reglab/statecodes huggingface dataset:
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 85 - Medical Assistance Benefits › Nonprescription Drugs in the Medicaid Program › Section 85.22 - Maximum reimbursable price and limitations on reimbursement for non-prescription drugs

Current through Register Vol. 46, No. 28, July 10, 2024
Pursuant to section 365-a  of the Social Services Law, the
						amount which may be reimbursed for those nonprescription drugs specified in
						this Part by the commissioner as a reimbursable item of medical assistance
						shall be the lower of:
(a) the
					 provider's usual and customary price to the general public on the date of
					 provision of service, but not to exceed the lower sale price, if any, in effect
					 on that date;
(b) the maximum
					 reimbursable price established and maintained by the commissioner; or
(c) reimbursement shall not be available
					 under the medical assistance program for any nonprescription drug in the
					 following categories:
(1) a drug regularly
					 supplied as an integral part of a medical care program activity to a Medicaid
					 recipient by private, voluntary or public agencies such as the Veterans
					 Administration, Department of Health and Human Services, State Department of
					 Health or other funded programs;
(2) any drug for which there are low-cost
					 alternatives if purchased by a Medicaid recipient, either nonprescription or
					 prescription drugs;
(3) any drug
					 considered ineffective in accordance with standards developed by the Food and
					 Drug Administration;
(4) any drug
					 sold after the expiration date printed on the container label; and
(5) any drug in a container whose expiration
					 date has been altered, mutilated, destroyed, obliterated or removed by means of
					 an affixed price sticker or other change.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 85 - Medical Assistance Benefits › Outpatient Psychiatric Care › Section 85.28 - Applicability and general requirements

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Sections 85.28 and
					 85.29 
					 of this Part shall only apply to outpatient psychiatric care provided by a
					 private practicing psychiatrist.
(b) A private practicing psychiatrist is a
					 physician who renders treatment to a patient on a fee- for-service basis and
					 who is compensated for those services directly through the medical assistance
					 for the needy program, except that payment for services may be made directly to
					 a professional corporation or partnership in which the private practicing
					 psychiatrist is a member or with which the private practicing psychiatrist is
					 associated, or in the case of a shared health facility as provided in
					 subdivision 8 of section 4708  of the Public Health Law.
(c) To be a covered benefit under medical
					 assistance for the needy as provided in section 365-a  of the Social Services Law,
					 outpatient psychiatric care rendered by a private practicing psychiatrist must
					 be provided by a qualified psychiatrist in accordance with the requirements of
					 this section and section
					 85.29 
					 of this Part.
(d) A qualified
					 psychiatrist shall meet the requirements contained in the Social Services
					 regulations (18 NYCRR 505.2).
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 85 - Medical Assistance Benefits › Outpatient Psychiatric Care › Section 85.29 - Maintenance of medical records

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
					 Private practicing psychiatrists shall maintain medical records containing
					 information sufficient to justify the diagnosis and warrant the treatment of
					 each medical assistance patient served.
(b) As part of this documentation, each
					 medical record shall include:
(1) identifying
					 information about the person treated;
(2) current diagnosis as contained in an
					 approved nomenclature manual such as the Diagnostic and Statistical Manual of
					 Mental Disorders, 3rd edition, 1980 (copies are available from the publisher,
					 American Psychiatric Association, 1700 18th Street, N.W., Washington, DC 20009)
					 or the International Classification of Diseases, 9th revision, Clinical
					 Modification, 1978 (copies are available from the publisher, Commission on
					 Professional and Hospital Activities, 1968 Green Road, Ann Arbor, MI 48105).
					 Both publications are available for inspection and copying at the offices of
					 the records access officer of the Department of Health, Corning Tower, Empire
					 State Plaza, Albany, NY;
(3) a
					 description of the patient's problems, strengths, conditions, disabilities and
					 needs;
(4) a statement of the goals
					 and objectives of treatment to address the patient's problems, disabilities and
					 needs, including an estimate of the duration of the patient's need for
					 treatment, a description of the proposed treatment and prognosis;
(5) progress notes providing a chronological
					 description of the patient's progress in relation to the goals and objectives
					 of the established plan of treatment; and
(6) a summary of the patient's condition and
					 disposition when treatment is completed or terminated.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 85 - Medical Assistance Benefits › Outpatient Psychiatric Care › Section 85.32 - Social work

