New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIV - Office for People With Developmental Disabilities
Part 680 - Specialty Hospitals
Section 680.12 - Rate setting and financial reporting
Universal Citation: 14 NY Comp Codes Rules and Regs ยง 680.12
Current through Register Vol. 46, No. 39, September 25, 2024
(a) For the purposes of this section the following definitions shall apply:
(1)
Specialty hospital or facility shall mean
that program and site for which OPWDD has issued an operating certificate,
pursuant to Mental Hygiene Law article 16, to operate as a specialty hospital,
and for which the New York State Department of Social Services has issued a
Medicaid provider agreement.
(2)
Provider shall mean the individual, corporation, partnership
or other organization to which the OPWDD has issued an operating certificate,
pursuant to Mental Hygiene Law, article 16, to operate a specialty hospital,
and to which the New York State Department of Social Services has issued a
Medicaid provider agreement for such facility.
(3)
Alternate care determined
individual or ACD individual shall mean an individual
who has been determined not to require specialty hospital care after completion
of an independent utilization review, pursuant to section
680.9 of this
Part.
(4)
A newly certified
facility shall mean a facility which has been in operation less than
two years and has not yet submitted a cost report which covers a full 12 months
of operation for any rate period January 1st to December 31st or any other
12-month period designated by the commissioner according to section
680.12(b)(1)(ii) (b) of this Part.
(5)
Actual cost shall mean
the costs that were audited and stepped-down by OPWDD or its agent for the
specialty hospital and which are taken from the financial reports filed
annually in accordance with section 680.12(b)(1)(ii) of this Part and which
cover a full 12-month period of operation beginning 24 months prior to the
effective date of the rate period in question. For the rate period from June
10, 1988 to December 31, 1988, as stated in section 680.12(d)(3) of this Part,
the actual costs defined in the preceding sentence shall be taken from the
annual financial information filed by the provider for the calendar year 1985
with Blue Cross/Blue Shield of Greater New York.
(6)
Budget costs shall man
the financial information submitted by a provider in accordance with section
680.12(b)(1)(i) of this Part.
(7)
Reimbursable costs shall mean those actual or budget costs
which are determined, based on a line item review/desk audit process by OPWDD
or Blue Cross/Blue Shield of Greater New York, to be allowable in accordance
with section 680.12(d)(8) of this Part.
(8)
Operating costs shall
mean a facility's costs, other than capital costs or start-up costs, which
include personal service costs, administrative and general services costs, and
other than personal service (OTPS) costs.
(i)
Personal service costs include costs such as salaries, fringe benefits and
accrued vacation costs for employees of the specialty hospital; and costs of
persons performing services under contract to the specialty hospital. Services
refers to the provisions of routine and ancillary care of individuals admitted
to the specialty hospital in accordance with the provisions of this
Part.
(ii) Administrative and
general service costs refer to departments, divisions or other units which are
operated for the benefit of the specialty hospital as a whole, and includes
activities such as management, housekeeping, laundry, dietary services and
operation and maintenance of grounds and physical plant.
(iii) OTPS costs include, but are not limited
to, the costs of items such as food, minor equipment, supplies and materials,
travel, medications and utilities.
(9)
Capital costs shall mean
property costs subject to the limitations contained in this section, Subpart
635-6 of this Title and Medicare principles of reimbursement, except that costs
of ownership of real property shall not include principal or provider
equity.
(b) Reporting requirements.
(1) Financial
reports shall include the following:
(i)
Budget reports.
(a) Each provider intending
to operate a specialty hospital shall include budget reports in its application
to receive an operating certificate.
(b) The budget report shall cover a 12-month
period from January 1st to December 31st unless another time frame is specified
by the commissioner.
(c) If a
facility has undergone a change in its site specific certified capacity, the
commissioner may, at his discretion, request the provider to submit a budget
report subject to requirements listed in sections 680.12(b)(1)(i)
(b) and 680.12(b)(3)(ii) of this Part.
(ii) Financial and statistical reports.
(a) Each provider that operates a specialty
hospital certified by OPWDD shall, on an annual basis, complete and file with
the OPWDD and/or Blue Cross/Blue Shield of Greater New York, annual financial
reports and related statistical information in the form and format supplied by
OPWDD and/or Blue Cross/Blue Shield of Greater New York.
(b) Such report shall cover a 12-month period
from January 1st to December 31st, unless another time frame is specified by
the commissioner.
(c) Each such
report shall be forwarded so that it is received no later than 120 days after
the last day of the period which it covers, except as stated in section
680.12(4)(i) and (ii) of this Part.
