Current through Register Vol. 46, No. 39, September 25, 2024
(a) Reimbursement for Mental Health
Outpatient Treatment and Rehabilitative Service programs procedures will be fee
based.
(b) A weight for each Mental
Health Outpatient Treatment and Rehabilitative Service program procedure shall
be established by the Department of Health in conjunction with the Office which
reflects the relative anticipated resource utilization for such procedure. For
some procedures, fees shall be enhanced pursuant to section
599.14 of this Part through the
use of billing modifiers for such things as procedures delivered after hours,
services provided in languages other than English, and services of a minimum
duration of 15 continuous minutes delivered by a physician or nurse
practitioner in psychiatry.
(c)
Providers will be categorized into peer groups pursuant to this section. The
Office will establish a base fee for reimbursement for each peer group. Such
fee shall be reduced by 25 percent during the period in which any such provider
retains an operating certificate with a duration of less than six months as a
result of having been determined to be deficient in meeting applicable
standards and requirements, pursuant to this Part.
(d) Peer group specific base fees may be
adjusted as applicable by the Office. Provider specific fee adjustments may be
made to reflect pay for performance enhancements, penalties resulting from the
Office inspection and certification process, or for other reasons described in
the regulations of the Office.
(e)
Payments for procedures will be determined by multiplying the assigned weight
for the appropriate procedure code set forth at 10 NYCRR Part 86 by the base
fee, and adjusting such fee for modifiers and discounts, as appropriate. When a
modifier or discount is expressed as a percentage, it will adjust the payment
by its percentage of the procedure weight. When more than one procedure applies
to a visit, the highest value procedure shall be paid at its full fee value.
(1) Payments for additional procedures
related to the visit will be discounted by 10 percent, except for Mental
Health Outpatient Treatment and Rehabilitative Service Programs approved by the
Office to provide Intensive Outpatient Program (IOP) where there will be no
discounted services for additional procedures.
(2) Payments will be reduced by 25 percent
for any visit in excess of 30, excluding crisis intervention services, off-site visits, complex care management, peer/family support services, any
services that are provided as part of IOP, and any services that are counted as
health services, provided during a state fiscal year to any individual who is
21 years of age or older on the first day of such fiscal year, and 50 percent
for any visit in excess of 50, excluding crisis intervention services, off-site
visits, complex care management, peer/family support services, any services
that are provided as part of IOP, and any services counted as health services,
provided during such fiscal year to any individual, for fiscal years
commencing on or after April 1, 2011, except that effective January 1, 2015,
this reduction in payment will not apply to court-mandated services.
(f) The Office will annually
review procedure weights, modifier values, peer groupings and the base fees for
each of the peer groupings, and will update them as needed. Any changes will be
published in the State Register and posted on the Office's website.
(g) The Office will establish and make public
a list of weights associated with all CPT and HCPCS procedure codes which can
be used to bill specific mental health Mental Health Outpatient Treatment and
Rehabilitative Service program procedures through Medical Assistance. The
Office will update this list as needed.
(h) Providers licensed solely under article
31 of the Mental Hygiene Law shall be classified by the following peer groups.
(1) Upstate. All non-Local Governmental Unit
operated Mental Health Outpatient Treatment and Rehabilitative Service programs
operating solely under an Office of Mental Health operating certificate and
located in the following counties shall be considered to be included in the
upstate peer group: Albany, Allegany, Broome, Cattaraugus, Cayuga, Chautauqua,
Chemung, Chenango, Clinton, Columbia, Cortland, Delaware, Erie, Essex,
Franklin, Fulton, Genesee, Greene, Hamilton, Herkimer, Jefferson, Lewis,
Livingston, Madison, Monroe, Montgomery, Niagara, Oneida, Onondaga, Ontario,
Orleans, Oswego, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie,
Schuyler, Seneca, St. Lawrence, Steuben, Sullivan, Tioga, Tompkins, Ulster,
Warren, Washington, Wayne, Wyoming, and Yates counties.
(2) Downstate. All non-Local Governmental
Unit operated Mental Health Outpatient Treatment and Rehabilitative Service
programs operating solely under an Office of Mental Health operating
certificate and located in the following counties shall be considered to be
included in the downstate peer group: Bronx, Kings, New York, Queens, Richmond,
Nassau, Suffolk, Dutchess, Orange, Putnam, Rockland and Westchester
counties.