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Social work
					 services may be provided by a social worker, practicing under the direct
					 supervision of a qualified psychiatrist in private practice as part of a course
					 of treatment provided by the supervising psychiatrist.
(b) For purposes of this section, the term
					 social worker shall mean a person authorized pursuant to the Education Law to
					 use the title "certified social worker."
(c)
(1) A
					 social worker may provide services only under the continuing direct supervision
					 of a qualified psychiatrist. Such supervision must include regular
					 communication and consultation between the social worker and the supervising
					 psychiatrist, but shall not be construed as requiring the physical presence of
					 the supervising psychiatrist at the time the services are being performed by
					 the social worker. The number of social workers supervised by the supervising
					 psychiatrist shall not exceed four.
(2) Duties and responsibilities performed by
					 the social worker must be assigned to him by the supervising psychiatrist,
					 within the scope of practice of the supervising psychiatrist, and appropriate
					 to the education, training and experience of the social worker.
(3) The provision of services by a social
					 worker must be preceded by the completion of a diagnostic evaluation of the
					 patient by the supervising psychiatrist.
(4) The supervising psychiatrist shall be
					 responsible for developing an overall treatment plan which integrates the
					 social worker's study of the patient, and describes the services to be provided
					 by the social worker.
(5) When
					 enrolling in the medical assistance program, a supervising psychiatrist must
					 provide the Department of Social Services with the names of any social workers
					 for whose services he may bill.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 85 - Medical Assistance Benefits › Outpatient Psychiatric Care › Section 85.33 - Nursing service

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Where
					 nursing care may be provided. Nursing service as medically needed shall be
					 provided to medical assistance recipients in the patient's home or in a
					 hospital.
(b) Who may provide
					 nursing care.
(1) Nursing care to patients in
					 New York State shall be provided by a person possessing a license and current
					 registration from the New York State Education Department to practice as a
					 registered professional nurse or licensed practical nurse.
(2) Out-of-state nurses providing care to a
					 New York State Medical Assistance patient who is temporarily located outside
					 New York State, must be licensed and registered in the state in which they are
					 practicing.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 85 - Medical Assistance Benefits › Outpatient Psychiatric Care › Section 85.34 - Rehabilitation services

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
					 Provision of care. Rehabilitation services shall be made available, only at the
					 direction of a physician, to eligible persons as medically needed and as an
					 integral part of a comprehensive medical care program. Such services include
					 not only service to the patient but also instructions to responsible members of
					 the family in follow-up procedures necessary for the care of the
					 patient.
(b) Where care may be
					 provided. Rehabilitation services may be provided in the patient's own home, in
					 a hospital outpatient department, in an approved clinic or outpatient medical
					 facility not part of a hospital, in an approved medical institution or
					 facility, in an approved home health agency, or in the office of a qualified
					 private practicing therapist or speech pathologist.
(c) Who may provide care. Rehabilitation
					 services shall be provided by:
(1) qualified
					 professional personnel employed by:
(i) an
					 approved home health agency;
(ii) a
					 hospital; or
(iii) an approved
					 clinic or outpatient medical facility not part of a hospital;
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 85 - Medical Assistance Benefits › Outpatient Psychiatric Care › Section 85.35 - Podiatry services

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
					 Qualified podiatrist.
(1) A podiatrist
					 qualified to participate in the medical assistance program means a podiatrist
					 who is licensed and currently registered to practice podiatry in New York State
					 by the State Education Department.
(2) Podiatry services provided to eligible
					 medical assistance patients while temporarily out-of-state shall be provided by
					 podiatrists qualified to practice podiatry by the appropriate licensing agency
					 of the state in which podiatry services are provided.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 85 - Medical Assistance Benefits › Outpatient Psychiatric Care › Section 85.36 - Licensed midwife services

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
					 Definitions. As used in this section:
(1)
					 Licensed midwife means a person who is granted a license by the State Education
					 Department and provides care pursuant to article 140 of the State Education
					 Law.
(2) Licensed midwife services
					 means those services which are concerned with the management of the care of
					 mothers and newborns throughout the maternity cycle as well as primary
					 preventive reproductive health care of essentially healthy women.
(3) Maternity cycle means a period limited to
					 pregnancy, labor, birth, and the immediate postpartum period not to exceed six
					 weeks.
(4) [Reserved]
(5) Department means the New York State
					 Department of Health.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 85 - Medical Assistance Benefits › Prior Approval for Care and Services › Section 85.37 - Time limits within which determinations shall be made

