New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIV - Office for People With Developmental Disabilities
Part 635 - General Quality Control and Administrative Requirements Applicable to Programs, services or Facilities Funded or Certified by the Office for People With Developmental Disabilities
Subpart 635-10 - Provision of Home and Community-Based Waiver Services
Section 635-10.5 - Reimbursement of HCBS waiver services

(i) Provider. OPWDD or an authorized vendor of Medicaid service coordination (MSC) (see Subpart 635-5 of this Part), which has also been specifically authorized by OPWDD to deliver the HCBS waiver service known as plan of care support services (PCSS).

(ii) Eligible persons. Those persons meeting the criteria set forth at paragraph (2) of this subdivision.

(iii) Plan of care support services. Activities and assistance necessary to conduct timely reviews and updates of a person's individualized service plan (ISP), to maintain the documentation supporting the person's HCBS waiver level of care eligibility determination and to meet the needs of the individual. PCSS shall be provided during at least two months each year spaced at appropriate intervals. For individuals who have not been enrolled in the HCBS waiver or in MSC prior to receiving PCSS, PCSS may also include activities and assistance necessary for initial service plan development and implementation.

(iv) Qualified service coordinator. Someone who meets the requirements of either clause (a) or (b) of this subparagraph:

(i) Only HCBS waiver participants shall receive plan of care support services.

(ii) In order for the service to be reimbursable, the person receiving the service shall:

(i) Reimbursement to a provider of PCSS shall be on a fee for service basis.

(ii) The unit of service for PCSS is one month. Effective April 1, 2010, the fee for PCSS is $238.99 per unit of service.

(iii) Effective February 1, 2010, the fee will be subject to a trend factor if one is specified in paragraph (i)(4) of this section.

(iv) A maximum of four PCSS units of service per person are reimbursable on an annual basis.

(v) PCSS shall be provided during two months each year for the purpose of reviewing and updating the person's individualized service plan, related records, and ensuring that the annually required HCBS waiver level of care eligibility determination is completed.

(vi) PCSS provided during an additional month in a year is reimbursable if additional service coordination activities and assistance are provided during that month and are necessary to meet the needs of the individual. A provider shall not be paid for more than two units of PCSS per year for such additional services.

(vii) Reimbursement for PCSS shall be contingent upon the services being delivered by a qualified service coordinator.

(i) If a provider provides initial PCSS to an individual, the provider shall receive an initial PCSS payment. Initial PCSS is PCSS that is provided to an individual who has not been enrolled in the HCBS waiver or in MSC prior to receiving PCSS and that includes activities and assistance necessary for initial service plan development and implementation.

(ii) The fee for initial PCSS is equal to three times the PCSS fee as described in paragraph (3) of this subdivision.

(iii) A provider shall only be paid for initial PCSS once for an individual. If a provider provides PCSS described in paragraph (3) of this subdivision in the same month during which it provides initial PCSS, the provider shall only be paid for initial PCSS.

(i) for providers in the counties of New York, Bronx, Queens, Kings, and Richmond, July 1st to June 30th;

(ii) for providers in all other counties, January 1st to December 31st; and

(iii) for IRA providers defined in subparagraph (ii) of this paragraph, there will be a one- time, six-month price period from July 1, 2002 to December 31, 2002.

(i) Reimbursement for residential habilitation services provided in non-state operated IRAs and CRs on or after July 1, 2014 shall be in accordance with the provisions of Subpart 641-1 of this Title. Subpart 641-1 supersedes the provisions of subparagraphs (iii)-(vii) of this paragraph for reimbursement of residential habilitation services provided in non-state operated supervised IRAs and CRs on and after July 1, 2014.

(ii) The unit of service for residential habilitation services provided in non-state operated supervised IRAs and CRs on or after July 1, 2014 shall be a daily unit of service. The requirements of this subparagraph supersede the provisions of subparagraph (v) of this paragraph for residential habilitation services provided in non-state operated supervised IRAs and CRs on or after July 1, 2014.

(iii) A monthly supervised IRA price will be effective for residential habilitation services delivered in a provider's supervised IRAs and supervised community residences that have:

(iv) Effective January 1, 2010, the IRA operating and capital reimbursement shall be consolidated with the community residence operating and capital reimbursement and the IRA price shall be calculated as follows:

(v) Countable service days.

(vi) Newly certified sites. A newly certified site is an IRA whose reimbursable costs are not already included in the monthly price and at which a provider is initially approved to deliver services pursuant to an operating certificate issued by OPWDD. A newly certified site's annual total reimbursable residential habilitation costs and certified capacity shall be included in the monthly price as calculated in accordance with subparagraph (iv) of this paragraph except for capital moveable equipment and property insurance components after December 31, 2010. If two countable service days are possible in the month of certification, the new site shall be included in the monthly price in the month of certification. If two countable service days are not possible in the month of certification, the new site shall be included in the monthly price effective the month after the month of certification.

(vii) Effective January 1, 2011, capital moveable equipment and property insurance shall become fixed values contained in the cost category other than personal services.

(i) Reimbursement for residential habilitation services provided in non-state operated IRAs and CRs on or after July 1, 2014 shall be in accordance with the provisions of Subpart 641-1 of this Title. Subpart 641-1 supersedes the provisions of subparagraphs (ii) - (v) of this paragraph for reimbursement of residential habilitation services provided in non-state operated supportive IRAs and CRs on and after July 1, 2014.

(ii) A monthly supportive IRA price will be effective for residential habilitation services delivered in a provider's supportive IRAs and supportive community residences that have:

(iii) Effective January 1, 2010, the IRA operating and capital reimbursement shall be consolidated with the community residence operating and capital reimbursement and the IRA price shall be calculated as follows:

(iv) Countable service days.

(v) Newly certified sites. A newly certified site is an IRA whose reimbursable costs are not already included in the monthly price and at which a provider is initially approved to deliver services pursuant to an operating certificate issued by OPWDD. The approved total annual budgeted costs established for newly certified supportive IRA sites after June 30, 2011 shall reflect a two percent reduction in operating costs as was implemented for providers on July 1, 2011 pursuant to subparagraph (18)(iii) of this subdivision. A newly certified site's annual total reimbursable residential habilitation costs and certified capacity shall be included in the monthly price as calculated in accordance with subparagraph (iii) of this paragraph except for capital moveable equipment and property insurance components after December 31, 2010. If two countable service days are possible in the month of certification, the new site shall be included in the monthly price in the month of certification. If two countable service days are not possible in the month of certification, the new site shall be included in the monthly price effective the month after the month of certification.

(vi) Effective January 1, 2011, capital moveable equipment and property insurance shall become fixed values contained in the cost category other than personal services.

(i) Effective July 1, 2014, for the provider to be paid for a daily unit of supervised IRA RH the individual must be enrolled at the supervised IRA and either services are provided or the person is eligible for a therapeutic leave or retainer day in accordance with the provisions of paragraph (12) of this subdivision.

(ii) Prior to July 1, 2014, for the provider to be paid a full month supervised IRA price, the individual must be enrolled in the provider's supervised IRA program for a minimum of 22 days in the calendar month.

(iii) Prior to July 1, 2014, for the provider to be paid a one-half month supervised IRA price, the individual must be enrolled in the provider's supervised IRA program for a minimum of 11 days in the calendar month.

(iv) For the provider to be paid a full month supportive price or rate, the individual must be enrolled in the provider's supportive IRA program for a minimum of 22 days in the calendar month.

(v) For the provider to be paid a one-half month supportive price or rate, the individual must be enrolled in the provider's supportive IRA program for a minimum of 11 days in the calendar month.

(i) Supervised IRA RH service days, effective July 1, 2014, require:

(ii) Theraputic leave and retainer days. Effective July 1, 2014, a supervised IRA provider will be paid for therapeutic leave days and retainer days in accordance with Subpart 641-1 of this Title.

(iii) Countable service days prior to July 1, 2014:

(i) Effective January 1, 2003, there shall be an efficiency adjustment for IRAs as follows:

(ii) Effective October 1, 2010, for providers in all regions there shall be an efficiency adjustment applied to the IRA price for the residential habilitation services provided in supervised IRAs and supervised community residences.

(iii) Effective July 1, 2011, supportive IRA prices shall be revised to reflect a two percent reduction to the operating components of the price in effect on June 30, 2011. For the purposes of a vacancy price adjustment, the effects of this reduction shall not be construed as a basis for loss.

(iv) Effective July 1, 2011, supervised IRA prices shall be reduced according to the measures outlined in this subparagraph. There are two distinct actions to the price reductions. The personal services action addresses provider surpluses in funding for direct care, clinical and support staff and the associated fringe benefits. The administrative action addresses reimbursable administrative costs and holds reimbursement to a level of efficiency. Providers may be subject to only one action or to both actions or they may be exempt from both.

(i) AHRH services are residential habilitation services provided to individuals who do not reside in a residence which is certified or operated by OPWDD.

(ii) AHRH services may be self-directed, family-directed, or managed solely by an agency.

(iii) services must be delivered at the individual's home, or be initiated or concluded there.

(iv) Reimbursement shall be contingent upon prior OPWDD approval.

(v) Reimbursement shall be contingent on documentation that those receiving the service have received the services specified in each person's Individualized Service Plan (ISP) and at home residential habilitation plan.

(vi) The unit of service for AHRH services shall be one hour equaling 60 minutes, and is reimbursed in 15-minute increments. When there is a break in the service delivery during a single day, the provider may combine, for billing purposes, the duration of each continuous period of service provision (or session) that is provided during the day.

(vii) Only time when AHRH staff are present with the individual and providing services may be counted toward the billable service time.

(viii) For each continuous service delivery period or session, the AHRH provider must document the service start time and the service stop time, the ratio of individual to staff at the time of service delivery, and the provision of at least one service/staff action delivered in accordance with the individual's AHRH Plan.

(ix) Billable service time is time when staff are providing face-to-face AHRH services to an individual in accordance with the individual's AHRH Plan. Time spent receiving another Medicaid service cannot be counted toward the AHRH billable service time, except as follows:

(i) Self-direction or family direction in AHRH services is established to permit greater flexibility and freedom of choice in obtaining such services.

(ii) The management of these self-directed or family-directed services is described in a co-management agreement between the individual, the AHRH provider and, if one exists, an identified adult.

(iii) AHRH services which are self-directed are available when all parties to the co-management agreement concur that the individual receiving the AHRH services:

(iv) AHRH services which are family-directed are available when all parties to the co-management agreement concur that an adult receiving the AHRH services does not qualify for self-direction and there is an identified adult who is willing and able to make informed choices and co-manage the family-directed services for the benefit of the person.

(v) Eligible individuals and identified adults (if they exist) assume the responsibilities as mutually agreed to by the provider, individual, and identified adult in the co-management agreement. The co-management agreement shall specify the responsibilities of the provider, the individual, and any identified adult who will be managing or assisting in the management of the self-directed or family-directed services. The co-management agreement shall be documented in the individual's record.

