New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIV - Office for People With Developmental Disabilities
Part 681 - Intermediate Care Facilities for Individuals with Intellectual Disabilities
Section 681.14 - Rate setting for intermediate care facilities for persons with developmental disabilities (ICF/DD)
Universal Citation: 14 NY Comp Codes Rules and Regs ยง 681.14
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Rates of reimbursement for intermediate care facilities for persons with developmental disabilities (ICF/DD), other than those operated by OPWDD, shall be determined in accordance with Title 10 NYCRR Part 86-11. The rates of payment made for services rendered to title XIX recipients established in accordance with the methodology contained in 10 NYCRR Part 86-11 shall be contingent upon Federal financial participation (FFP) and approval.
(b) Reporting requirements.
Each provider shall submit reports in accordance with the requirements of Subpart 635-4 of this Title.
(c) Rate setting.
(1) Units of service.
(i) A unit of service is the unit of measure
denoting lodging and services rendered to one individual between the
census-taking hours of the facility on two successive days; the day of
admission but not the day of discharge shall be counted. One unit of service
shall be counted if the individual is discharged on the same day the consumer
is admitted, providing there was an expectation that the admission would have
at least a 24-hour duration.
(ii)
Reserve bed days determined in accordance with subdivision (i) of this section
and 18 NYCRR 505.9 are units of service.
(2) Rate cycle.
(i) For facilities of over 30 beds, the rate
cycle is comprised of two 12-month rate periods.
(ii) For facilities of under 31 beds, the
rate cycle is comprised of a base period and a subsequent period or periods.
(a) The base period is the first 12-month
period of the rate cycle.
(1) The base period
is from January 1st to December 31st for Region II or III facilities. The first
base period begins January 1, 1988 for over 30-bed Region II or III facilities.
The base period begins January 1, 2003 for under 31-bed Region II or III
facilities.
(2) The base period is
from July 1st to June 30th for Region I facilities. The first base period
begins July 1, 1988 for over 30-bed Region I facilities. The base period begins
July 1, 2003 for under 31-bed Region I facilities.
(b) The subsequent period for over 30-bed
facilities is the second 12-month period of the rate cycle. The subsequent
periods for under 31-bed facilities are the subsequent 12-month periods.
(1) The subsequent period is from January 1st
to December 31st for Region II or III facilities. The first subsequent period
begins January 1, 1989 for over 30-bed Region II or III facilities. The first
subsequent period begins January 1, 2004 for under 31-bed Region II or III
facilities.
(2) The subsequent
period is from July 1st to June 30th for Region I facilities. The first
subsequent period begins July 1, 1989 for over 30-bed Region I facilities. The
first subsequent period begins July 1, 2004 for under 31-bed Region I
facilities.
(3) Computation of rates (general).
(i) All rates shall not be final unless
approved by the Director of the Division of the Budget.
(ii) The commissioner may make adjustments to
rates calculated in accordance with this section based upon the allowability of
costs as determined by subdivision (f) of this section and Subpart 635-4 of
this Title. In addition, costs may be reallocated and adjusted following a desk
audit of cost reports. The desk audit will examine the allocation of costs and
OPWDD will reallocate unidentified and improperly classified costs, if any, to
appropriate costs categories.
(iii)
The commissioner may also make adjustments to rates calculated in accordance
with subdivision (f) of this section, and Subpart 635-4 of this Title based on
errors which occurred in the computation of the rate. A provider may request a
rate revision based on rate computation errors by notifying OPWDD by certified
mail, return receipt requested, either within 90 days of the provider receiving
the rate computation or within 90 days of the beginning of the rate period in
question, whichever is later. However, if the requested rate revision is
related to the resubmission of an annual cost report, OPWDD shall not accept
the request. The commissioner may also adjust for changes in certified
capacity, changes in payments for real property which have the prior approval
of the commissioner and the Director of the Division of the Budget, or changes
based upon previously determined final audit findings. If a facility has
undergone a change in certified capacity, the commissioner may:
(a) request the facility to submit a budget
report subject to Subpart 635-4 of this Title;
(b) request the facility to submit
incremental/decremental cost data which is associated with the capacity change.
Utilizing the submitted incremental/decremental data or budget report, OPWDD shall make the appropriate upward or downward adjustment in a facility's rate; or continue the then existing rate for the remainder of the subject rate period in those instances where the commissioner has determined that the facility is operating at a loss for the rate period in question and adjusting the current rate would further increase such loss, or the facility is operating at a surplus for the rate period in question and adjusting the rate would further increase such surplus.
(iv) Rate adjustments as described
in subparagraph (iii) of this paragraph will be limited to those adjustments
which will result in an annual increase or decrease in reimbursement of $5,000
or more.
(v) Notwithstanding any
other provisions of this section, for over 30-bed facilities the reimbursable
operating costs contained in the rates shall be computed as follows. OPWDD
shall determine the total reimbursable operating costs (with the exception of
education and related service costs, sheltered workshop services, and day
training services) included in the payment rate in effect on December 31st or
June 30th, of the immediately preceding rate period applicable to that
facility. The dollars for sheltered workshop, day program services identified
in clause (4)(viii)(e) of this subdivision and day training
services shall be revised based upon the number of individuals participating in
the program. The reimbursable operating cost plus any revised sheltered work
and day training costs will be increased by the trend factor identified in
subdivision (h) of this section and may be adjusted for appropriate appeals,
except that day program services costs identified in clause
(4)(viii)(e) of this subdivision are not subject to the trend
factors identified in subdivision (h) of this section, but will be increased by
the trend factors used by OPWDD for day services similar to those paid for
through the add-on described in clause (4)(viii)(e) of this
subdivision. Education and related services will be updated in accordance with
clause (4)(ix)(c) of this subdivision. To determine the
capital cost portion of the subsequent period rate, OPWDD shall review the
component relating to capital costs for substantial material changes and, if
said changes conform to the requirements of paragraphs (f)(1) and (3) of this
section and Subpart 635-4 of this Title, make corresponding adjustments in
computing the subsequent period rate.
(vi) The computation of the rate resulting
from the application of this paragraph can also be represented by the following
formula:
(a) trended reimbursable operating
costs + untrended reimbursable operating costs + reimbursable capital costs
equal total reimbursable costs;
(b)
total reimbursable costs / units of service = the rate.
(vii) If OPWDD is unable to compute a rate
for a newly certified facility, it may establish an interim rate which shall be
the regional average for other facilities.
(a) OPWDD shall replace the interim rate
retroactively to the starting date of such interim rate by a rate developed
from the initial budget report submitted by the facility.
(b) The rate developed from the initial
budget report shall be subject to all the requirements of this section, and
shall be effective for the remainder of the then current rate period.
(viii) Providers shall be
responsible for any necessary transportation to and from physician, dentist,
and other clinical services, and any other transportation appropriate to the
individual's participation in community-based out-of-residence activities
planned for or sponsored by the facility. Nothing herein shall be interpreted
as precluding the accessing of separate Medicaid claiming for
emergency/nonemergency ambulance services (as defined in 18 NYCRR 505.10)
necessitated by the individual's medical condition.
(4) Computation of the base period.
(i) For each facility the commissioner shall
establish rates in accordance with the certified capacity as stated in a
facility's provider agreement.
(ii)
Base period rates for over 30-bed facilities shall be computed on the basis of
a full 12-month cost report submitted by the provider for the 12-month period
beginning 24 months prior to the effective date of the base period, and subject
to the cost category screens described herein. For a newly certified over
30-bed facility, OPWDD shall use budget data, as submitted pursuant to Subpart
635-4 of this Title.
(iii) The base
period rate for under 31-bed Region 11 and III facilities shall be computed on
the basis of a full 12-month base year cost report submitted by the provider
for the 12-month period beginning January 1, 1999 and adjusted in accordance
with subparagraph (3)(ii) of this subdivision. The base period rate for under
31-bed Region I facilities shall be computed on the basis of a full 12-month
base year cost report submitted by the provider for the 12-month period
beginning July 1, 1999 and adjusted in accordance with subparagraph (3)(ii) of
this subdivision. For a newly certified under 31-bed facility, OPWDD shall use
the budget data submitted pursuant to Subpart 635-4 of this Title.
(iv) For a newly certified facility, the base
period rate shall be determined pursuant to subparagraph (vii) of this
paragraph. For under 31-bed facilities the units of service are determined by
multiplying the certified capacity of the facility by 365 days. For over 30-bed
facilities, units of service are the certified capacity of the facility
multiplied by 365 days multiplied by 99 percent. A facility's submitted budget
costs may be adjusted based on a comparison to the actual costs of other
existing facilities operated by the provider in order to determine the costs of
an efficient and economic operation. If the provider does not operate other
facilities, the submitted budget costs may be adjusted based on a comparison to
the average costs of other facilities in the same region.
(v) For facilities which are not newly
certified facilities, the base period rate shall be determined pursuant to
subparagraph (vii) of this paragraph. For under 31-bed facilities, the units of
service are determined by multiplying the certified capacity of the facility by
365 days. For over 30-bed facilities, units of service are the higher of the
certified capacity of the facility multiplied by 365 days multiplied by 99
percent, or the actual reported units of service.
(vi) As appropriate, OPWDD shall apply trend
factors to each facility's reimbursable operating costs, except for education
and related services. However, day program services costs identified in clause
(viii)(e) of this paragraph are not subject to the trend
factors identified in subdivision (h) of this section, but will be increased by
the trend factors used by OPWDD for day services similar to those paid for
through the add-on described in clause (viii)(e) of this
paragraph.
(vii) The computation of
the rate resulting from the application of this paragraph can also be
represented by the following formula:
(a)
trended reimbursable operating costs + untrended reimbursable operating costs +
reimbursable capital costs = total reimbursable costs;
(b) total reimbursable costs / units of
service = the rate.
(viii) For all facilities there shall be a
day program services add-on so that facilities which have day program services
included in their rate shall be reimbursed as follows for these services. The
add-on shall reflect services needs as well as efficiency and economy of
operation.
(a) For sheltered workshop
services, effective July 1, 1995, the facility will receive a reimbursable cost
of $9,899 per annum for each program participant. For program participants to
whom the conditions set forth in subparagraph (ix) of this paragraph apply, the
facility will receive a reimbursable cost of $9,499 per annum for each program
participant.
(b) For day training
programs, effective July 1, 1995, the facility will be reimbursed $11,033 per
annum for each program participant. For program participants to whom the
conditions set forth in subparagraph (ix) of this paragraph apply, the facility
will be reimbursed $10,633 per annum for each program participant.
(c) If an agency applies to OPWDD prior to
January 1, 2003, and for participants receiving services in day training
facilities where the developmental disability profile average score for the
site exceeds 348 for the adaptive score and exceeds 10 for the health score,
the amount of the add-on shall be determined by a budget review. The amount of
the add-on received by the ICF/DD for such day training services shall reflect
individual service needs as well as efficiency and economy of service
provision. Effective January 1, 2003, for any facility to which this subclause
applies, the add-on shall be equal to the reimbursement that was in the
facility's rate on December 31, 2002, and that was applicable to day training
services described in this subclause.
(d) The costs of day program services
delivered in a certified day treatment facility (see Part 690 of this Title)
may not be included as an add-on to the ICF/DD rate.
(e) Effective January 1, 2003, a provider may
request that a day program services add-on be included in the facility's rate.