Current through Register Vol. 46, No. 28, July 10, 2024
(a) All decisions on requests for prior
					 approval must be made and all required notices shall be sent by the New York
					 State Department of Health to the requesting provider and, where required, to
					 the medical assistance patient-recipient, within 21 calendar days of receipt of
					 such requests by the New York State Department of Health; except that in cases
					 where prior approval requests for dental care are received in area offices
					 outside the five boroughs of New York City and a clinic examination is
					 necessary, the required notices above shall be transmitted within 30 calendar
					 days of receipt of such requests by the respective upstate area
					 office.
(b) In the event prior
					 approval requests must be returned to the requesting provider for submission of
					 additional information, the calendar day limit in subdivision (a) of this
					 section will be tolled from the day the request is returned to the provider
					 until the day the request plus additional information is returned to the New
					 York State Department of Health.
(c) In the event the prior approval request
					 and the requested additional information from the provider is received on a
					 Thursday or Friday which occurs after the 19th calendar day referenced in
					 subdivision (b) of this section, two additional working days may be added to
					 the 21-calendar day limit specified in subdivision (a) of this
					 section.
(d) If a determination is
					 not made and transmitted in accordance with provisions in subdivisions (a)-(c)
					 of this section, the New York State Department of Health shall, within two
					 working days from the expiration of the time limits set forth in subdivisions
					 (a)-(c) of this section, notify the requesting provider and patient-recipient
					 of such fact and of the patient's-recipient's right to request a fair hearing
					 to determine whether the prior approval request should be approved.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 85 - Medical Assistance Benefits › Prior Approval for Care and Services › Section 85.38 - Child/teen health plan (also known as child health assurance program)

Current through Register Vol. 46, No. 28, July 10, 2024
A free-standing diagnostic and treatment center which
						participates in the Medicaid program shall submit billings with the appropriate
						specialty codes which accurately reflect all health services provided to
						children eligible for the Child/Teen Health Plan (also known as Child Health
						Assurance Program) as defined in 18 NYCRR 501.1(a) in order to assure maximum
						utilization of such services.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 85 - Medical Assistance Benefits › Prenatal Care Services › Section 85.41 - Approval of residential health care facility (rhcf) admission and continued stay

Current through Register Vol. 46, No. 28, July 10, 2024
(a) For
					 purposes of this section:
(1) An RHCF shall
					 mean any health care provider with an operating certificate as a skilled
					 nursing facility (SNF) or health related facility (HRF) issued by the
					 department.
(2) Level of care
					 approval shall mean a determination that the care and services furnished by an
					 RHCF are necessary and adequate to meet a patient's clinical needs.
(3) Commissioner's designee shall mean:
(i) an RHCF utilization review agent, as
					 specified in Section
					 416.9 or
					 421.13 of this Title; or,
(ii) an
					 agency of local government which has a written Memorandum of Understanding
					 (MOU) with the commissioner for making Medicaid payment determinations with
					 respect to RHCF admission and/or continued stay.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 85 - Medical Assistance Benefits › Prenatal Care Services › Section 85.42 - Catastrophic health care expense program

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The Expanded Health Care Coverage Act of
					 1988 (chapter 703 of the Laws of 1988) establishes, under the jurisdiction of
					 the New York State Department of Social Services, the Catastrophic Health Care
					 Expense Program (CHCEP). The Department of Social Services will permit
					 authorized counties to make available assistance with cost sharing to eligible
					 county individuals and families for the purpose of assisting such individuals
					 and families with catastrophic health care expenses. The CHCEP program requires
					 participants eligible for cost sharing to receive such assistance in accordance
					 with a schedule that sets forth the cost sharing shares between the participant
					 and the program.
(b) The following
					 schedule entitled "Cost Sharing Proportional Schedule" shall be used by the New
					 York State Department of Social Services in determining a beneficiary's fiscal
					 responsibility for catastrophic health care expenses covered under the CHCEP
					 assistance with cost sharing program:
Cost Sharing Proportional Schedule
Category of Service
Recipient Cost Share
								  Responsibility
Hospital Emergency Room
75 percent
Selected Optional Services
50 percent
Podiatry
Clinical Psychology
Optometry/Eye Care Services
Transportation
Inpatient Hospitalization
30 percent
Physician, Dental & Clinic Services,
25 percent
Health Maintenance Organization, Home Health
								  Care
(freestanding and hospital-based) including ordered
								  diagnostic and treatment services:
Pharmacy
Durable Medical Equipment
Laboratory
Radiology
Referred Ambulatory
Audiology (Hearing Aid)
Ambulatory Surgery and Outpatient Surgery
15 percent
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 85 - Medical Assistance Benefits › Prenatal Care Services › Section 85.43 - Nurse practitioner services