(vi) The following responsibilities (except as noted in subparagraph [vii] of this paragraph) shall be the individual's and/or the identified adult's:

(vii) The provider may agree to assist with one or more of the responsibilities specified in subparagraph (vi) of this paragraph. The provider's agreement to assist with those responsibilities shall be documented in the individual's record.

(viii) The provider's responsibilities shall include:

(ix) The following requirement applies to self-directed and family-directed services. The individual receiving the AHRH service, any identified adults, and the provider shall review their respective management responsibilities to evaluate whether self-direction or family direction continues to be appropriate on at least a bi-annual basis.

(x) The following requirement applies to individuals receiving family-directed services. If the individual receives any services outside the home which are certified, authorized, operated or funded by OPWDD, the participation of a representative of at least one such service is required at a review of the individualized service plan (ISP) on at least an annual basis.

(xi) All agencies authorized by OPWDD to provide AHRH are also authorized to provide self-direction and family direction as an option under AHRH.

(i) Hourly fee schedule structure. Hourly fees are based on the following:

(ii) Transitional hourly fees - 2009 and 2010. Providers may be eligible to receive a transitional hourly fee for AHRH - Individual or AHRH - Group during a 23-month phase-in period. For the period beginning February 1, 2009 and ending December 31, 2009, for each region, there will be the standard hourly fee and there will be level I and level II transitional hourly fees. In 2010, for each region, there will be the standard hourly fee and there will be a level I transitional hourly fee. OPWDD shall determine a provider's eligibility for the transitional hourly fee(s) based on its examination of the provider's costs relative to an estimate of the service hours delivered.

(iii) Fee schedules:

(i) Individual day habilitation services are services that are provided with a staff-to-individual ratio of no greater than one individual per staff member. Individual day habilitation services are delivered on weekdays and have a service start time prior to 3:00 p.m. OPWDD will authorize a provider to deliver supplemental individual day habilitation services only where at least 90 percent of the planned schedule of activities involves one-on-one service provision. There will be one supplemental individual day habilitation price for each agency that OPWDD authorizes to deliver the service.

(ii) Supplemental individual day habilitation services are services that are provided with a staff-to-individual ratio of no greater than one individual per staff member. services are delivered on weekdays with a start time at 3:00 p.m. or later or anytime on weekends. OPWDD will authorize a provider to deliver supplemental individual day habilitation services only where at least 90 percent of the planned schedule of activities involves one-on- one service provision. There will be one supplemental individual day habilitation price for each agency that OPWDD authorizes to deliver the service.

(iii) Group day habilitation services are services that are typically provided to two or more enrolled consumers. Group day services are delivered on weekdays and have a service start time prior to 3:00 p.m. There will be one group day habilitation price for each agency that OPWDD authorizes to deliver the service.

(iv) Supplemental group day habilitation services are services that are typically provided to two or more enrolled consumers. Group day habilitation services are delivered on weekdays with a start time at 3:00 p.m. or later or anytime on weekends. There will be one supplemental group day habilitation price for each agency that OPWDD authorizes to deliver the service.

(i) for providers in the counties of New York, Bronx, Queens, Kings and Richmond, July 1st to June 30th;

(ii) for providers in all other counties, January 1st to December 31st;

(iii) for day habilitation providers defined in subparagraph (i) of this paragraph, there will be a one-time, six-month price period from January 1, 2006 to June 30, 2006.

(i) Total allowable day habilitation costs shall be determined in accordance with the provisions of section 635-10.4(b)(2) of this Subpart and Subpart 635-6 of this Part.

(ii) Total budgeted costs for day habilitation services shall be compared to the provider's historical costs for comparable services in day treatment or workshop or similar programs for persons demonstrating similar needs, or to the provider's historical costs for included expenditure categories where the provider had not delivered prior comparable services.

(iii) Reimbursement shall be contingent upon prior OPWDD approval and documentation that those participating in the program have received the services as specified in each person's individualized service plan (ISP) and day habilitation plan.

(iv) For individual day habilitation and supplemental individual day habilitation services provided prior to October 1, 2015, total annual reimbursable costs derived through the application of the above methodology shall be trended in accordance with subdivision (i) of this section and divided by the total annual projected hours of utilization.

(v) For group day habilitation and supplemental group day habilitation services, total annual reimbursable costs derived through the application of the above methodology shall be trended in accordance with subdivision (i) of this section and divided by total annual projected full and half units.

(vi) Allowable capital costs for group day habilitation services shall be reimbursed. Effective January 1, 2009, the capital cost portion for group day habilitation shall be included in the group day habilitation price as follows:

(i) Only time when individual day habilitation or supplemental individual day habilitation staff are present with the individual and providing services may be counted toward the billable service time (see subparagraph [iii] of this paragraph).

(ii) For each continuous service delivery period or session, the individual day habilitation or supplemental individual day habilitation provider must document the service start time and the service stop time and the provision of at least one service/staff action delivered in accordance with the individual's day habilitation plan.

(iii) Billable service time is time when staff are providing face-to-face individual day habilitation or supplemental individual day habilitation services to an individual in accordance with the individual's day habilitation plan. The following cannot be counted toward the individual day habilitation or supplemental individual day habilitation billable service time:

(iv) When individual day habilitation or supplemental individual day habilitation staff provide time-limited travel training services to a individual who is traveling to the first individual day habilitation or supplemental individual day habilitation activity of the day and traveling home or to another service at the conclusion of the individual day habilitation or supplemental individual day habilitation service, the time spent receiving travel training services may be counted as billable service time as long as:

(v) Supplemental individual day habilitation services may not be billed to Medicaid for individuals who live in residential settings with 24-hour staffing; for example, supervised individual residential alternatives (IRAs) and supervised community residences (CRs).

(i) Group day habilitation and supplemental group day habilitation services are reimbursed in full or half units of service:

(ii) The program day duration for both group day habilitation and supplemental group day habilitation is the length of time that the person is participating in the group day habilitation or supplemental group day habilitation services. The following cannot be counted as part of the program day duration:

(iii) Supplemental group day habilitation services may not be billed to Medicaid for:

(i) Limit of one full unit or two half units.

(ii) Limit of one and a half units or three half units.

(iii) For individuals who live in an IRA, CR or FCH and receive community habilitation on a given day, additional billing limits are described in paragraph (ab)(11) of this section.

(iv) Where more than one agency delivers services on a given day to the same individual, the total number of units and/or hours of CH services billed for that day by all agencies may not exceed the maximum allowed daily units and/or hours described in subparagraphs (i)-(iv) of this paragraph.

(v) Exceptions. The following applies only to requests made prior to October 1, 2014.

(i) Using a payment/rate data sample from calendar years 1995 and 1996, the weighted transportation average shall be calculated by dividing the aggregate transportation payments by the aggregate transportation units of service. One round trip shall equal one unit of service.

(ii) If an agency currently providing day habilitation does not have to and from transportation payment/rate data available for a particular program for the period used to calculate the modified weighted transportation averages, or if an agency opens a new day habilitation program, the modified weighted transportation average shall be equal to the lesser of the program's budgeted amount for transportation based on the transportation requirements of the person(s) to be transported to and from the day habilitation program or the average of the modified weighted transportation averages for all other day habilitation programs operated by the agency.

(iii) If an agency does not currently operate a day habilitation program, and opens a day habilitation program or if an agency does not have to and from transportation payment/rate data for any of its day habilitation programs for the period used to calculate the modified weighted transportation averages, the modified weighted transportation average shall be equal to the lesser of the day habilitation program's budgeted amount for transportation based on the transportation requirements of the person(s) to be transported to and from the new day habilitation program or the average of the modified weighted transportation averages for all day treatment facilities operated by the agency as described in section 690.7(e)(3) of this Title.

(iv) If the agency does not currently operate a day habilitation program or day treatment facility, the modified weighted transportation average shall be equal to the lesser of the new day habilitation program's budgeted amount for transportation based on the transportation requirements of the persons to be transported to and from the new day habilitation program or 75 percent of the regional modified weighted transportation average associated with transporting individuals to and from day habilitation programs. The table below shows the regional modified weighted transportation averages:

(v) Agencies that operated only day treatment facilities prior to July 1, 1996, and opened a day habilitation program for the first time between July 1, 1996 and September 3, 1996 shall receive a one time fee adjustment if the agency received 75 percent of the regional modified weighted transportation average for day habilitation transportation and is now receiving either the new day habilitation program's budgeted transportation amount or the average of the agency's day treatment modified weighted transportation averages. The one time fee adjustment shall be either:

(i) A determination shall be made as to whether each provider has a surplus or loss for all its day habilitation programs.

(ii) Regional ranking of the surplus/loss.

(iii) Determination of total adjustment per fee.

(iv) Exceptions to assignment of efficiency group.

(v) Recalculation of surplus/loss.

(i) All providers shall be subject to the first tier of the efficiency adjustment which shall reduce total reimbursable operating costs inclusive of transportation and health care adjustments (HCA) in the price in effect on May 1, 2010. The reduction shall be 2.5 percent.

(ii) The second tier adjustment shall be applied to all non-personal services (NPS) reimbursable operating costs reflected in the reimbursement prices for providers at or above the benchmark described in clause (b) of this subparagraph.

(iii) For purposes of price adjustments, the effects of this efficiency adjustment shall be not be construed as a basis for loss. OPWDD shall offset any price adjustment it would otherwise make by the efficiency adjustment described in this paragraph.

(i) Applicability. The price reductions will apply to all providers except for those which meet the criteria for exemption. The first criterion, in order for any provider to be exempt from the impact of the reductions on any basis, is a cost report requirement. Region I providers must have filed a 2008-2009 cost report and Regions II and III providers must have filed a 2008 cost report before or on December 23, 2010, except that a provider may submit the cost report after December 23, 2010 if the cost report represents an original submission or a resubmission specifically requested by OPWDD due to identified inaccuracies or insufficiencies. Cost reports submitted after December 23, 2010 must be submitted by May 1, 2011 unless the commissioner exercises or has exercised his or her discretion to extend the May 1, 2011 deadline. Providers with cost reports submitted in accordance with the deadlines in this subparagraph may qualify for exemption from the personal services surpluses action pursuant to clause (ii)(a) of this paragraph. Providers with cost reports submitted in accordance with the deadlines in this subparagraph may qualify for exemption from the administrative action pursuant to clause (iii)(a) of this paragraph. Providers which did not submit cost reports in accordance with the deadlines in this subparagraph shall be subject to price reductions pursuant to subparagraph (iv) of this paragraph. OPWDD shall employ data extracted from the most recent 2008/2008-2009 cost report submitted by a provider on or before December 23, 2010, except that data from a 2008/2008-2009 cost report submitted after December 23, 2010 representing an original submission or a resubmission specifically requested by OPWDD due to identified inaccuracies or insufficiencies and submitted by May 1, 2011 or a later deadline extended by the commissioner shall also be utilized. For providers of group day habilitation and/or supplemental group day habilitation services which did not operate any supervised IRAs for the cost reporting year 2008/2008-2009, the components subjected to analysis relate to the provider's group day habilitation and supplemental group day habilitation services. For providers which did operate a supervised IRA(s) for the cost reporting year 2008/2008-2009, the components subjected to analysis relate to the combination of the provider's group day habilitation, supplemental group day habilitation, and supervised IRA services. Additionally, for providers which converted a day program to a group day habilitation or supplemental group day habilitation program or a residential program to a supervised IRA subsequent to the 2008/2008-2009 cost report period, OPWDD incorporated the data included in the 2008/2008-2009 cost reports for the converted program(s) prior to conversion into its analyses.