The day program services add-on for all day program services shall be either
the day program services reimbursement included in the rate on December 31,
2002 and adjusted for actual service delivery; or the lower of:
(1) the actual costs per the most recent cost
report accepted by OPWDD net of any surplus calculated for the day program
services; or
(2) the budget
costs;
(3) the costs in subclauses
(1) and (2) of this clause are subject to a
desk audit. Administrative review of these desk audits shall be in accordance
with section
635-4.6(h)
of this Title.
(f)
Effective June 1, 1995, the facility will be reimbursed for education and
related services in accordance with Title 8 NYCRR. These costs shall not be
trended.
(ix) Effective
July 1, 1997 an under 31-bed facility may submit to the commissioner a request
for a transportation add-on for transportation of persons to and from an
outpatient service certified pursuant to article 28 of the Public Health Law
for certain persons if:
(a) in order to meet
a person's active treatment needs the person's individual program plan requires
a day service (comprising regular attendance at a sheltered workshop or a day
training service) in combination with visits to the outpatient service
described above;
(b) prior to July
1, 1996, transportation to and from the outpatient service was not included in
the rate for the operator of the outpatient service;
(c) prior to July 1, 1996, the rate approved
by the local social services district was billed separately by a transportation
vendor for transportation to and from the outpatient service; and
(d) the vendor ceased billing for
transportation of persons residing in the facility to and from the outpatient
service.
(x) The
transportation add-on shall be a reimbursable cost added to a facility's rate
subject to the conditions set forth in subparagraph (ix) of this paragraph. The
transportation add-on shall be calculated using payment/rate data based on
local social service district approved Medicaid payment rates made to
transportation vendors as of June 30, 1996. A weighted transportation average
shall be calculated for each facility by dividing the aggregate transportation
payments by the aggregate day service transportation round trips for all
persons described in subparagraph (ix) of this paragraph.
(a) The weighted transportation average for
each facility shall be ranked among all day treatment facilities statewide
pursuant to the methodology for calculating the transportation component add-on
for day treatment facilities described in section
690.7(e)(3)(vii)
(a)(1) through and including
(a)(3) of this Title.
(b) The modified weighted transportation
average shall be multiplied by the total to and from day service transportation
units of service to determine reimbursable transportation costs.
(xi) Effective September 1, 2011,
the rate shall be adjusted for providers with ICF/DD populations that include
individuals who are Willowbrook class members and who are accessing Willowbrook
case services delivered by a non-state provider.
(a) The add-on to the rate shall be
predicated on the number of Willowbrook class members accessing Willowbrook
case services delivered by a service coordinator who is qualified to provide
Medicaid service coordination (see Subpart 635-5 of this Title), Willowbrook
case services are those case management services required by appendix I of the
permanent injunction ordered by the United States District Court of the Eastern
District of New York on March 11, 1993 in the case of New York State
Association for Retarded Children v. Cuomo, that
exceed the case management services delivered by the QIDP in the
ICF/DD.
(b) The amount of the
additional reimbursement per provider on an annual basis shall be equal to the
sum of the months in which each Willowbrook class member residing in any of the
provider's ICF/DDs receives Willowbrook case services over the span of the
ICF/DD provider's accounting/reporting year multiplied by one half of the
Medicaid service coordination fee established for Willowbrook class members as
identified in the Medicaid service coordination contract for providers of that
service.
(5)
Computation of the subsequent period rate.
(i) The reimbursable operating costs
contained in the subsequent period rates shall be computed as follows. OPWDD
shall determine the total reimbursable operating costs (with the exception of
education and related service costs, sheltered workshop services, day training
services) included in the payment rate in effect on December 31st or June 30th
of the immediately preceding rate period applicable to that facility. The
dollars for sheltered workshop and day training services shall be revised based
upon the number of individuals participating in the program. The reimbursable
operating costs plus any revised sheltered work and day training costs will be
increased by the trend factor identified in subdivision (h) of this section and
may be adjusted for appropriate appeals, except that day program services costs
identified in clause (4)(viii)(e) of this subdivision are not
subject to the trend factors identified in subdivision (h) of this section, but
will be increased by the trend factors used by OPWDD for day services similar
to those paid for through the add-on described in clause
(4)(viii)(e) of this subdivision. Education and related
services will be updated in accordance with clause (4)(ix)(c)
of this subdivision. OPWDD will determine the capital cost portion of the
subsequent period rate by reviewing the component relating to capital costs for
substantial material changes. If such changes conform to the requirements of
paragraphs (f)(1) and (3) of this section and Subpart 635-6 of this Title,
OPWDD will make corresponding adjustments in computing the subsequent period
rate.
(ii) The computation of the
rate resulting from the application of this paragraph can also be represented
by the following formula:
(a) trended
reimbursable operating costs + untrended reimbursable operating costs +
reimbursable capital costs = total reimbursable costs;
(b) total reimbursable costs/units of service
= the rate.
(iii) For a
newly certified facility which begins to provide services that fall within a
subsequent period, the initial rate shall be calculated as though it were a
base period rate.
(d) Cost category screens, reimbursement for under 31-bed facilities, and July 1, 2011 consolidation. In order to determine the reimbursable operating costs to be included in the rate calculation, the following screens (i.e., the maximum amount that will be allowed for a specific item or group of items) will be used. The regional screens corresponding to the actual geographic location of the facility will be applied.
(1) Administration screens and
reimbursement.
(i) Screens.
(a) Administrative screen values shall be
equal to the sum of the total reimbursable administrative costs and the total
reimbursable administrative fringe benefits, less the value of the efficiency
adjustment, included in the rate effective on the last day of the immediately
preceding rate period. This amount shall be detrended to the base
year.
(b) For facilities without a
screen as determined in clause (a) of this subparagraph,
operated by a provider which does operate other facilities, an agency
administrative percentage based on the current reimbursement of those other
facilities shall be applied.
(c)
For facilities without a screen as determined in clauses (a)
and (b) of this subparagraph, operated by a provider which
operates other OPWDD certified residential programs, an agency administrative
percentage based on the current reimbursement of the other OPWDD certified
residential programs shall be applied.
(d) For facilities without a screen as
determined in clauses (a)-(c) of this
subparagraph, operated by a provider which does not operate any other OPWDD
certified residential programs, a regional average administrative percentage
based on the current reimbursement of facilities operated by other providers
shall be applied.
(e) For
facilities without a screen value as determined per clause (a)
of this subparagraph, the administrative screen value shall be equal to the
percentages derived from clause (b), (c) or
(d) of this subparagraph times the reimbursable operating
costs other than administration. This value shall be detrended to the base
year.
(ii) Reimbursable
administration costs shall be the lesser of administrative base year
costs/budget costs, or the screen value as determined in subparagraph (i) of
this paragraph. Effective July 1, 2011, for providers in all regions, rates
shall be revised such that reimbursable administration costs shall be the
lesser of:
(a) administrative costs as
reported in the provider's 2008-2009 cost report for Region I providers or 2008
cost report for Regions II and III providers detrended to the 1999/1999-2000
base year or administrative budget costs detrended to the 1999/1999-2000 base
year; or
(b) 85 percent of the
screen value as determined in subparagraph (i) of this paragraph.
(2) Direct care screens
and reimbursement.
(i) Screen. The direct
care screen value shall be the direct care FTEs multiplied by the regional
salary.
(a) Direct care FTEs shall be
calculated utilizing the facility specific disability increment plus bed size
increment. The term disability increment shall mean the
process of developing facility specific direct care FTEs based upon aggregate
consumer disability characteristics as referenced and described in section
690.7(d)
of this Title and reported on the developmental disabilities profile (DDP). The
disability increment methodology will only be calculated if at least 50 percent
of the DDP scores are available. If less than 50 percent of the DDP scores are
available, the direct care FTEs calculated shall be based upon bed size
increment alone. The disability increment using the DDP scores is calculated as
follows: 0.063 FTEs times the facility mean direct care score plus 0.008 FTEs
time the facility mean behavior score plus 0.062 FTEs times the facility
standard deviation direct care score minus 0.019 FTEs times the facility
standard deviation behavior score. The direct score is computed for each
consumer from the DDP adaptive and health/medical scores as follows: 7.962 plus
0.156 times the adaptive score plus 1.611 times the health/medial score. The
bed size increments are as follows:
| Bed size | Bed size increment |
| 4 | 5.700 |
| 5 | 8.310 |
| 6 | 6.448 |
| 7 | 7.123 |
| 8 | 8.294 |
| 9 | 9.171 |
| 10 | 10.957 |
| 11 | 10.939 |
| 12 | 12.746 |
| 13 | 9.277 |
| 14 | 15.154 |
| 15 | 10.507 |
| 16 | 14.530 |
| 17 | 16.987 |
| 18 | 18.501 |
| 19 | 18.751 |
| 20 | 15.115 |
| 21 | 20.515 |
| 22 | 24.873 |
| 23 | 19.688 |
| 24 | 22.935 |
| 25 | 24.043 |
| 26 | 30.361 |
| 27 | 31.325 |
| 28 | 32.265 |
| 29 | 33.205 |
| 30 | 34.145 |
(b)
Direct care regional salaries.
| Region | |
| I | $29,375 |
| II | 29,522 |
| III | 25,005 |
Note:
The above values are in base year dollars.
(ii) Reimbursable direct care
costs shall be the lesser of the base year costs/budget costs or the screen
values established by subparagraph (i) of this paragraph. Effective July 1,
2011, for providers in all regions, rates shall be revised such that
reimbursable direct care costs shall be the lesser of:
(a) direct care costs as reported in the
provider's 2008-2009 cost report for Region I providers or 2008 cost report for
Regions II and III providers detrended to the 1999/1999-2000 base year or
direct care budget costs detrended to the 1999/1999-2000 base year;
or
(b) the screen value as
determined in subparagraph (i) of this paragraph.
(3) Support personal service
screens and reimbursement.
(i) Screen. The
support screen value shall be the support FTEs multiplied by the regional
salary.
(a) Support FTE screen values for
budget-based facilities:
| Bed size | Support FTE value |
| 4 | 0.55 |
| 5 | 0.71 |
| 6 | 0.87 |
| 7 | 1.03 |
| 8 | 1.19 |
| 9 | 1.35 |
| 10 | 1.50 |
| 11 | 1.66 |
| 12 | 1.82 |
| 13 | 1.98 |
| 14 | 2.14 |
| 15 | 2.30 |
| 16 | 2.46 |
| 17 | 2.61 |
| 18 | 2.77 |
| 19 | 2.93 |
| 20 | 3.09 |
| 21 | 3.25 |
| 22 | 3.41 |
| 23 | 3.56 |
| 24 | 3.72 |
| 25 | 3.88 |
| 26 | 4.04 |
| 27 | 4.20 |
| 28 | 4.36 |
| 29 | 4.52 |
| 30 | 4.67 |
(b)
Support FTE screen values for cost-based facilities are based on the base year
cost report.
(c) Support regional
salaries.
| Region | |
| I | $29,375 |
| II | 29,522 |
| III | 25,005 |
Note:
The above values are in base year dollars.
(ii) Reimbursable support personal
service costs shall be the lesser of the base year costs/budget costs, or the
screen values established in subparagraph (i) of this paragraph. Effective July
1, 2011, for providers in all Regions, rates shall be revised such that
reimbursable support personal service costs shall be the lesser of:
(a) support personal service costs as
reported in the provider's 2008-2009 cost report for Region I providers or 2008
cost report for Regions II and III providers detrended to the 1999/1999-2000
base year or support personal service budget costs detrended to the
1999/1999-2000 base year; or
(b)
the screen value as determined in subparagraph (i) of this paragraph.