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Definitions.
(1) Nurse practitioner means a person who is
					 licensed and currently registered as a registered professional nurse in New
					 York State and who is certified as a nurse practitioner by the Department of
					 Education (see section 6910  of the Education Law and 8 NYCRR
					 sections 64.5 and 64.6).
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 85 - Medical Assistance Benefits › Prenatal Care Services › Section 85.44 - Minimum standards preferred primary care providers (ppcp)

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Purpose. The
					 purpose of these regulations is to establish minimum standards to qualify as a
					 preferred primary care provider (PPCP). Preferred primary care is a
					 comprehensive range of services aimed at improving access to and availability
					 of comprehensive primary health care to Medicaid eligible and medically
					 indigent persons and persons in underserved areas and assuring that minimum
					 standards of care and services will be upheld.
(b) Eligibility.
(1) Eligibility is extended to providers of
					 comprehensive Primary care services licensed under article 28 of the Public
					 Health Law:
(i) licensed diagnostic and
					 treatment centers which primarily provide a comprehensive range of primary
					 medical services; or
(ii)
					 hospital-based outpatient departments.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 85 - Medical Assistance Benefits › Prenatal Care Services › Section 85.47 - Alternate level of care placement-trial discharge

Current through Register Vol. 46, No. 28, July 10, 2024
Trial discharges from an acute care hospital to a
						specialty rehabilitation hospital or a physical medicine and rehabilitation
						unit of a general hospital shall be in accordance with subdivisions (a), (c)
						and (d) of this section. Trial discharges from an acute care hospital to mental
						health facilities licensed under article 31 of the Mental Hygiene Law or to a
						residential health care facility (RHCF), licensed under article 28 of the
						Public Health Law shall be in accordance with subdivisions (b), (c) and (d) of
						this section.
(a) Hospitals shall
					 receive Medicaid reimbursement at the alternate level of care (ALC) rate as
					 established by section 2807-c  of the Public Health Law for
					 patients readmitted to such acute care hospitals from a specialty
					 rehabilitation hospital or physical medicine and rehabilitation unit of a
					 general hospital pursuant to the following requirements:
(1) The initial admission to the acute care
					 hospital complied with the requirements of 18 NYCRR 505.20(b)(7).
(2) The purpose of the trial discharge to the
					 specialty rehabilitation hospital or physical medicine and rehabilitation unit
					 of a general hospital was to evaluate the facility's ability to care for that
					 patient.
(3) The patient's acute
					 care hospital medical record and discharge plan fully documented the reason for
					 the trial discharge as well as the possibility of readmission if the trial
					 discharge was unsuccessful.
(4) The
					 specialty rehabilitation hospital or physical medicine and rehabilitation unit
					 of a general hospital determined, in writing, that the facility does not have
					 the capability to meet the patient's assessed needs.
(5) The patient's readmission to the acute
					 care hospital occurred within 30 calendar days from the date of the original
					 discharge to the receiving facility.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 86 - Reporting and Rate Certifications for Facilities › Subpart 86-1 - Medical Facilities › Section 86-1.1 - Definition

Current through Register Vol. 46, No. 28, July 10, 2024
As used in this Subpart, the term
medical
						facility
or
facility
shall mean all facilities
						covered by the terms
general hospital
or
certified
						home health agency
as defined in articles 28 and 36 of the Public
						Health Law, provided that such facility possesses a valid operating certificate
						or certificate of approval issued by the State Commissioner of Health and has
						been established, licensed or certified as required by law.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 86 - Reporting and Rate Certifications for Facilities › Subpart 86-1 - Medical Facilities › Section 86-1.3 - Uniform system of accounting and reporting