(ii) Personal services surpluses action.

(iii) Administrative action.

(iv) Total impact limitation. Before OPWDD revises a provider's group day habilitation and/or supplemental group day habilitation price, it shall assess the total impact on a provider of all the tentative gross reductions and tentative aggregate gross reductions pursuant to this paragraph and subparagraph (b)(18)(iv), paragraph (e)(6) of this section and section 671.7(a)(13) of this Title combined with the final price and fee reductions pursuant to subparagraph (b)(18)(iii), paragraph (d)(6), clauses (h)(3)(iii)(d), (ab)(12)(iii)(b) of this section and section 671.7(a)(12) of this Title. The total impact to an individual provider shall be limited to an amount not to exceed 6.5 percent of the aggregated total gross reimbursable operating costs as reflected in a provider's June 30, 2011 prices and the aggregated total gross allowable reimbursement reflected in a provider's June 30, 2011 fees for the provider's programs and/or services subject to the price and fee revisions. The lesser of the amount of the total impact or the amount of the total impact as limited by the 6.5 percent provision represents the final impact. For providers for which no 2008/2008-2009 cost reports were available because the conditions established in subparagraph (i) of this paragraph were not met, the total impact is calculated as follows: The aggregated total gross reimbursable operating costs as reflected in a provider's June 30, 2011 prices and the aggregated total gross allowable reimbursement as reflected in a provider's June 30, 2011 fees for the provider's programs and/or services subject to the price and fee revisions are summed. The total is multiplied by 6.5 percent. The product is the final impact for these providers.

(v) Allocation of final impact. Before allocation, the final impact on a provider shall be reduced by the final price and fee reductions pursuant to subparagraph (b)(18)(iii), paragraph (d)(6), clauses (h)(3)(iii)(d), (ab)(12)(iii)(b) of this section and section 671.7(a)(12) of this Title because those reductions are not subject to any further revisions. The remainder of the final impact on a provider shall be distributed equitably across the reimbursable operating costs in that provider's group day habilitation and supplemental group day habilitation services, supervised residential habilitation, and prevocational services in proportion to the amount of reduction each of these programs would have incurred had the reductions been calculated separately. OPWDD shall make an internal allocation within the price for providers subject to both the personal services surplus action and the administrative action pursuant to this paragraph.

(vi) Final group day habilitation and supplemental group day habilitation price reduction percentage. The allocation of the final impact to a provider's group day habilitation and supplemental group day habilitation services shall be expressed as a percentage of the total gross reimbursable operating costs reflected in the price in effect on June 30, 2011.

(vii) The final group day habilitation and supplemental group day habilitation price shall be the group day habilitation and supplemental group day habilitation price in effect on June 30, 2011 reduced by the final group day habilitation and supplemental group day habilitation price reduction percentage pursuant to subparagraph (vi) of this paragraph applied to that price.

(viii) For the purposes of requesting a price adjustment, the effects of this price reduction shall not be construed as a basis for loss. In processing a price adjustment, any revised price will be offset by the monetary impact, prorated as appropriate, of the price reduction as calculated pursuant to this clause.

(ix) The commissioner, at his or her discretion, may waive all or a portion of this adjustment for a provider upon the provider demonstrating that the imposition of the reduction would jeopardize the continued operation of the group day habilitation and/or supplemental group day habilitation services.

(i) On a given weekday, a maximum of the following may be reimbursed for group day habilitation services:

(ii) Delivery of group day habilitation services is not permitted on a weekend day.

(iii) On a given weekend day a maximum of the following may be reimbursed for supplemental group day habilitation:

(iii) Time spent receiving another Medicaid service shall not be counted toward billable service time in instances when the Medicaid service is received simultaneously with group day habilitation services (see section 635-10.4[b][2] of this Subpart). An exception is the provision of Medicaid Service Coordination (MSC), which may be received simultaneously with group day habilitation services.

(i) The total monthly number of day habilitation units claimed during the COVID-19 Public Health Emergency do not exceed the average monthly units for each service claimed from the period of July 1, 2019 through December 31, 2019;

(ii) The combined average monthly revenue for day habilitation, site based prevocational services, community-based prevocational services, and community habilitation during the COVID-19 Public Health Emergency claimed by the provider may not exceed the provider's combined average monthly revenue for those services for the period of July 1, 2019 through December 31, 2019;

(iii) Any claims in excess of the monthly averages from this period will be subject to immediate recoupment if the agency has submitted any claims during the month that do not meet the full program day duration requirements; and

(iv) Providers will continue to work in partnership with OPWDD to make more available non-center-based and telehealth modalities in an effort to increase community involvement of waiver enrollees and to protect the delivery of services during future emergencies.

(i) The provider operates day habilitation services in a geographic area that meets Department of Health thresholds for program closure due to increased rates of COVID-19 cases or the local public health agency has required a program to close. This designation requires that center-based day services are closed and that community-based services are operating at a reduced capacity. This authorization for the use of the modified billing rules will end with the de-designation of the area; or

(ii) The provider is not required to close its day habilitation services by either New York State or the local public health agency. However, the provider closes the program as a preemptive measure due to the elevated percentage of individuals and staff at a particular site that have either tested positive for COVID-19 or are required to quarantine because of close contact with a person who tests positive for COVID-19. These modifications to the program day durations associated with nonmandatory closures may be in effect for a period of up to fourteen (14) days for risk mitigation. Longer durations of the flexibilities (beyond fourteen days) would occur only where there is a subsequent designation of the region as being subject to closure or another period of quarantine is determined to be necessary. The agency must report the closure to OPWDD and demonstrate the need for the closure based on Incident Reporting Management Application (IRMA) reporting of positive COVID-19 cases among individuals and staff at the affected sites; and

(iii) Providers will continue to work in partnership with OPWDD to make more available non-center-based and telehealth modalities in an effort to increase community involvement of waiver enrollees and to protect the delivery of services during future emergencies.

(i) The regions will consist of New York City (including the counties of New York, Bronx, Kings, Queens and Richmond) and, the rest of the State.

(ii) The level of support will be established based on information obtained in accordance with the Developmental Disabilities Profile (DDP-2) (1/87), which is a developmental/demographic inventory of each person's personal characteristics.

(iii) If the historical monthly budgeted average cost per person for HCBS waiver supported employment service exceeds the average monthly regional fee per person receiving the service by 80 percent or more, the historical monthly budgeted cost per person for HCBS waiver supported employment service shall apply.

(iv) Effective April 1, 2005, costs incurred as a result of requests for criminal history record checks under section 16.33 of the Mental Hygiene Law and section 845-b of the Executive Law shall be allowable costs and shall be considered part of the fee.

(v) Effective January 1, 2008, for providers which participated in Health Care Enhancement (III) and which were deemed eligible for funding below the benchmark level, an amount equal to 1.0 percent of the fee will be added to the fees prescribed pursuant to subclauses (ii)(c)(1) and (2) of this paragraph.

(i) A provider may claim the monthly supported employment service fee, as calculated in clause (1)(ii)(c) of this subdivision, for an eligible person who is employed and to whom the provider has rendered, on separate days, at least two face-to-face documented supported employment services in accordance with the person's individualized service plan (ISP) and supported employment plan.

(ii) A provider may claim the monthly supported employment service fee, as calculated in clause (1)(ii)(c) of this subdivision, for an eligible person for whom the provider is actively engaged in preparatory and placement activities leading to competitive employment or reemployment. The provider must have rendered, on separate days, at least four such documented supported employment services, in accordance with the person's ISP and supported employment plan, of which at least two are face-to-face contacts.

(iii) Only one provider of supported employment service may claim for a supported employment service fee for an eligible person in a given calendar month.

(i) for providers in the counties of New York, Bronx, Queens, Kings and Richmond, July 1st to June 30th;

(ii) for providers in all other counties, January 1st to December 31st;

(iii) for prevocational services providers defined in subparagraph (i) of this paragraph there will be a one-time, six-month price period from January 1, 2006 to June 30, 2006.

(i) In such budget review, OPWDD shall consider the following limitations: provider historical costs for salaries, fringe and administration for such services. If service specific costs are not available, OPWDD shall consider regional salary, fringe and administration costs and the provider's historical costs for salaries, fringe and administration in other comparable OPWDD programs. In addition, OPWDD will consider specific service requirements documented in the ISPs of persons to be served, approved fringe benefit appeals in other OPWDD programs, levels of staff treatment responsibility, the impact of provider agency expansion on agency administration costs, and the allocation of clinical titles required for service.

(ii) That portion of costs related to actual products (i.e., the production of a saleable good or performance of a service of economic benefit), shall not be reimbursable under this section. Such shall include wages and fringe benefits of the service recipient and others not included in the approved budget; the cost of raw materials and manufacturing equipment; capital costs solely related to production work space; and administration and overhead solely related to the job task oriented aspects of the prevocational service environment.

(iii) The hourly price for prevocational service shall be determined by dividing the approved budgeted costs for all individuals included in the budget by the total annual projected full and half units.

(iv) Effective January 1, 2009, the capital cost portion for prevocational services shall be reimbursed as follows:

(i) Applicability. The price reduction shall apply to all providers except for those which meet the criteria for exemption. The first criterion, in order for any provider to be exempt from the impact of the reduction on any basis, is a cost report requirement. Region I providers must have filed a 2008-2009 cost report and Regions II and III providers must have filed a 2008 cost report on or before December 23, 2010, except that a provider may submit the cost report after December 23, 2010 if the cost report represents an original submission or a resubmission specifically requested by OPWDD due to identified inaccuracies or insufficiencies. Cost reports submitted after December 23, 2010 must be submitted by May 1, 2011 unless the commissioner exercises or has exercised his or her discretion to extend the May 1, 2011 deadline. Providers with cost reports submitted in accordance with the deadlines in this subparagraph may qualify for exemption pursuant to subparagraph (ii) of this paragraph. Providers which did not submit cost reports in accordance with the deadlines in this subparagraph shall be subject to price reductions pursuant to subparagraph (vii) of this paragraph. OPWDD shall employ data extracted from the most recent 2008/2008-2009 cost report submitted by a provider on or before December 23, 2010, except that data from a 2008/2008-2009 cost report submitted after December 23, 2010 representing an original submission or a resubmission specifically requested by OPWDD due to identified inaccuracies or insufficiencies and submitted by May 1, 2011 or a later deadline extended by the commissioner shall also be utilized.