(4) Clinical screens
and reimbursement.
(i) Clinical regional
salaries are:
| Region | |
| I | $56,510 |
| II | 53,584 |
| III | 40,414 |
Note:
The above values are in base year dollars.
(ii) Rates prior to July 1, 2011.
(a) For newly certified facilities, that have
a rate effective on the last day of the immediately preceding rate period, the
reimbursable clinical costs will be the clinical FTEs approved and reimbursed
in the rate effective on the last day of the immediately preceding rate period
multiplied by the lesser of:
(1) the clinical
average salary reimbursed in the rate on the last day of the immediately
preceding rate period detrended to the 1999/1999-2000 base year; or
(2) the appropriate clinical regional salary
listed in subparagraph (i) of this paragraph.
(b) For newly certified facilities, that do
not have a rate effective on the last day of the immediately preceding rate
period, OPWDD will consider budgeted FTEs and average salaries, reviewed and
adjusted if necessary through a desk audit process. The reimbursable clinical
costs shall be the desk-audited budgeted clinical FTEs multiplied by the lesser
of:
(1) the desk-audited budgeted clinical
average salary, detrended to the 1999/1999-2000 base year; or
(2) the appropriate regional clinical salary
listed in subparagraph (i) of this paragraph.
(c) For facilities which are not newly
certified, the reimbursable clinical costs shall be the base year cost report
clinical FTEs multiplied by the lesser of:
(1) the base year cost report clinical
average salary; or
(2) the
appropriate regional clinical salary listed in subparagraph (i) of this
paragraph.
(iii) Rates effective July 1, 2011.
(a) For Region I providers that do not have a
2008-2009 cost report but that operate an under 31-bed ICF/DD(s) that has
(have) a rate in effect on June 30, 2011, or for Regions II and III providers
that do not have a 2008 cost report but that operate an under 31-bed ICF/DD(s)
that has (have) a rate in effect on June 30, 2011, the reimbursable clinical
costs will be the clinical component of the June 30, 2011 rate(s) detrended to
the 1999/1999-2000 base year.
(b)
For facilities that do not have a rate in effect on June 30, 2011, OPWDD shall
use the budgeted FTEs and budgeted average salaries, reviewed and adjusted if
necessary through a desk audit process. The reimbursable clinical costs for
such facilities shall be the desk-audited budgeted clinical FTEs multiplied by
the lesser of:
(1) the desk-audited budgeted
clinical average salary, detrended to the 1999/1999-2000 base year;
or
(2) the appropriate regional
clinical salary listed in subparagraph (i) of this paragraph.
(c) For Region I providers that
have a 2008-2009 cost report or for Region II or III providers that have a 2008
cost report, the reimbursable clinical costs shall be the FTEs from the
provider's cost report multiplied by the lesser of:
(1) the clinical average salary as reported
in the provider's 2008-2009 cost report for Region I providers or 2008 cost
report for Regions II and III providers detrended to the 1999/1999-2000 base
year; or
(2) the appropriate
regional clinical salary listed in subparagraph (i) of this
paragraph.
(5) Fringe benefit screens and reimbursement.
(i) Rates prior to July 1, 2011.
(a) For every new rate cycle, OPWDD shall
compute a facility-specific fringe benefit percentage. This percentage shall be
determined by summing the direct care, clinical and support fringe benefit
costs from the base year budget or cost report and dividing this sum by the sum
of direct care, clinical and support personal service costs (exclusive of
contracted personal service) from the base year budget or cost
report.
(b) For newly certified
facilities, that have a rate effective on the last day of the immediately
preceding rate period, the fringe benefit percentage screen shall equal the
fringe benefit percentage contained in the rate effective on the last day of
the immediately preceding rate period.
(c) For newly certified facilities, that do
not have a rate effective on the last day of the immediately preceding rate
period, the fringe benefit percentage screen (as calculated in subparagraph [i]
of this paragraph) shall equal the average percentage reimbursed to existing
facilities currently operated by the provider. If there are no existing
facilities, then the fringe benefit percentage screen shall equal the average
reimbursed fringe benefit percentage of any other programs operated by the
provider. If the provider does not operate any other programs, then the fringe
benefit percentage screen shall equal the regional average percentage
reimbursed to other facilities.
(d)
Reimbursable fringe benefit costs shall be equal to the computed fringe benefit
percentage established in subparagraph (i), (ii) or (iii) of this paragraph
multiplied by the reimbursable direct care, clinical and support personal
service dollars, exclusive of contracted personal service.
(ii) Effective July 1, 2011.
(a) OPWDD shall compute a facility-specific
fringe benefit percentage by summing a facility's direct care, clinical and
support fringe benefit costs detrended to the 1999/1999-2000 base year and
dividing this sum by the sum of direct care, clinical and support personal
service costs (exclusive of contracted personal service) detrended to the
1999/1999-2000 base year:
(1) for Region I
providers that have a 2008-2009 cost report or for Regions II and III providers
that have a 2008 cost report, for facilities that are in the cost report, the
direct care, clinical, and support fringe benefit costs and direct care,
clinical, and support personal service costs shall be those costs reported by
the providers in their cost reports; and/or
(2) for facilities that opened after the
beginning of the provider's respective reporting period as described in
subclause (1) of this clause but that have a rate in effect on
June 30, 2011, the direct care, clinical, and support fringe benefit costs and
direct care, clinical, and support personal service costs shall be those costs
reflected in the provider's site-specific rates in effect on June 30, 2011;
and/or
(3) For facilities that do
not have a rate in effect on June 30, 2011, the fringe benefit percentage shall
equal the average percentage reimbursed to existing facilities currently
operated by the provider. If there are no existing facilities, then the fringe
benefit percentage shall equal the average reimbursed fringe benefit percentage
of any other programs operated by the provider. If the provider does not
operate any other programs, then the fringe benefit percentage shall equal the
regional average percentage reimbursed to other facilities.
(b) Reimbursable fringe benefit
costs shall be equal to the computed fringe benefit percentage established
pursuant to clause (a) of this subparagraph multiplied by the
reimbursable direct care, clinical and support personal service dollars,
exclusive of contracted personal service.
(6) Support OTPS (other than personal
service) screens and reimbursement.
(i) The
facility's support OTPS screen is determined by multiplying the certified
capacity by the appropriate regional per bed value.
(ii) Support OTPS regional per bed values.
| Region | |
| I | $16,097 |
| II | 13,085 |
| III | 16,418 |
Note:
The above values are in base year dollars.
(iii) Reimbursable support OTPS costs shall
be the lesser of the base year costs/budget costs, or the screen values
established in subparagraph (i) of this paragraph. Effective July 1, 2011, for
providers in all regions, rates shall be revised such that reimbursable support
OTPS shall be the lesser of:
(a) support OTPS
costs as reported in the provider's 2008-2009 cost report for Region I
providers or 2008 cost report for Regions II and III providers detrended to the
1999/1999-2000 base year or support OTPS budget costs detrended to the
1999/1999-2000 base year; or
(b)
the screen value as determined in subparagraph (i) of this paragraph.
(7) Utility costs will
not be included within the support OTPS screen. Prior to July 1, 2011,
reimbursable utility costs shall be the base year costs or budget costs.
Effective July 1, 2011, the reimbursable utility costs shall be the 2008-2009
costs for Region I providers or the 2008 costs for Regions II and III providers
detrended to the 1999/1999-2000 base year or the budget costs detrended to the
1999/1999-2000 base year.
(8)
Effective July 1, 2011. Consolidation of site-specific rates into a single rate
applicable to all facilities operated by a provider.
(i) Site-specific rates shall be revised to
effect new July 1, 2011, rates in accordance with the processes outlined in
this subdivision. OPWDD shall then consolidate the site-specific rates for each
provider to produce a single rate for all facilities operated by a provider
according to the steps outlined as follows:
(a) For each provider, the individual cost
categories total reimbursable costs contained in the site-specific rates in
effect on July 1, 2011 for each site operated by that provider shall be
summed.
(b) For each provider, the
individual certified capacities upon which the site-specific rates in effect on
July 1, 2011 are predicated for each site operated by that provider shall be
summed.
(c) For each provider, the
individual potential maximum client days upon which the site-specific rates in
effect on July 1, 2011 are predicated for each site operated by that provider
shall be summed.
(d) If the
operating component of the single provider-specific rate calculated in
accordance with clauses (a), (b) and
(c) of this subparagraph represents an ICF/DD operating
funding level which is greater than the aggregate ICF/DD operating funding
level at June 30, 2011 for the provider, then the July 1, 2011
provider-specific rate will be the consolidation of the provider's June 30,
2011 ICF/DD rates. If the single provider-specific operating rate calculated in
accordance with clauses (a), (b) and
(c) of this subparagraph represents an ICF/DD operating
funding level for the provider which is less than the aggregate ICF/DD
operating funding level at June 30, 2011, then the July 1, 2011
provider-specific rate will be the higher of the single provider-specific
operating rate calculated in accordance with clauses (a),
(b) and (c) of this subparagraph or the
operating rate which represents a funding reduction of 10 percent of the
aggregate ICF/DD operating funding level for the provider at June 30,
2011.
(ii) Sites opening
after July 1, 2011. For a facility that was not operating on June 30, 2011, or
was not certified as an ICF/DD on June 30, 2011, the initial site-specific
rate shall be the current agency ICF/DD rate or a rate based on budgeted costs
if the commissioner determines that a rate based on budgeted costs is needed
because the current agency ICF/DD rate would not appropriately reimburse the
ICF/DD when taking into consideration the disability levels of the ICF/DD
individuals. In establishing a rate based on budgeted costs, the commissioner
shall adjust the budgeted costs for the facility by whichever of the following
cost information is available and reflects necessary costs for operating the
new facility: actual costs of similar existing facilities operated by the
provider, or average costs of other facilities in the same region and
historical data for similar facilities, in order to establish a rate that uses
the most comparable data when taking into consideration the disability levels
of the ICF/DD individuals. The approved site-specific rates shall be
incorporated into the single rate for all facilities operated by a provider
according to the process outlined in clauses (i)(a),
(b) and (c) of this paragraph. The
recalculated provider-specific rate will be effective on the date of the
certification of the new site.
(iii) As of July 1, 2011, all unresolved desk
audits precipitated by rebasing to the base year 1999/1999-2000 shall be closed
and there shall be no further attempts to effect rate adjustments or
reconciliations.
(e) Cost category screens and reimbursement for over 30-bed facilities.
In order to determine the reimbursable operating costs to be included in the rate calculation, the following screens (i.e., the maximum amount that will be allowed for a specific item or group of items) will be used.
(1) Direct care,
mid-level supervision, and clinical personal service cost category screens:
(i) For every new rate cycle, OPWDD shall
develop values by applying a maximum statewide salary amount to a facility's
applicable individual specific staffing standards. Refer to paragraphs (5)-(8)
of this subdivision.
(ii) These
standards shall reflect the severity of disabilities of the population residing
at the facility as determined by the procedures outlined in paragraphs (5)-(7)
of this subdivision; the number of beds in the facility; whether or not a
facility provides on-site day program services; and the persons the facility
provides services to (i.e., adults, children or
both).