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Medical facilities shall maintain their
					 records in accordance with:
(1) Accounting
					 and reporting. Hospitals shall maintain their accounts and records in
					 accordance with the Healthcare Financial Management Association's (HFMA)
Introduction to Hospital Accounting,
5th edition, written by
					 Michael Nowicki and published by the Health Administration Press. Such accounts
					 and records are to be maintained on an accrual basis except where an alternate
					 system is mandated by law. Hospitals shall also submit to the department or its
					 authorized agent a certified institutional cost report within five months after
					 the close of each hospital's fiscal year. The data shall be reported as
					 follows:
(i) In accordance with the policies
					 and instructions in the following:
(a)
The Financial Management of Hospitals and Healthcare
					 Organizations,
4th edition, written by Michael Nowicki and published
					 by the Health Administration Press;
(b) HFMA, Glossary of Terms;
(c)
Health Care Entities-American
					 Institute of Certified Public Accountants (AICPA) Audit and Accounting
					 Guide
published by the AICPA; and
(d) Medicare Provider Reimbursement Manual,
					 Part 1.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 86 - Reporting and Rate Certifications for Facilities › Subpart 86-1 - Medical Facilities › Section 86-1.5 - Effective period of reimbursement rates

Current through Register Vol. 46, No. 28, July 10, 2024
Certification of reimbursement rates of payment shall be
						for a 12-month calendar year period or for such other period as may be
						prescribed by the Commissioner of Health.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 86 - Reporting and Rate Certifications for Facilities › Subpart 86-1 - Medical Facilities › Section 86-1.7 - Recoveries of expense

Current through Register Vol. 46, No. 28, July 10, 2024
Operating costs shall be reduced by the cost of services
						and activities which are not properly chargeable to patient care. In the event
						that the State Commissioner of Health determines that it is not practical to
						establish the costs of such services and activities, the income derived
						therefrom maybe substituted for costs of these services and activities.
						Examples of activities and services covered by this provision include:
(a) drugs and supplies sold for use outside
					 the medical facility;
(b) telephone
					 and telegraph services for which a charge is made;
(c) discount on purchases;
(d) living quarters rented to
					 employees;
(e) employee
					 cafeterias;
(f) meals provided to
					 special nurses or patients' guests;
(g) operation of parking facilities for
					 community convenience;
(h) lease of
					 office and other space of concessionaires providing services not related to
					 medical service;
(i) tuitions and
					 other payments for educational service, room and board and other services not
					 directly related to medical service.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 86 - Reporting and Rate Certifications for Facilities › Subpart 86-1 - Medical Facilities › Section 86-1.8 - Research and educational activities

Current through Register Vol. 46, No. 28, July 10, 2024
(a) All research costs shall be excluded from
					 allowable costs in computing reimbursement rates. Research includes those
					 studies and projects which have as their purpose the enlargement of general
					 knowledge and understandings, are experimental in nature and hold no prospect
					 of immediate benefit to the hospital or its patients.
(b) The costs of educational activities less
					 tuition and supporting grants shall be included in the calculation of the basic
					 rate, provided such activities are directly related to patient care
					 services.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 86 - Reporting and Rate Certifications for Facilities › Subpart 86-1 - Medical Facilities › Section 86-1.9 - Compensation of operators and relatives of operators

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Reasonable compensation for operators or
					 relatives of operators for services actually performed and required to be
					 performed shall be considered as an allowable cost. The amount to be allowed
					 shall be equal to the amount normally required to be paid for the same service
					 provided by a nonrelated employee, as determined by the State Commissioner of
					 Health. Compensation shall not be included in the rate computation for any
					 services which the operator or relative of the operator is not authorized to
					 perform under New York State law and regulation.
(b) Any amount reported as compensation for
					 services rendered by an operator or relative of an operator shall not be
					 allowed in excess of the maximum allowance for full time services in carrying
					 out his primary function.
(c) For
					 purposes of subdivision (a) of this section, in determining a reasonable level
					 of compensation for operators or relatives of operators, the commissioner may
					 consider the quality of care provided to patients by the facility during the
					 year in question.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 86 - Reporting and Rate Certifications for Facilities › Subpart 86-1 - Medical Facilities › Section 86-1.10 - Related organizations