(ii) Exemptions.

(iii) Providers subject to prevocational services price reduction are those providers which are not specifically exempted pursuant to subparagraph (ii) of this paragraph.

(iv) Untrended gross surplus. A provider is identified as having an untrended gross surplus when the analysis as conducted and described in clause (ii)(b) of this paragraph demonstrated an excess of reimbursable costs as reflected in the price for the respective reporting period and designated for direct care, clinical care and support and the associated fringe benefits over actual expenses for direct care, clinical care and support and the associated fringe benefits as reported in the provider's 2008/2008-2009 cost report. The amount of this excess is the untrended gross surplus.

(v) Untrended tentative gross reduction. The untrended gross surplus multiplied by 40 percent is referred to as the untrended tentative gross reduction.

(vi) Tentative gross reduction. The tentative gross reduction equals the untrended tentative gross reduction pursuant to subparagraph (v) of this paragraph trended to June 30, 2011 dollars.

(vii) Total impact limitation. Before OPWDD revises a provider's prevocational services price, it shall assess the total impact on a provider of all the tentative gross reductions and tentative aggregate gross reductions pursuant to this paragraph and subparagraph (b)(18)(iv), paragraph (c)(16) of this section, and section 671.7(a)(13) of this Title, combined with the final price and fee reductions pursuant to subparagraph (b)(18)(iii), paragraph (d)(6), clauses (h)(3)(iii)(d), (ab)(12)(iii)(b) of this section and section 671.7(a)(12) of this Title. The total impact to an individual provider shall be limited to an amount not to exceed 6.5 percent of the aggregated total gross reimbursable operating costs as reflected in a provider's June 30, 2011 prices and the aggregated total gross allowable reimbursement reflected in a provider's June 30, 2011 fees for the provider's programs and/or services subject to the price and fee revisions. The lesser of the amount of the total impact or the amount of the total impact as limited by the 6.5 percent provision represents the final impact. For providers for which no 2008/2008-2009 cost reports were available because the conditions established in subparagraph (i) of this paragraph were not met, the total impact is calculated as follows: The aggregated total gross reimbursable operating costs as reflected in a provider's June 30, 2011 prices and the aggregated total gross allowable reimbursement as reflected in a provider's June 30, 2011 fees for the provider's programs and/or services subject to the price and fee revisions are summed. The total is multiplied by 6.5 percent. The product is the final impact for these providers.

(viii) Allocation of final impact. Before allocation, the final impact on a provider shall be reduced by the final price and fee reductions pursuant to subparagraph (b)(18)(iii), paragraph (d)(6), clauses (h)(3)(iii)(d), (ab)(12)(iii)(b) of this section and section 671.7(a)(12) of this Title because those reductions are not subject to any further revisions. The remainder of the final impact on a provider shall be distributed equitably across the reimbursable operating costs in that provider's prevocational, supervised residential habilitation, group day habilitation, and supplemental group day habilitation services in proportion to the amount of reduction each of these programs would have incurred had the reductions been calculated separately.

(ix) Final prevocational services price reduction percentage. The allocation of the final impact to a provider's prevocational services shall be expressed as a percentage of the total gross reimbursable operating costs reflected in the price in effect on June 30, 2011.

(x) The final prevocational services price shall be the prevocational services price in effect on June 30, 2011 reduced by the final prevocational services price reduction percentage pursuant to subparagraph (ix) of this paragraph applied to that price.

(xi) For the purposes of requesting a price adjustment, the effects of this price reduction shall not be construed as a basis for loss. In processing a price adjustment, any revised price will be offset by the monetary impact, prorated as appropriate, of the adjustment as calculated pursuant to this paragraph.

(xii) The commissioner, at his or her discretion, may waive all or a portion of this adjustment for a provider upon the provider demonstrating that the imposition of the reduction would jeopardize the continued operation of the prevocational services.

(i) Reimbursement for prevocational services shall be claimed on an individual basis. Prevocational services shall be billed on a full and half unit basis.

(ii) The program day duration for prevocational services is the length of time that the person is present at the provider's "vocational/work program" where prevocational services are provided. The following cannot be counted as part of the program day duration:

(i) Limit of one full unit or two half units.

(ii) Limit of one and a half units or three half units.

(iii) For individuals who live in an IRA, CR or FCH and receive community habilitation on a given day, additional billing limits are described in paragraph (ab)(11) of this section.

(iv) On a given day, a maximum of one full unit per individual, either one full unit or two half units, may be reimbursed for supplemental group day habilitation.

(v) Where more than one agency delivers services on a given day to the same individual, the total number of units and/or hours of CH services billed for that day by all agencies may not exceed the maximum allowed daily units and/or hours described in subparagraphs (i)-(iv) of this paragraph.

(vi) Exceptions. The following applies only to requests made prior to October 1, 2014.

(i) Effective July 1, 2013, reimbursement of prevocational services delivered in a sheltered workshop is limited to those individuals who:

(ii) Notwithstanding the requirements in subparagraph (i) of this paragraph, reimbursement shall be provided for individuals who were enrolled in prevocational services at a sheltered workshop on or before June 30, 2013 but began receiving such services after June 30, 2013 and continuously received such services on and after the date that the individual began services.

(iii) Reimbursement of prevocational services delivered in a sheltered workshop is limited to services provided to the individuals specified in subparagraphs (i) and (ii) of this paragraph by either:

(i) The requested environmental modifications must be included in and consistent with the person's individualized service plan (ISP).

(ii) The contractor shall seek reimbursement from alternative payers before requesting reimbursement for environmental modification services as an HCBS waiver service.

(iii) The contractor shall solicit bids for the service(s) pursuant to a bidding process which will ensure the prudent purchase of goods.

(iv) At sites where construction and/or renovations beyond environmental modifications are to be performed, the scope of work for the environmental modification(s) may be included, but if so, shall be identified separately in the estimate(s) for the overall construction and/or renovations.

(i) The requested adaptive technologies must be included in and consistent with the person's individualized service plan (ISP).

(ii) The contractor shall seek reimbursement from alternative payers before requesting reimbursement for adaptive technologies services as an HCBS waiver service.

(iii) The contractor shall solicit bids for the service(s) pursuant to a bidding process which will ensure the prudent purchase of goods.

(iv) At sites where construction and/or renovations beyond adaptive technologies are to be performed, the scope of work for the adaptive technologies may be included, but if so, it shall be identified separately in the estimate(s) for the overall construction and/or renovations.

(i) In-Home Respite services. Services provided in a person's family home and may include staff accompanying the person to non-certified community settings.

(ii) Camp Respite services. Services provided at site-base d locations that possess a permit under Subpart 7 of the New York State Sanitary Code.

(iii) Site-Based Respite services. Services are provided on a property that the provider owns, leases, or for which the provider pays property costs or usage fees. The property may be:

(iv) Recreational Respite services. Services provided with a focus on recreational activities and/or community integration activities. Recreational Respite services are delivered in a community setting which the provider does not own or for which the provider does not pay property costs or usage fees.

(v) Intensive Respite services. Services provided based on an individual's level of need rather than the location. Individuals must be authorized to receive these services by OPWDD Regional Offices.

(i) Non-overnight Respite services are those an individual receives for a portion of the day but not overnight. For all Respite Services described in paragraph (4), except In-Home Respite services, the provider may bill for up to ten (10) hours of service provision of Respite services in a calendar day when not associated with overnight service provisions. For In-Home Respite services, there is no daily billing limit associated with non-overnight services.

(ii) Overnight Respite is defined as Respite services provided to a person on two (2) consecutive days when Respite staff are providing oversight to a person during nighttime hours. Overnight Respite Services may be delivered for In-Home, Site Based, Camp, and Intensive Respite service categories.

(i) In-Home, Camp, Site-Based and Recreational Respite services:

(ii) Intensive Respite services:

(i) Individual's name and, if applicable, the Medicaid ID (CIN);

(ii) Identification of the waiver service provided;

(iii) Identification of the category of Respite service provided;

(iv) The name of the agency providing the Respite service;

(v) The date the service was provided;

(vi) The start time and stop time for each continuous period of Respite service;

(vii) Verification of service provision by the Respite staff person who delivered the service (accomplished with providing the staff person's signature and title); and

(viii) The date the service was documented (the date must be contemporaneous with service provision).

(i) Respite must be included as a waiver service the individual receives;

(ii) For frequency and duration, the ISP/LP must specify that the frequency is "hourly" and the duration is "ongoing"; and

(iii) The effective date for Respite services.

(i) 3.53 percent to trend 1987 to 1988 costs to 1988-1989.

(ii) 5.71 percent to trend 1988 to 1989 costs to 1989-1990.

(iii) 7.51 percent to trend 1989 to 1990 costs to 1990-1991.

(iv) 6.24 percent to trend 1990 to 1991 costs to 1991-1992.

(v) 4.85 percent to trend 1991 to 1992 costs to 1992-1993.

(vi) 3.73 percent to trend 1992 to 1993 costs to 1993-1994.

(vii) 3.79 percent to trend 1993 to 1994 costs to 1994-1995.

(viii) 3.16 percent to trend 1994 to 1995 costs to 1995-1996.

(ix) Except for residential habilitation services provided in family care homes which will not receive a trend, 2.92 percent to trend 1995 to 1996 costs to 1996-1997.

(x) Except for residential habilitation services provided in family care homes which will not receive a trend, 5.23 percent to trend 1996-1997 costs to 1997-1998.

(xi) Except for residential habilitation services provided in family care homes which will not receive a trend, 2.88 percent to trend 1997-1998 costs to 1998-1999. The application of this trend factor shall include services provided in accordance with paragraph (c)(2) of this section.

(xii) Except for residential habilitation services provided in family care homes which will not receive a trend, 3.19 percent to trend 1998-1999 costs to 1999-2000. The application of this trend factor shall include services provided in accordance with paragraph (c)(2) of this section.

(xiii) Except for residential habilitation services provided in family care homes which will not receive a trend, 2.90 percent and an enhanced trend of 2.10 percent to trend 1999-2000 costs to 2000-2001. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section.

(xiv) Except for residential habilitation services provided in family care homes which will not receive a trend, 3.52 percent to trend 2000-2001 costs to 2001-2002. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section.

(xv) Effective February 1, 2002, except for residential habilitation services provided in family care homes which will not receive a trend, facilities will receive an amount that they would have received if the trend factor in subparagraph (xiv) of this paragraph for the fee period July 1, 2001 to June 30, 2002 were increased in the amount of 3.0 percent. The trend factor in effect for the fee period ending June 30, 2002 shall be deemed to be increased in the amount of 3.0 percent. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section.

(xvi) 3.69 percent to trend 2001-2002 costs to 2002-2003. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section. For agency sponsored family care, the agency must pay the trend related to the difficulty of care payment to the individual family care provider.