(iii) For any facility which
elects to participate in the salary enhancement plan as evidenced by adoption
of a resolution of its governing body, effective on the later of October 1,
1987, or the date of adoption of such resolution, the direct care/support
reimbursement will be adjusted to reflect the obligation to pay salary levels
established by adoption of the resolution referred to in this subparagraph. In
absence of such an election, the standard shall be determined by the facility's
actual salary amount based upon the budget or cost report used to establish the
rate being adjusted or calculated.
(2) Administrative and support cost category
screens:
(i) OPWDD shall develop values for
every new rate cycle by application of a statewide maximum allowable
cost.
(ii) The personal service
costs shall be determined by applying a maximum statewide salary amount to the
allowable staffing level contained in this subdivision.
(iii) For any facility which elects to
participate in the salary enhancement plan as evidenced by adoption of a
resolution of its governing body, effective on the later of October 1, 1987, or
the date of adoption of such resolution, the direct care/support reimbursement
will be adjusted to reflect the obligation to pay salary levels established by
adoption of the resolution referred to in this subparagraph. In the absence of
such an election, the standard shall be determined by the facility's actual
salary amount based upon the budget or cost report used to establish the rate
being adjusted or calculated.
(3) Fringe benefit cost category screens:
(i) For every new rate cycle, OPWDD shall
compute a facility-specific fringe benefit percentage. This percentage shall be
determined by computing the total fringe benefit cost from the base year budget
or cost report and dividing this total by the total personal service cost
(exclusive of contracted personal service) from the base year budget or cost
report. For every rate cycle after April 1, 1984, this percentage shall be the
lower of the previous rate cycle cost-based fringe benefit percentage plus one
percent or a new percentage computed in accordance with the immediately
preceding sentence. If a facility's previous rate is based upon a budget, it is
not subject to the aforementioned one-percent fringe benefit
limitation.
(ii) To determine the
fringe benefit component of the rate, the facility-specific fringe benefit
percentage shall be multiplied by the total reimbursable personal service
dollars exclusive of contracted personal services.
(iii) For newly certified facilities, the
fringe benefit percentage allowed shall not exceed the average allowed for
existing facilities (regardless of size) currently operated by the provider. If
there are no existing facilities, then the fringe benefit percentage allowed
shall not exceed the fringe benefit percentage of any other programs operated
by the provider. If the provider does not operate any other programs, then the
fringe benefit percentage allowed shall not exceed the regional average for
other facilities.
(iv) Any increase
in the fringe benefit percentage due to Federal or State laws, rules or
regulations shall not be subject to the percent increase limitation described
in subparagraph (i) of this paragraph.
(v) If a newly certified facility whose base
period rate was determined from total reimbursable budget costs, submits a cost
report for the subsequent period in accordance with Subpart 635-4 of this
Title, a new fringe benefit percentage shall be computed by dividing these
costs by the total personal service costs (exclusive of contracted services) as
submitted in the new cost report. This percentage shall be subject to the
limitations of subparagraphs (i) and (ii) of this paragraph.
(4) Other than personal service
(OTPS) and overhead shall be combined into one cost category screen.
(i) The other than personal service cost
category screen will be based on a per bed amount effective at the beginning of
each new rate cycle (see paragraph [8] of this subdivision).
(ii) The overhead cost category screen will
be a percentage of reimbursable personal service and fringe benefits (see
paragraph [8] of this subdivision). This screen will be compared to reported
cost or budget costs (agency administration, personal service, OTPS, fringe
benefits and capital costs) to determine reimbursable costs.
(iii) Costs associated with transportation to
and from physician, dentist and other clinical services shall be included in
the other than personal service screen and subject to the limitations contained
therein.
(5) Over 30 bed
facility staffing standards, algorithm and screens. FTE factors to determine
staff allocations for individuals with differing day programs, who reside in
over 30 bed facilities.
| Current Willow-brook ratios | Ratios with offsets for adults with outside day program | Ratios with offsets for children with outside day program | On site day program requiring 1:1 | 31-bed facility children on-site day program |
| Direct Care 1:4 0.9917 FTE 1:6 0.7083 FTE 1:16 0.3541 FTE | Direct Care 1:4 0.8889 FTE 1:6 0.6399 FTE 1:16 0.3285 FTE | Direct Care 1:4 0.9442 FTE | Direct Care 3.5417 FTE | Direct Care 1:4 0.9917 |
| Mid-level supervision 0.1771 FTE | Mid-level supervision 0.1599 FTE | Mid-level supervision 0.1692 FTE | Mid-level supervision 0.1771 FTE | Mid-level supervision 0.1771 FTE |
| General clinical 0.3333 FTE | General clinical 0.2934 FTE | General clinical 0.3147 FTE | General clinical See below | General clinical 0.4878 FTE |
| 60+ bed facility children on-site day program | 100+ bed facility children on-site day program | 31-bed facility adults on-site day program | 60-bed facility adults on-site day program | 100+ bed facility adults on-site day program |
| Direct Care 1:4 0.9917 FTE | Direct Care 1:4 0.9917 FTE | Direct Care 1:4 0.9917 FTE 1:6 0.7083 FTE 1:16 0.3541 FTE | Direct Care 1:4 0.9917 FTE 1:6 0.7083 FTE 1:16 0.3541 FTE | Direct Care 1:4 0.9917 FTE 1:6 0.7083 FTE 1:16 0.3541 FTE |
| Mid-level supervision 0.1771 FTE | Mid-level supervision 0.1771 FTE | Mid-level supervision 0.1771 FTE | Mid-level supervision 0.1771 FTE | Mid-level supervision 0.1771 FTE |
| General clinical 0.4350 FTE | General clinical 0.3883 FTE | General clinical 0.4046 FTE | General clinical 0.3651 FTE | General clinical 0.3518 FTE |
(6)
For the purposes of developing an economy of scale, the following FTE offsets
shall be applied against the clinical ratios listed in paragraph (5) of this
subdivision:
(i) For children, bed sizes
32-59, a straight deduction of 0.00182 will be computed per 1-bed increase from
the 0.4878 at 31 beds.
(ii) For
children, bed sizes 61-99, a straight deduction of 0.00119 will be computed per
1-bed increase from the 0.4350 at 60 beds.
(iii) For adults, bed sizes 32-59, a straight
deduction of 0.00136 will be computed per 1-bed increase from 0.4046 at 31
beds.
(iv) For adults, bed sizes
61-99, a straight deduction of 0.00034 will be computed per 1-bed increase from
0.3651 at 60 beds.
(7)
An assessment of an individual's level of disability for the purposes of
designating direct care staffing levels, as listed in paragraph (5) of this
subdivision, shall be completed utilizing the following criteria.
| Direct Care Shift | Ratio | Factor | Description |
| Day or Evening | 1:4 | 0.25000 | 1) All children age 21 and under |
| 2) All individuals who are nonambulatory or wheelchair only) | |||
| 3) All multiply individuals with disabilities (blind or deaf or tube-fed) | |||
| 4) All individuals who are nonself-preserving | |||
| 1:16 | 0.06250 | All individuals over age 22 who: | |
| 1) walk freely | |||
| 2) have a mental level moderate or above | |||
| 3) are toilet-trained | |||
| 4) do not need help eating or dressing | |||
| 5) have no serious behavior problems | |||
| 6) do not have any mild behavior problems in the following categories: | |||
| a) assaults others | |||
| b) self-abusive | |||
| c) destroys property | |||
| d) runs away | |||
| 7) have some speech and comprehension | |||
| 1:6 | 0.16666 | All others not in above categories | |
| Night | 1:12 | 0.08333 | All individuals |
(8)
Cost center screens for over 30-bed facilities.
(i) From July 1 to June 30, the cost center
screens shall be:
(a) Salaries.
(a) Cost area
Administration and support
Direct care and mid-level supervision
Clinical
$21,751
20,814
34,824
(b)
Other cost center screens.
(b) Cost
area
OTPS/bed
Overhead
Administration and support FTE
$ 9,190
7.29%
0.6284/bed
(ii) From January 1st to December 31st, the
cost center screens shall be:
(a) Salaries.
(a) Cost area
Administration and support
Direct care and mid-level supervision
Clinical
$19,413
19,956
31,931
(b)
Other cost center screens.
(b) Cost
area
OTPS/bed
Overhead
Administration and support FTE
$ 9,180
6.76%
0.56/bed
(f) Allowable costs.
To be considered allowable, costs must be properly chargeable to necessary individual care rendered in accordance with the requirements of this Part.
(1) Allowable costs
(general).
(i) Except where rules concerning
allowability of costs are stated herein, the Medicare Provider Reimbursement
Manual, commonly referred to as HIM-15, shall be used to determine the
allowability of costs. HIM-15 is published by the U.S. Department of Health and
Human Services' Health Care Financing Administration (HCFA) and 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. It may be reviewed in person during
regular business hours at the NYS Department of State, 41 State Street, Albany,
NY 12207; or, by appointment, at the NYS Office for People With Developmental
Disabilities, Division of Revenue Management, 44 Holland Avenue, Albany, NY
12229-0001.
(ii) Where rules stated
herein, or in Subpart 635-6 of this Title, or in HIM-15 are silent concerning
the allowability of costs, the commissioner shall determine allowability of
costs based on reasonableness and relationship to individual care and generally
accepted accounting principles.
(iii) Expenses or portions of expenses
reported by a facility that are not reasonably related to the efficient and
economical provision of care in accordance with the requirements of this Part,
because of either the nature or amount of the item, shall be not
allowed.
(iv) Costs which are not
properly related to individual care or treatment, and which principally afford
diversion, entertainment or amusement to owners, operators or employees of the
facility, shall not be allowed.
(v)
The OPWDD shall reduce a facility's base year costs/budget costs by the costs
of such services and activities that are not chargeable to the care of
individual in accordance with this subdivision.
(a) In the event that the commissioner
determines that it is not practical to establish the costs of such services and
activities, the income derived therefrom shall be substituted as the basis for
reductions of the facility's reported or estimated costs.
(b) Examples of sources of such income
include, but are not limited to:
(1) supplies
and drugs sold by the facility for use by nonresidents;
(2) telephone and telegraph services for
which a charge is made;
(3)
discount on purchases;
(4)
employees' rental of living quarters;
(5) cafeterias;
(6) meals provided to staff or an
individual's guests for which there is a charge;
(7) operating parking facilities for
community convenience; and
(8)
lease of office and other space by concessionaires providing services not
related to intermediate care facility services.
(vi) Costs for any interest expense related
to funding expenses in excess of an approved rate, or penalty imposed by
governmental agencies or courts and the costs of insurance policies obtained
solely to insure against such penalty, shall not be allowed. OPWDD will not pay
interest on the final dollar settlement resulting from the retrospective impact
of the rate appeals.
(vii) Costs of
contributions or other payments to political parties, candidates or
organizations shall not be allowed.
(viii) Restricted funds are funds expended by
the facility, which include grants, gifts, and income from endowments, whether
cash or otherwise, which must be used only for a specific purpose as designated
by the donor or grant instrument. Except as provided for in subparagraphs (iii)
and (iv) of this paragraph, restricted funds are to be deducted from the
designated costs when determining allowable costs. The commissioner may waive
the provisions of this subparagraph at his discretion only in those instances
where the provider makes a reasonable showing that the imposition of the
requirements of this subparagraph would cause undue financial harm to the
existence of the facility.
(ix)
Only that portion of the dues paid to any professional association which has
been demonstrated to be attributable to expenditures other than for lobbying or
political contributions shall be allowed.
(x) A monetary value assigned to services
provided by a religious order for services rendered to an owner and operator of
a facility shall be considered allowable subject to review by OPWDD for
reasonableness.
