New York Codes, Rules and Regulations
Title 18 - DEPARTMENT OF SOCIAL SERVICES
Chapter II - Regulations of the Department of Social Services
Subchapter E - Medical Care
Article 3 - Policies and Standards Governing Provision of Medical and Dental Care
Part 505 - Charges For Professional Health Services
Section 505.25 - Ambulatory care for recipients with mental illness

(1) For the purposes of the Medical Assistance Program, ambulatory care for eligible recipients with mental illness means any arrangement or therapeutic environment for the delivery of medical care, health care, or services meeting the criteria set forth in sections 7.09, 7.15 and 31.04 and article 43 of the Mental Hygiene Law, as implemented by appropriate sections of 14 NYCRR Parts 579 and 585.

(2) All definitions specified in Parts 579 and 585 of 14 NYCRR apply to this section.

(1) Clinic treatment programs provide a comprehensive array of services for mentally ill persons and collaterals, usually during visits of less than three hours. The frequency of visits, the duration of treatment, and the extent of services provided during a visit or during the course of treatment are variable, depending upon the identified needs of the patient. A clinic treatment program shall provide, but need not be limited to the following services:

(2) Day treatment programs provide a comprehensive array of services for mentally ill persons and collaterals through the use of supervised, planned services and extensive patient-staff interaction. In general, the duration of a visit exceeds three hours, visits occur with regular frequency usually declining over the course of treatment, and more than one service is provided during a visit. Except for patients under the age of 18, the program is designed for patients who are expected to need day treatment services for a limited period. The average length of stay is expected to be six months or less. A day treatment program shall provide, but need not be limited to the following services:

(3) Continuing treatment programs provide a comprehensive array of services for mentally ill persons and collaterals on a relatively long-term basis in a therapeutic environment through the use of supervised, planned services for the purpose of maintaining the patient in the community. In general, the duration of a visit exceeds three hours, visits occur with a regular frequency determined by the patient's condition, and more than one service is provided during a visit. The program is designed primarily for patients at least 18 years of age who are expected to require services for an extended period of time, usually exceeding six months. A continuing treatment program shall provide, but need not be limited to the following services:

(1) Programs for ambulatory care for mental illness shall be provided in a facility which is certified under article 31 of the Mental Hygiene Law and located in free-standing facilities, the outpatient departments of acute care hospitals, diagnostic and treatment centers, the outpatient departments of private or public psychiatric hospitals, or in county-sponsored community mental health facilities.

(2) Services may be delivered to a recipient in his home only when home visits are a component of the individual's service plan, prepared under the supervision of a physician and subject to periodic review and evaluation, in accordance with 14 NYCRR Parts 579 and 585.

(3) Crises services which are appropriately documented may be delivered in any setting and regardless of another reimbursable service delivered on the same date.

(1) All programs must meet the standards set forth by 14 NYCRR Parts 579 and 585, as revised on April 1, 1991, by the addition of 14 NYCRR Parts 587 and 588.

(2) All services shall be delivered in accordance with a written individual treatment plan.

(3) All programs shall be authorized by a valid operating certificate issued to the facility by the Office of Mental Health.

(4) Each facility, regardless of sponsorship, providing outpatient programs for the mentally ill shall establish a utilization review plan that is acceptable to the Office of Mental Health.

(5) All occasions of services billed as clinic visits shall reflect face-to-face interaction between recipient and appropriate personnel.

(1) Services required for ambulatory care for mental illness when certified by a physician to be medically necessary and appropriate, are covered services under the Medical Assistance Program.

(2) Except for crisis services, no more than one visit for mental health services per patient per day is reimbursable regardless of the number of mental health services provided or the number of mental health programs in which the recipient participates.

(3) Any service provided by a clinic, day or continuing treatment program to an eligible individual at a setting other than those listed in subdivision (c) of this section shall have the location identified in the treatment plan along with the justification of the need for such off-site services except in annotated emergency conditions.

(4) Collateral (as defined in 14 NYCRR 585.4[a][3]) services may be provided to assist in the gathering of information for diagnosis and evaluation, to assure appropriate planning of care for the recipient, to ameliorate those factors of the home environment which interfere with treatment goals of the therapeutic setting, and to enhance the therapeutic environment by treatment continuation in the home. Such services shall be physician-approved and subject to utilitization review procedures. An occasion of collateral service shall be billed against the primary patient's Medicaid identification card, and may occur on the same date as another service provided to the primary patient.

(5) All reimbursable billings shall only be for a documented, definable medical service of face-to-face professional exchange between provider and client, or collateral, in accordance with goals stated in the treatment plan.

(1) Only covered services which are actually delivered to eligible recipients shall be reimbursed.

(2) The cost of routine physicians' services are included in facilities' rate or fee and shall not be billed separately.

(3) Educational services or patient education programs are not coverable, except that services may be utilized to meet the duration of visit requirements specified in subparagraph (h)(2)(ii) of this section.

(4) Sheltered workshop services are not coverable.

(5) Telephone contacts are not reimbursable.

(1) Payment for ambulatory care to Medicaid recipients with mental illness in facilities licensed or operated by the Office of Mental Health shall be at rates or fees certified by the Commissioner of Mental Health and approved by the State Director of the Budget, except that payment for ambulatory mental health care provided in an outpatient department of an acute care hospital licensed pursuant to article 28 of the Public Health Law shall be at rates or fees certified by the Commissioner of the State Department of Health and approved by the State Director of the Budget.

(2) Payment for services to collaterals of Medicaid recipients shall be made in accordance with regulations of the Office of Mental Health and this department.

(3) Payment for ambulatory care to Medicaid recipients with mental illness who are in a residential health care facility shall not be made by the Department of Social Services. Payment shall be made to the provider of mental health services by the residential health care facility.

(4) Medications administered or dispensed in conjunction with ambulatory care programs are included in the rate or fee of the facility. A visit to monitor medication shall be paid as a brief clinic visit if on a date different from another service.

(1) State reimbursement shall be available for expenditures made in accordance with the provisions of this section and when the following conditions are met:

(2) State reimbursement shall be available, at fees approved by the New York State Director of the Budget, for ambulatory care for eligible recipients with mental illness when billed according to the following structure:

(4) The effective date of this schedule shall be August 1, 1982.