
detoxification, withdrawal, and observation services. Medically managed
detoxification services are for patients who are acutely ill from alcohol
and/or substance related addictions or dependence, including the need or risk
for the need of medical management of severe withdrawal, and/or are at risk of
acute physical or psychiatric co-morbid conditions. Medically supervised
withdrawal services are for patients at a mild or moderate level of withdrawal,
or are at risk for such, as well as patients with sub-acute physical or
psychiatric complications related to alcohol and/or substance related
dependence, are intoxicated, or have mild withdrawal with a situational crisis,
or are unable to abstain yet have no past withdrawal complications. The per
diem rates for inpatient detoxification, withdrawal, and observation services
will be determined as follows:
(1) The
operating cost component of the per diem rates will be computed using 2006
costs and statistics, excluding physician costs, as reported to the department
by general hospitals prior to 2008, adjusted for inflation. The inflation
factor will be calculated in accordance with the trend factor methodology
described in this Subpart. The average operating cost per diem for the region
in which the hospital is located will be calculated using costs incurred for
patients requiring detoxification services. The operating cost component of the
per diem rates will be transitioned to 2006 as follows:
(i) for the period December 1, 2008 through
March 31, 2009, 75 percent of the operating cost component will reflect the
operating cost component of rates effective for December 31, 2007, adjusted for
inflation, and 25 percent will reflect 2006 operating costs in accordance with
paragraphs (2) through (6) of this subdivision.
(ii) for April 1, 2009 through March 31,
2010, 37.5 percent of the operating cost component will reflect the December
31, 2007 operating cost component, adjusted for inflation, and 62.5 percent
will reflect 2006 operating costs in accordance with paragraphs (2) through (6)
of this subdivision.
(iii) for
periods on and after April 1, 2010, 100 percent of the operating cost component
will reflect 2006 operating costs in accordance with paragraphs (2) through (6)
of this subdivision.
(2)
For purposes of establishing the average operating cost per diem by region for
medically managed detoxification and medically supervised withdrawal services,
the regions of the state are defined as follows:
(i) New York City - Bronx, New York, Kings,
Queens and Richmond Counties;
(ii)
Long Island - Nassau and Suffolk Counties;
(iii) Northern Metropolitan - Columbia,
Delaware, Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster and Westchester
Counties;
(iv) Northeast - Albany,
Clinton, Essex, Fulton, Greene, Hamilton, Montgomery, Rensselaer, Saratoga,
Schenectady, Schoharie, Warren and Washington Counties;
(v) Utica/Watertown - Franklin, Herkimer,
Lewis, Oswego, Otsego, St. Lawrence, Jefferson, Chenango, Madison and Oneida
Counties;
(vi) Central - Broome,
Cayuga, Chemung, Cortland, Onondaga, Schuyler, Seneca, Steuben, Tioga and
Tompkins Counties;
(vii) Rochester
- Monroe, Ontario, Livingston, Wayne and Yates Counties; and
(viii) Western - Allegany, Cattaraugus,
Chautauqua, Erie, Genesee, Niagara, Orleans and Wyoming Counties.
(3) For each of the regions, the
2006 operating costs incurred by general hospitals in such region for providing
care to inpatients requiring detoxification services, as defined by OASAS, and
reported in the 2006 ICR submitted to the department prior to 2008, are
adjusted by a length of stay (LOS) factor. This LOS factor reflects the loss of
revenue due to the reduction of payments for services over the 5th day of stay.
The total adjusted operating costs for each region, divided by the total
regional days, is the average operating cost per diem for the region.
(4) The per diem rates for inpatients
requiring medically managed detoxification services will reflect 100 percent of
the average operating cost per diem for the region in which the hospital is
located, adjusted for inflation, for the first five days of service. However,
such payments will be reduced by 50 percent for services provided on the 6th
through 10th day of service. No payments will be made for any services provided
on and after the 11th day.
(5) Per
diem rates for inpatients requiring medically supervised withdrawal services,
will reflect 100 percent of the average operating cost per diem for the region
in which the hospital is located, adjusted for inflation, for the period
January 1, 2009 through December 31, 2009. For periods on and after January 1,
2010, the per diem rates for withdrawal services will reflect 75 percent of the
average operating cost per diem for the region, adjusted for inflation, and
will be reduced by 50 percent for care provided on the 6th through 10th day of
service. No payments will be made for any services provided on and after the
11th day.