(xi) Funded
depreciation.
(a) Applicability. This
subparagraph shall apply to all facilities except those governed by
subparagraph (iii) or (iv) of this paragraph and those for which the provider
is receiving or has a commitment to receive HUD funding. This section shall
apply to facilities which were governed by subparagraph (3)(iii) or (iv) of
this subdivision but which are no longer governed by either such section
because the provider has repaid the entire principal owed on the real property
of the facility.
(b) Effective
April 1, 1986, for any rate period during which the reimbursement attributable
to depreciation on a facility's real property, excluding equipment, exceeds the
provider's principal repayment obligations on indebtedness attributable to such
real property, such provider shall fund depreciation by depositing such
difference in an interest- bearing checking account or other secure investment.
If the provider operates more than one facility governed by this paragraph, the
provider may maintain one funded depreciation account for two or more
facilities. The provider shall not commingle such funded depreciation accounts
with other monies of the provider. The provider shall not be required to fund
depreciation attributable to the provider's equity in such real property. The
provider may expend the funds in such account, including accrued interest, to
retire all or a portion of the indebtedness attributable to such real property,
or for building improvements and/or fixed equipment necessary to the
facility.
(c) OPWDD will not
reimburse interest expense incurred to meet funded depreciation, pursuant to
this subparagraph and subparagraphs (iii) and (iv) of this paragraph.
(2) Allowable costs
(operating).
(i) Interest on working capital
indebtedness in accordance with standards listed in section
635-6.4(h)
of this Title and subject to the limitations of paragraph (d)(1) or (e)(4) of
this section will be considered allowable. In the event that a loan is not in
accordance with the standards listed above, then the approval of the
commissioner is required.
(ii)
Effective April 16, 1992, costs incurred as a result of the provider of
services assessment charged pursuant to section 43.04 of the Mental Hygiene Law in the
amount of 2.4 percent of the 3 percent assessment charged on cash receipts
shall be included in the rate.
(iii) Effective April 4, 1996, costs in
excess of 0.6 percent incurred as a result of the provider of services
assessment charged on cash receipts pursuant to section 43.04 of the Mental Hygiene Law shall be
included in the rate. Effective April 1, 1999, costs in excess of 0.3 percent
incurred as a result of the provider of services assessment charged on cash
receipts pursuant to section 43.04 of the Mental Hygiene Law shall be
included in the rate. Effective April 1, 2000, the assessment charged on cash
receipts pursuant to section 43.04 of the Mental Hygiene Law shall be a
reimbursable expense.
(iv)
Allowable operating costs shall also include, but not be limited to, personal
service, fringe benefits, OTPS, utility, administration costs, as well as day
treatment, day services, and transportation costs, and regional FTE
add-ons.
(v) 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 rate.
(3) Allowable costs (capital).
(i) Start-up costs are those costs which are
incurred from the period the provider receives approval pursuant to Part 620 of
this Title for a facility to become an intermediate care facility to the date
the first individual is admitted. However, costs incurred during the period
from the first admission to the effective date of the initial provider
agreement shall not be considered as start-up costs.
(a) OPWDD may, at the discretion of the
commissioner, reimburse a provider for all allowable start-up costs incurred in
the preparation of the provider during that six-month period prior to the date
of the first admission. A provider may apply to the commissioner for an
extension of the six-month reimbursable start-up period, provided that the
provider can demonstrate why such an extension is necessary. However, under no
circumstances shall a facility be allowed reimbursement of start-up costs for
any period of time exceeding 18 months prior to the date of the first
admission.
(b) Allowable start-up
costs may include, but not be limited to:
(1)
personal service expenses;
(2)
utility expenses;
(3)
taxes;
(4) insurance
expenses;
(5) employee training
expenses;
(6) housekeeping
expenses;
(7) repair and
maintenance expenses; and
(8)
administrative expenses.
(c) Any costs that are properly identifiable
as organization costs, or capitalizable as construction costs, shall be
classified as such and excluded from start-up costs.
(d) If a provider intends to prepare all
portions of its entire facility at the same time, start-up costs for all
portions of the facility shall be accumulated in a single deferred account and
shall be amortized from the date of the first admission. However, if a provider
intends to prepare only portions of its facility (e.g.,
preparation of a floor or wing), start-up costs shall be capital and amortized
separately. In either case, unless reimbursed as described in subparagraph (iv)
of this paragraph, start-up costs shall be amortized over a period not to
exceed 60 months from the date of the first admission.
(ii) For any transaction resulting in a
change of ownership, the valuation of the assets shall be limited to the lesser
of the allowable acquisition cost of the assets to the first owner of record
who has received Medicaid payment for the assets in question on or after August
1, 1982, minus any paid depreciation (i.e., seller's net book
value) or the acquisition cost of the asset to the new owner.
(iii) Notwithstanding subparagraph (1)(viii)
of this subdivision, in the case of any provider which has been notified by
OPWDD on or after April 1, 1986 that there is a preliminary reservation of
State aid funds for a capital grant pursuant to Mental Hygiene Law, section
41.18(c) or 41.23, the
basis for computing depreciation on the facility which is the subject of the
capital grant shall include the facility's depreciable project costs which were
funded with such capital grant, provided that the provider is not receiving and
does not have a commitment to receive HUD funding for the facility, and has not
repaid the entire principal owed on the real property of the facility. If the
depreciable project costs are adjusted after audit, the basis for computing
depreciation on the facility will be changed to such adjusted depreciable
project costs. Upon full repayment of principal, the basis for depreciation for
the facility will cease to include the amount of the capital grant. Any
provider which receives such a capital grant shall enter into certain
assurances with the OPWDD whereby the provider agrees that:
(a) The difference between depreciation in
the rate attributable to the facility's depreciable project costs (other than
depreciation attributable to the provider's equity in the facility's real
property at the time such property is put into use as a facility) and the
principal which is repaid shall be deposited in a secure investment approved by
the commissioner.
(b) Withdrawals
from such investment shall be made only for the purpose of repayment of
indebtedness owed on the real property of the facility. With the commissioner's
approval based on cost savings, a provider may use withdrawals from such
investment for repayment of indebtedness owed on the real property of another
facility which received a capital grant under this subparagraph or under
subparagraph (iv) of this paragraph, or if there is no such other facility
which is mortgaged, for the repayment of indebtedness owed on the real property
of another facility which is mortgaged under the same mortgage as the
facility.
(c) Each withdrawal must
be approved by the commissioner.
(d) If the provider ceases to operate the
facility as an intermediate care facility for developmentally disabled, or as
any facility certified by OPWDD, it will repay to the OPWDD the balance on
deposit in the secure investment at the time of such cessation, including
interest earned on the investment.
(e) Depreciable project costs shall mean
those acquisition and construction costs of a facility which have been
approved, either before or after audit, by the New York State Office of the
State Comptroller or by OPWDD or by OPWDD's designee. Such costs shall not
include the cost of land.
(f) HUD
funding shall mean lower income housing assistance under section 8 of the
United States Housing Act of 1937, as amended
42
U.S.C. section 1437(f)
and/or a loan or loans pursuant to section 202 of the Housing Act of 1959, as
amended
12
U.S.C. section
1701(q).
(iv) Notwithstanding subparagraph
(1)(viii) of this subdivision, any provider which has been notified by OPWDD
before April 1, 1986 that there is a preliminary reservation of State aid funds
for a capital grant pursuant to Mental Hygiene Law, section
41.18(c) or 41.23, which
is not receiving and has no commitment to receive HUD funding for the facility
which is the subject of the capital grant, may apply to the commissioner to
have the basis for computing depreciation on the facility include the
facility's depreciable project costs which were funded with the capital grant.
Such application must be submitted to the commissioner on or before September
30, 1986 on the forms prescribed by the commissioner. Such application shall be
granted at the discretion of the commissioner upon a showing that inclusion in
the depreciation basis of the facility's depreciable project costs which were
funded with the capital grant is necessary to the financial viability of the
facility and will not impede the facility's efficient and economical operation.
If the commissioner approves such application, the facility's rate shall be
revised retroactive to April 1, 1986 to include in the depreciation basis the
facility's depreciable project costs which were funded with the capital grant,
and the provider shall enter into certain assurances described in subparagraph
(iii) of this paragraph. Upon full repayment of principal, the basis for
depreciation for the facility will cease to include the amount of the capital
grant. If the depreciable project costs are adjusted after audit, the basis for
computing depreciation on the facility will be changed to such adjusted
depreciation project costs.
(g) Adjustments.
Effective January 1, 2005 for Region II and III facilities, and effective July 1, 2005 for Region I facilities, there shall be an efficiency adjustment for under 31-bed facilities as described herein and applied as a reduction to reimbursable operating costs.
(1) A determination shall be made as to
whether each provider has a per bed surplus or loss for all its under 31-bed
facilities.
(i) Surplus/loss shall equal
operating revenue minus operating costs.
(a)
For purposes of this efficiency adjustment, operating revenue and costs are net
of day treatment, day service, transportation, and regional FTE
add-ons.
(b) Revenue for
determining the surplus/loss calculations for all facilities in all regions is
from the rate effective July 1, 2004.
(c) Costs for determining the surplus/loss
calculations are from the 2001 or 2001-2002 cost reporting year, trended to
2004 or 2004-2005 dollars.
(ii) The value of the surplus/loss is divided
by the total number of beds in all of the provider's under 31-bed facilities to
determine the provider's per bed surplus/loss value.
(2) Regional ranking of the per bed
surplus/loss value.
(i) Within each of the
three regions, the per bed surplus/loss values are ranked and identified in
descending order.
(ii) Within each
region, the ranking is divided into five groups.
| Region I | Surplus/Loss Range (Per Bed) |
| Efficiency Group 5 | $17,498 to $4,289 |
| Efficiency Group 4 | $4,288 to $523 |
| Efficiency Group 3 | $522 to ($2,986) |
| Efficiency Group 2 | ($2,987) to ($7,465) |
| Efficiency Group 1 | ($7,466) to ($42,035) |
| Region II | Surplus/Loss Range (Per Bed) |
| Efficiency Group 5 | $17,478 to $6,354 |
| Efficiency Group 4 | $6,353 to $4,081 |
| Efficiency Group 3 | $4,080 to $873 |
| Efficiency Group 2 | $872 to ($5,343) |
| Efficiency Group 1 | ($5,344) to ($16,087) |
| Region III | Surplus/Loss Range (Per Bed) |
| Efficiency Group 5 | $12,398 to $7,216 |
| Efficiency Group 4 | $7,215 to $2,207 |
| Efficiency Group 3 | $2,206 to ($1,049) |
| Efficiency Group 2 | ($1,050 to ($6,440) |
| Efficiency Group 1 | ($6,441) to ($15,631) |
(3) Each of the five groups within each
region is assigned an ordinal weight.
Group 5 = 5 Group 4 = 4 Group 3 = 3 Group 2 = 2 Group 1 = 1
(4) Determination of
total adjustment per facility.
(i) The number
of beds in the facility is multiplied by its assigned ordinal weight and the
result is multiplied by $334.
(ii)
The facility's reimbursable operating costs are reduced by the amount
determined in subparagraph (i) of this paragraph.
(5) Reallocation of costs. The following
changes to cost allocations for all under 31-bed facilities are effective
January 1, 2005 for Region II and III facilities, and effective July 1, 2005
for Region I facilities.
(i) General
insurance costs are reallocated from base year administration OTPS costs to
base year support OTPS costs.