(xvii) Effective February 1, 2003, facilities will receive an amount that they would have received if the trend factor in subparagraph (xvi) of this paragraph for the fee period July 1, 2002 to June 30, 2003 were increased in the amount of 3.0 percent. The trend factor in effect for the fee period ending June 30, 2003 shall be deemed to be increased in the amount of 3.0 percent. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section.

(xviii) 3.43 percent to trend 2002-2003 costs to 2003-2004. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section. For agency-sponsored family care, the agency must pay the trend related to the difficulty of care payment to the individual family care provider.

(xix) Effective February 1, 2004, facilities will receive an amount that they would have received if the trend factor in subparagraph (xviii) of this paragraph for the fee period July 1, 2003 to June 30, 2004 were increased in the amount of 3.12 percent. The trend factor in effect for the fee period ending June 30, 2004 shall be deemed to be increased in the amount of 3.12 percent. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section.

(xx) 3.20 percent to trend 2003-2004 costs to 2004-2005. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section. For agency sponsored family care, the agency must pay the trend related to the difficulty of care payment to the individual family care provider.

(xxi) Effective February 1, 2005, facilities will receive an amount that they would have received if the trend factor in subparagraph (xx) of this paragraph for the fee period July 1, 2004 to June 30, 2005 were increased in the amount of 1.1 percent. The trend factor in effect for the fee period ending June 30, 2005 shall be deemed to be increased in the amount of 1.1 percent. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section.

(xxii) 3.33 percent to trend 2004-2005 costs to 2005-2006. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section. For agency sponsored family care, the agency must pay the trend related to the difficulty of care payment to the individual family care provider.

(xxiii) Effective February 1, 2006, facilities will receive an amount that they would have received if the trend factor in subparagraph (xxii) of this paragraph for the fee period July 1, 2005 to June 30, 2006 were increased in the amount of 2.0 percent. The trend factor in effect for the fee period ending June 30, 2006 shall be deemed to be increased in the amount of 2.0 percent. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section.

(xxiv) 3.03 percent to trend 2005-2006 costs to 2006-2007. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section. For agency sponsored family care, the agency must pay the trend related to the difficulty of care payment to the individual family care provider.

(xxv) 2.97 percent to trend 2006-2007 costs to 2007-2008. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section. For agency sponsored family care, the agency must pay the trend related to the difficulty of care payment to the individual family care provider.

(xxvi) 3.52 percent to trend 2007-2008 costs to 2008-2009. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section. For agency sponsored family care, the agency must pay the trend related to the difficulty of care payment to the individual family care provider.

(xxvii) 0.00 percent to trend 2008-2009 costs to 2009-2010.

(xxviii) Effective February 1, 2010, facilities shall receive an amount that they would have received if the trend factor in subparagraph (xxvii) of this paragraph for the price or fee period of July 1, 2009 through June 30, 2010 had been 3.06 percent. The trend factor in effect for the price or fee period ending June 30, 2010 shall be deemed to be the 3.06 percent full annual trend. Retention of the proceeds attributable to the application of the trend factor increase shall be contingent upon the provider reporting the use of the funds in the form and format specified by the commissioner. In addition, for agency sponsored family care, the agency must pay the trend related to the difficulty of care payment to the individual family care provider.

(xxix) 2.08 percent to trend 2009-2010 costs to 2010-2011. Retention of the proceeds attributable to the application of the trend factor increase shall be contingent upon the provider reporting the use of the funds in the form and format specified by the Commissioner. In addition, for agency sponsored family care, the agency must pay the trend factor related to the difficulty of care payment to the individual family care provider.

(xxx) Where appropriate, the commissioner shall use some combination in whole or in part of the yearly components to adjust any cost or budget report data into the appropriate fee period.

(xxxi) Once reimbursable costs are determined in accordance with this section, OPWDD shall apply an appropriate combined trend factor to the HCBS residential habilitation costs.

(i) 3.53 percent to trend calendar 1987 costs to calendar year 1988.

(ii) 5.71 percent to trend calendar 1988 costs to calendar year 1989.

(iii) 7.51 percent to trend calendar 1989 costs to calendar year 1990.

(iv) 6.24 percent to trend calendar 1990 costs to calendar year 1991.

(v) 4.85 percent to trend calendar 1991 costs to calendar year 1992.

(vi) 3.73 percent to trend calendar 1992 costs to calendar year 1993.

(vii) 3.79 percent to trend calendar 1993 costs to calendar year 1994.

(viii) 3.16 percent to trend calendar 1994 costs to calendar year 1995.

(ix) To trend calendar 1995 costs to calendar year 1996:

(x) Except for residential habilitation services provided in family care homes which will not receive a trend, 5.23 percent to trend calendar 1996 costs to calendar year 1997.

(xi) Except for residential habilitation services provided in family care homes which will not receive a trend, 2.88 percent to trend calendar 1997 costs to calendar year 1998. The application of this trend factor shall include services provided in accordance with paragraph (c)(2) of this section.

(xii) Except for residential habilitation services provided in family care homes which will not receive a trend, 3.19 percent to trend calendar 1998 costs to calendar year 1999. The application of this trend factor shall include services provided in accordance with paragraph (c)(2) of this section.

(xiii) Except for residential habilitation services provided in family care homes which will not receive a trend, 2.90 percent and an enhanced trend of 2.10 percent to trend calendar 1999 costs to calendar year 2000. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section.

(xiv) Except for residential habilitation services provided in family care homes which will not receive a trend, 3.52 percent to trend calendar 2000 costs to calendar year 2001. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section.

(xv) Effective February 1, 2002, except for residential habilitation services provided in family care homes which will not receive a trend, facilities will receive an amount that they would have received if the trend factor in subparagraph (xiv) of this paragraph for calendar year 2001 were increased in the amount of 3.0 percent. The trend factor in effect for the fee period ending December 31, 2001 shall be deemed to be increased in the amount of 3.0 percent. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section.

(xvi) 3.69 percent to trend calendar 2001 costs to calendar year 2002. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section. For agency sponsored family care, the agency must pay the trend related to the difficulty of care payment to the individual family care provider.

(xvii) Effective February 1, 2003, facilities will receive an amount that they would have received if the trend factor in subparagraph (xvi) of this paragraph for calendar year 2002 were increased in the amount of 3.0 percent. The trend factor in effect for the fee period ending December 31, 2002 shall be deemed to be increased by 3.0 percent. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section.

(xviii) 3.43 percent to trend calendar 2002 costs to calendar year 2003. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section. For agency sponsored family care, the agency must pay the trend related to the difficulty of care payment to the individual family care provider.

(xix) Effective February 1, 2004, facilities will receive an amount that they would have received if the trend factor in subparagraph (xviii) of this paragraph for calendar year 2003 were increased in the amount of 3.12 percent. The trend factor in effect for the fee period ending December 31, 2003 shall be deemed to be increased in the amount of 3.12 percent. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section.

(xx) 3.20 percent to trend calendar 2003 costs to calendar year 2004. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section. For agency sponsored family care, the agency must pay the trend related to the difficulty of care payment to the individual family care provider.

(xxi) Effective February 1, 2005, facilities will receive an amount that they would have received if the trend factor in subparagraph (xx) of this paragraph for calendar year 2004 were increased in the amount of 1.1 percent. The trend factor in effect for the fee period ending December 31, 2004 shall be deemed to be increased in the amount of 1.1 percent. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section.

(xxii) 3.33 percent to trend calendar 2004 costs to calendar year 2005. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section. For agency sponsored family care, the agency must pay the trend related to the difficulty of care payment to the individual family care provider.

(xxiii) Effective February 1, 2006, facilities will receive an amount that they would have received if the trend factor in subparagraph (xxii) of this paragraph for calendar year 2005 were increased in the amount of 2.0 percent. The trend factor in effect for the fee period ending December 31, 2005 shall be deemed to be increased in the amount of 2.0 percent. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section.

(xxiv) 3.03 percent to trend calendar 2005 costs to calendar year 2006. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section. For agency sponsored family care, the agency must pay the trend related to the difficulty of care payment to the individual family care provider.

(xxv) From February 1, 2007 to December 31, 2007, facilities will be reimbursed operating costs that result in a full annual trend factor of 2.97 percent for the fee period. On January 1, 2008, the trend factor for the previous fee period shall be deemed to be the 2.97 percent full annual trend. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section. For agency sponsored family care, the agency must pay the trend related to the difficulty of care payment to the individual family care provider.

(xxvi) From February 1, 2008 to December 31, 2008, facilities will be reimbursed operating costs that result in a full annual trend factor of 3.52 percent for the fee period. On January 1, 2009, the trend factor for the previous fee period shall be deemed to be the 3.52 percent full annual trend. The application of these trend factors shall include services provided in accordance with paragraph (c)(2) of this section. For agency sponsored family care, the agency must pay the trend related to the difficulty of care payment to the individual family care provider.

(xxvii) 0.00 percent to trend calendar 2008 costs to calendar year 2009.

(xxviii) Effective February 1, 2010, facilities shall receive an amount that they would have received if the trend factor in subparagraph (xxvii) of this paragraph for the price or fee period of January 1, 2009 through December 31, 2009 had been 3.06 percent. The trend factor in effect for the calendar year price or fee period ending December 31, 2009 shall be deemed to be the 3.06 percent full annual trend. Retention of the proceeds attributable to the application of the trend factor increase shall be contingent upon the provider reporting the use of the funds in the form and format specified by the commissioner. In addition, for agency sponsored family care, the agency must pay the trend related to the difficulty of care payment to the individual family care provider.

(xxix) From February 1, 2010 to December 31, 2010, facilities shall be reimbursed operating costs that result in a full annual trend factor of 2.08 percent for the calendar year price or fee period. For providers operating both individual residential alternatives (IRA) and community residences (CR) before January 1, 2010, the trend factor shall be applied to the allowable operating costs contained in the initial consolidated IRA/CR price in effect on January 1, 2010 instead of December 31, 2009. The trend factor in effect for the price or fee period ending December 31, 2010 shall be deemed to be the 2.08 percent full annual trend. Retention of the proceeds attributable to the application of the trend factor increase shall be contingent upon the provider reporting the use of the funds in the form and format specified by the commissioner. In addition, for agency sponsored family care, the agency must pay the trend related to the difficulty of care payment to the individual family care provider.

(xxx) Where appropriate, the commissioner shall use some combinations in whole or in part of the yearly components to adjust any cost or budget report data into the appropriate fee period.

(xxxi) Once reimbursable costs are determined in accordance with this section, the OPWDD shall apply an appropriate trend factor to the HCBS services costs. Such trend factors shall be applied only to operating costs.

(i) Effective February 1, 2010, providers shall receive an amount that they would have received if the trend factor of 3.06 percent had been incorporated into the standard regional fees on February 1, 2009. The trend factor in effect for the period February 1, 2009 through December 31, 2009 shall be deemed to be the 3.06 percent full annual trend. Retention of the proceeds attributable to the application of the trend factor increase shall be contingent upon the provider reporting the use of the funds in the form and format specified by the commissioner.

