N.Y. Comp. Codes R. & Regs. tit. 14 § 599.13

Current through Register Vol. 46, No. 45, November 2, 2024

Section 599.13 - Medical assistance Mental Health Outpatient Treatment and Rehabilitative Service program reimbursement system

(a) Reimbursement for Mental Health Outpatient Treatment and Rehabilitative Service programs procedures will be fee based.

(b) A weight for each Mental Health Outpatient Treatment and Rehabilitative Service program procedure shall be established by the Department of Health in conjunction with the Office which reflects the relative anticipated resource utilization for such procedure. For some procedures, fees shall be enhanced pursuant to section 599.14 of this Part through the use of billing modifiers for such things as procedures delivered after hours, services provided in languages other than English, and services of a minimum duration of 15 continuous minutes delivered by a physician or nurse practitioner in psychiatry.

(c) Providers will be categorized into peer groups pursuant to this section. The Office will establish a base fee for reimbursement for each peer group. Such fee shall be reduced by 25 percent during the period in which any such provider retains an operating certificate with a duration of less than six months as a result of having been determined to be deficient in meeting applicable standards and requirements, pursuant to this Part.

(d) Peer group specific base fees may be adjusted as applicable by the Office. Provider specific fee adjustments may be made to reflect pay for performance enhancements, penalties resulting from the Office inspection and certification process, or for other reasons described in the regulations of the Office.

(e) Payments for procedures will be determined by multiplying the assigned weight for the appropriate procedure code set forth at 10 NYCRR Part 86 by the base fee, and adjusting such fee for modifiers and discounts, as appropriate. When a modifier or discount is expressed as a percentage, it will adjust the payment by its percentage of the procedure weight. When more than one procedure applies to a visit, the highest value procedure shall be paid at its full fee value.

(1) Payments for additional procedures related to the visit will be discounted by 10 percent, except for Mental Health Outpatient Treatment and Rehabilitative Service Programs approved by the Office to provide Intensive Outpatient Program (IOP) where there will be no discounted services for additional procedures.

(2) Payments will be reduced by 25 percent for any visit in excess of 30, excluding crisis intervention services, off-site visits, complex care management, peer/family support services, any services that are provided as part of IOP, and any services that are counted as health services, provided during a state fiscal year to any individual who is 21 years of age or older on the first day of such fiscal year, and 50 percent for any visit in excess of 50, excluding crisis intervention services, off-site visits, complex care management, peer/family support services, any services that are provided as part of IOP, and any services counted as health services, provided during such fiscal year to any individual, for fiscal years commencing on or after April 1, 2011, except that effective January 1, 2015, this reduction in payment will not apply to court-mandated services.

(f) The Office will annually review procedure weights, modifier values, peer groupings and the base fees for each of the peer groupings, and will update them as needed. Any changes will be published in the State Register and posted on the Office's website.

(g) The Office will establish and make public a list of weights associated with all CPT and HCPCS procedure codes which can be used to bill specific mental health Mental Health Outpatient Treatment and Rehabilitative Service program procedures through Medical Assistance. The Office will update this list as needed.

(h) Providers licensed solely under article 31 of the Mental Hygiene Law shall be classified by the following peer groups.

(1) Upstate. All non-Local Governmental Unit operated Mental Health Outpatient Treatment and Rehabilitative Service programs operating solely under an Office of Mental Health operating certificate and located in the following counties shall be considered to be included in the upstate peer group: Albany, Allegany, Broome, Cattaraugus, Cayuga, Chautauqua, Chemung, Chenango, Clinton, Columbia, Cortland, Delaware, Erie, Essex, Franklin, Fulton, Genesee, Greene, Hamilton, Herkimer, Jefferson, Lewis, Livingston, Madison, Monroe, Montgomery, Niagara, Oneida, Onondaga, Ontario, Orleans, Oswego, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Schuyler, Seneca, St. Lawrence, Steuben, Sullivan, Tioga, Tompkins, Ulster, Warren, Washington, Wayne, Wyoming, and Yates counties.

(2) Downstate. All non-Local Governmental Unit operated Mental Health Outpatient Treatment and Rehabilitative Service programs operating solely under an Office of Mental Health operating certificate and located in the following counties shall be considered to be included in the downstate peer group: Bronx, Kings, New York, Queens, Richmond, Nassau, Suffolk, Dutchess, Orange, Putnam, Rockland and Westchester counties.