(ii)
Property and casualty insurance costs are removed from base year administration
OTPS costs. Property and casualty insurance costs from the appropriate cost
report period are included in capital costs.
(iii) Expensed equipment costs from the base
year cost report are included in support OTPS costs. Expensed equipment costs
are not included in capital costs.
(h) Trend factors.
OPWDD shall employ any or all of the following trend factor components to the reimbursable operating costs.
(1) For under 31-bed Region I facilities:
(i) 3.16 percent for 1994-95 to
1995-96;
(ii) 2.92 percent for
1995-96 to 1996-97;
(iii) 5.23
percent for 1996-97 to 1997-98;
(iv) 2.88 percent for 1997-98 to
1998-99;
(v) 3.19 percent for
1998-1999 to 1999-2000;
(vi) 2.90
percent and an enhanced trend of 2.10 percent for 1999-2000 to
2000-2001;
(vii) 3.52 percent for
2000-2001 to 2001-2002;
(viii)
effective February 1, 2002, facilities will receive an amount that they would
have received if the trend factor in subparagraph (vii) of this paragraph for
the rate period of July 1, 2001 to June 30, 2002 were increased in the amount
of 3.0 percent. The trend factor in effect for the rate period ending June 30,
2002 shall be deemed to be increased in the amount of 3.0 percent;
(ix) 3.69 percent for 2001-2002 to
2002-2003;
(x) effective February
1, 2003, facilities will receive an amount that they would have received if the
trend factor in subparagraph (ix) of this paragraph for the rate period of July
1, 2002 to June 30, 2003 were increased in the amount of 3.0 percent. The trend
factor in effect for the rate period ending June 30, 2003 shall be deemed to be
increased in the amount of 3.0 percent;
(xi) 3.43 percent for 2002-2003 to
2003-2004;
(xii) effective February
1, 2004, facilities will receive an amount that they would have received if the
trend factor in subparagraph (xi) of this paragraph for the rate period of July
1, 2003 to June 30, 2004 were increased in the amount of 3.12 percent. The
trend factor in effect for the rate period ending June 30, 2004 shall be deemed
to be increased in the amount of 3.12 percent;
(xiii) 3.20 percent for 2003-2004 to
2004-2005; and
(xiv) effective
February 1, 2005, facilities will receive an amount that they would have
received if the trend factor in subparagraph (xiii) of this paragraph for the
rate period of July 1, 2004 to June 30, 2005 were increased in the amount of
1.1 percent. The trend factor in effect for the rate period ending June 30,
2005 shall be deemed to be increased in the amount of 1.1 percent;
(xv) 3.33 percent for 2004-2005 to
2005-2006;
(xvi) effective February
1, 2006, facilities will receive an amount that they would have received if the
trend factor in subparagraph (xv) of this paragraph for the rate period of July
1, 2005 to June 30, 2006 were increased in the amount of 2.0 percent. The trend
factor in effect for the rate period ending June 30, 2006 shall be deemed to be
increased in the amount of 2.0 percent;
(xvii) 3.03 percent for 2005-2006 to
2006-2007;
(xviii) 2.97 percent for
2006-2007 to 2007-2008;
(xix) 3.52
percent for 2007-2008 to 2008-2009;
(xx) 0.00 percent for 2008-2009 to
2009-2010;
(xxi) effective February
1, 2010, facilities shall receive an amount that they would have received if
the trend factor in subparagraph (xx) of this paragraph for the rate period of
July 1, 2009 through June 30, 2010 had been 3.06 percent. The trend factor in
effect for the rate 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; and
(xxii) 2.08
percent for 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.
(2) For
under 31-bed Region II and III facilities:
(i) 3.16 percent for 1994 to 1995;
(ii) 2.92 percent for 1995 to 1996;
(iii) 5.23 percent for 1996 to
1997;
(iv) 2.88 percent for 1997 to
1998;
(v) 3.19 percent for 1998 to
1999;
(vi) for 1999 to 2000:
(a) 2.90 percent from January 1, 2000 to
December 31, 2000; and
(b)
effective April 1, 2000, an enhanced trend factor of 2.80 percent. On January
1, 2001, the trend factor in effect for the previous rate period shall be
deemed to be the equivalent of a combined annual trend of 5.0
percent;
(vii) 3.52
percent for 2000 to 2001;
(viii)
effective February 1, 2002, facilities will receive an amount that they would
have received if the trend factor in subparagraph (vii) of this paragraph for
calendar year 2001 were increased in the amount of 3.0 percent. The trend
factor for the rate year ending December 31, 2001 shall be deemed to be
increased in the amount of 3.0 percent;
(ix) 3.69 percent for 2001 to 2002;
(x) effective February 1, 2003, facilities
will receive an amount that they would have received if the trend factor in
subparagraph (ix) of this paragraph for calendar year 2002 were increased in
the amount of 3.0 percent. The trend factor for the rate year ending December
31, 2002 shall be deemed to be increased in the amount of 3.0
percent;
(xi) 3.43 percent for 2002
to 2003;
(xii) effective February
1, 2004, facilities will receive an amount that they would have received if the
trend factor in subparagraph (xi) of this paragraph for calendar year 2003 were
increased in the amount of 3.12 percent. The trend factor for the rate year
ending December 31, 2003 shall be deemed to be increased in the amount of 3.12
percent;
(xiii) 3.20 percent for
2003 to 2004;
(xiv) effective
February 1, 2005, facilities will receive an amount that they would have
received if the trend factor in subparagraph (xiii) of this paragraph for
calendar year 2004 were increased in the amount of 1.1 percent. The trend
factor for the rate year ending December 31, 2004 shall be deemed to be
increased in the amount of 1.1 percent;
(xv) 3.33 percent for 2004 to 2005;
(xvi) effective February 1, 2006, facilities
will receive an amount that they would have received if the trend factor in
subparagraph (xv) of this paragraph for calendar year 2005 were increased in
the amount of 2.0 percent. The trend factor in effect for the rate year ending
December 31, 2005 shall be deemed to be increased in the amount of 2.0
percent;
(xvii) 3.03 percent for
2005 to 2006;
(xviii) 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 rate period.
On January 1, 2008, the trend factor for the previous rate period shall be
deemed to be the 2.97 percent full annual trend;
(xix) 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 2008 rate period. On January 1,
2009, the trend factor for the previous rate period shall be deemed to be the
3.52 percent full annual trend;
(xx) 0.00 percent for 2008 to 2009;
(xxi) effective February 1, 2010, facilities
shall receive an amount that they would have received if the trend factor in
subparagraph (xx) of this paragraph for the rate period of January 1, 2009
through December 31, 2009 had been 3.06 percent. The trend factor in effect for
the rate 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;
and
(xxii) 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 2010 calendar year rate
period. The trend factor in effect for the rate 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.
(3) For over 30-bed Region I facilities:
(i) 3.37 percent for 1986-87 to
1987-88;
(ii) 3.53 percent for
1987-88 to 1988-89:
(iii) 5.71
percent for 1988-89 to 1989-90;
(iv) 7.51 percent for 1989-90 to
1990-91;
(v) 6.24 percent for
1990-91 to 1991-92;
(vi) 4.85
percent for 1991-92 to 1992-93;
(vii) 3.73 percent for 1992-93 to
1993-94;
(viii) 3.79 percent for
1993-94 to 1994-95;
(ix) 3.16
percent for 1994-95 to 1995-96;
(x)
2.92 percent for 1995-96 to 1996-97;
(xi) 5.23 percent for 1996-97 to
1997-98;
(xii) 2.88 percent for
1997-98 to 1998-99;
(xiii) 3.19
percent for 1998-1999 to 1999-2000;
(xiv) 2.90 percent and an enhanced trend of
2.10 percent for 1999-2000 to 2000-2001;
(xv) 3.52 percent for 2000-2001 to
2001-2002;
(xvi) effective February
1, 2002, facilities will receive an amount that they would have received if the
trend factor in subparagraph (xv) of this paragraph for the rate period of July
1, 2001 to June 30, 2002 were increased in the amount of 3.0 percent. The trend
factor in effect for the rate period ending June 30, 2002 shall be deemed to be
increased in the amount of 3.0 percent;
(xvii) 3.69 percent for 2001-2002 to
2002-2003;
(xviii) effective
February 1, 2003, facilities will receive an amount that they would have
received if the trend factor in subparagraph (xvii) of this paragraph for the
rate period of July 1, 2002 to June 30, 2003 were increased in the amount of
3.0 percent. The trend factor in effect for the rate period ending June 30,
2003 shall be deemed to be increased in the amount of 3.0 percent;
(xix) 3.43 percent for 2002-2003 to
2003-2004;
(xx) effective February
1, 2004, facilities will receive an amount that they would have received if the
trend factor in subparagraph (xix) of this paragraph for the rate period of
July 1, 2003 to June 30, 2004 were increased in the amount of 3.12 percent. The
trend factor in effect for the rate period ending June 30, 2004 shall be deemed
to be increased in the amount of 3.12 percent;
(xxi) 3.20 percent for 2003-2004 to
2004-2005;
(xxii) effective
February 1, 2005, facilities will receive an amount that they would have
received if the trend factor in subparagraph (xxi) of this paragraph for the
rate period of July 1, 2004 to June 30, 2005 were increased in the amount of
1.1 percent. The trend factor in effect for the rate period ending June 30,
2005 shall be deemed to be increased in the amount of 1.1 percent;
(xxiii) 3.33 percent for 2004-2005 to
2005-2006;
(xxiv) effective
February 1, 2006, facilities will receive an amount that they would have
received if the trend factor in subparagraph (xxiii) of this paragraph for the
rate period of July 1, 2005 to June 30, 2006 were increased in the amount of
2.0 percent. The trend factor in effect for the rate period ending June 30,
2006 shall be deemed to be increased in the amount of 2.0 percent;
(xxv) 3.03 percent for 2005-2006 to
2006-2007;
(xxvi) 2.97 percent for
2006-2007 to 2007-2008;
(xxvii)
3.52 percent for 2007-2008 to 2008-2009;
(xxviii) 0.00 percent for 2008-2009 to
2009-2010;
(xxix) effective
February 1, 2010, facilities shall receive an amount that they would have
received if the trend factor in subparagraph (xxviii) of this paragraph for the
rate period of July 1, 2009 through June 30, 2010 had been 3.06 percent. The
trend factor in effect for the rate 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; and
(xxx) 2.08 percent for 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.