(ii) From February 1, 2010 to December 31, 2010 providers shall be reimbursed operating costs that result in a full annual trend factor of 2.08 percent for the 2010 calendar year fee period. The trend factor in effect for the annual period ending December 31, 2010 shall be deemed to be the 2.08 percent full annual trend. Retention of the proceeds attributable to the application of the trend factor increase shall be contingent upon the provider reporting the use of the funds in the form and format specified by the commissioner.

(i) Effective February 1, 2010, providers shall receive an amount that they would have received if the trend factor of 3.06 percent had been incorporated into the fees on April 1, 2009. The trend factor in effect for the annual period ending March 31, 2010 shall be deemed to be the 3.06 full annual trend. Retention of the proceeds attributable to the application of the trend factor increase shall be contingent upon the provider reporting the use of the funds in the form and format specified by the commissioner.

(ii) 2.08 percent to trend 2009-2010 to 2010-2011. Retention of the proceeds attributable to the application of the trend factor increase shall be contingent upon the provider reporting the use of the funds in the form and format specified by the commissioner.

(i) Determination of program surplus/deficit group designation. A determination shall be made as to whether each provider has a program surplus or deficit, for the combined total of all of its community residence and day treatment programs and all individualized residential alternative and at home residential habilitation and day habilitation services. Surplus/deficit shall equal gross revenue (less any prior period adjustments) minus allowable costs.

(ii) Determination of a calculated administration percentage group. A determination shall be made of a provider's calculated administration percentage, where administration percentage shall equal the sum of agency administration plus the program administration divided by the result of total program cost minus the sum of capital costs, agency administration and program administration. There shall be five group designations that express the calculated administration percentage as a departure from the regional average percentage for all provider agencies within a total program cost size designation. Those percentages centered around the average are designated with the abbreviation AVG. There are also two group designations for percentages over the average, abbreviated OA2 and OA1 and two group designations for under the average, abbreviated UA2 and UA1. These abbreviations appear in subparagraph (iii) of this paragraph as well as in the following regional tables. Each provider's assignment to one of the five group designations shall be based on the provider's calculated administration percentage, total program cost and elected or assigned region (refer to section 686.13[c][1][vii] of this Title). Each provider's administration percentage group designation shall be determined using the following tables.

REGION ONE

Program Cost in Millions of Dollars (< less than; > greater than)

REGION TWO

Program Cost in Millions of Dollars (< less than; > greater than)

REGION THREE

Program Cost in Millions of Dollars (< less than; > greater than)

(iii) Determination of the efficiency adjustment percentage. Each provider shall be assigned an efficiency adjustment percentage value from the following table, based on the surplus/deficit group designation and the administration percentage group designation. This efficiency adjustment percentage shall be applied to costs reimbursed for administration in the fees for residential habilitation and day habilitation services.

(i) Providers whose employee health care benefits are at or above the benchmark shall receive an amount equaling 3.0 percent of the operating costs contained in the rate in effect on December 31, 2005 net of any funding provided pursuant to paragraph (4) of this subdivision. Providers which receive this 3.0 percent increase may not apply for employee health care funding described in subparagraph (ii) of this paragraph.

(ii) Providers whose employee health care benefits and below the benchmark may apply to OPWDD for additional funding as follows:

(i) Providers whose employee health care benefits are at or above the benchmark shall receive an amount equaling 3.0 percent of the operating costs contained in the rate in effect on December 31, 2005, adjusted for the 21-month period from April 1, 2004 through December 31, 2005. Providers which receive this 3.0 percent increase may not apply for employee health care funding described in subparagraph (ii) of this paragraph.

(ii) Providers whose employee health care benefits are below the benchmark may apply to OPWDD for additional funding as follows:

(i) The annual allocation at the $2,500 level is determined by OPWDD based on the total number of employee included in the provider's approved HCE II application multiplied by $2,500. Funding at the $2,500 level is available to providers which:

(ii) The annual allocation at the $425 level is determined by OPWDD based on the total number of employees included in the provider's approved HCE II application multiplied by $425. Funding at the $425 level is available to providers which:

(i) Providers deemed eligible for HCE III funding at the benchmark level shall receive an amount equaling 3.0 percent of the operating costs exclusive of any HCE III component contained in the fee or price in effect on January 1, 2008 net of any funding provided pursuant to subparagraph (iii) of this paragraph. A provider eligible for HCE III funding at the benchmark level will receive a 1.0 percent funding increase in all its programs and services eligible under this Chapter if the provider notified OPWDD by October 31, 2007 that it was declining the 3.0 percent funding level increase and electing instead to receive a 1.0 percent funding level increase in all its programs and services eligible under this Chapter. Providers which receive this 3.0 percent of 1.0 percent funding level increase may not apply for employee health care funding described in subparagraph (ii) of this paragraph.

(ii) Providers deemed eligible for HCE III funding below the benchmark level may apply to OPWDD to receive an amount equaling 1.0 percent of the operating costs exclusive of any HCE III component contained in the fee or price in effect on January 1, 2008 net of any funding provided pursuant to subparagraph (iii) of this paragraph.

(iii) A provider approved to receive HCE III funding pursuant to subparagraph (i) or (ii) of this paragraph shall receive an amount that would have been paid if the HCE III initiative had been implemented April 1, 2007.

(i) Providers eligible for HCA IV and HCA V funding at the benchmark level.

(ii) Providers eligible for HCA IV and HCA V funding below the benchmark level may apply to OPWDD to receive this funding.

(i) Effective November 1, 2009, for services and programs described in paragraphs (b)(1)-(18), and subdivisions (c) and (e) and (h) of this section, benchmark providers shall be eligible and non-benchmark providers with approved applications shall be eligible to receive additional funding for HCA IV in an amount that would have been received for the period of April 1, 2008 through October 31, 2009 if the applicable increment had been implemented on April 1, 2008. Effective November 1, 2009, benchmark providers shall be eligible and non-benchmark providers with approved applications shall be eligible to receive additional funding for HCA V in an amount that would have been received for the period of April 1, 2009 through October 31, 2009 if the applicable increment had been implemented on April 1, 2009.

(ii) Effective November 1, 2009, for services and programs described in subdivisions (a), (d) and (aa) of this section, benchmark providers shall be eligible and non-benchmark providers with approved applications shall be eligible to receive additional funding for HCA IV in an amount that would have been received for the period of April 1, 2008 through December 31, 2009 if the applicable increment had been implemented on April 1, 2008. Effective November 1, 2009, benchmark providers shall be eligible and non-benchmark providers with approved applications shall be eligible to receive additional funding for HCA V in an amount that would have been received for the period of April 1, 2009 through December 31, 2009 if the applicable increment had been implemented on April 1, 2009. Non-benchmark providers may apply for this funding by following the application process described in subparagraph (3)(ii) of this subdivision.

(iii) Effective November 1, 2009, for services and programs described in paragraphs (b)(19)-(21) of this section, benchmark providers shall be eligible and non-benchmark providers with approved applications shall be eligible to receive additional funding for HCA IV in an amount that would have been received for the period of April 1, 2008 through January 31, 2009 if the applicable increment had been implemented on April 1, 2008. Non-benchmark providers may apply for this funding by following the application process described in subparagraph (3)(ii) of this subdivision.

(iv) Nothing in this paragraph shall entitle a provider to receive payment for services which have not been provided.

(i) Effective January 1, 2010, for services and programs described in paragraphs (b)(1)-(18) and subdivisions (c), (e) and (h) of this section and as applicable to each provider and to each program, the health care adjustments (HCE I through III and HCA IV and V) included in the price shall be consolidated into a single discrete amount. For purposes of determining this amount, OPWDD shall combine the HCE and HCA components contained in the initial price in effect on January 1, 2010. OPWDD shall use this fixed amount as the HCA payment for the price periods beginning on or after January 1, 2010.

(ii) Effective January 1, 2010, with the consolidation of the health care adjustments, non-benchmark providers shall use HCE I, II and III funds first to either offset health care premium increases and/or to maintain benefits that were established and funded with previous HCE I, II and III receipts. Remaining funds shall be used to establish or enhance employee health care related benefits and/or to reduce employee out-of-pocket health care related expenses. Non-benchmark providers shall continue to use HCA IV and V funds first to offset health care premium increases. Remaining funds shall be used to establish or enhance employee health care related benefits and/or to reduce employee out-of-pocket health care related expenses. Health care enhancement/adjustment funds included in prices for services delivered on or after July 6, 2011 shall be used by non-benchmark providers for the purposes described in this subparagraph and/or for any other options that continue and/or enhance existing health care benefits and/or improve the recruitment and/or retention of the provider's lower paid employees. However, in using these funds accordingly, non-benchmark providers may establish which priorities serve the needs of such employees. Additionally, on July 6, 2011, health care enhancement/adjustment funding shall be included in the reimbursable cost category of fringe benefits in the price.

(i) Providers eligible for HCA VI funding at the benchmark level.

(ii) Providers eligible for HCA VI funding below the benchmark level may apply to OPWDD to receive this funding.

(iii) Benchmark providers shall be eligible and non-benchmark providers with approved applications shall be eligible to receive additional funding for HCA VI in an amount that they would have received if the health care adjustment VI had been in effect for the period from April 1, 2010 through September 30, 2010. Nothing in this subparagraph shall entitle a provider to receive payment for services which have not been provided.

(i) Provider - OPWDD or an authorized vendor of Medicaid service coordination which has been specifically authorized by OPWDD to provide the home and community-based services (HCBS) waiver service known as family education and training.

(ii) Eligible persons - Those persons meeting the criteria set forth at paragraph (2) of this subdivision.

(iii) Family education and training services - The training provided by qualified personnel to the family of those who are under the age of 18, and who are enrolled HCBS waiver participants. Such training focuses on enhancing the family's decision making capacity through providing orientations regarding the nature and impact of the person's developmental disability upon the person and the family, and by educating the family regarding service alternatives (e.g., learning about the services in their community, dealing with transition to adult services, future planning and placement planning). The goal of any presentation shall not be to sell any product or service.

(iv) Qualified personnel - Those parties who are knowledgeable in the presentation topic (such as, but not limited to, self advocacy, self-determination, family life with a child with disabilities) and who conduct the family education and training session. Such parties may include qualified service coordinators (see subparagraph [a][1][iv] of this section), and clinicians with appropriate licensure/certification, or other recognized credentials appropriate to their discipline. It may also include those with expertise in such fields as law and/or finances and how the topics (consistent with the definition of family education and training services), pertain to persons with disabilities and their families.

(i) In order for the service to be reimbursable the person whose family is receiving the service shall be an enrolled HCBS waiver participant; and

(ii) The person whose family is receiving service shall be under the age of 18.

(i) Reimbursement to a provider of family education and training shall be on a fee for service basis.