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A
related organization
shall be defined as any entity which the
					 medical facility is in control of or is controlled by, either directly or
					 indirectly, or an organization or institution whose actions or policies the
					 facility has the power, directly or indirectly, to significantly influence or
					 direct, or a special purpose organization, or where an association of material
					 interest exists in an entity which supplies goods and/or services to the
					 medical facility, or any entity which is controlled directly or indirectly by
					 the immediate family of the operator. Immediate family shall include each
					 parent, child, spouse, brother, sister, first cousin, aunt and uncle, whether
					 such relationship arises by reason of birth, marriage or adoption. A special
					 purpose organization shall be defined as an organization which is established
					 to conduct certain of the facility's patient-care-related or
					 non-patient-care-related activities. The special purpose organization shall be
					 considered to be related if:
(1) the facility
					 controls the special purpose organization through contracts or other legal
					 documents that allow direct authority over the organization's activities,
					 management and policies; or
(2) the
					 facility is, for all practical purposes, the sole beneficiary of the special
					 organization's activities. The facility shall be considered the special purpose
					 organization's sole beneficiary if one or more of the three following
					 circumstances exist:
(i) a special purpose
					 organization has solicited funds in the name of and with the expressed or
					 implied approval of the facility, and substantially all the funds solicited by
					 the organization were intended by the contributor or were otherwise required to
					 be transferred to the facility or used at its discretion or
					 direction;
(ii) the facility has
					 transferred some of its resources to a special purpose organization,
					 substantially all of whose resources are held for the benefit of the facility;
					 or
(iii) the facility has assigned
					 certain of its functions (such as the operation of a dormitory) to a special
					 purpose organization that is operating primarily for the benefit of the
					 facility.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 86 - Reporting and Rate Certifications for Facilities › Subpart 86-1 - Medical Facilities › Section 86-1.11 - Termination of service

Current through Register Vol. 46, No. 28, July 10, 2024
The Division of Health Care Financing in the department
						shall be notified immediately of the deletion of any previously offered service
						or of the withholding of services from patients paid for by government
						agencies. Such notification shall include a statement indicating the date of
						the deletion or the withholding of such service and the cost impact on the
						medical facility of such action. Any overpayments by reason of such deletion of
						previously offered service shall bear interest and be subject to penalties both
						in the manner provided in section
						86-1.4(f) 
						of this Subpart.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 86 - Reporting and Rate Certifications for Facilities › Subpart 86-1 - Medical Facilities › Section 86-1.12 - Federal financial participation

Current through Register Vol. 46, No. 28, July 10, 2024
The rates of payment made for inpatient hospital services
						rendered to title XIX recipients established in accordance with the methodology
						contained in this Subpart shall be contingent upon Federal financial
						participation (FFP) and approval.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 86 - Reporting and Rate Certifications for Facilities › Subpart 86-1 - Medical Facilities › Section 86-1.14 - Allowance for certified home health agencies providing a disproportionate share of bad debt and charity care

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
					 Basic rates of payment by governmental agencies for voluntary nonprofit,
					 private proprietary and publicly sponsored nonhospital based certified home
					 health agencies which can demonstrate losses as a result of providing a
					 disproportionate share of bad debt and charity care, shall include a bad debt
					 and charity care allowance.
(b) The
					 provisions of this section shall apply to rates of payment during the period
					 July 1, 1990 through December 31, 1990, and for each calendar year period
					 commencing on January first thereafter. The provisions of this section shall be
					 effective, if, and as long as, Federal financial participation is available for
					 expenditures made for the allowance for beneficiaries eligible for medical
					 assistance under title XIX of the Federal Social Security Act.
(c) Eligibility shall be limited to voluntary
					 nonprofit, private proprietary and publicly sponsored nonhospital based
					 certified home health agencies which meet the following criteria:
(1) the facility must ensure the availability
					 of patient service 24 hours a day, 7 days a week as specified in section
					 763.3(d) 
					 of this Title;
(2) the facility
					 must demonstrate compliance with minimum charity care service requirements
					 specified in section
					 763.11(a)(11) 
					 of this Title;
(3) the facility
					 must receive a cost based Medicaid reimbursement rate pursuant to section
					 86-1.46 
					 of this Title;
(4) the facility
					 must be able to demonstrate upon request, that it has made reasonable efforts
					 to maintain financial support from community and public funding
					 sources;
(5) the facility must be
					 able to demonstrate upon request, that it has made reasonable efforts to
					 collect payments for services from third-party insurance payors, governmental
					 payors and self-paying patients; and
(6) the facility must have no petition for
					 bankruptcy filed under either chapter 7 or 11 of Title 11 of the U.S. Code. The
					 commissioner may waive this criteria if the facility demonstrates that it is
					 financially viable or a potentially financially viable organization with a
					 comprehensive plan to maintain fiscal integrity.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 86 - Reporting and Rate Certifications for Facilities › Subpart 86-1 - Medical Facilities › Section 86-1.15 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
As used in this Subpart, the following definitions shall
						apply:
(a)
Diagnosis related
					 groups (DRGs)
shall mean the all-patient-refined (APR) classification
					 system which utilizes diagnostic related groups with assigned weights that
					 incorporate differing levels of severity of a patient's condition and the
					 associated risk of mortality, and reflects such factors as the patient's
					 medical diagnosis, severity level, sex, age, and procedures
					 performed.
(b)
DRG
					 case-based payment per discharge
shall mean the payment to be received
					 by a hospital for all inpatient services, except for physician services,
					 rendered to each patient based on the DRG to which that patient has been
					 assigned, as determined by multiplying the statewide base price by the
					 applicable service intensity weight (SIW) and facility-specific wage
					 equalization factor (WEF) and as further adjusted for teaching hospitals by the
					 inclusion of reimbursement for direct and indirect graduate medical education
					 (GME) costs and for all hospitals, the inclusion of non-comparable
					 costs.
(c)
Service
					 intensity weights (SIWs)
are the cost weights established such that
					 the SIW for any given DRG indicates the relative cost of the average cost of
					 the patient in the DRG as compared to the average cost of all patients in all
					 DRGs. Weights are developed using cost data from Medicaid fee-for-service,
					 Medicaid managed care and commercial payors as reported to the Statewide
					 Planning and Research Cooperative System (SPARCS).
(d)
Case mix index (CMI)
shall mean the relative costliness of a hospital's case mix relative to the
					 case mix of all other hospitals as reflected in the weighted aggregate SIW for
					 the hospital.
(e)
Reimbursable operating costs
shall mean reported operating
					 costs which relate to the cost of providing inpatient hospital services to
					 Medicaid patients, adjusted for inflation between the base period used to
					 determine the statewide base price and the rate period in accordance with trend
					 factors determined pursuant to the applicable provisions of section 2807-c (10)  of the Public
					 Health Law, but excluding the following costs:
(1) ALC costs;
(2) exempt unit costs;
(3) transfer costs; and
(4) high-cost outlier costs.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 86 - Reporting and Rate Certifications for Facilities › Subpart 86-1 - Medical Facilities › Section 86-1.16 - Statewide base price