(d) If a facility has undergone a change in
its site specific certified capacity, the commissioner may, at his discretion,
request the facility to submit the incremental/decremental cost data associated
with the capacity change. Such data shall comply with the requirements of
section 680.12(b)(3)(i) of this Part.
(2) Statistical reporting requirements for
specialty hospitals shall include, but not be limited to, the following:
(i) Each provider shall submit with its
annual financial report, statistical data relevant to program utilization and
in the form and format supplied by OPWDD or its agent, Blue Cross/Blue Shield
of Greater New York. Such data shall include a roster of individuals and their
utilization review status for the financial reporting period in question, a
listing of the actual number of service days for the specialty hospital and a
listing by individual of the total number of days any individual was on
alternate care determination status as defined in section 680.12(a)(3) of this
Part. This data will correspond to the identical time period of the financial
report.
(ii) Each provider shall,
upon the request of OPWDD, submit statistical data relevant to the
administration and operation of the program as determined by the commissioner.
Such data shall be submitted within the time frames specified in the
request.
(3)
Requirements for certification of financial reports and related statistical
information.
(i) Each provider shall complete
the required financial reports in accordance with generally accepted accounting
principles, unless other principles are specified by this Part or the
Medicare Provider Reimbursement Manual, commonly referred to
as HIM-15, published by the U.S. Department of Health and Human Services Health
Care Financing Administration (HCFA). The HIM-15 document is available from:
Health Care Financing Administration
Division of Communication Services
Production and Distribution Branch
Room 577, East High Rise Building
6325 Security Boulevard
Baltimore, MD 21207
(ii) The Medicare Provider
Reimbursement Manual may be reviewed in person during regular business
hours at the:
(a) NYS Department of State, 99
Washington Avenue, Albany, NY 12231; or by appointment at the
(b) NYS Office for People With Developmental
Disabilities, Office of Counsel, 44 Holland Avenue, Albany, NY 12229.
(iii) Financial reports
information shall be certified for their compliance with section
680.12(b)(3)(i) of this Part the provider's executive director or officer and
by an independent licensed public accountant or certified public accountant who
is not on the staff of the provider, on the staff of a program operated by the
provider, and who has no financial interest in the provider nor is a related
party as defined in Subpart 635-99 of this Title; and include a statement of
the findings and opinion of the certified public accountant or licensed public
accountant.
(iv) Budget reports
shall be certified for their fair representation of anticipated expenditures by
the provider's executive director or officer.
(4) Failure to file required financial and
statistical reports.
(i) The commissioner may
grant an extension of time of up to 30 days for filing the required reports if
OPWDD receives a written request for an extension from a provider, at least 15
days prior to the initial due date. Such request for extension shall document,
in writing, that the provider cannot file the report by the due date for
reasons beyond its control, and shall include an explanation of such
reasons.
(ii) The commissioner may
grant an additional extension of 30 days if the provider applies for an
extension in accordance with the procedure stated in section 680.12(b)(4)(i) of
this Part. The maximum allowable extension that may be granted will not exceed
60 days in total unless the commissioner, upon investigation, finds that
failure to report is beyond the control of the provider and/or enforcement of
the reporting time frame requirements would jeopardize the program's
operation.
(iii) If a provider
fails to file the required reports, on or before the due dates, taking into
account any granted extensions, the commissioner may, at his or her discretion,
reduce the specialty hospital's existing rate, exclusive of State-paid items,
by five percent for a period beginning on the first day of the month following
the due date of the required reports and continuing until the last day of the
calendar month in which the required information is received.
(iv) In the event that the rate for a
specific rate period cannot be developed so that it will be effective on the
first day of the rate period, due to the facility's not submitting the required
reports by the due date, the rate in existence on the last day of the rate
period (i.e., the length of time as determined by the
commissioner that an approved rate is valid) prior to the subject rate period,
will be in effect until such time as OPWDD can develop a new rate. The rate in
existence on the last day of the rate period may be reduced by five percent
according to the provisions of section 680.12(b)(4)(iii) of this
Part.
(v) When OPWDD develops a new
rate for a specialty hospital for which a rate was paid in accordance with
section 680.12(b)(4)(iv) of this Part, the rate developed will be effective on
the first day of the first month following receipt of the required reports. The
commissioner may, at his discretion and based on his finding that the factor(s)
causing the delay has/have been corrected, make the rate retroactive to the
beginning of the rate period in question if the provider makes such a request
within 60 days subsequent to submission of the delinquent report.
(5) Requirements for the revision
of financial reports shall include the following:
(i) In the event that OPWDD determines that
the required financial report is incomplete, inaccurate, incorrect or otherwise
unacceptable, the provider shall have 30 days from the date of its receipt of
notification to submit revised financial reports or additional data. Such data
or reports shall be certified by the provider's executive director or officer
and an independent licensed public accountant or certified public accountant
pursuant to the requirements stipulated in section 680.12(b)(3) of this
Part.