(4) For over 30-bed Region II and
III facilities:
(i) 3.37 percent for 1986 to
1987;
(ii) 3.53 percent for 1987 to
1988;
(iii) 5.71 percent for 1988
to 1989;
(iv) 7.51 percent for 1989
to 1990;
(v) 6.24 percent for 1990
to 1991;
(vi) 4.85 percent for 1991
to 1992;
(vii) 3.73 percent for
1992 to 1993;
(viii) 3.79 percent
for 1993 to 1994;
(ix) 3.16 percent
for 1994 to 1995;
(x) for 1995 to
1996:
(a) 0.00 percent from January 1, 1996
to June 30, 1996;
(b) from July 1,
1996 to December 31, 1996, facilities will be reimbursed operating costs that
result in a full annual trend factor of 2.92 percent for the rate period. On
January 1, 1997, the trend factor for the previous rate period shall be deemed
to be the 2.92 percent full annual trend;
(xi) 5.23 percent for 1996 to 1997;
(xii) 2.88 percent for 1997 to
1998;
(xiii) 3.19 percent for 1998
to 1999;
(xiv) for 1999 to 2000:
(a) 2.90 percent from January 1, 2000 to
December 31, 2000; and
(b)
effective April 1, 2000, an enhanced trend factor of 2.80 percent. On January
1, 2001, the trend factor in effect for the previous rate period shall be
deemed to be the equivalent of a combined annual trend of 5.0
percent;
(xv) 3.52
percent for 2000 to 2001;
(xvi)
effective February 1, 2002, facilities will receive an amount that they would
have received if the trend factor in subparagraph (xv) of this paragraph for
calendar year 2001 were increased in the amount of 3.0 percent. The trend
factor for the rate year ending December 31, 2001 shall be deemed to be
increased in the amount of 3.0 percent;
(xvii) 3.69 percent for 2001 to
2002;
(xviii) effective February 1,
2003, facilities will receive an amount that they would have received if the
trend factor in subparagraph (xvii) of this paragraph for calendar year 2002
were increased in the amount of 3.0 percent. The trend factor for the rate year
ending December 31, 2002 shall be deemed to be increased in the amount of 3.0
percent;
(xix) 3.43 percent for
2002 to 2003;
(xx) effective
February 1, 2004, facilities will receive an amount that they would have
received if the trend factor in subparagraph (xix) of this paragraph for the
calendar year 2003 were increased in the amount of 3.12 percent. The trend
factor for the rate year ending December 31, 2003 shall be deemed to be
increased in the amount of 3.12 percent;
(xxi) 3.20 percent for 2003 to
2004;
(xxii) effective February 1,
2005, facilities will receive an amount that they would have received if the
trend factor in subparagraph (xxi) of this paragraph for calendar year 2004
were increased in the amount of 1.1 percent. The trend factor for the rate year
ending December 31, 2004 shall be deemed to be increased in the amount of 1.1
percent;
(xxiii) 3.33 percent for
2004 to 2005;
(xxiv) effective
February 1, 2006, facilities will receive an amount that they would have
received if the trend factor in subparagraph (xxiii) of this paragraph for
calendar 2005 were increased in the amount of 2.0 percent. The trend factor in
effect for the rate year ending December 31, 2005 shall be deemed to be
increased in the amount of 2.0 percent;
(xxv) 3.03 percent for 2005 to
2006;
(xxvi) 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 rate period. On January
1, 2008, the trend factor for the previous rate period shall be deemed to be
the 2.97 percent full annual trend;
(xxvii) 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 2008 rate period. On January 1,
2009, the trend factor for the previous rate period shall be deemed to be the
3.52 percent full annual trend;
(xxviii) 0.00 percent for 2008 to
2009;
(xxix) effective February 1,
2010, facilities shall receive an amount that they would have received if the
trend factor in subparagraph (xxviii) of this paragraph for the rate period of
January 1, 2009 through December 31, 2009 had been 3.06 percent. The trend
factor in effect for the calendar year rate 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; and
(xxx) 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 2010 calendar year rate period. The
trend factor in effect for the rate 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.
(5) Where appropriate, the commissioner shall
use some combination in whole or in part of the yearly components to project
cost data into the appropriate rate period.
(i) Appeals to rates.
(1) For appeals for rate periods before July
1, 2011, the commissioner will consider only the following appeals for
adjustment to the rates which would result in an annual increase of $1,000 or
more in a facility's allowable costs, and are:
(i) needed because of changes in the
statistical information used to calculate a facility's staffing or utilization
standards;
(ii) requests for relief
from the standards contained in subdivision (d) or (e) of this section which
were applied to costs used in calculating the base period and subsequent period
rates;
(iii) appeals for
adjustments needed because of material errors in the information submitted by
the facility which OPWDD used to establish the rate, or material errors in the
rate computation; or
(iv) appeals
for significant increases or decreases in a facility's overall base period
operating costs due to implementation of new programs, changes in staff or
service, changes in the characteristics or number of individuals, changes in a
lease agreement so as not to involve a related party, capital renovations,
expansions or replacements which have been either mandated or approved by the
commissioner and, except in life-threatening situations, approved in advance by
the appropriate State agencies.
(2) For rate periods beginning July 1, 2011
and thereafter, the commissioner will consider appeals for adjustment to the
rates which:
(i) would result in an annual
increase of $5,000 or more in the provider's allowable costs; and
(ii) are needed because of the occurrence of
bed vacancies.
(3)
Notification of first level appeal.
(i) In
order to appeal a rate in accordance with subparagraphs (1)(ii)-(iii) of this
subdivision, the provider must send to OPWDD an appeal application by certified
mail, return receipt requested, either within 90 days of the facility receiving
the rate computation or within 90 days of the beginning of the rate period in
question, whichever is later.
(ii)
In order to appeal a rate in accordance with subparagraph (1)(i) or (iv) or
paragraph (2) of this subdivision, the provider must send to OPWDD, within one
year of the close of the rate period in question, a first level appeal
application by certified mail, return receipt requested.
(4) First level rate appeal applications
shall be made in writing to the commissioner.
(i) The application shall set forth the basis
for the first level appeal and the issues of fact. Appropriate documentation
shall accompany the application and OPWDD may request such additional
documentation as it deems necessary.
(ii) Actions on first level rate appeal
applications will be processed without unjustifiable delay.
(5) The burden of proof on the
first level appeal shall be on the provider to demonstrate that the rate
requested in the appeal is necessary to ensure efficient and economical
operation.
(6) A rate revised by
OPWDD pursuant to an appeal shall not be considered final unless and until
approved by the State Division of the Budget.
(7) At no point in the first level appeal
process shall the provider have a right to an interim report of any
determinations made by any of the parties to the appeal. At the conclusion of
the first level appeal process OPWDD shall notify the provider of any proposed
revised rate or denial of same. Once OPWDD has informed the provider of the
appeal outcome, a provider which submits a revised cost report for the period
reviewed on appeal shall not be entitled to an increase in the award
determination based on that resubmission. OPWDD shall inform the provider that
it may either accept the proposed revised rate or request a second level appeal
in accordance with section
602.9
of this Title in the event that the proposed revised rate fails to grant some
or all of the relief requested.
(8)
If OPWDD approves the revision to the rate and State Division of the Budget
denies the revision, the provider shall have no further right to administrative
review pursuant to this section.
(9) Any rate revised in accordance with this
subdivision shall be effective according to the dates indicated in the rate
appeal notification.
(10) Any
additional reimbursement received by the provider, pursuant to a rate revised
in accordance with this subdivision, shall be restricted to the specific
purpose set forth in the appeal decision.
(11) Second level appeals to rates.
(i) OPWDD's denial of the first level appeal
of any or all of the relief requested in the appeal provided for in paragraph
(1) or (2) of this subdivision shall be final, unless the provider requests a
second level appeal to the commissioner in writing within 30 days of service of
notification of denial or proposed revised rate.
(ii) Second level appeals shall be brought
and determined in accordance with the applicable provisions of Part 602 of this
Title.
(j) Employee health care enhancement (HCE).
(1) Providers are eligible to have additional
funding included in their rate if they submitted a completed 2005 OPWDD survey
on health care benefits for all full- and part-time employees.
(2) Based on a survey of providers, OPWDD
determined a benchmark of health care benefits offered to employees by
providers. In September 2005, OPWDD notified those providers if their health
care benefits were at, above, or below the benchmark.
(3) Effective January 1, 2006, providers may
receive 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 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:
(a) For providers which reported on
the survey that no health care benefits are offered, OPWDD determined an
allocation for each provider based on the total number of employees reported
multiplied by $2,500, except that if there are any employees who were reported
on the survey and to whom the provider chooses not to offer this funding, the
allocation based on the total number of employees reported will be reduced by
the number of excluded employees reported multiplied by $2,500. These funds
must be used to establish employee health care benefits or to reduce employee
out-of-pocket health- related expenses.
(b) For providers which reported on the
survey that employee health care benefits are offered to some or all employees,
OPWDD determined an allocation for each provider based on the total number of
employees reported multiplied by $325, except that if there are any employees
who were reported on the survey and to whom the provider chooses not to offer
this funding, the allocation based on the total number of employees reported
will be reduced by the number of excluded employees reported multiplied by
$325. These funds must be used to enhance employee health care benefits or to
reduce employee out- of-pocket health-related expenses.
(4) Effective January 1, 2006,
providers may receive additional funding that would have been received during
the period of April 1, 2004 through December 31, 2005 if the funding described
in paragraph (3) of this subdivision had been paid.
(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:
(a) For
providers which reported on the survey that no employee health care benefits
are offered, no additional funding for the period of April 1, 2004 through
December 31, 2005 is available.
(b)
For providers which reported on the survey that employee health care benefits
are offered to some or all employees, OPWDD determined an allocation for each
provider based on the total number of employees reported multiplied by $325,
except that if there are any employees who were reported on the survey and to
whom the provider chooses not to offer this funding, the allocation based on
the total number of employees reported will be reduced by the number of
excluded employees reported multiplied by $325. The annual allocation of $325
will be adjusted for the 21-month period of April 1, 2004 through December 31,
2005. These funds must be used to reimburse health care expenses paid by
employees.
(5) In order to receive an allocation
described in subparagraph (3)(ii) or (4)(ii) of this subdivision, the provider
must send to OPWDD a completed written application submitted in the form and
format specified by the commissioner.
(6) Funding is contingent upon OPWDD's
approval of the application. OPWDD will base its decision on whether the
application is complete; whether it complies with the requirements of this
subdivision; and whether the application recognizes the provider's lowest paid
employees. OPWDD may request additional information and/or documentation as
needed before approving the application.
(7) Payment of the allocation described in
subparagraph (3)(ii) or (4)(ii) of this subdivision shall be subject to the
provider submitting a resolution by its governing body that funds received will
be used to implement the plans described in the provider's approved
application. To receive the allocation, the provider must submit the resolution
and the commission may approve it.
(8) For the purposes of the July 1, 2011,
rate calculations, OPWDD shall assume that providers have allocated all
expenses matched to their HCE I revenues to the fringe benefit cost category in
their cost reports.
(9) A rate
revised by OPWDD pursuant to this subdivision shall not be considered final
unless and until approved by the State Division of the Budget.
(k) Employee health care enhancement II.
(1) Effective January
1, 2007 providers may be eligible to receive funding for the health care
enhancement II (HCE II). Provides must use these funds to establish or enhance
employee health care benefits or to reduce employee out of pocket health care
expenses.
(2) In order to receive
funding described in this subdivision the provider must have sent to OPWDD a
completed written application by July 31, 2006, unless this deadline was
extended by the commissioner.
(3)
Funding is contingent upon OPWDD's approval of the application. OPWDD shall
decide whether to approve the application based on whether the application is
complete; whether it complies with the requirements of this subdivision; and
whether the application recognizes the provider's lowest paid employees. OPWDD
may request additional information and/or documentation, or revisions to an
application, before approving the application.
(4) Funding for HCE II is available at either
$2,500 per employee or $425 per employee, as follows:
(i) The annual allocation at the $2,500 level
is determined by OPWDD based on the total number of employees included in the
provider's approved HCE II application multiplied by $2,500. Funding at the
$2,500 level is available to providers which:
(a) submitted an application for HCE II
funding at the $2,500 level; and
(b) do not offer health care benefits;
and
(c) were insufficiently funded
for health care, as determined by OPWDD. Affected providers were notified by
OPWDD of this determination.
