Current through Register Vol. 46, No. 39, September 25, 2024
(a)
Applicability. The provisions of this section are applicable to programs
certified or co-certified to provide ambulatory care services provided by the
following:
(1) substance use disorder
outpatient clinics certified or co-certified pursuant to Part 822 of this
Title;
(2) opioid treatment
programs providing opioid full agonist treatment medications and certified
under Part 822 of this Title;
(3)
substance use disorder outpatient rehabilitation programs certified or
co-certified pursuant to Part 822 of this Title; and
(4) substance use disorder medically
supervised outpatient withdrawal and stabilization services certified under
Section
816.8
of this Title; and
(5) integrated
outpatient programs certified pursuant to Part 825.
Each program shall contain two peer groups, one upstate and
one downstate.
(b) Billable services requirements and
limitations must be delivered in accordance with the provisions of the
Ambulatory Patient Groups (APG) Clinical and Medicaid Billing Guidance, as
incorporated by reference in this Title (hereinafter referred to as the APG
Manual), in effect at the time the service(s) was delivered.
(c) Definitions. All applicable definitions
and rules covering standardized APG pricing logic for New York State's
Medical Assistance program are found at Title 10 NYCRR Part 86-8.
(d) APGs and associated weights.
(1) APGs shall be subject to periodic
revision; the most current listing shall be published in the APG Manual
available on the Office website.
(2) The Department of Health, in consultation
with the office, shall assign weights associated with all CPT and HCPCS
procedure codes that can be used to bill under the APG methodology.
The office shall maintain and update a list of weights
associated with APGs as published in the "APG Policy and Medicaid Billing
Guidance" manual on the OASAS website. Such list may include APGs not
specifically associated with addiction outpatient and opioid treatment
services, but which may appropriately be billed by providers subject to this
Part.
(e) Base
Rates. Base rates for addiction outpatient services shall be developed by the
Office, and subject to the approval of the Department of Health, in accordance
with the following:
(1) Separate base rates
shall be established for each peer group. Base rates shall reflect differing
regional cost factors, variations in patient population and service delivery,
available funding levels, and capital expenditures;
(2) Additional discrete base rates may be
developed by the Office for such peer groups as may be established by
regulation in this Part; and
(3)
Base rates may be periodically adjusted to reflect changes in provider case
mix, service costs and other factors as determined by the Office.
(4) All base rates established by the Office
shall be published on the Office's website.
(f) System Updating. The following elements
of the APG rate-setting system shall be reviewed at least annually, with all
changes posted on the New York State Department of Health's website:
(1) The listing of reimbursable APGs and
associated weights,
(2) The
applicable International Statistical Classification of Diseases and Related
Health Problems, as incorporated by reference in this Title (ICD),-10 codes, or
subsequent ICD categorization, utilized in the APG software system,
(3) The Applicable CPT/HCPCS codes utilized
in the APG software system; and
(4)
The APG software system's grouping and pricing logic.
(g) Bundled payment for opioid treatment
program (OTP) services.
(1) OASAS will
establish regional weekly bundled payments for freestanding opioid treatment
programs. Such payments will be available as an alternative to the
reimbursement under the Ambulatory Patient Group (APG) fee methodology already
in place for OTPs. Programs may bill any given week of OTP service for any
given patient under either methodology (APGs or the bundled payment
methodology), but not both. The initial bundled fees shall be effective March
16, 2020.
(2) For purposes of these
bundled payments there will be two regions, downstate and upstate, with the
regional assignment based on program location. The downstate region includes
the following counties: New York, Kings, Queens, Richmond, Bronx, Nassau,
Suffolk, Westchester, Rockland, Putnam, Dutchess and Orange. The upstate region
includes all other counties in the State.
(3) The proposed bundled payments are based
on service delivery that mirrors a subset of the Medicare OTP bundles in terms
of both services and practitioners, as well as in terms of cost by practitioner
for each service. Services covered by the bundled payment include: FDA-approved
opioid agonist and antagonist treatment medications, dispensing and
administering medications, substance use disorder counseling, individual and
group therapy, toxicology testing, intake activities, and periodic
assessments.
(4) Weekly fees shall
be established in the following rate code classifications:
(i) Methadone Dispensing and/or Counseling
- This code covers all of the services listed above for a patient being
treated with Methadone.
(ii)
Methadone Take Home - This code is billable when the patent has a supply
of take-home medication in their possession for the week being billed. It
cannot be billed for the same week as the dispensing and/or counseling
code.
(iii) Buprenorphine
Dispensing and/or Counseling - This code covers all of the services
listed above for a patient being treated with Buprenorphine.
(iv) Buprenorphine Take Home - This code is
billable when the patent has a supply of take-home medication in their
possession for the week being billed. It cannot be billed for the same week as
the dispensing and/or counseling code.
(5) The initial bundled payments, effective
March 16, 2020, shall be calculated by using the unregionalized Medicare fees
for the same services, meaning those fees shall not vary by region.
(6) Effective August 2, 2021 the fees shall
be regionalized using the OASAS OTP regional factor of 1.1700 (Downstate
relative to Upstate) for freestanding facilities. The regional factor shall be
applied on a budget neutral basis assuming that the Downstate region would have
94.41% of the methadone bundle service volume based on a historical volume
calculation by the Office. The medication take home fees shall continue to be
identical to those used by Medicare, and, as with Medicare, not
regionalized.
(7) The Office, may,
at its discretion, periodically update the bundled fees using trends, actual
cost, Medicare benchmarking, program modeling, or some combination of these
techniques - subject to available funding, Federal approval, and NYS Division
of the Budget approval.
