New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIII - Office of Mental Health
Part 508 - Medical Assistance Rates Of Payment For Assertive Community Treatment Services
Section 508.5 - Standards pertaining to reimbursement

Universal Citation: 14 NY Comp Codes Rules and Regs ยง 508.5

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

(a) General requirements.

(1) ACT programs are required to be approved or certified by the office to provide ACT treatment services.

(2) ACT staff shall have responsibility for treatment, rehabilitation, case management, and support services for ACT clients.

(3) There shall be at least one direct care staff person for every 10 clients. Exceptions to the case ratio requirement may be allowed by the office.

(4) In no instance shall an individual be admitted to an ACT program while concurrently enrolled in an Health Home Care Management, licensed day treatment program for children, or licensed continuing day treatment program as defined in Parts 506, 587 and 599 of this Title.

(5) An individual may be both an active ACT client and enrolled in a personalized recovery-oriented services (PROS) program, operating pursuant to Part 512 of this Title, for no more than three months within any 12-month period.

(6) Providers of ACT services shall furnish any and all information and records requested by the office, including, but not limited to, clientspecific, statistical, administrative, and fiscal information.

(7) A child may be both an active Youth ACT client and enrolled in CFTSS and/or HCBS 30 days prior to discharge from Youth ACT only as a transition from Youth ACT to an alternate or lower level of care.

(b) Reimbursement standards.

(1) Reimbursement shall be made only for services provided to persons who:
(i) meet the definition of persons with serious mental illness or serious emotional disturbance as set forth in section 1.03 of the Mental Hygiene Law;

(ii) have been referred or approved by the SPOA for enrollment in ACT services; and

(iii) are active clients of the ACT provider.

(2) Rates of payment shall be established on a prospective basis.

(3) Each rate of payment established under this Part shall be a monthly fee determined by the commissioner and approved by the Division of the Budget.

(4) Reimbursement for services provided to a client who is admitted to an ACT treatment program and active in ACT treatment services shall only be made for the client's participation in that program, except as otherwise provided in paragraph (c)(3) of this section.

(5) Reimbursement for clinic or continuing day treatment services provided to a client, other than for pre-admission visits, will be deducted from the amount paid to the provider of ACT services.

(6) Reimbursement for services provided to clients who are receiving both ACT and Child and Family Treatment and Support Services (CFTSS) or Home and Community Based Services (HCBS) or PROS services as permitted by subdivision (a) of this section will be limited to the partial step-down payment rate specified in subdivision (c) of this section.

(7) No more than one client or collateral contact per day shall be allowed as a billable service, except that two contacts per day shall be allowed as a billable service if one contact is face-to-face with the client and the other contact is face-to-face with a collateral. The two contacts must occur separately.

(8) Reimbursement shall be made only for services identified and provided in accordance with an individual's treatment plan. The treatment plan shall develop, evaluate and revise, as needed, an individual's course of treatment based on the client's diagnosis, expressed desires, behavioral strengths and weaknesses, problems and service needs.

(9) Reimbursement for collateral contacts may be made for:
(i) contacts by ACT team members with collaterals; or

(ii) contacts by ACT team members with a group composed of collaterals of more than one client, for the purpose of goal-oriented problem solving, assessment of treatment strategies, assisting family members for the benefit of the client and provision of practical skills for assisting a client in the management of their illness. No more than one collateral contact for any recipient shall be allowed as a billable service regardless of how many of their collaterals participate in the session. The total number of individuals in any group shall not exceed six.

(c) Reimbursement rate.

ACT treatment services shall be reimbursed at the following rates: full; partial step-down; and Inpatient. In no instance shall a program bill more than one rate code during the same month for the same individual.

(1) Reimbursement shall be made at the full payment rate for services provided to active clients who receive a minimum of six face-to-face contacts in a month, up to three of which may be collateral contacts.

(2) Reimbursement shall be made at the partial step-down payment rate for services provided to active clients who receive a minimum of two, but fewer than six, face-to-face contacts in a month.

(3) Reimbursement for services to ACT clients who are admitted for treatment to an inpatient facility and are anticipated to be discharged within 180 days of admission shall be made in accordance with section 508.7 of this Part.

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