(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:
(a)
offer health care benefits to some or all employees and submitted an
application for HCE II funding at the $425 level; or
(b) applied for HCE II funding at the $2,500
level but received funding at the $2,500 per employee level pursuant to
subdivision (j) of this section; or
(c) submitted an application at the $2,500
level but have sufficient funding for health care, as determined by OPWDD.
Affected providers were notified by OPWDD of this determination.
(5) The application
submitted to OPWDD shall include plans for the expenditure of the HCE II
allocation in conformance with this subdivision. Such HCE II plans shall assure
that all employees included in the application are entitled to some benefit
from HCE II, although the value per employee may be lesser or greater than
$2,500 or $425 per employee. Higher paid employees whose earnings exceed a
salary cap established by the provider may be excluded from receipt of any HCE
II funds if these funds are reallocated to lower paid staff.
(6) A provider approved to receive HCE II
funding pursuant to subparagraph (4)(ii) of this subdivision shall receive an
amount that would have been paid if the HCE II initiative had been implemented
April 1, 2006.
(7) Payment of the
HCE II funding shall be subject to the provider submitting a resolution by its
governing body that funds received shall be used to implement the plans
described in the provider's approved application. To receive the allocation the
provider must submit the resolution and the commissioner must approve
it.
(8) For the purpose of the July
1 2011 rate calculations, OPWDD shall assume that providers have allocated all
expenses matched to their HCE II revenues to the fringe benefit cost category
in their cost reports.
(9) A rate
revised by OPWDD pursuant to this subdivision shall not be considered final
unless and until approved by the State Division of the Budget.
(l) Employee health care enhancement III.
(1) Effective January
1, 2008 providers may be eligible to receive funding for the health care
enhancement III (HCE III) included in their rate.
(2) Funding. Based on a survey of providers'
historical data as of January 1, 2005, OPWDD determined a benchmark of health
care benefits offered to employees by providers. Prior to September 30, 2007,
OPWDD notified those providers which OPWDD deemed eligible for HCE III funding
at the benchmark level. Providers deemed eligible for HCE III funding below the
benchmark level were mailed applications with instructions.
(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 rate 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 or 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 rate in effect on January 1, 2008 net of any funding provided
pursuant to subparagraph (iii) of this paragraph.
(a) Providers shall use these funds to
establish or enhance employee health care benefits and/or to reduce employee
out-of-pocket health care expenses and/or to offset the portion of premium
increases paid by the provider which exceeds the portion of the trend factor or
COLA applicable to those premium increases. Providers shall assure that
benefits resulting from this additional funding recognize their lower paid
employees.
(b) In order to receive
the funding described in this subdivision, the provider must have sent to OPWDD
a completed application and attestation received or postmarked by October 1,
2007, unless the deadline was extended by the commissioner. In the application
and attestation, the provider must have indicated its intended use of the
funds; agreed to obtain a resolution by December 31, 2007 from its governing
body authorizing such use; and agreed to maintain on file the resolution as
well as records detailing the distribution of HCE III funds.
(c) Funding is contingent upon OPWDD's
approval of the application and attestation. OPWDD shall decide whether to
approve the application and attestation based on whether it is complete and
conforms to the requirements of this subdivision. OPWDD may request additional
information or documentation before approving the application and
attestation.
(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.
(3) For the purpose of the July, 1 2011 rate
calculations, OPWDD shall assume that providers have allocated all expenses
matched to their HCE III revenues to the fringe benefit cost category in their
cost reports.
(4) A rate revised by
OPWDD pursuant to this subdivision shall not be considered final unless and
until approved by the State Division of the Budget.
(m) Health care adjustments (HCA) IV and V.
(1) Effective November 1, 2009,
providers may be eligible to receive funding for health care adjustments IV and
V included in their rates.
(2)
Benchmark providers and non-benchmark providers. Based on a survey of
providers' historical data as of January 1, 2005, OPWDD determined a benchmark
of health care related benefits offered to employees by providers. Prior to
October 31, 2007, OPWDD notified those providers which OPWDD deemed eligible
for HCE III funding at the benchmark level. Providers eligible for HCE III
funding at the benchmark level are eligible for HCA IV and HCA V funding at the
benchmark level. All other providers are eligible for HCA IV and HCA V funding
below the benchmark level.
(3)
Funding.
(i) Providers eligible for HCA IV
and HCA V funding at the benchmark level.
(a)
The HCA IV and HCA V funding levels for benchmark providers shall be 3.0
percent of the allowable operating costs used in establishing the provider
specific rates. Each adjustment shall be applied sequentially to effect
compounding of the adjustments.
(b)
Alternatively, a provider deemed eligible for HCA IV and HCA V funding at the
benchmark level shall receive for each adjustment (IV and V) a 1.0 percent
funding increase in all its programs and services eligible under this Chapter
if the provider notified OPWDD by September 11, 2009 in writing that it was
declining the 3.0 percent funding level increase and electing instead to
receive a 1.0 percent funding level increase for each adjustment (IV and V) in
all its programs and services eligible under this Chapter. Increases for HCA IV
and HCA V shall be applied sequentially to effect compounding of the
adjustments.
(c) Providers eligible
for funding at the benchmark level may not apply for employee health care
funding described in subparagraph (ii) of this paragraph.
(ii) Providers eligible for HCA IV and HCA V
funding below the benchmark level may apply to OPWDD to receive these funds.
(a) The HCA IV and HCA V funding levels for
non-benchmark providers shall be 1.0 percent of the allowable operating costs
used in establishing the provider specific rates. Each adjustment shall be
applied sequentially to effect compounding of the adjustments.
(b) Providers shall use these 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.
(c) In order to receive HCA IV and HCA V
funds, the provider must have sent to OPWDD a completed application and
attestation received or postmarked no later than September 11, 2009 unless the
deadline was extended by the commissioner. In the application and attestation,
the provider must have indicated its intended use of the funds; agreed to
obtain a resolution by October 31, 2009 from its governing body authorizing
such use; and agreed to maintain on file the resolution as well as records
detailing the distribution of HCA IV and HCA V funds.
(d) Funding is contingent upon OPWDD's
approval of the application and attestation based on whether it is complete and
conforms to the requirements of this subdivision. OPWDD may request additional
information or documentation before approving the application and
attestation.
(4) Catch-up provisions. 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
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 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. Nothing in this paragraph shall entitle
a provider to receive payment for services which have not been
provided.
(5) Consolidation of HCE
and HCA funds effective January 1, 2010.
(i)
Effective January 1, 2010, the HCE I through III and HCA IV and HCA V
components contained in the rate shall be consolidated into a single discrete
amount. For purposes of determining this amount, OPWDD shall combine the HCE I
through III and HCA IV and HCA V components contained in the initial rate in
effect on January 1, 2010. OPWDD shall use this fixed amount as the HCA payment
for the rate 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 the rates 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 rate.
(6) Providers' distribution of HCA IV and HCA
V funds is subject to audit to ensure conformity with the requirements of this
subdivision and distribution of funds consistent with the provider's approved
application.
(7) A rate revised by
OPWDD pursuant to this subdivision shall not be considered final unless and
until approved by the State Division of the Budget.
(n) Health care adjustment (HCA) VI.
(1) Effective October 1, 2010,
providers may be eligible to receive funding for health care adjustment VI
included in their rates.
(2)
Benchmark providers and non-benchmark providers. Based on a survey of
providers' historical data as of January 1, 2005, OPWDD determined a benchmark
of health care related benefits offered to employees by providers. Prior to
October 31, 2007, OPWDD notified those providers which OPWDD deemed eligible
for health care enhancement (HCE) III funding at the benchmark level. These
providers are "benchmark providers" and are eligible for HCA VI funding at the
benchmark level. All other providers ("non-benchmark providers") are eligible
for HCA VI funding below the benchmark level.
(3) Funding.
(i) Providers eligible for HCA VI funding at
the benchmark level.
(a) The HCA VI funding
levels for benchmark providers shall be 3.0 percent of the allowable operating
costs used in establishing the provider specific rates in effect on April 1,
2010.
(b) Alternatively, a provider
eligible for HCA VI funding at the benchmark level shall receive a 1.0 percent
funding increase in all its programs and services eligible under this Chapter
if the provider notified OPWDD by August 13, 2010 in writing that it was
declining the 3.0 percent funding level increase and electing instead to
receive a 1.0 percent funding level increase for HCA VI in all its programs and
services eligible under this Chapter.
(c) Providers eligible for funding at the
benchmark level may not apply for HCA VI funding described in subparagraph (ii)
of this paragraph.
(ii)
Providers eligible for HCA VI funding below the benchmark level may apply to
OPWDD to receive these funds.
(a) The HCA VI
funding level for non-benchmark providers shall be 1.0 percent of the allowable
operating costs used in establishing the provider specific rates in effect on
April 1, 2010.
(b) Providers shall
use these 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 adjustment funds included in the rates for services delivered on or after
July 6, 2011 shall be used by non-benchmark providers for the purposes
described in this clause 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 adjustment
funding shall be included in the reimbursable cost category of fringe benefits
in the rate.
(c) In order to
receive HCA VI funds, the provider must have sent to OPWDD a completed
application and attestation received or postmarked no later than August 13,
2010 unless the deadline was extended by the commissioner. In the application
and attestation, the provider must have indicated its intended use of the
funds; agreed to obtain a resolution by September 30, 2010 from its governing
body authorizing such use; and agreed to maintain on file the resolution as
well as records detailing the distribution of HCA VI funds.
(d) Funding is contingent upon OPWDD's
approval of the application and attestation based on whether it is complete and
conforms to the requirements of this subdivision. OPWDD may request additional
information or documentation before approving the application and
attestation.
(iii)
Effective October 1, 2010, 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 been 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.
(4) Providers'
distribution of HCA VI funds is subject to audit to ensure conformity with the
requirements of this subdivision and distribution of funds consistent with the
provider's approved application.
(5) A rate revised by OPWDD pursuant to this
subdivision shall not be considered final unless and until approved by the
State Division of the Budget.
(o) Reserve bed days for overnight absences for hospitalization or leaves of absence in facilities.
(1) Payment.
(i) Payment for overnight absences due to
hospitalization shall be in accordance with 18 NYCRR section
505.9.
(ii) Payment for overnight absences due to
leaves of absence shall be in accordance with 18 NYCRR section
505.9 and
the following additional requirements.
(a) A
leave of absence due to visits with relatives or friends, must not be medically
or programmatically contraindicated.
(b) In the case of a leave of absence due to
medically acceptable therapeutic leave or rehabilitative plans of care, the
plan of care must be documented.
(c) Leaves of absence covered under the bed
reservation program must be provided for in the individual's individual program
plan as designated by the interdisciplinary team.
(d) Such planning should most appropriately
take place during the development and monitoring process of the individual
program plan during the quarterly and annual reviews. A person's assigned bed
cannot be reserved if another person is occupying that bed.
(2) Reporting.
(i) Each facility shall maintain an absence
register for each individual who is absent overnight.
(ii) The facility shall record the duration
and purpose of each absence and make an annotation indicating whether or not
the individual's bed was reserved.
(iii) Each month the facility shall complete
a report summarizing all individual absences and submit the report to OPWDD.
The facility shall submit the report to the individual's sponsoring local
social services district within 10 working days following the end of the month.
This report shall reflect the information contained in each individual's
absence register.
(iv) The facility
shall report reserve bed absences in the form and format as prescribed by the
commissioner.
Disclaimer: These regulations may not be the most recent version. New York may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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