(ii) Reimbursement for family education and training can be claimed on either a single family or group of families (up to a maximum of eight families) session basis.

(iii) A unit of service for a training session shall be a minimum of two hours. No more than two units of service per eligible person shall be provided on an annual basis to each family.

(iv) The service shall be reimbursed at a fee of $100 per unit for an individual family, and a fee of $50 per unit for training sessions involving 2-8 families.

(v) Effective November 1, 2009. In addition to the health care enhancements (HCE) I through III and health care adjustments (HCA) IV and V prospective add-ons to the fees which will be effective on January 1, 2010 as described in subparagraph (vi) of this paragraph, providers may be eligible to receive HCA IV and HCA V funding according to the catch-up provision described in subparagraph (n)(4)(ii) of this section.

(vi) Fees effective January 1, 2010. Effective January 1, 2010, there shall be an add-on to the fees described in subparagraph (iv) of this paragraph. Family education and training fees shall incorporate health care adjustments (HCE I through III and HCA IV and HCA V) equivalent to a 1.0 percent funding increase per adjustment applied to the fees sequentially to effect compounding of the adjustments. The resulting fees are $105.10 per unit for an individual family and $52.55 per unit for training sessions involving 2-8 families.

(vii) Effective February 1, 2010, the fee will be subject to a trend factor if one is specified in paragraph (i)(4) of this section.

(viii) Effective October 1, 2010, there shall be an add-on to the fees described in subparagraph (iv) of this paragraph. Family education and training fees shall incorporate health care adjustment (HCA) VI funding equivalent to a 1.0 percent increase applied to the fees in effect on April 1, 2010. The resulting fees are $111.68 per unit for an individual family and $55.84 per unit for training sessions involving 2-8 families.

(ix) Effective October 1, 2010 providers shall receive additional HCA VI funds in an amount that they would have received if the health care adjustment VI had been in effect from April 1, 2010 through September 30, 2010.

(x) Reimbursement for family education and training shall be contingent upon the services being delivered as specified in the person's individualized service plan.

(i) The following individuals are eligible to receive CH services:

(ii) Prior to October 1, 2014, no individual who lived in a residence certified or operated by OPWDD (including a family care home) was eligible to receive CH services.

(i) For all individuals (except for those who live in an Individualized Residential Alternative [IRA], a Community Residence [CR], or a family care home [FCH]), OPWDD shall approve persons for CH services based on the individual's relative need for supports for daily living and the individual's need for community-based activities.

(ii) For individuals who live in an IRA, CR or FCH, OPWDD shall approve persons for CH services based on the individual's need for community-based activities.

(i) Prior to August 1, 2011, notwithstanding any other provision of this Title, an ISP which identifies at home residential habilitation (AHRH) services shall be deemed to include CH services, with the same frequency and duration. The CH services shall be delivered in accordance with the parameters specified in the ISP for AHRH.

(ii) Prior to August 1, 2011, notwithstanding any other provision of this Title, the provider of CH services is not required to develop or review a CH plan if an AHRH plan is developed and reviewed in lieu of the CH plan. Prior to such date, CH services may be delivered in accordance with the AHRH plan in lieu of the CH plan.

(i) If the individual lives in a setting which is not certified or operated by OPWDD (e.g., a private home) or a FCH:

(ii) For individuals who live in an IRA or CR:

(i) the service start time and the service stop time;

(ii) the provision of at least one service/staff action delivered in accordance with the individual's CH plan;

(iii) for individuals who do not live in an IRA, CR or FCH; the ratio of individuals to staff at the time of service delivery; and

(iv) for individuals who live in an IRA, CR or FCH; whether the CH service is delivered on an individual or group basis.

(i) Community habilitation (CH) services may only be reimbursed if the services are delivered on weekdays and have a service start time prior to 3:00 p.m.

(ii) On a given weekday, a maximum of the following may be reimbursed:

(iii) Time spent receiving another Medicaid service shall not be counted toward billable service time in instances when the Medicaid service is received simultaneously with CH services (see section 635-10.4[b][3] of this Subpart). An exception is the provision of Medicaid Service Coordination (MSC), which may be received simultaneously with CH services.

(i) Self-direction or family direction in CH services is established to permit greater flexibility and freedom of choice in obtaining such services.

(ii) The management of these self-directed or family-directed services is described in a co-management agreement between the individual, the CH provider and, if one exists, an identified adult.

(iii) CH services which are self-directed are available when all parties to the co-management agreement concur that the individual receiving the CH services:

(iv) CH services which are family-directed are available when all parties to the co-management agreement concur that an adult receiving the CH services does not qualify for self-direction and there is an identified adult who is willing and able to make informed choices and co-manage the family-directed services for the benefit of the person.

(v) Eligible individuals and identified adults (if they exist) assume the responsibilities as mutually agreed to by the provider, individual, and identified adult in the co-management agreement. The co-management agreement shall specify the responsibilities of the provider, the individual, and any identified adult who will be managing or assisting in the management of the self-directed or family-directed services. The co-management agreement shall be documented in the individual's record.

(vi) The following responsibilities (except as noted in subparagraph [vii] of this paragraph) shall be the individual's and/or the identified adult's:

(vii) The provider may agree to assist with one or more of the responsibilities specified in subparagraph (vi) of this paragraph. The provider's agreement to assist with those responsibilities shall be documented in the individual's record.

(viii) The provider's responsibilities shall include:

(ix) The following requirement applies to self-directed and family-directed CH services. The individual receiving the CH service, any identified adults, and the provider shall review their respective management responsibilities to evaluate whether self-direction or family direction continues to be appropriate at least once every two years.

(x) The following requirement applies to individuals receiving family-directed services. If the individual receives any services other than the CH services which are certified, authorized, operated or funded by OPWDD, the participation of a representative of at least one such service is required at a review of the individualized service plan (ISP) on at least an annual basis.

(xi) All agencies authorized by OPWDD to provide CH are authorized to provide self-direction and family direction as an option under CH.

(i) Hourly fee schedule structure. Hourly fees are based on the following:

(ii) Transitional hourly fees.

(iii) Fee schedules.

(i) Effective October 1, 2012 providers of CH services must ensure that at least 90 percent of the Medicaid revenue billed and received for the provision of CH services is used to fund the direct support of individuals within the CH program. For the purpose of this calculation, such direct support includes allowable administrative expenses. Any Medicaid revenue below such 90 percent not spent on CH services is subject to recoupment.

(ii) Effective January 1, 2014 providers of CH services must ensure that at least 95 percent of the Medicaid revenue billed and received for the provision of CH services is used to fund the direct support of individuals within the CH program. For the purpose of this calculation, such direct support includes allowable administrative expenses. Any Medicaid revenue below such 95 percent not spent on CH services is subject to recoupment.

(iii) The fees contain funding for clinical oversight. Clinical oversight includes the training and mentoring of direct support staff on diagnostic issues, care plan/habilitation plan issues and behavior management issues, as well as the troubleshooting of any plan issues discovered during plan reviews. Effective October 1, 2012, clinicians must document discussions with direct support staff and include that documentation as supplemental clinical notes in individuals' files at least annually. The documentation requirement will be applicable for any 12 month period in which an individual is enrolled in CH for the entire 12 month period and has received any CH service during that period.

(i) OPWDD shall approve the person's need for CH II services prior to the receipt of services. OPWDD shall approve persons for CH II services based on the compatibility of the individual with available CH II services and the potential economy and efficiency of the delivery of CH II compared to residential habilitation and day habilitation services.

(ii) The individual must reside in a supervised IRA or supervised CR.

(i) The unit of service is one month. Providers may bill for a full month or for a half month.

(ii) For a full month, the provider must document the delivery of:

(iii) For a half month, the provider must document the delivery of:

(iv) CH II services delivered when an individual is admitted to a hospital, nursing home, intermediate care facility for persons with developmental disabilities (ICF/DD) or other certified, licensed or government funded residential setting may not be used to meet the minimum requirements for service delivery established in subparagraph (ii) or (iii) of this paragraph. CH II services delivered on the day of admission or on the day of discharge may be used to meet the minimum standards if the CH II services are delivered prior to admission or after discharge and the services are not delivered in those settings.

(v) During the month or half month that the individual is receiving CH II, no provider will be reimbursed for the delivery of any of the following services to the individual: residential habilitation, group day habilitation, individual day habilitation, prevocational services, supported employment services, blended services (which are a combination of day habilitation, prevocational services and/or supported employment services), comprehensive services (which are a combination of IRA residential habilitation services and day habilitation), and consolidated supports and services.

(i) operates at least one facility certified by OPWDD which is designated as a supervised IRA or supervised CR; and

(ii) is authorized to provide group day habilitation.

(i) The management of self-directed or family-directed services is described in a co-management agreement between the individual, the CH II provider and, if one exists, an identified adult as that term is used in subparagraph (ii) of this paragraph.

(ii) CH II services which are self-directed are available when all parties to the co-management agreement concur that the individual receiving the CH II services:

(iii) CH II services which are family-directed are available when all parties to the co-management agreement concur that an adult receiving the CH II services does not qualify for self-direction and there is an identified adult who is willing and able to make informed choices and co-manage the family-directed services for the benefit of the person.

(iv) Eligible individuals and identified adults (if they exist) assume the responsibilities as mutually agreed to by the provider, individual, and identified adult in the co-management agreement. The co-management agreement shall specify the responsibilities of the provider, the individual, and any identified adult who will be managing or assisting in the management of the self-directed or family-directed services. The co-management agreement shall be documented in the individual's record.

(v) The following responsibilities (except as noted in subparagraph [vi] of this paragraph) shall be the individual's and/or the identified adult's:

(vi) The provider may agree to assist with one or more of the responsibilities specified in subparagraph (v) of this paragraph. The provider's agreement to assist with those responsibilities shall be documented in the individual's record.

(vii) The provider's responsibilities shall include:

(viii) The individual receiving the CH II service, any identified adults, and the provider shall review their respective management responsibilities to evaluate whether self-direction or family direction continues to be appropriate at least once every two years.

(ix) All agencies authorized by OPWDD to provide CH II are authorized to provide self-direction and family direction as an option under CH II.

(i) On October 1, 2012, for each agency which is authorized to provide CH II (see paragraph [3] of this subdivision), OPWDD shall establish an individual CH II price that represents an amalgamation of the provider's IRA price and its group day habilitation price. It shall be calculated as follows:

(ii) Subsequent prices. In the event that either the IRA price or the group day habilitation price used to calculate the individual CH II price is revised, the CH II price shall be revised accordingly.

(iii) The prices determined in accordance with this paragraph shall not be considered final unless approved by the director of the Division of the Budget.

(iv) The individual CH II price determined through the application of this paragraph may be corrected or appealed pursuant to either section 686.13(h) or (i) of this Title, except that the determination following a first level appeal process shall be the commissioner's final decision.