(3) Local Governmental Unit-Operated. All Mental Health Outpatient Treatment and Rehabilitative Service programs operated by a local governmental unit which are operating solely under an operating certificate from the Office.

(4) State-operated. All hospital-based Mental Health Outpatient Treatment and Rehabilitative Service programs operated by the Office.

(i) Hospital-based providers licensed under article 28 of the Public Health Law and article 31 of the Mental Hygiene Law shall be classified by the following peer groups. The base rates will be calculated pursuant to 10 NYCRR Part 86.

(1) Upstate hospital - All hospital-based Mental Health Outpatient Treatment and Rehabilitative Service programs in Albany, Allegheny, Broome, Cattaraugus, Cayuga, Chautauqua, Chemung, Chenango, Clinton, Columbia, Cortland, Delaware, Erie, Essex, Franklin, Fulton, Genesee, Greene, Hamilton, Herkimer, Jefferson, Lewis, Livingston, Madison, Monroe, Montgomery, Niagara, Oneida, Onondaga, Ontario, Orleans, Oswego, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Schuyler, Seneca, St. Lawrence, Steuben, Sullivan, Tioga, Tompkins, Ulster, Warren and Washington, Wayne, Wyoming, and Yates counties.

(2) Downstate hospital- All hospital-based Mental Health Outpatient Treatment and Rehabilitative Service programs in Bronx, Kings, New York, Queens, Richmond, Nassau, Suffolk, Dutchess, Orange, Putnam, Rockland and Westchester counties.

(3) The fee paid to new Mental Health Outpatient Treatment and Rehabilitative Service programs, or Mental Health Outpatient Treatment and Rehabilitative Service programs commencing service in a new county, shall be calculated pursuant 10 NYCRR 86-8.6.

(j) Diagnostic and treatment center (D&TC) providers licensed under Article 28 of the Public Health Law and Article 31 of the Mental Hygiene Law shall be classified by the following peer groups. The base rates will be calculated pursuant to this Part.

(1) Upstate D&TC - All diagnostic and treatment centers in Albany, Allegheny, Broome, Cattaraugus, Cayuga, Chautauqua, Chemung, Chenango, Clinton, Columbia, Cortland, Delaware, Erie, Essex, Franklin, Fulton, Genesee, Greene, Hamilton, Herkimer, Jefferson, Lewis, Livingston, Madison, Monroe, Montgomery, Niagara, Oneida, Onondaga, Ontario, Orleans, Oswego, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Schuyler, Seneca, St. Lawrence, Steuben, Sullivan, Tioga, Tompkins, Ulster, Warren and Washington, Wayne, Wyoming, and Yates counties.

(2) Downstate D&TC - All diagnostic and treatment centers in Bronx, Kings, New York, Queens, Richmond, Nassau, Suffolk, Dutchess, Orange, Putnam, Rockland and Westchester counties.

(k) D&TCs and hospitals - Where a corporation operates a hospital and a D&TC, the Office will determine the primary relationship between the mental health program and the hospital or D&TC and assign the Mental Health Outpatient Treatment and Rehabilitative Service program to the appropriate peer group.

(l) Supplemental Payments. Provider peer group base fees paid pursuant to this section shall be supplemented as appropriate for individual providers participating in the Office of Mental Health quality improvement initiative, or other performance initiatives developed by the Office.

(1) In order to be enrolled in such quality improvement initiative or other Office of Mental Health performance-based payment system, the program shall execute an agreement with the Office under which the provider agrees to participate in such initiative, and undertake such measures as shall be developed by the Office.

(2) Any program eligible to receive supplemental medical assistance reimbursement for participation in a quality improvement initiative, which fails at any time to meet the requirements set forth in the agreement, shall have its quality improvement supplement to its peer group base fee suspended until such time as the program meets such requirements, as determined by the Office.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 599.13

Amended, New York State Register April 1, 2015/Volume XXXVII, Issue 13, eff. 4/1/2015

Amended New York State Register November 23, 2022/Volume XLIV, Issue 47, eff. 11/23/2022