(6) Per diem rates for
inpatients placed in observation beds, as defined by OASAS, will reflect 100
percent of the average operating cost per diem for the region in which the
hospital is located, adjusted for inflation, and will be paid for no more than
two days of care. After two days of care the payments will reflect the
patient's diagnosis as requiring either detoxification or withdrawal services.
The days of care in the observation beds will be included in the determination
of days of care for either detoxification or withdrawal services. Furthermore,
days of care provided in observation beds will, for reimbursement purposes, be
fully reflected in the computation of the initial five days of care.
(7) Capital cost reimbursement for the
general hospitals which are certified by OASAS to provide substance abuse
services will be based on the current reimbursement methodology for determining
allowable capital for exempt unit per diem rates. Such capital cost will be
added to the applicable operating cost component as a per diem amount to
establish the per diem rate for each service.
(h) Hospitals or distinct units of hospitals
that fail to maintain qualifying criteria for exempt status for reimbursement
purposes, as set forth in this section or in section 2807-c(4)(e-2) of the
Public Health Law, shall continue to be reimbursed in accordance with such
exempt status until the commencement of the next rate period, as determined by
the department.
(i) Rates of
payment for inpatient services for exempt distinct units of hospitals described
in subdivisions (a), (b), (c), (d) and (e) of this section, for which
separately identifiable 2005 reported costs data are not available, shall
reflect the average reported 2005 operating cost per day for comparable exempt
units, as determined by the department.
(j) Rates of payment for inpatient services
described in subdivisions (a) and (b) of this section which utilize regional
averages for determining a cost ceiling shall utilize regions of the State set
forth in section
2807-c
(4)(l)(iii)(E) of the Public Health Law and
this subdivision, except that if the otherwise applicable region has less than
five exempt hospitals or units in the service, facilities located in the
nearest regions will be used to establish a minimum of five hospital or units
for the purpose of determining ceilings. Such regions are as follows:
(1) New York City, consisting of the Counties
of Bronx, New York, Kings, Queens and Richmond;
(2) Long Island, consisting of the Counties
of Nassau and Suffolk;
(3) Northern
Metropolitan, consisting of the Counties of Columbia, Delaware, Dutchess,
Orange, Putnam, Rockland, Sullivan, Ulster and Westchester;
(4) Northeast, consisting of the Counties of
Albany, Clinton, Essex, Fulton, Greene, Hamilton, Montgomery, Rensselaer,
Saratoga, Schenectady, Schoharie, Warren and Washington;
(5) Utica / Watertown, consisting of the
Counties of Franklin, Herkimer, Lewis, Oswego, Otsego, St. Lawrence, Jefferson,
Chenango, Madison and Oneida;
(6)
Central, consisting of the Counties of Broome, Cayuga, Chemung, Cortland,
Onondaga, Schuyler, Seneca, Steuben, Tioga and Tompkins;
(7) Rochester, consisting of the Counties of
Monroe, Ontario, Livingston, Wayne and Yates;
(8) Western, consisting of the Counties of
Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans and
Wyoming.
(k) Capital
cost components of per diem rates determined pursuant to this section shall be
computed on the basis of budgeted capital costs allocated to the exempt
hospital or distinct unit of a hospital pursuant to the provisions of section
86-1.25 of this Subpart divided by
exempt hospital or unit patient days reconciled to actual total
expense.
(l) New hospitals
and new hospital units.
The operating cost component of rates of payment for new
hospitals, or hospital units, without adequate cost experience shall be
computed based on either budgeted cost projections, subsequently reconciled to
actual reported cost data, or the regional ceiling calculated in accordance
with subdivision (i) of this section, whichever is lower. The capital cost
component of such rates shall be calculated in accordance with section
86-1.25 of this
Subpart.
(m) Inpatient
psychiatric services. Per diem rates of payment for a general hospital or a
distinct unit of a general hospital for inpatient psychiatric services shall
continue to be determined in accordance with the reimbursement methodology set
forth in section
86-1.57 of this Subpart which was
in effect for periods prior to December 1, 2009.