Current through Register Vol. 46, No. 28, July 10, 2024
(a) For periods
					 on and after December 1, 2009, a statewide base price per discharge shall be
					 established based on targeted statewide Medicaid inpatient hospital
					 expenditures and case-mix and wage neutral reimbursable Medicaid acute
					 operating costs derived from the base period identified in subdivision (b) of
					 this section, and as adjusted for inflation between the base period and the
					 rate period in accordance with trend factors determined pursuant to applicable
					 provisions of section 2807-c (10)  of the Public
					 Health Law, but excluding costs related to graduate medical education, exempt
					 units, patient transfers, high-cost outliers, alternate level of care, and
					 non-comparables. Such trended operating costs shall then be divided by Medicaid
					 inpatient discharges in the base period identified in subdivision (b) of this
					 section to establish the average statewide base price per discharge for the
					 applicable rate period.
(b) For
					 periods on and after December 1, 2009, the "base period" shall be the 2005
					 calendar year and "operating costs" shall be those reported by each facility to
					 the department prior to July 1, 2009.
(1) For
					 those hospitals operated by the New York City Health and Hospitals Corporation,
					 the base period shall be for the period which ended June 30, 2005, and for
					 those hospitals operated by New York State, excluding the hospitals operated by
					 the State University of New York, the base period shall be the 12-month period
					 which ended March 31, 2006.
(2)
					 Discharges, as defined in section
					 86-1.15(n) 
					 of this Subpart, used for direct graduate medical education adjustments shall
					 be based on reported 2007 data.
(3)
					 Discharges, as defined in section
					 86-1.15(n) 
					 of this Subpart, but excluding the factors set forth in section
					 86-1.15(n)(3) 
					 of this Subpart, as used for non-comparable adjustments shall be based on
					 reported 2007 data.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 86 - Reporting and Rate Certifications for Facilities › Subpart 86-1 - Medical Facilities › Section 86-1.17 - Exclusion of outlier and transfer costs