(ii) If the revised data
referred to in section 680.12(b)(5)(i) of this Part are not received within 30
days of the provider's receipt of notification, the facility's existing rate
may be reduced in accordance with section 680.12(b)(4)(iii) unless the
commissioner has granted an extension pursuant to section 680.12(b)(4)(i) or
(ii).
(iii) In the event the
provider discovers that the financial reports it has submitted are incomplete,
inaccurate or incorrect prior to receiving its new rate, the provider must
notify OPWDD that such error exists. The provider will have 30 days from the
date such notification is received by OPWDD to submit revised reports or
additional data. Such data or report shall meet the certification requirements
of the report being corrected. If the corrected data or report are received
within a reasonable time before the issuance of the rate, OPWDD shall
incorporate the corrected data or report into its computation of the rate
without the provider having to file an appeal application. However, OPWDD will
not accept the resubmission of a January 1-December 31, 2008 cost report
subsequent to January 1, 2011 for the purposes of the calculation of the rate
effective July 1, 2011 as described in clause (d)(5)(ii)(f) of
this section.
(iv) If the revised
data or report referred to in section 680.12(b)(5)(iii) of this Part are not
received within the time periods set forth in section 680.12(b)(5)(iii), the
facility's existing rate may be reduced in accordance with section
680.12(b)(4)(iii).
(c) Requirements of financial records.
(1) Each provider shall
maintain financial records which reflect all expenditures made and revenues
received for its operations.
(2)
Each provider shall complete and file with the New York State Department of
Health and/or its agent, annual financial and statistical report forms supplied
by the New York State Department of Health and/or its agent.
(3) The financial records shall include
separate accounts for each type of expense and revenue included on the annual
budget or annual cost report. Such subaccounts and control accounts as are
necessary for effective financial management may be established by the
specialty hospital. A separate expense and revenue account shall be established
to properly identify the expense and revenues directly and indirectly
attributable to ACD individuals.
(4) All such financial records and any
related records shall be subject to audit by the commissioner or his agent, the
Office of the State Comptroller, the State Department of Social Services and by
agencies of the Federal government as provided by law.
(d) Rates of payment made for specialty hospital services rendered to title XIX recipients shall be at the levels set forth in the approved New York Medicaid State Plan. The rates shall be contingent upon Federal financial participation (FPP) and approval.
(e) Audits.
(1) Each provider shall maintain the
statistical and financial records which formed the basis of the reports
submitted to the commissioner or his agent for six years from the date on which
the reports were submitted or due, whichever is later.
(2) All such records shall be subject to
audit for a period of six years from the date on which the reports were
submitted or due to the commissioner or his agent, whichever is later.
(i) Field audits or desk audits shall be
conducted by the commissioner or his agent or the Department of Social Services
at a time and place and in a manner to be determined by the commissioner or the
DSS.
(ii) The audits may be
performed on any financial or statistical records required to be
maintained.
(iii) Any finding of an
above-described audit shall constitute grounds for recoupment at the discretion
of the commissioner, provided that such audit finding relates to the allowable
costs, and to the extent that, except as authorized in 18 NYCRR 517.16, the
audit finding has been upheld in a decision after a hearing or a hearing has
not been requested on such finding.
(iv) The six-year limitation shall not apply
in situations in which fraud may be involved or where the provider or an agent
thereof prevents or obstructs the commissioner from performing an audit
pursuant to this section.
(3) All administrative review (including
hearings) of audits conducted to determine allowable Medicaid expenses and
offsetting revenues shall be in accordance with 18 NYCRR Part 517.
(4) All administrative review of audits which
are conducted by OPWDD, and which are not described in paragraph (3) of this
subdivision, shall be in accordance with the following:
(i) At the conclusion of the audit, the
provider shall be afforded an opportunity to submit additional documentation to
the commissioner. After the receipt and review of such additional
documentation, a copy of the audit findings shall, within 120 days, be sent to
the provider by certified mail, return receipt requested. In order to have the
additional documentation considered, the provider must submit the documentation
within the time specified.
(ii) The
audit findings shall become final unless, within 30 days of receipt thereof,
the provider requests an administrative review of the audit findings.
(iii) Request for administrative review of
audit findings shall be sent to the commissioner by registered or certified
mail.
(iv) Such requests shall
contain a detailed statement of the provider's objections to the findings,
along with copies of any documentation the facility wishes to submit.
(v) The provider shall be notified in writing
of the determination of those items to which the provider objected, including a
statement of the reasons therefor. The audit findings, as adjusted in
accordance with the determination after administrative review, shall be
final.
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