(i) the individual must express an interest in competitive employment or self-employment. Competitive employment or self-employment must be identified as a goal in the individual's individualized service plan (ISP);

(ii) the individual must be enrolled in the Home and Community Based Services (HCBS) Waiver; and

(iii) delivery of the service must be in the best interests of the individual.

(i) The region in which the individual lives - Region 1, Region 2 or Region 3.

(ii) The number of individuals being served simultaneously - Individual (1) or Group (serving two or four individuals; or, for job readiness training, 10 individuals). Group size shall be limited to no more than four individuals, with the exception of job readiness training, which can include up to 10 individuals.

(i) If the service provider considers that an individual needs more than 12 months and/or additional hours to complete the service, the service provider may submit a written request to OPWDD, in the form and format specified by OPWDD, for an extension(s) of a period of time and/or number of hours.

(ii) OPWDD's decision on the extension request will be based on the following:

(iii) In the event that an extension(s) is authorized by OPWDD, the extension(s) shall not exceed 12 months and 278 hours of service.

(iv) The service provider shall maintain documentation of OPWDD's authorization of the extension.

(i) time when staff are providing pathway to employment allowable activities listed in section 635-10.4(h)(1) of this Subpart in accordance with the individual's pathway to employment service delivery plan; and

(ii) time when staff are developing the pathway to employment service delivery plan.

(i) Time spent receiving another Medicaid service shall not be counted toward pathway to employment billable service time in instances when the Medicaid service is received simultaneously with one or more pathway to employment allowable activities that involve direct service provision to the individual (see section 635-10.4[h][1] of this Subpart). An exception is the provision of Medicaid Service Coordination (MSC), which may be provided simultaneously with allowable activities that involve direct service provision to the individual.

(ii) Pathway to employment billable service time for allowable activities that involve indirect service provision to the individual shall be limited to 60 hours of billable service time (see section 635-10.4[h][1][ii] of this Subpart).

(iii) Pathway to employment billable service time for job readiness training specified in section 635-10.4(h)(1)(i) (a) of this Subpart shall be limited to 20 hours of billable service time.

(i) The service provider shall maintain documentation that the individual receiving pathway to employment services has received the services in accordance with the individual's ISP and pathway to employment service delivery plan (see section 635-10.4[h][5] of this Subpart).

(ii) For each continuous indirect service provision period/session, the service provider shall document the service start time and the service stop time, the ratio of individuals to staff at the time of the indirect service provision and the provision of all allowable activities that were delivered in accordance with the individual's pathway to employment service delivery plan.

(iii) For each continuous direct service provision period/session, the service provider shall document the service start time and the service stop time, the ratio of individuals to staff at the time of the direct service provision and the provision of at least one allowable activity that was delivered in accordance with the individual's pathway to employment service delivery plan.

(iv) The service provider must maintain a copy of the letter of agreement between OPWDD and the NYS Education Department related to pathway to employment services.

(i) retain receipts to support allowable expenditures; and

(ii) bill for allowable expenditures in $10 increments.

(i) the individual's choice of CTS must be documented in their Life Plan in the format specified by OPWDD; and

(ii) the individual must be enrolled in the Home and Community Based Services (HCBS) Waiver.

(i) the total of CTS allowable expenses, rounded down to the nearest $10; or

(ii) $5,000.

(i) time when the service provider is providing SEMP services as specified in this Subpart in support of the individual's supported employment /staff action plan; and

(ii) time when service provider is developing the supported employment staff action plan.

(i) Allowable SEMP services provided without the individual present may be delivered when the individual is simultaneously receiving another direct Medicaid service. Allowable SEMP services provided with the individual present must not be delivered when the individual is simultaneously receiving another direct Medicaid service (except for Care Management).

(ii) Intensive and Extended SEMP cannot be delivered to an individual on the same date of service.

(i) The service provider must maintain documentation and a monthly summary to show that an individual received SEMP services in accordance with their Life Plan and supported employment staff action plan.

(ii) For each continuous SEMP service session, the service provider must document at least one allowable service delivered during the SEMP service session.

(iii) The service provider must maintain documentation that funding is not available or not required from NYS ACCES-VR.

(iv) The service provider must report quarterly on Supported Employment (SEMP) data and related requested information in a form and format specified by OPWDD.

(i) the individual must have a goal to develop pre-employment skills, which must be identified in the individual's individualized service plan (ISP);

(ii) delivery of the service will assist the individual with improving participation in the general work force; and

(iii) delivery of the service must be in the best interests of the individual.

(i) The agency can bill a full unit of service when the agency delivers and documents:

(ii) The agency can bill a half unit when the agency delivers and documents at least:

(iii) The following cannot be counted as part of the program day duration:

(iv) During the period beginning on July 22, 2020 and ending on October 14, 2020, due to the COVID-19 Public Health Emergency, site-based prevocational services may be delivered, and payment for such services made, for durations set forth in guidance issued by the OPWDD Commissioner.

(v) Beginning on October 15, 2020 and ending upon revocation by OPWDD, due to the COVID-19 Public Health Emergency, site-based prevocational services may be delivered, and payment for such services made, for durations set forth in guidance issued by the OPWDD Commissioner.

(i) On a given weekday, a maximum of the following may be reimbursed for site based prevocational services:

(ii) Delivery of site based prevocational services is not permitted on a weekend day for individuals residing in IRAs, CRs, and Family Care Homes.

(iii) On a given weekend day, a maximum of the following may be reimbursed for site based prevocational services for individuals not residing in IRAs, CRs, and Family Care Homes:

(iv) Allowable Community Based Prevocational services provided without the individual present may be delivered when the individual is simultaneously receiving another direct Medicaid service. Allowable Site Based Prevocational services provided with the individual present may not be delivered when the individual is simultaneously receiving another direct Medicaid service. An exception is the provision of Medicaid Service Coordination/Care Coordination, which may be provided simultaneously with allowable Site Based Prevocational services activities. Existing Paragraph 635-10.5(ag)(5) is renumbered as follows:

(i) For individuals who were receiving prevocational services at a site before July 1, 2015, prevocational services identified in the individual's ISP are deemed to be site based prevocational services effective July 1, 2015. The service provider must identify site based prevocational services in the ISP by the next ISP review, or December 31, 2015, whichever is sooner.

(ii) For individuals receiving prevocational services at a site and in the community before July 1, 2015, the service provider must identify both site based prevocational services and community prevocational services in the ISP by the next ISP review, or December 31, 2015, whichever is sooner.

(iii) The service provider must develop a service delivery plan in the form and format specified by OPWDD that guides the delivery of the service for each individual receiving services. The plan must be documented, reviewed, and updated in accordance with section 635-99.1 of this Part.

(iv) The service provider shall maintain documentation that the individual receiving site based prevocational services has received the services in accordance with the individual's ISP and service delivery plan.

(v) For each continuous site based prevocational service period/session, the service provider shall document the service start time and the service stop time, and the provision of at least one allowable activity that was delivered in accordance with the service delivery plan.

(i) The total monthly number of site-based prevocational services units claimed during the COVID-19 Public Health Emergency do not exceed the average monthly units for each service claimed from the period of July 1, 2019 through December 31, 2019;

(ii) The combined average monthly revenue for day habilitation, site based prevocational services, community-based prevocational services, and community habilitation during the COVID-19 Public Health Emergency claimed by the provider may not exceed the provider's combined average monthly revenue for those services for the period of July 1, 2019 through December 31, 2019;

(iii) Any claims in excess of the monthly averages from this period will be subject to immediate recoupment if the agency has submitted any claims during the month that do not meet the full program day duration requirements; and

(iv) Providers will continue to work in partnership with OPWDD to make more available non-center-based and telehealth modalities in an effort to increase community involvement of waiver enrollees and to protect the delivery of services during future emergencies. This notice is intended: to serve as both a notice of emergency adoption and a notice of proposed rule making. The emergency rule will expire November 28, 2020.

(i) The provider operates site-based prevocational services in a geographic area that meets Department of Health thresholds for program closure due to increased rates of COVID-19 cases or the local public health agency has required a program to close. This designation requires that center-based prevocational services are closed and that community-based prevocational services are operating at a reduced capacity. This authorization for the use of the modified billing rules will end with the de-designation of the area; or

(ii) The provider is not required to close its site-based prevocational services by either New York State or the local public health agency. However, the provider closes the program as a preemptive measure due to the elevated percentage of individuals and staff at a particular site that have either tested positive for COVID-19 or are required to quarantine because of close contact with a person who tests positive for COVID-19. These modifications to the program day durations associated with nonmandatory closures may be in effect for a period of up to fourteen (14) days for risk mitigation. Longer durations of the flexibilities (beyond fourteen days) would occur only where there is a subsequent designation of the region as being subject to closure or another period of quarantine is determined to be necessary. The agency must report the closure to OPWDD and demonstrate the need for the closure based on Incident Reporting Management Application (IRMA) reporting of positive COVID-19 cases among individuals and staff at the affected sites; and

(iii) Providers will continue to work in partnership with OPWDD to make more available non-center-based and telehealth modalities in an effort to increase community involvement of waiver enrollees and to protect the delivery of services during future emergencies.

(i) The individual must have a goal to develop employment and pre-employment skills identified in his or her individualized service plan (ISP)/life plan;

(ii) Delivery of the service will assist the individual with improving his or her participation in the general work force; and

(iii) Delivery of the service must be in the best interests of the individual.

(i) On a given weekday, a maximum of the following may be reimbursed for community prevocational services:

(ii) on a given weekend day, a maximum of the following may be reimbursed for community prevocational services:

(iii) Allowable Community Based Prevocational services provided without the individual present may be delivered when the individual is simultaneously receiving another direct Medicaid service. Allowable Community Based Prevocational services provided with the individual present may not be delivered when the individual is simultaneously receiving another direct Medicaid service. An exception is the provision of Medicaid Service Coordination/Care Coordination, which may be provided simultaneously with allowable Community Based Prevocational services activities.

(i) For individuals who were receiving prevocational services in the community before July 1, 2015, daily prevocational services identified in the individual's ISP are deemed to be hourly community prevocational services effective July 1, 2015. The service provider must identify community prevocational services and the associated unit of service change in the ISP by the next ISP review, or December 31, 2015, whichever is sooner.

(ii) For individuals who were receiving prevocational services at a site and in the community before July 1, 2015, the service provider must identify both site based prevocational services and community prevocational services in the ISP by the next ISP review, or December 31, 2015, whichever is sooner.

(iii) The service provider must develop a service delivery plan in the form and format specified by OPWDD that guides the delivery of the service for each individual receiving services. The plan must be documented, reviewed, and updated in accordance with section 635-99.1 of this Part.

(iv) The service provider shall maintain documentation that the individual receiving community prevocational services has received the services in accordance with the individual's ISP and service delivery plan.

(v) For each continuous community prevocational service period/session, the service provider shall document the service start time and the service stop time, the ratio of individuals to staff at the time of service provision and the provision of at least one allowable activity that was delivered in accordance with the service delivery plan.