Current through Register Vol. 46, No. 28, July 10, 2024
(a) In calculating rates pursuant to this
					 Subpart, high-cost outlier costs from hospitals with ancillary and routine
					 charges schedules shall be excluded from the statewide base price and shall
					 equal 100 percent of the excess costs above the high cost outlier threshold
					 which shall be developed using acute Medicaid operating costs derived from the
					 base period used to calculate the statewide base price. The Medicaid discharges
					 to be applied to the high-cost outlier thresholds shall be those that occurred
					 in the base period used to calculate the statewide base price.
(b) In calculating rates pursuant to this
					 Subpart, transfer case costs shall be excluded from the statewide base price by
					 excluding the transfer discharges that occurred in the base period used to
					 calculate the statewide base price, except for those transfer cases that are
					 assigned to a DRG specifically identified as a DRG for transferred patients
					 only.
Audit of state rates of payment to providers of health
						  care services, Social Services Law §
						  368-c.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 86 - Reporting and Rate Certifications for Facilities › Subpart 86-1 - Medical Facilities › Section 86-1.18 - Service intensity weights (SIW) and average length-of-stay (LOS)

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The table of
					 SIWs and statewide average LOS for each effective period is published on the
					 New York State Department of Health website at:
					 http://www.health.state.ny.us/and reflects the cost weights and LOS assigned to
					 each all-patient refined (APR) diagnosis related group (DRG) patient
					 classification category. The SIWs assigned to each APR/DRG indicates the
					 relative cost variance of that APR/DRG classification from the average cost of
					 all inpatients in all APR/DRGs. Such SIWs are developed using three years of
					 Medicaid fee-for-service cost data, Medicaid managed care data and commercial
					 third party payor data as reported to the Statewide Planning and Research
					 Cooperative System (SPARCS) for the years set forth in subdivision (b) of this
					 section. Costs associated with hospitals that do not have an ancillary charge
					 structure or associated with hospitals and services exempt from the case
					 payment methodology, and costs associated with statistical outliers are
					 excluded from the SIW calculations.
(b) For periods on and after December 1,
					 2009, the SIW and statewide average LOS table shall be computed using SPARCS
					 and reported cost data from the 2005, 2006 and 2007 calendar years as submitted
					 to the department by September 30, 2009.
(c) For periods on and after January 1, 2011,
					 the SIW and statewide average LOS table shall be computed using SPARCS and
					 reported cost data from the 2006, 2007 and 2008 calendar years as submitted to
					 the department by June 30,2010.
(d)
					 For each calendar year thereafter, the SIW and statewide average LOS table
					 shall be updated by dropping the earliest year of SPARCS data and including the
					 next subsequent calendar year data as submitted to the department by September
					 30th of the year prior to the rate year.
(e) For the period beginning January 1, 2014
					 and ending, at the discretion of the commissioner, no sooner than April 1,
					 2014, but no later than July 1, 2014, the SIWs and statewide average LOS
					 utilized for the 2013 calendar year will be utilized by the
					 department.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 86 - Reporting and Rate Certifications for Facilities › Subpart 86-1 - Medical Facilities › Section 86-1.19 - Wage equalization factor (WEF)

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The statewide base price per discharge
					 shall be adjusted by a facility-specific wage equalization factor (WEF) to
					 reflect differences in labor costs between hospitals. Such WEF adjustment shall
					 be used to adjust for the level of wage and fringe benefit costs for each
					 hospital in accordance with the following:
(1) the WEF shall be based on each hospital's
					 occupational mix and wages for registered nurses, licensed practical nurses,
					 surgical technologists, nursing aides, orderlies, attendants and medical
					 assistants as reported and approved by the Federal Medicare program, and the
					 hospital's proportion of salaries and fringe benefit costs to total operating
					 costs as reported to the institutional cost report. The WEF shall be computed
					 as follows:
(i) for each occupation described
					 in this paragraph, a statewide average salary shall be calculated by dividing
					 the statewide sum of hospitals' total dollars paid by the statewide sum of
					 hospitals' hours paid; and
(ii) for
					 each hospital an actual weighted average salary shall be calculated by dividing
					 the total dollars paid for such occupations by the total hours paid for such
					 occupations; and
(iii) an initial
					 WEF shall be calculated for each hospital by dividing the hospital-specific
					 actual weighted average salary as calculated pursuant to subparagraph ( ii) of
					 this paragraph by the statewide average salary calculated pursuant to
					 subparagraph (i) of this paragraph; and
(iv) the final WEF shall be calculated using
					 the following formula:
where "Labor Share" is calculated by dividing the
						hospital's total salary cost plus the hospital's total fringe benefits by the
						hospital's total operating costs as reported in the institutional cost report
						for the same calendar year used to calculate the statewide base price for the
						applicable rate period. The "Non-Labor Share" equals total operating costs less
						the "Labor Share" of costs.