(3) Local Governmental
Unit-Operated. All Mental Health Outpatient Treatment and Rehabilitative
Service programs operated by a local governmental unit which are operating
solely under an operating certificate from the Office.
(4) State-operated. All hospital-based Mental
Health Outpatient Treatment and Rehabilitative Service programs operated by the
Office.
(i)
Hospital-based providers licensed under article 28 of the Public Health Law and
article 31 of the Mental Hygiene Law shall be classified by the following peer
groups. The base rates will be calculated pursuant to 10 NYCRR Part 86.
(1) Upstate hospital - All hospital-based
Mental Health Outpatient Treatment and Rehabilitative Service programs in
Albany, Allegheny, Broome, Cattaraugus, Cayuga, Chautauqua, Chemung, Chenango,
Clinton, Columbia, Cortland, Delaware, Erie, Essex, Franklin, Fulton, Genesee,
Greene, Hamilton, Herkimer, Jefferson, Lewis, Livingston, Madison, Monroe,
Montgomery, Niagara, Oneida, Onondaga, Ontario, Orleans, Oswego, Otsego,
Rensselaer, Saratoga, Schenectady, Schoharie, Schuyler, Seneca, St. Lawrence,
Steuben, Sullivan, Tioga, Tompkins, Ulster, Warren and Washington, Wayne,
Wyoming, and Yates counties.
(2)
Downstate hospital- All hospital-based Mental Health Outpatient Treatment and
Rehabilitative Service programs in Bronx, Kings, New York, Queens, Richmond,
Nassau, Suffolk, Dutchess, Orange, Putnam, Rockland and Westchester
counties.
(3) The fee paid to new
Mental Health Outpatient Treatment and Rehabilitative Service programs, or
Mental Health Outpatient Treatment and Rehabilitative Service programs
commencing service in a new county, shall be calculated pursuant 10 NYCRR
86-8.6.
(j) Diagnostic
and treatment center (D&TC) providers licensed under Article 28 of the
Public Health Law and Article 31 of the Mental Hygiene Law shall be classified
by the following peer groups. The base rates will be calculated pursuant to
this Part.
(1) Upstate D&TC - All
diagnostic and treatment centers in Albany, Allegheny, Broome, Cattaraugus,
Cayuga, Chautauqua, Chemung, Chenango, Clinton, Columbia, Cortland, Delaware,
Erie, Essex, Franklin, Fulton, Genesee, Greene, Hamilton, Herkimer, Jefferson,
Lewis, Livingston, Madison, Monroe, Montgomery, Niagara, Oneida, Onondaga,
Ontario, Orleans, Oswego, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie,
Schuyler, Seneca, St. Lawrence, Steuben, Sullivan, Tioga, Tompkins, Ulster,
Warren and Washington, Wayne, Wyoming, and Yates counties.
(2) Downstate D&TC - All diagnostic and
treatment centers in Bronx, Kings, New York, Queens, Richmond, Nassau, Suffolk,
Dutchess, Orange, Putnam, Rockland and Westchester counties.
(k) D&TCs and hospitals -
Where a corporation operates a hospital and a D&TC, the Office will
determine the primary relationship between the mental health program and the
hospital or D&TC and assign the Mental Health Outpatient Treatment and
Rehabilitative Service program to the appropriate peer group.
(l) Supplemental Payments. Provider peer
group base fees paid pursuant to this section shall be supplemented as
appropriate for individual providers participating in the Office of Mental
Health quality improvement initiative, or other performance initiatives
developed by the Office.
(1) In order to be
enrolled in such quality improvement initiative or other Office of Mental
Health performance-based payment system, the program shall execute an agreement
with the Office under which the provider agrees to participate in such
initiative, and undertake such measures as shall be developed by the
Office.
(2) Any program eligible to
receive supplemental medical assistance reimbursement for participation in a
quality improvement initiative, which fails at any time to meet the
requirements set forth in the agreement, shall have its quality improvement
supplement to its peer group base fee suspended until such time as the program
meets such requirements, as determined by the Office.
